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HomeMy WebLinkAbout2016-698 Emergency Svc - North State Medical Transport - Application for Services Franchise by Ordinance �tauet. fan++�b ORANGE COUNTY EMERGENCY SERVICES ` { APPLICATION FOR SERVICE FRANCHISE a Tar+b �a24tiir Franchise Application Category (A separate application must be completed for each general category of service.) Convalescent Transport Services Rescue Services _ ❑X ALS Transport ElConfined Space For OCES use_ a] BLS Transport ❑ Extrication ( y) Emergency Services ❑ Heavy Rescue Date Received: ❑ BLS Supplemental Transport ❑ High/Low Angle ❑ BLS System Surge Transport ❑ Swift Water ❑ BLS Special Event Transport ' ❑ Trench Collapse ❑ Medical Responder Non-transport ❑ Underwater ❑ EMT Non-transport ❑ Wilderness Search & Rescue Name of Applying Organization: North State Medical Transport LLC. Primary Local Business Address: 1240 Corporation Pkwy. Local Address City/State/Zip: Raleigh, NC 27610 Telephone number at local base of operations: 919- 1-8911 Name of Owner/Contact Person: Stuart Coward Contact Email Address: scoward@nsmt.biz Main Office/Owner/Contact Person Address: SAA Main Office City/State/Zip: SAA Telephone number at main office: SAA Operating Business/Trade Name: North State Investment Group. DBA, North State Medical Transport Application Attachments Required (See Orange County Franchise Ordinance for Additional Details) *Place a check mark in the check-box to indicate that the attachment has been included in the application. FX� See Attached Certified copy of an assumed name certificate if applicant does business under a trade name AND trade name does not appear on the Articles of Incorporation or Charter. 2. X❑ See Attached Certified copy of Articles of Incorporation and/or Charter. 3. 0 See Attached Applicant's resume' of training and experience for the applicable service. 4. © See Attached—A full description of the type and level of service to be provided including the location of the place or places from which it is intended to operate, the manner in which the public will be able to obtain assistance and how the vehicle will be dispatched. 5. El N/A —Financial statement pertaining to(proposed)operations in Orange County. 6. [Z See Attached—A list of radio frequencies the applicant is authorized to operate on, and a copy of the FCC license(s) in the name of the person providing the service. 7. El See Attached A description of the applicant's capability to provide twenty-four hour coverage, seven days per week for the district covered by the franchise applied for. 8. nX See Attached —An accurate estimate of the minimum and maximum times for a response to calls within the district covered by the franchise applied. 9. R See Attached A written plan detailing how the applicant will furnish credentialed personnel and a current roster of all credentialed personnel with a list of their credentials. 1 O.nX See Attached —A copy of the applicant's written standard operating procedures including but not limited to the management of equipment, supplies, and medications. 11.[:] N/A Copy of organization by-laws (if applicable). 12. [@ See Attached—Roster of all members and employees, including name, address, and NCDL number. 13. nX See Attached List all vehicles owned and operated by applicant. 14, nX See Attached Proposed fee schedule for service in Orange County. CERTIFICATIONS Provide initials in each certification blank to indicate agreement to each statement I certify on behalf of the named franchise applicant the following: That the information contained within and any attachments provided is true and correct and to the best of my knowledge; 27 2- That the franchise applicant is compliance with North Carolina General Statutes 131 E, Article 7; �3. That,the applicant shall provide notices to Orange County Emergency Services of any changes to the information provided in this Application within five (5) days of any changes and/or any relinquishment of the franchise; 4 Z4. That I am the duly authorized agent of the Board and have been authorized to submit this application and certification to the Orange County; and X25. That any information found to be false or misleading may be grounds for termination of the franchise and the franchise agreement. Authorizing Name/Title: Bryan Perry-Compliance Officer Authorizing Signature: Date: WAKE COUNTY, NC 29 LAURA M RIDDICK REGISTER OF DEEDS PRESENTED & RECORDED OH 08/24/2004 AT 09:09:38 . BOOK:010982 PAGE:019?2 — 019 73 CERTIFICATE OF ASSUMED NAME FORA LIMITED LIABILITY COMPANY LLC /�q, � County,North The undersigned LLC,proposing to engage in business In__.L_ Carolina,under an assumed name other than its LLC name,hereby codifies that: 1.The name under which the business Is to be conducted is: NO -4-�. 5 -1-A..4'c. rn e d 1 te, ,.'> - r 'f" r (Insert assumed name) 2.The name and address of the owner(s)of such business is(are): s' /4—. 4 t 44_ L 3 4-4 4-lv ti Ai 4, , 27S-1 7 et r. t «. , p 6 P ..� i t k !4 l) '�-j '�' N G L 24& 1. -MOM, , C z.7$ 7 .�} { (� j ,Q,, !..,„ - L L 6 7..t ? 44.1, . 1•cr A. (Insert name and address of LLC) In witness whereof, this certificate is signed in the name of the LLC by its manager(s), this day of 20——'. By: /L.%►A A SEAL Ma a!er By: _ 4.16,.. aA. ►a Il1.. -EAL Manag.r �`; ✓ r% ritim ar. .,.L //''�� Mana�Y IL� S N Q. state of A/1-431.,1.+•1 A County of A'"K� t.4 •.,� S a Notary Public, do herebyD fy t �1 ell,a f�.+- „/ f r : .managers)of rn, � • r� t" ��r-..+ ` LLC,personally appeared before me this day of C,... #. . '�,20 . and that they signed the foregoing certificate on behalf of the LLC. Lr r hand and official seal,this the 1 i day of r —'20 Witness my 00411111ffirrt ••. 0 ry it II Notary Public Uri.,,.I"' ^. My Commission Expires: . o 0 :,` I—1 Mailing Address: Wake County Register of Deeds,F.D.Box 1�igb . 1N,,•ti rr4trttiontotNttti,�� ! i. Il001; 010982 PFlGE:01972 - 01973 Yellow In ohite shut is a vital purl of your recorded document. Please retain original document and submit fur rerecor'ding. irsiorAw fake County Register of Deeds WAKE Laura 1•l. Riddiclt cc7u 'rY Register of Deeds North Carolina Waite County The lorecoing certiticatc of 7 �\"ti.� { Lt.,a l c ti\otarvties) Public is tare)certilicd to be correct.This instrument and this certificate arc duly registered at the date and time and in the book and page shown on the first page hereof. t.anra i+t. Ridciicl. Rc1'i,tcr of l) eds ;i t ipvl:)etutty Register or Deeds 'rhh(u lomer Group Chia I) to ui nl cf Ilnu `uunr .,il..,I n� rime:,hmip is Lac 1 or Partnership Agreement The partnership agreement is the document which t�svreferred s nce�t prao�des evidence partnership. supporting the i�tent of written. Hoavever, a written partnership a9oeamartnerldispute. the partners, in the event of an IRS audit p Any modifications and/or amendments to a written partnership agreement should also be in writing. If the partnership agreement is silent with regard to a specific matter, local law will be deemed to be part of the agreement. Partnership agreements are sometimes referred to as "Articles of Partnership". The partnership agreement generally contains the following information: - Names of the partners and the partnership; - Designation of partner type (i.e. general or limited); -The method of accounting and accounting period of the partnership; - Business purpose; -The proportional sharing of ownership, profit, and loss; -Any special allocations of income, deductions or credits; - Duration of the partnership; - Rights and obligations of the partners upon the death or retirement of a partner; - Procedures for dissolution of the partnership; -The original contribution of each partner in money and assets; - Partner debt assumed by the partnership; - Liability for the debts of the partnership; -The intended contribution of each partner of skill, labor, and/or additional money or assets. Partnership A partnership may be a syndicate, group, pool,joint venture, or other unincorporated organization in which a business or financial operation or venture is conducted.A partnership is not a corporation, trust or estate. Partner A member of a partnership. A partner can be an individual, corporation, partnership, estate and/or trust. • file://C:\Program Files\furho'1'ax\Business ;/12/2U05 ,,..../4,. ... ..., °a:,, NORTH CAROLINA Iv..‘'. . =- Department of The Secretary of State To all whom these presents shall come, Greetings: I, ELAINE F. MARSHALL,Secretary of State of the State of North Carolina, do hereby certify the following and hereto attached to be a true copy of ARTICLES OF ORGANIZATION OF NORTH STATE INVESTMENT GROUP, LLC the original of which was filed in this office on the 14th day of June, 2004. • r-,-0"-iiiR7rij `s, iM mny #- . „' F °' `'t, IN WITNESS WHEREOF,I have hereunto , set my hand and affixed my official seal at the I; ,, ,'j�'�i ' City of Raleigh,this 14th day of June,2004 .,..7.4 4111 voos ......' ,1101;Ae,Nce.4. 4 ,0461,42,..6' ~` `__ Secretary of State Document td: 020041880032 2 _ • SOSID:730075 Date Filed:61141200411:41:00 AM Elaine F.Marshall North Carolina Secretary of State State of North Carolina C200416600322 Department of the Secretary of State Limited Liability Company ARTICLES OF ORGANIZATION Pursuant to§57C-220 of the General Statutes of North Carolina,the undersigned does hereby submit these Articles of Organization for the purpose of forming a limited liability company. 1. The name of the limited liability company is: North State Investment Group,LLC 2. If the limited liability company is to dissolve by a specific date,the latest date on which the limited liability company is to dissolve:(If no date for dissolution is specified,there shall be no limit on the duration of the limited liability company.) 3. The name and address of each person executing these articles of organization is as follows: (Slate whether each person is executing these articles of organization in the capacity of a member,organizer or both). LegatZoom.cam.Inc.,as Organizer 7083 Hollywood Blvd.,Suite 180 Los Angeles,CA 90028 4. The street address and county of the initial registered office of the limited liability company is: Number and Street 213 Chamberlain Drive City,State,Zip Code Clayton,NC 27520 County Johnston 5. The mailing address,if different from the street address,of the initial registered office is: 6. The name of the initial registered agent is: Michael Jason Wells 7. Principal office information: (Select either a or b.) a. The limited liability company has a principal office. The street address and county of the principal office of the limited liability company is: Number and Street 213 Chamberlain Drive City,State,Zip Code Clayton,NC 21520 County Johnston The mailing address,if different front the street address,of the principal office of the corporation is: b. 0 The limited liability company does not have a principal office. 1 • 8. Check one of the following: (i) Member-managed LLC: all members by virtue of their status as members shall be managers of this limited liability company. ✓ (ii) Manager-managed LLC.. except as provided by N.C.G.S.Section 57C-3-20(a),the members of this limited liability company shall not be managers by virtue of their status as members. 9. Any other provisions which the limited liability company elects to include are attached. 10. These articles will be effective upon filing,unless a date and/or time is specified: This is the 11 day of June ,20 04 Signature Patricia Madn.Assistant Secretary.LogatZoan.00m.trta.O+ganfzer 7)pe or Print Name and Title NOTES: I. Filing fee Is$125. This document must be tiled with the Secretary of State. CORPORATIONS DIVISION P.O.Box 29622 RALEIGH,NC 27626.0622 (Revised January 2002) (Form L.01) Management of the Limited Liability Company Articles of Organization or the unless the A The LLC will be a member-managed company, Operating Agreement state otherwise. In a member-manag ed company, management is vested in the members in proportion to the current percentage ge be allocated of a otherwise, all the members. If the LLC determines that manag e the Articles of Organization or the Operating Agreement should so state. The decision of a majority-in-interest of the members shall be controlling. The members may vote in person or by proxy. If the LLC is to be managed by managers,the Articles of Organization or the Operating Agreement must indicate that the LLC is a manager-managed company. In a manager- managed company,the decision of the manager(if only one manager)or a majority of the managers (if more than one manager) shall be controlling. The managers may vote in person or by proxy. Managers'Responsibilities Principal officers and managers of every limited liability company must be mindful of the following specific and important duties and responsibilities: Payments of Salaries to Employees. Officers responsible for the payment of salaries must see that those salaries are paid by the limited liability company. Managers establish salaries for officers. Payroll Taxes. All payroll taxes must be paid by the limited liability company. Nonpayment may result in personal,civil or criminal liability to the officers and managers. Duty to Inspect. Managers have the absolute right to inspect all company record books,records,documents and property at any time. If they do not exercise that right,they may be held liable for negligence in the event that the company suffers loss or its creditors suffer loss by reason of failure to exercise diligence in such matters. Members'Rights The limited liability company must allow the members to access company records. Additionally,the company must provide each member with information necessary for the exercise of the member's duties under the operating agreement. This requirement cannot be waived in the Operating Agreement. 1 ,,,,:,..;.. ...,,,,..—r P ORM 4.A'A;‘,:::: I ,,, it—t.°4 g fl 0 •.r+At. ' ■ f/ ' I { I ll'''T. ',::A11\ '''''' k:%:If'iii'l ' . CZI I),:+7,.7..1'• (------7.,0,j2;tx . .....,*0., , . ,. ... ... . .9, ft•N., ft, 1 44'4■Iti,,,, 4, \.) .,..... ,.., k.,,..._ ,,,-„,- - , tu ,--thz- -Q .t- - ' ..., ,.. . ,.., iii.....,:t:-.: t,:i..;;,t.:N..4. 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CC) ''''Sft 4tft4ft. ''' COCI ft t ft E 0 0 7/3 ,_. I r 0 0 ,......, ,..., \rz .s7.4— 111;:;i: :( :: (4:). .-4-4-:- ii .,,.....4-- ,....,..- 3; Po— .;;:-",-•\ ,...`s" .■,C) , ,-,-- ?* ,,....„,,*/4".:.;;, 1 4, ,,,, !„.,„• ..:J.,,,,=;-, ?;;;;,;;;:.?; ,,,,. ::\ --e'*--c t-Lt ...c- ..._,,.... _ c„, oe 0•. t....>' ,, ...., it-4 t.4 1 ■4...■ _ t+.4 t?,,-"•'t:: i ,,m .) .. - I'----- DATE(MMIDDlYYYY} ACC) CERTIFICATE OF LIABILITY INSURANCE ( 9/22/2016 THITCERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES i 3ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED `. REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT (''�C PRODUCER NAME: Elizabeth Holden Sentinel Risk Advisors, LLC PHONE fALC,NE.FYt)'919-388-1914 1(a/c.Ng):919-926-4664 . 4700 Six Forks Road Suite 200 E-MAIL ADDRESS:Iholden @sentinelra.com Raleigh NC 27609 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Arch Insurance Company 11150 INSURED NORT-29 INSURER B:ACCIDENT FUND INS CO 10166 North State Investment Group LLC INSURER C: Richard Hardin INSURER D: 1240 Corporation Pkwy INSURER E: Raleigh NC 27610 INSURER F: COVERAGES CERTIFICATE NUMBER: 1050186112 REVISION NUMBER: THIS IS TO INDICATED.CNOTWITHSTANDING ANY IREQUIREMENT,TERM OR CONDITION V OF ANY CONTRACT OR OTHER DOCUMENT WIDTH RESPECT PECT TO LWHICH TIHIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.. INSR -ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM!DDIYYYY) A x COMMERCIAL GENERAL LIABILITY MAPK08365703 8/25/2016 8/25/2017 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED $100,000 CLAIMS-MADE ( X I OCCUR PREMISES(Ea occurrence) MED EXP(Any one person) _$5,000 X Professional Lia PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: - X POLICY 71N-j- — PRODUCTS-COMP/OP AGG $2,000,000 I ,LOC $ OTHER: COMBINED SINGLE LIMIT $ s 1 AUTOMOBILE LIABILITY MAPK08365703 8/25/2016 8/25/2017 (Ea accident 1,000,000 BODILY INJURY(Per person) $ ANY AUTO AUTOS NED © SCHEDULED BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ ident X HIRED AUTOS © Per acc AUTOS $ A X UMBRELLA LIAB X OCCUR MAUM08498003 8/25/2016 8/25/2017 EACH OCCURRENCE $4,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000,000 DED RETENTION$ PER OTH- B WORKERS COMPENSATION WCV6095375-00 11/4/2015 11/4/2016 X I STATUTE ( ER AND EMPLOYERS'LIABILITY Y/N E.L.EACH ACCIDENT $500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N/A OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS below , DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County P.O.Box 8181 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 S.Cameron Street ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough NC 27278 AUTHORIZED REPRESENTATIVE atii,44-c. a.i.v.„-A, 1 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD NORTH STATE MEDI ° ' SPORT Resume of training and experience of the applicant in transportation and care of patients. Our Team Is Here For You Stuart Coward (CEO): Stuart has lived in Franklin County for the past 30 years. He previously owned and operated a moving and furniture business and is married with 2 children. He proudly served with the Pilot Fire Department where he rose to the rank of captain, and was later Chairman of the Board of Directors. Stuart was instrumental in the implementation of Franklin County's earliest First Responder Program. In 1992, Stuart became involved in Zebulon Rescue Squad and through hard work received his paramedic credentials. This opened new avenues and he began a second career with Wake County EMS. Stuart is a current EMT-Paramedic certified in Advanced Cardiac Life Support (ACLS), Basic Trauma Life Support (BTLS),and Pediatric Advanced Life Support(PALS). Stuart has over 36 years of managerial experience. Bryan Perry (COO): Bryan is a lifelong Franklin County resident, and is married with 4 children who reside with him on his family farm in Pilot. Bryan was heavily involved with the Pilot Fire department where he rose to the rank of Captain. Bryan has an A.S. in Emergency Medical Science from Wake Tech Community College and a B.S. in Health and Business Administration from Campbell University, where he graduated Magna Cum Laude. Bryan was with Wake County EMS for 20 years where he served as a Field Paramedic, Paramedic II/Field Training Officer, and Supervisor. Richard Hardin (Communications Director): Richard is a resident of Washington, North Carolina, where he has lived on a family farm since 1972 with his wife and 2 children. Richard has been involved with EMS since 1977,beginning his career with Beaufort County shortly after completing his EMT. He moved later to Winterville Rescue Squad, and lastly to Wake County EMS 27 years ago. Richard has served on the EMS Audit and Review Committee and as an acting supervisor. He is current EMT-Paramedic with ACLS, BTLS, and PALS certifications. Quint Coward (Daily Operations Supervisor): Quint received his BS from NC State University and supervises daily operations bridging the gap between field and management operations. Quint has an MBA from North Carolina State University and is a valuable asset to the North State Medical Transport team. Carlie Coward(Director of Business Development) Carlie graduated with her MBA from East Carolina University in May 2014. Since graduating, Carlie has worked with North State Medical Transport in developing its' Marketing and HR practices. Carlie spends her days managing NSMT staffing as well as visiting our customers to assure their needs are met. Tyler Macemore(Communications Manager) Tyler graduated with a B.S. in Public Health from East Carolina University. He oversees our Dispatch& Communications Department. Field Staff: In any EMS operation the most important part of our team is our field staff. They are vital as the initial point of contact for those in need of service. We have a well trained staff of EMT-Basics, EMT-Intelinediates, and Paramedics. Our medical professionals provide transportation services and medical care Orange County and its customers should expect. NORTH MEDI A T ' A SPORT Describe type and level of service to be provided and your capacity to provide twenty-four (24) hour coverage, seven days per week for the area to be served? Description of the type and level of service NSMT has the capabilities to provide ALS and BLS emergent and non-emergent services. Services provided will be in compliance with county franchise agreement. Our stocked and staffed units provide twenty-four hour coverage for point-to-point and out-of-county services to the citizens of Orange County. We work with existing services to determine system needs and continue to reevaluate the need for additional resources over the long-term. Short-term needs for additional resources are evaluated on a daily basis and additional resource needs will be located accordingly. Through system status management, additional North State Medical Transport resources will be brought into the county from our other base locations, such as Wake and Franklin Counties, to cover any overflow needs. Our service currently provides 24 hour ALS/BLS coverage to our customers. Location from which vehicles intend to operate North State Medical Transport provides services from existing locations in Wake and Franklin counties. Units are staged in Orange county based on call volume needs. Current bases of operation meet all county codes and safety requirements for EMS quarters. NSMT locations meet OEMS requirements for safety and protection from heat or cold exposure. Units dispatched from the local office. Backfill calls not prescheduled will be worked out with local facilities based on response requirements. The manner in which the public will access the system and how the vehicles will be dispatched Dispatching will be handled through our dispatch center which is staffed 24 hours a day. Toll- free phone numbers will be provided to agencies throughout Orange County. Our field units are equipped with fleet management systems (Teletrac)that allow for easy communication via messaging between the dispatch center and each ambulance. In addition, each unit has cellular phone service and local Orange County radio channels for communication.Toll-free contact information will be listed with the 911 center, local agencies, and local phone directories. North is State Medical Transport currently utilizes the 800 mhz North Carolina Viper Medical Network (VMN) for its radio communications between hospitals and other public service agencies should the need arrive. This system is within the 800 mhz state trunked Viper radio network."Voice Interoperability Plan for Emergency Responders". North State Medical Transport will still maintain the capability of the VHF 155.280 and 155.340 communications in all its ambulances. Public contact will be accomplished through many of the same methods as above. All contact information would be listed at local facilities, hospitals, emergency dispatch center, and phone directory. Our Market Development Manager will conduct awareness visits with agencies and public groups which use medical transport services. These visits will be regularly conducted to ensure service needs are being met. We would work closely with existing agencies to identify areas that are potentially in need of additional services. NORTH STATE MEDI`._ A. T5 A SPORT Vehicle Radio Information: The North State Medical Transport ambulance fleet is equipped with VHF (high band)radios. The frequency range is between 150-160 MHz. They are all 50-100 Watts with 16-100 channel capability. The list of ambulances and the radios are as follows. Additional frequencies will be added per system requirements.North State Medical Transport currently utilizes the 800 mhz North Carolina Viper Medical Network(VMN) for its radio communications between hospitals and other public service agencies should the need arrive. This system is within the 800 mhz state trunked Viper radio network."Voice Interoperability Plan for Emergency Responders"North State Medical Transport also still has the capability of the VHF 155.280 and 155.340 communications in all its ambulances. Additional frequencies can be added as needed.All Radios are programed for the state Viper Medical Network UNIT 0614-Motorola 6500 Duel Head Viper UNIT 0715-Motorola 6500 Duel Head Viper UNIT 1114-Motorola 6500 Duel Head Viper UNIT 0612-Motorola 6500 Duel Head Viper UNIT 1214-Motorola 6500 Duel Head Viper UNIT 0411-Motorola 6500 Duel Head Viper UNIT 0511-Motorola 6500 Duel Head Viper UNIT 0613-Motorola 6500 Duel Head Viper UNIT 0313-Motorola 6500 Duel Head Viper UNIT 0713-Motorola 6500 Duel Head Viper UNIT 1015-Motorola 6500 Duel Head Viper UNIT 0814-Motorola 6500 Duel Head Viper UNIT 0714-Motorola 6500 Duel Head Viper UNIT 0516-Motorola 6500 Duel Head Viper UNIT 0416-Motorola 6500 Duel Head Viper UNIT 0816-Motorola 2500 Duel Head Viper UNIT 0916-Motorola 2500 Duel Head Viper Current frequency in each Ambulance: 001- WAKE CO HOSP. 155.340 CTCSS 192.8 002-DURHAM CO HOSP. 155.340 CTCSS 114.8 003- ORANGE CO HOSP. 155.340 CTCSS 107.2 004- FRANKLIN REG. 155.340 CTCSS 136.5 005-BETSY JOHNSON 155.340 CTCSS 146.2 006-JOHNSTON MEM. 155.340 CTCSS 110.9 007-NASH GEN. 155.340 CTCSS 107.2 008-PITT CO HOSP. 155.340 CTCSS 107.2 009-NORTH STATE MEDICAL TRANSPORT 156.075 CTCSS 192.8 010-FRANKLIN CO FIRE 154.145 CTCSS 136.5 011-FRANKLIN CO EMS 155.580 CTCSS 136.5 012-NASH CO EMS 155.055 CTCSS 107.2 013- STATE EMS 155.280 CTCSS 014-DISPATCH WAKE CO EMS 156.225 CTCSS 192.8 015-MARIAH PARHAM HOSP. 155.340. CTCSS 131.8 016-VANCE CO EMS/FIRE 154.355 CTCSS 131.8 017- WX 1 162.550 018-WX 2 162.500 019-WX 3 162.400 020-WX 4 162.47 021-WX 5 162.425 74 'GomMtw Federal Communications Commission `` \' Public Safety and Homeland Security Bureau RADIO STATION AUTHORIZATION LICENSEE:NORTH STATE MEDICAL TRANSPORT Call Sign File Number WQAX350 0006323146 ATTN:RICHARD HARDIN NORTH STATE MEDICAL TRANSPORT Radio Service 1240 CORPORATION PKWY PW-Public Safety Pool,Conventional RALEIGH,NC 27610-1348 Regulatory Status PMRS Frequency Coordination Number FCC Registration Number(FRN): 0011225604 Grant Date Effective Date Expiration Date Print Date 07-07-2014 07-07-2014 08-23-2024 07-08-2014 STATION TECHNICAL SPECIFICATIONS Fixed Location Address or Mobile Area of Operation Loc.1 Area of Operation Countywide:WAKE,NC Antennas Loc. Ant. Frequencies Sta. No. No. Emission Output ERP Ant. Ant. Construct No. No. (MHz) Cls. Units Pagers Designator Power (watts) Ht./Tp AAT Deadline (watts) meters meters Date 1 1 000155.34000000 MO 10 11 K2F3E 100.000 100.000 08-23-2005 1 1 000155.28000000 MO 10 11K2F3E 100.000 100.000 08-23-2005 1 1 000156.07500000 MO 10 11 K2F3E 100.000 100.000 08-23-2005 Control Points Control Pt.No.3 _ ____Address:1240 CORPORATION PKWY City:RALEIGH County:WAKE State:NC Telephone Number:(919)815-2745 Waivers/Conditions: NONE Conditions: Pursuant to§309(h)of the Communications Act of 1934, as amended, 47 U.S.C.§309(h),this license is subject to the following conditions: This license shall not vest in the licensee any right to operate the station nor any right in the use of the frequencies designated in the license beyond the term thereof nor in any other manner than authorized herein. Neither the license nor the right granted thereunder shall be assigned or otherwise transferred in violation of the Communications Act of 1934, as amended.See 47 U.S.C.§310(d). This license is subject in terms to the right of use or control conferred by §706 of the Communications Act of 1934, as amended. See 47 U.S.C. §606. FCC 601-ULSHS1 Page 1 of I August 2007 NoRTH STATE MEDI Describe your capacity to provide twenty-four (24) hour coverage, seven days per week for the area to be served? Our stocked and staffed units provide twenty-four hour coverage for point-to-point and out-of-county services to the citizens of Orange County. We work with existing services to detetiuine system needs and continue to reevaluate the need for additional resources over the long-term. Short-term needs for additional resources are evaluated on a daily basis and additional resource needs will be located accordingly. Through system status management, additional North State Medical Transport resources will be brought into the county from our other base locations, such as Wake and Franklin Counties,to cover any overflow needs. Our service currently provides 24 hour ALS/BLS coverage to our customers. On Time Performance Trip Date IS BETWEEN 08/01/2015 AND 08/01/2016;AND Ordering Facility IS UNC AMBULATORY CARE CENTER OR UNC HEALTH CARE OR UNC HEALTHCARE-HILLSBOROUGH CAMPUS OR UNC HEART&VASCULAR CARE CLINIC OR UNC HIGHGATE SPECIALTY CENTER OR UNC HILLSBO... North State Medical;Transport Percentage Cumulative Time after Pick-Up #of Trips Total Trips of Total Trips Percentage Early or On Time 1,044 1,044 70.21% 70.21% 01:00-01:59 Mins 25 1,069 1.68% 71.89% 02:00-02:59 Mins 22 1,091 1.48% 73.37% 03:00-03:59 Mins 25 1,116 1.68% 75.05% 04:00-04:59 Mins 14 1,130 0.94% 75.99% 05:00-09:59 Mins 72 1,202 4.84% 80.83% 10:00-14:59 Mins 49 1,251 3.30% 84.13% 15:00-19:59 Mins 55 1,306 3.70% 87.83% 20:00-29:59 Mins 74 1,380 4.98% 92.80% 30:00-44:59 Mins 40 1,420 2.69% 95.49% 45:00-59:59 Mins 41 1,461 2.76% 98.25% Over 1 Hour 26 1,487 1.75% 100.00% RescueNeF Reporting \1ZOLL-DATA\RESCUENET\REPORTS32\DISPATCH\FACILITY STATISTICS\ON TIME PERFORMANCE.RPT Printed on 9/22/2016, 4.42:22PM Page 1 On Time Performance Trip Date IS BETWEEN 08/01/2015 AND 08/01/2016;AND Ordering Facility IS UNC AMBULATORY CARE CENTER OR UNC HEALTH CARE OR UNC HEALTHCARE-HILLSBOROUGH CAMPUS OR UNC HEART&VASCULAR CARE CLINIC OR UNC HIGHGATE SPECIALTY CENTER OR UNC HILLSBO... North State Medical Transport Percentage Cumulative Time after Pick-Up #of Trips Total Trips of Total Trips Percentage Total Trips for North State Medical Transport: 1,487 AN • h*if-h I Early or On Time 70.2% 3 0100-0159 1.7% p 0200-0259 1.5% , , 03:00-03:59 1.7% ri 0400-0459 0.9% E 0500-0959 4.8% i 1000- 1459 3.3% 1500- 1959 3.7% 'k\t El 2000-2959 5.0% 3000-4459 2.7% [14500-5959 2.8% ri Over 1 Hour 1.7% Total: 100.0% Total Trips:1,487 RescueNetTm Reporting \\ZOLL-DATA\RESCUENETREPORTS32\DISPATCH\FACILITY STATISTICS\ON TIME PERFORMANCE.RPT Printed on 9/22/2016, 4:42:22PM Page 2 NORTH STATE MEDI T !` SPORT Proof of Valid Personnel Certifications as issued by OEMS The attached Employee roster was taken from the OEMS CIS site. All employees are current. If copies of NC-OEMS certifications are required in addition to the attached OEMS roster we will provide upon request.NSMT staff roster is managed and kept up to date in the NCOEMS CIS system which is accessible by Orange county at any time for review. Continuing Education Program North State Medical Transport falls under the Franklin County EMS system as a Paramedic level ambulance provider. As part of the Franklin county system NSMT meets all continuing education and peer review requirements mandated by OEMS. Our Continuing education program is provided through the Franklin County EMS Teaching Institution. Franklin County EMS is recognized as its own Training Center by NCOEMS. All North State Medical Transport ALS and BLS employees meet or exceed all NCOEMS continuing education and recertification training requirements. For any specific CE requirement questions, you may contact Jeff Bright, Teaching Institution Coordinator and Franklin County EMS Training Officer at 919-496-5005. I L '. I. l 11111.111 , 1 v 4V, r. 7 4. 4 % '' M y. 2 . ,. i ...._,-,_,... , , , I 1 ir ➢,� L d !I / � r ]� = � _ l � I ` i71 a r�// Y APT z its ir„ *1, } ° a 4 i 1 ride 41 unomensum NAM BMW _ ii Administrative North State Medical Transport Policies & Procedures Effective Date: 10/01/2014 Fotmat of Policies and Procedures 3 Maintenance of Policies and Procedures 3 Changes to Policies and Procedures 3 Distribution of Policies and Procedures 3 Administration of Policies and Procedures 3, 4 2 A-1-Format of Policies and Procedures 1. These standards will outline the format of North State Medical Transport's Policies and Procedures,the process for maintaining these standards, and the process for distributing changes to the Policies and Procedures. 2. Standards will be formatted to clearly explain the purpose of the Policies and Procedures, any references to other documentation supporting the Policies and Procedures, and any defined procedure to ensure their proper application. 3. The reference number will be the numeric identifier for the Title of the Policies and Procedures 4. The Title will indicate the area covered by the Policies and Procedures. 5. The Policies and Procedures categories will be identified by a descending numerical sequence. 6. The Policies and Procedures sub-categories will be identified by a descending roman numerical sequence. 7. The effective date will indicate the calendar date the Policies and Procedures will be in effect and under enforcement. A-2-Maintenance of Policies and Procedures 1. For the duration of this policy the Operations Director/Compliance Officer/HR Director will remain synonymous unless otherwise noted. 2. Policies and Procedures will be maintained in both printed and electronic format. 3. The official copy of the Policies and Procedures will be maintained by the Operations Director of North State Medical Transport or his/her designee. A-3-Changes to Policies and Procedures 1. The Operations Director of North State Medical Transport at his/her discretion will issue additions or changes to the Policies and Procedures. A-4-Distribution of Policies and Procedures 1. An initial version of the Policies and Procedures will be issued to all personnel during the hiring process. 2. All personnel will submit a signed statement of receipt of the Policies and Procedures to be maintained in their personnel file. A-S-Administration of Policies and Procedures 1. Distribution and review of the Policies and Procedure will be covered in all new employee orientations. 2. Updated versions of Policies and Procedures will be announced by the Operations Director of North State Medical Transport or his/her designee by email. 3. The updated version will be in a downloadable and printable format. 4. Complete versions of each Policy and Procedure will be available electronically as an 3 employee resource. 5. Any employee without a copy of the Policies and Procedures may request one through their supervisor or any management member at North State Medical Transport Questions ? If you have any questions or concerns regarding these policies or the interpretation of these policies you should contact a member of Management: NSMT FIR Department of the NSMT Compliance Officer. 4 Human Resources North State Medical Transport Policies & Procedures Effective Date: Effective Date: 10/01/2014 Introduction 7 Continuity of Policies—Right to Change or Discontinue 7 Confidentiality of Policies 7 Employment Openings 7, 8 Employing of Full-time and Part-time Positions 8 Equal Opportunity Statement 8 Americans with Disability Act and the ADA Amendments Act 8, 9 Recruitment 9 Employee Selection Development 9 Interviewing 9 Pre-Employment Screening Process 9 Interviewing 9 Pre/Post Employment Credentialing 10 Pre/Post Employment Background Checks 10 Pre/Post Employment EMS Credentialing 10 Pre/Post Employment Criminal History Record Background Checks 10, 11 Pre/Post Employment Driving Checks 11, 12 Pre/Post Employment Drug Testing 12, 13, 14 OIG Exclusions 14 Initial Hiring Process 14 Probationary Period 15 Orientation Training 15 Evaluation 16 Sexual Harassment 16, 17, 18, 19 Work Place Violence 19, 20 Employee Personnel Files 20 Medical and Dental Insurance 20, 21 Cobra Continuation 21 Illegal Drug Abuse/Alcohol Abuse 21, 22 Smoking 22 Employment Classification Categories 22, 23 General Employee Responsibilities 23, 24 Employee Contact Information 24 Paid Time Off/Leave Without Pay 24, 25 Scheduled PTO 25 Unscheduled PTO 26, 27 Reasons for Taking Leave 27, 28, 29, 30, 31, 32 Bereavement Leave 32, 33 Voting Time 33 Military Leave 33 Work Time Substitution 33, 34 5 Scheduling Availability 34, 35 Failure to Appear for Work 35 Employee Safety and Wellness 35 Return to Work after Serious Injury or Illness 35, 36 Employee Fitness for Duty Standard 36 Workplace Injuries/Workers Compensation 36, 37 Exposures to Pathogens 37 Progressive Disciplinary Process 37, 38, 39, 40 Termination Processing Procedures 40, 41 Separation of Employment 41 Return of Company Property upon Separation 41 Accrued PTO upon Separation 41 Health Care upon Separation 41 Eligibility for Rehire 42 Performance Appraisals 42 Compensation 42, 43 Job Descriptions 44, 45, 46, 47, 48, 49, 50, 51,52,53,54, 55, 56, 57, 58, 59, 60, 61, 62, 63 Workday 64 Payday 64 Employee Payroll Standards 64, 65 On-Call Scheduling 65 Pay Advances 65 Employee-Incurred Expenses Reimbursement 65 HIPAA Compliance 66 Compliance Policy Manuals 66 Confidentiality of Company Information 66, 67 Confidentiality of Company Electronic Information 67, 68, 69 Computer Usage Policy 69, 70 Conflict of Interest 70, 71 Outside Employment 71 Gratuities to Government Employees or Officials 71, 72 Gratuities to Customer or Supplier Representatives 72 Political Activities 72 Kitchen/Break Room 72 Visitors 72, 73 Office Status during Inclement Weather/Disaster Operation 73 6 `kf r4� H-1-Introduction 1. These policies and procedures outline numerous aspects of initiating and maintaining employment with North State Medical Transport. H-2-Continuity of Policies -Right to Change or Discontinue 1. The policies and procedures in this document are not intended to be contractual commitments by North State Medical Transport and employees shall not construe them as such. 2. Policies and Procedures are intended to be guides to management and merely descriptive of suggested procedures to be followed. 3. North State Medical Transport reserves the right to revoke, change, or supplement these guidelines at any time without notice. 4. Such changes shall be effective immediately upon approval by management unless otherwise stated. 5. No policy is intended as a guarantee of continuity of benefits or rights. 6. No permanent employment or employment for any term is intended or can be implied by statements in this manual. H-3-Confidentiality of Policies 1. The Policies and the information contained within should be treated as confidential. 2. No portion of this handbook should be disclosed to others, except North State Medical Transport employees and others affiliated with North State Medical Transport whose knowledge of the information is required in the normal course of business. H-4-Employment Openings 1. When a vacancy occurs, notification may occur through multiple avenues outlined in this document. 2. Positions will be posted by North State Medical Transport Human Resources Department. 3. Additional advertising may be accomplished at the direction and authorization of the Human Resources Department. 4. The human resources director shall publicize all established vacant positions. Such announcements must be directed toward all potential sources of applicants, including minorities, women, and the disabled. 5. Announcements used in recruitment must, at a minimum, include the title of the position, minimum salary,minimum qualifications, and an equal employment opportunity statement. 6. No employee shall post position openings without the approval of the North State Medical Transport human resources director. This includes postings to interne sites, 7 email lists, bulletin boards, fax lists, etc. 7. Employees are permitted at all times to make direct person-to-person notification of position vacancies. 8. Upon receipt of approved applications the North State Medical Transport Human Resources Department(or his/her designee) shall initiate the selection/development process. H-5-Employing of Full and Part-Time Positions 1. Whenever there is a determined need for additional employees, the North State Medical Transport Human Resources Department shall initiate the hiring process. H-6- Equal Employment Opportunity Statement NSMT provides equal employment opportunities (EEO)to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity, national origin, age, disability, genetic info Illation, marital status, amnesty or status as a covered veteran in accordance with applicable federal, state and local laws. NSMT complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including hiring, placement, promotion, termination, layoff, recall, transfer, leave of absences, compensation and training. NSMT expressly prohibits any form of unlawful employee harassment based on race, color, religion, gender, sexual orientation,national origin, age, genetic information, disability or veteran status. Improper interference with the ability of NSMT employees to perform their expected job duties is absolutely not tolerated. 11-7-Americans with Disabilities Act (ADA) and the ADA Amendments Act(ADAAA) The Americans with Disabilities Act(ADA) and the Americans with Disabilities Amendments Act, known as the ADAAA, are federal laws that prohibit employers with 15 or more employees from discriminating against applicants and individuals with disabilities and that when needed provide reasonable accommodations to applicants and employees who are qualified for a job, with or without reasonable accommodations, so that they may perform the essential job duties of the position. It is the policy of NSMT to comply with all federal and state laws concerning the employment of persons with disabilities and to act in accordance with regulations and guidance issued by the Equal Employment Opportunity Commission (EEOC). Furthermore, it is our company policy not to discriminate against qualified individuals with disabilities in regard to application procedures, hiring, advancement, discharge, compensation, training or other terms, conditions and privileges of employment. The company will reasonably accommodate qualified individuals with a disability so that they can perform the essential functions of a job unless doing so causes a direct threat to 8 these individuals or others in the workplace and the threat cannot be eliminated by reasonable accommodation and/or if the accommodation creates an undue hardship to NSMT. Contact the Human Resource department with any questions or requests for accommodation. 11-8-Recruitment 1. North State Medical Transport aggressively recruits to attract top caliber individuals. 2. Company positions may be filled by either transfer or promotion of existing employees or by new employees who are recruited or apply. 3. Recruitment may be conducted through advertising, employment agencies, schools, employee referrals or technical and trade referrals. Supervisors/managers should consider the most appropriate method of recruitment for filling departmental positions. 4. All recruitment shall be conducted in an ethical,professional and non-discriminatory manner. 5. North State Medical Transport provides equal employment opportunity to all applicants on the basis of demonstrated ability, experience, and training. H-9-Employee Selection and Development 1. North State Medical Transport provides equal opportunity to all applicants on the basis of demonstrated ability, experience,training, and potential. 2. Qualified persons are selected without prejudice or discrimination as stated in the company's equal opportunity policy. 3. The employment recruitment, initiated by the HR manager,will define the job-related tasks and qualifications necessary to assume and maintain the position. 4. The defined tasks and stated qualifications will be the basis for screening applications. 5. The supervisor/manager will conduct structured initial interviews limited to job-related questions to assess each candidate's experience, demonstrated ability and training. 6. The telephone may be used for these initial interviews. 7. Recruiting is only one part of continued employee development,which is a five-part process designed to help retain good workers. H-10-Interviewing 1. Interviewing can involve a variety of factors: A. Telephone screening to determine if candidates meet the job description B. Initial one-on-one interviews C. Follow-up interviews with peers D. Checking references,backgrounds, qualifications and eligibility. E. Gaining the consensus of interviewers to hire or not to hire 9 H-11-Pre/Post Employment Credentialing 1. Employment is contingent upon certain job-related factors, such as obtaining and maintaining specific state or federal license and credential. 2. The responsibility for maintaining these credentialing lies entirely with the employee 3. Any lapse in valid credentialing is subject to the disciplinary process up to and including termination. 4. Any falsification or concealment of loss of credentialing is a basis for termination 11-12-Pre/ Post - Employment Background Checks Various background Checks will be conducted on all applicants for employment to follow state and federal laws, and to ensure the highest degree of safety for our personnel and patients by adequately screening the background of our personnel North State Medical Transport shall perform all necessary background checks, including criminal history, child or elder abuse history, driving record, and other required background checks prior to any service performed by a potential employee. Each employee must satisfactorily complete the background check process prior to performing any services. H-13-Pre-Post- EMS Credentialing 1. Each Applicant for employment must provide proof of a valid North Carolina EMS Certification and AHA CPR certification. 2. These certifications must remain up to date during employment with North State Medical Transport. 3. Any laps in certifications may result in disciplinary action up to and including dismissal. 4. It is the sole responsibility of the employee to maintain all EMS credentials required for employment. 5. The North State Compliance Officer must be notified any time there is a potential laps in mandatory credentials. H-14-Pre/Post- Criminal History Record Background Checks 1. Each applicant for employment must provide necessary information required for the necessary regional state or federal criminal background check form. 2. Each applicant shall also complete a background check authorization form. 3. Applicants will not be eligible for employment until the results of the background check are received. 4. If a criminal history record check indicates that a potential employee has been convicted (including any crime that is relevant when considering employment, he or she may not be I0 eligible for employment. Additionally, any employee who is later convicted of a crime may be subject to disciplinary action up to and including termination. (Convictions for offenses will not necessarily preclude employment, but will be considered in making employment decisions based on the relevance of the conviction to the work performed). 5. If the criminal background check returns with a record of a conviction that is relevant to preclude employment, the applicant will receive notice that he or she is precluded from employment because of the results of the criminal background check. 6. Any applicant for employment who does not cooperate with the criminal history records check process will not be considered for employment. 7. Each applicant for employment shall provide a criminal background history. 8. Convictions will be considered based on factors that relate to suitability for employment in the position applied for, including the type and severity of the crime, and when the conviction occurred. 9. North State Medical Transport may periodically request that additional criminal background checks occur throughout the term of employment. 10. Full cooperation with such periodic checks is expected, and failure to cooperate will result in discipline up to and including dismissal. 11. All personnel have an ongoing obligation to disclose to North State Medical Transport any convictions during their employment. 12. Personnel who fail to make such a disclosure will be subject to appropriate disciplinary action. H-15-Pre/Post- Employment Driving Checks All current and prospective and current driver/attendant employees must meet the minimum driving requirements of North State Medical Transport. Additional requirements are provided in the initial employee handbook titled Motor Vehicle Record (MVR)Notice 1. 2. These requirements are as follows: A. Employees must have a valid North Carolina Drivers License. North Carolina DMV law requires anyone who establishes a permanent residence in the State are required to have a NC Drivers License within 60 days [NC General Statutes § 20-7. [Issuance and renewal of driver's license]]. Any employee holding a license from another state other than North Carolina is required to provide North State Medical Transport valid driving record documentation from the issuing state prior to employment. B. Prospective employee applicants must submit a current seven year driving history with their employment application. This can be obtained from the North Carolina Department of Motor Vehicles. C. Full time employees are subject to an annual review of their driving history. D. Additional reviews may be conducted if warranted. E. North State Medical Transport employee/drivers and applicants must be a minimum of 21 years of age to meet North State Medical Transport minimum driving requirements. F. Employees must have emergency vehicle operation training. This training is currently 11 part of current DOT/NHTSA-EMT standard curriculum. G. Any employee who is charged with a moving violation must inform North State Medical Transport administrative staff of each charge. H. Employees must also inform the administrative staff of the outcome of such charges; i.e. convictions, prayer for judgments, and/or dismissals. I. The following are examples and are not all inclusive: a) Driver's license has been suspended or revoked. b) Is no longer eligible to obtain a valid Driver's license. c) Has been involved in 1 or more at-fault accidents in three years. d) Has been convicted of Driving While Impaired. e) Has violated North State Medical Transport policies concerning use of or possession of intoxicants or controlled substances f) Is experiencing a mental or physical condition that adversely affects their ability to drive 3. Any employee who is convicted by the Court System of Driving While Impaired, shall have their employment terminated upon such conviction 4. Any employee who is convicted by the Court System for traffic offenses shall be subject to sanctions or disciplinary action up to and including termination 5. Any falsification or concealment of loss of credentialing is a basis for termination 6. Failure to comply with these requirements may lead to denial of employment for prospective employees or disciplinary action up to and including dismissal for current employees of North State Medical Transport. H-16-Pre-Employment Drug Testing All candidates who have received a preliminary offer of employment will be required to undergo testing for commonly-abused controlled substances. 1. Substances Covered By Drug/Alcohol Testing Candidates will be tested for their use of commonly-abused controlled substances, including, but not limited to: Amphetamines, Barbiturates, Benzodiazepines, Opiates, Cannabinoids, Cocaine, Methadone, Methaqualone, Phencyclidine (PCP), Propoxyphene, and chemical derivatives of these substances Candidates must advise the testing lab of all prescription drugs taken in the past month before the test, and to be prepared to show proof of such prescription to testing lab personnel. 12 2. Testing Methods and Procedure All testing will be conducted by a licensed independent medical laboratory, which will follow established testing standards. Testing will be conducted on a urine sample provided by the candidate to the testing laboratory under procedures established by the laboratory to insure privacy of the employee, while protecting against tampering/alteration of the test results. North State Medical Transport will pay for the upfront cost of the testing. The testing lab will retain samples in accordance with State law, so that a candidate may request a retest of the sample at his/her own expense if he or she disagrees with the test result. North State Medical Transport will recoup the cost of drug testing from the employees first pay check. If the employee does not maintain an employment period of greater than 90 days North State Medical Transport will retain the payment deducted for testing. If employment last for a period greater than 90 days the cost of drug testing will be reimbursed to the employee following the 90 day period. 3. Refusal to Undergo Testing Candidates who refuse to submit to a drug test or who fail to show up for a drug test will no longer be considered for employment. 4. Positive Test If a candidate tests positive on an initial screening test, the employment offer will be formally withdrawn and the candidate will be provided with a copy of the test results. 5. Right to Explain Test Results All Candidates has the right to meet with the testing laboratory personnel, and with the Company, to explain their test results. These discussions shall be considered confidential except that infoimation disclosed in such tests will be communicated to personnel within NSMT or within the Lab who need to know such information in order to make proper decisions regarding the test results or regarding the employment of the individual. 6. Right to Review Records North State Medical Transport will only provide a copy of test results to candidates who test positive. 7. Confidentiality Requirements All records concerning test results will be kept in medical files which are maintained separately from North State Medical Transport personnel files. Testing laboratories may conduct testing only for substances included on the disclosure list f; 13 provided to the individual, and may not conduct general testing related to the medical conditions of the individual which are unrelated to drug usage. 8. Re-testing Candidates may request a retest of their positive test, within five (5)working days after notification by North State Medical Transport of such positive test result. This retest is at the expense of the individual,unless the original test result is called into question by the retest. 9. Re-Application and Rehire North State Medical Transport understands that individuals who are rehabilitated drug users or engaged in a supervised drug rehabilitation program and are no longer using drugs are protected under the Americans with Disabilities Act. Therefore, North State Medical Transport will consider the applications of candidates who formerly tested positive for drugs if candidates can subsequently show evidence of rehabilitation. H-17 - OIG Exclusions: 1. The Department of Health and Human Services, Office of Inspector General (OIG) reports those individuals or organizations that have been excluded from participating in federal health care programs. 2. Those on the excluded list are not permitted to provide services that will be billed to a federal health care program (such as treating Medicare/Medicaid patients) and are not permitted to be involved in billing or related functions. 3. As part of its application process,North State Medical Transport will search the OIG database for possible applicant exclusion. Exclusion from any federal health care program constitutes grounds for disqualification of employment/membership. 4. North State Medical Transport will conduct periodic re-checks of the OIG exclusion database. In the event that a current employee is found to appear on the exclusion list, employment with North State Medical Transport will be terminated. H-18-Initial Hiring Process 1. Once the manager has made a decision to make the offer and has confirmed key terms, the next step involves making the verbal offer culminating in the employee's first day as a member of the North State Medical Transport team. 2. After candidate interviews, verification of employment history and reference inquiries, the Operations Director is responsible for the employment offer. 3. After the verbal offer has been made and the candidate has agreed to the essential terms of the offer(typically the position, employee classification, salary or rate, and the starting date) the employee will be placed in the available position for that employee. 4. This verbal offer must never express or imply that employment is "permanent," "long- term," of a specific duration, or words of similar meaning. An exception may be made where a temporary position of known duration is to be filled. 5. After the candidate has accepted his/her preliminary employment offer, she or he will be 14 required to provide documentation of identity and employment eligibility in accordance with federal law. Form I-9, shall be used for this purpose. H-19-Probationary Period 1. All new employees undergo a 90 day probationary period which begins on the first full day of employment. 2. During the probationary period NSMT will have the opportunity to determine the employee's suitability for the position for which he or she was employed. 3. All probationary employees who incur two or more unexcused absences during the initial 90-day probationary period will have his/her employment terminated. 4. If the employee's performance is not satisfactory, his or her employment maybe tei iiinated at any time during their probationary period. 5. If the employee's job performance during their initial 90 probationary period has not been satisfactory but discharge is not justified,the probationary period may be extended for up to 90 calendar days. 6. Counseling sessions will be held between NSMT and the employee during this extended 90 day probationary period. 7. All counseling sessions with an employee during a probationary period will be documented with copies of the records placed in the employee's permanent personnel file. 8. At the conclusion of an extended probationary period, the employee will be re-evaluated and his or her employment either will be terminated or will be continued subject to performance. 9. During this period a probationary employee will not be eligible to earn PTO. 10. Once released from a probationary period employees will begin accrual of PTO as outlined in NSMT Policy titled-Paid Time Off I Leave Without Pay I' 11-20-Orientation Training 1. All new employees will be provided with an orientation packet,which will be held within their first week of employment with the company. 2. The orientation is designed to acquaint the new employee with the company and its policies. Supervisors/managers will be responsible for ensuring the attendance of new employees at the company orientation sessions. 3. Orientation will include Compliance training on HIPAA, Documentation and BBP. For a more detailed overview please refer to the North State Medical Transport Compliance Training Manual 4. Upon hire employees will be provided an electronic copy of the NSMT: A. NSMT Policies and Procedures Manual B. NSMT Compliance Policies Manual C. HIPAA Policies Manual D. NSMT Code of Conduct E. NSMT BBP 15 F. Employment Documents G. ACA and Health Care Information H-21-Evaluation 1. Giving constructive feedback at various times during the employment relationship is the final stage of the employment development process. 2. New and existing employees will be provided with feedback at different times during the year. 3. Supervisors/managers will provide the following: A. Annual performance reviews for all employees. H-22-Sexual Harassment North State Medical Transport has a zero tolerance policy and will not allow any foiin of sexual harassment within the work environment. Sexual harassment interferes with work performance and creates an intimidating,hostile or offensive work environment. Sexual harassment influences or tends to affect the career, salary, working conditions, responsibilities, duties or other aspects of career development of an employee or prospective employee; or creates an explicit or implicit term or condition of an individual's employment. It will not be tolerated. Sexual harassment, as defined in this policy, includes, but is not limited to, sexual advances, verbal or physical conduct of a sexual nature, visual foiiiis of a sexual or offensive nature (e.g., signs and posters) or requests for sexual favors. Any intentional sexual harassment is considered to be gross misconduct and a major violation of company policy. Any employee/s found to be involved in any such activity will be terminated. Sexual harassment is unwanted sexual attention of a persistent or offensive nature made by a person who knows, or reasonably should know, that such attention is unwanted. Sexual harassment includes sexually oriented conduct that is sufficiently pervasive or severe to unreasonably interfere with an employee's job perfoiuiance or create an intimidating,hostile or offensive working environment. Sexual harassment can be physical and/or psychological in nature. An aggregation of a series of incidents can constitute sexual harassment even if one of the incidents considered on its own would not be harassing. Employees are prohibited from harassing other employees whether or not the incidents of harassment occur on employer premises and whether or not the incidents occur during working hours. While sexual harassment encompasses a wide range of conduct, some examples of specifically prohibited conduct include: A. Physical assaults of a sexual nature, such as rape, sexual battery, molestation or attempts to commit these assaults, and intentional physical conduct that is sexual in nature, such as touching, pinching, patting, grabbing,brushing against another employee's body or poking another employee's body. 16 B. Unwanted sexual advances, propositions or other sexual comments, such as sexually oriented gestures, noises, remarks,jokes, or comments about a person's sexuality or sexual experience (especially when directed at or made in the presence of any employee who indicates or has indicated in any way that such conduct in his or her presence is unwelcome). C. Preferential treatment or promises of preferential treatment to an employee for submitting to sexual conduct, including soliciting or attempting to solicit any employee to engage in sexual activity for compensation or reward. D. Subjecting, or threats of subjecting, an employee to unwelcome sexual attention or conduct or intentionally making performance of the employee's job more difficult because of that employee's sex. E. Sexual or discriminatory displays or publications anywhere in NSMT's workplace by the NSMT employees, such as: F. Displaying pictures, posters, calendars, graffiti, objects, promotional materials, reading materials or other materials that are sexually suggestive, sexually demeaning or pornographic, or bringing into the [Company Name] work environment or possessing any such material to read, display or view at work. A picture will be presumed to be sexually suggestive if it depicts a person of either sex who is not fully clothed or in clothes that are not suited to or ordinarily accepted for the accomplishment of routine work in and around the workplace and/or who is posed for the obvious purpose of displaying or drawing attention to private portions of his or her body. G. Reading or otherwise publicizing in the work environment materials that are in any way sexually revealing, sexually suggestive, sexually demeaning or pornographic. H. Displaying signs or other materials purporting to segregate an employee by sex in any area of the workplace (other than restrooms and similar semi-private lockers/changing rooms). Retaliation for sexual harassment complaints, such as A. Disciplining, changing work assignments of, providing inaccurate work information to, or refusing to cooperate or discuss work-related matters with any employee because that employee has complained about or resisted harassment, discrimination or retaliation. B. Intentionally pressuring, falsely denying, lying about or otherwise covering up or attempting to cover up conduct such as that described in any item above. 1. Responsibilities Employees If employees believe that they have been subject to sexual harassment or any unwanted sexual attention, they should make their unease and/or disapproval directly and immediately known to the harasser whenever possible. If the situation is not immediately resolved or if the employee is unable to or uncomfortable to address the alleged harasser directly, he or she should report the incident to the employee's manager, human resources or his or her own 17 I,, supervisor. It may be helpful to make a written record of the date, time and nature of the incident(s) and the names of any witnesses. It is important to report concerns of sexual harassment or inappropriate sexual conduct regardless of the seriousness to human resources or a supervisor/manager as soon as possible. Management cannot assist in stopping the harassment from continuing if it is unaware of the problem. Publicizing information about alleged harassment without following the reporting procedures might be considered evidence of a vexatious intent on part of the accuser. Supervisors Supervisors must deal expeditiously and fairly with allegations of sexual harassment within their departments whether or not there has been a written or formal complaint. Supervisors must: A. Take all complaints or concerns of alleged or possible harassment or discrimination seriously no matter how minor or who is involved. B. Ensure that harassment or inappropriate sexually oriented conduct is reported to human resources immediately so that a prompt investigation can occur. C. Take any appropriate action to prevent retaliation or prohibited conduct from reoccurring during and after any investigations or complaints. D. Supervisors who knowingly allow or tolerate sexual harassment or retaliation are in violation of this policy and subject to the disciplinary process. Human Resources Human resources are responsible for: A. Ensuring that both the individual filing the complaint (hereafter referred to as the complainant) and the accused individual(hereafter referred to as the respondent) are aware of the seriousness of a sexual harassment complaint. B. Explaining employer's sexual harassment policy and investigation procedures to the complainant and the respondent. C. Exploring infoii►ial means of resolving sexual harassment complaints. D. Notifying the police if criminal activities are alleged. E. Arranging for an investigation of the alleged harassment and the preparation of a report. 2. Resolution Procedures Incidents of sexual harassment or inappropriate sexually oriented conduct should be reported following the above complaint procedures. To initiate a formal investigation into an alleged violation of this policy, employees will often be asked to provide a written sexual harassment complaint with human resources. Complaints should be submitted as soon as possible after an incident of alleged sexual harassment. To ensure the prompt and thorough investigation of a sexual harassment complaint, the complainant should provide as much of the following information as is possible: 18 A. The name and position of the person or persons allegedly causing the harassment. B. A description of the incident(s), including the date(s), location(s) and the presence of any witnesses. C. The names of other employees who might have been subject to the same or similar harassment. D. The steps the complainant has taken to try to stop the harassment. E. Any other information the complainant believes to be relevant to the harassment complaint. 3. Discipline If an investigation results in a finding that this policy has been violated,the employee will be termination.Persons who violate this policy also may be subject to civil damages or criminal penalties. 4. Confidentiality All inquiries, complaints and investigations are treated confidentially. Information is revealed strictly on a need-to-know basis. Information contained in a formal complaint is kept as confidential as possible. However,the identity of the complainant usually is revealed to the respondent and witnesses. The manager of human resources takes adequate steps to ensure that the complainant is protected from retaliation during the period of the investigation. All information pertaining to a sexual harassment complaint or investigation is maintained by the human resources in secure files.Human resources can answer any questions relating to the procedures for handling infoimation related to sexual harassment complaints and investigations to complainants and respondents. This policy do not preempt or supersede any legal procedures or remedies otherwise available to a victim of sexual harassment under state or federal law. 5. Administration This policy will be administered through human resources. H-23-Work Place Violence North State Medical Transport maintains a zero tolerance in regards to workplace intimidation or violence. Any employee found to be involved in any such activity will be immediately is terminated. Incidents of intimidation or work place violence should be reported to a supervisor or any member of management immediately. Law enforcement should be called in any situation where an employee feels themselves or other staff is threatened or in danger. To initiate a formal investigation into an alleged violation of this policy, employees will often be asked to provide a written complaint with human resources. Complaints should be submitted as soon as possible 19 after an incident of alleged intimidation or work place violence. To ensure the prompt and thorough investigation of an intimidation or work place violence complaint, the complainant should provide as much of the following information as is possible: A. The name and position of the person or persons allegedly causing the incident. B. A description of the incident(s), including the date(s), location(s) and the presence of any witnesses. C. The names of other employees who might have been subject to the same or similar intimidation or work place violence t. D. Any other information the complainant believes to be relevant to the intimidation or work place violence complaint. H-24-Employee Personnel Files Employee files are maintained by the Human Resource department and are considered confidential. Managers and supervisors may only have access to personnel file infoimation on a need-to-know basis. Personnel fills may be reviewed by the HR Department and Compliance Officer when warranted in accordance with privacy laws. Personnel file access by current employees and former employees upon request will generally be permitted within 10 days of the request unless otherwise required under state law. Personnel files are to be reviewed in the Human Resource department. Personnel files may not be taken outside the department. Representatives of government or law enforcement agencies, in the course of their duties,may be allowed access to file information. H-25-Medical and Dental Insurance The company currently offers regular full-time employees regularly scheduled to work a minimum of 36 hours per week enrollment in medical and dental insurance coverage options after they have been employed for 90 days. Employees have up to 60 days from their date of hire to make medical and dental plan elections. Once made, elections are fixed for the remainder of the plan year. Changes in individual and family status may allow and employee to make changes in coverage consistent with qualifying events outlined in the healthcare section of the employee hire information packet. Coverage may be voluntarily terminated at any point unless subject to mandatory coverage resulting from a court judgment. In the case of court ordered coverage for a spouse or dependent the employee must maintain employee coverage in order to cover spouse and/or dependents. Please contact the Human Resource department to determine if a family status change qualifies under the Plan document and IRS regulations. During the annual open enrollment period employees may change medical and dental elections for the following calendar year. 20 For Detailed information regarding Health and Dental please refer to Information found in your NSMT Employee Packet The Human Resource department is available to answer benefits plan questions and assist in answering questions, enrollment or plan election changes. H-26-Cobra Continuation North State Medical Transport has retained Ceridian COBRA Continuation Services to administer its COBRA continuation group health insurance program. For Detailed information Regarding Cobra please refer to Cobra Continuation Information found in your NSMT Employee Packet H-27-Illegal Drug Abuse/Alcohol Abuse 1. This policy is implemented because we believe that the impairment of any North State Medical Transport employee due to his or her use of illegal drugs or due to alcohol abuse is likely to result in the risk of injury to other employees, the impaired employee, or to third parties, such as customers or business guests. Moreover illegal drug abuse adversely affects employee morale and productivity. 2. "Impairment" or"being impaired"means that an employee's noiinal physical or mental abilities or faculties while at work have been detrimentally affected by the use of illegal drugs or alcohol. 3. Any employee who begins work while impaired or who becomes impaired while at work is guilty of gross misconduct and a violation of company policy and is subject to severe disciplinary action. Severe disciplinary action can include suspension, dismissal, or any other penalty appropriate under the circumstances. Likewise the use, possession,transfer, or sale of any illegal drugs on company premises or in any North State Medical Transport area is prohibited. 4. Employees who violate this rule are subject to severe disciplinary action up to and including termination. In all instances disciplinary action to be administered shall be at the sole discretion and determination of the company. 5. When an employee is involved in the use,possession,transfer, or sale of illegal drugs in violation of this policy, the company may notify appropriate authorities. Such notice will be given only after such an incident has been investigated and reviewed by the employee's supervisor and the personnel director. 6. North State Medical Transport is aware that illegal drug abuse is a complex health problem that has both physical impact and an emotional impact on the employee,his or her family, and social relationships. 7. A drug abuser is a person who uses illegal drugs, as defined above, for non-medical reasons, and this use affects job perfotmance detrimentally or interferes with nolival social intercourse at work. Illegal drug abuse is both a management and a medical 21 problem. 8. A manager who suspects a drug or alcohol abuse case should discuss the situation immediately with his or her supervisor/manager. Because each case is usually different, the handling and referral of the case must be coordinated with the supervisor/manager and the personnel director. 9. Management has chosen to adopt an alcoholic beverage policy in keeping with the concern for and the risks associated with alcohol use. Alcoholic beverages shall not be served or used on the North State Medical Transport premises at any time. Alcoholic beverages shall not be used in conjunction with any company business meeting. 10. Social activities held off-premises and paid for on a personal basis are not affected by this policy. 11. The company is concerned with its employee's privacy, especially when matters regarding medical and personal information are involved. As long as the infoiniation is not needed for police or security purposes, the company shall maintain employee medical and personal information in confidence and release this infoiination to authorized company personnel on a"need to know"basis. 12. An exception to this policy is when the employee signs a release for the transfer of such information on forms acceptable to the company to designated persons or agencies. Nothing contained in this section shall eliminate or modify the company's right to terminate any employee at any time for any reason. H-28-Smoking Smoking at work is highly discouraged but will be allowed only in designated areas. No smoking will be allowed in the office area at any time. No Smoking will be allowed in any North State Medical Transport vehicle at any time. This policy is for the health and safety of all employees. H-29-Employee Classification Categories All employees are designated as either nonexempt or exempt under state and federal wage and hour laws. The following is intended to help employees understand employment classifications and employees' employment status and benefit eligibility. These classifications do not guarantee employment for any specified period of time. The right to tei ininate the employment-at-will relationship at any time is retained by both the employee and NSMT. Nonexempt employees are employees whose work is covered by the Fair Labor Standards Act (FLSA). They are NOT exempt from the law's requirements concerning minimum wage and overtime. Exempt employees are generally managers or professional, administrative or technical staff who ARE exempt from the minimum wage and overtime provisions of the FLSA. Exempt employees hold jobs that meet the standards and criteria established under the FLSA by the U.S. Depatlment of Labor. NSMT has established the following categories for both nonexempt and exempt employees: 22 1. Regular, full time: Employees who are not in a temporary status and who are regularly scheduled to work the company's full-time schedule of 36 hours per week. Generally, these employees are eligible for the full benefits package, subject to the terms, conditions and limitations of each benefits program. 2. Regular,part time: Employees who are not in a temporary position but works less than 30 hours a week on either a regularly scheduled basis or on an irregular basis. 3. Temporary,full time: Employees who are hired as interim replacements to temporarily supplement the workforce or to assist in the completion of a specific project and who are temporarily scheduled to work the company's full-time schedule for a limited duration. Employment beyond any initially stated period does not in any way imply a change in employment status. 4. Temporary,part time: Employees who are hired as interim replacements to temporarily supplement the workforce or to assist in the completion of a specific project and who are temporarily scheduled to work less than the company's full-time schedule for a limited duration. Employment beyond any initially stated period does not in any way imply a change in employment status. Temporary workers are not eligible for company benefits unless specifically stated otherwise in company policy or are deemed eligible according to plan documents. ti H-30- General Employee Responsibilities 1. Employees are required to report to work at their assigned time and at their assigned station. 2. Employees should be in unifoim and ready to respond at the assigned shift change time and are unable to relieve others until they are in uniform. 3. Employees should remain ready to respond according to operational policies throughout their respective shift. 4. Employees shall notify management staff immediately should they for any reason be unable to respond. 5. Any employee arriving at their assigned station after the designated start of their shift shall be subject to See: Policy Paid Time Off/Leave Without Pay 6. Failure to report for work on time is addressed in: See: Policy Paid Time Off/Leave Without Pay. 7. Employees may be reassigned to a different duty location at anytime and are responsible for reporting in a timely manner. 8. Employees may be reassigned to a different shift in order to maintain a manpower resource balance between the shifts. 9. North State Medical Transport employees who desire employment outside of North State Medical Transport are required to submit to the director a written request prior to beginning the outside employment. 10. Outside employment is defined as any work undertaken North State Medical Transport employees, either for another agency, person, or self 23 11. Approved off-duty employment requests are only valid for 1 year and must be updated annually. H-31- Employee Contact Information 1. Employees are required to maintain the following information with North State Medical Transport: A-Primary phone number B-Secondary phone number, when available C-Mailing address information D-Emergency contact(for at least one individual) E-Email Address 2. NSMT shall be made aware of any changes to the employee information at the beginning of that employee's next regular shift. 3. Crew Scheduler should be updated with any pertinent changed information as soon as the employee is aware of the change. 4. North State Medical Transport requires employees to maintain some form of working telephone access. 5. North State Medical Transport expects employees to respond to phone messages as soon as possible when left by a company representative. H-32-Paid Time Off/Leave Without Pay For the purpose of this policy, holiday time and sick leave will be synonymous with PTO 1. Probationary Period A. All employees upon hire will be subject to a 90 day probationary period. During this period a probationary employee will not earn PTO for the first 90 days of employment. B. Once released from a probationary status an employee will accrue PTO as outlined below. 2. Accrual A. Employees accrue paid leave, paid time off(PTO), on a monthly basis. PTO will be added to an employee's time bank on the last pay period of each month and may be used for scheduled or unscheduled absences. B. PTO, for the first twelve (12) months, will be accrued at a rate of 5.75 hours per month(one-half day/month) C. All full-time employees will begin accumulating leave based on their anniversary date. Full-time employees will be allowed to accrue leave with no annual limit; 24 however, leave requests for time periods greater than one week shall be subject to approval. D. When an employee reaches his/her one(1) year anniversary, he/she will begin accruing PTO at a rate of 11.5 hours per month(one full day/month). 3. Accrued PTO will be paid in the last paycheck unless; A. The employee resigned and did not give and/or work a full two weeks' notice. B. The employee was terminated due to reasons of Gross Misconduct such as but not limited to: a) Sexual Harassment b) Intimidation, Workplace Violence or Harassment c) Criminal Offences: d) Loss of essential job specific credentials. ( Certification, Driving Privileges ) e) Loss of the ability to participate in federal healthcare programs. ( OIG Exclusion) f) Fraudulent Activity g) Loss of his/her ability to operate as a Technician by the Local Medical Director or State of North Carolina. h) Patient mistreatment i) Intentional false statements, j) Disregard for the wellbeing, safety or rights of others. These examples are not all inclusive. 11-33-Scheduled PTO 1. Employees should have sufficient time accumulated prior to requesting PTO. 2. Requests for PTO should be posted on Crew Scheduler; the date and time stamp of PTO requests submitted to Crew Scheduler will serve as the variable by which priority for coverage is assigned—first come, first served. If necessary, employee seniority will be used to determine any ties for PTO requests. 3. Scheduled PTO request must be submitted as soon as possible but no later than(3)weeks before the desired date off. 4. PTO will be granted based on staff availability to fill the open slot. 5. If an employee fails to request PTO at least(3)weeks from the desired date(s)requested, the employee is responsible for finding coverage for his/her shifts via work time substitution with another full time employee. 6. When coverage is granted for requested PTO, it will be reflected on Crew Scheduler via an explanation in the PTO or work time substitution request notes. 7. The employee is responsible for ensuring his/her PTO is covered prior to the requested date and before failing to report for a scheduled shift. 25 (' H-34-Unscheduled PTO 1. Unscheduled PTO, a"call-out," is defined as any absence that is not prearranged 2. An unscheduled absence period will be defined as any non prearranged absence during a consecutive given period of time 3. This policy applies to full-time and part-time employees alike. 4. Call-outs should be requested as soon as the employee feels they are unable to work. This "call-out"time should be at least two (2) hours before the employee's scheduled shift time. 5. It is the expectation that employees or their designee speak with a member of dispatch or management staff and not merely leave a voicemail. 6. It is acceptable to have another individual contact appropriate NSMT staff should you be incapacitated beyond the ability to do so yourself. 7. For any"call-out," the employee or their designee that is missing work should call the on-duty dispatcher (919.261.8911), who will fill out an absentee form for the employee's personnel file. 8. The on-duty dispatcher will then call to notify the member of management when"call outs" occur. 9. If the paramedic who is on-duty needs to leave due to illness or the next paramedic on- duty is "calling out" for a shift, at least one (1)member of management needs to be notified in order to attempt to fill the ALS shift. 10. Employees requesting unscheduled PTO may be queried as to the cause of the request and the expected duration they will be unable to report to work. 11. If out of work for greater than one (1) work day due to illness a doctor's note may be required. 12. North State Medical Transport has a no fault absence policy. This policy is based on the following points system. 13. The Attendance Point System will accrue as follows: Attendance Points The threshold will be 12 points in a rolling 12 month period with point remaining on record for 1 year from the date of the infraction before disappearing. • 0.5 points for Late Clock In • 1.5 point for standard Call-out from scheduled shift • 3.0 points for Call-outs on a day that was denied PTO • 12 points for a No Call/No Show without due reason 8.0 points will result in a verbal warning. 10.0 points will result in a written warning. 12.0 points, will result in termination. 14. An absence will be defined as any given consecutive period of unscheduled missed work 26 that does not meet one of the approved categories below or are subject to ADA guidelines when applicable. H-35-Reasons for Taking Leave 1.FMLA The function of this policy is to provide employees with a general description of their FMLA rights. In the event of any conflict between this policy and the applicable law, employees will be afforded all rights required by law. If you have any questions, concerns or disputes with this policy, you must contact Bryan Perry 919-210-1172 bperry @nsmt.biz in writing. General Provisions Under this policy,NSMT will grant up to 12 weeks(or up to 26 weeks of military caregiver leave to care for a covered service member with a serious injury or illness) during a 12-month period to eligible employees. The leave may be paid, unpaid or a combination of paid and unpaid leave, depending on the circumstances of the leave and as specified in this policy. Eligibility To qualify to take family or medical leave under this policy,the employee must meet the following conditions: 1. The employee must have worked for the company for 12 months or 52 weeks. The 12 months or 52 weeks need not have been consecutive. Separate periods of employment will be counted,provided that the break in service does not exceed seven years. Separate periods of employment will be counted if the break in service exceeds seven years due to National Guard or Reserve military service obligations or when there is a written agreement, including a collective bargaining agreement, stating the employer's intention to rehire the employee after the service break. For eligibility purposes, an employee will be considered to have been employed for an entire week even if the employee was on the payroll for only part of a week or if the employee is on leave during the week. 2. The employee must have worked at least 1,250 hours during the 12-month period immediately before the date when the leave is requested to commence. The principles established under the Fair Labor Standards Act(FLSA) determine the number of hours worked by an employee. The FLSA does not include time spent on paid or unpaid leave as hours worked. Consequently, these hours of leave should not be counted in determining the 1,250 hours eligibility test for an employee under FMLA. 3. The employee must work in a work site where 50 or more employees are employed by the company within 75 miles of that office or work site The distance is to be calculated- by using available transportation by the most direct route. 27 Type of Leave Covered To qualify as FMLA leave under this policy, the employee must be taking leave for one of the reasons listed below: 1. The birth of a child and in order to care for that child. 2. The placement of a child for adoption or foster care and to care for a newly placed child. 3. To care for a spouse, child or parent with a serious health condition(Under the FMLA, a "spouse"means a husband or wife as defined under the law in the state where the employee resides, including same-sex marriages in states that legally recognize such civil unions). 4. The serious health condition(described below) of the employee. 5. An employee may take leave because of a serious health condition that makes the employee unable to perform the functions of the employee's position. 6. A serious health condition is defined as a condition that requires inpatient care at a hospital, hospice or residential medical care facility, including any period of incapacity or any subsequent treatment in connection with such inpatient care or as a condition that requires continuing care by a licensed health care provider. A. This policy covers illnesses of a serious and long-term nature, resulting in recurring or lengthy absences. Generally, a chronic or long-term health condition that would result in a period of three consecutive days of incapacity with the first visit to the health care provider within seven days of the onset of the incapacity and a second visit within 30 days of the incapacity would be considered a serious health condition. For chronic conditions requiring periodic health care visits for treatment, such visits must take place at least twice a year. B. Employees with questions about what illnesses are covered under this FMLA policy are encouraged to consult with the Human Resource manager. C. If an employee takes PTO for a condition that progresses into a serious health condition NSMT may designate all or some portion of related leave taken as leave under this policy, to the extent that the earlier leave meets the necessary qualifications. 7. Qualifying exigency leave for families of members of the National Guard or Reserves or of a regular component of the Armed Forces when the covered military member is on covered active duty or called to covered active duty. 28 A. An employee whose spouse, son, daughter or parent has been notified of an impending call or order to covered active military duty or who is already on covered active duty may take up to 12 weeks of leave for reasons related to or affected by the family member's call-up or service. The qualifying exigency must be one of the following: a) short-notice deployment, b)military events and activities, c) child care and school activities, d)financial and legal arrangements, e) counseling, f)rest and recuperation, g)post-deployment activities, and h) additional activities that arise out of active duty,provided that the employer and employee agree, including agreement on timing and duration of the leave. 8.Covered active duty means: A. In the case of a member of a regular component of the Aimed Forces, duty during the deployment of the member with the Armed Forces to a foreign country. B. In the case of a member of a reserve component of the Armed Forces, duty during the deployment of the member with the Aimed Forces to a foreign country under a call or order to active duty under a provision of law referred to in Title 10 U.S.C. §101(a)(13)(B). 9. The leave may commence as soon as the individual receives the call-up notice. (Son or daughter for this type of FMLA leave is defined the same as for child for other types of FMLA leave except that the person does not have to be a minor.)This type of leave would be counted toward the employee's 12-week maximum of FMLA leave in a 12- month period. A. Military caregiver leave(also known as covered service member leave)to care for an injured or ill service member or veteran. B. An employee whose son, daughter,parent or next of kin is a covered service member may take up to 26 weeks in a single 12-month period to take care of leave to care for that service member. 10.Next of kin is defined as the closest blood relative of the injured or recovering service member. 11. The teen covered service member means: A. A member of the Armed Forces (including a member of the National Guard or Reserves)who is undergoing medical treatment,recuperation or therapy or is otherwise in outpatient status, or is otherwise on the temporary disability retired list, for a serious injury or illness. B. A veteran who is undergoing medical treatment,recuperation or therapy for a serious injury or illness and who was a member of the Armed Forces (including a member of the National Guard or Reserves) at any time during the period of five years preceding 29 is fi the date on which the veteran undergoes that medical treatment, recuperation or therapy. 12. The term serious injury or illness means: A. In the case of a member of the Armed Forces (including a member of the National Guard or Reserves), an injury or illness that was incurred by the member in line of duty on active duty in the Armed Forces (or that existed before the beginning of the member's active duty and was aggravated by service in line of duty on active duty in the Armed Forces) and that may render the member medically unfit to perform the duties of the member's office, grade, rank or rating. B. In the case of a veteran who was a member of the Armed Forces (including a member of the National Guard or Reserves) at any time during a period when the person was a covered service member, a qualifying (as defined by the Secretary of Labor) injury or illness that was incurred by the member in line of duty on an active duty in the Armed Forces (or that existed before the beginning of the member's active duty and was aggravated by service in line of duty on active duty in the Armed Forces) and that manifested itself before or after the member became a veteran. Amount of Leave An eligible employee may take up to 12 weeks for the first five FMLA circumstances above (under heading"Type of Leave Covered")under this policy during any 12-month period. The company will measure the 12-month period as a rolling 12-month period measured backward from the date an employee uses any leave under this policy. Each time an employee takes leave, the company will compute the amount of leave the employee has taken under this policy in the last 12 months and subtract it from the 12 weeks of available leave, and the balance remaining is the amount of time the employee is entitled to take at that time. An eligible employee can take up to 26 weeks for the FMLA military caregiver leave circumstance above during a single 12-month period. For this military caregiver leave, the company will measure the 12-month period as a rolling 12-month period measured forward. FMLA leave already taken for other FMLA circumstances will be deducted from the total of 26 weeks available. If a husband and wife both work for the company and each wishes to take leave for the birth of a child, adoption or placement of a child in foster care, or to care for a parent (but not a parent "in- law")with a serious health condition, the husband and wife may only take a combined total of 12 weeks of leave. If a husband and wife both work for the company and,each wishes to take leave to care for a covered injured or ill service member, the husband and wife may only take a combined total of 26 weeks of leave. Employee Status and Benefits During Leave 30 While an employee is on leave, the company will continue the employee's health benefits during the leave period at the same level and under the same conditions as if the employee had continued to work. It is the employee's responsibility to maintain his/her portion of health benefits. The employee must maintain communications with the employer to prevent any laps in benefits. Lapses in employee payments without communication with the company will cause loss of coverage. If coverage is lost the employee will be offered cobra coverage. See Cobra Coverage Policy for Additional Information) Employee Status after Leave An employee who takes leave under this policy will be asked to provide a fitness for duty(FFD) clearance from the health care provider. Use of Paid and Unpaid Leave All PTO leave will run concurrently with FMLA leave. Intermittent Leave or a Reduced Work Schedule The employee may take FMLA leave in 12 consecutive weeks,may use the leave intermittently (take a day periodically when needed over the year for qualifying reasons) or,under certain circumstances,may use the leave to reduce the workweek or workday,resulting in a reduced- hour schedule for permitted reasons. In all cases, the leave may not exceed a total of 12 workweeks (or 26 workweeks to care for an injured or ill service member over a 12-month period). Certification for the Employee's Serious Health Condition The company may require certification for the employee's serious health condition. The r` employee must respond to such a request within 15 days of the request or provide a reasonable explanation for the delay. Failure to provide certification may result in a denial of continuation of leave. Certification for the Family Member's Serious Health Condition The company will require certification for the family member's serious health condition. The employee must respond to such a request within 15 days of the request or provide a reasonable explanation for the delay. Failure to provide certification may result in a denial of continuation of leave. Certification of Qualifying Exigency for Military Family Leave The company may require certification of the qualifying exigency for military family leave. The employee must respond to such a request within 15 days of the request or provide a reasonable explanation for the delay. Failure to provide certification may result in a denial of continuation of leave. 31 Certification for Serious Injury or Illness of Covered Service Member for Military Family Leave The company may require certification for the serious injury or illness of the covered service member. The employee must respond to such a request within 15 days of the request or provide a reasonable explanation for the delay. Failure to provide certification may result in a denial of continuation of leave. Recertification The company may request recertification for the serious health condition of the employee or the employee's family member when circumstances have changed significantly, or if the employer receives information casting doubt on the reason given for the absence, or if the employee seeks an extension of his or her leave. Otherwise, the company may request recertification for the serious health condition of the employee or the employee's family member every six months in connection with an FMLA absence. Procedure for Requesting FMLA Leave All employees requesting FMLA leave must provide the HR manager with verbal or written notice of the need for the leave. Within five business days after the employee has provided this notice, the HR manager will provide the employee with the DOL Notice of Eligibility and Rights. When the need for the leave is foreseeable, the employee must provide the employer with at least 30 days'notice. When an employee becomes aware of a need for FMLA leave less than 30 days in advance,the employee must provide notice of the need for the leave either the same day or the next business day. When the need for FMLA leave is not foreseeable, the employee must comply with the company's usual and customary notice and procedural requirements for requesting leave. Designation of FMLA Leave Within five business days after the employee has submitted the appropriate certification four, the HR manager will provide the employee with a written response to the employee's request for FMLA leave. Intent to Return to Work from FMLA Leave The company may require an employee on FMLA leave to report periodically on the employee's status and intent to return to work. H-36-Bereavement Leave When a death occurs in an employee's immediate family, all employees may take up to three (3) days off to attend the funeral or make funeral arrangements. The Company may require 32 verification of the need for the leave. Immediate family members are defined as an employee's spouse,parents, stepparents, siblings, children, stepchildren, grandparent, father-in-law, mother-in-law,brother-in-law, sister-in-law, son-in-law, daughter-in-law, or grandchild. Individuals outside of this definition will be considered on a case by case basis. H-37-Voting Time North State Medical Transport encourages all employees to vote. All employees should be able to vote either before or after regularly assigned work hours. However,when this cannot be arranged, your supervisor/manager will approve time off to vote either at the beginning or end of your workday,provided that you give at least one day's notice to your supervisor/manager. Time off for voting will be unpaid and should be reported appropriately on timekeeping records. H-38-Military Leave of Absence NSMT is committed to protecting the job rights of employees absent on military leave. In accordance with federal and state law, it is the company's policy that no employee or prospective employee will be subjected to any form of discrimination on the basis of that person's membership in or obligation to perform service for any of the Uniformed Services of the United States. Specifically, no person will be denied employment,reemployment,promotion or other benefit of employment on the basis of such membership. Furthermore,no person will be subjected to retaliation or adverse employment action because such person has exercised his or her rights under applicable law or company policy. If any employee believes that he or she has been subjected to discrimination in violation of company policy,the employee should immediately contact Human Resources. Employees taking part in a variety of military duties are eligible for benefits under this policy. Such military duties include leaves of absence taken by members of the uniformed services, including Reservists and National Guard members, for training, periods of active military service and funeral honors duty, as well as time spent being examined to determine fitness to perform such service. Subject to certain exceptions under the applicable laws,these benefits are generally limited to five years of leave of absence. Employees requesting leave for military duty should contact management to request leave as soon as they are aware of the need for leave. H-39-Work Time Substitution 1. Work time substitution is used when full-time employees desire to substitute work time with another full-time employee to avoid using leave time (PTO) and is permitted under the Fair Labor Standards Act. 2. The employee who will be substituted for must submit to management a completed Crew Scheduler Time Swap (work time substitution)Request,prior to the time the trade is to 33 occur. 3. This work-time substitution should put no employee into excessive overtime (up to the discretion of management). 4. It is preferred that a work time substitution be in the same pay period(one week intervals from Thursday to Wednesday). 5. Management may refuse to honor the agreement at his/her discretion. 6. The person agreeing to substitute for a shift shall be responsible for reporting for duty as if it were that person's normal assignment and that person shall be held responsible as if it were his/her regular duty assignment. 7. The substitute may not result in an employee working more than thirty-six hours in a forty-eight hour window. 8. The substitute must be qualified to do the same job as the regularly assigned employee. 9. Only current full-time employees are peiinitted to participate in the work time substitution program. 10. North State Medical Transport incurs no expense and assumes no responsibility for compensation of the substitute. Repayment of the substitution is between the employee requesting the agreement and the substitute, if the two (2) employees so choose to work out such agreement. 11. Failure to report to work for a work time substitution is subject to time deduction of appropriate leave from the employee deemed responsible and subsequent occurrences will result in additional disciplinary action, including the loss of privilege in participating in work time substitution for up to twelve (12)months. 12. If the employee agreeing to substitute is unable to work due to illness, the appropriate leave will be deducted from their available balances. H-40-Scheduling Availability 1. All full and part-time employees are required to post their availability through Crew Scheduler. 2. It is suggested that for those full-time employees that wish to pick up extra shifts should submit availability up to three (3) weeks ahead of time, for scheduling reasons. 3. Changes to availability for a certain date span (for those dates that an employee is not already scheduled to work), after a schedule for a specific pay period has been created, 34 should be reflected on Crew Scheduler as soon as the change is known 4. Part-Time Staff shall submit a minimum of five days of availability per 30 day period. H-41-Failure to Appear for Work 1. An employee that fails to report for work without notice shall be subject to dismissal without due reason. 2. Any employee that fails to report for an assigned shift will be required to report in person to the scheduler prior to his/her next scheduled shift to explain their action. 3. An employee is considered tardy for work 7 minute after the report time for his/her assigned shift. H-42-Employee Safety and Wellness It is the responsibility of each employee to conduct all tasks in a safe and efficient manner complying with all local, state and federal safety and health regulations and program standards, and with any special safety concerns for use in a particular area or with a client. 1. North State Medical Transport strives to provide its employees with a safe and healthy workplace environment. To accomplish this goal,both management and employees must diligently undertake efforts to promote safety. 2. North State Medical Transport will strive to make available at no cost to employees work-related vaccinations,protective equipment, and procedures in order to maintain personnel in a healthy,productive state 3. All job-related injuries or illnesses are to be reported to your supervisor/manager immediately,regardless of severity. In the case of serious injury, an employee's reporting obligation will be deferred until circumstances reasonably permit a report to be made. 4. Failure to report an injury or illness may preclude or delay the payment of any benefits to the employee and could subject North State Medical Transport to fines and penalties. 5. Failure to report an injury or illness may result in employee disciplinary action up to and including termination. 6. Failure to follow company safety and health guidelines or engaging in conduct that places the employee, client or company property at risk can lead to employee disciplinary action up to and including termination. 7. When an injury occurs the employee will be give assistance in the reporting process. II-43-Return to Work after a Serious Injury or Illness 35 G'; 1. As a joint protection to the employee and the company, employees who have been absent from work because of serious illness or injury are required to obtain a doctor's release specifically stating that the employee is capable of performing his or her normal duties or assignments. A serious injury or illness is defined as one which may limit the employee's future performance of regular duties or assignments. (Also see medical/family leave policy.) 2. A North State Medical Transport Fitness for Duty forms must be filled out prior to any return to work. 3. Fitness for duty forms will be provided by the NSMT HR Department 4. North State Medical Transport management shall ensure that employees who return to work after a serious injury or illness are physically capable of perfoiming their duties or assignments without risk of re-injury or relapse. 5. If the cause of the employee's illness or injury was job-related,the employee's supervisor/manager will make every reasonable effort to assign the returning employee to assignments consistent with the instructions of the employee's doctor until the employee is fully recovered. A doctor's written release is required. H-44-Employee Fitness for Duty Standard 1. North State Medical Transport requires all employees to report to work mentally and physically capable to complete their assigned duties. 2. North State Medical Transport maintains a"zero tolerance" standard for employees reporting to work under the influence of any substance legal or illegal which impairs judgment or motor function. 3. Employees will not be peii►iitted to function as an employee of North State Medical Transport if they are found to be impaired in any way when reporting to or while on duty. 4. Employees suspected of being in violation of this standard will be removed from service and subjected to analysis to determine their status. Upon deteumination of impairment said employee will be terminated in accordance with the NSMT disciplinary process. H-45- Workplace Injuries/Workers Compensation 1. North State Medical Transport strives to provide its employees with a safe and healthy workplace environment. To accomplish this goal, both management and employees must diligently undertake efforts to promote safety. 2. Workers' compensation leave may only be used in accordance with work place injuries. 3. The severity and urgency of medical attention to workplace injuries will be detetiiiined by the employee; however workers compensation will only cover certain charges based on medical necessity 4. All job-related injuries or illnesses are to be reported to your HR Department immediately, regardless of severity. In the case of serious injury, an employee's reporting obligation will be deferred until circumstances reasonably permit a report to be made. 36 5. Failure to report an injury or illness may preclude or delay the payment of any benefits to the employee and could subject North State Medical Transport to fines and penalties. 6. When injuries occur employees will be given assistance in the reporting process. 7. Employees should report to the Compliance Officer immediately upon realization of the injury or as soon as possible following medical care treatment. 8. Employee injuries that require medical attention shall immediately be sent to an appropriate medical facility. 9. Injuries occurring after hours requiring medical attention should be seen at the closest appropriate medical facility. 10. Employee injuries that do not require medical attention shall be documented to the director by the employee to include the nature of the injury,the practice that caused the injury, and what post-event action they took. 11. A management member of North State Medical Transport shall complete a worker's compensation report for the NC Industrial Commission. 12. All documentation of employee injuries shall be forwarded to the director. 13. Any employee who requires medical attention may not return to work without a completed Fitness for Duty form. 14.For further information please contact the NSMT HR Department. H-46-Exposures to Pathogens 1. Employees will receive initial training and annually thereafter outlined in the NSMT Infectious Control Plan. 2. Upon completion of the call, any employee who is exposed to blood or other bodily fluids shall immediately notify the infectious control officer. Bryan Perry-Home-919-269-5743 Cell 919-210-1172. 3. The employee will immediately be subject to the exposure management process as outlined in the North State Medical Transport Infectious Control Plan. 4. The NSMT Exposure Control Plane may be viewed upon request in the office of the NSMT Compliance Officer. Bryan Perry-Home-919-269-5743 Cell 919-210-1172. 11-47-Progressive Disciplinary Process Every employee has the duty and the responsibility to be aware of and abide by existing rules and policies. Employees also have the responsibility to perform his/her duties to the best of 37 his/her ability and to the standards as set forth in his/her job description or as otherwise established. NSMT supports the use of progressive discipline to address issues such as poor work performance or misconduct. Our progressive discipline policy is designed to provide a corrective action process to improve and prevent a recurrence of undesirable behavior and/or performance issues. Our progressive discipline policy has been designed consistent with our organizational values, HR best practices and employment laws. Outlined below are the steps of our progressive discipline policy and procedure. NSMT reserves the right to combine or skip steps in this process depending on the facts of each situation and the nature of the offense. Some of the factors that will be considered are whether the offense is repeated despite coaching, counseling and/or training; the employee's work record; and the impact the conduct and performance issues have on our organization. The following outlines NSMT's progressive discipline process: Coaching Session 1. A coaching session is a formal session providing remediation to the employee on a minor infraction of company policies or procedure. 2. The manager should consider the severity of the problem, the employee's previous performance appraisals and all of the circumstances surrounding the particular case. Stating that a verbal warning, probation, or possible termination could result if the problem is not resolved and will indicate the seriousness of the performance or misconduct. 3. The employee will be asked to review what has been discussed to ensure his or her understanding of the seriousness of the problem and the corrective action necessary. 4. The supervisor/manager should document the verbal counseling for future reference immediately following the review. Verbal Coaching 1. As the first step in correcting unacceptable performance or behavior, the supervisor/manager should review pertinent job requirements with the employee to ensure his or her understanding of them. 2. The manager will consider the severity of the problem,the employee's previous performance appraisals and all of the circumstances surrounding the particular case stating that a written warning,probation, or possible termination could result if the problem is not resolved and should indicate the seriousness of the performance or misconduct. Certain circumstances, such as violation of a widely known policy or safety requirement,may justify a verbal warning without first using a verbal coaching. 3. The employee will be asked to review what has been discussed to ensure his or her understanding of the seriousness of the problem and the corrective action necessary. 4. The supervisor/manager should document the verbal counseling for future reference 38 immediately following the review. Written Warning 1. If the unacceptable performance or behavior continues or additional issues arise, the next step can be a written warning. Certain circumstances, such as violation of a widely known policy or safety requirement, may justify a written warning without first using a verbal warning. 2. The written warning defines the problem and how it may be corrected. 3. The seriousness of the problem is again emphasized, and the written warning shall indicate that probation or termination or both may result if improvement is not observed. Written counseling becomes part of the employee's personnel file, although the supervisor/manager may direct that the written warning be removed after a period of time,under appropriate circumstances. Involuntary Termination 1. Employees of NSMT are employed on an at-will basis, and the company retains the right to terminate an employee at any time. 2. Terminations are to be treated in a confidential and professional manner by all concerned. 3. The supervisor/manager must assure thorough, consistent and evenhanded termination procedures. 4. This policy and its administration will be implemented in accordance with the company equal opportunity statement. Terminated employees are entitled to receive all earned pay. 5. This is contingent on return of company equipment. I understand that continued failure to return equipment may be considered theft by the company or lead to a delay in receiving or deductions from your last paycheck. 6. Employment with the company is normally terminated through one of the following actions: Dismissal Involuntary termination for substandard performance or misconduct Substandard Performance 1. An employee may be discharged if his or her performance is unacceptable. 2. The supervisor/manager shall have counseled the employee concerning performance deficiencies, provided direction for improvement, and warned the employee of possible 3. The supervisor/manager is expected to be alert to any underlying reasons for performance deficiencies such as personal problems or illegal drug abuse. 4. The management team must concur in advance of advising the employee of discharge action. Documentation to be prepared by the supervisor/manager shall include reason for separation,performance history, corrective efforts taken, alternatives explored and any 39 additional pertinent information. Gross Misconduct 1. An employee found to be engaged in activities such as, but not limited to, theft of company property, insubordination, conflict of interest or any other activities showing willful disregard of company interests or policies will be terminated as soon as the supervisor/manager and management team have concurred with the action and appropriate documentation has been prepared. 2. Termination resulting from gross misconduct shall be entered into the employee's personnel file. The employee shall be provided with a written summary of the reason for termination. No salary continuance or severance pay will be allowed. 3. North State Medical transport defines gross misconduct as any action which is intentional and detrimental to the company. Examples include patient: A. Sexual Harassment B. Intimidation, Workplace Violence or Harassment C. Criminal Offences: D. Loss of essential job specific credentials. ( Certification, Driving Privileges ) E. Loss of the ability to participate in federal healthcare programs. F. Fraudulent Activity G. Loss of his/her ability to operate as a Technician by the Local Medical Director or State of North Carolina. H. Patient mistreatment I. Intentional false statements, J. Disregard for the wellbeing, safety or rights of others. These examples are not all inclusive H-48-Termination Processing Procedures 1. The management team will approve and direct all termination procedures. 2. On the final day of employment, the supervisor/manager must receive all keys and company property from the employee. 3. Upon termination an employee's access to sensitive and or protected information will be terminated. Access to all facilities will be prohibited unless permitted with a member of management. 4. The employee will be mailed his or her final payroll check upon termination. 5. The final check shall include all earned pay and any expenses due the employee minus any 40 financial obligations owed to North State Medical Transport. See Policy: (Paid Time Off/Leave Without Pay) for information regarding PTO leave upon separation. 11-49-Separation of Employment Resignation: 1. Although we hope your employment with us will be a mutually rewarding experience, we understand that varying circumstances cause employees to voluntarily resign employment. Resigning employees should provide two weeks' notice, preferably as much as possible, to facilitate a smooth transition out of the organization. If an employee provides less notice than requested,the employer may deem the individual to be ineligible for rehire depending on the circumstances regarding the notice given. Job abandonment: 1. Employees who fail to report to work or contact their supervisor shall be considered to have abandoned the job without notice, effective at the end of their shift. The supervisor shall notify the Human Resource department at the expiration workday and initiate the paperwork to terminate the employee. Employees who are separated due to job abandonment are ineligible to receive accrued benefits and are ineligible for rehire. H-50-Return of Company Property upon Separation The separating employee must return all company property at the time of separation, including unifoiius, cell phones, keys, PCs and identification cards. Failure to return some items may result in deductions from the final paycheck. An employee will be required to sign the Wage Deduction Authorization Agreement to deduct the costs of such items from the final paycheck upon hire. H-51-Accrued PTO Leave upon Separation Please refer to policy- Paid Time Off/Leave Without Pay H-52-Health Care upon Separation Health insurance terminates the last day of employment. Information for Consolidated Omnibus Budget Reconciliation (COBRA) continued health coverage will be provided through Ceridian. Ceridian will be contacted regarding an employee's separation from NSMT. Employees should expect information regarding COBRA eligibility shortly following separation from NSMT. For additional help a separated employee may contact Bryan Perry NSMT 919-210-1172 or bperry @nsmt.biz 41 H-53-Rehire Former employees who left NSMT in good standing and were classified as eligible for rehire may be considered for reemployment. An application must be submitted to the Human Resource department, and the applicant must meet all minimum qualifications and requirements of the position, including any qualifying exam, when required. Approval must be obtained from the Human Resource director or designee prior to rehiring a former employee. Rehired employees begin benefits just as any other new employee. Previous tenure will not be considered in calculating longevity, leave accruals or any other benefits. An applicant or employee who is teiniinated for violating policy or who resigned in lieu of termination from employment due to a policy violation will be ineligible for rehire. FI-54-Performance Appraisals Performance appraisals are conducted on an annual cycle. Employees will receive a performance review on the established date each year. The performance appraisal will be discussed, and both the employee and manager to ensure that all strengths, areas for improvement and job goals for the next review period have been clearly communicated. Performance evaluations will be retained in the employee's personnel file. Merit increases are based on company performance and financials and are not guaranteed. A performance review does not always result in an automatic salary increase. The employee's overall perfoiinance and salary level relative to his/her position responsibilities are evaluated to determine if a salary increase would be warranted. Merit increases percentages are planned for and allocated before the start of each calendar year. The annual salary increase program is designed to assist management in planning and allocating merit and promotional increases that reward individual performance, that are market competitive and that are internally equitable. Salary adjustments are occasionally requested or warranted at times other than the employee's scheduled annual salary reviews. Out-of-cycle salary increases must be preapproved by the HR Director and the company CEO. Human Resources will review all salary increase/adjustment requests to ensure internal equity and compliance with company policies and guidelines. Merit increases in pay, if any, are deemed to be confidential matters between the company and each employee and are not to be discussed among employees. H-55-Compensation 1. North State Medical Transport will not pay wages to any employee at a rate less than the company pays employees of the opposite sex for work that is substantially equivalent requiring comparable skills. 2. Any oversight noticed in this area by any North State Medical Transport Employee will be 42 brought to the attention of a management member for corrective action. 3. This policy is to be construed in accordance with applicable federal and state laws and regulations. 43 H-56-JOB DESCRIPTIONS Job Title: Emergency Medical Technician Class: Technician Department: Operations Revised: April-2014 FLSA: Non-exempt Pay Range: $11.50 to $20.00 [This job description supersedes any prior description for the EMT.) GENERAL DESCRIPTION Work involves transporting patients to and from doctor's offices, residences, nursing facilities, hospitals and various other medical facilities. Assess the medical needs of the sick or injured and provide medical care for those in need of help. Once this assessment takes place, they perform whatever medical assistance is needed as long as it's within the scope of their training. ESSENTIAL JOB FUNCTIONS (Any one position may not include all of the duties listed, nor do the listed examples include all tasks which may be found in the position.) 1. Maintain OEMS and CPR required certifications. See policy H-11 through H-17 for credentialing requirements. 2. Maintain NCDL. See policy H-11 through H-17 for credentialing requirements. 3. Maintain eligibility to participate in all Federal and State healthcare programs. 4. Responds to calls; transports patients; loads and unloads patient; transports patient to or from residences and medical facilities; completes call report. 5. Provides the necessary care and treatment of the patient to include cardiopulmonary resuscitation, suctioning, bandaging, splinting, administering oxygen and other skills within the scope of their training, etc. 6. Inspects ambulance regarding supplies, drugs, equipment, safety gear, tools, maps, and paperwork and function ability of all equipment, lights, tires, belts and fluid levels; washes ambulance. 7. Cleans inside of ambulance after each call; changes linen on stretcher and restocks supplies used on call. 8. Studies street and road patterns and networks of County in direct relationship to each call to insure prompt response with minimal difficulty and delay. 9. Communicates with hospital, during each call using proper radio etiquette. 10. Keeps in contact with dispatch and maintain statue update information on calls 11. Precepts and trains new employees on various aspects of their job duties 12. Maintains logs various logs, medical charting attends training on job specific topics. 13. Complies with all policies on Compliance, Documentation, BBP, and HIPAA OTHER JOB FUNCTIONS 44 1. Performs related duties as required. (Management reserves the right to add or amend ditties at any time.) KNOWLEDGE, SKILLS,AND ABILITIES 1. Ability to prepare ambulance call reports and other reports using appropriate grammar, medical terminology and abbreviations, and to write legibly. 2. Ability to perfoiui blood pressure„medical documents, distinguishes colors, and exercise full field of vision while working. 3. Ability to exercise independent judgment in determining the appropriate medical treatment of a patient according to existing protocols and standards of care per the employee's level of certification. 4. Ability to operate an ambulance for long periods of time in congested traffic and in unsafe road conditions caused by factors such as fog, rain, ice, and snow. 5. Ability to communicate effectively and coherently. 6. Ability to perform medical care and other duties which may involve lifting, carrying patients over uneven surfaces, climbing up to and down from elevated surfaces, carrying equipment and patients down steps. 7. Ability to effectively communicate when confronted with views and opinions of patients, family members and facility staff in an antagonistic environment. 8. Ability to operate medical equipment properly within their scope of training. 9. Ability to resolve problems in order to complete daily duties. PHYSICAL REQUIREMENTS 1. Work includes sitting,walking, running,bending, stooping and lifting weights in excess of 250 lbs with assistance. 2. Work includes both indoor and outdoor activity where employee is exposed to elements of nature: cold, hot, rain, snow, sleet, ice, etc. 3. Employee must be able to maneuver in tight places, climb ladders or stairs, step over obstacles, step on and off machinery, etc. 4. Work includes operation of a motor vehicle. EXPOSURE CONTROL Work may cause direct contact with blood or other potentially infectious pathogens which universal precautions apply. Personal protective equipment is available and must be worn,thus the work is subject to the OSHA requirements for blood borne pathogens f MINIMUM EXPERIENCE AND TRAINING 1. High school graduation or GED. 2. Certification as Emergency Medical Technician by North Carolina with one year of experience as an EMT preferred. 3. Valid NC driver's license is required. 45 4. CPR Certification (This job description does not create an employment contract, Implied or otherwise.) 46 Job Title: Emergency Medical Technician-Paramedic Class: Technician Department: Operations Revised: April- 2014 FLSA: Non-exempt Pay Range: $15.75 to $23.00 (This job description supersedes any prior description for the EMT—Paramedic.) GENERAL DESCRIPTION Work involves transporting patients to and from doctor's offices, residences,nursing facilities, hospitals and various other medical facilities. Assess the medical needs of the sick or injured and provide medical care for those in need of help. Perform appropriate level life support work in the emergency medical setting. Work involves responding to the ALS Level Transports, emergency and non-emergency transports, applying necessary medical treatment to sick or injured patients as long as it's within the scope of their training. ESSENTIAL JOB FUNCTIONS (Any one position may not include all of the duties listed, nor do the listed examples include all tasks which may be found in positions of this class.) 1. Maintain OEMS and CPR required certifications. See policy H-11 through H-17 for credentialing requirements. 2. Maintain NCDL. See policy H-11 through H-17 for credentialing requirements. 3. Maintain eligibility to participate in all Federal and State healthcare programs. 4. Responds to emergency and non-emergency calls;transports out-of-town,transfer, and convalescent patients; loads and unloads patient;transports patient to or from hospital; completes call report. 5. Provides the necessary care and treatment of the patient to include cardiopulmonary resuscitation, suctioning, bandaging, splinting, administering oxygen, cardiac monitoring and drug administration etc within the scope of their training. 6. Inspects ambulance regarding supplies, drugs, equipment, safety gear,tools,maps, and paperwork and function ability of all equipment, lights,tires, belts and fluid levels; washes ambulance. 7. Clean inside of ambulance after each call; changes linen on stretcher and restocks supplies used on call. 8. Studies streets and road networks to insure prompt response with minimal difficulty and delay. 9. Communicates by radio with hospital, during calls using proper radio etiquette. 10. Keeps in contact with dispatch while on calls. 11. Maintains logs various logs,medical charting attends training on job specific topics. 12. Complies with all policies on Compliance,Documentation,BBP, and H1PAA 47 OTHER JOB FUNCTIONS 1. Performs related duties as required. (Management reserves the right to add or amend duties at any time.1 KNOWLEDGE, SKILLS,AND ABILITIES 1. Ability to prepare ambulance call reports and other reports using appropriate grammar, medical terminology and abbreviations, and to write legibly. 2. Ability to use and apply appropriate medical skill sets while treating patients. 3. Ability to exercise independent judgment in deteimining the appropriate medical treatment of a patient according to existing protocols and standards of care per the employee's level of certification. 4. Ability to operate an ambulance for long periods of time in congested traffic and in unsafe road conditions caused by factors such as fog, smoke, rain, ice, and snow. 5. Ability to communicate effectively and coherently with the 9-1-,1 emergency center, other units, public service agencies, and the public using existing communications equipment. 6. Ability to perform medical care and other duties which may involve lifting, carrying patients over uneven surfaces, climbing up to and down from elevated surfaces, carrying equipment and patients down steps. 7. Ability to effectively communicate when confronted with views and opinions of patients, family members and facility staff in an antagonistic environment. 8. Ability to operate medical equipment properly such as CPAP, drug pumps, cardiac monitor, 12 lead EKG oxygen equipment, ventilators etc. PHYSICAL REQUIREMENTS 1. Work includes sitting, walking,running, bending, stooping and lifting weights in excess of 250 lbs with assistance. 2. Work includes both indoor and outdoor activity where employee is exposed to elements of nature: cold, hot, rain, snow, sleet, ice, etc. 3. Employee must be able to maneuver in tight places, climb ladders or stairs, step over obstacles, step on and off machinery, etc. 4. Work includes normal and emergency operation of a motor vehicle. EXPOSURE CONTROL Work is likely to cause direct contact with blood or other body fluids to which universal precautions apply. Personal protective equipment is available and must be worn, thus the work is subject to the OSHA requirements for blood borne pathogens. MINIMUM EXPERIENCE AND TRAINING 1. High school graduation or GED. 2. Certification as Emergency Medical Technician- Paramedic by North Carolina, one year 48 of experience as an EMT-Paramedic preferred. 3. The ability to pass oral boards with the Franklin County EMS Medical Director. 4. High school graduation or GED. 5. Valid NC driver's license is required. 6. CPR Certification 7. ACLS,PALS preferred (This lob description does not create an employment contract, Implied or otherwise.) I[I: Ii Ii 49 Job Title: Technician Supervisor Class: Supervisor Department: Operation Revised: April-2014 FLSA: Non-exempt Pay Range: $14.50.00 to $25.00 [This job description supersedes any prior description for the Technician Supervisor classification.) GENERAL DESCRIPTION, Work involves transporting patients to and from doctor's offices, residences, nursing facilities, hospitals and various other medical facilities. Assess the medical needs of the sick or injured and provide medical care for those in need of help. Perform appropriate level life support work in the emergency medical setting. Work involves responding to the ALS Level Transports, emergency and non-emergency transports, applying necessary medical treatment to sick or injured patients as long as it's within the scope of their training Work in cooperation with managers in supervising and conducting day to day operations. Considerable tact, courtesy, and firmness are required with frequent contact with the general public, other health care professionals and vendors. Work is performed under supervision of company managers ESSENTIAL JOB FUNCTIONS (Any one position may not include all of the duties listed, nor do the listed examples include all tasks which may be found in positions of this class.) 1. Maintain OEMS and CPR required certifications. See policy H-11 through H-17 for credentialing requirements. 2. Maintain NCDL. See policy H-11 through H-17 for credentialing requirements. 3. Maintain eligibility to participate in all Federal and State healthcare programs. 4. Responds to emergency and non-emergency calls as other crew members; administers necessary medical care. 5. Assists with arranging coverage for shift employee leave requests. 6. Enforces departmental policies and procedures. Trains new employees; answers questions and solves operational problems for other crews. 7. Assists administration with equipment inventory, record keeping, vehicle maintenance, field audits, unifoluus, and special projects. 8. Serves as an extension of administration in evaluating employee performance to be used in performance improvement and annual evaluation recommendations 9. Assumes shift responsibilities in the absence of management. 10. Performs additional certification specific job functions outlined in EMT and EMT Paramedic job descriptions. 11. Complies with all policies on Compliance, Documentation, BBP, and HIPAA 50 OTHER JOB FUNCTIONS 1. Performs related duties as required. (Management reserves the right to add or amend duties at any time.) KNOWLEDGE, SKILLS,AND ABILITIES 1. Thorough knowledge of emergency medical service regulations, company policies, protocols or operating procedures. 2. Thorough knowledge of equipment and supplies used in the care of patients and victims of accidents. 3. Considerable knowledge of medical procedures and techniques. 4. Working knowledge of radio communication equipment. 5. Ability to train, supervises, and guides the work of others. 6. Ability to maintain effective working relationships with other agencies, government officials, the general public, and other employees. 7. Performs additional certification specific job functions outlined in EMT and EMT Paramedic job descriptions. PHYSICAL REQUIREMENTS 1. Work includes sitting,walking, running,bending, stooping and lifting weights in excess of 250 lbs with assistance. 2. Work includes both indoor and outdoor activity where employee is exposed to elements of nature: cold,hot,rain, snow, sleet, ice, etc. 3. Employee must be able to maneuver in tight places, climb ladders or stairs, step over obstacles, step on and off machinery, etc. 4. Work includes normal and emergency operation of a motor vehicle. EXPOSURE CONTROL Work is likely to cause direct contact with blood or other potentially infectious pathogens which universal precautions apply. Personal protective equipment is available and must be worn,thus the work is subject to the OSHA requirements for blood borne pathogens MINIMUM EXPERIENCE AND TRAINING 1. Two years of emergency services experience. Supervisory experience preferred. 2. High school graduation or GED. 3. Certification as Emergency Medical Technician-Paramedic by North Carolina, one year of experience as an EMT-Paramedic preferred. 4. The ability to pass oral boards with the Franklin County EMS Medical Director. 5. High school graduation or GED. is 51 t; 6. Valid NC driver's license is required. 7. CPR Certification 8. ACLS, PALS preferred (This job description does not create an employment contract, Implied or otherwise.) 52 Job Title: Dispatcher Class: Communication Technician Department: Operations Revised: April-2014 FLSA: Non-exempt Pay Range: $11.50 to $19.00 (This job description supersedes any prior description for the Dispatcher.) GENERAL DESCRIPTION Answers phone calls, schedules and dispatches transports, and serves as initial customer information resource. This job is the company's primary connection to the population it serves, and is designed to be a liaison between management and the public. ESSENTIAL JOB FUNCTIONS (Any one position may not include all of the duties listed, nor do the listed examples include all tasks which may be found in positions of this class.) 1. Answers phone calls. 2. Receives requests for transports and schedules transports based on the availability of ambulances throughout the day, as well as for future days. 3. Assigns crew members to vehicles and dispatches them for transports according to their availability. 4. Monitors unit locations and status through available monitoring systems. 5. Advises customers when delays arise 6. Directs customer and employee questions to the appropriate member of management. 7. Operates dispatch computer and all dispatch program software, i.e. Zoll Data Dispatch program and Fleet Direct Teletrac GPS software. 8. Maintains the incident number log book, as well as entering transports into the book and giving the numbers to the pertinent crew members. 9. Oversees end of day functions of the ambulance crews, i.e. chart completion, logs, cleaning trucks, and clocking out. 10. Responsible for checking crew schedule to manage the number of trucks available and which crew to assign to which truck. 11. Reports to Communications Supervisor. 12. Basic keyboard and mouse skills. 13. Verifies completion of patient care paperwork 14. Makes appropriate notifications when documentation errors or omissions are found to assure compliance. 15. Scans patient paperwork and attaches to correct chart in the EMS-Charts system. 16. Verifies correct scanning and attachment of patient paperwork in the EMS-Charts system. 17. Gives transportation price quotes to customers requesting services. 53 18. Logs any missed or turned-down calls on the website we have for logging these instances 19. Notify designated member of management upon field staff call-out 20. Assess call schedule and crew schedule to deteiniine if on-call crew is needed, and call them in as necessary 21. Attends training on job specific topics. 22. Complies with all policies on Compliance, Documentation, BBP, and HIPAA OTHER JOB FUNCTIONS 1. Performs related duties as required. (Management reserves the right to add or amend duties at any time.) KNOWLEDGE, SKILLS,AND ABILITIES 1. Professionalism-Approaches others in a polite and tactful manner;Maintains composure and reacts well under pressure; Treats others with respect and consideration; Accepts responsibility for own actions; Follows through on commitments. 1 Problem Solving- Identifies and resolves problems time efficiently; Gathers and analyzes information; Develops solutions; Uses reason. 3. Interpersonal Skills - Listens to others without interrupting; Keeps emotions under control; Supports others' ideas and tries new things. 4. Oral Communication- Speaks clearly and persuasively; Listens and gets clarification when necessary; Responds informatively to questions; Demonstrates presentation skills; Participates in, and sometimes leads, meetings. 5. Written Communication- Writes clearly and concisely; Edits work;Presents data effectively; Able to read and interpret written information. 6. Leadership -Exhibits confidence in self and others; Inspires and motivates others; Accepts feedback from others; Gives recognition when appropriate. 7. Planning/Organizing - Uses time efficiently; Plans for additional resources; Sets goals and objectives; Organizes or schedules other people and their tasks. 8. Cost Consciousness - Develops and implements cost saving measures; Contributes to profits and returns; Conserves company resources. 9. Strategic Thinking - Develops strategies to achieve organizational goals; Understands organization's strengths & weaknesses; Analyzes market and competition; Identifies external threats and opportunities; Adapts strategy to changing conditions. 10. Judgment-Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate individuals in decision-making process; Makes timely decisions. 11. Motivation-Sets and achieves challenging goals; Demonstrates persistence and overcomes obstacles;Measures self against standard of excellence; Takes calculated risks to accomplish goals. 12. Quality-Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality. 54 13. Adaptability-Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation;Able to handle frequent change, delays, or unexpected events. 14. Dependability-Follows instructions, responds to management direction; Takes responsibility for own actions;Keeps commitments; Completes tasks on time or notifies appropriate person with an alternate plan. 15. Innovation-Displays original thinking and creativity; Meets challenges with resourcefulness; Generates suggestions for improving work;Develops innovative approaches and ideas; Presents ideas and infoiuiation in a manner that gets others' attention. PHYSICAL REQUIREMENTS 1. Frequently required to sit. 2. Occasionally required to walk. 3. Occasionally required to reach with hands and arms. 4. Constantly required to talk or hear. 5. Usually required to use a computer. 6. Occasionally required to bend, lift or climb. 7. Occasionally required to lift light weights (less than 25 pounds) 8. Occasionally required to lift moderate weights (25-50 pounds). MINIMUM EXPERIENCE AND TRAINING 1. Minimum Education: High School Diploma or GED 2. Minimum Field-of-Expertise: Basic computer skills. Basic Windows operating systems skills 3. Preferred Experience: 1+year(s)previous dispatching or medical transport. 4. Preferred Field-of-Expertise: Zoll Data, E-Pro scheduler, and Microsoft Office (This job description does not create an emplo Jnent contract, Implied or otherwise.) 55 Job Title: Communications Supervisor Class: Supervisor Department: Administrative Revised: April- 2014 FLSA Status: Non-Exempt Pay range $12.00 to 23.00 (This job description supersedes any prior description for Communications Supervisor.) GENERAL DESCRIPTIONS: 1. Assist Office Manager in perfoiniance and oversight of duties performed by office staff. Additional duties may include training, evaluating, and disciplinary counseling of on-site employees. ESSIENTIAL JOB FUNTIONS: (Any one position may not include all of the duties listed, nor do the listed examples include all tasks which may be found in positions of this class.) 1. Assist Office Manager with employee staffing/scheduling. 2. Participate in staff meeting and assist with the relay of information to field staff. 3. Provide training and support to field and dispatch staff as necessary. 4. Maintain open and clear communication with the general staff and Office Manager. 5. Insure the quality and professionalism of the company. 6. Represent the company in a professional manner at all times. 7. Ensures completion of various daily, weekly and monthly reports in a timely and accurate manner. 8. Review reports for accuracy, scan and report identified errors. 9. Have the ability to communicate instructions clearly and precisely. 10. Assists on-site employees as needed. 11. Perform, Q/A on Charts, Dispatch staff work, Insurance approvals. 12. Work with office and dispatch personnel to insure work duties are carried out in accordance with established company policies and procedures. 13. Interact with customers to insure appropriate customer relations are maintained. 14. Have the ability resolve issues which arise during daily schedule. 15. Attends and participates in training seminars as requested OTHER JOB FUNCTIONS 1. Perfoiins related duties as required. (Management reserves the right to add or amend duties at any time.) KNOWLEDGE, SKILLS,AND ABILITIES: 56 1. Problem Solving- Identifies and resolves problems time efficiently; Gathers and analyzes information; Develops solutions; Uses reason. 2. Oral Communication- Speaks clearly and persuasively; Listens and gets clarification when necessary; Responds informatively to questions. 3. Written Communication- Writes clearly and concisely;Edits work; Presents numerical data effectively; Able to read and interpret written information. 4. Works within approved budget; Develops and implements cost saving measures; Conserves company resources. 5. Prioritizes and plans staff work activities; Uses time efficiently; Plans for additional resources; Sets goals and objectives. 6. Demonstrates accuracy and thoroughness; Applies feedback to improve performance; Monitors own work to ensure quality. 7. Demonstrates attention to detail. 8. Leadership -Exhibits confidence in self and others; effectively influences actions and opinions of others; Gives recognition when appropriate. 9. Managing People- Includes staff in planning and decision-making processes; Makes self accessible to staff;Provides regular feedback;Develops subordinates' skills and encourages growth; Solicits and applies customer feedback; Improves processes, products and services. 10. Planning/Organizing-Prioritizes and plans work activities; Uses time efficiently;Plans for additional resources; Sets goals and objectives; Organizes or schedules other people and their tasks. 11. Teaching/Training; clearly explains concepts; Varies presentation style to satisfy different learning needs. 12. Knowledgeable towards Zoll Rescuenet Dispatch and Epro-Scheduler software. PHYSICAL REQUIREMENTS 1. Usually required to sit. 2. Usually required to use a computer. 3. Usually required to talk or hear. 4. Occasionally required to reach with hands and arms. 5. Occasionally required to walk. 6. Occasionally required to bend, lift or climb. 7. Occasionally required to lift light weights(less than 25 pounds) 8. Occasionally required to lift moderate weights (25-50 pounds). MINIMUM EXPERIENCE AND TRAINING 1. Preferred Education: Bachelor's Degree 2. Minimum Experience: 1 Year 3. Employee Management Skills Preferred 4. Dispatching Experience 5. Computer and Keyboarding skills preferred. 6. Critical Thinking Skills 7. Preferred; Knowledgeable towards Microsoft Windows and Microsoft Office suite. 57 8. Preferred; Knowledgeable towards Zoll Rescue-net Dispatch and E-pro-Scheduler software. (This job description does not create an employment contract, Implied or otherwise.) 58 Job Title: General Manager Class: Supervisor Department: Marketing FLSA Status: Exempt Revised: April-2014 Pay range: Salaried Job Summary Manages multiple departments and functions, including scheduling, dispatching, and supervising employee performance. ESSIENTIAL JOB FUNTIONS: (Any one position may not include all of the duties listed, nor do the listed examples include all tasks which may be found in positions of this class.) 1. Performs duties noinially associated with supervisory position, such as training, evaluating, and disciplinary counseling of all on-site employees,under the direction of the Director of Operations. 2. Participates in general staff meetings on regular basis. 3. Attends management meetings when scheduled. 4. Provides additional training as necessary. 5. Maintains open and clear communication with the general staff and Director of Operations. 6. Develops an integral team of dispatchers that effectively portrays the quality and professionalism of the Company. 7. Represents the company in a professional manner at all times. 8. Ensures completion of various daily, weekly and monthly reports in a timely and accurate manner. 9. Reviews reports and makes operating recommendations to Director of Operations. 10. Reviews time cards for payroll and payroll-related forms; discusses exceptions and unusual circumstances with Property Manager and approves/disapproves as appropriate. 11. Assists on-site employees as needed. 12. Supports overall marketing efforts and offers input and suggestions. 13. Oversees, develops and participates in various company programs to ensure their success. 14. Prepares and follows guidelines of company operating budget, and makes recommendations to maximize income and minimize expenses. 15. Offers recommendations for company capital improvements or repairs,the development of job specifications, bid acquisitions, contract developments and negotiations, etc. 16. Oversees use of proper supervision methods by department supervisors and those personnel issues are carried out in accordance with established company policies and procedures. 17. Solicits and reacts accordingly to positive and negative resident feedback. 18. Attends and participates in training seminars as requested. 19. Performs other related duties as assigned or requested. 59 OTHER JOB FUNCTIONS 1. Performs related duties as required. (Management reserves the right to add or amend duties at any time.) KNOWLEDGE, SKILLS, AND ABILITIES 1. Problem Solving- Identifies and resolves problems time efficiently; Gathers and analyzes information; Develops solutions; Uses reason. 2. Oral Communication- Speaks clearly and persuasively; Listens and gets clarification when necessary; Responds informatively to questions. 3. Written Communication- Writes clearly and concisely; Edits work; Presents numerical data effectively; Able to read and interpret written information. 4. Cost Consciousness - Works within approved budget; Develops and implements cost saving measures; Conserves company resources. 5. Planning/Organizing-Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Sets goals and objectives. 6. Quality- Demonstrates accuracy and thoroughness; Applies feedback to improve performance; Monitors own work to ensure quality. 7. Designs and Develops and produces creative solutions; Translates concepts and information into images; Uses feedback to modify designs; Demonstrates attention to detail. 8. Leadership - Exhibits confidence in self and others; effectively influences actions and opinions of others; Gives recognition when appropriate. 9. Managing People - Includes staff in planning and decision-making processes; Makes self accessible to staff; Provides regular feedback; Develops subordinates' skills and encourages growth; Solicits and applies customer feedback; Improves processes, products and services. 10. Planning/Organizing -Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Sets goals and objectives; Organizes or schedules other people and their tasks. 11. Teaching/Training; clearly explains concepts; Varies presentation style to satisfy different learning needs. Physical Demands 1. Usually required to sit and stand. 2. Usually required to use a computer. 3. Usually required to talk or hear. 4. Occasionally required to reach with hands and arms. 5. Occasionally required to bend, lift or climb. 6. Occasionally required to lift light weights (less than 40 pounds) MINIMUM EXPERIENCE AND TRAINING 60 1. Preferred Education: Bachelor's Degree 2. Minimum Experience: 1 Year 3. Employee Management Skills Preferred 4. Dispatching Experience 5. Computer and Keyboarding skills preferred. 6. Critical Thinking Skills 7. Preferred; Knowledgeable towards Microsoft Windows and Microsoft Office suite. 8. Preferred;Knowledgeable towards Zoll Rescue-net Dispatch and E-pro-Scheduler software. (This job description does not create an employment contract, Implied or otherwise.) 61 Job Title: Marketing Specialist Class: Sales Department: Marketing FLSA Status: Exempt Revised: April- 2014 Pay range: Salaried Job Summary Marketing Specialist will contribute to developing Ambulance Service marketing for North State Medical Marketing Specialist must be well versed in tools, benchmarks and trends as pertains to marketing. Specialist will contribute to and then implement, track and report on outcomes of marketing initiatives. Marketing Specialist must be able to work with customers as well as develop and maintain positive relationships with a variety of individuals. Marketing Specialist will be marketing to Individuals, Municipalities,Nursing Homes, Hospice, Hospitals, and other facilities for an ambulance company ESSIENTIAL JOB FUNTIONS: (Any one position may not include all of the duties listed, nor do the listed examples include all tasks which may be found in positions of this class.) 1. Work in conjunction with NSMT-CEO to develop marketing strategy for NSMT. 2. Develops and implements marketing initiatives for NSMT, and provides back-end analytics/reporting for same to NSMT-CEO and other as needed or requested. 3. Participates in general staff meetings on regular basis. 4. Attends management meetings when scheduled. 5. Represents the company in a professional manner at all times. 6. Communicates in writing and verbally with staff to ensure on time performance and quality customer service. 7. Serves as Liaison between Customers and NSMT 8. Assist customers with billing questions for facility 9. Develops and execute marketing and social media content. 10. Develops strong relationships with external partners and customers 11. Ensures all work is properly reviewed and approved prior to release. 12. Works with the President/CEO to develop customer contract agreement. 13. Ensures company brand and marketing standards are maintained. 14. Adheres to all company policies and procedures, compliance and applicable regulations. 15. Coordinates, Provides and Attends job related training 16. Solicits and reacts accordingly to positive and negative resident feedback. 17. Attends and participates in training seminars as requested. OTHER JOB FUNCTIONS 62 1. Performs related duties as required. (Management reserves the right to add or amend duties at any time.) KNOWLEDGE, SKILLS,AND ABILITIES 1. Must possess ability to provide clear, concise communication.. 2. Must possess strong writing skills with good grammar, spelling and punctuation. 3. Must possess communications and interpersonal skills. 4. Must possess the ability to develop effective presentations. 5. Must possess demonstrated ability to meet tight deadlines in highly visible projects. 6. Must possess excellent work ethic and time management skills; must be a highly motivated and highly organized independent thinker and worker. 7. Excellent marketing planning and analysis skills required. 8. Strong organizational skills required. 9. Strong creativity, imagination, enthusiasm and customer-service focus are desired.. 10. Proficiency in Microsoft Word, Outlook, Excel and PowerPoint are required. 11. Must possess ability to provide clear, concise communication.. 12. Must possess strong writing skills with good grammar, spelling and punctuation. 13. Must possess communications and interpersonal skills. 14. Must possess the ability to develop effective presentations. 15. Must possess demonstrated ability to meet tight deadlines in highly visible projects. 16. Must possess excellent work ethic and time management skills; must be a highly motivated and highly organized independent thinker and worker. 17. Excellent marketing planning and analysis skills required. 18. Strong organizational skills required. 19. Strong creativity, imagination, enthusiasm and customer-service focus are desired.. 20. Proficiency in Microsoft Word, Outlook, Excel and PowerPoint are required. Physical Demands 1. Minimal lifting under 25 pounds. 2. Sitting for long periods of time. 3. Extended periods of work on the computer. MINIMUM EXPERIENCE AND TRAINING 1. Computer and Keyboarding skills preferred. 2. Must possess experience developing marketing plans. 3. Must possess experience implementing social media strategies. 4. Experience in sales and recruitment. 5. Must possess familiarity with marketing metrics and key performance indicators. 6. Health care industry experience is a plus but not required. (This job description does not create an employment contract, Implied or otherwise.) 63 is H-57-Workday 1. Office staff: Various Regular Rotating Schedules 2. Crew shifts;Various Regular Rotating Schedules 3. Staff schedules are based on various rotating shifts. Positions will be advised of specific hourly schedules upon hire. 4. During busy periods employees may be required to work extended hours. 5. The nature of our business sometimes demands workday or workweek hours differ from those set forth above. Variation to the schedule will be made or approved by department managers. 6. Staff will be advised of all long-term schedule changes prior to implementation. NSMT reserves the right to implement short term reassignments and schedule changes at will with prior notification to the employee. 7. Situations arise in which employees may be assigned to calls during their regularly scheduled shift that will make leaving at the appointed `end-of-shift' time impossible. Call which are assigned during the employee's regular shift hours, are expected to be completed. 8. At no time will any employee be given a call which was received after the end of their assigned shift without the agreement of the employee to take said call. 9. Refusing a call is considered gross misconduct and will lead to disciplinary action, up to, or including termination of employment. H-58-Payday Field Staff-Payday will take place on Wednesday of each week. Office Staff-Payday will take place on Friday of every other week. H-59- Employee Payroll Standards 1. Nonexempt(hourly)North State Medical Transport Employees will be compensated at a pre-determined hourly rate up to 40 hours a week and will be compensated at a rate of 1.5 times their hourly rate for hours worked over 40 in a given work week. 2. 30 minutes will be deducted for lunch daily per 12 hour shift. If an employee is unable to have 30 minutes of uninterrupted time during the employees 12 hour shift they shall notify the dispatcher to make appropriate changes to the employee time sheet. 3. Overtime is never at the employee's discretion. It shall only be incurred and paid at the request of the company through the employee's scheduler/manager. Scheduler/manager shall ensure that no unauthorized overtime hours are worked. 4. North State Medical Transport work week runs Thursday through Wednesday ending at shift change Thursday morning. 5. Exempt North State Medical Transport Employees generally work a standard work week but schedules will fluctuate based on job requirements. 6. Full Time employees are classified as any employee who works a regularly set schedule 36 hours or greater a week. 7. Employees not meeting the full time requirements will be classified as part-time and are 64 not eligible for full time benefits such as paid leave, health, dental and supplemental coverage. 8. North State Medical Transport pays nonexempt employees via direct deposit on Wednesday of each week. 9. North State Medical Transport pays exempt employees via direct deposit on Friday of each week. 10. Employees who anticipate the need for overtime to complete the week's work must notify the supervisor or dispatch staff to obtain approval before working hours that extend beyond their normal schedule. 11. All Time punches outside of normal work schedules require a reason be documented in Crew Scheduler. 11-60-On-Call Scheduling 1. An employee, who elects to sign up for an on call shift and is called in to work, shall be paid for the time worked or a minimum of two hours, whichever is greater. 2. An employee,who elects to sign up for an on call shift(M-F) and is not called in to work, shall be paid for(1)hour of pay. 3. An employee, who elects to sign up for an on call shift(S-Su) and is not called in to work, shall be paid for (2)hours of pay. 4. Time worked while on call will be calculated at the employee's regular rate unless overtime compensation is applicable. 5. Overtime will only be paid when total hours worked exceed 40 hours in a workweek. 11-61-Pay Advances 1. North State Medical Transport will decline all requests for early paychecks or pay advances. 11-62-Employee-Incurred Expenses Reimbursement 1. This policy establishes general guidelines and procedures to be followed when business travel or expenses are incurred. 2. North State Medical Transport will pay all actual and reasonable business-related expenses incurred by employees in the performance of their job responsibilities. 3. All expenditures must be approved by a manager prior to purchase. 4. Expenses not pre-approved will be subject to review. 5. Expenses incurred that were not pre-approved will be reimbursed if deemed to be necessary. 6. Expense request are to be submitted to Richard Hardin and supported by evidence of , proof of purchase, e.g.,receipts. 7. All overnight accommodations will be scheduled and paid through NSMT. 65 H-63-HIPAA Compliance... ..----<. See: NSMT HIPAA Compliance Policy Guide H-64-Compliance Policies Manual See: NSMT Compliance Policy Guide H-65-Confidentiality of Company Information Our clients, customers and other parties with whom we do business entrust the company with important infoiniation relating to their businesses, financial. It is our policy that all information considered confidential will not be disclosed to external parties or to employees without a"need to know."If an employee questions whether certain information is considered confidential, he/she should first check with the HR/Compliance department. This policy is intended to alert employees to the need for discretion at all times and is not intended to inhibit normal business communications. This policy provides guidance on non- HIPAA related Data. See: NSMT HIPAA Compliance Policy Guide for HIPAA related guidance It is the responsibility of all North State Medical Transport employees to safeguard sensitive company information. All employees sign confidentially agreements upon accepting employment with the company. In cases of conflict, these agreements supersede the Policy Manual guidelines that follow. 1. The nature of our business and the economic well being of North State Medical Transport are dependent upon protecting and maintaining proprietary company information. Continued employment with the company is contingent upon compliance with this policy. 2. Sensitive company information is defined as trade secrets or confidential information relating to products, processes, know-how, customers, designs, drawings, formulas, test data, marketing data, accounting, pricing or salary information, business plans and strategies, negotiations and contracts, inventions and discoveries. 3. When such information is transferred from one employee to another, the transferor must do all of the following: 4. Determine that the transfer is necessary and in the interest of regular company business; 5. Determine that the transferee has a need to know the information and has the necessary clearance. 6. Determine the information does not contain HIPAA or other protected information. 7. Ensure that all cover sheets or markings which identify the information as confidential 8. Give the information directly to the intended individual. 9. Electronic information requires delivery confirmation of protected company information. 66 10. Do not give it to a non-cleared employee, and do not leave it on the transferee's desk unattended. In consideration of their employment with North State Medical Transport employees will be exposed to information and materials which are confidential and proprietary and of vital importance to the economic well-being of the company. 1. Employees will not at any time disclose or use, either during or subsequent to their employment, any information, knowledge or data which they receive or develop during their employment which is considered proprietary by North State Medical Transport or which relates to the trade secrets of the company. 2.. Such information,knowledge or data includes the following which is by example only: policies, procedures,processes,know-how, designs, drawings, diagrams, formulas,test data, accounting or financial data,pricing or salary data,marketing data, business plans and strategies,negotiations and contracts, research, customer or vendor lists, inventions and discoveries. 3. Upon termination of their employment with North State Medical Transport they must promptly return any and all documents containing the above infoiination,knowledge or 1, data, or anything relating thereto,to the company. All inquiries from the media must be referred to Compliance Officer. H-66-Confidentiality of Company Electronic Information E-Mail The following guidelines have been established for using the Internet, company-provided cell phones and e-mail in an appropriate, ethical and professional manner: 1. Internet, company-provided equipment(e.g., cell phone, laptops, and computers) and services may not be used for transmitting, retrieving or storing any communications of a defamatory, discriminatory, harassing or pornographic nature. 2. The following actions are forbidden: using disparaging, abusive,profane or offensive language; creating,viewing or displaying materials that might adversely or negatively reflect upon NSMT or be contrary to NSMT's best interests; and engaging in any illegal activities, including piracy, cracking, extortion,blackmail, copyright infringement, and unauthorized access of any computers and company-provided equipment such as cell phones and laptops. 3. Employees may not copy, retrieve, modify or forward copyrighted materials, except with permission or as a single copy to reference only. 67 4. Employees must not use the system in a way that disrupts its use by others. Employees must not send or receive large files that could be saved/transferred via thumb drives. Employees are prohibited from sending or receiving files that are not related to work. 5. Employees should not open suspicious e-mails, pop-ups or downloads. Contact IT with any questions or concerns to reduce the release of viruses or to contain viruses immediately. 6. Internal and external e-mails are considered business records and may be subject to discovery in the event of litigation. Be aware of this possibility when sending e-mail within and outside the company. Right to Monitor All company-supplied technology and company-related work records belong to the company and not to the employee. NSMT routinely monitors use of company-supplied technology. Inappropriate or illegal use or communications may be subject to disciplinary action up to and including termination of employment. 1. Company computers and e-mail system are company property. 2. All employees are expected to use good judgment in using electronic mail and to avoid indiscretions such as offensive or inappropriate messages or any other message, the company deems inappropriate. 3. E-mail messages should be used for business and not for soliciting outside business ventures or other matters unrelated to the company's affairs. 4. Misuse of e-mail may result in disciplinary action up to and including termination. See: NSMT HIPAA Compliance Policy Guide for HIPAA Electronic Data and Hardware Guidance Social Media Purpose: The purpose of this policy is to provide North State Medical Transport employees with requirements and guidelines for participation in social media, where the employee's North State Medical Transport affiliation is known, identified, expected and presumed. North State Medical Transport views social networks such as web based discussion or conversation pages and other foiins of social networking such as Facebook, Twitter, etc. as significant new forms of public communication. As such, we hold all of our employees who engage in social networking to the same standards we hold for any public communications. Therefore, all employees have an obligation to North State Medical Transport to ensure any public communication they make, including social networking communications, must not negatively impact the reputation of the company or disrepute in any way to the company, its management, employees, patients,referring providers, suppliers, etc. Further, only management members are authorized to publicly speak on 68 behalf of North State Medical Transport. Therefore an employee must have prior authorization to be a company spokesperson to the extent that his/her social networking communications represent, or appear to represent, the view of North State Medical Transport. Guidelines: Identified below are general guidelines and examples of prohibited communications. Please note that this list shows examples only and is not intended to be, nor is it, an exhaustive list of prohibited communications. Instead, we have included this list to provide you guidance with respect to your social networking and other public communications. 1. Assume at all times your connection to North State Medical Transport is or will be known when engaging in any form of social networking. If you are expressing a personal opinion, make it very clear that your opinion does not reflect that of North State Medical Transport. 2. If you wouldn't say it at North State Medical Transport, don't post it on Twitter, Facebook, or any other public website while at or away from the office. 3. Never identify any patient or post any information that could allow others to identify a patient. Observe HIPAA restrictions at all times. Violation of HIPAA restrictions are grounds for immediate termination of employment. Release of HIPAA information may also subject the employee to legal action. For further guidance regarding HIPAA see: NSMT HIPAA Compliance Policy Guide. 4. At all times exercise discretion, thoughtfulness and respect for your colleagues, business associates and our customers. 5. Do not discuss internal policies or company operational issues in any manner. 6. Do not engage in public criticism or disparagement of North State Medical Transport, employees, patients, customers, partners, suppliers or competitors. 7. Do not share confidential or proprietary company information or similar information of third parties who have shared such information with North State Medical Transport. 8. Be mindful that all public communications that reference North State Medical Transport, including social networking communications, are subject to review by North State Medical Transport. Violations and Enforcement: 1. Violations of this policy may result in disciplinary action, up to and including termination of employment. Disciplinary action may depend on the extent that the public communication harms our practice. For certain violations, legal action and/or criminal liability are possibilities. H-67-Computer Usage Policy The purpose of this policy is to reduce the legal exposure to the company of unlicensed software and reduce the effort required to operate and troubleshoot employee's machines,this policy has been established to restrict the installation of unauthorized software and the use of company computers to visit and site deemed offensive. 69 This policy covers all electronic devices owned or operated by North State Medical Transport and covers operating systems, 3rd party software, freeware and shareware applications, utilities and servers. 1. Under no circumstances will any employee will be allowed to load software not permitted without petiiiission on any North State Medical Transport electronic device. 2. Under no circumstances will any employee will be allowed on any North State Medical Transport computer other than in the course of normal job duties. 3. Under no circumstances will any employee use North State Medical Transport computers to conduct personal business without pre-approval. 4. Under no circumstances will any employee use North State Medical Transport computers to conduct criminal activity. 5. Under no circumstances shall any employee use North State Medical Transport computers to visit any web site that is found to be sexually explicit, offensive or racially bias. 6. Any infraction of this policy will result in the immediate termination of said employee. 7. All electronic devices used to generate patient care records are the responsibility of the employee at all time. 8. See: NSMT Compliance and HIPAA Policy Guides for addition guidance Right to Monitor All company-supplied technology and company-related work records belong to the company and not to the employee. NSMT routinely monitors use of company-supplied technology. Enforcement Inappropriate or illegal use or communications may be subject to disciplinary action up to and including termination of employment. Any employee found in violation of this policy may be subject to disciplinary action up to and including tettuination. H-68-Conflicts of Interest The following policies are but a brief overview of NSMT expectation of Compliance. For additional information see: NSMT Code of Conduct Compliance Policy and HIPAA Policy Guide. 1. Employees must avoid any relationship or activity that might impair, or even appear to impair,their ability to make objective and fair decisions when perfoiniing their jobs. 2. At times, an employee may be faced with situations in which actions taken on behalf of NSMT may conflict with the employee's own personal interests. 70 3. Company property, information or business opportunities may not be used for personal gain. Employees with a conflict-of-interest question should seek advice from management or the North State Medical Transport Compliance Officer. 4. Before engaging in any activity, transaction or relationship that might give rise to a conflict of interest, employees must seek review from management or the North State Medical Transport Compliance Officer. 5. Violation of this policy will result in immediate dismissal. H-69-Outside Employment 1. Employees are permitted to engage in outside work or to hold other jobs, subject to certain restrictions as outlined below. 2. Employees with questions about possible conflicts regarding outside employment should seek advice from management or the North State Medical Transport Compliance Officer. 3. Activities and conduct away from the job must not compete with, conflict with or compromise the company interests or adversely affect job performance and the ability to fulfill all job responsibilities. 4. Employees are prohibited from performing any services for customers on nonworking time that are normally performed by NSMT. 5. This prohibition also extends to the unauthorized use of any company tools or equipment and the unauthorized use or application of any confidential information. 6. In addition, employees are not to solicit or conduct any outside business during paid working time. 7. Employees are cautioned to carefully consider the demands that additional work activity will create before accepting outside employment. 8. Outside employment will not be considered an excuse for poor job performance, absenteeism, tardiness, leaving early, refusal to travel or refusal to work overtime or different hours. 9. If NSMT determines that an employee's outside work interferes with performance, the employee may be asked to terminate the outside employment. 11-70-Gratuities to Government Employees or Officials 1. In adherence to government regulations,no employee may offer a gratuity to any government employee or official on behalf of, or in pursuance of, North State Medical Transport business. 2. Gratuities are defined as meals, drinks, gifts, expenses, cash or any other item of value, including personal service. 3. North State Medical Transport strictly forbids any form of a business gift to federal, state, or municipal employees. is 4. Management is charged with the responsibility of informing all employees of this policy and maintaining adherence to it 5. Violation of this policy in any forin will require immediate disciplinary action up to an including termination. 6. The severity of the violation may subject the individual to additional criminal charges 71 See: NSMT Code of Conduct and Compliance Policy Guide for Additional Guidance H-71-Gratuities to Customer or Supplier Representatives 1. Employees of North State Medical Transport may not offer to give or accept a gift, cash or other item of value including personal service from an existing or prospective customer, supplier or a representative of either in pursuance of business or in conjunction with negotiating business on behalf of this company. 2. Invitations extended by a customer or supplier to participate in any event or program should be referred to the NSMT Compliance Officer for approval on a case-by-case basis. 3. Violation of this policy in any form will require immediate disciplinary action up to an including termination. 4. The severity of the violation may subject the individual to additional criminal charges See: NSMT Code of Conduct and Compliance Policy Guide for Additional Guidance H-72-Political Activities In recognition of its responsibilities as a business citizen,North State Medical Transport encourages its employees to accept the personal responsibility of good citizenship, including participation in civic and political activities, in accordance with their interests and abilities. North State Medical Transport accepts without reservation the basic democratic principle that all employees are free to make their own individual decisions in civic and political matters. 1. No political activities or solicitations will be carried on within company premises or on behalf of the company. 2. Political activities are defined for purposes of this policy as activities in support of any partisan political issue or activities in support of, or in concert with, any individual candidate for political office, or of a political party, which seek to influence the election of candidates to federal, state, or local offices. The definition includes employees who are or may be candidates for political office. H-73-Kitchen/Break Room North State Medical Transport provides a kitchen/break room for the benefit of its employees. 1. Employees shall be responsible for keeping this area clean. 2. All trash should be disposed of in the trash container. Any empty aluminum cans or glass bottles shall be disposed of in the trash container marked"Aluminum Cans Only" or "Glass Bottles Only," whichever is applicable. 11-74-Visitors North State Medical Transport may occasionally get visitors. 1. Visitors shall be allowed entry after stating the reason for their visit. All visitors must 72 remain in the company of a staff member while on North State Medical Transport property. Visitors or individuals who provide services shall be escorted to the appropriate staff member for introduction upon arrival. 2. Access to the Dispatch area or any area containing patient information is prohibited unless proper authorization has been confirmed. 3. Access to all North State Medical Transport premises shall be restricted in accordance to HIPAA regulations. 4. No visitors will be allowed in the sleeping quarters of a NSMT facility at any time. 5. No visitors will be allowed to remain in the station or on NSMT property when the ambulance crew is not present.. 11-75-Office status during Inclement Weather/Disaster Operation 1. North State Medical Transport will be open for business at all times. 2. North State Medical Transport recognizes that circumstances beyond its control, such as inclement weather, national crisis or other emergencies do occur in such event the company will endeavor to notify all personnel of any change in scheduling or operations. 3. Employees may also contact their manager or company offices for infoimation regarding changes in scheduling or operations. Questions ? If you have any questions or concerns regarding these policies or the interpretation of these policies you should contact a member of Management: NSMT HR Department of the NSMT Compliance Officer. 73 Field Operations North State Medical Transport Policies & Procedures Effective Date: Effective Date: 010/01/2014 Command Structure 75 Safety 75 Personal Protective Equipment 75-76 Intended Use of Personal Protective Equipment 76 Dress Code/Uniforms 76-77 Jewelry and Accessories 77 Grooming and Hygiene 77-78 Daily Logs 78 Shuttle service Opertions 78, 79 Vehicle Operations 79, 80, 81 Responding to Calls 81-82 Medical Performance Standards 82-83 Transport Criteria 83 Deceased Patients 83-84 Transportation of Deceased Bodies 84 Hospital and Medical Facility Conduct 84 Supervisory Notifications 84-85 On-Duty Activities 85 74 0-1-Command Structure North State Medical Transport will at all times operate with the use of a command structure. The North State Medical Transport organizational diagram indicates the basic command structure: See Organizational Chart ADENDUM A Should any question arise over chain of command when there are no supervisors or ranking staff members present, the employee of highest certification and tenure shall be the determining factor? 0-2-Safety 1. It will be the responsibility for all employees engaging in field operations to maintain safety as the utmost priority in any situation. 2. Any employee who witnesses the potential for an unsafe act shall immediately call this to the attention of those in harm's way. 0-3-Personal Protective Equipment 1. North State Medical Transport will make available personal protective equipment(PPE) in compliance with all directives from the Occupational Safety and Health Administration [OSHA 1926.28a1. 2. North State Medical Transport field staff shall utilize all protective equipment provided. Should they not have the necessary equipment; personnel should immediately notify a supervisor/management member and avoid any situation where its use would be indicated. 3. Issued PPE will include, but not be limited to, protective eyewear, respiratory protection, non-latex gloves, safety vests, etc. 4. North State Medical Transport employees shall wear no PPE in the course of work until they have been properly trained with the equipment [OSHA 1910.132.F.1]. 5. OSHA does allow an exemption for emergency situations if the employee is briefed on the PPE and accompanied by another trained person while it is in use. 6. All PPE shall be properly maintained and kept in sound working order at all times by the individual employee. 7. If any PPE is found to be unable to function as intended, the employee should immediately contact his/her supervisor or a management member for replacement. 8. All PPE should be stored properly when not in use. 9. For the purpose of this policy, on-duty shall be defined as any time that an employee is actively engaged in field operations, including special events. 10. Personnel will not be permitted to wear protective equipment that was not issued to them by North State Medical Transport without specific permission from the Director of Operations [OSHA 1910.132(b)]. 11. Employees wishing permission to use equipment not provided by North State Medical Transport should place a written request to the Director of Operations completely describing the need and the piece of equipment. 75 12. This request to wear non-issued North State Medical Transport equipment will be evaluated to determine if the equipment meets adopted standards and is a suitable substitute. 13. Approved non-issued equipment will not be replaced by North State Medical Transport should it become damaged or destroyed. 14. Individual employees will be financially liable for the replacement of any lost or damaged equipment based on the negligence of the employee. 15. Accountability for PPE is the responsibility of the employee. 0-4-Intended Use of Personal Protective Equipment 1. Protective eyewear shall be worn in any situation where there exists a potential for flying objects and/or splashes from blood, body fluids, or other hazardous material. 2. Protective gloves shall be worn in any situation where there exists a potential for injury or exposure to an employee's hands. 3. Latex-style gloves shall be worn during all patient contact scenarios and whenever blood or bodily fluids are present. 4. Reflective traffic vests shall be worn at all incidents near the flow of moving vehicles or the need for the personnel to be highly visible. 0-5- Dress Code/Uniforms: 1. Employees shall maintain the highest standard of personal hygiene. 2. North State Medical Transport personnel shall always present themselves in a neat, clean, and professional-appearing uniform. 3. Uniforms shall be maintained in that manner throughout the entire shift. 4. Personnel are expected to report for duty in uniform and remain in uniform until a time that they are relieved and no longer are responsible for responding to calls. 5. After shave, perfume, or other scents shall be used sparingly. Office Staff: The office dress shall be business casual dress compliant with a business setting. Field Staff Uniform: 1. North State Medical Transport shall provide all full-time employees uniform shirts, winter wear. 2. North State Medical Transport shall provide all part-time employees uniform shirts and sweatshirts. 3. Each North State Medical Transport shall be responsible for furnishing their own, pants, shoes and sox which comply with the unifoliu standards. 4. Pants shall be khaki non-BDU type with no cargo pockets and free from wrinkles and soil. Uniforms shall not be excessively worn(i.e. rips, holes, faded, etc.) 5. Shirts shall be company-issue and clearly display the company name on the left chest. 76 6. Shirts shall be free from wrinkles and soil. They should not be excessively worn. 7. Any employee who has a uniform which does not meet the unifonn standard should notify the logistics officer for a replacement.- 8. Shoes shall be brown and cover the entire toe area, sandals or the like are prohibited for safety. 9. Footwear will be maintained in a clean manner. 10. Footwear that becomes worn to the point of not being safe or practical(worn soles, holes in material, etc) shall be replaced. 11. North State Medical Transport personnel shall wear brown or black socks with the uniform, and they shall be provided by the employee. 12. Belts shall be brown with a conservative buckle. 13. Scissor holsters, glove pouches and pager cases are strongly discouraged and must be approved by the management before use. 14. Jackets or sweat shirts shall be free from wrinkles and soil. They should not be excessively worn. 15. No employee shall wear the logo, emblem or partial uniform of any other agency while in a North State Medical Transport uniform. 16. North State Medical Transport personnel shall not wear North State Medical Transport issued equipment when working other jobs. 17. Personnel shall not wear any part of his/her North State Medical Transport uniforms in public, except while on duty. 18. Company picture ID with name and certification level shall be displayed at all times. 19. State OEMS certification or credential cards are considered a part of the duty uniform and each employee must be able to produce them while on duty. 20. North State Medical Transport personnel shall have available at least one replacement uniform (pants and shirt) whenever on-duty. 21. North State Medical Transport personnel may wear plain white sleeved, standard length crew-neck undershirts beneath the uniform shirt if desired. 22. The undershirts shall be free of any lettering or graphics. 23. Black, plain toboggan-style caps are permitted for wear during the winter months when weather conditions indicate that such protection is desirable. 0-6-Jewelry and Accessories These Policies and Procedures are to define what is permissible in the way of uniform or personal accessories. 1. North State Medical Transport personnel shall wear a watch capable of displaying seconds. 2. North State Medical Transport personnel may only wear sunglasses that are subdued in color-no bright colors 3. Any type of glasses or sunglasses keeping device shall be complimentary of the uniform— no bright colors. 0-7- Groomin g Hygiene H iene 77 1. Personnel will maintain their personal hygiene and appearance to the highest of standards, as this is important when dealing with members of the public. 2. Personnel will keep their hair neat and well groomed at all times, as it might interfere with their job function. 3. Hair will be maintained above the bottom edge of the shirt collar. 4. Hair restraint devices shall be of a single color and complimentary in nature to the color of the unifolin. 5. Employees shall be clean-shaven at the beginning of each shift. 6. Sideburns are not permitted to grow beneath the lobe of the ear and should be no more than 2" in width at their end. 7. Fingernails should be clean, short, and well manicured. 8. Personnel are discouraged from the use of fragrances designed to be long lasting (i.e. colognes, perfumes, etc.) or smoking while on-duty, as the resulting odors tend to aggravate certain medical conditions. 9. North State Medical Transport requires that any on-duty employee with a tattoo, that is visible when wearing any of the uniforms; have the tattoo completely covered if possible. 0-8- Daily Logs 1. North State Medical Transport personnel will be required to maintain a number of daily logs in order to document activity and to serve as a communications medium between crews. 2. ALS Personnel will properly document the transfer of responsibility for narcotics when changing shifts or roles. 3. ALS personnel finding any controlled substance missing without documentation should refer to Policy-E/F-18. 4. All narcotic use and waste will be properly documented on the patient care report. 5. Personnel will complete the daily inventory sheet for all ALS, BLS and Transport NSMT Vehicles. 6. North State Medical Transport personnel will notify their supervisor within 15 minutes of finding any equipment missing or any critical equipment not operating properly. 0-9—Shuttle Service Vehicle Operations All NSMT Shuttle vehicles must be equipped with the following equipment. All North State Medical Transport personnel are expected to operate shuttle vehicles in an efficient manner with regards to the safety of themselves and others. Nothing in this policy may be construed to permit the driver of a North State Medical Transport vehicle to operate in a reckless manner. 1. No employee of North State Medical Transport will operate any vehicle on duty without first having proper training for this equipment. 2. All Shuttle Drivers must hold a valid NC Drivers Licenses and be approved for coverage by the North State Medical Transport Insurance carrier. 3. All clients must be safely escorted to and from the vehicle by NSMT staff 4. Shuttle staff must assist all clients entering and exiting the vehicle. 78 5. The number of clients transported must not exceed available vehicle seating. 6. Once a passenger is safely in the vehicle they must be secured with proper safety devices such as lap and shoulder belts. 7. All clients' belongings must be secured safely in the back of the vehicle to reduce the potential of injury before a transport begins. 8. All clients' belonging must be stored securely in the vehicle and retrieved from the vehicle for the client by NSMT staff. 9. All clients' needs which arise must be addressed with regular regularly scheduled rest stops as needed but not to exceed 30 minutes. 10. In case of a medical emergency NSMT shuttle drivers must immediately call 911 to attend to shuttle clients then render first aid until EMS services arrive. Contact the office dispatch staff and notify them of the situation. 11. NSMT dispatch will immediately contact the facility, family or an appropriate contact for the client to notify them of the situation. 12. In case of an emergency situation NSMT staff will immediately contact 911 for appropriate response needs. Remove themselves and the client from any immediate life threatening hazard. Provide the appropriate care until additional services arrive. 13. In case of vehicle failure shuttle staff will notify dispatch staff to make appropriate transport arrangements along with notifications. Shuttle Service Vehicle Inspection 1. All Shuttle Vehicles must be inspected daily for (Safety issues, equipment, fuel and fluid levels. Any recognized issue must be addressed prior to operation. 2. Daily equipment inspections must me noted in the daily vehicle log book. 3. Any deficiencies must be corrected or brought to the attention of management. Shuttle Service Vehicle Equipment 1. Standard vehicle safety equipment and warning devices 2. Emergency First Aid Kit 3. Outside communication capabilities- (Cell Phone or Radio) C: 4. An approved vehicle fire extinguisher. 5. A copy of NSMT policies and procedures regarding shuttle transports. 0-10- Vehicle Operations AU North State Medical Transport personnel are expected to operate vehicles in an efficient manner with regards to the safety of themselves and others. Nothing in this policy may be construed to permit the driver of a North State Medical Transport vehicle to operate in a reckless manner. 1. All ambulances are prohibited from going into any space marked less than 10 feet in height. 2. If in doubt to the height of an opening, always use a spotter and proceed slowly. 79 Modes of Operation: Will address the operation of a North State Medical Transport vehicle as non-emergency, emergency, backing, or stationary. Non-Emergency Operation: Routine operation without the use of warning devices and in complete compliance with traffic laws. Vehicles in the non-emergency mode will adhere to all standard driving regulations. Emergency Operation: Urgent operation with the use of warning devices in compliance with applicable traffic laws. 1. Vehicles in the emergency mode may exceed posted speed limits and other applicable traffic laws when operated with due regard for safety. This exemption shall not,however, protect the driver of any such vehicle from the consequence of a reckless disregard of the safety of others (NC General Statute § 20-145). 2. Personnel operating North State Medical Transport vehicles will be individually responsible for moving violations, including"red light camera" citations (when not in the emergency mode). 3. All vehicles will come to a complete stop at all intersections until traffic is controlled in all directions. This includes stop signs, stoplight-controlled intersections, and caution light intersections. 4. All vehicles will utilize visual and audible signaling devices while in the emergency mode. 5. The intermittent use of warning devices is strictly prohibited; their use may only be discontinued once the vehicle has safely arrived at its' destination. 6. The use of air horns should be limited to intersections or other situations when encountering traffic. 7. When traveling through posted school zones, vehicles will continue in the emergency mode but shall observe all posted speed limits and traffic regulations for that zone. 8. When encountering stopped school buses, the vehicle will come to a complete stop to ensure that all pedestrians and the bus driver recognize the vehicle and not proceed until there are no hazards evident and all school bus warning devices have been suspended. 9. When encountering posted work zones, the vehicle will continue in the emergency mode but shall observe all posted speed limits for that zone. 10. Drivers of vehicles shall refrain whenever possible from using radios, telephones, or any other device that may degrade their ability to safely operate the vehicle. 11. Cellular phone usage is prohibited in the patient care area, while transporting a patient, except in the case of providing medical care. 12. All North State Medical Transport staff should limit telephone conversations while driving vehicles to only those necessary for current operations. Backing Operation: Any situation where the vehicle is moving in a reverse direction. 1. A spotter will be used whenever a North State Medical Transport vehicle is backing up as to avoid collisions. 2. Exemptions are allowed whenever personnel are involved with patient care and acting as 80 a spotter would impair patient care and for single-personnel vehicles. 3. Vehicle operators under these exemptions should make all attempts to ensure that their path is clear prior to moving the vehicle, as they remain responsible for the safe operation of the vehicle. Stationary Operation: Any situation where the vehicle is parked,either attended or unattended. 1. Vehicles parked at scenes should be placed to minimize, as much as possible, any hazards to the personnel,the vehicle, and the patient(s)with the emergency brake engaged. 2. At any scene potentially involving hazardous materials, vehicles should be parked to avoid hazards to the personnel,the vehicle, and the patient(s). 3. North State Medical Transport Vehicles should always be parked in marked spaces. 4. No vehicle shall be parked in restricted parking spaces (fire lanes,handicapped designated,no parking zones). 5. Whenever a vehicle is positioned in a manner that potentially blocks normal traffic flow (i.e. double parked, in or alongside roadways, etc.),the emergency warning lights will be activated to warn others of its location and increase scene safety. 6. Headlights shall be used at any time when windshield wipers are in use as a result of smoke, fog,rain, sleet, or snow, or when inclement weather or environmental factors severely reduce the ability to clearly discern persons and vehicles on the street and highway at a distance of 500 feet ahead(NC General Statute §20-129). 7. Each front seat occupant shall have safety and restraint devices fastened whenever the vehicle is in motion(NC General Statute §20-135.2A). 8. Personnel shall use seat and shoulder restraints in the patient care area of the vehicle whenever it will not impact patient care delivery. 9. Passengers riding in EMS vehicles shall be properly restrained at all times with either a seatbelt or stretcher cot straps. 10. Only approved personnel are permitted to operate North State Medical Transport ambulances while transporting patients. 11. The number of patients transported in an ambulance will be limited to one per transport unless operating in a governmental declared state of emergency. 12. All patients will be restrained on the cot with all safety devices prior to the vehicle moving. 13. North State Medical Transport prohibits the use of all tobacco products in North State Medical Transport vehicles. 0-11-Responding to Calls p g 1. North State Medical Transport personnel shall respond to calls as soon as they are available or within no more than ninety seconds from dispatch. 2. En route times which fall outside of defined guidelines may require written explanation at the request of the supervisor or Director of Operations. 3. Personnel shall assure that the station is securely locked and all security system are activated prior to leaving the station. 4. Appliances and other electrical devices shall be turned off prior to crews departing an NSMT station. 81 r' 5. Candles or other open flames are prohibited in North State Medical Transport stations. 6. Unit Staff are responsible for properly recording the location of the call and acknowledging the dispatch information. Dispatchers have final authority over call assignments. 7. Extensive dialogue between units and dispatching staff shall be kept to a minimum for safety. 8. Dispatch staff shall be notified of all unit status changes via Zoll Fleet Tracker or cellular phone. 9. Should a unit become delayed for any reason, they should immediately notify the dispatcher on duty. 10. This should be noted within the response delay areas on the patient call report. 11. When requesting additional resources to a scene, the request should be specific in nature and indicate a response mode. 12. Additional assistance should be requested for manpower whenever potential employee or patient injury or safety is compromised. 13. Any request for manpower or additional resources must be documented on the patient call report and an email notification sent to the Director of Operation. 14. When a patient presents at any North State Medical Transport station needing medical assistance or a North State Medical Transport unit comes upon a scene where medical assistance is required, they should immediately render care within their scope of practice. Crews shall immediately contact the on duty dispatcher and the local county 911 center via radio or telephone to initiate a local EMS response. 15. Patient shall be defined as any individual who meets any of the following criteria: A. Any person who receives basic or advanced medical treatment B. Any person who is physically examined by a medical responder C. Any person who has any visible signs of injury or illness D. Any person who has any medical complaint E. Any person who requires assistance F. Any person who is identified by anyone as a possible patient because of some known, or reasonably suspected, illness or injury G. Any individual that meets the criteria above will be documented using a call report and other necessary accompanying documentation 16. A false call shall be defined as: A. A call in which no patient is found B. A call in which the parties at the incident location deny calling North State Medical C. Transport, and all individuals and circumstances are not within the definition of a patient. D. Any call determined to be false should be properly documented to include any actions taken to find the patient and why the call was determined to be false. 0-12-Medical Performance Standards 1. North State Medical Transport personnel shall take to the patient any equipment 82 identified by dispatch staff or requested by facility staff. 2. An exception to this rule can be made when a source with the patient indicates that such equipment is not necessary. 3. Any additional equipment in which a need has been identified should be taken in upon arrival. 4. The attendant shall assume the primary responsibility for patient assessment and treatment on a call as well as all related documentation and reporting. 5. The driver shall be responsible for confirming the vehicle is in a state of readiness after each call. 6. Both crew members are responsible for ensuring their unit is clean, sanitized and restocked. 7. Day to day operations of crews is not a specific responsibility of one crew member or the other but rather the joint responsibility of both driver and attendant. 8. The vehicle should be ready to answer a call at all times. 9. Paramedics shall be the lead attendant in regard to final patient treatment. 10. ALS and BLS staff shall share patient care responsibilities. 0-13-Transport Criteria Refer to NCOEMS patient care Protocol and Procedures for additional guidance regarding treatment and transport. 1. Cardiac arrest patients should be transported to the nearest hospital. 2. Hospitals on diversion—North State Medical Transport dispatching staff should be notified for further transport instructions. 3. The attendant will contact the receiving hospital as early as possible in the transport sequence. 4. A brief radio notification should be given to the receiving hospital: A. Estimated time of arrival B. Patient Age C. Patient Sex D. Reason for Transport E. Vital Signs 5. The receiving facility staff should be made aware of the patient's arrival, belongings transported, paperwork and appropriate signatures should be obtained. 6. All signatures shall be acquired and witnessed by a third party whenever possible. 7. North State Medical Transport units clearing a hospital will return to service for the return of hospital personnel or equipment to the original location and dispatch staff should be notified of this diversion. 0-14—Deceased Patients North State Medical Transport Protocols and Procedures identify the indications and procedures for the management of deceased subjects. 83 1. EMS personnel should provide clear, concise, and detailed documentation of all death scenes as they are often cited as components of legal actions. 2. Patients with valid Do Not Resuscitate orders or Most forms will be managed according to North State Medical Transport Protocols. 3. Staff should be notified of any deceased patient found in a facility, the local 911 center should be notified for any patient found at home and witnessed arrest should follow the patient care protocols unless they have advanced directives. 4. Unless needed to assist with the medical, emotional needs of the family, or bystanders, North State Medical Transport units should leave the scene and returned to service when the call has been turned over to the appropriate agency or agencies. 5. No unit shall leave a scene until the patient has been released to another appropriate agency. 6. Any staff having questions regarding the above Policies &Procedures should immediately contact the management staff after rendering medical care. 7. Hospice patients shall be transported to the original point of destination unless otherwise pre-determined. 0-15- Transportation of Deceased Bodies I. It is not the responsibility of North State Medical Transport to transport deceased persons. At times this need may be required. 2. North State Medical Transport personnel shall only transport non-contagious, non- decomposing, deceased persons at the authorization of the Director of Operations or other administrator. 0-16-Hospital and Medical Facility Conduct 1. North State Medical Transport personnel should conduct themselves as health care professionals whenever at a hospital or medical care facility. 2. North State Medical Transport personnel will comply with facility regulations whenever at a hospital or other medical facilities, including but not limited to tobacco use, vehicle parking, etc. 3. Any staff which does not adhere to local facility policies will be subject to the disciplinary process. 0-17- Supervisory Notifications 1. Supervisors and managers will be notified of incidents based upon the severity of the event and potential for impact on operations. 2. Incidents will be categorized as either basic or significant in nature. 3. Each category will require notifications and documentation. 4. Basic and significant Incidents will require notification of the Supervisor, Director of Operations or administrative staff and the completion of an incident report on the event. Examples of Basic incidents include but are not limited to: 84 1. Minor damage to vehicle, station, or equipment. Missing equipment where theft is not suspected. 2. Non-functional equipment that did not result in a critical failure. 3. Damage by North State Medical Transport personnel to another's personal property. Examples Significant incidents include but are not limited to: 1. Significant damage to vehicle, station, or equipment. 2. Missing equipment. 3. Missing medications. 4. Non-functional equipment that resulted in a critical failure 5. Involvement of EMS in an incident that resulted in personal injury to either an employee or a citizen. 6. Assault on a North State Medical Transport employee. 7. Involvement of North State Medical Transport personnel in an incident that resulted in life-threatening injury or death to either a North State Medical Transport employee or a citizen. 8. Patient Care Outcomes with significant deterioration of a patient's condition. 9. Personnel will be responsible for making notifications to a member of company management. 10. If an employee has doubt about the severity of an incident a manager should be contacted for clarification. 0-18-On-Duty Activities For the purpose of this policy, on-duty shall be defined as any time that an employee is actively engaged in field operations, including special event stand-by coverage,training, and other like events. 1. North State Medical Transport crews are permitted to travel within their primary response areas when not assigned to calls. 2. North State Medical Transport vehicles should only be used for North State Medical Transport work related business. 3. Visits to private residences are prohibited without prior approval. 4. North State Medical Transport crews are permitted to dine outside of their station within their primary response areas. Questions ? If you have any questions or concerns regarding these policies or the interpretation of these policies you should contact a member of Management: NSMT HR Department of the NSMT Compliance Officer. 85 Equipment and Facilities North State Medical Transport Policies & Procedures Effective Date: Effective Date: 010/01/2014 North State Medical Transport Policies &Procedures NSMT Stations 87, 89 EMS Vehicles 89 Disinfection of EMS Vehicles 89, 90 Vehicle Maintenance 90 Tobacco 90, 91 Food and Beverages 91 Refueling of Ambulances 91 Changing Ambulances 91 Staff Vehicles 91 Medical Equipment 91, 92 Critical Failures 92 Documentation of Critical Failures 92 Lost or Stolen Equipment 92, 93 Cleaning Equipment 93, 94 Medical Supplies 94 Phaimaceutical Supplies 94 Controlled Substances 94, 95 Accountability for Controlled Substances 95, 96 Special Event Controlled Substances 96 Employee Parking 96 86 E/F-1-NSMT Stations North State Medical Transport stations will be kept clean and ready for public review at all times Completing daily station maintenance will be a second priority to ensuring the response readiness of the ambulance. Daily station duties shall include: 1. Sweeping and mopping all interior hard surfaced floors. 2. Sweeping out apparatus bays and cleaning up any fluid spills. 3. Vacuuming all carpeted floors. 4. Cleaning all bathroom facilities. 5. Removing all trash and replacing liners. 6. Wiping down all kitchen surfaces and dusting all other surfaces. 7. Straightening out all workstations, including forms, books, etc. 8. Washing and storing all dishes. 9. Smokers will empty ash containers and pick up any cigarette butts at the end of every shift and dispose of refuse in outside trash containers. Weekly station duties shall include: 1. Mopping out apparatus. 2. Cleaning of refrigerator and other appliances. 3. Thorough vacuuming behind and under furniture and beds. 4. Picking up debris in the outside areas of the station, including cigarette butts. 5. Weekly duties should be coordinated by the shift personnel assigned at each location. 6. Facility maintenance will be coordinated through a supervisor or North State management. 7. Requests for repairs at the stations, both during and after regular hours, should be coordinated through the management supervisor. ' Station regulations for maintaining order: 1. No weapons are permitted in North State Medical Transport facilities and vehicles except for firearms carried by sworn law enforcement officers acting in an official capacity. This includes all handguns,rifles, shotguns, bows,knives,pepper spray, mace, or other devices that are intended for use as a weapon. 2. No alcoholic beverages are permitted in North State Medical Transport facilities. 3. No medications, other than those properly prescribed to an employee or that are available over-the-counter, shall be in possession of employees on North. State Medical Transport 87 property. 4. The possession of sexually explicit materials in North State Medical Transport facilities is prohibited. 5. No pets will be maintained in North State Medical Transport Stations. 6. Personal vehicles should be parked in the marked spaces at each facility, respectful of handicapped spaces. 7. Personal vehicles should at no time be parked inside a station. 8. North State Medical Transport provides telephone service to all facilities for North State Medical Transport business and occasional personal use. 9. The use of computer,telephone or fax service at the stations for any business other than North State Medical Transport is strictly prohibited. 10. Use of telephone service for personal matters should be limited so as to not interrupt access to the station or units for official matters. 11. Under no circumstances should employees place personal long distance calls from a North State Medical Transport phone that will be billed to North State Medical Transport. 12. Employees will be expected to reimburse North State Medical Transport for any and all charges billed to North State Medical Transport telephone accounts, hardwire and cellular. 13. The use of company internet access for personal computer use is prohibited. 14. Cellular telephones provided in North State Medical Transport vehicles are exclusively for use on NSMT business. 15. Cellular telephone bills will be reviewed on a regular basis, resulting in detailed audits for any phone exceeding standard airtime amounts. 16. Any abuse of cellular telephones found through audits will result in disciplinary action, including reimbursement to North State Medical Transport for actual airtime used. 17. North State Medical Transport provides computers with Internet access at all NSMT facilities. 18. North State Medical Transport owns the internal email system and intranet, and all electronic communications sent, received, or stored on North State Medical Transport computer systems are the sole property of NSMT, and not the property of any employee. 19. Employee email is not to be considered"confidential" or"private."North State Medical Transport reserves the right to access and monitor computer systems, including employee communications, as it deems necessary. 20. Software is provided by North State Medical Transport and is not to be shared, copied, or otherwise pirated. 21. Only North State Medical Transport provided or authorized software is to be loaded onto North State Medical Transport computers. 22. The use of personal software or programs is prohibited, unless specifically authorized by North State Medical Transport administration. 23. The use of the Internet provides significant dangers to an organization. The Internet is to be used professionally and appropriately at all times. North State Medical Transport computers are not to be used for the upload, download, viewing, or distribution of any foiin of pornography or other obscene material or text. 24. Language used in electronic communications, including paging, is to be professional at all times. The use of inappropriate language (obscene, illegal, discriminatory, and intended to harass or defame others) is unauthorized. Its use may result in significant 88 disciplinary action, up to and including termination of employment. 25. Only computers authorized by North State Medical Transport are to be connected to the North State Medical Transport network connections provided at each facility. 26. North State Medical Transport facilities shall remain locked whenever crews are not present at the stations. See: North State Medical Transport Compliance and HIPAA policies for further guidance. E/F-2-EMS Vehicles 1. North State Medical Transport ambulances are designed to ensure the highest degree of safety, efficiency, effectiveness, and operability for NSMT personnel. 2. Ambulances will be cleaned in order to maintain a neat appearance and to ensure they are sanitary for patients, personnel, and visitors. 3. All response vehicles will be washed daily if weather conditions deem this feasible. 4. Vehicles will be washed at any time prior to 10:00 hours where the appearance of the vehicle is such that it does not properly represent the image of North State Medical Transport. This will be dependent upon the ongoing weather conditions. 5. Vehicles should be washed and dried with supplies as provided by North State Medical Transport 6. The interiors will be cleaned daily to ensure that all trash and debris are removed and that it presents with a neat, clean image for riders. 7. Vehicles should be vacuumed many times as needed basis or no less than once a week 8. Interior cab surfaces should be wiped down daily for infection control purposes 9. Interior cabinets will have all equipment removed and be wiped down weekly E/F-3-Disinfection of EMS Vehicles The procedure for the disinfection of North State Medical Transport vehicles will be categorized as either gross contaminated or non-gross contaminated. For non-gross contaminated vehicles, the following will apply: 1. Vehicle surfaces that are free from gross contamination will be wiped down daily with an EPA registered and approved tuberculocidal solution. 2. Employees are to wear gloves for hand protection during this process. 3. The doors to the vehicle should remain open until the product is dried to ensure proper ventilation. 4. The use of any diluted bleach solution is prohibited due to the potential for damage to metal surfaces and clothing For gross-contaminated vehicles, the following will apply: 1. Vehicles requiring significant decontamination will be removed from service until cleaning is completed. 2. Vehicle surfaces that are obviously contaminated with blood or other potentially 89 4: infectious product should be thoroughly cleaned so that all visible material is removed prior to disinfection. Such surfaces should be cleaned with a hot soapy water solution or commercial cleaner. 3. Employees are to wear gloves for hand protection during this process and at anytime such solution s are sprayed, facemask should be donned. 4. The doors to the vehicle should remain open until the product is dried to ensure proper ventilation. 5. Once the surface has dried and is determined to be free from gross decontamination, it should be disinfected according to the non-gross contaminated procedure. E/F-4-Vehicle Maintenance North State Medical Transport personnel will be required to perform basic maintenance and evaluation daily on their assigned response vehicle. For specific duties employees should follow the North State Medical Transport daily check off sheet. 1. The following is a list of tasks that should be completed as early into every shift as possible. A. Check oil level B. Check coolant level C. Check windshield washer solution D. Check tires for sufficient pressure and for wear E. Check all vehicle and emergency lighting F. Check all vehicle and emergency audible warning devices G. Check all seatbelts to ensure they are operating properly H. Check vehicle integrity for safety issues (broken windshields,mirrors, improperly functioning doors, damaged steps, etc) 2. Should any deficiencies be noted they should be reported through E-Pro to a member of management in order to maintain safe working conditions. 3. All mechanical defects and deficiencies should be noted in E-Pro online vehicle maintenance database as soon as they are identified. 4. At no time should a North State Medical Transport vehicle with a known deficiency, that impacts crew safety or medical operations, remain in service as a response unit. 5. Richard Hardin will maintain scheduled maintenance on North State Medical Transport vehicles. 6. Personnel should weeldy check mileage to identify service periods. If the vehicle has exceeded or is approaching the mileage limit, they should notify their district supervisor or Richard Hardin to schedule servicing. 7. North State Medical Transport personnel are prohibited from performing any maintenance on vital functions of the ambulances for which they have not been trained and approved by administration to complete. 8. Whenever a vehicle is removed from service for a mechanical problem, it is essential that 90 the crew inform Richard Hardin. 9. Crews should identify the reason for removing the vehicle from service and E-Pro online should updated in the vehicle maintenance database E/F-5-Tobacco 1. The use of tobacco products is prohibited in North State Medical Transport vehicles. 2. The use of tobacco products is prohibited in North State Medical Transport facilities. 3. Tobacco products shall only be used in designated areas. 4. Tobacco products shall be disposed of in appropriate receptacles after usage. E/F-6-Food and Beverages 1. No food or beverages will be allowed in either the patient module or exterior compartments of the ambulances due to the potential for contamination. 2. There shall be no consumption of food or beverages while driving an ambulance. 3. Employees are urged to use all diligence with open food and/or beverages in the cab of the ambulance to avoid spillage, especially in or near electronic equipment such as radios or sirens. 4. All spills should be cleaned up as soon as possible and all other debris vacuumed. E/F-7-Refueling of Ambulances 1. With the potential for all units to transport out-of-county or extended distances,North State Medical Transport units must maintain enough reserve fuel to complete the next call. 2. No North State Medical Transport unit will return to service with less than one-quarter a tank of fuel. 3. Units should be refueled whenever call volume is low. 4. Units refueling will remain in service for calls. E/F-8-Changing Ambulances 1. Whenever it is deemed necessary, crews will change over to a spare ambulance. 2. Crews are responsible for ensuring that all necessary equipment is transferred and that all equipment on the new unit is functioning properly. 3. When the change is complete North State Medical Transport personnel should notify their dispatcher which ambulance they are on in order to update the online vehicle database. E/F-9-Staff Vehicles 1. Non-Ambulance vehicles are to be maintained to the same standards as the ambulances. 2. Non-Ambulance vehicles should be kept refueled and clean 91 E/F-10-Medical Equipment 1. North State Medical Transport personnel shall inventory their vehicle at the beginning of each shift to ensure that equipment is present and functional and that the prescribed amount of supplies is on hand. 2. This inventory will include a set quantity of many items to ensure that overstocking or under stocking is not taking place. 3. The North State Medical Transport crew should immediately address deficiencies found during the daily inventory. 4. Personnel should perform daily maintenance checks on all equipment. 5. Personnel should monitor equipment throughout the work day, especially when on calls, to ensure that items are not left at scene. 6. Defective equipment should be reported immediately. 7. The defective equipment should be labeled as being defective with an explanation. E/F-11-Critical Failures 1. The critical failure of a piece of equipment is defined as any time the equipment did not operate according to specification while being used for its intended purpose. 2. Personnel should make notification to a supervisor/management to secure a replacement piece of equipment after a critical failure if its absence will have an impact on the quality of care delivered. For example, another unit should intercept should a cardiac monitor fail on a patient worthy of being monitored. 3. Upon a critical failure occurring, the personnel should immediately contact their supervisor/management. 4. That supervisor/manager will coordinate replacement of the piece of equipment and complete necessary documentation. E/F-12-Documentation of a critical failure shall include: 1. Incident report by employee using equipment at the time of failure on EPro. 2. Documentation by the supervisor/management of actions taken post-event. 3. Copy of call documentation should failure have occurred during patient care. 4. The role of investigating critical failures will lie with the Operations Director. 5. Should there be a need to make additional notifications (i.e. manufacturers, other EMS agencies, medical director etc.) regarding critical failures; this responsibility will lie with the Operations Director. E/F-13- Lost or Stolen Equipment In the event that a piece of equipment is lost, North State personnel making the discovery should contact their supervisor/management to initiate the replacement process and an investigation towards its recovery. 1. An incident report will be completed by the personnel making the discovery detailing when and where the equipment was discovered missing on E-Pro. 92 2. NSMT management will be responsible for an initial investigation to determine who would have last used the missing item and attempt to determine where it may have been left. 3. Should the staff suspect theft of the item, law enforcement agency with jurisdiction should immediately be contacted. 4. Any area that may be considered a crime scene should be preserved as such until determined otherwise by law enforcement. 5. The management member investigating the loss or theft will be responsible for completing the Property Damage/Theft Report via E-Pro. 6. If the missing equipment is a controlled substance, refer to Policy-E/F-18 for special procedures relating to these items. 7. If employee negligence resulted in the lost equipment,they may be asked to cover cost associated with replacing the item. E/F-14-Cleaning Equipment The procedure for the cleaning of North State Medical Transport equipment will be defined as p g p either non-gross contaminated or gross contaminated. 1. For non-grossly contaminated equipment,the following will apply: Equipment that is free from gross contamination should be wiped down after every use with an EPA registered and approved tuberculocidal solution. The following should be wiped down daily without exception: stretcher, mattress, and handles on all portable equipment. Employees are to wear gloves for hand protection during this process and at anytime such solutions are sprayed, a facemask should be donned. The equipment should be left outside of the unit until it has thoroughly dried and then restocked. The equipment should be checked for proper operation prior to being replaced on the ambulance. 2. For grossly contaminated equipment,the following will apply: Equipment that is obviously contaminated with blood or other potentially infectious product should be thoroughly cleaned so that all visible material is removed prior to disinfection. This equipment should be cleaned with a hot soapy water solution or commercial cleaner Employees are to wear gloves for hand protection during this process. If feasible, this equipment should be moved to a designated area at either the station or hospital for the decontamination process. The equipment should be left outside of the unit until it has thoroughly dried and then restocked. The equipment should be checked for proper operation prior to being replaced on the ambulance 3. For grossly contaminated biomedical equipment that cannot be cleaned and disinfected, this equipment should be removed from service and placed into a biohazard bag. This information shall be relayed to Richard Hardin as to the nature of contamination. Units will be out-of-service until restocked and ready to respond. 4. For non-disposable airway equipment,the following will apply: All non-disposable airway equipment should be thoroughly cleaned and disinfected after each use and properly stored to prevent contamination prior to its next use This category of equipment will include laryngoscope blades and handles, oxygen-powered ventilators, oxygen regulators, and CPAP control modules. The laryngoscope blades will be thoroughly cleaned after each use with a hot soapy water solution then secured in a latex glove. Upon return to the station,the blade will be placed in a sterilizing solution for an established 93 time period. After that time is complete,the blade shall be removed and dried, then replaced in the backup airway supply pack. All other non-disposable airway equipment will be wiped down using an EPA registered and approved tuberculocidal solution. Employees are to wear gloves for hand protection during this process and at anytime such solutions are sprayed, a facemask should be donned. The equipment should be left outside of the unit until it has thoroughly dried and then restocked. The equipment should be checked for proper operation prior to being replaced on the ambulance. E/F-15-Medical Supplies 1. Each station will have a designated area in which supplies will be stored. This will be separate from the storage for pharmaceuticals. 2. It will be the responsibility of the personnel assigned to that station inventory supplies to ensure it meets minimum required stock levels to operate. 3. Personnel should only reorder supplies when needed through. 4. The Quality Assurance officer will maintain a list of exactly what supplies should be maintained on each vehicle, including a quantity for each item. 5. Personnel assigned to vehicles should inventory them each day to ensure that the desired quantity is present at the beginning of each shift and is replenished upon returning to the station after each call. 6. Ambulances should be restocked after each run or as soon as possible to ensure they are at all times ready for response to full capabilities. 7. Medical supplies stocked by North State Medical Transport are intended for use in the treatment of patients encountered in the course of work and should not be used otherwise. E/F-16-Pharmaceutical Supplies 1. All medications and intravenous fluids will be stored within climate-controlled areas of North State Medical Transport facilities in the provided metal locker. 2. The ambient temperature of these storage areas will be maintained at all times between 50 and 80 degrees F. 3. All medications will be stored within their original packaging material. 4. The exception will be vials that come in a bulk packed and not individually packaged. 5. Vials will be stored so they are not routinely exposed to long periods of sunlight. 6. At any time medications and intravenous solutions are exposed to temperature extremes, management should be consulted to determine if that stock should remain in service. 7. All medications, intravenous solutions, and other dated materials shall be visually inspected on the 15th of the month to determine what stock will expire at the end of the month. 8. A list should be sent to Richard Hardin on this day to ensure that sufficient stock is on- hand for replacement at the end of the month. 9. Expired medications, intravenous solutions, and other dated materials will be removed from stock on the last day of every month. 10. All vehicles should be restocked to established quantities immediately upon returning to a North State Medical Transport station after a call. 94 E/F-17-Controlled Substances 1. ALS Personnel will properly document the administration and waste of controlled substances. 2. Personnel will complete the daily inventory sheet for all ALS, BLS and Transport NSMT Vehicles. 3. All controlled substances will be maintained in a secure locked location. 4. The system for maintaining inventory on controlled substances will involve two separate logbooks. 5. The paramedic administering the controlled substance will be responsible for documenting the information in the logbook assigned to the specific North State Medical Transport response unit, stored in the locked drug cabinet. 6. The logbook will remain together if a unit is switched. 7. The paramedic administering the controlled substance will contact the operations chief when narcotics are used to obtain replacement. 8. All narcotic use and waste will be properly documented on the patient care report 9. The operations chief will document the appropriate information into a master log located in the pharmacy supply safe. 10. All broken or contaminated controlled substances will be properly documented in all logbooks with a written explanation of how the substance was disposed. 11. All actions regarding controlled substances shall be witnessed by a second party. 12. All amounts of wasted controlled substances will be properly documented and witnessed. 13. The manager will not issue replacement controlled substances unless presented with the properly documented call report and log book. E/F-18-Accountability for Controlled Substances The following procedure will be used to establish the accountability for controlled substances on a daily basis and applies to response units 1. The off-going shift's attending paramedic will unlock the drug locker to visually inspect all controlled substances with the off-going shift's employee in their presence. 2. Both paramedics will sign a daily accountability form verifying the process took place and noting the quantities present 3. Failure to complete and document this process will result in disciplinary action. 4. North State Medical Transport personnel will notify the Operations Chief immediately of �. finding any missing controlled substances. 5. The supervisor is accountable for ensuring that this process and documentation occurs on a consistent basis. 6. If all controlled substances are not accounted for, both the oncoming and off going paramedics, supervisor and director shall be notified. 7. Failure to immediately call a supervisor/manager establishes acceptance of accountability for the controlled substances by the oncoming shift paramedic. 8. All personnel that were assigned to the unit where the controlled substance is missing shall remain until a supervisor/manager arrives. 95 9. Once it has been determined that the controlled substance was not misplaced, the law enforcement agency with jurisdiction will be requested to complete a theft report and initiate an investigation. 10. A separate investigation will be initiated by the director of operations to determine what accountability practices North State personnel did or did not follow. 11. North State personnel are subject to investigation procedures at the direction of law enforcement 12. The Director of Operations will be responsible for making the necessary notifications to the Drug Enforcement Administration and State DHHS. E/F-19-Special Event Controlled Substance Issuance 1. Controlled substances for special event crews will be stored in the locked drug safes 2. Employees will contact a member of management to receive the narcotic for a specific event 3. Upon returning the medications the on duty supervisor or a member of management shall be notified to re-secure the controlled substances E/F-20-Employee Parking 1. North State Medical Transport Employees should park personal vehicles in marked parking spaces. 2. Employees should avoid parking in any area which poses an obstruction to any unit travel Questions ? If you have any questions or concerns regarding these policies or the interpretation of these policies you should contact a member of Management: NSMT HR Department of the NSMT Compliance Officer. 96 1 i A. h4 r .� �), _— ICJ7� -, , , i. 1 si'' i F_ i ia• , ek P ' �v'r(' ,7-7 ' ,1 i t s ' (.' 1 ,_._ I _,. : ;y, U �([ __ J �� �RIfl 3lhlr A�iy. �-f J d 1 passion ■ i I I l 1 J 1 1 Table of Contents Cover Page 1 Table of Contents 2 Policy on Duties of Compliance Personnel 3,4,5 Policy on Patient Confidentiality 6 Policy on Reporting Issues and Areas of Non-Compliance 7,8 Policy on Compliance Committee 9 Policy on Excluded or Debarred Persons or Entities 10 Policy on Non-Retaliation 11 Policy on Employee Training 12,13 Policy on Records Management 14,16 Policy on Relevant Health Care Laws 17,22 Policy on Marketing to Consumers and Patient Referral Sources 23,26 North Carolina False Claims Act 27,28 Policy for Contractual Agreements with Health Facilities 29,30 Policy on Personal Service Agreements with Potential Sources or Recipients of Patient Referrals 31 Policy on Hardship Waivers of Coinsurance and Deductibles 32,34 Policy on Relationships with Billing Agents 35,36 Policy for Dispatch Personnel 37,40 Policy for Medical Transport Personnel 41,44 Policy on Obtaining Patient Signatures 45,46 Policy on Determination of Medical Necessity 47,49 Policy on Repetitive Patients 50,52 Repetitive Patient Assessment Form 53,54 Physician Certification Statement Form 55 Advance Beneficiary Notice of Non-Coverage Form 56 Policy on External Audit Notifications 57 2 Policy on Duties of Compliance Personnel PURPOSE: NSMT has adopted this Duties of Compliance Personnel Policy to provide an overview of the responsibilities the Compliance Department has to ensure NSMT operates within the parameters of all applicable healthcare laws and regulations. POLICY AND PROCEDURE: INTRODUCTION The NSMT Compliance Officer is charged with overseeing the overall administration of NSMT Compliance Program. An individual may hold more than one title with regard to the position of Compliance Officer. The NSMT Compliance Officer may be assisted by Managers, Compliance Administrative Assistants and Administrative personnel (collectively referred to as (`Compliance Personnel".) NSMT has delegated authority to the NSMT Compliance Officer to undertake and comply with these responsibilities and to have open access to senior management. ETHICS &COMPLIANCE PERSONNEL North State Medical Transport Compliance Officer The Compliance Officer shall be responsible for directing and supervising the compliance functions at NSMT, and all aspects of the development, execution,monitoring of the NSMT Compliance Program. Duties will include but are not limited to: • Report regularly to the NSMT CEO; i". • Oversee the implementation and administration of NSMT Compliance Program; • Develop programs to educate and train NSMT employees with respect to NSMT Compliance Program; • Ensure that all employees are complying with NSMT Compliance Program; • Ensure that any potential violations or irregularities are promptly investigated and addressed; • Attend training to maintain a knowledge of current trends in compliance, including, but not to, Medicare and Medicaid; f' • Be available to discuss, confidentially, employee concerns regarding compliance with the law and NSMT operating policies and procedures; 3 • Oversee both internal reviews and reviews performed by outside professional firms; and • Assist management in communicating with the Billing Contractors, Medicare carriers, and Federal or State agencies to discuss reimbursement issues. • Assisting with programs to educate and train all employees with respect to the NSMT Compliance Program; • Performing or assisting in reviews of various aspects of NSMT operations and presenting findings to the CEO and NSMT Management; • Determine the adequacy of any corrective action taken to improve deficient or problematic conditions or processes; • Overseeing preparation of responses to Carrier audit requests; • Reviewing Patient Business Services personnel files to ensure that employees have been properly screened prior to employment with NSMT; • Ensuring that contractual agreements with facilities receive proper review for compliance with all applicable laws, regulations and NSMT policies; • Maintaining a log of various compliance issues and all other tasks as identified. GENERAL DUTIES OF ALL COMPLIANCE PERSONNEL The NSMT Compliance Personnel are responsible for assisting with the following activities within the organization: Compliance reviews of the following departments: • Communications (Dispatch)procedures • Operational procedures • Medical Transport Personnel • Billing Contractors • Excluded employee screens • Fraud and abuse issues • Other areas of potential non-compliance • Monitor outside investigations/audits of all billing and operational procedures. • Implement and conduct employee training. 4 • Monitor for E-Pro anonymous compliance incident reporting. • Investigate areas of potential non-compliance. • Update management on new/revised federal and state regulations that affect the healthcare industry. The NSMT Compliance Department has developed and implemented specific policies to address the activities listed above. Please refer to the specific policy for more details. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 5 Policy on Patient Confidentiality INTRODUCTION NSMT is committed to protecting patient privacy. This Policy shall govern the storage, use and disclosure of any patient information. POLICY A.To ensure that all patient information remains confidential,NSMT employees, managers and owners are required to comply with all federal privacy regulations such as the Health Insurance Portability & Accountability Act (HIPAA) as well as all applicable state privacy statutes that are not contrary to the HIPAA regulations. B. To comply with the HIPAA regulation, NSMT has adopted specific policies and procedures related to the HIPAA Privacy Rule and Physical and Technical Security Rule. These policies govern NSMT actions with regard to protecting the privacy of all patient information. C. Questions related to NSMT's HIPAA Compliance Program should be directed to the Compliance Officer. For additional information regarding NSMT HIPAA Compliance please refer to the North State Medical Transport HIPAA Compliance Manual. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 6 Policy on Reporting Issues and Areas of Non-Compliance PURPOSE: NSMT has adopted this Reporting Potential Issues or Areas of Non-Compliance Policy to provide an overview of the responsibilities of both the employees and the Compliance Department to ensure NSMT operates within the parameters of all applicable healthcare laws and regulations. POLICY AND PROCEDURE: I. INTRODUCTION Adherence to the NSMT Compliance Program is vital. Accordingly, violations of law or the program will not be tolerated. Violators will be subject to corrective and disciplinary action in accordance with NSMT disciplinary policy. Violators may also be subject to state and federal penalties. Management is responsible for ensuring that employees are aware of and adhere to the NSMT Compliance Program. For clarification or guidance on any point in the Compliance Program, please contact the NSMT Compliance Officer. II. DUTY TO REPORT AND COMPLIANCE OFFICER INVESTIGATIONS Employees are expected to report any suspected violations of the Compliance Program, or other irregularities to their supervisor, manager, or the Compliance Officer. If the employee wishes to remain anonymous, that employee may submit his/her report through the anonymous NSMT notification portal found in E-pro under the anonymous incident reporting tab. All reports must contain sufficient inforniation for the Compliance Officer to investigate the concerns raised. No adverse action or retribution of any kind will be taken by the Company against an employee solely because he or she reports in good faith a suspected violation of the Compliance Program or other irregularity by any person other than the reporting employee. The Company will attempt to treat such reports confidentially to protect the identity of the employee who has made a report to the maximum extent consistent with fair and rigorous enforcement of Compliance Program. Any manager, supervisor, or other high-ranking employee who receives a report of a suspected violation or irregularity shall contact the Compliance Officer regarding this report. Upon receipt of a suspected compliance violation, the NSMT Compliance Officer will immediately begin a detailed investigation. The investigation by the Compliance Officer shall include interviews and the review of relevant documents. If the Compliance Officer believes that the integrity of an investigation may be compromised because of the presence of employees under investigation, the employee(s) allegedly involved in the misconduct may be removed from his/her present work activity, with or without pay, pending the outcome of the investigation. G The Compliance Officer will strive to keep all concerns/complaints confidential to the extent it is possible to do so. III. CORRECTIVE ACTION 7 The Compliance Officer will work with managers and supervisors to inforin any employee of allegations that may have been filed against him or her. Such notification may be delayed pending the outcome of any internal investigation the Compliance Officer deems appropriate. The employee will be given the opportunity, as appropriate; to state his or her position before any corrective action is imposed. If the NSMT Compliance Officer determines that an employee, agent, or independent contractor has clearly violated the law or Compliance Program, that employee, agent, or independent contractor shall be subject to appropriate corrective action as determined by NSMT Managers, and Human Resources Department. The extent of the corrective action will depend on the seriousness of the offense. A record of the event and the corrective action imposed shall be maintained in the employee's personnel file. Corrective action will be taken against a violator's manager(s) or supervisor(s) to the extent that circumstances reflect inadequate supervision or a lack of due diligence. In addition, managers and supervisors may be sanctioned for failing to detect non-compliance with applicable policies and legal requirements, where reasonable diligence on the part of the manager or supervisor would have led to the discovery of any problems or violations and given the Company the opportunity to correct them earlier. A record of the event and the discipline imposed against the manager or supervisor shall be maintained in the employee's personnel file. IV. RETALIATION Retaliation will not be tolerated against any employee. Corrective action will be taken against any employee who retaliates, directly or indirectly, against an employee who makes a good faith report of a violation of law or Compliance Program. In addition, managers and supervisors may be sanctioned for failing to detect non-compliance with applicable policies and legal requirements, where reasonable diligence on the part of the manager or supervisor would have led to the discovery of any problems or violations and given the company the opportunity to correct them earlier. A record of the event and the discipline imposed against the manager or supervisor shall be maintained in the employee's personnel file. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 8 Policy on Compliance Committee PURPOSE: Although it is the responsibility of all personnel to comply with the NSMT Compliance Program, NSMT has adopted this Compliance Committee Policy in order to establish a committee of personnel to have primary responsibility of the NSMT Compliance Program. Day-to-day administrative responsibilities are assigned to the NSMT Compliance Officer(CO). POLICY AND PROCEDURE: The NSMT Compliance Committee's responsibilities include: • Ensuring the proper evaluation and response to ethical and regulatory issues and concerns. Reviewing and revising NSMT compliance policies to ensure the standards are reasonably capable of reducing improper conduct. • Recommending and monitoring educational and teaching activities to ensure the Company's standards and procedures are communicated effectively to all employees. • Assessing results of internal/external reviews to achieve compliance with the NSMT standards. • Analyzing reports of misconduct and recommending and monitoring appropriate corrective action. • Ensuring proper enforcement with the Company's standards and procedures through appropriate disciplinary measures. Developing and publicizing a confidential reporting system that enables personnel and to report improper conduct without fear of retaliation. • The Compliance Officer/Committee is responsible for developing meeting agendas and distributing pertinent review information to members. • Members will be reviewed and set annually. • Members of this Committee include,but are not limited to (SEE ATTACHED) POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 9 Policy on Excluded or Debarred Persons or Entities PURPOSE: NSMT has adopted this Excluded or Debarred Persons or Entities Policy in order to ensure compliance with all applicable federal or state laws and regulations related to the employment of individuals or entities who are ineligible to participate in any federal or state healthcare reimbursement program including, but not limited to, Medicare and Medicaid. POLICY ANDPROCEDURE: I. INTRODUCTION NSMT is committed to hire and retain employees; independent contractors and officers ("employees")who will meet NSMT's high ethical standards for employment. NSMT has a duty to avoid hiring or retaining employees or contractors who have engaged in unlawful conduct including fraud or financial irregularities or other conduct which may harm other employees, patients, or the general public. NSMT will not knowingly employ any individual or entity that is listed by a federal agency as excluded, debarred, or otherwise ineligible for federal programs. NSMT shall not allow any person convicted in any local, state or federal court of any felony to hold the position of officer or director of the Company. II. SCREENING Prior to hiring any new employee, or contracting with entities, the OIG (Office of Inspector General) List of Excluded Individuals and Entities (LEIS) and GSA (General Services Administration) Excluded Parties List(EPLS) are reviewed to ensure none are excluded from participating in federal programs. For new employees, the OIG and GSA exclusion checks are conducted as part of an overall background check. If the potential employee is a clinician, it is the responsibility of NSMT to conduct the above verification on all potential hires. For new contractors,the exclusion checks shall be conducted as part of the initial due diligence process. A copy of verification of the screening for the new contractor will be sent to the Compliance Department and maintained on file. After the initial screening checks are conducted, the Compliance Depai tinent, or its designee shall conduct regular checks of the OIG and GSA exclusion lists to ensure no employees and/or contractors are listed as excluded or debarred. III. DOCUMENTATION OF COMPLETED SCREENINGS The Compliance Department designee will maintain confirmation that the screenings have been completed. As requested, or contractually required, the Compliance Officer or their designee will maintain a log that regular screenings have occurred and the results of the screenings. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 10 Policy on Non-Retaliation PURPOSE: NSMT has adopted this Non-Retaliation Policy to reinforce its commitment to prevent and protect employees from retaliation for reporting, in good faith, suspected wrongdoings and/or for assisting in an investigation. POLICY AND PROCEDURE: I. INTRODUCTION As outlined in NSMT Code of Conduct, it is the policy of NSMT to foster an environment of open communication so that all employees understand their obligations to report compliance concerns and understand that the Company will not tolerate retaliation against those who do so. In addition, reported concerns will be maintained confidentially, to the extent it is possible to do so. "Getting even"behavior is not tolerated and all reported allegations of retaliation are fully investigated by the Compliance Officer with the assistance of other departments, as appropriate. All Management is responsible for enforcing this policy. Individuals who violate this policy will be subject to the appropriate and applicable disciplinary process, up to and including termination or dismissal. II. INVESTIGATION OF RETALIATION CLAIMS, Employees who believe they have been retaliated against for reporting, in good faith, suspected wrongdoings and/or assisting with an investigation, should report the issue by submitting a report through the anonymous reporting portal found in E-Pro or by calling the Compliance Officer directly at 919-210- 1172. It is important to file the report of retaliation as soon as possible after the occurrence as a delay can impact the effectiveness of the investigation. After a report of retaliation has been received, the NSMT Compliance Officer will begin an investigation. The investigation involves interviewing all appropriate individuals and reviewing relevant documentation to determine the validity of the report of retaliation. Corrective action may be warranted pending the outcome of the investigation. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 11 Policy on Employee Training 1. INTRODUCTION NSMT recognizes that for this Compliance Program to be effective, employees must receive education and training as to the importance of compliance with applicable law and the Compliance Program. In this regard, NSMT has developed a training program for all of its employees so that all employees are familiar with the Compliance Program and understand all of its policies and procedures, including the Code of Conduct. IL IMPLEMENTATION A. As part of new hire orientation, all new employees will complete a one hour training session within the first thirty(30)days of employment that discusses the goals and objectives of the Compliance Program and familiarizes new employees generally with the Compliance Program. At the conclusion of the training session,new employees will be asked to complete the Statement of Understanding that they are aware of, understand, and will abide by the Compliance Program and Code of Conduct and Ethics. The Statement may be completed electronically if the training is completed online. B. After the initial orientation, all existing employees will receive annual training on the Compliance Program and Code of Conduct. In this training session, employees will review the existing Compliance Program, the Code of Conduct, any applicable policies and procedures, and will discuss material changes in these policies and procedures. The training session also will focus upon changes in federal laws and regulations. This training session will be conducted at the direction of the Compliance Officer. The training session may be completed online, or if needed face-to-face. When face-to-face training is necessary employees will sign an attendance form immediately after each face-to-face training session. The executed attendance form shall be filed in the secure Compliance department. Each employee must complete a minimum of at least one (1) hour of Compliance Program training every calendar year. Employees completing the training online will complete the Acknowledgment Form electronically. The Form will be tracked electronically by the Compliance department. An employee returning from leave, who has missed a regularly scheduled training session, must complete the training session within thirty(30)days of return. III. TRAINING SESSIONS A. The NSMT Compliance Department shall be responsible for developing and oversight of the annual training and new hire orientation sessions. The Compliance Officer shall keep a record of all such training sessions either electronically or via hard copy. Additional training sessions may be conducted as the need arises. When necessary, the Compliance Officer will take attendance at all training sessions with a Sign-In Form and will maintain a record of course attendance at any training session which is performed as part of the Compliance Program. Participation in and attendance at training sessions is mandatory and attendance of training sessions, including Code of Conduct, will be one of the criteria for which employees will be evaluated during their annual reviews. B. At the direction of the Compliance Officer, other training sessions may be held as the need arises to address changes in the NSMT Compliance Program, federal laws and regulations, or other issues of interest. Additional training sessions may be conducted for employees who have 12 responsibilities for specific compliance issues, such as employees responsible for billing government programs. In addition, the NSMT Compliance Officer may direct certain employees to attend additional continuing education classes. IV. TRAINING CONTENT - COMPLIANCE WITH NSMT's COMPLIANCE PROGRAM A. Employees shall be informed during the training session that compliance with the Compliance Program and the Code of Conduct is a condition of employment and that compliance with the Compliance Program and the Code of Conduct is one of the criteria upon which employees will be evaluated. B. Employees also may be required to participate in other mandatory training sessions. NSMT training sessions include, but are not limited to: sexual harassment, BBP, safety, and company policies. These sessions are in addition to those conducted by Compliance Officer pursuant to the Compliance Program. C. Failure to complete a training session conducted pursuant to the Compliance Program shall result in disciplinary procedures, up to and including discharge or teiinination from employment. D. Annually, each employee shall complete a Statement of Understanding which, among other items, certifies that he or she received and completed the general one-hour training session and any other training sessions applicable to that employee's position. The Compliance Officer shall keep these certifications on file for at least ten(10) years. The Statement can be completed electronically or hard copy. E. Managers and supervisors are responsible for ensuring adherence to the Compliance Program by the employees under their supervision. In this regard, it is the responsibility of every manager and/or supervisor to distribute all compliance guidance and revised training materials to every employee promptly upon receipt of the material. They must also infoini their subordinates regarding the requirements of, and compliance with, the Compliance Program. Supervisor and Managers are expected to maintain an open line of communication with their employees in which concerns can be reported and addressed without fear of retaliation. F. Managers and supervisors who fail to meet these requirements or fail to detect non-compliance with applicable policies and legal requirements,where reasonable diligence on the part of the manager or supervisor would have led to the discovery of any problems or violations and given NSMT an opportunity to correct them earlier, will be subject to disciplinary procedures,up to and including discharge or termination from employment. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 13 Policy on Records Management I. INTRODUCTION A. It is the policy of NSMT to have in place a cost effective records management policy addressing appropriate retention procedures. B. During the course of its business, NSMT generates and receives a substantial volume of documents. Certain records must be maintained for given periods of time, as specified in applicable laws or in contracts. The several purposes of this Records Management Policy are to: ensure that records are retained for appropriate periods of time; provide that records which are no longer useful are destroyed; and provide that records to be retained are stored methodically and economically. This Policy establishes procedures for the systematic review, retention and/or destruction of NSMT records. H. OBJECTIVES A. NSMT will maintain all records for the minimum period required by applicable state or Federal law or regulation or by contract. B. NSMT will retain records which may affect the obligations of NSMT for a period of time which will reasonably ensure the availability of those records when needed. C. NSMT will develop and maintain records management files adequate to document NSMT's compliance with all relevant laws. D. NSMT will destroy records regularly and methodically pursuant to a standard policy so as to avoid any implication that NSMT deliberately destroyed records in anticipation of a particular problem. E. NSMT will maintain a safeguard for all destruction procedures to ensure that the destruction of relevant records is halted immediately upon receipt of notice of investigation or legal process. F. NSMT will identify and safeguard appropriately all vital records. G. NSMT will ensure that records are secure and private, as appropriate. H. NSMT will maintain a policy that encompasses records maintained on electronic data processing media, as well as printed documents. III. RECORDS REVIEW AND RETENTION A. Annual Review NSMT will conduct a file review and purge process on at least an annual basis. This process consists of identifying and destroying unnecessary duplicate and multiple copies of documents, including drafts; reviewing and destroying documents which have exceeded 14 their required retention period; and identifying, grouping and labeling documents which require retention and transferring these documents to the designated Records Center or records storage site. Documents will be purged in accordance with the Records Retention Schedule attached to this Policy. B. Departing Employees The business files of employees who are terminating their employment will be reviewed concurrent with the employee's departure. These files may be destroyed, stored or released to the employee, as appropriate. C. Labeling and Marking Records storage containers must be labeled in sufficient detail that they may be promptly and accurately identified should retrieval prove necessary. D. Destruction In January of each year the Compliance Officer may designate an employee to review documents, to determine which records have reached their disposal date and to arrange for destruction of the documents. The destruction policy must take into account the need for confidentiality, e.g., shredding of confidential documents (see below). E. Confidentiality Patients' medical records, employee medical records and other records subject to confidentiality restrictions must be stored securely and destroyed in a manner that ensures confidentiality, such as shredding, mutilation or incineration. F. Documentation Each manager will develop a log system or control form to document the following steps in the records management process: 1. identification, control and maintenance of records in storage; 2. destruction of records when necessary and deletion from the records inventory. H. Vital Records NSMT will designate vital records those records which: are essential to the continuity of NSMT or to NSMT's legal and financial status; are necessary for fulfillment of obligations to employees, customers, patients. Vital records must be stored as necessary in a location for reconstructive use in the event of catastrophic document loss. J. Electronic Storage Records generated and maintained in NSMT's information systems or equipment may be archived electronically in lieu of maintaining paper records only with the use of technology, 15 policies and procedures approved by the Compliance Officer. When the records to be archived are patient records, billing records or any other records used in preparing or submitting claims, the policies and procedures shall also be approved by the Compliance Officer. Such policies and procedures shall provide for the maintenance of original paper records in the event of litigation or a government investigation potentially involving any record until such litigation or investigation is resolved. K. Investigations and Litigation Upon NSMT's receipt of notice regarding the initiation of an investigation or the service of legal process, the NSMT's Compliance Officer will notify management of potentially relevant documents as promptly as practicable and direct them to cease the destruction of any relevant documents pending further notice that the investigation or litigation has been concluded. L. Interpretation Any questions regarding the application of this Policy should be referred to the Compliance Officer. IV. POLICY REVIEW The Compliance Committee will review and update this Policy and the sample records retention guide in the normal course of its review of the Compliance Program, 16 Policy on Relevant Health Care Laws I. INTRODUCTION There are several federal and state fraud and abuse laws which govern the health care industry. The following federal laws are particularly applicable: 1. The Federal Anti-kickback Statute; 2. The Federal False Claims Statute; 3. The Program Fraud Civil Remedies Act; 4. State False Claims Acts; and 5. The Health Insurance Portability and Accountability Act of 1996/HITEC act of 2009 The policies included in Part II of NSMT's Ethics & Compliance Program have been developed in light of these specific health care laws and regulations. Each law is discussed briefly below. If you have any questions, you should consult your immediate supervisor,NSMT's Compliance Officer. 1 II. ANTI-KICKBACK STATUTE A. Overview The Federal health care program Anti-kickback Statute(the "Anti-kickback Statute"), (42 U.S.C. § 1320a-7b), imposes criminal penalties on individuals and entities that knowingly and willfully solicit or receive remuneration "in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service" or "in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under. . ." a Federal health care program. 1. Prohibited Inducements The Anti-kickback Statute prohibits a person from knowingly and willfully offering or paying remuneration to any person to induce that person to refer or purchase, lease, order or arrange for or recommend the purchasing, leasing or ordering of items or services for which payment may be made by a Federal health care program. 2. Remuneration The types of remuneration prohibited by the Anti-kickback Statute include, but are not limited to,kickbacks,bribes and rebates. Additionally,the Anti-kickback Statute expressly prohibits both "direct" and "indirect" remuneration. 17 3. Penalties Any person convicted of knowingly and willfully violating the Anti-kickback Statute shall be found guilty of a felony, and fined not more than $25,000 or imprisoned for not more than 5 years, or both, for each violation. Violators of the Anti-kickback Statute also are subject to exclusion from the federal health care programs upon a determination of a violation by the Secretary of Health and Human Services ("HHS"), regardless of whether a criminal conviction has been obtained. In addition, the Balanced Budget Act of 1997 grants the Secretary of HHS new authority to impose civil monetary penalties for each violation of the Anti-kickback Statute of: a. up to $50,000; and b. three times the amount of the remuneration in question. B. Safe Harbors and Exceptions 1 . Overview The Anti-kickback Statute includes limited statutory exceptions for certain fmancial arrangements, specifically an exception for employment arrangements and discounts. Additionally, the Department of Health and Human Services ("DHHS") has promulgated regulations,teliued "safe harbors," specifying certain payment practices that are excepted from the prohibitions of the Anti-kickback Statute. 42 C.F.R. § 1001.952, et. seq. However, the protection afforded by the safe harbor regulations is limited to very narrow circumstances. Paragraphs 2 through 7 below describe some of the statutory and regulatory safe harbors most pertinent to NSMT. 2. The Statutory Exception For Employment Arrangements and the Employment Safe Harbor The Anti-kickback Statute includes a statutory exception for "any amount paid by an employer to an employee (who has a bona fide employment relationship with such employer) for employment in the provision of covered items or services." Specifically, the safe harbors provide that the term "employee" has the same meaning as it does for purposes of 26 U.S.C. 3121(d) (2),which adopts the "usual common law rules." Nevertheless, DHHS also considers the purpose of the employment, the amount paid for the service, and whether• services were performed, in assessing the employment relationship, and might be expected to challenge "sham" employment arrangements despite the arguably blanket protection of this exception. 3. The Statutory Exception for Discounts and the Discount Safe Harbor The Anti-kickback Statute includes a statutory exception for "a discount or other reduction in price obtained by a provider of services or other entity under a federal healthcare program if the reduction in price is properly disclosed and appropriately reflected in the costs claimed or charges made by the provider or entity." The discount safe harbor regulation narrows the statutory exception through its restrictive definition of the word "discount". The discount safe harbor also prescribes specific disclosure standards for different categories of purchasers. 18 4. The Space and Equipment Rental and Personal Services and Management Agreement Safe Harbors The regulations create safe harbors for certain contracts for space and equipment rental and personal services and management contracts. These three separate safe harbors are virtually identical in their requirements. For each safe harbor, a written agreement must be executed. The term of the agreement must be for at least one year and must specify the aggregate payment amount as well as the premises, equipment, or services covered. If the agreement does not contemplate full-time services, the agreement must also specify the schedule of intervals, their precise length, and the exact charge for such intervals. In addition,the payments must be based upon fair market value, and not vary on the volume or value of any Federal health care program covered referrals or business generated between the parties. The services performed under the agreement must not involve the counseling or promotion of a business activity or other activity that violates any state or federal law. 5. The Small Entity Investment Interest Safe Harbor In addition to a safe harbor for large, publicly traded companies, the regulations create a safe harbor for investment interests in smaller companies, as long as these eight standards are satisfied: a. no more than forty percent(40%) of the value of the investment interests of each class of investments may be held by investors who are in a position to make or influence referrals to the entity; b. the terms on which an investment interest is offered to a passive investor in a position to make or influence referrals to the entity may not be any different from the terms offered to other passive investors; c. the terms on which an investment interest is offered to an investor in a position to make or influence referrals to the entity may not be related to previous or expected referrals; d. passive investor cannot be required to refer patients to the entity; e. the entity may not market or furnish the entity's items or services to passive investors differently than to non-investors; E no more than forty percent (40%) of the gross revenue of the entity may come from referrals generated from investors; an investor who is in a position g, the entity must not loan funds to or guarantee a loan for a v p to make or influence referrals; and h. the amount of payment to an investor in return for the investment interest must be directly proportional to the amount of the capital investment of that investor. 6. Restocking Safe Harbor 19 The OIG promulgated a safe harbor that protects ambulance restocking of emergency ambulances. The conditions for that safe harbor are found in the NSMT Compliance Policy on Hospital Restocking. 7. Compliance with Safe Harbor Provisions is Voluntary Compliance with the terms of each criterion in a safe harbor regulation is voluntary. Although compliance with these safe harbor regulations assures an entity or an individual that a particular practice does not violate the Anti-kickback Statute, an action or arrangement that does not satisfy each criterion of a safe harbor does not necessarily violate the Anti-kickback Statute. Rather, that financial arrangement merely lacks the assurance that it is protected from liability under the Anti-kickback Statute. M. FEDERAL FALSE CLAIMS STATUTES A. The Federal False Claims Act("FCA")prohibits anyone from knowingly presenting, or causing to be presented, a false or fraudulent claim in order to secure payment from the federal government. A person found to have violated this statute is liable of not less than $5,500 and not more than $11,000 for each claim, plus three times the amount of damages sustained by the federal government. The False Claims Act defines "knowing" and "knowingly" as: actual knowledge; deliberate ignorance of the truth; or,reckless disregard of the truth or falsity. Therefore, no proof of specific intent to defraud is required to demonstrate a violation of this Act. B. The FCA helps the federal government combat fraud and recover losses resulting from fraud in federal programs, purchases, or contracts. A person or entity may violate the FCA by knowingly: (1) submitting a false claim for payment, (2)making or using a false record or statement to obtain payment for a false claim, (3) conspiring to make a false claim or get one paid, or(4)making or using a false record to avoid payments owed to the U.S. Government(the "Government"). Lawsuits must be filed by the later of either: (1)three years after the violation was discovered by the federal official responsible for investigating violations (but no more than ten years after the violation was committed), or(2) six years after the violation was committed. C. An individual also has the right to file a civil suit for him or herself and for the government to challenge a FCA violation. The suit must be filed in the name of the government. Such an individual is called a qui tarn plaintiff or "relator". Successful relators may receive between 15 and 30 percent of the total amount recovered(plus reasonable costs and attorney fees) depending on the involvement of the relator and whether the government prosecuted the case. An individual cannot file a lawsuit based on public information,unless he or she is the original source of the information. D. The FCA contains important protections for whistleblowers. Employees who report fraud and consequently suffer discrimination are entitled to all relief necessary to be made whole, including two times their back pay plus interest, reinstatement at the seniority level they would have had except for the discrimination, and compensation for any costs or damages they have incurred. E. The Program Fraud Civil Remedies Act 20 Under the Program Fraud Civil Remedies Act, federal law also provides for administrative remedies against providers for false claims and statements, in the amount of$5,000 for each false claim or statement, and an assessment of up to twice the amount of such claim. These administrative civil remedies are described further in the Program Fraud Civil Remedies Act, 31 U.S.C. Sections 3801-3812. A "false claim" (for purposes of the administrative remedies) is defined as a claim that the person knows or has reason to know(i) is false or fraudulent, (ii) includes or is supported by any written statement which asserts a material fact which is false, (iii) includes or is supported by any written statement that omits a material fact, is false as a result of such omission, and is a statement in which the person making such statement has a duty to include such material fact, or (iv) is for payment for the provision of property or services which the person has not provided as claimed. A "false statement" is defined as a statement that the person knows or has reason to know asserts a material fact that is false or omits a material fact that makes the statement false. IV. STATE FALSE CLAIMS ACTS North Carolina also has a state false claims act that prohibits anyone from knowingly presenting, or causing to be presented, a false or fraudulent claim in order to secure payment from local and/or state government. North Carolina's false claims act is similar to the federal FCA and provide for lawsuits either by the government or a qui tam plaintiff(or "relator"). This law also includes whistleblower protection similar to the federal FCA. V. HIPAA ACT OF 1996 and HITEC ACT OF 2009 HIPAA includes three provisions pertinent to NSMT's Compliance program. These are summarized below: A. Beneficiary Inducements HIPAA specifically created a new provision which authorizes the imposition of civil money penalties for offering inducements to individuals eligible for Medicare or Medicaid if the offer or knows or should know that it will influence the patient to order or receive items or services from a particular provider, practitioner or supplier. Significantly, the statute defines remuneration as including the waiver of coinsurance and deductibles and transfers of items or services for free or for other than fair market value. However, there are limited exceptions provided in the statute. For instance coinsurance waivers that are based on financial need and meet other requirements are protected. There also are exceptions for incentives given to individuals to promote the delivery of preventive care as determined by HHS in regulations and gifts to beneficiaries of nominal value. B. HIPAA specifically makes it unlawful to "knowingly and willfully" embezzle, steal, intentionally misapply, or "otherwise without authority" convert any of the money, property, premiums, or other assets of a"health care benefit program" to the use of any person other than the rightful owner. HIPAA defines "health care benefit program" as "any public or private plan or contract, affecting commerce, under which any medical benefit, item, or service is provided to any individual. , ." HIPAA therefore makes it unlawful to engage in this conduct with respect to private health plans. C. HIPAA established certain requirements regarding the submission of electronic claims and the privacy and security of protected health information. Those requirements are set forth in NSMT's HIPAA policies and procedure 21 POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 22 Policy on Marketing to Consumers and Patient Referral Sources I. INTRODUCTION A. The objective of this Policy is to assist employees of NSMT in complying fully with all of the complex laws and regulations governing sales and marketing practices in the health care industry, B. This Policy governs interactions with all consumers, existing NSMT sources of patient referrals as well as those sources of referrals with whom NSMT is not currently doing business, but who may become NSMT sources of referrals. As this Policy cannot address all situations that may arise, this Policy also is intended to educate employees so they can recognize practices that are permissible, practices that are prohibited and practices for which employees should seek additional guidance from their supervisor and/or NSMT 's Management before proceeding. II. BRIEF OVERVIEW OF THE HEALTH CARE LAWS THAT REGULATE NSMT's MARKETING ACTIVITIES WITH SOURCES OF PATIENT REFERRALS It is against the law for anyone to offer anything of value to a consumer, referral source, or potential referral source, in order to influence that consumer, referral source or potential referral source to select NSMT's products or services for their patients. For more information, see NSMT's Policy on Health Care Laws. -T. GENERAL MARKETING POLICY FOR CONSUMERS AND POTENTIAL PATIENT REFERRAL SOURCES A. From time to time, NSMT may market its services directly to consumers and potential sources of patient referrals, and may desire to offer certain free items and services to consumers, potential referral sources or the general community in order to enhance NSMT's name recognition, visibility and goodwill in the community. B. Under no circumstances will employees of NSMT, or anyone acting on behalf of NSMT, offer any free item or service (or any item or service for less than a fair market value payment)outside the items authorized in this Policy to consumers, referral sources with whom NSMT is currently doing business or those referral sources with whom NSMT is not currently doing business, but who are in a position to do business with NSMT(i.e., become a referral source of NSMT). C. Marketing Personnel should not market NSMT's services as being "medically necessary" because the determination of medical necessity requires a case-by-case review of the particular facts and circumstances. Rather, it is important for Marketing Personnel to explain accurately what NSMT services may be covered depending upon key facts and circumstances. All Marketing Personnel shall receive training regarding "medical necessity" as part of their standard initial compliance training. This training shall be similar to the "medical necessity" training that Intake Personnel and Medical Transport Personnel will receive. See NSMT's Policies on Intake Personnel, Policy, Medical Transport Personnel and Policy on Medical Necessity. '. D. To prevent requests for services that are not medically necessary, Marketing Personnel, in conjunction with the Compliance Officer and Managment, shall develop a medical necessity training program for customers. This training should be available to all customers, and required for those requesting an excessive number of non-covered transports. In addition to the training, customers shall be provided with written material regarding 23 medical necessity and covered transports for distribution to appropriate facility personnel. Marketing personnel shall only use marketing and training materials which have been approved. IV. GIFTS AND HOSPITALITY FOR CUSTOMERS AND REFERRAL SOURCES A. NSMT occasionally may provide modest gifts to customers and parties who may be in a position to make referrals,but any gift from NSMT should have a fair market value of less than $100 (irrespective of NSMT's cost). The aggregate value of all such items given to any individual in any consecutive twelve month period must be less than$300. The purpose of the gift may not be to reward or induce referrals. B. In addition,NSMT may occasionally give customers and referral sources branded promotional items of minimal value related to a health care professional's work or for benefit of patients. Gifts may not be given in fog ii of cash or cash equivalents such as gift cards. C. It is appropriate for NSMT to meet with potential customers and referral sources to discuss its services, contract negotiations, and sales terms. It is appropriate for NSMT to pay for occasional hospitality only in the form of modest meals, receptions and other events for such personnel in settings that are conducive to the exchange of information. Hospitality extended in such situations should comply with the guidelines in A above(i.e., no more than$100 per event per person and$300 during any consecutive twelve month period.) It is also appropriate to pay for reasonable travel costs of attendees when necessary(e.g., for site tours or demonstrations of non-portable equipment). However, it is not appropriate to pay for meals, hospitality, travel, or lodging of guests of such persons or any other person who does not have a bona fide professional interest in the information being shared at the meeting. D. If an employee of NSMT, or anyone acting on behalf of the employee, would like to offer a nominal item or service not specifically authorized, or which exceeds the amount specified in this policy, the employee must seek review and prior approval from the Compliance department. V. AUTHORIZED INCENTIVES FOR INDIVIDUALS TO RECEIVE PREVENTIVE HEALTH CARE A. Incentives given to individuals to promote the delivery of preventative care are specifically recognized as exceptions to these health care fraud and abuse laws. Preventive care is defined in 42 CFR 1003.101 to mean items and services that; 1. are covered by Medicare or Medicaid; and are either pre-natal or post-natal well-baby services or are services described in the Guide to Clinical Preventive Services published by the U.S. Preventive Services Task Force (available online at http://odphp.osphs.dhhs.gov/pubs/guidecps). Such incentives may not be in the form of cash or cash equivalents and may not be disproportionate to the value of the preventive care provided.NSMT must receive fair market value compensation for the preventative services themselves(as distinct from the incentives to obtain such services). In accordance with this exception,NSMT has authorized that employees of NSMT, or anyone acting on behalf of NSMT, to offer the following incentives to receive preventative care(as defined above)without charge or at a reduced charge to NSMT's patients or potential patients in a reasonable and necessary quantity solely for the patient's use: a) health care pamphlets and similar informational items or training tapes are permissible if they are of nominal value and serve a genuine educational function; 24 b) transportation to and from preventative care services where such preventative services are offered on a compensated basis by NSMT at fair market value; and 4 any of the items specified in Part VI below or other items specifically approved by the Compliance department. VI. OTHER AUTHORIZED ITEMS FOR INDIVIDUALS A. The OIG has interpreted the prohibition on remuneration to beneficiaries to permit providers to offer beneficiaries inexpensive gifts (other than cash or cash equivalents) or services without violating the statute. For enforcement purposes, inexpensive gifts or services are those that have a retail value of no more than$10 individually, and no more than$50 in the aggregate annually per patient. The following are the only non- health related items that employees of NSMT, or anyone acting on behalf of NSMT, may offer, without charge, to NSMT patients or potential patients, so long as they meet the forgoing definition of"inexpensive": 1. CPR training offered to the public (or a segment thereof) at large; 2. participation in health fairs; 3. written materials (books, pamphlets, etc.) emphasizing relevant health and public safety matters; 4. small items with NSMT's logo, such as coffee mugs, pens, notepads, key chains, calendars and kitchen magnets; 5. greeting cards; 6. refreshments; and 7. other items that have been specifically approved by the Compliance Officer. VII. UNAUTHORIZED ITEMS A. Under no circumstances should employees of NSMT, or anyone acting on behalf of NSMT, offer any of the following types of free items or services to NSMT's consumers, referral sources or potential referral sources (or their respective patients), regardless of the retail value of the item or service: 1. cash or cash equivalents such as gift cards or gift certificates; 2. payment of patient's insurance premiums; 3. payment of patient's living expenses; 4. waivers of coinsurance and deductibles unless based on financial hardship authorized by other relevant NSMT policies; 5. free NSMT services (e.g., paramedics performing services other than caring for an NSMT patient); 6. courtesy transports; 25 7. any free use of NSMT vehicles by referral sources; 8. computers, computer software or fax machines (unless solely for use related to NSMT services approved by a Compliance Officer ; 9. TVs, VCRs and other entertainment-related equipment; 10. gifts or other items to any individual exceeding a retail (or fair market) value of$100 per item or $300 in any consecutive twelve month period; 11. lodging or travel expenses, except as provided in Section III.B above or with the express prior approval of the Compliance Department; and 12. other items not within the parameters in Section III above, unless approved by the Compliance department. 13. If an employee believes that an item or service is distinguishable from items listed above, the employee must seek review and obtain prior approval from the Compliance Officer, who may consult legal counsel in making the final determination. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 26 North Carolina False Claims Acts Information As referenced in Section IV of this Policy,the following is detailed summery of the North Carolina False Claims Law. This information is intended to comply with Section 6032 of the Deficit Reduction Act of 2005. If you have any questions regarding these summaries or other state laws, please contact the Ethics and Compliance Department. 27 ATTACHMENT I SUMMARY OF RELEVANT STATE FALSE CLAIMS LAWS NORTH CAROLINA The North Carolina False Claims Act("NCFCA") is intended to deter individuals from submitting false claims to the State. N.C. Gen. Stat. §§ 1-605, et sec] Liability and Damages/Statute of Limitations • Actions that violate the NCFCA include, but are not limited to: (1) knowingly presenting, or causing to be presented, a false claim for• payment or approval, (2)knowingly making or using a false record or statement to get paid by the state; (3) conspiring to defraud the government by getting a false or fraudulent claim allowed or paid; and(4)knowingly making,using or causing to be made or used, a false record or statement to conceal, avoid or decrease an obligation to pay the state. • Violations of the NCFCA are punishable by civil fines of not less than S5,500 or more than S11,000 per violation, plus three times the amount of damages which the state sustains because of the violation. Damages may be reduced if the party committing the violation discloses information prior to learning of an investigation, and the party cooperates with the investigation. • A civil action under the NCFCA must be commenced before the later of: (1) six years after the date on which the violation is committed; and (2)three years after the date when the facts material to the right of action are known or reasonably should have been known by the official charged with responsibility to act in the circumstances, but in no event more than ten years after the date on which the violation is committed. Qui Tam Actions/Whistleblower Protections • An individual (or qui tam plaintiff) may sue for violations of the NCFCA. Individuals who do so receive between 15 and 25 percent of the total amount recovered if the state takes over the case, and between 25 and 30 percent (plus reasonable costs and attorneys' fees) if the qui tarn plaintiff litigates the case on his or her own. If the suit is based primarily on information that was not provided by the qui tarn plaintiff, the court may limit the award to the qui tam plaintiff to no more than 10%. • The NCFCA provides whistleblower protections for employees who are discharged, demoted, threatened, harassed or in any other manner discriminated against by his or her employer because of acts taken to further actions brought under the NCFCA. Such employees are entitled to (1) reinstatement to the individual's position; (2) reinstatement of full fringe benefits and seniority rights; (3)payment of two times back pay,plus interest; and(4) compensation for any special damages sustained as a result of the discrimination, including attorney's fees. 28 Policy for Contractual Arrangements with Health Facilities I. INTRODUCTION A.As part of its business operations, NSMT enters into contractual relationships with various health facilities, such as hospitals and skilled nursing facilities (SNFs) ("health facilities"), to provide medical transportation and other services to patients of these facilities. Because health facilities are generally in a position to refer or influence the referral of patients to NSMT, and in some cases NSMT may be in a position to refer or influence the referral of patients to them (i.e., through the delivery of 911 patients), such contracts must be reviewed to assure compliance with state and federal anti-kickback statutes. B. The purpose of this Policy is to provide guidance to NSMT personnel in competing effectively for hospital and nursing home contracts ("health facility contracts")while remaining in compliance with the anti-kickback statute. That statue has been interpreted by the HHS Office of Inspector General("OIG") as prohibiting discounts on transports for which a health facility is financially responsible under Medicare Part A ("facility- responsible business") if even "one purpose" of the discount is to induce the referral of Medicare Part B or other federal fee for service business ("federal FFS business"). The OIG refers to trading discounts on facility- responsible business for referrals of federal FFS business as "swapping". II. GENERAL REQUIREMENTS FOR HEALTH FACILITY CONTRACTS NSMT's policy is to compete as aggressively and effectively as possible for health facility contracts within the bounds of the law. To accomplish this,the following guidelines will apply to health facility contracts. These guidelines are based in part on the OIG's anti-kickback safe harbor for services contracts and also on other guidance provided by the OIG. A. Contracts with health facilities shall be in writing, be signed by both parties, specify all the services that NSMT will perform for the facility, and have a term of at least one year(subject to earlier termination for cause). 1. An exception may be made to the requirement of a one year term in contracts where the health facility is charged rates equal to or greater than the Medicare allowable. 2. Exceptions to the requirement of a one year term may be made in contracts where the rates charged to the facility are below the Medicare rate then in effect only following approval by NSMT CEO. B. The rates payable by the facility must be consistent with the fair market value of the services rendered by NSMT, and may not be determined in a manner that takes into account the value or volume of any federal FFS business referred by the facility. 1. It is permissible to offer a health facility rates on its facility-responsible business which are equal to or greater than the Medicare allowable rate in effect at the time. 2. In the event NSMT wishes to negotiate with a health facility rates which are below the Medicare allowable then in effect,the discount below the allowable must be justified based on legitimate business factors. Such factors do not include the expectation of federal FFS business, since granting a discount on facility-responsible business for the purpose of securing referrals of federal FFS business is precisely the conduct that is prohibited by the anti-kickback statute. 29 c.In the event that a proposed health facility contract provides for a discount below the Medicare allowable, the contract must be reviewed and approved by the NSMT CEO. The CEO will only approve the proposed contract if: (1) the discount is based on legitimate business factors; and the contract negotiator(s)have certified the transaction does not breach the anti-kickback statue . POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 30 Policy on Personal Service Agreements with Potential Sources or Recipients of Patient Referrals I. INTRODUCTION From time to time, NSMT enters into arrangements for personal or professional services with other health care providers or organizations that will provide those services. Such arrangements include but are not limited to NSMT contracting for the services of a physician as a medical director. These arrangements are referred to as "personal services contracts". If such providers or organizations may be in a position to refer or influence the referral of patients to NSMT, or if NSMT is in a position to refer or influence the referral of patients to them, such contracts must be structured to assure compliance with state and federal anti-kickback statutes. Such contracts shall comply with this policy, except to the extent that any lawful exception may be approved by NSMT Ethics & Compliance Department. H. GENERAL POLICY FOR PERSONAL SERVICE AGREEMENTS A. All personal service agreements must specify the services covered under the Agreement. B.NSMT payments under the agreement must be specified in advance, commensurate with the fair market value of the services to be rendered for NSMT, and shall not be based directly or indirectly on the volume or value of any referrals between the parties. The personal services arrangement must not be intended even in part to induce the referral of business between the parties. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 31 Policy on Hardship Waivers of Coinsurance and Deductibles I. INTRODUCTION A.It is the policy of NSMT that all NSMT employees will make reasonable and consistent attempts to collect co- insurance and unpaid deductible amounts from patients.There are two exceptions to this collection rule:(1)if the patient is truly indigent and the patient's financial hardship has been established or if it is not cost-effective to collect the outstanding amount,the collection of these amounts may be waived.In the case of financial hardship,a Hardship Waiver Form will be signed by the patient. B. Items and services provided to patients of NSMT are reimbursed primarily through payments from third party payers and secondarily through payments from patients.Patient participation in the cost of health care has the effect of reducing the cost incurred by payers as well as creating a financial incentive for patients to be cost conscious consumers.Both Medicare law and contracts with third party payers require reasonable attempts to collect coinsurance and unpaid deductible amounts from NSMT patients. According to the Office of the Inspector General,the routine waiver of co-insurance and deductible amounts is considered to be a violation of Medicare law,which can result in: False Claims.-By routinely waiving co-insurance and deductible amounts,providers are indicating a willingness to accept a lesser charge.The assumption is made that the lower amount is actually the charge and that the provider is submitting false claims. Violations of the Anti-Kickback Statute-Routine waivers can be interpreted as an inducement to entice patients to a particular health care provider.Such an inducement violates the anti-kickback statute. Excessive Utilization-Routine waivers of co-insurance and deductible amounts can be viewed as encouragement by providers for patients to receive care that may not be needed because there is no out-of-pocket expense involved.This result in excessive utilization of items and services paid for by the third party payer. Medicare fraud and abuse laws have been extended to private insurance through the health insurance Portability and Accountability Act of 1996. GUIDELINES: Demonstrating a "Reasonable Attempt" A. Patients requesting Hardship Waivers ("Applicants") will be considered on a case by case basis. The total number of patients receiving waivers at the same time will be at the discretion of the NSMT CEO. B. An attempt to collect co-insurance and deductible amounts is considered reasonable and consistent if NSMT's Billing Contractor uses the same reasonable policy of collection for all patient accounts. Therefore, NSMT's Billing Contractor will use the same billing techniques, the same internal and external collections techniques, etc., for all similar accounts regardless of the desire to collect the patient balance. In situations in which it costs more to bill the patient than the amount being collected, these amounts may be waived. NSMT's patient accounts department will provide documentation for this exception to be valid. 32 All questions regarding this Policy on(ROUTINE WAIVERS OF COINSURANCE AND DEDUCTIBLES) shall be directed to Compliance Department. II. PROCESS FOR REVIWING HARDSHIP WAIVERS A. Decisions to provide Hardship Waivers shall be made on a case-by-case basis. B. Decisions to provide Hardship Waivers shall be based solely upon the information that the Applicant(or another authorized party on the Applicant's behalf)is required by this Policy to supply to NSMT. C. Applicants requesting Hardship Waivers must provide NSMT with the following: 1.The Applicant's most recent tax return, or other documentation of the Applicant's net income for the most recent year; 2. Information regarding the Applicant's current income status; and 3. Information regarding the Applicant's insurance status, including: a, the name of the insurance company; 4. the name of the policy holder; 5. the policy number; 6. the effective date of the policy; or a statement certifying that the Applicant is uninsured. D. All infoimation provided by an Applicant to NSMT regarding a request for Hardship Waivers will be kept confidential by NSMT.. III. DETERMINATIONS REGARDING REQUESTS FOR HARDSHIP WAIVERS A. NSMT will provide Hardship Waivers to an Applicant only if the following criteria are met: 1. The Applicant's net income for the previous year is equal to or less than the state defined poverty level, as evidenced by the Applicant's most recent tax return or other documentation; 2. The Applicant has no current source of income in an amount equal to or greater than the state defined hardship level; and 3. NSMT has determined that the Applicant is uninsured or underinsured B. If the Designated Personnel determine that the Applicant does not qualify for Hardship Waivers,then they shall: 1. Complete a Hardship Waivers Certification Form (See approved Compliance Forms), indicating that the criteria for Hardship Waivers have not been met. The Hardship Waivers Certification Form should be filed with the Patient Care Report; and 33 2. Notify the,Applicant of this determination. C. If the Designated Personnel determine that the Applicant qualifies for Hardship Waivers, then they shale: 1. Complete a Hardship Waivers Certification Form indicating that the income threshold level has been met, that the Applicant is uninsured or underinsured and recommend the level of Hardship Waivers to be provided. The Hardship Waivers Certification Form should be filed with the Patient Care Report; and 2. Notify the Applicant after final approval of the determination and advise the Applicant of the amount of the Hardship Waivers. IV. OBLIGATIONS OF NSMT PERSONNEL A, Under no circumstances will NSMT 's employees, or anyone acting on behalf of NSMT, offer any Hardship Waivers to NSMT 's patients, or potential patients. B. NSMT's employees shall not advertise the availability of Hardship Waivers in any way. C. Employees shall direct any questions regarding Hardship Waivers to NSMT Billing Contractor. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 34 Policy on Relationships With Billing Agents I. INTRODUCTION, Policy addresses general guidelines regarding the structure of billing agent agreements/contracts as well as operational considerations regarding the extent of billing agent rights and responsibilities. Such contracts shall comply with this policy. II. GENERAL STRUCTURE AND COMPENSATION ISSUES 1. provide that in receiving payment from Medicare, the agent acts only on behalf of North State Medical Transport; and 2. provide that the agent will act under strict compliance with all state and federal laws. III. OPERATIONAL ISSUES A. In addition to the general reimbursement issues discussed in Section II, billing agent agreements should address all of the following operational issues: 1. overpayments - how will overpayments be handled, what authority will the billing agent have to deal with third party payors.(Documentation, Timeline etc. 2. billing/medical records - what steps will the billing agent be required to take when a billing/medical record is incomplete and/or lacks sufficient documentation of medical necessity, who will the billing agent be required to contact and what authority will the billing agent have to fill in missing information? 3. payor contacts - when will a billing agent be peticiitted to contact a third party payor, what authority will a billing agent have in such a situation and how will the billing agent document third party payor contracts? 4. government audits - how will a billing agent be required to act during the course of a government audit, and if the agent will be following a government audit policy developed by the provider, how will the provider ensure that the agent is trained regarding the provider's policy? 5. general policies and procedures—Attestation that the billing agent maintains and adhere to compliance policies and how will compliance with these policies and requirements be ensured? 6. determinations of medical necessity - while billing agents will be without authority to determine medical necessity or to complete certificates of medical necessity, billing agents will provide routine education to customers, who will control the type of education information furnished and how will billing agents be trained in this regard? IV. LEGAL REVIEW AND RECORDKEEPING 35 A. All billing agent agreements to which NSMT is a party shall be reviewed and approved prior to execution by the CEO. B. All contract and/or changes to contracts for billing services shall be maintained by North State Medical Transport. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 36 Policy for Intake and Dispatch Personnel I. INTRODUCTION A.Dispatch Personnel play a vital role in NSMT's operational success and in NSMT's ability to comply with policies, procedures, complex health care laws and regulations. Dispatch Personnel are the "voice"NSMT and are the first contact patients or sources of patients (such as hospital)have with NSMT. B.NSMT has designed this Policy(the "Policy")to help you better understand the importance of your job tasks in light of these laws and regulations so that you can aid NSMT in complying with these laws and regulations. C. This Policy is in addition to any other Dispatch Personnel policies,procedures, or job descriptions. H. GENERAL DUTIES FOR INTAKE PERSONNEL A.As a Dispatch Person, you are responsible for making an initial assessment of"medical necessity" for each request for non-emergency transport before scheduling takes place. This determination is extremely important because payors generally do not reimburse NSMT for transports that are not "medically necessary". Also, inaccurate determinations of"medical necessity" may violate applicable law and/or make NSMT financially responsible for NSMT's ambulance services without recourse to the patient. In order to help you make accurate determinations of"medical necessity", you must obtain certain information during the phone call. This process should be in accordance with NSMT Operating Procedures. It is recommended that, at a minimum,the following information be requested: 1. The name of the requesting party/facility. The name and phone number of the person calling from the requesting organization; 2. The name of the primary payor and any secondary payor. (Local or regional policy may provide for additional questions regarding the payor(s)); 3. The origin and destination of the transport for the patient(important to verify addresses with the caller); 4. The reason for the transport(e.g., "patient discharged for rehabilitation post CVA" or "patient requires MRI") 5. For hospital to hospital, obtain the reason for the transfer: 6. Requires higher level of care or specialty services not available at sending facility((e.g. cardiac cath, pediatric neurology, liver transplant); B.Patient request(e.g. want to be closer to home—regular doctor does not practice at sending facility). 1. The condition of the patient that requires ambulance transportation(e,g, "immobilized fracture"); and 2. Inpatient status. C.NSMT must attempt to obtain a Physicians' Certification Statements (PCS)before it can bill Medicare for scheduled repetitive non-emergency transports and for other scheduled and unscheduled non-emergency ambulance transports of patients under the direct care of a physician. The specific requirements for a PCS depend on whether the transport is a repetitive transport or a non-repetitive transport. Dispatch Personnel must understand these requirements so that, when appropriate,they can explain them to requesting facilities and provide Operations and Billing Personnel with the information they need to comply with the PCS requirements 37 applicable to a particular patient. NSMT operating procedures may prescribe additional specific procedures for Dispatch Personnel to address PCS issues, so long as such procedures are approved by NSMT's Compliance Department. 1. Scheduled Repetitive Non-Emergency Transports: NSMT is required to obtain a PCS dated no earlier than sixty days prior to the date of service in order to bill Medicare for repetitive transports. The PCS must be on file, or must be obtained prior to the transport. "Repetitive transports" are those transports that occur three or more times during a ten day period or at least once per week for at least three weeks for treatment of the same condition, such as dialysis and respiratory therapy. This would exclude transports for follow-up visits relating to a single and non-continuing incident. The PCS for a repetitive transport must be signed by a physician. Subject to any approved local standard operating procedures, Dispatch Personnel should either verify that a PCS dated within the last 60 days is already on file at NSMT, or should notify the requesting party that a PCS will be needed before the transport. If the requesting party indicates that they do not have a PCS, Dispatch Personnel should offer to fax over a PCS foriii and should note that the patient is a repetitive patient and that no PCS is on file. Any information regarding the existence of a PCS or the need for one should also be included in the Zoll notes. It will be the responsibility of Medical Transport Personnel to obtain a PCS if required during transport. 2.Non-Emergency Services for a Facility Patient under the Care of a Physician: For these patients, NSMT must attempt to obtain a PCS within 48 hours after the transport whenever possible. If it is not possible to obtain a PCS signed by the physician, a signed PCS can be obtained from a P.A.,N.P., clinical nurse specialist, R.N. or discharge planner who is employed by the hospital/facility where the beneficiary is being treated and from which the beneficiary is transported, or employed by the beneficiary's attending physician, and who has personal knowledge of the beneficiary's condition at the time the transport is ordered or performed. Dispatch Personnel should mention the need for a PCS and, if needed, offer to fax over a PCS form. Any information regarding the existence of a PCS or the need for one should be included in the Zoll notes. D. If you determine that a Medicare transport is NOT "medically necessary" and therefore will not be a covered service, you should follow the NSMT operating procedures, which may include notification of the appropriate supervisor of the transport. The supervisor will assist in handling these types of transport requests. Some recommendations of appropriate processes include: 1. inform the person or facility who scheduled the transport that the payor will probably not cover the service and that the patient or facility will likely be responsible for the entire bill; 2. give the patient or facility the option to downgrade to a lower mode of transport, such as "Wheelchair Service"; 3. include in Zoll Dispatch Notes any approved rates; or 4. request payment at time of transport for all non-covered services to prevent improper billing to third party payors. See NSMT's Policy on Determination of Medical Necessity. E. Under the PPS system applicable to Skilled Nursing Facilities, some Medicare transports are the financial responsibility of the facility and some transports are billable to the Medicare Carrier. Dispatch Personnel shall determine whether the transport may be included in the PPS program. The process for making this determination should be done in accordance with approved operating procedures. Some recommendations of appropriate processes include; 38 1. ask the requesting party whether the patient is currently in a stay which is covered by Medicare Part A; and if so 2. obtain sufficient information about the reason for the transport to make a preliminary determination whether the transport is the financial responsibility of the facility. This information should be included in the Zoll Dispatch notes. III. GENERAL DUTIES FOR DISPATCH PERSONNEL A. Dispatch Personnel interact with Medical Transport Personnel to ensure that the appropriate level of service is sent to transport the patient from the point of origin to the point of destination. To that end, Dispatch Personnel have the primary responsibility for assuring that the appropriate level of service for transporting the patient is being dispatched at the appropriate time, and that this level of service is documented accurately. B. Dispatch Personnel must be able to convey, accurately, orders for transports and alert Medical Transport Personnel to any changes in the type of transport vehicle used. Dispatching the appropriate level of service is necessary in order to insure that the appropriate level of care is available to the patient and for NSMT to receive the proper level of reimbursement. For example, it is necessary to document the details when a patient requires a wheelchair level of service but is transported in an ambulance based on extenuating circumstances) C. Dispatch Personnel must document, accurately, information provided to the crew with respect to the patient condition, changes in call information and other pertinent information regarding the patient and/or the transport. D. For non-emergency transports, Dispatch Personnel are responsible for: 1. notifying Field Providers when an Advance Beneficiary Notice of Non-coverage is required; 2. receiving requests for specific levels of service (types of transports) from Intake Personnel; 3. dispatching Medical Transport Personnel, and a vehicle to transport the patient with the appropriate level of service (includes 911 transports); 4. notifying the Medical Transport Personnel of the level of service downgrade to ensure appropriate documentation on the Patient Care Report for billing purposes in cases where a higher level of service than that required had to be dispatched due to a shortage of vehicles and/or personnel (e.g. ALS ambulance dispatched due to system overload with no BLS Ambulances or wheelchair units available); 5. providing information to Medical Transport Personnel regarding the need to obtain a PCS, when appropriate. IV. QUALITY IMPROVEMENT A. NSMT will be responsible to develop, implement, and maintain ongoing quality improvement procedures to monitor call intake procedures. V. CORRECTIVE ACTION A. This Policy for Dispatch Personnel establishes the general policies and procedures which all Personnel must comply as a condition of employment with NSMT, This Policy is designed to ensure that each employee's performance conforms to the highest ethical standards and is in accordance with all applicable laws, rules and regulations. Any doubts or questions whatsoever as to the propriety of a particular situation, whether or not the situation is described within this Policy, should be referred either to your immediate supervisor or the Compliance Officer. 39 B. Any Dispatch employee violating any provision of this Policy will be subject to disciplinary action, up to and including discharge from employment. In addition, promotion of and adherence to this Policy and to the Compliance Program will be one criterion used in evaluating the performance of supervisors, managers, directors, and officers. See NSMT's Policy on Reporting of Potential Issues or Areas of Noncompliance. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 40 Policy for Medical Transport Personnel A. Compliance with the wide array of complex federal and state health care laws and regulations is a top priority of NSMT. B. Medical Transport Personnel ("Field Providers")play a vital role in NSMT's operational success and in NSMT's ability to comply with the complex health care laws and regulations. While Dispatch/Intake Personnel are the "voice" of NSMT, Field Providers are the "face" of NSMT,because they directly interact with patients. Because providing and documenting patient care is the center of your duties, it is very important for you to be courteous, customer friendly, and provide exceptional patient care at all times. C.NSMT has designed this Policy to help you better understand the importance of your job tasks and how they relate to NSMT's compliance to these health care laws and regulations. D. This Policy is in addition to any existing Medical Transport Personnel policy, protocols, or job descriptions. II. GENERAL DUTIES FOR CREW MEMBERS A. Ambulance Field Providers are the personnel who are responsible for transporting the patient and are generally paramedics or emergency medical technicians who must be licensed or certified according to state laws. B. Field Providers must notify management if there is a lapse, for any reason, of any required licenses and/or certifications required based on local and state regulations. Failure to immediately notify will result in disciplinary actions up to and including termination. C. Field Providers have an ethical obligation to treat each patient consistently and adequately regardless of patient's race, color, religion, sexual orientation, or potential billing status.NCOEMS, and company protocols have been developed to help Field Providers provide the required level of patient care. Patient care should be in accordance with medical protocols as established and/or approved by the local and state Medical Director. D. During the transport of a patient, or as soon thereafter as possible, Field Providers must complete a Patient Care Report("PCR"). The PCR is confirmation that the transport took place describes the need for the ambulance and services provided and allows NSMT to seek reimbursement from the patient's health insurance, when appropriate. Each PCR should provide a thorough and accurate description of the patient encounter. III. PROCESSING THE PATIENT CARE REPORT A. PCRs should contain information that provides patient demographics along with a thorough and accurate description of the entire patient encounter. Documentation requirements should be in accordance with local Standard Operating Procedures and contain the following recommended items. Please note these are recommended items but in some rare instances, some of the information may not be available to the Field Personnel. 1. Origin and Destination; 2. Dispatch Information; 3. Patient Demographics; 4. Reason for Transfer; 5. Physical Findings; 41 6. Chief complaint at time of transport; 7. Past Medical History; 8. Narrative - Thorough description of the patient encounter at the time of transport; 9. Vital signs; 10. Treatment rendered (e.g. oxygen, EKG, drugs); 11. Loaded miles using trip counter/Mapping mileage (Medicare requires mileage be documented to the nearest tenth of a mile 12. Field Provider signatures (Attendant and Driver); and 13. Patient signature or alternate signature/documentation; B. There are often other forms of medical documentation that Field Providers receive, such as PCS forms and hospital and nursing home face sheets. All additional information regarding the patient's medical condition must be attached to the PCR before it is sent to the Billing Contractor, C. The PCR should be completed by the end of the shift during which the transport occurred, must contain accurate information, and must be received by the Dispatch Office during the assigned shift. Addendums must be completed within the same timeframes, as applicable. IV. DOCUMENTATION Accurate and complete documentation of the entire patient encounter is extremely important to comply with health care rules and regulations. A PCR should contain the items listed in Section III., along with the following: A. Describe the patient's medical condition at the time of transport and the reason for transport. B. Describe how the patient was found (e.g. in bed, in a wheelchair, standing,unconscious); C. Describe how the patient got to the stretcher and ambulance (e.g. walked with assistance, lifted by draw sheet); D. Use only acceptable abbreviations in completing the PCR. E. Document the patient's physical and mental assessment and other pertinent findings. Explain why the patient could or could not go by other means (e.g. comatose, severe lower extremity contractures, why patient could not self-regulate oxygen during transport, required restraints, physical limitations and deficits, etc.). These are merely a few examples and are not all inclusive. F. Paint an accurate picture of the entire patient encounter. V. PATIENT SIGNATURES Field Providers are responsible for obtaining the patient's signature on the Patient Signature Form, as specified in NSMT 's Policy on Patient Signatures.. 42 VI. ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE An Advance Beneficiary Notice of Non-coverage (ABN)notifies patients that NSMT believes the service provided may not be fully covered by Medicare because it is not "reasonable and necessary" under Section 1862(a)(1) of the Social Security Act. For more information related to ABNs, see NSMT-Policy on Patient Signatures. VII. PHYSICIAN CERTIFICATION STATEMENT NSMT must attempt to obtain Physicians' Certification Statements (PCS)before it can bill Medicare for scheduled repetitive non-emergency transports and for other scheduled and unscheduled non-emergency ambulance transports of patients under the direct care of a physician. The specific requirements for a PCS depend on whether the transport is a repetitive transport or a non-repetitive transport. Medical Transport Personnel must understand these requirements so that, when appropriate, they can explain them to requesting facilities and assist in obtaining PCS forms required for specific patients. In very(limited) situations a PCS faun may not be obtained at the time of transport. If this situation arises do not create a conflict with facility staff On the (rare) occasion this situation may arise, the dispatch staff must be notified verbally of the situation so that appropriate steps can be taken with the referring customer. A. Dispatch Personnel may instruct Field Providers regarding the need to obtain a PCS at the time of transport, in which case the Field Provider should briefly review the form to make sure it has all the required information and is signed by an appropriate person, as indicated above. B. NSMT Personnel can assist with completion of the demographic portion of the PCS form but cannot enter any of the information in the medical necessity portion of the document. No modifications to the PCS form can be made after it has been signed and dated by an authorized signor. 1. Scheduled Repetitive Non-Emergency Transports: NSMT is required to obtain a PCS dated no earlier than sixty days prior to the date of service in order to bill Medicare for repetitive transports. The PCS must be on file, or must be obtained, prior to the transport. "Repetitive transports" are those transports that occur three or more times during a ten day period or once per week for at least 3 weeks for treatment of the same condition, such as dialysis and respiratory therapy. This would exclude transports for follow-up visits relating to a single and non-continuing incident. The PCS for a repetitive transport must be signed by a physician; These type transport PCS's will typically be handled by dispatch personnel. 2. Non-Emergency Services for a Facility Patient under the Care of a Physician: For these patients, NSMT must attempt to obtain a PCS within 48 hours after the transport whenever possible. If it is not possible to obtain a PCS signed by the physician, a signed certification can be obtained from a P.A.,N.P., clinical nurse specialist, R.N. or discharge planner who is employed by the hospital/facility where the beneficiary is being treated and from which the beneficiary is transported, or employed by the beneficiary's attending physician, and who has personal knowledge of the beneficiary's condition at the time the transport is ordered or performed. VIII. TRAINING OF MEDICAL TRANSPORT PERSONNEL A. Required compliance training for Medical Transport Personnel will be provided by NSMT's Compliance Department and/or designated employees. Training should take place upon initial employment and annually thereafter. B. Ongoing training for Field Providers, according to NSMT policy, shall include specialized training regarding PCR documentation. NSMT management will work jointly with the Compliance Department to develop and present the specialized training. 43 IX. QUALITY IMPROVEMENT A. NSMT Compliance Department with Management staff will be responsible to develop, implement, and maintain ongoing quality improvement procedures to monitor the services provided by field providers. B. The results of quality improvement reviews shall be retained in accordance with the NSMT 's Corporate Policy on Records Retention C. The quality improvement process shall include procedures to provide timely corrective feedback and training to employees, as necessary. X. CORRECTIVE ACTION A. This Policy for Medical Transport Personnel establishes the general policies and procedures with which all Field Providers must comply as a condition of employment with NSMT. This Policy is designed to ensure that each employee's performance conforms to the highest ethical standards and is in accordance with all applicable laws, rules and regulations. Doubts or questions whatsoever as to the propriety of a particular situation, whether or not the situation is described within this Policy, should be directed either to your immediate supervisor or the NSMT Compliance Officer. B. Any Field Provider violating any provision of this Policy will be subject to disciplinary action, up to and including discharge from employment. In addition, promotion of and adherence to this Policy and to the Compliance Program will be one criteria used in evaluating the performance of supervisors, managers, directors, and officers. See: NSMT's Policy: Reporting of Potential Issues or Areas of Noncompliance POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 44 Policy on Obtaining Patient Signatures I. PATIENT SIGNATURES A. Medical Transport Personnel are responsible for obtaining the patient's signature on the Ambulance Billing/Privacy Acknowledgment Signature Statement Form. B. If a patient is unable to sign the Signature Statement Form because he or she is illiterate or handicapped, a signature by mark (e.g. X) of the patient is valid. The mark must be witnessed by a third party whose name and signature are noted on the Signature Form. If no third party is available, an NSMT crew member may witness the signature, and must note his/her name. C. If the patient is physically or mentally unable to sign, the crew must attempt to obtain the signature of a representative. The representative can include a legal representative (e.g., guardian), relative or other person who arranges the patient's treatment or manages the patient's affairs. The representative must state their relationship to the patient. In addition to the foregoing, the crew member or the representative must document the specific medical/mental condition that prevents the patient from signing. This condition must be supported in the documentation on the PCR. D. if the patient is physically or mentally unable to sign, and there is no representative, as listed in section I.C. above, available and willing to do so, the PCR must contain: 1. Documentation on the PCR Signature Statement that at the time of the transport the patient was physically or mentally unable to sign and that no representative was present or willing to sign on behalf of the patient (NOTE: documentation on the PCR should support the reason utilized on the PCR Signature Statement for the patient's inability to sign); 2. Signature of the crew member; and 3. A signed statement at the time of transport from a sending or receiving facility representative which lists the name and location of the facility and the date and time of the transport. This infoimation may be contained within the PCR or in a separate attachment. E. If the patient is physically or mentally unable to sign, and there is no representative (a representative listed in section I.C. above or a facility representative in the Signature Statement available to sign, the Field Provider may obtain: f 1. A hospital or facility face sheet, hospital or facility log, or other internal facility record indicating that the beneficiary was received. These documents must be on facility forms and do not require a signature. F. If the patient is capable of signing the PCR but refuses to do so, the Field Provider should explain that the signature is necessary to bill Medicare or certain other payors for the service, and if NSMT does not have a signature the patient or family may have to pay the entire amount of NSMT's charges (instead of just being responsible for any co-payment and deductible amount). If the patient still refuses to sign, the Field Provider should document "Patient capable of signing but refuses to do so." II. ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE ' . An Advance Beneficiary Notice of Non-coverage (ABN) notifies patients that NSMT believes the service provided may not be fully covered by Medicare because it is not "reasonable and necessary" under Section 45 1862(a) (1) of the Social Security Act. ABN forms do not apply to emergency transports. The ABN guidelines include the following ground transports: 1. the level of care being provided is higher than the level of care the patient requires. 2. transport from a residence to a hospital for a service that could be performed more economically in the residence. 3. transport of a SNF patient to a hospital or second SNF for a service that could be performed more economically in the first SNF. B. Field providers may be informed by Dispatch Personnel when a patient requires an ABN or may make this determination themselves. C. In the rare circumstances when an ABN is required,NSMT follows the following procedures: 1. If the patient has the capacity to understand or there is an authorized representative (e.g., a family member or other person authorized to make health care decisions on the patient's behalf), field providers must inform the patient or representative that NSMT has reason to believe their ambulance transport is not a covered Medicare benefit because it will likely not be deemed by Medicare to be reasonable and necessary for one of the reasons specified above. These reasons are also set forth on the ABN form used by NSMT, and the Field Provider must check the applicable box corresponding to the reason. The crew member must also complete certain other parts of the ABN by filling in the patient's name, trip/run report number, reason Medicare may not pay and estimated cost of service. 2. The ABN form gives a beneficiary three options with respect to the provision of the service. If the beneficiary chooses "Option 1," the beneficiary chooses to receive the service and to be responsible for payment if Medicare does not pay. If the beneficiary chooses "Option 2", the beneficiary is accepting responsibility for payment without Medicare being billed. If the beneficiary chooses "Option 3," the beneficiary chooses not to receive the service. The crew member should ask the beneficiary to indicate which option he/she chooses by checking the box and then signing the form, acknowledging his/her understanding of the form. a. A beneficiary should not be asked to sign an ABN form under duress, e.g., during a medical emergency. Also, if a beneficiary is comatose, confused, or legally incompetent, the use of an authorized representative is required, if one is available. An authorized representative or interpreter must also be used, if available, if the beneficiary is not literate in the language of the ABN or if the beneficiary is visually impaired. 3. In situations where an ABN is required, if a beneficiary is able to sign but refuses to sign an ABN and still requests the service, the crew should have a second person witness the beneficiary's refusal to sign the ABN and then furnish the service. Ideally, the second witness should be someone other than the other NSMT crew member, but that crew may witness the refusal if there is no one else available to do so. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 46 Policy on Determination of Medical Necessity INTRODUCTION A. The accurate determination and documentation of "medical necessity" is extremely important because payors generally do not reimburse NSMT for transports that are not "medically necessary". For this reason, payors require documentation to verify that a transport was "medically necessary" before reimbursing for that transport. Inaccurate determinations of"medical necessity" in claims made to government payors can subject NSMT to legal liability. B. "Medical necessity" under Medicare is established when the patient's condition is such that they meet the criteria for bed confinement or use of any other method of transportation is contraindicated. In other words, the patient could not be transported by any other means of transportation without endangering his/her health. If other modes of transportation (such as automobile, taxi, wheelchair-van, bus, etc.) could have been used without endangering the patient's health, then benefits cannot be paid for ambulance service. II. THE DOCUMENTATION OF MEDICAL NECESSITY A. The documentation of medical necessity is a function of several NSMT components: 1. intake documentation see NSMT Dispatch Personnel Policy 2. field provider documentation see Medical Transport Personnel Policy the billing department's additional research and interpretation of the provided documentation. B. No government payor shall be billed unless "medical necessity" has been established and documented. Examples of transports which may be medically necessary include, but are not limited to, the following: 1. patient requires transport as a result of an emergency 2. patient needed to be restrained; or 3. patient was unconscious or in shock; or 4. patient required emergency oxygen or other emergency treatment on the way to his or her destination; or 5. patient required oxygen on the way to his/her destination and could not self administer• or regulate his/her own oxygen; or 6. patient had to remain immobile because of a fracture that had not been set or the possibility of a fracture; or F 7. patient sustained an acute stroke or myocardial infarction; or 8. patient was experiencing a severe hemorrhage. 47 If= C. In order for a patient to qualify as bed confined the condition causing the bed confinement must be clearly documented on the Patient Care Report. "Bed-confined" means that all three of the following conditions exist: 1. The patient is unable to get out of bed without assistance; 2. The patient is unable to ambulate; and 3. The patient is unable to sit in a chair or wheelchair. "Nonemergency transportation by ambulance is appropriate if either: the beneficiary is bed-confined and it is documented that the beneficiary's condition is such that other methods of transportation are contraindicated; or, if his or her medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required. Bed confinement is not the sole criterion in determining the medical necessity of ambulance transportation, but is instead one factor that is considered in medical necessity determinations. Bed confinement alone does not necessitate the use of an ambulance. In order for the transport to meet the medical necessity criteria, there must be a reason why other modes of transport are contraindicated. Bed-confined is not synonymous with non-ambulatory since a paraplegic or quadriplegic person is non-ambulatory but spends a significant amount of time in a wheelchair. Bed- confined is also not synonymous with bed rest, a recommended state that does not exclude occasional ambulation to the commode or time spent in a chair. III. PHYSICIAN CERTIFICATION STATEMENTS A. NSMT must attempt to obtain Physicians' Certification Statements (PCS) before it can bill Medicare for scheduled repetitive non-emergency transports and for other scheduled and unscheduled non-emergency ambulance transports of patients under the direct care of a physician. 1. Scheduled Repetitive Non-Emergency Transports: NSMT is required to obtain a PCS dated no earlier than sixty days prior to the date of service in order to bill Medicare for repetitive transports. The PCS must be on file, or must be obtained, prior to the transport. "Repetitive transports" are those transports that occur three or more times during a ten day period for treatment of the same condition, such as dialysis and respiratory therapy. This would exclude transports for follow-up visits relating to a single and non- continuing incident. The PCS for a repetitive transport must be signed by a physician. 2. Non-Emergency Services for a Facility Patient under the Care of a Physician: For these patients, NSMT must attempt to obtain a PCS within 48 hours after the transport whenever possible. If it is not possible to obtain a PCS signed by the physician, a signed PCS can be obtained from a P.A., N.P., clinical nurse specialist, R.N. or discharge planner who is employed by the hospital/facility where the beneficiary is being treated and from which the beneficiary is transported, or employed by the beneficiary's attending physician, and who has personal knowledge of the beneficiary's condition at the time the transport is ordered or performed. If unable to obtain the required PCS from either the physician or one of the other parties above within 21 days, a non-repetitive transport can be billed if there is documentation of the attempts to obtain it. Acceptable documentation includes any U.S. Postal document (e.g., signed return receipt or Postal Service Proof of Service Form 3877) that reflects that an attempt was made to obtain the PCS. B. Dispatch Personnel should instruct Field Providers regarding the need to obtain a PCS at the time of transport, in which case the Field Provider should briefly review the form to make sure it has all the required information and is signed by an appropriate person, as indicated above. 48 C. NSMT personnel cannot enter any of the information in the medical necessity portion of the document. No modifications to the PCS form can be made after it has been signed and dated by an authorized signor. by an authorized signor. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. } 49 Policy on Repetitive Patients I. INTRODUCTION A. This Policy is intended to help assure that NSMT bills Medicare and other government programs for repetitive transports only when those transports meet medical necessity requirements. "Repetitive transports" are those transports that occur three or more times during a ten day period or at least once per week for at least three weeks for treatment of the same condition, such as the types of treatment listed below. This would exclude transports for follow-up visits relating to a single and non-continuing incident. A repetitive patient Physician Certification Statement (PCS) must be signed by a physician and is valid for 60 days from the date of signature. The following are some examples of services that may result in repetitive transports: 1. dialysis; 2. hyperbaric services; 3. radiation treatment; 4. chemotherapy treatment; 5. wound care; and 6. physical therapy services. II. RULES FOR REPETITIVE PATIENTS A. In situations where services are provided to repetitive patients, NSMT will ensure that ambulance transportation is medically necessary, and transport by other means is contraindicated by the patient's condition. In this regard, a repetitive patient must meet the following criteria: 1. The patient meets medical necessity criteria for ambulance transport. See NSMT Determination of Medical Necessity Policy. 2. A PCS form or other verification of medical necessity signed by the patient's physician is on file; See NSMT Determination of Medical Necessity Policy. 3. The treatment received by the patient is consistent with the patient's diagnosed condition. B. It is recommended that Intake Personnel perform the following tasks when a call is received requesting transport services for a repetitive patient: 1. Conduct a regular "medical necessity" assessment and identify likely or potential repetitive patients. 2. Request a PCS form for Medicare patients as applicable. Verify the medical necessity from the caller upon scheduling the trip. Stress to the caller the importance of this documentation. 3. At the time the first transport for a repetitive patient is ordered, inform the caller that a medically trained employee of NSMT will conduct a site survey to further document the patient's condition. 50 4. If the patient is an ESRD patient, inquire about insurance coverage and how long the patient has been diagnosed with ESRD and make notation. C.NSMT shall perform the following tasks regarding each repetitive patient forwarded for review: 1. Verify the insurance coverage of the patient; 2. For Medicare patients, ensure that a PCS has been completed by the patient's physician prior to the transport but no earlier than 60 days prior to the date of transport. The PCS should be updated, at a minimum, every 60 days, or whenever there is a material change in the condition of the patient which bears on the medical necessity of ambulance transport.For patients with other types of third party coverage, a certificate of medical necessity or other verification of medical necessity may also be necessary. Such documentation should be reevaluated and renewed on a periodic basis,not to exceed every 60 days or as required by the payor. 3. Ensure perfolinance of a site survey of the patient to document the patient's condition and the level of nursing care being received. The initial Site Survey should be completed as quickly as possible, once notified of the repetitive patient status and every 60 days to assess any changes in the patient's condition. A Site Survey Form (See: Repetitive Patient Assessment Form) should be completed during each patient visit. 4. Review PCRs to determine if the patient's condition has changed since the previous transport and PCS. If the patient's condition has changed, a new site survey is required immediately to verify the patient's continued need for ambulance transportation. 5. For End Stage Renal Disease ("ESRD")Medicare patients, determine if the patient is in a skilled bed and confirm that the correct modifiers have been used in the billing process. If an incorrect modifier has been used, ensure that the Billing Department makes the appropriate change of modifier. Modifiers generally associated with dialysis transports include: a. "G" -hospital-based dialysis facility; b. ".I" -non hospital-based dialysis facility; c. "E"residential, domiciliary, custodial facility(other than a skilled nursing facility); d. "R" - residence; and e. "N"- Skilled Nursing Facility 6. Maintain a computerized spreadsheet of all Repetitive Patients that includes first date of service, origin/destination, modifiers (Medicare patients), primary and secondary insurance, effective date of the most recent PCS (e.g.,physician's signature date), date of most recent Site Survey, and last date transported, as applicable. 7. Ensure that follow-up PCS's and Site Surveys are requested and received every 60 days. 8.Notify Dispatch Department whenever a repetitive patient's condition no longer- qualifies for ambulance transportation. 51 9. When a repetitive patient is determined not to meet the medical necessity requirements, contact the patient or facility representative (Social Worker)to arrange for transportation by other means. 10. Develop and implement a notification process to address repetitive patients that are being transported without the required documentation on file. This process should identify repetitive patients whose documentation is near expiration so that the appropriate persons can proactively work to secure said documentation. D. Crew Members shall perform the following tasks regarding repetitive patients: 1. Clearly and completely document the patient's condition during each leg of the transport; 2. Notify Dispatch of changes in the patient's condition which contraindicate ambulance transportation; 3. Perform Site Surveys, as requested by the repetitive patient coordinator, to accurately assess the patient's need for ambulance transportation; 4. Accurately complete all questions on the Site Survey Form whenever a Site Survey is perfotimed. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 52 NORTH STATE REPETITIVE PATIENT ASSESSMENT FORM Section-1 Patient Information 111?DICAI,TRANSPORT Name: Sex: ❑M❑F DOB: Age: SS#: Primary Insurance: Policy Number Secondary Insurance: Policy Number Origin/Facility: Destination/Facility: Address: Address: City: State: Zip: City: State: Zip: I am requesting ambulance transportation on a repetitive basis and certify that I have consulted with my Physician and 1 can not safely be transported by any other means. I am unable to be transported by Wheelchair van,Cab or Private auto because of my medical condition. Patient's signature: Date signed: I am requesting ambulance transportation on a repetitive basis for the patient listed at the top of this form and certify that he/she cannot safely be transported by any other means. He/She is unable to be transported by Wheelchair van,Cab or Private Auto because of his/her medical condition. Signature of person requesting the ambulance transportation if patient is unable to sign: Signature: Date signed: Printed Name: Relationship: Facility: Section 2-Medical Necessity Assessment Information Describe the medical condition(physical and/or mental)of this patient that requires him or her to be transported in an ambulance and why transport by other means is contraindicated by the patient's condition. Yes/ Assessment/Questionnaire No Comments Is the patient able to go to the lunch room?If so,how? Does the patient ever leave the facility/home for family visits,shopping,etc.?If so,how? Is the patient able to get up from bed without assistance? Is the patient able to ambulate? Is the patient able to sit unassisted in a chair or a wheelchair(does not include a reclining wheelchair. Can this patient safely be transported by car,or wheelchair van(i.e.,seated during transport,without a medical attendant or monitoring)? Does this patient have contractures?Where? Does this patient have non-healed fractures?Where? Is this patient confused or likely to become confused during transport? Does this patient have moderate/severe pain on movement? Is this patient a danger to self/others? Are IV meds/fluids required during transport? Does this patient need or is likely to need restraints during transport? Does this patient have DVT requiring elevation of a lower extremity? Does this patient have a condition that requires monitoring by a medical attendant? Does this patient require oxygen and unable to self-administer? Does this patient need special handling/isolation/infection control precautions required? Is this patient unable to tolerate seated position for time needed to transport?If so why? Does this patient require hemodynamic monitoring required en-route? Is the patient unable to sit in a chair or wheelchair due to decubitus or other wounds? Provide location and approximate size? Does this patient require cardiac monitoring during transport? Is this patient morbidly obese and requires additional personnel/equipment to safely handle patient? Does this patient require orthopedic device,backboard,halo,pins,brace,wedge,etc. Requiring special handling?If so why? This document contains HIPPA information and precautions shall be taken to protect patient privacy 1240 Corporation Parkway • Raleigh, NC 27610 • 919-261-8911 • 919-261-8991 Fax • www.nsmt.biz NORTH STATE REPETITIVE PATIENT ASSESSMENT FORM Section 3-Supporting Information MEDICAL TRANSPORT Please explain the patient's medical condition to support why medical transport is required. Section 4-History Past Medical History: Medications: Allergies: Section 5-Contact Information Patient's Primary Care Physician: Phone Numbers:Office Fax: Nephrologists/Wound Care Physician: Phone Numbers: Fax: Social Worker: Phone Numbers: Fax: Next of Kin/POA: Phone Numbers: Fax: Signature of Provider Who Performed the Assessment: Print Name of Provider: Date Completed: Location where assessment took place: Assessment Review: ❑Q/A Complete Signature: Date Completed: Printed Name: Place this form,along with any supporting documents(MAR's,History Sheets,Medical Records)in the Repetitive patient book. This document contains HIPPA information amt precautions shall be taken to protect patient privacy. 1240 Corporation Parkway • Raleigh, NC 27610 • 919-261-8911 • 919-261-8991 Fax • www.nsmt.biz ORTH STATE Physician Certification Statement (PCS) Phone: 919-261-8911 .MEDICAL TRANSPORT Required for all Non-Emergency Ambulance Transports Or Toll Free 877-261-8911 Fax 919-261-8991 Section 1 - Patient and Transport Information Patient Name: Date of Birth: SSN: Sex: Medicare Number: ❑M OF Date of Transport: Time: Round Trip: Type: Transport Agency; Medicaid Number: North State Medical Transport ❑ Yes ❑ No ❑ ALS❑ BLS Transport From: Room/Bed Transport To: Room/Bed Ins. Type/Policy Number: Section 2 Medical Necessity Information YOU MUST COMPLETE ALL STEPS IN ORDER FOR THIS FORM TO BE VALID Ambulance Transportation is medically necessary only if other means of transport are contraindicated or would be potentially harmful to the patient. To meet this requirement,the patient must be either"bed confined"or suffer from a condition such that transport by means other than ambulance is contraindicated by the patient's condition.The following steps must be completed by the medical professional signing in Section 3 for this form to be valid. Step 1—Are ALL of the following true for this patient? Step 2—Can this patient safely be transported by car or wheelchair van? l-Patient is unable to get up from bed without assistance; (i.e.,seated during transport,without medical attendant or monitoring) 2- Patient is unable to ambulate; and 3- Patient is unable to sit in a chair, including a wheelchair ❑ Yes ❑No ❑ Yes ❑No If No,use Step 3 to identify reasons for transport. "A.NO'does not automatically indicate the transport will notbecovered. If Yes,transport is not medically necessary. Step 3—Check all that apply to the patient at the time of transport ❑ Requires Continuous Oxygen ❑Assistance required to apply, administer,regulate, or adjust oxygen in route ❑ Requires airway maintenance ❑ Ventilator dependent ❑ Requires cardiac/hemodynamic monitoring ❑ Moderate/severe pain on movement ❑ Requires IV meds/Fluid Maintenance ❑ DVT requires elevation of a lower extremity ❑Non-healed fractures ❑ Requires immobilization of fracture or possible fracture ❑ Contractures ❑ Requires orthopedic device(backboard, halo, use of pins in traction,etc.) ❑ Danger to self/others ❑ Requires monitoring because patient is confused or combative ❑Altered mental status ❑ Requires monitoring due to a decreased level of consciousness or lethargy ❑ Comatose and requires monitoring ❑ Restraints(chemical or physical)required or anticipated during transport ❑ Requires Monitoring due to seizures Morbid obesity ❑ Unable to maintain erect sitting position in a chair for duration of transport Special handling/Isolation Precaution ❑ Unable to sit in a chair/wheelchair due to decubitus ulcer or other wounds Facility to Facility Transfer: ❑No bed available OTHER(specify) ❑ Services not available at originating facility ❑ Transport to nearest appropriate facility *Supporting documentation for any boxes checked must be maintained in the patient's medical record* Section 3 - Authorization and Signature I certify that the above information is true and correct based on my evaluation of this patient,and represent that the patient requires transport by ambulance and that other forms of transport are contraindicated.I understand that this information will be used by the Centers for Medicare and Medicaid.Services(CMS)to support the determination of medical necessity for ambulance services,and I represent that I have personal knowledge of the patient's condition at the time of transport. ki Step 1 Print the name of the individual who will sign this form Step 2 Choose credentials corresponding to the name in Step I ❑Physician ❑ Registered Nurse ❑ Nurse Practitioner ❑ Discharge Planner ❑Clinical Nurse Specialist PRINTED Name of Physician or Medical Staff *Per CMS,these individuals are the only ones authorized to complete the PCS form. Step 3 Sign in ONE of the designated boxes.(Physicians in the left box,all others in the box on the right) Physician Signature: Medical Staff Signature: (Only valid for a single transport) Physician's Signature Credentials Date Medical Staff Signature Credentials Date 55 NORTH STATE North State Medical Transport MEDICAL TRANSPORT 1240 Corporation Pkwy,Raleigh,NC 27610 Phone:(919)261-8911 Fax:(919)261-8991 Patient Name: Social Security Number: Advance Beneficiary Notice of Non-coverage(ABN) NOTE: If Medicare doesn't pay for the ambulance services below,you may have to pay.Medicare does not pay for everything,even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the ambulance services listed below. Services Reason Medicare May Not Pay: Estimated Cost Medicare does not pay for transportation from a residence or a SNF for Ambulance services that could more economically be performed at the residence or SNF $ transport and mileage _Medicare does not pay for ambulance service that is not medically necessary BLS Ambulance Service BLS _Medicare does not pay for transports to a doctor's office or other non-covered $ per mile destinations $ Ambulance _Medicare does not pay for transports for the convenience of a patient,family ALS Ambulance Service mileage or physician $ ALS Ambulance —Medicare does not pay for mileage beyond the closest appropriate facility $ per mile _Medicare does not pay for a higher level of service(Advanced Life Support) Non-Covered when a lower level of service(Basic Life Support)would suffice Additional Cost Milage Medicare will not pay for air ambulance service if the patient could have been $ safely transported by ground ambulance. Medicare does not pay for non-transporting paramedic intercept services $ Medicare does not pay for wheelchair van or stretcher car services WHAT YOU NEED TO DO NOW: • Read this notice,so you can make an informed decision about your care. • Ask us any questions that you may have after you finish reading. • Choose an option below about whether to receive the ambulance services listed above. Note: If you choose Option 1 or 2,we may help you to use any other insurance that you might have,but Medicare cannot require us to do this. OPTIONS Check only one box. We cannot choose a box for you. ❑OPTION 1. I want the ambulance services listed above. You may ask to be paid now,but 1 also want Medicare billed for an official decision on payment,which is sent to me an a Medicare Summary Notice(MSN). I understand that if Medicare doesn't pay,1 am responsible for payment,but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay,you will refund any payments I made to you,less co-pays or deductibles. ❑OPTION 2. I want the ambulance services listed above,but do not bill Medicare.You may ask to be paid now as I am responsible for payment.I cannot appeal if Medicare is not billed. ❑OPTION 3.I don't want the ambulance services listed above. I understand with this choice I am not responsible for payment,and I cannot appeal to see if Medicare would pay. Additional Information: This notice gives our opinion,not an official Medicare decision. If you have other questions on this notice or Medicare billing,call 1-880-MEDICARE(1-800-633-4227111Y:1-877-486-2048). Your Signature below means you have received a copy of this ABN and understand this notice. Signature: Date: According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid 0141E control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response,including the time to review instructions,search existing data resources,gather the data needed,and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form,please write In:CMS,7500 Security Boulevard,Attn:PRA Reports Clearance Officer,Baltimore,Maryland 21244-1850. 56 Policy on External Audit Notifications I. INTRODUCTION NSMT has relationships with numerous payors who handle many claims for payment. Payors or their contractors will sometimes conduct Pre-Payment Reviews and Post-Payment Audits (collectively, "external audit notification") of NSMT's claims in order to verify the appropriateness of NSMT's billing. NSMT has adopted this Policy because it is extremely important for NSMT to respond to these audit notifications in a timely and organized manner. II. EXTERNAL AUDIT PROCESS A. NSMT employees must be able to differentiate between a pre-payment review and a post-payment audit notification/request for documentation letter. Generally, a pre-payment review is a payer's request for additional information prior to payment and is most often for one single claim or beneficiary. A post- payment audit involves the payer's review of specific claims to deter mine if these claims were billed appropriately. Both types of external requests will have an identified response due date and it is imperative that any response be coordinated through NSMT management and the Compliance Department to mitigate any potential legal liability for NSMT. B. Any NSMT employee who receives any external audit notification for documentation must be aware that it is a time-sensitive document. If you receive such correspondence, you must take the following steps immediately: 1. Date stamp the letter as "received"; 2. Send all requests for information to the Compliance Officer; 3. At the direction of the Compliance Officer will work with the Billing Contractor to collect all potentially relevant documents as requested by the payors. Documents should be organized according to the foiniat requested by the external agency and should be checked for accuracy; 4. The Compliance Officer will work with the Billing Contractor to appropriately log all relevant documents; 5. This log will track specific claim information as the documentation is being gathered in accordance with the request; C. The Compliance Officer shall work with the Billing Contractor to oversee the process of responding to an external audit notification. Never respond to, or contact, the Medicare Administrative Contractor(MAC) or Medicaid Fiscal Intermediary(FI)without the prior review and approval of NSMT Management and the Compliance Officer. D. The Compliance Officer will notify the requestor if an extension is needed. E. For Compliance and HIPAA security never provide documentation or correspond to an external request for information without first informing Compliance Officer. POLICY REVIEW The NSMT Compliance Officer will review and update this Policy and all Compliance policies when necessary in the normal course of its review of the NSMT Compliance Program. 57 x,10 -chi, ' fti 1 Y+1 d _ _ - l '; lr 1 - _ _ r.� 11 r' f I 1 I `v ��'. -or 4 ,•- 1' 1 1v���� ,�`�� � �� J, ;�,n� [ .. T 1 A S 4 y,�,, _ 2 67 i , 4- / - i 1(( 1911 { , L i ■ V,, � _ 1 J 1 J I I altiligin , „ ,rib301:1511,1171Itt rtill‘Car, , „ HIPAA Risk Analysis Policy 1 Patient Requests for Access to PHI Policy 2 Patient Requests for Amendment of PHI Policy 3 Patient Requests for Restriction of PHI Policy 4 Patient Requests for Accounting of Disclosures of PHI Policy 5 Patient Requests for Confidential Communications Policy 6 HIPAA Compliance Officer Action Plan for Patient Requests Relating to PHI Policy 7 HIPAA Training Policy 8 Updating HIPAA Policies,Procedures &Training Policy 9 Contracting With Business Associates Policy 10 Workforce Sanctions for Violations of HIPAA Policies and Procedures Policy 11 Minimum Necessary Requirement&Role-Based Access to PHI Policy 12 Designated Record Sets Policy 13 News Media Interaction Policy 14 Action Plan on News Media Interaction Policy 15 Release of PHI to Law Enforcement Without Legal Process Policy 16 Staff Member Action Plan for Release of PHI to Law Enforcement Without Legal Policy 17 Process Release of PHI to Law Enforcement With Legal Process Policy 18 HIPAA Compliance Officer Action Plan for Court-Ordered Requests for PHI Policy 19 HIPAA Compliance Officer Action Plan for Administrative Requests for PHI from Policy 20 Government Agencies HIPAA Compliance Officer Action Plan for Attorney-Issued Subpoenas and Policy 21 Discovery Requests Breaches of Unsecured PHI Policy 22 HIPAA Compliance Officer Action Plan: Breach Analysis Steps Policy 23 Staff Member Access to e-PHI Policy 24 Contingency Planning Policy 25 Disaster Management and Recovery of e-PHI Policy 26 Physical Security of PHI and e-PHI Policy 27 Electronic Information System Activity Review and Auditing Policy 28 Third Party Access to e-PHI Policy 29 Creating Backups of e-PHI Policy 30 Encryption of e-PHI Policy 31 Security Incident Management Policy 32 Staff Member Electronic Communications Policy 33 Staff Member Medical Records Policy 34 Policy on Releasing PHI to Family Members and Others Policy 35 Policy 1: Policy on HIPAA Risk Analysis North State Medical Transport Policy on HIPAA Risk Analysis Purpose North State Medical Transport is responsible, under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"),to ensure the privacy and security of all protected health information ("PHI") that we use or disclose. The foundation of compliance with the HIPAA is the completion of a "Risk Analysis"to identify existing risks and vulnerabilities in the way we create, receive, maintain or transmit our PHI. This policy describes our general approach to our HIPAA Risk Analysis. Scope North State Medical Transport's HIPAA Risk Analysis includes an assessment of potential risks and vulnerabilities to the confidentiality, availability and integrity of all PHI that North State Medical Transport creates, receives, maintains or transmits. This includes assessing any risks and vulnerabilities to the confidentiality, integrity and availability of non-electronic PHI (such as papers and documents) and electronic protected health information (e-PHI). At a minimum, the risk analysis will include a review of North State Medical Transport's: + General security hardware and procedures to protect our facility, vehicles, and electronic assets; + Computer servers (on or off-site) that store PHI; ❖ Computer network (including any local and wide area networks, communications servers and bandwidth connections, and storage devices and hardware); •• Databases where patient information is created, stored, and accessed by North State Medical Transport, whether on or off-site; • Electronic media that store e-PHI such as hard drives, disks, CDs, DVDs, USB drives or other storage devices,transmission media, or portable electronic media; + Electronic devices used for processing patient information (such as laptops and field data collection devices); + Workstations and access points where PHI is created, accessed and used; •• Policies and procedures (written and unwritten)that involve the creation, use, or access to e-PHI; and • Vendors, billing companies, clearinghouses and others who create, receive, maintain or transmit PHI for North State Medical Transport. Procedure The HIPAA Compliance Officer will utilize North State Medical Transport's HIPAA Risk Analysis Tool to identify all current and potential risks and vulnerabilities to PHI at North State Medical Transport and to develop a plan to manage those risks. Annual Risk Analysis North State Medical Transport will, on an annual basis, undertake a risk analysis that includes the following: 1. Identifying and documenting all places where the physical (paper) PHI and e-PHI is stored, received, maintained or transmitted at North State Medical Transport (i.e., all sources of PHI at North State Medical Transport whether on or off-site). 2. Identifying and documenting all current and potential risks to the confidentiality, security, integrity and availability of all PHI sources identified at North State Medical Transport. 3. Assessing the likelihood of each identified risk and assigning the risk to a "risk level" and "potential impact" category. 4. Identifying and documenting any measures that North State Medical Transport currently has in place to address each identified risk, including any policies, procedures, hardware/software, security devices, etc. Then, identifying any methods that are not currently in place that may eliminate or mitigate the risk. 5. Providing recommendations to North State Medical Transport that might remedy identified risks and vulnerabilities and improve the security, integrity and availability of all PHI sources identified at North State Medical Transport. 6. Implementing methods that might remedy identified risks and vulnerabilities and improve the security, integrity and availability of all PHI sources identified at North State Medical Transport. Implementation Specifications Implementation specifications under HIPAA that are "required" must be implemented and documented that they were in fact implemented, including how the specification was implemented. Implementation specifications under HIPAA that are "addressable" will be implemented as follows: 1. If the implementation specification is reasonable and appropriate, North State Medical Transport will implement it. 2. If the implementation specification is determined to be inappropriate and/or unreasonable, but the security standard cannot be met without implementation of an additional security safeguard, North State Medical Transport may implement an alternative measure that achieves the addressable specification. 3. If North State Medical Transport meets the standard through alternative measures,the decision not to implement the specification will be documented, including the reason for the decision,the rationale, and a description of the alternative safeguard that was implemented. Policy 2: Policy on Patient Requests for Access to PHI North State Medical Transport Policy on Patient Requests for Access to Protected Health Information Purpose The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") grants individuals the right to access their protected health information ("PHI")contained in a designated records set ("DRS"). (See, Policy on Designated Records Sets). North State Medical Transport must afford individuals this right of access in accordance with federal and state law. To ensure that North State Medical Transport complies with its obligations,this policy outlines our procedures for handling requests for patient access and establishes the procedures by which patients or authorized representatives may request access to PHI. Scope This policy applies to all North State Medical Transport staff members who receive requests from patients for access to PHI. Generally, all access requests will be directed to the HIPAA Compliance Officer and it shall be the responsibility of the HIPAA Compliance Officer to handle all access requests. Procedure Requests for Access from the Patient or the Patient's Personal Representative 1. Patients and their authorized representatives shall be granted a right of access to inspect and obtain a copy of their PHI contained in a DRS maintained by North State Medical Transport. 2. If a patient or their authorized representative requests access to or a copy of a patient's PHI,the requestor shall be referred to the HIPAA Compliance Officer. The HIPAA Compliance Officer shall request that the patient or authorized representative complete North State Medical Transport's "Request for Access to Protected Health Information" Form. 3. The HIPAA Compliance Officer must verify the patient's identity, or, if the requestor is not the patient, the name and identity of the representative and whether the representative has the authority to act on the patient's behalf. The use of a driver's I`4 license, social security card, or other form of government-issued identification is acceptable for this purpose. If it is impossible for the requestor to physically come in to make the request and verify this information,the HIPAA Compliance Officer shall ask the requestor to verify the patient's name, date of birth, SSN, address and telephone number over the phone and ask the requestor to submit the "Request for Access to Protected Health Information Form" via email, mail or fax. 4. Upon receipt of the completed "Request for Access to Protected Health Information Form" and verification of the requestor's identity, the HIPAA Compliance Officer will act upon the request within 30 days, preferably sooner. Generally, North State Medical Transport must respond to requests for access to PHI within 30 days of receipt of the access request. 5. If North State Medical Transport is unable to respond to the request within these time frames, the requestor must be given a written notice no later than the initial due date for a response, explaining why North State Medical Transport coul not respond within the time frame, and in that case North State Medical Transport may extend the response time by an additional 30 days. Requests for Access from the Patient's Attorney 1. If North State Medical Transport receives a request for a patient's PHI from the patient's attorney, the HIPAA Compliance Officer shall verify that the patient has authorized the release of PHI. Generally, the request should be accompanied by a form or letter, signed by the patient, stating that the patient authorizes the release of the requested PHI to the attorney. If there isa signed form or letter from the patient authorizing the release of the PHI requested (or some other valid authorization from the patient), then the HIPAA Compliance Officer may release the PHI to the attorney in accordance with what the authorization states. Z. If the request from the patient's attorney is not accompanied by a signed request form or letter from the patient (or some other valid patient authorization), the HIPAA Compliance Officer shall contact the attorney and inform the attorney that North State Medical Transport will not release the information without valid authorization from the patient. North State Medical Transport shall not release any PHI to the attorney until the patient authorizes the release. Approval of a Request for Access 1. Upon approval of access,the patient or authorized representative should generally be provided the right of access in the manner requested on the Form. North State Medical Transport will either provide a copy of the PHI to the requestor in the format requested or arrange for a convenient time for the patient to come into North State Medical Transport to copy their PHI. If North State Medical Transport uses or maintains the PHI requested electronically, North State Medical Transport will provide a copy of the PHI in an electronic format if the patient or authorized representative requests an electronic copy. North State Medical Transport will also transmit a copy of the PHI directly to an entity or person designated by the patient or authorized representative, provided that the written direction is signed and clearly identifies the designated party. 2. North State Medical Transport will establish a reasonable charge for copying PHI for the patient or authorized representative in accordance with federal and state laws. The fee for providing an electronic copy of PHI shall not be greater tha North State Medical Transport's labor costs in responding to the request for the copy. The HIPAA Compliance Officer shall consult with legal counsel regarding applicable laws regarding fee limitations. 3. The requestor will not be given access to the actual files or systems that contain the DRS. Rather, copies of the records shall be provided for the patient or requestor to view in a confidential area under the direct supervision of a designated Company staff member. UNDER NO CIRCUMSTANCES SHOULD ORIGINALS OF PHI LEAVE THE PREMISES. 4. Whenever a patient or requestor accesses a DRS, a note should be maintained in a log book indicating the time and date of the request,the date access was provided, what specific records were provided for review, and what copies were left with the patient or requestor. Denial of a Request for Access 1. If the request for access is denied,the HIPAA Compliance Officer shall send the requestor a "Denial of Request for Access to Protected Health Information Form," outlining the reason for the denial and explaining the individual's rights regarding the denial. Patient access may be denied for the reasons listed below: a. If the information the patient requested was compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding; b. If the information the patient requested was obtained from someone other than a healthcare provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information, c. If a licensed healthcare professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to endanger the life or physical safety of the individual or another person; d. If the PHI makes reference to another person (other than a healthcare provider) and a licensed health professional has determined, in the exercise of professional judgment,that the access requested is reasonably likely to cause substantial harm to that person, or e. If the request for access is made by a requestor as a personal representative of the individual and a licensed health professional has determined, in the exercise of professional judgment,that access is reasonably likely to cause harm to the individual or another person. 2. If the denial of the request for access to PHI is for reasons c., d., ore. above, then the patient may request a review of the denial of access by sending a written request to the HIPAA Compliance Officer. a. North State Medical Transport will designate a licensed health professional, who was not directly involved in the denial, to review the decision to deny the patient access. North State Medical Transport will promptly refer the request to this designated review official. The review official will determine within a reasonable period of time whether the denial is appropriate. North State Medical Transport will provide the patient with written notice of the determination of the designated reviewing official. b. The patient may also file a complaint in accordance with North State Medical Transport's "Procedure for Filing Complaints About Privacy Practices" if the patient is not satisfied with North State Medical Transport's determination. Policy 3: Policy on Patient Requests for Amendment of PHI North State Medical Transport Policy on Patient Requests for Amendment of Protected Health Information Purpose The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") grants individuals the right to request that North State Medical Transport amend their protected health information ("PHI") contained in a Designated Record Set("DRS"). (See, Policy on Designated Record Sets). North State Medical Transport has an obligation to afford individuals the right to request an amendment to their PHI in accordance with federal and state law. To ensure that North State Medical Transport complies with its obligations,this policy outlines procedures for handling patient requests for amendment of their PHI and establishes the procedures by which patients or authorized representatives may make a request for an amendment to PHI. Scope This policy applies to all North State Medical Transport staff members who handle requests from patients for amendment to PHI. Generally, all requests will be directed to the HIPAA Compliance Officer and it shall be the responsibility of the HIPAA Compliance Officer to handle all requests for amendment of PHI. Procedure Requests for Amendment of PHI 1. Patients or their authorized representatives shall be granted the right to request an amendment to a patient's PHI contained in the DRS. 2. If a patient or authorized representative requests an amendment to PHI,the requestor shall be referred to the HIPAA Compliance Officer. The HIPAA Compliance Officer shall request that the patient or authorized representative complete North State Medical Transport's "Patient Request for Amendment of Protected Health Information" Form. 3. The HIPAA Compliance Officer must verify the patient's identity, or, if the requestor is not the patient,the name and identity of the representative and whether the representative has the authority to act on the patient's behalf. The use of a driver's license, social security card, or other form of government-issued identification is acceptable for this purpose. If it is impossible for the requestor to physically come in to make the request and verify this information,the HIPAA Compliance Officer shall ask FI the requestor to verify the patient's name, date of birth, SSN, address, and telephone number over the phone and ask the requestor to submit the "Request for Amendment of Protected Health Information Form" via email, mail or fax. 4. North State Medical Transport must act upon a request for amendment of PHI within 60 days of the request. If North State Medical Transport is unable to act upon the request within 60 days, it must provide the requestor with a written statement of the reasons for the delay, and in that case may extend the time period in which to comply by an additional 30 days. Granting the Request for Amendment of PHI 1. If the HIPAA Compliance Officer grants the request for amendment,then the requestor will receive a letter (See, "Acceptance of Patient Request for Amendment" Form), indicating that the appropriate amendment to the PHI or record that was the subject of the request has been made. 2. The letter will contain a form for the patient to complete, sign, and return to North State Medical Transport. On the form, the patient must identify individuals who may need the amended PHI and sign the statement giving North State Medical Transport permission to provide them with the updated PHI. 3. North State Medical Transport must provide the amended information to individuals identified by the patient as well as persons or business associates that have such information and who may have relied on or could be reasonably expected to rely on the amended PHI. Denying the Request for Amendment of PHI 1. North State Medical Transport may deny a request to amend PHI for the following reasons: a. If North State Medical Transport did not create the PHI at issue; b. The information is not part of the DRS; c. The PHI is accurate and complete; d. The information would not be available for inspection as provided by law; or e. The information was received from someone else under a promise of confidentiality. 2. North State Medical Transport must provide a written denial (See, "Denial of Patient Request for Amendment" Form), and the denial must be written in plain language and contain the following information: a. The reason for the denial; b. The individual's right to submit a statement disagreeing with the denial and how the individual may file such a statement; c. A statement that, if the individual does not submit a statement of disagreement,the individual may request that North State Medical Transport provide the request for amendment and the denial with any future disclosures of the PHI; and d. A statement that the individual may file a complaint with North State Medical Transport or with the Office for Civil Rights of the Department of Health and Human Services. 3. North State Medical Transport shall provide a copy of our "Procedure for Filing Complaints About Privacy Practices" if the requestor indicates that he or she wants to file a complaint against North State Medical Transport. 4. If the individual submits a "statement of disagreement," North State Medical Transport may prepare a written rebuttal statement to the patient's statement of disagreement. The statement of disagreement will be appended to the PHI, or at North State Medical Transport's option, a summary of the disagreement will be appended, along with the rebuttal statement of North State Medical Transport. Administrative Obligations 1. If North State Medical Transport receives a notice from another covered entity, such as a hospital,that the other covered entity has amended its own PHI in relation to a particular patient, North State Medical Transport must amend its own PHI that may be affected by the amendments. The HIPAA Compliance Officer shall be responsible for performing this task. 2. North State Medical Transport will add the "Patient Request for Amendment of Protected Health Information Form," the denial or granting of the request, as well as any statement of disagreement by the patient and any rebuttal statement by North State Medical Transport to the DRS. The HIPAA Compliance Officer shall be responsible for performing this task. Policy 4: Policy on Patient Requests for Restriction of PHI North State Medical Transport Policy on Patient Requests for Restriction of Protected Health Information Purpose The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and the Health Information Technology for Economic and Clinical Health Act ("HITECH Act") grant individuals the right to request that North State Medical Transport restrict its use of PHI containedinaOesignatedRecnrdSet (''ORS"). (See, Policy on Designated Record Sets). North State Medical Transport has an obligation to abide by a requested restriction in accordance with federal and state law. To ensure that North State Medical Transport complies with its obligations under HIPAA and the HITECH Act, this policy outlines procedures for handling requests for restrictions on the use of PHI and establishes the procedures by which patients or their authorized representatives may request a restriction on the use of PHI. Scope This policy applies to all North State Medical Transport staff members who handle requests from patients for a restriction on the use of their PHI. Generally, all requests will be directed to the HIPAA Compliance Officer and it shall be the responsibility of the HIPAA Compliance Officer to handle all requests for restrictions on the use of PHI. Procedure Requests for Restriction 1. North State Medical Transport will permit patients to request restrictions on the use and disclosure of their PHI: (i) to carry out treatment, payment or health care operations and/or (ii) to people involved in their care or for notification purposes. Z. All requests for restriction on the use and disclosure of PHI shall be referred to the HIPAA Compliance Officer who shall request that the patient or authorized representative complete and submit North State Medical Transport's "Patient Request for Restriction of Protected Health |nfornnation" Form. All requests will be reviewed and denied or approved by the HIPAA Compliance Officer in accordance with this policy. The HIPAA Compliance Officer shall utilize the "Review of Patient Request for Restriction of Protected Health |nforrnation" Form when reviewing restriction requests. 3. The HIPAA Compliance Officer must verify the patient's identity, or, if the requestor is not the patient, the name and identify of the representative and whether the representative has the authority to act on the patient's behalf. The use of a driver's license, social security card, or other form of government-issued identification is acceptable for this purpose. If it is impossible for the requestor to physically come in to make the request and verify this information,the HIPAA Compliance Officer shall ask the requestor to verify the patient's name, date of birth, SSN, address, and telephone nurnberoverthephoneandasktherequesto[tosubnnitthe "PatientRequestfor Restriction of Protected Health Information" Form via email, mail or fax. 4. Under most circumstances, North State Medical Transport is not legally required to agree to any request to restrict the use and disclosure of PHI, and given the emergent nature of our operation, North State Medical Transport generally will not agree to a restriction unless required by law to do so. However, North State Medical Transport is required to abide by any restrictions that it agrees to. Granting a Request for Restriction 1. North State Medical Transport will and must comply with a requested restriction if: (i) the request concerns the disclosure of PHI to a health plan for purposes of carrying out payment or healthcare operations; and (ii)the request pertains to a service for which North State Medical Transport has been paid out-of-pocket in full. In other words, North3totuK4edioa|Trensportnouytg[aDtpatientytheriQhttopoyforeuervioaout-of- pocketandabidebyorequestnottosubrnitac|oirntotheinsurerforthotserv|ce service. 2. If North State Medical Transport receives a request from a patient or authorized representative asking North State Medical Transport to refrain from submitting PHI to a health plan and the HIPAA Compliance Officer determines that North State Medical Transport has either been paid in full, or that North State Medical Transport has received reasonable assurances that it will be paid in full for that service,then North State Medical Transport will grant the request for restriction and not submit a claim to insurance for that service. Patients must make a new request for all subsequent services. ]. If North State Medical Transport agrees to a requested restriction,the HIPAA Compliance Officer shall inform the patient of that fact in writing, by sending an "Acceptance of Request for Restriction of Protected Health Information" letter to the patient. The HIPAA Compliance Officer shall also note on the "Review of Patient Request for Restriction of Protected Health Information" Form that the request was accepted and document all pertinent information regarding the request and acceptance (date, payment received, etc.). 4. North State Medical Transport may not use or disclose PHI in violation of the agreed upon restriction. Notwithstanding, if the individual who requested the restriction is in need of an emergency service, and the restricted PHI is needed to provide the emergency service,then North State Medical Transport may use the restricted PHI or may disclose such PHI to another healthcare provider to provide treatment to the individual. 5. The HIPAA Compliance Officer shall also inform all other necessary parties at North State Medical Transport and its business associates, such as its billing company, about the accepted restriction and take all appropriate steps to ensure that those parties abide by the restriction. 6. The HIPAA Compliance Officer shall add the "Patient Request for Restriction of Protected Health Information" Form, the Acceptance letter and documentation regarding the acceptance of the request to the DRS. Denying the Request for Restriction 1. Unless North State Medical Transport is required by law to agree to a request for restriction of PHI, the HIPAA Compliance Officer shall deny the request in writing, by dispatching a "Denial of Patient Request for Restriction of PHI" letter to the patient. 2. The HIPAA Compliance Officer shall also note on the "Patient Request for Restriction of Protected Health Information" Form that the request was denied, and document all pertinent information regarding the request and denial (date, reason for denial, etc.). Termination of Restrictions 1. A restriction may be terminated if the individual agrees to or requests the termination. 2. Oral agreements to terminate restrictions must be documented. 3. Most restrictions may also be terminated by North State Medical Transport as long as North State Medical Transport notifies the patient that PHI created or received after the restriction is removed is no longer restricted. PHI that was restricted prior to the notice voiding the restriction must continue to be treated as restricted PHI. 4. North State Medical Transport should not terminate a restriction regarding PHI that pertains to a service for which North State Medical Transport has been paid in full and where a patient has requested that such PHI not be disclosed to the patient's health plan. Such restriction will only apply with respect to that service and not to subsequent services. The patient must make another request, and pay out-of-pocket for each service. Policy 5: Policy on Patient Requests for Accounting of Disclosures of PHI North State Medical Transport Policy on Requests for Accounting of Disclosures of Protected Health Information Purpose The Health Insurance Portability and Accountability Act of 16 ("HIPAA") grants individuals the right to an accounting of disclosures of their protected health information ("PHI")from paper and electronic records. North State Medical Transport has an obligation to render an accounting to individuals in accordance with federal and state law. To ensure that North State Medical Transport complies with its obligations,this policy outlines our procedures for handling requests for an accounting and establishes the procedures by which patients or their authorized representatives may request an accounting of disclosures of PHI from North State Medical Transport. { Scope This policy applies to all North State Medical Transport staff members who receive requests from patients for an accounting of disclosures of PHI. Generally, all requests will be directed to the HIPAA Compliance Officer and it shall be the responsibility 99 of the HIPAA Compliance Officer to handle all accounting requests. Procedure Requests for an Accounting 1. Patients and their authorized representatives shall have a right to request an accounting of certain disclosures of PHI made by North State Medical Transport. 2. If a patient or their authorized representative requests an accounting of disclosures of PHI,the requestor shall be referred to the HIPAA Compliance Officer. The HIPAA Compliance Officer shall request that the patient or authorized representative complete North State Medical Transport's "Patient Request for Accounting of Disclosures Protected Health Information" Form. 3. The HIPAA Compliance Officer must verify the patient's identity, or, if the requestor is not the patient,the name and identity of the representative and whether the representative has the authority to act on the patient's behalf. The use of a driver's license, social security card, or other form of government-issued identification is acceptable for this purpose. If it is impossible for the requestor to physically come in to 4'. make the request and verify this information,the HIPAA Compliance Officer shall ask the requestor to verify the patient's name, date of birth, SSN, address, and telephone number over the phone and ask the requestor to submit the "Patient Request for Accounting of Disclosures of Protected Health Information" Form via email, mail or fax. 4. Upon receipt of the completed "Patient Request for Accounting of Disclosures of Protected Health Information" Form and verification of the requestor's identity, the HIPAA Compliance Officer will respond to a request for an accounting of disclosures within 60 calendar days of receipt of a request, preferably sooner. 5. If North State Medical Transport is unable to provide the accounting within 60 calendar days, North State Medical Transport may extend the time for responding to the request by no more than 30 calendar days, provided that within the 60 day period North State Medical Transport provides a written statement to the individual explaining the reasons for delay and the date by which the accounting will be provided. Only one 30-day extension may be exercised per accounting request. Fulfilling an Accounting Request 1. North State Medical Transport will provide the patient or their authorized representative with a written or electronic accounting of disclosures of their PHI made by North State Medical Transport or its business associates on North State Medical Transport's behalf, as required by HIPAA. North State Medical Transport will render an accounting of all disclosures of PHI during the period requested by the patient or other requestor. If the requestor does not specify a time period for the accounting, North State Medical Transport will render an accounting of disclosures of PHI made during the past six (6) years. The following disclosures are excluded from the HIPAA accounting requirement: a. Disclosures to carry out treatment, payment or health care operations; b. Disclosures made to the patient or to the patient's authorized representative; c. Disclosures incident to a use or disclosure otherwise permitted or required by HIPAA; d. Disclosures pursuant to the patient's authorization; e. Disclosures for a facility directory or to persons involved in the patient's care; f. Disclosures for national security or intelligence purposes; g. Disclosures to correctional institutions or law enforcement officials to provide them with information about a person in their custody; and h. Disclosure made as part of a limited data set. North State Medical Transport will not render an accounting for disclosures that are exempt from the HIPAA accounting requirement. 2. All accountings shall include the following information regarding each disclosure of PHI addressed in the accounting: a. The date of the disclosure; b. The name of the entity or person who received the PHI and, if known, the address of such entity or person; c. A brief description of the PHI disclosed; and d. A brief statement of the purpose of the disclosure that reasonably informs the patient of the basis for the disclosure. Tracking Disclosures of PHI 1. In order to fulfill its obligations to render an accounting of disclosures of PHI under HIPAA, North State Medical Transport shall track all necessary disclosures of PHI. The '~- HIPAA Compliance Officer is responsible to ensure North State Medical Transport is tracking disclosures when required by HIPAA to do so. 2. Generally North State Medical Transport shall track all disclosures for or pursuant to: a. Research purposes, unless authorized by the patient; b. Subpoenas, court orders or discovery requests c. Abuse and neglect reporting; d. Communicable disease reporting; and e. Other reports to a Department of Health TheH|PAAConnp|ianraOffoernnayutiUzethe "AccountingLogfor0sdosuresofPH|" Form for this purpose and track all information required on the Form. Administrative Requirements North State Medical Transport shall retain the following documentation, in either written or electronic form,for 6 years: 1. Written requests by an individual for an accounting of disclosures Z. Accountings of disclosures that have been provided to an individual, including the titles of the persons and offices responsible for receiving and processing the request for accounting; and S. Copies of any notices to the individual explaining that North State Medical Transport requires an extension of time to prepare the requested accounting. Policy 6: Policy on Patient Requests for Confidential Communications North State Medical Transport Policy on Patient Requests for Confidential Communications of Protected Health Information Purpose The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") grants individuals the right to request that North State Medical Transport send PHI to an alternate location (e.g., somewhere other than a home address), or through alternate means (e.g., by email rather than regular mail). This is called the right to "confidential communications." North State Medical Transport has an obligation to grant patients this right and it must abide by a request for confidential communications of PHI in accordance with federal and state law. To ensure that North State Medical Transport complies with its obligations, this policy outlines procedures for handling requests for confidential communications of PHI and establishes the procedures by which patients or their authorized representatives may request confidential communications. Scope This policy applies to all North State Medical Transport staff members who handle requests from patients for confidential communications of their PHI. Generally, all requests will be directed to the HIPAA Compliance Officer and it shall be the responsibility of the HIPAA Compliance Officer to handle all requests for confidential communications. Procedure Requests for Confidential Communications 1. North State Medical Transport will permit patients to request that North State Medical Transport send PHI to individuals at an alternate location (e.g., somewhere other than a home address), or in a specific manner (e.g., by email rather than regular mail). 2. All requests for confidential communications PHI shall be referred to the HIPAA Compliance Officer who shall request that the patient or authorized representative complete and submit North State Medical Transport's "Patient Request for Confidential Communications of Protected Health Information" Form. All requests will be reviewed and denied or approved by the HIPAA Compliance Officer in accordance with this policy. The HIPAA Compliance Officer shall utilize the "Review of Patient Request for Confidential Communications of Protected Health Information" Form when reviewing requests for confidential communications of PHI. 3. The HIPAA Compliance Officer must verify the patient's identity, or, if the requestor is not the patient, the name and identify of the representative and whether the representative has the authority to act on the patient's behalf. The use of a driver's license, social security card, or other form of government-issued identification is acceptable for this purpose. If it is impossible for the requestor to physically come in to make the request and verify this information, the HIPAA Compliance Officer shall ask the requestor to verify the patient's name, date of birth, SSN, address, and telephone number over the phone and ask the requestor to submit the "Patient Request for Confidential Communications of Protected Health Information" Form via email, mail or fax. 4. North State Medical Transport is required to and will agree to any "reasonable requests" for confidential communications. Granting a Request for Confidential Communications 1. North State Medical Transport will and must comply with a confidential communications request if the request is "reasonable."The HIPAA Compliance Officer shall take into account logistical reasons and other factors, such as the cost of making the alternate confidential communications, when determining whether the request is reasonable. 2. If North State Medical Transport receives a request from a patient or authorized representative asking North State Medical Transport to communicate PHI in an alternate manner and North State Medical Transport determines that the request is reasonable, it will agree to the request and the HIPAA Compliance Officer shall inform the patient of that fact, in writing, by sending an "Acceptance of Request for Confidential Communications of Protected Health Information" letter to the patient. The HIPAA Compliance Officer shall also note on the "Review of Patient Request for Confidential Communications of Protected Health Information" Form that the request was accepted and document all pertinent information regarding the request and acceptance. Denying the Request for Confidential Communications 1. 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Y 7 L E o E z o c CC o C m y-p E m u `^ = Q u c 0 a o v a ° " -cO, rn C 0> 1 C u C ,,a ,, 3 + +' W O „0 To o ¢ aro°u i, i a; ,n C(‘' 12 4_ Q O E O aJ E Q ,_ LL. w E L.Q a u. 'n+, c c �p c z _ v. � d w O UU - ` c V c U a cU ° al° c Qa a cv , - v t 0,1 CU . t 4- o n E Y = p a E °' ::•13 ..-7 i 4" a C d `O 'D - U Q' 1 Q m ar et000 Cr- c-:,© < !ll C U N cu cr.+ as a • �s> P o a)r c t s cv, a :41MA O tw tll ?a+treol' E ro rF t a� z nNr N # car w5 r rp. t6 fFJ Qt 0".•. Policy 8: Policy on HIPAA Training North State Medical Transport Policy on HIPAA Traini Purpose ThaHeolth |nounanoePortabi|h»andAcoountabi|kvAcLof1996 (°H|PAA") requinesthat all members of North State Medical Transport's workforce be trained on our policies and procedures regarding privacy and security. This policy is meant to ensure that all of North State Medical Transport staff- including all employees,volunteers, students and trainees (collectively referred to as "staff members") -who have access to protected health information ("PHI") understand and are trained regarding North State Medical Transport's HIPAA policies and procedures. Scope This policy applies to all North State Medical Transport staff members. This includes those who have access to PHI in any form Procedure 1. All current staff members must be trained on North State Medical Transport's HIPAA policies and procedures in accordance with HIPAA. 2. All new staff members will be required to undergo privacy training within a reasonable time upon association with North State Medical Transport. 3. All staff members who have undergone initial HIPAA training will be required to undergo HIPAA training within a reasonable time after there is a material change to North State Medical Transport's HIPAA policies and procedures 4. TheH|PAAtrainiDgvVi|| becoV[diD8ted8ndtrackedonthe "H|PAATroiningLo8" Forrnby the HIPAA Compliance Officer or his or her designee Training documentation will be maintained for six(6) years 5. All staff members will receive copies of North State Medical Transport's HIPAA policies and procedures. 6. All staff members must personally complete the HIPAA training and verify completion and agree to adhere to North State Medical Transport's HIPAA policies and procedures. 7. Training will be conducted through the following method PWW HIPAA TV-Classroom. 8. All staff members shall sign the "HIPAA Training Log" after completing HIPAA training. Policy 9: Policy on Updating HIPAA Policies, Procedures &Training North State Medical Transport Policy on Up HIPAA Policies,Procedures and Procedures and Training Purpose The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") requires North State Medical Transport to ensure that its HIPAA policies, procedures and training materials are up to date and effective in safeguarding the confidentiality, integrity and availability of protected health information ("PHI"). This policy` ' adjust and update our policies and procedures accordingly, based on periodic reviews and evaluations of our existing practices and in light of new and changing risks to PHI. North State Medical Transport will also evaluate and consider new technologies and methodologies for securing PHI, as specified by guidance from the Secretary of Health and Human Services /"HHS"\. Scope This policy applies to all North State Medical Transport staff members who are responsible for evaluating and updating current HIPAA policies and procedures and providing the updates to staff members. The HIPAA Compliance Officer will have the overall responsibility for monitoring all new developments in patient privacy and security of PHI and will recommend updates to our HIPAA Compliance Program, as necessary. The HIPAA Compliance Officer should perform these duties in consultation with North State Medical Transport management and solicit the input of appropriate North State Medical Transport staff members, when appropriate. Procedure Maintaining Knowledge 1. The HIPAA Compliance Officer will strive to keep current with all changes in the law and regulations that address the privacy and security of PHI. 2. The HIPAA Compliance Officer will review journals and newsletters on the subject of HIPAA, and will sign up for appropriate list-serves to obtain current information. 3. The HIPAA Compliance Officer will monitor HIPAA websites, such as the site for the Office of Civil Rights,for new information on HIPAA compliance 4. The HIPAA Compliance Officer will participate in seminars and conferences on HIPAA as needed and as the budget allows S. The HIPAA Compliance Officer will consult with legal counsel as necessary to learn of new legal developments that could affect North State Medical Transport with respect to HIPAA issues. Evaluation of HIPAA Policies and Procedures 1. On at least an annual basis, the HIPAA Compliance Officer will convene a committee of managers and/or appropriate staff members to identify and review all existing HIPAA policies and procedures for compliance with current HIPAA laws and regulations. Z. Any member of the review committee or any other staff member may suggest changes to our HIPAA Policies or Procedures by submitting the suggestion to the HIPAA Compliance Officer for consideration. 3. The annual policy and procedure review will identify all changes that need to be made to our policies, based on the experience of staff and management, technological developments and changes in the regulatory environment during the prior year. 4. Any critical changes in the law or regulations that require a change in our privacy practices will be addressed immediately and incorporated into our privacy compliance program. ) 5. All complaints and concerns regarding the safeguarding of patient information will be evaluated by the HIPAA Compliance Officer to determine if policy or procedure changes need to be implemented. 6. Unwritten procedures and practices will also be reviewed to ensure compliance with HIPAA regulations. Evaluating and Updating HIPAA Training Programs 1. The HIPAA Compliance Officer annually reviews all HIPAA-related training materials and will update those materials and keep them current with recent changes in privacy practices as necessary. 2. Additional in-service training will be scheduled as necessary to ensure that all current staff members are kept up to date on our current HIPAA policies and procedures. Policy 10: Policy on Contracting With Business Associates North State Medical Transport Policy on Contracting With Business Associates Purpose North State Medical Transport is responsible for ensuring the privacy and security of all protected health information ("PHI")that we create, receive, maintain or transmit under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). HIPAA requires that North State Medical Transport ensure that those persons and entities that perform services on our behalf using PHI agree to protect that PHI as we would by requiring those parties to sign a "business associate agreement" ("BAA") with North State Medical Transport. This policy describes our approach to entering into business associate agreements with persons and organizations that perform services on our behalf involving the use of PHI. Scope This policy applies to all North State Medical Transport staff members who are responsible for entering into agreements with outside vendors or persons who might have access to PHI. Generally,the HIPAA Compliance Officer of North State Medical Transport is responsible to initiate a business associate agreement with any person or entity that performs a service on behalf of North State Medical Transport that involves the use or disclosure of PHI. Procedure 1. The HIPAA Compliance Officer is responsible for identifying persons and organizations that perform services on our behalf and who in any manner create, receive, maintain or PHI about our patients. All such persons or entities are called "business associates" ("BAs") of North State Medical Transport. For example, our business associates include, but are not limited to, our outside billing company, our outside consultants, and our outside attorney. Workforce members are not business associates, nor are organizations that share a direct treatment relationship with patients to whom North State Medical Transport provides services. When in doubt,the HIPAA Compliance Officer should consult qualified legal counsel when determining whether an entity meets the legal definition of a BA. 2. All identified BAs of North State Medical Transport must enter into a BAA if they wish to do business with us. Even if we do not have a written services contract with a party, HIPAA requires that we have a written business associate agreement with all BAs. No K disclosures of PHI will be made by North State Medical Transport to a BA until the BRA F' has been signed. I`< 3. Whenever possible, North State Medical Transport will use its standard business associate agreement. If the BA insists on using its own business associate agreement, the HIPAA Compliance Officer must ensure that the agreement proposed by the BA conforms to HIPAA's requirements. 4. Whenever North State Medical Transport modifies its existing business associate agreement, the HIPAA Compliance Officer shall ensure that we enter into a new business associate agreement with our current BAs. 5. Whenever possible, all contracts and service agreements between North State Medical Transport and any BA should include the relevant business associate language directly in the contract or service agreement. Otherwise, a stand-alone business associate agreement is required. If there is a business associate agreement separate from the main contract or service agreement, then the main agreement must specifically refer to the business associate agreement. 6. The HIPAA Compliance Officer will maintain a current list of business associates. 7. At times, North State Medical Transport may be asked to enter into business associate agreements. The HIPAA Compliance Officer shall evaluate the appropriateness of the business associate agreement under the circumstances and enter into the agreement only when required by law and if the agreement meets the legal requirements under HIPAA. 8. The HIPAA Compliance Officer is responsible for maintaining BA agreements on file for periodic review and inspection. 9. With respect to a person or entity that is not a BA, but which may potentially come into contact with PHI, such as janitorial services or information technology service providers, the HIPAA Compliance Officer should seek to have a "Confidentiality Agreement" in place with the entity. Policy 11: Policy on Workforce Sanctions for Violations of HIPAA Policies and Procedures North State Medical Transport Policy on Workforce Sanctions for Violations of HIPAA Policies and Procedures Purpose North State Medical Transport is responsible under the Health Insurance Portability and Accountabi|ityActof199G ("H|PAA")toadnministeroppropriatesanctionstoitsvvorkforce members who violate the HIPAA policies and procedures of the organization. This policy outlines our approach to violations of our HIPAA policies and procedures and emphasizes the fact that North State Medical Transport takes any breach of our policies and procedures very seriously. Scope This policy applies to all North State Medical Transport staff members, including those staff members who may learn of patient information indirectly, and even if use of this /,- information is not part of the staff member's responsibilities with North State Medical Transport. NOTE: Any sanctions under this policy or any other policy will not apply to staff members who 1) file a complaint with the federal government about potential HIPAA violations, 2)testify assist, or participate in an investigation or compliance review proceeding or official government proceeding investigating HIPAA issues, and 3) oppose any actions by North State Medical Transport that are unlawful under HIPAA, when that opposition is made with the good faith belief that North State Medical Transport was violating HIPAA (as long as any opposition or filing of a complaint did not result in improper disclosure of PHI) Procedure I. North State Medical Transport will implement sanctions that are to be used when any staff member fails to comply with or violates our HIPAA policies and procedures. 2. Sanctions will be administered in a progressive manner, wherever possible. North State Medical Transport will administer sanctions to the degree necessary to correct improper behavior and to ensure the protection of patient privacy. The nature of the PHI involved in the incident will be considered. (EXAMPLE: A first time violation where an employee revealed PHI to another staff member without any need to know may receive a verbal counseling or written warning, but if a first violation resulted in revealing PHI to someone who was not a staf member or business associate, a suspension may be warranted.) 3. Progressive sanctions may include the following: a. Remedial HIPAA training and education b. Informal verbal counseling c. Formal verbal counseling with written documentation of the counseling d. Written warning e. Suspension f. Termination or expulsion from North State Medical Transport 4. Staff members have an affirmative duty to report to management or the HIPAA Compliance Officer any suspected violation of our HIPA policies and procedures. S. Staff members shall be educated about this policy and the serious nature of violating our HIPAA policies. Staff members will be made aware of the potential sanctions that may occur, and will be made aware of any changes to this sanction policy. 6. A record of individual staff member sanctions will be kept in the respective staff member's file. Adherence to our HIPAA policies may also be considered as part of the staff member's performance evaluation. 7. In the event of a suspected or reported violation of our HIPAA policies, the HIPAA Compliance Officer will initiate an objective and comprehensive investigation that will include: a. Interviews of potential witnesses b. Interviews of the alleged violator c. Preparation of an investigative report d. Presentation of the report to management with recommendations for sanctions (if any) or changes in our policies or practices 8. At all times, whenever there is a suspected violation of our HIPAA policies or other breach of privacy, the HIPAA Compliance Officer will recommend immediate action to be taken to mitigate the violation and its impact on North State Medical Transport and any other parties. Policy 12: Policy on Minimum Necessary Requirement&Role-Based Access to PHI North State Medical Transport Policy on Minimum Necessary Requirement and Role-Based Access to PHI Purpose Generally,the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") requires that North State Medical Transport only use or disclose the minimum amount of protected health information ("PHI")that is needed to accomplish the intended purpose for which the use or disclosure is made. This policy outlines North State Medical Transport's commitment to adhere to HIPAA's "minimum necessary requirement." In order to effectively meet our obligations,this policy outlines the appropriate levels of access to PHI that specific staff members of North State Medical Transport should have—"Role Based Access." This policy does not in any way limit the amount of PHI that may be exchanged between North State Medical Transport staff members or between North State Medical Transport staff members and other individuals during the course of treating patients. Scope This policy applies to all North State Medical Transport staff members who have any degree of access to PHI at North State Medical Transport. Procedure North State Medical Transport retains strict requirements on the security, access, disclosure and use of PHI. Access, disclosure and use of PHI will be based on the role of the individual staff member in the organization, and only to the extent that the person needs to access and use the PHI to complete necessary responsibilities for North State Medical Transport. When PHI is accessed, disclosed and used,the individuals involved will make every effort, except in patient care situations,to only access, use, and disclose the minimum necessary amount of information needed to accomplish the intended purpose. Role Based Access Access to PHI will be limited to those who need access to carry out their duties. The following table describes the specific categories or types of PHI to which identified persons need access, and any conditions that would apply to such access. £"" job Title Description of PHI to Be y k Conditions,+of Access to PHI ti EMT Intake information from dispatch, May access only as part of completion of a patient patient care reports,QA and 01 event and post-event activities and only while reports actually on duty Paramedic Intake information from dispatch, May access only as part of completion of a patient patient care reports,QA and 01 event and post-event activities and only while reports actually on duty Billing Clerk Intake information from dispatch, May access only as part of duties to complete patient care reports,billing claim patient billing and follow up and only while actually information,remittance advice, on duty other patient information from facilities necessary for billing Field Supervisor Intake information from dispatch, May access only as part of completion of a patient patient care reports,QA and 01 event and post-event activities,as well as for quality reports assurance checks and corrective counseling of staff Dispatcher Intake information,preplanned CAD May access only as part of completion of an information on patient address incident,from receipt of information necessary to dispatch a call,to the closing out of the incident and only while on duty Training Intake information from dispatch, May access only as a part of training and quality Coordinator patient care reports,QA and 01 assurance activities. All individually identifiable reports patient information should be redacted prior to use in training and quality assurance activities Managers Intake information from dispatch, May access only to the extent necessary to monitor patient care reports,QA and 01 compliance and to accomplish appropriate reports,billing claim forms, supervision and management of personnel and remittance advice,other patient compliance with the law information necessary for oversight Access to a patient's entire file will not be allowed except when necessary for a legitimate treatment, payment, or healthcare operations-related reason. Disclosures to and Authorizations from the Patient North State Medical Transport may freely disclose PHI to patients who are the subject of the information and we may freely use and disclose PHI to the extent authorized by a patient. North State Medical Transport is required to limit disclosure to the minimum amount of information necessary when releasing it pursuant to a patient request or formal Authorization. is North State Medical Transport Requests for PHl from Other Parties �( If North State Medical Transport needs to request PHI from another party on a routine or recurring basis, we must limit our requests to only the minimum amount of information needed for the intended purpose, as described in the table below. For requests not addressed in the table below, North State Medical Transport must make this determination individually for each request, and this determination should be made by the HIPAA Compliance Officer. For example, if the request is non-recurring or non-routine, like making a request for documents pursuant to an audit request, we must make sure our request covers only the minimum necessary amount of information needed to accomplish the purpose of the request. Holder of PHI Purpose of Request f Information Reasonably Skilled Nursing To have adequate patient records to treat Patient face sheets,discharge Facilities the patient,determine medical necessity summaries, Physician Certification for service,and to properly bill for services Statements and Statements of Medical provided Necessity, Mobility Assessments Hospitals To have adequate patient records to treat Patient face sheets,discharge the patient, determine medical necessity summaries,Physician Certification for service,and to properly bill for services Statements and Statements of Medical provided Necessity, Mobility Assessments Mutual Aid To have adequate patient records to treat Patient care reports Ambulance or the patient,conduct joint billing Paramedic Services operations for patients mutually treated/transported by the Company PHI Requests to North State Medical Transport from Other Parties North State Medical Transport will make reasonable efforts to release only the minimum amount of PHI that is necessary to accomplish the actual purpose of a request from a third party. Incidental Disclosures North State Medical Transport understands that there will be times when there are incidental disclosures about PHI in the context of caring for a patient. HIPAA was not intended to impede common healthcare practices that are essential in providing healthcare to the individual. Incidental disclosures are inevitable, but these will typically occur in radio or face- to-face conversations between healthcare providers, or when PHI is able to be viewed by others, despite reasonable efforts to protect the PHI from view. But all personnel must be sensitive to avoiding incidental disclosures to other healthcare providers and others who do not have a need to know the information. North State Medical Transport staff should be attentive to who is within earshot when making verbal statements about a patient's health information, and follow some of these common sense procedures for avoiding accidental or inadvertent disclosures: Measures to Protect PHI 1. Verbal PHI. Staff members should only discuss PHI with those who are involved in the care of the patient, regardless of physical location. When discussing PHI with patients, staff members should make sure that there are no other persons (including other North State Medical Transport staff members) in the area that could overhear the discussion. If so, the patient should be brought into a screened area before engaging in discussion. 2. Hard Copy PHI. All paper patient care reports should be stored in safe and secure areas when not in use. No paper records concerning a patient should be left in open bins or on desktops or other surfaces. Only those with a need to have the information for the completion of their job duties should have access to any paper records. Additionally, billing records, including all notes, remittance advices, charge slips or claim forms should not be left out in the open and should be stored in files or boxes that are secure and in an area with access limited to those who need access to the information for the completion of their job duties. 3. E-PHI. Computer access terminals and other mobile devices should be kept secure. Staff members should be sensitive to who may be in viewing range of the monitor screen and take simple steps to shield viewing of the screen by unauthorized persons. All mobile devices such as laptops, ePCRs and cell phones should remain in the physical possession of the individual to whom they are assigned at all times. I'; Policy 13: Policy on Designated Record Sets North State Medical Transport Policy on Designated Record Sets Purpose To ensure that North State Medical Transport patients and their authorized representatives are granted rights regarding Protected Health Information ("PHI") in accordance with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), this policy establishes what protected health information ("PHI") at North State Medical Transport should be accessible to patients as part of a Designated Record Set ("DRS"). Under HIPAA, a DRS includes medical records that are created or used by North State Medical Transport to make decisions about the patient. Scope This policy applies to all North State Medical Transport staff members responsible for the designation of PHI into designated record sets and those responsible for fulfilling patient requests pertaining to PHI. All staff members should be familiar with the types of information that will be part of a DRS. Generally, the HIPAA Compliance Officer will be responsible for fulfilling patient requests related to PHI and for ensuring that the correct information is made part of the DRS. Procedure The DRS should only include PHI as defined under HIPAA, and should be comprised of individually identifiable healthcare and billing information created, received, maintained or transmitted by or on behalf of North State Medical Transport that is used, in whole or in part, by North State Medical Transport to make decisions about individuals. The HIPAA Compliance Officer shall be the party in charge of designating what information is part of a DRS at North State Medical Transport and for ensuring that appropriate information is being maintained by North State Medical Transport in its designated record sets. The Designated Record Set at North State Medical Transport 1. The DRS at North State Medical Transport for any requests regarding PHI includes the following records: a. Paper or electronic patient care reports ("PCR" or "ePCR") created or received by North State Medical Transport and supplementary information regarding the patient's condition. This includes any photos, videos, monitor strips, Physician Certification Statements, Refusal of Care forms, Advance Beneficiary Notice of Noncoverage forms, or information from other source used by North State Medical Transport to treat patients or bill for services. b. The electronic claims records or other paper records of submission of actual claims to Medicare or other insurance companies. c. Any patient-specific claim and billing information, including responses from insurance payers, such as remittance advice statements, Explanation of Medicare Benefits (EOMBs), charge screens, patient account statements, and signature authorization and agreement to pay documents. d. Notices from insurance companies indicating coverage determinations, documentation submitted by the patient, and copies of the patient's insurance card or policy coverage summary,that relate directly to the care of the patient or payment for that care. e. Amendments to PHI, or statements of disagreement by the patient requesting the amendment when PHI is not amended upon request, or an accurate summary of the statement of disagreement. 2. The DRS should also include treatment related records created by other parties such as first responder units, assisting ambulance services, air medical services, nursing homes, hospitals, police departments, coroner's offices, etc.,that are used by North State Medical Transport for treatment and payment related purposes. 3. A designated record set should not include: a. Quality assurance data collected and maintained for peer review purposes; b. Accident reports; c. Incident reports; d. Duplicate information maintained in other systems; e. Data collected and maintained for research; f. Information compiled in reasonable anticipation of litigation or administrative F action; g. Employment records; or h. Student records. Policy 14: Policy on News Media Interaction North State Medical Transport Policy on News Media Interaction Purpose The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") establishes the circumstances under which individuals' protected health information ("PHI") can be disclosed. Generally, North State Medical Transport may not disclose PHI to the news media without the patient's written express authorization. In addition, state laws may also grant patients additional privacy protections and may enable parties to bring legal action for invasion of privacy or other related causes of action for improper releases of patient information to the news media—sometimes even information that might not qualify as PHI under HIPAA. This policy establishes consistent guidelines for North State Medical Transport to follow when dealing with requests from the media so that North State Medical Transport respects individual privacy rights and complies with applicable federal and state law. This policy will is meant to work in conjunction with North State Medical Transport's "Action Plan on News Media Interaction." North State Medical Transport fully respects the right of the public to know about events, but we will provide information to the news media only to the extent that the law allows us and only when it would not infringe on the privacy rights of our patients. Scope This policy applies to all North State Medical Transport staff members who might come into contact with or who may be contacted by various media outlets. Generally, all requests from the media for any information about an incident involving North State Medical Transport will be directed to our Public Information Officer to handle. Or, if North State Medical Transport does not have a designated Public Information Officer, all requests should be directed to our HIPAA Compliance Officer. Procedure Requests from the News Media 1. North State Medical Transport staff members will at all times treat members of the media in a professional manner when a request for information is made. 2. All information requests from the news media received by any North State Medical Transport staff members shall be directed to the Public Information Officer. Or, if North State Medical Transport does not have a designated Public Information Officer, all requests from the news media shall be directed to the HIPAA Compliance Officer. Upon receipt of a request for information from the news media, staff members should inform the news media requestor that it is the policy of North State Medical Transport that all media requests be handled by one official and staff members should provide the media requestor contact information for the Public Information Officer or HIPAA Compliance Officer, as appropriate. Or, the staff member may contact the Public Information Officer or HIPAA Compliance Officer to inform the Officer of the request and request authorization to release information to the media. 3. Staff members other than North State Medical Transport's Public Information Officer or HIPAA Compliance Officer are not permitted to release information to the news media, unless authorized or directed by the appropriate Officer to do so. 4. The Public Information Officer or HIPAA Compliance Officer shall use discretion in handling requests from the news media and when deciding whether to release (or permit the release) of information to the media. The Public Information Officer or HIPAA Compliance Officer should only release information to the media when such release would not violate federal or state laws and when release would not infringe a patient's reasonable expectation to privacy. For example, if North State Medical Transport transported a high profile member of the community, North State Medical Transport should probably decline to disclose even general information that does identify the individual to the media since it is likely the patient's identity would be known to anyone hearing the report. Releasing Information to the News Media 1. North State Medical Transport may not release any PHI to the news media, absent a patient's written, signed authorization. In the event that the patient or the patient's authorized representative signs a HIPAA-compliant authorization form, disclosures of information, including PHI, may be made so long as they are done in accordance with the express terms of the written Authorization. North State Medical Transport's "Authorization to Use and Disclose Protected Health Information" Form should be used for this purpose. 2. If there is no written authorization from the patient, North State Medical Transport may only release information that is "de-identified/' De-identified information is information that does not identify an individual and there is no reasonable basis to believe that the information can be used to identify a specific individual. North State Medical Transport may only release the following types of"de-identified" information to members of the media where appropriate: a. Name of hospital. North State Medical Transport may provide the name of the hospital to which patients have been transported. (Example: The media calls about "the accident at Third and Main earlier this afternoon." North State Medical Transport may inform the media that "a patient was transported from the accident scene to ABC Hospital.") b. Number of patients. North State Medical Transport may provide the total number of patients involved in an incident or transported to a facility. North State Medical Transport may not indicate specifics, such as the type of vehicle a patient was driving or which patient went to a particular facility. (Example: North State Medical Transport may inform the media that "four patients were transported from the fire at the Chemical Factory. Two were taken to County General and two were taken to the Regional Medical Center.") c. Age &Gender. North State Medical Transport may provide the age of a patient and the gender of the patient, unless it could reasonably be used to identify the patient. (Example: North State Medical Transport may inform the media that "a 39 y/o male was transported from the accident on the Interstate.") d. Designation of crew members. North State Medical Transport may state, for example,that one paramedic and two EMTs were involved in caring for the patients involved in a motor vehicle accident. North State Medical Transport may identify the names of the personnel who responded. (Example: North State Medical Transport may inform the media that "North State Medical Transport personnel on the scene of the incident included two paramedics and a supervisor and advanced life support was administered.") e. Type of Transport. North State Medical Transport may indicate that a particular call was an emergency and that transportation was facilitated by ambulance or helicopter. (Example: "Of the 3 patients on the scene of the incident, one was transported by helicopter to the Trauma Center and two were transported as non- emergency patients to the local hospital emergency department.") kk Policy 15: Action Plan on News Media Interaction North State Medical Transport Action Plan on News Media Interaction Step 1: Is the request asking North State Medical Transport to disclose PHI? YES NO Upon receipt of a request for information from the news media,the Public Information Officer or HIPAA Compliance Officer shall determine whether the request is asking Go to Step 2 Go to Step 3 North State Medical Transport to disclose PHI. Step 2: North State Medical Transport will not release any PHI to the news media absent a patient's written,signed authorization. The Public Information Officer or HIPAA Compliance Officer may consider asking the patient,or the patient's personal representative,whether they would agree to allow North State Medical Transport to release the requested PHI to the news media. In the event that the patient or the patient's authorized representative does agree to permit North State Medical Transport to make the disclosure,the Public Information Officer or HIPAA Compliance Officer shall require the individual to complete and sign North State Medical Transport's"Authorization to Use and Disclose Protected Health Information"Form to permit the disclosure. North State Medical Transport may only disclose PHI to the media in strict compliance with what the Authorization states. Step 3: North State Medical Transport may release the following types of"de-identified"information to members of the media in accordance with North State Medical Transport's"Policy on News Media Interaction": • Name of hospital • Number of patients • Age and gender of patients • Designation of crew members • Type of transport \ Policy 16: Policy on Release of PHI to Law Enforcement Without Legal Process North State Medical Transport Policy on Release of Protected Health Information to Law Enforcement Without Legal Process Purpose Protected health information ("PHI") may only be released to law enforcement officials under specific and limited circumstances under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). This policy provides consistent guidelines for North State Medical Transport staff members to follow regarding the release of PHI to law enforcement when the law enforcement official does not serve some type of legal process, such as a summons, subpoena, or warrant, so that staff only release PHI in accordance with HIPAA. This policy will work in conjunction with North State Medical Transport's "Staff Member Action Plan for Release of PHI to Law Enforcement Without Legal Process." Scope This policy applies to all North State Medical Transport staff members who may come in contact with law enforcement including field personnel who may encounter law enforcement off�c|�|sa�theaceneof�niDoid�ntaDdntherstaffvvhonmaybeapprnachedby |avv enforcement directly after an incident. This policy applies to situations where law enforcement is seeking PHI from a staff member and the law enforcement official does not present North State Medical Transport with legal process, such as a subpoena, summons or warrant. North State Medical Transport's Policy on Release of Protected Information Pursuant to Warrant, Subpoena, Summons or Administrative Request applies to situations where law enforcement or other parties are seeking information pursuant to legal process. Procedure General Procedure for Handling Requests 1. If a staff member of North State Medical Transport is approached by a law enforcement official and the official makes requests a request for PHI about a patient from the staff member, the staff member should verify the identity of the law enforcement official and ask the official what is the purpose for which the request is being made 2. If the request is being made for one of the purposes listed in this policy,then the staff member may release the PHI to the law enforcement official, in accordance with this policy. Formal written patient authorization is not required when releasing PHI pursuant to one of the purposes listed in this policy; however, where the patient is readily available and able to consent to the disclosure, verbal consent should be obtained and documented by the staff member before disclosure of PHI is made to the law enforcement official. 3. If the staff member is unsure about whether the release of PHI is proper, the staff member should contact North State Medical Transport's HIPAA Compliance Officer or an immediate supervisor for guidance. Under no circumstance should any staff member release PHI to law enforcement if the staff member is unsure about the appropriateness of the disclosure. 4. If the request for PHI does not fall under one of the purposes listed in this policy, the staff member should inform the law enforcement officer that s/he is not permitted under HIPAA to release the information. The staff member may inform the law enforcement official of the following two options: a. The law enforcement official may obtain legal process, such as a warrant, summons, or subpoena, to obtain the information from North State Medical Transport. b. The law enforcement official may obtain the information directly from the patient if the patient is stable and willing to speak with the official. Staff members should only provide this option to a law enforcement official when doing so would not impede patient care and where the patient is willing to speak with the official. For a stable patient, the staff member should first consult with the patient to determine whether the patient is willing to speak with the official. If the patient declines to speak with the official, the staff member should inform the enforcement official. 5. Staff members should record, at a minimum,the following information about all law enforcement requests that are unaccompanied by legal process: a. The name of the law enforcement official; b. The date and time of the request; c. The purposes for which the request was made (if provided); d. What information the law enforcement official requested; e. Whether the patient was consulted about the request and the patient's response; f. Whether the HIPAA Compliance Officer or other individual at North State Medical Transport was consulted about the request; g. Whether the law enforcement official made any representations to North State Medical Transport; h. Whether PHI was released and what PHI was released; and i. The reason(s) why the PHI was released. Purposes for Which Disclosure Can Be Made to Law Enforcement Without Legal Process Disclosures of PHI Required by State Reporting Law 1. North Carolina law requires that North State Medical Transport staff members report the following types of incidents to law enforcement agencies in North Carolina: [N/A.] 2. If there is any doubt regarding whether or not North Carolina requires reporting of a particular injury or incident,the staff member should contact a supervisor for a list of incidents that must reported under North Carolina law. Disclosures of PHI to Locate or Identify a Suspect, Material Witness, Fugitive or Missing Person 1. PHI may be disclosed to law enforcement for purpose of locating or identifying a suspect, material witness,fugitive or missing person only upon request of a law enforcement official. The disclosure may not be initiated by North State Medical Transport. 2. If a law enforcement official indicates to a staff member that they need PHI about an individual to identify or locate a suspect, material witness,fugitive or missing person, the staff member should ask the law enforcement official to confirm that the sole purpose of the request is to locate or identify one of the listed individuals. If the law enforcement official already knows who the individual is and where the individual is located, then the staff member should not proceed to disclose PHI for this purpose. 3. Although no formal written request is required from law enforcement, the staff member should ask that the PHI request be documented in writing, preferably on the law enforcement department's letterhead. In the absence of a written request from the law enforcement agency, the staff member should, at a minimum, document that the law enforcement officer verified that the PHI was needed to identify or locate a suspect, material witness,fugitive or missing person. 4. If the staff member is satisfied that law enforcement has made a good faith representation that the information requested is needed to locate or identify a suspect, fugitive,material witness, or missing person,then the staff member may disclose only the following PHI about that individual to the official: - Name -Address - Date of birth - Place of birth - Social Security Number - Blood type -Type of injury - Date of treatment -Time of treatment - Description of distinguishing physical characteristics (i.e. weight, hair color, eye color, gender,facial hair, scars and tattoos) Disclosing PHI About Crime Victims 1. PHI about crime victims may be disclosed to law enforcement only upon request of a law enforcement official. The disclosure may not be initiated by North State Medical Transport. 2. If a law enforcement officer requests PHI about an individual who may be the victim of a crime, North State Medical Transport staff members should first discern whether the individual is in fact a victim of a crime. Victims of a crime may include motor accident victims because often a summary or misdemeanor offense is involved (like when the accident is the result of the driver of another vehicle violating traffic laws). In many cases, the determination that a patient is or may be a crime victim can be inferred from the circumstances and the presence of law enforcement at the scene. 3. North State Medical Transport may disclose PHI about a crime victim to a law enforcement official if the individual agrees to the disclosure. If the patient is conscious and alert, and it would not impede the provision of care, the staff member should ask the patient if it is acceptable to disclose the PHI to law enforcement. If the patient does not consent to the disclosure,then PHI should not be disclosed and law enforcement should be informed of that fact. If the victim does consent to the disclosure, the PHI may be released in accordance with the patient's wishes. The consent may be verbal, but it should be documented on a patient care report or other document. 4. If the patient is unable to consent, due to incapacity or other reason,the staff member should ask law enforcement if they can wait until the patient is able to consent to the release of the PHI. If the law enforcement official represents that waiting until the patient is capable of agreeing to the disclosure would compromise an immediate law enforcement activity,then PHI may be disclosed to law enforcement provided the following conditions are met: a. The staff member, in the exercise of professional judgment determines that disclosure would be in the best interests of the crime victim; b. The law enforcement officer needs the information to determine whether a violation of law has occurred; and c. The law enforcement officer represents that the information requested is not intended to be used against the crime victim. Representations from law enforcement may be verbal and should be documented in a patient care report or other document. Disclosing PH!Regarding Victims of Abuse, Neglect, or Domestic Violence 1. If law enforcement makes a request for PHI regarding someone who a North State Medical Transport staff member reasonably believes to be the victim of violence or abuse, North State Medical Transport may release PHI to law enforcement if the patient agrees to the disclosures. The staff member should first ask the patient for his/her consent to release the information. If the patient does not consent to the disclosure, no PHI should be provided to law enforcement and law enforcement should be informed of this fact. If the individual agrees to the disclosure of PHI,the staff member may give the , PHI to law enforcement in accordance with the patient's consent This consent can be verbal but it should be documented on the patient care report 2. If the individual is unable to consent to the disclosures due to incapacity, mental condition, etc., and the laws of North Carolina expressly authorize reporting of this type of information to law enforcement, North State Medical Transport staff members may release PHI to law enforcement provided that either of the following conditions are met: ■ G. The staff member, in the exercise of professional judgment, believes that the disclosure is necessary to prevent serious harm to the patient or other potential victims; or b. Law enforcement assures the staff member that the PHI will not be used against the victim and represents that an immediate law enforcement activity that depends upon the disclosure would be materially and adversely affected by waiting until the individual is able to agree to the disclosure. 3. Representations from law enforcement may be verbal and should be documented in a patient care report by the staff member along with all details regarding the disclosure including the identity of the requestor, the purpose of the request,the date and time of the request, and the PHI released about the victim 4. If North State Medical Transport discloses PHI without the patient's consent because the patient was unable to consent,the HIPAA Compliance Officer must contact the patient and alert them of the disclosure, unless North State Medical Transport believes contacting the patient will only put the patient at greater risk. Disclosing PHI Regarding Decedents 1. PHI can be released to law enforcement about decedents without a request for PHI from a law enforcement official (i.e., North State Medical Transport may initiate this type of disclosure). 2. North State Medical Transport staff members may disclose limited PHI to law enforcement about an individual who has died when staff members have a reasonable, good faith belief that the death may have resulted from criminal conduct. The staff member does not necessarily have to come to a legal conclusion, or know with complete certainty, that the death resulted from a crime. This includes any type of crime. 3. Disclosure regarding suspected victims of a crime should be limited to basic facts about the victim and the circumstances of the death. Disclosing PHI to Report a Crime on North State Medical Transport's Premises 1. North State Medical Transport may initiate this type of disclosure to law enforcement absent a request from`a law enforcement official. 2. North State Medical Transport staff members may disclose to law enforcement any PHI that staff members in good faith believe constitutes evidence of a crime committed on North State Medical Transport's premises. North State Medical Transport's premises include the station, headquarters, parking lot, the ambulance, etc. 3. Disclosure of PHI to report a crime on the premises should be limited to information that is necessary to alert law enforcement about the crime and to describe the crime to law enforcement. Disclosing PHI to Report a Crime in an Emergency 1. North State Medical Transport may initiate this type of disclosure to law enforcement absent a request from a law enforcement official. 2. North State Medical Transport staff members may disclose PHI to law enforcement when they believe it is necessary to alert law enforcement to: -The commission of a crime -The nature of a crime -The location of the crime -The location of a crime victim -The identity, description, and location of the perpetrator of a crime 3. Disclosures of PHI to report a crime in an emergency should be limited to necessary information about the nature of the crime and information about the suspect(s). Disclosure of PHI to Avert a Serious Threat to Health or Safety 1. North State Medical Transport may initiate this type of disclosure to law enforcement absent a request from a law enforcement official. 2. North State Medical Transport staff members may disclose PHI to avert a serious threat to health or safety so long as a staff member believes that the disclosure is necessary to: a. Avert a serious and imminent threat to a person's safety or the public at large; b. Identify or apprehend an individual because that individual admitted to participating in a violent crime that may have caused serious harm to someone; or c. Identify or apprehend someone who escaped from a correctional institution or from lawful custody. 3. Disclosures of PHI to prevent or lessen a serious and imminent threat to the health or safety should only be made to alert persons who are reasonably able to prevent or lessen the threat. 4. Disclosures of PHI to prevent or lessen a serious threat to health or safety should be limited to necessary information to prevent or lessen the threat, and necessary information about the individual who poses the threat. iF. t'; Policy 17: Staff Member Action Plan for Release of PHI to Law Enforcement Without Legal Process North State Medical Transport Staff Member Action Plan: Release of PHI to Law Enforcement Without Legal Process Step 1: If the request comes from law enforcement,verify the identity of the law enforcement official and ask the official what is the purpose for which the request is being made. Step 2: Is the law enforcement officer requesting N4 YES information for one of the law enforcement purposes listed in this action plan? Go to Step-A You may release the PHI in accordance with the corresponding guidance for each purpose,listed in the column directly across from the stated purpose. Formal written patient authorization is not required when releasing PHI pursuant to one of the purposes listed in this policy. But;if the patient is readily available and able to consent to the disclosure,verbal consent should be obtained and documented before disclosure of PHI is made to the law enforcement official. In addition,you should record,at a minimum,the following information about all law enforcement requests that are unaccompanied by legal process: • The name of the law enforcement official; • The date and time of the request; • The purposes for which the request was made(if provided); • What information the law enforcement official requested; • Whether the patient was consulted about the request and the patient's response; • Whether the HIPAA Compliance Officer or other individual at North State Medical Transport was consulted about the request; • Whether the law enforcement official made_ any representations to North State Medical Transport; • Whether PHI was released and what PHI was released;and • The reason(s)why the PHI was released. Required by State Reporting Law Required by State Reporting Law The information that the law enforcement officer is asking You may release any PHI that is necessary to comply with state reporting law and should track the disclosure on a for is required to be reported to law enforcement under patient care report or other form and inform the patient about the disclosure,whenever possible. state law(e.g., animal bites,gunshot wounds,burn injuries, out-of hospital deaths,vehicle accidents,etc.). Identify or Locate a Suspect,Material Witness,Fugitive,or Identify or Locate a Suspect,Material Witness,Fugitive,or Missing Person Missing Person You may release only the following types of PHI about the individual to law enforcement: The information is needed by law enforcement for the sole Name;Address;Date of Birth;Place of Birth;Social Security Number;Blood Type;Type of injury;Date of Treatment purpose of identifying or locating a suspect,material Time of Treatment;A Description of Distinguishing Physical Characteristics. witness,fugitive,or missing person. Crime Victims Crime Victims The information is needed by law enforcement about a You should first ask whether the victim agrees to the disclosure and if the victim refuses,the PHI should not be person who is or who is suspected by the law enforcement released and the officer should be informed that s/he may speak with the victim directly. If the patient agrees, officer to be the victim of a crime. information may be disclosed pursuant to the patient's wishes and the agreement should be documented along with the disclosure. If the patient is unable to agree to the disclosure because he/she is incapacitated or some other reason and the law enforcement official represents that waiting until the patient is capable of agreeing to the disclosure would compromise an immediate law enforcement activity,then you may release the PHI requested provided all the following conditions are met: • You determine that disclosure would be in the best interests of the victim; • The officer needs the information to determine whether a violation of law has occurred;and • The law enforcement officer represents that the information requested is not intended to be used against the crime victim and you document that representation. Death from Criminal Activity Death from Criminal Activity You need to disclose PHI to law enforcement regarding a You must first have a reasonable,good faith belief that that the individual's death resulted from criminal conduct. decedent because it appears that the decedent died as a This does not require a legal conclusion and the death may have been the result of any criminal conduct. You result of criminal conduct. should only release information that is necessary to alert law enforcement about the death,such as the identity of the patient and basic facts about the circumstances of the death. Crime on Premises Crime on Premises You need to disclose PHI to report a crime that occurred on You may disclose PHI to law enforcement if you believe in good faith the PHI constitutes evidence of criminal the premises of North State Medical Transport or in one of conduct on the premises of North State Medical Transport's station house,headquarters,parking lot,or any our vehicles. vehicle. The information should be limited to basic information about the patient and circumstances about the crime. Reporting Crime in Emergency Reporting Crime in Emergency You need to disclose PHI to report a crime in an emergency. You may disclose PHI to a law enforcement official if such disclosure appears necessary to alert law enforcement to: • The commission and nature of a crime; • The location of the crime;and • The identity,description,and location of the perpetrator of such crime. To Avert a Serious Threat to Health or Safety To Avert a Serious Threat to Health or Safety You need to disclose PHI to someone who is able to prevent You may disclose PHI to someone who is able to prevent or lessen a threat to health or safety if you believe it is or lessen a serious threat to health or safety. necessary to do so in order to: • Avert a serious and imminent threat to a person's safety or the public at large; • Identify or apprehend an individual because that individual admitted to participating in a violent crime that may have caused serious harm to someone;or • Identify or apprehend someone who escaped from a correctional institution or from lawful custody. Disclosures of PHI to prevent or lessen a serious threat to health or safety should be limited to necessary information to prevent or lessen the threat,and necessary information about the individual who poses the threat. Step 3. If the request for PHI does not fall under one ofthe pgrposes fisted in this action plan,you should inform the law enforcement official you`a. not permitted under HIPAA to release the information. You may inform the law enforcement officiat of the.following two options: • The law enforcement official may obtain legal process,such as a warrant,summons;subpoena or administrative request to obtain the information from North State „- Medical Transport,.' • The law enforcement official May obtain the information directly from the patient if the patient is stable and willingto speak with the official. You should only provide this option to a law enforcement official when doing so would not impede patient care and where the patient is willingtospeak with the official.You should first consult with the patient to determine whether the patient is Willing to speak with the official. If the patient declines to speak with the official,you should inform the enforcement official. Policy 18: Policy on Release of PHI to Law Enforcement With Legal Process North State Medical Transport Policy on Release of Protected Health Information Pursuant to Legal Process Purpose Protected health information ("PHI") may be released pursuant to valid legal process undertheHea|th |nsurancePortabi|ityandAccountabi|ityActof1996 (''H|PAA"). This policy provides guidelines for North State Medical Transport regarding the release of PHI pursuant to court orders, summonses, subpoenas, warrants, administrative requests, and discovery requests (collectively referred to in this policy as "legal process"), so that North State Medical Transport only releases PHI in accordance with HIPAA and as required by state law. This policy will work in conjunction with North State Medical Transport's HIPAA Compliance Officer Action P|anson "RequestsforPH| fronnAttorneys," ''AdnninistrativeRequestsforPH| fronn GovernnnentAgencies,'' ond "[ourt-OrderedRequestsforPH|." Scope This policy applies to all North State Medical Transport staff members who may receive or respond to requests for PHI accompanied by legal process. These requests typically occur after a call is completed and are generally served on staff at North State Medical Transport's station in person or through the mail. Generally, all such requests will be directed to and handled by the HIPAA Compliance Officer. Procedure General Procedure for Handling Requests 1. North State Medical Transport is permitted by HIPAA, and may be required by North Carolina law and federal law, to furnish requested PHI to certain parties pursuant to a valid legal process. Z. If North State Medical Transport receives a request for PHI accompanied by legal process, the request shall be directed to the HIPAA Compliance Officer. 3. The HIPAA Compliance Officer shall first determine whether the request is: (a) a court order or a court-ordered subpoena, summons or warrant ("SSW"); (b) an administrative request; or (c) a subpoena, discovery request, or other legal process issued by an attorney. When determining what type of request has been received, the HIPAA Compliance Officer shall look to the issuer of the request (i.e., who the requesting party is) and keep in mind the following guidelines: a. Court orders and court-ordered SSWs are issued by courts, grand juries, and administrative tribunals and signed by a judge or other judicial officer. b. Administrative requests are issued by a federal, state, or local administrative agency such as a department of health, a law enforcement agency, or other similar type of agency. Administrative agencies are permitted to issue "administrative" warrants, subpoenas, summonses or other similar type requests for information. These documents are likely to be signed by a high level official from the requesting administrative agency. c. Attorneys may issue subpoenas and discovery requests. These requests can usually be distinguished from other types of"official" court-ordered or administrative requests because they are signed by an attorney, not a judge,judicial officer or administrative official. When in doubt,the HIPAA Compliance Officer should solicit the assistance of legal counsel in determining what type of request was received. 4. Patient authorization is not required when releasing PHI pursuant to a request for PHI accompanied by legal process. However, patients may need to be notified about certain requests in accordance with this policy before PHI is released. 5. All disclosures of PHI pursuant to requests accompanied by legal process must be documented by the HIPAA Compliance Officer in North State Medical Transport's "Accounting Log for Disclosures of PHI" and a copy of the request shall be maintained with that log in the patient file, along with other information required by this policy. Responding to Court-Ordered Requests 1. If the HIPAA Compliance Officer determines that the request is a court order or a court- ordered SSW, the HIPAA Compliance Officer shall first verify that the request has been signed by a judge or other judicial officer of a court, grand jury, or administrative tribunal. If the request has not been signed by a judge or judicial officer, the HIPAA Compliance Officer shall send the requestor a letter stating that North State Medical Transport will not disclose any PHI until North State Medical Transport receives a court order or court-ordered SSW that is signed by the appropriate party. 2. If the request is signed by a judge or judicial officer, North State Medical Transport may disclose ONLY the information that is specifically requested by the court order or court- ordered SSW. For example,the HIPAA Compliance Officer should not simply turn over a copy of all records (including records relating to prior transports and billing records) if the request asks North State Medical Transport to "provide any treatment records about John Smith from April 15, 2013." However, if the request asks North State Medical Transport to provide "any and all records pertaining to John Smith,"then North State Medical Transport must generally provide all PCRs, all billing records, and any other information maintained about the patient. The HIPAA Compliance Officer shall also contact the issuer of the request whenever it is unclear what PHI North State Medical Transport is required to disclose. If necessary, the HIPAA Compliance Officer shall ask that the requester re-issue a more specific request. 3. The HIPAA Compliance Officer shall retain a copy of the court-ordered request and document the name of the requesting party, the date of the request, the date of disclosure, and the PHI that was disclosed. Responding to Administrative Requests from Government Agencies 1. If the HIPAA Compliance Officer determines that a request for PHI qualifies as an administrative request (including an administrative subpoena or summons, a civil or an authorized investigative demand, or similar process) issued by a federal, state, or local government agency,the HIPAA Compliance Officer should first determine whether the agency has the authority to make the request and to receive the PHI requested. The HIPAA Compliance Officer should look to any statutory or regulatory authority cited in the request and consult with legal counsel when making this determination. If the HIPAA Compliance Officer determines that the agency does not have the legal authority to request and receive the PHI requested, the HIPAA Compliance Officer shall send the requestor a letter stating that North State Medical Transport will not disclose any PHI until the agency provides North State Medical Transport with a statement citing appropriate legal authority to request and receive the PHI requested. 2. If the HIPAA Compliance Officer determines that the agency is authorized by law to make the request, the HIPAA Compliance Officer must then verify that: a. The PHI sought by the request is relevant and material to a legitimate law enforcement inquiry; b. The request is specific and limited in scope to the extent reasonable and practicable in light of the purpose for which the PHI is sought; and c. De-identified information could not reasonably be used. The HIPAA Compliance Officer should look to the administrative request to determine whether these conditions are clearly met. If it is not clear from the administrative request that all three of the above-listed conditions are met, then the HIPAA Compliance Officer shall contact the administrative agency who issued the request and inform the agency that PHI will not be released until North State Medical Transport receives written assurances from the requestor that the conditions are met. 3. If the HIPAA Compliance Officer determines that the above-listed conditions are met, the HIPAA Compliance Officer may release ONLY the PHI that the administrative request asks for. The HIPAA Compliance Officer shall also contact the issuer of the request whenever it is unclear what PHI North State Medical Transport is required to disclose. If necessary,the HIPAA Compliance Officer shall ask that the requester re-issue a more specific request. 4. The HIPAA Compliance Officer shall retain a copy of the administrative request as well as any assurances, and document: the name of requesting party; the date of the request;the date of disclosure; and the PHI that was disclosed. Responding to Requests from Attorneys 1. If the HIPAA Compliance Officer determines that the request is a subpoena, discovery request, or other legal process from an attorney (that is not accompanied by an official order from a court, grand jury or administrative tribunal),the HIPAA Compliance Officer shall first verify that the original subpoena, discovery request, or other legal process is enclosed with the request. References to a subpoena or other document in the request are not sufficient. If the original legal process has not been provided to North State Medical Transport, the HIPAA Compliance Officer shall send the requestor a letter stating that North State Medical Transport will not disclose any PHI until the original process has been provided. 2. Then,the HIPAA Compliance Officer shall verify that "satisfactory written assurances" have been provided to North State Medical Transport by the requestor. This means that North State Medical Transport must receive written documentation from the attorney requesting the PHI that demonstrates either of the following: a. The attorney requesting the PHI made a good faith attempt to provide written notice to the patient that included information about the litigation or proceeding and the PHI request and such notice was sufficient to permit the individual the opportunity to raise an objection to the court or administrative tribunal. Additionally,the time for the patient to raise objections to the court or administrative tribunal has elapsed, and either: (i) no objections were filed; or (ii) all objections filed by the individual have been resolved by the court or the administrative tribunal and the disclosures being sought are consistent with such resolution. Documentation may include,for example, a copy of the notice mailed to the individual that includes instructions for raising an objection with the court and the deadline for doing so, and a written statement or other documentation demonstrating that no objections were raised or all objections raised were resolved and the request is consistent with the resolution.To the extent that the subpoena or I;, other request itself demonstrates the above elements, no additional documentation is required; ii OR b. The parties to the dispute giving rise to the request for PHI have agreed to a "qualified protective order" and have presented it to the court or administrative tribunal with jurisdiction over the dispute; or the attorney seeking the PHI has requested a qualified protective order from such court or administrative tribunal. A "qualified protective order" is an order of a court or of an administrative tribunal or a stipulation by the parties to the litigation or administrative proceeding that: (i) prohibits the parties from using or disclosing the PHI for any purpose other than the litigation or proceeding for which such information was requested; and (ii) requires the return of the PHI or destruction of the PHI (including all copies made) at the end of the litigation or proceeding. Documentation may include, for example, a copy of the qualified protective order that the parties have agreed to and documentation or a statement that the order was presented to the court, or a copy of the motion to the court requesting a qualified protective order. If all written assurances have not been provided to North State Medical Transport,the HIPAA Compliance Officer shall send the requestor a letter stating that North State Medical Transport will not disclose any PHI until the proper written assurances have been provided. 3. If the required satisfactory written assurances have been provided to North State Medical Transport, then the HIPAA Compliance Officer may disclose PHI as requested in the subpoena or other legal process. The HIPAA Compliance Officer shall ONLY disclose the PHI that has been requested in the document. The HIPAA Compliance Officer shall also contact the issuer of the request whenever it is unclear what PHI North State Medical Transport is required to disclose. If necessary, the HIPAA Compliance Officer shall ask that the requester re-issue a more specific request. 4. The HIPAA Compliance Officer shall retain a copy of the request from the attorney as well as the satisfactory written assurances from the attorney in the patient file. The HIPAA Compliance Officer shall also document the name of requesting party, the date of the request, the date of disclosure, and the PHI that was disclosed. Policy 19: HIPAA Compliance Officer Action Plan for Court-Ordered Requests for PHI North State Medical Transport HIPAA Compliance Officer Action Plan: Court-Ordered Requests for PHI Step 1: Is the court order or a court-ordered subpoena,summons or warrant("SSW") YES NO signed by a judge or other judicial officer of a court,grand jury or administrative tribunal? Go to Step 2 The HIPAA Compliance Officer should deny the request in writing stating that a court order or court-ordered SSW signed by a judge or judicial officer must be provided to North State Medical Transport before the request will be considered. Ste 2: If the request is signed by a judge or judicial officer, North State Medical Transport may disclose ONLY the information that is specifically requested by the court order or court-ordered SSW. The HIPAA Compliance Officer shall also contact the issuer of the request whenever it is unclear what PHI North State Medical Transport is required to disclose. If necessary,the HIPAA Compliance Officer shall ask that the court,grand jury or administrative tribunal re-issue a more specific request. The HIPAA Compliance Officer shall retain a copy of the court-ordered request in the patient file,track the disclosure in an accounting log,and document:the name of requesting entity;the date of the request;the date of disclosure and the PHI that was disclosed. Policy 20: HIPAA Compliance Officer Action Plan for Administrative Requests for PHI from Government Agencies North State Medical Transport HIPAA Compliance Officer Action Plan: Administrative Requests for PHI from Government Agencies Step 1: Does the federal,state,or local government agency have the authority to YES NO make the administrative request(an administrative request can include an administrative subpoena,summons,civil or other authorized investigative demand or similar process)? Go to Step 2 The HIPAA Compliance Officer should deny the request in The HIPAA Compliance Officer should look to any statutory or regulatory authority cited in writing stating that proper legal authority,demonstrating that the request and consult with legal counsel when making this determination. the agency has the right to request and receive the PHI, must be provided to North State Medical Transport by the administrative agency before the request will be considered. Step 2: Is it clear from the request that all 3 conditions below are satisfied? YES NO 1. The PHI sought by the request is relevant and material to a legitimate law Go to Step 3 The HIPAA Compliance Officer should send the requestor a enforcement inquiry; letter stating that North State Medical Transport will not 2. The request is specific and limited in scope to the extent reasonable practicable in disclose any PHI until the administrative agency certifies in light of the purpose for which the PHI is sought;and writing that the three conditions have been met. 3. De-identified information could not reasonably be used? Step 3: The HIPAA Compliance Officer shall ONLY disclose the PHI that has been requested in the administrative request. The HIPAA Compliance Officer shall also contact the issuer of the request whenever it is unclear what PHI North State Medical Transport is required to disclose. If necessary,the HIPAA Compliance Officer shall ask the requesting agency to re-issue a more specific request. The HIPAA Compliance Officer shall retain a copy of the administrative request as well as any written assurances in the patient file. The HIPAA Compliance Officer shall also track the disclosure in an accounting log and document:the name of requesting agency;the date of the request;the date of disclosure and the PHI that was disclosed. Policy 21: HIPAA Compliance Officer Action Plan for Attorney-Issued Subpoenas and Discovery Requests North State Medical Transport HIPAA Compliance Officer Action Plan: Attorney-Issued Subpoenas and Discovery Requests Step 1: Does the request contain the original subpoena,discovery request,or other YES NO legal process? References to a subpoena or other document in the request letter are not sufficient. Go to Step 2 The HIPAA Compliance Officer should deny the request in writing stating that the original subpoena,discovery request, or other legal process must be provided to North State Medical Transport before North State Medical Transport will consider the request. Step 2: Does the request seeking PHI also contain"satisfactory written assurances?" YES NO In order to contain satisfactory written assurances,the request must include documentation that demonstrates either of the following: Go to Step 3 The HIPAA Compliance Officer should send the requester a letter stating that North State Medical Transport will not • The attorney requesting the PHI made a good faith attempt to provide written notice to disclose any PHI until the proper satisfactory written the patient that included information about the litigation or proceeding and the PHI assurances have been provided to North State Medical request,and such notice was sufficient to permit the individual the opportunity to raise Transport. an objection to the court or administrative tribunal.Additionally,the time for the patient to raise objections to the court or administrative tribunal has elapsed,and either:(i)no objections were filed;or(ii)all objections filed by the individual have been resolved by the court or the administrative tribunal and the disclosures being sought are consistent with such resolution. Documentation may include,for example,a copy of the notice mailed to the individual that includes instructions for raising an objection with the court and the deadline for doing so,and a written statement or other documentation demonstrating that no objections were raised or all objections raised were resolved and the request is consistent with the resolution.To the extent that the subpoena or other request itself demonstrates the above elements,no additional documentation is required; OR • The parties to the dispute giving rise to the request for PHI have agreed to a"qualified protective order"and have presented it to the court or administrative tribunal with jurisdiction over the dispute;or the attorney seeking the PHI has requested a qualified protective order from such court or administrative tribunal. A"qualified protective order"is an order of a court or of an administrative tribunal or a stipulation by the parties to the litigation or administrative proceeding that:(i)prohibits the parties from using or disclosing the PHI for any purpose other than the litigation or proceeding for which such information was requested;and(ii)requires the return of the PHI or destruction of the PHI(including all copies made)at the end of the litigation or proceeding. Documentation may include,for example,a copy of the qualified protective order that the parties have agreed to and documentation or a statement that the order was presented to the court,or a copy of the motion to the court requesting a qualified protective order. Step 3: The HIPAA Compliance Officer shall ONLY disclose the PHI that has been requested in the subpoena. The HIPAA Compliance Officer shall also contact the issuer of the request whenever it is unclear what PHI North State Medical Transport is required to disclose. If necessary,the HIPAA Compliance Officer shall ask the requesting agency to re-issue a more specific request. The HIPAA Compliance Officer shall retain a copy of the request from the attorney as well as the satisfactory written assurances in the patient file. The HIPAA Compliance Officer shall also track the disclosure in an accounting log and document:the name of requesting party; the date of the request;the date of disclosure and the PHI that was disclosed. Policy 22: Policy on Breaches of Unsecured PHI North State Medical Transport Policy on Breaches of Unsecured Protected Health Information Purpose Under the Health Information Technology for Economic and Clinical Health Act (the "HITECH Act") North State Medical Transport has an obligation, following the discovery of a breach of unsecured protected health information ("PHI"), to notify each individual whose unsecured PHI has been, or is reasonably believed to have been, accessed, acquired, used, or disclosed. North State Medical Transport also has an obligation to notify the Department of Health and Human Services ("HHS") of all breaches. In some cases, North State Medical Transport must notify media outlets about breaches of unsecured PHI. This policy details how North State Medical Transport will handle and respond to suspected and actual breaches of unsecured PHI. Scope This Policy applies to all North State Medical Transport staff members who come into contact with PHI. All suspected breach incidents shall be brought to the attention of the HIPAA Compliance Officer and the HIPAA Compliance Officer shall investigate each incident and initiate the appropriate response to the incident. Procedure Breach Defined 1. A breach is the acquisition, access, use, or disclosure of unsecured PHI in a manner not permitted under the HIPAA Privacy Rule which compromises the security or privacy of the PHI. a. An acquisition, access, use, or disclosure of PHI created, received, maintained or transmitted by North State Medical Transport that is not permitted by HIPAA is presumed to be a breach unless North State Medical Transport demonstrates that there is a low probability that the PHI has been compromised based on a "risk assessment" of at least the following factors: i. The nature and extent of the PHI involved, including the types of identifiers and the likelihood of re-identification; ii. The unauthorized person who used the PHI or to whom the disclosure was made; iii. Whether the PHI was actually acquired or viewed; and iv. The extent to which the risk to the PHI has been mitigated. b. "Unsecured protected health Information"is PHI that has not been rendered unusable, unreadable, or indecipherable to unauthorized individuals through the use of a technology or methodology specified by HHS for securing PHI - available on HHS's website at: http://www.hhs.gov/ocr/privacy. Generally, PHI is "unsecured" if it is not encrypted by strong encryption technology or if it has not been properly destroyed. If the PHI is able to be used, read, or deciphered it is "unsecured." 2. A breach does not include any of the following: a. Unintentional acquisition, access, or use of unsecured PHI by a staff member at North State Medical Transport or someone acting under the authority of North State Medical Transport if the acquisition, access, or use was made in good faith and within that individual's scope of authority, so long as the information was not further used or disclosed in violation of HIPAA. b. Any inadvertent disclosure of PHI by a North State Medical Transport staff member who is generally authorized to access PHI to another person at North State Medical Transport who is generally authorized to access PHI, so long as the information received as a result of such disclosure was not further used or disclosed in violation of HIPAA. c. A disclosure of PHI where North State Medical Transport has a good faith belief that an unauthorized person to whom the disclosure was made would not reasonably have been able to retain the information. Reporting a Suspected Breach Incident 1. All North State Medical Transport staff members are responsible for immediately reporting a suspected breach incident to a supervisor or the HIPAA Compliance Officer. North State Medical Transport staff members shall report all known and suspected HIPAA violations. 2. The HIPAA Compliance Officer will notify management about the suspected incident. 3. The HIPAA Compliance Officer shall document the date that the suspected breach of unsecured PHI occurred (if known) and the date(s) on which the supervisor and the HIPAA Compliance Officer were notified about the incident. Investigating a Suspected Breach Incident 1. The HIPAA Compliance Officer shall then initiate an investigation to determine whether an actual breach has occurred and what actions, if any, are necessary. 2. The HIPAA Compliance Officer shall interview all necessary parties who may have information about the incident. The staff member who reported the suspected incident and other members with knowledge of the incident should be asked to complete North State Medical Transport's "Internal Breach Incident Reporting Form." Staff members should be required to convey all information that they know about the incident and to cooperate in any subsequent investigation regarding the incident. 3. After gathering all available information about the incident,the HIPAA Compliance Officer shall conduct an analysis to determine whether an actual breach of unsecured PHI occurred. North State Medical Transport shall consult with legal counsel whenever necessary in making this determination. The HIPAA Compliance Officer shall utilize North State Medical Transport's "HIPAA Compliance Officer Action Plan: Breach Analysis Steps" in making this determination. 4. If the Compliance Officer determines that a breach of unsecured PHI has not occurred, the reasons behind that conclusion shall be thoroughly documented. 5. If the HIPAA Compliance Officer determines that a breach of unsecured PHI has occurred,theneasonubehindthatoono|usionshaUb�thonmu�h|ydo�urnentedandthe HIPAA Compliance Officer shall proceed to notify all necessary parties in accordance with this policy. Breach Notification to Affected Individuals 1. Following the discovery of a breach of unsecured PHI, North State Medical Transport will notify each individual whose unsecured PHI has been, or is reasonably believed to have been, accessed, acquired, used, or disclosed as a resultof such breach. The HIPAA Compliance Officer shall be the party who is primarily responsible to make proper notice, in consultation with North State Medical Transport management. 2. A breach shall be treated as discovered by North State Medical Transport as of the first day on which the breach is known, or, by exercising reasonable diligence would have been known to North State Medical Transport or any person, other than the person committing the breach,who is a staff member or agent of North State Medical Transport. 3. North State Medical Transport shall provide the notification without unreasonable delay and in no case later than 60 calendar days after discovery of a breach 4. If a law enforcement official states to North State Medical Transport that a notification, notice, or posting would impede a criminal investigation or cause damage to national security, North State Medical Transport shall: a. Delay notification for the time period specified by the official if the statement is in writing and specifies the time for which a delay is required; or b. If the notice is a verbal statement, delay notification temporarily, and no longer than 30 days from the date of the oral statement, unless a written statement is submitted during that time. If the statement is made orally, the HIPAA Compliance Officer shall document the statement, including the identity of the official making the statement. 5. North State Medical Transport shall provide written notification, in plain language, by first-class mail to each affected individual at the last known address of each individual. If the affected individual agreed to receive electronic notice of breaches, North State Medical Transport may provide notice by electronic mail. The notification may be provided in one or more mailings as information becomes available. 6. The HIPAA Compliance Officer shall utilize North State Medical Transport's "Individual Notice of Breach of Unsecured PHI" when sending notice to affected parties. The Notice shall include, to the extent possible: a. A brief description of what happened, including the date of the breach and the date of the discovery of the breach, if known; b. A description of the types of unsecured PHI that were involved in the breach (such as whether full name, social security number, date of birth, home address, account number, diagnosis, or other types of information were involved); c. Any steps individuals should take to protect themselves from potential harm resulting from the breach; d. A brief description of what North State Medical Transport is doing to investigate the breach, to mitigate harm to individuals, and to protect against any further breaches; and e. Contact procedures for individuals to ask questions or learn additional information about the incident from North State Medical Transport. These contract procedures shall include a toll-free telephone number and an e-mail address to reach North State Medical Transport's HIPAA Compliance Officer. 7. If the HIPAA Compliance Officer determines that affected individuals need to be contacted immediately to protect them from potential harm, the HIPAA Compliance Officer shall contact those individuals by telephone or other means as soon as possible. North State Medical Transport shall still send written notice to these individuals about the incident. 8. If North State Medical Transport knows that any affected individual is deceased and North State Medical Transport has the address of the next of kin or personal representative of the individual, North State Medical Transport shall provide written notification by first class mail to either the next of kin or personal representative. 9. If North State Medical Transport has insufficient or out-of-date contact information for any affected individuals, North State Medical Transport shall use a substitute form of notice that, in the informed opinion of the HIPAA Compliance Officer,will reach the individual. Substitute notice is not required in cases where there is insufficient or out- of-date contact information for the next of kin or personal representative of a deceased individual. Substitute notice will be provided in the following manner: a. If there is insufficient or out-of-date contact information for fewer than 10 affected individuals,then substitute notice may be provided by an alternative form of written notice such as placing a notice in the newspaper, calling the patient, or other means. b. If there is insufficient or out-of-date contact information for 10 or more individuals, then the substitute notice shall: (i) be conspicuously posted on North State Medical Transport's home page of its website for 90 days, or conspicuous notice in major print or broadcast media in geographic areas where each affected individual likely resides; and (ii) include a toll-free phone number for North State Medical Transport that remains active for at least 90 days where individuals can learn whether their unsecured PHI may be included in the breach. Breach Notification to the Media 1. For a breach of unsecured PHI involving more than 500 residents of a single state or jurisdiction, North State Medical Transport shall notify prominent media outlets serving the state or jurisdiction about the breach. The HIPAA Compliance Officer shall be the party in charge of making such notice and shall make such notification in consultation with North State Medical Transport management and legal counsel. 2. Notification to the media shall be made without unreasonable delay and in no case later than 60 calendar days after discovery of the breach. 3. Notification to the media shall include all information that must be included in individual notice. Breach Notification to HHS 1. North State Medical Transport shall notify HHS of all breaches of unsecured PHI in accordance with this policy. a. For breaches of unsecured PHI involving 500 or more individuals, North State Medical Transport shall provide notice to HHS when it provides notice to affected individuals. Notice must be provided in the manner specified on the HHS Website at: http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/. The HIPAA Compliance Officer shall be responsible for ensuring that such notice is submitted to HHS and must consult management before submitting the information to HHS. b. For breaches of unsecured PHI involving less than 500 individuals, North State Medical Transport shall maintain a log of such breaches and report them to HHS on an annual basis. The HIPAA Compliance Officer shall track these breaches on North State Medical Transport's "Log for Tracking Breach Incidents." The HIPAA Compliance Officer shall report these breaches to HHS annually, no later than 60 days after the end of the calendar year in which these breaches were discovered. This shall be done in the manner specified on the HHS Website at: http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/. The HIPAA Compliance Officer shall ensure that the information is submitted to HHS by March 1 of each year and must consult with management before submitting the information to HHS. Breach Notification in Accordance with State Law 1. The HIPAA Compliance Officer shall also determine, in consultation with legal counsel, whether North State Medical Transport has any additional breach notification obligations under applicable North Carolina laws or other state laws. 2. North State Medical Transport must look to each state in which an affected individual resides when making this determination and shall consult legal counsel licensed to practice in those states. Administrative Requirements 1. The HIPAA Compliance Officer shall record and maintain thorough records of all activities related to suspected and actual breach incidents. 2. In the event of a suspected crime, or other unlawful activity, local, state, or federal law enforcement may need to be notified. That determination will be made by management with recommendation from the HIPAA Compliance Officer.The HIPAA Compliance Officer shall coordinate communications with outside organizations and law enforcement. 3. North State Medical Transport will train all members of its staff so that they are able to identify suspected breaches of unsecured PHI and know to report all suspected breaches to the appropriate party immediately. 4. Staff members who violate this policy will be subject to disciplinary action, up to and including termination. Policy 23: HIPAA Compliance Officer Action Plan: Breach Analysis Steps North State Medical Transport HIPAA Compliance Officer Action Plan: Breach Analysis Steps Step 1: Was there an acquisition,access,use or disclosure of PHI that was created, YES NO received,maintained,or transmitted by North State Medical Transport? The HIPAA Compliance Officer shall determine whether PHI was actually involved in the incident, Go to Step 2 There has been no breach of unsecured PHI and breach keeping in mind that PHI only includes individually identifiable information that relates to an notification is unnecessary. individual's healthcare or payment for healthcare. Ste 2: Was the PHI involved in the incident"unsecured?" PHI involved in an incident YES NO will be considered to be"unsecured"when it is in electronic form and it is not encrypted in accordance with North State Medical Transport's"Policy on Encryption and Decryption of e- Go to Step 3 If the HIPAA Compliance Officer determines that the PHI PHI;' involved in the incident was secured in accordance with North State Medical Transport's policies on securing hard copy and electronic PHI,then there has been no breach of unsecured PHI and breach notification is unnecessary. Step 3: Was there a HIPAA violation? The HIPAA Compliance Officer must make a YES NO determination that there was a violation of the HIPAA Privacy Rule. The incident must involve a use or disclosure that is not permitted by HIPAA. Go to Step 4 There has been no breach of unsecured PHI and breach notification is unnecessary. Step 4: Did the incident compromise the security or privacy of the PHI involved? To Yes NO determine whether the incident compromised the security or privacy of the PHI that was potentially breached,the HIPAA Compliance Officer must look to the 4-factors outlined Go to Step 5 There has been no breach of unsecured PHI and breach below: notification is unnecessary. Factor Explanation 1. The nature and Consider the type and amount of PHI involved and whether the extent of the PHI incident involved sensitive information. For example,credit card involved numbers,social security numbers,or other information that could be used for identity theft or financial fraud more likely compromises the security of information.The same is true for clinical information,especially detailed clinical information(e.g., treatment,medication,medical history information,etc.). 2. The person who Consider whether the person who received the information has used the PHI or to obligations to protect the information. For example,other whom the covered entities are obligated to protect PHI that they receive in disclosure was the same manner as North State Medical Transport. made 3. Whether the Determine whether the improperly disclosed PHI was returned PHI was actually before being accessed for an improper purpose. acquired or viewed 4. The extent to Consider whether immediate steps were taken to mitigate the which the risk to potential harm from the improper use or disclosure of the PHI. the PHI has been mitigated Step Five: Does a breach exception apply? The HIPAA Compliance Officer must also Yes NO determine whether one of the breach exceptions outlined in the Breach Notification Rule applies to the incident. if so,there is no reportable breach. The three breach exceptions North State North State Medical Transport must make breach notification are: Medical in accordance with North State Medical Transport's"Policy on Transport does Breaches of Unsecured Protected Health Information." • Unintentional Access,Acquisition or Use of PHI. The incident involved unintentional not have to access,acquisition or use of PHI by a workforce member of North State Medical make breach Transport or someone acting under the authority of North State Medical Transport. notification. The unintentional incident must:(1)be made in good faith;(2)made within the scope of employment;and(3)not result in further improper use or disclosure of PHI. • Inadvertent Disclosure to an Authorized Party. Inadvertent disclosure between parties at North State Medical Transport who are authorized to access PHI is not a breach if the PHI is not further used or disclosed in violation of HIPAA. "Authorized to access PHI" means that the two parties involved in the incident are authorized to access PHI in general-not necessarily that they are authorized to access the same type of PHI. • Disclosure Where Retention Was Not Possible. If the HIPAA Compliance Officer can demonstrate that an unauthorized recipient of the improperly disclosed PHI would not reasonably have been able to retain the PHI,this breach exception applies. Policy 24: Policy on Staff Member Access to e-PHI North State Medical Transport Policy on Staff Member Access to e-PHI Purpose Under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") North State Medical Transport is required to ensure that all staff members have appropriate access to e-PHI, and that his or her identity is properly verified before access to North State Medical Transport's networks, systems and applications containing e-PHI can be obtained. This policy establishes procedures to prevent staff members (including former staff members)who should not have access to e-PHI from obtaining it, and ensures that those who are authorized to have access to e-PHI obtain access in a secure fashion. Scope This policy applies to all North State Medical Transport staff members who have access to any e-PHI that is created, received, maintained or transmitted by North State Medical Transport. The HIPAA Compliance Officer shall be responsible for ensuring proper administration of this policy. Procedure Authority to Access e-PHI 1. Staff members seeking access to any network, system, or application that contains e-PHI must satisfy a user authentication mechanism such as unique user identification and password, biometric input, or a user identification smart card to verify their identity and authority to access e-PHI. Z. Staff members seeking access to any network, system, or application must not misrepresent themselves by using another person's User ID and password, or other authentication information. 3. Staff members should take reasonable steps to ensure that they verify the identity and correct address (digital or physical) of the receiving person or entity prior to transmitting e-PHI. This might include sending a "test email" or calling a party before a fax is sent. Unique User Identification . . . � 1. Any staff member or authorized user that requires access to any network, system, or application that creates, receives, maintains or transmits e-PHI at North State Medical Transport must be provided with a Unique User Identification Number. 2. When requesting access to any network, system, or application that creates, receives, maintains or transmits e-PHI at North State Medical Transport, a staff member or authorized user must supply their assigned Unique User Identification in conjunction with a secure password. 3. If a staff member or authorized user believes their User Identification has been comprised,they must report that incident to the appropriate supervisor or the HIPAA Compliance Officer immediately. Security Password Management 1. All staff members must create a password in conjunction with their Unique User Identification to gain access to any network, system or application used to create, receive, maintain or transmit e-PHI at North State Medical Transport. Z. A generic User Identification and password may be utilized for access to shared or common area workstations so long as the login provides no access to e-PHI. An additional Unique User Identification and password must be supplied to access networks, systems applications and database systems containing e-PHI at North State Medical Transport. 3. Managers of networks, systems, or applications used to create, receive, maintain or transmit e-PHI at North State Medical Transport must ensure that passwords set by staff members meet the minimum level of complexity described in this policy. 4. Managers of networks, systems, or applications used to create, receive, maintain or e- PH| are responsible for educating staff members about all password related policies and procedures, and any changes to those policies and procedures. 5. Password "aging times" (i.e.,the period of time a password may be used before it must be changed) must be implemented in a manner commensurate with the criticality and sensitivityofthee-PH| containedvvithineachnetxvorksyotonn, app|icationnrdatabase. 6. Staff members are responsible for the proper use and protection of their passwords and must adhere to the following guidelines: a. Passwords are only to be used for legitimate access to networks, systems, or applications. b. Passwords must not be disclosed to other staff members or individuals. c. Staff members must not allow other staff members or individuals to use their password. d. Passwords must not be written down, posted, or exposed in an insecure manner such as on a notepad or posted on the workstation. 7. All passwords used to gain access to any network, system, or application used to access, transmit, receive, or store e-PHI must be of sufficient complexity to ensure that it is not easily guessable. a. Passwords should be a minimum of eight characters in length. b. Passwords should incorporate three of the following characteristics: i. Any lower case letters (a-z) ii. Any upper case letters (A-Z) iii. Any numbers (0-9) iv. Any punctuation or non-alphanumeric characters found on a standard ASCII keyboard (! @ #$ Y6 « /& * ( )_-+=( } |l : ; " ' | \ /7 < >, . ~ `). c. Passwords must not include easily guessed information such as personal information, names, pets birth dates, etc. d. Passwords must not be words found in a dictionary. Emergency Access to e-PHI and PHI If a system, network or application contains e-PHI used to provide patient treatment, and the denial or strict access to that e-PHI could inhibit or negatively affect patient care, staff members responsible for electronic information systems must ensure that access to that system is made available to any caregiver in case of an emergency. Termination of Access I. All supervisors will immediately notify the HIPAA Compliance Officer when a staff member has been separated from service with North State Medical Transport or when the person no longer is permitted to access e-PHI on North State Medical Transport's systems, networks, or applications. 2. Staff members' access to North State Medical Transport's systems, networks and applications containing e-PHI will immediately be disabled on the effective date of the separation or, if still on the staff,the effective date when authorization for access to e- PHI has ended. 3. The staff member will be removed from all information system access lists. 4. The staff member will be removed from all user accounts. 5. The staff member will turn in all keys,tokens, or access cards that allow access to the information system. 6. The "Staff Member Termination Checklist" will be completed by the supervisor the last day of the staff member's authorized access. Policy 25: Policy on Contingency Planning North State Medical Transport Contingency Planning Policy Purpose The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") requires North State Medical Transport to implement a policy to ensure that we effectively protect the integrity of protected health information ("PHI")that we hold in the event of an emergency. This policy ensures that our response to an emergency or other occurrence that threatens or damages our computer, electronic, or other information systems is appropriate and provides for the contingencies necessary to protect and preserve PHI in accordance with the HIPAA. Scope This policy contains procedures for protecting the integrity of PHI (including e-PHI) and other essential patient information, billing and business information, and confidential information in the event of an emergency or other occurrence (i.e.,fire,vandalism, system failure and natural disaster). The HIPAA Compliance Officer shall oversee the implementation of these procedures. Procedure Applications and Data Criticality Analysis 1. North State Medical Transport will assess the relative criticality of specific applications and data within the company for purposes of developing its Data Backup Plan, its Disaster Recovery Plan and its Emergency Mode Operation Plan. 2. The assessment of data and application criticality should be conducted periodically and at least annually as part of the Security Risk Analysis to ensure that appropriate procedures are in place for data and applications at each level of risk. Data Backup Plan 1. Each functional area of North State Medical Transport (Operations, Billing, Administration, etc.) will establish and implement a Data Backup Plan that ensures that each area of North State Medical Transport will create and maintain retrievable exact copies of all PHI and other essential business information that is at a medium to high risk for destruction or disruption. 2. The Data Backup Plan must apply to all medium and high risk files, records, images, voice or video files that may contain PHI and other essential business information. 3. The Data Backup Plan must require that all media used for backing up PHI and other essential business information be stored in a physically secure environment such as a secure, off-site storage facility or cloud server. Where backup media remains on site, it will be kept in a physically secure location, different from the location of the computer systems have been backed up. 4. If an off-site storage facility or backup service is used, a written Business Associate Agreement must entered into with the outside party maintaining the data to ensure that the Business Associate will safeguard any PHI and other essential business information in an appropriate manner. 5. Data backup procedures and contingency plan shall be tested on a periodic basis to ensure that exact copies of PHI and other essential business information can be retrieved and made available whenever it is needed. 6. The HIPAA Compliance Officer will ensure that each functional area of the Company with medium and high risk to PHI has an appropriate Data Backup Plan in place. Disaster Recovery Plan 1. To ensure that each functional area of North State Medical Transport can recover from the loss of data due to an emergency or disaster such as fire,vandalism,terrorism, system failure, or natural disaster affecting information systems containing PHI or other essential business information, each functional area will establish and implement a Disaster Recovery Plan. 2. The Plan must ensure that each area can restore or recover any loss of this information and the systems needed to make that information available in a timely manner. 3. The Disaster Recovery Plan will include procedures to restore PHI and other essential business information from data backups in the case of a disaster causing data loss. 4. The Disaster Recovery Plan will include procedures to log system outages, failures, and data loss to critical systems, and procedures to train the appropriate personnel to implement the disaster recovery plan. 5. The Disaster Recovery Plan must be documented and easily available to the necessary personnel at all time, who should be trained to implement the Disaster Recovery Plan. G. The disaster recovery procedures outlined in the Disaster Recovery Plan must be tested OD a periodic basis to ensure that PHI and other essential business information and the systems needed to make e-PHI available can be fully restored or recovered. 7. The HIPAA Compliance Officer will ensure that each functional area of the Company with medium and high risk to PHI has an appropriate Disaster Recovery Plan in place. Emergency Mode Operation Plan 1. Each functional area of North State Medical Transport must establish and implement (as needed) procedures to enable continuation of administrative, patient care, and billing and business processes for protection of the security of PHI and other essential business information while operating in emergency mode. 2. Emergency mode operation procedures outlined in the Emergency Mode Operation Plan must be tested periodically to ensure that critical business processes can continue in a satisfactory manner while operating in emergency mode. 3. The HIPAA Compliance Officer will ensure that each functional area of the Company with medium and high risk to PHI has an appropriate Emergency Mode Operation Plan in place. Policy 26: Policy on Disaster Management and Recovery of a-PHI North State Medical Transport Policy on Disaster Management and Recovery of e-PHI Purpose North State Medical Transport is responsible under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") for ensuring that we have a process in place to ensure that we can recover from the catastrophic disruption of our information system and loss of any data or information, especially electronic protected health information (" e-PHI"), which may be stored on that system. This policy will be followed in an emergency situation such as or disaster such as fire,vandalism,terrorism, system failure, or natural disaster. Scope This policy applies to all North State Medical Transport staff members who create, receive or use PHI and e-PHI, and any other confidential patient or business information. It is intended to cover all information system hardware, software and operational procedures. The HIPAA Compliance Officer shall be the primary party in charge of disaster management and recovery. Procedure To ensure that North State Medical Transport will be able to recover from a serious information system disruption, including situations that could lead to the loss of data in the event of an emergency or disaster (such as fire, vandalism,terrorism,system failure, or natural disaster)the following procedures are established: 1. A disaster recovery plan will be established and implemented to restore or recover any loss of e-PHI and any loss or disruption to the systems required to make e-PHI available. 2. The disaster recovery plan will be developed by staff members responsible for the maintenance of the security and integrity of the information system and will be reviewed and approved by the HIPAA Compliance Officer and senior management. 3. The disaster recovery plan must include: a. A data backup plan including the storage location of backup media. b. Procedures to restore e-PHI from data backups in the case of an emergency or disaster that results in a loss of critical data. c. Procedures to ensure the continuation of business critical functions and processes for the protection of e-PHI during emergency or disaster situations. d. Procedures to periodically test data backup and disaster recovery plans. e. Procedures to periodically perform an application and data criticality analysis establishing the specific applications and e-PHI that is necessary to maintain operation in an emergency mode. f. Procedures to log system outages,failures, and data loss to critical systems. g. Procedures to train the appropriate personnel to implement the disaster recovery plan. h. The disaster recovery plan must be documented and easily available to the necessary personnel at all times. K ) Policy 27: Policy on Physical Security of PHI and e-PHI North State Medical Transport Policy on Physical Security of PHI and e-PHI Purpose North State Medical Transport is obligated under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA")to establish physical safeguards to protect electronic protected health information ("e-PHI") and other PHI. This policy establishes our security measures to protect our electronic information systems, networks and applications and as well as buildings and equipment from natural and environmental hazards, and unauthorized intrusion. Scope This policy applies to all North State Medical Transport staff members. All staff members should be on the lookout for any potential problems that could jeopardize the security of electronically stored information, especially e-PHI. This policy describes our general approach to facility security and the steps necessary to prevent a breach in the physical security system in place. It also describes our general procedures to limit physical access to electronic information systems and the buildings and rooms in which they are housed, and our general procedures on disposal or reissuance of equipment containing e-PHI. Procedure Facility Access Controls 1. Access to areas of our facility that contain our information system with e-PHI will be granted only to those with a verifiable and approved business need to have access. Z. All North State Medical Transport staff members will be issued identification cards or badges for security purposes. These badges and identification must be displayed at all times while on the premises. 3. Access control will be established with physical hardware that prevents improper or inadvertent entry into a secure area. This hardware may include combination locks, swipe cards, smart cards and other devices on all doors housing our information system equipment. 4. Any space in a building that we share with another entity that contains PHI that we create, receive, maintain or transmit will be maintained at the same level of security as k if we owned the space. Specifically, we will protect that area from access by others in the building who are not part of North State Medical Transport. 5. Disabling or circumventing any of the physical security protections is strictly prohibited. Any problems with physical security measures must be reported to the HIPAA Compliance Officer immediately. Facility Security Plan 1. The HIPAA Compliance Officer will be responsible for developing a facility security plan that protects our buildings from unauthorized physical access,tampering, and theft. 2. The plan will incorporate hardware to limit access to our buildings to only those persons with proper keys and/or access codes. 3. North State Medical Transport will maintain a current list of all staff members who have authorization to access our facilities with PHI. Where appropriate, North State Medical Transport will install security systems including video surveillance to protect PHI and to ensure the security of our information systems. Access Control and Validation Procedures 1. North State Medical Transport has established procedures for controlling and validating a staff member's access to our facilities. Access to various areas of the facilities will be based on the role of the staff person and their need to access a particular area. 2. Access to locations that house our systems, networks or applications with PHI that we create, receive, maintain or transmit will have the greatest limitations on access, and access to these critical areas will be reviewed frequently by management and the HIPAA Compliance Officer. Maintenance Records 1. To help ensure that our physical security systems are in continuous operation, North State Medical Transport has developed a maintenance program for all security devices, including locks, keypads, and other access devices. 2. Any repairs or change outs of any security devices will be recorded. Workstation Security and Use 1. A"workstation" is defined as any electronic computing device, such as a desktop computer, laptop computer, mobile electronic device or any other device that is used to create, receive, maintain or transmit PHI. . . I. All workstations (including fixed locations such as in our billing or business office and mobile workstations such as with portable electronic devices for field use) should be password protected so that they may not be accessed without authentication by an authorized user. 3. All workstations are set up to lock out after a set time period so that if the staff member is no longer using the workstation for a set period of time, access will not be permitted without the proper password. 4. Procedures are established for each work area, depending on the nature of the work area to limit viewing of workstation device screens to only those operating the workstation wherever possible. a. In office areas, all screens should be pointed away from hallways and open areas. The screens should be pointed away from chairs or other locations where non staff members, such as patients, may be. b. In field operations, ambulance personnel will need to follow procedures to ensure that the devices are not left in an open area, such as a countertop in the Emergency Department. S. Workstations will be set so that staff members may not inadvertently change or disable security set ings, oraccessareosoftheinfornnationsystemntheyarenotauthorizedto access. 6. Only those authorized to access and use the workstation will be permitted to use the workstation. 7. No software may be downloaded or installed on the workstation in any manner without prior authorization. (This prohibition includes computer games, screen savers, and anti- virus or anti-spam programs). O. All staff members will log out or lock workstations whenever they are left unattended or will not be in use for an extended period of time. 9. All portable workstation devices will be physically secured wherever possible when not in use. Laptops will be locked with security cables and other mobile devices will be locked physical locations or in an appropriate storage compartment when not in use. 10. Remote access to access e-PHI on our information system must be approved by North State Medical Transport. Disposal of Hardware and Electronic Media Devices and Media Controls 1. North State Medical Transport carefully monitors and regulates the receipt and removal of hardware and electronic media that contain PHI and other patient and business information into and out of our stations and other facilities. 2. As a general rule, simple deletion of files or folders is not sufficient to ensure removal of the file or data. This simply removes the directional "pointers"that allow a user to find the file or folder more readily. Deleted files are usually completely retrievable with special software and computer system expertise. 3. North State Medical Transport has in place the following procedures governing the disposal of hardware, electronic media, and e-PHI stored on hardware and other electronic media: • Sanitizing Hard Disk Drives. All hard disk drives that have been approved by the HIPAA Compliance Officer for removal and disposal (or taken out of active use) shall be sanitized so that all programs and data have been removed from the drive. North State Medical Transport will follow industry best practices (such as the U.S. Department of Defense clearing and sanitizing standard — DoD 5220.22-M) when cleaning off hard drives. Proper sanitizing usually involves a reformatting of the hard drive in a secure manner with an approved wipeout utility program. Degaussing software may need to be used to ensure total removal of files. No hard drive will be reissued, sold or otherwise discarded until the drive has been L sanitized. • Media Re-Use. All e-PHI and other patient and business information shall be t' removed from any media devices before they are made available for reuse. • Accountability. North State Medical Transport tracks the movement of all computer hardware, workstations, and data storage devices. Movement both within the organization and outside the organization is tracked. • Data Backup and Storage. Each information system area will create an exact copy of all e-PHI when necessary immediately prior to any movement or disposal.This procedure is in addition to the standard routine backup protocol to ensure that all e- PHI is preserved before potential compromise. • Destruction of Paper and electronic PHI. When destroying and/or permanently removing PHI from electronic media for any purpose, North State Medical Transport shall adhere to HHS's "Guidance Specifying the Technologies and Methodologies ^ ' That Render Protected Health Information Unusable, Unreadable, or Indecipherable toUnauthVhzed |ndixidua|s." In accordance with that Guidance, paper,film, or other hard copy media shall be shredded or destroyed such that the PHI cannot be read or otherwise reconstructed. Electronic PHI is considered to be destroyed or permanently removed from electronic media when the media that contain the PHI have been cleared, purged, or destroyed consistent with "NIST Special Publication OOO-88, Guida|ineGf0[Media5anitization," suchthotthee|eotronioPH| C8DDotbe retrieved. (NIST Special Publication available at: vvxvvv.nist.Rov). Policy 28: Policy on Electronic Information System Activity Review and Auditing North State Medical Transport Policy on Electronic Information System Activity Review and Auditing Purpose The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires North State Medical Transport to monitor and audit its electronic information system used to create, receive, maintain or transmit electronic protected health information ("e-PHI") so that quality assurance procedures will detect and address problems with the system. North State Medical Transport needs to identify the specific actions that have taken place such as timing and completion of back-up procedures, tracking server file access, and tracking power interruptions and other unusual events that could compromise our system and threaten the integrity of e- PHI. Scope This policy applies to all North State Medical Transport staff members who are responsible for monitoring and maintaining our electronic information system or are responsible for its security. The policy also applies to staff members assisting with the audit and review process. The HIPAA Compliance Officer shall have overall responsibility for monitoring, maintaining, and overseeing the security of our electronic information system and conducting audits. Procedure 1. The HIPAA Compliance Officer will develop procedures to document the creation, receipt, maintenance and transmission of e-PHI within the information system. 2. The HIPAA Compliance Officer will review the records of information system activities, including a review of audit logs, security incident tracking reports, back-up records, etc., as necessary. 3. Uses and disclosures need not be documented for purposes of an audit trail if the use is made entirely within the internal information system and the use did not involve any outside parties. 4. Disclosures that are required to be accounted for under HIPAA shall be recorded and tracked. Generally all non-patient authorized disclosures that are not related to treatment, payment and healthcare operations will be accounted for. An accounting of these disclosures must include: ' ^ a. The date of the disclosure; b. The name and address of the organization or person receiving the disclosure (if known); c. A brief description of the PHI disclosed; and d. A brief statement of the purpose of the disclosure that reasonably informs the individual of the basis for the disclosure. ) Policy 29: Policy on Third Party Access to e-PHI North State Medical Transport Policy on Third Party Access to e-PHI Purpose North State Medical Transport is required by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA")to control access to our physical locations, such as stations, buildings, garages and offices, vehicles, and secured areas where our electronic protected health information ("e-PHI") is stored as well as system hardware, software, or other mobile electronic devices that are used to create, receive, maintain or transmit e-PHI. This policy outlines our approach to limiting third party access to our e-PHI while at the same time, permitting authorized access in the event that our contingency plan is operation. Scope This policy applies to all North State Medical Transport staff members who control third party access to our e-PHI and systems, hardware and mobile electronic devices used to create, receive, maintain or transmit e-PHI. It is intended to cover all physical locations that house our information system hardware, software and related devices and equipment that are utilized to create, receive, maintain or transmit e-PHI at North State Medical Transport. Procedure Access During Contingency Operations 1. The HIPAA Compliance Officer will work with individuals who manage electronic information systems to determine contingency plans and procedures that should be implemented in the event of the need to restore lost data and to maintain uninterrupted access to e-PHI. 2. The HIPAA Compliance Officer will identify outside parties who have permission to access our electronic systems and secured areas in the event that restoration and preservation of data is necessary. 3. TheH|PAACn[np|ianceOffnervVi|| vvorkvVithOmaneQe[nenttodove|opo "ua|| |ist" nf persons who need immediate notification when the contingency plan is in operation. Facility Security 1. The HIPAA Compliance Officer will work with management to determine what outside parties, in general, should have access to e-PHI and the electronic information system and determine the extent of that access. 2. The HIPAA Compliance Officer will maintain an inventory of all software, hardware and mobile electronic devices used to create, receive, maintain or transmit e-PHI at North State Medical Transport. That inventory should include: a. A unique identification number for hardware and other devices that are part of the electronic information system. b. A file to catalog all software, hardware and mobile electronic devices with their unique identification numbers. 3. Any discrepancies in the current inventory of software, hardware and mobile electronic devices will be reported to management and will be investigated to ensure that there is a proper accounting of all items and to determine whether further action may need to be taken in response to the loss of an item (e.g., breach notification in the event of a breach of unsecured PHI. 4. If North State Medical Transport implements keypad access to physical facilities,the HIPAA Compliance Officer will ensure that access codes are changed or disabled when staff members leave. 5. There will be measures at the entrance to North State Medical Transport's facility and at key access points that require personal identification, so that only authorized parties gain access to areas where e-PHI can be accessed. These procedures will be reviewed periodically to ensure only authorized persons with a legitimate purpose for access actually have access to the facility or secured area. Access Control and Validation 1. The HIPAA Compliance Officer will maintain a list of all third parties with approved access to e-PHI and the electronic information system. This list will include names of approved vendors and other outside parties who have permission to access our facilities and secure areas. 2. Software testing and other maintenance or service of the electronic information system will be carefully monitored by the HIPAA Compliance Officer to ensure that only necessary e-PHI is accessed and that e-PHI is not being improperly used or disclosed. 3. North State Medical Transport will ensure that only approved parties with a legitimate need to access our electronic information system are granted access. If outside parties need physical access to an area with e-PHI,they must present valid credentials (such as a driver's license and business card or badge). Maintenance Records 1. The HIPAA Compliance Officer will ensure that all repairs and maintenance to the electronic information system hardware, software and mobile electronic devices is properly logged and documented. 2. The repair or maintenance records will contain, at a minimum: a. Name of person completing the maintenance or repair; b. Purpose of the maintenance or repair; c. Name of person at North State Medical Transport authorizing the maintenance or repair; d. Date and time the work started and ended; and e. Brief description of the work completed and the outcome of it (more work required, alternative procedure to put in place, etc.) 3. The HIPAA Compliance Officer will periodically review the documentation of maintenance and repairs to determine trends or changes in procedures to e-PHI security that should be made. Accountability 1. North State Medical Transport shall have a way to record the addition or removal of any hardware, software or mobile electronic devices to or from our electronic information system. 2. No hardware, software or mobile electronic devices will be added to the electronic information system without notifying the HIPAA Compliance Officer. The HIPAA Compliance Officer shall review any additions and ensure that any addition will comply f' with North State Medical Transport's HIPAA Policies and Procedures. 3. To maintain security and to help prevent viruses from attacking our information system, no downloads or software additions are permitted without approval of management and only after consultation with the HIPAA Compliance Officer. 4. Policy 30: Policy on Creating Backups Creating Backups of e-PHJ North State Medical Transport Policy on Creating B s of e-PHI Purpose The Health Insurance Portability and Accountability Act of 1996 ("H|PAA") requires North State Medical Transport to back up and preserve all e-PHI created, received, used, and stored by North State Medical Transport in the event of an emergency or disaster. This policy outlines the procedures for preserving and protecting e-PHI and other important business information from tampering, theft, fire, flood, and other physical damage. Key to this process is the proper replication of exact copies of data in a secondary system so that if the primary system fails,the data will be completely preserved and accessible. Scope This policy applies to all e-PHI created, received, maintained or transmitted by North State Medical Transport. Creating backups will be the responsibility of the manager in charge of the particular electronic equipment for his/her area of responsibility, in close coordination with the HIPAA Compliance Officer. This policy applies to all electronic equipment and devices that are used to create, receive, maintain or transmit e-PHI at North State Medical Transport. This policy applies to all staff members and vendors or contracted parties who are responsible for completing backups of North State Medical Transport's e-PHI. Procedure Physical Access Controls 1. All backup systems will be located in a secure area, with limited access so that only those with responsibility for the backup system will have access to it. 2. Servers, backup drives and other data and information saving hardware will be located in a locked room. 3. Only authorized parties will have access to a physical location where backup devices are stored. Backup Schedule 1. Data and information stored on any computers or electronic devices will, at a minimum, be backed up at sufficient intervals to ensure that critical data (especially PHI) can be restored and recovered immediately. A full system backup will be completed at least monthly. 2. North State Medical Transport will verify that the backups are successfully completed at the end of each backup process to ensure that a complete replication of the data and information backed up has actually been created. Backup Schedule Logs 1. The backup software will capture a list of all files and directories encountered and saved. Logs will be maintained and will contain information about successful backups, unsuccessful backups, backup media that was left in place and overwritten, when and where the media was sent or transmitted off-site,the success or failure of restore tests aDdbadnnediaencounteredvvhimhnnoya�eotnurobi|itytoobtoinfi|esfrorneprevious backup. Z. A primary and secondary staff member will be assigned to rotate the media used for backups if North State Medical Transport backs up e-PHI with physical media. This staff member will track the following information: a. Whether the backup was successful; b. Date and time the backup began and the date and time it was completed; c. Description of any problems encountered during the backup; and d. Verification that a check was made to ensure that the backup was complete. Marking and Storage of Backup Media 1. All backup disks, drives,tapes or other physical backup media will be legibly and clearly marked that it is a backup,the date and time the backup was completed, and the initials of the staff member who completed the backup. Z. All backup tapes, drives and other physical storage media should be stored at a secure off-site location to ensure the preservation of all but the most recent data and information in the event of a catastrophic fire,flood, or other damage to the primary backup location. The media must be transported in a secure manner by a supervisor or other official. North State Medical Transport may contract with a reputable vendor to manage its backup process and media storage The vendor must execute a business associate agreement with North State Medical Transport to ensure that the vendor will, among other things, protect the integrity of the data stored and protect it from improper use or disclosure. Security access controls implemented at the off-site backup and storage location must meet or exceed the security access controls of the source systems. In other words, information security at the backup storage location must equal or exceed the security where the primary computers and servers are located. 3. North State Medical Transport may electronically backup PHI to a cloud server if North State Medical Transport obtains a business associate agreement from the server agency and all PHI is maintained in a manner that enables North State Medical Transport to meet is HIPAA compliance obligations. Data Retention 1. Full system backups will be copied and/or archived. 2. Archived backups must be periodically tested to ensure that they are recoverable. Documentation The backup restore and recovery processes must be documented by the HIPAA Compliance Officer. Storage of Media Other Than Backups Old hard drives or other media storage devices that have been removed from the information system will be handled as follows: 1. If the device is to retain PHI, it will be stored in the same fashion as the backup devices. 2. If the device is to be taken out of service and no longer used to store PHI, it shall be "sanitized" and erased prior to disposal in accordance with North State Medical Transport's "Policy on Physical Security of PHI and e-PHI." Emergency Contact information North State Medical Transport will maintain a list of designated staff to be contacted in an emergency. A copy of this list will be kept in a secure location at the main facility and the off- site backup location (if applicable). The list must be kept up to date and readily accessible in case of an emergency. The list will also include vendor contact and support information and contacts for the off-site media storage location. Policy 31: Policy on Encryption of a-PHI North State Medical Transport Policy on Encryption of a-PHI Purpose The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") requires North State Medical Transport to consider encryption as a method for securing our electronic protected health information ("e-PHI") and to implement a mechanism to encrypt and decrypt e-PHI if North State Medical Transport determines that doing so is reasonable and appropriate. Further, encrypting e-PHI consistent with the Department of Health and Human Services' ("HHS") "Guidance Specifying the Technologies and Methodologies That Render Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized Individuals" will create the equivalent of a "safe harbor"for North State Medical Transport in the event that there is a breach of North State Medical Transport's PHI. It is the policy of North State Medical Transport to use encryption consistent with HHS's Guidance wherever possible, as outlined in this policy. Scope This policy applies to all North State Medical Transport staff members who are responsible for the manner in which e-PHI is created, received, maintained or transmitted by North State Medical Transport. The HIPAA Compliance Officer, in conjunction with appropriate technology professionals,shall be responsible for implementing appropriate mechanisms to encrypt e-PHI consistent with this policy. Procedure 1. The HIPAA Compliance Officer shall, on a periodic basis, meet with appropriate parties, i. such as management, information technology professionals, software vendors, and others, to discuss the steps necessary to encrypt all e-PHI that North State Medical Transport creates, receives, maintains or transmits consistent with HHS's Guidance at: '' http://www.hhs.gov/ocr/privacy. a. The HIPAA Compliance Officer shall review or refer appropriate parties to the National Institute of Standards and Technology("NIST") Special Publications referenced in this policy(available at www.nist.gov) so that North State Medical Transport implements appropriate technologies and methodologies to secure e-PHI as prescribed in the Publications. b. The HIPAA Compliance Officer shall also annually review HHS's updated Guidance (available at http://www.hhs.gov/ocr/privacy)for any additional resources referenced by HHS and ensure that those resources are furnished to appropriate parties. 2. Whenever possible, North State Medical Transport shall convert all paper and hard copy PHI into electronic format and then secure it consistent with encryption methods outlined in this policy. Paper or other hard copy PHI should be scanned or otherwise converted into digital format and then the original hard copy should be shredded or destroyed in a manner that ensures that the PHI can no longer be read or otherwise reconstructed. If North State Medical Transport utilizes an outside agency to shred, destroy or digitize paper and hard copy PHI, North State Medical Transport shall enter into a business associate agreement with that outside party. 3. All e-PHI created, received, maintained or transmitted by North State Medical Transport must be encrypted through the use of an algorithmic process that transforms data into a form in which there is a low probability of assigning meaning without use of a confidential process or key. All encryption keys must be stored in a different location than the data which it is meant to decrypt. North State Medical Transport shall adhere to the following guidelines when encrypting PHI data in various forms: a. PHI at Rest. For PHI data that is "at rest," (i.e., PHI in databases, file systems, stored on flash drives, electronic device memory, and other structured storage methods), North State Medical Transport shall utilize encryption processes that are consistent. with NIST Special Publication 800-111, "Guide to Storage Encryption Technologies for End User Devices." (available at www.nist.gov) b. PHI in Motion. For PHI data "in motion," (i.e., PHI that is being transmitted through a network, wireless transmission, email, or other electronic transmission), North State Medical Transport shall utilize encryption processes that comply with the requirements of Federal Information Processing Standards ("FIPS") 140-2. These include standards described in NIST Special Publications 800-52, "Guidelines for the Selection and Use of Transport Layer Security(TLS) Implementations;" Special Publication 800-77, "Guide to IPsec VPNs;" or Special Publication 800-113, "Guide to SSL VPNs," and may include others which are FIPS 140-2 validated. (NIST Special Publications available at: www.nist.gov). Policy 32: Policy on Security Incident Management North State Medical Transport Policy on Security Incident Management Purpose The Health Insurance Portability and Accountability Act ("HIPAA") requires North State Medical Transport to track and appropriately respond to all incidents that could compromise our electronic protected health information ("e-PHI"). This policy establishes North State Medical Transport's procedures for reporting a security incident and the steps that will be taken by North State Medical Transport to investigate and take action when a potential or actual security incident occurs. Scope This policy applies to all North State Medical Transport staff members who utilize the electronic information system. Everyone at North State Medical Transport is responsible to know what to do when confronted with a security incident. The Security/Breach Incident Reporting Form should be used in conjunction with this policy. Procedure Security Incident Defined A "security incident" is an attempted or successful unauthorized entry, breach or attack on the electronic information system that we use to create, receive, maintain or transmit e-PHI. Security incidents include unauthorized probing and browsing of the files, a disruption of service in our information system and incidents where e-PHI has been improperly altered or destroyed. Security incidents also include things such as a virus, hacking attempt or incident, "phishing" incident, malware installation, corrupt data or other similar incident involving North State Medical Transport's information system. Reporting a Security Incident 1. All staff members are responsible for immediately reporting a suspected security incident immediately to the HIPAA Compliance Officer or an immediate supervisor. 2. When a suspected security incident occurs,the HIPAA Compliance Officer shall have the reporting staff member and other members with knowledge of the incident complete North State Medical Transport's "Internal Breach/Security Incident Reporting Form." 3. The HIPAA Compliance Officer will be responsible for initiating an immediate investigation to isolate the problem and take whatever action is necessary to protect the information system and e-PHI and other vital electronic information. 4. The HIPAA Compliance Officer will notify management immediately in the event the incident cannot be immediately corrected, or if any e-PHI or other vital information is altered or destroyed. Management will also be notified of any completed investigation and the outcome of the investigation. 5. In the event of unlawful activity via the use of North State Medical Transport's information system, local, state, or federal law enforcement may be notified. That determination will be made by management with recommendation from the HIPAA Compliance Officer. The HIPAA Compliance Officer is responsible for coordinating communications with outside organizations and law enforcement. 6. Whenever a security incident is suspected or confirmed to have occurred, remedial action will be taken, including action against any individual staff members when it has been confirmed that they caused or contributed to the incident. HIPAA Compliance Officer Responsibility The HIPAA Compliance Officer is responsible for the following: 1. Initiating the appropriate incident management action, including restoration. 2. Determining the physical and electronic evidence to be gathered as part of the incident investigation. 3. Monitoring that any damage from a security incident is repaired or mitigated and that the vulnerability is eliminated or minimized where possible. 4. Determining if a widespread communication is required,the content of the communication, and how best to distribute the communication. 5. Communicating new issues or vulnerabilities to the system vendor and working with the vendor to eliminate or mitigate the vulnerability. 6. Initiating, completing, and documenting the incident investigation. 7. Determining whether the incident may qualify as a breach of unsecured PHI requiring breach notification under North State Medical Transport's "Policy on Breaches of Unsecured Protected Health Information." Policy 33: Policy on Staff Member Electronic Communications North State Medical Transport Policy on Staff Member Electronic Communications Purpose: North State Medical Transport is required under the Health Information Portability and Accountability Act of 1996 ("HIPAA")to ensure that protected health information ("PHI")that we create, receive, maintain or transmit is not improperly disclosed through any means, including electronic means. The purpose of this policy is to prevent the improper use or disclosure of PHI through electronic means, while staff members are on and off-duty. Scope: This policy covers any and all electronic communications of North State Medical Transport staff members when those communications involve the use or disclosure of PHI created, received, maintained or transmitted by North State Medical Transport. This policy applies to all staff members both on and off duty,whether using company or personal equipment. Procedure: General Rules Regarding Company Equipment 1. All PHI created, received, maintained or transmitted using any "Company Equipment" is at all times the property of North State Medical Transport and may be considered to be part of the official records of North State Medical Transport. "Company Equipment" is any electronic device that is owned, leased, controlled, or used for the benefit of North State Medical Transport. This includes, but is not limited to: computers, cell phones, cameras, USB drives, and other devices that are capable of creating, capturing, storing, and/or transmitting electronic information, 2. All Company Equipment shall remain at all times the property of North State Medical Transport, even if being used for personal use. 3. North State Medical Transport cannot guarantee the confidentiality of information stored on any Company Equipment, except that it will take all steps necessary to secure the privacy of all PHI in accordance with all applicable laws. Information stored on Company Equipment is subject to disclosure to law enforcement or other third parties at the sole discretion of North State Medical Transport. IF 4. North State Medical Transport may monitor activity on Company Equipment, our information systems and our network(s) at any time for the purpose of ensuring that PHI is not being improperly used or disclosed. This includes the ability to monitor internet activity and email, as permitted by law. S. All internet activity (browsing, email, etc.) using Company Equipment must comport with North State Medical Transport's HIPAA Policies and Procedures and staff members may not disclose PHI on the internet using Company Equipment unless the disclosure is authorized by North State Medical Transport, would not violate HIPAA or other applicable federal and state laws, and the disclosure is for a legitimate, business-related purpose. For example, emailing demographic information about a patient to a patient's insurer for purposes of billing may be a permissible use. General Rules Regarding Personal Eq ' nnent 1. Staff members must comply with North State Medical Transport's HIPAA Policies and Procedures when engaging in internet activity on "Personal Equipment," both on and off-duty. "Personal Equipment" includes any internet-capable device that is not owned, leased or otherwise controlled or used for the benefit of North State Medical Transport. Z. Where permitted by law to do so, North State Medical Transport will investigate internet activity, whether on or off-duty, and take appropriate disciplinary action against staff members whenever North State Medical Transport learns about a possible or actual violation of our HIPAA Policies and Procedures. 3. Staff members should consult with the HIPAA Compliance Officer whenever there is a question regarding whether an internet posting or internet activity might violate our HIPAA Policies and Procedures. 4. The following types of activities are prohibited at all times and can result in disciplinary action: a. Posting, sharing, or otherwise disseminating any PHI relating to North State Medical Transport patients without authorization fro North State Medical Transport. b. Posting, sharing or otherwise disseminating information that could potentially identify a patient, including: photos, videos or other images of a scene or patient; a description of patient injuries, or; other activities that could be identified with a specific scene without authorization from North State Medical Transport. Use of Company Electronic Mail 1. North State Medical Transport's email is intended to be used as a tool to facilitate communications on behalf of North State Medical Transport. 2. All email transmissions that originate from North State Medical Transport staff members on Company email must contain, at a minimum, a signature section that contains the following information: a. The sender's full name; b. North State Medical Transport's name; c. The telephone number of North State Medical Transport; and d. An approved notice and disclaimer. 3. Below the signature section,the following notice and disclaimer must appear on all transmissions from North State Medical Transport staff members in at least 10 point font: CONFIDENTIALITY NOTICE:This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential, proprietary, and/or privileged information protected by law. If you are not the intended recipient, you may not use, copy, or distribute this e-mail message or its attachments. If you believe you have received this e-mail message in error, please contact the sender by reply e-mail and telephone immediately and destroy all copies of the original message. Facsimile Transmissions Using Company Fax Machine 1. North State Medical Transport's fax machine is intended to be used as a tool to facilitate communications and the exchange of information, including patient information that is needed to perform our services. 2. All outgoing facsimile transmissions using the Company fax machine must contain a cover sheet that includes at a minimum,the following information: a. The name of North State Medical Transport; E I b. The name of the intended recipient; c. The name of the sender; d. Facsimile number of the recipient; e. Telephone number of the sender; f. Date of the transmission; g. The number of pages in the transmission; and h. An approved notice and disclaimer. 3. At the bottom of the facsimile cover sheet, the following notice and disclaimer must appear in at least 10 point font: Confidentiality Notice: This facsimile transmission is confidential and is intended only for the review of the party to whom it is addressed. It may contain proprietary and/or privileged information protected by law. If you are not the intended recipient, you may not use, copy or distribute this facsimile message or its attachments. If you have received this transmission in error, please immediately telephone the sender above to arrange for its return. Images and Videos That May Contain PHI 1. Staff members are strictly prohibited from capturing any images or videos that could potentially identify a patient PHI while on duty without the express permission of a supervisor. Staff members may carry a personal electronic device (such as a cell phone) that is capable of capturing images; but, staff members must adhere to our HIPAA Policies and Procedures when using the device and the device may never be used to capture PHI (unless expressly permitted by a supervisor). No other personal electronic devices that function as a camera and/or video recorder shall be carried by staff members while engaged in any work activities. 2. Staff members may only capture images or video while on-duty with a company-issued device and only for legitimate business-related purposes. Staff members must be authorized by North State Medical Transport to capture images or video while on duty. 3. Images or videos taken with Company Equipment may only be disseminated in accordance with North State Medical Transport's HIPAA Policies and Procedures and all such images and videos are the sole property of North State Medical Transport. 4. Any images or videos that might identify a patient may not be posted on the internet without the express approval of North State Medical Transport. Policy 34: Policy on Staff Member Medical Records North State Medical Transport Policy on Staff Member Medical Records Purpose The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") requires North State Medical Transport to treat protected health information ("PHI")contained in the medical records of our staff members with the same degree of protection as the PHI of our other patients. This policy provides guidance to management and staff concerning the privacy and security of North State Medical Transport staff member medical records. Scope This policy applies to PHI of all staff members and it applies equally to management and non-management staff members. Procedure Distinguishing PHI omd . emtRemmr�� ^ 1. Health information that is obtained about staff members in the course of providing ambulance or other medical services directly to them is considered to be PHI under HIPAA. 2. Health information that North State Medical Transport receives in its role as an employer is not considered to be PHI. Rather, the information is an employment record to which North State Medical Transport does not have an obligation to extend HIPAA protections. For example, if a staff member submits a doctor's statement to a supervisor to document an absence or tardiness from work, North State Medical Transport does not need to treat that statement as PHI. Other health information that could be treated as an employment record, and not PHI, includes: a. Medical information that is needed for North State Medical Transport to carry out its obligations under the FMLA, ADA and similar laws; b. Information related to occupational injury, disability insurance eligibility, drug screening results, workplace medical surveillance, and fitness-for-duty-tests of employees. General Policy Regarding Staff Me b r~s PHI 1. North State Medical Transport will,to the extent required by law, protect, use and disclose PHI it receives about staff members in accordance with HIPAA and our HIPAA Policies and Procedures. 2. Only those with a legitimate need to use or disclose PHI about staff members will have access to that information. 3. In accordance laws concerning disability discrimination, all medical records of staff will be kept in separate files apart from the employee's general employment file. These records will be secured, used and disclosed in accordance with applicable laws. General Policy Regarding Employment Records 1. Employment records are not considered to be PHI. As such, North State Medical Transport is not required to protect, use and disclose employment records in accordance with HIPAA. 2. Employment records that are not covered under HIPAA include, but are not limited to: a. Information obtained to determine suitability to perform the job duties (such as physical examination reports); b. Drug and alcohol tests obtained in the course of employment; c. Doctor's excuses provided in accordance with the attendance policy; d. Work-related injury and occupational exposure reports; and e. Medical and laboratory reports related to such injuries or exposures, especially to the extent necessary to determine workers' compensation coverage. 3. Despite the fact that North State Medical Transport is not required to protect, use and disclose employment records in accordance with HIPAA, North State Medical Transport will limit the use and disclosure of these records to only those necessary to perform business-related functions authorized by law. North State Medical Transport will also secure all employment records of staff members and ensure that only staff members with a legitimate need to have access to them, such as certain management staff, North State Medical Transport's designated physician and state agencies pursuant to state law, have access to employment records. Policy 35: Policy on Releasing PHI to Family Members and Others North State Medical Transport Policy on Releasing PHI to Family Members and Others Purpose The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") permits North State Medical Transport to release protected health information ("PHI") about patients to family members,friends and others involved in the treatment of the patient or payment for that treatment. This policy outlines our procedures for releasing PHI to family members and others involved in our patients' care. Scope This policy applies to all North State Medical Transport staff members who receive requests from family members,friends and others for PHI of patients of North State Medical Transport. This policy does not apply to formal requests from patients or their personal representatives for: access to PHI; amendment of PHI; restriction of PHI; accounting of disclosures of PHI; or confidential communications. This policy shall apply to requests for PHI from family members of the patient or others who do not qualify as the patient's personal representative, but who are involved in the patient's care or payment for that care. Procedure General Procedure for Releasing PHI to Family Members and Others 1. HIPAA permits North State Medical Transport staff members to release PHI that is directly relevant to the patient's care or payment for care to family members, friends and others involved in a patient's care, or payment for that care,whenever releasing PHI to that individual would be in the best interest of a patient. North State Medical Transport may also use or disclose PHI to notify family members or others about a patient's location, general condition, or death. 2. If an individual other than the patient or the patient's personal representative makes a request for PHI from a North State Medical Transport staff member,the staff member shall first determine whether the patient about whom the request pertains to is present, competent and able to make healthcare decisions. 3. If the patient is present, competent and able to make healthcare decisions,the staff +, member should obtain the patient's agreement to share the requested PHI with the individual, or give the patient an opportunity to object. The staff member may ask the patient whether it is okay to talk to the individual and release PHI to them. Or, the staff member can simply infer from the circumstances that the patient does not object to sharing the information with the individual. For example, if the patient's neighbor asks to ride along in the ambulance and the patient smiles, the staff member could infer that the patient is fine with the neighbor riding along and overhearing any PHI that is discussed. Or, if the staff member starts asking the patient about his or her medical history and the patient motions for a family member to come over, the staff member can infer that the patient wants the staff member to speak with the family member about his or her medical history. 4. If the patient is unavailable or unable to make medical decisions because of a physical or mental reason at the time of the request,then the staff member may only disclose PHI to the requestor if the requestor is involved with the patient's treatment or payment for the patient's treatment and the staff member believes that releasing PHI to the requestor is in the best interests of the patient. First, the staff member should ask the requestor what his or her relationship is to the patient. Then, the staff member should determine whether disclosure of PHI to the requestor would be in the best interest of the patient. In making this determination, the staff member should consider things such as: a. Who the requestor is and what the requestor's relationship is to the patient b. Whether the requestor appears to have a legitimate interest in the patient's care or payment for that care c. Whether the staff member believes that the patient would want that requestor to know the PHI or whether the patient would benefit from the requestor knowing the PHI 5. If the patient is deceased, a staff member may release relevant PHI to family members and others who were involved in the deceased patient's care prior to death or payment for care, unless doing so would be inconsistent with any prior expressed preference of the patient. The staff member should only disclose PHI that is relevant to the requestor's involvement with the patient's care prior to death or payment for that care. Name Cert P# Exp Date NCDL# Exp Date CPR Exp Date ALDRIDGE,TINA, EMT-B P098778 2018-07-31 20775434 2023-04-08 AHA 2017-11-18 BALLARD,SPENSER, EMT-B P102625 2020-07-31 39355950 2018-11-01 AHA 2018-06-30 BARONA, DAVID EMT-P P024754 2019-08-31 27556452 2024-01-14 AHA 2018-03-31 BRAME,VALEREE, EMT-B P112167 2020-07-31 32401076 2019-03-28 AHA 2018-02-28 - BROWN, GEOFFREY EMT-P P001754 2019-07-31 9817304 2019-07-01 AHA 2017-03-31 BUTLER,TABITHA, EMT-B P049950 2019-09-30 2282099 2017-10-10 AHA 2017-06-30 CARPENTER, CHRISTIN, EMT-B P104351 2019-02-28 39995660 2023-07-18 AHA 2016-10-31 CHIARAMONTE, GARY EMT-B P047264 2019-01-31 33727550 2023-01-16 AHA 2018-05-31 CLODFELTER, ERIKA, EMT-B P100035 2018-04-30 35053338 2023-09-21 AHA 2017-11-24 CORNELISSE,TAYLER, EMT-B P112969 2020-05-31 36173021 2022-09-04 AHA 2017-11-30 COSTELLO,STEFANY, EMT-P P100931 2018-05-31 34140171 2017-12-06 AHA 2017-04-30 CRITTENDEN, MATTHEW, EMT-B P112029 2020-06-30 31607732 2019-02-14 AHA 2018-02-28 CUNIN,ANDREA, EMT-B P100194 2019-01-31 26437855 2024-04-28 AHA 2017-08-31 CUTHBERTSON,JOI EMT-P P086782 2019-01-31 33953747 2020-09-29 AHA 2017-06-30 DAILY,SAMANTHA, EMT-B P105802 2019-06-30 35744565 2021-08-18 AHA 2017-03-21 DAVIS,AMY, EMT-B P112866 2020-05-31 24990758 2018-07-30 AHA 2016-10-31 DUNHAM, DANIEL, EMT-P P069971 2018-04-30 27658259 2018-03-22 AHA 2017-03-31 EDDINS, KELLY, EMT-B P079305 2018-02-28 26144430 2016-12-12 AHA 2017-06-30 ERNISSE,TRISH EMT-P P097633 2020/09/30 33660569 2018-05-12 AHA 2017-03-31 ESTES, KATHRYN, EMT-B P098633 2018-04-30 8922295 2019-04-07 AHA 2017-03-31 FULLER, CYRUS, EMT-B P086916 2020-08-31 4671918 2016-10-22 AHA 2017-07-31 HAMILTON, LEONARD, EMT-P P022477 2017-06-30 3438699 2022-07-30 AHA 2018-02-28 HANCOCK,ASHLEY, EMT-B P110743 2020-01-31 24696659 2023-10-20 AMA 2017-08-01 HEATH,ALAN, EMT-P P079148 2016-12-31 20691159 2017-04-13 AMA 2018-05-31 HOBBS,JIMMIE,Jr. EMT-P P007677 2016-12-31 5450629 2023-02-10 AHA 2016-12-31 HORNE, HANNAH, EMT-P P093159 2020-06-30 34566385 2017-06-28 AHA 2016-11-30 KALEEL, KEVIN EMT-B P063286 2017-04-30 21115653 2018-06-14 AMA 2018/09/30 KORNEGAY, RONALD, EMT-B P014942 2017-09-30 228516 2018-03-13 AMA 2017-02-28 LAREAU, BRIANNA, EMT-B P112569 2020-05-31 32870110 2022-03-07 AHA 2017-09-30 LEIMBERGER, DAVID, EMT-B P103189 2019-02-28 32932539 2018-09-15 AHA 2018/09/30 LOBO, CARLTON, EMT-B P088791 2020-08-31 30808539 2017-03-28 AMA 2017-03-31 LYNCH, RICHARD EMT-P P008646 2017-01-31 9796064 2021-02-03 AHA 2020-03-01 MACEMORE,TYLER, EMT-B P066534 2019-01-31 25287957 2015-11-23 AMA 2018/07/01 MASSEY, PATRICK EMT-B P096134 2017-09-30 35946364 2022-12-29 AHA 2016-10-11 McCALL,JAMES, EMT-B P099172 2018-08-31 8819241 2018-05-31 AHA 2017-04-30 McGEE, ASHLEY, EMT-B P103931 2019-03-31 37242276 2022-05-15 AMA 2018-08-31 MCKENZIE, KATHERINE, EMT-P P010518 2018-04-30 26860993 2024-06-08 AHA 2018-08-31 MEIER BENJAMEN EMT-P P078795 2020-06-30 20376290 2020-05-26 AHA 2018-07-31 . MERCER,ART, EMT-P P019525 2017-01-31 2321258 2020-09-22 AMA 2018-03-31 MINOR,ASH LYN EMT-P P098337 2018-02-28 29892017 2023-04-03 AHA 2017-04-30 MOSER,AMBER, EMT-B P105744 2019-05-31 28721515 2021-11-21 AHA 2017-02-28 MULLEN,JOHN, EMT-B P108007 2019-08-31 21092825 2023-04-28 AHA 2017-06-30 O'NEILL, MICHAEL, EMT-B P060456 2018-12-31 36444016 2023-05-17 AHA 2017-06-30 ORR,JAMIE, EMT-P P099426 2019-08-31 37418959 2020-03-18 AHA 2016-10-31 PIPER,SARAH, EMT-B P060874 2017-05-31 31802190 2018-08-23 AHA 2017-03-31 POWERS, IAN, EMT-B P107956 2019-10-31 542114562 2017-07-15 AHA 2017-07-31 RAMIREZ, RUBEN, EMT-B P091056 2018-05-31 30307795 2018-04-14 AHA 2018-03-31 RATLIFF, MICHAEL,Jr. EMT-B P112746 2020-08-31 36629523 2021-02-27 AHA 2017-09-30 RAYNOR, DANIEL, EMT-B P105514 2019-04-30 37826495 2018-02-14 AHA 2017-10-31 REINER, NICK, EMT-B P003487 2017-07-31 20667157 2017-02-11 AHA 2017-06-30 ROTHERMEL, BENJAMIN, EMT-B P108248 2020-02-29 31954227 2020-11-04 AHA 2017-06-30 SANCHEZ,SHERWYN, EMT-B P107002 2018-02-28 45902876 2023-03-12 AGA 2016-11-30 SCHIEBER, NICOLE, EMT-B P108840 2020/09/30 195288029 2022-08-02 AHA 2018-06-30 SCHIRMER, CAITLIN, EMT-B P112786 2020-06-30 35749117 2022-11-17 AHA 2018-04-30 SHAW,JESSIE, EMT-P P098691 2020-03-31 37188284 2022-08-07 AHA 2017-05-31 SHEARIN, PHILLIP EMT-B P027672 2018-05-31 2390785 2021-09-18 AHA 2016-10-31 SMITH, EVELYN EMT-B P031341 2020-03-31 672376 2024-05-20 AHA 2017-06-30 SPENCE, MARY, EMT-B P077877 2018-12-31 29684454 2020-11-16 AHA 2018-11-30 SPOENEMAN, LAUREN, EMT-B P106140 2019-09-30 32041657 2022-01-25 AHA 2017-01-31 STANSELL, EARL, EMT-P P086233 2019-06-30 30552576 2023-08-18 AHA 2018-02-28 STELZNER, DAVID, EMT-I P005546 2019-02-28 21016175 2023-07-22 AHA 2018-02-28 STRICKLER,ALEXANDER, EMT-B P108241 2019-10-31 35130601 2021-08-03 AHA 2017-05-30 TALLEY, DYLAN, EMT-B P098436 2018-02-28 30164920 2022-01-05 AHA 2018-05-06 TAYLOR, HOLLY, EMT-B P103217 2019-02-28 35752305 2023-09-14 AHA 2018-07-31 THOMAS,JACOB, EMT-B P105208 2019-10-31 38506777 2018-02-14 AHA 2017-02-28 TOMKOSKI,JOSHUA, EMT-B P112648 2020-06-30 38446050 2018-07-12 AHA 2017-09-30 TONEY,TAMIKA, EMT-B P099830 2020-04-30 32883228 2021-01-14 AHA 2018-02-28 VANDERWEIDE, KATHRYN EMT-B P068808 2017-12-31 29313026 2017-10-23 AHA 2016-10-31 WALKER, HANNAH, EMT-B P108865 2018-03-31 38454060 2022-11-04 AHA 2016-11-22 WALSTON, LISA EMT-B P082241 2019-12-31 5419996 2018-11-14 AHA 2016-10-31 WESTER,ANGELA, EMT-P P063262 2019-11-30 28715160 2021-10-04 AHA 2019-07-31 WILLIAMS, NATALIE, EMT-P P033950 2019-08-31 8300119 2019-08-03 AHA 2017-02-28 WILLIAMS,STEPHANIE, EMT-B P105115 2019-02-28 29576392 2020-02-03 AHA 2018/09/30 YOUNG, KAYLA, EMT-B P112144 2020-06-03 33866620 2017-04-26 AHA 2018-02-28 YOUNG, ROBERT, EMT-B P108585 2019-09-30 37865802 2017-05-09 AHA 2017-01-10 ZANI,ANDREA, EMT-B P104241 2019-01-31 31618453 2017-10-07 AHA 2018-06-25 List all Vehicles Owned and O.crated b the A• •llcarit ,;Vehicle , r � �.ii � � . ., DKA7684 16,002 , 1015 201 MERCEDES 3500 WDAPF3CCXF•60474 0313 2013 FORD E-350 1 FDWE3F55CDB19175 BJL3113 246,099 0612 2011 CHEVY 4500 1GB6G5CLX61151485 BCF8162 325,611 0814 2014 MERCEDES 3500 WDAPF3DC8E9562916 DAY3182 55,117 _ 0714 2014 FORD E-350 1FDWE3FSOEDA74911 CKJ6784 117,907 0713 2013 FORD E-350 1 FDWE3FS9DDA74890 BLV2390 175,809 0614 2014 FORD E-350 1 BG6BSCLOE1189425 DHW3306 154,019 0715 2015 FORD E-350 1FDWE3FS5FDA29187 CKJ6483 62,0132 0411 2011 REIGHTLINER 2500 WDYPE7CC9A5468669 AAH7722 227,061 0511 2011 REIGHTLINER 2500 WDYPE7CC8A5464984 ACV2390 254,103 1214 2015 MERCEDES 3500 Wf?APF2C:C:SFQ91440 DPB4840 46,319 0613 2p13 DODGE 2500 WD3PE7CC0D5771527 BLV2012 155,983 1114 2014 F-EIGHTLINER , 2500 WDAPF3CC5E9562518 DAY4617 46,101 0416 2016 FORD E-350 1FDWE3FSOGDC27578 ECT-1722 25,630 0516 2016 FORD E-350 1FDWE3FS2GDC27582 ECT-1723 2530 0816 2016 CHEVY 4500 1GB3GRCG2G1230508 EEL-7292 3214 0916 2016 CHEVY 4500 1GB3GRCG161229656 EEL-7423 1106 w FOR OCES USE ONLY Reviewed by: Date Filed: '` Approved by BOCC: Expiration Date: , NORTH STATE Disclaimer:NSMT Is not a 911 provider,Rates are subject to change. Additionally,the information provided below is typical but not definite and is intended to assist customers understand pricing and which transportation best meets their needs. All pricing will be M l'l)1 CAL TRANS l't.)R l determined on a case by case basis. Specific questions can be answered by contacting ___ our office: P(919)261-8911;F(919)261-8991 North State Medical Transport Fee Schedule-11112/2015 ALS Advanced Life Support Base Cost each way plus Typical Provider Service Type mileage Customer(s) Level Description Any patient deemed emergent by a physician and requires Emergency $406 paramedic level monitoring,ie-IV fluids and/or cardiac monitor. Patient is deemed non-emergent by physician,but still requires Non-Emergency $249 Hospital Paramedic paramedic monitoring,ie-IV fluids and/or cardiac monitor. Patient requires the assistance of a ride-a-long specialist.LE- Specialty Care $694 Respiratory therapist or RN Patients are critical/extremely acute and require special ALS 2 $587 interventions during transfer. BLS Basic Life Support lJ0i1.loU71 Gal.11 way plus Typical Provider Service Type mileage Customer(s) Level Description Immediate response to call(Non-scheduled);Patient is not on any Hospital, drugs or IVs,doesn't need cardiac monitor.A BLS crew may SNFs, perform basic airway management,bleeding control,or patient Emergency $341 Hospice, stabilization while at the scene or during the transfer, Dialysis EMT Scheduled calls:Dialysis transfers,Hospital discharges,Medically Centers, necessary procedures,medical appointments not covered by Non-Emergency $213 Private Medicare or insurance Rural Emergency $332 Citizens Same as an emergency BLS but originating from a rural zipcode Rural Non-Emergency $207 zipcode Wheel Chair Van max l.,wl maw 1 way plus Typical Provider Service Type mileage Customer(s) Level Description SNFs, Hospice, Dialysis Patient does not have a diagnosis which requires stretcher Centers, EMT transport.Typically to medical appointments.Note-Wheelchair services are not available in all areas, Private Wheel Chair Van $63 Citizens Mileage Service Type Cost Pick-Up Explanation If the zipcode at the orgination of the call is considered urban(see attached ALS and BLS $7.16 Urban zipcode)this mileage rate will be used. If the zipcode at the orgination of the call is considered rural(see attached ALS and BLS $7.23 Rural zipcode)this mileage rate will be used. Wheel Chair $3.15 In-County Starting in the county of pick up the patient will be charged$3.15 per mile until they leave the county of orgination of the call at which time the cost will be$4.20 Wheel Chair $4.20 Out-County per mile. Wait Fee All calls are subject to a wait-fee depending upon the circumstances; $1 per minute after the first 30 minutes.