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I State of North Carolina Category I Inspection Report Provider Lic. #:. 1.503 Depa, rtment of Health and Human Service.. Office of Emergency Medical Services Exp. Date: 1113012002 ! Division of Facility Services 2707 Mail Service Center Raleigh, NC 27699-270 Date: 07/1812000 Pray!der: HARRISBURG VFD AND RESCUE Provider #: 0130402 VIN:i IFDKE3OF4VHA94565 Year:. 1997 Make: FORD 1 Amb Mfr.: Excellance~ Inc. Mile,age: Fuel: .D Diesel Type: t Track Chassis/Mod Vehicle #: 810 Inter!or Dimensions: 64 H X 12 W X 142 L Level/ALS Packages: EMT ~ EMT-D Current Permit #: 436~.~ ~::~/~/ ~, Exp. Date: 0813~/~e~ / EMT~J/~ "~ EMT-P New,,Permit #: ~'~' Issued: ~-~ J Communications EOC~.YES Base: YES Hospital: YES" '. Rescue: YES Fire:~ Law: YES Other Radi? Frequencies: 154.340 155,280 155.340 155.160 Cellu, lar Phone:~ Phone #: . FCC Call Sign: KAV461 Exp. Date: 09128/2000 i Section A (15 points each) S~cflon B (7 points each) Section C Cont'd (4 points each) I~terior dimensions (rain 48xl lx102) [.0901] Seat belts [.0910] 5 - Individually wrapped, sterile, 5"x9" Warning devices [./0903] . , Ambu ance etteringlmarklngs [.0915] or larger absorbent dressings Vehicle body [...0904] Cleanliness - interior [.0916] [.1001 (a)(l 1)] ,1 o Portable~a~pfrator and rinsing bottle Compartment~lighting [.1003(a)(4)] 12 - roils of Roller gauze [. 1001(a)(12)] [~1001(/a)(~1)] ' . - ,1 ea Adul/t,al~'d Child size lower .- 4- rolls Adhesive tape [.1001(a)(13)} 2;- B~V.M - Adult/Child sizes with 02 I~oo~up r~xtre~it'y Traction splint [.1001(a)(9)] 2 - Stroh-adhering, non-porous - [:~.001(a)(2)] . ' I~j~a'Pediatri¢ and Small/Medium/Large k~_d~esslngs, (min 3"x8") [.1001(a)(14)] ~ .6~- gPA ranging from 55mm to 110mm Adult extrication collars [.1001(a)(5)] 6 - Triangular bandages [.1001(a)(15)] V [11001(a)(3)] 1 - OB Kit with supplies [.1001(a)(20)] 1 - bandage shears [;1001(a)(16)] 2!- 02 cylinders (D size or larger) 2 ea Rigid padded board splints, sizes 2 - Bum sheets (rain 40"x72") [i1001(a)(4)] 3"x15", 3"x3' & 3"x4.5'. Other splints, [.1001(a)(17)] __ 1 ~- 02 flow and contents gauge in kit form, of inflatable design or rigid 1000cc Irrigation solution [.1001 (a)(18)] ii 1001 (a)(4)] laminated, high-density polyurathane. 2 - Head immobilization devices for use 3,- Aneroid OR Electronic BP cuffs: Kits must contain at least two full arm with long backboards [.1001 (a)(7)] Small/Medium/Large [.1001 (a)(21)] and two full leg splints, [. 1001 (a)(8)] 2 - Nonporous pillows [.1001 (a)(25)] 1 - Adult I Pediatric Stethoscope- 2 - Blankets (washable) [.1001(a)(26)] [~ 1001 (a)(21)] 2 - Operational flashlights [,1003(a)(1 )] __ 1 i- Rigid short backboard or stabilization Section C (4 points each) 1 - 5lb mounted fire extinguisher device with 2 straps & other accessories Equipment secured [,0906] [, 1003(a)(2)] __ Cleanliness - Exterior [,0916] [!1001 (a)(6)] , ~ - BVM~..Infant size with 02 hookup Section D (2 points each) 2:- Rigid long backboards with 2 straps each [,1001(a)(7)] [.~061 (a)(2)] Med~lcal supply cabinets [.0916] , 1 ,- Ch id restraint device [.1001(27)] 3 - Rigid suction instruments, OR ..,.~,l,<'Emesis basin OR sealable emesis 1 I- Four-wheeled elevating cot with replacemen~ collection containers for container [.1001(a)(19)] mattress pad, straps and crash stable manual suction devices [.I001(a)(1)] No Smoking signs in cab or cabin and fastener [.1001(a)(23)] ,3 ~ 02 supply tubes [.1001(a)(2)] and patient compartment [.1003(a)(3)] 1 - Two-way radio [.1103] 3 ce Adult/Child sized 02 cannulas 3 - Pillowcases [.1001 (a)(24)] [,1001 (a)(4)] 6 - Cot sheets [.1001(a)(24)] 3 ea Adult/Child sized 02 masks I - Body bag [.1001(a)(22)] [.1001 (a)(4)] 2 pr Heavy-d uty work gloves [. 1002(1)] 12 - Individually wrapped, sterile, 4"x4" 2 pr Safety glasses [.1002(2)] gauze pads [.1001 (a)(10)] 2 - Safety helmets [. 1002(3)] Inspection Results: BLS Uni,t.~.~ttng Remarks: TotaliPoint Loss l/'~ "~ !(15 - Over) = Unsatisfactory /"[. (11-~4)=Conditional · [ALS: S)U (10 - Under) = Satisfactory ~. A letler of compliance indicatin~tb~./ discre, pancies noted have been corrected must be received at the above address no ~.~, i later than: Provider Rep: OEMS Inspector: ........ Discrepancies noted are in violation of North Carolina Law and the signed Inspection Repor~ se~Rs as notice of such, OEM$ Category I Inspection Report (11/99)