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HomeMy WebLinkAboutAgreement_General_11/10/2022_PBC COPCN PALM BEACH COUNTY DEPARTMENT OF PUBLIC SAFETY AZ� OFFICE OF EMERGENCY MEDICAL SERVICES APPLICATION FOR PRIMARY ADVANCED LIFE SUPPORT (ALS) PROVIDER CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) COPCN's for Primary Providers are issued every six years for a six year term. Applications for COPCN's are accepted only during the time specified in the public notice. Section 1: (Check one) rgi Application for renewal Primary Provider Certificate of Public Convenience and Necessity (COPCN) ❑ Application for new Primary Provider Certificate of Public Convenience and Necessity (COPCN) The below named Agency is hereby applying for a Primary Provider Certificate of Public Convenience and Necessity for a tern from 1/1/2023 to 12/31/2028 , with an ALS Endorsement and the following additional Endorsements(check all that apply): Advanced Life Support Transport Service ❑ Routinely Transports Basic Life Support ❑ Air Ambulance Services Section 2: AGENCY INFORMATION Name of Agency Village of Tequesta Fire Rescue Mailing address 357 Tequesta Drive,Tequesta, FL 33469 Base station address 357 Tequesta Drive,Tequesta, FL 33469_ Phone # 561-768-0550 Agency is public sector private sector Note: The name of the service that is placed on the"Name of Agency" line will be identical to the name listed on your COPCN. Chief s/ Manager's/Owner's name James Trube, Fire Chief Medical Director's name Dr. Don Tanabe Medical Director's business address 357 Tequesta Drive,Tequesta, FL 33469 Medical Director's Medical License# ME 61426 Exp. Date 1/31/2024 Section 3: ATTACHMENTS REQUIRED Applicants shall submit the application for COPCN as set forth in Chapter 13,Article II, Division 1, of the Palm Beach County Code (EMS Ordinance), and satisfy all requirements therein.In addition, applicants shall also provide satisfactory completion of the following requirements. Please be sure to include with the application, as separately numbered attachments in a three(3) ring binder,the following: 1. Describe the need and area(s) for the proposed service to be covered by your agency. You must submit copies of any municipal resolution(s), contractual agreements, allowing your agency to provide medical response services to any municipality or community. 2. Copy of current State Emergency Medical Services (EMS) license(s) and/or current COPCN, if any. 3. Copy of profile sheet(s) relating to current Florida State license(s), if any, or the equivalent information sheet listing all of the agency's vehicles. In order to maintain an acceptable level of service response time, all applicants must have a sufficient number of ALS vehicles available for response. This number will vary based on the area of assignment. In no event shall any COPCN holder have less than one ALS unit and one ALS vehicle fully staffed, operationally available, and in service at all times ready for simultaneous response to calls. The COPCN holder must also have one ALS spare unit fully equipped in the event that their primary ALS unit is not in service. It is the intent of this provision that each COPCN holder is responsible to have sufficient ALS units available as necessary to demonstrate ability to ensure continuity of operations and to provide mutual assistance as reasonably required upon request. 4. Provide a current personnel roster. Personnel must meet all requirements of certification and training referred to in 64J-1.020, Florida Administrative Code ("F.A.C.") and Section 401.2701,Florida Statutes.. The applicant must have at least one(1)supervisory or higher level employee who possesses a minimum of three (3) years of experience in pre-hospital ALS Services. 5. Liability Insurance: Insurance coverage is required for claims arising out of injury or death of persons and damage to the property of others resulting from any cause for which applicant's business or service would be liable. Non-government operated service vehicles shall be insured for the sum of at least $200,000.00 for injuries to or death of any one person arising out of any one accident; the sum of at least $300,000.00 for injuries to or death of more than one person in any one accident; and, for the sum of at least $50,000.00 for damage to property arising from any one accident. Government operated service vehicles shall be insured for at least the limitation amounts set forth in Florida Statutes 768.28, as may be amended, for any and all claims or judgments. Compliance with these insurance requirements is required at all times while operating under the COPCN. Evidence of compliance is required at the time of application and thereafter as requested by the Department of Public Safety, Office of Emergency Medical Services. 2 6. Insurance verification. A copy of an insurance policy, a self-insurance policy, or a Certificate of Insurance is acceptable. Documentation must be current, and include a schedule of vehicles covered, if the policy is not blanket coverage or self-insurance. Limits of liability, effective, and expiration date must be indicated on the proof of coverage. 7. The Medical Director must be a Florida licensed physician. Provide a copy of a fully executed contract or agreement. Include copies of current DEA and Florida Physician's License. Must meet requirements of 64J-1.004, F.A.C. and Section 401.265, Florida Statutes. 8. A letter from your Medical Director stating your agency has adopted minimum standard, pre-hospital treatment/transport protocols that,at a minimum, meet the requirements of all applicable laws and regulations. 9. A letter from your Medical Director stating your agency has adopted the countywide approved Trauma Transport Protocols or more stringent standards as approved by the applicant's Medical Director. 10. Copy of proposed rate structure. 11. The financial information of the applicant to ensure financial ability to provide and continue to provide service to the area. Such financial information shall include copies of the applicant's past two (2) Medicare audits, if any. Government entities must provide the past three(3)years Comprehensive Annual Financial Reports via hard copy, or electronically. 12. Except for current COPCN Holders a summary history of applicant's emergency services performance record, which provides proof that at the time of application, the applicant has demonstrated experience providing ALS or BLS services. Experience providing ALS or BLS services must include experience proving the full continuum of patient care from call initiation, during patient transport and through to final patient transfer to hospital or other final destination. This is not a personal reference for the agency but how the agency had provided ALS or BLS services in the past. 13. Disclosure of litigation involving patient care, for the past six (6) years which resulted in a judgement, award, or finding in favor of a patient or the complaining party, including case number,nature of the claim and allegations,and a copy of final judgment or award. The administrator may request additional information regarding the litigation. 14. Proof of satisfactory completion of all federal, state, and/or local agency vehicle and staff inspections for the last six (6) years including copies of all deficiency reports. Current COPCN Holders need not provide vehicle and staff inspections performed by the Palm Beach County Office of EMS (except deficiencies reports). 15. Records substantiating the implementation of a formal quality assurance system consistent with Florida Statute Section 401.265 and Rule 64J-1.004(3)(b), Florida Administrative Code, as may be amended. 3 16. Records substantiating that applicant has an Emergency Medical Dispatch (EMD) program or an agreement for appropriate EMD service consistent with Section 768.1335, Florida Statutes, titled "The Emergency Medical Services Dispatch Act", as may be amended. 17. A memorandum of understanding for radio communications that is executed between the applicant and Palm Beach County. (Facilities Development and Operations Dept.) 18. The applicant must provide a certified letter from the COPCN holder's Chief Executive Operating Office or Fire Chief that the applicant has met all applicable federal,state and local requirements pertaining to the delivery of EMS. 19. A non-refundable application fee in the amount of five-hundred dollars($500.00)made payable to: "Palm Beach County Board of County Commissioners." 4 SECTION 4: AUTHORIZED SIGNATURE I, the undersigned Agency Representative of the applicant Agency, do hereby attest that said Agency meets all the requirements of the EMS Ordinance, as codified in Chapter 13, Article II, Division 1, of the Palm Beach County Code, and any accompanying Rules and Regulations, as well as all the requirements for the operation of an emergency service as provided for in Chapter 401,Part Ill, Florida Statutes, and Chapter 64J, Florida Administrative Code. I,the undersigned Agency Representative of the applicant Agency, further attest that this Agency is in compliance with the State of Florida EMS Communications Plan. I, the undersigned Agency Representative of the applicant Agency, acknowledge that any discrepancies discovered by the Palm Beach County Emergency Medical Services staff during the annual mandatory inspections may subject my Agency and its representatives to corrective action and possible penalty as provided for by Florida law and applicable Rule. Further, I understand that an annual vehicle inspection permit-fee of fifty dollars ($50.00)per-vehicle shall be paid for any EMS vehicle or ambulance utilized in Palm Beach County. I, the undersigned Agency Representative of the applicant Agency,hereby submit this application on behalf of the applicant Agency,and hereby affirm that I am authorized to submit this application on behalf of the applicant Agency and that, to the best of my knowledge, all statements on this application and the included attachments in support of the application are true and correct. .^J A1 l e-rem y 1k 1 , V i I�aae, ana er Printed/Typed'Name of Agency Representative 2toejk. A"^-eit"--- Signature Date 5 PUBLIC RECORDS. In accordance with Sec. 119.0701, Florida Statutes, CONTRACTOR must keep and maintain this Agreement and any other records associated therewith and that are associated with the performance of the work described in the Proposal or Bid. Upon request from the Village's custodian of public records, CONTRACTOR must provide the Village with copies of requested records, or allow such records to be inspected or copied, within a reasonable time in accordance with access and cost requirements of Chapter 119, Florida Statutes. A CONTRACTOR who fails to provide the public records to the Village, or fails to make them available for inspection or copying, within a reasonable time may be subject to attorney's fees and costs pursuant to Sec. 119.0701, Florida Statutes, and other penalties under Sec. 119.10, Florida Statutes. Further, CONTRACTOR shall ensure that any exempt or confidential records associated with this Agreement or associated with the performance of the work described in the Proposal or Bid are not disclosed except as authorized by law for the duration of the Agreement term, and following completion of the Agreement if the CONTRACTOR does not transfer the records to the Village. Finally, upon completion of the Agreement, CONTRACTOR shall transfer, at no cost to the Village, all public records in possession of the CONTRACTOR, or keep and maintain public records required by the Village. If the CONTRACTOR transfers all public records to the Village upon completion of the Agreement, the CONTRACTOR shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. If the CONTRACTOR keeps and maintains public records upon completion of the Agreement, the CONTRACTOR shall meet all applicable requirements for retaining public records. Records that are stored electronically must be provided to the VILLAGE, upon request from the Village's custodian of public records, in a format that is compatible with the Village's information technology systems. IF CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS AGREEMENT, PLEASE CONTACT THE VILLAGE CLERK, RECORDS CUSTODIAN FOR THE VILLAGE, AT (561) 768-0440, OR AT Imcwilliams@tequesta.org, OR AT 345 TEQUESTA DRIVE, TEQUESTA, FLORIDA 33469. Pursuant to Article XII of the Palm Beach County Charter, the Office of the Inspector General has jurisdiction to investigate municipal matters, review and audit municipal contracts and other transactions, and make reports and recommendations to municipal governing bodies based on such audits, reviews, or investigations. All parties doing business with the Village shall fully cooperate with the inspector general in the exercise of the inspector general's functions, authority, and power. The inspector general has the power to take sworn statements, require the production of records, and to audit, monitor, investigate and inspect the activities of the Village, as well as contractors and lobbyists of the Village in order to detect, deter, prevent, and eradicate fraud, waste, mismanagement, misconduct, and abuses. "The Village of Tequesta strives to be an inclusive environment. As such, it is the Village's policy to comply with the requirements of Title II of the American with Disabilities Act of 1990 ("ADA") by ensuring that the Contractor's [agreement/bid documents and specifications] are accessible to individuals with disabilities. To comply with the ADA, the Contractor shall provide a written statement indicating that all [ agreement /bid documents and specifications], from Contractor, including files, images,graphics,text, audio,video, and multimedia,shall be provided in a format that ultimately conforms to the Level AA Success Criteria and Conformance Requirements of the Web Content Accessibility Guidelines 2.0 (Dec. 11, 2008) ("WCAG 2.0 Level AA"), published by the World Wide Web Consortium ("W3C"), Web Accessibility Initiative ("WAI"), available at www.w3.org/TR/WCAGi."