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Surveillance Checklist Tomah VAMC
| Contract: Ground Ambulance |
| Date/Time of Inspection: |
Government POC Primary: Cory Hayes Government POC Alternate: Taylor Hennessy
Organization:
Tomah VAMC Location: Bldg. Post 500 E Veterans St, Tomah, WI 54660
| SS |
| Performance Objective |
| PWS Para |
| Performance Threshold |
| Method of Surveillance |
| Met |
| Not Met |
| Remarks |
| SS 1 |
| The contractor shall provide Ambulance service, 24 hours per day, 365 days per year, as required in accordance with the terms and conditions contained herein. |
| 1 |
| 95% Compliance |
| 100% Surveillance of each patient pick-up. |
| SS 2 |
| The objective of Standards for Maintenance is to protect veterans and to cause no harm to all parties. The contractor shall maintain all vehicles in a clean and orderly condition, free from debris and accumulations which may create an accident, injury, or fire hazard. |
| 4.4.3 |
| 95% Compliance |
| 100% |
Surveillance
| SS3 |
| The contractor shall maintain (and furnish upon request) procedures that outline preventive maintenance and/or repairs on each vehicle in an individual vehicle file and in chronological order, latest service on top. A statement from the Contractor indication compliance of vehicle maintenance files is in place should be submitted at time of offer for evaluation purposes. Requested submission and verification of these documentation requirements will be a quality assurance procedure during the contract period. |
| 4.4.3 |
| 95% Compliance |
| 100% |
| SS4 |
| The contractor shall furnish qualified personnel as required by contract specifications to accomplish all services under this contract. |
| 4.3.1 |
| 100% Compliance |
| 100% |
| SS5 |
| Have completed training in accordance with the standards published by the Department of Health and Human Services with a minimum curriculum of 150 hours or equivalent including an in-hospital training period. Such training programs must also be acceptable under the regulating requirements for local EMS Systems supported by DHHS under PL 93-154, Federal Register 39:24304. (1974). |
| 4.3.1 |
| 100% Compliance |
| 100% |
| SS6 |
| A licensed MTO shall ensure that sanitation procedures are provided to all personnel in a written document that conforms with current standards as set forth in occupational safety and health administration-blood borne pathogens protocol. |
| Attachment B |
| 100% Compliance |
| 100% |
