REQUEST FOR PROPOSALS 10735

Draft Approved by Counsel Printed Name _________________ Draft Approved by Counsel Signature ____________________ Draft Approved by C/P Supervisor__________

COUNTY OF MONTEREY

CONTRACTS/PURCHASING DIVISION

1488 SCHILLING PLACE

SALINAS, CA 93901

(831) 755-4990

REQUEST FOR PROPOSALS 10735

For Exclusive Ambulance Services Provider for the

Monterey County Exclusive Operating Area

Proposals are due by 1500 (local time) on Friday, February 19, 2020

RFP # 10735 Exclusive Ambulance Services Provider for the Monterey County Exclusive Operating Area

RFP # 10735 Exclusive Ambulance Services Provider for the Monterey County Exclusive Operating Area C/P rev. 11/20/17 MRD

(THIS PAGE INTENTIONALLY BLANK)

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TABLE OF CONTENTS

1.0: INTENT ................................................................................................................................................. 6

2.0: BACKGROUND AND ESSENTIAL CONSIDERATIONS ................................................................ 6

3.0: CALENDAR OF EVENTS ................................................................................................................. 14

4.0: COUNTY POINTS OF CONTACT .................................................................................................... 15

5.0: SCOPE OF WORK .............................................................................................................................. 16

6.0: CONTRACT TERM ............................................................................................................................ 70

7.0: LICENSING/SECURITY REQUIREMENTS .................................................................................... 70

8.0: PROPOSAL REQUIREMENTS ......................................................................................................... 71

9.0: SUBMITTAL INSTRUCTIONS & CONDITIONS ........................................................................... 80

10.0: SELECTION CRITERIA .................................................................................................................. 81

11.0: PRICING ........................................................................................................................................... 87

12.0: PREFERENCE FOR LOCAL CONTRACTORS ............................................................................. 88

13.0: CONTRACT AWARDS .................................................................................................................... 88

14.0: PREVAILING WAGE ...................................................................................................................... 90

15.0: AGREEMENT TO TERMS AND CONDITIONS ........................................................................... 90

16.0: COLLUSION / UNFAIR COMPETITION / FALSE CLAIMS ....................................................... 90

17.0: RIGHTS TO PERTINENT MATERIALS ........................................................................................ 91

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SOLICITATION DETAILS SECTION

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1.0 INTENT

1.1 The County of Monterey, hereinafter referred to as “County,” and the County of Monterey Health Department, Emergency Medical Services Agency, hereinafter referred to as “EMS Agency,” are soliciting proposals from experienced and well qualified organizations, to be the exclusive provider of Ambulance Services, including all emergency Ambulance Services, advanced life support (ALS) Ambulance Services, basic life support (BLS) Ambulance Services, critical care transport (CCT) Ambulance Services, all interfacility (IFT) Ambulance Services, standby services with transport authorization, Ambulance response to all medical seven-digit emergency response, and medical 911 calls within the Monterey County Exclusive Operating Area (“EOA”), as provided for in Section 1797.224 of the California Health and Safety Code. The Monterey County EOA includes all geographic areas of Monterey County, except for certain federal property, the City of Carmel-by-the-Sea, and the certain portions of the Monterey County Regional Fire District, which are currently exempted or “carved out” from the EOA as illustrated in the EOA Maps in Exhibit A. The Monterey County EOA does not include air Ambulance Services or medical standby without transport services.

1.2 To maximize efficiency and performance, and to minimize financial and operational risk to

taxpayers, the EMS Agency intends to award an Agreement to a Bidder experienced in the business management, financing, fleet management and maintenance, provision of direct clinical oversight and quality improvement, billing, and operation of 911 ALS Ambulance Services operating through a High-Performance Agreement (See Contractor Minimum Qualifications – outlined in Section 8).

1.3 The EMS Agency and County intend to award a single, exclusive Agreement to the successful

Bidder whose proposal conforms to the RFP and whose proposal receives the highest score awarded by the Proposal Review Panel. The term of the Agreement shall be from the date of approval of the Agreement by the Board of Supervisors to January 31, 2027 at 2400, local time. Contractor may earn extensions not to exceed a total of an additional five (5) years according to the terms of the renewal provisions of the Agreement.

2.0 BACKGROUND AND ESSENTIAL CONSIDERATIONS

2.1 BACKGROUND

2.1.1 The County of Monterey

The County of Monterey is located on the Central Coast of California, approximately 120 miles south of San Francisco. The County measures approximately 105 miles north to south, and approximately 30 miles east to west (approximately 3,326 square miles), with a population of approximately 420,000 residents. Monterey County is densely populated in the northern Salinas Valley and northern coastal peninsula areas, while the southern coastal, valley, and inland mountain regions are sparsely populated. During fair weather months, the county’s population increases as tourists visit its Big Sur coastline, 17 Mile Drive on the Monterey Peninsula, WeatherTech Laguna Seca raceway, the Monterey Bay Aquarium, numerous wineries, and peaceful communities. The Monterey County and Visitors Bureau estimates there are 4.6 million visitors to Monterey County each year.

2.1.2 Monterey County EMS and Healthcare Information

A significant amount of healthcare and demographic information regarding Monterey County can be found on the World Wide Web at: http://www.co.monterey.ca.us/government/departments-a-h/health/general. Additional demographic information may be available from the California Department of Finance, at

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http://www.co.monterey.ca.us/government/departments-a-h/health/general



http://www.dof.ca.gov/Forecasting/Demographics/projections/ The Monterey County EMS Agency’s website contains EMS System and EMS Agency information, including EMS Plans, EMS Annual Reports, contracts and agreements, EMS Systems Policies, Protocols and Procedures, EMS System performance reports, and other information that may be valuable in responding to this RFP. This website is located at: http://www.mocoems.org.

2.1.3 The EMS Agency and the RFP Process

1. Pursuant to California Health and Safety Code, Section 1797.200, the Monterey County

Board of Supervisors has designated the Health Department’s Emergency Medical Services (EMS) Agency as the Local Emergency Medical Services Agency (LEMSA) for the County of Monterey. In this role, the EMS Agency has the exclusive responsibility to plan, implement, evaluate, and regulate the Monterey County EMS System. California Health and Safety Code, Section 1797.224 authorizes the local EMS Agency, using its competitive process, to issue exclusive operating rights to an Ambulance provider. The EMS Agency must submit its competitive process to the State of California Emergency Medical Services Authority (EMSA) for their review and approval. EMSA approval of the competitive process is necessary to secure Anti-Trust immunity, as provided for in California Health and Safety Code Section 1797.6.

2. In June 2017, the EMS Agency engaged Fitch and Associates to conduct a

comprehensive assessment of the Monterey County EMS System and to assist in the development, release, and evaluation of the EOA RFP. The Monterey County EMS System Assessment is a product of this process. That document can be found at: http://www.co.monterey.ca.us/home/showdocument?id=60566.

3. The Monterey County EMS System Strategic Plan is another product of this process. That document can be found at: http://www.co.monterey.ca.us/government/departments-a-h/health/emergency-medical-services/ems-20-30-ems-system-redesign-process/ems-20-30-phase-two.

2.1.4 Statutory and Regulatory Requirements

The Monterey County Ambulance Ordinance and the specifications of this RFP establish broad standards for the operations, equipment, and personnel of Ambulance Services. The successful Bidder shall provide all services consistent with the requirements of California Health and Safety Code Sections 1797 et seq., California Code of Regulation, Title 22, Division 9, and Monterey County Code of Ordinances. Additionally, requirements that are more specific to day-to day operations can be found in the Monterey County EMS System Policies, Protocols and Procedures, and any amendments or revisions thereof, which are incorporated into the agreement by reference. The successful Bidder shall comply with all Monterey County EMS System Policies, Protocols and Procedures or any amendments or revisions thereof.

2.1.5 Overview of EMS in Monterey County

1. Monterey County is a complex service area for emergency medical services providers,

primarily due to the county’s geography and disparate population densities. Numerous special events that require Ambulance standbys, some occurring simultaneously over long weekends also increase the complexity of the EMS System.

2. Sixteen public safety departments and districts provide first response service. Most first response organizations provide care at the emergency medical technician-basic (EMT-B) level, but some provide care at the emergency medical technician-paramedic (EMT-P) level. In some rural or remote areas of the county, first responders provide care at the emergency medical responder (EMR) level.

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http://www.dof.ca.gov/Forecasting/Demographics/projections/

http://www.mocoems.org/

http://www.co.monterey.ca.us/home/showdocument?id=60566

http://www.co.monterey.ca.us/government/departments-a-h/health/emergency-medical-services/ems-20-30-ems-system-redesign-process/ems-20-30-phase-two





3. In Monterey County, Ambulance Services are currently provided by four ground Ambulance and two air Ambulance provider organizations. All ground and air Ambulance providers provide ALS level care. Most of the county is currently served by American Medical Response-West (AMR), which is contracted to serve the Monterey County EOA. Monterey County Regional Fire District provides Ambulance Services to portions of the Carmel Valley area. Carmel-by-the-Sea Fire Ambulance provides Ambulance Services to the City of Carmel-by-the-Sea. The federal Fort Hunter Liggett Fire Department provides Ambulance Services to Fort Hunter Liggett. These Ambulance providers are assisted by Air Ambulance providers, REACH and Mercy Air. The California Highway Patrol provides Air Rescue services from their base in Paso Robles.

4. MCECD is the primary PSAP in Monterey County. MCECD operates the countywide

consolidated primary Public Safety Answering Point (PSAP). Emergency and non-emergency call answering and dispatch services are provided to the County Sheriff, 11 of the 12 incorporated city police departments, fire agencies for all 12 cities, three County fire districts, one volunteer fire brigade, the Monterey Regional Airport District, Salinas Valley State Prison, and California State University, Monterey Bay police department. These services are provided under the Agreement for 9-1-1 Emergency Communications Dispatch Services. In 2019 the Department received 725,492 phone calls, of which 222,773 were emergency calls and processed 539,749 Computer Aided Dispatch events.

5. The Big Sur area presents a unique EMS coverage challenge. It is a remote area with limited road access that has high transient populations during tourist season and on weekends. This area is often isolated from Monterey County due to significant mud slides during the rainy season. The failure of the Pfeiffer Bridge, which took over eight months to reopen, required creative methods to ensure response to calls and subsequent transport to the hospital.

6. The EMS Agency encourages Bidder to contact Big Sur Fire for more information.

2.2 ESSENTIAL CONSIDERATIONS

2.2.1 Responsibilities of the EMS Agency

The Monterey County EMS Agency is responsible to: • Select and enter into an Agreement with the successful Bidder • Provide contract administration and management and oversight of Contractor for

services provided pursuant to the resulting Agreement • Monitor the EMS System’s performance and compliance with the performance-based

specifications applicable to Contractor • Provide the services of an EMS Medical Director, as defined in California Health and

Safety Code, Sections 1797.202 and 1798 • Develop and modify EMS System Policies, Protocols and Procedures • Assure Contractor is the exclusive Ambulance provider in the Monterey County

Exclusive Operating Area, as defined herein • Oversee medical dispatch procedures for all EMS calls in the County • Provide for on-line medical control • Oversee and evaluate the EMS System’s specialty programs, including Trauma, Stroke,

and STEMI programs • Secure, in the event of Contractor’s default, an alternate EMS Ambulance delivery

system

2.2.2 EMS Agency’s Philosophy, Best Practices, and Expectations of the Provider

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1. Monterey County EMS Agency’s first responsibility and primary focus is to the people of Monterey County and the next patient of the Monterey County EMS System. Consequently, the Monterey County EMS Agency expects the successful Bidder to be ethical, responsible, and transparent in all dealings throughout the term of the Agreement. The performance and behavior expectations as stated in this RFP and the resulting Agreement will be enforced throughout the Agreement. The Agreement may be modified based on identified EMS system needs related to response time performance, response area changes, revisions to clinical care practices, required equipment and supplies changes, and for other good cause. Proposed modifications to the Agreement will be limited to the extent possible and will be submitted to California EMS Authority for approval before implementation (See Section 2.2.9).

2. The Monterey County and the EMS Agency’s goal is the delivery of high-quality and cost-effective 911 and emergency Ambulance Service, basic expanded scope and advanced life support, and critical care transport services within its service areas to provide for the public health and safety of the people of Monterey County, while developing an EMS System that is financially solvent, follows best practices, utilizes current data and research, and is self-sustaining during the term of the Agreement.

3. This procurement moves the EMS System, and the Ambulance Services provided

therein toward a new framework of “providing the right resource, to the right patient, at the right time, and at the lowest responsible cost” -- a direction that is supported by clinical research and is necessary for the financial stability of the system. In this framework, the EMS Agency provides statutory, regulatory, policy, and contractual oversight and guidance, while providing the successful Bidder discretion, within applicable state and federal law, Monterey County EMS policies, and Agreement provisions, to leverage its expertise and experience to manage its day-to-day operations, to optimize clinical operation and financial performance, and to implement the vision and strategic plan of the EMS Agency. The EMS Agency expects and encourages Contractor to identify and recommend opportunities for adaptation and improvement. The EMS Agency also closely monitors clinical practice and operational and financial performance to assure that Ambulance Services meet each of the EMS Agency’s overarching goals for the EMS System. These goals include the Institute for Health Improvement’s Triple Aim for health care, which when applied to emergency medical services, are:

• To sustain and improve the quality of clinical care the patient receives • To stabilize or reduce the cost of emergency medical services • To improve patient satisfaction

4. To support these goals, the EMS Agency has identified the following six tenets for EMS System improvement: • To ensure an EMS System that is cost-effective and sustainable in the long term,

while preserving a high level of emergency response and care throughout the county.

• To transition the function of emergency medical services from episodic care to a component of integrated health care.

• To maintain and support the current and future EMS workforce. • To integrate the EMS System with other local and regional medical and health care

resources. • To design an EMS System that is county-wide (i.e., current EOA), allowing for

economies of scale and consistency of service throughout all areas and jurisdictions of the Monterey County.

• To strengthen the regulatory and oversight functions provided by the Local EMS Agency (LEMSA) to the selected Bidder.

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2.2.3 Procurement Goals and Values

1. The EMS Agency’s overarching goals in the conduct of this procurement process are to

promote public health and safety by: • Minimizing the loss of life • Identifying and reducing illness and injury • Minimizing patients’ discomfort • Reducing disability and disfigurement • Decreasing costs and financial impacts of catastrophic injury or illness • Ensuring the quality of the clinical care provided by EMS personnel • Improving the safety of the community we serve and the EMS professionals who

deliver this service

2. To achieve these overarching goals, the EMS Agency is working to promote a quality EMS System that includes the following essential elements: • Emergency System access • Emergency Medical Dispatch (EMD)

a) 911 caller interrogation protocols b) Pre-arrival instructions c) First responder and Ambulance dispatch

• First responder services • Ambulance treatment and transport services • Transportation to an appropriate medical facility when indicated • Direct (on-line) medical control as required • Receiving facility interface • Transparency and independent monitoring • Quality improvement activities and monitoring

3. A fully functioning EMS system requires high levels of performance. Exceptional

performance in medical dispatch, and in the field, are required to achieve a high-quality emergency medical service. Likewise, the public is interested in the response times of first responders and ALS or BLS Ambulances. Thus, this RFP identifies and incentivizes response times, clinical outputs and outcomes measures that Contractor must meet while providing Ambulance Services. It is in meeting these response time, clinical outputs and outcome measures that Contractor may earn Agreement extensions not to exceed an additional five (5) years.

4. This approach also requires the EMS Agency to strengthen its emergency medical services coordination, oversight, and accountability function, while allowing Contractor the flexibility to use its expertise and entrepreneurial talent to manage its day-to-day operations. This model is intended to promote high-quality clinical care, reliability, operational efficiency, and financial stability.

2.2.4 Clinical Goals

1. The EMS Agency’s goal is to provide a clinically-sophisticated and financially-sustainable EMS System that achieves contemporary benchmarks of clinical excellence. The system specifications included in this RFP are drawn from applicable reference sources and are generally consistent with the direction provided in the National Highway Traffic Safety Administration’s document, The EMS Agenda for the Future, and the core recommendations of the more recent Institute for Medicine report on EMS: Emergency Medical Services: At the Crossroads.

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2. The clinical goals of progressive EMS Systems are guided by broad outcome measures. These include: • Discomfort is minimized • Disability is reduced • Death is minimized • Disfigurement is reduced • Disease is identified and reduced

3. In addition, there is a focus on meeting the six aims of the Institute of Medicine report on

healthcare quality, Crossing the Quality Chasm: A New Health System for the 21st Century, which stresses that systems should be: safe, effective, patient-centered, timely, efficient, and equitable. Information developed for the federal EMS Compass Measures project have also been considered in outlining these specifications.

4. Appropriate measures will be utilized and further developed throughout the term of the Agreement.

2.2.5 Ambulance Services Rates

The Board of Supervisors must approve Contractor’s proposed rates within Monterey County. The current Ambulance Services rates are included in Exhibit C.

2.2.6 Payer Mix While no definitive estimates on future payer mix can be provided, an estimate for various classes of payers is outlined below:

Monterey County Payer Mix

Calendar Year 2019

Medicare Fee for Service 35.70%

Medicare HMO 0.9%

Contracted Government Medicare HMO 2.0%

Medi-Cal 3.0%

Medi-Cal HMO 0.7%

Contracted Government Medi-Cal HMO 25.0%

Private Insurance 9.9%

Self-Pay 13.5%

Facility Contracts 5.9%

HMO Managed Care 2.6%

Veterans Administration 0.9%

Total 100.00%

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Payer mix affects collection rates and possible federal, state, or local changes in healthcare access, and delivery, may significantly impact payment for Ambulance Services. Therefore, Section 5.13.2 this RFP provides provisions for regular CPI-based rate adjustments and other rate adjustments as necessary.

2.2.7 Historic Service Volume

1. The number of Ambulance responses within the EOA for the 2019 calendar year ending December 31, 2019 was approximately 33,900 and the number of patients transported was approximately 25,000. Bidders may use these call and transport figures as a basis for preparing their proposals. The County will use these figures for reviewing and comparing proposals.

2. The County makes no representations, promises, or guarantees concerning the actual number of emergency or non-emergency, behavioral health, mutual aid calls or transports, number of patients or distance of transports, or any other revenue or subsidy related to the activities that will be associated with this procurement. Every effort has been made to provide accurate data and information, but the EMS Agency and County do not guarantee the accuracy of any data included in the RFP or on any of the linked websites. Bidders will need to use their own professional judgment and expertise to develop estimates, economic models and operational plans and proposals.

3. Electronic data files related to the call locations, times and call type as categorized under the current dispatch system are available by contacting Gina Encallado, at the contact information provided in Section 4.0: County Points of Contact. Note: These data files do not reflect the call priorities that may be achieved under this RFP. To receive access to these files, Bidders will be required to complete a special Business Associate Agreement (Exhibit D) and guarantee that this information will not be released or used for any other purpose than preparing a Proposal in response to this RFP.

2.2.8 System Efficiency and Enhancement Opportunities 1. The EMS Agency believes that a sophisticated and experienced Contractor can leverage

numerous opportunities to increase system efficiency under the requirements of this RFP and EMS System Policies, Protocols and Procedures, as compared to the requirements of previous RFPs, Agreements, and EMS System Policies, Protocols and Procedures. Contractor is encouraged to use its entrepreneurial expertise to work collaboratively with the EMS Agency throughout the term of the Agreement to identify and implement appropriate opportunities to improve clinical care and reduce inefficiencies.

2. Bidders should identify and leverage opportunities in formulating a response to this solicitation. For illustration purposes, examples may include but are not limited to the following:

2.2.8.1 Enhanced Medical Priority Dispatch Procedures The Monterey County EMS System is committed to appropriately prioritizing EMS calls according to the protocols of the Medical Priority Dispatch System (MPDS) and best practices in EMS systems. Bidders should consider: a) The proportion of calls dispatched as a Priority 1 call appear greater than necessary

before November 1, 2019. As a result of policy changes in categorizing 911 medical calls a number of these calls are now dispatched as Priority 2 calls with a more appropriate response time requirement as of November 1, 2019.

b) Approximately 50% of 911 calls received MPDS caller interrogation and categorization prior to November 1, 2019. Increased use of the MPDS countywide

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since November 2019 have allowed the prioritization of additional calls with more appropriate response time requirements. Currently, approximately 63% of 911 calls receive MPDS caller interrogation and categorization.

2.2.8.2 Service to Exclusive Operating Area The Agreement will require Contractor to handle all calls within the EOA. Contractor cannot delegate, assign, or subcontract parts of the EOA to other Ambulance providers. The only exceptions to this provision are for special events standby services, Difficult-to-Serve Areas as defined in Exhibit G, back-up CCT services, and mutual aid. Contracts for these services must receive EMS Agency approval. It is expected that Contractor will dispatch, or have dispatched, the closest ambulance available to respond to the request for service for any calls in Priority 1, 2, and 3. The closest ambulance may not be the geographically closer ambulance due to traffic patterns or other accessibility issues.

2.2.8.3 Financial Incentive for Superior Clinical Performance

Certain provisions of this RFP, including Sections 5.4.21, encourage and financially incentivize Contractor to achieve defined Key Performance Clinical Outcomes, as defined by Key Performance Clinical Indicators. In those instances, where stipulated outcomes are met, there are provisions to forgive certain response time liquidated damages.

2.2.8.4 Case Management, Alternative Transportation, and EMS Innovation

Certain provisions of this RFP require Contractor to work collaboratively with the EMS Agency, the Health Department, the Monterey County Behavioral Health Bureau, and Monterey County hospitals and health systems during the term of the Agreement to develop a comprehensive, medically-appropriate alternate care, alternate destination, case management, transportation, and/or referral model for 5150/behavioral health patients, high frequency/low acuity patients, and other medical transportation requests that are not best served by Ambulance response or transport.

2.2.8.5 Assess, Treat, and Refer

Currently, Contractor does not bill for services that do not result in transport, such as care provided on scene without transport. In this RFP, Bidders may propose rates for certain non-transport services, including: (1) ALS treatment without transport; and, (2) on scene treatment and referral when a treat and refer program is established. “Medical Response” charges, which are charges for only responding to a call, and “assessment only” charges will not be allowed.

2.2.8.6 “Bundled” Rate Structure

With the implementation of the new Agreement, the County will adopt a “bundled” rate for Ambulance Services, whereby most fees for service are included in the base rate, with the exception of oxygen, mileage, emergency for BLS, standby, and Treat-No transport.

2.2.8.7 Implementation of BLS and ALS Base Rates

The EMS Agency has recently allowed the use of BLS Ambulance Service by the current Ambulance Contractor. This established BLS base rates in addition to the ALS and CCT-RN base rates. With the implementation of the new Agreement, in addition to the CCT-RN base rate, the County will allow for separate BLS and ALS Base Rates. The

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EMS Agency does not have verified information on the number or proportion of calls that would be properly categorized as ALS and BLS. Therefore, Contractor will use its own professional judgement and expertise to estimate the proportion of ALS and BLS calls and develop appropriate estimates and operational economic models.

2.2.9 Modifications to Agreement to Improve Efficiency and Clinical Care

During the term of the Agreement, the Agreement may be modified in writing by consent of the EMS Agency, the Board of Supervisors, and the Contractor. Modifications to the Agreement may be proposed by the EMS Agency or Contractor. Acceptable modifications include changes to improve the efficiency of the EMS System, to reduce costs, or to improve clinical care. This includes, but may not be limited to: (1) modifying response time standards, deployment of ambulances and personnel within the EOA, and Response Areas within the EOA, based on clinical evidence, quality improvement processes, or scientific research; (2) implementing case management, alternate destination, non-Ambulance transport program, and treat and refer programs.

3.0 CALENDAR OF EVENTS

1 Issue RFP Monday, November 2, 2020

2 Mandatory Pre-Bidders’ Conference Wednesdy, November 18, 2020

3 Deadline for Written Questions Monday, November 23, 2020

4 Questions Answered/Addendum Issued Will be made available on County Website upon release

5 Proposal Submittal Deadline Friday, February 19, 2021, 1500,local time

7 Proposal Review By Friday, March 19, 2021

8 Notification & Negotiation & Agreement Finalized March/Arpil 2021

9 Expected Board of Supervisors Decision April 2021

10 Implementation Period May 2021-January 2022

11 Service Start Date February 1, 2022 This schedule is subject to change as necessary.

3.1 Mandatory Pre-Bidders’ Conference: A mandatory Pre-Bidders Conference will be held at the Monterey County EMS Agency’s office, located at 1441 Schilling Place, Salinas, CA 93901 on Wednesday, November 18, 2020 at 0900, local time. Attendance at the mandatory Pre-Bidders’ Conference is required for all Bidders. Bidders may attend in person or via Zoom. The EMS Agency may issue an addendum to the RFP after the Pre-Bidders’ Conference if the EMS Agency determines that additional clarifications or revisions are required. At the Pre-Bidders’ Conference, the EMS Agency will summarize key points of the RFP and the RFP process. The Monterey County Emergency Communications Department (MCECD) Director will be in attendance to provide a brief overview of the MCECD and existing operational space and cost. All questions will be submitted to the EMS Agency in writing on the Pre-Bidders Conference Questions Form provided. The EMS Agency will not answer any RFP questions orally; however, it may choose to answer those questions related to administrative matters. The EMS Agency will answer questions in writing following the Pre-Bidders’ Conference.

3.2 Any and all questions regarding this Request for Proposals must be submitted in writing by,

Monday, November 23, 020, no later than 1500, local time. All questions must be directed to the

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individual listed below under correspondence in Section 4.0. Questions and comments received after the deadline will not be acknowledged.

3.3 If requesting changes to a part of this solicitation, identify the specific words or phrases and the sections and paragraphs in which they occur. State the reason for each request and provide alternative suggested language. Requests submitted after the deadline will not be accepted. The EMS Agency’s consideration of a suggestion does not imply acceptance. The EMS Agency retains the sole responsibility to accept or reject any changes. All proposed changes will be sent to the California EMS Authority for their review and approval before any addendum is issued.

3.4 All questions must be directed to the individual listed below under correspondence. These questions

and questions raised at the mandatory Pre-Bidders’ conference will be answered in writing and distributed to all potential Bidders and placed on the EMS Agency’s website and the Contracts/Purchasing website following the mandatory Pre-Bidders’ conference.

3.5 FUTURE ADDENDA: Bidders, who received notification of this solicitation by means other than

through a County of Monterey mailing, shall contact the person designated in the COUNTY POINTS OF CONTACT herein to request to be added to the mailing list. Inclusion on the mailing list is the only way to ensure timely notification of any addenda and/or information that may be issued prior to the solicitation submittal date. IT IS BIDDERS’ SOLE RESPONSIBILITY TO ENSURE THAT THEY RECEIVE ANY AND ALL ADDENDA FOR THIS RFP by either informing the County of their mailing information or by regularly checking the County’s Solicitation Center web page at www.co.monterey.ca.us/admin/solicitcenter.html. Addenda will be posted on the website the day they are released.

3.6 Bidders will be notified of any delays that postpone the contract award.

3.7 Bidders with responsive proposals will be asked to participate in an interview and provide a

presentation. The oral presentation by each Bidder shall not exceed 60 minutes. The oral interview will consist of standards questions asked of each Bidder and specific questions regarding Bidder’s proposal.

3.8 Once responsive proposals are scored, parties shall be informed via correspondence of a tentative

award. The selected Contractor must be approved by the Board of Supervisors’ prior to final award.

3.9 The Implementation Period will be considered a pre-operational phase of the contract. The selected Contractor will have contractual responsibilities as outlined in this RFP to which they will be held accountable by the EMS Agency.

4.0 COUNTY POINTS OF CONTACT

4.1 Questions and correspondence regarding this solicitation shall be directed to:

Gina Encallado, Management Analyst I Monterey County Contracts and Purchasing 1488 Schilling Place Salinas, CA 93901 PHONE: (831) 796-1336 Email: [email protected]

4.2 All questions regarding this solicitation shall be submitted in writing (E-mail is acceptable). The

questions will be researched, and the answers will be communicated to all known interested Bidders after the deadline for receipt of questions.

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http://www.co.monterey.ca.us/admin/solicitcenter.html

mailto:[email protected]



4.3 Only answers to questions communicated by formal written addenda will be binding.

4.4 Bidders shall not contact, directly or through proxies or intermediaries, County officers or employees with questions or suggestions regarding this solicitation except through the primary contact person listed above. Any unauthorized contact or attempts by Bidders or their proxies or intermediaries to contact and/or influence County officers, employees of the EMS Agency, their consultants, or members of the Proposal Review Panel may be considered undue pressure and cause for disqualification of Bidder.

5.0 SCOPE OF WORK

It is the responsibility of Bidder to ensure its proposal responds to every section and sub-section of the RFP. Contractor shall perform the following services to the complete satisfaction of the EMS Agency.

5.1 BASIC AMBULANCE SERVICES

5.1.1 Exclusive Provider 1. Contractor shall be the exclusive provider of all Ambulance Services, including all emergency

Ambulance Services, all advanced life support (ALS) Ambulance Services, all basic life support (BLS) Ambulance Services, all critical care transport (CCT) Ambulance Services, all interfacility (IFT) Ambulance Services, all standby services with transport authorization, Ambulance response to all medical seven-digit emergency response, and all medical 911 calls within the Monterey County Exclusive Operating Area (“EOA”), as provided for in Section 1797.224 of the California Health and Safety Code. The Monterey County EOA includes all geographic areas of Monterey County, except for certain federal property, the City of Carmel-by-the-Sea, and the certain portions of the Monterey County Regional Fire District, which are currently exempted or “carved out” from the EOA. The Monterey County EOA does not include air Ambulance Services or Ambulance standby without transport services.

2. Contractor shall provide Ambulance Services, without interruption, 24 hours per day, 7 days

per week, 52 weeks per year, for the full term of the Agreement.

5.1.2 Difficult-to-Serve Areas 1. The EMS Agency recognizes access to some geographical areas of Monterey County as

unusually difficult to serve. These areas have other ambulance providers (Peripheral Service Providers) that are typically able to respond in a more timely manner than the Contractor. Therefore, the Monterey County EOA will include the following four Difficult-to-Serve Areas where the services of a Peripheral Service Provider may be utilized:

• Highway 1, typically to Mile Marker 13 • Parkfield, South Shore Lake San Antonio, and Highway 101 South of the Bradley Rest

Stop • The Cachagua area • The Pajaro and Las Lomas areas in North County

2. Notwithstanding Section 1.1, Contractor may use Peripheral Service Providers only in the

Difficult-to-Serve Areas identified in this Section and illustrated as an overlay in the Difficult-to-Serve Areas Maps in Exhibit B, and only when the Peripheral Service Provider has the closest Ambulance.

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3. Contractor is responsible for response time compliance in the Difficult-to-Serve Areas.

5.1.3 Service Exception (Carveout)

1. Contractor will not be responsible for wheel chair and non-medical gurney transportation services, including requests made by the Monterey County Health Department, Behavioral Health Bureau for psychiatrically and/or physically disabled clients to/and from State hospitals, VA hospitals, locked psychiatric inpatient facilities, and other facilities located throughout California and to and or from the County’s Mental Health Inpatient Unit, Superior Court, or the Public Guardian/Lanterman-Petris-Short Conservator’s office, except for requests for emergency response and transportation to hospital emergency departments.

2. In addition, the EMS Agency will allow specialty care outbound transports from within the

EOA to tertiary and specialty medical facilities (such as specialty-team transports of critical pediatric and adult patients), and for back-up CCT services.

5.1.4 Response Time and Staffing Requirements

Contractor shall ensure Ambulance response times meet or exceed the response-time standards set forth herein. Every Ambulance provided by Contractor must always be equipped and staffed to operate at the basic (EMT-Basic with Expanded Scope), advanced life support (Paramedic) or CCT-RN (Critical Care Registered Nurse) level on all Ambulance responses, including immediate, urgent and routine services, including ambulance stand-bys. Equipment, staffing, and clinical performance must be consistent with all EMS System Policies, Protocols and Procedures.

5.1.5 Conduct and Appearance

The conduct and appearance of Contractor’s personnel must always be courteous and professional.

5.1.6 Service Standards

Contractor will provide all services according to EMS System Policies, Protocols and Procedures and the terms of the Agreement resulting from this RFP.

5.1.7 No Discrimination Contractor shall provide Ambulance Services without regard to any discriminatory classification, including without limitation: race, color, national origin, religious affiliation, sexual orientation, age, sex, ability to pay, disability, genetic information, marital status, gender identity, gender expression, HIV/AIDS status, medical condition, political activities or affiliation, military or veterans status, status as a victim of domestic violence, sexual assault, or stalking.

5.1.8 Transport Requirement and Limitation

1. Contractor shall respond to all medical requests in the Monterey County EOA and provide

Ambulance transport and medical treatment as medically required.

2. Contractor and its personnel are prohibited from attempting to direct or influence a patient’s destination selection other than as prescribed in the EMS System Policies, Protocols and Procedures. Attempting to direct or influence a patient’s destination selection other than as prescribed in EMS System Policies and Procedures will result in liquidated damages in the amounts stated in Exhibit O.

5.1.9 Special Events Coverage

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1. Contractor shall prepare for the needs of special events by having adequate ambulance vehicles and equipment available to cover large events without decreasing or impacting system ambulance coverage.

2. Contractor may sub-contract for additional ambulance services when a special event requires a greater number of ambulances than Contractor is able to provide. Contractor may sub-contract for special event stand-by coverage when the special event stand-by coverage needs equals or exceeds 20% of the number of ambulances specified in the deployment plan most recently submitted to and approved by the EMS Agency.

3. Contractor shall attempt to utilize Contractor’s resources from other areas first and other Monterey County based ambulance providers next, before contracting with other ambulance providers. Contractor is responsible for ensuring coordination under Monterey County EMS policies with ambulance providers from outside Monterey County.

4. Contractor shall pay the sub-contractor for special event coverage.

Proposal Instructions 1. Proposal shall include a response to Sections 5.1.1 to 5.1.9.

2. Proposal shall include a statement that Bidder agrees to comply with all EMS System Policies, Protocols and

Procedures and all other requirements and standards established by the EMS Agency. 3. Proposal shall demonstrate Bidder’s ability and commitment to serve the Monterey County EOA. 4. Proposal shall demonstrate Bidder’s ability and commitment to meet, or exceed, the service standards. 5. Proposal shall describe Bidder’s plan to manage special event coverage for large events or multiple events with

eleven (11) dedicated ambulances.

5.2 EMS DISPATCH AND COMMUNICATIONS

Monterey County has traditionally required its EOA Ambulance Provider to dispatch its own ambulances and to provide an approved Medical Priority Dispatch System. Monterey County expects this to remain in place for the duration of any contract as a result of this RFP. However, the County and Contractor must comply with Government Code sections 53110 and 53100.5 and Health and Safety Code sections 1797.223 and 1798.8. As such, should a substantial change in dispatching processes and procedures arise as a result of the requirements found in these statutes or other unforeseen complexities in medical dispatch, the County agrees to re-open the exclusive ambulance service provider agreement to meet and confer on a suitable contract amendment.

5.2.1 EMS Medical Dispatch

1. Contractor shall function as a designated Monterey County Emergency Medical Services

(EMS) Medical Dispatch pursuant to EMS System Policies, Protocols and Procedures and may include the staffing of trained and qualified Emergency Medical Dispatchers (EMD) that must answer requests for service promptly. A designated Monterey County EMS Medical Dispatch must follow EMS Medical Director-approved Medical Priority Dispatch System (MPDS) call processing and EMD dispatch procedures and deliver protocol-based, pre-arrival instructions.

2. Given the nature of the request for service, Contractor must manage the appropriate EMS

response, including timely backup Ambulance coverage and the competing demands upon the system at that point and time, including, when appropriate, the notification of non-transport first responder and EMS air transport provider agencies.

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Note: Contractor is encouraged, not required, to become an IAED Accredited Center of Excellence (ACE).

Proposal Instructions 1. Proposal shall demonstrate Bidder’s acceptance and ability to function as a designated EMS Medical Dispatch.

2. Proposal shall describe Bidder’s experience performing these functions and its approach to performing these

functions in Monterey County.

3. Proposal shall include Bidder’s detailed plan to provide call intake, MPDS, System Status Management (SSM), and dispatch services consistent with the requirements of this RFP and EMS System Policies, Protocols and Procedures.

4. Proposal shall include Bidder’s agreement to the use of MPDS, describes its previous use of MPDS, and describes its approach to implementation.

5. Proposal shall include Bidder’s plan for the seamless implementation of its Computer Aided Dispatch (CAD) system, linking its CAD system with the Monterey County Emergency Communications Department (MCECD) CAD system, integration into the Monterey County radio and other communications systems, and coordination with MCECD and other Public Safety Answering Point (PSAP) CAD systems.

6. Additional points may be awarded for commitment to obtain IAED accreditation.

5.2.2 EMS Medical Dispatch Location

1. Contractor’s emergency call processing and dispatch functions, and non-emergency call

referral and nurse advice line-type functions may be co-located with MCECD, or it may be a stand-alone center located within or outside of Monterey County. The MCECD Director will be in attendance at the bidders’ conference to provide a brief overview of MCECD and existing operational space and cost. Although the current ambulance provider is operating EMS Medical Dispatch out of MCECD, space is limited within the facility.

2. Contractor shall be responsible for all costs related to establishing EMS Medical Dispatch.

5.2.3 EMS Agency Designation of EMS Medical Dispatch Required

Contractor’s EMS Medical Dispatch must comply with EMS System Policies, Protocols and Procedures related to the designation of an EMS Medical Dispatch and must meet all minimum requirements to receive designation by the EMS Agency no later than six (6) months after the start of service.

5.2.4 PSAP / Contractor Function and Relationship

1. MCECD, the California Highway Patrol, Presidio of Monterey, Fort Hunter-Liggett, and

Carmel-by-the-Sea Police Department operate Primary Public Safety Answering Points (Primary PSAPs) within Monterey County. CAL FIRE operates a secondary PSAP in its respective response areas. Contractor shall work closely with these PSAPs to coordinate communication services. At the request of the EMS Agency or MCECD, Contractor will participate in appropriate communications-related committees.

2. County requires that, should the Contractor choose to utilize a dispatch and communications subcontractor, Contractor shall develop and provide detailed instructions to the communications subcontractor regarding its system status and deployment plan. The Contractor will be responsible for all results.

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5.2.5 Call Receipt and Dispatch Contractor shall be responsible for ensuring the effectiveness, accuracy, and prioritization of requests for Ambulance Services within the EOA to promote a seamless call dispatch process.


2. Proposal shall include Bidder’s plan for the location of the EMS Medical Dispatch, site development, backup

power generation, and site security. Bidder may submit more than one option for location of the EMS Medical Dispatch. Proposed rates should reflect any difference in cost based on location option.

3. Proposal shall describe Bidder’s plan to obtain EMS Medical Dispatch designation by the EMS Agency. 4. Proposal shall describe Bidder’s plan to attain and maintain high levels of MPDS performance and QI functions

aligned to IAED standards and to achieve a seamless call dispatch process. 5. Proposal shall include Bidder’s commitment to plan, work and coordinate with local PSAP’s and other Medical

Dispatch centers.

5.2.6 EMS Medical Dispatch Staffing Requirements 1. Contractor may receive both data and “live” transferred callers from 911 PSAPs to

appropriately prioritize each 911 call and enhance Contractor’s ability to effectively manage its resources.

2. Contractor shall be responsible for staffing and supervising its EMS Medical Dispatch and

shall be responsible for the actions of these personnel.

3. Contractor shall ensure that personnel assigned to the EMS Medical Dispatch are Emergency Medical Dispatcher (EMD) certified in accordance with EMS System Policies, Protocols and Procedures.

4. Contractor shall provide EMD continuing education and Quality Improvement (QI) processes to allow EMDs to maintain their skills and certifications in accordance with EMS System Policies, Protocols and Procedures.

5. Contractor’s staffing levels shall be such that callers with critical life-threatening emergencies and callers who are deemed medically unstable shall receive pre-arrival instructions consistent with guidelines established by the EMS System Policies, Protocols and Procedures. The EMD should be able to remain on the line until medical assistance arrives on scene with other dispatchers being available for call receipt and dispatch functions.

6. Contractor staffing must assure that, at a minimum, EMD-certified personnel are always on

duty. Contractor’s staffing may vary based upon predictable system service demand and other workload fluctuations but shall be sufficient so that emergency calls are answered within 8 seconds, 90 percent of the time. Failure of Contractor to answer emergency calls within ten (10) seconds, 90 percent of the time will result in liquidated damages in the amounts stated in Exhibit O.

Proposal Instructions 1. Proposal shall include Bidder’s detailed plan to ensure adequate staffing and supervision of the EMS Medical

Dispatch at levels necessary to meet required call receipt/answering times.

2. Proposal shall specifically address Bidder’s plan to surge the staffing of EMS Medical Dispatch

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3. Proposal shall include Bidder’s plan to address workload fluctuations, including unplanned surge events.

5.2.7 Interoperable Communications System

1. Contractor shall use the Monterey County Next Generation (NGEN) Communications

Network and other conventional communications network for verbal radio communications employed in Contractor’s delivery of services as specified in Exhibit F.

2. Contractor shall provide all Federal Communications Commission (FCC) required NGEN and

conventional mobile and portable radios, including necessary user licensing and pro rata share costs, for all Ambulances and field supervisor units. Contractor’s designated EMS Medical Dispatch shall be capable of functioning on the Monterey County NGEN and conventional communications networks.

3. Contractor shall ensure that each crew member operating an Ambulance or supervisor vehicle is equipped with mobile and portable radio equipment that meets the specifications in Exhibit F.

4. Contractor shall assure that each Ambulance and supervisor vehicle and static Ambulance station(s), if any, have redundant alerting and communication capability.

5. Contractor shall ensure NGEN and conventional radio communication interoperability between EMS Agency designated EMS Medical Dispatch, first responders, base hospitals, and receiving hospitals, utilizing designated disaster and mutual aid frequencies, based on EMS Agency-approved frequency specifications and channel loads.

6. Contractor shall be able to receive and reply to requests for Emergency Ambulance Services by voice and mobile data linkage. Contractor's communications system shall be able to receive and transmit all communications necessary to provide Emergency Ambulance Services pursuant to the Agreement and EMS System Policies, Protocols and Procedures.

7. Contractor shall be responsible for the costs of any modifications to the CAD system that Contractor determines necessary to effectively monitor, deploy, redeploy, and manage its Ambulance resources, including system surge events, in accordance with EMS System Policies, Protocols and Procedures. Contractor must work with MCECD to ensure necessary modifications are approved by MCECD and coordinated with MCECD to ensure there will be no interruption in CAD function.

8. Contractor shall be responsible for the full costs of all systems necessary, including its CAD technology should Contractor elect to directly provide call intake, MPDS (if provided), SSM and dispatch services.

9. Contractor shall be responsible for all costs associated with its choice of and linkage into the EMS Agency designated EMS Medical Dispatch, CAD system(s) for deployment management / measuring software, hardware, and network connections.

10. Each EMT, paramedic and supervisor shall continuously monitor the appropriate channel(s) at all times while on duty.

11. Contractor shall equip each Ambulance and supervisor's vehicle with a mobile gateway that shall provide wireless access to CAD, ePCR, billing system data, and ReddiNet.

12. Contractor shall be responsible for the cost of acquisition, maintenance, repair, and replacement of computers/MDC, mobile and portable radios, cell phones, tablets, mobile data terminals and or displays, mobile gateways, cellular cards, and cellular accounts.

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13. Contractor shall install necessary communications equipment in all its ALS Ambulances capable of transmitting 12-lead electrocardiograms to receiving facilities, in accordance with EMS Agency specifications.

14. Contractor shall install and maintain Automatic Vehicle Locator (AVL) devices on all its Ambulances used within the Monterey County EMS System. The AVL system must be compatible and able to interface with the CAD and other technology used for System Status Management, dispatch and response time reporting. AVL system access shall be made available to designated EMS Agency staff for system monitoring purposes.

15. Contractor shall be financially responsible for its ongoing, pro-rata costs of the County’s NGEN Radio System, conventional radio system, and all interfaces with the MCECD CAD, and all other costs of their directly provided or contracted EMS Medical Dispatch.

16. Contractor shall maintain commercial wireless / data access fully compatible with the MCECD CAD and pay any costs of developing and maintaining a data interface from the MCECD CAD to Contractor’s CAD. The data interface shall provide real-time monitoring of Contractor’s Ambulance data screens and, at a minimum, provide the location and status of active Ambulance calls, pending calls, and locations and status of Ambulances and crews. Any costs of developing the data interface from the MCECD CAD to Contractor’s CAD to monitor deployment shall be borne by Contractor.

Proposal Instructions

1. Proposal shall include Bidder’s detailed Interoperability Communications System Equipment and

Management Plan that meets, or exceeds, the minimum requirements and functionality outlined this Section and Exhibit F.

2. Proposal shall describe Bidder’s ability to maintain an interoperable communications system.

5.3 EMS MEDICAL DISPATCH REDUNDANCY Contractor shall develop the capability for backup/redundant EMS Medical Dispatch should the Contractor’s EMS Medical Dispatch be rendered inoperable by a disaster, power failure, cyber-incident or another event. Redundant EMS Medical Dispatch capability may be created within or outside of Monterey County. This capability shall minimally include call receipt, dispatching, and communications with each Ambulance.

Proposal Instructions Proposal shall identify specific and implementable provisions for backup/redundant EMS Medical Dispatch operation should Contractor’s EMS Medical Dispatch be rendered inoperable by a disaster or other event.

5.4 RESPONSE TIME INTERVAL PERFORMANCE

5.4.1 Response Time Interval performance is the result of effective and coordinated efforts throughout

the Contractor's total operation. Therefore, Response Time Interval performance is solely the Contractor’s responsibility. An error on the Contractor’s part in one phase of its operation, e.g. dispatch, system deployment planning, Ambulance maintenance, assignment of an Ambulance to a given call shall not be the basis for the EMS Agency to grant an exception to the Contractor's requirements in another phase of its operation, e.g. clinical requirements or response time requirements.

5.4.2 “Response Time Interval,” as defined in Section 5.4.9 and Exhibit G, are a combination of

dispatch operations and field operations. Response Time Intervals shall be measured and recorded

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in integer minutes and seconds by the CAD system the Contractor uses. Contractor shall commit to conform to the Response Time Interval requirements set forth in Section 5.4.9, Exhibit I and Exhibit K.

5.4.3 All “Time Point” and “Time Intervals” use the definitions identified in Exhibit G: Monterey

County EMS System Time Points and Time Interval Definitions.

5.4.4 The term “appropriately staffed and equipped Ambulance” denotes that each Ambulance used for a Response must be properly staffed and equipped, as indicated in Sections 5.5.9 and Section 5.5.11, and Exhibit M.

5.4.5 Description of Response Classification and Response Time Interval Requirements

Within the Monterey County EOA, the Response Time Interval requirements for each response is determined by the Response’s Priority within Response Area. The specific Response Time Interval requirements are defined in this Section 5.4.9 and in Exhibits I and K.

5.4.6 Response Classification by Response Priority

1. Monterey County EMS Agency requires designated EMS Medical Dispatch Centers to

use MPDS Protocols to properly categorize caller acuity levels. The current EMS Agency Response Priorities to MPDS Levels can be found in Exhibit H and Exhibit J. These Response Priorities to MPDS Levels may be changed by the EMS Agency Medical Director as new data and/or science suggests.

2. Contractor must comply with the Response Time Interval requirements in each of the

following seven (7) Response Priorities. Responses to Priorities are determined by the current EMS System Policies, Protocols and Procedures, as defined based on the Medical Priority Dispatch System (MPDS) and as approved by the EMS Medical Director.

RESPONSE CLASSIFICATION BY RESPONSE PRIORITY

Priority Response Red Lights and Sirens

Description

1 Life Threatening Emergency Yes These calls typically include MPDS Echo and some MPDS Delta calls. These calls are non-divertible.

2 Emergency Response Yes These calls typically include some MPDS Delta calls, MPDS Charlie, and some MPDS Bravo calls. Specific calls, identified in EMS System Policies, Protocols and Procedures, such as calls in which transfer of the calling party is not indicated or possible, are categorized as Priority 2 Responses. These calls are only divertible to Priority 1 Responses.

3 Urgent Response No These typically include MPDS Alpha calls, and in this system, until call referral is implemented, some MPDS Omega calls. These calls are divertible to Priority 1 or Priority 2 Responses.

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RESPONSE CLASSIFICATION BY RESPONSE PRIORITY Priority Response Red Lights

and Sirens Description

4 Immediate Interfacility Transport

No These calls typically include responses to interfacility transports that require an immediate response, without red lights and siren. Interfacility transfer requests for an emergency response that require red lights and sirens (Code 3) will remain categorized as Priority 2 response time interval. First responders are normally not dispatched to Priority 4 calls or Priority 2 interfacility transfers

5 Prescheduled Interfacility Transport

No These calls typically include responses to interfacility transports that have agreed, prescheduled times of not less than 60 minutes. Priority 5 responses require an on-time response, without red lights and siren. First responders are normally not dispatched to Priority 5 calls.

6 Critical Care Interfacility Transport Using CCT Unit

May use red light

and sirens

Typically include Critical Care Transport Ambulance (CCT-RN) responses to interfacility transports. Priority 6 responses are prescheduled and may require use of red lights and siren. The requesting facility may schedule an immediate time no earlier than thirty (30) minutes from the time of the request in the Urban Response Area and sixty (60) minutes from the time of the request in the Suburban Response Area. First responders are normally not dispatched to Priority 6 calls.

7 Non-Medical Behavioral Health and 5150 Transports

These typically include responses to scene or facilities for the transport of patients, without medical symptoms or etiology, who are being held pursuant to Welfare and Institutions Code, Section 5150 or require a transport due to other behavioral health problems. Priority 7 interfacility transports may be prescheduled or immediate and include 5150 and behavioral health transports that are in-county and out of county. Ideally, a resource that is less expensive and more appropriate than an Ambulance will be used for these transports.

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RESPONSE CLASSIFICATION BY RESPONSE PRIORITY Priority Response Red Lights

and Sirens Description

0 Potential Non-Response and Call Referral for Future Use

N/A This category may be used in the future for some MPDS Omega requests as approved by the EMS Medical Director as a non-EMS response and/or referral to non-Ambulance transportation or case management service, another nurse or other medical call-center for further review. The future use of this category may also assist Contractor in offsetting future EMS system call volume growth.

5.4.7 Response Classification by Response Area

The three Monterey County EOA call frequency-based Response Areas are: Urban, Suburban, and Rural. These Response Areas are based on historical call frequency, with that frequency of calls decreasing from Urban to Suburban to Rural. The call frequency-based Response Areas, are shown in the EOA maps in Exhibit A. Exhibit A also includes a brief overview of the process used to create the Response Areas.

5.4.8 Response Time Interval Measurement

1. Contractor's Response Time Interval performance shall be calculated monthly to determine compliance with the requirements set forth in Exhibit I and Exhibit K, and as described throughout the Response Time Interval Requirements Section.

2. For each Response Priority in each Response Area, Contractor’s appropriately staffed and

equipped Ambulance must arrive on the scene within the specified Response Time Interval for that Response Priority and Response Areas as defined in Exhibit I and Exhibit K on not less than 90 percent of responses. Monthly Compliance Measurement and Liquidated Damages are based on Response Priority in each Response Area, as defined in Exhibit I, Exhibit K, and Exhibit O.

3. Response Time Interval Compliance is met when a measurement of 90.00% or higher is achieved based on contractual minimum requirements. Any measurement below 90.00% is considered non-compliant. Measurements will be conducted on a monthly basis for compliance reporting purposes but will be monitored continuously throughout the month. Liquidated damages are assessed for non-compliance. The liquidated damages structure is shown in Exhibit I, Exhibit K, and Exhibit O.

5.4.9 Response Time Interval Defined

The Response Time Interval is defined as beginning at Medical Call Dispatch Queue Time and ending at Unit On-Scene Time or the Unit Cancelled Time, as measured and recorded in integer minutes and seconds.

5.4.10 Calculating Upgrades, Downgrades, Reassignments Enroute, and Canceled Responses

Circumstances may cause changes in a call’s Response Priority classification. Response Time Interval calculations to determine minimum compliance with the Agreement standards and liquidated damages for non-compliance will be as follows:

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5.4.10.1 Upgrades If the response is upgraded prior to the arrival on scene of the Ambulance (e.g. from Priority 3 to Priority 1), Contractor’s compliance and liquidated damages will be determined based on the shorter interval of: • Time elapsed from Medical Call Dispatch Queue Time to Time of Upgrade plus the

higher priority’s (More Stringent) Response Time Interval; or • The original (lower priority) Response Time Interval

5.4.10.2 Downgrades

If the response is downgraded prior to arrival on scene of the Ambulance (e.g. from Priority 1 to Priority 3), Contractor’s compliance will be determined as follows: • If the time of the downgrade occurs after the Ambulance has already exceeded the more

stringent (shorter) Response Time Interval, that more stringent (shorter) Response Time Interval shall apply (the response is late); or

• If the time of the downgrade occurs before the Ambulance has exceeded the more stringent (shorter) Response Time Interval requirement, the less stringent (longer) Response Time Interval requirement shall apply. In such cases, Contractor must document the legitimate reason the downgrade occurred. This documentation shall be submitted to the EMS Agency within 10 days of the date of the call. If the downgrade was justified, in the sole discretion of the EMS Agency, the less stringent (longer) time requirement shall apply.

5.4.10.3 Reassignment Enroute When an Ambulance is reassigned to a higher priority request during a response to a prior call, the Response Time Interval requirement for the initial call does not change and will be calculated based on the Medical Call Queue Time. The Response Time Interval will not stop until an Ambulance arrives on the scene. The Response Time Interval shall not be reset, based upon reassignment between different responding units.

5.4.10.4 Canceled Responses If an assignment is canceled prior to Ambulance arrival on the scene, Contractor’s Response Time interval requirement will be calculated based on the Time Interval from EMS Call in Dispatch Queue Time to the Unit Cancelled Time.

5.4.11 Procedure for Measuring Low Call Volume Response Areas

Compliance calculations for any Response Priority in each Response Area with less than 100 requests for service per month shall be tolled until a minimum of 100 calls has been reached or surpassed. Compliance calculations shall include the calls for the full month in which 100 calls were reached. Response Time Interval calculations will be reviewed monthly. Response Time Interval compliance for assessment of liquidated damages will not occur until 100 or more requests for service have been received.

5.4.12 Response Times outside the EOA are Excluded The Contractor shall not be held accountable for Response Time Interval requirements for any assignment located outside the Monterey County EOA. Responses to requests for service outside the Monterey County EOA response area will not be counted in the total number of calls used to determine compliance.

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5.4.13 Each Incident a Single Response Each response to an incident will be counted as a single response. The Response Time Interval of the first arriving Ambulance will be used to compute the Response Time Interval for compliance purposes on all multi-unit response incident. All subsequent unit responses to a multi-unit response incident will be counted for compliance but not assessed any liquidated damages based on subsequent Response Time Intervals through the Good Cause Exception process.

5.4.14 EOA Response Areas Revisions

It is anticipated that continued population growth in the County of Monterey will result in changes in call volume within the EOA. Population growth may cause locations within the EOA to meet a different Response Area definition during the term of the Agreement. Contractor must anticipate that the Response Area boundaries at the start of the Agreement may need to be adjusted accordingly to ensure high-quality service levels within the EOA are maintained. To this end, the EMS Agency and Contractor will review the call volume within the EOA every two years using the current call volume measurement methodology. This methodology has three tiers of response areas. The Rural Response Area uses 0-10 calls per year in a given location of 1 square mile. The Suburban Response Area is 11-299 calls. The Urban Response Area is 300 or more calls. More detailed information related to the creation of the Response Area boundaries is found in Exhibit A. If there is an increase or decrease in call volume in a specific location within the EOA, as averaged over the preceding two-year period, the Response Area will be adjusted accordingly. For instance, should the averaged number of calls in specific location show an increase moving it from Suburban to Urban, the response area boundary will be adjusted accordingly. Response Area boundaries may then be adjusted as needed for a rational boundary to account for small locations of greater or lower call volume as described in Exhbit A. Contractor will be expected to adjust its deployment plan accordingly to meet the changing service needs within the EOA.

5.4.15 Response Time Exception Requests

1. The Contractor shall maintain mechanisms for backup capacity or reserve production capacity

to increase production should a temporary system overload persist. However, from time to time unusual factors beyond the Contractor’s reasonable control affect the Contractor’s ability to meet Response Time Interval requirements. In the monthly calculation of the Contractor's performance to determine compliance with the Response Time Interval requirements, every request originating from within the EOA shall be included.

2. Contractor may request exceptions in the following instances:

5.4.15.1 Multi-Casualty and Disaster Response Time Interval requirements may be suspended at the sole discretion of the EMS Agency during a declared Multi-Casualty Incident (MCI) or disaster in the County or during a declared disaster in a jurisdiction to which the Contractor is providing Ambulance assistance at the request of the EMS Agency. Subsequent Ambulance response(s) after the first Ambulance response to a single incident, shall not be subject to Response Time Interval requirements; however, they shall be counted to determine compliance. The declared MCI is considered completed at the later of either the Incident Command declaring the MCI over or upon arrival at the hospital or cancellation of the last Ambulance utilized at the MCI.

5.4.15.2 Good Cause Exceptions 1. The EMS Agency may allow exceptions to the Contractor’s Response Time Interval

requirements for good cause as determined at the EMS Agency’s sole discretion. At a minimum, the asserted grounds for exception:

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a) Must have been a substantial factor in producing an excess Response Time Interval;

b) The asserted grounds must have been outside of the Contractor’s reasonable control;

and,

c) If predictable, that the Contractor took reasonable steps to mitigate the asserted grounds for the exception. Examples include: incorrect location information provided by calling party or Primary PSAP, inability to locate scene due to non-existent address, or periods of unusual system overload.

2. Unusual System Overload is defined as at least double the average demand for the day of the week and hour of day. The average demand for each day and hour is to be calculated on an annual basis using the prior two (2) calendar year’s actual run volume for that day and hour. The EMS Agency shall only grant Unusual System Overload-based exceptions if the Contractor took reasonable steps to mitigate the asserted grounds for exception. For example, if the Unusual System Overload was caused by weather, which was known days in advance, the Contractor must have increased staffing or taken other reasonable steps to qualify for an Unusual System Overload exemption.

3. Extended delays at hospitals for transferring patients to receiving facility personnel shall not be a criterion for exceptions except as noted herein. The EMS Agency will work with Contractor to ensure receiving hospitals maintain Ambulance Patient Offload Times within the standards identified in EMS System Policies, Protocols and Procedures.

4. Equipment failure, Ambulance failure, missing equipment, or other causes deemed by EMS Agency within the Contractor’s control or awareness shall not be grounds to grant an exception to compliance with the Response Time Interval requirements.

5.4.16 Exception Request Procedure 1. It is the Contractor’s responsibility to apply to the EMS Agency for an exception to Response

Time Interval requirements.

2. For calls that meet the requirements in Section 5.4.15.2, the Contractor may submit a late call exception request to the Response Time Interval requirements. For each call submitted, Contractor shall provide detailed documentation to the EMS Agency and request that the EMS Agency except the late designation from the calculations. The EMS Agency will review each exception request and decide to approve or deny. By example only: For each call in which the EMS Agency approves an exception, the total number of calls will not change, and the number of late calls will decrease by one (1) and the number of on-time calls increases by one (1).

3. Contractor shall submit any such exception request to the EMS Agency within 10 days of the end of each month. A request for an exception received after the 10 days will not be considered. The EMS Agency will review each exception request and decide to approve or deny.

4. Should the Contractor desire to appeal the EMS Agency’s decision, a written request must be submitted to the EMS Agency within 10 days after the decision by the EMS Agency. All decisions by the EMS Agency shall be considered final.

5.4.17 Performance Reporting Requirements

1. The Contractor shall be responsible and capable of documenting the Time Points identified in

Exhibit G.

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2. Contractor is required to report performance compliance for each Response Priority within each Response Area (Urban, Suburban, and Rural) monthly.

3. Documentation of other times may be required for specific activities such as time of defibrillation, administration of treatments and medications and other instances deemed important for clinical care monitoring and research activities. All times on the Patient Care Report Form (PCR) and in Contractor’s CAD system shall be accurately recorded. The Contractor will provide an interface with the CAD database and Electronic Patient Care Report Form (EPCR) database for EMS Agency to independently extract and corroborate Response Time Interval performance.

4. Original CAD data shall not be changed by any party. Data extracted from the CAD system for the purpose of measuring compliance shall be modified and managed through an EMS Agency-approved data management utility, based upon the EMS Agency-approved Call Compliance Adjudication Process. Changing Time Points in Computer Aided Dispatch System will result in liquidated damages in the amounts stated in Exhibit O. Within 10 business days following the end of each month, Contractor shall document and report to EMS Agency, in a manner required by EMS Agency, information as specified in Section 5.16.6. Failure to timely provide reports within the time required in EMS System Policies, Protocols and Procedures will result in liquidated damages in the amounts stated in Exhibit O.

5. The Contractor shall identify the analysis, causes and action plans to correct performance failures to meet the Agreement standards and work to continuously improve performance. These efforts shall be documented in reports provided to the EMS Agency.

6. At EMS Agency request, Contractor shall describe steps taken to reduce extended responses in the future.

5.4.18 Response Time Interval Liquidated Damages Assessments

1. Failure to comply with any Response Time Interval, performance or other requirements in this RFP or the final Agreement will result in damage to the County. It will be impracticable to determine the actual amount of damage whether in the event of delay, nonperformance, failure to meet standards, or any other deviation. Therefore, the Contractor and County agree to the liquidated damages specified herein. It is expressly understood and agreed that the liquidated damages amounts are not to be considered a penalty, but shall be deemed taken and treated as reasonable estimate of the damages to the County. It is also expressly understood and agreed that County’s remedies in the event of the Contractor’s breach or any noncompliance, are not limited to this RFP or the final Agreement liquidated damages provisions. Chronic failure to comply with the Response Time Interval requirements may constitute breach of contract.

2. Liquidated Damages are based on measurement of Response Time Interval performance for

all responses within each Response Area (Urban, Suburban, and Rural) within the Monterey County EOA, grouped by Response Priority.

3. Isolated instances of individual deviations of Response Time Interval compliance shall be

treated as instances of minor non-compliance under the Agreement. However, severe or chronic deviations of Response Time Interval compliance may constitute a breach of the Agreement as defined below.

5.4.19 Liquidated Damages for Failure to Comply with Response Time Interval Requirements

1. Contractor shall pay liquidated damages each month that Contractor fails to comply with

the Response Time Interval requirements within this Agreement. The amount of the

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liquidated damages is commensurate with the Response Time Interval compliance percentages achieved by Contractor and quantified in the table immediately below.

2. In addition, failure of Contractor to achieve at least 88% in Response Time Interval compliance requires Contractor to submit and implement a plan that includes additional staffed Ambulance hours aimed to achieve at least 90% compliance with Response Time Interval requirements within ten (10) working days.

5.4.20 Repetitive Non-Compliance

1. Repetitive non-compliance is defined as Contractors’ failure to achieve the Response

Time Interval requirements in any Response Priority or in any Response Area defined herein for: (a) three non-compliant months in any six-month period; or (b) four non-compliant months in any twelve-month period.

2. If Contractor is repetitively non-compliant, Contractor shall submit a plan of corrective action to the EMS Agency within 30 days of being notified of repetitive non-compliance by the EMS Agency. Failure to correct repetitive non-compliance may result in a separate assessment of liquidated damages as listed in Exhibit O and/or be considered a material breach of the Agreement.

5.4.21 Financial Incentive for Superior Clinical Performance

3. Consistent with the importance of clinical outcomes, this RFP significantly financially

incentivizes superior clinical performance. In each month that Contractor’s EMS System performance meets or exceeds a Key Performance Indicator (KPI) Goal for the Clinical Care KPIs in Exhibit L, the Contractor’s monthly Liquidated Damages shall be reduced by five percent (5%). See example below:

0 Monthly Key Performance Indicator Met 0 percent (0%) reduction 1 Monthly Key Performance Indicator Met 10 percent (10%) reduction 2 Monthly Key Performance Indicators Met 20 percent (20%) reduction 3 Monthly Key Performance Indicators Met 30 percent (30%) reduction 4 Monthly Key Performance Indicators Met 40 percent (40%) reduction 5 Monthly Key Performance Indicators Met 50 percent (50%) reduction 6 Monthly Key Performance Indicators Met 60 percent (60%) reduction 7 Monthly Key Performance Indicators Met 70 percent (70%) reduction 8 Monthly Key Performance Indicators Met 80 percent (80%) reduction 9 Monthly Key Performance Indicators Met 90 percent (90%) reduction 10 Monthly Key Performance Indicators Met 100 percent (100%) reduction

4. The above criteria shall only apply to the Response Time Interval Compliance Monthly Liquidated Damages.

Compliance % Liquidated Damages

89.99% to 89.00% $5,000

88.99% to 88.00% $10,000

87.99% to 87.00% $15,000

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5. Contractor’s Liquidated Damages for other criteria shall not be reduced for meeting the KPI Goals for Clinical Care KPIs in Exhibit L.

5.4.22 Waiver of Liquidated Damages During First Six Months of Agreement

All Response Time Interval liquidated damages shall be waived for the first six (6) months of the Agreement in recognition of the complexity of an EMS system transition.

Proposal Instructions Proposal shall include Bidder’s acknowledgment, commitment, and acceptance of the Response Time Interval requirements, measurement, and liquidated damages as specified in Section 5.4 of this RFP by executing Form G.

5.5 AMBULANCE OPERATIONS

5.5.1 Fleet Vehicle Requirements 1. Contractor shall provide vehicles, replacement vehicles, and a maintenance and repair

program that meets or exceeds the requirements specified herein. 2. At start of service and throughout the term of the Agreement, Contractor shall use an

Ambulance type and design most suited to its operation in Monterey County that have less than 125,000 miles; are similarly-configured; with the capability to carry all supplies necessary to function in accordance with EMS System Policies, Protocols and Procedures.

3. At start of service and throughout the term of the Agreement, Contractor shall ensure that all supervisor vehicles have less than 50,000 miles; are similarly-configured; Code-3-equipped; with the capability to carry all supplies necessary to function in accordance with EMS System Policies, Protocols and Procedures.

4. Contractor shall, at a minimum, maintain the number of fully equipped and fully operational Ambulances that constitute at least 130% of the peak deployment level, rounded to the next highest Ambulance. For example, if Contractor’s peak number of Ambulances is twenty-three (23), Contractor is to maintain a fleet of at least thirty Ambulances, based on the following equation: (23 x 130% = 29.9) rounded to 30.

5. Contractor shall ensure an adequate number of fully equipped and operational ambulances to

meet their deployment plan and have a ready reserve of at least five (5) fully equipped and operational ambulances available. These reserve ambulances may be utilized for replacement of ambulances removed from service for maintenance or repair and to have a readily available fleet for ambulance strike team or disaster response. Additional ambulances either to meet the formula above or for Contractor preference shall be operational mechanically with fixed equipment in place (e.g., radios, gurneys). These additional ambulances are not required to be fully stocked until placed in service or available for ambulance strike team or disaster response.

6. Contractor shall prepare for the needs of special events by having an adequate number of ambulances to cover large special events or multiple special events held on the same day without impacting system deployment coverage. Contractor may augment special event coverage through the use of other ambulance providers as specified.

7. Failure to maintain a fleet that meets the requirements of this section shall result in liquidated

damages as listed in Exhibit O.

8. Contractor is not required to provide dedicated Bariatric Ambulances or Ambulances capable of transporting patients with a communicable disease (such as Ebola); however, Contractor shall make provisions to provide these services, should they become necessary.

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9. Contractor shall provide a list of ambulances to be used in Monterey County operations 30

days prior to start of service. The list shall include license number or VIN if new and license not received, year of manufacture, and mileage.

5.5.2 Vehicles Meet State Law and Administrative Rules Contactor shall ensure that all Ambulances and vehicles meet applicable State law and Administrative Rules at the start of service. Any Ambulances and vehicles provided under the Agreement shall meet CAAS-GVS standards and relevant California Code of Regulations, local ordinances, and regulations.

5.5.3 Vehicle Appearance

The appearance of Ambulances and equipment impacts customers’ perceptions of the services provided. Therefore, the EMS Agency requires that Ambulances, other vehicles, and equipment that have defects, including a cumulative appearance of being worn out, dirty, or not maintained, determined at the sole discretion of the EMS Agency, be removed from service for repair without undue delay.

5.5.4 Vehicle Markings

1. All vehicle markings shall be consistent with California Civil Code, Sections 3273 et seq.,

which restricts the markings of certain vehicles used to provide contracted public health and safety services.

2. Emergency vehicles shall be equipped with appropriate lighting and reflective markings as

defined by the National Fire Protection Association (NFPA) Standard 1901 (2016).

3. Ambulances, supervisor vehicles, and support vehicles shall bear the markings "Monterey County Emergency Medical Services System" in at least four (4) inch letters on both sides.

4. Vehicles shall not display any advertisement.

5. Ambulances, supervisor vehicles, and support vehicles shall be marked to identify the name of Contractor.

6. Contractor shall utilize a uniform color, markings, lettering, and design scheme for all Ambulances and supervisor vehicles. The EMS Agency shall have the right to approve or modify the overall design, color, and lettering used for all vehicles in its sole discretion.

7. The EMS Agency shall approve numbering and radio identification conventions.

Note: Contractor is encouraged, not required, to become accredited as an ALS Ambulance Services from the Commission on Accreditation of Ambulance Services (CAAS).


2. Proposal shall describe the number, type (Type I, II, or III), make, model, year, mileage (may be estimated), and

key specifications of Ambulances, supervisor vehicles, and support vehicles. Describe whether these vehicles will be new or used and purchased or leased. Bidder’s proposal shall detail the rationale for the type and design most suited for Monterey County.

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3. Proposal shall include Bidder’s plan to equip vehicles with appropriate technologies that are compatible with the various communication and navigation systems used in the Monterey County EMS system.

4. Proposal shall describe specific provisions to provide bariatric Ambulance Services and Ambulances capable of transporting patients with a communicable disease. If relying on Ambulances from other areas, identify the area and provide a written commitment to use these resources, including the reasonably expected response time and any constraints to the use of these resources.

5. Proposal shall include Bidder’s vehicle replacement plan. This plan shall include replacement schedules and policies and criteria (e.g. years of use, mileage, and condition) that Bidder will use to determine whether an Ambulance will be continued to be used in the Monterey County EOA, or when it will be replaced.

6. Contractor shall describe its plan to ensure adequate ambulance vehicle availability to cover the deployment

plan and large special events with up to eleven (11) ambulances dedicated to the event. 7. Contractor shall provide a list of ambulances to be used in Monterey County operations at least 30 days prior to

start of service. The list shall include license number or VIN if new and license has not been received, year of manufacture, and mileage.

Note: Additional points may be awarded for commitment to become accredited as an ALS Ambulance Services from the Commission on Accreditation of Ambulance Services (CAAS).

5.5.5 Vehicle Maintenance and Repair 1. Contractor shall be responsible for maintaining and repairing Ambulances, supervisor

vehicles, support vehicles, and equipment used in the performance of its work.

2. Contractor shall be responsible for all costs of vehicle maintenance and repair, including parts, supplies, spare parts and costs of extended maintenance agreements.

3. Contractor shall meet or exceed the maintenance standards as outlined in the Accreditation of

Ambulance Services published by the Commission on Accreditation of Ambulance Services.

4. Contractor shall immediately remove from service any Ambulance, supervisor vehicle, support vehicle and/or piece of equipment with any deficiency that compromises or may reasonably compromise its function or the safety of the operators or the public.

5. Contractor shall implement an Ambulance maintenance program that is designed and

conducted to achieve the highest standard of reliability appropriate to a modern high performance 911 Ambulance Services by: • Utilizing appropriately trained personnel, knowledgeable in the maintenance and repair

of Ambulances, • Developing and implementing standardized maintenance practices, and • Incorporating an automated electronic maintenance program record keeping system.

6. Contractor shall maintain detailed vehicle maintenance and repair records in an electronic

database that is easily queried as to work performed, costs related to repairs, and operating and repair costs analyses where appropriate. Maintenance and repairs shall be performed to achieve at least the industry norms in vehicle performance and reliability. Contractor shall provide EMS Agency with access to the database upon request.


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1. Proposal shall include Bidder’s fleet maintenance and repair program to be employed that addresses the requirements in Section 5.5.5. The proposal shall specifically address how any instance which would render an Ambulance unable to respond to or transport a patient would be resolved, tracked, improved and minimized.

2. Proposal shall describe Bidder’s training and certification standards, such as ASE (Automotive Service Excellence) certification, of its vehicle service technicians.

5.5.6 Vehicle Inspection

1. The EMS Agency may inspect Contractor's vehicles at any time, without prior notice. If a supervisor vehicle or Ambulance fails to meet the minimum inventory requirements in EMS System Policies, Protocols and Procedures, as determined by the EMS Agency, the EMS Agency may:

• Immediately remove the vehicle from service until the deficiency is corrected if the

missing item is deemed a critical omission • Subject Contractor to liquidated damages in the amount stated in Exhibit O.

2. The foregoing shall not preclude dispatch of the nearest available Ambulance even though not

fully equipped, in response to a life-threatening emergency, as long as it is reasonably equipped and supplied to provide patient care as might be expected for he reported condition of the patient.

5.5.7 Vehicle Equipment Failure While Providing Ambulance Services

Contractor shall report any vehicle or equipment failure through the Unusual Occurrence reporting process as outlined in EMS System Policies, Protocols and Procedures. Contractor will also report any vehicle or equipment failure in monthly reports to the EMS Agency for sharing with various oversight groups.

5.5.8 Vehicle Replacement

Ambulance replacement shall occur on a regular schedule. Contractor shall identify its policy for the maximum number of years and mileage that an Ambulance will be retained in the EMS System. Replacement vehicles are to be new or be approved by the EMS Agency. Any replacement vehicles that are remounted must meet CAAS-GVS 2.0 standards for remounted vehicles.


2. Proposal shall include a vehicle replacement schedule and identify its policy for reporting failures to the EMS

Agency and for the maximum number of years and mileage that an Ambulance will be retained in the EMS System.

3. Proposal shall include Bidder’s agreement to allow EMS Agency to inspect is vehicles a specified in this section of the RFP.

5.5.9 Ambulance Staffing Requirements

1. All ALS Ambulances shall be staffed and equipped to render paramedic level care and

transport with a minimum of one (1) state licensed and locally accredited Paramedic and one (1) EMT-Expanded Scope. The paramedic is the ultimately-responsible caregiver and must accompany patients in the patient compartment when required by EMS System Policies, Protocols and Procedures or paramedic judgement. At those times that a patient does not require paramedic level monitoring or care, an EMT may accompany the patient in the patient

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compartment and may provide care per Monterey County EMS System Policies, Protocols and Procedures.

2. All BLS Ambulances shall be staffed and equipped to render BLS level care and transport with a minimum of two (2) state licensed and locally credentialed EMT-Basic with Expanded Scope. The criteria for BLS Ambulance use will be determined by the EMS Medical Director. It is anticipated that, at a future time, Contractor may use BLS Ambulances to respond to some Priority 3, some behavioral health / 5150 calls, and other low-acuity calls consistent with EMS System Policies, Protocols and Procedures.

3. All CCT Ambulances rendering CCT-RN services under the Agreement shall be staffed with

an appropriately licensed Registered Nurse with proper critical care credentials and one (1) EMT-Basic with Expanded Scope or one (1) locally accredited paramedic.

5.5.10 Deployment Plan

1. Contractor will be expected to work continuously to refine and improve its coverage and deployment plans throughout the term of the Agreement. All plan modifications will be at Contractor’s sole discretion and expense.

2. Contractor shall deploy Ambulances and other resources consistent with their written

Deployment Plan. Contractor shall provide the initial deployment plan to the EMS Agency no less than 60 days before the service start date and shall provide a copy of revised Deployment Plans to the EMS Agency before, or immediately following, implementation throughout the term of the Agreement. All plan modifications will be at Contractor’s sole discretion and expense. Contractor’s proposed Deployment Plan and updated deployment plans will identify the level at which Contractor will request mutual aid responses within the Monterey County EOA. The system status levels initiating a mutual aid response into the EOA shall be approved by the EMS Agency.

3. Contractor shall staff and deploy its Ambulances to achieve the Response Time Interval performance and other performance requirements. Contractor shall also commit to modify and adjust its deployment strategies if Response Time Interval performance does not comply with Agreement requirements or if areas of the county are chronically experiencing delayed responses.

4. Contractor shall base one ALS Ambulance in the Big Sur area. This Ambulance will be part

of the Contactor’s coverage to the EOA and may be moved consistent with Contractor’s Deployment plan.

5. The EMS Agency may also evaluate any area of the Monterey County EOA to identify specific areas of substandard Response Time Interval performance and refer such findings to the Contractor for mitigation. The Contractor shall affirmatively act to modify its response plan to address identified performance issues. Failure to mitigate chronic under-performance or disparate performance will constitute a breach of the Agreement.

6. Contractor shall ensure communities within each of the Response Areas each receive response

time performance that meets the stated response time requirements. Monitoring of response time compliance at the community level will be reviewed by a Contract Compliance Committee on a periodic basis, or when there is evidence the response to a community is failing to meet standard. Community response times chronically below the established response time standard shall require Contractor to develop and implement a plan of correction. Response times chronically below the established response time standards is defined as three (3) consecutive months below the standard or three (3) months in any six (6) month rolling period.

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1. Proposal shall include Bidder’s deployment and staffing plan as required in Sections 5.5.9 and 5.5.10. This plan must meet the requirements of this RFP on a 24/7/365 basis. High level descriptions and/or assurances are not sufficient. At a minimum, a complete deployment submittal shall contain: a) A copy of the proposed system status plan, including a list of all proposed post locations throughout the

EOA. Posts selected as comfort stations, if any, shall be identified as such.

b) A table showing proposed unit hours by hour of the day and day of the week. The Bidder is to state if the table is static and will be staffed for at least six months in contract year one. If not, then submit Unit Hour tables for all seasonal variations.

c) A GIS travel time estimate of coverage from all posts, in each Response Area for the unit hour plan(s)

submitted. Submit one map per Response Area, in full page, landscape format. Reduced size images inserted into a page of text are not acceptable.

d) Exhibits from Bidder’s deployment analysis software to justify that off peak to peak hour deployment plans

are consistent with the incident workload and locations provided to you in the incident data provided with this RFP.

e) If the proposal offers deployment options, such as BLS services, Bidder’s proposal shall include all the

exhibits as listed in 1 through 4 above to justify that the alternative plan meets the EOA’s response time measures without excessive (planned) penalties.

f) Proposal shall include a sample monthly response time compliance report from Bidder’s preferred software

system. The monthly report shall identify in and out of compliance responses for each Response Time Measurement as indicated in Exhibit I. The report shall also identify aggregate performance at the EOA level.

g) If in the Bidder’s provided operating budget, there is an expense listed for liquidated damages payments,

the Bidder shall submit an explanation for how the estimated damages were developed.

h) Proposal identifies the number of reserve units Bidder suggests for utilization and detail of the process for handling “surge,” disasters, and callbacks.

2. Proposal shall include a statement of commitment to modify and adjust its deployment strategies if Response

Time performance is not compliant or if areas of the county are chronically experiencing delayed responses.

5.5.11 Equipment Requirements

1. Contractor shall have sole responsibility for furnishing all equipment and replacement equipment.

2. Contractor shall have the sole responsibility for furnishing on-board equipment, medical

supplies and personal communications equipment that meets or exceeds the minimum requirements specified in EMS System Policies, Protocols and Procedures. A listing of the required on-board equipment, medical equipment, and supplies can be found at Exhibit M.

3. Contractor shall equip all Ambulance gurneys with power-activated lifting technologies.

4. Contractor agrees that equipment and supply requirements may be modified/upgraded during the term of the Agreement with the approval of the EMS Agency due to emerging changes in technology, medicine, and research.

5. As soon as reasonably possible, Contractor shall use equipment and systems that coordinate with those currently in use in Monterey County.

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5.5.12 Equipment Maintenance

1. Contractor shall maintain all bio-medical equipment to the recommendations of the

manufacturer, The Joint Commission, or the equivalent. All costs of compliance testing, maintenance and repairs, including parts, supplies, spare parts and inventories of supplies, labor, subcontracted services and costs of extended warranties shall be at Contractor’s expense.

2. Contractor shall maintain detailed equipment maintenance and repair records in an electronic

database that is easily queried as to work performed, costs related to repairs, and operating and repair costs analyses where appropriate. Maintenance and repairs shall be performed to achieve at least the industry norms in equipment performance and reliability. Contractor shall provide EMS Agency with access to the database upon request.

Proposal Instructions 1. Proposal shall describe, in detail and with brand name and model type, the major equipment that will be used

for the provision of services, and whether the items are to be leased or purchased.

2. Proposal shall provide the policies regarding scheduled replacement and anticipated safe, useful life expectancies of all types of equipment to be furnished by Contractor and employed in the performance of the Agreement.

3. Proposal shall describe the equipment maintenance and repair program, including the mechanism used to track such maintenance and repair.

4. Proposal shall describe the medical supply and equipment distribution system to be employed by Contractor to serve Contractor's units.

5. Proposal shall describe whether the major equipment interfaces with the equipment used by First Responders in Monterey County.

6. The LifeNet 12-Lead ECG transmission system is currently the system in use to transmit ECG’s suspicious of

STEMI to STEMI Receiving Centers and interventionalists. Proposal shall describe Bidder’s intent to integrate into this system for the transmission of 12-Lead ECG. Contractor is responsible for the cost to transmit.

5.6 MEDICAL REQUIREMENTS

5.6.1 Medical Oversight

1. The EMS Agency shall furnish the services of a system EMS Medical Director, pursuant to

California Health and Safety Code, Section 1797.202. The EMS Medical Director shall exercise the authorities and responsibilities provided in California Health and Safety Code, Sections 1797 through 1799, including Section 1797.220

2. The EMS Agency, through Base Hospital Physicians, shall provide online medical control to

field personnel 24 hours a day, 7 days a week, 52 weeks a year.

5.6.2 Medical Protocols

5.6.2.1 The EMS Agency shall review and revise medical protocols periodically with input from system participants. Current EMS System Policies, Protocols and Procedures, including medical protocols, are available on the EMS Agency’s website at: http://www.mocoems.org/

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5.6.2.2 Compliance with EMS System Policies, Protocols and Procedures

1. Contractor shall comply with all EMS System Policies, Protocols and Procedures, including medical protocols and administrative policies established by the EMS Agency, as well as all other requirements and standards established by the EMS Medical Director and EMS Agency.

2. Contractor shall have its own DEA registrant for the procurement of controlled

substances and for oversight of Contractor’s narcotics management program. Contractor shall maintain the services of a California licensed physician throughout the term of the Agreement. Any lapse in having a DEA registrant shall be reported to the EMS Agency immediately.

3. Contractor shall develop and implement a controlled substance tracking and control

policy. This controlled substance tracking and control policy shall comply with all applicable federal, state, and local laws, ordinances, rules, regulations, and EMS System Policies, Protocols and Procedures.

5.6.3 Medical Control

5.6.3.1 Personnel Professional Responsibility

Contractor personnel functioning under the specifications in this Agreement have the right and professional responsibility to interact directly with the EMS System’s medical leadership (EMS Medical Director, base and receiving hospitals, and EMS Agency clinical personnel) on all issues related to patient care.

5.6.4 Quality Improvement (QI) Program

1. Contractor shall develop a Quality Improvement (QI) Program for their Monterey County

operation that will be inclusive of the whole of the operation. The QI program shall be described in the Contractor’s QI Plan.

2. Contractor shall submit its QI Plan to the EMS Agency for approval no less than 30 days

before the service start date.

3. Contractor’s QI Plan shall, at all times, comply with the requirements of California Code of Regulations, Title 22, Division 9, Chapter 12, and EMS System Policies, Protocols and Procedures.

4. Contractor shall participate in the Monterey County EMS QI program as well as maintain an

active internal QI program.

5. Contractor’s QI program shall identify current performance through the development of QI indicators and measure performance through the QI indicators. Contractor will use the QI program to identify the root cause of problems and failures and will correct these problems and failures through a Just Culture process.

6. The QI program shall include a mechanism for recognition of excellence and high

performance.

7. Contractor shall evaluate all services and care through its internal QI program and through the EMS Agency’s QI program to maintain and continuously improve clinical performance.

5.6.5 Medical Review/Audits

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1. Contractor shall participate in a medical review and audit process as established by the EMS Medical Director or as requested for incident review. The purpose of the medical review and audit process is to review clinical care to ensure compliance with EMS System Policies, Protocols and Procedures.

2. Contractor shall comply with the EMS Medical Director audit/review process and to initiate

process measurement and improvement activities based on the results of the audit/review and overall EMS system performance.

3. Contractor’s participation in medical reviews and QI efforts shall be at no cost to the EMS

Agency. Proposal Instructions

1. Proposal shall describe Bidder’s approach and experience developing and implementing successful QI programs.

2. Proposal shall describe Bidder’s experience participating in medical reviews and audit process. Proposal shall describe how quality review findings are translated into priorities for improvement, decisions on resource allocation, and opportunities for system enhancement.

3. Proposal shall describe how new, modified, and customized products and services, and production/delivery processes are designed and implemented.

4. Proposal shall describe Bidder’s approach to remedial training/education, censure, and monitoring. 5. Proposal shall include Bidder’s commitment to securing and maintaining its own DEA registrant during the

term of the Agreement. 6. Proposal shall describe Bidder’s controlled substance tracking program.

5.6.6 Clinical Outcomes

1. Contractor must commit to working actively and cooperatively with other system participants

in EMS Agency-coordinated efforts to improve system level performance in the Clinical Outcome/Output performance measures identified in Contractor’s QI Plan, the EMS Agency’s QI Plan, California EMSA’s Core Measures, and Exhibit L. This includes providing appropriate service delivery and supervisory personnel to participate in developing and implementing improvement processes. (NOTE: It is anticipated that Clinical Outcomes and Care Elements, and their associated Key Performance Indicators (KPIs), will evolve over time with the development of the local EMS system.).

2. Contractor must measure, monitor, and benchmark KPIs for each Clinical Outcome/Output

described in Contractor’s QI Plan, the EMS Agency’s QI Plan, California EMSA’s Core Measures, Exhibit L, and other Clinical Outcome/Outputs as required by the EMS Medical Director. This includes producing periodic reports which describe overall compliance with policy and protocols and provide analysis of compliance challenges and ideas for their resolution.

3. Contractor must commit to providing data necessary for the multi-agency outcomes

improvement processes coordinated by the EMS Agency.

4. Contractor shall develop and implement a comprehensive quality management system that addresses the key areas in Contractor’s organization that are essential for accomplishing the organization’s purpose vision, values, and strategic objectives.

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5. Contractor shall work with the EMS Agency and the EMS Medical Director, and any relevant QI committees, to finalize KPIs and to update them no less than annually, to help define and measure progress toward clinical improvement.

6. Contractor shall list its KPIs (include a definition and measurable performance indicator)

along with a description of how that area contributes to the accomplishment of the organization’s purpose, vision, values, and strategic objectives. At minimum, Contractor must have KPIs that track:

• On-scene time and total pre-hospital time for time dependent clinical conditions like

cardiac chest pain, stroke, and major trauma. • Compliance with EMS Policies, Protocols and Procedures, timelines, and destination for:

a. ST-elevation myocardial infarction (STEMI) b. Cardiac arrest c. Trauma d. Suspected stroke

• Compliance with EMS System Policies, Protocols and Procedures, for use of advanced airways and for patients in whom an advanced airway was or reasonably should have been considered.

7. Contractor shall provide a list of suggested KPIs and goals (see Exhibit L for an example) and

shall include a specific data definition and data source for each KPI. Proposal Instructions 1. Proposal shall include Bidder’s commitment to submit a comprehensive quality management system, including

a written quality improvement plan, at least 30 days before the service start date.

2. Proposal shall describe how Bidder will measure, monitor, benchmark, and achieve specified levels of performance on the corresponding KPIs.

3. Proposal shall describe appropriate methods for handling, analyzing, and contributing data for use in multi-agency outcomes improvement processes.

4. Proposal shall describe how field personnel participate in the organization's quality improvement plans and programs, including the linkage between the quality improvement program and training program for EMDs, EMTs, paramedics, and EMS Field Supervisors.

5. Proposal shall describe how quality findings are deployed throughout the organization and, as appropriate, to the organization's suppliers and/or business partners, such as the EMS Agency/EMS Medical Director, Emergency Communications Department, first responders, and other service providers.

5.6.7 Medical Pilot Projects & Research

Contractor may participate in pilot or research programs as requested by the EMS Medical Director and authorized by the EMS Agency. Contractor may propose a pilot or research project as per EMS Agency policy 6170. The EMS Medical Director and the EMS Agency must approve all pilot programs.

5.7 CASE MANAGEMENT, ALTERNATIVE TRANSPORTATION, AND EMS INNOVATION

Contractor shall work collaboratively with the EMS Agency, the Health Department, the Monterey County Behavioral Health Bureau, and Monterey County hospitals and health systems during the term of the agreement to develop a comprehensive medically-appropriate alternate care, alternate-destination, case management, transportation, and/or referral model for 5150/behavioral health patients, high frequency/low

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acuity patients, and other medical transportation requests that are not best served by Ambulance response or transport.

Proposal Instructions 1. Proposal shall describe Bidder’s experience and plans to provide case management, alternative transportation

and innovative EMS services. Speak specifically to medically-appropriate alternate care and transportation, case management, and/or referral models for 5150/behavioral health patients, high frequency/low acuity patients, and other medical transportation requests that are not best served by Ambulance response or transport. Proposal includes Bidder’s solutions for the Monterey County EMS System, based on the following two scenarios:

Scenario 1: Current constraints of state law and regulation.

Scenario 2: State law authorization of community paramedics, presuming this state law would authorize community paramedics, consistent with the California EMS Authority’s Community Paramedic Pilot Project Concepts as defined at: https://emsa.ca.gov/community_paramedicine/.

2. Proposal describes financing options, acceptable to Bidder, for Scenario 1 and Scenario 2.

5.8 PERSONNEL

5.8.1 Treatment of Incumbent Work Force 1. In the event the successful Bidder is not the incumbent service provider, the successful Bidder

is encouraged to make every reasonable effort to ensure a smooth transition and for current EMS personnel to remain with the system. In the event of a change in service providers, the EMS Agency encourages successful Bidder to consider all qualified non-management employees (dispatchers, EMTs, paramedics, and supervisors) for preferential hiring in substantially similar positions in accordance with all applicable laws and protections. The EMS Agency encourages successful Bidder to consider current employee scheduling and make reasonable efforts to transition its new employees to its organization as smoothly as possible. While a plan for the transition of paramedics is an element of this RFP, Bidders are encouraged to exceed the minimum requirements and provide the strongest plan possible to retain and hire the incumbent workforce.

2. The EMS Agency encourages the successful Bidder to allow incumbent personnel to retain

seniority status earned while working in the Monterey County EMS System.

3. If the incumbent service provider is the successful Bidder, the EMS Agency encourages it to maintain, at a minimum, current salary and benefit levels for personnel and consistent with offerings included in its proposal.

Note: The EMS Agency’s goal is simply to encourage Contractor initially and throughout the term of the Agreement to provide a financial benefit to encourage employee recruitment and retention. Employees are represented by IAFF local 4513. Bidders are encouraged to meet with local labor officials.

Proposal Instructions 1. Proposal shall describe Bidder’s efforts to retain personnel through the term of the Agreement.

2. Proposal shall describe how Bidder intends to maintain continuity of service in the system by employing current

personnel.

3. Proposal shall describe the program and policies that would govern employment opportunities for incumbent personnel.

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5.8.2 Character, Competence, and Professionalism of Personnel 1. Contractor’s employees will operate in a professional and courteous manner. All Contractor

employees shall be competent and shall, at all times, hold the appropriate licenses, certifications, and accreditations as required for their positions. Contractor’s use of any person without current and proper credentials for their position shall result in liquidated damages as outlined in Exhibit O.

2. Before starting service, Contractor shall conduct a fingerprint-based criminal record check, a

DMV records check and other checks as necessary, of each employee to ensure that Contractor is aware of any felony or misdemeanor convictions or other actions that could be a factor related to an individual’s performance in an EMS system. These checks must minimally identify whether any employee has:

• Debarment from federal Medicare/Medicaid program • Felony or misdemeanor convictions related to diving under the influence • Drug-related offenses • Sexual offenses including rape, child abuse, spousal abuse, and those criminal offenses

specified in California Health and Safety Code, Section 1798.200 • Felony convictions, moral turpitude, chronic or habitual use of alcohol, drugs, probation

status, sanctions for unsafe driving, and other offenses specified in California Vehicle Code, Section 13372

• Felony or misdemeanor convictions related to theft

3. Contractor shall commit to ensuring that employees are free from the influence of alcohol and intoxicating drugs while on duty.

4. Contractor shall maintain policy and labor relations agreements requiring employees to be free from the influence of alcohol, or any other substance known to impair motor skills and cognitive ability, while on duty.

5. Contractor shall maintain an enforcement and investigatory policy to enforce violations related to items in this Section, to include, at a minimum, random and post incident drug testing, and an employee assistance program and multi-step rehabilitation program, as needed.

6. Contractor shall have a random and post-incident illicit substances testing requirement for all personnel who provide services under this Agreement.

7. Contractor shall submit any badges, patches, or insignia proposed as part of the uniform for EMS Agency approval no less than 60 days before the service start date.

Proposal Instructions 1. Because impaired EMS providers present a significant safety risk for patients, partners, and others in the

community, proposal shall describe Bidder’s commitment to ensuring that providers are free from the influence of alcohol and intoxicating drugs.

2. Proposal shall include Bidder’s policy requiring employees to be free from the influence of alcohol, or any other substance known to impair motor skills and cognitive ability, while on duty.

3. Proposal shall include copies of all workplace rules, measures and procedures for identifying and working with

impaired employees.

4. Proposal shall describe Bidder’s approach to minimizing drug use among employees, including pre-employment drug screening of potential employees, and workforce policies and procedures related to drug use.

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5. Proposal shall include Bidder’s enforcement and investigatory policy to enforce violations related to items in this Section.

5.8.3 Key Personnel

1. Contractor shall ensure adequate management of operations, supervision of its personnel, and

the delegation of authority to address day-to-day operational needs.

2. Contractor shall directly employ all Key Personnel. Key Personnel shall be full-time employees of Contractor but are not required to be solely dedicated to EMS operations within Monterey County, except as specified in this section. The EMS Director, Medical Director, and EMS Agency staff shall have direct access to these individuals.

3. Contractor’s personnel must have appropriate authority to direct and oversee Contractor’s

Monterey County EOA Ambulance Services.

4. Each of the employees filling the Key Personnel positions responsible for the functions listed in this section shall have demonstrated experience and qualifications preparing them to perform the function assigned.

5. Should any Key Personnel turnover occur during the term of the Agreement, Contractor shall

appoint an equally qualified replacement.

5.8.4 Key Personnel Functions

5.8.4.1 Overall Operations 1. Contractor shall employ a qualified individual to oversee and be wholly responsible for

the overall function of Contractor’s Monterey County EOA Ambulance Services and all ancillary services. This individual shall be responsible for Monterey County EOA Ambulance Agreement performance and compliance. This individual shall have prior proven experience managing an Ambulance Services operating under a 911 emergency Ambulance performance and response time requirement Agreement. This individual shall be a champion of quality management and ensure all upper-level management positions are properly trained and participate in Contractor’s Quality Management Program.

2. This individual shall successfully complete the American Ambulance Association’s Ambulance Services Manager Certificate Program within eighteen (18) months of their appointment.

5.8.4.2 Day-to-Day Operations

Contractor shall employ a qualified individual who is responsible for Contractor’s day-to-day EMS and Ambulance operations. This individual shall be dedicated to the Monterey County EOA operations. This individual shall successfully complete the American Ambulance Association’s Ambulance Services Manager Certificate Program.

5.8.4.3 Clinical Quality and Performance Management 1. Contractor shall employ a paramedic or registered nurse who is highly experienced in

EMS and/or in emergency and critical care, to implement and oversee Contractor's Quality Management program. This position shall have a direct collateral reporting relationship to the EMS Medical Director. This individual shall be trained in Just Culture or a similar program, experienced in quality improvement programs, and successfully complete the NAEMSE Level 1 and Level 2 instructor course.

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2. This individual shall be responsible for the medical quality improvement activities of all services provided pursuant to this Contract. This individual will have sufficient authority and ability to directly conduct clinical investigations and the authority to take appropriate corrective action. This individual shall be dedicated to the Monterey County EOA operations.

5.8.4.4 Clinical Education/Training Contractor shall employ qualified personnel to provide clinical education and training, training of Field Training Officers, and training and coordination of paramedic preceptors under the direction of the individual responsible for clinical quality and performance. Clinical Education personnel shall have significant experience in the field provision of EMS. Personnel in this position shall have completed the NAEMSE Level 1 and Level 2 instructor courses and have an active paramedic or RN license. This position has a direct collateral reporting relationship to the EMS Medical Director.

5.8.4.5 EMS Medical Dispatch 1. Contractor shall employ qualified EMS Medical Dispatch personnel to provide overall

management and performance compliance of the EMS Medical Dispatch.

2. It is encouraged, not required, that this individual successfully complete the American Ambulance Association’s Communications Center Manager (CCM) or the International Academies of Emergency Dispatch’s Communication Center Manager Course.

5.8.4.6 In the event that any of the key personnel identified in this section fail to perform to the satisfaction of the EMS Agency or Medical Director, Contractor shall timely appoint a suitable replacement acceptable to the EMS Agency.

5.8.5 EMS Medical Dispatch Personnel Supervision 1. Contractor shall ensure that an EMS Medical Dispatch Supervisor or a Shift Lead Dispatcher

is available on site 24 hours a day, 7 days a week, 52 weeks a year, for direct supervision of all MPDS and dispatch related operations at the designated EMS Medical Dispatch.

2. The EMS Medical Dispatch Supervisors or Shift Lead Dispatchers shall be both operational

and protocol knowledgeable leaders in MPDS and dispatch procedures, who shall serve as Contractor’s on-duty EMS Medical Dispatch contact. They must be operationally-experienced, and administratively sophisticated. Accordingly, Contractor’s EMS Medical Dispatch Supervisors or Shift Lead Dispatchers must be certified Emergency Medical Dispatchers who are qualified in the supervision of complex systems as demonstrated through extensive training.

3. Examples of the EMS Medical Dispatch Supervisor or Shift Lead Dispatcher duties include

but are not limited to: • Initiate real time dispatch center-System Status Plan staffing adjustments as directed. • Facilitate with prompt turnaround times at receiving facilities. • Resolve employee performance issues. • Resolve or investigate customer or stakeholder complaints. • Facilitate and provide reports and data requests. • Collaborate with the EMS Agency. • Liaise and communicate with EMS Agency on-call personnel. • Ensure appropriate notifications of unusual EMS System occurrences as described in

EMS System Policies Protocols and Procedures. • Provide direct, case-by-case MPDS and dispatch oversight of all personnel on duty.

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• Direct and assist with research and compliance for research in trial studies, focused audits, and state-directed demonstration projects.

• Teach and reinforce MPDS and dispatch related policies, protocols and procedures. • Serve as a resource for difficult MPDS and dispatch related issues. • Communicate with Contractor’s Operations and EMS Agency personnel. • Coordinate with MCECD supervisors and management. • Participate in the Quality Improvement Technical Advisory Group and/or other internal

and external performance improvement committees, as requested. • Investigate and provide information, as needed.

5.8.6 EMS Field Personnel Supervision

1. Contractor shall deploy EMS Supervisors such that no less than one (1) EMS Supervisor is

available 24 hours a day, 7 days a week, 52 weeks a year, deployed in an emergency response supervisor vehicle. At least one EMS Supervisor shall normally be deployed in the field and not routinely used for office-type work, such as scheduling.

2. The EMS Supervisors shall be both operational and clinical leaders, who serve as

Contractor’s on-duty EMS Field Commander. Accordingly, Contractor’s EMS Supervisors must be licensed and locally accredited paramedics who are qualified in the management of large and complex emergencies as demonstrated through extensive, relevant training and experience.

3. It is required that EMS Supervisors are authorized Ambulance Strike Team Leaders (ASTL).

4. Examples of the EMS Supervisor duties include but are not limited to:

• Initiate real time, non-dispatch center-System Status Plan staffing adjustments. • Decrease turnaround times at receiving facilities. • Resolve employee performance issues. • Resolve or investigate customer or stakeholder complaints. • Integrate into an ICS structure, assisting with management of complex incident as needed

or requested by partner agencies. • Collaborate with the EMS Agency. • Liaise and communicate with EMS Agency Duty Officer. • Respond to Priority 1 and other MPDS determinant-coded calls with associated high risk

and/or frequent potential for critical ALS interventions, as specified by the EMS Medical Director.

• Provide direct, case-by-case medical oversight of all clinical personnel on scene. • Coordinate data collection for ongoing compliance in collection and reporting of data

required by the EMS Agency. • Direct and assist with research and compliance for research in trial studies, focused

audits, and state-directed demonstration projects. • Teach and reinforce clinical policies, protocols and procedures. • Serve as a resource for difficult clinical issues. • Communicate with base physicians. • Participate in the Quality Improvement Technical Advisory Group and/or other internal

and external performance improvement committees, as requested. Note: It is encouraged, not required, that Contractor’s EMS Supervisors be credentialed as Supervising Paramedic Officers (SPO) by the National EMS Management Association. Proposal Instructions 1. Proposal shall provide a list/chart specifically identifying Bidder’s Key Personnel, and how each of Bidder’s

Key Personnel meets the requirements of the RFP.

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2. Proposals shall include an organizational chart and a list of employees and resumes for Key Personnel

associated with the RFP. Provide no more than two pages of information for each person. The following information shall be included:

• Relationship with Bidder, including job title and years of employment with Bidder • Role that the person will play in connection with the Agreement • Business address, telephone, fax number, and e-mail • Education and training • Relevant experience • Relevant awards, certificates or other achievements

3. Additional points may be awarded for commitment that Contractor’s EMS Supervisors be credentialed as

Supervising Paramedic Officers (SPO) by the National EMS Management Association. 5.8.7 Personnel Licensure, Certification and Training Requirements

1. All Contractor's Ambulance, supervisory, and communications personnel responding to

emergency medical requests shall be currently and appropriately licensed, accredited, certified and/or credentialed, as appropriate, to practice in Monterey County.

2. Contractor shall always retain on file copies of the current and valid licenses and/or

certifications of all emergency medical personnel performing services under this Agreement. Monterey County EMS Agency certification/licensure requirements may be downloaded from the EMS Agency website, at: www.mocoems.org. State requirements may be downloaded from www.emsa.ca.gov. Should these requirements change during the term, Contractor will maintain the then current standards.

3. Contractor shall participate in the DMV Employer Pull Notice Program. Contractor shall

submit to the EMS Agency its policies for managing employees who have driving license privileges suspended or revoked no less than 45 days before the service start date.

4. Replacement Key Personnel must meet the training and credentialing standards for their

respective Key Personnel position, within 18 months of their start date in that position. Proposal Instructions 1. Proposal shall include Bidder’s commitment to ensure all personnel have and will maintain all required licenses,

certifications, and certificates.

2. Proposal shall describe Bidder’s system for maintaining employee records of all required licenses, certifications, and certificates.

3. Proposal shall include Bidder’s policies describing the processes in place for licensure, certification, and

certificate review to ensure all are valid and current.

5.8.8 Commitment to Personnel

5.8.8.1 Posting Practices The EMS Agency expects that Contractor will use best efforts to provide clean and safe rest areas in geographically-diverse areas of the County.

5.8.8.2 Meal and Comfort Breaks

Contractor shall develop and implement a plan for meal and comfort breaks for field and dispatch/communications personnel.

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5.8.8.3 Work Schedules

Contractor shall develop and maintain a detailed and comprehensive work schedule for EMT’s, paramedics, dispatchers, and Supervisors to assure optimum response that will include for each, but not limited to: shift schedules, mandatory time off, mandatory hours worked in a row, hold over provisions, rotation of shift schedules, mechanisms to monitor employees work hours and unit hours, schedules to address skill degradation, and Unit Hour monitoring practices.

Note: Bidder is strongly encouraged to consider providing Comfort Stations at strategic posts that are available to on duty personnel 24/7. Nothing in this section, of the RFP as a whole, is intended to imply control or supervision of Contractor’ employees. Rather, this section is a recognition of best practices to ensure alert and attentive medical care. Proposal Instructions 4. Proposal shall demonstrate Bidder’s efforts to build and maintain a high-performing workforce and

establish an environment conducive to organizational excellence through employee participation, personal, and organizational growth.

5. Proposal shall describe the proposed hiring procedures.

6. Proposal shall include staffing and work schedule plan that meets or exceeds the requirements outline in the RFP.

7. Proposal shall describe Bidder’s method for providing and documenting system and individual performance

feedback to employees.

8. Proposal shall describe the compensation and benefits package that will be offered to Paramedics, EMTs, EMS Field Supervisors, EMS Managers and other personnel. The package should include minimum and maximum ranges of compensation for all personnel classifications and the benefits offered.

9. Proposal shall include Bidder’s posting plan that describes its strategy to provide Ambulance crews with access

to adequate rest areas and/or comfort stations, if applicable, at post locations. Strategy describes the number, location, and physical features of each post.

10. Proposal shall identify that suitable rest areas will remain available to crews throughout the term of the Agreement, even if posting locations change.

5.8.8.4 Fatigue Risk Management

1. Contractor shall develop and maintain a comprehensive Fatigue Risk Management

program, based on evolving evidence and research.

2. Contractor shall provide regularly scheduled reports that identify the number of hours and consecutive hours worked for each employee, in a form acceptable to the EMS Agency.

Proposal Instructions 1. Proposal shall include Bidder’s Fatigue Risk Management Plan. That plan shall describe procedures regarding

monitoring of employee work patterns and demonstrates compliance with the consecutive hour limitations in the RFP.

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2. Proposal shall describe the overall approach to scheduling and its impact on coverage and potential for worker fatigue - e.g., lengths of shifts, frequency of shifts, time off between shifts, shift-trading, use of voluntary and mandatory overtime, and policies regarding outside work.

5.8.9 Internal Health and Safety Programs

Contractor shall implement necessary programs to create a culture of safety and enhance the safety and health of the work force. These shall include driver-training, infection control processes, and safety and risk management training.

Proposal Instructions 1. Proposal shall describe the organization’s mechanism for involving front line employees in quality and

performance improvement projects.

2. Proposal shall describe Bidder’s infection control and safety risks policies, procedures and programs. 3. Proposal shall describe Bidder’s plan to provide initial and ongoing training to support appropriate professional

behaviors including safe driving, safe lifting techniques, basic cultural competence, and managing assaultive behavior.

5.8.10 Personal Protective Equipment (PPE)

Contractor shall provide adequate PPE and other equipment to employees working in hazardous environments such as infectious disease environments, routine care, rescue operations, and motor vehicle accidents. PPE shall include appropriate head, eye, ear, respiratory and flesh protection for employees and high visibility apparel jackets for use on highways. High visibility apparel shall comply with ANSI/ISEA 107-2015 Type P standards. Policies and procedures should clearly describe the routine use of appropriate PPE on all patient encounters.

Proposal Instructions 1. Proposal shall include Bidder’s PPE policies and procedures.

5.8.11 Stress Management and Employee Resilience Program

Contractor shall develop and maintain a stress management and employee resilience program for its employees, which, at a minimum, includes an on-going stress management program, a critical incident stress action plan, and reliable access to trained and experienced professional counselors through an employee assistance program.

5.8.12 Employee Satisfaction and Development Contractor shall develop, implement, and maintain an ongoing process for assessing the engagement and satisfaction level of employees, produces qualitative and quantitative KPIs for employee satisfaction, which includes, but is not limited to: • Strategy for on-going retention of the workforce • Strategy to promote health, safety, and education in the workforce • Two-way communications process between front line employees and the leadership team • Mechanism for encouraging, gathering, providing feedback on, and acting on employee

improvement suggestions • Method for providing system and individual performance feedback to employees • Mechanism for involving front line employees in quality and performance improvement

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• Career ladder and professional development process for members of the workforce. Include a description of the succession plan for key positions

• Mechanism that utilizes experienced clinicians to mentor, monitor and assist paramedics and EMTs in the field

• Methods to assess, maintain, and develop new skills for employees in the workforce • Practices to ensure diversity in the workforce. Address the organization’s level of diversity

alignment with the communities that are served by Bidder • Practices and policies designed to promote workforce harmony and prevent discrimination

based on race, color, national origin, religious affiliation, sexual orientation, age, sex, disability, genetic information, marital status, gender identity, gender expression, HIV/AIDS status, medical condition, political activities or affiliation, military or veteran’s status, status as a victim of domestic violence.

Proposal Instructions 1. Proposal shall include Bidder’s plan to assess the development, engagement and satisfaction level of employees. 2. Proposal shall include Bidder’s stress management and employee resilience program.

5.8.13 Discrimination Not Allowed 1. During the performance of the Agreement, Contractor agrees that it will comply with all

applicable provisions of federal, state, and local laws and regulations prohibiting discrimination.

2. Contractor warrants that it will fully comply with Title VI and VII of the Civil Rights Act of

1964, as amended, the Americans with Disabilities Act (ADA) and all other regulations promulgated thereunder. Contractor will not discriminate against any employee or applicant for employment because of race, religion, color, disability, national origin, sex, sexual orientation, or age. Contractor will take affirmative action to ensure that employment is offered and that employees are treated during employment without regard to their race, color, national origin, religious affiliation, sexual orientation, age, sex, disability, genetic information, marital status, gender identity, gender expression, HIV/AIDS status, medical condition, political activities or affiliation, military or veteran’s status, status as a victim of domestic violence. Such action shall include but is not limited to the following: employment-upgrade, demotion, or transfer; recruitment or recruitment advertising; lay-off or termination; rates of pay or other forms of compensation; and selection, including apprenticeship.

5.8.14 OSHA & Other Regulatory Requirements

1. Contractor shall comply with all regulatory requirements for occupational safety and health,

including but not limited to infection control, blood borne pathogen protection, and TB prevention.

2. Contractor shall adopt procedures that meet or exceed all requirements for protecting

employees.

3. Contractor shall make available, at no cost to its employees, all currently recommended immunizations and health screenings to its high-risk personnel.

5.8.15 Title 8 Compliance

Contractor shall comply with all requirements of California Code of Regulations, Title 8, including standards relating to Injury and Illness Prevention Programs, the California OSH Act, Bloodborne Pathogen and Hepatitis Protection Standards, and toilet facilities.


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1. Proposal shall include a response to Sections 5.8.13 to 5.8.15.

2. Proposal describes the organization’s practices and policies designed to prevent discrimination based on race,

color, national origin, religious affiliation, sexual orientation, age, sex, disability, genetic information, marital status, gender identity, gender expression, HIV/AIDS status, medical condition, political activities or affiliation, military or veteran’s status, status as a victim of domestic violence.

3. Proposal shall include Bidder’s policies and procedures to ensure compliance with OSHA, Title 8, and any other regulatory requirements.

5.9 TRAINING AND CONTINUING EDUCATION Contractor shall assure that all Ambulance, EMS Medical Dispatch, and supervisory personnel maintain current training, licenses, certifications, and accreditations as defined in the Agreement and as prescribed in EMS System Policies, Protocols and Procedures. The EMS Agency may add or delete training requirements during the term of the Agreement as educational or training requirements change.

5.9.1 Learning Management System Required

1. Contractor shall supply a Learning Management System (LMS), approved by the EMS

Agency, capable of electronically delivering training courses and critical messages (e.g. from the EMS Medical Director, threat information, information about new policies, etc.) to system participants as a part of the EMS System’s CQI and accountability mechanisms. Contractor’s LMS shall be web-based and include the capability for training and instructor evaluation. Contractor shall maintain by policy and enforce individual LMS sign in for all personnel at the beginning of each shift to facilitate critical message reception.

2. Contractor’s LMS must retain records for no less than 4 years and shall meet the requirements

of California Code of Regulations, Title 22, Chapter 11 and EMS System Policies, Protocols and Procedures.

5.9.2 Orientation and On-going In-service Training Requirements and Mechanisms

5.9.2.1 Field and EMS Medical Dispatch Personnel Orientation

Contractor shall properly orient all field and EMS Medical Dispatch personnel before assigning them to work. Such orientation shall minimally include:

• EMS System Policies, Protocols and Procedures • EMS System overview, including EOA, First Responders, response areas, and zones • Radio communications with and among the provider agency, first responders,

hospitals, and EMS Medical Dispatch centers • Map reading skills including key landmarks, routes to hospitals and other major

receiving facilities within the county and in surrounding areas • Ambulance and equipment utilization and maintenance • Emergency Medical Dispatcher and MPDS orientation • Provider’s policies and procedures • Requirements of state and federal law

5.9.2.2 Continuing Education (CE) Program

1. Contractor shall apply for and maintain continuous approval as an EMS Continuing

Education Provider (CE Provider), as defined in California Code of Regulations, Title 22, Division 9, Chapter 11, to conduct continuing education courses, classes, activities or experiences; issue earned continuing education hours to EMS personnel for the purposes of maintaining certification/licensure or re-establishing lapsed

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certification or licensure. Contractor shall maintain course records for at least four years.

2. All in-service education and training programs offered for CE credit must comply

with applicable state regulations and Monterey County EMS Agency Policies, Protocols and Procedures.

3. Contractor shall provide and focus training content to address local system needs.

The EMS Medical Director may mandate specific continuing education program and content requirements. The EMS Agency may review and audit any continuing education programs offered by Contractor.

4. Contractor shall assure that relevant and frequent training courses are offered to

assist field and dispatch personnel in maintaining certification/licensure/accreditation as defined in California Code of Regulations, Title 22, Division 9, Chapters 2, 4 and 11, EMS System Policies, Protocols and Procedures, and, to the extent possible, shall be built upon observation and findings derived from Contractor’s and EMS Agency’s CQI system.

5.9.2.3 Training Plan

Contractor shall provide the EMS Agency with a Training Plan to ensure compliance with training and certification requirements. At a minimum, the Training Plan shall delineate the programs that will be provided, by whom, and the proposed location. The Training Plan should provide for a two-year training cycle.

5.9.2.4 Mandatory Trainings

1. Preparation for Mass-Casualty Incidents Training Contractor shall train all field and dispatch personnel and supervisory personnel in their respective roles and responsibilities under EMS System Policies, Protocols and Procedures and prepare them to function within the Incident Command System. The specific roles of Contractor and other EMS System personnel will be defined by relevant plans and command structure.

2. Incident Command System (ICS) Training

Contractor shall train all field, dispatch, supervisory, and management personnel in the Incident Command System (ICS), Standardized Emergency Management System (SEMS), and National Incident Management System (NIMS), consistent with federal, state, and local doctrine. Current training standards include: Non-supervisory field and dispatch personnel: ICS-100, ICS-200, IS-700, and SEMS Management, Supervisory field and dispatch personnel, and other personnel with potential EOC assignments: ICS-100, ICS-200, ICS-300, ICS-400, IS-700, IS-800, and SEMS

3. Cultural Competence Training

Contractor shall provide field, dispatch, supervisory, and management personnel with the training necessary to achieve levels of knowledge, understanding and skills to work successfully with diverse patient populations and communities. More information on cultural competency, cultural responsiveness and other equity-related requirements is provided in Exhibit N.

4. Assaultive Behavior Management/Secure Transport Training

Contractor shall provide training to field and dispatch personnel on an ongoing basis to support the knowledge, understanding, and skills necessary to effectively manage patients with psychiatric, drug/alcohol or other behavioral or stress related problems,

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as well as difficult or potentially difficult scenes. Emphasis shall be on techniques for establishing a climate conducive to effective field management and for preventing the escalation of potentially volatile situations.

5. Driver Training

Contractor shall maintain an ongoing driver training program for field personnel. Training and skill proficiency are required at initial employment with annual training refresher and skill confirmation.

6. Environmental Factors and Infection Control Training

Contractor shall create a culture focused on infection prevention that focuses on aggressive hygiene practices and proactive personal protective equipment donning and doffing (e.g. eye protection, gloves, etc.).

Contractor shall develop and strictly enforce policies for infection control, cross contamination, and soiled materials disposal to decrease the chance of communicable disease exposure. Included shall be an ongoing infection prevention training program for its employees.

7. Critical Incident Stress Management/Resilience Training

Contractor shall establish a repetitive stress and critical incident stress action plan. Included shall be an ongoing stress reduction resilience training program for its employees and access to trained and experienced professional counselors. Plans for these programs shall be submitted to the EMS Agency for approval.

8. Tactical Casualty Care Training

Contractor shall provide initial and ongoing training for all field personnel in Tactical First Aid/TEMS First Responder Operations, which meets or exceeds the training standards identified in EMSA Guideline 370: California Tactical Casualty Care Training Guidelines.

9. HIPAA/HITECH/CMIA Compliance Training

Contractor shall provide initial and ongoing training for all personnel requiring compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the Health Information Technology for Economic and Clinical Health Act (HITECH), the current rules and regulations enacted by the U.S. Department of Health and Human Services, and the California Confidentiality of Medical Information Act (CMIA).

10. Compliance Training

Contractor shall provide initial and ongoing compliance training for all personnel. This training shall be in accordance with the Office of Inspector General (OIG) Compliance Program Guidance for Ambulance Suppliers. This training is one component of the required Compliance Plan required of Contractor.

11. HAZMAT Training

Contractor shall provide required hazardous materials (HAZMAT) training for all EMTs paramedics, and supervisors to comply with OSHA HAZWOPER training requirements pursuant to 29 CFR 1910.120(q)(6)(ii) and 29 CFR 1926.65(q)(6)(ii).

Proposal Instructions 1. Proposal shall identify the LMS Bidder intends to provide within the Monterey County EMS System. Bidder

shall describe use of the system by trainers and learners and identify its methods to assure all personnel shall receive EMS updates at the beginning of each shift.

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2. Proposal shall describe Bidder’s plan to provide mandatory training, indicating for each subject area, whether training will be provided internally or through outside organizations.

3. Proposal shall describe Bidder’s training and CE program, including the process by which training deficiencies identified through quality improvement activities are translated into training courses.

4. Proposal shall describe how education and training are planned, provided, evaluated and improved, considering

organization and employee performance, employee development and learning objectives, leadership development, and other factors, as appropriate.

5. Proposal includes a copy of Bidder’s Training Plan that meets or exceeds the requirements set forth in the RFP.

5.10 MULTI-CASUALTY INCIDENTS (MCI) AND MEDICAL DISASTERS

5.10.1 MCI/Disaster Response Preparedness and Response

1. Contractor shall actively participate in developing, training, planning, exercising and

evaluating MCI and medical disaster plans and medical disaster capabilities for the Monterey County Operational Area and Region II.

2. Contractor shall cooperate fully with the EMS Agency in rendering emergency assistance

during disasters, or in MCI responses as identified in the EMS Agency’s plans.

3. In the event the County declares a disaster within the County, Contractor will deploy at least one management employee to the designated Emergency Operations Center or Medical Coordination Center (when activated) as a liaison upon request.

4. In the event the County declares a disaster, or in the event the EMS Agency directs Contractor

to respond to an out of county disaster, normal operations may be suspended at the discretion of the EMS Agency, and Contractor shall respond consistent with the MCI or disaster plan.

5. Contractor shall use best efforts to maintain primary services and may suspend non-

emergency services upon notification and concurrence of the EMS Agency.

6. Contractor’s personnel shall follow the direction of the EMS Agency during a disaster.

7. At a multi-victim scene, Contractor's personnel shall perform in accordance with the Monterey County MCI Plan and the Incident Command System (ICS).

8. During a disaster declared by the County, the EMS Agency will determine, in writing, on a

case-by-case basis, if Contractor may be temporarily exempt from certain provision of the Agreement.

9. When Contractor is notified that multi-casualty or disaster assistance is no longer required, Contractor shall return its resources to its primary area of responsibility and shall resume operations as required under the Agreement.

5.10.1.1 Deployment of Ambulance Strike Teams

1. Contractor shall ensure that an Ambulance Strike Team (AST) is available at all times to

respond to disaster requests from the Regional Disaster Medical Health Specialist Regional Disaster Medical Health Coordinator (RDMHS), or the Medical Health Operational Are Coordinator (MHOAC), as approved by the EMS Agency.

2. Contractor must ensure that AST members and AST leaders have been appropriately

trained.

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3. Contractor shall deploy, within 2 hours of receiving a request for mutual aid, one

Ambulance Strike Team (with or without a Disaster Medical Support Unit) staffed and equipped according to the EMSA Ambulance Strike Team Guidelines when directed by the EMS Agency.

5.10.1.2 Deployment of Contractor Resources Contractor shall only deploy Ambulances, strike teams, and other resources, as directed by the EMS Director, or if unavailable, the MHOAC, via the MHOAC and RDMHS mutual aid system.

5.10.1.3 Disaster Medical Support Unit Management Throughout the term of the Agreement, Contractor shall house, maintain, manage, staff and maintain ready for deployment, within two hours of receiving a request for mutual aid, one or more EMSA state-issued Disaster Medical Support Unit (DMSU). This includes deploying the unit when requested by the EMS Director, or if unavailable, the MHOAC, via the MHOAC/RDMHS mutual aid system. This vehicle shall not be used in routine, day-to-day operations, but shall be kept in good working order and available for emergency response to the disaster site. This vehicle may be used to carry personnel and equipment to a disaster site.

5.10.1.4 Disaster Response Notification of Staff Contractor shall develop and continuously maintain the capability to immediately alert and/or recall off duty personnel during an MCI or widespread disaster.

5.10.1.5 Incident Notification

Contractor shall have a mechanism in place to communicate information to appropriate EMS Agency personnel during MCIs, disaster responses, hazardous materials incidents, and other unusual occurrences.

Proposal Instructions 1. Proposal shall include a response to Sections 5.10.1.1 to 5.10.1.5.

2. Proposal shall describe Bidder’s experience and approach to disaster preparedness, including planning and

responding to MCI and local disasters.

3. Proposal shall describe Bidder’s capability to immediately alert and/or recall off duty personnel during an MCI or widespread disaster.

4. Proposal shall describe Bidder’s capability to communicate information to appropriate EMS Agency personnel during MCIs, disaster responses, hazardous materials incidents, and other unusual occurrences.

5.10.2 Mutual Aid

5.10.2.1 Mutual Aid Coordination

1. Contractor shall respond in a mutual aid capacity to service areas outside of Monterey County only if so directed by the MHOAC or the EMS Agency or as specified in EMS Agency-approved mutual aid agreements.

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2. Contractor shall only provide or receive mutual aid, as requested or directed by the MHOAC or the EMS Agency and only through Mutual Aid Agreements or the California Medical and Health Mutual Aid System.

3. Contractor shall maintain documentation of the number and nature of mutual aid

responses it makes, and nature of mutual aid responses made by other agencies to calls originating within the County.

5.10.2.2 Contractor’s Use of Mutual Aid 1. Contractor may enter into EMS Agency-approved mutual aid agreements for the

occasional use of mutual aid Ambulances to respond to calls within the EOA.

2. Contractor may use mutual aid to augment, but not replace, the services that Contractor provides pursuant to this Agreement in order to have the closest available Ambulance respond to a medical emergency.

3. Contractor’s use of mutual aid shall be limited to five percent (5%) of its total call

volume.

4. Mutual aid received due to a disaster situation or a Level 2 or 3 MCI will not count against the 5% limit on mutual aid.

5. Contractor’s use of mutual aid shall be reviewed monthly by the EMS Agency.

6. Contactor shall be assessed liquidated damages in the amount stated in Exhibit O per call serviced by non-contracted Ambulance providers in the EOA in excess of five percent (5%) of Contractor’s call volume for that reporting period.

5.10.3 Continuity of Operations Planning

1. Contractor shall develop and be capable of implementing a Continuity of Operations Plan

(COOP). The COOP will comprehensively describe Contractor’s continuity of business plans, including scaling efforts for management of incidents or disasters that disrupt Contractor’s normal ability to provide emergency medical services and scaling efforts to normal business continuity following a disaster.

2. Contractor shall submit its COOP to the EMS Agency for approval no less than 30 days

before to the service start date.

5.10.4 Disaster Cache Contractor shall create and maintain on site within Monterey County, medical supply and equipment inventories of no less than 21 day necessary for Ambulance operations.

Proposal Instructions 1. Proposal shall include Bidder’s proposed use of mutual aid.

2. Proposal shall include Bidder’s commitment to submit a COOP Plan to the EMS Agency for approval no less

than 30 days before to the service start date.

3. Proposal shall provide an inventory list of Bidder’s Disaster Cache and plan to maintain medical supply and equipment inventories of no less than 21 day necessary for Ambulance operations.

5.11 EMS SYSTEM PARTICIPATION

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5.11.1 Participation in EMS System Development 1. Contractor shall support and cooperate in EMS activities, committee meetings, and work

groups. Contractor agrees to participate and assist in the development of system changes.

2. Contractor shall collaborate and cooperate with the EMS Agency in the development of standards and practices for most appropriate patient care.

5.11.1.1 Interagency Training for Exercises/Drills Contractor shall participate in EMS System-related emergency and disaster exercises and drills, and other interagency trainings upon request. This participation includes the use of staffed Ambulances and EMS Supervisors.

5.11.1.2 Joint Training with First Responders 1. Contractor shall participate in EMS System-related joint first responder/Ambulance

training programs and mandatory in-service trainings and assist the EMS Agency with the support, coordination and logistics of such sessions. The training programs may include, but not be limited to ACLS/PALS/NRP, Trauma, PHTLS, and MCI updates.

2. Contractor shall allow first responders’ personnel to attend its scheduled continuing

education events.

3. Contractor shall provide access to its LMS at no cost to designated first responder agencies that do not charge for services and at pro-rata cost to first responder agencies and other Ambulance agencies that charge for services.

5.11.1.3 Collaboration and Communication with First Responder

1. Contractor shall designate from among its Key Personnel a single individual as its

primary liaison for the first response agencies within the service area.

2. Contractor shall develop and implement policies to facilitate Monterey County First Responders to schedule time on Ambulances to fulfill training, internship and accreditation requirements.

5.11.1.4 Support and Integration of First Responders

1. Contractor shall develop and maintain a written policy and processes to exchange re-

usable medical supplies and restock disposable ALS and BLS medical supplies and pharmaceuticals, other than narcotics, used by first responders that do not charge the patient or their insurance for services. Exchange will be on a one-for-one basis, when treatment has been provided by first responder personnel and patient care is assumed and transport provided by Contractor’s personnel. Contractor shall also exchange, on a one-for-one basis, supplies used by a first response paramedic service provider when the patient receives ALS care with no transport and/or under the established treat and refer program. The policy and processes to exchange and/or restock reusable medical equipment and supplies must comply with all state and federal laws, including the Drug Supply Chain Security Act (DSCSA).

2. Contractor shall be responsible for its costs in resupplying on a one-for-one basis, the

disposable medical supplies of first responder agencies used on Contractor-transported patients within the EOA for those first response agencies that do not charge for services. Contractor shall not resupply those first responder agencies who charge for services.

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3. Contractor shall allow authorized first responders agencies participating in the EMS

System to purchase disposable and reusable clinical supplies, pharmaceuticals, other than narcotics, equipment and capital items through Contractor’s purchasing and materials management system. Contractor shall develop and maintain a policy to allow this practice and to specify the terms and conditions for its use, which Contractor shall submit as a policy to the EMS Agency for approval no less than 30 days before the service start date. This policy shall specify any charges to the first responder agency in addition to Contractor’s actual cost (and mark up if any) for purchasing and delivering such transactions. Any policy and processes to exchange and/or restock reusable medical equipment and supplies must comply with all state and federal laws, including the Drug Supply Chain Security Act (DSCSA).

4. Contractor shall not stock or provide items that are not included in the EMS Agency

Policies, Protocols and Procedures to first responders. Contractor is not responsible to restock items that it does not utilize on its Ambulances (e.g., epinephrine auto-injector) or items from a manufacturer that may be different than its own stock (e.g., nitroglycerine spray or nitroglycerine tabs).

5. Contractor shall develop, maintain, and provide to the EMS Agency, a written policy

outlining its commitment and proposed methods to return first responder and hospital personnel in a timely fashion if they assist Contractor during transport from scene or hospital.

6. In a situation when first responders assist Contractor during transport to the hospital,

Contractor shall provide or arrange timely return transportation for first responder personnel.

7. In a situation when a hospital assists Contractor during transport to another hospital,

Contractor shall provide or arrange timely return transportation for the hospital personnel.

8. Contractor shall take reasonable measures to assure that the vehicle returning first

responder or hospital personnel is not assigned to another call until it has completed the return of first responder personnel.

5.11.2 Stand-by Service for Government Agencies

Contractor shall provide, at no charge to the EMS Agency or requesting government agency, Ambulance stand-by services at the scene of an emergency incident where there may be an imminent life threat as directed by the Incident Commander. A unit placed on standby shall be dedicated to the incident. Dedicated stand-by periods exceeding two hours may be billed to the requesting agency for stand-by services without an active patient.

Proposal Instructions 1. Proposal shall describe Bidder’s plan to participate in EMS Agency-defined joint first responder/Ambulance

training programs and mandatory in-service trainings. 2. Proposal shall include Bidder’s written policy to restock disposable ALS and BLS medical supplies and

pharmaceuticals other than narcotics, as specified in the RFP. 3. Proposal shall describe Bidder’s plan to return first responder personnel to their station when the first responder

personnel assisted Contractor personnel during transport to the hospital.

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4. Proposal shall include Bidder’s experience providing stand-by services at the scene of an emergency incident where there may be an imminent life threat as directed by the Incident Commander.

5.12 COMMITMENT TO LOCAL COMMUNITY

5.12.1 Community Education

1. Contractor shall develop community education programs related to improving the public’s

understanding of the EMS System, injury and illness prevention, and appropriate use of 911.

2. Contractor shall conduct community education programs including but not limited to CPR training and Stop the Bleed.

3. Contractor shall work collaboratively with other EMS providers, community organizations,

and groups to expand opportunities for community education and to improve the scope of the community education.

4. On December 1st of each year, Contractor shall submit its plan for community education

programs to the EMS Agency for review and approval. The plan shall describe intended partner organizations for collaborative efforts in community education.

Proposal Instructions 1. Proposal shall describe the health issues on which Bidder proposes to focus, and the general nature and scope of

proposed health status improvement and community education activities. 2. Proposal shall describe Bidder’s commitment in staff FTE/hours dedicated to health status improvement and

community education. 3. Proposal shall describe Bidder’s planned community outreach and education approaches and activities. 4. Proposal describes how Bidder plans to use data to guide various health improvement and community education

activities.

5.12.2 Enhancing Health Equity and Cultural Competence

1. Contractor shall perform specific tasks and achieve outcomes designed to support achieving countywide health goals addressing equity in access and quality of services.

2. Contractor shall develop a diverse EMS workforce that:

• Reflects the composition of the community • Improves patient experience through culturally responsive and linguistically appropriate

services • Conducts outreach to high-risk, high-need communities to identify and address barriers in

service and communication. The specific requirements are outlined in Exhibit N. Proposal Instructions

1. Proposal includes Bidder’s plan that describes specific goals to address equity in access and quality of

services.

2. Proposal describes Bidder’s methods for ensuring provision of culturally responsive and linguistically appropriate services (e.g., commitment to hire bilingual/bicultural staff, use of translation services/applications).

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3. Proposal shall describe Bidder’s use of linguistically and culturally-related data collection and analysis to identify and mitigate disparities in service, and how these analyses are used to improve services to marginalized populations.

4. Proposal shall describe Bidder’s proposed approach to outreach to high-risk, high-need communities

including issue identification, potential role(s) of community members/community organizations and plans to carry out further assessment and cooperative planning with other EMS stakeholders and the EMS Agency and County.

5.12.3 Patient Satisfaction Surveys

Contractor shall perform patient satisfaction surveys not less than annually across all service lines. Surveys will evaluate patient satisfaction with Contractor and EMS System.

Proposal Instructions Proposal shall describe Bidder’s experience and approach to using independent surveys to benchmark and monitor community perceptions of its service.

5.12.4 Local Presence, Service Inquiries and Complaints

1. At least 90 days before the service start date, Contractor shall open a local headquarters in

Monterey County, staffed with Key Personnel. Contractor shall maintain a local headquarters in Monterey County throughout the term of this Agreement.

2. Contractor shall establish a web-based customer service portal to include complaints

submittals and frequently asked questions. Complaints may be anonymous, but are to be counted with a unique identification number and date/time stamp.

3. Contractor shall develop and maintain a customer service plan. The plan shall include the

process to receive and respond to questions, concerns, and suggestions. The plan shall describe how phone calls, e-mails, and written correspondence are received, routed internally, and responded to.

4. Contractor shall electronically log all inquiries and service complaints.

5. Contractor shall electronically submit to the EMS Agency monthly, a summary of all service

inquiries/complaints received and their appropriate disposition/resolution. Copies of any inquiries and resolutions of a clinical nature shall also be referred to the EMS Medical Director and EMS Agency personnel.

Proposal Instructions 1. Proposal shall provide Bidder’s proposed local headquarters location.

2. Proposal shall describe Bidder’s web-based customer service portal and complaint resolution practice, including

identifying the process by which Bidder’s leadership team will be notified of any incoming complaints calls.

5.13 FINANICAL REQUIREMENTS

5.13.1 Compensation and Method of Payment 1. Contractor shall receive income from patient charges.

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2. The EMS Agency will subsidize Contractor’s cost of using Peripheral Service Providers up to $120,000 annually in this Agreement. Contractor is responsible for any additional cost to utilize Peripheral Providers.

3. Effective February 1, 2022 rates and charges for all Ambulance Services will be bundled,

whereby most fees for service are included in the base rate, except for oxygen, mileage, emergency for BLS, and treatment without transport.

4. Contractor shall not charge more than the rates approved by the Board of Supervisors.

Proposed patient charges must take into consideration the cost of providing care to indigent and under-insured patients.

Proposal Instructions 1. Besides the $120,000 described in this section, Bidder’s proposal shall assume no other subsidies from the EMS

Agency or County.

2. Proposal shall include Bidder’s proposed fee schedules and rates which, when approved by the Board of Supervisors, will be in the provider’s negotiated Agreement with the County. The current rates are included in Exhibit C.

5.13.2 Rate Adjustments

1. Regular and ordinary annual Consumer Price Index (CPI)-based rate adjustments will be

provided following completion of the first year of service and annually thereafter throughout the term of the Agreement, following approval by the Board of Supervisors.

2. Contractor shall submit CPI-based rate adjustment requests to the EMS Agency within 30

days following completion of the first year of service and annually thereafter. If approved by the Board of Supervisors, the amount of the annual rate adjustment will be effective upon approval of the Board of Supervisors.

3. The Board of Supervisors has final authority to set the CPI rate adjustment, which may vary

anywhere in the CPI adjustment range created between Option 1 and Option 2:

Option 1: The CPI, (as recorded by the Department of Labor, Bureau of Labor Statistics CPI as of the previous twelve (12) month period for which published figures are then available for all urban consumers, San Francisco-Oakland-San Jose, with equal weighting of the Medical Care Group and the Transportation Group. (50% Medical Care Group and 50% Transportation Group). Option 2: The CPI, (as recorded by the Department of Labor, Bureau of Labor Statistics CPI as of the previous twelve (12) month period for which published figures are then available for all urban consumers, San Francisco-Oakland-San Jose, with equal weighting of the Medical Care Group and the Transportation Group. (50% Medical Care Group and 50% Transportation Group) divided by Contractor’s Average Collection Rate from the previous twelve-month period for which audit-verified figures are available.

4. In the event changed circumstances beyond the control of Contractor which substantially impact Contractor’s costs of providing services, or in the event there are substantial reductions in revenue caused by factors that are beyond the control of Contractor, Contractor may request adjustment to charges to patients to mitigate the financial impact of such changed circumstances. The changed circumstances shall be well documented to demonstrate that Contractor was unable to mitigate the circumstances causing the reduction in revenue or increased cost of service. Failure to adequately estimate the cost of providing ambulance services to the EOA will not be considered a cause of changed circumstances.

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5. Contractor shall submit its request for changes to charges to patients to the EMS Agency no

less than 90 days before the end of the fiscal year. This request will be reviewed by an Ambulance Rate Review Committee, minimally consisting of the EMS Agency’s Business and Contracts Manager and the EMS Director. This committee shall confidentially review Contractor’s request and evidence Contractor submits to justify the request. The Ambulance Rate Review Committee shall make a recommendation for or against or suggest another rate to the Board of Supervisors of Supervisors, who have final authority to approve or deny the rate adjustment.

6. Contractor shall submit necessary documentation to substantiate the need for a rate adjustment. Such documents may include but are not limited to audited financial statements, collection rate, and payor mix. The decision of the Board of Supervisors is final.

Proposal Instructions Proposal shall include Bidder’s acceptance of the rate adjustment process specified in Section 5.13.2 by executing Form G.

5.13.3 Financial Hardship

1. Contractor shall have a written Financial Hardship/Compassionate Care Program, which shall apply to patients who do not have medical insurance or have limited financial capacity. This Program policy shall describe the process of identifying patients that quality for financial hardship consideration. The Program policy shall include the process to inform the patient of the Program and contact information.

2. The Financial Hardship/Compassionate Care Program shall include the qualification

requirements and process for payment forgiveness, billing discounts, account write-offs, and payment options to include extended payment at low to no rate of interest.

3. Contractor shall develop a “Financial Statement” form to be used in the Financial

Hardship/Compassionate Care Program. This form and all information it contains shall be considered confidential and used only for the purpose of this program.

Proposal Instructions 1. Proposal shall include Bidder’s Financial Hardship/Compassionate Care Program Policy and shall include

approach to ensure patients learn how they can access the Financial Hardship/Compassionate Care Program.

5.13.4 Billing/Collection Services 1. Contractor shall operate a billing and accounts receivable system that is well documented,

easy to audit, and which minimizes the effort required of patients to recover from third party pay sources for which they may be eligible. The billing and accounts receivable process shall be “consumer friendly” to minimize complaints and undue stress on the customer. The billing system shall: • Electronically generate and submit Medicare and Medicaid claims.

• Be capable of responding to patient and third-party payer inquiries regarding submission

of insurance claims, dates and types of payments made, itemized charges, and other inquiries.

2. Contractor shall not attempt to collect its fees for local service at the time of service.

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3. Contractor shall conduct all billing and collection functions under the Agreement in a professional and courteous manner and in compliance with federal, state, and local law.

4. Contractor personnel who answer the telephone requests for service shall be easily understood

by English speakers. Contractor shall have available staff to assist Spanish speakers and shall be easily understood by the caller. Contractor shall make arrangements to effectively communicate with callers who speak other languages.

5. Contractor shall create an appeals process that allows the consumer sufficient time for appeal

of claims that are denied or not fully paid to go through governmental and private insurers appeals processes before being sent collections.

6. Contractor shall work cooperatively with the EMS Agency and Health Department to

maximize revenue from Medi-Cal Managed Care and Fee for Service programs.

7. Contractor shall respond to patient and third-party payer inquiries regarding billing, submission of insurance claims, dates and types of payments made, and other inquiries.

8. Contractor shall electronically submit to the EMS Agency monthly, a summary of all billing

inquiries/complaints received and their appropriate disposition/resolution. Copies of any inquiries and resolutions of a clinical nature shall also be referred to the EMS Medical Director and EMS Agency clinical personnel.

Proposal Instructions Proposal shall describe Bidder’s billing and collection policies and procedures.

5.13.5 Reasonable Rates

The County has a duty to its constituents to keep rates paid to its vendors at fair market value. At periodic intervals at the discretion of the EMS Director, but no less than every four years, an audit of the fair market value of services will be conducted to determine whether rates should be adjusted so that County residents can be assured that rates currently reflect fair market value. If it is determined that Contractor rates do not reflect fair market value, new rates may be negotiated at the discretion of the EMS Director to assure fair market value is paid for future services. Such rate increases or decreases shall become effective as of the start of the next year of the contract.

5.13.6 Accounting Procedures Contractor shall maintain separate financial records, in accordance with Generally Accepted Accounting Principles, for services provided pursuant to the Agreement.

5.13.7 Audits and Inspections

1. The EMS Agency shall have the right to review all business records including financial

records of Contractor pertaining to the Agreement.

2. All records shall be made available to the EMS Agency at Contractor’s local office or other mutually agreeable location. The EMS Agency may audit, copy, make transcripts, or otherwise reproduce such records, including but not limited to confidential patient records, contracts, payroll, inventory, personnel and other records, daily logs, and employment agreements.

3. On an annual basis, Contractor shall provide the EMS Agency with audited financial

statements by certified public accountants for Contractor's Ambulance Services operations in the County and, if applicable, separate business records of financial accounting of any other businesses that share overhead with Contractor's Ambulance Services operations.

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4. The EMS Agency may require Contractor to provide periodic report(s) in the format specified

by the EMS Agency to demonstrate billing compliance with relevant rules and regulations and adherence with approved and specified rates.

5. On an annual basis, or whenever updated, Contractor shall provide the EMS Agency with its

cost allocation plan.

6. On an annual basis, Contractor shall provide EMS Agency with audited financial statements of each entity that allocated costs to Contractor's Ambulance Services operations in the County during the past fiscal year.

Proposal Instructions Proposal shall describe each cost expected to be allocated from related entities to Contractor's Ambulance Services operations in the County, including methodology and amount.

5.13.8 Federal Healthcare Program Compliance Requirements Contractor shall comply with all applicable Federal laws, rules and regulations for operation of its enterprise and its Ambulance services. This includes compliance with all laws and regulations relating to the provision of services to be reimbursed by Medicare, Medi-Cal, and other government funded programs.

5.13.9 Medicare and Medi-Cal Program Compliance Requirements 1. Contractor shall implement a comprehensive Compliance Program for all activities,

particularly those related to documentation, claims processing, billing, and collection processes.

2. Contractor’s Compliance Program shall comply with the current guidelines and

recommendations outlined in the Office of Inspector General (OIG) Compliance Program Guidance for Ambulance Suppliers as published in the Federal Register on March 24, 2003 (03 FR 14255).

5.13.10 HITECH/HIPAA Federal Program Compliance Requirements

Contractor is required to implement a comprehensive plan and develop the appropriate policies and procedures to comply with the provisions of the Health Information Technology for Economic and Clinical Healthy (HITECH) Act and the Health Insurance Portability and Accountability (HIPAA) Act of 1996 and the current rules and regulations enacted by the US Department of Health and Human Services. The three major components of HIPAA include:

• Standards for Privacy and Individually Identifiable Health Information • Health Insurance Reform: Security Standards • Health Insurance Reform: Standards for Electronic Transaction Sets and Code Standards • Contractor is responsible for all aspects of complying with these rules and particularly

those enacted to protect the confidentiality of patient information. Any violations of the HIPAA rules and regulations will be reported immediately to the EMS Agency along with Contractor’s actions to mitigate the effect of such violations.

5.13.11 CCMIA/State Compliance Requirements

Contractor shall comply with all applicable state and local laws, rules and regulations for businesses, Ambulance Services, and those associated with employees, including the California Confidentiality of Medical Information Act (CCMIA). Contractor shall also comply with the County policies, procedures, and protocols and EMS System Policies, Protocols and Procedures.

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5.13.12 Other Requirements

County and Contractor recognize that new or emerging State and Federal laws and/or regulation may impact the current agreement. In those cases, where State and/or Federal law and/or regulations substantially affect the operation or provisions of the Agreement in a material manner, both parties agree to meet and confer in good faith to resolve the specific issue so that the original intent of the Agreement is retained, to the extent possible.

5.13.13 Other Financial Requirements

5.13.13.1 Administrative Oversight Fee

1. Contractor is responsible for a pro-rata share of the costs of regulation, oversight, administration, quality improvement, and EMS System infrastructure as identified herein.

2. Contractor shall reimburse the EMS Agency at the end of each quarter for its pro-

rata portion of EMS Agency’s actual cost to provide to Contractor, medical control, clinical oversight, and contractual, regulatory and administrative oversight. The annualized share to be reimbursed by Contractor is $175,000. This amount is less than the actual cost of the EMS Agency to provide these services. This amount will be adjusted annually, at the same rate as the Contractor’s CPI rate adjustment, as specified in Section 5.13.2.

5.13.13.2 Liquidated Damages

Contractor shall pay liquidated damages as specified throughout this RFP and as summarized in Exhibit O. The EMS Agency shall render its invoice for any liquidated damages to Contractor within 30 business days of the EMS Agency receipt of Contractor’s monthly performance reports.

5.13.13.3 Payment

Contractor shall pay the EMS Agency on or before the 30th day after receipt of the invoice. Any disputes of the invoiced amounts should be resolved in this thirty-day period. If they have not been resolved to the EMS Agency’s or Contractor’s satisfaction, the invoice shall be paid in full and subsequent invoices will be adjusted to reflect the resolution of disputed amounts.

5.13.13.4 Irrevocable Letter of Credit

At the execution of the Agreement, Contractor shall furnish an irrevocable letter of credit in the amount Two Million dollars ($2,000,000 USD) in the form attached hereto as Exhibit P. The letter of credit shall be issued by any of the following financial institutions: • Bank of America • Citibank • Wells Fargo • JP Morgan Chase • US Bank • Other such financial institution reasonably acceptable to the County

(hereafter the “Financial Institution”)

The letter of credit shall be maintained by Contractor in full force and effect during the entire period of the performance under the Agreement. In the event

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Contractor breaches the Agreement, the County shall be entitled to exercise its rights under the letter of credit. Contractor acknowledges that if the Issuer (as defined in the letter of credit) notifies the County that the letter shall not be extended or renewed, and Contractor does not provide a substitute letter of credit in a form acceptable to the County in its sole and absolute discretion within forty-five (45) days of such notice, Contractor shall be deemed in breach of the Agreement and the County shall be entitled to draw upon the letter of credit.

5.13.13.5 Performance Guarantee

Performance Guarantee. If Contractor’s RFP proposal is evaluated based on the combined financial strength of both Contractor and its parent company, Contractor, concurrently with Contractor’s execution of the Agreement and as a condition precedent to the effectiveness of the Agreement, shall deliver an original guaranty executed by Contractor’s parent company (“Performance Guarantee”) in the form attached as Exhibit Q.

Proposal Instructions Proposal shall include Bidder’s acceptance of the terms specified in Section 5.13.5 to Section 5.13.13 by executing Form G. 5.14 ANNUAL PERFORMANCE EVALUATION

The EMS Agency shall annually evaluate the performance of the Ambulance Contractor. As part of this evaluation, Contractor shall provide a self-evaluation report to the EMS Agency. At a minimum, the following information shall be included in the performance evaluation: • Response time performance • Clinical Performance • Workforce and health equity initiatives • Community engagement activities • Compliance with pricing and revenue recovery • Compliance with information reporting requirements • Initiation of innovative programs

Proposal Instructions Proposal shall include Bidder’s acceptance of the requirements specified in Section 5.14 by executing Form G. 5.15 PERFORMANCE MONITORING

The result of this procurement will be the award of a High-Performance Agreement, which will require Contractor to achieve and maintain high levels of performance and reliability. The demonstration of effort, even diligent and well-intended effort, will not suffice to meet the requirements of the Agreement with respect to prescribed performance requirements. Failure to meet specified service standards will result in liquidated damages and may lead to termination of the Agreement.

Proposal Instructions Proposal shall include Bidder’s acceptance of the requirements specified in Section 5.15 by executing Form G. 5.16 REPORTING REQUIREMENTS

5.16.1 Data Collection and Reporting Requirements

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1. Contractor shall provide detailed operational, clinical, and administrative data to facilitate retrospective analysis, in the form and frequency requested by the EMS Agency.

2. Reporting requirements may change from time to time at the sole discretion of the EMS

Agency.

5.16.2 Dispatch Computer/Data System Interface 1. The Contactor shall utilize a data management system that interacts with the MCECD CAD or

shall include security features that prevent unauthorized access or retrospective adjustment and provide full audit trail documentation.

2. Contractor shall provide the EMS Agency 24-hour access to all data maintained by

Contractor’s CAD or other Data System(s) as necessary to analyze demand and determine deployment procedures.

3. Contractor agrees to allow EMS Agency, at Contractor’s expense, to install an interface with

the CAD or other Data System(s) to collect and monitor computer-aided dispatch information and patient care reports.

4. Contractor, in conjunction with the EMS Agency, shall establish procedures to fully automate

the reporting requirements. 5. Contractor's interface made available to the MCECD and the EMS Agency shall provide real-

time monitoring of Contractor’s Ambulance data screens and at a minimum provide the location and status of active Ambulance calls, pending calls, location and status of Ambulances and crews.

5.16.3 EMS System Monitoring 1. Contractor shall provide at its cost and for its own use and for the use of the EMS Agency, an

EMS Agency approved data management utility monitoring and reporting system, including the following modules: First Pass, Online Compliance Utility, Hospital Status Dashboard, ProQA DashBoard, Reports, Performance Plus, and Threat Assessment. The electronic access shall also include real-time monitoring of CAD/data interface systems.

2. Contractor shall provide the EMS Agency 24-hour access to its data management utility monitoring and reporting system purpose of monitoring performance and compliance, as well as general and quality improvement data analysis and syndromic surveillance. Monitoring dashboards shall be configured to the extent possible as specified by the EMS Agency.

5.16.4 Essential Patient Care Record and Assignment Data

1. Contractor shall utilize an electronic patient care record system (ePCR) that is the current

NEMSIS Gold-compliant, meets the requirements of the state, and is approved by the EMS Agency for patient documentation on all EMS System responses including first response, patient contacts, canceled calls, and non-transports.

2. Contractor’s personnel shall assure that each ePCR is accurately completed to include all

information required by established EMS System Policies, Protocols and Procedures.

3. Contractor shall provide a copy of the ePCR (electronic or printed) to the base and receiving hospital as specified in EMS System Policies, Protocols and Procedures.

4. Contractor shall provide access for the EMS Agency, base and receiving hospitals to patient

care records in computer readable format and suitable for statistical analysis. Records shall

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contain all information documented on the ePCR for all EMS system responses, as stipulated in EMS System Policies, Protocols and Procedures.

5. Contractor shall identify files or ePCRs for trauma transports (patients meeting trauma field

triage criteria).

6. Contractor shall be required to provide other data points, which the EMS Agency may request, including any needed modifications to support EMS System data collection.

7. Pursuant to California Health and Safety Code, Section 1797.227, the EMS Agency may not

prescribe a specific electronic patient care record system. However, the EMS Agency has entered into a contract with ESO Solutions for a single, EMS System-wide EMS data system. This data system is used by nearly all the first responder and Ambulance provider organizations in the Monterey County EMS System. To minimize disruption to the Monterey County EMS System, including disruption to First Responders, the EMS Agency strongly prefers, but cannot mandate, that Contractor continue to use this system.

8. Should Contractor use the EMS Agency’s existing ESO data system, the EMS Agency will

make that data system available to Contractor at the pro-rata cost of that system, based upon the following formula: EMS Responses by Contractor / (EMS Responses by All Ambulance Providers + EMS Responses by All First Responders)

9. Based upon the current call distribution in the EMS System, Contractor’s pro-rata cost for the

Monterey County ESO Data System is approximately $64,060 annually. This cost may vary annually, based on proportion of total call volume.

10. Should Contractor utilize a data system other than ESO, Contractor shall bear all costs and responsibility to seamlessly integrate that data system into the Monterey County EMS Data System, including complying fully with the requirements of EMS System Policies, Protocols and Procedures relating to data and data management, to the satisfaction of the EMS Agency.

11. Should Contractor utilize a data system other than ESO, Contractor shall ensure that its

electronic health record system can be seamlessly integrated with the EMS Agency’s data system, so the EMS Agency may collect data from Contractor. Seamlessly means that the process must be automatic and timely and will not require any effort or cost on the part of the EMS Agency to integrate Contractor’s data and provide Search, Alert, File and Reconcile capability.

12. If changes are made to the EMS Agency’s data system, Contractor shall ensure continued

integration with the EMS Agency’s data system.

13. Should Contractor utilize a data system other than ESO, Contractor shall provide real time access to the data system to ensure that the EMS Agency’s independent statistical analysis of contract activity can take place on a real-time basis.

5.16.5 Records

Contractor shall complete, maintain, and provide to the EMS Agency, when requested, adequate records and documentation to demonstrate its performance compliance and aid the EMS Agency in improving, modifying, and monitoring the EMS System in a form approved by the EMS Agency.

5.16.6 Reports

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1. Contractor shall document and report to the EMS Agency in writing in a form and frequency required by the EMS Agency.

2. Contractor shall provide, within 10 business days after the first of each calendar month when

a report is due, computer database data in an electronic format and reports pertaining to its performance during the preceding month as it relates to the clinical, operational, and financial performance stipulated herein.

3. Contractor shall provide the EMS Agency with response time compliance and customer

complaints/resolutions reports monthly. Reports other than Response Time Interval compliance and customer complaints/resolutions may be required less frequently than monthly.

4. At the end of each calendar year, no later than November 30, the EMS Agency shall provide a

list of required reports and their frequency and due dates to Contractor.

5. Reports shall minimally include those reports listed in Exhibit E.

5.16.6.1 Failure to Provide Timely Reports

Contractor’s failure to timely provide reports, including failure to provide Unusual Occurrence reports, within the time required by EMS System Policies, Protocols and Procedures, or failure to provide/transmit ePCR reports to hospitals as required in EMS Agency Policies, Protocols and Procedures will result in liquidated damages as stated in Exhibit O.

Proposal Instructions 1. Proposal shall describe Bidder’s electronic patient care record system.

2. Proposal shall include Bidder’s acceptance of reporting requirements set forth in Section 5.16 by executing

Form G.

5.17 TRANSITION PLAN

Contractor shall successfully implement its transition plan. The transition plan shall identify dates for all milestones, coordination with EMS Agency and MCECD staff, and shall demonstrate Contractor’s readiness to provide services at the service start date. Proposal Instructions Proposal shall include a transition plan that describes in detail, Bidder’s activities, timelines, milestones, and coordination with MCECD and EMS staff, to ensure Bidder’s readiness to provide the services described in this RFP at the service start date. 5.18 EARNED EXTENSIONS

Contractor may earn extensions not to exceed a total of an additional five (5) years based on meeting specified clinical, response time, medical dispatch, and reporting metrics. In addition to the metrics for earned extensions below, Contractor shall not have been declared in Breach of the contract during the review period prior to request submission. The EMS Agency shall determine whether contract extensions will be granted.

5.18.1 Clinical Metrics

1. Minimum of 500 hours of FTO field coaching per year in the review period prior to the date

of submission of the extension request.

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2. Number of unrecognized esophageal intubations is two (2) or less per year for the review

period prior to the date of submission of the extension request.

3. Number of under-triage of STEMI patients is two (2) or less per year for the review period prior to the date of submission of the extension request.

5.18.2 Response Time Metrics 1. Monthly Response Time Interval compliance in Priority 1, 2, and 3 is not lower than 87%,

two times for any priority for each 12 month in the review period prior to the date of submission of the extension request.

2. Response Time Interval compliance in the review period is 90% for each contract quarter for Priority 1, 2, and 3 to include each response area for each Priority.

5.18.3 Medical Dispatch Metrics 1. Performance against MPDS Quality Improvement metrics demonstrates 90% or better

compliance for each month in the review period prior to the date of submission of the extension request.

5.18.4 Reporting Metrics

1. Contractor is in compliance with information reporting requirements for each of the 12 month

periods in the reporting period prior to the date of submission of the extension request.

2. Contractor provides an approved data management utility monitoring and reporting system with EMS Agency personnel access for the reporting period prior to the date of the submission of the extension request.

3. Contractor achieves the specific goals to address equity in access and quality of services described in its plan for the review period prior to the date of the submission of the extension request.

5.18.5 Transitional Period

Contractor may request one contract extension based on successful implementation of its transition plan that identifies dates for milestones to be achieved during the transition period in place of meeting the metrics in 5.18.2, 5.18.3, and 5.18.4. Contract Extension Application Process 1. Contractor may request contract extensions for a successful transition period and/or after

completing the second operational year. Subsequent extension requests shall follow the schedule outlined in the table below.

2. Contractor shall submit its request for contract extension by March 31st of the year Contractor is eligible to request an extension.

3. The contract extension request shall include documentation of successfully meeting all

metrics described in this RFP for the reporting period. The reporting period will be the two contract years prior to the request submission.

Contract Extension

Eligibility Review Period Year Extension to Be

Earned Transitional Period

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2/1/22 Upon approval of the Agreement by the Board of Supervisors to 1/21/2022

2/1/2027-1/31/2028 2/1/2028-1/31/2029 2/1/2029-1/31/2030 2/1/2030-1/31/2031 2/1/2031-1/31/2032

Operational Period 2/1/2024 2/1/2022-1/31/2023

2/1/2023-1/31/2024 2/1/2026 2/1/2024-1/31/2025

2/1/2025-1/31/2026 2/1/2028 2/1/2026-1/31/2027 2/1/2029 2/1/2027-1/31/2028 2/1/2030 2/1/2028-1/31/2029

5.19 Appeal of Extension Award Denial

Contractor may appeal denial of a contract extension award to the EMS Director. The appeal must be in writing and clearly and in detail describe any mitigating factors beyond Contractor’s control which caused Contractor to not meet the requirements for award of an extension. Denial of the appeal may be appealed to the Director of Health. This appeal must be in writing and shall describe the rationale for Contractor’s belief that the determination by the EMS Director should be reversed. The determination by the Director of Health will be final.

6.0 CONTRACT TERM

6.1 The term of the Agreement shall be from the date of approval of the Agreement by the Board of Supervisors to January 31, 2027 at 2400, local time. Contractor may earn extensions not to exceed a total of an additional five (5) years according to the terms of the renewal provisions of the Agreement.

6.2 Contractor will provide all services required in this RFP, to the satisfaction of the EMS Agency,

continuously from February 1, 2022 at 0001, local time, through January 31, 2027 at 2400, local time and through all earned contract extensions.

6.3 The transition period from the date of approval of the Agreement by the Board of Supervisors to February

1, 2022 will be considered a pre-operational phase of the Agreement where Contractor is responsible for meeting all pre-operational requirements outlined in this RFP, Exhibit E, and successful implementation of its transition plan that identifies dates for milestones to be achieved during the transition period.

Proposal Instructions Proposal shall include a Transition Plan as described in Section 5.17 that ensures that Bidder can commence provision of all services provided pursuant to this RFP at 0001 on February 1, 2022, local time.

7.0 LICENSING/SECURITY REQUIREMENTS

7.1 Contractor is required to ensure that all services, costs, and materials must, at minimum, meet the specifications for State of California and CAL/OSHA regulations, as applicable.

7.2 Contractor shall ensure that the insurance and required licenses under both state and local jurisdictions are current during the full term of the Agreement.

7.3 Contractor shall maintain business or professional licenses, permits or certificates required by the nature of the contract work to be performed during the full term of the Agreement.


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Bidder shall provide copies of business or professional licenses, permits or certificates required by the nature of the contract work to be performed. If Bidder does not have a local operation, examples of state licenses, and local permits for other operational locations may be submitted to fulfill this requirement.

8.0 PROPOSAL REQUIREMENTS

1. County and EMS Agency require a well-qualified and experienced Contractor to provide Ambulance Services. An inexperienced Contractor increases the risk of clinical, operational and financial failure associated with this Service. Therefore, use of an inexperienced contractor poses a preventable risk to public health and safety that is unacceptable to the EMS Agency.

2. Bidders must demonstrate ability to provide and coordinate Ambulance Services and associated systems of care to meet the needs of the people of Monterey County. Each Bidder is limited to submitting one Proposal. A Bidder may not submit multiple proposals.

3. Proposals not meeting the minimum qualifications will be disqualified. To qualify for an evaluation by the Proposal Review Panel, a Bidder must meet the following Proposal Minimum Qualifications:

8.1 GENERAL PROPOSAL INSTRUCTIONS

1. The proposal narrative shall respond to each topic listed in Section 5.0 in the sequence that the

topics appear within Section 5.0. The Proposal must utilize the stipulated sections, heading titles and numbering set forth in Section 8.5.

2. The response to each item must contain all the information that Bidder is providing with respect to that topic. The response may incorporate by reference information contained in the proposal exhibits but may not incorporate by reference any information contained in other portions of the proposal narrative.

3. Except for information appearing in a proposal exhibit that is expressly referenced in a

response, information not set forth in the portion of the proposal narrative clearly identified as responding to a specific topic in Section 5.0 may be disregarded in the rating of the proposal. Reviewers may disregard information submitted in the proposal if it is not included in the mandated location defined by these instructions

4. Each Bidder shall confirm acceptance of the core requirements, and where appropriate, describe

in detail how it proposes to meet or exceed each of the requirements. Failure to comply with these instructions may result in the rejection of the proposal.

5. This includes:

• Bidder must explain how it will achieve the required level of performance. For example,

what activities it will undertake, the specific organizational capabilities will support achievement of the requirement, resources that will be applied, etc.

8.2 OPERATIONAL EXPERIENCE

Bidder shall include a statement of Bidder’s relevant experience, including its corporate background and experience in providing the required service. Bidder should thoroughly describe, in the form of a narrative, its experience and success in providing the services described in this RFP.

8.2.1 Ambulance Services Experience and EMS Medical Dispatch

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1. Bidder shall be regularly and continuously engaged in the business of providing emergency and non-emergency Ambulance response, deployment, and transportation services, with specialty care transportation services, and CCT or ALS interfacility transports, through a performance contract at an ALS level for a specified area of greater than 250,000 persons for at least a three (3) year period in the last five (5) years. Any documentation for whom the services are provided and CAAS accreditation history of the center (if any) shall be included. Bidder shall provide a list and description of the Ambulance Services contracts to include location of service area, level of services provided, population served, length of contract, and whether the contract is performance or level of effort based. Bidder shall also describe specialty care transport services provided to include type of services provided, organization for whom services have been provided, and the number of transports provided each year.

2. Bidder shall be regularly and continuously engaged in providing Emergency Medical Dispatch services, using the Medical Priority Dispatch System, and responsible for the dispatch, deployment, and movement of Ambulances for a specified area of greater than 250,000 persons for at least a three (3) year period in the last five (5) years. Any documentation for whom the services are provided and IAED accreditation history that the center may have (if any), shall be included. Bidder shall document its service history providing Emergency Medical Dispatch services using MPDS.

Note: For purposes of Section 8.1.1 above, the three (3) year requirement may be satisfied by demonstrating continued operation of qualified Ambulance Services systems/contracts and Emergency Medical Dispatch Services under a changed ownership and/or legal structure whereby there was no material change to policies, procedures or personnel.

8.2.2 Organizational Requirements

8.2.2.1 Organizational Ownership and Legal Structure

1. Bidder shall describe, in detail, its legal structure including type of organization, as well as

its date and place (state) of formation.

2. Bidder shall be a single legally established entity. If a joint venture or joint powers agency responds to this RFP, questions regarding experience, organizational structure, financial strength, and other items on this RFP must be answered by each member of the joint venture or joint powers agency.

3. The County will scrutinize the organizational structure, experience, financial strength, and

other items in this RFP as they relate to each member of the entity. Of particular interest to the County is the impact to patient rates and the EMS Agency’s ability to administer the Agreement.

4. Bidder shall identify and describe each related entity that may allocate costs to

Contractor's Ambulance Services operations in the County and provide justification of the costs that the entity may allocate.

8.2.2.2 Continuity of Business

Bidder shall provide the organization’s background and history, including the number of years it has operated under the present business name, as well as under prior business names.

8.2.2.3 Government Investigations

1. Bidder must provide a listing of all federal, state, or local government regulatory

investigations, findings, actions or complaints brought against Bidder’s organization and any parent or affiliated organization within the last five (5) years.

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2. If Bidder has not existed in its present legal form for five (5) years but is a continued operation of qualified Ambulance Services systems/contracts under a changed ownership and/or legal structure whereby there was no material change to policies, procedures or personnel, Bidder must also provide a listing of all federal, state, or local government regulatory investigations, findings, actions or complaints brought against Bidder’s predecessor organization including any parent or affiliated organization within the last five (5) years.

3. The Government Investigation listing is to include the respective resolutions of each investigation or action. THIS ITEM MAY BE SUBMITTED SEPARATELY IN AN ELECTRONIC FORMAT SUCH AS A USB DRIVE and will not count against the limits on Proposal length set forth in 9.0. Bidder must:

• Provide documentation that it has resolved all issues arising from closed/resolved

government investigations including any continued obligations of Bidder, and • Describe the status and expected outcome of any open/ongoing investigations.

8.2.2.4 Litigation History

1. Bidder shall document its litigation history. Bidder may be disqualified if a final judgment

was issued against Bidder or any affiliated organization for breach of contract or failure to competently and adequately perform Ambulance Services. For purposes of this litigation history, “affiliated organization” means any organization owned by Bidder, any organization for which Bidder is a successor entity, any organization that either merged with Bidder or divested from Bidder, or any organization which is a parent or subsidiary of Bidder.

2. If Bidder has not existed in its present legal form for five (5) years but is a continued operation of qualified Ambulance Services systems/contracts under a changed ownership and/or legal structure whereby there was no material change to policies, procedures or personnel, Bidder must also document the litigation history of Bidder’ predecessor organization including any parent or affiliated organization within the last five (5) years.

3. The proposal must include a listing of all resolved or ongoing litigation involving Bidder’s organization, including a narrative describing the claim or case and the resolution or status for the past five (5) years. This listing shall include litigation brought against Bidder’s organization or affiliated organizations and any litigation initiated by Bidder’s organization or affiliated organizations against any governmental entity or competing Ambulance provider. The term “litigation” includes disputes resolved by mediation or arbitration. THIS ITEM MAY BE SUBMITTED SEPARATELY IN AN ELECTRONIC FORMAT SUCH AS A USB DRIVE and will not count against the limits on Proposal length set forth in Section 9.0.

8.2.2.5 Contracts in Good Standing

1. Bidder shall possess current Ambulance Services contracts in good standing. Bidder may

be disqualified if found to have a history of contract terminations.

2. Bidder shall provide a statement that all existing Ambulance Services contracts with any governmental jurisdiction are in good standing with no delinquent obligations, financial or otherwise. Failure to provide accurate information may lead to disqualification.

3. If Bidder has not existed in its present legal form for five (5) years but is a continued

operation of qualified Ambulance Services systems/contracts under a changed ownership and/or legal structure whereby there was no material change to policies, procedures or personnel, Bidder must also document the Ambulance Services contract history of

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Bidder’s predecessor organization including any parent or affiliated organization within the last ten (10) years.

4. Bidder shall submit a list or table of every community Bidder currently serves and every

contract area it has served in the ten years prior to submission of its proposal. Indicate:

• Type and level of service provided including the population served • The contract period • Whether Bidder held exclusive market rights for emergency Ambulance Services to

the community • Whether the contract was competitively awarded • The community name, address, contact person and telephone number • Dollar amount of the services provided • The name of the contracting agency • The remaining term of each contract • The circumstances under which any contracts were terminated, prior to expiration, the

cause of the failure to complete and any allegations of deficient service if applicable. 8.2.2.6 Contracts with EMS System Participants

Bidder shall submit with its proposal, each and every proposed or executed contract or agreement with any participant in the Monterey County EMS System including, but not limited to, hospitals, health systems, cities, fire departments, fire districts, dispatch centers, and other public or private-sector organizations. If no executed or proposed contracts are established or planned, this must be stated.

8.2.2.7 References

1. Bidder shall provide five current and/or former public entities to whom Bidder has or is

providing EMS Medical Dispatch and Ambulance Services and Prehospital ALS Emergency Medical Services as described in Section 8.2. Report references on Form H. References must include verification of the requisite experience including that required for all Key Personnel in the delivery of Ambulance Services. All references must be satisfactory in the EMS Agency’s sole determination. Entities used as references must have, at least, similar scope, volume, and requirements to those outlined in the specifications, terms and conditions of the RFP.

2. If Bidder has not existed in its present legal form for five (5) years but is a continued

operation of qualified Ambulance Services systems/contracts under a changed ownership and/or legal structure whereby there was no material change to policies, procedures or personnel, provide five current and/or former public entities to whom Bidder has or is providing EMS Medical Dispatch and Ambulance Services and Prehospital ALS Emergency Medical Services as described in Section 8.2. Report references on Form H. References must include verification of the requisite experience including that required for all Key Personnel in the delivery of Ambulance Services. All references must be satisfactory in the EMS Agency’s sole determination. Entities used as references must have similar scope, volume, and requirements to those outlined in the specifications, terms and conditions of the RFP.

3. Bidder must verify that the contact information for all references provided is current and

valid.

4. Bidder is strongly encouraged to notify all references that the EMS Agency may contact them to verify Bidder’s information and to obtain a reference.

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5. The EMS Agency may contact some or all of the references provided in order to determine Bidder’s performance record on work similar to that described in this RFP. The EMS Agency reserves the right to contact references other than those provided in the Proposal and to use the information gained from them in the evaluation process.

8.2.2.8 Debarment and Suspension

1. Bidder must disclose whether it is currently debarred, or was previously debarred, by a public entity. If Bidder is or was previously debarred, Bidder must describe in detail the circumstances giving rise to its debarment, the public entity that debarred Bidder, and the date that Bidder was debarred.

2. Bidder must disclose whether it and/or its key personnel are identified on the list of federally debarred, suspended or other excluded parties located at www.sam.gov or the Department of Health Service’s List of Excluded Individuals and Entities.

3. Bidder shall complete and submit Form D.

4. Bidder may be disqualified if found to have been debarred.

8.3 KEY PERSONNEL

1. Key Personnel are expected to be competent and of sound moral and ethical character. Bidder

shall disclose any litigation initiated, final judgment issued or action by any regulatory entity taken against any member(s) of its Key Personnel for breach of contract or failure to competently and adequately perform Ambulance or other emergency services.

2. This item may be submitted in an electronic format, such as compact disc or USB drive. The proposal must include a listing of each such resolved or ongoing litigation or action, including a narrative describing the claim or case and the resolution or status for the past five (5) years. The term “litigation” or action includes disputes resolved by mediation or arbitration.

8.4 FINANCIAL CONDITION

8.4.1 Financial Stability

1. Bidder shall provide evidence that clearly documents the financial history of the organization and demonstrates that it has the financial capability to handle the expansion (including implementation and start-up costs) necessitated by the award of the contract.

2. Bidder shall provide a statement of the organization’s current estimated net worth and the form of the net worth (liquid and non-liquid assets).

3. Bidder shall provide copies of externally-audited financial statements for the most recent five (5) years. If the organization is a wholly owned subsidiary of another corporation, Contractor shall also provide externally audited financial statements for the parent corporation for the most recent five (5) years. If consolidated financial statements are utilized, the individual program unit’s financial statements must be separately shown. Such a parent entity shall be required to guarantee the performance of Bidder.

4. If Bidder has not existed in its present legal form for five (5) years but is a continued operation of qualified Ambulance Services systems/contracts under a changed ownership and/or legal structure whereby there was no material change to policies, procedures or personnel, provide copies of externally-audited financial statements for the entire time of the current organization’s existence, up to five (5) years. The parent entity shall be required to guarantee the performance of Bidder.

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http://www.sam.gov/



5. Bidder shall provide a statement disclosing whether Bidder holds a controlling interest in any other organization is or owned or controlled by any other organization.

6. Bidder shall provide a statement disclosing Bidder’s financial interests in in other related businesses.

7. Bidder shall provide a statement disclosing the names of persons with whom Bidder has been associated in business as partners or business associates in the last five (5) years. If Bidder has not existed in its present legal form for five (5) years but is a continued operation of qualified Ambulance Services systems/contracts under a changed ownership and/or legal structure whereby there was no material change to policies, procedures or personnel, Bidder must also provide a statement disclosing the names of persons with Bidder’s predecessor organization including any parent or affiliated organization has been associated in business as partners or business associates within the last five (5) years.

8.4.2 Working Capital

1. Bidder shall possess sufficient working capital to support the terms of the Agreement, if

awarded.

2. Bidder shall provide a statement of the organization’s amount of working capital and the estimated amount that will be committed to startup costs.

3. Bidder shall provide a statement of the method of financing, attach any endorsement documents necessary, of all startup and operational costs including, but not limited to, the initial Ambulance fleet and equipment and facility leases required to begin operations.

4. Bidder shall provide a statement of the amount of funding that will be dedicated to "Reserve for Contingencies."

5. Bidder shall provide a list of commitments, and potential commitments which may impact assets, lines of credit, guarantor letters, or otherwise affect the responder's ability to perform the contract.

8.5 Proposal Content and Layout To be considered responsive, Bidder’s proposal must: • Meet the minimum qualifications set in this RFP • Include response to Sections 5.0, 6.0, 7.0, and 8.0 • Include all forms

o Form A – Cover Letter o Form B – Signature Page o Form C – Table of Contents o Form D – Debarment and Suspension Certificate o Form E – Non-Collusion Declaration o Form F – Acknowledgments o Form G – Acceptance of Terms o Form H – Experience and References o Form I – Patient Charges o Forms J, J1, J2, and J3 – Revenue and Expense Reporting

• Affix signatures to each document requiring signatures • Include pricing, revenue, and expenses using Form I and Forms J, J1, J2, and J3, following

the proposal instructions as described in Section 11.0 Revenue, Expenses and Pricing • Follow the submittal instructions and conditions outlined in Section 9.0 Submittal Instruction

and Conditions.

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The table below is a summary of requirement is provided as a guide only. It is the Bidder’s responsibility to ensure its proposal is complete.

PROPOSAL PACKAGE AND LAYOUT

Item Description Form Pass/ Fail

Cover Letter All proposals must be accompanied by a

cover letter not exceed two pages and provide firm information and Contact information as follows: Contact Info: The name, address, telephone number, e-mail, and fax number of Bidder’s primary contact person during the solicitation process through to potential contract award. Firm Info: Description of the type of organization under its present business name and related prior business names, how many years it has been in existence, and how many years it has provided the required services.

A

Signature Page To validate the proposal, Bidder shall submit the SIGNATURE PAGE with its proposal. Proposals submitted without that page will be deemed non-responsive. Proposal signature must be manual, in BLUE ink, and included with the original copy of the proposal. Photocopies of the Signature Page may be inserted into the remaining proposal copies. All prices and notations must be typed or written in BLUE ink in the original proposal copy as well. Errors may be crossed out and corrections printed in BLUE ink or typed adjacent and must be initialed in BLUE ink by the person signing the proposal.

B

Signed Addenda If any addenda were released for this solicitation, each addendum should bear the Bidder’s signature.

Table of Contents Proposal must be organized in the order outlined in the Table of Contents.

C

8.2.8 Debarment and Suspension

Bidder must disclose whether they are currently debarred, or were previously debarred, by a public entity.

D

16.0 Non-Collusion Collusion, bid-rigging, bid-suppression, or similar attempts to manipulate the outcome of this procurement are prohibited, and will be cause for immediate disqualification of all Bidders involved.

E

Acknowledgements Among other things, Bidder acknowledges that • the data in its response is true and

accurate • It has investigated all aspects of the RFP

F

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PROPOSAL PACKAGE AND LAYOUT Item Description Form Pass/

Fail

• Is aware of the applicable facts pertaining to the RFP process, procedures, and requirement

• Has read and understands the RFP • Has the capability to successfully

undertake and complete the responsibilities and obligations of its response being submitted

• Will be able to meet the minimum proposal requirements as specified in this RFP

• Will comply with the necessary certifications and assurances if a contract is awarded

15.0 Acceptance of Terms • Bidder must accept and check all boxes in Form G. Failure to do so may be viewed as a material deviation from the requirements of this RFP and may result in disqualification of the bid proposal.

• The Acceptance Form must be signed by an individual with authority to bind Bidder.

G

8.2.1 Operational Experience Ambulance Services and EMS Medical Dispatch Experience

8.2.2 Organizational Requirements

Proposal includes: 8.2.2.1 Description of Organizational and Legal Structure 8.2.2.2 Continuity of Business Organizational background and history 8.2.2.3 Government Investigations-List of federal, state, or local government investigations or statement indicating that Bidder has no investigations to report. 8.2.2.4 Litigation History or statement indicating Bidder has no litigation history to report. 8.2.2.5 Contracts in good standing statement 8.2.2.6 Contracts with EMS System Participants or statement of no contracts.

8.2.2.7 References Proposal shall include five current and/or former references

H

8.3 Key Personnel Proposal includes disclosure of any litigation initiated, final judgment issued or action by any regulatory entity taken against any member(s) of its Key Personnel for breach of contract or failure to competently and adequately perform Ambulance or other

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Fail

emergency services or statement indicating Bidder has nothing to disclose.

This item may be submitted in an electronic format, such as compact disc or USB drive

8.4 Financial Condition 8.4.1 Financial Stability Proposal includes Bidder’s documentation related to the financial history of the organization.

8.4.2 Working Capital Proposal includes information related to its working capital.

5.0 Scope of Work 5.1 Basic Ambulance Services 5.2 EMS Dispatch and Communications 5.3 EMS Medical Dispatch Redundancy 5.4 EMS Call Processing and Response Time Performance 5.5 Ambulance Operations 5.6 Medical Requirements 5.7 Clinical Management, Alternative Transportation, and EMS Innovation 5.8 Personnel 5.9 Training and Continuing Education 5.10 Multi-Casualty Incidents (MCI) and Medical Disasters 5.11 EMS System Participation 5.12 Commitment to Local Community 5.13 Financial Requirements 5.14 Annual Performance Evaluation 5.15 Performance Monitoring 5.16 Reporting Requirements 5.17 Transition Plan

11.0 Revenue and Expenses, and Pricing

Form I: Patient Charges Forms J, J1, J2, and J3: RFP Revenue, Expenses and Pricing Reporting Template Forms submitted in a sealed envelope and enclosed with the other proposal materials

I J J1 J2 J3

Appendix Appendices may not exceed 100 pages. Bidders may provide additional information that it believes to be applicable to this proposal package and include such information in an Appendix section. Any such information provided in the Appendix must reference the mandatory table of contents section of the RFP it supports.

7.0 Licensing/Security Requirements

Copies of licenses and permits (as applicable)

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Fail

9.0 Submittal Instructions and Conditions

Proposal followed instructions in this section of the RFP.

Pass Responded to Section 5.0 Scope of Work, forms are included, all required documents have signatures, meets minimum qualifications set in Section 8.0 Proposal Requirements of the RFP. Fail Response to Section 5.0 Scope of Work is incomplete/not included, missing forms, documents are missing signatures, does not meet minimum qualifications set in Section 8.0 Proposal Requirements of RFP.

9.0 SUBMITTAL INSTRUCTIONS & CONDITIONS

9.1 Submittal Identification Requirements: ALL SUBMITTALS MAILED OR DELIVERED CONTAINING PROPOSALS MUST BE SEALED AND BEAR ON THE OUTSIDE, PROMINENTLY DISPLAYED IN THE LOWER LEFT CORNER: THE SOLICITATION NUMBER RFP #10735 and BIDDER’S COMPANY NAME.

9.2 Mailing Address: Proposals shall be mailed to County at the mailing address indicated on the

Signature Page of this solicitation.

9.3 Due Date: Proposals must be received by County ON OR BEFORE the time and date specified, at the location and to the person specified on the Signature Page of this solicitation. It is the sole responsibility of Bidders to ensure that the proposal is received at or before the specified time. Postmarks and facsimiles are not acceptable. All Proposals received after the deadline shall be rejected and returned unopened.

9.4 The County shall record on each Proposal received by County ON OR BEFORE the date and time specified, a separately identified proposal number, and the date and time the Proposal was received. These proposals shall be kept unopened and secured in a locked receptacle.

9.5 Shipping Costs: Unless stated otherwise, the F.O.B. for receivables shall be destination. Charges for

transportation, containers, packaging and other related shipping costs shall be borne by the shipper.

9.6 Withdrawal: A proposal may be withdrawn in person by a Bidder or an authorized representative, provided his/her identity is made known, and he/she signs a receipt for the proposal, but only if the withdrawal is made prior to the exact time set for the opening of proposals.

9.7 Acceptance: Proposals are irrevocable and subject to acceptance at any time within 180 days after opening. Monterey County reserves the right to reject any and all proposals or part of any proposals or to postpone the scheduled deadline date(s), and to waive any informalities or technicalities that do not significantly affect or alter the substance of an otherwise responsible proposal and that would not affect a Bidder’s ability to perform the work adequately as specified.

9.8 Ownership: All submittals in response to this solicitation become the property of the County of

Monterey. If a Bidder does not wish to submit a Proposal but wishes to acknowledge the receipt of the request, the reply envelope shall be marked “No Bid”.

9.9 Compliance: Proposals that do not follow the format, content and submittal requirements as

described herein, or fail to provide the required documentation, may receive lower evaluation scores or be deemed non-responsive. Any and all USB devices submitted as part of the proposal shall be free of viruses and other malware.

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9.10 CAL-OSHA: The items proposed shall conform to all applicable requirements of the California Occupational Safety and Health Administration Act of 1973 (CAL-OSHA).

9.11 Nine (9) sets of the proposal (one original proposal marked “Original” plus eight (8) copies shall be

submitted in response to this solicitation. Each copy shall include a cover indicating the company name submitting, and reference to “RFP 10735 Exclusive Ambulance Services Provider for the Monterey County Exclusive Operating Area (EOA). In addition, submit an electronic version of the entire proposal on a USB memory stick. Additional copies may be requested by the COUNTY at its discretion.

9.12 Proposals shall be prepared on 8-1/2” x 11” paper, preferably duplex printed bound with front and back covers. Fold out charts, tables, spreadsheets, brochures, pamphlets, and other pertinent information or work product examples may be included as Appendices. The total number of pages, excluding requested attachments or USB drives, must not exceed 500 pages.

9.13 Attachments and supporting documents not specifically required by the RFP will not be evaluated. Supporting materials submitted with the proposal, if any, will not be returned. Pages in excess of the page limitation will not be evaluated.

9.14 Reproductions of the Monterey County Seal shall not be used in any documents submitted in response to this solicitation.

9.15 Bidders shall not use white-out or a similar correction product to make late changes to their proposal but may instead line out and initial in BLUE ink any item which no longer is applicable or accurate.

9.16 To validate your proposal, submit the SIGNATURE PAGE (contained herein) with your proposal. Proposals submitted without that page will be deemed non-responsive. Proposal signature must be manual, in BLUE ink, and included with the original copy of the proposal. Photocopies of the Signature Page may be inserted into the remaining proposal copies. All prices and notations must be typed or written in BLUE ink in the original proposal copy as well. Errors may be crossed out and corrections printed in BLUE ink or typed adjacent and must be initialed in BLUE ink by the person signing the proposal.

9.17 CONFIDENTIAL OR PROPRIETARY CONTENT: Any page of the proposal that is deemed by Bidders to be a trade secret by Bidders shall be clearly marked “CONFIDENTIAL INFORMATION” or “PROPRIETARY INFORMATION” at the top of the page. Notwithstanding the above, the entire proposal cannot be marked as Confidential or Proprietary and may ultimately be subject to release upon the award of the Agreement. The County and EMS Agency must comply with California Public Records Act requests pursuant to California Government Code, Section 6240 et. Seq.

10.0 SELECTION CRITERIA

ONLY PROPOSALS THAT MEET THE MINIMUM PROPOSAL QUALIFICATIONS LISTED BELOW AND FURTHER DESCRIBED IN SECTIONS 8.0 - PROPOSAL REQUIREMENTS AND SECTION 9.0 – SUBMITTAL INSTRUCTIONS & CONDITIONS WILL BE EVALUATED

10.1 PROPOSAL REVIEW PANEL The EMS Director shall appoint a Proposal Review Panel to evaluate the proposals received in response to the RFP. The Proposal Review Panel shall be selected by the EMS Agency in order to ensure that as a whole, the Proposal Review Panel includes members who are familiar with or oriented to various aspects of EMS systems, members who are knowledgeable with EMS needs of Monterey County, and members who have expertise in various EMS disciplines. Members may not have a conflict of interest.

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10.2 PROPOSAL EVALUATION REVIEW

1. The selection of Contractor and subsequent contract award will be based on the criteria contained

in this RFP, as demonstrated in the submitted proposal. Bidders should submit information sufficient for the County to easily evaluate proposals with respect to the selection criteria. The absence of required information may cause the proposal to be deemed non-responsive and may be cause for rejection.

2. The goal of this procurement is to select an exclusive contracted provider of Ambulance Services

for the Monterey County EOA based on clinical and operational quality of service while also constraining service costs to the public and other payers. To achieve these goals, all proposals will be scored on the criteria herein, which are designed to objectively identify proposals that will provide for higher service quality and cost effectiveness.

3. Evaluation of proposals received in response to this RFP will be conducted comprehensively,

fairly and impartially. Structured quantitative scoring methods will be used to maximize the objectivity of the evaluation. The Proposal Review Panel of designated reviewers will review and evaluate proposals. Independent and unbiased technical experts may provide analysis to the Proposal Review Panel.

4. Since this process is focused on a comparison of Bidders’ responses to criteria defined in this RFP,

the review and scoring of the proposals will be based on comparing Bidders’ responses to the criteria. Each set of criteria will be allocated a specific number of maximum available points.

Note: The EMS Agency’s priorities are cost containment and to provide members of the community high quality service at the lowest reasonable cost. Bidders are discouraged from submitting proposals that increase cost but do not add measurable or quantifiable value. Failure to provide required specified documentation related to any of the criterion outlined in this RFP may be cause for the proposal to be considered non-responsive. 10.3 SCORING METHODOLOGY

Evaluators will use the following methodology as guidance for assigning objective scores to the elements and overall subject. 100% = Excellent: The proposal successfully addresses all relevant aspects of the element being evaluated. There are no shortcomings and the element contributes appropriately to meeting the requirements of the criterion. 75% = Good: The proposal addresses the element well; although, certain improvements are possible in relation to meeting the overall criterion. There are minor shortcomings, but the element contributes appropriately to meeting the requirements of the criterion. 50% = Fair: The proposal broadly addresses the element; however, there are clear weaknesses that would need additional clarification or justification in relation to meeting the overall criterion. 25% = Poor: The proposal has inherent and or significant weaknesses with respect to the element being evaluated and does not materially support the criterion. 0% = Fail: The proposal fails to address any of the elements or fails to address in all aspects and its relationship to supporting the criterion.

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The following table provides an example of how the scoring methodology can be used to evaluate proposals.

Area of Evaluation Maximum

Points Available

Evaluation Rating

Percentage Awarded

Points Awarded

EMS Dispatch and Communications

200 Excellent 100% 200

Ambulance Operations 400 Good 75% 300

Medical Requirements 200 Fair 50% 100

Commitment to Personnel 200 Excellent 100% 200

Training and CE 100 Good 75% 75

MCI and Medical Disasters 100 Fair 50% 50

EMS System Participation 100 Poor 25% 25

Commitment to Local Community 300 Good 75% 225

Financial Requirements/Condition 300 Excellent 100% 300

Transition Plan 200 Good 75% 150

Costs/Pricing 400 Excellent 100% 400

Additional Points Awarded 150 100

Oral Presentation/Interview 0

Total Points 2,500

2,125

10.4 MAXIMUM POINTS AND ALLOCATION OF POINTS

The following table identifies the maximum points allocated in total and the maximum allocation of points for each area of evaluation.

Proposal demonstrates the ability to meet the requirements of the RFP in order to serve the EOA throughout the term of the Agreement.

Proposal demonstrates the ability to meet or exceed the standards outlined in the RFP and specified in Monterey County EMS Policies, Protocols and Procedures.

It is the responsibility of Bidder to ensure its proposal responds to every section of the RFP. AREA OF EVALUATION MAXIMUM

POINTS AVAILABLE

1. EMS DISPATCH AND COMMUNICATIONS 300 5.2.1 • Demonstrates experience, ability, and commitment to function as EMS Medical

Dispatch. • Details a plan that demonstrates the ability to seamlessly integrate Bidder’s CAD

system with MCECD CAD and other PSAPs CAD systems. • Detailed plan that demonstrates ability to provide call intake, MPDS, SSM, and

dispatch services. 5.2.2 • Includes proposed location of the dispatch center and capability for site

development, backup power generation, and site security. 5.2.3 • Includes a plan to obtain EMS Agency designation as an EMS Medical Dispatch. 5.2.4 • Describes adequate plan to coordinate with other PSAPs.

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POINTS AVAILABLE

5.2.5 • Includes the plan demonstrating the process to maintain high levels of MPDS and QI functions.

5.2.6 • Plan provides adequate staffing of EMS Medical Dispatch and to address workload fluctuations, including unplanned surge event.

5.2.7 • Provides a detailed Interoperability Communications System Equipment and Management Plan that meets, or exceeds, the minimum requirements and functionality outlined this RFP.

5.3 • Includes specific and implementable provisions for backup/redundant EMS Medical Dispatch.

Additional points for commitment to obtain IAED accreditation. 50 2. AMBULANCE OPERATIONS 500

5.1.1-5.1.9 5.4.1-5.4.22 8.2

• Describes proven, successful experience providing ambulance services and to comply with all EMS System Policies, Protocols and Procedures.

• Demonstrates ability to meet, or exceed, service standards, including response time standards.

• Describe plan to manage special event coverage for large events or multiple events 5.5.1 5.5.2 5.5.3 5.5.4

• Proposes an adequate number of reliable ambulances and supervisor vehicles that are well maintained, properly equipped, and replaced to service the Monterey County EOA.

• Shows ability to equip vehicles with appropriate technologies that are compatible with various communication and navigation systems used in the Monterey County EMS system.

5.5.5 • Describes a robust and effective fleet maintenance and repair program. 5.5.6 5.5.7 5.5.8

• Proposes a satisfactory vehicle replacement schedule is satisfactory that meets, or exceeds, RFP requirements.

• Provides clear policy for reporting failures to EMS Agency and for the maximum number of years and mileage vehicles will be retained in the EMS System.

5.5.9 • Describes staffing plan to ensure appropriately staffed ambulances available for response.

Deployment Plan 5.5.10 • Deployment plan provides sufficient detail to demonstrate Bidder’s ability and

commitment to meet, or exceed, the requirements of the RFP on a 24/7/365. • Proposal and deployment plan reflect sufficient unit hours, vehicles, and

deployment locations to meet the provision of Section 5.4. Equipment 5.5.11 • Demonstrates that the proposed equipment and supplies will be suitable for use

under Monterey County Policies, Protocols and Procedures and will coordinate with systems currently in use.

• Provide detailed policies regarding scheduled replacement and anticipated safe, useful life expectancies of all types of equipment to be furnished.

5.5.12 • Includes a detailed equipment maintenance and repair program, including the mechanism used to track such maintenance and repair.

Additional points for commitment to become accredited as an ALS Ambulance Services from the Commission on Accreditation of Ambulance Services (CAAS).

50

3. MEDICAL REQUIREMENTS 500

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POINTS AVAILABLE

5.6.1 5.6.2 5.6.3 5.6.4 5.6.5

• Demonstrates successful experience and approach to implementing and maintaining successful QI programs.

• Describes successful experience in participating in medical reviews and audit processes and how Bidder translates findings into system improvements.

• Describes commitment to securing and maintaining own DEA registration during the term of the Agreement.

Clinical Outcomes 5.6.6 • Describes demonstrated experience using KPIs and the process to measure, monitor,

benchmark, and achieve specified levels of performance on the corresponding KPIs and clear, and realistic.

• Describes appropriate methods for handling, analyzing, and contributing data for use in multi-agency outcomes improvement processes.

Case Management and Alternative Transportation 5.7 • Describes successful experience participating in case management and alternate

transportation of 5150/behavioral health patients, and high frequency/low acuity patients.

• Provides viable, innovative solutions to the two scenarios provided. 4. PERSONNEL 300

5.8.1 • Presents a plan and commitment to retain personnel throughout the term of the Agreement.

• Provides programs and policies to govern employment opportunities for incumbent personnel.

5.8.2 • Policies clearly demonstrate commitment to ensuring that providers are free from influence of alcohol and intoxicating drugs.

• Describes a strong approach to minimizing drug use among employees. 5.8.3 5.8.4 5.8.5 5.8.6 5.8.7

• Key personnel committed to Monterey County EOA operations are highly qualified. • Key personnel’s experience, education and training are well-suited for their

positions. • Describes the system and processes for maintaining employee records of all

required licenses, certifications, and certificates. 5.8.8 5.8.9 5.8.10 5.8.11 5.8.12 5.8.13 5.8.14 5.8.15

• Documents programs, plans and policies which demonstrate a strong commitment to the well-being, safety, professional development, and engagement of personnel.

• Includes policies that show compliance with regulatory requirements and prevention of discrimination.

Additional points for commitment that Contractor’s EMS Supervisors be credentialed as Supervising Paramedic Officers (SPO) by the National EMS Management Association.

50

5. TRAINING AND CONTINUING EDUCATION 200 5.9.1 5.9.2

• Includes a robust and reliable Learning Management System. • Describes a robust Training Plan to provide mandatory training that meets or

exceeds requirements.

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POINTS AVAILABLE

6. MULTI-CASUALTY INCIDENTS (MCI) AND MEDICAL DISASTERS

200

5.10.1 5.10.2 5.10.3 5.10.4

• Documents successful experience, capability, and approach to disaster preparedness, including planning and responding to MCI and local disasters.

• Includes a plan for use of mutual aid that adheres to RFP requirements. • The proposed disaster cache will adequately meet, or exceeds, RFP requirements.

7. EMS SYSTEM PARTICIPATION 200 5.11.1 5.11.2

• Describes successful experience and plan to participate in EMS Agency-defined joint first responder/Ambulance training programs and mandatory in-service trainings.

• Includes a policy to restock disposable ALS and BLS medical supplies and pharmaceuticals other than narcotics.

8. COMMITMENT TO LOCAL COMMUNITY 500 5.12.1 5.12.2 5.12.3 5.12.4 5.13.3

• Commits sufficient staff/FTE hours dedicated to health status improvement and community education.

• Demonstrates understanding of local needs through planned community outreach, educational approaches, and activities.

• Describes successful experience and approach to using appropriate linguistically and culturally-related data collection and analysis to identify and mitigate disparities in service, and how these analyses are used to improve services to marginalized populations.

• Describes the approach to using independent surveys to benchmark and monitor community perceptions of its service.

• Provides commitment to a local headquarters location. • Describes Bidder’s web-based, customer friendly, customer service portal and

complaint resolution practice. • Describes the financial Hardship program in detail to include qualification

requirements and process to inform the patient of the program. 9. FINANCIAL REQUIREMENTS/CONDITION 500

5.13.1 5.13.4 5.13.5 5.13.6 5.13.7

• Include proposed fee schedules and rates which, when approved by the Board of Supervisors, will be in the provider’s negotiated Agreement with the County.

• Describes billing and collection policies and procedures that are easy to understand and audit, are customer friendly, and include an appeal process that delays sending the account to collections during the resolution process.

8.4.1 8.4.2

• Demonstrates excellent strength of financial stability that is well documented and includes sufficient working capital to ensure adequate equipment and supplies for start-up and ongoing operations.

• Describes adequate methods of financing, start-up and ongoing operations costs. 10. TRANSITION PLAN 300

5.17 • Describes a transition plan for start-up to include dates and milestones to ensure readiness to begin operations at service start date.

11. COST AND PRICING 500

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POINTS AVAILABLE

11.1 • Includes a fully completed Form I and Forms J, J1, J2, and J3 and demonstrate a reasonable cost of providing service and cost to the patient.

Maximum Possible Points to Be Awarded (not including additional points)

4,000

11.0 REVENUE, EXPENSES AND PRICING 11.1 Bidder shall complete Form I: Patient Charges and Form J: RFP Revenue, Expense, and Pricing

Reporting Template for the provision of services as outlined within this RFP.

11.2 Bidder shall submit Form I and Forms J, J1, J2, and J3 as an electronic Excel spreadsheet and in hardcopy.

11.3 Pricing increases will be allowed in accordance with the terms outlined herein. Proposal Instructions 1. Proposal shall include Bidder’s submittal, in the requested format and form (hard copy and electronic Excel

spreadsheet), of the following forms to describe its financial proposal for the Monterey County EMS System:

a. Form I: Patient Charges: Indicate Bidder’s proposed charges for Year 1

b. Form J: RFP Revenue, Expense, and Pricing Reporting Template

c. Form J1: Charge Scenario #1

d. Form J2: Charge Scenario #2

e. From J3: Charge Scenario #3

2. Form J: Revenue, Expense, and Pricing Reporting Template Instructions

a) Using Table 1 of Form J provide the expected revenues and expenses for each of the first three years of operation.

b) Provide expected start-up costs separately.

c) Provide the expected payor mix on Table 2.

d) Using Table 3, list all allocations of indirect costs from parent and other payments to parent or affiliates

expected for each of the first three years of operation and for the start-up period. For any of these allocations not separately listed on Table 1, tell which expense line item(s) each is. Typical indirect costs include but are not limited to: risk management, insurance, accounting, information technology, purchasing, maintenance, legal and human resources, or other functions that are not solely dedicated to EOA Ambulance Services in Monterey County. Table 3 shall include, if applicable, the interest or money

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use rate at which the parent corporation loans money or services to the subsidiary corporation serving Monterey County.

e) Complete the Charge Scenarios #1, #2, and #3 on forms J1, J2, and J3.

12.0 PREFERENCE FOR LOCAL CONTRACTORS

12.1 There shall be no local preference under this procurement due to the unique nature of the services that will be provided.

13.0 CONTRACT AWARDS

13.1 The EMS Agency reserves the right to reject any or all responses that materially differ from any terms contained in this RFP or from any Exhibits attached hereto, to waive informalities and minor irregularities in responses received such as typographical errors and page numbering errors, and to provide an opportunity for Bidders to correct minor and immaterial errors contained in their submissions. The decision as to what constitutes a minor irregularity shall be made solely at the discretion of the EMS Agency.

13.2 The EMS Agency reserves the right to cancel the procurement process after opening, but prior to award, when it determines in writing that the cancellation is in the best interest of the agency. Reasons for cancellation may include but are not limited to:

• The services are no longer required • the EMS Agency determines that its needs can be satisfied by a less expensive method • no proposal is received that meets the minimum requirements of the RFP, or • All otherwise acceptable proposals received are at unreasonable prices

13.3 If the EMS Agency cancels the procurement process, it shall notify all Bidders in writing, including

the reasons why the procurement was cancelled.

13.4 Pursuant to California Health and Safety Code Section 1797.224, The EMS Agency has the authority to cancel the procurement process or to decline to recommend award of this contract or any part thereof for failure to meet the requirements of the solicitation or if the proposals were not independently arrived at in open competition, were collusive or were submitted in bad faith or if the RFP process has been unduly influenced or its integrity compromised.

13.5 The Proposal Review Panel shall review all responsive proposals and submit a written report and recommendations to the EMS Director. The EMS Director shall forward his or her recommendations for the award of the RFP, together with the recommendations of the Proposal Review Panel, to the Monterey County Board of Supervisors.

13.6 An agreement must be finalized by the EMS Agency and signed by the recommended awardee before submission to the Board of Supervisors for approval.

13.7 The Board of Supervisors shall review the recommendations of the Proposal Review Panel and the

EMS Director. The Board shall either accept or reject the recommendations, and on that basis either award the Agreement or decline to award the Agreement.

13.8 The County and EMS Agency are not liable for any cost incurred by Bidder in response to this

solicitation.

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13.9 All Bidders that have submitted a Proposal will be notified of the final decision as soon as it has been determined.

13.10 Protests Protests that do not comply with the protest procedures outlined below will be rejected.

13.10.1 Protest Eligibility, Format, and Address 1. Protests or objections may be filed regarding the procurement process, the content of the

solicitation or any addenda, or contract award.

2. The County will only review written protests submitted by an interested party, defined as an actual or prospective Bidder whose direct economic interest could be affected by the County’s conduct of the solicitation.

3. Submit written protests to the County Contracts and Purchasing Department by e-mail or hard copy to Gina Encallado, using the contact information in Section 4.0: County Points of Contact.

4. The decision regarding the protest may be appealed to the Contracts/Purchasing Officer.

13.10.2 Protest Deadlines 1. Submit protests with any supplemental materials by 1700, local time, as appropriate, on the

deadlines set forth below. The date of filing is the date the County receives the protest, unless received after 1700, local time, or on other than a Business Day, in which case the date of filing will be the next Business Day. Failure to file by the relevant deadline constitutes a waiver of any protest on those grounds. Supplemental materials filed after the relevant deadline may be rejected by the County.

2. If relating to the content of the solicitation or to an addendum, file within seven Business Days after the date the County releases the solicitation or addendum.

3. If relating to any notice of non-responsiveness or non-responsibility, file within seven Business Days after the County issues such notice.

4. If relating to intent to award, file within seven Business Days after the County issues notice of Intent to Award. No protests will be accepted once actual award has been made.

13.10.3 Protest Contents The letter of protest must include all the following elements: • Detailed grounds for the protest, fully supported with technical data, test results,

documentary evidence, names of witnesses, and other pertinent information related to the subject being protested; and

• The law, rule, regulation, ordinance, provision or policy upon which the protest is based, with an explanation of the violation.

• Protests that simply disagree with decisions of the Proposal Review Panel will be rejected.

13.10.4 Reply to Protest The County will send a written response to the protesting party and to any other party named in

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the protest.

13.10.5 No Stay of Procurement Action during Protest Nothing in these protest requirements will prevent the County from continuing with the Contract Award process while a protest is pending.

14.0 PREVAILING WAGE

14.1 There are no state mandated prevailing wage provisions required under this procurement. However, Bidders should take notice of the Treatment of Incumbent Workforce provisions found at Section 5.8.1.

15.0 AGREEMENT TO TERMS AND CONDITIONS

15.1 Bidder selected through the solicitation process will be expected to execute a formal Agreement with County for the provision of the requested service. The Agreement shall be written by County in a standard format approved by County Counsel. The Agreement shall contain mandatory provisions similar to the “SAMPLE STANDARD AGREEMENT TERMS AND CONDITIONS” herein (Exhibit R). Submission of a signed bid/proposal and the SIGNATURE PAGE will be interpreted to mean CONTRACTOR HAS AGREED TO ALL THE TERMS AND CONDITIONS set forth in the pages of this solicitation and the standard provisions included in the SAMPLE STANDARD AGREEMENT TERMS AND CONDITIONS Section herein.

15.2 Bidder’s Proposal shall be accompanied by cash, a certified or cashier’s check, or a bond in the sum of $100,000. The check or bond must be made payable to “The County of Monterey.” In the event the Contractor withdraws its proposal before execution of a contract awarded under this RFP, the cash, check, or bond will be retained by the County. The County will release Bidder’s cash, certified or cashier’s check, or bond, after the Agreement with the winning Bidder is executed by the Monterey County Board of Supervisors, which is not to exceed 180 days from the date of Proposal submission.

Proposal Instructions Bidder shall complete and submit Form G.

16.0 COLLUSION / UNFAIR COMPETITION / FALSE CLAIMS

16.1 Bidder shall not conspire, attempt to conspire, or commit any other act of collusion with any other interested party for the purpose of secretly or otherwise, establishing an understanding regarding rates or conditions to the solicitation that would bring about any unfair conditions. Collusion, bid-rigging, bid-suppression, or similar attempts to manipulate the outcome of this procurement are prohibited, and will be cause for immediate disqualification of all Bidders involved. Discovery of collusion, bid-rigging, bid-suppression, or similar attempts to manipulate the outcome of this procurement after a Contract has been awarded and approved will result in sanctions up to and including determination of material breach, emergency takeover, termination of the Contract, and referral to local, state and federal law enforcement and regulatory enforcement agencies.

16.2 California Government Code Section 4552: In submitting a bid to a public purchasing body, Contractor offers and agrees that if the proposal is accepted, it will assign to the purchasing body all rights, title, and interest in and to all causes of action it may have under Section 4 of the Clayton Act

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(15 U.S.C. Sec. 15) or under the Cartwright Act (Chapter 2, commencing with Section 16700, of Part 2 of Division 7 of the Business and Professions Code), arising from purchases of goods, materials, or services by Contractor for sale to the purchasing body pursuant to the bid. Such assignment shall be made and become effective at the time the purchasing body tenders final payment to Contractor.

16.3 Bidder expressly acknowledges that it is aware that if a false claim is knowingly submitted (as the terms “claim” and “knowingly” are defined in the California False Claims Act, Cal. Gov. Code, §12650 et seq.), County will be entitled to civil remedies set forth in the California False Claim Act. It may also be considered fraud and Contractor may be subject to criminal prosecution.

Proposal Instructions Bidder shall complete and submit Form E.

17.0 RIGHTS TO PERTINENT MATERIALS

17.1 All responses, inquiries, and correspondence related to this solicitation and all reports, charts, displays, schedules, exhibits, and other documentation produced by Bidder that are submitted as part of the submittal will become the property of the County when received by the County and may be considered public information under applicable law. Any proprietary information in the submittal must be identified as such and marked “CONFIDENTIAL INFORMATION” or “PROPRIETARY INFORMATION”. The County will not disclose proprietary information to the public, unless required by law; however, the County cannot guarantee that such information will be held confidential. As a California government entity, County is subject to the California Public Records Act and other public transparency laws and, as such, cannot guarantee the confidentiality of information marked confidential or proprietary. County will respond to requests for disclosure of records related to this solicitation in accord with applicable law on disclosure requirements and exemptions to disclosure.

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EXHIBIT A – RESPONSE AREA MAPS

The Response Area Maps were created using a different process than previous RFP’s and contracts for Ambulance Services in Monterey County. Previous Response Area Maps were created with a focus on population densities as well as historical boundaries. These new Response Area Maps have been created using a starting point of the actual number of calls per square mile. The areas with the greatest number of calls per square mile are identified as the “Urban” Response Area. The Urban area has 300 or more calls per square mile on an annual average basis over the last two calendar years. The areas with the next greatest number of calls per square mile are identified as the “Suburban” Response Area. This area has between 10 and 299 calls per square mile on an annual average basis over the last two calendar years. The areas with the fewest number of calls per square mile are identified as the “Rural” Response Area. This area has between 0 and 10 calls per square mile on an annual average basis over the last two calendar years. Using call volume as the starting point, the response area boundaries were then adjusted to reflect reasonable boundaries. One such adjustment was to align the boundaries to city limit boundaries when a specific Response Area, such as Urban, was close to, but short of, the city limit. For example, the city of Salinas has farmland at the edge of the city that would be considered rural. The city of Salinas also has a large area of farmland within a populated area that would also be considered rural. This was adjusted to match the surrounding area. In other words, these two farmland areas were included in the Urban response area. and designated as an Urban Response Area. The major highways between Urban and Suburban areas were identified by call volume as Rural. Due to the time-critical nature of trauma, and in consideration that most ambulance responses to calls on highways are traumatic in nature, the highway corridors between the Urban and Suburban areas were designated as a Suburban response area even if the call volume for the location would cause a Rural designation. There were also a few places where a concentration of calls would cause a small geographic location to receive either an Urban or Suburban designation. An example is the city of Greenfield. One portion of Greenfield has enough calls to be considered Urban. As it is a compact and isolated location surrounded by a large area identified as Suburban, this was adjusted to a Suburban designation. Lake San Antonio had enough calls to be designated as Suburban. It is believed that the number of calls was related to special events at the park. Because special events can be managed by having an ambulance present for the event, the area was designated as Rural to be consistent with the surrounding area. The Highlands area outside of Carmel was identified by call volume as Rural. As it has received the fastest response time requirement under the current ambulance Agreement, and because it is adjacent to Suburban areas, Highlands was upgraded to Suburban Response Area. These response areas also generally consolidate the previously designated “Yellow” and “Orange” zones into the Suburban designation resulting in a faster response time requirement for the “Orange” area and a marginally longer response requirement for the “Yellow” area.

Response areas will be adjusted when there is an increase or decrease in call volume in a specific location within the EOA, as averaged over the preceding two-year period. For instance, should the averaged number of calls in specific location show an increase moving it from Suburban to Urban, the response area boundary will be adjusted accordingly subject to the same adjustments described above to create the current Response Areas.

Contractor will be expected to adjust its deployment plan accordingly to meet the changing service needs within the EOA.

US 101

Hwy 1

Hwy 25

Hwy 198

Jolon

Rd

River Rd

Metz Rd

Carmel Valley Rd

Old Stage Rd

Indian

Valle

y Rd

Hwy 129 Hwy 25

Sargents Rd

Interlake Rd

Peach Tree Rd

Cholame Rd

Hwy 68

Hwy 156

Oasis Rd Cattlemen Rd

Hwy 1

46

Vineyar

d Cany

on Rd

King C

ity Rd

Iverson Rd

Slacks Canyon Rd

HWY 41

Nacimiento-Fergusson RdMission Creek Rd

17-Mile Dr

US 10

1

Hwy 68

Legend:Rural ( 0 to ~10 calls/sq mi) Suburban (~11 to ~299 calls/sq mi) Urban (Over 300 calls/sq mi) Difficult-to-Serve AreasExclusion AreasMajor Roads & HighwaysCity Limits

²5 0 5 10 15 202.5

Miles

Monterey County EMS Exclusive Operating Area

Map 1

EXHIBIT A

Hwy 1

Hwy 1

Hwy 25

Old Stage Rd

Hwy 25

River Rd

US 10

1

Hwy 129

Hwy 68

Hwy 156

Hwy 1

56

Hwy 183

San J

uan Grad

e Rd

Elkhorn Rd

Abbott St

Alisal Rd

Carmel Valley Rd

Davis R

dEspinosa Rd

Iverson Rd

Lewis Rd

Hall Rd

Dolan Rd Castroville Blvd

Nashua Rd

US 101

Beach Rd

Maher Rd

San Juan Canyon Rd

Harris R

d

US 101

17-M

ile D

r

Hwy 156

San Benancio Rd

Moler

a Rd

San Juan Rd

Portola

Dr

San Juan Rd

Hwy 6

8

US 101

US 101

US 101

US 101

US 101

Hwy 156

Hwy 1

US 101

US 101

LegendRural ( 0 to ~10 calls/sq mi) Suburban (~11 to ~299 calls/sq mi) Urban (Over 300 calls/sq mi) Dificult-to-Serve AreasExclusion AreasMajor Roads & HighwaysCity Limits

²2 0 2 4 6 81

Miles


Map 2

EXHBIT A

US 101

River Rd

Old Stage Rd

Reservation Rd

Alisal Rd

Hwy 183

Carmel Valley Rd

Blanco Rd

Hwy 68

Davis R

d

Iverson Rd

E Boronda Rd

Eucalyptus Rd

Williams Rd

Harris R

d

Coop

er Rd

San Benancio Rd

Corral De Tierra Rd

Nashua Rd

Harki

ns Rd

Gloria Rd

Alta St

Spence Rd

Porto

la Dr

5th St

Hartn

ell R

d

E Alvin Dr

Rider Ave

Chualar Rd

Spreckels Blvd

Barlo

y Can

yon R

d

Iverson Rd

Portola

Dr

Hwy 68

Hwy 6

8

US 101

LegendRural ( 0 to ~10 calls/sq mi) Suburban (~11 to ~299 calls/sq mi) Urban (Over 300 calls/sq mi) Difficult-to-Serve AreasExclusion AreasMajor Roads & HighwaysCity Limits

²1 0 1 2 3 40.5

Miles


Map 3

EXHIBIT A

US 101

River Rd

Carmel Valley Rd

Hwy 68

Old St

age R

d

Reservation Rd

Alisal Rd

Blanco Rd

Davis R

d

Hwy 183

E Boronda Rd

Eucalyptus Rd

Williams Rd

Robinson Canyon Rd

Harris R

d

17-M

ile Dr

Coop

er Rd

San Benancio Rd

Corral De Tierra Rd

Harki

ns Rd

Laureles Grade

Spence Rd

Porto

la Dr

Nashua Rd

Hartn

ell R

d

E Alvin Dr

Rider Ave

Spreckels Blvd

Barlo

y Can

yon R

d

17-Mile

Dr17-Mile Dr

Hwy 6

8

US 101

Hwy 68

Portola

Dr


²1 0 1 2 3 40.5Miles


Map 4

EXHIBIT A

US 101

River Rd

Metz Rd

Hwy 25

Hwy 146

Old Stage Rd

HWY 146

Iverson Rd

Arroyo Seco Rd

Foothill Rd

Carmel Valley Rd Elm Ave

Fort Romie Rd

Thorne Rd

Paraiso Springs Rd

Gloria Rd

Alta St

Clark Rd

5th St

Chualar Rd

US 101

US 101

Iverson Rd


²1 0 1 2 3 40.5Miles


Map 5

EXHIBIT A

US 101

Metz Rd

Hwy 25

Elm Ave

Hwy 198

Jolon RdOa

sis R

d

Central Ave Bitterw

ater R

d

Arroyo Seco Rd

King C

ity Rd

Thorne Rd

Spreckels Rd

Paraiso Springs Rd

San Lucas Rd

Espinosa Rd

Clark Rd

Cattlemen Rd

Pine C

anyo

n Rd

Hwy 2

5

US 101

LegendRural ( 0 to ~10 calls/sq mi) Suburban (~11 to ~299 calls/sq mi) Urban (Over 300 calls/sq mi) Difficutlt-to-Serve AreasExclusion AreasMajor Roads & HighwaysCity Limits

²2 0 2 4 6 81

Miles


Map 6

EXHIBIT A

Hwy 1

US 101 Hwy 25

Hwy 198

Jolon

Rd

River Rd

Metz Rd

Carmel Valley Rd

Old Stage Rd

Indian

Valle

y Rd

Hwy 129

Cholame Rd

Sargents Rd

Interlake Rd

Elm Ave

Peach Tree Rd

Hwy 68

Hwy 156

Oasis Rd Cattlemen Rd

Hwy 1

46

HWY 41

Central Ave

Paris Valley Rd

Vineyar

d Cany

on Rd

King C

ity Rd

Iverson Rd

Mission Creek Rd

17-Mile D

r

US 101

US 101

Monterey County EMS Difficult-to-Serve Areas - All

.6 0 6 12 18 243

Miles

LegendRoad CenterlineDifficult-to-Serve AreasRural ( 0 to ~10 calls/sq mi) Suburban (~11 to ~299 calls/sq mi) Urban (Over 300 calls/sq mi)City LimitsMonterey County Boundary

Pajaro

Bradley

Cachagua

Gorda

EXHIBIT B

Hall Rd

Hwy 1

Lewis RdBeach R

d

Hwy 1

Elkhorn R

d

San Juan Rd

Riverside D

r

Salinas Rd

Hwy 129

Porter Dr

Lee Rd

Monterey County EMS Difficult-to-Serve Area - Pajaro

.0.4 0 0.4 0.8 1.2 1.60.2

Miles

LegendHighways & Major Roads

Difficult-to-Serve AreaRural ( 0 to ~10 calls/sq mi) Suburban (~11 to ~299 calls/sq mi) Urban (Over 300 calls/sq mi) Monterey County Boundary

Pajaro

EXHIBIT B

Carmel Valley Rd

River Rd

US 101

Arroyo Seco Rd

Tassajara Rd

Cachagua Rd

Hwy 1

Foothill Rd

Fort Romie Rd

US 101

Cachagua Rd

Monterey County EMS Difficult-to-Serve Area - Cachagua

.2.5 0 2.5 5 7.5 101.25

Miles


Difficult-to-Serve AreaMonterey County Boundary Rural ( 0 to ~10 calls/sq mi) Suburban (~11 to ~299 calls/sq mi) Urban (Over 300 calls/sq mi)

Cachagua

EXHIBIT B

Hwy 1

4

3 2

5

9

8

1

6

7

12

10

11

13

Monterey County EMS Difficult-to-Serve Area - Gorda

.1 0 1 2 3 40.5

Miles

LegendMilepost MarkersHighways & Major Roads


Gorda

EXHIBIT B

Indian Valley RdCholame Rd

US 101

Hwy 198

Sarge

nts Rd

Hwy 46

US 101

HWY 41

Nacimiento Lake Dr

Jolon RdVin

eyard

Cany

on Rd

Peach Tree Rd

Bradley Rd

Slacks Canyon Rd

Hare Canyon Rd

San Marcos Rd

Cross Canyons Rd

Cattlemen Rd

Von Dollen Rd

US 101

US 101

US 101

US 10

1

Vineyard Canyon Rd

Monterey County EMS Difficult-to-Serve Area - Bradley

.4 0 4 8 12 162

Miles



Bradley

EXHIBIT B

Effective: February 1, 2020

Service/Procedure/Supply Rate

ALS Base Rate $2,798.78

Non-Emergency BLS Rate $2,648.78

SCT Base Rate $4,426.93

Non-Emergency Base $2,798.78

Mileage $60.37

SCT Mileage $60.37

Oxygen $180.44

Intubation Supplies $483.42

IO Supplies $439.88

EKG Electrodes $94.02

Supraglotic Airway $463.34

Cannula $24.45

Non-Rebreather Oxygen Mask $13.75

Emesis Basin $6.24

Disposable Linen $45.11

Bag Valve Mask $107.32

Restraints (Disposable) $46.96

Splint $22.93

Chux Pad $8.44

Aspirin $1.27

Albuterol Nebulizer $57.05

Atropine $46.70

Dextrose 50% $45.89

Morphine $36.01

Narcan $90.46

Nitrospray $23.67

Adenosine $213.27

Glucose $29.76

Nitroglycerine (Tablet) $20.46

Normal Saline Infusion $131.17

Cervical Spine $186.37

Pulse Oximetry $74.60

EKG Monitor $164.23

Blood Glucose Test $83.69

Universal Precautions $33.87

CPAP Procedure/Supplies $335.38

Night Charge $154.12

Standby Services $192.37

Monterey County Ambulance Rates

Exhibit B to Advanced Life Support Services Agreement No. A-11610

EXHIBIT C

BAA- Health Department Revised 12/12/2014

2.1 Unless otherwise limited herein, Business Associate may:

(a) use or disclose PHI to perform functions, activities or Services for, or on behalf of,Covered Entity as requested by Covered Entity from time to time, provided that such use or disclosure would not violate the Privacy or Security Rules or the standards for Business Associate Agreements set forth in 45 C.F.R. § 164.504(e), exceed the minimum necessary to accomplish the intended purpose of such use or disclosure, violate the additional requirements of HITECH contained in Public Law 111-005 that relate to privacy and security, or violate the CMIA;

EXHIBIT D

BUSINESS ASSOCIATE AGREEMENT

This Business Associate Agreement (“Agreement”), effective ___________, 20__ (“Effective Date”), is entered into by and among the County of Monterey, a political subdivision of the State of California, on behalf of the Health Department (“Covered Entity”) and ________________________________________ (“Business Associate”) (each a “Party” and collectively the “Parties”).

Business Associate provides certain services for Covered Entity (“Services”) that involve the use and disclosure of Protected Health Information that is created or received by Business Associate from or on behalf of Covered Entity (“PHI”). The Parties are committed to complying with the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. Part 160 and Part 164, Subparts A and E as amended from time to time (the “Privacy Rule”), and with the Security Standards, 45 C.F.R. Part 160 and Part 164, Subpart C as amended from time to time (the “Security Rule”), under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as amended by the Health Information Technology for Economic and Clinical Health Act and its implementing regulations (“HITECH”). Business Associate acknowledges that, pursuant to HITECH, 45 C.F.R. §§ 164.308 (administrative safeguards), 164.310 (physical safeguards), 164.312 (technical safeguards), 164.316 (policies and procedures and documentation requirements) and 164.502 et. seq. apply to Business Associate in the same manner that such sections apply to Covered Entity. The additional requirements of Title XIII of HITECH contained in Public Law 111-005 that relate to privacy and security and that are made applicable with respect to covered entities shall also be applicable to Business Associate. The Parties are also committed to complying with the California Confidentiality of Medical Information Act, Ca. Civil Code §§ 56 et seq. (“CMIA”), where applicable. Business Associate acknowledges that the CMIA prohibits Business Associate from further disclosing the PHI it receives from Covered Entity where such disclosure would be violative of the CMIA. The Parties are also committed to complying with applicable requirements of the Red Flag Rules issued pursuant to the Fair and Accurate Credit Transactions Act of 2003 (“Red Flag Rules”). This Agreement sets forth the terms and conditions pursuant to which PHI, and, when applicable, Electronic Protected Health Information (“EPHI”), shall be handled. The Parties further acknowledge that state statutes or other laws or precedents may impose data breach notification or information security obligations, and it is their further intention that each shall comply with such laws as well as HITECH and HIPAA in the collection, handling, storage, and disclosure of personal data of patients or other personal identifying information exchanged or stored in connection with their relationship.

The Parties agree as follows:

1. DEFINITIONS

All capitalized terms used in this Agreement but not otherwise defined shall have the meaning set forth in the Privacy Rule, Security Rule and HITECH.

2. PERMITTED USES AND DISCLOSURES OF PHI

(b) disclose PHI for the purposes authorized by this Agreement only: (i) to itsemployees, subcontractors and agents; (ii) as directed by this Agreement; or (iii) as otherwise permitted by the terms of this Agreement;

(c) use PHI in its possession to provide Data Aggregation Services to Covered Entity aspermitted by 45 C.F.R. § 164.504(e)(2)(i)(B);

(d) use PHI in its possession for proper management and administration of BusinessAssociate or to carry out the legal responsibilities of Business Associate as permitted by 45 C.F.R. § 164.504(e)(4)(i);

(e) disclose the PHI in its possession to third parties for the proper management andadministration of Business Associate to the extent and in the manner permitted under 45 C.F.R. § 164.504(e)(4)(ii); provided that disclosures are Required by Law , or Business Associate obtains reasonable assurances from the persons to whom the information is disclosed that it will remain confidential and used or further disclosed only as Required by Law or for the purpose for which it was disclosed to the person, and the person notifies the Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached;

(f) use PHI to report violations of law to appropriate Federal and state authorities,consistent with 45 C.F.R. § 164.502(j)(1);

(g) de-identify any PHI obtained by Business Associate under this Agreement for furtheruse or disclosure only to the extent such de-identification is pursuant to this Agreement, and use such de-identified data in accordance with 45 C.F.R. § 164.502(d)(1).

3. RESPONSIBILITIES OF THE PARTIES WITH RESPECT TO PHI

3.1 Responsibilities of Business Associate. With regard to its use and/or disclosure of PHI, Business Associate shall:

(a) use and/or disclose the PHI only as permitted or required by this Agreement or asotherwise Required by Law;

(b) report to the privacy officer of Covered Entity, in writing, (i) any use and/ordisclosure of the PHI that is not permitted or required by this Agreement of which Business Associate becomes aware, and (ii) any Breach of unsecured PHI as specified by HITECH, within two (2) days of Business Associate’s determination of the occurrence of such unauthorized use and/or disclosure. In such event, the Business Associate shall, in consultation with the Covered Entity, mitigate, to the extent practicable, any harmful effect that is known to the Business Associate of such improper use or disclosure. The notification of any Breach of unsecured PHI shall include, to the extent possible, the identification of each individual whose unsecured PHI has been, or is reasonably believed by the Business Associate to have been, accessed, acquired, used or disclosed during the Breach.

(c) use commercially reasonable safeguards to maintain the security of the PHI and toprevent use and/or disclosure of such PHI other than as provided herein;

(d) obtain and maintain an agreement with all of its subcontractors and agents thatreceive, use, or have access to, PHI pursuant to which agreement such subcontractors and agents

EXHIBIT D

agree to adhere to the same restrictions and conditions on the use and/or disclosure of PHI that apply to Business Associate pursuant to this Agreement;

(e) make available all internal practices, records, books, agreements, policies andprocedures and PHI relating to the use and/or disclosure of PHI to the Secretary for purposes of determining Covered Entity or Business Associate’s compliance with the Privacy Rule;

(f) document disclosures of PHI and information related to such disclosure and, withinten (10) days of receiving a written request from Covered Entity, provide to Covered Entity such information as is requested by Covered Entity to permit Covered Entity to respond to a request by an individual for an accounting of the disclosures of the individual’s PHI in accordance with 45 C.F.R. § 164.528, as well as provide an accounting of disclosures, as required by HITECH,directly to an individual provided that the individual has made a request directly to BusinessAssociate for such an accounting. At a minimum, the Business Associate shall provide theCovered Entity with the following information: (i) the date of the disclosure, (ii) the name of theentity or person who received the PHI, and if known, the address of such entity or person; (iii) abrief description of the PHI disclosed; and (iv) a brief statement of the purpose of such disclosurewhich includes an explanation of the basis for such disclosure. In the event the request for anaccounting is delivered directly to the Business Associate, the Business Associate shall, withintwo (2) days, forward such request to the Covered Entity. The Business Associate shallimplement an appropriate recordkeeping process to enable it to comply with the requirements ofthis Section;

(g) subject to Section 4.4 below, return to Covered Entity within twenty-one (21) days ofthe termination of this Agreement, the PHI in its possession and retain no copies, including backup copies;

(h) disclose to its subcontractors, agents or other third parties, and request from CoveredEntity, only the minimum PHI necessary to perform or fulfill a specific function required or permitted hereunder;

(i) if all or any portion of the PHI is maintained in a Designated Record Set:

(i) upon ten (10) days’ prior written request from Covered Entity, provideaccess to the PHI in a Designated Record Set to Covered Entity or, as directed by Covered Entity, the individual to whom such PHI relates or his or her authorized representative to meet a request by such individual under 45 C.F.R. § 164.524; and

(ii) upon ten (10) days’ prior written request from Covered Entity, make anyamendment(s) to the PHI that Covered Entity directs pursuant to 45 C.F.R. § 164.526;

(j) maintain policies and procedures to detect and prevent identity theft in connectionwith the provision of the Services, to the extent required to comply with the Red Flag Rules;

(k) notify the Covered Entity within five (5) days of the Business Associate’s receipt ofany request or subpoena for PHI. To the extent that the Covered Entity decides to assume responsibility for challenging the validity of such request, the Business Associate shall cooperate fully with the Covered Entity in such challenge;

EXHIBIT D

(l) maintain a formal security program materially in accordance with all applicable datasecurity and privacy laws and industry standards designed to ensure the security and integrity of the Covered Entity’s data and protect against threats or hazards to such security

The Business Associate acknowledges that, as between the Business Associate and the Covered Entity, all PHI shall be and remain the sole property of the Covered Entity.

3.2 Additional Responsibilities of Business Associate with Respect to EPHI. In the event that Business Associate has access to EPHI, in addition to the other requirements set forth in this Agreement relating to PHI, Business Associate shall:

(a) implement administrative, physical, and technical safeguards that reasonably andappropriately protect the confidentiality, integrity, and availability of EPHI that Business Associate creates, receives, maintains, or transmits on behalf of Covered Entity as required by 45 C.F.R. Part 164, Subpart C;

(b) ensure that any subcontractor or agent to whom Business Associate provides anyEPHI agrees in writing to implement reasonable and appropriate safeguards to protect such EPHI; and

(c) report to the privacy officer of Covered Entity, in writing, any Security Incidentinvolving EPHI of which Business Associate becomes aware within two (2) days of Business Associate’s discovery of such Security Incident. For purposes of this Section, a Security Incident shall mean (consistent with the definition set forth at 45 C.F.R. § 164.304), the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with systems operations in an information system. In such event, the Business Associate shall, in consultation with the Covered Entity, mitigate, to the extent practicable, any harmful effect that is known to the Business Associate of such improper use or disclosure.

3.3 Responsibilities of Covered Entity. Covered Entity shall, with respect to Business Associate:

(a) provide Business Associate a copy of Covered Entity’s notice of privacy practices(“Notice”) currently in use;

(b) notify Business Associate of any limitations in the Notice pursuant to 45 C.F.R.§ 164.520, to the extent that such limitations may affect Business Associate’s use or disclosure ofPHI;

(c) notify Business Associate of any changes to the Notice that Covered Entity providesto individuals pursuant to 45 C.F.R. § 164.520, to the extent that such changes may affect Business Associate’s use or disclosure of PHI;

(d) notify Business Associate of any changes in, or withdrawal of, the consent orauthorization of an individual regarding the use or disclosure of PHI provided to Covered Entity pursuant to 45 C.F.R. § 164.506 or § 164.508, to the extent that such changes may affect Business Associate’s use or disclosure of PHI; and

(e) notify Business Associate, in writing and in a timely manner, of any restrictions onuse and/or disclosure of PHI as provided for in 45 C.F.R. § 164.522 agreed to by Covered Entity, to the extent that such restriction may affect Business Associate’s use or disclosure of PHI.

EXHIBIT D

4. TERMS AND TERMINATION

4.1 Term. This Agreement shall become effective on the Effective Date and shall continue in effect unless terminated as provided in this Article 4. Certain provisions and requirements of this Agreement shall survive its expiration or other termination as set forth in Section 5.1 herein.

4.2 Termination. Either Covered Entity or Business Associate may terminate this Agreement and any related agreements if the terminating Party determines in good faith that the terminated Party has breached a material term of this Agreement; provided, however, that no Party may terminate this Agreement if the breaching Party cures such breach to the reasonable satisfaction of the terminating Party within thirty (30) days after the breaching Party’s receipt of written notice of such breach.

4.3 Automatic Termination. This Agreement shall automatically terminate without any further action of the Parties upon the termination or expiration of Business Associate’s provision of Services to Covered Entity.

4.4 Effect of Termination. Upon termination or expiration of this Agreement for any reason, Business Associate shall return all PHI pursuant to 45 C.F.R. § 164.504(e)(2)(ii)(I) if, and to the extent that, it is feasible to do so. Prior to doing so, Business Associate shall recover any PHI in the possession of its subcontractors or agents. To the extent it is not feasible for Business Associate to return or destroy any portion of the PHI, Business Associate shall provide Covered Entity a statement that Business Associate has determined that it is infeasible to return or destroy all or some portion of the PHI in its possession or in possession of its subcontractors or agents. Business Associate shall extend any and all protections, limitations and restrictions contained in this Agreement to any PHI retained after the termination of this Agreement until such time as the PHI is returned to Covered Entity or destroyed.

5. MISCELLANEOUS

5.1 Survival. The respective rights and obligations of Business Associate and Covered Entity under the provisions of Sections 4.4, 5.1, 5.6, and 5.7, and Section 2.1 (solely with respect to PHI that Business Associate retains in accordance with Section 4.4 because it is not feasible to return or destroy such PHI), shall survive termination of this Agreement until such time as the PHI is returned to Covered Entity or destroyed. In addition, Section 3.1(i) shall survive termination of this Agreement, provided that Covered Entity determines that the PHI being retained pursuant to Section 4.4 constitutes a Designated Record Set.

5.2 Amendments; Waiver. This Agreement may not be modified or amended, except in a writing duly signed by authorized representatives of the Parties. To the extent that any relevant provision of the HIPAA, HITECH or Red Flag Rules is materially amended in a manner that changes the obligations of Business Associates or Covered Entities, the Parties agree to negotiate in good faith appropriate amendment(s) to this Agreement to give effect to the revised obligations. Further, no provision of this Agreement shall be waived, except in a writing duly signed by authorized representatives of the Parties. A waiver with respect to one event shall not be construed as continuing, or as a bar to or waiver of any right or remedy as to subsequent events.

5.3 No Third Party Beneficiaries. Nothing express or implied in this Agreement is intended to confer, nor shall anything herein confer, upon any person other than the Parties and the respective successors or assigns of the Parties, any rights, remedies, obligations, or liabilities whatsoever.

EXHIBIT D

If to Business Associate, to: __________________________ __________________________ Attn: ____________________ Tel: ____________________ Fax: ____________________

If to Covered Entity, to:

Attn: Tel: Fax:

Each Party named above may change its address and that of its representative for notice by the giving of notice thereof in the manner hereinabove provided. Such notice is effective upon receipt of notice, but receipt is deemed to occur on next business day if notice is sent by FedEx or other overnight delivery service.

5.5 Counterparts; Facsimiles. This Agreement may be executed in any number of counterparts, each of which shall be deemed an original. Facsimile copies hereof shall be deemed to be originals.

5.6 Choice of Law; Interpretation. This Agreement shall be governed by the laws of the State of California; as provided, however, that any ambiguities in this Agreement shall be resolved in a manner that allows Business Associate to comply with the Privacy Rule, and, if applicable, the Security Rule and the CMIA.

5.7 Indemnification. Contractor shall indemnify, defend, and hold harmless the County of Monterey (hereinafter County), its officers, agents, and employees from any claim, liability, loss, injury, cost, expense, penalty or damage, including the County’s reasonable cost of providing notification of and of mitigating any acquisition, access, use or disclosure of PHI in a manner not permitted by this BAA, arising out of, or in connection with, performance of this BAA by Contractor and/or its agents, members, employees, or sub-contractors, excepting only loss, injury, cost, expense, penalty or damage caused by the negligence or willful misconduct of personnel employed by the County. It is the intent of the parties to this BAA to provide the broadest possible indemnification for the County. Contractor shall reimburse the County for all costs, attorneys’ fees, expenses, and liabilities incurred by the County with respect to any investigation, enforcement proceeding or litigation in which Contractor is obligated to indemnify, defend, and hold harmless the County under this BAA. This provision is in addition to and independent of any indemnification provision in any related or other agreement between the Covered Entity and the Business Associate.

EXHIBIT D

5.4 Notices. Any notices to be given hereunder to a Party shall be made via U.S. Mail or express courier to such Party’s address given below, and/or via facsimile to the facsimile telephone numbers listed below.

IN WITNESS WHEREOF, each of the undersigned has caused this Agreement to be duly executed in its name and on its behalf as of the Effective Date.

COUNTY OF MONTEREY, ON BEHALF OF [BUSINESS ASSOCIATE] THE HEALTH DEPARTMENT

By: By:

Print Name: Print Name:

Print Title: Print Title:

Date: Date:

EXHIBIT D

EXHIBIT E – List of Reports and Other Deliverables

The table below does not represent an all-inclusive list of deliverables due during the transition period and is provided for informational purposes only. Contractor is responsible for ensuring its Transition Plan incorporates all deliverables due to the EMS Agency during the transition period.

TRANSITION PERIOD DELIVERABLES Section Deliverable Due Date

5.5.1 Fleet Vehicle Requirements Vehicle information No less than 30 days before service start date 5.5.10 Deployment Plan Initial Deployment Plan No less than 60 days before the service start date 5.6.4 Quality Improvement Program QI Plan No less than 30 days before the service start date 5.8.2 (7) Character, Competence, and

Professionalism of Personnel Badges, patches, or insignia proposed as part of the uniform

No less than 60 days before the service start date

5.8.7 Personnel Licensure, Certification and Training Requirements

Policies for managing employees who have driving license privileges suspended or revoked


5.10.3 Continuity of Operations Planning (COOP)

COOP Plan No less than 30 days before the service start date in that position

5.11.1.4 (3) Support and Integration of First Responders

Policy that allows authorized first responders agencies participating in the EMS System to purchase disposable and reusable clinical supplies, pharmaceuticals, other than narcotics, equipment and capital items through Contractor’s purchasing and materials management system


5.12.4 Local Presence, Service Inquiries, and Complaints

open a local headquarters in Monterey County, staffed with Key Personnel. Contractor shall maintain a local headquarters in Monterey County throughout the term of this Agreement


5.17 Transition Plan A transition plan that describes in detail, Bidder’s activities, timelines, and milestones to ensure Bidder’s readiness to provide the services described in this RFP at the service start date

To be submitted with proposal.


The table below does not represent an all-inclusive list of reports and other deliverables is provided for informational purposes only. The EMS Agency, at is sole discretion, may change the frequency of any report.

Report Detail Proposed Frequency Operational

• Calls and transports, by priority for each response area and areas outside the EOA

Monthly

• Response • A list of each call where there was a failure to

properly record all times necessary to determine the Response Time

Monthly

• All vehicle breakdowns • All vehicle accidents

Monthly

• Mutual or automatic aid received or provided Monthly • EMS transports to and from medical aircraft

performed by Contractor

• Summary of interrupted calls due to vehicle/equipment failures

Monthly

• Fleet report TBD • Self-evaluation Annually • Number of hours and consecutive hours worked for

each employee Monthly

• All other operational reports as required by EMS System Policies and Procedures, or as required by the EMS Director or EMS Medical Director

TBD

Response Time Compliance • A list of each call dispatched for which Contractor did not meet the Response Time standard

• Explanation of reason calls were late

Monthly

• Canceled calls Monthly • Exception reports and resolution Monthly • All other Response Time reports as required by

EMS System Policies and Procedures, or as required by the EMS Director or EMS Medical Director

TBD

Clinical

• Clinical metrics Report as determined by Medical Director

Quarterly

• Continuing education compliance reports Quarterly • Summary of clinical/service inquiries and

resolutions Monthly

• Summary of interrupted calls due to vehicle/equipment failures

Monthly

• All other clinical reports as required by EMS System Policies, Protocols and Procedures, or as required by the EMS Medical Director

ePCR and Response Time Statistical Data

• Unit identifier • Location of call – street address • Location of call - longitude and latitude • Nature of call (EMD Code) • Code to scene • Time call received (or for transfers; time pick-up

requested) • Time call dispatched • Time unit en route

Monthly


• Time unit on-scene • Time contact with patient • Time unit en route to hospital • Time unit at hospital • Time unit clear and available for next call • Disposition (dry run, transport) • Receiving hospital • Code to hospital • Major trauma

Number of patients transported • Number of first responders accompanying if any

Financial Reports • Billing compliance with relevant rules and regulations and adherence with approved and specified rates

TBD

• Income Statement Quarterly

• Balance Sheet Quarterly • Cash Flow Statement Quarterly • Accounts Receivables by Pay Source, with Aging Quarterly • Other reports, as requested by EMS Agency TBD

Community/Governmental Affairs Report

• Number of conducted community education events Monthly • Health Equity Enhancement and Cultural

Competence activities Monthly

• Public Relations (PR) activities Monthly • Government relations contact report Monthly • Other reports, as requested by EMS Agency TBD

Personnel Reports

List of EMTs, paramedics and EMS communications personnel currently employed by Contractor and shall update that list whenever there is a change. Alternatively, at Contractor’s option this information may be provided to the EMS Agency via read only access to that database. The personnel list shall include, at a minimum:

• Name • City and state of address • Company email • Telephone number • EMT certification and expiration date • Paramedic license and expiration date • Paramedic accreditation and expiration date • Specialty certifications and expiration date

Annually and upon request by EMS Agency

Other Reports Contractor shall provide the EMS Agency with such other reports and records as may be required by the EMS Director. Contractor will ensure that the EMS Agency has direct access to all information that the EMS Agency deems necessary for oversight and control of the EMS System, and that any impediment to direct communication with the EMS Agency is eliminated.


OTHER DELIVERABLES DURING CONTRACT PERIOD

Section Deliverable Due Date 5.2.3 EMS Agency

Designation of EMS Medical Dispatch Required

Must meet all minimum requirements to receive designation by the EMS Agency

No later than six (6) months after the start of service

5.4.19 Liquidated Damages for Failure to Comply with Response Time Interval Requirements

Failure of Contractor to achieve at least 88% in Response Time Interval compliance requires Contractor to submit and implement a plan that includes additional staffed Ambulance hours aimed to achieve at least 90% compliance with Response Time Interval requirements

Within 10 working days

5.4.20 Repetitive Non-Compliance

Plan of corrective action Within 30 days of being notified of repetitive non-compliance by the EMS Agency

5.5.1 Fleet Vehicle Requirements

Ambulances Supervisor vehicles

At start of service and throughout the term of the Agreement

5.5.2 Vehicles Meet State Law and Administrative Rules

Ensure that all Ambulances and vehicles meet applicable State law and Administrative Rules


5.5.4 Vehicle Markings • Vehicle markings • Numbering and radio identification

conventions


5.8.2 Character, Competence, and Professionalism of Personnel

Conduct a fingerprint-based criminal record check, a DMV records check and other checks as necessary, of each employee to ensure that Contractor is aware of any felony or misdemeanor convictions or other actions that could be a factor related to an individual’s performance in an EMS system

Before start of service

5.8.7 Personnel Licensure, Certification and Training Requirements

Meet the training credentialing standards for their respective Key Personnel positions

Within 18 months of their start

5.12.1 Community Education Plan for community education programs for the following calendar year to the EMS Agency for review and approval

On December 1st of each year

5.12.4 Local Presence, Service Inquiries and Complaints

• Summary of all service inquiries/complaints received and their appropriate disposition/resolution

• Copies of any inquiries and resolutions of

a clinical nature

Monthly

5.13.2 Rate Adjustments • CPI-based rate adjustment requests

• In the event of change in circumstances

• Within 30 days following completion of the first year of service and annually thereafter

• No less than 90 days before the end of the fiscal year

5.13.4 Billing/Collection Services

A summary of all billing inquiries/complaints received and their appropriate disposition/resolution in electronic format

Monthly


5.13.13.1 Administrative Oversight Fee

$175,000.00 At the end of each quarter

5.13.13.3 Payment Payment of Liquidated Damages Within 30 business days of the EMS Agency receipt of Contractor’s monthly performance reports

5.13.13.4 Irrevocable Letter of Credit

An irrevocable letter of credit in the amount Two Million dollars ($2,000,000 USD) in the form attached hereto as Exhibit P

At execution of the Agreement

5.13.13.5 Performance Guarantee

An original guaranty executed by Contractor’s parent company (“Performance Guarantee”) in the form attached as Exhibit Q

Concurrently with Contractor’s execution of the Agreement

5.14 Annual Performance Evaluation

Self-evaluation report Annually

5.16.4 Essential Patient Care Record and Assignment Data

Contractor’s pro-rata cost for the Monterey County ESO Data System is approximately $64,060

Annually

EXHIBIT F – CAD / Radio and Communication Specifications

Contractor Co-location with Monterey County Emergency Communications Department (MCECD) Contractor will work with MCECD and County IT department for work necessary to co-locate Contractor’s Medical Dispatch with MCECD. A separate contract with MCECD and County ITD may be required. Contractor will be responsible for all costs of co-locating with MCECD. MCECD, which integrates countywide law, fire, and EMS resources, utilizes a Central Square CAD system and utilizes County personnel and / or vendor support personnel for CAD maintenance including but not limited to CAD versioning upgrades. County personal and vendor support is also used for maintaining and supporting interfaces into CAD such as, not limited to, GIS, radio, paging, ANI-ALI, and digital audio recording interfaces. In the event of a CAD outage MCECD employs a continuity of operations manual mode dispatching plan. At a cost to Contractor, and upon EMS Agency approval, MCECD will complete initial programming necessary to support the selected Contractor’s system needs, and will make CAD system modifications and / or enhancements in the future when needed to support Contractor requests to modify dispatch procedures for ambulance deployment. MCECD will provide remote CAD query and one-way or two-way data access to Contractor to facilitate service delivery and performance monitoring, at Contractors cost. Contractor will be required to purchase all appropriate licenses for searching and analytics functionality, at their cost. Contractor Stand-Alone EMS Medical Dispatch If Contractor chooses to staff and equip its own stand-alone EMS Medical Dispatch, Contractor shall be responsible for all costs associated with necessary facilities, hardware, software, staffing, interfaces, maintenance and support, and all other necessary technology and equipment specified within this RFP and that is necessary to effectively provide all of the EMS Medical Dispatch functions described herein. Contractor shall establish and maintain necessary commercial wireless / data access fully compatible with MCECD and its CAD / phones / radios and pay any costs of developing and maintaining necessary data / voice interfaces from the MCECD CAD / phones / radios to Contractor’s CAD / phones / radios. The data / voice interfaces shall provide real-time monitoring and recording of Contractor’s ambulance data and, at a minimum, provide the accurate location and status of active ambulance calls, pending calls, and locations and status of ambulances. Any costs of developing the data / voice interfaces from the MCECD CAD to Contractor’s CAD to monitor deployment shall be borne by Contractor. Mobile Data Terminals (MDT) / Mobile Data Computers (MDC) Contractor shall provide and install mobile data terminals/computers in each ambulance and each supervisor vehicle. The MDT/MDC shall enable two-way data communication of call information and unit status between MCECD, ambulances, and supervisor units. The MDT/MDC equipment shall be approved by the EMS Agency. The MDT/MDC and/or modems shall be installed and functional before the start of the agreement at the expense of Contractor. Global Positioning System (GPS) Automatic Vehicle Location (AVL) Requirements

EXHIBIT F – CAD / Radio and Communication Specifications

Contractor shall be responsible to purchase, install, maintain, repair and replace, as needed, GPS / AVL equipment that will integrate with the MCECD CAD system and Contractor’s CAD system, if different, for each ambulance and field supervisor vehicle. Contractor shall ensure that the GPS / AVL system used is reliable, accurate, and capable of providing wheels rolling and wheels stopped time measurements. Should the GPS / AVL system be upgraded or replaced within the terms of the contract, Contractor, at their cost, will upgrade or replace their GPS / AVL equipment to be compatible with and operate on the new system. Radio, Tone and Voice Requirements All base, mobile, and portable radios shall be capable of transmitting and receiving audio on the Monterey County conventional and next generation radio systems (VHF/UHF/700/800/Wi-Fi/LTE). These radios will be Project 25 Phase-1; upgradable to Phase-2 (TDMA) digital capable, Common Air Interface (CAI), conventional and trunked system protocols, AES256 encryption equipped with support for multi-key, Over-the-Air Programming (OTAP) and Over-the-Air Rekey (OTAR). Conventional radios will be MDC1200 encode/decode equipped. All equipment will be approved by County Radio Shop. The Information Technology (IT) Department’s County Radio Shop will help Contractor purchase appropriate base, mobile, and portable radios and will provide initial programming services. Contractor may contract with ITD vendor for ongoing programming services, or its designee, at a cost to the Contractor, based on current fiscal year published technical rates for service. The County Radio Shop does not provide radio maintenance or repair services, beyond programming and reprogramming. Should the Monterey County NGEN radio communication system be upgraded or replaced within the terms of the contract, Contractor shall, at their cost, upgrade or replace their radio communication equipment to be fully compatible with and operate on the new system. The County Radio Department will make every effort to provide advanced notification to Contractor for timely compliance with system changes. Contractor shall maintain a minimum cache of five (5) spare mobile radios to replace those radios sent for maintenance or for repair. Contractor shall maintain a minimum cache of ten (10) portable radios for use within the EMS System

EXHIBIT G – Definitions, Acronyms, Time Points, and Time Intervals

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Definitions, Acronyms, Terms, Time Points and Time Intervals ACE Accredited Center of Excellence by International Academy of

Emergency Dispatch.

AED Automated External Defibrillator. A computerized portable device that automatically detects specific heart rhythms and may deliver an electric shock through the chest to the heart.

Agreement When capitalized, refers to the agreement between Monterey County, the EMS Agency, and Contractor awarded pursuant to this solicitation.

Air Ambulance As defined in California Code of Regulations, Title 22, Section 100280.

Air Ambulance Service As defined in California Code of Regulations, Title 22, Section 100285.

Air Rescue Service As defined in California Code of Regulations, Title 22, Section 100286.

ALS Advanced Life Support, with the meaning as defined in California Health and Safety Code Section 1797.52.

ALS Ambulance An ambulance especially equipped to provide advanced life support services, staffed by at least one EMT-1 and one state licensed and Monterey County accredited EMT-P.

ALS Unit

An authorized emergency vehicle staffed with a state licensed and locally accredited paramedic and equipped with ALS equipment, as required by EMS System Policies and Procedures.

Ambulance

Any vehicle specially constructed, modified or equipped and used for transporting sick, injured, infirmed or otherwise incapacitated person and capable of supporting BLS or a higher level of care.

Ambulance Service(s)

Ambulance Services, when capitalized means all ambulance services, including all emergency ambulance services, all advanced life support (ALS) ambulance services, all basic life support (BLS) ambulance service, all critical care transport (CCT) ambulance services, all interfacility (IFT) ambulance services, all standby services with transport authorization, and ambulance response to all medical seven-digit emergency response and all medical 911 calls within the Monterey County Exclusive Operating Area (“EOA”).

AVL

Automatic Vehicle Locator. A device that utilizes the Global Posting System to identify, remotely track, and display the location of a vehicle. An Automatic Vehicle Locator is also described as automatic vehicle location device.

Bariatric Ambulance An ambulance designed to carry the significantly obese. They have extra-wide interiors, carry "bariatric stretchers" and specialized lifting gear capable of carrying very large patients.


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Base Hospital

As defined in California Health and Safety Code, Section 1797.58.

Base Hospital Physicians As defined in California Health and Safety Code, Section 1797.59.

Bidder

An organization making a formal proposal to this RFP.

BLS

Basic Life Support, as defined in California Health and Safety Code, Section 1797.60.

BLS Ambulance An Ambulance staffed with two individuals who are currently certified as s defined in Health and Safety Code Section 1797.60. Emergency first aid and cardiopulmonary resuscitation procedures which, as a minimum, include recognizing respiratory and cardiac arrest and starting the proper application of cardiopulmonary resuscitation to maintain life without invasive techniques until the patient may be transported or until advanced life support is available. A unit staffed by at least two individuals, certified at or above the level of an EMT-I as defined in California Health and Safety Code 1797.80.

Board The Board of Supervisors of Monterey County.

Business Day

Monday through Friday except for holidays as observed per the California Government Code, Section 6700 et seq.

CAD

Computer-Aided Dispatch. A system consisting of but not limited to associated hardware and software to facilitate call taking, system status management, unit selection, ambulance coordination, resource dispatch and deployment, event time stamping, creation and real time maintenance of incident database, and providing management and quality improvement information.

California Medical and Health Disaster System

The medical and health mutual aid system as defined in California Health and Safety Code Sections 1797.151 through 1797.153, and regulations, programs, policies, documents, and practices developed consistent with those statutes.

Call Prioritization

A process in which requests for service are prioritized based on predefined criteria.

Call Reception The process of answering the telephone and processing information for the caller in an emergency dispatch center.

CCMIA or CMIA California Confidentiality of Medical Information Act. California Government Code, Section 56 et seq.

CISM

Critical Incident Stress Management. Adaptive, short-term psychological helping-process that focuses solely on an immediate and identifiable problem.

Code 2 Call Any request for service, as determined by dispatch personnel, in accordance with EMS System Policies and Procedures and MPDS protocols, requiring immediate dispatch without the use of red lights and sirens.


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Code 3 Call

Any request for service, as determined by dispatch personnel, in accordance with EMS System Policies and Procedures and MPDS protocols, requiring immediate dispatch with the use of red lights and sirens.

Comfort Station

A facility contracted or arranged by the Contractor to provide restrooms and other suitable space/accommodations for crews to wait for assignments other than in an ambulance. Optimally, Comfort Stations should provide: (1) climate controlled (air conditioning and heat); (2) adequate and comfortable seating to accommodate a complete on-duty crew; (3) have at least one operable toilet, sink, microwave oven, refrigerator, desk and chair; (4) wireless data capability to enable patient care charting; and, (5) adequate accommodations to meet the needs of nursing mothers.

Contract

Used synonymously with Agreement. See Agreement.

Contract Materials

Finished or unfinished documents, data, studies, maps, photographs, reports, specifications, lists, manuals, software, and other written or recorded materials produced or acquired. by the Contractor pursuant to the Contract for or on behalf of the County, whether or not copyrighted.

Contractor When capitalized and used during this RFP process AND in an Agreement, Contractor is the qualifying entity that has been awarded the contract by the Monterey County Board of Supervisors, based upon the criteria, requirements, and processes in RFP #10735: Exclusive Ambulance Service Provider for the Monterey County Exclusive Operating Area.

CCT Critical Care Transport. A ground ambulance specially equipped to provide critical care services such as ventilator, IV pumps, and medications necessary for the interfacility transport of unstable patients who need patient care beyond the scope of the EMT or paramedic. The CCT ambulance is staffed with a licensed RN with critical care credentials and at least one EMT-Expanded Scope or paramedic.

County The County of Monterey.

County Data

All information, data, and other content, including Confidential Information and other information whether or not made available by Monterey County or Monterey County’s agents, representatives or users, to a Contractor or potential Contractor or their employees, agents, or representatives, and any information, data and content directly derived from the foregoing, including data reflecting user access or use.

County Systems

The information technology infrastructure of Monterey County or any of its designees, including computers, software, databases, networks, voice and data radio systems, and related electronic systems.

CPI Consumer Price Index. For this Agreement, CPI indicates the CPI as recorded by the Department of Labor, Bureau of Labor Statistics CPI as of the previous twelve (12) month period for which published figures are then available for all urban consumers, San Francisco-Oakland-San Jose, with equal weighting of the Medical Care Group and the Transportation Group. (50% Medical Care Group and 50% Transportation Group).


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CQI

Continuous Quality Improvement. An approach to quality management that builds upon traditional quality assurance methods by emphasizing the organization and systems.

DCF Disaster Control Facility. Also, known as Operational Area Patient Distribution Center (OAPDC). The EMS Communications Center-based function to coordinate the distribution of patients within and outside of the County during MCIs, medical disasters, and other incidents, as specified in EMS System Policies and Procedures.

Deployment Plan

The procedures by which ambulances are distributed throughout the service area. Deployment includes the locations at which the ambulances are placed (or posted) and the number of ambulances placed in service for the particular time period.

Difficult-to Serve Areas

Difficult-to Serve Areas are areas identified within the RFP and on the Response Area Maps where Contractor may use a Peripheral Service Provider’s ambulance to provide service, pursuant to an EMS-Agency approved agreement, when the Peripheral Service Provider’s ambulance is the closest ambulance to the scene of a medical emergency. Effective February 1, 2022, the Monterey County EOA will include the following four Difficult-to-Serve Areas: (1) Highway 1, typically to Mile Marker 13; (2) Parkfield, South Shore Lake San Antonio, and Highway 101 South of the Bradley Rest Stop; (3) the Cachagua area; and, (4) the Pajaro and Los Lomas areas in North County, (“Difficult-to-Serve Areas”).

ED

Emergency Department. A Department of Public Health Department’s Licensing and Certification-designated area within a state-licensed general acute care hospital that provides basic or comprehensive emergency services.

ePCR

Electronic Patient Care Report. An electronic document and system that is used by prehospital or medical personnel to document response, patient information, assessment, care, treatment, and disposition.

Emergency

Any real or self-perceived event which threatens life, limb or well-being of an individual in such a manner that a need for immediate medical care is created.

Emergency Call

A real or self-perceived event where the EMS system is accessed by the 9-1-1 emergency access number, or an interfacility transfer where the patient’s health or well-being could be compromised if the patient is held at the originating facility.

EMD

Emergency Medical Dispatch. Services provided pursuant to the authorized use of the Medical Priority Dispatch System (MPDS), including call reception, call and resource prioritization, and caller instruction, as approved by the EMS Medical Director. Emergency Medical Dispatcher. The single form of Emergency Medical Dispatchers.


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EMDs Emergency Medical Dispatchers certified by the International Academy of Emergency Dispatch, who are trained to use protocol-based prearrival instructions and call categorization based on established protocol, with integrated quality improvement.

EMS

Emergency Medical Services. This refers to the full spectrum of pre-hospital care and transportation (including interfacility transports), encompassing bystander action (e.g. CPR), priority dispatch and prearrival instructions, first response and rescue service, ambulance services, and on-line medical control.

EMS Agency

The Monterey County Health Department’s Emergency Medical Services Agency.

EMS Authority or EMSA

The State of California’s Emergency Medical Services Authority.

EMS Aircraft As defined in California Code of Regulations, Title 22, Section 100279.

EMS Director The Bureau Chief of the Monterey County EMS Agency.

EMS Medical Director

The EMS Medical Director of the Monterey County EMS Agency.

EMS Medical Dispatch An EMS Agency-designated center authorized to dispatch medical resources to emergency medical calls and to perform other medical functions. EMS Medical Dispatch provides MPDS call prioritization pre-arrival instructions consistent with EMS Agency-approved protocols.

EMS System

The combination of organizations, resources, and personnel with defined and organized responsibilities during a medical emergency. The EMS system includes organizations and personnel from dispatch and communications, first responder organizations, air and ground ambulance providers, hospitals and specialty centers, others, and the EMS Agency. When capitalized, refers to the Monterey County EMS System.

EMS System Policies and Procedures

The policies and procedures created by the Monterey County EMS Agency prescribing the operational and clinical practices of the Monterey County EMS System.

EMS Unit

A generic term for an ambulance or other vehicle used in the Monterey County EMS System.

EMT

Emergency Medical Technician, with the meaning as defined in California Health and Safety Code, Section 1797.80.

EMT-P or Paramedic

Emergency Medical Technician-Paramedic, with the meaning as defined in California Health and Safety Code Section 1797.84.

ePCR Electronic Patient Care Report.

EOA

Exclusive Operating Area. An EMS area or subarea defined by the emergency medical services plan for which a local EMS agency, upon the recommendation of a county, restricts operations to one or more emergency ambulance services or providers of limited advanced life support or advanced life support. Exclusive Operating Area for


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Ambulance Service, as designated in the County’s EMS plan and approved by the State EMSA.

Federal Refers to the Government of the United States of America, it’s departments, and/or agencies.

Field Personnel EMTs, Paramedics, and EMS Supervisors assigned to work in the prehospital environment.

First Responder

A fire department, fire district, police department, park rangers or other organization, authorized by the EMS Agency, whose personnel provide BLS or ALS first response, non-transport services within the Monterey County EMS System. Used in context, first responder may also mean the individual first responder.

First Watch/First Pass

A propriety system and service that mines data from one or more sources, such as CAD, ProQA, and ePCR to provide situational awareness, to measure operational performance, resource status, and to notify EMS System personnel.

First Responder Agencies Agencies that are medical first responders, as authorized by the EMS Agency. Also see First Responder.

FTE Full Time Equivalent.

GIS

Geographical Information Systems. A data and geographic framework for gathering, managing, analyzing, mapping, and displaying data.

GPS

Global Positioning System. A satellite-based radio-navigation system operated by the US Air Force that utilizes satellite data to determine location.

High Performance Agreement An agreement between a LEMSA and an Ambulance Provider by which the Ambulance Provider is required to meet specific response interval, operational, clinical, and other performance standards, and are financially sanctioned for failure to meet these standards.

HIPAA

Health Insurance Portability and Accountability Act. Federal Regulations that prescribe standards for the security, pricy, and access to Protected Health Information.

IAED International Academy of Emergency Dispatch.

ICS

Incident Command System. A standardized system Standardized approach to command, control, and coordinate emergency planning, response, and recovery. ICS provides common structures and processes used to standardize the planning, response and recovery involving multiple agencies.

IFT Interfacility Transports. Transports, usually by ambulance, between licensed healthcare facilities. Often these transports are non-emergency.


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Key Personnel

Employees of the Contractor jointly identified by the EMS Agency and the Contractor as possessing unique skills and experience that were a material consideration in the Monterey County EMS Agency’s and Monterey County’s decision to award a contract. Key Personnel are the personnel who fill the following positions: (1) Overall Operations; (2) Day-to-Day Operations; (3) Clinical Quality and Performance Management; (4) Clinical Education/Training; and, (5) EMS Communications.

KPI(s) Key Performance Indicator(s).

LMS

Learning Management System. A software application for the administration, documentation, tracking, reporting and delivery of training courses or training programs or learning and development programs.

LEMSA

Local EMS Agency. The Monterey County Health Department’s Emergency Medical Services Agency. Also see EMS Agency.

MCI

Multi-Casualty Incident. An incident that results in more victims than can normally be managed by the EMS System. The event takes place within a distinct location; rather than being a generalized increased call volume throughout a population.

MCECD Monterey County Emergency Communications Department Medical Protocol

Written standards for patient medical assessment and management.

MDC

Mobile Data Computer. A computer that is portable or vehicle mounted. MDCs are often used with Automatic Vehicle Location devices, which allow personnel to acknowledge or answer messages from the Communications Center or other units.

MHOAC Medical Health Operational Area Coordinator, with the meaning and responsibilities identified in California Health and Safety Code, Section 1797.153.

MPDS

Medical Priority Dispatch System. A protocol-based system used utilized by Certified Emergency Medical Dispatchers to provide and dispatch appropriate medical aid to emergencies. MPDS includes systematic caller interrogation, pre-arrival instructions, and quality improvement components.

Mutual Aid

The voluntary aid and assistance by the provision of services and facilities, including but not limited to: fire, police, medical and health, communication, transportation, and utilities. Mutual aid is intended to provide adequate resources, facilities, and other support to jurisdictions whenever their own resources prove to be inadequate to cope with a given situation

NIMS

National Incident Management System.

OCU

Online Compliance Utility. Software that interprets real-time CAD and ePCR data in order to produce reports and online tools to track EMS system effectiveness and compliance.


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Paramedic Unit

An ambulance staffed and equipped to provide advanced life support at the scene of a medical emergency and during transport in an ambulance. The minimum standard for a paramedic unit in Monterey County shall be one (1) EMT-P and one (1) EMT-1.

PCR Patient Care Report.

Peak-Load Staffing

The design of shift schedules and staffing plans so that coverage by crews matches the System Status Plan’s requirements.

Peripheral Service Provider

The ambulance provider that serves one or more of the four Difficult-to-Serve Areas, based on an EMS Agency-approved agreement between Contractor and Peripheral Service Provider to provide service, when the Peripheral Provider’s ambulance is the closest ambulance to the scene of a medical emergency.

Post

A designated location for ambulance placement within the System Status Plan (SSP). Depending upon its frequency and type of use, a “post” may be a facility with sleeping quarters or day rooms for crews, or simply a street-corner or parking lot location to which units are sometimes deployed.

PPE Personal Protective Equipment, including personal protective equipment used to prevent the transmission of infectious diseases and to prevent injury while at accident scenes on highways and other dangerous environments. High visibility apparel shall comply with ANSI/ISEA 107-2015 Type P standards.

Primary PSAP

Primary Public Safety Answering Point. A PSAP to which 9-1-1 calls are routed directly from the 9-1-1 Control Office.

Priority 1 Response Life Threatening Emergency Response. Priority 1 responses are defined based on the Medical Priority Dispatch System (MPDS) as approved by the EMS Medical Director. These typically include MPDS Echo and some MPDS Delta calls. Priority 1 calls normally receive a response using red lights and sirens.

Priority 2 Response Emergency Response. Priority 2 responses are defined based on the Medical Priority Dispatch System (MPDS) protocols as approved by the EMS Medical Director. These typically include some MPDS Delta calls, MPDS Charlie, and some MPDS Bravo calls. Priority 2 calls normally receive a response using red lights and sirens. Specific calls, identified in EMS System Policies and Procedures, such as calls in which transfer of the calling party is not indicated, are categorized as Priority 2 responses. Interfacility transports that require an immediate response, with red lights and sirens are also categorized as Priority 2 responses.

Priority 3 Response

Urgent Response. Priority 3 responses are defined based on the Medical Priority Dispatch System (MPDS) protocols as approved by the EMS Medical Director. Priority 3 call typically include MPDS Alpha and some MPDS Bravo calls, and in this system, until call referral is implemented, some MPDS Omega calls. Priority 3 calls normally receive a response without red lights and sirens.


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Priority 4 Response Immediate Interfacility Response. Priority 4 responses are responses to

interfacility transports that require an immediate response, without red lights and siren. Interfacility transports that require an immediate response, with red lights and sirens are categorized as Priority 2 responses.

Priority 5 Response

Prescheduled Interfacility Transfer. Priority 5 responses are responses to interfacility transports that are prescheduled no less than 60 minutes before the requested transport time. Priority 5 responses require an on-time response, without red lights and siren.

Priority 6 Response Critical Care Transport Response. Priority 6 responses are Critical Care Transport Ambulance (CCT-RN) responses to interfacility transports. Priority 6 responses may be prescheduled or immediate and may require use of red lights and siren.

Priority 7 Response Non-Medical 5150 and Behavioral Health Transport Response. Priority 7 responses are responses to scene or facilities for the transport of patients, without medical symptoms or etiology, who are being held pursuant to Welfare and Institutions Code, Section 5150 or require a transport due to other behavioral health problems. Priority 7 interfacility transports may be prescheduled or immediate and include 5150 and behavioral health transports that are in-county and out of county. Ideally, a resource that is less expensive and more humane than an ambulance will be used for these transports.

Priority 0 Non-Response Non-Response Priority. Priority 0 may be used in the future for some MPDS Omega requests as approved by the EMS Medical Director as a non-EMS response and/or referral to non-ambulance transportation or case management service, another nurse or other medical call-center for further review. The future use of this category may also assist the Contractor in offsetting future EMS system call volume growth.

Pro-rata Costs Costs allocated among beneficiaries based on a proportional and calculable factor.

Proposal Review Panel A panel, selected by the EMS Director, consisting of professional subject matter experts with experience in healthcare delivery models and/or government procurement procedures, and including members who are familiar with or oriented to various aspects of EMS systems, members who are knowledgeable with EMS needs of Monterey County, and members who have expertise in various EMS disciplines. PRP members shall be bound by the terms of a conflict of interest statement and confidentiality agreement and shall not have a conflict of interest.

PSAP Public Safety Answering Point.

PAD (or PAD Program) Public Access Defibrillation (Program). A program that place automatic external defibrillators throughout communities.

Proposer Used Synonymously with Bidder. See Bidder Region Region denotes the greater bay area region.


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When capitalized, Region denotes Region 2. Region 2 is one of six mutual aid regions established by the California Office of Emergency Services. Region 2 includes 16 coastal counties from Del Norte to Monterey, including Alameda County. Regions are described in EMSA document #218a, the California Disaster Medical Response Plan.

Response Area Response areas are geographic areas, based on historical call frequency within the Monterey County EOA. The three Monterey County EOA call frequency-based Response Areas are: Urban, Suburban, and Rural. These areas are based on historical call frequency, with that frequency of calls decreasing from Urban to Suburban to Rural. Generally, Urban could be considered the call frequency normally associated with an area of high to moderate call volume. Suburban could be considered the area with a moderate to low call volume. Rural could be considered the call frequency normally associated with a rural, remote, wilderness or frontier area. The call frequency-based Response Areas, are shown in the maps in Exhibit A.

Response Priority

A numbering system that incorporates presumptively-defined patient acuity, whether the call requires response with Red Light and Siren, whether the call is from the field or is a prescheduled or immediate interfacility transfer, whether the call is a non-medical behavioral health or 5150 call. Response Priorities are categorized Priority 1 through Priority 7. In the future, a non-response protocol, Priority 0, may be incorporated into the EMS System.

Response Time Interval The difference in time between EMS Call Queue Time and Unit On-Scene, as measured and recorded in integer minutes and seconds, for the purposes of measuring response time compliance in this Agreement.

RFP

Request for Proposal. Refers to this document and all attachments and exhibits to it, which is the Monterey County EMS Agency’s and County of Monterey’s request for proposals for experienced and well qualified organizations to provide Ambulance Service and other services within the Monterey County EOA.

Secondary PSAP A PSAP to which 9-1-1 calls are transferred from a Primary PSAP.

Stand-by Services The provision of a staffed and equipped ambulance at a specified location for either a planned event or an incident at the request of the Incident Commander. May be BLS or ALS based on the needs of the event or incident.

STEMI ST-Elevation Myocardial Infarction. A type of heart attack caused by the complete blockage of a heart artery. STEMI heart attacks have a substantial risk of death and disability and require rapid response and transport.

State The State of California, its departments, and/or agencies.

System Standard of Care

The combined compilation of all priority-dispatching protocols, pre-arrival instruction protocols, medical protocols, protocols for selecting destination hospitals, standards for certification of pre-hospital personnel, as well as standards governing requirements for on-board medical equipment and supplies, and licensing of ambulance services and first


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responder agencies. The System Standard of Care simultaneously serves as both a regulatory and contractual standard.

SSM System Status Management. A management tool to define the "unit hours" of production time, their positioning and allocation, by hour and day of week to best meet demand patterns.

Time Interval The difference in time between two time points, as measured and recorded in integer minutes and seconds.

Time Point An instant in time with a base granularity measured and in integer minutes and seconds.

Transport Volume

The number of requests for service that result in patient transport.

Unit Hour One hour of service by a fully equipped and staffed ambulance assigned to a call or available for dispatch.

UHU (or UHU Ratio)

Unit Hour Utilization. A measurement of effectiveness or efficiency, which is calculated by dividing the number of transports initiated during a given period of time, by the number of unit hours (hours of service) deployed during the same period of time.

Utilization A measure of work that compares the available resources (unit-hours) with actual time that those unit-hours are being consumed by productive activity. The measure is calculated to determine the percentage of unit-hours actually consumed in productivity with the total available unit-hours.

Workload

A measure of work performed by on-duty units during any given period of time.


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Time Points Arrived Patient Side Time The time the personnel from the unit arrived at the patient’s side, as

measured and recorded in integer minutes and seconds. (NEMSIS eTimes.07)

EMS Call Complete Time The time the unit completed all tasks associated with the event including transfer of the patient and such things as cleaning and restocking, as measured and recorded in integer minutes and seconds. (NEMSIS eTimes.16)

EMS Call Pick Up Time The time the EMS Communication Center receives/answers the 9-1-1 caller from the Primary PSAP, as measured and recorded in integer minutes and seconds. (NEMSIS eTimes.02)

Facility (Hospital) Patient Transfer of Care Time

The time that patient care responsibility was transferred from the EMS provider to the personnel of another facility. Relative to a hospital, this means: the time the patient is: (1) transferred to an Emergency Department gurney, bed, chair, or other acceptable location; and, (2) the ED personnel assume the responsibility for the care of the patient, as measured and recorded in integer minutes and seconds. (NEMSIS eTimes.08 and APOT Definitions)

Field Transfer of EMS Patient Care Time

The time that patient care was transfer from one EMS provider to another EMS provider, as measured and recorded in integer minutes. (NEMSIS eTimes.08)

Medical Call Queue Time The time the EMS call is ready for dispatch and enters the EMS Dispatch Assignment Queue, as measured and recorded in integer minutes and seconds.

MPDS Determinate Time The time the MPDS Determinate is selected, as measured and recorded in integer minutes and seconds.

Patient (Ambulance) Arrival at Destination/Rendezvous (Hospital) Time

The time the ambulance stops (actual wheel stop) at the location outside the facility where the patient is unloaded from the ambulance, as measured and recorded in integer minutes and seconds. (NEMSIS eTimes11 and APOD Toolkit 9)

Primary PSAP (9-1-1) Call Time The time the phone rings at the Primary PSAP, as measured and recorded in integer minutes and seconds. (NEMSIS eTimes.01)

Primary PSAP (9-1-1) Pick Up Time The time the Primary PSAP’s 9-1-1 call taker answers the phone, as measured and recorded in integer minutes and seconds.

Unit Acknowledged Time The time the unit acknowledged the notification from dispatch, as measured and recorded in integer minutes and seconds. (NEMSIS eTimes.04)

Unit Back at Home Location Time The time the unit was back in their service area. With agencies who utilize Agency System Status Management, home location means the service areas as assigned through the agency status management


13

protocol, as measured and recorded in integer minutes and seconds. (NEMSIS eTimes.15)

Unit Back In Service Time The time the unit was back in service and available for a response, as measured and recorded in integer minutes and seconds. This time used may be the time recorded in CAD as the time the unit was cancelled by fire or law enforcement on the scene. (NEMSIS eTimes.14)

Unit Cancelled Time The time the unit was cancelled, as measured and recorded in integer minutes and seconds. This time used may be the time recorded in CAD as the time the unit was cancelled by fire or (NEMSIS eTimes.14)

Unit Enroute Time The time the unit advises they are enroute to the call via radio or Mobile CAD. as measured and recorded in integer minutes and seconds. (NEMSIS eTimes.05)

Unit Left Scene Time The time the responding unit left the scene (wheels moving) with a patient, as measured and recorded in integer minutes and seconds. (NEMSIS eTimes.09)

Unit Notified by Dispatch Time The time the unit was notified by dispatch, as measured and recorded in integer minutes and seconds. (NEMSIS eTimes.03)

Unit On-Scene Time The time the responding unit arrived on scene; that is, the time the vehicle is placed in park at the scene, as measured and recorded in integer minutes and seconds. If staging is required for crew safety, at scene is determined when the unit reaches a safe distance from the call and waits for law enforcement to determine the scene safe to enter. If an off-road location, such as a park or private road with gated access, at scene is determined by reaching the end of paved roadway or closed gate. (NEMSIS eTimes.06)


14

Time Intervals Ambulance at Hospital Time Interval The time interval starting at Patient (Ambulance) Arrival at the ED and

ending at Unit Back In Service Time, as measured and recorded in integer minutes and seconds.

Ambulance Patient Offload Time Interval

The time interval starting at Patient (Ambulance) Arrival at the Hospital Time and ending at Facility (Hospital) Patient Transfer or Care Time, as measured and recorded in integer minutes and seconds.

Dispatch Queue Interval The time interval starting at MPDS Determinate Time / Medical Queue Time and ending Unit Notified by Dispatch Time, as measured and recorded in integer minutes and seconds.

Dispatch Chute Time Interval The time interval starting at Unit Notified by Dispatch and ending at Unit Enroute, as measured and recorded in integer minutes and seconds.

Patient Response Interval The time interval starting at Medical Call Queue Time and ending at Arrived Patient Side Time, as measured and recorded in integer minutes and seconds.

Prehospital Interval The time interval starting EMS Pick Up Time a and ending at Patient (ambulance) Arrival and Destination/Rendezvous (Hospital) Time, as measured and recorded in integer minutes and seconds.

Response Time Interval The time interval starting at Medical Call Queue Time and ending at Unit On-Scene Time or the Unit Cancelled Time, as measured and recorded in integer minutes and seconds.

Travel Time Interval The time interval starting at Unit Enroute time and ending at Unit On-Scene Time or Unit Cancelled Time, as measured and recorded in integer minutes and seconds.

Total Call Time on Task Interval The time interval starting at EMS Pick Up Time and ending at EMS Call Complete Time, as measured and recorded in integer minutes and seconds.

Scene Time Interval The time interval starting at Unit On-Scene and ending at Unit Left Scene, as measured and recorded in integer minutes and seconds.

Unit Arrival to Patient Contact Interval

The time interval starting at Unit On-Scene Time and ending at Arrived Patient’s Side Time, as measured and recorded in integer minutes and seconds.

EXHIBIT H – Response Priorities to MPDS Levels

1

Priority 1 - Lights and Siren – Non-divertible MPDS Level MPDS Protocol Description

01D Abdominal Pain NOT ALERT 02E Allergies (Reactions) / Envenomations (Sting,Bites) NOT ALERT 02D Allergies (Reactions) / Envenomations (Sting,Bites) INEFFECTIVE BREATHING 03D Animal Bites / Attacks ARREST or UNCONSCIOUS or NOT ALERT 04D Assault ARREST or UNCONSCIOUS or NOT ALERT 05D Back Pain NOT ALERT 06E Breathing Problems INEFFECTIVE BREATHING 06D Breathing Problems NOT ALERT 07E Burns / Explosions PERSON ON FIRE 07D Burns / Explosions ARREST or UNCONSCIOUS or NOT ALERT 08D Carbon Monoxide / HAZMAT ARREST or UNCONSCIOUS or NOT ALERT 09E Cardiac or Respiratory Arrest 10D Chest Pain NOT ALERT 11E Choking NOT ALERT 11D Choking COMPLETE OBSTRUCTION or INEFFECTIVE BREATHING 13C Diabetic Problem NOT ALERT 13D Diabetic UNCONSCIOUS 14E Drowning ARREST or UNDERWATER 14D Drowning UNCONSCIOUS or NOT ALERT 15E Electrocution UNCONSCIOUS or NOT ALERT 15D Electrocution NOT BREATING or INEFFECTIVE BREATHING 16D Eye Problem / Injury NOT ALERT 17D Falls ARREST or UNCONSCIOUS or NOT ALERT 18C Headache NOT ALERT 19D Heart Problems NOT ALERT 20D Heat / Cold Exposure NOT ALERT 21D Hemorrhage ARREST or UNCONSCIOUS or NOT ALERT 23E Overdose / Poisoning NARCOTIC/OPIOD ARREST 23D Overdose / Poisoning ARREST or UNCONSCIOUS 23C Overdose / Poisoning NOT ALERT 25D Psychiatric / Suicide Attempt ARREST or UNCONSCIOUS or NOT ALERT 26D Sick Person NOT ALERT 27D Stab / Gunshot ARREST or UNCONSCIOUS or NOT ALERT 28C Stroke NOT ALERT 29D Traffic Incidents ARREST or UNCONSCIOUS or NOT ALERT 30D Traumatic Injuries ARREST or UNCONSCIOUS or NOT ALERT 31E Unconscious INEFFECTIVE BREATHING 31D Unconscious AGONAL or ABNORMAL or EFFECTIVE or NOT ALERT or

CHANGING COLOR


2

Priority 2 – Lights and Siren MPDS

Protocol & Level

MPDS Protocol Description

01D Abdominal Pain 01C Abdominal Pain 02D Allergies (Reactions) / Envenomations (Sting, Bites) 02C Allergies (Reactions) / Envenomations (Sting, Bites) 02B Allergies (Reactions) / Envenomations (Sting, Bites) 03D Animal Bites / Attacks 03B Animal Bites / Attacks 04D Assault 04B Assault 05D Back Pain 05C Back Pain 06D Breathing Problems 06C Breathing Problems 07D Burns 07C Burns 07B Burns 08D Carbon Monoxide / HAZMAT 08C Carbon Monoxide / HAZMAT 08B Carbon Monoxide / HAZMAT 09D Cardiac or Respiratory Arrest 09B Cardiac or Respiratory Arrest 10D Chest Pain 10C Chest Pain 11D Choking 12D Convulsions / Seizures 12C Convulsions / Seizures 12B Convulsions / Seizures 13D Diabetic Problem 13C Diabetic Problem 14D Drowning / Near Drowning 14C Drowning / Near Drowning 14B Drowning / Near Drowning 15D Electrocution 15C Electrocution 16D Eye Problem / Injury 16B Eye Problem / Injury 17D Falls 17B Falls 18C Headache 18B Headache


3

19D Heart Problems 19C Heart Problems 20D Heat / Cold Exposure 20C Heat / Cold Exposure 20B Heat / Cold Exposure 21D Hemorrhage 21C Hemorrhage 21B Hemorrhage 22D Inaccessible Incident / Entrapments 22B Inaccessible Incident / Entrapments 23D Overdose / Poisoning 23C Overdose / Poisoning 23B Overdose / Poisoning 24D Pregnancy / Childbirth / Miscarriage 24C Pregnancy / Childbirth / Miscarriage 24B Pregnancy / Childbirth / Miscarriage 25D Psychiatric / Suicide Attempt 25B Psychiatric / Suicide Attempt 26C Sick Person 26B Sick Person 27D Stab / Gunshot 27B Stab / Gun Shot 28C Stroke 29D Traffic Incidents 29B Traffic Incidents 30D Traumatic Injuries 30B Traumatic Injuries 31C Unconscious / Fainting 32D Unknown Problem (Person Down) 32B Unknown Problem (Person Down)

Priority 3 – No Lights and Siren MPDS

Protocol & Level

MPDS Protocol Description

01A Abdominal Pain 02A Allergies (Reactions) / Envenomations (Sting, Bites) 03A Animal Bites / Attacks 04A Assault 05A Back Pain 07A Burns 08Ω Carbon Monoxide / HAZMAT 09Ω Cardiac Arrest EXPECTED DEATH unquestionable


4

10A Chest Pain 11A Choking 12A Convulsions / Seizures 13A Diabetic Problems 14A Near Drowning 16A Eye Problem / Injuries 17A Falls 18A Headache 19A Heart Problems 20A Heat / Cold Exposure 21A Hemorrhage 22A Inaccessible Incident / Entrapments 23Ω Overdose / Poisoning 24A Pregnancy / Childbirth / Miscarriage 24Ω Pregnancy / Childbirth / Miscarriage 25A Psychiatric / Suicide Attempt 26A Sick Person 26Ω Sick Person 27A Stab / Gunshot 28A Stroke / TIA 29A Traffic Incidents 29Ω Traffic Incidents 30A Traumatic Injuries 31A Unconscious / Fainting (Near)

*All Priority assignments to MPDS levels subject to change based on EMS Agency Medical Director review and approval

EXHIBIT I - Response Time Interval Compliance & Liquidated Damages Measurement Charts

12 Compliance measurements

Priority

Response Area Compliance

Standard

Overall Compliance

Standard Priority 1

Urban 90% N/A Suburban 90%

Rural 90% Priority 2


Rural 90% Priority 3


Rural 90% Priority 4 90% Priority 5 90% Priority 6 90% Priority 7 TBD 90%

EXHIBIT J - MPDS Response Matrix Chart

Response Level Capability Ambulance Response Rationale

ECHO ALS Red Lights and Sirens

• Information exists that death is imminent • Closest any First Response and ALS

Ambulance • Immediate lights and siren response

needed • Multiple resources necessary • Rapid ALS transport almost certain

DELTA ALS Red Lights and Sirens

• Closest First Response and ALS Ambulance

• Immediate lights and siren response needed

• Multiple resources necessary • ALS transport likely

CHARLIE Urban ALS Red Lights and Sirens • ALS Ambulance / First Response for

extended ETA • Multiple resources not necessary • ALS or BLS transport likely

CHARLIE Rural ALS Red Lights and Sirens

BRAVO Urban

BLS or ALS Red Lights and Sirens • BLS or ALS Ambulance / First

Response for extended ETA • Rapid BLS evaluation indicated

BRAVO Rural

BLS or ALS No Red Lights and Sirens

ALPHA Closest BLS or

ALS No Red Lights and Sirens

• BLS or ALS Ambulance / First Response not needed

• Multiple resources not necessary • Transport less likely

OMEGA Referral or BLS No Red Lights and Sirens • Ambulance transport not indicated and

referral to specialty service appropriate

* This response matrix defines the general assignment of ALS or BLS ambulance and first responder resources, based on MPDS protocols.

Variation may occur, based on MPDS experience, research, response history, and the ETA of responding resources.

EXHIBIT K - Response Time Interval Requirement by Priority and Response Area

Priority Classifications EOA Response Area

Priority

Red

Lights and

Siren

Response

Type of Call

First

Responder

Response

Call

Processing

and

Dispatch

Urban

(>300 calls

per square

mile

annually)

Suburban

(~11-299

calls per

square mile

annually)

Rural

(~0-10

calls per

square

mile

annually)

1 Yes

Life

Threatening

Emergency

Response

Determined

by local

jurisdiction

0:59 8:00 13:00 45:00

2 Yes Emergency

Response

Determined

by local

jurisdiction

0:59 10:00 16:00 45:00

3 No Urgent

Response

Determined

by local

jurisdiction

0:59 12:00 18:00 59:00

4 No

Immediate

Interfacility

Transfer

No

N/A 60 minutes

from request

60 minutes

from request N/A

5 No

Pre-

Scheduled

Interfacility

Transfer

(more than

60 minutes)

No

N/A Initial Time

Requested

Initial Time

Requested N/A

6 As

requested

Critical Care

Transport

Interfacility

Transfer

No

N/A

Scheduled

Initial Time

Requested

Immediate

Code 3:

At least 30:00

Code 2:

At least 45:00

when

available

Scheduled

Initial Time

Requested

Immediate

Code 3:

At least

60:00

Code 2:

At least

90:00 when

available

N/A

7 TBD No

Non-Medical

– 5150 w/o

other

medical

condition

NO

N/A

60:00 60:00 90:00

* During the contract period, Response Time Interval performance standards may be modified, based on the decision of

the EMS Medical Director, based on scientific or clinical research.

** All Time Point and Time Interval Standards are based on the Time Points and Time Intervals identified in Exhibit G –

Definitions, Acronyms, Time Points and Time Intervals

EXHIBIT L - Monterey County EMS KPI’s

1

Clinical Condition

Care Element or Clinical Outcome

Key Performance Indicator

Notes on Metrics

Exclusions Key Performance Indicator Goal

Comments/ References

Rationale for measuring

1 CPR a Clinical

Care KPIs Quality of CPR

% of cardiac arrest cases in which manual CPR was performed by contracted ambulance personnel, and had a compression fraction > 80% as measured by Code-Stat software or equivalent

Data Source: Code-Stat software or equivalent Denominator: Total number of cardiac arrest cases in which CPR was performed by contracted ambulance personnel. Numerator: Number of denominator cases in which contracted ambulance personnels' compression fraction was >80%.

None >60% 2017 AHA Guidelines

Fewer interruptions in chest compressions maximizes coronary perfusion and blood flow during CPR.


2

2 Myocardial Infarction (STEMI/Acute Coronary Syndrome - ACS)

a Clinical Care KPIs

Under-triage of STEMI patients

To identify the number and percentage of patients transported by the contracted ambulance to a STEMI Receiving Center (SRC) who are identified as STEMI patients at the hospital but were not so identified in the prehospital environment.

Denominator: All patients with complaints of chest pain/discomfort or other symptoms suggestive of ACS transported by the contracted provider who were not identified as STEMI patients. Numerator: All patients transported to a hospital who were identified as STEMI patients based on the prehospital ECG, but were not so identified by the contracted ambulance personnel

1. Patient is in full arrest and ROSC is not achieved prior to arrival at the receiving hospital. 2. Patient is a critical trauma patient.

<99%

Identification of possible training issues for paramedics


3

b Clinical Care KPIs

Suspected STEMI scene time

For patients with suspected STEMI and a positive field ECG: Interval from arrival of first unit on-scene (either fire first responder or ambulance) to departure of ambulance from scene is < 15:00 minutes

Data Source: ePCR software Denominator: Number of patients with complaints of chest pain/discomfort or other symptoms suggestive of ACS and an abnormal prehospital ECG suggesting STEMI. Numerator: Number of denominator cases in which the ambulance leaves the scene within 15:00 minutes of arrival on scene

1. Difficulty finding or getting to the patient. 2. Difficulty getting the patient from where they are to the ambulance

>90%

CA EMS Performance Measure ACS-3; Minnesota Mission: Lifeline EMS STEMI Transport Guideline

Shorter scene times contribute to the overall goal of EMS to Device time of 90" or less

3 Stroke


Glucose testing in suspected stroke patients

Glucose testing is performed for all patients with suspected stroke

Data Source ePCR software Denominator: Number of patients with a positive prehospital Stroke exam and a Provider

None >99%

CA Performance Measure STR-2 AHA/ ASA 2018 Guidelines

Hypoglycemia is frequently found in patients with stroke like symptoms; thus, prehospital glucose testing is critical.


4

Impression of Suspected Stroke or TIA. Numerator: Number of denominator cases on whom blood glucose testing is performed in the prehospital setting


A stroke screening assessment using the stroke screening tool (selected and approved by the EMS Agency) is done on all patients with a suspected Stroke or TIA

Initial stroke screening assessment on all patients with a suspected Stroke

Data Source: ePCR software Denominator: Number of patients with signs and symptoms of a possible stroke or TIA Numerator: Number of denominator cases on whom screening is carried out using the Monterey County approved Prehospital Stroke Scale

1. Patient is unconscious or too obtunded to be able to perform a Prehospital Stroke assessment.

>99%

CA EMS Performance Measure SRT-1 AHA/ASA Guidelines 2018

EMS leaders, in coordination with local, regional, and state agencies and in consultation with medical authorities and local experts, should develop triage paradigms and protocols to ensure that patients with a known or suspected stroke are rapidly identified and assessed by use of a validated and standardized instrument for stroke screening, such as the FAST (face, arm, speech test) scale, Los Angeles Prehospital Stroke Screen, or Cincinnati Prehospital Stroke Scale


5

c Clinical Care KPIs

Under Triage of Stroke Patients

To identify the number and percentage of patients transported by contracted ambulance to a Stroke Center who are identified as Stroke patients at the hospital but were not so identified in the prehospital environment.

Denominator: All patients transported by the contracted ambulance provider who were not identified as Stroke patients. Numerator: All patients transported to a hospital by the contracted ambulance provider who were identified as Stroke patients but were not so identified by the contracted ambulance personnel

None <1%

Identification of possible training issues for paramedics

d Clinical Care KPIs

Scene time for patients with a suspected stroke

For patients with suspected Stroke and a positive prehospital Stroke Assessment and for whom a Stroke Alert has been issued: Interval from arrival of first unit on-scene (either fire first responder or ambulance) to departure of ambulance from scene is < 15:00 minutes

Data Source: ePCR software Denominator: Number of patients with suspected Stroke and a positive Stroke assessment and for whom a Stroke Alert has been issued;

None >90%

CA EMS Performance measure STR-3 AHA/ASA Stroke Guidelines 2018

Shorter scene times contribute to the overall goal of getting patients to definitive care and tPA within 3 hours of onset of symptoms, or intervention within the shortest possible times.


6

Numerator: Number of denominator cases in which the ambulance leaves the scene within 15:00 minutes of arrival on scene

4 Trauma


Scene time for patients meeting CDC Field Trauma Triage Criteria Steps 1, 2 or 3 (physiological, anatomical, or mechanism of injury criteria)

Scene time (measured from time of arrival of the first unit on-scene (either fire first responder or ambulance) to time of departure from scene is 10:00 or less in cases which meet CDC Field Trauma Triage Criteria Steps 1, 2 or 3.

Data Source: ePCR software Denominator: Number of patients meeting CDC Field Trauma Triage Criteria Steps 1, 2 or 3 Numerator: Number of denominator cases in which the ambulance scene time (measured from time of arrival of ambulance on-scene to time of departure from scene) is 10:00 minutes or less

1. Patient refusing care on scene, and changes their mind. 2. Prolonged extrication. 3. Multiple patients on scene with few resources (MCI).

>85%

National Model EMS Clinical Guidelines

Shorter scene times for identified Trauma patients have been shown to decrease morbidity and mortality. Rapid transport of critical patients decreases the time between the injury and definitive care in the operating room.


7

5 CQI Indicators


Esophageal intubations

Total Number of esophageally placed ET Tubes placed in the field

Data Source: Hospital Records Denominator: All patients on whom an oral endotracheal intubation was attempted. Numerator: All denominator cases in which the endotracheal tube was placed in the esophagus

None <1%

An endotracheal tube placed in the esophagus and not immediately recognized and removed is not compatible with life.


Use of Capnometry

Capnometry will be used to confirm all advanced airway placements

Data Source: Patient Care Reports; ECG monitor reports. Denominator: all advanced airway placements. Numerator: all denominator cases where End Tidal CO2 is measured and documented

None 100%

https://www.sciencedirect.com/science/article/pii/S0733862708000862 , retrieved 10/02/2018

Capnography provides continuous, dynamic assessment of the ventilatory status of patients

https://www.sciencedirect.com/science/article/pii/S0733862708000862






Exhibit M -- Minimum Equipment Lists by Scope of Practice

1

PARAMEDIC PROVIDER AUTHORIZED STOCK

I. PURPOSE

A. To establish equipment standards for paramedic service providers based in Monterey County

II. POLICY

A. Every paramedic unit, either first response or ambulance, shall have no less than the

specified amount of equipment at all times. An ALS unit shall not respond to a request for service without the equipment and supplies necessary to provide care under Monterey County EMS policies and protocols.

B. All equipment and supplies must be clean or sterile as appropriate and in good working order. Medications and supplies shall be replaced prior to their expiration.

C. The paramedic service provider shall implement an inventory control program to ensure that all system units have at least the minimum levels of supplies and equipment listed below. Paramedic service providers are encouraged to carry greater amounts of equipment and supplies than the minimum specified in this policy.

D. This stocking level is to augment any requirements established by Federal, State, or other regulations.

E. Only the items specified on this list may be carried on Monterey County paramedic units. Items carried must be approved in advance by the Monterey County EMS Medical Director.

F. Monterey County EMS Agency personnel may inspect any ALS unit, at any time, for compliance with the identified standards for equipment and supplies.


2

Paramedic

Minimum Stock Non- Transport

Minimum Stock Transport

ITEM

1 1 Needle Thoracotomy set N/A 1 Main Oxygen Tank. “M” size or larger. Minimum 500psi. 2 2 Portable Oxygen Tank. “D” size or larger. Mandatory 1000psi 1 1 Regulator for Portable Oxygen Tank 1 2 Adult BVM Resuscitator with Oxygen Supply Tubing 1 2 Child BVM Resuscitator with Oxygen Supply Tubing 1 2 Adult Nasal Cannula 1 2 Pediatric Nasal Cannula 1 2 Adult Nonrebreather Mask 1 2 Pediatric Nonrebreather Mask 1 2 Hand-held Nebulizer for Inhaled Medications 1 2 Nebulizer Mask for Inhaled Medications 1 2 Nebulizer Adapter for BVM 1 2 Oropharyngeal Airways. Each Size 6-10 (or equivalent size) 1 2 Nasopharyngeal Airways. Each Size 28-34Fr 1 2 Endotracheal Tubes cuffed. Each Size 6.0 - 8.0 (whole sizes only) 1 1 Laryngoscope Handle 1 1 Laryngoscope Blades. Miller. Each Size 0-4 1 1 Laryngoscope Blades. Mac. Each Size 0-4 2 2 Extra Batteries for Laryngoscope (or equivalent) 1 2 ET Stylet. 1 2 ET Securing Device. 1 2 ET Tube Inducer 1 1 Magill Forceps. Each Adult and Pediatric 1 2 10cc Syringe 1 1 Extra Laryngoscope Lightbulbs. Each size 4 4 Water soluble Lubricating Jelly Packets 1 1 CO2 Detector. Adult and pediatric capable 1 2 King Airway. Each 3, 4, 5 1 1 Pulse Oximetry Device 1 1 Pulse Oximetry Sensor. Each for adult and pediatric use N/A 1 Fixed Suction unit with Suction Tubing and Rigid Suction Catheter 1 1 Portable Suction unit with Suction Tubing and Rigid Suction Catheter 1 2 Extra Rigid Suction Catheter 1 2 Extra Suction Tubing 1 2 8, 10, 18fr Flexible Suction Catheter each 1 1 Heart Monitor/defibrillator. 12-Lead with capability to transmit to

Monterey County STEMI Receiving Centers.


3



ITEM

1 1 ECG leads 1 1 12-Lead ECG Cables 1 1 ECG Recording Paper-extra 2 2 ECG Defibrillator Pads. Each Size Adult and Pediatric 2 2 Pacing Pads. Each Size Adult and Pediatric

May be combination pads 4 sets 4 sets ECG Electrodes. Adult 2 sets 4 sets ECG Electrodes. Pediatric 2 2 Ringer Lactate. 1000 ml 2 8 Normal Saline for IV. 1000cc 2 4 Normal Saline for IV. 250cc 4

4/2 8

8/4 IV Tubing with Extension Sets if Combination Tubing IV Tubing with Extension Sets if Macrodrip and Microdrip separately

2 8 IV Catheters 14, 16, 18, 20, 22, 24 Gauge. Each Size 1 1 Alcohol Preps. Box (10) 4 8 Tourniquets for IV Start 2 4 Tape Rolls. 1 Inch Plastic to Secure IV or other device 1 1 EZ-IO Driver 1 2 EZ-IO Needles. Each Adult and Pediatric with Connecting Tubing 1 2 IO Needle for Manual Insertion 2 5 Syringes. 1, 3, 5, 10cc. Each Size 2 5 Needles. 18, 20, 25 Gauge. Each Size 2 3 Intra-nasal Atomizer 1 1 Sharps Container 1 1 Glucometer with Test Strips (10) 5 10 Lancets 2 3 Transfer needles 2 3 Activated Charcoal. 25Gm. One (1) without Sorbitol 5 6 Adenosine. 6mg 4 6 Albuterol. 2.5mg Individual Unit Dose 1 1 Aspirin. 81mg Chewable. Bottle. 2 6 Atrovent. 0.5mg Individual Unit Dose 1 3 Atropine. 1mg Pre-load Syringe 1 2 Atropine. 8mg Vial 1 2 Calcium chloride 1Gm 2 2 Diphenhydramine. 50mg Vial 2 4 Dextrose. 25Gm Pre-load Syringe (D50) 2 2 Dextrose. 12.5Gm Pre-load Syringe (D25) 1 2 Dopamine. 400mg Vial or premixed bag 4 8 Epinephrine. 1:10,000. 1mg Pre-load Syringe


4



ITEM

2 2 Epinephrine. 1:1,000. 1mg Ampule 2 4 Fentanyl. 100mcg or equivalent 2 3 Glucagon. 1mg 2 3 Oral Glucose. 30Gm tube 4/3 8/6 Lidocaine. 100mg Pre-load Syringe and/or Amiodarone 150mg 2 2 Midazolam. 5mg Preload Syringe or Vial 2 4 Morphine. 10mg Preload Syringe or Vial 3 4 Naloxone. 2mg Pre-load Syringe 1 2 Nitroglycerine. 1 1 2% Nitroglycerine Paste. Does There needs to be a dose/concentration

associated with this?1 tube with patches 2 4 Sodium Bicarbonate. 50MEQ Pre-load Syringe N/A 1 Gurney N/A 1 Stair Chair N/A 1 Break-away Flat 1 1 Traction Splint 1 1 KED or Short Immobilization Board or Similar Device 1 2 Backboard with adequate strapping materials for each board 2 2 Blanket and Pillow. Each. Blanket only for non-transport units. N/A 4 Pillowcase 2 2 Cervical Collar. Adult Adjustable 2 2 Cervical Collar. Pediatric Adjustable 2 2 Head Immobilizing Device 2 4 Splints. Arm/Leg. Cardboard or Equivalent. Each Size N/A 2 Emesis Basin N/A 1 Bed Pan and Urinal. Each 1 1 Stethoscope 1 1 BP Cuff. Each Size Adult, Child, Infant, Large 1 1 1 5 Triangular Bandage 12 12 Sterile Dressings 4 6 Roller Bandage (Kerlix) 4 4 Trauma Dressing 2 2 2 Inch Adhesive Tape 2 2 Burn Sheet 6 6 Occlusive Dressing 2 4 Cold Pack 2 4 Hot Pack 1 1 Scissors 1 1 Flashlight


5



ITEM

N/A 1 Restraints. Four Point. 1 1 Obstetrical Kit with blanket to preserve neonate warmth 4 4 Sterile Water or Saline for Irrigation 2 2 Tourniquet (Bleeding Control) 1 1 Length-based pediatric treatment tape (Broselow or similar) 5 10 Patient Care Report Form 5 5 Refusal of Care Forms 10 15 Triage Tags 2 2 CPAP with (1 large and 1 medium mask) 1 1 Hard hat for each person. Meets NFPA 1951, ANSI Z89.1-1986 (Class

and B), OSHA: 29 CFR 1910.135 &29 CFR 1926.100(b), CSA Z94.1- M1992 (Class G), or equivalent.

1 1 Eye protection-Glasses, face shield, goggles, or mask with side protection for each person. Meets NFPA 1999, ANSI Z87.1

1 1 Hearing protection for each person 1 1 Barrier garment for each person. Meets NFPA 1999 such as Tyvek. 3 pairs 3 pairs Exam gloves for each person. Nitrile-type or equivalent. 1 pair 1 pair Boot/shoe covers for each person. Meets NFPA 1999. Chemical

Resistant. 1 1 Face shield for each person. Meets NFPA 1999, ANSI Z87.1. 1 pair 1 pair Work gloves for each person. Meets NFPA 1999 2 2 Respirator mask for each person. N-100 or N-95. Meets OSHA 42

CFR 84, 8CCR 5144, NIOSH Respirator Selection Logic 2004.


6

EMT SCOPE OF PRACTICE-EXPANDED SCOPE

I. PURPOSE

To define the scope of practice for the EMT-Expanded Scope in Monterey County.

II. POLICY

A. EMT-Expanded Scope personnel shall adhere to the Monterey County EMT scope of practice while working in a BLS assignment. This includes volunteer and paid call duty.

B. The scope of practice of EMT-Expanded Scope personnel shall not exceed those activities authorized in California Code of Regulations Title 22 and by Monterey County EMS policy.

C. Only those EMT-Expanded Scope personnel who hold a current California EMT certificate and authorization from the Monterey County EMS Agency may function under this policy as part of the Monterey County EMS system.

D. EMT-Expanded Scope personnel may provide expanded scope skills when working in an EMT-Expanded Scope role with an approved EMT-Expanded scope service provider.

III. SCOPE OF PRACTICE

A. The EMT-Expanded Scope is authorized to do any of the following:

1. EMT scope of practice. 2. Administer intranasal naloxone. 3. Administer epinephrine by auto-injector for suspected anaphylaxis and/or severe

asthma. 4. Perform finger stick blood glucose testing. 5. CPAP


7

AUTHORIZED STOCK-BLS UNITS

I. PURPOSE To establish the stock to be carried and minimum equipment standards for BLS service providers based in Monterey County to include EMT, EMT-Enhanced Scope, Emergency Medical Responder (EMR), and Public Safety First Aid.

II. POLICY A. Every BLS unit shall have no less than the specified amount of equipment at all times. A

BLS unit shall not respond to a request for medical service without the equipment and supplies necessary to provide care under Monterey County EMS policies and protocols.

B. All equipment and supplies must be clean or sterile as appropriate and in good working order. Medications and supplies shall be replaced prior to their expiration.

C. The BLS service provider shall implement an inventory control program to ensure that all system units have at least the minimum levels of supplies and equipment listed below.

D. This stocking level is to augment any requirements established by Federal, State, or other regulations.

E. Only the items specified on this list may be carried on Monterey County BLS units. Items carried must be approved in advance by the Monterey County EMS Medical Director.

F. BLS units placed in service for event stand-by purposes may utilize an alternate minimum stock standard with written approval of the Monterey County EMS Agency.

G. Monterey County EMS Agency personnel may inspect any BLS unit, at any time, for compliance with the identified standards for equipment and supplies.

H. The list below is the minimum stock that must be available on the EMT, EMT Expanded Scope, EMR, or First Aid staffed unit before responding to a request for service.


8

BLS

EMT EMT

Exp. Scope

EMR First Aid

ITEM

1 1 1 Regulator for Portable Oxygen Tank 1 1 1 Adult BVM Resuscitator with Oxygen Supply Tubing 1 1 1 Child BVM Resuscitator with Oxygen Supply Tubing 1 Perilaryngeal Airway 1 CPAP with large and medium mask 2 2 2 Adult Nasal Cannula 1 1 1 Pediatric Nasal Cannula 2 2 2 Adult Nonrebreather Mask 1 1 1 Pediatric Nonrebreather Mask 1 1 1 Oropharyngeal Airways. Each Size 6-10 (or equivalent size) 1 1 Nasopharyngeal Airways. Each Size 28-34Fr 4 4 Water soluble Lubricating Jelly Packets 1 1 Pulse Oximetry Device 1 1 Pulse Oximetry Sensor. Each for adult and pediatric use 1 1 1 Portable Suction unit 2 2 2 Rigid Suction Catheter 2 2 2 Suction Tubing 1 1 1 8, 10, 18fr Flexible Suction Catheter each 1 1 1 1 AED with pads 2 2 2 Tape Rolls. 1 inch plastic 1 1 Aspirin. 81mg chewable. Bottle with minimum of 6. 2 2 1 Naloxone. Intranasal. 1 Epinephrine auto-injector 1 1 Glucometer 3 3 Glucometer test strips 1 1 Sharps container 2 2 Oral Glucose. 30Gm tube 1 1 Traction splint 1 1 KED or short immobilization board or similar device 1 1 1 1 Backboard with adequate strapping materials for each board 2 2 2 Blanket 4 4 4 4 Cervical collar. Adult adjustable 2 2 2 4 Cervical collar. Pediatric adjustable 2 2 2 2 Head immobilizing device 2 2 2 2 Splints. Arm/Leg. Cardboard or equivalent. Each size. 1 1 1 Stethoscope 1 1 1 BP cuff. Each size: Adult, child, infant, large. 1 1 1 Triangular bandage 12 12 12 12 Sterile dressings 4 4 4 4 Roller bandage (Kerlix)


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2 2 2 2 Trauma dressing 2 2 2 2 Chest seal 2 2 2 2 Hemostatic dressing 2 2 2 2 2 inch adhesive tape 2 2 1 1 Burn sheet 4 4 4 4 Occlusive dressing 2 2 2 2 Cold pack 2 2 Hot pack 1 1 1 Scissors 1 1 Flashlight 1 1 1 Obstetrical kit with blanket to preserve neonate warmth 4 4 4 2 Sterile water or saline for irrigation 2 2 2 2 Tourniquet 5 5 5 Patient care report forms 5 5 Refusal of Care forms 10 10 10 Triage tags 1 1 1 1 Hard hat for each person-Blue. Meets NFPA 1951, ANSI Z89.1-1986

(Class and B), OSHA: 29CFR 1910.135 &29 CFR 1926.100(b), CSA Z94.1-M1992 (Class G), or equivalent.

1 1 1 1 Eye protection-Glasses, face shield, goggles, or mask with side protection for each person. Meets NFPA 1999, ANSI Z87.1

1 1 1 1 Hearing protection for each person 1 1 1 1 Barrier garment for each person. Meets NFPA 1999 such as Tyvek. 3

pairs 3

pairs 3

pairs 3

pairs Exam gloves for each person

1 pair

1 pair

1 pair

1 pair

Boot/shoe covers for each person. Meets NFPA 1999. Chemical resistant.

1 1 1 1 Escape mask for each person 1 1 1 1 Face shield for each person. Meets NFPA 1999, ANSI Z87.1. 1

pair 1

pair 1

pair 1

pair Work gloves for each person. Meets NFPA 1999

2 2 2 2 Respirator mask for each person. N-100 or N-95. Meets OSHA 42 CFR 84, 8CCR 5144, NIOSH Respirator Selection Logic 2004.

EXHIBIT N - Health Equity and Cultural Competence Enhancements

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Health Equity and Cultural Competence Enhancements

I. Introduction The Monterey County EMS Agency is committed to building a more just and equitable community. This commitment begins with ensuring equity in access to and quality of services. The County has a responsibility to:

• examine the ways that its own policies, procedures, practices and organizational culture, and

those of its partners and contractors, contribute to injustice and institutional racism, and • take steps to address these factors.

It is the policy of the Monterey County Health Department that all programs, services and care are designed, implemented, evaluated, and delivered in a manner that advances health equity, improves quality and helps eliminate health and healthcare disparities. All programs and services must comply with federal and state law including Title VI of the Civil Rights Act of 19641 which “prohibits discrimination based on race, color, and national origin in programs and activities receiving federal financial assistance” and California’s Fair Employment and Housing Act, which protects California employees from discrimination based on many different factors, including race, religion, gender, disability, sexual orientation, veteran status, and age. Programs and services must incorporate and comply with all applicable cultural competence standards to ensure that the respectfulness and responsiveness of our services and care meet the cultural and linguistic needs of all individuals in Monterey County.

Monterey County’s EMS Agency has also identified access to culturally responsive EMS care as one of the top priorities within our community.

The contractor will be expected to examine cultural competency of its EMS services and use a framework to identify and improve structures and processes that support health equity for all individuals and communities.

The EMS Agency has identified three primary long-term equity-related outcomes to be addressed during the ambulance contract:

1. Developing a diverse EMS workforce that reflects the composition of the community, 2. Assuring and improving the quality of EMS care and the EMS patient experience through

providing culturally responsive and linguistically appropriate services [see definitions below], and

3. Conducting community outreach to identify and address barriers in service and communication and implement community-level interventions to improve the use and outcomes of the EMS system.

The EMS Agency recognizes that making structural and systemic changes to achieve health equity is a long-term process. However, these changes are achievable through targeted and intentional activities and investments, and evaluation-based refinements.

1 https://www.justice.gov/crt/fcs/TitleVI

http://www.justice.gov/crt/fcs/TitleVI


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II. Organizational Cultural Competence

The National Standards for Culturally and Linguistically Appropriate Services (CLAS) provide a blueprint to advance health equity, improve quality, and help eliminate healthcare disparities. The principal standard is:

• Provide effective, equitable, understandable, and respectful quality care and services that are

responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

Two key concepts from the HRSA tool provide the foundation for conducting an assessment tool and developing a plan for action:

• An organization’s efforts to improve cultural competence in service delivery must be supported

by specific measurable organizational capacities - e.g., leadership, ability to plan, staff development, etc.

• With these supports, cultural competence and the ability to deliver culturally-responsive services becomes an institutionalized part of the organization.

Minimum Level of Commitment- Cultural Competence

As part of this minimum commitment, the Proposer must also describe its:

• Current organizational commitments to health equity at the leadership/governance level of the organization

• Current mission, vision, values, and policies that promote linguistically appropriate and culturally responsive supports for staff, partner organizations, and the community

• Current organizational resources dedicated to ensuring that staff have the requisite skills, knowledge, and attitudes to provide culturally responsive services to the diverse communities they serve

• Current collection of data that is or can be analyzed to identify disparities in service • Current quality improvement efforts enacted to meet the needs of marginalized populations

Proposers will be scored on their planned activities and commitments over the course of the term of the agreement that clearly articulate a commitment to health equity. Proposers should clearly:

• identify activities across equity domains, and • describe the resources and capacity to carry out these activities and meet equity commitments,

and • clearly articulate how they will fully support and evaluate National CLAS standards within their

implementation plan.

III. Long-term Equity-related Outcomes A. Equity-Related Outcome: Developing a diverse EMS workforce that reflects the composition of the community,

The Monterey County EMS Agency is proud of the capable and compassionate professionals who make up the local EMS workforce. At the same time, the County recognizes that the EMS workforce does not adequately reflect the increasingly diverse communities it serves. In this regard, the County is similar to most of the nation.


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Despite the complexity of the causes, the County believes that progress can be made over the longer term - e.g., the five (5) to potentially ten (10) years of the upcoming contract period. The County is looking for the successful proposer in this RFP process to be a full partner in increasing the diversity of its own workforce, and in serving as a model and resource for the rest of the local EMS community.

Minimum Level of Commitment – Diverse EMS Workforce Proposers must commit to developing and implementing plans to measurably improve participation of women, people of color, linguistic minorities and members of other culturally defined communities over the life of the agreement. In response to this section of the RFP, proposers must describe:

• Current capabilities and approaches - describe the following about what is currently in place in your organization with regard to:

o Approaches to recruiting of direct service and supervisory staff to reflect the communities being served,

o Structures, systems and practices in place to support staff to be successful, and to continue their employment and professional advancement in your organization, and

o How your organization takes into account the racial, ethnic, cultural, socioeconomic or other personal background experiences of direct service staff in training, and staff retention and promotion.

• Initial proposed plans and commitments to increase the diversity of your line-level, supervisory and leadership staff through the life of the contract:

o Overall approach o Roles of your organization’s leadership, supervisory and direct service staff in the effort o Partnerships - for example with other EMS providers, training organizations, and

community-based organizations o Resources required and applied - money, staff commitments, consultants, etc.

B. Equity-Related Outcome: Improving quality of EMS care through providing culturally responsive and linguistically appropriate services

As discussed in the Introduction of this section of the RFP, Monterey County EMS Agency seeks to assure equity in access to and quality of EMS services. This includes assuring quality and acceptability of care through providing culturally responsive services. Providing such services requires, at minimum, a basic level of cultural competence, as a first step in the longer process of ensuring more fully equity-informed EMS services.

Minimum Level of Commitment —Culturally Responsive Services

Proposers must commit to providing culturally responsive care to all members of the service population and developing necessary organizational capacities to do so. These capacities include:

• Providing training for direct service and supervisory staff that is adequate to promote a basic level of cultural knowledge and competence

• Providing training for direct service and supervisory staff to develop knowledge and skills to support specific behaviors to be applied in cross-cultural situations

• Developing and implementing key organizational features that support basic cultural competence, for example:

o Leadership support for improved cultural competence o Funding for cultural competence and responsiveness training o Inclusion of culturally responsive service in key organizational policies and foundational


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documents o Organizational mechanisms for accountability around culturally responsive services - e.g.,

recognition of improvements in service and management of complaints and other adverse occurrences

• Offering language assistance at no cost to the individual for people who have limited English proficiency and/or other communication needs in order to facilitate timely and appropriate access to EMS care and services.

• Providing easy to understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

C. Equity-Related Outcome: Conducting community outreach to implement community-level interventions to improve the use and outcomes of the EMS system within high risk/high need communities.

Monterey County EMS Agency has opportunities to improve the use and effectiveness of its EMS system. One example is the growth in the volume of calls for low-acuity medical needs. Another is the opportunity to save lives and preserve health through integrated community systems to address specific health conditions such as acute ST elevation myocardial infarction (STEMI), cardiac arrest, and timely intervention for stroke symptoms. All these examples require knowledge and effective action on the part of community members. While mass media and social media approaches can reach some affected populations, there is also a role for outreach through established community networks and organizations.

Minimum Level of Commitment — Outreach to High Risk/Need Communities Proposers must commit to developing and implementing a systematic approach to community outreach. This must include culturally responsive approaches to culturally-defined communities as appropriate to the health issue being addressed.

In responding to this section, Proposers must:

• Identify at least three issues that they feel are amenable to community-based intervention, including an explanation of the critical need for community involvement.

• Describe the potential role(s) of community members and community organizations in addressing the issue.

• For one of the issues: o Discuss potential concerns and opportunities that may be of interest to one or more

specific culturally-defined communities o Propose a plan to carry out further assessment and planning with the County EMS

Program and community organizations as partners.

EXHIBIT O – Liquidated Damages Summary

Event Section Liquidated Damages Attempting to direct or influence a patient’s destination selection other than as prescribed in EMS System Policies and Procedures. 5.1.8 $2,000 per incident

Failure for the designated EMS Medical Dispatch to answer emergency calls within ten (10) seconds, 90 percent of the time. 5.2.6

$500 per occurrence

Changing or “correcting” Time Points in Computer Aided Dispatch System. 5.4.17 $5,000 per incident

Failure of the Contractor to comply with the Response Time Interval Requirements* 5.4.18

5.4.19

89.99% to 89.00% $5,000

88.99% to 88.00% $10,000 87.99% to 87.00% $15,000

Failure to correct repetitive non-compliance. 5.4.20 $10,000

Failure of Contractor to maintain a fleet that meets Contract requirements 5.5.1

$50/day/ambulance for reserve ambulances $500/day/ambulance for system deployed ambulances

Failure to pass EMS Agency vehicle inspection 5.5.6 $50-$500 uncorrected discrepancy

Use of an improperly licensed or credentialed employee 5.8.2 $500 per day per person

Number of calls serviced by non-contractor’s ambulance in excess of five percent (5%) of Contractor’s call volume, for that reporting period.

5.10.2.2 $500 per call

Contractor’s failure to timely provide reports, including failure to provide Unusual Occurrence reports, within the time required by EMS Systems Policies, Protocols and Procedures, or failure to provide/transmit ePCR reports to hospitals as required in EMS Agency Policies, Protocols and Procedures

5.4.17 5.16.6.1 $100 per report per day received after specified due date

Failure to comply with any provision of the Agreement $500 per day following notice

*Financial Incentive for Superior Clinical Performance. Contractor’s liquidated damages in that month may be reduced in the Response Time Interval category based on Clinical Performance chart in Section 5.4.21.

EXHIBIT P IRREVOCABLE LETTER OF CREDIT

TO: Letter of Credit Number Monterey County Emergency Medical Services Agency Attn: EMS Director 1441 Schilling Pl. South Building Salinas, CA 93901

Initial Expiration Date June 30, 201_

DATE:

Dear Director:

This is an irrevocable Letter of Credit issued by ("Issuer") in favor of the beneficiary County of Monterey ("County") for the account of [Contractor] (the “Account Party”).

This Letter of Credit is in an amount of United States Dollars. Upon County’s

presentation of a written, dated and signed statement and sight draft, similar to the form attached as Attachment 1, signed by the County Executive of the County of Monterey, State of California, stating that the Account Party is in default of its obligations (“Obligations”) under that certain Emergency Medical Services Agreement between the Account Party and the County dated [date] (as the same may be amended from time to time), Issuer shall pay to County the amount claimed to be due, ___________________________(the “Stated Amount”). Except as expressly stated herein, Issuer’s obligation to pay is not subject to any agreement, requirement or qualification.

All drafts drawn on this Letter of Credit must be marked “Drawn on ‘Issuer’, Letter of

Credit Number .”

It is a condition of this Letter of Credit that it shall be deemed automatically extended without amendment for one year from the present or any future expiration date hereof, unless at least sixty (60) days prior to any such date, Issuer notifies County in writing by certified mail or courier service at the above listed address, that Issuer elects not to consider this Letter of Credit extended for any such additional period. Upon receipt by County of such notice, County may draw hereunder by means of County's drafts on Issuer at sight accompanied by County's written statement reciting that: “by not extending this Letter of Credit or providing a substitute therefor prior to the expiration of this Letter of Credit, the Account Party is deemed in default of its Obligations and that the proceeds of County of Monterey's drafts will be retained and used by County to meet Account Party’s Obligations.” Partial drawings are permitted under this Letter of Credit; provided, however, that partial drawings in the aggregate shall not exceed the Stated Amount.

In each case where Issuer has received a draft described above prior to 5:00 p.m. Pacific Time, on a Business Day, payment shall be made by 5:00 p.m. Pacific Time on the following Business Day. As used herein, “Business Day” means any day on which inter-bank payments can be effected through the use of the Fedwire system other than (i) a Saturday or Sunday, or (ii) a legal holiday on which banking institutions in the State of California are closed. Issuer may effect payment through use of the Fedwire system if County provides wiring instructions to Issuer.

Issuer covenants that all drafts drawn under and in compliance with the terms of this

Letter of Credit will be honored if presented at Issuer's office on or before the Initial Expiration Date of this Letter of Credit, or any automatically extended date as set forth above.

This credit is subject to the Uniform Customs and Practice for Documentary Credits

(2007 Revision) International Chamber of Commerce, Publication No. 600. As to matters not governed by the UCP, this Letter of Credit shall be governed by the internal laws of the State of California (without regard to conflicts of law provisions).

Sincerely,

[Issuer - Insert Name and Address of Issuing Bank and Name of Contact Individual]

ATTACHMENT 1 - IRREVOCABLE LETTER OF CREDIT SIGHT DRAFT

Letter Of Credit No.: Date Of Letter Of Credit: Date Of Draft: To: (Bank) (Address) (Fax): Attention:

For value received, pay on demand to the order of County of Monterey the amount of dollars ($ ).

[Contractor] is in default of its obligations under that certain EMS Medical Services Agreement between [Contractor] and the County of Monterey dated [date] (as the same may be amended from time to time).

The amount of this draft does not exceed the amount available to be drawn by the beneficiary under the letter of credit. We acknowledge that, upon your honoring the drawing herein requested, the amount of the letter of credit available for drawing shall be automatically decreased by an amount equal to this drawing.

Charge to the account of [Contractor].

Drawn under [name of bank] letter of credit no. . Funds to be wired to: ABA routing number:

Receiving bank: Beneficiary: County of Monterey

Very Truly Yours, By Name: Title: Date:

EXHIBIT Q PERFORMANCE GUARANTEE

This Performance Guarantee, dated as of (this “Guarantee”) is made by

[NAME OF GUARANTOR], a (the “Guarantor”), in favor of THE COUNTY OF MONTEREY, a political subdivision of the State of California (the “County”).

WHEREAS, the County and [Contractor], a , (“Contractor”) are entering into that certain Emergency Medical Services Agreement, dated as of , and as may be amended from time to time (the “EMS Contract”), pursuant to which Contractor has offered to provide certain services to the County as more particularly set forth in the EMS Contract (the “Services”), and the County has agreed to receive the Services from Contractor;

WHEREAS, it is a condition to the effectiveness of the EMS Contract that the Guarantor execute and deliver this Guarantee, guaranteeing Contractor’s obligations under the EMS Contract;

NOW THEREFORE, for valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Guarantor agrees as follows:

Section 1. Guarantee. The Guarantor hereby unconditionally and irrevocably (i) guarantees the full and prompt payment and performance of all obligations and liabilities, accrued and executory, fixed or contingent, due or to become due, direct or indirect, now existing or hereafter and howsoever arising or incurred under the EMS Contract which Contractor presently or hereafter may have to the County under the terms, conditions and covenants of the EMS Contract (collectively, the “Obligations”) strictly in accordance with the terms thereof, and (ii) covenants and agrees to the County that if for any reason whatsoever Contractor shall fail to so perform and observe any of the Obligations, the Guarantor will duly and punctually perform and observe the same.

Section 2. Guarantee Unconditional. The obligations of the Guarantor hereunder

shall be unconditional and absolute and, without limiting the generality of the foregoing, shall not be released, discharged, limited or otherwise affected by (and the Guarantor hereby waives, to the fullest extent permitted by applicable law) any act or omission to act or delay of any kind by Contractor, the County or any other person or any other circumstance whatsoever (including the bankruptcy of Contractor), which might, but for the provisions of this Section, constitute a legal or equitable discharge, limitation or reduction of the Guarantor’s obligations hereunder. This Guarantee shall continue to be effective or be automatically reinstated, as the case may be, if at any time any payment, or any part thereof, of any of the Obligations is rescinded or must otherwise be restored or returned by the County for any reason whatsoever, whether upon insolvency, bankruptcy, dissolution, liquidation or reorganization of the Guarantor, all as though such payment had not been made, and the Guarantor agrees that it will indemnify the County on demand for all reasonable costs and expenses (including, without limitation, reasonable fees and disbursements of counsel) incurred by the County in connection with such rescission or restoration. Guarantor hereby expressly waives all defenses which might constitute a legal or equitable discharge of a surety or guarantor, and agrees that this Guarantee shall be valid and unconditionally binding upon Guarantor regardless of (i) the reorganization, merger, or

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consolidation of Contractor into or with another entity, corporate or otherwise, or the liquidation or dissolution of Contractor, or the sale or other disposition of all or substantially all of the capital stock, business or assets of Contractor to any other person or party, or (ii) the institution of any bankruptcy, reorganization, insolvency, debt agreement, or receivership proceedings by or against Contractor, or adjudication of Contractor as a bankrupt, or (iii) the assertion by the County against Contractor of any of the County’s rights and remedies provided for under the EMS Contract, including any modifications or amendments thereto, or under any other document(s) or instrument(s) executed by Contractor, or existing in the County’s favor in law, equity, or bankruptcy.

Section 3. Corporate Authority. The County may rely upon any signature,

instrument, notice, resolution, request, consent, order, certificate, report, opinion, bond or other document or paper reasonably believed by it to be genuine and reasonably believed by it to be signed by the proper party or parties of Contractor or the Guarantor in connection with the EMS Contract and this Guarantee. The County may accept a copy of a resolution of the board of directors or other governing body of Contractor, certified by the President, Treasurer or Secretary of Contractor, as conclusive evidence that such resolution has been duly adopted by such body and that the same is in full force and effect. As to any fact or matter the method of determination of which is not specifically prescribed herein, the County may for all purposes hereof rely on a certificate, signed by a duly appointed officer of Contractor or the Guarantor in connection with the Services contemplated by the EMS Contract, and this Guarantee and with respect to the Obligations contemplated hereby or thereby, as evidenced by the incumbency certificate, as to such fact or matter and such certificate shall constitute full protection to the County for any action taken or omitted to be taken by it in good faith in reliance thereon.

Section 4. Recourse against Contractor.

(a) Guarantor agrees that its liability under this Guarantee shall be continuing,

absolute, primary, and direct.

(b) Guarantor affirms that the County shall not be required to first commence any action or obtain any judgment against Contractor before enforcing this Guarantee against Guarantor, and that Guarantor will, upon demand, pay the County any amount, the payment of which is guaranteed hereunder and the payment of which Contractor is in default under the EMS Contract or under any other document(s) or instrument(s) executed by Contractor .

(c) Each of the obligations of the Guarantor under this Guarantee is separate

and independent of each other obligation of the Guarantor under this Guarantee and separate and independent of the Obligations, and the Guarantor agrees that a separate action or actions may be brought and prosecuted against the Guarantor to enforce this Guarantee, irrespective of whether any action is brought against Contractor or Contractor is joined in any such action or actions.

Section 5. No Subrogation. Until all the Obligations have been performed, the

Guarantor will have no right of subrogation to, and waives, to the fullest extent permitted by law, any right to enforce any remedy which the County now has or may hereafter have against

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Contractor in respect to the Obligations; and the Guarantor waives any benefit of and any right to participate in, any security now or hereafter held by the County for the Obligations.

Section 6. Representations and Warranties. The Guarantor represents and warrants to

the County, upon each of which representations and warranties the County specifically relies as follows:

(a) Good Standing, etc. The Guarantor is a corporation duly incorporated and validly existing under the laws of the State of . The Guarantor is duly authorized and licensed to carry on its businesses as presently owned and carried on by it. The Guarantor has the necessary power and authority to enter into and perform its obligations hereunder,

(b) Burdensome Provisions, etc. The Guarantor is not a party to any

agreement or instrument, or subject to any corporate restriction or any judgment, order, writ, injunction, decree, award, rule or regulation, which precludes its ability to issue this Guarantee or to perform its obligations under this Guarantee.

(c) Consents. No consent, approval or authorization of, or declaration,

registration, filing or qualification with, or giving of notice to, or taking of any other action, in respect of any person, governmental authority or agency is required on the part of the Guarantor in connection with the execution and delivery and enforcement of this Guarantee.

(d) Due Execution, etc. This Guarantee has been duly executed and delivered

by the Guarantor and constitutes a valid and binding obligation of the Guarantor enforceable in accordance with its terms.

(e) No Default, etc. Neither the execution nor the delivery of this Guarantee,

conflicts with or will conflict with, or results or will result in, any breach of, or constitutes a default under any of the provisions of the Articles of Incorporation or Bylaws of the Guarantor or of any agreement or instrument to which the Guarantor is a party or by which the Guarantor is bound, or to which any of its property or assets are subject or results or will result in the contravention of any law, rule, regulation or court or administrative order to which the Guarantor or its property or assets are subject.

(f) No Proceedings, etc. There are no proceedings pending or contemplated

for the merger, consolidation, sale, liquidation, dissolution or bankruptcy of the Guarantor.

Section 7. Termination. This Guarantee shall terminate on the fulfillment of all of

the Obligations under the EMS Contract.

Section 8. Further Assurances. The Guarantor shall, from time to time, do and perform any and all acts and execute any and all further instruments which may be required or which may be reasonably requested by the County more fully to effect the purpose of this Guarantee.

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Section 9. Payments. All payments to be made by the Guarantor under this Guarantee shall be made in full, without set-off or counterclaim and without deduction for any taxes, levies, duties, fees, deductions, withholdings, restrictions or conditions of any nature whatsoever.

Section 10. Costs and Expenses. The Guarantor shall pay all reasonable out-of-pocket

costs and expenses of the County (including the reasonable fees and disbursements of counsel) in connection with the enforcement of the obligations of the Guarantor under this Guarantee or any related document. The Guarantor agrees to indemnify and hold harmless the County from and against any and all liability incurred by the County or its nominee or agent or any of its employees hereunder or in connection herewith, including the enforcement of this Guarantee; provided, however, that the Guarantor shall have no such obligation in connection with any action brought by the County against the Guarantor to the extent that the Guarantor is the prevailing party in the judgment rendered in any such action.

Section 11. Governing Law. This Guarantee shall be governed by, and construed in

accordance with, the laws of the State of California.

Section 12. No Waiver, Cumulative Remedies. No failure to exercise and no delay in exercising, on the part of the County, any right, remedy, power or privilege hereunder, shall operate as a waiver hereof; nor shall any single or partial exercise of any right, remedy, power or privilege hereunder preclude any other or further exercise thereof or the exercise of any other right, remedy, power or privilege. The rights, remedies, powers and privileges herein provided are cumulative and not exhaustive of any rights, remedies, powers and privileges provided by law.

Section 13. Amendments. Any provision of this Guarantee may be amended or waived if but only if, such amendment or waiver is in writing and is signed by the Guarantor and the County.

Section 14. Notices. All communications and notices pursuant hereto shall be in

writing (including bank wire, telex, telecopier, electronic facsimile transmission or similar writing) and shall be given to any party at its address or facsimile number set forth below or at such other address or facsimile number as such party may hereafter specify for the purpose of notice to the other. Each such notice or other communication shall be effective (i) if given by facsimile, when such facsimile is transmitted to the facsimile number specified in this Section and the receipt thereof is confirmed, or (ii) if given by any other means, when received at the address specified in this Section.

If to the Guarantor:

[Name of Guarantor]

Attention: Facsimile:

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If to the County: The County of Monterey c/o EMS Agency Director 1441 Schilling Place Salinas, CA 93901 Facsimile: (831) 775-8040

Section 15. Successors and Assigns. This Guarantee shall be binding upon the Guarantor and its successors and assigns and inure to the benefit of the County and its successors and permitted assigns. This Guarantee shall extend to any person acquiring, or from time to time carrying on, the business of Contractor. The Guarantor may not assign any of its obligations under this Guarantee without the prior written consent of the County.

Section 16. Jurisdiction and Venue. The Guarantor hereby irrevocably submits to the

jurisdiction of any court sitting in Monterey County, California in any action or proceeding arising out of or relating to this Guarantee, and the Guarantor hereby irrevocably agrees that all claims in respect of such action or proceeding shall be heard and determined in such court. The Guarantor hereby irrevocably waives, the forum non conveniens defense to the maintenance of such action or proceeding. The Guarantor agrees that a final judgment in any action or proceeding shall be conclusive and may be enforced in other jurisdictions by suit on the judgment or in any other manner provided by law.

Section 17. Entire Agreement. This Guarantee contains the entire agreement between

the parties related to the subject matter hereof and supersedes all prior and contemporaneous agreements, term sheets, commitments, understandings, negotiations and discussions, whether oral or written. There are no warranties, representations or other agreements between the parties in connection with the subject matter hereof except as specifically set forth herein.

Section 18. Failure to Perform. If the Guarantor fails to perform any of its agreements or

obligations hereunder, the County may (but will not be required to) itself perform, or cause to be performed, such agreement or obligation, and the reasonable expenses of the County incurred in connection therewith will be payable by the Guarantor.

Section 19. Severability. If one or more of the covenants, agreements, provisions or

terms of this Guarantee shall be for any reason whatsoever held invalid, then such covenants, agreements, provisions or terms shall be deemed severable from the remaining covenants, agreements, provisions or terms and shall in no way affect the validity or enforceability of the other covenants, agreements, provisions or terms of this Guarantee.

Section 20. References to “Person”. Any reference in this Guarantee to a “person”

means and includes an individual, a partnership, a corporation, a joint stock company, a trust, an unincorporated association, a limited liability company, a joint venture or other entity, or a government or any agency or political subdivision thereof.

Section 21. Headings. The headings of the Sections herein are for convenience of

reference only and shall not limit any of the terms or provisions hereof.

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IN WITNESS WHEREOF the Guarantor has executed this Guarantee as of the date first above written.

[NAME OF GUARANTOR]

By:_ Name: Its:

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EXHIBIT R

STANDARD AGREEMENT TERMS AND CONDITIONS The following terms and conditions are expected to be included in any Agreement with successful bidder. Regulatory and Policy Requirements Contractor will provide services in accordance with the requirements of California Health and Safety Code sections 1797 et seq., California Code of Regulation, Title 22, Division 9, and Monterey County EMS Agency Policies and Procedures, and any amendments or revisions thereof. Contractor shall follow all Monterey County EMS Agency Policies and Procedures. Contractor shall follow all direction provided by the EMS Director, EMS Medical Director or Medical Health Operational Area Coordinator (MHOAC). Contractor shall comply with response time standards to all areas of the EOA. See Section 5.4 of the Agreement for additional information on response time requirements. Annual Performance Evaluation County may evaluate the performance of the ambulance provider on an annual basis. The report, at a minimum, shall include the following in the performance evaluation:

a. Response time performance standards have been met at or above the minimum requirements in this Agreement;

b. Clinical performance standards have been met at or above the minimum requirements in this Agreement;

c. Innovative programs to improve system performance have been initiated;

d. A stable work force has been maintained and there have been documented efforts to minimize employee turnover.

Continuous Service Delivery Contractor agrees that, in the event of a material breach by Contractor, Contractor will work with County to ensure continuous and uninterrupted delivery of services that meet or exceed all performance standards under the Contract, regardless of the nature or causes underlying such breach. Contractor agrees that there is a public health and safety obligation to assist County in every effort to ensure uninterrupted and continuous service delivery in the event of a material breach, even if Contractor disagrees with the determination of material breach. Material Breach and Provisions for Termination of this Agreement County shall have the right to terminate or cancel this Agreement or to pursue any appropriate legal remedy in the event Contractor materially breaches this Agreement and fails to correct such material breach within seven (7) days following the service on it of a written notice by County specifying the material breach complained of and the date of intended termination of rights hereunder absent cure.

https://leginfo.legislature.ca.gov/faces/codes_displayexpandedbranch.xhtml?tocCode=HSC&division=2.5.&title&part&chapter&article

https://leginfo.legislature.ca.gov/faces/codes_displayexpandedbranch.xhtml?tocCode=HSC&division=2.5.&title&part&chapter&article



http://www.acphd.org/media/410502/2016_alco_field_manual.pdf



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County reserves the right to immediately terminate or cancel this Agreement if in the determination of the EMS Director continued service by Contractor poses an immediate threat to public health and safety. Definitions of Breach Conditions and circumstances that shall constitute a material breach by Contractor shall include but not be limited to the following:

a. Willful failure of Contractor to operate the 911 Ambulance Services system in a manner which enables County or Contractor to remain in substantial compliance with the requirements of the applicable Federal, State, and County laws, rules, and regulations. Individual minor infractions of such requirements shall not constitute a material breach but such willful and repeated breaches shall constitute a material breach;

b. Willful falsification of data supplied to County by Contractor during the course of operations, including by way of example but not by way of exclusion, dispatch data, patient report data, response time data, financial data, or falsification of any other data required under contract;

c. Willful failure by Contractor to maintain equipment in accordance with good maintenance practices;

d. Deliberate and unauthorized scaling down of operations to the detriment of performance by Contractor during a "lame duck" period;

e. Willful attempts by Contractor to intimidate or otherwise punish employees who desire to sign contingent employment contracts with competing Bidders during a subsequent proposal cycle;

f. Willful attempts by Contractor to interfere with State or Federal protected labor activities;

g. Chronic and persistent failure of Contractor's employees to conduct themselves in a professional and courteous manner, or to present a professional appearance;

h. Willful or repeated failure of Contractor to comply with approved rate setting, billing, and collection procedures;

i. Failure of Contractor to correct any violation of any clause of the Agreement upon notice from the EMS Director;

j. Repeated failure of Contractor to meet response time requirements after receiving notice of non-compliance from the EMS Director;

k. Repeated failure of Contractor to pay liquidated damages to the EMS Agency on or before the 30th day after receipt of the invoice;

l. Failure to continuously employ Key Personnel or suitable replacement(s) approved by and performing to the satisfaction of the EMS Director and/or EMS Medical Director at any time during the course of this Agreement term;

m. Failure of Contractor to provide and maintain the required insurance as described in Exhibit S, and the performance security bond;

n. Repeated failure to provide data and/or reports generated in the course of operations, including, but not limited to, dispatch data, patient care data, response time data, or financial data, within the time periods specified;

o. Any failure of performance, clinical or other, which is determined by the EMS Director and confirmed by the EMS Medical Director to constitute an endangerment to public health and safety;

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p. Failure of Contractor to comply with the vehicle lease provisions, if applicable.

County's Remedies Termination If conditions or circumstances constituting a material breach exist, County shall have all rights and remedies available at law and in equity, specifically including the right to terminate this Agreement. Emergency Takeover County shall have the right to pursue Contractor for damages and the right of Emergency takeover as set forth in the Agreement. All County's remedies shall be non-exclusive and shall be in addition to any other remedy available to County. Provisions for Curing Material Breach Specifications

a. In the event the EMS Director determines that there has been a material breach by Contractor of the standards and performances as described in this Agreement, which breach represents an immediate threat to public health and safety, such action shall constitute a material breach of this Agreement. In the event of a material breach, County shall give Contractor written notice, by regular mail, return receipt requested, setting forth with reasonable specificity the nature of the material breach.

b. Except where the EMS Director and the EMS Medical Director determines that the breach presents an immediate threat to public health and safety requiring an immediate termination of this Agreement, Contractor shall have the right to cure such material breach within seven (7) days of delivery of such notice and the reason such material breach endangers the public's health and safety. However, within twenty-four (24) hours of receipt of such material breach notice, Contractor shall deliver to EMS Agency, in writing, a plan of action to cure such material breach. If, within the EMS Agency’s sole determination, Contractor fails to cure such material breach within the period allowed for cure or Contractor fails to deliver the cure plan to the EMS Agency in a timely manner, EMS Agency may take over Contractor's operations. Contractor shall cooperate completely and immediately with EMS Agency to affect a prompt and orderly transfer of all responsibilities to EMS Agency.

c. Contractor shall not be prohibited from disputing any such finding of material breach through litigation, provided, however that such litigation shall not have the effect of delaying, in any way, the immediate takeover of operations by County. These provisions shall be specifically stipulated and agreed to by both parties as being reasonable and necessary for the protection of public health and safety, and any legal dispute concerning the finding that a material breach has occurred, shall be initiated, and shall take place only after the emergency takeover has been completed.

d. Contractor's cooperation with and full support of such emergency takeover shall not be construed as

acceptance by Contractor of the findings and material breach, and shall not in any way jeopardize Contractor's right of recovery should a court later find that the declaration of material breach was made in error. However, failure on the part of Contractor to cooperate fully with County to affect a smooth and safe takeover of operations, shall itself constitute a breach of this Agreement, even if it was later determined that the original declaration of material breach by County was made in error.

e. For any material breach by Contractor, which does not endanger public health and safety, or for any material breach by County, which cannot otherwise be resolved, early termination provisions that may be agreed to

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by the parties will supersede these specifications.

Termination WRITTEN NOTICE This Agreement may be canceled immediately by written mutual agreement of the Contractor and County. FAILURE TO PERFORM If Contractor fails to cure a material breach under the terms of the Agreement, or County invokes an Emergency Takeover in accordance with Section _______, County, upon written notice to Contractor, may immediately terminate this Agreement. In the event of such termination, EMS Agency may proceed with the work in any reasonable manner it chooses. The cost to County of completing Contractor's performance shall be partially supported by securing the funds of the Performance Security Bond (or letter of credit) and any sum due Contractor under this Agreement or from third-party payors or clients who have paid Contractor a fee for services within Monterey County, without prejudice to County's rights otherwise to recover its damages. The EMS Agency and Contractor may meet and confer regarding County’s assumption of sums due to Contractor. Emergency Takeover Specifications

a. In the event of a material breach that failed to be cured by Contractor, or a material breach that is of an immediate threat of public safety, an emergency takeover may be initiated by the EMS Director or EMS Medical Director, Contractor shall cooperate fully with County to affect an immediate takeover by EMS Agency of Contractor's ambulances and comfort stations. Such takeover shall be affected within not more than 72 hours.

b. In the event of an emergency takeover and upon written request by County, Contractor must lease to County any and all service vehicles used by Contractor in the performance under the Contract, including, but not limited to, fully equipped ambulances and supervisor vehicles, for one dollar ($1.00) per month per vehicle. County may also lease Contractors comfort stations for one dollar ($1.00) per month per station. County shall have full use of vehicles and equipment and may, at County’s sole option, hire another company or entity approved by the EMS Agency to manage ambulance operations until a replacement provider for the EOA is selected through a procurement process conducted by the EMS Agency in accordance with EMSA requirements.

c. Contractor shall fully cooperate if County elects to lease any or all service vehicles pursuant to the above

provision. Alternatively, County may elect to purchase the vehicles at their depreciated value as of the date of such election. County shall have sole discretion as to which vehicles it leases, subleases, or purchases pursuant to these provisions.

d. Contractor shall deliver ambulances and comfort stations to the EMS Agency in mitigation of any damages to County resulting from Contractor’s material breach. EMS Agency shall have immediate access to Contractor’s Performance Guarantee Letter of Credit to allow continuous delivery of services during the takeover period. All funds recovered and equipment leased, subleased, or purchased from Contractor by County will be used for the sole purpose of ensuring continuous 911 Ambulance Services. Examples of how funds will be used are: personnel salaries and benefits, building and vehicle lease payments, and insurance premiums.

e. The EMS Agency shall have the right to authorize the use of Contractor’s vehicles, equipment and rest

stations by another company or entity. Should County require a substitute contractor to obtain insurance on equipment, vehicles or rest stations, or should County choose to obtain insurance on

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vehicles/equipment/rest stations, Contractor shall be a "Named Additional Insured" on the policy, along with the appropriate endorsements and cancellation notice.

f. All of Contractor's vehicles and related equipment necessary for provision of 911 Ambulance Services under this Agreement will be delivered to the EMS Agency during an emergency takeover period. Contractor shall maintain and provide to the EMS Agency a listing of all vehicles used in the performance of this Agreement, including reserve vehicles, their license numbers, and name and address of lien holder, if any, and all comfort station locations. Changes in lien holder, as well as the transfer, sale, or purchase of vehicles used to provide 911 Ambulance Services hereunder shall be reported to the EMS Agency within thirty (30) days of said change, sale, transfer or purchase. Contractor shall inform and provide a copy of takeover provisions contained herein to lien holder(s) within five (5) days of emergency takeover.

"Lame Duck" Provisions Conditions Should this Agreement not be renewed or extended, or if the EMS Agency has indicated its intent to enter into a procurement process to seek a different 911 Ambulance Services provider, Contractor agrees to continue to provide all services required in and under this Agreement until County or a new entity approved by the EMS Agency assumes service responsibilities. Under these circumstances, Contractor will serve as a lame duck contractor for an extended period of time, which could be a year or longer. To ensure continued performance fully consistent with the requirements in this Agreement through any such period, the following provisions shall apply:

(1) Contractor shall continue all operations and support services at the same level of effort and performance as were in effect prior to the award of the subsequent contract to a competing organization, including but not limited to compliance with provisions of this Agreement related to qualifications of key personnel. Neither shall the Contractor inflate costs that a new Contractor would be required to assume.

(2) Contractor shall make no changes in methods of operation that actually reduce or could reasonably be considered to be aimed at reducing Contractor’s service and operating costs to maximize or affect a gain during the final stages of this Agreement.

(3) Contractor shall make no changes to employee salaries during this period that could reasonably be

considered to be aimed at increasing costs to the incoming provider. Regularly scheduled increases based on length of service or contained in pre-existing binding contracts or labor agreements will be allowed.

(4) Should there be a change in provider, the current service provider shall not penalize or bring personal

hardship to bear upon any of its employees who apply for work on a contingent basis with competing Bidders, and shall allow without penalty its employees to sign contingent employment agreements with competing Bidders at employees' discretion. The current service provider acknowledges and agrees that supervisory personnel, EMTs, paramedics, and dispatch personnel working in the EMS system have a reasonable expectation of long-term employment in the system, even though contractors may change. However, the current service provider may prohibit its employees from assisting competing Bidders in preparing proposals by revealing trade secrets or other information about the current service provider business practices or field operations.

(5) The EMS Agency recognizes that if another organization should be selected to provide service, the

current service provider may reasonably begin to prepare for transition of service to the new entity. The EMS Agency shall not unreasonably withhold its approval of the current service provider request to begin an orderly transition process, including reasonable plans to relocate staff, scale down certain inventory items, etc., as long as such transition activity does not impair the current service provider performance during this period.

(6) Should the EMS Agency select another organization as a service provider in the future, the current service

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provider personnel shall have reasonable opportunities to discuss issues related to employment with such organizations without adverse consequence by the current service provider or County.

REGULATORY COMPLIANCE Federal Healthcare Program Compliance Provisions Contractor shall comply with all applicable Federal laws, rules and regulations for operation of its enterprise, 911 Ambulance Services and those associated with employees. Medicare Compliance Program Requirements Contractor shall implement a comprehensive Compliance Program for all activities, particularly those related to documentation, claims processing, billing and collection processes. Contractor’s Compliance Program shall substantially comply with the current regulatory approach program outlined in the Office of Inspector General (OIG) Compliance Program Guidance for Ambulance Suppliers as published in the Federal Register on March 24, 2003 (03 FR 14255). Health Insurance Portability and Accountability Act (HIPAA) Contractor is required to implement a comprehensive plan and develop the appropriate policies and procedures to comply with the provisions of the Health Insurance Portability and Accountability Act of 1996 and the current rules and regulations enacted by the Department of Health and Human Services. Contractor is responsible for all aspects of complying with these rules and particularly those enacted to protect the confidentiality of patient information. Any violations of HIPAA rules and regulations will be reported immediately to County along with Contractor’s actions to mitigate the effect of such violations. The three major components of HIPAA include: Standards for Privacy and Individually Identifiable Health Information. Health Insurance Reform: Security Standards. Health Insurance Reform: Standards for Electronic Transaction Sets and Code Standards. State and Local Regulations Compliance Provisions Contractor shall comply with all applicable state and local laws, rules and regulations for businesses, ambulance services, and those associated with employees. Contractor shall also comply with County policies, procedures and protocols. Contractor is responsible for complying with all rules and regulations associated with providing services for recipients of and being reimbursed by state Medi-Cal and other state and federally funded programs. GENERAL PROVISIONS Assignment Except for the subcontracting provisions specified herein, Contractor shall not assign or subcontract any portion of the Agreement for services to be rendered, except for those services noted within the Agreement. Any assignment made contrary to the provisions of this section may be deemed a material breach of the Agreement and, at the option of the EMS Agency shall not convey any rights to the assignee. Permits and Licenses Contractor shall be responsible for and shall hold all required federal, state or local permits or licenses required to perform its obligations under the agreement. Contractor shall make all necessary payments for licenses and permits for the services and for issuances of state permits for all ambulance vehicles used.

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It shall be entirely the responsibility of Contractor to schedule and coordinate all such applications and application renewals as necessary to ensure that Contractor is in complete compliance with federal, state and local requirements for permits and licenses as necessary to provide the services. Contractor shall be responsible for ensuring that its employee’s state and local certifications as necessary to provide the services, if applicable, are valid and current at all times. Compliance with Laws and Regulations All services furnished by Contractor under this Agreement shall be rendered in full compliance with all applicable federal, state and local laws, ordinances, rules and regulations. It shall be Contractor’s sole responsibility to determine which, and be fully familiar with all laws, rules, and regulations that apply to the services under this Agreement, and to maintain compliance with those applicable standards at all times. Private Work Contractor shall not be prevented from conducting private work that does not interfere with the requirements of this Agreement or allocation of overhead and that is not inconsistent with the terms of this Agreement. In the event Contractor does private work outside of this Agreement, and if any overhead costs are shared between the two businesses, financial information provided regarding this Agreement shall clearly identify the relation and percentage shared. Retention of Records Contractor shall retain all documents pertaining to this Agreement as required by Federal and State laws and regulations, and no less than seven years from the end of the fiscal year following the date of service and until all Federal/State audits are complete and exceptions resolved for this Agreement's funding period. Upon request, and except as otherwise restricted by law, Contractor shall make these records available to authorized representatives of County, the State of California, and the United States Government. Product Endorsement/Advertising Contractor shall not use the name of Monterey County or Monterey County EMS for the endorsement of any commercial products or services without the prior express written permission of the EMS Director. Liquidated Damages Reflect Actual Damages Contractor understands and agrees that the failure to comply with any call processing time, response time, performance or other requirements under this Agreement will result in damage to County and that it will be impracticable to determine the actual amount of damage whether in the event of delay, nonperformance, failure to meet standards, or any other deviation. Therefore, the Contractor and County agree to the liquidated damages specified in this Agreement. It is expressly understood and agreed that the liquidated damages amounts are not to be considered a penalty, but shall be deemed, taken and treated as reasonable estimate of the damages to County. It is also expressly understood and agreed that County’s remedies in the event of Contractor’s breach or any noncompliance, are not limited to the liquidated damages provisions of this Agreement. Observation and Inspections EMS Agency representatives may, at any time, and without notification, directly observe Contractor's operations at the Contractors dispatch center and/or at an EMS Agency-approved EMD center participating in system status management and / or dispatch of Contractors resources, the maintenance facility, or any ambulance post location.

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Ann EMS Agency representative may ride along on any of Contractor's ambulance units at any time, provided, that EMS Agency representatives shall conduct themselves in a professional and courteous manner, and shall at all times be respectful of Contractor's employer/employee relationships. At any time during normal business hours and as often as may be reasonably deemed necessary by County, County representatives may observe Contractor's office operations, and Contractor shall make available to County for its examination any and all business records, including incident reports, patient records, financial records of Contractor pertaining to this Agreement. County may audit, copy, make transcripts, or otherwise reproduce such records including but not limited to contracts, payroll, inventory, personnel and other records, daily logs, employment contracts, and other documentation for County to fulfill its oversight role. Omnibus Provision Contractor understands and agrees that for five years following the conclusion of this Agreement it may be required to make available upon written request to the Secretary of the US Department of Health and Human Services, or any other fully authorized representatives, the specifications and subsequent contracts, and any such books, documents, and records that are necessary to certify the nature and extent of the reasonable costs of services. Rights and Remedies Not Waived Contractor covenants that the provision of services to be performed by Contractor under this Contract shall be completed without compensation from County, except as specified herein. The acceptance of work under this Agreement shall not be held to prevent maintenance of an action for failure to perform work in accordance with this Agreement. Consent to Jurisdiction Contractor shall consent to the exclusive jurisdiction of the courts of the State of California or a federal court in California in all actions and proceedings between the parties hereto arising under or growing out of this Agreement. Venue shall lie in Monterey County, California. End-Term Provisions Contractor shall have ninety (90) days after termination of this Agreement in which to supply the required audited financial statements and other such documentation necessary to facilitate the close out of this Agreement at the end of the term. Notice of litigation Contractor shall agree to notify the EMS Agency within 24 hours of any litigation or significant potential for litigation of which Contractor is aware. Cost of Enforcement If County or Contractor institutes litigation against the other party to enforce its rights pursuant to performing the work under this Agreement, the actual and reasonable cost of litigation incurred by the prevailing party, including but not limited to attorney's fees, consultant and expert fees, or other such costs shall be paid or reimbursed within ninety (90) days after receiving notice by the prevailing party following a final decision. Contractor to Supply Own Facilities

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Except as described herein Contractor is to supply its own office facilities, furnishings, and voice/IT equipment to be used by Contractor to perform its Ambulance Services GENERAL TERMS AND CONDITIONS Independent Contractor No relationship of employer and employee is created by this Agreement; it being understood and agreed that Contractor is an independent contractor. Contractor is not the agent or employee of County in any capacity whatsoever, and County shall not be liable for any acts or omissions by Contractor nor for any obligations or liabilities incurred by Contractor. Contractor shall have no claim under this Agreement or otherwise, for seniority, vacation time, vacation pay, sick leave, personal time off, overtime, health insurance medical care, hospital care, retirement benefits, social security, disability, Workers’ Compensation, or unemployment insurance benefits, civil service protection, or employee benefits of any kind. Contractor shall be solely liable for and obligated to pay directly all applicable payroll taxes (including federal and state income taxes) or contributions for unemployment insurance or old age pensions or annuities which are imposed by any governmental entity in connection with the labor used or which are measured by wages, salaries or other remuneration paid to its officers, agents or employees and agrees to indemnify and hold County harmless from any and all liability which County may incur because of Contractor’s failure to pay such amounts. In carrying out the work contemplated herein, Contractor shall comply with all applicable federal and state workers’ compensation and liability laws and regulations with respect to the officers, agents and/or employees conducting and participating in the work; and agrees that such officers, agents, and/or employees will be considered as independent contractors and shall not be treated or considered in any way as officers, agents and/or employees of County. Contractor does, by this Agreement, agree to perform his/her said work and functions at all times in strict accordance with currently approved methods and practices in his/her field and that the sole interest of County is to insure that said service shall be performed and rendered in a competent, efficient, timely and satisfactory manner and in accordance with the standards required by County agency concerned. Notwithstanding the foregoing, if County determines that pursuant to state and federal law Contractor is an employee for purposes of income tax withholding, County may upon two weeks’ notice to Contractor, withhold from payments to Contractor hereunder federal and state income taxes and pay said sums to the federal and state governments. Indemnification To the fullest extent permitted by law, Contractor shall hold harmless, defend and indemnify County of Monterey, its Officers, Agents and employees from and against any and all claims, losses, damages, liabilities and expenses, including but not limited to attorneys’ fees, arising out of or resulting from the performance of services under this Agreement, provided that any such claim, loss, damage, liability or expense is attributable to bodily injury, sickness, disease, death or to injury to or destruction of property, including the loss therefrom, or to any violation of federal, state or municipal law or regulation, which arises out of or is any way connected with the performance of this agreement (collectively “Liabilities”) except where such Liabilities are caused solely by the negligence or willful misconduct of any indemnitee. County may participate in the defense of any such claim without relieving Contractor of any obligation hereunder. The obligations of this indemnity shall be for the full amount of all damage to County, including defense costs, and shall not be limited by any insurance limits. In the event that Contractor or any employee, agent, or subcontractor of Contractor providing services under this Agreement is determined by a court of competent jurisdiction or the Monterey County Employees’ Retirement Association (ACERA) or California Public Employees’ Retirement System (PERS) to be eligible for enrollment in

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ACERA and PERS as an employee of County, Contractor shall indemnify, defend, and hold harmless County for the payment of any employee and/or employer contributions for ACERA and PERS benefits on behalf of Contractor or its employees, agents, or subcontractors, as well as for the payment of any penalties and interest on such contributions, which would otherwise be the responsibility of County. Insurance Contractor shall at all times during the term of the Agreement with County maintain in force, at minimum, those insurance policies as designated in the attached Exhibit S, and will comply with all those requirements as stated therein. County and all parties shall be considered an additional insured or loss payee if applicable. All of Contractor’s available insurance coverage and proceeds in excess of the specified minimum limits shall be available to satisfy any and all claims of County, including defense costs and damages. Any insurance limitations are independent of and shall not limit the indemnification terms of this Agreement. Contractor’s insurance policies, including excess and umbrella insurance policies, shall include an endorsement and be primary and non-contributory and will not seek contribution from any other insurance (or self-insurance) available to County. Contractor’s excess and umbrella insurance shall also apply on a primary and non-contributory basis for the benefit of County before County’s own insurance policy or self-insurance shall be called upon to protect it as a named insured. Hold Harmless / Defense / Indemnification / Taxes / Contributions In General, Contractor has the contracted duty (hereinafter "the duty") to indemnify, defend and hold harmless, County, its Board of Supervisors of Supervisors, officers, employees, agents and assigns from and against any and all claims, demands, liability, judgments, awards, interest, attorney’s fees, costs, experts’ fees and expenses of whatsoever kind or nature, at any time arising out of or in any way connected with the performance of this Agreement, whether in tort, contract or otherwise. This duty shall include, but not be limited to, claims for bodily injury, property damage, personal injury, and contractual damages or otherwise alleged to be caused to any person or entity including, but not limited to employees, agents and officers of Contractor. Contractor’s liability for indemnity under this Agreement shall apply, regardless of fault, to any acts or omissions, willful misconduct or negligent conduct of any kind, on the part of Contractor, its agents, subcontractors and employees. The duty shall extend to any allegation or claim of liability except in circumstances found by a jury or judge to be the sole and legal result of the willful misconduct of County. This duty shall arise at the first claim or allegation of liability against County. Contractor will on request, and at its expense, defend any action suit or proceeding arising hereunder. This clause for indemnification shall be interpreted to the broadest extent permitted by law. County Not Responsible for Employee Character and Fitness of Contractor Employees Contractor accepts responsibility for determining and approving the character and fitness of its employees (including volunteers, agents, or representatives) to provide the services required of Contractor under this Agreement, including completion of a satisfactory criminal/background check and period rechecks to the extent permitted by law. Notwithstanding anything to the contrary in this Paragraph, Contractor shall hold County, and its officers, agents and employees harmless from any liability for injuries or damages resulting from a breach of this provision or Contractor’s actions in this regard. Conflict of Interest; Confidentiality Contractor covenants that it presently has no interest, and shall not have any interest, direct or indirect, which would conflict in any manner with the performance of services required under this Agreement. Without limitation, Contractor represents to and agrees with County that Contractor has no present, and will have no future, conflict of interest between providing County services hereunder and any other person or entity (including but not limited to any federal or state wildlife, environmental or regulatory agency) which has any interest adverse or potentially adverse to County, as determined in the reasonable judgment of the Board of Supervisors of County.

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The Contractor agrees that any information, whether proprietary or not, made known to or discovered by it during the performance of or in connection with this Agreement for County will be kept confidential and not be disclosed to any other person. The Contractor agrees to immediately notify County by notices provided in accordance with Section 23.6 of this Agreement, if it is requested to disclose any information made known to or discovered by it during the performance of or in connection with this Agreement. These conflict of interest and future service provisions and limitations shall remain fully effective five (5) years after termination of services to County hereunder. Notices All notices, requests, demands, or other communications under this Agreement shall be in writing. Notices shall be given for all purposes as follows:

a. Personal delivery: When personally delivered to the recipient, notices are effective on delivery.

b. First Class Mail: When mailed first class to the last address of the recipient known to the party giving notice, notice is effective three (3) mail delivery days after deposit in a United States Postal Service office or mailbox. Certified Mail: When mailed certified mail, return receipt requested, notice is effective on receipt, if delivery is confirmed by a return receipt.

c. Overnight Delivery: When delivered by overnight delivery (Federal Express/Airborne/United Parcel Service/DHL WorldWide Express) with charges prepaid or charged to the sender’s account, notice is effective on delivery, if delivery is confirmed by the delivery service.

d. Telex or facsimile transmission: When sent by telex or facsimile to the last telex or facsimile number of the recipient known to the party giving notice, notice is effective on receipt, provided that (a) a duplicate copy of the notice is promptly given by first-class or certified mail or by overnight delivery, or (b) the receiving party delivers a written confirmation of receipt. Any notice given by telex or facsimile shall be deemed received on the next business day if it is received after 5:00p.m. (recipient’s time) or on a non-business day.

Addresses for purpose of giving notice are as follows:

To County: Emergency Medical Services Agency 1441 Schilling Place, South Building, Salinas, CA 93901 Attn: EMS Director To Contractor: Any correctly addressed notice that is refused, unclaimed, or undeliverable because of an act or omission of the party to be notified shall be deemed effective as of the first date that said notice was refused, unclaimed, or deemed undeliverable by the postal authorities, messenger, or overnight delivery service. Any party may change its address or telex or facsimile number by giving the other party notice of the change in any manner permitted by this Agreement. No Waiver No waiver of a breach, failure of any condition, or any right or remedy contained in or granted by the provisions of this Agreement shall be effective unless it is in writing and signed by the party waiving the breach, failure, right or remedy. No waiver of any breach, failure, right or remedy shall be deemed a waiver of any other breach, failure, right or remedy, whether or not similar, nor shall any waiver constitute a continuing waiver unless the writing so specifies. Workers’ Compensation

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Contractor shall provide Workers' Compensation insurance, as applicable, at Contractor's own cost and expense and further, neither the Contractor nor its carrier shall be entitled to recover from County any costs, settlements, or expenses of Workers' Compensation claims arising out of this Agreement. Conformity with Law and Safety In performing services under this Agreement, Contractor shall observe and comply with all applicable laws, ordinances, codes and regulations of governmental agencies, including federal, state, municipal, and local governing bodies, having jurisdiction over the scope of services, including all applicable provisions of the California Occupational Safety and Health Act. Contractor shall indemnify and hold County harmless from any and all liability, fines, penalties and consequences from any of Contractor’s failures to comply with such laws, ordinances, codes and regulations. Equal Employment Opportunity Practices Provisions Contractor assures that he/she/it will comply with Title VII of the Civil Rights Act of 1964 and that no person shall, on the grounds of race, creed, color, disability, sex, sexual orientation, national origin, age, religion, Vietnam era Veteran’s status, political affiliation, or any other non-merit factor, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under this Agreement. Contractor shall, in all solicitations or advertisements for applicants for employment placed as a result of this Agreement, state that it is an “Equal Opportunity Employer” or that all qualified applicants will receive consideration for employment without regard to their race, creed, color, disability, sex, sexual orientation, national origin, age, religion, Vietnam era Veteran’s status, political affiliation, or any other non-merit factor. Contractor shall, if requested to so do by County, certify that it has not, in the performance of this Agreement, discriminated against applicants or employees because of their race, creed, color, disability, sex, sexual orientation, national origin, age, religion, Vietnam era Veteran’s status, political affiliation, or any other non-merit factor. If requested to do so by County, Contractor shall provide County with access to copies of all of its records pertaining or relating to its employment practices, except to the extent such records or portions of such records are confidential or privileged under state or federal law. Contractor shall recruit vigorously and encourage minority - and women- owned businesses to bid its subcontracts. Nothing contained in this Agreement shall be construed in any manner so as to require or permit any act, which is prohibited by law. Contractor shall include the provisions set forth in paragraphs A through E (above) in each of its subcontracts. Drug Free Workplace Contractor and Contractor's employees shall comply with County's policy of maintaining a drug-free workplace. Neither Contractor nor Contractor's employees shall unlawfully manufacture, distribute, dispense, possess or use controlled substances, as defined in 21 U.S. Code § 812, including, but not limited to, marijuana, heroin, cocaine, and amphetamines, at any County facility or work site. If Contractor or any employee of Contractor is convicted or pleads nolo contendere to a criminal drug statute violation occurring at a County facility or work site, the Contractor within five days thereafter shall notify the head of County department/agency for which the contract services are performed. Violation of this provision shall constitute a material breach of this Agreement. Time of Essence

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Time is of the essence in respect to all provisions of this Agreement that specify a time for performance; provided, however, that the foregoing shall not be construed to limit or deprive a party of the benefits of any grace or use period allowed in this Agreement. Accidents If a death, serious personal injury, or substantial property damage occurs in connection with Contractor’s performance of this Agreement and warrants submission of a Monterey County EMS Unusual Occurrence Report (as per EMS Policy). Contractor shall immediately notify County by contacting the EMS Dispatch Center and asking to speak to the EMS person on call. The EMS person on call shall immediately notify the Monterey County Risk Manager’s Office by telephone. If after business hours, this message may be left as a voicemail. Contractor shall promptly submit to County a written report, in such form as may be required by County of all accidents, which occur in connection with this Agreement. This report must include the following information:

a. name and address of the injured or deceased person(s);

b. name and address of Contractor's sub-Contractor, if any;

c. name and address of Contractor's liability insurance carrier; and

d. a detailed description of the accident and whether any of County's equipment, tools, material, or staff were involved.

e. Contractor further agrees to take all reasonable steps to preserve all physical evidence and information which may be relevant to the circumstances surrounding a potential claim, while maintaining public safety, and to grant to County the opportunity to review and inspect such evidence, including the scene of the accident.

Headings Headings herein are for convenience of reference only and shall in no way affect interpretation of the Agreement. Debarment and Suspension Certification Contractor shall comply with applicable Federal suspension and debarment regulations, including but not limited to 7 Code of Federal Regulations ("CFR") 3016.35, 28 CFR 66.35, 29 CFR 97.35, 34 CFR 80.35, 45 CFR 92.35 and Executive Order 12549. By signing this agreement and FORM B – DEBARMENT AND SUSPENSION CERTIFICATE, Contractor certifies to the best of its knowledge and belief, that it and its principals:

a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntary excluded by any federal department or agency;

b. Shall not knowingly enter into any covered transaction with a person who is proposed for debarment under federal regulations, debarred, suspended, declared ineligible, or voluntarily excluded from participation in such transaction.

Taxes Payment of all applicable federal, state, and local taxes shall be the sole responsibility of Contractor. Ownership of Documents Contractor hereby assigns to County and its assignees all copyright and other use rights in any and all proposals, plans, specification, designs, drawings, sketches, renderings, models, reports and related documents (including computerized or electronic copies) respecting in any way the subject matter of this Agreement, whether prepared by County, the Contractor, the Contractor’s sub-Contractors or third parties at the request of the Contractor

14

(collectively, “Documents and Materials”). This explicitly includes the electronic copies of all above stated documentation. Contractor also hereby assigns to County and its assignees all copyright and other use rights in any Documents and Materials including electronic copies stored in Contractor’s Information System, respecting in any way the subject matter of this Agreement. Contractor shall be permitted to retain copies, including reproducible copies and computerized copies, of said Documents and Materials. Contractor agrees to take such further steps as may be reasonably requested by County to implement the aforesaid assignment. If for any reason said assignment is not effective, Contractor hereby grants County and any assignee of County an express royalty – free license to retain and use said Documents and Materials. County’s rights under this paragraph shall apply regardless of the degree of completion of the Documents and Materials and whether or not Contractor’s services as set forth in this Agreement have been fully performed or paid for. In Contractor’s contracts with other Contractors, Contractor shall expressly obligate its Sub-Contractors to grant County the aforesaid assignment and license rights as to that Contractor’s Documents and Materials. Contractor agrees to defend, indemnify, and hold County harmless from any damage caused by a failure of the Contractor to obtain such rights from its Contractors and/or Sub-Contractors. Contractor shall pay all royalties and license fees which may be due for any patented or copyrighted materials, methods or systems selected by the Contractor and incorporated into the work as set forth in this Agreement, and shall defend, indemnify and hold County harmless from any claims for infringement of patent or copyright arising out of such selection. County’s rights under this Paragraph shall not extend to any computer software used to create such Documents and Materials. Conflicts and Interpretation This Agreement has been drafted to include the requirements contained in the Request for Proposal #10735 and all addenda thereto and the Contractor’s proposal in response to that RFP. In the event of any conflict (direct or indirect) among this Agreement, the RFP and the Response, the more stringent requirements providing County with the broader scope of services shall have precedence, such that services provided under this Agreement, the scope of work described in the RFP, and the scope of work described in Contractor’s proposal shall be performed to the greatest extent feasible. The RFP and Response may be relied upon to interpret this Agreement and shall be applied in such a manner so that the obligations of Contractor are to provide County with broadest scope of services for the best value. Severability If a court of competent jurisdiction holds any provision of this Agreement to be illegal, unenforceable, or invalid in whole or in part for any reason, the validity and enforceability of the remaining provisions, or portions of them, will not be affected, unless an essential purpose of this Agreement would be defeated by the loss of the illegal, unenforceable, or invalid provision. Environmentally Friendly Business Practices Environmentally Preferable Products It is the intent of these specifications, terms, and conditions to procure the most environmentally preferable products with equivalent or higher performance and at equal or lower cost than traditional products.

EXHIBIT S

INSURANCE REQUIREMENTS

Evidence of Coverage

Prior to commencement of the Agreement, Contractor shall provide a “Certificate of Insurance” certifying that coverage as required herein has been by Contractor’s insurer as evidence that the coverage: (1) is placed with reasonably acceptable insurers; (2) is detailed on the Certificates as specified in the Agreement; and (3) is in full force and effect upon the commencement date of services. Contractor shall furnish to the County updated Certificates as policies are renewed. Individual endorsements executed by the insurance carrier shall accompany the certificate. In addition, Contractor upon request shall provide a certified copy of the policies or policies.

This verification of coverage shall be sent to the County’s Contracts/Purchasing Department, unless otherwise directed. Contractor shall not receive a “Notice to Proceed” with the services under the Agreement until it has obtained all insurance required and County has approved such insurance. This approval of insurance shall neither relieve nor decrease the liability of Contractor.

Qualifying Insurers

All coverage’s, except surety, shall be issued by companies which hold a current policy holder’s alphabetical and financial size category rating of not less than A- VI, according to current Best’s key Rating Guide or a company of equal financial stability that is approved by the County’s Purchasing Manager.

Insurance Coverage Requirements

Without limiting Contractor’s duty to indemnify, Contractor shall maintain in effect throughout the term of the Agreement a policy or policies of insurance with the following minimum limits of liability:

Commercial General Liability, including but not limited to premises, products and operations, contractual liability including for bodily injury and property damage, personal injury, severability of interest, advertisements, abuse, molestation, sexual actions, and sexual assault and battery with a limit of no less than $5,000,000 for each occurrence and $5,000,000 aggregate limit.

Business General Liability, covering all motor vehicles, including owned, leased, non-owned, borrowed, permissive uses, and hired vehicles used in providing services under the Agreement, with a combined single limit for bodily injury and property damage of not less than $5,000,000 for each occurrence and $5,000,000 aggregate limit.

Workers' Compensation, in accordance with obligations imposed by federal and state statutes for all employees who are subject to the Agreement, including broad all-states coverage; and Employer’s Liability Insurance with a limit of not less than $1,000,000 per occurrence.

Professional Liability, in the amount of not less than $5,000,000 per claim and $5,000,000 aggregate limit, to cover liability for bodily injury, malpractice, or errors or omissions made in the course of rendering professional services. Contractor shall, upon the expiration or termination of the Agreement, obtain extended reporting coverage (“tail coverage”) with the same liability limits. Any such tail coverage shall continue for at least three (3) years following the expiration or early termination of the Agreement.

.

Other Requirements

All insurance required by the Agreement shall be with a company acceptable to County and issued and executed by and admitted insurer authorized to transact insurance business in the State of California. Unless otherwise specified by the Agreement, all such insurance shall be written on an occurrence basis, or, if the policy is not written on an

occurrence basis, such policy with the coverage required herein shall continue in effect for a period of three years following the date Contractor completes its performance of services under the Agreement.

Notice to County

Each liability policy shall provide that County shall be given notice in writing at least thirty (30) days in advance of any endorsed reduction in coverage or limit, cancellation, or intended non-renewal thereof. Each policy shall provide coverage for Contractor and additional insureds with respect to claims arising from each subcontractor, if any, performing work under the Agreement, or be accompanied by a certificate of insurance form each subcontractor showing each subcontractor has identical insurance coverage to the above requirement.

Endorsements

Commercial general liability and automobile policies shall provide an endorsement naming the County of Monterey, its officers, agents, and employees, individually and collectively, as additional insureds with respect to liability arising out of Contractor’s performance of services under the Agreement, including ongoing and completed operations.

Primary and Non-Contributory Insurance

Contractor’s insurance shall provide that such insurance is primary insurance to any insurance or self-insurance maintained by County and that the insurance of the additional insureds shall not be called upon to contribute to a loss covered by Contractor’s insurance.

Waiver

The Commercial General Liability and Automobile Liability policies shall contain a waiver of recovery (subrogation) against County for any claims arising out of Contractor’s performance of its services under the Agreement.

Supplemental Insurance

During the term of the Agreement, County, in its reasonable discretion, may require Contractor to obtain additional coverage or increase the amount of any insurance Contractor carries to the extent the coverage is reasonably and commercially available to Contractor (“Supplemental Coverage”). County shall allow reasonable time for Contractor’s insurance broker to research the market availability of such required Supplemental Coverage.

Additional Insurance

Contractor may obtain additional insurance not required by the Agreement.

Reservation of Rights

County reserves the right, from time to time, to review Contractor’s insurance coverage, limits, deductible and self-insured retentions to determine if they are acceptable to the County.

Cost of Insurance

Contractor shall, at its sole cost and expense, comply with the insurance requirements set forth above. Any deductible or self-insured retention amount or other similar obligation under the policies shall be the sole responsibility of Contractor.

No Cap on Contractor Liability

The foregoing requirements as to the types and limits of insurance coverage to be maintained by Contractor and any approval of said insurance by County or its insurance consultant(s) are not intended to and shall not in any manner limit or qualify the liabilities and obligations otherwise assumed by Contractor pursuant to the Agreement, including but not limited to the provisions concerning indemnification.

Self-Insurance

County acknowledges that some insurance requirements contained in the Agreement may be fulfilled by self-insurance on the part of Contractor. However, this shall not in any way limit liabilities assumed by Contractor under the Agreement. Any self-insurance shall be approved in writing by County upon satisfactory evidence of financial capacity. Contractor’s obligation hereunder may be satisfied in whole or in part by adequately funded self-insurance programs or self-insurance retentions.

Prior to the execution of the Agreement by County, Contractor shall file certificates of insurance with County’s contract administrator and County’s Contracts/Purchasing Division, showing that Contractor has in effect the insurance required by this Agreement. Contractor shall file a new or amended certificate of insurance within five days after any change is made in any insurance policy, which would alter the information on the certificate then on file. Acceptance or approval of insurance shall in no way modify or change the indemnification clause in the Agreement, which shall continue in full force and effect.

Contractor shall at all times during term of the Agreement maintain in force the insurance coverage required under the Agreement and shall send, without demand by County, annual certificates to County’s contract administrator and County’s Contracts/Purchasing Division. If the certificate is not received by the expiration date, County shall notify Contractor and Contractor shall have five calendar days to send in the certificate, evidencing no lapse in coverage during the interim. Failure by Contractor to maintain such insurance is a default under the Agreement, which entitles County, at its sole discretion, to terminate the Agreement.

RFP No. 10735 Form A

Section 1: COVER LETTER FORMAT

Cover letter must not exceed two (2) pages and must include:

a) Contact Information

Organization Name:

Title/Position of Primary Contact Person:

Contractor’s Primary Contact Person During Solicitation:

Telephone Number:

Mailing Address:

Fax Number:

City, State, Zip:

Email Address:

b) Organization Information Describe: • Type of organization under its present name • Related prior business names • Number of years the organization has been in existence • Number of years the organization has provided the required services • Number of years key personnel proposed for Monterey County have been with the organization

and their roles within the organization.

RFP No. 10735

Form B

Section 1: REQUIRED SIGNATURE PAGE

COUNTY OF MONTEREY RFP No.10735

CONTRACTS/PURCHASING DIVISION ISSUE DATE: _______________

RFP TITLE: Exclusive Ambulance Service Provider the Monterey County Exclusive Operating Area

PROPOSALS ARE DUE IN THE OFFICE OF THE CONTRACTS/PURCHASING

OFFICER BY 1500, LOCAL TIME, ON _____________________

MAILING ADDRESS:

COUNTY OF MONTEREY

CONTRACTS/PURCHASING OFFICE

1488 SCHILLING PLACE

SALINAS, CA 93901

QUESTIONS ABOUT THIS RFP SHOULD BE DIRECTED TO:

Gina Encallado, Management Analyst I

Monterey County Contracts and Purchasing

1488 Schilling Place

Salinas, CA 93901

PHONE: (831) 796-1336

Email: [email protected]

CONTRACTOR MUST INCLUDE THE FOLLOWING IN EACH PROPOSAL (1 original plus 8 copies):

ALL REQUIRED CONTENT AS DEFINED IN RFP SECTION 5, 6, 7, 8, AND 11.

This Signature Page must be included with your submittal in order to validate your proposal.

Proposals submitted without this page will be deemed non-responsive.

CONTRACTOR MUST AGREE TO THE FOLLOWING TO VALIDATE PROPOSAL.

I hereby agree to furnish the articles and/or services stipulated in my proposal at the price quoted, subject to the instructions and

conditions in the Request for Proposal package. I further attest that I am an official officer representing my firm and authorized with

signatory authority to present this proposal package.

Company Name: ______________________________________________________ Date _________________

Signature: ________________________________ Printed Name: _____________________________________

Street Address: _____________________________________________________________________________

City: ___________________ State: ______ Zip: ______________

Phone: ( ) ____________________ Fax: ( ) ________________ Email: ___________________________

License No. (If applicable): _____________________________

License Classification (If applicable): _____________________________________

Signature continued on page 2.

RFP No. 10735

Form B

OTHER (describe):

Company Name: ______________________________________________________ Date _________________

Signature: ________________________________ Printed Name: _____________________________________

Street Address: _____________________________________________________________________________

City: ___________________ State: ______ Zip: ______________

Phone: ( ) ____________________ Fax: ( ) ________________ Email: ___________________________

License No. (If applicable): _____________________________

License Classification (If applicable): _____________________________________

RFP No. 10735 Form C

Table of Contents Section 1. SUBMISSION OF REQUIRED FORMS

1. Form D Debarment (Section 8.2.2.8) 2. Form E Non-Collusion (Section 16.0) 3. Form F Contractor Acknowledgments

Section 2. FORM G CONTRACTOR’S ACCEPTANCE OF TERMS (Section 15.0)

Section 3. RFP RESPONSE

Minimum Qualifications

8.2 Organizational Operational Experience

8.2.1 Ambulance Services and EMS Medical Dispatch Experience

8.2.2 Organizational Requirements 8.2.2.1 Organizational Ownership and Legal Structure 8.2.2.2 Continuity of Business 8.2.2.3 Government Investigations 8.2.2.4 Litigation History 8.2.2.5 Contracts in Good Standing 8.2.2.6 Contracts with EMS System Participants 8.2.2.7 References (Form H) 8.2.2.8 Debarment and Suspension (insert form D as instructed in Section 1 above)

8.3 Key Personnel

8.4 Financial Condition

8.4.1 Financial Stability 8.4.2 Working Capital

Scope of Work

5.1 Basic Ambulance Services

5.2 EMS Dispatch and Communications

5.3 EMS Medical Dispatch Redundancy

5.4 Response Time Interval Performance

5.5 Ambulance Operations

5.6 Medical Requirements

5.7 Clinical Management, Alternative Transportation, and EMS Innovation

RFP No. 10735 Form C

5.8 Personnel

5.9 Training and Continuing Education

5.10 Multi-Casualty Incidents (MCI) and Medical Disasters

5.11 EMS System Participation

5.12 Commitment to Local Community 5.13 Financial Requirements

5.14 Annual Performance Evaluation

5.15 Performance Monitoring

5.16 Reporting Requirements

5.17 Transition Plan

Section 5. PRICING (submitted as an electronic Excel spreadsheet and in hardcopy in a sealed envelope)

11.0 Revenue, Expenses and Pricing

11.1 Patient Charges (Form I) 11.2 Revenue, Expenses, and Pricing Reporting (Forms J, J1, J2, and J3)

Section 6. APPENDIX

Section 7. Licensing/Security Requirements

RFP No. 10735

Form D

DEBARMENT AND SUSPENSION CERTIFICATE

1.

Bidder, under penalty of perjury, certifies that, except as noted below, the company, its principal, and any

named subcontractor:

a. Is not currently under suspension, debarment, voluntary exclusion, or determination of ineligibility

by any Federal agency;

b. Has not been suspended, debarred, voluntary excluded, or determined ineligible by any Federal

agency within the past three (3) years;

c. Does not have a proposed debarment pending; and

d. Had not been indicted, convicted, or had a civil judgement rendered against it by a court of

competent jurisdiction in any matter involving fraud or official misconduct within the past three (3)

years.

2. If there are any exceptions to this certification, insert the exceptions in the following space.

3.

Exceptions shall not necessarily result in denial of award but shall be considered in determining Bidder

responsibility. For any exception noted above, indicate below to whom it applies, initiating agency, and dates

of action.

4.

Providing false information may result in criminal prosecution or administrative sanctions. The above

certification is part of the Agreement. Signing the Agreement on the signature portion thereof shall also

constitute signature of this Certification.

Printed Name: Title:

Date:

Signature

Other (Describe):

Printed Name: Title:

Date:

Signature:

RFP No. 10735

Form E

NON-COLLUSION DECLARATION

I, ____________________________________________am the ________________________

(Name) (Position Title)

Of __________________________________________________

(Agency Name)

the party making the foregoing proposal that the proposal is not made in the interest of, or on behalf of, any

undisclosed person, partnership, company, association, organization, or corporation; that the proposal is genuine and

not collusive or sham; that the proposal has not directly or indirectly induced or solicited any other vendor to put in a

false or sham proposal; and has not directly or indirectly colluded, conspired, connived, or agreed with any vendor

or anyone else to put in a sham proposal, or that anyone shall refrain from proposing; that the vendor has not in any

manner directly or indirectly, sought by agreement, communication, or conference with anyone to fix the proposal

price of the vendor or any other vendor, or to fix any overhead, profit, or cost element of the proposal price, or of

that of any other vendor, or to secure any advantage against the public body awarding the contract of anyone

interested in the proposed contract; that all statements contained in the bid are true; and, further, that the vendor has

not, directly or indirectly, submitted his or her proposal price or any breakdown thereof, or the contents thereof, or

divulged information or data relative thereto, or paid, and will not pay, any fee to any corporation, partnership,

company association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or

sham proposal.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct:

_______________________________________ _____________________

(Signature) (Date)

Executed at

_________________________________________

At City, County, State (Location Signed)

Other (Describe):

_______________________________________ _____________________

(Signature) (Date)

Executed at

_________________________________________

At City, County, State (Location Signed)

RFP No. 10735

Form F

Bidder understands, agrees, and warrants that:

a. Bidder has carefully read and fully understands the information that was provided by the County to serve

as the basis for submission of this proposal;

b. Bidder has the capability to successfully undertake and complete the responsibilities and obligations of

the proposal being submitted;

c. All information contained in the proposal is true and correct to the best of Bidder’s knowledge;

d. Bidder signed a non-collusion affidavit herewith attached with the proposal;

e. That Bidder did not receive unauthorized information from any County staff or consultant during the

proposal period except as provided for in the RFP packet, or addenda thereto;

f. That by submission of this proposal, Bidder acknowledges that the County has the right to make any

inquiry it deems appropriate to substantiate or supplement any information supplied by the Bidder, and

Bidder hereby grants the County permission to make said inquiries, and to provide any and all requested

documentation in a timely manner; and

g. That Bidder offers and agrees to furnish the services specified in the proposal.

No proposal shall be accepted which has not been signed in ink in the appropriate space below.

I hereby certify that I am an authorized representative of the above-mentioned agency or name and to the best of my

knowledge and belief that:

The data in this response is true and accurate; Bidder has investigated all aspects of the RFP; Bidder is aware of

the applicable facts pertaining to the RFP process, procedures, and requirements; Bidder has read and understands

the RFP; Bidder has the capability to successfully undertake and complete the responsibilities and obligations of

their response being submitted; Bidder will be able to meet all of the minimum proposal requirements as specified in

this RFP; and Bidder will comply with the necessary certifications and assurances if a contract is awarded.

This shall constitute a warranty, the falsity of which entitles County to pursue any remedy authorized by law, at the

option of County, the right of declaring any contract made as a result thereof to be void.

By signing below, the submission of a proposal shall be deemed a representation and certification by Bidder that

• Bidder has investigated all aspects of the RFP

• Bidder is aware of the applicable facts pertaining to the RFP process, its procedures and requirements

• Bidder has read and understands the RFP. No request for modification of the proposal shall be considered

after its submission on the grounds that Bidder was not fully informed as to any fact or condition.

The duly authorized officer(s) signature(s)

Other (Describe):

Signature Signature Signature

Printed Name Printed Name Printed Name

Title Title Title

Date Date Date

RFP No. 10735 Form G

Section 2: BIDDER’S ACCEPTANCE OF TERMS

Bidder must accept and check all boxes below. Failure to do so may be viewed as a material deviation from the requirements of this RFP, and may result in disqualification of the bid proposal. This Acceptance Form must be signed by an individual with authority to bind Bidder, and by signing below, Bidder acknowledges that the signatory has that authority. A signature on this form acknowledges Bidder’s acceptance of all checked terms.

Accept Basic Ambulance Services Requirements (Sections 5.1)

Accept EMS Medical Dispatch Requirements (Section 5.2)

Accept EMS Redundancy Requirements (Section 5.3)

Accept Response Time Interval Performance Requirements (Section 5.4)

Accept Ambulance Operations Requirements (Section 5.5)

Accept Medical Requirements (Section 5.6)

Accept Case Management, Alternative Transportation, and EMS Innovation Requirements (Section 5.7)

Accept Personnel Requirements (Section 5.8)

Accept Training and Continuing Education Requirements (Section 5.9)

Accept Multi-Casualty (MCI) and Medical Disasters Requirements (Section 5.10)

Accept EMS System Participation Requirements (Section 5.11)

Accept Commitment to Local Community Requirements (Section 5.12)

Accept Financial Requirements (Section 5.13)

Accept Annual Performance Evaluation Requirements (Section 5.14)

Accept Performance Monitoring Requirements (Section 5.15)

Accept Reporting Requirements (Section 5.16)

Accept Transition Plan Requirements (Section 5.17)

Accept Contract Term (Section 6.0)

Accept Licensing/Security Requirements (Section 7.0)

Accept Sample Standard Agreement Terms and Conditions (Section 15, Exhibit R)

Accept all Terms and Conditions Set Forth in the Pages of this Solicitation

Other (Describe):

Signature Signature

Printed Name /Title Printed Name / Title

Date Date

RFP No. 10735

Form H

BIDDER EXPERIENCE AND REFERENCES

Bidder Name: _________________________

Program Name: _________________________

1. Bidder’s Status (check one):

Private Nonprofit Educational Institution

Corporation – Private Public Agency (non-county)

Corporation – Public Other:

2. Is the entity and/or any person providing the proposed services suspended or debarred from receiving funds as

listed in the List of Parties excluded from Federal Procurement or Non-Procurement Programs Issued by the

Federal Government Services Administration (https://sam.gov/SAM/)

YES NO

If YES, please explain circumstance:

3. Number of years Bidder has been in business:

• Under the Present Name: ________________________________

• Under Other Name (Please specify): _______________________

4. Number of years of experience Bidder has had providing the kind of services required in this RFP. _____

• Under the Present Name: ________________________________

• Under Other Name (Please specify): _______________________

5. Please explain on a separate sheet of paper, information to show that Bidder has the administrative and fiscal

capability to administer the proposed program and has internal procedures to:

a. Establish and maintain a system of financial controls and accounting in conformance with generally

accepted accounting principles (GAAP).

b. Maintain accurate and complete financial reports for all costs and operating expenses in connection

with the proposed program funding, including but not limited to subcontracts, invoices, timecards,

cash receipts, vouchers, cancelled checks, bank statements, and other official documentation

indicating in proper detail the nature and propriety of all costs incurred.

c. Maintain financial records that show funds received under the proposed program are used for

purposes consistent with the terms of the proposed program.

d. Comply with current and subsequently amended or added statutes, regulations, policies, procedures,

program rules, or other requirements of the Federal Government, State of California, and Monterey

County.

6. Attach a copy of Bidder’s most recent year’s independently audited financial statements, as well as those for

the preceding two years, if they exist. The submission shall include the audit opinion, balance sheet, income

statement, retained earnings, cash flows, and notes to the financial statements. If independently audited

https://sam.gov/SAM/

RFP No. 10735

Form H

financial statements do not exist for Bidder, Bidder shall state the reason and, instead, submit the latest

currently maintained comprehensive Dunn and Bradstreet report.

7. For the kind of services required in this RFP, how many contracts has Bidder completed? _________

8. Bidder shall provide five (5) current and/or former public entities to whom Bidder has or is providing

Ambulance Services. Entities used as references must have similar scope, volume, and requirements to those

outlined in the specifications, terms and conditions of the RFP. Please use the following table to provide the

requested information.

a. Name of Contracting Entity: Contact Person:

Address: Telephone Number:

City, State, Zip: E-Mail Address:

Location of Services:

Date(s) of Service: Contract Amount:

Description of Services Provided:

Key Personnel Associated with Service Delivery:

b. Contracting Entity: Contact Person:







RFP No. 10735

Form H

c. Contracting Entity: Contact Person:







d. Contracting Entity: Contact Person:




Term of Contract: Contract Amount:



e. Contracting Entity: Contact Person:




Term of Contract: Term of Contract:



RFP No. 10735

Form I

PATIENT CHARGES

1. Bidder shall submit proposed Patient Charges on this form. Proposed patient charges submitted should be the

"year-one" rate. Proposed patient charges should take into consideration the cost of providing care to indigent

patients. No alterations or changes of any kind are permitted.

2. With the implementation of the new Agreement, the EMS Agency will adopt a “bundled” rate for Ambulance

Services, whereby most fees for service are included in the base rate, with the exception of oxygen, emergency,

mileage, standby, and Treat-No transport.

3. With the implementation of the new Agreement, in addition to the CCT-RN base rate, the County will allow for

separate BLS and ALS Base Rates. The EMS Agency does not have verified information on the number or

proportion of calls that would be properly categorized as ALS and BLS. Therefore, Bidder will need to use its

own professional judgement and expertise to estimate the proportion of ALS and BLS calls, and develop estimates

and operational economic models.

4. The current ambulance rates, as approved by the Monterey County Board of Supervisors, are identified in Exhibit

C: Monterey County Ambulance Rates.

5. Bidder is encouraged to review all data in the RFP and associated documents, including the following

spreadsheets, which will be provided electronically:

a. 911 Calls by Determinate

b. Monterey County CCT Transports

c. 2017 CCT-RN Transports Monterey

d. 2018 CCT-RN Transports Monterey

e. Monterey IFT County Destination

f. AMR Three-year Listing of Calls

Patient Charges quoted on this form shall include all taxes and all fees charged to patients or third party payers.

Proposals should reflect a bundled rate structure and no other charges for supplies, equipment, procedures, or

other services will be accepted, except those listed below. Bidder shall comply with fee schedule and rates

proposed in response to this RFP and as approved by the County Board of Supervisors.

Proposed Charges (based on all specifications

contained in the RFP)

Complete the proposed charge for each item listed

below. No other patient charges will be considered.

Indicate pricing in dollars and cents

• Bundled BLS Base Rate $

• Bundled ALS Base Rate $

• Bundled Critical Care Transport-RN Base Rate $

• Emergency Charge (for BLS only) $

RFP No. 10735

Form I

• Mileage/per mile (for all transport types) $

• Oxygen $

• Treat, Non-transport charge* $

• Standby rate (per hour) $

*Treat, Non-transport rate applies to patients who

receive a treatment intervention (such as 50% dextrose)

and subsequently refuse transport. ALS or BLS

Assessment (vital signs, EKG, etc.) does not constitute

treatment interventions

Bidder agrees that the prices quoted are the maximum that they will charge during the term of any contract awarded,

with the exception of fee increases based on the consumer price index and other fee increases approved by the

Monterey County Board of Supervisors.

Organization: ______________________________________

Signature: _________________________________________

Name (Printed/Typed) _______________________________

Title: _____________________________________________

Date: ______________________________________________

FORM J

Proposer:

TABLE 1 - P&L BUDGET

Start-Up Year 1 Year 2 Year 3

REVENUES

Private payments

Medicare

Medi‐Cal

Other third‐party payments

Other (describe)

Total Revenues

EXPENSES

Personnel

Paramedic wages

Paramedic benefits

EMT wages

EMT benefits

Other personnel wages

Other personnel benefits

Other (describe)

Subtotal personnel

Vehicles

Fuel

Repairs & maintenance

Equipment lease

Other (describe)

Subtotal vehicles

Medical equipment & supplies

Supplies

Equipment lease

Repairs & maintenance

Other (describe)

Subtotal medical equip. & supplies

Facilities

Rent/Lease

Property taxes

Insurance

Utilities

Other (describe)

Subtotal facilities

Total Expenses

INCOME (LOSS) BEFORE INCOME TAXES

Income Taxes

NET INCOME (LOSS)

TABLE 2 - BASIS FOR REVENUE PROJECTIONS

Average

Annual # of Payment per Annual

Transports % Transport Revenue

Source of Payment:

Private

Medi‐Cal

Medicare

Other (describe)

No payment

Total 100%

TABLE 3 - INDIRECT COST ALLOCATIONS AND PAYMENTS TO PARENT/AFFILIATES

Expense line item Start-Up Year 1 Year 2 Year 3

Total payments to parents/affiliates

Form J1: Charge Scenario #1

Proposer:

SCENARIO #1: A 56-year-old male is complaining of chest pain. This call occurs at 2:00 a.m. and the patient’s home

is 12 miles from the receiving hospital.

Base rate $

Emergency response $

Night charge $

12 miles transport $

Oxygen $

Oxygen administration equipment $

I.V. administration equipment $

Cardiac monitor $

Nitroglycerin gr. 1/150 s.l. $

Morphine Sulfate 4 mg. I.V. $

Aspirin $

$

$

$

$

Total $

Completion instructions: Complete the three tables below based on the three charge scenarios presented and the rate

schedule submitted in this proposal. Assume that any an all care expected by current protocols is provided. If an item is

included in the base rate, or if there is no charge for an item, indicate this in the table. Identify additional specific charges (e.g.,

charges to perform any of the identified skills) or routine charges (e.g., infection control charge) in the blanks provided. The

total shall reflect all specific and routine charges that a patient in this type of scenario would be billed.


Proposer:

SCENARIO #2: A 17 year-old male has overdosed on heroin and is combative and needs restraints once revived. This

call occurs at 5:00 p.m. and the patient’s home is 20 miles from the receiving hospital. Parent rides to hospital.

Base rate $



Oxygen $



Cardiac monitor $

Narcan X2 $

Restraints $

Glucose check $

$

$

$

$

Total $







Proposer:

SCENARIO #3: An 8-year-old female suffers a broken leg after a moving vehicle accident. This call occurs at 4:00 a.m. and the patient is

transported out of county to a trauma center by medical control 28 miles from the scene.

Base rate $


Out of county/LD charge $


Oxygen $



Trauma dressing and bandaging $

Splint $

$

$

$

$

$

$

Total $






REQUEST FOR PROPOSALS 10735

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