Request for Proposal # 7144

County of Merced

We believe the key to continuing superior EMS now and in the future, is in growing and

sustaining our system of partnerships and cooperation.

Proposal submitted jointly by Air Methods Corporation and Riggs Ambulance Service County of Merced Request for Proposal #7144

Air Ambulance Services

Here, there are no second chances. No Do-overs. No Mulligans. No “A for Effort”. Here, it’s not physics that gets a helicopter off the ground. It’s the dedication of over 4,000 employees ready to answer the call. It’s having the right people, in the right place, at the right time.

It’s innovation that brings critical care to those in need. WHENEVER. WHEREVER. Because here, what we do IS ALL ABOUT WHOM WE DO IT FOR. WE ARE THE DEFENDERS OF TOMORROW. AND WE’RE READY FOR IT.

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A. Signature Page

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B. Cover Letter

July 12, 2016

Kim Nausin, Procurement Manager County of Merced Department of Administrative Services - Purchasing 2222 M Street Merced, CA 95340

Dear Ms. Nausin,

Attached please find the Air Methods response to RFP #7144 for Air Ambulance Services for Merced County.

Air Methods is the primary responder to the RFP and will be providing services with the support of SEMSA/Riggs Ambulance Service and the Riggs Air 1 clinical team.

Air Methods/Mercy Air Service, Inc. has provided service in California for over 27 years and has been contracted with Merced County as the exclusive provider of services since 2007. Under the current service agreement Air Methods/Mercy Air Service, Inc. has provided high quality performance based services to the county with continuous reporting to and monitoring by the county.

As the largest air medical provider in the world, Air Methods is uniquely positioned to provide a depth of services and support that will assure that the citizens of Merced County are receiving the best possible service. With 14 bases of operations in California Air Methods has the depth of personnel and resources needed to provide the expected level of service for the county from our base of operations centrally located in Merced.

I affirm that Air Methods fully understands and agrees to provide the services as outlined in RFP #7144. This letter certifies the completeness and accuracy of the information provided in our response. Air Methods, working with our clinical partner will provide a fully integrated critical care transport system to the citizens and visitors of Merced County during the period outlined in the RFP.

Kevin Stanhope, Vice President West Coast Operations Air Methods Corporation 625 E. Carnegie Drive, Suite 150 San Bernardino, CA 92408

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C. TABLE OF CONTENTS

A. SIGNATURE PAGE ...... 2 B. COVER LETTER ...... 3 C. TABLE OF CONTENTS ...... 4 D. EXECUTIVE SUMMARY ...... 6 E. EXCEPTIONS ...... 9 F. 2.5 BIDDER’S QUALIFICATIONS ...... 11

2.5.1 BIDDERS SHALL AFFIRM THEIR INITIAL AND ONGOING AGREEMENT TO COMPLY WITH EACH REQUIREMENT LISTED IN SECTION 2.4, SPECIFIC COMPLIANCE ...... 11 2.5.2 BIDDERS SHALL BE REPRESENTATIVE OF ENTITIES IN GOOD STANDING THAT HAVE PROVIDED AVIATION AND MEDICAL SERVICES IN THE MOST RECENT 5 YEARS...... 12 2.5.3 BIDDERS SHALL BE, OR SHALL SUBCONTRACT WITH, AN AVIATION SERVICES COMPANY THAT HAS PROVIDED FAA PART 135 SERVICES TO MEDICAL ORGANIZATIONS IN THE MOST RECENT 5 YEARS ...... 13 2.5.4 BIDDERS SHALL BE CURRENTLY CAMTS ACCREDITED ...... 13 2.5.5 BIDDERS SHALL HAVE PROVIDED SERVICES SIMILAR TO THOSE REQUIRED IN THIS RFP IN THE MOST RECENT 5 YEARS ...... 15 2.5.6 BIDDERS SHALL HAVE PROVIDED SERVICES SIMILAR TO THOSE REQUIRED IN THIS RFP TO THREE OR MORE HOSPITALS AND/OR EMS AGENCIES IN THE MOST RECENT 5 YEARS ...... 18 2.5.7 BIDDERS SHALL HAVE EXPERIENCED KEY PERSONNEL IDENTIFIED TO MANAGE THE REQUIRED SERVICES ...... 19 G. 2.6 BIDDER’S EXPERIENCE, SERVICES ...... 29

2.6.1 FAA PART 135 EXPERIENCE ...... 29 2.6.2 PRIMARY RW AIRCRAFT ...... 29 2.6.3 BACK-UP RW AIRCRAFT ...... 31 2.6.4 AVIATION PERSONNEL ...... 31 2.6.5 MEDICAL CREW ...... 36 2.6.6 SERVICE DELIVERY PLAN (SDP) ...... 39 2.6.7 READINESS AND RESPONSE ...... 43 2.6.8 INTERFACE WITH THE MERCED COUNTY EMS DISPATCH CENTER ...... 46 2.6.9 BASE OF OPERATIONS ...... 49 2.6.10 QUALITY MANAGEMENT ...... 50 2.6.11 EMS PERSONNEL SAFETY TRAINING ...... 52 2.6.12 SAFETY AND RISK PROGRAM ...... 53 2.6.13 PATIENT SAFETY PROGRAM ...... 61 2.6.14 PATIENT RIGHTS, MEDICAL CARE ...... 63

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2.6.15 INSURANCE COVERAGE ...... 63 H. 2.7 PATIENT CHARGE MASTER AND PAYMENT COLLECTIONS ...... 64 I. FINANCIAL STATEMENT ...... 66 ATTACHMENT #1 – SECTION 2.5.2, 2.5.5 - AIR METHODS PATIENT TRANSPORT SERVICE HISTORY ...... 67 ATTACHMENT #2 – SECTION 2.5.3 - AIR METHODS OPS SPECS AND FAA PART 135 AIR CARRIER CERTIFICATE ...... 69 ATTACHMENT #3 – SECTION 2.6.11 - CREWMEMBER TRAINING CURRICULUM SEGMENT ...... 70 ATTACHMENT # 4 – SECTION 2.6.14 - HIPAA POLICY AND PATIENT’S RIGHTS ...... 49 ATTACHMENT # 5 – SECTION 2.6.15 - INSURANCE CERTIFICATES ...... 112 ATTACHMENT # 6 – SECTION 2.6.10 - CQI PLAN ...... 120 ATTACHMENT # 7 – SECTION 2.6.4 - LOCAL FLYING AREA CURRICULUM ...... 161

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D. Executive Summary

Air Methods and Sierra Medical Services Alliance (SEMSA)/Riggs Ambulance Service have demonstrated a commitment to the Riggs Air 1 Program, the hospitals and people of Merced County, and the Central Valley Region of California through development of an integrated air and ground medical transport system. Our support of this network is demonstrated by the marketing, development, management, financial and resource commitment we have made to this program since we first proposed it in 2014. SEMSA/Riggs Air 1 has the mission to serve the rural areas of Merced County and Central California through designated critical care transport from local hospitals and appropriate scene responses for acute and critical patients. This service is provided in the out-of-hospital environment where rapid transport to appropriate medical care is best performed by rotary aircraft when available while backed-up by a ground critical care transport service using the same highly trained care providers.

True commitment to the success of this program is demonstrated by our promise from the beginning to meet or exceed all CAMTS standards and FAA Part 135 Standards.

Our Bell 407 rotor wing aircraft is based at the Merced Municipal Airport. The aircraft is equipped with Night Vision Goggles (NVG), Terrain Avoidance & Warning Systems (TAWS), Satellite Phones, and dual moving GPS Systems with live feeds which are tracked by the Air Methods Operational Control Center in Denver, Colorado. This provides the crew and patients with state-of-the-art safety support.

RIGGS Air 1 is a part of a comprehensive system of pre-hospital care offered by SEMSA. SEMSA oversees the clinical operation of RIGGS Air 1 and, through an exclusive franchise with the Merced County Health Department, the ALS, BLS, and CCT ground ambulance service for the entire county.

RIGGS Dispatch Center is the Regional Emergency Medical Dispatch Center for Merced County as designated by the County Health Department. It has received and maintained accreditation by the National Academy of Emergency Medical Dispatch (NAED) for the past 12 years and works in cooperation with Air Methods AirCom Dispatch located in Omaha, Nebraska.

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On January 1, 2015 SEMSA/Riggs Ambulance Service was awarded a 10 year exclusive contract for ALS, BLS, and Critical Care ground ambulance transport services, and all the allied services required for maintaining an integrated response system for Merced County. SEMSA, in its bid and subsequent award, partnered with Air Methods to fully integrate critical care responses and transports by incorporating the air ambulance component into the ground ambulance system throughout the County and surrounding areas thus enhancing service delivery.

We have also integrated ground and air education and quality assurance services drawing on the strength of each company. Air Methods and SEMSA are working directly with the First Watch/Pass Corporation and are developing sophisticated compliance and quality assurance tools, as a beta test project, to be further distributed to other critical care air and ground services as these systems are developed, tested and refined.

Air Methods and SEMSA have a contractual commitment to meet every 6 months and review performance, needs, projects, and finance to ensure the parties are both providing high quality critical care, in a rural and economically challenged environment. In essence we work together to always improve quality and fiscal stability.

This unique partnership has incorporated some of the most seasoned and experienced leaders in both the air and ground ambulance industries to directly collaborate and review every area of service through the lens of fully integrated critical care rural health care. The combined expertise, experience and most important “successful track records” have literally reshaped the EMS industry over the past 45 years. Humbly, their lasting effects of positive industry changes are at best difficult to match. SEMSA’s CEO, COOs and Medical Directors have well over 150 years combined experience in both air and ground prehospital and critical care throughout the United States. Combine that with the depth of experience Air Methods has with a national footprint on the country, the combined effect is a model that could become the industry standard and draws on a nation-wide brain trust that assures the highest level of care possible in this one little area of the country.

Air Methods and SEMSA are dedicated to the support of every aspect of all of our programs to assure the safety of our services, the quality of care to our patients, our continued growth, and helping other struggling rural areas to be able to provide superior care while being financially stable to maintain those services.

“Bidders should note that Merced County is very diverse in its population and geography. A comprehensive proposal from a Bidder will require extensive orientation and familiarity to the unique service requirements of the County to include integrating services with the County’s contracted ground ambulance services and its first-responder agencies.” Page 3 County of Merced Request for Proposal Number 7144.

Air Methods/Mercy Air Service, Inc. and SEMSA/Riggs Ambulance Service have 79 years of combined experience of meeting the challenge of providing emergency medical care and transportation for Merced County. On January 1, 2015 we fully integrated the air and ground transport resources and have further strengthened our long-standing

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relationships with our first responder agencies. We have been, we are, and we will continue to be the best option for emergency medical transport services for Merced County.

Kevin Stanhope, Vice President West Coast Operations Air Methods

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E. Exceptions

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Section 2.5 BIDDER’S QUALIFICATIONS

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F. 2.5 BIDDER’S QUALIFICATIONS

2.5.1 Bidders shall affirm their initial and ongoing agreement to comply with each requirement listed in Section 2.4, Specific Compliance

Air Methods and RIGGS affirms the initial and ongoing agreement to comply with each requirement listed in Section 2.4, Specific Compliance.

• We agree to the assessment of a onetime fee to offset the cost of the procurement process. • We agree to the annual license fee understanding the fee is subject to annual cost evaluation through county cost system. • We agree to abide by all compliance requirement in Section 2.4 a. – w. • We agree to provide FirstWatch Online Compliance Utility (OCU) described in RFP Attachment C. • We agree to communicate directly with the Designated EMS Aircraft Dispatch Center for 911 scene flight requests and flight following. • We agree to provide communications equipment in our aircraft that are capable of communicating with the Designated EMS Aircraft Dispatch Center and all agencies listed in section 2.4. • We agree to provide all insurance coverage limits listed in section 2.4.

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2.5.2 Bidders shall be representative of entities in good standing that have provided aviation and medical services in the most recent 5 years.

Since 1980, Air Methods has been dedicated to air medical transport, focusing on the quality of care to patients, and safety in aviation operations. Air Methods prides itself on its leadership role in the industry through safety initiatives, customer service, and its interactions with the FAA and other organizations for the advancement of this vital service; being publicly traded emphasizes Air Methods’ transparency and visibility. Since 1991, the company has been a publicly traded company under the NASDAQ ticker “AIRM.”

For further information on Air Methods’ experience in air medical helicopter transport operations, please see Attachment #1 entitled, “Air Methods’ Patient Transport Service History.”

On January 30, 2013, we were served with a class action lawsuit, Helmick and Williams v. Air Methods Corporation, filed in Superior Court in Alameda County, California. The lawsuit alleges failure to pay wages and overtime, failure to provide rest and meal breaks or to pay compensation in lieu of such breaks, failure to pay timely wages on termination, failure to provide accurate wage statements, and unlawful business practices and unfair competition within the jurisdiction of the state of California. Plaintiff is seeking compensatory damages and other applicable statutory damages, penalties and wages under the California Labor Code, and attorneys' fees, interest and costs.

We continue to evaluate the merits of the lawsuit and are vigorously defending against this suit. However, we cannot predict the outcome of this lawsuit or whether we may be required to pay damages, settlement costs, or legal costs.

In the normal course of business, there are various other claims in process, matters in litigation and other contingencies. These include claims resulting from helicopter accidents, billing reimbursement challenges, employment-related claims and claims from patients transported by our company alleging negligent medical care or transport. To date, no claims of these types of litigation, certain of which are covered by insurance policies, have had a material effect on us. While it is not possible to predict the outcome of these other suits, legal proceedings and claims with certainty, management is of the opinion that adequate provision for potential losses associated with these other matters has been made in the financial statements and that the ultimate resolution of these other matters will not have a material adverse effect on our financial position and results of operations. Any such material lawsuits are reported in Air Methods’ SEC filings, which are available online at: https://www.sec.gov/cgi- bin/browse-edgar?company=&CIK=AIRM&filenum=&State=&SIC=&owner=include&action=getcompany.

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2.5.3 Bidders shall be, or shall subcontract with, an aviation services company that has provided FAA part 135 services to medical organizations in the most recent 5 years

Please see Attachment #2 – Air Methods Ops Specs and FAA Part 135 Air Carrier Certificate

2.5.4 Bidders shall be currently CAMTS accredited

Air Methods, the primary bidder, is currently accredited by the Commission on Accreditation of Medical Transport Systems. Utilizing the Alternative Delivery Model, Air Methods has an established partnership with RIGGS to provide both Air and Ground CCT Services. RIGGS has maintained ground ambulance accreditation since 2010 with the Commission on Accreditation of Ambulance Services (CAAS).

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Alternative Delivery Model (ADM)

The objective of an ADM is to minimize or eliminate fiscal risk to our partners while securing air medical transports for our partners in their market. The Air Methods ADM is a shared risk partnership. Under the ADM, Air Methods receives support from RIGGS in medical staffing, medical direction, marketing and other items as agreed to. In this model, Air Methods provides aviation, fuel, maintenance, aircraft, billing and EMS licensure.

2.5.5 Bidders shall have provided services similar to those required in this RFP in the most recent 5 years

Nationally, Air Methods operates approximately 30% of the U.S. air medical fleet and in 2015 the company flew approximately 150,000 air medical specific flight hours. Air Methods has become the largest air medical provider in the world, and manages the sixth-largest operating certificate in the U.S. with more than 450 aircraft. Air Methods has air medical and tourism operations serving 48 of the 50 states. Please see the following map highlighting our air medical operations and locations in the US:

As the leader of air-medical operations in the United States, Air Methods has relationships with numerous hospitals and EMS services providing aviation duties through various traditional contracts and alternative delivery models. We are experienced in the total delivery of Helicopter Air Ambulance Services as well as providing contractual

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aviation and maintenance support.

Air Methods is directly involved in the Association of Air Medical Services (AAMS)—to include having employees as board members; the Commission on Accreditation of Medical Transport Systems (CAMTS); the Air Medical Operators Association (AMOA); Helicopter Association International (HAI); and many regional and local organizations for the advancement of safety, patient care, and operations.

Air Methods is the most experienced air medical operator in the industry because we offer all key core competencies in-house including aviation operations; billing and collections; dispatch and communications; field maintenance; medical staffing and training; and installation of medical interiors. For further information on Air Methods’ experience in air medical helicopter transport operations, please see Attachment #1 entitled, “Air Methods’ Patient Transport Service History.”

Medical personnel staffing is handled by SEMSA/Riggs Ambulance Service. Minimum medical personnel staffing requirements are listed in the Medical Operations Manual included with this proposal (Title 507, Page 195).

The culture of Air Methods and Riggs Ambulance Service are very similar. Both entities place the patient’s best interest first and foremost.

WHAT WE DO To give more tomorrows by extending the reach of critical care access to anyone, anywhere, across the nation. We accomplish this through the vast experience and ingenuity of our people to create comprehensive solutions supported by our innovation, adaptability and financial stability.

WHERE WE’RE HEADED To be the dominant global expert of comprehensive, vertically-integrated, critical-care-access solutions supporting patient logistics—the movement of patients and their medical analytics.

OUR BELIEFS

Safe Return Though we celebrate each opportunity to extend and enhance a patient’s life, our greatest celebration is the daily, safe return of each member of our team to their loved ones—this is our highest priority. At times, this may require the courage to stop or not accept a mission due to factors in the moment that exceed what we believe, and have

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been taught, are unacceptable risks for our team.

Patient Champion We skillfully and passionately serve those who have unexpectedly found themselves threatened by life’s unforeseen situations. We devote ourselves—safely and prudently—to ensuring patients get our full expertise, resources and focus to preserve and enhance their lives until they are delivered to definitive care. This is at the heart of what we do.

Fiscal Balance Safe Return With our passion and commitment to "giving more tomorrows,” comes a balance of ensuring we have the Customer Paent financial wherewithal to do it. Platitudes of Advocates Champion greatness and aspiration are empty without the stable, unrelenting focus of the financial integrity of our efforts. This balance is evident of our current success and essential for our future growth. One Mission, Fiscal Balance One Team Accountable To Each Other

We believe our greatest accomplishments are not only Accountability in the things we do as a company, in general, but more importantly in the day-to-day decisions we make, individually, to do the right thing, to make a difference, to be the strongest link in the performance of our individual duties. We depend on each other to do our best—to have each other’s back—to ensure we are safe, impactful and successful. This is more important than hierarchy, status or personal agenda.

One Mission, One Team As team members, we celebrate each other’s strengths, abilities and contributions because in total, united, we are better together. We have chosen each other because of our mutual skills of leadership, ingenuity, experience and

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extraordinary performance: all of which help us be the world’s experts in patient critical care logistics.

Customer Advocates We see ourselves as partners, in the highest order, with our customers, sharing in their success and struggles, finding ways to effectively solve their challenges regardless of who owns the program, regardless of what business model they choose. We are their champions, solution collaborators and biggest fans. It is our goal to bring measurable value to every relationship. The relationship developed with RIGGS since 2015 has been rewarding and beneficial to Air Methods, RIGGS and the patients we serve.

2.5.6 Bidders shall have provided services similar to those required in this RFP to three or more hospitals and/or EMS agencies in the most recent 5 years

References provided:

Merced County EMS Agency Mercy Merced Medical Center Jim Clark, EMS Administrator Timothy Vietmeier, Cardiology Manager 260 E. 16th Street 333 Mercy Avenue Merced, CA 95311 Merced, CA 95340 209-381-1258 702-204-3959 [email protected] [email protected]

Memorial Hospital Los Banos Mountain Valley EMS Agency Jennifer Nunes, ED Director Richard Murdock, Executive Director 520 West I Street 1101 Standiford Ave, Suite D1 Los Banos, CA 93635 Modesto, CA 95350 209-826-0591 X 56306 209-539-5085 [email protected] [email protected]

Emanuel Hospital John C. Fremont Hospital Chris O’Brien, Certified Chest Pain Coordinator Nanette Wardle, ED Manager 825 Delbon Avenue 5189 Hospital Road Turlock, CA 95382 Mariposa, CA 95338 209-664-2865 209-966-3631 X 250 [email protected] [email protected]

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2.5.7 Bidders shall have experienced key personnel identified to manage the required services

Key staff members assigned to the Air Methods/RIGGS Program:

Key Personnel % Qualifications and Percentage assigned dedicated to to local program Merced Kevin Stanhope 5% Kevin Stanhope is the Regional Vice President for Air Methods with Air Methods oversight for 29 aircraft and over 300 employees in California, Regional Vice President Nevada, Oregon, Washington and Alaska. He has 26 years’ West Coast Operations experience in air medical transport with 17 years in senior leadership roles. He is a Registered Nurse and Paramedic and worked as a flight [email protected] crew member for 9 years. Additional relevant experience includes 6 years as the co-owner of a private ambulance service including BLS, ALS and Critical Care ground transport in rural Ohio. He currently leads a team of Regional Directors in Aviation, Maintenance, Clinical, Business and Safety roles in support of Air Method’s west coast operations. His office is located in San Bernardino Ca. His time is 100% focused on leadership of the bases he is responsible for with approximately 5% focused on the operation in Merced county.

William Hinton 5% William Hinton, RN is the Regional Business Development Director Air Methods for Air Methods – Region 2. Bill has been with Air Methods since Regional Business Director 2006 and started his 10-year tenure with the company as a Flight Nurse and Clinical Base Supervisor with Mercy Air 6 in El Cajon, CA. [email protected] Prior to his current role, Bill was the Regional Clinical Director for Region 2. Before joining the Air Methods team, Bill was a Flight Nurse for Geisinger Health System’s Life Flight program in Pennsylvania. He studied nursing at The Pennsylvania State University and is completing a Master of Science Degree in Nursing Leadership and Management. Bill is a member of Air and Surface Transport Nurses Association (ASNTA), the Emergency Nurses Association and the Association of Critical Care Nurses. He maintains certifications in Adult Critical Care, Emergency, and Flight Nursing and is a Certified Medical Transport Executive (CMTE). Before embarking on his nursing career, Bill was a Paramedic.

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Roy Cox 5% Roy Cox began his career at Mercy Air in 1989; as a pilot flying Mercy Air Methods Air’s first helicopter, Bell 412 out of Rialto, CA. He became Mercy Operations Manager Air’s Director of Operations until the Mercy Air was acquired by Air Methods Corporation in 1997. Over the years he has held various [email protected] positions to include Business Manager, Program Director and most recently Regional Logistics Manager. As Regional Logistics Manager, Roy ensures the daily operation is maintained by keeping track of aircraft availability and in-service ability along base logistics.

Benjamin Miller, RN 5% Graduated nursing school in 2005 and worked in the Emergency Air Methods Department in Louisiana. After one year, signed on with American Regional Clinical Director Mobile and worked as a travel nurse throughout various cities in California, Colorado, and Illinois. After traveling for four years, [email protected] moved back to San Diego and signed on at a county trauma center. Hired for Mercy Air in 2010 and flew in El Cajon, Ca. Moved into the Medical Education Coordinator role half time and flew half time, then with a reorganization, went back to the flight line full time. Applied for and promoted to the Medical Manager position for region 2 which covered Southern California for a little over two years and Las Vegas for part of that time. During this time, Ben completed his MBA. Ben relocated to region 8 to be closer to family and covered Mississippi MedFlight, MedFlight Alabama, and Alabama LifeSaver for one year. As of June, 2016, Ben has been promoted to Clinical Director for Region 2.

Stephen Latham 50% Born Spoke Washington-Fairchild Airbase 21 March 1961, father was Air Methods a B-52 tail gunner with 160 mission over Viet Nam. Regional Maintenance Steve grew up in Albuquerque NM, enlisted in the Marine Corps Director 1980. He served 7 years in Marine Corps as a helicopter mechanic air crew on UH-1N Huey and test flight mechanic AH-1J Cobras, was an [email protected] aerial gunner instructor. Steve received Airframes and Power License 1986 while still in the Marines. Hired by McDonnell Douglas Aircraft Company 1987, Steve worked at the flight line delivery center on the MD-80, MD-11 and C17 aircraft, laid off in 2002. Steve was hired by Gulfstream in 2002, to work as A&P mechanic at the Long Beach, Ca service center. Steve was then hired by Air Methods/Mercy Air 2003 as a base mechanic at the Rancho Cucamonga base. In 2004, Steve was promoted to CA2 Area Maintenance Manager and then in 2009 promoted to Regional Maintenance Director for Region 2.

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James Wisecup 5% Jim was trained by the U.S. Army in 1968-1969. Flew in Vietnam for Air Methods a year, and then returned to the U.S. for the remainder of his time. Regional Aviation Director Once discharged, Jim worked for the Department of the Interior for 3 years while attending the University of Houston. Jim started flying [email protected] offshore in the Gulf of Mexico for Offshore Helicopters (later bought by Bristow Helicopters). Jim advanced to be the Chief Pilot/Check Airman, and then transferred overseas with Bristow, flying SK61s and SK76s in the North Sea and Malaysia. He then went to Arctic Air Service flying offshore in California, as the Chief Pilot/Check Airman in the SK76. He then went to work for Rocky Mountain Helicopters flying EMS in a BK117 as a line pilot and Check Airman. He advanced to be the Chief Pilot until the company was purchased by Air Methods. Jim then became a Check Airman for AMC until taking a line pilot position in Salt Lake City, UT. He then became the Program Aviation Manager, then Area Aviation Manager, then Regional Aviation Director. He has served on the Board of Directors for the Helicopter Association International for the past 5 years. He is also a Designated Pilot Examiner issuing Pilot Certificates for the Federal Aviation Administration. Jim has been married to Jessica for 29 years, has 5 children and 6 grandchildren.

Jonathan Gryniuk 5% Jonathan Gryniuk has worked in the Emergency Medical Services Air Methods since 1985 and in Air Medical Transport since 1992. He flew for 17 Regional Safety Director years as both a Certified Flight Paramedic and as a Flight Respiratory Therapist for various critical care air medical transport programs [email protected] before moving into management positions. Mr. Gryniuk is a past- president of the International Association of Flight and Critical Care Paramedics and serves as their representative to the CAMTS board where he holds a position as an executive board member. Mr. Gryniuk has been active with CAMTS since 1998 serving as both a board member and a site surveyor and most recently as a founding board member for CAMTS-Europe. He is also a founding board member of the Tim Hynes Foundation, a not-for-profit organization dedicated to reinforcing and advancing air medical transport safety. Mr. Gryniuk is currently employed as a Regional Safety Director for Air Methods Corporation, where he has oversight of safety programs for over forty rotor and fixed wing air medical aircraft in the western United States. His duties include conducting field safety audits for compliance with federal aviation regulation, OSHA and company policy; accident and incident investigation, root cause analysis,

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facilitating risk assessments, oversight of conducting field safety audits for compliance with federal aviation regulation, OSHA and company policy; accident and incident investigation, root cause analysis, facilitating risk assessments, oversight of company field safety representatives and participation in safety promotion activities.

Rich Canino 5% Rich Canino, served 23 years in the U.S. Army. His first 8 years as Air Methods enlisted and CH-47 Flight Engineer followed by 15 years as a Pilot, Aviation Manager retired as a Chief Warrant Officer 3, flying UH-1H's and UH-60 Blackhawks performing a variety of missions from Troop movement, [email protected] sling loads, re-supply, Search & Rescue to being the assigned Pilot for a General Officer. Rich was hired by Air Methods Corp/Mercy Air in June, 2006, as a Helicopter Air Ambulance (HAA) Pilot. Rich’s career began with Mercy Air at the Victorville, CA location which was one of the busiest bases in Air Methods and became the Lead Pilot in 2007. In 2011, he was selected to become the Aviation Manager for Mercy Air overseeing 23 bases initially and which was later reduced to 11. As the Aviation Manager he is responsible for managing pilots, their schedules, overseeing medical crewmember aircraft training as well as Specialty Team training. He also serves as the Companies Bell 412 Check Airmen overseeing the training of thirteen pilots who are qualified in this airframe.

Bruce Harriman 5% Bruce has a 40 year aviation career as an airframe and powerplant Air Methods mechanic, maintenance supervisor, project manager, Maintenance Manager logistics/warehouse manager, service manager, and aviation business owner. His education consists of an Airframe and Power [email protected] Plant Course at Northrup University in Englewood, California, numerous aeronautical factory courses, and most recently completed most of the requirements for a Bachelor of Science in Aviation Management degree with Emery Riddle Aeronautical University. His current licenses held are an FAA Airman Certificate as Mechanic, Airframe and Powerplant and an FAA Inspection Authorization. Ron Haver 90% Ron has two wonderful kids Jordan 9 and Mickenzie 20. He spent 4 Air Methods years in the US Army. After getting out of the Army he was hired by Merced Lead Pilot the Stanislaus County Sheriff Department where he spent 25 years as a deputy sheriff. Ron retired from the sheriff's office in 2010, and [email protected] was hired as a pilot by Air Methods/Mercy Ai. Ron began flying in

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Mojave before moving to the Merced, CA base. Ron is now Lead Pilot for the Merced base.

Patrick Smith 5% Patrick is considered among the foremost EMS experts in the SEMSA/RIGGS nation. His career has spanned over 45 years and covers virtually President/CEO every aspect of ambulance service delivery. Patrick is a recognized expert in EMS system design, communication system design and [email protected] organizational/company restructuring/turnarounds. For many years, he was a partner with Jack Stout, known as the creator of high performance or “modern” EMS. Patrick has consulted across the country in creating some of the most recognized high performance EMS systems. He has also lead two of the most noted EMS systems as the President and CEO at both REMSA for 23 years and SEMSA for the last ten years.

Michael Williams 5% Mike’s career has spanned over 45 years and covered virtually every SEMSA aspect of ambulance service delivery. He is a recognized expert in Vice President and COO EMS system design, operations, organizational structure, administration, human resources, funding, communications, health [email protected] & safety, special operations, mass-gathering events, mass-casualty response & management, medical disaster preparedness and response, air ambulance operations, grant funding, budgeting, public information & education & relations, and education. He has led some of the largest EMS systems in the country including those in Atlanta, Las Vegas, and New Orleans. He has also led some of the smallest EMS systems in the country in Idaho, Florida and those of SEMSA. He served six years as the EMS Director for the State of Florida and another six years as a Regional CEO of the nation’s largest publically-traded ambulance service. Mike has a Master of Business Administration, a Master of Arts in Management and Human Relations, a Bachelor of Science in Occupational Education and Associate degrees in EMS and Instructor Technology.

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Steve Melander 10% Steve Melander, EMT-P, AS is our Vice President and Chief Operational SEMSA/RIGGS Officer of Central California Operations. He is responsible for all operations Vice President of California in Central California to include: RIGGS Ambulance Service in Merced Operations County, Westside Ambulance Service in Merced and Stanislaus Counties, and Escalon Community Ambulance in San Joaquin County He is a

[email protected] California licensed Paramedic with over 17 years of experience in a multitude of high performance EMS systems both ground and air throughout Central and Northern California. His EMS experience is vast and includes: · EMT · Paramedic · Paramedic Preceptor · Field Training Officer · Clinical Field Evaluator · Tactical Paramedic · Instructor – CPR, ACLS, PEPP, BTLS, EMT, Pre-Paramedic, Paramedic, EMS Continuing Education Courses, Adult Vocational Courses · Critical Care Paramedic · Paramedic Program Clinical Coordinator · Continuing Education Programs Director · QA / QI Coordinator · Director of Clinical Services · Flight Paramedic and Crew Chief · Paramedic Field Supervisor · Operations Supervisor · Health, Safety & Risk Manager · Designated Infection Control Officer · Operations Manager · General Manager

He carries a variety of EMS related certifications and is a graduate of the American Ambulance Association’s Ambulance Service Management course. He has been a resident of Merced County for the past 28 years and currently resides with his wife and children in Atwater.

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Rob Smith 20% Rob Smith, General Manager, BS, FP-C, EMT-P RIGGS Rob is a lifelong resident of Merced County, growing up in the Le General Manager Grand area. After completing his course work at Cal-Poly SLO, he returned to Le Grand as owner operator of the Le Grand Land and [email protected] Cattle Company LLC. Rob served as a Paid Call Firefighter for Merced County for over 15yrs, worked as LT Fire Apparatus Engineer for the California Department of Forestry and Fire Prevention for 5yrs. After finding his passion in Emergency Medical Service at Riggs Ambulance in 1998, Rob worked as an EMT 1 until completing the West Med Paramedic program in 2005. As a Paramedic, Rob served as a Field Training Officer (FTO), Field Supervisor, East Side Liaison, certified CISM counselor, CSTI certified HAZMAT instructor, HAZMAT Officer, Operations Manager, and now as the Riggs General Manager over seeing both Air and Ground Operations in Merced County.

In addition to Riggs Ambulance Service, Rob worked as an EMT and Paramedic for Turlock AMR, West-Med Monterey and 3yrs as a Flight Paramedic for PHI Air Medical Group LLC in Modesto. During this time Rob was the Vice President of Turlock Emergency Services Assoc. (TEMSA) for 14yrs, representing the EMTs, Paramedics, Flight paramedics, Flight Nurses and EMS Dispatchers in Merced County, Stanislaus County, and at Naval Air Station Lemoore. He continues to serve as a member of the Merced County MAC board (District 1), Merced County Emergency Medical Care Committee member and as a newly appointed commissioner of the Central California Alliance for Health.

Steve Crabtree 60% PROGRAM DIRECTOR SEMSA/RIGGS Stephen Crabtree, RN, CCRN, CFRN, CEN - is the Program Director for Program Director SEMSA/RIGGS Air and Critical Care Transport Program. He is Chief Flight Nurse responsible for the administration, operations, and physician - aviation interface with for bases in Merced County – RIGGS AIR and [email protected] Lassen County - SEMSA AIR. Starting with a basic EMT course 26 years ago, he found his passion in emergency and critical care medicine attending nursing school locally. Stephen has dedicated himself to advancing the practice of emergency and flight nursing serving in various leadership, instructor, mentoring positions committing to education and critical care practice including

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management and clinical experiences:

Shift Manager Progressive Cardiovascular Care Unit Coronary Critical Care Surgical Intensive Care Cardiovascular Intensive Care (Open Heart) Flight Nurse – MediFlight of California Medical Education Manager – Air Methods – Mercy Air Medical Base Manager – Air Methods – Mercy Air SEMSA/RIGGS Air & CCT – Program Director & Chief Flight Nurse Board Certified Flight Registered Nurse Board Certified Emergency Nurse Board Certified Critical Care Registered Nurse

He has primarily focused on helicopter and ground emergency critical care for the last 13 years serving the California Central Valley hospitals and public safety agencies. As the Program Director for SEMSA/RIGGS Air & CCT he has implemented and developed various operational policies and procedures working with hospitals, physicians, and emergency providers to improve service delivery to our communities. He continues to focus on advancing emergency medical practice in critical care transport and opening new helicopter/ ground service locations in northern California.

Eric Rudnick, MD 30% Eric’s career has spanned over 23 years in emergency medicine. He SEMSA/RIGGS has completed an Emergency Medicine Residency at Michigan State Medical Director University and is board certified in Emergency Medicine and EMS Medicine. He is an active fellow with the American College of EMS [email protected] Physicians and the American Academy of Emergency Medicine. He has successfully completed the prestigious California Healthcare Foundation Fellowship for Medical Leadership. For many years, Eric has sat on the State of California Emergency Medical Advisory Committee. Since 2005, he has been the Medical Director of the Northern California EMS Agency (NORCAL) covering six counties and is a County Health Officer. His passion is teaching EMS students and he is the Medical Control Officer for Medical Disaster Preparedness in the State’s Northern California disaster response.

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DeeAnn Dion 15% Our Clinical Director comes to us with a well-rounded background in SEMSA/RIGGS EMS. As a volunteer EMT first responder for a small rural Director of Clinical Services community it became clear early on that EMS was to be her chosen career path. DeeAnn began her professional EMS career in 1990 [email protected] with REMSA (Regional Emergency Medical Services Authority) where, as an EMT Intermediate she advanced to hold the following positions: Paramedic, Paramedic Preceptor, Flight Paramedic, Operations Supervisor and Director of Operations. DeeAnn is an actively practicing critical care flight paramedic certified in California and Nevada. DeeAnn spends her off time sailing, scuba diving, paddle boarding, skiing, road biking and enjoying backyard gatherings with family and friends.

Jimmy Whitworth 30% Jimmy Whitworth started his EMS career at age 16, joining the RIGGS Modesto Fire explorer program. He attended EMT school at 17 years CQI Coordinator old through Ceres Adult School. At 18 he was hired at American Medical Response (Stanislaus County) as an EMT. He attended [email protected] Paramedic school and transitioned into a full time Paramedic position. In January, 2013 he was offered a full time Flight Paramedic Position with Mercy Air/Air Methods and later as a full time Flight Paramedic with Riggs Ambulance service. During his employment with Mercy Air he served as a Clinical Base Supervisor. Jimmy currently serves as the CQI Coordinator in a full time position with RIGGS.

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G. 2.6 BIDDER’S EXPERIENCE, SERVICES

2.6.1 FAA part 135 Experience

Air Methods is the sixth largest certificate in the United States; our flight hour breakdown is the following for rotor- wing flight hours by category:

Air Methods Flight Hours

160,000 140,000 120,000 100,000 80,000 60,000 40,000 Number of Hours 20,000 0 2015 2014 2013 2012 VFR operaons 143,701 129,830 136,242 147,027 SPIFR operaons 4,089 1,161 1,330 1,204 NVG operaons 48,731 37,238 43,571 36,408

2.6.2 Primary RW Aircraft

The primary RW aircraft assigned for this bid is a Bell 407 helicopter (Tail # N184AM, Serial # 54044). The Bell 407 is a four-blade single-engine, civil utility helicopter; a derivative of the Bell 206L-4 Long Ranger. The 407 uses the four-blade, soft-in-plane design rotor with composite hub developed for the United States Army's OH-58D Kiowa Warrior instead of the two-blade, semi-rigid, teetering, rotor of the 206L-4. The Bell 407 is frequently used for corporate and offshore transport, as an air ambulance, law enforcement, electronic news gathering and movie making.

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General characteristics of the Bell 407

• Crew: 1 pilot • Capacity: Air Ambulance configuration for 1 pilot, Nurse, Paramedic and patient. Max hook capacity 1200 kg (2645 lb). • Length: 41 ft 8 in • Rotor diameter: 35 ft 0 in • Height: 11 ft 8 in • Disc area: 962 ft² • Empty weight: 2,668 lb • Useful load: 2,347 lb • Max. takeoff weight: 6,000 lb • Powerplant: 1 × Allison 250- C47B turboshaft, 813 shp (606 kW) Bell 407 currently utilized in Merced Co Performance

• Maximum speed: 140 knots • Cruise speed: 133 knots • Range: 324 nmi • Service ceiling: 18,690 ft

Interior of Bell 407

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2.6.3 Back-Up RW Aircraft

Air Methods utilizes regional spares to back up primary aircraft for both scheduled and un-scheduled maintenance events. Mercy Air 31 is the primary back up helicopter and regional back up helicopters are readily available and will be onsite within 12 hours.

The primary back-up RW Aircraft is Mercy Air 31 based in Modesto, CA. Tail # N113AM, Serial # 54027

The regional back-up RW Aircraft is Air Methods “spare”. Tail # N224AM, Serial # 54070

2.6.4 Aviation Personnel

All Minimum credentials, qualifications, and clinical experience of proposed aviation personnel are documented in the Medical Operations Manual included with this submission (Pages 19 – 25).

Pilot Staffing Air Methods’ full-time dedicated pilots work a seven day on, seven day off rotation, and the schedule is posted 60 days in advance via a web-based schedule. Pilot duty-times and rest times are compliant with the FAA regulations 135.63, 135.263 and 135.267—for each of these requirements. Air Methods tracks the duty-time to show compliance through a web-based tracking program called ‘411’.

Float and Relief Pilots Float and relief pilots get a local area orientation that is focused on a map recon and actual training, covering where the most used hospitals are, and where the noise sensitive areas are. We currently have 3 Relief pilots in the Region and are increasing that number to 6. We have a number of float pilots that volunteer to do workovers at other bases.

Air Methods recommends having the pilot shift change occur prior to the medical crew shift change to ensure the base is flight-ready as the medical crew starts their new shift. For example, if the medical crew shift change is at 0730, Air Methods would define the pilot shift time start at 0715.

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Location Specific Training Upon completion of initial training, and prior to a pilot being assigned duty at the designated flight program, an extensive base orientation is completed. This consists of a comprehensive review of local program procedures as well as day and night flights to familiarize pilots with terrain, communication procedures, airspace requirements and local hazards. The local orientation training for Air Methods’ pilots includes the following subjects for pilots beginning to work in an area:

1. Local organization policies and procedures 2. Ground and flight safety operations 3. Local flying area – between three to five hours in area to include multiple hours at night a. Local water flight operations will be addressed in the local flying area training b. To include specific airports and helipads frequently utilized by the Program 4. Local area communications 5. Local area maintenance

The Local Flying Area Curriculum can be found in Attachment # 7

Minimum Pilot Qualifications Pilot in Command Visual Flight Rules (VFR) Program: • 2000 total flight hours with minimum of 1500 flight hours in category • 1000 hours PIC in category • 500 turbine (If less, an experience review will be made by certificate management.) • 100 hours unaided night time as PIC (50 hours of unaided can be substituted by 100 hours of NVG time, but cannot be reduced below 50 hours of unaided time.) • 50 hours total actual or hood instrument time in category (for a RW candidate who is FW rated, 100 hours or greater of FW actual or hood Instrument time can reduce the required instrument time to 25 hours)

Instrument Flight Rules (IFR) Program: • 2500 total flight hours with minimum of 2000 flight hours in category • Remainder is the same as VFR minimums with the exception of the following: Must have 75 hours of actual or simulated instrument time, at least 50 hours of which were actual flight, including at least 20 hours in actual instrument conditions in category. (For a RW candidate who is FW rated, 100 hours or greater of FW Instrument time can reduce the required instrument time to 50 hours)

Mountainous Terrain Orientation Air Methods evaluates each pilot on their previous work experience and flight time in experience in mountainous

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areas. In initial training, mountain flying techniques are covered. In our Local Area Orientation, we give pilots some exposure to all areas that they will be flying in.

Air Methods uses an FAA Approved Flight Training Program. Under that program, Air Methods meets or exceeds all regulatory training requirements.

Training Standards Pilot in Command (PIC) – will be trained in accordance with the appropriate aircraft annex standards, and Commercial Pilot Standards, demonstrating mastery of the aircraft with successful outcome of each task performed never seriously in doubt. Any task selected by the check airman during a practical test shall be evaluated in its entirety. The pilot shall demonstrate good judgment and crew resource management, while displaying single-pilot competency. The ground portion of the practical test must be accomplished before the flight portion. Second in Command (SIC) – SIC pilots shall be trained and evaluated to the same standard as PICs.

Facilities Normally, training will be conducted at Air Methods Corporation facilities, in a classroom. On occasions, when it is warranted, an Training with Mercy Hospital personnel exportable training package may be used at locations other than an Air Methods Corporation Training Department classroom.

Authorized Instructors Ground training, flight training, and the appropriate written, oral, and flight competency / proficiency tests will only be administered by crewmembers who have satisfactorily completed the FAA approved Air Methods check airman / training captain training program, and have those duties listed as authorized assignments in their pilot record. A representative from the Air Methods Human Resource Department may teach Operator Specific Basic Indoctrination. Designated Air Methods management personnel or other designated personnel may conduct

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designated training modules, e.g., Crewmember Training, Communication Specialist Training.

An Air Transport Ground Instructor (ATGI) may conduct medical crew training. NVG medical crew training may be conducted by an ATGI that has been qualified to instruct on NVGs.

Initial New Hire Training This training category is for personnel who have no previous experience with Air Methods (newly hired personnel). However, it also applies to personnel employed by Air Methods who have not previously held a flight crewmember duty position. Initial new-hire training includes basic indoctrination training and training for a specific duty position and aircraft type. Except for a basic indoctrination curriculum segment, the requirements for initial new-hire and initial equipment training are the same. Since initial new-hire training is usually the RIGGS Air Flight Crew training employee’s first exposure to specific company methods, systems, and procedures, it must be the most comprehensive of the six categories of training. For this reason, initial new-hire training is a distinct, separate category of training and should not be confused with initial equipment training. Initial equipment training is a separate category of training.

Initial Equipment This category of training is for personnel who have been previously trained and qualified for a flight crewmember duty position by Air Methods (not new hires) and who are being reassigned for the following reason:

Flight crewmember is being assigned to a different flight crewmember duty position on a different aircraft type and the flight crewmember has not been previously trained and qualified for that flight crewmember duty position and aircraft type.

Transition Training This category of training is for a flight crewmember who has been previously trained and qualified for a specific flight crewmember duty position by Air Methods and who is being reassigned to the same flight crewmember duty position on a different aircraft type. If the different aircraft is not in the same group, initial equipment training is

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the applicable category of training.

Upgrade Training This category of training is for a flight crewmember who has been previously trained and qualified as an SIC by Air Methods and is being reassigned as a PIC, to the same aircraft type for which the flight crewmember was previously trained and qualified.

Recurrent Training This category of training is for a flight crewmember who has been trained and qualified by Air Methods, who will continue to serve in the same duty position and aircraft type, and who must receive recurring training and/or checking within an appropriate eligibility period per 14 CFR Part 135.

Requalification Training This category of training is for a flight crewmember who has been trained and qualified by Air Methods but has become unqualified to serve in a particular flight crewmember duty position on an aircraft type due to not having received recurrent ground or flight training and/or a required proficiency check, flight check, line check, or competency check within the appropriate eligibility period. Requalification training is also applicable in the following Routine inspection and service situations: If a crewmember fails a check ride in one aircraft, that crewmember cannot fly in revenue service in another aircraft until the crewmember’s qualification has been re- established.

Flight Simulator Training Training is conducted in simulators and actual aircraft dependent on device/aircraft availability, but Air Methods is authorized to conduct all required training and checking (Excluding 14 CFR Part 135.299 Line checks) in Flight Safety’s FAA Certified Full Motion Level D Flight Simulators. Air Methods BH407, AS-350, and EC-130 will also be trained in Flight Safety Full Motion Level D simulators upon the completion of Flight Safety’s Denver Learning Center.

In 2015, Air Methods entered into a comprehensive long-term agreement with Flight Safety International to provide four Level-D qualified full-motion simulators for the new Learning Center in Colorado set to open in 2016. Air Methods is setting a new standard for helicopter safety by insisting on Level-D qualified simulator-based training for its pilots who fly single and twin-engine helicopters.

Mechanic Staffing

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Full time base/aircraft dedicated Mechanics work a guaranteed 40 hours a week and are on-call. Mechanics are onsite daily to perform inspections and maintenance. Mechanics are not permitted to work more than 14 cumulative hours in a 24 hour period; for example, if a mechanic works 10 hours from 7AM to 5PM then goes home and is called back in at 7PM, they may only work an additional 4 hours. This restriction may be waived by a maximum of 2 hours providing the project can be completed, verbal approval of the assigned Regional Maintenance Director has been given, and safety is not compromised. Following extended maintenance of 12 to 14 continuous hours, it is recommended that a mechanic should be scheduled for an uninterrupted rest period of at least 8 hours. A mechanic should be relieved from duty for at least 24 consecutive hours following 10 consecutive extended duty days (14 cumulative hours of aircraft maintenance activity in a 24 hour period).

2.6.5 Medical Crew

All minimum credentials, qualifications, and clinical experience of proposed medical flight crews are documented in the Medical Operations Manual included with this submission (Pages 19 – 25).

Additionally, a full description of the medical crews clinical and safety related initial and ongoing training can be found in the Medical Operations Manual (Pages 229 – 249).

Medical crew members work a fixed schedule consisting of two 24 hour shifts per week. Flight Paramedics work on the helicopter. Critical Care RNs work a combination of helicopter and ground CCT shifts. All shifts are scheduled from 0700 to 0700.

Initial New Hire Training This training category is for personnel who have no previous experience with Air Methods (newly hired personnel). However, it also applies to personnel employed by Air Methods who have not previously held a flight crewmember duty position. Initial new-hire training includes basic indoctrination training and training for a specific duty position and aircraft type. Except for a basic indoctrination curriculum segment, the requirements for initial new-hire and initial equipment training are the same. Since initial new-hire training is usually the employee’s first exposure to specific company methods, systems, and procedures, it must be the most comprehensive of the six categories of training. For this reason, initial new-hire training is a distinct, separate category of training and should not be confused with initial equipment training. Initial equipment training is a separate category of training.

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and aircraft type.

Requalification Training This category of training is for a flight crewmember who has been trained and qualified by Air Methods but has become unqualified to serve in a particular flight crewmember duty position on an aircraft type due to not having received recurrent ground or flight training and/or a required proficiency check, flight check, line check, or competency check within the appropriate eligibility period. Requalification training is also applicable in the following situations: If a crewmember fails a check ride in one aircraft, that crewmember cannot fly in revenue service in another aircraft until the crewmember’s qualification has been re-established.

Medical Crew Aircraft Safety Training In addition to annual on-site training conducted by Air Methods, Air Methods uses an on-line tool known as “LINK” for all required annual recurrent training for air medical crewmembers. These modules cover all safety topics required by the FAA to maintain our SMS Level 4 status as well as CAMTS standards for accreditation.

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Additionally, RIGGS maintains a web-based “dashboard” that Air/CCT crews utilize to submit all required daily forms via an electronic format. These forms are automatically sent to the Program Manager for review. After each response, the Air/CCT crew is required to submit a Debriefing Form. Other forms available via the dashboard are:

• Links to EMS Resources • Patient Care guidelines • Reference guides • Electronic forms for scheduling, Peer Review, Evaluation forms and other employee related tasks • Aircraft checklists • Health & Safety form • Blog that is utilized to get information to all crews, on or off duty • And many other links and forms useful to the Air Crews.

Crew Dashboard displaying AIR/CCT Tab

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2.6.6 Service Delivery Plan (SDP)

Mercy Air is a division of Air Methods serving California communities. Since 2006 Mercy Air has been providing air medical services to Merced County as ‘Mercy Air 32’ based at the Merced Regional Airport. To advance the community needs, services provided in Merced County, and the surrounding region; Mercy Air continued the legacy program established by Medi-Flight and fully committed resource support from the Modesto base location ‘Mercy Air 31’ at Memorial Medical Center.

Mercy Air, Air Methods, and RIGGS Ambulance have consistently collaborated and strategized to meet the ever changing needs of the communities in Merced County. To maximize resources and ability to deliver emergency and critical care transport services, Riggs entered a partnership with Air Methods and Mercy Air on January 1, 2015. As detailed in the Executive Summary, this unique partnership offers a new service delivery model previously unknown to this region integrating AIR, ALS, BLS, and CCT ground ambulance service RIGGS with Medi-Flight 1 for the entire county.

The new partnership transitioned ‘Mercy Air 32’ into what is now ‘RIGGS AIR 1’. The base of operations remains centralized in Merced County at the Merced Regional Airport to continue to meet compliance standards within established response guidelines. Using the extensive emergency medical ground transport experience of Riggs combined with the air transport experience of Air Methods/Mercy Air, the current all-inclusive operational delivery model in Merced County is another example of the continued commitment to provide the highest level of care with the most appropriate mode of transport for patients of any acuity and need.

The first division of our new advanced model of care delivery RIGGS Air 1 - Bell 407 begins with the RIGGS Air providing emergency scene and critical care air transport through the Merced Dispatch Center. By utilizing local dispatch resources, RIGGS Air is able to maintain local area operational knowledge, resources available at any given time, and crew activation for improved readiness and response.

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Improved communication also carries over into patient care as RIGGS Paramedics and EMT’s on ground ambulance who can immediately communicate with the RIGGS Air crew for patient updates or plan of care before arrival. The RIGGS Air Program has established itself in the surrounding region by enhancing the long-held working relationship with neighboring ground EMS programs. RIGGS Air has been utilized under mutual aid agreements when regional systems become overwhelmed demonstrating Mercy Air/Air Methods/Riggs partnership’s commitment and willingness to cooperate at any level when asked to provide assistance.

The second unique division is our ground Critical Care Transport (CCT) Program. Air Methods/Mercy Air/Riggs have been able to integrate specialized, highly trained Flight Nurses and Flight Paramedics into the ground CCT program allowing for rapid response to emergency requests for transport. This critical need was identified in Merced County with weather patterns commonly preventing aircraft from transporting the critically ill and injured or RIGGS AIR BASE - Merced Airport simply no aircraft availability leaving outlying hospitals or ALS ground ambulances with critically ill patients needing rapid transport without a resource to fulfill that need.

The CCT Program includes one Critical Care Registered Nurse assigned a quick response vehicle (QRV) available to immediately respond to emergency transport requests of any acuity level at surrounding medical centers rendezvousing with a RIGGS ALS Ambulance to facilitate transport.

Under this program there are two response vehicles ‘RN-1’ (Primary Unit) and ‘RN-2’ (Support/Management Unit) being operated; each unit is fully equipped with the exact equipment located in our helicopter which allows us the ability to put the very same advanced skilled provider at the bedside with the same critical care equipment and capability in any weather or circumstance 24 hours a day, 365 days a year.

With positive feedback and successful expansion of services to fulfill needs, the CCT program has continued to develop into an integral part of critical care services in Merced County with local RIGGS CCT - RN1 area hospitals now relying on the specialized skill set brought to the bedside by RIGGS CCT Staff. For example, Mercy Medical

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Center Merced is expanding the cardiac interventional capability to improve services and survivability for patient in Merced County. A vital component of the interventional program is the ability to rapidly transport any ‘procedural emergency’ or patient who is too ‘critically unstable’ being placed on intra-aortic balloon pump therapy which is used as a bridge device to emergency surgical intervention at specialized medical centers all within a standard 90 minute window.

Riggs was called upon to provide this specialized transport capability in Air and CCT services being the first in this region to provide such transports. After 8 months of planning and specialized education, both Air and CCT division successfully provided transports for Mercy Medical Center to meet California Department of Public Health Standards

Additional specialized areas continue to evolve including High Risk Obstetrics Transports with RIGGS Air and CCT Staff being trained on a newly purchased Tocodynamometer which allows continuous fetal and maternal monitoring during transport.

Further integration of the Air and CCT program is the ability of helicopter flight crew members to convert to emergency ground transport if needed. Current standards with other community based flight programs do not allow a mechanism for providing response if a flight request is declined. Identifying this as a critical need for our hospitals within Merced County needing to transfer a patient regardless of service limitations, Riggs Air Intra-Aortic Balloon Pump Transport Medical Crew has the ability to provide emergency ground CCT services in conjunction with the RN1 and RN2 Registered Nurses. Having this capability has made a considerable improvement in transporting those critically ill or injured patients (stable or unstable) to a higher level of care for the best chance of survival.

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Because of the standardized advanced procedures and Patient Care Guidelines for Riggs Air and CCT crew members, they may also be called upon to assist Riggs Ground Ambulance Units with mass casualty incidents, hazardous materials events, medical requests (if closest unit), or patients who may require advanced critical care on-scene (ex: rapid sequence intubation or surgical airway).

Included in the Air Methods/Mercy Air/Riggs Air partnership is the ability to provide immediate back-up aircraft alternative from Mercy Air 31 in Modesto or the Air Methods Regional Spare frequently staged at Air Methods hangers at Merced Airport.

The practice of providing support to the Merced Base established during Medi-Flight operations is carried on today.

For instances when Riggs Air 1 is committed on another request, Mercy Air Dispatch (AIRCOMM) is immediately contacted by the Merced Communications Center for back-up response from Mercy Air 31 in Modesto into Merced County. If both aircraft are unavailable or committed to requests, the nearest most appropriate aircraft is contacted for utilization with preference to CAMTS accreditation.

Programs immediately surrounding Merced County for mutual aid response include:

PHI – Modesto Airport REACH – Stockton CALSTAR - Gilroy

PHI – Columbia Airport SkyLife – Fresno/Madera

Physical Locations:

Riggs Air & CCT Base (Merced Airport) 1398 Falcon Wy. Merced, CA 95341

Air Methods Maintenance Hangar (Merced Airport) Mechanics Offices 44 MacReady Dr. Merced, CA 95341

Mercy Air 31 (Memorial Medical Center) 1700 Coffee Rd Modesto, CA 95355

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On occasions when the aircraft is undergoing extended maintenance, inspections, or has experienced a mechanical event, Air Methods has a dedicated back-up 407 Aircraft which can be immediately utilized to sustain air transport services.

Weekly communication between Air Methods/Mercy Air/Riggs Air Pilots, Mechanics, and Managers assure planned maintenance is scheduled appropriately to prevent any out of service time at the Merced Base.

The final facet of the service delivery plan is outreach with hospitals, public safety agencies, and the community we serve.

Outreach includes aviation safety education, landing zone training, transport capabilities of the Riggs Air and CCT program, community events, health and safety promotion, hospital staff education, community events and gatherings.

Air Methods, Mercy Air, and Riggs Air are committed to providing exceptional patient care services to the communities of Merced County. This partnership has dedicated extensive resources to achieve the over-all goal of serving rural areas and continuing to improve upon the established legacy program in Merced County. Since January 1, 2015 the Service Delivery Plan has demonstrated the effectiveness of our response to the needs of our community, the patients we serve, and we look forward to continuing this progressive delivery model.

2.6.7 Readiness and Response

Air Methods / SEMSA commit to continue to staff Riggs Air 1 at our Merced Airport base 24/7 with a qualified pilot and crew as outlined in our proposal.

Air Methods / SEMSA encourages all of our staff and crews to move with a sense of purpose, but keeping safety as the priority in everything that we do. Air Methods / SEMSA provides realistic ETAs based on average response times, but Air Methods / SEMSA does not compromise safety.

Air Methods and SEMSA coordinate all aviation maintenance and training activities with respect to the needs of the Merced County EMS system first. We coordinate the repositioning of Mercy Air 31 and backup aircraft to minimize out of service time and to remain in a response-ready mode.

Air Methods has demonstrated through experience (10 years serving Merced County under contract) that we maintain a high degree of reliability with a in-service rate of 97% or higher. In-service rates are tracked and trended monthly for all Air Methods programs and scrutinized to identify any opportunities for improvement.

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Additionally, Air Methods/Mercy Air Service, Inc. and now Riggs Air 1 have maintained a high degree of compliance every month for 10 consecutive years under contract with Merced County. We have never consistently fell below the 90% compliance threshold.

There is no substitute for demonstrated experience.

Crew Staffing and Readiness

Please refer to included Medical Operations Manual Flight and CCT Response Readiness Policy found on page 186

Maintenance Support Air Methods is currently utilizing Approved Aircraft Inspection Programs (AAIP) for all aircraft. These programs are developed from the aircraft/engine manufacturer’s requirements as well as any additional requirement from regulation or modifications. These inspections are tracked and monitored utilizing a robust software system with the Air Methods information system (RAMCO). RAMCO is the primary system utilized for tracking scheduled maintenance and aircraft parts and equipment. RAMCO has been utilized by Air Methods since July 2011 and is a fundamental component of our maintenance processes within the company from forecasting maintenance to parts and equipment tracking.

Some features of the RAMCO system include:

Parameter Value Tracking Ramco Aviation Suite facilitates tracking of rotor parameter values at various levels. In addition to Flight Hours & Landings tracking, additional parameters like rotor brakes, rescue brake hoists, rotor coast downs, engine starts, hobbs meter, Retirement Index Number (RIN) etc. can be tracked. Maintenance programs for components can also be tracked for trackable parameters. Position Base Schedule Schedules which change based on the attachment of the part to a location in the rotorcraft Tracking can be effectively managed by using position based schedules available in Ramco Aviation Suite. This feature provides flexibility to have different schedules for the same task in part to adjust automatically based on its current location on the rotor craft. Offline Field Maintenance Ramco Aviation Suite is now providing a solution to overcome the challenge for operators System having remote operations. Asynchronous mode of data transfer is also possible: which implies that the same data can be updated from the main and field bases and system takes care of merging the data. Moreover, data transfer can happen using any media like email, USB drive etc. Auto data transfer using file transfer protocol is also supported which handles movement of extracted data movement from field to main bases and vice versa. The most exciting part is that the entire data transfer can be at the click of a button.

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Power by Hour (PBH) PBH model is gaining wide acceptance as there is no capital cost involved and replenishment and maintenance is typically managed by OEMs. Many operators enter PBH agreements for Engines/APU/Landing Gears with OEMs where payment is made on monthly basis based on the usage of the part. Ownership of these parts lies with the OEMs and the repair is done by the OEM with zero exchange costs. Ramco Aviation Suite manages PBH agreements for any part type on a supplier on a specified list of parts for specific tail numbers. In addition multiple contracts with different OEMs can be modeled with programs which aim to boost part availability and lower customer risk. The system also tracks core due part which needs to be returned to the supplier and tracks the ownership of the part in the inventory. Electronic Flight Bag Ramco Electronic Flight Bag (EFB) offers flight crew an on-board flight management system to effectively manage on-board tasks. By integrating with downstream processes like maintenance, billing delivers significant savings on time and money. It makes paperless flying a reality. Ramco Electronic Flight Bag is packed with a wide range of features to help with on-board tasks like:

• Navigation Planning • Weight & Balance Calculations • Reference Manuals, Checklists, Route Maps, Runway Maps etc. • Discrepancy Reporting and Tracking • Integrated with Maintenance and Billing Modules

Air Methods has also created a Maintenance Control and Support Program, or “MCAS”, to provide corporate-wide oversight, including our field based A&P mechanics, to track aircraft status, aid in technical support, aid in coordination of support services to include outside vendors and OEM interface, and ensure the highest level of compliance with Federal Regulations.

Specific duties of our MCAS include:

Tracking (monitoring) aircraft maintenance events in real-time. Monitors out-of-service (OOS) aircraft utilizing maintenance 411 tracking system and the company’s KPI dashboard as well as appropriate Minimum Equipment Lists (MEL).

Identifies safe, approved, and effective solutions to technical support requests from maintenance operations in accordance with applicable regulatory guidelines and the company's maintenance and inspection programs.

Air Methods’ Maintenance Control and Support, “MCAS”, is designed to reduce maintenance discrepancies and to aid in the coordinated response to any failures by doing the following:

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• Act as liaison with Maintenance, Compliance, Materials, Engineering and Reliability, Aircraft Records, Operations, and regional maintenance management as required to assist Regional maintenance management with effective and expedient solutions to return AOG aircraft to service.

• Communicates with OEMs, the FAA, vendors, and internal departments, in order to assist regional maintenance management in the acquisition of approved maintenance and/or repair data, OEM advice, approval or deferral solutions as appropriate.

• Provides troubleshooting advice to maintenance crews by reference to related publications and/or historical data or through communication with subject matter experts, internal and external, as required.

• Assists other departments in the determination of appropriate support priorities.

• Ensures maintenance control processes and procedures are implemented and feedback provided for continuous improvement.

The maintenance technicians assigned to the program will be required to resolve maintenance discrepancies and/or failures to provide the best aircraft availability. Regional management has oversight and supports base maintenance activities to include a daily conference call with corporate support teams.

2.6.8 Interface with the Merced County EMS Dispatch Center

Air Methods/SEMSA is already fully integrated with the Merced County EMS Dispatch Center as we have been providing air ambulance services in Merced County since January 1, 2015. The RIGGS EMS Dispatch Center is scheduled to expand their capabilities in the 1st quarter of 2017 with the addition of 5 new dispatch stations. The new dispatch center will provide all communications and logging via the Zoll RescueNet CommCAD software.

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Specialized training has been provided at no cost to the County for all Merced County EMS Dispatch Center (RACC) personnel.

Operational Control Center (OCC)

Air Methods operates an FAA required and approved Operations Control Center (OCC). With a staff of twenty Operational Control Specialists, the Air Methods OCC monitors certificate compliance 24 hours a day, seven days a week without any out-of-service time. These capabilities include three stations with recorded phone lines through the HiPath phone system, backup IP phones, traditional phone line, independent satellite phone (with direct-to-cockpit communications), FMS displays, as well as radio systems that are connected with Air Methods’ communication dispatch center. All of these systems are capable of being seamlessly “rolled- over” from the primary to the backup OCC at a moment’s notice by the Air Methods’ IT department. All Operational Control Specialists Air Methods OCC are trained in accordance with the FAA regulatory requirements.

Additionally, Riggs Ambulance Communications Center follows the orientation process below:

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SEMSA RIGGS AIR – DISPATCH ORIENTATION COURSE

Purpose: to provide aviaon, safety, transport limits, and regulaon educaon for emergency dispatchers involved with transferring Air Ambulance ﬂight requests through the Merced Emergency Communicaons Center. (4 hours) I. Orientaon to Program Structure a. SEMSA/RIGGS Leadership b. AIRMETHODS Leadership c. Divisions of AIRMETHODS II. Local Area Structure and Requests a. SEMSA i. Air/CCT Medical Crews & Pilots b. RIGGS i. Air/CCT Medical Crews & Pilots III. Aviaon Safety – Rules Governing Air Ambulances a. FAA Part 135 / Part 92 b. Pilot Mission Acceptance Process i. Risk Matrix / Weather Minimums / Crew Factors / Aircra Factors c. CAMTS Standards d. AIRMETHODS Safety Management System e. Crew Member Safety Training IV. Air Ambulance Incident Plan a. Post Accident Incident Plan b. Safety Concerns for SEMSA / RIGGS & Pilot Turn-Downs i. Weather ii.Risk Matrix iii. Crew Factors iv. Aircra Factors v. Aborts In-Flight c. Radio Communicaons During Incident i. AirCrew / AIRCOMM ii.SEMSA /RIGGS Leadership Noﬁcaons V. Air Ambulance Crash Causes and Dangerous Condions a. Weather i. Weather Shopping Requests b. Mechanical Events c. Bird Strikes d. Brown-Outs / White-Outs e. Landing Zones f. Landing at Hospitals g. Paent Deterioraon / Combave Paents h. Lost Contact with Aircra / Missing Aircra VI. Review

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2.6.9 Base of Operations

The Base of Operations for the Air Methods / RIGGS EMS Helicopter will be at the Merced Municipal Airport. We have built an Air Base that houses the pilot, nurse and paramedic. The Air Base has separate sleeping quarters for all personnel, kitchen and bathroom facilities and a day room. Radio, telephone and internet capabilities have been installed and are fully operational. The Bell 407 EMS Helicopter is located on a landing pad adjacent to the Air Base for immediate response.

Adjacent to the RIGGS Air Base is the Merced City Fire Department which houses the Crash Rescue Unit. Also adjacent to the RIGGS Air Base is the operations and deployment center for RIGGS Ambulance which houses the Merced County EMS Communications Center.

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2.6.10 Quality Management

Please refer to the included Medical Operations Manual (Pages 254 – 268).

Air Methods utilizes the Air Methods Total Quality Management Plan (TQM). The TQM plan is a multi-disciplinary activity including aviation, maintenance, safety, communications, business and clinical operations.

The goals and objectives of the TQM plan are:

• Create a process in which all members have input and vested interest in achieving the goals set forth by Air Methods;

• Inspire all members as firmly committed to the belief that safety and optimum patient care are core values of both management and staff personnel;

• Create an atmosphere of teamwork between management and staff personnel in which mutual goals are supported;

• Employ the principles of a “Just Culture” to improve the safety and quality of our services through the management of risk, threat, and error;

• Create an atmosphere where team members freely report error without fear of retribution.

• Dismantle obstacles that prevent team members from admitting mistakes, speaking out, and implementing new ideas into the system;

• Inspect and monitor the entire process for deficiencies rather than focusing on mistakes after the fact, making changes in the process as needed;

• Complete outcome studies that result in process improvement activities and continuing education activities.

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CQI Plan

The RIGGS CQI Plan is provided as Attachment #6.

Loop Closure

The main tool utilized by Air Methods in the TQM process is the "Dashboard" where data is collected and benchmarked. The quality indicators selected for tracking and trending focus on safety, business development, aviation, logistics, communications, education and training, employee wellness, equipment, and maintenance. Air Methods ensures an appropriate utilization review process through trending, tracking, and loop closure.

Additionally, RIGGS provides Continuous Quality Improvement (CQI) with a full-time CQI Director and a full-time CQI Coordinator. The CQI Team maintains a 100% audit of all Patient Care Records utilizing the Physio Control HealthEMS platform.

Internal Quality Assurance Monitoring

Procedures for quality assurance monitoring include retrospective patient chart audits, monitoring and evaluation of seldom used skills and quality indicators that focus on system or individual performance improvements.

Patient Care Records (PCRs) are audited for provider skill proficiency, high-level of patient care and protocol compliance. The CQI Coordinator audits 100% of all Merced County EMS indicators. In addition, any indicators developed through the Plan-Do-Study-Act process (PDSA), internal Core Measures or system initiatives all receive 100% chart review. All charts with ALS2 or medication administration are reviewed within 48 business hours of the call and feedback is provided directly to the attending crew through our electronic messaging and CQI Feedback system. As an additional check to ensure compliance with all protocols, policies and procedures, the CQI Director performs further audits and may refer issues of concern to HealthEMS CQI Dashboard the local Medical Director or will consult with the CQI Coordinator to address issues. Finally, the local Medical Director reviews all Sentinel Events and may be involved in the resolution of identified clinical issues.

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We provide feedback to employees on the quality of patient care report (PCR) documentation. Special attention is directed to incidents where clinical decision-making requires use of high risk, seldom used skills (intubations, needle thoracotomy, etc.) Those cases where a patient is directed outside the local system for specialty care such as STEMI or trauma triage for appropriateness of decision making.

We integrate the “Health EMS” ePCR documentation system into a searchable database along with our dispatch database to evaluate individual and system-wide quality indicators. Traditional indicators include intubation success rates, defibrillation attempts, compliance with trauma triage criteria, aggressive airway management of children with altered mental status (aggressive management of children’s airways focuses on good basic airway management – not necessarily advanced techniques), and individual paramedic percentages for patients released at-scene and released against medical advice. This robust database allows for a wide variety of query filters for in-depth data mining.

Quality indicators are data that prompt in-depth review of events in operations. Our indicators are developed as part of the monthly internal CQI Committee meetings and feedback from our healthcare partners such as first responders, hospitals and other allied healthcare providers. Seldom- used skills (i.e. intubation, cardiac arrest management, trauma care, etc.) are constantly monitored to insure appropriate decision making and skill competency. We carefully evaluate any new prehospital treatments, equipment and interventions to insure they would be appropriate for use in the Merced EMS system using the PDSA cycle

External Quality Improvement Monitoring

The Merced County Continuous Quality Improvement Reporting policy #650.00 is the basis for external Quality Improvement Monitoring. Through cooperative efforts by representatives from RIGGS, the Merced County EMS Agency, local hospitals, and first-responder agencies, this monitoring process works well to document and track interagency sentinel quality issues. A unique level of trust and collaboration between RIGGS, the County EMS Agency and the Base Hospital allow for an open and objective CQI process that brings combined expertise to the task of improving the quality of service provided.

Linkages between evaluations and in-service training are divided into either individual employee issues or system- wide trends, and then incorporated into our continuing education programs. This creates a direct and intentional link between issue identification and continuing education, which is critical for improvement to occur.

2.6.11 EMS Personnel Safety Training

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required by the FAA to maintain our SMS Level 4 status as well as CAMTS standards for accreditation.

Please see the Attachment #3 – Crew Member Training Curriculum.

2.6.12 Safety and Risk Program

In May 2013, Air Methods became the first helicopter company and air medical provider to successfully reach the highest and final level (Level 4) of the FAA’s voluntary Safety Management System (SMS) program—this is the continuous improvement stage. With this milestone, Air Methods became the first helicopter operator and air medical provider to join the elite company of major commercial air operators to reach this level.

Currently, Air Methods is transitioning to the SMS Voluntary program governed by Part 5 of the Federal Aviation Regulations (FARs.) Having previously attained Level 4 of the FAA SMS Pilot Project allowed Air Methods to achieve one of the most robust safety systems within the air medical industry.

Through the continuous improvement process, we continue to actively pursue and invest in technology, systems and training while encouraging a culture of compliance. Currently, Air Methods conforms to SMS Part 5 of the Federal Aviation Regulations (FARs).

The continuous improvement status and transition to Part 5 Voluntary Program conformance was achieved in part by actively participating in FAA voluntary safety programs. The Part 5 Voluntary Program requirements are identical to those required by major passenger commercial airlines and cargo operations.

Starting in 2007, Air Methods has been systematically implementing five of the six voluntary safety programs. With the addition of level D flight simulators, Air Methods will begin participation in the Advanced Qualification Program (AQP)—the sixth and final voluntary safety program sponsored by the FAA.

The following descriptions detail these programs:

Aviation Safety Action Program (ASAP), Maintenance Safety Action Program (MSAP)—The first FAA program implemented, ASAP/MSAP is a voluntary non-punitive employee safety reporting for pilots and the mechanics. This program provides tremendous information for Air Methods to implement solutions to common issues across its entire fleet and operations.

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Line Operations Safety Audit (LOSA) Program—A proactive program which monitors line pilots’ performance through ride-along observations by a peer (line pilot trained in threat and error management observation methods.) Air Methods is currently the only helicopter operator in the world to participate in this program in partnership with the FAA sanctioned LOSA Collaborative.

Internal Evaluation Program (IEP)—This is a high level program that assures FAA, state and local regulatory compliance and additionally monitors efficacy and efficiency of company processes and systems.

Flight Operations Quality Assurance (FOQA)—Program to improve operational safety through the use of recorded flight data. The FOQA program is a voluntary safety program recommended by the National Transportation Safety Board (NTSB) and codified by the Federal Aviation Administration (FAA) to increase safety and maintenance effectiveness, reduce operational costs and mitigate risks. All digital data captured is protected by federal law from disclosure.

In 2014, Air Methods reached an agreement with its pilots, and the union representing them, to proceed with the Flight Operations Quality Assurance (FOQA) program. The memorandum of understanding was signed by both the union and Air Methods on August 1.

With this milestone, Air Methods is one of the first air medical provider and emergency medical services companies to commence the FOQA program, joining several Part 121 air carriers. Appareo Vision 1000

This program improves flight safety by providing more information and greater insight into the total flight operations environment through automated recording and analysis of data generated during flight operations. Analysis of FOQA data can reveal situations that require improved operations, training, maintenance procedures, practices, equipment, and infrastructure.

In 2013, Air Methods purchased 150 Appareo Vision 1000 flight data monitoring devices with picture cameras. Through the FOQA program, the Vision 1000 will capture event sets such as time, date, longitude, latitude, altitude, ground speed, vertical speed, heading, pitch and roll attitude, pitch, roll and yaw rates, as well as normal, lateral, and longitudinal acceleration. Currently, the FOQA program is expanding at Air Methods with installations of Appareo Systems Vision 1000s to encompass the Air Methods’ fleet of aircraft and is actively feeding information and trends discovered through FOQA data back to the pilot training program and operational safety groups.

Air Methods’ Operational Control Center currently monitors air speed, altitude and heading, coupled with

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proprietary software which alerts the center to risks such as deteriorating and hazardous weather, deviations from planned flight route, and potential incursions into Restricted or Temporary Restricted Airspace, and approaching duty time limits.

Air Methods’ Voluntary Safety Programs (VSPs) are a critical component of its Safety Management System (SMS). A key tenet of the Air Methods SMS is the ability to effectively leverage the outputs of these various programs in a coordinated fashion. Fundamental to the coordination of VSPs and the furthering of a just safety culture at Air Methods are the pilot protections afforded by all programs.

Specifically, the FOQA program provides pilot protections that prevent identification by anyone but a gatekeeper. If a pilot is identified and subsequently contacted, the gatekeeper does not judge the pilot’s performance. Rather they will gather information surrounding the event in question in an attempt to find the underlying cause(s) of the event.

At a corporate level, the OPEIU Local 109 FOQA Letter of Agreement ensures FOQA Data or FOQA Information developed as a result of flight data monitoring will not be used for a discipline/discharge action against a pilot. Additionally, the corporation accrues protections of the data from Freedom of Information Act requests and possible demands for the data in the legal discovery process once it is part of the FOQA via FAA Order 8000.81 and 14 CFR part 193 (Protection of Voluntarily Submitted Information).

Current Air Methods processes for analysis consist of event validation and statistical analysis utilizing CAE CAE Flightscape flight analysis Flightscape flight data monitoring software and JMP statistical software. Once validated, FOQA data is subject to review by a team consisting of the FOQA manager, gatekeepers and fleet representatives; results of the event review can then be released for use in data analysis and sharing.

Data releases to outside parties (customers) can be permitted with the use of a non-disclosure agreement which will contain guidance for intended use and handling of the information. The non-disclosure agreements, once established, will not expire if the customer has an ongoing need for data.

Air Methods is looking forward to further developing safety data sharing and benchmarking for our customers. FOQA data provides valuable addition to Air Methods SMS and has proved to be a useful tool in furthering Helicopter Air Ambulance safety.

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Level D Flight Simulators—In 2015, Air Methods entered into a comprehensive long-term agreement with FlightSafety International to provide four Level-D qualified full-motion simulators for the Learning Center in Colorado. Air Methods is setting a new standard for helicopter safety by insisting on Level-D qualified simulator- based training for its pilots who fly single and twin-engine helicopters.

The Learning Center will be equipped with FlightSafety built Level-D qualified simulators for the Bell 407GX, Airbus AS350 B3, Airbus EC-130 T2, and Airbus EC-135. The Airbus EC-135 is currently being used by Air Methods at FlightSafety’s Learning Center in Dallas, Texas and will be the first simulator to be installed in Denver.

In addition to the FAA sanctioned programs, Air Methods bases its safety performance on the use of several “best practices.” These aviation industry best practices include Corrective Action/Preventative Action (CAPA) tracking, Root Cause Analysis (RCA), Accident Incident Damage Malfunction Operations Reports (AIDMOR) and Safety Risk Management (SRM) processes.

Program Data Integration & Benchmarking

True Level 4 SMS function is dependent not only on participating in the validated safety programs but also on the integration of data collected by each of the respective programs. Air Methods’ Safety System utilizes a variety of analytical methods to quantify and benchmark safety program data in an effort to neutralize risk before it creates significant operational hazards.

Examples of integrated safety research projects that have been completed include an analysis of lift time variability and occurrence of pre-flight error, Human Factors Analysis and Classification (HFACS) of Root Cause Analysis data and Observed compliance changes pre & post program management.

Elements of Air Methods’ safety performance are measured through a number of Key Performance Indicators (KPIs). These KPIs include aircraft incident/damage and near event tracking, aircraft damage cost, CAPA closure time, IEP base audit completions and findings, and safety reporting rates. Air Methods is committed to continuous improvement and is optimistic that the combination of technology enhancements and a mature SMS can reduce our accident potential by as much as 90%.

Please see the following written descriptions of each accident and incident experienced by the company in addition to policy changes:

2013

Seminole, OK – Ice ingestion and engine flameout. Findings revealed engine inlet barrier filters were collecting water/ice. Post-accident policies around filter installation and pre-flight were changed to more closely monitor icing potential.

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Grand Prairie, TX – Loss of control during simulated hydraulic failure. Following this event, AS350 startup checklists were modified to better access pedal function in the event of a hydraulic failure.

2014

Temple, TX – Hard landing – no action

Dayton, OH – Aircraft fenestron housing scraped hangar door during landing. Pilot received additional training, no policy change required.

2015

Superior/Globe, AZ – AS350B3, N74317, 2 fatalities, 1 Injury, aircraft substantially damaged. Aircraft impacted terrain while maneuvering near Superior, Arizona. The commercial pilot and flight nurse sustained fatal injuries and the flight paramedic sustained serious injuries.

Frisco, CO – AS350B3E, N390LG, 1 fatal, 2 serious injuries, on public relations flight. Aircraft impacted the upper west parking lot 360 feet southwest of the Summit Medical Center helipad (91CO), Frisco, Colorado. A post-impact fire ensued.

St. Louis MO – EC-130, N356AM, 1 fatality, aircraft destroyed. While approaching a helipad, aircraft struck the side of a building and impacted into the parking lot. NTSB investigation is looking at winds as a potential contributing factor.

2016

Jasper/Gainesville, GA – AS350B2, N561AM, no Injuries, damaged, tail boom separated from aircraft. Currently under investigation by NTSB.

Air Methods employs a Regional Safety Director who is available for any safety related consultation. The Corporate Safety Department is committed to providing the safest environment for our employees and partners.

Air Methods has implemented a variety of changes and process improvements as a result of internal findings including initiatives to include the use of AS350 Level B full motion flight simulator for AS350 pilots to perform exercises that cannot really be performed in the actual aircraft where circumstances surrounding an engine failure that would potentially require an auto rotation.

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Final Accident Reports can be found on www.NTSB.gov. Follow the links to Investigations then to Aviation finally sort by date of incident.

Worker’s Compensation Losses for Air Methods (a publicly traded company) can be found at: https://www.sec.gov/cgi-bin/browse- edgar?company=&CIK=AIRM&filenum=&State=&SIC=&owner=include&action=getcompany

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Worker’s Compensation Loss History for RIGGS:

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Worker’s Compensation Loss Listing for RIGGS:

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2.6.13 Patient Safety Program

Patient Safety is integrated into all transport activities and continuously monitored by leadership staff through Quality Management/Continuous Improvement Program outlined in the Medical Operations Manual included with this submission (Series 800, Pages 254 – 268).

In Addition, see SEMSA SAFETY MANAGEMENT SYSTEM AND RISK MANAGEMENT POLICY BELOW:

SUBJECT: SAFETY MANAGEMENT SYSTEM AND RISK MANAGEMENT DIVISION: AVIATION EFF. DATE: January 1, 2015 REV. DATE: CAMTS: 04.04.00 CAAS:

PURPOSE: This organization is committed to providing a safe and healthy working environment for its employees and patients. This policy is aimed at minimizing then exposure of our employees, patients, and other agencies and personnel that work with RIGGS Air to all safety risks. Safety is our highest priority for all flight and non-flight related activities. RIGGS Air management will ensure adherence to safety principles by all staff and aviation personnel. RIGGS Air management will ensure an environment that promotes safety and personal responsibility for safety. POLICY: To accomplish this objective, all employees are expected to work diligently to maintain safe and healthy working conditions and to adhere to proper operating practices and procedures. The RIGGS Air medical, administrative, and aviation staff have a duty and a responsibility to maintain safe practice in all aspects of the work environment. RIGGS Air management will act immediately to mitigate any non-compliance, adverse safety or risk situation. PROCEDURE: A. It is the responsibility of all RIGGS employees and aviation personnel to: 1. Exercise maximum care and good judgement at all times to prevent accidents and injuries.

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2. To adhere to all policies that provide for safety safeguards and to report all failures to adhere to safety policies. 3. Report unsafe conditions, equipment, or practices to supervisory personnel in a timely manner. 4. Use safety equipment provided by the company at all times. 5. Observe conscientiously all safety rules and regulations at all times. B. To ensure the appropriate condition exists to maintain a safe environment, policies and procedures, reporting systems and committees have been implemented by Air Methods Corporation (aviation vendor) to accomplish the following: 1. Training and orientation standards are established through the aviation vendor by virtue of their Safety Program and documented in the Air Methods Corporation (AMC) G.O.M., Training Manual and Safety Management System policy. 2. Support all requirements of law regarding safety. 3. To prevent aircraft incidents 4. To minimize damage and severity of injury as a result of aircraft accidents. 5. To prevent damage to non-company property and personnel as a result of aircraft operations. 6. To incorporate flight safety and noise abatement planning into all flight activities. 7. To provide safety training to all employees 8. To identify and eliminate all hazardous conditions 9. To maintain an accident-free environment through active participation in the aviation vendor’s accident prevention program. 10. To provide an Operational Control Policy that includes: a. Risk assessment tool that establishes guidelines for acceptance of request for service. AMC G.O.M. Risk Assessment Program and SMS policy. b. Search and Assist Policy. AMC G.O.M. Search and Rescue Flight Limitations. c. Safety Program. AMC SMS policy. C. Medical Decision Making for flight acceptance: 1. The medical staff members will have daily base briefings and a joint briefing to include: a. Weather forecast b. Aircraft readiness c. Planned flights

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d. Medical readiness e. Communications Center information 2. After the pilot’s ‘go - no go’ decision, the medical staff will use the information from the briefing and the risk assessment provided on every flight by the pilot, the fatigue assessment tool as well as any information pertaining to the flight to make a ‘go – no go’ decision. 3. The medical staff will use the medical information received from the Communications Center to determine a ‘go – no go’ decision for medical reasons. 4. The medical staff or aircraft communications center will not discuss patient medical information with the pilot that may influence the pilot’s decision to accept or decline a flight. 5. The Medical staff may determine that a call back to the requestor may be necessary prior to departure to receive an in-depth report on the patient’s condition.

2.6.14 Patient Rights, Medical Care

Please see Attachment # 4 – Patient Rights

Please see Attachment # 4 – HIPAA Policy and Patient’s Rights for both Air Methods and RIGGS.

Please see included SEMSA/RIGGS Air Operations & Critical Care Transport Guidelines June 2016 textbook.

2.6.15 Insurance Coverage

Air Methods meets or exceeds all required insurance coverage limits as outlined in Section 2.4

Please see Attachment #5 – Insurance Certificates

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H. 2.7 PATIENT CHARGE MASTER AND PAYMENT COLLECTIONS

Please see Envelope #1 – Patient Charge Master and Payment Collections Omni Advantage Hospital staff and EMS personnel may be hesitant to utilize a helicopter due to the high cost associated with air medical transport. Air Methods offers a solution to help alleviate the out-of-pocket exposure to the family of someone who is transported by air with the Omni- Advantage membership program. Families may be unaware that the majority of commercial insurance providers look at air medical transport as an out-of- network expense, oftentimes leaving the patient responsible for a portion of the bill. The benefit of being a member of Omni-Advantage is that Air Methods will accept what insurance pays as “payment in full” for any medically necessary transport if transported by an Air Methods Community-Based Services Division subsidiary, OMNI Advantage brochure and the member will not be balance billed for the remaining flight costs associated with the transport. The Omni- Advantage membership can be purchased for a $49 annual fee for those individuals and families who currently have medical insurance. However, those that are uninsured can have the same financial peace-of-mind for a $99 annual fee. Discounts are available for groups of ten or more. The coverage map below displays the state that are included in our Omni-Advantage Plan: See our webpage at www.airmethods.com/omniadvantage for our terms and conditions.

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Omni Care provided in red colored states

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I. Financial Statement

Please see Envelope #2 – Financial Statement

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Attachment #1 – Section 2.5.2, 2.5.5 - Air Methods Patient Transport Service History

From a single contract in 1980, we have grown to become the most experienced air medical transport company in the nation. That year, Mr. Roy Morgan purchased a Bell 206 helicopter and became the Partner of Choice for a hospital in Grand Junction, Colorado.

Over the years, we have fortified our market presence through a variety of acquisitions. In 1997, we purchased Mercy Air Services, San Bernardino, Calif., and in 2000, ARCH Air Medical, St. Louis. Two years later in 2002, we made our largest acquisition, Rocky Mountain Helicopters (RMH), Provo, Utah. In 2007, we acquired CJ Systems Aviation Group, West Mifflin, Pa., 2011 Omniflight Helicopters, in 2012 Sundance Helicopters, and in 2013 Blue Hawaiian.

Timeline

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1980 Air Methods is established with 1st rotor-wing Hospital Program

1983 Air Methods 1st fixed-wing Hospital-Based Program

1991 Air Methods becomes publicly traded

1993 Completion of proof of principle for U.S. Army UH60Q helicopter multi-mission interior

1995 Products Division established

1996 Award of first contract for UH60Q (later HH60L) military helicopter multi-mission interiors

1997 Mercy Air Service, Inc. acquisition; commencement of community-based operations

2000 ARCH Air Medical Service, Inc. acquisition

2002 Rocky Mountain Holdings, LLC acquisition

2005 Deployment of aircraft to Hurricane Katrina response

2007 CJ Systems Aviation Group acquisition; Establishes Operational Control Center

2008 Enters FAA SMS program; Deploys METI mobile medical simulator; Customer Service Advisory Board (CSAB) celebrates fifth anniversary 2009 Acquires Omniflight’s Atlanta/North Georgia operations; Purchases three advanced aviation training devices; Successfully completes U.S. Department of Defense CARB certification; The Air Methods Medical 2010 Application (TAMMA) launchesCelebrates 30-year anniversary; Exits Level 1 FAA SMS voluntary implementation program; Completes First Bell 429 Helicopter Medical Interior; Director of Safety earns industry’s prestigious Jim Charlson safety 2011 award; Unveils new EZ Lift 1300 Patient StretcherExits Level 2 FAA SMS voluntary implementation program; Air Methods purchases United Rotorcraft Solutions; RSQ911 Solutions customer survey tool deployed; DirectCall Transfer Center expands; acquires 2012 Omniflight Helicopters; selected as Preferred Provider of air medical transport to Community Health Begins use of full motion simulation for all AS350 pilots; National Training Center for all new hire pilots Systems Hospital Affiliatesmedical and mechanics opens; purchases 42 new Eurocopter and Bell helicopters; completes acquisition of 2013 Sundance HelicoptersUtilizes FlightSafety’s EC135 Simulator; Reaches Highest Level in FAA’s Safety Management System Program; Successfully Renews DOD CARB Approval; Purchases 150 Appareo Vision 1000 Flight Data 2014 Monitoring Devices; Fully Equips Fleet with NVG Technology; Acquires Blue Hawaiian HelicoptersAwarded Contract to Provide Services to Haiti Air Ambulance; Acquires Baptist LifeFlight

2015 Develops ADM with RIGGS to provide Air Ambulances in Merced County.

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Attachment #2 – Section 2.5.3 - Air Methods Ops Specs and FAA Part 135 Air Carrier Certificate

AIR METHODS AIR CARRIER CERTIFICATE

Air Carrier Certificate

This certifies that

Air Methods Corporation 7301 South Peoria Street Englewood, Colorado 80112

has met the requirements of the Federal Aviation Act of 1958, as amended, and the rules, regulations, and standards prescribed thereunder for the issuance of this certificate and is hereby authorized to operate as an air carrier and conduct common carriage operations in accordance with said Act and the rules, regulations, and standards prescribed thereunder and the terms, conditions and limitations contained in the approved operations specifications.

This certificate is not transferable and, unless sooner surrendered, suspended, or revoked, shall continue in effect indefinitely.

By Direction of the Administrator

Effectlve Date:

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Attachment #3 – Section 2.6.11 - Crewmember Training Curriculum Segment

7301 South Peoria Street Englewood, CO 80112-4133

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Annex 22 – Crewmember Training Curriculum Segment

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County of Merced Request for Proposal #7144 Air Ambulance Services

Published by: Air Methods Corporation Corporate Publications ([email protected]) 7301 South Peoria Street Englewood, CO 80112

Document Owner: Chief Pilot, Flight Operations Department Copyright © 2015 Air Methods Corporation All Rights Reserved. No part of the contents of this document may be reproduced or transmitted in any form by any means without the written permission of Air Methods Corporation.

Air Methods, the Air Methods Logo and AirCom are registered trademarks of Air Methods Corporation. NOTE: Please refer to the List of Effective Pages for FAA approval.

Record of Approvals

DATE APPROVED:

FAA PRINCIPAL OPERATIONS INSPECTOR

ANM-FSDO-03

County of Merced Request for Proposal #7144 Air Ambulance Services

Change Summary

This change summary table lists the major changes made to each revision, not all changes. Actual changes are indicated by revision bars throughout the manual.

Rev Rev Section Title Summary of Changes Requestor Date No. Date Title Received IR 08/10/07 Original 1 08/10/07 No changes 2 11/01/07 No changes 3 02/15/08 No changes 4 05/29/08 No changes 5 01/31/09 No changes 6 11/30/09 Terms and Definitions updated. 7 06/10/11 No changes. 8 01/31/2 No changes. 9 06/07/13 Terms and Definitions updated. Dale Hannaly Reformatted manual into Corp Pubs standard Corp Pubs 05/30/14 template Dale Hannaly 10 Requalification Training Element added Changed Assistant Chief Pilot to Senior Aviation Training Corp Pubs Manager All Pages Updated company logo Corp Pubs 03/26/15

Copyright Page Updated copyright page to reflect current year 2015; Corp Pubs 03/26/15 added Document Owner Change Summary Updated Corp Pubs 03/26/15

Revision Control Manual Revisions and Control – retitled and updated Corp Pubs 03/26/15 All Pages Added NTSB trade secret footer statement to every page Chief Pilot 03/26/15

11 09/25/15 Overall Corrected form naming convention to precede with Corp Pubs 03/26/15 TFxxx including forms location 2.Basic Indoc 2.3.1 – 14 CFR Par 91 – deleted entire sub section ACPs 08/28/15 2.4.1 – Organization – removed actual name associated ACPs 08/12/15 with job title 2.16 – Module 15 – Replaced HEMS reference with HAA DO 03/26/15 8. NVG Training 8.2 – Terms & Definitions – deleted and referred to PTP ACPs 08/28/15 Program main manual

County of Merced Request for Proposal #7144 Air Ambulance Services

Record of Revisions

For owners of hard copy manuals: After inserting each revision, record the Revision Date, the Date Posted, and your initials next to the appropriate revision number.

Rev No. Rev Date Insertion Date By IR 08/10/07 1 10/19/07 2 11/01/07 3 02/15/08 4 05/29/08 5 01/31/09 6 11/30/09 7 02/28/11 8 01/31/12 9 06/07/13 10 05/30/14 11 09/25/15 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

County of Merced Request for Proposal #7144 Air Ambulance Services

List of Effective Pages

PAGE STATUS DATE PAGE STATUS DATE PAGE STATUS DATE I Revision 11 09/25/15 34 Revision 11 09/25/15 II Revision 11 09/25/15 35 Revision 11 09/25/15 III Revision 11 09/25/15 36 Revision 11 09/25/15 IV Revision 11 09/25/15 37 Revision 11 09/25/15 V Revision 11 09/25/15 38 Revision 11 09/25/15 VI Revision 11 09/25/15 39 Revision 11 09/25/15 VII Revision 11 09/25/15 40 Revision 11 09/25/15 VIII Revision 11 09/25/15 41 Revision 11 09/25/15 1 Revision 11 09/25/15 42 Revision 11 09/25/15 2 Revision 11 09/25/15 3 Revision 11 09/25/15 4 Revision 11 09/25/15 5 Revision 11 09/25/15 6 Revision 11 09/25/15 7 Revision 11 09/25/15 8 Revision 11 09/25/15 9 Revision 11 09/25/15 10 Revision 11 09/25/15 11 Revision 11 09/25/15 12 Revision 11 09/25/15 13 Revision 11 09/25/15 14 Revision 11 09/25/15 15 Revision 11 09/25/15 16 Revision 11 09/25/15 17 Revision 11 09/25/15 18 Revision 11 09/25/15 19 Revision 11 09/25/15 20 Revision 11 09/25/15 21 Revision 11 09/25/15 22 Revision 11 09/25/15 23 Revision 11 09/25/15 24 Revision 11 09/25/15 25 Revision 11 09/25/15 26 Revision 11 09/25/15 27 Revision 11 09/25/15 28 Revision 11 09/25/15 29 Revision 11 09/25/15 30 Revision 11 09/25/15 31 Revision 11 09/25/15 32 Revision 11 09/25/15 33 Revision 11 09/25/15

County of Merced Request for Proposal #7144 Air Ambulance Services

Purpose

This manual has been prepared to describe the pilot training program and policies and procedures of Air Methods for training in all company owned and operated aircraft.

Distribution

This manual will be provided at the following locations and be readily available to Air Methods’ personnel:

• Flight Standards District Office (FAA) • The director of operations will have a copy of this manual at their office. • A PDF (portable document format) file of the manual is posted on the Air Methods intranet (Flightdeck > Resources > Corp Pubs > Flight Operations Publications) and available for review by all Air Methods’ employees.

Manual Revisions and Control

The Corporate Publications Department oversees the creation and revision of Air Method’s controlled documents/manuals. Department managers may submit suggestions and corrections for incorporation into the Pilot Training Program, Annex 22 manual by emailing Corporate Publications at [email protected] or by contacting the manual’s owner directly with recommended changes. Corporate Publications will save suggested updates for the next revision of the manual and coordinate with the manual owner to incorporate changes. Changes will be summarized in the change summary table and indicated throughout the manual by revision bars. Each revision will have a revision number and date, which will be reflected in the List of Effective Pages (LOEP). Revisions will be consecutively numbered. Revisions to this manual will be routed internally to identified stakeholders for review and feedback.

This manual requires FAA approval prior to release. Revisions to this manual must be routed for AMC internal review and FAA approval prior to distribution. This manual cannot be published or distributed to end users prior to formal submission to and approval by the FAA.

Corporate Publications will post a master electronic copy of the most current revision of this manual on Flightdeck (as well as on the FAA Extranet site). Always refer to the electronic posted copy on the corporate publications site for the most current version of this manual.

For further details on manual revisions and control, access the Document Control Manual on FlightDeck.

County of Merced Request for Proposal #7144 Air Ambulance Services

1. General

1.1 Authorized Instructors Persons designated as check airman / instructor or designated PAM, AAM, or Air Transport Ground Instructors.

1.2 Testing/Checking Written or oral exams will be conducted for each module except Operator Specific Module 1.

2. Basic Indoctrination

2.1 Objective To introduce new-hire medical crewmembers (Air Methods or Customer employees) to Air Methods manner of conducting operations in air transportation, policies, procedures, organization, administrative practices, and basic aviation knowledge. (14 CFR 135.329, 135.331, 135.349, 135.351, and Inspectors Handbook 8900.1) Hands on equipment training will be accomplished every 24 months in conjunction with Recurrent Flight Training and annotated on form TF115, Emergency Drill Training Form (5273), (a sample of this form can be found in the Appendix of the PTP manual – the actual form is on Flightdeck> Resources> Corp Forms (AMC)). During the alternate 12-month periods, the emergency drill training may be accomplished by pictorial presentation or demonstration.

2.2 Module 1 Air Methods Organization 2.2.1 Module 1 – An overview of company history, brief overview of management structure, operational concepts, policies and types of operation. Employee standards and rules of conduct (Air Methods’ employees only)

2.3 Module 2 Code of Federal Regulations 2.3.1 14 CFR Part 1 Definitions and Abbreviations 2.3.1.1 Pilot in Command 1. Has final authority and responsibility for the operation and safety of the flight. 2. Has been designated as pilot in command before or during the flight. 3. Holds the appropriate category, class, and type rating, if appropriate, for the conduct of the flight. 2.3.1.2 Crewmember 1. Crewmember means a person assigned to perform duty in an aircraft during flight time.

County of Merced Request for Proposal #7144 Air Ambulance Services

2. Per 8900.1, Volume 4, Chapter 5, Section 4, Paragraph 4-964B – Medical Personnel Considered Crewmembers – Medical personnel are considered crewmembers when assigned duties such as but not limited to “assisting in seeing and avoiding other aircraft, evaluating a landing site, coordinating with ground personnel at a landing site, and emergency shutdown of aircraft systems in a crash”.

2.3.2 14 CFR Part 119 1. Definitions – On-Demand Operations (119.3) a. On-demand operation means any operation for compensation or hire that is one of the following: 1) Passenger-carrying operations in which the departure time, departure location, and arrival location are specifically negotiated with the customer or the customer's representative that are any of the following types of operations: 2) Common carriage operations conducted with airplanes, including turbojet- powered airplanes, having a passenger-seat configuration of 30 seats or fewer, excluding each crewmember seat, and a payload capacity of 7,500 pounds or less, except that operations using a specific airplane that is also used in domestic or flag operations and that is so listed in the operations specifications as required by §119.49(a)(4) for those operations are considered supplemental operations 3) On-demand operations in accordance with the applicable requirements of Part 135, and shall be issued operations specifications for those operations in accordance with those requirements. a) Any rotorcraft operation. i. On-demand operations in accordance with the applicable requirements of part 135, and shall be issued operations specifications for those operations in accordance with those requirements.

2.3.3 14 CFR Part 135 – Applicability (Part 135) 1. This part prescribes rules governing: a. On-demand operations of each person who holds or is required to hold an Air Carrier Certificate or Operating Certificate under part 119. b. Each person employed or used by a certificate holder conducting operations under this part c. Each person employed or used by an air carrier or commercial operator under this part to perform training, qualification, or evaluation functions.

County of Merced Request for Proposal #7144 Air Ambulance Services

d. Each person who is on board an aircraft being operated under this part. 2. Rules Applicable to Operations subject to Part 135 (135.3) a. Each person operating an aircraft in operations under Part 135 shall — While operating inside the United States, comply with the applicable rules of Part 135. 3. Emergency Operations (135.19) a. In an emergency involving the safety of persons or property, the certificate holder may deviate from the rules of this part relating to aircraft and equipment and weather minimums to the extent required to meet that emergency. b. In an emergency involving the safety of persons or property, the pilot in command may deviate from the rules of this part to the extent required to meet that emergency. c. Each person who, under the authority of this section, deviates from a rule of this part shall, within 10 days, excluding Saturdays, Sundays, and Federal holidays, after the deviation, send to the FAA Flight Standards District Office charged with the overall inspection of the certificate holder a complete report of the aircraft operation involved, including a description of the deviation and reasons for it. 4. Flight Locating Requirements (135.79)

a. Each certificate holder must have procedures established for locating each flight: 1) Provide at least the information required to be included in a VFR flight plan; 2) Provide for timely notification of an FAA facility or search and rescue facility, if an aircraft is overdue or missing. 3) Provide the location, date, and estimated time for reestablishing communications, if the flight will operate in an area where communications cannot be maintained. b. Flight locating information shall be retained at the certificate holder's principal place of business, until the completion of the flight. 5. Carriage of Cargo (135.87) a. No person may carry cargo, including carry-on baggage, in or on any aircraft unless: 1) It is carried in an approved cargo rack, bin, or compartment installed in or on the aircraft; 2) It is secured by an approved means; or 3) It is carried in accordance with each of the following: a) For cargo, it is properly secured by a safety belt or other tie-down having enough strength to eliminate the possibility of shifting under all normally anticipated flight and ground conditions, or for carry-on baggage, it is restrained so as to prevent its movement during air turbulence. b) It is packaged or covered to avoid possible injury to occupants.

County of Merced Request for Proposal #7144 Air Ambulance Services

c) It does not impose any load on seats or on the floor structure that exceeds the load limitation for those components. d) It is not located in a position that obstructs the access to, or use of, any required emergency or regular exit, or the use of the aisle between the crew and the passenger compartment, or located in a position that obscures any passenger's view of the “seat belt” sign, “no smoking” sign, or any required exit sign, unless an auxiliary sign or other approved means for proper notification of the passengers is provided. e) It is stowed in compliance with this section for takeoff and landing. 6. Manipulation of Flight Controls (135.115) a. No pilot in command may allow any person to manipulate the flight controls of an aircraft during flight conducted under Part 135, nor may any person manipulate the controls during such flight unless that person is: 1) A pilot employed by the certificate holder and qualified in the aircraft; or 2) An authorized safety representative of the Administrator who has the permission of the pilot in command, is qualified in the aircraft, and is checking flight operations. 7. Briefing of Passenger before Flight (135.117) – See Module 16 for AMC / GOM specific requirements a. Before each takeoff each pilot in command of an aircraft carrying passengers shall ensure that all passengers have been orally briefed on — (shall be given by the pilot in command, a crewmember, or other qualified person designated by the certificate holder and approved by the Administrator): b. The oral briefing required must be supplemented by printed cards which must be carried in the aircraft in locations convenient for the use of each passenger, appropriate for the aircraft being operated.

2.4 Module 3 Air Methods’ General Operations Manual and Policies 2.4.1 Organization and familiarity with GOM sections applicable to medical crewmembers: 1. Director of Operations 2. Chief Pilot 3. Director of Maintenance

2.4.2 Oxygen Use (14 CFR 135.157,14 CFR 135.91; 49 CFR 175.8 and 175.9) a. Air Methods aircraft are equipped with oxygen delivery systems (liquid or gaseous) for medical use. Operations of these systems are in accordance with 14 CFR 135.91; 49 CFR 175.8 and 175.9. They are not considered HAZMAT. b. Aircraft maintenance is not allowed during refueling, including servicing of

County of Merced Request for Proposal #7144 Air Ambulance Services

oxygen, LOX or batteries (GOM, B17). c. Normal and emergency use of oxygen, if the flight is above 12,000 feet MSL 1) At cabin pressure altitudes above 12,500 feet (MSL) up to and including 14,000 feet (MSL) unless the required minimum flight crew is provided with and uses supplemental oxygen for that part of the flight at those altitudes that is of more than 30 minutes duration. 2) At cabin pressure altitudes above 14,000 feet (MSL) unless the required minimum flight crew is provided with and uses supplemental oxygen during the entire flight time at those altitudes; and 3) At cabin pressure altitudes above 15,000 feet (MSL) unless each occupant of the aircraft is provided with supplemental oxygen. 4) Pressurized cabin aircraft. (1) No person may operate a civil aircraft of U.S. registry with a pressurized cabin.

2.4.3 Flight Locating Air Methods has established the below procedures for VFR flight following (Flight Locating): 1. The Communications Specialist will enter the initial flight information on the Air Methods internet based Flight Log prior to aircraft departure. 2. When an aircraft lifts off on an assigned flight, communications will receive from the pilot or their designee, the number of people on board, fuel load remaining in flight time, destination, ETA, and risk assessment value. 3. Every 15 minutes into the flight, the pilot will give his/her present position in latitude and longitude or by ground reference and the remaining time left to the destination. Each position report will be entered on the Air Methods internet based Flight Log. If the pilot fails to call within 15 minutes the Communications Specialist(s) will call the aircraft and request an up-dated position report. NOTE: If the aircraft is equipped with an operable GPS based flight following system, such as Outerlink and the flight is continuously tracked by the Communications Center, the position reports are not required. 4. When landing is assured at the intended destination the pilot will notify the communications center by radio (or telephone after landing) of the landing time.

5. At the completion of the mission the flight will be “Completed” on the Air Methods internet based Flight Log. 6. If the pilot has to land for any unforeseen reason before reaching the intended destination, i.e.; malfunction or weather related, he/she will call the communication center either by radio or telephone. The pilot shall give their approximate location, reason for landing, estimated lift off time (if possible), and a revised ETA to the hospital or scene.

County of Merced Request for Proposal #7144 Air Ambulance Services

7. If the flight takes the aircraft out of the communication center radio range, then the pilot will give position reports to another facility (hospital, airport UNICOM, air medical program communication center, etc.) that is within radio range and request the position report be relayed to the appropriate communication center by telephone. 8. If, for any reason, the pilot knows he/she will be out of radio contact for an extended period of time, he/she will contact the communication center with reason and expected time of delay. 9. After 30 (thirty) minutes on a scene, or 45 (forty five) minutes for an inter-hospital flight, if the crew has not contacted the communication center with a liftoff time and an ETA back to the receiving facility, the Communications Specialist shall attempt to ascertain the status of the flight. The pilot will follow the above, as appropriate, for the return trip. 10. Air Methods’ aircraft on an IFR flight plan will file an IFR flight plan with the controlling agency. Flight Service Station or appropriate facility as required. Prior to takeoff and after landing the pilot-in-command will contact the appropriate communication center to advise of any updated information concerning the flight. This information will be entered by the Communications Specialist on the Air Methods internet based flight log. NOTE: Air Methods owned AirCom and ARCH Communications Centers who use Air Methods Approved flight following software are not required to complete the Air Methods internet based Flight Log as described in this paragraph.

2.5 Module 4 Administrative and Local Procedures Local administrative requirements

2.6 Module 5 Duties, Responsibilities per GOM 1. Supervise patient during fueling procedures (hot-engine operating and cold-engine shutdown) FAA 8900.1 Volume 4, Chapter 5, Section 3, paragraph 4-950, Chg. 22. 2. Assist the PIC during cabin emergencies (fire, medical equipment malfunction, etc.). 3. Assist the PIC during emergency egress. 4. Load and unload patient (hot-engine operating and cold-engine shutdown). 5. Secure medical equipment/baggage in the cabin compartment. 6. Assist with crowd control at landing areas, including acting as the tail rotor guard or briefing a ground emergency worker to as the tail rotor guard. 7. Perform a walk-around of the aircraft before flight. 8. Ensure that the EPU (External Power Unit) / APU (Auxiliary Power Unit) is disconnected after start. 9. Ensure cabin exits in cabin compartment are secure. 10. Assist the PIC during approach and landing. 11. Assist PIC with charts, approach plates, checklists, coordinates, and other reference material as appropriate.

County of Merced Request for Proposal #7144 Air Ambulance Services

12. Be able to perform an emergency aircraft engine shutdown in the event the PIC is incapacitated. 13. Perform normal and emergency operation of medical equipment.

2.7 Module 6 Air Medical Resource Management References: AC 120-51E, AC 00-64 1. Background – Air Ambulance Emergency Medical Service is a very demanding and time critical/mission orientated operation. One consistent priority that needs to be addressed by each individual air ambulance organization is the safety of the flight-crew, medical crew, patient passengers, and support personnel. No flight crew goes out anticipating the occurrence of an accident, and like most aviation accidents there is rarely a single event that is the cause of an accident. It is usually a multitude of contributing factors that lead to potentially catastrophic results. Preventing accidents is the responsibility of everyone involved and takes the dedicated involvement of all of the aviation and medical professionals involved in the operation to provide the public the safest possible air ambulance service. Remember, the patient does not get a choice of when or where they may have to take an air ambulance flight, the carrier and service involved, or even if they will take a flight. 2. Air Medical Resource Management has been conceived to enhance the safety culture within the Air Medical Community by promoting team cohesiveness and adaptation during change through management of all available resources. 3. AMRM is comprised of: a. Assertiveness – This is the ability to verbalize a series of “rights” that belong to every team member. Some of these “rights” include: the right to express feelings and ideas, the right to ask for information, and, most importantly, the ability to question decisions when in doubt. Assertiveness also includes achieving and maintaining a proper balance between respecting authority, practicing assertiveness, and recognizing when a crewmember is exercising assertiveness in an appropriate manner. Accomplishing the right task, at the right time, for the right reason, every time is necessary for effective AMRM. b. Communication – This is the means or process of exchanging information which conveys meaning from one team member to another. c. Complacency – This is a condition where a person is satisfied with a situation to the extent that a degradation of vigilance occurs. d. Human Factors – Human factors is the multidisciplinary field devoted to optimizing human performance and reducing human error. It incorporates the methods and principles of the behavioral and social sciences, engineering, and physiology and is the applied science that studies people working together in concert with machines. Human factors’ training embraces variables which influence individual performance and/or team or crew performance. Inadequate system design or inadequate operator training can contribute to individual human error that leads to system performance degradation.

County of Merced Request for Proposal #7144 Air Ambulance Services

Further, inadequate design and management of crew tasks can contribute to group errors that lead to system performance degradation. Human Factors entails a multidisciplinary effort to generate and compile information about human capabilities and limitations and to apply that information to equipment, systems, facilities, procedures, jobs, environments, training, staffing, and personnel management for safe, comfortable, effective human performance.

e. Situational Awareness – Situational Awareness is the accurate perception of the factors and conditions currently affecting the safe operation of the aircraft and crew. f. Team Members – are a group of independent individuals working together to complete a specific task. g. Teamwork – Is joint action by a group of people, in which each person subordinates his or her individual interests and opinions to the unity and efficiency of the group in order to complete the specific task at hand. h. Team Situation – This is maintaining a collective awareness across the entire team of important current and predictable job-related conditions.

2.8 Module 7 Aviation Terminology 1. ATC – Air Traffic Control 2. NDB – Non Directional Beacon 3. DME – Distance Measuring Equipment 4. VOR – Very High Frequency Variable Omni Range 5. GPS – Global Positioning System 6. RNAV – Area Navigation 7. IAP – Instrument Approach Procedure 8. Radar 9. Weather radar 10. IMC – Instrument Meteorological Conditions 11. VMC – Visual Meteorological Conditions 12. IFR – Instrument Flight Rules 13. VFR – Visual Flight Rules 14. Pitot tube – Airspeed measuring device 15. FSS – Flight Service Station 16. Restricted area 17. Prohibited area 18. TFR – Temporary Flight Restriction 19. MOA – Military Operations Area

County of Merced Request for Proposal #7144 Air Ambulance Services

2.9 Module 8 Weather Conditions Meteorology Reference: Aviation Weather Services AC 00-6A, Inspectors Handbook 8900.1 Volume 3, Chapter 23, Section 3 General Orientation – A basic understanding of turbulence, clouds, thunderstorms, and winter operations. 1. Fixed Wing Operations – Ground Icing and Frost – Pre-contamination Check (fixed wing) a. The Pre-takeoff Contamination Check is performed from the cockpit or cabin area, within 5 minutes of departure, visually checking upper surfaces and leading edges of wings, engine inlets and nacelles, windshield and windshield wipers. These areas are representative of the condition of the aircraft, and must be clean, and the aircraft in a condition for safe flight. The pre-takeoff contamination check is a critical ingredient in ensuring a safe departure and flight. It should be noted that under some weather or operational conditions, the time of effectiveness of FPD fluids may be less than 1 minute. Under those conditions, it is recommended that takeoff be delayed until the weather conditions abate, and then additional checks should be conducted just prior to initiating takeoff roll to achieve compliance with the clean aircraft concept. 2. Rotary Wing Operations a. Ingestion of ice and snow accumulated on the airframe may cause major engine damage and or power loss. There are a number of accidents documented that have involved major aircraft damage. b. Older turbo shaft engines with axial inlets are particularly susceptible to loss of power due to ice and snow ingestion. On the ground with the engine(s) operating at a low power setting, ice and snow can accumulate on the airframe cowl forward of the inlet, on the inlet lip, and inside the inlet. Under extreme conditions, usually when the rotorcraft is on the ground waiting for clear weather, the buildup of ice and snow can be enough to cause the engine(s) to lose power or fail completely if the ice or snow is ingested. On the ground with the engine(s) not operating, proper use of inlet inserts or inlet covers can eliminate the accumulation of snow, but these measures cannot fully guarantee that ice will not form in the inlet. Ice can develop in the inlet areas when water seeps into the inlet from rain or snow melting on a warm cowling, even when proper inlet protection is used. It never hurts to mention that snow and ice should not be removed by chipping or scraping, as this will cause damage. 3. Effect of Icing on Fixed Wing and Rotary Wing aircraft a. Structural icing refers to the accumulation of ice on the exterior of the aircraft and is broken down into three classifications; rime ice, clear ice, and mixed ice. For ice to form, there must be moisture present in the air, and the air must be cooled to a temperature of 0° C (32° F) or less. Aerodynamic cooling can lower the surface temperature of an airfoil and cause ice to form on the airframe even though the ambient temperature is slightly above freezing. Rime ice forms if the droplets are small and freeze immediately when contacting the aircraft surface. This type of ice

County of Merced Request for Proposal #7144 Air Ambulance Services

usually forms on areas such as the leading edges of wings, stabilizers or struts. It has a somewhat rough-looking appearance and a milky-white color. Clear ice is usually formed from larger water droplets or freezing rain that can spread over a surface. This is the most dangerous type of ice since it is clear, hard to see, and can change the shape of the airfoil. Mixed ice is a mixture of clear ice and rime ice. It has the bad characteristics of both types and can form rapidly. Ice particles become embedded in clear ice, building a very rough accumulation. Significant structural icing on an aircraft can cause aircraft control and performance problems. The formation of structural icing could create a situation from which the pilot might have difficulty recovering and, in some instances, may not be able to recover at all. 4. Post flight: The use of hangars on the road is encouraged if actual or forecast conditions exist that may adversely affect the “Clean Aircraft Concept” for departure. These conditions may include but are not necessarily limited to snow, blowing snow, ice, freezing rain, or extreme cold. 5. Thunderstorms and Turbulence a. Flying through thunderstorms of any intensity should always be avoided. However, certain conditions may be present that could lead to an inadvertent thunderstorm encounter. For example, flying in areas where thunderstorms are embedded in large cloud masses may make thunderstorm avoidance difficult, even when the aircraft is equipped with thunderstorm detection equipment. Therefore, pilots must be prepared to deal with an inadvertent thunderstorm penetration. At the very least, a thunderstorm encounter subjects the aircraft to turbulence that could be severe. The pilot and passengers should tighten seat belts and shoulder harnesses and secure any loose items in the cabin. b. Three stages of thunderstorms (All three stages may be present at the same time): 1) Cumulus stage 2) Mature stage 3) Dissipating stage c. Down Drafts / Up draft Intensities – Down drafts can reach up to 3,000 feet per minute. Conversely, updrafts can reach 6,000 per minute. d. Turbulence – Inflight turbulence can range from occasional light bumps to extreme airspeed and altitude variations that make aircraft control difficult. To reduce the risk factors associated with turbulence, pilots must learn methods of avoidance, as well as piloting techniques for dealing with an inadvertent encounter. To avoid turbulence associated with strong thunderstorms, circumnavigate cells by at least 20 miles. Turbulence may also be present in the clear air above a thunderstorm. 6. Inadvertent IMC a. General / Background – Inadvertent IMC is often combined with a CFIT (Controlled Flight into Terrain) accident. Conditions present may include deteriorating weather, and decreasing visibilities. The pilot often begins a slow descent and begins to

County of Merced Request for Proposal #7144 Air Ambulance Services

reduce airspeed to remain in VMC (Visual Meteorological Conditions). The time to avoid an IIMC event is now. The options are to turn around and proceed to the departure point, proceed to a different destination, or land the helicopter, or if the aircraft is equipped, file an IFR flight plan. b. Pre-Mission Planning is important to making timely decisions in flight and remaining aware of available options. c. Procedure: The priority and most important aspect of an IIMC procedure is to maintain aircraft control. Positive control of the aircraft with reference to instruments must take priority over all else. The pilot will be very busy, and may need your assistance with terrain and obstacle avoidance. In addition, you may be asked to assist with instrument approach charts and providing radio frequencies. The procedure called for by the GOM is: 1) Attitude (Level) 2) Heading (Turn only to avoid known obstacles) 3) Power (Adjust to climb power) 4) Airspeed (Adjust to climb airspeed) 5) Climb to the minimum safe altitude (MSA) to clear all obstacles in the area. 6) De-goggle when safely able (if appropriate). 7) Make all turns no greater than standard rate. 8) Contact appropriate Approach Control/Center and Declare an Emergency. Squawk 7700 when able; a) Report location, altitude, heading, fuel status, and number of persons on board. State that you are inadvertent IMC and b) Request assistance. 7. Winter Operations – Fog, Blowing Snow, Icing, Frost, Whiteout/Brownout, and Flat Light are all winter conditions that we confront. a. A thorough preflight inspection is extra important in temperature extremes. At extremely low temperatures, the urge to hurry the preflight of aircraft and equipment is natural, particularly when the aircraft is outside and adverse weather conditions exist. This is the very time to run the most thorough preflight inspection. b. Aircraft preheat. Low temperatures may cause a change in the viscosity of engine oils, batteries may lose a high percentage of their \ effectiveness, and instruments may stick. Because of the above, preheat of engines as well as the cabin before starting is desirable in low temperatures. Extreme caution should be used in the preheat process to avoid fire. The following precautions are recommended: 1) Preheat the aircraft by storing in a heated hangar, if possible. 2) Use only heaters that are in good condition. 3) Do not place heat ducting so it will blow hot air directly on combustible parts of the aircraft; such as, upholstery, canvas engine covers or flexible fuel, oil, and

County of Merced Request for Proposal #7144 Air Ambulance Services

hydraulic lines. c. If the country over which the flight is planned is such that a survival problem would be created in a forced landing, appropriate survival gear should be carried. Survival gear will vary with individual needs, temperature, and routes. Probably the most important piece of survival gear is the clothing of the aircraft occupants. Survival clothing should be worn as much as possible or kept handy so that if the aircraft is forced down and a fire ensues, the survival clothing will not be lost. d. Engine starts 1) Turbine engines can accumulate internal ice overnight and resist rotation when starting is attempted. With any indication of locked rotor, unusual noise or low RPM, the start must be aborted. The procedure here is fundamental. Always be aware that the rotors could freeze on any cold weather start and be alert enough to discontinue the start before damaging the engine. When weather forecasts include snow, ice, or sleet, engine cowl plugs for turbine engine outlet openings should be installed if the aircraft is to be exposed to the elements. e. In-flight Icing 1) Some Air Methods helicopters require a snow protection kit for the airframe engine inlet in order to successfully operate in falling and blowing snow. Operation in snow without the kit is prohibited and can be especially risky when hovering in snow and then transitioning to takeoff when weather conditions clear. Snow may accumulate on or in the engine inlet area during hover, and then be dislodged and ingested into the inlet during takeoff. Pilots should not believe they have escaped the danger following successful hover in snow with an unprotected inlet. If possible, land the aircraft immediately after the hover and thoroughly inspect the engine inlet prior to takeoff. If terrain will not allow an immediate safe landing, transition to takeoff as smoothly as possible when the weather clears with minimum application of engine power. Land and inspect the inlet area as soon as practical. Most rotorcraft are not approved for flight in known icing conditions, this true of all Air Methods Helicopters. For rotorcraft not approved for flight into know icing conditions, a pilot can expect icing any time when operating in visible moisture, such as fog, rain, or clouds, when the temperature is below 5° C or 41° F.

Pilots should be aware that icing is possible in these ambient conditions and should immediately leave the area of visible moisture or change to a warmer altitude (The warmer altitude may above and not necessarily below your current altitude). When winter flying conditions are eminent it is a good idea to review the RFM for operating limitations, and servicing requirements. Use manufacturer approved covers, plugs and tie-downs to protect exposed surfaces. The best solution to this is to hangar the aircraft. Ensure that all covers, and inlet plugs are removed before engine start, and perform a thorough inspection paying particular attention to those areas of the

County of Merced Request for Proposal #7144 Air Ambulance Services

aircraft that may accumulate snow and ice. Should detrimental weather conditions persist, it will mean that the aircraft will stay on the ground.

2.10 Module 9 Aviation Physiology Reference: Inspectors Handbook 8900.1 Volume 4, Chapter 5, Section 4 Air Ambulance Operations Training Program. 1. Types and Causes of Hypoxia - Hypoxia is a state of oxygen deficiency in the body sufficient to impair functions of the brain and other organs. Hypoxia from exposure to altitude is due only to the reduced barometric pressures encountered at altitude, for the concentration of oxygen in the atmosphere remains about 21 percent from the ground out to space. 2. Although deterioration in night vision occurs at a cabin pressure altitude as low as 5,000 feet, other significant effects of altitude hypoxia usually do not occur in the normal healthy pilot below 12,000 feet. a. Hypoxic Hypoxia b. Hypemic Hypoxia c. Stagnant Hypoxia d. Histotoxic Hypoxia 3. Signs and Symptoms of Hypoxia – From 12,000 to 15,000 feet of altitude, judgment, memory, alertness, coordination and ability to make calculations are impaired, and headache, drowsiness, dizziness and either a sense of well-being (euphoria) or belligerence occur. The effects appear following increasingly shorter periods of exposure to increasing altitude. In fact, pilot performance can seriously deteriorate within 15 minutes at 15,000 feet. 4. Hyperventilation a. Definition – Hyperventilation, or an abnormal increase in the volume of air breathed in and out of the lungs, can occur subconsciously when a stressful situation is encountered in flight. As hyperventilation "blows off" excessive carbon dioxide from the body, a pilot can experience symptoms of lightheadedness, suffocation, drowsiness, tingling in the extremities, and coolness and react to them with even greater hyperventilation. Incapacitation can eventually result from in lack of coordination, disorientation, and painful muscle spasms. Finally, unconsciousness can occur. b. Symptoms – Early symptoms of hyperventilation and hypoxia are similar. Moreover, hyperventilation and hypoxia can occur at the same time. Therefore, if an individual is using an oxygen system when symptoms are experienced, the oxygen regulator should immediately be set to deliver 100 percent oxygen, and then the system checked to ensure that it has been functioning effectively before giving attention to rate and depth of breathing. c. Treatment – The symptoms of hyperventilation subside within a few minutes after the rate and depth of breathing are consciously brought back under control. The

County of Merced Request for Proposal #7144 Air Ambulance Services

buildup of carbon dioxide in the body can be hastened by controlled breathing in and out of a paper bag held over the nose and mouth. 5. Middle Ear Discomfort a. Symptoms – As the aircraft cabin pressure decreases during ascent, the expanding air in the middle ear pushes the eustachian tube open, and by escaping down it to the nasal passages, equalizes pressure with the cabin pressure. Either an upper respiratory infection, such as a cold or sore throat, or a nasal allergic condition can produce enough congestion around the eustachian tube to make equalization difficult. Consequently, the difference in pressure between the middle ear and aircraft cabin can build up to a level that will hold the eustachian tube closed, making equalization difficult if not impossible. The problem is commonly referred to as an "ear block." An ear block produces severe ear pain and loss of hearing that can last from several hours to several days. Rupture of the ear drum can occur in flight or after landing. Fluid can accumulate in the middle ear and become infected. b. Prevention – During descent, an individual must periodically open the eustachian tube to equalize pressure. c. Treatment – Swallowing, yawning, tensing muscles in the throat, or if these do not work, a combination of closing the mouth, pinching the nose closed, and attempting to blow through the nostrils (Valsalva maneuver). 6. Sinuses Discomfort a. During ascent and descent, air pressure in the sinuses equalizes with the aircraft cabin pressure through small openings that connect the sinuses to the nasal passages. Either an upper respiratory infection, such as a cold or sinusitis, or a nasal allergic condition can produce enough congestion around an opening to slow equalization, and as the difference in pressure between the sinus and cabin mounts, eventually plug the opening. This "sinus block" occurs most frequently during descent. b. A sinus block can occur in the frontal sinuses, located above each eyebrow, or in the maxillary sinuses, located in each upper cheek. It will usually produce excruciating pain over the sinus area. A maxillary sinus block can also make the upper teeth ache. Bloody mucus may discharge from the nasal passages. c. A sinus block is prevented by not flying with an upper respiratory infection or nasal allergic condition. Adequate protection is usually not provided by decongestant sprays or drops to reduce congestion around the sinus openings. Oral decongestants have side effects that can impair pilot performance. d. If a sinus block does not clear shortly after landing, a physician should be consulted. 7. Self-imposed Stress – Definition: a. Stress from the pressures of everyday living can impair crewmember performance, often in very subtle ways. Difficulties, particularly at work, can occupy thought processes enough to markedly

County of Merced Request for Proposal #7144 Air Ambulance Services

decrease alertness. Distraction can so interfere with judgment that unwarranted risks are taken, such as flying into deteriorating weather conditions to keep on schedule. Stress and fatigue (see above) can be an extremely hazardous combination. b. Certain emotionally upsetting events, including a serious argument, death of a family member, separation or divorce, loss of job, and financial catastrophe, can render a pilot unable to fly an aircraft safely. The emotions of anger, depression, and anxiety from such events not only decrease alertness but also may lead to taking risks that border on self-destruction. Any crewmember that experiences an emotionally upsetting event should not fly until satisfactorily recovered from it. c. Most crewmembers do not leave stress "on the ground”. Therefore, when more than usual difficulties are being experienced, consideration should be given to delay flight until these difficulties are satisfactorily resolved. Take some time off. 8. Self –imposed Stress PERSONAL CHECKLIST. I'm physically and mentally safe to fly; not being impaired by:

Illness Medication

Stress Alcohol Fatigue Emotion 9. Night Vision Techniques a. Off-Center Viewing – To see and identify objects under conditions of low ambient illumination, avoid looking directly at an object for more than 2 to 3 seconds (because it will bleach out). Instead, use the off-center viewing that consists of searching movements of the eyes (10 degrees above, below, or to either side) to locate an object, and small eye movements to keep the object in sight. By switching your eyes from one off-center point to another every 2 to 3 seconds, you will continue to detect the object in the peripheral field of vision. The reason for using off-center viewing has to do with the location of rods in the periphery of the retina for night or low- intensity night vision (peripheral), and their absence in the center of the retina (fovea). Crewmembers should practice this off-center scanning technique to improve safety during night flights.

County of Merced Request for Proposal #7144 Air Ambulance Services

b. Scanning – It is necessary for you to develop and practice a technique that allows the efficient scanning of the surrounding airspace. You can accomplish this by performing a series of short, regularly spaced eye movements that bring successive areas of the sky into the central (foveal) visual field. To scan effectively, scan from right to left or left to right. Begin scanning at the top of the visual field in front of you and then move your eyes inward toward the bottom. Use a stop-turn-stop type eye motion. The duration of each stop should be at least 1 second but not longer than 2 to 3 seconds. 10. Spatial Disorientation – Two illusions that lead to spatial disorientation, false horizon and autokinesis, are concerned with only the visual system. a. False Horizon – A sloping cloud formation, an obscured horizon, an aurora borealis, a dark scene spread with ground lights and stars, and certain geometric patterns of ground lights can provide inaccurate visual information, or false horizon, for aligning the aircraft correctly with the actual horizon. The disoriented pilot may place the aircraft in a dangerous attitude. b. Autokinesis – In the dark, a stationary light will appear to move about when stared at for many seconds. The disoriented pilot could lose control of the aircraft in attempting to align it with the false movements of this light, called autokinesis. 11. Prevention of Spatial Disorientation – Understand the causes of these illusions and remain constantly alert for them.

2.11 Module 10 Blood Borne Pathogens NOTE: A block of instruction provided by a hospital or medical program will meet this requirement. Air Methods’ chief pilot will make the determination of adequacy. CAMTS 09-02-02 1. Definition – Blood borne pathogens are microorganisms that are present in human blood and can infect and cause disease in people who are exposed to blood containing the pathogen. These microorganisms can be transmitted through contact with contaminated blood and body fluids. 2. Examples – Human Immunodeficiency Virus (HIV), Hepatitis B (HBV), Hepatitis C (HCV), Non A, Non B Hepatitis, Syphilis, Malaria, Babesiosis, Brucellosis, Leptospirosis, Arboviral infections, Relapsing fever, Creutzfeld-Jakob disease, Human T-lymphotrophic Virus Type 1, and Viral hemorrhagic fever. 3. Other Potential Hazardous Material – Cultures and Stocks, Pathological Wastes, Human Blood and Blood Products, Sharps, Isolation Waste, Unused Sharps. 4. Engineering and Work Practice Control – It is important that all persons involved in accepting baggage or cargo are aware of these items so that inadvertent acceptance of hazardous materials is minimized. A partial list of items containing hazardous materials that may be found in air cargo and passenger baggage offered for air carriage is located in the GOM. It is very important to take proper precautions when cleaning an aircraft after a scene call or patient transfer.

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5. Biohazard Label:

6. Risk Potential at Air Methods – Risk potential is very real, given the nature of our business. Crewmembers, Mechanics, and pilots are individuals that have potential of coming into contact with blood borne pathogens and hazardous materials.

7. Hepatitis Vaccination – Hepatitis vaccination is available thru Air Methods, but is not required.

2.12 Module 11 Survival Training Courseware: CAMTS 01-07-08, AC 121-34B, AC 120-47, FAA Survival Training Videos, AOPA Survival Training Library, FM 21-76, Survival. Tailor the course content to the Program area of operations, and having the proper equipment to survive in the environment to include appropriate clothing. 1. There is a psychology to survival. You will face many stressors in a survival environment that ultimately will affect your mind. These stressors can produce thoughts and emotions that, if poorly understood, can transform a confident, well-trained person into an indecisive, ineffective individual with questionable ability to survive. Thus, you must be aware of and be able to recognize those stressors commonly associated with survival. It is also imperative that you be aware of your reactions to the wide variety of stressors associated with survival. The nature of stress, the stressors of survival, and those internal reactions that you will naturally experience when faced with the stressors of a real-world survival situation are important. The knowledge you gain will prepare you to come through the toughest times alive. 2. Stressors are not courteous; one stressor does not leave because another one arrives. Stressors add up. The cumulative effect of minor stressors can be a major distress if they all happen too close together. As the body's resistance to stress wears down and the sources of stress continue (or increase), eventually a state of exhaustion arrives. At this point, the ability to resist stress or use it in a positive way gives out and signs of distress appear. Anticipating stressors and developing strategies to cope with them are two ingredients in the effective management of stress. Therefore, it is essential that you be aware of the types of stressors that you will encounter. 3. Land Environment: a. Survival in hot and cold environments 1) Cold weather survival – One of the most difficult survival situations is a cold

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weather scenario. Remember, cold weather is an adversary that can be dangerous. Every time you venture into the cold, you are pitting yourself against the elements. With a little knowledge of the environment, proper plans, and appropriate equipment, you can overcome the elements. As you remove one or more of these factors, survival becomes increasingly difficult. Remember, winter weather is highly variable. Prepare yourself to adapt to blizzard conditions even during sunny and clear weather. 2) Arid or desert area survival – To survive in arid or desert areas, you must understand and prepare for the environment you will face. You must determine your equipment needs, the tactics you will use, and how the environment will affect you and your tactics. Your survival will depend upon your knowledge of the terrain, basic climatic elements, your ability to cope with these elements, and your will to survive. 3) Topical Environment – Most people think of the tropics as a huge and forbidding tropical rain forest through which every step taken must be hacked out, and where every inch of the way is crawling with danger. Actually, over half of the land in the tropics is cultivated in some way. b. Water – Of all the physical problems encountered in a survival situation, the loss of water is the most preventable. Always drink water when eating, acclimatize, conserve sweat, not water, and ration water. You should have water purification tablets in a survival kit. Water is your most important need.

With it alone, you can live for ten days or longer, depending on your will to live. When drinking water, moisten your lips, tongue, and throat before swallowing. Locating water should be the first priority after shelter. c. Primitive and modern fire-building techniques. There are several methods for laying a fire and each one has advantages. The situation you are in will determine which of the following fires to use: 1) TEPEE – To make a tepee fire arrange the tinder and a few sticks of kindling in the shape of a tepee or cone. Light the center. As the tepee burns, the outside logs will fall inward, feeding the fire. This type of fire burns well even with wet wood. 2) LEAN-TO – To lay a lean-to fire, push a green stick into the ground at a 30-degree angle. Point the end of the stick in the direction of the wind. Place some tinder deep under this lean-to stick. Lean pieces of kindling against the lean-to stick, and light the tinder. As the kindling catches fire from the tinder, add more kindling. 3) CROSS-DITCH – To use the cross-ditch method scratch a cross about 12 inches in size in the ground. Dig the cross about 3 inches deep. Put a large wad of tinder in the middle of the cross. Build a kindling pyramid above the tinder. The shallow ditch allows air to sweep under the tinder to

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provide a draft. 4) PYRAMID – To lay the pyramid fire place two small logs or branches parallel on the ground. Place a solid layer of small logs across the parallel logs. Add three or four more layers of logs, each layer smaller than and at a right angle to the layer below it. Make a starter fire on top of the pyramid. As the starter fire burns, it will ignite the logs below it. This gives you a fire that burns downward, requiring no attention during the night. 5) Always light a fire from the upwind side. Make sure you lay the tinder, kindling, and fuel so that your fire will burn as long as you need it. Igniters provide the initial heat required to start the tinder burning. They fall into two categories: modern methods and primitive methods. d. Medical Emergencies– Medical problems and emergencies you may face include breathing problems, severe bleeding, and shock. Lifesaving steps includes controlling panic, both your own and the victim’s, try to keep him quiet. Perform a rapid physical exam. Look for the cause of the injury and follow the ABCs of first aid. Start with the airway and breathing, but be discerning. In some cases, a person may die from arterial bleeding more quickly than from an airway obstruction. e. Hypothermia/frostbite 1) Hypothermia is defined as the body's failure to maintain an inner core temperature of 36° C (97° F). Exposure to cool or cold temperature over a short or long time can cause hypothermia. Dehydration and lack of food and rest predispose the survivor to hypothermia. Immediate treatment is the key. Move the victim to the best shelter possible away from the wind, rain, and cold. Remove all wet clothes and get the victim into dry clothing. Replace lost fluids with warm fluids, and warm him in a sleeping bag using two people (if possible) providing skin-to- skin contact. If the victim is unable to drink warm fluids, rectal rehydration may be used. 2) Frostbite is an injury resulting from frozen tissues. Frostbite extends to a depth below the skin. The tissues become solid and immovable. Your feet, hands, and exposed facial areas are particularly vulnerable to frostbite. When with others, prevent frostbite by using the buddy system. Check your buddy's face often and make sure that he checks yours.

If you are alone, periodically cover your nose and lower part of your face with your mittens. Do not try to thaw the affected areas by placing them close to an open flame. Frostbitten tissue may be immersed in 37 to 42° C (99 to 109° F) water until thawed. (Water temperature can be determined with the inside wrist or baby formula method.) Dry the part and place it next to your skin to warm it at body temperature. f. Building shelters – A shelter can protect you from the sun, insects, wind, rain, snow, hot or cold temperatures. It can give you a feeling of well-being and help you maintain your will to survive. Seek natural shelters or alter them to meet your

County of Merced Request for Proposal #7144 Air Ambulance Services

needs, therefore, saving energy. A common error in making a shelter is to make it too large. A shelter must be large enough to protect you and small enough to contain your body heat, especially in cold climates. 1) Your primary shelter in a survival situation will be your clothing. This point is true regardless of whether you are in a hot, cold, tropical, desert, or arctic situation. For your clothing to protect you, it must be in as good of a condition as possible and be worn properly. 2) You should focus on your safety when considering these requisites. You must also consider whether the site is suitable for signaling, if necessary, provides protection against wild animals, rocks, and dead trees that might fall. Is free from insects, reptiles, and poisonous plants. 3) You must consider the problems that might arise in your environment. For instance, avoid flash flood areas in foothills. Avalanche or rockslide areas in mountainous terrain. Sites near bodies of water that are below the high-water mark. 4) Ideal sites for a shelter differ in winter and summer. During cold winter months you will want a site that will protect you from the cold and wind, but will have a source of fuel and water. During summer months in the same area you will want a source of water, but you will also want the site to be almost insect free. 5) When looking for a shelter site, keep in mind the type of shelter you need. However, you must also consider the following: a) How much time and effort will you need to build the shelter? b) Will the shelter adequately protect you from the elements (sun, wind, rain, snow)? c) Do you have the tools to build it? If not, can you make improvised tools? d) Do you have the type and amount of materials needed to build it? 6) PONCHO LEAN-TO – It takes only a short time and minimal equipment to build this lean- to. You need a poncho, 7 to 10 feet of rope, three stakes about 1 foot long, and two trees or two poles 7 to 10 feet apart. Before selecting the trees you will use or the location of your poles, check the wind direction. Ensure that the back of your lean-to will be into the wind. 7) PONCHO TENT – This tent protects you from the elements on two sides. It has, however, less usable space and observation area than a lean-to. To make this tent, you need a poncho, two 5- to 8-foot ropes, six sharpened sticks about 1 foot long, and two trees 7 to 10 feet apart. 8) ONE-MAN SHELTER – A one-man shelter you can easily make using a large cloth requires a tree and three poles. One pole should be about 15 feet long and the other two about 10 feet long. To make this shelter, you should secure the 15- foot pole to the tree at about waist height. Lay the two 10-foot poles on the ground on either side of and in the same direction as the 15-foot pole.

County of Merced Request for Proposal #7144 Air Ambulance Services

Lay the cloth over the 15-foot pole so that about the same amount of material hangs on both sides. Tuck the excess material under the 10-foot poles and spread it on the ground inside to serve as a floor. Stake down or put a spreader between the two 10-foot poles at the shelter's entrance so they will not slide inward. Use any excess material to cover the entrance. 9) DEBRIS HUT – For warmth and ease of construction, the debris hut is one of the best. When shelter is essential to survival, build this shelter. To make a debris hut, you should build it by making a tripod with two short stakes and a long ridgepole or by placing one end of a long ridgepole on top of a sturdy base. Secure the ridgepole (pole running the length of the shelter) using the tripod method or by anchoring it to a tree at about waist height. Prop large sticks along both sides of the ridgepole to create a wedge-shaped ribbing effect. Ensure the ribbing is wide enough to accommodate your body and steep enough to shed moisture. Place finer sticks and brush crosswise on the ribbing. These form a latticework that will keep the insulating material (grass, pine needles, and leaves) from falling through the ribbing into the sleeping area. Add light, dry, if possible, soft debris over the ribbing until the insulating material is at least 3 feet thick (the thicker the better). Place a 1-foot layer of insulating material inside the shelter. At the entrance, pile insulating material that you can drag to you once inside the shelter to close the entrance or build a door. As a final step in constructing this shelter, add shingling material or branches on top of the debris layer to prevent the insulating material from blowing away in a storm. g. Signaling devices – be ready to use any means for signaling, such as pyrotechnics, signal mirrors, or marker panels, and smoke if available. h. Magnetic Compass – In a survival situation, you will be extremely fortunate if you happen to have a map and compass. An important addition to any survival kit is a compass, and you should be able to use the charts in the aircraft. If you do have these two pieces of equipment, you will most likely be able to move toward help. If you are not proficient in using a map and compass, you must take the steps to gain this skill. i. First Aid Kits – A first aid kit is an essential item in a survival kit. Remarkably, EMS aircraft are equipped with many lifesaving items, but few have a simple item like a first aid kit with band aids, but that could help prevent infection in a survival situation. j. Using the aircraft and its equipment as tools for survival. 4. Water Environment: Sea survival is perhaps the most difficult survival situation. Short- or long- term survival depends upon rations, equipment available, and your ingenuity. You must be resourceful to survive. Water covers about 75% of the earth's surface, with about 70 percent being oceans and seas. You may cross vast expanses of water at some time. The aircraft will be equipped with the required equipment for the environment. The equipment may include: a. Life Vests

County of Merced Request for Proposal #7144 Air Ambulance Services

b. Lift Rafts c. Water Catchment Devices d. Signaling Devices e. Magnetic Compass f. Fishing Kit g. First Aid Kits

5. It is essential that you are familiar with the location and use of these items before you are caught in a survival situation.

2.13 Module 12 Hazmat 2.13.1 Courseware: Air Methods General Operations Manual, 49 CFR 1. Air Methods will not accept and/or knowingly transport hazardous materials as defined by 49 CFR onboard our aircraft. The Hazardous Materials (HM) Operations Manual and Training Program is intended to ensure that AMC employees, agents, and contract employees are prepared and knowledgeable regarding company policies and procedures as a “Will-Not” carry certificate holder. The company will ensure that all hazardous materials being handled as Company Materials (COMAT) will be transported by a different mode and or Air Carrier that is authorized to transport hazardous materials. 2. Physically inspect “Carry-on” baggage for HAZMAT (CAMTS 04-01-09)

2.14 Module 13 Basic Aircraft Description (Specific to Assigned Aircraft Dimensions 1. Other major systems and components or appliances 2. Instrument Panel 3. Cyclic / Collective 4. Cockpit and cabin configurations 5. Passenger Compartment, with emphasis on the medical interior

2.15 Module 14 Aircraft and Ambulance Safety – CAMTS 2.15.1 Courseware: NTSB Accident Reports and AMC AIDMOR Reports, AMC Media Presentation. 1. Review of Air Methods Accidents / Incidents (previous year), Human factors considerations. 2. Scene Operations (Helicopter only) Day Response and Night Response: To maintain a safe environment when operating into a landing zone, one of the following procedures will be utilized: a. Aircraft will be shutdown. At any time when the security of the scene is in question, and/or no positive crowd control is actively in place, one crew member shall remain

County of Merced Request for Proposal #7144 Air Ambulance Services

in the vicinity of the aircraft and provide scene security until the pilot shuts down the aircraft. b. Aircraft power will be reduced to ground idle or a reduced power setting as specified in the Aircraft Flight Manual. Attitude / Auto Trim mode shall be off and SAS mode selected if appropriate. Controls will be secured in one of the following manners, positively locked, force trim on or frictioned as not to move The pilot will get out of the aircraft and guard the area around the aircraft. The pilot shall stay within the rotor diameter of the aircraft. c. Aircraft power will be reduced to ground idle or a reduced power setting as specified in the Aircraft Flight Manual, pilot will stay in seat in cockpit, and a trained crewmember will guard the area around the aircraft. d. Aircraft power will be reduced to ground idle or a reduced power setting as specified in the Aircraft Flight Manual, pilot will stay in seat in cockpit, and a trained crewmember will brief a first responder, such as a law enforcement officer of fireman. After being briefed the person briefed will ensure that no one approaches the aircraft without the knowledge of the pilot.

The contents of the briefing that the crewmember will give to the appropriate first responder is as follows: 1) Stay at least 50 feet from aircraft. 2) Do not allow anyone to approach the aircraft without permission from the pilot or a crewmember. 3) Anyone that approaches the aircraft must be accompanied by a crewmember. 4) Crew will assign personnel to help carry the stretcher to the aircraft. 5) Remember to exit in the same direction that you approached the aircraft. 3. Basic safety rules in and around the aircraft: a. Do not allow emergency vehicles to approach the aircraft without coordinating with the pilot; under no circumstances should vehicles be allowed under the rotor system (operating or not). b. Ensure that all passengers are closely supervised and accompanied by appropriately trained crewmembers. c. Ensure that no unauthorized persons approach the aircraft unless properly escorted. First Responders shall remain at least 50 feet from the aircraft. d. To avoid contact with the main rotor blades, long pieces of equipment or tools should be carried horizontally at or below waist level. An example of this equipment is IV poles. e. Before takeoff, ensure that all people, cargo, baggage, or anything that might be blown around by the force of the downdraft. f. Ensure that all loose cargo/equipment within the aircraft is secure.

County of Merced Request for Proposal #7144 Air Ambulance Services

g. Instruct all boarding passengers and ground personnel to stay away from the rear of the helicopter. h. Crouch low before getting to and going under the main rotor. i. Approach the helicopter from the side or front, but never out of the pilot’s line of sight. j. Hold firmly to hats and loose articles. k. Never reach up or dart after a hat or other object that might be blown off or away. l. Protect eyes by shielding with a hand or by squinting. m. If the landing site is on a slope, passengers should not approach or depart the helicopter on the upslope side. Avoid the area of lowest rotor clearance. Approach the helicopter from the front, never the rear. n. Medical personnel/crewmembers or passengers shall not depart the aircraft until the pilot verbally notifies them that they have landed and are cleared to deplane. The medical personnel or passengers shall inform the pilot prior to departing the aircraft. o. Pilots shall not takeoff until they have received verbal confirmation from onboard medical personnel/medical crewmembers or other passengers that they are seated, safety belts/shoulder harnesses (as applicable) are fastened, and doors are closed and secured. 4. Obstacle Recognition: Assist the pilot in avoiding other aircraft; identify obstacles such as towers, wires, or threatening terrain, as appropriate. 5. Adequacy at Landing Sites (Helicopter only): Evaluate landing site adequacy: a. size b. wind c. obstacles d. approach and departure paths 6. In-flight Passenger and Patient Restraining Methods: Each required flight crewmember, occupying a station equipped with a seat belt and/or shoulder harness, shall have that seat belt and (when equipped) shoulder harness fastened at all times when at that station. The shoulder harness may be removed if it inhibits performance of the individual’s required duties, except during takeoff, approach, landing, and surface operations. Each passenger, including medical personnel, who has reached their second birthday, shall occupy an approved seat or berth with a separate safety belt properly secured about them during surface movement, takeoff, and landing. 7. Handling Problem Patients (FAA Handbook 8900.1, Volume 4, Chapter 5, Section 3, Chg. 22, 4- 944, B): Passengers who may pose a hazard to the aircraft or to its occupants must be properly restrained before takeoff (such as hysterical patients or combative passengers). 8. Patient Boarding / Loading and Deplaning / Unloading 9. Emergency Procedures 10. Inadvertent IMC: The priority and most important aspect of an IIMC procedure are to

County of Merced Request for Proposal #7144 Air Ambulance Services

maintain aircraft control. Positive control of the aircraft with reference to instruments must take priority over all other duties. Crewmembers should assist the pilot with charts, approach plates, checklists, coordinates, and other reference material as appropriate. 11. In-Flight Medical Emergencies are not aircraft emergencies and may not be declared as emergencies to Air Traffic Control. The pilot may request expedited handling if appropriate. 12. Emergency Evacuation Procedures Post Accident: It is the responsibility of the pilot and medical personnel/crewmembers to assist passengers and/or patients in emergency evacuation. These duties will include but not limited to: a. Open main exit doors, if possible, b. Assisting Passengers/Patients to disembark, c. Leading Passengers/Patients to safe area, d. Notifying proper authorities and requesting aid, and e. Give necessary medical attention if necessary. f. If an emergency occurs on the ground, or once an aircraft is returned to the surface, the pilot(s) will evacuate the aircraft via any normal or emergency exit. After successfully evacuating themselves, each pilot will assist in passenger evacuation. It will be the duty of both the pilot and medical personnel/crewmembers to assist in the evacuation of any and/or all handicapped persons or those needing assistance that are aboard the aircraft.

2.16 Module 15 EMS Radio Communications Helicopter Air Ambulance (HAA) operations often occur in complex, controlled-airspace environments found in the areas supporting major medical centers. The time of day when air traffic is generally heavy and inter- facility patient transfers are most likely to take place, is also a factor contributing to a busy work environment. For these reasons medical crewmembers shall be responsible for air to ground communications with first responders and medical facilities in regard to patient information. In regards to landing zone information (obstructions, coordinates, etc.); the PIC may delegate this to medical crewmembers. The pilot is able to control and override radio transmissions from the cockpit in the event of an emergency situation. Reference: GOM and CAMS 02-06-04.

Crewmembers shall be familiar with the following equipment specific to the assigned aircraft: 1. Power EMS radio equipment 2. Tune EMS radios 3. Use proper radio communication procedures 4. Operate installed aircraft satellite telephone

County of Merced Request for Proposal #7144 Air Ambulance Services

2.17 Module 16 Passenger Briefing This subject is also covered in Module 2 Code of Federal Regulations (14 CFR 135.117) The pilot-in-command shall ensure that the briefing is completed prior to taxi or takeoff. The briefing shall be supplemented by the Air Methods’ approved passenger briefing card (one per seat / litter) for the make and model of aircraft operated and shall be available to each passenger. The briefing shall be given by the pilot in command, a crewmember, or other qualified person designated by the pilot-in--command. The following items shall be briefed: 1. No smoking. 2. Use of seatbelts. 3. If available, all seat backs should be in an upright position before takeoff and landing. 4. Location and operation of passenger entry doors and emergency exits. 5. Location of survival equipment. 6. Location and operation of fire extinguishers. 7. If the flight involves extended over water operation, ditching procedures and use of required flotation equipment. 8. If the flight involves operations above 12,000 feet MSL, the normal and emergency use of oxygen.

3. Transition Training

This category of training is for a medical crewmember that has been previously trained and qualified on a specific aircraft type and is now qualifying on another aircraft type. Transition training emphasizes the unique features of the aircraft and the specific flight attendant duties on that aircraft.

3.1 Objective To ensure that each medical crewmember achieves an acceptable level of knowledge and procedures in all assigned duties.

3.2 General Aircraft Module Elements Module 13 Basic Aircraft Description Module 15 EMS Radio Communications Module 14 Aircraft and Ambulance Safety

3.3 Emergency Situation Training Module Elements Module 1 Rapid Decompression (If Applicable) Module 2 In-flight Fire and Smoke Control Procedures

County of Merced Request for Proposal #7144 Air Ambulance Services

Module 3 Ditching & Evacuation Situations (If Module 4 Illness, Injury, The Proper Use of First applicable) Aid Equipment, and Other Abnormal Situations Involving Crewmembers and Passengers

Module 5 Hijacking and Other Unusual Situations Module 6 Pyrotechnic Signaling Devices (If applicable) Module 7 Emergency Assignments & Module 8 Ground Evacuation. Procedures (AMRM)

3.4 Emergency Drill Training and Hazardous Materials Module Elements Module 9 Emergency Exits in Normal and Module 10 Operation of Handheld Fire Emergency Mode Extinguishers Module 11 Use of Crew and Passenger Module 12 Donning, Use, and Inflation of Life emergency Oxygen System (If applicable) Preservers and Other Flotation Devices (If applicable)

4. Recurrent Training

4.1 Objective To provide the Medical Personnel with the knowledge to remain adequately trained and currently proficient for his/her assigned duty position. Recurrent training may be completed via CTS or other computer media. NOTE: Completing CTS satisfies Recurrent Ground Training Requirements.

4.1.1 Instructional Delivery Method: Lecture, guided discussion, or practical exercise.

4.1.2 Testing/Checking: Written or Oral exam may be administered at the end of each module or segment.

4.2 Air Methods Specific Segment Module 2 Federal Aviation Regulations Module 3 Air Methods General Operations Manual & Policies Module 4 Administrative (Local Requirements)

4.3 Medical Crewmember Specific Modules Module 5 Duties and Responsibilities to include Day Module 9 Physiological Aspects of Flight and Night Scene Operations

County of Merced Request for Proposal #7144 Air Ambulance Services

Module 8 Weather Conditions Module 12 Hazmat Module 11 Survival

4.4 General Aircraft Modules Module 14 Aircraft and Ambulance Safety Module 15 EMS Radio Communications

4.5 Emergency Situation Training Modules Module 1 Rapid Decompression (If Applicable) Module 2 In-flight Fire and Smoke Control Procedures Module 3 Ditching & Evacuation Situations (If Module 4 Illness, Injury, The Proper Use of applicable) First Aid Equipment, and Other Abnormal Situations Involving Crewmembers and Passengers Module 5 Hijacking and Other Unusual Situations Module 6 Pyrotechnic Signaling Devices (If applicable) Module 7 Emergency Assignments & Procedures Module 8 Ground Evacuation. (AMRM)

4.6 Emergency Drill Training and Hazardous Materials will not carry Module. Module 9 Emergency Exits in Normal and Module 10 Operation of Handheld Fire Emergency Mode Extinguishers Module 11 Use of Crew and Passenger emergency Module 12 Donning, Use, and Inflation of Life Oxygen System (If applicable) Preservers and Other Flotation Devices (If applicable)

4.7 Recurrent Emergency Drill Training Hands on equipment training will be accomplished every 24 months in conjunction with Recurrent Training and annotated on form TF115, Emergency Drill Training Form (5273) (a sample of this form can be found in the Appendix of the PTP manual – the actual form is on Flightdeck> Resources> Corp Forms (AMC)). During the alternate 12-month periods, the emergency drill training may be accomplished by pictorial presentation or demonstration. Type of General Recurrent Emergency Months Since First Emergency Training Curriculum Drill Training Required Segment Was Completed

Cycle 12 MONTHS 24 MONTHS 36 MONTHS 48 MONTHS

County of Merced Request for Proposal #7144 Air Ambulance Services

Emergency Situation Training X X X X

Emergency Drill (either hands-on or X X X X pictorial presentation/demo)

Emergency Drill (hands-on required) X X

5. Requalification Training

This category of training is for a medical crew member who has been trained and qualified but has become unqualified to serve as a medical crewmember on an aircraft due to not having received recurrent ground training within the appropriate eligibility period.

5.1 Objective To provide the Medical Personnel with the knowledge to perform his/her assigned crewmember duty position. Requalification training may be completed via classroom instruction, CTS or other computer media. NOTE: Completing CTS satisfies Requalification Ground Training Requirements.

5.1.1 Instructional Delivery Method: Lecture, guided discussion, or practical exercise.

5.1.2 Testing/Checking: Written or Oral exam may be administered at the end of each module or segment. 5.2 Specific Air Methods Module Elements Module 2 Federal Aviation Regulations Module 3 Air Methods General Operations Manual & Policies Module 4 Administrative (Local Requirements)

5.3 Specific Medical Crewmember Module Elements Module 5 Duties and Responsibilities to Module 9 Physiological Aspects of Flight include Day and Night Scene Operations Module 8 Weather Conditions Module 12 Hazmat Module 11 Survival 5.4 Aircraft General Module Elements Module 14 Aircraft and Ambulance Module 15 EMS Radio Communications Safety

County of Merced Request for Proposal #7144 Air Ambulance Services

5.5 Emergency Situation Training Module Elements Module 1 Rapid Decompression (If Module 2 In-flight Fire and Smoke Control Applicable) Procedures Module 3 Ditching & Evacuation Situations Module 4 Illness, Injury, The Proper Use of First (If applicable) Aid Equipment, and Other Abnormal Situations Involving Crewmembers and Passengers

Module 5 Hijacking and Other Unusual Module 6 Pyrotechnic Signaling Devices (If

Situations applicable) Module 7 Emergency Assignments & Module 8 Ground Evacuation. Procedures (AMRM)

5.6 Emergency Drill Training and Hazardous Materials Module Element Module 9 Emergency Exits in Normal Module 10 Operation of Handheld Fire and Emergency Mode Extinguishers Module 11 Use of Crew and Passenger Module 12 Donning, Use, and Inflation of Life emergency Oxygen System (If applicable) Preservers and Other Flotation Devices (If applicable) 5.7 Requalification Emergency Drill Training Elements Hands on equipment training will be accomplished every 24 months in conjunction with Requalification or Recurrent Training and annotated on form TF115, Emergency Drill Training Form (5273) (a sample of this form can be found in the Appendix of the PTP manual – the actual form is on Flightdeck> Resources> Corp Forms (AMC)). During the alternate 12-month periods, the emergency drill training may be accomplished by pictorial presentation or demonstration.

Type of General Recurrent Emergency Months Since First Emergency Training Drill Training Required Curriculum Segment Was Completed

Cycle 12 MONTHS 24 MONTHS 36 MONTHS 48 MONTHS

Emergency Situation Training X X X X

County of Merced Request for Proposal #7144 Air Ambulance Services

Emergency Drill (either hands-on or pictorial presentation/demo) X X X X

Emergency Drill (hands-on required) X X

6. Emergency Situation Modules

Objective: To develop the necessary knowledge and skills in the actual use of certain items of emergency equipment, as well as the procedures to be followed, when emergency situations occur. 1. Instructional Delivery Method: Lecture 2. Testing/Checking: Written or Oral

6.1 Module 1 Rapid Decompression (If applicable) 6.1.1 Courseware: AMC General Operations Manual, AMC Media Presentation

6.2 Module 2 In-flight Fire (or on-the-surface) and Smoke Control Procedures 1. Principles of combustion, and classes of fires 2. Toxic fumes and chemical irritants 3. Use of hand-held fire extinguishers and smoke control procedures 4. Electrical equipment and circuit breakers found in the cabin area

6.3 Module 3 Ditching and Evacuation Situations (If applicable) 1. Cockpit and cabin preparation 2. Passenger briefing 3. Crew coordination 4. Primary swells, secondary swells, and sea conditions 5. Ditching heading and water landings

6.4 Module 4 Illness, Injury, the Proper Use of First Aid Equipment, and Other Abnormal Situations Involving Crewmembers and Passengers 6.4.1 Courseware: AMC Media Presentation, American Red Cross First Aid Fast 1. Ear and sinus blocks

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2. Seeking medical assistance 3. Treatment of shock 4. First aid kit location 5. Contents of first aid kit 6. Function and operation of individual items 7. Crewmember incapacitation 8. NTSB reporting requirements 9. Symptoms and onset of incapacitation 10. Actions upon recognition 6.5 Module 5 Hijacking and Other Unusual Situations 6.5.1 Courseware: Aeronautical Information Manual, AMC Media Presentation 1. Pilot’s procedures during hijack 2. Transponder codes 3. Communications procedures 4. Pilot interaction with hijacker 5. Bomb threat procedures 6. Evacuation of the area 7. Notification of authorities

6.6 Module 6 Pyrotechnic Signaling Devices (if applicable) 6.6.1 Courseware: Aeronautical Information Manual, AMC Media Presentation 1. Location of Devices 2. Operation and Use

6.7 Module 7 Emergency Assignments and Procedures 6.7.1 Courseware: AMC General Operations Manual, AMC AMRAM Training, AMC Media Presentation 1. Emergency assignments 2. PIC emergency authority 3. Reporting incidents and accidents 4. PIC responsibilities 5. Air Medical-crew Resource Management 6. Passenger notification procedures 7. ATC notification 8. AMC communications procedures 9. Coordination among crewmembers

County of Merced Request for Proposal #7144 Air Ambulance Services

6.8 Module 8 Ground Evacuation 6.8.1 Courseware: Aircraft Flight Manual, AMC GOM, AC 20-118A 1. Aircraft configuration 2. Exiting the aircraft 3. Blocked or jammed exits 4. Fuel spills and other ground hazards 5. Patients / injured persons 6. Evacuation equipment

7. Emergency Drill Training

NOTE: “Emergency Drill” training provides instruction and practice in the actual use of certain items of emergency equipment, such as fire extinguishers, life vests, oxygen bottles, and first aid equipment.

7.1 Module 1 Emergency Exits in Normal and Emergency Modes 1. Operation of each exit 2. Emergency evacuation of aircraft, including deployment and use of evacuation chutes (if applicable)

7.2 Module 2 Operation of Hand Held Fire Extinguishers 1. Inspection tags, date, and proper charge levels 2. Removal and stowage of extinguisher 3. Hands on demonstration of extinguisher and fire extinguishing 4. Smoke control 5. Maintenance procedures

7.3 Module 3 Use of Crew and Passenger Emergency Oxygen System (if applicable) 1. Donning the oxygen mask 2. Operation of the emergency oxygen system

7.4 Module 4 Donning Use and Inflation of Life Preservers and other Flotation Devices (if applicable)

County of Merced Request for Proposal #7144 Air Ambulance Services

7.5 Module 5 Ditching Procedures (if applicable) 1. Cockpit preparation 2. Crew coordination 3. Passenger briefing 4. Use of life lines 5. Removal of life rafts and inflation 6. Boarding of crew and passengers into life rafts, as appropriate

8. Night Vision Goggle Training Program (Medical Crewmember)

8.1 General 8.1.1 Objective This section specifies Air Methods Corporation training program for employing night vision goggles (NVG) in 14 CFR Part 135 operations. This program is to be used by instructors in conducting a course of training to ensure that all medical crewmembers employing night vision goggles have the necessary skill, knowledge, proficiency, and judgment to perform all assigned flight duties employing night vision goggles. To conduct flights with NVGs the medical crewmember must complete this training program and the Medical Personnel Ground Curriculum Module Elements. Prior to NVG training, crewmember training is required for all medical personnel involved in helicopter NVG operations. For HNVGO operations that are authorized below 500 feet AGL at least one other required crewmember shall utilize NVGs during the landing to assist in clearing the site. The other required crewmember, when able, will be located on the side opposite the pilot, in either the front or rear compartment. The “other required crewmember” referenced in this paragraph must be current and trained in accordance with the approved training program.

8.2 Terms and Definitions All Terms and Definitions are recorded in the Pilot Training Program Main document.

8.3 Training Standards Each individual must successfully complete all applicable portions of the training program as specified.

8.4 Authorized Night Vision Goggles Any Night Vision Goggle utilized for training or operational missions shall meet or exceed the minimum operational performance standards established by RTCA/DO-275 or TSO-C164, and comply with Company Operations Specification requirements.

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8.5 Authorized Instructors 1. Persons designated as an NVG check airman / instructor or a designated RAD, RAM, PAM, or an Air Transportation ground instructor shall conduct ground training (ATGI designee’s will be observed teaching NVG ground school and recommended by an NVG ACE, prior to being designated). 2. An NVG pilot-in-command, appropriate to the aircraft being flown, may conduct flight training. The pilot-in-command must still comply with all applicable procedures listed in the General Operations Manual and Rotorcraft Flight Manual Supplement, i.e., another qualified and current person must be on the helicopter to conduct training. 3. Flight training for a medical crewmember may be conducted with the individual in their appropriate seating position.

8.6 Training Records The instructor will complete form TF121, NVG Medical Training (5276) (a sample of this form can be found in the Appendix of the PTP manual – the actual form is on Flightdeck> Resources> Corp Forms (AMC)).and email the completed form to appropriate area [email protected].

9. NVG Initial Qualification Training

NVG Initial Qualification Training is comprised of a Ground Training Curriculum and an Aircraft Training Curriculum. Document training on form TF121, AMC NVG Crewmember Training Form (5276) (a sample of this form can be found in the Appendix of the PTP manual – the actual form is on Flightdeck> Resources> Corp Forms (AMC)), retain a copy at the base, and forward a copy to the Flight Records Department. The minimum training times for NVG Initial Qualification Training are: 1. Ground Training: 5 hours 2. Flight Training: Flight training at night employing NVGs consists of a minimum of three (3) takeoffs and landings with an enroute phase between each landing.

9.1 NVG Ground Training Module 9.1.1 Courseware: Air Methods Corporation General Operations Manual; Operations Specifications; CFRs; NVG Operator’s Manual. Ground Training Curriculum listed in Annex 24 NVG Training will be utilized.

9.2 Operator Specific Training Elements 1. Authorized Types of Operations 2. Forms and Records 3. Responsibilities of the Duty Position

County of Merced Request for Proposal #7144 Air Ambulance Services

4. Applicable Regulations and OpsSpecs 5. AMC General Operation Manual (GOM)

9.3 Medical Crewmember Specific Training Elements 1. Introduction to Night Vision Goggles 2. Limitations / Emergency Procedures 3. NVG Aeromedical Considerations / Aviation Physiology 4. NVG / Night Flight Planning and Terrain Interpretation 5. Risk Management

9.4 Aircraft Training Module

9.5 Aircraft Ground Training Element 9.5.1 Courseware: Rotorcraft Flight Manual and Supplement. 1. Lighting Systems 2. Caution Warning Systems 3. Duty Station Familiarization and NVG Compatibility

9.6 Aircraft Flight Training Element Medical crewmembers shall be trained on all maneuvers listed in the following training module.

9.6.1 Courseware: Rotorcraft Flight Manual Preflight, Night Vision Goggle Operator’s Manual, NVG Operational Inspection, Pilot Training Program Annex 24.

9.6.2 Preparation: 1. NVG Equipment Assembly/Initial Focus. 2. Preflight Planning. 3. Aircraft visual inspection 4. Before Takeoff NVG Check 5. Emergency Procedures Training During Any Airborne Phase or Takeoff/Landing 6. NVG Failure 7. NVIS Failure 8. Inadvertent IMC procedures 9. Enroute 10. Reconnaissance Procedures

County of Merced Request for Proposal #7144 Air Ambulance Services

11. Traffic Advisories 12. Obstacles 13. Weather Conditions (Snow, Fog, Rain, Dust, Smoke) 14. Terrain (Mountainous, High Desert) 15. Confined Area Operations 16. Crew Resource Management (CRM) 17. Post Flight 18. NVG recording flight time 19. NVG Discrepancies 20. Aircraft Discrepancies including NVIS lighting

10. NVG Transition Training

NVG Transition Training is comprised of a Ground Training Curriculum and a Flight Training Curriculum. This is appropriate for medical crewmembers who are current and qualified in HNVGO in one type aircraft and transitioning to another type. Minimum training times for NVG Transition Training are: 1. Ground Training: 1 hour 2. Flight Training: Refer to Flight Training Curriculum below.

10.1 Flight Training Curriculum Medical crewmembers should complete flight training at night, employing NVGs, consisting of a minimum of one (1) takeoff and landing.

10.2 NVG Recurrent Training NVG Recurrent Training is comprised of a Ground Training Curriculum. Recurrent training is annual training required for medical personnel who will continue to serve in the same duty position. Recurrent training may be completed via CTS or other computer media.

10.3 Ground Training Curriculum The minimum ground training time for NVG Recurrent Training is: - 2 hours. Medical crewmembers will complete the following: 1. NVG Initial Qualification Ground Training Curriculum; Limitations / Emergency Procedures, NVG Aeromedical Considerations / Aviation Physiology, Risk Management. 2. NVG Initial Qualification: Adjusting the NVG for Operation, Night Vision Goggles Visual Deficiencies.

County of Merced Request for Proposal #7144 Air Ambulance Services

3. NVG Initial Qualification, Aircraft Ground Training Module.

10.4 NVG Requalification Training NVG Requalification Training is required specifically to restore a previously qualified medical crewmember to an NVG qualified status. 1. A medical crewmember may lose qualification status and become unqualified if NVG recurrent training is not completed within the eligibility period. 2. A medical crewmember that becomes unqualified due to a failure to complete recurrent training may be re-qualified by the following:

Time Past Month Due Ground Training Flight Training Up to 12 months Same as NVG Recurrent Training Same as NVG Initial Qualification

12 to 18 months 50% of hours required for Same as NVG Initial Qualification Initial Qualification More than 18 months Same as NVG Initial Qualification Same as NVG Initial Qualification

10.5 NVG Currency Medical crewmembers must log a minimum 3 HNVGOs within a 180 day period to maintain NVG currency.

10.6 Medical Crewmember NVG Currency Training NVG currency training is comprised of a Flight Training Curriculum only. This training is required for a medical crewmember who has exceeded six months since his / her last HNVGO. This training will be accomplished with an NVG qualified and current pilot in command and without a patient onboard.

11. Flight Training Module

Medical crewmembers will complete flight training at night, employing NVGs, consists of a minimum 3 landings (to unimproved sites) with an enroute phase between each landing.

11.1 Aircraft and NVG Operational Inspection 11.1.1 Procedure: 1. Conduct a preflight inspection of the aircraft internal lighting systems. 2. Conduct a preflight and operational inspection of the NVG in accordance with the operator’s specified procedure.

County of Merced Request for Proposal #7144 Air Ambulance Services

3. Record discrepancies in the applicable document.

11.1.2 Standard: Properly conduct the preflight inspections and operational checks using appropriate checklists.

11.2 Before Takeoff NVG Checks 11.2.1 Procedure: 1. With helmet on and aircraft running, medical crewmembers should lower the NVG to the operational position. 2. Medical crewmembers should complete the specified steps for adjusting the NVG for operations.

11.2.2 Standard: Correctly follow the applicable steps to adjust the NVG for flight and verify satisfactory operation.

11.3 NVG Failure 11.3.1 Procedure: 1. The instructor should announce “Simulated NVG Failure”. 2. Medical crewmembers should immediately announce “Goggle Failure”. 3. Medical crewmember should switch to the second battery (if applicable). If aided vision is not restored, the NVG should be placed in the stowed position and flight continued unaided.

11.3.2 Standard: 1. Correctly identify or describe indications of impending NVG failure. 2. Correctly perform or describe emergency procedures for NVG failure.

11.4 Post Flight Procedures 11.4.1 Procedure: Medical crewmembers should conduct a post flight inspection and ensure that the aircraft, NVIS lighting, windows, and NVG are suitable for further HNVGO. Discrepancies noted should be logged as appropriate.

11.4.2 Standard:

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Medical crewmembers should log appropriate discrepancies and debrief accordingly to ensure safety of flight and operational effectiveness.

12. Fueling Procedures Training Module

Training shall be conducted by the program aviation manager (PAM) / aviation service manager (ASM), lead pilot, pilot, or AMC Training / Flight Standards representative, for crewmembers within their programs on an annual basis, for each type aircraft, model, and configuration operated by the crewmember. Document training on form TF118, AMC Refueling Training Form (5285) (a sample of this form can be found in the Appendix of the PTP manual – the actual form is on Flightdeck> Resources> Corp Forms (AMC)),and forward a scanned copy to [email protected]; maintain documentation for 24 months, and dispose of appropriately.

12.1 Safety Precautions (Cold Refueling) 1. No smoking, open flames, or fires shall be permitted within 50 feet of an aircraft while refueling. Fueling personnel should not carry cigarette lighters, matches, or any type of sparking igniter device on their person while fueling. 2. In the event of spillage, all pumps and electrical equipment will be shut down. Refueling may be restarted after spillage has been removed. 3. Line personnel will remove any loose objects from their person that could possibly enter a fuel or oil service port. 4. Fire extinguisher will be available. 5. The aircraft will be grounded for all refueling operations and engines shut down, except where authorized in this annex, see “Rapid Refueling”. 6. The refueling unit/truck will remain outside the rotor arc. 7. Refueling operations shall not be conducted during periods of active thunderstorms, and detected lightning, within 5 miles of the fueling operations. 8. Aircraft maintenance is not allowed during refueling, including servicing of oxygen, LOX or batteries. 9. Aircraft ground-power units should be located as far away from the fueling point as practicable and neither connected or disconnected during fueling. 10. Electric tools, such as drills or buffers, shall not be used in or near the aircraft during refueling. 11. Aircraft radios, portable radios, or cell phones shall not be operated in the vicinity of any aircraft refueling operation. 12. Use caution in removing the fuel tank cap, and place the tank cap where it will not get contaminated.

County of Merced Request for Proposal #7144 Air Ambulance Services

13. Place the tank cap where it will not get contaminated. 14. Make sure the nozzle is properly bonded to the aircraft and placed in the filler neck. 15. Do not block the nozzle trigger in the open position unless the nozzle is of the type that shuts off automatically, and then only use the system provided on the nozzle handle. 16. Never leave the nozzle unattended. 17. Make frequent visual checks of the amount of fuel in the tank and take extreme care to prevent spills and over-filling of the tanks. 18. Upon completion of the refueling, close the filler cap properly, disconnect all grounding, and bonding cables, remove the hose and cables from the vicinity of the aircraft. 19. If an aircraft fuel apparatus or spilled fuel catches fire, engage all fuel shut-offs. Notify the Fire Department immediately. If possible, and without endangering self or others, fight the fire with all means available. 12.2 Additional Procedures for Refueling with Patient Onboard (Cold Refueling) 1. The PIC will conduct an exit briefing before exiting the aircraft. 2. An attendant with a fire extinguisher, who has completed the Air Methods Emergency Drills Training will remain onboard the aircraft with the patient. The patient will be prepared for rapid evacuation. 3. The second attendant will position himself / herself, with a fire extinguisher (if available) in a position that will allow monitoring of the refueling operation and the onboard attendant simultaneously, so as to be able to coordinate emergency evacuation / firefighting assistance as necessary. 12.3 Rapid Refueling with Rotors Turning without Medical Personnel or Passengers 1. The aircraft will be grounded for all refueling operations. 2. Aircraft power will be reduced to ground idle or a reduced power setting as specified in the Rotorcraft Flight Manual, controls positively locked or friction applied to prevent movement. Force trim shall be on (if installed), autopilot turned off (if installed), and the rotor disc level. 3. The pilot may go beyond the rotor arc of the aircraft to retrieve the fuel nozzle, grounding cables or secure the previously mentioned items. 4. Fire extinguisher will be accessible near fueling port. 5. If an aircraft fuel apparatus or spilled fuel catches fire, engage all fuel shut-offs, shut down the aircraft if possible. Notify the Fire Department immediately. If possible and without endangering self or others, fight the fire with all means available. 12.4 Rapid Refueling with Rotors Turning with Medical Personnel 1. Aircraft power will be reduced to ground idle or a reduced power setting as specified in the Aircraft Flight Manual, controls positively locked or friction applied to prevent movement. Force trim shall be on (if installed), autopilot turned off (if installed), and the rotor disc level. 2. The pilot may go beyond the rotor arc of the aircraft to retrieve the fuel nozzle, grounding cables or secure the previously mentioned items.

County of Merced Request for Proposal #7144 Air Ambulance Services

3. All Medical Personnel will exit the aircraft. One attendant will position himself / herself, with a fire extinguisher in a position that will allow monitoring of the refueling operation, to lend firefighting assistance as necessary. The other attendant will act as tail rotor guard. 4. A Fire extinguisher will be accessible near fueling port. 5. If an aircraft fuel apparatus or spilled fuel catches fire, engage all fuel shut-offs, shut down the aircraft if possible. Notify the Fire Department immediately. If possible and without endangering self or others, fight the fire with all means available. 12.5 Rapid Refueling with Rotors Turning with Medical Personnel and Patient 1. It is Air Methods policy that no one should be aboard the aircraft during refueling, with the following exception: on rare occasions it may become necessary while en route to a hospital with a critically ill or injured patient to stop for fuel. In this case refueling with the patient onboard is permitted. The patient will be prepared for rapid evacuation and attended by medical personnel. It should be emphasized that the pilot-in-command will make every reasonable effort in his flight planning to avoid fueling with a patient aboard. The refueling may be done by FBO refueling personnel. The PIC may brief a medical crewmember on supervising the refueling personnel during rapid refueling at an FBO. 2. The PIC will conduct an exit briefing before medical personnel and or passengers deplane the helicopter. 3. PIC will remain at his station with the pilot door open and seatbelt/shoulder harness fastened. 4. Engine/rotor RPM shall be set to the lowest appropriate setting, the force trim shall be on (if installed), the autopilot turned off (if installed) and the rotor disc level. 5. An attendant with a fire extinguisher, who has completed the Air Methods Emergency Drills Training will remain onboard the helicopter with the patient. 6. The other attendant will position himself / herself, with a fire extinguisher in a position that will allow monitoring of the refueling operation, to lend firefighting assistance as necessary. 7. Fuel Truck will be placed a minimum of 30 feet beyond the rotor arc. 8. If available, a fire truck will be located near the aircraft. 9. If an aircraft fuel apparatus or spilled fuel catches fire: 10. Engage all fuel shut-offs. 11. Shut down and evacuate the aircraft. 12. Notify the Fire Department immediately. 13. If possible and without endangering self or others; fight the fire with all means available.

County of Merced Request for Proposal #7144 Air Ambulance Services

Attachment # 4 – Section 2.6.14 - HIPAA Policy and Patient’s Rights

PATIENT RIGHTS

• The patient has the right to considerate and respectful care. • The patient has the right to and is encouraged to obtain from healthcare providers relevant, current, and understandable information concerning diagnosis, treatment, and prognosis.

Except in emergencies when the patient lacks decision-making capacity and the need for treatment is urgent, the patient is entitled to the opportunity to discuss and request information related to the specific procedures and/or treatments, the risk involved, and the medically reasonable alternatives and their accompanying risks and benefits. Patients have the right to know the identity of physicians, nurses, and others involved in their care, as well as when those involved are students, residents, or other trainees.

The patient has the right to have an advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designating a surrogate decision maker with the exception that we will honor the intent of that directive to the extent permitted by law and county policy.

The patient has the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and county policy and to be informed of the medical consequences of this action.

The patient has the right to every consideration of privacy. Case discussion, consultation, examination, and treatment should be conducted so as to protect each patient's privacy.

The patient has the right to expect that all communications and records pertaining to his/her care will be treated as confidential by all healthcare providers, except in cases such as suspected abuse and public health hazards when reporting is permitted or required by law. The patient has the right to expect that the healthcare provider will emphasize the confidentiality of this information when it releases it to any other parties entitled to review information in these records.

The patient has the right to review the records pertaining to his/her medical care and to have the information explained or interpreted as necessary, except when restricted by law.

The patient has the right to expect that, within its capacity and policies, a healthcare provider will make reasonable response to the request of a patient for appropriate and medically indicated care and services. The healthcare provider must provide valuation, service and/or

County of Merced Request for Proposal #7144 Air Ambulance Services

referral as indicated by the urgency of the case. When medically appropriate and legally permissible, or when a patient has so requested, patient may be transferred to another facility. The institution to which the patient is to be transferred must first have accepted the patient for transfer. The patient must also have the benefit of complete information and explanation concerning the need for, risks, benefits, and alternatives to such a transfer.

The patient has the right to ask and be informed of the existence of business relationships among the healthcare providers or payers that may influence the patient's treatment and care.

The patient has the right to consent to or decline to participate in proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent. A patient who declines to participate in research or experimentation is entitled to the most effective care that the healthcare provider can otherwise provide.

The patient has the right to expect reasonable continuity of care when appropriate and to be informed by physicians and other caregivers of available and realistic patient care options when the care is no longer appropriate.

The patient has the right to be informed of policies and practices that relate to patient care, treatment, and responsibilities. The patient has the right to be informed of available resources for resolving disputes, grievances, and conflicts, such as ethics committees, patient representatives, or other mechanisms available. The patient has the right to be informed of the charges for services and available payment methods.

County of Merced Request for Proposal #7144 Air Ambulance Services

Health Care Compliance Plan Of Air Methods Corporation

County of Merced Request for Proposal #7144 Air Ambulance Services

GENERAL PRINCIPLES OF THE COMPLIANCE PLAN

INTRODUCTION

It is the fundamental policy of Air Methods Corporation, (the “Company” or “Air Methods”) that all of its business and other practices be conducted at all times in compliance with all applicable laws and regulations of the United States, all other applicable state and local laws and ordinances, and the ethical standards/practices of the Company. This policy statement is a reaffirmation of the importance of the highest level of ethical conduct and standards.

The Board of Directors of the Company, at its regularly scheduled meeting on November 2, 2011, adopted the resolution attached hereto as EXHIBIT A and approved the development of a Health Care Compliance Plan (the “Plan” or “Compliance Plan”). A Health Care Compliance Subcommittee of the Company’s Compliance Committee will be formed to review and modify the Plan as appropriate. This Plan was approved and adopted by the Company’s Board of Directors on that same day, November 2, 2011.

The Company provides several types of air ambulance services, including hospital-based services (“HBS”) and community-based services (“CBS”), using both rotary wing and fixed- wing aircraft in emergent and non-emergent situations. In the Company’s HBS operation, Air Methods contracts with a hospital or other medical facility to provide only air transport equipment and maintenance; the hospital provides appropriate medical personnel and facilitates payment. In the CBS operation, the Company provides full- service air ambulance transport, including transport equipment, maintenance, and personnel as well as all medical equipment, personnel, and billing.

Each service segment and affiliated equipment must comply with all applicable state and federal regulations. The Plan is intended as a guide to help the Company implement its policy of compliance with all applicable standards. However, the federal, state and local laws, regulations, and ethical rules that govern medical care are too numerous to list in the Plan and vary to some extent from state to state. Accordingly, while most sections of the Plan apply to all Company operations, some provisions of the Plan may not be relevant to the entire Company.

Fundamentally, all individuals associated with the Company by employment, contract, or otherwise are expected to conduct all business activities honestly and fairly. Any conduct which does not conform to applicable standards is forbidden. The Plan applies to all board members, professional and clinical staff, administrative personnel, and all other health care professionals affiliated with, employed by, or contracting with the Company, all Company Employees, consultants, and others doing business with the Company

County of Merced Request for Proposal #7144 Air Ambulance Services

(collectively, “Employees” and noted specifically as “Contractors” where appropriate). The Plan further applies to all business decisions in every area of the Company and to decisions regarding the Company’s relationships with patients, Company-based and affiliated healthcare professionals, third-party payors, regulatory agencies, subcontractors, independent contractors, vendors, and consultants.

The Plan will be distributed and explained to all management officials in each Air Methods base location. In addition, the Plan and supplemental information dealing with specific topics within the Plan will be distributed to Employees or Contractors in certain areas as deemed appropriate, including but not limited to, all personnel involved in billing and collections, contracts and arrangements with third parties, and marketing. Each Employee or Contractor is responsible for his or her own conduct in complying with the Plan’s content. Employees and Contractors are expected to regularly consult the written policies and procedures that take into consideration various functions and operations of the Company.

The Plan is monitored on a regular basis and reviewed no less than annually by the Compliance Officer (“CO”). From time to time, in coordination with the Compliance Committee and the Health Care Compliance Subcommittee, the CO may recommend for approval by the Board of Directors the addition, deletion or revision of parts of the Plan.

INTEGRATION OF COMPANY POLICIES AND PROCEDURES

The Company believes that dedication to high ethical standards and compliance with all applicable laws and regulations is essential to its mission. Our internal policies and procedures provide guidance to all Employees and Contractors and facilitate the achievement of daily activities in accordance with appropriate ethical and legal standards.

The Company’s individual policies and procedures should comply and be consistent with the Plan and with appropriate training and educational programs. These activities should emphasize areas of special concern that have been identified by the U.S. Department of Health and Human Services’ Office of the Inspector General (“OIG”). The OIG periodically issues Advisory Opinions, Special Fraud Alerts, Bulletins and other guidance on a variety of issues and potentially improper activities. The Company’s Compliance Plan requires that the CO, the Company’s legal counsel, or other appropriate personnel carefully consider any and all guidance issued by the OIG.

EMPLOYEE RESPONSIBILITIES

It is impossible to fully anticipate every scenario in which personal judgments must be made by an Employee or Contractor that implicates a compliance issue. Thus, if an Employee or Contractor is uncertain about his or her own or another Employee or Contractor’s compliance with the Company’s policies or with the law, it is incumbent upon the Employee

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or Contractor to ask questions and raise concerns. It is the right of the Employee and Contractor to do so without fear of retaliation. For more information on reporting concerns, see Sections III.E-F of this Compliance Plan.

Failure to adhere to Company policies, procedures, and the Compliance Plan may result in disciplinary action, up to and including termination. As such, all Employees and Contractors are required to understand the Company’s policies and procedures relating to their job duties and report activities that may violate the terms of any Company policy. All Air Methods management officials are further obligated to educate Employees and Contractors about compliance risks and Company policies, identify compliance violations, take prompt corrective action to address compliance issues, and fully cooperate with the CO to ensure thorough management of compliance investigations and evaluations, as well as implementation of enhancements to the Plan.

SUBSTANTIVE GUIDELINES OF THE COMPLIANCE PLAN

QUALITY OF PATIENT CARE AND PATIENT BILL OF RIGHTS

The Company has standards of patient care that reflect federal, state and local laws and regulations, respective medical, professional and clinical practice guidelines, and professional and accrediting body standards.

Quality of Care

OIG has authority to exclude an entity from participation in any and all federal health care programs if an entity provides substandard care to its patients. In order to ensure the care that the Company renders meets professionally recognized standards, the Company will comply with all nationally recognized standards of care for ambulance and air ambulance operation. In addition, the Company will develop protocols that it will utilize to monitor the quality of care provided in its various departments. At a minimum, the Company will ensure that it:

• Provides targeted training for the providers, managers, administrative staff, officers, and directors regarding applicable standards of care for air ambulance services;

• Maintains adequate staffing levels of professionals with sufficient training and regularly assesses staffing patterns considering, at a minimum, staff skill levels, staff turnover, staffing schedules, disciplinary records, and adverse event reports; and

• Provides adequate services to treat a patient’s clinical condition in accordance with all national standards of care.

County of Merced Request for Proposal #7144 Air Ambulance Services

The Company must periodically review its surveys and plans of correction to ensure that any deficiencies cited in prior surveys relating to the quality of patient care are not recurring. Likewise, the Company should review all corrective action plans instituted in response to previous survey findings to determine whether such corrective action has resolved all previously cited deficiencies.

Patient Bill of Rights

The Company’s patients deserve services with concern for personal safety and dignity, and it is the responsibility of all Employees and Contractors to respect and preserve these rights. Attached as EXHIBIT B is the Company’s Patient Bill of Rights. In furtherance of the Patient Bill of Rights, the Company will follow the following guidelines in addition to developing corresponding policies and procedures regarding patient rights:

• The Company will have policies and procedures in place to respond appropriately to patient grievances, complaints, and concerns. • A patient’s personal records, including medical records, shall be made available to the patient upon request. The Company shall safeguard the confidentiality of all patients’ medical and other confidential and proprietary records as required by law.

• The Company will implement effective recruitment, screening and training of Employees and Contractors to minimize risks to patient safety, including verification of education, licensing, and certification and the use of criminal record databases for screening purposes.

• The Company will maintain an effective training program in which Employees and Contractors will be educated regarding the Company’s policies and procedures involving patient rights.

FEDERAL FRAUD AND ABUSE, ANTI-KICKBACK, AND SELF- REFERRAL LAWS

The Company is subject to numerous federal and state laws regulating practices and relationships within the health care industry. These laws are designed to prevent fraud in federal and state health care programs, including Medicare and Medicaid, and abuse of the public funds supporting the programs, to regulate patient referrals, and to prohibit false statements to the government. The Company is committed to compliance with all applicable federal and state rules. All Employees and Contractors throughout the Company should be aware of these laws and notify the CO of any potential violations by the Company.

County of Merced Request for Proposal #7144 Air Ambulance Services

Fraud and abuse, anti-kickback, and self-referrals are areas in which the Company should be particularly cautious to differentiate the risks posed by its CBS operations from its HBS operations due to the potential for abuse in both operations. Specifically, although the hospital, not the Company, bills the federal and state health care programs for the Company’s HBS services, the HBS arrangements with hospitals nevertheless present risk of kickbacks and referrals. For example, there may be risks associated with certain efforts of the Company or its Employees and Contractors to retain HBS contracts. Additionally, with respect to the Company’s CBS operations, the comingling of medical and transportation services increases the likelihood of referrals, kickbacks, and other potential abuses as the Company competes with other ambulance service providers for business and medical facilities compete for patients.

The Federal Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b)

Generally, the Federal Anti-Kickback Statute makes it a criminal offense to knowingly and willfully offer, pay, solicit or receive any remuneration, directly or indirectly, in return for referrals or to induce referrals, or to arrange for or recommend goods, facilities, services or items for which payment may be made under a Federal Health Care Program. The term “Federal Health Care Programs” is broadly defined to include any plan or program that provides health benefits funded in whole or in part, by the federal government except for the Federal Employees Health Benefits Program.1

The Federal Anti-Kickback Statute has been interpreted to cover arrangements where one purpose of the remuneration is to induce referrals, even though other legitimate business purposes may exist. Legal counsel should be consulted whenever there is a concern regarding a potential or actual kickback issue, and prior to entering into relationships with physicians and other health care professionals. The federal government has identified certain business arrangements, some of which are discussed below, which could potentially violate the Federal Anti-Kickback Statute.

Penalties for violations of the Federal Anti-Kickback Statute can be severe and it is a criminal statute. Potential criminal penalties include fines of up to $25,000 per violation, felony conviction punishable by imprisonment up to five years, or both, as well as possible exclusion from participation in the Federal Health Care Programs. The government may issue a civil fine of up to $50,000 for each violation and an assessment of three times the amount of the kickback.

The Federal Anti-Kickback Statute and corresponding regulations establish a number of “safe harbors” for common business arrangements. Arrangements that fit squarely under one of the safe harbors are protected from liability under the statute. Several of the safe harbors are particularly relevant to the Company’s operations, including the safe harbor for ambulance restocking, space and equipment rental, personal services and management contracts, warranties, discounts, employee contracts, electronic health

County of Merced Request for Proposal #7144 Air Ambulance Services

records items and services, group purchasing, and cost-sharing and deductible arrangements. Although failure to comply with a safe harbor does not necessarily result in an illegal arrangement, the Company will structure arrangements to fit in a safe harbor wherever possible.

In addition to the Federal Anti-Kickback Statute, states have adopted laws that are designed to prohibit payment by health care providers to induce referrals of items or services reimbursed by federal, state or commercial payors. Accordingly, any relationships or payments to or from any physician or healthcare provider must be scrutinized under applicable state laws as well.

To identify potential risks under the Federal Anti-Kickback Statute requiring the Company’s careful scrutiny, the Company shall engage regularly in the following inquiries:

• Does the Company or its agents or employees provide anything of value to persons or entities in a position to influence or generate Federal Health Care Program business for the Company directly or indirectly?

• Does the Company or its agents or employees receive anything of value from persons or entities for which the Company generates Federal Health Care Program business directly or indirectly?

1 The term “Federal Health Care Programs” means those programs discussed in section 1128B(f) of the Social Security Act.

• Could one purpose of an arrangement be to induce or reward the generation of business payable in whole or in part by a Federal Health Care Program?

• Does a given arrangement or practice have a potential to interfere with or skew clinical decision-making?

• Does a given arrangement or practice have a potential to increase costs to Federal Health Care Programs or beneficiaries?

• Does a given arrangement or practice have a potential to increase the risk of overutilization or inappropriate utilization?

• Does a given arrangement or practice raise patient safety or quality

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of care concerns?

In addition to the above-listed inquiries, the Company should, depending on the particular circumstances, consider the following factors in evaluating potentially problematic arrangements that do not fit into a safe harbor:

• Nature of the relationship between the parties;

• Manner in which participants were selected;

• Manner in which the remuneration is determined;

• Value of the remuneration;

• Nature of items or services provided;

• Potential Federal Health Care Program impact;

• Potential conflicts of interest; and

• Manner in which the arrangement is documented.

Ambulance Restocking

Hospitals and other medical facilities are permitted to enter into certain arrangements for restocking ambulances with medical supplies, drugs, and linens under a safe harbor to the Anti- Kickback Statute. In order to obtain protection from this safe harbor, both the Company and the medical facility must ensure proper, non-duplicative billing for the restocked supplies; one party must generate appropriate documentation for the restocked supplies, and both parties must retain copies of the documentation for a minimum of five (5) years; restocking must in no way be related to referrals, and both parties must comply with other applicable laws, particularly those involving controlled substances. Although most restocking arrangements are made to facilitate emergency transports, restocking may be provided for non-emergency transports as long as the restocked vehicle is also used to respond to emergency calls.

In addition to the requirements above, the restocking arrangement must fall within one of the safe harbor categories discussed below. The Company will ensure legal counsel and the CO have reviewed and approved the terms of all restocking arrangements.

General Restocking

General restocking may occur with or without a fee, but it requires that the arrangement be

County of Merced Request for Proposal #7144 Air Ambulance Services

publicly disclosed or made in accordance with a generally-applicable EMS protocol. Additionally, the restocking facility must treat all ambulance providers in a particular category (for-profit, non-profit, or non-charging) equally.

Fair Market Value Restocking

Fair Market Value Restocking is permitted if the ambulance provider provides the restocking facility with a commercially reasonable fair market value reimbursement based on an arms- length transaction. Additionally, the payment arrangements for restocking must be made in advance. Fair Market Value Restocking applies only to medical supplies and linens, and it does not apply to drug restocking arrangements.

Government-Mandated Restocking

The safe harbor provides a blanket exception for all restocking done pursuant to state or local law, ordinance, regulation, or binding protocol that requires medical facilities to restock ambulances with supplies used during the transport of a patient to the facility.

Joint Ventures

From time to time, the Company may enter into relationships with health care entities, physicians or other providers in a position to refer patients to the Company. These relationships may take the form of joint ownership in a corporate entity. Where the Company and a potential referral source invest money jointly in an entity, payments received from the entity and/or any other financial transaction surrounding the formation of the entity, may be scrutinized to determine whether the joint venture runs afoul of the Federal Anti-Kickback Statute. The Company will ensure that it structures any relationship with a potential referral source in a manner that is consistent with the provisions of the Federal Anti-Kickback Statute. When possible, the Company will attempt to structure transactions so that such transactions fit within the safe harbors set forth in the Federal Anti-Kickback Statute and its regulations. In addition, the Company will ensure that any sum of money that it receives from or provides to any venture with a potential referral source is not a payment for referrals.

No Company Employee or Contractor shall enter into any agreement or incur any obligation to any joint venture partner until legal counsel and the CO have reviewed and approved the terms and provisions of the joint venture.

Gifts

The Company and its Employees and Contractors will not routinely give anything of value—either goods or services—to physicians or other individuals that are in a position to

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refer patients to the Company. The Company and its Employees and Contractors also will not receive any goods or services of value from any entity or person to which the Company refers patients. Such prohibited gifts include goods or services that have independent value to the recipient or that the recipient would otherwise have to provide at its own expense. Additionally, such prohibited gifts include anything with more than nominal value, namely $10, including event tickets, entertainment, and meals.

While there may be some instances where specific items may be given or accepted, Employees and Contractors should always consult with the CO prior to providing any gift to a referral source or potential referral source, and prior to receiving any gift from any individual or entity to which the Company refers patients or will potentially refer patients.

Relationships with Physicians

The Company may enter into contracts and other arrangements with physicians and other health care entities to provide or receive services reimbursed under the Federal Health Care Programs and by commercial payors. These agreements may include, but are not limited to, billing and staffing services agreements, medical director agreements, and agreements with pharmaceutical distributors or manufacturers.

The Company will ensure, at a minimum, that any payments made under such arrangements are at fair market value, based on an arms-length transaction, and that they do not take into account, directly or indirectly, the volume or value of referrals or other business generated between the parties to the contract. In order to ensure that all such agreements are compliant with state and federal anti-kickback statutes, the CO or legal counsel (as appropriate) will review all agreements with the aforementioned providers, manufacturers and suppliers before such agreements are executed.

Relationships with Non-Physicians

In addition to engaging in arrangements with physicians, the Company may also enter into contracts and other arrangements with non-physicians for goods and services reimbursed under the Federal Health Care Programs. These agreements may include, but are not limited to, space and equipment leases, arrangements with hospitals and other medical facilities for ambulance restocking or other services, medical staffing firms, medical suppliers, and ground and other air ambulance providers. The CO and/or legal department will review all such agreements to ensure that payments under such agreements do not violate the Federal Anti- Kickback Statute or similar state laws.

The Company should ensure that in such arrangements, there is a legitimate need for the services or supplies, the services or supplies are actually provided and adequately documented, the compensation is at fair-market value based on an arms-length transaction and the arrangement does not take into account, directly or indirectly, the

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volume or value of referrals or other business generated between the parties to the contract.

Discounts

The Company may enter into agreements whereby it provides or receives discounts for specific services. All discounts or rebates must be in the form of a reduction in the price of the good or service based on an arms-length transaction. The Company must properly disclose and accurately report these discounts in its billing to the Federal Health Care Program. In addition, the Company must ensure that there is no link or connection, explicit or implicit, between discounts and a referral of business billable to the agreement to a Federal Health Care Program. These improper arrangements are commonly referred to as “swapping” and may implicate the Federal Anti-Kickback Statute. To ensure proper reporting of these arrangements and avoidance of improper swapping, the CO must approve all such agreements before they are executed.

Arrangements Between the Company and Hospitals or Other Referral Sources

Agreements between the Company and hospitals or other referral sources should be scrutinized to determine if goods or services are provided to or by the Company at or below fair market value in an effort to induce the referral of patients to the Company, hospitals, or other health care entities. Employees and Contractors should be particularly careful that the Company and/or Employees and Contractors do not receive anything of value for free from a hospital in an effort to induce the referral of patients to these entities. Employees and Contractors should also be cautious to not give anything of value for free or below fair market value to a hospital in an effort to retain an HBS arrangement.

Several types of arrangements between the Company and hospitals that are particularly suspect under the Anti-Kickback Statute, include the following:

• The Company offering free goods or goods at below fair-market value to induce the hospital to continue its contractual arrangement with the Company for ambulance services;

• The Company offering free goods or goods and below fair-market value to first responders or dispatch centers to induce patient referrals to the Company;

• A hospital offering the Company below fair-market goods to induce the Company to refer its patients to that hospital; and

• The Company providing staff or services to a hospital at the Company’s expense or for a below fair-market value rate.

Due to the increased scrutiny that these arrangements receive from enforcement agencies,

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the CO or legal counsel must review all arrangements with the aforementioned providers.

The Physician Self Referral Act (“Stark Law”), 42 U.S.C. § 1395nn

The Stark Law provides that if a physician (or a family member) has a “financial relationship” with a company, then the physician is prohibited from referring patients to that company for the provision of “designated health services” (“DHS”), as defined by the Stark Law and corresponding regulations, that are paid for by Medicare or Medicaid, unless an exception applies. The Stark Law also prohibits companies from submitting, and Medicare from paying, any claim for a DHS if the referral of the DHS comes from a physician with whom the company has a prohibited financial relationship. This is true even if the prohibited financial relationship is the result of an inadvertence or error. A “financial relationship” includes direct or indirect ownership or investment interests and direct or indirect compensation arrangements between a physician (or the physician’s family member) and any entity that provides DHS.

“Designated Health Services” include:

Clinical laboratory services; physical therapy services; occupational therapy services; radiology or other diagnostic services; radiation therapy services; durable medical equipment and supplies; parenteral and enteral nutrients, equipment, and supplies; prosthetics, orthotics and prosthetic devices and supplies; home health services; outpatient prescription drugs; and inpatient and outpatient hospital services.

Although Air Methods does not provide DHS, the Company and its Employees and Contractors routinely engage in the referral of patients for DHS. Most often, these referrals are for inpatient and outpatient hospital services. Thus, the Company must ensure compliance with the Stark Law and corresponding regulations.

There are various penalties for violating the Stark Law. First, an entity to which a prohibited referral was made may not bill for services rendered. Therefore, if an entity provides DHS to a client referred by a physician who has a financial relationship which does not meet one of the exceptions to the Stark Law, the entity will not be paid for providing those services. An entity which received payment pursuant to an illegal referral must refund the payment. In addition to having to return the money, both the physician and the entity who accepted the prohibited referral may be subject to civil monetary penalties and exclusion from the Medicare and Medicaid programs for making such illegal referrals. A violation of the Stark Law may result in penalties of $15,000 per claim, plus triple the amount claimed, and $100,000 for participation in a circumvention scheme. Further, a violation of the Stark Law also could form the basis for a False Claims Action.

Unlike the Federal Anti-Kickback Statute, whether a particular arrangement violates the Stark Law does not depend on the intent of the parties. Therefore, an arrangement

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which implicates the Stark Law must qualify for an exception. There are a number of exceptions to the Stark Law which, if met, have the effect of permitting a physician with an ownership interest or compensation arrangement with an entity to refer Medicare or Medicaid clients to such entity for the provision of DHS. Legal counsel should be consulted regarding the availability of these exceptions. A comprehensive Stark Law analysis must be undertaken when the Company and any physician enter into any financial arrangement. While exceptions may exist for certain types of arrangements, such as equipment and office leases, bona fide employment arrangements, personal services arrangements and one-time isolated transactions, any such arrangements must be reviewed by the CO and legal counsel, as appropriate, to determine whether the arrangement fits squarely within one of the enumerated exceptions. It is important to note that compliance with the Stark Law exception does not immunize an arrangement under the Federal Anti- Kickback Statute. Accordingly, the CO and legal counsel must examine arrangements under both legal analyses.

In addition to analyzing each arrangement carefully, the Company should also implement several systemic measures to decrease the likelihood of Stark Law violations. The Company should enter into appropriate written agreements with physicians and regularly review their contracting processes to ensure that the Company obtains and maintains signed agreements for all arrangements with physicians. The Company should also ensure that its operations have appropriate processes for making and documenting reasonable, consistent and objective determinations of fair-market value for goods and services that facilities receive. Finally, the Company should implement systems to track non-monetary compensation that the Company provides to physicians (i.e., free parking or gifts) and ensure that such compensation does not exceed permissible limits under the Stark Law.

FEDERAL AND STATE FALSE CLAIMS STATUTES

The federal civil False Claims Act (“FCA”) is designed to enhance the government’s ability to identify and recover losses it suffers due to fraud. The FCA aims to detect fraud by encouraging individuals, often called “whistleblowers” or “relators,” to uncover and report fraud, and to prevent fraud by creating strong incentives for companies and individuals to be vigilant in their pursuit of compliance and avoid liability for multiple damages and penalties under the statute.

The federal FCA prohibits any individual or company from knowingly making certain false or fraudulent claims for federal funds, causing someone else to make such false or fraudulent claims, or making a false statement related to such a false or fraudulent claim. The federal FCA also prohibits any individual or company from knowingly and improperly avoiding or decreasing an obligation to the federal government, such as failing to return an overpayment to a Federal Health Care Program within 60 days of identifying such overpayment. Any individual who conspires to do any of these actions is also subject to

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liability under the federal FCA. Violations of the FCA are subject to repayment of up to three times the government’s damages plus civil penalties of $5,500 to $11,000 per false claim.

In addition, the federal FCA authorizes private citizens to file a lawsuit in the name of the United States in a lawsuit commonly known as a qui tam action. Whistleblowers are offered certain protections against retaliation for bringing an action under the FCA. Employees and Contractors who are discharged, demoted, harassed, or otherwise confront discrimination in furtherance of such an action or as a consequence of whistleblowing activity are entitled to all relief necessary to make the employee whole. Such relief may include reinstatement, double back pay, and compensation for any special damages including litigation costs and reasonable attorneys’ fees.

Many states have enacted statutes similar to the federal FCA, providing a civil remedy for the submission of false and fraudulent claims to state health care programs, including primarily Medicaid. The state statutes also contain whistleblower provisions that allow enforcement through qui tam actions, and protect whistleblowers from retaliation. Several states also impose criminal penalties for the submission of false claims to a state health care program.

Under the Deficit Reduction Act of 2005, the Company is required to establish written policies for all employees with detailed information about the FCA, administrative remedies for false statements under federal law, applicable state laws establishing civil or criminal penalties, the existence of whistleblower protections, and the role of federal and state laws in preventing and detecting fraud, waste, and abuse.

Please refer to the Company’s Employee Handbook as well as its policies and procedures for detecting and preventing fraud, waste, and abuse as well as a discussion of the applicable laws and rights of employees to be protected as whistleblowers.

DEALINGS WITH GOVERNMENT AGENCIES

Any communication with a government agency must be responsive, accurate, and complete. Any data or other information provided to a government agency must be accurate, complete, and include an explanation of any omission or inability to respond. All government agents will be treated with respect. Any inquiry from a government agent outside the normal course of ministerial interactions for purposes of compliance with mandatory reporting requirements will be referred to the CO. In no event will any Employee or Contractor of the Company be prohibited from speaking voluntarily with a government agent engaged in an investigation or an enforcement action, although they may be advised that they are not obligated to speak with an agent.

CLAIMS DEVELOPMENT: BILLING AND COLLECTIONS

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The Company has an obligation to its patients, third party payors, and the federal and state governments to exercise diligence, care and integrity when submitting claims for payment for services rendered. To uphold this obligation, the Company shall maintain honest, fair, and accurate billing practices. All individuals involved in the billing functions of the Company, including Employees, Contractors and any outside vendors, shall have experience and knowledge, and billing personnel shall be appropriately trained to perform all billing functions in accordance with federal, state and local law.

To the extent that is has not already done so, the Company shall develop or adopt and maintain detailed written billing policy and procedure manuals to provide guidance to billing and coding staff. It should include job descriptions and the duties and minimum experience and educational requirements for each position in the billing department. With respect to reimbursement claims, the Company’s written policies and procedures should reflect and reinforce current federal and state statutes and regulations regarding the submission of claims. These policies must create a mechanism for the billing or reimbursement staff to communicate effectively and accurately with the clinical staff.

To avoid potential criminal and civil liability for violations of the Civil False Claims Act, 31 U.S.C. §§3729a-3733; the False Statements Act, 18 U.S.C. § 1001; the corresponding administrative prohibitions for false claims and statements, 42 U.S.C. § 1320a-7b(a); and all applicable state laws and regulations, the Company’s billing policies and procedures should particularly emphasize the following:

• Bill third-party payors only for those services ordered and provided, as supported by valid, non-falsified medical record documentation; • Submit claims only when appropriate documentation supports the claims and only when such documentation is maintained and available for review; • Avoid any duplicate billing; • Avoid billing for non-covered services as if covered; • Avoid billing for services and items not rendered; • Avoid knowingly billing for substandard care; • Avoid submitting claims for medically unnecessary services;

Ensure that claims submitted for air ambulance services meet the medical necessity standard for air ambulances, namely that other methods of transport are contraindicated due to distance to nearest appropriate facility, travel time required, or the pickup locality is inaccessible by ground transportation;

Avoid upcoding the HCPCS procedure code if upcoded services were not provided; Avoid billing for each patient transported in a group as if he or she was transported separately;

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Avoid misrepresentation of the transport destination to make it appear as if the transport was covered (e.g., Medicare will only reimburse air ambulance flights to hospitals); Avoid hiring or contracting with anyone excluded from the Federal Health Care Programs by implementing appropriate screening and removal mechanisms; Accept only Medicare or Medicaid payments for services provided to Medicare or Medicaid beneficiaries and avoid accepting any supplemental payments (i.e., cash, or free or discounted items and services) for services provided to these beneficiaries; Provide procedures for proper and timely identification and refund of any credit balances (excess payments made to a health care provider due to billing or claims processing errors); Assure that written policies and procedures regarding billing are designed to ensure that the procedure codes selected represent the actual services provided; Assure that the compensation for any Employee or Contractor, including any billing coders and billing consultants, does not provide any financial incentive to upcode claims; and Provide for proper and timely documentation of the services of health care providers.

CREDIT BALANCES

All providers who receive excess amounts of reimbursement from Medicare or other Federal Health Care Programs are required to report and return such overpayments within 60 days after identification. Providers are required to describe any credit balances that exist and provide their justification for retaining any overpayment. Providers may not retain overpayments on the basis that a federal payor owes them money for other services rendered to Federal Health Care Program beneficiaries. In fact, providers may be liable under the Federal False Claims Act for failing to report and repay any overpayment to which the provider is not entitled. In addition, many commercial payor contracts contain provisions that relate to recoupment of overpayments and the appropriate treatment of amounts paid in excess of that to which a provider is entitled.

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RECORD STANDARDS, RETENTION, AND CONFIDENTIALITY

Documentation

In addition to facilitating high quality patient care, properly documented patient records verify and document precisely what services were actually provided. Internal guidelines the Company may use to ensure accurate medical record documentation shall include, but not be limited to, the following:

Patient medical records are complete and legible; Maintain complete and thorough records of all services provided to patients;

If not documented, the rationale for ordering all medical services can be easily inferred by an independent reviewer or a third party with appropriate medical training;

Clinical documentation for all transports includes:

• The patient’s presentation; • The patient’s chief complaint; • The history of the patient’s present illness; • Past medical, family and relevant social history; • Documentation of current medications and status of allergies; • Physical assessment, clinical impression, treatments provided; • Method of transfer; • Changes in patient status; and • Transfer of care.

Each patient encounter contains the following demographic and billing information:

• Address where patient was found including city, county, and state; • The correct name of person who initiated call and the source of the call; • The type of location where the incident occurred; • The accurate date of incident; • Nature of call with related response; • Time of the event; • Response mode; • Service type; • Incident and response numbers; • Patient record number; • Agency and unit number; • Vehicle type; • Crew members and level(s) of certification;

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• Transport mode; • Destination type; and • Mileage.

Additionally, there are two elements of documentation that must be addressed in every record: (1) patient demographics; and (2) clinical justification for the service. In order to assure accurate payment for services, documentation must include accurate patient demographic information; insurance information; prior authorization if required by payer (not applicable for Medicare); Physician Certification Statement; patient signatures; designation of the responsible party; service levels; and documentation of medical necessity relevant to ambulance or EMS services.

The Company will implement a process to audit documentation regularly and to notify personnel on a routine basis if documentation is not adequate to support the services that are performed. Inadequate documentation may be the root of both internal and external investigations of inappropriate conduct, and have been identified by the OIG as a leading cause of improper payments.

Record Retention

Unless otherwise stated in a record retention policy, all records of the Company shall be maintained for a period not less than seven (7) years, and in accordance with Medicare, Medicaid, and all federal, state and local regulatory guidelines. Medical records shall be secured against loss, destruction, unauthorized access, unauthorized reproduction, corruption, or damage.

In addition to medical records, the Company should, at a minimum, develop protocols and policies to address maintenance and retention of the following records:

Records and documentation that support billing and other financial information; Records sufficient to verify the compliance status of equipment, medical supplies, and staff licensure; Surveys and corrective action plans; Documents that illustrate the effectiveness of the Compliance Plan; Documents memorializing discussions with state or federal regulators; and All documents required for participation in the state and Federal Health Care Programs.

Integrity of data systems

The Company will ensure the maintenance and security of the Company’s information systems and resource materials used by the billing department. The Company will require that all Employees and Contractors with access to the information systems use secured password settings. The information systems shall be “backed up” on a regular basis.

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HIPAA

As of April 14, 2003, all companies transmitting electronic transactions to health plans were required to comply with the privacy rules of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as amended by the Health Information Technology for Economic and Clinical Health (“HITECH”) Act, enacted as part of the American Recovery and Reinvestment Act of 2009.

Generally, the HIPAA privacy rule (“Privacy Rule”) addresses the use and disclosure of individuals’ health information (“protected health information” or “PHI”) by companies and other covered entities, as well as standards for individuals’ privacy rights to understand and control how their health information is used. The Company shall ensure that it is compliant with all applicable provisions of the Privacy Rule, including provisions pertaining to required disclosures (such as required disclosures to the Department of Health and Human Services when it is undertaking an investigation or review or enforcement action) and that the Company’s privacy procedures are tailored to fit its particular size and needs. In addition, the HIPAA security rule (“Security Rule”) specifies a series of administrative, technical, and physical security procedures for companies that are covered entities and business associates to use to assure the confidentiality of electronic PHI. The Company shall implement and update as necessary appropriate safeguards to ensure continued compliance with the Security Rule.

For additional guidance on HIPAA, please refer to the Company’s HIPAA policies and procedures.

ADMINISTRATION OF THE PLAN

DESIGNATING A COMPLIANCE OFFICER

The responsibility for the direction and operation of this Compliance Plan shall be vested in the Compliance Officer (“CO”). The CO shall be a high-level Employee of the Company, and shall be appointed by the chief executive officer (“CEO”) of the Company. The CO shall report directly and be responsible to the CEO, or officers designated by the CEO, and to the Board of Directors.

The CO’s duties shall include: • Overseeing and monitoring the Company’s health care compliance activities;

• Reporting to the Board of Directors on the progress of implementation of the Company’s Compliance Program;

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• Assisting the CEO and the Board in establishing methods to improve the Company’s efficiency and quality of services, and to reduce the Company’s vulnerability to health care fraud, abuse and waste;

• Ensuring that the Compliance Plan is being implemented and evaluating its progress;

• Periodically reviewing the Compliance Plan and recommending revisions as necessary to meet changes in the business and regulatory environment;

• Developing, coordinating, and participating in a multifaceted educational and training program that focuses on the elements of the Compliance Program, and ensures that all appropriate Employees and Contractors are knowledgeable of, and comply with, pertinent federal and state law;

• Ensuring that independent contractors and other third parties dealing with the Company are aware of the Company’s Compliance Plan;

• Ensuring that state licensure records, OIG List of Excluded Individuals and Entities, and the General Services Administration’s (“GSA”) List of Parties Debarred from Federal Programs have been checked with respect to all Employees and Contractors;

• Working closely with legal counsel to review and update the education, training, and the Company’s Compliance to reflect the current federal, state and local laws;

• Coordinating internal auditing and monitoring of activities within the Company as necessary in connection with the Compliance Plan;

• Reviewing all departments on a periodic basis, but not less than annually;

• Reviewing and assessing business contracts involving the Company’s clinical staff and contractors where appropriate;

• Ensuring that the Compliance Plan has been effectively communicated to all Employees and Contractors of the Company;

• Administering a communication system (or hotline) that is available to all Employees or Contractors to report any suspected illegal conduct or other conduct that violates the Compliance Plan or applicable law;

• Receiving and investigating reports of possible illegal conduct or other conduct that violates the Compliance Plan;

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• Developing policies and programs that encourage managers, Employees, Contractors and clinical staff to report suspected fraud and other improprieties without fear of retaliation; and

If so directed by the CEO, the Board of Directors of the Company or legal counsel, to notify appropriate law enforcement authorities of possible illegal misconduct.

COMPLIANCE COMMITTEE

The Company will establish the Health Care Compliance Subcommittee of the Company’s Compliance Committee to identify and build upon existing Company policies and procedures and to develop and implement a work plan for the creation and establishment of the Plan.

In coordination with the CO, the Health Care Compliance Subcommittee shall meet periodically to discuss, review and resolve health care compliance issues. In coordination with the CO, Health Care Compliance Subcommittee’s functions may include, but are not limited to:

• Analyzing the business, industry, environmental and legal requirements with which the Company must comply, including specific risk areas;

• Assessing existing policies and procedures that address these areas for possible incorporation into the Compliance Program;

• Developing and maintaining policies and procedures to promote compliance with the Company’s Compliance Plan and policies;

• Recommending and monitoring the development of internal systems and controls to carry out the Company’s standards, policies, and procedures as part of its daily operations;

• Developing a system to solicit, evaluate, and respond to complaints; and

• Determining the appropriate approach or strategy to promote compliance with the Plan and detect potential violations.

Acting through the CO and in conjunction with, as necessary, the Company’s legal department, the Health Care Compliance Subcommittee is empowered to investigate, evaluate and report facts, and make recommendations to the Company’s management of possible responses or initiatives, including disciplinary or other adverse action for misconduct by Employees or Contractors.

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EDUCATION AND TRAINING

Effective implementation of the Compliance Plan requires training and education for all Employees and Contractors so that each has a clear understanding of his or her responsibilities and rights under the Plan. Education and training emphasizes the Company’s commitment to full compliance with all laws, regulations and guidelines of federal and state programs.

It is not essential, however, that every Employee and Contractor be educated concerning every aspect of the Plan. Indeed, given the wide variety of services in which the Company engages, all aspects of the Plan will not be relevant to all Employees. Accordingly, in addition to the Plan, each Employee and Contractor shall receive compliance materials appropriate to his or her particular position and duties within the Company, as determined by the CO.

It is anticipated that the Company will require annual compliance program education and training of its medical professional staff, administrative Employees, billing personnel, and, if appropriate, Contractors providing similar services or functions. Additionally, individuals directly involved with billing and related aspects of the Federal Health Care Programs shall receive appropriate education throughout the year, as necessary, specific to each individual’s responsibilities on claims development and submission. The Company shall maintain updated Medicare contractor/fiscal intermediary bulletins relating to billing for hospitals and ambulance suppliers and make them available to all Employees and Contractors involved in the billing processes. The Company shall also make available updates on current billing standards and procedures.

See EXHIBIT C for more details on the Company’s fraud and abuse education.

AUDITING AND MONITORING

An ongoing evaluation process is critical in detecting noncompliance and improving the quality of work, and will help ensure the success of the Company’s Plan. This ongoing evaluation will include internal audits of compliance with the Plan, to be conducted or directed by the CO, and evaluation of claims development and submission as well as contracts and arrangements between potential referral relationships.

Upon receipt of a credible allegation or complaint alleging improper or inaccurate billing practices of the Company, or upon the initiation of an external Medicare or Medicaid audit, the Company will undertake a review of the matter in accordance with the Company’s Federal Health Care Program Investigation and Corrective Action Policy, attached hereto as EXHIBIT D.

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Internal Audits

The internal audits and reviews should target the Company’s compliance with specific rules and policies that have been the focus of particular attention on the part of the Medicare carriers, Medicaid, appropriate state entities, and law enforcement, as evidenced by OIG Special Fraud Alerts, OIG audits and evaluations, OIG annual work plan, and law enforcement initiatives.

Audits or reviews should be conducted in an objective and supportable fashion. Audit decisions based on discretion or the exercise of subjective judgment should be carefully documented. The CO will coordinate all health care compliance internal audits, and in certain circumstances, involving legal counsel in the audit process when appropriate. Audit techniques may include, but are not limited to:

• Personnel interviews;

• General questionnaires submitted to all or a subset of Employees and Contractors;

• Reviews of claims or other documentation submitted to payors including the state and Federal Health Care Programs and commercial payors; and

• Review of written materials and documentation prepared by the Company related to services provided to patients or residents.

It is anticipated that within 120 days after the adoption of this Compliance Plan, the Company will initiate a baseline audit to determine its current state of compliance. Thereafter, the Company will conduct annual education and training programs to address identified deficiencies and conduct focused issue audits in areas that the CO or Compliance Committee has determined present compliance issues or challenges for the Company.

Ongoing Monitoring

Other steps in monitoring compliance with the Plan include:

• An annual review, which shall be undertaken with legal counsel of all records of communications and reportings by all Employees or Contractors kept in accordance with this Plan;

• Any correspondence from any regulatory agency charged with administering a federally funded program received by any Employee of the Company shall be immediately copied to the CO;

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• Employees and Contractors shall notify the CO of any visits, audits, investigations or surveys by any payor, including any federal or state agency or authority;

If an audit reveals potential noncompliant conduct, the procedures set forth in the Plan shall be followed; and

Procedures shall be established by the CO to ensure that appropriate personnel are notified of changes in laws, regulations or policies, and that additional training is provided as necessary to assure continued compliance.

External Audits

It is also possible that an external audit of the Company’s billing practices may be ordered by Medicare administrators through the compliance audit program. The compliance audit program provides independent oversight of the assessment process which is the foundation of the Medicare payment system. This is achieved by random audits of all Medicare providers by Recovery Audit Contractors (“RACs”). The audit is a multi-faceted review of processes and systems that support various Medicare programs. Once data is collected from a company, a Compliance Audit Report is created and given to management. Based on the results of the audit, the audited company may be liable for returning overpayments and implementing a corrective action plan under the guidance of the auditing RAC or Medicare administrators.

DEVELOPING EFFECTIVE LINES OF COMMUNICATION

An open line of communication between the CO and all Employees or Contractors subject to this Plan is critical to the successful implementation and operation of the Plan. Confidentiality and anonymity are respected, and retaliation is never tolerated.

Employees’ and Contractors’ Duties

Employees or Contractors of the Company shall have the following duties and obligations with respect to this Plan:

To review the Plan thoroughly and ask questions when appropriate;

To report to the Company any good faith belief of any violations occurring within the Company or involving the Company’s assets, or any violation of this Plan; and to cooperate fully with the Health Care Compliance Subcommittee and the CO and their agents in their investigations.

Reporting Methods

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An Employee or Contractor shall report his or her good faith belief of violations of the Compliance Plan or applicable laws as follows, consistent with the Company’s Corporate Compliance Policies and the Employee Handbook:

• Orally or in writing to his or her supervisor or a director or officer of the Company;

• Calling the Compliance Hotline, which may be anonymous (see information listed below);

• Calling the Compliance Officer directly (see information listed below); and/or

Mailing a “Report of Violation or Suspected Violation” (see attached EXHIBIT E) describing his or her concern to:

Compliance Officer Air Methods Corporation 7301 S. Peoria Englewood, CO 80112

In addition, an Employee or Contractor may seek guidance with respect to the Plan at any time by following the reporting mechanisms outlined above.

Hotline Compliance Officer

877-874-8416 (303) 256-4182

Immediate Response to Compliance Reports

Upon receipt of a question or concern, any supervisor, officer or director shall immediately create a record of the report on a form prepared for this purpose (see EXHIBIT F). The creator of the report shall deliver it to the CO, with the condition that, if the question or concern is an allegation of a violation of the Compliance Plan or law by the CO, the report of the question or concern shall instead be immediately delivered to the CEO and legal counsel. Additionally, the hotline must be monitored and all calls must be reported in the hotline log, attached here as EXHIBIT G.

The Company, at the request of a reporting Employee or Contractor, shall provide anonymity to the Employee or Contractors who report as is possible under the circumstances in the judgment of the CO, consistent with the Company’s obligation to investigate concerns and take necessary corrective action.

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The CO, or his or her designee, shall document the information necessary to conduct an appropriate investigation of all complaints. If the Employee or Contractor was seeking information concerning the Compliance Plan or its application, the CO or his or her designee shall record the fact of the call and the nature of the information sought and respond as appropriate.

Any threat of reprisal against a person who acts pursuant to his or her responsibilities under the Plan is not only contrary to the Company’s policy, it may in some instances be a violation of the law. Any attempt to harm or slander another through false accusations, malicious rumors or other irresponsible actions is also a violation of the Company’s policy. Such actions shall be subject to discipline.

ENFORCING STANDARDS THROUGH WELL-PUBLICIZED DISCIPLINARY GUIDELINES

Disciplinary action for Employees or Contractors who have failed to comply with the Company’s policies and procedures, including federal and state laws, or for those who have otherwise engaged in conduct that has the potential of impairing the Company’s status as a reliable, honest and trustworthy health care provider, is an important part of this Plan. Therefore, violations shall subject the offender to some manner of discipline or corporate action.

Management’s Responsibility for Discipline

Under the direction of the CEO, the CO shall assure that the Company establishes procedures for the discipline of Employees or Contractors for violation of the Compliance Plan. The procedures shall become part of the Company’s Employee Handbook.

Compliance as an Element of Performance Reviews

The Company’s Compliance Plan requires that the promotion of, and adherence to, the elements of the Compliance Plan be a factor in evaluating the performance of Employees and Contractors. Employees and Contractors will be periodically trained in new compliance policies and procedures. In addition, all managers and supervisors involved in the coding, claims development, and submission process will:

• Discuss with all supervised Employees and Contractors the compliance policies and legal requirements applicable to their function;

• Inform all personnel that strict compliance with these policies and requirements is a condition of employment; and

• Disclose to all supervised personnel that the Company will take disciplinary action up

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to and including termination or revocation of privileges for violation of these policies and requirements.

Managers and supervisors will be sanctioned for failure to instruct adequately their subordinates, or for failing to detect noncompliance with applicable policies and legal requirements, where reasonable diligence on the part of the manager or supervisor would have led to the earlier discovery of any problems or violations and would have provided the Company the opportunity to correct them.

Persons Involved in Improper Activities

Any Employee or Contractor who violates the Plan shall be appropriately disciplined in accordance with the Company’s policies and procedures and, if applicable, contractual terms. Violations include the failure to report suspected improper activity. Any discipline shall be appropriately documented in the Employee’s or Contractor’s personnel file, along with a statement of reasons for imposing such discipline.

Record and Reporting of Disciplinary Actions

The CO shall maintain a record of all disciplinary actions involving the Plan and report at least annually to the Board of Directors regarding such actions.

RESPONDING TO DETECTED OFFENSES AND DEVELOPING CORRECTIVE ACTION INITIATIVES

Investigation

Upon receipt of audit results or a report or other information suggesting a possible compliance issue in which applicable laws, rules and standards of a health care program may have been breached, the Company’s Federal Health Care Program Investigation and Corrective Action Policy as set forth herein at EXHIBIT D shall be followed.

Upon receipt of audit results or a report or other information suggesting a possible compliance issue other than one involving the Medicare and Medicaid programs, the CO shall make a record of the information and confer with legal counsel before any investigation is undertaken to determine who should conduct the investigation. The investigation should be conducted by the CO with staff assistance and appropriate review by legal counsel. The CO may refer the matter to legal counsel for investigation by legal counsel or by an outside expert retained by legal counsel. An investigation shall be commenced by the appropriate person as soon as reasonably possible.

After consulting with legal counsel, the CO shall complete a written report describing the facts and circumstances surrounding the alleged problem. If the identity of the

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complainant is known, the CO shall report to the complainant that an investigation has been completed and, if appropriate, that corrective action has been taken. Notice to the complainant of the results of the investigation and any corrective action taken may be provided through the use of the Corrective Action Form found at EXHIBIT H.

Corrective Action

Corrective action for compliance issues involving the Federal Health Care Program Investigation and Corrective Action Policy is contained in EXHIBIT D.

If, following the conclusion of an investigation involving a compliance issue, it appears that there are genuine compliance concerns, the CO shall immediately formulate and implement a corrective action plan. The CO shall obtain the advice and guidance of legal counsel and approval of the CEO and/or the Board in formulating and implementing the corrective action plan. The corrective action plan shall be designed to ensure that the specific issue is addressed and, to the extent possible, that similar problems do not occur in other departments or areas.

Possible Criminal Activity

If the investigation reveals possible criminal activity (conduct which is intentional, knowing and/or willful), the Company shall:

• Immediately stop the activity related to the problem until the offending practice is corrected; • Initiate appropriate disciplinary action against the person or persons whose conduct appears to have been intentional, willfully indifferent, or with reckless disregard for the law; • Make such disclosure to any regulatory or prosecutorial authorities as legal counsel advises; • Promptly undertake an appropriate program of education to prevent future similar problems; and • Document corrective actions taken upon notice.

Other Noncompliance

If the investigation reveals noncompliant conduct that does not appear to be criminal, the Company shall:

• Immediately stop the activity related to the problem until the offending practice is corrected; • Initiate such disciplinary action, if any, as may be appropriate given the facts and circumstances;

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• Make such disclosure to any regulatory or prosecutorial authorities as legal counsel advises; • Promptly undertake an appropriate program of education to prevent future similar problems; and • Document corrective actions taken upon notice.

Any issue for which a corrective action plan is implemented shall be specifically targeted for monitoring and review in audits of that department or area.

Self-Reporting

If the CO, Compliance Committee or a member of senior management at the Company discovers credible evidence of misconduct from any source and, after reasonable inquiry, believes that the misconduct may violate any law or regulation, the Company must promptly alert appropriate Federal and State authorities. The Company must report the violation to authorities within sixty (60) days from the time the Company determines there is credible evidence of a violation. Prompt reporting demonstrates the Company’s good faith and willingness to work with authorities to correct the problem.

EMPLOYEE, CONTRACTOR AND VENDOR SCREENING

It is the policy of the Company to make reasonable inquiry into the background of current and prospective Employees, Contractors and vendors who are engaged in business or activity which by its nature might place the Company at risk for violation of the law or this Compliance Plan. See attached EXHIBITS I, J and K.

In conjunction with policies and procedures developed and administered by the Company, all Employees, Contractors, and vendors shall be screened to determine whether they have been: (a) convicted of a criminal offense related to health care; or (b) listed by a federal agency as debarred, excluded, or otherwise ineligible for federal program participation. All such screenings conducted shall be properly documented and maintained by the Company.

Where appropriate, contractual arrangements with vendors shall contain a statement that the vendor agrees to abide by any applicable provisions of the Company’s Compliance Plan.

NEW EMPLOYEES

All new Employees and Contractors including, but not limited to, professional and billing personnel, who have discretionary authority to make decisions that may involve compliance with the law or compliance oversight, shall undergo a reasonable and prudent background investigation, including a reference check. This investigation shall be conducted by the Company as part of every such employment application. The application should

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specifically require the applicant to disclose any criminal conviction for Medicare/Medicaid fraud and abuse, as defined by 42 U.S.C. § 1320a-7(i), or program exclusion. This information can be obtained through the Employee Screening Questionnaire and Acknowledgement Forms attached as EXHIBITS I, J and K.

The Company will not knowingly employ or contract with any individual who has been convicted of any criminal offense or who is listed as debarred, excluded or otherwise ineligible for participation in Federal Health Care Programs. Any current Employees or Contractors will be removed from direct responsibility for or involvement with any Federal Health Care Program, pending the resolution of any criminal charges or proposed debarment or exclusion. If resolution of the matter results in conviction, debarment or exclusion, the Company will terminate its employment or other contract arrangement with the Employee or Contractor.

The Company shall ensure that all new Employees and Contractors are trained with respect to the applicable components of this Compliance Plan.

EXHIBIT A

AIR METHODS CORPORATION COMPLIANCE PLAN

RESOLUTION OF THE BOARD OF DIRECTORS OF AIR METHODS CORPORATION

WHEREAS, the policy of Air Methods Corporation (the “Company”) is and has been to comply with federal and state laws and the Company’s own ethical standards. In some circumstances, the interpretation and application of the law is highly technical. Thus, employees, contractors, and vendors who believe that they are conducting themselves properly may, in fact, be violating applicable laws. Violations of the law by Employees, contractors, and vendors, even unintentional or unknowing violations, can potentially subject the Company to the risk of legal and/or contractual violations, penalties and embarrassment.

WHEREAS, the Company can meet its legal and ethical commitment only through the efforts of our dedicated professionals, Employees and highly skilled contractors. It is they who must earn the trust and respect of patients and others by continuing to conduct their daily affairs with honesty, integrity, and in compliance with the letter and spirit of all applicable laws. The Company is committed to maintaining a working environment that promotes these ideals and permits employees and contractors to demonstrate the highest ethical standards in performing their daily tasks.

WHEREAS, the Board believes that the adoption of a formal Health Care Compliance Plan (the “Plan”) is an additional means to foster adherence to the Company’s policy. The Board’s action in directing management to proceed in the development and implementation of a Compliance Plan should not be interpreted as concern that present management

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systems are inadequate. Rather, development and implementation of a Plan represents an element in the Company’s continuing effort to improve quality and performance. The Board also recognizes that federal agencies responsible for enforcement of Medicare and Medicaid laws and regulations applicable to health care providers have mandated the development and implementation of Compliance Plans by health care providers.

WHEREAS, the Board recognizes the importance of the development, implementation, and enforcement of a uniform compliance program throughout the Company. Given the Company’s recent acquisitions of other air ambulance companies, the Board believes it is essential to effectively integrate the Company’s compliance efforts with the compliance efforts of those entities which it has acquired.

WHEREFORE, BE IT RESOLVED:

Management of the Company is directed to dedicate the necessary resources toward development of a comprehensive Plan, consistent with the Company’s policy of compliance with federal, state and local laws and its own ethical standards. The Plan will be designated to prevent and detect violations of federal or state law in the conduct of the Company’s operations by the governing board, employees, contractors and consultants.

Crystal Gordon, Associate General Counsel and Compliance Officer of the Company, is hereby appointed as the Company’s compliance officer (the “CO”), and shall report to the Company’s Board of Directors.

The Plan will require the Company to:

• Establish compliance standards and procedures reasonably capable of reducing the prospect of wrongful conduct;

• Appoint a specific, high-level individual with overall responsibility to oversee health care compliance with such standards and procedures;

• Exercise due care not to delegate substantial discretionary authority to individuals with a propensity to engage in unlawful activities;

• Take steps to communicate effectively the compliance standards and procedures to all employees and contractors by, for example, mandatory training sessions or the dissemination of publications;

• Take reasonable steps to achieve compliance by, for example, utilizing monitoring and auditing systems, and by publicizing a reporting system whereby employees and contractors can report suspected wrongful conduct by others within the Company without fear of retribution;

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• Consistently enforce its standards through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals for failure to detect noncompliance; and

• Take responsible steps to respond appropriately to noncompliance after detection and to prevent recurrence, which may require modification of the Plan.

The development and implementation of specific standards, the education and training of employees and contractors with respect to those specific standards, and the review and possible enhancement of internal controls and monitoring systems will be time-consuming. Accordingly, management may proceed in phases, but should make steady progress towards the creation and implementation of specific standards and systems relating to all material areas of the Company’s operations where there are compliance obligations. Management shall periodically review the Plan for effectiveness and shall provide periodic progress reports to the Health Care Compliance Subcommittee.

The Plan attached hereto as Exhibit 1 is hereby adopted by the Board of Directors as the Company’s Plan.

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EXHIBIT B

AIR METHODS CORPORATION

Compliance Plan Patient Bill of Rights

• Patients have the right to receive appropriate emergency medical care as available without regard to age, race, religion, gender or national origin. • Patients have the right to be informed of the need to be taken to a medical facility capable of providing appropriate emergency medical care. • Patients have the right to be transported in a clean and properly maintained air ambulance which is in compliance with all applicable laws and regulations. • When fully aware of the consequences of their illness or injury, patients have the right to refuse medical care or transport to a medical facility. • Patients have the right to receive, upon request, the names of those providing medical care. • Patients have the right to receive, upon request, a reasonable explanation of any charges for medical care provided or for ambulance services. The patient has the right to be informed of the Company’s charges for services and available payment methods. • Patients have the right to every consideration of privacy. Case discussion, consultation, examination, and treatment should be conducted so as to protect patient privacy. • Patients have the right to expect that all communications and records pertaining to his/her care will be treated as confidential. Patients have the right to expect that the Company will emphasize the confidentiality of this information when it releases it to any other parties entitled to review information in these records. • Patients have the right to review the records pertaining to his/her medical care and to have the information explained or interpreted as necessary, except when restricted by law. • Patients have the right to expect reasonable continuity of care when appropriate and to be informed by physicians and other caregivers of available and realistic patient care options. • Upon request, patients have the right to be informed of Company policies and practices that relate to patient care, treatment, and responsibilities. Patients have the right to be informed of available resources for resolving disputes, grievances, and conflicts.

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EXHIBIT C

AIR METHODS CORPORATION Compliance Plan

Fraud and Abuse Education Policy

Air Methods Corporation (the “Company”) has adopted a Compliance Plan (“Plan”). As a part of that Plan, it is the policy of the Company to provide Employees and Contractors involved in the claim development and submission process or in business activities which may be subject to the fraud and abuse laws with such training which is reasonably necessary and appropriate to ensure material compliance with applicable laws relating to the submission of claims or business relationships with potential sources of referrals.

Claim Development and Submission Process

The Company shall provide the following mandatory education to Employees and Contractors involved in the claim development and submission process:

Medical Professional Staff and Non-Billing Administrative Personnel

Not less than 2 hours annually of training relating to the following subjects: The Plan;

An overview of the fraud and abuse laws as they relate to the claim development and submission process and the importance of their role in such a process;

A review of Medicare and Medicaid requirements relating to documentation billing and reporting of costs;

HIPAA and patient privacy; and The consequences to both individuals and the Company of failing to comply with applicable laws.

Billing Personnel

Not less than 3 hours annually of training relating to the following subjects: The Plan;

An in-depth review of the fraud and abuse laws as they relate to the claim development and submission process;

An in-depth review of Medicare and Medicaid requirements applicable to the preparation of claims;

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The consequences to both individuals and the Company of failing to comply with applicable laws, particularly for submitting deliberately false or reckless billings;

The need to obtain or seek appropriate documentation; and HIPAA and patient privacy. Payments for Referrals and Related Fraud and Abuse Issues

The Company provides the following education to all Company Employees and Contractors involved in negotiating business relationships or contracts with companies or other health care providers or suppliers on behalf of the Company. Such training includes, at a minimum, not less than 3 hours annually of training relating to the following subjects:

The Plan;

An overview of the fraud and abuse laws as they relate to prohibitions against payments for referrals, kickbacks and rebates, and other illegal inducements;

HIPAA and patient privacy; and the consequences to both individuals and the Company of failing to comply with applicable laws.

Training Documentation

The Company documents the training provided to each Employee and Contractor according to the Company’s education plan. The documentation includes the name and position of the Employee or Contractor, the date and duration of the educational activity or program, and a brief description of the subject matter of the training session.

Educational activities include, but are not necessarily limited to, the Company’s sponsored programs or educational sessions, educational videos or web-based presentations, department meetings in which compliance and the claim submission process issues are specifically addressed, attendance at carrier, intermediary or state-sponsored educational sessions, and attendance at seminars, workshops or similar education sessions.

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EXHIBIT D

AIR METHODS CORPORATION Compliance Plan

Federal Health Care Program Investigation and Corrective Action Policy

The purpose of this policy is to set forth the procedures to be used by Air Methods Corporation (the “Company”) to respond to reports by Employees or Contractors that an individual or individuals affiliated with or employed by the Company are engaging in activity which may be contrary to applicable Federal Health Care Program (as that term is defined in section 1128B(f) of the Social Security Act) laws or regulations or that such person(s) may be submitting claims in a manner which does not meet the Federal Health Care Program requirements, as applicable.

Purpose of Investigation

The purpose of the investigation is to identify those situations in which the laws, rules and standards of the Federal Health Care Programs may not have been followed; to prevent legally impermissible contractual or investment relationships; to identify individuals who may have knowingly or inadvertently caused claims to be submitted or processed in a manner which violated Federal Health Care Program laws, rules and standards; to facilitate the correction of any practices not in compliance with the Federal Health Care Program laws, rules and standards; to implement those procedures necessary to ensure future compliance; to protect the Company in the event of civil or criminal enforcement action and to preserve and protect the Company’s assets.

Control of Investigation

The Compliance Officer (“CO”) is responsible for directing the investigation, which may include the assistance of legal counsel, of the alleged problem or incident. Reports of investigation are presented to the Board of Directors. At the discretion of the Board of Directors, a report may be forwarded to legal counsel, in which case legal counsel may conduct a further investigation of the alleged problem or incident. In undertaking an investigation, the CO or legal counsel will solicit the support of an auditor, or other legal resources with knowledge of the applicable laws and regulations and required policies, procedures or standards that relate to the specific problem in question. These persons function under the direction of the CO or legal counsel and are required to submit relevant evidence, notes, findings and conclusions to the CO or legal counsel, depending upon who is directing the investigation.

Investigative Process

Upon receipt of an Employee or Contractor complaint or other information (including audit

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results) which suggests the possible existence of conduct or a pattern of conduct in violation of compliance policies or applicable laws or regulations, an investigation under the direction and control of the CO or legal counsel is initiated within 5 business days or as expeditiously as possible and as appropriate. When undertaking the investigation the CO or legal counsel may take the following steps, which is not an all-inclusive list: An interview of the complainant and other persons who may have knowledge of the alleged problem or process and a review of the applicable laws and regulations which might be relevant to or provide guidance with respect to the appropriateness or inappropriateness of the activity in question, to determine whether or not a problem actually exists.

The identification and review of representative claims submitted to the Federal Health Care Program at issue to determine the nature, scope, frequency, duration, and potential financial magnitude of the problem.

An interview of the person or persons in the department(s) who appeared to play a role in the process in which the problem exists. The purpose of the interview is to determine the facts related to the complained of activity, and may include, but is not limited to:

Personal understanding of the Federal Health Care Program laws, rules and regulations;

The identification of persons with supervisory or managerial responsibility in the process;

The adequacy of the training of the individuals performing the functions within the process;

The extent to which any person knowingly or with reckless disregard or intentional indifference acted contrary to the Federal Health Care Program laws, rules or regulations; and

The nature and extent of potential civil or criminal liability of individuals of the Company.

The CO and/or legal counsel will take additional steps that may include, but are not limited to:

Preparation of a summary report which: (a) defines the nature of the problem; (b) summarizes the investigation process; (c) identifies any person whom the investigator believes to have either acted deliberately or with reckless disregard or intentional indifference toward the Federal Health Care Program laws, regulations and rules; (d) if possible, estimates the nature and extent of the resulting overpayment by the government; and (e) summarizes the corrective action steps to be taken;

If the review results in conclusions or findings that the complained-of conduct is permitted under applicable laws, regulations or rules, or that the complained-of act did not occur as alleged or that it does not otherwise appear to be a problem, the investigation is closed;

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If the initial investigation concludes that there are practices occurring which are contrary to applicable law, that inaccurate claims are being submitted, or that additional evidence is necessary, the investigation proceeds to the next step; and

An organizational response is required in accordance with the Compliance Plan.

Possible Criminal Activity

In the event the Company uncovers what appears to be criminal activity on the part of any Employee or Contractor, the Company shall undertake the following steps.

It shall immediately stop all billing related to the problem until such time as the offending practices are corrected; It shall initiate appropriate disciplinary action against the person or persons whose conduct appears to have been knowing and willful, intentional, willfully indifferent or with reckless disregard to the Federal Health Care Program laws. Appropriate disciplinary action shall include, at a minimum, the removal of the person from any position with oversight for or impact upon the claims submission or billing process and may include, in addition, suspension, demotion or discharge; and The Company shall make such disclosure as legal counsel for the Company advises. Other Noncompliance

In the event the investigation reveals billing or other problems which do not appear to be the result of conduct which is knowing and willful, intentional, willfully indifferent, or with reckless disregard for the Medicare and Medicaid laws, the Company shall nevertheless undertake the following steps:

Correct the defective practice or procedure as quickly as possible; Initiate such disciplinary action, if any, as may be appropriate given the facts and circumstances. Appropriate disciplinary action may include, but is not limited to, reprimand, demotion, suspension and discharge or termination of contract; Promptly undertake an appropriate program of education to prevent future similar problems; and Update the Compliance Plan, if necessary. Improper Payments

In the event the problem results in duplicate payments by a Federal Health Care Program, or payments for services not provided other than as claimed, the Company shall:

Stop all billing of the type which is a problem until such time as the offending practice is corrected;

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Calculate and repay to the appropriate carrier or payor identified overpayments resulting from the act or omission; Initiate such disciplinary action, if any, as may be appropriate given the facts and circumstances. Appropriate disciplinary action may include, but is not limited to, reprimand, demotion, suspension and discharge or termination of contract; Promptly undertake an appropriate program of education to prevent future similar problems; and Update the Compliance Plan, if necessary. No Improper Payment

In the event the problem has not resulted or does not result in an overpayment by a Federal Health Care Program, the Company shall:

Correct the defective practice or procedure as quickly as possible;

Initiate such disciplinary action, if any, as may be appropriate given the facts and circumstances. Appropriate disciplinary action may include, but is not limited to, reprimand, demotion, suspension and discharge or termination of contract;

Promptly undertake an appropriate program of education to prevent future similar problems; and Update the Compliance Plan, if necessary.

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EXHIBIT E

AIR METHODS CORPORATION Compliance Plan

Reporting a Violation or Suspected Violation

The Company will take reasonable steps to ensure the confidentiality of the information contained in this report, however, under certain circumstances disclosure of such information may be required by law.

Name (Optional): Position: Department: Supervisor: Office Location: Work Telephone Number: Home Telephone Number:

Description of suspected violation:

Please state the date(s) this suspected violation occurred, where the suspected violation occurred, and the person(s) involved:

What is your specific knowledge of the incident? How did you acquire this knowledge?

Please state whether you have discussed the suspected violation with anyone else, and if so, with whom? What other individuals may have information regarding this matter?

Would you be willing to discuss this matter with the Compliance Officer, members of the Health Care Compliance Subcommittee, or other members of management or the Company’s legal counsel?

Submitted By (Optional)

Signature Date

Printed Name

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EXHIBIT F

AIR METHODS CORPORATION Compliance Plan Reported Violation Intake Form

Report Number/Reference:

Receiving Date:

Time:

Date Violation Occurred:

Report Received By: Position:

Reporting Individual: Position:

Individual(s) and/or Department(s) Involved: Description of Incident or Possible Violation:

Type of Possible Violation: Dishonesty and/or Fraud: Billing: Antitrust: Safety/Health: Conflict of Interest: Human Resources/Labor: Other:

Report Completed By: Date:

Submitted to Compliance Officer on the following date:

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EXHIBIT G

AIR METHODS CORPORATION Compliance Plan Hotline Call Log Date of Name of Caller, If Description of Issue Name of Resolution (Including Call Provided Individuals Date Resolved) Involved

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EXHIBIT H

AIR METHODS CORPORATION Compliance Plan Corrective Action Form Date report received:

Referred for investigation to:

Date investigative report received:

Reported By/Anonymous:

Investigative Results: (Attach if appropriate)

Action taken: (Attach report if appropriate)

Were the persons who reported the violation notified of the Corrective Action Taken?

Yes No

Date: Form Completed By:

Date Investigation Closed:

Compliance Officer (Signature) Date

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EXHIBIT I AIR METHODS CORPORATION Compliance Plan Screening Questionnaire For Professional Personnel

Name: Address: State(s) Licensed: Certification/Specialty:

Education:

Please list all of your current professional licenses, including the state of issuance and expiration date for each.

Have you ever had a professional license suspended or revoked for any reason? If the answer to this question is YES, please include a full description of each incident.

Have you ever been or are you currently suspended, excluded or debarred from any federally funded health care program, including Medicare or Medicaid, or convicted of any felony, misdemeanor, or health care related crime? If the answer is YES, please include a full description of each incident.

Please list any health care or related business in which you or a member of your immediate family hold a direct or indirect ownership interest. Also, please note whether any business in which you or an immediate member of your family hold an ownership interest, contractual relationship or compensation arrangement has ever been suspended from any federally-funded health care program, including Medicare or Medicaid.

I certify that the above responses are complete, true and correct and authorize the Company to research and verify my responses.

Signature Date

(Print Name) Social Security No.

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EXHIBIT J

AIR METHODS CORPORATION Compliance Plan

Screening Questionnaire For Administrative or Billing Personnel

Name: Address:

Phone:

Have you ever been convicted of a felony or a misdemeanor, or currently or in the past excluded or suspended from any federally-funded government health care program, including Medicare or Medicaid? If YES, please include a full description of the charges and resulting disposition.

Please list any health care or related business in which you or a member of your immediate family hold an ownership interest, whether direct or indirect. Also, please note whether any business in which you or an immediate member of your family hold an ownership interest has ever been suspended, excluded or debarred from any federally- funded health care program, including Medicare or Medicaid.

I certify that the above responses are complete, true and correct and authorize the Company to research and verify my responses.

Signature Date

(Print Name)

Social Security No.

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EXHIBIT K

AIR METHODS CORPORATION Compliance Plan

Acknowledgement and Compliance Certification (Signature Page)

I have received the Compliance Plan dated November 2, 2011, and I understand that I am responsible for its contents and I have retained copy for my guidance.

I understand that violation of the Compliance Plan may be grounds for dismissal.

I agree to immediately report to the Compliance Officer any changes that may potentially place me in violation of the Compliance Plan.

I am aware of the following present violations or potential violations (if none, state “none”):

I agree that I will report to the Company under the Compliance Plan any suspected or known violation of the Compliance Plan prior to making any disclosure to governmental authorities. I understand that such notification does not restrict or limit my ability to notify governmental authorities any time I believe illegal activity has occurred or is occurring.

Name: Position:

Signature: Date:

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RIGGS – Policies & Procedures

NUMBER: G14 EFFECTIVE DATE: 01/01/2007 TITLE: HIPAA REVISION DATE: 03/28/2016

DIVISION: ALL DEPARTMENTS REFERENCE: CAMTS 01.05.00

PURPOSE:

This policy applies to all SEMSA entities, departments, etc. To ensure patient confidentiality and the privacy of patient information and to enable patients to understand and control how their health information is used and disclosed.

Under California Law and HIPAA regulations, contact between the patient, user agencies, and SEMSA/RIGGS is a highly privileged and confidential relationship. Every employee must maintain strict and absolute confidence regarding privacy, privileged professional information and peer relations. This includes discussions with friends, neighbors or even family members. Medical information should only be shared with other allied health care personnel and medical professionals who need to know this information in the course of normal patient verbal and written reporting. It is SEMSA’s policy therefore, to guard against an improper disclosure of such confidential and privileged communications and records in the following manner.

A formal HIPAA Plan is in place, which provides all policy guidelines for all personnel of SEMSA and RIGGS. Employees can review the HIPAA plan; a copy of this plan is located in the Human Resources office. A HIPAA Privacy Officer has been appointed to oversee all HIPAA Plan and privacy related matters and inquires. All personnel are responsible to know and understand their responsibilities under the HIPAA Plan.

POLICY:

This HIPAA Plan is adopted by the Sierra Medical Services Alliance (“SEMSA”), its internal division (RIGGS Air 1) and its wholly owned subsidiary RIGGS and will apply to all ground ambulance operations, and air ambulance operations. This Plan will not apply to wheelchair transports performed by Med-Express Transport, Inc. as the services performed by this division are non- covered functions making it a “hybrid entity” as outlined in the HIPAA regulations. All full time, part time and per diem employees, as well as volunteers, trainees, leased employees, and applicable independent contractors shall comply with its provisions.

This plan covers all patient information (medical records or patient identifiable health information of a given individual used or disclosed whether transmitted electronically, orally or in writing). As a covered entity, SEMSA must guard against misuse of individuals’ identifiable protected health information (“PHI”) and limit the sharing of such information. In addition, this plan describes the rights of patients to control the use and disclosure of their health information.

The responsibility for compliance with this plan rests with all managers and employees, as well as volunteers, trainees, leased employees, and applicable independent contractors. Oversight of this plan will be provided by the SEMSA Compliance/Privacy Officer, as defined below, or his/her designee.

GENERAL DESCRIPTION:

The Federal HIPAA Regulations consist of three primary areas (The Privacy Rule, The Transaction and Code Set (TCS) Rule, and The Security Rule). This HIPAA Plan will therefore address these three areas and other relevant HIPAA requirements.

The Privacy Rule sets standards for the privacy of individually identifiable health information and implements the privacy requirements of the Administrative Simplification Act (subtitle of the Health Insurance Portability and Accountability Act) of 1996 (HIPAA). HIPAA preempts state laws unless the state law is more stringent in protecting patient privacy.

The TCS Rule sets standards for the electronic transmission of information for certain administrative and financial health care transactions. The intended results are to; reduce administrative burdens, lower operating costs and improve overall data quality.

The Security Rule deals with the administrative, physical and technical safeguards necessary to ensure the availability, integrity and confidentiality of electronic protected health information (e- PHI).

Civil and criminal penalties may be imposed for improper use of a patient’s health information and violations of the covered privacy rights.

Examples of PHI in the ambulance service context include:

1. Patient care reports (PCR) or “trip sheets” 2. Follow-up letters 3. Dispatch information received by the ambulance service, e.g., location address, mechanism of injury, etc.) 4. Physician certification statements 5. Call intake records 6. Medical records and insurance information received from hospitals and other health care facilities 7. Claim, remittance advice documents, invoices and other payment-related forms

Health information held by SEMSA in its role as an employer is not PHI under the Privacy Rule.

THE “MINIMUM NECESSARY” REQUIREMENT

The general rule under HIPAA is that SEMSA must provide its employees and others with only the minimum amount of PHI necessary to perform their job or accomplish the intended purpose of the disclosure. SEMSA will identify precisely what information its employees need to do their jobs and take reasonable steps to ensure that employees’ access to PHI is limited only to that PHI that is necessary to perform their specific jobs.

When fulfilling requests for PHI, or making disclosures of PHI, SEMSA will ensure that only the “minimum necessary” amount of PHI is disclosed to achieve the purpose of the disclosure. SEMSA has implemented policies and procedures that limit the PHI disclosed to the amount reasonably necessary to achieve the purpose of the disclosure for routine and recurring types of requests. If the disclosure is a non-routine or non-recurring type (for instance, in response to a subpoena), SEMSA will review the request on an individual basis to ensure that the disclosure includes only the minimum PHI necessary to fulfill the purpose of the request.

When requesting PHI from others, SEMSA will request only the minimum amount of PHI necessary to accomplish the purpose of the request.

The “Minimum Necessary” Requirement does not apply in the following situations:

1. Disclosures to or requests by a health care provider for treatment purposes (SEMSA may give the entire PCR to the hospital or other facility when transporting a patient to that facility). 2. Disclosures to the patient who is the subject of the information. 3. Uses or disclosures required by law. 4. Uses or disclosures pursuant to a patient’s written Authorization. 5. Disclosures to the Department of Health and Human Services when required by the Privacy Rule for enforcement purposes.

SEMSA will take reasonable measures to ensure that only the minimum necessary PHI is released.

PATIENT RIGHTS UNDER THE PRIVACY RULE:

A. Notice

SEMSA has a written Notice of Privacy Practices which describes the privacy rights afforded to patients, as well as SEMSA’s obligations in implementing HIPAA’s privacy protections. The Notice will be distributed to patients in the following manner: 1. Patients who are transported

As SEMSA is an advanced life support (“ALS”) ambulance service, the majority of its calls are emergent in nature. Accordingly, the Notice of Privacy Practices will be sent to every transported patient with the initial billing. 2. Patients who refuse Treatment and /or Transport

SEMSA personnel will provide the Notice of Privacy Practices to patients that refuse care/transport or are treated on scene with no transport and will make a good faith effort to obtain a written Acknowledgement of Receipt of the Notice of Privacy Practices, signed by the patient or the patient’s representative.

B. Consent

Ambulance services may use or disclose patient PHI for the three purposes listed below without any written consent, authorization or other approvals from the patient: 1. Treatment which includes sharing PHI with other providers involved in the care of the patient.

2. Payment which includes filing claims, coordinating benefits, making eligibility inquiries, remittance advice, collections, and more.

3. Health Care Operations which includes quality assessment and improvement activities, provider evaluation and credentialing, obtaining legal or medical review or auditing, fraud and abuse detection and compliance and the business management of the organization.

Each of these uses is discussed in more detail in the Ambulance Operations section below.

SEMSA will continue to use the “assignment of benefits” form that the patient signs to give permission to the provider to share their medical information with Medicare or other payers and to accept payment of benefits on the patient’s behalf.

C. Authorization

SEMSA will obtain a signed Authorization from the patient or the patient’s authorized representative if SEMSA wishes to use or disclose PHI for reasons other than treatment, payment, or health care operations (TPO uses) and where the disclosure is not allowed under one of the exceptions listed below. SEMSA will not require the patient to grant the authorization as a condition of providing treatment. A person who signs an authorization may cancel or modify the authorization, but the cancellation or modification is effective only after SEMSA actually receives written notice of the cancellation or modification.

D. Personal Representatives

If under state law a person has the authority to act on behalf of an adult or emancipated minor in making health care decisions, SEMSA will allow the patient’s personal representative to exercise all rights of the patient including the patient’s rights to access, amendment, accounting, etc. SEMSA may elect not to treat a person as the patient’s personal representative, however, if there is a reasonable belief that the patient has been subjected to abuse, neglect or domestic violence by such person, or believes providing this information could endanger the patient. Also, if a minor is permitted to act on his or her own behalf under state law for the provision of health care services, SEMSA will not treat a parent, guardian, or person acting in loco parentis as the patient. An executor, administrator, or other such person with legal authority may act as the decedent’s personal representative with respect to PHI. SEMSA will obtain verification of the personal representative’s identity and status prior to providing requested PHI.

An example of a personal representative is a person with a valid durable power of attorney, a court- appointed guardian for a legally incapacitated person, a parent or legal guardian or those acting in loco parentis with regard to minors, or other such duly appointed personal representative.

E. Uses and Disclosures Requiring an Opportunity for the Individual to Agree or Object

Under the Privacy Rule, there are some types of PHI disclosures (beyond those for treatment, payment, or health care operations) that may be made without the Authorization of the patient, but require that the individual ordinarily be given oral or written notice of the intended disclosure and be afforded an opportunity to agree or object to the intended disclosure.

SEMSA will attempt to provide notice to the individual when PHI is used to notify a family member or personal representative of the patient of patient’s location, general condition or death.

When the individual is not present, or is incapacitated or involved in an emergency, SEMSA may, in the exercise of professional judgment, determine whether the disclosure is in the best interests of the individual and, if so, disclose only the “minimum necessary” PHI to achieve the purpose of the disclosure.

F. Uses and Disclosures for Which Authorization or Opportunity to agree or Object are not required

SEMSA is permitted to use and disclose PHI without the patient’s authorization and without affording the individual an opportunity to agree or object to the use or disclosure under the following circumstances:

1. Uses and Disclosures Required by Law – the use or disclosure must comply with and is limited to the relevant requirements of such law.

Pursuant to the provisions of NRS 49.225 and relevant provisions of California law, SEMSA can provide copies of patient care reports or trip sheets to hospitals and other people participating in the diagnosis or treatment of the patient. In addition, pursuant to NRS 450B.810 and relevant provisions of California law, SEMSA is required to

provide certain information which may contain PHI to entities such as the State Health Division.

2. Uses and Disclosures for Public Health Activities

SEMSA can disclose PHI to a public health authority that is authorized by law to collect such information to prevent or control disease or injury.

3. Disclosures about Victims of Abuse, Neglect or Domestic Violence

SEMSA may disclose PHI to a government authority about individuals they reasonably believe are victims of abuse, neglect or domestic violence when:

a. Required by law and the disclosure must be made consistent with that law;

b. The victim agrees to the disclosure; OR

A law or regulation specifically authorizes such a disclosure and SEMSA believes the disclosure is necessary to prevent serious harm to the individual or other potential victims; OR

If the individual cannot agree because of incapacity, a law enforcement or other public official authorized to receive the report represents that the PHI is not intended to be used against the individual and that an immediate enforcement activity depends upon the disclosure and would be adversely affected by waiting for the individual’s agreement.

4. Uses and Disclosures for Health Oversight Activities

SEMSA may disclose PHI to a health care oversight agency for purposes such as audits, investigations, inspections, licensure or disciplinary actions or other such activities related to health care oversight, government benefit programs and other such enumerated purposes.

SEMSA may disclose PHI to the State and County Departments of Health, regional EMS agencies, or other entities that conduct licensure inspections or enforcement actions in the event of a licensure-related complaint, etc.

5. Disclosures for Judicial and Administrative Proceedings

Disclosures permitted without patient authorization or agreement include:

a. In response to a direct order from a court or administrative tribunal (such as an agency hearing officer or administrative law judge) OR;

b. In response to a valid subpoena, discovery request or other lawful process.

PHI may be released for litigation purposes to the patient directly or with a signed patient authorization.

6. Disclosures for Law Enforcement Purposes

There are specific Federal requirements for the release of protected health information to law enforcement officials.

SEMSA may disclose PHI for law enforcement purposes to a law enforcement official only when the following conditions are met:

a. Disclosures pursuant to laws that require the reporting of certain types of conditions, (i.e. child abuse, elder abuse).

b. Disclosures pursuant to a court-ordered warrant or a subpoena or summons issued by a judicial officer. (NOTE: this is different than a subpoena issued by an attorney or a party in litigation.)

c. Disclosure as ordered by a grand jury subpoena.

d. Disclosure as ordered by an administrative subpoena or summons by an authorized agency if the information sought is relevant and material to a legitimate law enforcement inquiry, and provided that the request is specific and limited in scope.

e. Disclosure to a law enforcement official for purposes of identifying or locating a suspect, fugitive, material witness or missing person. The only PHI that may be released for such purposes includes:

1. Name 2. Address 3. Date 4. Place of birth 5. Social security number 6. Blood type 7. Type of injury 8. Date and time of treatment 9. Date and time of death, if applicable 10. Description of distinguishing physical characteristics such as weight, hair color, eye color, gender, presence or absence of facial hair, scars and tattoos.

SEMSA will not disclose PHI to law enforcement officers for purposes of assisting generally in their investigation or building a case against a suspect. SEMSA will not provide law enforcement officers with copies of the PCR or access to EMS personnel for interviews or questioning unless required by law.

f. Disclosures regarding victims of a crime.

SEMSA may disclose PHI about a crime victim to a law enforcement official if the affected individual agrees to the disclosure.

SEMSA may disclose the “minimum necessary” PHI to law enforcement without the individual’s agreement if the agreement cannot be obtained due to the individual’s incapacity or other emergency, and if the law enforcement officer needs the information to determine whether a violation of law has occurred. Law enforcement must assure SEMSA that the information will not be used against the victim. Law enforcement must also represent that waiting until the patient is capable of agreeing to the disclosure would compromise an immediate law enforcement activity. SEMSA must use professional judgment to determine whether the disclosure would be in the best interests of the individual.

7. Uses and Disclosures about Decedents

SEMSA may disclose minimum necessary PHI to a coroner, or medical examiner, or investigating police officer for the purpose of identifying a deceased person, determining a cause of death or other duties authorized by law. SEMSA may also disclose minimum necessary PHI to funeral directors to carry out their duties. The protection of the Privacy Rule still applies in all other respects even after the patient is deceased.

8. Uses and Disclosures Related to Organ and Tissue Donation

SEMSA may disclose PHI to an organ procurement organization for the purpose of facilitating organ, eye or tissue donation or transplantation.

9. Uses and Disclosures for Research Purposes

If SEMSA engages in research, it shall consult the HIPAA regulations and/or legal counsel to determine compliance with the provisions of the law before disclosing any PHI.

10. Uses and Disclosures to Avert Threats to Safety

SEMSA may disclose PHI if personnel believe in good faith that disclosure is necessary to prevent or lessen a serious and imminent threat to the health

or safety of a person or the public; or if disclosure is necessary for law enforcement authorities to identify or apprehend a suspect because the individual made a statement admitting participation in a violent crime or where it appears that the individual has escaped from a correctional facility (i.e., jail, prison, detention center, etc.)

11. Uses and Disclosures for Specialized Government Functions

SEMSA may make disclosures in other, limited situations related to government operations, such as military and veterans’ affairs, Department of Defense activities, national security purposes, Presidential protection activities, security clearances, and other similar purposes.

SEMSA will consult with legal consul if it receives any such unusual requests for a patient’s protected health information.

G. Patient’s Access to PHI

SEMSA has established a designated record set. Medical records prepared by SEMSA personnel are the property of SEMSA; however, pursuant to NRS 629.061(2) and California Civil Code § 56.07(a), patients have the right to inspect and copy their medical records. The patient may be charged for copying, postage or administrative preparation in accordance with state law.

There are three (3) types of information that do not have to be released to the patient:

1. Psychotherapy notes 2. Information generated in anticipation of litigation

This information would include, for example, incident reports that are not part of the PCR and were written specifically for risk management purposes.

3. Information that is maintained by SEMSA subject to the Clinical Laboratory Improvements Amendments

If SEMSA denies access to PHI, it will inform the patient of the denial in writing.

The patient’s rights to have the denial reviewed are categorized below:

1. Unreviewable grounds for denials:

a. PHI generated in anticipation of litigation b. The patient is an inmate of a correctional facility c. PHI was obtained from someone other than a health care provider under a promise of confidentiality and granting access to the patient would likely reveal the source of the information.

2. Reviewable grounds for denials: (Patient retains the right to review these denials)

a. Access is likely to endanger the life or safety of the patient or another person; b. The PHI refers to another person, and access would likely cause substantial harm to that person; or c. The request for access is made by a representative of the patient, and SEMSA determines that access by the representative to the PHI is likely to cause harm to the patient.

The decision to issue a “reviewable” denial must be made by a licensed health professional (Physician or Registered Nurse) in the exercise of his/her professional judgment. The “review” of the denial, if requested by the patient, must be made by a second licensed health care professional (Physician or Registered Nurse) who was not involved in the initial decision to deny access.

Denials will be in writing, in plain language, and will explain the basis for the denial and will contain information on how the individual may request and obtain a review of the denial, if the denial is reviewable. See the Access Denial Form in the Appendix.

H. Patient’s Right to Amend PHI

If a patient wishes to amend PHI, SEMSA requires that the patient’s request be in writing and supported by a reason. SEMSA can deny an individual’s request for amendment. Permissible reasons for denial are:

1. The record at issue was not created by SEMSA, unless the individual reasonably believes that the originator of the PHI is no longer available to act on the requested amendment. 2. The record is not maintained by SEMSA. 3. The information is contained on a record to which SEMSA could properly deny access. (See Patient’s Access to PHI) 4. SEMSA determines that the record is accurate and complete as written.

SEMSA will act on requests for amendments within 60 days following receipt of the request. If SEMSA accepts the amendment request, SEMSA will:

1. Add an amendment clarifying the change to the original record. (The original record will not be changed.) 2. Inform the patient on a timely basis that the amendment has been accepted 3. Make reasonable efforts to inform certain others of the amendment a. SEMSA will notify those individuals or organizations identified by the patient as having his/her PHI and who would need the amendment to update their information. b. SEMSA will send the amendment to the PCR to the receiving hospital and all other business associates that may need the correction.

If SEMSA denies the amendment request, SEMSA will:

1. Notify the patient in writing in plain language 2. State clearly the reason for the denial and the individual’s right to submit a statement disagreeing with the denial. SEMSA shall also explain how the individual may file such a statement 3. Include a statement that, if the individual does not submit a statement of disagreement, said individual may ask SEMSA to include the request for amendment and the denial with any future disclosures of the PHI, along with a description of how the individual may file a complaint with SEMSA, including the name and telephone number of an appropriate contact person or to the Secretary of Health and Human Services.

If the individual submits a statement of disagreement, SEMSA may prepare a written rebuttal statement to that statement.

If SEMSA receives notice from another covered entity that it has amended its PHI in relation to a particular patient, SEMSA will attach the amendment to its own PHI to reflect these changes.

I. Accounting

Patients have the right to receive an “accounting” of certain uses and disclosures of PHI made by SEMSA for the six (6) years prior to the date of the accounting request. SEMSA is not required to render an accounting to the patient of:

1. Uses and disclosures made for the TPO purposes – treatment, payment, or health care operations 2. Uses and disclosures made pursuant to a patient’s written authorization 3. Disclosures of PHI made to the patient

SEMSA is required to render an accounting to the patient on only non-routine, non-authorized disclosures such as those in response to a subpoena or for law enforcement purposes.

SEMSA will inform a patient of all occasions on which SEMSA or SEMSA’s Business Associates have disclosed any PHI about the patient over the previous six (6) year period within 60 days of receiving a written request from a patient or his authorized representative. The 60 day response period may be extended by 30 days, but only if SEMSA sends a written notice to the individual describing the reason for the delay.

The accounting will include:

1. Date of the disclosure 2. Name and address of the organization or person receiving the disclosure 3. Brief description of the information disclosed

4. Copies of any authorizations

SEMSA will track the types of PHI disclosures that are subject to the accounting requirement with its commercial computer software.

J. HIPAA Complaints, Recourse and Enforcement

Individuals have the right under the Privacy Rule to file complaints about breach of the privacy standards with both the Secretary of Health and Human Services (DHHS) and with SEMSA.

Complaints must:

1. Be in writing, 2. Be filed within 180 days of the act or omission, 3. Name the entity that is the subject of the complaint, and 4. Have a description of the act or omission believed to be in violation of the Rule.

If a complaint is filed with DHHS, and the Secretary finds SEMSA to be in violation of the Rule, the DHHS will notify both SEMSA and the source of the complaint in writing. DHHS will then attempt to resolve the matter by informal means if possible. If DHHS finds that SEMSA has not violated the Rule, both SEMSA and the source of the complaint will be notified in writing and no further action will be taken.

The DHHS may conduct compliance reviews to determine whether SEMSA is complying with the applicable standards, requirements and implementation specifications established in the Privacy Rule. SEMSA will keep accurate records and submit compliance reports in a timely manner when requested by DHHS. SEMSA will also cooperate with any investigation or compliance review of its policies, procedures, or practices when initiated by DHHS. This includes allowing DHHS access during normal business hours to facilities, books, records, accounts and other sources of information, including protected health information pertinent to compliance verification.

AMBULANCE OPERATIONS

The following information details situations where ambulance services may use and disclose protected health information for purposes of treatment, payment and health care operations:

A. Radio Communications of Protected Health Information

SEMSA personnel may transmit medical information by radio to receiving facilities for the purpose of relaying information about incoming patients. Although SEMSA personnel may share information with another health care provider for treatment purposes, without the written consent of the patient or other responsible party, SEMSA has implemented a reporting procedure to prevent radio communications from being intercepted or overheard (incidental disclosures) whenever possible.

B. Other Oral Communications

SEMSA personnel may disclose PHI through oral means, such as when delivering the patient to a treating facility and when talking with family members. SEMSA has implemented reasonable safeguards to protect PHI from intentional and unintentional disclosures.

C. Multiple Agency Responses

SEMSA provides service in a tiered EMS system. The following are HIPAA issues in tiered EMS systems:

1. Co-Responders – agencies that do not bill electronically for their services Most co-responders do not meet the definition of a “covered entity” under the Privacy Rule. As non-covered entities, co- responders can freely share PHI with ambulance services without any HIPAA restrictions and without consent or authorization from the patient or any other party. Once the non-covered entity provides a verbal patient report or a history of the incident or provides a written PCR to SEMSA, this information becomes PHI and will be protected by SEMSA.

SEMSA can share PHI with the co-responder if necessary for treatment purposes. Discussion about the patient’s care is allowed on the scene; however, SEMSA will not give the co- responder a copy of SEMSA’s PCR without the patient’s authorization unless it is for a use or disclosure for which the patient’s authorization is not required. SEMSA personnel will not disclose PHI to co-responders beyond that which is genuinely needed for treatment purposes.

2. Joint Response – agencies that bill electronically for their services are covered entities

If the ambulance service that SEMSA is jointly responding with is a covered entity, the disclosure of PHI is permitted without patient consent or authorization, and without the need for a business associate agreement, under the “treatment” provision of the Privacy Rule. SEMSA may also provide a copy of its PCR to the joint responder under the “payment” and “compliance” provisions of the Privacy Rule and under the QA/CQI analysis if applicable.

3. Mutual Aid and Other Multiple-Agency Responses

SEMSA may share PHI with other health care providers (regardless of whether they are covered entities) for purposes of “treatment” and “payment.” SEMSA may also share PHI with other covered entities for health care operations purposes (e.g., quality improvement activities).

D. Exchanging Medical Records with Facilities

1. Ambulance Service to Facility

SEMSA may provide copies of PCR’s to hospitals and other medical facilities without the consent or authorization of the patient under the “treatment” exception.

2. Facility to Ambulance Service

a. Transfer or Transport

Under the “treatment” exception, the facility can provide necessary PHI to SEMSA for treatment during transfer or transport or for treatment at a subsequent facility.

b. Billing

The Privacy Rule permits a covered entity, such as a hospital, to provide PHI to other covered entities and even to health care providers that are not covered

entities for “payment” activities, without patient consent or authorization. A facility may provide a face sheet and other payment information to SEMSA without the need for business associate agreements, patient consent or authorization, or other formal approval. Under the “minimum necessary” provision of the Privacy Rule, however, the PHI that the facility gives to SEMSA for payment purposes must be limited to the minimum amount necessary to permit SEMSA to conduct its billing operations. The facility can provide a face sheet with insurance information but cannot provide a discharge summary, lab tests, operative notes or other such documents that are unrelated to billing, unless allowed under some other exception (e.g. QA/CQI).

c. Other exceptions (e.g. appeals of insurance denials) may apply to this category.

E. QA/CQI

SEMSA may use PHI prepared by its personnel for quality assurance (QA), continuous quality improvement (CQI), and related activities, without patient consent or authorization. In addition, a facility may share PHI with SEMSA, because SEMSA is a covered entity, for the purpose of QA or CQI activities without the need for patient consent, authorization, a business associate agreement, or any other formal approvals as long as the following criteria are met:

1. If each entity (i.e., the hospital and SEMSA) either has or had a relationship with the patient

2. The PHI pertains to such relationship, and

3. The disclosure is for the purposes of QA or CQI, credentialing, personnel evaluation or fraud and abuse detection or compliance.

The “minimum necessary” rule applies to PHI given to SEMSA by a facility for QA/CQI purposes. SEMSA will only request, and the facility will only furnish, the minimum amount of PHI necessary to permit SEMSA to perform its QA/CQI activities. Once received, SEMSA will protect the information in the same manner it would protect its own PHI.

F. CISD/CISM Teams

Participation in stress debriefings using the services of Critical Incident Stress Debriefing (CISD) or Critical Incident Stress Management (CISM) teams often requires personnel to discuss aspects of the incident, and perhaps the patient’s condition, in a manner that would involve individually identifiable health information. When SEMSA personnel are involved in CISD/CISM sessions they will: 1. Minimize any disclosures of PHI and will discuss the incident in general terms without revealing individually identifiable health information.

2. SEMSA will obtain a written business associate agreement with the CISD/CISM team. (The CISD/CISM team can be viewed as performing a service, i.e., stress debriefing that could involve disclosure of PHI.)

3. SEMSA will obtain a written business associate agreement, as necessary on a case by case basis, with agencies (e.g., police, fire, EMS and others) that participate with SEMSA in a CISD/CISM session as they may have access to individually identifiable PHI.

G. Mass Casualty Incidents

SEMSA is permitted to disclose PHI to a public or private entity authorized by law or by its charter to assist in disaster relief efforts (e.g., an entity such as the Red Cross), for the purposes of notifying or assisting in notifying a family member, a personal representative of the individual, or another person responsible for the care of the individual, of the individual’s location, general condition, or death.

BUSINESS ASSOCIATES

Business Associates are separate organizations, such as a collection agency, accounting service, software vendor, legal counsel, administrative services, hardware maintenance contractor, or consultant. SEMSA will obtain written assurances in the form of Business Associate Agreements that each business associate will uphold and be in compliance with the Privacy Rule. If SEMSA becomes aware of violations by its business associate, it will take appropriate measures to correct the deficiencies or terminate the business associate relationship without delay.

SAFEGUARDING PHI

The Privacy Rule requires the implementation of reasonable security safeguards.

SEMSA will implement appropriate administrative, technical, and physical safeguards to protect the privacy of protected health information.

SEMSA will:

1. Establish Access Rights in Job Descriptions

All job descriptions for members of the workforce including employees, independent contractors, leased personnel, etc. of SEMSA and its contractor(s) shall identify that individual’s need for PHI in their job functions and limit their access only to that PHI.

2. Properly handle and store PCRs

a. All completed paper PCRs will be submitted via secure means.

b. All completed PCRs will be placed in a secure area and not be left in generally accessible areas of an office, vehicle, or post.

c. For long-term storage, completed PCRs will be kept in a secure area with limited access.

3. Handle faxes appropriately

Other than for rare and approved exceptions, documents containing PHI shall not be faxed from SEMSA to other fax machines. This is due to SEMSA not being able to assure the security of the devise on the receiving end. However, SEMSA does receive PHI by fax on a regular basis. These instances include receiving physician certification statements, face sheets, etc., from other entities and facilities.

Fax machines at SEMSA that receive PHI must be located in a secure area. For outgoing (non-PHI documents) fax cover sheets shall be used by SEMSA and will include a confidentiality statement.

4. Use E-mail appropriately

SEMSA will limit, whenever possible, the transmission of PHI via e-mail. In addition, confidentiality statements will be used on all e-mail messages that go outside SEMSA.

5. Implement password protection on computers and networks

SEMSA has password protections on computers and networks in which PHI is stored or maintained.

HIPAA TRAINING PROGRAM

SEMSA will provide the required training to all employees, volunteers, trainees, leased employees, applicable independent contractors, and other individuals who are under the direct control of SEMSA, regardless of whether they are paid by SEMSA, and to all incoming members of the SEMSA workforce as part of their initial orientation to the company. The required training shall be determined by the HIPAA Compliance Officer and the following plan.

SEMSA will document the provision of all required HIPAA training.

1. Copies of all rosters and sign-in sheets showing the training dates and the names of attendees at HIPAA training sessions will be maintained in the organization’s files, along with copies of handouts, tests or other documents used in the training. It shall be the responsibility of each employee’s supervisor to assure each employee receives the required HIPAA training.

2. Personnel records and training rosters will be reviewed periodically by employee supervisors or managers in an attempt to make sure everyone has received the required training.

3. The HIPAA Plan will be made available to each employee as needed in the HR Department and will be referenced in the Employment Policies and Procedures Handbook. Employee supervisors for each employee with access to PHI will have the employee sign an acknowledgement and understanding of “Employee Responsibility for Confidentiality” and this form will be maintained in their personnel file.

4. Training records of the required HIPAA training will be retained by SEMSA for a period of six (6) years.

The HIPAA training program for employees who handle patient records or other PHI will include the following areas, in addition to training covering basic HIPAA awareness and responsibilities:

1. Documentation of SEMSA’s confidentiality policy. 2. Employee expectations for upholding confidentiality. 3. SEMSA’s position on privacy practices concerning the HIPAA Privacy Rule. 4. Overview of the federal and state laws concerning patient privacy including the Privacy Regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 5. Description of Protected Health Information (PHI). 6. Patient rights under the HIPAA Privacy Rule.

7. Staff member responsibilities under the Privacy Rule. 8. The Privacy Officer and reporting PHI concerns regarding privacy issues. 9. Importance of and benefits of privacy compliance. 10. Consequences of failure to follow established privacy policies.

11. Current procedures in place that address notice, access, amendment, and emergency situations. 12. Description of process for authorized access, uses and disclosures of PHI. 13. The “minimum necessary” PHI requirement. 14. Oral communications and minimizing incidental disclosures. 15. Proper PCR/trip sheet documentation 16. All QI processes and the documentation involved with those processes. 17. Use of SEMSA’s Notice of Privacy Practices form.

SEMSA’s DOCUMENTATION OF COMPLIANCE

SEMSA will document compliance of this plan in the following manner:

1. SEMSA will maintain records showing that all members of the workforce have received HIPAA training. 2. SEMSA will maintain all versions of the Notice of Privacy Practices. 3. All privacy-related policies and procedures will be made available to the workforce. 4. All existing policies and procedures relating to the privacy of health information will be identified and gathered in one location so they are easily identifiable. 5. Personnel with access to PHI will sign an acknowledgment form indicating their receipt and understanding of confidentiality expectations of SEMSA. 6. Personnel with access to PHI will sign an acknowledgement to indicate the individual’s agreement to abide by SEMSA’s PHI confidentiality procedures. 7. The privacy-related policies and procedures will make it clear that a breach of patient confidentiality will be taken seriously. 8. An outline of repercussions for breach will be included in the disciplinary policy in the employee handbook. 9. SEMSA will document all the required policies and procedures and retain all required documentation in the files for a period of six (6) years.

HIPAA Violation Reporting Information:

HIPAA Compliance Officer Debi Kubiak, CACO, CAPO 209-725-7009 [email protected] Merced County EMS Agency (209) 381-1250

Attachment # 5 – Section 2.6.15 - Insurance Certificates

Willis of New York, Inc. 200 Liberty Street, New York, NY 10281

d/b/a Willis Aerospace (212) 915-8888, Fax (212) 519-5431 CERTIFICATE OF INSURANCE

This Is To Certify To:

To Whom It May Concern

(Sometimes referred to herein as the Certificate Holder(s))

that the Insurers listed, each for their own part and not one for the other, are providing the following insurance: NAMED INSURED: Air Methods Corporation, including:

Mercy Air Service, Inc., LifeNet., Inc., dba ARCH Air Medical Services Inc., Rocky Mountain Holdings, LLC, FSS Airholdings, Inc., CJ Systems Aviation Group, Inc., CJ Critical Care Transportation Systems Inc., Special Jet Services, Inc., CJ Critical Care Transportation Systems of Florida, Inc., CJ Critical Care Transportation Systems of Kentucky, Inc., United Rotorcraft Solutions, LLC, OF Air Holdings Corporation, Omniflight Helicopters, Inc., Omniflight Helicopter Services, Inc. dba Fleet Management Resources, Inc., Georgia Aeromedical dba Air Rescue 1, Air Medical Partners, LLC, Omni Transport Systems, Alabama, LLC aka LifeSaver, LLC, Omni Transport Systems, Charleston, LLC aka Meducare, LLC, Native Air Services, Inc., Native American Air Ambulance, Inc., Native American Air Ambulance, LLC, OTS (SUB), LLC, Enchantment Aviation, Inc. dba Southwest Air Ambulance dba Southwest Med Evac, American Jets, Inc., TriState Careflight, LLC and/or any associated, subsidiary, affiliated, managed, owned or controlled companies or entities thereof.

NAMED INSURED’S ADDRESS: 7211 S. Peoria

Englewood, CO 80112

SEC URIT Y ( th e “In su re rs”)

Policy Period: July 1, 2016 – July 1, 2017

Insurer: Policy Numbers:

Allianz Global Risks US Ins. Co. A2GA000137616AM

1 Chase Manhattan Plaza, 37th Floor New York, NY 10005

W. Brown & Associates Insurance Services NQC6002141 19000 MacArthur Blvd., Suite 700 Irvine, CA 92612

Starr Indemnity & Liability Company through SASICOM60015915-06 Starr Aviation Agency, Inc 3353 Peachtree Road NE, Suite 1000 Atlanta, GA 30326

National Union Fire insurance Company of Pittsburgh, PA FQ001851188-14 through AIG Aerospace 100 Colony Square 1175 Peachtree Street NE, Suite 1000 Atlanta, GA 30361

Underwriters at Lloyd’s & Various Companies 22255A16 through Willis Limited The Willis Building, 51 Lime Street London, England EC3M 7DQ

Several Liability Notice:

The subscribing Insurer’s obligations under contracts of Insurance to which they subscribe are several and not joint and are limited solely to the extent of their individual subscriptions. The subscribing Insurers are not responsible for the subscription of any co-subscribing Insurer who for any reason does not satisfy all or part of its obligations.

Each of the above insures, individually for its proportion only, has authorized the undersigned to issue this Certificate on its behalf as a matter of convenience.

If Certificate(s) have been issued prior to the Date of Issue of this Certificate, this Certificate cancels and supersedes each such Certificate.

SPECIAL PROVISIONS

Subject always to the scope of the policies noted above and all the policies’ declarations, insuring agreements, definitions, terms, conditions, limitations, exclusions, deductibles, warranties and endorsements thereof remaining paramount: Solely as respects: (i) The Coverage(s) noted above; (ii) the Contract(s) (and then only to the extent of the Named Insured’s obligation to provide insurance under the terms of the Contract(s)); and (iii) the operations of the Named Insured; the following provision(s) apply(ies):

The use of the terms ''Additional Insured'' / ''Additional Insureds'', when used in the context of coverages other than Liability Coverage(s), are solely for the purpose of identifying parties and does not, by virtue of the use of these terms, convey any benefits or rights not provided for under the policies.

As respects each Certificate Holder(s) respective interests, this Certificate of Insurance shall automatically terminate upon the earlier of: (i) Policy expiration; (ii) Cancellation of the policies prior to policy expiration, as notified to the Certificate Holder(s) as required herein; (iii) agreed termination of the Contract(s); and/or in the case of physical damage insurance relating to those Certificate Holder(s) who have an insurable interest in the Equipment as of the date of issuance of this Certificate of Insurance: agreed termination of the Named Insured’s and/or the Certificate Holder(s) insurable interest in the Equipment

This Certificate of Insurance is issued as summary of the insurances under the policies noted above and confers no rights upon the Certificate Holders as regards the insurances other than those provided by the policies. The undersigned has been authorized by the above insurers to issue this certificate on their behalf and is not an insurer and has no liability of any sort under the above policies as an insurer as a result of this certification.

Date of Issue: January 20, 2016

Tom Klaus, Authorized Representative Willis of New York

Attachment # 6 – Section 2.6.10 - CQI Plan

Continuous Quality Improvement Plan 2016

Revised May 2016

I. Organizational Description

Founded by Ken RIGGS in 1948, RIGGS Ambulance Service has proudly served the residents and visitors of Merced County for over 68 years. A true visionary committed to patient safety and quality of care, Ken Riggs can be credited with the advancement of EMS not only in California; but throughout the EMS industry.

History and evolution of RIGGS Ambulance Service

1948: The first two ambulances placed in to service were a 1948 Packard and a1948 Cadillac. At the time, ambulance services in the area were sparse and the initial service area stretched from Mariposa (on the east) to Hollister (on the west). RIGGS Ambulance Service became the first in California to stock oxygen onboard; Ken joined the California Ambulance Association as a charter member.

1949: Ken required everyone working on the ambulances to receive Advanced First Aid training.

1952: Ambulances were placed in Los Banos and Gustine to better serve the community.

1955: Ken was appointed County Coroner, Public Administrator and Public Guardian; positions he held until 1982. Ken Riggs held the Coroner’s position longer than anyone in California history.

1968: RIGGS Ambulance Service provided an Advanced Course in Emergency Care under the auspices of the American Academy of Orthopedic Surgeons. Ken was appointed to the National Highway Traffic Safety Advisory Board by President Lyndon B. Johnson.

1974: Ken required all ambulance personnel to become certified Medical Technicians - 2 years prior to mandated implementation.

1976: Ken was appointed to the Committee of Emergency Medical Services by President Gerald Ford. This committee is responsible for the implementation of medical network radio frequencies in use today.

1980: Ken Riggs passed the reins to his son Kraig making him President and CEO of RIGGS Ambulance Service.

1985: Kraig required RIGGS Ambulance Service paramedics to become Mobile Intensive Care Paramedic certified and created an all ALS service.

2003: RIGGS Ambulance Service entered into an exclusive operating agreement with Merced County to provide medical transportation for all of Merced County. The Tactical EMS Team began operations assisting local law enforcement agencies throughout Merced County.

2006: As a small company facing unprecedented challenges in a rapidly changing and increasingly uncertain industry, Kraig sought a strategic partner to ensure the future sustainability of RIGGS Ambulance Service. To that end, Kraig approached SEMSA with regard to taking over the day-to-day management and a collaborative partnership was born.2010: RIGGS Ambulance Service was awarded CAAS accreditation. Current accreditation extends through May of 2016. 2013: The logo was redesigned to reflect the full name of the company and incorporate the image of EMS; the Pulse Point program was adopted by Merced County EMS responders.

2014: 10 brand new Chevrolet Ambulances were added to the fleet.

2015: January 1, 2015, RIGGS Ambulance Service was awarded an exclusive 10 year (5+5) contract for the provision of ground ALS and critical care transport services inclusive of all allied services required for maintaining a sophisticated ground ambulance response system in Merced County. RIGGS Ambulance Service was purchased by Sierra Medical Services Alliance (SEMSA). Having been known as RIGGS Ambulance Service for more than 66 years in Merced County, SEMSA maintained the RIGGS name.

Although the organization has grown considerably, our core values and commitment to excellence remain the cornerstone of our company culture.

RIGGS Ambulance Service is a not-for-profit 501(c) (3) corporation; a financially self-supported agency receiving no tax payer subsidy or financial aid from any hospital, community or government entity (See Appendix 1: RIGGS Ambulance Service Organizational Chart).

Organizational Mission and Purpose

The mission, purpose and guiding principles of RIGGS Ambulance Service are rooted in STAR CARE; a system used to define how we treat ourselves, our patients, our partners and our co-workers.

SAFE - Were my actions safe - for me, for my colleagues, for other professionals and for the public?

TEAM-BASED - Were my actions taken with due regard for the opinions and feelings of my co-workers, including those from other agencies?

ATTENTIVE TO HUMAN NEEDS - Did I treat my patient as a person? Did I keep him/her warm? Was I gentle? Did I use his/her name throughout the call? Did I tell him/her what to expect in advance? Did I treat his/her family and/or relatives with similar respect?

RESPECTFUL - Did I treat my patient, my colleagues, first-responders, hospital staff and the public with the kind of respect that I would have wanted to receive myself?

CUSTOMER ACCOUNTABLE - If I were face-to-face right now with the customers I dealt with on this response, could I look them in the eye and say, “I did my very best for you”.

APPROPRIATE - Was my care appropriate - medically, professionally, legally and practically considering the circumstances I faced?

REASONABLE - Did my actions make sense? Would a reasonable colleague of my experience have acted similarly under the same circumstances?

ETHICAL - Were my actions fair and honest in every way? Are my answers to these questions yes?

*Used with the permission of Mr. Thom Dick*

Clinical Vision and Mission Vision: An organizational culture in which we accept and take accountability for our actions and behaviors. To create and maintain a safe and supportive learning environment where areas and opportunities for improvement are recognized, reported and driven by those closest to the situation without fear of punitive action. To view each incident as an opportunity to mitigate risk, re-examine existing systems, enhance safety and improve quality of service.

Mission: To champion ongoing clinical excellence in an organizational culture founded on personal and professional accountability.

Tag Line: Do the right thing ~

With an emphasis on total quality management (TQM) (http://asq.org/learn-about-quality/total-quality- management/overview/overview.html) we continually strive to raise the bar throughout the organization. RIGGS Ambulance Service employs quality improvement methodology both within the organization and externally in the community.

A progressive EMS system operates on the premise that defects are prevented rather than repaired. Our program goes beyond traditional retrospective efforts reflecting currently accepted approaches of quality improvement. The assessment of baseline processes and outcomes are determined through quality assurance reviews.

RIGGS Ambulance Services employs several methodologies to examine areas of improvement and implement Best Practices (See Appendix 4: Best Practice process). Root Cause Analysis (RCA), Risk Mitigation Strategies (RMS), FADE (Focus-Analyze-Develop-Execute-Evaluate) and Plan-Do-Study-Act (PDSA) cycles (See Appendix 5: PDSA Process and Appendix 6: FADE Process).

The clinical department is a collaborative effort between our organizational Medical Director, regional Medical Director, Clinical Manager and Clinical Coordinator. The Clinical Manager is our point person for continuous quality improvement, quality assurance, and performance improvement efforts. In this model the local EMS agency (LEMSA) and in particular the LEMSA Medical Director has great input into many aspects of the CQI process. For example, once developed all performance improvement plans (PIPs) for our clinical employees will be evaluated and approved by the LEMSA Medical Director.

Our continuous quality improvement (CQI) program is multi-faceted and begins with the selection of high-quality employees. Field employees receive approximately 400 hours of training in a multi-phase

orientation (prospective CQI effort). The orientation process includes both company and Merced County EMS Agency (MCEMSA) policies, protocols and procedures. The skills necessary to perform under these requirements are obtained through lecture, kinesthetic and computer based training modules which are verified through competency based evaluation. Once employees are working within the EMS system, they receive ongoing education from a standard curriculum where sentinel and frequency-based indicators are gathered through our quality improvement (QI) process. This process reports policy and procedure variances, performance data and recommendations to MCEMSA. This process is the basis for improvement in education and employee performance.

The broad quality categories are determined by many methods including but not limited to; stakeholder input (hospitals, specialty care centers, and healthcare providers), root cause analysis, changes in standard of care, operational issues and feedback from fire dept. first responders and our EMS providers. These categories are further broken down into specific, measureable, achievable, realistic and timely (SMART) metrics. These SMART metrics are in-depth data sets that reveal insights into the many tasks and events that occur in EMS. These metrics may also be developed from the internal and external CQI committee feedback.

High risk, low volume skills (i.e. intubation, needle cricothyrotomy, needle thoracotomy, cardiac arrest management, etc.) are continuously monitored to ensure appropriate decision making and skill competency. We work closely with the MCEMSA to carefully vet any new pre-hospital treatment procedures or equipment in order to ensure they are appropriate for use in the Merced County EMS system.

The Continuous Quality Improvement Committee (CQI Committee) plays an integral role in directing selected activities aligned with the overall Strategic Plan. Members of the RIGGS Ambulance Service CQI Committee include (See Appendix 2: CQI Committee and Appendix 10: Quality Improvement/CQI Bylaw):

• Organizational Medical Director - Chairperson • Regional Medical Director • Clinical Manager • Clinical Coordinator • General Manager • Communications Manager • Billing Department Manager/Supervisor • 2 ALS Field Providers • 1 BLS Field Provider

In addition to the CQI Committee, various sub-committees comprised of volunteer members from our staff of EMT’s and Paramedics assist the CQI committee in reviewing or monitoring major portions of the Continuous Quality Improvement Process. These subcommittees include (See Appendix 3: CQI Sub- committees):

• Scheduling and Deployment Committee (SDC)

o Participates in development of employee schedules and performs/oversees the bi- annual shift bid process. o The SDC reviews, evaluates and advises the RIGGS Ambulance Service CQI Committee regarding the System Status Plan (SSP). o Provides input and assists in the development of SSP’s and post locations. o This committee meets bi-annually and reports to the General Manager.

• Equipment Evaluation Team (EET)

o Provides feedback regarding the potential replacement of existing equipment and evaluation and/or purchase of new products. o Makes recommendations for improvements, additions and/or changes to existing equipment. o Collaborates with internal and external stake holders to vet impact of potential equipment changes. o This is an Ad Hoc committee.

• Health and Safety Committee (HSC)

o The HSC provides assessment of all safety and risk issues. o Assists in oversight of Safety & Risk Management (SRM) in all aspects of the organization. o The HSC reports to the RIGGS Ambulance Service General Manager on occurrences and submits recommendations for improvement. o This committee meets bi-monthly.

• ePCR Committee

o The ePCR Committee oversees the selection, implementation, review and ongoing efforts to improve the e-PCR tool (Physio-Control Health EMS). o Participates in the verification and re-evaluation of FirstWatch triggers, reports findings and makes recommendations for improvement to the CQI Committee. o The committee will meet (quarterly at a minimum) to evaluate current data fields, ensure documentation needs are being met by the product and make recommendations to the CQI committee

• Field Training Officer (FTO) Academy

o An FTO academy is provided to new and experienced FTO’s on an annual basis. Additionally, the Education & Training Manager, Clinical Manager and/or their designee meet with the FTO’s and Preceptors quarterly to discuss and evaluate the current program and develop program improvement processes. The FTO program is based on national information and curriculum provided at training sessions such as those developed by the National Association for EMS Educators.

• Communications Center Quality Improvement Committee

o The Quality Improvement Committee (Dispatch Review Committee by definition) oversees the development, implementation, and ongoing review of the CQI plan for Communications. o Compliance scoring is established by the International Academies of Emergency Dispatchers (IAED). o Oversees the training program specific to Emergency Medical Dispatchers. o The Communications CQI Committee activities run concurrently with the RIGGS Ambulance Service CQI Committee. o This committee meets monthly.

II. Data Collection and Reporting

Collection

RIGGS Ambulance Service uses sophisticated electronic charting and database tools to review and understand the practice of pre-hospital medicine in the Merced County EMS system. All patient charts are written using Physio-Control HealthEMS e-PCR; a robust platform allowing customized searches, access to California EMS Information System (CEMSIS) and National EMS Information System (NEMSIS) data, and capable of individual as well as systemic performance reporting. Clinical reviews and audits are performed by the Company Medical Director, Regional Medical Director, Clinical Manager, Clinical Coordinator, select Operations Supervisors and the Education & Training Manager.

Currently, individual feedback (positive as well as constructive) is provided to employees using a closed- loop communication cycle through Team Support (http://www.teamsupport.com) and individual face-to- face counseling where appropriate. We are actively working with FirstWatch to enhance and strengthen our current methods of conducting clinical reviews and providing employee feedback (http://www.firstwatch.net).

“FirstPass is a clinical quality measurement and protocol monitoring tool designed to alert users to deviations in expected treatments to medical protocols. FirstPass provides continuous monitoring of ePCR and other data to quickly identify and provide real-time alerts related to protocol deviations,

incomplete “care bundles” (which include scientifically validated patient care protocols), missing data elements or urgent patient safety issues. A standard bundle of protocols designed to measure predefined quality metrics; protocols are configured with quality metrics, yet the agency has the ability to add metrics specific to their needs. The goal is not just quality improvement; it is the quality of care to the patient.

The FirstPass “Bundle of Care” includes the following protocols: ACS/STEMI, Stroke, Trauma, Airway Management, Cardiac Arrest, Universal and Billing. Additional metrics to consider might be: Pain Management, Patient Care Aspect, High Risk/Low Frequency Event or Non-Transports/Refusals”.

Used with the permission of Mr. Terry Fitch, Regional Manager – First Watch

As mentioned earlier, our work group process improvements are achieved through system based approaches using RCA, RMS, traditional FADE/PDSA cycles and through the development and implementation of Best Practices.

2016 clinical indicators for RIGGS Ambulance Service mirror those set forth by the State of California, as specified in EMSA #166 – Appendix E (3rd Edition) to meet required EMS Agency reporting of designated California Core Measures (http://www.emsa.ca.gov/Quality_Improvement). These indicators are in alignment with those required by the MCEMSA for monthly reporting. RIGGS Ambulance Service is working with FirstWatch to develop a California Core Measure Reporting Tool (See Appendix 7: FADE - California Core Measure Reporting Tool and Appendix 8: California Core Measure Report).

2016 Clinical Indicators include:

• Trauma - scene times (>20 min) • Acute Coronary Syndrome (12 lead ECG performed-obtained / <10 min. patient contact) • Cardiac Arrest - collection of CARES data • Response and Transport - dispatch determinate/provider impression/mode of transport (lights/sirens to receiving) • Pain - documentation of pain scale (pre/post analgesia administration) • Stroke - data set TBD • Respiratory - data set TBD • Pediatric - data set TBD • Performance of Skills - data set TBD

New indicators may be developed throughout the year based on feedback from CQI Committee with input from the following:

• Organizational Medical Director • Regional Medical Director • RIGGS Ambulance Service Occurrence Reporting • RIGGS Ambulance Service Employee Feedback / Self-reporting • RIGGS Ambulance Service Emergency Medical Dispatch EMD-Q AQUA review • Merced County EMS Medical Director • Merced County EMS Agency staff • Merced County Technical Advisory Group (TAG) • Merced County Emergency Medical Care Committee (EMCC) • Local and regional allied healthcare providers (STEMI & Trauma Committees) • National/State standard of care trends • Patient/Customer Feedback

Reporting

Required reporting – EMS Authority: The Merced County Emergency Medical Services Agency (MCEMSA) grants and oversees the exclusive franchise for Merced County’s ground ALS ambulance service. This exclusive franchise has a franchise document that lists specific criteria that is reviewed on an annual basis by the MCEMSA. On a monthly basis, RIGGS Ambulance Service reports compliance for Priority 1, Priority 2 and Priority 3 calls. Other items such as quality reviews, patient comments, and public relations activities are also shared with this Agency. Monthly compliance of 90% or greater for Priority 1, Priority 2 and Priority 3 calls must be maintained in order to be compliant with the franchise. The General Manager of RIGGS Ambulance Service has reporting responsibilities to the MCEMSA.

Required reporting – EMS authority: Merced County Contract Compliance Committee (M4C) is an independent advisory committee of community members, fire departments and law enforcement agencies overseen by MCEMSA that bimonthly review the company compliance submissions. The RIGGS Ambulance Service Strategic Deployment Manager prepares the reports and sits on the committee.

Required reporting – EMS authority: Emergency Medical Care Committee (EMCC) functions as an advisory committee to both the County Board of Supervisors and the MCEMSA on matters pertaining to the delivery of emergency medical services and meets quarterly. The company President and General Manager sit on this committee.

Required reporting – Medical oversight: The Technical Assessment Group (TAG) is the County’s CQI committee. Composition includes a representative from local ambulance companies, local hospitals, and local fire departments. The purpose is to assess the overall county performance related to patient care issues. The TAG meets bimonthly. The RIGGS Ambulance Service Clinical Manager sits on this committee.

Required reporting – Medical oversight: The MCEMSA is responsible for accreditation and certification of the paramedics and EMTs. The RIGGS Ambulance Service renews its operating license annually. Certification of Paramedics and EMTs occurs every two (2) years. MCEMSA and California Highway Patrol performs annual inspections of the ambulances. The RIGGS Ambulance Service General Manager has reporting responsibilities to the MCEMSA; the Operations Manager has reporting responsibilities to the California Highway Patrol.

RIGGS Ambulance Service adheres to Health and Safety Codes in regards to all performance improvement plans (PIP) when reporting to the MCEMSA, and in collaboration with the MCEMSA Medical Director.

Personnel

In partnership with our Education & Training Manager, the Clinical Manager oversees and directs the orientation of new employees, monitors employee certification and provides for one-on-one education on the use and implementation of new equipment.

All certifications, licenses and employment requirements are monitored and tracked through Ninth Brain Suite (NBS). Classes applicable to individual employee classification are assigned at the beginning of the fourth quarter for completion by year end. Additionally, annual mandatory OSHA training is administered through the NBS. NBS automatically sends email certification status reports to the employee and his/her manager at the following intervals prior to the expiration of the certificate:

• 180 days • 60 days • 10 days • Every day for the 10 days preceding expiration

The Education & Training Manager is responsible for maintaining all training and certification records for each employee. Monthly, the appropriate department manager receives a report documenting current and outstanding certification or educational requirements for follow-up with employees.

Required Certifications

Certification Type Paramedic EMT EMD

Merced Co. Certification √ √ √

CPR* √ √ √

California Driver’s License √ √ N/A

Ambulance Driver’s License √ √ N/A

Medical Examiners Certificate √ √ N/A

NAEMD N/A N/A √

ITLS or PHTLS √ √ N/A

ACLS √ N/A N/A

AMLS √ N/A N/A

PEPP or PALS √ √ N/A

Annual TB Test √ √ N/A

Lastly, all field employees, supervisors and operations managers possess the appropriate incident command system (ICS) training to meet NIMS compliance.

Equipment and Supplies

Employee concerns regarding safety or injury prevention are presented to the Health and Safety Committee for evaluation and development of an action plan for change. If changes necessitate new equipment, the Equipment Evaluation Team participates in the evaluation and implementation of new equipment. The implementation process includes the development of training programs for familiarization of the equipment prior to placing the equipment into service. Methods for training include the use of NBS and the provision of “hands on” application.

RIGGS Ambulance Service maintains contracts for the periodic maintenance on all durable equipment used for monitoring, training or patient movement (i.e.; cardiac monitors, Stryker Power-Pro cots etc.).

Our System Support Technicians (SST’s) monitor supplies and maintain system-wide inventory levels for the ambulances and out station locations. Inventory control is facilitated through the use of an online tool capable of communicating with outlying 24-hour stations and providing real time inventory and supply needs to supervisors and managers.

Documentation

The HealthEMS (Physio-Control) ePCR has built-in capabilities to access individual PCRs based on provider name, run number and/or any specifically chosen criteria identified for review.

As a component of the orientation process, field employees receive extensive lecture and computer based training on EMS documentation. Material covered in the module include, “Defensible EMS Documentation” (NBS) and instruction on how to write a billable chart.

Appropriateness of interventions are evaluated according to standards of care and in compliance with protocols. If interventions are not appropriate and/or care is not compliant with protocols, feedback is provided through Team Support and one-on-one intervention. Results are trended and areas that continue to be below threshold are addressed with field members per the Individual Education Process (See Table-1 below).

Table 1 – Individual Education Process

Documentation Process Clinical Review Personal Improvement Plan (PIP)

Minor Issues / Events Significant Issues / Events Threat to Public Health & Safety I As soon Practical Immediate Action Required

Including but not limited to Including but not limited to: Significant adverse event causing harm the following areas: grammar, medication errors regardless of or death; or potential for harm or death. spelling, failure to document clinical outcome, deviation from treatment and/or generally accepted patient care Including but not limited to: operating interventions performed, standards, deviation from outside the scope of practice or in direct failure to document current MCEMSA and/or RIGGS violation of MCEMSA and/or RIGGS treatment and/or Ambulance Service policies Ambulance Service policies and/or interventions performed prior and/or procedures. procedures. Certain arrests including but to arrival and discordance of not limited to those associated with documentation. concern for individual and/or public safety, substances, violence and/or abuse.

PCR returned to individual Direct discussion with Clinical Meeting with Clinical and or Operations II with patient identifier Manager manager. information deleted and clinical comments added. PCR returned via secure electronic means. Tools include but not limited to: HealthEMS, FirstPass and Team Support.

Remains in database Permanent Entry into CQI Individualized PIP and/or entry into III Database formal disciplinary process. PIP will specify performance or behaviors that require improvement as well as action plan for accomplishing the improvement including timeline for completion.

Recurrent errors may lead to Based upon severity or clinical Immediate notification of MCEMSA IV the next phase for continued impact one event may lead Two clinical review. or more in one year leads to May include placing individual on Performance Improvement Plan administrative leave pending outcome (PIP). Notification of CAEMSA if we feel MCEMSA is unresponsive

Clinical Care and Outcomes

Our clinical team (Company Medical Director, Regional Medical Director, Clinical Manager, Clinical Coordinator and CQI Committee) is committed to ongoing system / process improvement. Using proactive, concurrent and retrospective CQI analysis, we are working with the MCEMSA Medical Director to develop State of the Art Protocols for the evaluation and management of patients in Merced County.

The following is a sampling of treatments, patient conditions and specific indicators (based on patient categories, populations and conditions) to be reviewed in 2016:

Review of STEMI transports. Indicators to include:

• Patient Contact to 12-Lead under ten minutes • STEMI Center notification within ten minutes of STEMI using algorithmic interpretation • 100% STEMI Activation • 100% Protocol compliance

A 100% retrospective review of AMA/Refusals for 2015. Indicators to include:

• Adult • Pediatric • In Custody • Treat/No Transport • Protocol compliance

100% retrospective review of 2015 trauma scene times > 20 min. Indicators to include:

• Adult • Pediatric • Time stamp - Arrive scene to depart scene • Time stamp - patient contact to departure from scene • Extrication • Documentation of reason for delay

Field Training Officer QI process All new field employees complete a rigorous 3 Phase orientation process comprised of classroom instruction and field training.

The field employee orientation (FTO Program) is comprised of 3 phases including classroom education, field training and written evaluation. Under the guidance and observation of a field training officer (concurrent CQI) trainees progress through each phase by demonstrating proficiency and meeting phase specific performance criteria.

The allotted time specified for each phase is approximate and should be considered as a guideline. Actual length of time spent in each phase of orientation may vary by individual, and will be based on experience. The successful completion of each phase is based on measurable, objective and outcome- based criteria.

Phase 1 is approximately 80 hours and typically consists of 10 days of classroom-type orientation to include lecture, kinesthetic and computer based modules.

Components of Phase 1 include, but are not limited to

a. History of RIGGS Ambulance Service b. Orientation to Health EMS ePCR system c. OSHA-required education and training d. Documentation e. Mapping f. Vehicle maintenance g. Vehicle and Equipment orientation h. Safe patient lifting and moving i. Emergency Vehicle Operator Course j. HAZMAT Awareness k. The Ninth Brain assignments (to be completed prior to completion of class time)

Phases 2 and 3 are field-based with the following processes for quality assurance (QA) and quality improvement (QI):

Phase 2 is approximately 360 hours. The actual duration of this phase is based on the successful completion of the performance measures. In Phase 2, the trainee is required to meet the following performance measures:

a. Demonstrate consistent progress and improvement. b. Demonstrate proficiency and safety in emergent and non-emergent vehicle operations. c. Demonstrate proficiency and safety in patient lifting and moving. d. Demonstrate proficiency in mapping and routing. e. Demonstrate proficiency in equipment location and use. f. Complete and review daily evaluation with FTO g. Submit bi-weekly FTO/orientation evaluation forms as defined in policy. h. Complete patient encounter worksheet and demonstrate competencies appropriate for level of certification through documented patient contacts and/or scenario-based review. i. Demonstrate proficiency in assisting the paramedic (EMT trainee) with BLS/ALS patient care. j. Demonstrate competent, proficient and safe BLS and ALS (Paramedic trainee) patient assessments as described in the clinical performance standards.

All Phase 2 PCRs are reviewed by the FTO and feedback is provided daily through discussion and the use of Daily Evaluation forms.

To progress into Phase 3, the trainee is required to meet the following performance measures:

a. Consistently achieve, maintain and/or exceed all applicable Phase 2 performance measures. b. Consistently demonstrate competent, proficient and safe practices in all Phase 2 competencies. c. Demonstrate competency with consistent scores of > 2 in all areas of the daily evaluation. d. Both the FTO and trainee will review and sign the end of Phase 2 checklist form; available through the Clinical Department. e. Successfully complete a “second look” FTO check off (approx. 24-48 hrs).

f. Successfully pass the RIGGS Ambulance Service Phase 2 Orientation exam. A passing score of 80% is required. Subsequent retesting will require a passing score of 90%.

Phase 3 trainees are the second crew member on the ambulance. The duration of Phase 3 is based on patient encounters and documentation of same. The Clinical Manager or their designee will conduct 100% chart review to ensure the trainee meets the following:

a. Adherence to patient care standards and protocols. b. No major breach of policy or protocol. c. Protocol Compliance Report review with a focus on seldom used protocols or skills.

All Phase 3 PCRs are reviewed by the Clinical Manager or their designee. Feedback is provided based on the findings of chart review throughout Phase 3. Completion of Phase 3 will be determined through consistent demonstration of competent, proficient and safe BLS and ALS patient assessments as described in the clinical performance standards. Treatment rendered and documentation of patient care undergoes evaluation in accordance with standards of care and compliance with protocols. If documented interventions and/or care is not compliant with protocols, methods and routes for feedback may be provided to FTOs and trainees using HealthEMS, Team Support and through one on one conversations. PCRs containing reviewer comments and observations can be returned to the provider/documenter with PHI removed. Members of RIGGS Ambulance Service leadership receive weekly updates with regard to the progress of all employees in orientation.

Communications CQI Process

Overview: The RIGGS Ambulance Service Communications Center (RACC) utilizes the International Academies of Emergency Dispatch quality improvement system, Advance Quality Assurance (AQUA), for call review and performance improvement. Specially trained RACC EMD-Q dispatchers provide call review scoring and feedback.

Collection Method: EMD-Q review 100 random cases per month per guidelines set by the National Academy of Emergency Medical Dispatch. There are six scoring categories counting towards compliance:

• Case Entry (100 pts) • Chief Complaint (100 pts) • Key Questions (100 pts) • Dispatch Life Support Instructions (100 pts) • Final Coding (100 pts) • Customer Service (100 pts)

AQUA scores are calculated based on the above review for both systemic and individual evaluation. The Emergency Medical Dispatcher’s AQUA score is reviewed with each individual by the EMD-Q. Any individual case scoring below 75% compliance is referred to the Communications Manager for review with individual employees. Cumulative AQUA scores are posted monthly in the RACC and reviewed during scheduled RACC and CQI Committee meetings.

Performance Threshold:

• ≥ 95% Case Entry • ≥ 90% Key Questions • ≥ 90% Post-Dispatch Instructions • ≥ 95% Pre-Arrival Instructions • ≥ 95% Chief Complaint Selection • ≥ 90% Final Coding • ≥ 90% Total Compliance Score

Cumulative AQUA scores are to be reviewed during the monthly RIGGS Ambulance Service CQI Committee meeting. RACC personnel meet every two months to discuss quality improvement initiatives and to review AQUA scores.

Risk Management

Risk management is monitored by the Health & Safety Manager and members of Health and Safety Committee. Processes monitored include, but are not limited to:

• All vehicle accidents, minor or major; and in cooperation with appropriate Law Enforcement. • All backing incidents • All job-related employee injuries • All job-related exposures

Miscellaneous Non-Clinical CQI Processes

All members of the organization are encouraged to take an active role in identifying opportunities for improvement, reducing risk and assisting in the development Best Practices. The Deming Plan-Do-Study- Act cycle is an excellent tool for the development of system and process improvements (See Appendix 5: PDSA Process and Appendix 6: FADE Process).

Current initiatives include:

• Decreasing cost of annual /required training – reduce overtime • Development of alternative training modalities – mobile education / training • Employee recruitment and retention – entry level to career

Public Education and Prevention

RIGGS Ambulance Service plays an integral role in EMS public education throughout Merced County. Below is a sampling of our ongoing education and prevention programs:

• Every 15 Minutes programs are conducted each spring at local area high schools. Local EMS agencies get involved; local police departments, local fire departments, local CHP units, local hospitals and RIGGS Ambulance Service. Programs such as the Dos Palos Every 15 Minutes program are held in collaboration with MCEMSA.

• RIGGS Ambulance Service Boy Scout Explorer Post #1948. In addition to training in first aid, and CPR, members receive exposure to careers in pre-hospital as well as general emergency medical services. The Explorer Post often participates in local community service events and offers first aid services to the Merced County Fair and the Atwater 4th of July Festival.

• RIGGS Ambulance Service offers AHA CPR for Healthcare Providers and both traditional and compression only HeartSaver CPR to the residents of Merced County. These classes are provided at least twice monthly. • RIGGS Ambulance Service opens its healthcare provider courses to area professionals. Courses include: ACLS, PALS, AMLS and ITLS.

• RIGGS Ambulance Service is actively involved in presenting 9-1-1 Awareness throughout Merced County schools and a variety of youth programs throughout the county.

• RIGGS Ambulance Service is an active participant in the Atwater Caring for Kids Council Drug Store Project. This program is made available to every 6th grader in Atwater. This popular program facilitates a dramatic introduction illustrating how drugs affect kids and their communities.

• RIGGS Ambulance Service participates in numerous health and safety fairs in Merced County. Health and safety fairs are conducted in collaboration with local health care providers, non-profit organizations and schools to offer health and safety information to local communities.

III. Evaluation of Clinical Indicators

ALS Skills-Based Indicators

The CQI committee receives suggestions and feedback from various sources such as hospitals, specialty centers, physicians, and EMS providers. The committee then identifies clinical indicators that will be reviewed as appropriate (long-term or short-term). Each indicator may be broken down into critical steps: successful, unsuccessful, number of times attempted, and appropriateness of decision to perform. Certain of these clinical indicators may require one hundred percent (100%) audit of all patient care records. This will enable the CQI Manager and team to discern whether remediation or further action is needed; up to and including PIP.

Our long-term goal is to develop BLS skills based clinical indicators. Although BLS skills tend to be less invasive, performed improperly can lead to significant morbidity. All these indicators will be discussed on a scheduled basis allowing review, modification, and helping to ensure the loop-closure process. These performance indicators will be reported to the County LEMSA on a quarterly basis.

RIGGS Ambulance Service will review the indicators monthly. However, reporting monthly may not allow for statistical significance. Internally we will evaluate and discuss monthly, quarterly, ninetieth (90%) percentile, and rolling averages. Aberrant clinical events are categorized as individual or system issues.

Although laudable the goal of reaching hundred percent (100%) appropriate care in clinical outcomes are not attainable. There are always unexpected adverse outcomes no matter whether the appropriate treatment protocol or procedure were chosen and/or performed.

The real goal of any CQI process is discerning whether the treatment/procedure that resulted in a therapeutic misadventure (poor outcome) was ill-chosen due to knowledge base deficit, early closure issues, or a behavioral issue. Looking at the suitability of the selection of the treatment protocol in that clinical scenario can help distinguish deliberate versus ill-chosen decisions.

Upon evaluating the clinical provider’s choices and the decision to provide remediation and education rather than discipline has been made, the provider receives constructive feedback and education. This may include a tailored Performance Improvement Plan (PIP); a structured pathway to correct knowledge deficits while ensuring personal accountability and competency based expectations.

The essential components of a PIP include the following:

1) Employee information 2) Relevant dates of services provided 3) Description of the clinical decision making issue(s) that resulted in the adverse outcome(s) 4) A plan of action that includes a timeline for completion of the PIP with a specific end point

5) A description of the expected goals and objectives to be achieved with specific competencies. 6) The consequences for continued inappropriate behavior(s) or failure to obtain competency 7) Signatures of the clinical and/or operational manager, employee, and medical director 8) Set specific dates with expected goals including the completion date 9) Decide on a date for review of the completed plan

System issues can be addressed by the development and implementation of evidence-based Best Practices. Clinical training for psychomotor skills and education can be performed using Ninth Brain software, email communication, and blogs. Training requiring face-to-face evaluation and demonstration of practicum skills can be done during bi-annual mandatory training. In addition, some of this remediation and new knowledge dissemination can be performed through interaction with supervisor and/or FTOs in the field.

IV. Actions to Improve

RIGGS Ambulance Service uses a systems approach to evaluate indicators and deficiencies requiring improvement. Through the use of RCA, RMS and PDSA cycles, the CQI Committee addresses indicators that do not show improvement or have demonstrated less than expected improvement. The internal evaluation process can be implemented quickly and with relative ease.

On review of clinical indicators or other internal system processes, should an area for improvement be identified; any member of management can recommend a PDSA process for their department. The cycle can be initiated under the guidance of the Clinical Manager, Operations Manager and/or General Manager in order to develop a clear understanding of the area for improvement. The PDSA cycle allows appropriate management to develop a plan, carry out the process improvement with indicators, analyze the change and make adjustments as indicated by the data analysis.

Clinical deficiencies discovered during chart review, employee self-reporting, sentinel event reporting, occurrence reports, supervisor interaction forms and/or public/stakeholder complaints are referred to the Clinical Manager for investigation. Reported deficiencies are subject to thorough evaluation in order to differentiate root cause: System problem – Process problem – Behavioral problem. Any resulting actions are based upon the findings and systematically addressed.

Individual remediation/chart feedback is catalogued in the Team Support database for future access. Individuals who consistently show deficiencies with protocol adherence, documentation or patient care treatments enter the Individual Education Process (Table 1) for education and professional improvement. RIGGS Ambulance Service employs various tools and strategies for individual remediation depending on the employee’s learning style and severity of the defect. Individual deficiencies can result in work group education and potentially protocol review and change.

• Individual Remediation o Team Support o One-on-one remediation o Referral to Education Coordinators

o Research Projects o Performance Improvement Plan (in collaboration with MCEMSA Medical Director and in accordance with Health and Safety Standards)

Support Closed-Loop Feedback Interface

Process improvements developed through the formal PDSA cycle or the FADE process focus on system events. Employee work group development generally occurs through one or a combination of the following:

• Systemic/Work Group Remediation o NBS o Mandatory Training o Clinical Refreshers o Field In-Services o Multi-agency Training

CQI Initiatives - 2016 (immediate)

• 12 lead ECG transmission

• HealthEMS - Data System Refinement • FirstWatch - Data System Refinement • California EMS System Core Quality Measures • Development of BLS Clinical Indicators • Refinement of ALS Clinical Indicators • 10 Commandments of Quality EMS • Just Culture

CQI Initiatives - 1 to 5 years (intermediate and long term)

• Ground Operations o Recruitment and retention o Educational opportunities § Internal § External o Staff development § Personal Growth § Professional Growth § Accountability § Validation of personal values

• Clinical Operations o Improve Data System § User Friendly § Relevant § Dynamic o Improve reporting performance - consistency of reporting • Self • Partner o Re-invigorate committees o Propose and implement navigation committee o Departmental support § Clinical Assistant § CQI Coordinator

• Education and Training o Culture Breeds Performance - in development o Discordance in Documentation - in development o Release at Scene / Refusal of Care - in development o Best Practice Development § Minimize risk § Decrease liability § Increase knowledge base § System wide change o Patient simulators § Adult § Pediatric

§ Neonate o Outreach Education § Mobile Education Unit • Internal Stakeholders • External Stakeholders

• Communications Center o Recruitment o Education opportunities § Internal § External o Staff development § Personal growth § Professional growth § Validation of personal values o Staffing § Supervisor § Quality Assurance § Aviation Communications Specialist o ACE Accreditation

• Organization o Just Culture

Occurrence Reporting/Sentinel Events

RIGGS Ambulance Service uses an online feature for electronic Occurrence Reports (OR). This form is accessible by all employees through the Crew Dashboard and all external stakeholders through the RIGGS website. Once submitted, the OR is transmitted to the General Manager and Operations Manager via email for prioritization and assignment to the appropriate department manager for investigation and follow-up. 100% of all ORs that meet sentinel event criteria are investigated and reported to MCEMSA (See Appendix 11: for Sentinel Event Policy). ORs generated outside of the organization by the general public or system stakeholders are investigated and the reporting party contacted within 24 business hours.

V. Training and Education

Mandatory training is conducted bi-annually (or more frequently as indicated) for all staff. New equipment, policy changes and the introduction of new and proposed protocol enhancements are among typical topics covered. During mandatory training, all field employees are required to undergo skills review inclusive of high risk low volume skills including but not limited to: adult and pediatric intubation, needle cricothyrotomy, needle thoracotomy, external cardiac pacing, synchronized cardioversion, external jugular IV cannulation and intraosseous access.

Our Education & Training Department maintains a pool of qualified ACLS, PALS, PEPP, ITLS and PHTLS instructors. Classes are offered on a rotational basis throughout the year to provide RIGGS personnel and outside providers ample and varied opportunities to renew and maintain required certifications. Classes are free to all current employees and tracked through NBS.

In collaboration with the Clinical Manager, CQI Committee, Medical Director and MCEMSA TAG Committee; the Education & Training Manger provides and oversee training offered to RIGGS Ambulance Service Employees. RIGGS Ambulance Service has developed an extensive Continuing Education (CE) program driven to fill specific needs of:

• Community Education • Training and Education to meet National, State, Local and Organizational Standards • Training and Education as a direct result of prospective and/or retrospective CQI analysis in accordance with CQI initiatives.

Community Education

RIGGS Ambulance Service provides American Heart Association courses to the general public including Free Community “Hands Only” CPR training, CPR for Healthcare Providers, CPR HeartSaver, First Aid and AED training. Additionally, we provide 911 awareness education programs to elementary and preschool- age children throughout Merced County (See Public Education and Prevention Page 14).

Standard of Care Continuing Education & Training

As an American Heart Association approved Training Site, RIGGS Ambulance Service provides Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), and CPR for our current employees at no cost. These training courses are available to our external customers at competitive rates. Additionally, RIGGS is an approved training center for the following classes:

• Advanced Medical Life Support (AMLS) • International Trauma Life Support (ITLS) • Pediatric Education for Pre-Hospital Care Providers (PEPP)

CQI Training & Education

Based upon results and findings of the internal CQI process or as a directive by the Merced County Technical Advisory Group, continuing education initiatives are created and implemented using multiple methods including lecture/skill classes, clinical educational articles and information on our internal communication platforms (Team Support, company education portal (NBS), Clinical/Education electronic Bulletin Board, and email distribution), and sponsorship of external medical presentations by allied healthcare provider partners. RIGGS Ambulance Service provides monthly, “lunch time” CEs designed to

meet the requirement of instructor-based CEs for NREMT recertification. Lastly, all RIGGS Ambulance Service employees have access to 24/7 CE opportunities through Ninth Brain Suite’s education module.

Lecture/Skill CE Classes provided include:

• Advanced Critical Airway Access • Designer Drugs • Respiratory Failure • Pediatric Burn • 12-Lead EKG Refresher • CPAP Utilization • PIT Crew CPR (Winter 2013) • PIT Crew CPR (Spring 2014) • CHEM- 7 and CBG Values (Spring 2014) • Trauma and Tourniquets (Spring 2014) • RAD 57 PULSE CO2 training (Summer 2015) • Metronome training (Summer 2015) • PIT Crew CPR refresher (Summer 2015) • HealthEMS documentation updates Summer (2015) • Review and Practice of Seldom Used Skills (Fall 2015) • Violent Incident Response Training (Fall 2015)

Examples of educational articles and clinical refreshers using our internal communications platforms include:

• How to be successful with a First Pass Intubation • External Laryngeal Manipulation and tube verification (protocol) • ETT Sizing and placement tips • 12 lead cases, lead placement and charting reminders • Case study on Geriatric trauma considerations- • AMA protocol Reminders • Medication shortages, a demonstration through pictures of how to mix to get doses. • Pediatric protocol reminders-BP on all patients • Pediatric assessment and treatment for winter respiratory illnesses • Field glucose testing protocol • Trauma Destination reminder and case study • Adult respiratory protocol differentiation CHF vs. COPD • Protocol refresher regarding NTG in CHF • Hypothermia in the Trauma Patient • Culture Breeds Performance

Support and Sponsorship of External CE classes

RIGGS Ambulance Service regularly partners with the various stakeholders in Merced County to provide coordinated training to all field responders. Examples include Active Shooter Training, MCI Training, PULSE Program/hands-only CPR training and participation in the Mercy Medical Center, Merced MICN training program.

The Clinical Manager is responsible for insuring that changes to company or MCEMSA protocol/policy are communicated in a standardized method to all field employees. Communication methods were shown above in Section IV: Actions to Improve

The Education & Training Manager is responsible for monitoring and ensuring employee compliance with all required certifications and Title 22 requirements. Our education and clinical managers collaborate to develop the annual Education Calendar. The calendar is designed to mirror past years in order to allow employees to recertify on a regular, 2-year cycle. Additionally, the Education & Training Manager has scheduled office hours throughout the month to sign off skills for re-certifying EMTs, online classes or employee remediation. RIGGS Ambulance Service uses Ninth Brain Suite to track all certifications as was discussed in Section III: Evaluation of Clinical Indicators, Personnel.

The Education Department maintains a list of eligible instructors for the following classes: BLS-CPR, EVOC, ACLS, AMLS, PALS, PEPP and ITLS. Many of these adjunct instructors are experienced RIGGS field employees who are interested in furthering their personal development through education. This pool of instructors is occasionally utilized for other education opportunities, including Mandatory Training, new protocol or equipment training (CPAP, PIT Crew Resuscitation, etc.) or training based on their areas of expertise (i.e., ALICE Training, HazMat, Tactical Operations, WMD, etc.).

VI. Annual Update

The Clinical Manager is responsible for updating the CQI Plan annually and submitting to MCEMSA every two years. The February meeting of the RIGGS CQI Committee is dedicated to reviewing the prior year’s clinical indicators, Core Measures and PDSAs as indicated in the CQI Plan. While initial planning of clinical initiatives for the year occurs in the December meeting, the CQI Committee can modify existing initiatives or add new indicators based on the annual review.

General goals of the annual review are to evaluate the effectiveness of the clinical plan and prior year’s initiatives. PDSA cycles may be extended or terminated, Core Measures are re-evaluated and clinical indicators finalized for the upcoming year. New training and education focuses are developed based on the annual plan and the relative success of the prior year’s clinical achievements.

Appendix 1: RIGGS Organizational Chart

Appendix 2: Continuous Quality Improvement Committee Membership

SEMSA Medical Director (Company)

RIGGS Ambulance Service Medical Director Clinical Manager (Regional)

Clinical Coordinator

Administrative CQI Field CQI Committee Communications CQI Committee Members Members Committee Members

Education Coordinators FT Paramedic FTOs Communications Manager

Operations Manager FT EMT FTOs Lead Dispatcher

Business Office Manager Field Supervisors

Appendix 3: Continuous Quality Improvement Sub-Committees

CQI Sub-Committees

Continuous Quality Improvement Sub- Committees

Scheduling & Equipment Health & Safety FTO Training Communications ePCR Committee Deployment Evaluation Committee Program CQI Committee Committee (SDC) Committee

Equipment Health & Safety Communications ePCR Chairperson SDC Chairperson Evaluation Chairperson Manager Chairperson

Appendix 4: Best Practice Development*

Stake Holder Inquiry

Findings Acons RIGGS Clinical for Review Improvement

Best Practice

Development Cycle Provider(s) Medical Educated Director CE's Care Review

Evidence Literature based Best Based Review Pracce developed

Example shown not include an engineering change*

Appendix 5: PDSA Process

Riggs Data Collection and Reporting Flow Describe the flow of data, from indicator development through data collection, review, analysis and corrective action implementation

1 2 Develop Clinical Query Data relevant to Indicators Clinical Indicators

5 6 With input from CQI Committee, the CQI & Ed. Manager develops CQI & Ed. Manager education plan including desired Plan Do Implements Education outcomes, goals & objectives Plan

3 4 CQI Committee Reviews CQI Committee determines need and performance related to Clinical desired outcomes for Indicators on a monthly basis, education/training plan Act Study looking for systemic and individual trends

8 7 CQI Committee reviews progress of Follow-up data query Education Plan, determines if relevant to Education Plan goal/objectives are met or if further Goals & Objectives corrective action is needed

11-15-07

Appendix 6: FADE Process - EMD

• EMD Focus

• IAED Benchmarks • Chief Complaint • Pre-arrival Instrucons Analyze • System -vs- Individual

• AQUA Tool • Staﬃng Develop

• Data analysis • Feedback to dipatchers • Educaon Execute • Professional development

• System Issue • Process Issue Evaluate

Appendix 7: FADE Process - California Core Measure Reporting Tool

• County Reporng Focus • State Reporng

• Data collecon • Current method • Exisng tool(s) Analyze • Areas for improvement

• California Core Measure Reporng Tool Develop

• FirstWatch - inquiry/collaboraon/development • PhysioControl - inqiry Execute

• TEST Tool - Evaluate / Modify Evaluate

Appendix 8: California Core Measures Reporting Tool

Appendix 9: CREW Dashboard

Appendix 10: Continuous Quality Improvement Policy PENDING REVISION

POLICIES & PROCEDURES RIGGS Ambulance Service, Inc.

NUMBER: E-3

SUBJECT: CONTINUOUS QUALITY IMPROVEMENT COMMITTEE

DIVISION: EDUCATION & TRAINING

EFF. DATE: 01/01/07

REV. DATE: 5/1/2012

REFERRENCE:

Purpose: To ensure quality of patient care rendered by personnel.

Policy: RIGGS Ambulance Service, in conjunction with MCEMSA has established a

Continuous Quality Improvement Committee to review the quality and consistency

of care provided.

Procedure:

A. AUTHORITY

California Health and Safety Code, Division 2.5, Sections 1797.202, 1797.204, 1797.220

California Code of Regulations, Division 9, Chapter 4, Sections 100166 – 100169, California

Evidence Code, Section 1040. B.

PURPOSE

CQI Committees are professional standards committees that act in an advisory capacity to RIGGS Ambulance Service management. The purpose of the CQI Committee shall be to provide a confidential forum for the review and evaluation of the provision, necessity and quality of prehospital emergency medical care and training, and to provide organized reporting and recommendations for the improvement of said provisions to RIGGS Ambulance Service.

All proceedings, documents and discussions of the CQI Committee are confidential and protected from discovery under Section 1040 of the Evidence Code of the State of California.

It shall not be the purpose or function of this committee to become directly involved in the certificate review process of any specific individual. The authority for certificate review is vested in the MCEMSA Medical Director in accordance with Section 1797.200, Division 2.5, California Health and Safety Code, and MCEMSA Policy No. 610.00.

C. POLICY

1. COMMITTEE MEMBERSHIP

Members shall be designated by the current CQI Committee members. In the absence of the Medical Director, the Clinical Manager shall perform the duties of the Chairperson. Membership shall be from the following provider entities:

a. RIGGS Ambulance Regional Medical Director b. RIGGS Ambulance General Manager c. RIGGS Ambulance Clinical Manager d. Two field paramedics who may be Field Training Officers e. Communications Manager f. EMT g. Billing Department Manager/Supervisor

2. ATTENDANCE

a. Resignation from the committee may be submitted, in writing, to the Clinical Manager, and is effective upon receipt. b. Members who miss 4 meetings are subject to release from the committee. c. At the discretion of the Clinical Manager, other invitees may participate in the medical audit review of specific cases when their expertise is relevant to the cases being reviewed.

3. MEETINGS

The committee shall meet on a monthly basis at a time and place agreed upon by consensus of the committee membership.

4. COMMITTEE PURPOSE

It shall be the primary purpose of the committee to advance the concept of continuous quality improvement within the EMS System. To this end the committee shall:

a. Ensure the quality standards for prehospital patient care

b. Develop and maintain a systematic process for collection, evaluation and analysis of data

c. Define quality indicators / audit filters

d. Identifying adverse outcomes / deviations from the standards

e. Develop a process for implementing corrective action and reevaluating the effect of said corrective action

5. SCOPE OF REVIEW

The committee may review any prehospital patient care or scene management case discovered through an internal audit, base hospital audit, EMS agency incident reporting process, or specific database extractions as approved by the Medical Director.

6. CASE PRESENTATIONS

Cases shall be selected by the CQI Coordinator or his/her designee for presentation at the committee meetings. At the conclusion of each committee meeting, a consensus of the committee shall be reached regarding the type of cases to be reviewed at the next meeting, and Clinical Manager shall prepare the cases for review. Voting criteria i.e.: acceptable, room for improvement, not acceptable.

7. MEETING PROCEEDINGS

Proceedings of all CQI Committee meetings shall be administered by the Clinical Manager. All printed materials will be distributed to the members and guests at each meeting. Due to the confidentiality of the committee, minutes and documents will be numbered to ensure collection by the Clinical Manager at the close of each meeting.

No other means of documenting meeting proceedings shall be used other that the aforementioned minutes.

8. CONFIDENTIALITY

All proceedings, documents and discussions of the CQI Committee are confidential and protected from discovery under Section 1040 of the Evidence Code of the State of California.

All members and guests shall be required to sign a confidentiality statement in which they agree not to discuss, or disclose in any way, information that would have been obtained solely through membership of the CQI Committee or attendance at meetings of said committee. Confidentiality agreements are subject to annual renewal by all parties.

Appendix 11: Sentinel Event Policy PENDING REVISION

POLICIES & PROCEDURES RIGGS Ambulance Service, Inc.

NUMBER: O-54

SUBJECT: SENTINEL EVENT REPORTING

DIVISION: OPERATIONS

EFF. DATE: 01/01/07

REV. DATE: 11-15-12

REFERRENCE: CAAS 202.05.01

Purpose: To ensure proper reporting of any event, occurrence, or loss (incident) that adversely involves patients, employees, the company or the public which is outside of normal operating policies and procedures.

Policy: Any event, occurrence, or loss (incident) that involves patients, employees, or the public which is outside of normal operating procedures must be reported in accordance with this policy. These incidents may expose the patient and/or organization to risk, a PR issue or may simply warrant an immediate high-level comprehensive review of policy or procedure. This policy is intended to ensure adequate notification to senior management, and ensures that senior management has the opportunity to review, address and/or improve problems in a timely manner. Remember, it is always preferred to over-report than under-report these incidents.

Procedure:

A Sentinel Event includes, but is not limited to, the following:

• Any major communications failure, power failure, or facilities problem • Any employee injury that may result in lost time for the employee • Any injury to a patient after our contact with the patient (i.e., accidental skin tears, drops, falls, etc. • Any patient drops, whether there is a complaint of injury or not • Major traffic accident with a company vehicle • Any employee arrest on duty

• Any controversial or adversarial media inquiry • Any major theft or intentional damage to property • Bomb threats or incidents or workplace violence • Any act, by any provider, bystander, or patient assault and/or battery • Any major negative encounter with healthcare providers, public safety providers or member of the public • Any reported or potential harassment • Any significant incident with another agency • Anything that may result in media attention outside our normal scope of duty • Anything else where the supervisor feels senior management should be notified • Performance of work duties while impaired reported by self or others - i.e.: emotionally, under the influence of medication, alcohol or other substances.

MEDICAL ERRORS

It is the expressed responsibility of the employee to provide immediate, verbal notification to their supervisor for any of the following situations, in addition to the completion of the Medical Error field of the Occurrence Report:

• Medication errors o In addition to immediate verbal notification of the supervisor, Medication Errors also require notification of the receiving physician and/or Medical Control physician as soon as the patient is delivered to the hospital. • An unrecognized esophageal intubation discovered at the receiving facility • Any major breach of medical protocol or standard of care by any organization • Deviation from Treatment Protocols without online medical control authority • Failure or inability to follow verbal orders of online medical control • Equipment failure that results in alteration of patient care • Critical Vehicle Failure - each failure will be evaluated to assess for impact on the delivery of care

The reporting employee must complete and submit an Occurrence Report for any Sentinel Event before the end of their scheduled shift.

When any Sentinel Event occurs, the employee should immediately contact his/her immediate supervisor. The supervisor should take actions to mitigate further loss and follow established procedure where present. The supervisor should then notify senior management of the situation.

Senior Management will make additional notifications if needed and convene a Root Cause Analysis (RCA) meeting.

To prevent a reoccurrence of the sentinel event, education (lesson learned competency) will be delivered to appropriate personnel.

County of Merced Request for Proposal #7144 Air Ambulance Services

Attachment # 7 – Section 2.6.4 - Local Flying Area Curriculum

Local Flying Area

Local flying areas are those areas in which the rotary wing pilot has demonstrated a level of familiarity which allows the use of lower VFR operating minima as described in AMC General Operations Manual, Flight Operations – Helicopter Specific VFR Weather Minimums.

Local flying area minima may only be used by rotary wing pilots who have passed a local flying area written examination on the appropriate local flying area within the previous 12 calendar months. Pilots may be qualified for more than one local flying area.

Any flight outside a local flying area is a cross-country operation. Pilots who have not passed the local flying area written examination for a particular local flying area within the previous 12 calendar months, regardless of operational experience in that area, must use the cross-country VFR minima described in AMC Operations Specifications, – Helicopter Emergency Services (HEMS) Operations, Table 1 Weather Minimums, when operating in that area.

The local flying area examination will be administered by the program aviation manager (PAM) / regional aviation manager (RAM), or lead pilot familiar with the local flying area. The examination will be maintained locally. The manager administering the examination will email the test results, pilot’s name, date of successful completion of the examination and the name of the base to the flight records specialist. The local flying area examination to be used by all bases is located on the following page. Local Flying Area training does not apply to fixed wing pilots.

Rev 10 1

Uncontrolled copy when downloaded or printed.

Refer to the Corporate Publications site for the most current version. County of Merced Request for Proposal #7144 Air Ambulance Services

Base Orientation

1.1 Introduction

New hire and relief pilots will be given day and night orientation flights as necessary prior to operating as PIC. Conduct orientation flights during daylight hours first, followed by a night orientation. Required flight times for day and night orientation will be determined after discussion between the regional aviation director and regional aviation manager. The pilot receiving the orientation will fly the aircraft. The pilot should fly approaches, both day and night. Orientation training may be conducted by any base pilot and training hours in the aircraft type and area orientation may be combined depending on the experience and background of the pilot. Dual flight controls may be installed for orientation flights, but the pilot conducting the orientation from a pilot station not normally flown and manipulating the flight controls must have completed Seat Dependent Training in accordance with Air Methods Pilot Training Program.

1.2 CAMTS Orientation Requirements

CAMTS Accreditation Standards, paragraph 5.07.04 (j.), requires 5 hours local area orientation of which 2 hours must be at night as pilot in command or at the controls prior to performing EMS missions. If the program is CAMTS certified follow CAMTS requirements after completing day and night orientation flights described in the above paragraph.

1.3 Training Documentation

After completing Local Area Flight training, fill out form 5272, and forward to the Flight Records Specialist (a sample of this form can be found in the Appendix of the PTP manual – the actual form is on Flightdeck> Resources> Corp Forms).

1.4 Administration

1. Program Organization 2. Program Policies (General, Parking, ID Badges, Keys, etc.) 3. Facilities Familiarization 4. Air Methods Organization 5. Air Methods Policies (Schedule, Vacation, etc.) 6. Air Methods Office (Housekeeping, Equipment, Storage/Files, etc.)

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County of Merced Request for Proposal #7144 Air Ambulance Services

7. Air Methods Computer 8. Records/Reports (Flight Log, Flight and Duty Time, AIDMOR, Fuel Log, Expenses, etc.) 9. Meetings (Air Methods, Safety Committee, etc.)

1.5 Operations

1. Orientation to the hospital or health care system associated with. 2. Ground and Flight Safety 3. Program Safety Philosophy 4. Pre-Accident Plan 5. Login into 411 System, check pilot status (notify the training department if pilot is unable to login). 6. Weather. 7. Applicable Air Methods and Program Minimums 8. Reporting Points/Times 9. Local Phenomena 10. Weather Data Sources (DUAT, WSI, DTN, FSS) 11. Inadvertent IMC Procedures 12. Severe Weather Procedures 13. Operating Altitudes 14. Minimum Safe Altitudes 15. Medical Protocol for Altitude (Notification points for medical personnel) 16. Patient Loading/Unloading 17. Helipad Security

1.6 Operating Area

1. Local Area Definition 2. Map Study (Sectionals, Road Maps, City Maps, IFR Publications, etc.) 3. Hospitals (Reference Book) 4. Scene Response Area (Procedures, Pre-Designated Areas) 5. Programmed Waypoints (Reference Book) 6. Airports 7. Special Use Airspace 8. ATC Facilities 9. Landmarks 10. Hazards (Wires, Towers)

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County of Merced Request for Proposal #7144 Air Ambulance Services

11. Inadvertent IMC Procedures 12. Site specific OHSA requirements

1.7 Communications

1. Assigned Communications Center 2. Flight Request Notification (Pager, Phone, Radio etc.) 3. Flight Following (Format, Interval, etc.) 4. Local Agencies (Frequencies, Procedures, etc.) 5. Transponder Codes 6. Emergency/Precautionary Landings

1.8 Aircraft Orientation

1. General discussion of the aircraft 2. Avionics 3. ATC communications 4. Medical communications (PL Tones, Encoder, etc.) 5. Navigation (VOR, ADF, Loran, GPS, Associated Displays, etc.) 6. Oxygen system (Operating, Servicing, etc.) 7. Survival equipment (Location, Operation, etc.) 8. Medical equipment (Location, Operation, etc.) 9. Aircraft winter Covers/Sunscreens/Tie-downs 10. Two patient configuration (If Applicable) 11. Weight and Balance (Computer, Trip/Load Manifests, etc.) 12. Lighting systems (Primary Aircraft, Searchlight, Supplemental, etc.) 13. Auxiliary equipment (Hoist, Skis, etc.) 14. Shoreline power Procedures (Heaters, etc.) 15. Aircraft logbooks (ADs, Status Sheets, Cycle Count, Power Check etc.) 16. On-board publications (Charts, Manuals, Location References, etc.)

1.9 Flight Operations

1. Standby requests 2. Flight requests (Medical, Neonate, Balloon, etc.) 3. Search and rescue Requests 4. Public relations Requests

Air Methods / RIGGS Proposal| Attachment # 7 – Section 2.6.4 - Local Flying Area Curriculum 164

County of Merced Request for Proposal #7144 Air Ambulance Services

5. Refueling (Locations, Payment, Records, etc.) 6. Non-revenue flights (Maintenance, Training, Ferry)

1.10 Maintenance (PMSP)

1. Maintenance procedures training (AAIP, PM Servicing Training) 2. Mechanical interruption summary 3. Aircraft cleaning & decontamination (Cleaning supplies, etc.) 4. Fuel samples 5. Maintenance publications 6. Maintenance facilities (Location of Tools, Parts, etc.) 7. MEL procedures

1.11 Additional Items as required by the PAM / RAM:

1. 2. 3.

1.12 Examination

Pilots must demonstrate a level of familiarity with the local flying area by passing an examination given by Air Methods within the 12 calendar months prior to using the local flying area. (14 CFR Part 135.609). A copy of the dated examination will remain on file at the base until replaced by the succeeding examination (RW only).

Air Methods / RIGGS Proposal| Attachment # 7 – Section 2.6.4 - Local Flying Area Curriculum 165

County of Merced Request for Proposal #7144 Air Ambulance Services

Local Flying Area Examination (RW only)

Name: Date:

Base: Score:

Describe the dimensions and boundaries of your local

flying area. Describe the major terrain features in your

local flying area.

What effect does the terrain features have on the weather in your local

flying area? What are your local flying area weather minimums?

What are your cross-country weather minimums?

How frequently must you be evaluated on your local flying area?

What are your limitations if you are not successful in the evaluation of your local

flying area? What is the MSA at your home base?

What is the frequency of your nearest Approach Control?

What airports and instrument approaches are available in your area?

Instructor/Lead Pilot certification signature:

Air Methods / RIGGS Proposal| Attachment # 7 – Section 2.6.4 - Local Flying Area Curriculum 166