PA LICENSURE INSPECTION

Information

Document No.
Audit Title
Client / Site
Conducted on
Prepared by
Location
Personnel

General requirements for each Ambulance

100 Watt Siren working ?
All interior lighting functional ?
1- 5lb ABC Fire Extinguisher in Cab or outside body secured properly, Safety seal intact & valid inspection tag within the previous 12 months attached ?
Exp. Date
1- 5lb ABC Fire Extinguisher in Pt. Comp., secured properly, Safety seal intact and valid inspection tag witan the previous 12 months attached ?
Exp. Date
All portable equipment secured ?
Stretcher with 3 operational straps ?
All doors function properly with seals in good condition ?
"No Smoking Oxygen Equipped" & "Fasten Seat Belts" signage (CAB) ?
"No Smoking Oxygen Equipped" & "Fasten Seat Belts" signage (Pt. Compartment) ?
Current & Valid PA Vehicle Inspection ?
Exp. Date
Current motor vehicle insurance ?
Exp. Date
Functional dispatch radio ?
Functional command radio ?

REQUIRED MEDICAL EQUIPMENT

Main O2 supply 500 psi (min), 3 restraints, regulator, 0-25LPM Flow meter ?
Main Suction operational ?
Large bore suction tubing that can reach the foot of the stretcher ?
Functional Portable suction unit with wide bore tubing ?
Suction catheters Rigid - 2 sterile ?
6FR AND 8FR EACH - 1 sterile ?
10FR or 12FR - 2 sterile ?
14FR or 16FR - 2 sterile ?
Nasal airways 5 different sizes minimum 1 of 16FR-24FR sterile ?
Nasal airways 5 different sizes minimum 1 of 26FR-34FR sterile ?
Portable Oxygen tanks 2 properly secured ?
Humidifier bottle ?
Non rebreather 1 Adult, 1 Pediatric & 1 Infant ?
Pocket mask with one way oxygen valve ?
Nasal cannula 1 Adult & 1 Pediatric ?
Folding litter ?
Manual blood pressure cuff: Child, Adult & Large ?
Stethoscope 1 Adult & 1 Pediatric ?
Penlight ?
4 rolls of assorted size tape, 1 must be hypoallergenic ?
4 Muli. - Trauma 10"x30"
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4 Occlusive 3"x4"
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25 Gauze 4"x4" sterile
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6 soft self-adhering gauze rolls
1 Bandage Shears
1 lateral cervical spine device ?
1 long board
1 short board
Cervical collar Adult 1 EACH S, M, L total 3 ? Multi size adjustable permitted
Cervical collar Pediatric 1 EACH S, M, L total 3 ? multi size adjustable permitted
BVM Adult 1 ?
BVM Pediatric child 1 ?
BVM Pediatric infant/neonatal 1 ?
Pediatric length based dosage/sizing tape most current version.
Straps 9' total 5
Traction splint, adult 1
Traction splint pediatric 1
Board splints, Large 2
Board splints, medium 2
Board splints, small 2
Sterile water 6
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Normal saline 6
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Burn sheet, 4'x4' sterile 2
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Cold packs 4
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Heat packs 4
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Triangular bandages 8
OB Kits, sterile 2
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Bulb Syringe, sterile 2
Thermal blanket, sterile or sterile foil roll 1
Blankets 2
Sheets 4
Pillow cases 2
Pillow 1
Towels 4
Tissues, disposable, box 1
Urinal 1
Emesis container 1
Bed pan 1
Drinking cups, disposable, paper 4
Triage tags 20
Lights, hand held, 6 volt, 2
Hazard warning device, roadway 3
Emergency jump kit 1
Emergency Response Guidebook, current edition, 1
Thermometer, electronic, digital, not tympanic 1
Sharps receptacle, secured 1
Glucose, Instant, oral 45g
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PPE, Helmet, eye protection, gloves & Hi Vis vest 1 PER CREW MEMBER
Sponges, alcohol, prep 10
ET 2.5 or 3.0 uncuffed sterile 2
ET 3.5 or 4.0 uncuffed sterile 2
ET 4.0 or 5.0 sterile 2
ET 5.5 or 6.0 sterile 2
ET 6.5 or 7.0 sterile 2
ET 7.5 or 8.0 sterile 2
ET 8.5 or 9.0 sterile 2
Sz3 King LT 1
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Sz4 King LT 1
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Sz5 King LT 1
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Nebulizer - 1
Laryngoscopes handle with batteries and spares 1
#1 Straight blade 1
#2 Straight blade 1
#3 Straight blade 1
#3 Curved blade 1
#4 Curved blade 1
Merconium aspirator 1
2cc lubrication, water soluble, sterile 2
Select date
Forceps, Magill, adult 1
Forceps, Magill, pediatric 1
LP-15 operational, Stocked & AED Capable 1
LP-15 SELF TEST
Defibrillator pads 2
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Electrodes, Adult 6
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Electrodes, Pediatric 6
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CPAP, operational & stocked 1
Stylette, Malleable, Adult 2
Stylette, Malleable, Pediatric 2
Phlebotomy Equipment per Protocols
Glucose Meter Stocked & Operational 1
IV solutions 2,250 ml total minimum
DRUG BOX complete date check
HOUSE BAG complete date check
PEDI BAG complete date check
TRAUMA BAG complete date check
IV START KIT complete date check
IV catheters 14ga - 4
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IV catheters 16ga - 4
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IV catheters 18ga - 4
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IV catheters 20ga - 4
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IV catheters 22ga - 4
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IV catheters 24ga - 2
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Micro Drip - 2
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Macro Drip - 2
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Tourniquets 2
I.O. Needles 14-18ga - 3
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Tourniquet, Commercial, mechanical - 1
Protocols, Statewide, EMS, most recent version - 1
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Needles, hypodermic 16-18ga - 4
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Needles, hypodermic 20-22ga - 4
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Needles, hypodermic 23-25ga - 4
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Syringes- 2
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Eye protection, clear disposable - 3
Mask, face, disposable - 3
Coverings, foot - 3 sets
Sharps containers & red bags as needed
N-95 masks minimum - 3
Gloves, double barrier - 3 sets
Cleaner, hand, Non water - 1 container
Gown, disposable - 3
Cap, surgical - 3
Supervisor
Crew 1
Crew 2