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HomeMy WebLinkAboutDoc 275 - Agrmt - Coppedge - Health SvcsDeschutes County Board of Commissioners 1300 NW Wall St., Suite 200, Bend, OR 97701-1960 (541) 388-6570 -Fax (541) 385-3202 -www.deschutes.org AGENDA REQUEST & STAFF REPORT For Board Business Meeting of August 19, 2013 Please see directions for completing this document on the next page. DATE: August 8, 2013 FROM: Nancy Mooney, Contract Specialist Phone: 322-7516 Health Services--Behavioral Health Division TITLE OF AGENDA ITEM: Consideration of Board Signature of Document #2013-275, personal services contract between Kate Coppedge, Nurse Practitioner and Deschutes County Health Services. PUBLIC HEARING ON THIS DATE? No BACKGROUND AND POLICY IMPLICATIONS: Mary K. Coppedge (Kate Coppedge) provides behavioral health services to persons diagnosed with serious behavioral health illness, or other behavioral or emotional disturbance posing a danger to the health and safety of themselves or others. These services include psychiatric assessments, medication prescribing and medication management, and provision of group and individual therapy for qualifying individuals. County will provide payments to Kate Coppedge (upon receipt of invoice) on a fee-for­ service basis of $105 per hour for a maximum of thirty (30) hours per week. Kate Coppedge will pay a monthly rent of $250 in return for the County providing an office, meeting space, use of a computer, phone, e-mail and any other general office supplies required to carry out the terms of the contract. FISCAL IMPLICATIONS: Maximum compensation for the duration of the contract is $151,000. RECOMMENDATION & ACTION REQUESTED: Behavioral Health requests approval. ATTENDANCE: Consent Agenda please DISTRIBUTION OF DOCUMENTS: Executed originals to: f Nancy Mooney, Contract Specialist, Health Services f t [ I DESCHUTES COUNTY DOCUMENT SUMMARY (NOTE: This fonn is required to be submitted with ALL contracts and other agreements, regardless of whether the document is to be on a Board agenda or can be signed by the County Administrator or Department Director. If the document is to be on a Board agenda, the Agenda Request Fonn is also required. If this fonn is not included with the document, the document will be returned to the Department. Please submit documents to the Board Secretary for tracking purposes, and not directly to Legal Counsel, the County Administrator or the Commissioners. In addition to submitting this fonn with your documents, please submit this fonn electronically to the Board Secretary.) Please complete all sections above the Official Review line. Date: I June 13, 2013 I Department: I Health Services, Behavioral Health I Contractor/Supplier/Consultant Name: I Mary K. Coppedgel Contractor Contact: I Mary K. Coppedgel Type of Document: Personal Services Contract Goods and/or Services: Mary K. Coppedge (Kate Coppedge) provides behavioral health to persons diagnosed with serious behavioral health illness, or other behavioral or emotional disturbance pOSing a danger to the health and safety of themselves or others. Background & History: Kate Coppedge, will provide behavioral health services as a Licensed Medical Practitioner. These services include psychiatriC assessments, medication prescribing and medication management, and provision of group and individual therapy for qualifying individuals. Medical services will be provided and documented in a legible manner consistent with professional and community standards of care. Subject to availability of funds, County shall provide monthly payments to Contractor upon receipt of payment from the Oregon Health Authority. County shall pay Contractor on a fee-for­ service basis at $105 per hour for services provided. The maximum number of hours Contractor is authorized to work under this contract is thirty (30) hours per week. The Contractor agrees to pay County monthly rent of $250 in return for the County providing office and meeting space, use of a computer, phone, e-mail and any other general office supplies required to carry out the terms of the Contract. Agreement Starting Date: I July 1, 2013 I Ending Date: I June 30,2014 I Annual Value or Total Payment: I Maximum compensation $151,000. I:8J Insurance Certificate Received ZCheck box) Insurance Expiration Date:! lP IQ{tot4 Check all that apply: D RFP, Solicitation or Bid Process D Informal quotes «$150K) I:8J Exempt from RFP, Solicitation or Bid Process (specify -see DCC §2.37) Funding Source: (Included in current budget? I:8J Yes D No If No, has budget amendment been submitted? DYes D No 6/13/2013 Is this a Grant Agreement providing revenue to the County? DYes cgJ No Special conditions attached to this grant: Deadlines for reporting to the grantor: If a new FTE will be hired with grant funds, confirm that Personnel has been notified that it is a grant-funded position so that this will be noted in the offer letter: DYes D No Contact information for the person responsible for grant compliance: Name: D Phone#:D Deputy Director Approval: ~O!MIlA (1,}\1\ {J S' nature Department Director Approval: ------3o,__t-f...:..u:'-------to\1\3 Date Distribution of Document: Return both originals to Nancy Mooney, Behavioral Health Department. D Official Review: County Signature Required (check one): ~CC D Department Director (if <$25K) ~ Administrator (if >$25K but <$150::'1 ->-$150K, SOCC Order No . _____ & tir-I > Legal Review Date¥ (l..&c;/) Document Number 2013-275 ~~~'------- 6113/2013 Connie Thomas From: Nancy Mooney Sent: Wednesday, August 07,201311:21 AM To: Connie Thomas Subject: FW: Subcontracts listing State as additional insured From: Barrett April 0 [mailto:april.d.barrett@state.or.us] sent: TuesdaYI August 06 1 2013 4:38 PM To: Nancy Mooney Subject: Subcontracts listing State as additional insured Hi NancYI Thanks for contacting me today in regards to your subcontractors, specifically nurse practitioners, having a hard time getting insurance agencies to list the State of Oregon, Oregon Health Authority as an additional insured per your County Financial Assistance Agreement 141408. In looking further into this requirement and speaking to my management, it has been determined that the County subcontractors should only be listing the County as an additional insured. I will get an amendment going to correct this requirement in all the County/CMHP Financial Assistance Agreements. Reason being is that the Agreement is really between State and County in which we have contribution language that covers any claims made. If County chooses to subcontract, that contract is only between subcontractor and County, therefore, the County would go after the subcontractor at fault to cover the claims, not the State. I hope this makes sense, and sorry for all the confusion! It will take a few weeks to get the amendment ready and all my buyoffs, but with this email please continue your subcontracts without listing the State of Oregon, Oregon Health Authority as an additional insured on the subcontractors insurance. If you have any questions please let me know. Thank you, April D. Barrett, OPBC DHS IOHA Office of Contracts & Procurement Contracts Specialist 250 Winter Street NE Salem, OR 97301 if: (503) 945-58211 : april.d.barrett@state.or.us 1 HEAL THCARE PROVIDERS PROFESSIONAL LIABILITY INSURANCE ENDORSEMENT Additional Insured -Genefal Liability In consideration of the premium paid, and subject to the General Liability limit of liability shown on the certificate of insurance, it is agreed that the GENERAL LIABILITY COVERAGE PART is amended as follows: The person or entity named below (the «Additional Insured") is an insured under this Coverage Pare but only as respects its liability arising out of named insured's operations, or premises owned by or rented by the named insured and solely to the extent that: 1. a general liability claim is made against the named insured and the additional insured; and 2. in any ensuing litigation arising out of such claim, the named insured and the additional insured remain as co-defendants. In no event is there any coverage provided under this policy for an occurrence that is the direct liability of the additional insured. Additional Insured: Deschutes County Health Services 2577 NE Courtney Drive Bend, OR 97701 ENDT. NO. POLICY NO. ISSUED TO ENDORSEMENT EFFECTNE DATE 423500419 Mary K Coppedge 06/10/2013 G-123827-B (07/2001) 08072013 =Atj;;; LEGAL ~UNSEL For Recording Stamp Only DESCHUTES COUNTY SERVICES CONTRACT CONTRACT NO. 2013-275 This Contract is made and entered into by and between Deschutes County, a political subdivision of the State of Oregon, acting by and through the Deschutes County Health Services Department, Behavioral Health division, 2577 NE Courtney Drive, Bend, OR 97701, hereinafter referred to as "County", and Mary K. Coppedge, hereinafter referred to as "Contractor". The parties agree as follows: Effective Date and Termination Date. The effective date of this Contract shall be July 1, 2013. Unless extended or terminated earlier in accordance with its terms, this Contract shall terminate when County accepts Contractor's completed performance or on June 30, 2014, whichever date occurs last. Contract termination shall not extinguish or prejudice County's right to enforce this Contract with respect to any default by Contractor that has not been cured. This Contract may be renewed or extended only upon written agreement of the Parties. Statement of Work. Contractor shall perform the work described in Exhibit 1. Payment for Work. County agrees to pay Contractor in accordance with Exhibit 1. Contract Documents. This Contract includes Page 1-9 and Exhibits 1, 2, 3, 4, 5, 6 and 7 & 8. CONTRACTOR DATA AND SIGNATURE Contractor Address: 61368 Elk Horn Street, Bend, OR 97702 Federal Tax 10# or Social Security #: Is Contractor a nonresident alien? DyeS~NO Business D~signation (?heck one): Sole Proprietorship D Partnership D Corporation-for profit Corporation-non-profit D Other, describe: LLC A Federal tax ID number or Social Security number is required to be provided by the Contractor and shall be used for the administration of state, federal and local tax laws. Payment information shall be reported to the Internal Revenue Service under the name and Federal tax ID number or, if none, the Social Security number provided above. I have read this Contract including the attached Exhibits. I understand this Contract and agree to be bound by its term NOTE: Contractor shall also sign Exhibits 3, 4, 6, 7 and 8. f!1ff f Date DESCHUTES COUNTY SIGNATURE Contracts with a maximum consideration of not greater than $50,000 are not valid and not binding on the County until signed by the appropriate Deschutes County Department Head. Additionally, Contracts with a maximum consideration greater than $50,000 but less than $150,000 are not valid and not binding on the County until signed by the County Administrator. Dated this ~of _--"",-u-,,---r---'2013J--=.' Y Tom Anderson, County Administrator Page 1 of 9 -Personal Services Contract No. 2013-275 DC -2013-2 5 DATED this dayof ___________2013 for the Deschutes County Board of Commissioners. ALAN UNGER, Chair TAMMY BANEY, Vice Chair ATTEST: ANTHONY DEBONE, Commissioner Recording Secretary [ I STANDARD TERMS AND CONDITIONS 1. Time is of the Essence. Contractor agrees that time is of the essence in the performance of this Contract. 2. Compensation. Payment for all work performed under this Contract shall be made in the amounts and manner set forth in Exhibit 1. a. Payments shall be made to Contractor following County's review and approval of billings and deliverables submitted by Contractor. b. All Contractor billings are subject to the maximum compensation amount of this Contract. c. Contractor shall not submit billings for, and County shall not pay, any amount in excess of the maximum compensation amount of this Contract, including any reimbursable expenses, (See Exhibit 5). 1) If the maximum compensation amount is increased by amendment to this Contract, the amendment shall be signed by both parties and fully executed before Contractor performs work subject to the amendment. 2) No payment shall be made for any services performed before the beginning date or after the expiration date of this Contract. d. This Contract shall not be amended after the expiration date. e. Unless otherwise specifically provided in Exhibit 5, Contractor shall submit monthly invoices for work performed. The invoices shall describe all work performed with particularity and by whom it was performed and shall itemize and explain aU expenses for which reimbursement is claimed. f. The invoices also shall include the total amount invoiced to date by Contractor prior to the current invoice. g. Prior to approval or payment of any billing, County may require and Contractor shall provide any information which County deems necessary to verify work has been properly performed in accordance with the Contract. h. Expenditures of Contractor may be charged to this Contract only if they: (1) are in payment for services performed under this Contract; (2) conform to applicable State and Federal regulations and statutes; (3) are in payment of an obligation incurred during the period of this Contract; and (4) are not in excess of 100% of program costs. Any County funds spent for purposes not authorized by this Contract shall be deducted from payments or refunded to County, at County's option. Payments by County in excess of authorized actual expenditures shall be deducted from payment or refunded to County no later than thirty (30) days after the expiration of this Contract. If Contractor fails to provide an acceptable audit performed by a certified public accountant for federal funds received under this Contract, or if federal authorities demand the repayment of federal funds received under this Contract, County may recover all federal funds paid under this Contract, unless a smaller amount is disallowed or demanded. If Oregon Health Authority (Department) disallows or requests repayment for any funds paid under this Contract due to Contractors' acts or omissions, Contractor shall make payment to the County of the amount disallowed or requested. In the event that the Department determines that County is responsible for the repayment of any funds owed to the Department by Contractor, Contractor agrees to make such payment within ten (10) days of notification by County or the Department of said determination by the Department. i. In the event that a statutorily required operating license or letter of approval is not extended or suspended, County's obligation to provide reimbursement for services or program expenses hereunder related to services rendered without the necessary license or approval will cease on the date of termination of this Contract (whether in whole or in part) or the date of expiration or suspension of the license or letter of approval, whichever date is earlier. 3. Delegation, Subcontracts and Assignment. Contractor shall not delegate or subcontract any of the work required by this Contract or assign or transfer any of its interest in this Contract, without the prior written consent of County. a. Any delegation, subcontract, assignment, or transfer without prior written consent of County shall constitute a material breach of this Contract. b. Any such assignment or transfer, if approved, is subject to such conditions and provisions as the County may deem necessary. c. No approval by the County of any assignment or transfer of interest shall be deemed to create any obligation of Ithe County to increase rates of payment or maximum Contract consideration. d. Prior written approval shall not be required for the purchase by the Contractor of articles, supplies and services I which are incidental to the provision of services under this Contract that are necessary for the performance of the l r. work. e. Any subcontracts that the County may authorize shall contain all requirements of this Contract, and unless otherwise specified by the County the Contractor shall be responsible for the performance of the subcontractor. Page 2 of 9 -Personal Services Contract No. 2013-275 4. No Third Party Beneficiaries. a. County and Contractor are the only parties to this Contract and are the only parties entitled to enforce its terms. b. Nothing in this Contract gives or provides any benefit or right, whether directly, indirectly, or otherwise, to third persons unless such third persons are individually identified by name in this Contract and expressly described as intended beneficiaries of this Contract. 5. Successors in Interest. The provisions of this Contract shall be binding upon and inure to the benefit of the parties and their successors and approved assigns, if any. 6. Early Termination. This Contract may be terminated as follows: a. Mutual Consent. County and Contractor, by mutual written agreement, may terminate this Contract at any time. b. Party's Convenience. County or Contractor may terminate this Contract for any reason upon 30 calendar days written notice to the other party. c. For Cause. County may also terminate this Contract effective upon delivery of written notice to the Contractor, or at such later date as may be established by the County, under any of the following conditions: 1) If funding from state or other sources is not obtained and continued at levels sufficient to allow for the purchase of the indicated quantity of services as required in this Contract. 2) This Contract may be modified to accommodate the change in available funds. 3) If state laws, regulations or guidelines are modified, changed or interpreted in such a way that the services are no longer allowable or appropriate for purchase under this Contract or are no longer eligible for the funding proposed for payments authorized by this Contract. 4) In the event sufficient funds shall not be appropriated for the payment of conSideration required to be paid under this Contract, and if County has no funds legally available for consideration from other sources. 5) If any license or certificate required by law or regulation to be held by the Contractor to provide the services required by this Contract is for any reason denied, revoked, suspended, not renewed or changed in such a way that the Contractor no longer meets requirements for such license or certificate. d. Contractor Default or Breach. The County, by written notice to the Contractor, may immediately terminate the whole or any part of this Contract under any of the following conditions: 1) If the Contractor fails to provide services called for by this Contract within the time specified or any extension thereof. 2) If the Contractor fails to perform any of the other requirements of this Contract or so fails to pursue the work so as to endanger performance of this Contract in accordance with its terms, and after receipt of written notice from the County specifying such failure, the Contractor fails to correct such failure within ten (10) calendar days or such other period as the County may authorize. 3) Contractor institutes or has instituted against it insolvency, receivership or bankruptcy proceedings, makes an assignment for the benefit of creditors, or ceases doing business on a regular basis. e. County Default or Breach. 1) Contractor may terminate this Contract in the event of a breach of this Contract by the County. Prior to such termination, the Contractor shall give to the County written notice of the breach and intent to terminate. 2) If the County has not entirely cured the breach within ten (10) calendar days of the date of the notice, then the Contractor may terminate this Contract at any time thereafter by giving notice of termination. 7. Payment on Early Termination. Upon termination pursuant to paragraph 6, payment shall be made as follows: a. If terminated under subparagraphs 6 a. through c. of this Contract, the County shall pay Contractor for work performed prior to the termination date if such work was performed in accordance with the Contract. Provided however, County shall not pay Contractor for any obligations or liabilities incurred by Contractor after Contractor receives written notice of termination. b. If this Contract is terminated under subparagraph 6 d. of this Contract, County obligations shall be limited to payment for services provided in accordance with this Contract prior to the date of termination, less any damages suffered by the County. c. If terminated under subparagraph 6 e of this Contract by the Contractor due to a breach by the County, then the County shall pay the Contractor for work performed prior to the termination date if such work was performed in accordance with the Contract: 1) with respect to services compensable on an hourly basis, for unpaid invoices, hours worked within any limits set forth in this Contract but not yet billed, authorized expenses incurred if payable according to this Contract and interest within the limits set forth under ORS 293.462, and Page 3 of 9 -Personal Services Contract No. 2013-275 2) with respect to deliverable-based Work, the sum designated for completing the deliverable multiplied by the percentage of Work completed and accepted by County, less previous amounts paid and any claim(s) that County has against Contractor. 3) Subject to the limitations under paragraph 8 of this Contract. 8. Remedies. In the event of breach of this Contract the parties shall have the following remedies: a. Termination under subparagraphs 6 a. through c. of this Contract shall be without prejudice to any obligations or liabilities of either party already reasonably incurred prior to such termination. 1) Contractor may not incur obligations or liabilities after Contractor receives written notice of termination. 2) Additionally, neither party shall be liable for any indirect. incidental, consequential or special damages under this Contract or for any damages of any sort arising solely from the termination of this Contract in accordance with its terms. b. If terminated under subparagraph 6 d. of this Contract by the County due to a breach by the Contractor, County may pursue any remedies available at law or in equity. 1) Such remedies may include, but are not limited to, termination of this Contract, return of all or a portion of this Contract amount, payment of interest earned on this Contract amount, and declaration of ineligibility for the receipt of future contract awards. 2) Additionally, County may complete the work either by itself, by agreement with another Contractor, or by a combination thereof. If the cost of completing the work exceeds the remaining unpaid balance of the total compensation provided under this Contract, then the Contractor shall be liable to the County for the amount of the reasonable excess. c. If amounts previously paid to Contractor exceed the amount due to Contractor under this Contract, Contractor shall repay any excess to County upon demand. d. Neither County nor Contractor shall be held responsible for delay or default caused by fire, civil unrest, labor unrest, riot, acts of God, or war where such cause was beyond reasonable control of County or Contractor, respectively; however, Contractor shall make all reasonable efforts to remove or eliminate such a cause of delay or default and shall, upon the cessation of the cause, diligently pursue performance of its obligations under this Contract. For any delay in performance as a result of the events described in this subparagraph, Contractor shall be entitled to additional reasonable time for performance that shall be set forth in an amendment to this Contract. e. The passage of this Contract expiration date shall not extinguish or prejudice the County's or Contractor's right to enforce this Contract with respect to any default or defect in performance that has not been cured. f. County's remedies are cumulative to the extent the remedies are not inconsistent, and County may pursue any remedy or remedies singly, collectively, successively or in any order whatsoever. g. Differences between a Contractor and County, or between contractors, will be resolved when possible at appropriate management levels, followed by consultation between boards, if necessary. County's Director will have ultimate responsibility for resolution of disagreements among subcontract agencies. 9. Contractor's Tender upon Termination. Upon receiving a notice of termination of this Contract. Contractor shall immediately cease all activities under this Contract unless County expressly directs otherwise in such notice of termination. a. Upon termination of this Contract, Contractor shall deliver to County all documents, information, works-in-progress and other property that are or would be deliverables had this Contract been completed. b. Upon County's request, Contractor shall surrender to anyone County deSignates, all documents, research, objects or other tangible things needed to complete the work. 10. Work Standard. a. Contractor shall be solely responsible for and shall have control over the means, methods, techniques, sequences and procedures of performing the work, subject to the plans and specifications under this Contract and shall be solely responsible for the errors and omissions of its employees, subcontractors and agents. b. For goods and services to be provided under this Contract, Contractor agrees to: 1) perform the work in a good, workmanlike, and timely manner using the schedule, materials, plans and specifications approved by County; 2) comply with all applicable legal requirements; 3) comply with all programs, directives, and instructions of County relating to safety, storage of equipment or materials; 4) take all precautions necessary to protect the safety of all persons at or near County or Contractor's facilities, including employees of Contractor, County and any other contractors or subcontractors and to protect the work and all other property against damage. Page 4 of 9 -Personal Services Contract No. 2013-275 11. Drugs and Alcohol. Contractor shall adhere to and enforce a zero tolerance policy for the use of alcohol and the unlawful selling, possession or use of controlled substances while performing work under this Contract. 12. Insurance. Contractor shall provide insurance in accordance with Exhibit 2 attached hereto and incorporated by reference herein. 13. Expense Reimbursement. If the consideration under this Contract provides for the reimbursement of Contractor for expenses, in addition to Exhibit 5, Exhibit 1 shall state that Contractor is or is not entitled to reimbursement for such expenses. a. County shall only reimburse Contractor for expenses reasonably and necessarily incurred in the performance of this Contract. b. Expenses reimbursed shall be at the actual cost incurred; including any taxes paid, and shall not include any mark-up unless the mark-up on expenses is specifically agreed to in this Contract. c. The cost of any subcontracted work approved in this Contract shall not be marked up. d. Contractor shall not bill County for any time expended to complete the documents necessary for reimbursement of expenses or for payment under this Contract. e. The limitations applicable to reimbursable expenses are set forth in Exhibit "5," attached hereto and by reference incorporated herein. 14. Criminal Background Investigations. Contractor understands that Contractor and Contractor's employees and agents are subject to periodic criminal background investigations by County and, if such investigations disclose criminal activity not disclosed by Contractor, such non-disclosure shall constitute a material breach of this Contract and County may terminate this Contract effective upon delivery of written notice to the Contractor, or at such later date as may be established by the County. 15. Confidentiality. Contractor shall maintain confidentiality of information obtained pursuant to this Contract as follows: a. Contractor shall not use, release or disclose any information concerning any employee, Individual, applicant or person doing business with the County for any purpose not directly connected with the administration of County's or the Contractors responsibilities under this Contract except upon written consent of the County, and if applicable, the employee, Individual, applicant or person. b. The Contractor shall ensure that its agents, employees, officers and subcontractors with access to County and Contractor records understand and comply with this confidentiality provision. c. Contractor shall treat all information as to personal facts and circumstances obtained on Medicaid eUgible individuals as privileged communication, shall hold such information confidential, and shall not disclose such information without the written consent of the individual, his or her attorney, the responsible parent of a minor child, or the child's guardian, except as required by other terms of this Contract. d. Nothing prohibits the disclosure of information in summaries, statistical information, or other form that does not identify particular individuals. e. Personally identifiable health information about applicants and Medicaid recipients will be subject to the transaction, security and privacy provisions of the Health Insurance Portability and Accountability Act (UHIPAA"). f. Contractor shall cooperate with County in the adoption of policies and procedures for maintaining the privacy and security of records and for conducting transactions pursuant to HIPAA requirements. g. This Contract may be amended in writing in the future to incorporate additional requirements related to compliance with HIPAA. h. If Contractor receives or transmits protected health information, Contractor shall enter into a Confidentiality Contract with County, which, if attached hereto, shall become a part of this Contract. i. Individually Identifiable Health Information about specific individuals is confidential. Individually Identifiable Health Information relating to specific individuals may be exchanged between County and OHA for purposes directly related to the provision of Services to Individuals which are funded in whole or in part under this Contract. Contractor shall maintain the confidentiality of records of Individuals as required by applicable state and federal law, including without limitation, ORS 179-495 to 179.507, 45 CFR Part 205, 42 CFR Part 2, any administrative rule adopted by the Oregon Health Authority, implementing the foregoing laws, and any written poliCies made available to Contractor by County or by the Oregon Health Authority. Contractor shall create and maintain written policies and procedures related to the disclosure of an Individual's information and shall make such policies and procedures available to County and the Oregon Health Authority for review and inspection as reasonably requested by County or the Oregon Health Authority. Page 5 of 9 -Personal Services Contract No. 2013-275 16. Reports. Contractor shall provide County with periodic reports at the frequency and with the information prescribed by County. Further, at any time, County has the right to demand adequate assurances that the services provided by Contractor shall be in accordance with the Contract. Such assurances provided by Contractor shall be supported by documentation in Contractors possession from third parties. Contractor agrees to prepare and furnish such reports and data as may be required by County and the Oregon Health Authority, including but not limited to Individual's records which contain an Individual's identification, problem assessment, Individual Service and Support Plan (including any training and/or care plan), appropriate medical information, and Individual Service Notes, including a service termination summary and current assessment or evaluation instrument as designated by the Oregon Health Authority in the administrative rules. Contractor shall retain Individual records in accordance with OAR 166-150-0005 through 166-150-0215 (State Archivist). Unless OAR 166-150-0005 through 116­ 150-0215 requires a longer retention period, Individual records must be retained for a minimum of ten (10) years from termination or expiration of this Contract. It is understood that due to the limited nature of Contractors services under this Contract, not all of these documents will have been prepared by Contractor and therefore need not be fumished. Oregon Health Authority Client Process Monitoring System (CPMS) data, Community Mental Health Provider Report, and Termination Service Recording Form shall, jf necessary, be completed in accordance with Oregon Health Authority requirements and submitted to Oregon Health Authority through County. Contractor agrees to, and does hereby grant County and the Oregon Health Authority the right to reproduce, use and disclose for County or Oregon Health Authority purposes, all or any part of the reports, data, and technical information furnished to County under this Contract. Contractor shall make available to County, Oregon Health Authority and any Individual enrolled in and/or seeking services from Contractor as defined in Exhibit 1, of this Contract, any and all written materials in alternate formats in compliance with Oregon Health Authority's policies .or administrative rules. For purposes of the foregoing, "written materials" includes, without limitation, all work product and contracts related to this Contract. 17. Access to Records. Contractor shall maintain fiscal records and all other records pertinent to this Contract. a. All fiscal records shall be maintained pursuant to generally accepted accounting standards, and other records shall be maintained to the extent necessary to clearly reflect actions taken. 1) All records shall be retained and kept accessible for at least three years following the final payment made under this Contract or all pending matters are closed, whichever is later. 2) If an audit, litigation or other action involving this Contract is started before the end of the three year period, the records shall be retained until all issues arising out of the action are resolved or until the end of the three year period, whichever is later. b. County and its authorized representatives shall have the right to direct access to all of Contractors books, documents, papers and records related to this Contract for the purpose of conducting audits and examinations and making copies, excerpts and transcripts. 1) These records also include licensed software and any records in electronic form, including but not limited to computer hard drives, tape backups and other such storage devices. County shall reimburse Contractor for Contractors cost of preparing copies. 2) At Contractor's expense, the County, the Secretary of State's Office of the State of Oregon, the Federal Government, and their duly authorized representatives, shall have license to enter upon Contractor's premises to access and inspect the books, documents, papers, computer software, electronic files and any other records of the Contractor which are directly pertinent to this Contract. 3) If Contractors dwelling is Contractor's place of business, Contractor may, at Contractor's expense, make the above records available at a location acceptable to the County. 18. Ownership of Work. All work of Contractor that results from this Contract (the "Work Product") is the exclusive property of County. a. County and Contractor intend that such Work Product be deemed "work made for hire" of which County shall be deemed author. b. If, for any reason, the Work Product is not deemed "work made for hire," Contractor hereby irrevocably assigns to County all of its right, title, and interest in and to any and all of the Work Product, whether arising from copyright. patent, trademark, trade secret. or any other state or federal intellectual property law or doctrine. c. Contractor shall execute such further documents and instruments as County may reasonably request in order to fully vest such rights in County. d. Contractor forever waives any and all rights relating to Work Product, including without limitation, any and all rights arising under 17 USC § 106A or any other rights of identification of authorship or rights of approval, restriction or limitation on use or subsequent modifications. Page 6 of 9 -Personal Services Contract No. 2013-275 e. County shall have no rights in any pre-existing work product of Contractor provided to County by Contractor in the performance of this Contract except an irrevocable, non-exclusive. perpetual. royalty-free license to copy, use and re-use any such work product for County use only. f. If this Contract is terminated prior to completion, and County is not in default. County, in addition to any other rights provided by this Contract, may require Contractor to transfer and deliver all partially completed work products. reports or documentation that Contractor has specifically developed or specifically acquired for the performance of this Contract. g. In the event that Work Product is deemed Contractor's Intellectual Property and not "work made for hire," Contractor hereby grants to County an irrevocable. non-exclusive. perpetual, royalty-free license to use. reproduce, prepare derivative works based upon, distribute copies of, perform and display the Contractor Intellectual Property, and to authorize others to do the same on County's behalf. h. In the event that Work Product is Third Party Intellectual Property. Contractor shall secure on the County's behalf and in the name of the County. an irrevocable, non-exclusive, perpetual, royalty-free license to use. reproduce, prepare ~ derivative works based upon, distribute copies of, perform and display the Third Party Intellectual Property, and to r authorize others to do the same on County's behalf. f £. 19. County Code Provisions. Except as otherwise specifically provided, the provisions of Deschutes County Code, Section 2.37.150 are incorporated herein by reference. Such code section may be found at the following URL address: http://www.deschutes.org/County-Code.aspx. 20. Partnership. County is not, by virtue of this Contract, a partner or joint venturer with Contractor in connection with activities carried out under this Contract, and shall have no obligation with respect to Contractor's debts or any other liabilities of each and every nature. Unless Contractor is a State of Oregon governmental agency. Contractor agrees that it is an independent contractor and not an agent of the State of Oregon, the Oregon Health Authority or County. 21. Indemnity and Hold Harmless. a. To the fullest extent authorized by law Contractor shall defend, save, hold harmless and indemnify the County and its officers. employees and agents from and against all claims, suits, actions, losses, damages, liabilities costs and expenses of any nature resulting from or arising out of, or relating to the activities of Contractor or its officers, employees, contractors, or agents under this Contract, including without limitation any claims that the work, the work product or any other tangible or intangible items delivered to County by Contractor that may be the subject of protection under any state or federal intellectual property law or doctrine, or the County's use thereof, infringes any patent, copyright. trade secret. trademark, trade dress, mask work utility design or other proprietary right of any third party. b. Contractor shall have control of the defense and settlement of any claim that is subject to subparagraph a of this paragraph; however neither Contractor nor any attorney engaged by Contractor shall defend the claim in the name of Deschutes County or any department or agency thereof, nor purport to act as legal representative of the County or any of its departments or agencies without first receiving from the County's legal counsel, in a form and manner determined appropriate by the County's legal counsel, authority to act as legal counsel for the County, nor shall Contractor settle any claim on behalf of the Count without the approval of the County's legal counsel. c. To the extent permitted by Article XI, Section 10, of the Oregon Constitution and the Oregon Tort Claims Act, ORS 30.260 through 30.300, County shall defend, save, hold harmless and indemnify Contractor and its officers, employees and agents from and against all claims, suits, actions, losses, damages, liabilities costs and expenses of any nature resulting from or arising out of, or relating to the activities of County or its officers, employees, contractors, or agents under this Contract. 22. Compliance with provisions, requirements of funding source and Federal and State laws, statutes, rules, regulations, executive orders and policies. See Exhibit 6 23. Waiver. a. County's delay in exercising, or failure to exercise any right, power, or privilege under this Contract shall not operate as a waiver thereof, nor shall any single or partial exercise or any right, power, or privilege under this Contract preclude any other or further exercise thereof or the exercise of any other such right, power, or privilege. b. The remedies provided herein are cumulative and not exclusive of any remedies provided by law. 24. Governing Law. This Contract shall be governed by and construed in accordance with the laws of the State of Oregon without regard to principles of conflicts of law. Page 7 of 9 -Personal Services Contract No. 2013-275 a. Any claim, action, suit or proceeding (collectively, "Claim") between County and Contractor that arises from or relates to this Contract shall be brought and conducted solely and exclusively within the Circuit Court of Deschutes County for the State of Oregon; provided, however, if a Claim shall be brought in federal forum, then it shall be brought and conducted solely and exclusively within the United States District Court for the District of Oregon. b. CONTRACTOR, BY EXECUTION OF THIS CONTRACT, HEREBY CONSENTS TO THE IN PERSONAM JURISDICTION OF SAID COURTS. The parties agree that the UN Convention on International Sales of Goods shall not apply. 25. Severability. If any term or provision of this Contract is declared by a court of competent jurisdiction to be illegal or in conflict with any law, the validity of the remaining terms and provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if this Contract did not contain the particular term or provision held invalid. 26. Reserved. 27. Notice. Except as otherwise expressly provided in this Contract, any communications between the parties hereto or notices to be given hereunder shall be given in writing, to Contractor or County at the address or number set forth below or to such other addresses or numbers as either party may hereafter indicate in writing. Delivery may be by personal delivery, facsimile, or mailing the same, postage prepaid. I a. Any communication or notice by personal delivery shall be deemed delivered when actually given to the designated person or representative. b. Any communication or notice sent by facsimile shall be deemed delivered when the transmitting machine generates receipt of the transmission. To be effective against County, such facsimile transmission shall be confirmed by telephone notice to the County Administrator. c. Any communication or notice mailed shall be deemed delivered five (5) days after mailing. Any notice under this Contract shall be mailed by first class postage or delivered as follows: To Contractor: To County: Mary K Coppedge Scott Johnson 61368 Elk Horn Street Deschutes County Health Services Bend, OR 97702 2577 NE Courtney Dr. Bend, Oregon 97701 Phone No. Phone No. 541-322-7500 28. Merger Clause. This Contract and the attached exhibits constitute the entire agreement between the Parties. a. All understandings and agreements between the Parties and representations by either Party concerning this Contract are contained in this Contract. b. No waiver, consent, modification or change in the terms of this Contract shall bind either Party unless in writing signed by both Parties. c. Any written waiver, consent, modification or change shall be effective only in the specific instance and for the specific purpose given. 29. Identity Theft Protection. Contractor and subcontractors shall comply with the Oregon Consumer Identity Theft Protection Act (ORS 646A.600 et seq.). 30. Survival. All rights and obligations shall cease upon termination or expiration of this Contract, except for the rights and obligations setforth in Sections 4,5,8,9,15,17,18,20-27,28 and 30-31. 31. Representations and Warranties. a. Contractor's Representations and Warranties. Contractor represents and warrants to County that: 1) Contractor has the power and authority to enter into and perform this Contract; 2) This Contract, when executed and delivered, shall be a valid and binding obligation of Contractor enforceable in accordance with its terms; 3) Contractor has the skill and knowledge possessed by well-informed members of its industry, trade or profeSSion and Contractor will apply that skill and knowledge with care and diligence to perform the Work in a professional manner and in accordance with standards prevalent in Contractor's industry, trade or profession; 4) Contractor shall, at all times during the term of this Contract, be qualified, professionally competent, and duly licensed to perform the Work; Page 8 of 9 -Personal Services Contract No. 2013-275 5) Contractor prepared its proposal related to this Contract, if any, independently from all other proposers. and without collusion. fraud. or other dishonesty; and 6) Contractors making and performance of this Contract do not and will not violate any provision of any applicable law. rule or regulation or order of any court. regulatory commission. board or other administrative agency. 7) Contractor is and shall remain an independent contractor as that term is defined in ORS 670.600. b. Warranties Cumulative. The warranties set forth in this paragraph are in addition to. and not in lieu of. any other warranties provided. Page 9 of 9 Personal Services Contract No. 2013-275 EXHIBIT 1 DESCHUTES COUNTY SERVICES CONTRACT Contract No. 2013-275 STA'rEMENT OF WORK, COMPENSATION PAYMENT TERMS and SCHEDULE 1. Contractor shall perform the following work: Contractor shall provide Medical Services as a Licensed Medical Practitioner (LMP) in accordance with OAR's 309-032-1505(68) and (74); 309-032-1530(2)(e);and 309-032-1535(3). Contractor shall perform the services described and funded by and through County's contract with the Oregon Health Authority ("OHA" or "Departmenr). Services shall be performed in accordance with a schedule approved by the County. Contractor shall provide Medical Services in a manner that is in accordance with Deschutes County Health Services' Policy "Integrated Policies for Delivery of Behavioral Health Outpatient Services and Supports" and Oregon Health Authority's "Integrated Services and Supports Rules", OAR's 309-032-155 through OAR 309-032-1565, which is incorporated into this Contract herein by reference. A. SERVICES TO BE PERFORMED For the purposes of this Contract, "Individual" means any persons being considered for or receiving services regulated by County's Integrated Policies for Delivery of Behavioral Health Outpatient Services and Supports. Definitions, laws, regulations as defined by the OAR 309-032-1500 through 309-032-1565 are incorporated by reference herein to the extend that they are applicable to the Contract or required by law to be so incorporated. Contractor shall provide Medical services as a LMP and document Services using County's Electronic Health Record (EHR) system, in a legible manner consistent with professional and community standards of care and shall include the following: 1) Orders for medication, laboratory and other medical procedures shall be recorded for each Individual using County's EHR and in conformance with standard medical practice. Such orders, whether written or verbal, shall be initiated by Contractor. Consultation and/or eXChange of information with other medical personnel who are not employed by, or under contract to, County shall be documented in the Individual Service Record. 2) Written documentation of medications prescribed for the Individual by Contractor shall be maintained in the EHR's Individual Service Record. Documentation for each medication prescribed shall follow the appropriate protocols developed by the EHR and my include but is not limited to the following: a) A copy or detailed written description of the signed prescription order; b) The name of medication prescribed; c) The prescribed dosage and method of administration; d) The date medications were prescribed, reviewed, or renewed; e) The date, the signature and credentials of staff administering and/or prescribing medications; and 3) Medication use record which contain: a. Medication Individual Service Notes b. Observed side effects including laboratory findings; c. Medication allergies and adverse reactions; and d. Documentation that the consumer was asked about possible adverse effects of medications, including sexual dysfunction, and evaluation for tardive dyskinesia when appropriate. 4) Contractor shall provide Medical Supervision in determining the medical appropriateness of rehabilitative behavioral health services. Medical supervision shall be performed at least annually by reviewing the Comprehensive Mental Health Assessment and approving the revised Individual Service and Support Plan. 5) Contractor shall also provide: psychiatric assessments, medication prescribing and medication management, individual therapy, training of Primary Care Providers in the community, community education and staff consultations at Deschutes County Health Services Department, as funded by and through County's contract with the State of Oregon, Oregon Health Authority. Page 1 of 4 -Exhibit 1 -Personal Service Contract No. 2013-275 6) Contractor shall use County's EHR and legibly document all Individual contacts including assessments, chart notes, medication records, service conclusion summaries and service notes (unless completed by behavioral health staff at time of service) to facilitate County accurately recording services provided to Individuals. 7) Contractor shall facilitate communication with the "Primary Care Provider" and county providers, via telephonic and/or written methods, for each Individual seen including Contractor initiated changes in medication regimen, pertinent chart notes and other information to coordinate a high quality of Individual care. Contractor will comply with all privacy and security regulations under the Health Information Portability and Accountability Act (HIPAA). 8) Contractor shall provide full assistance to County in billing and recovering revenue from all legal resources by keeping all licenses and certificates current including all credentialing and certification required by state and federal governments to provide reimbursement for services (OHP/Medicaid/Medicare, etc.) Contractor shall provide County with copies of licenses, certificates of insurance and evidence of Continuing Medical Education credits (CME's). 9) Contractor shall provide County with a detailed billing statement on a monthly basis which notes dates of service, number of Individuals seen, hours worked and is consistent with County requirements. Invoices are to be submitted to Accounts Payable for review and reimbursement. Contractor shall submit the final monthly detailed billing statement no later than thirty (30) days following the end of the fiscal year. Fiscal year shall be based on the period July 1 through June 30. 10) Contractor will give advanced notice to County of planned and/or anticipated absences and assist County in arranging psychiatric coverage when absences exceed one week. Contractor shall alert County as soon as possible in the event of unanticipated absence. 11) Contractor shall maintain all requirements to perform services as a LMP according to OAR 309­ 032-0505 (68) which includes maintaining license as a physician within the state of Oregon 12) Effective Date of Amendment. This Contract shall take effect as soon as executed by the Parties, but no later than July 1, 2013. All other provisions of the Contract shall continue in full force and effect for the duration of the Contract. B. REGULATIONS & DUTIES IContactor shall comply with all applicable provisions of that certain Financial Assistance Contract, as amended, including applicable Service Descriptions attached thereto, effective July 1, 2013, between the State of Oregon acting by and through its Oregon Health Authority (OHA) and Deschutes County. Contractor agrees to comply with the rules and regulations of County, I applicable provisions in the Contract between County and OHA, incorporated herein by reference, as of the effective date of the Contract, applicable provisions of the Administrative Rules and Procedures of OHA, applicable Federal regulations and all provisions of Federal and I State statutes, rules and regulations relating to Contractor's performance of services under this Contract. Any act or duty of County, imposed upon County by OHA, which, by the nature of this Contract County determines to be within the scope of this Contract and is to be performed by Contractor, Contractor shall perform on behalf of County. No federal funds may be used to provide services in violation of 42 USC 14402. C. METHOD AND PLACE OF GIVING NOTICE, SUBMITTING BILLS AND MAKING PAYMENTS Contractor shall submit a monthly invoice following the end of each calendar month, but no later than thirty (30) days following the end of the calendar month. The report shall include a summary of services, including, but not limited to, date of bill, amount billed, billing period including month and year and amount billed year-to-date. All notices, bills and payments shall be made in writing and may be given by personal delivery or by mail. Contractor shall submit the final monthly report under this Contract no later than thirty (30) days following expiration or I termination of the Contract. Notices, bills, and payments sent by mail should be addressed as Ifollows: f Contractor: Mary K Coppedge I61368 Elk Horn Street Bend, OR 97702 Attn: Kate Coppedge Phone: Page 2 of 4 -Exhibit 1 -Personal Service Contract No. 2013-275 I County: Deschutes County Health Services 2577 NE Courtney Drive Bend, OR 97701 Attn: Loretta Gertsch Fax: (541) 322-7565 2. County Services. County shall provide Contractor, at County's expense, with material and services described as follows: a. County shall provide an EHR, training and technical support where Contractor will record data as described in Paragraph 1 of this Exhibit for each specific Individual Contractor provides Services for. b. County shall provide an office or other location mutually agreed upon between the Contractor and the County. c. County shall provide meeting space (subject to availability), use of a computer, phone. e-mail via County Intra-net, Electronic Health Record system, and general office supplies required to carry out the terms of the Contract. 3. Consideration. Subject to availability of funds from OHA, County shall provide payments to Contractor based upon Contractor's monthly billing statement for rendering Services listed in this Contract. a. County shall pay Contractor on a fee-for-service basis at $105 per hour. The maximum number of hours Contractor is authorized to work under this Agreement is thirty (30) hours per week. r b. Notwithstanding any other payment provision of this Contract, should Contractor fail to submit required reports when due, or fail to perform or document the performance of contracted Services; County shall immediately withhold payments under this Contract. I c. Contractor shall be entitled to reimbursement for expenses as set forth in Exhibit 5: ! DYES I25J NO [Check one] 4. The maximum compensation. Ia. The maximum compensation under this Contract, including allowable expenses, $151,000. b. Contractor shall not submit monthly billing statements, and County shall not pay for any amount in excess of the maximum compensation amount set forth above. I1) County may be required to modify the maximum compensation through amendment of this Contract. If this maximum compensation amount is decreased or increased by amendment of this Contract, the amendment shall be fully effective before Contractor performs work subject to the amendment. 2) Contractor shall notify County in writing of the impending expiration of this Contract thirty (30) calendar days prior to the expiration date. I3) If federal or state authorities disallows or requests repayment for any funds paid under this Contract due to Contractor's acts or omissions, Contractor shall make payment to County of the amount disallowed or requested. In the event that federal or state authorities determines I that County is responsible for the repayment of any funds owed to state or federal authorities by Contractor, Contractor agrees to make such payment within ten (10) days of notification by County or federal or state authority of said determination. I4) Notwithstanding any other payment provision of this Contract, should Contractor fail to submit required reports or documentation as outlined in this Contract. or fail to perform or document the performance of contracted Services; County shall immediately withhold payments under this Contract. I5) In the event that a statutorily required license or insurance is suspended or not extended, County's obligation to provide reimbursement for Services rendered without the necessary 1 f license or insurance will cease on the date of expiration or suspension of license and/or insurance. I i c. Rent. Contractor agrees to pay the County monthly rent of $250.00 in return for the County providing the Contractor office and meeting space, use of a computer, phone, e-mail via the County fIntra-net, Electronic Health Record system, and any other general office supplies required to carry out the terms of the Contract. Rent is due on the last day of each month through the duration of this IContract i I IPage 3 of 4 -Exhibit 1 -Personal Service Contract No. 2013-275 I t f 5. Schedule of Performance or Delivery. a. County's obligation to pay depends upon Contractor's delivery or performance in accordance with the schedule listed in Exhibit 1, Paragraph 1. b. County will only pay for completed work that conforms to the terms of the Contract. 6. Renewal. This Contract may be renewed, subject to the following conditions: a. Renewal will be based on the County Annual Implementation Plan approved by the Department. b. Renewal is subject to the availability of funding. I ! I Page 4 of 4 -Exhibit 1 - Personal Service Contract No. 2013-275 EXHIBIT 2 DESCHUTES COUNTY SERVICES CONTRACT Contract No. 2013-275 INSURANCE REQUIREMENTS Contractor shall at all times maintain in force at Contractor's expense, each insurance noted below. Insurance coverage must apply on a primary or non-contributory basis. All insurance policies, except Professional Liability, shall be written on an occurrence basis and be in effect for the term of this Contract. Policies written on a "claims made" basis must be approved and authorized by Deschutes County. Contractor Name: Mary K Coppedge Commercial General Liability insurance with a combined single limit of not less than: Per Single Claimant and Incident All Claimants Arising from Single Incident X $1,000,000 0 $2,000,000 o $2,000,000 X $3,000,000 o $3,000,000 0 $5,000,000 Commercial General Liability insurance includes coverage for personal injury, bodily injury, advertising injury, property damage, premises, operations, products, completed operations and contractual liability. The insurance coverages provided for herein must be endorsed as primary and non-contributory to any insurance of County, its officers, employees or agents. Each such policy obtained by Contractor shall provide that the insurer shall defend any suit against the named insured and the additional insureds, their officers, agents, or employees, even if such suit is frivolous or fraudulent. Such insurance shall provide County with the right, but not the obligation, to engage its own attorney for the purpose of defending any legal action against County, its officers, agents, or employees, and that Contractor shall indemnify County for costs and expenses, including reasonable attorneys' fees, incurred or arising out of the defense of such action. I The policy shall be endorsed to name Deschutes County, the State of Oregon, the Oregon Health Authority, their i officers, agents, employees and volunteers as an additional insured. The additional insured endorsement shall not include declarations that reduce any per occurrence or aggregate insurance limit. The contractor shall provide additional coverage based on any outstanding claim(s) made against policy limits to ensure that minimum insurance limits required by the County are maintained. Construction contracts may include aggregate limits that apply on a "per location" or "per project" basis. The additional insurance protection shall extend equal protection to County as to Contractor or subcontractors and shall not be limited to vicarious liability only or any similar limitation. To the extent any aspect of this Paragraph shall be deemed unenforceable, then the additional insurance protection to County shall be narrowed to the maximum amount of protection allowed by law. 1 X Required by County o Not required by County (One box must be checked) I r Workers Compensation insurance in compliance with ORS 656.017, requIring Contractor and all subcontractors to provide workers' compensation coverage for all subject workers, or provide certification of exempt status. Worker's Compensation Insurance to cover claims made under Worker's Compensation, disability benefit or any other employee benefit laws, including statutory limits in any state of operation with Coverage B Employer's Liability coverage all at the statutory limits. . In the absence of statutory limits the limits of said Employers liability coverage shall be not less than $1,000,000 each accident, disease and each employee. This insurance must be endorsed with a waiver of subrogation endorsement, waiving the insured's right of subrogation against County. Professional Liability insurance with an occurrence combined single limit of not less than: Per Occurrence limit Annual Aggregate limit X $1,000,000 0 $2,000,000 o $2,000,000 X $3,000,000 o $3,000,000 0 $5,000,000 Professional Liability insurance covers damages caused by error, omiSSion, or negligent acts related to professional services provided under this Contract. The policy must provide extended reporting period coverage, sometimes referred to as "tail coverage" for claims made within two years after the contract work is completed. X Required by County o Not required by County (one box must be checked) Page 1 of 2 -Exhibit 2 -Personal Services Contract No. 2013-275 Automobile Liability insurance with a combined single limit of not less than: Per Occurrence o $500,000 X $1,000,000 o $2,000,000 Automobile Liability insurance includes coverage for bodily injury and property damage resulting from operation of a motor vehicle . Commercial Automobile Liability Insurance shall provide coverage for any motor vehicle (symbol 1 on some insurance certificates) driven by or on behalf of Contractor during the course of providing services under this contract. Commercial Automobile Liability is required for contractors that own business vehicles registered to the business . Examples include: plumbers, electricians or construction contractors . An Example of an acceptable personal automobile policy is a contractor who is a sole proprietor that does not own vehicles registered to the business . o Required by County X Not required by County (one box must be checked) Additional Requirements. Contractor shall pay all deductibles and self-insured retentions . A crOSS-liability clause or separation of insured's condition must be included in all commercial general liability policies required by this Contract. Contractor's coverage will be primary in the event of loss . Certificate of Insurance Required. Contractor shall furnish a current Certificate of Insurance to the County with the signed Contract. Contractor shall not ify the County in writing at least thirty (30) days in advance of any cancellation, termination, material change, or reduction of limits of the insurance coverage . The Certificate shall also state the deductible or, if applicable, the self-insured retention level. Contractor shall be responsible for any deductib le or self-insured retention . If requested, complete copies of insurance policies shall be provided to the County . DateRisk Ma ~e ~iew Page 2 of 2 -Exhibit 2 -Personal Services Contract No. 2013-275 EXHIBIT 3 DESCHUTES COUNTY SERVICES CONTRACT Contract No. 2013-275 CERTIFICATION STATEMENT FOR CORPORATION OR INDEPENDENT CONTRACTOR NOTE: Contractor Shall Complete A or B in addition to C below: A. CONTRACTOR IS A CORPORATION, LIMITED LIABILITY COMPANY OR A PARTNERSHIP. I certify under penalty of perjury that Contractor is a [check one]: o Corporation 0 Limited Liability Company 0 Partnership authorized to do business in the State of Oregon. Title Date B. CONTRACTOR IS A SOLE PROPRIETOR WORKING AS AN INDEPENDENT CONTRACTOR. Contractor certifies under penalty of perjury that the following statements are true: 1. If Contractor performed labor or services as an independent Contractor last year, Contractor filed federal and state income tax returns last year in the name of the business (or filed a Schedule C in the name of the business as part of a personal income tax return), and 2. Contractor represents to the public that the labor or services Contractor provides are provided by an independently established business registered with the State of Oregon, and 3. All of the statements checked below are true. NOTE: Check all that apply. You shall check at least three (3) -to establish that you are an Independent Contractor. The labor or services I perform are primarily carried out at a location that is separate from my residence or primarily carried out in a specific portion of my residence that is set aside as the location of the business. B. I bear the risk of loss related to the business or provision of services as shown by factors such as: (a) fixed-price agreements; (b) correcting defective work; (c) warranties over the services or (d) indemnification agreements, liability insurance, performance bonds or professional liability insurance. I have made significant investment in the business through means such as: (a) purchasing -I-C . necessary tools or equipment; (b) paying for the premises or facilities where services are provided; or (c) paying for licenses, certificates or specialized training. D. I have the authority to hire other persons to provide or to assist in providing the services and if necessary to fire such persons. E. Each year I perform labor or services for at least two different persons or entities or I routinely engage in business advertising, solicitation or other marketing efforts reasonably calculated to obtain new contracts to provide similar services. J Date Page 1 of 2 -Exhibit 3 -Personal Services Contract No. 2013-275 C. Representation and Warranties. Contractor certifies under penalty of perjury that the following statements are true to the best of Contractor's knowledge: 1. Contractor has the power and authority to enter into and perform this Contract; 2. This Contract, when executed and delivered, shall be a valid and binding obligation of Contractor enforceable in accordance with its terms; 3. The services under this Contract shall be performed in a good and workmanlike manner and in accordance with the highest professional standards; and 4. Contractor shall, at all times during the term of this Contract, be qualified, professionally competent, and duly licensed to perform the services. 5. To the best of Contractor's knowledge, Contractor is not in violation of any tax laws described in ORS 305.380(4), 6. Contractor understands that Contractor is responsible for any federal or state taxes applicable to any consideration and payments paid to Contractor under this Contract; and 7. Contractor has not discriminated against minority, women or small business enterprises in obtaining any required subcontracts. Co . rac ature Page 2 of 2 -Exhibit 3 -Personal Services Contract No. 2013-275 EXHIBIT 4 DESCHUTES COUNTY SERVICES CONTRACT Contract No. 2013-275 Workers' Compensation Exemption Certificate (To be used only when Contractor claims to be exempt from Workers' Compensation coverage requirements) Contractor is exempt from the requirement to obtain workers' compensation insurance under ORS Chapter 656 for the following reason (check the appropriate box): ~SOLE PROPRIETOR • Contractor is a sole proprietor, and • Contractor has no employees, and • Contractor shall not hire employees to perform this Contract. D CORPORATION· FOR PROFIT • Contractor's business is incorporated, and • All employees of the corporation are officers and directors and have a substantial ownership interest* in the corporation, and • The officers and directors shall perform all work. Contractor shall not hire other employees to perform this Contract. D CORPORATION· NONPROFIT • Contractor's business is incorporated as a nonprofit corporation, and • Contractor has no employees; all work is performed by volunteers, and • Contractor shall not hire employees to perform this Contract. PARTNERSHIP • Contractor is a partnership, and • Contractor has no employees, and • All work shall be performed by the partners; Contractor shall not hire employees to perform this Contract. and • Contractor is not engaged in work performed in direct connection with the construction, alteration, repair, improvement, moving or demolition of an improvement to real property or appurtenances thereto. D LIMITED LIABILITY COMPANY • Contractor is a limited liability company, and • Contractor has no employees, and • All work shall be performed by the members; Contractor shall not hire employees to perform this Contract, and • If Contractor has more than one member, Contractor is not engaged in work performed in direct connection with the construction, alteration, repair, improvement, moving or demolition of an improvement to real property or appurtenances thereto. *NOTE: Under OAR 436-050-050 a shareholder has a "substantial ownerShip" interest if the shareholder owns 10% of the corporation or, if less than 10% is owned, the shareholder has ownership that is at least equal to or greater than the average percentage of ownership of all shareholders. "NOTE: Under certain circumstances partnerships and limited liability companies can claim an exemption even when performing construction work. The requirements for this exemption are complicated. Consult with County Counsel before an exemption request is accepted from a contractor who shall perform construction wo~rk.. 11M.( .i:IJrfk ~ YM~ ) Contra0t0r Printed N~ C ra~ature -------­o /fAIR ---'~'4-1,L-=,1&'-J-jiLr-;-::;·31---------- Contractor TiUe Date Page 1 of 1 -Exhibit 4 -Personal Services Contract No. 2013-275 EXHIBIT 5 DESCHUTES COUNTY SERVICES CONTRACT Contract No. 2013-275 Expense Reimbursement 1. Travel and Other Expenses. (When travel and other expenses are reimbursed.) a. It is the policy of the County that all travel shall be allowed only when the travel is essential to the normal discharge of the County responsibilities. 1) All travel shall be conducted in the most efficient and cost effective manner resulting in the best value to the County. 2) Travel expenses shall be reimbursed for official County business only. 3) County shall not reimburse Contractor for any item that is not otherwise available for reimbursement to an employee of Deschutes County per Deschutes County Finance Policy F-1, "REIMBURSEMENT FOR MISCELLANEOUS EXPENSES AND EXPENSES INCURRED WHILE TRAVELING ON COUNTY BUSINESS," dated 11/8/06. 4) County may approve a form other than the County Employee Reimbursement Form for Contractor to submit an itemized description of travel expenses for payment. 5) Personal expenses shall not be authorized at any time. 6) All expenses are included in the total maximum Contract amount. b. Travel expenses shall be reimbursed only in accordance with rates approved by the County and only when the reimbursement of expenses is specifically provided for in Exhibit 1, paragraph 3 of this Contract. c. The current approved rates for reimbursement of travel expenses are set forth in the above described policy. d. County shall not reimburse for any expenses related to alcohol consumption or entertainment. e. Except where noted, detailed receipts for all expenses shall be provided. f. Charge slips for gross amounts are not acceptable. g. County shall not reimburse Contractor for any item that is not otherwise available for reimbursement to an employee of Deschutes County. 2. Approved reimbursements: a. Mileage. Contractor shall be entitled to mileage for travel in a private automobile while Contractor is acting within the course and scope of Contractor's duties under this Contract and driving over the most direct and usually traveled route to and from Bend, Oregon. 1) Reimbursement for mileage shall be equal to but not exceed those set by the United States General Services Administration ("GSA") and are subject to change accordingly. 2) To qualify for mileage reimbursement, Contractor shall hold a valid, current driver's license for the class of vehicle to be driven and carry personal automobile liability insurance in amounts not less than those required by this Contract. 3) No mileage reimbursement shall be paid for the use of motorcycles or mopeds. b. Meals. 1) Any reimbursement for meals shall be for actual cost of meals incurred by Contractor while acting within the course and scope of Contractor's duties under this Contract. 2) For purposes of calculating individual meals where the Contractor is entitled only to a partial day reimbursement, the following maximum allocation of the meal expenses applies: a) Breakfast. $10; b) Lunch, $15; c) Dinner, $31. 3) Except in the event of necessary overnight travel as provided below, partial day meal expenses shall be reimbursed as follows and only while Contractor is acting within the course and scope of Contractor's duties under this Contract: a) Breakfast expenses are reimbursable if Contractor is required to travel more than two (2) hours: before the start Contractor's regular workday (i.e. 8:00 a.m.). b) Lunch expenses are reimbursable only if Contractor is required to travel overnight and begins the journey before 11 :00 am or ends the journey after 11 :00 a.m. c) Dinner expenses are reimbursable only if Contractor is required to travel more than two (2) hours after Contractor's regular workday (i.e. 5:00 p.m.). Page 1 of 2 -Exhibit 5 to Personal Services Contract No. 2013-275 4) Breakfast and dinner expenses are reimbursable during Contractor's necessary overnight travel while acting within the course and scope of Contractor's duties under this Contract and shall not exceed those set by the GSA and are subject to change accordingly. c. Lodging. 1) County shall reimburse Contractor for Contractor's actual cost of lodging necessary to provide service to the County and shall not exceed the maximum lodge set by the GSA for Bend, Oregon. 2) Reimbursement rates for lodging are not considered "per diem" and receipts are required for reimbursement. d County shall not reimburse Contractor in excess of the lowest fair for any airline ticket or vehicle rental charges. 3. Exceptions. Contractor shall obtain separate written approval of the County Administrator for any exceptions to the expense items listed above prior to incurring any expense for which reimbursement shall be sought. Page 2 of 2 -Exhibit 5 to Personal Services Contract No. 2013-275 Exhibit 6 DESCHUTES COUNTY SERVICES CONTRACT Contract No. 2013-275 Compliance with provisions, requirements of funding source and Federal and State laws, statutes, rules, regulations, executive orders and policies. Contractor shall comply with the following federal requirements. For the purposes of this Contract, all references to federal and state laws are references to federal and state laws as they may be amended from time to time. 1. Miscellaneous Federal Provisions. Contractor shall comply with all federal laws, regulations, and executive orders applicable to the Contract or to the delivery of Services. Without limiting the generality of the foregoing, Contractor expressly agrees to comply with the following laws, regulations and executive orders to the extent they are applicable to the Contract: (a) Title VI and VII of the Civil Rights Act of 1964, as amended, (b) Sections 503 and 504 of the Rehabilitation Act of 1973, as amended, (f) the Age Discrimination in Employment Act of 1967, as amended, and the Age Discrimination Act of 1975, as amended, (g) the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended, (h) all regulations and administrative rules established pursuant to the foregoing laws, (i) all other applicable requirements of federal civil rights and rehabilitation statutes, rules and regulations, and U) all federal law governing operation of Community Mental Health Programs, including without limitation, all federal laws requiring reporting of Client abuse. These laws, regulations and executive orders are incorporated by reference herein to the extent that they are applicable to the Agreement and required by law to be so incorporated. No federal funds may be used to provide Services in violation of 42 U.S.C. 14402. 2. Equal Employment Opportunity. If this Contract, including amendments, is for more than $10,000, then Contractor shall comply with Executive Order 11246, entitled "Equal Employment Opportunity," as amended by Executive Order 11375, and as supplemented in Department of Labor regulations (41 CFR Part 60). 3. Clean Air, Clean Water, EPA Regulations. If this Contract, including amendments, exceeds $100,000 then Contractor shall comply with all applicable standards, orders, or requirements issued under Section 306 of the Clean Air Act (42 U.S.C. 7606), the Federal Water Pollution Control Act as amended (commonly known as the Clean Water Act) (33 U.S.C. 1251 to 1387), specifically including, but not limited to Section 508 (33 U.S. C. 1368). Executive Order 11738. and Environmental Protection Agency regulations (2 CFR Part 1532), which prohibit the use under non-exempt Federal contracts, grants or loans of facilities included on the EPA List of Violating Facilities. Violations shall be reported to OHA, United States Department of Health and Human Services and the appropriate Regional Office of the Environmental Protection Agency. Contractor shall include in all contracts with subcontractors receiving more than $100,000, language requiring the subcontractor to comply with the federal laws identified in this section. 4. Energy Efficiency. Contractor shall comply with applicable mandatory standards and policies relating to energy efficiency that are contained in the Oregon energy conservation plan issued in compliance with the Energy Policy and Conservation Act 42 U.S.C. 6201 et. seq. (Pub. L. 94-163). 5. Truth in Lobbying. By signing this Contract, the Contractor certifies under penalty of perjury that the following statements are true to the best of the Contractor's knowledge and belief that: a. No federal appropriated funds have been paid or will be paid, by or on behalf of Contractor, to any person for influencing or attempting influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment or modification of any federal contract, grant, loan or cooperative agreement. Page 1 of 8 -Exhibit 6 to Personal Services Contract No. 2013-275 b. If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this federal contract, grant, loan or cooperative agreement, the Contractor shall complete and submit Standard Form LLL, "Disclosure Form to Report Lobbying" in accordance with its instructions. c. The Contractor shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients and subcontractors shall certify and disclose accordingly. d. This certification is a material representation of fact upon which reliance was placed when this Contract was made or entered into. Submission of this certification is a prerequisite for making or entering into this Contract imposed by section 1352, Title 31 of the U.S. Code. Any person who ails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. e. No part of any federal funds paid to Contractor under this Contract shall be used other than for normal and recognized executive legislative relationships for publicity or propaganda purposes, for the preparation, distribution, or use of any kit, pamphlet, booklet, publication, electronic communication, radio, television, or video presentation deSigned to support or defeat the enactment of legislation before the United States Congress or any State or local legislature or legislative body, except in presentation to the Congress or any Stage or local legislature itself, or designed to support or defeat any proposed or pending regulation, administrative action, or order issued by the executive branch of any State or local government, except in presentation to the executive branch of any Sate or local government itself. f. No part of any federal funds paid to Contractor under this Agreement shall be used to pay the salary or expenses of any grant or contract reCipient, or agent acting for such recipient, related to any activity deSigned to influence the enactment of legislation, appropriations, regulation, administrative action, or Executive order proposed or pending before the United States Congress or any State government, State legislature or local legislature or legislative body, other than for normal and recognized executive-legislative relationships or participation by an agency or officer of a State, local or tribal government in policymaking and administrative processes within the executive branch of that government. g. The prohibitions in subsections (b) and (c) of this section shall include any activity to advocate or promote any proposed, pending or future Federal, State or local tax increase, or any proposed, pending, or future requirement or restriction on any legal consumer product, including its sale or marketing, including but not limited to the advocacy or promotion of gun control. h. No part of any federal funds paid to Contractor under this Contract may be used for any activity that promotes the legalization of any drug or other substance included in schedule I of the schedules of controlled substances established under section 202 of the Controlled Substances Act except for normal and recognized executive congressional communications. This limitation shall not apply when there is significant medical evidence of a therapeutic advantage to the use of such drug or other substance or that federally sponsored clinical trials are being conducted to determine therapeutic advantage. 6. HIPAA Compliance. Contractor is a Covered Entity with respect to its health care components as described in OAR 943-014-0015 for purposes of the Health Insurance Portability and Accountability Act and the federal regulations implementing the Act (collectively referred to as HIPAA). and OAR 125-055­ 0100 through OAR 125-055-0130. Contractor must comply with HIPAA to the extent that any Services or obligations of Contractor arising under this Contract are covered by HIPAA. County shall determine if County will have access to, or create and protected health information in the performance of any Service or any other obligations under this Contract. To the extent that Contractor will have access to, or create any protected health information to perform functions. activities, or Services for. or on behalf of a healthcare component of OHA in the performance of any Service required by this Contract. County shall Page 2 of 8 -Exhibit 6 to Personal Services Contract No. 2012-275 comply and Contractor shall comply with OAR 125-055-0100 through OAR 125-055-0130 and the following: a. Privacy and Security of Individually Identifiable Health Information. Individually Identifiable Health Information about specific individuals is confidential. Individually Identifiable Health Information relating to specific individuals may be exchanged between County and OHA for purposes directly related to the provision of Services to clients which are funded in whole or in part under this Contract. To the extent that Contractor is performing functions, activities, or services for, or on behalf of, a healthcare component of OHA in the performance of Services required by this Contract, Contractor shall not use or disclose any Individual Identifiable Health Information about specific individuals in a manner that would violate OHA Privacy Rules, OAR 943-014-0000 et. seq., or OHA Notice of Privacy Practices. A copy of the most recent OHA Notice of Privacy Practices may be obtained by contacting OHA or by looking up form number 2090 on the OHA web site at https:llapps.state.or.uslcf1/FORMS/. b. Data Transactions Systems. If County and Contractor intends to exchange electronic data transactions with a health care component of OHA in connection with claims or encounter data, eligibility or enrollment information, authorizations or other electronic transaction, County and Contractor shall execute an EDI Trading Partner Agreement and shall comply with OHA EDI Rules. c. Consultation and Testing. If County or Contractor reasonably believes that the County's or Contractor's data transactions system or other application of HIPAA privacy or security compliance policy may result in a violation of HIPAA requirements, County or Contractor shall promptly consult the OHA Information Security Office. County or Contractor may initiate a request for testing of HIPAA transaction reqUirements, subject to available resources and the OHA testing schedule. 7. Resource Conservation and Recovery. Contractor shall comply with all mandatory standards and policies that relate to resource conservation and recovery pursuant to the Resource Conservation and Recovery Act (codified at 42 U.S.C. 6901 et. seq.). Section 6002 of that Act (codified at 42 U.S.C. 6962) requires that preference be given in procurement programs to the purchase of specific products containing recycled materials identified in guidelines developed by the Environmental Protection Agency. Current guidelines are set forth in 40 CFR Part 247. 8, Audits. a. Contractor shall comply with applicable audit reqUirements and responsibilities set forth in this Contract and applicable state or federal law. b. Contractor shall also comply with applicable Code of Federal Regulations (CFR) and OMB Circulars governing expenditure of federal funds. Including, but not limited to, OMB A-133 Audits of States, Local Governments and Non-Profit Organizations. 9. Debarment and Suspension. County shall not permit any person or entity to be a contractor if the person or entity is listed on the non-procurement portion of the General Service Administration's "List of Parties Excluded from Federal Procurement or Nonprocurement Programs~ in accordance with Executive Orders No. 12549 and No. 12689, "Debarment and Suspension". (See 2 CFR Part 180). This list contains names of parties debarred, suspended, or otherwise excluded by agencies, and contractors declared ineligible under statutory authority other than Executive Order No. 12549. Contractors with awards that exceed the simplified acquisition threshold shall provide the required certification regarding their exclusion status and that of their principals prior to award. 10. Drug-Free Workplace. Contractor shall comply with the following provisions to maintain a drug-free workplace: (i) Contractor certifies that it will provide a drug-free workplace by publishing a statement notifying its employees that the unlawful manufacture, distribution, dispensation, posseSSion or use of a controlled substance, except as may be present in lawfully prescribed or over-the-counter medications, is prohibited in Contractor's workplace or while providing services to OHA clients. Contractor's notice shall specify the actions that will be taken by Contractor against its employees for violation of such prohibitions; (ii) Establish a drug-free awareness program to inform its employees about: the dangers of drug abuse in the workplace, County's policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed Page 3 of 8 -Exhibit 6 to Personal Services Contract No. 2012-275 upon employees for drug abuse violations; (iii) Provide each employee to be engaged in the performance of services under this contract a copy of the statement mentioned in paragraph (i) above; (iv) Notify each employee in the statement required by paragraph (i) above that, as a condition of employment to provide services under this Contract, the employee will: abide by the terms of the statement, and notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five (5) days after such conviction; (v) Notify OHA within ten (10) days after receiving notice under subparagraph (iv) above from an employee or otherwise receiving actual notice of such conviction; (vi) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program by any employee who is so convicted as required by Section 5154 of the Drug-Free Workplace Act of 1988; (vii) Make a good-faith effort to continue a drug-free workplace through implementation of subparagraphs (i) through (vii) above; (ix) Neither County, Contractor nor any of County's or Contractor's employees, officers, agents may provide any service required under this Contract while under the influence of drugs. For purposes of this provision, "under the influence" means: observed abnormal behavior or impairments in mental or physical performance leading a reasonable person to believe the County or Contractor's employee, officer, agent has used a controlled substance, prescription or non-prescription medication that impairs the County or Contractor, County or Contractor's employees, officers, agents performance of essential job function or creates a direct threat to OHA clients or others. Examples of abnormal behavior include, but are not limited to: hallucinations, paranoia or violent outbursts. Examples of impairments in physical or mental performance include, but are not limited to: slurred speech, difficulty walking or performing job activities; and (x) Violation of any provision of this section my result in termination of this Contract. 11. Pro-Children Act. Contractor shall comply with the Pro-Children Act of 1994 (codified at 20 U.S.C. section 6081 et. seq.). 12. Medicaid Services. To the extent Contractor provides any service whose costs are paid in whole or in part by Medicaid, Contractor shall comply with all applicable federal and state laws and regulation pertaining to the provision of Medicaid Services under the Medicaid Act, Title XIX, 42 U.S.C. Section 1396 et. seq., including without limitation: a. Keep such records as are necessary to fully disclose the extent of the services provided to individuals receiving Medicaid assistance and shall furnish such information to any state or federal agency responsible for administering the Medicaid program regarding any payments claimed by such person or institution for providing Medicaid Services as the state or federal agency may from time to time request. 42 U.S.C. Section 1396 a(a)(27); 42 CFR 431.107(b)(1) & (2). b. Comply with all disclosure requirements of 42 CFR 1002.3(a) and 42 CFR 455 Subpart (8). c. Maintain written notices and procedures respecting advance directives in compliance with 42 U.S.C. Section 1396(a)(57) and (w), 42 CFR 431.107(b)(4), and 42 CFR 489 subpart I. d. e. Certify when submitting any claim for the provision of Medicaid Services that the information submitted is true, accurate and complete. Contractor shall acknowledge Contractor's understanding that payment of the claim will be from federal and state funds and that any falsification or concealment of a material fact may be prosecuted under federal and state laws. Entities receiving $5 million or more annually (under this Contract and any other Medicaid Agreement) for furnishing Medicaid health care items or services shall, as a condition of receiving such payments, adopt written fraud, waste and abuse policies and procedures and inform employees, contractors and agents about the policies and procedures in compliance with Section 6032 of the Deficit Reduction Act of 2005, 42 U.S.C. § 1396a(a)(68). 13. ADA. Contractor shall comply with Title" of the Americans with Disabilities Act of 1990 (codified at 42 U.S.C. 12131 et. seq.) in the construction, remodeling, maintenance and operation of any structures and facilities, and in the conduct of all programs, services and training associated with the delivery of Services. Page 4 of 8 -Exhibit 6 to Personal Services Contract No. 2012-275 14. Agency-Based Voter Registration. If applicable, Contractor shall comply with the Agency-based Voter Registration sections of the National Voter Registration Act of 1993 that require voter registration opportunities be offered where an individual may apply for or receive an application for public assistance. 15. Disclosure. a. 42 CFR 455.104 requires the State Medicaid agency to obtain the following information from any contractor of Medicaid or CHIP services, including fiscal agents of providers and managed care entities: (1) the name and address (including the primary business address, every business location and P.O. Box address) of any person (individual or corporation) with an ownership or control interest in the provider, fiscal agent or managed care entity; (2) in the case of an individual, the date of birth and Social Security Number, or, in the case of a corporation, the tax identification number of the entity, with an ownership interest in the provider, fiscal agent or managed care entity or of any subcontractor in which the provider, fiscal agent or managed care entity has a 5% or more interest; (3) whether the provider, fiscal agent, or managed care entity is related to another person with ownership or control interest in the provider, fiscal agent or managed care entity as a spouse, parent, child or sibling; (4) the name of any other provider, fiscal agent or managed care entity in which an owner of the provider, fiscal agent or managed care entity has an ownership or control interest; and, (5) the name, address, date of birth and Social Security Number of any managing employee of the provider, fiscal agent or managed care entity. b. 42 CFR 455.434 requires as a condition of enrollment as a Medicaid or CHIP provider, to consent to criminal background checks, including fingerprinting when required to do so under state law, or by the category of the provider based on risk of fraud, waste and abuse under federal law. As such, a provider must disclose any person with a 5% or greater direct or indirect ownership interest in the provider whom has been convicted of a criminal offense related to that person's involvement with the Medicare, Medicaid, or title XXI program in the last 10 years. c. OHA reserves the right to take such action required by law, or where OHA has discretion, it deems appropriate, based on the information received (or the failure to receive) from the provider, fiscal agent or managed care entity. 16. Special Federal Requirements Applicable to Addiction Services. a. Women's Services. If Contractor provides A&D 61 or A&D 62 Services, Contractor must: (1) Treat the family as a unit and admit both women and their children if appropriate. (2) Provide or arrange for the following services to pregnant women and women with dependent children: (a) Primary medical care, including referral for prenatal care; (b) Pediatric care, including immunizations, for their children; (c) Gender-specific treatment and other therapeutic interventions, e.g. sexual and physical abuse counseling, parenting training, and child care. (d) Therapeutic interventions for children in custody of women in treatment, which address, but are not limited to, the children's developmental needs and issues of abuse and neglect; and (e) Appropriate case management services and transportation to ensure that women and their children have access to the services in (a) through (d) above. b. Pregnant Women. If Contractor provides any A&D Services other than A&D 70 Services, Contractor must: Page 5 of 8 -Exhibit 6 to Personal Services Contract No. 2012-275 t f I ! l t J ! j f t [ t t I l (1) Within the priority categories, if any, set forth in a particular Service Description, give preference in admission to pregnant women in need of treatment who seek, or are referred for, and would benefit from, such services; (2) Perform outreach to inform pregnant women of the availability of treatment services targeted to them and the fact that pregnant women receive preference in admission to these programs; (3) If Contractor has insufficient capacity to provide treatment services to a pregnant woman, refer the women to another provider with capacity or if no available treatment capacity can be located, refer the women to OHA's Addictions and Mental Health Division for referral to another provider in the state, If capacity cannot be located, AMH will make available interim services within 48 hours, including a referral for prenatal care, c, Intravenous Drug Abusers, If Contractor provides any A&D Services other than A&D 70 Services, Contractor must (1) Within the priority categories, if any, set forth in a particular Service Description and subject to the preference for pregnant women described above, give preference in admission to intravenous drug abusers; (2) Programs that receive funding under the grant and that treat individuals for intravenous substance abuse, upon reaching 90 percent of its capacity to admit individuals to the program, must provide notification of that fact to the State within seven days, (3) If Contractor receives a request for admission to treatment from an intravenous drug abuser, Contractor must, unless it succeeds in referring the individual to another provider with treatment capacity, admit the individual to treatment not later than: (a) 14 days after the request for admission to Contractor is made; or (b) 120 days after the date of such request if no provider has the capacity to admit the individual on the date of such request and, if interim services are made available not less than 48 hours after such request (4) For the purposes of (3) above, Ulnterim Services" means: (a) Services for reducing the adverse health effects of such abuse, for promoting the health of the individual, and for reducing the risk of transmission of disease, including counseling and education about HIV and tuberculosis, the risks of needle sharing, the risks of transmission of disease to sexual partners and infants, and steps that can be taken to ensure that HIV and tuberculosis transmission does not occur; (b) Referral for HIV or TB treatment services, where necessary; and (c) Referral for prenatal care if appropriate, until the individual is admitted to a provider'S services, (d) If Contractor treats recent intravenous drug users (those who have injected drugs within the past year) in more than one-third of its capacity, Contractor shall carry out outreach activities to encourage individual intravenous drug abusers in need of such treatment to undergo treatment, and shall document such activities. d, Infectious Diseases. If Contractor provides any A&D Services other than A&D 70 Services, Contractor must: (1) Complete a risk assessment for infectious disease including Human Immunodeficiency Virus (HIV) and tuberculosis, as well as sexually transmitted diseases, based on protocols established by OHA, for every individual seeking Services from County; and Page 6 of 8 -Exhibit 6 to Personal Services Contract No. 2012-275 (2) Routinely make tuberculosis services available to each individual receIVIng Services for alcohol/drug abuse either directly or through other arrangements with public or non-profit entities and, if Contractor denies individual admission on the basis of lack of capacity, refer the individual to another provider of tuberculosis Services. (3) For the purposes of (2) above, "tuberculosis services" means: (a) Counseling the individual with respect to tuberculosis; (b) Testing to determine whether the individual has contracted such disease and testing to determine the form of treatment for the disease that is appropriate for the individual; and (c) Appropriate treatment services. e. OHA Referrals. If Contractor provides any A&D Services other than A&D 70 services, Contractor must, within the priority categories, if any, set forth in a particular Service Description and subject to the preference for pregnant women and intravenous drug users described above, give preference in A&D service delivery to persons referred by OHA f. Barriers to Treatment. Where there is a barrier to delivery of an A&D Service due to culture, gender, language, illiteracy, or disability, Contractor shall develop support services available to address or overcome the barrier, including: (1) Providing, if needed, hearing impaired or foreign language interpreters. (2) Providing translation of written materials to appropriate language or method of communication. I(3) Providing devices that assist in minimizing the impact of the barrier. (4) Not charging clients for the costs of measures, such as interpreters, that are required to provide nondiscriminatory treatment. I ,l g. Misrepresentation. Contractor shall not knowingly or willfully make or cause to be made any false t statement or representation of a material fact in connection with the furnishing of items or Services for which payments may be made of OHA. h. Oregon Residency. A&D Services funded through this Contract may only be provided to residents of IOregon. Residents of Oregon are individuals who live in Oregon. There is no minimum amount of time an individual must live in Oregon to qualify as a resident so long as the individual intends to remain in Oregon. A child's residence is not dependent on the residence of his or her parents. A ! child living in Oregon may meet the residency requirement if the caretaker relative with whom the child is living is an Oregon resident. i. Tobacco Use. If Contractor has A&D Services treatment capacity that has been deSignated for I children, adolescents, pregnant women, and women with dependent children, Contractor must implement a policy to eliminate smoking and other use of tobacco at the facilities where the Services I are delivered on the grounds of such facilities. j. Client Authorization. Contractor must comply with 42 CFR Part 2 when delivering an Addiction Service that includes disclosure of Client information for purposes of eligibility determination. Contractor must obtain Client authorization for disclosure of billing information, to the extent and in I~ the manner required by 42 CFR Part 2, before a Disbursement Claim is submitted with respect to delivery of an Addiction Service to that individual. f ,f 17. Community Mental Health Block Grant. All funds, if any, awarded under this Contract for MHS 20, MHS 22, MHS 37 or MHS 38 Services are subject to the federal use restrictions and requirements set ~ forth in Catalog of Federal Domestic Assistance Number 93.958 and to the federal statutory and regulatory restrictions imposed by or pursuant to the Community Mental Health Block Grant portion of I l r: Page 7 of 8 -Exhibit 6 to Personal Services Contract No. 2012-275 I the Public Health Services Act, 42 U.S.C. 300x*1 et. seq., and Contractor shall comply with those restrictions. 18. Substance Abuse Prevention and Treatment. To the extent Contractor provides any Service whose costs are paid in whole or in part by the Substance Abuse, Prevention, and Treatment Block Grant, Contractor shall comply with federal rules and statutes pertaining to the Substance Abuse, Prevention, and Treatment Block Grant, including the reporting provisions of the Public Health Services Act (42 U.S.C. 300x through 300x-66). Regardless of funding source. to the extent Contractor provides any substance abuse prevention or treatment services, Contractor shall comply with the confidentiality requirements of 42 CFR Part 2. Date: &&;/t3 Title pPlltAleSignature #~/ Contraetbr: I I I t I Page 8 of 8 -Exhibit 6 to Personal Services Contract No. 2012-275 Exhibit 7 DESCHUTES COUNTY SERVICES CONTRACT Contract No. 2013-275 CONFIDENTIALITY AGREEMENT County will make available and/or transfer to Contractor certain Information, in conjunction with goods or services that are being provided by Contractor to County that is confidential and must be afforded special treatment and protection. Contractor will have access to and/or receive from County certain Information that can be used or disclosed only in accordance with this Agreement and the HHS Privacy Regulations. To the extent required by 42 U.S.C. 1171 et seq. enacted by the Health Insurance Portability and Accountability Act of 1996 and regulations promulgated thereunder, Contractor assures County that Contractor will appropriately safeguard protected health information made available to or obtained by Contractor. Contractor further agrees to comply with applicable laws relating to protected health information and with respect to any task or other activity Contractor performs on behalf of County, to the extent County would be required to comply with such requirements. For purposes of this Contract, the following terms shall apply: A Contractor shall be considered a Contractor; B. County shall be considered a COVERED ENTITY; I F. Information shall mean any health information provided and/or made available by County to lContractor, and has the same meaning as the term 'health information' as defined by 45 C.F.R 160.102. I Contractor agrees it shall: i 1. Not use or further disclose such information other than as permitted or required by this Agreement. Contractor shall not, except as necessary for the proper management, administration and performance of its duties under this Agreement, use, reproduce, disclose, or provide to third parties, any confidential I document or information relating to the County, its members or to clients of County or its members without the prior written consent or authorization of the County or of the client. If Contractor uses such information for the purposes set forth above, it will only do so if the disclosure is required by law or Contractor obtains reasonable assurances from the person to whom the information is disclosed that it I will be held confidentially and used or further disclosed only as required by law or for the purpose for which Contractor disclosed it to the person. Contractor shall ensure that its personnel, employees, ! affiliates and agents maintain the confidentiality of patient health information and business information of [ County. 2. Not use or further disclose the information in a manner that would violate the requirements of applicable law, if done by County; Page 1 of 2 -Exhibit 7 to Personal Services Contract No. 2013-275 C. HHS Privacy Regulations shall mean the Code of Federal Regulations (C.F.R) at Title 45, Sections 160 and 164; D. Individual shall mean the person who is the subject of the Information, and has the same meaning as the term 'individual' is defined by 45 C.F.R 164.501; and E. Secretary shall mean the Secretary of the Department of Health and Human Services (HHS) and any other officer or employee of HHS to whom the authority involved has been delegated; 3. Use appropriate safeguards to prevent use or disclosure of such information other than as provided for by this Agreement; 4. Report to County any use or disclosure of such information not provided for by this Agreement of which Contractor becomes aware; 5. Ensure that any subcontractors or agents to whom Contractor provides protected health information received from County agree to the same restrictions and conditions that apply to Contractor with respect to such information; 6. Make available protected health information in accordance with applicable law, i.e., the Code of Federal Regulations (C.F.R.) at Title 45, Sections 160 and 164; 7. Maintain standard records, pursuant to this Contract, and to provide such records and other necessary information to the County as may be requested in writing and as permitted by law. Contractor agrees that all records kept in connection with this Contract are subject to review and audit by the County upon reasonable notice of a minimum of 14 work days from the date of written request by the County. 8. Make Contractor's internal practices, books, and records relating to the use and disclosure of protected health information received from County available to the Secretary of the United States Health & Human Services for purposes of determining County's compliance with applicable law (in all events, Contractor shall immediately notify County upon receipt by Contractor of any such request, and shall provide County with copies of any such materials); 9. Upon termination of this Contract, Contractor shall promptly return all protected health information received from County. If the return of protected health information is not feasible, Contractor shall continue the protections required under this Contract to the protected health information consistent with the requirements of this Attachment and the HIPAA privacy standards. I Date: &!tqI15 Signature~ Title tft1f;V fJ Contractor: I t t Page 2 of 2 -Exhibit 7 to Personal Services Contract No. 2013-275 I ! I I I I Exhibit 8 DESCHUTES COUNTY SERVICES CONTRACT Contract No. 2013-275 CONTRACT PROVISIONS REQUIRED BY OREGON HEALTH AUTHORITY Oregon Health Authority Exhibit I of 2013-2015 Intergovernmental Agreement 1. Expenditure of Funds. Contractor may expend the funds paid to Contractor under this Contract solely on the delivery of services as described in Exhibit 1 of this Contract ("Services"), subject to the following limitations (in addition to any other restrictions or limitations imposed by this Contract): a. Contractor may not expend on the delivery of Services any funds paid to Contractor under this Contract in excess of the amount reasonable and necessary to provide quality delivery of Services. b. If this Contract requires Contractor to deliver more than one service, Contractor may not expend funds paid to Contractor under this Contract for a particular service on the delivery of any other service. c. If this Contract requires Contractor to deliver alcohol, drug abuse and addiction services, Contractor may not use the funds paid to Contractor under this Contract for such services: (1) To provide inpatient hospital services; (2) To make cash payments to intended recipients of health services; (3) To purchase or improve land, to purchase, construct or permanently improve (other than minor remodeling) any building or other facility or to purchase major medical equipment; (4) To satisfy any requirement for expenditure of non-federal funds as a condition for receipt of federal funds (whether the federal funds are received under this Contract or otherwise); (5) With respect to federal Substance Abuse Prevention and Treatment Block Grant moneys only, to purchase services from any person or entity other than a public or non-profit entity; or (6) To carry out any program prohibited by section 245(b) of the Health Omnibus Programs Extension Act of 1988 (codified at 42 U.S.C. 300ee(5». d. Contractor may expend funds paid to Contractor under this Contract only in accordance with federal OMB Circular A-87 as that circular is applicable on allowable costs. 2. Records Maintenance, Access and Confidentiality. a. Access to Records and Facilities. County, the Oregon Health Authority, the Secretary of State's Office of the State of Oregon, the Federal Government, and their duly authorized representatives shall have access to the books, documents, papers and records of Contractor that are directly related to this Contract, the funds paid to Contractor hereunder, or any services delivered hereunder for the purpose of making audits, examinations, excerpts, copies and transcriptions. In addition, Contractor shall permit authorized representatives of County and the Oregon Health Authority to perform site reviews of all services delivered by Contractor hereunder. b. Retention of Records. Contractor shall retain and keep accessible all books, documents, papers, and records, that are directly related to this Contract, the funds paid to Contractor hereunder or to any services delivered hereunder, for a minimum of six (6) years, or such longer period as may be required by other provisions of this Contract or applicable law, following the termination or expiration of this Contract. If there are unresolved audit or other questions at the end of the Six-year period, Contractor shall retain the records until the questions are resolved. c. Expenditure Records. Contractor shall document the expenditure of all funds paid to Contractor under this Contract. Unless applicable federal law requires Contractor to utilize a different Accounting system, Contractor shall create and maintain all expenditure records in accordance with generally accepted accounting prinCiples and in sufficient detail to permit County and the Oregon Health Authority to verify how the funds paid to Contractor under this Contract were expended. Page 1 of 4 -Exhibit 8 to Personal Services Contract No. 2013-275 I I ! f I I I I i I ~ t, f l d. Individual's Records. Unless otherwise specified in this Contract, Contractor shall create and maintain a records for each Individual who receives Services under this Contract. The Individual's record must contain: (1) Individual's identification; (2) Problem assessment; (3) Services and supports, training and/or care plan; (4) Medical information when appropriate; and (5) Progress notes including service termination summary and current assessment or evaluation instrument as designated by the Oregon Health Authority in administrative rules. Contractor shall retain an Individual's records in accordance with OAR 166-150-0005 through 166-150-0215 (State Archivist). Unless OAR 166-150-0005 through 166-150-0215 requires a longer retention period, records of Individual's must be retained for a minimum of ten (10) years from termination or expiration of this Contract. e. Safeguarding of Individual's Information. Contractor shall maintain the confidentiality of records of Individual's as required by applicable state and federal law, including without limitation, ORS 179.495 to 179.507,45 CFR Part 205,42 CFR Part 2, any administrative rule adopted by the Oregon Health Authority, implementing the foregoing laws, and any written policies made available to Contractor by County or by the Oregon Health Authority. Contractor shall create and maintain written poliCies and procedures related to the disclosure of Individual's information, and shall make such policies and procedures available to County and the Oregon Health Authority for review and inspection as reasonably requested by County or the Oregon Health Authority. f. Data Reporting. All individuals receiving services with funds provided under this Contract must enroll and maintain that client's record in either: (1) The Client ProceSSing Monitoring System (CPMS) as specific in OHA's CPMS manual located at: http://www.oregon.gov/OHAlamh/training/cpms/index.shtml.asit may be revised from time to time; or (2) The Measures and Outcome Tracking System (MOTS) as specified in OHA's MOTS manual located at: http://www.oregon.gov/oha/amh/pageslcompass/electronic-data-capture.aspx, as may be revised from time to time. Over the next two years AMH will be closing the CPMS system and replacing it with the MOTS system. Providers will be notified of the change. 3. Alternative Formats of Written Materials. In connection with the delivery of Services, Contractor shall: a. Make available to an Individual, without charge to the Individual, upon the Individual's, the County's or the Oregon Health Authority's request, any and all written materials in alternate, if appropriate, formats as required by the Oregon Health Authority's administrative rules or by the Oregon Health Authority's written policies made available to Contractor. b. Make available to an Individual, without charge to the Individual, upon the Individual's, County's or the Oregon Health Authority's request, any and all written materials in the prevalent non-English languages in the area served by Contractor. c. Make available to an Individual, without charge to the Individual, upon the Individual's, County's or the Oregon Health Authority's request, oral interpretation services in all non-English languages in the area served by Contractor. d. Make available to an Individual with hearing impairments, without charge to the Individual, upon the Individual's, County's or the Oregon Health Authority's request, sign language interpretation services and telephone communications access services. For purposes of the foregoing, "written materials" Page 2 of 4 -Exhibit 8 to Personal Services Contract No. 2013-275 I I I ! I f t ( r I ~ I I, i I [ I I I t t includes, without limitation, all written materials created or delivered in connection with the services and all subcontractor contracts related to this Contract. 4. Reporting Requirements. Contractor shall prepare and furnish the following information to County and the Oregon Health Authority when a service is delivered under this Contract: a. Individual, service and financial information as specified in the applicable Service Description attached hereto and incorporated herein by this reference. b. AU additional information and reports that County or the Oregon Health Authority reasonably requests, including, but not limited to, the information or disclosures described in Exhibit 6, Required Federal Terms and Conditions, Section 15, Disclosure .. I 5. Compliance with Law. Contractor shall comply with all state and local laws, regulations, executive orders and ordinances applicable to the Contract or to the delivery of services hereunder. Without Ilimiting the generality of the foregoing, Contractor expressly agrees to comply with the following laws, regulations and executive orders to the extent they are applicable to the Contract: I I(a) all applicable requirements of state civil rights and rehabilitation statutes, rules and regulations; I f (b) all state laws governing operation of community mental health programs, including without limitation, all administrative rules adopted by the Oregon Health Authority related to community mental health programs; I t (c) all state laws requiring reporting of abuse of an Individual; (d) ORS 659A.400 to 659AA09, ORS r 659A.145 and all regulations and administrative rules established pursuant to those laws in the construction, remodeling, maintenance and operation of any structures and facilities, and in the i conduct of all programs, services and training associated with the delivery of services under this lContract. These laws, regulations and executive orders are incorporated by reference herein to the extent that they are applicable to the Contract and required by law to be so incorporated. All temployers, including Contractor, that employ subject workers who provide services in the State of Oregon shall comply with ORS 656.017 and provide the required Workers' Compensation coverage, t unless such employers are exempt under ORS 656.126. In addition, Contractor shall comply, as if it were County thereunder, with the federal requirements set forth in Exhibit H to the certain 2013-2015 Intergovernmental Agreement for the Financing of Community Addictions and Mental Health I Services between County and the Oregon Health Authority dated as of July 1, 2013, which Exhibit is incorporated herein by this reference. For purposes of this Contract, all references in this Contract to federal and state laws are references to federal and state laws as they may be amended from time to time. 6. Unless Contractor is a State of Oregon governmental agency, Contractor agrees that it is an independent contractor and not an agent of the State of Oregon, the Oregon Health Authority or County 7. To the fullest extent permitted by applicable law, Contractor shall defend (in the case of the state of Oregon and the Oregon Health Authority, subject to ORS Chapter 180), save and hold harmless the State of Oregon, the Oregon Health Authority, County, and their officers, employees, and agents from and against all claims, suits, actions, losses, damages, liabilities, costs and expenses of any nature whatsoever resulting from, arising out of or relating to the operations of the Contractor, including but not limited to the activities of Contractor or its officers, employees, subcontractors or agents under this Contract. 8. Contractor understands that Contractor may be prosecuted under applicable federal and state criminal and civil laws for submitting false claims, concealing material facts, misrepresentation, falsifying data system input, other acts of misrepresentation, or conspiracy to engage therein. 9. Contractor shall only conduct transactions that are authorized by the County for transactions with the Oregon Health Authority that involve County funds directly related to this Contract. Page 3 of 4 -Exhibit 8 to Personal Services Contract No. 2013-275 10. Contractor(s) that are not units of local government as defined in ORS 190.003 shall obtain, at Contractor's expense, and maintain in effect with respect to all occurrences taking place during the term of the Contract, insurance requirements as specified in Exhibit 2 of this Contract. 11 Contractor(s) that are not units of local government as defined in ORS 190.003, shall indemnify, defend, save and hold harmless the State of Oregon and its officers, employees and agents ("Indemnitee") from and Cilgainst any and all claims, actions, liabilities, damages, losses, or expenses (including attorneys' fees) arising from a tort (as now or hereafter defined in ORS 30.260) caused, or alleged to be caused, in whole or in part, by the negligent or willful acts or omissions of Provider or any of the officers, agents, employees or subcontractors of the contractor( "Claims"). It is the specific intention of the parties that the Indemnitee shall, in all instances, except for Claims arising solely from the negligent or willful acts or omissions of the Indemnitee, be indemnified by the Contractor from and against any and all Claims. 12. Contractor shall include sections 1 through 11. in substantially the form set forth above, in all permitted Contractor contracts under this Contract. f I Date: lR/t'j/t:3 Signature: p~ Title Mil-AlI' I Contractor: f Page 4 of 4 -Exhibit 8 to Personal Services Contract No. 2013-275 Hi:.AL TriCJ.\Ht:. t-rtU" lUi.;.f"\~ ~I.:.l"" Y I~l:. ORGANIZATION PURCHASING GROUP CNA ClCertificate of 3Jnsurance lInsa nurses set'Vice organi%ation OCCURRENCE POLICY FORM POLICY NUMBER 018098 970 PRODUCER BRANCH 0423500419-8 Named Insured Mary K Coppedge 61368 Elkhom St Bend, OR 97702-2189 .;;.;M"-'e;..;;d.;.;.ic.;;.;a""I...;;S;.a;pe;...;;...;;.c.;;.;;ia.;.;.lt;;.r.y____________...;:C;;.;o;;.;d;;.;:e;... Psychiatric Nurse Practitioner 80965 Excludes Cosmetic Procedures .!...P~ol~ic:u!y...!.P-=:e:'.!,;ri~od~;_____________ From 06/10/13 to 06/10/14 at 12:01 AM Standard Time Program Administered by: Nurses SelVice Organization 159 E. County Line Road Hatboro, PA 19040-1218 1-800-247-1500 www.nso.com Insurance is provided by: American Casualty Company of Reading, Pennsylvania 333 South Wabash Avenue Chicago, Illinois 60604 Professional Liability $1,000,000 each claim $3,000,000 aggregate . -.YCM 1llil1I3ssLof'l@UilWll.i!Y.Jirnits shQWf'lILQOVI3 i[]Cll,!dELlhelo1lowing; _ ._ _ _ • Good Samaritan Liability • Malplacement Liability • Personal Injury Liability • Sexual Misconduct included in the PL Limit shown above subject to $25,000 aggregate sub limit Coverage Extensions License Protection $ 25,000 per proceeding $ 25,000 aggregate Defendant Expense Benefit $ 1,000 per day limit $ 25,000 aggregate Deposition Representation $ 10,000 per deposition $ 10,000 aggregate Assault $ 25,000 per incident $ 25,000 aggregate Includas Workplace VIOlence Counseling Medical Payments $ 25,000 per person $ 100,000 aggregate First Aid $ 10,000 per incident $ 10,000 aggregate Damage to Property of Others $ 10,000 per incident $ 10,000 aggregate Information Privacy (HIPAA) Fines &Penalties $ 25,000 per incident $ 25,000 aggregate General Liabilitv General Liability $1,000,000 each claim 1 $1,000,000 aggregate Fire and Water Legal Liability Included in the PL limit above subject to $250,000 aggregate sub limit Personal Liability $1,000,000 aggregate Total: $1,472.00 Premium reflects self-employed, full-time rate. Policy Forms & Endorsements (Please see attached list for a general description of many common policy fOnTIS and endorsements.) G-121500-D G-121501-C G-145184-A G-147292-A GSL3886 GSL3908 GSL13424 GSL15563 GSL15564 GSL15565 GSL17101 G-123846-C36 G-123827-B GSL19904 G-121504-C ~~7fv~ Chairman of the Board Secretary Keep this Certificate of Insurance in a safe place. This Certificate of Insurance and proof of payment are your proof of coverage. There is no coverage in force unless the premium is paid in full. In order to activate your coverage, please remit premium in full by the effective date of this Certificate of Insurance. Form #: G-141241-B (3/2010) Master Policy: 188711433 NSO-402-R·PNM-N1 20130401-125-000147 1463 I CNA THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ECONOMIC AND TRADE SANCTIONS CONDITION The following condition is added to the Policy: ECONOMIC AND TRADE SANCTIONS CONDITION In accordance with laws and regulations of the United States concerning economic and trade embargoes, this policy is void from its inception with respect to any term or condition of this policy that violates any laws or regulations of the United States concerning economic and trade embargoes including, but not limited to the following: 1. Any insured under this Policy, or any person or entity claiming the benefits of such insured, who is or becomes a Specially Designated National or Blocked Person or who is otherwise subject to U.S. economic or trade sanctions; 2. Any claim or suitlflat IS brought in a Sanctioned Country or fly aSa:n~ctiolied Country Government, where any action in connection with such claim or suit is prohibited by U.S. economic or trade sanctions; 3. Any claim or suit that is brought by any Specially Designated National or Blocked Person or any person or entity who is otherwise subject to U.S. economic or trade sanctions; 4. Property that is located in a Sanctioned Country or that is owned by, rented to or in the care, custody or control of a Sanctioned Country Government, where any activities related to such property are prohibited by U.S. economic or trade sanctions; or 5. Property that is owned by, rented to or in the care, custody or control of a Specially Designated National or Blocked Person, or any person or entity who is otherwise subject to U.S. economic or trade sanctions. As used in this endorsement a Specially Designated National or Blocked Person is any person or entity that is on the list of Specially Designated Nationals and Blocked Persons issued by the U.S. Treasury Department's Office of Foreign Asset Control (O.F.A.C.) as it may be from time to time amended. As used in this endorsement a Sanctioned Country is any country that is the subject of trade or economic embargoes imposed by the laws or regulations of the United States of America. f I I t i l t f r I G-145184-A (Ed. 6/03) t I 1465 .. , L r', i-.... " , • Exclusion -Asbestos, Fungi, Silica In consideration of the premium paid, it is agreed that the GENERAL LIABILITY COVERAGE PART or the WORKPLACE LIABILITY COVERAGE PART that is attached to this policy is amended as follows: I. Section IV. EXCLUSIONS is amended by the addition of the following: We will not defend any claim for, or pay any amounts, including claim expenses, based on or arising out of, or related to: • Loss due to asbestos, meaning: 1. injury or damage arising in whole or in part out of the actual, alleged or threatened exposure at any time to asbestos; or 2. any loss, cost or expense that may be awarded or incurred: a. by reason of a claim or suit for any such injury or damage; or b. in complying with a governmental direction or request to test for, monitor, clean up, remove, contain or dispose of asbestos. • loss due to Fungi or microbes, meaning: 1. Injury or damage arising out of or relating to, in whole or in part, the actual, alleged or threatened inhalation of, ingestion of, contact with, exposure to, existence of, or growth or presence of any fungi or microbes. 2. Any loss cost or expense arising out of or relating to the testing for, monitoring, cleaning up, removing, containing, treating, detoxifying, neutralizing, remediating, or disposing of, or in any way responding to or assessing the effects of fungi or microbes by any insured or anyone else. 3. Damage caused by water where there also exists any damage arising out of or relating to, in whole or in part, the actual, alleged or threatened inhalation of, ingestion of, Contact with, exposure to, existence of, or growth or presence of allY 'tlltg! or microbes. This exclusion applies regardless of any other cause or event that contributes concurrently or in any sequence to such injury or damage, loss, cost or expense. This exclusion does not apply where your business is food processing, sales, or serving. and the injury is caused solely by food poisoning in connection with such processing, sales or serving. • Loss due to silica, meaning: 1. Injury arising in whole or in part out of the actual, alleged or threatened respiration or ingestion at any time of silica; or 2. damage arising in whole or in part out of the actual, alleged or threatened presence of silica. II. Section III. AOOmONAL DEFINmONS is amended by the addition of the following: •Asbestos-means the mineral in any form whether or not the asbestos was at any time: 1. airborne as a fiber. particle or dust; 2. contained in or formed a part of a product, structure or other real or personal property; 3. carried on dothing; 4. inhaled or ingested; or 5. transmitted by any other means. "Fungi" means any form of fungus, including but not limited to, yeast, mold, mildew, rust, smut or mushroom, and including any spores, mycotoxins, odors, or any other substances, products, or byproducts produced by, released by, or arising out of the current or past presence of fungi. But fungi does not include any fungi intended by the insured for consumption. "Microbe" means any non-fungal microorganism or non-fungal, colony-form organism that causes infection or disease. Microbe includes any spores, mycotoxins, odors, or other substances, products, or byproducts produced by, released by, or arising out of the current or past presence of microbes. But microbe does not mean microbes that were transmitted directly from person to person. a SIlica-means the chemical compound silicon dioxide (Si02) in any form. including dust which contains silica. a Suit-means a civil proceeding in which damages because of Injury or damage to which this insurance applies are alleged. Suit includes: 1. an arbitration proceeding in which such damages are claimed and to which you must submit or does submit with our consent; or 2. any other alternative dispute resolution proceeding in which such damages are claimed and to which you submit with our consent. This endorsement is a part of your policy and takes effect on the effective date of your policy, unless another effective date is shown below. All other provisions ofthe policy remain unchanged. I I I I I I t t I i f ! i Must Be Completed Complete Only When This Endorsement Is Not Prepared with the Policy Or Is Not to be Effective with the Policy ISSUED TO: ENDORSEMENT EFFECTIVE DATE: I tENDT. NO. I POLICY NO. G-147292-A (312004) Page 1 of 1 AMERICAN CASUALTY COMPANY OF READING, PA 1466 POLICY FORMS & ENDORSEMENTS The list below contains general descriptions of the policy foons and endorsements that mayor may not apply to your professional liability insurance policy. State specific policy forms and endorsements are not included in the list below. Should you require descriptions or samples of these documents, please visit us online at www.nso.com/policyforms. Please refer to your Certificate of Insurance for the policy forms & endorsements specific to your state and your policy period. All products and services may not be available in all states and may be subject to change without notice. Think Green expanded definitions and copies of these policy forms and endorsements are available online at www.nso.comIpolicyforms. COMMON POLICY FORMS & ENDORSEMENTS FORM # DESCRleIlQN G-121500-D Common Policy Conditions G-121501-C Occurrence Policy Form G-121502-C Claims Made Policy Form G-121503-C Workplace Liability Form G-145184-A Policyholder Notice -OFAC Compliance Notice G-147292-A POlicyholder Notice -Silica. Mold & Asbestos Disclosure GSl3886 Coverage & Cap on Losses from Certified Acts of Terrorism GS1.3908 Notice Offer of Terrorism Coverage & Disclosure of Premium GSL13424 Services to Animals GSL15563 Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs GSl15564 Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion GSL15565 Healthcare Providers Professional Liability Assault Coverage GSI1710.l~ Exclusion.olSpecified Activities &!u~9Le.~rent~.!!I.tQ~~! and..§l!2flIies Coverage for Cosmetic Procedures .. .-,,--.--.----.--.GSl19843 GSL19904 Cosmetic Procedures Exclusion OPTIONAL ENDORSEMENTS EO&U DESCRIPTION GSL5587 Consulting Services Liability Endorsement GSL5548 Case Management Services G-121504-C General Liability Form PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC TO YOUR STATE AND YOUR POLICY PERIOD. Self-employed individuals may be eligible for General Liability coverage subject to underwriting approval. Should an individual practitioner's status change from self-employed to employed, general liability coverage will be deleted and replaced with workplace liability. Please contact Nurses Service Organization for details. Nl0412 1464