HomeMy WebLinkAboutDoc 408 - Sage View AgrmtDeschutes County Board of Commissioners
1300 NWWali 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 22, 2012
DATE: July 25, 2012
FROM: Lori Hill, Adult Treatment Program Manager
Nancy Mooney, Contract Specialist Phone: 322-7516
TITLE OF AGENDA ITEM:
Consideration of Board Signature of Document #2012-408, Agreement between St. Charles Health
System, Inc. and Deschutes County Health Services (DCHS).
PUBLIC HEARING ON THIS DATE? No
BACKGROUND AND POLICY IMPLICATIONS:
St. Charles Health System Inc. operates a facility that can serve up to fifteen (15) clients in need of
short-term psychiatric care, also referred to as acute psychiatric care services. Acute psychiatric care
services are services delivered to individuals who are suffering from a mental illness, or mental or
emotional disturbance and are posing a danger to the health and safety of the individual or others.
The intention of these services is to control or reduce the psychiatric symptoms or behaviors in order
that the individual can return to a less restrictive environment.
Since 2005, Deschutes County, on behalf of Crook and Jefferson counties has contracted with St.
Charles to ensure indigent residents of our three counties have access to these services and the Sage
View facility. The resources are subject to funding from the State of Oregon Office of Mental Health
and Addiction Services. Under the terms of this contract, St. Charles agrees to provide acute
psychiatric care services on an in-patient basis. (In-patient meaning that the individual remains at the
facility until transferred to another facility or discharged.) Acute psychiatric care services may include:
twenty-four (24) hour supervision and nursing care; health screening or medical care; psychiatric
assessment; medication management; individual and group therapy; education regarding mental
health and addiction issues; family involvement and transportation services between Sage View and
St. Charles Hospital (Bend) as needed for medical or other services.
In additional to the acute psychiatric care, St. Charles also agrees to provide post-commitment care for
individuals who are civilly committed by a judge. This includes clients already admitted and return to
the Sage View facility after a commitment hearing. Post-commitment care includes professional
psychiatrist staff time, psychiatric medications, lab work and medical care.
FISCAL IMPLICATIONS:
Maximum compensation is $439,679 for acute psychiatric care services and $529,250 for post
commitment care services.
RECOMMENDATION &ACTION REQUESTED:
Behavioral Health requests approval.
ATTENDANCE: Lori Hill, Adult Treatment Supervisor
DISTRIBUTION OF DOCUMENTS:
Executed copies to: Nancy Mooney, Contract Specialist, Health Services
DESCHUTES COUNTY DOCUMENT SUMMARY
(NOTE: This form 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 Form is also required. If this form 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 form with your documents, please submit this form
electronically to the Board Secretary.)
Please complete all sections above the Official Review line.
Date:
Department: IDeschutes County Health Services, Behavioral Healthl
Contractor/Supplier/Consultant Name: 1st. Charles Health System, Inc.1
Contractor Contact: I Maryclair Jorgensen I Contractor Phone #: I 541-280-1141
Type of Document: IPersonal Services Contract.1
Goods and/or Services: Secure inpatient acute psychiatric care is provided to indigent
residents of Deschutes, Crook and Jefferson counties at Sage View, a facility and
program of St. Charles Health System, Inc. (St. Charles)
Background & History: St. Charles operates Sage View as a secure inpatient
psychiatric facility, serving residents of Central Oregon and others in need of acute
psychiatric care. The facility has fifteen (15) beds to serve patients. Since 2005,
Deschutes County, on behalf of Crook and Jefferson counties, has contracted with St.
Charles to ensure indigent residents of our three (3) counties have access to these
services and this facility. Under the terms of this contract, St. Charles agrees to provide
in-patient psychiatric services to any and all indigent residents of our three (3) counties
who need short term acute stabilization. Acute care services may include: twenty-four
(24) hour supervision and nursing care; health screening or medical care; psychiatric
assessment; medication management; individual and group therapy; psycho-education
regarding mental health and addiction issues; family involvement; case management
and transporation services between Sage View and St. Charles Hospital (Bend) as
needed for medical or other services.
St. Charles also agrees to provide Post-Commitment Care for individuals who are civilly
committed by a judge. This includes individuals who are already admitted and return to
the facility after a civil commitment hearing. This service includes professional staff time
(psychiatrisUMD), psychiatric medications, lab work and medical care. Post
Commitment Care shall be provided until transfer to a long-term care facility at the state
hospital or discharge from the facility.
Agreement Starting Date: July 1, 20121 Ending Date: I June 30, 20131
Annual Value or Total Payment: $439,679 for acute s chiatric care and
$529,250 for ost-commitment care.
C8J Insurance Certificate Received (check box)
Insurance Expiration Date: I t -I I to, '3
6/25/2012
Check all that apply:
D RFP, Solicitation or Bid Process
D Informal quotes «$150K)
~ Exempt from RFP, Solicitation or Bid Process (specify -see DCC §2.37)
Funding Source: (Included in current budget? ~ Yes D No
If No, has budget amendment been submitted? DYes D No
Is this a Grant Agreement providing revenue to the County? D Yes ~ 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:
Phone #:
L....-----l
Departmental Contact and Title: I Nancy Mooney, Contract Specialist
Phone #: I 541-322-7516 I
Department Director APproval~III¥. ~'ittAc ~;7J,./l--
Signat e Date
Distribution of Document: Return both originals to Nancy Mooney, Health Services
Department
Official Review:
County Signature Required (check one): JXI BOeC Department Director (if <$25K)
Administrator (if ~$25K but/l$15~K; if >$150K, BOee Order No. ____----I)
Legal Review ---i1~ t JeaQ Date 7 -1(. -1'
Document Number ~2=..:O~1:..::2,---4.:...:0=8_______
6/25/2012
For Rec ording Stamp Only
DESCHUTES COUNTY SERVICES CONTRACT
CONTRACT NO. 2012-408
This Contract (the "Contract") is made and entered into by and between Deschutes County , a political subdivision of
the State of Oregon, by and through Deschutes County Health Services, Behavioral Health Division, hereinafter referred to
as "County," and St Charles Health System, Inc ., an Oregon non-profit corporation (hereinafter referred to as "Hospital"),
doing business as Sage View, Federal Tax Identification No. 93-0602940, hereinafter referred to as "Contractor."
WHEREAS, County and Hospital (or its predecessor in interest, Cascade Health Services, Inc.) have caused to be
constructed an acute psychiatric treatment facility (hereinafter referred to as "Sage View") for Individuals in need of mental
health services, including indigent individuals residing in Crook, Deschutes and Jefferson Counties and served under this
Contract ; and
WHEREAS, the parties agree that a crisis center and facility for acute psychiatric care and treatment of acute mental
health patients is the preferred acute care model for mental health care and treatment in Central Oregon ;
WHEREAS , Contractor operates the facilities therein; and
WHEREAS , County is authorized pursuant to ORS 430.670 to obtain, by contract, the services necessary to
conduct and operate a community mental health and developmental disabilities program; and
WHEREAS, Contractor has available, or can provide Sage View facilities and staff for the performance of the
services described in this Contract; and
WHEREAS, Contractor has obtained and shall continue to qualify for approval from the Oregon Health Authority
("OHN) for purposes of providing services under this Contract; now, therefore,
WHEREAS, County is authorized pursuant to ORS 426.241 and Service Element 24 (State of Oregon grant
Exhibit 5) to obtain, by contract, the emergency psychiatric care necessary for indigent residents of Crook, Deschutes and
Jefferson counties (collectively, "Counties"); and
IT IS HEREBY AGREED by and between the parties above mentioned, for and in consideration of the mutual
promises hereinafter stated as follows:
1. Effective Date . This Contract is effective July 1, 2012 and, except as otherwise specifically provided herein, shall
expire on June 30, 2013 unless earlier terminated or renewed by agreement of the parties .
2. Contractor's Services . This Contract will cover services as outlined below for:
A. Acute Psychiatric Care: Both Contractor and County agree to adhere to the principles and agreements for
this Contract as outlined in Exhibit 1. Contractor shall perform the services described as Acute Psychiatric
Care in Exhibit 2 attached hereto and incorporated herein , as funded by and through the County's contract
with the Oregon Health Authority (OHA). Services shall be financed in accordance with a schedule
contained in Exhibit 2. For the full term of this Contract, Contractor agrees to the payment methodology as
outlined in Section 8 and Exhibits 1 and 2 to provide service to all indigent Individuals residing in Crook,
PAGE 1 OF 34 -BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
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Deschutes, and Jefferson Counties who meet admission criteria as defined in Exhibit 2. Contractor agrees
to maintain this arrangement for the Contract period. Acute Psychiatric Care will include all bed days up to
and including day of commitment if applicable. All days post-commitment will be covered under payment
and services outlined in paragraph 2(b) below. If Individual is not committed, payment will include all bed
days excluding day of discharge.
B. Post-Commitment Care: Contractor shall perform the services described as Post Commitment Care in
Exhibit 3 attached hereto and incorporated herein, as funded by and through the County's contract with
the Oregon Health Authority (OHA). Services shall be financed in accordance with a schedule contained
in Exhibit 3. For the period of July 1, 2012 -June, 30, 2013, Contractor agrees to the payment
methodology outlined in Section 8 and Exhibit 3 to provide post-commitment service to all indigent
Individuals residing in Central and Eastern Oregon Counties as defined in Exhibit 3. Any services funded
beyond June 30, 2013, if approved, would be made by separate amendment to this Contract.
3. Regulations and Duties. Contactor shall comply with all applicable provisions of the County Financial Assistance
Contract, including applicable Service Descriptions attached thereto, in place at the time this Contract is executed
and effective July 1, 2011, (Contract #134309, the "Contract") between the Oregon Health Authority ("OHA") and
Deschutes County, as the same may be amended, replaced and/or renewed from time to time. Contractor agrees to
comply with the rules and regulations of County, applicable provisions in the Contract between County and the OHA,
incorporated herein by reference, as of the effective date of such regulations, applicable provisions of the
Administrative Rules and Procedures of the OHA, applicable Federal regulations and all provisions of Federal and
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.
4. Reporting.
A. 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.
B. 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 records of Individuals which contain 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 records of Individuals 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, records
of Individuals 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 Contractor's services under this Contract, not all of these
documents will have been prepared by Contractor and therefore need not be furnished. Oregon Health Authority
Client Process Monitoring System (CPMS) data, Community Mental Health Provider Report, and Termination
Service Recording Form shall, if 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 patient of
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.
PAGE 2 OF 34 -BEHAVIORAL HEALTH PERSONAL SERVICES CONTRACT No. 2012-408
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C. Contractor shall prepare and furnish the following information to Oregon Health Authority when a Service is
delivered:
1) Patient, Service and financial information as specified in the Service Description.
2) All additional information and reports that Oregon Health Authority or County reasonably
requests.
D. Contractor shall submit reports as requested by County. All notices, bills and payments shall be made in writing
and may be given by personal delivery or by mail. Notices, bills, and payments sent by mail should be
addressed as follows:
Contractor: St. Charles Health System, Inc.
2500 NE Neff Road
Bend, OR 97701
Attn: Karen M. Shephard
County: Deschutes County Health Services
2577 NE Courtney Dr.
Bend, OR 97701 Phone: (541) 322-7535
Attn: Lori Hill
5. 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) 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 ten (10) years, or such longer period as may be required.
2) If an audit, litigation or other action involving this Contract is started before the end of the ten-year (10)
period, the records shall be retained until all issues arising out of the action are resolved.
B. 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 the right to direct access to all of
Contractor's books, documents, papers and records related to this Contract, the funds paid to Contractor
hereunder, or any services delivered hereunder for the purpose of conducting audits and examinations,
making copies, excerpts and transcripts. 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.
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 Contractor's 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 Contractor's 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.
6. 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, patient. applicant or
person doing business with the County for any purpose not directly connected with the administration of
County's or the Contractor's responsibilities under this Contract except upon written consent of the County,
and if applicable, the employee, patient, applicant or person.
PAGE 3 OF 34 BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
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 eligible
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
("HIPAA").
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 Business
Associate 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 Individuals' records 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 Individuals' 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.
7. County Monitoring and Site Visits. Contractor agrees that services provided under this Contract by Contractor,
Facilities used in conjunction with such services, Individuals' records, Contractor's policies, procedures, performance
data, financial records, and other similar documents and records of Contractor, that pertain, or may pertain, to
services under this Contract, shall be open for inspection by County, or its agents, at any reasonable time during
business hours. Contractor agrees to retain such records and documents for a period of ten (10) years, or such
longer period as may be prescribed for such records and documents by the State of Oregon Archivist or until the
conclusion of any dispute or proceeding related to the services under this Contract or involving the records of
Contractor, whichever is longer. Contractor shall permit County and Department to make site visits upon reasonable
notice to monitor the delivery of services under this Contract.
8. Payment of Contract.
a. Acute Psychiatric Care
County shall provide quarterly payments to Contractor as outlined in Exhibit 2 for rendering the services
listed in this Contract. Funds may only be used for the delivery of the service or services set out in this
paragraph unless written permission is granted to use the funds for other services in accordance with this
Contract.
Subject to Annual Payment Reconciliation and adjustment, for the period between and including July 1,
2012 through June 30, 2013, Contractor shall receive a total of $439,679 in four quarterly payments
PAGE 4 OF 34 -BEHAVIORAL HEALTH PERSONAL SERVICES CONTRACT No. 2012-408
I
(Exhibit 2) from County for Acute Psychiatric Care services to all indigent Individuals served during those
twelve months. This payment arrangement for 2012-13 requires Contractor to comply with the conditions
outlined in Exhibit 1 and 2 for all services described in this Contract. Reconciliation based on actual
utilization of bed days will be made in accordance with "Annual Payment Reconciliation" in Exhibit 2.
b. Post-Commitment Care
County shall provide monthly payments to Contractor as outlined in Exhibit 3 for rendering the services
listed in this Contract. Funds may only be used for the delivery of the service or services set out in this
paragraph unless written permission is granted to use the funds for other services in accordance with this
Contract.
Notwithstanding the foregoing, for the period between and including July 1, 2012 through June 30,2013,
Contractor shall receive no more than $529,250 in twelve (12) monthly payments (Exhibit 3) from County
for Post-Commitment services to all indigent Individuals as defined in Exhibit 3 served during those twelve
months. This payment arrangement for 2012-13 requires Contractor adhere to the conditions outlined in
Exhibit 3 for all services described in this Contract.
9. Bed Day Rate.
A. Acute Psychiatric Care:
For the purpose of this Contract for Acute Psychiatric Care and extensions or renewals of this Contract,
the Contractor and the County have established a Bed Day Rate to assist in calculating future payments if
both parties agree to discontinue the heretofore described method of calculating compensation payable to
Contractor and replace the same with a fee-for-service payment method. This calculation is based on a
2012-13 bed day rate of $695. This Bed Day Rate will be utilized to calculate any 'Annual Reconciliation
Based on Actual Bed Day Usage' as outlined in Exhibit 2.
Any change to this bed day rate will be indicated by amendment to this Contract.
By mutual agreement between Contractor and County at time of initial contract for Sage View Acute
Psychiatric Care services, an annual bed day rate increase will not exceed 5% in any calendar year
through December 31, 2024. This provision, as well as the provisions of Section 32, shall survive
termination of this Contract.
B. Post-Commitment Care:
For the purpose of this Contract for Post-Commitment Care and extensions or renewals of this Contract,
the Contractor and the County have established a Bed Day Rate to assist in calculating future payments
based on actual usage under this portion of the Contract and future negotiations with the OHA for
continued services. This calculation is based on a 2012-13 bed day rate of $725. This Bed Day Rate will
not affect payment or service levels for the 2012-13 service period.
10. Payments in Future Years beyond June 30, 2013. Not later than April 2013, Contractor and County shall meet to
review the Contract and negotiate the program and reporting requirements, protocols and payment to be paid by
County to Contractor beginning on and immediately after July 1, 2013. The parties may at that time also negotiate
payment methods and amounts for one or more years after 2013.
The County shall furnish Contractor with relevant information concerning OHA funds anticipated to be provided for
services covered under this Contract, together with budgeted amounts, if any, of the County General Fund for such
services. Contractor shall furnish relevant information concerning Contractor's costs and overhead related to
performance of services covered by this Contract. The parties shall consider amounts previously paid by County
under this Contract and determine whether and to what extent such payments have fairly compensated Contractor
for such services. The parties shall also consider amounts paid and received by similar providers of acute psychiatric
care for indigent mental health patients. In deciding the appropriate compensation level for future services, the
parties shall consider adjustments in service levels or funding or both.
PAGE 5 OF 34 -BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
11. Mediation. If the parties cannot reach agreement in matters other than Section 15 of this Contract, they shall submit
the matter to mediation. The parties shall agree upon a single mediator who is experienced in the area involving the
dispute. If the parties are unable to agree on a mediator, each party shall submit two (2) to three (3) names of people
acceptable as mediator to the Presiding Judge of the Deschutes County Circuit Court, who shall select the mediator
from the list provided. Thereafter, the parties shall participate in the mediation process in good faith. If mediation fails
to resolve the issue then either party may proceed to arbitration.
12. Arbitration. If the parties are unable to resolve the dispute over compensation by mediation, they shall submit the
matter to arbitration as follows: Either party may at any time request final and binding arbitration of the matter,
provided the parties have first tried in good faith to settle the matter by nonbinding mediation. A party may request
arbitration by giving notice to that effect to the other party. The dispute shall be determined in Deschutes County,
Oregon, by three (3) arbitrators, one selected by each party and the two (2) arbitrators selecting a third arbitrator.
The arbitration shall be conducted in accordance with the rules of the Deschutes County Circuit Court Arbitration
Program, except to the extent provided otherwise under Oregon laws on arbitration and as otherwise provided
herein. All arbitrators shall be people having at least 10 years experience with health or behavioral health business
transactions. Each party shall submit its position to the arbitrators, together with evidence thereon, and the
arbitrators shall decide the issue and determine the prevailing party, which decision is final. On the application of
either party, the award in the arbitration may be enforced by the order of judgment of a court of competent
jurisdiction.
13. Recovery of Funds. 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) when added to other compensation
pursuant to this Contract are not in excess of 100% of the maximum amount detailed in Exhibit 1.
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 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.
14. Retention of Revenue and Earned Interest. Fees and third-party reimbursements, including all amounts paid
pursuant to Title XIX of the Social Security Act by the aHA, for services rendered by Contractor, and interest earned
on such funds in the posseSSion of Contractor, shall be retained by Contractor provided that it is expended for a
mental health service which meets the standards of the aHA.
15. Withholding of Payments. Notwithstanding any other payment provision of this Contract, should Contractor fail to
submit required reports required by Section 4(A) and Exhibits 1, 2 and 3 when due, or fail to perform or document
the performance of contracted services, County shall immediately withhold payments under this Contract.
16. Termination. All or part of this Contract may be terminated by mutual consent of both parties, or by either party at
any time for convenience upon three (3) months notice in writing to the other party. If the County initiates the
termination, payment of the usual and customary expenses of termination shall be made to the Contractor. If the
initial provider investment is substantial, this Contract may not be terminated by the County for convenience.
The County may also terminate all or part of this Contract as specified below:
A. With thirty (30) days written notice, if funding to the County from Federal, State, or other sources is not
obtained or is not continued at levels sufficient to allow for purchase of the indicated quantity of services.
The County will give more notice whenever possible.
PAGE 6 OF 34 -BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
B. With thirty (60) days written notice, if Federal or State regulations are modified or changed in such a way
that services are no longer allowable for purchase under this Contract.
C. Upon notice of denial, revocation, or non-renewal of any letter of approval, license. or certificate required by
law or regulation to be held by the Contractor to provide a service element under this Contract.
D. With thirty (30) days written notice, if Contractor fails to provide services. or fails to meet any performance
standard as specified by the County in this Contract (or subsequent modifications to this Contract) within the
time specified herein. or any extensions thereof.
E. Upon written or oral notice, if County has evidence that the Contractor has endangered or is endangering
the health and safety of Individuals, residents, staff, or the public.
F. Failure of the Contractor to comply with the provisions of this Contract and all applicable Federal, State and
local laws and rules which may be cause for termination of this Contract. The circumstances under which
this Contract may be terminated by either party under this paragraph may involve major or minor violations.
Major violations include, but are not limited to:
1. Acts or omissions that jeopardize the health. safety. or security of Individuals.
2. Misuse of funds.
3. Intentional falsification of records.
In the case a failure to perform jeopardizes the safety and security of the Counties' (Deschutes, Crook and
Jefferson) Individual{s), the Contractor and the County shall jointly conduct an investigation to determine whether an
emergency exists and what corrective action will be necessary. Such an investigation shall be completed within five
(5) working days from the date the County determines that such failure exists.
In those circumstances where a major violation is substantiated, continued performance may be suspended by the
County immediately. In all cases involving a major violation. a written notice of intent to terminate this Contractor
shall be sent to the OHA and the Contractor found to be in violation.
Minor violations usually involve less than substantial compliance with the general or special conditions of this
Contractor. Continued substantial minor violations that threaten adequacy of services may be treated like a major
violation.
Prior to termination for major or minor violations, the Contractor shall be given a reasonable opportunity to refute the
findings. If the problem is not corrected or remedied within thirty (30) days after the County has given written notice
to the Contractor, or in the case the problem cannot be corrected or remedied within the thirty-day period the
Contractor fails to commence and pursue corrective action with reasonable diligence and good faith, then the
County may terminate this Contract or initiate other remedial action.
Termination shall be without prejudice to any obligations or liabilities of either party accrued prior to such termination.
17. Encumbrance or Expenditure After Notice of Termination. Contractor shall not make expenditures, enter into
contracts, or encumber funds in its possession that belong to the County, after notice of termination or termination as
set out above, without prior written approval from County. County will continue to be obligated to pay for authorized
services to the date on which termination takes effect.
18. Independent Contractor. Contractor is engaged hereby as an independent contractor, and will be so deemed for
purposes of the following:
A Contractor will be solely responsible for payment of any Federal or State taxes required as a result of this
Contract.
PAGE 7 OF 34 -BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
B. Contractor shall be solely responsible for and shall have control over the means, methods, techniques,
sequences and procedures of performing the work, and shall be solely responsible for the errors and
omissions of its employees, subcontractors and agents. For goods and services to be provided under this
Contract, Contractor agrees to:
a. perform the work in a good, workmanlike, and timely manner;
b. comply with all applicable legal requirements;
c. take all precautions necessary to protect the safety of all persons at or near Sage View, including
employees and patients of Contractor and County;
d. take full responsibility for wages and entitlements of Contractor's employees assigned to or
furnishing services at Sage View.
C. It is agreed by and between the parties that Contractor is not carrying out a function on behalf of the County,
OHA or State of Oregon, and County, OHA and State of Oregon do not have the right of direction or control
of the manner in which Contractor delivers services under this Contract or exercise any control over the
activities of the Contractor. Contractor is not an officer, employee or agent of County as those terms are
used in ORS 30.265.
D. County is not, by virtue of this Contract, a partner or joint venturer with Contractor in connection with
activities carried on under this Contract, and shall have no obligation with respect to Contractors debts or
any other liabilities of each and every nature.
E. The Contractor is an independent contractor for purposes of the Oregon Workers' Compensation law (ORS
Chapter 656) and is solely liable for any Workers' Compensation coverage under this Contract.
19. Contractor and Subcontractors. Contractor agrees to make all provisions of this Contract with the County applicable
to any subcontractor performing work under this Contract. Contactors who perform the work without the assistance
of labor or any employee, as determined under ORS Chapter 656 and rules adopted pursuant thereto, need not
obtain Workers Compensation coverage.
20. Constraints.
A. The provisions of ORS 279B.220, 2798.230, and 279B.235, are by this reference incorporate and made a part of
this Contract:
a. Contractor shall pay employees for overtime work performed under this Contract in accordance
and otherwise comply with applicable prOVisions of ORS 653.010 to 653.261 and the Fair Labor
Standards Act of 1938 ("FLSA") (29 U.S.C 201 et. seq.).
B. This Contract is expressly subject to the debt limitation of Oregon counties set forth in Article XI, Section 10, of
the Oregon Constitution, and is contingent upon funds being appropriated therefore. Any provisions herein,
which would conflict with law, are deemed inoperative to that extent.
C. Unless exempted under the rules, regulations and relevant orders of the Secretary of Labor, 41 CFR, Chapter
60, Contractor agrees to comply with all provisions of Executive Order No. 11246, as amended by Executive
Order No. 11375 of the President of the United States dated September 24, 1965 as supplemented in
Department of Labor regulations (41 CFR Part 60), Titles VI and VII of the Civil Rights Act of 1964 as amended,
Sections 503 and 504 of the Rehabilitation Act of 1973 as amended and 45 CFR 84.4, which states, "No
qualified person shall, on the basis of handicap, be excluded from participation in, be denied benefits of, or
otherwise be subjected to discrimination under any program or activity which receives or benefits from Federal
financial assistance." Contractor will also comply with all applicable rules, regulations and orders of the
Secretary of Labor concerning equal opportunity in employment and the provisions of ORS Chapters 659 and
659A.
PAGE 8 OF 34 -BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
D. If the limitation amount specified in this Contract for Title XIX Clinic Services exceeds $100,000, Contractor shall
provide the State of Oregon with written assurance that Contractor will comply with all applicable standards,
orders, or requirements issued under Section 306 of the Clean Air Act (42 USC 1857 (h), the Federal Water
Pollution Control Act as amended (commonly known as the Clean Water Act) including but not limited to Section
508 of the Clean Water Act (33 USC 1368) Executive Order 11738 and Environmental Protection Agency
regulations (40 CFR Part 15) 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 the OHA, HHS and the
appropriate Regional Office of the Environmental Protection Agency.
E. Contractor shall comply with Federal rules and statutes pertaining to the Addictions and Mental Health (AMH)
and Social Security (formerly Title XX) Block Grant(s); including the Public Health Services Act, especially
sections 1914 (b)(1-5), 1915 (c)(12), 1916 (b)(2) and Public Law 97-35.
F. The individual signing on behalf of Contractor hereby certifies and swears under penalty of perjury that she/he is
authorized to act on behalf of Contractor.
21. Hold Harmless. Contractor shall indemnify, save and hold harmless and defend the State of Oregon, Human
Resources Department, the County, and their Departments and their officers, employees and agents from and
against any and 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 Contractor, including, but not limited to the
activities of Contractor, its officers, employees, subcontractors and agents under this Contract. 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. Insurance. Prior to the effective date of this Contract. Contractor shall obtain, at Contractor's expense, and maintain
in effect all insurance requirements as outlined in Exhibit 4.
Contractor may satisfy the requirements for liability insurance by obtaining from Hospital a defense. indemnity and
hold harmless agreement, together with evidence of coverage under Hospital's program of self insurance and
umbrella insurance policies for the defense and satisfaction of claims. In the event of unilateral cancellation or
restriction by the insurance company of any insurance policy referred to in this paragraph, Contractor shall
immediately notify County verbally and in writing.
23. Settlement of Disputes. 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. Where
resolution of such disputes is not achieved after consultation with the respective Boards of Contractor and County,
the parties shall proceed with mediation and binding arbitration in accordance with Sections 10 and 11 of this
Contract.
24. Financial Audit. Contractor shall provide County with a copy of each and every audit which it prepares in order to
comply with the applicable audit requirements and responsibilities set forth in the Office of Management and Budget
Circular A-133 entitled "Audits of States, Local Governments and Non-Profit Organizations."
25. Assignment. Contractor shall not assign this Contract, except to Hospital, without the prior written consent of
County.
26. Renewal. This Contract may be renewed, subject to the following conditions: (1) renewal will be based on the
County Annual Implementation Plan approved by the OHA, and (2) renewal is subject to the availability of funding.
27. Compliance with provisions, requirements of funding source and Federal and State laws, statutes, rules,
regulations, executive orders and policies.
PAGE 9 OF 34 -BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
28. Debt Limitation. This Contract is expressly subject to the debt limitation of Oregon counties set forth in Article XI,
Section 10, of the Oregon Constitution, and is contingent upon funds being appropriated therefore.
A. Any provisions herein, which would conflict with law, are deemed inoperative to that extent.
B. Contractor shall comply with all federal, state and local laws, regulations, executive orders and ordinances
applicable to the Contract.
C. 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:
1) Titles VI and VII of the Civil Rights Act of 1964, as amended;
2) Sections 503 and 504 of the Rehabilitation Act of 1973, as amended;
3) the Americans with Disabilities Act of 1990, as amended and ORS 659A.112 through 659A.139;
4) Executive Order 11246, as amended;
5) the Health Insurance Portability and Accountability Act of 1996;
6) the Age Discrimination in Employment Act of 1967, as amended, and the Age Discrimination Act of 1975,
as amended;
7) the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended;
8) ORS Chapter 659A, as amended;
9) all regulations and administrative rules established pursuant to the foregoing laws; and
10) all other applicable requirements of federal and state civil rights and rehabilitation statutes, rules and
regulations.
11) all federal law governing operation of Community Mental Health Programs, including without limitation, all
federal laws requiring reporting of patient abuse. 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. No federal funds may be used to provide services in violation of 42 USC 14402.
12) 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).
13) If Contract maximum compensation, 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. 1857 (h)), 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 offacilities included on
the EPA List of Violating Facilities. Violations shall be reported to the Oregon Health Authority, Human
Services (HHS) and the appropriate Regional Office of the Environmental Protection Agency.
14) 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 (Pub. L. 94-163).
15) Contractor shall not knowingly and willfully make or cause to be made any false statement or representation
of a material fact in connection with the furnishing of items or Services for which payments may be made by
Department.
16) Contractor may not use the funds paid under this Contract for the following services:
a) To make cash payments to intended recipients of health services;
b) 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;
c) 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);
d) With respect to 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
e) To carry out any program prohibited by section 245(b) of the Health Onmibus Programs Extension Act
of 1988 (codified at 42 USC 300ee(E).
17) Contractor may expend funds paid to Contractor under this Contract only in accordance with federal OMB
Circular A-87 as that circular is applicable to allowable costs.
18) Contractor shall comply with the Pro-Children Act of 1995 (codified at 20 USC Section 6081 et. seq.).
PAGE 10 OF 34 -BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
!
19) The above listed laws, regulations and executive orders and all regulations and administrative rules
established pursuant to those laws are incorporated by reference herein to the extent that they are
applicable to the Contract and required by law to be so incorporated.
20) 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 USC 6901 et. seq.)
Section 6002 of that Act (codified at 42 USC 6962) requires that preference be given in procurement
programs to the purchase of specific products containing recycled material identified in guidelines
developed by the Environmental Protection Agency. Current guidelines are set forth in 40 CFR Parts 247
253.
27. Non-Discrimination. Contractor agrees that no person shall, on the grounds of race, color, creed, national origin,
sex, marital status, disability, association, or age, suffer discrimination in the performance of this Contractor when
employed by Contractor. Contractor agrees to comply with title VI of the Civil Rights Act of 1964, with section Vof
the Rehabilitation Act of 1973 as implemented by 45 CFR Section 84.4, with the Age Discrimination Act of 1975 as
amended, the Age Discrimination Act of 1974 as amended, the Vietnam Era Veterans' Readjustment Assistance Act
of 1975 as amended and with all applicable regulations, administrative rules and requirements of federal and state
civil rights and rehabilitation statues. Additionally, Contractor shall comply with Title II of the Americans with
Disabilities Act of 1990 as amended (42 USC 12131 et. Seq.), ORS 30.670 to 30.685, ORS 659.425, ORS 659.430,
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 conduct of all programs, services and training
associated with services delivered under the Contract. Unless exempted under 41 C.F.R. 60-1.1 to 60.999.1 (1997),
the Contractor agrees to comply with all provisions of Executive Order No. 11,246, 30 F.R. 12319 (1965), as
amended by Executive Order No. 11,375,32 F.R. 14303 (1967), reprinted in 42 U.S.C. 2000e (1994) and Executive
Order No. 12,086, as supplemented by 41 CFR Part 60, and all applicable rules, regulations, and orders of the
Secretary of Labor concerning equal opportunity in employment and the provisions of ORS Chapter 659. Contractor
shall comply with all federal law governing operation of Community Mental Health Programs, including without
limitation, all federal laws requiring the reporting of patient abuse. 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.
28. Reductions in Contract Funding.
A. Any funds spent by Contractor for purposes not authorized by this Contract shall either be paid directly by
the Contractor to the County or, if not so paid, at the discretion of County, shall be deducted from future
payments from County to the Contractor. Payments by County in excess of authorized amounts that have
not been repaid by the Contractor within thirty (30) days after the Contract's expiration or after notification by
the County, whichever date is earlier, shall be deducted from future payments from County to the
Contractor.
B. In the event that a statutorily required operating license or letter of approval is not extended or is 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.
C. Any funds awarded to the Contractor pursuant to a fee-for-service payment method under this Contract that
are not obligated and/or spent within the term of this Contract shall be cancelled and revert to the County.
29. Attorney Fees. In the event an action, suit or proceeding, including appeal there from, is brought for breach of any of
the terms of this Contract, or for any controversy arising out of this Contract, each party shall be responsible for its
own attorney's fees, expenses, costs and disbursements for said action, suit, proceeding or appeal.
30. Entire Contract. This Contract constitutes the entire Contract between the parties on the subject matter hereof.
There are no understandings, Contracts, or representations, oral or written, not specified herein regarding this
Contract.
J
PAGE 11 OF 34 BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
I
31. Survival. The provisions of paragraphs 3 to 12, 17 to 20, 23 to 27, and 29 and 30, shall survive the termination or
expiration of this Contract.
32. 20·Year Dedicated Use. Notwithstanding any other provision of this Contract, Contractor and Hospital
agree that the Sage View facility will for a period of not less than twenty (20) years be operated and
maintained for the principal purpose of providing a psychiatric treatment program for mental health
patients, including indigent mental health patients who are residents of Crook, Deschutes and Jefferson
Counties. This prOVision, as well as the provisions of Section 8, shall survive termination of this Contract.
Dated this ___ of ________, 2012
TAMMY BANEY, County Commissioner
ANTHONY DeBONE, County Commissioner
ALAN UNGER, County Commissioner
,2012.DATEDthiS3~YOf ~
CONTRACTOR:
PAGE 12 OF 34 -BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
EXHIBIT 1
SE24 Funding for Local Acute Care Access
Proposed Plan for 2012-13
Principles:
1. Maintain a shared risk management payment method for Acute Psychiatric Care as outlined in Section 8 of main
body of the Contract.
2. Increase oversight and focus on diversion (when clinically appropriate). Establish process for admission
authorization and utilization management for length of stay that is consistent with fee for service model. Exact
details of process will be determined by mutual agreement of the Directors of Deschutes, Crook and Jefferson
Counties and S1. Charles Health System, Inc. or designees.
3. The approach is regional with all three (3) Central Oregon counties committing to this Contract.
4. Each of the three (3) counties will have designated diversion funds to assist with such things as motels,
transportation, and medication as clinically appropriate,
Bed days:
1. Number -632/year
2. Bed Day Rate -$695/day
Contract for Successful Management of Resources within Risk Agreement:
1. Hospital and Community Mental Health Program (CMHP) staff will follow admission authorization protocol as
outlined in "County Acute Care Authorization" in Exhibit 2 for voluntary and involuntary admissions to Sage
View that fall under this Contract.
2. In order to best facilitate the potential for diversion, Hospital staff will contact the responsible CMHP when
admission is being considered and prior to the subject being given an indication of admission intent. All
admissions, both voluntary and involuntary, must be pre-authorized by the appropriate CMHP crisis staff.
3. CMHP and Hospital staff will actively work on diversion. CMHP staff will access designated diversion funds
when needed through processed outlined in individual counties.
4. Deschutes Crisis team staff will have daily (Monday-Friday) in-person contact with Sage View to participate in
the review of all Deschutes County admissions and assist in discharge planning. Crook and Jefferson county
staff will have daily contact with Sage View via telephone. The Regional Utilization Manager (UM) will attend
team meetings on a weekly basis. The Regional UM will provide authorizations for continued stay based on
clinical necessity for all Central Oregon admissions covered under this Contract. (Same process as for
Individuals participating on the Oregon Health Plan)
5. Protocol for initial authorization and utilization management may be modified during the Contract by written
agreement between and among the Manager of Hospital and the three (3) Central Oregon Directors.
6. For Individuals anticipated to need a long term stay -an Extended Care Management Unit (ECMU) referral
packet will be completed by SCMC staff immediately after an Individual is civilly committed by a judge (Le.
within 1-2 days)
7. MCAT supervisor will continue to work with local law enforcement to improve contact with MCAT prior to a
person being brought to ER -goal will be to divert when possible.
Additional Considerations: In addition to the adjusted payment rate, Contractor agrees to the following additional
considerations:
1. To provide the counties with a financial report showing total revenue and expenses by category (including
salary/benefits, materials and services, capital costs, etc)and the operating deficit for the facility as well as the bed
day rate associated with the Medicare cost report, a financial report will be provided every twelve (12) months at
the Central Oregon Regional Acute Care Committee (CORACC) meeting;
2. To jOintly sponsor training(s) and planning to strengthen the system in its use of beneficial interventions for
suicidal Individuals seeking hospital, crisis or outpatient services;
3. To join with Jefferson, Crook and Deschutes counties in advocating for improvements in the State and Regional
acute care system, with shared advocacy for State reimbursement for the cost of care for indigent Individuals on
the State wait list for long term care;
4. To advocate and offer support for the development of hold room services and hospital diversion options at area
hospitals; and
5. To not charge Central Oregon counties for transport costs between the Psychiatric Emergency Services unit at St.
Charles Health System, Inc., and Sage View.
PAGE 13 OF 34 -BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012·408
EXHIBIT 2
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2012-408
SE24 Funding for Local Acute Care Access
Description of Covered Services & Authorization Process for
Acute Psychiatric Care
Preamble
The Central Oregon Acute Care Region consists of Crook, Deschutes and Jefferson counties operating through Lutheran
Community Services Northwest, Deschutes County Health Services Department and Best Care Treatment Services
respectively.
Within available resources, consistent with ORS 426.241 and Service Element 24, and subject to funding from the Office
of Mental Health and Addiction Services, Counties assume the fiduciary accountability and ethical obligation to meet the
acute care mental health service needs of those Central Oregon residents, who lack the financial resources and I or
insurance to cover payment for such mental health services. In an effort to ensure the judicious use of scarce resources,
this Exhibit defines those urgent mental health services and outlines the processes involved in accessing authorization for
those services rendered under this Contract.
Sage View Services:
Contractor agrees to admit all eligible, indigent Individuals from Crook, Deschutes and Jefferson counties who meet
medical necessity criteria (as defined in this exhibit) as long as Sage View has available bed space. In recognition that
Contractor also provides Psychiatric Emergency Services as outlined in separate contract, it is agreed that Individuals will
receive treatment at the least restrictive level of care possible.
Medical Necessity is defined as follows:
o Individual has a primary DSM-IV mental health diqgnosis AND meets one of more of the following factors
describing the Individual's condition:
o Individual presents as a significant danger as evidenced by person is at imminent risk to self or others or
unable to meet their basic needs due to a major mental illness OR
o Individual is at high risk for self destructive acts secondary to severe psychiatric symptoms (i.e. command
hallucinations or persecutory delusions, severe depression); OR
o Individual is at significant risk of committing violent, aggressive or impulsive acts that can best be explained
as resulting from a severe emotional state or exacerbation of an existing psychiatric condition; OR
o Individual has acute onset of psychosis, severe thought disorganization or deterioration of a chronic psychotic
condition so that the Individual is unmanageable and unable to cooperate in treatment in a less restrictive,
less intensive setting; OR
o Individual needs psychiatric medication adjustment that cannot be managed in the community including
monitored administration of medication; OR
o Individual presents severe functional impairment resulting from an acute psychiatric condition such that the
member is unable to provide for basic self-care without 24-hour supervision; OR
o The Individual's condition is such that proposed treatments require 24 hour nursing observation (ie. side
effects of atypical complexity, presence of a medical condition that complicates psychiatric treatment) which
are not appropriate outside of a hospital setting and are not primarily for a substance abuse or medical
condition. OR
o It is considered likely that the Individual will require restraint or seclusion
o AND in addition to one or more of the criteria outlined above, there are no available less restrictive out-patient
alternatives to provide for the safety and supervision of Individual's needs
Contractor will maintain accreditation from the Joint Commission on the Accreditation of Hospital Organizations as an
inpatient facility. Furthermore, they will maintain compliance with the Center for Medicare and Medicaid Services
standards as applicable.
PAGE 14 OF 34-BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
Services available will include but not be limited to:
• 24 -hour supervision and nursing care.
• Any required health screening or medical care (including medications and lab work).
• Multidisciplinary assessment initiated at the time of admission and completed within two (2) days of admission.
• Service coordination with appropriate CMHP.
• Development of an appropriate treatment plan that addresses service needs, desired outcomes and strategies to
be implemented to resolve the crisis.
• A variety of treatment modalities to meet Individual's needs including: psychiatric assessment; medication
management and supervision; individual and group therapy; psycho-education regarding mental health and
addiction issues; skill development in the areas of self-care, social-emotional adjustment, behavioral concerns,
independent living and community navigation; family involvement; case management.
• Transportation between Sage View and St Charles Hospital -Bend as needed for medical or other services
Payment for Acute Psychiatric Care at Sage View (SV»:
Contractor agrees to the payment methodology outlined in this Contract to provide acute psychiatric care at Sage View to
all indigent Individuals residing in Crook, Deschutes, and Jefferson counties who meet admission criteria, with the only
exception of bed space being unavailable. The payment will cover all charges associated with the admission of indigent
Individuals for Sage View services, including but not limited to room rate, associated staff time and professional fees
(including psychiatrist / MD), psychiatric medications, lab work and medical care. This Contract will include all bed days
excluding day of discharge.
Contractor shall neither bill nor expect payment for any additional services as part of Sage View service and payment
authorization from any of the three (3) counties, except as outlined below under "Annual Reconciliation Based on Actual
Bed Day Usage". County shall provide quarterly payments to Contractor, for rendering the services listed in this Contract.
Funds may only be used for· the delivery of the service or services set out in this Contract unless written permission is
granted to use the funds for other services in accordance with this Contract.
Subject to Annual Payment Reconciliation, for the period between and including July 1, 2012 through June 30, 2013,
Contractor shall receive $439,679 for Sage View services in four (4) quarterly payments as outlined below. The total amount
will cover all Sage View services to all Central Oregon indigent Individuals served during those twelve (12) months.
October 15, 2012 $109,919.75 April 15, 2013 $109.919.75
January 15,2013 $109.919.75 June 30, 2013 $109.919.75
Annual Reconciliation Based on Actual Bed Day Usage:
At the close of the fiscal year (June 30, 2013). three provisions related to a financial reconciliation will be considered to
determine the final payment to St Charles Health System, Inc. Annual bed day usage will be calculated based on fiscal
year July 1-June 30.
1. If the total 2012-2013 bed days under this Contract is less than 632:
The actual number of days under 632 will be valued at the bed day rate for that fiscal year. The dollar amount
of this saVings due to a lower level of service will be shared equally (50%) by both Deschutes County and
Contractor. Contractor will refund amount to Deschutes County equal to 50% value of bed days less than 632.
2. If the total 2012-13 bed days under this Contract is more than 632 and less than 790:
No additional compensation will be expected by either party and the stated payment level will prevail.
3. If the total 2012-13 bed days used under this Contract equal or exceed 790:
County will pay Contractor at the bed day rate for each day at 790 days and above.
PAGE 15 OF 34 -BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
If there are any discrepancies in the number of actual bed days covered under this Contract:
Any discrepancies will be referred to the Utilization Management Committee for resolution utilizing
guidelines of this Contract.
If services are provided without authorization as outlined in Exhibit 2:
Any discrepancies will be brought to the Utilization Management Committee for discussion and resolution.
Process for Obtaining Authorization for Covered Mental Health Services
Authorization Process:
In order to track bed day utilization and assure optimum usage of resources, it is agreed that Contractor and County will
adhere to an admission authorization process that is mutually agreed upon between and among Contractor, the County,
Best Care Treatment Services (on behalf of Jefferson County) and Lutheran Community Services Northwest (on behalf of
Crook County).
Contractor will contact the appropriate county when admission is being considered, and prior to the subject
being given an indication of admission intent, to obtain authorization on all patients who meet indigent status
(both voluntary and involuntary) as outlined by:
1) At the time of admission, patient has no third party insurance and has no ability to pay as defined by
federal guidelines; or
2) At the time of admission, patient has exhausted their Medicare and/or Commercial insurance benefits for
mental health; or
3) During the course of care, patient has exhausted all ability to pay for services under this Contract and is
receiving involuntary treatment. Contractor agrees to contact appropriate county with update regarding
*Pended Patients status and county will authorize services depending upon county continued stay
criteria; or
4) During the course of care if Contractor discovers that at the time of admission, the patient had no third
party insurance as reported and there is no other ability to pay for services, Contractor agrees to contact
appropriate county with update regarding *Pended Patients status and county will decide whether to
authorize services depending upon county continued stay criteria.
5) Contractor agrees to utilize the same ability~to-pay criteria, as well as make the same efforts to collect
payment as for any other patient admitted for hospital services.
6) Contractor is responsible for providing to County a monthly *Pended Patients and **Posted Patients list,
due on the 15th day of each month. The report will include pended and posted patients for all three (3)
counties.
*Pended Patients: This status is descriptive of the period of time the Contractor is engaging in due diligence to
determine the patient's ability to pay as outlined by Contractor guidelines.
"Posted Patients: Patients that have been approved for indigent care through the County.
Report Data from SCMC
Each person admitted under approved indigent funding, must also meet Contractor's internal requirements (as stated
above in Paragraph 6) for "free care" and go through Contractor's process to make this determination. In essence the
patient is "pended" to indigent funding, contingent upon the outcome of Contractor's due diligence process for funding
under this Contract. The following process outlines the approval process for Individuals to be "pended" to indigent
contract as well as the finalization of the list of Individual's bed days that will be actually "paid" or credited to usage under
this Contract.
Upon authorization for admission under indigent funds (pended), the intake worker for SV will notify the Regional UM
Manager (UM) via telephone with the following information: Individual's Name, OOB, Admit Date. Funding, Level of Care
(LOC), Hold Status ELOS (Estimated Length of Stay). UM will then access Hospital EHR for any additional information
needed specific to authorization.
PAGE 16 OF 34 -BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
This Regional LIM wilt utilize this data to compile the Regional Case List Report.
Contractor will provide a monthly list of the posted patients who also have met Contractor's internal requirements for "free
care" and whose admission will be "paid" or credited under this Contract. These lists will be provided by the 15th of each
month and include "free care" Individuals from admissions one month prior (i.e. on 3/15 a report would be provided for
Individuals meeting free care criteria between 1/15-2/15) This report will run off of the admission date (Le. a patient
admitted April 30 and discharged May 5 will show up on April list). The required date by which this list is to be emailed or
faxed allows the "lag time" it takes for internal hospital due diligence for posting cost to the risk based agreements. The
report will contain Protected Health Information, thus must either be faxed or encrypted if sent via e-mail. This report will
go to the Regional LIM. The required data elements in this report will be:
1. Patient Name (last, first)
2. Hospital internal record number
3. Admit date
4. Discharge date
5. Follow-up care
6. location of service PES or SV
Once the Regional LIM has the patient list from Contractor, he/she will access Contractor electronic medical records
(TIER and/or CERNER) to ascertain qualitative data required for the Regional Case List. This Case List will be reviewed
at the monthly Central Oregon Regional Acute Care Committee (CORACC) LIM group meeting. The Regional LIM will
follow established Contractor procedures for access to the Contractor's electronic medical records.
Modification of Exhibit 2
It is understood and agreed that this Exhibit will be revised periodically. Authority to change this Exhibit shall rest with the,
Deschutes County Health Services and the St. Charles Health System, Inc. Community Directors. Both parties must
agree for the Exhibit to be modified.
PAGE 17 OF 34-BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
EXHIBIT 3
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2012-408
SE24 Funding for Local Acute Care Access
Post-Commitment Care
Payment for Post-Commitment Care:
Contractor agrees to the payment methodology outlined in this Contract for post-commitment care at Sage View (SV) or
Psychiatric Emergency Services (PES) at St. Charles Health System, Inc. to all indigent Individuals residing in
Deschutes, Crook or Jefferson ("Central Oregon") counties as well as Individuals who reside in Eastern Oregon counties
who are civilly committed by a judge. Eastern Oregon Counties are defined as: Wasco, Sherman, Hood River, Lake,
Wheeler, Morrow, Harney, Grant, Malheur, Baker, Gilliam, Union, Wallowa, and Umatilla. This includes Individuals who
are already admitted to either SV or PES and return to the facility after civil commitment hearing, as well as Individuals
who are committed elsewhere in the state and are clinically appropriate for transfer post-commitment, with the only
exception of bed space being unavailable. Central Oregon residents have first priority for admission, followed by residents
of Eastern Oregon counties. This portion of the Contract will cover aU services as of the day post-commitment until
transfer to long-term care at the state hospital or other discharge from the facility.
Residents of other Oregon counties may be served under this Contract on a case by case basis and with joint approval of
Director of Behavioral Health Services at Cascade Healthcare Community and Deschutes County Health Services
Director.
The payment will cover all charges associated with the admission of indigent Individuals for SV or PES services, including
but not limited to room rate, associated staff time and professional fees (including psychiatrist I MD), psychiatric
medications, lab work and medical care. This Contract will include all bed days beginning the first day post-commitment
until transfer to long-term care or other discharge
Contractor shall neither bill nor expect payment for any additional services as part of this Contract. County shall provide
monthly payments to Contractor, for rendering the services listed in this Contract. Funds may only be used for the delivery
of the service or services set out in this Contract unless written permission is granted to use the funds for other services in
accordance with this Contract..
For the period between and including July 1, 2012 through June 30, 2013, Contractor shall receive a maximum
compensation of $529,250 for all post-commitment services regardless of whether admission is at SV or PES unit in
twelve (12» payments as outlined below. This payment is calculated at a bed day rate of $725 for 730 bed days. The
total amount will cover all SVIPES services to all post-commitment indigent Individuals served during those twelve (12)
months.
July 15, 2012 $44,104.16 January 15, 2013 $44,104.16
August 15, 2012 $44,104.16 February 15, 2013 $44,104.16
September 15, 2012 $44,104.16 March 15,2013 $44,104.16
October 15,2012 $44,104.16 April 15, 2013 $44,104.16
November 15,2012 $44,104.16 May 15, 2013 $44,104.16
December 15,2012 $44,104.16 June 15, 2013 $44,104.24
PAGE 18 OF 34-BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
Reporting Requirements:
Contractor shall provide monthly reports to the County for all usage under this portion of the Contract. Monthly reports
shall include the following:
Individual's Name
County of Responsibility/Residence
Date of Commitment
Date Extended Care Management Unit (ECMU) application was approved
Date of Discharge
Discharge location (i.e. state hospital or other)
Total bed days for the month
Cumulative bed days
PAGE 19 OF 34 -BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
EXHIBIT 4
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2012-408
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: St. Charles Health Svstem Inc.
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 Employer's Liability Insurance with coverage shall not
be 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
[8J $1,000,000 0 $2,000,000
o $2,000,000 [8J $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.
[8J Re uired b Count 0 Not re uired b Count one box must be checked
Commercial General Liability insurance with a combined single limit of not less than:
Per Single Claimant and Incident All Claimants Arising from Single Incident
[8J $1,000,000 0 $2,000,000
o $2,000,000 t8J $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 named
insured and 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.
The policy shall be endorsed to name Deschutes County, the State of Oregon, the Oregon Health Authority, their
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 insured 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
I of protection allowed by law.
! [8J Required by County 0 Not required by County (one box must be checked)
PAGE 20 OF 34 -BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No. 2012-408
Automobile Liability insurance with a combined single limit of not less than :
Per Occurrence
t $500 ,000
$1 ,000,000 ~
$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 serv ices 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 v/iRitles registered to the business . o Required by County l:8J ~t 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. The Contractor shall notify the County in writing at least thirty (30) days in advanceof 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 respons ible for any deductible or self-insured retention .
If requested, complete copies of insurance policies shall be provided to the County.
PAGE 21 OF 34 -BEHAVIORAL HEALTH -PERSONAL SERVICES CONTRACT No . 2012-408
EXHIBIT 5
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2012-408
Regional Acute Psychiatric Inpatient Services
Service Name: REGIONAL ACUTE PSYCHIATRIC INPATIENT SERVICES
Service 10 Code: MHS 24
I. Service Description
Regional Acute Psychiatric Inpatient Services (MHS 24) are inpatient psychiatric services delivered to
individuals who are suffering from an acute mental illness, or other mental or emotional disturbance posing a
danger to the health and safety of the individual or others. The services are primarily delivered on an inpatient
basis and are intended to stabilize, control or ameliorate acute psychiatric dysfunctional symptoms or behaviors
in order to return the individual to a less restrictive environment at the earliest possible time. MHS 24 Services
also include ancillary services such as regional coordination and enhancements to Community Mental Health
Program (CIVIHP) services that serve to expedite the movement of individuals into and out of facilities where
inpatient psychiatric services are delivered and to divert persons from acute care services.
II. Performance Requirements
MHS 24 Services funded through this Agreement may only be delivered to the following individuals:
A. An individual in need of emergency hold services under ORS 426.232 and ORS 426.233; or
B. An individual committed to Oregon Health Authority (OHA) under ORS 426.130; or
C. An individual voluntarily seeking MHS 24 Services provided that service capacity is available and the
individual satisfies one or more of the following criteria:
1. The individual is at high risk for an emergency hold or civil commitment without voluntary inpatient
psychiatric services; or
2. The individual has a history of psychiatric hospitalization and is beginning to decompensate and for
whom a short period of intensive inpatient psychiatric treatment would reverse the decompensation
process; or
3. The individual is an appropriate candidate for inpatient psychiatric treatment but other inpatient
psychiatric treatment resources are unavailable.
D. Hospital and Providers at Secure Residential Treatment Facilities of MHS 24 Services funded through this
Agreement must comply with OAR 309-031-0200 to 309-031-0255as such rules may be revised from time
to time. Facilities in which a Provider delivers MHS 24 Services funded through this Agreement must:
1. If a hospital, be licensed under ORS 441.015 or certified by the Joint Commission on Accreditation of
Health Care Organization ("JCAHO") for the hospital services; or 134309 Deschutes County Approved
5/9/2011 79 of 220 OHA 11-13 GT0217-11
2. Be approved under applicable portions of OAR 309-033-0500 through 309-033-0560, as such rules may
be revised from time to time, for emergency hold beds.
E. Secured Transportation services under MHS 24 will be approved under OAR 309-033-0432 through 309
033-0440, as such rules may be revised from time to time.
PAGE 22 OF 34 -PERSONAL SERVICES CONTRACT No. 2012-408
III. Special Reporting Requirements
A. Reports of JCAHO reviews of the facility where a Provider delivers MHS 24 Services funded through this
Agreement must be submitted to OHA within sixty (60) days after the Provider's receipt of such reports or
reviews. Submit reports to:
Oregon Health Authority
Addictions and Mental Health Services Division
Attention: Contracts Administrator
500 Summer Street N.E. E86
Salem, OR 97301-1118
Reports must be prepared using forms and procedures prescribed by OHA.
B. Hospital and Providers at Secure Residential Treatment Facilities of MHS 24 Services funded through this
Agreement must submit the following information to OHA electronically through the Oregon Patient and
Resident Care System (OP/RCS) within 12 hours of an individual's admission to and discharge from the
Provider's facility for MHS 24 Services, as outlined in the OP/RCS Manual located at
http://www.oregon.gov/OHNmentalhealth/publications/oprcs/oprcs-manual.pdf?ga=t.
C. Contractor must submit an annual accounting report of MHS 24 funds using forms prescribed by OHA by
August 31 for the prior state fiscal year.
IV. Financial Assistance Calculation and Disbursement Procedures
A. Calculation of Financial Assistance: OHA will provide financial assistance for MHS 24 Services identified in
a particular line of the Financial Assistance Award from funds identified on that line in an amount equal to
the amount set forth in that line of the Financial Assistance Award; provided, however, that OHA's obligation
to provide financial assistance for MHS 24 Services under a particular line of the Financial Assistance
Award is conditioned on delivery, during the period specified on that line, of the number of units of MHS 24
Services service capacity specified on that line
B. Disbursement of financial assistance: OHA will disburse the funds awarded for MHS 24 Services in a
particular line of the Financial Assistance Award to County in substantially equal monthly allotments during
the period specified in that line of the Financial Assistance Award, subject to the following:
1. OHA may after 30 days (unless parties agreed otherwise) written notice to County, reduce the monthly
allotments based on under used allotments identified through 134309 Deschutes County Approved
5/9/2011 80 of 220 OHA 11-13 GT0217-11 Oregon PatienUResident Care System (OP/RCS) or through
other method permitted or required by this Service Description or an applicable Specialized Service
Requirement.
2. OHA may, upon written request of County, adjust monthly allotments.
3. Upon amendment to the Financial ASSistance Award, OHA shall adjust monthly allotments as
necessary, to reflect changes in the funds awarded for MHS 24 Services on that line of the Financial
Assistance Award. 134309 Deschutes County Approved 5/9/2011 81 of 220 OHA 11-13 GT0217 -11
Attachment 1 (revised 'Level of Need Determination Data' 1/2010) -Level of Service IntenSity
Determination Data
Providers of MHS 22 Services funded through this Agreement must use the CAS II as the statewide tool
In order to assist in the determination for ISA Services for children age six (6) and older and the ECSII for
children birth through age five (5).
PAGE 23 OF 34 -PERSONAL SERVICES CONTRACT No. 2012-408
Provider shall submit a report to aHA, within sixty (60) calendar days after the end of each calendar quarter of
the Level of Service Intensity Determination Data screenings completed in that quarter.
o 1st Quarter (Jan-Mar) 0 2nd Quarter (Apr-Jun)
o 3rd Quarter (Jul-Sep) 0 4th Quarter (Oct-Dec)
Formatting CASII and ECSII data for submission to aHA:
Data shall be in a comma-delimited format;
Each child shall be represented by a Medicaid 10 number and Level of Service Intensity Determination Date;
Complete Data Set: A complete data set will be comprised of a minimum of the following elements:
Eight alphanumeric character Medicaid 10 number
o Child's date of birth DO/DO/DODO)
C Child's gender
Date of referral
C Referral Source
[l Date of Determination
Contractor
L Scores for CASH Domains I to VI-B (each score must be in the range 1-5) or ECSII Domains I to V.
c Composite CASII score or ECSII score.
ISA eligibility YIN (circle one).
Levels of Care recommended -(Note: Base the recommended level of care on both CASII or ECSII data and
other data indicative of the child's and family's needs and/or functioning
Date the child is determined not to be ISA eligible or the last day the child is considered ISA eligible. Field will
be blank if the child continues to be ISA eligible. A blank field will be considered complete. Instructions for
submission and validation of Level of Service Intensity Determination Data shall be provided by aHA as a
separate document. 134309 Deschutes County Approved 5/9/2011 82 of 220 aHA 11-13 GT0217 -11
Attachment 2 (revised 'Integrated Service Array' 1/2010) -Integrated Service Array (ISA) Progress
Review Report
The ISA Progress Review is to be administered for each child found eligible for ISA services upon admission
and discharge to that level of service. A child shall be reviewed no less than annually, should the child remain in
ISA longer than one (1) year. Contractor must submit a Complete Data Set to aHA on those children that were
reviewed during the quarter within sixty (60) calendar days following the end of the calendar quarter.
Complete Data Set: A complete data set will be comprised of the following elements:
1. Child's last name, first name.
2. Child's date of birth (~O/~O/~O~O).
3. Date ISA Progress Review was completed using 0010010000 format.
4. ISA status of child at time of progress review:
"New", first review.
"Open", continuing review.
"Close", final review.
5. Child's current residence:
Biological/adoptive family member.
Other than relative/friend (Not foster care).
Long-term foster care placement.
Temporary foster care placement.
Residential treatment center.
Other (include statement describing type of residence).
6. Number of times child changed residence for any reason within the last 90 days.
a. Indicate the number of times that the child has changed residence, for any reason, in the past 90
calendar days. Do not include planned respite. Do not include Acute Care hospitalizations. Do not
include vacations or recreational stays with friends or relatives that are unrelated to changes in the
child's condition or the Family's circumstances. Do include any planned or unplanned stay with friends
PAGE 24 OF 34 -PERSONAL SERVICES CONTRACT No. 2012-408
or relatives, if the stay lasted more than seven (7) days and was: (a) precipitated by a worsening of the
child's condition, a change in the Family's circumstances, or increased stress in the child's environment
and; (b) the parent or legal guardian was made aware of and permitted the stay. (Note: Unplanned
stays with others not permitted by the parent or legal guardian should be regarded as runaways rather
than changes of residence). Each time that a child moves out of and then back to, his or her primary
residence is counted as two (2) moves.
b. Parent or legal guardian were made aware of and permitted to stay. Each time that a child moves out of
and back to hislher primary residence, count as two (2) stays. 134309 Deschutes County Approved
5/9/2011 83 of 220 OHA 11-13 GT0217 -11.
7. Did parent or adult caregiver participate in current and most recent Child and Family Team (CFT) meeting?
(Include those whose primary role with child is that of paid provider of services, i.e. clinical, educational or case
management services.)
8. Caregiver Rating:
a. Social network over the past thirty (30) calendar days:
(1) No family or social network that could help with raising the child.
(2) Some family or friend social network that could help with raising the child.
(3) Some family or friend social network that actively helps with the raising of the child.
(4) Significant family and friend social network that actively helps with raising the child.
(5) NK (Not Known).
b. Child has been producing schoolwork of acceptable quality for his or her ability level over the past
twenty (20) scheduled school days:
(1) Never.
(2) Seldom.
(3) Sometimes.
(4) Frequently.
(5) Very Frequently or Always.
(6) Not applicable (if child has not been in school over past 20 days).
c. Substance abuse over the past thirty (30) days:
O. None.
1. Suspicion of substance abuse.
2. Clear evidence of substance abuse that is interfering with child's ability to function in at least one role
or setting.
3. Clear evidence of substance dependence and lor child requires detoxification.
d. Risk of delinquency in consideration of all acts of delinquency (misdemeanors, felonies and all status
offenses except runaways), with or without awareness by legal authorities:
O. No History.
1. None in past thirty (30) days.
2. Some in past thirty (30) days.
3. Several in past thirty (30) days.
e. Risk of self-harm (includes reckless or intentional risk taking behavior that may endanger the child):
O. No history.
1. None in past thirty (30) days.
2. Some in past thirty (30) days.
3. Several in past thirty (30) days.
f. History of and risk of danger to others:
O. No history.
1. None in past thirty (30) days. 134309 Deschutes County Approved 5/9/2011 84 of 220 OHA 11-13 GT0217-11
2. Some in past thirty (30) days.
PAGE 25 OF 34 -PERSONAL SERVICES CONTRACT No. 2012-408
g. History and risk of running away:
O. No history.
1. None in past thirty days.
2. Some in past thirty (30) days.
3. Several in past thirty (30) days.
9. Behavioral and Emotional Rating Scale, 2nd Edition (Bers2) Parent/Caregiver Rating Scale, Raw Scores of
Subscales.
Formatting the ISA Progress Review Data for Submission to OHA:
Instructions for submission of the ISA Progress Review Report data shall be provided by OHA as a separate document.
Modification of Exhibit 5, State Requirements for Mental Health Subcontract
In the event the State of Oregon modifies the terms of SE 24, it is understood that this Contract will be revised
accordingly. Authority to change this Exhibit to comply fully with Deschutes County's State Contract shall rest with the
Director of Behavioral Health Services, St. Charles Medical Center and the Deschutes County Health Services Director.
Both parties must agree for the Exhibit to be modified.
PAGE 26 OF 34 -PERSONAL SERVICES CONTRACT No. 2012-408
Exhibit 6
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2012-408
Compliance with provisions, requirements of funding source and
Federal and State laws, statutes, rules, regulations, executive orders and policies.
Conflicts of Interest
Contractor certifies under penalty of perjury that the following statements are true to the best of
Contractor's knowledge:
1. If Contractor is currently performing work for the County, State of Oregon or federal government, Contractor
by signature to this Contract declares certifies that; Contractor's Work to be performed under this Contract
create no potential or actual conflict of interest as defined by ORS 244 and no rules or regulations of
Contractor's employee agency (County State or Federal) would prohibit Contractors Work under this
Contract. Contractor is not an "officer," "employee," or "agent" of the County, as those terms are used in
ORS 30.265.
2. Audits.
a. Contractor shall comply, if applicable, with the applicable audit requirements and responsibilities set
forth in the Office of Management and Budget Circular A-133 entitled "Audits of States, Local
Governments and Non-Profit Organizations."
b. Contractor shall also be required to comply with applicable Code of Federal Regulations (CFR)
sections and OMB Circulars governing expenditure of federal funds. State, local and Indian Tribal
Governments and governmental hospitals must follow OMB A-102. Non-profits, hospitals, colleges and
universities must follow 2 CFR Part 215. Sub-recipients shall be required to monitor any organization to
which funds are passed for compliance with CFR and OMB requirements.
3. No federally appropriated funds have been paid or shall be paid, by or on behalf of Contractor, 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
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.
a. If any funds other than federally appropriated funds have been paid or shall 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, Contractor agrees to complete and submit
Standard Form-LLL "Disclosure Form to Report Lobbying," in accordance with its instructions.
1) Standard Form-LLL and instructions are located in 45 CFR Part 93 Appendix B.
2) If instructions require filing the form with the applicable federal entity, Contractor shall then as a
material condition of this Contract also file a copy of the Standard Form-LLL with the Oregon Health
Authority.
3) This filing shall occur at the same time as the filing in accordance with the instructions.
b. Contractor understands this certification is a material representation of fact upon which the County and
the Oregon Health Authority has relied in entering into this Contract. Contractor further understands that
submission of this certification is a prerequisite, imposed by 31 USC 1352 for entering into this Contract.
c. Any person who fails 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.
d. Contractor shall include the language of this certification in the award documents for all sub-awards at
all tiers (including subcontracts, sub-grants, and contracts under grants, loans and cooperative
agreements) and that all sub-recipients shall certify and disclose accordingly.
e. Contractor is solely responsible for all liability arising from a failure by Contractor to comply with the
terms of this certification.
f. Contractor promises to indemnify County for any damages suffered by County as a result of
Contractor's failure to comply with the terms of this certification.
PAGE 27 OF 34 -BEHAVIORAL HEALTH SERVICES CONTRACT No. 2012-408
4. Contractor understands that, if this Contract involves federally appropriated funds, this certification is a
material representation of facts upon which reliance was placed when this Contract was made or entered
into, submission of this certification is a prerequisite for make or entering into this Contract imposed by
Section 1352, Title 311, U.S. Code and that any person who fails 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 failure.
~t:!~Da7/5/t;L
PAGE 28 OF 34 -BEHAVIORAL HEALTH SERVICES CONTRACT No. 2012-408
EXHIBIT 7
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2012-408
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 Agreement, the following terms shall apply:
A. Contractor shall be considered a Contractor;
B. County shall be considered a COVERED ENTITY;
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;
F. Information shall mean any health information provided and/or made available by County to
Contractor, and has the same meaning as the term 'health information' as defined by 45 C.F.R.
160.102.
Contractor agrees it shall:
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
document or information relating to the County, its members or to Individuals seeking services from
County or its members without the prior written consent or authorization of the County or of the
Individual. 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 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 29 OF 34 BEHAVIORAL HEALTH SERVICES CONTRACT No. 2012-408
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 Agreement, 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 agreement 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 Agreement, 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.
PAGE 30 OF 34 -BEHAVIORAL HEALTH SERVICES CONTRACT No. 2012-408
Exhibit 8
DESCHUTES COUNTY SERVICES CONTRACT
Contract No. 2012-408
REQUIRED PROVIDER CONTRACT PROVISIONS
Oregon Health Authority Exhibit H of 2011-2013 Intergovernmental Agreement #134309
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 USC 300ee(5).
d. Contractor may expend funds paid to Contractor under this Contact only in accordance with federal
OMB Circular A-8? 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 31 OF 34 -BEHAVIORAL HEALTH SERVICES CONTRACT No. 2012-408
d. Individual Records. Unless otherwise specified in this Contract, Contractor shall create and
maintain an Individual record for each Individual who receives services under this Contract. The
Individual record must contain:
(1) Individual identification;
(2) Problem assessment;
(3) Services and supports, training and/or care plan;
(4) Medical information when appropriate; and
(5) Service notes including service conclusion summary and current assessment or evaluation
instrument as designated by the Oregon Health Authority in 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.
e. Safeguarding of Individual Information. Contractor shall maintain the confidentiality of Individual
records 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 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. CPMS Enrollment (If Applicable to Contract). As specified in the Oregon Health Authority's Client
Process Monitoring System ("CPMS") manual (for Alcohol, Drug Abuse and Addiction Services or
Mental Health Services, as appropriate), Contractor shall enroll in CPMS, each Individual receiving a
service under this Contract and maintain that Individual's CPMS record as specified in the CPMS
manual available at http://www.oregon.gov/OHNmentalhealth/publications/main.shtml
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 a 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 a 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" 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.
PAGE 32 OF 34 -BEHAVIORAL HEALTH SERVICES CONTRACT No. 2012-408
b. All additional information and reports that County or the Oregon Health Authority reasonably
requests.
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
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) all applicable requirements of state civil rights and rehabilitation statutes, rules and regulations;
(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;
(c) all state laws requiring reporting of Individual abuse; (d) ORS 659A.400 to 659A.409, ORS
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
conduct of all programs, services and training associated with the delivery of services under this
Contract. 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
employers, 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,
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 G to the certain 2011
2013 Intergovernmental Agreement for the Financing of Community Addictions and Mental Health
Services between County and the Oregon Health Authority dated as of July 1, 2011, 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 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.
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 I of the certain 2011-2013
Intergovernmental Agreement for the Financing of Community Addictions and Mental Health Services
between County and the Oregon Health Authority dated as of July 1, 2011, which Exhibit is incorporated
herein by this reference.
PAGE 33 OF 34 -BEHAVIORAL HEALTH SERVICES CONTRACT No. 2012-408
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 against 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 10, in substantially the form set forth above, in all permitted
Contractor contracts under this Contract.
Datef/3/(J.-Signa~h1~tI.jrvl'n~
Contractor: /
PAGE 34 OF 34 -BEHAVIORAL HEALTH SERVICES CONTRACT No. 2012-408
~ DA"IE (MM/DlJYYY)ACORD·
~ CERTIFICATE OF LIABILITY INSURANCE I 07/10/2012
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOS NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE
OR PRODUER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the
terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER ~O:~CT I Candy Mirabillo
CHIVAROLI & ASSOCIATES INC ~371.3680 I i~ Not I 805.371.3684
200 N Westlake Blvd Ste 101 dvmliVchivaroli.com
Westlake Village, CA 91362
INSURER(S) AFFORDINJ COVERAGE HAIC# ~ERA: LexinQton Insurance Company 19437
INSURED ERB:
st. Charles Health System, Inc INSURERC:
2500 NE Neff Rd INSURERD:
Bend, OR 97701 INSURERE:
INSURERF:
COVERAGES CERTIFICATE NUMBER' REVISION NUMBER'
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BEL.OW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDiCATED.
NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED
OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN RE DUCED BY PAID CLAIMS.
THE INSURED HAS A LIMIT AS INDICATED BELOW, EXCESS OF A $500 000 SEL.F INSURED RETENTION APPLICABLE TO EACH AND EVERY CLAIM.
INSR AOOL SU~~ POUCYEFF POLICYEXP
LTR TYPE OF INSURANCE INSR VWO POLICY NUMBER {MMIOOlYYYYI (MMlOOIYYYYJ LIMITS
GENERAL UABIUTY EACH OCCURENCE $1,000,000I-DAMAGE TO RENTEDX COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ ex ~CLAIMS MADE D OCCUR MED EXP (Anyone person) $
A t 6792944 07/01/2012 07/01/2013 PERSONAL & ADV INJURY $
GENERAL AGGREGATE $3,000,000
roeN'l AGGREGATE LIMIT APPLIES PER: PRODUCTS -CQMPIOP AGG $!xl POLICY n ~:& n LOC
AUTOMOBILE UABILITY COMBINED SINGLE LIMIT $(Ea aoodent) ~ANY AUTO BODILY INJURY (per pe",on) $
I-ALLOJVNEO ,..... SCHEDULED
AUTOS AUTOS BODilY INJURY (Per accidenl) $
I-'-NON.QII\A'lED PROPERTY OAMi'GEHIREOAUTOS AUTOS (Per accident) $
c-
UMBRELLA UAB HOCCUR : EACH OCCURENCE $
I-EXCESS LIAS CLAIMS·MADE AGGREGATE $
OED I I RETENTION $
OORKERS COMPENSATION AND I we STATUI 10TH . $EMPLOYERS' UABILITY TORYUMITS ER
AXY PROPRIETORIPARTNERIE)(fCUTIVEi E.l. EACH ACCIDENT $OFFICERIMEMBCR E)CLUDEO? NIA
,Mandatory in NH) E.L DISEASE -EA MPlOYEE $.' yes, describe under DESCRIPTION OF OPERAnONS bdow E.L DISEASE -POLICY LIMIT $
A
Claims-Made 6792944 07/0112012 07/01/2013 $1,000,000 Each Claim
Professional Liability Insurance $3,000,000 Annual Aggregate
DES;RIPllON OF OPERA llONS IlOCA liONS I VEHICLES (AttacIlACORD 101. Additional Remarks Schedule,lf more space i. required)
Evidence of Professional and General liability insurance as resepcts Sage View Center.
The State of Oregon, Human Resources Department, Deschutes County, its divisions, employees, volunteers are inCluded as Additional
Insureds as their interests may appear.
CERTIFICATE HOLDER
I
I
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THEDeschutes County Health Services EXPIRATION DATE THEREOF, NOTICE WIL.L BE DELIVERED IN ACCORDANCE WITH
2577 NE Courtney Dr THE POLICY PROVISIONS.
Bend, OR 97701
ACORD 25 (2010/05)
I
ENDORSEMENT NO.1 6
ThIs endorsement, effectiVe 12:01 AM: July 1. 2011
Forms a part of policy no.: 6792944
Issued to: ST CHARLES HEALTH SYSTEM, INC.
Sy: LEXINGTON INSURANCE COMPANY
ADDrTIONAL INSUREDS ENDORSEMENT
The Po/icy is amended as follows:
Section II. WHO IS AN INSURED of the EXCESS HEALTHCARE PROFESSIONAL LJABIUTY COVERAGE
PART is amended by adding the following:
Deschutes County, its divisions. Officers. agents, employees and volunteers are
included as additional insureds. but only as respects any contract or agreement
with you.
but only as respects liability ariSing out of the conduct of your business.
Section II. WHO IS AN INSURED of the HEAL THCARE UMBRELLA COVERAGE PART is amended by adding
the following:
Deschutes County, its divisions. officers, agents, employees and volunteers are
included as additional insureds, but only as respects any contract or agreement
with you.
but only as respects liabmty arising out of the conduct of your buSiness.
AI! other terms, conditions and exclusions of the policy remain unchanged.
Authorized Representative
or countersignature (where required by law)
94487 (5/07)
HC0511