HomeMy WebLinkAboutDoc 012 - Agrmt - St. Charles - Health SvcsDeschutes County Board of Commissioners
1300 NW Wall St., Suite 200, Bend, OR 97701-1960
(541) 388-6570 - Fax (541) 385-3202 - www.deschutes.org
AGENDA REQUEST & STAFF REPORT
For Board Business Meeting of January 26, 2011
DATE: January 11, 2011
FROM: Lori Hill, Adult Treatment Program Manager
Nancy England, Contract Specialist Phone: 322-7516
TITLE OF AGENDA ITEM:
Consideration of Board Signature of Document #2011-012, Agreement between St. Charles Healthcare
Community, Inc. and Deschutes County Health Services (DCHS).
PUBLIC HEARING ON THIS DATE? No
BACKGROUND AND POLICY IMPLICATIONS:
St. Charles Healthcare Community, Inc. operates a facility that can serve up to fifteen 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. These services are intended 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 who are 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 $380,165 for acute psychiatric care services and $529,250 for post -commitment
care services.
RECOMMENDATION & ACTION REQUESTED:
Behavioral Health requests approval and signature.
ATTENDANCE: Lori Hill, Adult Treatment Supervisor & Nancy England, Contract Specialist
DISTRIBUTION OF DOCUMENTS:
Executed copies to: Nancy England, 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.)
Date:
Please complete all sections above the Official Review line.
December 28, 2010
Department:
[Deschutes County Health Services, Behavioral Health
Contractor/Supplier/Consultant Name:
Contractor Contact:
Type of Document:
St. Charles Healthcare Community, Inc.
Robin Henderson
Contractor Phone #:
Personal Services Contract.
541-706-2791
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 Healthcare Community, 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 its clients. 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 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 clients who are already admitted and return to the
facility after a civil commitment hearing. This service includes professional staff time
(psychiatrist/MD), 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, 2010
Ending Date:
June 30, 2011`
Annual Value or Total Payment: p80,165 for acute psychiatric care anci
$529, 250 for post -commitment carel
® Insurance Certificate Received (check box)
Insurance Expiration Date:
July 1, 2011
17rMr')11111
For Recording Stamp Only
DESCHUTES COUNTY SERVICES CONTRACT
CONTRACT NO. 2011-012
This Agreement (the "Agreement") 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 Healthcare Community, 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 mental health clients, 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 clients and/or 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 State of
Oregon, Department of Human Services ("Department") 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, 2010 and, except as otherwise specifically
provided herein, shall expire on June 30, 2011 unless earlier terminated or renewed by agreement
of the parties.
2. Contractor's Services. This Contract will cover services as outlined below for: Acute Psychiatric
Care
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 State of Oregon Department of
PAGE 1 OF 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT NO. 2011-012
13C-2011-012
Check all that apply:
❑ RFP, Solicitation or Bid Process
❑ Informal quotes (<$150K)
® Exempt from RFP, Solicitation or Bid Process (specify — see DCC §2.37)
Funding Source: (Included in current budget? ® Yes ❑ No
If No, has budget amendment been submitted? ❑ Yes ❑ No
Departmental Contact:
Title:
Scott Johnson
Health Services Director
Department Director Approval:
Signatu -
Phone #:
322-7502
D 30,10
Date
Distribution of Document: Include complete information if document is to be mailed.
Official Review:
County Signature Required (check one): 0 BOCC ❑ Department Director (if <$25K)
❑ Administrator (if >$25K but <150K, . >$150K, BOCC Order No. )
r
Legal Review
Document Number O(; .2011 0 1
Date (- /O- //
12/28/2010
Human Services (Department). 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 7 and Exhibits 1 and 2 to provide service to all indigent
clients residing in Crook, Deschutes, and Jefferson Counties who meet admission criteria
as defined in Exhibit 2. Contractor agrees to maintain this arrangement for the remainder
of 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 client 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 State of Oregon Department of Human Services
(Department). Services shall be financed in accordance with a schedule contained in
Exhibit 3. For the period of July 1, 2010 — June, 30, 2011, Contractor agrees to the
payment methodology outlined in Section 7 and Exhibit 3 to provide post -commitment
service to all indigent clients residing in Central and Eastem Oregon Counties as defined
in Exhibit 3. Any services funded beyond June 30, 2011, if approved, would be made by
separate amendment to this Contract.
c.
3. Regulations and Duties. Contactor shall comply with all applicable provisions of the annual County
Financial Assistance Contract, including applicable Service Descriptions attached thereto, in place
at the time this Contract is executed and effective July 1, of each biennium between the Department
and Deschutes County, as the same may be amended 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 Department, incorporated herein by reference, as of the effective
date of such regulations, applicable provisions of the Administrative Rules and Procedures of the
Department, 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 Department, which, by the nature of this Contract, County
determines to be within the scope of this Agreement 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 agrees to prepare and furnish such reports and data as may be required by the
Department, including but not limited, to financial reports documenting all expenditures of
funds under this Contract in accordance with generally accepted accounting rules and
procedures, client records which contain client identification, problem assessment,
treatment (including any training and/or care plan), appropriate medical information, and
progress notes, including a servioe termination summary and current assessment or
evaluation instrument as designated in the administrative rules. Department Client Process
Monitoring System (CPMS) data shall be completed in accordance with Department
requirements and submitted to Department. Contractor agrees to, and does hereby grant
County and the Department the right to reproduce, use and disclose for County or
Department purposes, all or any part of the reports, data, and technical information
furnished to County under this Contract. Contractor shall make available to County,
Department and any client of Contractor any and all written materials in altemate formats in
compliance with Department's policies or administrative rules. For purposes of the
foregoing, "written materials" includes, without limitation, all work product and contracts
related to this Contract.
B. Access to Records and Facilities. Department, 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 financial assistance provided hereunder, or any Service for the purpose
PAGE 2 OF 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
of making audits, examinations, excerpts, copies and transcriptions. Contractor shall
permit, authorized representatives of Department to perform site review of all Services
delivered by County or a Provider.
C. Reporting Requirements. Contractor shall prepare and fumish the following information to
Department when a Service is delivered:
1. Client, Service and financial information as specified in the Service Description and
other Exhibits.
2. All additional information and reports that Department or County reasonably requests
that are applicable to the services provided to covered patients.
5. Confidentiality and HIPAA Compliance.. The parties shall comply with the terms of Exhibit
6 concerning Protected Health Information, as well as the Health Insurance Portability and Accountability
Act (the "Act") and the federal regulations implementing the Act (collectively referred to as HIPAA).
6. County Monitoring and Site Visits. Contractor agrees that services provided under this
Contract by Contractor, facilities used in conjunction with such services, client 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 lime during business hours. Contractor agrees to retain such records and
documents for a period of seven (7) 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.
7. 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, 2010 through June 30, 2011, Contractor shall receive
$ 4-65 in four quarterly payments (Exhibit 2) from County for Acute Psychiatric Care
services to all indigent clients served during those twelve months. This payment
arrangement for 2010-11 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 Agreement.
Notwithstanding the foregoing, for the period between and including July 1, 2010 through
June 30, 2011, Contractor shall receive no more than $529,250 in 12 monthly payments
(Exhibit 3) from County for Post -Commitment services to all indigent clients as defined in
Exhibit 3 served during those twelve months. This payment arrangement for 2010-11
PAGE 3 OF 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT NO. 2011-012
requires Contractor adhere to the conditions outlined in Exhibit 3 for all services
described in this Contract
8. Bed Day Rate.
a. Acute Psychiatric Care:
For the purpose of this Agreement for Acute Psychiatric Care and extensions or
renewals of this Contract, the Contractor and the County have established a Bed Day
Rate to assist in calculating future payments if both parties discontinue the heretofore
described method of calculating compensation payable to Contractor and replace the
same with a fee-for-service payment method. This calculation is based on a 2010-11
bed day rate of J$. 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 Department for continued services. This
calculation is based on a 2010-11 bed day rate of $725. This Bed Day Rate will not
affect payment or service levels for the 2010-11 service period.
9. Payments in Future Years beyond June 30, 2011. Not later than April 2011, the affected
parties shall meet to review the Contract and negotiate the program and reporting requirements, protocols
and payment to be paid by County to Contractor beginning July 1, 2011. The parties may at that time also
negotiate payment methods and amounts for one or more years after fiscal year 2010-11.
The County shall fumish Contractor with relevant information concerning Department 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.
10. 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 2-3 names of people acceptable as mediator to the Presiding Judge of Deschutes County, 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.
PAGE 4 OF 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
11. 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 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.
12. 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) are not in excess of 100% of the maximum amount detailed in Exhibit 2. In the event the parties
convert to a fee-for-service method of payment any County funds spent for purposes not authorized by this
Contract shall be deducted from payments or refunded to County, at County's option. Payments by County
under a fee-for-service method in excess of authorized actual expenditures shall be deducted from
payment or refunded to County no later than thirty (30) days after the expiration of this Contract If
Contractor fails to provide an acceptable audit performed by a certified public accountant for federal funds
received under this Contract, or if federal authorities demand the repayment of federal funds received
under this Contract, County may recover all federal funds paid under this Agreement, unless a smaller
amount is disallowed or demanded. It Department disallows or requests repayment for any funds paid
under this Agreement 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 days of
notification by County or the Department of said determination by the Department.
13. 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 Department, 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
Department.
14. 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.
15. 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 5 OF 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
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 clients, 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 clients.
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) client(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 Department 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.
16. 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.
17. jndependent 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 6 OF 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT NO. 2011-012
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, Department or State of Oregon, and County, Department 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 Contractor's 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
18. 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.
19. Constraints.
A. The Provisions of ORS 2798.220, 279B.230, and 279B.235, are by this reference
incorporate and made a part of this Contract
1. 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.0 201 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.
PAGE 7 OF 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
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.
D. If the limitation amount specified in this Agreement 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 Department, 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.
20. 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 Agreement 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.
21. 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.
PAGE 8 OF 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
22. 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
23. 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 Govemments and Non -
Profit Organizations.'
24. Assignment Contractor shall not assign this Contract, except to Hospital, without the prior
written consent of County.
25. Renews . This Contract may be renewed, subject to the following conditions: (1) renewal will
be based on the County Annual Implementation Plan approved by the Department, and (2) renewal is
subject to the availability of funding.
26. Additional Federal Law Compliance Requirements.
A. Contractor shall comply with all applicable federal, state and local laws, administrative
rules, ordinances and regulations including but not limited to the following:
i. Contractor must comply with OAR 309-032-0850 through 309-032-0890, as such
rules may be revised from time to time
ii. Contractor must maintain approval 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 for persons in custody, committed persons, or persons on
diversion
iii. Contractor must submit reports of Joint Commission on Accreditation of Health
Care Organizations (JCAHO) reviews of the facility to State of Oregon Addictions
and Mental Health Division within 60 days after Contractor's receipt of such reports
or reviews.
iv. Contractor must submit admission and discharge information to Addictions and
Mental Health Division through the Oregon Patient and Resident Care System
(OP/RCS) within 12 hours of admission and discharge.
B. 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 fumishing of items or Services for
which payments may be made by Department.
C. To the extent Contractor provides any service whose costs are paid in whole or in part by
Medicaid, Contractor shall comply with the federal and state Medicaid statutes and
regulations applicable to the service, including but not limited to:
1. Keep such records as may be necessary to disclose the extent of services fumished to
clients and, upon request, fumish such records or other information to the Department,
the Medicaid fraud section of the Oregon Department of Justice and the Secretary of
Health and Human Services;
2. Comply with all applicable disclosure requirements set forth in 42 CFR Part 455,
Subpart B;
3. Comply with any, applicable advance directive requirements specified in 42 CFR
Section 431.107(b)(4); and
4. Comply with the certification requirements of 42 CFR Sections 455.18 and 455.19.
D. Prohibitions Against Lobbying.
PAGE 9 OF 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT NO. 2011-012
1. Contractor, or any person, firm or corporation acting on behalf of Contractor, certifies
that no funds paid under this Contractor will be used to influence or attempt to influence
an officer or employee of any agency, a Member of Congress, an officer or employee
of Congress, or any 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.
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 V of 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 11 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 conceming 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 Client 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.
PAGE 10 OF 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
30. Entire Agreement 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 Agreement.
31. Survive(. 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. 30 -Yea' Derlwaeed Use,
Notwithstancfing any other provision of this Contract, Contractor and Hospital agree that the
Sage Wm facility wW for a period of not loss than twenty (20) priors be operated and maintained for
the pdnpal purpose of providing a psychiatric treabnent program for mental health patients,
induding huligent mental health patients who we residents of Crook, Deschutes and Jefferson
Counties. This provision, as well as the provisions of Section 3, shall survive termination of this
Contract
DATED this day of , 2011.
DAVE KANNER Deschutes County Administrator
'7.
DATED this '3 E-pday of , 2011.
5tiv-t
CONTRACTOR (/ St. Charles Hea , Ins.
PGE 11 OF 26— BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
EXHIBIT 1
SE24 Funding for Local Acute Care Access
Sage View contract
Proposed Plan for 2010-11
Principles:
1. Maintain a shared risk management payment method for Acute Psychiatric Care as outlined in
Section 7 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 St. Charles Healthcare Community 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,
Agreement 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 client 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 (weekdays) 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 Oregon Health Plan clients)
5. Protocol for initial authorization and utilization management may be modified during the
Contract by written agreement between the Manager of Hospital and the three (3) Central
Oregon Directors.
6. For clients anticipated to need a long term stay — an Extended Care Management Unit
(ECMU) referral packet will be completed by SCMC staff immediately after a client is civilly
committed by a judge (i.e. within 1-2 days)
7. County will work with Accountable Behavioral Health Alliance (ABHA) to provide continued
training and consultation in Acceptance Commitment Therapy (ACT) model for both County
and Hospital staff
8. 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:
PAGE 12 of 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
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 6 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 clients 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 clients 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 Medical Center and Sage View.
PAGE 13 OF 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
EXHIBIT 2
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 / 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 clients 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 clients will receive treatment at the least restrictive level of care possible.
Medical Necessity is defined as follows:
o Client has a primary DSM -IV mental health diagnosis AND meets one of more of the following
factors describing the clients condition:
o Client 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 Client is at high risk for self destructive acts secondary to severe psychiatric symptoms (i.e.
command hallucinations or persecutory delusions, severe depression); OR
o Client 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 Client has acute onset of psychosis, severe thought disorganization or deterioration of a
chronic psychotic condition so that the client is unmanageable and unable to cooperate in
treatment in a less restrictive, less intensive setting; OR
o Client needs psychiatric medication adjustment that cannot be managed in the community
including monitored administration of medication; OR
o Client 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 client'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 client 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 altematives to provide for the safety and supervision of client 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 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
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) clays
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 client 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 clients 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 clients 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 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, 2010 through June
30, 2011, Contractor shall receive $380:65 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 clients
served during those 12 months.
October 15, 2010 $95,041.25 April 15, 2011 $95,041.25
January 15, 2011 $95,041.25
June 30, 2011 $95,041.25
Annual Reconciliation Based on Actual Bed Day Usage:
At the close of the fiscal year (June 30, 2011), three provisions related to a financial reconciliation will be
considered to determine the final payment to St Charles Healthcare Community. Annual bed day usage
will be calculated based on fiscal year July 1 -June 30.
1. If the total 2010-2011 bed days under this Contract is less than 547:
PAGE 15 OF 26 - BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT NO. 2011-012
The actual number of days under 547 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 Tess than 547.
2. If the total 2010-11 bed days under this Contract is more than 547 and Tess than 683:
No additional compensation will be expected by either party and the stated payment level
will prevail.
3. If the total 2010-11 bed days used under this Contract equal or exceed 683:
County will pay Contractor at the bed day rate for each day.
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, BestCare 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
client 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
Agreement and is receiving involuntary treatment. Contractor agrees to contact
appropriate county with update regarding *fended 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 *fended 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 3 counties.
*fended 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.
PAGE 16 OF 26 - BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
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 clients to be upended' to indigent contract as well as the finalization of
the list of client 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: Client Name, DOB, 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. .
This Regional UM will 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 intemal
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' clients from admissions one month
prior (i.e. on 3115 a report would be provided for clients meeting free care criteria between 1115-2115) This
report will run off of the admission date (i.e. 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 UM. 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 UM has the patient list from Contractor, he/she will be 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) UM group meeting. The Regional UM 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 Healthcare Community
Directors. Both parties must agree for the Exhibit to be modified.
PAGE 17 OF 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
EXHIBIT 3
Description of Services and Reporting Process for
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 Medical Center to all indigent
clients residing in Deschutes, Crook or Jefferson ("Central Oregon") counties as well as clients who reside
in Eastem 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 clients who are already admitted to either SV or PES and
return to the facility after civil commitment hearing, as well as clients 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
Eastem Oregon counties. This portion of the Contract will cover all 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 clients for SV or PES
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 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 ContractAgreement.
For the period between and including July 1, 2010 through June 30, 2011, 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 SV/PES services to all post -commitment
indigent clients served during those 12 months.
July 15, 2010 $44,104.16 January 15, 2011 $44,104.16
August 15, 2010 $44,104.16 February 15, 2011 $44,104.16
September 15, 2010 $44,104,16 March 15, 2011 $44,104,16
October 15, 2010 $44,104,16 April 15, 2011 $44,104,16
November 15, 2010 $44,104.16 May 15, 2011 $44,104.16
December 15, 2010 $44,104.16 June 15, 2011 $44,104.16
PAGE 18 OF 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
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:
Client 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 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
EXHIBIT 4
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 Systems, 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. Employer's Liability Insurance with coverage limits of not less than $500,000 must be
included.
Professional Liability insurance with an occurrence combined single limit of not less than:
Per Occurrence limit Annual Aggregate limit
❑ $500,000 0 $500,000
pif $1,000,000 0 $1,000,000
0 $2,000,000 cs, $2,000,000
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.
Required by County
❑ Not required by County (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
pi. Oregon Tort Claims Act limits Oregon Tort Claims Act limits
0 $1,000,000 $2,000,000
0 $2,000,000 0 $3,000,000
Commercial General Liability insurance includes coverage for personal injury, bodily injury, advertising
injury, property damage, premises, operations, products, completed operations and contractual liability.
The Oregon Legislature has adopted legislation which establishes tort claims limits for actions against local
public bodies, including their officers, agents and employees. The tort claims act limits are automatically
adjusted on July 1 every year.
The policy shall be endorsed to name Deschutes County, its 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.
Required by County 0 Not required by County (One box must be checked)
PAGE 20 OF 26 — BEHAVIORAL HEALTH - PERSONAL SERVICES CONTRACT No. 2011-012
Automobile Liability insurance with a combined single limit of not less than:
Per Occurrence
❑ $500,000
❑ $1,000,000
O $2,000,000
Automobile Liability insurance includes coverage for bodily injury and property damage resulting from
operation of a motor vehicle. Commercial Automobile Liability Insurance shall provide coverage for any
motor vehicle (symbol 1 on some insurance certificates) driven by or on behalf of Contractor during the
course of providing services under this contract. Commercial Automobile Liability is required for contractors
that own business vehicles registered to the business. Examples include: plumbers, electricians or
construction contractors. An Example of an acceptable personal automobile policy is a contractor who is a
sole proprietor that does not own vehicles registered to the business.
❑ Required by County 0 Not required by County (one box must be checked)
Additional Requirements. Contractor shall pay all deductibles and self-insured retentions. A cross -liability
clause or separation of insured's condition must be included in all commercial general liability policies required by
this Contract. Contractor's coverage will be primary in the event of loss.
Certificate of Insurance Required. Contractor shall fumish a current Certificate of Insurance to the County with
the signed Contract. Contractor shall notify the County in writing at least 30 days in advance of any cancellation,
termination, material change, or reduction of limits of the insurance coverage. The Certificate shall also state the
deductible or, if applicable, the self-insured retention level. Contractor shall be responsible for any deductible or
self-insured retention. If requested, complete copies of insurance policies shall be provided to the County.
Risk Manage
e eview
PAGE 21 OF 26 — PERSONAL SERVICES CONTRACT NO. 2011 -012
Date
Exhibit 5
MHS 24/2009 - 2011
Pagel of 3
Service Name: REGIONAL ACUTE PSYCHIATRIC INPATIENT SERVICES
Service ID Code: MRS 24
I. Service Description
Regional Acute Psychiatric Inpatient Services (MBS 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 and/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 (CMHP) 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 Department 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 but 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 Secure Residential Treatment Providers of MHS 24 Services funded
through this Agreement must comply with OAR 309-032-0850 through 309-032-
0890, as such rules may be revised from time to time. Facilities in which a Provider
delivers MSS 24 Services funded through this Agreement must maintain:
PAGE 22 OF 26 - PERSONAL SERVICES CONTRACT No. 2011-012
MHS 24/2009 - 2011
Page 2 of 3
1. Hospitals Licensed under ORS 441.015 or certified by the Joint Commission on
Accreditation of Health Care Organization ("JCAHO") for the hospital
services; or
2. Approval 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 Providers transportation services under MHS 24 will be
approved under OAR 309-033-0432 through 309-033-0437, as such rules may be
revised from time to time.
III. Special Reportinz Requirements
A. Reports ofJCAHO reviews of the facility where a Provider delivers MHS 24 Services
funded through this Agreement must be submitted to Department within 60 days after
the Provider's receipt of such reports or reviews. Submit reports to Addictions &
Mental Health Division, Contracts Administrator.
B. Hospital and Secure Residential Treatment Providers of MHS 24 Services funded
through This Agreement must submit the following information to Department
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.
C. Contractor must annually submit an accounting report of MHS 24 funds using forms
prescribed by Department by August 31 for the prior state fiscal year.
N. Financial Assistance Calculation and Disbursement Procedures
A. Calculation of Financial Assistance: Department 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 Department's
obligation to provide financial assistance for MRS 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 (whether or not such capacity is utilized). If the number of units
of MHS 24 Services service capacity specified on the line are not delivered during the
entire period specified on that line, Department shall have no obligation to provide
financial assistance for MHS 24 Services from funds awarded on that line.
B. Disbursement of financial assistance: Department 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:
MHS 24/2009 - 2011
Page 3 of 3
1. Department may after 30 days (unless parties agreed otherwise) written notice to
County, reduce the monthly allotments based on under used allotments
identified through Oregon Patient/Resident Care System (OP/RCS)or through
other method permitted or required by this Service Description or an applicable
Specialized Service Requirement.
2. Department may, upon written request of County, adjust monthly allotments.
3. Upon amendment to the Financial Assistance Award, Department 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.
C. Agreement Settlement. Agreement Settlement will reconcile any discrepancies that
may have occurred during the term of this Agreement between actual Department
disbursements of funds awarded for MRS 24 Services under a particular line of the
Financial Assistance Award and amounts due for such services based on the required
number of units of MHS 24 Services service capacity set forth on that line and the
actual amount of service capacity delivered under that line of the Financial Assistance
Award during the period specified in that line of the Financial Assistance Award, as
properly reported in OP/RCS.
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 also be
revised accordingly. Authority to change this Exhibit to comply fully with Deschutes County's State Agreement
shall rest with the Director of Behavioral Health Services at St Charles Health System and the Deschutes
County Health Services Director. Both parties must agree for the Exhibit to be modified.
PAGE 24 OF 26— PERSONAL SERVICES CONTRACT No. 2011-012
Exhibit 6
Disclosure of Protected Health Information
1. Purpose. The purpose of this exhibit is to set forth the terms and conditions of disclosure of "protected
health information" (as defined in Section 2.1 of this exhibit) by Contractor to County. It is the intent of
County and Contractor that this exhibit will meet the requirements of 45 CFR § 164.504(e) of the privacy
regulations and 45 CFR § 164.314(a) of the security regulations promulgated by the_U.S. Department of
Health and Human Services under the Health Insurance Portability and Accountability Act of 1996
(HIPAA) (collectively the "HIPAA Regulations").
2. Use And Disclosure Of PHI.
2.1 Definitions. For purposes of this exhibit, the term "protected health information" (PHI) means
Individually Identifiable Health Information transmitted or maintained in any form or medium.
"Individually Identifiable Health Information" is information, including demographic information, that:
(a) relates to (i) the past, present or future physical or behavioral health or condition of an individual
person,. (ii) the provision of health care to an individual person, or (iii) the past, present or future
payment for the provision of health care to an individual person; and (b) identifies that person (or
with respect to which there is a reasonable basis to believe the information can be used to identify
the person). Terms used by but not otherwise defined in this exhibit shall have the same meaning
as those in 45 CFR Parts 160, 162, and 164.
2.2 Security and Confidentiality. If Contractor discloses any PHI to County, or if County creates or
receives any PHI on behalf of Contractor, County will maintain the security and confidentiality of
such PHI in County's possession as is required by the HIPAA Regulations.
2.3 Use and Disclosure. County may not use or disclose PHI except as permitted by this exhibit or
other parts of this Contract, or as required by law.
2.4 Disclosure Procedure. Unless such disclosure is required by law, County may not disclose PHI
unless: (a) County obtains reasonable assurances from the person towhom the PHI is disclosed
that the PHI will be held confidentially and used or further disclosed only as required by law or for
the purpose for which it was disclosed to the person, and (b) the person notifies County of any
instances of which the person is aware of breaches of confidentiality of the PHI.
3. Other Obligations.
3.1 Safeguards. County will use appropriate safeguards to prevent use or disclosure of PHI otherwise
than as permitted by this exhibit.
3.2 Reports. County will report to Contractor any use or disclosure of PHI by County or its Workforce
not provided for by this exhibit of which County becomes aware.
3.3 Agents. County will ensure that any agents, including subcontractors, to whom County provides
PHI received from Contractor (or created or received by County on behalf of Contractor) agree to
the same restrictions and conditions that apply to County with respect to such PHI.
3.4 Availability. County shall make PHI in its possession available to the individual who is the subject
of the PHI as required by the HIPAA Regulations.
3.5 Amendment. County shall make available PHI in its possession for amendment of the PHI by the
person identified in the PHI and incorporate any such amendments in accordance with the HIPAA
Regulations.
PAGE 25 OF 26 — PERSONAL SERVICES CONTRACT No. 2011-012
3.6 Access. If County has PHI in a designated record set, County will provide Contractor, upon
Contractor's reasonable request, access for inspection of County's books, records, policies,
practices and procedures concerning the use and disclosure of PHI for purposes of assisting
Contractor with its obligations for record keeping and compliance with complaint investigations and
compliance reviews as required by the HIPAA Regulations_
4. Accounting Of Disclosures. Although County does not anticipate making disclosures other than for the
purposes of this Contract, County will maintain a record of all disclosures of PHI made otherwise than for
the purposes of this Contract, including the date of the disclosure, the name and address (if known) of the
recipient of the PHI, a brief description of the PHI disclosed, and the purpose of the disclosure as
necessary to permit Contractor to respond to a request by an individual for an accounting of disclosures
in accordance with 45 CFR § 164.528. COUNTY will make such record available to Contractor on
request.
5. Disclosure To U.S. Department Of Health And Human Services. County will make its internal
practices, books, and records relating to the use and disclosure of PHI received from Contractor (or
created or received by County on behalf of Contractor) available to the Secretary of the United States
Department of Health and Human Services, for purposes of determining County's and Contractor's
compliance with the HIPAA Regulations.
6. Procedure Upon Termination. Upon termination of this Contract, County will, if feasible, return or
destroy all PHI that County maintains in any form, and will retain no copies of such PHI or, if the parties
agree that retum or destruction is not feasible, County will continue to extend the protections of this
exhibit to such PHI, and limit further use of the PHI to thosepurposesthat make the retum or destruction
of the PHI infeasible.
7. No Third Party Beneficiaries. There are no third party beneficiaries to the Contract or this exhibit.
PAGE 26 OF 26 — PERSONAL SERVICES CONTRACT NO. 2011-012
CERTIFICATE OF LIABILITY INSURANCE
06/112010
PROOUCER
CHIVAROLI & ASSOCIATES INC
200 N Westlake Blvd #101
Westlake village, CA 91362
(805) 371 — 3680
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
NAICB
INSURED
St. Charles Health System, Inc
2500 NE Neff Road
Bend, OR 97701
INSURER A: Lexington Insurance Company
19437
INSURER B:
UMITS
INSURER C
Ar
INSURER 0:
RAL LIABILITY
OOIWERcW.GENERAL UABWri
NSR E
01 July 2010
COVERAGES
TIE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE MISURED NAMED ABOVE FOR11 POUCY K.'Y PERIODINDICATED.
REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WiTH RESPECT TO WHICH THIS CERTIFICATE
TRIS QISUtANCE AFFORD® BY TINE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND
AGGREGATE UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
The Insured has a limit as indicated below, excess of a $500,000 self insured retention applicable to
NOTWITHSTANDING ANY "
MAY BE ISSUED OR MAY PERTAiN,
COND[TI0 5 OF SUCH POUCES.
each and every dakn
am
m
paft
TYPE OF INSURANCE
POLICY NUMBER
FFECTIVE
YQIWDDIYY)
POLICY SCPIRATION
DATE (MMOODKY)
UMITS
_
Ar
GENE
X.
RAL LIABILITY
OOIWERcW.GENERAL UABWri
6792944
01 July 2010
01 July 2011
EACHOOCURENcE
$ 1000000
DAMAGE TO RBITED P
$
4 C1AI MS MADE 0 OCCUR
MED EXP (Any an R
$
PERSONALaADVMAIM
$
GLIAL AGGREGATE
$ 3000000
GENU AGGREGATE UNIT APPLIES PER
-I�n n�
'Rote= -coUPIOP AOG
$
�. --
AUTOMOBILE
_
......
.
UABIUTY
ANY AUTO
ALL OMED AUTOS
UL
SCHEDED AUTOS
HIRED AUTOS
-
NDN.01ANEDAUTOS
-
comma SINGLE LIVET
$
BODILY INAJRY
V
$
(Perp
BODILY MIRY
- - -
roc ---
-$
PROPERTY DAMAGE
(Per socideat)
$
GARAGEUABSUTY
-
ANY AUTO
AUTO ONLY- EA ACCIDENT
$
OTHER THAN EA ACC
$
AUTO AGO
$
EXCESS
DOCCUR
LWBIUTY
❑ CLAIMS MADE
DEDUCTIBLE
RETENTION $
EACH OCCURENCE
$
AGGREGATE
$
WORKERS
EMPLOYERS'
ANY
ORBER
O )01.
IPECIPL
COMPENSATION AND
LIABILITY
PROPRIETORRIPRTNER/EXECUOYE/
D IMU0®T
1wc minx 1
_
$
EL EACH ACCIDENT
$
E.L 0196144E- EA fJ:FLO'YEE
$
desedba wader
PROVOIONG WYw
El DISEASE —POLICY LM/T .
$
A
Health Care Professional OTHER
Liability — Claims Made
6792944
01 July 2010
01 July 2011
$1000000 Each Occurrence
$ 3000000 Annual Aggregate
DESCRIPiION
Evidence
Inc, St Charles
It is agreed
respects liabnity
performance
OF OPERATIONS! LOCATIONS I VEHICLES 1 EXCLUSIONS ADDEO BY ENDORSEMENT I SPECIAL
of Professional and General Liability insurance as respects the HealthyStart
Medical Center Foundation and Deschutes County.
that Deschutes County, its divisions, officers, agents, employees and
incurred from the actions of St Charles Health System, Inc or St
of their duties under the HealthyStart Prenatal Program agreement
I
PROVISfONS
Prenatal Program between St Charles Health System,
volunteers are included as Additional Insureds, but only as
Charles Medical Center Foundation employees in the
effective July 1, 2010.
CERTIFICATE HOLDER
CANCELLATION
S t . Charles Health System, Inc
2 500 NE Neff Road
Bend, OR 97 701
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF. THE ISSUING INSURER BILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE
TO THE CERTIFICATE HOLDER NAMED PO THE LEFT. BUT FALURE TO DO SO SHALL IMPOSE NO
OBLIGATION OF UABIU1 Y OF ANY KW UPON THE INSURER ITS AGENTS OR
REPRESENTATIVES
AUTHORIZED REPRESENTATIVE f�
le
ACORD 25 (2001108)
0 ACOJ CORPORATION 1988
ENDORSEMENT NO. 17
Thls endorsement, effective 12:01 AM: July 1, 2010
Forms a part of policy no.: 6792944
Issued to: ST CHARLES HEALTH SYSTEM, INC.
By: LEXINGTON INSURANCE COMPANY
ADDITIONAL INSUREDS ENDORSEMENT
The Policy is amended as follows:
Section H. WHO IS AN INSURED of the EXCESS HEALTHCARE PROFESSIONAL LIABILITY 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 HEALTHCARE 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 liability arising out of the conduct of your business.
Alt other terms, conditions and exclusions of the policy remain unchanged.
Authorized Representative
or countersignature (where required by law)
94487 (5/07)
HC0511
www.saif.com
OREGON WORKERS COMPENSATION
CERTIFICATE OF INSURANCE
CERTIFICATE HOLDER:
DESCHUTES COUNTY, HEALTH SERVICES
ATTN: NANCY ENGLAND, CONTRACT SPECIALIST
1300 NW WALL
BEND, OR 97701
Ittsaif
The policy of insurance listed below has been issued to the insured named below for the
policy period indicated. The insurance afforded by the policy described herein is subject to
all the terms, exclusions and conditions of such policy.
POLICY NO.
417940
POLICY PERIOD
07/01/2010 to 01/01/2011
ISSUE DATE
12/29/2010
INSURED:
ST CHARLES HEALTH SYSTEM INC
ST CHARLES MEDICAL CENTER
ATTN: REBECCA MORGAN, HUMAN RESOURCES
2500 NE NEFF RD
BEND, OR 97701-6015
BROKER OF RECORD:
LIMITS OF LIABILITY:
Bodily Injury by Accident
Bodily Injury by Disease
Body Injury by Disease
$500,000 each accident
$500,000 each employee
$500,000 policy limit
DESCRIPTION OF OPERATIONS/LOCATIONS/SPECIAL ITEMS:
IMPORTANT:
The coverage described above is in effect as of the issue date of this certificate. It is subject to change
at any time in the future.
This certificate is issued as a matter of information only and confers no rights to the certificate
holder. This certificate does not amend, extend or alter the coverage afforded by the policies above.
AUTHORIZED REPRESENTATIVE
3r�r1d�,�P 1Z�.Cl.�►--�.
President and CEO
400 High Street SE
Salem, OR 97312
P: 800.285.8525
F: 503.373.8020
Pot cy_Catif rates_CerURcateOflnwra nce
www.saif.com
OREGON WORKERS COMPENSATION
CERTIFICATE OF INSURANCE
��lisaif
MAIL TO: CERTIFICATE HOLDER:
ST CHARLES HEALTH SYSTEM INC DESCHUTES COUNTY, HEALTH
ST CHARLES MEDICAL CENTER SERVICES
ATTN: REBECCA MORGAN, HUMAN RESOURCES ATTN: NANCY ENGLAND, CONTRACT
2500 NE NEFF RD SPECIALIST
BEND, OR 97701-6015 1300 NW WALL
BEND, OR 97701
The policy of insurance listed below has been issued to the insured named below for the
policy period indicated. The insurance afforded by the policy described herein is subject to
all the terms, exclusions and conditions of such policy.
POLICY NO.
417940
POLICY PERIOD
07/01/2010 to 01/01/2011
ISSUE DATE
12/29/2010
INSURED: BROKER OF RECORD:
ST CHARLES HEALTH SYSTEM INC
ST CHARLES MEDICAL CENTER
ATTN: REBECCA MORGAN, HUMAN RESOURCES
2500 NE NEFF RD
BEND, OR 97701-6015
LIMITS OF LIABILITY:
Bodily Injury by Accident
Bodily Injury by Disease
Body Injury by Disease
$500,000 each accident
$500,000 each employee
$500,000 policy limit
DESCRIPTION OF OPERATIONS/LOCATIONS/SPECIAL ITEMS:
IMPORTANT:
The coverage described above is in effect as of the issue date of this certificate. It is subject to change
at any time in the future.
This certificate is Issued as a matter of information only and confers no rights to the certificate
holder. This certificate does not amend, extend or alter the coverage afforded by the policies above.
AUTHORIZED REPRESENTATIVE
J
President and CEO
r
400 High Street SE
Salem, OR 97312
P: 800.285.8525
F: 503.373.8020
Policy_Certtficates_CertlficateORnsura nce