HomeMy WebLinkAbout2011-194 Health - Piedmont Health Services, Inc. for dietitian services~~~
NORTH CAROLINA
l~
ORANGE COUNTY
REGISTERED DIETITIAN SERVICES AGREEMENT
This Services Agreement (hereinafter "Agreement"), made and entered into this first day of
July, 2011, ("Effective Date") by and.between Orange County, North Carolina a body politic and
corporate of the State of North Carolina (hereinafter; the "County") through their Department of
Health (hereinafter, the "OCHD") and Piedmont Health Services, Inc, (hereinafter, the "PHS").
WITNESSETH:
That the County and PHS, for the consideration herein named, do hereby agree as follows:
1. Services
a. Scope of Work.
i) This Agreement is for services to be rendered by the County to PHS with respect
to: Twenty hours (20) per week services of a North Carolina licensed Registered
Dietitian ("RD"), as provided in Exhibit 1, PHS Job Description and Section 3
below, Basic Services.
ii) By executing this Agreement, the County represents and agrees that OCHD is
qualified to perform and fully capable of performing and providing the services
required or necessary under this Agreement in a fully competent, professional and
timely manner.
iii) Time is of the essence with respect to this Agreement.
iv) The services to be performed under this Agreement consist of Basic Services, as
described and designated in Section 3 hereof and as provided in Exhibit 1, PHS
Job Description. Compensation to the County for Basic Services under this
Agreement shall be as set forth herein.
2. Responsibilities of PHS
a. Services to be provided. The County shall provide PHS with all services required in
Section 3 to satisfactorily complete the Project within the time limitations set forth
herein and in accordance with the highest professional standards.
b. Standard of Care.
i) The County shall exercise reasonable care and diligence in performing services
under this Agreement in accordance with the highest generally accepted standards
of this type of practice throughout the United States and in accordance with
applicable federal, state and local laws and regulations applicable to the
performance of these services. County is solely responsible for the professional
quality, accuracy and timely completion and/or submission of all work related to
the Basic Services.
Revised April 2010
ii) The County shall be responsible for all errors o'r omissions, in the performance of
the Agreement. The County shall correct any and all errors, omissions,
discrepancies, ambiguities, mistakes or conflicts at no additional cost to the PHS.
iii) The .County shall not, except as otherwise provided for in this Agreement,
subcontract the performance of any work under this Agreement without prior
written permission of PHS. No permission for subcontracting shall create,
between the PHS and the subcontractor, any contract or any other relationship.
iv) The County is an independent contractor of PHS. Any and all employees of the
County engaged by the County in the performance of any work or services
required of the County under this Agreement, shall be considered employees or
agents of the County only and not of PHS, and any and all claims that may or
might arise under any workers compensation or other law or contract on behalf of
said employees while so engaged shall be the sole obligation and responsibility of
the County.
v) The County agrees that its employees, agents and its subcontractors, if any, shall
be required to comply with all federal, state and local antidiscrimination laws,
regulations and .policies that relate to the performance of County's services under
this Agreement.
vi) If activities related to the performance of this Agreement require specific licenses,
certifications, or related credentials County represents that it and/or its employees,
agents and subcontractors engaged in such activities possess such licenses,
certifications, or credentials and that such licenses certifications, or credentials are
current, active, and not in a state of suspension or revocation.
3. Basic Services
a. Basic Services. The Services to be rendered pursuant to this Agreement are as follows
(fully describe services to be provided): Twenty hours per week services of a Registered
Dietitian as provided in accordance with Exhibit 1 PHS Job Description and this Section
of the Agreement as provided below:
i) Hiring Responsibility:
(a) OCHD will conduct the recruitment process; however, the PHS shall review
and contribute to the job posting;
(b)~All job application must follow the Orange County and OCHD policies
hiring and recruitment policies;
(c) The position will be posted on the Orange County job vacancy website. The
PHS may create a link to the Orange County vacancy website to advertise
the position;
(d) The PHS will collaborate with OCHD in the selection process by helping to
develop interview questions and serving on the interview and selection
panel.
Revised April 2010
2
ii) Job Description: The person in the position will follow the duties described within
the Orange County job description when working with OCHD. While working at
PHS, the person will follow the job duties as described in the PHS job description
for MNT Dietitian (Exhibit 1). Job duties will be consistent with the scope of
practice for dietitians registered and licensed to practice in North Carolina.
iii) Supervision: OCHD Nutrition Program Manager is the primary supervisor of the
RD. However, PHS will provide on-site supervision of the dietician for the 20
hours per week the person is at PHS. PHS will report any practice infractions to
OCHD within twenty-four hours. PHS will work with OCHD to create WPPR
performance measures and consult with OCHD on the annual performance review.
Supervisors will communicate monthly.
iv) Orientation/Training: The RD must attend any County, OCHD and PHS required
orientation and training. OCHD and PHS will discuss training needs and
requirements and develop a mutually agreed upon schedule to meet the
requirements. Training and Orientation may cause the normal work schedule to
vary.
v) Probationary Period: Orange County Health Department has a statutorily required
24 month probationary period to assess if the employee can perform proficiently.
During this period of time the Orange County Health Director has the right to
terminate the employment due to unsatisfactory performance. Since this employee
will be employed by Orange County Health Department, this would supersede the
90-day probationary period normally applied to PHS employees. Termination of the
RD employment will terminate this Agreement.
vi) Any revenue generated by the RD at PHS while providing the twenty hours of
service shall be the property of PHS.
vii) PHS assumes responsibility for setting fees, billing, collections and dispute
resolutions for RD services provided at the PHS site.
4. Duration of Services
a. Term. The term of this Agreement shall be from July 1, 2011 to June 30 2012.
b. Scheduling of Services.
r) Regular Schedule: The RD shall work at OCHD on Tuesday and Thursday (all day)
and Wednesday (1:00 pm to 5:00 pm). The RD shall work at PHS on Monday and
Friday (all day) and Wednesday (8:00 am to 12:00 pm). The schedule may change
due to orientation and training needs upon mutual agreement of the parties. PHS
Supervisor and the OCHD Nutrition Program Manager will annually agree on the
regular schedule of work and location for the RD.
ii) If overtime is incurred because the RD works more than the twenty hours per week
required under this Agreement, the overtime cost shall be paid by PHS.
Revised April 2010
3
iii) Holiday Schedule: The RD will follow the holiday schedule adopted by the Orange
County Board of County Commissioners for County employees. If PHS requires
the RD to work during a scheduled holiday, PHS will be responsible for any
overtime or holiday pay.
iv) Leave: The RD will be provided with vacation and sick leave as an Orange County
employee. When the employee is on scheduled leave from Orange County and
PHS, PHS will be required to pay for services when the RD is on approved leave.
The OCHD Nutrition Program Manager will consult with the PHS Supervisor prior
to approving employee requests for vacation and sick leave.
v) The Commencement Date for the PHS Basic Services shall be July 1, 2011.
5. Compensation
a. Compensation for Basic Services. Compensation for Basic Services shall include all
compensation due to the County from PHS for all services under this Agreement. The
maximum amount payable for Basic Services shall not exceed $24.23/per hour or
($25,198 annually) exclusive of any overtime or holiday pay. Payment for Basic
Services shall become due and payable within thirty (30) days of the County properly
invoicing PHS. The County shall invoice PHS quarterly. Payment shall be subject to
provisions of Section 5(b). Payment will begin only after the employee has been hired to
the position and has begun receiving compensation from the County.
b. Disputes. In the event the amount stated on an invoice is disputed by the PHS, PHS may
withhold payment of all or a portion of the amount stated on an invoice until the parties
resolve the dispute. Should the County fail to perform its duties under the terms of this
Agreement, PHS may, without fault or penalty, withhold any payment associated with
the work to be performed until such time as said work is completed.
Additional Services. PHS shall not be responsible for costs related to any services in
addition to the Basic Services performed by County unless County requests such
additional services in writing and such additional services are evidenced by a written
amendment to this Agreement.
6. Responsibilities of the County
a. Cooperation and Coordination. The ,County has designated Renee Kemske to act as the
County's representative with respect to Agreement and shall have the authority to render
decisions within guidelines established by the Health Director and/or the County Board
of Health and shall be available during working hours as often as may be reasonably
required to render decisions and to furnish information.
7. Insurance
a. General Requirements. PHS shall purchase and maintain and shall cause each of his
subcontractors to purchase and maintain, during. the period of performance of this
Agreement:
Revised April 2010
4
i) Comprehensive General Liability Insurance covering claims arising out of or
relating to bodily injury, including bodily injury, sickness, disease or death of any
of the PHS's employees or any other person and to real and personal property
including loss of use resulting thereof in the amount of at least $ 1,000,000 for
each occurrence and $2,000,00 in the aggregate;
b. Additional Insured. All insurance policies required under this Agreement shall name the
County as an additional insured party. Evidence of such insurance shall be furnished to
the County, together with evidence that each policy provides the County with not less
than thirty (30) days prior written notice of any cancellation, non-renewal or reduction
of coverage.
8. Indemnity
a. Indemnity. PHS agrees to defend, indemnify and hold harmless the County from all loss,
liability, claims or expense, including attorney's fees, arising out of or related to the
Agreement and arising from bodily injury including death or property damage to any
person or persons caused in whole or in part by the negligence or misconduct of PHS
except to the extent same are caused by the negligence or willful misconduct of the
County. It is the intent of this provision to require the PHS to indemnify the County to
the fullest extent permitted under North Carolina law.
9. Amendments to the Agreement
a. Changes in Basic Services. Changes in the Basic Services and entitlement to additional
compensation or a change in duration of this Agreement shall be made by a written
Amendment to this Agreement executed by the County and the PHS. The County shall
proceed to perform the Services required by the Amendment only after receiving a fully
executed Amendment from PHS.
10. Termination
a. Termination for Convenience of the County. This Agreement may be terminated without
cause by the County and for its convenience upon seven (7) days' prior written notice to
the PHS.
b. Other Termination. PHS may terminate this Agreement based upon the County's
material breach of this Agreement provided the County has not taken all reasonable
actions to remedy the breach. PHS shall give the County seven (7) days' prior written
notice of its intent to terminate this Agreement for cause.
c. Compensation After Termination.
i) In the event of termination, the County shall be paid that portion of the fees and
expenses that the employee has earned to the date of termination.
Revised April 2010
ii) Should this Agreement be terminated, the County shall deliver to PHS within
seven (7) days, at no additional cost, all deliverables including any electronic data
or files relating to this Agreement.
d. Waiver. The continuation of services by the County under this Agreement or the failure
of the County to require compliance by the PHS with any provisions of this Agreement
or the waiver by the County of any breach of this Agreement shall not constitute a
waiver of any claim for damages by the County for any breach of this Agreement or a
waiver of any other required compliance with this Agreement.
11. Additional Provisions
a. Limitation and Assi nment. The County and the PHS each bind themselves, their
successors, assigns and legal representatives to the terms of this Agreement. Neither the
County nor the PHS shall assign or transfer its interest in this Agreement without the
written consent of the other.
b. Governing Law. This Agreement and the duties, responsibilities, obligations and rights
of respective parties hereunder shall be governed by the laws of the State of North
Carolina.
c. Dispute Resolution. Any and all suits or actions to. enforce, interpret or seek damages
with respect to any provision of, or the performance or non-performance of, this
Agreement shall be brought in the General Court of Justice of North Carolina sitting in
Orange County, North Carolina. It is agreed by the parties that no other court shall have
jurisdiction or venue with respect to such suits or actions. The Parties may agree to
nonbinding mediation of any dispute prior to the bringing of such suit or action.
d. Entire Agreement. This Agreement represents the. entire and integrated agreement
between the County and the PHS and supersedes all prior negotiations, representations
or agreements, either written or oral. This Agreement may be amended only by written
instrument signed by both parties. Modifications may be evidenced by facsimile
signatures.
e. Severability. If any provision of this Agreement is held as a matter of law to be
unenforceable, the remainder of this Agreement shall be valid and binding upon the
Parties.
f. Non-Appropriation. PHS acknowledges that County is a governmental entity, and the
validity of this Agreement is based upon the availability of public funding under the
authority of its statutory mandate.
In the event that public funds are unavailable and not appropriated for the performance of
County's obligations under this Agreement, then this Agreement shall automatically
expire without penalty to County immediately upon written notice to PHS of the
unavailability and non-appropriation of public funds. It is expressly agreed that County
shall not activate this non-appropriation provision for its convenience or to circumvent
the requirements of this Agreement, but only as an emergency fiscal measure during a
substantial fiscal crisis.
Revised April 2010
6
In the event of a change in the County's statutory authority, mandate and/or mandated
functions, by state and/or federal legislative or regulatory action, which adversely affects
County's authority to continue its obligations under this Agreement, then this Agreement
shall automatically terminate without penalty to County upon written notice to PHS of
such limitation or change in County's legal authority.
g. Notices. Any notice required by this Agreement shall be in writing and delivered by
certified or registered mail, return receipt requested to the following:
Orange County
Attention: Health Director
P.O. Box 8181
Hillsborough, NC 27278
Piedmont Health Services, Inc.
Attention: Brian Toomey
299 Lloyd Street
Carrboro, NC 27510
IN WITNESS WHEREOF, the Parties, by and through their authorized agents, have
hereunder set their hands and seal, all as of the day and year first above written.
ORANGE COUNTY:
By:
Frank .Clifton my Manager
PHS:
By:
Brian Toomey, Executive rector
Printed Name and Title
Federal Tax ID #:
This instrument has been approved as to technical content.
Dorothy Cilenti MPH, DrPH
Health Director
This instrument has been pre-audited in the manner required by the Local Government Budget
and Fiscal Control Act.
~ 1~. ~~
Clarence G. Grier, Finance Director
This n rument has been approved as to form and legal sufficiency.
Anne e M. oore, Office of the County Attorney
Revised April 2010
BUSINESS ASSOCIATE AGREEMENT
This Agreement is made effective the 1St day of July, 2011, by and between Orange County
Health Department, hereinafter referred to as "Covered Entity", and Piedmont Health Services, Inc.
hereinafter referred to as "Business Associate," (individually, a "Party" and collectively, the "Parties").
WITNESSETH:
WHEREAS, Sections 261 through 264 of the federal Health Insurance Portability and
Accountability Act of 1996, Public Law 1.04-191, known as "the Administrative Simplification provisions,"
direct the Department of Health and Human Services to develop standards to protect the security,
confidentiality and integrity of health information; and
WHEREAS, pursuant to the Administrative Simplification provisions, the Secretary of Health and
Human Services has issued regulations modifying 45 CFR Parts 160 and 164 (the "HIPAA Security and
Privacy Rule"); and
WHEREAS, the Parties wish to enter into or have entered into an arrangement whereby
Business Associate will provide certain services to Covered Entity, and, pursuant to such arrangement,
Business Associate may be considered a "business associate" of Covered Entity as defined in the
HIPAA Security and Privacy Rule (the agreement evidencing such arrangement is entitled Registered
Dietitian Services Agreement with PHS Inc., dated July 1, 2011, and is hereby referred to as the
"Arrangement Agreement"); and
WHEREAS, Business Associate may have access to Protected Health Information (as defined
below) in fulfilling its responsibilities under such arrangement;
THEREFORE, in consideration of the Parties' continuing obligations under the Arrangement
Agreement, the Parties agree to the provisions of this Agreement in order to address the requirements
of the HIPAA Security and Privacy Rule and to protect the interests of both Parties.
DEFINITIONS
Except as otherwise defined herein, terms. used in this Agreement shall have the same meaning as
those terms set forth in the HIPAA Security and Privacy Rule.
CONFIDENTIALITY REQUIREMENTS
(a) Business Associate shall:
(i) use or disclose any protected health information solely as permitted or
required by this Agreement, the Arrangement Agreement (if consistent with this
Agreement and the HIPAA Security and Privacy Rule), or as required by law.
(ii) ensure that its agents, including a subcontractor, to whom it provides
protected health information received from or created by Business Associate on behalf
of Covered Entity, agrees to the same restrictions and conditions that apply to Business
Associate with respect to such information. In addition, Business Associate agrees to
take reasonable steps to ensure that its employees' actions or omissions do not cause
Business Associate to breach the terms of this Agreement;
(iii) implement appropriate safeguards to prevent use or disclosure of
protected health information other than as permitted or required by this Agreement;
(iv) permit the Secretary of Health and Human Services to audit Business
Associate's records and practices related to use and disclosure of protected health
information to ensure Covered Entity's compliance with the terms of the HIPAA Security
and Privacy Rule;
(v) report to Covered Entity any use or disclosure of protected health
information which is not in compliance with the terms of this Agreement of which it
becomes aware;
(vi) report to Covered Entity any Security Incident of which it becomes aware.
For purposes of this Agreement, "Security Incident" means the attempted or successful
unauthorized access, use disclosure, modification, or destruction of information or
interference with system operations in an information system; and
(vii) mitigate, to the extent practicable, any harmful effect that is known to
Business Associate of a use or disclosure of protected health information by Business
Associate in violation of the requirements of this Agreement.
(b) Notwithstanding the prohibitions set forth in this Agreement or the Arrangement
Agreement, Business Associate may use and disclose protected health information as follows:
(i) if necessary, for the proper management and administration of Business
Associate or to carry out the legal responsibilities of Business Associate, provided that
as to any such disclosure, the following requirements are met:
(A) the disclosure is required by law; or
(B) the disclosure is required to report a breach of professional
conduct or standard on the part of the employee of PHS
(B) Business Associate 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 it
was disclosed to the person, and the person notifies Business Associate of any
instances of which it is aware in which the confidentiality of the information has
been breached;
(ii) for data aggregation services, if such services are to be provided by
Business Associate for the health care operations of Covered Entity pursuant to any
agreements between the Parties evidencing their business relationship.
III. AVAILABILITY OF PROTECTED HEALTH INFORMATION
Business Associate shall:
(a) at the request of Covered Entity, provide access to protected health information in a
designated record set to Covered Entity or, as directed by Covered Entity, to an individual, in a time
and manner sufficient to permit Covered Entity to comply with the requirements of 45 CFR 164.524.
(b) at the request of Covered Entity or an individual, make any amendment(s) to protected
health information in a designated record set that are directed by or agreed to by Covered Entity, in a
time and manner sufficient to permit Covered Entity to comply with the requirements of 45 CFR
164.526.
(c) document disclosures of protected health information and information related to such
disclosures in a manner sufficient to permit Covered Entity to respond to a request by an individual for
2
an accounting of disclosures of protected health information in accordance with 45 CFR 164.528 and
provide such documentation to Covered Entity or an individual as directed by Covered Entity.
IV. TERMINATION
(a) Term: This Agreement terminates when the Arrangement Agreement terminates or as
provided in Paragraph IV.b. below (termination for cause).
(b) Termination for cause: Upon Covered Entity's knowledge of a material breach by
Business Associate, Covered Entity shall either:
(i) provide an opportunity for Business Associate to cure the breach or end
the violation or, if Business Associate does not cure the breach or end the violation
within the time Specified by Covered Entity, terminate this Agreement and the
Arrangement Agreement; or
(ii} immediately terminate this Agreement and the Arrangement Agreement if
Business Associate has breached a material term of this Agreement and cure is not
possible.
(c) Return or destruction of protected health information: At termination of this Agreement,
the Arrangement Agreement (or any similar documentation of the business relationship of the Parties),
or upon request of Covered Entity, whichever occurs first,. Business Associate shall:
(i) if feasible, return or destroy all protected health information received from
or created or received by Business Associate on behalf of Covered Entity that Business
Associate still maintains in any form. Business Associate shall only destroy protected
health information with the written approval of Covered Entity. After return or
destruction, Business Associate shall retain no copies of such information.
(ii) if return or destruction is not feasible, Business Associate wi11 provide
Covered Entity with documentation explaining the reason that it is not feasible. If the
protected health information is not returned or destroyed, Business Associate will extend
the protections of this Agreement to the information and limit further uses and
disclosures to those purposes that make the return or destruction of the information not
feasible.
(d) Survival: The obligations of Business Associate under this Agreement shall survive the
expiration, termination, or cancellation of this Agreement, the Arrangement Agreement and/or the
business relationship of the parties, and shall continue to bind Business Associate, its agents,
employees, contractors, successors, and assigns as set forth herein.
V. MISCELLANEOUS
(a) All protected health information that is created or received by Covered Entity and
disclosed or made available in any form, including paper record, oral communication, audio recording,
and electronic display by Covered Entity or its operating units to Business Associate or is created or
received by Business Associate on Covered Entity's behalf shall be subject to this Agreement.
(b) A reference in this Agreement to a section in the HIPAA Security and Privacy Rule
means the section as in effect or as amended.
3
(c) In the event of an inconsistency between the provisions of this Agreement (including
definitions) and mandatory provisions of the HIPAA Security and Privacy Rule, as amended, the HIPAA
Security and Privacy Rule shall control. Where provisions of this Agreement are different than those
mandated in the HIPAA Security and Privacy Rule, but are nonetheless permitted by the HIPAA
Security and Privacy Rule, the provisions of this Agreement shall control.
(d) Except as expressly stated herein or the HIPAA Security and Privacy Rule, the parties to
this Agreement do not intend to create any rights in any third parties.
(e) This Agreement may be amended or modified only in a writing signed by the Parties. No
Party may assign its respective rights and obligations under this Agreement without the prior written
consent of the other Party. None of the provisions of this Agreement are intended to create, nor will
they be deemed to create any relationship between the Parties other than that of independent parties
contracting with each other solely for the purposes of effecting the provisions of this Agreement and
any other agreements between the Parties evidencing their business relationship.
(f) This Agreement will be governed by the laws of the State of North Carolina.
(g) No change, waiver or discharge of any liability or obligation hereunder on any one or
more occasions shall be deemed a waiver of performance of any continuing or other obligation, or shall
prohibit enforcement of any obligation, on any other occasion.
(h) The parties agree that, in the event that any documentation of the arrangement pursuant
to which Business Associate provides services to Covered Entity contains provisions relating to the use
or disclosure of protected health information that are more restrictive than the provisions of this
Agreement, the provisions of the more restrictive documentation will control.
(i) In the event that any provision of this Agreement is held by a court of competent
jurisdiction to be invalid or unenforceable, the remainder of the provisions of this Agreement will remain
in full force and effect.
(j) The headings in this Agreement are for convenience of reference only and shall not
define or limit any of the terms or provisions hereof.
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the day and year
written above.
COVERED ENTITY:
By:
Title: Interim Health Di ctor
BUSINESS A CIATE:
By:
Ti le: Exe ive Dir for
4
pi~Dn~on T
Health Servlc es. Inc.
Piedmont Health Services
Performance Evaluation/Job Description
Name: Lead Nutritionist/MNT Dietitian
Reports to: WIC and Nutrition Services Director
FLSA Status: OSHA Category:
Review Period:
Type of Evaluation:
JOB SUMMARY
Performs a variety of responsible tasks involving counseling of individuals and families in nutrition principals, diet, food selection, and. economics focusing on
and other nutritionists on site. Provides medical nutrition therapy counseling to patients referred by providers. Conducts evaluations and audits on clinic staff
manual. Communicates with other management and leadership staff and community agencies and members to support the needs of the patient and the pro
MINIMUM QUALIFICATIONS
Educafion. Bachelors degree from an accredited college or university in Nutrition, Public Health Nutrition or Dietetics.
Current/valid License: Com letion of an AD
A a roved dietetic intern '
P shi with
ADA re istration.
PP p
9
Experience: One year of public health or similar experience.
PATIENT POPULATION SERVED
Ethnically and racially diverse population of pregnant, breastfeeding, postpartum women, infants and young children and all family members involved.
PHYSICAL DEMANDS/ WORKING CONDITIONS
Requires frequent sitting for long periods, operation of standard office machines and computer. May require lifting of up to 25 pounds. Requires hand-eye
coordination and manual dexterity. Requires use of office equipment, such as computer terminals, telephones or copiers. Requires normal vision range.
Work is performed in an office environment. Contact with staff and external clients and vendors.
Revised: March 2011
RESPONSIBILITIES AND DUTIES
'~
~ ~
~ ~ ~ o
~
~ ~
~ a
~ ~
~ c, W a,
W
Al v~ Z ~ W
1. Patient Care:
Determine WIC Program eligibility based on the medical and nutrition risk identified.
Determines risk codes, based on assessment and information presented.
Provides individualized counseling in nutrition and breastfeeding based on needs and resources identified above. Consults with
medical providers, social work and other healthcare providers as needed to rovide optimal care.
Conducts counseling in culturally appropriate way to meet the needs of the patients.
Screens immunization records of clients and makes referral as appropriate.
Proper documentation, based on contact, on all forms and in computer.
Based on professional discretion and risk code determines follow schedule for patient
Contacts other health professionals or agencies if needed to provide optimal care for the patient
Works with other health center staff or outside medical professionals to provide care for patients
Establishes relationships with community partners
Demonstrates the ability to work with diverse patient populations served
Provides referral as needed to patients
Provide medical nutrition therapy counseling to patients based on provider referral, based on the ADA care process
Competency Validation: ^ 1 ^ 2 ^ 3 ^ 4
Comments:
.RESPONSIBILITIES AND DUTIES
-~ ~
~ A b
~ ~
~ ~ ~ ~e
~ ~
~ ~ ~
Z ~ ~ ~
~ W ~ a
W W
2. Procedure Execution:
Reviews chart notes, past visits prior to meeting with patient
Performs anthropometric measurements as needed per standards in the WIC Local Policy and Procedures Manual and State
WIC Polic and Procedures Manual
Follows all procedures and policies as outlined by the WIC local and state Policy and Procedure Manuals
Conducts evaluations and audits as required by PHS policies and procedures.
Complete all necessary documentation related to MNT counseling sessions
Competency Validation: ^ 1 ^ 2 ^ 3 ^ 4 ^ 5
Comments:
3. Patient Education:
Utilizes open-ended questions to obtain additional information.
Provides thorough assessment of each patient and determine appropriate education
Based on family centered approach, determines educations topic.
Effectively presents education topic with appropriate handouts.
Documents nutrition education contacts.
Interprets, evaluates, and utilizes pertinent current research relating to nutrition care.
Develop and select nutrition education materials for use by clients.
Assists in outreach activities.
Competency Validation:
Comments:
,~
iv
~
a
.o
a
0
RESPONSIBILITIES AND DUTIES '~ ~ ~ ~
~ > w b
~~ z~
4. Administrative Duties
Conduct evaluations on staff as required by PHS policies and procedures.
Handles scheduling for site, including approval of vacation requests
Ordering of supplies such as State WIC, and free materials.
Monthly monitoring of formula log and otherinventories in clinic
Submission of all purchased supply orders to Director
Conducts staff meetings as needed for updates and discussion
Assists in problem solving and making recommendations concerning issues pertinent to the WIC Program guidelines
Assists in training and mentoring of new staff members and interns
Performs other administrative duties in relationship to the WIC Program.
Competency Validation: ^ 1 ^ 2 ^ 3 ^ 4 ^ 5
Comments:
ESPONSIBILITIES AND DUTIES
~ .~
~
~
~
o
w
a
~ o
'~ w
~
o ~ ~
'ti ~°,
a
~ ~ v
~ o. v v
~ c.
W
~ ~
W ~ a
i
Z ~ ~
W ~
W
5. Management
Trains, supervises, and evaluates nutritionists and WIC Clinic Assistants.
Responsible for making immediate decisions regarding client services (walk-in clients, clinic closure, and interpretation of WIC
re ulations at the WIC clinic as need arises.
Able to handle and confront difficult situations to resolution
Communicates regularly with supervisor and direct reports.
Works with Director to administer PIP's and disciplinary actions to direct reports.
Supports the organizations mission, goals and objectives.
Competency Validation: ^ 1 ^ 2 ^ 3 ^ 4 ^ 5
Comments:
UNIVERSAL PERFORMANCE STANDARDS ~
~ c a
~
~ 'ti
o c .d ° ~ ~
_
c~
a~~
~~
~ ~
z~ c,
~
~W
W_,W
6. Customer Service (Internal and External Customers)
Demonstrates concern for the rights, privacy and confidentiality of patients and others
Understands the urgency of customer needs and responds quickly
Treats all patients in accordance with the Patient's Bill of Rights
Considers the impact on patients, visitors and peers when taking action and carrying out one's own job tasks
Anticipates the needs of patients, visitors, providers and peers and assists them in a helpful, positive manner
Seeks to solve problems for patients and their families and offers assistance and encouragement to others
Communicates with patients/families, visitors and coworkers in a courteous and respectful manner
Demonstrates effective communication recognizing diversity among age groups, cultures, and educational levels
Competency Validation: ^ 1 ^ 2 ^ 3 ^ 4 ^ 5
Comments:
7. Teamwork
Consistently works in a positive and cooperative manner with o#her employees in and outside of departmental unit
Values and incorporates the contributions of people from diverse backgrounds; demonstrates respect for the opinions and ideas of
others
Assist in training and orientation of new staff
Shares information and own expertise with others to enable them to accomplish goals and objectives
Seeks out opportunities to help rather than waiting to be asked
Assist other team members in the performance of their assignment
Competency Validation: ^ 1 ^ 2 ^ 3 ^ 4 ^ 5
Comments:
~"'
~ N
C N
C
O
~ O O
UNIVERSAL PERFORMANCE STANDARDS ~ °' a v
3~ N a N ~ m ~
o ~
~ ~ a ~ ~
~, v Q
~ ~ Z ~ ~ W W W
8. Professional Conduct
Maintains professional demeanor in all interactions with patients and staff
Functions independently and completes assignments with minimal supervision
Adapts to changes in the work environment
Maintains acceptable attendance record
Observes work schedule by being punctual for shift, observing designated break schedule, and not leaving work area while on
duty
Adheres to all applicable Center and department rules, policies and procedures
Participates in continuing education , in-services, staff development and meetings
Has completed annual retraining
Responds positively to constructive criticism from peers and supervisors
Competency Validation: ^ 1 ^ 2 ^ 3 ^ 4 ^ 5
Comments:
NIVERSAL PERFORMANCE STANDARDS
~
~
~
~°
~
~
~
~
~
N
C
N .0
~ `~
~ ~ i
~
C
~
°' `~
~ ~
o ~ o
~
Q- ~ Q
x w ~
x
~
m a
i
z ~ W w
9. .Efficiency
Completes work in an organized and timely manner
Prioritizes and plans work activities to achieve maximum efficiency
Meets productivity standards
Strives to improve productivity
Minimize non-productive time by filling slow periods with activities such as assisting others, professional development and
education, or anization of work area, housekeepin ,etc.
Organize job functions and work area to effectively complete assignments
Manage resources efficiently and works to reduce costs and improve quality
Competency Validation: ^ 1 ^ 2 ^ 3 ^ 4 ^ 5
Comments:
10. Quality of Work /Problem Solving
Demonstrates commitment to excellence by consistently looking for ways to improve and promote quality
Identifies problems in a timely manner and develops alternative solutions to problems
Contribute to Continuous Quality Improvement activities
Reports to appropriate person any conflicting cultural values, ethics, or religious beliefs that may impact patient care
Consistently evaluates work and evaluate if further steps are needed to meet customer/patient/managementexpectstions
Demonstrates sound judgment by taking appropriate actions regarding questionable findings or concerns
Competency Validation: ^ 1 ^ 2 ^ 3 ^ 4 ^ 5
Comments:
Performance Category
Unit requirements for
half-time Dietitian
Quarter 1 Quarter 2 Quarter 3 Quarter 4 Total
Year1 168 339 507 675 1689
Year2 675 675 675 675 2700
Due to the nature of
this position, material
breach and
termination could
result if unit goals are
not met.
Overall Performance Category for this review period:
Exceeds Expectation (An employee consistently exceeds all performance expectations for this period.)
Meets Expectations (An employee in this category has met all areas of expectations and effectively demonstrated relevant
competencies.)
Needs Improvement (Performance that is acceptable is some, but not all aspects of the job and does not consistently meet basic position
requirements.)
Next Review will be conducted on
Summary /Areas for Improvement
to
Signature Page
Employee Comments:
Employee Signature
I have received a written and verbal Performance Review. My signature does not indicate agreement or disagreement with this review.
Employee Signature Department Date,
Supervisor Signature
I have written and delivered a performance Review for this employee:
Supervisor Signatu
Position Date
Executive Director Signature Date
I1