HomeMy WebLinkAbout2013-259 DSS - Charles House Associates for Adult Day Services to Clients of Orange County $25,000 sZd�3 - .z .S
Contract#68-2009 S5
Charles House Association
Contract# 68-2009 Fiscal Year Begins Julyl,2013 Ends June 30,2014
This contract is hereby entered into by and between the Orange County Department of Social Services (the "County") and
Charles House Association (the "Contractor") (referred to collectively as the "Parties"). The Contractor's federal tax
identification number or S r is $
1. Contract Documents: This Contract consists of the following documents
(1) This contract
(2) The General Terms and Conditions(Attachment A)
(3) The Scope of Work, description of services,and rate(Attachment B)
(4) Federal Certification Regarding Drug-Free Workplace&Certification Regarding Nondiscrimination(Attachment C)
(5) Conflict of Interest(Attachment D)
(6) No Overdue Taxes(Attachment E)
(7) HIPAA Business Associate Addendum(Attachment 1)
(8) Certification of Transportation(Attachment J)
(9) IRS Federal Tax Exempt Letter or 501(c)(3)(Attachment K)
(10)Outcomes and Reporting(Attachment N)
(11)Contract Determination Questionnaire
These documents constitute the entire agreement between the Parties and supersede all prior oral or written statements or
agreements.
2. Precedence Among Contract Documents: In the event of a conflict between or among the terms of the Contract
Documents, the terms in the Contract Document with the highest relative precedence shall prevail. The order of
precedence shall be the order of documents as listed in Paragraph 1, above, with the first-listed document having the
highest precedence and the last-listed document having the lowest precedence. If there are multiple Contract
Amendments, the most recent amendment shall have the highest precedence and the oldest amendment shall have the
lowest precedence.
3. Effective Period: This contract shall be effective on July 1,2013 and shall terminate on June 30, 2014.
This contract must be twelve months or less.
4. Contractor's Duties: The Contractor shall provide the services and in accordance with the approved rate as described in
Attachment B, Scope of Work, and shall meet the requirements set forth in Attachment N, Outcomes and Reporting.
5. County's Duties: The County shall pay the Contractor in the manner and in the amounts specified in the Contract
Documents. The total amount paid by the County to the Contractor under this contract shall not exceed$25,000. This
amount consists of$25,000 in Federal (CFDA # ), State and County funds, $0 (source of other funds if
applicable).
[X] a. There are no matching requirements from the Contractor.
[ ] b. The Contractor's matching requirement is$ Vwhich shall consist of
[ ] In-kind [ ] Cash
[ ] Cash and In-kind [ ] Cash and/or In-kind
The contributions from the Contractor shall be sourced from non-federal funds.
The total contract amount incid'hing any Contractor match shall not exceed$25,000.
6. Reporting Requirements:
Contractor shall comply with audit requirements as described in N.C.G.S. § 143C-6-22&23 and OMB Circular A-133.
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Contract 468-2009
Charles House Association
7. Payment Provisions:
Payment shall be made in accordance with the Contract Documents as described in the Scope of Work,
Attachment B.
8. Contract Administrators: All notices permitted or required to be given by one Party to the other and all questions about
the contract from one Party to the other shall be addressed and delivered to the other Party's Contract Administrator. The
name,post office address,street address,telephone number,fax number,and email address of the Parties'respective initial
Contract Administrators are set out below. Either Party may change the name, post office address, street address,
telephone number,fax number,or email address of its Contract Administrator by giving timely written notice to the other
Party.
For the County:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Denise Shaffer, Social Work Program Director Denise Shaffer, Social Work Program Director
Orange County Department of Social Services Orange County Department of Social Services
P.O. Box 8181 2501 Homestead Road
Hillsborough,NC 27278 Chapel Hill,NC 27516
(919)968-2000 ext.246
(919)968-2012
dshaffer co.oran e.nc.us
Program Contact:
Renee Bynum,Adult Services Supervisor
Orange County Department of Social Services
P.O. Box 8181
113 Mayo Street
Hillsborough,NC 27278
(919)245-2881
bynum@co.orqnge.nc.us
For the Contractor:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Paul Klever Paul Klever
'Charles House Association Charles House Association
109 Hillcrest Avenue 109 Hillerest Avenue
Carrboro,NC 27510 Carrboro,NC 27510
(919)967-7570
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Charles House Association
9. No Assignment or Sub-Contract: Contractor shall not sub-contract out any of the services provided for in this
Agreement or make any assignment of this Agreement(including rights to payments)without the prior written Consent of
the County as specified more fully in Attachment A, General Terms and Conditions.
10. Supplementation of Expenditure of Public Funds: The Contractor assures that funds received pursuant to this contract
shall be used only to supplement, not to supplant, the total amount of federal, state and local public funds that the
Contractor otherwise expends for contract services and related programs.Funds received under this contract shall be used
to provide additional public funding for such services; the funds shall not be used to reduce the Contractor's total
expenditure of other public funds for such services.
11. Disbursements: As a condition of this contract, the Contractor acknowledges and agrees to make disbursements in
accordance with the following requirements:
a. Implement adequate internal controls over disbursements;
b. Pre-audit all vouchers presented for payment to determine:
i. Validity and accuracy of payment
ii. Payment due date
iii. Adequacy of documentation supporting payment
iv. Legality of disbursement
c. Assure adequate control of signature stamps/plates;
d. Assure adequate control of negotiable instruments;and
e. Implement procedures to insure that account balance is solvent and reconcile the account monthly.
12. Outsourcing to Other Countries: The Contractor certifies that it has identified to the County all jobs related to the
contract that have been outsourced to other countries,if any.The Contractor further agrees that it will not outsource any
such jobs during the term of this contract without providing notice to the County.
13. Federal Certifications: Individuals and Organizations receiving federal funds must ensure compliance with certain
certifications required by federal laws and regulations. The contractor is hereby complying with Certifications regarding
Nondiscrimination, Drug-Free Workplace Requirements, Environmental Tobacco Smoke, Debarment, Suspension,
Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions, and Lobbying. These assurances and
certifications are to be signed by the contractor's authorized representative.
14. Relationship of the Parties: Contractor is an independent contractor of the County.Contractor represents that it has or
will secure,at its own expense,all personnel required in performing the services under this Agreement. Such personnel
shall not be employees of or have any contractual relationship with the County. All personnel engaged in work under this
Agreement shall be fully qualified and shall be authorized or permitted under state and local law to perform such services.
It is further agreed by Contractor that it shall obey all State and Federal statutes,rules and regulations which are applicable
to provisions of the services called for herein. Neither Contractor nor any employee of the Contractor shall be deemed an
officer,employee or agent of the County.
15. Signature Warranty:
The undersigned represent and warrant that they are authorized to bind their principals to the terms of this agreement. The
Contractor and the County have executed this contract in duplicate originals,with one original being retained by each party.
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Contract 968-2009
Charles House Association
CHARLES HOUSE ASSOCIATION
�61 P'�'
Signature Date
tAL 5. l��lll��Z- irFeuyry� ,e_k0#749
Printed Name Title �—
ORANGE COUNTY
716
Frank W. Clifton, ., unt an r Date
This instrument has been approved as to technical content.
Na y C son, ep ment Social Services Director Date
This i strument has been pre-audited in the manner required by the Local Government Budget a d Fiscal Control Act.
#711711
Clarence G.Grier, Asst. County Manager/CFO Date
This co has en approved as to form and legal sufficiency.
� 2 L3
Annette t. Moor Staff A orney ate
,
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Contract#68-2009
Charles House Association
ATTACHMENT A
GENERAL TERMS AND CONDITIONS
Orange County Department of Social Services
Relationships of the Parties the County or the Contractor,receiving services or benefits
under this contract shall be deemed an incidental
Independent Contractor: The Contractor is and shall be beneficiary only.
deemed to be an independent contractor in the performance
of this contract and as such shall be wholly responsible for
the work to be performed and for the supervision of its Indemnity and Insurance
employees. The Contractor represents that it has, or shall
secure at its own expense, all personnel required in Indemnification: The Contractor agrees to indemnify and
performing the services under this agreement. Such hold harmless the County and any of their officers,agents
employees shall not be employees of, or have any and employees,from any claims of third parties arising out
individual contractual relationship with the County. or any act or omission of the Contractor in connection with
the performance of this contract.
Subcontracting: The Contractor shall not subcontract any
of the work contemplated under this contract without prior Insurance: During the term of the contract,the Contractor
written approval from the County. Any approved at its sole cost and expense shall provide commercial
subcontract shall be subject to all conditions of this insurance of such type and with such terms and limits as
contract.Only the subcontractors specified in the contract may be reasonably associated with the contract. As a
documents are to be considered approved upon award of minimum, the Contractor shall provide and maintain the
the contract. The County shall not be obligated to pay for following coverage and limits:
any work performed by any unapproved subcontractor. (a) Worker's Compensation - The contractor shall
The Contractor shall be responsible for the performance of provide and maintain Worker's Compensation
all of its subcontractors. Insurance as required by the laws of North
Carolina,as well as employer's liability coverage
Assignment: No assignment of the Contractor's with minimum limits of$500,000.00,covering all
obligations or the Contractor's right to receive payment of Contractor's employees who are engaged in any
hereunder shall be permitted. However, upon written work under the contract. If any work is sublet,the
request approved by the issuing purchasing authority,the Contractor shall require the subcontractor to
County may: provide the same coverage for any of his
(a) Forward the Contractor's payment check(s) employees engaged in any work under the
directly to any person or entity designated by the contract.
Contractor,or (b) Commercial General Liability - General
(b) Include any person or entity designated by Liability Coverage on a Comprehensive Broad
Contractor as a joint payee on the Contractor's Form on an occurrence basis in the minimum
payment check(s). amount of$1,000,000.00 Combined Single Limit.
In no event shall such approval and action obligate the (Defense cost shall be in excess of the limit of
County to anyone other than the Contractor and the liability.)
Contractor shall remain responsible for fulfillment of all (c)Automobile Liability Insurance: The Contractor
contract obligations. shall provide automobile liability insurance with a
combined single limit of$500,000.00 for bodily
Beneficiaries: Except as herein specifically provided injury and property damage; a limit of
otherwise,this contract shall inure to the benefit of and be $500,000.00 for uninsured/under insured motorist
binding upon the parties hereto and their respective coverage; and a limit of$25,000.00 for medical
successors. It is expressly understood and agreed that the payment coverage. The Contractor shall provide
enforcement of the terms and conditions of this contract, this insurance for all automobiles that are:
and all rights of action relating to such enforcement,shall (a) owned by the Contractor and used in the
be strictly reserved to the County and the named performance of this contract;
Contractor.Nothing contained in this document shall give (b) hired by the Contractor and used in the
or allow any claim or right of action whatsoever by any performance of this contract;and
other third person.It is the express intention of the County (c) Owned by Contractor's employees and
and Contractor that any such person or entity, other than used in performance of this contract("non-
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Contract#68-2009
Charles House Association
owned vehicle insurance"). Non-owned
vehicle insurance protects employers when
employees use their personal vehicles for Default and Termination
work purposes. Non-owned vehicle
insurance supplements, but does not Termination Without Cause: The County may terminate
replace,the car-owner's liability insurance. this contract without cause by giving 30 days written
notice to the Contractor.
The Contractor is not required to provide and maintain
automobile liability insurance on any vehicle—owned, Termination for Cause: If, through any cause, the
hired, or non-owned--unless the vehicle is used in the Contractor shall fail to fulfill its obligations under this
performance of this contract. contract in a timely and proper manner,the County shall
(d) The insurance coverage minimums specified in have the right to terminate this contract by giving written
subparagraph(a)are exclusive of defense costs. notice to the Contractor and specifying the effective date
(e) The Contractor understands and agrees that the thereof. In that event,all finished or unfinished deliverable
insurance coverage minimums specified in items prepared by the Contractor under this contract shall,
subparagraph (a) are not limits, or caps, on the at the option of the County, become its property and the
Contractor's liability or obligations under this contract. Contractor shall be entitled to receive just and equitable
(f) The Contractor may obtain a waiver of any one or more compensation for any satisfactory work completed on such
of the requirements in subparagraph (a) by materials,minus any payment or compensation previously
demonstrating that it has insurance that provides made. Notwithstanding the foregoing provision, the
protection that is equal to or greater than the coverage Contractor shall not be relieved of liability to the County
and limits specified in subparagraph(a). The County for damages sustained by the County by virtue of the
shall be the sole judge of whether such a waiver Contractor's breach of this agreement,and the County may
should be granted. withhold any payment due the Contractor for the purpose
(g) The Contractor may obtain a waiver of any one or more of setoff until such time as the exact amount of damages
of the requirements in paragraph(a)by demonstrating due the County from such breach can be determined. In
that it is self-insured and that its self-insurance case of default by the Contractor, without limiting any
provides protection that is equal to or greater than the other remedies for breach available to it,the County may
coverage and limits specified in subparagraph(a). The procure the contract services from other sources and hold
County shall be the sole judge of whether such a the Contractor responsible for any excess cost occasioned
waiver should be granted. thereby. The filing of a petition for bankruptcy by the
(h) Providing and maintaining the types and amounts of Contractor shall be an act of default under this contract.
insurance or self-insurance specified in this paragraph
is a material obligation of the Contractor and is of the Waiver of Default: Waiver by the County of any default
essence of this contract. or breach in compliance with the terms of this contract by
(i) The Contractor shall only obtain insurance from the Provider shall not be deemed a waiver of any
companies that are authorized to provide such subsequent default or breach and shall not be construed to
coverage and that are authorized by the Commissioner be modification of the terms of this contract unless stated
of Insurance to do business in the State of North to be such in writing, signed by an authorized
Carolina.All such insurance shall meet all laws of the representative of the County and the Contractor and
State of North Carolina. attached to the contract.
(j) The Contractor shall comply at all times with all lawful
terms and conditions of its insurance policies and all Availability of Funds: The parties to this contract agree
lawful requirements of its insurer. and understand that the payment of the sums specified in
(k) The Contractor shall require its subcontractors to this contract is dependent and contingent upon and subject
comply with the requirements of this paragraph. to the appropriation, allocation, and availability of funds
(1) The Contractor shall demonstrate its compliance with for this purpose to the County.
the requirements of this paragraph by submitting
certificates of insurance to the County before the Force Majeure: Neither party shall be deemed to be in
Contractor begins work under this contract. default of its obligations hereunder if and so long as it is
prevented from performing such obligations by any act of
Transportation of Clients by Contractor: war,hostile foreign action,nuclear explosion,riot,strikes,
The contractor will maintain Insurance requirements if civil insurrection,earthquake,hurricane,tornado,or other
required as noted under Article 7 Rule R2-36 of the North catastrophic natural event or act of God.
Carolina Utilities Commission.
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Contract 968-2009
Charles House Association
Survival of Promises: All promises,requirements,terms, The Contractor will comply with the requirements of
conditions, provisions, representations, guarantees, and Section 106(g)of the Trafficking Victims Protection Act
warranties contained herein shall survive the contract of 2000,as amended(22 U.S.C. 7104)
expiration or termination date unless specifically provided
otherwise herein, or unless superseded by applicable Confidentiality
Federal or State statutes of limitation.
Confidentiality: Any information, data, instruments,
Intellectual Property Rights documents, studies or reports given to or prepared or
assembled by the Contractor under this agreement shall be
Copyrights and Ownership of Deliverables: All kept as confidential and not divulged or made available to
deliverable items produced pursuant to this contract are the any individual or organization without the.prior written
exclusive property of the County. The Contractor shall not approval of the County.The Contractor acknowledges that
assert a claim of copyright or other property interest in in receiving,storing,processing or otherwise dealing with
such deliverables. any confidential information it will safeguard and not
further disclose the information except as otherwise
Federal Intellectual Property Bankruptcy Protection provided in this contract.
Act: The Parties agree that the County shall be entitled to
all rights and benefits of the Federal Intellectual Property Oversight
Bankruptcy Protection Act,Public Law 100-506,codified
at 1 l U.S.C. 365 (n) and any amendments thereto. Access to Persons and Records: The State Auditor shall
have access to persons and records as a result of all
Compliance with Applicable Laws contracts or grants entered into by State agencies or
political subdivisions in accordance with General Statute
Compliance with Laws: The Contractor shall comply 147-64.7. Additionally,as the State funding authority,the
with all laws, ordinances, codes, rules, regulations, and Department of Health and Human Services shall have
licensing requirements that are applicable to the conduct of access to persons and records as a result of all contracts or
its business, including those of federal, state, and local grants entered into by State agencies or political
agencies having jurisdiction and/or authority. subdivisions.
Title VI,Civil Rights Compliance: In accordance with Record Retention: Records shall not be destroyed,
Federal law and U.S. Department of Agriculture(USDA) purged or disposed of without the express written consent
and U.S. Department of Health and Human Services of the County. The North Carolina State basic records
(HHS) policy, this institution is prohibited from retention policy requires all grant records to be retained for
discriminating on the basis of race,color, national origin, a minimum of five years or until all audit exceptions have
sex, age or disability. Under the Food Stamp Act and been resolved, whichever is longer. If the contract is
USDA policy, discrimination is prohibited also on the subject to federal policy and regulations,record retention
basis of religion or political beliefs. may be longer than five years since records must be
retained for a period of three years following submission of
Equal Employment Opportunity: The Contractor shall the final Federal Financial Status Report, if applicable,or
comply with all federal and State laws relating to equal three years following the submission of a revised final
employment opportunity. Federal Financial Status Report. Also, if any litigation,
claim, negotiation, audit, disallowance action, or other
Health Insurance Portability and Accountability Act action involving this Contract has been started before
(HIPAA): The Contractor agrees that, if the County expiration of the five-year retention period described
determines that some or all of the activities within the above,the records must be retained until completion of the
scope of this contract are subject to the Health Insurance action and resolution of all issues which arise from it, or
Portability and Accountability Act of 1996,P.L. 104-91, until the end of the regular five-year period described
as amended("HIPAA"),or its implementing regulations, above, whichever is later.
it will comply with the HIPAA requirements and will
execute such agreements and practices as the County Warranties and Certifications
may require to ensure compliance.
Date and Time Warranty: The Contractor warrants that
Trafficking Victims Protection Act of 2000 : the product(s) and service(s) furnished pursuant to this
contract("product"includes,without limitation,any piece
of equipment,hardware,firmware,middleware,custom or
General Terms and Conditions—(07/10) Page 3 of 5
Contract#68-2009
Charles House Association
commercial software,or internal components,subroutines,
and interfaces therein)that perform any date and/or time Time of the Essence: Time is of the essence in the
data recognition function, calculation, or sequencing will performance of this contract.
support a four digit year format and will provide accurate
date/time data and leap year calculations. This warranty Executive Order#24: It is unlawful for any vendor,
shall survive the termination or expiration of this contract. contractor, subcontractor or supplier of the state to make
gifts or to give favors to any state employee. For
Certification Regarding Collection of Taxes: G.S. 143- additional information regarding the specific
59.1 bars the Secretary of Administration from entering requirements and exemptions,contractors are
into contracts with vendors that meet one of the conditions encouraged to review Executive Order 24 and G.S. Sec.
of G.S. 105-164.8(b)and yet refuse to collect use taxes on 133-32.
sales of tangible personal property to purchasers in North
Carolina. The conditions include: (a) maintenance of a Key Personnel: The Contractor shall not replace any of
retail establishment or office; (b) presence of the key personnel assigned to the performance of this
representatives in the State that solicit sales or transact contract without the prior written approval of the County.
business on behalf of the vendor; and (c) systematic The term "key personnel" includes any and all persons
exploitation of the market by media-assisted, media- identified as such in the contract documents and any other
facilitated, or media-solicited means. The Contractor persons subsequently identified as key personnel by the
certifies that it and all of its affiliates (if any) collect all written agreement of the parties.
required taxes.
Care of Property: The Contractor agrees that it shall be
Miscellaneous responsible for the proper custody and care of any property
furnished to it for use in connection with the performance
Choice of Law: The validity of this contract and any of its of this contract and will reimburse the County for loss of,
terms or provisions,as well as the rights and duties of the or damage to, such property. At the termination of this
parties to this contract,are governed by the laws of North contract, the Contractor shall contact the County for
Carolina.The Contractor, by signing this contract,agrees instructions as to the disposition of such property and shall
and submits,solely for matters concerning this Contract,to comply with these instructions.
the exclusive jurisdiction of the courts of North Carolina
and agrees, solely for such purpose, that the exclusive Travel Expenses: Reimbursement, if provided in this
venue for any legal proceedings shall be Orange County, Agreement, to the Contractor for travel mileage, meals,
North Carolina. The place of this contract and all lodging and other travel expenses incurred in the
transactions and agreements relating to it, and their situs performance of this contract shall not exceed the rates
and forum,shall be Orange County,North Carolina,where established in County policy.
all matters,whether sounding in contract or tort,relating to
the validity,construction,interpretation,and enforcement Sales/Use Tax Refunds: If eligible,the Contractor and all
shall be determined. subcontractors shall: (a) ask the North Carolina
Department of Revenue for a refund of all sales and use
Amendment: This contract may not be amended orally or taxes paid by them in the performance of this contract,
by performance. Any amendment must be made in written pursuant to G.S. 105-164.14; and (b) exclude all
form and executed by duly authorized representatives of refundable sales and use taxes from all reportable
the County and the Contractor. expenditures before the expenses are entered in their
reimbursement reports.
Severability: In the event that a court of competent
jurisdiction holds that a provision or requirement of this Advertising: The Contractor shall not use the award of
contract violates any applicable law, each such provision this contract as a part of any news release or commercial
or requirement shall continue to be enforced to the extent it advertising.
is not in violation of law or is not otherwise unenforceable
and all other provisions and requirements of this contract Orange County Living Wage: Orange County is
shall remain in full force and effect. committed to providing its employees with a living wage
and encourages agencies to which it provides funding to
Headings: The Section and Paragraph headings in these pursue the same goal. The County's living wage hourly
General Terms and Conditions are not material parts of the standard, as adopted by the Orange County Board of
agreement and should not be used to construe the meaning County Commissioners annually, can be found in the
thereof. Orange County Budget Ordinance. To the extent
General Terms and Conditions—(07/10) Page 4 of 5
Contract#68-2009
Charles House Association
possible,Orange County recommends that the
Contractor and all subcontractors provide a living wage,
as defined in this section,to their employees.
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Contract#68-2009
Charles House Association
ATTACHMENT B
SCOPE OF WORK
Orange County Department of Social Services
Federal Tax Id. o
Contract 4 68-2009
A. CONTRACTOR INFORMATION
1. Contractor Agency Name: Charles House Association
2. If different from Contract Administrator Information in General Contract:
Address
Telephone Number:�*AG 7 7.0&--> _ Fax Number:9Y9•*07 X57&Email: -,n
o tiQti/rs/tlhlQ�.or g
3. Name of Program(s): Adult Day Service J
4. Status: ( )Public (X) Private,Not for Profit ( ) Private, For Profit
5. Contractor's Financial Reporting Year July 1,2013 through June 30,2014
B. Explanation of Services to be provided and to whom(include SIS Service Code): The
Contractor will provide Adult Day Services(SIS Code 030)to clients of the Orange County
Department of Social Services. These services will be provided in accordance with provisions set
forth in Volume IV of the Adult and Family Services Manual,Chapter II-Adult Day Care
Services. The Contractor is required to meet all goals and outcomes listed in Attachment N.
C. Rate per unit of Service(define the unit):
1. If Standard Fixed Rate, Maximum Allowable,(See Rates for Services Chart)
$33.07/day
2.Negotiated County Rate.
D.Number of units to be provided:
E. Details of Billing process and Time Frames;The County will reimburse the Contractor for
services described in this contract up to the budgetary limits of the contract allotment. The
County will reimburse the Contractor at a rate of$33.07/day for approved services provided. For
reimbursement the Contractor must submit an original and two copies of an invoice by the fifth
of the month for the preceding month's expenditures to the designated County Administrator.
The County will reimburse the Contractor monthly upon receipt of a complete and correctly filed
report.
The service(s) under contract with the Contractor are services for which a client may voluntarily
contribute to the cost. Policies regarding the solicitation and acceptance of voluntary
Contract-Scope of Work(06/04) Page Iof 2
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Charles House Association
contributions are contained in Family Services Manual Volume VI Chapter III If a client
voluntarily contributes to the cost of service the County will inform the Contractor of the amount
of the contribution and of any subsequent changes The Contractor will establish aplan with the
client for accepting the contribution on at least a monthly basis, when contributions are not
received within ten days of the agreed upon date will notify the client in writing and send a copy
of the notification to the County. No other fees for services may be charged to the client Client
contributions are to be reported monthly to the County.
F. Area to be served/Delivery site(s): Orange County
Nancy Coston, cial Services Director (Signature of Contractor)
CO- 15-O
(Date Submitted) (Date Submitted)
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Contract#68-2009
Charles House Association
ATTACHMENT C
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
AND CERTIFICATION REGARDING NONDISCRIMINATION
Orange County Department of Social Services
I. By execution of this Agreement the Contractor certifies that it will provide a drug-free workplace by:
A. Publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance is prohibited in the Contractor's
workplace and specifying the actions that will be taken against employees for violation of such
prohibition;
B. Establishing a drug-free awareness program to inform employees about:
(1)The dangers of drug abuse in the workplace;
(2)The Contractor's policy of maintaining a drug-free workplace;
(3)Any available drug counseling,rehabilitation, and employee assistance programs; and
(4)The penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace;
C. Making it a requirement that each employee be engaged in the performance of the agreement be
given a copy of the statement required by paragraph(A);
D. Notifying the employee in the statement required by paragraph(A)that,as a condition of
employment under the agreement,the employee will:
(1)Abide by the terms of the statement; and
(2)Notify the employer of any criminal drug statute conviction for a violation occurring
in the workplace no later than five days after such conviction;
E. Notifying the County within ten days after receiving notice under subparagraph(D)(2)from an
employee or otherwise receiving actual notice of such conviction;
F. Taking one of the following actions,within 30 days of receiving notice under subparagraph
(D)(2), with respect to any employee who is so convicted:
(1)Taking appropriate personnel action against such an employee, up to and including
termination; or
(2)Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local health,
law enforcement, or other appropriate agency; and
Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs(A), (B), (C), (D), (E), and(F).
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Contract 968-2009
Charles Douse Association
II. The site(s)for the performance of work done in connection with the specific agreement are listed
below:
(Street address)
(City,county, state, zip code)
2.
(Street address)
(City,county,state,zip code)
Contractor will inform the County of any additional sites for performance of work under this agreement.
False certification or violation of the certification shall be grounds for suspension of payment, suspension
or termination of grants,or government-wide Federal suspension or debarment(45 C.F.R. Section
82.510. Section 4 CFR Part 85, Section 85.615 and 86.620).
CERTIFICATION REGARDING NONDISCRIMINATION
The Vendor certifies that it will comply with all Federal statutes relating to nondiscrimination. These
include but are not limited to: (a)Title VI of the Civil Rights Act of 1964(P.L. 88-352)which prohibits
discrimination on the basis of race,color or national origin; (b)Title IX of the Education Amendments of
1972, as amended(20 U.S.C. §§1681-1683, and 1685-1686),which prohibits discrimination on the basis
of sex;(c) Section 504 of the Rehabilitation Act of 1973,as amended(29 U.S.C. §794),which prohibits
discrimination on the basis of handicaps; (d)the Age Discrimination Act of 1975, as amended(42 U.S.C.
§§6101-6107), which prohibits discrimination on the basis of age; (e)the Drug Abuse Office and
Treatment Act of 1972(P.L.92-255), as amended,relating to nondiscrimination on the basis of drug
abuse;(f)the Comprehensive Alcohol Abuse and Alcoholism Prevention,Treatment and Rehabilitation
Act of 1970(P.L. 91-616),as amended,relating to nondiscrimination on the basis of alcohol abuse or
alcoholism;(g)Title VIII of the Civil Rights Act of 1968(42 U.S.C. §§3601 et seq.), as amended,
relating to nondiscrimination in the sale, rental or financing of housing; (h)the Food Stamp Act and
USDA policy, which prohibit discrimination on the basis of religion and political beliefs; and(i)the
requirements of any other nondiscrimination statutes which may apply to this Agreement.
6Lr O�-
Signature Title
(�w X; WM I kgTIO,J 1��- 2q.
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Federal Certification-Drug-Free Workplace(07/10) Page 2 of
Contract#68-2009
Charles House Association
ATTACHMENT D
CONFLICT OF INTEREST POLICY
Orange County Department of Social Services
The Board of Directors/Trustees or other governing persons, officers, employees or agents are to
avoid any conflict of interest, even the appearance of a conflict of interest. The Organization's
Board of Directors/Trustees or other governing body, officers, staff and agents are obligated to
always act in the best interest of the organization. This obligation requires that any Board member
or other governing person, officer, employee or agent, in the performance of Organization duties,
seek only the furtherance of the Organization mission. At all times, Board members or other
governing persons, officers, employees or agents, are prohibited from using their job title, the
Organization's name or property,for private profit or benefit.
A. The Board members or other governing persons, officers, employees, or agents of the
Organization should neither solicit nor accept gratuities, favors, or anything of monetary value
from current or potential contractors/vendors, persons receiving benefits from the Organization or
persons who may benefit from the actions of any Board member or other governing person,
officer, employee or agent. This is not intended to preclude bona-fide Organization fund raising-
activities.
B. A Board or other governing body member may, with the approval of Board or other governing
body, receive honoraria for lectures and other such activities while not acting in any official
capacity for the Organization. Officers may, with the approval of the Board or other governing
body, receive honoraria for lectures and other such activities while on personal days,
compensatory time, annual leave, or leave without pay. Employees may, with the prior written
approval of their supervisor, receive honoraria for lectures and other such activities while on
personal days, compensatory time, annual leave, or leave without pay. If a Board or other
governing body member, officer, employee or agent is acting in any official capacity, honoraria
received in connection with activities relating to the Organization are to be paid to the
Organization.
C. No Board member or other governing person, officer, employee, or agent of the Organization
shall participate in the selection, award, or administration of a purchase or contract with a vendor
where,to his knowledge,any of the following has a financial interest in that purchase or contract:
1. The Board member or other governing person,officer,employee,or agent;
2. Any member of their family by whole or half blood, step or personal relationship or
relative-in-law;
3. An organization in which any of the above is an officer,director,or employee;
4. A person or organization with whom any of the above individuals is negotiating or has
any arrangement concerning prospective employment or contracts.
D. Duty to Disclosure-- Any conflict of interest, potential conflict of interest, or the appearance
of a conflict of interest is to be reported to the Board or other governing body or one's supervisor
immediately.
E. Board Action -- When a conflict of interest is relevant to a matter requiring action by the
Board of Directors/Trustees or other governing body, the Board member or other governing
person, officer,employee, or agent(person(s))must disclose the existence of the conflict of
interest and be given the opportunity to disclose all material facts to the Board and members of
Conflict of Interest Policy(06/04) Pagel of 3
Contract#68-2009
Charles House Association
committees with governing board delegated powers considering the possible conflict of interest.
After disclosure of all material facts, and after any discussion with the person, he/she shall leave
the governing board or committee meeting while the determination of a conflict of interest is
discussed and voted upon. The remaining board or committee members shall decide if a conflict
of interest exists. In addition,the person(s)shall not participate in the final deliberation or
decision regarding the matter under consideration and shall leave the meeting during the
discussion of and vote of the Board of Directors/Trustees or other governing body.
F. Violations of the Conflicts of Interest Policy -- If the Board of Directors/Trustees or other
governing body has reasonable cause to believe a member, officer, employee or agent has failed
to disclose actual or possible conflicts of interest, it shall inform the person of the basis for such
belief and afford the person an opportunity to explain the alleged failure to disclose. If, after
hearing the person's response and after making further investigation as warranted by the
circumstances, the Board of Directors/Trustees or other governing body determines the member,
officer, employee or agent has failed to disclose an actual or possible conflict of interest, it shall
take appropriate disciplinary and corrective action.
G. Record of Conflict -- The minutes of the governing board and all committees with board
delegated powers shall contain:
1. The names of the persons who disclosed or otherwise were found to have an actual or
possible conflict of interest, the nature of the conflict of interest, any action taken to
determine whether a conflict of interest was present, and the governing board's or
committee's decision as to whether a conflict of interest in fact existed.
2. The names of the persons who were present for discussions and votes relating to the
transaction or arrangement that presents a possible conflict of interest, the content of the
discussion, including any alternatives to the transaction or arrangement, and a record of
any votes taken in connection with the proceedings.
Approved by:
NAT2�XS 46A5 Ass od4A-0 DK
Name of Organization
Signature of Organization Official
ce 13
Date
Conflict of Interest Policy(06/04) Page 2 of 3
Contract#68-2009
Charles House Association
NOTARIZED CONFLICT OF INTEREST POLICY
State of North Carolina
County of Orange
I, Notary Public for said County and State,
certify that 43LA-4,, `e;LLVVa, personally appeared before me this
day and acknowledged that he/she is PA of
C 1. ,.41a-(kMno ASSPCA`C- *tl - and by that authority duly given and as the
act of the corporation, affirmed that the foregoing Conflict of Interest Policy was adopted by the
Board of Directors in a meeting held on the 10 day of /at" zoQS
Sworn to and subscribed before me this 'Z N day of
(Official Seal)
Notary Public
My Commission expires G / t ,20 /57/
Conflict of Interest Policy(06/04) Page 3 of 3
CHARLES HousE AsSOO O TR oON
109 Hilicrest Ave. Carrboro, NC 27510
Conflict ®f Interest Policy
August, 2005
PURPOSE:
The purpose of the conflict of interest policy is to protect Charles House Association's
(Organization) interest when it is contemplating entering into a transactions or
arrangement that might benefit the private interest of an officer or director of the
organization or might result in a possible excess benefit transaction. This policy is
intended to supplement but not replace applicable state and federal laws governing
conflict of interest application to nonprofit and charitable organizations.
DEFINITIONS:
Interested Person
A conflict of interest is defined as an actual or perceived interest by a staff member,
contractor, Board member or volunteer, in an action that results in, or has the
appearance of resulting in, personal, organizational or professional gain. A conflict of
interest occurs when an employee, contractor or board member has a direct or fiduciary
interest in another relationship. A conflict of interest could include:
• Ownership with a member of the Board of Directors or an employee where
one or the other has supervisory authority over the other or with a client
who receives services.
• Employment of or by a member of the Board of Directors or an employee
where one or the other has supervisory authority over the other or with a
client who receives services.
• Contractual relationship with a member of the Board of Directors or an
employee where one or the other has supervisory authority over the other
or with a client who receives services.
• Creditor or debtor to a member of the Board of Directors or an employee
where one or the other has supervisory authority over the other or with a
client who receives services.
• Consultative or consumer relationship with a member of the Board of
Directors or and employee where one or the other has supervisory
authority over the other or with a client who receives services.
The definition of conflict of interest includes any bias or the appearance of bias in a
decision-making process that would reflect a dual role played by a member of the
organization or group. An example, for instance, might involve a person who is an
employee and a Board Member, or a person who is an employee and who hires family
members as consultants. i
i
RESPONSIBILITIES:
Employees, Contractor, Board Member
It is in the interest of the organization, individual staff and Board Member to strengthen
trust and confidence in each other, to expedite resolution of problems, to mitigate the
effect and to minimize organizational and individual stress that can be caused by a
conflict of interest.
Employees are to avoid any conflict of interest, even the appearance of a conflict of
interest. This organization serves the community as a whole rather than only serving a
special interest group. The appearance of a conflict of interest can cause
embarrassment to the organization and jeopardize the credibility of the organization.
Any conflict of interest, potential conflict of interest or the appearance of a conflict of
interest is to be reported to your supervisor immediately. Employees are to maintain
independence and objectivity with clients, the community and organization. Employees
are called to maintain a sense of fairness, civility, ethics and personal integrity even
though law, regulation or custom does not required them.
Acceptance of Gifts
Employees, members of employee's immediate family and members of the Board are
prohibited from accepting gifts, money or gratuities from the following:
1. Persons receiving benefits or services from the organization
2. Any person or organization performing or seeking to perform services uner
contract with the organization; and
3. Persons who are otherwise in a position to benefit from the actions of any
employee of the organization.
Employees may, with the prior written approval of their supervisor, receive honoraria for
lectures and other such activities while on personal days, compensatory time, annual
leave or leave without pay. If the employee is acting in any official capacity, honoraria
received by an employee in connection with activities related to employment with the
organization are to be paid to the organization.
(DSS Template)
CHARLES HOUSE ASSOCIATION
Helping People Age the Way They Have Lived
July 24,2013
Serving Seniors and Their TO: Orange County Department of Social Services
Families Since 1990
CERTIFICATION:
Enriching the lives of seniors
Supporting families caring for We certify that Charles House Association does not have any overdue tax debts,as
aging family members defined by N.C.G.S. 105-243.1,at the federal,state or local level.We further
Representing the community's understand that any person who makes a false statement in violation of N.C.G.S. 143-
commitment to its elders
6.2(b2)is guilty of a criminal offense punishable as provided by N.C.G.S. 143-34(b).
BOARD OF DIRECTORS
SWORN STATEMENT:
PRESIDENT
Beth Tillman Beth Tillman and Paul Klever being duly sworn,say that we are the Board President
VICE PRESIDENT and the Executive Director,respectively,of Charles House Association of Carrboro in
Luke Riggsbee the state of North Carolina;and that the foregoing certification is true,accurate and
complete to the best of our knowledge and was made and subscribed by us.We also
SECRETARY acknowledge and understand that any misuse of State funds will be reported to the
Dickie Andrews appropriate authorities for further action.
TREASURER
Cindy Skocik
1 _
Board President
Michael Bradley
Shelly Craig-Taylor CW /
Shelly Eubanks �wL/`'
Deborah Frazier Executive Director
Michael Hill
Patty Hill Sworn to and subscribed before me on the day of the date of said certification.
Norman Klase ````�4�,
Katie Koenig \\\�.'SNON M.
Caroline Resnick
Jerry Salak
Tammie Stanton M . = Notary Public
Sheryl Zimmerman Q4otdy Signature and Seal) = Durham County
EXECUTIVE
DIRECTOR My Commission Expires:
Paul Klever
paul @charleshouse.org
G.S. 105-243.1 defines:Overdue tax debt.—Any part of a tax debt that remains unpaid 90 days
or more after the notice of final assessment was mailed to the taxpayer. The term dows not
include a tax debt,however,if the taxpayer entered into an installment agreement for the tax
debt under G.S. 105-237 within 90 days after the notice of final assessment was mailed and has
not failed to make any payments due under the installment agreement.
109 Hillcrest Avenue, Carrboro, NC 27510 (919) 967-7570
Contract#68-2009
Charles House Association
ATTACHMENT I
BUSINESS ASSOCIATE ADDENDUM
Orange County Department of Social Services s
This Agreement is made effective the 1 rday of�3 , 20_4 by and between Orange
County ("Covered Entity") and Charles House Associatio ("Business Associate") (collectively
the"Parties").
1. BACKGROUND
a. Covered Entity and Business Associate are parties to a contract entitled #68-2009 (the
"Contract"), whereby Business Associate agrees to perform certain services for or on
behalf of Covered Entity.
b. Covered Entity is an organizational unit of Orange County (the "County") that has been
designated in whole or in part by the County as a health care component for purposes of
the HIPAA Privacy and Security Rules.
c. The relationship between Covered Entity and Business Associate is such that the Parties
believe Business Associate is or may be a"business associate"within the meaning of the
HIPAA Privacy and Security Rules.
d. The Parties enter into this Business Associate Addendum to the Contract with the
intention of complying with the HIPAA Privacy and Security Rules provision that a
covered entity may disclose electronic protected health information or other protected
health information to a business associate,and may allow a business associate to create or
receive electronic protected heath information or other protected health information on its
behalf,if the covered entity obtains satisfactory assurances that the business associate
will appropriately safeguard the information.
2. DEFINITIONS
Unless some other meaning is clearly indicated by the context,the following terms shall have
the following meaning in this Agreement:
a. "Electronic Protected Health Information" shall have the same meaning as the term
"electronic protected health information"in 45 CFR 160.103, limited to the information
created or received by Business Associate from or on behalf of Covered Entity.
b. "HIPAA" means the Administrative Simplification Provisions, Sections 261 through 264,
of the federal Health Insurance Portability and Accountability Act of 1996,Public Law
104-191.
c. "Individual"shall have the same meaning as the term"individual"in 45 CFR160.103 and
shall include a person who qualifies as a personal representative in accordance with 45
CFR 164.502(g).
d. "Privacy and Security Rules"shall mean the Standards for Privacy of Individually
Identifiable Health Information and the Security Standards for the Protection of
Electronic Protected Health Information set out in 45 CFR part 160 and part 164,
subparts A and E.
e. "Protected Health Information'shall have the same meaning as the term"protected
health information'in 45 CFR 160.103, limited to the information created or received by
Business Associate from or on behalf of Covered Entity.
Contract-Scope of Work(07/08) Page lof 5
Contract#68-2009
Charles House Association
f. "Required By Law"shall have the same meaning as the term"required by law" in 45
CFR 164.103.
g. "Secretary"shall mean the Secretary of the United States Department of Health and
Human Services or his designee.
h. "Security Incident"shall have the same meaning as the term"security incident"in 45
CFR 164.304.
i. Unless otherwise defined in this Agreement,terms used herein shall have the same
meaning as those terms have in the Privacy and Security Rules.
3. OBLIGATIONS OF BUSINESS ASSOCIATE
a. Business Associate agrees to not use or disclose electronic protected health information
or other protected health information other than as permitted or required by this
Agreement or as required by law.
b. Business Associate agrees to implement administrative, physical, and technical
safeguards that reasonably and appropriately protect the confidentiality,integrity, and
availability of the electronic protected health information and other protected health
information that it creates, receives,maintains,or transmits on behalf of Covered Entity,
as required by the Privacy and Security Rules.
c. Business Associate agrees to mitigate,to the extent practicable,any harmful effect that is
known to Business Associate of a use or disclosure of electronic protected health
information or other protected health information by Business Associate in violation of
the requirements of this Agreement.
d. Business Associate agrees to report to Covered Entity(i) any use or disclosure of
electronic protected health information or other protected health information not provided
for by this Agreement of which it becomes aware and(ii)any security incident of which
it becomes aware.
e. Business Associate agrees to ensure that any agent, including a subcontractor,to whom it
provides electronic protected health information and/or other protected health
information received from, or created or received by Business Associate on behalf of
Covered Entity(i) agrees to be bound by the same restrictions and conditions that apply
through this Agreement to Business Associate with respect to such information,and(ii)
agrees to implement reasonable and appropriate safeguards to protect such information.
f. Business Associate agrees to provide access,at the request of Covered Entity,to
electronic protected health information and other protected health information in a
Designated Record Set to Covered Entity or,as directed by Covered Entity,to an
individual in order to meet the requirements under 45 CFR 164.524.
g. Business Associate agrees, at the request of Covered Entity,to make any amendment(s)
to electronic protected health information and other protected health information in a
Designated Record Set that Covered Entity directs or agrees to pursuant to 45 CFR
164.526.
h. Unless otherwise prohibited by law, Business Associate agrees to make internal practices,
books, and records, including policies and procedures concerning electronic protected
health information and other protected health information,relating to the use and
disclosure of electronic protected health information and other protected health
information received from, or created or received by Business Associate on behalf of,
Covered Entity available to the Covered Entity,or to the Secretary, in a time and manner
Contract-Scope of Work(07(08) Page 2of 5
Contract 468-2009
Charles House Association
designated by the Secretary, for purposes of the Secretary determining Covered Entity's
compliance with the Privacy and Security Rules.
i. Business Associate agrees to document such disclosures of electronic protected health
information and other protected health information related to such disclosures as would
be required for Covered Entity to respond to a request by an individual for an accounting
of disclosures of electronic protected health information and other protected health
information in accordance with 45 CFR 164.528,and to provide this information to
Covered Entity or an individual to permit such a response.
4. PERMITTED USES AND DISCLOSURES
a. Except as otherwise limited in this Agreement or by other applicable law or agreement, if
the Contract permits,Business Associate may use or disclose electronic protected health
information and other protected health information to perform functions, activities,or
services for, or on behalf of, Covered Entity as specified in the Contract,provided that
such use or disclosure:
1) would not violate the Privacy and Security Rules if done by Covered Entity; or
2) would not violate the minimum necessary policies and procedures of the Covered
Entity.
b. Except as otherwise limited in this Agreement or by other applicable law or agreements,
if the Contract permits,Business Associate may use electronic protected health
information and other protected health information as necessary for the proper
management and administration of the Business Associate or to carry out the legal
responsibilities of the Business Associate.
c. Except as otherwise limited in this Agreement or by other applicable law or agreements,
if the Contract permits,Business Associate may disclose electronic protected health
information and other protected health information for the proper management and
administration of the Business Associate,provided that:
1) disclosures are required by law; or
2) Business Associate obtains reasonable assurances from the person to whom the
information is disclosed that it will remain confidential and will be 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 the Business Associate of any instances of which
it is aware in which the confidentiality of the information has been breached.
d. Except as otherwise limited in this Agreement or by other applicable law or agreements,
if the Contract permits,Business Associate may use electronic protected health
information and other protected health information to provide data aggregation services
to Covered Entity as permitted by 45 CFR 164.504(e)(2)(i)(B).
e. Notwithstanding the foregoing provisions, Business Associate may not use or disclose
electronic protected health information or other protected health information if the use or
disclosure would violate any term of the Contract or other applicable law or agreements.
5. TERM AND TERMINATION
a. Term. This Agreement shall be effective as of the effective date stated above and shall
terminate when the Contract terminates.
b. Termination for Cause. Upon Covered Entity's knowledge of a material breach by
Business Associate,Covered Entity may, at its option:
Contract-Scope of Work(07/08) Page 3of 5
Contract#68-2009
Charles House Association
1) Provide an opportunity for Business Associate to cure the breach or end the
violation, and terminate this Agreement and services provided by Business
Associate,to the extent permissible by law, if Business Associate does not cure the
breach or end the violation within the time specified by Covered Entity;
2) Immediately terminate this Agreement and services provided by Business
Associate,to the extent permissible by law; or
3) If neither termination nor cure is feasible,report the violation to the Secretary as
provided in the Privacy and Security Rules.
c. Effect of Termination.
1) Except as provided in paragraph(2)of this section or in the Contract or by other
applicable law or agreements, upon termination of this Agreement and services
provided by Business Associate,for any reason, Business Associate shall return or
destroy all electronic protected health information and other protected health
information received from Covered Entity, or created or received by Business
Associate on behalf of Covered Entity. This provision shall apply to electronic
protected health information and other protected health information that is in the
possession of subcontractors or agents of Business Associate. Business Associate
shall retain no copies of the electronic protected health information or other
protected health information..
2) In the event that Business Associate determines that returning or destroying the
electronic protected health information or other protected health information is not
feasible, Business Associate shall provide to Covered Entity notification of the
conditions that make return or destruction not feasible.Business Associate shall
extend the protections of this Agreement to such electronic protected health
information and other protected health information and limit further uses and
disclosures of such electronic protected health information and other protected
health information to those purposes that make the return or destruction infeasible,
for so long as Business Associate maintains such electronic protected health
information and other protected health information.
6. GENERAL TERMS AND CONDITIONS
a. This Agreement amends and is part of the Contract.
b. Except as provided in this Agreement,all terms and conditions of the Contract shall
remain in force and shall apply to this Agreement as if set forth fully herein.
c. In the event of a conflict in terms between this Agreement and the Contract,the
interpretation that is in accordance with the Privacy and Security Rules shall prevail. In
the event that a conflict then remains,the Contract terms shall prevail so long as they are
in accordance with the Privacy and Security Rules.
d. A breach of this Agreement by Business Associate shall be considered sufficient basis for
Covered Entity to terminate the Contract for cause.
Contract-Scope of Work(07/08) Page 4of 5
Contract#68-2009
Charles House Association
Nancy Coston, Soc' Services Director (Signature of ontracto/r)
(Date Submitted) (Date Submitted)
Contract-HIPAA(06/04) Page 5 of 5
Contract#68-2009
Charles House Association
ATTACHMENT J
CERTIFICATION REGARDING TRANSPORTATION
Orange County Department of Social Services
By execution of this Agreement the Contractor certifies that it will provide safe client transportation by:
I. Insuring that all drivers(including employees,contractors, contractor's employees, and
volunteers)shall be at least 18 years of age;
2. Insuring that all drivers(including employees, contractors, contractor's employees, and
volunteers)shall be licensed to operate the specific vehicle used in transporting clients in
accordance with Chapter 20-7 of the General Statutes of North Carolina and the Division of
Motor Vehicle requirements;
3. Insuring that all vehicles transporting clients shall have at least the minimum level of liability
insurance appropriate for the type of vehicle as defined by Article 7, Rule R2-36 of the North
Carolina Utilities Commission;
4. Insuring that the contractor shall have written policies and procedures regarding how drivers
handle and report client emergencies and/or vehicle crashes involving clients to contractor and
how contractor notifies the Orange County Department of Social Services;
S. Contractor will maintain records documenting the following(County may require contractor to
provide):
a.Valid current copies of Drivers License for all drivers;
b.Current valid Vehicle Registration, for all vehicles transporting clients;
c.Driving records for all drivers for the past three years and with annual updates;
d.Criminal Background checks through North Carolina Law Enforcement or NCIC
prior to employment and every three years thereafter;
e.Alcohol and Drug Testing policy to meet the Federal Transit Authority guidelines.
6. Disclosing, at the outset of the contract, upon renewal and upon request,any criminal convictions
or other reasons for disqualifications from participation in Medicare, Medicaid or Title XX
programs. Signature on this form confirms this statement.
Signature Title
p4t*"U-su,;.� I%9K) ;Lc/ Do
ency/Organization Date
(Certification signature should be same as Contract signature.)
Transportation Certification(05/09) Page 1 of 1
Contract#68-2009
Charles House Association
ATTACHMENT K
501(c)(3) and TAX EXEMPT STATUS
Orange County Department of Social Services
What is a Private Non Profit Agency?
Answer: A private non profit is an organization that is incorporated under State law and whose
purpose is not to make a profit, but rather to further a charitable, civic, religious, scientific, or
other lawful purpose. The Secretary of State's office grants corporate status to organizations in
North Carolina.
What is a 501(c)(3)designation?
Answer: When the agency becomes a state private non profit corporation, it can then apply for
501(c)(3)designation through the IRS. Once the IRS grants 501(c)(3) status,the organization is
exempt from certain taxes and any donations to the charitable organization are tax deductible.
Many individuals and organizations prefer to make donations to 501(c)(3) private non profits.
Who can obtain a 501(c)(3) designation?
Answer: Any organization or group can apply for 501(c)(3) status,provided their charter or
mission focuses on the non profit's objective.
Another option is to apply for a 509(a)(1) status which falls under the 501(c)(3) umbrella. Being
a 509(a)(1) designates an organization as a tax-free public charity that receives most of its
support from a governmental unit or from the general public. Becoming a 509(a)(1)provides
public recognition of tax-exempt status, advance assurance to donors of deductibility of
contributions, exemption from certain State and federal taxes, and non profit mailing privileges.
Organizations that typically qualify are churches, educational institutions,hospitals, and
governmental units.
To learn more about non profits, visit www.irs.gov, or call the tax-exempt helpline at 877-829-
4933.
How does a Private Non Profit obtain Tax Exempt Status?
A private non profit must apply to the IRS for tax exempt status. To qualify, applicants must
complete and submit to the IRS Form 1023. Once federal tax exempt status is granted,the
private non profit applies for State tax exempt status by completing Form CD-435 and
submitting it to the N. C. Department of Revenue.
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
Please attach proof of 501(c)(3) or IRS tax-exempt status to this page.
�
/
/oterna| Revenue Service Department of the Treasury
'—
District Director
F-.. ID o0X RM ll12
«TLawTx. SA 3030l
Datc, «DD 1 91OUCi Emp | oyer Idcntiri cat ivo Numhe''
� K � w .°.~
C.--,ntact Person :
BARBARA HARRIS
CHARLES HI-JUSE ABSCICIATIVN Cvntact Telephone Number ,
709 WILLIAM STREET ( 4n4 > oo1 -7 4:7_:5
CHAPEL HzLL, mc z75|4
Our Lette, Dated ,
10-26- 4
Addendem App | ies :
Yes
__!)ea/ App | i c art C z
This modifies our | etter o the above datp / n wxich we stated that you
wou | u be treatell as an vry art izatior, whic» / s nvt a pr / va t fcundation unti /
thc pxpiration of your advance ru | / nS period '
-Y-our`exempt status under- section 501 (a) of the Internal Revenue Code as'*a
.organization described in section 501 ( c > (3> is stiI | in effect ' Based on the
i ^iFormatioo you submitted , we have determined that YOU are not a private
foundation within the meaning of section 509( a / of the code because you are an
organization of the type ue.scribed in section and 170 ( b ) ( 1. ) (A) (vi ) '
'
Grantors and contribo��rs may rely on this detprminat / "n unless the
Internal Revenue Service publishes ootice to the contrary ' However , if you
iose your sec tioo 509( a ) ( 1 ) status , a grantor or contributor may no re | y on
this dpterm \ nation if h or she was in part respc�nsib | e for , or was aware c,f,
the act or failure to act , or the substantia | or materia ( change o^ the part o
the or9anizatio^ that resu | ted in your loss of such status , or if he or she
acqu | rnd know | edge that the Interoa| Revenue Service had 3iven notice that yQ U
vou | d no 10n3er be c | assified as a secti �o 509( a> ( 1 > or3ahization -
If we h a v e iodicated in the head irig of this | etter that an addendum
app ( ies , the addendum enc | osed is an inteSra | part of this | etter ' '
Because this | etter cou | d Vie | p rpso | ve any qupsti "ns about your priviate
f»undat i on status , p | ease keep i t i n your permanent records .
`
Letter l �50( DO/CG )
Contract#68-2009
Charles House Association
ATTACHMENT N
OUTCOMES AND REPORTING
Orange County Department of Social Services
By signing and submitting this document,the Contractor certifies that it agrees to the following:
1. The Contractor agrees to participate in program, fiscal and administrative monitoring and/or audits,
making records and staff time available to Federal, State and County staff.
2.The Contractor agrees to take necessary steps for corrective action, as negotiated within a corrective
action plan,for any items found to be out of compliance with Federal, State, and County laws,regulations,
standards and/or terms of the Contract.
3. The Contractor agrees that continuation of and/or renewal of this Contract is contingent on meeting the
following requirements. The Contractor agrees to:
A. Provide Adult Day Care Services,according to the North Carolina State Standards for
Certification,to clients referred by the County.
B. Comply with all State licensing standards,all applicable accrediting standards and any other
standards or criteria established by the North Carolina Department of Health and Human
Services to assure quality of services
C. Maintain all financial and program records for a period of three years from the date of final
payment under this agreement for inspection by the County,the Area Agency on Aging and the
Comptroller General of the United States, or any of their duly authorized representatives. If any
claim, litigation,negotiation,audit or other action involving the Contractor's records has been
started before the expiration of the three-year period,the records must be retained until
completion of the action and resolution of all issues that arise from it.
D. Maintain appropriate program records, client case files which document the provision of the
agreed upon service(s); and maintain a valid authorization for services for each client
determined to be eligible by the County and authorized by the County for service(s)provided
under this agreement.
E. Furnish financial and program data as required to document the basis for the reimbursement rate
and to document that applicable standards have been met.
F. Be responsible for compliance with the audit requirements of the Department of Health and
Human Services.
a. An annual audit is to be performed in accordance with OMB Circular A-110 by an
"independent auditor." "Independent auditor"means either:
i. A state government auditor for the Department of Human Resources or the
Department of Administration, Office of the State Auditor; or
ii. A certified public accountant.
b. Upon completion of the audit,a copy of the audit report must be forwarded to the
County.
G. Notify the County of participant absences of more than 5 days.
H. Notify the County, in a timely manner, of significant changes in the.clients' conditions or
situations.
Outcomes (06/04) Page 1 of 2
Contract#68-2009
Charles House Association
1�--
Signature Title
&W",r7 Za- a r3
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Outcomes (06/04) Page 2 of 2