HomeMy WebLinkAbout2015-440-E Finance - The Art Therapy Institute - 2015-16 Outside Agency Performance Agreement $1,000 DocuSign Envelope ID: 78F206FF-A138-4129-88A7-AC03812E2BD1
2015-16 OUTSIDE AGENCY PERFORMANCE AGREEMENT
THIS AGREEMENT,made and entered into the first day of July 2015, ("Effective Date")by and between
the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street,
Hillsborough, North Carolina, 27278, ("County") and The Art Therapy Institute, a not-for-profit
corporation, located at 200 N. Greenboro St., Suite D-6, Carr Mill Mall, Carrboro,NC 27510 ("Provider").
WITNES SETH:
WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby
enhance its availability to residents of the County, and said program addresses an important community
human services need, as identified by the Board of Commissioners;
NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set
forth, the County and The Art Therapy Institute agree as follows:
1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1,
2015 to June 30, 2016.
2. Scope of Services.
a. Provider will provide services, as outlined in the attached Outside Agency Funding
Application Scope of Services and any amendments or revision thereto which is attached as
Exhibit "A" and incorporated by reference,to the residents of Orange County. The Scope
of Services may be different from the original application based on County appropriation;
however, any revisions or amendments to this Agreement must be approved in writing by
the County and attached to this Agreement.
b. The Provider shall be solely responsible for the means, methods, techniques, sequence,
safety program and procedures necessary to properly and fully complete the work set forth
in the Scope of Services.
3. Funding.
a. The County agrees to appropriate for the provision of services described in Exhibit A,
Scope of Services and more particularly described in the Program Budget, the maximum
sum of S 1,000.
b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not
used for the purposes stated shall be returned to the County. Any changes in the use of
funds must be authorized in writing by the County prior to any expenditure of the funds by
the Provider. If the funds are expended not in accordance with the Scope of Services, at the
discretion of the County the Provider may be required to repay the funds to the County.
c. The Provider shall be paid in four equal installments in the amount of S 250. The first
payment is contingent upon receipt of the agency's performance agreement; the remaining
payments are contingent upon receipt of the request for reimbursement and related
supporting documentation.
d. The County's obligation to make the quarterly payments is contingent upon receipt of
Progress Reports, which show satisfactory progress toward completion of performance
measures and an accounting of expenditures as detailed in the attached Scope of Services.
(The Art Therapy Institute)
Orange County Outside Agency Performance Agreement Page 1 of 7
DocuSign Envelope ID: 78F206FF-A138-4129-88A7-AC03812E2BD1
e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21
days after receipt of the Progress Report and Request for Reimbursement or 21 days after
due date of Progress Report whichever is later.
f. The County is not obligated to provide any other support to Provider in this or in
succeeding fiscal years.
4. Agency Reporting.
a. Provider will provide Orange County a Progress Report that includes a fiscal report and
updates on 2015-16 performance measures as outlined in the Scope of Services. Progress
Report dates are: July 1 — December 31; January 1 — March 31 and April 1 - June
30. Reports are due on January 11, April 15, and July 8 of the program fiscal year.
b. Provider agrees to allow the County to inspect its financial books and records, which
document costs of those services,upon reasonable notice during normal working hours.
5. Termination.
a. In the event of any of the circumstances set forth below (hereinafter referred to as
"default"), the County may immediately terminate this Agreement, in whole or in part, and
from time to time. Notice of termination must be in writing, state the reason or reasons for
the termination, and specify the effective date of the termination:
i. In the event that Provider shall cease to exist as an organization or shall enter
bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all
of its assets, or significantly reduce its services or accessibility to Orange County
residents during the term of this Agreement; or
ii. In the event that Provider shall fail to render a satisfactory accounting as provided
section 4 above, the County may terminate this Agreement and Provider shall
return all payments already made to it by the County for services which have not
been provided or for which no satisfactory accounting has been rendered; or
iii. In the event of any fraudulent representation by the Provider in an invoice or other
verification required to obtain payment under this Agreement or other dishonesty
on a material matter relating to the performance of services under this Agreement.
iv. Nonperformance,incomplete service or performance, or failure to satisfactorily
perform any part of the work identified in the Scope of Services or to comply with
any provision of this Agreement, as determined by the County in its sole discretion.
v. Failure to adhere to the terms of applicable county, state or federal laws,
regulations, or stated public policy.
b. In the event of default by the Provider, the county may elect to terminate this Agreement,in
whole or in part and/or require the Provider to repay the funds within ten(10)business days
from written notice of default. The County may (but shall not be required to) grant the
Provider an opportunity to cure the default without termination of this Agreement. This
clause shall not be interpreted to limit the County's remedies in law or in equity.
(The Art Therapy Institute)
Orange County Outside Agency Performance Agreement Page 2 of 7
Rev. 6115
DocuSign Envelope ID: 78F206FF-A138-4129-88A7-AC03812E2BD1
c. Notwithstanding the foregoing, either party may terminate the agreement at any time
without penalty; provided that written notice of such termination is furnished to the other
party at least 30 days prior to termination. In the event of such termination, any payment
due shall be prorated to the date of termination and any unused funds shall be returned to
the County within 10 days of termination.
d. Any termination of this Agreement for default under this section that is later deemed to be
unjustified shall be deemed a termination for convenience.
6. Insurance.
a. General Requirements. The Provider shall purchase and maintain, during the period of
performance of this Agreement,insurance:
i. Worker's Compensation. For protection from claims under workers' or workmen's
compensation acts;
ii. 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 Consultant's employees or any other person and to real and personal property
including loss of use resulting thereof,
iii. Comprehensive Automobile Liability Insurance,including hired and non-owned
vehicles,if any, covering personal injury or death, and property damage; and
iv. Professional Liability Insurance, covering personal injury,bodily injury and
property damage and claims arising out of or related to the performance under this
Agreement by the Consultant or his agents, consultants and employees.
b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows:
INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE
• Worker's Compensation Limits for Coverage A - Statutory State
NC& Coverage B -Employers Liability
$500,000 each accident, disease policy limit and
disease each employee
• Commercial General $1,000,000 Each Occurrence
Liability $2,000,000 Aggregate
• Automobile Liability $500,000 Combined Single Limit
• Professional Liability $1,000,000 Each Occurrence
$2,000,000 Aggregate
c. All insurance policies (with the exception of Worker's Compensation and Professional
Liability)required under this Agreement shall name the County as an additional insured
party and as a certificate holder. Evidence of such insurance and all correspondence shall
be sent to:
Orange County Risk Manager
Post Office Box 8181
(The Art Therapy Institute)
Orange County Outside Agency Performance Agreement Page 3 of 7
Rev. 6115
DocuSign Envelope ID: 78F206FF-A138-4129-88A7-AC03812E2BD1
Hillsborough,NC 27278
d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity
defenses.
7. Relationship of the Parties. Provider is an independent contractor of the County. Provider
represents that they have or will secure, at his own expense, all personnel required in performing
the services under this Agreement. Such personnel shall not be employees or have any
contractual relationship with the County. All personnel engaged in work under this Agreement
shall be fully qualified and shall be authorized and permitted under federal, state and local law to
perform such services.
8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws,
ordinances, orders and regulations of the federal, state or local governments, as well as their
respective departments, commissions, boards, and officers, which are in effect at the time of
execution of this Agreement or are adopted at any time following execution of this agreement.
9. Subcontract. The County and Provider deem the services provided under this Agreement to be
personal in nature and Provider may not subcontract any rights or duties under this Agreement to
any other party without prior written consent from the County.
10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to
any other party without the prior written consent of the County.
11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all
loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury,
including death or property damage, to any person or persons caused in whole or in part by the
negligence or willful misconduct of the Provider, except to the extent same are caused by the
negligence or willful misconduct of the County. It is the intent of this section to require Provider
to indemnify the County to the extent permitted under North Carolina law. Nothing in this
section is intended to affect or abrogate the County's sovereign immunity defenses.
12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the
specified services and may be terminated at any time if such funds become unavailable.
13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange
County the parties hereto for themselves, their agents, officials, employees and servants agree not
to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap,
religion, sexual orientation, familial status or veterans status with reference to any activities
carried out by the grantee,no matter how remote. The parties hereto further agree in all respects
to conform to the provision and intent of Orange County Civil Rights Ordinance, as
amended. This provision is enforced by action for specific performance, injunctive relief, or
other remedy as by law provided; this provision shall be binding on the grantees, the successors
and assigns of the parties hereto with reference to the above subject manner.
14. Living Wage. Orange County is committed to providing its employees with a living wage and
encourages agencies if funds to pursue the same goal. The County's living wage is $12.76 per
hour. To the extent possible, Orange County recommends that The Art Therapy Institute provide
a living wage to its employees.
15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the
last known address shall constitute sufficient notice to the County and the Provider. All notices
(The Art Therapy Institute)
Orange County Outside Agency Performance Agreement Page 4 of 7
Rev. 6115
DocuSign Envelope ID: 78F206FF-A138-4129-88A7-AC03812E2BD1
required and/or made pursuant to this Agreement to be given to the County and the Provides shall
be in writing and mailed to the party addressed as follows:
County: Finance & Administrative Services Provider: The Art Therapy Institute
Orange County 200 N. Greenboro St., Suite D-6,
Post Office Box 8181 Carr Mill Mall
Hillsborough,NC 27278 Carrboro,NC 27510
16. Entire Agreement. This Agreement,including any referenced attachments, constitutes the entire
Agreement between the parties and shall supersede, replace or nullify any and all prior
Agreements of understandings; written or oral, relating to the matters set forth herein, and any
such prior Agreements or understandings shall have no force or affect whatsoever on this
Agreement. The County and Provider have read this Agreement and agree to be bound by all of
its terms, and further agree that this Agreement constitutes the complete and exclusive statement
of the Agreement between the County and Provider.
17. Severability. All clauses found herein shall act independently of each other. If a clause is found
to be illegal or unenforceable,it shall have no effect on the other provisions of this Agreement. It
is understood by the parties hereto that if any part, term or provision of this Agreement is by the
Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United
States, the validity of the remaining portions or provisions shall not be affected, and the rights
and obligations of the parties shall be construed and enforced as if the Agreement did not contain
the particular part, term or provision held to be invalid.
18. Governing Law. The laws of the State of North Carolina shall govern all aspects of this
Agreement. In the event that it is necessary for either party to initiate legal action regarding this
Agreement, venue shall lie in Orange County, North Carolina. The parties hereby waive their
right to trial by jury in any action,proceeding or claim, arising out of this Agreement,which may
be brought by either of the parties.
19. Signatures. This Agreement together with any amendments or modifications may be executed
electronically. All electronic signatures affixed hereto evidence the intent of the Parties to
comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66.
IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on
the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures
below.
For and on behalf of the Provider
---DocuSigned by:
t. SRI& r Ldp 8/14/2015
Si VUSBCA1753403_ Date
Kristin Linton
Printed Name
For and on behalf of Orange County Government
D ocu Signed by:
jOVuLkAf, huhmvsbS 8/14/2015
Boum&W 1 W§ley, County Manager Date
(The Art Therapy Institute)
Orange County Outside Agency Performance Agreement Page 5 of 7
Rev. 6115
DocuSign Envelope ID: 78F206FF-A138-4129-88A7-AC03812E2BD1
ATTACHMENT "A"
Orange County Certifications—FY 2015-16
Outside Agency Performance Agreement
Chief Contact,Administrators, Chief Executive Officer and Chief Financial Officer
I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief
financial officer for my agency with this Agreement and that I will keep it current to the County of Orange.
The list should be in writing with the name, title,residential address;phone and email address and if
possible, fax number.
Officers and Board of Directors
I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and
that we will continue to update the list as changes occur. The list should be in writing,with the name,
physical address,mailing address and if possible,phone, fax and email address.
Budget Submission
I certify that I have provided a budget for the period to be covered by funding Orange County, and that any
substantive changes made to this budget have been in advance authorized in writing by Orange County.
Annual Financial Review
I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget
adopted by the agency for the fiscal years encompassing this Agreement. If not,please explain on a
separate sheet of paper.
Alignment with Organization's Mission
I certify that the programs and services for which this funding is requested align with the mission of the
organization.
Intended Purpose
I certify that the funds provided to the agency under the terms of this Agreement will be used for a public
purpose and shall only be used for the purposes intended and any money not used for those purposes will be
promptly returned to Orange County.
5:-Vmv,DocuSigned by:
Certified by: uvj01& Title: Executive Director Date: 8/14/2015
p%M&FF A'Signature)
(The Art Therapy Institute)
Orange County Outside Agency Performance Agreement Page 7 of 7
Rev. 6115
DocuSign Envelope ID: 78F206FF-A138-4129-88A7-AC03812E2BD1
E"6T'L'gffi'Y]'9�"A" ..
Sc99od�pYYeB��oDDfi SertvYices.—FY 2015-16
Outside Agency Performance Agreement
Agency Name:. The Art Therapy Institute,knc.
Program Name: The Burma Art Therapy Project
Funding Award: $1,000
Outline how the agency will spend Orange County's funding award.
Ex ense Description Amount
10 art therapy groups $1,000
Program Services
For assistance with this or the following section, please reference the Exhibit A instructions and example, located within the I
contract and reporting memorandum. Outline the major activities the agency will employ to attain the Anticipated Outcomes
below,by June 30,2016.
® Provide 1 art therapy group for 10 weeks to refugees in Orange County
Anticipated Outcomes
The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange
Con , k (all Towns and municipalities). If you use percentages, you must also provide the total number of participants
within that measure's description or for an earlier performance measure.
Performance Measures Anticipated
Results.
From baseline to follow-up,40%of participating children will experience fewer emotional 4Q/
difficulties measured by SDQ(4 out of 10 children)
From baseline to follow-up,40%of participating children will experience fewer`peer difficulties, 40°r,
as measured by SDQ(4 out of 10 children)
DocuSigned by: -
�VtSRV1 UvIbly
4F1D6BCA1753408...
Certified
{Provider's Signature}
DocuSign Envelope ID:78F206FF-A138-4129-88A7-AC03812E2BD1
MHPSO159 East County Line Road • Hatboro,PA 19040,1218
Healthcare Providers Service Organizations' 1-800-982-9491 * Fax 1-800-739-8818 • www.hpso.com
08/10/15
Institute of Art Therapy, Inc. dba The Art Thera
Institute
200 N Greensboro St Ste D6
Carrboro, NC 27510-1849
Dear Kristin Linton:
Enclosed is the replacement certificate of insurance that you requested.
If you have any questions or need assistance, please call us toll free at 1-800-982-9491. Our
Customer Service Representatives are available weekdays from 8:00 a.m. to 6:00 p.m., EST.
Sincerely,
Customer Service
Enclosure
Q032
Dedicated To Serving The Insurance Needs of Healthcare Providers
Healthcare Providers Service Organization is a division of Affinity Insurance Services,Inc.;in NY and NH,AIS Affinity Insurance Agency;
in MN and OK,AIS Affinity Insurance Agency,Inc.;and in CA,AIS Affinity Insurance Agency,Inc.dba Aon Direct Insurance Administrators
License#0795465.
DocuSign Envelope ID:78F206FF-A138-4129-88A7-AC03812E2BD1
.,, —OVIDERS SERVICE
CNAORGANIZATION PURCHASING GROUP MHPSO
(Certificate of 3Snorance HeAtheare Providers Service Ornanization-
OCCURENCE POLICY FORM Print Date: 8/10/2015
Producer Branch Prefix Policy Number Policy Period
018098 970 HPG 0613252987 from 06/15/15 to 06/15/16 at 12:01 AM Standard Time
Named Insured and Address: Program Administered by:
Institute of Art Therapy, Inc. dba The Art Thera Healthcare Providers Service Organization
Institute 159 E. County Line Road
200 N Greensboro St Ste D6 Hatboro, PA 19040-1218
Carrboro, NC 27510-1849 1-888-288-3534
www.h pso.com
Medical Specialty: Code: Insurance is provided by:
Art Therapist Firm 80967 American Casualty Company of Reading, Pennsylvania
Excludes Cosmetic Procedures 333 S. Wabash Avenue, Chicago, IL 60604
Professional Liability $1,000,000 each claim $ 3,000,000 aggregate
Your professional liability limits shown above include the following:
* Good Samaritan Liability * Malplacement Liability Personal Injury Liability
* Sexual Misconduct Included in the PL limit shown above subject to $25,000 aggregate sublimit
Coverage Extensions
License Protection $ 25,000 per proceeding $ 25,000 aggregate
Defendant Expense Benefit $ 1,000 per day limit $ 25,000 aggregate
Deposition Representation $ 10,000 per deposition $ 10,000 aggregate
Assault $ 25,000 per incident $ 25,000 aggregate
Includes Workplace Violence Counseling
Medical Payments $ 25,000 per person $ 100,000 aggregate
First Aid $ 10,000 per incident $ 10,000 aggregate
Damage to Property of Others $ 10,000 per incident $ 10,000 aggregate
Information Privacy (HIPAA) Fines and Penalties $ 25,000 per incident $ 25,000 aggregate
General Liability
General Liability $1,000,000 each claim / $3,000,000 aggregate
Fire &Water Legal Liability Included in the GL limit shown above subject to$250,000 aggregate sublimit
Total: $2,988.00
Base Premium $2,988.00
Policy Forms & Endorsements(Please see attached list for a general description of many common policy forms and
endorsements.)
G-121500-D GSL10546NC G-121501-C G-145184-A G-147292-A GSL15563
GSL15564 GSL15565 GSL17101 GSL13424 GSL13425 G-123846-C32
GSL3886 GSL3908 G-123827-B G-121487-B G-121504-C CNA79575
Keep this document in a safe place.It
and proof of payment are your proof of
coverage. There is no coverage in force
unless the premium is paid in full.In order
Chairman of the Board Secretary to activate your coverage, please remit
premium in full by the effective date of
this Certificate of Insurance.
Master Policy# 188711433
G-141241-B(03/2010) Coverage Change Date: Endorsement Change Date: 8/10/2015
DocuSign Envelope ID:78F206FF-A138-4129-88A7-AC03812E2BD1
POLICY FORMS & ENDORSEMENTS
The list below contains general descriptions of the policy forms and endorsements that may or may not apply to your
professional liability insurance policy. Please refer to your Certificate of Insurance for the policy forms &
endorsements specific to your state and your policy period. Coverages, rates and limits may differ or may not be
available in all states. All products and services are subject to change without notice.
1-Hill,Goreeri —expanded definitions and copies of these policy forms and endorsements are available online at
www.hpso.com/policyforms
COMMON POLICY FORMS& ENDORSEMENTS
FORM # DESCRIPTION
G-121500-D Common Policy Conditions
GSL10546NC North Carolina Amendatory Endorsement
G-121501-C Occurrence Policy Form
G-145184-A Policyholder Notice - OFAC Compliance Notice
G-147292-A Policyholder Notice - Silica, Mold &Asbestos Disclosure
GSL15563 Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs
GSL15564 Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion
GSL15565 Healthcare Providers Professional Liability Assault Coverage
GSL17101 Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies
GSL13424 Services to Animals
GSL13425 Business Owner Coverage Extension Endorsement
G-123846-C32 North Carolina Cancellation and Non-Renewal
GSL3886 Coverage & Cap on Losses from Certified Acts Terrorism
GSL3908 Notice - Offer of Terrorism Coverage & Disclosure of Premium
CNA79575 Exclusion of Cosmetic Procedures
OPTIONAL ENDORSEMENTS
FORM # DESCRIPTION
G-123827-B Additional Insured General Liability
G-121487-B Amendment to Certificate
G-121504-C General Liability Form
CNA79575 Exclusion of Cosmetic Procedures
PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC
TO YOUR STATE AND YOUR POLICY PERIOD.
For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance
Guaranty Association.
For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement
Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which
includes charges at a municipality and/or county level.
For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge.
For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association
- 2012 Regular Assessment.
Form#:G-141241-B (03/2010) Named Insured:Institute of Art Therapy
Master Policy#:188711433 Policy#: 0613252987
DocuSign Envelope ID: 78F206FF-A138-4129-88A7-AC03812E2BD1
HEALTHCARE PROVIDERS
GENERAL LIABILITY COVERAGE PART ENDORSEMENT
Additional Insured —General Liability
In consideration of the premium paid, and subject to the General Liability limit of liability shown on the
certificate of insurance, it is agreed that the GENERAL LIABILITY COVERAGE PART is amended as
follows:
The person or entity named below (the "additional insured") is an insured under this Coverage Part but
only as respects its liability arising out of named insured's operations, or premises owned by or rented by
the named insured and solely to the extent that:
1. a general liability claim is made against the named insured and the additional insured; and
2. in any ensuing litigation arising out of such claim, the named insured and the additional insured
remain as co-defendants.
In no event is there any coverage provided under this policy for an occurrence that is the direct liability of
the additional insured.
Additional Insured:
County of Orange
State of North Carolina
200 South Cameron Street
Hillsborough
NC Zip Code. . . 27278
This endorsement is a part of your policy and takes effect on the effective date of your policy, unless
another effective date is shown below. All other provisions of the policy remain unchanged.
Must Be Completed Complete Only When This Endorsement Is Not Prepared with the Policy
Or Is Not to be Effective with the Policy
ENDT. NO. POLICY NO. ISSUED TO ENDORSEMENT EFFECTIVE DATE
1 613252987 Institute of Art Therapy 8/10/2015
Inc dba The Art
Therapy Institute
G-123827-B (07/2001) Page 1 of 1