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2017-590-E Finance - Duke HomeCare & Hospice - Outside Agency Performance Agreement
DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2017, ("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 Duke HomeCare & Hospice, a not-for-profit corporation, located at 4321 Medical Park Drive, Suite 101, Durham,NC 27704 ("Provider"). WITNESSETH: 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 Duke HomeCare&Hospice agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2017 to June 30,2018. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application 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 and the Program Budget 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 as Exhibit B. 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 B, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 1100 b. All funds appropriated shall be used for purposes described in Exhibit B. 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 275. 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. (Duke HomeCare&Hospice) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 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 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 12, April 13, and July 13 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. (Duke HomeCare&Hospice) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 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 Hillsborough,NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (Duke HomeCare&Hospice) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 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 and the Orange County Non-discrimination Policy. 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 $ 13.75 per hour. To the extent possible, Orange County recommends that Duke HomeCare & Hospice 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 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: (Duke HomeCare&Hospice) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 County: Finance &Administrative Services Provider: Duke HomeCare&Hospice Orange County 4321 Medical Park Drive, Suite Post Office Box 8181 101 Hillsborough,NC 27278 Durham,NC 27704 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. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php). Any violation of this requirement is a breach of the Agreement and County may immediately terminate this Agreement without further obligation on part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 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 bat, o the Provider 1 S(Ar OWVuVL.P 8/31/2017 BE6DB595A60B4C 1_. , Date (Duke HomeCare&Hospice) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 For and on resits& Orange,C,ounty Government botAAAAG WSItti 10/24/2017 06379948755E477... Bonnie Hammersley, County Manager Date (Duke HomeCare&Hospice) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Duke University Health System, Inc.d/b/a Duke HomeCare&Hospice Applicant Organization's Physical Address: 4321 Medical Park Drive, Suite 101, Durham, NC 27704 Applicant Organization's Mailing Address: 4321 Medical Park Drive,Suite 101,Durham, NC 27704 Applicant Organization's Web Address: https://dhch.duhs.duke.edu Executive Director: Belle Starr Browning Telephone Number: 919.620.3853 E-Mail: starr.browning@duke.edu Tax ID Number: b) Funding Request List all FY17-18 Human Services (HS) Funding Being Requested — For All Programs) and the Proposed Use of Funds (2-3 lines or less) Program Carrboro Chapel Orange Total - HS Hill - HS County-HS Duke Hospice Bereavement Services will use the $3,800 $3,200 $1,200 $8,200 funds to offset the costs of providing care to grieving individuals in Chapel Hill, Carrboro and Orange County. We continue to offer our services at no cost to any individual in the area who request our support. Totals $3,800 $3,200 $1,200 $8,200 c) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. „..am Signature: - -puck Executive Director Date Signature: Oi/t\ 2-tr Board Chairperson Date DO NOT SUBMIT THIS PAGE 1/25/2017 11:08:11 AM Page I of 6 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ri El a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? LI b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? El c) Current beneficiaries of the program for which funds are being requested? {9..d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. NON-DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to 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, gender identity/expression, 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 and the Orange County Anti-discrimination Policy. 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. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: ckv. :`1-, C)tv )1Ac ■ r1.4)C' Executive Director H- ate Signature: 1,4r ktitT ) (7 Board Chairperson Date DO NOT SUBMIT THIS PAGE 1/25/2017 11 :08:22 AM Page 2 of 6 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, Date of Incorporation (Month/Year): 38 years in operation, incorporated in 1979 b) Agency's Purpose/Mission (no more than a few sentences): The mission of the Duke Hospice Bereavement Services (DIIBS) is to facilitate a safe and healing grief process for persons who are adjusting to a loss due to death. It is a direct clinical service outreach into the community for Duke HomeCare & Hospice. c) Types of Services the Agency Provides (bullet format): Duke Hospice Bereavement Services (DHBS) support to grieving people. There are two service lines provided through DHBS: hospice support and community support. The hospice benefit requires that hospice services offer grief support and education to hospice family members and operate a program through which grieving family members of hospice patients can receive counseling, information and resources to assist them in coping with the death of a loved one. In addition to the hospice level of care, DUBS extends its support to the community by offering individual grief support, access to workshops and grief groups, education and resources to help any member of the community adjust to living life after the death of a loved one. Services to both program lines: • Grief support through individual counseling and grief group support • Community education available to any civic or religious group which requests that type of support • Crisis intervention after the sudden death in the work place • School based interventions including education and workshops for administrative staff, teachers, social workers, counselors • School based interventions including training of social workers and counselors to respond to grief in the school. • School based grief support groups with an emphasis on providing training and supervision for school social workers and counselors to feel better equipped to address symptoms of grief which may occur in schools. • Annual memorial services to commemorate people lost to death. These services are open to the community. • Annual Camp ReLEAF for children kindergarten through 8i', grade. An annual overnight camp to assist children in adjusting to the death of a significant person and to develop coping skills to better understand and manage their own grief responses. • Family grief support groups to provide education to parents/guardians and children to enhance communication and understanding of the impact of grief on the family system. DO NOT SUBMIT THIS PAGE 1/25/2017 11 :08:31 AM Page 3 o 1 6 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION d) Agency's History with Providing These Services: Now in its 38th year, Duke Hospice (formally Triangle Hospice) was founded by a group of volunteers in 1979. During this span, it became one of the largest and foremost providers of hospice care in North Carolina. During the early 1990's these volunteers, led by former governor, the late Terry Sanford, raised $2 million to build a 6-bed Inpatient Care Facility in the Meadowlands in Hillsborough, which provides 24-hour care for those hospice patients in psychosocial crisis, unmanageable pain and/or need for respite care. In 1995, with a gift from GlaxoWellcome, the Beard House, which is on the same 11-acre site, was transfoinied into the Unicorn Bereavement Center. Staffed with two full-time bereavement counselors and one part-time bereavement counselor, the UBC serves both hospice families and those in the community who have lost a loved one. Each year, more than nine multi-week support groups and workshops are held at the UBC. We provide medical, psychosocial, spiritual and bereavement care for terminally ill patients and families, regardless of ability to pay. Bereavement services are provided to anyone in the community, regardless of connection to hospice, through individual, family, and group sessions, as well as in the Chapel Hill- Carrboro and Orange County School Systems. e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year?Is there a new Executive Director?Are there new initiatives?) f) Schedule of Positions (For Entire Agency) • Full Time Equivalent(FTE) staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE # of FTE - Full-Time Paid Positions: See attached # of FTE - Paid Part-Time Positions: See attached # of Volunteers: 1,635 # of FTE Volunteers:1,635 g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes/No) Yes If yes, is this agency an Orange Count Livin• VVase Certified Em'to er? No If no, please explain. Duke University and Duke University Health System pay the minimum wage of$13.00 per hour, effective January 1, 2017. This will be the second increase in Duke's minimum wage within the last two years, representing a 19.2 percent increase during that time, as we moved from $10.91 to $12.00, and now to $13.00/ hour. We anticipate reviewing this threshold each year to ensure Duke remains highly competitive in the area of total compensation. DO NOT SUBMIT THIS PAGE 1/25/2017 11:09:12 AM Page 4 of 6 0 0 0 c c/) M =1 chedule of Positions < If -- ---- 2provided,d* -An indicate;{ Estimated ' 2 015- roiect6d Plan (H) Health Plan -IFTE _-2016 Position-Titles Program taff, otal,Budget -n ,DMINISTRATIVE ASSISTANT 1 33.74 -n 'LINICAL NURSE 11 0.44 ',LINICAL NURSE 111 0.09 :LINICAL NURSE IV 0.04 OOD PRODUCTION ASSOCIATE 1.19 IEALTH UNIT COORD 1.02 1URSING CARE ASSISTANT 1 17.77 > 0 0 'URSING CARE ASST 1 MW M JURSING CARE ASSISTANT 11 5.68 M Ln 4 > 'HARMACY TECH 1 0 Cn 0 c: 'HARMACY TECH 11 0.21 �2 'ROJECT COORDINATOR 0.66 0 M X M IURSING CARE ASST/HEALTH UNIT COORD 0.49 > 'ATIENT SERVICE REPRESENTATIVE 1.05 z M > IELD CLINICIAN 4.57 'HAPLAIN 2.85 LINICAL SOCIAL WORKER 6.02 IURSING PROGRAM COORD 0.02 :LINICAL COUNSELOR 0.88 0z 'LINICAL PHARMACIST 0.2 OCIAL WORKER 2.01 TRATEGIC SERVICES ASSOCIATE 0.25 UPERVISOR, CLINICAL SERVICES 2.78 MANAGER, CLINICAL SERVICES 1 UPERVISOR, PATIENT ACCESS SERVICES 0.25 UPERVISOR, VOLUNTEER SVCS, PS 1 '.LINICAL SERVICES NURSE 11 19.14 .LINICAL SERVICES NURSE fl] 2.73 ',LINICAL SERVICES NURSE IV 3.65 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Duke HomeCare& Hospice Actual 11 Estimated Projected 2017 ;;; Percent AGENCY REVENUE l''1, '2015-16 ■ 1" '' 2016-17 ., ! 18 ' '1' '',1' Change Private Donations $ 593,040 $ 535,300 $ 535,300 0% Agency Generated Revenue(fees) $ 11,168,284 $ 12,185,000 $ 12,509,000 3% Local Government Grants: i/gWiiitH''IA4sailli#','llilNniQ,r4i'iltj-rAlvj.,;t,:d;qfo.(,MP:tiNili!''linill,V4VAAPllifO41CA Human Services-Town of Carrboro S 3,800 $ 3,800 $ 3,800 0% Other-Town of Carrboro $ - $ - $ 0 Human Services-Town of Chapel Hill S 2,900 $ 2,900 $ 2,900 0% Other-Town of Chapel Hill $ - $ - $ 0 Human Services-Orange County $ 1,000 S 1,000 $ 1,000 0% Other-Orange County S - $ - $ 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants :IfOlilagalt1100,10MV,4. .grig.k20.112$61,qtelgilV'1172,i1Z.(il.746-14,.0,Zifl, Triangle United Way $ $ 0 State Government $ $ - 0 Federal Government(CDSG/HOME/etc.) $ :: $ - 0 Private Foundation Grants $ $ - 0 ViAl1 iPliatilk,IMPOI.VARIVOMIN41;03101.11Vigri4%.413,M4.10 Other Revenue $ - 1111111111111111111101111111111111111 0 V.IMI411114,71R3501.44111'a,O.C.e.i411114Xtzttiaolffirig!°414,1111f01160111'111'Zr4WAI.;°i1.1,'P',.'= 0 Total Ag6rnpyReveny.9 , $ 11,769,025 $ 12,728,000 $; 13,052,000, ' , 3/a 'llaillInt0:9;g0VMSVMMENtrigila AtIllinginalitoutivegoko;;;,ogyulimis,,,,,,,ii,:onfoimmiof,,,iliowniyiripatlitizmy,Fgwiii AGENCY EXPENSES ItiNl1;i'',0''f,1F41610.1: 1'Ialilit5Iiikailiptlflaili"nliigallit*fillijklilgisfiriogefotai,l,n1: Compensation S 5,588,972 $ 6,205,000 $ 6,443,000 4% Rent&Utilities $ 298,220 S 110,000 $ 101,000 -8% Supplies& Equipment $ 1,249,425 S 1,172,000 S 1,352,000 15% Travel &Training $ 188,768 $ 198,207 $ 203,117 5% Other Expenses: S 4,336,227 S 5,099,793 $ 5,133,883 1% 1611131rilltellilllillrilni5321111135MVIHIllintrigAllit;;14APSI . „., ' ,.. 1... ,,' ■ , , . . Total Agency Expenses 1",$ '11,661,612 $ 12,785,000, ,,$„ 13;243,000 4% SURPLUS/(DE. .CI.I PI T1 FOR PERIOD: - $ 107,412 $ (57,000) $ ” (191,000)1 .235% FY 2015-16 Comparative Agency Budget Revised 9/2912014 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Orange County Other(DO NOT Include HOME funding here) O Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG/HOME/etc.) • Private Foundation Grants o Other Revenue • Expenditures o Compensation O Rent & Utilities O Supplies & Equipment o Travel & Training o Other Expenses iii. Does your agency budget show a Surplus or Deficit? Surplus Is there a significant change?Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. Actual hospice patient day volume was higher than budgeted. iv. What is your agency's fiscal year? July 1 , 2016 through June 30, 2017 (Example: July 1, 2016 through June 30, 2017) DO NOT SUBMIT THIS PAGE 1/25/2017 11:09:42 AM Page 6 of DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Duke HomeCare & Hospice Program Primary Contact and Title: William Holloman Telephone Number: 919.644.6869 E-Mail: William.holloman@duke.edu a) Indicate the type of Human Service Needs Priority, if program applicable: Human Services Li Priority Area#1: safety-net services for disadvantaged residents E Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges E Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) public Housing Program Category, Youth Adult Elderly Disabled Neighborhoods/Residents Affordable Housing Affordable Healthcare Education x x X Family Resources Jobs/Jobs Trainins Food Transportation Mentoring Other: Please specify counseling c) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated/collaborative efforts. See attached. Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town/County priority/goal? See attached. PROGRAM INFORMATION 1/30/2017 11:11:11 AM Page 11 of 18 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. See attached. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? See attached. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) See attached. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. See attached. Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) See attached. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. See attached. k) Include any other pertinent information. See attached. PROGRAM INFORMATION 1/30/2017 11:11:20 AM Page 1 2 o f 1 8 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Page 12 — Program / Project Description (c) Bulleted list of other agencies: • Chapel Hill-Carrboro and Orange County School System • Triangle Consortium for Suicide Prevention • Perinatal Loss Education Consortium • A Helping Hand • UNC Health System • Durham Coalition on Grief • S.O.S • Compassionate Friends • Other local non-profit organizations to meet the unmet needs of patients with limited resources. (d) Programs: Duke Hospice Bereavement Services has a vibrant and active children's bereavement program which emphasizes the importance of recognizing the developmental consequences of death and grief during the early years. We have developed a workshop which targeted all school personnel who may have contact with children. The goal of this workshop was to provide education and resources to assist school personnel to better understand the impact of grief and loss on the cognitive, physical and emotional well-being of children. The Bereavement Center is located in Hillsborough and serves as a primary resource for grief support and education for both the Chapel Hill/Carrboro and Orange County School system. We receive regular calls from school personnel in both districts requesting support, resources, education and intervention for the children in their districts. (e) Town/county priority: Protect and Provide for a safe community (0 Population to be served. Duke Hospice Bereavement Services has been a leader in providing grief support and education in the Triangle Area and has partnered with local school systems to address the needs of grieving students in the school setting. For over 15 years we have consulted with and responded to requests for support in the local school systems and in the communities we serve. (g) Who specifically will carry out? The Bereavement Center staff consisting of 2.88 full time staff will provide the services indicated. The staff provides training to student interns who will also be available on a limited basis to provide these services. The primary location will be the Unicorn Bereavement Center located in Hillsborough. Additional sites will include any school in the districts serving student DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION in Orange County as well as administrative offices of those districts and other gathering places which will accommodate the provision of services requested. (h) Describe period: Camp ReLEAF is an annual event and is next scheduled for April 28 — 30, 2017. It will be held at Camp New Hope. This schedule is followed as closely as possible each year after adjusting for holidays or religious events which may interfere with those periods of time. During the school year school based grief support groups are located at the requesting school site and will run for a total of 6 weeks. The frequency will be determined by the number of requests received. Individual, group and family grief support is provided as needed and according to mutual developed goals established between the requesting person and the Duke Hospice Bereavement staff. Crisis intervention is available as requested. School consultation is available upon request throughout the year. (i) Why is funding a good investment? • Death touches the lives of young people far more frequently than most of us would like to admit. • US Census Bureau stars— 5% by 16; 11% by 20 • 90% of HS Students say they have experienced the death of a significant person in their life • 40% will experience the death of a peer. 20% will have witnessed a death. • Impact is widespread and not contained to a specific period of time. Grief is a multi- dimensional experience Developmental in nature— change in understanding and experience. • Impacts learning, behavior, and development. Our work supports school personnel are in a unique position to interact with children who are challenged to meet educational objectives while trying to negotiate the very difficult emotional terrain in adjusting to the death of a family member or friend. • Many feel unprepared to respond to the needs of grieving students. The 2012 Study by AFT and NY Life revealed: DocuSign Envelope ID:E522oFFc+634-4A11~w62-1e5A3eEe57A4 EXHIBIT A PROVIDERS OUTSIDE AGENCY APPLICATION • 69% of classroom teachers (almost 7 in 10) have a student who lost someone close to them in past year • Only 7% of those teachers had ever received Bereavement Training and only 3% said their school or district offers it. Of the 7% who had training, 46% sought it out themselves • Only 1% of teachers received bereavement training as part of their coursework in college or graduate school • 63% said insufficient training and professional development are the primary things that hinders them from supporting grieving students. • Still "taboo" topics. Don't deny the reality of death, but we often deny the grief and the powerlessness that accompanies death. Bereaved can be under supported, which adds to the negative emotional impact of loss. 6l Describe what would happen: Duke Hospice Bereavement Services provides the most comprehensive children's bereavement program in the or nu. The area likely to be most impacted by a reduction in funding would be our ability to respond to all of the requests for support services to the schools. We would continue to provide counseling and support to any child but would be challenged in our ability to take those services to the children; instead the parents/guardians would bear sonic of the burden of getting their children to the site where our services are offe ed. We would continue to seek funding from other sources to ensure our ability to reach children where they are and not increase the burden of seeking care during a time when families lives are in disarray due to the death of a significant family member. (k) Other pertinent information: Minimizing change in aohUd`o life will often lead to a better outcome,but change is inevitable when an integral member of the family dies. Death can have a ripple cffectundmouroi the secondary losses can become an important part of the grieving process.These losses can be numerous and can continue for a child's lifetime A significant loss creates changes in relationship both within the family and beyond. Mourning family members may be unavailable to the child in the same way and thus the child "looses" them in a way too.These changes effect the relationships within the family,and people outside the family may also act differently.The child's.friends may act differently or the child may seek out other friends or peer groups as a result of the loss. There can be major lifestyle changes with a death. l[Uhe deceased contributed to the family's finances, there can be significant financial implications. Some children will need to move,which could involve the loss of not only their home but also perhaps the school they were in,tile neighbors they left behind, etc. The child's extracurricular activities may no longer be possible due to financial or logistical reasons DocuSign Envelope ID:E522oFFc+634-4A11~w62-1e5A3eEe57A4 EXHIBIT A PROVIDERS OUTSIDE AGENCY APPLICATION (one parent can only do so roocl.). Child is likely to have new responsibilities at home and can be resentful about this. A death may lead to a change in tile child's plans for the future. Perhaps,after a parent's death,a teen may not be able to afford to attend his or her college of choice,or may not have the help with college applications that the deceased parent would have provided. And as previously discussed,grieving children of all ages may experience a decreased sense of security and safety, which can be experienced as another loss. Duke Bereavement Services cannot meet all of these needs. It is our hope to provide as much support as possible to families to support theni as they learn to cope with change brought about by loss. Additionally,we strive to provide educational opportunities for school personnel to assist them in learning about the unique challenges brought about by loss and support them in developing successful interventions for meeting tile children's needs while in the school setting. DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Proqram Information I) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender , Male 51 38 40 Female 63 56 59 Total 114 94 99 .. Ethnicity ,, 1 African-American 12 0 0 ., American Indian or Alaska Native 0 0 0 Asian 0 2 3 Caucasian 89 84 88 Native Hawaiian or other Pacific Islander 0 0 0 Other: specify 13 8 8 Total 114 94 99 Of the above, how many Hispanic/Latino 1 4 4 Of the above, how many non-Hispanic/Latino 113 90 95 Total 114 94 99 .. ;Age 0-5 years 0 0 0 6-18 years 0 0 0 19-50 years 1 2 2 51+ years 113 92 97 Total 114 94 99 ._ Geographic Location .. Alamance County 0 0 0 Chatham County 0 0 0 Durham County 0 0 0 Wake County 0 0 0 Orange County Breakdown Chapel I-lill Public Housing Town of Chapel Hill (Non-Public Housing) 27 40 42 Town of Carrboro 4 4 4 Tovvn of Hillsborough 39 38 40 ' City of Mebane (Orange County) 8 4 4 Orange County(Outside Municipalities) 36 8 8 Total 114 94 99 PROGRAM INFORMATION 1/23/2017 11:04:43 AM Page 13 of 17 DocuSign Envelope ID:E522oFFc+634-4A11~w62-1e5A3eEe57A4 EXHIBIT A PROVIDERS OUTSIDE AGENCY APPLICATION Work Statement (Page 14) Goals: Duke Hospice Bereavement Services (DHBS) offers bereavement support to both hospice and community clients 1) DHBS will schedule 200 community adult client encounters in FY16 2) DHBS will schedule 64 community child/teen encounters in FY16 3) DHBS will schedule 345 hospice adult client encounters in FY16 4) DHBS will schedule 26 hospice child/teen encounters in FY16 5) Camp ReLEAF will provide an overnight camp experience for children K-8th grade 6) DHBS will provide grief education and support to local educational and civic organizations as requested Goal# Actual 15-16 Actual 16-17 Estimated 17-18 1 277 205 150 2 24 33 24 3 446 491 450 4 38 47 42 5 10= .334 of total 16= .381 of total 1O= .334oftotal 6 17 18 13 Performance measures for all of the listed activities will be through service evaluation requested at the time of the event or at the conclusion of a series of related events. Related events would be ongoing individual or group counseling. Goal 5 Camp ReLEAF: each camper provides feedback regarding likes and dislikes of camp activities and overall participation. Each activity scored well in different age groups. There are no numbers associated with the scoring of satisfaction. Parents provide feedback about their children's reported experience with approximately 30%of campers requesting to come back the next year. 31 campers out of 34 total campers completed a group evaluation with 9696 responding favorably to the camp experience. Predominant responses from campers indicated the importance of meeting other children their age who had experience something similar which reduces the isolation, loneliness and sense of being different. Goal # Actual Estimated 3 98%satisfaction 97% 95% 100 refer services 100 refer services 95% refer services 4 95% satisfaction 96% satisfaction 95% satisfaction 98% refer services 99% refer services 95% refer services 6 94% satisfaction 96% satisfaction 95% satisfaction 100% refer 100% refer 95% refer 'services DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 EXHIBIT A PROVIDERS 9)L 1SIDEo?ENCYtP APPLICATION CATI 0 N rogram Budge Operating Budget for Entire Agency AGENCY NAME: Duke HomeCare & Hospice Actual Estimated Projected 2017 Percent AGENCY REVENUE 2015-16 ' 2016-17 18 ■ Change Private Donations $ 593,040 $ 535,300 $ 535,300 0% Agency Generated Revenue(fees) $ 11,168,284 $ 12,185,000 $ 12,509,000 3% Local Government Grants: 11111101110'lll'll'ill,101r4;,1,41":04i1111116111ililillli■1111110410110411111f0111111111111,11;11,1:41■1,11';o" -.. ',11,1,,,■1;,ii,ili,111,'10(„Illlil'1100,14141i11.01l,14111111 Human Services-Town of Carrboro $ 3,800 $ 3,800 $ 3,800 0% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ 2,900 $ 2,900 $ 2,900 0% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 1,000 $ 1,000 $ 1,000 0% Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants P111,14,11;11;111iii:,, ,,,,'1,:l11,„'(;;III.;„:„',4[",,':,,1;1;;1?,''J;,l'i'l,,:',;;V;1,,,1:11l,'1,:,[1;'i', '''''',',11,1,1'1■,11■',„.',. '.ho;',,',1',1: ,r1,1:k,11;'1',41;',1,11;1,11',e,,,',!...t1i1;',101," Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ - $ - $ - 0 11111111Ril"!1:1C11',1°1:,:r;.:,!'..::"';i'd°,:INIIP,il■lillliIIIIIIillidiMI,Ill1:1'11;11!1:'1[1',11.1' ■.'1":',1,11iil;'Il'r'rr! ,II■;,, ' ',3'..P..i'll!'"7,',.li"4.1:,:i'„1.,':',1'.' Other Revenue $ - $ - $ - 0 11.114111101,,'1''i ''' .1''l''. '1,,,,':11ii1i';11.1111,1111111011411111,11111,111,11t 101110'1 l''1,'11 . Total otal Agency Revenue $ 11,769,025 $ 12,728,000 $ 13,052,000 3% fic,„'1,1',i11,,',■1,1010711,0i1,4,6N:% ', ."', ',1?„,11$ii l'Af,11,,Pmr1.1!,1,11:1,:::INI',141C;1411111'111,,,Ptvii:),',';:'I, .1''.'1.1" ,01')11'1' AGENCY EXPENSES rl'Ji$'',1,:',0°:11',,,l'ij,,.. .,':,,I,11,,(11,;!Iii,1)1111(i.■'111;i;,1',11:1'FI:q':,''.1, ,' l':, ,".."1 ,.,, .,, ,',,.:'.. ,,' .o,11,1 , ., l'I'pdiltillt Compensation $ 5,588,972 $ 6,205,000 $ 6,448,000 4% Rent& Utilities $ 298,220 $ 110,000 $ 101,000 -8% Supplies&Equipment $ 1,249,425 $ 1,172,000 $ 1,352,000 15% Travel &Training $ 188,768 $ 198,207 $ 208,117 5% Other Expenses: $ 4,336,227 $ 5,099,793 $ 5,133,883 1% 0111,Cri10,111,1,"2,,',i'1,1!iirli(1,1'f'',,/,1,,q,'1;,1`,„(,,,r,l i'l,r,j,',q,',,i,;;(11;.11!;,1;,■41,,i1;;;',i`,9'41,,17,I,'Id;`1"," ,).(„:"kr.iii'll11111,i'll' ',,):/',,!ii.,:`":'''','I To1a! '4,‘LgrI9YExPerlises $ 11,661,612 $ 12,765,000 $ 13,243,000 ' 4% SURPLUS/(DEFICIT) FOR PERIOD: $ 107,412 1 $ (57,000)1 $ (191,000)1 -235% FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION n) Program Budget 1. Submit your program budget. You may complete the provided template (separate xis file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues O Private Donations O Program Generated Revenue O Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other(DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other(DO NOT Include HOME funding here) o Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG/HOME/etc.) • Private Foundation Grants O Other Revenue • Expenditures o Compensation o Rent & Utilities O Supplies & Equipment o Travel & Training O Other Expenses 2. Program Budget Detail — Provide description of "other" budget items, not defined. (3) Largest Expenses: Administrative Allocation $2,323,790.08** Professional Services $1,085,997 Nursing Home Room & Board $ 416,675 **Hospice portion of administrative departments, referral center, development, finance, marketing, facilities management. 3. This program budget represents what percent of the agency budget? 7% 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. --Actual 2015-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program J $18,911 $19,000 $19,000 Total # of Individuals J 42 45 50 Cost Per Individual j 450 422 380 PROGRAM INFORMATION 1/26/2017 9:44:41 AM Page 15 of 18 DocuSign Envelope ID:E522oFFc+634-4A11~w62-1e5A3eEe57A4 EXHIBIT "B" Scope ot Services -----FY2Ol7-l8 Outside Agency Performance Agreement Agency Name: Duke University l-Iealth Systems, Inc. d/b/u Duke II000e Caro& Hospice Program Name: Duke 1-lospice Children's Bereavement Funding Award: $1,100 Outline how the agency will spend Orange County's funding award. Expense Description Amount Wages _ __— _ __ _____ __ $600 Grief skills program supplies including duplication expenses and classroom supplies $56 Camp ReLEAF supplies and activites $450 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Grief Education and Support to 24 children—to include individual, family and group support o Consultation with schools when requested o Development of effective coping skills • Camp ReLEAF I weekend grief support for 10 children o Enrollment in weekend intensive grief support designed for ages 6-14 o Grief activities designed to enhance skills to understand grief/ompouoc o Education and support to enhance coping skills Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form 01 nuITber of persons/units served within Orange County,only(all Towns and municipalities). If you use percentages,you must also provide the total number of participants within that measure's dv,oripbvno,foronew�ierpe,hvnnox,,n"rx,vn� Anticipated Performance Measures Results Initial Grief Risk Assessment and Intervention 24 children Enrollment in grief support group/family intervention 80% Evaluation/Self-Report success measur x 95% Enrollment in Camp ReLEAF 50% Satisfaction 95% Recommendation of Serives 95% / DocuSigned by: u�" " � '=v�» Qk �� v 8/31/2017 � oc^o Executive Di a�y ',vo^o,` _ Certified by: �� �, �� . Title: 4»*i Date: '/- 2�— /~7 (Provider's Signature) DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 ATTACHMENT "A" Orange County Certifications—FY 2017-18 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. Cbatt, Star browtAAI4 DocuSigned by: Executive Director 8/31/2017 Certified by: BE6DB595A60B4C1... Title. Date: (Provider's Signature) (Duke HomeCare&Hospice) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 DUKEUNI-01 SEQUEIRARR ,4 G'ORC1" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `..•--'� 1/6/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Willis Towers Watson Certificate Center NAME: Willis of North Carolina,Inc. PHONE 877 945-7378 FAx 888 467-2378 c/o 26 Century Blvd (A/C,No,Ext):( ) (NC,No):( ) P.O. Box 305191 ADDRESS:certificates @willis.com Nashville,TN 37230-5191 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Duke University Risk Management Trust Fund B1512 INSURED INSURER B:Durham Casualty Company LTD-Bermuda C6616 Duke University Attn Chris Boroski INSURER C PO Box 104143 INSURER D: Durham,NC 27708 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR W POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD VD (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR X GL-DURMRA 01/01/2017 01/01/2018 PREM SET Ea oNcur ante) $ 0 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 2,000,000 (Ea accident) X ANY AUTO SI-163 01/01/2017 01/01/2018 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Professional Liab. 17 PL 1027-P 07/01/2016 07/01/2017 Occ: $1,000,000/Agg: 3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) With respects to Policy No. 17 PL 1027-P,Named Insured includes:Duke University Health System. With respects to the General Liability Insurance,Orange County is included as an Additional Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (Orange County ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD