HomeMy WebLinkAbout2018-381-E DSS - MediSolutions in-home aide servicesDocuSign Envelope ID: 3E4B4B91-8AA8-41 OB-8584-1 1 AAECCBC787
Contract #68-2039
Medisolutions, Inc.
CONTRACT #,68 -2039 Fiscal Year Begins July 1, 2018 Ends June 30, 2019
NORTH CAROLINA
ORANGE COUNTY
IN -HOME AIDE PROVIDER SERVICES AGREEMENT
THIS AGREEMENT, is made and entered into this I day of July, 2018 by and between Orange
County, North Carolina for and on behalf of the Orange County Department of Social Services and the
Orange County Department of Aging (the "County "); and Medisolutions, Inc. (the "Contractor ") whose
federal tax identification number or Social Security Number is: 36-4651170
WITNESSETH:
For the purpose and subject to the terms and conditions hereinafter set forth, the County hereby
contracts for the services of the Contractor, and the Contractor agrees to provide the services to the
County in accordance with the terms of this Agreement.
I. Contract Documents: This Agreement consists of this document as well as each of the
documents listed below as indicated (collectively referred to as the "Contract Documents "). If the word
"Yes" appears beside the title of the contract document at the time both parties execute this Agreement,
then that document is included as part of this Agreement. If the word "No" appears beside the title of the
contract document at the time both parties execute this Agreement, then that document is not included as
part of this Agreement. Each of the Contract Documents made part hereof are attached hereto and
incorporated herein by reference to the same:
TITLE OF CONTRACT DOCUMENT
Rev. 6116
YES/NO
(1) The General Terms and Conditions (Attachment A) YES
(2) The Scope of Work, services, and rate (Attachment B) YES
(3) Federal Drug Free Workplace & Nondisci-iinination Certification (Attachment C) YES
(4) Conflict of Interest Policy (Attachment D) YES
(5) No Overdue Taxes Certification (Attachment E) YES
(6) Certification Regarding Lobbying (Attachment G) YES
(7) Certification Regarding Debarment (Attachment H) YES
(8) Certification Regarding Transportation (Attachment J) YES
(9) State Certifications (Attachment M) YES
(10) Non - Discrimination, Clean Air Act, Clean Water Act (Attachment N) YES
DocuSign Envelope ID: 3E4B4B91-8AA8-41 OB-8584-1 1 AAECCBC787
Contract #68 -2039
Medisolutions, Inc.
(11) Outcomes & Reporting (Attachment O) YES
(12) Contract Determination Questionnaire YES
2. Precedence Amona Contract Documents: In the event of a conflict between or among the
terms of the Contract Documents and this Agreement, the terms of this Agreement shall control. In the
event of a conflict between or among the terms of the Contract Documents, then the Contract Documents
with the highest relative precedence shall prevail. The order of precedence shall be the order of
documents as listed in Section 1, above, with Attachment A having precedence over Attachment B and so
forth. 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 Agreement shall be effective from July 1, 2018 through June 30, 2019.
4. Contractor's Duties: The Contractor shall provide the services to the County described in
Attachment B 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.
(a) The total amount paid by the County to the Contractor under this Agreement for the
provision of services to the Department of Social Services shall not exceed: $415,647. This amount
consists of $4I5,647 in Federal, State and County funds (CFDA 4 $0 (source of
other funds if applicable).
(b) The total amount paid by the County to the Contractor under this Agreement for the
provision of services to the Department on Aging shall not exceed: $75,000. This amount consists of
$75,000 in Federal, State and County funds (CFDA # $0 (source of other funds if
applicable).
E] (c) There are no snatching requirements from the Contractor.
® (d) The Contractor's matching requirement is $ , which shall consist of:
❑ In -kind ❑ Cash
❑ Cash and In -kind ❑ Cash and/or In -kind
The contributions from the Contractor for matching requirements for the provision of services to
the Department of Social Services shall be sourced from non - federal funds.
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 and shall disclose all information required by 42
USC 455.104, or 42 USC 455.105, or 42 USC 455.106.
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
2
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Contract #68 -2039
Medisolutions, Inc.
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 Services Performed on Behalf of the Department of Social Services:
IF DELIVERED BY US POSTAL SERVICE
IF DELIVERED BY ANY OTHER MEANS
Kim Lassiter Fisher, Adult Services Supervisor
Kim Lassiter Fisher, Adult Services Supervisor
Orange County Department of Social Services
Grange County Department of Social Services
P.O. Box 8181
113 Mayo Street
Hillsborough, NC 27278
Hillsborough, NC 27278
(919) 245 -2880
336- 329 -9060
Lassitergoranvecountync.gov
For Services Performed on Behalf of the Department on Alaing:
IF DELIVERED BY US POSTAL SERVICE
IF DELIVERED BY ANY OTHER MEANS
Janice Tyler, Director
Janice Tyler, Director
Orange County Department on Aging
Orange County Department on Aging
2551 Homestead Road
2551 Homestead Road
Chapel Hill, NC 27516
Chapel Hill, NC 27516
(919) 968 -2071
336- 329 -9060
jtyler@co.Qrqage.nc.us
For the Contractor:
IF DELIVERED BY US POSTAL SERVICE
IF DELIVERED BY ANY OTHER MEANS
Robin Creason
Rabin Creason
Medisolutions, Inc.
Medisolutions, Inc.
100 N. Church Street, Suite B
100 N. Church Street, Suite B
Burlington, NC 27217
Burlington, NC 27217
336- 329 - 9060
336- 329 -9060
9. No Assi nment 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 Fun_ ds: The Contractor assures that funds
received pursuant to this contract shall be used only to supplement, not to supplant, the total amount of
0
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Contract #68 -2039
Medisolutions, Inc.
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:
• Validity and accuracy of payment
• Payment due date
• Adequacy of documentation supporting payment
• 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.
1.4. 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. Termination: This Agreement may be terminated as specified in Attachment A, General
Terms And Conditions.
16. Insurance Requirements: Contractor shall obtain, at its sole expense, all insurance as
required in Attachment A, General Terms And Conditions.
17. Indemnification: Contractor 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 Contractor in
accordance with Attachment A, General Terms And Conditions. It is the intent of this Section that
Contractor indemnify County to the full extent permitted by law.
M
Rev. 6116
DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 11AAECCBC787
Contract #68 -2039
Medisolutions, Inc.
18, Entire A reement: The parties have read this Agreement, including the Contract Documents,
and agree to be bound by all of its terms, and further agree that it constitutes the complete and exclusive
statement of the Agreement between the parties.
19. Interpretation: When the context in which words are used in this Agreement indicates that such
is the intent, words shall in the singular number shall include the plural and vice versa. The masculine
gender shall include the feminine and neuter.
IN WITNESS WHEREOF, the County and the Contractor have been first duly authorized, have
executed and entered into this Agreement as of the day and year first above written..
Mr.7,-, -Uocu Signed Eby: -T~ INC.
By'- 9C88E10AE89C476...
Signature
]ohn okafor
Printed Name
OJ;L T p, �VMT %T T,"mH CAROLINA us9
by,
1�6y. G37994B755E477...
Bonnie B. Hammersley, County Manager
Rev. 6116
8/3/2018
Date
ceo
Title
8/13/2018
Date
DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 11AAECCBC787
ATTACHMENT A
GENERAL TERMS AND CONDITIONS
Orange County Department of Social Services and Department on Aging
Relationships of the Parties
Independent Contractor: The Contractor is and shall be
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
employees. The Contractor represents that it has, or shall
secure at its own expense, all personnel required in
performing the services under this agreement. Such
employees shall not be employees of, or have any
individual contractual relationship with the County.
Subcontracting: The Contractor shall not subcontract any
of the work contemplated under this contract without prior
written approval from the County. Any approved
subcontract shall be subject to all conditions of this
contract. Only the subcontractors specified in the contract
documents are to be considered approved upon award of
the contract. The County shall not be obligated to pay for
any work performed by any unapproved subcontractor.
The Contractor shall be responsible for the performance of
all of its subcontractors.
Assignment: No assignment of the Contractor's
obligations or the Contractor's right to receive payment
hereunder shall be permitted. However, upon written
request approved by the issuing purchasing authority, the
County may:
(a) Forward the Contractor's payment check(s)
directly to any person or entity designated by the
Contractor, or
(b) Include any person or entity designated by
Contractor as a joint payee on the Contractor's
payment check(s).
In no event shall such approval and action obligate the
County to anyone other than the Contractor and the
Contractor shall remain responsible for fulfillment of all
contract obligations.
Beneficiaries: Except as herein specifically provided
otherwise, this contract shall inure to the benefit of and be
binding upon the parties hereto and their respective
successors. It is expressly understood and agreed that the
enforcement of the terms and conditions of this contract,
and all rights of action relating to such enforcement, shall
be strictly reserved to the County and the named
Contractor. Nothing contained in this document shall give
or allow any claim or right of action whatsoever by any
other third person. It is the express intention of the County
and Contractor that any such person or entity, other than
the County or the Contractor, receiving services or benefits
under this contract shall be deemed an incidental
beneficiary only.
Indemnity and Insurance
Indemnification: The Contractor agrees to indemnify and
hold harmless the County and any of their officers, agents
and employees, from any claims ofthird parties arising out
or any act or omission of the Contractor in connection with
the performance of this contract.
Insurance: During the term of the contract, the Contractor
at its sole cost and expense shall provide commercial
insurance of such type and with such terms and limits as
may be reasonably associated with the contract. As a
minimum, the Contractor shall provide and maintain the
following coverage and limits:
(a) Worker's Compensation - The contractor shall
provide and maintain Worker's Compensation
Insurance as required by the laws of North
Carolina, as well as employer's liability coverage
with minimum limits of $500,000.00, covering all
of Contractor's employees who are engaged in any
work under the contract. If any work is sublet, the
Contractor shall require the subcontractor to
provide the same coverage for any of his
employees engaged in any work under the
contract.
(b) Commercial General Liability - General
Liability Coverage on a Comprehensive Broad
Form on an occurrence basis in the minimum
amount of $1,000,000.00 Combined Single Limit.
(Defense cost shall be in excess of the limit of
liability.)
(c) Automobile Liability Insurance: The Contractor
shall provide automobile liability insurance with a
combined single limit of $500,000.00 for bodily
injury and property damage; a limit of
$500,000.00 for uninsured/under insured motorist
coverage; and a limit of $25,000.00 for medical
payment coverage. The Contractor shall provide
this insurance for all automobiles that are:
(a) owned by the Contractor and used in the
performance of this contract;
(b) hired by the Contractor and used in the
performance of this contract; and
(c) Owned by Contractor's employees and
used in performance of this contract ("non -
owned vehicle insurance "). Non -owned
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vehicle insurance protects employers when
employees use their personal vehicles for
work purposes. Non -owned vehicle
insurance supplements, but does not
replace, the car - owner's liability insurance.
The Contractor is not required to provide and maintain
automobile liability insurance on any vehicle — owned,
hired, or non -owned -- unless the vehicle is used in the
performance of this contract.
(d) The insurance coverage minimums specified in
subparagraph (a) are exclusive of defense costs.
(e) The Contractor understands and agrees that the
insurance coverage minimums specified in
subparagraph (a) are not limits, or caps, on the
Contractor's liability or obligations under this contract.
(f) The Contractor may obtain a waiver of any one or more
of the requirements in subparagraph (a) by
demonstrating that -it has insurance that provides
protection that is equal to or greater than the coverage
and limits specified in subparagraph (a). The County
shall be the sole judge of whether such a waiver
should be granted.
(g) The Contractor may obtain a waiver of any one or more
of the requirements in paragraph (a) by demonstrating
that it is self- insured and that its self-insurance
provides protection that is equal to or greater than the
coverage and limits specified in subparagraph (a). The
County shall be the sole judge of whether such a
waiver should be granted.
(h) Providing and maintaining the types and amounts of
insurance or self-insurance specified in this paragraph
is a material obligation of the Contractor and is of the
essence of this contract.
(i) The Contractor shall only obtain insurance from
companies that are authorized to provide such
coverage and that are authorized by the Commissioner
of Insurance to do business in the State of North
Carolina. All such insurance shall meet all laws of the
State of North Carolina.
(j) The Contractor shall comply at all times with all lawful
terms and conditions of its insurance policies and all
lawful requirements of its insurer.
(k) The Contractor shall require its subcontractors to
comply with the requirements of this paragraph.
(1) The Contractor shall demonstrate its compliance with
the requirements of this paragraph by submitting
certificates of insurance to the County before the
Contractor begins work under this contract.
Transportation of Clients by Contractor: The contractor
will maintain Insurance requirements if required as noted
under Article 7 Rule R2 -36 of the North Carolina Utilities
Commission.
Default and Termination
Termination Without Cause: The County may terminate
this contract without cause by giving 30 days written
notice to the Contractor.
Termination for Cause: If, through any cause, the
Contractor shall fail to fulfill its obligations under this
contract in a timely and proper manner, the County shall
have the right to terminate this contract by giving written
notice to the Contractor and specifying the effective date
thereof. In that event, all finished or unfinished deliverable
items prepared by the Contractor under this contract shall,
at the option of the County, become its property and the
Contractor shall be entitled to receive just and equitable
compensation for any satisfactory work completed on such
materials, minus any payment or compensation previously
made. Notwithstanding the foregoing provision, the
Contractor shall not be relieved of liability to the County
for damages sustained by the County by virtue of the
Contractor's breach of this agreement, and the County may
withhold any payment due the Contractor for the purpose
of setoff until such time as the exact amount of damages
due the County from such breach can be determined. In
case of default by the Contractor, without limiting any
other remedies for breach available to it, the County may
procure the contract services from other sources and hold
the Contractor responsible for any excess cost occasioned
thereby. The filing of a petition for bankruptcy by the
Contractor shall be an act of default under this contract.
Waiver of Default: Waiver by the County of any default
or breach in compliance with the terms of this contract by
the Provider shall not be deemed a waiver of any
subsequent default or breach and shall not be construed to
be modification of the terms of this contract unless stated
to be such in writing, signed by an authorized
representative of the County and the Contractor and
attached to the contract.
Availability of Funds: The parties to this contract agree
and understand that the payment of the sums specified in
this contract is dependent and contingent upon and subject
to the appropriation, allocation, and availability of funds
for this purpose to the County.
Force Majeure: Neither party shall be deemed to be in
default of its obligations hereunder if and so long as it is
prevented from performing such obligations by any act of
war, hostile foreign action, nuclear explosion, riot, strikes,
civil insurrection, earthquake, hurricane, tornado, or other
catastrophic natural event or act of God.
Survival of Promises: All promises, requirements, terms,
conditions, provisions, representations, guarantees, and
warranties contained herein shall survive the contract
expiration or termination date unless specifically provided
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otherwise herein, or unless superseded by applicable
Federal or State statutes of limitation.
Intellectual Property Rights
Copyrights and Ownership of Deliverables: All
deliverable items produced pursuant to this contract are the
exclusive property of the County. The Contractor shall not
assert a claim of copyright or other property interest in
such deliverables.
Federal Intellectual Properly Bankruptcy Protection
Act: The Parties agree that the County shall be entitled to
all rights and benefits of the Federal Intellectual Property
Bankruptcy Protection Act, Public Law 100 -506, codified
at 11 U.S.C. 365 (n) and any amendments thereto.
Compliance with Applicable Laws
Compliance with Laws: The Contractor shall comply
with all laws, ordinances, codes, rules, regulations, and
licensing requirements that are applicable to the conduct of
its business, including those of federal, state, and local
agencies having jurisdiction and/or authority. 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.
Title VI, Civil Rights Compliance: In accordance with
Federal law and U.S. Department of Agriculture (USDA)
and U.S. Department of Health and Human Services
(HHS) policy, this institution is prohibited from
discriminating on the basis of race, color, national origin,
sex, age or disability. Under the Food Stamp Act and
USDA policy, discrimination is prohibited also on the
basis of religion or political beliefs.
Equal Employment Opportunity: The Contractor shall
comply with all federal and State laws relating to equal
employment opportunity.
Health Insurance Portability and Accountability Act
(HIPAA): The Contractor agrees that, if the County
determines that some or all of the activities within the
scope of this contract are subject to the Health Insurance
Portability and Accountability Act of 1996, P.L. 104 -91,
as amended ( "HIPAA "), or its implementing regulations,
it will comply with the HIPAA requirements and will
execute such agreements and practices as the County
may require to ensure compliance.
(a) Data Security: The Contractor shall adopt and
apply data security standards and procedures
that comply with all applicable federal, state and
local laws, regulations, and rules.
(b) Duty to Report: The Contractor shall report a
suspected or confirmed security breach to the
local Department of Social Services Contract
Administrator within twenty-four (24) hours
after the breach is first discovered, provided that
the Contractor shall report a breach involving
Social Security Administration data or Internal
Revenue Service Data within one (1) hour after
the breach is first discovered.
(c) Cost Borne by Contractor: If any applicable
federal, state, or local law, regulation or rule
requires the Contractor give written notice of a
security breach to affected persons, the Contract
shall bear the cost of the notice.
Trafficking Victims Protection Act of 2000:
The Contractor will comply with the requirements of
Section 106(g) of the Trafficking Victims Protection Act
of 2000, as amended (2.2 U.S.C. 7104)
Executive Order # 24: It is unlawful for any vendor,
contractor, subcontractor or supplier of the state to make
gifts or to give favors to any state employee. For
additional information regarding the specific
requirements and exemptions, contractors are
encouraged to review Executive Order 24 and G.S. Sec.
133 -32.
Confidentiality
Confidentiality: Any information, data, instruments,
documents, studies or reports given to or prepared or
assembled by the Contractor under this agreement shall be
kept as confidential and not divulged or made available to
any individual or organization without the prior written
approval of the County. The Contractor acknowledges that
in receiving, storing, processing or otherwise dealing with
any confidential information it will safeguard and not
further disclose the information except as otherwise
provided in this contract.
Oversight
Access to Persons and Records: The State Auditor shall
have access to persons and records as a result of all
contracts or grants entered into by State agencies or
political subdivisions in accordance with General Statute
147 -64.7. Additionally, as the State funding authority, the
Department of Health and Human Services shall have
access to persons and records as a result of all contracts or
grants entered into by State agencies or political
subdivisions.
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Record Retention: Records shall not be destroyed,
purged or disposed of without the express written consent
of the Division. State basic records retention policy
requires all grant records to be retained for a minimum of
five years or until all audit exceptions have been resolved,
whichever is longer. If the contract is subject to federal
policy and regulations, record retention may be longer than
five years since records must be retained for a period of
three years fallowing submission of the final Federal
Financial Status Report, if applicable, or three years
following the submission of a revised final Federal
Financial Status Report. Also, if any litigation, claim,
negotiation, audit, disallowance action, or other action
involving this Contract has been started before expiration
of the five -year retention period described above, the
records must be retained until completion of the action and
resolution of all issues which arise from it, or until the end
of the regular five -year period described above, whichever
is later. The record retention period for Temporary
Assistance for Needy Families (TANF) and MEDICAID
and Medical Assistance grants and programs must be
retained for a minimum of ten years.
Warranties and Certifications
Date and Time Warranty: The Contractor warrants that
the product(s) and service(s) furnished pursuant to this
contract ( "product" includes, without limitation, any piece
of equipment, hardware, firmware, middleware, custom or
commercial software, or internal components, subroutines,
and interfaces therein) that perform any date and/or time
data recognition function, calculation, or sequencing will
support a four digit year format and will provide accurate
date /time data and leap year calculations. This warranty
shall survive the termination or expiration of this contract.
Certification Regarding Collection of Taxes: G. S. 143-
59.1 bars the Secretary of Administration from entering
into contracts with vendors that meet one of the conditions
of G.S. 145- 164.8(b) and yet refuse to collect use taxes on
sales of tangible personal property to purchasers in North
Carolina. The conditions include: (a) maintenance of a
retail establishment or office; (b) presence of
representatives in the State that solicit sales or transact
business on behalf of the vendor; and (c) systematic
exploitation of the market by media - assisted, media -
facilitated, or media- solicited means. The Contractor
certifies that it and all of its affiliates (if any) collect all
required taxes.
E- Verify
Pursuantto G.S. 143 -48.5, the undersigned hereby certifies
that the Contractor named below, and the Contractor's
subcontractors, complies with the requirements of Article 2
of Chapter 64 of the NC General Statutes.
Miscellaneous
Choice of Law: The validity of this contract and any of its
terms or provisions, as well as the rights and duties of the
parties to this contract, are governed by the laws of North
Carolina. The Contractor, by signing this contract, agrees
and submits, solely for matters concerning this Contract, to
the exclusive jurisdiction of the courts of North Carolina
and agrees, solely for such purpose, that the exclusive
venue for any legal proceedings shall be Orange County,
North Carolina. The place of this contract and all
transactions and agreements relating to it, and their situs
and forum, shall be Orange County, North Carolina, where
all matters, whether sounding in contract or tort, relating to
the validity, construction, interpretation, and enforcement
shall be determined.
Amendment: This contract may not be amended orally or
by performance. Any amendment must be made in written
form and executed by duly authorized representatives of
the County and the Contractor.
Severability: In the event that a court of competent
jurisdiction holds that a provision or requirement of this
contract violates any applicable law, each such provision
or requirement shall continue to be enforced to the extent it
is not in violation of law or is not otherwise unenforceable
and all other provisions and requirements of this contract
shall remain in full force and effect.
Headings: The Section and Paragraph headings in these
General Terms and Conditions are not material parts of the
agreement and should not be used to construe the meaning
thereof.
Time of the Essence: Time is of the essence in the
performance of this contract.
Key Personnel: The Contractor shall not replace any of
the key personnel assigned to the performance of this
contract without the prior written approval of the County.
The term "key personnel" includes any and all persons
identified as such in the contract documents and any other
persons subsequently identified as key personnel by the
written agreement of the parties.
Care of Property: The Contractor agrees that it shall be
responsible for the proper custody and care of any property
furnished to it for use in connection with the performance
of this contract and will reimburse the County for loss of,
or damage to, such property. At the termination of this
contract, the Contractor shall contact the County for
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instructions as to the disposition of such property and shall
comply with these instructions.
Travel Expenses: Reimbursement, if provided in this
Agreement, to the Contractor for travel mileage, meals,
lodging and other travel expenses incurred in the
performance of this contract shall not exceed the rates
established in County policy.
Sales[Use Tax Refunds: If eligible, the Contractor and all
subcontractors shall; (a) ask the North Carolina
Department of Revenue for a refund of all sales and use
taxes paid by them in the performance of this contract,
pursuant to G.S. 105- 164.14, and (b) exclude all
refundable sales and use taxes from all reportable
expenditures before the expenses are entered in their
reimbursement reports.
Advertising: The Contractor shall not use the award of
this contract as a part of any news release or commercial
advertising.
Orange County Living Wage: Orange County is
committed to providing its employees with a living wage
and encourages agencies to which it provides funding to
pursue the same goal. The County's living wage hourly
standard, as adopted by the Orange County Board of
County Commissioners annually, can be found in the
Orange County Budget Ordinance. To the extent possible,
Orange County recommends that the Contractor and all
subcontractors provide a living wage, as defined in this
section, to their employees.
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.
General Terms and Conditions — (06116) Page 5 of 5
DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 11AAECCBC787
ATTACHMENT B
SCOPE OF WORK
Orange County Department of Social Services and Orange County Department on Aging
Federal Tax Id. or SSN 36-4651170
Contract # 68 -2039
A. CONTRACTOR INFORMATION
1, Contractor Agency Name: Medisolutions Inc.
2, If different from Contract Administrator Information in General Contract:
Address
Telephone Number: Fax Number: Email:
3. Name of Program (s): In -Home Services
4. Status: ( ) Public ( ) Private, Not for Profit (X) Private, For Profit
5. Contractor's Financial Reporting Year July 1 2018 through _ June 30� 2019
B. Explanation of Services to be provided and to whom (include SIS Service Code): _The
Contractor will provide employees to perform in-home services for the Department of Social_
Services' clients and the Department on Agin,g's clients, at the level, amount and frequent
specified by the social worker in the In -Home Aide Services Plan (SIS Code 042
Contractor will provide Level 11 Home Management and Level 11 Personal Care. 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)
A maximum allowable rate of `1;22.74 /hour, of which the Contractor must pa y the In
Home Aide at least the County's Liming Wage f currently $14.25 per/hr). The County has
increased the standard fixed rate to compensate Contractor for any amount above Federal
Minimum Wage.
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 uts to the budizetary limits of the contract allotment. The
County will reimburse the Contractor at a rate of $22.74/hour 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. All
invoices for the provision of services to the Department of Social Services shall be submitted to
the Administrator for said Department. All invoices for the provision of services to the
Contract -Scope of Work (05104) Page lof 2
DocuSign Envelope ID: 3E4B4B91-8AA8-41 OB-8584-1 1 AAECCBC787
Department on Aging shall be submitted to the Administrator for said Department. The Couuty
will reimburse the Contractor month! y upon receipt of a complete and coffecft filed me ort,
F. Area to be served/Delivery site(s): Qrange County
DocuSigned. by:
Nan r� Wou
DAE1E198A83B455...
Xancy Coston, Social Service
8/10/2018
(Date Submitted)
DocuSigned by:
67E962MBF454FA... --
Janice Tyler, Dept.
8/10/2018
(Date Submitted)
Director
on Aging Director
DocuSigned by:
66t �r
9C86E1OAE89C476...
(Signature of Contractor)
8/3/2018
(Date Submitted)
Contract -Scope of Work (06/04) Page 2af 2
DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 11AAECCBC787
ATTACHMENT C
CERTIFICATION REGARDING DRUG -FREE WORKPLACE REQUIREMENTS
AND CERTIFICATION REGARDING NONDISCRRVHNATION
Orange County Department of Social Services and Department on Aging
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 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
(13)(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).
Federal Certification - Drug -Free Workplace & Nondiscrimination rev. 06-20 15
Page I of 2
DocuSign Envelope ID: 3E4B4B91-8AA8-41 OB-8584-1 1 AAECCBC787
Il. The site(s) for the performance of work done in connection with the specific agreement are listed
below:
1.
R
(Street address)
(City, county, state, zip code)
(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.
DocuAASigned by:
4� �r
OC96E1OAE89C478...
Signature
ceo
Title
Medisolutions Inc. 8/3/2018
Agency /Organization Date
(Certification signature should be same as Contract signature.)
Federal Certification - Drug -Free Workplace cc Nondiscrimination rev. 06 -2015
Page 2 of 2
DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 11AAECCBC787
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 'ctions of any Board member or other governing person,
officer, employee or agent. This is not intended to preclude bona -fide Organization fund raising -
activities. i
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 (06115) Pagc 1 of 3
DocuSign Envelope ID: 3E4B4B91- 8AA8 -410B- 8584- 11AAECCBC787
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 persons) 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 ofiDirectors/Trustees or other governing body.
I
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 wl�o 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 conflicj 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 w�o 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:
Name Clrganizati n
,_--- Signature 11f Org nization Official
Date
Conflict of Interest Policy (06115)
Page 2 of 3
DocuSign Envelope ID: 3E4B4B91- 8AA8 -410B- 8584- 1IAAECCBC787
NOTARIZED CONFLICT OF INTEREST POLICY
State of North Carolina
County of Orange
1, 'r"p— 1 , Notary Public for said County and State,
certify that k.A,yQ'Q ko' personally appeared before me this
day and acknowledged that he/she is Rzo of
gew tS01L+k0 a'_- 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/Trustees or other governing body in a meeting held on the _ day of
11 -ems, �31
Sworn to and subscribed before ene this 49 day of TUB
,
',.�f�f 1111F111Irprll
�.•� N A
Seal)
Notary Public
_f0A+(Official
� +=
_ �OT'��'� -� =
My Commission expires q,� .2o , 204/
G? �w A G '
S r- '., CI BLI r+ G r`
Conflict of Interest Policy (06/15) Page 3 of 3
DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 11AAECCBC787
ATTACHMENT E
OVERDUE TAXES
Orange County Department of Social Services
Instructions: Grantee /Provider should complete this certification for all funds received. Entity
should enter appropriate data in the yellow highlighted areas. The completed and signed form
must be provided to the County Department of Social Services,
Medisolutions Inc.
0612912018
To: Orange County Department of Social Services
Certification:
We certify that Med isol utions, Inc. does not have any overdue tax debts, as defined by N.C.G.S.
1 05- 243.1', at the federal, State, or ioc tl level. We further understand that any person who makes
a false statement in violation ofN.C.GI�S. 1430- 6 -23(c) is guilty of a criminal offense punishable
as provided by N.C.G.S. 1430- 10 -1(b).
Sworn Statement:
I
Oswald Nwogbo and ,lohn Okafor being duly sworn, say that we are the Board Chair and Chief
Operating Officer, respectively, of MOS011.16011s, Inc. of Burlington in the State of North
Carolina; and that the foregoing certification is true, accurate and complete to the hest of our
knowledge and as made and subscribed by us. We also acknowledge and understand that any
misuse of State/funds will I be re�orll:A to the appropriate authorities for further action.
Chief Operating Officer Cj
+`', %q'j„111'1F?Gwprn to and subscribed before me on the day of the date of said certification.
p o+
1z 11 07A� }- `"
�
~ "r r My Commission Expires; - -6 2.01 Cr
s n'• AUBLrN064 Signature and Seal)
A�'/11111I11 i1N M1 +t ►"
I
' G.S, 105 -243.1 defines: Overdue lax debt. — A{ y part of a tax deist that remains unpaid 90 days or more after the
notice of final assessment was mailed to the taxpayer. The term aloes not include a tax debt, however, if the taxpayer
catered into an installliient ab cement for the tax debt under G.5. 105 -237 within 90 days after the notice of final
assessment was mailed and has not failed to mane any payments due under the installment agreement."
Overdue Taxes — (07108) Page i of I
DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 11AAECCBC787
ATTACHMENT G
CERTIFICATION REGARDING LOBBYING
Orange County Department of Social Services and Department on Aging
Certification for Contracts Grants Loans and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to
any person for influencing or attempting to influence an officer or employee of any Federal, state or
local government agency, a Member of Congress, a Member of the General Assembly, an officer or
employee of Congress, an officer or employee of the General Assembly, an employee of a Member
of Congress, or an employee of a Member of the General Assembly in connection with the awarding
of any Federal or state contract, the making of any Federal or state grant, the making of any Federal
or state loan, the entering into of any cooperative agreement, and the extension, continuation,
renewal, amendment, or modification of any Federal or state contract, grant, loan, or cooperative
agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any Federal, state or local
government agency, a Member of Congress, a Member of the General Assembly, an officer or
employee of Congress, an officer or employee of the General Assembly, an employee of a Member
of Congress, or an employee of a Member of the General Assembly in connection with the awarding
of any Federal or state contract, the making of any Federal or state grant, the making of any Federal
or state loan, the entering into of any cooperative agreement, and the extension, continuation,
renewal, amendment, or modification of any Federal or state contract, grant, loan, or cooperative
agreement, the undersigned shall complete and submit Standard Form LLL, "Disclosure Form to
Report Lobbying," in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose
accordingly..
(4) This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making or
entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails
to file the required certification shall be subject to a civil penalty of not less than $10,004 and not
more than $100,000 for each such failure.
Notwithstanding other provisions of federal OMB Circulars -CFR Title 2, Grants and Agreements, Part 204,
costs associated with the following activities are unallowable:
Paragraph A.
(1) Attempts to influence the outcomes of any Federal, State, or local election, referendum, initiative, or
similar procedure, through in kind or cash contributions, endorsements, publicity, or similar activity;
(2) Establishing, administering, contributing to, or paying the expenses of political party, campaign,
political action committee, or other organization established for the purpose of influencing the
outcomes of elections;
(3) Any attempt to influence: (i) The introduction of Federal or State legislation; or (ii) the enactment or
modification of any pending Federal or State legislation through communication with any member
or employee of the Congress or State legislature (including efforts to influence State or local
Federal Certification — Lobbying (06115) Page l of 3
DocuSign Envelope ID: 3E4B4B91- 8AA8 -410B- 8584- 11AAECCBC787
officials to engage in similar lobbying activity), or with any Government official or employee in
connection with a decision to sign or veto enrolled legislation;
(4) Any attempt to influence: (i) The introduction of Federal or State legislation; or (ii) the enactment or
modification of any pending Federal or State legislation by preparing, distributing or using publicity
or propaganda, or by urging members of the general public or any segment thereof to contribute to
or participate in any mass demonstration, march, rally, fundraising drive, lobbying campaign or
letter writing or telephone campaign; or
(5) Legislative liaison activities, including attendance at legislative sessions or committee hearings,
gathering information regarding legislation, and analyzing the effect of legislation, when such
activities are carried on in support of or in knowing preparation for an effort to engage in
unallowable lobbying.
The following activities as enumerated in Paragraph B are excepted from the coverage of Paragraph A:
Paragraph B.
(1) Providing a technical and factual presentation of information on a topic directly related to the
performance of a grant, contract or other agreement through hearing testimony, statements or letters
to the Congress or a State legislature, or subdivision, member, or cognizant staff member thereof, in
response to a documented request (including a Congressional Record notice requesting testimony or
statements for the record at a regularly scheduled hearing) made by the recipient member, legislative
body or subdivision, or a cognizant staff member thereof; provided such information is readily
obtainable and can be readily put in deliverable form; and further provided that costs under this
section for travel, lodging or meals are unallowable unless incurred to offer testimony at a regularly
scheduled Congressional hearing pursuant to a written request for such presentation made by the
Chairman or Ranking Minority Member of the Committee or Subcommittee conducting such
hearing.
(2) Any lobbying trade unallowable by subparagraph A (3) to influence State legislation in order to
directly reduce the cost, or to avoid material impairment of the organization's authority to perform
the grant, contract, or other agreement.
(3) Any activity specifically authorized by statute to be undertaken with funds from the grant, contract,
or other agreement.
Paragraph C.
(1) When an organization seeks reimbursement for indirect costs, total lobbying costs shall be
separately identified in the indirect cost rate proposal, and thereafter treated as other unallowable
activity costs in accordance with the procedures of subparagraph B.(3).
(2) Organizations shall submit, as part of the annual indirect cost rate proposal, a certification that the
requirements and standards of this paragraph have been complied with.
(3) Organizations shall maintain adequate records to demonstrate that the determination of costs as
being allowable or unallowable pursuant to this section complies with the requirements of this
Circular.
(4) Time logs, calendars, or similar records shall not be required to be created for purposes of
complying with this paragraph during any particular calendar month when: (1) the employee
engages in lobbying (as defined in subparagraphs (a) and (b)) 25 percent or less of the employee's
compensated hours of employment during that calendar month, and (2) within the preceding five -
year period, the organization has not materially misstated allowable or unallowable costs of any
nature, including legislative lobbying costs. When conditions (1) and (2) are met, organizations are
not required to establish records to support the allowability of claimed costs in addition to records
already required or maintained. Also, when conditions (1) and (2) are met, the absence of time logs,
calendars, or similar records will not serve as a basis for disallowing costs by contesting estimates of
lobbying time spent by employees during a calendar month.
Federal Certification — Lobbying (06115) Page 2 of 3
DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 11AAECCBC787
(5) Agencies shall establish procedures for resolving in advance, in consultation with ON1B, any
significant questions or disagreements concerning the interpretation or application of this section.
Any such advance resolution shall be binding in any subsequent settlements, audits or investigations
with respect to that grant or contract for purposes of interpretation of this Circular; provided,
however, that this shall not be construed to prevent a contractor or grantee from contesting the
lawfulness of such a determination.
Paragraph D.
Executive lobbying costs. Costs incurred in attempting to improperly influence either directly or indirectly,
an employee or officer of the Executive Branch of the Federal Government to give consideration or to act
regarding a sponsored agreement or a regulatory matter are unallowable. Improper influence means any
influence that induces or tends to induce a Federal employee or officer to give consideration or to act
regarding a federally sponsored agreement or regulatory matter on any basis other than the merits of the
matter.
DocuSigned by:
3 4 D cr
9C88E10AE89C478...
Signature
Medisolutions Inc.
Agency /Organization
ceo
Title
8/3/2018
Date
(Certification signature should be same as Contract signature.)
Federal Certification — Lobbying (06/15) Page 3 of 3
DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 11AAECCBC787
ATTACHMENT H
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY
AND VOLUNTARY EXCLUSION -LOWER TIER COVERED TRANSACTIONS
Grange County Department of Social Services and Department on Aging
Instructions for Certification
1. By signing and submitting this proposal, the prospective lower tier participant is providing
the certification set out below.
2. The certification in this clause is a material representation of the fact upon which reliance
was placed when this transaction was entered into. If it is later determined that the prospective
lower tier participant knowingly rendered an erroneous certification, in addition to other
remedies available to the Federal Government, the department or agency with which this
transaction originated may pursue available remedies, including suspension and/or debarment.
3. The prospective lower tier participant will provide immediate written notice to the person to
which the proposal is submitted if at any time the prospective lower tier participant learns that its
certification was erroneous when submitted or has become erroneous by reason of changed
circumstances.
4. The terms "covered transaction," "debarred," "suspended," "ineligible," 'dower tier covered
transaction," "participant," "person," "primary covered transaction," "principal," "proposal," and
"voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and
Coverage sections of rules implementing Executive Order 12549. You may contact the person to
which this proposal is submitted for assistance in obtaining a copy of those regulations.
5. The prospective lower tier participant agrees by submitting this proposal that, should the
proposed covered transaction be entered into, it shall not knowingly enter any lower tier covered
transaction with a person who is debarred, suspended, determined ineligible or voluntarily
excluded from participation in this covered transaction unless authorized by the department or
agency with which this transaction originated.
6. The prospective lower tier participant further agrees by submitting this proposal that it will
include this clause titled "Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion - Lower Tier Covered Transaction," without modification, in all lower tier
covered transactions and in all solicitations for lower tier covered transactions.
7. A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or
voluntarily excluded from covered transaction, unless it knows that the certification is erroneous.
A participant may decide the method and frequency of which it determines the eligibility of its
principals. Each participant may, but is not required to, check the Nonprocurement List.
8. Nothing contained in the foregoing shall be construed to require establishment of a system of
records in order to render in good faith the certification required by this clause. The knowledge
and information of a participant is not required to exceed that which is normally possessed by a
prudent person in the ordinary course of business dealings.
Federal Certification - Debarment (06115) Page l of 2
DocuSign Envelope ID: 3E4B4B91-8AA8-41 OB-8584-1 1 AAECCBC787
9. Except for transactions authorized in paragraph 5 of these instructions, if a participant in a
covered transaction knowingly enters into a lower tier covered transaction with a person who is
suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in
addition to other remedies available to the Federal Government, the department or agency with
which this transaction originated may pursue available remedies, including suspension, and/or
debarment.
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower
Tier Covered Transactions
(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it
nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from participation in this transaction by any Federal department or
agency.
(2) Where the prospective lower tier participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this proposal.
I OocuSigned by:
366, �r ceo
9C88E10AE89C478...
Signature Title
Medisolutions Inc. 8/3/2018
Agency /Organization Date
(Certification signature should be same as Contract signature.)
Federal Certification - Debarment (05/15) Page 2 of 2
DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 11AAECCBC787
ATTACHMENT J
CERTIFICATION REGARDING TRANSPORTATION
Orange County Department of Social Services and Orange County Department on Aging
By execution of this Agreement the Contractor certifies that it will provide safe client
transportation by:
1. 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;
5. Insuring that no more than one quarter of one percent of all trips be missed by the
contractor during the course of the contract period; (Medicaid only)
6. Insuring that that no more than five percent (5 %) of trips should be late for recipient drop
off to their appointment per month; ( Medicaid only)
7. 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.
8. Disclosing, at the outset of the contract, upon renewal and upon request, any criminal
convictions or other reasons for disqualifications from participation in Medicare,
DocuSi n a by;" °;.` . or Title programs (signature on this form confirms this statement).
J6� �r ceo
9C88E10AE89C478... -
Signature Title
Medisolutions Inc. 8/3/2018
Agency /Organization Date
(Certification signature should be same as Contract signature.)
Transportation Certification (06/16) Page 1 of I
DocuSign Envelope ID: 3E4B4B91-8AA8-41 OB-8584-1 1 AAECCBC787
ATTACHMENT M
STATE AND LOCAL CERTIFICATION
Contractor Certifications Required by North Carolina Law
Orange County Department of Social Services
Instructions
The person who signs this document should read the text of the statutes listed below and consult with counsel and other
knowledgeable persons before signing.
• The text of Article 2 of Chapter 64 of the North Carolina General Statutes can be found online at:
http• / /www ncga state ne.us /EnactedLegislation/ Statutes /PDFByArtiele /Chapter,64 /Article 2.pdf
• The text of G.S. 105- 164.8(b) can be found online at:
htt : / /www.nc a.state.ne.us /EnactedLe islationIStatutes/PDF /B Section/Cha ter 105 /GS 1 fly - 164.8. df
• The text of G.S. 143 -48.5 (S.L. 2013 -418, s. 2.(d)) can be found online at:
http• / /www ncga state.nc.us /Sessions /2013 /Bills /House /PDF/H786v6.pdf
• The text of G.S. 143 -59.1 can be found online at:
htt : / /www.nc a.state.nc.us /EnactedLe islation /Statutes /PDF/B SectionICha ter 143 /GS 143- 59.1. df
• The text of G.S. 143 -59.2 can be found online at:
http: / /www.nega. state. nc. us /EnactedLegislation/ Statutes /PDF /BySection/Chaptere1431GS 143- 59.2.12df
• The text of G.S. 147 - 33.95(8) (S.L. 2013 -418, s. 2. (e)) can be found online at:
http• / /www ncga. state. nc. us / Sessions /2013Bills /House /PDF /H786v6.pdf
• The text of Orange County Living Wage Contractor Policy which is attached to this document.
Certifications
(1) Pursuant to G.S. 143 -48.5, the undersigned hereby certifies that the Contractor named below, and the
Contractor's subcontractors, complies with the requirements of Article 2 of Chapter 64 of the NC General
Statutes, including the requirement for each employer with more than 25 employees in North Carolina to verify
the work authorization of its employees through the federal E- Verify system." E- Verify System Link:
www.uscis.gov
Local government is specifically exempt from Article 2 of Chapter 64 of the North Carolina General Statutes.
However, local government is subject to and must comply with North Carolina General Statute § 153A- 99.1.,
which states in part as follows:
Counties Must Use E- Verify. - Each county shall register and participate in E- Verify to verify the work
authorization of new employees hired to work in the United States.
(2) Pursuant to G.S. 143- 59.1(b), the undersigned hereby certifies that the Contractor named below is not an
"ineligible Contractor" as set forth in G.S. 143- 59.1(a) because:
(a) Neither the Contractor nor any of its affiliates has refused to collect the use tax levied under Article 5 of
Contractor Certifications Required by North Carolina Law Page 1 of 3
revised May 30, 2018
DocuSign Envelope ID: 3E4B4B91- 8AA8 -410B- 8584- 11AAECCBC787
Chapter 105 of the General Statutes on its sales delivered to North Carolina when the sales met one or
more of the conditions of G.S. 105- 164.8(b); and
(b) [check one of the following boxes]
❑ Neither the Contractor nor any of its affiliates has incorporated or reincorporated in a "tax haven
country" as set forth in G.S. 143- 59.1(c) (2) after December 31, 2001; or
❑ The Contractor or one of its affiliates has incorporated or reincorporated in a "tax haven country"
as set forth in G.S. 143- 59.1(c)(2) after December 31, 2001 but the United States is not the
principal market for the public trading of the stock of the corporation incorporated in the tax
haven country.
(3) Pursuant to G.S. 143- 59.2(b), the undersigned hereby certifies that none of the Contractor's officers, directors,
or owners (if the Contractor is an unincorporated business entity) has been convicted of any violation of Chapter
78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 years
immediately prior to the date of the bid solicitation.
(4) The undersigned hereby certifies further that:
(a) He or she is a duly authorized representative of the Contractor named below;
(b) He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of the
Contractor; and
(c) He or she understands that any person who knowingly submits a false certification in response to the
requirements of G.S. 143- 59.land -59.2 shall be guilty of a Class T felony.
(5) Pursuant to the Orange County Living Wage Contractor's Policy:
(a) The undersigned certifies that the Contractor pays the employees who perform services under this contract a
living wage (in Change County currently $14.25 per /hr) Check here ® if contractor pays employees
performing under this contract a living wage. If Contractor does not pay employees a living wage, what is the
wage that employees performing services under this contract paid
Medisolutions Inc.
—'�1�1u1j(ouu� Iy 11 UU any: e AaAr
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Nagnature or uontractor's Authorized Agent
John Okafor
NWutl W606
`71 X221 A4S85A40 E...
Nignature or wimess
Oswald Nwogbo
tractor's Authorized Agent
Printed Name of Witness
8/3/2018
Date
ceo
Title
coo
Title
8/9/2018
Date
The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and date
this document immediately thereafter.
Contractor Certifications Required by North. Carolina Law Page 2 of 3
revised May 30, 2018
DocuSign Envelope ID: 3E4B4B91-8AA8-41 OB-8584-1 1 AAECCBC787
Section I:
General Government and Administration
Policy 10.0:
Living Wage Contractor Policy
Reviewed by:
County Attorney /County Manager
Approved by:
County Manager
Original Effective Date:
April 21, 2016
Revisions:
Policy Statement
It is the policy of Orange County to ensure its employees, and all individuals who provide services for Orange County, are
paid a living wage.
Purpose
To encourage all vendors and contractors to pay a living wage to all employees who perform work pursuant to a contract
with Orange County.
Applicability
Applies to all Orange County contracts and purchases.
Policy
10.1 Living Wage
10.1.1 Orange County is committed to providing its employees with a living wage and encourages all contractors
and vendors doing business with Orange County to pursue the same goal. Orange County's living wage is $14.25
per hour. To the extent possible, Orange County recommends that contractors and vendors seeking to do business
with Orange County provide a living wage to their employees.
1.0.1.2 Prior to final execution of a contract with Orange County all contractors and vendors seeking to do
business with Orange County shall submit to the County's representative a statement indicating whether those
employees who will perform work on the Orange County contract are paid at least the living wage amount set out
above. If such employees do not make at least the living wage amount set out above the contractor or vendor
shall indicate in the statement the actual amount paid to such employees. For bid projects this statement should
be submitted as part of the bid packet.
This policy may be reviewed annually and updated as needed by the Manager's Office
Contractor Certifications Required by North Carolina Law Page 3 of 3
revised May 30, 2018
DocuSign Envelope ID: 3E4B4B91-8AA8-41 OB-8584-1 1 AAECCBC787
Contract #68 -2039
Medisolutions, Inc.
ATTACHMENT N
Grange County Department of Social Services/Human Services
CERTIFICATION REGARDING NONDISCRIMINATION, CLEAN AIR ACT, CLEAN
WATER ACT
Certification Regarding Nondiscrimination
The Contractor 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.
The Contractor must comply with Executive Order 11246, entitled "Equal Employment
Opportunity," as amended by Executive Carder 11375, and as supplemented by the Department of
Labor Regulations (41 CFR Part 60): The Executive Order prohibits federal contractors and
federally- assisted construction contractors and subcontractors who do over $10,000 in
Government business in one year from discriminating in employment decisions on the basis of
race, color, religion, sex, or national origin. The Executive Order also requires Government
contractors to take affirmative action to ensure that equal opportunity is provided in all aspects of
their employment.
Meaninizful Access for LEP Individuals: The Contractor that participate in the SNAP must take
reasonable steps to ensure that LEP persons have meaningful access to programs, services, and
benefits. This includes the requirement to provide bilingual program information and
certification materials and interpretation services to single language minorities in certain project
areas. SNAP Contractors that do not provide meaningful access for LEP individuals risk
violating prohibitions against discrimination based on National Origin in the Food and Nutrition
Act of 2008, as amended, Title VI of the Civil Rights Act of 1964 (Title VI) and SNAP program
regulations at 7 CFR 272A(b). They also risk noncompliance with the USDA policy guidance
titled, "Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition
Against National Origin Discrimination Affecting Limited English Proficient Persons ",
published in 79 FR 70771 - 70784 (November 28, 2014).
The Contractor should develop an implementing plan to address the language assistance needs
of the LEP population served. This may include contracting for oral interpretation services,
hiring bilingual staff, arranging telephone interpreters and/or language lines, coordinating
community volunteers, translating vital documents, and providing written notice that language
services are available in appropriate languages. quality and accuracy of the language service is
(Federal Certification- Non - Discrimination, Clean Air, Clean Water) (01 /2018)Page 1 of 4
DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 11AAECCBC787
Contract #68 -2039
Medisolutions, Inc..
critical in order to avoid serious consequences to the LEP person and to the recipient. LEP needs
should be considered in developing budgets and front line staff should understand how to obtain
language assistance services. For additional assistance and information regarding LEP matters,
please also visit http://www.lep.pov.
Ensuring Equal Opportunity Access for Persons with Disabilities: The Contractor must also
ensure equal opportunity access for persons with disabilities. This includes ensuring that
communications with applicants, participants, members of the public, and companions with
disabilities are as effective as communications with people without disabilities. Contractors that
do not provide persons with disabilities equal opportunity access to programs may risk violating
prohibitions against disability discrimination in the Rehabilitation Act of 1978, the American
with Disabilities Act (ADA) of 1990, as amended, and SNAP program regulations.
DDJ published revised final regulations implementing Title 11 and Title III of the ADA on
September 15, 2010. These regulations are codified at 28 CFR Part 35 "Nondiscrimination on
the Basis of Disability in State and Local Government Services" and at 28 CFR Part 36
"Nondiscrimination on the Basis of Disability in Public Accommodations and Commercial
Facilities ". In accordance with the implementing regulations, Contractors must provide auxiliary
aids and services where necessary to ensure effective communication and equal opportunity
access to program benefits for individuals with disabilities. The type of auxiliary aids and
services required will vary, but a Contractor may not require an individual with a disability to
bring another individual to interpret, and may rely on a person accompanying a disabled
individual only in limited circumstances. When a Contractor communicates with applicants and
beneficiaries by telephone, it must provide text telephone services (ITY) or have access to an
equally effective electronic telecommunications system to communicate with individuals who are
deaf, hard of hearing, or hearing impaired. Contractors must also ensure that interested persons,
including persons with impaired vision or hearing, can obtain information as to the existence and
location of accessible services, activities, and facilities. For more information, please visit the
ADA website: http: / /www.ada.gov.
IV. The Clean Air Act, Section 306; 42 U.S.C. §7401 et seq. (1970)
a. No Federal agency may enter into any contract with any person who is convicted of any
offense under section 113(c) for the procurement of goods, materials, and services to
perform such contract at any facility at which the violation which gave rise to such
conviction occurred if such facility is owned, leased, or supervised by such person. The
prohibition in the preceding sentence shall continue until the Administrator certifies that
the condition giving rise to such a conviction has been corrected. For convictions arising
under section 113(c)(2), the condition giving rise to the conviction also shall be
considered to include any substantive violation of this Act associated with the violation
of 113(c)(2). The Administrator may extend this prohibition to other facilities owned or
operated by the convicted person.
b. The Administrator shall establish procedures to provide all Federal agencies with the
notification necessary for the purposes of subsection (a).
c. In order to implement the purposes and policy of this Act to protect and enhance the
quality of the Nation's air, the President shall, not more than 180 days after enactment of
the Clean Air Amendments of 1970 cause to be issued an order (1) requiring each
Federal agency authorized to enter into contracts and each Federal agency which is
empowered to extend Federal assistance by way of grant, loan, or contract to effectuate
the purpose and policy of this Act in such contracting or assistance activities, and (2)
(Federal Certification-Non-Discrimination, Clean Air, Clean Water) (0112018 )Page 2 of 4
DocuSign Envelope ID: 3E4B4B91-8AA8-41 OB-8584-1 1 AAECCBC787
Contract ##68.2034
Medrsolutions, Inc.
setting forth procedures, sanctions, penalties, and such other provisions, as the President
determines necessary to carry out such requirement.
d. The President may exempt any contract, loan, or grant from all or part of the provisions
of this section where he determines such exemption is necessary in the paramount
interest of the United States and he shall notify the Congress of such exemption.
e. The President shall annually report to the Congress on measures taken toward .
implementing the purpose and intent of this section, including but not limited to the
progress and problems associated with implementation of this section. [42 U.S.C. 7646]
V. The Clean Water Act; 33 U.S.C. §1251 et seq. (1972)
a. No Federal agency may enter into any contract with any person who has been convicted
of any offense under Section 309(c) of this Act for the procurement of goods, materials,
and services if such contract is to be performed at any facility at which the violation
which gave rise to such conviction occurred, and if such facility is owned, leased, or
supervised by such person. The prohibition in preceding sentence shall continue until
the Administrator certifies that the condition giving rise to such conviction has been
corrected.
b. The Administrator shall establish procedures to provide all Federal agencies with the
notification necessary for the purposes of subsection (a) of this section.
c. In order to implement the purposes and policy of this Act to protect and enhance the
quality of the Nation's water, the President shall, not more than 180 days after the
enactment of this Act, cause to be issued an order:
(i) requiring each Federal agency authorized to enter into contracts and each Federal
agency which is empowered to extend Federal assistance by way of grant, loan, or
contract to effectuate the purpose and policy of this Act in such contracting or assistance
activities, and
(ii) setting forth procedures, sanctions, penalties, and such other provisions, as the
President determines necessary to carry out such requirement.
d. The President may exempt any contract, loan, or grant from all or part of the provisions
of this section where he determines such exemption is necessary in the paramount
interest of the United States and he shall notify the Congress of such exemption..
e. The President shall annually report to the Congress on measures taken in compliance
with the purpose and intent of this section, including, but not limited to, the progress and
problems associated with such compliance.
f. No certification by a contractor, and no contract clause, may be required in the case of a
contract for the acquisition of commercial items in order to implement a prohibition or
requirement of this section or a prohibition or requirement issued in the implementation
of this section.
g. In paragraph (1), the term "commercial item" has the meaning given such term in section
4(12) of the Office of Federal Procurement Policy Act (41 U.S.C. 403(12)).
(Federal Certification- Non - Discrimination, Clean Air, Clean Water) (4112018)Page 3 of 4
DocuSign Envelope ID: 3E4B4B91-8AA8-41 OB-8584-1 1 AAECCBC787
Contract #68 -2039
UocuSigned by: Medlsolutlons, Inc.
4� �r ceo
OC96EIOAE88C476...
Signature Title
Medisolutions Inc. 8/3/2018
Agency /Organization Date
(Certification signature should be same as Contract signature.)
(Federal Certification - Non - Discrimination, Clean Air, Clean Water) ([}1 /2(]18)Page 4 of
DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 11AAECCBC787
ATTACHMENT O
OUTCOMES AND REPORTING
Orange County Department of Social Services and Orange County Department on Aging
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. Allow the County to complete the assessment of each client. The County will complete an In-
Home Aide Service Plan as part of the assessment. The County will provide the In -Home Aide
Service Plan to the Contractor prior to the start of service. The County will update the In -Home
Aide Service Plan as needed.
B. Provide employees to perform in -home services for the County's clients, at the level, amount
and frequency specified by the social worker in the In -Home Aide Service Plan.
C. Assure that employees meet the competency requirements for the level(s) of service provided.
The Contractor will provide verification, upon request, that the selected employee has been
properly licensed and trained and is qualified to perform assigned tasks.
D. Select and assign qualified employees to clients according to the clients' needs and the
employees' abilities and experience. The Contractor agrees to honor requests made by the
County for a change in assignment.
E. Fulfill all employer financial obligations.
F. In a timely manner, provide the County with information on significant changes in the clients'
conditions or situations.
G. Assure that the client is treated with dignity and respect, assist in protecting the client's assets
and possessions, and assure confidentiality of client's circumstances.
H. Allow aides to provide transportation, within reason, for both medical and personal reasons.
1. Provide care at Level 11 as appropriate to the needs of the client.
J. Complete, for employees serving Level I1 clients, at least a quarterly on site visit to the home of
at least one client the employee is serving.
K. 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.
L. Monthly contact and annual on -site visits with the County. The Contractor agrees to client
contact per Home and Community Care Block Grant guidelines for frequency of required aide
supervision by RN, competency testing, and document provision including:
a. A supervisory on site home visit by RN within the first calendar week of an aide
assignment to observe the work of the aide.
b. A supervisory on site home visit by RN within calendar weeks 2 through 4 of an aide
assignment to observe the work of the aide.
Outcomes (06/04) Page ] of 3
DocuSign Envelope ID: 3E4B4B91-8AA8-41 OB-8584-1 1 AAECCBC787
c. A quarterly on site home visit by RN made at least every 3 months and an annual visit.
Aide must be observed in performance of duties.
d. A telephone contact made with aide and client/designated person by RN during non -
quarterly review month.
e. The provider agency will assure that competency testing is appropriately administered.
The aide will demonstrate the tasks before the RN and competency testing reflects the
task and the knowledge required of the aide. A check list may be used. The date of
competency testing is documented and signed off on by the RN and by the aide who is
being competency tested.
f. The provider agency will assure that the aide has sufficient training to pass a
competency test for the level of service provision requested. The provider agency will
have written documentation of the competencies completed, trainings completed, etc.
All information will be dated and signed by RN.
g. Provider agency will comply with all necessary documentation needed by Orange
County Department of Social Services including but not limited to an assessment
addressing the following areas: social, environmental, activities of daily living,
instrumental activities of daily living, economic, physical, and mental.
h. RN will document information regarding economic status at least quarterly. (For
example: Client has sufficient income to meet current needs.)
i. RN will participate in and sign Orange County DSS In -Home Aide Service Plan.
j. RN will participate in and sign Orange County DSS Adult Services Functional
Assessment.
M. Protective Service In -Home Aide requests are to be staffed within 24 hours and the hours to be
worked are to be strictly adhered to. Referral acceptance by the Contractor is conditional on
worker availability. The Contractor will notify the County within two hours if the request
cannot be honored.
N. Provide backup service when a client's usual In -Home Aide is unavailable.
O. High Risk In -Home Aide Service requests are to be staffed within five days. All other requests
are to be filled within ten working days of the request.
P. Changes in the service hours are to be made by the County. Requests for changes may be made
by the Contractor, but are not finalized until notification is given by the County.
Q. The Contractor will immediately notify the County when Protective Services Cases are not
staffed, when In -Home Aide workers are absent, and/or when any of the following occur:
a. The client dies.
b. The client enters a rest home, nursing home, or hospital.
c. The client moves from the original address on the request.
d. The client refuses to accept the services or to comply with care requirements.
e. There are significant factors that affect the client or significant changes in a client's
situation.
I ��``DocuSigned by:
.166, O r ceo
9C88E10AE89C478...
Signature Title
Outcomes (06/44) Page 2 of 3
DocuSign Envelope ID: 3E4B4B91-8AA8-41 OB-8584-1 1 AAECCBC787
Medisolutions Inc.
Agency /OrganizatiOD
8/3/2018
Date
(Certification signature should be same as Contract signature.)
Outcomes (06104) Page 3 of 3
DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 11AAECCBC787
® DATE (MMIDDIYYYY)
n CERTIFICATE OF LIABILITY INSURANCE
07/24/2018
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 IN8URER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 NAME: An ie Cox
161Q - Capital Insurance & Financial Services, Inc. PHONE 91$- 571.0585 FAX Noc 919 571 -0584
3701 Lake Boone Trail no RI ES ' aCtcC�ca Ital ins.cam
Suite 200 INSURER(S)AFFORDING CDVERAGE NAIC6
Raleigh NC 27807 INSURERA: Ph1ladel ph ia Insurance Cam pan ies
INSURED INSURERS: Travelers
Medisolutions Inc INSURERC -
100 N Church St INSURER D:
Suite B INSURER E: _
BURLINGTON NC 27217 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 huh; Ilya FULIL;Y i-'Orcltju
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.
THE EXPIRATION HATE. THEREOF, NOTICE WILL BE DELIVERED IN
OLICY EFF LIC EXP
I "SR TYPE OF INSURANCE POLICY NUMBER MMIDoNyyy MhVDDfYYYY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1000000
f`. COMMERCIAL GENERAL LIABILITY
PREMISES Eaaccurrance $ 100000
CLAIMS -MADE F—vil OCCUR
MED EXP (Anyone person) $ 5000
A N N PHPI(1742845 11/22/2017 11/22/2018
PER SO NAL & ADV I NJU RY $ 1000000
GENERAL AGGREGATE $ 2000000
GGEEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMPIOP AGO $ 2000000
!. POLICY PRO- LOC
$
C e eBciNd.n SINGLE LIMIT
$
AUTOMOBILE LIABILITY
BODILY INJURY (Per person)
$
ANY AUTO
BODILY INJURY (Per accident)
$
ALL OWNED SCHEDULED
AUTOS AUTOS
DAMAGE
Peracmden!
$
HIRED AUTOS _ AUTOSNMED
UMBRELLA LIAB
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EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAR
CLAIMS -MADF.
DED I I RETENTION
$
4VORKE�RSCOMPENSATION
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AND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE YIN
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11/2212018
E.L EACH ACCIDENT
$ 100000
E.L DISEASE - EREMPLOYEE
$ 100000
B
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(Mandaloryin NH)
E.L DISEASE - POLICY LIMET
_
$ 500000
-
If s describe under
DESCRIPTION Of OPERATIONS belc vl
Professional Liability
1.000,000 each occurrence
A
N
N
PHPK174845
11/22/2017
1112212018
2,000,000 aggregate
DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (Attach ACORD 101, Additlanal Remarks Schedule, It morespace is required)
nA Alf`CI I Ar!nKI
%.Crt I IFI%.,n I
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION HATE. THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Orange County
PO BcK 8181
AUTHORIZED REPRESENTATIVE
Hillsborough NC 27278
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ACORD 25 (2010105) W I U0c-GV IV SL +J RLJ l VRFVnn i Tvrr. nn r IUL— ,
The ACORD name and logo are registered marks of ACORD
DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 1IAAECCBC787
,-- -1 e
'4CR 0 CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIODNYYY)
7/24/2018
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 pollcy(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
Morgans & Associates LLC - GA
PO Box 456
Kennesaw GA 30156
NAME: Donald Morgan _
AIC, No, No : 7798617509 ( VC, No): 1 -866 -713 -5171
ADDRfsa: dmorgan@maginsurance.com
INSURER(S) AFFORDING COVERAGE
NAIL #
INSURER A; EVANSTON INS CO
35378
INSURED
Medlsoultion
100 N Church ST
Burlington NC 27217
INSURER B:
NP343324
INSURER C;
07/1512019
INSURER D;
5 1,000,fl00
INSURER E:
PREMISES Es occurrence
INSURER F:
MEO EXP (Any one person)
rnwc:oAn=a rrC92TIFIr'ATG MWARFR• REVISION NUMBER:
v 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 LTR
TYPE OF INSURANCE
INSD
MD
POLICY NUMBER
MMIODNYYYI
(MMIDDMM)
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
X CLAIMS -MADE El OCCUR
NP343324
07115/2018
07/1512019
EACH OCCURRENCE
5 1,000,fl00
PREMISES Es occurrence
S 100,000
MEO EXP (Any one person)
$ 5,000
PERSONAL BADV INJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY O PRO-
POLICY 7 LOC
OTHER;
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMPICP AGG
$ 1,000,000
Sexual and Physical Abus
$ 1,000,000
AUTOMOBILE LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIREO NON -OWNED
AUTOS ONLY AUTOS ONLY
(Ea acchient]
$
BODILY INJURY (Per parson)
$
BODILY INJURY (Per accident)
$
Per accEdenl]
_
$
$
UMBRELLA LIAR
EXCESS LIAB
OCCUR
OLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DED RETENTION
$
ORKERS COMPENSATION
NO EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNERIEXECUTIVE F7
OFFICERIMEMBER EXCLUDED?
IMandatory In NH)
f yyes, descrlbe under
DESCR€PTION OF OPERATIONS below
NIA
_
PER
STATUTE ER
E,L. EACH ACCIDENT
$
E,L, DISEASE - EA EMPLOYEE
- -
E,L, DISEASE - POLICY LIMIT
$
A
Sexual Misconduct/Molestation/Abuse
NP343324
07/15/2018
07/15/2019
$1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS F VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
CERTIFICATE HOLDER S.:ANUr_LLAIIIlN
Orange County Goverment
P.O. Box 8181
Hillsbor"gh, NC 27278
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
D&Ka . J Margaw
tJ 19t5t5 -ZU1 5 Ai.;UKU UVKIIF -UIiA I IUN. Ali rlgms reserveaz.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD