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2018-475-E Finance - Piedmont Health Services Inc outside agency agreement
DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2018, ( "Effective Date ") by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ( "County") and Piedmont Health Services, a not - for - profit corporation, located at 127 Kingston Drive, Chapel Hill, NC 27514 ( "Provider "). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners. NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Piedmont Health Services agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2018 to June 30, 2019. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit "A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of $16,500. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. The Provider shall be paid in four equal installments in the amount of $4,125. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Piedmont Health Services) Orange County Outside Agency Performance Agreement Revised 712018 Page 1 of 9 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. £ The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 — December 31; January 1 — March 31 and April 1 - June 30. Reports are due on January 11, April 12, and July 12 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services, upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default "), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten (10) business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. (Piedmont Health Services) Orange County Outside Agency Performance Agreement Page 2 of 9 Rev. 7118 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof, iii. Comprehensive Automobile Liability Insurance, including hired and non -owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury, bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION • Worker's Compensation • Commercial General Liability • Automobile Liability • Professional Liability MINIMUM REQUIRED COVERAGE Limits for Coverage A - Statutory State NC & Coverage B - Employers Liability $500,000 each accident, disease policy limit and disease each employee $1,000,000 Each Occurrence $2,000,000 Aggregate $500,000 Combined Single Limit $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability) required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough, NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (Piedmont Health Services) Orange County Outside Agency Performance Agreement Page 3 of 9 Rev. 7118 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 12. Non - Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non - Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Non - discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 14.25 per hour. To the extent possible, Orange County recommends that Piedmont Health Services provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (Piedmont Health Services) Orange County Outside Agency Performance Agreement Page 4 of 9 Rev. 7118 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 County: Finance & Administrative Services Orange County Post Office Box 8181 Hillsborough, NC 27278 Provider: Piedmont Health Services 127 Kingston Drive Chapel Hill, NC 27514 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147 - 86.58. 18. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF, the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. , For ar DocuSigned - - by: r -' - - Provider TWA" F8B86BFCB02540B... For an. ' DocuSigned by:f inty Government 0�3799dB755E477... Bonnie Hammersley, County Manager (Piedmont Health Services) Orange County Outside Agency Performance Agreement Rev. 7118 8/23/2018 Date 8/24/2018 Date Page S of 9 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Piedmont Health Services, Inc. Applicant Organization's Physical Address: 127 Kingston Drive, Chapel Hill, NC 27514 Applicant Organization's Mailing Address: 127 Kingston Drive, Chapel Hill, NC 27514 Applicant Organization's Web Address: www.piedmontheaIth.org Executive Director: Brian Toomey, MSW Telephone Number: (919) 537 -7485 E -Mail: toomeyb(a7piedmonthealth.org Tax ID Number: 56- 0952737 b) Funding Request List a I I FYI 8-19 Human Services (HS) Funding Being Requested For All Pro - grams) and the Proposed Use of Funds (2 -3 lines or less) Program Carrboro Chapel Hill - HS Orange County-HS Total - HS Carrboro Community Health Center $15,000 $15,000 $16,500 $46,500 Totals $15,000 $15,000 $16,500 $46,500 c) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Brian Toomey Oecutive Director Signature: 1 /11,0 bb�R- Date Signature: a, 4,4d_ I /rG12 -,,I - Kenneth Reeb, Jr. Board Chairperson Date AGENCY INFORMATION 1/1612018 2:16:48 PM Page 8 of 25 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ❑ ® a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ® b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? 0 ❑ c) Current beneficiaries of the program for which funds are being requested? El ® d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. Please note that by Federal law, a majority of PHS Board members must be consumers of health care services at PHS. Consumer representation is a Federal requirement of Board membership to assure that services appropriately address community need. We now have five volunteer Board members who currently receive health care services at CCHC, although none are uninsured or currently in need of interpretation support (i.e. impacted by funding request). NON - DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity /expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti - discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of Interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict alt in the termination of anv arant awarded. Signature: Executive Direcloor Signature: Board Chairperson 1 1z-,-l( 2- CAS- Date Date AGENCY INFORMATION 1122/2018 1:34:09 PM Page 9 of 23 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, Date of Incorporation (Month /Year): 3/1970 b) Agency's Purpose /Mission (no more than a few sentences): Piedmont Health Services, Inc. (PHS) is part of the community's primary health care safety net for vulnerable and /or financially- disadvantaged residents. PHS' mission is: "to improve the health and well -being of the community by providing high quality, affordable and comprehensive primary health care. Our vision is a health community in which all people have timely access to quality health care." Like health centers nationally, PHS offers a sliding fee scale for services tied to the Federal Poverty Guideline for those who qualify. c) Types of Services the Agency Provides (bullet format): 1) Community Health Centers (10 sites, open to anyone, serves >40,000 individuals /yr.) • Sliding -fee, English /Spanish - bilingual medical care for individuals across the lifespan (e.g. well /preventive including family planning /prenatal care and acute /chronic illness management) with integrated behavioral health, on -site laboratory services, and 24 -hour access to medical advice; • Sliding -fee, English /Spanish - bilingual dental care for individuals across the lifespan (e.g. preventive, restorative, prosthodontic); • Pharmacy services, with seven on -site pharmacies available to any registered patient, with a full formulary of low -cost medications available through PHS' participation in the Federal 340B Drug Pricing Program and selected patient assistance programs; • Women Infant Child (WIC) Supplemental Nutrition Program, with services offered at four CHC locations, the Orange County Health Department, and on outreach to UNC Hospitals. • Health support services including care management, Medicaid and ACA Healthcare Marketplace eligibility assistance, and interpretation support. • Population health- specific programming varies by site including but not limited to refugee health; health care for the homeless; transgender health care; HIV /AIDs care, and school health. 2) Piedmont Health SeniorCare, a Program of All- Inclusive Care for the Elderly (PACE) (2 sites, open to PACE - eligible residents of Orange, Alamance, Caswell, Chatham, and Lee Counties, current enrollment is 273) • PACE is a nationally successful model of long -term, community -based geriatric care which seeks to maximize the independence and quality of life of the frail elderly who wish to age in place in the community and avoid nursing home institutionalization. • PACE is a voluntary option under the Medicare and state Medicaid programs open to individuals who are: age 55 years and older, declared nursing home eligible by the state (throughout the FL -2 process), live in a defined service area served by a PACE program, and capable of living safely at home with PACE supports at the time of admission to the program (7% of PACE participants nationally reside in nursing homes and continue to participate). Participants may dis- enroll at any time and resume traditional Medicare and Medicaid benefits. • As a PACE provider, PHS is fully "at risk," responsible for paying for the TOTAL care of participants, including all medically necessary primary, specialty and tertiary care (e.g. hospital, nursing home) and social support services for which it receives per member per month (PMPM) capitation from Medicare and Medicaid. • Most Piedmont Health SeniorCare services are provided directly by staff at two Adult Day Health Center locations in Burlington and Pittsboro where participants are typically transported several days a week to receive health monitoring, rehabilitative therapies, socialization activities and meals. Each participant is cared for according to an individual care plan which is monitored in on -going fashion by an interdisciplinary team of professionals including medical, nursing, rehabilitative therapies, nutrition, social work, and transportation staff. Agency Information 1/23/2018 11:00:54 AM Page 10 of 23 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION d) Agency's History with Providing These Services: University health officials and health- access concerned citizens opened Piedmont Health Services, Inc. (then called Orange Chatham Comprehensive Health Services, Inc.) in 1970 with three locations in Prospect Hill (Caswell County); Chapel Hill (Orange County); and, Moncure (Chatham County). The organization changed its name in 1995 to better reflect its growing service area as it opened Charles Drew CHC in Alamance County. Through aggressive pursuit of HRSA competitive health center expansion opportunities, PHS now operates 10 health center locations, including in Orange County, the newly opened Chapel Hill CHC and IFC CHC (shelter) sites. The PHS Board elected to pursue the development of a CMS - deemed Program of All Inclusive Care for the Elderly (PACE) as a natural extension of its health center mission with its most medically vulnerable population, the frail elderly. It received a CMS Federal Rural PACE to open its SeniorCare adult day health center (ADHC) site in Burlington in 2008, and it was the first PACE organization in the state to open a second site in 2014 in Pittsboro NC (both sites serve PACE - eligible Orange County residents). e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director? Are there new initiatives ?) There are three points of relevance to this year's application. First, to better meet demand, the Carrboro Community Health Center has just been renovated to expand the dental program from 3 to 6 exam rooms, the medical program from 15 to 18 exam rooms, and the pharmacy space. In order to accomplish the renovation, CCHC temporarily closed and relocated its services to its Chapel Hill and IFC CHCs in summer 2017 (August- October). This situation decreased CCHC's 2017 total patients served compared to 2016 (see 2017 demographics in table below) and its reported annual outcomes (see table). With the health center now fully operational again, it expects to return to and surpass 2016 total patients served. Second, despite slowing of new refugee families via the health department the refugee community continues to grow in Orange County via immigration from other US states. Finally, as of submission of this grant, reauthorization of the community health center Federal funding remains undone in Congress. If not reauthorized, health centers stand to lose 70% of their Federal grant support, making this year's request critical. f) Schedule of Positions (For Entire Agency) • Full Time Equivalent (FTE) staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 2,080 # of FTE - Full -Time Paid Positions: 466 # of FTE - Paid Part -Time Positions: 114 # of Volunteers: 0 Other than its all- volunteer Board of Directors, PHS does not use volunteers in its sites, instead focusing on formal health professional student rotation opportunities. g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes/ No) Unclear If yes, is this agency an Orange County Living Wage Certified Employer? No PHS minimum wage across the agency (multi- county — Alamance, Caswell, Chatham, Orange) is $12.00 /hour, and PHS offers health insurance benefits to its employees who work at least 24 hours /week (they may accept or decline). In recent years it has met with Orange Agency Information 1/23/2018 11:00:54 AM Page 11 of 23 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION County about certification, but there was a technical issue around PHS' prn employees in the County. PHS would like to reinvestigate certification. h) Agency Budget i. Is your agency currently receiving and /or requesting other (non -Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes /No) No If yes, please list below: Include all programs that have funding requests /awards /totals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FY17 -18 Award FY18 -19 Request Source Ex: Affordable Rental Rehabilitation 0 $20,000 Carrboro - Affordable Housing Ex: Agency Administration $15,000 $15,000 Carrboro — Other Ex. Total $15,000 $35,000 Carrboro Total Funding Not Applicable *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate As file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: Revenues • Private Donations • Program Generated Revenue • Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) • Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG /HOME /etc.) • Private Foundation Grants • Other Revenue • Expenditures o Compensation Agency Information 1/23/2018 11:00:54 AM Page 12 of 23 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION • Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses iii. Does your agency budget show a Surplus or Deficit? No (balanced) Is there a significant change? Yes /No No Please provide a brief explanation for Surplus or Deficit, and significant changes. iv. What is your agency's fiscal year? January 1, 2018 -Dec 31, 2018 (Example: July 1, 2016 through June 30, 2017) Agency Budget Operating Budget for Entire Agency AGENCY NAME: Piedmont Health Services. Inc. AGENCY REVENUE Private Donations Agency Generated Revenue lfees) Local Government Grants: Human Services -Town of Carrboro Other - Town of Carrboro Human Services -Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other- Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CaBGfHOME ?etc.) Private Foundation Grants Other Revenue Total Agency Revenue AGENCY EXPENSES Compensation Rent R Utilities Supplies & Equipment Travel 9 Training Other Expenses: Total Agency Expenses SURPLUS!(DEFICIT) FOR PERIOD Actual FY1-6 Estimated EY17 Projected FY18 Percent Change $ 349,615 $ 20.256 $ - - 100% $ 38,135,519 $ 43,884,683 $ 55,777,152 27% $ 3,000 $ 5,000 $ 15,000 200% $ - $ - $ 0 $ 2,000 $ 2.000 $ 15,000 650% $ - $ - $ - 0 $ 11,000 $ 16,500 $ 16,500 0% $ $ $ 0 $ $ $ 0 $ $ $ 0 $ 543,506 $ 360,607 $ 517,533 $ 0.44 $ 8,879,101 $ 10,901,684 $ 9,121.885 $ 0.161 $ 1,017,000 $ 1,301,268 $ 916,000 $ 0.30 $ 1,254,240 $ 869,058 $ 441,636 $ 0.49 $ 50,194,981 $ 28,838,007 $57,361,056 $ 33,362,859 $66,820,706 $ 37,609,040 16% 13% $ 945,792 $ 1,038,516 $ 2,527,171 143% $ 1461240 $ 4,760,000 $ 4,774.803 0% $ 515,918 $ 479,535 $ 464,902 -3% 16.340,805 $ 18,589,472 $ 21,444,790 15 °I¢ $ 50,101,762 $58,230,382 $66,820,706 15 °Ia $ 93,219 1 $ (869,326) $ - 1 1{?0 Agency Information 1/23/2018 11:00:54 AM Page 13 of 23 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Carrboro Community Health Center Program Primary Contact and Title: Jen Cunningham, Data Analyst Telephone Number: 919 - 013 -1097 E -Mail: cunningj@piedmonthealth.org a) Indicate the type of Human Service Needs Priority, if program applicable: ® Priority Area #1: safety -net services for disadvantaged residents ❑ Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ® Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods /Residents Affordable Housing Affordable Healthcare X X X X X Education Family Resources Jobs /Jobs Training Food Transportation Other: Please specify c) Provide a bulleted list of other agencies, if any, with which your agency coordinates /collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated /collaborative efforts. Refugee Health: The Orange County Health Department conducts the initial health screening (communicable disease - focused) of all refugees referred to them by local resettlement agencies (e.g. Lutheran Family Services, USCRI, World Relief, Church World Service). When the initial assessment is complete, refugees are referred to PHS for on -going primary care. PHS also has worked closely with UNC's (Josh Hinton) refugee health program. Low - income, uninsured: UNC is PHS' primary referral center for specialty and inpatient care. PHS works closely with UNC's SHAC Free Clinic, providing its Carrboro Community Health Center at no cost for operation of the SHAC free clinic on Wednesday evenings. It also participates in UNC's Carolina Health Net Program for the Uninsured, accepting unassigned uninsured patients identified at UNC. Second, PHS works closely with the IFC, with PHS medical and dental staff collocated at the IFC Community House delivering care. PHS also collaborates with the health department on the Family Success Alliance project and the WIC program. NC Prevent Blindness, Susan G Komen for the Cure, Book Harvest, and Strowd Roses also support population health projects at our Carrboro Community Health Center. PROGRAM INFORMATION 1/23/2018 11:00:54 AM Page 14 of 23 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town /County priority /goal? The Carrboro Community Health Center (CCHC) aims each year to be a high quality, affordable primary care home which works to reduce barriers to health care access for low- income and other vulnerable individuals of all ages in the community. Each year it serves more than 3,400 Orange County residents. As discussed in the agency's description of the health center program, CCHC is a "one -stop shop" for primary care services including: sliding fee medical care (e.g. well /preventive care including prenatal care and family planning, acute /chronic illness management, transgender health care) with on -site lab and newly, an integrated behavioral health consultant; sliding fee family dental services, on -site pharmacy with a full formulary of affordable medicines available through the Federal 340B drug pricing program and various patient assistance programs, the Women Infant Child (WIC) supplemental nutrition program (available to any individual regardless of registration as a patient), and care support services including care management, ACA/Medicaid outreach /enrollment, and interpretation assistance. Population health programming at CCHC includes a focus on early literacy (work with the Reach Out and Read initiative funded by Strowd Roses, Inc. and Book Harvest, Inc. to provide children with early access to language and reading -level appropriate books); on -site access to free diabetic retinopathy screening provided by Prevent Blindness NC; and the refugee health program that takes referral from the Orange County Health Department (no current funders). To date, Town and County funding has been used just like PHS' Federal health center grant dollars, supporting sliding -fee medical care by staff medical providers to low- income uninsured residents, and this need continues to be great. Funding is also used to support CCHC's refugee health program, specifically contracted professional interpretation services. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council /Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. PHS exists to address community access to affordable health care and basic human services for low income populations (approximately 32.5% of Orange County population lives below 200% of poverty), priority needs clearly identified in the Chapel Hill Human Services Needs Assessment and Orange County BOCC goals and priorities. Consistent with both Town and County social justice values, PHS health centers strive daily to create care environments where all people, regardless of race /ethnic group, nationality, language, or other group affiliation feel comfortable in receiving care. To improve access, health centers are located in close proximity of those they serve, with CCHC located on the edge of the Northside Neighborhood and in Zone 6 of Orange County's Family Success Alliance. The diverse low- income populations served by CCHC face documented disparities in health status (e.g. self- reported physical and mental health status, cancer outcomes, chronic and infectious disease prevalence, low birth weight, dental caries) that can be positively impacted by a continuous relationship with a primary care home. Despite the success of the ACA in improving access to care by newly insuring millions of Americans, there are still large numbers of uninsured individuals in our community who are ACA - ineligible, or are in fact too poor to qualify for insurance subsidies, falling into the gap crated by the state's decision not to expand Medicaid. Pre -ACA, it was estimated that 16.4 %of the Orange County population age 0 -64 years lacked health insurance, and in North Carolina approximately 60% of the uninsured are low- income. PROGRAM INFORMATION 1/23/2018 11:00:54 AM Page 15 of 23 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Finally, many individuals in the County also face cultural /linguistic barriers to care. First, Orange County has experienced rapid growth of the Latino population since the early 1990s (in 2015, an estimated 8.2% of the population was of Hispanic ethnicity), with many preferring care in Spanish. PHS hires Spanish - bilingual professionals in lieu of separate interpreters. Second, over the last decade, there has also been significant growth in the county's refugee population, primarily from Burma (speak multiple languages /dialects), and more recently from Syria and the Democratic Republic of Congo. The Orange County health department began its refugee health program in FY 2007 -2008 to better address the unique health care needs of these newcomers, and asked PHS to be the principal on -going primary care home for the population. The program has grown rapidly as the number of new arrivals through resettlement agencies has grown, and with in- migration of refugees from other counties and states. CCHC served no refugee patients in CY 2006, by CY 2011 it had 399 refugee patients, and in CY2017 it served 590 refugee patients (PHS served a total of 695 refugees across the agency, with Orange County CHC sites serving 680). Many refugees are also public housing residents. Due to growth in the number of patients and increasing breadth of languages spoken, since 2013, CCHC is now spending nearly 90% (approximately $40,000 annually) of the total agency budget for interpretation. CCHC is striving to have a best practice refugee health program based on national guidelines. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The Carrboro Community Health Center is open to all comers (subject to appointment availability for medical and dental visits) regardless of county of residency, citizenship status, or insurance status. The target population for FQHC services is the low- income population living below 200% of the Federal Poverty Guideline, and the funding request will be directed toward the medical program. Most hear of the program word -of- mouth, but many are referred to our program by other health and human services programs. With the exception of WIC, HRSA requires all individuals receiving primary care services at CCHC to register as patients, at which time they are provided information about all CCHC program services and its sliding fee scales for medical and dental care. Those who wish to be placed on CCHCs sliding fee scales (overwhelmingly those without health insurance, although those with health insurance may also apply) submit their family size and income documentation on an annual basis to qualify for sliding fees. With regard to the refugee health program, CCHC accepts direct referral of patients through the Orange County Health Department following completion of the initial screenings. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) CCHC's administrative site director is Tinesha Smith. Its lead medical provider is Kim Christopher, MSN, RN, FNP -BC, while Quang Pham, MD is lead for the refugee health initiative. The Table below presents a staffing picture for the Carrboro Health Center by service. A majority of staff speak Spanish, and again, the Center uses contracted interpreters or language line as necessary. CCHC Prim ry Care Program Staffing Service Staffing Primary Medical Care with integrated 3.656 FTE physicians, 2.2 FTE advanced practitioners behavioral health on -site Lab (FNP); 2 FTE RNs, 6.6 medical assistants, 1.2 FTE behaviorist, 1 FTE contract phlebotomist Lab Corp) Dental Care 2.0 FTE dentists, 1.475 FTE hygienists, 8.025 dental assists Pharmacy walk -in 1.9 FTE pharmacists, 3 FTE pharmacy technicians WIC Nutrition Program 2 FTE nutritionists, 0.4 FTE breastfeeding peer counselor, 1.6 admin PROGRAM INFORMATION 1/23/2018 11:00:54 AM Page 16 of 23 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Care Management & ACA Assistance 2.2 Care Managers, 1 ACA outreach worker Center Administrative Staff i.e. front desks 1.6 FTE center managers, 6.5 FTE office staff Contracted Interpreters 4 contracted interpreters for hourly in person interpretation with additional use of the CallPointe language line. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Services are continuously available at the times listed in table below, including two weeknights and Saturday mornings. The center is closed in observation of holidays (9 days per year). Carrboro Community Health Center: Hours of Operation by Service CCHC Service Total Hours Schedule Primary Medical Care by appt with on- site lab, part -time integrated behavioral 55 hours /week M /Th: 8 am. -8 pm. T: 9 a -5 p W /Fri: 8a -5p; Sat: 8a -1p health clinician (BHC) Dental Care by appt. 49 hours /week M /T /W /Th: 8a -6p; Friday 8a -5p Pharmacy (walk -in) 48 hours /week M /Th: 8:30a -8 p. T: 9a -5p W /Fr: 8:30 a -5 p. Interpretation (by contracted staff)* Full time weekday support for Burmese dialects, with ad- hoc hours for other languages. Women Infant Child Nutrition Program 53.5 hrs /week (note part of agency budget, not CCHC Same as Medical except Thursday close is 6:30 pm. budget) Care Management 55 hours /week Same as Primary Medical Care * PHS uses a language line service when live interpreters are not available. i) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) The Federal Qualified Health Center (FQHC) program is consistently ranked among the nation's most cost - effective Federally- supported programs, with a 2011 study of NC health centers demonstrating every dollar of Federal investment generated another $3.50 in economic activity for an overall economic impact of $359 million (Capital Link, 2011). Further, a research brief by the Geiger Gibson /RCHN Community Health Foundation (Richard et al, 2011) found that North Carolina FQHC patients' annual health expenditures were 62% less than comparable patients receiving care in other ambulatory settings, with an estimated health system savings of $3,400 annually for every patient served by an FQHC (most system savings realized by reduced use of tertiary services (i.e. ER and hospitalization)). FQHCs are uniquely positioned to bring Federal dollars to bear on community health access, minimizing cost to local and state budgets, while maximizing the impact of these investments. Showing local support is critical to PHS success in seeking other funding. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. PHS cannot sustain the current CCHC program without grant support beyond that provided by HRSA. To sustain CCHC, PHS currently uses other grant funds and program revenue generated by its other health centers to help offset a predicted operational loss. Were the City and County not to fund PHS, it would have to 1) continue to search for other sources of grant income, 2) increase sliding fee payment expectations on patients (current nominal fee a medical visit for patient living below 100% of poverty is $25), and /or 3) decrease available services at CCHC. k) What percentage of your target population is low- moderate income? 99% of those served by the program are of low- moderate income. 1) What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc. ?) PHS monitors patient satisfaction using the validated Midwest Clinician's Network patient satisfaction survey, and additionally tracks grievances. m) Include any other pertinent information: See section II e). PROGRAM INFORMATION 1/23/2018 11:00:54 AM Page 17 of 23 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information n) Target Population (NOTE: As the target of requested funding, the medical population served is presented based on data from the electronic medical record. PHS does not project patient demographics but would anticipate the program to serve at least as many residents in 2018 as 2017 of similar demographics). Program Target Population Demographics Gender Male Female Total Ethnicity African - American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: specify: more than one race, unreported Total Of the above, how many Hispanic /Latino Of the above, how many non - Hispanic /Latino Total Age 0 -5 years 6 -18 years 19 -50 years 51 + years Total Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non - Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) Other (unincorporated above) Total Actual Actual Projected 2016 2017 2018 2,854 2,528 see note 4,205 3,888 see note 7,059 6,416 see note 730 676 see note 0 0 see note 807 715 see note 5,325 4,792 see note 0 0 see note 197 233 see note 7,059 6,416 see note 1,001 831 see note 4,512 4,036 see note 2,547 2,380 see note 7,059 6,416 see note 1,001 831 see note 1,987 1,684 see note 2,781 2,642 see note 1,290 1,259 see note 7,059 6,416 see note 574 296 see note 128 109 see note 1,629 1,466 see note 203 196 see note 85 71 see note 2,035 2,324 see note 1,156 1,116 see note 354 301 see note 240 209 see note 229 220 see note 426 108 see note 7,059 6,416 see note PROGRAM INFORMATION 1/23/2018 11:00:54 AM Page 18 of 23 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement o) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time - bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (Le. Deliver meals to elderly /disabled residents.) • Program Goal should explain what the program is trying to achieve /accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday- Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program: Carrboro Community Health Center 1. Program Activity Name Refugee Health Care Population Health Program Support Program Goal CCHC will be a comprehensive primary care medical home to 650 refugee patients from Orange County, providing culturally /linguistically appropriate care with the help of Town/county-supported interpretation services. Performance Measures # Refugee Health Patients Served; Value of Interpretation Service Provided. Previous Year Program Results 2016 -2017 served estimated 703 Refugees. Current Year Estimated Results 2017 -2018 6 month results; 444 Next Year Projected Results 2018 -2019: CCHC will care for 650 refugees. 2. Program Activity Name Affordable Medical Care for Low - income Individuals Program Goal CCHC will effectively reach its target low- income population with comprehensive primary medical care ( >21,700 medical visits ( >8,400 self - pay)), serving more than 3,400 Orange County /Town of Chapel Hill /Carrboro residents annually. Performance Measures #Individuals served medically by insurance status #Individuals served medically by income status #Total number of medical visits Total # served and # Orange County residents served Previous Year Program Results 2016 -2017 — 3,595 Orange County residents served at Carrboro CHC Current Year Estimated Results 2017 -2018 6 month data — 2,451 Orange County residents served at Carrboro CHC. So estimate on track to achieve 3,400 Orange County residents at CCHC, 3,728 across PHS. Next Year Projected Results PHS will serve more than 3,400 Orange County/Town of Chapel Hill/Town of Carrboro residents with medical homes services (total number of visits, income status, and insurance status are not projected, but will be reported as descriptors of the population served. PROGRAM INFORMATION 1/23/2018 11 :00 :54 AM P a g e 1 9 o f 2 3 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION p) Program Budget 1. Submit your program budget. You may complete the provided template (separate As file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: Revenues • Private Donations • Program Generated Revenue • Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) • Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG /HOME /etc.) • Private Foundation Grants • Other Revenue Expenditures • Compensation • Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses 2. Program Budget Detail — Provide description of "other" budget items, not defined. 3. This program budget represents what percent of the agency budget? 8_1% 4. COST PER INDIVIDUAL PHS budgets using a cost per visit framework as provided below. Once a year, HRSA estimates the cost per patient for the agency by service. In CY 2016, the total medical cost per PHS medical patient served was $440.81, while the total dental cost per dental patient served was $568.37. CY2017 total cost per individual figures by service will be available from HRSA in summer 2018. PROGRAM INFORMATION 1/23/2018 11:00:54 AM Page 20 of 23 Actual 2016 Estimated 2017 Projected 2018 Total Cost of Program $4,320,260 $4,447,072 $4,981,531 Total # of Encounters 24,913 (19,823 medical + 5,090 dental ) 21,071 (15,663 medical + 5,408 dental ) 32,569 (21,769 medical + 10,800 dental Cost Per Encounter $173.41 $211.05 $152.95 PROGRAM INFORMATION 1/23/2018 11:00:54 AM Page 20 of 23 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION PROGRAM NAMI PROGRAM REVENUE Primate Donations Program Budget Operating Budget for Program Carrboro, Community Health Center Program Generated Revenue Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services -Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBG'HOME±etc_) Private Foundation Grants Other Revenue Total Program Revenue PROGRAM EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: Total Program Expenses SURPLUSI(DEFICIT) FOR PERIOD $ 244,697 1 $ 257,543 1 $ 420,952 63/9, PROGRAM INFORMATION 1/23/2018 11:00:54 AM Page 21 of 23 Actual FY1€ Estimated FY17 Projected FY18 Percent Change $ - $' 262 $ - - 100% $ 3,636,939 2,961,641 $ 4,572.303 54% $ 3,000 $ 5.000 $ 15.000 200% $ - $ $ - 0 $ 2,000 $ 2.000 $ 15,000 650% $ - $ - $ 0 $ 11,000 $ 16.500 $ 16.500 0% $ - $ $ 0 $ - $ $ 0 $ - $ $ 0 $ 61925 $ 160,266 $ 100.000.00 $ 0.38 $ 652,123 $ 1,127,575 1 494,553.00 $ "0.56 $ 153.133 5 237,525 $ 105,500.00 $• 0.56 $ 42,837 $ 193.846 $ 83,627 $ 0.57 $4,564,957 $ 2,810,627 $4,704,615 $ 2,846,781 $ $ 5;402,483 3,522,621 15% 24% $ 82,128 $ 98,929 $ 296,869 200% $ 440,757 $ 665,610 $ 490,731 -26 %6 $ 34.931 $ 28.207 $ 39.322 39% $ 951,818 $4,320,260 $ 807,545 $ 631.988 -22% $ 4,951,531 120 $4,447,072 $ 244,697 1 $ 257,543 1 $ 420,952 63/9, PROGRAM INFORMATION 1/23/2018 11:00:54 AM Page 21 of 23 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXl111Bff "B" Scope of Services — FY 2018 -19 Outside Agency Performance Agreement Agency Name: Piedmont Health Services, Inc. Program Name: Carrboro Community Health Center Funding Award: $16,500 Outline how the agency will spend Orange County's handing award. Expense Description Amount Salary support for a medical provider at Carrboro Community Health Center $10,000 Interpretation services for refugee population at Carrboro Community Health Center ;$6,500 Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2019. • Refugee health care population health program support • Affordable medical care for low- income individuals Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Number of refugee health patients served 650 refugees Number of unique medical patients served (including insurance status, income status, Town/County residency) and number of medical visits rovided 3,100 Orange County/Town of Chapel Hill/ Town of Carrboro residents ,.p r Certified by: eocuSigned by: 1. V (P Oi� T6aA" F8 @8FiBFCBD "ea10 @... Title: iG GGC7 Date: A I � If 56 0952737 8/23/2018 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 ATTACHMENT "A" Orange County Certifications — FY 2018 -19 Outside Agency Performance Agreement Chief Contact, Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title, residential address; phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing, with the name, physical address, mailing address and if possible, phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not, please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. Uocusigned hy: ^care. 'NaA" Certified by: F8B86BFCB02540B (Provider's Signature) Title: 56 0952737 Date: 8/23/2018 (Piedmont Health Services) Orange County Outside Agency Performance Agreement Page 9 of 9 Rev. 7118 DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 CERTIFICATE OF LIABILITY INSURANCE 7DAT7E1,IyIM1DD[YYYY) 89/2018 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 policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Marsh & McLennan Agency LLC 440 South Church St., Ste 500 Charlotte NC 28202 CONTACT NAME: Kendra A. Biddle, CPCU, CIC PHONE FAX AIC No Ext : 336- 899 -2410 AIC No): 212- 607 -6554 ADDRESS: Kendra.Biddle@marshmma.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: AIX Specialty Insurance Company 13763 10/11/2017 INSURED PIEDMHEAL9 Piedmont Health Services Inc. 127 Kingston Drive INSURER 13: StarNet Insurance Company 40045 INSURER C: AllmeriCa Finanical Benefit Insurance 41840 INSURER D: Chapel Hill NC 27516 INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: 116533626 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICYNUMBER POLICY EFF MM /DDIYYYY POLICY EXP MM /DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY L16A73441101 10/11/2017 10/11/2018 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS -MADE X OCCUR PREMISES Ea occurrence $ 100,000 X MED EXP (Any one person) $ 5,000 1,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY ❑ PRO- ❑ LOC JECT PRODUCTS - COMP /OP AGG $ 3,000,000 $ OTHER: C AUTOMOBILE LIABILITY AW6A534528 10/11/2017 10/11/2018 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY A UMBRELLA LIAB OCCUR L16A73441201 10/11/2017 10/11/2018 EACH OCCURRENCE $ 5,000,000 X AGGREGATE $ 5,000,000 EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN KEY0136292 2/1/2018 2/1/2019 X PER 0TH- STATUTE ER ANYPROPRIETOR /PARTNER /EXECUTIVE E.L. 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