HomeMy WebLinkAbout2019-702-E DSS - Personalized Patient Home Assistance Inc in home aide services DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2 Contract#68-2045
Personalized Patient Home Assistance, Inc.
Contract#68-2045 Fiscal Year Begins July 1, 2019 Ends June 30 . 2020
This contract is hereby entered into by and between the Orange County Department of Social Services (the"County") and
Personalized Patient Home Assistance, Inc. (the "Contractor") (referred to collectively as the "Parties"). The Contractor's
federal tax identification number or Social Security Number is 56-1629016 and DUNS Number is 09-157-5191,
1. Contract Documents: This Contract consists of the following documents:
(1) This contract
(2) The General Terms and Conditions (Attachment A)
(3) The Scope of Work, description of services, and rate (Attachment B)
(4) Federal Certification Regarding Drug-Free Workplace&Certification Regarding Nondiscrim€nation(Attachment C)
(5) Conflict of Interest(Attachment D)
(6) No Overdue Taxes (Attachment F)
(7) Certification Regarding Lobbying (Attachment G)
(8) Certification Regarding Debarment (Attachment H)
(9) Certification Regarding Transportation (Attachment J)
(10) State Certification (Attachment M)
(11) Non-Discrimination, Clean Air, Clean Water(Attachment N)
(12) Outcomes and Reporting (Attachment O)
(13) Contract Determination Questionnaire (required)
These documents constitute the entire agreement between the Parties and supersede all prior araI or written statements
or agreements.
2. Precedence among Contract Documents: In the event of a conflict between or among the terms of the Contract
Documents, the terms in the Contract Document with the highest relative precedence shall prevail. The order of
precedence shall be the order of documents as listed in Paragraph 1, above, with the first-listed document having the
highest precedence and the last-listed document having the lowest precedence. if there are multiple Contract
Amendments, the most recent amendment shall have the highest precedence and the oldest amendment shall have the
lowest precedence.
3. Effective Period: This contract shall be effective on October 1, 2019 and shall terminate on June 30, 2020.
This contract must be twelve months or less.
4. Contractor's Duties: The Contractor shall provide the services and in accordance with the approved rate as described in
Attachment B, Scope of Work, and shall meet the requirements set for in Attachment O, Outcomes and Reporting,
5. County's Duties: The County shall pay the Contractor in the manner and in the amounts specified in the Contract
Documents. The total amount paid by the County to the Contractor under this contract shall not exceed$253,600. This
amount consists of$253.600in Federal funds(CFDA# ), $ 0 in State Funds, $0 in County funds
® a. There are no matching requirements from the Contractor.
❑ b. The Contractor's matching requirement is$ , which shall consist of:
❑ In-kind ❑ Cash
❑ Cash and In-kind ❑ Cash and/or In-kind
The contributions from the Contractor shall be sourced from non-federal funds.
The total contract amount including any Contractor match shall not exceed $ 253.600.
6. Reversion of Funds:
Any unexpended grant funds small revert to the County Department of Social Services/Human Services upon
termination of this contract.
7. Reporting Requirements:
Contractor shall comply with audit requirements as described in N.C.G.S. § 143C-6-22&23 and OMB Circular-CFR Title
2 Grants and Agreements, Part 200, and shall disclose all information required by 42 USC 455.104, or 42 USC 455.105,
or 42 USC 455,106.
Contract-General (06M 9) Page 1 of 5
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2 Contract#68-2045
Personalized Patient Home Assistance, Inc.
8. Payment Provisions:
Payment shall be made in accordance with the Contract Documents as described in the Scope of Work,
Attachment B.
9. Contract Administrators: All notices permitted or required to be given by one Party to the other and all questions about
the contract from one Party to the other shall be addressed and delivered to the other Party's Contract Administrator.
The name, post office address, street address, telephone number, fax number, and email address of the Parties'
respective initial Contract Administrators are set out below. Either Party may change the name,post office address,street
address, telephone number, fax number,or email address of its Contract Administrator by giving timely written notice to
the other Party.
For Services Performed on Behalf of the Department of Social Services:
IF DELIVERED BY US POSTAL SERVICE TF DELIVERED BY ANY OTHER MEANS
Kim Lassiter Fisher,Adult Services Supervisor Kim Lassiter Fisher,Adult Services Supervisor
Orange County Department of Social Services Orange County Department of Social Services
P.O.Box 8181 113 Mayo Street
Hillsborough,NC 27278 Hillsborough,NC 27278
(919)245-2880 (919)245-2880
Lassiter@orangecQqntKnc.gov Lassiter&oran ecount nc. ov
For Services Performed on Behalf of the Department on.Avinp_
IF DELIVERED BY US POSTAL SERVICE LF 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 (919)968-2071
jt ler aloran ecoun nc. ov jjylerg_orangecounjync.gov
For the Contractor:
IF DELIVERED BY US POSTAL SERVICE E'DELIVERED BY ANY OTHER MEANS
Dorothea Farrington Dorothea Farrington
Personalized Patient home Assistance Personalized Patient Home Assistance
109 Concord Drive 109 Concord Drive
Chapel Hill,NC 27516-3216 Chapel Hill,NC 27516-3216
(919)929-4943 (919)929-4943
(919)929-7811 (919)929-7811
dmf nc.rr.com dmf(&nc.rr.com
Contract-General (06119) Page 2 of 5
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2 Contract468-2045
Personalized Patient Home Assistance, Inc.
10. Supplementation of Expenditure of Public Funds:
The Contractor assures that funds received pursuant to this contract shall be used only to supplement, not to
supplant, the total amount of federal, state and local public funds that the Contractor otherwise expends for contract
services and related programs. Funds received under this contract shall be used to provide additional public funding
for such services; the funds shall not be used to reduce the Contractor's total expenditure of other public funds for
such services.
11. Disbursements:
As a condition of this contract, the Contractor acknowledges and agrees to make disbursements in accordance with
the following requirements:
(a) Implement adequate internal controls over disbursements;
(b) Pre-audit all vouchers presented for payment to determine:
• 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.
14. Specific Language Not Previously Addressed:
( can be deited if not needed)
15. Signature Warranty: The undersigned represent and warrant that they are authorized to bind their principals to the
terms of this agreement.
Contract-General (06/19) Page 3 of 5
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2 Contract#68-2045
Personalized Patient Home Assistance, Inc.
The Contractor and the County have executed this contract in duplicate originals, with one original being retained by each
party.
PERSONALIZED PATIENT HOME ASSISTANCE, INC.
IDacu5igned by,
106V'b{�.t.a. h. Fa.VYt46t& 9/30/2019
73BC2F0DOAA.94BE .
signature Date
Dorothea M. Farrington Agency director
Printed Name Title
[�ocuSigned by:
6 � Rm&ety5� 10/2/2019
Oi3799d6755E477 .
Sag nature Date
Bonnie Hammersley County Manager
Printed Name Title
Docu5igned by: yen pre-audited in the manner required by the Local Government Budget and Fiscal Control Act.
10/2/2019
7D4E51S1ACC1409.
5rgnature of Uounty rinance Officer Date
Contract-General (06119) Page 4 of 5
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
ATTACHMENT A
GENERAL TERMS AND CONDITIONS
Orange County Department of Social Services and Department on Aging
Relationships of the Parties the County or the Contractor,receiving services or benefits
under this contract shall be deemed an incidental
Independent Contractor: The Contractor is and shall be beneficiary only.
deemed to be an independent contractor in the performance
of this contract and as such shall be wholly responsible for Indemnity and Insurance
the work to be performed and for the supervision of its
employees.The Contractor represents that it has,or shall Indemnification: The Contractor agrees to indemnify and
secure at its own expense, all personnel required in hold harmless the County and any of their officers,agents
performing the services under this agreement. Such and employees,from any claims ofthird parties arising out
employees shall not be employees of, or have any or any act or omission of the Contractor in connection with
individual contractual relationship with the County. the performance of this contract.
Subcontracting: The Contractor shall not subcontract any Insurance: During the term of the contract,the Contractor
ofthe work contemplated under this contract without prior at its sole cost and expense shall provide commercial
written approval from the County. Any approved insurance of such type and with such terms and limits as
subcontract shall be subject to all conditions of this may be reasonably associated with the contract. As a
contract.Only the subcontractors specified in the contract minimum, the Contractor shall provide and maintain the
documents are to be considered approved upon award of following coverage and limits:
the contract. The County shall not be obligated to pay for (a) Worker's Compensation - The contractor shall
any work performed by any unapproved subcontractor. provide and maintain Worker's Compensation
The Contractor shall be responsible for the performance of Insurance as required by the laws of North
all of its subcontractors. Carolina,as well as employer's liability coverage
with minimum limits of$500,000.00,covering all
Assignment: No assignment of the Contractor's of Contractor's employees who are engaged in any
obligations or the Contractor's right to receive payment work under the contract. If any work is sublet,the
hereunder shall be permitted. However, upon written Contractor shall require the subcontractor to
request approved by the issuing purchasing authority,the provide the same coverage for any of his
County may: employees engaged in any work under the
(a) Forward the Contractor's payment check(s) contract.
directly to any person or entity designated by the (b) Commercial General Liability - General
Contractor, or Liability Coverage on a Comprehensive Broad
(b) Include any person or entity designated by Form on an occurrence basis in the minimum
Contractor as a joint payee on the Contractor's amount of$1,000,000.00 Combined Single Limit.
payment cheek(s). (Defense cost shall be in excess of the limit of
In no event shall such approval and action obligate the liability.)
County to anyone other than the Contractor and the (c)Automobile Liability Insurance: The Contractor
Contractor shall retrain responsible for fulfillment of all shall provide automobile liability insurance with a
contract obligations. combined single limit of$500,000.00 for bodily
injury and property damage; a limit of
Beneficiaries: Except as herein specifically provided $500,000.00 for uninsured/under insured motorist
otherwise,this contract shall inure to the benefit of and be coverage; and a limit of$25,000.00 for medical
binding upon the parties hereto and their respective payment coverage. The Contractor shall provide
successors. It is expressly understood and agreed that the this insurance for all automobiles that are:
enforcement of the terms and conditions of this contract, (a) owned by the Contractor and used in the
and all rights of action relating to such enforcement,shall performance of this contract;
be strictly reserved to the County and the named (b) hired by the Contractor and used in the
Contractor.Nothing contained in this document shall give performance of this contract; and
or allow any claim or right of action whatsoever by any (c) Owned by Contractor's employees and
other third person.It is the express intention of the County used in performance ofthis contract("non-
and Contractor that any such person or entity, other than owned vehicle insurance"). Non-owned
General Terns and Conditions-(06116) Pagel of 5
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
vehicle insurance protects employers when
employees use their personal vehicles for Termination Without Cause: The County may terminate
work purposes. Non-owned vehicle this contract without cause by giving 30 days written
insurance supplements, but does not notice to the Contractor.
replace,the car-owner's liability insurance.
Termination for Cause: If, through any cause, the
The Contractor is not required to provide and maintain Contractor shall fail to fulfill its obligations under this
automobile liability insurance on any vehicle--owned, contract in a timely and proper manner, the County shall
hired,or non-owned--unless the vehicle is used in the have the right to terminate this contract by giving written
performance of this contract. notice to the Contractor and specifying the effective date
(d) The insurance coverage minimums specified in thereof. In that event,all finished or unfinished deliverable
subparagraph(a)are exclusive of defense costs. items prepared by the Contractor under this contract shall,
(e) The Contractor understands and agrees that the at the option of the County, become its property and the
insurance coverage minimums specified in Contractor shall be entitled to receive just and equitable
subparagraph (a) are not limits, or caps, on the compensation for any satisfactory work completed on such
Contractor's liability or obligations under this contract. materials,minus any payment or compensation previously
(f) The Contractor may obtain a waiver of any one or more made. Notwithstanding the foregoing provision, the
of the requirements in subparagraph (a) by Contractor shall not be relieved of liability to the County
demonstrating that it has insurance that provides for damages sustained by the County by virtue of the
protection that is equal to or greater than the coverage Contractor's breach of this agreement,and the County may
and limits specified in subparagraph(a). The County withhold any payment due the Contractor for the purpose
shall be the sole judge of whether such a waiver of setoff until such time as the exact amount of damages
should be granted. due the County from such breach can be determined. In
(g) The Contractor may obtain a waiver of any one or more case of default by the Contractor, without limiting any
of the requirements in paragraph(a)by demonstrating other remedies for breach available to it,the County may
that it is self-insured and that its self-insurance procure the contract services from other sources and hold
provides protection that is equal to or greater than the the Contractor responsible for any excess cost occasioned
coverage and limits specified in subparagraph(a). The thereby. The filing of a petition for bankruptcy by the
County shall be the sole judge of whether such a Contractor shall be an act of default under this contract.
waiver should be granted.
(h) Providing and maintaining the types and amounts of Waiver of Default: Waiver by the County of any default
insurance or self-insurance specified in this paragraph or breach in compliance with the terms of this contract by
is a material obligation of the Contractor and is of the the Provider shall not be deemed a waiver of any
essence of this contract. subsequent default or breach and shall not be construed to
(i) The Contractor shall only obtain insurance from be modification of the terms of this contract unless stated
companies that are authorized to provide such to be such in writing, signed by an authorized
coverage and that are authorized by the Commissioner representative of the County and the Contractor and
of Insurance to do business in the State of North attached to the contract.
Carolina.All such insurance shall meet all laws of the
State of North Carolina. Availability of Funds: The parties to this contract agree
(j) The Contractor shall comply at ail times with all lawful and understand that the payment of the sums specified in
terms and conditions of its insurance policies and all this contract is dependent and contingent upon and subject
lawful requirements of its insurer. to the appropriation, allocation, and availability of funds
(k) The Contractor shall require its subcontractors to for this purpose to the County.
comply with the requirements of this paragraph.
(1) The Contractor shall demonstrate its compliance with Force Majeure: Neither party shall be deemed to be in
the requirements of this paragraph by submitting default of its obligations hereunder if and so long as it is
certificates of insurance to the County before the prevented from performing such obligations by any act of
Contractor begins work under this contract. war,hostile foreign action,nuclear explosion,riot,strikes,
civil insurrection,earthquake,hurricane,tornado,or other
Transportation of Clients by Contractor:The contractor catastrophic natural event or act of God.
will maintain Insurance requirements if required as noted
under Article 7 Rule R2-36 of the North Carolina Utilities Survival of Promises: All promises,requirements,terms,
Commission. conditions, provisions, representations, guarantees, and
warranties contained herein shall survive the contract
Default and Termination expiration or termination date unless specifically provided
General Terms and Conditions-(06116) Page 2 of 5
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
otherwise herein, or unless superseded by applicable that comply with all applicable federal,state and
Federal or State statutes of limitation. local laws,regulations,and rules.
Intellectual Property Rights (b) Duty to Report: The Contractor shall report a
suspected or confirmed security breach to the
Copyrights and Ownership of Deliverables: All local Department of Social Services Contract
deliverable items produced pursuantto this contract are the Administrator within twenty-four(24)hours
exclusive property ofthe County. The Contractor shall not after the breach is first discovered,provided that
assert a claim of copyright or other property interest in the Contractor shall report a breach involving
such deliverables. Social Security Administration data or Internal
Revenue Service Data within one(1)hour after
Federal Intellectual Property Bankruptcy Protection the breach is first discovered.
Act:The Parties agree that the County shall be entitled to
all rights and benefits of the Federal Intellectual Property (c) Cost Borne by Contractor: If any applicable
Bankruptcy Protection Act,Public Law 100-506,codified federal,state,or local law,regulation or rule
at 11 U.S.C.365 (n)and any amendments thereto. requires the Contractor give written notice of a
security breach to affected persons,the Contract
Compliance with Applicable Laws shall bear the cost of the notice.
Compliance with Laws: The Contractor shall comply Trafficking Victims Protection Act of 2000:
with all laws, ordinances, codes, rules, regulations, and The Contractor will comply with the requirements of
licensing requirements that are applicable to the conduct of Section 106(g)of the Trafficking Victims Protection Act
its business, including those of federal, state, and local of 2000,as amended(22 U.S.C. 7104)
agencies having jurisdiction and/or authority. By
executing this Agreement Provider certifies that Executive Order#24: It is unlawful for any vendor,
Provider has not been identified,and has not utilized contractor, subcontractor or supplier of the state to snake
the services of any agent or subcontractor,on the list gifts or to give favors to any state employee. For
created by the State Treasurer pursuant to G.S. 147- additional information regarding the specific
86.58. requirements and exemptions,contractors are
encouraged to review Executive Order 24 and G.S. Sec.
Title VI,Civil Rights Compliance: In accordance with 133-32.
Federal law and U.S.Department of Agriculture(USDA)
and U.S. Department of Health and Human Services Confidentiality
(HHS) policy, this institution is prohibited from Confidentiality: Any information, data, instruments,
discriminating on the basis of race,color,national origin, documents, studies or reports given to or prepared or
sex, age or disability. Under the Food Stamp Act and assembled by the Contractor under this agreement shall be
USDA policy, discrimination is prohibited also on the kept as confidential and not divulged or made available to
basis of religion or political beliefs. any individual or organization without the prior written
Equal Employment Opportunity: The Contractor shall approval ofthe County.The Contractor acknowledges that
comply with all federal and State laws relating to equal in receiving,storing,processing or otherwise dealing with
any confidential information it will safeguard and not
employment opportunity. further disclose the information except as otherwise
Health Insurance Portability and Accountability Act
provided in this contract.
(HIPAA): The Contractor agrees that,if the County Oversight
determines that some or all of the activities within the
scope of this contract are subject to the Health Insurance Access to Persons and Records:The State Auditor shall
Portability and Accountability Act of 1996,P.L. 104-91, have access to persons and records as a result of all
as amended("HIPAA"),or its implementing regulations, contracts or grants entered into by State agencies or
it will comply with the HIPAA requirements and will political subdivisions in accordance with General Statute
execute such agreements and practices as the County 147-64.7. Additionally,as the State funding authority,the
may require to ensure compliance. Department of Health and Human Services shall have
(a) Data Security: The Contractor shall adopt and access to persons and records as a result of all contracts or
apply data security standards and procedures grants entered into by State agencies or political
subdivisions.
General Terms and Conditions-(06/16) Page 3 of 5
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
subcontractors,complies with the requirements ofArticle 2
Record Retention: Records shall not be destroyed, of Chapter 64 of the NC General Statutes.
purged or disposed of without the express written consent
of the Division. State basic records retention policy Miscellaneous
requires all grant records to be retained for a minimum of
five years or until all audit exceptions have been resolved, Choice of Law: The validity of this contract and any of its
whichever is longer. If the contract is subject to federal terms or provisions,as well as the rights and duties of the
policy and regulations,record retention may be longer than parties to this contract,are governed by the laws of North
five years since records must be retained for a period of Carolina.The Contractor,by signing this contract,agrees
three years following submission of the final Federal and submits,solely for matters concerning this Contract,to
Financial Status Report, if applicable, or three years the exclusive jurisdiction of the courts of North Carolina
following the submission of a revised final Federal and agrees, solely for such purpose, that the exclusive
Financial Status Report. Also, if any litigation, claim, venue for any legal proceedings shall be Orange County,
negotiation, audit, disallowance action, or other action North Carolina. The place of this contract and all
involving this Contract has been started before expiration transactions and agreements relating to it, and their situs
of the five-year retention period described above, the and forum,shall be Orange County,North Carolina,where
records must be retained until completion of the action and all matters,whether sounding in contract or tort,relating to
resolution of all issues which arise from it,or until the end the validity,construction,interpretation,and enforcement
of the regular five-year period described above,whichever shall be determined.
is later. The record retention period for Temporary
Assistance for Needy Families (TANF)and MEDICAID Amendment: This contract may not be amended orally or
and Medical Assistance grants and programs must be by performance. Any amendment must be made in written
retained for a minimum of ten years. forth and executed by duly authorized representatives of
the County and the Contractor.
Warranties and Certifications
Severability: In the event that a court of competent
Date and Time Warranty: The Contractor warrants that jurisdiction holds that a provision or requirement of this
the product(s) and service(s) furnished pursuant to this contract violates any applicable law, each such provision
contract("product"includes,without limitation,any piece or requirement shall continue to be enforced to the extent it
of equipment,hardware,firmware,middleware,custom or is not in violation of law or is not otherwise unenforceable
commercial software,or internal components,subroutines, and all other provisions and requirements of this contract
and interfaces therein)that perform any date and/or time shall remain in full force and effect.
data recognition function, calculation,or sequencing will
support a four digit year format and will provide accurate Headings: The Section and Paragraph headings in these
date/time data and leap year calculations. This warranty General Terms and Conditions are not material parts ofthe
shall survive the termination or expiration of this contract. agreement and should not be used to construe the meaning
thereof.
Certification Regarding Collection of Taxes: G.S. 143-
59.1 bars the Secretary of Administration from entering Time of the Essence: Time is of the essence in the
into contracts with vendors that meet one of the conditions performance of this contract.
of G.S. 1 05-164.8(b)and yet refuse to collect use taxes on
sales of tangible personal property to purchasers in North Key Personnel: The Contractor shall not replace any of
Carolina. The conditions include: (a) maintenance of a the key personnel assigned to the performance of this
retail establishment or office; (b) presence of contract without the prior written approval of the County.
representatives in the State that solicit sales or transact The term "key personnel" includes any and all persons
business on behalf of the vendor; and (c) systematic identified as such in the contract documents and any other
exploitation of the market by media-assisted, media- persons subsequently identified as key personnel by the
facilitated, or media-solicited means. The Contractor written agreement of the parties.
certifies that it and all of its affiliates (if any) collect all
required taxes. Care of Property: The Contractor agrees that it shall be
responsible for the proper custody and care of any property
E-Verify furnished to it for use in connection with the performance
of this contract and will reimburse the County for loss of,
Pursuant to G.S. 143-48.5,the undersigned hereby certifies or damage to, such property. At the termination of this
that the Contractor named below, and the Contractor's contract, the Contractor shall contact the County for
General Terms and Conditions-(06/16) Page 4 of 5
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
instructions as to the disposition of such property and s}ial I
comply with these instructions. Orange County Living Wage: Grange County is
committed to providing its employees with a living wage
Travel Expenses: Reimbursement, if provided in this and encourages agencies to which it provides funding to
Agreement, to the Contractor for travel mileage, meals, pursue the same goal. The County's living wage hourly
lodging and other travel expenses incurred in the standard, as adopted by the Orange County Board of
performance of this contract shall not exceed the rates County Commissioners annually, can be found in the
established in County policy. Orange County Budget Ordinance. To the extent possible,
Orange County recommends that the Contractor and all
Sales[Use Tax Refunds: If eligible,the Contractor and all subcontractors provide a living wage, as defined in this
subcontractors shall: (a) ask the North Carolina section,to their employees.
Department of Revenue for a refund of all sales and use
taxes paid by them in the performance of this contract, Signatures: This Agreement together with any
pursuant to G.S. 105-164.14; and (b) exclude all amendments or modifications may be executed
refundable sales and use taxes from all reportable electronically. All electronic signatures affixed hereto
expenditures before the expenses are entered in their evidence the intent of the Parties to comply with Article
reimbursement reports. i 1A and Article 40 of North Carolina General Statute
Chapter 66.
Advertising: The Contractor shall not use the award of
this contract as a part of any news release or commercial
advertising.
General Tereus and Conditions—(06/16) Page 5 of 5
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
ATTACFIAWNT B
SCOPE OF WORK
Orange County Department of Social Services and Orange County Department on Aging
Federal Tax Id.or SSN 56-1629016
Contract# 68-2045
A. CONTRACTOR INFORMATION
1. Contractor Agency Name: Personalized Patient Home Assistance, Inc.
2. If d ierent 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 1,2019 through June 30,2020
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 Aging's clients,at the level,amount and frequency
specified by the social worker in the In-Home Aide Services Plan (SIS Code 042). The
Contractor will provide Level II Home Management and Level II Personal Care. The Contractor
is required to meet all goals and outcomes listed in Attachment O.The Contractor may be asked
to provide employees to perform personal care services during an emergency shelteringevent.
vent.
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$23.881hour,of which the Contractor must pay the In
Home Aide at least the County's Living Wage_(currently 14.95 perlhr).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 up to the budgetary limits of the contract allotment. The
County will reimburse the Contractor at a rate of$23.881hour 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
Contract-Scope of Work(06/04) Page lof 2
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
the Administrator for said Department. All invoices for the provision of services to the
Department on Aging shall be submitted to the Administrator for said Department. The County
will reimburse the Contractor monthly upon receipt of a complete and correctly filed report.
F. Area to be served/Delivery site(s): Orange County
DocuSigned by:
(, Sf bw
�AE1E198A83B455 .
Nancy Coston,Social Services Director
10/1/2019
(Date Submitted)
DocuSigned by:
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67E962M BF454FA..
Janice Tyler,Dept. on Aging Director
10/1/2019
(Date Submitted)
IGacuSigned by:
106V'b{�.t.A. fit.. Fa.Vl✓'46t&
73BC2FODOAA94BE .
(Signature of Contractor)
9/30/2019
(Date Submitted)
Contract-Scope of Work(06/04) Page 2of2
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
ATTACHM ENT C
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
AND CERTIFICATION REGARDING NONDISCR 41NATION
Orange County Department of Social Services
I. By execution of this Agreement the Contractor certifies that it will provide a drug-free workplace by:
A. Publishing a statement notifying employees that the unlawful manufacture,distribution,
dispensing,possession or use of a controlled substance is prohibited in the Contractor's
workplace and specifying the actions that will be taken against employees for violation of such
prohibition;
B. Establishing a drug-free awareness program to inform employees about:
(1)The dangers of drug abuse in the workplace;
(2)The Contractor's policy of maintaining a drug-free workplace;
(3)Any available drug counseling,rehabilitation,and employee assistance programs; and
(4)The penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace;
C. Making it a requirement that each employee be engaged in the performance of the agreement be
given a copy of the statement required by paragraph(A);
D. Notifying the employee in the statement required by paragraph(A)that,as a condition of
employment under the agreement,the employee will:
(1)Abide by the terms of the statement;and
(2)Notify the employer of any criminal drug statute conviction for a violation occurring
in the workplace no later than five days after such conviction;
E. Notifying the County within ten days after receiving notice under subparagraph(D)(2)from an
employee or otherwise receiving actual notice of such conviction;
F. Taking one of the following actions,within 30 days of receiving notice under subparagraph
(D)(2),with respect to any employee who is so convicted:
(1)Taking appropriate personnel action against such an employee,up to and including
termination;or
(2)Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local health,
law enforcement,or other appropriate agency;and
Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs(A),(13),(C),(D),(E),and(F).
Federal Certification-Drug-Free Workplace&Nondiscrimination rev.06-2015
Page 1 of 2
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
II. The site(s)for the performance of work done in connection with the specific agreement are listed
below:
1.
(Street address)
(City,county,state,zip code)
2.
(Street address)
(City,county, state,zip code)
Contractor will inform the County of any additional sites for performance of work under this agreement.
False certification or violation of the certification shall be grounds for suspension of payment,suspension
or termination of grants,or government-wide Federal suspension or debarment
45 C.F.R. Section 82.510. Section 4 CFR Part 85,Section 85.615 and 86.620.
CERTIFICATION REGARDING NONDISCRIMINATION
The Vendor certifies that it will comply with all Federal statutes relating to nondiscrimination. These
include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352)which prohibits
discrimination on the basis of race,color or national origin; (b)Title IX of the Education Amendments of
1972, as amended(20 U.S.C. §§1681-1683, and 1685-1686), which prohibits discrimination on the basis
of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §794), which prohibits
discrimination on the basis of handicaps;(d)the Age Discrimination Act of 1975, as amended(42 U.S.C.
§§6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P.L, 92-255), as amended, relating to nondiscrimination on the basis of drug
abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation
Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as amended,
relating to nondiscrimination in the sale, rental or financing of housing; (h) the Food Stamp Act and
USDA policy, which prohibit discrimination on the basis of religion and political beliefs; and (i) the
requirements of any other nondiscrimination statutes which may apply to this Agreement.
IOacuSignec[by,
10br'bkta At. aYVtln btn. Agency director
73BC2FODOAA94BE .
Signature Title
Personalized Patient Home Assistance 9/30/2019
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Federal Certification-Drug-Free Workplace&Nondiscrimination rev.06-2015
Page 2 of 2
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
ATTACMMENT 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 Organizations
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
Organizati&s name or property, for private profit or benefit.
A. The Board members or other governing persons, officers,.employees, or agents of the
Organization should neither solicit nor accept gratuities, favors, or anything of monetary value
from current or potential contractors/vendors,persons receiving benefits from the Organization or
persons who may benefit from the actions of any Board member or other governing person,
officer, employee or agent. This is not intended to preclude bona-fide Organization fund raising-
activities.
B. A Board or other governing body member may,with the approval of Board or other governing
body, receive honoraria for lectures and other such activities while not acting in any official
capacity for the Organization. Officers may, with the approval of the Board or other governing
body, receive honoraria for lectures and other such activities while on personal days,
compensatory time, annual leave, or leave without pay. Employees may, with the prior written,
approval of their supervisor, receive honoraria for lectures and other such activities while on
personal days, compensatory time, annual leave, or leave without pay. If a Board or other
governing body member, officer, employee or agent is acting in any official capacity, honoraria
received in connection with activities relating to-the Organization are to be paid to the
Organization.
C.No Board member or other governing person, officer, employee, or agent of the Organization
shall participate in the selection, award, or administration of a purchase or contract with a vendor
where,to his knowledge,any of the following has a financial interest in that purchase or contract:
1. The Board member or other governing person,officer,employee, or agent;
2. Any member of their family by whole or half blood, step or personal relationship or
relative-in-law;
3. An organization in which any of the above is an officer, director, or employee;
4. A person or organization with whom any of the above individuals is negotiating or has
any arrangement concerning prospective employment or contracts.
D.Duty to Disclosure--Any conflict of interest, potential conflict of interest, or the appearance
of a conflict of interest is to be reported to the Board or other governing body or one's supervisor
immediately.
E.Board Action--When a conflict of interest is relevant to a matter requiring action by the
Board of Directors/Trustees or other governing body,the Board member or other governing
person,officer,employee, or agent(person(s))must disclose the existence of the conflict of
interest and be given the opportunity to disclose all material facts to the Board and members of
Conflict of Interest Policy(06115) Page 1 of 3
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
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 conunittee meeting while the determination of a conflict of interest is
discussed and voted upon. The remaining board or committee members shall decide if a conflict
of interest exists. In addition,the person(s)shall not participate in the final deliberation or
decision regarding the matter under consideration and shall leave the meeting during the
discussion of and vote of the Board of Directors/Trustees or other governing body.
F. Violations of the Conflicts of Interest Policy -- If the Board of Directors/Trustees or other
governing body has reasonable cause to believe a member, officer, employee or agent has failed
to disclose actual or possible conflicts of interest, it shall inform the person of the basis for such
belief and afford the person an opportunity to explain the alleged failure to disclose. If, after
hearing the persons response and after making further investigation as warranted by the
circumstances, the Board of Directors/Trustees or other governing body determines the member,
officer, employee or agent has failed to disclose an actual or possible conflict of interest, it shall
take appropriate disciplinary and corrective action.
G. Record of Conflict -- The minutes of the governing board and all committees with board
delegated powers shall contain:
1. The names of the persons who disclosed or otherwise were found to have an actual or
possible conflict of interest, the nature of the conflict of interest, any action taken to
determine whether a conflict of interest was present, and the governing board's or
committee's decision as to whether a conflict of interest in fact existed.
2. The names of the persons who were present for discussions and votes relating to the
transaction or arrangement that presents a possible conflict of interest, the content of the
discussion, including any alternatives to the transaction or arrangement, and a record of
any votes taken in connection with the proceedings.
Approved by:
9.11,4
Name of Or atio,-
G i Sipes re of Orga ation Official
Date
Conflict of Interest Policy(06/15) Page 2 of 3
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
NOTARIZED CONFLICT OF INTEREST POLICY
State of North Carolina
County of Orange
I,C ri Notary Public for said County and State,
certify that r personally appeared before me this
day and acknowledged that�.Ii&sh�eis of
Ta_�tLeA:ahw._ ' 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 2— day of
Sworn to and subscribed before me this��day of �� f
=-
/14ARD
(Official Seal}
Notary Public Orange
My Commission expires F� 5 , zap
Conflict of Interest Policy(06/15) Page 3 of 3
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
ATTACHWNT E
OVERDUE TAXES
orange County Departiaient of Social Services
PERSONALIMD PATIENT IE OMM ASSISTANCE
109 Concord Drive
Chapel Hail,N.C.27516
September 12,2019
To: Orange County Department of Social Services
Certification;
We certify that Personalized Patient FI❑me Assistance does not have any overdue tax debts,as
defined byIN.C.G.S. 105-243.11,at the federal,State,or local Icyel. We further understand that
any per-son who makes a false statement in violation of N.C.G.S. 143C-6-23(c)is guilty of a
criminal offense pui ishable as provided by N.C.G.S. 143C-1 0-1(b).
Sworn Statement:
Dorothea M.Farrington and Ross L,Farrington being duly sworn,say that we are the Director
and Accounts Payable,respectively,of Personalized Patient Home Assistance of Chapel Hill in
the State of North Carolina,and that the foregoing certification is true,accurate and complete to
the best of our knowledge and was made and subscribed by us. We also acknowledge and
understand that any misuse of State f mds will be reported to the appropriate authorities for
further acti
Director
Accounts Payable
S to and subscrib before m on the day of the date of said certification.My Conunission Expires_ �yy��
U 8 9,9,
otary Signature an eal)
17.
ON MARIE HOWARD SHANNON MARIE HOWARD
Notary ?tabfir Notary Public
North Carol- 3 North Carolina
Orange Courtity Orange County
G_S. 105-243.1 defincs:Overdue mx debt.—Any part of a tax debt that remains unpaid 90 days or more aftex the
notice of final assessment was Tnailed to the taxpayer.Tbo term does not include a tax debt however,if the taxpayer
entered into qn installment agreement for the tax debt under 0.5. 105•237 within 90 days after the notice of final
assessment was mailed And has not failed to make any payments duo under the installment agreement."
Overdue Taxes—(07108) Page 1 of 1
L�ELB 3Jdd i-UVVHWQ L956ZCEb0b 9I:91 6107,/ZZ16la
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
ATTACHI4ENT 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 fie the required certification shall be subject to a civil penalty of not less than$10,000 and not
more than$100,000 for each such failure.
Notwithstanding other provisions of federal OMB Circulars A-122 and A-37,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 a 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(07/08) Page I of 3
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
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 made 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(07/08) Page 2 of 3
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
(5) Agencies shall establish procedures for resolving in advance, in consultation with OMB, 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 platter 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.
GocuSigned by,
06A.t.a. h. Fa.Vl✓[46t& Agency director
73BC2FODOAA94BE .
signature Title
Personalized Patient Home Assistance 9/30/2019
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Federal Certification—Lobbying(07/08) Page 3 of 3
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
Contract#68-2045
Personalized Patient Home Assistance,Inc.
ATTACB3ffNT H
CERTIFICATION REGARDING DEBARMENT, SUSPENSION,INELIGIBILITY
AND VOLUNTARY EXCLUSION-LOWER TIER COVERED TRANSACTIONS
Orange County Department of Social Services
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," "lower 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.
d. 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(07/08) Pagel of 2
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
Contract#68-2045
Personalized Patient Home Assistance,Inc.
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.
EOacu'Signec[by,
106V'b{1�.t.A. h. FAM'46t& Agency director
73BC2FOBOAA94BE .
Signature Title
Personalized Patient Home Assistance 9/30/2019
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Federal Certification-Debarment(07/08) Page 2 of 2
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
Contract 968-2045
Personalized Patient Home Assistance, Inc.
ATTACHMENT d
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,
Oacusig tl A;Psi `� "r T;tlp X programs(signature on this form confirms this statement).
101)73Br-2FODOAA94BE
bVbiu�.ak. aYVtln btn. Agency director
.
Signature Title
Personalized Patient Home Assistance 9/30/2019
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Transportation Certification(06/16) Page 1 of i
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
ATTACHMENT M
State and Local Certifications
Contractor Certifications Required by North Carolina Law
Orange County Department of Social Services and Department on Aging
Instructions: The person who signs this document should read the text of the statutes and Executive Order listed below and consult
with counsel and other knowledgeable persons before signing.The text of each North Carolina General Statutes and of the Executive
Order can be found online at:
• Article 2 of Chapter 64: h ://www.nc a.state.nc.usfEnactedI.e islatioti/Statute /PDFB Article/Cha ter 64/Article 2. df
• G.S. 133-32: htt ://www.nc a.state.nc.usl ascri is/statutes/statutelooku l?statut =133-32
• Executive Order No.24(Perdue,Gov.,Oct. 1,2009): httl2-./iwww.othicscommission.nc.gov/librarv1 dfslLaws/FO24. df
• G.S. 105-164,8(b): htip:llwww.ncga.state.nc.us/EnactedLe&is[ation/Statutes/PDF/BySection/Chapter 105/6S�105-164.8.pdf
• G.S. 143-48.5: http:llwww.ncea.state.ne.usXnactedLegis[at ion/Statutes/HTMUBySection/ChVter 143/G_S 143-48.5.htm]
• G.S. 143-59.1: hnp://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySectioii/Chaeer_143iGS 143-59A.pdf
• G.S. 143-59.2: htt ://www.nc a.state.ne.us/EnactedLe islation/Statutevd?DFB ection/Cha ter 1431GS 143-59.2. df
• G.S. 143-133,3: hLr,:llwww.ncga.state.nc.us/EnactedLegislation/Statutes/14'1'MUBySection/Chapter 1431GS 143-133.3.htm]
• G.S. 143B-139.6C: htt ://www.nc a.state.nc.us/EnactedLe islation/Statutes/iIDF/B Section/Chapter 143BIGS 143B-139.6C. df
• The text of Orange County Living Wage Contractor Policy which is attached to this document.
Certifications
(1) Pursuant to G.S. 133-32 and Executive Order No.24 ❑Neither the Contractor nor any of its affiliates
(Perdue, Gov., Oct. 1, 2009), the undersigned hereby has incorporated or reincorporated in a "tax
certifies that the Contractor named below is in
haven country" as set forth in G.S. 143-
compliance with,and has not violated,the provisions of 59.1(c)(2)after December 31,2001; or
either said statute or Executive Order.
(2) Pursuant to G.S. 143-48.5 and G.S. 143-133.3, the
undersigned hereby certifies that the Contractor named ® The Contractor or one of its affiliates has
below, and the Contractor's subcontractors, complies incorporated or reincorporated in a "tax haven
with the requirements of Article 2 of Chapter 64 of the country" as set forth in G.S. 143-59.1(c)(2)
NC General Statutes, including the requirement for after December 31, 2001 but the United States
each employer with more than 25 employees in North is not the principal market for the public trading
Carolina to verify the work authorization of its of the stock of the corporation incorporated in
employees through the federal E-Verify system." E- the tax haven country.
Verify System Link: www.uscis.goy (4) Pursuant to G.S. 143-59.2(b), the undersigned hereby
certifies that none of the Contractor's officers,
Local government is specifically exempt from Article 2 directors, or owners (if the Contractor is an
of Chapter 64 of the North Carolina General unincorporated business entity) has been convicted of
Statutes. However,local government is subject to and any violation of Chapter 78A of the General Statutes or
must:comply with North Carolina General Statute the Securities Act of 1933 or the Securities Exchange
153A-99.1,which states in part as follows: Act of 1934 within 10 years immediately prior to the
Counties Must Use E-Verify-Each county shall date of the bid solicitation.
register and participate in E-Verify to verify the work (5) Pursuant to G.S. 143B-139.6C, the undersigned
authorization of new employees hired to work in the hereby certifies that the Contractor will not use a
United States. former employee, as defined by G.S. 143B-
(3) Pursuant to G.S. 143-59.1(b), the undersigned hereby 139.6C(d)(2), of the North Carolina Department of
certifies that the Contractor named below is not an Health and Human Services in the administration of a
"ineligible Contractor" as set forth in G.S. 143-59.1(a) contract with the Department in violation of G.S.
because: 143B-139.6C and that a violation of that statute shall
void the Agreement.
(a) Neither the Contractor nor any of its affiliates has (6) The undersigned hereby certifies further that:
refused to collect the use tax levied under Article 5
of Chapter 105 of the General Statutes on its sales (a) He or she is a duly authorized representative of the
delivered to North Carolina when the sales met Contractor named below;
one or more of the conditions of G.S. 105-
164.8(b);and
(b) He or she is authorized to make, and does hereby
(b) [check one of the following boxes] make, the foregoing certifications on behalf of the
Contractor;and
Contractor Certifications Required by North Carolina Law(Rev.8/2016) Page t of
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
(c) He or she understands that any person who services under this contract a living wage (in
knowingly submits a false certification in response Orange County currently $14.95 per/hr.) Check
to the requirements of G.S. 143-59.1and -59.2 here ❑ if contractor pays employees performing
shall be guilty of a Class I felony. under this contract a living wage. If Contractor
does not pay employees a living wage, what is the
(1) Pursuant to the Orange County Living Wage wage that employees performing services under this
Contract's Policy, the undersigned certifies that contract paid?
the Contractor pays the employees who perform
Contractor's Name: Personalized Patient Home Assistance
ri—usigned by:
Contractor's L06 k. FGt.VYYIti:I 6t& 9/30/2019
Authorized Agent: Signature Date
73HC2FOOOPP.94BE .
Dorothea M. Farrington Agency director
Printed Nor oocusigned by: Title
1 q. crVyibin. 9/30/2019
Witness: Signature Date
A1EA2�E'1OF204B7
Printed Name
Carmilla Y. Farrington Title Attorney
The witness should be present when the Contractor's Authorized Agent signs this certificate and should sign and
date the document immediately thereafter.
Contractor Certifications Required by North Carolina Law fRev.8/2016) Page 2 of 3
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
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$14.95
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.
10.1.2 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 Orange County and North Carolina Law
Revised 6119 Page 3 of 3
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
Contract 468-2045
Personalized Patient Home Assistance.Inc.
ATTACHMENT N
Orange County Department of Social Services and Department on Aging
CERTIFICATION REGARDING NONDISCRMINATION,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 trust comply with Executive Order 11246, entitled "Equal Employment
Opportunity," as amended by Executive Order 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.
Meaningful 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-Nan-Discrimination, Clean Air, Clean Water) (01/2018)Page 1 of 4
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
Contract#68-2045
Personalized Patient Home Assistance, 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 littp://www.lep.gov.
Ensuring Equal 01212ortunity 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.
DQJ 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.
IM 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:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
Contract 068-2045
Personalized Patient Home Assistance,Inc.
setting forth procedures, sanctions, penalties, and such other provisions, as the President
determines necessary to carry out such requirement.
d1 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. 76061
V.The Cleans 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-Nan-Discrimination, Clean Air, Clean Water)(0112018)Page 3 of 4
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
Contract 468-2045
Personalized Patient Home Assistance, Inc.
Docu''Srrigned by,
10 br'bt(aa At. Agency director
73BC2FODOAA94BE .
Signature Title
Personalized Patient Home Assistance 9/30/2019
Agency/Organization Date
(Certification signature should he same as Contract signature.)
(Federal Certification-Non-Discrimination, Clean Air, Clean Water)'(01/201 S)Page 4 of 4
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
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.
I. Provide care at Level II as appropriate to the needs of the client.
T. Complete, for employees serving Level II 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.
Outcomes (06/04) Pagel of 3
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
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.
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.
a. 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.
Outcomes (06/04) Page 2 of 3
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
IGacuSigned by,
.t.a. h. FAM'tn./�{`6t& Agency director
73BC2FODOAA94BE .
Signature Title
Personalized Patient Home Assistance 9/30/2019
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Outcomes (06/04) Page 3 of 3
DocuSign Envelope ID:412EAE5F-3824-43FA-AC95-54AOC4DF83A2
ACC>R" CERTIFICATE OF LIABILITY INSURANCE DATE911W201YYVY)
��. 0911 01 0 19
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Carla Dubuc
NAME:
Sanford Insurance Center H NE Exs: (919)775-7216 �yj X No): (888)280-1597
(Af1722 S HORNER BLVD -MA L
ADDRESS:
INSURER{SyAFFORDING COVERAGE NAIL#
SANFORD NC 27330 INSURERA: National Liability and Fire
INSURED INSURERS: United States Liability Insurance 25895
Dorothea Farrington RBA INSURER C
Personalized PatienIS Home Assistance INSURER D:
109 Concord Dr INSURER E
Chapel Hill NC 2751E INSURER F:
COVERAGES CERTIFICATE NUMBER: CL1991005245 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,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
WSR TYPE OF INSURANCE POL C ❑LICY EXP LIMITS
LTR INSD WVD POLICY NUMBER M'MDDIYYYY MMIDDIYYYY
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,o00
��,,// A 100,000
CLAIMS-MADE /'\ OCCUR PREMISES Ea occurrence $
MED EXP(Any one person) $ 5,OD0
B AH1565797B 07117/2019 07/17/2020 PERSONAL&ADV INJURY $ 1,000,000
P'OTHER;
LAGGREGATE LIIMITAPPLIES PER: GENERAL AGGREGATE $ 3,000,000
POLICY JECT LOC included
PRODUCTS-COMPIOPAGG $$
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY Ea accldeni $
ANY AUTO BODILY INJURY{per person) $
CWNE❑ SCHEDULED BODILY INJURY(Per accldenl) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per aocadent
$
UMBRELLA LLAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
❑E❑ RETENTION$ r $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y'" STATUTE I ER
10a,000
ANY PROPR CEWMEMB RIPAR-UDEDxECUTIVE E.L.EACH ACCIDENT $
p' ❑FFiCER1MEMeER EXCLUPEO7 ❑ H IA A9WC9&7430 07/05/2019 07/0512020 100,D00
{Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under 500,D00
DESCRIPTION!OF OPERATIONS bald E.L.DISEASE:-POLICY LIMIT $
Each Claim 1,000,000
Allled Healthcare Professional Liability
B Abuse/Molestation AH 1555797B 07/17/2019 07/17/2020 Aggregate 3,000,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Orange County OSS ACCORDANCE WITH THE POLICY PROVISIONS.
PO Box 8181
AUTHORIZED REPRESENTATIVE
Hillsborough NO 27278 /C
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