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HomeMy WebLinkAbout2021-336-Health-Piedmont Health Services-Outside Agency Piedmont Health Services Orange County Outside Agency Performance Agreement Revised 7/2018 Page 1 of 9 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2020, (“Effective Date”) by and between the County of Orange, a political subdivision of the State of North Carolina, Post Office Box 8181, Hillsborough, North Carolina, 27278, ("County") and Piedmont Health Services, a not-for-profit corporation, located at 88 Vilcom Center Drive, Suite 110, Chapel Hill, North Carolina 27514 (“Provider”). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners. NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and «Agencys_Name» agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2020 to June 30, 2021. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit “A” and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of $16,500. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $4,125. The first payment is contingent upon receipt of the agency’s performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County’s obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 Orange County Outside Agency Performance Agreement Page 2 of 9 Rev. 1/21 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 – December 31; January 1 – March 31 and April 1 - June 30. Reports are due on January 10, April 10, and July 10 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services, upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as “default”), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten (10) business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County’s remedies in law or in equity. DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 Orange County Outside Agency Performance Agreement Page 3 of 9 Rev. 1/21 c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker’s Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance, including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury, bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A - Statutory State NC & Coverage B - Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability) required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough, NC 27278 d. Nothing in this section is intended to affect or abrogate the County’s sovereign immunity defenses. DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 Orange County Outside Agency Performance Agreement Page 4 of 9 Rev. 1/21 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County’s sovereign immunity defenses. 12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Non-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County’s living wage is $ 14.95 per hour. To the extent possible, Orange County recommends that Provider provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: County: Finance & Administrative Services Provider: Piedmont Health Services DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 Orange County Outside Agency Performance Agreement Page 5 of 9 Rev. 1/21 16. E n tire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 18. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF, the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For and on behalf of the Provider _____________________________ _______________________ , Date For and on behalf of Orange County Government _______________________________ ________________________ Bonnie Hammersley, County Manager Date Orange County Post Office Box 8181 Hillsborough, NC 27278 88 Vilcom Center Drive, Ste. 110 Chapel Hill, NC 27514 DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 Brian Toomey 6/28/2021 CEO 6/29/2021 Orange County Outside Agency Performance Agreement Page 6 of 9 Rev. 1/21 ORANGE COUNTY—DEPARTMENT USE ONLY ______________________________________________________________________________ Party/Vendor Name: Piedmont Health Services Party/Vendor Contact Person: Marni Holder Contact Phone: (919) 537-7497 x1497 Party/Vendor Address: 88 Villcom Cntr. Dr., Ste 110 City Chapel Hill State: NC Zip: 27514 Department: Health Amount: $16,500 Purpose: Outside Agency Budget Code(s): 10495050-719021 Vendor # 27898 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date 7-1-20 Approved by Board Yes No Agenda Date: This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this project has not been initiated prior to execution of the agreement: Department Director’s Signature ________________________________________ Date: ________ Agreements for emergency services or repair are not subject to the above affirmation. If services related to this agreement have already begun or been completed please briefly describe the nature of the emergency condition that was addressed: Turnover in original department generating contract. Information Technologies (Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer___________________________________ Date: ________ Risk Management This agreement is approved for sufficiency of insurance standards, specifications, and requirements: Office of the Risk Management Officer___________________________________ Date: _________ Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer ____________________________________ Date: _________ Legal Services This agreement is approved as to legal form and sufficiency: Office of the County Attorney __________________________________________Date: ________ Clerk to the Board Received for record retention: All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board __________________________________________Date:_________ DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 6/28/2021 6/29/2021 6/29/2021 6/29/2021 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 Program information P a g e 8 o f 2 2 AGENCY INFORMATION Please provide the following information about your agency: 1. Date of Incorporation (Month/Year): 03/1970 2. Agency’s Purpose/Mission (no more than a few sentences): Piedmont Health Services, Inc. (PHS) is critical part of the community’s primary health care safety net for vulnerable and/or financially-disadvantaged residents. PHS’ mission is “to improve the health and well- being of the community by providing high quality, affordable and comprehensive primary health care.” PHS operates two major programs, the Community Health Center (CHC) program (10 sites) and a CMS-deemed Program of All-Inclusive Care for the Elderly (PACE) (2 sites) which serve a multi-county area. Community health centers nationally offer care on a sliding fee scale for services for those living at or below 200% of the Federal poverty guideline. 3. Please provide a brief description of your organization’s past achievements in carrying out similar projects and evidence of successful record of meeting proposed budgets and timetables (no more than 100 words). PHS has been working locally since 1970 to assure access to comprehensive, culturally competent primary health care, and now provides services at three locations (Carrboro CHC, Chapel Hill CHC and the IFC CHC located in the IFC’s Community House shelter). These locations served more than 8,400 people in 2019 with sliding-fee family medical and dental care, integrated behavioral health, pharmacy and health support services including interpretation, care management, WIC/nutrition and eligibility assistance . PHS manages multiple grants to support this mission and consistently meets obligations. PHS is Joint Commission-accredited and recognized by the National Committee for Quality Assurance Level 3 Patient Centered Medical Home. 4. Living Wage: Does this agency pay permanent employees a minimum living wage? (Yes / No) Yes If yes, is this agency an Orange County Living Wage Certified Employer? No If no, please briefly explain. PHS’ current minimum hourly rate is $12.00/hr. plus health insurance. Living wage rates per the Living Wage calculator (http://livingwage.mit.edu) across the PHS service area range from $10.43/hr in Person County to $12.28/hr in Chatham and Orange Counties. Pay rates are examined on a regular basis using wage data from other community health centers and local care providers. Schedule of Positions: # of FTE – Full-Time Paid Positons: 531 # of FTE – Part-Time Paid Positions: 67 PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 5. Program Name: PHS Community Health Centers Program Primary Contact and Title: Jen Cunningham, Data Analyst Telephone Number: 919-913-1097 E-Mail: cunningj@piedmonthealth.org EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 Program information P a g e 9 o f 2 2 6. Please briefly describe the proposed program, including an explanation of how it aligns with the Town of Chapel Hill and Carrboro’s Results Framework, and Orange County BOCC Goals and Priorities, and the target population to benefit from the program. (100 words or less) PHS’ Community Health Center program (see table summary below) meets the Towns’ Strategic Objective of improving resident health outcomes (specifically Intermediate objective 3.1), and also Orange County’s goal of “ensuring a community network of basic human services and infrastructure that maintains, protects, and promotes the well-being of county residents.” Funding directly supports interpretation costs for services to large immigrant and refugee populations, as well as medical care for the low-income uninsured. The Table below provides detail of the services offered at each site. PHS CHC Program: Locations, Hours, Services and Populations CHC Program location CHC Appt. Hours/ Week CHC Services (2020-20201) CHC Target Population Additional special population programs Carrboro 58 Medical/ Behavioral/ Dental/Onsite Pharmacy/WIC/Care Support Low-income (<200% FPG) -Refugee Health -MAT for Opioid Use Disorder -Formerly Incarcerated Transitions (FIT) Program -Transgender Care Chapel Hill 45 Medical/Behavioral /Onsite Pharmacy /Care Support Low-income (<200% FPG) IFC 8 Medical/Dental/Behavioral/Pharmacy by delivery/Care Support Health Care for the Homeless (Shelter Site) 7. Target Population: Please complete the table below with numbers (not percentages) of individuals served and projected to be served. Program Target Population Demographics Actual 2017-181 Actual 2018-19 Projected 2019-20 Projected 2020-21 Gender Men 3,332 3,479 3,530 3,636 Women 4,717 4,862 4,916 5,063 Nonbinary/Genderqueer 0 0 0 0 Self-Describe: Transgender 0 3 14 16 Total 8,049 8,344 8,460 8,715 Race and Ethnicity Black or African-American 972 1,002 1,043 1,074 American Indian or Alaska Native 0 0 0 0 Asian 845 891 899 926 White 5,730 5,847 5,985 6,165 Native Hawaiian or other Pacific Islander 0 0 0 0 Two or more races 54 58 64 66 Some other race 448 546 469 484 Total 8,049 8,344 8,460 8,715 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 Program information P a g e 1 0 o f 2 2 Of the above, how many Hispanic/Latino 4,517 4,659 4,857 5,003 Of the above, how many non-Hispanic/Latino 3,532 3,685 3,603 3,712 Total 8,049 8,344 8,460 8,715 Age 0-5 years 791 772 915 942 6-18 years 2,027 2,119 2,094 2,157 19-50 years 3,506 3,668 3,690 3,801 51+ years 1,725 1,785 1,761 1,815 Total 8,049 8,344 8,460 8,715 Geographic Location Town of Chapel Hill 3,159 3,257 3,304 3,403 Town of Carrboro 1,190 1,259 1,383 1,424 Orange County ( Outside of Chapel Hill/Carrboro) 661 727 955 984 Outside of Orange County 3,039 3,101 2,818 2,904 Total 8,049 8,344 8,460 8,715 Income Low-income (80% of the Area Median Income and Below) Please see income table in the attachments ***see note*** Est. 7,400 Est. 7,500 Est. 8,000 Est. 8,100 Total 8,049 8,344 8,460 8,715 1) Piedmont Health’s 2018-19 application was written only for the Carrboro Community Health Center, therefore the table above has been modified from projected 2018-19 to actual 2017-18, to give actual patient demographics for all 3 Orange County CHC locations to give reviewers more data about the locations for whom funding is being requested in this application. ***The PHS sliding fee scale is open to all individuals living at or below 200% of poverty, and PHS has income data for those who choose to apply. Importantly many low-income individuals (including those with Medicaid and Medicare) do not typically supply PHS income information because their care at PHS is covered by their insurance. 99% of those who applied for our sliding fee scale in 2018 had documented incomes below 200% of poverty (which is much less than 80% of the median). 8. Cost Per Individual This cost per individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2018 Projected 2019 Projected 2020 Total Cost of Program $6,267,229 $7,437,645 $7,737,616 Total # of Individuals 8,214 8,460 8,715 Cost Per Individual $762.99 $879.11 $887.85 9. Performance Indicators For Chapel Hill and Carrboro applicants: Please complete the following chart with information about the Strategic Objective, Intermediate Result, and the Agency Performance Indicator for each program for which you are applying for funding. Please see the Results Framework in the Attachments section as a reference. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 Program information P a g e 1 1 o f 2 2 Program Name: Community Health Center Program Strategic Objective (please choose one from the Results Framework)  Children improve their educational outcomes  Residents Increase their livelihood security  Residents improve their health outcomes Intermediate Result (please choose one from the Results Framework) Insert Intermediate Result here. 3.1: Residents access basic health care services (primary, behavioral, dental). RESULTS Actual 2018-19 Projected 2019-20 Projected 2020-21 Performance Indicators (Please choose at least one performance indicator to report on from the Results Framework, and add additional performance indicators that you would like to report to the Towns. Please insert additional rows as needed, listing one per row). Insert Performance Indicator here. Preventive Screening #1 (MEDICAL): #/% Women 23-64 who were appropriately screened for cervical cancer (i.e. pap smear). 1,774 (66%) 1,499 (77%) 7/1/19 through 12/31/19 1,850 (70%) Preventive Screening #2 (MEDICAL/BEHAVIORAL)): #/% of individuals 18 years and older who were screened for tobacco use one or more times in the last 24 months, and if identified to be a tobacco user, received cessation counseling intervention. 3,801 (90%) 2,265 (88%) 7/1/19 through 12/31/19 3,800 (90%) Preventive Screening #3 (MEDICAL/BEHAVIORAL): #/% of individuals 12 years or older who were screened for depression using an age appropriate standardized depression screening tool, and if positive, had a follow-up plan documented. 3,411 (66%) 2,453 (63%) 7/1/19 through 12/31/19 3500 (70%) EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 Outside Agencies/Human Services Outside Agencies/Human Services Outside Agencies/Human Services Outside Agencies/Human Services Program information P a g e 1 2 o f 2 2 Please use the drop down menu below to select which function area best aligns with your agency and program(s) in which you are requesting funding. Please select only one from the drop down menu below. Public Health and Health Education If you selected other, please tell us what function area best aligns with your organization: Please indicate three program goals/performance measures below. A few notes: • If you use percentages, please put the actual number equivalence. • Please ensure your performance measures are outcome based and not outputs. Program Goal # 1 Refugee Health Care Performance Measure (How will you accomplish your goal?) PHS Community Health Center Program will be a primary care home for 650 unduplicated refugee patients over the 2020-2021 grant year. Actual Results (Outcome) Ending FY18-19 801 refugees Projected Results (Outcome) Ending FY2020 600 refugees thus far served between 7/1/19 – 12/31/19 (goal of 650) Projected Results (Outcome) Ending FY2021 650 Program Goal # 2 Primary Care for Low-Income, Uninsured Patients Performance Measure (How will you accomplish your goal?) PHS Community Health Center program will be a primary care home for over 3,700 low income uninsured patients in the 2020- 2021 grant period. Actual Results (Outcome) Ending FY18-19 3,691 Primary Care (medical, dental, behavioral) for low-income and other medically vulnerable groups EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 Outside Agencies/Human Services Outside Agencies/Human Services Outside Agencies/Human Services Outside Agencies/Human Services Program information P a g e 1 3 o f 2 2 Projected Results (Outcome) Ending FY2020 2,640 low-income, uninsured patients thus far served between 7/1/19 -12/31/19 (goal of 3,700) Projected Results (Outcome) Ending FY2021 3,700 Program Goal # 3 Health Care for the Homeless Performance Measure (How will you accomplish your goal?) PHS Community Health Center Program will care for 180 people experiencing homelessness during the 2020-2021 grant period. Actual Results (Outcome) Ending FY18-19 176 Projected Results (Outcome) Ending FY2020 130 homeless patients served between 7/1/19 – 12/31/19 (goal of 80) Projected Results (Outcome) Ending FY2021 180 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 Agency Budget Operating Budget for Entire Agency Actual 2018 Estimated 2019 Projected 2020 Percent Change 30,406$ 29,842$ -$ -100% 47,447,146$ 49,419,298$ 61,577,549$ 25% 9,000$ 8,100$ 9,000$ 11% -$ -$ 0 6,160$ 2,000$ 2,000$ 0% -$ -$ 0 16,500$ 16,500$ 16,500$ 0% -$ -$ ` -$ -$ 0 -$ -$ 0 417,103.00$ 507,885.00$ 567,000.00$ 12% 9,121,885.00$ 10,173,060.00$ 10,039,403.00$ -1% Private Foundation Grants 977,155.00$ 836,347.00$ 1,155,800.00$ 38% 523,907$ 649,742$ 273,459$ (0.58)$ 58,549,262$ 61,642,774$ 73,640,711$ 19% 33,024,910$ 39,722,372$ 43,707,599$ 10% 1,166,373$ 988,405$ 1,695,710$ 72% 4,859,212$ 4,554,364$ 4,596,658$ 1% 515,654$ 608,930$ 493,893$ -19% 17,600,053$ 19,747,052$ 23,146,851$ 17% 57,166,202$ 65,621,123$ 73,640,711$ 12% 1,383,060$ (3,978,349)$ -$ 100% AGENCY EXPENSES AGENCY REVENUE Private Donations Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Piedmont Health Services, Inc. Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other Expenses: Total Agency Expenses Supplies & Equipment Travel & Training SURPLUS/(DEFICIT) FOR PERIOD: Other Government Grants Triangle United Way State Government Federal Government (CDBG/HOME/etc.) Compensation Rent & Utilities Total Agency Revenue Agency Generated Revenue (fees) AGENCY NAME: Other Revenue FY 2020-21Budget Worksheets EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 Program Budget Operating Budget for Program Actual 2018 Estimated 2019 Projected 2020 Percent Change 2,944$ -$ -$ 0 5,017,043$ 5,090,673$ 6,619,255$ 30% 9,000$ 8,100$ 9,000$ 11% -$ -$ -$ 0 6,160$ 2,000$ 2,000$ 0% -$ -$ -$ 0 16,500$ 16,500$ 16,500$ 0% -$ -$ -$ 0 -$ -$ -$ 0 -$ -$ -$ 0 242,811$ 75,708$ -$ (1.00)$ 872,619$ 773,563$ 1,125,048$ 0.45$ Private Foundation Grants 154,698$ 148,162$ 53,820$ (0.64)$ 38,930$ 247,964$ 81,320$ (0.67)$ 6,360,705$ 6,362,670$ 7,906,943$ 24% 3,679,996$ 3,817,176$ 5,561,178$ 46% 154,154$ 92,547$ 365,926$ 295% 734,742$ 893,621$ 718,883$ -20% 48,378$ 57,188$ 59,945$ 5% 1,649,959$ 2,816,742$ 1,031,684$ -63% 6,267,229$ 7,677,274$ 7,737,616$ 1% 93,476$ (1,314,604)$ 169,327$ 113%SURPLUS/(DEFICIT) FOR PERIOD: Total Program Expenses Travel & Training Other Expenses: Federal Government (CDBG/HOME/etc.) Supplies & Equipment Other Revenue Total Program Revenue PROGRAM EXPENSES Compensation Rent & Utilities Other Government Grants Triangle United Way State Government Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Private Donations Program Generated Revenue Local Government Grants: Human Services - Town of Carrboro PROGRAM REVENUE PROGRAM NAME:PHS Community Health Center Program FY 2020-21Budget Worksheets EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 Certified by:________________________ Title: ____________________ Date: ____________ (Provider’s Electronic Signature) **You will sign this document electronically with your performance agreement. EXHIBIT “B” Scope of Services – FY 2020-21 Outside Agency Performance Agreement Agency Name: Program Name: Funding Award: Outline how the agency will spend Orange County’s funding award. Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2021. x x x Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure’s description or for an earlier performance measure. Performance Measures Anticipated Results Expense Description Amount Primary medical care for low-income, uninsured patients at PHS's three Orange County health centers $5,500 Interpretation costs for services to large immigrant and refugee populations $5,500 Primary medical care for patients experiencing homelessness at PHS IFC Community Health Center $5,500 PHS Community Health Center program will be a primary care home for over 3,700 low-income, uninsured patients in the 2020-2021 grant period. 3,700 PHS Community Health Center program will be a primary care home for 650 unduplicated refugee patients over the 2020-2021 grant period. 650 PHS Community Health Center program will care for 180 people experiencing homelessness during the 2020-2021 grant period. 180 Piedmont Health Services Inc. PHS Community Health Centers $16,500 primary medical care for low-income, uninsured patients primary medical care for immigrant and refugee popluations primary medical care for people experiencing homelessness DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 CEO 6/28/2021 Orange County Outside Agency Performance Agreement Page 9 of 9 Rev. 1/21 ATTACHMENT “A” Orange County Certifications – FY 2020-21 Outside Agency Performance Agreement Chief Contact, Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title, residential address; phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing, with the name, physical address, mailing address and if possible, phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not, please explain on a separate sheet of paper. Alignment with Organization’s Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. Certified by: _______________________ Title: __________________________ Date: ___________ (Provider’s Signature) DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 6/28/2021CEO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 8/31/2020 Marsh &McLennan Agency LLC 5605 Carnegie Blvd. Suite 300 Charlotte NC 28209 Christina Luckey,CISR,CLCS 704-556-3329 christina.luckey@marshmma.com AIX Specialty Insurance Company 12833 PIEDMHEAL9 Allmerica Finanical Benefit Insurance 41840PiedmontHealthServicesInc. 127 Kingston Drive Chapel Hill NC 27516 StarNet Insurance Company 40045 1056402395 A X 1,000,000 X 100,000 X 1,000 5,000 1,000,000 3,000,000 X L16A73441104 10/11/2019 10/11/2020 3,000,000 B 1,000,000 X AW6A53452804 10/11/2019 10/11/2020 A X X 5,000,000L16A7344120410/11/2019 10/11/2020 5,000,000 X 0 C XKEY01362922/1/2020 2/1/2021 1,000,000 1,000,000 1,000,000 A PL/AM/EBL L16A73441104 10/11/2019 10/11/2020 LIMIT/DED *SEE BELOW *PROFESSIONAL LIABILITY--- LIMIT $1,000,000 AGGREGATE $3,000,000 DED $1,000 ABUSE OR MOLESTATION--- LIMIT $1,000,000 AGGREGATE $3,000,000 See Attached... Orange County Government Attn:Risk Manager 200 S Cameron Street P O Box 8181 Hillsborough NC 27278 DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0 ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: PIEDMHEAL9 1 1 Marsh &McLennan Agency LLC Piedmont Health Services Inc. 127 Kingston Drive Chapel Hill NC 27516 25 CERTIFICATE OF LIABILITY INSURANCE Orange County,NC,as Designated Organization,is an Additional Insured as respects General &Auto Liability when required by written contract subject to the terms,conditions and exclusions of the policy. DocuSign Envelope ID: EEE4BE29-5C31-4220-A7C0-E3D3B4C537B0