Loading...
HomeMy WebLinkAbout2023-415-E-Health Dept-Ashley Brewer-Reimbursement for WIC Hemoglobin Testing and use of facilitiesPHS/OCHD Memo of Agreement Revised 06/23 Memorandum of Agreement Between Piedmont Health Services, Inc. WIC Program and Orange County Health Department For WIC Program Services This Memorandum of Agreement made and entered into the 1st day of July 2023 by and between the Orange County Health Department (“OCHD”) and Piedmont Health Services WIC Program (“PHS”). WITNESSETH: WHEREAS, both PHS and OCHD deem it to be of mutual interest to their patients/clients and their respective organizations to enter into this agreement for certification of WIC clients at OCHD; and WHEREAS, both parties desire to reduce the terms of this agreement to writing; NOW THEREFORE, and in consideration of the mutual promises to the other as hereinafter set forth, the parties hereby mutually agree as follows: A. PHS agrees to perform in a manner satisfactory to OCHD the following responsibilities: 1. Provide WIC services to Maternal and Child Health clinic clients at OCHD in Hillsborough following the policies, procedures and flow of patients as established by OCHD. Services will include height and weight assessment, nutrition assessment and education, WIC certification, food vouchers issuance, child immunization assessment, and appropriate patient referrals in accordance with state WIC policies. 2. Provide the necessary supervision, training and policy guidance to carry out the tasks identified above in consultation with the designated OCHD liaison. 3. Provide personnel for coverage during vacations and other approved leave except PHS scheduled holidays and unavoidable emergencies. Inform the OCHD liaison when WIC staff will be absent so that OCHD clinic staff can be notified. 4. Schedule meetings as needed with the OCHD liaison and WIC Director to discuss problems, procedures, changes in policy and to establish and review objectives. 5. Reimburse OCHD, on a quarterly basis, Eleven dollars ($11) per client for each client that is not an OCHD patient, for testing of hemoglobin on WIC clients. This fee is the fee charged to non-insured patients according to OCHD’s fee schedule. DocuSign Envelope ID: 08925F64-88E8-4AA4-9586-9F43CE43874B PHS/OCHD Memo of Agreement Revised 06/23 6. Piedmont Health Services will provide their own interpreter services for clients receiving WIC services, including laboratory services at the OCHD location in accordance with Title VI and Title II requirements. B. OCHD agrees to perform in a manner satisfactory to PHS the following responsibilities: 1. Provide reasonable working space and equipment necessary for carrying out WIC responsibilities in the Hillsborough office. 2. Provide reasonable working space in the Chapel Hill office for WIC staff to meet with clients referred by Orange County Health Department. 3. Provide access to Medical Records for the purpose of gathering medical information and for project evaluation. 4. Through its liaison, OCHD shall be responsible for the following: a. Meet, as needed, with the PHS WIC Director to discuss problems, procedures, changes in policy and to establish and review objectives. b. Inform WIC staff of OCHD holidays, closings, clinic changes, and staff absences, which may affect the delivery of WIC services. 5. Perform hemoglobin testing for all WIC clients served at the Hillsborough OCHD site and submit invoices on a quarterly basis to Piedmont Health Services, Inc. for non-OCHD clients. C. Term. This agreement is for the performance of services rendered during the period beginning July 1, 2023 and ending June 30, 2024. D. Termination. Either party may terminate this agreement by giving 90 days written notice to the other party. E. Non-Appropriation. It is understood and agreed between PHS and OCHD that continuation or any renewal or extension thereof, is dependent upon and subject to the allocation or appropriation of funds to PHS and/or to OCHD for the purposes set forth in this agreement. It is also understood and agreed that either party shall involve the other in significant scheduling or program changes, which may affect services. F. Access to Records. OCHD agrees that the State of North Carolina, United States Department of Agriculture, the Controller General of the United States, or any of their duly authorized representatives, shall have access to any books, documents, papers and records of OCHD which are directly pertinent to this specific agreement, for the purposes of audit, making excerpts and transcriptions. G. Governing Law and Priority. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. Provider shall at all times remain in compliance with all applicable local, DocuSign Envelope ID: 08925F64-88E8-4AA4-9586-9F43CE43874B PHS/OCHD Memo of Agreement Revised 06/23 state, and federal laws, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php). Any violation of this requirement is a breach of this Agreement and County may immediately terminate this Agreement without further obligation on the part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.81. In determining the basic services to be provided, should any documents be referenced in or attached to this Agreement, the terms herein shall have priority in any conflict between the terms of referenced documents and the terms of this Agreement. H. Confidentiality of Patient Records. All parties agree to abide by all laws and regulations governing the confidentiality of patient information, including HIPAA privacy rules and further agree to vigorously safeguard privileged information. I. Non-discrimination. All activities under this contract will be conducted in accordance with Title VI of the Civil Rights Act of 1964 (42 U.S.C.2000d et seq.), Title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C.794), Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.); Title II and Title III of the Americans with Disabilities Act (ADA) of 1990 as amended by the ADA Amendment Act of 2008 (42 U.S.C. 12131-12189) as implemented by Department of Justice regulations at (28 CFR Parts 35 and 36); Executive Order 13166, "Improving Access to Services for Persons with Limited English Proficiency." (August 11, 2000), all provisions required by the implementing regulations of the U.S. Department of Agriculture (7 CFR Part 15 et seq); and FNS directives and guidelines to the effect that no person shall, on the ground of race, color, national origin, age, sex (including gender identity and sexual orientation), or disability, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity for which Federal financial assistance is received for the administration of the WIC Program; and hereby gives assurances that it will immediately take measures necessary to effectuate this agreement. By providing this assurance, the contractor agrees to compile data, maintain records and submit records and reports as requested by the Community Nutrition Services Section to permit effective enforcement of the nondiscrimination laws, and to permit the Community Nutrition Services Section personnel during normal working hours to review and copy such records, books and accounts, access such facilities, and interview such personnel as needed to ascertain compliance with the non-discrimination laws. If there are any violations of this assurance, the Community Nutrition Services Section shall have the right to seek judicial enforcement of this assurance. This assurance is given in consideration of and for the purpose of obtaining any and all Federal financial assistance, grants, and loans of Federal funds, reimbursable expenditures, grant, or donation of Federal DocuSign Envelope ID: 08925F64-88E8-4AA4-9586-9F43CE43874B PHS/OCHD Memo of Agreement Revised 06/23 property and interest in property, the detail of Federal personnel, the sale and lease of, and the permission to use Federal property or interest in such property or the furnishing of services without consideration, or at a consideration that is reduced for the purpose of assisting the recipient, or any improvements made with Federal financial assistance extended to the Program applicant by USDA. This includes any Federal agreement, arrangement, or other contract that has as one of its purposes the provision of cash assistance for the purchase of food, and cash assistance for the purchase or rental of food service equipment or any other financial assistance extended in reliance on the representations and agreement made in this assurance. J. Renewal of Agreement. This agreement may be renewed upon the mutual agreement of both parties. Any renewal shall be negotiated 30 days prior to the beginning date of the new contract period. K. Amendment. This agreement may be amended upon the mutual agreement of the parties. All amendments shall be in writing and signed by both parties to the agreement. k. Notices. Any notice required by this Agreement shall be in writing and delivered by certified or registered mail, return receipt requested to the following: Orange County Health Department Piedmont Health Services, Inc. Attention: Accounts Payable Attention: Brian Toomey 300 West Tryon Street 88 Villcom Cntr. Dr., Ste 110 Hillsborough, NC 27278 Chapel Hill NC, 27514 l. 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 Parties, by and through their authorized agents, have hereunder set their hands and seal, all as of the day and year first above written. _______________________________________ ____________ Brian Toomey, Executive Director Date Piedmont Health Services, Inc. ______________________________________ ____________ Bonnie Hammersley, County Manager Date Orange County DocuSign Envelope ID: 08925F64-88E8-4AA4-9586-9F43CE43874B 8/7/2023 8/14/2023 PHS/OCHD Memo of Agreement Revised 06/23 ORANGE COUNTY—INTERNAL USE ONLY ______________________________________________________________________________ Finance Information Vendor Name: Ashley Brewer Vendor Contact Person: Ashley Brewer Phone: 336-382-0242 Address: 88 Villcom Center Drive Ste. 110 City Chapel Hill State: NC Zip: 27514 Department: Health Amount: $3,000 Purpose: Reimbursement for WIC Hemoglobin Testing and use of facilities Budget Code(s): 10414001-476020- 71403 - This is a contract for Piedmont to pay us. Vendor # 27898 Vendor Status with NCSOS: Current-Active Vendor is a BOCC consultant: Yes No Contract Details Contract Type: New Amendment (Original Contract: ) (Most Recent Amendment ) Effective Date 7-1-23 End Date 6-30-23 Notice Date (Notice Purpose ) Award Approved by Board (Agenda Date: 6-20-23); Made or Administered by Signature Authority - BOCC Express Delegation (Agenda Date: ) - Policy 9.4: Under $5,000; Service Under $90,000; Construction Under $250,000 - Budget Policy Section XV (Capital Improvement Project: ) Bidding Informal Bidding ($30k-$90k); Formal RFP ($90k+); Other (<$30k); Exception(# ) Department Affirmation 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. Services related to this agreement have already begun or been completed. Description of the nature of the emergency condition that was addressed: Department Director’s Signature ________________________________________ Date: ________ Information Technologies This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer___________________________________ Date: ________ Inapplicable because no hardware/software purchases or related services 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 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: DocuSign Envelope ID: 08925F64-88E8-4AA4-9586-9F43CE43874B 8/7/2023 8/9/2023 8/9/2023 8/14/2023 PHS/OCHD Memo of Agreement Revised 06/23 Received for record retention: Office of the Clerk to the Board __________________________________________Date:_________ DocuSign Envelope ID: 08925F64-88E8-4AA4-9586-9F43CE43874B 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 1/26/2023 Marsh &McLennan Agency LLC 5605 Carnegie Blvd. Suite 300 Charlotte NC 28209 Erica Stowe,CIC,CISR 704-556-3326 212-948-9443 erica.stowe@marshmma.com Allmerica Finanical Benefit Insurance 41840 PIEDMHEALT7 StarNet Insurance Company 40045PiedmontHealthServicesInc. 88 Vilcom Center Dr,Suite 110 Chapel Hill NC 27514 The Hanover Atlantic Insurance Co Ltd 55555 953189019 C X 1,000,000 X 100,000 X 1,000 5,000 1,000,000 3,000,000 L36A73441108 2/1/2023 2/1/2024 3,000,000 A 1,000,000 X AW6A53452809 2/1/2023 2/1/2024 C 5,000,000 X L36A73441208 2/1/2023 2/1/2024 5,000,000 B KEY0136292 2/1/2023 2/1/2024 1,000,000 1,000,000 1,000,000 C PL/AM/EBL L36A73441208 2/1/2023 2/1/2024 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 Health Dept 300 W Tryon St Hillsborough NC 27278 DocuSign Envelope ID: 08925F64-88E8-4AA4-9586-9F43CE43874B 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: PIEDMHEALT7 1 1 Marsh &McLennan Agency LLC Piedmont Health Services Inc. 88 Vilcom Center Dr,Suite 110 Chapel Hill NC 27514 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: 08925F64-88E8-4AA4-9586-9F43CE43874B