Appendix E

JOSEPHINE COUNTY PROVIDER AGREEMENT

Addiction Services

THIS AGREEMENT is hereby established by and between JOSEPHINE COUNTY (hereinafter "County"), and ______(hereinafter referred to as "Provider").

WHEREAS, the State of Oregon Department of Human Services has entered into an Intergovernmental Agreement for the Financing of Community Mental Health, Developmental Disability and Addiction Services, by Agreement Number ______, dated July 1, 2011, (hereinafter referred to "IGA") to assist counties in the establishment and financing of community mental health, developmental disabilities and addiction programs.

WHEREAS, IGA Number ______allows the County to purchase services from a third person or entity; and

WHEREAS, County desires to enter into an agreement with Provider for provision of services in accordance with the terms and conditions of IGA Number ______; and

WHEREAS, Provider is willing, able, and qualified to perform and provide such services;

NOW, THEREFORE, in consideration of the terms and conditions contained herein, it is mutually agreed as follows:

1. TERM: This Agreement shall commence on ______and shall continue until ______unless terminated or amended as provided herein.

2. COMPLIANCE WITH IGA: Provider shall comply with all applicable provisions of that certain 2009-2011 IGA Number ______for the financing of Community Mental Health, Developmental Disability and Addiction Services (the "Intergovernmental Agreement") dated July 1, 2009 between the State of Oregon acting by and through its Department of Human Services ("DHS") and Josephine County ("County").

3. DEFINITIONS: As used in this Agreement, the following words and phrases shall mean as follows:

3.1 "Clients" means those individuals receiving Services with funds provided under this Agreement.

3.2 ""County" means Josephine County, its officers, agents, and employees.

3.3 "CPMS or Client Process Monitoring System" means DHS information system that tracks and documents service delivery or any successor system designated by DHS.

3.4 "Services" means those services to be performed by Provider as described in Exhibits “A”, "B” and “C” attached hereto and incorporated herein.

3.5 "DHS" means the Department of Human Services of the State of Oregon.

3.6 "Intergovernmental Agreement" or “IGA” means that certain contract Number ______by and between the state Department of Human Services and Josephine County for financial assistance for the operation of community mental health, developmental disabilities, and addiction services dated July 1, 2011.

3.7 "OAR" means the Oregon Administrative Rules as amended, which may be found on the Internet at http://arcweb.sos.state.or.us/banners/rules.htm.

3.8 "Provider" means ______its officers, agents, and employees.

4. SERVICES: Provider shall perform or cause to be performed the necessary Services for eligible Clients as described in the Service Description attached hereto as Exhibits “A”, "B" and “C” and incorporated herein.

4.1 Provider shall work cooperatively with County to coordinate services, and to integrate its services with other services so as to avoid duplication. Provider shall develop a systematic process for monitoring, evaluating, and improving the quality and application of services provided.

4.2 Criminal Background Checks: Provider shall perform criminal background checks of all employees who will render services under this Agreement, and shall retain information on the results of such background checks in accordance with the Records Retention provisions of this Agreement.

4.3 Licenses: Provider and its agents and employees performing Services under this Agreement shall hold all licenses, certificates, authorizations, and other approvals required by applicable law to deliver Services, and shall maintain such licenses and certificates in good standing for the duration of this Agreement. Provider shall provide County with copies of licenses and certificates upon the commencement of this Agreement.

4.5 Provider shall only conduct transactions that are authorized by the County for transactions with DHS that involve County funds directly related to this Agreement.

5. REPORTING REQUIREMENTS: Provider shall prepare and furnish the following information to County and DHS when a Service is delivered under this Agreement.

5.1 Client, service, and financial information as specified in the applicable Service Description attached hereto and incorporated herein by this reference.

5.2 All additional information and reports that County or DHS reasonable requests.

6. MONITORING: County shall monitor Provider's delivery of Services and promptly report to DHS when County identifies a major deficiency in a Provider's delivery of a Service or in Provider's compliance with this Agreement. County shall promptly take all necessary action to remedy any identified deficiency. County shall also monitor the fiscal performance of each Provider and shall take all lawful management and legal action necessary to pursue this responsibility. In the event of a major deficiency in a Provider's delivery of Services or in a Provider's compliance with this Agreement, nothing in this Agreement shall limit or quality any right or authority of DHS under state or federal law to take action directly against Provider.

6.1 Monitoring Procedures: Provider shall permit authorized DHS agents and employees to monitor the provision of Services under this Agreement. Monitoring procedures include, but are not limited to the following:

A. Entry and inspection of any facility used in the delivery of Services on a fee-for-service basis;

B. A request for submission to DHS of a copy of any document or record required by this Agreement or by any application administrative rule or regulation this is needed to verify compliance with this Agreement, rule or regulation, or access to such documents for on site review;

C. The completion by Provider of a self-assessment checklist reporting compliance or noncompliance with specific Agreement rule, or regulation requirements; and

D. Interviews with, and administration of questionnaires to persons with knowledge of Service operations.

6.2 Year End Audit: Provider shall conduct a formal year-end audit of all accounts related to this Agreement at the Provider's expense, and shall submit a copy of that audit to County.

7. RECORDS MAINTENANCE, ACCESS, AND CONFIDENTIALITY:

7.1 Access to Records and Facilities: The County, DHS, the Secretary of State's Office of the State of Oregon, the Federal Government, and their duly authorized representatives shall have access to the books, documents, papers and records of Provider that are directly related to this Agreement, the funds paid to Provider hereunder, or any Services delivered hereunder for the purpose of making audits, examinations, excerpts, copies and transcriptions. Provider shall permit authorized representatives of County and DHS to perform site reviews of all Services delivered by Provider pursuant to this Agreement.

7.2 Retention of Records: Provider shall retain and keep accessible all books, documents, papers, and records that are directly related to this Agreement, the funds paid to Provider, or any Service delivered under this Agreement for a minimum of three (3) years or such longer period as may be required by other provisions of this Agreement or applicable law following the termination of this Agreement. If there are unresolved audit or other questions at the end of the three-year period, Provider shall retain the records until the questions are resolved.

7.3 Expenditure Records: Provider shall document the expenditure of all funds paid to Provider under this Agreement. Unless applicable federal law requires Provider to use a different accounting system, Provider shall create and maintain all expenditure records in accordance with generally accepted accounting principles and in sufficient detail to permit County and DHS to verify how the funds paid to Provider under this Agreement were expended.

7.4 Client Records: Unless otherwise specified in this Agreement, Provider shall create and maintain a record for each client who receives Services under this Agreement.

A. Contents: The Client record must contain:

1. Client identification;

2. Problem assessment;

3. Treatment, training, and/or care plan;

4. Medical information when appropriate, and

5. Progress notes, including service termination summary and current assessment, or evaluation instrument as designated by DHS in OAR.

B. Retention: Provider shall retain Client records in accordance with OAR 166-005-0000 through 166-40-1050 (State Archives). Unless OAR 166-005-0000 through 166-40-1050 requires a longer retention period, Provider shall retain Client records for a minimum of seven (7) years from termination of this Agreement.

7.5 Confidentiality: Provider shall maintain the confidentiality of Client records as required by applicable state and federal law, including but not limited to: ORS 179.495 to 179.507, 45 CFR Part 205, 42 CFR Part 2, any administrative rule adopted by DHS implementing the foregoing laws, and any written policies and procedures made available to Provider by County or DHS. Provider shall create and maintain written policies and procedures related to the disclosure of client information, and shall make such policies and procedures available to County and DHS for review and inspection as reasonably requested by County or DHS.

A. HIPAA: Provider shall ensure that Client's privacy is protected and that confidential records are secure from unauthorized disclosure consistent with the confidentiality requirements of 45 CFR parts 160 and 164, and consistent with other state or federal regulations governing privacy and confidentiality of mental health records.

B. eXPRS: Provider is responsible for protecting the confidentiality of and regulating the use of eXPRS user ids and passwords furnished to or created by Provider’s authorized officials. Provider shall keep all eXPRS user ids and passwords secure by taking security measures to prevent unauthorized access to, or disclosure, loss, compromise, or use of, the eXPRS user ids and passwords. The security measures must be equivalent to or stricter than the security measures adopted by DHS in Policy Number AS-090-002, version 1.0, effective November 1, 2003.

7.6 CPMS Enrollment: As specified in DHS’s Client Process Monitoring System (“CPMS”) manual (for Alcohol, Drug Abuse and Addiction Services, Developmental Disability Services or Mental Health Services, as appropriate), Provider shall enroll in CPMS each Client receiving services under this Agreement and maintain that Client's CPMS record as required by the CPMS manual.

7.7 Alternative Formats of Written Materials: In connection with the delivery of services, Provider shall:

A. Make available to a Client, without charge to the Client, upon the Client’s, the County’s or DHS’s request, any and all written materials in alternate, if appropriate, formats as required by Oregon Department of Human Services administrative rules or by Oregon Department of Human Services written policies made available to Provider.

B. Make available to a Client, without charge to the Client, upon the Client’s, County’s or DHS’s request, any and all written materials in the prevalent non-English languages in the area served by Provider.

C. Make available to a Client, without charge to the Client, upon the Client’s, County’s or DHS’s request, oral interpretation services in all non-English languages in the area served by Provider.

D. Make available to a Client with hearing impairments, without charge to the Client, upon the Client’s, County’s or DHS’s request, sign language interpretation services and telephone communications access services.

For purposes of the foregoing, “written materials” includes, without limitation, all work product and contracts related to this Contract.

8. INDEPENDENT CONTRACTOR: Unless Provider is a State of Oregon governmental agency, Provider agrees that it is an independent contractor and not an agent of the State of Oregon, the Oregon Department of Human Services or County. Provider shall be responsible for payment of all Social Security, and Federal and State taxes on any wages paid to Provider’s employees.

9. PAYMENT:

9.1 County shall pay Provider the amount listed in Exhibit "A" through monthly allotments upon receipt of funds by County from DHS. Payment to Provider will be mailed no more than 10 working days after County's receipt of funds from DHS. Adjustments may be made after receipt of Final Provider Financial Statements from DHS as necessary.

9.2 Payments shall be made according to the Financial Procedures Manual of DHS. County may suspend or withhold payments if Provider fails to comply with requirements of this Agreement. Payments to Provider pursuant to this Agreement shall be only for Services provided in accordance with the provisions of the Services Description and the IGA.

9.3 Notwithstanding any other payment provision of this Agreement, the failure of Provider to submit required reports when due, or to perform or document the performance of contracted Services, may result in the withholding of payments by County. County shall notify DHS when such payments are withheld.

9.4 Limitations: County shall not be liable for any expenditure without statutory appropriations pursuant to ORS 294.305 et seq. (Local Budget Law). County shall not be indebted or liable for any obligation created by this Agreement in violation of the debt limitation of Article XI, Section 10 of the Oregon Constitution.

10. EXPENDITURE OF FUNDS: Provider may expend the funds paid to Provider under this Agreement solely on the delivery of Services described in Exhibits “A”, "B” and “C”, subject to the following limitations (in addition to any other restrictions or limitations imposed by this Agreement):

10.1 Provider may not expend on the delivery of Services any funds paid to Provider under this Agreement in excess of the amount reasonable and necessary to provide quality delivery of Services described in Exhibits “A”, "B" and “C”.

10.2 If the Agreement requires Provider to deliver more than one service, Provider may not expend funds paid to Provider under this Agreement for a particular Service on the delivery of any other Service.

10.3 If this Agreement requires Provider to deliver alcohol, drug abuse and addiction services, Provider may not use the funds paid to Provider under this Agreement for such services as:

A. To provide inpatient hospital services;

B. To make cash payments to intended recipients of health services;

C. To purchase or improve land, to purchase, construct, or permanently improve (other than minor remodeling) any building or other facility or to purchase major medical equipment;

D. To satisfy any requirement for expenditure of non-federal funds as a condition for receipt of federal funds (whether the federal funds are received under this Agreement or otherwise);

E. With respect to federal Substance Abuse Prevention and Treatment Block Grant moneys only, to purchase Services from any person or entity other than a public or non-profit entity; or

F. To carry out any program prohibited by Section 245(b) of the Health Omnibus Programs Extension Act of 1988 (codified at 42 USC 300ee(5)).

10.4 Provider shall make expenditures under this Agreement only in accordance with OMB Circular A-87, as that circular is applicable on allowable costs.