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Amerihealth Caritas Iowa, Inc.-12/7/2015
AMERIIIEALTII CARITAS IOWA, INC. ANCILLARY SERWCES AGREEMENT with [PROVIDER NAME] ftterc)o jf\bacoa flt AMERILIEALTIJ CARITAS JOWA, INC. ANCIIJLARY SERVICES AGREEMENT This Provider Services Agreement (the "Agreement"), dated as ofthe Effective Date (defined below), is made by and between Amerillealth Caritas Iowa, Inc., a corporation organized under the laws ofthe State oflowa, (hereinafler referred to as "ACIA") and the provider ("Provider") identifled on the signature page. WIIEREAS, ACIA is a managed eare organization that is responsible for providing or arranging for the provision of health care services to its Members; and WIIEREAS, rovider is duly licensed to fiirnish certain health care services; and WIIEREAS, Provider thd ACIA mutually desire to enter into this Agreement, whereby Provider shall render services to Mernbers enrolled vith ACM. and be compensated by ACM. in aeeordance with the terms and conditions hereof. NOW, THFREFORE, in d�psideration of the mutual promises made herein, it is mutually agreed by and between ACIA and Provider as foliows: 1. DEFJNITIIONS As used in this Agreement, eaeh pf the foliowing terms shall have the meaning specified herein, unless the context elearly requires otherwise. • 1.1 AFIIIJJATES. An. Affiiiateis any corporation or other organization that is identified as an Affihiate in a titten notice toProvider and is owned or controlled, either direetly or through parent or subsidiary �orothtibns, by or under common eontrol with, ACIA. ACIA shall give Provider thirty (30) days advance written notice of the addition of Afflliates added under this proviion. Uthess �therwie speeified in this Agreement or any other attachment hereto, references lo "ACM." shall inelude the Afflhiates refereneed in Appendix 11. 1.2 AGENCY. The State andk* Federal governmental agency that administers the Program(s) under whieh ACIA iS obligated to provide or arrange for the provision of Covered Services. 1.3 AGENCY CONTRACT; Th e�ntract or contraets between ACM. and the Ageney, as in eff'ect from time to time, pursuant to which ACIA is responsible for coordinating health eare serviees and supplies for Program recipients enrolled with ACIA. 1.4 CLEAN CLAIIVI. A claim for payment for a health care service, which has been received by ACIA, has no defect or impropriety. A defeet or impropriety shall inelude a lack ofrequired substantiating documentation or a particular circumstance requiring special treatment that prevents timely payment from being made on the claim. Consistent with 42 CFR §447.45(b), the term shall not inelude a claim from a health care provider who is under investigation for fraud or abuse regarding that claim, or a claim under review for medical necessity. 1.5 COVERED SERYICES. Those Medically Necessaiy health care services and supplies to which Members are entitled pursuant to the Agency Contract, and which shall be provided to Members by 1 AGIA Ancilkay FroviderAgreenient 8/24/15 Provider, as described more specifically in Appendix A. Covered Services shall be furnished in the arnount, duration and scope required under the Program. 1.6 EFFECT1VE DATE. The later of (1) the effective date on the signature page of this Agreement or (ii) the effective date of the Agency Contract, provided that Provider has been successftilly eredentialed by ACJA, as applicable, and that all required regulatory approvals have been obtained byACIA. 1.7 EMIERGENCY MEDICAL CONDITION. Health eare serviees provided to a Member after the sudden onset of a medical condition that manifests itself by acute symptoms of sufflcient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expeet the absenee of iminediate medical attention to result in: (a) P1acingihe health of th Member (or with respeet to a pregnant woman, the health of the Member or her unborn child) in serious jeopardy; (b) Serious impairment to bodily functions; or (c) Serious dysfunetion of any bodily organ or part. 1.8 EMERGENCY SERVICES. Covered inpatient and outpatient services that are fiimished by a • provider that is qualified to fiirnish these services under 42 C.F.R. Section 438.1 14(a) and 42 IJ.S.C. Secti�n 1 932(b)(2)and that afe needed to screen, evaluate, and stabiize an Emergency Medical Condition. 1.9 MEDICALLY NECESSARY. Those Covered Services that are, under the terms and conditions ofthe Ageney Contraqt, deterind through ACIA utilization management to be: (1) appropriate and rthcess.aiy for the sympt�ms, diagnosis or treatment of the condition of the Member; (2) provided for the diagnosis or direct care and treatment of the condition of Member enabling the Member to make reasonable progress in treatment; (3) within standards ofprofessional praetice and given at the appropriate time and in the appropriate setting; (4) not primarily for the convenience of the Member, the Member's physician or other provider; and (5) the most appropriate level of Covered Services which can safely be provided. (Ref. Ageney Contract - Scope of Work document) .1.10 MEMBER. An individual who is eligible for the Program and who has enrolled in ACJA under the Program. 1.11 MEMBER APPEAL PROCEDUIRIES. The written procedures deseribing ACIA's standards for thg prompt resolution ofMember problems, grievances and appeals, as described in the Provider Manual. 1.12 PARTICIPATING PROY]IDER. A duly licensed or certified, as applicable, health care provider that has entered into an agreement with ACJA to provide health care services to Members. 1.13 PROGRAM. The Iowa High Quality Health Initiative proeured by the Iowa Department of Human Services ("IDHS") under RFP #MED -16-009, for the delivery of high quality healthcare services for the Iowa Medicaid, Iowa Health and Wellness Plan and Healthy and Well Kids in Iowa (hawk -i) programs. 2 AGIA Ancillwy Provider Agreernent 8/24/15 1.14 1'ROYIDER MANUAL. The ACIA manual of standards, policies, procedures and corrective actions together with amendments or modifieations ACJA may adopt from time to tinie. The Provider Manual is herein ineorporated by reference and made part of this Agreement. The Provider M anual may be amended or modified by ACIA. from tirne to time in accordanee with &ti�n 3. herein below. 1.15 QUALITY MANAGEMENT PROGRAM. An ongoing review proeess and plan which functions to defme, monitor, review, and recommend corrective action for managing and irnproving the quality of health care services to Members. 1.16 UTILIZATION MANAGEMENT FROGRAM. A process of review of the medieal necessity, appropriateness and efficiency of health care services, procedures, equipment, supplies, and facilities rendered to Members. 2. OBLIGATIONS OF PROVIDER: 2.1 Throughout the term of this Agre�ment, Provider shall have and maintain, without restriction, all 1icenses certificates, registrations and permits as are required under applicable State and federal statutes and regulations to provide .the Covered Services furnished by Provider and/or other related activities delegatedby ACIA under this Agreement. Provider shall obtain a unique identifler (national provideridentifier) in accordance with the system established under Section 1 173(b) of the SociaLSecurity Act, submit such identifier number to ACJA, and include such identifier on all :claims. At all times duringihethrrn of this Agreement, Provider shall be eligible for participation in the Iowa Medicaid program; and, if required by the Iowa Medicaid program as a condition of fiirnishing services to Iowa Medkaid recipients, Provider shall participate in the Iovra Medicaid prograrn. To the extent that C�Vered Services are furnished to Medicare beneficiaries uncler this Agreement, Provider shall algo paiticipate in the Medicare program. Provider shall ensure that all services provided puruant to This Agreement are within the lProvider' s scope of professional responsibility. 2.2 Provider shall provide to Members the Covered Services described in Appendix A hereto; provided, however, that Provider shall only be obligated to provide Covered Services to a Member in accordance with ACIA's pre -authorization and other Utiization Management Program policies as described in the Provider Manual, other than Emergency Services, which will be provided as needed. In providing Coverd Services, Provider agrees to abide by the relevant standards, policies and procedures of ACIA, including, but not Iimited to adniinistrative, credentialing, quality management, utilization management, and Member Appeal Procedures set forth in the Provider Manual and other ACJA notices. Provider shall provide Covered Services in the same manner and with the same availability as services provided to other patients without regard to reimbursernent and shall ftirther provide these services in the most cost effective setting in accordanee with appropriate quality of care and performance standards which are professionally recognized as industry standards andlor otherwise adopted, accepted or established byACJA. 2.3 Provider shall provide ACIA with complete and accurate statements of all Covered Services provided to Members in confoimanee with ACIA billing proeedures as set forth in the applicable Program manuals, the Provider Manual and other written ACIA billing guidelines. ACM. will not be liable for any bilis relating to services that are submitted the later of: (a) after twelve (12) months from the date the serviees were provided (consistent with 42 CFR §447.45(d)), or (b) after sixty (60) days ofthe date ofthe Explanation ofBenefits from another payor when services are first billed by Provider to another payor. Any appeal or request for adjustment of a payment 3 AGIA Ancilla;y Provider Agree,nent 8/24/15 by Provider must be made in accordance with applicable provisions of the Provider Manual and ACIA policies and procedures and, in any case, must be reeeived by ACIA within sixty (60) days of the original payment or denial. Provider may not bring legal action 011 elaims which have not been appealed through the appeal meehanisins described herein. Eneounter Data and Other Reports. Provider shall deliver all reports and elinical information required to be submitted to ACL& pursuant to this Agreement for reporting purposes, ineluding but not limited to encounter data, Healtheare Effectiveness Data and Information Set (IHEDIS), Agency for Healthcare Research and Quality (ATTRQ), and EPSDT data in a format which will allow ACIA to transmit required data to the Ageney eleetronically and 111 a format identical to or consistent with the foiniat used or otherwise required by ACIA and the Agency. Provider shall subniit this information to ACIA within the time frames set forth in the Provider Manual or as otherwise requfred by the Ageney. Provider shall submit all eneounter data to the sarne standards of completeness and accuracyas required for proper adjudication of fee-for-serviee claims by ACIA. 2.4 Provider may directly hill Members for non -Covered Serviees if the Member is advised in writing before the .service is rendered: (i) the nature of the service(s) to be rendered; (11) that ACIA does not cover thesbrvices; and (iii) that the Member will be tinaneially responsible for the services if the Member eleets to receive the serviees. Furthermore, Provider shall hold harmless ACIA for any elaim or expense arising from sueh services. 2.5 Provider shall not hill or collect from any Member any amount or eharges for any Covered - Serviees provided hereundei; exeept for authorized co -payments, eo-insuranee, and/or deductibies. Provider shall not deny Covered Serviees to a Member in the event that a Ivlember is unable to pay any authorized eo-payment arnounts. 42 CFR §447.15. 2.6 Under 110 eircunistances, rnneludingAClA's failure to pay for Covered Services, termination ofthis Agreernent, or the inselveney pf ACJA, will Provider make any eharges or elaims against any Member direetly or indireetly f�r Covered Services authorized by ACJA, except for authorized co- paymdnts. Provider shall look onlyto ACIA for compensation for Covered Serviees. 2.7 During the term of this Agreement and in the event of termination ofthis Agreement for any - reason, Frovider agreea to fhuly eooperate with eaeh Member and with ACIA in arranging for the transfer of eopies of Member medieal records to other ACJA Participating Providers. 2.8 Reeord Maintenance, Inspeetion, Reporting and Auditing (a) Record Retention. As required by 42 CFR 434.6(a)(7) and otherwise in aeeordanee with the standards of ACJA, Provider shall maintain an adequate reeord system for recording services, service providers, eharges, dates and all other connnonly required information elements for serviees rendered to Members pursuant to this Agreement (ineluding but not lirnited to such reeords as are neeessary for the evaluation ofthe quality, appropriateness, and timeliness of serviees -performed under this Agreement and the Ageney Contraet). (b) All records originated or prepared in eonneetion with Provider's performance of its obligations under this Agreernent will be retained and safeguarded by Provider in aeeordanee with the terms and eonditions of the Ageney Contraet and other relevant State and federal law. Provider agrees to retain all finaneial and progrannnatie records, supporting doeuments, statistical records and other reeords of Members relating to the delivery of care or serviee under the Ageney Contract and as fiirther required by the Ageney, for a period of 110 less than 4 ACM Anelilary ProviderAgreeinent 8/24/15 seven (7) years from the expiration date of the Ageney Contraet, including any eontraet extension(s), and to retain all Member reeords, ineluding but not liniited to administrative, financial and medical records (whether eleetronie or paper) for a period of no less than seven (7) years after the last payment was made for services provide to the Member. If any audit, litigation, claim, or other aetions involving the reeords have been initiated prior to the expiration of the seven (7) year period, the records shall be retained until completion ofthe action and resolution of all issues whieh arise from it or until the end of the seven (7) year period, whichever is later. If Provider stores records on microfilm or rnicroflche or other electronie means, Provider agrees to produce, at its expense, legible hard copy records promptly upon the request of state or federal authorities. (c) Medieal Reeord Maintenance. Frovider shall ensure that all medieal records are in complianee with the medical reeord keeping requirements set forth in the Provider Manual, th-Agency Contraet and Ageney guides. Provider shall maintain up-to-date medieal reeords at the site where medical serviees are provided for each Member enrolled under this Agreement. Edh Member's reeord must be aceurate, legible and maintained in detail consistent with good mediealand professional practice whieh perniits effeetive internal and exteriial -quality review andlor medical audit and faeilitates an adequate system of follow-up treatment. (d) ACIA shall be entitled to audit, examine and inspeet Provider's books and reeords, including -but not limited to medieal r eeords, fnaneial information and administrative information pertaining to Provider!s:relationship with ACJA, at any time during normal business hours, upon reasonable notice. Provider agrees to provide ACIA, at 110 eost to ACIA, with such medical, financial and administrative information, and other records as may be neeessary for ACIA to meet its obligations .related to the Agency Contraet and other regulatory obligations, Utilization Managemeht Pro:gram and Quality Management Program standards, including NCQA sthndards,-and othef relevant acereditation standards whieh ACIA may require of ACIA Partieipating Providers. 2.9 Provider authorizes ACIA to hielude Provider's name, address, telephone number, infonnation related to Provider's !facilities, serviees and staff, and other siniilar information relevant to Provider, its operations and staff in the ACIA provider directory and in various marketing materials identif'ying Provider as a provider of services to Members. Provider agrees to afford ACIA the same opportunity to dthplay broehures, signs, or advertisements in Frovider's facilities as Frovider affords any other insuranee company or other third party payor. 2.10 While both parties sttpport Provider's open and active communication with Members concerning Medically Necessary services, available treatrnent alternatives, benefit eoverage itiformation and/or any other information pertaining to the provider -patient relationship, Provider shall not,. during the term of this Agreement, and any renewal thereof, solicit or require any Member, either orally or in wntrng, to subseribe to or enroll in any managed eare plan other than ACJA. The provisions of' tks etion 2 10 shall sumlarly apply to Frovider's employees, agents andlor contractors. 2.11 Provider shall eooperate with ACIA in the identifieation of other sources of payment available to Members, sueh as other health insuranee, govemment programs, liability eoverage, motor vehicle coverage or worker's eompensation eoverage, as applicable. Provider shall be responsible for reporting all applicable third party resources to ACIA in a timely marmer. 5 AGIA Ancilla;y Proi'iderAgreernent 8/24/15 Provider will cooperate with ACIA in coordinating benefits with other payors in accordance with coordination ofbenefits claim processing rules and requirements outlined in the Provider Manual, the Agency Contract, and applicable Program manuals, as amended from time to time. Provider will make a reasonable attempt to determine whether any other payor has primary responsibility for the payment of a claim for services that Provider rendered to a Member and hill that payor before billing ACJA. Unless otherwise prohibited by applicable law, ACL& retains the right to recover payments made to Provider in the event ACIA determines that another payor is primarily responsible for all or a portion of the claim. 2.12 Provider understands and agrees that any payments ACIA makes directly or indirectly to Provider under this Agreement shall not be made as an inducement to reduee, limit or delay Medically Neeessary serviees to any Member. 2.13 Provider will refer Members to ACIA-Partieipating Pospitals whenever Provider is unable to - - provide Medically Neeessary services and when eonsistent with sound medical judgment and accepted standards of eare. 2.14 Provider shall use best efforts to use ACJA's electronie utilization management and claims interfaces to improvetheeffieieney of utilization management and claims payment processes. 2.15 -Provider wilt assist ACIA in providing orientation services to Provider staff to the extent ACIA may reasonably request. 2.16 Fraud and Abuse. Provider.recognizes that payments made by ACIA pursuant to this Agreement are derived from federal. and State ftmds, and acknowledges that it may be held civilly and/or criminally iiable-to ACIA andlof theAgeney, in the event of non-performanee, misrepresentation, fraud or abuse for serviees rendered to Members, ineluding but not limited to, the subniission of false elaims/statements for payment by Frovider, its employees or agents. Provider shall be reqcired to cbmply with 11 poJieies and procedures as developed by ACIA and the Agency, ineluding but not limited to the requirements set forth in the Provider Manual and the Ageney Contract, for the detection and prevntion of fraud and abuse. Such compliance may inelude, but not be limited to, referral of suspeeted or confirmed fraud or abuse to ACL&. 2.17 Provider wil deliver location-baed services to Members only at those service locations set forth in &ppendix C hereto as such appendix is rnodified from time to time by mutual agi eement of the parties. Provider shall notify ACI at least sixty (60) days prior to making any addition or ehange to service loeations. 3, OBLIGATIONS OF ACM.: 3.1 ACL& shall pay Provider for Covered Services provided to Members pursuant to the terms of this Agreement. ACIA shall have the right to offset claims payments to Provider by any amount owed by Provider to ACIA, following at least thirty (30) days' written notiee. Provider shall not be entitled to reimbursement if the Member was not eligible at the tirne services were rendered. 3.2 ACIA shall compensate Provider forC oyered Services provided to Members upon receipt of a statement thereof, as defined rn Section 2 3, and m accordance with Section 2 11 and the Covered Services Payment Schedule set forth in Appendix A-1 but, in no event, will ACIA's payment exceed submitted charges. No additional charges will be made by Provider to ACIA for Covered Serviees provided hereunder, and Provider recognizes and accepts the fees set forth in AppernJix A-1 as payment in full. 6 AGfA AnciI/aiy Provkler Agreement 8/24/15 3.2 ACIA will establish payment polieies for inpatient and outpatient services including, but not limited to, policies with respect to pre -admission testing, services included in inpatient rates and services included in outpatient rates. ACIA will provide at least thirty (30) days' prior written notice of any modifications to such payment policies. ACIA may, based on ehanges in clinical practiee and modifications to standard coding systems, add and/or delete outpatient fee sehedule proeedures and re -categorize outpatient surgery fee schedule procedures, upon thirty (30) days' prior written notice to Provider. 3.3 ACIA shall fbrnish or otherwise make available to Provider a copy of the Provider Manual, as amended from time to time. Provider Manual updates will become effective thirty (30) days from the date of notifieation, unless otherwise specified in writing by ACJA. 3.4 ACIA shall pay all Clthn Claims for Covered Services in accordance with applieable laws, regulations and Agency requirements; and ACJA will in any event meet the claim payment timeftames required under 42 CFR §447.45(d). 3.5 Provider Protections. (a) ACIA shall not exclude ot terminate Provider from ACJA' s provider network because the Provider adVocatd .011 behalf of a Member ineluding in the context of a utilization management appeal or anoth�r dispute with ACIA over appropnate medical care, provided that sueh advocacy is. consistet with the degree of learning and skill ordinarily possessed by a ha1th eare proVider practicing in accordanee with the applieable standard of care. (b) No Provider -shall be excluded or terminated from participation with ACIA due to the faet that - the Provider has a praeticethat ineludes a substantial number of patients with expensive medical conditions. • (e) Provider shall not be exeluded from participation, nor shall this Agreement be terminated, because Provider obj eets to the provision of or refuses to provide a healthcare service 011 moral or religious grounds. 4. QUALITY MANAGEMENT/UTILIZATION MANAGEMENT: 4.1 Whether announced or unannounced, Provider agrees to eooperate with, participate in, and abide by intemal or extemal quality assessment reviews, Member Appeal Proeedures, Utiization Management Program procedures, and Quality Management Program procedures established by ACJA and/or the Agency or their designees, and to follow practiee guidelines as described in the Provider Manual, the Agency Contract, and the applicable Program manuals. Provider shall permit a representative of ACJA, or its designee, to review medical records eoncurrently as well as retrospectively. Provider shall provide eopies of sueh medical reeords, either in paper or electronic form, to ACJA or its designee upon request. The Uti.lization Management and Quality Management Programs are deseribed in the Provider Manual. 4.2 ACIA's Quality Management Prograrns eonsist ofreview ofcredentials and performance of ancillaiy and other provider types that are applying for participation in, or are partieipating in, ACIA's network ofproviders to determine whether the provider meets ACJA's standards for quality, availability, accessibility and cooperation. 7 ACIA Ancillary Frovider Agreernent 8/24/15 4,3 ACIA's Utilization Management Programs inelude requirements for pre -authorization ofcertain services rendered in physicians' offices and in inpatient, outpatient and ancillary settings. Utilization Management Programs inelude coneurrent, retrospeetive and prospeetive review of certain services and procedures to assure that care is delivered in the most appropriate setting and is Medically Necessary. Certain Covered Serviees may require prior approval from ACIA. The Covered Serviees subject to prior approval are more fiully described in the Provider Manual and other ACIA notices. ACTA is obligated to pay for and Provider is entitled to reimbursement for only those serviees that are Medically Necessary. Where reimbursement for an admission, inpatient day or outpatient service is denied as not prior approved or Medically Neeessary, the Provider shall not eharge either ACIA or the Mernber for any health care services rendered or fiirnished with respeet to sueh admission, inpatient day or outpatient serviee. If Provider disputes any sueh denial, the case in question shall be appealed through ACIA's provider appeal process. Provider may not bring legal.action for disputes which have not been appealed through the provider appeal proeess. 4.4 ACTA shall monitor and report the quality of services delivered under the Agreement and initiate a plan of correetion, where necessat', to improve quality of eare, in accordanee with that level of care whieh is reeognized as eceptable professional practiee in the respeetive eoinmunity in whieh the Provider praetics andlor the standards established by ACL&, the Agency, or their respective designees; -Provider shall cooperate with and abide by any correetive action plan initiated by ACIA andlor required by the Agency or any other State or federal regulatory ageney with.governing authority over the serviees provided under this Agreement. 4.6 - Provider agrees thatto the extent penalties, fmes or sanctions are assessed against ACIA by the Agency or another regulatoiy agncy with goveniing authority over the services provided under this Agreement as a result of-Pr�vider's failure to comply with Provider's obligations under this Agreement, ineluding but not liniited to, Provider's failure or refhsal to respond to ACIA's the - - - Agency's request for medical rec�rds, applieable eredentialing infoiuiation, and other information • required to be -provided underthis Agreement, Provider shall be responsible for the immediate payment of sueh .penalties, fines or sanetions. In the event such payment is not made in a timely manner to ACJA, ACIA shall have the right to offset claims payments to Provider by the amount owed by Provider to ACIA. 5. PROFESSJONAL LTABILITY INSURANCE/MWERSE ACTIONS: 5.1 Provider, at its sole expense, shall provide professional liability, comprehensive general liabiity, and, as applicable, medical malpractiee insuranee coverage (ineluding coverage for viearious liability, if any, for the acts of employees, agents and representatives of Provider) upon exeeution of this Agreement and at all times during the term ofthis Agreement, as foliows: (a) Amounts and extent of such insuranee eoverage as deemed neeessary by ACJA to adequately insure Members and ACJA against any elaim or claims for damages arising by reason of personal injuiy or death oceasioned, directly or indireetly, in eonneetion with Provider's performanee of any service pursuant to this Agreement; in no event shail sueh coverage be Iess than the amounts required by law. (b) Frovider shall provide ACJA with written veriflcation of the existence of sueh coverage upon exeeution ofthis Agreement and as otherwise requested by ACIA throughout the term ofthe Agreement, whieh may inelude providing copies of faee sheets of sueh eoverage. Provider shall notif ACIA reasonably in advanee of any ehange or eaneellation of sueh eoverage. 8 ACJA Ane/liwy ProviderAgreement 8/24/15 5.2 Provider shall immediately notify ACIA in writing, by certified mail, of any written or oral notice of any adverse action, ineluding, without liniitation, litigation, investigation, complaint, claim or transaction, regulatory action or proposed regulatory action, or other action naming or otherwise involving Provider or ACJA, or any other event, occurrence or situation which may reasonably be considered to have a material impact on Provider's ability to perform Provider's duties or obligations under this Agreement. Provider also shall immediately noti1' ACIA of any action against any applicable license, certiflcation or participation under Title XVffl or other applicable provision ofthe Social Security Act or other State or federal law, State andlor DEA narcotic registration certificate, or medical staffprivileges at any facility, and of any material change in the ownership or busmess opeiations ofProvider All notices required by tins ection 5 2 shall be fiirmshed as provided m ction 10 6 of this Agreement 53 Provider agrees to defend, indenmify and hold hamiless ACIA and its officers, directors and employeesfrom and against any and all claims, costs and liabilities (including the fees and expenses of counsel) as a result of d breach of this Agreement by Provider, the negligent or willful misconduct ofProvider andlor Provider's employees, agents and representatives, and from and against any death, personal injuiy or malpractice arising in eonnection with the performance of any services by the Provider in comiection with this Agreement. This section shall survive the termination or expiration of tbis Agreement for any reason. --ACIA agrees to defend, indeftmify and hold harmless Provider and its officers, directors and ernployees from and against allclaims, costs and Iiabilities (including the fees and expenses of - counsel) as a result of ACIA's breach ofthis Agreement or the negligent or wilful misconduct of ACIAand/or ACL&'s employees, agents and representatives in connection with ACI[A's performanceunder this Agreemeht. This section shall survive the terinination or expiration ofthis Agreement for any reason. 6. CONFIDENTIALITY: ACIA and Provider shalt thch comply with all applicable State and federal laws respecting the confidentiality of the medical, personal or business affairs ofMembers acquired in the course of providing services pursuant to this Agreement. Each• party shall maintain as confidential and shall not diselose to third parties fmancial, operating,1proprietary or business infoiuiation relating to the other party which is not otherwise public inf�rmation. The payment rates in this Agreement are confidential and proprietary and shall not be disclosed by either party. However, nothing herein shall prohibit either party from making any disclosure or transniission of information to the extent that such disclosure or transmision is required by the Agencyor other applicable state regulatory agency, or is necessary or appropriate to enable the disclosing party to perform its obligations or enforce its rights under this Agreement, or is required by Iaw or legal process. Should disclosure be required by law or legal process, the disclosing party shall immediately notif' the other party of the disclosure. 7. COOPERATION; RESOLUTION OF DISPUTES: 7.1 Cooperation. To the extent compatible with separate and independent management of each, ACIA and Provider shall at all times maintain an effective liaison and close cooperation with eaeh other to provide maximum beneflts to Members at the most reasonable cost consistent with high standards of care. ACIA and Provider shall use best efforts to exchange infoiniation regarding material matters directly or indirectly related to this Agreement. 7.2 Resolution ofDisputes. ACIA and Provider shall both fiully cooperate in resolving any and all controversies among or between said parties, their employees, agents, or representatives pertaining 9 ACM Aneilloay ?roviderAgreernent 8/24/15 to their respective duties under this Agreement. Sueh disputes shall be subniltted for resolution in accordance with the provider appeal proeedures as referenced in the Provider Manual and ACIA policies and proeedures. Neither ACJA nor Provider shall permit a dispute between the parties to disrupt or interfere with the provision of services to Members. 8. TERM; TERMINATION: The term of this Agreement shall commence as of the Effeetive Date and continue for an initial one (1) year term (the "Initial Term"). After the Initial Teim, the Agreement shall automatically renew for successive one (1) year terms unless the Agreement is terminated pursuant to this ection 8 as set forth herein. Either party may terniinate this Agreement without cause at the end ofthe Initial Term or at the end ofthe subsequent terms by providing the other party with at least niiiety (90) days' priorwritten notice before the end of the then eurrent term. The effective date of termination without cause will be on the flrst of the :monthfollowing.the expiration ofthe notice period. Bither party may terminate this Agreement for cause due to a material breachbygivhig thfrty (30) days' prior written notice. The notiee of termination for cause will not be effective if the breaehing party eures the breaeh within the thirty (30) day notice period. 111 the event that the breaehing party does not cure the breach within the thirty (30) day period, the effective date of termination will bethe first of the month foliowing the expiration of the thirty (30) day notiee period. - Jn.the event -any ehange in federalor State laws, rules and regulations or the Iowa Medicaid Program or the Medieare Advantage program- Would have a material adverse impaet on either ACL& or Provider in eonnection with the perfoixuance of this Agreement (the "Mandated Changes") sueh that the basis for the financial:bargain of this Agieement i underniined, then the affected party shall have the right to require the other, by written notib, to ent�f into negotiations regarding the affected or pertinent terms of this Agreement whild sti1maintaining the original Agreement purposes. If renegotiated, such terms shall beeomeeffective 110 later than thirty(3O) da's afier the parties have reached agreement on the renegotiated Ierms. The parties agree to make t good fajth attempt to renegotiate the Agreement to the extent necessary to comply with aiy Mandthd Chahges. If, after good faith renegotiations, the parties fail to reaeh an agreement satisfactory to both -parties within thirty (30) days ofthe request for renegotiation, the party requesting sueh renegotiation may terminate this Agreement upon ninety (90) days prior written notice to the other party. Notwithstanding the above, ACIA may terminate this Agreement immediately in the event any of the foliowing oceur: 8.1 Tf Provider is expelled, diseiplined, barred from partieipation in, or suspended from receiving payment under any state's Medicaid program, Children's Health Jnsurance Program (CHIP), the Medicare Program or any other federal health eare program. 8.2 If Provider is debarred, suspended or otherwise excluded from proeurement or non-proeurement activities under the Federal Aequisition Regulations. 8.3 Upon the Ioss or suspension of the Provider's liability coverage set forth under ofthis Agreement. 8.4 The suspension or revoeation of Provider' s lieense or other certifieation or authorization, including Provider's JCAHO or other applicable acereditation, neeessary for Provider to render Covered Serviees, or upon ACTA's reasonable determination that the health, safety or welfare of any Member may be in j eopardy ifthis Agreement is not terminated. 10 ACIA AnciIla;y PzvviderAgree;nenl 8/24/15 Upon terniination of this Agreernent for any reason, ACIA shall notify affected Members ofthe termination of Provider prior to the effective date of termination. Regardless of the reason for termination, Provider shall promptly supply to ACIA all hiformation necessary for the reimbursement of outstanding elaims. 42 CFR 434.6(a)(ff). 9. REGULATORY AND PROGRA1VI-SPECWIC PROVISIONS: Attaehed hereto and ineorporated herein by referenee is IIi2du1e 9, setting forth sueh terms and conditions as are neeessary to meet State and Federal statutory and regulatory requirements, and other Agency requirements, of the Program. hedijIe9 is consecutively sub -numbered as neeessary for eaeh Program under which Provider is fiimishing services under this Agreement. Provider acknowledges that the specifie terms as set forth ft S& Ediile 9 are subjeet to amendment in aeeordanee with federal and/or State statutory and regulatory ehanges to the Program. Such amendment shall not require the eonsent of the Provider or ACJA and will be effective nmnediately on the effeetive date thereof, as set forth mS&tion 10 3 10. MIISCELLANFOUS: 10.1 It is understood that Provider is an independent contractor and in no way is Provider to be - eonsidered an employee, agent, or representative of ACJA. It is fiirther understood that Provider provides secified services to Menibers in exehange for an agreed upon fee. This Agreement shall not ereate, nor be deemed or construed to ereate any relationship between ACIA and Provider other than that of independent contraetors, eontracting with eaeh other solely for the purpose of perforniing thia Agreement and aeh party shall be liable solely for their own activities and neither ACIA nor Provider shail- be liable to any third party for the activities of the other party to this Agreement. 10.2 This Agreement, being for the purpose of retaining the professional services of Provider, shall not be assigued, subcontraeted, or d1egated by Provider without the express written consent of ACIA. 10.3 No alterations or modifications ofthe terms ofthis Agreement shall be valid unless such alterations or modifications are incorporated into the Agreement through a written amendment, signed by both parties hereto, and attached to this Agreement; provided, however, ACJA may amend this Agreernent with 30 days' notice t� Provider via a(n) ACIA bulietin or other written conimunication provided in aecordance with the notice provisions in ection 10 6, and unless Provider notifies ACIA, as applicable, of any objection, sueh amendment shall then take effect. Any amendment to this Agreement subjectto prior regulatory approval(s) shall be effective once sueh regulatory approval(s) has been received. Notwithstanding the foregoing, amendments required beeause of legislative, regulatoiy or governmental ageney requirements do not require the consent of Provider or ACJA and shall be effective immediately on the effective date thereof. This Agreement remains subj ect to the approval of the State of Iowa, and may be amended by ACJA to eomply with any requirements of the State of Iowa. Provider acknowledges that all Ageney requirements, as may be amended from time to time, are ineorporated to this Agreement. 10.4 This Agreement shall be deemed to have been made and shall be eonstrued and interpreted in aeeordanee with the laws of the State of Iowa. 10.5 Tliis Agreement and its exhibits, appendiees, sehedules, addenda or other attachments constitute the entire understanding and agreement between the parties eoneerning the subjeet matter hereof. This Agreement supersedes all prior written or oral agreernents or understandings existing between the 11 AC!A Ancil!ary Proyider Agreeme 8/24/15 parties concerning the subj ect matter hereof including, but not limited to, any such agreement which may have been previously executed between Provider and ACJA or any of its Affiliatos relating to the provision of Covered Serviees under the Progrant In the event of a conflict between the terms of tbis Agreement and the Provider Manua1 the tenns of the later document shall control. 10.6 Written notiees to be given hereunder shall be sent by Certified Mail, Retum Receipt Requested, or by an overnight delivery service whieh provides a written receipt evidencing delivery to the address set forth by the party, or by confrmed f'acsimile followed by written notice tbrough the U. S. postal service. All notices ealled for hereunder shall be effeetive upon receipt. If to Provider: URicr3D Q -e 5QL6 -t3S J—OLO A 53 If to AmeriHealth Caritas Iowa ThD With a eopy to: General Counsel Ameiffiealth Caritas 200 Stevens Drive Philadelphia, PA 19113 10.7 Both parties agr that there shall be no diserinTh ation in the performance of this Agreement against any patient or other person as the result ef that individual' s race, color, religion, gender, sexual orientation, handieap, age,national origin, source ofpayment, or any other basis prohibited bylaw. 10.8 The failure of any of the parties to insist upon strict perfonnance of any ofthe terms ofthis Agreement shall not be deemed waiver of any of their respective rights or remedies, and shall not be deemed a waiver of any subsequent breach or default in any ef the terms contained in this Agreement. 10.9 In the event that any provision under tbis Agreement is declared null or void, for any reason, the remaining provisions of this Agreement shall remain in fiuil force and effect. 10.10 The parties will use reasonable care and due diligence in performing this Agreement. Provider will be solely responsible for the services provided under this Agreement. 10.11 All captions eontained in this Agreement are solely for the convenience of the parties hereto and shall not be deemed part of the content of this Agreement. 10.12 All terms used in this Agreement are deemed to refer to the masculine, feniinine, neuter, singular or plural as the content may require. 12 .4 CIA Ancillaiy ProviderAgree,nent 8/24/15 10.13 Non-Discriniination. Provider shall comply with (i) Title VI of the Civil Rights Act of 1964 and the rules, regulations, and order; (11) the Rehabiitation Act of 1973 and the rules, regulations, and orders thereunder; (iii) the Americans With Disabilities Act of 1990 and the rules, regulations, and orders thereunder; and (iv) any and all applicable laws, niles and regulations prohibiting discrimiratory praetices. Furthennore, in accordance with Title VI of the Civil Rights Act of 1964 and the rules, regnlations and orders thereunder, Provider shall take adequate steps to ensure that Members with limited English sIdlls receive ftee of charge the language assistance necessary to afford them meaningfiil and equal access to the benefits and services provided under this Agreement (see 42 U.S.C. 2000d seq. and 45 C.F.R. Part 80, 2001 as amended). 10.14 No Offshore Contracting. No Covered Services under this Agreement may be performed outside of the United States without ACIA's prior written consent. In addition, Provider will not hire any individual to perform any servioes under this Agreement if that individual is required to have a wotk visa approved by th U;S;•Department of Homeland Seeurity and such individual has not met this requirement. [SIGNATURES ON FOLLOWII'4G PAGE; REMAINDER OF PAGE INTENTIONALLY BLANK] 13 AGFA Ancillary Provider Agreement 8/24/15 IN WITNES S WHEREOF, and intendiig to be legaily bound hereby, the parties hereto, eaeh by its offieers duly authorized, hereby affix their hands as ofthe date written below. ANCILLAIRY PROVTDER « Print Name 7/(AttL Signature r1&tttc tQtu cf0 itle '7i iIca&WJ( S' thiztta, £74 sV7oS Address j3lID7(oS1o5 National Provider ID Number Ot) '7 Medicaid ID Number q a -o053 (S9o./ Medicare ID Nuinb& Tax ID Number Date Assignment of Payment (qpplicable to Grotp Fitysielan only): fly signing below, Provider hereby assigns and transfers all Frovider's right to and interest in compensation payable by ACJA pursuant to this Agreement to tlie party identified belo*, and Frovider therefore directs ACIA to pay sueh eompensation to sa!d party: Provider Signature Name of Group Address Group Tax ID Number Check and initia! if Assignment of Paynient Not Applicable: 0 Provider Initials AMERIIIEALTH CARITAS IOWA, INC. Name Signature Title Date Effeetive Date of Agreement: [To be cornpleted by Amerillealth Caritas Iowa] 14 ACM Anelilaty ProviderAgreernent 8/24/15 APPENDIX A ANCIEJLARY SERVICES PROVIDER COYERED SERVICES Provider shall furnish the foliowing Covered Services to Members: [J7ft tIoEpfCovpted •EcWzc to Frovider] Provider's c�mpensation for Covered Services is set forth in Appendix A-1. 15 ACIA Ancillwy Provider Agreernent 8/24/15 APPENDIX A-1 ANCIIJLARY SERVICES PROVIDER COVERED SERYICES COMPENSATION SCIIEDULE Commencing on the Effective Date, ACIA will compensate Provider for Covered Services rendered by Provider to Members in accordance with the terms ofthis Agreement at a rate of 100% in aecordance with Medieaid Payment Polieies, less applicable co-insurance and deductibies.. In no event will ACJA's payment exeeed Provider's charges. 16 ACM Anelilaty Provider Agreeme 8/24/15 ALPPENJJIX 11 ANCJLLARY SERVICES PROVIDER ACIA AFFILL&TES [Insert ACM Afffliates Covered by Agreement] 17 ,iCL4 Ancillwy ProviderAgree,nent 8/24/15 ALPFENDJX C ANCILLARY SERVICES PROVTDER PROVIDERS AND SERVICE LOCATIONS COVERED BY AGREEMENT PROVIDER AND &ERVICE LOCATJON L)4tUJoore RPmeL5 &41'YL / Naine qj t3rd CV Address City, State, Zip 3n ( jqo Phone Number FROVIDER ANTD SERYICE LOCATION JA atne Ferlcjo E L L,Porte x-\ Address City, State, Zip / (3\P\&0U Lj4- Phone Number PROVIDER AND SERVTCE LOCATION LJ{rtoo [f&3aUC t 3 Name Address City, State, Zip '2o 993j LJL44J5 Phone Number 18 ACJA Ancillwy ProviderAgseement 8/24/15 APFENDTX C ANCIIJLARY SERVJCES PROVIDER PROVIDERS AND SERVICE LOCATIONS COVFRED BY AGREEMENT PROVIDE1t ANID SERVICE LOCATION Lk)o !1n5yncrk Pi -t Address [AJYtk(100 U9f City, State, Zip / °cP" <jc) Phone Number PROVIDER AND SERVTCJE LOCATION L\A4tCLD S7,rp PAAJLlAJ$ �f Nanie t3 33 tTh 5borout4n iQvt Address 14\Mw /oo, 56 City, State, Zip yo LILI(4 Phone Number PROVIDER AND SERVICE LOCATJON Name Address City, State, Zip Phone Number 18 ACIA AncilIrny Provider Agreemenl 8/24/15 Schedule 9-1 Federal Reciuirements - Medieaid and Medicaid Managed Care 1. No payment will be made to Provider for provider -preventable conditions or health eare-acquired conditions. For purposes hereof: a. llealth care-acqnired eondition ("}{AC") means a condition oeeurring in any inpatient hospital setting, identified as a HAC by the Secretary of the U. 5. Department of Health and Human Services ("HHS") under section 1 886(d)(4)(D)(iv) of the Social Security Act (the "Act") for purposes of the Medicare program identified in the State plan as described in se�tion 1 886(d)(4)(D)(ii) and (iv) ofthe Act, other than deep vein thrombosis/pulmthary embolism as related to total knee replacement or hip replacement surgery in pediatric and obstetric patients. b. Other provider -preventable condition means a condition occurring in any health care setting that meets the folkjwing criteria: (1) 18 identified in the Iowa Medicaid plain; (ii) has been fopnd by the Iowa, based upon a review of medical literature by qualified professioa1s, t� be reasonably preventable through the application of procedures supported by evidence-bbsed guidelines (iii) has a negative consequence for the Member; (iv) is auditable; ahd (v) includes, at a minimum, wrong surgical or other invasive procedure jerformed on a patient, surgical or other invasive procedure performed on the wrong body part, or surgical or other invasive procedure performed on the wrong patient. - c. Provider -preventable condition ("PPC") means a condition that meets the definition of "health careacqdired condition" or an "other provider -preventable condition." No reduction in payment will -be 'tade for a PPC when the condition existed prior to the initiative of treatment for that patiQ;t by PrcMder. Provider shall identi' PPCs when submitting claims for payrnent or, ifno claim will be subniitted, ifMedicaid payment would otherwise be available for the course of tretment in which the PPC occurred, or as otherwise required by the State. 42 CFR §438.6(ij(2), 434.6(a)(12) and 447.26. 2. The State Agency and HHS may inspect and audit any frnancial records ofProvider or its subcontractors. 42 CFR §438.6(g). 3. Physician Jncentives. P±ovidbr shall disclose to ACIA annually any Physician hcentive Plan (PIP) or risk arrangenients Provider may have with physicians, either within Provider's group practice or other physicians not associated with Provider's group.practice, even if there is no substantial financial risk between ACIA and the physician or physician group. The tenn "substantial fmancial risk" means a financial risk set at greater than twenty-five percent (25%) of potential payments for Covered Services, regardless of the frequency of assessment (i.e., collection) or distribution of payrnents. The term "potential payments" means simply the maximum anticipated total payments that the physician or physician group could receive if the use or cost of referral services were significantly low. 42 CFR §438.6(g), 422.208, 422.210. 4. Provider Diserimination Prohibited. ACIA may not, with respect to Provider eompensation or indemnification under this Agreement, diseriminate against Provider to the extent that the Provider is acting within the scope ofbis, her or its lieense or certification under applicable State law, solely on the basis of that license or certiflcation. Without lindting the foregoing, ACIA shall not diseriminate against Provider for serving high-risk populations or specializing in 19 AGIA Ancilla,y Fruvider Agreement 8/24/15 conditions that require costly treatment. Nothing hercin shall be construed to: (i) require ACIA to eontraet with Provider if not necessary to meet the needs of Members; (ii) preclude ACIA from using different reimbursement amounts for different speeialties or for different praetitioners in the same specialty; or (iii) preclude ACIA from establishing measures that are designed to maintain quality of services and eontrol costs and are eonsistent with ACIA's responsibilities to Members. 42 CFR §438.12. 5. Continued Treatment Obligation. Notwithstanding any other provision of this Agreement, in the event of either party' s termination of this Agreement, insolvency of either ACIA, or other Qessation ofACJA's operations, Provider shall continue to provide Covered Services to Members (i) until the end of the month in wlth the effective date of tennination of this Agreement falis, (ii) until the end of the month for whieh capitation or premium has been paid to ACJA by Ageney, or (iii) until the date of a Member's diseharge from an inpatient facility, whiehever is later. 42 CFR §438.62. 6. Member Rights. Provider shall adhere to all applicable Federal and State laws that pertain to - Member rights, and shall talce such rights into aceount when furnishing services to Members. 42 CFR §438.100(a)(2). • 7. Provider -Member Cominunications. Nothing in this Agreement shall be eonstrued to prohibit, restrict or impede Provider's abiity to freely and openly discuss with Members, within the Provider's lawfiul scope ofpractiee, all available treatment options and any information the Member may need in order to deeide among all relevant treatment options, including but not limited to the risks, benefits and eonsequenees oftreatment or non -treatment, regardless of whether the servi�S may be considered Covered Serviees in accordance with this Agreement. Further, nothing in this Agreement shall be construed to prohibit, restriet or impede Provider from discussing Medically Necessar' bare and advising or advoeating appropriate medical care with or. on behalf of a Member, ineluding: information regarding the nature of treatment options risks of treatment, alternative treatments or the availability of alternative therapies, eonsultation or tests that may be self-administered, and the Member's right to participate in decisions regarding his or her care, ineluding the right to ref'use treatment and to express preferenees about ffiture treatment decisions. 42 C1?R §438.102(a). 8; Member Hold Harmless. Provider shall aecept the final payment made by ACIA as payment in thhl for Covered Services provided pursuant to this Agreement. Provider agrees that in no event, ineluding, but not Iiniited to, nonpayment by the Agency to ACJA, nonpayment by ACL& to Provider, the insolvency of ACJA, or breaeh of this Agreement, shall Provider bill, charge, eollect a deposit from, seek compensation, remuneration or reimbursement from, solicit or accept any surety or guarantee ofpayment, or have any recourse agathst Members or persons other than ACIA acting on their behalf (ineluding parent(s), guardian, spouse or any other person legaily, or potentially legaily, responsible person of the Member) for Covered Serviees listed in this Agreement. This provision shall not prohibit colleetion of supplemental charges or co -payments on ACIA' s beh&f made in aceordance with terms of an enrollment agreement between ACIA and Members. Provider fiirther agrees that: a. this hold harmless proyision shall survive the termination of this Agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of Members; and that 20 AGfA Anelilary Provider Agree;nent 8/24/15 b. this hold harniless provision supersedes any oral ar written eontrary agreement now existing or hereafter entered into between Provider and Members or persons acting on their behalf. 42 CFR §438.1O6, 447.15. 9. Coverage and Payment for Emergency Serviees. ACJA shall eover and pay for Emergency Services rendered by Provider and obtainecl when a Member had an Emergency Medieal Condition, or when a representative of ACIA has instructed the Member to seek Emergency Serviees. 42 CFR §438.114(c)(1)Qi). 10. Timely Aceess. Provider shall meet Ageney standards for timely access to eare and services, taking into account the urgeney of the need for services. Provider shall offer hours operation to Meinbers that are no less than the hours of operation offered to conimercial enrollees or comparable to Medicaid fee-fdr-service, ifProvider serves only Medicaid enrollees. Provider -services shall be available 24 hours a day, 7 days a week, when medically neeessary. 11. Exeluded Providers. Pursuant t� 42 CFR §438.214(d), ACJA may not employ or contract with providers excluded from partieipation in Federal health eare programs under either Section 1128 or 1 128A of the Aet. Jn addition, section 2455 of the Federal Acquisition Streamlining Act of 1994 and he Federal Acquisition Reguilations (inchiding but not limited to 48 CFR §9.405), ACTA may not make payment to any person or entity, or an affiliate thereof, who has been • debarred or suspended form pirticipation in federal procurement or non -procurement activities. Provider shalLcomply with the disclosure requirements of 42 C.F.R. Section 455, Subpart B and, upon reasonable request, provide such information to ACIA in accordance with the reqnirements specified therein. Provider represents and warrants that neither it, nor any of its contractors or employees who will ftirnish goods or services under the Agreement, directors or officers, or any person with an ownership interest in Provider of five percent (5%) or more, is or ever has been: (i) debarred, suspended or excluded from participation in Medicare, Medicaid, the State Children's Health Jnsurance Program (SCH]P) or any other Federal health care program; (ii) convicted of a criminal offense related to thedeliveiy of items or services under the Medicare or Medicaid program; (iii) had any disciplinary action taken against any professional license or certification held in any state U.S. territory, including diseiplinary action, board consent order, suspension, revocation, voluntary sunender of a license or certification; or (iv) debarred or suspended from participation in procurement or non -procurement activities by any federal agency (collectively, "Sanctioned Persons"). Provider shall screen all employees and contractors who will furnish goods or services under this Agreement to determine whether they have been excluded from participation in any Federal health care program, by searching applicable Federal and State databases (including but not linijted to the OIG's LETE and the H]PDB) upon initial employment or engagement of or contracting with a contractor, employee, director or officer, and on a monthly basis thereafler. Provider shall imrnediately notify ACIA upon knowledge by Provider that any of its contractors or employees who thrnish goods or services under the Agreement, directors, officers or owners has become a Sanctioned Person, or is under any type of investigation which may result in their beconiing a Sanctioned Person. In the event that Subcontractor cannot provide reasonably satisfactory assurance to ACJA that a Sanctioned Person will not receive payment from ACIA under this Agreement, ACIA may inimediately tenninate this Agreement. ACIA resen'es the right to recover all amounts paid by ACIA for items or services fumished by a Sanctioned Person. Further, and without limiting Provider' s indemniflcation obligations set forth elsewhere in this 21 ACM Anci11ay Frovider Agreeinent 8/24/15 Agreement, to the extent penalties, fines or sanetions are assessed against ACJA as a result of Provider's having a relationship with a Sanctioned Person, Provider shall be responsible for the immediate payment of such penalties, fines or sanctions. In the event such payment is not made in a timely manner to ACL&, ACIA shall have the right to offset elaims payments to Provider by the amount owed by Provider to ACL&. 12. State and Federal Regulator Aceess. Provider aeknowledges that the U.S. Department of Health and Human Serviees (BBS), Centers for Medieare and Medicaid Serviees (CMS), Office of the Inspeetor General, the Comptroller, the Agency [SPECII?Y STATE AGENCIES/REPRESENTATIYES], and their designees have the right to evaluate through audit, inspeetion, or other means, whether announeed or imannounced, any reeords pertinent to this Agreement, ineluding quality, appropriateness and timeliness of services and the timeliness and aeeuracy of encounter data and Provider elaims submitted to ACIA. Such evaluation, when performed, shall be perfonned with the cooperation of the Provider and ACL&. Upon request, Pr�vider and ACJA shall assist in sueh reviews. 42 CFR §434.6(a)(5). 13. Provider shall safegu.ard information about Members as required by Part 431, Subpart D of 42 CFR. 42 CFR 434.6(a)(8). 14. Any permitted subeontraets entered into by Provider in order to earry out its obligations under tbis Agreement must be in writing and fulfihl the requirements of 42 CFR Part 434 that are appropriate to the serviee or activity delegated under the subcontract. 42 CFR 434.6(a)(11), (b). 22 ACM Anelilaty Frovider Agreement 8/24/15 Schedule 9-2 (Ancilary Frovider Form) State of Iowa Requiremeiits - Medicaid and Medicaid Managed Care 1. Unless defined in this 14ijIe9or elsewhere in the Agreement, all capitalized terms used herein shall have their respeetive meanings given to them in the contraet between the Iowa Depaitment ofHuman Services ("IDHS") and AmeriHealth Caritas Iowa, Inc., ,, r ,, ( ACIA ) dated as of :1, 201[J (the State Contract ). 2. In accordance with 191 IAC 40.18, Provider, or its assignee or subcontractor as applicable, hereby agrees that in no event, including but not limited to nonpayment by the ACIA, ACJA insolvency or breach of this Agreement, shall Provider, or its assignee or subcontractor if applicable, bill, eharge, collect a deposit from, seek eompensation, remunerationorreimbursement from, or have any recourse against any Member or persons otherthan ACIA acting on the Member's behalf for services provided pursuant to this Agreement. This provision shall not prohibit collection of supplemental eharges or copayments �n ACINs behalfmade in aceordance with terms ofthe Program. Provider,or its assignee or subcontractor ifapplicable, fiarther agrees that (1) this provision shall survive the tenthnation ofthis Agreement regardless ofthe cause giving riseto termjnation and shall be cdnstrued to be for the benefit of the Member; and that (2) this provisionsupersdes anyoiai or written contrary agreement now existing or hereafter entered into between Providerand Mernber or persons acting on behalf ofthe Member. 3. Pursuant to 191 TAC 40.22: a. ACIA shall not prohibit Provider from or penalize Provider for discussing treatment optibns withMembers, irrespective ofACIA's position on the treatment options, or from advoeating on behalf ofMembers within tlie utilization review or grievance :processes established by ACIA or a person contracting with ACIA. b. ACIA shall not penalize Provider because Provider, in good faith, reports to state or federal authorities anyact or practice by ACIA that, in the opinion ofProvider, jeopardizes patient health or welfare. 4. Coinpliance with Pro -Children Act of 1994. Provider hereby certifies compliance with Public Law 103-227, Part C Enviromnental Tobacco Smoke, also known as the Pro - Children Act of 1994 ("Act"). The Act requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted by an entity and used routinely or regularly for the provision ofhealth, day care, education or library services to children under the age of 18, ifthe services are funded by federal programs either directly or through State or local governments. Federal programs include grants, cooperative agreements, loans or loan guarantees, and contracts. The law also applies to children's services that are provided in indoor facilities that are constructed, operated or maintained with such federal funds. The law does not apply to children's services provided in private residences, portions of facilities used for inpatient drug or alcohol treatnient, service providers whose sole source of applicable federal finds is Medicare or Medicaid, 23 ACIA Ancillaiy Prov!derAgreernent 8/24/15 or faeilities (other than clinies) where WIC coupons are redeemed. (Ref. RFP Exhibit D) 5. AC[A foliows all applicable Federal and State laws pertinent to Member eonfidentiality and rights; Provider shall talce those rights mb account when thrnishing services to Members. (SOW §1.4.1) 6. Provider shall not require any cost-sharing or Mernber liability responsibilities for Covered Serviees exeept to the extent that cost-sharing or Member liability responsibilities are required for those services in accordanee with law and as deseribed in the Ageney Contract. Further, Provider shall not eharge Members for rnissed appointments. (SOW §3.2.15.3) 7. Provider agrees that alt applicable terms and eonditions set out in the RFP, the Agency - - Contract, any ineorporated documents and all applicable State and federal laws, as amended, governthe duties and responsibilities of Provider with regard to the provision ofservices to Members. (SOW §6.1.2) 8. Provider' s responsibi1itis regarding third -party liability (TPL) inelude Provider' s obligations to identif5i TPL coverage, ineluding Medicare and long-term care coverage as applieable, and except as otherwise required, seek such TPL payment before submitting claims to ACIA. (SOW §6.1.2) • 9. Providershall submit elaims wltkh do not involve a third -party payer within ninety (90) days ofthe date ofserviee. (SOW §6.1.2) 10. IDHS resei*es the right tb direct ACIA to tenninate or modif' this Agreement when IDHS determines it to be in the best interest of the State. (SOW §6.1.2) 11. ACL& may not prohibit or otherwise restriet a health eare professional aeting within the lawfhHeope ofpraetiee, fr�madvising or advoeating on behatf ofa Member who is his or her patient regarding: (1) the Mernber's health status; (2) medical, behavioral heatth, or long-term eare treatiiient options, ineluding any alternative treatment that inay be self- adrninistered; (3) any inforination the Member needs in order to decide among all releyant treatment options; (4) the risks, benefits and consequences of treatment or non- treatment; or (5) the Member's right to participate in deeisions regarding his or her health eare, ineluding the right to refuse treatment, and to express preferenees about fiiture treatrnent decisions. (SOW §�.1.5) 12. Provider shall maintain eomplete and legible medieal and finaneial (fiseal) records s required pursuant to TAC 441-79.3. Without limiting the foregoing, Provider's medieal reeords shati doeument all rnedical serviees that the Member reeeives from Provider. Medieal reeords shall be maintained in a detailed and cornprehensive manner that eonforms to good professional medical practiee, pennits effeetive professional medieal review and medieal audit proeesses, and faeilitates an aceurate systein for follow-up treatment. Medieal records must be legible, signed, dated and maintained as required by law. (SOW §6.1.9) 24 AGfA Anail/wy Provider Agreernent 8/24/15 As required pursuant to IAC 441-79.3(3), Provider shall maintain medical records: (1) during the time the Member is receiving serviees from Provider; (2) for a minimum of five (5) years from the date wlien a elaim for the serviee was submitted to ACIA for payment; and (3) as may required by any lieensing authority or aeerediting body assoeiated with deterrnining Provider's qualifieation. 13. Ea�h Member shall have the right to request and reeeive a copy of his her medical records, and to request that they be ainended or corrected. Upon reasonable request of a Mernber, Provider shall provide a eopy of a Member's medieal record at no charge. Provider must facilitate the transfer ofa Member's medical reeord to another provider at the Member's request. (SOW §6.1.9.2) 14. Within the timeframe designated by IDHS or other authorized entity, Provider must pennit ACIA, representatives of IDHS, and other authorized entities to review Members' reeords for the purpose of monitoring Providers' eompliance with the records standards, capturing informatjon for clinical studies, monitoring quality of eare, or any other reason. (SOW 6.1.9.3) 15. All medjcal reeords of Members shall be confidential and shall not be released without the written eonsent of the Member or responsible party. Written consent is not required under the foliowing cireumstantes: (1) for transmission of medieal reeord information to physicians, other praetitioners or facilities who are providing serviees to Members under eontraet with ACIA; and (2) for transjnission of medieal reeord inforrnation 10 physicians or faqilitiea providihg emergency care. Written consent is required for the transmissiofl of -the mdical record information of a former Member to any physieian not conneeted with ACIA. The e*thnt bf medical record infoiination to e-f&eased in eaeh instance - shall be basectupon tests ofmedical necessity and a "nee4 to know" on the part of the praetitioner or facility requesting the information. All release ofmedieal records shall be eothpliant with 45 CFR Parts 162 and 164. (SOW §6.1.9.4) 16. Provider shall offer hours of operation that are no less than the hours of operation offered to eommereial members or comparable Medieaid members, ifProvider sees only the Medieaid population. Covered Services shall be available twentyO-fo%ir(24) hours a day, seven (7) days a week, when medicallynecessary. (SOW 6.1.9.5) 17. Upon detennination by IDHS of a eredible aliegation of fraud for which an investigation is pending under the Medicaid program against Provider and upon the approval ofthe Medicaid Fraud Control TJnit (IVIFCU) and IDHS, ACJA shall suspend all payrnents to Provider, in compliance with 42 CFR 455.23. ACIA shall issue a notice ofpayment suspension that eornports in alt respeets with the obligations set forth in 42 CFR 455.23(b) (ineluding notiee that payments are being withheld in accordance with 42 CFR 455.23), and shall maintain the suspension for the durational period set forth in 42 CFR 455.23(c). ACIA will afforda grievance proeess 10 Provider in the event ofpayment suspension undei this paragraph 17 (SOW §12 7) 18. Nursing Faeility Provisions. (SOW §6.1.2.1) 25 ACIA Ancilla,y Providev Agiee,nent 8/24/15 a. Provider shall promptly notify ACIA ofa Member's admission or request for adrnission to the Provider nursing facility as soon as Provider has knowledge of such admission or request for admission. b. Provider shall notift ACIA immediately and consult with the Member's care coordinator if Provider is considering discharging a Member. c. Provider shall notify the Member and/or the Member's representative (if applicable) in writing prior to discharge in accordance with State and Federal requirements. d. Provider shall b� responsible for the collection of any patient liability (also referred to as "client participation") amounts, as such amounts are determined by the State of Iowa. The patient Iiability amount must be met before reimbursement from ACIA will be available under this Agreement, and ACIA's payment obligations under this Agreernent are net of the applicable payment liability amount. • e. Provider shall notify ACIA of any change in a Member's medical or firnctional condition that could impact the Member's level of care e1ibi1ity for the cunently authorized level ofnursing facility services. f Provider.mtffit-eomply with the federal Preadrnission Screening and Resident Review (PASSR) requirements to provide or arrange to provide specialized services, and all applicable Iowa state law goveming admission, transfer and discharge policies. Notwithstandrng any other termination piovision set forth in eahon 8 ofthe Agreement, this Agreenwnt shall automatically teiminate in accordance with federal requirernents in the event Provider is involuntarily decertified by the State orCMS. g. 19. Home & Community Based Services (HCBS) Providers. (SOW §6.1.2.2) a. Provider shall fumish ACLA. with at least thirty (30) days' advance written notice when Provider is no Ionger willing or able to provide services to a Member. Provider will cooperate with the Member's care coordinator to facilitate a seamless transition to another provider. In the event of a change from Provider to another FICBS provider, regardless of any other provision in this Agreement, Provider shall continue to provide services to the Member in accordanee with the Member's plan of care until the Member has been transitioned to a new provider, as determined by ACJA, or as otherwise directed by ACJA, which may exceed the thirty (30) -day notice period. b, Provider shall innnediately report to the Member's care coordinator any deviations from a Member's service schedule. 26 ACJA AndUlaty ProvklerAgreement 8/24/15 c. Provider shall comply with ACIA's critical incident reporting requirements. Provider's obligations thereunder shall inelude, at minimum: (1) the reporting of critical incidents to ACJA and other appropriate entities within required timeframes; (2) addressing and responding to critical incidents; (3) docnmentation of critical incidents; and (4) cooperating with any critical incident investigation by ACIA or an outside agency. d. Provider shall comply with all chlld and dependent adult abuse reporting requirements. 27 ACM Anctllwy PivviderAgree;nent 8/24/15 SECTION 11: MALPRACTICE HISTORY: A. Jn the past five years: Yes No 1. Has this facility' s professional liability insurance coverage ever been denied or cancelled? 0 2. Has this fadility's current or previous professional liability carrier ever made an out of court settlement or paid a judgment of a professional liability claim 011 the f'acility/service behalf? D 0 3. Is or has the facility ever been involved in a malpractice suit(s), grievance(s) filed with a eounty or state medical society or licensing agency, or arbitration(s) proceeding(s)? 0 If you answered "Yes" to any of the above tbree questions, please supply a elaims sununary from your malpractice carrier. SECTION 1: CERTIFICATION ANI) RELEASE: 1 understand that any.information entered on this application and any addenda appropriate to my specialty, w1tich subsequently is found to be faise, could result in imnwdiate dismissal from the health insurance program or health plan. 1 hereby certify that the information eontained in my completed application is accurate, true and complete. 1 authorize release of information asit rnayberquired to proeess this application. My signature on this complete application does not eonstitute a contract with the health uranee program or health p1 n. - Officer/CBO/Owner Signathre: 7.-- - 1 Date: / / /26/4 R2LST 4 Narne: SECTION J: (Please type orprint) CERTIFICATION ANI) RELEASE OF TIIE IND1VIDUAL PREPARING TIIE APPLICATION: This section is to be completed if someone other than this applicant has prepared this application: 1, hcA CA , hereby attest that the information included on this application is true and can be (Freparer r Nwne) retrieved from the files located at: Facility Narne, Address/City: Preparer' s Signature: Date: / / © April 2011 Iowa Credentialing Coalition (ICC) Version 1.1 Page 6 of 8 IOWA STATE WIDE UNIVERSAL FACILITY APPLICATION Name: 0 -t Uu \o ire R3nit 1 (Please print ftul name of facility) FOR: -6 INTTIAL CREDENTIALrNG 0 RECREDENTTALING 0 OTHER • Type or print responses in !nk. • .-CoxnpIete this forrn in its entirety:a[ndattach all requested documentat!on and explanations. Ifaquestion �oesnotapplyt� our fadility, answerw!th "Non -Applicable" or "NA". • Jf additional space is netesary to, provide answers, attach additional sheet(s) of paper. All dates irnstbe formatted as: Month/Dateear (MMD). :'fllJ APPLICATIONMUST BE SIGNFi» AND DATEI) WIIERE INDICATEI) SECTION A: PROVTDER INFORMATION: Type ofProvider: (Choose all that apply) tAmbu1ance • / 0 Ambu1aoySurgery Center o Birthing 5eiiter 0 Cornmunity Mental Health Center o Dialysis Center o Durable/Home Medical Equipment Supplier o Free Standing Substance Abuse Faeility o Home Health Agency o Other: 0 Home Infusion Therapy 0 Hospice O Hospital D Acute Care 0 Critical Accs o Independent Laboratory 0 Magnetic Resonance Irnagthg Center o Orthotics & Prosthetics Supplier o Radiology Center (XRay) o Skilled Nursing Facility Is your faeility ADA aceessible? 0 Yes © April 2011 Iowa Credentialing Coalition (IC Version 1.1 Page 2 of 8 SECTION B: DEMOGItAPHJC INFORMATION: (Please provide appropriate infonnation for all your .vervices/locations.) Faei1iName: \MtC \ ¥fr Street Address: 4 5 .3 rc\ 5eat City: Akt( 1O County: )1 CAC -kUJ K State: TIA Zip Code: 5) 763 PhoneNumber: CR ) ;:2cl FaxNumber: ((Cj ) c29( '47'T Contact Person (the person youIwish us to contact regarding infonnation on this application): Title: Phone Nurnber; ) »'\k Fax Nuiiber: (C( R ) AYI ( 4U(P() EmailAddress: \3kbc\c-SoN'e &u3A4r\&Hn.0 SECTION C: PAYMENTIBILLING flNFORMATION: Facilit3TName: L (c 4ecH o)pCe SLk%ktN\ 3 Street Address: 6\\ee PQwi Y. City: Ph�ne N(imben ifl ) 09 1. NFI#: Billing Cofttact Narne: Countyf. e State: _L (M Zip Code: = 5( 3 1. Fax Number: ( ) Tax Identification Nuthber: (Please provide an Or ginal Federal W-9 tax identification forrn) nt3fl Quality Assuran�e ontact:'*W SECTION D: OWNERSHIPJMANAGEMENT: President /CEO Name: Phone#:(%) qj- 3 j Phone#:(fS) -L- (g1( Tit1e:W\t4f( Phone#:(?Xt )q( CFO Name1 (h& Title: Medical Director Name:\(\ Phone#:(3 )(L 33 Tit1e:\c rc)( Phone#:(5(5 )Jij 'q © April 2011 lowa Credentialing Coalition (ICC) Version 1.1 Page 3 of 8 SECTION B: DEMOGRAPIIJC INFORMATION: (P lease provide appropriate infonnation for all your se,-vices/locations.) Faci1iName: A€( OO R StreetAddress: \'t Qrte f2ct City: County: jjc State: Zip Code: g7Oc PhoneNumber: (31,11 ) c9 Li4 L Fax Number: ( ) P3'4 Contact Person (theperson you wish us to contact regarding infonnation on this application): Contact Namt $\'e C\ PhoneNumber: ( SECTION C: Facility Name: Street Address: Title: Fax Number: ( ) Bmail Address: PAYMENTIBILLING INFORMATION: SRfne s54( City: County: State: ZipCode: Phcine Ntiml3er: Fax Number: ( ) NPI ]�: Tax Identification Nuthber: (Please provide an Odginal Federal W-9 tax identifleation form) Billing Contaet Name: Phone #: ( ) Quality Assurance Contact:; Phone #: ( ). SECTION D: President /CBO Name: CFO Name: Medical Director Nanie: OWNERSHIPJMANAGEMENT: A '- TitIe: Phone #: ( ) Title: Phone #: ( ) Title: Phone #: ( ) © April 2011 Iowa Credentialing Coalition (ICC) Version 1.1 Page 3 of 8 SECTION B: DEMOGRAPIIIC INFORMATJON: (Please provide appropriate inforinationfor all your services/locations) Faci1iName: uLE 3 StreetAdess: \ to' city:\jk& \ o County: State: UJJ- Zip Code: 50 Th3 PhoneNumber: - Fax Number: ( ) Contact Person (theperon youwish us lo contact regarding infonnation on tliis application): ContaetNan&' Title: - Phone Number: ( Fax Number: ( ) Email Address: SECTION C: Facility Narne: Street Address: PAYMENT/BILLING ffiFORMATION: City: - - c: -1-x: Connty: State: Zip Code: - Ph�fieNtTmber ( Fax Number: ( ) NPI#: Tax identific&tion Nuthber: (Please provide an Original Federal W-9 tax identification forrn - Billing Contact Narne: ) Phone #: ( ) Quality Assuran�e Contact: SECTION D: President /CEQ- Name: CFO Name: Phone #: ( ) OWNERSHIP/MANAGEMENT: *o- ( Medieal Director Narne: Title: Title: Tifle: Phone #: ( ) Phone#:( ) Phone #: ( ) © April 201 lowa credentialing Coalition (ICC) Version 1.1 Page 3 of 8 SECTION B: DEMOGRAPHIC INFORMATJON: (.Please provide appropriate inforrncitionfor all your services/locations) Faci1iName: ri S&L + 4 Street Address: r o lxc City\ )ti( County\e1. '\SV1 State: TTk\ Zip Code: ETL)i 6 PhoneNumber: (7)V\ )_ Fax Number: ( ) 4 Contact Person (theperson you wish us to contact regarcling information on this application): ContactNathe:": 6 [ Title: - PhoneNumber:( .. 1): .1 FaxNurnber: ( ) EmailAddress: SECTION C: FacilityName: Stet Address: PAYMENTIBILLING INFORMATION: D-{C\Q .A4 ..3( - City: .\PICS(\P ......:i.*t County: State: ZipCode: PhdneNtimber:(' FaxNumber: ( ) . ..... NPI #: Tax Identifieation Nuthber ... .;:. (Please provide an Original Federal W-9 tax identification form) Billing Coritact Narne: . Phone #: ( ) Quality Assuran�e.Contact:. Phone #: ( SECTION 11: OWNERSHIP/MANAGEMENT: President ICEO , Name: CFO Name: Medical Director Narne: Title: Title: Title: Phone #: ( ) Phone#:( ) Phone #: ( © April 2011 Iowa Credentialing Coalition (ICC) Version 1.1 Page 3 of 8 SECTION B: DEMOGRAPIILC INFORMATION: (Flease provide appropriate inforrnation for all your services/locations) Faei1i Name: tc \ D C- StreetAddress: 33 rflsjcr \1f_ City: \j County: \P( State: Zip Code:SC k) PhoneNumber: C?J\P ) Pk - 44,ct0 Fax Number: ( Contaet Person (the person you wish us to contact regarding infonnation on this application): ContactName::' . 1 Phone Numbe SECTION C: Facility Name: Street Address: Title: - Fax Number: ( ) Email Address: PAYMENTIBILLING INFORMATION: City: County: State: Zip Code: PhdneNttmber: (; Fax Number: ( ) NPI //: Tax Tdentification Nuthber: (Please provide an Original Federal W-9 tax idefttifieation forrn) Billing Contact Name: Phone #: ( Quality Asurane Contaet: Phone #: ( ) SECTION D: President /CEO Name: OWNERSHIP[MANAGEMENT: fTitle: Phone #: CFO Name: Title: Phone #: ( ) Medical Director Name: Title: Phone #: ( © April 2011 Iowa Credentialing Coalition (ICC) Version 1.1 Page 3 of 8 SECTION E: ACCREDITATION/CERTIFICATIONILICENSURE {See (A.) or (B.) below}: Ageney License or Certification or Accreditation Number (if applicable) Last Review fRenewal Expiratioii Date Accrediting Association for Ambulatory Healthcare American Board of Certification N/4 American College ofRadiology American Institute ofUltrasound in Medical QB & Abdominal Ultrasound Ameriean Osteopathic Association tJy% Chemical Dpendency Certificate Clinical Laboratory Jmprovement Act '1t 9 -3LJV+ College of American Pathologists DBA Registtation 1 Department f Health andHuman Serviees )'J It FDA Mammography Faeility Certification Joint Comniission Medicaid Medicare State Controlled Substanee Certificate State License State Nuelear/Radioactive Materials Liense yvJ State Radiol�gieal Registration The Rehabilitation Acereditation Commission Others (please list) A. Please provide a eopy of thes documents as a13plicable, including the results of the survey and a report that shows the effective dates of accreditation or certification, deficieneies, and approved plan for eorrective actioC - B. If not aceredited or certified, please note where you are in the process of obtaining accreditation or certification and by what date you expect to complete the process. C. Hospice providers - If not lieensed, please provide copy of most reeent MS survey. © April 2011 Iowa Credentialing Coalition (ICC) Version 1.1 Page 4 of 8 SECTION F: LIABILLTY COVETtAGE: A. In the spaee provided, list your liability carrier and the dates of general liability coverage to include month, day and year of beginning coverage and expiration date. 0 J-cuA Lfnc tCrc\ Current CalTier: Agency Name: City: \ kc 00 State: Phonefl: C3Vk )2f3ti 3'S8 $ Amount Per Oceurrence: \ 300 $ AmountAggregate: O 000 COD .1 .J 1 Dates ofCoverage: From: (vf / Ot / c9aSTo: 07 "0 ( / List any privileges/procedureswhich.are excluded orrestricted under your current poliey. Be specific. Tfnone, clicic this box.D B» Please check the appropriate ans*&for the foliowing questions: Yes No 1. Have you ever had a liabiliW ae brought aginst you? . U D . 2: Hve any judgments ever been brought agathst you in a liability ease? 0 0 3. Have any settlements ever beeh made on youtbehalf? 0 0 4. Are there any open elaims or cases presently.filed against you? 0 0 ::If.you answered a question, explain ona separate sheet. Explanations should inelude a coneise summary ofall pertinent facts, dates, and current status or disposition. SECTION G; AIWLTIONAL INFORMATION: Please answer all of the questions, explaining any "Yes" answers on the space provided below. A. In the past five years: . . Yes No NA -1: Has the corporation, an officer or a board member ever been eonvicted ofa felony? 0 ..2. Has your State License 4fapplicable,) ever been denied, suspended or revoked for any 0 0 reason? 3. Has your DEA Registration or State Controlled Substance Certificate (fcspp1icabIe) 0 0 ever been denied, suspended, or revoked for any reason? 4. Have you ever been subjected to sanctions by a Professional Review Organization 0 (FSRO or.PRO), the Medicare/Medieaid Program, a Third Party Payor, or a Regulatory agency (CLI.A, OSHA, ete.)? Explanation: © April 2011 lowa Credentialing Coalition (ICC) Version 1.1 Page 5 of 8 SECTION 11: MAIJPItACTICE HISTORY: A. In the past five years: 1. Has this facility's professional Iiability insurance coverage ever been dethed or caneelled? Yes No 2. Has this faeility's current or previous professional liability carrier ever made an out of court settlement or paid a judgment of a professional liability elaim on the faeility/serviee behalf? El 0 3 Is or has the facility ever been involved in a malpractice suit(s), grievanee(s) filed with a county or state medieal society or licensing agency, or arbitration(s) proceeding(s)? 0 Ifyou answered "Yes" to anyofthe above thpe qtaestions please supply a claims summary from your malpraetiee ean'ier. SECTION 1: CERTIFICATION ANI) RELEASE: tiunderstand-tht any infduuationentered thj)Xhis4plieation and any addenda appropriate to my specialty, whieh :subsequently is Sound t� be faise, epul4 result ih• ithdiate dismissal from the health thsurance proam or health plan. Lhereby certi thatthe foation coitaihedinffiydomp1eted application is accurate, tme and complete. 1 authothe release of infdritatiowasdtmaybe reqthre,t6 pi6cesThtffls application. My signature on this complete application does :nbt tdnt1tute a contract with the health i': 0' anee program or health plan. OfficerlCEOlOwner Siathre: 1 Date: S1 / /'#/ iLI es' T e/'l,Q 4' /77' 1ease pe orprint) SECTION J: .CERTIFICATIONAND RELEASE OF T1-1 F IN]MVIJ)UAL PREPARING TIIIIJ APPLICATION: mis ebtion isto be c�mplt&14fsomeone other than this applicant has prepared this application: ,•h'erebyattthttlthtthe information ineluded on this application is true and canbe (Freparer 's Narne) retrieved from the ffles loeated at: Facility Narne, AddresslCity: Freparer's Signature: Date: / / © April 2011 Iowa Credentialing Coalition (ICC) Version 1.1 Page 6 of 8 SECTION K: IIOSPITAL ADDENIDUM (Gomolete onlv ifvou are a Jzospital provider): A. Beds Total Licensed Bed Capacity: B. Services Available o Air Ambulance 0 AlcohollChemical Dependency o Jupatient o Outpatient 0 Adolescent o Alzheimer's Diagnosis and Assessment DBirthing Rooms • - 0 Blood Bank 0 Burn-Tjnit 0 Cardiac Care Tinit o Cardiac Rehab Program 0 CTScanner 0 Diabetic Education Program 0 Dialysis 0 Geriatric Services o -Home Health Services O Home Infusion q H�s�ice • 0 F1osiita1 Based Ambulance D Jntnsive Care Unit LI Lithdtripsy o MRI Scanner Total Number ofMedicare Certified Beds: 0 Neonatal ICU o Nuclear Medicine o Nursery o Nursing Facility o Obstetrics o Occupational Therapy o Inpatient o Outpatient 0 Open Heart Surgery •fl Organ Transplant o Specify 0 Outpatient Surgery O Pairi Management o Pediatrics U -PBT Scanner o Physical Therapy o Inpatient o Outpatient o Psychiatric Services 0 Inpatient o Outpatient 0 Pediatric 0 Adolescent 0 Radiation Therapy o Speech Pathology o Jnpatient o Outpatient 0 Tissues Transplant o Trauma Facility/ER Dept. o Resource o RegionaL o Area - 0 Community 0 Ultrasound 0 Urgent Care Centei o Ventilator Care —Long Term o Residential Day Care 0 Skilled Nursiiig Facility o Sports Medicine o Swing Bed Program OtherServices: (orQu-j Pu,ln-t3€ Are there services provided off -campus that would fall under the hospital outpatient billing and Tax ID? DYes lfyes, please 1itthese services, names, and Iocations: ('inc additional shect fneccssary) Are thei:e any other certified facilities based at your hospital and ifso, what are they (i.e., home health, hospice, skilled nursrng, dialysis)? Do you contract with any facility or provider group to provide services at the hospital? Jf go, what are the services, i.e., radiology, MRI, lab, ER, anesthesiology, DME, reference lab) tJIA. © April 2011 Iowa Credentialing Coalition (ICC) Version 1.1 Page 7 of 8 Iowa Department of Public Heaith Promodng and protecting tho health oflowans S&oSt Edit Onsite Review (Last updated 6/23/2015) Back Lo Onslte Reviews Print Version Service Name Physical Acldress Contact Name Daytime Phone Review Date * Completion Date Responsible Person * Drug Box* Waterloo Fire Rescue 425 East 3rd Street Waterloo, JA 50703 Black F-lawk County Barbara McBride 319-291-4460 6/23/2015 (mni/dd/yyyy) (mm/dd/y) j»arbnzMcBrith .- - Onsitefleview Questions - -132.7(1)a. Defic Resolution Time Resolved Date Notes 132.7(1)d. 132.8(1)ft 132.8(1)c. 1328(1)c.(2). 1328(1)c.(2). 132.8(1)d. 132.8(1)f. 132.8(1)h. 132.8(3)a. 1328(3)b, 1328(3)c. 1328(3)d(1). 132.8(3)d(2). 132.8(3)d(3). 132.8(3)f. 30 Days Currnf, complete appflcation on Ole (System Registry) - & 5tP*_- /' ET1 (mm/dd/yn'y) d€JnpniL1o4 No driver and communicati�ns traininkdateA listed in Ibe system regist[y for .Ion Eastman, Travis Jhnen, Micha Moore, and Ben Smilh. Steve Jorden's CPR shows expired. Compliant -Compliant Compliant Compliant Conipliant Compiiant Compliant Not Applicable Compliant Complianl Compliant Compliant Compliant Compiianl Compliant Read 641-132(147A) Ambulance(s) and personnel to maintain 24/7 Appropriate staffing Emergency driving policy Driver training: CPR/emergency driving & comm. Written contingency plan Written transportation agreement Critical care transport: P/PS levels only Patient care report for every patient - Protocols: current year, signed, changes filed Personnel function within SOP and level of service auth. Personnel rosters and files current MD required CEH on Ole RN/PA exceptions and MD required CEH on Ole Physician medical director 132.8(3)g. 132.8(3)h. 132.8(3)j, 132.8(3)m(1). 132,8(3)rn(2). 132.8(3)m(3). 132.8(3)o. 132.8(4)b. 132.8(4)c. 132.8(4)d,e. Resolution Tinle Resolved Date Nots ----1 132.8(5),-- 132;8(5)a,(2,3) 1328(5)b. 1328(5)c. • 132.8(5)d. ::i2.8(5)i. 132.8(6)a. 132.8(6)b. 132.8()c, - ---132.9(2)c. 132.9(2)g. 132.9(3). 132.9(4). 132.9(4). 132.9(4)a,b,c,d, 136.2(3)a. 136.2(3)b. Resolution Time Resolved Date Notes Compliant Compliant Compliant Compliant Compliant Compliant Compliant Cornpliani CDmpliant Defieie 30 Days Appropriate staif responds - reasonable aniount of time Wrilten notification (7 days)—chanqe of clir/owner Written notification (7 days)—change of med direction CQI policy includes medical audits CQI poflcy includes skills cornpetency CQI policy includes follow-up (loop-closure/resolution) Docunient an equipment niaintenance program Equip and supplies per physician approved protocol Rx and OTC druq training per protocols Pharmacy agreement and p and p per agreement - Eek .- (mm/dd/y) The pharmacy agreement that was available was incomplete. Complete it and send me a copy. Also update tlie drug lisI inihe protocols 80 it matches what the serviees is canyinand send me a copy of the list. Compliant - - Compliait Cosiiliaii Coinpliant Compliant - Compliant CompijanL Not Apj1ieable Not Applieable Not Applicable Compliant - Compliant Coinpiimt Co,npliant Coinpliant Compliant Deficient 30 Days Document a preventative vehide maintenance program Garage climate controlied, maintained, clean and safe Interior & exterior of vehicle and equip clean/disinfected Equiprnent properly secured Airway, electrical, niechanical equip clean/operational Proper disposal for soiled supplies Repoft (48 hrs): Fire, damage or theft of amb, equip, Rx Submit (7 days): MVC rpt. crash with PD, P1, or F Report (10 days): Provider ternination CQI poUcy: measurable oulconies CQI policy: type/rrequency of review, action plan and f/u Assistant(s) appointed in writing in CQI policy Randonily review written audits (medical director) Quarterly written audfts: niedical director or designee Written audits review pt. care, times, system resp, doc. Data collection niethod Data subrnitted (90 days) foliowing the end of a quarter L—' �I] (mrn/dd/yyyy) The serviee has not entered the lat Quarter2�l5 data into Field Bridge. Enter isi qnarter EMS dMa into Field Bddge and e-mail me when completed. - _ty_t ,J ) Comments Any deficiencies identified during todays inspeetion must be eorrected in 30 days or 110 later than July 23, 2015. Send deficiency resolutions by e-mail to Merril1.meeseidph.iowa.gov or by mail to: Merrill Meese P0 Box4l Alexander, Iowa 50420 © 2005 Iowa Department of PubRc Health, AU rights reserved. Privacy Statement 1 v6010.Y5 912/2015 Iowa FireBridge Fire Oepertrnents i Data Exehange Dispatch Moro Wolcome, ErIca Christlanson Logout Walerloo Fire Oepartmeril * Waterino Fire Department > Reports > Data Transfer Elistory Dashboarcl lncidents Modules 1 Staif Setup Data Transfer History Completed & = Cornpleted w/ Errors Pending 9 tneomplete Total Records Total Records status Oata QuaIIty User Imported File Uploaded Date UtIIIty Found in FIle * Xmported t lniport Update Validation Report j 06/31/15 09:08 AM NFIRS Data 186 165 Kevin Lee augl6-30-2015.LNC 17 8' 17 j 06/31/15 09:04 AM NEmS Data 110 110 Kevin isa augl-15-2015.INC 17 17 8' 17 2' 17 14' 17. j 08/10/15 09:06 AM NFIRS Data 142 136 Kevin Lee ju1y29-augB.INC 13 17 ] 07/29/15 10:11 AM NRRS DMa 145 144 Kevin Lee juIyl6-28.INC 14' 17 j 07/29/15 10:07 AM NFIRS Date 193 193 Kevin Lee julyl-15.INC 17 17 j] 07/17/15 04:47 P8 XML 2.0 539 539 ESO ESO NEMStSlmport.xmI 13 8 07/07/15 10:41 AM XML 2.0 594 594 650 650 WATERLOOIMAGETREND2O15O1O12O1SO1312.XML 14' 17 07/07/15 10:21 »i XMLZ.0 - --ESoES0.wA1EanoJMAGeTRENo.2oa5rno1-201s0131LNL4cu) 0 j 07/02/15 01:55 PM NFTRS Data 2 2 Kevin Les resubz.INC 17 14' 07/02/15 01:46 PM NEIRS Data 79 76 kevin Les may24-31.INC 8' 14' j] 07/02/15 01:42 P8 NFRS Date 1 1 kevin Lee resub.INC 14' 8' I] 07/02/15 01:34 PM NFIRS Dote 1 - 0 kevin Lee 1A07009062015JNC 17 14' I] 07/02/15 11:51 AM NFIRS Date 2 - 1 kevin Lee june resubikc 14' (7 j] 07/02/15 11:39 AM MFIRS Date 196 92 kevin Lee JunelG-30.INC (7 8' ]. 07/02/15 11:34 AM NFIRS Data 200 199 kevin Lee Junel-15.INC 8' 14' Recotds 1-16 ot 325 • NOTES 1)TetIs malI reprssent more than one seivlees recozda 1 mere than one servise was uploeded at the same time. 2)TotaI Records Found In FIte account for all recerds that could be foundlread In Irom ths irioded data file. 3)Total Records tmported tedlcates the total nurnber of records tbst mported arul are available through ttun Histoiy and Repoittng. ImageTrend Sorvice Bridge v6.8 412015 ImageTrend, Inc. Version 6.8.3.2 1/1 Iowa Depariment of Hurnan Services Iowa Medicaid Ownership and Control Diselosure Provider Name LiifaI°° t-t(e Federal Tax ID or SSN LJ3.. (O() 331 Pursuantto 42 C.F.R. sections 455.104 through 455.106, providers applying for Medicaid must disclose certain information about those who have a sufficient ownership interest in the provider as well as those who act as managers or agerits of the provider. The foliowing series of questions seeks the necessary information to comply with these reguiations. It is the provider's responsibility to ensure all information is accurate and to report any changes immediately by completing a new Ownership and Disclosure form. See Section 1.6 and Section 3 of the Provider Agreement. Only one form is required per Tax Identification Number (TIN) or SociaI Security Number (SSN). Iri the questionsthat fouow, the pr�vider Iisted above is referred to as "You" or "Your." Section 1: Provider Type Are you an individual practitioner or a group of practitioners? Individual Practitioner: EJ Yes oi No Group of Individual Practitioners Ell Yes orj No If you answered "Yes" and you re an individual practitioner or a group of individual practitioners, please skip to Section 5. Th owriership disclosure requirements do not apply to these entities that generally do nothave :bwners, such as individual practitioner or groups of practitioners. If you answered "No" because your entity is some form of business other than an individual practitioner �r a group of practitioners, please complete all sections. Section 2: Ownership Jnclividual Ownership Please list in the foliowing table all individua!s with an ownership or control interest in you. Include each person's name, address, date of birth (DOB), and SSN, title (e.g., chief executive office, owner, board member, etc.) and if an owner, the percent of ownership. "Persons with an ownership or control nterest" means: a) has an ownershi� interest totaling five percent or more in you; fl° b) has an indirect ownership interest equal to five percent or more in you; (W c) has a combination of direct and indirect ownership interest equa! to five percent or more in you; d) owns an interest of five percent or more in any mortgage, deed of trust note, or other obligation secured by the disclosing entity if that interest equals at least five percent of the value of the property or assets of you; 3° e) is an officer or director of your organization if you are organized as a corporation; or f) is a partner in your organization if orgariized as a partnership. t'Se 470-5186 (Rev. 3/15) Page 1 of 8 Table 1: Individual Owners Name of Individual Title Ownership Percentage (If applicable) Address Date of Birth SociaI Security Number Non -individual Ownership Please list all corporations or other form of business eritity with an ownership or control interest .in.. you. tricludeihe. TIN, the percerit of ownership, the primary address, all business Iocations, and the P.O. Box address. :A corporation or otherforrn ofbusiness entity is deemed to have an ownership or control interest in you if it: a) has anownership interest totaling five percent or more in you; fl) b) has an indirect ownership interest equal to five percent or more in you; ro c) has a combination of direct and indirect ownership interest equal to five percent or more in you; jD d) owns an interest of five percent or more in any mortgage, deed of trust note, or other obligation secured by you if that interest equals at Teast five percent of the value of the property or assets of you; f) e) 5 aiiofflcer or director of you if organized as a corporation; or f) 15 a partner in you if organized as a partnership. n' Table 2: Non -individual Owners Name af- Business Entity TIN Ownership Percentage Primary Business Address Alt Business Addresses All P0. Box Addresses Please copy this page if additional space is needed. Your Ownership of Subcontractors Please Iist all subcontractors in which you have an ownership interest of five percent or more. Include the TIN or SSN, the percent of ownership, the primary address, all business Iocations, and al! RO. Boxaddresses. 470-5186 (Rev. 3/15) Page 2 of 8 Table 3: Subcontractors Name of Subcontraetor TIN/SSN Ownership Percentage Primary Business Address All Business Addresses Alt P.O. Box Addresses Section 3: Individual Relationships If you Iisted in Table 1 any individual own&s of you, are any of the individual owners related to each other as a spouse, parent, child or sibling? LI Yes ora No If yu answered Yes, pleae provide ll of th,e foliowing information about each individual owner in the table below. Table 4: Social Security Number Person Nam� Relationship Date of Birth Ifyou Iisted in Tabie 1 anyindividual o:wners of you and also Iisted in Table 3 subcontractors in which you have an ownership interest, areany of the individual owners listed in Table 1 reiated to any owner of any subcontractors listed in Table 3 as a spouse, parent, child or sibling? 1111 Yesor[No If you answered Yes, please provide all of the foliowing information about each individual owner in the following table. Table 5: Social Secutlty Number Person Name Re!ationship Date of Birth Flease copy this page if additional space is needed. 470-5186 (Rev. 3/15) Page 3 of 8 Section 4: Other Disclosing Entities Do any owners of you have an ownership or control interest in any "other disclosing entity"? This question is asking if any of your owners have an ownership or control interest in any other organization that would qualify as a "disclosirig entity." "Other disctosirig entity" means any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs estabhshed under TitIe V, XVIII or XX or the Act. This inctudes: a) Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rurat health clinic, or health maintenance organization that participates in Medicare (TitIe XVIII); b) Any Medicare intermediary or carrier; and c) Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the:furnishing of, health-related services for which it claims payment under any�[an or program established under Title V orTitle XX of the Act. Whereas "disctosing entity" is timited to Medicaid provider, "other disclosing entity" can inciude • entities that are not enrofled in a Medicaid program. • List in the foliowing tabte the name of each owner of you who has such interest and the name of other disctosing entity in which the owner has an ownership or control interest in: Tabte 6: Name of Owner - Name of Other DiscIosng Entity Please copy this page if additional space is needed. Section 5: Mariaging Employees Federal regulations require that Medicaid agencies require providers to submit information about managing employees. The term "managing emptoyees" means a general manager, business manager, administrator, director, or other individuals who exercise operational or managerial control over, or who directly or indirectly conduct the to-toperation of an institution, organization, or agency. The term "managing employees" includes any "agent" of the provider, which would include any person who has been delegated the authority to obligate or act on behalf of the provider. All managing employees of the provider at any of the provider's practice tocations must be reported in this section. Flease provide the foliowing information in the table below; the name of alt managing employees, titte, address, DOB, and SSN. 470-5186 (Rev. 3/15) Page 4 of 8 Table 7: Name Titie Address DOB SSN 4 e to acLn&rtj rNe oWI O {I91 «\d\Utic&( «Ec I3Looercu ro cqo( O3Vit! O3 - �&2?3IJ ca V(3 P15D&f t Lo Please copy this page if additional space is needed. Section 6: Final Adverse Actions Thissectidn captures informationon "Finai Adverse Actions," such as convictions, excftisions, revocationsarictsuspensions: All applicable final adverse actions must be reported, regardless of whether any records were expunged or any appeals are pending. Enrolled providers are required to report aIhFinIAdverseActions/Convictioris within 30 days of the reportable event. Final Adverse Actions That Must Be Reported: \P CriminaI Conduct: The provider, supplier, or any owner of the provider or supplier must report any convictions of criminal offenses related to thatperson's involvement in any program under Medicare, Medicaid, orTitle XXservice program since the inception ofthose programs. Criminal offenses inelude: • Felony corivictions, guilty ptSs and adjudicated pre-trial diversions; financial erimes, suchas extortion, ernbezzlement, iricome tax evasion, insurance fraud, and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pre- trial diversions; any felony that placed the Medicaid program or its beneficiaries at immediate risk (such as a malpractice sult that results in a conviction of criminal neglect or misconduct); and any felonies that would result in a mandatory exclusion under Section 11 28(a) of the SociaI Security Act. • Misdemeanor conviction, under federal or state law, related to: (1) the delivery of an item or service under Medicare or a state health care program, or (2) the abuse or neglect of a patient in connection with the delivery of a health care item or service. • Misdemeanor conviction, under federal or state Iaw, related to theft, fraud, embezzlement, breach of fiduciary duty, or other financiai misconduct in connection with the delivery of a health care item or service. • Felony or misdemeanor conviction, under federal or state Iaw, relating to the interference with or obstruction of any investigation into any criminal offense described in 42 C.F.R. Section 1001.101 or 1001.201. • Felony or misdemeanor conviction, under federal or state Iaw, relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance. 470-5186 (Rev. 3/15) Page 5 of 8 Exclusions, Revocations, or Suspensions: Providers must also report any: • Revocation or suspension of a license to provide health care by any state Iicensing authority. This includes the surrender of such a Iicense while a formal disciplinary proceeding was pending before a state Iicensing authority. • Revocation or suspension of accreditatiori. • Suspension or exclusion from participation in, or any sanction imposed by, a federal or state health care program, or any debarment from participation in any federal executive branch procurement or non -procurement program. • Current Medicare or a state health care program paymentsuspension under any Medicare or a state health care program bililing number. • Medicare or a state health careprogram revocation of any Medicare or a state health care program billing number. Finat Adverse Action Reporting: :ForaIt individuals or entities Iistecl in any of the previous tabies, as well as the provider submitting this appflcation, provide aIIinformation required below for any individual or entity • that has been the subject of a Final Adverse Action. li_Havb you, underanypurrent or fdrmer•name or business identity, ever had a final adverse action? fl Yes or LJ[ No ••Report each final adverse action, when it occurred, the federal or state agency or the - court/administrative-body that imposed the action, and attach the resolution, if any. Table 8: - Organization or Person Name Final Adverse Action Taken By Date of Final Adverse Action Please copythis page if additional space is needed. 470-5186(Rev. 3/15) Page 6 of 8 Section 7: Patient Protection and Affordable Care Act Please answer all five quesflons: Does the provider appflcant have ariy current or previous direct or indirect affiliation (as defined below) with a present or forrner Medicaid provider? The term "affitiation" includes, but is not Iimited to, relationships between individuals, busiriess entities, or a combination of the twa. The term includes direct or indirect business relationships that involve: 1 a campensation arrangement, 2. an ownership arrangement, 3. managerial authority over either member of the affiliation, 4. the ability of one member of the affiliation to control the other, or 5. the ability of.a third party to controt both members of the affiliatian. 1 .Fbor:aiMndividuals or entities1isted:in-aiiyof the previous tabies, Iist all that have uncollected - debt owed to Medicaid ar any ather health program funded by any governmental entity, including, but notIirnited to, the federal and towa governments or mark none. None Name: For alt individuals or entities listed in atiy of the previous tabies, Iist all that have been or is subject to a payment supension uriderafederatly-funded heatth care program or mark norie. Nane ra Name: 3. For all individuals or entities listed in any af the previous tabies that have had its bitlirig priviteges denied or revoked or mark none. E/None Name: Please copythis page ifadditional space is needed. 470-5186 (Rev. 3/15) Page 7 of 8 4. For all individuals or entities Iisted in any of the previous tabies that have been excluded from participation under Medicaid, Medicare or any other federally -funded health care program or mark none. "None Name: 5. For all individuals or eritities Iisted in any of the previous tabies that have shared a National Provider Identifier (NPI) number or Federal Tax Identification number with another provider who has uncollected debt or mark none. "None Name: Rlease copy this page if additional space is needed. The provicier certifies that the information submitted on this form is, to the best ofthe provider's knowledge, true, accurate, and complete and that the provider has read this entire form before signing. The provider also understands that payment of claims will be from federal and state funds and that any falsification of conceatment of a material fact may be prosecuted under federal and state law. Printed Name of Legar Entity Signatory. ,&?lc7EsT g C/nfc' Signature of Authorized Sign ay, Date 470-5186 (Rev. 3/15) Fage 8 of 8 IOWA STATE WIDE UNIVERSAL FACILITY APPLICATTON ATTACHMENT WORKSHEET This worksheet is intended to provide you with additional information that may be required to be submitted with or attached to your Iowa Statewide Facility Application. Credentialing eutities to which you are applying will require some or all of the foliowing documents to be submitted with this application. Some entitiesrequire originals, copies or notarized copies. This list may not beall-inclusive. A specific listot'tequired documents is available from the entity to which you reapp1ying or providing credentialing infounation. Documcnts that may be required: Copy of Malpractice Insurance Face Page / Original Federal W-9 Tax Identification Form Copy of Quality Assurance Plan / You should contact the entity to whichyou are providing the Iowa Statewide Facffity Application for additional inf�rmation on any documents that will be required. © April 2011 Iowa Credentialing Coalition (ICC) Version 1.1 Page 1 of 8 WAThRLO-02 JDUFEL 4CORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD[?YYY) 91412015 THIS CERTIFICATE 3 ISSUED AS A MATrER OF INEORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFEIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE GOVERAGE AFFORDED BY THE POLICTES BELOW. THIS CERTIFICATE OF INSUaANCE DOES NOT CQNSTITUTE A CONTRACT BETWEEN THE ISSUING INSTJRER(S), AUTHORIZED REPRESENTATIVE OR PRODIJCER, AND TI -JE CERTIFICATE HGLDER. IMPORTANT: If the certifjcate holcler is an ADDITIONAL INSURED, the poIicyes) must be endorsed. If SUBROGATION 15 WAIVED, subject to the terms and condftions of the policy, certain policies may require an endorsement. A statenient on this certificate does not eonfer rigbts to the certificate holder in !ieu of such endorsement(s). PRODUCER PDCM Insurance 3927 University Ave P.O. Box 2597 Waterloo, JA 50704 CONTACT NAME: PHONE FAX CAIC No Ext):(319) 234-8888 (AJC.No): (319) 2344702 E-MAIL ADDRES$: pdcm@pdcm.com INSURER(5)AFFORDING GOVERAGE NAIC 11 INSIJRERA:TraVelers 40282 INSURED City of Waterloo 715 Mulberry Waterloo, IA 50703 INSURER 8 Satety National Casualty Corp. . ZLP15P3053A .. . . . .- .. . . INSIJRER C: 07/01/2016 INSURER 0: $ 1,000,000 INSIJRER E: INSURERF: X COVERAGES CERTIFICATENUMBER: REVISION NUMBER: THIS 5 TO CERTJFY THATTHE POLIGIES .OF INSURANCE LISTED BELOW HAVEBEEN ISSUED TO THE INSURED NAMED ABOVE FOR TI -IE POLICY PERIOD • INDICATED. NOTWITF-ISTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTR4CT OR OTHER DOCUMENT WTH RESPECT TO WHICF-J THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLIC ES DESCRIBED I-IEREIN 8 SUBJECT TO ALL THE TERMS, - EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SROWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR •LTR - . •: - ± TPOFINSURANCE ADDLSUBR INSO WVD - POLICYNUMBER « POLICYEFF (MM!00!YYYY) POLICYEXP (MM/DD/YYYY) LIMITS K X COMMERCIALGENERALLIABILITY . . ZLP15P3053A .. . . . .- .. . . 07/01/2015 07/01/2016 EACHOCCURRENCE $ 1,000,000 •CLAIMS44ADE X OCCUR . EME ce) $ 100,000 MED EXP (Any one person) $ PERSONAL&ADVIMJURY $ 1,000,000 GENLAGGREGATE POLICY OTHER: LIMiTAPPLIES PER LOC GENERALAGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 $ A AUTOMOBILE X LIABILITY ANYAUTO b8/NED HIREDAUTOS . - . .. SCHEDULD NON -OWNED AUTOS •1.. . H8109157P459 1 . «-. 1 H . 07101/2015 07/0112016 OMBIEOINGLELIMIT 1,000,000 BODILYINJURY(Perperson) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Peraccident) A X UMBRELLALIAB EXCESS LIAB X QCCUR CLAIMS -MADE ZUPI5P3OSS3 07/01/2015 07/01/2016 EACF4OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 DED X RETENTON$ 10,000 $ B WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY ANY PROPRIETORJPARTNER'EXEGUTIVE OFFICEF?V1EMBEREXCLUDED? (Manda(oy in NH) Ifyes, describo under DESCRIPT!ONOFOPERATIDNSbeIow YIN 1 j N/A 1• AGC4053449 ,. 07/01/2015 07/01)2016 PER STATUTE x OTH- ER E.L. EACH ACCIDENT $ 1,000,000 EL. DISEASE - EA EMPLOYEE $ E.L. DISEASE-POLICYLIMIT $ 1,000,000 A Professional -EMT ZLPI5P3OS3A 07/01/2015 07/01/2016 Each Occurrence 1,000,000 DESCRIPTION OF OPERATIONS! LOCATIONS / VEHICLES (ACORD 101. AddiUonal Remarks Sebedule, may be attacbed If more space Is requi ed) CERTIFICATE HOLDER CANCELLATION Amerigroup of Iowa, Inc. 5088 NorthAmpton iNorfolk VA23502 SI-IOULD ANY OF THE ABOVE DESCRIBED POLIGIES BE CANCELLED BEFORE THE EXPIRATI0N DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITI-1 THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2014/01) © 1988-2014 ACORD CORPORATION. AlT rights reserved. The ACORD narne and logo are registered marks ofACORD (Rev. Oclaber2007) Departu ent laternal 3venue er 3m Treasury Servlce Request for Taxpayer Jclentiflcation ftirnber and CertWcation - - - Glve forni to Ilte requester. IDe not send to the IRi. Nleme (as eltcwn on your lncome tax return) CITYOFWATERLOO fluslness natho, 11 dir(erent (ram abovo Print or te See Spec&ic Instmc-tions Oheck appropriate box: • lndivldual/Sole proprtetor 1 CorporatIon 0 Partnershlp jJ Limited Iiabillty ccmpahy. Euler Ilte tax classlflcntion (O=dlsregarded enilty, Ocorporalion, Pnpartnersltlp) !4 Olher (soe lnstruelions) 1"- GOVERWMEWT E 11111 Mdress (nuniber, street, and apt or sulte no.) 715MULBERRY STREET flequester's 000te and address (cpttonal) City, stato, and ZIP ccde - WATERLOO, IA 50703 List account nurnber(s) Itere (optlonal) - - - Tj,flThaxpayer Udentificaflon Nurnber (T(N) Enter your TIN in the appropdate box, llie TIN �rovlded tnust match Uie name given on LIne 1 to avokl backup wilhholding. For lndtvIduals, thls is your social sacurlty ttumber (SSN. However, for a resklent alten, solo proprietor, ou' dlsregarded entlty, see the Part 1 lnstnjbtlons on page 3. For other enIliles, It Is your employer kfentlffcaUon nurnber (EIN). If you do not have a nurnber, see I-Iow to get a 111'! on page 3. Note. l( He account Es Ili rnoreltian one narne, see tli chatt dn page 4 for gufdelines ort whose number to enter. - Certification Soolal sectirity nurnbor er Employer ideiti(ication number 42 6005327 Linder penalties o( pe4ury, 1 certlfy that: - 1. The nurnber shown on thls forni le my correct taxpayer ldentificatlon nuruber (or 1 ani waiting for a numher to be lssued to nile), and 2. 1 am not subject to backup wilhholdlrig because: (a.l amexempt froin backup wltiiholding, or (b) 1 have not been notifled by the Internal R�venue Servlce (1113) [hall arn subject to bSckup withhoiding as a result cIa failure to report alt lnterest or divirlends, cr (c) the 1118 has nolilled rio that am no Ionger subject to ha�kup wlthholding, and 3. 1 arn a U.S. clllzen or otlier U.S. person (delined beIcw. Certlfication instructions. Ycu must cross out Ibm 2 aboye Ifyou have been notllied by [he 115 Ihat you are curren[Iy subject to backup wlthholding because you have falled to report all-lnterest �nddlvldends en your tax return. For -eal estate transactlons, bern 2 doos not apply. For rnortgage interest paid. acquisltlon or abondonment b[seburcd prcperty, cancellation of debt, confrlbubloris to en lndividual retirernent arrangement (IPA), and generalty, payrnents other than interest and divklends, ycu are not requlred to slgn lhe Certiricatiorm, but ycu musi provirle your con-eot TIN. See tktmjn tftrct)cns o pag 4. 1 - Sign Sigriatore of ZIt?c1MY./c2./ Here u.s. person ' Dde t- Generaj nstructions Section references are to the Internet Revertue Gode unless o[herwise noted, Purpose af Forrn A person who is required to file an lnfcrmatlori return with the 1118 must obtain your correct Iaxayer identiflcatlon nurnber (TIN) to report, for exarnple, lncome paid to you, real estate transactlons, niortgage inlereat you pald, acquisltlon. or ahandcnrnent cf secured property, cancellallon of debt, or oontributions ycu made to an IFIA. Usa Forni W-9 only 1 ycu are a U.S. person (lncludlng a resident allen), to provide your correct TIN to the perscn requestlng It (tIle requestei) ancl, when applicable, to: 1. Cartlfy [Itat bbs TIN you ars giving is correct (or ycu are waltlng fcr a nuniber to be Issued) 2. CertIfy Uat you are not subject to backup wlthhoidlng. cr 3. ClaIm exemptlon from backup wlthhold!ng If you are 3m U.8. exempt payee. 1 applicable, you are also certi(ylng that as a U.5. person, ycur allocable share of ariy pattnershlp Income frorn a U.8. trade or busineso Is not subject to lhe wlthholdlng tax on foralgn pariners' sharsof effectivelyconnected Income. Note. (1 a requester gives y6u a fcrm other (han Forrn W-9 to request your TIN, you rnust use the requester's forrn if 1 Is substantially sirnilar to thls Fcrrn W.-9. Detinition of a U.S. person. For federal tax purposes, you are consldered a U.5. person if you are: e An lndivldual who 9 a U.. cltizen or U.8. esident alien, o A partnership, corpot-ation, company, or assoolatlon created or organlzed In the United States cr under Ihe laws of the Uniled - States, o An estate (euler [hari a fcrelgn estate, or o A domestjc twst (as defined In flegulations sectlon 301.7701-7). Speoial rules for partnershlps. Partnerships that conduct a trade cr buslness In the linited States are generaily required to pay a withholdlng tax on any forelgn partners' share of incorne bern such buslnese. Further, in certaln pases wheie a Form W-9 has not been recelved, 3m partnership 15 requlred to presunie that a partner is 3m fcreign person, and pay the wlthhclding tax. Tllerefore, 1 you are a U.S. person that 5 a partner In a partnershlp conductlng a Irade or buslness In tlie United Stabes, provlde Forrn W-9 to the parinership to establlsh ycur U,S. status and vold withholdlnri on your shai'e of partnei-shlp inccme. The perscn who gives Forrn W-9 lo bbs padnershlp for purposes of establlshing its U.S. status and avoldlng withholdlng dri Ito dIk5dbl&sFare of net lncome frorn tlie partnership conductlng a trade or business In the iinited States is In the foliowing cases: s The U.S. owner of a disregarded enlily and not tlie enlity, cat. No. 1c23IX Fcrrtm W-0 (Rev. 10-2007) EMS SERVIGE OR SYSTEM CONTINUOUS QUALITY IMPROVEMENT (CQI) GNEEAPPOINTMEN Generat Purpose: Ths 001 Poticy estabHshes guidelines for the rnplementation of a program to support EMS providers as they strive to provide excellent patient care. These policies intend to provide direction to set measurable goals and detine minimum performance standards f�r the individuals and service. This consistent, fair evaluation practice will provide th routine feedback every provider deserves. This policy meets or exceeds the requirements of Iowa Gode Chapter 147A: Emergency Medical Gare– Trauma Gare and the Iowa Administrative Gode (IAC): 641- 132.6(147A)Service program evels of care and staffing standards and 641-132.9(147A) Service program—off-Iine medical direction. General Procedure: The interaction of the physician, service Ieadership and providers is critical for the success ofthisCQI program. AtFstaff must understand their role, responsibilities and duties as part of the 001 team. Every tem mrnber shall receive an initia! orientatiori to this policy and be provided with an opportunity fbr input and updats when amended. Approvat& Affirmation: The sigiatures within this document indicate approval of the policy and agreement to perform the duti6sas an official deslgnee of the physician medical director. SERViCENAME: /n1er1oo F: Re3ecE SERVICE LOCATION: td f,irLdDJ-)3 • Designee Appointment: The medical director shall conduct 001 «6tivities or appoint individual(s) to ensure written audits of the patient care reports are completed; staff orientation, GEH and skUI competencies are conducted and documented; and actions plan, follow-up and resolution are done as defiried within this policy. 1 acknowtedge that 1 am appointed, by the medica! director, as an officiai 00! designee. 1 understand my duties and will implement and maintain this CQI program as directed. PA fl &rbr' AM(TcLc \J&ban F(arMt-iv1 tf( (o(fe3s-l±. (\F\1±e /Th-tcPh• Siguttij- '.-' \JL4 Dthe - 7 Policy: EMS providers shal! provide care within the current lowa Scope of Practice and as authorized, in writing, by the medical director. Procedure: J bt�- Medical Director C1+STopfeR )J; ?-/ S Service or System Director - &rbpwn. j}'f:cL2 a 4i&!a --J--7- \ • Designee Appointment: The medical director shall conduct 001 «6tivities or appoint individual(s) to ensure written audits of the patient care reports are completed; staff orientation, GEH and skUI competencies are conducted and documented; and actions plan, follow-up and resolution are done as defiried within this policy. 1 acknowtedge that 1 am appointed, by the medica! director, as an officiai 00! designee. 1 understand my duties and will implement and maintain this CQI program as directed. PA fl &rbr' AM(TcLc \J&ban F(arMt-iv1 tf( (o(fe3s-l±. (\F\1±e /Th-tcPh• Siguttij- '.-' \JL4 Dthe - 7 Policy: EMS providers shal! provide care within the current lowa Scope of Practice and as authorized, in writing, by the medical director. Procedure: 1. EMS providers shali review the Scope of Practice for EMS Froviders during initia! orientation to the service and whenever the scope is officially amended. 2. The service shall maintain documentation of initia! and periodic staif reviews of the Scope of Practice. 3. EMS providers shall provide care within the Scope of Practice for their certification eve! Iimited by the service program level of authorization. ECTI�NB PROTOCOLSHT PoIicy: EMS providers shall detiver care as directed in the medical director authorized protocols. Procedure: 1. The.medical director shall reviewand authorize aH protocol modifications including any state and/or Iocal protocol changes. 2. The service shall ensure the Regional EMS Coordinator promptly receives the medical director signed protocol authorization, change pages and medication Iist each time the protocols are amended. 3: The EMS servicewiII maintain documentation of protocol education for EMS providers. - 4. The EMS servibe will provide and document training after the medicai director has authorized any state or Ioca! changes to the protocols. 5. EMS providers shall deIive care asdirected within the approved patient care protocols. 6. Treatment rendered that deviates from the approved protoco!s must be documented on the patient care report (PCR) and reported to the service director and to the attention of the medical director. SECTION C; INJTJAL ORIENTATION PROCES Policy: New staif shall comp!ete a standard credentialing orientation process that includes basetine medical competencies. Procedure: 1. The service shall maintain documentation of new staif orientation under the direction of an assigned preceptor using the service Orientation Form. 2. As a niinimum, the orientation will inc!ude training on all service agreements, policies, procedures and protoco!s. (e.g., current Protocois, CQI Po!icy, Emergency Driving & Communication Po!icy, Pharmacy Agreement and Policies & Procedures, etc.) 3. The service shali maintain documentation of RN or PA equivalency training and forms as required by the Bureau of EMS. 4. The conipleted Orientation Form shall be kept on file. SECTION D SKILL MAINTENANCE Page 2 af 7 CQI PoIicy Manual & Designee Appointments Octcber 2014 EMS SERVICE OR SYSTEM PHARMACY -BASED OPTION AGREEMENT, POLICIES AND PROCEDURES FOR PRESCRIPTON DRUGS AND CONTROLLED SUBSTANCES Waterloo Fire Rescue, 425 E. 3 Street, Waterloo, A 50703 Typeor Print Name and Location of any Satelilte Services: 1812 LaPorte Rd, Waterloo, IA 50702 222 W. Donald Street; Watertoo, IA 59703 1200 Ansborough Ave. Waterloo, IA 50701 617 Nevada Street, Waterloo, IA 50703 3233 Ansborough Ave. Waterloo, IA 50701 General Purpose: To estabflsh a medication prograrn that meets or exceeds the requirements of Iowa Code Chapter 657-11(124, 147A, 155A) Drugs ir Ernergency Medical Service Programs and 641-132.8(147A) Service rogram levels of care and staffing standards and 641- 132.9(147A) Service program—off-Une medical direction. General Procedure: The interaction ofthe phyaician medical director, pharmacist, service leadership and EMS providers is critica[ for the success of the medication program. Alt staif must understand their role, responsibiflties as part of the team. Every team mernber shau receive an initial orientation to thts poRcy ahd be provided with an opportunity for in�ut and updates whenarnended. tEmaiF a sighcd erectrortic dopy or mail a copy ef this sigrted pollcy to your Regional EMS Coordinator*** Approval & Afflrmation: The stgnatures within this document indicate approval of the po[icies and procedures and commitment to perform the assigned duties as described within the agreement. Pollcy Appr�vat TYPE or Print Narne Signature Date Pharmacist in -ArSie-Wright thargeBase \ Service Director at the Primary Site Barbara McBride 4 526-2015 Page 1 of 7 CS - Pharmacy Option October2fll2 If using a Gombination Pharmacy -Based Option and Medical Director -Based Opflon, list the drugs that wiil be owned by the pharmacy. If not, deiete this from tho policy List the drugs that will be owned by the pharmacy: PRINT OR TYPE BASE PHARMACY INFORMATION: Pharmacy Name Street Address or P0 Box City State, Zip Code Covenant Medbai Center 3421 W 9 Street Waterioo, IA 50702 DPh6iiS t1drhber; Efriail Address: 319-272-8800 M"r<v .nc'<xQ QDJ' '- c ¼ Pharmacist in Char.e Narne License Number License Ex.iration \fl51 13b SECTION kRESPbNSIBiLiTY, WRITThNAGREEMEWt OWNERSHIP Policyt The service shall rnaintain a formal wrltten agreernent and policies and proceduresthatdescribe the role and responsibilities of the parties thatenterthe agreement. Procedure: 1. Pharmacy -based prograrns are operating as an extension of the pharmacy. Ownership of the drugs remakis with the lowa-licensed pharmaoy. '1 2. The pharmacist in charge shall be responsible for ensuring the management of alt prescription drugs complies with federai and state laws and regulations. 3 The pharmacist in charge and the service director shall sign the agreement. 4. The agreement shall be rnaintained at both the pharmacy and the primary program site. 5. The service shall ernail a signed e[ectronic copy or mali a COpy of the signed agreement to the Regionat FMS Coordinator promptty when initiated or amended. SECTION B: TERMINATIONOP SERVEGES PoIicy This agreementmay be terminated at the discretion of the se.rvice director orthe pharrnacy. Procedure: 1. Written notification af termination shall he provided to the other party at teast 30 days pr[or to terminatiori of services. 2. immediately upon termination, alt controlled substances shalt be jointly inventoried by the pharmacist in charge and the service director or their designees. 3. A record ofthe inventory shall be maintained atthe pharmacy. 4. Alt drugs that are the property of the pharmacy shall be irnrnediately returned to the pharrnacy. Page 2 of 7 05 - Pharmacy Option Octnber2�l2 >1 .SECTION C PCL1CIESAND.PROCEDURES. Policy: The pharmacist in charge and service director shall develop, implement and adhere to these written pharmacy procedures for the operation and management with respect to prescription drugs. Procedure: 1. The service shall maintain documentation of periodic reviews of these policies and procedures by the pharmacist in charge or designee, medical director and service director. 2. The service shall maintain documentation of staif training to the service pharmacy agreement and po!icies & procedures when initiated and amended. 3. Ali records regarding prescription drugs shall be maintained and be availab!e for inspection and copying by the lowa Board of Pharmacy and the Bureau of Emergency and Trauma Services. 4. Identification, Access and Administration a. The service shall ensure that access is Iimited to appropriate staif and proper documentation is maintained. • b. The service shati maintain records that Iog access to prescription drugs and records regarding procurement, storage and administration ofthe drugs. c. The Iog shall be maintained in a readily -retrievable manner and be made •available for inspection and copying by the Iowa Board of Pharmacy and the Bureau of Emergency and Trauma Services. d. The og shallinciudethe staif printed name and signature, printed and signed initials, level of certification and other unique identification used in the service records. e. Access to prescription drugs shall be Iimited to certified EMS providers that are isted on the pharmacy signature Iog and System Registry roster. Drug box is iri a Iocked cabinet with keypad entry. The drug kit itself is Iocked with a color coded tag. f. EMS providers may administer prescription drugs that are within their Scope of Practice and authorized in written protocols by the service medical director. 5. Procurernent, Storage, lnspection and lnventory Control a. The pharmacist in charge shal! order, receive and distribute prescription drugs. b. Records of ordering and receipt of drugs shall be maintained by the pharmacist. CS - Pharmacy Option October 2012 c. The service shall maintain, at the primary site, an accurate list of all prescription d ru g s. d. The service shail maintain records of monthly inspections of all drugs at the primary site and all satelhtes. e. The inspection shall include removal of outdated or adulterated drugs that are quarantined for disposal. f. Staif may handie drugs within their current scope of practice as defined by the Bureau of Emergency and Trauma Services. All staif is authorized to perform and document monthly inspections of security and temperature. h. Storage at the primary site and all sateliltes will be in a designated, secure, clean and free of debris climate -controlled area. g. i. Envirohrnental temperatures shall be recorded on a monthiy basis, as a minimum. Drugs exposed to extreme temperatures (>104 degrees and <13 degrees Fahrenheit) shall not be administered to patients and removed from usable stock and quarantined for proper disposal. k. The pharmacist in charge shall notify the service regarding recalls and ensure removal and replacement. I. Expired,recalled and damaged drugs (except controlled substances) shall be rernoved from usab!e stock and returned to the pharmacy. 6. Replenishment a. Service staif may request replenishment of drugs maintained at the primary program site or sateilites provided that the pharmacy has been supplied with administration records justifying the order. Used drug kits are turned into the pharmacy, and exchanged with a new one. A Iog sheet is signed at that time. After hours at Covenant hospital an RN will get into their Pyxes System and exchanges one used kit for 1 new kit. b. The pharmacist shall approve every drug taken from the pharmacy's dispensing stock. The pharmacist shall document and maintain verification of approval. CS - Pharmacy Option October 2012 1 1 :1 1 1 1 3. Ariy deficiencies shall be documented on the checklist and brought to the attention of the service director for corrective action(s) and the resolution shall be documented. 4. Documentation of vehicle checks and maintenance shall be kept on file. SECTION K: PHARMACY POLICIES & PROCEDURES Policy: Certified EMS providers shall read and provide care within the service program's pharmacy agreement, policies & procedures, as authorized in writing. Procedure: 1. The service director and the medical director and/or pharmacist -in -charge of the base pharmacy shall maintain agreements and policies & procedures that comply with Pharmacy Administrative Code Chapter 11 [657] - Drugs in Emergency Medical Service Programs. 2. Theservice willmaintain dccumentation of stafftraining ofthe pharmacy policies & procedures. 3. The service will maintain documentation of staif training of alt over-the-counter and other medications authorized within the protocols. 4 The servicewill provide and document training each time the pharmacy policies & procedures or authorized drugs are modified. 5. Alt EMS providers must follow the approved pharmacy policies & procedures. 6. Any deviations from the servide program pharmacy policies and procedures shall be broughtto the attention ofthe service program director. Page 7 of 7 CQI Poticy Manual & Designee Appointments october2Ol4 11 2014-2015 WATERLOO FIRERESCUE EMS REPORT Complete this form and share with the service owner, medical director and staif. Keep copies on file. Service/System Name Waterloo Fire Rescue Location(s) Waterloo, lowa Standby (sporting and school events, fairs, rodeos,etc.) Print Name: Signature: Date: Service Owner City ofWaterloo Emergency transports 5963 Medical Director Chris Hill Medical Supervisor Barbara McBride Typ�s�fResponses ... . Number Cancelled 3 Standby (sporting and school events, fairs, rodeos,etc.) 13 No patientfound . 18 Treat ani release 196 Emergency transports 5963 Total number of responses for EMS 6,756 Times for 911 CalIs — - - Minutes Average time from first page to enroute- both truck and ambulance 00:01:06 Average time from flrst page to arrival at the scene- both truck and arnbulance 00:04:40 Ambulance services only: Average scehetime- mdical 00:13:23 Ambulance services only: Average scene.time .trauma 00:14:23 Page 1 of 1 Annual EMS Report June 2015 * S .;: PoIicy: All staif shall mairitain skiII competency for all procedures & equipment as aflowed by the medical director. Procedure: 1. ALI staif will promptly complete assigned ongoing skiII competericies, within their Scope of Practice, as defined by the medical director. 2. The service will maintain documentation of completion of the skiII competencies as designated by the medical director within the established timeframes. The medical director may add or detete criteria to nieet the unique needs of the service. FREQUENCY OF PRACTICE Q = quarterly, B = biannuatly, A = annually, NA = not a.plicable Q A NA ASSESSMENT: vital signs for all ages ADULT & PEDIATRIC AIRWAY: BVM, suctioning, oral & riasal, and/or per protocol CARDIAC ARREST MANAGEMENT: CPR, AED for all age groups / MEDICATION ADMINISTRATION: over-the- dounter, patient assisted, aridlor per protocol IIVHVIOBIUZATION DEVICES: cervict collars, I�ng and thort boarUs, extrmity splints including fraction / AT ADULT & PEDIATRIC AIRWAY: bridge, double- lumen, endotracheal / ADULT & PEDIATRIC IV/tO ACCESS v NEEDLE CRICOTHYROTOMY v NEEDLE THORACOSTOMY Page 3 of 7 CQI Policy Manua! & Designee Appointments October 2014 ..t:•• ..<4rt[E SECTION E: CONTINLJINGEDUCATION - PoIicy: Alt staffwill maintain the appropriate EMS education to be prepared to provide comprehensive, competent, quality care to all patients. P roced u re: 1. EMS staif will maintain current lowa EMS certification, Healthcare Provider CPR and emergency driving and communications training. 2. Drivers on the roster will maintain Healthcare Provider CPR and emergency driving and communications training. 3. Alt staif Iisted on the roster shal! promptty provide the service director with the docurnentation required to maintain current personnet and/or trairiing files (e.g.; CPR card, driver's license, etc.) 4. Alt staif will document course completion in any or all of the foliowing courses, within their scope of practice, as assigned by the medical director. The medical director may add or detete criteria to meet the unique needs of the service. COURSE DESCRIPTION NO Advanced Cardiac Life Support (ACLS) 7 Pediatric Advanced Life Support (PALS) SECTION F: WRITTEN MEDICAL AUDITS Policy: The EMS service shall ensure that writteri medical audits review patient care & protocol compliance, response time & time spent at the scene, system response, and completeness of documentatiori. Providers shall receive timely feedback on audited PCR's. Procedure: 1. Within 24 hours, the responding staif shall complete and file a written patient care report and ensure that the receiving facility has a copy of the completed PCR. 2. Any significant deviation from the approved protocols or standard of care will be brought to the attention of the CQI appointee. 3. Any discussion of EMS responses shall be confidentia! and limited to current staif. 4. Assigned CQI auditors shall perform written audits quarterly. 5. An audit shall be complete when it is signed by the PCR author, reviewed by responding staff and the auditor is satisfied with the loop closure. Page 4 af 7 CQI Poticy Manual & Designee Appointments October 2014 d) For ambulance services: average scene times for medical and trauma. 2) In addition to resporise and scene times, the staif and rnedical director shall select at least one additional indicator to measure and include in the Annual Report. ria to meet the uniciue needs of the service. Indicator - ¥es No One full set of vital signs and the GCS will be completed 95% of adult and pediatric patients. MuItipIe, complete sets of vital signs and the GCS will be documented on 75% of the patients with transportation times greater than 15 minutes. Eligible chest pain patierits will receive aspirin (ASA) per protocol before transport 90% of the time. 90%ofsuspectedstroke patients will receive a neurological examination per protocol. Scenetime fortraumapatients with time critical injuries shall be 10 minutes or less 90% of the time. Reasorrfor useof lights &sirens to the scene and to the destination will be documented on 75% of responses. IVIAINTENANCE.:: Poticy Theservicewill aintain equipment in a mannerthat ensures equipment is cleah andfunctions well. Equipment maintenance shall, at a minimum, fpllow - the manufacturers recommendations. Supplies shall be routinely inventoried to - - - ensure appropriate quantities are available and not outdated. Procedure: 1 Any equipmerit used shall be cleaned and supplies replaced foliowing each response. 2. Assigned staif shall complete a detailed equipment checklist (including quantities and outdates) month!y, as a minimum. 3. Any deficiencies shati be documented on the checklist and brought to the attention of the service director for corrective action(s) and the resolution shall be documented. 4. Documentation of equipment checks and maintenance shalt be kept on file. SETION.J: VEHICLE MAINTENANCE PoHcy: Preventive maintenance shali be routinely conducted on alt vehictes to limit downtime, minimize inadvertent failures and reduce maintenance costs. Procedure: 1. Vehicles shal! be maintained according to manufacturer's recommendations. 2. Assigned staif shall cornplete and document a detailed vehicle checklist as a minimum, monthly. Page 6 of 7 CQI Policy Manual & Designee Appointments October2Ol4 4 0 1 3:' r Jn 1 1! ) -\S ?W'°QSfl ttt 0 0 1::' ¥-9 pJt- 3 0 0 (11 rP 0- - 1 (D FACILITY ENROLLMENTSPREADSHEET -t t 1 u3 C?°)ht Ib' b) c (D rt - 0• t og < (D - CKV) -t'h = m c (D n 0 2 -u u s -s (7? LQ(J 0) J) 'R*ij J4J c'. - 2> n (D rt :3 rt rn ,