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HomeMy WebLinkAboutC-2919\ONAI C0 m O n Z 2'p CTI q� INSTRUCTION TM since 1988 100-SO C 011 AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE THIS AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE is made between American Medical Response West, d /b /a National College of Technical Instruction, ( "School ") and the City of Arcadia (the "Contractor ") effective as of October 1, 2014. WHEREAS, School is a program which offers a program of instruction leading to certification or licensure of its students as Emergency Medical Technician, Emergency Medical Technician - Paramedic and other, similar health care and pre - hospital providers ( "Students "); WHEREAS, As a part of the licensing and /or certification requirements Students must complete a course of study including a field internship experience ( "Field Internship Experience ") by and through assignment to various mobile intensive care units operated by Contractor; WHEREAS, Contractor is a provider of emergency medical service, including both advanced life support and basic life support pre - hospital care and transport, and Contractor has agreed to assist School by providing a limited Field Internship Experience for Students, upon certain terms and conditions, so long as its participation in the program does not jeopardize patient care or compromise Contractor's standards of service to its patients. NOW THEREFORE, in consideration of the foregoing and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereto agree as follows: 1. TERM. 1.1. Commencement Date. This agreement shall become effective when signed by all of the parties ( "Effective 2007 NCTI Affiliation Agreement Confidential and Proprietary Date ") and completion of the written approval and certification contemplated in paragraph 2.2, 2.3 and 2.4. This agreement shall be for a term of twenty - four (24) months from the Effective Date. Any renewal shall be set forth in a writing signed by the parties. 1.2. Termination. This agreement may be terminated by either party, with or without cause, upon thirty (30) days written notice to the other party as provided herein. 2. RIGHTS AND OBLIGATIONS OF SCHOOL. 2.1. School's Accreditation. School shall maintain a qualified educational program for Students designed to provide a smooth transition into licensure /certification of Students as Emergency Medical Technicians, Emergency Medical Technician - Paramedics or other similar pre - hospital health care providers. School's program shall include programming, administration, matriculation, promotion and graduation and shall be approved or accredited by relevant licensing /certifying agencies in the state(s) and county(ies) in which School resides and in which the program contemplated herein is to operate. 2.2. Approval by Licensing /Certifying Agency(ies). School shall secure from all relevant licensing /certifying agencies written approval for the Field Internship Experience program contemplated herein and shall maintain such approval throughout the course of the program. School shall provide Contractor with a copy of the written approval and applicable guidelines or protocols �V�oNAL co m � m o Z T 2'o CTS 94 N5TPUCTION TM c�— !1,, AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE applicable to the program before assigning a Student to the Field Internship Experience program. 2.3. Student Licensure /Certification. School shall ensure that each Student enrolled in the clinical program is compliant with any Licensure certification required for participation in this program, which may include, but is not limited to state EMT and CPR credentials or any provisional Licensure /certification. School shall provide Contractor with a copy of the requisite Licensure and or certification for any Student enrolling in the Field Internship Experience before the Student is allowed to participate in the program unless, the licensing /certifying agencies advise School and Contractor, in writing, that Licensure /certification is not required and the Field Internship Experience program is approved under all applicable, or potentially applicable, laws and regulations. 2.4. Approval by Doctor or Agency Having Medical Control. If applicable, School will secure from the doctor or agency having medical control in the state(s) or county(ies) in which program will operate, written approval for the Field Internship Experience. Such written approval shall, at a minimum, define the scope of practice and required supervision of any Student participating in the course of clinical education. School will provide Contractor with a copy of the approval contemplated in this paragraph before assigning any Student to the clinical program. 2007 NCTI Affiliation Agreement 7 Confidential and Proprietary 2.5. Records. School will keep and maintain accurate records for all Students participating in the Field Internship Experience. The records will include the Students transcript, Licensure or certification, temporary license or certification (if applicable), pre- assessment health record, and record of history / vaccination / immunization as set forth in paragraph 2.8 hereof. School will maintain the records for a period of at least four (4) years (or any greater period as may be required by applicable) from the date Student completes, or ceases to participate in, the Field Internship Experience contemplated herein. 2.6. List of Participants, Qualifications, Objectives and Representations. School will notify Contractor at least thirty (30) days prior to the inception of a course of Field Internship Experience of the names, qualifications and performance objectives for each Student scheduled to begin their Field Internship Experience. Inclusion by School of a Student's name on this list is School's representation that the Student possesses the necessary skills, licensure /certification and immunizations to engage in the Field Internship Experience. The School shall comply with any requirements or procedures that Contractor requires regarding documentation to verify the Student's qualifications for the Field Internship Experience. 2.7. Contractor Rules and Regulations. School will use all reasonable efforts to cause Students to comply with Contractor's policies, procedures, work -1 m m O 0 T 2 '0 CTi 94 INSTRUCTION TM Su.��r /9FF AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE rules and regulations, including preservation of the confidentiality of patient care and patient care records. School will, prior to allowing a Student to participate in the Field Internship Experience, review patient confidentiality as well as the Contractor's policies, procedures, work rules and regulations with Student and secure Student's agreement to abide by all such rules and regulations. 2.8. Pre - assignment Health Assessment. School will cause Student to complete a pre- assignment health assessment, at Student's or School's expense, which includes, but is not limited to: history of communicable diseases and immunizations, proof of tetanus vaccination or immunization, proof of Hepatitis B vaccination or executed declination and waivers of the Hepatitis B vaccination by the Student, proof of MMR vaccination, respiratory certification by a physician and PPD test. School will provide proof of satisfactory completion /vaccination to Contractor upon request. Inclusion of a Student's name on the list referenced in paragraph 2.6 is School's representation that Student has completed the pre - assignment assessment and is physically able to perform the tasks associated with the program. 2.9. OSHA Compliance. Prior to allowing Student to enroll in the course of Field Internship Experience, School will educate and train Student in compliance with all relevant and required OSHA regulations including, but not limited to, Blood -borne Pathogens Standard and TB Standard. 2007 NCTI Affiliation Agreement j Confidential and Proprietary 2.10. Personal Protective Equipment. School shall provide Student with all necessary personal protective equipment, including fitting, as is, or may be, required by OSHA or other regulatory agency as required in locale of Contractor prior to assignment to the Field Internship Experience. Such equipment may include: safety glasses, face shields and particulate respirators. School recognizes and will inform Student that this equipment must be in the possession of the Student as a condition of their participation in the program. Failure to possess and use the required OSHA equipment will result in Student's dismissal from the program. 2.11. Assistance in Obtaining Signatures and Compliance. School recognizes that its Students have certain obligations and will be required to execute certain documentation in order to be eligible to participate in the program. School shall assist Contractor in obtaining any necessary signatures and ensuring Student compliance with Contractor rules and this agreement including, but not limited to, those contained in part 3 of this agreement. 2.12. Evaluation of Performance. School, in conjunction with Contractor personnel, is responsible for and shall make arrangements for evaluating Student's performance during the clinical program. 2.13. Minimum Age of Participants. School and Contractor will only allow Students that are at least eighteen (18) years of age to participate in this �1S\ONAL CO! G/ o Z T 2'o CTI I' INSTRUCTION Sirtrr roxx AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE program. Inclusion of a Student's name on the list referenced in paragraph 2.6 is School's representation that Student is at least eighteen (18) years of age. 3. STUDENT OBLIGATIONS AND REQUIREMENTS. 3.1. Release. Student will, prior to participating in the clinical experience, read, understand and sign a ride -along waiver releasing Contractor from any and all liability and /or responsibility arising out of Student's participation in the Clinical Experience. This release of claims must be executed, and on file with the School, prior to Student participation in the program. The release is a condition precedent to Student's participation in the clinical experience and no Student will be permitted on a Contractor vehicle without having signed the release. The release is attached hereto and made a part hereof as Exhibit A. 3.2. Pre - assignment Health Assessment. Student shall complete a pre - assignment health assessment as set forth in paragraph 2.8 hereof. 3.3. Contractor Rules and Patient Confidentiality. Student shall comply with Contractor's procedures, policies, rules and regulations, including maintenance of patient and records confidentiality. Students, while participating in the clinical program, on Contractor property, must meet all standards of appearance and conduct required by Contractor of its own employees. Student shall comply with all applicable OSHA rules or regulations. 2007 NCTI Affiliation Agreement 4 Confidential and Proprietary Student shall have in their possession at all times when on board a Contractor vehicle personal protective equipment and use such equipment when, as and where designated by Contractor personnel. Any information generated as a result of the activities set forth in this agreement, including information regarding patients or business activities of Contractor, as well as any information regarding the students and their performance or the Training Program itself, shall remain confidential. Students will be required to sign an acknowledgement of their understanding of the mandates for confidentiality as imposed by the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA); the U.S. Privacy Act of 1974 and any applicable state laws. 3.4. Student Intern Agreement. Student will read and execute the student intern agreement. Execution of the student intern agreement is a condition precedent to participation in the Field Internship Experience program. The student intern agreement is attached hereto and made a part hereof as Exhibit A. 4. CONTRACTOR RIGHTS AND OBLIGATIONS. 4.1. Contractor Rules. Contractor requires Students, while participating in the clinical program, on Contractor property, to meet all standards of appearance and conduct required by Contractor of its own employees. Contractor reserves the right to refuse to allow any Student to participate in the clinical program for 0NAL Co! M ` m n G/ o s 2'o CTi q� hVSTRUCTION rr S—, 1988 AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE failure to comply with Contractor standards. 4.2. Student's Skill Level. Contractor reserves the right to discontinue Student's participation in the program should Contractor, in its sole discretion, determine that Student's skill level is substandard. Contractor will immediately advise School of any such concerns or situations. 4.3. Orientation Program. Contractor may require Student to attend an orientation program designed to orient Student to Contractor's rules regulations and policies prior to beginning their Field Internship Experience. The details and procedures for the orientation program shall be in the Contractor's sole discretion. 4.4. Contractor's Control of Patient Care. Contractor reserves the right to determine where, when and if a Student may participate in the provision of care to its patients. Contractor will endeavor to utilize Student, and allow them to utilize as many of their skills in as many situations as possible. However, patient care is paramount and Student shall follow Contractor's instructions with respect to the provision of patient care. 4.5. Right to Control Participation. Company reserves the right to refuse to allow any Student to participate in the provision of care at the scene of an emergency where, in company's sole discretion, permitting Student to participate would endanger the Student, a patient or an employee of Company or otherwise be inappropriate. 2007 NCTI Affiliation Agreement Confidential and Proprietary 4.6. Student Evaluations. Contractor will cooperate with School in performing evaluations of Student's Field Internship Experience. 4.7. Provision of Field Internship Experience. Contractor will provide a Field Internship Experience for the School's Students in compliance with the guidelines, protocols, scope of practice provided by the licensing /certifying agency and in accord with the instructions of the doctor or agency having medical control, if applicable. The number of Students that Contractor accepts into the Field Internship Experience shall be determined by mutual agreement between School and Contractor. 5. INDEMNIFICATION 5.1. Indemnity for Third Party Claims. School will save, defend, indemnify and hold harmless Contractor, its officers, employees, agents, affiliates and representatives of and from any and all claims, suits, costs and actions arising out of the provision of the Field Internship Experience. This indemnity shall survive and remain enforceable after the expiration or termination of this Affiliation Agreement, provided however, that this indemnity is not intended to cover claims against Contractor arising solely out of Contractor's own negligence or intentional conduct. 5.2. Indemnity for Student Claims. School will save, defend, indemnify and hold harmless Contractor, its officers, employees, agents, affiliates and �V� 0NAL Co�� C Z r 210 CTS h 4' INSTRUCTION ' AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE representatives of and from any and all claims, suits, costs and actions brought by any Student, or their heirs, against company arising out of their participation in this program or by any patient claiming that the negligence of Student caused, compounded or exacerbated their injuries. This indemnity shall survive and remain enforceable after the expiration or termination of this Affiliation Agreement; provided, however, that this indemnity is not intended to cover claims against Contractor arising solely out of Contractor's own negligence or intentional conduct. 5.3. Defense Obligation. In any action in which School is obligated to provide Contractor with a defense, School shall at its cost and expense, fully and diligently defend Contractor against any claims brought, investigations undertaken or actions filed which concern claims for which Contractor is entitled to indemnification under paragraphs 5.1, 5.2, and 5.3. 6. INSURANCE. 6.1. Professional Medical Liability and General Liability Coverage. School will maintain Professional Medical Liability and General Liability coverage of not less than one million dollars ($1,000,000.00) per occurrence and three million dollars ($3,000,000.00) aggregate. Coverage must specifically cover Students in the Field Internship Experience, working under this agreement and within the course of their training and education during this program. School will name Contractor 2007 NCTI Affiliation Agreement 6 Confidential and Proprietary as an Additional Insured under the policy and include an indemnification provision, by endorsement, to be attached to the certificate of insurance. School will provide Contractor with written verification of coverage in the form of a certificate of insurance, which will be attached to this agreement. School covenants to keep the required insurance in force and effect through the term of this agreement and maintain tail coverage for five (5) years thereafter if the coverage was a "claims made" policy. 6.2. Endorsement for Student Activities. School assures Contractor that all coverage of insurance required herein includes specific provisions and /or endorsements to include Students within School's Medical Liability and General Liability coverage for all activities conducted under this program. 6.3. Coverage for Student Injuries. School recognizes that Students are NOT covered by Contractor's Workers Compensation Insurance or Self Insured Program. School represents and warrants that it will maintain, or ensure that its Students are covered, for bodily injury and disease should any Student be injured or become ill during the course of their Field Internship Experience. School will provide Contractor with a written verification of insurance coverage in the form of a certificate of insurance which will be attached to this agreement. 6.4. Amount of Coverage Not a Limitation. The amount of insurance required hereunder shall not limit School's liability DVS ONAL Co m m Z a 2'o WCTI q� INSTRUCTION M AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE nor relieve School of any obligation hereunder. 6.5. Minimum Qualifications of Insurer. Any policies of insurance shall be maintained with insurance companies: (i) holding a "General Policyholder's Rating" of AIV or better, as set forth in the most current issue of "Best's Insurance Guide," or comparable rating from reputable rating organizations; (ii) licensed to operate and sell insurance in the state in which the Field Internship Experience will occur; and (iii) in good standing and admitted, if applicable, with the state's Department of Insurance or other similar regulatory agency in the state in which the Field Internship Experience will occur. 7. NOTICES. 7.1. Any notice required or permitted by this Agreement shall be in writing and shall be delivered as follows, with notice deemed given as indicated: (a) by personal delivery, when delivered personally; (b) by overnight courier, upon written verification of receipt; (c) by facsimile transmission, upon acknowledgment of receipt of electronic transmission; or (d) by certified or registered mail, return receipt requested, upon verification of receipt. Notice shall be sent to the following addresses: 2007 NCTI Affiliation Agreement 7 Confidential and Proprietary If to Contractor: Battalion Chief Kevin Valentine Arcadia Fire Department 710 South Santa Anita Avenue Arcadia, California 91006 If to School: American Medical Response West d /b /a National College of Technical Instruction 333 Sunrise Avenue, Suite 500 Roseville, California 95661 With Mandatory Copy to: Legal Department American Medical Response, Inc. 6200 South Syracuse Way, Suite 200 Greenwood Village, Colorado 80111 8. Fees, Compensation and Tuition 8.1. Fees, Compensation and Tuition. If applicable, any fees, compensation and tuition that Contractor shall receive will be set forth in Exhibit B. 9. Scope of Field Internship Experience 9.1. Scope of Field Internship Experience. The specific scope of the Field Internship Experience that the Contractor shall provide will be set forth in Exhibit C. 10. MISCELLANEOUS. 10.1. Miscellaneous. This Agreement (including the Schedules and Exhibits hereto): (a) constitutes the entire agreement between the parties �P�`ONAL colF -r m M o Z T Z'o CTi AVSTRUCTION TM S­, 1488 AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE with respect to the subject matter hereof, superseding all prior oral or written agreements with respect thereto; (b) may be amended only by written instrument executed by both parties; (c) may not be assigned by either party without the written consent of the other party, such consent not to be unreasonably withheld; (d) shall be binding on and inure to the benefit of the parties hereto and their respective successors and permitted assigns; (e) shall be interpreted and enforced in accordance with the laws of the State of the principal office of the School, without regard to the conflict of laws provisions thereof, and the federal laws of the United States applicable therein; (f) this Agreement may be executed in several counterparts (including by facsimile), each of which shall constitute an original and all of which, when taken together, shall constitute one agreement; and (g) this Agreement shall not be effective until executed by both parties. In the event of a disagreement between this Agreement and any Schedule hereto, the terms of this Agreement shall govern. 11. Other. 11.1. Compliance with Laws. The parties will comply in all material respects with all applicable federal and state laws and regulations including, the federal Anti - kickback statute. 11.2. Compliance Program and Code of Conduct. The Contractor acknowledges that School has made available to School a copy of its Compliance Program and Code of 2007 NCTI Affiliation Agreement 8 Confidential and Proprietary Conduct at School's web site, located at: www.amr.net. The School shall comply with any training requirements that may be legally imposed upon School by any applicable regulatory authority. 11.3. Non - Exclusion. Each party represents and certifies that it has not been convicted of any conduct identified on Exhibit D. Each party further represents and certifies that it is not ineligible to participate in Federal health care programs or in any other state or federal government payment program, as provided on Exhibit D or otherwise. Each party understands that if DHHS or OIG excludes it, or any of its employees who provide health care services, from participation in Federal health care programs, the party must notify the other party within 5 days of knowledge of such fact, and the other party may immediately terminate the Agreement. [Signature Page Follows] �0 ONAL COI R l m ` m CIA G/ O ZZ T 'p CTi q4 INSTRUCTION .Since 1QRR AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE IN WITNESS WHEREOF, the parties have hereto executed this Agreement. AMERICAN MEDICAL RESPONSE, WEST d /b /a NATIONAL COLLEGE OF TECHNICAL INSTRUCTION By: ' dilu z6z��=> Lori ns Direct r of Learning CITY OF ARCADIA Print Name: Dominic Lazzaretto Print Title: City Manager APPROVED AS TO FORM: P 6-16� -§tepheb P. Deitsch City Attorney City of Arcadia 2007 NCTI Affiliation Agreement 9 Confidential and Proprietary ,oNAL Co! m ` m ? GJ� o 2'P WCTi 4� INSTRUCTION AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE Exhibit A Student Intern Agreement and Release Student is enrolled in a course of study at School designed to enable Student to become a licensed/certified Emergency Medical Technician, Emergency Medical Technician- Paramedic or other similar pre - Contractor health care provider. As part of the curriculum, Student has enrolled in the Field Internship Experience, which is offered through the School, with Contractor's assistance. The Field Internship Experience involves: 1) Student's performing acquired pre - hospital skills alongside Contractor's personnel; and, 2) accompanying and observing the Contractor's personnel providing emergency and non - emergency ambulance transport, care and related services.. Student has asked to participate in Field Internship Experience knowing that participation will require Student to accompany Contractor personnel in dangerous and potentially life- threatening situations. Student realizes that Contractor could not, and would not, allow Student to accompany its personnel without his/her agreement to: (i) release the Contractor from any and all claims for injury or death which may result from Student's participation in the program; (ii) assume the risk of death or injury associated with the Field Internship Experience; (iii) agree to read, understand and follow Contractor's policies, procedures and guidelines; (iv) act in a professional and respectable manner at all times; and (v) follow the instruction/direction of Contractor personnel with respect to patient care, demeanor, safety, use of personal protective devices, etc. Student understands that he or she is exposing himself or herself to certain risks inherent in the activities associated with the Field Internship Experience. Student hereby represents that he or she AGREES TO ASSUME THE RISKS INHERENT IN THE ACTIVITY. These risks include, but are not limited to, being hurt or injured: (1) by broken glass (or other scene hazards) including various cuts about the head, face, eyes, hands, legs, and torso; (2) by exposure to tetanus or contagious diseases such as the Hepatitis B virus and the Human Immunodeficiency Virus ( "HIV "); (3) injury due to gurney lifts and or drops; (4) injury from slip and fall type incidents; (5) various strains 2007 NCTI Affiliation Agreement 1 Q Confidential and Proprietary and /or sprains to one and/or all muscle groups; (6) risks associated with emergency vehicle operation; and (7) risks at the scene of emergencies including assault and battery. In consideration of Contractor's agreement to provide the Field Internship Experience to Student, Student agrees to release and forever discharge Contractor and its agents, employees affiliates, parent corporation, successors and assigns of and from all claims, demands, suits, injuries or damages of any kind arising in any way out of the participation in this program. Student further agrees to: (i) follow Contractor's policies, procedures and work rules; (ii) follow Contractor's instruction and direction with respect to patient care, safety, personal protection; and, abide by Contractor rules and direction. Student understands that failure to follow the Contractor's direction may result, in Contractor's sole discretion, in his/her expulsion from the Field Internship Experience program. The School shall require its students to complete a Criminal Offenders Record Information ( "CORI ") check. By virtue of this agreement, the School assures Contractor that it found no information that would, in accordance with the provisions of state EMS regulations, preclude the Student from the duties of an EMS provider. The relationship of field internship Student and Contractor is that of a student being provided an educational experience by Contractor and such activity shall in no way be construed as creating any other relationship including an employment relationship. The Student shall receive no compensation from Contractor for activities during the internship. The Student will comply in all material respects with all applicable federal and state laws and regulations including, the federal Anti- kickback statute. The Student acknowledges that School has made available to Student a copy of its Compliance Program and Code of Conduct at School's web site, located at: www.amr.net. The Student ONAL C0 n � T 2'o �C"ri 4 INSTRUCTION M Since 19A'T AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE shall comply with any training requirements that may be legally imposed upon School by any applicable regulatory authority. The Student represents and certifies that he /she has not been convicted of any conduct identified on Attachment "A ". The Student further represents and certifies that he /she is not ineligible to participate in Federal health care programs or in any other state or federal government payment program, as provided on Attachment "A" or otherwise. The Student understands that if DHHS or OIG excludes he /she from participation in Federal health care programs, he /she must notify the School and Contractor within 5 days of knowledge of such fact, and the Contractor may immediately terminate the Agreement. Student certifies that he /she is at least eighteen (18) years old and is an adult with full legal authority to execute this release. By Signing this Document You Acknowledge That You Have Been Advised That There Are Risks Inherent in this Type of Activity and Have Decided to Assume That Risk and Release the Company of and from All Liability. You Agree to Release the Company from Any Claims Associated with the Event and That You, Not the Company, Are Assuming Complete and Total Responsibility for and Any and All Injuries, Damages or Losses That You May Suffer as a Result of Participating in the Field Internship Experience Program. I agree to all terms set forth above. Dated: Signature of Student: Print Name: 2007 NCTI Affiliation Agreement Confidential and Proprietary 11 Attachment "A" Overview of law regarding exclusion from Medicare and State Health Care Programs 42 U.S.C. 1320a -7 (a) Mandatory exclusion. The Secretary shall exclude the following individuals and entities from participation in any Federal health care program (as defined in section 1320a -7b(f) of this title): (1) Conviction of program- related crimes. Any individual or entity that has been convicted of a criminal offense related to the delivery of an item or service under subchapter XVI1I of this chapter or under any State health care program. (2) Conviction relating to patient abuse. Any individual or entity that has been convicted, under Federal or State law, of a criminal offense relating to neglect or abuse of patients in connection with the delivery of a health care item or service. (3) Felony conviction relating to health care fraud. Any individual or entity that has been convicted for an offense which occurred after August 21, 1996, under Federal or State law, in connection with the delivery of a health care item or service or with respect to any act or omission in a health care program (other than those specifically described in paragraph (1)) operated by or financed in whole or in part by any Federal, State, or local government agency, of a criminal offense consisting of a felony relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct. (4) Felony conviction relating to controlled substance. Any individual or entity that has been convicted for an offense which occurred after August 21, 1996, under Federal or State law, of a criminal offence consisting of a felony relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance. (b) Permissive exclusion. The Secretary may exclude individuals and entities from participation in any Federal health care program. These Permissive Exclusions are for misdemeanors of the above (see 42 USC 1320a- 7(b)(1-15)) offenses plus other infractions that shall be determined on an individual case -by -case basis. �PA,pNAL CO M A C ZZ T �p CTS 9� INSTRUCTION M AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE (NOTE: the DHHS and OIG list of excluded individuals /entities is available through the Internet at 2007 NCTI Affiliation Agreement 12 Confidential and Proprietary http: / /www.hhs.gov /oig), and an overview of the exclusion regulations is attached hereto). `ONAI 00 M ` > m a G/ o T Z10 CTS 44 /NSTRUCTION AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE Exhibit "B" Fees, Compensation and Tuition Neither party to this agreement shall receive any fees, compensation, or tuition from the other party for the provision of any services pursuant to the terms hereof. 2007 NCTI Affiliation Agreement 13 Confidential and Proprietary _,OOAL 00 /`�` � m M O Z T Z'p CTi 44 INSTRUCTION M AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE Exhibit "C" Scope of Field Internship Experience Clinical Performance Standards The following performance evaluation standards have been developed as an objective measurement of the intern's performance. These standards are to be utilized when completing the intern's evaluations. Interns are expected to achieve a "3" rating in every rating factor on the final major evaluation in order to be eligible for internship. EVALUATION RATING 1 RATING 2 RATING 3 FACTOR ASSESSMENT /PATHOLOGIES Assessment and Interventions Performs a Unable to perform a Performs a Independently primary complete or complete primary performs a complete assessment and organized primary assessment, but is and organized intervenes as assessment without either slow or assessment in a necessary prompting. Omits disorganized and timely manner, portions of the inconsistent in recognizes findings assessment and /or recognizing findings and intervenes fails to recognize or intervening appropriately in a findings or appropriately. timely manner. intervene a ro riatel . Asks appropriate Fails to ask details Asks questions Asks questions questions, specific to chief specific to the chief pertinent to the chief specific to patient complaint; rambles complaint but is complaint; chief complaint or does not appear either slow or deliberate and to have a focus to disorganized. timely. the questions. 2007 NCTI Affiliation Agreement 14 Confidential and Proprietary �p�00AI COI F l in � M O Z r 'p CTS 4� INSTRUCTION iM Shur= "" AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE EVALUATION FACTOR RATING 1 RATING 2 RATING 3 Obtains patient Does not obtain Obtains an Obtains an history, pertinent adequate patient adequate patient medications and information; is assessment but is history, medications allergies incomplete or either slow in and allergies in a inaccurate. assessing and /or fairly organized and disorganized. timely manner. 2007 NCTI Affiliation Agreement ] 5 Confidential and Proprietary `ONAL COl lF m � m n o 2 2'P4 CTi /NSTRUCTION $inre 19NN AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE Exhibit "D" Overview of law regarding exclusion from Medicare and State Health Care Programs 42 U.S.C. 1320a -7 (a) Mandatory exclusion. The Secretary shall exclude the following individuals and entities from participation in any Federal health care program (as defined in section 1320a -7b(f) of this title): (1) Conviction of program- related crimes. Any individual or entity that has been convicted of a criminal offense related to the delivery of an item or service under subchapter XVIII of this chapter or under any State health care program. (2) Conviction relating to patient abuse. Any individual or entity that has been convicted, under Federal or State law, of a criminal offense relating to neglect or abuse of patients in connection with the delivery of a health care item or service. (3) Felony conviction relating to health care fraud. Any individual or entity that has been convicted for an offense which occurred after August 21, 1996, under Federal or State law, in connection with the delivery of a health care item or service or with respect to any act or omission in a health care program (other than those specifically described in paragraph (1)) operated by or financed in whole or in part by any Federal, State, or local government agency, of a criminal offense consisting of a felony relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct. (4) Felony conviction relating to controlled substance. Any individual or entity that has been convicted for an offense which occurred after August 21, 1996, under Federal or State law, of a criminal offence consisting of a felony relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance. (b) Permissive exclusion. The Secretary may exclude individuals and entities from participation in any Federal health care program. These Permissive Exclusions are for misdemeanors of the above (see 42 USC 1320a- 7(b)(1 -15)) offenses plus other infractions that shall be determined on an individual case -by -case basis. (NOTE: the DHHS and OIG list of excluded individuals /entities is available through the Internet at http: / /www.hhs.gov /oig), and an overview of the exclusion regulations is attached hereto). 2007 NCTI Affiliation Agreement 16 Confidential and Proprietary