Exhibit_A_SOW_To Attachment A_SampleContract.docx

Exhibit A

Statement of Work

Operation Services

Health Professionals’ Services Program

Contractor shall perform operation and monitoring Services for the Health Professionals’ Services Program and provide the Deliverables as defined below. Unless otherwise noted, all section references refer to this SOW.

1. Administrative Requirements

1.1 Program Operations

1.1.1 Contractor shall operate a consolidated, statewide, standardized monitoring program (“Program”) for health professionals (“Licensees”) who are diagnosed with substance use disorders, mental health disorders, or dual diagnosis, and who are licensed by, certified by, or registered with participating health professional licensing boards (“Boards”).

a. Contractor shall operate the Program in a way that protects the public from a Licensee who is unable to practice with professional skill and safety due to Licensee’s substance use disorder, mental health disorder, or dual diagnoses by reporting Substantial Non-Compliance to the Board(s) who have statutory authority to regulate health professionals in the state of Oregon.

b. Contractor shall ensure the Program supports each Board’s mission of protecting the public through access to quality health care.

c. Contractor shall operate the Program in a way that assists Licensees to achieve their own health, safety and independence in order to remain a safe and productive member of their profession.

1.1.2 Contractor shall comply with applicable federal and state laws and apply evidence-based best-practices.

a. Contractor shall operate the Program in compliance with applicable federal and state confidentiality laws and regulations, including but not limited to the Health Insurance Portability and Accountability Act; federal regulations related to confidentiality of substance use disorder patient records, 42 CFR, part 2; Oregon Revised Statute (ORS) 179.505; ORS 192.553 through 192.581; and ORS 646A.

b. Contractor shall participate as a member of the Federation of State Physician Health Programs (FSPHP), https://www.fsphp.org and the National Organization of Alternative Programs (NOAP) www.alternativeprograms.org.

1.2 Contractor General Requirements

1.2.1 Contractor shall:

a. Maintain a Program website;

b. Make Program diagramming documents available in Visio or PowerPoint;

c. Create and/or update Program brochures and have them available upon request;

d. Provide informational presentations about the Program, as described in section 11.1;

e. Provide each Licensee a unique identification number, the Program’s access information, and the Licensee’s toxicology testing collection site(s);

f. Maintain an electronic computer data collection and dissemination system that is designed to collect, process, organize, and disseminate Program data to the Boards and other interested parties as described in section 2.2.1d;

g. Maintain security of and dispose of written and electronic Program records and electronic Licensee individual service records, as per 42 CFR, part 2, HIPAA and other applicable state and federal laws; and

h. Retain individual closed service records, as described in section 2.1.2, for a minimum of 10 years after Licensee has ceased Program participation.

1.2.2 Contractor shall communicate timely:

a. When Board(s) request routine information or data from Contractor, Contractor shall acknowledge the request and respond by email or telephone within 1 Business Day of the request. For Board requests that require Contractor to provide data that is not typically used during regular administration for this Contract, Contractor shall acknowledge the request by email or telephone within 1 Business Day of the request and provide the information, data, or timeline required to gather information and data within 2 Business Days of the request.

b. Contractor shall respond to communications from Licensees and return email correspondence and respond to voice mail messages within 2 Business Days of a Licensee contacting Contractor.

1.3 Information Security Requirements and Standards

1.3.1 Contractor shall follow state of Oregon information security requirements and standards established for the security management of information technologies for state agencies and contractors that are hosted by third parties. Information Security policies and procedures are available at http://www.oregon.gov/DAS/pages/policies.aspx and also Enterprise Information Services : Guidance for State Agencies : Cyber Security Services : State of Oregon.

The requirements and standards are directed to and apply to the acquisition, design, development, implementation, and decommissioning for all state of Oregon applications and systems in contractor hosted facilities.

1.3.2 Contractor shall ensure all Contractor’s staff complete annual security training on these information and security requirements and standards. Contractor shall provide validation of training to Board(s) prior to each Contractor employee working with Program materials and Licensees and confirmation that training is completed annually.

2. Services and Delivery Schedule

2.1 Contractor shall enroll and monitor Licensees in the Program.

2.1.1 Licensees are eligible to enroll if they are:

a. Regulated by a participating Board and

b. Referred by their respective Board OR are self-referred

2.1.2 Licensee Record and Reporting System

a. Contractor shall maintain an individual service record for each Licensee. The record must contain the Program’s official electronic documentation of each Licensee’s entire involvement in the program and be retained as per section 1.2.1.

b. Contractor shall assign a unique identification number (“Number”) to each Licensee at the time Contractor enrolls Licensee in the Program.

c. Contractor shall include the Number in any communications or data exchanges involving Licensee.

d. Contractor shall never assign the Number to any other Licensee enrolled in the Program.

e. Contractor may reassign a Licensee’s Number to the same Licensee if Licensee reenrolls in the Program at a later date.

f. Contractor shall not use all or a recognizable part of Licensee’s personally identifying information as the Number.

g. Contractor shall manage a reporting system to monitor Licensees’ compliance with the elements of each monitoring agreement set forth in this statement of work.

h. Contractor shall respond immediately to emergent public safety concerns involving Licensee(s) to Board(s).

i. The total number of participating Licensees will determine the cost of the overall Program. Contractor shall bill the Boards per the tiered pricing structure in the MSA section 2.4.1.

2.2 Board-Referred Licensees: Program Enrollment

2.2.1 Before Contractor enrolls a Board-referred Licensee in the Program, Contractor shall:

a. Verify the Board has referred Licensee to the Program. The Board report and referral must include:

1. A statement that Evaluator has diagnosed Licensee with a substance use disorder, a mental health disorder, or dual diagnosis. The diagnosis must include the applicable disorder name and diagnostic code as listed in the current Diagnostic and Statistical Manual of Mental Disorders (DSM);

2. The Licensee’s treatment options, as determined by the Evaluator using ASAM treatment criteria;

3. A copy of Licensee’s written statement to the Board agreeing to enter the Program and agreeing to abide by all Contractor’s terms and conditions. Contractor’s terms and conditions must be pre-approved by the Board(s);

4. A copy of the Licensee’s written statement to the Board agreeing to report to the Board within 3 Business Days if Licensee is arrested for, or convicted of, a misdemeanor or felony crime;

5. A signed consent form for release of information between the Licensee, Contractor and Board(s) and

6. A description of any Board-imposed or recommended restrictions on Licensee’s professional practice.

b. Inform Licensee about Program services, requirements, benefits, risks, and confidentiality limitations and ensure Licensee has signed a consent for services agreement to enter the Program and that Licensee agrees to abide by all Contractor’s terms and conditions. At a minimum, the consent for services agreement must include, but is not limited to:

1. A description of the information Contractor provides to the Board and under what circumstances;

2. Notification that the Board may take action to suspend, restrict, modify, or revoke the Licensee’s license or end the Licensee’s participation in the Program based on information provided from Contractor.

c. Ensure Licensee has agreed and signed a Monitoring Agreement with Contractor in addition to any agreement Licensee may have made with Board; and

d. Ensure Licensee has signed a written consent with Contractor allowing disclosures and exchanges of information between: Contractor; Board; Third-Party Evaluators and treatment providers; Licensee’s employer, if applicable; workplace monitor; medical providers and any pertinent family, significant others, or stakeholders in compliance with ORS 179.505 and 42 CFR Part 2.

2.2.2 Contractor shall enroll Licensee in the Program effective on the date Contractor receives Licensee’s signed consents for disclosures and exchanges of information and the Monitoring Agreement.

2.2.3 Contractor shall report Licensee to the Board if Licensee does not contact the Program within 1 Business Day after Licensee is scheduled to report to the Program.

2.2.4 Contractor shall send an enrollment verification within 1 Business Day to the Board once Licensee has completed enrollment.

2.2.5 Contractor shall ensure that Licensee is assigned to an Agreement Monitor within 3 Business Days of completed enrollment.

2.3 Self-Referred Licensees: Provisional Program Enrollment

2.3.1 Contractor shall ensure Licensee is provisionally eligible for the Program when a Licensee self-refers to the program. To be provisionally eligible for the Program, Contractor shall ensure Licensee:

a. Is a Licensee of the Board(s)

b. Attests that Licensee is not, to the best of Licensee’s knowledge, under investigation by Licensee’s Board. If Licensee makes the attestation, Contractor shall provisionally enroll Licensee in the Program on the date Licensee makes the attestation;

c. Agrees to be evaluated, at Licensee’s own cost, by a Program-approved Evaluator for a substance use disorder, a mental health disorder or dual diagnosis;

d. Agrees to and signs a valid consent allowing disclosures and exchanges of confidential information among Contractor; consultants; Evaluators and treatment providers; Licensee’s employer, medical providers as applicable; and any other pertinent Licensee-identified family, significant others and stakeholders;

e. Agrees to and signs another valid consent allowing disclosures and exchanges of confidential information among Contractor, Board, and Licensee’s employer, if applicable, in order to disclose Substantial Non-Compliance with Licensee’s monitoring agreement; and

f. Agrees to and signs a Monitoring Agreement developed by Contractor as specified in section 2.10.

2.3.2 Contractor shall report Substantial Non-Compliance, as described in section 2.17.2, if Contractor determines Licensee to be in Substantial Non-Compliance for failure to complete enrollment. A self-referred Licensee’s failure to complete enrollment will constitute Substantial Non-Compliance once Contractor provisionally enrolls a Licensee in the program.

2.4 Self-Referred Licensees: Enrollment

2.4.1 Before moving a Licensee from provisional enrollment to enrollment, Contractor must ensure Licensee:

a. Obtains at Licensee’s own expense and provides to Contractor, an Evaluator’s written evaluation of the Licensee. The evaluation must contain a DSM diagnosis and diagnostic code and ASAM treatment recommendations from current edition of the DSM;

b. Agrees to cooperate with Contractor’s safe practice investigation, as described in section 2.4.2 to determine whether Licensee’s practice presents or has presented a danger to the public; and

c. Agrees to and signs an addendum to the Monitoring Agreement, if required by Contractor.

2.4.2 Before moving a Licensee from provisional enrollment to enrollment, Contractor must investigate to determine whether the licensee’s practice while impaired has presented or presents a danger to the public.

a. Contractor shall ensure a focused safe-practice investigation of a self-referred Licensee is conducted by Contractor or pre-approved subcontractor within 15 Business Days to determine whether Licensee’s practice presents or has presented a danger to the public. Such investigation, when determined necessary by Contractor or designated sub-contractor and allowed by Licensee’s Board, may include Contractor interviews with Licensee’s employer, supervisor, co-workers, family, and significant others. Contractor shall ensure Licensee pays for this service. If Contractor finds that a self-referred Licensee presents, or has ever been, a danger to the public, Contractor shall immediately contact the Board.

b. Contractor shall include in its safe-practice investigation a discrete factual background check of Licensee’s practice that allows Contractor to make an informed judgment about whether Licensee’s practice has presented or presents a danger to the public.

2.5 Self-Referred Licensees: Final Enrollment

2.5.1 Before moving a Licensee to final enrollment, Contractor shall ensure that Licensee has been evaluated by a Program-approved Evaluator, and that the Evaluator has:

a. Diagnosed Licensee with a substance use disorder; a mental health disorder, or dual diagnosis;

b. Provided Contractor with a copy of the full evaluation file containing Licensee’s diagnosis of a substance use disorder, a mental health disorder, or dual diagnosis, including the applicable disorder’s name and diagnostic code, as listed in the current edition of the DSM; and

c. Provided Licensee with Program-approved treatment providers.

2.5.2 Licensee must provide Contractor with evidence that Licensee has received the Evaluator treatment options from the Board-approved list.

2.5.3 Program may not report identifying information about a self-referred Licensee’s enrollment in or successful completion of the Program to the Licensee’s Board unless the Licensee demonstrates Substantial Non-Compliance or the Licensee has become known to the Board.

2.6 Multiple State Program Enrollment

2.6.1 In the event that a Licensee is enrolled in more than one state monitoring program, Contractor shall:

a. Work with Board(s) and Licensee to establish a Licensee's primary state’s monitoring program). The primary monitoring program is the program actively monitoring the Licensee; any secondary monitoring program(s) are additional state programs Licensee is enrolled in but is not receiving monitoring services from.

b. Provide Licensee’s secondary monitoring program(s), when the Licensee’s primary monitoring program is Oregon’s Program, quarterly compliance reports and reports of Substantial Non-Compliance. Reports of Substantial Non-Compliance must be made within 1 business day as outlined in section 2.17.2.

c. Receive and review quarterly compliance reports and reports of Substantial Non-Compliance when the Licensee’s primary program is another state’s program. Contractor shall inform the Board of all Substantial Non-Compliance reports sent to Contractor from other state program as outlined in section 2.17.2 of this Statement of Work.

2.6.2 Program Transfers

Contractor shall work collaboratively with Licensee, Board, and other state monitoring programs when Licensee is involved with or transfers between the other state’s monitoring program and Contractor’s Program.

2.7 When a Licensee’s employer(s) is identified, Contractor shall:

2.7.1 Implement a process to assess an employer’s ability to supervise Licensee;

2.7.2 Establish minimum educational or training standards and requirements for supervisor and workplace monitor skills and knowledge that can be used by employers to ensure effective supervision of Licensees in practice settings as specified in section 11.3.a of this Statement of Work;

2.7.3 Determine, with input from Board(s), if each supervisor or workplace monitor must complete training described in section 11.3;

2.7.4 Provide online training for all Licensee supervisors and the workplace monitors as specified in section 11.3.b; and

2.7.5 Provide education and information to Licensee employers and other interested parties regarding the signs and symptoms of relapse, including but not limited to, regional seminars and educational programs.

2.8 Third-Party Evaluator List

Contractor shall:

2.8.1 Maintain an approved Evaluator list and validate credentials of Evaluators and treatment providers upon Board request.;

2.8.2 Confer with Boards to update the approved Evaluator and treatment provider lists at least Annually or as needed;

2.8.3 Provide the Board-approved Evaluators and treatment providers with a Program orientation, described in section 11.2, within 1 month of the Evaluators and treatment providers being added to the list; and

2.8.4 Provide the Evaluators with a sample Program-approved assessment packet that is designed specifically for Evaluator’s use in evaluating Licensee.

2.9 Contractor shall not diagnose or treat a Licensee enrolled in the Program.

2.10 Monitoring Agreements

2.10.1 Contractor shall:

a. Develop, and require Licensee to sign, an individualized, written Monitoring Agreement that is based on Contractor’s comprehensive review of Licensee’s relevant and appropriate information. The Monitoring Agreement must consider third-party evaluation reports and treatment recommendations and may include information from employers; supervisors; co-workers; and family and significant others.

b. Give Licensee a copy of Licensee’s Monitoring Agreement, including any amendments, within 1 Business Day of when Contractor enrolls Licensee in the Program;

c. Place a copy of Licensee’s Monitoring Agreement in Licensee’s individual service record within 1 Business Day of when Contractor enrolls Licensee in the Program;

d. Amend the Monitoring Agreement, as necessary, to respond to changes in Licensee’s situation; and

e. Place a copy of the amendment in Licensee’s individual service record within 1 Business Day of when Licensee signs and returns the amendment.

2.10.2 The Monitoring Agreement must:

a. Require Licensee to comply continuously with the Monitoring Agreement for at least 2 years or longer, as specified by Board, statute, rule, or order, to successfully complete the Program;

b. Require Licensee to abstain from all mind-altering or intoxicating substances or potentially addictive drugs, based on the Evaluator’s assessment. Contractor may approve Licensee to use a particular drug prescribed for Licensee by a person authorized by law to prescribe the drug for Licensee’s documented medical condition or approved by the Program if the Licensee’s Board has granted the Program that authority in writing;

c. Require Licensee to report to Contractor Licensee’s use of any mind-altering or intoxicating substances or potentially addictive drugs within 24 hours of Licensee’s use;

d. Require Licensee to participate in a treatment plan as outlined by an independent Third-Party Evaluator upon review and approval by the Program;

e. Include any limits on Licensee’s health profession practice as determined by practice assessment and/or Board;

f. Outline methods for Licensee’s employer or workplace monitor, if applicable, to monitor and report Licensee’s compliance with the Monitoring Agreement;

g. Advise Licensee that Contractor, at Contractor’s discretion, may require Licensee to submit to an evaluation of Licensee’s fitness to practice before Contractor removes the limits on Licensee’s health profession practice;

h. Require Licensee to submit to random toxicology testing in accordance with state and federal regulations, per a Contractor-determined, individualized schedule; Licensee’s Monitoring Agreement must contain provisions requiring:

1. Expanded toxicology testing drug panels and long-acting alcohol consumption toxicology testing, as needed;

2. Random toxicology testing; and

3. Toxicology testing upon request when Contractor or Board

4. Each Board reserves the right to request additional or fewer testing requirements.

i. Require Licensee to report at least weekly to Contractor’s staff regarding Licensee’s compliance with the Monitoring Agreement. Reporting must be made by email, voice mail, person to person telephone call; face-to-face meeting; or by internet communications video calls. At a minimum 1 of the weekly reports must be made by person-to-person telephone call; face-to-face meeting; or by internet communications video call each month.

j. Require Licensee to report to Contractor, Licensee’s arrest for or conviction of a misdemeanor or felony crime within 3 Business Days of arrest or conviction;

k. Require Licensee to report to Contractor all places of employment, all active licenses, any applications for licensure in other jurisdictions, changes or additions in employment, changes in practice setting and changes in residence;

l. Hold Licensee responsible for the cost of evaluations, toxicology testing and treatment;

m. Require a Licensee to attend monitoring consultant meetings, consultation group meetings, and meetings required by the Board’s monitoring requirements;

n. Require a Licensee to follow any Board requirements, as outlined in rule, including but not limited to, allowing for practice supervision of a Licensee who is in solo practice or who is not in an employment setting; and

o. Require a self-referred Licensee to obtain and provide to Contractor a copy of Licensee’s criminal history report when it is determined by Contractor that a criminal history report is necessary or beneficial to monitoring Licensee’s compliance with their Monitoring Agreement.

2.11 Agreement Monitor

2.11.1 Contractor shall assign Licensee an Agreement Monitor (Monitor).

Monitor must assess and evaluate Licensee’s compliance with the Licensee’s Monitoring Agreement and any additional Board agreements including any applicable joint monitoring agreements with other states.

2.11.2 Contractor shall ensure that Monitor meets with Licensee by telephone, face-to-face, or by video conference calls unless Licensee is unavailable due to enrollment in an approved treatment program:

a. Within the first 5 Business Days of Licensee enrollment.

b. Thereafter, on a weekly, semimonthly, or monthly basis, as determined by Contractor’s oversight staff, and if necessary, Licensee’s Board, if Board-referred.

2.11.3 Contractor shall, at least 1 time per month, review and verify Licensee’s weekly report by cross referencing with information provided by at least one of the following: employer; worksite supervisor or monitor; treatment provider; consultation group meeting facilitator; self-help sponsor; toxicology lab; or other Contractor-approved person or entity that reports on Licensee’s compliance. Participating Boards may request copies of verification reports/communication logs.

2.11.4 Monitor shall assess—as applicable and based on the checklist created collaboratively by the Contractor’s oversight staff (as described in section 3) and the Board—the ability of the Licensee’s employer or Worksite Monitor to supervise Licensee when Licensee returns to work.

2.11.6 Contractor shall ensure that Monitor, as applicable and in consultation with Contractor’s oversight staff, staffs Licensee’s case with qualified independent third-party health care evaluators and treatment providers to determine Licensee’s need for additional medical or behavioral health care assessments and evaluations.

2.11.7 Contractor shall ensure that Monitor sends a Licensee status report to Contactor’s oversight staff for review at least 1 time per year.

2.12 Toxicology Testing System and Laboratory Requirements

Contractor shall:

2.12.1 Maintain an approved list of toxicology testing laboratories that are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) OR that are accredited through the College of American Pathologists Forensic Drug Testing Accreditation Program (CAP) AND that they follow SAMHSA and CAP’s published drug testing guidelines and comply with Oregon Administrative Rules 333-024-0305 through 333-024-0350. Contractor shall ensure all aspects of the testing system include at least the following: i)a randomized individual testing schedule for Licensee, ii) a secure chain of custody for all samples collected, iii) a toxicology testing notification system, iv) provide laboratory testing supplies, and v) and that specimen collection sites meet the requirements of the relevant Board(s). Contractor shall maintain a contractual agreement with one or more testing laboratory meeting the requirements specified in this section and in SOW section 2.12.2.

2.12.2 Provide toxicology testing daily Monday through Saturday, excluding state and federal holidays, and on a limited basis, per Licensee’s customized agreement, on Sundays. Contractor shall place heightened emphasis on providing toxicology testing on Mondays, Fridays and Saturdays ensuring that at least 55% of toxicology tests are taken on those days. In the event that Monday is an observed holiday in the state of Oregon, Contractor shall ensure that toxicology testing is provided on the Tuesday immediately following the observed holiday. Contractor shall develop a specific toxicology testing collection-site network that coordinates with the laboratory to offer toxicology testing on Saturdays. For a list of state observed holidays, please visit https://www.oregon.gov/das/pages/buildingclosure.aspx.

2.12.3 Ensure that laboratory tests Licensee’s toxicology specimen and notifies Contractor of the toxicology testing results within 72 hours of laboratory receiving the specimen. If the results are not available within the 72-hour window, the laboratory must provide a sufficient reason (such as waiting for a call back from a specimen provider).

2.12.4 Coordinate with laboratory provider to provide Contractor with remote, secure web-based access 24 hours a day, 7 days a week, to all toxicology testing results, and any missed toxicology appointments.

2.13 Licensee Toxicology Testing Requirements

2.13.1 Licensee Testing. Contractor shall:

a. Ensure that Licensee receives a baseline toxicology test within 10 Business Days of the date Contractor enrolls Licensee in the Program unless Licensee is unavailable due to enrollment in an approved treatment program;

b. Ensure that Licensee receives random toxicology testing customized to Licensee’s monitoring agreement. Customization must include providing:

1. Expanded toxicology testing drug panels including urine testing, as needed;

2. Long-acting alcohol consumption toxicology testing including blood testing, as needed; and

3. Hair and nail toxicology testing, as a supplement to standard toxicology testing.

Customized monitoring agreements and random toxicology testing may also include breathalyzer testing.

c. Ensure that a Licensee with a diagnosed substance use disorder or with a diagnosed substance use disorder and a diagnosed co-occurring mental health disorder receives and completes a minimum of 24 customized, random toxicology tests per year during the first year of Licensee’s enrollment in the Program with a minimum of 18 customized, random toxicology tests per year thereafter unless otherwise specified by Board;

d. Ensure that a Licensee with a diagnosed mental health disorder, but not with a co-occurring substance abuse disorder, receives and completes a minimum of 6 customized random toxicology tests during the first 6 months of Licensee’s enrollment in the Program if recommended by Evaluator;

e. Ensure that Licensees diagnosed with a substance use disorder or who are dually diagnosed with a co-occurring mental health disorder receive a final customized toxicology test. Contractor shall deem Licensee to have successfully completed the program only if the test is negative; and

f. Ensure Licensee pays for the testing.

2.13.2 Licensee Testing Schedule. Contractor shall:

a. Utilize a customized, randomized toxicology testing schedule for Licensee as provided in the Licensee’s monitoring agreement;

b. Require Licensee to contact Contractor, via Contractor’s system, on a daily basis Monday through Saturday, excluding state and federal holidays, to determine whether Licensee has been selected for toxicology testing on that day;

c. Require Licensee to submit to toxicology testing on the same day Licensee is scheduled to test;

d. Review the Licensee missed toxicology test report and review all tests with non-negative test results each business day.

2.14 Fitness to Practice Evaluations

Contractor shall, at Contractor’s discretion or as requested by Boards, require an evaluation of Licensee’s fitness to practice before removing the limits on the Licensee’s practice of the Licensee’s health profession. Contractor shall ensure Licensee pays for this service.

2.15 Meetings for Licensees with Substance Use Disorders

Participation in the substance use disorders Consultation Group Meetings and Monitoring Consultant Meetings may either be required by Licensee’s Board or may be voluntary.

2.15.1 Consultation Group Meetings

a. Contractor shall arrange for weekly consultation group meetings in which a Consultation Group Meeting Facilitator meets with a Licensee identified by a Board or a self-referred Licensee, either face-to-face, video or conference call. A minimum of 3 Licensees is required to establish a Consultation Group Meeting.

b. Contractor shall, as needed based on Licensee group enrollment, hold Consultation Group meetings in at least 1 city per Oregon geographic region in up to 6 Board-determined regions.

c. The Consultation Group Meeting Facilitator shall provide Contractor with a weekly report that lists Licensee’s group meeting attendance and the quality of Licensee’s participation in the Consultation Group Meeting.

d. Contractor shall ensure each Licensee participating pays for this service.

2.15.2 Monitoring Consultant Meetings

a. Contractor shall select a Monitoring Consultant (Consultant) to conduct Licensee compliance consultation monthly or quarterly meetings as determined by the Monitoring Agreement.

b. Contractor shall provide new Consultants with a Program and Licensee compliance consultation meeting orientation, as described in section 11.2, prior to Consultant providing consulting services.

c. Contractor shall ensure that Consultant is informed of any Program policy changes that relate to the Licensee consultation meetings.

d. Contractor shall ensure Consultant observes the Licensee’s behavior and engagement in the consultation meetings and supports Licensee’s recovery efforts.

2.16 Meetings for Mental Health Disorders

Participation in the mental health disorders monitoring consultant meetings may either be required by the Program or can be voluntary.

a. Contractor shall select a Consultant to conduct one-on-one, face-to-face, video or conference call, Licensee compliance consultation meetings either monthly or as frequently as determined by the Licensee’s Monitoring Agreement.

b. Contractor shall provide a new consultant with a Program and Licensee compliance consultation meeting orientation, as described in section 11.2, prior to consultant providing such services.

c. Contractor shall ensure that Consultant is informed of any program policy changes that relate to the Licensee consultation meetings.

d. Contractor shall ensure that consultant observes the Licensee’s behavior and engagement in the consultation meetings and supports Licensee’s recovery efforts.

2.17 Compliance Reports to Participating Boards

2.17.1 Compliance reports

a. No later than 5:00 p.m. Pacific time on Thursdays, Contractor shall provide the following to all participating Boards:

1. a list of Licensees who are enrolled in the Program during the subject week. Licensees will be identified by their unique identification number only; and

2. list of Licensees who have successfully completed the Program during that week.

b. Upon request, Contractor shall providecompliance reports with Licensee’s agreement to the Licensee’s Board;

These lists and reports submitted under section 2.17.1 (a) (b) are exempt from disclosure as a public record under ORS 192.410 to 192.505.

2.17.2 Substantial Non-Compliance Reports

Unless otherwise prohibited by law, Contractor shall report Substantial Non-Compliance with Licensee’s monitoring agreement to the Licensee’s board within 1 Business Day after Contractor learns of a confirmed Substantial Non-Compliance. Unless otherwise prohibited by law, when Contractor reports the Licensee’s Substantial Non-Compliance, the report must include:

a. the date and a description of the noncompliance;

b. a copy of the report from the independent third-party who diagnosed the Licensee stating the Licensee’s diagnosis;

c. a copy of the Licensee’s current monitoring agreement;

d. a statement about Licensee’s employment status; and

e. Specific Board requests must be included in Licensee’s monitoring agreement. In the event there is a non-compliance report, any special conditions requested by the Board are documented.

2.17.3 Substantial Non-Compliance as defined in ORS 676.185 to 676.200 and used in a monitoring agreement includes, but is not limited to, information that Licensee:

a. engaged in criminal behavior;

b. engaged in conduct that caused injury, death or harm to the public, including engaging in sexual impropriety with a patient or client;

c. was impaired in a health care setting in the course of Licensee’s employment;

d. tested positive for restricted substances on a toxicology test or was not in compliance with the toxicology testing schedule;

e. violated a restriction on Licensee’s practice, as imposed by Contractor or Board;

f. was adjudged to be mentally incompetent;

g. entered into a monitoring agreement but failed to participate in the Program;

h. was referred to Contractor’s Program but failed to enroll in the Program; or

i. provisionally enrolled as a self-referred Licensee in the Program but failed to complete enrollment.

3. Program Oversight

3.1 Contractor shall ensure that a designated oversight staff person is responsible for oversight of Contractor’s monitoring program. Contractor shall ensure that oversight staff have appropriate training, skills, and expertise working with impaired health professionals who have substance use disorders, mental health disorders, or both types of disorders.

3.2 Contractor shall ensure that its oversight staff are responsible for providing comprehensive monitoring Program oversight including, but not limited to:

a. reviewing and approving for Board specific requirements, as evidenced by oversight staff’s signature, credentials and date of signature, all third-party evaluations and treatment provider recommendations;

b. reviewing and approving for Board(s) specific requirements, as evidenced by oversight staff’s signature, credentials and date of signature, independent Third-Party Evaluators recommended limitations on each Licensee’s health profession practice;

c. reviewing and approving, as evidenced by oversight staff’s signature, credentials and date of signature, each Licensee’s initialed and updated addenda to Licensee’s monitoring agreements. Initial reviews must occur within 14 Business Days of Licensee’s enrollment in the Program. Updated reviews must occur within 14 Business Days of the update;

d. consulting with qualified independent third-party health care providers to monitor Licensee’s use of potentially addictive medication, as medically required;

e. ensuring Contractor’s oversight staff obtains, as required, Licensee’s fitness to practice assessment from an independent third party before removing the limits on Licensee’s practice of the Licensee’s health profession; and

f. being available for face-to-face or telephone conferences regarding urgent Program matters or urgent Licensee compliance reviews.

4. Quality Assurance and Performance Improvement

Contractor shall evaluate and maintain an effective, on-going, data-driven quality assessment and performance improvement program (QAPIP). Contractor’s QAPIP must include, but is not limited to:

4.1 retaining staff, subcontractors, and other service providers who meet health profession standards for credentialing and experience;

4.2 maintaining and updating a QAPIP policies and procedures manual and implementing such policies and procedures;

4.3 ensuring all Contractor’s Program staff, its subcontractors, and other service providers are trained on QAPIP usage;

4.4 having a mechanism in place to ensure Contractor’s Program staff, its subcontractors or other service providers maintain fidelity to the QAPIP;

4.5 providing a written policy and procedure for reporting unusual or critical Program noncompliance incidents to the Board representative and the Board’s Program Advisory Committee that includes a detailed description of such incident, the persons involved in such incident and action taken to address such incident. Contractor shall report to affected Board(s) within 1 Business Day of confirmation of a Program noncompliance incident. Contractor shall provide to Board’s Program Advisory Committee a summary of such incident and action taken to address such incident;

4.6 ensuring stakeholders are given routine opportunities to provide feedback to Contractor’s Program and ensuring Boards and the Board’s Program Advisory Committee receive a written summary of the findings;

4.7 ensuring a Licensee has the opportunity to have an exit interview that occurs within 3 months after Licensee’s successful completion of Contractor’s Program;

4.8 conducting bi-annual satisfaction surveys that include, but are not limited to, representative samplings from the Licensees. Representative sampling means a cross section of Licensees who participate in the Program; and

4.9 conducting bi-annual stakeholder satisfaction surveys that include, but are not limited to, sampling representatives from the professional health associations; other employers; independent Third-Party Evaluators and treatment providers; and the participating boards, as applicable.

5. Program Performance Criteria

5.1 Contractor shall meet or exceed the performance criteria described below. Failure to meet or exceed the stated performance criteria may result in withholding or reducing of payment as defined in section 5.2 and 5.3. Performance criteria will be measured on an aggregate scale. Contractor shall meet or exceed the following performance criteria and required minimal success rate standards (or “benchmarks”):

Program Performance Criteria

2.17.1.a 7.1

5.2 Withholding of payment for missed benchmarks.

For benchmarks 2.17.1.a and 10.4 described in the table above, 5% of the payment due will be withheld until the benchmark is met for each performance criteria. Once the benchmark has been met, the Board will pay the withheld payment relating to the Benchmark to the Contractor with the payment for the next invoice received. These performance measures will be reviewed for completion each month.

5.3 Reduction of payment for missed benchmarks (liquidated damages).

For each remaining benchmarks described in the table above, the performance measure will be reviewed on a rolling year basis. For the first year, the Board(s) will measure the performance every 6 months. After the first year, the performance measures will be reviewed monthly based on a rolling year for the duration of the WOC. Reduction of payment for missed benchmarks will only be released should the Contractor provide sufficient evidence that the benchmark was met. Reduction of payment will be 5% of the monthly payment due. The maximum amount of withheld or reduced payment, in any combination, will not exceed a total of 15% of the total payment due.

5.4 Resolution of performance.

For each performance measure Contractor misses, the Board(s) will send a letter to Contractor listing each performance measure missed, including any back up documentation. Contractor will have 5 Business Days to contest or resolve the missed performance measure(s) and provide any necessary documentation. Board(s) will respond within 10 Business Days to any contested performance measure(s). If after reviewing Contractor’s documentation the Board(s) determine the Contractor did not miss a performance measure(s) or has resolved the missing benchmark, payment that was due will be applied to the next invoice received.

6. Advisory Committee Meetings

Contractor shall convene a teleconference with designated Board representatives to review Program operations and Contractor performance at least quarterly or more frequently as requested by a Board.

7. Required Weekly, Monthly, Bi-Annual, and Yearly Reports

7.1 Contractor shall report to Board representatives by email no later than 5:00 pm Pacific time every Thursday, as evidenced by date of Contractor’s email, the weekly (Thursday through Wednesday) total number of:

a. Licensees enrolled in the Program, including the number of Licensees board-referred and the number self-referred; and

b. Licensees from each Board that are enrolled in the Program, including the number of Licensees Board-referred and the number self-referred.

7.2 Contractor shall prepare and submit written monthly progress reports to the designated Board representatives which include:

a. Outcomes of specified Program Performance Criteria (Section 5.1);

b. Number of Licensees referred to the Program during the month, including each Licensee’s:

1. Referral source; and

2. Health profession.

c. Number of Licensees Contractor enrolled during the month, per Contractor’s enrollment forms, including each Licensee’s:

1. Referral source; and

2. Health profession.

d. Number and percentage of Licensees, by Board, who are in compliance with their monitoring agreements for the subject month, per Contractor’s records;

e. Number and percentage of Licensees, by Board, who received, Substantial Non-Compliance reports during the subject month per Contractor’s records, and a list of the number of Substantial Non-Compliance reports each Licensee received; and

f. Number of Licensees, by Board, who successfully completed the Contractor’s monitoring program during the subject month, per Contractor’s records.

7.3 Bi-annually, Contractor shall report to the designated Board representatives and Board’s Program Advisory Committee the findings of the surveys conducted as described in 4.8 and 4.9 and a summary of the findings from the Licensee exit interviews conducted as described in 4.7. Contractor shall prepare and submit written stakeholder survey and the summary of findings from the Licensee exit interviews within 30 days following June 30 and December 31 of each year during the term of this Contract. The Board may require revisions to the survey reports to improve readability and understanding of licensees’ experience with the Program.

8. Reports to Employers

Upon request, Contractor shall provide Licensee’s employer with a summary of Licensee’s compliance with the Monitoring Agreement.

9. Contract and Performance Monitoring

Boards may monitor Contractor’s performance through a variety of processes, including, but not limited to:

9.1 Contractor’s monthly reports to Boards;

9.2 Boards and independent third-party audits;

9.3 Compliance reviews for Contract standards and performance criteria;

9.4 Site reviews in which Board personnel conduct on-site program visits to review Contractor’s compliance with this Contract. The Board shall schedule site reviews with Contractor. The Board reserves the right to conduct site reviews with no prior notice given to Contractor. Site reviews may include, but are not limited to:

a. Audits of individual service records;

b. Interviews with monitoring program staff, subcontractors, Licensees, boards, others, and;

c. Stakeholder satisfaction surveys which will include but may not be limited to Licensees, Licensee’s employer, and Licensee’s coworkers.

10. Court Orders for Disclosure of Records

10.1 Contractor shall seek a court order authorizing Contractor to release identifying information to a Licensee's Board, including a report of Substantial Non-Compliance, if a self-referred Licensee enrolled in the Program, or a provisionally enrolled Licensee with a qualifying diagnosis, revokes his or her consent to report Substantial Non-Compliance to the Licensee's board.

10.2 Contractor shall file documents with the court seeking a court order as soon as possible but no later than 3 Business Days from the date Contractor was notified that the Licensee revoked consent to report Substantial Non-Compliance.

10.3 Contractor shall comply with 42 USC § 290dd-2(b)(2)(C); 42 CFR Part 2; the Health Insurance Portability and Accountability Act (HIPAA), Public Law 104- 191, 45 CFR Parts 160, 162, and 164; and ORS 179.505, ORS 192.553 - 192.581 in seeking such a court order.

10.4 Contractor shall disclose to the Licensee's board, within 1 Business Day, any information the court authorizes it to disclose.

11. Educational Materials

11.1 Contractor shall provide outreach presentations to meet the following objectives:

· to ensure Licensees, as well as their peers and their supervisors, are aware of the HPSP and are informed regarding its purpose and potential benefits;

· to inform Licensees, their peers, and supervisors of the signs and symptoms of mental health disorders and/or substance abuse; and

· to ensure health professional students are informed of available programs and issues they may face in the workplace.

a. Contractor shall provide a minimum of 12 outreach presentations per year or an average of 1 per month.

b. Contractor shall provide a minimum of 2 outreach presentations per region per year.

c. Contractor shall provide a list of outreach presentations conducted including location, time, and number of participants to the Program Advisory Committee quarterly.

d. Presentation content must be pre-approved annually, in writing by the Program Advisory Committee. The presentation review and approval will be added to the meeting agenda at the first quarterly meeting each year. In addition, each quarter, the presentation content and outreach plans for the coming quarter will be an agenda item to discuss any changes the Contractor wishes to make.

e. Board staff may be present at any outreach presentations.

f. After each presentation, Contractor shall provide a copy of the presentation invite including the venue information and a head count of attendees...

11.2 Independent Third-Party Evaluator, Consultant, and Treatment Provider Orientation

a. Contractor shall develop and have all orientation materials pre-approved by the Board(s).

b. All changes to the orientation materials must be submitted to the Board(s) allowing at least 1 week for Board(s) to respond. If the Program Advisory Committee determines that the materials are generic for all Boards to use, Contractor shall submit changes 1 week prior to the next Program Advisory Committee meeting with a request to add it to the agenda.

c. All orientation materials must be provided in an electronic format.

11.3 Licensee Supervisor Training

Contractor shall provide:

a. Educational and training materials as described in section 2.7.2.

1. All educational and informational materials must be pre-approved by the Program Advisory Committee.

2. All changes to the materials must be submitted to the Program Advisory Committee 1 week prior to the next upcoming meeting with a request for it to be added to the meeting agenda.

3. Materials must be available in both electronic and physical format.

b. Online training tools as described in section 2.7.4.

1. All online training material must be pre-approved by the Program Advisory Committee prior to release.

2. All changes to the materials must be submitted to the Program Advisory Committee 1 week prior to the next upcoming meeting with a request for it to be added to the meeting agenda.

3. Contractor shall post online training tools on the Program website.

12. Contract Close Out Procedures

Contractor shall provide all Deliverables…