SN169006ExbA.docx

Contractor Exhibit A SN169006 Page 1 of 3 Scope of Work

1. General Scope

Contractor agrees to provide the “consultative” services of their Medicare-certified Hospice organization to individuals residing at Sonoma Developmental Center (SDC) and to provide admission to their service for individuals who are determined to meet the Hospice admission criteria with a terminal prognosis of six (6) months or less. Services to include but not be limited to: assisting the nursing and medical staff in providing the highest quality of medical care reasonable while preserving dignity by either consultation by phone or on site by a Medicare-certified Hospice Medical Director, and Registered Nurse.

2. Exclusion to Services

Contractor does not provide Home Health Aids, hands on nursing care, pharmaceuticals, durable medical equipment (DME) or supplies related to the care and treatment of the Hospice client at SDC.

3. Project Representative

The Project Representative during the term of this agreement shall be:

Sonoma Developmental Center Carol Castillo M.D., or Marni Sager

(707) 938-6816

Contractor Contractor Phone

4. Contractor Requirements

Contractor agrees that all consultative services shall be performed by experienced and certified Hospice practitioners in accordance with current Standard of Practice Guidelines.

These services are to be provided for individuals at SDC with a terminal diagnosis, as defined by Medicare Guidelines, via SDC’s primary care physician and/or Medical Officer of the Day (MOD) as outlined below:

· Provision to possess appropriate license/permits and/or certification at all times during the term of this contract July 1, 2016 through June 30, 2018,

· Provision of intermittent nursing “consultative” services in collaboration with SDC’s Clinical Nursing Services (CNS) Department.

· Provision of medical “consultative” services in collaboration with SDC’s primary care physician or MOD.

· Provision of on-site visits by Hospice staff for assessment and on-going oversight of the Hospice Treatment Plan. Frequency of visits to be determined by the need of the individual.

· Provision of 24 hour on-call availability 7 days/week for telephone consultation to SDC caregivers and/or on-site visits as needed to assess/reassess plan of care, pain and symptom management. If the Hospice Nurse determines a need to modify care or treatment, she/he will contact the SDC Physician on duty with a recommendation for modification of orders. SDC staff will receive orders only from a licensed medical doctor or nurse practitioner legally authorized to give medical ordering at SDC

· Contractor agrees to assure quality and appropriateness of patient health care consultative services and to provide assurances that those services are medically necessary.

· Contractor will review all health care objectives and plans for need of modification or discontinuance consistent with the goal of care and make recommendations accordingly.

· Contractor will review the hospice care plan at least every thirty (30) days.

· Contractor agrees to submit a signed summary/report of consultation on the date of the examination/

· Contractor acknowledges and agrees to be willing and able to provide services outlined in the Agreement.

5. Records and Reports

· Contractor agrees to maintain reports of all visits using their organization’s forms.

Contractor

SN169006

· SDC will file Hospice related information into the individual’s clinical record under a separate “Other” tab.

· The Hospice Nurse or Physician will document a consultation meeting note on the “Consultation Form”, to be filed in the “consults” section of the individual’s clinical record. Hospice Care Team is otherwise not to write in the SDC record.

· Contractor agrees to bill for daily per diem rate while the SDC client remains on their service.

6. Sign In Log

All Hospice staff shall sign in Visitor Log on individual’s home residence.

7. Facility Orientation

· Members of the Hospice Care Team will be oriented to SDC facilities, pertinent policies, and procedures as per SDC’s Staff Development Plan.

· Members of the Hospice Care Team agree to be fingerprinted at SDC.

· Members of the Hospice team agree to be accompanied by a SDC staff until fingerprints are cleared by both the DOJ and FBI.

8. Duration of Service

· Hospice services will remain in place as long as the individual meets hospice criteria, or per agreement of the Primary Care Physician and IDT. Services can be re-instituted at a later time if necessary.