LIVINGSTON COUNTY PURCHASING LIVINGSTON COUNTY, MICHIGAN 304 E. Grand River Avenue, Suite 204 Howell, MI 48843

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1 LIVINGSTON COUNTY PURCHASING LIVINGSTON COUNTY, MICHIGAN 304 E. Grand River Avenue, Suite 204 Howell, MI ROBERTA M. BENNETT TEL: (517) PURCHASING AGENT FAX: (517) December 12, 2016 RFP-LC-16-26: Inmate Medical Services RE: Addendum #2 Extension of Question and Bid due dates, Clarification to Addendum #1 and Answers to Questions received QUESTION PERIOD: The question period has been extended to Wednesday, December 14, 2016 at 5:00 pm EST. The intent is to allow follow-up questions/clarification as it relates to information provided in Addendum #2. BID DUE DATE: The new bid due date is Wednesday, December 21, All proposals are due to the Purchasing Office no later than 2:00 pm EST. CLARIFICATION ON ADDENDUM # 1 In regards to question #45 as it relates to pic-lines: Is the medical staff able to maintain them or set them up? The answer should read - RN s can administer meds to pic lines and LPN s can monitor them. VENDOR QUESTIONS: 1. What JMS system do you currently utilize? a. Sunguard OSSI 2. Where do you have Wi-Fi access throughout the facility? a.all of the housing units, medical offices, medical exam and housing units, intake area,classrooms and all of the control pods. The Wi- Fi is everywhere you would need to use it. 3. Is the county open to a new contractor hiring the current contractor s employees? a. Yes, we are not opposed to that.. 4. Can you provide a detailed staffing plan with each of the above s licensure and years of experience at Livingston County? a. 4 RN S, 2 Fill in RN S that help out once in a while, 4 LPN S, 1 fulltime MHP, 1 part time MHP, 1 fulltime Administrative Assistant Clerk, 1 fill in records clerk, 1 HSA, 1 Physician (subcontracted), 1 Mobile Dental Team (subcontracted) and 1 Psychiatrist. All of the nurses and MHP S have 1-3 years experience with the county, Health Care Administrator has 7 years and the Administrative Assistant has 18 years. 5. Do any of the above employees have a non-compete clause? a. Only the Physcian does. RFP-LC ADDENDUM #2 INMATE MEDICAL SERVICES Page 1 of 5

2 6. Which RX is currently used? a. Diamond 7. How many med passes are performed by the medical team each day? a. 2 main med passes a day at 0700 and There also may be an additional med pass around 1400 for inmates on detox protocol. 8. How much does each med pass take? a. 2 to 2.5 hours if there is 1 nurse present to do the whole jail. If we have 2 nurses working it ususally will take 1.5 hours. 9. Is the County open to alternative staffing to address psychiatric needs (i.e. jail physician with referral to psychiatry as needed)? a. We would be open to this but would like to see a staffing proposal with psychiatrist and without and weigh the pros and cons. We have increased our psychiatric hours recently just to cover assessments for medication refills. 10. What types of services do agencies such as Community Mental Health, Community Public Health and Community Corrections provide Livingston County Jail inmates? a. Community Mental Health does mental health screenings for possible diversions, diversion support, coordination of care and support while in jail and at discharge, prerelease planning and referral. They also screen for co-occurring substance abuse treatment for Livingston County eligible inmates diverting them to substance abuse treatment or drug court if the goal is shortening their jail time. Community Public Health has recently started working with us on a closed Point of Dispensing Plan for inmates, Sheriff Department and their families and vendors working in the jail and their families. This would ensure that inmates, first responders and vendors working in the jail would get proper medication in case of a public health emergency. Community Correction role has lessened due to us losing the PA 511 grant- Classes (Inmate Improvement classes) that were put in place and funded by this grant have been picked up by the courts and CMH. They include Thinking Matters and Moral Recognizance training. 11. What mental health services are currently offered at Livingston County Jail? a. Assessments with follow-ups, Suicide Precautions and Prevention, Coping Group Sessions, Special needs list, Medication coordination with the psychiatrist and creating list for the psychiatrist for inmates to be seen. 12. What is the monthly frequency of send outs for offsite care? a can be higher if we have a high number of incarcerated pregnant females. 13. Would the County share a copy of the contract with your existing medical services provider? a. Yes, see attached. 14. Can you share or obtain current salaries for medical staff? a. LPN S average pay $22, RN S Average pay $25, Medical Administrative Clerk $15, MHP S $26-$30. The jail administration feels these numbers are low and need to be competitive with the market in this region of the state. These wages have caused difficulty in hiring and retaining nurses. 15. What is the typical turnaround time when the County conducts comprehensive background investigations on temporary, emergent staff such as nurse travelers? a. The county needs about 48 hours to conduct a lien check (warrant search, criminal history) on any vendor s employee and we will contact the vendor to let them know if the employee has clearance to the jail. The county does not conduct background RFP-LC ADDENDUM #2 INMATE MEDICAL SERVICES Page 2 of 5

3 investigations on vendor s employees we leave that up to vendor. We will assist you with an interview or advice if you ask us. 16. Would the County clarify whether it intends jail staff to complete pre-booking medical screens or would this be the responsibility of the contractor? a. Medical screenings prior to booking is done when the receiving officer goes to vestibule and ask the incoming inmate a series of medical questions. Example would be: Are you suicidal? Do you take meds for anything and what are they? Do you have any existing medical conditions? Are you under a doctor s care? We would only call medical to the vestibule if we thought they had a serious medical condition or were unsure. We currently do medical screenings after the inmate has already gone through the booking process. 17. Who is the current pharmacy vendor? a. Diamond 18. It was mentioned at the pre-bid that CCS had bought the contract for medical services at the jail. From whom did CCS buy the contract and what was the date CCS took over? a. CHC, July It was stated at the pre-bid that the female jail population is running around 33% currently. What do you think is causing such a high rate of female incarceration? a. The main cause is the opiate drug problem in the country as well as the county. The judges have been more willing two incarcerate female drug users to get them the help that they need. The drug usage has also caused an increase in more petty crimes such as retail fraud, larceny and operating vehicle under the influence of drugs. 20. Under 4.D.2 of the RFP on p.19, it states Medications for the treatment of HIV, Hep C and Biological shall be defined in accordance with the Physician s Desk Reference. Are these medicines excluded from the vendor s current pharmacy costs? If not, would the county consider such exclusions if it reduced overall medication costs to the County? a. These meds are currently included with the vendor s pharmacy cost. It is very rare that we need these meds usually on an average a couple of times a year. We would like a proposal that that includes the HIV meds and that does not in the pharmacy cost. See revised pricing proposal sheet. 21. Current nursing coverage is 18 hours a day, but has only a single nurse on duty at the beginning and end of the day in a 300 ADP jail population. 18 hours coverage is tough to cover using the common 8 and 12 hour shifts. Would the County consider 16 hours of coverage a day if it included 2 nurses on duty at all times, 7 days a week? /Is the County open to considering staffing patterns other than what is specified in the RFP? a. We would prefer the 18 hour coverage because the inmates are active between the hours of 0600 and midnight but would consider an alternative staffing model that would work for the vendor and the county. Some type of an overlap during the busiest times and then back down to 1 nurse later in the night is what we are currently doing. 22. What offsite providers/inpatient facilities does the jail currently use? a. Offsite providers: St. Joes- Livingston, St. Joes-Ann Arbor and U of M. Impatient Facilities: CPI, Great Lakes Recovery, Pine rest, Tri Cap and KPEP. RFP-LC ADDENDUM #2 INMATE MEDICAL SERVICES Page 3 of 5

4 23. F. (pg. 17) covers the County s right to enter into an agreement with a third party for Medical Billing services. a.is it the County s intent for the selected vendor to pay offsite healthcare claims on the county s behalf? b. If yes, what is the purpose for that alternative service? c. If no, what party would initially pay claims? a. The county is doing a trial run contract with a third party billing service to see how much of a cost savings they can get for the counties offsite medical bills. Nothing has been determined yet with what we are going to do. We wanted the clause in the medical RFP in case this is the road we choose to go down. The third party medical service would pay the claims if we decided to go that direction. The vendor would pay the offsite bills if we don t. 24. Page 12 lists the ADP on September 15 as 288. This is a one-day snapshot subject to variability and could highly influence the amount vendors bid, particularly for pharmacy and off-site healthcare. Would the County share your year-to-date average and average for 2015? a. ADP average for 2015 is 262 and year to date average for 2016 is RFP p. 7, PRICING. Regarding CPI, will the County consider use of the Midwest Urban Region- Medical Care index (CUUR0200SAM) rather than Midwest Urban- All Items? This assists in ensuring inflationary adjustments are in line with community medical care increases. a.yes we will. 26. RFP p.31 PRICING PRPPOSAL. Please confirm where on the procomg proposal form Pharmaceutical and Off-Site Care costs should be allocated. a. See revised Pricing Proposal form. 27. RFP p.31 PRICING PRPPOSAL. Addendum #1 indicates the County would like EMR pricing. Please confirm where on the pricing form these costs should be allocated. a. See revised Pricing Proposal form. Questions not answered yet: 1. The County has stated that there is a $150,000 cap on off-sie expenses currently. The RFP suggests that above this cap, all expenses are shared 50/50 between the county and the vendor. Is this requirement currently in place with the vendor? Would the county consider a hard cap at $150,000 if savings below that amount were shared 50/50 with the County? a. To clarify the County pays all expenses over $150, M. (pg. 15) Cost Containment, Shared Cost Program(s) and Optional Alternate Proposed Solution. a. Is the vendor required to price and bid the Shared Cost Approach? i. If so, can you provide annual off-site costs for the prior 3 years, alond with the ADP for that year. Ii. Any other data relating to the off-site utilization (e.g. Inpatient Hospital costs and frequency, Emergency Room costs and frequency, etc )? RFP-LC ADDENDUM #2 INMATE MEDICAL SERVICES Page 4 of 5

5 ACCEPTANCE/ ACKNOWLEGEMENT OF ADDENDUM #2- RFP-LC-16-26: Inmate Medical Services to be returned with proposal submission. Company: Date: Authorized Signature: Printed: RFP-LC ADDENDUM #2 INMATE MEDICAL SERVICES Page 5 of 5

6 APPENDIX F: PRICING PROPOSAL - REVISED Professional On-Site Staffing Description Hrs/Week Hourly Rate Annual Cost Physician 6 Registered Nurse (RN) 76 Health Services Administrator (HSA) 40 Licensed Practical Nurse (LPN) (2 ppl) 124 Medical Assistant/ Medical Records Clerk 40 (MA/MRC) Dentist 8 hrs. per month Psychiatrist 16 hrs. per month Mental Health Professional (Master Level) 56 hrs. Professional On-Site Services Description Monthly Rate Annual Cost Medical Supplies Mobile Dental Services Laboratory Services Medical Services Medical Waste Removal Services On-Call 24/7 X-Ray Services Mental Health Training Jail Staff Comprehensive Medical Malpractice Insurance Corporate Management and Oversight Pharmaceutical includes HIV, Hep C and Biological Pharmaceutical excludes HIV, Hep C and Biological Electronic Medical Records (EMR) Off Site Services

7 AGREEMENT FOR INMATE HEALTH CARE SERVICES AT LIVINGSTON COUNTY JAIL, MICHIGAN BETWEEN COUNTY OF LIVINGSTON AND CARE COMPANIES, INC. FOR TERM OF MARCH 18, 2012 TO MARCH 18, 2014 WITH ONE (1) OPTION TO EXTEND TWO (2) ADDITIONAL YEARS

8 TABLE OF CONTENTS I. SCOPE OF SERVICES... 2 A. GENERAL... 2 B. STAFFING... 2 C. ON CALL... 3 D. CHANGE IN TOTAL STAFFING HOURS... 3 E. STAFFING LEVELS WAIVER... 3 F. STAFFING CHANGES BY CONTRACTOR... 3 G. HIRING COUNTY EMPLOYEES... 4 H. MICHIGAN DEPARTMENT OF CORRECTIONS REQUIREMENTS FOR ON-SITE CARE... 4 I. BODY CAVITY SEARCHES... 4 J. RECEIVING (INTAKE) SCREENING... 5 K. ACCESS TO MEDICAL CARE... 6 L. INMATE/DETAINEE INJURY OR ILLNESS PRIOR TO BOOKING... 7 M. DETOXIFICATION/WITHDRAWL MANAGEMENT... 7 N. COMMUNICABLE DISEASES... 8 O. MEDICAL CLEARANCE FOR INMATE/DETAINEE WORKERS... 8 P. INFECTION CONTROL PROGRAM... 8 Q. SICK CALL... 9 R. MEDICATION VERIFICATION, SET UP, AND ORDERS S. COMPLETE HEALTH ASSESSMENTS T. ON-GOING MEDICAL CARE U. PHYSICIAN SERVICES V. PROVIDING JAIL STAFF WITH TRAINING DEALING WITH EMERGENCY ON-CALL SITUATIONS W. DENTAL SERVICES X. PATIENT EDUCATION & IMPROVEMENT OF SELF CARE II. QUALITY ASSURANCE, PEER REVIEW COMMITTEE, AND GRIEVANCE PROCEDURE A. QUALITY ASSURANCE PROGRAM & PLAN B. PEER REVIEW COMMITTEE C. GRIEVANCE PROCEDURES III. HOSPITALIZATON/OFF-SITE SERVICES/SPECIALTY SERVICES A. HOSPITALIZATION B. SPECIALTY SERVICES C. MEDICAL RECORDS MANAGEMENT D. MANAGEMENT INFORMATION SYSTEM E. AMBULATORY SERVICE i- IV. F. PHARMACY G. PATHOLOGY AND RADIOLOGY SERVICES H. MENTAL HEALTH I. MEDICAL SUPPLIES J. MEDICAL WASTE & SHARPS K. COLLECTION OF PHYSICAL EVIDENCE L. PARTICIPATION IN MEETINGS AND COLLABORATION WITH SUPPORT AGENCIES AND SERVICES M. HEALTH EDUCATION AND TRAINING N. MEDICAL LIBRARY REPORTS, INFORMATION, REVIEWS, RECORD RETENTION, ACCESS AND INSPECTION OF RECORDS A. MEETINGS B. MONTHLY REPORTS C. REPORT REVIEW D. ACTIVITY REVIEW E. ADDITIONAL INFORMATION AND REPORTS F. ACCESS TO AND REVIEW OF RECORDS G. MAINTENANCE OF RECORDS H. MEDICAL RECORDS REQUIREMENTS I. CONFIDENTIALITY OF HEALTH RECORDS J. OFF-SITE SERVICES, MEDICAL RECORDS AND COMPLIANCE WITH HIPAA V. COST CONTAINMENT AND SHARED COST PROGRAM(S) AND ANNUAL COST RECONCILIATION A. COST CONTAINMENT B. SHARED COST APPROACH C. ANNUAL COST RECONCILIATION D. QUARTERLY COST RECONCILIATION...35 VI. PEOPLE COVERED UNDER THIS AGREEMENT A. GENERAL B. INMATES/DETAINEES IN ACTIVE CUSTODY C. INMATES/DETAINEES FROM OTHER COUNTIES/STATES OR FEDERAL GOVERNMENTAL AGENCIES VII. PEOPLE NOT COVERED UNDER THIS AGREEMENT A. COUNTY INMATES/DETAINEES HOUSED IN OTHER COUNTIES B. INMATES/DETAINEES RELEASED FROM CUSTODY ii-

9 VIII. SHERIFF S DUTIES AND OBLIGATIONS A. COMPLIANCE WITH HIPAA B. OWNER OF RECORDS C. RECORDS ACCESS D. EMPLOYMENT USE OF INMATES/DETAINEES E. SECURITY OF THE JAIL FACILITY AND CONTRACTOR F. SHERIFF S POLICIES AND PROCEDURES G. DAMAGE TO EQUIPMENT H. SECURE TRANSPORTATION I. STAFF SCREENING J. OFFICE EQUIPMENT AND SUPPLIES IX. COMPENSATION/ADJUSTMENTS A. ANNUAL AMOUNT/MONTHLY PAYMENTS B. NEGOTIATED ANNUALIZED AMOUNT INCREASE UPON RENEWAL X. TERM, OPTION TO RENEW AND TERMINATION A. TERM B. OPTION TO RENEW C. GROUNDS FOR TERMINATION D. TERMINATION OF AGREEMENT FOR CAUSE E. TERMINATION WITHOUT CAUSE F. REMOVAL OF CONTRACTOR S PROPERTY FROM JAIL XI. CONTRACTOR S INSURANCE COVERAGE A. WORKERS COMPENSATION AND EMPLOYER S LIABILITY INSURANCE COVERAGE B. INSURANCE COVERING CONTRACTOR S PROPERTY C. COMMERCIAL GENERAL LIABILITY INSURANCE D. PROFESSIONAL LIABILITY INSURANCE E. MOTOR VEHICLE LIABILITY INSURANCE F. ADDITIONAL INSURED G. CANCELLATION NOTICE H. RENEWAL OR REPLACEMENT POLICIES XIV. EQUAL EMPLOYMENT OPPORTUNITY; APPLICABLE LAW AND VENUE; AND COMPLIANCE WITH LAWS A. EQUAL EMPLOYMENT OPPORTUNITY B. NONDISCRIMINATION IN PERFORMANCE OF SERVICES C. APPLICABLE LAW AND VENUE D. COMPLIANCE WITH LAWS AND REGULATIONS AND SHERIFF S POLICIES XV. ENTIRE AGREEMENT XVI. WAIVER OF BREACH XVII. THIRD-PARTY BENEFICIARIES XVIII. ASSIGNMENT XIX. NOTICES XX. MODIFICATIONS, AMENDMENT OR WAIVER OF PROVISIONS OF THE AGREEMENT XXI. SECTION AND SUBSECTION TITLES XXII. INVALID/UNENFORCEABLE PROVISIONS XXIII. SURVIVAL CLAUSE XXIV. CERTIFICATION OF AUTHORITY TO SIGN AGREEMENT APPENDIX A: SELECTED PROPOSALPAGES APPENDIX B: MONTHLY MEDICAL STATISTICS REPORT FORM APPENDIX C: CHC PRICE BREAKDOWN XII. INDEMNIFICATION AND HOLD HARMLESS XIII. RELATIONSHIP OF THE PARTIES A. INDEPENDENT CONTRACTOR B. SUBCONTRACTING iii- -iv-

10 AGREEMENT FOR INMATE HEALTH CARE SERVICES AT LIVINGSTON COUNTY JAIL, MICHIGAN THIS AGREEMENT, which is effective March 18, 2012, is entered into by and between the COUNTY OF LIVINGSTON, a municipal corporation and political subdivision of the State of Michigan, (hereinafter referred to as the COUNTY ), acting on behalf of the LIVINGSTON COUNTY SHERIFF (hereinafter referred to as the SHERIFF ) and CARE COMPANIES, INC., a Delaware Corporation doing business in the State of Michigan as Correctional HC Companies, Inc. and whose corporate headquarters offices are located at 6200 S. Syracuse Way, #440, Greenwood Village, Colorado (hereinafter referred to as the CONTRACTOR ). RECITALS: WHEREAS, the COUNTY has requested proposals to provide professional and responsive health services to the inmates and detainees of County of Livingston at the Livingston County Jail at 150 S. Highlander Way, Howell, Michigan (hereinafter referred to as the Jail ) with a medically responsive on-site and off-site program with emphasis and focus on a COST SAVINGS PROGRAM to help reduce the Jail s Inmate/Detainee health care cost; and WHEREAS, the COUNTY is a unit of local government and its subagencies, more specifically, the Livingston County Sheriff s Department requires health services for the Jail s inmates and detainees (hereinafter referred to collectively as Inmates/Detainees ); and WHEREAS, the CONTRACTOR has submitted a proposal, dated December 20, 2011, to the County to provide correctional health care and health care management services on behalf of the COUNTY to the Jail s Inmates/Detainees (hereinafter referred to as the Proposal ); and WHEREAS, the CONTRACTOR is a corporation in the business of providing correctional health care and health care management services; and WHEREAS, the COUNTY accepts the Proposal subject to the terms and conditions of this Agreement. NOW, THEREFORE, for and in consideration of the covenants hereinafter contained, IT IS HEREBY AGREED as follows: I. SCOPE OF SERVICES A. GENERAL. The CONTRACTOR shall provide the Inmate/Detainee health care services and health management services required at the Jail. These services shall be at CONTRACTOR S cost, and in exchange for the compensation provided herein. B. STAFFING. The CONTRACTOR shall provide professional physician, nursing, medical assistant, psychiatrist, dentist, and mental health specialist for the Jail as follows: 1. Registered Nurse (RN) performing on-site nursing duties for twenty (20) hours per week. 2. RN acting in capacity of Jail s Health Services Administrator (HSA) twenty (20) hours per week. 3. Licensed Practical Nurse (LPN) performing on-site nursing duties required by this Agreement sixteen (16) hours per day seven (7) days per week for a total of one hundred twelve (112) hours per week. 4. Physician shall be on-site a total of six (6) hours per week performing physician services as well as overseeing all medical services at the Jail. The physician shall be in charge of overseeing sick call, reviewing charts, and signing off on all medical decisions. 5. Mobile Dental Services shall be provided on-site once per month for a total of eight (8) hours. 6. Medical Assistant/Medical Records Clerk (MA/MRC) shall be onsite forty (40) hours per week to perform administrative duties in conjunction with maintaining medical records. Under CONTRACTOR S medical staff s immediate supervision, the MA/MRC shall organize and maintain medical records by collecting information about patients. The information shall include test results, diagnosis, exam results, recommended treatments, prior medical history and other relevant data. The MA/MRC shall ensure the Jail s Inmate/Detainee medical records are well-organized and be able to provide quality reports. The MA/MRC must also maintain security and accuracy of the records as required by this Agreement and deliver records as requested. -& Option To Extend to 3/18/16) -& Option To Extend to 3/18/16)

11 7. Mental Health Services (a) (b) Psychiatrist shall be on-site eight (8) hours per month. Responsibilities shall include intake, post admission evaluation, counseling and suicide prevention. Mental Health Professional with Master s Degree, shall be on-site forty (40) hours per week. Responsibilities shall include intake, post admission evaluation, counseling, and suicide prevention. C. ON CALL. CONTRACTOR shall provide twenty-four (24) hour, seven (7) days per week on-call physician coverage and specific written policies and procedures to address both medical and dental issues and emergency transfer of Inmates/Detainees. The CONTRACTOR shall provide telephones and/or pagers to certain specified health care staff (i.e., Site Managers and Provider/Medical Director) to ensure their availability. D. CHANGE IN TOTAL STAFFING HOURS. The total staffing hours to be provided under this Agreement may be subject to change as determined by mutual written agreement of the SHERIFF and the CONTRACTOR S authorized representatives. Should any part of the original terms of this Agreement be changed by the change in total staffing hours such change(s) must be set forth in writing in the form of an amendment to this Agreement and signed by the authorized representatives of both the COUNTY and the CONTRACTOR. The staffing hours required in B. STAFFING of this Section I are for ACTUAL HOURS WORKED and shall not include any time for paid leave. E. STAFFING LEVELS WAIVER. Based on actual staffing needs as affected by medical emergencies, riots, increased or decreased Jail population, and other unforeseen circumstances, certain staffing level requirements may be temporarily waived as mutually agreed to by the SHERIFF and CONTRACTOR. In the event of such a waiver, adjustments to the compensation to be paid the CONTRACTOR during the period covered by the waiver shall be as mutually agreed upon, in writing in the form of an amendment, by the COUNTY and the CONTRACTOR and signed by the authorized representatives of both parties. F. STAFFING CHANGES BY CONTRACTOR. The CONTRACTOR shall not make staffing changes without prior notice to the SHERIFF or SHERIFF S designee. In recognition of the sensitive nature of correctional services, if the SHERIFF or SHERIFF S designee becomes dissatisfied with any health care personnel provided by the CONTRACTOR, the CONTRACTOR shall, following written notice from the SHERIFF or SHERIFF S designee of dissatisfaction and the reasons therefore, exercise its best efforts to resolve the problem. If the problem is not -& Option To Extend to 3/18/16) resolved to the SHERIFF S or SHERIFF S designee s satisfaction within ten (10) days of CONTRACTOR S receipt of the notice of dissatisfaction, the CONTRACTOR shall remove the individual about whom the dissatisfaction has been expressed. Should removal of an individual become necessary, the CONTRACTOR shall be allowed reasonable time not exceeding thirty (30) days, to find an acceptable replacement. In the event the individual removed, is a nurse or physician the CONTRACTOR shall fill the position immediately with a substitution with equal qualification until a permanent replacement is found. If in the sole judgment of the SHERIFF or SHERIFF S designee, immediate removal of any health care personnel is necessary, that person shall be removed and replaced at once. If an employee or subcontractor of the CONTRACTOR violates one of the COUNTY S or SHERIFF S policies that if violated by a COUNTY employee would result in severe disciplinary action, up to, and including termination of the employee, then the CONTRACTOR agrees the SHERIFF or SHERIFF S designee may require the immediate removal of that employee or subcontractor from the Jail and the performance of services under this Agreement. In this circumstance, the CONTRACTOR agrees not to charge for services performed by CONTRACTOR S employee or subcontractor until a replacement is hired and commences work at the Jail or the hours and duties of such employer or subcontractor are otherwise filled in a manner satisfactory to the SHERIFF or the SHERIFF S designee. G. HIRING COUNTY EMPLOYEES. The CONTRACTOR shall not hire any COUNTY employee for any of the services required by this Agreement without the COUNTY S prior written approval. H. MICHIGAN DEPARTMENT OF CORRECTIONS REQUIREMENTS FOR ON-SITE CARE. All on-site care required by this Agreement shall be in accordance with: 1. MICHIGAN DEPARTMENT OF CORRECTIONS ADMINISTRATIVE RULES FOR JAIL AND LOCKUPS. R , Health Screening, Rule MICHIGAN DEPARTMENT OF CORRECTIONS ADMINISTRATIVE RULES FOR JAIL AND LOCKUPS, R , Health Appraisals, Rule 32. I. BODY CAVITY SEARCHES. When directed by the SHERIFF, pursuant to the laws of the State of Michigan, being section b of the Michigan Compiled Laws (i.e., MCL b) the physician(s) the CONTRACTOR has assigned to the Jail or the RNs or LPNs assigned to the Jail acting with the physician s approval shall perform body cavity searches on individuals, designated by the SHERIFF. The physician, RN or LPN conducting body cavity searches must possess a current valid license in -& Option To Extend to 3/18/16)

12 the State of Michigan to practice medicine or perform RN or LPN nursing services. If the body cavity search is to be conducted by a person of the opposite sex of the person being searched, the search shall be conducted in the presence of a person of the same sex as the person being searched. J. RECEIVING (INTAKE) SCREENING. All Inmates/Detainees being booked into the Jail shall be given an Inmate/Detainee receiving screening, which is completed by Jail staff. During working hours, CONTRACTOR S health care staff shall triage any Inmate/Detainee when requested by a detention officer during the receiving screening process. This preliminary health triage shall occur as soon as possible after the referral but no later than twenty-four (24) hours after the referral. When CONTRACTOR S nurses perform this service, the triage includes, but is not limited to, the following: 1. Inquiry into: (a) Any current illnesses, health conditions, medications, or special health requirements (e.g., dietary needs). (b) Diagnosis of serious infectious diseases (hepatitis, HIV/AIDS, TB, STDs). (c) Current communicable illness symptoms (e.g., chronic cough, coughing up blood, lethargy, weakness, weight loss, loss of appetite, fever, night sweats). (d) Past or current mental health treatment, hospitalizations, or medications. (e) History of current suicidal ideation. (f) Dental problems. (g) Allergies. (h) For females, whether pregnant and history of pre-natal care. (i) Alcohol and legal or illegal drug use (including the time of last use). (j) History of seizure activity, drug withdrawal symptoms. (k) History of tobacco use. (l) Other health problems as designated by the responsible provider. 2. Observation of the following: (a) Appearance (e.g., tremors, anxious, disheveled). (b) Behavior (e.g., hostile, appropriate, cooperative). (c) State of consciousness (e.g., alert, disoriented, lethargic). -& Option To Extend to 3/18/16) (d) Mobility (e.g., limp, crutches, wheelchair). (e) Breathing (e.g., cough, hyperventilation). (f) Skin (e.g., lesions, jaundice, rashes, infestations, bruises, scars, tattoos, and needle marks or other indications of drug abuse). 3. Disposition into one of the following categories: (a) Referral to an appropriate medical or mental health service on an emergency basis. (b) Referral to special housing. (c) Placement in the general Inmate/Detainee population and later referral to an appropriate health care service. When the receiving screening indicates that an Inmate/Detainee has a contagious disease, is on medication, has immediate medical needs, is intoxicated, or is experiencing substance withdrawal, CONTRACTOR S staff shall notify the SHERIFF and/or SHERIFF S designee and refer the Inmate/Detainee to a provider for further review and treatment. In addition, CONTRACTOR shall use prescribed medication to delouse any Inmate/Detainee entering the Jail with scabies or lice, with the exception of Inmates/Detainees who are pregnant, have allergies, open sores, or who are on seizure medication. CONTRACTOR shall also administer tuberculosis (PPD) skin tests, as clinically indicated or required. K. ACCESS TO MEDICAL CARE. During the receiving screening, each Inmate/Detainee shall receive orientation and information from CONTRACTOR S health care staff on how to access health care services while housed at the Jail. Non-English speaking Inmates/Detainees shall receive verbal and/or written instructions, in their native language, regarding access to the health care services in the Jail. This orientation may include: 1. The purpose of receiving history and physical evaluations, provision of emergency services, pharmaceutical services and policies, infirmary and inpatient care. 2. The procedures for sick call and the times they are held during the week. 3. The procedures for obtaining health care services. 4. How to file a health care grievance. 5. Information on oral hygiene. -& Option To Extend to 3/18/16)

13 L. INMATE/DETAINEE INJURY OR ILLNESS PRIOR TO BOOKING. Inmates/Detainees who arrive at the Jail with an injury or illness will be thoroughly assessed prior to booking. Based on a favorable evaluation by a CONTRACTOR-qualified health care team member when on-site, the Inmate/Detainee shall be accepted and booked into the Jail. The CONTRACTOR and its physician assigned to the Jail, together with the COUNTY and the SHERIFF, shall develop medical admission criteria for the health care team member to follow when medically accepting an Inmate/Detainee into the Jail. If, in the opinion of the health care team member, the injuries or illness can be treated effectively on-site, the Inmate/Detainee will be accepted. Should the Inmate/Detainee have injuries or illnesses beyond the capacity of treatment within the Jail, the health care team will immediately advise SHERIFF S detention and/or transport staff to transfer the Inmate/Detainee to an appropriate off-site medical/mental health treatment center. M. DETOXIFICATION/WITHDRAWAL MANAGEMENT. Inmates/Detainees arrested under the influence of alcohol or drugs will be separated from the general population and kept under close observation. The health care team, including the provider when on-site, shall use established protocols to monitor intoxicated Inmates/Detainees during the detoxification period. If the Inmate/Detainee indicates a history or exhibits signs of an intense detoxification period, a provider may need to evaluate the Inmate/Detainee. Under extreme conditions, the Inmate/Detainee will be transported to a hospital for evaluation and treatment. Generally, Inmates/Detainees displaying acute detoxification symptoms shall be admitted to the medical observation unit managed by the nursing team and the CONTRACTOR S physician assigned to the Jail and the SHERIFF and the Jail s Administration, or their designee, shall be immediately notified. The Inmate/Detainee shall be monitored for the following conditions, any of which may indicate that additional medical attention may be warranted: 1. Tremors and/or agitation 2. Nausea and/or vomiting 3. Sweating, rapid pulse, fever 4. Seizures, confusion 5. Auditory and/or visual hallucinations The CONTRACTOR S physician assigned to the Jail shall be contacted regarding Inmates/Detainees whose condition begins to deteriorate during detoxification, and the physician may refer the Inmate/Detainee to a hospital if necessary. At the next sick call clinic, the physician shall see any Inmate/Detainee who is admitted to the infirmary or is exhibiting concerning withdrawal signs/symptoms. N. COMMUNICABLE DISEASES. CONTRACTOR S health care team shall closely monitor communicable diseases such as tuberculosis (TB), HIV, AIDS, hepatitis, and sexually transmitted diseases (STDs). Screenings for TB, STDs, HIV, and hepatitis shall be conducted as clinically indicated. When communicable diseases are diagnosed, CONTRACTOR shall take appropriate isolation precautions and shall treat the individuals in accordance with protocols established by the local health department and Centers for Disease Control and Prevention (CDC). If available, the CONTRACTOR shall utilize the negative pressure rooms in the medical observation unit for Inmates/Detainees requiring respiratory isolation. Reports of communicable diseases shall be sent to the Michigan Department of Community Health. O. MEDICAL CLEARANCE FOR INMATE/DETAINEE WORKERS. Upon the request of the COUNTY and SHERIFF the CONTRACTOR shall examine and provide medical clearance for Inmate/Detainee workers. This medical clearance process shall be completed within a reasonable timeframe after receiving the list of names to be cleared, unless laboratory or other applicable testing increases the time required for clearance. P. INFECTION CONTROL PROGRAM. The CONTRACTOR shall provide an Infection Control Program that shall focus on the prevention, identification, and control of infectious diseases, whether they are acquired within the correctional setting or introduced from the outside community. To facilitate the prevention, identification, and control of communicable diseases, the CONTRACTOR shall use an Infection Control Program that utilizes an infection control manual that focuses on education, prevention, and monitoring infection control issues. The CONTRACTOR shall also provide training to health care and security staff on the latest standard precautions to be utilized when handling Inmates/Detainees with communicable diseases. The CONTRACTOR S health care team at the Jail shall monitor and collect data regarding the incidence of communicable diseases, including: 1. Inmates/Detainees testing positive for HIV, hepatitis or sexually transmitted diseases 2. Inmates/Detainees diagnosed with AIDS 3. Inmates/Detainees testing positive for TB -& Option To Extend to 3/18/16) -& Option To Extend to 3/18/16)

14 INFECTION CONTROL MEETINGS The CONTRACTOR S Continuous Quality Improvement committee shall oversee the Infection Control Program and shall be responsible for: 1. Review and revision of infection control policies and procedures 2. Monitoring of infectious disease data 3. Monitoring of cleaning and sterilization techniques 4. Review of environmental inspection reports 5. Other matters related to infection control, as they emerge INMATE/DETAINEE ISOLATION PRECAUTIONS CONTRACTOR shall ensure that guidelines are in place or are established to facilitate isolation precautions of an Inmate/Detainee with a specific infection or communicable disease. Guidelines on ventilation, respiratory infection programs, and other infection control measures shall be reviewed and revised as needed. RECOMMENDATIONS Any written recommendations generated under CONTRACTOR s Infection Control Program shall be submitted to the Jail s administration and the Health Service Administrator for corrective action. Q. SICK CALL. The CONTRACTOR shall ensure that sick call coverage is provided seven (7) days per week for the Jail s Inmates/Detainees. Each request for care shall be triaged and referred to the appropriate health or mental health provider. Urgent medical problems shall be treated immediately. Non-emergent requests for health care shall be responded to within twenty four (24) hours of receipt. The CONTRACTOR shall also ensure that Inmates/Detainees shall have the opportunity to request medical assistance on a daily basis and that requests shall be documented and responded to per CONTRACTOR S policy and procedures. Where an Inmate/Detainee s segregation status prevents him/her from attending sick call, arrangements shall be made to provide sick call to the segregated Inmate/Detainee in his/her housing unit as necessary. The CONTRACTOR and the SHERIFF shall develop procedures for Inmates/Detainees who have difficulty communicating (e.g., illiterate, developmentally disabled, mentally ill, deaf, non-english speaking, etc.) to ensure that every Inmate/Detainee has full access to medical care services provided at the Jail. -& Option To Extend to 3/18/16) A log shall be utilized to record each request for sick call services, the date the Inmate/Detainee was seen, and disposition of the sick call visit. Appropriate documentation shall be recorded and maintained for all Inmates/Detainees seen at sick call and shall be incorporated into the Inmate/Detainee s health record. Thus each Inmate/Detainee s health record shall contain appropriate entries documenting all sick call encounters: 1. The Inmate/Detainee s specific health care complaint 2. The examining health care professional s assessment 3. The prescribed treatment plan 4. Follow-up encounters to the point of health care problem s resolution R. MEDICATION VERIFICATION, SET UP, AND ORDERS. The CONTRACTOR shall document administration of medication in each Inmate/Detainee s medical record to confirm an Inmate/Detainee has received the medication. The CONTRACTOR S consulting pharmacist shall review, on-site, the provision of pharmacy services on a quarterly basis, and follow up with a written report of his/her findings. To the extent not in conflict with the provisions set forth in this Agreement the CONTRACTOR shall maintain a medication administration system as set forth on pages 55 to 56 of the Proposal, attached hereto as Appendix A. All needles and syringes shall be stored according to the CONTRACTOR S policy and procedures, and within security conditions established by the SHERIFF. In addition to the services required above, the CONTRACTOR shall provide the following services: 1. Verification of medication with outside physicians or agencies for those Inmates/Detainees who are booked into the Jail with active prescriptions. 2. Monitored distribution of medications to the Inmate/Detainee population including psychotropic medications. 3. Pharmacy maintenance. 4. Inventory control including the secured and specialized strategies for the inventory and containment of narcotics. 5. The CONTRACTOR S health staff shall set up medication to be distributed by Jail s staff to Inmate/Detainee patients when CONTRACTOR S health staff are not on-site. -& Option To Extend to 3/18/16)

15 6. If a Inmate/Detainee has a third party insurer, the CONTRACTOR shall order prescriptions from a local pharmacy. S. COMPLETE HEALTH ASSESSMENTS. The CONTRACTOR shall provide a complete health assessment of an Inmate/Detainee as soon as possible after his/her admission into the Jail, but no later than fourteen (14) calendar days after the date of his/her arrival. The health assessment shall follow the guidelines of the current NCCHC jail standards. Following completion of the physical exam, the designated Jail staff shall be informed of the relevant aspects of the treatment plan, to enhance continuity of care, and so that they can assist in promoting compliance by the Inmate/Detainee. If the assessment is performed by a nurse, the Jail s physician shall review the results of the assessment to address any problems. The health assessment shall include the following components: 1. Review of the receiving screening results and the collection of additional data to complete the medical, dental, mental health, and immunization histories. 2. A complete and thorough physical examination, including comments about mental status, skin abnormalities and tattoos. 3. Review of the significant findings of the health assessment, tests, and identification of problems by physician. 4. Record of the Inmate/Detainee s height, weight, pulse, blood pressure, temperature, respiratory rate, and pulse oximetry. 5. Initiation of therapy and immunizations when appropriate. 6. Clinically indicated lab work, urinalysis, STD testing, HIV testing consistent with applicable law and the SHERIFF S Jail procedures. 7. Court ordered tests and medical exams. 8. Immunization history and needs. 9. Social history (including psych/substance abuse and sexual histories). 10. Allergies and allergic responses. 11. Additional testing as clinically indicated. 12. Instructions to Inmate/Detainee for future access to the Jail s Health Clinic. For pregnant Inmates/Detainees, the health assessment shall also include: 1. Pregnancy test to confirm positive pregnancy. 2. Routine prenatal education and care. 3. Management of chemically addicted pregnant Inmates/Detainees. 4. Postpartum follow-up care. If the Inmate/Detainee requires further evaluation or treatment, a referral to the appropriate health provider shall be made. CONTRACTOR shall provide annual health assessments, including physical examinations, to Inmates/Detainees who have been incarcerated at the Jail for over one (1) year. T. ON-GOING MEDICAL CARE. Routine non-emergency health care shall include, but not be limited to, the following: 1. Physician and nursing clinics for assessment, follow-up care, and routine preventative and therapeutic intervention of established and emerging medical needs. 2. Special treatment and minor surgeries (to be done within limitations of the Jail s capabilities). 3. Scheduling routine specialty clinics (e.g. asthma, diabetes, etc.). 4. Follow-up on calls received the previous day after hours regarding medical concerns of Inmates/Detainees. U. PHYSICIAN SERVICES. A board eligible/certified family practice or internal medicine physician licensed to practice in the State of Michigan shall be on-site twice weekly, for up to a total of six (6) hours per week for assessment and treatment of acute and chronic care conditions. The physician shall also be available to the nurse assigned to the Jail outside of these hours for consultation/prescriptions if needed, via phone twentyfour (24) hours per day seven (7) days per week. When the physician is on-site to hold clinic for evaluation and treatment of non-emergent health care concerns, the nurse shall assist with assessment, follow-up care, and routine preventative and therapeutic intervention of established and emerging medical needs. The nurse may also assist with special treatment and minor surgeries (to be done within limitations of capabilities of the facilities at the Jail). In order to handle Inmate/Detainee medical concerns and requests in a prompt and appropriate manner. CONTRACTOR shall implement the sick call triage system to accomplish the aforementioned as described in the Scheduled Sick Call section on page 51 of the Proposal, attached hereto -& Option To Extend to 3/18/16) -& Option To Extend to 3/18/16)

16 as Appendix A. The CONTRACTOR S Medical Director shall regulate the triage system, which shall be adhered to by all medical personnel. The triage system is to assure that Inmates/Detainees and their concerns or requests are properly processed and resolved. Medical personnel shall review Inmate/Detainee medical complaints or requests daily, with referrals to appropriate medical personnel as deemed necessary. When medically possible, the trained medical personnel shall handle the request or complaint at that time. Generally, all sick call requests shall be reviewed within 24 hours by the medical staff. Any Inmate/Detainee requiring a physician will be seen within one (1) week or sooner if medically warranted. If the physician determines the Inmate/Detainee s medical condition needs further evaluation or treatment than can be provided on-site, the Inmate/Detainee shall be referred appropriately. V. PROVIDING JAIL STAFF WITH TRAINING DEALING WITH EMERGENCY ON-CALL SITUATIONS. The CONTRACTOR shall provide an On-Call RN and physician backup, 24 hours/day, 7 days/week, for telephone consultation during off hours for urgent/emergent medical concerns regarding all the Inmate/Detainee patients. The CONTRACTOR shall assist with providing training to the Jail staff regarding guidelines of when to contact medical staff or emergency medical responders regarding urgent/emergent medical conditions. Topics shall include but not be limited to, the following: 1. Abdominal Distress 2. Ankle Sprains 3. Asthma/Allergic Reactions/Anaphylactic Shock 4. Bleeding/Shock 5. Bone & Joint Injuries 6. Breathing Stoppage 7. Burns 8. Chest Pain 9. Choking 10. Detox 11. Eye Injuries 12. Flesh Wounds/Punctures 13. Hangings (Conscious/Unconscious) 14. Head Lice & Crabs 15. Head, Neck, & Back Injuries -& Option To Extend to 3/18/16) 16. Hyperglycemia (High Blood Sugar) 17. Hypoglycemia (Low Blood Sugar) 18. MRSA 19. Poison/Drug Overdose 20. Seizures/Stroke 21. Suicide Prevention 22. Unconsciousness W. DENTAL SERVICES. CONTRACTOR shall arrange and bear the cost of mobile dentistry services to be provided onsite at the Jail once per month for a total of eight (8) hours. Dental care shall be provided for all Inmates/Detainees at the Jail by a dentist, licensed in the State of Michigan. An oral screening shall be performed by health care staff during an Inmate/Detainee s comprehensive health assessment, within fourteen (14) days of admission. The CONTRACTOR S health care staff shall provide the Jail s Inmates/Detainees with instruction in oral hygiene, examination, and how to address dental problems. The CONTRACTOR shall address emergent dental needs and develop a system for prioritizing responses to dental needs. When dental care is provided on-site, current infection control procedures shall be followed. Routine dental problems shall be managed in a timely fashion in keeping with current community standards of practice. Extractions shall be prioritized based upon emergent need and when medically necessary shall be performed in a manner consistent with community standards of care and in adherence with the American Dental Associations clinical guidelines. Appropriate inventory and control of all dental supplies, instruments, and chemicals used in provision of dental services shall be maintained. If a dentist serving the Jail s Inmates/Detainees determines that an Inmate/Detainee needs oral surgery or other specialty services that cannot be provided on-site, the CONTRACTOR, subject to the SHERIFF S approval, shall make arrangements with an off-site oral surgeon or dental specialist within Livingston County to provide such services. The cost of offsite dental services shall be included in the offsite cap amount. X. PATIENT EDUCATION & IMPROVEMENT OF SELF CARE. The CONTRACTOR S nurses shall provide explanations of disease status, health conditions, and risk consideration when interacting with Inmates/Detainees. When allowed by law and possible, the Jail s staff members shall also be involved in such discussions. The information shall -& Option To Extend to 3/18/16)

17 be presented in a manner that meets the Inmate/Detainee s level of understanding and education and shall be documented in the Inmate/Detainee s medical record with each contact. Promoting health education amongst Inmates/Detainees and the SHERIFF S staff shall be an important aspect of improving overall health and hygiene at the Jail. Inmates/Detainees shall also be encouraged by CONTRACTOR S nurses to participate in their own treatment plans to the greatest extent feasible. Examples include exercise programs, wound treatment, acne treatment, and observation log maintenance. II. QUALITY ASSURANCE, CONTINUOUS QUALITY IMPROVEMENT COMMITTEE, AND GRIEVANCE PROCEDURE. A. QUALITY ASSURANCE PROGRAM & PLAN. The CONTRACTOR shall develop and maintain a Quality Assurance Program and Plan for the SHERIFF mutually agreed upon by the COUNTY, SHERIFF and the CONTRACTOR specifying how each party shall work toward meeting the quality objectives. The Jail s Quality Assurance Program shall include, but shall not be limited to: 1. Customer (i.e. SHERIFF and Inmate/Detainee) Satisfaction - An important aspect of this component shall be utilizing/establishing a mechanism for tracking satisfaction over time. 2. Process Improvement - The process improvement component is aimed at improving an important work process. Interdisciplinary collaboration shall be an important aspect of this component. Any area that has implemented changes as a result of a redesign project, a complaint/grievance, a sentinel event analysis, or a prospective risk analysis shall include measures of these improvements in this section of their quality plans. Once improvement has been demonstrated, these measures may be moved to the quality control section. 3. Quality Control - The quality control component shall be directed at ensuring excellence at the most basic level. Included in this portion of the plan shall be any data elements accrediting bodies require. Indicators used in quality improvement projects may be moved into quality control once an improvement has been demonstrated. For those quality control indicators not required by a regulatory agency, once an improvement has been sustained, the quality control indicator may be dropped. 4. Regulatory Agency Violations or Recommendations - This component shall be included to focus attention on known areas for improvement related to ensuring achievement of regulatory standards. -& Option To Extend to 3/18/16) The goal of the Quality Assurance Program shall be to achieve continuous quality improvement. Acceptable performance standards for each item shall be established prior to the audit, which shall consider service provision, cost containment, customer satisfaction, and concurrence with, if appropriate, American Correctional Association Standards for jails, National Commission on Correctional Health Care Standards for jails, and the Michigan Department of Corrections Administrative Rules for Jails and Lockups. The CONTRACTOR shall develop and implement an improvement plan for the Jail s health care services for all items showing significant deviation from those standards. Deficient items shall be re-audited until acceptable standards are achieved and maintained. The Jail s Quality Assurance Program shall conduct monthly on-site chart audits. Charts shall be randomly selected and reviewed for documentation, timely physicals, timely medication orders, follow-up, and other information as needed. Audits of policies and procedures compliance shall be conducted as necessary. B. CONTINUOUS QUALITY IMPROVEMENT COMMITTEE. The CONTRACTOR shall have a Continuous Quality Improvement (CQI) Committee for the health care services to be provided at the Jail similar as described on page 35 of the Proposal, attached hereto as Appendix A. The CQI Committee shall be responsible for developing, recommending and implementing all policies and procedures necessary for the operation of the Jail s health care program. The COUNTY shall have final approval of the CQI Committee membership. The CQI Committee shall meet on a schedule mutually agreed to between the COUNTY and the CONTRACTOR which shall, at a minimum, be quarterly. C. GRIEVANCE PROCEDURES. Inmate/Detainee complaints and grievances regarding health care services shall be reviewed as part of CONTRACTOR S Quality Assurance Program. The CONTRACTOR shall establish health care services grievance procedures as a part of the SHERIFF S Policies and Procedures Manual to be used on-site. Upon being informed by SHERIFF S Jail Administration of a health care services grievance, the nurse shall respond in writing within twenty-four (24) hours of receipt of notice of the grievance. The COUNTY S and SHERIFF S Jail Administration shall be provided with copies of both the grievance and the nurse s written response. Grievances shall be copied to the CONTRACTOR S corporate office as part of the quality assurance process and followed up immediately. The Contract Manager or Divisional Vice President of Operations shall discuss the situation with the SHERIFF S Jail Administration and if it is determined that there is a deficiency in medical services, shall act as indicated or -& Option To Extend to 3/18/16)

18 III. appropriate to correct the situation. Grievances determined to be part of nursing service procedures or of the procedures of other health care services to be provided under this Agreement shall be documented in the quality improvement report and progress monitored until the situation is resolved. HOSPITALIZATION/OFF-SITE SERVICES/SPECIALTY SERVICES. A. HOSPITALIZATION. The CONTRACTOR shall arrange and bear the cost of hospitalization of the Jail s Inmate/Detainees who in the opinion of the CONTRACTOR S treating physician and/or medical director requires hospitalization. The CONTRACTOR shall facilitate the transportation with the SHERIFF S Office. The SHERIFF will be responsible for routine/security transportation. The CONTRACTOR S responsibilities regarding hospitalization shall include, but not be limited to, those described in the Hospital Care section, on page 53, of the Proposal, attached hereto as Appendix A. B. SPECIALITY SERVICES. The CONTRACTOR shall bear all cost of specialty services. Specialty services shall be defined as medical services that require physicians to be licensed in a specialty such as obstetrics, gynecology, dermatology, dietetic and any other specialized field of medicine. The CONTRACTOR S authorized physician shall determine and refer Inmates/Detainees for specialty services when medically necessary. The CONTRACTOR S authorized personnel shall make a recommendation and obtain approval from the SHERIFF S Office for specialty services prior to the arrangement of services. The services shall be performed at the Jail to the extent reasonably possible. To the extent specialty care is required and cannot be rendered at the Jail, the CONTRACTOR shall arrange, bear the cost of offsite specialty services. CONTRACTOR shall coordinate with the SHERIFF S Office for transportation for the provision of such services off-site. The SHERIFF will be responsible and bear the cost of transporting Inmates/Detainees to the CONTRACTOR S designated facilities for the approved specialty service. C. MEDICAL RECORDS MANAGEMENT. The CONTRACTOR shall maintain records in compliance with all applicable State of Michigan and Federal laws, rules and regulations including but not limited to the Health Insurance Portability and Accountability Act of 1996, Public Law , as amended ( HIPAA ) and amended by the Health Information Technology for Economic and Clinical Health Act, as amended ( HITECH Act ) part of the American Recovery and Reinvestment Act of 2009, as amended ( ARRA ) and Genetic Information Nondiscrimination Act of 2008 ( GINA ), as amended, and the Standards for Privacy of Individually Identifiable Health Information (the Privacy Standards ) and the Security Standards and Implementation Specifications (the Security Rule ) promulgated by the U. S. Department of Health and Human Services pursuant to such Acts, and consistent with community standards of practice. Standardized forms, developed by the CONTRACTOR and as mutually agreed upon with the COUNTY and SHERIFF, shall be used unless otherwise indicated. Medical records shall be kept separate from confinement records and shall contain accurate, comprehensive, legible, up-to-date medical information. Medical records management shall also comply with the following: 1. No information from an Inmate/Detainee s medical records shall be released over the telephone, except in special circumstances, e.g., emergency room transfer, history of sexually transmitted reportable disease (only to authorized public health authorities), or tuberculosis (only to authorized public health authorities). 2. Copies of an Inmate/Detainee s medical record may be released only after the Inmate/Detainee has signed and dated a release of information document that is received and placed in the medical record. 3. Information regarding testing for HIV antibodies and/or test results shall not be released without a specific release for the disclosure of such information by the Inmate/Detainee. 4. Any Inmate/Detainee admitted to the Jail who is treated for a medical, dental, or mental health problem shall be asked to sign a Consent/Release of Information form. 5. The Inmate/Detainee shall be informed of the primary purpose of the consent, i.e., to release information in an emergency situation. 6. Each Inmate/Detainee shall be informed that information regarding certain conditions cannot be released without additional Inmate/Detainee consent (e.g. HIV testing, HIV results, alcohol and/or drug addiction). 7. Each Inmate/Detainee shall be informed of certain information in his/her medical record that may be released without his/her consent, to authorized public health authorities (e.g. a sexually transmitted reportable disease, or tuberculosis). 8. Each Inmate/Detainee shall be informed that other information in his/her medical record may not be released over the telephone. 9. All medical and dental health records shall be kept in the Jail s medical unit in the active files for any Inmate/Detainee presently housed at the Jail. All medical records are the property of the COUNTY. The COUNTY shall be responsible for the storage of inactive medical records. -& Option To Extend to 3/18/16) -& Option To Extend to 3/18/16)

19 10. An Inmate/Detainee has the right to refuse recommended medical treatment. This shall be documented on the appropriate form, signed by the Inmate/Detainee, and maintained in the Inmate/Detainee s medical record. 11. The contents of the medical record, shall contain, but are not limited to: (a) Completed receiving screening form, health assessment forms (b) Physician orders (c) Problem list (when indicated), physician order sheets, progress notes (d) All diagnostic findings, treatments, and dispositions (e) Inmate/Detainee requests for health services and immunization records (f) Record of prescribed medications and their administration (g) Reports of laboratory, x-rays and diagnostic (h) Studies (i) Consent and Refusal forms (j) Release of Information Forms (k) Discharge summary of hospitalization (l) Reports of dental, psychiatric, and other consultations (m) Specialized treatment plan, if indicated (n) Place, date and time of each medical encounter (o) Any other miscellaneous forms or documentation of any and all health care, dental, and mental health services issues 12. The CONTRACTOR shall require all health care providers and hospitals to maintain confidentiality with regards to Inmate/Detainee medical records and to comply with all applicable state and federal laws, including HIPAA and with the SHERIFF S policies regarding access by Inmates/Detainees and the Jail s staff. 13. A complete copy of the applicable medical record shall be available to accompany each Inmate/Detainee who is transferred from the Jail to another location for off-site services or transferred to another institution. -& Option To Extend to 3/18/16) To the extent that they do not conflict with the requirements for Medical Records set forth above the CONTRACTOR shall comply with the terms for Medical Records set forth on pages of the Proposal, attached hereto as Appendix A. In the event of a conflict between this Agreement and the Proposal the terms of this Agreement shall take precedence and prevail. D. MANAGEMENT INFORMATION SYSTEM. The CONTRACTOR shall employ a data collection system to gather and analyze statistical data and utilization rates. Monthly statistics shall be provided to the CONTRACTOR S corporate office by the medical staff at the Jail. That data shall be compiled to determine health care trends and utilization, diseases, clinic needs, and other aspects of Inmate/Detainee health care. This system shall provide information for the monitoring and evaluation of health services, trend identification, and cost saving opportunities involved in quality assurance and reporting. The CONTRACTOR shall collaborate with the SHERIFF to tailor the information being monitored to suit the needs of the Jail. The following standard information shall be tracked in addition to any additional information determined appropriate: 1. Inmate/Detainee population 2. Physician sick call 3. Nurse sick call 4. Physicals 5. Ambulance trips 6. Emergency Room trips 7. Hospital admissions 8. Length of hospital stays 9. Off-Site specialty consultations 10. Communicable diseases 11. Dental visits 12. Prescription medication use and cost 13. Psychotropic medication use and cost To ensure all related information is obtained to be used in quality analysis, the COUNTY, in its sole discretion, may provide the CONTRACTOR with access to information gathered by the COUNTY that may be an ancillary factor in health care costs and utilization. For example, the CONTRACTOR may be provided with information that would enable the CONTRACTOR to be able to include the Jail staffing cost associated with -& Option To Extend to 3/18/16)

20 transporting off-site trips such as staff wages for guarding Inmates/Detainees at the hospital, vehicle costs and maintenance, etc. in reporting. By including this related data a more comprehensive view of the true costs related to health services provided and their effectiveness may be developed. The CONTRACTOR may additionally incorporate the Management Information System described in pages of the Proposal, attached hereto as Appendix A. E. AMBULANCE SERVICE. Health care personnel, upon determining that an Inmate/Detainee s condition is a medical emergency, shall notify the Duty Sergeant or Jail Administrator s designee. Any Inmate/Detainee whose medical condition is deemed critical shall be transported to the hospital by ambulance. It will be the responsibility of the Duty Sergeant or his/her designee to call for the ambulance for transport, and to notify next of kin. In the event that an ambulance is required, the CONTRACTOR shall bear the cost. If the Inmate/Detainee s medical condition is of an emergent, but stable nature, he/she may be transported by means of a SHERIFF vehicle. F. PHARMACY. The CONTRACTOR shall provide monitoring of pharmacy usage as well as the development of a preferred medication list. The CONTRACTOR shall bear the cost of all prescription and non-prescription medications prescribed by CONTRACTOR S licensed physician(s) to Inmates/Detainees housed under jurisdiction of the COUNTY. The CONTRACTOR shall also provide and bear the cost of non-prescription over-the-counter medications to out of County Inmates/Detainees housed in the Jail. The CONTRACTOR shall provide and the COUNTY shall bear the cost of prescription medications provided to out of County Inmates/Detainees. The procedures CONTRACTOR shall follow in administering pharmaceuticals at the Jail shall include the following: 1. Medications shall be administered at the time indicated by the physician. 2. Medication that requires counting, such as controlled substances, shall be counted each shift. Each dosage administered shall be signed out on a narcotics flow sheet for each Inmate/Detainee with the Inmate/Detainee s name, dose of medication, time, medical staff administering, and physician name. 3. All medications shall be administered by medical staff to the individual for whom it was prescribed by direct person-to-person contact. All Inmates/Detainees must take medications in front of -& Option To Extend to 3/18/16) medical staff to verify that the Inmate/Detainee does take the medication as it is prescribed. 4. When a particular medication has expired, it shall be given to the Jail s RN Clinical Administrator or his/her designee, who shall assume responsibility for its disposal. 5. All prescribed medications shall be documented by utilizing a progress note (for one time orders) or by a medication administration record. 6. All DEA controlled substances shall be kept in a locked cabinet. A flow sheet for each medication shall be kept and each shall be counted at each shift to verify the number remaining. 7. No Inmate/Detainee shall be forced to take psychotropic medications or other medications for disciplinary reasons. 8. All needles and syringes shall be kept in a locked cabinet. 9. No Inmate/Detainee shall be allowed to prepare, dispense, or administer medications other than self administration of insulin or inhalers. 10. Medications may be administered or distributed only by trained health care personnel. 11. Medication utilization shall be monitored monthly for accuracy. 12. A Drug Formulary shall be maintained in the Jail s medical unit. 13. All DEA controlled substances, psychotrophic drugs, or other drugs that may be abused, shall have automatic stop orders or periodic reviews as defined by the contracted pharmacy. 14. All drugs shall be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security. 15. All medications used for external purposes shall be stored separately from internal and injectable medications. 16. Any medication that requires special storage shall be stabilized as appropriate, i.e. refrigerated. 17. A pharmacist shall be available to CONTRACTOR S staff at all times when members of CONTRACTOR S staff are on duty at the Jail. The Pharmacy Program that the CONTRACTOR shall provide under this Agreement shall be as set forth on pages of the Proposal, attached hereto as Appendix A. In the event the CONTRACTOR S Pharmacy Program conflicts with or fails to meet all the procedures for administering pharmaceuticals at the Jail that are set forth in this Agreement the -& Option To Extend to 3/18/16)

21 CONTRACTOR S Pharmacy Program for the Jail shall be adjusted so as to comply with the procedures required by this Agreement. G. PATHOLOGY AND RADIOLOGY SERVICES. 1. PATHOLOGY SERVICES. To the extent possible, CONTRACTOR S staff shall provide laboratory and diagnostic services on-site. Laboratory services shall include routine, special chemistry, and toxicology analysis. All laboratory testing performed on-site shall be in compliance with the Clinical Laboratory Improvement Amendments. Services shall include timely pickup and delivery, accurate reporting, and all necessary supplies. Laboratory specimens shall be drawn by the health care staff and sent to the reference laboratory, and arrangements shall be made with the local hospital or laboratory service for stat testing. A computer and printer shall be installed to receive all test results, and the laboratory shall call the Jail to provide notification of all critical results. All laboratory results will be reviewed and initialed by the Medical Director with a follow-up plan of care if indicated. Should an Inmate/Detainee require additional diagnostic services not able to be performed on-site, the CONTRACTOR shall arrange for off-site laboratory services. 2. RADIOLOGY SERVICES. Standard X-rays shall be completed onsite whenever possible. Positive results shall be reviewed within two (2) hours of the X-ray. In some cases, ECG services may be conducted on-site within the scope of licensure. It may be necessary to send some ECG and radiology patients to an urgent care center or hospital as determined by the health care staff, at which point the CONTRACTOR shall make appropriate off-site arrangements for any radiology services. Off-site services shall be coordinated with SHERIFF S staff for required security transport to and from the off-site facility. All radiology and ECG results shall be reviewed and initialed by the Jail s Medical Director with a follow-up plan of care as indicated. 3. PATHOLOGY AND RADIOLOGY COSTS AND ON-SITE SERVICES. The CONTRACTOR shall bear the cost of all onsite or offsite pathology and radiology services (also referred to as laboratory and X-ray). CONTRACTOR shall make reasonable attempts to perform services on-site at the Jail. To the extent pathology and radiology services are required and cannot be rendered on-site the CONTRACTOR shall arrange and coordinate with the SHERIFF the transportation required for the provision of such services off-site. The SHERIFF shall be responsible for and -& Option To Extend to 3/18/16) bear the cost of transporting Inmates/Detainees to off-site facilities for pathology and radiology services. H. MENTAL HEALTH. The CONTRACTOR shall provide and bear the cost of onsite mental health services. Mental health services to be provided shall generally include but not be limited to intake, post admission evaluation, counseling and suicide prevention. The specific mental health services to be provided by the CONTRACTOR shall be as follows: 1. The CONTRACTOR shall provide a psychiatrist on-site two (2) hours per week up to eight (8) hours per month to evaluate, prescribe medications, treat and monitor dosage levels for mental health patients. The CONTRACTOR S psychiatrist shall collaboratively work with the CONTRACTOR S mental health professional assigned to the Jail. 2. The CONTRACTOR shall provide forty (40) hours of screening and intervention services per week for the Jail Inmates/Detainees. This shall include the identification of at-risk individuals and a comprehensive, integrated approach with the delivery of medical care. 3. The CONTRACTOR shall assure that an evaluation of all identified Inmates/Detainees by qualified mental health professionals is completed within fourteen (14) calendar days of admission. Results of the evaluation shall become a part of the Inmate/Detainee s health record. Any psychopathology identified in an Inmate/Detainee which compromises the safety of the individual or others at the Jail shall be evaluated and transferred, if appropriate, to the regional inpatient psychiatric facility. Medical staff shall monitor discharge planning to include referrals to local mental health providers. 4. Through screening and assessments conducted by CONTRACTOR S personnel, all Inmates/Detainees shall have the opportunity to have their mental health status evaluated. The medical staff assigned to the Jail shall assist the mental health professional in the identification, treatment, and referral of clients with serious mental health needs and developmental disabilities. This treatment model shall assure that Inmates/Detainees receive the level of care that is required for optimum mental health. 5. The care of Inmates/Detainees with special needs requires close medical supervision and/or multidisciplinary care by CONTRACTOR S medical and mental health professionals. Inmates/Detainees with special mental health needs and the developmentally disabled are among the Jail s Inmate/Detainee -& Option To Extend to 3/18/16)

22 population. For each of these special needs Inmates/Detainees, the CONTRACTOR shall prepare a written, individual treatment plan developed by a licensed medical provider in conjunction with the mental health professional. The plan shall include instructions about diet, exercise, adaption to the correctional environment, medication, the type and frequency of diagnostic testing, and the frequency of follow-up for medical evaluation and adjustment of treatment modality. The treatment plan shall be individualized, multidisciplinary, and based on the assessment of the Inmate/Detainee s needs. 6. Inmates/Detainees identified with mental health conditions shall be referred to follow up clinics or community resources when discharged from incarceration for continuing therapy when discharged from the Jail. 7. The CONTRACTOR S mental health professional shall provide training sessions each calendar year for all SHERIFF S Jail staff. These trainings shall be agreed upon by the RN Health Services Administrator and the Jail Administrator or his designee. These training sessions shall include, minimally, education on suicide prevention. 8. The CONTRACTOR S mental health professional shall utilize a problem oriented health record structure consistent with the medical record. All clinical encounters and findings shall be recorded in each Inmate/Detainee s medical records. All entries in the record shall have date and time noted, be legible, and be authenticated by a method that identifies the author. Inmate/Detainee medical charts shall be randomly selected for review as part of an on-going Quality Assurance initiative by the Jail s medical department. 9. The CONTRACTOR S mental health professional shall provide recommendations to the Jail s personnel regarding placement of Inmates/Detainees, integration issues, risk assessment, and transfer information. This shall be coordinated through the RN Health Services Administrator. Neither the mental health professional nor the medical staff shall be involved with disciplinary actions with the Inmates/Detainees. Information that is pertinent to the safe incarceration of a Inmate/Detainee shall be provided as part of an integrated team approach with the Jail s staff. 10. The CONTRACTOR shall maintain a medication system that complies with all applicable State of Michigan and Federal laws governing the dispensation and control of classified drugs. A licensed pharmacist shall audit for compliance of applicable laws on a quarterly basis. Mental health professionals shall not dispense -& Option To Extend to 3/18/16) any medication. The psychiatrist and physician(s) CONTRACTOR has assigned to perform services under this Agreement who are licensed to prescribe psychotropic medication shall prescribe necessary psychotropic medication for Jail Inmates/Detainees per the preferred medication list when applicable. 11. No forced psychotropic medications or chemical restraints shall be utilized at the Jail. Should an Inmate/Detainee require this level of intervention, medical staff shall coordinate transfer of the Inmate/Detainee to an emergency room for psychiatric stabilization. The CONTRACTOR S mental health professional shall coordinate follow up care based on Inmate/Detainee need, i.e., pink slipped or continued care at the Jail. 12. The CONTRACTOR S mental health professional, as part of an orientation program, shall be familiar with safety precautions required to work within the Jail. The CONTRACTOR shall be responsible for the oversight of the mental health staff and shall assure a proper orientation period is completed. 13. All current policies and procedures governing the operations at the Jail and CONTRACTOR shall be adhered to. This includes a comprehensive suicide response policy. 14. As part of the CONTRACTOR S team, the mental health professionals shall work under the direction of the Psychiatrist and report to the Psychiatrist on mental health issues, report to RN Health Services Administrator at the Jail and/or such other person(s) designated by the CONTRACTOR on medical issues and to the CONTRACTOR S Administrative Office on administrative issues. This affords continuous feedback and accountability within the CONTRACTOR S health care team assigned to the Jail as well as access to the Jail Administrator as required. The RN Health Services Administrator shall meet with the Jail Administrator on a monthly basis to discuss common issues. 15. The CONTRACTOR S mental health professionals shall collect statistics for the RN Health Services Administrator to incorporate into the current reports prepared for the Jail Administrator. All statistics shall be bundled and presented to the Jail Administrator at the end of each quarter and annually in a format approved by the SHERIFF. 16. The CONTRACTOR shall maintain or exceed compliance with all medical and mental health requirements for Inmates/Detainees set by the Michigan Department of Corrections. This shall include review of mental health services. The Quality Assurance Program shall be operated and maintained by the CONTRACTOR to assure -& Option To Extend to 3/18/16)

23 that all mental health programming reflects current standards and trends in the delivery of mental health services. 17. The CONTRACTOR S RN Health Services Administrator shall coordinate with the Jail Administrator or SHERIFF transport for Inmates/Detainees with special needs due to security issues. The mental health services to be provided by the CONTRACTOR shall be as further described in pages of the Proposal, attached hereto as Appendix A. In the event of any conflict between the term and conditions of this Agreement with respect to mental health services and the mental health services described in the Proposal, the terms and conditions of this Agreement shall take precedence and prevail. A conflict, however, shall not be deemed to exist where the Proposal provides for CONTRACTOR S mental health services and responsibilities not specifically required in this Agreement. I. MEDICAL SUPPLIES. The CONTRACTOR shall procure and supply all medical supplies necessary to implement and run the Inmate/Detainee health services the CONTRACTOR is required to provide under this Agreement. Medical supplies shall be defined as all medical equipment and commodity items with a unit cost of $ or less. Examples of medical supplies may include: hand instruments, syringes, bandages, gloves, needles, etc. supplies shall be maintained at such levels to accommodate usage for a period of fourteen (14) days. It is understood that all supplies provided under this section shall become the property of the COUNTY at the termination of this Agreement. J. MEDICAL WASTE & SHARPS. All medical instruments utilized for treatment shall be counted both before and after utilization. Needles and syringes shall be kept in a locked room or cabinet. If a sharp count does not balance, the RN Health Services Administrator and the Jail s Duty Sergeant, or his/her designee, shall be notified immediately. The CONTRACTOR shall be responsible for training its health care staff to implement the proper methods of handling and storage of hazardous and/or contaminated medical waste in accordance with all applicable federal and state laws, rules and regulations and OSHA-regulated standards. All solid waste or semi-solid waste shall be double bagged in red biohazard bags, and contaminated laundry shall be placed in the properly designated bags. Used needles, syringes, and other sharps shall be placed in biohazard sharps containers and properly disposed of. -& Option To Extend to 3/18/16) Cleanup kits for bodily fluid spills shall be available at all Inmate/Detainee housing units. The CONTRACTOR shall be responsible for the cost of removal and disposal of medical waste. K. COLLECTION OF PHYSICAL EVIDENCE. The CONTRACTOR shall assist law enforcement with the collection of physical evidence as follows: 1. The CONTRACTOR shall collect physical evidence when the request is accompanied by a written court order or legal consent of a person in lawful custody. 2. The CONTRACTOR shall provide specimens to the SHERIFF or a Court designated representative for necessary testing and completion of lab requisition. 3. The CONTRACTOR shall provide test results to individuals in a confidential setting and distribute education and health materials provided by the Livingston County Department of Public Health. L. PARTICIPATION IN MEETINGS AND COLLABORATION WITH SUPPORT AGENCIES AND SERVICES. The CONTRACTOR S medical staff shall be sensitive to the security needs and overall operating policies of the Jail. Jail staff members shall assist the medical staff in identifying real or potential health problems. A cooperative working relationship between medical and Jail staff is necessary to ensure that health care problems are identified early, treated properly, and then carefully monitored until recovery/resolution. At the same time, security concerns and other institutional objectives must be met. The CONTRACTOR S Contract Manager, Divisional Vice President of Operations, and/or Senior Vice President of Operations shall meet quarterly, or as desired by the COUNTY or SHERIFF with designated COUNTY and SHERIFF administrators to discuss the services being provided by CONTRACTOR under this Agreement. At this meeting, the CONTRACTOR S representatives shall respond to all questions, and discuss any particular problems or concerns. This meeting shall also provide an on-going opportunity to evaluate and identify areas in need of improvement. The CONTRACTOR shall provide allowances for selected nurses or corporate representatives to participate in joint meetings and possible collaboration/cooperation with support agencies and services such as Livingston Community Mental Health Authority, Livingston County Department of Public Health, and Livingston Community Corrections, if so desired by the COUNTY. Information and group participation by CONTRACTOR S staff shall be at such times and locations as mutually -& Option To Extend to 3/18/16)

24 IV. agreed upon, by CONTRACTOR and SHERIFF and in compliance with SHERIFF S goals and objectives. The CONTRACTOR shall also participate in any external reviews, meetings, inspections, and audits as may be requested. The CONTRACTOR shall also provide staffing allowances for SHERIFF S mandated orientations and training for medical staff. Medical staff shall be required to attend any regularly scheduled or special meetings regarding the Jail s policies and procedures when their attendance is requested by the Jail s Administrator. M. HEALTH EDUCATION AND TRAINING. The CONTRACTOR shall coordinate dates and times with the Jail Administrator, to provide Blood Borne Pathogens and Cardio Pulmonary Resuscitation (CPR) training for SHERIFF S personnel. If requested by the SHERIFF the CONTRACTOR shall provide in-service training to SHERIFF employees on other subjects, such as: 1. Suicide Prevention 2. Mental health education 3. Communicable diseases, including Tuberculosis 4. Other classes as deemed appropriate The health education and training services to be provided by the CONTRACTOR shall also include those services which are set forth in pages 59 and 60 of the Proposal. The CONTRACTOR shall also develop staff training programs on specific subjects as reasonably requested by the SHERIFF. N. MEDICAL LIBRARY. The CONTRACTOR, as proposed on page 59 of the Proposal, attached hereto as Appendix A, shall establish a medical library on-site at the Jail for use by the health care staff. The library at a minimum shall include basic reference texts related to diagnosis and treatment in a primary setting. REPORTS, INFORMATION, REVIEWS, RECORD RETENTION, ACCESS AND INSPECTION OF RECORDS. A. MEETINGS. The CONTRACTOR S Contract Manager, Divisional Vice President of Operations, and/or the Senior Vice President of Operations shall meet quarterly with COUNTY and SHERIFF administration concerning the overall operation of health care services and general health of the Inmate/Detainee population. Such meetings may be more frequent than quarterly if so requested by the COUNTY S or SHERIFF S administration. The CONTRACTOR shall cooperate and confer as necessary with the COUNTY S and SHERIFF S representatives to ensure satisfactory work progress. B. MONTHLY REPORTS. The CONTRACTOR shall provide to the SHERIFF and/or his designees with reports concerning the overall operation of the Jail s health care services program, as well as details on the general health of Inmates/Detainees at the Jail. 1. Monthly Medical Statistics Report. This report shall be maintained in accordance with the sample provided in the attached Appendix B of this Agreement and shall include summaries of all on-site and off-site services performed by CONTRACTOR s medical staff. Attached to this report shall be a detailed report indicating the following: date of service, time of service, and reason for off-site visit. CONTRACTOR shall also identify actual costs and estimated costs with monthly service totals. 2. Monthly Pharmacy Statistics. This report shall summarize monthly and year-to-date medication utilization and shall be organized by category. The CONTRACTOR shall include the quantity dispensed for each drug and will identify actual and estimated costs based on utilization. These reports shall be in a format with details agreed upon by both the CONTRACTOR and the COUNTY. All monthly reports shall be provided to the Jail Administrator no later than thirty (30) days after the end of the month that services were provided. C. REPORT REVIEW. All reports made in connection with the services provided under this Agreement shall be subject to review and final approval by the COUNTY and the SHERIFF administration. D. ACTIVITY REVIEW. The SHERIFF may review and inspect the CONTRACTOR S activities during the term of this Agreement. E. ADDITIONAL INFORMATION AND REPORTS. The CONTRACTOR shall provide the COUNTY and/or the SHERIFF with such information regarding CONTRACTOR S services under this Agreement as is required for the COUNTY/SHERIFF to meet reporting requirements to health insurers, or to State or Federal Authorities, or to State or Federal Courts. Such information shall be provided within ten (10) business days after CONTRACTOR receives written notice of the information that is required. When reasonably requested by the COUNTY or the SHERIFF, the CONTRACTOR shall submit additional written reports containing information regarding the services required by this Agreement and the cost thereof. Such additional reports shall be submitted to the COUNTY and SHERIFF within ten (10) business days after CONTRACTOR has -& Option To Extend to 3/18/16) -& Option To Extend to 3/18/16)

25 received written notice of the information desired or such longer period of time as the COUNTY or SHERIFF may set in their sole discretion. F. ACCESS TO AND REVIEW OF RECORDS. After not less than five (5) business days prior written notice to the CONTRACTOR, the COUNTY S and SHERIFF S representatives, including those acting on COUNTY S and SHERIFF S behalf such as contracted auditors, shall have access to and may review/examine the CONTRACTOR S internal, electronic and/or written records, financial records, reports, memoranda, s, or insurance policies pertaining to services provided under this Agreement or costs billed to the COUNTY under this Agreement. G. MAINTENANCE OF RECORDS. The CONTRACTOR shall maintain and retain all electronic and/or written records, financial records, reports, memoranda, s pertaining to the services provided under this Agreement that have not been turned over to the SHERIFF for period of not less than ten (10) years after termination of this Agreement or such longer period as may be required by law. H. MEDICAL RECORDS REQUIREMENTS. All medical records, on each Inmate/Detainee in CONTRACTOR S care under this Agreement, that is developed by CONTRACTOR S staff shall be accurate, comprehensive, legible, up-to-date, and in compliance with the requirements of Section III, Subsection C of this Agreement. I. CONFIDENTIALITY OF HEALTH RECORDS. All Inmate/Detainee health records shall be the property of the SHERIFF. Management of Inmate/Detainee health records shall be as set forth in Section III, Subsection C of this Agreement. CONTRACTOR shall act as custodian of the health records, and such records shall be kept confidential subject to the rights of access thereto by the SHERIFF. The CONTRACTOR shall ensure that access to Inmate/Detainee health care records is consistent with the applicable Local, State, and Federal confidentiality laws, rules and regulations including but not limited to HIPAA, as amended. The confidential relationship of doctor and patient extends to Inmate/Detainee patients and their clinicians. The CONTRACTOR shall maintain a current record of all applicable laws, rules and regulations at the Jail covering the confidentiality of health care records and the types of information that may and may not be shared. The release of an Inmate/Detainee s health record shall occur only through policy approved by the SHERIFF. This policy shall ensure that appropriate legal measures are taken when anyone is requesting an Inmate/Detainee s health record. In the case of discharged Inmates/Detainees, the health record will be maintained in accordance with the laws of the State of Michigan. Inactive medical records will be maintained according to State and Federal statutes and the American Medical Association. Upon an Inmate/Detainee s return to incarceration, any prior health records shall be incorporated into the new record to ensure continuity of care. It is understood that all medical records shall remain the property of the SHERIFF and/or the COUNTY. In the event of any Inmate/Detainee litigation involving medical care provided, CONTRACTOR may have access to the relevant Inmate/Detainee health records, or as permitted by law. Notice of all legal actions involving Inmates/Detainees and their medical care will be provided to the Jail s Administrator within twenty-four (24) hours. J. OFF-SITE SERVICES AND MEDICAL RECORDS. The CONTRACTOR shall maintain established procedures for the receipt and filling of requests for medical records from all outside consults, emergency room visits, and inpatient hospitalizations. The CONTRACTOR shall comply with all State statutes regarding retention of health records and the requirements of the Health Insurance Portability and Accountability Act of 1996, Public Law , as amended (hereinafter, HIPAA ), as amended by the Health Information Technology for Economic and Clinical Health Act (hereinafter, HITECH Act ), part of the American Recovery and Reinvestment Act of 2009 (hereinafter referred to as ARRA ) and the Genetic Information Nondiscrimination Act of 2008 (hereinafter GINA ), and the rules and regulations promulgated pursuant to said statutes. V. COST CONTAINMENT AND SHARED COST PROGRAM(S) AND ANNUAL COST RECONCILIATION. A. COST CONTAINMENT. It is expressly understood and agreed by the COUNTY and the CONTRACTOR that cost containment of medical and psychiatric health care services shall be given high priority in the provision of such services under this Agreement. The cost-effective long term strategy for the delivery of health and mental health services under this Agreement shall be through a proactive system that emphasizes screening, early disease detection, treatment, health promotion, and disease prevention. Identified health problems shall be treated promptly. The importance of health maintenance and disease prevention shall be emphasized to Inmates/Detainees through educational presentations. The following are some ways by which overall costs for health services shall be contained by the CONTRACTOR: 1. On-site health services shall be utilized to the maximum extent possible. -& Option To Extend to 3/18/16) -& Option To Extend to 3/18/16)

26 2. Hospitalizations of Inmates/Detainees shall be aggressively managed. Utilization review shall occur in a real time, anticipatory manner. The CONTRACTOR shall be actively involved with the ongoing care provided to any hospitalized Inmate/Detainee. Through personal discussions with involved physicians, an appropriate diagnostic and therapeutic plan shall be developed, implemented, and monitored. Hospital lengths of stay shall be the shortest possible duration consistent with appropriate medical care. 3. All Inmates/Detainees requiring chronic medical or mental health treatment shall be identified at the time of initial health screening or as necessary. A treatment plan shall be developed for each Inmate/Detainee requiring ongoing care. Each plan shall be individualized to the specific needs of the Inmate/Detainee and shall identify the therapeutic goals, course of therapy, and medical and non-medical personnel responsible for implementation of the plan. Chronic medical services shall be provided on a scheduled basis. The need for change in continuation of chronic medical services shall be assessed by the CONTRACTOR S medical director, at appropriate intervals. The goal for chronic treatment shall be to meet the basic health needs of the Inmate/Detainee. The CONTRACTOR S strategy to cost-effectively manage all chronic illnesses shall be compliance with prescribed therapy, continual monitoring, and prompt treatment of complications. 4. Effective management of pharmaceutical prescribing. Generic drugs shall be used when medically applicable to assist in decreasing pharmacy costs. In addition, the pharmacy provider(s) used by CONTRACTOR shall evaluate prescribing patterns of physicians and psychiatrists to provide recommendations for improving cost efficiencies. 5. Pursuing third party reimbursement. At the time of booking screening, the Inmate/Detainee shall be asked about health insurance. When identified, off-site health care and prescriptions shall be submitted through the third party payer. In addition, when an Inmate/Detainee is hospitalized, the CONTRACTOR shall assist in the evaluation if the Inmate/Detainee/patient has Medicaid or is eligible. If eligible, an application shall be submitted to Medicaid. To the extent that it does not conflict with the cost containment requirements set forth in this Agreement the CONTRACTOR shall use the Cost Containment Approach set forth on page 36 of the Proposal, attached hereto as Appendix A. In the event of a conflict between the cost containment provisions set forth in this Agreement and those in the Proposal the provisions in this Agreement shall take precedence and prevail. -& Option To Extend to 3/18/16) B. SHARED COST APPROACH. The following shared cost approach shall be adhered to by the COUNTY and the CONTRACTOR: 1. Annual pharmacy costs up to SIXTY THOUSAND AND NO/100 DOLLARS ($60,000.00) shall be paid by the CONTRACTOR. Annual pharmacy costs in excess of $60, shall be the responsibility of the COUNTY. In the event the annual pharmacy costs during any year covered by this Agreement are less than $60, one hundred percent (100%) of the difference between the actual annual cost and $60, shall belong to the COUNTY. The COUNTY at its option may either (a) require the CONTRACTOR to apply the difference between the actual annual pharmacy cost and $60, to a credit to be applied toward pharmacy costs the COUNTY would have to pay in the next year on pharmacy costs that exceed $60,000.00, or (b) send the difference between $60, and the actual annual pharmacy cost to the COUNTY in the form of a refund check. The CONTRACTOR and the SHERIFF shall explore having Inmates/Detainees provide their own medications that are to be confirmed and verified along with meeting the CONTRACTOR S formulary. 2. Annual off-site costs (e.g. inpatient and outpatient hospitalization, ambulance, specialty services, offsite dental) up to ONE HUNDRED FIFTY THOUSAND AND NO/100 DOLLARS ($150,000.00) shall be paid by the CONTRACTOR. In the event the annual off-site costs during any year covered by this Agreement are less than $150, one hundred percent (100%) of the difference between the actual annual cost and $150, shall belong to the COUNTY. The COUNTY at its option may either (a) require the CONTRACTOR to apply the difference between the actual annual off-site costs to a credit to be applied toward off-site costs the COUNTY would have to pay in the next year on off-site costs that exceed $150,000.00, or (b) send the difference between the $150, and the actual annual off-site costs to the COUNTY in the form of a refund check. The credit or refund will be calculated three months after the end of each annual contract term to allow for processing of claims incurred during the annual contract term. Any claims for services from the prior annual contract term that are received and paid after this three month period will be calculated in the subsequent annual contract term cap amount. The CONTRACTOR shall assist with insurance verification so that the COUNTY shall be the payer of last resort. If total annual off-site costs are greater than $150,000.00, the COUNTY shall be solely responsible for the amount over $150, When the offsite cap -& Option To Extend to 3/18/16)

27 amount for each annual contract year is reached, CONTRACTOR will continue to provide utilization management, extend all provider and contractual discounts to the COUNTY and pay these expenses on behalf of the COUNTY as long as the COUNTY remains current with the monthly payments due under this AGREEMENT. C. ANNUAL COST RECONCILIATION. The COUNTY and the CONTRACTOR shall annually reconcile the sums paid by the COUNTY and actual services provided and costs incurred under this Agreement during the year which just ended. For the purposes of this Agreement the first year for which reconciliation shall occur shall be for the period covering March 18, 2012 to March 30, 2013, thereafter the cutoff date for reconciliation shall be March 30 th of each year in which this Agreement is in effect. The CONTRACTOR after the March 30 th cutoff date shall have until June 30 th of that year to tabulate all invoices it has received for services provided prior to the March 30 cutoff date. The CONTRACTOR shall provide the COUNTY with the annual reconciliation by no later than June 30 th. D. QUARTERLY RECONCILIATION PROCESS. CONTRACTOR will provide quarterly reconciliation with the COUNTY for any amounts owed by either party pursuant to the terms of this AGREEMENT, including adjustment for monthly average daily population. MONTHLY AVERAGE DAILY POPULATION (MADP) The average number of Inmates/Detainees housed in the Jail on a daily basis for the period of one month. The MADP shall include, but separately list, Out of County Inmates/Detainees. The MADP shall be figured by summing the daily population for the Jail and Out of County Inmates/Detainees (as determined by a count performed at the same time each day) for each day of the month and dividing this sum by the total number of days in the month. Jail records shall be made available to CONTRACTOR upon request to verify the MADP. Persons on work release and not indigent, home confinement, housed outside of the Jail, and parolees and escapees shall not be considered part of the Jail s MADP. ADJUSTMENT FOR MADP. For each month in the quarter reconciled, if the Jail s MADP is greater than Two Hundred Seventy-Five (275) Inmates/Detainees, the compensation payable to CONTRACTOR by the COUNTY shall be increased by the number of Inmates/Detainees over Two Hundred Seventy-Five (275) at the per diem rate of forty-eight cents ($0.48). If the Jail s MADP is less than Two Hundred Twenty-Five (225) Inmates/Detainees, then CONTRACTOR will issue a credit to the COUNTY for the number of Inmates/Detainees under Two Hundred Twenty-Five (225) at the per diem rate of forty-eight cents ($0.48). VI. VII. PEOPLE COVERED UNDER THIS AGREEMENT. A. GENERAL. The people to receive health services under this Agreement are those persons considered an Inmate/Detainee by the SHERIFF who are being held in the Jail and considered to be part of the Jail s average daily population. Such Inmates/Detainees shall be construed to be in the SHERIFF S custody. The average daily population shall be determined from the Jail s records. People on home confinement, or otherwise housed outside of the Jail shall not be considered part of the Jail s average daily population. The SHERIFF shall make said Jail records available to the CONTRACTOR at any time upon written notice. B. INMATES/DETAINEES IN ACTIVE CUSTODY. The CONTRACTOR shall be responsible for the payment of services rendered to Inmates/Detainees or detainees when such people are/were in the active custody of the COUNTY or under the jurisdiction of the COUNTY. In the event this Agreement is terminated, the CONTRACTOR shall continue to be responsible for all costs for any services provided to Inmates/Detainees in the SHERIFF S custody during the term of this Agreement. C. INMATES/DETAINEES FROM OTHER COUNTIES/STATE OR FEDERAL GOVERNMENTAL AGENCIES. Inmates/Detainees from other counties, state or federal agencies may be housed at the Jail. Such Inmates/Detainees are hereinafter referred to as Out of County Inmates/Detainees. Out of County Inmates/Detainees shall be included and identified in the average daily population count. The CONTRACTOR shall provide sick call, over-the-counter medications, medical supplies and medical waste services for Out of County Inmates /Detainees. However, cost of all prescription medication and other health care expenses shall be paid by the agency responsible for the Out of County Inmate/Detainee. The CONTRACTOR shall provide the same onsite care, at no additional cost for staffing if there are no substantial changes in the average daily population, as if the Out of County Inmate/Detainee were a COUNTY Inmate/Detainee. PEOPLE NOT COVEVED UNDER THIS AGREEMENT A. COUNTY INMATES/DETAINEES HOUSED IN OTHER COUNTIES. The CONTRACTOR shall not be responsible for the medical care and treatment of COUNTY Inmates/Detainees housed in jails in other counties. -& Option To Extend to 3/18/16) -& Option To Extend to 3/18/16)

28 VIII. B. INMATES/DETAINEES RELEASED FROM CUSTODY. The CONTRACTOR shall not be responsible for payment of any health services rendered to an Inmate/Detainee once the Inmate/Detainee is released from custody of or is no longer under the jurisdiction of the Jail. SHERIFF S DUTIES AND OBLIGATIONS A. COMPLIANCE WITH HIPAA. The SHERIFF and its agents shall comply with HIPAA, HITECH Act, and GINA, and the regulations promulgated pursuant thereto. The SHERIFF shall implement Inmate/Detainee medical records confidentiality policies in compliance with such laws and the rules and regulations promulgated pursuant thereto. B. OWNER OF RECORDS. The medical records of the Jail s Inmates/Detainees shall at all times be the property of the SHERIFF, subject to the rights of the Jail s Inmates/Detainees and applicable Federal and state laws, rules and regulations. C. RECORDS ACCESS. During the term of this Agreement and for a reasonable time thereafter, the SHERIFF will provide CONTRACTOR, at CONTRACTOR S request and to the extent permitted by HIPAA, as amended, and the rules and regulations promulgated pursuant thereto, access to the original and/or copies of the SHERIFF s records relating to the provision of health care services to the Jail population as may be reasonably requested by the CONTRACTOR in connection with an investigation of, or defense of, any claim by a third party related to the CONTRACTOR S conduct. To the extent allowed by law and the foregoing provision, the SHERIFF will make available to the CONTRACTOR such records as are maintained by the SHERIFF, hospitals and other outside health care providers involved in the care or treatment of the Jail population (to the extent the SHERIFF has any control over those records) as the CONTRACTOR may reasonably request. Any such information provided by the SHERIFF to the CONTRACTOR that the SHERIFF considers confidential shall be kept confidential by the CONTRACTOR and shall not, except as may be required by law, be distributed to any third party without prior written approval by the SHERIFF. Notwithstanding any provision of this Agreement to the contrary, the SHERIFF S internal affairs records and investigative records shall not be required to be provided to the CONTRACTOR or any other person or entity (except as may be required by law). D. EMPLOYMENT USE OF INMATES/DETAINEES. Inmates/ Detainees shall not be employed or otherwise engaged by either the CONTRACTOR or the SHERIFF in rendering any health care services. Upon prior written approval of the SHERIFF, Inmates/Detainees may be used in positions not directly involving health care or pharmacy services to Inmates/Detainees and not involving Inmate/Detainee records. E. SECURITY OF THE JAIL FACILITY AND CONTRACTOR. SHERIFF shall maintain responsibility for the physical security of the Jail Facility and the continuing security of the Jail population. The CONTRACTOR and the SHERIFF understand that adequate security services are necessary for the safety of the employees, agents and/or subcontractors of the CONTRACTOR as well as for the security of the Jail population and SHERIFF S staff, consistent with the correctional setting. The SHERIFF shall provide security sufficient to enable the CONTRACTOR, its employees, agents and/or subcontractors personnel to safely provide health care services. The CONTRACTOR, its employees, subcontractors and agents shall follow all security policies and directions of the SHERIFF while at the Jail or other premises under the SHERIFF s direction or control. F. SHERIFF S POLICIES AND PROCEDURES. The CONTRACTOR shall operate within the requirements of the SHERIFF S Policies and Procedures, which directly relate to the provision of health services. 1. A complete set of said Policies and Procedures shall be maintained by the SHERIFF and made available to the CONTRACTOR and its personnel and subcontractors assigned to the Jail. The CONTRACTOR may make a reasonable number of copies of any specific section(s) it wishes using the SHERIFF S photocopy equipment and paper. 2. Any policy or procedure that may impact on the provision of health services not made available to the CONTRACTOR shall not be enforceable until after it has been made available to the CONTRACTOR. 3. Said Policies and Procedures may change from time to time and, if so, the CONTRACTOR shall be promptly notified and shall comply with such modified policy and/or procedure. G. DAMAGE TO EQUIPMENT. The CONTRACTOR shall be liable for loss of or damage to equipment and supplies whether it is the equipment or supplies of the COUNTY or the CONTRACTOR if such loss or damage was caused by the sole negligence of the CONTRACTOR, its employees or subcontractors. The CONTRACTOR shall be responsible for repairing and/or replacing lost or damaged equipment and supplies and for ensuring -& Option To Extend to 3/18/16) -& Option To Extend to 3/18/16)

29 that all equipment is maintained and kept in good working condition at all times. An assessment of all COUNTY owned equipment shall be done annually with the coordination of both the CONTRACTOR S and the COUNTY S personnel, and kept on file with the SHERIFF. H. SECURE TRANSPORTATION. The SHERIFF shall provide security as necessary and appropriate in connection with transportation of Inmates/Detainees between the Jail and any other location for off-site services. I. STAFF SCREENING. The SHERIFF shall screen CONTRACTOR S personnel and subcontractors who will be assigned to the Jail to ensure that they will not constitute a security risk. It is expressly understood and agreed by the CONTRACTOR that such screening and approval of the SHERIFF are a condition precedent to any personnel or subcontractors being granted access to the Jail to provide services under this Agreement. The SHERIFF shall have final approval of CONTRACTOR S employees or subcontractors assigned to the Jail in regards to security/background clearance. In the event that the SHERIFF determines that any of CONTRACTOR S personnel or subcontractor constitutes a security risk after they have been previously approved and are working at the Jail the SHERIFF may require the CONTRACTOR to immediately remove such personnel or subcontractor from the Jail and the provision of services under this Agreement. At least forty-eight (48) hours prior to starting work at the Jail, the CONTRACTOR shall supply the full name, date of birth, and social security number for all new employees and subcontractors who will be working at the Jail. CONTRACTOR S personnel and those of its subcontractors must meet security standards required by the SHERIFF, which includes but is not limited to a criminal background check and shall not be unreasonably withheld or delayed. The SHERIFF shall have the right to reject any of CONTRACTOR S personnel or those of its subcontractors who do not meet the SHERIFF S security requirements or who violates any of the SHERIFF S security rules, regulations, or policies. J. OFFICE EQUIPMENT AND SUPPLIES. SHERIFF shall provide use of COUNTY-owned office equipment, supplies and all necessary utilities in place at the Jail s health care facilities. At the termination of this Agreement the CONTRACTOR shall return to COUNTY possession and control of all COUNTY-owned medical and office equipment. At such time, the office equipment shall be in good working order, ordinary wear and tear excepted. IX. COMPENSATION/ADJUSTMENTS A. ANNUAL AMOUNT/MONTHLY PAYMENTS. During the initial two (2) year term of this Agreement the annual sum which the COUNTY shall pay the CONTRACTOR shall be SEVEN HUNDRED NINETY-SIX THOUSAND FOUR HUNDRED TWENTY AND NO/100 DOLLARS ($796,420.00) to be paid in monthly installments of SIXTY-SIX THOUSAND THREE HUNDRED SIXTY-EIGHT AND 32/100 DOLLARS ($66,368.32) per month. The annual cost breakdown for the sum to be paid in each of the two (2) years of the initial term is set forth in the attached Appendix C CHC Price Breakdown. Commencing with the third year of this Agreement, if extended beyond the initial term pursuant to Section X, Subsection B, and each year thereafter in which this Agreement remains in effect the annual amount to be paid the CONTRACTOR shall be the same as paid in the previous year unless a cost adjustment is made pursuant to the third paragraph of this Section IX, Subsection A, or Section IX, Subsection B. It is expressly understood and agreed that sums to be paid under this Agreement during the Agreement s initial year and each year thereafter in which this Agreement remains in effect shall be based on the CONTRACTOR providing the SHERIFF with all the staffing and services required by this Agreement and the following: 1. Pharmacy Cost $60,000 Cap 2. Off Site Costs $150,000 Cap In the event the CONTRACTOR fails at any time during the initial term of this Agreement or any extension thereof to fully comply with the staffing and services requirements of this Agreement the COUNTY may make adjustments in its monthly payments by an amount which accurately represents the overall reduction in the value of services received by the COUNTY due to such non-compliance. The annual amount to be paid the CONTRACTOR shall also be adjusted to reflect the reduction in value of the CONTRACTOR S services due to CONTRACTOR S failure to provide the agreed upon level of staffing and services. B. NEGOTIATED ANNUALIZED AMOUNT INCREASE UPON RENEWAL. In the event the CONTRACTOR shall require an increase in the annual amount to be paid by the COUNTY for services provided under this Agreement, if extended by the COUNTY as authorized in Subsection B of Section X, the CONTRACTOR must provide the COUNTY with written notice of the amount of such increase not less than NINETY (90) DAYS prior to the end of the Agreement s current term. It is expressly understood and agreed that the amount of any such increase shall not exceed the percentage of increase in the Consumers Price Index (CPI) over the -& Option To Extend to 3/18/16) -& Option To Extend to 3/18/16)

30 previous twelve (12) months or FIVE PERCENT (5%), whichever is less, over the amount which will be paid the CONTRACTOR over the year immediately preceding the year in which the increase shall go into effect. For the purposes of this Agreement Consumer-Price Index shall mean Consumer Price Index All Urban Consumers United States Average All Items. U.S. Medical Care Services, =100 - CUUR0000SAM2 as published by the United States Department of Labor, Bureau of Labor Statistics. X. TERM, OPTION TO RENEW AND TERMINATION A. TERM. The term of this Agreement shall commence on March 18, 2012 at 12:01 a.m. and unless terminated as authorized in Subsections C, D or E of this Section X shall continue through March 18, 2014 at 12:01 a.m. at which time this Agreement shall terminate unless extended by the COUNTY as set forth in Subsection B of this Section X. B. OPTION TO RENEW. The COUNTY, in its sole discretion, shall have one (1) option to extend the term of this Agreement for two (2) additional years to March 18, This option may be exercised by the COUNTY S delivery to the CONTRACTOR, prior to the end of the Agreement s initial term, of written notice that the COUNTY is extending the Agreement s term for an additional year two (2) years. It is expressly understood and agreed that the total length of this Agreement s term shall not exceed four (4) years, i.e. this Agreement may not be extended beyond March 18, C. GROUNDS FOR TERMINATION. Repetitive substantiated complaints about service, inefficient operating procedures, poor service and/or incorrect billings may be grounds for the COUNTY S termination of this Agreement in whole or in part. D. TERMINATION OF AGREEMENT FOR CAUSE. Notwithstanding any other provision in this Agreement to the contrary the COUNTY shall have the right, in its sole discretion, to terminate this Agreement at any time with a minimum of thirty (30) days prior written notice to the CONTRACTOR in the event the services of the CONTRACTOR are deemed by the COUNTY to be unsatisfactory for any of the reasons stated in Subsection C of this Section X, or upon failure of the CONTRACTOR to comply with or to perform any of the terms and conditions of this Agreement. E. TERMINATION WITHOUT CAUSE. The COUNTY may at any time terminate this Agreement without cause on sixty (60) days prior written notice to the CONTRACTOR. XI. F. REMOVAL OF CONTRACTOR S PROPERTY FROM JAIL. Upon the termination or expiration of this Agreement, the CONTRACTOR shall remove all of its property from the Jail, and shall leave the Jail as well as any COUNTY property, equipment or supplies left in good order and condition in all respects, ordinary wear and tear excepted. Any property of the CONTRACTOR which is not removed at the termination or expiration of this Agreement or within thirty (30) days of the termination or expiration shall become the property of the COUNTY and may be used or disposed of as the COUNTY in its sole discretion may elect. CONTRACTOR S INSURANCE COVERAGE. The CONTRACTOR shall procure and maintain during the term of this Agreement the following insurance coverages. All coverage s shall be with insurance companies licensed and admitted to do business in the State of Michigan. All coverage s shall be with insurance companies acceptable to the COUNTY and have an A. M. Best Company s Insurance Reports Rating of not less than A or A- (Excellent). A. WORKERS COMPENSATION AND EMPLOYER S LIABILITY INSURANCE COVERAGE. Workers Compensation Insurance including Employers Liability Coverage in accordance with all applicable laws of the State of Michigan. In the event that the CONTRACTOR uses subcontractors and sub-subcontractors for the performance of services required under this Agreement, the CONTRACTOR shall ensure that said subcontractors and sub-subcontractors carry Workers Compensation Insurance including Employer s Liability as required by law. B. INSURANCE COVERING CONTRACTOR S PROPERTY. The CONTRACTOR shall be responsible for insuring all its instruments, tools and equipment and all materials which it may use and/or leave at the Jail. The COUNTY shall not be responsible for any loss or damage to the CONTRACTOR S instruments, tools, equipment and materials. C. COMMERCIAL GENERAL LIABILITY INSURANCE. Commercial General Liability Insurance on an Occurrence basis with limits of liability of not less than $1,000,000 per occurrence and aggregate combined single limit, for Personal Injury or Bodily Injury and $1,000,000 per occurrence and aggregate for Property Damage. Coverage shall include the following extensions: (1) Contractual Liability; (2) Products and Completed Operations Coverage; (3) Independent Contractors Coverage; (4) Broad Form General Liability Extensions or equivalent, if not in policy proper. D. PROFESSIONAL LIABILITY INSURANCE. Professional Liability (Medical Malpractice) Insurance covering all services rendered by the CONTRACTOR S physicians and other medical personnel (e.g. physicians assistants, nurses, etc.) including, but not limited to, testing procedures, reviews, recommendations and issuance of prescriptions. -& Option To Extend to 3/18/16) -& Option To Extend to 3/18/16)

31 Limits of liability of the Professional Liability Insurance shall not be less than $1,000,000 per occurrence or per claim. If the insurance is on a per claim basis, the insurance policy shall include a three (3) year extended reporting period. E. MOTOR VEHICLE LIABILITY INSURANCE. Motor Vehicle Liability Insurance including Michigan No-Fault Coverage of not less than $1,000,000 per occurrence combined single limit, personal injury, bodily injury, and property damage. The coverage shall include all owned, nonowned, and hired vehicles. F. ADDITIONAL INSURED. Commercial General Liability Insurance and Motor Vehicle Liability Insurance and Professional Liability Insurance as described above shall include the following as Additional Insured : County of Livingston and the County of Livingston s elected and appointed officers/officials and employees shall be added as Additional Insureds on the CONTRACTOR S Commercial General Liability Insurance, Motor Vehicle Liability Insurance, and Professional Liability Insurance. Said insurance coverages shall be primary coverage to the Additional Insureds, and not contributing with any other insurance or similar protection available to the Additional Insureds whether said other available coverage be primary, contributing or excess. G. CANCELLATION NOTICE. Workers Compensation Insurance, Commercial General Liability Insurance, Professional Liability Insurance, and Motor Vehicle Liability Insurance as described above shall include an endorsement stating the following: It is understood and agreed that thirty (30) days Advance Written Notice of Cancellation, Non- Renewal, Reduction and/or Material Change shall be sent to: Livingston County Purchasing, 304 East Grand River, Suite 204, Howell, MI, H. RENEWAL OR REPLACEMENT POLICIES. If any of the insurance coverage s required by this Section XI expire during the term of the Agreement, the CONTRACTOR S insurer shall deliver renewal certification and/or policies to: Livingston County Purchasing, 304 East Grand River, Suite 204, Howell, MI, 44842, at least thirty (30) days prior to expiration. No payment will be made to the CONTRACTOR until current certificates of insurance have been received and approved by the COUNTY. In the event the CONTRACTOR utilizes any subcontractors to perform any of its responsibilities under this Agreement the CONTRACTOR shall require and ensure that all such subcontractors also meet all the insurance requirements set forth in this Section XI. The CONTRACTOR shall provide the COUNTY with certificates of insurance or such other XII. XIII. evidence as the COUNTY may require that CONTRACTOR S subcontractors possess the required insurance. INDEMNIFICATION AND HOLD HARMLESS. The CONTRACTOR shall, at its own expense, protect, defend, indemnify and hold harmless the COUNTY, SHERIFF, and the COUNTY S and SHERIFF S elected and appointed officers, employees and agents from all claims, damages (including but not limited to direct, indirect, incidental, consequential, special and punitive damages), costs, lawsuits and expenses including, but not limited to, all costs from administrative proceedings, court costs, and attorney fees, that they may incur as a result of any acts, omissions or negligence of the CONTRACTOR, its employees or agents or its subcontractors or sub-subcontractors, or any of their officers, employees or agents which may arise out of this Agreement. CONTRACTOR, its agents, employees or independent contractors, shall not in any event be required to indemnify, defend, or hold harmless, the COUNTY, SHERIFF, or the COUNTY s and SHERIFF S elected and appointed officers, employees and agents with respect to any claims, damages (including but not limited to direct, indirect, incidental, consequential, special and punitive damages), costs, lawsuits and expenses including, but not limited to, all costs from administrative proceedings, court costs, and attorney fees resulting from any acts, omissions or negligence of the COUNTY, SHERIFF, or the COUNTY S or SHERIFF s elected and appointed officers, employees or agents. The CONTRACTOR S indemnification responsibilities shall include the sum of damages, costs and expenses which are in excess of the sum paid out on behalf of or reimbursed to the COUNTY, SHERIFF or the COUNTY S and SHERIFF S elected and appointed officers, employees, agents by the insurance coverage obtained and/or maintained by the CONTRACTOR pursuant to the requirements of this Agreement. RELATIONSHIP OF THE PARTIES. A. INDEPENDENT CONTRACTOR. It is mutually understood and agreed, and it is the intent of the parties hereto that an independent contractor relationship be and is hereby established under the terms and conditions of this Agreement. The employees or agents of the CONTRACTOR are not now nor shall they be deemed to be employees of the COUNTY or the SHERIFF and the employees of the COUNTY and the SHERIFF are not now nor shall they be deemed to be employees of the CONTRACTOR. The CONTRACTOR assumes all financial responsibility for the payment of compensation due its employees and subcontractors for performance of work required by this Agreement, and for workers compensation, unemployment insurance, withholding taxes, social security, sales and -& Option To Extend to 3/18/16) -& Option To Extend to 3/18/16)

32 XIV. other taxes that may be directly or indirectly related to the services to be provided under this Agreement. B. SUBCONTRACTING. No subcontractors shall be used in performing this Agreement without the prior written consent of the COUNTY. The CONTRACTOR shall exercise administrative supervision over such subcontractors as is necessary to ensure strict compliance with the terms and conditions of this Agreement. In order to discharge its obligations hereunder, the CONTRACTOR may engage certain physicians, psychiatrists and dentists as subcontractors rather than employees. EQUAL EMPLOYMENT OPPORTUNITY; APPLICABLE LAW AND VENUE; AND COMPLIANCE WITH LAWS. A. EQUAL EMPLOYMENT OPPORTUNITY. The CONTRACTOR and its subcontractors, as required by law, shall not discriminate against an employee or applicant for employment with the respect to hire, tenure, terms, conditions or privileges of employment, or a matter directly or indirectly related to employment, because of race, color, religion, national origin, age, sex, disability that is unrelated to the individual s ability to perform the duties of a particular job or position. Breach of this covenant shall be regarded as a material breach of this Agreement. The CONTRACTOR shall post notices containing this policy against discrimination in conspicuous places available to applicants for employment and employees. All solicitations or advertisements for employees, placed by or on behalf of the CONTRACTOR, shall state that all qualified applicants will receive consideration for employment without regard to race, color, sex, national origin, disability, age, height, weight, marital status and religion. B. NONDISCRIMINATION IN PERFORMANCE OF SERVICES. The CONTRACTOR and its subcontractors shall not in the performance of the services required by this Agreement discriminate against any person entitled to receive services under this Agreement because of race, color, religion, national origin, age, sex, mental or physical disability, sexual orientation, positive HIV status, communicable disease, or any other classification which State of Michigan or Federal laws, rules or regulations prohibit discrimination. C. APPLICABLE LAW AND VENUE. This Agreement shall in all respects be governed by, and construed in accordance with, the laws of the State of Michigan without regard to any Michigan choice of law rules that would apply the laws of any other jurisdiction to the extent not inconsistent with or pre-empted by federal law. XV. XVI. In the event any actions arising under this Agreement are brought by or against the COUNTY or SHERIFF, or the COUNTY or SHERIFF is made a party thereof, the venue for such actions shall be established in accordance with the statutes of the State of Michigan and/or Michigan Court Rules. In the event that any action is brought under this Agreement in or is moved to Federal Court, the venue for such action shall be the Federal Judicial District of Michigan, Eastern District, Southern Division. D. COMPLIANCE WITH LAWS AND REGULATIONS AND SHERIFF S POLICIES. The CONTRACTOR and its subcontractors shall comply with all federal, state and local laws, rules, and regulations including, but not limited to, all applicable OSHA/MIOSHA requirements, the Americans with Disabilities Act, Michigan Department of Corrections rules and regulations, Federal and/or State licensing and/or certification requirements of persons to provide services under this Agreement. The CONTRACTOR and its subcontractors shall also comply with all rules, regulations and policies of the SHERIFF pertaining to security and care of Inmates/Detainees at the Jail. ENTIRE AGREEMENT. This Agreement constitutes the entire agreement of the parties and is intended as a complete and exclusive statement of the promises, representations, negotiations, discussions and agreements that have been made in connection with the subject matter hereof. To the extent that they are referenced in this Agreement, selected pages of the Proposal are incorporated by reference into this Agreement and attached hereto as Appendix A. In the event of any conflicts between the terms and conditions contained in the body of this Agreement with those in the referenced sections of the Proposal, the terms and conditions contained in the body of this Agreement shall take precedence and prevail. WAIVER OF BREACH. The waiver by either party of a breach or violation of any provision of this Agreement shall not operate as, or be construed to be, a waiver of any subsequent breach of the same or any other provision hereof. XVII. THIRD-PARTY BENEFICIARIES. This Agreement is not intended to be a third party beneficiary contract and confers no rights on anyone other than the COUNTY, the SHERIFF and the CONTRACTOR. XVIII. ASSIGNMENT. No party to this Agreement may assign or transfer this Agreement, or any part thereof, without the prior written consent of the other parties. XIX. NOTICES. Any notices required by this Agreement shall be in writing and shall be deemed delivered when delivered in person or received by the other party by U.S. certified mail, return receipt requested, addressed as follows: -& Option To Extend to 3/18/16) -& Option To Extend to 3/18/16)

33 If for CONTRACTOR: SHELTON FREY, GENERAL COUNSELCorrectional Healthcare Companies 6200 S. Syracuse Way, #440 Greenwood Village CO BELINDA PETERS, Administrator Livingston County 304 E. Grand River - # 202 Howell MI If for COUNTY: & ROBERT BEZOTTE Livingston Co. Sheriff 150 S. Highlander Way Howell MI Such addresses may be changed from time to time by either party by providing written notice to the other in the manner set forth above. XX. MODIFICATIONS, AMENDMENT OR WAIVER OF PROVISIONS OF THE AGREEMENT. All modifications, amendments or waivers of any provision of this Agreement shall be made only by the mutual consent of the parties hereto set forth in writing and signed by their authorized representatives. XXI. SECTION AND SUBSECTION TITLES. The titles of the sections and subsections set forth in this Agreement are inserted for the convenience of reference only and shall be disregarded when construing or interpreting any of the provisions of this Agreement. XXII. INVALID/UNENFORCEABLE PROVISIONS. If any clause or provision of this Agreement is rendered invalid or unenforceable because of any State or Federal statute or regulation or ruling by any tribunal of competent jurisdiction, that clause or provision shall be null and void, and any such invalidity or unenforceability shall not affect the validity or enforceability of the remainder of this Agreement. Where the deletion of the invalid or unenforceable clause or provision would result in the illegality and or unenforceability of this Agreement, this Agreement shall be considered to have terminated as of the date in which the clause or provision was rendered invalid or unenforceable. XXIII. SURVIVAL CLAUSE. All rights, duties and responsibilities of any party that either expressly or by their nature, extend into the future, including the retention of and access to records and confidentiality provisions, shall extend beyond and survive the end of the term or termination of this Agreement. XXIV. CERTIFICATION OF AUTHORITY TO SIGN AGREEMENT. The people signing on behalf of the parties to this Agreement certify by their signatures that they are duly authorized to sign this Agreement on behalf of the party they represent and that this Agreement has been authorized by the party they represent. THE AUTHORIZED REPRESENTATIVES OF THE PARTIES HERETO HAVE FULLY EXECUTED THIS AGREEMENT FOR INMATE HEALTH SERVICES ON THE DAY AND YEAR FIRST ABOVE WRITTEN. -& Option To Extend to 3/18/16)

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57 CHC Price Breakdown EXHABIT Correctional Healthcare Companies CHC CATEGORY Unit Cost Extended NEGOTIATED Average Daily Population (250) Overview Average Daily Population (ADP) 250 $ - $ - County ADP Exceeds 275 Inmates 275 $ 0.48 $ County ADP Falls Below 225 Inmates 225 $ (0.48) $ (108.00) Professional On-Site Staffing Hrs/wk Hourly Rate Annual Cost Physician 6 $ $ 33, Administrator/Registered Nurse (RN) (1 ppl) 40 $ $ 110, Licensed Practical Nurse (LPN) (2 ppl) 112 $ $ 200, Medical Assistant 40 $ $ 51, Dentist - Every Other week (104 Hours Annually) See below See below Psychiatrist* 2 $ $ 23, Mental Health Professional* (Master Level) 40 $ $ 79, Professional Onsite Services Medical Supplies $ 7, Mobile Dental Services 8hrs/mo $ $ 30, Laboratory Services $ 6, Medical Services $ 231, Medical Waste Removal $ On-Call 24/7 $ 5, X-Ray Services $ 3, Mental Health Training - Jail Staff* $ - Comprehensive Medical Malpractice Ins.* $ 13, Corporate Management and Oversight* $ 29, Professional Offsite Services Annual Aggregate Cap (1) $ 150, $ - Percentage of Unused Cap Returned to County 100% $ - $ - Utilization Management Ambulance Services Cap (1) Hospitalization Cap (1) Laboratory Services Cap (1) X-Ray Services Cap (1) Dental Services Cap (1) Specialty Services Cap (1) Pharmacy Services Pharmaceutical Cap (2) $ 60, $ - Percentage of Unused Cap Returned to County 100% $ - $ - Pharmaceutical Management Pharmaceutical: Over-the-counter (OTC) Cap (2) Pharmaceutical: Prescriptions Cap (2) Pharmaceutical: Mental Health/Psychotropic Cap (2) Pharmaceutical: HIV, Hepatitis C and Biological Cap (2) Caps Comments: NEGOTIATED Monthly Cost: $ 68, $ 66, Annual Cost: $ 724, $ 693, Optional Psychiatrist*: $ 23, $ 23, Optional Mental Health Professional*: $ 79, $ 79, Annual Cost with Mental Health Services: $ 827, $ 796, COMMENTS: Electronic Medical Records (EMR) No cost to county if, Optional Mental Health Services are included with award Pricing firm for initial 12-mo period Prepared by: J. Daroczy, C:\Documents CPPBand Settings\carolj\Local Settings\Temporary Internet Files\Content.Outlook\DE5L5VP0\CHC - Price Breakdown Exhabit.xls 12/7/2012

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59 LIVINGSTON COUNTY PURCHASING 304 E. Grand River Avenue Suite 204 Howell MI Telephone: (5 17) FAX: (517) February 5, 2014 CHC I Correctional Healthcare Companies 6200 S. Syracuse Way, Suite 440 Greenwood Village, CO ATTN: Mr. Andrew Walter, VP of Operations RE: INMATE HEALTH CARE SERVICES AGREEMENT Dear Mr. Walter, Pursuant to the conditions of the Inmate Health Care Services Agreement between CHC I Correctional Healthcare Companies, and Livingston County effective March 18, 2012; Livingston County by this Jetter is renewing the terms of the Agreement for an additional term until March 17, 2016, per SECTION X: TERM. OPTION TO RENEW AND TERMINATION. All terms and conditions of the Agreement shall remain the same during the renewal period with no renewal options remaining. Please acknowledge this letter and acceptance of the additional renewal option by signature of a representative authorized to commit your organization to the applicable terms, and return the same back to Livingston County Purchasing at the address shown above. If you would like an original copy returned to you, please sign and return TWO copies. If you have any questions or concerns, please do not hesitate to contact Jana Daroczy at (517) e Companies: By: Name: Title: Signatur D~,.; Ji ~!J ~-J Date Cc: Lt. Cremonte

60 December 4, 2014 Emily Kuhn, Purchasing Agent Livingston County Purchasing Department 304 E Grand River Ave. Suite 204 Howell, MI RE: Contract Renewal for Dear Ms. Kuhn: I hope this letter finds you well. This letter shall serve as CHC s official proposal for renewal of our current inmate health care services agreement, effective March 18, The current CPI is 1.9%; therefore, CHC proposes an increase for renewal year of 1.9%. If accepted by Livingston County, the revised amount for professional health care services rendered at the Livingston County Jail, will be $67, per month from March 18, 2015 through March 17, 2016, or $811, annually. All terms of the current Agreement, including any changes detailed above, shall remain in full force and effect through March 17, If you have any questions, please do not hesitate to contact Mary Ann Wollett, Regional Manager for Livingston County directly at We greatly appreciate the relationship we have established with Livingston County over the years and look forward to another successful year working together. Warm regards, ACCEPTANCE OF RENEWAL: Chris Bove, Chief of Institutional Operations CAROL S. GRIFFITH - Chairwoman Livingston Co. Board of Commissioners Cc: Andrew Walter, Regional Senior VP Mary Ann Wollett, Regional Manager Cristina Capoot, Vice President, Client Services 1283 Murfreesboro Road # 500 Nashville TN S. Syracuse Way #440 Greenwood Village CO p: f:

61 AMENDMENT NO. 1 TO AGREEMENT FOR INMATE HEALTH CARE SERVICES AT LIVINGSTON COUNTY JAIL, MICHIGAN THIS AMENDMENT, is made and entered into by and between the COUNTY OF LIVINGSTON, a municipal corporation and political subdivision of the State of Michigan (hereinafter referred to as the COUNTY ), acting on behalf of the LIVINGSTON COUNTY SHERIFF (hereinafter referred to as the SHERIFF ), and CORRECTIONAL HEALTHCARE COMPANIES, INC., with offices at 1283 Murfreesboro Road, Suite 500, Nashville, TN (hereinafter referred to as the CONTRACTOR ), amends the Agreement for Inmate Health Care Services at the Livingston County Jail at 150 S. Highlander Way, Howell, MI 48843, which had an initial term of March 18, 2012 through March 18, 2014 with an option to extend through March 17, 2016, which option was exercised and acknowledged in a letter dated February 5, 2014 and signed by the authorized representatives of both the COUNTY and Correctional Healthcare Companies, Inc. WITNESSED: 1. Section I. SCOPE OF SERVICES, Subsection B. STAFFING, Item 1, page 2, of the above-stated Agreement shall be amended to read as follows: 1. Registered Nurse (RN) performing on-site nursing duties for thirty-six (36) hours per week. 2. Section IX. COMPENSATION/ADJUSTMENTS, Subsection A. ANNUAL AMOUNT/MONTHLY PAYMENTS, page 40, shall be amended by adding a fourth and fifth paragraph which shall read as follows: Commencing on the date in which the CONTRACTOR has increased RN staffing required in Section I. SCOPE OF SERVICES, Subsection B. STAFFING, 1. Registered Nursing (RN), page 2, of this Agreement to thirty-six (36) hours per week the annual compensation to be paid the CONTRACTOR shall be increased by a sum not to exceed THIRTY-THREE THOUSAND ONE HUNDRED NINETY- EIGHT AND NO/00 DOLLARS ($33,198.00) resulting in a TWO THOUSAND SEVEN HUNDRED SIXTY-SIX AND 50/100 DOLLARS ($2,766.50) increase in the monthly installments to be paid the CONTRACTOR pursuant to this Section IX. The Contract cost shall increase no more than THIRTY-THREE THOUSAND ONE HUNDRED NINETY-EIGHT AND NO/100 DOLLARS ($33,198.00) annually to cover the additional sixteen (16) hours of RN staffing per week. LIVINGSTON COUNTY / JAIL TERM: TO &- Page 1 of 2 CARE COMPANIES, INC. RES #

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63 JAIL SHERIFF CORRECTIONAL HEALTHCARE COMPANIES, INC. AMENDMENT # 2 TO INMATE HEALTH CARE SERVICES FOR: 1 ADDITIONAL STAFFING 2 INCREASE IN COST OF SERVICES 3 TERM EXTENSION TERM: TO DESTROY: #

64 AMENDMENT NO. 2 TO THE AGREEMENT FOR INMATE HEALTH CARE SERVICES AT LIVINGSTON COUNTY JAIL, MICHIGAN (Effective November 1, 2015) THIS AMENDMENT NO. 2, effective November 1, 2015 (this Amendment ), to the Agreement for Inmate Health Care Services at Livingston County, Michigan, dated March 18, 2012, as amended (the Agreement ), is by and between Correctional Healthcare Companies, Inc., ( CHC and CONTRACTOR ) and Livingston County, Michigan (the COUNTY ). WHEREAS, the parties wish to renew the Agreement for another year; and WHEREAS, Section IX.B of the Agreement provides that upon each renewal the parties shall negotiate an increase in compensation for such renewal year; and WHEREAS, the parties have determined that it is necessary and in the best interest of COVERED PERSONS to increase the number of service hours to be provided by Registered Nurses, Licensed Practical Nurses and Mental Health Professionals each week; and WHEREAS, the parties wish to amend the Agreement in accordance with Section XX to memorialize such changes in compensation and staffing. NOW, THEREFORE, in consideration of the mutual covenants herein contained and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the COUNTY and CHC agree: 1. RECITALS. The parties hereto incorporate the foregoing recitals as a material portion of this Amendment. 2. AMENDMENT TO SECTION I.B. OF AGREEMENT. The Agreement shall be amended by deleting Section I.B. in its entirety and inserting the following language in lieu thereof: A. STAFFING. The CONTRACTOR shall provide or arrange for the provision of Health Care Staff necessary to render the health care services contemplated in Section I, and further described in the Staffing Matrix attached hereto as Appendix D. 1. Registered Nurse (RN) performing on-site nursing duties for seventy-six (76) hours per week. 2. RN acting in capacity of Jail s Health Services Administrator (HSA) twenty (20) hours per week 3. Licensed Practical Nurse (LPN) performing on-site nursing duties required by this Agreement for one hundred forty-four (144) hours per week. LIVINGSTON COUNTY / JAIL TERM: TO &- CARE COMPANIES, INC. Page 1 of 4 RES #

65 4. Physician shall be on-site a total of six (6) hours per week performing physician services as well as overseeing all medical services at the Jail. The physician shall be in charge of overseeing sick call, reviewing charts, and signing off on all medical decisions. 5. Mobile Dental Services shall be provided on-site once per month for a total of eight (8) hours. 6. Medical Assistant/Medical Records Clerk (MA/MRC) shall be on-site forty (40) hours per week to perform administrative duties in conjunction with maintaining medical records Under CONTRACTOR S medical staff s immediate supervision, the MA/MRC shall organize and maintain medical records by collecting information about patients. The information shall include test results, diagnosis, exam results, recommended treatments, prior medical history and other relevant data. The MA/MRC shall ensure the Jail s Inmate/Detainee medical records are well-organized and be able to provide quality reports. The MA/MRC must also maintain security and accuracy of the records as required by this Agreement and deliver records as requested. 7. Mental Health Services (a) Psychiatrist shall be on-site eight (8) hours per month. Responsibilities shall include intake, post admission evaluation, counseling and suicide prevention. (b) Mental Health Professional with Master s Degree shall be on-site fifty-six (56) hours per week. Responsibilities shall include intake, post admission evaluation, counseling and suicide prevention. 3. ADDITION TO SECTION IX.A OF AGREEMENT. The Agreement shall be amended by adding the following paragraph after the initial paragraph of Section IX.A: Commencing on November 1, 2015 the monthly installments which the COUNTY shall pay the CONTRACTOR for all services performed pursuant to this Agreement on and after that date shall be EIGHTY-FIVE THOUSAND SEVEN HUNDRED NINETY-THREE DOLLARS AND EIGHTY-TWO CENTS ($85,793.82) per month. 4. AMENDMENT TO SECTION X.A OF AGREEMENT. The Agreement shall be amended by deleting Section X.A in its entirety and inserting the following language in lieu thereof: A. TERM. The term of this Agreement shall commence on March 18, 2012, at 12:01 a.m. and, unless terminated as authorized in Subsections C, D or E of this Section X, shall continue through March 31, 2017, at 11:59 p.m. at which time this Agreement shall terminate. B. VOID SECTION X.B OF AGREEMENT. The parties agree that Section X.B of the Agreement is void and of no force and effect as of January 1, C. SEVERABILITY. If any terms or provisions of this Amendment or the application thereof to any person or circumstance shall to any extent be invalid or unenforceable, the remainder of this Amendment or the application of such term or provision to person or circumstances other than those as to which it is held invalid or unenforceable shall not be affected thereby and each term and provision of this Amendment shall be valid and enforceable to the fullest extent permitted by law. LIVINGSTON COUNTY / JAIL TERM: TO &- CARE COMPANIES, INC. Page 2 of 4 RES #

66 D. DEFINITIONS. Capitalized terms used but not defined herein shall have the meaning ascribed to them under the Agreement. E. REMAINING PROVISIONS. The remaining provisions of the Agreement not amended by this Amendment shall remain in full force and effect. IN WITNESS WHEREOF, the parties have caused this Amendment to be executed in their names or their official acts by their respective representatives, each of whom is duly authorized to execute the same. LIVINGSTON COUNTY, MICHIGAN CARE COMPANIES, INC. BY: KATE LAWRENCE - CHAIRWOMAN COUNTY BOARD OF COMMISSIONERS BY: CHRIS BOVE - PRESIDENT LOCAL DETENTION DIVISION Dated: Dated: APPROVED AS TO FORM FOR COUNTY OF LIVINGSTON: COHL, STOKER & TOSKEY, P.C. By: ROBERT D. TOWNSEND - 6/15/16 On: June 15, 2016 N:\Client\Livingston\Sheriff\Amendments\Amd No. 2 to Inmate Healthcare Svcs Agr w CHC.docx Liv/Sheriff # S:\WP\Contracts\Agreements\WORD Agts\Sheriff XXX - CHC - Combined Amend 2 - Inmate Healthcare - COMPARE.doc LIVINGSTON COUNTY / JAIL TERM: TO &- Page 3 of 4 CARE COMPANIES, INC. RES # XXX