HomeMy WebLinkAboutIL152 Interlocal Agreement •
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INTERLOCAL AGREEMENT
PROVIDING AMBULANCE SERVICE
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THIS AGREEMENT is made to be effective as of th]i i day of-11 l4-L/‘2012 between the
City of Anacortes, Washington ("the City"), a municipal corporation, and Skagit County
Public Hospital District No. 2, ("the District"), d/b/a Island Hospital, a municipal
corporation.
RECITALS
1. The City has the power under RCW 35.23.456 and City of Anacortes Ordinance and
Municipal Code 13.54 to authorize the operation ambulance services within the City,
which may serve the City and surrounding areas. The City has been providing
ALS/BLS emergency medical services to the City and surrounding areas for over 20
years.
2. The District has the authority under RCW 70.44.060 to provide ambulance service
within its boundaries, and also subscribing to the provisions of AMC 13.54. The
District owns ambulances and related equipment and has been providing Inter-
facility ambulance service within its boundaries.
3. The City and the District have been acting jointly to furnish ambulance service to the
area encompassed within the District, including that area within the corporate limits
of the City and other areas where the City is contracted to provide service.
4. A cooperatively managed ambulance service is necessary to promote and protect the
public health, safety and general welfare of the area encompassed within the District
and the City, and will permit the most efficient and effective use of mutual
resources.
5. The City and the District are authorized to enter into an agreement for joint or
cooperative action to serve and benefit their constituents.
6. The City and the District have been parties to a similar inter-local agreement since
March of 1987.
NOW, THEREFORE, in consideration of the foregoing and the mutual promises contained
herein, the mutual benefits to be derived, and the public interest to be served, it is agreed as
follows:
Section 1: Definitions
1.1 Definitions.
1.2.1. Non-Emergency Inter-Facility Transfer (IFT) ambulance service -
Scheduled or unscheduled inter-facility transport of a patient from one
facility to another for the purpose of rendering further medical treatment
to the patient while delivering either ALS or BLS service.
1.2.2. Emergency ALS/BLS ambulance service - Response to an emergency
911 request for Pre-hospital service to provide immediate medical aid to
a patient when time and level of supervision could be critical factors in
well-being of patient.
1.2.3. Fire Department EMS Officer - An officer within the structure of the
fire department that has primary responsibilities for the operational
supervision of City ALS/BLS Emergency ambulance services.
1.2.4. Hospital EMS Officer - An officer hired by the district that has primary
responsibility for the operational supervision of Hospital's Non-
Emergency Interfacility (IFT) ambulance service.
1.2.5. ALS - Advanced Life Support - Paramedic level service initiating care
and treatment involving intravenous fluids, cardiac drugs, advanced
airway techniques, and cardiac monitoring within the scope of practice
dictated by Skagit County Medical Program Director.
1.2.6. BLS- Basic Life Support - Personnel certified at least at the EMT level
by the State of Washington to provide basic initial evaluation, care, and
stabilization until the patient is transferred to a higher standard of care.
1.2.7. Pre-Hospital - Routine or emergency response and care provided to
patients before being delivered to a hospital.
Section 2: Coordination of Services
2.1 Full-time ambulance emergency ALS/BLS service shall be provided by the
fire department within the area under agreement with EMS Commission,
including the corporate City limits.
2.2 The ambulance/emergency service to be provided under this Agreement shall
be coordinated by the Fire Chief for the City of Anacortes.
2.3 The Fire Department EMS Officer appointed by the Fire Chief shall be
responsible for overseeing the coordination of the Emergency ALS/BLS
ambulance service.
2.3 The Hospital EMS Officer shall be responsible for overseeing the
coordination of the Non-Emergency Inter-Facility Transfer (IFT} ambulance
service.
2.3 Each party is responsible for overseeing the financial and policy aspects for
each service they are responsible to provide.. The operation and
management of the ALS/BLS and IFT services shall be conducted in
accordance with policy/procedure for ambulance service to be established
by each agency after receiving the advice and assistance of the Local
Training and Supervising Physician as appointed by the Skagit County
Medical Program Director.
2.3 The Fire Department and Hospital EMS Officer shall be responsible for
making reports and recommendations to their supervisor on the following
matters: Each agency may consider the nature and extent of the ambulance
service; financial implications of operating the service; funding options
available for the service; and budget considerations for the service.
Section 3: Responsibilities of the City
3.1 The City shall provide full-time Emergency ALS/BLS ambulance service as
defined herein.
3.2 The City's dispatch service shall be responsible for providing dispatch
services for the City's ambulance service only.
3.3 Except as provided in Section 5 of this Agreement, the City shall fund and pay
the expense of providing Emergency ALS/BLS ambulance service required to
be provided by the City under this Agreement from whatever sources the City
Council of the City deems appropriate.
3.4 The City shall establish and maintain a budget for the ambulance service and
shall establish in that budget the manner of financing for the ambulance
service.
3.5 The City shall be responsible for the purchase, operating, and maintenance of
the ambulances and associated equipment needed to provide the ambulance
service required to be provided by the City under this Agreement.
3.6 The City agrees to provide mutual aid to the District and the District agrees
to provide mutual aid to the City when necessary and when available.
3.7 City shall set all rates for ambulance service provided under this
Agreement. The City shall notify the District in writing at least ten (10) days
before the effective date of any proposed rate change.
3.8 Each month the City purchases services from the District, and the cost of
those services will be deducted from the City's revenues collected by the
District. This sum is to be calculated and paid in accordance with the terms
of Section 5 of this Agreement and as further described in Appendix A.
Section 4: Responsibilities of the District
4.1 The District shall pay a sum each month to the City for Emergency ALS/BLS
ambulance service rendered. This sum is to be calculated and paid in
accordance with the terms of Section 5 of this Agreement and as further
described in Appendix A. These payments by the District shall constitute the
District's sole obligation to pay the City for providing ambulance service under
this Agreement.
4.2 The District shall provide dispatch service for transfers involving its ambulance
service.
4.3 The District shall establish alternative services for the Non-Emergency IFT of
patients from and to Island Hospital.
4.4 The District shall be responsible for billing individuals for ambulance service
provided by the City under this Agreement. The documentation of ambulance
service provided shall be submitted to the District by the City within twenty-four
(24) hours of each instance of providing ambulance service under this
Agreement. Documentation should include basic information required to bill
patient as established by the Hospital Patient Accounts Department.
4.5 The District shall provide the necessary laundry service, first aid supplies,
oxygen, and other similar operational supplies needed for the ambulance service.
These supplies shall be provided at the District's cost for such supplies and the
District shall bill individuals receiving such supplies based upon documentation
of the use of such supplies submitted to the District by the City. This
documentation shall be submitted to the District by the City within twenty-four
(24)hours of the use of such supplies.
4.6 The District shall be responsible for the collection of all payments for ambulance
services rendered and supplies provided and shall be entitled to retain all such
payments, which are collected, subject to paragraph 5.1 herein.
4.7 The District shall provide personnel for routine transfers after having consulted
with the Hospital EMS Officer.
4.8 The District shall be primarily responsible to provide Non-Emergency IFT
services.
4.9 The District shall separate the revenue for Emergency ALS/BLS ambulance
services provided by the City and the Hospital's Non-Emergency IFT services
provided by the District. The District shall also determine the revenues and
expenditures for each service. This will be the basis for distribution of revenue
paid to the City at each payment cycle.
Section 5: Payments Due to the City from the District
5.1 The basic method of payment by the District will be to pay to the City moneys
remaining after having deducted the costs of services agreed to, from the
acquired revenues from the Emergency ALS/BLS services only. For the
purpose of this Agreement"services agreed to" shall be defined as contractual
allowances, accounts payable, bad debts, salary for billers', supplies, materials
management, laundry, and applicable overhead.
5.2 Amounts paid to the City and applicability of the existing formula thereto will be
reassessed by the parties on an annual basis.
5.3 The Payment cycle shall be made in monthly installments.
Section 6: Boundary Changes
6.1 The City and District shall consult with each other to determine if any boundary
changes by either party would constitute a need to amend this agreement. If no
significant changes are needed, then this agreement shall serve the interests of
either party modifying their boundaries.
Section 7: Review, Modification, Termination, Effective Date, and Duration
7.1 This Agreement is subject to review each year on or before the December 31 st
anniversary.
7.2 No amendment or modification of this Agreement, including any additions or
deletions, shall be effective unless approved and executed by the parties in the
same form and manner as, and subject to the remaining provisions of, this
Agreement.
7.3 This Agreement shall automatically renew for additional one-year terms unless
either party provides the other with written notice of its intent to modify the
Agreement, including the suggested changes.
7.4 Either party may terminate this Agreement without cause at any time on ninety
(90) days written notice to the other party.
Section 8: Organized Health Care Arrangement.
8.1 As of the adoption of this inter-local agreement, the city and
district acknowledge the creation of an "Organized Health Care Arrangement",
(OCHA) between the District and City, under the privacy regulations
promulgated pursuant to the Health Insurance Portability and Accountability Act
of 1996 ("HIPAA"), 42 U.S.C. §1320d r. The District's hospital shall include
the city ambulance service in the District's "joint privacy notice" for all patients
delivered to or transported from the District's hospital by the City ambulance
service (See Appendix B). The City has promulgated this arrangement through
passage of City of Anacortes Resolution#1655.
Section 9: Disposition of Assets Upon Termination.
9.1 Should this Agreement be terminated or not renewed, ownership of all assets
owned by the City shall remain with the City. All assets owned by the District
shall remain with the District.
Section 10: Notice
10.1 All notices and payments relating to this Agreement shall be made at the
following addresses, unless the other party is otherwise previously notified in
writing:
Att. Finance Director
City of Anacortes
P.O. Box 547
Anacortes, WA 98221
Att. District Superintendent and CEO
Skagit County Public Hospital District No. 2
Island Hospital
1211 -24th Street
Anacortes, WA 98221
Section 11: Non-Assignability
11.1 This Agreement shall insure to the benefit of and be binding upon the
successors and assigns of the parties, and is not intended to confer rights or
benefits upon any third parties. This Agreement may not be assigned by either
party without prior written consent of both the parties. Any attempt to assign or
transfer any of the rights, duties or obligations of this Agreement without such
consent is void.
Section 12: Duty Created
12.1 Nothing herein contained shall create any duty on the part of the City or District
to any particular person or individual but only to each other and the public at
large
Section 13: Severability
13.1 If any term or condition of this Agreement or application thereof to any person or
circumstances is held invalid, such invalidity shall not effect other terms, conditions or
applications of this Agreement which can be given effect without the valid term, condition
or application.
Section 14: Integration
14.1 This Agreement is a complete and exclusive settlement of the agreement between
the parties and supersedes all proposals or prior agreements, or written and all
other communications between the parties relating to the subject matter of this
Agreement.
EXECUTED at Anacortes, Washington to be effective as of the day and year first above
written.
SKAGIT COUNTY PUBLIC HOSPITAL DISTRICT
NO.2, d/b/a HOSPITAL
Vincent C. Oliver
Superintendent and Chief Executive Officer
Date
CITY OF ANACOR I'ES, WASHINGTON
By: 4 . Le�C,n
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H. Dean Maxwell, Mayor
3 / gjtz
Date
ATTEST:
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Steve Hoglund, City Clerk Treasurer
Date
APPENDIX A (EXAMPLE ONL F)
Island Hospital
Ambulance Reconciliation
Ambulance Revenue _
Gross Ambulance Revenue Actual Billings
Deductions from Revenue Less Actual Contractual Adjustments
Net Ambulance Revenue
Expenses
Direct Expenses Direct expenses of the department
Indirect Expenses
Patient Accounts 4% of Gross billings
Percentage of Total ambulance supply costs to Total Hospital Supply
Materials Management Costs
Times the total cost of the Materials Management Department
Finance $62.50 per month($750 per year)
Laundry and Linen $3.02 per transfer
Total Expenses
Net Income
Less Prior Payments
Amount Due City
APPENDIX B
JOINT NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED,AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.
Island Hospital respects your privacy. It is required to maintain the privacy of your health
information and to provide you with a notice ("Notice") of its legal duties and privacy
practices. We understand that your personal health information is very sensitive. Island
Hospital will not use or disclose your health information except as described in this Notice, or
as permitted or required by law. We will not disclose your information to others unless you tell
us to do so, or unless the law authorizes or requires us to do so. This Notice applies to all of
the medical records generated by Island Hospital and its personnel, volunteers, students and
trainees. This Notice also applies to other health care providers that come to Island Hospital to
care for patients, such as physicians, physician assistants, therapists, and other health care
providers who are not employed by Island Hospital, such as ambulance services, including
ambulance services provided by the City of Anacortes (which participates in an organized
health care arrangement with Island Hospital), and emergency medical technicians who may
have brought you to the Hospital, unless those other providers give you their own Notice that
describes how they will protect your medical information. The Hospital and these other health
care providers work together to provide you with care and they will share your health
information with each other consistent with applicable law and as necessary to care for you, to
obtain payment for that care, or for health care operations purposes, such as quality assessment
and utilization review.
The law protects the privacy of the health information we create and obtain in providing our
care and services to you. For example, your protected health information includes your
symptoms, test results, diagnoses, and treatment, health information from other providers, and
billing and payment information relating to these services. Federal and state law allows us to
use and disclose your protected health information for purposes of treatment, payment and
health care operations. State law requires us to get your authorization to disclose this
information for payment purposes.
Examples of Use and Disclosures of Protected Health Information for Treatment,Payment,and
Health Operations
For treatment:
• Information obtained by a nurse,physician, or other member of our health care team will be
recorded in your medical record and used to help decide what care may be right for you.
• We may also provide information to others providing you care. This will help them stay informed
about your care.
For payment:
• We request payment from your health insurance plan with your consent. Health plans need
information from us about your medical care. Information provided to health plans may include
your diagnoses, procedures performed, or recommended care.
For health care operations:
• We use your medical records to assess quality and improve services.
• We may use and disclose medical records to review the qualifications and performance of our
health care providers and to train our staff.
• We may contact you to remind you about appointments and give you information about treatment
alternatives or other health-related benefits and services.
• We may contact you to raise funds.
• We may use and disclose your information to conduct or arrange for services, including:
• medical quality review by your health plan;
• accounting,legal, risk management, and insurance services;
• audit functions, including fraud and abuse detection and compliance programs.
Your Health Information Rights
The health and billing records we create and store are the property of Island Hospital. The protected
health information in it, however, generally belongs to you. You have a right to:
• Receive, read, and ask questions about this Notice;
• Ask us to restrict.certain uses and disclosures. You must deliver this request in writing to us. We
are not required to grant the request except as to physicians who previously treated you. But we
will comply with any request granted;
• Request and receive from us a paper copy of the most current Notice of Privacy Practices for
Protected Health Information ("Notice");
• Request that you be allowed to see and get a copy of your protected health information. You May
make this request in writing. We have a form available for this type of request.
• Have us review a denial of access to your health information—except in certain circumstances;
• Ask us to change your health information. You may give us this request in writing. You may write
a statement of disagreement if your request is denied. It will be stored in your medical record, and
included with any release of your records.
• When you request, we will give you a list of disclosures of your health information. The list will
not include disclosures made for purposes of treatment, payment or health care operations,
disclosures you authorized, disclosures to you, incidental disclosures, disclosures to family or other
persons involved in your care, disclosures to correctional institutions, and law enforcement in some
circumstances, disclosures of limited data set information or disclosures for national security. You
may receive this information without charge once every 12 months. We will notify you of the cost
involved if you request this information more than once in 12 months.
• Ask that your health information be given to you by another means or at another location. Please
sign, date, and give us your request in writing.
• Cancel prior authorizations to use or disclose health information by giving us a written revocation.
Your revocation does not affect information that has already been released. It also does not affect
any action taken before we have it. Sometimes,you cannot cancel an authorization if its purpose
was to obtain insurance.
For help with these rights during normal business hours, please contact:
Kathy McDermott,Privacy Officer
Island Hospital
1211 24th Street
Anacortes,WA 98221
(360)299-4202
Our Responsibilities
We are required to:
• Keep your protected health information private;
• • Give you this Notice;
• Follow the terms of this Notice.
We have the right to change our practices regarding the protected health information we maintain. If
we make changes, we will update this Notice and place the updated notice Notice on our website and
post it in appropriate locations. You may receive the most recent copy of this Notice by calling and
asking for it or by visiting our Admitting or Medical Records departments to pick one up.
To Ask for Help or Complain
If you have questions,want more information, or want to report a problem about the handling
of your protected health information,you may contact:
Kathy McDermott,Privacy Officer
Island Hospital
1211 24th Street
Anacortes,WA 98221
(360)299-4202
If you believe your privacy rights have been violated,you may discuss your concerns with any
staff member. You may also deliver a written complaint to Kathy McDermott, Privacy Officer,
at Island Hospital. You may also file a complaint with the U.S. Secretary of Health and
Human Services.
We respect your right to file a complaint with us or with the U.S. Secretary of Health and
Human Services. if you complain, we will not retaliate against you.
Other Disclosures and Uses of Protected Health Information
Notification of Family and Others
• Unless you object, we may release health information about you to a friend or family
member who is involved in your medical care. We may also give information to someone
who helps pay for your care. We may tell your family or friends your condition and that
you are in a hospital. In addition, we may disclose health information about you to assist in
disaster relief efforts.
• Information may be provided to people who ask for you by name. We may use and
disclose the following information in a hospital directory:
• your name,
• location,
• general condition, and
• religion (only to clergy).
You have the right to object to this use or disclosure of your information. if you object, we will
not use or disclose it.
We may use and disclose your protected health information without your authorization as follows:
• With Medical Researchers if the research has been approved and has policies to protect the
privacy of your health information. We may also share information with medical researchers
preparing to conduct a research project.
• To Funeral Directors/Coroners consistent with applicable law to allow them to carry out their
duties.
• To Organ Procurement Organizations(tissue donation and transplant) or persons who obtain,
store, or transplant organs.
• To the Food and Drug Administration (FDA) relating to problems with food, supplements, and
products.
• To Comply With Workers' Compensation Laws if you make a workers' compensation claim.
• For Public Health and Safety Purposes as Allowed or Required by Law:
• to prevent or reduce a serious, immediate threat to the health or safety of a person
• or the public.
• to public health or legal authorities
• to protect public health and safety
• to prevent or control disease, injury, or disability
• to report vital statistics such as births or deaths.
• To Report Suspected Abuse or Neglect to public authorities.
• To Correctional institutions if you are in jail or prison, as necessary for your health and the health
and safety.of others.
• For Law Enforcement Purposes such as when we receive a subpoena, court order, or other legal
process, or you are the victim of a crime.
• For Health and Safety Oversight Activities. For example,we may share health information with
the Department of Health.
• For Disaster Relief Purposes. For example, we may share health information with disaster relief
agencies to assist in notification of your condition to family or others.
• For Work Related Circumstances under the following conditions:
• the employer must have requested the health care service that was provided to the patient.
• the healthcare service provided must relate to the medical surveillance of the workplace or
be an evaluation to determine whether the individual has a work-related illness or injury.
• the employer must have a duty under the Occupational Safety and Health Administration
(OSHA), or requirements of a similar State law,to keep records on or act on such
information.
• To the Military Authorities of U.S. and Foreign Military Personnel. For example,the law may
require us to provide information necessary to a military mission.
• in the Course of JudiciaUAdministrative Proceedings at your request, or as directed by a court
order. Protected health information(PHI)may be released pursuant to a subpoena from an attorney
or other party if there is assurance that:
• the individual subject of the PHI has notice of the request
•
• the issuer of the subpoena has taken reasonable efforts to secure a qualified protective order
which prohibits the parties from using or disclosing the PHI for any purpose other than the
litigation or proceeding for which such information was requested AND requires the return
to the hospital or destruction of the PHI (including copies made) at the end of the litigation
or proceeding; and
• the individual subject of the PHI has had opportunity to object to the disclosure of his/her
PHI and has not done so, or all objections have been overruled..
•
• For Specialized Government Functions. For example, we may share information for national
security purposes.
Other Uses and Disclosures of Protected Health Information
• Uses and disclosures not in this Notice will be made only as allowed or required by law or with
your written authorization.
Web Site
• We have a Web site that provides information about us. For your benefit,this Notice is on
the Web site at this address: VRww.islandlhospital.org_
Effective Date: 1/1/2004
Revised: 1/13/2011