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SOUTHERN COOS HEALTH DISTRICT
Board of Directors Regular Meeting & Executive Session
February 27, 2020
Southern Coos Hospital & Health Center
6:00 p.m.
AGENDA
I. Call to Order
II. Public Input
III. Consent AgendaA. Regular Minutes – 01/23/2019
IV. Staff ReportsA. CEO & Clinic ReportB. CFO ReportC. Medical Staff ReportD. Marketing ReportE. SCHD Foundation Report
V. Old Business
VI. New BusinessA. Consideration of Natural Hazards Mitigation Plan AgreementB. Consideration of Compliance Plan PolicyC. Consideration of Trustee Code of Conduct
VII. Executive Session under ORS 192.660(2)(f) To consider information orrecords that are exempt from disclosure by law
VIII. Open Discussion
Adjournment
Next Regular Meeting – Thursday, March 26 – SCHHC
1
CONSENT AGENDA
Minutes
January 23, 2020
2
SCHD Board of Directors Meeting Minutes Page 1 of 4 January 23, 2020
Southern Coos Health District
Board of Directors Regular Meeting Minutes
January 23, 2020
7:00 p.m.
I. Call to Order This meeting of the Board of Directors for Southern Coos Health District was called to order at 7:00 p.m. by Esther Williams, Board Chair. Members Present: Esther Williams, Board Chair; Carol Acklin, Secretary; Tom Bedell, Treasurer; David Allen and Edie Jurgenson, Directors. Administration: Amy Fine, CEO; Deborah Ellis, CNO; Ana Mugica, CFO; Scott McEachern, CIO; Kerry Vincent, RN Supervisor. Absent: Philip Keizer, MD, Medical Staff President Other staff present: Dennis Jurgenson, Marlene Rocha, Victoria Schmelzer.
II. Public Input
None.
III. Consent Agenda – Regular Minutes 12/19/2019
Edith Jurgenson moved to approve the minutes as presented. Carol Acklin seconded the motion. All in favor. Unanimous decision.
IV. Staff Reports
A. CEO Hospital & Clinic Report
Provider news: Dr. Douglas Crane is relocating his practice to Bandon, to be located next to Southwest Physical Therapy in the 11th Street cul-de-sac adjacent to the hospital, to open February 7. Dr. Crane will also provide Hospitalist coverage at Southern Coos. On April 6, Dr. Olixn Adams will join Southern Coos, providing Hospitalist and Osteopathic Medicine Services. On January 1, Western Healthcare began providing Emergency Medicine Physicians to staff the SCHHC Emergency Department. Amy Hinshaw, FNP will be departing Southern Coos in February to relocate nearer to family out of the area. Debra Guzman, FNP will be available to Amy’s patients. Electronic Health Record: The reimplementation of the Evident electronic health record software is going smoothly for the February 1 live date for both hospital and clinic. Other News: A second Special Districts of Oregon de-escalation training was held for staff on January 15. Group acupuncture is offered weekly every Wednesday at 3:00 p.m. in the hospital conference room at a cost of $20. Amy Fine will attend the American Hospital Association Rural Health Conference February 2-5 in Arizona sponsored by the Oregon Hospital Association. Facility Master Plan: Preliminary work has begun with Amy Fine and Scott McEachern having met with District and Foundation Board members for input and a Medical Staff and Department Managers survey.
3
SCHD Board of Directors Meeting Minutes Page 2 of 4 January 23, 2020
Clinic Report: The number of Primary Care visits has been comparable to previous year. Podiatry Clinic visits are steadily increasing. The search for a Clinic Manager has been reopened.
B. CFO Report
Ana Mugica presented the CFO Report for the month of December. Utilization: Inpatient Days continued to increase from prior year, up 36%, and YTD. Swing Bed days and Emergency visits are comparable to December 2018 and increased YTD. Lab Tests, Radiology Procedures, Respiratory Visits, and Surgeries & Endoscopies show a decrease this month from last year and YTD. Specialty Clinic Visits, Podiatry Clinic, and Primary Care Visits have increased in December from prior year and YTD. Income Statement Summary: December Gross Revenue is $2.8M before contractual adjustments. Overall Gross Revenue YTD is higher than forecast by $2M. $300,000 was reserved this month for Medicare, increasing contractual adjustments as well as operating loss (total FY2020 Medicare reserve= $1.1M). Operating Expenses were higher than budget and YTD. Balance Sheet: Patient Accounts Receivable decreased by $300K with an uncollectable rate of 27.7%. December's current ratio is 2.78. Current Ratio=Total Current Assets/total Current Liabilities, meaning there is almost 3 times more Current Assets than Current Liabilities, allowing SCHHC to meet short term obligations. FinancialIndicators: December Days Cash on Hand improved from prior month at 58.3. Days in Accounts Receivable closed at 56.7, this reflects how quickly accounts are being paid. Payer Mix: The December payer mix shows the month trended higher in Medicare and self-pay patients with a slight decrease in Medicaid and Commercial insurance payers. State Investment Pool: The state pool closed with total reserves of $2.93M, earning 2.25% interest in December.
C. Medical Staff Report
On January 14 Medical Staff approved the following providers for Board consideration:
Robert K. Evans, MD – Emergency Medicine Brad “Dana” Hunter, MD – Emergency Medicine Frances K. Lawson, MD – Emergency Medicine David Marc Smith, MD – Emergency Medicine Don Hirschman, CRNA - Anesthesia
Edith Jurgenson moved to approve the Medical Staff Report as presented. Tom Bedell seconded the motion. All in favor. Unanimous decision.
4
SCHD Board of Directors Meeting Minutes Page 3 of 4 January 23, 2020
D. Marketing Report
Scott McEachern presented the Marketing and Foundation reports. Annual Wellness exams and same day appointments in the Clinic have been featured in digital and print advertising. In the last month the SCHHC website saw an increase in new users and overall number of users.
E. Southern Coos Health Foundation Report
Year-end/2020 Campaign: Fundraising efforts continue for the anesthesia machine and replacement of operating room lighting system. Just over $50,000 has been raised to-date with efforts continuing into 2020 to reach the goal of $120,000. SCHF Promotion: The SCHF Board has directed that a brochure about the Foundation be created to promote visibility and transparency of the Health Foundation including activities and board service. Promotion of the Health Foundation and board members will continue through the hospital website, press releases, and advertising. Upcoming Events: Women’s Health Day, next Saturday, February 1, 8am – 3pm at the Bandon Community Center sponsored by First Interstate, Carol Meijer, Joseph Bain, Roger Straus, Amy Fine, Advanced Health, and Sharen Strong, DMD. The annual Golf for Health Classic will be May 29 & 30, 2020 at Bandon Crossings Golf Course. On-line registration for WHD is available via the SCHHC website and Health Foundation Facebook page.
V. Old Business
None.
VI. New Business
A. Consideration of Change to Regular Board Meeting Time
Tom Bedell moved for the regular monthly board meeting time be changed from 7:00 p.m. to 6:00 p.m. to begin February 27, 2020. Edith Jurgenson seconded the motion. Discussion: If the 6:00 start time becomes problematic, the topic can be reviewed again. Ayes: 4 Nays: 1. Motion passed.
Open Discussion
Group discussion regarding Facility Master Plan and ED expansion possibilities with appreciation from providers for inclusion in master plan process; Tom Bedell will volunteer his services of tax preparation for seniors again this season; Cori Valet spoke of need to increase RN staffing with the consistent increase in inpatient and swing bed census, plus filling night shift positons; internal RN quarterly clinical skills training is scheduled March 19; Scott McEachern is pleased with the implementation of Versa Badge in the ED to track provider down time for Medicare reimbursement; the Foundation Gift Shop December revenue exceeded $5K; the Information Systems team and all staff were recognized for their efforts in preparation for the upcoming E.H.R. conversion. Employee W-2 forms will be ready for direct mail distribution by January 31 and available
5
SCHD Board of Directors Meeting Minutes Page 4 of 4 January 23, 2020
electronically. Thank you to Cori Valet, RN Manager, acting CNO while Deborah Ellis is out of office. Ms. Williams shared a reference paper on hospital boards and board functions. Members inquired about having marketing “rack cards” for Clinic services and providers.
Adjournment
Ms. Williams adjourned the meeting at 8:10 p.m. The next regular meeting of the Southern Coos Health District Board of Directors will be held on Thursday, February 27, 2020 at 6:00 p.m. in the Southern Coos Hospital conference room.
Esther Williams, Board Chair Carol Acklin, Secretary
6
CEO & CLINIC REPORT
7
CEO REPORT
February 2020
Provider news:
Dr. Douglas Crane has moved his Internal Medicine practice to Bandon. His first day seeing patients in his office was February 11. His staff and patients have been complimentary of the hospital and the warm welcome and efficient service they are receiving. The Southern Coos Laboratory reported a 25% increase in outpatient volume due to referrals from Dr. Crane’s office the first week. In addition to providing hospitalist coverage for all of our patients every other week, Dr. Crane is caring for his own patients while they are in the hospital. His first endoscopy at Southern Coos was completed on February 24, 2020. Dr. Olixn Adams will provide Hospitalist Services at Southern Coos Hospital and Health Center on April 2 and 3. He will serve as Hospitalist seven days per month and provide Osteopathic Medicine Services in the Clinic five days per month beginning in May. Western Healthcare began providing Emergency Medicine Physicians to staff the Southern Coos Hospital Emergency Department (ED) beginning January 1, 2020. The transition has been seamless. I am grateful for the highly competent physicians that are providing care to our community. Employees of the Month
Julie Buck, CNA II has been awarded Clinical Employee of the Month for February. Julie has worked for Southern Coos since May of 2008. Her peers commented that Julie has been an asset to our team for many years and continues to want to learn and grow to be even more helpful to the organization. Over the last few weeks, Julie has been instrumental in assisting the new ED providers, as well as Clinic staff, with navigating our systems and adjusting to new processes. Sherry Capobianco, Dietary Supervisor, has been awarded Non-Clinical Employee of the Month for February. Sherry has worked for Southern Coos since June of 2019. She was nominated by her peers because she is always supportive and easy to communicate with. She is able to problem solve and be supportive to all staff. She is open to suggestions and ideas of all. Great food! Athena and Evident
We went “live” with Evident in the hospital at 12:01 am on February 1. In addition to the regularly scheduled hospital staff, Cathy Mann, Jeff Weymouth, an Evident representative and I were on site. There were some issues with access and scanners that needed to be addressed, but overall the go-live in the hospital went smoothly.
The clinic went “live” on Monday, February 3 and has experienced some difficulties. We have committed extra help from IT, HIM and Nursing with chart prep, as well as adding scribes to help with chart prep, nursing has been helping to room patients and Evident remained on-site through last week.
8
We are working to make this implementation and reimplementation a success and continue to take care of patients. It is stressful and emotions are running high, but, we will get through this and come out stronger.
We will continue to utilize Athena until we have collected our outstanding receivables as of 1/31/2020.
Other News:
Cindy Kessler has accepted the position as Lab Manger to replace Shaun Magnuson. Cindy has been with Southern Coos for about a year in a per-diem role. She and Shaun are working side by side until Shaun’s last day with the District which is Friday, February 28.
I attended the American Hospital Association Rural Health Conference February 2-5 in Phoenix. There were many educational sessions and some great keynote speakers. Overall the conference was thought provoking, inspirational and informative. I brought back a lot of information and am looking forward to putting it to use. The conference and travel were sponsored by the Oregon Association of Hospitals and Health Systems.
We are starting work on updating the District Strategic Plan, Community Needs Assessment and Master Plan. Many of you will be asked for input in the next several months.
The 17th annual Women’s Health Day was held on Saturday, February 1. It was a wonderful day with a lot of great information. It was nice to see so many of our friends, neighbors and patients there. Sabrina Johnson, Carolyn Reed and Carol Meijer deserve special credit for all of their thoughtful work in making this event a huge success.
I will be on vacation March 4 through March 13. Deborah Ellis, CNO, will be acting CEO while I am away.
Clinic Report:
Year-to-date patient visits for the Primary Care have held steady with volumes for last year. Podiatry Clinic visits are steadily increasing.
Karen Stafford has accepted the position of Clinic Manager. She is an LVN and has terrific experience as a clinic manager for UC Davis. Karen will start with us on March 16.
9
CFO REPORT
10
Sou
ther
n C
oo
s H
osp
ital
an
d
Hea
lth
Cen
ter
CFO
Rep
ort
Jan
uar
y, 2
02
0
11
Uti
liza
tion
FY
19
-2
0F
Y 1
8 -
19
% V
ari
an
ce
FY
19
-2
0F
Y 1
8 -
19
% V
ari
an
ce
Act
ua
lP
rio
r Y
ea
rT
o P
rio
r Y
ea
rA
ctua
lP
rio
r Y
ea
rT
o P
rio
r Y
ea
r
Ho
spit
al
72 53
35.8
%54
7
40
2
36.1
%11
4
73
56.2
%71
7
64
8
10.6
%M
ajo
r D
epa
rtm
ents
Em
erg
ency
Vis
its
339
326
4.0%
2,86
1
2,58
7
10
.6%
Ra
dio
log
y P
roce
dure
s67
3
64
8
3.
9%4,
865
4,
975
-2.2
%L
abo
rato
ry T
est
s2,
950
3,
767
-2
1.7%
20,6
61
26
,733
-22.
7%R
esp
ira
tory
Vis
its
410
411
-0.2
%2,
500
3,
155
-20.
8%S
urg
eri
es
and E
ndo
sco
pie
s25
39 -3
5.9%
211
342
-3
8.3%
Po
dia
try
Clinic
446
311
43.4
%2,
541
1,
823
39.4
%S
peci
alt
y C
linic
Vis
its
329
293
12.3
%2,
214
2,
305
-3.9
%P
rim
ary
Ca
re C
linic
403
442
-8.8
%2,
766
2,
643
4.7%
Inp
atie
nt
Day
s, S
WB
Day
s &
Em
erge
ncy
Vis
its
had
a s
tro
ng
mo
nth
co
mp
arin
g to
th
is m
on
th la
st y
ear
and
YTD
. Rad
iolo
gy
pro
ced
ure
s in
crea
sed
slig
hty
fro
m J
anu
ary
20
19
& h
ad a
sm
all d
ecre
ase
YTD
. Lab
Tes
ts a
nd
Su
rger
ies
& E
nd
osc
op
ies
dec
reas
ed
in J
anu
ary
wh
en c
om
par
ing
to t
his
mo
nth
last
yea
r an
d Y
TD.
Spec
ialt
y C
linic
Vis
its
& P
od
iatr
y ar
e h
igh
er t
han
Jan
uar
y 2
01
9
and
on
ly P
od
iatr
y YT
D. P
rim
ary
Car
e V
isit
s ar
e d
ow
n in
co
mp
aris
on
to
th
is m
on
th, b
ut
slig
htl
y h
igh
er Y
TD.
for
the
Mo
nth
En
din
g J
an
ua
ry,
20
20
So
uth
ern
Co
os
Ho
spit
al
an
d H
ealt
h C
ente
r
Sw
ing
Bed D
ay
s
Mo
nth
Yea
r T
o D
ate
In P
ati
ent
Da
ys
12
Sou
the
rn C
oo
s H
osp
ital
an
d H
eal
th C
en
ter
13
Actu
alBu
dget
Varia
nce
Actu
alBu
dget
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nce
Gro
ss P
ati
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Rev
enue
2,91
3,58
8$
2,66
9,62
0$
24
3,96
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20
,947
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$
18,6
87,3
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C
ontr
act
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l A
dju
stm
ents
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et
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1,84
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3,39
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ting
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s1,
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me (
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rants
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24,0
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ss R
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tual
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ts
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me
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ur
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r co
st t
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atio
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st R
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th
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ou
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eiva
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ase
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rom
Dec
emb
er.
The
Allo
wan
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or
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ts is
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r th
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rren
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uth
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e S
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ent
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ets/
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l Cu
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r Ja
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able
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icar
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ith
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ent
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nth
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l Y
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ate
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1/31
/201
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ets
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1,
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stm
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stri
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est
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t -
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alth
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rmat
ion
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ard
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h E
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t P
atie
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ou
nts
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ceiv
able
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4,19
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3,
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3,39
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er
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ceiv
able
s11
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277,
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563
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pe
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ceiv
able
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urr
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l Cu
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nt
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ets
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pe
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ceiv
able
- P
rio
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ars
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stri
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ran
t A
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nt
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ip (
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t o
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ep
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atio
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6,66
6,58
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l Ass
ets
13,9
82,1
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13,9
30,0
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14,5
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15$
Bal
ance
Sh
ee
t
Sou
the
rn C
oo
s H
osp
ital
an
d H
eal
th C
en
ter
As
of
1/31
/202
0, 1
/31/
2019
, an
d 1
/31/
2018
15
1/31
/202
020
1/31
/201
91/
31/2
018
Liab
ilit
ies
and
Fu
nd
Bal
ance
Acc
ou
nts
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able
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$
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5,55
4$
85
9,48
9$
Acc
rue
d S
alar
ies
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mp
loye
e B
en
efi
ts97
8,28
3
915,
380
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5,79
4
Inte
rest
an
d O
the
r P
ayab
le1,
148,
381
645,
362
16
2,62
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rre
nt
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rtio
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f Lo
ng
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bt
218,
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9,96
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l Cu
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nt
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ies
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ase
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ans
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an P
ayab
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1,59
5,00
0
1,
720,
000
Less
Cu
rre
nt
Po
rtio
n o
f Lo
ng
Term
De
bt
(218
,793
)
(209
,969
)
(206
,310
)
Tota
l No
n-C
urr
en
t Li
abil
itie
s4,
377,
695
4,60
5,31
1
-
4,
818,
938
Tota
l Lia
bil
itie
s7,
316,
352
6,98
1,57
6
-
6,
863,
151
De
ferr
ed
Tax
/Gra
nt
Re
ven
ue
Fun
d B
alan
ce6,
665,
770
6,94
8,51
0
7,
640,
564
Tota
l Ne
t Eq
uit
y6,
665,
770
6,94
8,51
0
7,
640,
564
Tota
l Lia
bil
itie
s an
d F
un
d B
alan
ce13
,982
,122
$
13
,930
,086
$
14
,503
,715
$
Bal
ance
Sh
ee
t
Sou
the
rn C
oo
s H
osp
ital
an
d H
eal
th C
en
ter
As
of
1/31
/202
0, 1
/31/
2019
, an
d 1
/31/
2018
16
Act
ual
Bu
dge
tP
rio
r Ye
arV
aria
nce
to B
ud
get
Var
ian
ce t
o
Pri
or
Year
Act
ual
Bu
dge
tP
rio
r Ye
arV
aria
nce
to
Bu
dge
t
Var
ian
ce t
o
Pri
or
Year
Re
ven
ue
Inp
atie
nt
770,
014
$
510,
391
$
470,
163
$
259,
623
$
299,
851
$
4,
973,
033
$
3,57
2,73
6$
3,32
7,46
0$
1,
400,
297
$
1,64
5,57
3$
Ou
tpat
ien
t2,
143,
573
2,
159,
229
2,
122,
428
(1
5,65
6)
21
,145
15,9
74,0
10
15,1
14,6
05
14,6
17,2
88
859,
405
1,
356,
722
Tota
l Pat
ien
t R
eve
nu
e2,
913,
588
2,
669,
620
2,
592,
591
24
3,96
7
32
0,99
7
20,9
47,0
43
18,6
87,3
41
17,9
44,7
48
2,25
9,70
2
3,
002,
295
Less
Co
ntr
actu
al(1
,063
,540
)
(847
,708
)
(903
,633
)
(2
15,8
32)
(1
59,9
07)
(8
,310
,687
)
(5,9
33,9
54)
(5
,770
,974
)
(2,3
76,7
33)
(2
,539
,713
)
Less
Ch
arit
y C
are
- (1
1,52
8)
(6
,763
)
11,5
28
6,76
3
(8,3
95)
(80,
695)
(7
6,19
4)
72,3
00
67
,799
Less
Bad
De
bt
Exp
en
se(5
60)
(3
5,51
7)
(2
9,24
1)
34,9
57
28,6
81
(9
9,92
3)
(248
,617
)
(2
53,3
28)
148,
694
15
3,40
5
Tota
l De
du
ctio
ns
(1,0
64,1
00)
-3
6.5
%(8
94,7
53)
-3
3.5
2%
(939
,637
)
-3
6.2
4%
(169
,347
)
(124
,463
)
(8,4
19,0
05)
-4
0.1
9%
(6,2
63,2
66)
-3
3.5
2%
(6,1
00,4
96)
-3
4.0
%(2
,155
,739
)
(2,3
18,5
09)
Ne
t P
atie
nt
Re
ven
ue
1,84
9,48
7
1,77
4,86
7
1,65
2,95
4
74,6
20
196,
533
12
,528
,038
12
,424
,075
11
,844
,252
10
3,96
3
683,
786
Oth
er
Op
era
tin
g R
eve
nu
e5,
363
8,52
6
117,
143
(3,1
63)
(1
11,7
80)
23
4,54
7
59,6
82
14
2,46
6
174,
865
92
,081
Tota
l Op
era
tin
g R
eve
nu
e1,
854,
850
1,
783,
393
1,
770,
097
71
,457
84
,753
12,7
62,5
85
12,4
83,7
57
11,9
86,7
18
278,
829
77
5,86
8
Exp
en
ses
Sala
rie
s an
d B
en
efi
ts1,
068,
356
1,
062,
849
88
6,67
8
(5
,507
)
(181
,678
)
7,40
7,29
1
7,
354,
341
6,90
2,78
6
(5
2,95
0)
(504
,505
)
Pro
fess
ion
al F
ee
s23
3,42
3
213,
081
218,
600
(20,
342)
(14,
823)
1,
522,
788
1,49
1,56
7
1,
532,
946
(31,
221)
10
,158
Pu
rch
ase
d S
erv
ice
s26
4,18
4
226,
866
247,
600
(37,
318)
(16,
584)
1,
636,
124
1,58
8,06
5
1,
326,
994
(48,
059)
(3
09,1
30)
Me
dic
al S
up
pli
es
- 16
2,98
4
-
162,
984
-
1,07
0,50
6
1,
070,
506
Sup
pli
es
69,2
78
186,
361
29,5
30
117,
083
(39,
748)
1,
474,
691
1,30
4,53
1
19
6,53
6
(170
,160
)
(1
,278
,155
)
Oth
er
Op
era
tin
g Ex
pe
nse
106,
016
97
,726
11
4,40
8
(8
,290
)
8,39
2
727,
898
68
4,08
3
744,
158
(4
3,81
4)
16,2
60
Uti
liti
es
and
Insu
ran
ce29
,458
28
,007
28
,516
(1
,451
)
(942
)
216,
854
19
6,04
9
189,
954
(2
0,80
5)
(26,
900)
De
pre
ciat
ion
59,7
81
59,9
88
55,1
57
207
(4
,624
)
41
8,49
5
419,
915
40
6,43
3
1,41
9
(1
2,06
2)
Tota
l Op
era
tin
g Ex
pe
nse
1,83
0,49
5
1,87
4,87
8
1,74
3,47
3
44,3
83
(87,
022)
13
,404
,141
13
,038
,552
12
,370
,313
(3
65,5
89)
(1,0
33,8
28)
Op
era
tin
g In
com
e24
,355
(9
1,48
5)
26
,624
11
5,84
0
(2
,269
)
(6
41,5
56)
(554
,795
)
(3
83,5
95)
(86,
761)
(2
57,9
61)
Sou
ther
n C
oo
s H
osp
ital
an
d H
ealt
h C
ente
rIn
com
e St
ate
men
t
For
the
7 M
on
ths
End
ing
1/31
/202
0 an
d 1
/31/
2019
Cu
rren
t M
on
thYe
ar
to D
ate
17
Act
ual
Bu
dge
tP
rio
r Ye
arV
aria
nce
to B
ud
get
Var
ian
ce t
o
Pri
or
Year
Act
ual
Bu
dge
tP
rio
r Ye
arV
aria
nce
to
Bu
dge
t
Var
ian
ce t
o
Pri
or
Year
No
n-O
pe
rati
ng
Inco
me
Pro
pe
rty
Taxe
s9,
920
75,3
35
73,1
41
(65,
415)
(63,
221)
86
1,60
6
527,
346
51
1,98
6
334,
260
34
9,62
0
Oth
er
6,22
6
14
,831
13
,626
(8
,605
)
(7,4
00)
46,1
03
10
3,81
7
94,3
11
(5
7,71
4)
(48,
208)
Tota
l No
n-O
pe
rati
ng
Re
ven
ue
16,1
45
90,1
66
86,7
67
(74,
021)
(70,
622)
90
7,70
9
631,
163
60
6,29
7
276,
546
30
1,41
2
No
n-O
pe
rati
ng
Exp
en
se
Inte
rest
Exp
en
se16
,466
17
,135
17
,079
66
9
613
120,
624
11
9,94
5
124,
310
(6
79)
3,
686
Oth
er
-
1
5,
421
1
5,
421
7
(2
,902
)
7
(2
,902
)
Tota
l No
n-O
pe
rati
ng
Exp
en
se16
,466
17
,136
22
,500
67
0
6,03
4
120,
624
11
9,95
2
121,
408
(6
73)
78
4
Exce
ss R
eve
nu
e24
,035
(1
8,45
5)
90
,891
42
,490
(6
6,85
6)
145,
529
(4
3,58
4)
101,
294
18
9,11
3
44,2
35
-
Do
nat
ion
s-
10
,417
-
(1
0,41
7)
-
1,64
5
72,9
17
15
(71,
272)
1,
630
Gra
nt
Inco
me
8,33
3
(8,3
33)
-
58,3
33
(5
8,33
3)
-
Incr
eas
e in
Ne
t A
sse
ts24
,035
$
29
5$
90
,891
$
23
,740
$
(66,
856)
$
14
7,17
4$
87,6
66$
101,
309
$
59
,508
$
45,8
65$
Sou
ther
n C
oo
s H
osp
ital
an
d H
ealt
h C
ente
rIn
com
e St
ate
men
t
For
the
7 M
on
ths
End
ing
1/31
/202
0 an
d 1
/31/
2019
Cu
rren
t M
on
thYe
ar
to D
ate
18
So
uth
ern
Co
os
Ho
spit
al
an
d H
ea
lth
Ce
nte
rIn
com
e St
ate
men
t
Mo
nth
ly C
om
pa
riso
n F
Y2
02
0
July
-19
Au
gust
-19
Sep
tem
be
r-19
Oct
ob
er-
19N
ove
mb
er-
19D
ece
mb
er-
19
Re
ven
ue
Inp
atie
nt
565,
028
$
74
0,15
5$
675,
998
$
71
9,13
9$
78
4,95
0$
717,
749
$
Ou
tpat
ien
t2,
549,
970
2,
503,
428
1,
965,
568
2,
536,
035
2,
132,
525
2,
142,
911
Tota
l Pat
ien
t R
eve
nu
e3,
114,
998
3,
243,
583
2,
641,
566
3,
255,
174
2,
917,
474
2,
860,
660
Less
Co
ntr
actu
al(1
,272
,624
)
(1,4
16,1
20)
(8
77,0
53)
(1,2
36,3
85)
(1
,207
,328
)
(1
,237
,638
)
Less
Ch
arit
y C
are
(1,1
91)
(3
,360
)
(2,4
03)
(5
8)
(1,3
83)
-
Less
Bad
De
bt
Exp
en
se(2
5,86
2)
(18,
595)
(2
,853
)
(55,
326)
4,
378
(1
,105
)
Tota
l De
du
ctio
ns
(1,2
99,6
77)
-4
1.7
%(1
,438
,075
)
-44
.3%
(882
,309
)
-3
3.4
%(1
,291
,769
)
-39
.7%
(1,2
04,3
33)
-41
.3%
(1,2
38,7
43)
-43
.3%
Ne
t P
atie
nt
Re
ven
ue
1,81
5,32
1
1,80
5,50
8
1,75
9,25
7
1,96
3,40
5
1,71
3,14
2
1,62
1,91
8
Oth
er
Op
era
tin
g R
eve
nu
e5,
536
7,
266
14
,166
20
,334
3,
272
17
8,61
0
Tota
l Op
era
tin
g R
eve
nu
e1,
820,
857
1,
812,
774
1,
773,
423
1,
983,
739
1,
716,
414
1,
800,
528
Exp
en
ses
Sala
rie
s an
d B
en
efi
ts1,
028,
341
1,
045,
830
1,
059,
010
1,
088,
059
1,
084,
999
1,
032,
697
Pro
fess
ion
al F
ee
s22
4,31
4
19
7,51
0
19
3,85
3
21
0,09
2
23
0,13
7
23
3,45
9
Pu
rch
ase
d S
erv
ice
s20
1,56
6
18
0,58
2
17
8,41
3
28
9,49
0
23
0,41
5
29
1,47
3
Me
dic
al S
up
pli
es
- -
-
Sup
pli
es
221,
510
230,
321
208,
636
259,
304
231,
610
254,
033
Oth
er
Op
era
tin
g Ex
pe
nse
99,0
66
108,
238
99,2
84
105,
656
80,7
49
128,
889
Insu
ran
ce a
nd
Uti
liti
es
33,2
49
30,2
34
32,0
73
30,3
83
34,2
10
27,2
47
De
pre
ciat
ion
67,8
82
51,2
99
59,7
40
60,1
06
60,0
70
59,6
18
Tota
l Op
era
tin
g Ex
pe
nse
1,87
5,92
8
1,84
4,01
3
1,83
1,00
8
2,04
3,09
2
1,95
2,19
0
2,02
7,41
5
Op
era
tin
g In
com
e(5
5,07
1)
(31,
238)
(5
7,58
5)
(59,
353)
(2
35,7
76)
(2
26,8
87)
No
n-O
pe
rati
ng
Inco
me
Pro
pe
rty
Taxe
s75
,037
75
,037
75
,037
75
,037
26
6,15
7
28
5,38
3
Oth
er
6,59
1
6,33
0
5,96
1
6,33
9
7,
702
6,
955
Tota
l No
n-O
pe
rati
ng
Re
ven
ue
81,6
28
81,3
67
80,9
98
81,3
75
273,
859
292,
337
No
n-O
pe
rati
ng
Exp
en
se
Inte
rest
Exp
en
se16
,991
17
,126
17
,134
16
,759
19
,673
16
,476
Oth
er
- -
- -
-
Tota
l No
n-O
pe
rati
ng
Exp
en
se16
,991
17
,126
17
,134
16
,759
19
,673
16
,476
Exce
ss R
eve
nu
e9,
566
33
,002
6,
279
5,
263
18,4
10
48,9
75
Do
nat
ion
s-
- 92
5
720
-
Gra
nt
Inco
me
Incr
eas
e in
Ne
t A
sse
ts9,
566
$
33
,002
$
6,
279
$
6,
188
$
19
,130
$
48
,975
$
19
So
uth
ern
Co
os
Ho
spit
al
an
d H
ea
lth
Ce
nte
rIn
com
e St
ate
men
t
Mo
nth
ly C
om
pa
riso
n F
Y2
02
0
Jan
uar
y-20
Feb
ruar
y-20
Mar
ch-2
0A
pri
l-20
May
-20
Jun
e-2
0YT
D T
ota
l
Re
ven
ue
Inp
atie
nt
770,
014
$
4,97
3,03
3$
Ou
tpat
ien
t2,
143,
573
15
,974
,010
Tota
l Pat
ien
t R
eve
nu
e2,
913,
588
20
,947
,043
Less
Co
ntr
actu
al(1
,063
,540
)
(8,3
10,6
88)
Less
Ch
arit
y C
are
-
(8,3
95)
Less
Bad
De
bt
Exp
en
se(5
60)
(9
9,92
3)
Tota
l De
du
ctio
ns
(1,0
64,1
00)
-3
6.5
%(8
,419
,005
)
-40
.19
%
Ne
t P
atie
nt
Re
ven
ue
1,84
9,48
7
12,5
28,0
38
Oth
er
Op
era
tin
g R
eve
nu
e5,
363
234,
547
Tota
l Op
era
tin
g R
eve
nu
e1,
854,
850
12
,762
,585
Exp
en
ses
Sala
rie
s an
d B
en
efi
ts1,
068,
356
7,
407,
291
Pro
fess
ion
al F
ee
s23
3,42
3
1,
522,
788
Pu
rch
ase
d S
erv
ice
s26
4,18
4
1,
636,
124
Me
dic
al S
up
pli
es
-
-
Sup
pli
es
69,2
78
1,47
4,69
1
Oth
er
Op
era
tin
g Ex
pe
nse
106,
016
727,
898
Insu
ran
ce a
nd
Uti
liti
es
29,4
58
216,
854
De
pre
ciat
ion
59,7
81
418,
495
Tota
l Op
era
tin
g Ex
pe
nse
1,83
0,49
5
13,4
04,1
41
Op
era
tin
g In
com
e24
,355
(6
41,5
56)
No
n-O
pe
rati
ng
Inco
me
Pro
pe
rty
Taxe
s9,
920
861,
606
Oth
er
6,22
6
46
,103
Tota
l No
n-O
pe
rati
ng
Re
ven
ue
16,1
45
907,
709
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%
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-19
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19Se
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-19
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20
Annu
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d R
OI
26
MEDICAL STAFF REPORT
27
SOU
THER
N C
OO
S H
OSP
ITA
L C
RED
ENTI
ALI
NG
REP
OR
T Fe
bru
ary
27, 2
020
Ap
poin
tmen
t an
d P
riv
ileg
es –
MED
IC
AL S
TA
FF
Nam
e
Cate
go
ry
Area o
f P
racti
ce
Thom
as K
insle
y,
MD
60-D
ay T
em
pora
ry
Em
erg
ency M
edic
ine
Olixn A
dam
s
Active
Fam
ily P
ractice
Ap
poin
tmen
t an
d P
riv
ileg
es –
ALLIED
HEA
LTH
PR
OFES
SIO
NA
LS
STA
FF
Nam
e
Cate
go
ry
Area o
f P
racti
ce
Sta
ff C
ate
gory C
han
ge –
MED
IC
AL S
TA
FF
Nam
e
From
Sta
tus
To S
tatu
s
Area o
f P
racti
ce
Don H
irschm
an
Locum
Tenens
Court
esy
Anesth
esia
David
Marc
Sm
ith,
MD
60-D
ay T
em
pora
ry
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esy
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erg
ency M
edic
ine
Reap
poin
tmen
t an
d P
riv
ileg
es –
MED
IC
AL S
TA
FF
Nam
e
Cate
go
ry
Area o
f P
racti
ce
Note
s
Jam
es T
racy,
DO
Court
esy
Alle
rgy
28
MARKETING REPORT
29
Marketing Report to SCHD Board
February 2020
SCHHC Advertising
We have focused our advertising efforts on advertising Shane Matsui, LCSW, in digital and print
advertisements. We are also advertising Shane, Community Acupuncture, and podiatry through
our Facebook channel. In the Coffee Break, we have focused on advertising Shane and the monthly
Prostate Cancer Support Group held the last Monday of every month at the Seabird Chapel. We
are also advertising Shane and the Prostate Cancer Support Group on the radio.
SCHHC Website
The SCHHC website continues to be a source of information for the hospital, clinic, and services
provided. In February, the SCHHC website saw the following traffic:
southerncoos.org Metric Previous Month/Industry Benchmark
Trend
1,810 Users 1,555 users in December
1,629 New Users 1,385 New Users in December
55.90% Bounce Rate 58.32% in December 55-70% is industry average
1:25 Average Session Duration 1:32 in December 2-3 minutes is industry average
29a
SCH FOUNDATION REPORT
30
Officers
Joseph Bain | President
Mary Wilson | Vice-President
Sean Suppes | Treasurer
Carolyn Reed | Secretary
Directors
David Allen
John Ohanesian
Carol Meijer
Roger Straus
Becky Armistead
Dr. Henry Holmes
Southern Coos Health Foundation
February 2020
SCHF Promotion
At the last Foundation board meeting, the board directed that we develop a brochure about the
Foundation to give to visitors to the hospital, patients, and community. We will also raise visibility
of the Foundation by promoting the board of directors through our website, press releases, and
advertising. The brochure is in draft and will be ready by the end of February.
Women’s Health Day Report
This year’s event was held on Saturday, February 1, 2020. We had 138 attendees, including
vendors and volunteers. The event was a great success, with many people giving positive praise to
our speakers, Michelle Niesley, and Coast Community Health Center physician Dr. Hank Holmes.
Many thanks to all of our sponsors, volunteers, and speakers.
Upcoming Events
Golf for Health Classic
May 29 & 30, 2020
Bandon Crossings
30a
NEW BUSINESS
31
NHMP Agreement
32
Coos County Multi-Jurisdictional Natural Hazards Mitigation Plan Update DLCD IGA #: 19065 Page 1
Page 1 of 24
INTERGOVERNMENTAL AGREEMENT
This Agreement is between the State of Oregon acting by and through its Department of Land Conservation and Development (“DLCD”) and the Southern Coos Hospital District (“DISTRICT”), each a “Party”.
1. Authority
This Agreement is authorized by ORS 190.110.
2. Effective Date and Duration
This Agreement is effective on the date of the last signature (“Effective Date”), and terminates on March 31, 2022, unless terminated earlier in accordance with Section 8.
3. Background
Natural disasters occur when natural hazard events impact people, structures, and the environment. The dramatic increase in the costs associated with natural disasters over the past decades has fostered interest in identifying and implementing effective means of reducing these impacts. Natural hazards mitigation planning is a process for identifying and understanding the hazards facing a jurisdiction and prioritizing actions the jurisdiction can take to reduce injuries and deaths; damage to buildings, critical facilities, and infrastructure; interruption in essential services; economic hardship; and environmental harm. Reducing impacts also speeds up recovery and lowers its cost.
The Federal Emergency Management Agency (FEMA) approves Natural Hazards Mitigation Plans (NHMPs) meeting federal requirements at 44 CFR 201. Approval lasts five years. Having a current, FEMA-approved NHMP is a key factor in establishing eligibility for certain FEMA grants that fund natural hazards mitigation planning and projects.
Coos County’s Multi-Jurisdictional NHMP will expire on September 12, 2021. DLCD has received a FEMA Pre-Disaster Mitigation grant to assist Coos County, the cities of Bandon, Coos Bay, Coquille, Lakeside, Myrtle Point, North Bend, and Powers, and the Southern Coos and Coquille Valley Hospital Districts, the Coos Bay School District, the International Port of Coos Bay, and the Port of Bandon (“Jurisdictions”) with updating the Coos County Multi-Jurisdictional NHMP. The grant’s performance period is from October 1, 2018 through April 1, 2022.
4. Purpose
The purposes of this Intergovernmental Agreement are to:
(a) Formalize a working relationship between DLCD and the Jurisdictions that is to result in an updated Coos County Multi-Jurisdictional NHMP adopted by each Jurisdiction and approved by FEMA;
(b) Ensure the Jurisdictions are aware that the grant supporting this project requires the final deliverable to be a FEMA-approved NHMP, and that to achieve FEMA approval the
33
Coos County Multi-Jurisdictional Natural Hazards Mitigation Plan Update DLCD IGA #: 19065 Page 2
Page 2 of 24
Jurisdictions must not only consider, but also adopt an NHMP that FEMA has agreed to approve; and
(c) Ensure the Jurisdictions are aware of their responsibility to contribute financially to the Project using non-federal funds, and to track, document, and report its cost share as required.
5. Responsibilities of Parties
(a) Responsibilities of DLCD.
DLCD will provide financial, administrative, and technical oversight to the Natural Hazards Mitigation Plan ("NHMP" or “Plan”) Update project described in Exhibit A, Scope of Work, which is incorporated into and made part of this Agreement.
Specific DLCD responsibilities include:
i. Organizing, leading and managing the planning process;ii. Writing the Plan; andiii. Administering grant funds.
(b) Responsibilities of County.
The COUNTY shall appoint a one of its Steering Committee members to lead the project in partnership with DLCD’s Project Manager.
Specific Project responsibilities of the County Lead include:
i. Assisting DLCD with organizing, leading, and managing the planningprocess;
ii. Providing County Assessor’s data;iii. Providing GIS services;i. Carrying out other responsibilities enumerated in Section 5(c);ii. Performing any other Project work assigned to the County by Exhibit A.
(c) Responsibilities of the Jurisdictions:
The Jurisdictions will each appoint a Steering Committee member and alternate who already have or have been delegated decision-making authority for this Project.
Specific Project responsibilities of the Jurisdictions include:
i. Attending and actively participating in Steering Committee meetings;ii. Providing data and information;iii. Engaging with internal and external stakeholders;iv. Executing the Project’s public engagement program;v. Shepherding the plan through the public adoption process;vi. Tracking, accurately documenting, and reporting cost share as required;vii. Adopting a Plan that FEMA has agreed to approve; and
34
Coos County Multi-Jurisdictional Natural Hazards Mitigation Plan Update DLCD IGA #: 19065 Page 3
Page 3 of 24
viii. Performing any other Project work assigned to County, Cities, andDistricts by Exhibit A.
6. Compensation and Costs
Each Party shall assume its own costs of carrying out the tasks and responsibilities assigned to it under this Agreement.
FEMA does not permit DLCD to sub-grant funds to local governments. Therefore, DLCD will use the grant funds to provide financial, administrative, and technical oversight and assistance to the Jurisdictions to complete the update.
The federal grant supporting the Project requires a 25% cost share from non-federal funds. The DISTRICT shall commit to providing and documenting cash, in-kind, or a combination of both as its portion of the required 25% cost share.
7. Project Contacts
The designees named below shall be the contacts for all the work and services to be performed under this Agreement. A Party may designate a new contact by written notice to the other Party.
DLCD’s Project Contact is:
Pamela Reber, Natural Hazards Planner Oregon Department of Land Conservation and Development 635 Capitol ST NE, Suite 150 Salem, OR 97301 (503) 934-0066 [email protected]
Southern Coos Hospital District’s Project Contact is:
Dennis Jurgenson, Emergency Preparedness Manager Southern Coos Hospital District 900 11th Street SE Bandon, OR 97411 (541) 347-2426 [email protected]
8. Termination
(a) This Agreement may be terminated at any time by mutual written agreement of the Parties.
(b) This Agreement may be terminated by either Party with 30 days advance written notice.
9. Non-Discrimination
35
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In carrying out activities under this Agreement, no Party shall discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, national origin, disability, marital status, veteran status, disability or age. Each Party shall take affirmative actions to ensure that applicants for employment are employed and that employees are treated during employment, without regard to their race, color religion, sex, sexual orientation, national origin, disability, marital status, veteran status, disability or age. Such action shall include but not be limited to the following: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff of termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship.
10. Non-Appropriation
DLCD’s obligation to perform its duties under this Agreement is conditioned upon DLCD receiving funding, appropriations, limitations, allotments, or other expenditure authority sufficient to allow DLCD, in the exercise of its reasonable administrative discretion, to meet its obligations under this Agreement. Nothing in this Agreement may be construed as permitting any violation of Article XI, Section 7 of the Oregon Constitution or any law limiting the activities, liabilities or monetary obligations of DLCD.
11. Representations and Warranties
The DISTRICT represents and warrants that the making and performance by the DISTRICT of this Agreement:
(a) Has been duly authorized by the DISTRICT;
(b) Does not and will not violate any provision of any applicable law, rule, regulation, or order of any court, regulatory commission, board, or other administrative agency or any provision of the DISTRICT’s charters or other organizational documents; and
(c) Does not and will not result in the breach of, or constitute a default or require any consent under any other agreement or instrument to which the DISTRICT is a party or by which the DISTRICT may be bound or affected.
No authorization, consent, license, approval of, or filing or registration with or notification to any governmental body or regulatory or supervisory authority is required with or notification to any governmental body or regulatory or supervisory authority is required for the execution, delivery or performance by the Jurisdictions of this Agreement, other than those that have already been obtained.
12. Records
Parties and their duly authorized representatives shall have access to the books, documents, and records which are directly pertinent to Agreement for the purpose of making audit, examination, excerpts, and transcript. This does not require either Party to provide documents that are legally
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privileged or otherwise exempt from disclosure under the Oregon Public Records Law, ORS 192.311 to 192.478.
13. Contribution
If any third party makes any claim or brings any action, suit or proceeding alleging a tort as now or hereafter defined in ORS 30.260 (a “Third Party Claim”) against a Party (the “Notified Party”) with respect to which the other Party (the “Other Party”) may have liability, the Notified Party shall promptly notify the Other Party in writing of the Third Party Claim and deliver to the Other Party, along with the written notice, a copy of the claim, process and all legal pleadings with respect to the Third Party Claim that have been received by the Notified Party. Each Party is entitled to participate in the defense of a Third Party Claim, and to defend a Third Party Claim with counsel of its own choosing. Receipt by the Other Party of the notice and copies required in this Section and a meaningful opportunity for the Other Party to participate in the investigation, defense and settlement of the Third Party Claim with counsel of its own choosing are conditions precedent to the Other Parties’ contribution obligation under this Agreement with respect to the Third Party Claim.
With respect to a Third Party Claim for which DLCD is jointly liable with the Notified Party (or would be if joined in the Third Party Claim), DLCD shall contribute to the amount of expenses (including attorney fees), judgments, fines and amounts paid in settlement actually and reasonably incurred and paid or payable by the Notified Party in such proportion as is appropriate to reflect the relative fault of DLCD on the one hand and of the Notified Party on the other hand in connection with the events that resulted in such expenses, judgments, fines or settlement amounts, as well as any other relevant equitable considerations. The relative fault of DLCD on the one hand and of the Notified Party on the other hand shall be determined by reference to, among other things, the Parties’ relative intent, knowledge, access to information, and opportunity to correct or prevent the circumstances resulting in such expenses, judgments, fines or settlement amounts. DLCD’s contribution amount in any instance is capped to the same extent it would have been capped under Oregon law if the State had sole liability in the proceeding.
With respect to a Third Party Claim for which a Party is jointly liable with DLCD (or would be if joined in the Third Party Claim), the Other Party or Parties shall contribute to the amount of expenses (including attorney fees), judgments, fines and amounts paid in settlement actually and reasonably incurred and paid or payable by DLCD in such proportion as is appropriate to reflect the relative fault of the Other Party or Parties on the one hand and of DLCD on the other hand in connection with the events that resulted in such expenses, judgments, fines or settlement amounts, as well as any other relevant equitable considerations. The relative fault of the Other Party or Parties on the one hand and of DLCD on the other hand shall be determined by reference to, among other things, the Parties’ relative intent, knowledge, access to information and opportunity to correct or prevent the circumstances resulting in such expenses, judgments, fines or settlement amounts. The Other Party’s or Parties’ contribution amount in any instance is capped to the same extent it would have been capped under Oregon law if it had sole liability in the proceeding.
14. Subcontracting and Assignment
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The Jurisdictions acknowledge that DLCD intends to hire contractors to perform tasks and responsibilities related to the deliverables listed in the Scope of Work, Exhibit A to this Agreement. The DISTRICT shall not enter into any subcontract for any other work listed under this Agreement without written consent of DLCD.
15. Governing Law, Consent to Jurisdiction
This Agreement shall be governed by and construed in accordance with the laws of the State of Oregon without regard to principles of conflicts of law. Any claim, action, suit or proceeding (collectively “Claim”) between DLCD or any other agency or department of the State of Oregon, or both, and the DISTRICT that arises from or relates to this Agreement shall be brought and conducted solely and exclusively within the Circuit Court of Marion County for the State of Oregon; provided, however, if a Claim must, as mandated by federal law, be brought in a federal forum, then unless otherwise prohibited by law it shall be brought and conducted solely and exclusively within the United States District Court for the District of Oregon. In no event shall this Section be construed as a waiver by any Party of any form of defense or immunity, whether sovereign immunity, governmental immunity, immunity based on the eleventh amendment to the Constitution of the United States or otherwise, to or from any Claim or from the jurisdiction of any court.
16. Indemnification
Except as provided in Section 13 of this Agreement, each Party shall defend, save, hold harmless, and indemnify the other Party and the other Party’s agencies, subdivisions, officers, directors, employees and agents from and against all claims, suits, actions, loses damages, liabilities, costs and expenses of any nature whatsoever (Claims), including attorney fees, resulting from, arising out of, or relating to the acts or omissions of the indemnifying Party’s officers, employees, or agents under this Agreement. Any indemnity by DLCD under this Section shall be subject to the limitations of Article XI, Section 7 of the Oregon Constitution and the Oregon Tort Claims Act, 30.260 to 30.300. Any indemnity by the DISTRICT shall be subject to the limitations of Article XI, Section 12 of the Oregon Constitution and the Oregon Tort Claims Act, ORS 30.260 to 30.300.
17. Insurance
Each Party shall be responsible for providing workers’ compensation insurance as required by law for its covered workers. Neither Party shall be required to provide or show proof of self-insurance, workers’ compensation or any other insurance coverage.
18. Severability
If any term or provision of this Agreement is declared by a court of competent jurisdiction to be illegal or in conflict with any law, the validity of the remaining terms and provisions shall not be affected, and the rights and obligations of the Parties shall be construed and enforced as if the Agreement did not contain the particular term or provision held to be invalid. In such event, the
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Parties intend that the conflict not invalidate the other provisions of this Agreement and the Parties shall negotiate in good faith to agree on replacement language for the offending term or provision that will be consistent with the purposes of this Agreement.
19. Compliance With Law
In connection with their activities under this Agreement, the Parties shall comply with all applicable federal, state and local law.
20. Force Majeure
Neither Party shall be held responsible for delay or default caused by fire, riot, acts of God, and war which are beyond its reasonable control. The affected Party shall, however, make all reasonable efforts to remove or eliminate such a cause of delay or default and shall, upon cessation of the cause, diligently pursue performance of its obligations under this Agreement.
21. No Third Party Beneficiary
DLCD and the DISTRICT are the only Parties to this Agreement and are the only Parties entitled to enforce its terms. Nothing contained in Agreement gives or shall be construed to give or provide any benefit, direct, indirect, or otherwise, to third parties. The contractors retained by DLCD are expressly excluded as parties or beneficiaries to this Agreement and are barred from enforcing the terms of this Agreement.
22. Merger, Waiver and Modification
This Agreement and all exhibits and attachments, if any, constitute the entire agreement between the Parties on the subject matter hereof. There are no understandings, agreements, or representations, oral or written, not specified herein regarding this Agreement. No waiver or consent under this Agreement binds either Party unless in writing and signed by both Parties. Such waiver or consent, if made, is effective only in the specific instance and for the specific purpose given. EACH PARTY, BY SIGNATURE OF ITS AUTHORIZED REPRESENTATIVE, HEREBY ACKNOWLEDGES THAT IT HAS READ THIS AGREEMENT, UNDERSTANDS IT, AND AGREES TO BE BOUND BY ITS TERMS AND CONDITIONS.
23. Amendments
The terms of this Agreement may not be altered, modified, supplemented or otherwise amended, except by written agreement of the Parties. Any amendment to this Agreement shall require the signatures of the approving authorities of both Parties.
24. Acknowledgment of Funds and Copyright
(a) Acknowledgment of Funds.
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Both Parties shall acknowledge their use of federal funding when issuing statements, press releases, requests for proposals, bid invitations, and other documents describing projects or programs funded in whole or in part with federal funds.
(b) Copyright.
Both Parties must affix the applicable copyright notices of 17 USC Section 401 or 402 and an acknowledgment of Government sponsorship (including sub-grant number) to any work first produced under a federal award unless the work includes any information that is otherwise controlled by the Government (e.g., classified information or other information subject to national security or export control laws or regulations). For any scientific, technical, or other copyright work based on or containing data first produced under this Agreement, including those works published in academic, technical or professional journals, symposia proceedings, or similar works, Parties grant the Government a royalty-free, nonexclusive and irrevocable license to reproduce, display, distribute copies, perform, disseminate, or prepare derivative works, and to authorize others to do so, for Government purposes in all such copyrighted works.
25. Survival
All provisions concerning the limitation of liability, indemnity, and conflicts of interest shall survive the termination of this Agreement for any cause.
26. Interpretation
The Parties agree that the provisions of this Agreement shall not be construed in favor of or against any Party based on the source of its drafting or any other circumstances.
27. Counterparts
This Agreement may be executed in several counterparts, all of which when taken together shall constitute one agreement, notwithstanding that both Parties are not signatories to the same counterpart. Each copy of the Agreement so executed constitutes an original.
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the dates set forth below.
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SOUTHERN COOS HOSPITAL DISTRICT APPROVED AS TO FORM:
Dennis Jurgenson, Emergency Preparedness Manager
Esther Williams
Chairman of Board of Directors
Date Date
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DEPARTMENT OF LAND CONSERVATION AND DEVELOPMENT (DLCD)
Jim Rue, Director
Date
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Multi-Jurisdictional Natural Hazards Mitigation Plan (MJNHMP) Update
for Coos County, the Cities of Bandon, Coos Bay, Coquille, Lakeside,
Myrtle Point, North Bend, Powers, and the Southern Coos and Coquille
Valley Hospital Districts, the Coos Bay School District, the International
Port of Coos Bay, and the Port of Bandon
Scope of Work
PROJECT DESCRIPTION The purpose of this Scope of Work (SOW) is to review and update Coos County’s Multi-Jurisdictional NHMP (MJNHMP) such that it is adopted by Coos County (COUNTY), Cities of Bandon, Coos Bay, Coquille, Lakeside, Myrtle Point, North Bend, and Powers (CITIES), the Southern Coos and Coquille Valley Hospital Districts, the Coos Bay School District, the International Port of Coos Bay and the Port of Bandon (DISTRICTS), collectively “JURISDICTIONS,” and ultimately approved by the Federal Emergency
Management Agency (FEMA). The update process may include drafting new NHMPs for cities and special districts who have not participated previously.
The Oregon Department of Land Conservation and Development (DLCD) and COUNTY will lead the MJNHMP update process in partnership. DLCD and JURISDICTIONS will participate and execute responsibilities and tasks as set forth in this SOW.
This project is funded by a FEMA Pre-Disaster Mitigation (PDM) mitigation planning grant. A PDM
mitigation planning grant must culminate in an NHMP that is adopted by JURISDICTIONS and approved
by FEMA. Therefore, JURISDICTIONS agree not only to consider but also to adopt the NHMP that FEMA
has agreed to approve.
The planning process will be open and transparent. All meetings will be duly advertised and open to the public. Each Steering Committee (SC) agenda will include time for public input. Effort will be focused on developing, to the extent data and capacity are available, a potential loss estimate, improving the capability assessment, and employing a greater range of public engagement methods.
PHASE 1: ORGANIZE
Purpose The purpose of Phase 1 is to organize and develop content for project initiation.
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Task 1: Prepare a Draft Intergovernmental Agreement (IGA) The purpose of the IGA is to formalize a working relationship between DLCD and JURISDICTIONS to execute an update of the Coos County MJNHMP; ensure that each jurisdiction adopts and obtains FEMA approval of the updated MJNHMP; and ensure that each jurisdiction provides cost share and documents its cost share contribution as required.
DELIVERABLES
DLCD 1. Draft IGA for review by COUNTY
Target Date: August 2019
Task 2: Prepare a Draft Scope of Work (SOW) DLCD will draft a SOW intended to produce an MJNHMP meeting the requirements of the Code
of Federal Regulations, Title 44, Part 201.6 (44 CFR 201.6) and therefore approvable by FEMA.
DELIVERABLES
DLCD 1. Draft SOW
Target Date: August 2019
Task 3: Develop a Project Schedule DLCD will develop a project schedule setting target dates for SC and, if applicable, Technical
Advisory Committee (TAC) meetings, public engagement opportunities, public review and comment periods, state and federal review processes, and local adoption proceedings.
A minimum of two opportunities for the public to comment will be included, one to review the Draft Risk Assessment and one to review at least the Draft Mitigation Strategy and Plan Maintenance Process, and as circumstances warrant potentially the entire Draft MJNHMP. Both opportunities will be offered prior to finalizing the plan for approval by each of JURISDICTIONS’
respective boards and councils. While only these two opportunities are required, providing as many opportunities as possible is encouraged, as greater public participation benefits the community and strengthens the MJNHMP.
“The public” is understood to include – but not be limited to – citizens and residents, neighboring communities, local and regional agencies involved in hazard mitigation activities; agencies that have the authority to regulate development, businesses, academia, and other private and non-profit interests.
DELIVERABLES
DLCD 1. Draft Project Schedule
Target Date: August 2019
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Task 4 Coordinate with COUNTY The following tasks will be accomplished collaboratively by DLCD and COUNTY for review and agreement by the SC at its organizational meeting (Task 6).
Meet remotely or in person with COUNTY and:
A. Discuss the Intergovernmental Agreement. B. Discuss the Scope of Work and revise as necessary or appropriate. C. Discuss the current MJNHMP’s strengths and opportunities for improvement and
recommend a strategy for addressing them. Effort will be focused on developing, to the extent data and capacity are available, a potential loss estimate, improving the capability assessment, and employing a greater range of public engagement methods;
D. Discuss the Draft Project Schedule (Task 3, Deliverable 1) and revise as necessary or appropriate;
E. Discuss Table 1: Allocation of Basic Responsibilities and Tasks and revise as necessary or appropriate. These basic responsibilities and tasks will be performed throughout the duration of the project in addition to other others described and deliverables assigned in Tasks 1 through 16.
F. Determine the method for and roles of DLCD and COUNTY in inviting cities, special districts, and tribes to participate in the planning process.
G. Designate SC members and alternates. SC members and alternates must have or have been delegated authority to make decisions and act on behalf of their jurisdictions for the purposes of this project;
H. Draft a list of stakeholders, technical advisors, and other interested parties including at a minimum representatives of FEMA’s six “whole community” sectors: (a) Emergency Management; (b) Economic Development; (c) Land Use and Development; (d) Housing; (e) Health and Social Services; (f) Infrastructure; and (g) Natural and Cultural Resources. Determine how to engage them in the planning process (e.g., Steering Committee, Technical Advisory Committee, one-to-one discussions, focus groups, etc.) and the roles of DLCD and COUNTY in inviting their participation.
I. Prepare a draft Public Engagement Program for SC discussion and finalization.
Table 1: ALLOCATION of BASIC RESPONSIBILITIES and TASKS
Responsibility/Task DLCD COUNTY CITIES SPECIAL DISTRICTS
Steering and Technical Advisory Committee Meetings Prepare and distribute agenda 7-10 days prior to
meetings via email. If a SC or TAC member does nothave access to email, JURISDICTIONS will ensure themember receives a hard copy 5 days prior to meetings.
X Assist Assist Assist
Prepare handouts. If appropriate, distribute handouts7-10 days prior to meetings via email. If a SC or TACmember does not have access to email, JURISDICTIONS
X Assist Assist Assist
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Responsibility/Task DLCD COUNTY CITIES SPECIAL DISTRICTS
will ensure the member receives a hard copy 5 days prior to meetings.
Provide language for public notice of meetings if requested. X
Lead and facilitate meetings. X Assist Prepare and distribute meeting notes. X Engage with local internal and external stakeholders
about the project and bring their input back to the committee discussions.
X X X
Public Engagement Program Execute Public Engagement Program. Assist X X X Lead public engagement meetings and events. Assist X X X Facilitate public engagement meetings and events. X Assist Assist Assist Provide public notice of meetings and events through a
variety of means. Assist X X X
Shepherd MJNHMP through Planning Commission, Board and Council work sessions and adoption process.
Assist X X X
Plan Development Gather hazard and vulnerability data, existing plans,
studies, reports, and technical information. X X X X
Provide information on climate change and its influence on hazards. X
Provide GIS services. X X X Provide assessor data. X Provide other data and information. X X X Analyze data. X Assist Assist Assist Write plan sections. X Assist Assist Assist Review plan sections. X X X X Edit plan sections. X Assist Assist Assist Finalize plan. X Administrative Functions Publish notice of meetings and events 7-10 days prior
to date of occurrence. X X X
Print agenda, sign-in sheet and handouts for meetings. DLCD will print color and 11x17 handouts only if none of the JURISDICTIONS has capability and no commercial printer with capability is reasonably available.
Assist X X X
Develop and maintain during the update and after completion an interactive project web page and link to that page on the jurisdiction’s home page.
X X X
Establish and maintain a listserv, email service, or dedicated email address accessible on the project web X X X
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Responsibility/Task DLCD COUNTY CITIES SPECIAL DISTRICTS
page for communication with the public (e.g., distribute news, receive comments).
Jurisdictions without web access will commit to othermethods for ensuring the project information is madeavailable to the public in a timely manner.
X X X
Track and accurately report cost-share in the requiredformat at least quarterly by the deadline set by DLCD. X X X
Document the planning process by keeping copies of allagendas, sign-in sheets, notices, publications, web pageupdates, etc. for inclusion in the updated MJNHMP.
X X X X
Monitor and adjust project schedule. X Assist Handle Logistics (space reservations, supplies, copies,
audio/visual equipment, etc.) for Steering Committeemeetings, Technical Advisory Committee meetings (ifapplicable), public engagement meetings and events,etc. occurring in your jurisdiction.
X X X
DELIVERABLES
DLCD 1. Meeting notes memorializing decisions of Task 4
2. Revised Draft Scope of Work
3. Revised MJNHMP Review and Strategy Memo
4. Revised Project Schedule
5. Revised Table 1: ALLOCATION of BASIC RESPONSIBILITIES and TASKS
6. Draft Public Engagement Program
7. Cost Share Documentation Forms and Instructions
COUNTY 1. Draft Steering Committee Roster
2. Initial Draft Stakeholder or if applicable, TAC Roster
Target Date: February 2020
Task 5 Invite and Confirm Participants In accordance with the method and roles determined in Task 4, (A) invite cities and special districts, to participate and appoint SC members and alternates. Members will serve as their jurisdictions’ official contact for the project; (B) Provide the IGA and Draft SOW to CITIES and
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DISTRICTS for review, noting that the IGA is not open to substantive revisions; and (C) invite stakeholders to participate. Confirm responses.
If necessary to meet time and budget constraints, DLCD and COUNTY will decide collaboratively and in consultation with the special districts which of them will be included in the updated Coos County MJNHMP. Others will be invited to participate and may leverage their participation to support development of addenda for later inclusion into the Coos County MJNHMP or into a stand-alone NHMP.
DELIVERABLES
COUNTY 1. Final Roster of Steering Committee members and alternates
2. Second Draft Stakeholder or, if applicable, TAC Roster
Target Date: March 2020
Task 6 Hold Organizational SC Meeting The purpose of this meeting is to initiate the project. DLCD and COUNTY will explain the project background, purpose, and requirements and will discuss with the SC the project participant roles, responsibilities, and expectations.
DLCD and COUNTY will lead the SC through discussion of the deliverables of Tasks 4 and 5 and note any revisions.
The SC will review the IGA and SOW and establish a date by which each jurisdiction will sign.
Each jurisdiction will identify a person responsible for cost share tracking and reporting.
Each jurisdiction will identify a person responsible for developing and maintaining an up-to-date project website or otherwise ensuring that project information is made available to the community in a timely manner.
DELIVERABLES
DLCD 1. Final Scope of Work
2. Final Project Schedule
3. Final SC Roster
4. Final Stakeholder or TAC Roster
5. Final Table 1, Allocation of Basic Responsibilities and Tasks
6. Final Public Engagement Plan
7. Cost Share Documentation Forms and Instructions
Target Date: April 2020
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SC 1. Person responsible for cost share tracking and reporting for each jurisdiction
2. Person responsible for developing and maintaining an up-to-date project website or otherwise ensuring project information is made available to the public in a timely manner for each jurisdiction
3. Signed IGA
Target Date: April 2020
PHASE 2: UPDATE THE COOS COUNTY MULTI-JURISDICTIONAL NHMP
Purpose
The purpose of Phase 2 is to update the current Coos County MJNHMP such that it meets the requirements of 44 CFR 201.6 and is therefore approvable by FEMA.
Task 7 Review and Update the Risk Assessment DLCD will lead the SC in reviewing and updating the risk assessment. For each jurisdiction, the updated risk assessment will:
A. To the extent data is available, describe the type, location, and extent (intensity) of each of the natural hazards to which it is subject and how they may be influenced by climate change.
B. Identify significant previous occurrences of each hazard.
C. Assess probability of future occurrence of each hazard.
D. Describe the geographic (political and physical), social, economic, cultural and historic characteristics, land use, development trends, and changes in development.
E. Identify NFIP-insured structures that have sustained repetitive flood damages.
F. To the extent data is available, assess potential dollar losses to buildings, repetitive flood loss structures, infrastructure, and critical facilities from each hazard.
G. Assess vulnerability to each hazard.
H. To the extent reasonable based on limitations of data and analysis, present findings and indicate mitigation priorities.
DELIVERABLES
SC 1. Plans, studies, reports, technical data and information available for review and potential incorporation into the risk assessment
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DLCD 1. Number of NFIP-insured structures in each jurisdiction including those having sustained repetitive losses and their respective dollar values
2. Coordinate and conduct group or individual meetings with DISTRICTS, if needed.
Target Date: May-August 2020
COUNTY 1. Coordinate up to two TAC meetings (if applicable).
2. Coordinate up to two SC meetings.
Target Dates: May-August 2020
DLCD 1. Initial Draft Risk Assessment for TAC (if applicable), SC, and public review
Target Date: August-October 2020
Task 8 Public Review of Risk Assessment DLCD will assist JURISDICTIONS in developing and executing at least one opportunity for the public to comment on the Draft Risk Assessment. “The public” is understood to include – but not be limited to – citizens and residents, neighboring communities, local and regional agencies involved in hazard mitigation activities; agencies that have the authority to regulate development, businesses, academia, and other private and non-profit interests.
DELIVERABLES
SC 1. At least one opportunity for public comment completed.
Target Date(s): October-December 2020
DLCD 1. Draft comment matrix containing public comments and draft responses for SC review
Target Date: January 2021
DLCD 1. Final comment and response matrix
2. Second Draft Risk Assessment incorporating public comments and final comment and response matrix
Target Date: January 2021
Task 9 Review and Update the Mitigation Strategy DLCD will lead the SC in reviewing and updating the mitigation strategy. The mitigation strategy is the blueprint for reducing the potential losses and vulnerabilities identified through the risk assessment. The mitigation strategy sets mitigation goals; establishes and prioritizes mitigation
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actions for each jurisdiction; establishes an implementation strategy for accomplishing each action; analyzes the capabilities of each jurisdiction for carrying out its mitigation actions; and describes a process for integrating the content of the MJNHMP into other planning mechanisms. Multi-jurisdictional mitigation actions may be established by some or all of the jurisdictions. For each jurisdiction, the Mitigation Strategy will:
A. Establish mitigation goals based on the risk assessment.
B. Assess each jurisdiction’s mitigation capabilities.
C. Document each jurisdiction’s participation in the NFIP and continued compliance with its
requirements.
D. Document status of mitigation actions in the current MJNHMP highlighting mitigation progress and successes.
E. Identify and discuss any changes in mitigation priorities.
F. Revise and add new mitigation actions reflecting any changes in mitigation priorities and emphasizing new and existing buildings and infrastructure.
G. Prioritize mitigation actions. Prioritization will include a general, qualitative cost/benefit assessment for mitigation projects.
H. Establish an implementation strategy for each priority mitigation action.
I. Describe the process, method, and timeline for integrating the content of the MJNHMP into other planning mechanisms and highlight any integration that has occurred.
Deliverables
SC 1. Information about participation in and continued compliance with NFIP
2. Information for and participation in capability assessment
3. Information about planning mechanisms and timeline for integration
Target Date: November 2020
COUNTY 1. Coordinate up to three SC meetings for Tasks 9 and 10 together.
Target Dates: September 2020 – April 2021
DLCD 1. Initial Draft Mitigation Strategy for TAC (if applicable), SC, and publicreview
Target Dates: January – February 2021
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Task 10 Review and Update the Plan Maintenance Process DLCD will assist JURISDICTIONS in reviewing the plan maintenance process and revising it as necessary. For each jurisdiction, the Plan Maintenance Process will:
A. Describe the method and schedule for monitoring, evaluating, and updating the mitigation plan within a five-year cycle.
B. Describe how the jurisdictions will continue public participation during the plan maintenance process.
DELIVERABLES
DLCD 1. Initial Draft Plan Maintenance Process for TAC (if applicable) and SC review
2. Second Draft Plan Maintenance Process incorporating TAC (if applicable) and SC comments for public review
Target Date(s): January – April 2021
Task 11 Public Review of Mitigation Strategy and Plan Maintenance Process
DLCD will assist JURISDICTIONS in developing and executing at least one opportunity for the public to comment on at minimum the Draft Mitigation Strategy and Plan Maintenance Process, and as circumstances warrant potentially the entire Draft MJNHMP. Therefore, this task may occur at this point in the process or later, but not later than between Tasks 13 and 14.
“The public” is understood to include – but not be limited to – citizens and residents, neighboring communities, local and regional agencies involved in hazard mitigation activities; agencies that have the authority to regulate development, businesses, academia, and other private and non-profit interests.
DELIVERABLES
SC 1. At least one opportunity for public comment completed.
Target Date(s): January – March 2021
DLCD 1. Draft comment matrix containing public comments and draft responses for SC review
Target Date: February – March 2021
DLCD 1. Final comment and response matrix incorporating SC comments
2. Second Draft Mitigation Strategy and Plan Maintenance Process incorporating public comments and final comment and response matrix
Target Date: March – May 2021
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Task 12 Document the Planning Process
DLCD will assist JURISDICTIONS in documenting the planning process. Copies of agendas, sign-in sheets, notices, publications, web page updates, etc. will be included in the updated MJNHMP. For each jurisdiction, the Planning Process chapter will:
A. Describe how the plan was prepared, who was included, how the public was involved, and the opportunity for neighboring communities, local and regional agencies involved in hazard mitigation activities; agencies that have the authority to regulate development, businesses, academia, and other private and non-profit interests to be involved in the planning process.
B. Describe opportunities for public comment during drafting and prior to plan approval.
C. Describe how plans, studies, reports, technical data and information were incorporated.
D. Include documentation of the planning process.
DELIVERABLES
SC 1. Provide copies of web page updates, notices, publications, etc.
DLCD 1. Initial Draft Planning Process chapter and documentation for SC review
2. Second Draft Planning Process chapter incorporating SC comments
Target Date(s): October 2019 – March 2022
Task 13 Review and Update Remaining Chapters
DLCD will assist the SC in reviewing and updating any remaining chapters or sections of the current MJNHMP and deciding if there is anything more that needs to be drafted. These may include an Executive Summary, Introduction, lists of tables and figures, glossary, list of acronyms, appendices, etc.
DELIVERABLES
DLCD 1. Initial draft of remaining chapters or sections for SC review
2. Second draft of remaining chapters or sections incorporating SC comments
Target Date(s): May – July 2021
Task 14 Finalize Draft MJNHMP for State and Federal Review
DLCD will edit the entire document and add a cover, title page, acknowledgements, page numbers, FEMA funding credit, etc. to finalize the draft MJNHMP for the review and approval process. Pages will be reserved to insert documentation of the approval process: FEMA’s
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“Approvable Pending Adoption” letter; evidence of adoption by each jurisdiction; FEMA’s final
approval letters; and FEMA’s final Local Mitigation Plan Review Tool.
DELIVERABLES
DLCD 1. Finalized Draft MJNHMP
Target Date: May – July 2021
PHASE 3: REVIEW AND APPROVAL PROCESS
Purpose The purpose of Phase 3 is to ensure that all the necessary steps toward final FEMA approval are taken; the JURISDICTIONS each adopt the updated MJNHMP without substantive changes; and FEMA approves the adopted MJNHMP. This project is funded by a FEMA Pre-Disaster Mitigation (PDM) mitigation planning grant. A PDM mitigation planning grant must culminate in an NHMP that is adopted by JURISDICTIONS and approved by FEMA. Therefore, JURISDICTIONS agree not only to consider but also to adopt the NHMP that FEMA has agreed to approve. If a jurisdiction requires a substantive change through its adoption process, the approval process will be restarted.
Task 15 Submit Draft MJNHMP for State and Federal Review
On behalf of JURISDICTIONS, DLCD will submit the Draft Coos County MJNHMP to the Oregon Office of Emergency Management (OEM) for review. OEM will review the draft MJNHMP and when it is FEMA-approvable will submit it to FEMA for formal review. DLCD, and JURISDICTIONS will make any necessary revisions with review by the SC and public as appropriate until FEMA issues its APA letter.
DELIVERABLES
DLCD 1. Submit finalized Draft MJNHMP with completed Local Mitigation Plan Review Tool to OEM.
2. Make any required changes in consultation with SC and resubmit until OEM and FEMA are satisfied that the draft MJNHMP is approvable as evidenced by receipt of FEMA’s APA letter.
Target Date: Submittal to OEM: August 16, 2021
Required Changes Completed: September 27, 2021
FEMA Review Completed: November 19, 2021
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APA Received: December 16, 2021
Task 16 Adopt Final Draft MJNHMP JURISDICTIONS will arrange for the FEMA-approvable Final Draft Coos County MJNHMP to be considered for adoption by each of their respective boards and councils. Following adoption, each jurisdiction will submit the evidence of adoption (generally a signed resolution) to DLCD. DLCD will then submit the resolutions to FEMA through OEM for final approval.
DELIVERABLES
SC 1. Provide evidence of adoption to DLCD.
DLCD 1. Submit evidence of adoption to OEM.
2. Insert approval process documents into plan.
3. Record effective date on cover.
4. Distribute FEMA-approved, finalized Coos County MJNHMP to SC members.
Target Date: Adoption Completed; Evidence to DLCD: Feb 10, 2022
DLCD Submit Evidence to OEM: February 15, 2022
FEMA Final Approval Received: March 8, 2022
Final Distribution: March 22, 2022
SCHEDULE
Project Organization May – December 2019
Plan Update January 2020 – July 2021
Review and Approval Process August 2021 – March 2022
Planning Process Documentation October 2018 – March 2022
FEMA Final Approval March 2022
BUDGET No funds will be exchanged. DLCD will use PDM 18 grant funds and state funds to execute its tasks. JURISDICTIONS will use their own funds to execute their responsibilities and tasks.
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COST SHARE PDM grants require a 25% cost share. JURISDICTIONS commit to providing cash, in-kind, or a combination of both as their portion of the required 25% cost share. Federal funds are not allowable as cost share. JURISDICTIONS will report cost share and provide documentation as required to DLCD on at least a quarterly basis. JURISDICTIONS together will provide a minimum cost share of $10,000.
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Compliance Plan Policy
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SOUTHERN COOS HOSPITAL AND HEALTH CENTER
TITLE: Compliance Plan DEPARTMENT: Administration PAGE 1 of 10
Filename: Compliance Plan Revised Date: Approved 1030/19 Risk and Compliance Committee
Introduction
Southern Coos Hospital and Health Center (SCHHC) strive to provide quality, cost-effective healthcare while adhering to the highest ethical standards and complying with all applicable federal and state laws. To evidence this commitment, SCHHC has developed and implemented this Compliance Plan.
The SCHHC Compliance Plan:
Establishes an administrative framework for conducting an effective anddiligent compliance effort
Creates effective communication channels to deliver the company’scommitment to ethical business practices and receive feedback regardingadherence to these practices
Outlines a commitment to educate personnel regarding compliancerequirements and how to conduct their job activities in compliance with stateand federal law and according to the policies and procedures of the CompliancePlan
Implements monitoring and auditing functions to measure the effectiveness ofthe Plan and to address problems in an efficient and timely manner
Outlines enforcement and discipline components that ensure that all personneltake their compliance responsibilities seriously
Identifies the company’s significant operating and legal risks and develops aplan to minimize those risks
The SCHHC Board of Directors is responsible for the operation and oversight of the Compliance Plan; however, the day-to-day responsibility for the operation and oversight of the Compliance Plan rests with the Corporate Compliance Officer and the Quality, Patient Safety Committee (QPSC). Risk and Compliance Committee
Administrative Structure
The compliance efforts for SCHHC are managed and overseen by a Corporate Compliance Officer and the QPSC. Risk and Compliance Committee
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SOUTHERN COOS HOSPITAL AND HEALTH CENTER
TITLE: Compliance Plan DEPARTMENT: Administration PAGE 2 of 10
Filename: Compliance Plan Revised Date: Approved 1030/19 Risk and Compliance Committee; BOD: _______
A. Corporate Compliance Officer
The Corporate Compliance Officer is responsible for directing and assuring the active functioning of the company’s compliance efforts. General responsibilities include the following:
Supervise implementation of the Compliance Program andcoordinate all compliance efforts
Assure that all hospital employees, medical staff and contractors or agentsreceive a copy of the SCHHC Code of Conduct and SCHHC CompliancePlan and, depending on an individual’s particular job responsibilities, anyother written compliance policies and guidelines that may be relevant
Report compliance statistics quarterly to the QPSC, bringing matters to thecommittee for further action when necessary; Work with QPSC to identifyrisk areas warranting compliance
Develop and approve compliance education and training materials;document and implement tracking mechanisms to document attendanceat or completion of required training; oversee annual employeeattestations regarding commitment to compliance
Coordinate compliance personnel issues with the hospital’s humanresources department to ensure that compliance is an integral part ofperformance assessment
Develop communications (e-mails, newsletters, etc.) that encourageemployees to report possible improper or illegal conduct
Implement and operate retaliation-free reporting channels. Allreports will be entered into Clarity, the hospital’s incident reportingprogram
Identify and assess areas of hospital operations that present thegreatest compliance risk; prioritize resources to address those riskareas
Monitor and evaluate the Compliance Plan’s effectiveness through internaland external audits; oversee internal or external resources conductingcompliance audits; assess results and develop any necessary responses
Oversee and document any compliance investigations, working withcounsel as the situation warrants
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SOUTHERN COOS HOSPITAL AND HEALTH CENTER
TITLE: Compliance Plan DEPARTMENT: Administration PAGE 3 of 10
Filename: Compliance Plan Revised Date: Approved 1030/19 Risk and Compliance Committee; BOD: _______
Report on a regular basis to the SCHHC Board of Directors regardingday- to-day compliance efforts; promptly report the results of material orsignificant investigations
Keep current with laws, regulations and policies applicable to compliance inorder to provide the best possible advice and guidance; obtain copies ofall OIG regulations, special fraud alerts and advisory opinions to ensurethat the company’s compliance policies reflect the guidance provided bythe OIG
Ensure that the hospital appropriately disciplines employees who do notadhere to the Code of Conduct and compliance policies
Periodically (at least annually), assess the adequacy of the hospital’sCode of Conduct and Compliance Plan and revise as necessary
B. Quality, Patient Safety Committee (QPSC) Risk and Compliance Committee
The QPSC Risk and Compliance Committee is responsible for supporting the Compliance Officer in developing, monitoring and assessing the Compliance Plan. The committee meets at least quarterly, or more frequently as necessary, monthly, at least ten (10) times per year and has the following duties and responsibilities:
Continually analyze the hospital’s risk environment, the legal requirementswith which it must comply and specific risk areas
Assess and revise existing compliance policies and procedures to assurecompliance with the law, regulations and policies and procedures ofgovernment and private payer health plans
Assist the appropriate personnel in designing and coordinatinginternal and external compliance reviews and monitoring activities
Review the results of investigations and resulting corrective actionplans for hospital departments, providers, or contractors
Assess and revise policies and programs to promote compliance andencourage reporting of suspected fraud and other improprieties without fearof retaliation and to ensure proper response to reports of non-compliance
Review the hospital’s compliance training efforts
Maintain minutes of the Committee’s meetings summarizingthe items addressed and actions taken at each meeting
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SOUTHERN COOS HOSPITAL AND HEALTH CENTER
TITLE: Compliance Plan DEPARTMENT: Administration PAGE 1 of 10
Filename: Compliance Plan Revised Date: Approved 1030/19 Risk and Compliance Committee; BOD: _______
Maintain the confidentiality of any sensitive or proprietary information learned by a member through the Compliance Committee process
Communications
SCHHC’s commitment to an active compliance effort is repeatedly communicated to employees through a variety of channels to encourage communication and the reporting of incidents of potential fraud and misconduct.
A. Communications to Employees
In addition to formal compliance training, employees, medical staff and outside contractors receive frequent reminders of the company’s commitment to compliance, the various avenues for reporting concerns, and the hospital’s strict policy of non-retaliation for reporting potential compliance issues. Such communications may take the following forms:
Periodic memos from the CEO Compliance articles in hospital newsletters E-mails Inserts in paychecks
B. Communications from Employees
Processes are in place to ensure that employees, medical staff and contractors know about the various communication channels they may use to express compliance concerns. Anyone who suspects improper or illegal activity is expected to report it. In some circumstances, a failure to report such activity may be grounds for discipline.
Seeking Clarification of Policy
Hospital employees may seek clarification from a supervisor or the Compliance Officer, regarding any confusion or questions about a compliance policy or procedure.
How to Report Potential Wrongdoing
Reports of concerns may be made orally or in writing, and should initially be directed to an employee’s supervisor. If an employee is not comfortable reporting concerns to a supervisor, or if an employee is not satisfied with the response to his or her inquiries, the concerns should be directed to the hospital’s Compliance Officer. Reports may be made directly into Clarity, the hospital incident reporting program or employees may use the Compliance Hot Line and leave a message which can be anonymous.
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SOUTHERN COOS HOSPITAL AND HEALTH CENTER
TITLE: Compliance Plan DEPARTMENT: Administration PAGE 2 of 10
Filename: Compliance Plan Revised Date: Approved 1030/19 Risk and Compliance Committee; BOD: _______
Responsibilities of Managers and Supervisors
Managers and Supervisors will respond appropriately and honestly when possible wrongdoing is brought to their attention. It is their responsibility to relay reports of noncompliance to the Compliance Officer. In keeping with the policy allowing anonymous reports, a manager or supervisor may decline to identify the employee who originally made the report.
Communicating Compliance Activities to Board of Directors
The Corporate Compliance Officer maintains a tracking log of all concerns and complaints received, as well as the results of any investigations conducted and the outcome of the investigation. The Compliance Officer reports at least annually to the Board of Directors regarding compliance efforts. Such reports include a report on all allegations of wrongdoing, the results of any investigations conducted and any subsequent disciplinary or remedial action taken, recent training efforts undertaken and an overview of current auditing and monitoring efforts. It may also include statistical and trending information.
Records Retention
The hospital document retention plan includes provisions to ensure that all records related to reports of wrongdoing are preserved in accordance with law and to assure maximum protection under the attorney-client privilege and attorney work-product doctrine.
Protection of Employees
Every effort is made to maintain, within the limits of the law, the confidentiality of the identity of any individual who reports possible misconduct. There will be no retribution or discipline for anyone who reports a possible violation in good faith.
Departing Employees
Departing employees are asked to submit to an exit interview. One of the purposes of the exit interview is to determine if the employee has knowledge of wrongdoing, unethical behavior or criminal misconduct. The interview may also be used to obtain information about unsafe or unsound business practices.
Responding to Detected Offenses
The Corporate Compliance Officer will review all allegations of potential wrongdoing arising from informal communications or audits conducted by the hospital. An initial assessment is made to determine the need to involve legal counsel to advise or direct the process and to assess the need for legal privilege to protect the process.
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SOUTHERN COOS HOSPITAL AND HEALTH CENTER
TITLE: Compliance Plan DEPARTMENT: Administration PAGE 3 of 10
Filename: Compliance Plan Revised Date: Approved 1030/19 Risk and Compliance Committee; BOD: _______
At the same time, an assessment is made to determine the appropriate resources required to conduct an investigation commensurate with the gravity of the allegation. The Compliance Officer conducts or oversees the initial investigation, along with legal counsel where it is warranted. Executive management is immediately notified if a serious allegation appears valid. Additional resources may be required to fully investigate a situation and outside resources may be utilized to conduct a full investigation. Records of an investigation contain:
Documentation of the alleged violation A description of the investigative process Copies of interview notes and key documents A log of the witnesses interviewed and the documents reviewed The results of the investigation
If the investigation indicates that a violation has occurred, appropriate corrective action will be taken, including the following:
Prompt restitution of any overpayments Notification to the appropriate government agency, where appropriate Review of current policies and procedures to determine if clarification is needed System modification Staff education Referral to criminal and /or civil law enforcement authorities Possible disciplinary action of involved employees, up to and
including termination
Education and Training
Compliance training is provided on a regular basis to ensure that all employees are educated as to the purpose, contents and requirements of the Compliance Program. The training program consists of two components: general training and supplemental training. The Corporate Compliance Officer develops and continuously updates such training information.
General training covers the material contained in the Code of Conduct and the Compliance Program, as well as other applicable laws, policies and procedures. It reinforces the need for strict compliance with applicable statutes, regulations, policies and procedures and advises employees about disciplinary action that may result from failure to comply. General compliance training is provided to all new employees as a part of new employee orientation. The training is updated on an annual basis thereafter.
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SOUTHERN COOS HOSPITAL AND HEALTH CENTER
TITLE: Compliance Plan DEPARTMENT: Administration PAGE 4 of 10
Filename: Compliance Plan Revised Date: Approved 1030/19 Risk and Compliance Committee; BOD: _______
Supplemental training covers those items that may present a heightened risk of non- compliance, particularly those directly affected by the statutes, regulations, policies, procedures and program guidelines for Medicare, Medicaid and all other federal healthcare programs. Likely areas for potential supplemental training include the following:
Government and private payer reimbursement principles General prohibitions on paying or receiving remuneration to induce referrals Proper confirmation of diagnoses Submitting a claim for physician services when rendered by a non-
physician (e.g., the “incident to” rules and the physician physical presencerequirement)
Signing a form for a physician without the physician’s authorization Alterations to medical records Prescribing medications and procedures without proper authorization Proper documentation of services rendered Duty to report misconduct Patient confidentiality Other areas identified by this Plan or by the Compliance
Committee as representing high risk areas
Attendance and participation in training is a condition of continued employment. Upon completing Compliance Program training, each employee is required to sign a written acknowledgement confirming his or her pledge to adhere to the Compliance Program and that the individual understands that failure to comply with the Compliance Program will result in disciplinary action, up to and including, termination of employment.
Auditing and Monitoring Compliance Efforts
SCHHC actively uses monitoring and auditing functions to assess the effectiveness of its Compliance Program. The types of audits and areas to be audited are determined by the QPSC. Audits are conducted by using outside resources such as counsel, auditors or other healthcare experts or through internal personnel or through an internal audit function. Audits may include the review of a statistically valid random sample of cases, staff interviews, and trend analysis studies. The results of such audits are presented to the QPSC, which assesses the results and recommends any necessary corrective measures. Such corrective measures may include additional auditing, monitoring, new policies, additional training and education. Monitoring efforts are also used to ensure compliance with laws governing:
kickback arrangements the physician self-referral prohibition
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SOUTHERN COOS HOSPITAL AND HEALTH CENTER
TITLE: Compliance Plan DEPARTMENT: Administration PAGE 5 of 10
Filename: Compliance Plan Revised Date: Approved 1030/19 Risk and Compliance Committee; BOD: _______
coding claims development and submission reimbursement cost reporting marketing practices
While the Compliance Officer and QPSC periodically assess the company’s risk areas to determine which areas may warrant a compliance audit, certain areas by their nature present significant hospital risk potential. Accordingly, coding and billing audits are conducted at least annually and more frequently where warranted. Similarly, a review of the hospital’s marketing practices and payments to physicians is conducted at least annually.
At least annually, a review is performed to assess whether the Compliance Program’s elements have been satisfied, e.g., whether there has been appropriate dissemination of the program’s standards, training, ongoing education programs and disciplinary actions.
Enforcement and Discipline
Any employee who violates the Compliance Program or healthcare laws, regulations, or program requirements is subject to disciplinary measures, up to and including termination. Such measures will be consistent with SCHHC’s progressive discipline policies.
Physicians with privileges who violate the Compliance Program or healthcare laws, regulations, or program requirements are subject to discipline, up to and including the loss of privileges. Such measures will be consistent with the medical staff by-laws.
If an agent or contractor violates the Compliance Program or healthcare laws, regulations, or program requirements, the company will take appropriate measures such as terminating the contract, requiring repayment or requiring additional training and education.
SCHHC has established a process to ensure that it does not knowingly hire, employ, or contract with any individual or entity whom the company knows or should have known, after reasonable inquiry, (a) has been convicted of a criminal offense related to healthcare (unless the individual or entity has been reinstated to participation in Medicare after being excluded because of the conviction), or (b) is currently listed by a federal agency as excluded, suspended or otherwise ineligible for participation in federal or federally funded programs such as Medicare and Medicaid.
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SOUTHERN COOS HOSPITAL AND HEALTH CENTER
TITLE: Compliance Plan DEPARTMENT: Administration PAGE 6 of 10
Filename: Compliance Plan Revised Date: Approved 1030/19 Risk and Compliance Committee; BOD: _______
Identification of Risks; Standards and Policies
The Corporate Compliance Officer, Executive Team and R i sk a n d C o m p l i a n ce Co m m i t t e e assess the company’s risk priorities at least annually. The areas identified below represent a starting point for this effort. These are areas that have been identified by the OIG as high risk areas to assist hospitals in focusing their compliance efforts. It also serves as a starting point for the hospital’s educational efforts. This is not an exclusive list of the hospitals risk areas and others will be identified over time. Detailed standard and policies for complying with the healthcare laws and regulations implicated by these risk areas are contained in the hospital’s clinical policies and procedures and are periodically reviewed to ensure that they fully address the risks presented by these areas. Further, such policies are periodically assessed to ensure consistency with the policy recommendations set forth in the OIG 1998 Model Compliance Program Guidance for Hospitals and the OIG 2005 Supplemental Compliance Program Guidance for Hospitals which can be found at http://oig.hhs.gov.
A. Billing and Coding Risks
Billing for items or services not actually rendered. Submitting a claim that represents that the hospital performed a service, all or part of which was not performed.
Providing medically unnecessary services. Intentionally seeking reimbursement for a service that is not warranted by a patient’s current and documented medical condition.
Upcoding. Using a billing code that provides a higher payment rate than the billing code that actually reflects the service furnished to the patient.
Duplicate billing. Submitting more than one claim for the same service or submitting a claim to more than one primary payor at the same time.
False cost reports. Submitting unallowable costs due the failure to provide proper controls over costs included in a hospital’s Medicare cost report; shifting certain costs to areas that are below their reimbursement cap; shifting non-Medicare related costs to Medicare cost centers.
Unbundling. Submitting bills piecemeal or in fragmented fashion to maximize the reimbursement for various tests or procedures that are required to be billed together and therefore at a reduced cost.
Credit balances. Failing to refund credit balances.
Admission and Discharge Issues. Failing to follow the “same–day” rule; same-day
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SOUTHERN COOS HOSPITAL AND HEALTH CENTER
TITLE: Compliance Plan DEPARTMENT: Administration PAGE 7 of 10
Filename: Compliance Plan Revised Date: Approved 1030/19 Risk and Compliance Committee; BOD: _______
discharge and readmission issues such premature discharges, medically unnecessary readmissions or incorrect discharge coding.
Supplemental Payment Considerations. Improperly reporting the costs of “pass- through” items; abuse of DRG outlier payments.
Use of Information Technology. Failing to fully understand the impact of computer systems and software that affect coding, billing or the generation or transmission of information related to the federal healthcare programs or their beneficiaries.
B. Risks Arising from the Referral Statutes: The Physician Self-Referral Law (the “Stark” Law) and the Federal Anti-Kickback Statute.
The Stark Law. The Stark law prohibits hospitals from submitting-and Medicare from paying- any claim for a “designated health service” (DHS) if the referral of the DHS comes from a physician with whom the hospital has a prohibited financial relationship. A financial relationship can be almost any kind of direct or indirect ownership or investment relationship or direct or indirect compensation arrangement, whether in cash or in-kind, between a referring physician (or immediate family member) and a hospital.
Any financial relationship between a hospital and a physician who refers to the hospital must fit into an exception or the statute has been violated. As a rule, there are no exceptions for inadvertence or error. Accordingly, SCHHC has adopted, at a minimum, specific policies to address the following aspects of physician relationships:
frequent and thorough review of all contracts and leases with physiciansto ensure that all conditions supporting the exceptions are fullysatisfied
appropriate processes for making and documenting reasonable,consistent and objective determinations of fair market value
monitoring the total value of monetary and non-monetarycompensation provided annually to each referring physician,
tracking the provision and value of medical staff incidental benefits
Compliance with a Stark law exception does not immunize an arrangement under the anti- kickback statute. Rather the Stark law sets a minimum standard for arrangements between physicians and hospitals. Even if a hospital-physician relationship qualifies for a Stark law exception, it is still reviewed for compliance with the anti-kickback statute.
The Federal Anti-Kickback Statute. The anti-kickback statute is a criminal prohibition against payments (in any form, whether the payments are direct or indirect) made purposefully to induce or reward the referral or generation of
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SOUTHERN COOS HOSPITAL AND HEALTH CENTER
TITLE: Compliance Plan DEPARTMENT: Administration PAGE 8 of 10
Filename: Compliance Plan Revised Date: Approved 1030/19 Risk and Compliance Committee; BOD: _______
federal healthcare program business. The statute extends equally to the solicitation or acceptance of remuneration for referrals or the generation of other business payable by a federal healthcare program. Although liability under the anti-kickback statute ultimately turns on a party’s intent, neither a legitimate business purpose for the arrangement nor a fair market value payment, will legitimize a payment if there is also an illegal purpose (i.e., an intent or desire to induce federal healthcare program business.).
Relationships with physicians may represent a significant referral sources for a hospital and accordingly all relationships with physicians are carefully reviewed as described above. In addition a hospital may receive referrals from other healthcare professionals such as physician assistants and nurse practitioners, and from other providers and suppliers such as, mental health clinics, nursing facilities and other hospitals. Each of these relationships is evaluated to ensure that the anti-kickback statute is not violated.
Certain arrangements or practices that may present a significant potential for abuse are identified below and an initial framework for assessing the risk associated with those practices are described below. Further tools for analysis are available in the OIG 2005 Supplemental Compliance Program Guidance and in relevant Special Fraud Alerts available at http://oig.hhs.gov/fraud.html.
Joint Ventures. Any joint venture with an entity in a position to refer or generate federal healthcare program business presents the potential that remuneration from such a venture might be a disguised payment for past or future referrals to the venture. Accordingly, the company considers the following factors in evaluating such ventures.
How the joint venture participants are selected and retained The manner in which the joint venture is structured The manner in which the investments are financed and profits are distributed
Whenever possible, joint ventures are structured to satisfy one of the safe harbors for investments interests.
Medical Staff Credentialing. Certain medical staff credentialing practices may implicate the anti-kickback statute such as conditioning privileges on a particular number of referrals or requiring the performance of a particular number of procedures, beyond volumes necessary to ensure clinical proficiency. Credentialing practices are reviewed periodically for compliance with these concerns.
Malpractice Insurance Subsidies. Any subsidy of a physician’s malpractice insurance raises the issue of whether the payments are being used to influence referrals. All malpractice insurance subsidy arrangements are reviewed closely
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SOUTHERN COOS HOSPITAL AND HEALTH CENTER
TITLE: Compliance Plan DEPARTMENT: Administration PAGE 9 of 10
Filename: Compliance Plan Revised Date: Approved 1030/19 Risk and Compliance Committee; BOD: _______
to ensure that there is no improper inducement to referral sources.
C. Substandard Care
The OIG may exclude a hospital from participating in federal healthcare programs if the hospital provides items or services that fail to meet professionally recognized standards of healthcare. To achieve quality related goals the hospital continually measures its performance against comprehensive standards. SCHHC has developed its own quality of care protocols and has implemented mechanisms for evaluating compliance with those protocols. In addition the hospital takes an active part in monitoring the quality of medical services provided by appropriately overseeing the credentialing and peer review of the medical staff.
D. Relationships with Federal Healthcare Beneficiaries
Hospitals are prohibited from offering remuneration to a Medicare or Medicaid beneficiary that the hospital knows or should know is likely to influence the beneficiary to order or receive items or services from a particular provider. The definition of “remuneration” expressly includes the offer or transfer of terms or services for free or other than fair market value, including the waiver of all or part of a Medicare or Medicaid cost-sharing amount. Specific items of concern include the following:
Gifts. SCHHC prohibits offers of gifts or gratuities to beneficiaries if the remuneration is something that is likely to influence a beneficiary’s selection of a particular provider. The restriction does not apply to items or services valued at less than $10 per item and $50 per patient in the aggregate on an annual basis. The company has educated its employees to ensure their understanding of these restrictions.
Cost Sharing Waivers. In general, a hospital is obligated to collect cost-sharing amounts owed by federal health care program beneficiaries. Waving owed amounts may constitute prohibited remuneration to beneficiaries. Certain waivers of Part A inpatient cost-sharing amounts may be protected by structuring them to fit in the safe harbor for waivers of beneficiary inpatient coinsurance and deductible amounts, e.g., waived amounts may not be claimed as bad debt, the waivers must be offered uniformly across the board, and waivers may not be made as part of any agreement with a third part payer (other than a Medicare SELECT plan.) The rules for this safe harbor are understood by employees with billing responsibility. In addition, a hospital may waive cost-sharing amounts on the basis of a beneficiary’s financial need under certain circumstances. These circumstances are understood by billing personnel and each hospital uses a reasonable set of financial need guidelines that are based on objective criteria and appropriate for the hospital’s location.
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SOUTHERN COOS HOSPITAL AND HEALTH CENTER
TITLE: Compliance Plan DEPARTMENT: Administration PAGE 10 of 10
Filename: Compliance Plan Revised Date: Approved 1030/19 Risk and Compliance Committee; BOD: _______
Free Transportation. While a hospital is prohibited from offering free transportation to Medicare or Medicaid beneficiaries to influence their selection of a particular provider, the hospital can offer free local transportation of low value (within the gift exception above). Certain other complimentary transportation programs may be permissible under currently evolving rules. Prior to undertaking such transportation efforts, each hospital will have processes in place to ensure that all statutory and regulatory requirements relating to free transportation are met.
E. HIPAA Privacy and Security Rules
SCHHC is subject to detailed rules that govern the use and disclosure of individuals’ health information and standards for individuals’ privacy rights to understand and control how their health information is used. These rules can be found at http://www.hhs.gov/ocr/hipaa. Penalties for failing to comply with these rules are significant. The company has developed privacy procedures to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) and HITECH rule and has instituted training programs to educate all employees of their obligations with respect to these requirements.
F. Other Hospital Practices
A variety of billing issues exist with respect to making sure that a hospital is billing the government appropriately or otherwise observing the applicable guidelines for services involving the situations described below.
Discounts to uninsured patients Provision of preventive care services Professional courtesy for a range of practices involving free or discounted
services (including “insurance only” billing) furnished to physicians and their families and staff
To the extent a hospital undertakes these practices, it is done in the context of understanding fully the laws and regulations pertinent to such practices and employees are educated as to those laws and regulations.
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Trustee Code of Conduct
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Southern Coos Hospital & Health Center
Trustee Pledge - Code of Conduct
Governance excellence is the life blood of a high-quality hospital board of directors. It is vital that each board member take their responsibilities seriously and pledge their best efforts to follow this code of conduct.
In pursuit of governance excellence, I pledge to:
A. Refrain from micromanagement and focus on strategic leadership and policy, not on administrative and operational detail. I will respect distinctions between board and staff roles and will manage any overlap between the respective roles in a spirit of collegiality and partnership that supports the authority of staff and maintains the proper lines of accountability. I will not discuss significant operational concerns or issues with employees or medical staff members without the knowledge of the CEO.
B. Attend board and committee meetings regularly and come prepared to fully discuss and deliberate all matters important to the business of the board.
C. Listen carefully to my fellow board members and be willing to consider all points of view during board discussions.
D. Share my point of view, do not dominate discussions, be respectful and courteous in debate, but do not shy away from difficult or contentious issues.
E. Fully support the decisions of the majority once a decision has been reached, even if I am in the minority.
F. Be inquisitive and ask any questions important to the discussions at hand. Strive to push the organization to continuous growth and excellence. Challenge the status quo.
G. Keep board discussions and decisions confidential, unless directed to solicit community feedback on specific topics of interest to the board and/or are a matter of public record.
H. Take all opportunities to be a good ambassador for the hospital and advocate on behalf of the hospital in matters of important public policy issues and encourage philanthropic support that would advance the mission of the hospital.
I. Be a continuous learner and look for opportunities to stay abreast of current topics and trends in healthcare delivery and policy.
J. Follow the conflict of interest policies and practices of the hospital.
K. Conduct myself in an ethical, moral and legal manner at all times.
L. Celebrate the joy of caring and the role I play in the mission of the hospital!
SIGNED DATE
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