HomeMy WebLinkAboutContract 49474 3456
CITY SECRETARY
a RECEIVED o CONTRACT NO.
r
0 -92017 HIPAA REQUIREMENT AGREEMENT
CQYOFFORT WORTH D NORTH TEXAS AREA COMMUNITY HEALTH CENTERS, INC.
CUY SECRETARY Ss
BUSINESS ASSOCIATE
PROTECTED HEALTH INFORMATION DISCLOSURE AGREEMENT
This Business Associate Protected Health Information Disclosure Agreement
("Agreement") is entered into effective as of May 31, 2016 ("Effective Date"), by and between
North Texas Area Community Health Centers,Inc. a Texas non-profit corporation("Covered
Entity"), and the City of Fort Worth, a Texas municipal corporation("Business Associate").
RECITALS
WHEREAS, Business Associate and Covered Entity have entered into City Secretary
Contract No. 47757 dated May 31, 2016 (the "CDBG Contract") under which Covered Entity
was provided by Business Associate with CDBG funds for a portion of the acquisition and soft
costs of the development of its Northside Community Health Center, and as part of its federally
required monitoring responsibilities under the CDBG regulations, Business Associate receives or
has access to Protected Health Information for clinic patients;
WHEREAS, Covered Entity is subject to the Administrative Simplification requirements
of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), and regulations
promulgated there under, including the Standards for Privacy of Individually Identifiable Health
Information ("Privacy Regulations") and the Security Standards for Electronic Protected Health
Information("Security Regulations") at 45 Code of Federal Regulations Parts 160, 162 and 164
(together, the "Privacy and Security Regulations"), and by provision of Title XIII of the
American Recovery and Reinvestment Act of 2009 (the"HITECH Act").
WHEREAS, the Privacy and Security Regulations require Covered Entity to enter into a
contract with Business Associate in order to mandate certain protections for the privacy and
security of Protected Health Information, and those Regulations prohibit the disclosure to or use
of Protected Health Information by Business Associate if such a contract is not in place;
NOW, THEREFORE, in consideration of the foregoing, and for other good and valuable
consideration, the receipt and adequacy of which is hereby acknowledged, the parties agree as
follows:
ARTICLE I
DEFINITIONS
1.1 "Disclose" and "Disclosure" mean, with respect to Protected Health Information, the
release, transfer, provision of access to, or divulging in any other manner of Protected Health
Information outside Business Associate's internal operations or to other than its employees.
OFFICIAL.RRCORD
HIPAA REQUIREMENT AGREEMENT CITY SICRLM" Page 1
North Texas Area Community Health Centers,Inc.
Northside Community Health Center FT'dIIORT'FI� TX Rev. 8.7.17
1.2 "Electronic Media"means:
(1) Electronic storage media including memory devices in computers (hard
drives) and any removable/transportable digital memory medium, such as magnetic tape or disk,
optical disk, or digital memory card; or
(2) Transmission media used to exchange information already in electronic
storage media. Transmission media include;for example,the internet(wide-open),extranet(using
internet technology to link a business with information accessible only to collaborating parties),
leased lines, dial-up lines, private networks, and the physical movement of removable
/transportable electronic storage media. Certain transmissions, including of paper, via facsimile,
and of voice, via telephone, are not considered to be transmissions via electronic media, because
the information being exchanged did not exist in electronic form before the transmission.
1.3 "Electronic Protected Health Information" means Protected Health Information that is
transmitted or maintained in Electronic Media.
1.4 "Information System" means an interconnected set of information resources under the
same direct management control that shares common functionality. A system normally includes
hardware, software, information, data, applications, communications, and people.
1.5 "Protected Health Information" means information that (i) relates to the past, present or
future physical or mental health or condition of an individual; the provision of health care to an
individual, or the past, present or future payment for the provision of health care to an individual;
(ii) identifies the individual (or for which there is a reasonable basis for believing that the
information can be used to identify the individual); and (iii) is received by Business Associate
fiom or on behalf of Covered Entity, or is created by Business Associate, or is made accessible to
Business Associate by Covered Entity. Protected Health Information includes Electronic
Protected Health Information.
1.6. "Review" means the quarterly submittal required by the Covered Entity to the Business
Associate by the CDBG Contract of the Unduplicated Client Data Report—Attachment III,
a part of Exhibit "G" - Documentation of CDBG Requirements regarding the household
income, size, race, ethnicity, gender of head of household, disability status, and income for all
patients served by the Northside Community Health Center operated by the Covered Entity, as
well as any in-house audit, performed from time to time by the staff of the Business Associate of
the patients' records.
1.6 "Security Incident"means the attempted or successful unauthorized access,use,disclosure,
modification, or destruction of information in, or interference with system operations of, an
Information System which contains Electronic Protected Health Information. However, Security
Incident does not include attempts to access an Information System when those attempts are not
reasonably considered by Business Associate to constitute an actual threat to the Information
System.
HIPAA REQUIREMENT AGREEMENT Page 2
North Texas Area Community Health Centers,Inc.
Northside Community Health Center Rev. 8.7.17
1.7 "Use" or "Uses" mean, with respect to Protected Health Information, the sharing,
employment, application,utilization,examination or analysis of such Information within Business
Associate's internal operations.
ARTICLE II
OBLIGATIONS OF BUSINESS ASSOCIATE
2.1 Permitted Uses and Disclosures of Protected Health Information. Business Associate:
(a) shall use Protected Health Information as necessary or appropriate to perform a
Review, and as provided in this Article II of this Agreement;
(c) may, as necessary for the proper management and administration of its business or
to carry out its legal responsibilities:
(i) Use Protected Health Information; and
(ii) Disclose Protected Health Information if(A) the Disclosure is required by
law, or (B) Business Associate obtains reasonable assurance from the person to
whom the information is Disclosed that the Protected Health Information will be
held confidentially and Used or further Disclosed only as required by law or for the
purpose for which it was Disclosed to the person, and the person agrees to notify
Business Associate of any instances of which the person is aware in which the
confidentiality of the Protected Health Information has been breached.
Business Associate shall not Use or Disclose Protected Health Information for any other purpose.
2.2 Adequate Safeguards for Protected Health Information. Business Associate warrants that
it shall implement and maintain appropriate safeguards to prevent the Use or Disclosure of
Protected Health Information in any manner other than as permitted by this Agreement.
Effective as April 20, 2005, specifically as to Electronic Protected Health Information,
Business Associate warrants that it shall implement administrative, physical and technical
safeguards that reasonably and appropriately protect the confidentiality, integrity and availability
of Electronic Protected Health Information.
2.3 Reporting Non-Permitted Use or Disclosure and Security Incidents. Business Associate
shall report to Covered Entity each Use or Disclosure that is made by Business Associate, its
employees, representatives, agents or subcontractors which is not specifically permitted by this
Agreement, as well as, effective as of July 30, 2013, each Security Incident of which Business
Associate becomes aware. The initial report shall be made by telephone call to the Covered
Entity's Compliance Officer Prashant Shinde,MHA at(817) 546-6483 within 48 hours from the
time the Business Associate becomes aware of the non-permitted Use or Disclosure or Security
Incident, followed by a written report to the Privacy Officer no later than 10 business days from
the date the Business Associate becomes aware of the non-permitted Use or Disclosure or Security
Incident.
HIPAA REQUIREMENT AGREEMENT Page 3
North Texas Area Community Health Centers,Inc.
Northside Community Health Center Rev. 8.7.17
2.4. Mitigation of Harmful Effect. Business Associate agrees to mitigate, to the extent
practicable, any harmful effect that is known to Business Associate of a Use or Disclosure of
Protected Health Information by Business Associate in violation of the requirements of this
Agreement.
2.5. Availability of Internal Practices, Books and Records to Government Agencies. Business
Associate agrees to make its internal practices, books and records relating to the Use and
Disclosure of Protected Health Information available to the Secretary of the Federal Department
of Health and Human Services for purposes of determining Covered Entity's compliance with the
Privacy and Security Regulations. Business Associate shall immediately notify Covered Entity of
any requests made by the Secretary and provide Covered Entity with copies of any documents
produced in response to such request.
2.6. Access to and Amendment of Protected Health Information. Business Associate shall, to
the extent Covered Entity determines that any Protected Health Information that may be retained
by Business Associate constitutes a "designated record set" under the Privacy Regulations, (a)
make the Protected Health Information specified by Covered Entity available to the individual(s)
identified by Covered Entity as being entitled to access and copy that Protected Health
Information, and (b)make any amendments to Protected Health Information that are requested by
Covered Entity. Business Associate shall provide such access and make such amendments within
the time and in the manner specified by Covered Entity.
2.7 Accounting of Disclosures. Upon Covered Entity's request, Business Associate shall
provide to Covered Entity an accounting of each Disclosure of Protected Health Information made
by Business Associate or its employees, agents, representatives or subcontractors.
Any accounting provided by Business Associate under this Section 2.7 shall include: (a)the date
of the Disclosure; (b) the name, and address if known, of the entity or person who received the
Protected Health Information; (c)a brief description of the Protected Health Information disclosed;
and (d) a brief statement of the purpose of the Disclosure. For each Disclosure that could require
an accounting under this Section 2.7,Business Associate shall document the information specified
in(a)through(d), above, and shall securely maintain that documentation for 6 years from the date
of the Disclosure.
2.8 Obligation of Covered Entity. Covered Entity shall notify Business Associate in writing
of any current or future restrictions or limitations on the use of Protected Health Information that
would affect Business Associate's performance of the Services, and Business Associate shall
thereafter restrict or limit its own uses and disclosures accordingly.
2.9. Term and Termination. The term of this Agreement shall continue until terminated by
Covered Entity. Business Associate's obligations under this Article II shall survive the termination
or expiration of this Agreement.
2.10. Disposition of Protected Health Information Upon Termination or Expiration. Upon
termination or expiration of this Agreement, Business Associate shall either return or destroy, in
HIPAA REQUIREMENT AGREEMENT Page 4
North Texas Area Community Health Centers,Inc.
Northside Community Health Center Rev. 8.7.17
Covered Entity's sole discretion and in accordance with any instructions by Covered Entity, all
Protected Health Information in the possession or control of Business Associate or its agents and
subcontractors. However, if Business Associate determines that neither return nor destruction of
Protected Health Information is feasible and notifies Covered Entity in writing of that
determination,Business Associate may retain Protected Health Information provided that Business
Associate (a) continues to comply with the provisions of this Agreement for as long as it retains
Protected Health Information, and (b) further limits Uses and Disclosures of Protected Health
Information to those purposes that make its return or destruction infeasible.
2.11. No Third Party Beneficiaries. There are no third party beneficiaries to this Agreement.
2.12. Use of Subcontractors and Ate. Business Associate shall require each of its agents and
subcontractors that receive Protected Health Information from Business Associate to execute a
written agreement obligating the agent or subcontractor to comply with all the terms of this
Agreement.
2.13. Relationship to Services Agreement Provisions. In the event that a provision of this
Agreement is contrary to a provision of the CDBG Contract,the provision of this Agreement shall
control. Otherwise,this Agreement shall be construed under, and in accordance with,the terms of
the CDBG Contract.
2.14 Interpretation. Any ambiguity in this Agreement shall be resolved in favor of a meaning
that permits Covered Entity to comply with the Privacy and Security Regulations.
2.15 Amendment. The parties agree to take such action as is necessary to amend this Agreement
from time to time as is necessary for Covered Entity to comply with the requirements of the Privacy
and Security Regulations.
IN WITNESS WHEREOF, Covered Entity and Business Associate have caused this
Addendum to be executed as of the Effective Date.
[SIGNATURES APPEAR ON NEXT PAGE]
HIPAA REQUIREMENT AGREEMENT Page 5
North Texas Area Community Health Centers,Inc.
Northside Community Health Center Rev. 8.7.17
"COVERED ENTITY" "BUSINESS ASSOCIATE"
North Texas Area Community Health Centers,Inc. City of Fort Worth
a Texas non-profit corporation a Texas municipal corporation
By: By:�
Name: Jerry yro Name: Fernando Costa
Title: Authori Representative Title: Assistant City Manager
Atta tPd 6,
APPROVED S T FORM AND LEGALITY:
M J. y r, ity Secretary
Jessica Sangsvan r
st t ty A rney
Contract Compliance Manager:
By signing I acknowledge that I am the person responsible ®-� ®
for the monitoring and administration of this contract, including
ensurin 11 perfo e and,reporting requirements _
Avis Chaisso , ousmg Development and Grants Manager �XAS
Date
M&C: C-27585 Date 1/12/16
M&C: C-27731 Date 5/24/16
Form 1295 Certification: 2016-1159
OFFICIAL RECOR®
CITY SECRE'T'ARY
FT.WORTH,TX
HIPAA REQUIREMENT AGREEMENT Page 6
North Texas Area Community Health Centers,Inc.
Northside Community Health Center Rev. 8.7.17
M&C Review Page 1 of 3
Official site of the City of Fort Worth,Texas
CITY COUNCIL AGENDA FoRTWORT11
COUNCIL ACTION: Approved on 1/12/2016
*
DATE: 1/12/2016
NO.:REFERENCE * 19NS
C-27585 LOG NAME: CDBG_NORTHSIDECLINIC
CODE: C TYPE: CONSENT PUBLIC NO
HEARING:
SUBJECT: Authorize Change in Use and Expenditure in the Amount of$300,000.00 in Community
Development Block Grant Funds to North Texas Area Community Health Centers, Inc., in
the Form of a Subordinate Forgivable Loan for the Northside Community Health Center to
be Located at 4900 and 4920 Jacksboro Highway, Authorize Execution of Contract and a
Substantial Amendment to the City's 2011-2012 Action Plan (COUNCIL DISTRICT 2)
RECOMMENDATION:
It is recommended that the City Council:
1. Authorize a Substantial Amendment to the City's 2011-12 Action Plan;
2. Authorize a change in use and expenditure in the amount of$300,000.00 in Community
Development Block Grant funds to North Texas Area Community Health Centers, Inc., in the form of
a subordinate forgivable loan for the new Northside Community Health Center to be located at 4900
and 4920 Jacksboro Highway;
3. Authorize the City Manager or his designee to execute a contract and any related documents with
North Texas Area Community Health Centers, Inc., for a two-year term beginning on the date of
execution;
4. Authorize the City Manager or his designee to extend the contract term for an additional one-year
term if North Texas Area Community Health Centers, Inc., requests an extension and such extension
is necessary for completion of the project; and
5. Authorize the City Manager or his designee to amend the contract, if necessary, to achieve project
goals provided that the amendment is within the scope of the project and in compliance with City
policies and applicable laws and regulations governing the use of federal grant funds.
DISCUSSION:
North Texas Area Community Health Centers, Inc. (NTACHC), proposes building a new Northside
Community Health Center to meet increased community need because its current location on North
Main Street in the Vinnedge Building is at capacity. The first phase of the project consists of land
acquisition and the new construction of an approximately 30,650 square-foot health center, including
office space for NTACHC office staff as well as 155 parking spaces. The new health center will offer
a wide range of services, such as primary health care, pediatric care, integrated mental health,
comprehensive dental, pharmacy, medication management, vision, patient education and health
promotion. At full operational capacity, the proposed health center will house 15 full time providers
who will serve an estimated 24,000 unduplicated patients resulting in an estimated 60,000 patient
visits per year. NTACHC plans to construct a wellness facility adjacent to the new health care center
for the second phase that will contain a health education room, community kitchen and exercise
areas.
The budget for both phases of the project is approximately $17,000,000.00. NTACHC has received
an allocation of approximately $5,000,000.00 in New Market Tax Credits and will apply for a
commercial loan of$5,000,000.00 for the first phase of the project. It has also started a capital
http://apps.cfwnet.org/council_packet/mc_review.asp?ID=21756&councildate=1/12/2016 8/11/2017
M&C Review Page 2 of 3
campaign to raise $4,500,000.00 for the first phase and expects to raise approximately
$7,000,000.00 in total for the project. Both the tax credits and the commercial loan are contingent
upon NTACHC having a successful capital campaign for the first phase of the project in cash and
pledges.
CDBG Contract and Loan
The City will enter into a contract with NTACHC for $300,000.00 of City CDBG grant funds in the form
of a subordinate forgivable loan.
Staff recommends the following contract and loan terms:
1. Contract term of two years commencing on the date of execution with one one-year
extension;
2. CDBG funds will be used for a portion of the predevelopment soft costs and acquisition costs
for
the land for the health center;
3. The health center must be operational by spring of 2018 and operate for five years;
4. The health center must serve at least 8,000 unduplicated patients annually;
5. Fifty-one percent of the patients served must have incomes at or below 80 percent of Area
Median Income as set by the United States Department of Housing and Urban Development
(HUD);
6. NTACHC will use its best efforts to create at least 15 jobs by year five of operation of the
health
center;
7. Loan term will be five years commencing on the date the health center gets its final
Certificate of
Occupancy;
8. Performance of the loan, the CDBG requirements and contract terms will be secured by a
deed
of trust; and
9. Loan will be deferred and forgiven at the end of the five-year term provided all CDBG
requirements and contract terms are met.
Expenditure of CDBG funds is conditioned upon the following:
1. Receipt of grant funds from HUD;
2. Satisfactory completion of an environmental review pursuant to 24 CFR Part 58;
3. Authorization to use grant funds from HUD;
4. Tax credit and commercial financing for the health center acceptable to City;
5. Successful capital campaign and award of New Market Tax Credits; and
6. Closing of tax credit and all other financing and contributions sufficient for completion of the
health center.
Staff recommends the change in use and expenditure of$300,000.00 of CDBG funds to NTACFC for
the project which will benefit moderate, low and very low-income citizens. The Action Plan funding
years selected may vary and be substituted in order to expend the oldest grant funds first. A public
comment period on the change in use of these CDBG funds was held from November 12, 2015 to
December 14, 2015. Any comments are maintained by the Neighborhood Services Department, in
accordance with federal regulations.
The project is located in COUNCIL DISTRICT 2, Mapsco 61 F.
FISCAL INFORMATION/CERTIFICATION:
The Financial Management Services Director certifies that funds are available in the current operating
budget, as appropriated, of the Grants Fund.
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M&C Review Page 3 of 3
TO
Fund Department Account Project Program Activity Budget Reference# Amount
ID ID Year (Chartfield 2)
21001 1 0190463 1 5330201 1 G00051 1 1 991918 1 $300,000.00
FROM
Fund Department Account Project Program Activity Budget Reference# Amount
ID ID Year (Chartfield 2)
210011 0190463 1 5330201 1 G00051 I 1 991999 1 $300,000.00
Submitted for City Manager's Office by: Fernando Costa (6122)
Originating Department Head: Aubrey Thagard (8187)
Additional Information Contact: Avis Chaisson (6342)
Bette Chapman (6125)
ATTACHMENTS
Form 1295 (19NSCDBG NORTHSIDE).pdf
Northside Comm Health Ctr Map.pdf
http://apps.cfwnet.org/council_packet/mc_review.asp?ID=21756&councildate=1/12/2016 8/11/2017
M&C Review Page 1 of 2
Official site of the City of Fort Worth,Texas
CITY COUNCIL AGENDA FoRTWORT11
COUNCIL ACTION: Approved on 5/24/2016
DATE: 5/24/2016 REFERENCE**C-27731 LOG NAME: 19NORTHSIDECLINICCONTRACTAMEND
CODE: C TYPE: CONSENT PUBLIC NO
HEARING:
SUBJECT: Amend Mayor and Council Communication C-27585 to Change the Terms of the
Community Development Block Grant Loan to North Texas Area Community Health
Centers, Inc., for the Northside Community Health Center to be Located at 4900 and
4920 Jacksboro Highway to Allow the City to Close on the CDBG Loan Prior to the
Closing of the Tax Credits (COUNCIL DISTRICT 2)
RECOMMENDATION:
It is recommended that the City Council amend Mayor and Council Communication C-27585 to
change the terms of the Community Development Block Grant loan to North Texas Area Community
Health Centers, Inc., for the Northside Community Health Center to be located at 4900 and 4920
Jacksboro Highway to allow the City to close on the CDBG loan prior to the closing of the tax credits.
DISCUSSION:
On January 12, 2016, the City Council approved a change in use and expenditure of$300,000.00 in
Community Development Block Grant (CDBG) funds to North Texas Area Community Health
Centers, Inc., in the form of a subordinate, forgivable loan for the Northside Community Health Center
(Health Center) to be located at 4900 and 4920 Jacksboro Highway (M&C C-27585).
The original conditions for expenditure of the CDBG funds approved by City Council required a
successful capital campaign and award of New Market Tax Credits. Among other things, it also
required the closing on the tax credits and all other financing and contributions sufficient for
completion of the Health Center. The Health Center was awarded tax credits; however, the closing of
the tax credits will not happen until later this year. This Mayor and Council Communication seeks to
modify the loan terms to allow the City to close on the CDBG loan prior to the closing of the tax
credits.
Staff has reviewed the current financing for the Health Center and recommends City Council approve
amending the loan terms to allow the CDBG funds to be used prior to closing on the tax credits. The
CDBG funds will be used for a portion of the land acquisition costs for the Health Center. Closing on
the land is expected to happen in the near future, several months before the closing on the tax
credits. Additionally, using the CDBG for acquisition costs allows the City to meet the federal CDBG
expenditure deadlines.
The project is located in COUNCIL DISTRICT 2, Mapsco 061 F.
FISCAL INFORMATION/CERTIFICATION:
The Director of Finance certifies that funds are available in the current operating budget, as
appropriated, of the Grants Fund. This is a reimbursement grant.
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TO
Fund Department Account Project Program Activity Budget Reference# Amount
ID ID Year (Chartfield 2)
FROM
Fund Department Account Project Program Activity Budget Reference# Amount
ID ID Year Chartfield 2
210011 0190463 1 5330201 1 G00005 1 991999 1 $300,000.00
Submitted for City Manager's Office by: Fernando Costa (6122)
Originating Department Head: Aubrey Thagard (8187)
Additional Information Contact: Bette Chapman (6125)
Avis Chaisson (6342)
ATTACHMENTS
FORM 1295 (Northside Clinic).pdf
Northside Comm Health Ctr Map.pdf
http://apps.cfwnet.org/council_packet/mc_review.asp?ID=22325&councildate=5/24/2016 8/11/2017
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
1 of 1
Complete Nos.1-4 and 6 if there are interested parties, OFFICE USE ONLY
Complete Nos.1,2,3,5,and 6 if there are no interested parties, CERTIFICATION OF FILING
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 2016-1159
North Texas Area Community Health Centers Inc.
Fort Worth,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 01/05/2016
being filed.
City of Fort Worth Date Acknowledged:
3 Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a
description of the goods or services to be provided under the contract.
Northside Clinic
City will contract with North Texas Area Community Health Centers, Inc.for$300,000.00 of Community Development Block Grant
4 Nature of interest(check applicable)
Name of Interested Party City,State,Country(place of business)
Controlling Intermediary
Northside Community Health Centers Inc. Fort Worth,TX United States X
5 Check only if there is NO Interested Party.
6 AFFIDAVIT I swear,or affirm,under penalty of perjury,that the above disclosure is true and correct.
MICHELLE J HILBERT
My Commission Expires
June 5,2016
Signature of au orized agent of contracting business entity
AFFIX NOTARY STAMP/SEAL ABOVE
Sworn to and subscribed before me,by the said � �, this the day of ahs
201 to certify which,witness my hand and seal of office.
I VA
Signature of officer a 's ering oath Printed name of officer administering oath Title of officer administering oath
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.33598