2024-09-25_skoyanagi_St.John's Outside Provider agreement.docx

OUTSIDE PROVIDER AGREEMENT

THIS OUTSIDE PROVIDER AGREEMENT dated 	, 20	is made and entered into by and between SAINT JOHN'S COMMUNITIES, INC. ("Saint John’s"),

(“Resident") and 	("Outside Provider").

PURPOSE

Resident desires to employ Outside Provider to perform certain personal, supportive and/or nursing services for Resident on the premises of Saint John’s. The purpose of this Agreement is to establish the obligations of Resident, Outside Provider and Saint John’s regarding services provided by Outside Provider. This agreement, and its associated attachments, must be in place prior to Outside Provider starting services to Resident on Saint John’s campus.

AGREEMENTS

Resident's Responsibilities

Payment of Wages and Benefits. As the employer or contractor of Outside Provider, Resident shall pay and/or arrange for payment of all wages, benefits or other remuneration owed to Outside Provider, provide unemployment compensation and worker's compensation benefits to the extent required by law, and comply with any federal or state tax filing obligations.

Payment of Criminal Background Check. Resident shall pay Saint John’s for the cost of conducting a background check on Outside Provider if Outside Provider does not have evidence of a criminal background check completed within one year prior to the date of this agreement. The background check must be repeated every four (4) years for as long as Outside Provider is employed by Resident. Resident shall immediately inform Saint John’s of any events that may change the information provided in the criminal background check form.

Saint John’s Not Responsible for Outside Provider's Services. Resident acknowledges and understands that the services provided under this Agreement are supplemental to the

services Saint John’s provides to Resident. Saint John’s is in no way responsible for the services provided by Outside Provider and will not supervise the performance of these services.

Indemnification. Resident shall indemnify and hold Saint John’s harmless from any and all claims, acts and omissions related to Outside Provider's performance of services under this Agreement.

Outside Provider Agreement Updated November 2021	Page 1

Notification of Changes. Resident shall immediately notify Saint John’s of any changes to this Agreement.

Saint John’s Right to Withdraw Access to Outside Provider. Resident acknowledges that Saint John’s has the right to withdraw Outside Provider's access to Saint John’s, without advance notice, in accordance with the attached Outside Provider Policy, as it may be revised from time to time.

Outside Provider's Responsibilities.

No Employment Status with Saint John’s. Outside Provider acknowledges that his or her presence on Saint John’s premises is in the status of a guest, and that there exists no employer-employee relationship between Saint John’s and Outside Provider.

Identification. Outside Provider must wear a visitor badge when he or she is on the premises of Saint John’s or wear a clearly visible name badge identifying Outside

Provider’s organization.

Professional Standards; Compliance with the Law. Outside Provider warrants and represents that all services shall be provided competently and in compliance with all applicable laws, rules, and regulations. Outside Provider warrants that the individuals providing services:

Are duly licensed, credentialed, certified, and/or registered as required under applicable state laws; and

Possess the education, skills, training, and other qualifications necessary to provide services. Services shall meet or exceed the standard of care for providers of such services. If requested, Outside Provider shall provide Saint John’s with proof of an individual's qualifications.

Services provided by Outside Provider in Saint John’s CBRF or SNF Care Neighborhoods exclude nursing services. Only certain personal or supportive services may be provided.

Compliance with Applicable Saint John’s Policies and Procedures. Outside Provider shall comply with the attached Outside Provider Policy, as it may be revised from time to time, and all other applicable Saint John’s policies and procedures.

Maintain Confidentiality of Resident Information. Outside Provider shall respect the dignity and independence of Resident and maintain the confidentiality of information regarding Resident, unless otherwise directed by Resident.

Provide Criminal Background Check Information. Outside Provider shall promptly complete documentation necessary for Saint John’s to conduct a criminal background check on Outside Provider and permit Saint John’s to disclose the results of the background check to Resident.

Free from Communicable Diseases. Outside Provider shall promptly provide Saint John’s evidence that he or she is currently free from communicable diseases, including, without limitation, tuberculosis. Further, Outside Provider shall promptly inform Saint John’s upon obtaining knowledge that he or she contracted a communicable disease, including, without limitation, tuberculosis. Additionally, Outside Provider shall promptly provide Saint John’s proof of COVID, seasonal flu, or other required and relevant vaccinations.

Indemnification. Outside Provider shall be responsible for the acts and omissions of itself and its employees and subcontractors. Outside Provider shall indemnify and hold Saint John’s harmless from any claims related to Outside Provider's performance of services under this Agreement .

Complete Outside Provider Registration Form. Outside Provider shall complete and amend, as necessary, the Outside Provider Registration and Information Form.

Billing and Payment. Outside Provider is solely responsible for billing Resident and/or other applicable payors for all services. Outside Provider acknowledges that Saint John’s shall bear no responsibility, obligation or other liability for any charges, costs, or other fees for services.

Coordination with Saint John’s. Outside Provider shall coordinate the provision of services to Resident with Saint John’s personnel and promptly notify Saint John’s of any changes regarding Resident's condition or status, as appropriate.

Supplies and Equipment. Outside Provider shall provide, maintain, and service all supplies, and equipment required for the provision of Outside Provider’s services.

Insurance. Outside Provider shall obtain and maintain appropriate comprehensive general liability and worker's compensation insurance in no less than the minimum amounts required from by applicable federal and state laws and regulations. If Outside Provider will be providing nursing services, Outside Provider shall also obtain and maintain appropriate professional malpractice insurance coverage of at least 1,000,000/occurrence and

$3,000,000/aggregate.

No Solicitation or Loitering. Saint John’s prohibits solicitation of business and loitering on

its premises.

Services Personal to Resident. Outside Provider shall only perform services for the Resident who hired him or her and only provide those services that Outside Provider designates on the Outside Provider Registration and Information Form.

Saint John’s Responsibilities.

Records. As permitted by law, Saint John’s shall make available to Outside Provider for review and inspection, upon reasonable request, any Resident records that are necessary for Outside Provider to render services to Resident. Outside Provider shall maintain the confidentiality of such records in accordance with applicable laws and this Agreement.

Access to Premises. Saint John’s will allow Outside Provider access to Saint John’s premises. Saint John’s has the right to withdraw Outside Provider's access to Saint John’s, without advance notice, in accordance with the attached Outside Provider Policy, as it may be revised from time to time.

By signing this Agreement, the parties acknowledge receipt of the Outside Provider Policy and the Outside Provider Registration and Information Form.

SAINT JOHN'S COMMUNITIES, INC.

By:

RESIDENT

By:

Name: 		Name:

Title: 		Date:

Date:

OUTSIDE PROVIDER

By: 	 Name: 	 Agency: 	 Date:

RESIDENT REPRESENTATIVE

Name:

Authority: 	 (e.g., POA or guardian of the person):

Date:

OUTSIDE PROVIDER REGISTRATION AND INFORMATION FORM

RESIDENT INFORMATION

SERVICES PERFORMED BY OUTSIDE PROVIDER

SCHEDULE

OUTSIDE PROVIDER INFORMATION

EMPLOYER (other than Resident)/AGENCY:

WHO SHOULD BE CONTACTED IN CASE PROVIDER HAS A MEDICAL EMERGENCY?

Please complete this form prior to initiation of any services provided to a Resident by an Outside Provider and return it to the Director of Nursing Services. If the caregiver works for a licensed agency, the agency maintains the criminal background check, TB skin test results and evidence of

receipt of the COVID and seasonal flu vaccine and must provide those to Saint John’s upon request. If the caregiver is self-employed, Saint John’s will maintain these records.

Resident/family Signature 	Date

OUTSIDE PROVIDER CHECKLIST

These documents need to be completed and on record prior to Outside Provider starting services to Resident:

Outside Provider Agreement.

Outside Provider Registration and Information Form.

Criminal Background Check.

Evidence of negative Tuberculosis test.

Evidence of COVID-19 and Seasonal Flu Vaccination.

If applicable and requested, Professional Qualifications.

Companionship | Transportation | Grocery shopping | Meal prep

Asst w/ bathing | Asst w/ dressing | Asst w/ personal grooming | Asst w/ personal grooming

Other: | Other: | Other: | Other:

Sunday | Monday | Tuesday | Wednesday | Thursday | Friday | Saturday

Start time

Stop time

Name: | Name: | Name:

Address: | Address: | Address:

City: | State: | Zip code:

Phone: | Phone: | Phone:

Make/Model of Car: | Make/Model of Car: | License Plate #

Agency Name: | Agency Name: | Self Employed

Address: | Address: | Address:

City: | State: | Zip code:

Phone: | Contact person: | Contact person:

Name: | Name:

Phone: | Phone: