HomeMy WebLinkAboutPR 16082: CONTRACT APPROVAL FOR PRIMARY HEALTH CARE GRANT FUNDS Memorandum
City of Port Arthur, Texas
Health Department
TO: Stephen Fitzgibbons, City Manager
FROM: Yoshi D. Alexander, MBA -HCM, Health Director
DATE: August 31, 2010
SUBJECT: Proposed Resolution No. 16082
Contract Approval for Primary Health Care Grant Funds
RECOMMENDATION
It is recommended that the City Council approve P.R. No. 16082, approving a contract between
the City of Port Arthur and the Texas Department of State Health Services Family and
Community Health Services Preventive and Primary Care Unit to provide primary and
preventive health care services to eligible participants.
BACKGROUND
The Texas Department of State Health Services has awarded the City of Port Arthur funding to
provide preventive health services including immunizations, diagnosis and treatment of acute
illnesses, family planning, health education, and diagnostic tests including lab and x -ray for
eligible participants at or below 150% of the current federal poverty guidelines.
BUDGETARY AND FISCAL EFFECT
The total budget is $114,377 to cover the cost of salaries, supplies, contractual and travel.
STAFFING EFFECT
This grant will allow us to hire an eligibility /billing clerk.
SUMMARY
It is recommended that the City Council approve P.R. No. 16082, approving a contract between
the City of Port Arthur and the Texas Department of State Health Services Family and
Community Health Services Preventive and Primary Care Unit to provide primary and
preventive health care services to eligible participants.
P. R. NO. 16082
8 /31 / /2010 -yda
RESOLUTION NO.
A RESOLUTION TO APPROVE A CONTRACT BETWEEN THE CITY
OF PORT ARTHUR AND THE TEXAS DEPARTMENT OF STATE
HEALTH SERVICES FOR PRIMARY HEALTH CARE GRANT FUNDS
IN THE AMOUNT OF $114,377
WHEREAS, the Texas Department of State Health Services Family and
Community Health Services Preventive and Primary Care Unit has awarded the City of
Port Arthur with grant funds to provide primary and preventive health care services to
eligible participants at or below 150% of the current federal poverty guidelines; and,
WHEREAS, the total grant award is for $114,377 for the period September 1,
2010 through August 31, 2011.
NOW THEREFORE BE IT RESOLVED BY THE CITY COUNCIL OF
THE CITY OF PORT ARTHUR:
Section 1. That, the facts and opinions in the preamble are true and correct.
Section 2. That, the City Manager and Director of Health Services are hereby
authorized to execute the contract with the Texas Department of State Health Services
Family and Community Health Services Preventive and Primary Care Unit attached
hereto as Exhibit "A ".
Section 3. That, a copy of the caption of this Resolution be spread upon the
Minutes of the City Council.
P. R. NO. 16082
Page 2
READ, ADOPTED, AND APPROVED, this day of September
2010 A.D., at a Regular Meeting of the City Council of the City of Port Arthur, Texas by
the following Vote:
AYES: Mayor:
Council members:
NOES:
Mayor
ATTEST:
Terri Hanks, City Secretary
APPROVED FOR ADMINISTRATION:
f � (C)-
Stephen Fitzgibbons, City Manager ( oshi D. Alexander, MBA -HCM
"d irector of Health Services
APPROVED AS TO FORM:
i ■.(e.de
CITY ATTORNEY,
ODEPARTMENT OF STATE HEALTH SERVICES
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This contract, number 2011- 036967 (Contract), is entered into by and between the Department
of State Health Services (DSHS or the Department), an agency of the State of Texas, and CITY
OF PORT ARTHUR (Contractor), a Government Entity, (collectively, the Parties).
1. Purpose of the Contract. DSHS agrees to purchase, and Contractor agrees to provide,
services or goods to the eligible populations as described in the Program Attachments.
2. Total Amount of the Contract and Payment Method(s). The total amount of this Contract
is $114,377.00, and the payment method(s) shall be as specified in the Program Attachments.
3. Funding Obligation. This Contract is contingent upon the continued availability of funding.
If funds become unavailable through lack of appropriations, budget cuts, transfer of funds
between programs or health and human services agencies, amendment to the Appropriations Act,
health and human services agency consolidation, or any other disruptions of current appropriated
funding for this Contract, DSHS may restrict, reduce, or terminate funding under this Contract.
4. Term of the Contract. This Contract begins on 09/01/2010 and ends on 08/31/2011. DSHS
has the option, in its sole discretion, to renew the Contract as provided in each Program
Attachment. DSHS is not responsible for payment under this Contract before both parties have
signed the Contract or before the start date of the Contract, whichever is later.
5. Authority. DSHS enters into this Contract under the authority of Health and Safety Code,
Chapter 1001.
6. Documents Forming Contract. The Contract consists of the following:
a. Core Contract (this document)
b. Program Attachments:
2011- 036967 -001 CHS - PRIMARY HEALTH CARE
c. General Provisions (Sub- recipient)
d. Solicitation Document(s), and
e. Contractor's response(s) to the Solicitation Document(s).
f. Exhibits
Any changes made to the Contract, whether by edit or attachment, do not form part of the
Contract unless expressly agreed to in writing by DSHS and Contractor and incorporated herein.
92648 -1
7. Conflicting Terms. In the event of conflicting terms among the documents forming this
Contract, the order of control is first the Core Contract, then the Program Attachment(s), then the
General Provisions, then the Solicitation Document, if any, and then Contractor's response to the
Solicitation Document, if any.
8. Payee. The Parties agree that the following payee is entitled to receive payment for services
rendered by Contractor or goods received under this Contract:
Name: PORT ARTHUR CITY HEALTH DEPT
Address: 449 AUSTIN AVENUE
PORT ARTHUR, TX 77640
Vendor Identification Number: 17460018850011
9. Entire Agreement. The Parties acknowledge that this Contract is the entire agreement of
the Parties and that there are no agreements or understandings, written or oral, between them
with respect to the subject matter of this Contract, other than as set forth in this Contract.
By signing below, the Parties acknowledge that they have read the Contract and agree to its
terms, and that the persons whose signatures appear below have the requisite authority to execute
this Contract on behalf of the named party.
DEPARTMENT OF STATE HEALTH SERVICES CITY OF PORT ARTHUR
By: By:
Signature of Authorized Official Signature
Date Date
Bob Burnette, C.P.M., CTPM Stephen Fitzgibbons, City Manager
Printed Name and Title
Director, Client Services Contracting Unit P.O. Box 1089
Address
1100 WEST 49TH STREET Port Arthur, TX 77641
AUSTIN, TEXAS 78756 City, State, Zip
(512) 458 -7470 409 983 -8101
Telephone Number
Bob.Burnette@dshs.state.tx.us
E -mail Address for Official Correspondence
92648 -1
DOCUMENT NO. 2011-036967
ATTACHMENT NO. 001
PURCHASE ORDER NO. 0000366339
CONTRACTOR: CITY OF PORT ARTHUR
DSHS PROGRAM: CHS - PRIMARY HEALTH CARE
TERM: 09/01 /2010THRU: 08/31/2011
SECTION I. STATEMENT OF WORK:
The purpose of the Department of State Health Services (DSHS) Primary Health Care Services
Program is to ensure that needy Texas residents who do not qualify for other state or federal health
care programs or funding sources have access to primary and preventive health services.
Contractor shall deliver comprehensive health care services to eligible low - income individuals as
authorized by the Texas Primary Health Care (PHC) Services Act, Health and Safety Code, Chapter
31. Contractor shall offer the following priority services: (1) diagnosis and treatment; (2) emergency
services; (3) family planning services; (4) preventive health services, including immunizations; (5)
health education; and (6) laboratory, x -ray, nuclear medicine, or other appropriate diagnostic
services. In addition to priority services, Contractor may provide the following optional PHC
services: nutrition services, health screening, home health care, dental care, transportation,
prescription drugs, environmental health, podiatry, and social services.
Contractor shall develop and implement policies and procedures to insure that all clients complete an
application for program services, and that eligibility is determined according to the eligibility
requirements as outlined in 25 Texas Administrative Code (TAC), § §39.6- 39.10.
Eligible Population:
To be eligible for primary health care services, an individual must:
• be in financial need based on a gross family income at or below 150% of the current Federal
Poverty Level (FPL) guidelines;
• be a Texas resident; and
• not be eligible for other publicly funded programs/benefits providing the same services.
Contractor shall comply with all applicable federal and state laws, rules, regulations, standards, and
guidelines in effect on the beginning date of this Program Attachment unless amended, including but
not limited to:
• Texas Health and Safety Code, Chapter 31, Primary Health Care; and
ATTACHMENT — Page 1
• DSHS Primary Health Care (PHC) Services Program rules, 25 TAC, § §39.1 - 39.11.
The following documents are incorporated by reference and made apart of this Program Attachment:
• DSHS Primary Health Care Program Policy Manual, revised for 2010, or latest revision;
• DSHS FY 2011 Primary Health Care Competitive RFP #CHS /PHC- 0385.1 issued March 5,
2010;
• Contractor's Response to DSHS FY 2011 Primary Health Care Competitive RFP, and any
revisions;
• Department of State Health Services Standards for Public Health Clinic Services, revised
August 2004, or latest revision;
• DSHS Quality Management Core Tool Onsite Evaluation Report, revised for 2010, or latest
revision, and Quality Management Core Tool Monitoring Instructions, FY 2010, or latest
revision;
• DSHS Quality Management Primary Health Care Onsite Evaluation Report, revised for
2010, or latest revision, and Quality Management PHC Tool Monitoring Instructions, FY
2010, or latest revision.
• DSHS Quality Management Clinical Record Review Tool, revised for 2010, or latest
revision; and
• DSHS Quality Management Eligibility and Billing Record Review Tool, revised for 2010, or
latest revision.
Contractor shall notify the Primary Care Group (PCG), in writing, within thirty (30) days of the
vacancy of a position funded under this Program Attachment. Contractor's contract award may be
subject to a decrease equal to the salary savings (salary and benefits) realized as a result of the
vacancy. Contractor shall begin operations within thirty (30) days of contract execution.
Contractor' s failure to begin operations within thirty (30) days of contract execution may result in a
decrease in Contractor's contract award. DSHS reserves the right to adjust funding allocations
pursuant to the terms of the contract. Funding may vary and is subject to change each budget period.
All activities shall be performed in accordance with Contractor's final approved work plan.
Within thirty (30) days of receipt of an amended standard(s) or guideline(s), Contractor shall inform
DSHS PCG in writing, if it will not continue performance under this Program Attachment in
compliance with the amended standard(s) or guideline(s). DSHS may terminate the Program
Attachment immediately or within a reasonable period of time as determined by DSHS.
Contractor shall investigate and apply for all other sources of third party funding available, including
any resources to enable individuals to receive essential primary health care services in a timely
manner before submitting requests for reimbursement to DSHS for services rendered under this
program. DSHS will not reimburse a Contractor for services provided to an individual who is
eligible for the same services from a third party source, with the exception of services provided to
individuals requiring immediate medical attention on a presumptive eligibility basis.
ATTACHMENT — Page 2
DSHS Health Service Regional Director or designee, as coordinator of regional services, will assist
DSHS staff in providing direction to Contractor. DSHS personnel may, from time to time, provide
technical assistance and training to Contractor. Contractor shall cooperate with DSHS staff to attain
the goals of policy application, coordinated services, and quality assurance.
Contractor shall coordinate its services with existing Federally Qualified Health Centers (FQHCs)
located in its county(ies) or examine seeking designation as an FQHC, if no FQHC is currently
available within its county.
A contractor that is designated as a FQHC shall provide services during extended weekend and
evening hours.
Contractor shall submit monthly, quarterly, and annual programmatic reports and /or financial
vouchers /reports as required in the Primary Health Care Policy Manual. Other data and /or reports
deemed necessary by DSHS may be required, upon reasonable notice to Contractor.
SECTION II. PERFORMANCE MEASURES:
The following performance measures will be used to assess, in part, Contractor's effectiveness in
providing the services described in this contract Attachment, without waiving the enforceability of
any of the other terms of the contract.
1. Contractor shall provide services to a minimum of 571 clients who live or receive services in
the following county(ies): :Jefferson.
2. Contractor shall provide supporting documentation for programmatic desk reviews within
fifteen (15) days of the request by the DSHS Primary Care Group (PCG).
3. Contractor shall send a minimum of two (2) eligibility staff members to attend a DSHS PHC
eligibility training session by December 1, 2010, if eligibility staff was not previously trained
in FY 2010.
4. Contractor shall submit its client co- payment (co -pay) policy and its FY 2011 staff in- service
training calendar to the PCG by October 1, 2010 for Program review and approval.
SECTION III. SOLICITATION DOCUMENT: Request for Proposal for Primary Health Care
issued on March 5, 2010, RFP# CHS /PHC- 0385.1
SECTION IV. RENEWALS:
FY2011 is the first year of a five -year project period for this Program Attachment. The contract may
be renewed for up to four (4) one -year budget periods. Continued funding of the project in future
years is contingent upon the availability of funds and the satisfactory performance of the contractor
ATTACHMENT — Page 3
during the prior budget period. Funding may vary and is subject to change each budget period.
SECTION V. PAYMENT METHOD:
Cost Reimbursement
Funding is further detailed in the attached Categorical Budget and, if applicable, Equipment List.
SECTION VI. BILLING INSTRUCTIONS:
Contractor shall submit requests for reimbursement for services provided with Primary Health Care
(PHC) funds. Contractor shall submit monthly requests for reimbursement for allowable services
provided to PHC eligible clients on a State of Texas Purchase Voucher (Form B -13) within thirty
(30) days following the end of the month covered by the bill. Contractor shall submit a
reimbursement request as a final close -out bill not later than sixty (60) days following the end of the
applicable Program Attachment term(s) for costs encumbered on or before the last day of the
Program Attachment term. Reimbursement requests received in DSHS offices more than sixty (60)
days following the end of the applicable Program Attachment term will not be paid.
In billing DSHS, Contractor shall certify that all billed services have been provided only to
individuals who have been determined to be eligible for DSHS Primary Health Care Program
services. DSHS will reimburse Contractor upon approval of Contractor's monthly report (PHC -200).
The Purchase Voucher (Form B -13) shall be submitted simultaneously to the DSHS Performance
Management Unit, Contract Development and Support Branch (CDSB) and to the DSHS Claims
Processing Unit (CPU).
Form B -13 (voucher) shall be clearly marked as "Primary Health Care" and shall either be emailed to
the Family and Community Health Services Division, Performance Management Unit, Contract
Development & Support Branch (CDSB) at cdsb @dshs.state.tx.us, or faxed to CDSB at: (512) 458-
7235. Form B -13 shall also be emailed to the DSHS Claims Processing Unit (CPU) at:
invoices @dshs.state.tx.us, or faxed to CPU at (512) 458 -7442.
Contractor shall submit quarterly Financial Status Reports (FSR/Form 269a) for services provided
with Primary Health Care funds. Each FSR shall be marked clearly as "Primary Health Care ". The
original signed FSR shall be scanned and emailed, faxed, or mailed to the DSHS Claims Processing
Unit at: invoices @ dshs.state.tx.us; fax 512- 458 -7442.
Claims Processing Unit, Mail Code 1940
Department of State Health Services
P.O. Box 149347
Austin, Texas 78714 -9347
ATTACHMENT — Page 4
In addition, Contractor shall submit an electronic version of each FSR to CDSB via email at:
cdsb @dshs.state.tx.us.
SECTION VII. BUDGET:
Contractor shall budget travel costs for a minimum of two eligibility staff to attend a DSHS PHC
eligibility training session in Austin.
SOURCE OF FUNDS: State of Texas
SECTION VIII. SPECIAL PROVISIONS:
For purposes of this Program Attachment only, the following provisions shall apply:
General Provisions, Compliance and Reporting Article I, Section 1.03, Reporting, is revised to
include:
Number of Unduplicated Clients Served: DSHS will monitor Contractor's performance
measure activity. If the number of unduplicated clients served is below that projected in
Contractor's final approved workplan, Contractor's funding award may be subject to a
decrease for the remainder of the Program Attachment period.
Eligibility Desk Reviews: Contractor shall provide information and supporting
documentation as requested by DSHS to conduct programmatic desk reviews to verify client
eligibility for PHC Program. Failure to submit requested information in a timely manner may
result in sanctions as authorized by the contract. If Contractor's desk review results in a
finding of misappropriation of DSHS PHC co- payment (co -pay) policy, Contractor shall
reimburse client(s).
Contractor shall submit its client co -pay policy to PCG by October 1, 2010, for Program
review.
Contractor shall submit its FY 2011 staff in- service training calendar to PCG by October 1,
2010, for Program review.
Contractor shall report to DSHS using established reports as directed by the Policy Manual
for Primary Health Care, and other data and/or reports as deemed necessary by DSHS, upon
reasonable notice to Contractor.
REPORT TITLE SUBMISSION FREQUENCY DUE DATE
Contractor Client Co- Within 30 days of contract start September 30, 2010
payment (co -pay) Policy date
ATTACHMENT — Page 5
Contractor FY 2011 Staff Within 30 days of contract start September 30, 2010
In- service Training date
Calendar
Monthly Report (Form Monthly Within five (5) business days
PHC 200) following the end of the
preceding month
State of Texas Purchase Monthly Within thirty (30) days
Voucher (Form B -13) following the end of the
preceding month
Financial Status Report Quarterly Within thirty (30) days after
(Form 269a) the end of each quarter; final
report due sixty (60) days
after the end of the contract
term
Note: Form 269a must be Sept 1- Nov 30 Dec 30, 2010
sent to both CDSB and Dec 1 — February 28 March 30, 2011
CPU. Form 269a must March 1 — May 31 June 30, 2011
have an original signature June 1 — August 31 October 31, 2011
for CPU.
Annual Report (Form PHC Annually - within sixty (60) days October 30, 2011
300) after the end of the contract term
List of Recipients of PHC Annually - within sixty (60) days October 30, 2011
300 Annual Report after the end of the contract term
Failure to submit required reports in a timely manner may result in sanctions according to
provisions of the contract.
Monthly Report: The Monthly Report (Form PHC 200) shall be sent to the Primary Care
Group (PCG) via e -mail or fax within five (5) business days following the end of the
preceding month. Failure to submit required reports in a timely manner may result in
sanctions as authorized by the contract. Program staff will review the report within five (5)
business days of receipt. If the report is not submitted or is unsatisfactory, Program staff will
request the missing or corrected document. Upon approval of the report, the Program will
notify the Contract Development and Support Branch (CDSB) to process the voucher. After
verifying funding information, CDSB will send approval to the Claims Processing Unit
(CPU) to pay the voucher. Vouchers will not be paid until the corresponding quarterly report
is approved.
Annual Report: Contractor shall provide an annual program report in the format specified
by the PHC Program (Form PHC 300), including both statistical data and a narrative report
detailing contract activities performed during the previous fiscal year, to the PCG, the
assigned Regional Contract Coordinator (RCC), and the local entity identified in
ATTACHMENT — Page 6
Contractor' s approved work plan, no later than sixty (60) days after the end of the contract
term. Contractor shall provide statistical data according to specified criteria (e.g., age, sex,
race, gender, ethnicity, contraceptive method, number of unduplicated clients, etc.) as
detailed in PHC 300 report. Contractor shall send a list of the recipients of the report to the
PCG no later than October 30, 2011.
General Provisions, Compliance and Reporting Article I, Section 1.04, Client Financial
Eligibility, is revised to include:
Eligibility: All individuals considered for PHC eligibility shall be screened and determined
eligible using a DSHS approved screening process, in accordance with the DSHS PHC policy
manual.
General Provisions, Services Article II, Section 2.05, Fees for Personal Health Services, is revised
to include:
Co- payment: Contractor may assess a co- payment (co -pay) from clients who receive
services under this Program Attachment, in accordance with DSHS the PHC policy manual.
A client shall not be denied services due to inability to pay.
Contractor shall make reasonable efforts to investigate and apply for all other sources of third
party funding available to, or identified by, the patient before submitting DSHS Program
claims for allowable costs.
General Provisions, Funding Article III, Section 3.05, Program Income, is revised to include:
All revenues directly generated by a Program Attachment(s) supported activity or earned only
as a result of the Program Attachment(s) during the term of the Program Attachment(s) are
considered program income. Contractor shall identify and report program income monthly
and annually as specified in the DSHS Contractor's Financial Procedures Manual.
This section shall not be construed to apply to funds raised by Contractor from fund - raising
activities or donations. Fund raising includes membership drives or special events used to
raise program funds. Donations include monies donated to the program by individuals and
private groups, such as churches or other organizations.
Program income may be collected and retained by Contractor so long as it is used to provide
services specified in the statement of work detailed in this Program Attachment.
General Provisions, Payment Methods and Restrictions Article IV, Section 4.06, Third Party
Payors, is revised to include:
Contractor shall not move funds from the Contractual budget category into any other budget
ATTACHMENT — Page 7
category without prior approval from DSHS Program.
General Provisions, Access and Inspection Article IX, Section 9.01, Access, is revised to include:
Contractor shall allow DSHS to conduct on -site quality assurance reviews as deemed
necessary by DSHS. Unsatisfactory review findings may result in implementation of General
Provisions, Breach of Contract and Remedies for Non - Compliance Article XIV.
General Provisions, General Business Operations of Contractor Article XII, Section 12.18, Notice
of Organizational Change, is revised to include:
Contractor shall notify the Performance Management Unit, Contract Development and
Support Branch, of any clinic site information changes, e.g., changes in contact person, hours
of operation, address, National Provider Identification (NPI) number, Texas Provider
Identification (TPI) number, and the closure, relocation, and /or opening of clinic site(s).
General Provisions, General Business Operations of Contractor Article XII, Section 12.19,
Quality Management, is revised to include:
Pharmacy: If Contractor dispenses and /or provides prescribed medications, e.g., birth
control pills, antibiotics, etc., on site, it shall have, at a minimum, a Class D pharmacy
license as provided by the Texas Pharmacy Act, Occupations Code, §560.051 or must
dispense and/or provide such medications in compliance with other pharmacy statutes with
prior approval from DSHS.
ATTACHMENT — Page 8
2011- 036967 -001
Categorical Budget:
PERSONNEL $75,411.00
FRINGE BENEFITS $22,623.00
TRAVEL $1,950.00
EQUIPMENT $0.00
SUPPLIES $3,593.00
CONTRACTUAL $10,800.00
OTHER $0.00
TOTAL DIRECT CHARGES $114,377.00
INDIRECT CHARGES $0.00
TOTAL $114,377.00
DSHS SHARE $114,377.00
CONTRACTOR SHARE $0.00
OTHER MATCH $0.00
Total reimbursements will not exceed $114,377.00
Financial status reports are due: 12/30/2010, 03/30/2011, 06/30/2011, 10/31/2011
l \O 'y TEXAS DEPARTMENT OF STATE HEALTH SERVICES
L .:r/
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE
AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and belief that:
(1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to
any person for influencing or attempting to influence an officer or an employee of any agency, a
member of Congress, an officer or employee of Congress, or an employee of a member of Congress in
connection with the awarding of any federal contract, the making of any federal grant, the making of
any federal loan, the entering into of any cooperative agreement, and the extension, continuation,
renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a member of Congress,
an officer or employee of Congress, or an employee of a member of Congress in connection with this
federal contract, grant. loan, or cooperative agreement, the undersigned shall complete and submit
Standard Form LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants,
loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction
was made or entered into. Submission of this certification is a prerequisite for making or entering into this
transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required
certification shall be subject to a civil penalty of not less that $10,000 and not more than $100,000 for each
such failure.
Signature Date
Stephen Fitzgibbons, City Manager
Print Name of Authorized Individual
2011- 036967
Application or Contract Number
CITY OF PORT ARTHUR
Organization Name
CSCU # EF29 -12374 - Revised 08.10.07
DEPARTMENT OF STATE HEALTH SERVICES
93856
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of Entity: CITY OF PORT ARTHUR D /B /A Provider No.: endor No.: Telephone No.
17460018850 4099838832
Street Address: City, County, State: Zip Code:
449 Austin Avenue Port Arthur, Texas 77640
Jefferson
II. Answer the following questions by checking "Yes" or "No." If any of the questions are answered "Yes,' list names and addresses of individuals or corporations under
Remarks on page 2. Identify each item number to be continued.
(a) Are there any individuals or organizations having a direct or indirect ownership or control interest of 5 percent or more in the institution, organization,
or agency that have been convicted of a criminal offense related to the involvement of such persons, or organizations in any of the programs established by titles
XVIII, XIX, or XX?
Yes No X
(b) Are there any directors, officers, agents, or managing employees of the institution, agency or organization who have ever been convicted of a criminal offense
related to their involvement in such programs established by titles XVIII, XIX, or XX?
Yes No X
(c) Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar capacity who were
employed by the institution's, organization's, or agency's fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only)
Yes No X
III. (a) List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. (See instructions for
definition of ownership and controlling interest.) List any additional names and addresses under "Remarks" on page 2. If more than one individual is reported
and any of these persons are related to each other, this must be reported under Remarks.
Name Address
EIN #
(b) Type of Entity: Sole Proprietorship Partnership Corporation
Unincorporated Associations Other (Specify) City Government
(c) If the disclosing entity is a corporation, list names, addresses of the Directors, and EINs for corporations under Remarks.
Check appropriate box for each of the following questions:
(d) Are any owners of the disclosing entity also owners of other Medicare /Medicaid facilities? (Example: sde proprietor, partnership or members of Board of
Directors.) If yes, list names, addresses of individuals and provider numbers. Yes No X
Name Address Provider Number
Page 1
DEPARTMENT OF STATE HEALTH SERVICES
IV. (a) Has there been a change in ownership or control within the last year?
If yes, give date Yes No-
(b) Do you anticipate any change of ownership or control within the year?
If yes, when? Yes No X
(c) Do you anticipate filing for bankruptcy within the year?
If yes, when? Yes No X
V. Is this facility operated by a management company, or leased in whole or part by
another organization? Yes No
If yes, give date of change in operations
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director
within the last year? Yes No X
VII. (a) Is this facility chain affiliated? (If yes, list name, address of Corporation, and EIN)
Yes No X
Name EIN #
(b) If the answer to Question VII(a) is No, was the facility ever affiliated with a chain?
(If yes, list Name, Address of Corporation, and EIN) Yes No X
Name EIN # Address
VIII. Have you increased your bed capacity by 10 percent or more or by 10 beds, whichever is greater, within the last 2 years?
Yes — No -
If yes, give year of change
Current beds Prior beds
WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION OF THIS STATEMENT, MAY BE
PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY
DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY
PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH DSHS.
Name of Authorized Representative (Typed) Stephen Fitzgibbons Title City Manager
Signature
Date
Remarks: