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4.28 4.28 2016 ORGANIZATIONAL MEETINGUens Falls Hospital-Dnig Testing&Physicals RESOLUTION AUTHORIZING AGREEMENT BETWEEN TOWN OF QUEENSBURY AND GLENS FALLS HOSPITAL - CENTER FOR OCCUPATIONAL HEALTH - FOR SUBSTANCE TESTING SERVICES AND PHYSICAL EXAMS RESOLUTION NO.: ,2016 INTRODUCED BY: WHO MOVED ITS ADOPTION SECONDED BY: WHEREAS, the Queensbury Town Board wishes to enter into an Agreement with the Glens Falls Hospital — Center for Occupational Health (Center) to provide such services as physical exams and substance testing in accordance with Federal Motor Carrier Safety Regulations (FMCSR) for the Town during 2016, and WHEREAS, the Center has offered to perform such services in accordance with the terms and provisions of the letter-form Agreement dated December 17, 2015 and presented at this meeting, NOW, THEREFORE, BE IT RESOLVED, that the Queensbury Town Board hereby approves the letter-form Agreement between the Town of Queensbury and the Glens Falls Hospital — Center for Occupational Health (Center) substantially in the form presented at this meeting to provide such services as physical exams and substance testing with the costs for such services to be paid for from the appropriate accounts, and BE IT FURTHER, RESOLVED, that the Town Board further authorizes and directs the Town Supervisor to execute the letter-form Agreement and the Town Supervisor and/or Town Budget Officer to take any other action necessary to effectuate the terms of this Resolution. Duly adopted this 1St day of January, 2016, by the following vote: AYES NOES ABSENT: Glens Falls Hospital CENTER FOR OCCUPATIONAL HEALTH 102 Park Street,Suite B-2 • Glens Falls,New York 12801 (518)926-2140•Fax(518)926-2151 135 North Road•Wilton,New York 12831 (518)926-4822•Fax(518)926-1905 December 17, 2015 Ms. Victoria LaMarque Town of Queensbury 742 Bay Road Queensbury,NY 12804 RE: Contract Renewal 1/1/16 through 12/31/16 Dear Ms. LaMarque, The Center for Occupational Health is pleased to offer you services to meet the healthcare and/or compliance needs of your organization. This letter will serve as a formal agreement for those services. If agreed,the Center for Occupational Health(COH)will be providing the following occupational health services for employees of the Town of Queensbury. DOT SERVICES • DOT Physical;Includes physical, DOT vision test, and urine dip $100.00 • Urine drug screens, 5 or 10 panel $35.00 Includes: collection, lab testing, MRO review • Urine drug screens, Expanded opiate panel $38.00 • Evidential Breath Alcohol test $25.00/test • Randomization of drug/alcohol program No charge • On-call after hours/holiday $75.00/hour,2 hour minimum RESPIRATOR EXAM: • Respirator Physical Exam $30.00 • - Pulmonary Function Test $35.00 • Respirator Fit Test $25.00 • Annual Respirator Questionnaire Review $10.00(no charge with physical) ADDITIONAL SERVICES • Job Placement Assessment $70.00 • Audiogram $16.00 • Audiogram Review by physician if a confirmed STS $25.00 • EKG,with MD interpretation,if medically indicated $35.00 • Fit for Duty Pre-Employment Exam $65.00 Includes: health history, urine dip, vision chart • Return to Work Evaluation $30.00 WORK INJURY MANAGEMENT* Rates are based on provider assessment.The treating provider will assign a level of visit according to the complexity of the injury. Initial Visits will range from $45 to$75;follow-up visits will range between $25 to$45. Please note that any open Workers' compensation cases will be billed at the prevailing New York State workers' compensation rate. Page 2:Town of Queensbury and the Center for Occupational Health The Emergency Care Center(ECC)at Glens Falls Hospital(GFH) is available when the Center for • Occupational Health(COH)is closed. If follow-up is necessary the employee will be referred to COH. Please inform the ECC that the employer is a client of COH. Drug/Alcohol Testing All urine drug testing specimens collected by COH(DOT and/or non-DOT)will be sent to a SAMHSA (Substance Abuse Mental Health Services Administration)certified laboratory for drug urinalysis testing as required in 49 CFR Part 40.39. Emit immunoassay screening is used as the initial drug test and gas chromatography/mass spectrometry(GCMS)is the authorized confirmation method. All alcohol testing(DOT and/or non-DOT)conducted by COH will be provided on an Evidential Breath Testing(EBT)device. The Center uses the CMI Intoxilyzer 200,which is on the Conforming Products List(CPL)approved by the National Highway Traffic Safety Administration(NHTSA). A certified Breath Alcohol Technician(BAT)will perform all EBT's. The BATs have met the requirements set forth by 49 CFR Part 40. The cutoff level for detection of alcohol is 0.02(WI). The Center for Occupational Health is pleased to have four physicians who are certified by the Medical Review Officer Certification Council: Michael Holland,MD,MROCC;Kenneth Stein,MD,MROCC; William R. Rogers,MD, MROCC; and Ruth Light,MD, MROCC. Certificates available upon request. COH has a 24-hour paging system for after hours, post accident and reasonable suspicion testing. To access the system,call 832-1389 and leave a contact name and phone number. The on-call technician will return the call promptly with instructions for meeting the employee. A company supervisor must accompany the employee for all after-hours testing. Substance Abuse Professional(SAP)referral information will need to be available for your employees in the event of a positive test result. If the Town of Queensbury is aligned with an EAP(Employee Assistance Program)they may very well provide this service. There may be choices listed in the yellow pages under counselors/counseling or on the web under http://saplist.com/or http://www.eap- sap.com/sap/1-NY.htm. I recommend that you check with any you might consider using to see if they satisfy the Substance Abuse Professional requirements of DOT. If you need information regarding the DOT Federal Highway Administration regulations and your responsibilities as the employer,we suggest the following websites: httD://www.fmcsa.dot.gov/ httD://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/dots/Implementation Guidelines for Alcohol and Drug Regulations.odf https://www.transportation.gov/sites/dot.gov/files/docs/ODAPC Employer Guidelines %20June 1 2015 0.pdf http://www.samhsa.gov/sites/default/files/workplace-kit.pdf Random Selection: A computer random selection process uses the names of the drivers you have in the random pool. It is extremely important that the random pool be accurate at all times to ensure a successful program. Participating consortium members are responsible for keeping COH updated with any changes,(e.g. terminations or new hires). COH complies with the DOT requirements of testing at least 50%of the drivers in the pool for drugs and 10%of the drivers in the pool for alcohol on an annual basis. Page 3:Town of Queensbury and the Center for Occupational rY Health P Random Consortium Employer Responsibilities: In order to manage the consortium to meet DOT requirements the employer has the following responsibilities: • Keep COH up-to-date with current employees, • Do not give advance notice to selected random employees, • Discreetly notify selected employees just before,during,or immediately after performing safety- sensitive work,to report to the collection site immediately for testing with proper ID, • Contact COH if randomly-selected employees cannot be tested and the reason, • Send employees for pre-employment testing before they begin performing safety-sensitive functions, even if they are a current employee changing jobs within the company. • Other responsibilities delineated by the FMCSA and available in the links above Non-compliance could result in heavy fines from DOT for each day that you are not in compliance. Non- compliance also causes problems for COH in managing the consortium and ensuring testing quotas are met, and can affect our ability to run this consortium,and may compromise the integrity of the entire program. Failure to meet these responsibilities will result in your company being dropped from the Center for Occupational Health's random consortium. COORDINATION OF SERVICES All services will be coordinated through Connie Paradis at(518)926-2143. Should you require any additional services,please call at any time to discuss your needs. AVAILABILITY OF SERVICES Hours of operation at 100 Park Street,Pruyn Pavilion in Glens Falls are: Monday through Thursday 6:30 am-5:00 pm;Friday 6:30 am-4:00 pm Hours of operation at 135 North Road in Wilton are: Monday—Thursday 7:30 am- 5:00 pm; Friday 7:30 pm-4:00 pm COMMUNICATION The employees of the Town of Queensbury will be requested to sign a consent form allowing testing and/or treatment to be conducted and permitting the release of information to the designated individual from the Town of Queensbury. A copy will be kept in the employee's medical file at the Center for Occupational Health. STANDARDS FOR PRIVACY OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION GFH and Town of Queensbury shall comply with 45 C.F.R.Parts 160 and 164(hereinafter referred to as "HIPAA"). Information obtained from your employees in accordance with this Agreement constitutes protected health information ("PHI")under HIPAA. Town of Queensbury is considered a"business associate"for purposes of this Agreement and HIPAA to the extent the employee health records are provided to Town of Queensbury as the employer. Any release of employee health records provided to it by GFH must comply with HIPAA requirements. The Town of Queensbury must advise GFH when violations of HIPAA have occurred. BILLING Invoices for COH charges will be submitted on a monthly basis to and payment is expected within thirty days. Payment outstanding greater than 30 days will be charged 1.5%per month. Charges for ECC visits will be billed through the hospital billing system. • Page 4:Town of Queensbury and the Center for Occupational Health NO SOLICITATION OF EMPLOYEES Neither party shall, directly or indirectly, engage, hire, offer to engage or hire, or employ, enter into business with any employee or independent contractor of the other, whether as a joint venture, partnership, corporation or otherwise, for the term of this Agreement and one(1)year thereafter, without the prior written consent of the other party. LENGTH OF THIS AGREEMENT This agreement is intended to cover only the indicated occupational health services for your employees through 12/31/16. Thereafter this Agreement will be automatically renewed for one year periods unless sooner terminated by either party. In the event that the fee structure changes, said information will be provided through a sixty(60)days advance written notice. Either party may terminate this Agreement upon forty-five(45)days written notice. Please feel free to contact me if you have any questions. If this agreement meets your approval,please sign below on both copies and return all originals for signature to: Connie Paradis Center for Occupational Health 102 Park Street, Suite B-2 Glens Falls,NY 12801 After all signatures are obtained,one original will be mailed to you for your records. Thank you for choosing our services at the Center for Occupational Health. Glens Falls Hospital Town of Queensbury Ann Marie Hatch John Strough Exec. Director,Adirondack Medical Services Town Supervisor Date Date