This AGREEMENT is made this ______ day of _________________, 20___
between American HealthCare, LLC (hereinafter “the Clinical Facility” or "AHC") and
__________________________ Community College, an agency of the Commonwealth
of Virginia (hereinafter “the College”).
WHEREAS, the College is an educational institution with an approved program or
approved programs in _________________________(Physician Assistant, Nursing,
Medical Lab Technician, Physical Therapy, Physical Therapy Assistant), (hereinafter
collectively referred to as “the Program”) which requires clinical experiences of students
enrolled therein; and
WHEREAS, the Clinical Facility is a health care facility which has the resources in
equipment and staff to provide the clinical experiences required by the
_________________________________Program of the College; and
WHEREAS, the health care facilities of the Clinical Facility covered by this Agreement
are listed in Exhibit A and the College’s Programs covered by this Agreement are listed
in Exhibit A; and
WHEREAS, it is to the benefit of the College that the resources of the Clinical Facility
be made available to its students for the required clinical experiences; and
WHEREAS, it is to the benefit of both the College and the Clinical Facility to cooperate
in the educational preparation of students enrolled in the Program so as to promote
excellence in patient care, to ensure professional competence, and to provide maximum
utilization of community resources;
NOW THEREFORE, in consideration of the promises herein contained and other good
and valuable consideration the parties agree as follows:
1. Purpose
The purpose of this AGREEMENT is to establish procedures and guidelines for
the provision of clinical experiences within the Clinical Facility for students of the
2. The College’s Responsibilities
The College agrees to:
a. Present students for clinical experiences who have adequate preclinical
instruction and who, in the discretion of the faculty of the College, have
adequately fulfilled the preclinical requirements of the curriculum;
b. Provide evidence demonstrating that students who are presented for
clinical experiences meet the Clinical Facility’s screening and immunizing
requirements as set forth in Exhibit B;
c. Inform Students that they will be required to submit to and pay for a
criminal background check performed by a third party clearinghouse or the
Clinical Facility, containing such search parameters as the Clinical Facility
indicates, to determine whether he/she is at a minimum listed on the “List
of Excluded Individuals and Entities” maintained by the Office of the
Inspector General for the Department of Health & Human Services, or
otherwise has a criminal record. The Clinical Facility’s current search
parameters are set forth in Exhibit C. Upon the Clinical Facility’s request,
the College will have Students provide, as a condition of their participation
in the Program, the release of evidence directly to the Clinical Facility
showing that a background check was performed and its results. In no
event, however, will the College further disseminate any student’s
background check results of which it might become aware, including the
fact that no record exists, in derogation of § 19.2-389(C) of the Code of
Virginia. If a Student does not have a satisfactory background check, the
Clinical Facility may prevent such Student from participating in the
d. Obtain, or provide evidence of, comprehensive insurance coverage for
students and faculty in accordance with Virginia law. In particular,
malpractice coverage shall be determined by § 8.01-581.15 of the Code of
Virginia, which provides that coverage will not exceed one million nine
hundred twenty-five thousand dollars ($1,925,000) per occurrence on and
after July 1, 2007 and two million dollars ($2,000,000) on and after July 1,
2008. Evidence of such insurance is provided herein;
e. Inform all students of the rules, regulations, policies and procedures of the
Clinical Facility and require their conformance to such rules, regulations,
policies and procedures as a condition of their clinical experience
f. Advise the Clinical Facility no less than three (3) weeks prior to the
commencement of the clinical experiences of the number of students who
will be presented for clinical experiences and the dates and hour each
such student will be assigned to clinical experiences as determined by the
Program curriculum and students’ class schedules;
g. Provide the services of a faculty member of the Program, or other College
liaison, who will:
(1) Plan, in conjunction with staff member(s) of the Clinical Facility the
clinical experiences and patient care assignments which will fulfill
the clinical requirements of the Program curriculum; and
(2) Meet with staff member(s) of the Clinical Facility to discuss the
quality of the clinical experiences and any problems which may
have arisen in the provision of those experiences.
h. Retain responsibility for the education of students in and for the curriculum
of the Program, its design, delivery, and quality; and
i. Maintain all educational records and reports relating to the experiences of
its students;
j. Require its students to execute the Clinical Facility’s pre-clinical
experience paperwork prior to beginning the clinical experience.
3. The Clinical Facility’s Responsibilities
The Clinical Facility agrees to:
a. Provide supervised clinical experiences for students which fulfill the
curriculum requirements of the Program and meet the objectives agreed
upon by the College and the Clinical Facility;
b. Provide the College with a minimum of 90 days written notice in the event
it is unable to place College students;
c. Provide the College’s participating students and faculty with an orientation
to the Clinical Facility, or orientation packets about the Clinical Facility,
which will include training about the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), especially as it relates to the Clinical
Facility’s confidentiality requirements;
d. Provide students with instruction regarding blood-borne pathogens, and
how, when and why to report incidents;
e. Require students to sign confidentiality statements regarding the
protection and confidentiality of patient medical records;
f. Provide facilities for clinical experiences which include reasonable library,
classroom, conference room and locker room space, and whenever
possible, office and storage space;
g. Provide the services of unit staff members who will:
(1) Assist the College’s coordinating faculty members with the planning
of clinical experiences and patient care assignments; and
(2) Meet with the College’s coordination faculty members to discuss
the quality of the clinical experiences and any problems which may
have arisen in the provision of those experiences; and
h. Plan, administer and retain responsibility for all aspects of the patient care
program and provide for qualified supervision of all patient activities; and
i. Allow faculty members of the College access to the facilities of the Clinical
Facility for the purposes of coordinating, observing and instruction of
students engaged in clinical experiences;
j. Provide, on forms furnished by the College or as otherwise approved by
the College, an evaluation and report on the performance of each student
participating on a full-time basis in the clinical experience.
4. Responsibility of the College and the Clinical Facility
The College and the Clinical Facility agree that:
a. The maximum number of students who may participate in clinical
experiences will be determined by mutual agreement of the parties;
b. The parties will advise one another of changes in supervision and
instructing personnel, changes in applicable policies, changes in student
enrollment, and changes in the availability of resources;
c. Emergency treatment of students for any injuries incurred during clinical
activities must be covered through the student’s personal health insurance
plan, or through his/her own resources. Personal health insurance
coverage for the College’s faculty and/or students will not be the
responsibility of the College and/or Clinical Facility;
d. The Clinical Facility may at any time summarily relieve a student from a
specific assignment, or request that a student or faculty member leave a
patient care area for causes related to the quality of patient care;
e. The Clinical Facility may require that student(s) be withdrawn from
participation in the clinical experience provided that the Clinical Facility
first consults with the College and gives specific reasons for the
withdrawal, which reasons shall not be among those prohibited under “f”
f. Neither party shall unlawfully discriminate against any student on the basis
of race, religion, sex, creed, age, national origin or disability;
g. Students are volunteers at the Clinical Facility and not employees of either
party during their clinical experience; and
h. The parties are independent contractors in relation to one another and
neither party is authorized or permitted to act as an agent or employee of
the other;
5. Governing Law
This Agreement is made in Roanoke, Virginia and shall be governed by the laws
of the Commonwealth of Virginia.
6. Length of Agreement
This Agreement commences on ________________________ and is in effect for
one (1) year with two (2) automatic renewals for subsequent one (1) year terms.
It shall be reviewed each year by the parties, and it may be terminated by either
party in writing or certified mail at least ninety (90) days prior to the date of
termination for that year. Either party may terminate this agreement at any time,
including during the initial term, with or without cause, upon 30 days written
notice to the other party.
Should notice of termination be given by either party to this Agreement, those
students currently assigned to the Clinical Facility by the College shall be
permitted to complete the prior schedule clinical internship assignment in
progress at the Clinical Facility.
7. HIPAA Compliance: College agrees to the requirements as specified in
Attachment A and will have every student and faculty member assigned to the
facility sign and comply with the Confidentiality Agreement as specified in
Attachment B; and both Attachments are incorporated herein by reference.
8. Referral Disclaimer and Statement of Eligibility
8.1 Referral Disclaimer and Freedom of Choice. The parties
acknowledge that the payment or receipt of any remuneration, direct or indirect,
to induce the referral of a patient or for the purpose of purchasing either goods or
services reimbursable under the federal Medicare or state Medicaid programs is
prohibited. No provision of this Agreement is intended to, nor shall it be
construed as requiring any party hereto to refer any patient to any other party
hereto nor shall any payment contemplated hereunder be contingent or
conditioned upon nor measured, by the referral by any party of patients, or for the
purchase of services or goods, to any of the other parties hereto; it being
expressly provided that no purpose of this Agreement is to induce referrals or
health care business. The parties further acknowledge that Facility's patients
shall have the right of freedom of choice to choose a vendor for services,
including medical services from private physicians, and the parties shall take
such reasonable steps as may be necessary and appropriate to ensure such
freedom of choice, including advising the patient as to the availability of such
services from other sources in the community and conforming to all requirements
of law.
8.2 Statement of Eligibility to Participate In Federal Health Care
Programs. College states that, to the best of its knowledge, it and any of its
employees/contractors is/are not (a) currently excluded, debarred, suspended, or
otherwise ineligible to participate in Federal health care programs or in Federal
procurement or non-procurement programs; and (b) has/have not been convicted
of a criminal offense that falls within the ambit of 42 U.S.C Section 1320a-7(a),
but has not yet been excluded, debarred, suspended, or otherwise declared
ineligible. Nothing herein should be interpreted as a waiver of the sovereign
immunity of the Commonwealth of Virginia.
Notice of termination to the Clinical Facility shall be directed to:
American HealthCare, LLC
5372 Fallowater Lane, Suite 200
Roanoke, VA 24018
Attn: Director of Contracting
Notice of termination to the College shall be directed to:
IN WITNESS THEREOF, the parties hereto have caused this Agreement to be
executed on the day, month, and year as written above:
American HealthCare. LLC ________________Community College
By: __________________________ By: __________________________
Authorized Officer Title _________________________
Authorized Officer’s Printed Name
Date: _______________________ Date: _________________________
Attachment A
Protected Health Information
A. General. It is recognized by each party to this Agreement that certain
information that is proprietary and non-public may be disclosed to the
other party pursuant to this Agreement, including protected health
information of Facility residents (“PHI”) which is regulated by the Health
Insurance Portability and Accountability Act healthcare privacy regulations
(“HIPAA”). Facility and College agree that confidential information will only
be available to officers, employees, or agents of the parties who may be
required to have access to such confidential information in order to
perform their duties under this Agreement and that confidential information
of the other party will not be disclosed to any other person, firm, or entity
without obtaining the prior written consent of the other party.
B. Permitted Uses. College is permitted to use the PHI only as necessary to
perform the Services set forth in this Agreement (“Permitted Uses”).
C. Duties of College to Protect PHI. College shall:
i. not use or further disclose any PHI other than as permitted or
required by this Amendment;
ii. not use or further disclose any PHI in a manner that would violate
the requirements of applicable law, including, but not limited to
iii. implement a policy and procedure that incorporates appropriate
safeguards to prevent the use or disclosure of such PHI other than
as provided for by this Amendment and provide a copy of such
policy and procedure to Facility upon request;
iv. immediately report to Facility any use or disclosure of such PHI not
provided for by this Amendment of which College becomes aware;
v. ensure that any subcontractor or agent to whom College provides
such PHI agrees, in a writing substantially similar to this
Amendment, to the same restrictions and conditions that apply to
College with respect to such information under this Amendment;
provided, however, that College shall not provide any PHI to any
subcontractor or agent without the prior written consent of Facility;
vi. make such PHI available for inspection and copying by the subjects
thereof in accordance with applicable law, including, but not limited
vii. incorporate any amendments or corrections to such PHI when
notified by Facility; and
viii. make available to Facility any information required to provide an
accounting of the College’s disclosures of PHI during the six-year
period prior to the date on which the accounting is requested;
provided that this information need not be maintained for
disclosures that occur in the course of treatment, payment and
operations transactions or disclosures to members of their PHI in
accordance with HIPAA.
D. Investigations. College shall makes its internal practices, books and
records relating to the use and disclosure of such PHI available to the
Secretary of the United States Department of Health and Human Services
(the “Secretary”) for purposes of determining Facility’s compliance with
applicable law, including, but not limited to HIPAA. College shall
immediately notify Facility upon receipt or notice of any request by the
Secretary to conduct an investigation of the use or disclosure of PHI.
College shall not disclose any information without Facility’s prior written
E. Records of PHI Disclosures. College shall maintain accurate and complete
records of any and all receipts, transmissions, uses, and disclosures of
any PHI, throughout the Term and for such longer period as may be
required by applicable law.
F. Termination
i. Without limiting any right or remedy of Facility provided elsewhere
in this Agreement or otherwise available under applicable law,
Facility may terminate the Agreement without penalty or recourse to
Facility if Facility determines that College has violated any material
term of this Exhibit.
ii. Upon termination of the Agreement, College shall return or destroy
all PHI that College maintains in any form and retain no copies of
PHI. If College is required to retain copies of such PHI pursuant to
law or return of the PHI is not feasible, College shall provide Facility
with a list of such PHI that must be retained, continue to protect
such PHI from unauthorized disclosure and provide Facility with an
accounting of such disclosures of PHI upon request, as required by
law, until such time as PHI may be destroyed.
G. Further assurances. In order to assure that this Agreement is consistent
with HIPAA, College agrees that this Exhibit may be amended from time to
time upon written notice from Facility to College as to the revisions
required, to make this Agreement consistent with HIPAA, provided
however, that if College does not agree to the revisions, it may terminate
this agreement.
H. Survival. The provisions of this Exhibit shall survive termination of the
Attachment B
College Confidentiality Agreement
I understand that American HealthCare, LLC (AHC) has a legal and ethical
responsibility to safeguard the privacy of all patients and to protect the confidentiality of
their health information. Additionally, AHC must assure the confidentiality of its human
resources, payroll, fiscal, research, computer systems, and management information
(collectively "Confidential Information").
In the course of my clinical assignment at AHC, I understand that I may come
into the possession of Confidential Information.
I further understand that I must sign and comply with this agreement in order to
get authorization for access to any of AHC's Confidential Information.
1. I will not disclose or discuss any Confidential Information with others, including
friends or family, who do not have a need to know it. In addition, I understand that my
personal access code, user ID(s), and password(s) used to access computer systems
are also an integral aspect of this Confidential Information.
2. I will not access or view any Confidential Information, or utilize equipment, other
than what is required to perform my clinical education experience.
3. I will not discuss Confidential Information where others can overhear the
conversation (for example, in hallways, on elevators, in the cafeteria, on the shuttle bus,
on public transportation, at restaurants, and at social events). It is not acceptable to
discuss Confidential Information in public areas even if my patient's name is not used.
Such a discussion may raise doubts among patients and visitors about our respect for
their privacy.
4. I will not make inquiries about Confidential Information for other personnel who
do not have proper authorization to access such Confidential Information.
5. I will not willingly inform another person of my computer password or knowingly
use another person's computer password instead of my own for any reason.
6. I will not make any unauthorized transmissions, inquiries, modifications, or
purgings of Confidential Information in AHC's computer system. Such unauthorized
transmissions include, but are not limited to, removing and/or transferring Confidential
Information from AHC's computer system to unauthorized locations (for instance,
7. I will log off any computer or terminal prior to leaving it unattended.
8. I will comply with any security or privacy policy promulgated by AHC to protect
the security and privacy of Confidential Information.
9. I will immediately report to my supervisor any activity, by any person, including
myself, that is a violation of this Agreement or of any AHC information security or
privacy policy.
10. Upon termination of my clinical assignment, I will immediately return any
documents or other media containing Confidential Information to AHC.
11. I agree that my obligations under this Agreement will continue after the
termination of my clinical assignment.
12. I understand that violation of this Agreement may result in disciplinary action, up
to and including termination of my clinical assignment and/or suspension and loss of
privileges, in accordance with AHC's sanction policy, as well as legal liability.
13. I further understand that all computer access activity is subject to audit.
By signing this document I understand and agree to the following:
I have read the above agreement and agree to comply with all its terms.
Signature of College Student/Faculty Member: ________________________________
Print name: ____________________________________ Date: ___________________
College Programs covered by the Clinical Affiliation Agreement to which this Exhibit A is
Health care facilities of American HealthCare, LLC covered by the Clinical Affiliation
Agreement to which this Exhibit A is attached:
813-Heritage Hall-Front Royal 933-Heritage Hall-Tazewell
400 West Strasburg Road 121 Ben Bolt Ave.
Front Royal, VA 22630 Tazewell, VA 24651
540-636-3700 276-988-2515
Fax-540-636-8558 Fax-276-988-5468
Anthony Larson-Administrator Mike Shelor-Administrator
814-Heritage Hall-Grundy 934-Heritage Hall-Blackstone
2966 Slate Creek Road 900 South Main Street, P.O. Box 550
Grundy, VA 24614 Blackstone, VA 23824
276-935-8144 434-292-5301
Fax-276-935-2316 Fax-434-292-6041
John Quintier- Administrator Betty Pomfrey-Acting Administrator
816-Heritage Hall-Virginia Beach 935-Heritage Hall-Leesburg
5580 Daniel Smith Road 122 Morven Park Road
Virginia Beach, VA 23462 Leesburg, VA 22075
757-499-7029 703-777-8700
Fax-757-499-1266 Fax-703-777-1532
Lisa Benjamin- Administrator Parker Jones-Administrator
817-Heritage Hall-Brookneal 936-Heritage Hall-Nassawadox
633 Cook Avenue 9468 Hospital Ave., P.O. Box 176
Brookneal, VA 24528 Nassawadox, VA 23413
434-376-3740 757-442-5600
Fax-434-376-3776 Fax-757-442-9401
Linda Haldaman-Administrator Allen Sinowitz- Administrator
818-Heritage Hall-Lexington 938-Heritage Hall-Clintwood
205 Houston Street 161 Hospital Drive
Lexington, VA 24450 Clintwood, VA 24228
540-464-8181 276-926-4693
Fax-540-464-8184 Fax-276-926-9128
Esteban Duran Ballen Ginger Kennedy- Administrator
819-Heritage Hall-Laurel Meadows 939-Heritage Hall-Dillwyn
16600 Danville Pike Road 9 Brickyard Drive, P.O. Box 580
Laurel Fork, VA 24352 Dillwyn, VA 23936
276-398-2117 434-983-2058
Fax-276-398-3122 Fax-434-983-2058
Rhonda Reef-Administrator Angela Davis-Administrator
931-Heritage Hall-Blacksburg 940-Heritage Hall-King George
3610 South Main Street 10051 Foxes Way, P.O. Box 529
Blacksburg, VA 24060 King George, VA 22485
540-951-7000 540-775-4000
Fax-540-951-4109 Fax-540-775-3637
Mark Peterson-Administrator Ben Higgins-Administrator
932-Heritage Hall-Big Stone Gap 942-Heritage Hall-Wise
2045 Valley View Drive 9434 Coeburn Mtn. Rd., P.O. Box 1009
Big Stone Gap, VA 24219 Wise, VA 24293
276-523-3000 276-328-2721
Fax-276-523-0531 Fax-276-328-1463
Patty Akers- Administrator Crystal McCarty-Administrator
American HealthCare, LLC
Human Resources Capability Development
Screening and Immunization Requirement Addendum
School to Complete and Save as Documentation for Contract Requirements: (Form to
be retained by School for records)
Student Name: ________________________________________________________
SSN: ________________________________________________________________
______ Urine Drug Screen results reported as negative. Positive drug screen
may be reported as negative if Designated Health Professional has reviewed and
verified actual prescription, or prescription bottle, prescribed for student only, or
has verified prescription with drug store where prescription was filled (prescribed
for student only).
Immunization Current
List what is needed: ___________________________________
PPD - 1. LF __________ RF __________ Date: Given by: ________
Read by: _________Date: ____________
2. LF__________RF _________ Date:
Given by: _______
Read by: Date:________
Signature - Health Professional Date
Address _____________________________________________________________
Fax: ______________________
Note: Must be completed for each student entering an American HealthCare, LLC
facility under a Clinical Experience Agreement.
Two Step PPD Skin Testing:
The Occupational Health and Safety Administration (OSHA, 1994) requires that a two-
step baseline be performed on students/health care workers who have not had a
documented negative skin result during the preceding 12 months.
Five (5) Day Process:
Two step testing may be accomplished by placing the first test on day one, reading
within 5 days. If read as negative, the second test may be placed on the same day the
first is read.
Second test is read within 48-72 hours.
PPD Skin Test
If PPD (only) skin test, (subcutaneous only), has been received within the past 12
months this will be acceptable as first step of 2 step process, provided proper
documentation can be produced (MD/facility letterhead, results in mm of induration).
The second test can be given and must be read within 48-72 hours, by an RN, MD, or
qualified health professional.
Reading cannot be performed by applicant.
All results must be read and recorded in mm of induration.
The two step method is a one time only requirement, and then the student is
annually tested if he or she continues in clinical participation within American
HealthCare, LLC.
Chest X-Ray:
Students reporting history of a previously (documented) positive PPD skin test are not
required to have a PPD test repeated. A chest X-ray will, however, be required unless
documentation of a negative chest x-ray, within the past 12 months, is available.
If required by American HealthCare, LLC, follow up evaluations are obtained through
the applicant’s personal physician or local Health Department.
Urine Drug Screen
A negative urine drug screen is required prior to and within thirty (30) days of the first
day of clinicals. Collection process must follow the Federal Drug Free Workplace
guidelines. The collection process must include eliminating water access in toilet facility,
placement of bluing in toilet bowl, (food coloring or blue cleaner acceptable), no soaps
or contaminants accessible, and all other required steps to preserve the integrity of the
specimen. Coats, purses are not allowed inside toilet facility and must be stored in a
secure area.
Testing must be performed by a SAMSHA (Federally) certified reference laboratory,
such as, (but not limited to), LabCorp, CompuChem, SmithKline, AML, or National
Diagnostics. A Custody and Control Form must be utilized for collection. Any positive
test result must be documented positive, with explanation from the health professional.
American HealthCare, LLC reserves the right to implement a random drug screen
collection policy.
The drug screen panel must screen for the presence of the following drugs:
Cocaine Metabolites
Marijuana Metabolites
Immunization Recommendations
Immunization against polio is recommended for those who have not had the vaccine.
Adsorbed Diphtheria Tetanus
After the preliminary immunization series, it is recommended that you receive a
Diphtheria Tetanus booster every ten years.
Immunization against measles is required for those born in or after 1957 who
have not had a booster since 1980; as well as born prior to 1957 with no history,
documentation or laboratory evidence of having had measles.
Immunization against mumps is recommended for those without documented
history or mumps vaccination.
Rubella immunization is strongly recommended for those who are susceptible
and not pregnant. A blood test known as Rubella titer can be done to determine
you susceptibility. Documentation of immunity by Rubella titer or Rubella
immunization will be necessary.
Hepatitis B Vaccine
Hepatitis B Vaccine is recommended for Health Care Workers who could be
exposed to blood and body fluids. It is recommended that the student have the
first injection in a series prior to beginning the Educational Experiences. If the
student declines to obtain the Vaccine, he or she must complete a declination
form and provide it to the School.
Many U.S. residents who were born outside the USA received the bacillus
Calmette-Guerin (BCG) TB immunization. It is important to understand that a
previous BCG vaccine does not negate the PPD skin test requirement.
*MMR acceptable
Search Parameters for Criminal Background Check
As a condition of participating in the Program at the Clinical Facility, the College
will inform each of its students and each member of its faculty entering the
Clinical Facility’s clinical areas that within sixty (60) days of the respective
student and/or faculty member beginning the Program at the Clinical Facility,
they must furnish the Clinical Facility with the results of a Criminal Background
Check that includes the following search parameters:
Social Security Identification;
Residence history trace;
Criminal records in all county/state jurisdictions of residence for a seven
(7) year period;
Whether student or faculty member appears on HHS/OIG list of excluded
Whether student or faculty member appears on GSA list of parties
excluded from federal programs.
After receiving this information, the Clinical Facility will inform the College
whether the respective student and/or faculty member is authorized to participate
in the Program.