HomeMy WebLinkAbout030915_ca06615 Sheridan Street
V Port Townsend, WA 98368
L 600son www.JeffersonCountyPublicHealth.org
PUblic He=A
Consent Agenda
San 30, 2015
01499-4
AGENDA REQUEST
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: Jean Baldwin, Director
DATE:
SUB3ECT: Agenda Item — Washington Statewide Pharmacy Emergency
Preparedness standardized protocol MOU; January 30, 2015—until
terminated
STATEMENT OF ISSUE:
Jefferson County Public Health, Community Health, requests Board approval of the Memorandum of
Understanding Statewide Pharmacy Emergency Preparedness standardized protocol; January 30, 2015 —
until terminated.
ANALYSIS ST O�G�C qOAemeP"RQo an The purpose of this nus establish a coordinated and standardized statewide protocol
utilizing existing pharmacy infrastructure to assist the medical and health needs of the affected population
should a public health incident, emergency, and/or disaster occur. The MOU sets out guidelines for defining
public health incident, emergency, and disaster; spells out how to request assistance and uses for and
distribution of the Strategic National Stockpile; and delineates cooperative responsibilities and adherence to
federal and state laws. Request to join the Statewide Pharmacy MOU was initiated by DOH, as coordinator,
and approved in this office by Dr. Tomas Locke, JCPH Health Officer.
F1 5CAL IMPACT ICOST BENEFIT ANALYSIS:
This MOU does not impact the budget.
RErequest management request approval of Washington Statewide Pharmacy emergency Preparedness
JCPH
standardized protocol MOU; January 30, 2015
REVIEWED BY::,
Philip Morley,10unty Administratbr
' of(WIUTJ�Jy , jcjcOlh
D
360
Date
Fwiironniemc1i
.360 -..385 -9 J, 4I
ri) 360 .,70
WAsmNGTON3TATEW0E PHARMACY-LOCAL HEALTH JURISDICTION
MEMORANDUM OF UNDERSTANDrNG
This Washjo@�ooS1a1evvideybucozaoy-Lo�dBea�bJu�od[odooyYeomormodunoofOndeotunding
(^^mOlJ"`)iurnudoandsniurodiuto6vtheoigmoLnz}Hcab6I}oparbnccdocoigouiocyBeald6
District, or signatory County within the State of Washington that operates m public health
department or division within its county government, ("Local Health Jurisdiction" or "LHY) and
each signatory pharmacy entity licensed iuthe State of Washington ("^yburnoucY"), individually,
and with all other signatory LBJmaod signatory Pharmacies.
ARTICLE
PURPOSE
The purpose of this hdOL/ is to utilize existing Pharmacy infrastructure to assist in addressing
health and medical needs of an affected population during a Public Health Incident, Emergency
or Disaster ("Incident"), using coordinated and standardized protocols atu1ovvidc. The
Washington State Department of Health (`DOB^') supports the development nfthir M0O
.
ARTICLE 11
DEFINITIONS
Local Health Jurisdiction: &signatory health department, health district, mcounty within the
State of Washington that operates u public health department or division within its county
government, pursuant toauthority granted under Chapters 70.05, 70.08, 70.46 RCW or other
applicable law. Each signatory party shall designate a representative for purposes of accepting
requests for assistance and notice.
Pharmacy: /\ signatory to this KJOQ who cueoLo the definition ofupharmacy as that term is
defined imRCW 18.64.011.
Plan: avyriticn Operation y|mn or procedure developed pursuant to this MQU,
Public Health Incident, Emergency, or Disaster (" Inci dent"): Any occurrence, or threat thereof,
whether natural or caused by rnan, in war or in peace, to which an LHJ may respond pursuant to
its authority uo6oz chapter 70.05` 70.08 or 70,46 8CW, or other mp9|icuhlc lovv` and that, in the
judgment of the LHJ, results ornouI result in circurostmocea sufficient to ezouod the day to day
operational capabilities of irru-nediate local or regional public health response.
Page I
ARTICLE III
PARTICIPATION
The Pharmacies have a desire to assist the LHJs in addressing health and medical needs of an
affected population during an Incident. The LHJs and Pharmacies agree that this MOU,
however, does not create a legal duty to do so. The LI-IJs and Pharmacies agree that any and all
actions taken pursuant to this MOU shall be voluntary and in each LHJ's arid Pharmacy's sole
discretion.
ARTICLE IV
HOW TO INVOKE ASSISTANCE
An LHJ may request assistance of a Pharmacy by contacting the designated representative of that
Pharmacy. The provisions of this MOU shall only apply to requests for assistance made by and
to such designees. Requests may be verbal or in writing. If verbal, the request shall be confirmed
in writing as soon as possible to the extent practical. LHJs intend to activate community-wide
mass vaccination and dispensing plans, to include delivery of medications by Pharmacy with
Phari,nacy I s agreement, only (a) after a declaration of "Public Health Emergency" made by the
Secretary of the Department of Health and Human Services under the Public Readiness and
Emergency Preparedness Act (PREP Act), 42 U.S.C.A. §2474 -6d, or (b) a locally or state
declared emergency, under chapter 38.52 RCW, requiring a public health and medical response,
or (c) the issuance of an event mission number by the Emergency Management Division of the
State Military Departi-tient for a public health arid medical response,
ARTICLE V
EFFECT OF DECLARATION OF EMERGENCY
The LlUs and Pharmacies recognize that state or federal declarations of emergency, or orders
related thereto, rnay supersede the arrangements made or actions taken pursuant to this MOU.
Nothing in this N40U sljouid be construed as independent of or bypassing established emergency
Nothing -nergencies, or any
I
management procedures, the provisions of county or state declarations of ei
conditions for the distribution and dispensing of the Strategic National Stockpile (SNS) or
administration of vaccines established by the federal or state governments.
Page 2
ARTICLE V1
RESPONSIBILITIES ()F LOCAL HEALTH JURISDICTIONS
Local )Kcuftb Jurisdictions responsibilities includes:
�
Coordinate with DOH and/or ai��� � ��� ���d consistency with
screening forms, tracking, training and other Pharmacy requirements if applicable.
�
Provide planning and technical assistance to Pharmacy, including but not firnited to, supply
lists, fact sheets, d\speusiog algorithms, and applicable requirements
�
Provide statewide consistent medical screening forms to Pharmacy asu guidance for
implementing dispensing operations
*
Provide technical assistance and training, uo mutually agreed upon by[D}and Pharmacy
°
Activate community-wide mass vaccination and dispensing plans as ncocuoory
m
Notify that community dispensing plans uhuo!d be iroplernco(od
' ciut�aon000touodt�pcmfnuediou1iomorvauoimoanduvui1ub�cou��|�raOnznm
*
Request appropriate , ,
local, state ocfederal sources, including use n[SNSresources
�
Facilitate u discussion with Pbuomuoy regarding the most appropriate locations for
distribution
* Qcguo»1 DOH to deliver, or have delivered medications to distribution centers ma determined
by the local bumlNz jurisdiction in consultation with the D()II and yhuommoy
• Provide Pharmacy with statewide consistent medical protocols regarding the Pharmacy's
response including, but not liroi1cd to, dosing and follow-up procedures
• provide phanoucy with zelomoub|o iofocrnm1iuu regarding the public bca}tb tnourguooy
situation
• Manage public iofocrnatinu activities with regard to the overall health and medical m:xp000m
across the L}{}`e jurisdiction
• provide educational materials, i[appropriate, bn Pharmacy for the put-poses ofdistributing to
all persons in emergencies impacting the public's health
• Make arran gern e tits to retrieve or dispose of any untised medications from Pharmacy
facilities and collect documentation forms io coordination with DOH
° providc guidance and criteria to Pharmacy for tracking levels of activity, supplies and
inventory, as applicable tmthe response and consistent across signatory L8J jurisdictions
mission number has been issued by the State Emergency Division,
^^ -- statewide
��
Pharmacy and Local Health Jurisdiction /\
iad[��ioo��r��dbutprio�to invoking Agreement during
cmergoo
ti�o Locu|B�u\th�ur�sdi��ion,tbrom�btb�|oou|d��u�oo�otofuroc��cooyomamu��rouuL
,
will request the issUance of a mission number frorn the Washington Military Department,
tmerCeocy Management Diviaioo�
Page 3
ARTICLE VII
RESPONSIBILITIES OF PHARMACIES
Pharmacies' responsibilities include:
Coordinate with DOH and/or signatory LHJs to insure statewide consistency with
screening forms, tracking, training, and other Pharmacy requirements
Comply with Pharmacy standards in effect during the Incident
Identify the approximate number of medication doses that could be administered by
Pharmacy in a specified time period and communicate that information to the LHJ
Identify Pharmacy sites to receive medication deliveries and communicate site locations
to the municate to
LHJ LHJs each site location's scope of Pharmacy practice regarding affected
Com
populations, e.g., convey age or prescriptive authority limitations
Receive and store medication deliveries, consistent with federal, state or local
government requirements, at Pharmacy- identified facilities during Incidents
Ensure that Pharmacy site locations serve the general public
0 At Pharmacy's discretion, ensure that its own employees, including those employed by its
parent company, and their families, are cared for consistent with public health
recommendations
Conduct medical, screening of individuals receiving medications, based on guidance
provided by LIV, to identify potential contraindications, and complications, and assure
dispensing and administration consistent with federal, state and local government
requirements the absence 0 f the issuance of an emergency use authorization, or a declared
In
emergency triggering RCW 38.52.180 (6) waiving license requirements for registered
emergency workers, prescribe and dispense medications under a collaborative agreement
with a licensed health care prescriber or lawful health order issued by a local health
officer
M n accur ate records of medications dispensed, administered, and remaining
0 aintai
inventory and inventory nventory the local, state or federal stock of medications, vaccines and
0 ain tain
supplies and ph ysically separate them from the regular inventory. The local, state and
federal stock cannot be used ill place of commercial pharmacy stock at any time.
Pharmacy stock may be used as a substitute for the local, state or federal stock, and
Pharmacy may seek reimbursement for this action, if available, in accordance with the
then current state or federal guidance
• Track contact information of individuals receiving medications
• colnulun 'Icate information regarding medications dispensed, administered, and contact
information to local health jurisdiction as required by local health jurisdiction
• Provide education materials, supplied by local health jurisdiction to all individuals
receiving medications
r_
Secure any unused medications until a time when I.,HJ can make arrangements for
rctrieval or disposal
Page 4
Participate, as appropriate, in LHJ- sponsored mass vaccination or medication dispensing
or administration training and exercises
Register and maintain qualifications of all Pharmacy personnel working under this
Agreernent as Emergency Workers within the Local Health Jurisdiction pursuant to
Chapters 38.52 RCW et seq., Chaptersl 18 -04 WAC et seq., and any other applicable
statute, regulation or law in order to obtain immunity from liability and the benefits of
workers compensation protection to the extent allowed by law.
ARTICLE VIII
COST AND PAYMENT
Local Health Jurisdiction shall provide the medications that are to be dispensed or administered
by Pharmacy as specified in this Agreement at no cost to Pharmacy. Pharmacy shall dispense or
administer these medications to patients or customers at no charge to the patient or customer
except for an administrative fee not to exceed the lesser of that reimbursed by the Medicare fart
B schedule, or emergency federal or state current guidance at the time. Pharmacy agrees to
waive this fee if required by then current federal or state guidance. Pharmacy may also, in its
discretion, waive this fee for patients or customers who demonstrate an inability to pay.
All other costs incurred by either Local Health Jurisdiction or Pharmacy through implementation
of this Agreement shall be borne by each respective agency.
ARTICLE IX
IMMUNITY, INDEM- NIFICATIONS AND LIMITATIONS
The Pat-ties acknowledge that if this Agreement has been triggered after a federal public health .
emergency declaration by the Secretary of the Department of Health and Human Services under
the PEEP Act, immunity under state and federal law will extend to covered persons involved in
dispensing, distributing, and administering countermeasures /prophylaxis under 42 i.i.S,C.A.
2474 -Fid. I�r�munity under the PREP Act does not apply to wil lful misconduct or acts conducted
outside the scope of the declaration,
Tile Parties further acknowledge that if this Agreement has been triggered after a locally or state
declared errrergcncy under chapter 38.52 RCW or after the issuance of an event mission number
by the Emergency Management Division of the Military Department, immunity and
indeninitication are provided under RCW 38.52.180 for activities within tite scope of assigned
responsilailitie sand under the direction of the local emergency management organization.
(rnmunity and indemnification does not apply to gross negligence„ willful or wanton misconduct,
or acts outside the scope of the assigned responsibilities or not under the direction of the local
emergency management organization.
Page 5
T he Part ies agree to assert immunity as applicable to any action against one or more of them,
The parties acknowledge that the indemnification and defense provisions herein do not abrogate
any statutory irrimunity.
If this Agreement has been triggered in circumstances when there is not a federal public health
emergency declaration or issuance of a state event mission number, or to the extent immunity
and indemnification under 42 U,S,C.A. §247d-6d or RCW 38.52.180 are determined by a court
of general jurisdiction in the State of Washington to be inapplicable, each party agrees to be
responsible and assume tort liability for its own wrongful acts or omissions, or those of its
officers, agents or employees to the fullest extent required by law, and agrees to save, indemnify,
defend and hold other parties harmless from any such tort liability. In the case of a determination
of negligence or wrongful acts by the Local Health Jurisdiction and one or more Pharmacy, any
damages allowed shall be levied in proportion to the percentage of fault attributable to each
party, and each party shall have the right to seek contribution from the other parties.
Notwithstanding anything to the contrary in this Agreement, once the Local Health Jurisdiction
has delivered the inventory to the Pharmacy, the LHJ will retain the risk of loss with respect to
the inventory unless the loss is the result of the Pharmacy's negligence, gross negligence or
intentional act or failure to act.
ARTICLE X
INFORMATION SHARING
Pharmacy will provide Local Health Jurisdiction with information Local Health Jurisdiction
deerns necessary for documentation of the actions taken and services, provided under this
Agreement, all of which is available under the public health exemption of HIPAA, 45 CFR
§164.512 {b), and the Health Care Information Act, RCW 70,02.050 (2)(a) .
Local Health Jurisdiction will advise Pharmacy of the information needed to protect the public
health and to prevent Or control disease, injury or disability and will only request the information
necessary to protect the public health and to prevent or control disease, injury or disability.
ARTICLE X1
TERM AND TERMINATION
'this Agreement shall become effective immediately upon its execution by any one Pharmacy
and one Local Health Jurisdiction. After the first two Such executions, this Agreement shall
effective as to any other Pharmacy or Local Health Jurisdiction upon its execution by
such rinacy or Local Ilealth Jurisdiction. The Agreement shall remain in effect as between
Pha
each and every Pharmacy and Local Health Jurisdiction until participation in this Agreement is
tel-111,111ated by a withdrawing Pharmacy or Local Health Jurisdiction by written notice to all of
the Agreement, Termination of'participation in this Agreement by a
01c other signatories to Pharmacy or Local I-lea I Ith Jurisdiction shall not affect the continued operation of
Page 6
this f\greeou#utos between the remaining Pharmacies and Local Health {o,isdiohouo so long as
at least one Pharmacy and one Local Health Jurisdiction remain.
Either Local Health Jurisdiction »r Pharmacy may toomioetcthis Agreement for convenience
with written notification to all oF the other signatories to the Agreement uo less than thirty 80
calendar days io advance of the termination date.
ARTICLE XII
AMENDMENTS
No provision of this ��grc:moeio�oy huonodifi ed uktrod ocrosciodtd by uuy individual
Pbmrn�ucyor�oualHeukbJwisdicdonvvtbwut1buouaninmuuscmmcurcenoe o[thcm1ber
Pharmacies and Local Health Jurisdictions. Modifications 10 this Agreement must bciuwriting
and will become effective upon the approval of the modification by all Pharmacies and Local
Health Jurisdictions. Mmdifivatlnoymust he signed 6y each Pharmacy and Local Health
f\R,[��BX8l
INDEPENDENT CAPACITY
Thp employees or agents of Pharmacy or Local Health Jurisdiction who are engaged io whole or
io part im the performance uf this Agreement shall continue 1obc employees or agents ofthat
party and shall not be considered for any purpose to be employees or agents of any other party to
this Agreement,
ARTICLE XIV
6EVERABlLOY
if any provision of this Agreement or any docurnent incorporated by reference shall be held
invalid, nuch�nvp6iddv shall not af��olthe other provisions of this ��Dceccocot»vbicbumohe
dhuinvu|idprovio�onifsuobrcnmuiodurcmnfomnmto1heroqu�remuen1sof
�vooc��ciwithout ,
�' d1U�[uudun��'ta|purpououftbis/\�nconm�o( and io this end the provisions of
|\cabi�\awuou `^" ,
n~~ uto�udccluced0o be severable.
this /+t��cx^ �
Page 7
ARTICLE XV
NO THIRD PARTY BENEFICIARIES
This Agreement is entered into solely for the mutual benefit of the parties to this Agreement.
This Agreement is not entered into with the intent that it shall benefit any other person and no
T
t' -party beneficiary of this Agreement.
other such person shall be entitled to be treated as a third
ARTICLE XVI
DISPUTE RESOLUTION
If a dispute between any parties to this Agreement arises out of or related to this Agreement, or i
the breach thereof, the parties agree to endeavor to settle the dispute n an amicable manner by
direct communication between or among each other before terminating the Agreement.
ARTICLE XVII
NOTICES
Whenever this Agreement provides for notice to be provided by one party to another, such notice
n
shall be i writing and directed to the designated representative of the party.
ARTICLE XVIII
SURVIVORSHIP
The following clauses SL'rV iVe the termination of this Agreement:
Ix. Immunity, Indemnification, and Limitations
XIV. severability
Xv. No Third Party Beneficiaries
ARTICLE XIX
OTHER OR PRIOR AGREEMENTS
Pharmacy and J,ocal I jellth 11.1fisdiction have a prior written agreement that relates to the
SL1bjCCt niatter of'this Atjeenient, namely, using existing Pharmacy infrastructure to assist in
Pm,e 8
1
addressing health and medical needs of an affected population during an Incident, including but
not limited to mass dispensing of antibiotics, antiviral medications or vaccines to the general
public during times of health and medical disasters, then, at such time that said Pharmacy and
said Local Health Jurisdiction both execute this Agreement, such prior written agreement
between them shall become null and void and of no further force and effect.
Notwithstanding the above provision in this Article XIX, any Pharmacy and/or Local Health
Jurisdiction may enter into other agreements with other Pharmacies and/or Local Health
Jurisdictions provided such other agreements govern stib,jcct matter not governed by this
Agreement
ARTICLE XX
GOVERNING LAW
This Agreement shall be interpreted, construed and enforced in accordance with the laws of the
State of Washington.
ARTICLE XXI
EXECUTION I-N COUNTERPARTS
This Agreement may be executed in two or more counterparts, each of which shall be deemed an
original, but all of which together shall constitute one and the same instrument. For purposes
hereof, a facsimile
copy ofthis Agreement, including the signature pages hereto, shall be deerned
to be an original.
IN WITNESS WHEREOF, this Agreement has been executed and approved and is effective and
operative as to each Pharmacy and each Local Health Jurisdiction as herein provided.
Company/ Organization
r)
Signature
Print Nanie and Title
Date:
A provr as form only .
�cutors fice
Co. P
jeffemn o. Prosecutoes ice
K�
David iv
David Alvarez, Chief Civi DPA
Page 9
WASHINGTON STATEWIDE
PHARMACY-LOCAL HEALTH JURISDICTION
MEMORANDUM OF UNDERSTANDING
Prepared by the Northwest Center for Public Health Practice,
School cfPublic Health, Principal
Investigator) Under the Guidance of the Local Health Jurisd Jurisdiction-rmu/n��� MOUOoeraUomPlanWnrkingGromp
,
This work Was supported by the Department of Health, State of Washington under Contract N19606. Its
contents are solely the responsibility of the authors and do not necessarily represent the official views of
the State of Washington.
------- members uf the Working Group, please see Appendix A
HE
ACRONYMS.............. ....................................................................................................... ............... 3
1. AUTHORITY ..................... ...................................................................... ..............................4
II. PURPOSE ................................................................................................ ..............................4
Ill. AUTHORIZED REPRESENTATIVES ............................... ...............................
IV. ACTIVATION PROCESS FOR THE MOU ..................... ...............................
...4
A. Who Can Activate the MOU and Planning Assumptions....... ........... .................... ......................4
B. Activation Process ...................................... ............................... ......... .................... ......................5
1. Type of Event... ......... -- ...... .................... ........ ____ ......... __ ........ __ ... .
, Procedures for MOU activation ........................ ...............................
6. Resource Request Form: Request and Response 'Procedures ......................... ..............................6
C. Communications .................................................................................................... ..............................6
D. Provision of Technical Assistance from Party LHJs .......................................... ..............................7
V. COST AND PAYMENT ................................................... ............................... ....................7
V1. INVENTORY TRACKING AND REPORTING ....................................... ..............................7
VII. TRAINING AND EXERCISES ........................................ .............................., 8
Vlll. DEMOBILIZATION ............................................................................... ..............................8
IX. OPERATIONAL PLAN REVIEW ............................................. ............................... .......9
APPENDIX A: MEMBERS OF THE WORKING GROUP ............................. .............................10
APPENDIX B: WASHINGTON STATEWIDE PHARMACY -LOCAL HEALTH JURISDICTION
MEMORANDUM OF UNDERSTANDING ( MOU) ............................... ............................... .....12
APPENDIX C: AUTHORIZED REPRESENTATIVES .................................... .............................18
APPENDIX D: TEMPLATE AGENDA FOR COORDINATION CALLS BETWEEN PARTIES ...
20
APPENDIX E: ACTIVATION REQUEST FORM .......................................... .............................21
APPENDIX F: TOOLKIT URL AND TABLE OF CONTENTS ........................ .............................25
APPENDIXG: GLOSSARY ........................................................................... .............................26
li
ACRONYMS
DOH
Department ofHealth
LHJ
Local HeefthJuhsdicbon
&Y[}U
Memorandum ofUnderstanding
RCVV
Revised Code ofWashington
SECURES
Washington Secure Electronic Communications, Urgent Response and Exchange System
SE{}{)
State Emergency Operations Officers
SNS
Strategic National Stockpile
SOP
Standard Operating Procedure
VVSpA
Washington State Pharmacy Association
i AUTHORITY
Thks operational planiadave|opedine000rdamoowiththeVVASH|NGTONSTATEVVDEpHARMACY-
0]CALHEALTHJUR|SD|CT0MMEKH[JRANDUK8C)FUNDERSTAND8NG(M(}U), Its contents have been
reviewed by the Local Health Jurisdiction (LNJ)-phermauy(Phermaoy) N1(}U Operational Plan Working
Group.
The purpose of the operational Plan is to set forth standard operating procedures (SOpu) and forms for
response under the WASHINGTON STATEWIDE PHARMACY-LOCAL HEALTH JURISDICTION MOU
(Appendix B). The purpose of this M()U is to utilize existing Pharmacy infrastructure to assist in
addressing the health and medical needs of an affected population during a Public Health Incident,
Emergency or Disaster (~incident"). using coordinated and standardized protocols statewide. The
Washington State Department of Health ("DOH") supports the development of this MOU. The types of
assistance that is envisioned that LHJs may request from pharmacies through this MOU include dispensing
medioadons, administering immunhza0ons, provision of pharmacy human resources and/or general or
targeted communication with the public.
UL AUTHORIZED REPRESENTATIVES
Each Party tu the MOU will designate its Authorized Re and will establish its own internal
procedures for authorizing, making nr agreeing torequests for Assistance. See Appendix C for LHJduty
officer and Pharmacy contact information to reach Authorized Representatives, Appendix C shall be
updated annually by each Party no later than February 1 of each year.
IV. ACTIVATION PROCESS FOR THE MOU
A. Who Can Activate the M(]U and Planning Assumptions
Activation of the MOU w0l be initiated by one or more Party LHJs when:
1 |n the judgment of the Party LHJ. circumstances are sufficient to exceed, or expected bz
exceed, the capabilities of its local or regional public health response�
Z The Party LHJ'm public health emergency operations plan isecUvahed-,
3. The Party LHJ is operating under the Incident Command System (ICS); and
4
4, A mission number2 has been requested by the local emergency management agency in
the Party LHJ's jurisdiction and received from the Washington State Emergency
Management Department.
B. Activation Process
1, Type of Event
Sjoqllp Jurisdiction: For low level emergencies or events that impact a single Party LHJ, the Party LHJ may
initiate a request for pharmacy assistance through the Washington State Pharmacy Association (WSPA).
WSPA would receive the request from the Party LHJ, assess the most appropriate means, for incorporating
pharmacies into the public health response, and convene a coordination call between the Party LHJ and
pharmacies, to discuss the situation and determine an appropriate course of action. The Party LHJ will lead
the conference call by following the draft agenda included in Appendix D. Following the conference call,
requests for assistance from the Party LHJ and actions agreed to by participating pharmacies will be
documented using the Assistance Request Form included as Appendix E.
Multi- Jurisdiction; When disasters affect multiple jurisdictions causing impacts that overwhelm the
response structure of more than one LHJ, WSPA will serve as the contact point for all LHJs requesting
pharmacy assistance. Upon receiving requests for assistance, WSPA will notify DOH that multiple LHJs
are requesting pharmacy support. DOH will then notify all LHJs in Washington, informing them that any
LHJs requesting pharmacy assistance should contact WSPA and participate in coordination conference
calls. WSPA will notify all appropriate pharmacies and all LHJs requesting assistance of the time and
contact number for coordination calls. WSPA will then facilitate all coordination calls following the Agenda
included in Appendix D. Requests for assistance from each Party LHJ and actions agreed to by
participating Pharmacies will be documented using the Assistance Request Form included as Appendix E.
2, Procedures for MOU activation
Activation will use the following standard operating procedures:
a. The MOU may be activated following a coordination call between Party LHJs, WSPA and
pharmacies to assess the nature and scope of the incident, and the potential need for assistance.
b. The MOU wifl be activated under the state mission number in support of the public health
response.
c. WSPA will coordinate requests for MOU-based assistance between impacted Party LHJs and
pharmacies using, the Assistance Request Form in Appendix E.
2 State Emergency Operations officers (SEGO) issue mission numbers to local authorized officials for approved
missions or other emergency activities. The mission number provides state liability coverage and reimbursement for
certain expenses of registered emergency workers involved in emergency response or training activities. Vi AC 11i 8
04-240 _
_ I
3. Resource Request Form-, Request and Response Procedures
a, Following 000rdinat�on calls convened bvVVSpA. party LHJa must complete the Assistance
Request Form in Appendix E and send it to WSPA unless it is electronically or logisticaUy
impossible todoso.
yyBpA will coilec Assistance Request Forms from eU requesting LHJs and forward boappropriate
pharmacies for review and approval. Xf the nature ofNleaasimtmnmsrequemhedimkdentica|amomg
multiple LHJs. VVSpA may consolidate all identical requests onto one form for transmission tp
pharmacies. The fbmo is complete when pharmacies sign the form agreeing to provide
assistance, and transmit the form back toVV5pA. VVSP& will then notify all LHJs that the request
for assistance is approved and can beimplemented.
c The Assistance Request Form may beemailedor faxed between the LHJe.WSP4and
pharmacies.
d Amendments hz the Assistance Request Form shall bein writing, and agreed between the parbes,
1
Parties will maintain and regularly update a contact list for authorized representatives, imdudinQ back-
up
2, Party LHJs would notify VVSP4 via phone, text, and/or email to assess the most appropriate means for
incorporating pharmacies into the public health response,
3. WSPA will convene a coordination call between the Party LHJ and pharmacies to discuss the situation
and determine onappropr�ahe course ofaction.
4, For the coordination call, pharmacies will receive a notification from LHJa via phone, fax and/or email
that consists of the following suggested statement:
"This iean urgent alert from the Washington State Pharmacy Association. Am incident warranting
the need for assistance from pharmacies has occurred and <LHJ> is activating its public health
emergency operations plan, VVe anticipate the need for </naaa dispensing, mass vaccination,
access to Pharmacy workers, communication with the public viaphannecies>, You are requested
bz join a conference call at <«««-xxx'»x«x conference |Dpuaacode:xxxxxxx>. |f You are unable tn
join this conference call, please contact <cxx-xxx-xxxx>
b, The following information is expected tobo discussed during the coordination oayy�
• Notify Pharmacy that community dispensing plans should beimplemented
• Facilitate adisousniom with Pharmacy regarding the most appropriate locations for distribution
• Provide Pharmacy with releasable information regarding the public health emergency situation
• Manage public information activities with regard to the overaiI health and medical response
across the Party LHJ's jurisdiction
• Identify the approximate number of medication doses that could be administered byPharmacy
in a specified time period and communicate that information to the Party LHJ
• Identify Pharmacy sites to receive medication deliveries and communicate site locations to the
LHJ
�
Communicate koLHJs each site location's scope of Pharmacy practice regarding affected
populations, e�g-. convey age or prescriptive authority limitations
8 party LHJs are expected to provide regular updates of the status of the event to WSPA and
Pharmacies. Connmun�
i mbonbotweenLHJaandWSPAandPharmmnlesduhnQthenasponaennay
occur through email, fax, conference calls, SECURES, and VVATnao.
7 /\||�mfmrrno±innsharimQvviUbedoneina«omrdanma»»ithHeabh|nsuranuePo�abNhh/and/�ccoun1ebi|ity
� » | v«�ive��yfed�na1�uth�ride�
�ct(N\�/��) unless .
D. provision of Technical Assistance from, Party LHJs
1 party LHJ will provide planning and technical assistance tn Pharmacy, including but not limited .to,
fact dispensing algorithms, and nnedima|protocols regarding the Phamnacys
supply lists, v^. .
response including, but not limited to, dosing and follow-up procedures.
21 Party LHJ will provide VVSPA and Pharmacy with releasable information regarding the public health
emergency situation,
3 party LHJ vvi|| provide Pharmacy with guidance and criteria for �aching levels ofactivity, supplies and
�
invenbary.asopp |iceb�abothenasponse'andtutheexhantpmsmib|e-oonsiohentacrmsosignatVryLHJ
V. COST AND PAYMENT
1 LH�sshm|\ id�the nnedioa�onsthat are habed�pensodoradrninis��nadbv Pharmacy aa
mt�1nu000t�oPhannooy
apeci�edin this Agnmeme
2 Pharmacy shaH not charge the patient or customer for the county, state or federally supplied drug,
vaccine or
other medical product, However, a dispensing or administration fee may be charged to
in accordance wvithemergency federal mr state current guidance atthe
�h� psdientmrcu�umer i |� Medicare ��d D m�hmdu|e this parioo|uro|ause related to Medicare
tim� S�nt��hemeimnosng .
Pert D in the template yN[)U is irrelevant so signatories are advised to iqmore this particular phase.
3
Pharmacy agrees tn waive this fee if required bv then current federal or state guidance. Pharmacy
may also, in its discretion, waive this fee for p�mentsor customers who demonstrate an inability tn
pay-
4, All other costs incurred by e�her Local Health Jurisdiction or Pharmacy through implementation of
this Agreement shall be borne by each respective agency,
3U.S. Department of Health & Human Services ht
V0. |h|\/ENT[2RY TRACKING AND REPORTING
1 LHJ shall specify the minimum detail of information needed from Pharmacy for imven*or� tracking
and reporting,
Pharmacy will work with LHJ to determine the format, mechanism and timing of reporting the
nninirnurn datammt The format should bake into account the need for multiple methods for
submitting date, potentially due to internal pharmacy restrictions on internetaocemm.
3. Pharmacy will be required to maintain an ongoing inventory record of supplied drug, vaccine or
other medical products throughout the duration of the period of activation of the MDU These
records should be kept in accordance with applicable rules and regulations. including Revised
Code of the State of Washington RCW 70.02 4 and Centers for Medicare and Medicaid guidance 5
4. if multiple LHJs have activated the MOU for the same event, standardized inventory tracking and
reporting forms wiH be used,
vil. TRAINING AND, EXERCISES
1 Pharmacy will be invited, as appropriate, to participate in LHJ- and DOH-sponsored mass
dispensing training and exercises.
2. Additional treinings are likely tobo convened or co-sponsored bvVVSPA.in conjunction withothor
key organizations.
3, A training archived webinar will be available for training purposes (URL to be provided),
NU. DEMOBILIZATION
The decision to return to normal operations and discontinue receipt of SNS supplies will be made
by the Local Health officer, or designee, after consultation with the appropriate parties. Triggers for
demobilization will be based on the foflowing factors� targeted population has received emergency
medications', sufficient distribution can be achieved through other mechanisms; mechanisms exist
for those without the ability to pay for emergency medications. LHJ will contact Pharmacy to
terminate dispensing operations.
2. Guidance for Pharmacy will be provided byLHJ for handling unused drugs and/or vaccines or
other medical products and for final reporting.
^
M
3, In the event that multiple LHJs have activated the MOU concurrently, the coordination of
demobilization activities will be facilitated by WSPA and will be communicated via conference call
and website updates as necessary.
Ix, OPERATIONAL PLAN REVIEW
1 , This operational plan will be reviewed at least once annually by an advisory group made up of
public health and pharmacy representatives, convened by Washington, State DOH.
2. This operational plan will also be reviewed following its use during a period of activation of the
MOU and recommendations from an after action report will be incorporated to update and improve
the operational plan.
APPENDIX A: MEMBERS OF T HE LOCAL HEALTH JUIRISDICTION-PHARMACY MOU
OPERATIONAL PLAN WORKING GROUP
Jenny Arnold, PharmD
Director of Pharmacy Practice Development
Washington State Pharmacy Association
Renton, WA
Shandra. Calm:es, PharmD
Patient Care Services Manager
Safeway-Northwest Division
Michelle Dulaney
Medical Countermeasures Program Manager
Public Health — Seattle & King County
Seattle, WA
Nancy Furness
Communicable Disease Special Assistant
Director
Snohomish Health District
Everett, WA
Gary Goldbaum, MID, MPH
Health officer and Director
Snohomish Health District
Everett, WA
German Gonzalez, MID, MPH
Epidemiologist & Manager
Communicable Disease and Epidemiology Division
Whatcom County Health Department
Jessica Guidry, MPH, CHES
Region 2 Coordinator, Emergency Preparedness
& Response
Kitsap Public Health District
Bremerton, WA
Tim S. Fuller, RPh
Pharmacist Consultant
Board of Pharmacy, Dept. of Health
Turnwater, WA
Michael Loehr, MRP, CBCP
Preparedness Director
Public Health — Seattle & King County
Seattle, WA
Cindy Myron
Regionai Emergency Response Coordinator
SNS/CRI Coordinator
10
Tacoma-Pierce County Health Department
Tacoma, WA
Chuck Paulsen, RPh
Pharmacy Merchandiser
QFC, Inc.
Bellevue, WA
Jeff Rochon, PharmD
CEO, Washington State Pharmacy Association
Renton, WA
Susan M. Sjoberg
Program Manager
Emergency Preparedness and Response,
Communicable Disease Epidemiology,
Spokane Regional Health District
Spokane, WA
Sepi Soleimanpour, RPh
Walgreens
Issaquah WA
Colleen M, Terriff, PharmD, BOPS, AAHIVE
Clinical Associate Professor
WSU College of Pharmacy
Deaconess Hospital and Rockwood Clinics
Cindy Thompson
Emergency Preparedness & Response Specialist
Spokane Regional Health District
Kathy Valluzzi
Acting Director Pharmacy Operations
Safeway Northwest Division-Seattle
Others:
Andy Stergachis, PhD, RPh
Professor, Epidemiology and Global Health
Northwest Center for Public Health Practice
Global Medicines Program
University of Washington
Mark Oberle, MID, MPH
Associate Dean for Public Health Practice
School of Public Health
University of Washington
Dave Owens
Emergency Health & Medical Logistics Manager Project Assistant
office of the Secretary University of Wash ington
Department of Health
Olympia, WA
Gillian Levine, MPH
Research Coordinator
Global Medicines Program
University of Washington
Rebecca Bartlein, MPH
11
��ppEN��|J�B:V�ASH|NGTON STATEVVDEpHARK0�\CY��'{�AL HEALTH J0R|S[��CT|ON
MEMORANDUM QF UNDERSTANDING (MOU)
WASHINGTON STATEWIDE PHARMACY-LOCAL HEALTH JURISDICTION
MEMORANDUM OF UNDERSTANDING
This Washington Statewide Pharmacy-Local Health Jurisdiction Memorandum cf Understanding ("K8(]U")ks
made and entered into by the signatory Health Department or signatory Hea|OhDisbiot.mrs|gnatoryCoomh/
within the State of Washington that operates a public health department ordivision within its county
government, ("Local Health Jurisdiction" or "LHJ") and each signatory pharmacy entity licensed in the State
of Washington ("Pharmacy"), individually, and with all other signatory LHJs and signatory Pharmacies.
ARTICLE
PURPOSE
The purpose of this MOU is to utilize existing Pharmacy infrastructure to assist in addressing health and
medical needs of an affected popmIadon during a Public Health Incident, Emergency or Disaster
(^|ncidmnt"), using coordinated and standardized protocols statewide. The Washington State Department
nf Health (^0[)H^) supports the development of this N10U,
ARTICLE 11
DEFINITIONS
Local, Health Jmimdictium�A signatory health department, health district, or county within the State of
Washington that operates a public health department or division within its county government, pursuant to
authority granted under Chapters 70.05, 70.08, 70.46 RCW or other applicable law. Each signatory party
shall designate representative for purposes ofaccepting maqueo1e for assistance and notice.
Pharmacy- /\ signatory to this M{)U who meets the definition of pharmacy as that term is defined in RCVV
18.64,011.
Plan- a written Operation Plan or procedure developed pursuant tn this K8DU.
Public Health Incident, Emergency, or Disaster ("Incident"): Any occurrence, or threat thereof, whether
ne1uroloroausedbynmmn.inwerorinpemcm.hz««hichenLHJmaymaopondpunouent0oitaauthorityumder
chapter 7D.O5.7O.OGor7O.48RCVV.»r other applicable law, and that, in the judgment of the LHJ.results
or may result in circumstances sufficient to exceed the day to day operational capabilities of immediate
local or regional public health response.
ARTICLE III
PARTICIPATION
The Pharmacies have a desire nm assist the LHJs in addressing health and medical needs of an afhaohad
population during anIncident. The LHJa and Pharmacies agree that this W1OQ. however, does not create a
legal duty to do so, The LHJs and Pharmacies agree that any and all actions taken pursuant to this MOU
shall be voluntary and in each LNJ`s and Pharmacy's sole discretion,
ARTICLE IV
HOW TO INVOKE ASSISTANCE
AoLHJ may request assistance mfm Pharmacy bv contacting the desi� netednapreseotahveofthat
Pharmacy. The provisions of this MOU shall only apply to requests for assistance made by and (usuch
designees. Requests may be verbal or in writing. If verbal, the request shall be confirmed in writing as soon
as possible 10 the extent practical. LHJs intend to activate community-wide mass vaccination and
dispensling plans, to include delivery of medications by Pharmacy with Pharmacy's agreement, only (a)
after a declaration of "Public Health Emergency" made by the Secretary of the Department of Health and
Human Services under the Public Readiness and Emergency Preparedness Act (PREP Ac�, 42 U-S CA.
12
§247d-6d, or (b) a locally or state declared emergency, under chapter 38.52 RCW, requiring a public
health and medical response, or (c), the issuance of an event mission number by the Emergency
Management Division of the State Military Department for a public health and medical response.
ARTICLE V
EFFECT OF DECLARATION OF EMERGENCY
The LHJs and Pharmacies recognize that state or federal declarations of emergency, or orders related
thereto, may supersede the arrangements made or actions taken pursuant to this MOU, Nothing in this
MOU should be construed as independent of or bypassing established emergency management
procedures, the provisions of county or state declarations of emergencies, or any conditions for the
distribution and dispensing of the Strategic National Stockpile (SNS) or administration of vaccines
established by the federal or state governments.
ARTICLE VI
R'ESPONSI'BILITIES OF LOCAL HEALTH JURISDICTIONS
Local Health Jurisdictions responsibilities includes:
coordinate with DOH and/or signatory pharmacies to ensure statewide consistency with screening
forms, tracking, training and other Pharmacy requirements if applicable.
Provide planning and technical assistance to Pharmacy, including but not limited to, supply lists, fact
sheets, dispensing algorithms, and applicable requirements
Provide statewide consistent medical screening forms to Pharmacy as a guidance for implementing
dispensing operations
« Provide technical assistance and training, as mutually agreed upon by LHJ and Pharmacy
Activate community -wide mass vaccination and dispensing plans as necessary
Notify Pharmacy that community dispensing plans should be implemented
« Request appropriate amounts and type of medication or vaccine, and available supplies, from local,
state or federal sources, including use of SNS resources
Facilitate a discussion with Pharmacy regarding the most appropriate locations for distribution
Request DOH to deliver, or have delivered medications to distribution centers as determined by the
local health jurisdiction in consultation with the DOH and Pharmacy
Provide Pharmacy with statewide consistent medical protocols regarding the Pharmacy's response
including, but not limited to, dosing and follow -up procedures
Provide Pharmacy with releasable information regarding the public health emergency situation
« Manage public information activities with regard to the overall health and medical response across the
LHXs jurisdiction
Provide educational materials, if appropriate, to Pharmacy for the purposes of distributing to all
persons in emergencies impacting the publ'ic's health
Make arrangements to retrieve or dispose of any unused medications from Pharmacy facilities and
collect documentation forms in coordination with DOH
Provide guidance and criteria to Pharmacy for tracking levels of activity, supplies and inventory, as
applicable to the response and consistent across signatory LHJ jurisdictions
If no statewide mission number has been issued by the State Emergency Management Division, Pharmacy
and Local Health Jurisdiction agree that prior to invoking this Agreement during emergencies, Local Health
Jurisdiction, through the local department of emergency management, will request the issuance of a
mission number from the Washington Military Department, Emergency Management Division.
ARTICLE VII
RESPONSIBILITIES OF PHARMACIES
Pharmacies' responsibilities include:
coordinate with DOH and/or signatory LHJs to insure statewide consistency with screening forms,
• tracking, training, and other Pharmacy requirements
• Comply with Pharmacy standards in effect during the Incident.
13
• Identify the approximate number of medication doses that could be administered by Pharmacy in a
specified time period and communicate that infumnshomho the LHJ
• Identify Pharmacy sites to receive medication deliveries and communicate site locations Lothe LHJ
• Communicate to LHJs each site location's scope of Pharmacy practice regarding affected
populations, e.g., convey age or prescriptive authority limitations
• Receive and store medication deliveries, consistent with federal, state orlocal government
requinannen{a, at Pharmacy-identified facilities during Incidents
• Ensure that Pharmacy site locations serve the general public
• At Pharmacy's discretion, ensure that its own employees, including those employed by its parent
company, and their families, are cared for consistent with public heaYthrecommendations
• Conduct medical screening of individuals receiving noedicat|mns, based on guidance provided by
LHJ, to identify potential contraindications and complications, and assure dispensing and
administration consistent with federaK, state and local government requirements
• In the absence of the issuance of an emergency use authorization, or a declared emergency
triggering RCVV3&52.18O (6) waiving license requirements for registered emergency workers,
prescribe and dispense medications under acollaborative agreement with g licensed health care
prescriber or lawful health order issued bya local health officer
• Maintain accurate records of medications diep*nsod, adnninistered, and remaining inventory
• Maintain and inventory the local, state or federal stock of Medications, vaccines and supplies and
physically separate them from the regular inventory. The local, state and federal stock cannot be
used hn place of commercial pharmacy stock ot any time, Pharmacy stock may be used aaa
substitute for the local, state or federal stock and Pharmacy may seek reimbursement for this
action, if available,, in accordance with the then current state or federal guidance
• Track contact information of individuals receiving medications
• Communicate information regarding medications dispensed, administered, and contact information
to |poeU health jurisdiction as required by |oom| heath jurisdiction
• Provide education mah*rio|o, supplied by Unce| health jurisdiction to all individuals receiving
medications
• Secure any unused medications until a time when LHJ can make arrangements for retrieval or
disposal
• Partioipate, as appropriate, in LHJ-sponsored mass vaccination ormedication dispensing or
administration training and exercises
• Register and maintain qualifications of all Pharmacy personnel working under this Agreement as
Emergency Workers within the Local Health Jurisdiction pursuant to Chapters 38.52 RCVV et seq.,
Chapters 118-04 VVAC etaeq., and any other applicable statute, regulation or law in order tuobtain
immunity from liability and'the benefits of workers compensation protection to the extent allowed
by law.
ARTICLE VIII
COST AND PAYMENT
Local Health Jurisdiction shall provide the medications that are to be dispensed or administered by
Pharmacy as specified in this Agreement atno cost k7Pharmacy, Pharmacy shall dispense oradminister
these medications to patients nr customers otnm charge tothe patient or customer except for an
administrative fee not to exceed the lesser nfthat reimbursed by the Medicare Pad D sohedu|e, or
emergency federal or state current guidance at the time. Pharmacy agrees to waive this fee if required by
then current federal or state guidance. Pharmacy may a|eo, in its discretion, waive this fee for patients or
customers who demonstrate an inability to pay.
All other costs incurred by either Local Health Jurisdiction or Pharmacy through implementation of this
Agreement shall be borne by each respective agency.
ARTICLE IX
IMMUNITY, INDEMNIFICATIONS AND LIMITATIONS
14
The Parties acknowledge that if this Agreement has been triggered after a federal public health emergency
declaration by the Secretary of the Department of Health and Human Services under the PREP Act,
immunity under state and federal law will extend to covered persons involved in dispensing, distributing,
and administering countermeasures /prophylaxis under 42 U.S.C.A. §247d -6d. Immunity under the PREP
Act does not apply to willful, misconduct or acts conducted outside the scope of the declaration.
The Parties further acknowledge that if this Agreement has been triggered after a locally or state declared
emergency under chapter 38.52 RCW or after the issuance of an event mission number by the Emergency
Management Division of the Military Department, immunity and indemnification are provided under RCW
38.52,186 for activities within the scope of assigned responsibilities and under the direction of the local
emergency management organization. Immunity and indemnification does not apply to gross negligence,
willful or wanton misconduct, or acts outside the scope of the assigned responsibilities or not under the
direction of the local emergency management organization.
The Parties agree to assert immunity as applicable to any action against one or more of them. The Parties
acknowledge that the indemnification and defense provisions herein do not abrogate any statutory
immunity.
if this Agreement has been triggered in circumstances when there is not a federal public health emergency
declaration or issuance of a state event mission number, or to the extent immunity and indemnification
under 42 LI.S.C.A. §247d -6d or RCW 38.52180 are determined by a court of general jurisdiction in the
State of Washington to be inapplicable, each party agrees to be responsible and assume tort liability for its
own wrongful acts or omissions, or those of its officers, agents or employees to the fullest extent required
by law, and agrees to save, indemnify, defend and hold other parties harmless from any such tort liability.
In the case of a determination of negligence or wrongful acts by the Local Health Jurisdiction and one or
more Pharmacy, any damages allowed shall be levied in proportion to the percentage of fault attributable
to each party, and each party shall have the right to seek contribution from the other parties.
Notwithstanding anything to the contrary in this Agreement, once the Local Health Jurisdiction has
delivered the inventory to the Pharmacy, the LHJ will retain the risk of loss with respect to the inventory
unless the loss is the result of the Pharmacy's negligence, gross negligence or intentional act or failure to
act. ARTICLE, X
INFORMATION SHARING
Pharmacy will provide vocal Health Jurisdiction with information Local Health Jurisdiction deems
necessary for documentation of the actions taken and services provided under this Agreement„ all of
which is available under the public health exemption of HIP'AA, 45 CFR §164.512(b), and the Health Care
Information Act, RCW 70.02.050 (2)(a).
Local Health Jurisdiction will advise Pharmacy of the information needed to protect the public healthh and to
prevent or control disease, injury or c or di di date and jury or ldisab request the information necessary to protect the
public health and to prevent
XI
TERM AND TERMINATION
This Agreement shall become effective immediately upon its execution by any one Pharmacy and one
Local Health Jurisdiction. After the first two such executions, this Agreement shall become effective as to
any other Pharmacy or Local Health Jurisdiction upon its execution by such Pharmacy or Local Health
Jurisdiction. The Agreement shall remain in effect as between each and every Pharmacy and Local Health
Jurisdiction until participation in this Agreement is terminated by a withdrawing Pharmacy or Local Health
Jurisdiction by written notice to all of the other signatories to the Agreement. Termination of participation in
this Agreement by a withdrawing Pharmacy or Local Health Jurisdiction shall not affect the continued
operation of this Agreement as between the remaining Pharmacies and Local Health Jurisdictions so long
as at least one Pharmacy and one Local Health Jurisdiction remain.
Either Local Health Jurisdiction or Pharmacy may terminate this Agreement for convenience with written
notification to all of the other signatories to the Agreement no less than thirty (30) calendar days in advance
of the termination date.
ARTICLE X1
15
AMENDMENTS
NopnovialoncfdhimAgreernentmaybemoddfied.alteredorrescmdedbvenyindk/iduo|PhannecyorL000|
Health Juriisdiction without the unanimous concurrence of the other Pharmacies and Local Health
Jurisdictions. Modifications to this Agreement must be in writing and will become effective upor the
approval mfthe modification by all Pharmacies and Local Health Jurisdictions, Modifications must be
signed by each Pharmacy and Local Health Jurisdiction,
ARTICLE X111
INDEPENDENT CAPACITY
The employees or agents of Pharmacy or Local Health Jurisdiction who are engaged in whole cr in part in
the performance of this Agreement shall continue to be empi or agents of that party and shall not be
considered for any purpose to be employees or agents of any other party to this Agreement.
ART1CLEXU\/
SEVERAB1L|T/
if any provision of this Agreement or any document incorporated by reference shall be held inva|id, such
invalidity shall not affect the other provisions of thlis Agreement which can be g:iven effect without the
invalid provisiom, if such remainder conforms to the requirements ofapplicable law and the fundamental
purpose cf this Agreement, and tothis end the provisions of this Agreement are declared tobeseverable.
ART|CLEXV
NO THIRD PARTY BENEFICIARIES
This Agreement ia entered into solely for the mutual benefit of the parties to this Agreement, This
Agreement is not entered into with the intent that it shall benefit any other person and no other such person
shall be entitled to be treated as o third-party beneficiary of this Agreement.
ART|CLEXV|
DISPUTE RESOLUTION
If a dispute between any parties to this Agreement arises out of or related to this Agreement, or the breach
thereof, the parties agree to endeavor to settle the dispute in an amicable manner by diirect communication
between or among each other before terminating the Agreement.
ARTICLE XVI|
NOTICES
Whenever this Agreement provides for notice to be provided by one party to another, such notice, shall be
in writing and directed 0o the designated repnesemtativeof the party.
ART|CLEXV|U
SURVIVORSHIP
The following clauses survive the termination of this Agreemnemt
Ix. immunity, Indemnification, and Limitations
XK/, Bevorab||by
XV, No Third Party Beneficiaries
ARTICLEX|X
OTHER C}R PRIOR AGREEMENTS
If a Pharmacy and Local Heaith Jurisdiction have a prior written agreement that relates to the subject
matter of this Agreement, mame|y, using existing Pharmacy infrastructure to assist in addressing health and
medical needs of an affected popu)ation during an Incident, including hut not ftited to mass dispensing of
antibiotics, antiVral medications or vaccines to the genera� public during times of health and medical
disoshsrs, then, at such time that said Pharmacy and said Local Health Jurisdiction both execute this
16
n�suchphmrwrhhenagreemantbetweenUhamshaUbeconnenuUmndvo�andmfmrfu�herforne
Ag�en�
and effect.
i the provision in this A��|eXJX, any Pharmacy and/or Local He�t Jurisdiction may
N�tm�th�t�mgm� ennentsv«i~�therPharmnacios and/or Local Health Juhsdictiomeprovided such other
enteriu1ooth�r�Qns�ubi�ctmn"'' matter by agreements govern . �^^~ , ~
ART|CLEXX
GOVERNING LAW
This Agreement shall be interpreted, construed and enforced in accordance with the laws of the State of
VVaahingtom
ARTICLEX>(h
EXECUTION IN COUNTERPARTS
ntmay bee � H
executed deemed mnoriginal,
Th\�A�nmern�
but all of which together shall constitute one and the same instrument For purposes hereof, afacsimile
copy of this Agreement, including the signature pages hereto, shall be deemed to be am original.
hW WITNESS WHEREOF, this Agreement has been executed and approved an di s effective and operative
ve
asto each Pharmacy and each Local Health Jurisdiction ae herein provided,
Organization
Signature
rint Name and Title
Date
17
APPENDIX C: AUTHORIZED REPRESENTATIVES
The following position titles are authorized to act for the listed Parties as the Authorized Representative
under the MOIL and the Operational Plan or to connect the caller to the person who is authorized to act:
�i_ealth
Title
Phone Contact
Email Contact
Alternative
Department/
Information
Information
Contact
Information,
District or
(if applicable)
Pharmacy
�rVA State
Duty Officer
360-888-0838
h_.analert(Qdoh.wa.
%0_v
Department of
360-971-0601
Health
(pager)
L
Washington State
Director of Practice
Jenny Arnold
_wsparx,org
jgD n, y( @
Jeff Rochon
Pharmacy
Development
206-948-1531
Leff@wsoarx.org
Association
(cell)
206-595-4276
425-369-2244
(cell)
(home)
425-207-3641
425-207-3642
(work)
work.)
Tacoma-Pierce
Duty Officer
253-798-6500
County Health
After hours
800-726-6404
De artment
Duty Officer
360-415-2005
Kitsap County
Health District
Snohomish Health
Duty Officer
425-339-5295
District
Chelan - Douglas
Daytime Mon-Thu
509-886-6400
Health District
After hours ww�
_i�
509-665-1509
Pubic a�th�
Duty 5ffici�_r_
206-296-4606
Seattle-King
County—.--,
Spokane Regional
Duty Officer
509-869-3133
Medical
i Health District
509-324-1500
Countermeasure
(after hours)
(Mass
Treatment/SNS)
Coordinator Patti
Richards
509-324-1451
(office)
prichards@srhd,or
—D—luty
As6_t_i�6`ounty__'_
Officer
509 -552 0049
Health Department
IN
I Michael
.ostco. Wholesale Mastromonica
425-313-2892
Assistant Vice
President-
Pharmacy
Whatcom County Answering service
360-715-2588
Health Department
19
mmastromon.ica@ Gabriel Marcus
costco.com gmarcus(a-)costco.c
om
General Description of the Public Health Hazard (i.e. type of disease outbreak, environmentu|
health threat, infrastructure impacts, etc.)
3. Type of Assistance Needed. Include types of medications to be dispensed or vaccines
administered', specific populations orphority groups that have been defined; types ofinformation
tobe communicated to the public; number uf pharmacy personnel requested bn support, public
health response facilities)
4 When and Where Assistance isNeeded
5 in�tia| Assessment oƒ Pharmacy Resources Available for Response
G. Initial Assessment cf Information needs or Logistical Support Required by Pharmacy from LHJ
7 Issues tobeAddressed
& Next Steps
M
APPENDIX E: ACTIVATION REQUEST FORM
Local Health Jurisdiction - Pharmacy MOU operational Plan ,
RESOURCE REQUEST FORM
PARTY'LbCAL'
—
Requesting parti L H J
Contact person/Title:
Telephone:
FAX (
Email:
to Mission #:,
General Description of the public health hazard (i.e. type of disease outbreak, environmental health threat,
infrastructure impacts, etc.):
--�ceeeded (use Part 3 if needed). Include types of medications to be dispensed or vaccines
fy—pe —of Aislsta types of information to be
administered; specific populations or priority groups that have been defined;
communicated to the public; number of pharmacy personnel requested to support public health response
facilities:
When assistance Wl�l b e7— needed, and for how long (approximately):
'
Geographic area where assistance is needed if known (countywide, region-wide, town or neighborhood level)
21
_�._.._ _ ............... ....._...._. _.....
PART 2: Gate: Time:
COMPLETED BY ASSISTING PHARMACY
Pharmacy Name: _ _._ . ......_.
Contact Person /Title:
Telephone: ( ) mm
FAX ( )
Email:
Pharmacy agrees to provide assistance as requested above
Pharmacy agrees to provide only the following forms of assistance (complete this part only if type of
assistance available differs from the request above):
Pharmacy cannot provide assistance
When assistance will be available, and for how long (approximately):
Information needs or logistical support required by Pharmacy from LHJ (use Part 3 if needed):
Authorized Representative (electronic signature)
22
23
_
Form Instructions
The Requesting Party LHJ is one that has been impacted by a public health incident, emergency or disaster and is
requesting Assistance, The Assisting Pharmacy is asked to respond hy providing Assistance, This form wUH serve omo
means to document assistance requests and authorizations.
PART 1:
The Requesting Party LHJ completes PART 1 (PART 3 serves as additional space for describing the type of
assistance needed and may be used ifnecessary).
The form is then amai|sd by the Requesting Party LHJ tu the VVSRA.
PART 2:
The Assisting Phanmacyies completes PART 2 and ema0a the form back 1mVVSpA.
The Assisting Pharmacy(ies) may contact the Requesting Party LHJ for clarification and coordination, or may make
such contact through VVSPA. while in process of completing PART 2
When PART 2 is completed, the Assisting Phamnacyemoi|e the form toVVSp8.
Part 3:
PART 3 servesas additional space for describing the type of assistance needed and additional information or logistical
�
support needs.
24
APPENDIX F:TOQLNJTURL AND TABLE QFCONTENTS
URL for Tom|Wt:
overview of material to be included in thetmo|k|t:
1'R8OU and Operational Plan Templates
• Washington Statewide Pharmacy-Local Health Jurisdiction Memorandum Of Understanding
template
• yyu`-�ngb»n���benvi6����mmm�y-Looa|Mma�hJu�sdiution88ernorondummOfk�ndwrsiandKn8
operational Plan
O� and
• Training video fmrK8 Operational �|�n
2. Facilitated Discussion K8ateria|, including ppT and After Action Report Template
3. Private 'Medication Center Partnership Materials
4. Additional Resources
and information
Medical screening forms
Education materials for the public
Anthem - amoxiciUin
Anthram - Ciproflmxin
Anthrmx - Ooxyoycnme
pill Crushing Instructions for DnxycyoUne
Template of Standing Orders and Protocols for Treatment ofIndividuals Exposed toAnthrax
Medication Dispensing Tracking Sheet
Medical Countermeasures Distribution Form
Medical Countermeasures Reference Table
SNS Formulary
25
Local Health Jurisdiction-. Asig0atory health department, health district, or county within the State of
Washington that operates a public health department or division within its county government, pursuant to
authority granted under Chapters 7O.O5.7Q,O8.7OA8RCWor other applicable law. Each signatory party
shall designate a representative for purposes of accepting requests for assistance and notice.
Pharmacy: A signatory to tNs K8[)U who meets the definition of a pharmacy as that term is defined in
RCVV18.G4.O11
Plan: a vvrhttem Operation Plan or procedure developed pursuant to this K8[;U
Public Health Incident, Emergency, or Disaster ("Incident"): Any occurrence, mr threat thereof, whether
natural or caused by mon, in war or in peaoe, to which an LHJ may respond pursuant to its authority under
chapter 70.05, 70.08 or 70.46 RCW, or other applicable law, and that, in the judgment of the LHJ, results
or may result in circumstances sufficient to exceed the day to day operationa! capabilities of immediate
local or regional public health nespomae-
2O