MEDSTAR ACADEMY AND MCCHS AFFILIATION AGREEMENT.PDF

FACILITY STUDENT AFFILIATION AGREEMENT  
THIS AFFILIATION AGREEMENT between _Maricopa County_ hereinafter known as the “FACILITY, 
located in _Phoenix, Arizona and MedStar Academy, Inc. RN/LPN/PN Refresher Program (“School”) 
located in __Peoria__, Arizona. The purpose of this Agreement is to jointly undertake a program whereby 
clinical instruction and learning experiences (“Program Services”) will be offered at the Facility, which is 
committed to training health care professionals, to Students in accordance with the policies and objective 
of the FACILITY, and in accordance with all applicable State and Federal statutes. In consideration of the 
mutual promises and covenants contained in this Agreement, Student and the Facility agree as follows: 
A. There will be no payment of charges or fees between MedStar Academy, Inc., Student, 
and the Facility. There will be no discrimination against any program participant or 
applicant covered under this Agreement because of race, color, religion, national origin, 
age, handicap, status as a Vietnam era or disabled veteran, or sex or gender, nor will 
School or the Facility engage in unlawful discrimination in their employment or 
personnel policies.  
I. 
RESPONSIBILITIES OF STUDENT:  
A. Student is responsible for acquiring his or her own health insurance. The Facility is not 
responsible or liable for injury, illness or disease sustained by Student while performing 
duties related to the Program Services.  
B. Student will provide evidence to the Facility of current immunizations against diphtheria, 
tetanus, measles, mumps, rubella (or a positive rubella titer), and of hepatitis B 
immunization status for those students who will be in contact with patients/clients. For 
any student born after 1956, Student will provide record of positive titer or of post-1967 
immunization for rubella and rubella. At the time of immunization, students with no history 
of exposure to varicella (chicken pox) will be advised to get an immune titer. MedStar 
Academy, Inc. will require yearly PPD testing, or follow-up as required by the Centers for 
Disease Control and the Facility. If the student is PPD-positive, he/she will provide an X-
ray showing negativity. MedStar Academy, Inc. will provide information to the Facility 
regarding student status concerning the above requirements upon request. 
C.  Student will provide copy of a Fingerprint Clearance card issued by the Department 
of Public Safety, State of Arizona. Student does not certify the veracity of the records 
provided and, furthermore, the obligation to conduct appropriate background checks and 
the liability for non-compliance therewith remains the responsibility of the Facility.  
D. Student shall maintain during the term of this Agreement, without cost to Facility, such 
insurance as is necessary to protect against liability arising from or incidental to the 
performances of services related to this Agreement. Coverage under such insurance 
shall be not less than One Million dollars ($1,000,000) for each occurrence and Six 
Million Dollars ($3,000,000) in the aggregate. Student shall provide the Facility with a 
certificate of insurance evidencing the insurance coverage required.  
E. Student is required to adhere to the standards, policies, and regulations of the Facility 
during his or her clinical education program. Noncompliance may result in withdrawal of 
clinical education/preceptorship privileges for Student.  
F. Student will maintain the confidentiality of patients’ records and will abide by the 
professional Code of Ethics.  
G. Student acknowledges that time spent gaining clinical experience is a non-wage 
experience.

H. Student will complete an orientation procedure normally offered to new employees.  
I. Student agrees to pursue the prescribed course of study of 160 hours of preceptorship as 
outlined in the Arizona State Board of Nursing RN Refresher Program guidelines. 
Schedule should reflect the training hours of the student. Student will take advantage of 
every opportunity to improve his or her skills, knowledge, efficiency, and professional 
attributes necessary to achieve the standards of practice and performance expected of 
a professional healthcare worker. Student will review the specific policy and procedure 
prior to observing or performing a new or unfamiliar task and seek prompt assistance 
when needed.  
J. Student will be punctual and prepared to perform on the dates scheduled for clinical 
education/preceptorship. If unable to be present on the scheduled dates, student will 
promptly notify the designated hospital supervisor.  
K. Student will be courteous, honest, maintain a cooperative attitude and demonstrate the 
integrity of a health care professional, especially during interactions with patients and in 
concern for the patient’s security and welfare.  
L. Students will wear appropriate attire and name tags, in conformance to the standards and 
practices established by the Facility during their clinical education program at the 
Facility.  
M. The student assigned to the Facility will be and will remain a student and will in no 
sense be considered an employee of the Facility. The Facility does not and will not 
assume any liability under any law relating to Worker's Compensation because any 
Student's performing, receiving training, or traveling pursuant to this Agreement. 
Student will not be entitled to any monetary or other remuneration for services 
performed by him or her at the Facility, nor will the Facility otherwise have any monetary 
obligation to Student by this Agreement.  
N.   The violation of this Agreement by a Student shall constitute sufficient cause for 
the Facility to terminate the Student from the Program Services. 
II.         SCHOOL'S RESPONSIBILITIES 
A. MedStar Academy, Inc. will provide information to the Facility concerning its curriculum 
that has been approved by the Arizona State Nursing Commission and the professional 
and academic credentials of its faculty for this student at the Facility if requested. 
MedStar Academy, Inc. will designate an appropriately qualified and credentialed faculty 
member to coordinate and function as the Liaison with the Facility. MedStar Academy, 
Inc. will be responsible for instruction and administration of the student’s academic 
educational programs. MedStar Academy, Inc. will notify the Facility in writing of any 
change or proposed change of its Liaison. MedStar Academy, Inc. will have the final 
responsibility for grading student.  
B. MedStar Academy, Inc. will provide the name and information pertaining to relevant 
education and training for this student enrolled in the clinical education program at least 
two weeks before the beginning date of the clinical education program. MedStar 
Academy, Inc. is responsible for supplying any additional information required by the 
Facility as set forth in this Agreement, prior to the arrival of the student. MedStar 
Academy, Inc. will notify the Facility in writing of any change or proposed change in a 
student's status.  
C. MedStar Academy, Inc. will assign to the Facility only those students who have 
satisfactorily completed the prerequisite didactic portion of the curriculum and who have 
current CPR certification.  
D. MedStar Academy, Inc. will encourage each student participating in the clinical 
education program to acquire comprehensive health and accident insurance that will 
provide continuous coverage of such student during his or her participation in the 
education program. School will inform students that they are responsible for their own 
health care costs, health insurance coverage, and their own health needs.

E. MedStar Academy, Inc. will comply with, and shall direct its students to comply with, the 
policies and procedures of the FACILITY/Training Site, including those governing the 
use and disclosure of individually identifiable health information under federal law, 
specifically 45 CFR parts 160 and 164 (HIPAA). Notwithstanding paragraph II.G, solely 
for the purpose of defining the student's role in relation to the use and disclosure of the 
Facility/Training Site's protected health information, such students are considered 
trainees and members of the Facility/Training Site's workforce, as that term is defined 
by 45 CFR 160.103, (Department of Health and Human Services) when engaged in 
activities pursuant to this Agreement. However, such students/trainees are not, and 
shall not be, considered to be employees of the Facility/Training Site. School will notify 
each student of his/her status and responsibilities pursuant to this Agreement.  
III.        FACILITY'S RESPONSIBILITIES  
A. The Facility will provide the student with a desirable clinical education experience within 
the scope of health care services provided by the Facility. The Facility will designate an 
individual to the role of clinical coordinator/preceptor, who will provide instruction for 
Student, when appropriate and needed, and information on procedures, equipment 
operation and responsibilities within the department. The clinical coordinator/preceptor 
will provide student with the needed opportunities to fulfill the clinical experience 
requirements in both observational and supervised hands-on experience.  
B. The clinical coordinator/preceptor (see separate document for the Preceptors Guide to 
the RN/PN Refresher Student for definition), will evaluate and/or assign other qualified 
professionals to assist in the evaluation of student’s competency level in performing 
program services. The original “Skills Checklist” and “Preceptor Evaluation” will be 
completed by the preceptor to verify satisfactory completion of the stated required 
elements. Experiences must include Nursing process, Pharmacology, Delegation, 
Management, and Supervision. Decision making and Critical Thinking, Patient 
Assessment and Evaluation of care and communication with health team members, 
also meeting psychosocial and physiological need of patients as per the Arizona Board 
of Nursing are to be included. The Facility will provide students with access to sources 
of information necessary for education within the Facility’s policies and procedures and 
commensurate with patients' rights, including library resources and reference materials.  
C.  The Facility will make available to student’s basic supplies and equipment necessary for 
care of patients/clients and the clinical education program. Within the limitation of 
facilities, the Facility will make available office and conference space for students.  
D.  The Facility will submit required reports on each student's performance and will provide 
an evaluation to School on forms provided by School.  
E.   The Facility retains full responsibility for the care of patients/clients and will maintain the 
quality of patient care without relying on the students' clinical training activities for 
staffing purposes.  
F.   Student shall not be considered an employee of the Facility. The Facility does not 
assume and shall not assume any liability under any law reliant to Worker’s 
Compensation because any act of student’s performing, receiving training, or traveling 
pursuant to this Agreement.  
G.  The Facility will have the right to take immediate temporary action to correct a situation 
where a student's actions endanger patient care. As soon as possible thereafter, the 
Facility’s clinical education Supervisor will notify MedStar Academy, Inc. of the action 
taken. All final resolutions of the student's academic status in such situations will be 
made solely by MedStar Academy, Inc. after reviewing the matter and considering 
whatever written information the Facility provides for School; however, the Facility 
reserves the right to terminate the use of its facilities by a student where necessary to 
maintain its operation free of disruption and to ensure quality of patient care.

H.  On any day when a student is participating in the clinical education program at its 
facilities, the Facility will provide to such student necessary emergency health care or 
first aid for accidents occurring in its facilities. Fiscal responsibility for such emergency 
care, including care described elsewhere in this Agreement, will be as follows:  
• 
The Facility will not bill students for the cost of initial emergency care.  
• 
Emergency care does not include follow-up for blood-borne pathogen exposure.  
I. At the student's expense, the student will have completed an HIV training prior to 
beginning clinical and will be responsible for all self-follow-up care if needed. The 
Facility shall recognize that the student has the status of learner and shall not 
replace staff or employees. Except as provided in this Agreement, the Facility will 
have no obligation to furnish medical or surgical care to any student. 
J. MedStar Academy, Inc., and student understands that the Facility will accept the 
student’s Arizona Fingerprint Clearance Card in lieu of a full background check. Should 
the facility require further background check they will do so at their decision and from 
within their Facility. 
IV 
JOINT RESPONSIBILITY  
MedStar Academy, Inc. and Facility will communicate by meeting, telephone, or email with either 
the Facility clinical educator, Supervisor or Preceptors, at the beginning or end of the clinical 
education program to discuss and evaluate the clinical education program.  
V.        LIABILITY COVERAGE PROVISIONS  
A. The Facility/Training Site will be responsible for the negligent acts and omissions of its 
own employees, officers, and agents, which may occur regarding this Agreement as 
provided by law.  
B. The student will obtain and maintain professional liability coverage with limits of not less 
than $1 million per occurrence and $3 million annual aggregate (or an equivalent 
program of self-insurance) before beginning their clinical experience. The student will 
provide a copy of this to the facility prior to beginning their clinical experience.  
C. Student shall forever hold the Facility, MedStar Academy, Inc. and its employees, 
agents and representatives harmless of, from and against, and shall defend the Facility 
against and indemnify the Facility for, any and all liability which might be asserted 
against the Facility, MedStar Academy, Inc. and any and all costs, expenses and 
damages (including attorneys’ fees) which might be sustained by the Facility, & MedStar 
Academy, Inc. by virtue of, or arising out of or in connection with the negligent acts or 
omissions in the performance of Program Services by student.  The indemnification 
provisions of this Section shall survive the termination and/or expiration of this 
Agreement.  
Vl.     TERM 
A. This Agreement is effective beginning January 26, 2022. The facility will commit to 
precepting students as they see availability when approached by MedStar Academy, 
Inc. 
B. This agreement may be canceled by either party by providing 30 days written notice to 
the other party. Students currently enrolled in a clinical rotation at the Facility at the time 
of termination will be permitted to complete the current semester/quarter.

VII.     PROVISIONS REGARDING BLOOD-BORNE PATHOGENS AND 
TUBERCULOSIS EXPOSURE  
A. MedStar Academy, Inc. certifies that it has trained each student it sends to the Facility in 
universal precautions and transmission of blood-borne pathogens and tuberculosis, and 
that it will send to the Facility only students who have been trained in and have 
practiced using universal precautions. MedStar Academy, Inc. requires that each 
student receive the Hepatitis B (HBV) vaccine before assignment to the Facility. The 
Facility will provide personal protection equipment that is appropriate for the tasks 
assigned to School's students, including appropriate fitting for respiratory protection 
masks.  
B. In the event a student sustains a needle-stick injury or other substantial exposure to 
bodily fluids of another or other potentially infectious material while participating in the 
clinical education program at the Facility, the Facility agrees to provide the following 
services:  
• 
Being seen by the Facility employee health service and/or nursing supervisor as soon 
as possible after the injury.  
• 
Emergency medical care following the injury.  
• 
Initiation of HBV, Hepatitis C (HCV) and HIV protocol; follow-up if needed will be the 
responsibility of each student. 
• 
HIV counseling and appropriate testing is the responsibility of each student. 
C. The source patient's HBV, HCV and HIV status will be determined by the Facility in the 
usual manner to the extent possible. Neither the Facility nor MedStar Academy, Inc. will 
accept liability for any illness or injury after such accidental exposure, except as 
otherwise provided in this Agreement. Each student is encouraged to carry their own 
personal health insurance. 
VIII.      MISCELLANEOUS PROVISIONS  
A. Entire Agreement. This Agreement constitutes the entire agreement between the 
parties, and supersedes all prior oral or written agreements, commitments, or 
understandings concerning the matters provided for herein.  
B. Amendment. This Agreement may only be modified by a subsequent written Agreement 
executed by the parties. The provisions in this Agreement may not be modified by any 
attachment or letter agreement as described elsewhere in this Agreement.  
C. Order of Precedence. Any conflict or inconsistency in this Agreement and its 
attachments will be resolved by giving the documents precedence in the following order:  
1. This Agreement.  
2. Attachments to this Agreement in reverse chronological order.  
D. Governing Law. The parties' rights or obligations under this Agreement will be construed 
in accordance with, and any claim or dispute relating thereto will be governed by the 
laws of the State of Arizona.  
E. Notices. All notices, demands, requests, or other communications required to be given or 
sent by School or the Facility, will be in writing and will be mailed by first-class mail, 
postage prepaid, or transmitted by hand delivery or facsimile, addressed as follows:

F. Cancellation  “This Agreement is subject to cancellation pursuant to A.R.S. §38-511. 
1. To School:  
MedStar Academy, Inc. 
Attn:  Linda Rose BSN, RN, MHA, Executive Nursing Director and President  
27200 N 130th Dr. 
Peoria, AZ 85383  
Cell: (480) 628-0937 
Fax:  1(623)-399-1192 
2. To: Facility: 
Maricopa County Correctional Health Services 
Attention: _Donna Campbell BSN, RN, CCHP 
Education Nursing Supervisor 
Lower Buckeye Jail 
3250 W. Lower Buckeye Rd. 
Phoenix, AZ 85009 
Office:  602-876-7115 
Donna.Campbell@Maricopa.gov

Wayne J. Peck
January 4, 2022