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HomeMy WebLinkAbout2008-061 Health - NC Department of Health and Human Services• PLEASE ACCEPT AS ORIGINAL ., SIGNATURES ~~~~~~ n~~a _ ~~~ Page 1 of 18 • ~ ~~~ ~ ~®1'a MAY ~ ~' 2~7 ~~iV~~A ors MAY 0127 CONSOLIDATED AGREEMENT ~~~~~~~ BETWEEN MAY 0 3.2001 THE STATE OF NORTH CAROLINA AS REPRESENTED BY THE STATE HEALTH DIRECTOR (Hereinafter called the "State") Orange Co Health Dept (Local Health Department/District/PublicHeahh Authority/Human Services Agency (Wake and Mecklenburg) -- Hereinafter called the "Department") FOR THE PURPOSE OF MAINTAINING AND PROMOTING THE ADVANCEMENT OF PUBLIC HEALTH IN NORTH CAROLINA This Amended Agreement Shall Cover a Period From July 1, 2007 to June 30, 2008 and shall remain in force until the next Fiscal Year Agreement is signed except as provided for in Section J. Termination. NOW, THEREFORE, the State and the Department agree that the provisions and clauses herein set forth shall be incorporated in and constitute the terms and conditions applicable for activities involving State funding. (State funding or funds means state, federal, and/or special funding or funds throughout this agreement.) • co~,sosaaua w~~ _ ~~i Page 2 of 18 A. RESPONSIBILITIES OF THE DEPARTMENT (LOCAL PUBLIC HEALTH LJNI'I? 1. The Department shall perform activities in compliance with applicable program rules contained in the North Cazolina Administrative Code, as well as all applicable Federal and State laws and regulations. 2. The Department shall perform the activities specified in the Program Agreement Addenda for State funded budgets. The Department must negotiate these Agreement Addenda in good faith to the satisfaction of state representatives as part of the agreement execution. The Department will meet or exceed the Agreement Addenda levels unless extenuating circumstances prevail and aze explained in writing to the state section, branch or program. 3. The Department shall report client, service, encounter, and other data as specified by applicable program rules, Program Agreement Addenda for State funded budgets, and by North Carolina Administrative Code. 4. The Department shall provide access to patient records to authorized staff from the Division of Public Health for technical consultation, program monitoring, and program evaluation, as specified by applicable program rules, Program Agreement Addenda for State funded budgets, and by North Carolina Administrative Code. 5. The Department shall provide client, service, encounter, and other data through the states' centralized automated systems for claims creation and submission for processing to the state's Medicaid agency except as allowed by NCGS 130A - 45.13. 6. The Department shall shaze data to support efforts of the public health system, represented by the local health departments, local health programs, and the State, in order to meet public health objectives while • respecting the confidentiality and integrity of each agency's data and protecting the privacy of individual client health information. Sharing data includes providing client information allowed as permitted disclosures under the Health Insurance Portability and Accountability Act of 1996, Public Law 104-91, HIPAA Administration Simplification Provisions Sections 261 through 264, 45 CFR 164.512, Uses and disclosures for which consent, authorization, or opportunity to agree or object is not required. 7. The Department shall administer and enforce all rules that have been adopted by the Commission for Health Services, ratified by the NC General Assembly, or adopted by the Local Board of Health. 8. The Department shall provide to the State copies of rules adopted by the Local Board of Health pwsuant to G.S. 130A-39 and Public Health Ordinances adopted by the County Commissioners, within 30 days of adoption. These rules/ordinances are to be sent to the Local Technical Assistance and Training Branch (I-TA~~ 9. The Department shall have policies related to conflict of interest and policies and procedwes for Human Subjects Clearance. Each staff member shall receive a copy of these documents. 10. The Department shall provide to the State a comprehensive community health assessment (CHA) every fow yeazs and a State of the County's Health Report each of the interim three years. Healthy Cazolinians/Health Education Branch/CDI Section will administer this fow-year cycle. The CHA should be a collaborative effort with the local Healthy Cazolinians Partnership, if such exists, and shall include collection of primary data at the county level. The CHA shall include a list of community health problems based on the findings and a narrative of the assessment findings. The agency is required to submit community action plans to address the selected priority issues. These plans are due to the Office of Healthy Cazolinians/Health Education by the first Friday in March unless the Agency's Healthy Carolinians Partnership is submitting an application for certification/recertification, in which case the community action plans can be submitted at that time as part of the application. The CHA will include data analysis of those indicators that aze listed in • the accreditation self-assessment. 11. The Department shall provide formal training for their Boazd of Health (BOIT) members through DHHS sponsored offerings through the UNC School of Public Health -Institute of Public Health. First priority will • 7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that is not debarred, suspended, ineligible, or voluntarily excluded from covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency of which it determines . the eligibility of its principals. EaLh participant may, but is not required to, check the Nonpmcurement List. 8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 9. Except for transactions authorised in paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension, and/or debarment. • Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - i,ower Tier Covered Transactions (1) The prospective lower tier participant certifies, by submission of this document, that neither it or its principals is presently debarred, suspend, proposed for debarment, declared ineligible, nor voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. ... Authorized ency Official Signature Title Q raw e ~oww + {-~ea.~~ ~ . Official Agency Name • (Signature should be same as Contract signature) Date Debarment 5/00 Page 2 of 2 C~ • • Consolidated Aunt - Final Page 4 of 18 b. Make every reasonable effort to collect its cost in providing services, for which Medicaid reimbursement is sought, through public or private third party payors except where prohibited by Federal regulations or State taw; however, no one shall be refused services solely because of an inability to pay. c. Establish one charge per clinical/support service for all payors (including Medicaid) based on their costs. All Payors must be billed the same established charge, but may accept negotiated or other agreed upon lower amounts (e.g., the Medicaid reimbursement rate) as payment in full. 10. Subject to the approval of the appropriate Section, a local health department may seek reimbursement for services covered b_ y a program operating under l0A NCAC 45 rules, Purchase of Medical Care Services (POMCS), when those services are not supported by other state or federal funds. All payment program rules and procedures as specified in the Purchase of Medical Care Services Manual must be followed. ' 11. Provision of Interpreter Services: a. Programs and services supported in whole or in part with federal funds must provide interpreter services at no charge to Limited English Proficiency clients. b. Only those programs and services funded entirely with state and/or local funds, unless prohibited by State law or rule, may chazge Limited English Proficiency clients for interpreter services. However, no one shall be refused services solely because of an inability to pay for interpreter services. 12. Subject to the availability of funds and approval of the Public Health Nursing and Professional Development Unit, a Department may request reimbursement for: a. Nursing service personnel participating in the "Introduction to Principles and Practices of Public Health and Public Health Nursing" course. Reimbursement is $400.00 per participant upon successful completion of the course. b. Nursing service personnel participating in the "Management and Supervision for Public Health Nurse Supervisors and Directors" course. Reimbursement is $600.00 per participant upon successful completion of the course. c. Health Department Management level staff (all disciplines) attending certain Management training endorsed by the State Health Director's Office when the local staff member is a part of a team accepted into these trainings/institutes. 13. Audits/Monitoring: a. The Department shall have an annual audit performed in accordance with "The Single Audit Act of 1984 as implemented by OMB Circulaz A-133." The audit report shall be submitted to the Local Government Commission (LGC) by the County Administration (if single county health department) or the District Health Department or Public Health Authority (if so organized) within (six) 6 months following the close of the agreement. Audit findings referred to the DHHS Controller's Office by LGC will be investigated and findings verified by the DHHS Controller's Office staff with assistance of the Division of Public Health Program Staff. . b. All District Health Departments and Public Health Authorities must complete quarterly a Fiscal Monitoring Report and submit to the DHHS Controller's Office based on the schedule published by the DHHS Controller's Office. 14. Equipment is a type of fixed asset consisting of specific items of property that: (1) aze tangible in nature; (2) have a life longer than one yeaz; and (3) have a significant value. . a. For Inventory Purposes Consolidated Agreement -Final Page 6 of 18 • d. The Department must receive prior written approval from the state to subcontract when any of the following conditions exist: i The Department proposes to subcontract to a single entity fifty percent (50%) or more of the total state and federal funds made available through this agreement. ii The Department proposes to subcontract fifty percent (50%) or more, or $50,000, whichever is greater, of the total state and federal. funds made available through this agreement for a single public health service or program. . iii The Department proposes to subcontract for services in the Women, Infants and Children (WIC) Program. e. The Department shall mail a signed copy of all final public health Funding Authorizations to the DPH Budget Office, 1931 Mail Service Center, Raleigh NC27699-1931. The Department shall retain a copy of all Funding Authorizations, the monthly.certified electronic printed screen of the Expenditure Reports with any amendments (via the Aid-to Counties Website), Consolidated Agreement, Agreement Addenda, Revisions and other financial records in accordance with the current Records Disposition Schedule for County and District Health Departments issued by the NC Division of Archives and History, Department of Cultural Resources. f. The Department shall mail a signed copy of all final environmental health Budget Forms (DENR 2948) and Addenda (DENR 3300) to the Division of Environmental Health, Environmental Health Services Section, 1632 Mail Service Center, Raleigh, NC 27699-1632. 2. The Department shall prepare and maintain a Local Appropriations Budget (reflecting the plans to use local appropriations or earned fees) for each activity covered by this agreement in a manner consistent with instructions provided in general budgetary guidance from the Division and the specific guidance from the respective programs. a. The Department shall do budget revisions to their Local Appropriation budgets when appropriations will be increased or decreased. b. The Department shall submit all revisions to Local Appropriations budgets prior to the end of the term specified in this agreement. Budget revisions received by the State after the end of the agreement period will be returned without action. 3. (Local Earned Revenues) The Department shall observe the following conditions when budgeting and reporting earned revenues: a. Locally appropriated funds may not be supplanted by earned revenues from persons, or public or private third party payors. Such revenue shall be used for the activity that generated the revenue, except in the WCH Section programs, where there is some flexibility (see "b.l ." below.) b. All earned revenue (officially classified as local funds) must be budgeted and spent in the program that earned it except, 1) Revenue generated by WCH Section Programs, except WIC, may be budgeted and expended (consequently reported) in any WCH Section Program activity. 2) Revenue generated by a local clinic or program that has no state funded activity budget (no statelfederal funds) should be budgeted and associated expenditures reported in a state program . activity that most closely matches the deliverables of the respective state program. This process will enable the collection of total expenditures in public health per program. c. All fees collected shall be used in the current year or succeeding fiscal years. Consolidated Agreemcm -Final Page S of 18 • For DENR: i. When reporting expenditures for Environmental Health, Childhood Lead, CDC Childhood Lead Poisoning Prevention, or Food and Lodging, the Department must use the electronic Expenditure Report - prepazed and maintained by the Departrnent of Environment and Natural Resources, Division of Environmental Health (DENR-DEH). This report shall be submitted monthly in an electronic format as an attachment to an email to designated staff in the DENR Controller's Office and the Division of Environmental Health. j. A "Certification of Expenditures" (for items in "i." above), signed by the health duector and finance officer, shall be submitted annually with original Budget Forms (DENR 2948) and shall be kept on file by the State. The "Certification" verifies in writing that total State expenditures reported are valid. Local expenditures are part of the Expenditure report, but are not included in the amount verified in the "Certification." 4. (State! Federal Revenues only) The Department shall submit a monthly report of actual expenditures (State and/or Federal) to the DHHS Controller's Office in the Electronic Aid-to-Counties Website as referenced in 3.f. above -all reported in one system, but separated here for clarity of instructions. a. The Department shall submit a monthly Expenditure Report of the pertinent month's actual expenditures for all programs via the Aid-to-Counties Website to the DHHS Controller's Office no later than the dates published annually in November or December for the next calendar yeaz. The schedule reflects a general period of 15-24 days from the end of the reporting month for submission of the Aid-to-Counties Website report, based on weekends and holidays, to allow processing time for the payment. Failure to meet the reporting deadline, as published, WILL result in the exclusion of those expenditures in the OSC E-Payment for that month. Early submission may result in earlier payment to the Department. The . Department must submit these monthly Expenditure Reports, via the Aid-to-Counties Website, consecutively throughout the agreement period. The health director and the finance officer will approve the monthly Expenditure Report in the Aid-to- Counties Website and the system will alert the staff in the DHHS Controller's Office that expenditures have been approved and certified. The "Certification" verifies that the total State and Federal expenditures reported are valid for the pertinent month's actual expenditures. Local expenditures are part of the Expenditure Report, but aze not included in the amount verified in the "Certification." Local appropriations must be reported monthly along with the State and Federal expenditures. b. Departments shall keep_expenditure reporting current and submit their certification of expenditures per the published DHHS Controller's Office Schedule. Funding is based on an Allocation Method, not a Contract Method, and counties receive reimbursement for services provided during one month in the following month. Therefore, the last service month to be paid in the SFY will be May services which are reported and paid in June. A department's June, 2008 expenditure report will be paid in July, 2008 and will be paid from a department's funding allocation for SFY 2008-09. Therefore a department will need to submit all requests for adjustments, corrections, or amendments to expenditure reports for fiscal year 07-08, with the May, 2008-expenditure report. c. Expenditures of federal funds must be reported according to the funding period for a grant. Care must be taken to be attentive to the service month/payment months for each grant as well as the ending settlement date for a grant. (For example, a grant which ends November 30 will have 6 service/payment months charged against it: 1 }June 2006 service month/paid in July; 2) July service month/paid in • August; 3) August service month/paid in September; 4) September service month/paid in October; 5) c.~ua8~a w~~~ - ~~~ D. PERSONNEL POLICIES Page 10 of 18 1. The Department shall adhere to and fully comply with State personnel policies as found in North Carolina General Statute, Chapter 126, and 1 NCAC 8. Such policies include, but are not limited to, the following: a Equal employment opportunity, b. Affnmadve action, c. Policies for local government employment subject to the State Personnel Act, d. "Local Classification and Salary Range," e. "Compensation Policy for Local Competitive Services Employees," and f. "Recruitment and Selection Policy and Procedures. " 2. Environmental Health Specialists employed by the Department shall be delegated authority by the State to administer and enforce State environmental health rules and laws as directed by the State pursuant to G.S. 130A-4(b). This delegation shall be done according to 15A NCAC 10.0100. a. Local health departments are responsible for sending their newly employed environmental health specialists (interns) to centralized training within 180 days from date of employment. J b. Arrangements for centralized training for newly-employed environmental health specialists will be handled by the Education and Training Staff, Division of Environmental Health. c. A local health department which is contracting with an environmental health specialist employed by another department shall be responsible for assuring that all original documents, correspondence, and other public records be maintained in the health department using the contractor and the contract shall stipulate that the contractor shall be available for consultation to the public being served. 3. The Department shall comply with Minimum Standard Health Department Staffing l OA NCAC Section 46 .0301(c), and shall assure that all nursing staff who provide public health services funded by this agreement comply with this rule. E. CONFIDENTIALITY All information as to personal facts and circumstances obtained by Department personnel in connection with the provision of services or other activity under this agreement shall be privileged communication, shall beheld confidential, and shall not be divulged without the client's, or responsible person's, written consent; except as may be otherwise required by applicable law or regulation. Such information may be disclosed in summary, statistical, or other form which does not directly or indirectly identify particular individuals. Department employees must sign confidentiality pledges documenting the knowledge of, and the agreement to maintain, personal and medical confidentiality. F. CTVII, RIGHTS 1. The Department shall assure that no person, on the grounds of race, color, age, religion, sex, marital status, immigration status, national origin or otherwise qualified handicapped individual, solely by reason of his/her handicap (unless otherwise medically indicated), be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity covered by this agreement. 2. The Department shall complete HHS Form 690, Assurance of Compliance with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973; Title D~ of the Education Amendments of 1972, and the Age Discrimination Act of 1975. Co~olidatod Agraaent - Final • Page 12 of 18 12. The State shall provide support and consultation to ensure that HSIS and the new Health Information System (HIS}, when implemented, can generate standard transactions for public health Medicaid claims submitted on behalf of the local health departments per HIPAA [the Adrninistrative~Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-91) subparts I through N, which define the standards for specific transactions.] 13. The State shall responsibly use data reviewed and received in its role as a public health authority and health oversight agency while respecting the confidentiality and integrity of the data and securing and protecting the privacy of individual client health information (see Business Associate Addendum to this Consolidated Agreement) 14. The State (DPH) shall provide to the Department "Estimates of Funding Allocations" no later than February I S of each year to use in preparation of their local budget proposals per current GS. 15. The State (DENR-DEH) shall provide to the Department the "Budget Form" (DENR 2948) indicating the estimated funding allocations no later than March 30a' of each year to use in the preparation of their local budget proposals per current GS. 16. The State (DHHS) shall provide a "Funding Authorization" to the Department after the receipt of the Certified State Budget. Funds must be appropriately budgeted by the State in the NC Accounting System INCAS) prior to the issuance of the "Funding Authorization." 17. The State (DENR-DEH) shall provide a final Budget Form to the Department after receipt of the Certified State Budget. ' 18. The State (DPH) shall provide funds to the Department upon receipt of this executed agreement and timely submissions of Expenditure Reports. Payment will be made to the Department according to the DHHS Controller's Office E-Payment Schedule issued November or December of each year for the following calendar year. 19. The State (DENR-DEH) shall provide funds monthly to the Department upon receipt of the executed Budget Forms, Addenda and timely submissions of monthly expenditure reports. Payments will be made to the Department according to expenditures reflected on the monthly Expenditure Reports. 20. The State shall assist the Department to comply with all applicable laws, regulations, and standards•relating to the activities covered in this agreement. 21. The State reserves the right to conduct reviews, audits, and program monitoring to determine compliance with the terms of this Agreement and its associated Agreement Addenda. 22. The State shall be assured that the Department maintains expenditures of locally appropriated funds (MOE) for maternal health, child health, and family planning program activities equal to, or greater than, that reported on the Staff Time Activity Report for the period beginning July 1, 1984, and ending June 30, 1985. This figure will be increased annually based on a federally accepted inflation index (first updated FY 2000- 2001 Agreement.) This revised baseline figure will be calculated and provided to Departments for use in budget preparation. This MOE shall be measured by salary equivalencies that are to be maintained in accordance with Section B. 8 of this agreement. • Page 14 of 18 b. ff the above deficiencies should not be corrected to the satisfaction of the State after the sixty (60) day period, disbursement of funds for the particular activity maybe temporazily suspended pending negotiation of a plan of corrective action. c. If the deficiency is still not corrected within the next thirty (30) days following temporary suspension of funding, program funds maybe permanently suspended until the Department can provide evidence that the deficiencies have been corrected. d. In the event of the Depaztment'soon-compliance with clauses of this agreement, the State may cancel, terminate, or suspend this agreement in whole or in part and the Department may be declared ineligible for further State contracts or agreements. Such terminations for non-compliance shall not occur until (1) the provisions of Section K-1 (a-c) have been followed, documented, and have failed to provide a resolution, and (2) all other reasonable administrative remedies have been exhausted. 2. Subrecipient Monitoring -OMB Circulaz A-133 (Audits of States, Local Government, and Non-Profit Organizations) as revised on June 27, 2003 requires that pass-through entities monitor the activities of their subrecipients as necessary to ensure that federal awards are used for authorized purposes in compliance with laws, regulations and the provision of contracts or grant agreements and that performance goals aze achieved North Cazolina establishes comparable monitoring requirements for State funds received by subrecipients in N.C.G.S.143-6.2, Use of State funds by non-State entities, for non-State subrecipients, and N.C.G.S.158-34, Annual independent audit: rules and regulations, for local units of government. Also, DHHS-DPH must perform subrecipient monitoring as required in the DHHS Policy and Procedure Manual entitled "Monitoring of Programs" dated August 1, 2002. DHHS-DPH conducts monitoring in accordance with its Subrecipient Monitoring Plan dated January, 2006. Additionally, each Local Health Department is required under Circular A-133, N.GG.S.143-6.2 and N.C,G.S.159-34 to perform monitoring of its subrecipients and to maintain records to support such monitoring activities and results. Accordingly, the Department shall participate fully in subrecipient monitoring by DHHS-DPH and shall appropriately monitor its subrecipients to the extent necessary based on the assessed level of risk, 3. If the Department or the State should be determined out of compliance with the provisions of the agreement, either party may file a formal appeal with the Office of Administrative Hearings. • IN WITNESS WHEREOF, the Department and the State have executed this agreement in duplicate originals, one of which is retained by each of the parties. L CAL SIGNAT S Health Dir or Da Finance Officer ~ Date ' STAr OF N TH CAROLINA . ' ~ _ S Health Dir for ~ ~ ~ ~D o~Authorized Agent / w Chair of County Commis ' ate ~ e of nment Date (when required) 'and Natural Resources or Authorized _ Agent Consolidstcd ApeemeM - Final Page 16 of 18 • h. "Security Incident" shall have the same meaning as the term "security incident" in 45 CFR 164.304. i. Unless otherwise defined in this Agreement, terms used herein shall have the same meaning as those terms have in the Privacy and Security Rules. 3. OBLIGATIONS OF BUSINESS ASSOCIATE a. Business Associate agrees to not use or disclose electronic protected health information or other protected health information other than as permitted or required by this Agreement or as required by law. b. Business Associate agrees to implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic protected health information and other protected health information that it creates, receives, maintains, or transmits on behalf of a Covered Entity, as required by the Privacy and Security Rules. c. Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known tv Business Associate of a use or disclosure of electronic protected health information or other protected health information by a Business Associate in violation of the requirements of this Agreement. d. Business Associate agrees to report to Covered Entity (i) any use or disclosure of electronic protected health information or other protected health information not provided for by this Agreement of which it becomes aware and (ii) any security incident of which it becomes aware. e. Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides electronic protected health information and/or other protected health information received from, or created or received by • Business Associate on behalf of Covered Entity (i) agrees to be bound by the same restrictions and conditions that apply through this Agreement to Business Associate with respect to such information, and (ri) agrees to implement reasonable and appropriate safeguards to protect such information. f. Business Associate agrees to provide access, at the request of Covered Entity, to electronic protected health information and other protected health information in a Designated Record Set to a Covered Entity or, as directed by a Covered Entity, to an individual in order to meet the requirements under 45 CFR 164.524. g. Business Associate agrees, at the request of a Covered Entity, to make any amendment(s) to electronic protected health information and other protected health information in a Designated Record Set that a Covered Entity directs or agrees to pursuant to 45 CFR 164.526. h. Unless otherwise prohibited by law, Business Associate agrees to make internal practices, books, and records, including policies and procedures concerning electronic protected health information and other protected health information, relating to the use and disclosure of electronic protected health information and other protected health information received from, or created or received by Business Associate on behalf of, Covered Entity available to the Covered Entity, or to the Secretary, in a time and manner designated by the Secretary, for purposes of the Secretary determining Covered Entity's compliance with the Privacy and Security Rules. i. Business Associate agrees to document such disclosures of electronic protected health information and other protected health information related to such disclosures as would be required for Covered Entity to respond to a request by an individual for an accounting of disclosures of electronic protected health information and other protected health information in accordance with 45 CFR 164.528, and to provide this information to Covered Entity or an individual to permit such a response. • • Consolidatcd Agroe~nt -Final o. Effect of Termination. Page 18 of 18 1) Except as provided in paragraph (2) of this section or in the MOU or by other applicable law or agreements, upon termination of this Agreement and services provided by Business Associate, for any reason, Business Associate shall return or destroy all electronic protected health information and other protected health information received from Covered Entity, or created or received by Business Associate on behalf of Covered Entity. This provision shall apply to electronic protected health information and other protected health information that is in the possession of subcontractors or agents of Business Associate. Business Associate shall retain no copies of the electronic protected health information or other protected health information. 2) In the event that Business Associate determines that returning or destroying the electronic protected health information or other protected health information is not feasible, Business Associate shall provide to Covered Entity notification of the conditions that make return or destruction not feasible. Business Associate shall extend the protections of this Agreement to such electronic protected health information and other protected health information and limit further, uses and disclosures of such electronic protected health information and other protected health information for those purposes that make the return or destruction infeasible, for so long as Business Associate maintains such electronic protected health information and other protected health information. • 6. GENERAL TERMS AND CONDITIONS a. This Agreement amends and is part of the MOU. b. Except as provided in this Agreement, all terms and conditions of the MOU shall remain in force and shall apply to this Agreement as if set forth fully herein. o, In the event of a conflict in terms between this Agreement and the MOU, the interpretation that is in accordance with the Privacy and Security Rules shall prevail. In the event that a conflict then remains, the MOU terms shall prevail so long as they are in accordance with the Privacy and Security Rules. d. A breach of this Agreement by Business Associate shall be considered sufficient basis for Covered Entity to terminate the MOU for cause. SIGNATURES of Public Health) • ASSURANCE OF COMPLIANCE ASSURANCE OF COMPLIANCE WITH TITLE VI OF THE CNIL RIGHTS ACT OF 1964, SECTION 504 OF THE REHABILRATION ACT OF 1973, TITLE OC OF THE EDUCATION AMENDMENTS OF 1972, AND THE AGE DISCRIMINATION ACT OF 1975 The AppficaM provides this assurance in consideration of and for the purpose of obtaining Federei grants, loans, contracts, property, discormts w other Federal financial assistance from the Department of Health and Human Services. - THE APPLICANT HEREBY AGREES THAT R WILL COMPLY WITH: 1. Title VI of the Civil Rights AcY of 1964 (Pub. L 88-352), as amended, and afl mquiremerrts imposed by w pun;uaM to tl-e Regulation of tl~e Department of Health and Human Services (45 C.F.R. Part 80), to the end that, in accordance with Title VI of that Act and the Regulatron, no person in the United States shad, on the ground ~ race, color, w national origin, be excluded from denied the benefits of, or be otherwise subjected to discrimination under arty Program w activity for wtrich the ~ ~, be Federal finandal assistance from the DepartrnenL APPS ~~ 2. Section 504 of the Rehabifdation Ad of 1973 (Pub. L 93-112), as amended, and ail requirements imposed by w pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 84), to the end that, in arccordance with Sedbn 504 of that Ad and the Regulation, no otherwise qualified handicapped individual in the United States shall, solely by reason of his handicap, be excluded from participation in, be denied the benefits of, w be subjected to discrimination under any program w acWity fw which the Applignt receives Federal financial assistance from the Departrr~ent 3. Title IX of the Educational Amendments of 1972 (Pub. L 92-318), as amended, and all requirements imposed by w pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 86), to the end that, in accordance wish Title IX and the Regulation, no person in the United States shall, on the basis of sex, be excluded from parfiapation in,. be denied the benefits of, w be otherwise subjected tb discriminafon under any education program w activity fw which the Applicant receives Federal financial assistance from the Department. . 4. The Age Discrimination Act of 1975 (Pub. L 944135), as amended, and all requirements imposed by w pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 91), to the end that, in accordance with the Act and the Regulation, no person &r the United States shall, on the basis of age, be denied the benefits of, be excluded from participation in, w be subjected to discrimination under any program w activity for which the Applicant receives Federal finandal assistance from the Department. The Applicant agrees that cornpC~ance with this assurance constitutes a condition of continued receipt of Federal finandal assistance, and that rt is binding upon the Applignt, its successors, transferees and assignees for the period during which such assistance is provided. H any real properly w structure thereon is provided w improved with the aid of Federal financial assistance extended to the Applicant by the Department, this assurance shad obligate the Appfignt, w in the case of any transfer of suds property, arty transferee, fw the period during which the real property w structure is used fo'r a purpose fw which the Federel financial assistance is extended w fw another purpose involving the govLSion of similar services w benefits. If any personal property is so provided, this assurance shatl obligate the Appficant fw the period during which it retains ownership w possession of the property. The Applicant further recognizes and agrees that the United States shall have the right to seek judidal enforcement of this assurance. The person w persons whose signature(s) appear(s) below is/are authorized to s'xln this assurance, and commit the Applicant to the above provisions. to ignature and Aufhonzed Officlal Drt;~no1e Cou.•-~-~, ~ ~ea.l`~ ~De~f . Name of Ap w Reclpient 30o W . T'r y an ~+ Street A I-~-i ~ ~S 6 bra u,~'~ N ~ 2 ~ ~. ? city, state. zlp code Maa Fonn to: ~ ~., _ DHHS/Office fw C'nril Rights Office ~ Program Operations Humphrey Building, Room 509E 200 Independence Ave., S.W. Washington, D.C. 20201 . Form HHS-690 5197 • • C7 DEPARTA~NT OF HEALTH AND HUMAN SERVICES DIVISION OF PUBLIC HEALTH CERTIFICATION REGARDING LOBBYIl~TG The undersigned certifies, to the best of his or her knowledge and belief, that: 1. No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. 2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress; or an employee of a Member of Congress in connection with this Federally funded contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions: 3. The undersigned shall require that the language of this certification be included in the award document for subawazds at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) who receive federal funds of $100,000 or more and that all subrecipients shall certify-and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Authorize gency Official Signature Title Official gency Name Date (Signature should be same as Contract signature) Lobby 5/00 II. The sites for the () performance of work done m connection with the specific agreement aze listed below: . 1. 30o W • Try an ~- • r ~ ~~ (street address) ti't~~~s ~rO ~ ~ 2 7Z'~8 (City, ty, state, zip code) 2. 2~0) }~orresfeac~ ~d (Street address) ~ `<< C 2 ~ s` ~6 (City, county, state, zip code) Contractor will inform the Department of any additional sites for performance of work under this agreement. . False certification or violation of the certification shall be grounds for suspension of payment, suspension or termination of grants, or government-wide Federal suspension or debarment (Section 4 CFR Part 85, Section 85.615 and 86.620). _~~~ ~tre~-fib Authorized ncy Official Signature .Title r Offici Agency Na (Signature should be same as Contract signature) ~ /~lv~- Date Drug Free 5/00 Page 2 of 2 • NORT>~ CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF PUBLIC HEALTH CERTIFICATION REGARDING ENVIItONMENTAL TOBACCO SMOKE Certification for Contracts, Grants, Loans and Cooperative Agreements • • Public Law 103-227, Part C-Environmental Tobacco Smoke, also known as the Pro-Children Act of 1994 (Act), requires that smoking not be pemutted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, education, or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, . contract, loan, or loan guarantee. The law does not apply to children's services provided in private residences, facilities funded solely by Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to SI,OOD per day and/or the imposition of an administrative compliance order on the responsible entity. By signing and submitting this application, the Contractor certifies that it will comply with the requirements of the Act. The Contractor further agrees that it will require the~language of this certification be included in any subawards that contain provisions for children's services and that all subgrantees shall certify accordingly. Authorized envy Official Signature ~~~~~~~~ Title U/k C. W U.n eQ.1't'h ~ ~ ~~~---~1 U~ ffi 'a A en ame O ci g cy N Date (Signature should be same as Contract signature) Smoke S/00