HomeMy WebLinkAbout2009-060 Health - State of NC Health Dept~ ~
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CONTRACTS ~aY o s Zoos I~AY i 12009
JUy 1 2 2009
CONSOLIDATED AGREE;1'!I~:NT
BETWEEN
THF, ST:'~TE OF NORTH CAROLINA
AS REPRESENTED BY
THE STATE HEALTH DIREC?OR
Hereinafter callod the "State'
ORANGI': CO['N"I'Y HEALTH Ul•:P:~RT:~]ENT
(I .oca{ Health 1)epartmenu'District'Puhlic health Authority~l Iuman Services .~zenc~~ I wake and
~•Iccklentiuru) -- f tcreinater called the "1)cpaf-tmcnt")
FOR THE PURPOSE OF
:~1.AINTAININC: r1N1) PROMOTING THF: ADVANCEMENT OF
.PUBLIC HF;ALTH IN NORTH CAROLINA
this Amended Agreement Sha(1 Cower a Period Froir~
.luiv 1, 2009 to June 30, 2010
and shall remain in force until the next Fiscal Year Agreement
is signed exrept as provided for in Section .1. "Germination.
\O~4'. THi~:Iti~.I~ORE, the State and the Ucpartment agree that the provisions aad
clauses herein set forth shall he incorporated in and constitute the terms and conditions
applicable Ibr activities involving State funding. (State funding or funds means state,
federal, and;"or special finding or funds throughout this agreuYient.)
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A RESPONS)BII.TITES OF 'HE DEPARTMENT (LOCAL PUBLIC HEALTH UNTf
The Department shall perform activities in compliance with applicable program rules contained in the North
Carolina Administrative Code, as weU as all applicable Federal and State laws and regulations.
The Department shall perform the activities specified in the Program Agreement Addenda for State funded
budgets. The Department must negotiate these Agroement Addenda in good faith to the satisfaction of stag
reprewatatives as part of the agreement execution. The Department will meet or exceed the Agrecntent
Addenda levels unless extenuating circunnstances prevail and are explained in writing to the state section,
branch or program.
The Dcparhnent 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
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 ~grcernent Addenda for State funded budgets, and by North Carolina Administrative Code.
The Department shall provide client, service, eacatntcr, and other data through the states' centralized
automated systems for claims creation and submission for processing to the state's Medicaid agency escept
as allowed b1' NCGS 130A - 45.13. To ensure that such data is accurately linked to the specific client
served is a meaner that nesuks m a unique identifier from the DHHS Common Name Data Service, the
Departrent shall allow DPH ip submit (on its behalf) the Social Security Numbers of all clients to the Social
Security Administration for verification.
The Department shall share data to support efforts of the public health system, represented by the local
health deparhnents, local health programs, and the Stag, is ordex to meet public heaNh objectives while
respecting the confidentiality and integrity of each agency's data sad protecxing the privacy of irxiividual
client health information. Sharing data includes providing cliwt information allowed as permitted
disclosures under the Health htsurance Portability and Accountability Act of l 996, Public Law 104-91,
H1PAA Administration Simplification Provisions Sections 261 through 264, 43 CFR 164.312, Uses and
disclosures for which consent, authorization, or opporhmity to agree or object is not required.
The Department shall administer and enforce all rules that have boa adopted by the Commission for Public
Health, ratified by the NC General Assembly, or adopted by the Local Board~of Health.
The Department shall provide to the State a copy of any rules adopted by the Local Board of Hea1W pursuant
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 Io the Local Technical Assistance and Training Branch
(LTAT).
9. The Deparirnent shalt have policies retorted to conflict of interest and policies and procedures for Human
Subjects Clearance. Each staff member shall receive a Dopy of these documents.
I0. The Department shall provide to the State a comprehensive community health assessment (CHA) every four
years and a State of the County's Health Report each of the interim three years. Healthy CarolinianslHealth
Education Branch/CDI Section will administer this four-year cycle. The CHA should be a collaborative
effort with the local Healthy Carolinians Partnership, if such exists, and shall include collection of primary
data at the county level and secondary data from the state and older sources. The CHA shall include a list of
community health problems based on the findings and a narrative of the assessrncnt fmdings. The CHA or
SOTCH is due by the first Monday of December. The agency is required to submit community action plans
to address the selected priority issues_ These plans are duc by the first Friday in June folbwing the
December subntissioa of the CHA. The Agency and the Healthy Carolinians Partnership may elect to
Combine action plans addressing the selected priority issues and submit them with the Healthy Carolinians
Partnership application. The same action p[aa form is used for both the CHA and the
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cxrtification/recertification process: NOTE that an action plan is e~rpected for every CFIA prioority. The
CHA will include data analysis of those indicators that are listed in the accreditation self-assessment.
11. The Department shall provide formal training for their Board of Health (BOH) members through DHHS
sponsored offerings. The LTAT Branch shall notify the Department no later than Apri130 of the name of
the contractor who is to provide this training during We upcoming fiscal year. First priority should be given
to training newly appointed members with the ultimate goal of having all BOH members trained as time and
resources allow. Continuing education updates on topics of special interest are strongly encouraged after
general board member orientation has been provided for all BOH Members.
12. The Department shall provide Network/Internet access at the Local Health Department (or to the county
network where desired) at a minimum speed of a full T-1 line in order to:
Connect with the North Carolina Health Alert Network (RAIN), Electronic Disease Surveillance System
(FOSS), Immunization Registry (IIt), Hea1W Information System (IRS)
Rapidly communicate e-mail alerts to a~ from the NC State Division of Public Health regarding
bioterrorism and public healW topics (outbreaks, emergency alerts, etc)
Access NCDPH training materia! and information used in self-study courses and PHT1N programs
Build steps of a secure infrastructure for remote data entry in the local health departments
The LHD will maintain the above-deacribod minimum connection. The LHD may choose any provider (ISP)
that they wish. The LHD will also ensure security of a minimum of a T-1 connection at the LHD location.
The LHD may utilize security products (i.e. firewalls) of Weir choosing to -maintain netwaic connectivity
and security integrity. The LHD network coaSgittation and security practices must allow communication
with systems within the state network.
13. The Department ~taq incorporate basic elements of the North Carolina Public Hea1W logo and themeline
(slogan) into communication materials developed for programs and services that depend, in whole a in part,
upon state finding. Such communication materials could inchrde: letterhead, business cards, brochures.
pamphlets, advertisements or announcements, signs and marketinglpromotional materials. The Department
is encouraged W incorporate its own name with the logo.
B. FUNDIING STIPULATIONS
Funding for this agreement is subject to We availability of State, Federal, and Special Funds for the purpose
set forth in this agreement.
2. During the period of Wis agreement, We Department shall not use State, Federal or Spacial Project fluids
received under this agreement to reduce locally appropriated funds as reflected in the Lacal Appropriations
Budget (see item C.2. below.)
The Department shall not use personal health program funds to support environmental health programs nor
use environmental health program finds to support personal health programs.
4. Fees generated by the Food and Lodging Foes Collection Program may only be used to support State and
Local food, lodging, and institution sanitation programs and activities.
S. The county shall submit monthly reports of On-Site Wastewater activities to We On-Site Wastewater Section
in Division of Environmental Health in the format provided by the Section.
6. The Department shall comply with Standards for Mandated Public Health Services, l0A NCAC 46, Section
.0200; and Administrative Procedures Manual for Fedual Block Grant Funds, 1 NCAC 33, Sections .0100 -
.1502.
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The Department shall maintain signed employce time records to document the actual work activity of each
employee on a daily basis. The percentage of time each employce spends in each activity shall be converted
to dollars based upon the employee's salary and benefits at least on a monthly basis. The computation shall
support the charges for salaries and benefits to all federal and state grants (as required in OMB Circular
A87) as well as provide the documentation of detailed labor cost per activity for preparation of Medicaid
Cost Report.
`~ For Departrncnts participating in Medicaid Reimbwsement, the Department shall:
a. Execute a Provider Participation Agreement with the Division of Medical Assistance. For selected
health departments receiving at least 55,000,000 in Medicaid receipts annually, as identified by the
Division of Medical Assistance, Sign, as part of their continuing participation as a Medicaid provider, a
Letter of Attestation affuming dial: 1) detailed information is provided to employees, contractors and
agents about the Federal & State False Claims Act and 2) written policies and procedures are in place to
detect and prevent fraud, waste and abuse. .
b. Make every reasonable effort to collxt its cost in providing services, for which Medicaid reimbursement
is sought, through public or private third party payers except where prohibited by Federal regulations or
State law; however, no one shall be refused services solely because of an inability to pay.
c. Establish one charge per elinical/support service for all payers (including Medicaid) based on they
costs. All Payers must be billed the same established charge, but the Department may accept negotiated
or other agreed upon borer 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 by a program operating under } OA NCAC 45 rules, Purchase of Medical Care Services
(POMCS), when those services are net supported by other state or federal funds. All payment program rules
and procedures as spxified in the Purchase of Medical Care Services Manual must be followed.
Provision of Interpreter Services: As required by Title VI of the Civil Rights Act, a local health department
that receives federal funds (either directly or through the Division of Public Health) for any program or
service must provide interpreter services ati no chazge to Limited English Proficiency clients in all programs
and services offered by the health department.
12. Subject to the availability of funds and approval of the Public Health Nursing and Professional Development
Unit, a Department may request reimbursanent for.
Nursing service personnel participating in the "Introduction to Principles and Practices of Public Health
and Public Health Nursing" course. Reimbursement is 5400.00 per participant upon successful
oompldion of the course.
b. Nursing service personnel participating in the "Management and Supervision for Public Health Nurse
Supervisors and Directors" course_ Reimbursement is 5600.00 pa participant upon successful
completion of the course.
Health Departmeut 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.
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3. Audits/Mvnitoring
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The Department shall have an annual audit performed in accordance with "The Single Audit Act of
1984 as implemented by OMB Circular A-133" The audit report shall be submitted to the Local
Govantnent 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 refcrred 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 Ot1ice.
14. Equipment is a type of fixed asset consisting of specific items of property that: (1) are tangible in nature; (2)
have a life longer than one y'~: and (3) have a significant value.
a. For Inventory Purooses
Equipment must be accounted for in accordance with the North Carolina Department of State
Treasure Policies Manual, Chapter 20, and Fixed Assets Policy.
u. AU equipment with an acgnisiti~ cost of 5500.00 or mare which is purchased with Women, Infants
and Children (WIC) Program Funds, must be inventoried with the Women's and Children's Health
Section.
b. For Prior Anoroval Purooses
i. A11 equipment pur+dtased m leased with as acquisition cost exceeding 52500.00 (earcept in WIC;
see item ii below for WIC requirements), where there is an option to purchase with State/Foderal
funds must deceive prior written approval from the appropriate Branch/Section. For PHPdrR
Grant funds only this is aay purchase exceeding 52500 per invoice (c.g., if the agency is
purchasing a computer, monitor, printer, etc. totaling more than 52500 m purchasing 6
computers at SS00 each, this should be treated as one purchase for pwpases of prim approval.)
For WIC, all computer and medical equipment purchased m leased, must receive prior written
approval from the Branch regardless of ccet. In addition, all other tangible assets (non
computer/medical} with an acquisition cost exceeding 5500.00 must receive prim approval.
iii. The use of Women's and Children's Health Medicaid fees fm capital improvements roquirzs
prior written approval from the Women's and Ch~7dren's Health Section.
For Accountin¢,The Department must utilize the depreciation schedule provided by the State
fm all assets with an acquisition cost of SS,000 m greater. The accumulated depreciation should be
recorded in the general fixed assets account group.
S. The Department agrees to execute the following Federal Certifications attached to this agreement as
applicable when receiving Federal funds:
a. Certification regarding Lobbying.
b. Certification regarding Debarment
G Certification regarding Drug-Free Workplace Requir+enxnts.
d Certification regarding Environmental Tobacco Stroke
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C. FISCAL CONTROL
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The Department shall comply with the Local Government Budget and Fiscal Contml Act, North Carolina
General Statute Chapter 159, Article 3.
a. The Department shall maintain a purchasing and procwemart system in accordance with generally
accepted accounting practices aid procedures set forth by the Local Government Commission.
b. The Department shall execute written agreements with all parties who invoice the Department for
payment for the provision of services to patients.
c. The Department, when subcontracting, must meet the following conditions:
i. The Department is not relieved of any of the duties and r+esponsrbilities provided in this agreement.
The subcontractor will agree to abide by the standards contained herein. or to provide such
information as to allow the Depardment to comply with these standards.
iii. The subcontractor will agrce to allow state and federal authorized representatives' access to any
records pertinent to its role as a subcontractor of the Department.
iv. Upon request, the Department will make available to the State a copy of subcontracts supported with
State/Federal funds.
d. The Department must receive prior written approval from the state to subcontract when any of the
following conditions exist:
The Department proposes to subcontract to a single entity fifty percent (50•i6) or more of the total
state and federal funds made available through this agreement.
u The Department proposes to subcontract fifty percent (50%) or more, or 550,000, 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 Departmart proposes to subcontract for services in the Women, Infants and Children (WIC)
Program.
e. The Department shat{ mail a signed copy of all final public health Funding Authorizations to the DPH
Budget Office, 1931 Mail Service Center, Raleigh, NC 27699-1 93 1. The Department shall retain a
copy of all Funding Authorizations, the monthly cert~ed electronic printed screen of the Expenditure
Reports with any amendments (via the Aid-to Counties Website), Consolidated Agreement, Agnxment
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 and located on their wcbsite at:
hitp://www.ah.dcr.statenc.usJrearrds/locaUdefault.httn.
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.
Z. 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 manna consistent with
instructions provided in general budgetary guidance from the Division and the specific guidance from the
respective programs and enter that budge information into the Electronic Aid to Counties Website for each
activity funded under this agreement.
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a. The Department shall do budget revisions to their Local Appropriation budgets when appropriations will
be increased a decreased and enter that information in the Electronic Aid to Counties Website.
3 (Local Earned Revenues) The Department shalt 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 payers.
b. AU earned revenue (officially classified as local limds) must be budgeted and apart in the program that
earned it except,
I) Revenue generated by WCH Suction 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 budgd (no
state/federal 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
arable the collection of total expenditures in public health per program.
a All foes collected shall be umd in the current year or succeeding fiscal years
d. Use of program i~omc generated by the expenditure of Federal categorical funds will be governed by
applicable Federal regulations. including, but not limited to, 45 CFR 4.
e. Local Budgets for DHHS Reporting.
1) After preparing Local Budgets you must uae the Allocatwe/County Lme on the Electronic Aid to
Counties Websile w show the approved local funding.
Line item 101 on the Electronic Aid to Counties Website must be used to budgd local
appropriations for each program activity, if applicable.
ii Line item 102 on the Electronic Aid to Counties Website must be used to budgd TXIX
Medicaid earned r+avarues for each program activity, if applicable.
iii Linc item 103 on the Electronic Aid to Counties Website must be used to budgd other earned
revenues (e.g., Home Health fees, patient fees (cash), other insurance payrnwts, and other
grants and donations) for each program activity, if applicable.
2) When preparing DENR Program Budgets:
i Line item 9000 on the program budget form must be used to budget the total of lines !01,102,
and 103.
ii Line item 101 on the program budget form must be used to budget local County appropriations
for each program budget, if applicable.
iii Line item 102 on the program budgd form is to be used to budget TXIX Medicaid earned
revenues fw each program budgd. However, eaviroomental bcslth programs should not have
any Medicaid to budgd.
iv Lme item 103 ar the program budgd form must be used to budgd other earned revenues (e.g.,
Environmental Health Fees, grants, donations, de.) for each program, if applicable.
v Under "STATE/FEDERAL/SPECIAL FUNDS" a new line has been added to reflect the amount
of "Temporary Food F.stablishmeai (7'FE)" fees collected rot behalf of the State.
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What repotting local expenditures (local appropriations, Medicaid or other earned revenues) the
department must use the electronic Aid-to-Counties Website to report the pertinent math's actual
expenditures (NOTE that an "actual expenditure" is one for which the item hss been ordered, received,
invoiced and the check bas been cut.) The Expenditure Reports must be submitted monthly in the
electronic website format and certified in the website to the DHHS Controller's Office.
Line item 101 on the Electronic Aid-to-Counties Website must be used to report local appropriations
that were expended on a monthly basis
2) Line item 102 on the Electronic Aidao-Counties Website must be used W report Title XDC
(Medicaid) canned revenues that were expended on a monthly basis
3) Give item 103 on the Electronic Aid-to-Counties Website must be used w report other earned
revenues that were expended on a tnonthty basis.
g. A local account shall be maintained for unexpended earned revenues [i.e., Title XDC fees, private
insurance or private pay {cash}]. Accounts shall be maintained in sufficient detail to identify the
program source generating the fees.
h. The amount of Title XIX fees budgeted and expended in FY 2009-20010 must equal or exceed the
amount of Title XIX revenues earned during FY 2007-2008. The state will not approve program
activity budgets that do not include an amount of Title XDC fees sufficient to moot the requirements of
this section. The State may waive this requirement if the Department provides sufficient justification.
For DENR:
When reporting expenditures for Enviratmental Heshh. Childhood Lead, or Food and Lodging, the
Departmwt must use the electronic Expenditure Report -prepared and maintained by the Department of
Environment and Natural Resources, Division of Environmental Health (DENR-DEH). This report
shall be submitted monthly in an electronic format ss an attachment to an email to designated staff in the
DENR Controller's Office and the Division of Environmental Health. NOTE that a new line has been
added to reflect the TFE feca expended.
A "Certification of Expenditures" (for items in "i." above), signed by the health director and finance
officer, shall be submitted atsanaUy with original Budgd 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 "
(StaW 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 monW's actual expenditures
for all programs via the Aid-to-Cotutties Website to the DHHS Controller's Office no later than the
dates published annually in November or December for We next calendar year. The schedule reflects a
general period of 1 S-20 days froze the end of the reporting month for aubtnission of the Aid-to-Counties
Website report, based rot 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 myth. Early submission may result in earlier payment to the Department. The
Departmatt 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 OtLce that expenditures
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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 tlrc Expenditure Report, but are not included is the amount verified in the "Certification." Local
appropriations must be reported monthly along with the State and Federal expenditures.
b. Departments shall koep_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
Contras Method, and counties receive reimbursement for services provided during one month in the
following monW. Therefore, the last service montb to be paid in the SFY will be May services which
are reported and paid in June.
A department's Lune, 2009 expenditure report will be paid in July, 2009 and will be paid from a
department's funding allocation for SFY 2009-10. Therefore a department will Hoed to submit all
requests for adjustments, corrections, or amendments to expenditure reports for fiscal year 08-09,
with the May, 2009 expenditure report.
e Expenditures of federal funds must be reported according to the lirndiag period for a great. 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: l) June 2009 service month/paid in July, 2) July service month/paid in
August; 3) August service monthlpaid in September; 4) September service monthJpaid is October; S)
October service month/ paid in November, and ~ November service month/paid either in December, or
before the ending date of that grant's settleromt period. In this example the remaining 6
scrvice/payment months will be December service month/paid in January through May service
aronth/psid in June, 2009.) For each Groat, the budgetary estimate, fundeng authorization and
agreement addendum will have aervice/paymmt month dates listed
d. The Department shall submit the final LHD Expenditure Report (Electronic, via the Ais-to-Counties
Website) for all programs to the DHHS Controller's Office according to the schedule published annually
in November or December for the next Calendar Year by the DHHS Controller's Office. The Msy
Services/Paid in June wiq be the heal report period paid trvm the SFY. Services provided is
June sad reported iu July will be paid out of the next SFY.
e. The DepartQrwt shall have the opportunity to submit amended expenditure reports as soon ss the error is
discovered. A Deparmsent Should Not Wait To Subaut AU Adjustments Witb The Invoice Submitted
To The Controller's Office At The End Of May As That Will Not Allow Sufficient Time For
Verification Of The Adjustments Before The Last Payment Ia The Stale Fiscal Year.
1) Tn a~nce with item 4.c, above, each departrnent must be mindful to keep current err reporting
adjustments against federal funds to ensure such adjustment is received is time to be paid wiWin the
grant period for that grant.
~~ The Department shall review their prior reimbursement claims against payments monthly
3) Amended reports (wiW the exception of WIC, FP and SFSP) must be submiried no later than the
next reportitg date after the grant period ends in order to be paid. (Example: if We groat period
ends 9/30109, the nmeaded report must be received by the Controller's Office no later than the next
reporting date suer that - i.e., October's reporting date.)
4) The enly adjustments, if any, that should be submitted with the May service expenditure report
submitted in lwre would be nay missed on the prior month's claim. If a departrnarit waits until the
May service month expenditure report submission to report adjustments, the DHHS Controller's
Office cannot guarantee those adjttsttn~ts can be verified in tune fa the Junc paymettt.
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5) Any overpayments identified by either the State or the Department will be adjusted out of the next
month's claim for reimbursement by the DHHS Controller's Office. There is no provision to carry
forward funds from one State Fiscal Year to another, therefore, any adjustment not included in the
June (or earlier if grant period expires during the fiscal year) Payment should be paid from local
funds. Ifreported to the State as an adjustment, the payment will come from (and will therefore,
reduce) the allocation for the next fiscal year.
,f The Department shall submit requests for payment for services provided under l0A NCAC 45.A rules to
the Claims Processing Unit, Purchase of Medical Care Services, DHHS Controller's Office.
g. The Department shall submit requests for reimbursement for nurse training to the Public Health Nursing
and Professional Development Utrit. Form 3300 -Public Health Nurse Training Activity must be used
as the invoice for payment.
S. The Department shall maintain expenditures for maternal health, child health and family planning programs
per General Statute 130A-4.1(a). The amount of expenditures gall be calculated by the State and provided
to the Department as desenbed in section G.22 of this document:
D. PERSONNEL POLICIES
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. Affirmative 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
"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 aad laws as directed by the State pursuant to G.S.
130A-4(b). This delegation shall be done according to 1 SA NCAC 10.0100.
a. -Local health departments are responsible for sending their newly employed environmental health
specialists (interns) to centralized training within 180 days fi~om date of employment.
'b. Arrangements for centralized training for newly~rnployed 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, correspoadence, and
other public records be maintained in the health department using the centractor and the contract shall
stipulate that the contractor shall be available for consultation to the public being served.
3. The Departrnent shall comply with Minimum Standard Health Department Staffing l0A 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.
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E. CONFIDEN77AI1TY
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All information as to personal facts and circumstances obtained by Department personnel in coascction with the
provision of services or other activity under this agreement shall be privileged communication, shall be held
confidential, a~ shall not be divulged without the client's, or responsible person's, written cooxnt; except as
rosy be otherwise required by applicable law or regulation. Such information maybe disclosed in summary,
statistical, or other form which does not directly or indirectly identify particular individuals. Department
employees must sign confidcatiality Pledges documenting the knowledge of, and the agreement to maintain,
personal and rnedieal confidentiality.
CML RIGHTS
The Department shall assure that no person, on the grounds of race, color, age, religion, sex, marital status,
immigration status, national origin or oWerwise qualified handicapped individual, solely by reason of his/her
handicap (unless otherwise medically indicated). be excluded from part~cipatioa in, be denied the benefits
of, or be subjected to discrimination under any program or activity covered by this agreement.
The Department shall complete HHS Form 690, Assuranec of Compliance with Title VI of the Civil Rights
Act of 1964, Section 504 of the Rehabilitation Act of 1973; Title DC of the Education Amendments of 1972.
and the Age Discrimination Act of 1975.
3. The American with Disabilities Act 1990 (ADA) makes it unlawful to disiximinate in empbymeat against a
qualified individual with a disability and ~tlaws discrimination against individuals with disabilities in State
and local government services and public acoornrmodations. The DepaRment certifies that it and its
principals and subcontractors will comply with regulations in ADA Title I (Employment), Title D (Public
Services), and Title ID (Public Accommodations) in fulfilling the obligations under this agreement.
G. RESPONSIBILITIES OF THE STATE
I The State shall provide to the Department regular training, and, upon request, technical assistance in the
preparation of the Consolidated Agr+eea~ent and Agreemealt Addenda.
2 The State shall conduct liaison activities with krcal health departments for general problem solving and
technical support.
The State shall provide high-level consultation, technical assistance, and advice to local health directors.
Broad content areas include, but are not limited to:
• Board Relations
• Management Teams/Staffmg
• Policy Development
• Program Planning and Implementation
^ Quality/Performance Improvement
• General Administrative Consultation, including cansiltation and technical assistance is budgeting,
fiscal, administrative and management support topic areas.
The State shall provide coordination sad support for the education sad training for the public health
workforce.
The State shall provide technics! assistance and consultant services, as required, for specific health program
areas, including providing guidance and c~sultadon about specific patient clinical issues, when roquestod.
6. The State shall provide course coordination, consultation, and technical assistance on nursing practice and
standards, policies and prooodttres that cross programs.
co..otrn.a no.....~ - R..i
Page 12 of t9
~~ The State shall provide support and consultation to the public health workforce in local health departments,
including regional public health consultants who offer technical assistance and training on professional
devebpment; program planning, program evaluation and quality assurance; data collection; and community
assesroterrt.
S. The State shall act as the principal liaison between the gublic health system and the state's Medicaid agency
on issues related to Medicaid reimbursed services provided by the state and local public bealth agencies and
shall cooperate with the state Medicaid agency to provide technical assistance, guidance, and consultation to
local health programs to ensure compliance with Medicaid policies and procedures.
9 The State Mall design and implement annual cost sNdies to ensure appropriate cost-based Medicaid
reimbursement.
10 The State shall work with the NC Division of Information Resource Management to provide automated
systems and facilities via the Heahh Services Information System (HSIS) and the new Health Infom~ation
System (HIS), when implemented HSIS is currently used to createand submit Medicaid claims, perform
accounts roceivables, and to collect other DPH program-related data from client, service, encounter and
other data on behalf of the local health departments and other public healhh programs. The State shall
providc business and technical support for the suteymatod systems to the users of these systems.
The State shall provide support and consultation b costae that the Health Information System (HIS) can
generate standard transactions fm public health Medicaid claims and (once HIS is implerttented) fa public
health claims to all insurers submitted on behalf of the local health departments per H1PAA [the
Administrative Simplification provisions of the Heahh Insurance Portability and Accountability Act of 1996
(P.L. 104-91) subparts I through N, which define the stmtdards for specific transactions.)
12. The State shall responsibly use data reviewed and received in its role as a public health authority and health
oversight agency while respecting the oonfidtantiality and integrity of the data and securing and protecting
the privacy of individual client health information (see Business Associate Addendum to this Consolidated
Agreement)
13. The State (DPH) shall provide to the Department "Estimates of Funding Allocations" no later than February
15 of each yt~r to use in preparation of their local budgd proposals per current GS.
14. The State (DENR-DEH) shall provide to the Department the "Budget Form" (DENR 2948) indicating the
estimated funding allocations no later than March 30"' of each year to use in the preparation of their local
budgd proposals per current GS.
16. The State (DHHS) shall provide a "Funding Authorization" to the Department aflex the receipt of the
Certified State Budget. Fonda must be appropriately budgeted by the Stale 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
Statc Budget.
18. The State (DPHj shall provide funds to the Department upon receipt of this executed agreement and timely
submissions of Expenditume Reports. Payment will be made to We Departrneat according to the DHHS
Controller's Office E-Payment Schedule issued November or Deecmber of each year for the following
calendar•year.
19. The State (DENR--DEH) shall provide funds monthly to the Department upon toceipt of the executed Budget
Forms, Addenda and timcly submissions of monthly expenditure reports. Payments will be made to the
Departmatt according to expenditures reflected on the monthly Expenditure Reports.
como~im~ed A~r~xunr _ ~.w
Page 13 of tit
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 Departrnent 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 Lune 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.
H DISBURSEMENT OF FUNDS
The State shall disburse funds to the Department on a monthly basis; monthly disbursements for each
program activity will be based on monthly expenditures reported
2. Food and Lodging foes will be disbursed to the departrnent by the State (DENR-DEH) in two separate
payments in accordance with NCAC T15A:18A . 2900 - "Restaurant and Lodging Foe Collection and
Inventory Program" in the month following receipt of the signed and completed Budget Foam (DENR 2948)
and Addendum (DENR 3300). The exception is that Temporary Food Establishment (TFE) fees MUST be
collected by the Department and must be expended to support-the food, lodging, and institution sanitation
programs and activities. Such fees shall be deemed to have been disbursed to the Department upon their
collection.
Funds for Childhood Lead Poisoning Prevention will be disbursed once per year. The numbs of confumod
cases identified in the prior calendar year will determine the amount received by each county. A separate
signed and completed Budget Fenn (DENR 2948) and Addendum (DENR 3300) for Childhood Lead
Poisoning Prevention must be submitted by December 31" in order to receive these funds.
4. Payments shaII be suspended when expenditure reports are not received by the time specified (see C.4.a.).
Payments will resume the month following the receipt of the delinquent expenditure reports according to the
DHHS CoatroUers office schedule for OSC E-Payments issued in November or December of each year for
the following calendar year.
5. Total payment by program activity is limited to the total amount of the "Funding Authorization" and any
revisions received after the initial "Funding Authorization" notification.
6. Final payments for the SFY will be made based on the Final monthly (May services/ submitted in June
Report) Expenditure Report. Final payments will be equal to the difference between approved reported
expenditures and the sum of previous payments up to the limits of the approved budget. Final payments
should be made no later than the Junc OSC E-Payment period per the DHHS Controller's Office schedule,
provided that an Expenditure Report and certification, via the Aid-to-Counties Website for each month have
been received by the DHHS Office of the Controller.
AMENDMENT OF AGREEMENT
Amendments, modifications, or waivers of t11is agreement maybe made at any time by mutual consent of all
parties. Amendments shall be in writing and signed by appropriate authorities.
J. PROVISION OF TERMIIVATION
Either party may terminate this agreta~ertt for reasons other than non-compliance upon sixty (60) days written
notice. if termination should occur, the Department shall receive payment only for allowable expenditures.
Consolidated A - Finl
Page 14 of 19
The State may withhold payment to the Department until the State can determine whether the Department is
entitled to further payment or whether the State is entitled to a refund.
K. COMPLIANCE
The State shall respond to non-compliance with all terms of this ag~~eement as follows:
a. Upon determination ofnon-compliance, the State shall give the Department sixty (60) days written
notice to come into compliance. If the deficiency is corrected, the Department shall submit a written
report to the State that sets forth the corrective action taken.
>r_ If the above deficiencies should not be corrected to the satisfaction of the State aRer the sixty (60) day
period, disbursement of funds for the particular activity may be temporarily suspended pending
negotiation of a plan of corrective action.
If the deficiency is still not corrected within the next thirty (30) days following temporary suspension of
fimdmg, program funds maybe permanently suspended until the Department can provide evidence that
the deficiencies have beat corrected '
d. In the event of the Department's non-compliance with clauses of this agreement, the State may cancel,
ternunate, or suspend this agreement in whole or in part and the Department maybe declared ineligible
-for further State contracts or amts. 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) aU older reasonable administrative remedies have been exhausted.
~~ Subrecipient Monitoring -OMB Circular A-133 (Audits of States. Local Government, and Non-Profit
Organizations) as revised on June 2'I, 2003 requires that pass-through entities monitor the activities of their
subrecipierlts 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 are
achieved. North Carolina establishes comparable monitoring requirements for State funds received by
subrecipients in N.C.G.S.143-6.2, Use ojState funds by non State entities, for non-State subrocipients, -and
N.C.G.S.158-34, An~rual independent audit: rules and regulations, for local units of government. Also,
DHHS-DPH must perform subreeipiemt 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 Subrocipient Monitoring Plan dated January, 2006.
Additionally, each Local Health Department is required under Circular A-133, N.C.G.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.
Coa~oli0akd AQOeaeat - Furl
Page 15 of t9
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 Oflic:e of Administrative Hearings.
IN WITNESS WHEREOF, the DepArhnent and the Sbte have executed this agreement in duplicate originals, one
of which is retained by each of the parties.
OF NORTH CAROLINA
Chair of County
(when required)
I
}coq
ite lldal i jlirretor
.~-uth~a -r~d Agent
~ ~
~~ '~
s ~ d
Secretary, Departmdtt of Environment
and Natural Resources or Authorized Agent
LOCAL SIGNATURES
Consolidsbd Ap~eement . FioN
Page 16 of t9
NORTH CAROLINA
DEPARTMENT OF HEALTA AND HiIMAN SERVICES
BU5IQVESS ASSOCIATE ADDENDUM TO MEMORANDUM OF UNDERSTANDING
This Agreement is made effective the 1st day of July, 2009, by and between
~'ro~~~ Cpt;~~ ~.Q,a~r•l'tir~
(name of Local Health Department or" overod Entity") and the Division of blic Health ("Business Associate")
(collectively the "Parties").
1. BACKGROUND
a. Covered Entity and Business Associate are parties to a Memorandum of Understanding "entitled" The FYZ009
Coasvtldated Agreantent (the "MOU'~, whereby Business Associate agrees to perform certain services for or
on behalf of Covered Entity.
b. Covered Entity is an organizational unit of the North Carolina DepaRmeat of Health and Human Services (the
"Department") that has been designated in whole or in part by the Department as a health care component for
purposes of the HIPAA Privacy and Security Rules.
c. The relationship between Covered Entity and Business Associate is such that the Parties believe Business
Associate is or may be a "business associate" within the meaning of the HIPAA Privacy and Security Rules.
d The Parties enter into this Business Associate Addendum to the MOU with the intention of complying with the
HIPAA Privacy and Security Rules provision that a covered entity may disclose electronic protected health
information or other protected health information to a business associate, and may allow a business associate to
create or receive electronic protected health information or other protected heath information on its behalf, if the
covered entity obtains satisfactory assurances that the business associate will appropriately safeguard the
information.
2. DEFINITIONS.
Unless some other meaning is clearly indicated by the context, the following terms shall have We following meaning in
this Agreement:
a. "Electronic Protected Health Infonanation" stall have the same meaning as the term "electronic protected health
information" in 45 CFR 160.103, limited to the information created or received by Business Associate fivm or
on behalf of a Covered Entity.
h. "HIPAA"means the Administrative Simplification Provisions, Sections 261 through 264, of the federal Health
Insurance Portability and Accountability Act of 1996, Public Law 104191.
e. "Indevidual" shall have the same meaning as the term "individual". in 45 CFR 160.103 and shag include a person
who qualities as a personal representative in accordance with 45 CFR 164.502(g).
d. "Privacy and Security Rules" shall mean the Standards for Privacy of Individually Identifiable Health
Information and Security Standards for the Protection of Elxtronic Protected Health Information in acxordance
with 45 CFR part 160 and part 164, subparts A and E.
e: "Protected Health Information" shall have the same meaning as the term "protected health information" in 45
CFR 160.103, limited to the information created or received by Business Associate from or on behalf of Covered
Entity.
"Required By Law" shall have the same meaning as the term "required by law" in 45 CFR 164.103.
g. "Seeretary" shall mean the Secretary of the United States Department of Health and Human Services ~ tus
:arolidned AOmaeM
designee.
Page T 7 of 19
h. "Security Incident" shell' have the same meaning as the term "security incident" in 45 CFR 164.304.
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 Agreenmennt ~ as required by Iaw.
b. Business Associate agrees to implement administrative, pbysical, 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 to 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 Agreerrrcnt.
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 recxived from, or created or received
by Business Associate on behalf of Covered Entity (i) agrees to be bound by the same restrictions antl
conditions that apply through this Agreement to Business Associate with respect to such information, and (ii)
agrces to implement reasonable and appropriate safeguards m protect such information.
Business Associate agrees to provide acces.~, at the request of Covered Entity, to electronic protected health
information and other protected health information in a Designated Record Sd to a Covered Entity or, as
directed by a Covered Entity, to an individual in order to rrtect the requirements order 45 CFR I64.524.
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 agr+ces 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 informration, 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.
Business Associate agrees to document such disclosures of electronic protected health information and other
protected heahh information related to such disclosures as would be raluirod 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.
Consolidate Agreement -Final Page l8 of ~'~'
4. PERMITTED USES AND DISCLOSURES
a. Except as otherwise limited in this Agreement or by other applicable law or agreements, if the MOU
pernvts, Business Associate may use or disclostr electronic protected health information and other protected
health infomtation to perform functions, activities, or services for, or on behalf of, Covered -Entity as
specified in the MOU, provided that such use or disclosure:
1) -would not violate the Privacy and Security Rules if done by Covered Entity; or
2) would not violate the minimum necessary policies and procedures of the Covered Entity.
b Except as otherwise, limited in this Agreement or by other .applicable law or agreements, if the MOU
permits, Business Associate may use electronic protected health information and other protected health
information as necessary for the- proper management and administration of the Business Associate or to
carry out the legal responsibilities of the Business Associate.
'c. Except as otherwise limited in this Agreement or by other applicable law or agreements, if the MOU
permits, Business Associate may disclose electronic protected health-information and other protected health
information for the proper management and administration of the Business Associate, provided that:
1) disclosures are required by law; or
2) Business Associate obtains reasonable assurances from the person to whom the information is
disclosed that it will remain confidential and will be used or further disclosed only as_required by taw
or for the purpose for which it was disclosed to the person, and the person notifies the Business
Associate of any instances of which iY is aware in which the confidentiality of the information has been
breached.
d. Except as otherwise limited in this Agreement ar by other applicable law or agreements, if the MOU
permits, Business Associate may use electronic protected health information and other" protected health
information to provide data aggregation services to Covered .Entity as pemutted by 45 CFR
164.SQ4(e)(2xixB).
e. Notwithstanding the foregoing provisions, Business Associate may not use or disclose electronic protected
health information or other protected health information if the use or disclosure would violate any term of
the MOU or by other applicable law or agreements.
5. TERM AND TERMINATION
a. Term. This Agreement shall be effective as of the effective date stated above and shall terminate when the
MOU terminates.
b. Termination for Caase. Upon Covered Entity's knowledge of a material breach by Business Associate,
Covered Entity may, at its option:
1) Provide an opportunity for Business Associate to cure the breach or end the violation, and terminate
this Agreement and services provided- by Business Associate, to the extent permissible by law, if
Business Associate does not cure the breach or end the violation within the time specified by Covered
Entity; .
2) Immediately terminate this Agreement and services provided by Business Associate, to the extent
permissible by law; or
3) If neither termination nor cure is feasible, report the violation to the Secretary as provided in the
Privacy and Security Rules.
Consolidate Agreetnp-t-Final
C. Effect of Termination.
Page 19 of I9
l) Except as provided in patagi~aph (Z) of this section or in the MOU or by other applicable law or
agreernents, upon termination of. this Agreement and services provided by Business Associate, for any
reason, Business Associate shall'retutn 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 chat 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 infon~raiion 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 CONDITION5
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 retrain in force
and shall apply to this Agreentettt as if set forth fully herein.
c. 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
~~
,, s1 r ~.~ ~ - r - -' ~.,L ~ -_
Covered Lntity (Local health Dept)
~a
~~L
~~~~ ~~ ~.
/ T
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND
VOLUNTARY EXCLUSION-LOWER TIER COVERED TRANSACTIONS (Note: The phrase
''prospective lower tier participant," means providers under contract with the Division of Public
Health.)
1. By signing and submitting this document, the prospective lower tier participant
providing the certification set out below.
2. The certification in this clause is a material representation of the fact upon which reliance
was placed when this transaction was entered into. If it is later determined that the
prospective lower tier participant knowingly rendered an erroneous certification, in
addition to other remedies available to the Federal t iovernment, the department or agency
with which this transaction originate may pursue available remedies, including
suspension and/or debarment.
3 The prospective lower tier participant will provide immediate written notice to the person
to which this proposal is submitted if at any time the prospective lower tier participant
learns that its certification was erroneous when submitted or has become erroneous by
reason of changed circumstances.
4. The teirrrrs "COVered tranSactlOn," wdebatied,w ns~~~w "ineligible," "lOWer her
COVered tra11S8ctlOn," "participant," "person," "primary COVered tranSactron," "principal,"
"proposal," and "voluntarily excluded," as used in this clause, have the meanings set out
in the Definitions and Coverage sections of rules implementing Executive Order 12549,
45 CFR Part 76. You may contact the person to which this proposal is submitted for
assistance in obtaining a copy of those regulations.
5 The prospective lower tier participant agrees by submitting this proposal that, should the
proposed covered transaction be entered into, it shall not knowingly enter any lower tier
covered transaction with a person who is debarred, suspended, determined ineligible or
voluntarily excluded from participation in this covered transaction unless authorized by
the department or agency with which this transaction originated.
6. The prospective lower tier participant firrther agrees by submitting this document that it
will include the clause titled "Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion -Lower Tier Covered- Transaction," without
modification, in all lower tier yovered transactions and in all solicitations for lower tier
covered transactions.
Debarment S/00
Page 1 of 2
7- A partieiparrt 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. Each participant may, but is not required to, check the
Nonprocurement 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 authorized in paragraph 5 of these instn~ctions, 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 Exciasion -
Lower Tier Covered Transactions
(1) The prospective tower 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 deparment 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 Ag cY Officisi Signature
u,n~ . ~~ ~~K'~r~'cr
Tide
Official ~tigency Name
(Signature should be same as Contract signature)
~~ ~;~ ~r~r~ts
3(~~~ a Tq____~~~'~
Debarment 5/00
Pago 2 of 2
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
CERTIFICATION REGARDING ENVIRONMENTAL 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 permitted 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 1;1,000 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.
_ ' ~' ~ t~ln ~P~ ~~G~C_ {fir'-
Agt6orized ncy Ofiieiat Signature Title
Official gency Na ~ ,
3/~c1oR
Date
(Signature should be same as Contract signature)
Smoke 3/00
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTII
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
I. By execution of this Agreement the Contractor certifies that it will provide adrug-free
workplace by:
A. Publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance is prohibited in the Contractor's
workplace and specifying the actions that will be taken against employees for violation of such
prohibition;
B. Establishing adrug-frce awareness program to inform employees about
(1) The dangers of drug abuse in the workplace;
(2) The Contractor's policy ofmaintaining adrug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that maybe imposod upon employees for drug abuse violations occurring in the
workplace;
C. Making it a requirement that each employee be engagod in the performance of the agreement
be given a copy of the statement roquirod by paragraph (a);
D_ Notifying the employee in the statement required by paragraph (a) that, as a condition of
employment under the agreement, the employee will:
Abide by the leans of the statement; and
(2) Notify the employer of any cximinal drug statute conviction for a violation occurring in the
workplace no later than five days after such conviction;
E. Notifying the Depardnent within ten days after receiving notice under subparagraph (dx2)
from an employee or otherwise receiving actual notice of such conviction;
F. Taking one of the following actions, within 30 days of receiving notice under subparagraph
(dx2), vinth respect to any employee who is so convicted:
(1) Taking appropriate personnel action against such an employee, up to and including
termination; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabiUtation program approved for such purposes by a Fodcral, State, or local health, law
enforcement, or other appropriate agency; and
Making a good faith effort to continue to maintain a dru -free workplace through
implementation of paragraphs (a), (b), (c), (d), (e), and (~•
Drug Free S/'00
Page 1 of 2
II. The site(s) for the performance of work done in connection with the specific agreement are
listed below:
Fh`~lsbo~,c~, NC 2TZ7~
~A[ (City, coun~y/ty/~~, state, zip code) ~ _-
(Street address) _ .- ~ .
~h~~t ill ~ G ~~s°~b
(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, Sa;tion 85.61 S and 86.620).
Authorized ncy Official Signature
C~~.~t ~-f~~-C~f ~, '~Dl~rec~'
Tide
~Q Ca a .~, _ :~
Official geacy Nam Date _ ..:~.,~~._,_~. _3....
(Signature should be same as Contract sigiiature)
Drug Free 5/00
Page 2 of 2
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
CERTIFICATION REGARDING LOBBYING
The undersigned cxrtifies, to the best of his or her knowledge and belief, drat
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
entptoyee of any agency, a Member of Cortgr~s, an officer or employce of Congress, or
an employce 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 agrcement.
2. If any funds other than Federal appropriated funds have been paid or wilt be paid to any
person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an oiBtxr or employee of Congress, or an employce of a Member
of Congress in connection with this Federally funded vontrad, grant, loan, or cooperative
agreement, the undersigned shall complete and submit 3tandand 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 subawards at all tiers (including subcontracts, subgrants, and
contracts under grants, loans, and cooperative agreements) who receive federal funds of
S 100,000 or more and that all subrecipients shall -cxrtify and disclose accordingly.
This certification is a material representation of fad upon which reliance was placed when this
transaction was made or entered into. Submission of this cetific~tion is a pra+oquisite for
making or entering into this transaction imposed by Section 1352, Tide 31, U.S. Code. Any
person who fails to file the required certification shall be subject to a civil penalty of not less
than S 10,000 and not more than S 100,000 for each such failure.
~~ ' "~~ -
f#uthurized ency Official Signature
Co tln'~.r ~P.4. t.1 r'- ~if e~
Tide ~
Official ency Nsme
(Signature should be some as Contract si~atur~e)
~I (~_
Date
t,obbv sroo
ASSURANCE OF COMPLIANCE
ASSURANCE OF ('.OMPIJANCE WITH TITLE VI OF THE CML RIGHTS ACT OF 1964, SECTION 504 OF THE REHABILITATION ACT OF
1973, TITLE IX OF THE EDUCATION AMENDMENTS OF 1972, AND THE AGE D13CRIMINATION ACT OF 1975
The AppNCant provWes this assurrxe in oorreideratlon of and fo- the purpose of obta&ring Federal gratis, bans. contracts, propsAy, discounts
or other Federal financial assistance b'om the Department of Flealth and Human Services.
THE APPLICANT HEREBY AGREES THAT R WILL COMPLY WITH;
Title VI ~ the Civil Riglrts Act of 1964 (Pub. L. li&352). as amended. and aN requirenrsnts impoeed by or pursuant b the Regulatlon
of the DeparfrtreM of Heald and Human Services (45 C.F.R. Part t10), b the end Ihat, in accordance with Title VI o1 that Act and the
RegrrleAion, rro person in the lJnited States shall, on the ground of race, color, or r>atlonal orlpin, be excluded from parddpelion in, be
denied the barteflts oi, or be otherwise subjected b disrxirnirra5on under arry txoprsm or actlrity for wt>ich the AppNcarrt rocsives
Federal financial assistance iron the Deparltnsnt.
2. Section 504 of 9ie RehabNilation Ad of 1973 (Pub. L. 93-112). as amended. and aM requirements imposed by or pursuant b fhe
Regulation of the Depertrnent of Heatlh and tirrrran SeMces (45 C.F.R. Part 84). b the end that, h accordance wNh Sedion 504 of
that Ad and the Regulation, no otl~erwise quaNfied handicapped irrdivktual in the United States shadl, solely by reason of f4s handicap.
be excluded horn partldpatlon In, be denied the benefits of. or be subjected b disahllnatlon urxler any program or actNity
for which the AppNcent -eceNes Federal tirreno3el iron the Departrnerrt.
Title IX of the Edrrcatlonal Amendments of 1972 (Pub. L. 92-318j, ss amended, and sA -equirerrrents imposed by or pursuant b the
Regulaton of the Dspartrrrsnt of tfeakh and Human Servbes (45 C.F.R. Part t16), b the end diet, M accordance with Title IX and the
Regtrlatlon, no person h the United States ahatl, an the basis d sex. be exofuded tFom patldpation in. De denied the benelks oi, or
be otlrerwise subjsded b ~saifnM+atlon under any education program or ariihrity for which the AppifcaM receives Federal tinarxial
assistance from the Dsparbnerk.
4. The Aga DispbnRretion Ad of 1975 (Pub. L 94-155). as anended. and aN requirements Nnpoeed by or pursuant b tiw Regulation of
the Departrrrart of HesNh and Fkrrnerr Services (45 C.F.R Part 91), b the end Brat, in acoorclarrce with the Ad and the Regulation, no
person in ttre United Sues shah. on the bask of arge, be denied the berwfits of, be excluded from patldpation in, a be subjected b
discrirrrinalion under any progrem or sctlNty for whir;h tlrs Appicarrt reoeNes Federal financfed assistance fiom the Depsrtrrrent.
The AppNcant agrees that ConpNaroe wNh tlds assurance oortitiprles a oondtlbn of oontlrwsd receipt of Federal 1nancial aafstance, and that it
~ bindkp ~ be Apptlcant, ICe suoce~ors, transferees and assignees ta- the perbd during which such assiatarr~ is provided. Ii arty real
properly a atnrcttrre thereon b provWed or improved with the aid of Fedad finarckl assidar-ce exlerrded b tfrs Apptlcasrt by ~ .
tlrls assurance shah obN~te the AppNcant, or Yt the case of any transfer ~ such properly, arty transferee. for the perbd during which the real
property or stnrcture is used for a purpose for which fhe Federal financial arssistaroe b ex0ended or for awlhsr purpose lnvdvirg tlrs provision
of similar Cervices or berrelils. M any personal property is so provided, tlris assuraros shah obligate the /IppNcarrt for the period during which it
retains ownersirp a pcesesaon of the propariy. The nppNcsnt lbrtlrer rooogniaes and agrees that the united states atraM have the right b seek
judicial enbresment of this assurance.
T~ P«~ or t vrlroCe sigrwbrre(s) appsa(a) below islaro autlrorized b sgn this wsuraros, and commit the AppNcant b the above
provisions.
~"-tl"
pAaN Farm b:
DHHS/08ioe for Civil Rights
Office of Program Operador-s
Flrxnplxey Building. Room 509E
200 indepsndenoe Ave., S.W.
Washingbn, D.C. 20201
,l ~ r.
.~ ,:
Signshrre and~~Titls dr 14rNrortz~ 1711iCiad ~ ~
IZOSewla,r L. S~t,w,iM~rS
Name of Apptlcant ar
p0 W/ . ~1 P~prl ~f~'.
SMt- -
cltr, slat., zlp cad.
Form HHS-680
5/97