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CGNTRACTS
MAY 0 3 2004
CONSOLIDATED AGREEMENT
BETWEEN
THE STATE OF NORTH CAROLINA
AS REPRESENTED BY
THE STATE HEALTH DIRECTOR
(Hereinafter called the "State")
AND
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Orange Co Health Dept
(Local Health Department/District/Public Health Authority/Human Services Agency (Wake and
Mecklenburg) -- Hereinafter called the "Department")
FOR THE PURPOSE OF
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PUBLIC HEALTH IN NORTH CAROLINA
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`,`° . This Amended Agreement Shall Cover a Period From
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July 1, 2004 to June 30, 2005
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 fiords means state,
federal., and/or special funding or funds throughout this agreement.)
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A. RESPONSIBILITIES OF THE DEPARTMENT (LOCAL PUBLIC HEALTH UNIT)
1. The Department shall perform activities in compliance with applicable program rules
contained in the North Carolina 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.
Departments will meet or exceed the Agreement Addenda levels unless extenuating
circumstances prevail and are 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.
6. The Department shall share 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 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 to the
Local Technical Assistance and Training Branch (LTAT).
9. The Department shall provide to the State a comprehensive community health assessment
every four years and a State of the County Report each of the interim three years. LTAT~
Healthy Carolinians/Health Education Unit will administer this four-year cycle. The
community assessment should be a collaborative effort with the local Healthy Carolinians
Partnership and shall include collection of primary data at the county level as appropriate.
The Assessment shall include a list of community health problems based on the findings, a
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narrative of the assessment findings, and community action plans to address the priority
issues.
10. The Department shall provide formal training for their Board of Health (BOH) members
through DHHS sponsored offerings through the UNC School of Public Health -Institute
of Public Health. First priority will 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. Individual need of Boards
and members will be considered in meeting this objective.
11. The Department shall maintain current membership in North Carolina's Health Alert
Network (NC HAN), which membership shall include the Local Health Director and at
least one other staff representative that the Director shall designate. The membership shall
log into NC HAN regularly and shall maintain current contact information in the system
(i.e., phone numbers, a-mail addresses, pager information, etc.). The membership shall
also maintain 24/7 contact availability. Department members shall be responsible for
accessing the NC HAN as soon as possible when an alert is issued. All NC HAN alerts
will be reviewed and acted on as necessary by the Department in a timely manner.
B. FUNDING STIPULATIONS
1. Funding for this agreement is subject to the availability of State, Federal, and Special
Funds for the purpose set forth in this agreement.
2. During the period of this agreement, the Department shall not use State, Federal or
Special Project funds received under this agreement to reduce locally appropriated funds
as reflected in the Local Health Department-Local Appropriations Budget.
3. The Department shall not use personal health program funds to support environmental
health programs nor use environmental health program funds to support personal health
programs.
4. Fees generated by the Food and Lodging Fees Collection Program may only be used to
support State and Local food, lodging, and institution sanitation programs and activities.
5. Funds for Childhood Lead Poisoning Prevention may be used to support both
environmental health and child health activities.
6. The county shall submit monthly reports of On-Site Wastewater activities to the On-Site
Wastewater Section in Division of Environmental Health in the format provided by the
Section.
7. The Department shall comply with Standards for Mandated Public Health Services, 15A
NCAC 25, Section .0200; and Administrative Procedures Manual for Federal Block Grant
Funds, 1 NCAC 33, Sections .0100 - .1502.
8. The Department shall maintain signed employee time records to document the actual work
activity of each employee on a daily basis. The percentage of time each employee spends
in each activity shall be converted to dollars based upon the employee's salary and benefits
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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.
9. The Departments participating in Medicaid Reimbursement shall:
a. Execute a Provider Participation Agreement with the Division of Medical Assistance.
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 law, however no one shall be refused
services solely because of an inability to pay.
c. Establish their Charge per clinicaUsupport service for all payors (including Medicaid)
based on their full costs. All Payors must be charged the same established charge, but
contract/program adjustments maybe accepted as negotiated 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 I SA NCAC 24A 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 non-English speaking clients.
b. Only those programs and services funded entirely with state and/or local funds, unless
prohibited by State law or rule, may charge non-English speaking 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 local health 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 limited to no
more than $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 limited to
no more than $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 and when the
local staff member is a part of a state team accepted into these trainings/institutes.
13. 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 Government Commission (LGC) by the County Administration (if
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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.
14. Equipment are a type of fixed asset consisting of specific items of property that: (1) are
tangible in nature; (2) have a life longer than one year; and (3) have a significant value.
a. For Inventor,~urposes
Equipment must be accounted for in accordance with the North Carolina
Department of State Treasurer Policies Manual, Chapter 20, Fixed Assets Policy.
ii. All equipment with an acquisition cost of $500.00 or more 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 AQproval Purposes
i. All equipment purchased or leased with an acquisition cost exceeding $1000.00,
where there is an option to purchase with State/Federal funds, must receive prior
written approval from the appropriate Section (EXCEFT in the WIC Program
where the limit for prior approval remains at $500).
ii. All medical equipment and computer equipment, (purchased or leased) regardless
of cost, purchased with WIC Program Funds, must receive prior approval from the
WIC Program Office.
iii. The use of Women's and Children's Health Medicaid fees for capital
improvements requires prior written approval from the Women's and
Children's Health Section.
c. For Accounting Purposes: The Department must utilize the depreciation schedule
provided by the State for all assets with an acquisition cost of $5,000 or greater. The
accumulated depreciation should be recorded in the general fixed assets account group.
15. The Department agrees to execute the following Federal Certifications attached to this
agreement applicable when receiving Federa] funds;
a. Certification regarding Lobbying.
b. Certification regadding Debarment.
c. Certification regarding Drums Free Workplace Requirements.
d. Certification regarding Environmental Tobacco Smoke
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16. The Department shall incorporate appropriate elements of the North Carolina Public
Health logo and themeline (slogan) into communication materials developed for programs
and services that depend upon, in whole or in part, state funding..
C. FISCAL CONTROL
1. The Department shall comply with the Local Government Budget and Fiscal Control Act,
North Carolina General Statute Chapter 159, Article 3.
a. The Department shall maintain a purchasing and procurement system in accordance
with generally accepted accounting practices and 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. When subcontracting, the following conditions must be met:
The Department is not relieved of any of the duties and responsibilities provided in
this agreement.
ii. The subcontractor will agree to abide by the standards contained herein or to
provide such information as to allow the Department to comply with these
standards.
iii. The subcontractor will agree 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:
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
which ever 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 DHHS Controller's Office, 2019 Mail Service Center, Raleigh NC27699-2019. The
Department shall retain a copy of all Funding Authorizations, Local Health Department-Local
Appropriations Budget, Electronic Spreadsheet -Local Health Department/District
Expenditure Report DHHS 2949, signed Consolidated Agreement, Agreement Addenda,
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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 prepare 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" 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 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 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 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.
d. Use of program income generated by the expenditure of Federal categorical funds will
be governed by applicable Federal regulations, including, but not limited to, 45 CFR 4.
e. When preparing Local Appropriation Budgets,
i. Line item 9000 on the program budget form must be used to budget the total of
line items 101, 102 and 103.
ii. Line item 101 on the program budget must be used to budget local appropriations.
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iii. Line item 102 on the program budget must be used to budget TXIX Medicaid
earned revenues.
iv. Line item 103 on the program budget must be used to budget other earned
revenues (e.g., Home Health fees, Environmental Health fees, patient fees (cash),
other insurance payments, and other grants and donations).
f. When reporting expenditures (local appropriations or earned fees) the department
must use the electronic spreadsheet (Local Health Department/District Form DHHS
2949 revised 5/03/01) -hereafter referred as DHHS Spreadsheet -prepared and
maintained by the DHHS Controller's Office. This report must be submitted monthly
in an electronic format (DHHS 2949 -Local Health Dept/District Expenditure
Report-Excel Spreadsheet File) as an attachment to an email to designated staff in
the Benefits and Payment Section of the Controller's Office.
At the time the electronic report is emailed to the DHHS Controller's Office, a
"Certification of Expenditures" signed by the health director, shall be faxed to the
DHHS Controller's Office. The "Certification" verifies in writing that the total State
and Federal expenditures reported were valid. Local expenditures are part of the
Expenditure report, but are not included in the amount verified in the "Certification."
i. Line item 101 on the DHHS Form 2949 Spreadsheet must be used to report local
appropriations that were expended
ii. Line item 102 on the DHHS Form 2949 Spreadsheet must be used to report Title
XIX (Medicaid) earned revenues that were expended.
iii. Line item 103 on the DHHS Form 2949 Spreadsheet must be used to report other
earned revenues that were expended.
g. A local account shall be maintained for unexpended earned revenues [i.e., Title XIX
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 2004-2005 must equal or
exceed the amount of Title XIX revenues earned during FY 2002-2003. The state will
not approve program activity budgets that do not include an amount of Title XIX fees
sufficient to meet the requirements of this section. The State may waive this
requirement if the Department provides sufficient justification.
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 -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 as an
attachment to an email to designated staff in the DENR Controller's Office and the
Division of Environmental Health.
A "Certification of Expenditures" (for items in "i." above), sinned by the health
director and finance officer, shall be submitted annually with original Budget Forms
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(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} The Department shall submit a monthly report of actual
expenditures (State and/or Federal) to the DHHS Controller's Office on the DHHS
(Electronic) Spreadsheet (same electronic Spreadsheet DHHS 2949 as referenced in 3.f.
above) -all reported in one spreadsheet, but separated here for clarity of instructions.
a. The Department shall submit monthly expenditures for all programs via DHHS 2949
(Electronic) Spreadsheet to the DHHS Controller's Office no later than the dates
published annually in December for the next calendar year. The schedule reflects a
general period of 15-20 days from the end of the reporting month for submission of
the DHHS Spreadsheet, based on weekends and holidays, to allow processing time for
the payment. Failure to meet the reporting deadline, as published, WII,L 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 this DHHS Spreadsheet, consecutively
throughout the agreement period.
b. Departments shall keep expenditure reporting current and submit their DHHS Form
2949 Spreadsheets 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, 2004 expenditure report will be paid in July, 2004 and will
be paid from a department's funding allocation for SFY 2004-05. Therefore a
department will need to submit all requests for adjustments, corrections, or
amendments to expenditure reports for fiscal year 03-04, with the May, 2004
c. Expenditures of federal funds must be reported according to the funding period for a
grant. Care must betaken 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 2004 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)
October service month/ paid in November; and 6) November service month/paid either
in December, or before the ending date of that grant's settlement period. In this
example the remaining 6 service/payment months will be December service month/paid
in January through May service month/paid in June, 2005.) For each Grant, the
budgetary estimate, funding authorization and agreement addendum will have
service/payment month dates listed. Billing the service month in the next month and
reporting adjustments whenever discovered but at least quarterly, should ensure that
Consolidated Aereement -Final
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the Department receives proper payment. Grant expenditures submitted after the
settlement date of a Grant will not be reimbursed, nor will there be any year end
settlement from any other source of funds.
d. The Department shall submit the final (DHHS 2949) LHD Expenditure Report
(Electronic Version) for all programs to the DHHS Controller's Office according to
the schedule published annually in December for the next Calendar Year by the DHHS
Controller's Office. The May Services/Paid in June will be the final report period
paid from the SFY. Services provided in June and reported in July will be paid
out of the next SFY.
e. The Department shall have opportunities to submit amended or corrected expenditure
reports as soon as the error is discovered, but at least quarterly. A DEPARTMENT
SHOULD NOT WAIT TO SUBMIT ALL ADJUSTMENTS WITH INVOICE
SUBMITTED TO THE CONTROLLER'S OFFICE AT THE END OF MAY AS
THAT WILL NOT ALLOW SUFFICIENT TIlVIE FOR VERIFICATION OF THE
ADJUSTMENTS BEFORE THE LAST PAYMENT IN THE STATE FISCAL
YEAR.
1) In accordance with item 4., c, above, each department must be mindful to keep
current on reporting adjustments against federal funds to ensure such adjustment is
received in time to be paid within the grant period for that grant.
2) In October, each department is to review all prior reimbursement claims against
payments and submit any request to add, correct, delete or amend any prior
month's payment with the October or November request for reimbursement.
3) In January, each department should review payments and expenditures for the
prior quarter, as well as run totals including the first quarter (July, August,
September) to obtain and verify amid-year reconciliation to ensure that claims are
accurate, and submit any request to add, correct, delete, or amend any payment in
the January or February expenditure report.
4) In April, each department should ensure that all claims are correct for the year to
date, and to submit any request to add, correct, delete, or amend any expenditures
with the expenditure report sent to the Controller's Office in May, that is, the
adjustment items would be sent in with the billing for the April services that will be
paid May.
5) The only adjustments, if any, that should be submitted with the May service
expenditure report submitted in June would be any missed on the prior month's
claim. If a department waits until May service month expenditure report
submission to report adjustments, the Controller's offiice cannot guarantee those
adjustments can be verified in time for the June payment.
6) Any adjustments not paid in the June payment for the current fiscal year either will
not be paid, or will have to be resubmitted for payment in the next fiscal year out
of that fiscal year's allocation. Any overpayments identified by either the State or
the Department will be adjusted out of the next month's claim for reimbursement
by the Controller's office.
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f. The Department shall submit requests for payment for services provided under 15A
NCAC 24 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 Unit. Form 3300 -Public
Health Nurse Training Activity must be used as the invoice for payment.
h. Departments providing the WIC Program shall limit the total expenditures for July,
August, and September (1st quarter of the State/County Fiscal Year) to no more than
one-fourth (1/4) of their total budget for the Agreement Period. If any local
encumbrances are recorded for July, August or September, to be paid in subsequent
months, these expenditures must be accounted for in the 25% limit imposed for July,
August and September expenditures.
The Department shall submit to Administrative, Local and Community Support Section on
an annual basis Staff Time Activity Report - DPH 3389, Environmental Health Report-
DENR 3738, and Food and Lodging Report-DENR 3888. These reports are due by July
20th.
D. PERSONNEL POLICIES
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. 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
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.
b. Arrangements for centralized training for newly-employed environmental health
specialists will be handled by the Education and Training Staff, Division of
Environmental Health.
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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 15A
NCAC Section. 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 be held 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 maybe 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. CIVII., RIGHTS
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 IX 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 discriminate in
employment against a qualified individual with a disability and outlaws discrimination
against individuals with disabilities in State and local government services and public
accommodations. The Department certifies that it and its principals and subcontractors
will comply with regulations in ADA Title I (Employment), Title II (Public Services), and
Title III (Public Accommodations) in fulfilling the obligations under this agreement.
G. RESPONSIBILITIES OF THE STATE
1. The State shall provide to the Department regular training, and, upon request, technical
assistance in the preparation of the Consolidated Agreement, Local Health Department -
Local Appropriations Activity Budgets and Agreement Addenda.
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2. The State shall conduct liaison activities with local 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/Staffing
^ Policy Development
^ Program Planning and Implementation
^ General Administrative Consultation, including consultation and technical assistance in
budgeting, fiscal, administrative and management support topic areas.
4. The State shall provide coordination and support for the education and training for the
public health workforce.
5. The State shall provide technical assistance and consultant services, as required, for
.specific health program areas, including providing guidance and consultation about
specific patient clinical issues, when requested.
6. The State shall provide consultation and technical assistance on nursing practice and
standards, policies and procedures that cross program boundaries and coordinate courses.
7. 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 development; program planning, program
evaluation and quality assurance; data collection; and community assessment to local
health educators for all public health programs.
8. The State shall act as the principal liaison between the public health system and the state's
Medicaid agency on issues related to Medicaid reimbursed services provided by the state
and local public health agencies.
9. The State 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.
10. The State shall design and implement annual cost studies to ensure appropriate cost-based
Medicaid reimbursement.
11. The State shall work with the NC Division of Information Resource Management to
provide automated systems and facilities via the Health Services Information System
(RBIs). HSIS is currently used to create and submit Medicaid claims, perform accounts
receivables, 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 health programs.
The State shall provide business and technical support for the automated systems to the
users of these systems.
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12. The State shall provide support and consultation to ensure that HSIS can generate
standard transactions for public health Medicaid claims submitted on behalf of the local
health departments per HIPAA [the Administrative 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 use data reviewed and received responsibly 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 (DPI-~ shall provide to the Department "Estimates of Funding Allocations" no
later than February 15 of each year to use in preparation of their local budget proposals
per current GS.
15. The State (DENR-DEI-1) shall provide to the Department the "Budget Form" (DENR
2948) indicating the estimated funding allocations no later than March 30`h of each year
to use in the preparation of their local budget proposals per current GS.
16. The State (DPH) 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-DEI-17 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 Steps-Out Schedule issued
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
Consolidated Agreement -Final
Page 15 of 21
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.
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,
and shall be adjusted either upward or downward accordingly.
2. Food and Lodging fees will be disbursed to the department by the State (DENR-DEH) in
three separate payments in accordance with NCAC T15A:18A . 2900 - "Restaurant and
Lodging Fee Collection and Inventory Program" in the month following receipt of the
signed and completed Budget Form (DENR 2948) and Addendum (DENR 3300).
3. Funds for Childhood Lead Poisoning Prevention will be disbursed once per year. The
number of confirmed cases identified in the prior calendar will determine the amount
received by each county. A separate signed and completed Budget Form (DENR 2948)
and Addendum (DENR 3300) for Childhood Lead Poisoning Prevention must be
submitted by December 31 ~` in order to receive these funds.
4. Funds for counties receiving the CDC Lead Poisoning Prevention Grant will be dispersed
monthly based upon monthly Expenditure Reports. For the current fiscal year these CDC
funds will be disbursed to Buncombe, Craven, Durham, Edgecombe, Forsyth, Guilford
and Mecklenburg Counties only.
5. Payments shall 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 Controllers office schedule for
OSC E-Payments issued December of each year for the following calendar year.
6. 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.
7. 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
June OSC E-Payment period per the DHHS Controller's office schedule issued December
of each year for the following calendar year, provided that an expenditure report (DHHS
2949 revised 5-03-01 electronic version) and the'"Certification of Expenditures Form" for
each month have been received by the DHHS Office of the Controller, and that the Staff'
Time Activity Report, 3389, Environmental Health Report, 3788, and Food and Lodging,
3888 have been received by the State. Corrections/Amendments to the Expenditures
reported by Departments will not be accepted after the May month of service claim for the
current year
Consolidated Agreement -Final
I. AMENDMENT OF AGREEMENT
Page 16 of 21
Amendments, modifications, or waivers of this agreement may be made at any time by mutual
consent of all parties. Amendments shall be in writing and signed by appropriate authorities.
J. PROVISION OF TERMINATION
Either party may terminate this agreement 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.
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
1. The State shall respond to non-compliance with all terms of this agreement 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.
b_ If 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 may be temporarily
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 may be permanently suspended until the Department
can provide evidence that the deficiencies have been corrected.
d. In the event of the Department's non-compliance with clauses of this agreement, the State
may cancel, terminate, or suspend this agreement in whole or in part and the Department
maybe 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 Circular 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 are achieved. The
State maintains comparable requirements for Subrecipient monitoring as outlined in NC
General Statute 143-6.1. Also, DHHS-DPH must perform subrecipient.monitoring as
required in the DHHS Policy and Procedure Manual entitled "Monitoring of Programs"
dated August 1, 2002.
Consolidated Agreement • Final
Page 17 of 21
DHHS-DPH conducts monitoring in accordance with its Subrecipient Monitoring Plan
dated January 14, 2000. Additionally, each Local Health Department is required under
Circular A-133 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.
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.
LOCAL SIGNATURES
l Q
Date
~,~~~®~
Date
l~
Date
STATE OF NORTH CAROLINA
By ~ a
St to Health Director Date
or Authorized Agent
Secretary Date
Department of Environment and Natural
Resources or Authorized Agent
PLEASE ACCEPT AS ORIGINAL
SIGNATURES
Health Directo
Consolidated Agreement -Final
NORTH CAROLINA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
BUSINESS ASSOCIATE ADDENDUM
TO CONSOLIDATED AGREEMENT
Page 18 of 21
This Agreement is made effective the first day of July, 2004, by and between the Division of Public
Health and ~ r ~,n 2 C b ~ t C--t of G-. n /v- ~-~..t' (name of .local health
department) ("Covered Enti y") (collectively the "Parties").
1. BACKGROUND
a. Covered Entity and Business Associate are parties to a Consolidated Agreement and
Agreement Addenda (CAAA), whereby Business Associate agrees to perform certain
services for or on behalf of Covered Entity.
b. Business Associate is an organizational unit of the North Carolina Department of Health and
Human Services (the "Department"). Covered Entity is a governmental entity.
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 Rule.
d. The Parties enter into this Business Associate Addendum to the CAAA with the intention
of complying with the HIPAA Privacy Rule provision that a covered entity may disclose
protected health information to a business associate, and may allow a business associate to
create or receive protected health information on its behalf, if the covered entity obtains
satisfactory assurances that the business associate will appropriately safeguard the
information.
2. DEFINITIONS
Unless otherwise clearly indicated by the context, the following terms shall have the following
meaning in this Agreement:
a. "HIPAA" means the Administrative Simplification Provisions, Sections 261 through 264, of
the federal Health Insurance Portability and Accountability Act of 1996, Public Law 104-
191.
b. "Individual" shall have the same meaning as the term "individual" in 45 CFR 164. 501 and
shall include a person who qualifies as a personal representative in accordance with 45 CFR
164.502(8).
c. "Privacy Rule" shall mean the Standards for Privacy of Individually Identifiable Health
Information at 45 CFR part 160 and part 164, subparts A and E.
d. "Protected Health Information" shall have the same meaning as the term "protected health
information" in 45 CFR 164. 501, limited to the information created or received by Business
Associate from or on behalf of Covered Entity.
Consolidated Agreement -Final Page 19 of 21
e. "Required By Law" shall have the same meaning as the term "required by law" in 45 CFR
164.501.
f. "Secretary" shall mean the Secretary of the United States Department of Health and Human
Services or his designee.
g. Unless otherwise defined in this Agreement, terms used herein shall have the same meaning
as those terms have in the Privacy Rule.
3. OBLIGATIONS OF BUSINESS ASSOCIATE
a. Business Associate agrees not to use or disclose Protected Health Information other than as
permitted or required by this Agreement or as Required By Law.
b. Business Associate agrees to use appropriate safeguards to prevent use or disclosure of the
Protected Health Information other than as provided for by this Agreement.
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 Protected Health Information by
Business Associate in violation of the requirements of this Agreement.
d. Business Associate agrees to report to Covered Entity any use or disclosure of the Protected
Health Information not provided for by this Agreement of which it becomes aware.
e. Business Associate agrees to ensure that any agent, including a subcontractor, to whom it
provides Protected Health Information received from, or created or received by Business
Associate on behalf of Covered Entity agrees to the same restrictions and conditions that
apply through this Agreement to Business Associate with respect to such information.
f. Business Associate agrees to provide access, at the request of Covered Entity, to Protected
Health Information in a Designated Record Set to Covered Entity or, as directed by Covered
Entity, to an Individual in order to meet the requirements under 45 CFR 164. 524.
g. Business Associate agrees to make any amendment(s) to Protected Health Information in a
Designated Record Set that the Covered Entity directs or agrees to pursuant to 45 CFR 164.
526 at the request of Covered Entity or an Individual.
h. Business Associate agrees to make internal practices, books, and records, including policies
and procedures and Protected Health Information, relating to the use and disclosure of
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 Rule.
i. Business Associate agrees to document such discloswes of Protected Health Information and
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 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.
Cons6lidated Ageement -Final
4. PERMITTED USES AND DISCLOSURES
Page 20 of 21
a. Except as otherwise limited in this Agreement, if the CAAA permits, Business Associate may
use or disclose Protected Health Information to perform functions, activities, or services for, or
on behalf of, Covered Entity as specified in the CAAA, provided that such use or disclosure:
1) would not violate the Privacy Rule 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, if the CAAA permits, Business Associate may
use Protected Health Information 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, if the CAAA permits, Business Associate may
disclose 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 used or further disclosed only
as Required By Law or for the purpose for which it was disclosed to the person, and the
person notifies the Business Associate of any instances of which it is aware in which the
confidentiality of the information has been breached.
d. Except as otherwise limited in this Agreement, if the CAAA permits, Business Associate may
use Protected Health Information to provide data aggregation services to Covered Entity as
permitted by 42 CFR 164. 504(e)(2)(i)(B).
e. Notwithstanding the foregoing provisions, Business Associate may not use or disclose
Protected Health Information if the use or disclosure would violate any term of the CAAA.
5. TERM AND TERMINATION
a. Term. The Term of this Agreement shall be effective as of the effective date stated above
and shall terminate when the CAAA terminates.
b. Termination for Cause. 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 if Business Associate does not cure the breach or end the
violation within the time specified by Covered Entity;
2) Immediately terminate this Agreement; or
3) If neither termination nor cure are feasible, report the violation to the Secretary as
provided in the Privacy Rule.
c. Effect of Termination.
1) Except as provided in paragraph (2) of this section or in the CAAA, upon termination of
this Agreement, for any reason, Business Associate shall return or destroy all Protected
Health Information received from Covered Entity, or created or received by Business
Consolidated Agreement -Final Page 21 of 21
Associate on behalf of Covered Entity. This provision shall apply to Protected Health
Information that is in the possession of subcontractors or agents of Business Associate.
Business Associate shall retain no copies of the Protected Health Information.
2) In the event that Business Associate determines that returning or destroying the 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 Protected Health
Information and limit further uses and disclosures of such Protected Health Information
to those purposes that make the return or destruction infeasible, for so long as Business
Associate maintains such Protected Health Information.
3. GENERAL TERMS AND CONDITIONS
a. This Agreement amends and is part of the CAAA.
b. Except as provided in this Agreement, all terms and conditions of the CAAA shall remain in
force and shall apply to this Agreement as if set forth fully herein.
c. In the event of a conflict in terms between this Agreement and the CAAA, the interpretation
that is in accordance with the Privacy Rule shall prevail. In the event that a conflict then
remains, the CAAA terms shall prevail so long as they are in accordance with the Privacy
Rule.
d. A breach of this Agreement by Business Associate shall be.considered sufficient basis for
Covered Entity to terminate the CAAA for cause.
STATE OF NORTH CAROLINA
LOCAL SIGNATURES
ealth Dire r
a~
~3 ~
ate
Date
PLEASE ACCEPT AS ORIGINAL
SIGNATURES
/. G~
Finance Officer
_ ASSURANCE OF COMPLIANCE
ASSURANCE OF COMPLIANCE WITH TITLE VI OF THE CIVIL RIGHTS ACT OF 1964, SECTION 504 OF THE REHABILITATION ACT OF
1973, TITLE IX OF THE EDUCATION AMENDMENTS OF 1972, AND THE AGE DISCRIMINATION ACT OF 1975
The Applicant provides this assurance in consideration of and for the purpose of obtaining Federal grants, loans, contrails, property, discounts
or other Federal financial assistance from the Department of Health and Human Services.
THE APPLICANT HEREBY AGREES THAT IT WILL COMPLY WITH:
1. Title VI of the Civil Rights Act of 1964 (Pub. L 88-352), as amended, and al! requirements imposed by or pursuant to the Regulation
of the 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
Regulation, no person in the United States shall, on the ground of race, color, or national origin, be exGuded from participation in, be
denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the Applicant receives
Federal financial assistance from the Departrnent.
2. Section 504 of the Rehabilitation Act of 1973 (Pub. L 93-112), as amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Health and Human Services (45 C.F.R. Part 84), to the end that, in accordance with Section 504 of
that Act 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, or be subjected to discrimination under any program or activity
for which the Applicant receives Federal financial assistance from the Department.
3. Title IX of the Educational Amendments of 1972 (Pub. L. 92-318), as amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Health and Human Services (45 C.F.R. Part 86), to the end that, in accordance with Title IX and the
Regulation, no person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or
be otherwise subjected to discrimination under any education program or activity for which the Applicant receives Federal financial
assistance from the Department.
4. The Age Discrimination Act of 1975 (Pub. L. 94-135),. as amended, and aN requirements imposed by or 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 in the United States shall, on the basis of age, be denied the benefits of, be exGuded from participation in, or be subjected to
discrimination under any program or activity for which the Applicant receives Federal financal assistance from the Department.
The Applicant agrees that compliance with this assurance constitutes a condition of continued receipt of Federal financial assistance, and that it
is binding upon the Applicant, its successors, transferees and assignees for the period during which such assistance is provided. If any real
property or structure thereon is provided or improved with the aid of Federal ftnanaal assistance extended to the Applicant by the Department,
this assurance shall obligate the Applicant, or in the case of any transfer of such property, any transferee, for the period during which the real
property or structure is used for a purpose for which the Federal financial assistance is extended or for another purpose invdving the provision
of similar services or benefits. If any personal property is so provided, this assurance shalt obligate the Applicant for the period during which it
retains ownership or possession of the property. The Applicant further recognizes and agrees that the Urwted States shall have the right to seek
judicial enforcement of this assurance.
The person or persons whose signature(s) appear(s) below is/are authorized to sign this assurance, and commit the Applicant to the above
provisions.
to Signature and Title Authorized Official
~~~ae.rH ~ ' ~ u,-~r ~-~+urS , Ira one 'Go • Hr°Q..l.~'i'
Name of Applicant or Recipient
street
I-~itlsbo~-~~ l~lc 2~Z~ s
C'~ty, State, Zip Code
Form HHS-690 PLEASE ACCEPT AS ORIGINAL
5/97
SIGNATURES
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
CERTIFICATION REGARDING LOBBYING
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 subawards at alI 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 Agency Official Signature
Hest, l 11~ ~~ ~ e~-I-or
Title
Official gency Name
(Signature should be same as Contract signature)
~ ~
_ PLEASE ACCEPT AS ORIGINAL SIGNATURES
~~
Date
DPH Lobby 1/02
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 is
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 Government, 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 terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier
covered transaction," "participant," "person," "primary covered transaction," "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 further 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 covered transactions and in all solicitations for lower tier
covered transactions.
DPH Debarment 1/02
Page 1 of 2
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. 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 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 -
Lower 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 A ency Official Signature
ea.lrt'h ~i rcL-~Ur
Title
D rcL nA E; Co ~, h`h~ ~ ~`~
Official Agency Name
~~
Date
(Signature should be same as Contract signature)
DPH Debarment 1/OZ
Page 2 of 2
_ PLEASE ACCEPT AS ORIGINAL SIGNATURES _
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
CERTIFICATION REGARDIl~tG DRUGFREE WORKPLACE REQUIREMENTS
I. By execution of this Agreement the Contractor certifies that it will provide a drub 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 betaken against employees for violation of such
prohibition;
B. Establishing adrug-free awareness program to inform employees about
(1) The dangers of drug abuse in the workplace;
(2) The Contractor's policy of maintaining a drubfree workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees far drug abuse violations occurring in the
workplace;
C. Making it a requirement that each employee be engaged in the performance of the agreement
be given a copy of the statement required 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:
(1) Abide by the terms of the statement; and
(2) Notify the employer of any criminal drug statute conviction for a violation occurring in the
workplace no later than five days after such conviction;
E. Notifying the Department within ten days after receiving notice under subparagraph (d)(2)
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
(d)(2), with 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
rehabilitation program approved for such purposes by a Federal, State, or local health, law
enforcement, or other appropriate agency; and
Making a good faith effort to continue to maintain a drubfree workplace through
implementation of paragraphs (a), (b), (c), (d), (e), and (f).
DPH Drug Free 1/OZ
Page 1 of 2
II. The site(s) for the performance of work done in connection with the specific agreement are
listed below:
~ oo W . I r' y o ~n ~~-r cG'f"'
address)
~~ l is Iv v r D u,~,(~-~ IV C. Z~ Z 7 8
(City, cou~ity, state, zip Conde)
2. LSD 1 ~es+e~ 1~-0
(Street address)
~~l«.Pe~ ~l`I( ~C ZZ~iy
(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).
Authorized A ncy Officia! Signature
~'~'Q•v~ ~ Cb Uiv1~y 'rT ~° 4~.~
Official Agency Name
(Signature should be same as Contract signature)
DPH Drug Free 1/02
Page 2 of 2
Title
Date
~ ~
_ PLEASE ACCEPT AS ORIGINAL SIGNATURES _
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 $1,000 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.
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Authorized gency Official Signature
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Official A ency Name
Title
Date
(Signature should be same as Contract signature)
DPH Smoke 1/02
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_ PLEASE ACCEPT AS ORIGINAL SIGNATURES _