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HomeMy WebLinkAbout1997 S Health - Consolidated Contract between The State of NC as Represented by the State Health Director AIIIIIIII • _RETURN THIS COPY TO THE CLERK'S OFFICE FOR THE PERMANENT AGENDA FILE �"/ � ��U+�� COPY FOR 1 of 12 CONSOLIDATED CONTRACT BETWEEN THE STATE OF NORTH CAROLINA AS REPRESENTED BY THE STATE HEALTH DIRECTOR (Hereinafter called the"State") AND ORANGE COUNTY HEALTH DEPARTMENT (Local Health Department-Hereinafter called the"Department") FOR THE PURPOSE OF MAINTAINING AND STIMULATING THE ADVANCEMENT OF HEALTH IN NORTH CAROLINA This Contract Shall Cover a Period From July 01, 1997 to June 30, 1998 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 the following activities involving State funding. (State funding or funds means state,federal, and/or special funding or funds throughout this contract) ACTIVITY ACTIVITY —General 4110 Comp Breast & Cervical Cancer Control 5452 Communicable Disease 4510 lea-kth-5502 A 5331 -Health Promotion°-5-50-3 Environmental Health 4751 Immunization Action Plan 5715 Food and Lodging 4752 AID-TO-COUNTY (FEDERAL) Childhood-Lead"Poll-dn:ttir PYeventiou 4754 - Maternal Health 5101 Family Planning 5151 Child Service Coordination 5318 6SHS-Ortheped-ie- 5323 Child-Health_.; 5351 Page 2 of 12 r ` A. WORK TO BE PERFORMED 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 submit for approval the required Program Contract Addenda for State funded budgets. 3. The Department shall submit completed reports as required by budgeted funding criteria and as specified in Listing of Required Fiscal and Statistical Reports (Addenda 1). 4. The Department shall administer and enforce all rules which have been adopted by the Commission for Health Services or approved by the State and adopted by the Local Board of Health. 5. 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. Copies of existing rules and ordinances shall be submitted to the State Health Director within 45 days. Thereafter, copies of rules adopted shall be submitted within 30 days of adoption. 6. The Department shall provide to the State a Community Diagnosis Prioritization of Problems every biennium. The Department shall also provide a Community Diagnosis narrative, if completed. B. FUNDING STIPULATIONS 1. Funding for this contract is subject to the availability of State, Federal, and special funds for the purpose set forth in this Contract. 2. During the period of this Contract, the Department shall not use State, Federal or Special Project funds received under this Contract to reduce locally appropriated funds as reflected in the Local Health Department Budgets. 3. The Department shall not use personal health program funds to support environmental health personnel 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 Environmental Health activities. 5. Funds for Childhood Lead Poisoning Prevention may be used to support both environmental health and child health activities. 6. 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. 7. The Department shall maintain employee time records for the contract period documenting the portion of time that each employee attributes to each activity when State funds are budgeted for the support of employee salaries and fringe benefits. The percentage of time Page 3 of 12 each employee spends in each activity shall be converted to dollars based upon the employees' salary and benefits. These records will serve to document salary and benefit expenditures reported on Local Expenditure Report Form DEHNR 2949 and Local Expenditure Report-WIC Form DEHNR 2950, and compliance with Chapter 479, Section 99 of the 1985 Session Laws. 8. The Department participating in Medicaid Reimbursement shall: a. Comply with the terms of the Interagency Agreement between the Division of Medical Assistance, Department of Human Resources and the Department of Environment, Health, and Natural Resources and the Provider Participation Agreement effective October 1, 1992 and any subsequent approved addenda or new Agreement approved and established during the period of this contract. 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. No one shall be refused services solely because of an inability to pay. 9. The Department agrees to match the expenditure of Adolescent Pregnancy Prevention Project grant funds with any in-kind source or newly generated funds, public or private available to the project. Payment from the State shall be in accordance with G.S. 130A- 131.15 (d) (5)through (8). 10. Funds budgeted for Adolescent Pregnancy Prevention Activities shall not be expended for dues or out-of-state travel unless prior approval is received from the program. 11. Subject to the approval of the appropriate Division, a local health department may seek reimbursement for services covered by a program operating under 15A NCAC 24A rules when those services are not supported by other state or federal funds. All payment program rules and procedures as specked in the Purchase of Medical Care Services manual must be followed. 12. Subject to the availability of funds and approval of the Office of Public Health Nursing, 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 (2 week course) and the Public Health Nurse Supervisors Training Course (3 week course). Reimbursement is limited to no more than $200.00 per week per participant upon successful completion of the course. b. Community Health Assistants and Public Health Nurses attending certain pre- approved Continuing Education courses offered by the Office of Public Health Nursing. Reimbursement is limited to $25.00 per participant per event. 13. The Department shall have an annual audit performed in accordance with The Single Audit Act of 1984 as implemented by OMB Circular A-128. The audit report should be submitted to the Office of the Controller within (six) 6 months following the close of the contract. Audit findings and resolution of said findings shall be handled by the Office of the Controller. Page 4 of 12 ' 14. Equipment is a of fixed asset consisting of specific items of property that: 1 are tangible in ' type 9 P P Pe�Y ( ) 9 nature; (2) have a life longer than one year, and (3) have a significant value. a. For Budgeting and Reporting Purposes 1. Equipment purchases meeting the above definition and having an acquisition cost of$500 or more must be budgeted and reported in Line Item 5000. b. For Inventory Purposes 1. Equipment must be accounted for in accordance with Local Government Accounting System Procedure No. 15. 2. Women, Infants and Children Program All equipment with an acquisition cost of$500.00 or more must be inventoried with the Division of Matemal and Child Health. C. For Prior Approval Purposes 1. Equipment purchased or equipment leased where there is an option to purchase with State/Federal funds must receive prior written approval from the appropriate Division, Section, or Branch when the acquisition cost exceeds$500.00. 2. Women, Infants and Children Program All medical equipment and computer equipment, regardless of cost and all other equipment with an acquisition cost of$500.00 or more must receive prior approval from the program office. 3. Equipment purchased with program income generated by the expenditure of Title X Family Planning Funds with an acquisition cost of$500.00 or more must receive prior written approval from the program. 4. The use of Maternal and Child Health program generated Medicaid fees for capital improvements requires prior written approval from the program. 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: Page 5 of 12 1. The Department is not relieved of any of the duties and responsibilities provided in this contract. 2. 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. 3. 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. 4. The Department will make available to the State upon request a copy of subcontracts supported with State/Federal funds. d. The Department shall receive prior approval from the State when subcontracting for services in the Women, Infants and Children Program. e. The Department shall retain all budgets, budget revisions, contracts, contract addenda, and financial records in accordance with the current Records Disposition Schedule for County and District Health Departments issued by the Division of Archives and History, Department of Cultural Resources. 2. The Department shall prepare and maintain a budget for each activity covered by this contract in a manner consistent with instructions provided with Local Health Department Budget-WIC Form DEHNR 3370 (Revised 2/93) and Local Health Department Budget Form DEHNR 2948 (Revised 2/93). a. The Department shall prepare budget revisions for prior approval of the State when those revisions are in the School Health Program (Line Item 6200). b. The Department shall prepare budget revisions for prior approval of the State when State funds will be increased or decreased. C. The Department shall prepare an informational copy for the State of all other budget revisions when proposed expenditures exceed the line amount budgeted. d. The Department shall submit all revisions prior to the end of the term specified in this Contract. Budget revisions received by the State after the end of the contract period will be returned without action. 3. The Department shall observe the following conditions when budgeting and reporting earned revenues: a. All payments from persons, and public or private third party payors, shall be utilized for the activity that generated the revenue and shall not reduce or replace locally appropriated funds during the period of this contract. The Department may use revenues from any Division of Maternal and Child Health supported activity in any other activity supported by the Division. b. All earned income must be budgeted in the program where earned, except that income earned by a program which has no activity budget can be budgeted in a program approved by the State. With regard to revenue generated by maternal and Page 6 of 12 t child health related services, program is defined as any activity supported by the Division of Matemal and Child Health. 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 74. e. When budgeting: I. Line item 9000 on the program budget must be used to budget the total of line items 101, 102 and 103. ii. Line item 102 on the program budget must be used to budget TXIX earned revenues. iii. Line item 103 on the program budget must be used to budget other earned revenues. -- f. When reporting: I. Line item 9000 on the Local Expenditure Report must be used to report the total of line items 101, 102, 103. ii. Line item 102 on the Local Expenditure Report must be used to report TXIX earned revenues that were expended. iii. Line item 103 on the Local Expenditure Report must be used to report other earned revenues that were expended. g. A local account shall be maintained for unbudgeted/unreported TXIX fees. Accounts shall be maintained in sufficient detail to identify the program source generating the fees. h. Title XIX revenues carried forward at the end of fiscal year 1998 may not exceed Title XIX revenues earned during fiscal year 95-96 or$10,000.00 whichever is greater. I. Program budgets that do not include an amount of TXIX funds sufficient to meet the requirements of 3. h.will not be approved by the State. 4. The Department shall submit a quarterly report of actual receipts and expenditures of the Department according to instructions provided with Local Expenditure Reports, Form DEHNR 2949 (Revised 8/95) and Form DEHNR 2950 (Revised 2/93). a. The Department shall submit quarterly expenditure reports to the State within 45 days from the end of the reporting quarter. Failure to meet the reporting deadline will result in an immediate suspension of payments until the overdue report is received. 1 r Page 7 of 12 b. The Department shall submit the final Expenditure Report to the State within 45 days after the end of the contract period. Report is due by August 14. C. The Department shall submit amended or corrected expenditure reports within four(4) months after the end of the contract period. Any such reports must be prepared for the speck quarter to be amended or corrected. Reports received after October 31 will be returned without action. - d. The Department shall refund to the State all State funds not supported by expenditures within 45 days after notification of overpayment. When payment is not received by the State within 45 days, future payments to the Department may be reduced by the amount due or payments may be suspended until the refund is received by the State. e. The Department shall follow Women, Infants and Children Program and other Federal program reporting requirements when they differ from those stated above. f. The Department shall submit monthly WIC expenditure reports to the State no later than the 8th of the following month. Final expenditure report is due by August 14. g. Reimbursement of WIC approved expenditures for July, August, and September cannot exceed one-fourth of the total budget for the contract period. h. The Department shall submit monthly Minority Infant Mortality Reduction expenditure reports to the state no later than the 15th of the following month. I. The Department shall submit expenditure reports for Mosquito Control activity in accordance with 15A NCAC 1813, Sections .0104 and .0107. j. The Department shall submit request for payment for services provided under 15A NCAC 24 A rules to the Claims Processing Unit, Purchase of Medical Care Services, DEHNR. k. The Department shall submit request for reimbursement for nurse training to the Office of Public Health Nursing. Form DEHNR 3300- Public Health Nurse Training Activity must be used as the invoice for payment. 5. The Department shall submit on an annual basis Staff Time Activity Report, DEHNR 3389, Environmental Health Report, DEHNR 3738, and Food and Lodging Report, DEHNR 3888. The reports shall accompany the final expenditure report and must be received by the State within 45 days after the end of the contract period. Page 8 of 12 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: 1. Equal employment opportunity; 2. Affirmative action; 3. Policies for local government employment subject to the State Personnel Act; 4. "Local Classification and Salary Range'; 5. "Compensation Policy for Local Competitive Services Employees'; and 6. "Recruitment and Selection Policy and Procedures'; 7. 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 18A .2300. a. Local health departments are responsible for sending their newly- employed environmental health specialists (interns)to 33 days (6.5 weeks)of initial field training/orientation at the training center within 180 days from date of employment. b. Arrangements for initial field traininglorientation for newly-employed environmental health specialists will be handled by the Education and Training Staff, Division of Environmental Health. C. A local health department which is contracting with an environmental health specialist employed by another department shall be responsible for assuring that all original documents, correspondence, and other public records be maintained in the health department using the contractor and the contract shall stipulate that the contractor shall be available for consultation to the public being served. 8. 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 contract 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 Contract shall be privileged communication, shall be held confidential, and shall not be divulged without the responsible person's written consent except as may be otherwise required by applicable law or regulation. Such information may be disclosed in Page 9 of 12 summary, statistical, or other form which does not directly or indirectly identify particular individuals. F. CIVIL RIGHTS 1. The Department shall assure that no person, on the grounds of race, color, age, religion, sex, marital status, immigration status, or national origin (unless otherwise medically indicated) or otherwise qualified handicapped individual solely by reason of his/her handicap be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity covered by this Contract. 2. The Department shall complete HHS Form 441, Assurance of Compliance with the Department of Health and Welfare regulations, under Title VI of the Civil Rights Act of 1964; for the Women, Infants and Children Program, FNS-64, Assurance of Compliance with the Department of Agriculture Food and Nutrition Service, under Title VI of the civil Rights Act of 1964; and HHS Form 641, Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973. 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 A.D.A. 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 upon request technical assistance in the preparation of the Consolidated Contract, Activity Budgets and Contract Addenda. 2. The State shall specify those administrative forms/reports and their respective revision dates that are required by particular activities pertaining to the Department's budget with the State in Listing of Required Fiscal and Statistical Reports(Addendum 1)for the contract period. New forms/reports not listed in Required Fiscal and Statistical Reports shall be implemented during a contract period only with the approval of the State Health Director. 3. The State shall provide to the Department within thirty (30) days after receiving an acceptable activity budget from the Department an approved signed copy of the budget. 4. The State shall provide funds to the Department upon approval of the Contract Addenda, activity budgets, and signing of this contract. 5. The State shall assist the Department to comply with all applicable laws, regulations, and standards relating to the activities covered in this contract. 6. The State reserves the right to conduct reviews to determine compliance with the terms of this contract. Page 10 of 12 7. The State shall be assured that the Department maintains expenditure of locally appropriated funds for maternal health, child health, and family planning 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 maintenance of effort shall be measured by salary equivalencies which are to be maintained in accordance with Section B. 7. of this contract. H. DISBURSEMENT OF FUNDS The State shall disburse funds to the Department as follows: 1. Provided the Consolidated Contract is properly executed and all quarterly expenditure reports are filed within the established time frames, payments equal to 1/12 of the total program approved budget shall be made in the following months: July August September October November January February April May Based on expenditures reported for the first, second,and third quarters, payments shall be adjusted either upward or downward, in payments made in the following months: December March June 2. For departments selecting quarterly reimbursement option, payments shall be made when the quarterly expenditure report is received. 3. For departments receiving Rural Obstetrical Care Incentive funds, payment of such funds shall be made in one lump sum the month following receipt and approval of the activity budget. 4. For departments receiving Minority Infant Mortality Reduction project funds, payment will be based on actual reported expenditures. Monthly payments will be made provided that expenditure reports are received as required in C. 4. h. 5. Food and lodging fees will be disbursed to the department in one sum the month following receipt and approval of the activity budget and any subsequent budget revisions. 6. Funds for Childhood Lead Poisoning Prevention will be disbursed once per year. The amount will be determined by the number of confirmed cases identified in each county. A separate contract addendum must be submitted with budget page in order to receive these funds. Funds for training will be disbursed upon request. 7. Quarterly payment for reported expenditures in Line Item 1000 shall be limited to one-fourth of the budgeted amount in that line item. 8. Increased or decreased payments necessitated by changes in the total budgeted amount will be reflected in the monthly payments subsequent to approval of the budget revision. Page 11 of 12 9. Payments shall be suspended when expenditure reports are not received by the time specked in C. 4. a and f. Payments will resume in the months subsequent to receipt of the expenditure reports. 10. Payment is limited to the total amount of the budget by line item as reported on Expenditure Report DEHNR 3389. 11. Final payments will be made based on the 4th quarter expenditure report. Final payments will be equal to the difference between approved reported expenditures and_the sum of previous payments. Final payments should be made not later than September provided that an original signed copy of an expenditure report for each quarter has been received by the Office of the Controller. Final payment will be made only after the Staff Time Activity Report, DEHNR 3389, Environmental Health Report, DEHNR 3788, and Food and Lodging, DEHNR 3888 are received by the State. I. AMENDMENT OF CONTRACT Amendments, modifications, or waivers of this contract may be made at any time by mutual agreement of all parties. Amendments shall be in writing and signed by appropriate authorities. J. PROVISION OF TERMINATION This contract may be terminated for reasons other than non-compliance upon sixty (60) days written notice by either party. 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 assure compliance with all terms of this contract. a. Upon determination of non-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 which 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. Page 12 of 12 d. In the event of the Department's non-compliance with clauses of this contract, the State may cancel, terminate, or suspend this contract in whole or in part and the Department may be declared ineligible for further State contracts or agreements. Such terminations for non-compliance shall not occur until: (1)the provisions of Section K-1 (a-c) have been followed, documented, and have failed to provide a resolution, (2) all other reasonable administrative remedies have been exhausted. 2. If the Department or the State should be determined out of compliance with the provisions of the contract, 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 STATE OF NORTH CAROLINA �9 Health Director Date By State Health Director or Authorized Agent Finance Officer Dafe wgm.,4A L s Lq Chairman of County Commissioners C ate (when required) DEPARTMENT OF HEALTH AND HUMAN SERVICES ASSURANCE OF COMPLIANCE WITH SECTION SU OF THE REHABILITATION ACT OF 1973, AS AMENDED The undersigned(hereinafter called the"recipient")HEREBY AGREES,THAT it will comply with Section 504 of the Rehabilitation Act of 1973.as amended(29 U.S.C.7K,all require. meats imposed by the applicable HHS regulation(45 C.F.R. Part 84),and all guidelines and interpretations issued pursuant thefeto. Pursuant to 184.5(a)of the regulation 145 C.F.R. 84.5(a)j.the recipient gives this Assurance in consideration of and for the purpose of obtaining any and all Federal grants,loans,con- tracts(except procurement contracts and contracts of insurance or guaranty), property, dis- counts,or other Federal financial assistance extended by the Department of Health and Human Services after the date of this Assurance, including payments or other assistance made after such date on applications for Federal financial assistance that were approved before such date.The recipient recognizes and agrees that such Federal financial assistance will be extended in reliance on the representations and agreements made irrthis Assurance and that the United States will have the right to enforce this Assurance through lawful means. This Assurance is binding on the recipient,its successors,transferees, and assignees,and the person or persons whose signatures appear below are authorized to sign this Assurance on behalf of the recipient. This Assurance obligates the recipient for the period during which Federal financial assistance is extended to it by the Department of Health and Human Services or, where the assistance is in the form of real or personal property, for the period provided for in §84.5(b) of the regulation (45 C.F.R. 84.5(b)). The recipient: (Check (a) or (b)) a. ( ) employs fewer than fifteen persons; b. ( ) employs fifteen or more persons and, pursuant to §84.7(x) of the regulation 145 C.F.R. 84.7(a)J, has designated the following person(s) to coordinate its efforts to comply with the HHS regulations: Daniel B. Reimer Name of Designees) (Type or Print) Orange County Health Department PO Box 8181 Name of Recipient4Type or Print) Street Address or P.O. Box 56-6000327 Hillsborough (IRS) Employer Identification Number City North Carolina 27278-8181 State Zip I certify that the above information is complete and correct to the best of my knowltdge. W&UM Date l Signature and Title of Authorized Official If there has been a change in name or ownership within the last year,please PRINT the former name below: HHS-641 fifty.42/821 ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF HEALTH AND HUMAN SERVICES REGULATION UNDER TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 Orange County Health Department (hereinafter called the "Applicant") Name of Applic= (tnw or prim) HEREBY AGREES THAT it will comply with Title VI of the Civil Rights?pct of 1964(P.L. SS-352) and ail requirements imposed by or pursuant to the Regulation o; the Department of Health and Human Services (45 C.F.R. Pan 80) issued pursuant to that title, 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 excluded 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 Depart- ment; and HEREBY GIVES ASSURANCE THAT it will immediate!y take any measures necessary to effectuate this agreement. If any real property or structure thereon is provided or improved with the aid of Federal financial 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 involving the provision of similar services or benefits. If any personal property is so provided, this Assurance shall obligate the Applicant for the period during which it retains ownership or possession of the propeny. In all other cases, this Assurance shall obligate the Applicant for the period during which the Federal financial assistance is extended to it by the Department. THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and all Federal grants, loans, contracts, property, discounts or other Federal financial assistance extended after the date hereof to the-Applicant by the Department, including installment payments after such date on account of applications for Federal financial assistance which were approved before such date.The Applicant recognizes and agrees that such Federal finan- cial assistance will be extended in reliance on the representations and agreements made in this Assurance, and that the United States shall have the right to seek judicial enforcement of this Assurance. This Assurance is binding on the Applicant. its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this Assurance on behzlf of the Applicant. Date S '93 L I Orange County Health Department wpp+ieaae carve of pnnt l By Lrut 1. 0 Sirmtute pad Tile of Authorued O(fiaal HHS-&II (Rcv. 32/22) tong ra"d U.S. DEPARTHINT OF AG1tICl1LnSRE •Nr�IN��e�w.���w.MY� Food and Nutrition Service ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF AGRICULTURE. FOOD AND NUTRITION SERVICE. UNDER TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 Orange County Health Department %Name of Applicant) (Hereissafter called the "Applicant.") 123IMT AGRELS THAT It trill comply with Title VI any improvements made with Federal financial of the Civil lights Act of 1964 (P.L. 88-352) assistance extended to the Applicant by the and all requisments Imposed by the Regulations Department. Ibis includes any Federal agreement, of the Department of Agriculture (1 CFR Part 13), arrangement. or other contract which has as one Department of Justice (28 CFA Parts 42 4 50). of its purposes the provision of assistance such and FNS directives or regulations issued as food. food Stamps, Cash assistance for the pursuant to that Act and the Regulations. to the purchase of food. and cash assistance for purchase effect that. no person in the United States shall, or rental of food service equipment or any other On the ground of race, color. or national origin. financial assistance extended in reliance on the be excluded from participation in, be denied the representations and agreements made in .this benefits of. or be otherwise subject to discrimi- assurance. nation under any program oz activity for which the Applicant received Federal financial assistance ET ACCEPTING THIS ASSURANCE, the applicant agrees iron the Department; and RER131 GIVES ASSURA%;CE to compile data, maintain records and submit THAT It will Immediately take any measures reports as required, to permit effective enforce- necesssry to effsc:uate this agreement. ment of Title VI and permit authorized USDA personnel during normal working hours to review THIS ASSUROLNCE Is given in considerazlon of and such records. books and accounts as needed to for the purpose of obtaining any and all Federal ascertain cos;;liance with Title VI. If there are financial assistance. grants and loans of Federal any violations of this assurance. the Department funds, reimbursable expenditures. grant or of Agriculture. Food and Nutrition Service, shall donation of Federal property and interest in have the right to seek judicial enforcement of property, the detail of Federal personnel, the this assurance. sale and lease of, and the permission to use, Federal property or interest in such property or This assurance is binding on the applicant, its the furnishing of services vizbout consideration successors, transferees, and assignees as long as or at a nominal consideration, or at a consider- It receives assistance or retains possession of ation which is reduced for the purpose of assist- any assistance from the Department. The person ing the recipient, or in recognition of the or persons whose signatures appear below are public interest to be served by such sale, lease, authorized to sign this assurance on the behalf of or furnishing of services to the recipleaz. or the applicant. Dated 5 3.1 Orange County Health Department (Applicant) sy, (Title of authorised official) PO Box 8181 Hillsborough NC 27278 (Address of Applicant) No further monies or other benefits may be paid out under Food and Nutrition Service Federal assistance programs ualesa this Asauraate 1, completed and filed as required by existing regulations () CFR 15).' *to Sol LOCAL HEALTH DEPARTMENT BUDGE N.C.Depertment of Environment, Health,and Natural Resources , J Revisior cumber Division Division of General Services r?2276 SFY Division of General Services �� � P.O.Number 7 / 97 6 / 98 - , .. � _ , �- ' 9 g 4 1 1 0 0 0 6 8 Effective Date Termination Date _ . _. _ Contract Number Contractor: Orange County Health Department. 'Activity: General Project Director: Daniel B. Reimer Total Budget:$ 2300123 ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT E STATE EXPENDITURES: X Salaries & Fringe Benefits SA/FR 1000 Operating Expenses OP EXP 2000 - P Purchase of Equipment EQUIP 5000 E General Contracted or N Purchased Services GENERAL 6100 School Health D Clinician I Laboratory ............. .......... .: L? c .... .:: . :.... .....T. - Pharmacy Services Transfer TXIX ............ .. S3�jG3 R Subtotal State Expend. $ 54;3Ct3 E LOCAL EXPENDITURES: LOCAL EXP 9000 175,7 0 S TOTAL EXPENDITURES—equal to Total Receipts $ �a'�^ �3 LOCAL FUNDS: R Appropriation APPROP 101 0 E TXIX TXIX 102 95,360 Other Receipts OTHR REC 103 80,400 C E Subtotal Local F,�nds $ 175,760 STATE/FEDERAL/SPECIAL FUNDS: - I P T S s � Subtotal State/Federal/Special $ TOTAL RECEIPTS—equal to Total Expenditures $ 4 3�-1� 3 �J�--- � - -S-L-2--Xhi-- — . - "I. QZ-Ie-X— �7 Local Authorized Official Signature Da Bnn.h Hnd Divis' n ection Signature Date w" Finance Officer Signature ., .. , Date A«ounbnt Fiscaoq#iagement Signature Date Wtw DEHNR 2948(Revised 2/93) 9; j "'7 General Services Division(Review 2/99 O "•'' LOC,-",L HEALTH DEPART NIENT BUDGET N.C.Department of Environment, Revision Number Health,and Natural Resources j G? ��' Division of General Services p. t SFY Division of E idezniol / 1 P. O.Number 7 / 97 6 / 98 9 8 4 5 1 0 0 0 6 8 Effective Date Termination Date Contract Number Contractor: Orange County Health Department Activity: Communicable Disease Project Director: Daniel B. Reimer Tom Budget:$ 32,806 ITEM DESCRIPTION TSA�7 SSIFICATION ITEM AMOUNT E STATE EXPENDITURES: 1000 17,018 Salaries &- Fringe Benefits X Operating Expenses P 2000 P Purchase of Equipment EQUIP 5000 E General Contracted or 6100 P Put Services GENERAL ........... N School Health D Clinician CLN 6863 I :::::.:::..::.::::........................ Laboratory LAB 6862 Services _............................... T .. �..BERN..........:.::::.::::..::: 8.: :::;::;:;.;:::.;:.;:;.;:.:.;:;:;:;:::»:::::<:<:;>:::::::<:::::;::>::»::>::»»::><::»�::>::;>::::>:;:: Pharmacy U Transfer TXIX R Subtotal State Expend. $ 17,018 E LOCAL EXPENDITURES: LOCAL EXP 9000 15,788 S TOTAL EXPENDITURES—equal to Total Receipts $ 32,806 LOCAL FUNDS: APPROP 101 0 R Appropriation 3,288 E TXIX TXIX 102 Oth OTHR REC 103 12,500 C er Receipts $ 15,788 Subtotal Local Funds E STATE/FEDERAL/SPECIAL FUNDS: I T S $ 17,018 Subtotal State/Federal/S ecial TOTAL RECEIPTS-equal to Total Expenditures $ 32,806 r 5J- 2��--'7— ate - Local Authorized Official Signature ate Branch Hid Divi ' n/Section i ture �— Date Accou,uanr Fisc Management S ature ate Finance Officer Signature _ )EHM 2948(Revised 2/93) 3ener2l Services Division(Review 2/94) LOCAL HEALTH DEPARTMENT BUDGET N.C.Department of Environment, Health, and Natural Resources �'•� Revision Number Division of General Services �.^�.;' ,e.,;,�' �, �`� 1 SFY Divisia"f Envi=otYm'e Her' —— — t^ ~i; f P. O.Number 7 / 97 6 / 98 �' - .:; vr" 9 8 4 7 5 1 0 0 6 8 Effective Date Termination Date i CC-21 Contract Number ~n y 0„ Contractor: Orange County Health Department ; %E t,. Environmental Health Project Director: Daniel B. Reimer Total Budget: $ 262,000 ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT E STATE EXPENDITURES: X Salaries & Fringe Benefits SA/FR 1000 4,000 Operating Expenses OP EX? 2000 2,000 P Purchase of Equipment EQUIP 5000 E General Contracted or N Purchased Services GENERAL 6100 Health School He al :.::... .: ..:....:..:.::..:. i ...............................................:: ::. .:.::::.::.::.: D Clinician j* :.. :.... i ... :.. I Laboratory »>LAB 6862 T Pharmac y Services ... ......... E ..................................................................................: Transfer rans e r TXIX R Subtotal State Expend. $ 6,000 E LOCAL EXPENDITURES: LOCAL EXP 9000 256,000 S TOTAL EXPENDITURES—equal to Total Receipts $ 262,000 LOCAL FUNDS: R Appropriation APPROP 101 0 E TXIX TXIX 102 0 Other Receipts OTHR REC 103 256,000 C E Subtotal Local Funds $ 256,000 STATE/FEDERAL/SPECIAL FUNDS: I P DEHNR 6,000 T S 6,000 Subtotal State/Federal/Special $ TOTAL RECEIPTS—equal to Total Expenditures $ 262,000 Local Authorized Official Signature Date B—ch Head Division/Section Signature Date ititial axc4j�J 6 1�Zf �2 Finance Officer Signature Dal t a owm,t 4iscal Manage!�d Signature DEHNR 2948(Revised 2/93) General Services Division(Review 2/94) '°°1 4 'j 06/05/97 07:53 1 Qw..,�uuo 19644a007 HEALTH DEPT X1002 -� �1JJ! Cdv�`�ti J Ld1Ciw{V c11 CIVVIKI"IM M.IM YLS[-.r F1l N .Degarbnem ofEavao=gm.Health and Natt ml Resources tine I}is WM of Gmami Services Fy 1997-1998 CONTRACT ADDENDUM > e Healtl► 4751 Offic,,% Sectim or Branch Ca U=Namber Orange Cc,mety Re$tth Deft Fnvi a�ntal sestfh Thffe fwzds Qre butted as revenues fot'ettt romnetl&akh and go town d szjbs,&=g the persormsl and operawig eour of the drvision and rte not targeted to afsy spearfic&W items.. ?he,folow-Ing yeas are thehided line items,far mmarrmental health in FY97 98. SALARIES AND BENS) TRAVEL&TRAMWCr' PERSONAL AJn E.AG£ TII�PHONE POSTAGE MOTOR POOL EQU PMENI'MAINT DUPL.ICATWO ],'RINT',tNG , PROF DUES DEPT SUPPLMS OFFICE SUPPLIES BONDS*INSURANCE r Reviewed by. DEEM 3300(Revised.230} / Genetal Services Divisiaa(Review LV5) Initial Date LOCAL HEALTH DEPARTMENT BUDGET 4.C.Department of Environment, Health,and Natural Resources Revision Number— 1 Division of General Services #2 Division of Environmental Health P.O.Number 7 / 97 6 / 98 9 8 4 7 5 2 0 0 6 8 E^ective Date Termination Date i Contract Number Contractor: Orange County Health Department Activity:Food and Lodging Project Director. Daniel H. Reimer Total Budget:$ 750.00 ITEM DESCRIPTION , CLASSIFICATION ITEM AMOUNT E STATE EXPENDITURES: X Salaries & Fringe Benefits SA/FR 1000 750.00 Operating Expenses OP E (P 2000 P Purchase of Equipment EQUIP 5000 E General Contracted or N Purchased Services GENERAL....................._6100.. School Health D - ,clinician ... ................................ ........................ T Laboratory LAB 6862 Pharmacy Services . ......... ::..:.tea .:::.. :.. ..:..... :.�:...:.:::.:.. Transfer TM R Subtotal State Expend. S 750.00 E LOCAL EXPENDITURES: LOCAL EXP 9000 - 0 S TOTAL EXPENDITURES--equal to Total Receipts $ 750.00 LOCAL FUNDS: R Appropriation APPROP 101 0 E TM TXIX 102 0 C Other Receipts OTHR REC 103 0 E Subtotal Local Funds $ 0 STATE/FEDERAL/SPECIAL FUNDS: I P DEHHR $ 750.00 T S Subtotal State/Federal/Special $ 750.00 - TOTAL RECEIPTS—equal to Total Expenditures is 750.00 ��1rti1. v s / I i if 2 (p 7 Local Authorized Official Signature Vare Branch Hod Division/Se on Signature Date Finance Officer Si a Date . An=ne 1� e� , -.� � .� ,r Fiscal Management- tgnature Dace DEHNR 2948(Revised 2/93) Geneni SerAces Division(Review Z( 7 N.C. Deoarcnent of Environment,Health,and Natural Resources' Page 1 or' 1 Division of General Services FY 1997 — 1998 CONTRACT ADDENDUM Environmental Health _ _. 98 47520 068 Office,Secdon,or Branch - Conte et Number Orange County Health Department Food and Lodging Concac_cr Acciviry These funds are budgeted as revenues for environmental health and go toward subsidizing the personnel costs of the division. Any funds in excess of the approved revenue budget are generally applied toward computer equipment for the division. Reviewed by DEN.NR 3300(Revised 2/90) LJUN 6 '1997 General Services Division(Review 1/95) Initials Date L CAL HEALTH DEPARTMENT BUDGET N.C.Department of Environment, �f, A? Revision Number Health,and Natural Resources �! l Division of General Services G Division of Maternal and Child Health P.O.Number SFY 7 / 97 6 / 98 9 8 5 1 0 1 0 0 6 8 Effective Date Termination Date Contract Number Orange County Health Department Activity' Maternal health Contractor. Project Director. Daniel B. Reimer Total Budget:$ 248,472 ITEM DESCRIPTION I CLASSIFICATION . IIMI AMOUNT TEXPENDI•IVRFS: SA/FR 1000 25,826 laries & Fringe Benefits 2000 m�g E es OP EXP rchase of Equipment EQUIP 5000 E General Contracted or ch GENERAL 6100 N Purchased Services , School Health D Cluuaan CLN 6863 Laboratory LAB 6862 ;y Pharmacy Services RX SERV 6865 x U Transfer TXIX R Subtotal State d. $ 25 826 E LOCAL EXPENDITURES: LOCAL EXP 9000 222.646 S TOTAL EXPENDITURES—equal to Total Receipts $ 248,472 LOCAL FUNDS: 0 R Appropriation APPROP 101 TXIX IOZ 222,646 E OT HR REC 103 0 Other Receipts C $ 222,646 Subtotal Local Funds E STATEIFEDER.AL/SPECIAL FUNDS: I P DEHNR $ 25,826 T S $ 25,826 Subtotal State/Federal/Special TOTAL RECEIP'T'S—equal to Total Expenditures $ 248,472• un L• �t �Y I ,n.t 3 h 'A � �� L Local Authorized Official Signature ate Hod Division/Sectiori Signature Date Date ��� Fiscal Management Signature Date finance Officer Signature _ rt DEHNR 2948(RcAs d 2/93) General Services e Division(Review..l94,: 1 en, un• - -SIS6l43U07 HEALTH DEPT P. JUN 23 'y7� 04�10P 2 M 9002 KC.Dg==Of=-w*M�F;=fta,and Naaa2i Page 1 Of 1I nivi�*M of C==-IL Sl=vic•°s FY 97-98_ Ct3mm4CT ADDYND nm i DNf��ttrw-41 ffeattir _98 57 0?Q 068 Oe7— Sertiaa.cs Hrsmch I C Nem3ca Activity Or-act�e ( _ _ ifs#arna3�I�slt� i - GOAL To reduce infant mor=IR4 and marbidity and to improve tb I health stains of wromen during . FcY SECTIOiv A:PROCESSIOt3TCt3M£OWECTIVES � L At Least jL �a of:0 resident live births will be to women who received adequare prenatal carte. Z No more than 5% of Ail resident We births wffl be to women who experienced pregnancy weight gain of less than 15 ponds. 3. No wore than 12% of all resident live births w l be to women who smoked tobacco during pregnancy- 4.4. _4t least 55 % of medicaid enrolled pregnant women who dcUver will.receive MCC services. �. At least o0_, % of Medicaid enrolled pregnant women who deliver will receive WIC Program services- (the percent2V for this item must be the same as fbr the corresponding WIC Program Contra tAAcldendam Quality Assurance Deliverable 6. At Least 26°l6 of infants enrolled in %�C�be breastf�ding at S weeks pastpart:rm_ (na' erCesata' for this item must be the same as for-the corresponding FMC Program ConAddendum QuaUty Assur=ce Deliverable) 7. At least LJO/o of aR Mddiraid earelled pregnant women who deliver will receive.2 pastparthua home v isiL Xc-imed by (Re,=d2M) I - ziftifids 1} Date N.C.Department of Environment,Health,and Natural Resources Page 1 of 11 Division of General Services FY 97-98 CONTRACT ADDENDUM DMCHJNMSIMaternal Health 98 51010 068 Office,Section,or Branch - - Contract Number Orange Maternal Health Contractor Activity GOAL To reduce infant mortality and morbidity and to improve the health status of women during pregnancy. SECTION A: PROCESS/OUTCOME OBJECTIVES 1. At least 94 % of all resident live births will be to women who received adequate prenatal care. 2. No more than 7 % of all resident live births will be to women who experienced pregnancy weight gain of less than 15 pounds. 1 No more than13 % of all resident live births will be to women who smoked tobacco during pregnancy. 4. At least 55 % of medicaid enrolled pregnant women who deliver will receive MCC services. 5. At least o9 % of Medicaid enrolled pregnant-women who deliver will receive WIC Program Services. (The percentage for this item must be the same as for the corresponding WIC Program Contract Addendum Quality Assurance Deliverable) 6. At least 26% of infants enrolled in WIC will be breastfeeding at 6 weeks postpartum. (The percentage for this item must be the same as for the corresponding WIC Program Contract Addendum Quality Assurance Deliverable) 7. At least Z1 % of all Medicaid enrolled pregnant women who deliver will receive a postpartum home visit. - Reviewed by n-PT4vR'1100!Revised 2/90 _ ! /'a N.C.Department of Environment,Health,and Natural Resources Page—of 11 Division of General Services FY 97-98 CONTRACT ADDENDUM DMCHIWHSIMaternal Health 98 51010 068 Office,Section,or Branch Contract Number Orange Maternal Health Contractor Activity SECTION B: NON-MEDICAID SERVICE DELIVERABLES Instructions: In the ESTIMATED NUMBER column, enter the projected number of non-Medicaid reimbursable services that the local agency plans to provide during the contract period. Multiply the ESTIAMATED NUMBER for each service by the reimbursement rate for that service and enter the amount in the ESTIMATED COST column. If the projected number for a service type is zero, enter"0" in both ESTIMATED NUMBER and ESTIMATED COST columns. ESTIMATED ESTIMATED SERVICE TYPE - NUMBER X RATE = COST Maternal Health (Pre,Perinatal) 195 X $129.94= $25,338-30 Non-Stress Test 0 X $ 59.60 = $ 0 Ultrasound _ 0 X $ 38.14 = $ 0 Maternity Home Visit(Prenatal) 0 X $ 108.05= $ 0 Parenting Class 0 X $ 92.38 = $ 0 Childbirth Class �— X $ 87.00 = $ 0 Maternal Care(Initial) 0 X $ 105.39 = $ n Maternal Care (Subsequent) 0 X S 56.70 = $ 0 Medical Nutrition Therapy 4 X S 40.61 = $ 162.44 Pregnancy Test 0 X S 10.51 = $ 0 RHO D Immune Globulin 0 X $ 46.11 = $ 0 Mat Care Coor Home Visit _-_ X $ 84.74= $ 0 Refresher Childbirth Class 0 X $ 69.18 = $ 0 Post Home Visit Mat Assess 9 X $ 85.90 = $ 773.10 Intensive Psych Counsel 0 X $ 63.59 = $ 0 Oral Glucose Tolerance �— X $ 45.98 = $ 0 MOW Brief 0 X $ 30.10 = $ 0 MOW Standard 0 X $ 54.66= $ 0 MOW Extended 0 X $ 123.12 = $ 0 Colposcopy without Biopsy 0 X $ 48.85= $ 0 TOTAL ESTIMATED COST OF SECTION B SERVICE DELIVERABLES $ 26,273.84 Instruction: If the TOTAL ESTIMATED COST OF SECTION B SERVICE DELIVERABLES is equal to or greater than the total amount of DEBM funds budgeted in the ACTIVITY BUDGET for this program,then skip to SECTION D. If less than the total amount of DEHNR funds budgeted,then continue on to SECTION C. Reviewed by DEHNR 3300(Revised 2/90) N.C.Department of Environment,Health,and Natural Resources Page 3 of 11 Division of General Services FY 97-98 CONTRACT ADDENDUM DMCH/WHS/Maternal Health 98 51010 068 Office,Section,or Branch Contract Number Orange Maternal Health Contractor Activity SECTION C: OTHER PROGRAM DELIVERABLES Instructions: If the TOTAL ESTIMATED COST OF SECTION B DELIVERABLES is less than the total amount of DEHNR funds budgeted in the ACTIVITY BUDGET, provide information on how the local agency will use the remaining DEHNR funds to further the program's goals and objectives. List only activities that are not Medicaid reimbursable and not part of the cost of the service deliverables in SECTION B. For examples of such activities, refer to the attached SUGGESTIONS FOR SECTION C OTHER PROGRAM DELIVERABLES. Include in SECTION C any DEHNR funds budgeted to meet infrastructure needs (e.g. clinic and computer equipment, waiting room furniture, records systems). The TOTAL ESTIMATED COST of all SECTION B and SECTION C deliverables must equal or exceed the total DEHNR funds budgeted. ESTIMATED COST Program Deliverable 41 $ a. Short descriptive title: New Initiative Existing Activity b. Target population (if applicable): c. What is to be accomplished: d. Major expense(s) included in estimated cost: e. Projected completion date (if applicable): f.Name, title and phone number of staff person with primary responsibility: TOTAL ESTIMATED COST OF SECTION C OTHER PROGRAM DELIVERABLES $ N.C.Department of Environment,Health,and Natural Resources Page 4 of 11 Division of General Services FY 97-98 CONTRACT ADDENDUM DMCH/WHS/Maternal Health 98 51010 068 Office,Section,or Branch Contract Number Orange Maternal Health Contractor Activity SECTION C: OTHER PROGRAM DELIVERABLES (continued) ESTIMATED COST Program Deliverable#2 $ a. Short descriptive title: New Initiative Existing Activity b. Target population(if applicable): c. What is to be accomplished: d. Major expense(s) included in estimated cost: e. Projected completion date(if applicable): f. Name, title and phone number of staff person with primary responsibility: Pro&ram Deliverable#3 $ a. Short descriptive title: New Initiative Existing Activity b. Target population(if applicable): c. What is to be accomplished: d. Major expense(s) included in estimated cost: — e. Projected completion-date(if applicable): f. Name, title and phone number of staff person with primary responsibility: TOTAL ESTIMATED COST OF SECTION C OTHER PROGRAM DELIVERABLES $ Reviewed by M43300(Revised 2190) N.C.Department of Environment,Health,and Natural Resources Page 5 of 11 Division of General Services FY 97-98 CONTRACT ADDENDUM DMCHIWHS/Maternal Health 98 51010 068 Office,Section,or Branch Contract Number Orange Maternal Health Contractor Activity SECTION C: OTHER PROGRAM DELIVERABLES (continued) Instructions: Make additional copies of this page if more than five (5)PROGRAM DELIVERABLES are listed. Remember to enter PROGRAM DELIVERABLE number(#) after each. ESTIMATED COST Proiaram Deliverable 9 $ a. Short descriptive title: New Initiative Existing Activity b. Target population (if applicable): c. What is to be accomplished: d. Major expense(s) included in estimated cost: e. Projected.completion date(if applicable): f. Name, title and phone number of staff person with primary responsibility: Program Deliverable 9 S a. Short descriptive title: New Initiative Existing Activity b. Target population(if applicable): c. What is to be accomplished: d. Major expense(s) included in estimated cost: e. Projected completion date (if applicable): f. Name, title and phone number of staff person with primary responsibility: Reviewed by N.C.Department of Environment,Health,and Natural Resources Page 6 of 11 Division of General Services FY 97-98 CONTRACT ADDENDUM DMCH/WHS/Maternal Health 98 51010 068 Office,Section,or Branch Contract Number Orange Maternal Health Contractor Activity SECTION D: QUALITY ASSURANCE DELIVERABLES Sudden Infant Death Syndrome The following local person(s) has attended the Division of Maternal and Child Health sponsored three- day SIDS Training Program and will provide SIDS grief counseling and information to bereaved families in the county: Name County Agency Betsy Knop Orange Orange C.ni,nt-v HPaI th nelat_ *"Local person" is defined as an individual who resides or works in the county, and who is not a DEHNR Regional or Central Office employee. •Counties that averaged less than one SIDS death per year for the last four ears may designate a grief counselor from a neighboring county or the DEHNR Regional Office grief counselor if a letter of agreement is obtained. It is recommended that all counties have a backup grief counselor for their primary counselor. Reviewed by DEHNR 3300(Revised 2/90) �� N.C.Department of Environment,Health,and Natural Resources Page 7 of i 1 Division of General Services FY 97-98 CONTRACT ADDENDUM DMCH/WHS/Maternal Health 98 51010 068 Office,Section,or Branch Contract Number Orange 'Maternal Health Contractor Activity SECTION D: QUALITY ASSURANCE DELIVERABLES (continued) 1. The health department has written policies in place for facilitating early entry into prenatal care which include the following: (a) Follow-up of positive pregnancy tests within two weeks to assure patient has access to health care provider. (b) Referral to WIC upon making contact with a pregnant woman. (c) Referral for Medicaid eligibility determination and maternity care coordination upon making contact with a pregnant woman. (d) For health departments that provide prenatal services, in the presence of a three week or greater waiting list, triage of those women who request prenatal services from the health department for purposes of determining their scheduling priority for their first visit. 2. The health department will offer Maternity Care Coordination services to Medicaid eligible patients. The health department has a written policy in place for providing MCC services to medicaid eligible patients. 3. At least 50 % of pregnant women enrolled in WIC will receive MCC. The percentage for this item must be the same as for the corresponding WIC Program Quality Assurance Deliverable. 4. Prenatal high risk nursing home visits will-be made upon the request of the prenatal care provider to those women experiencing difficulty with their pregnancy. 5. The health department will provide or make referrals for nutrition consultation, education on infant feeding, childbirth education and parenting classes to be provided to low income families. These referrals must be documented in the MCC chart or other client record. - - 6. The Lead Nurse Coordinator for the Maternal Health Clinic and Public Health Nurses who-are the highest level of medical provider for subsequent prenatal visits, will have completed the Matemal Health Nursing Training Program or a maternal health nursing course approved by the Maternal Health Branch. SECTION D: OUALITY ASSURANCE DELIVERABLES continued Reviewed by N.C.Department of Environment,Health,and Natural Resources Page 8 of 11 Division of General Services FY 97-98 _ CONTRACT ADDENDUM DMCHJWHS/Maternal Health 98 51010 068 Office,Section,or Branch Contract Number Orange Maternal Health Contractor Activity 7. The health department has written policies in place that appropriately address the following: (a) Follow-up of missed appointments. (b) Postpartum follow-up of women who received no prenatal care based upon information received from birth certificates or other appropriate sources. (c) Follow-up of pregnant women who express interest in permanent sterilization or contraception. (d) Referral to a high risk maternity clinic or obstetrician for identified high risk conditions. (e) Follow-up and care of pregnant women who have a past or current substance use/abuse issue. Policies must include confidentiality& release of information/medical records. (f) Follow-up and care of patients with positive HIV.or hepatitis B for both women and infants will be developed. (g) Follow-up and care of pregnant women who are experiencing domestic violence. 8. If any percent negotiated in 8.(a) through 8.0) is less than 90%, a statement of explanation needs to be provided as to why a 90%performance level cannot be obtained. Persons enrolled in the Health Department Maternity Program for prenatal care will be provided the following services as documented, in their medical records: (a) An estimated 100 %will receive an initial maternal health history which consists of the following: medical;family; surgical;immunization(Td, Rubella); drugs/medication; menstrual; contraceptive; obstetrical; and psychosocial. (b) An estimated 100 %will receive an initial physical examination which consists of the following components: thyroid; lungs; breast;heart; abdomen; extremities; pelvic(uterine Q ig ewed by DEHNR 3300(Revised 2/90) vi N.C.Department of Environment,Health,and Natural Resources Page 9 of 11 Division of General Services FY 97-98 CONTRACT ADDENDUM DMCHIWHS/Maternal Health 98 51010 068 Office,Section,or Branch Contract Number Orange Maternal Health Contractor Activity SECTION D: QUALITY ASSURANCE DELIVERABLES (continued) (c) An estimated 100%will receive the following component on a subsequent routine scheduled visits: interm ilsf ory/routine screening questions; weight- flood pressure; fetal heart tones; fundal height (after 14 wks); and fetal presentation after 31 weeks. (d) An estimated 95 fo will receive a nutrition assessment and have an appropriate care plan or referral to a nutritionist documented by the time of the initial physic exam. (e) An estimated 95 % will have their weights plotted on a weight gain grid for all routine visits. (This requirement is under study.) (f) An estimated 98 % of those with any of the following high risk conditions will be assessed by a nutritionist an receive education that addresses their specific condition(s) and referral as appropriate: 1. Maternal age:S 15 years 8. Preconceptional weight:< 2. Chronic hypertension 90% of standard body weight for 3. Diabetes mellitus height 4. Sickle cell disease 9. Weight loss > 21b./month in/2\or 5. Alcohol or substance abuse /3\ 6. History of previous LBW 10. Weight gain< 8 lbs. by 26 weeks infant 11. Intrauterine growth retardation 7. Multiple fetuses 12. Hgb< 10 or Hct <30% 13. Pica 14. Prior history of breastfeeding problems (g) An estimated 98 %will be provided with a prenatal supplement containing folic acid and iron. (h) An estimated 99% of those patients with abnormal clinical findings will be appropriately followed. (i) An estimated 95 % of those with a high risk condition will receive consultation from or be referred to an o stetrcian or high risk maternity clinic. (j) An estimated 95 %will have completed a risk assessment for preterm labor if admitted prior to 35 weeks of pregnancy. (This requirement is under study.) (k) -STS on the initial visit and a repeat STS between 30 and 34 weeks. (I) Screening for hepatitis B on the initial visit, unless known to be infected, and follow-up of an infant born to an infected mother to assure he/she receives prophylactic treatment. (m) Screening for HIV on the initial visit, with consent, or documentation in the chart that HIV testing was refused by the client. (n) Screening for Gonorrhea(culture) on the initial visit and repeated in the third trimester -- Reviewed by N.C.Department of Environment,Health,and Natural Resources Page 10 -of 11 Division of General Services FY L7-98 CONTRACT ADDENDUM DMCHIWHS/Maternal Health 98 51010 068 Office,Section,or Branch Contract Number Orame Maternal Health Contractor Activity SE(MON T): OTTALTTY ACSTTRAN('F,T)FT.TVFRABT FS (Sontirni (o) trimester Sgnng or lam 4it(culture) on the initial visit and repeated in the third (p) Screening for AFP at 16-18 weeks with consent, or documented in the chart that patient enrolled after 18 weeks into services or was refused by the client. (q) Screening at initial visit for Blogd Group Rh Determination, and Antibody Screen (repeated as indicated). Antibody Titer will be done if positive Antibody Screen and repeated as indicated. (r) Screening at initial visit for Rubella immune Status, unless documented in patient's record vaccine or previous laboratory test indicating immunity. (s) Pap smear,limitunless last documented i t pap smear was done within last six months and judged within (t) Urine Dipstick at each visit. (u) Quantitative Urine Culture will be done at initial visit, and repeated if needed. (v) Hgb/Hct. screening each trimester. (w) Screening at 26-28 weeks for Diabetes with 50 g. glucose and OGTT if indicated. (x) Screenin if indicated for H b electrophoresis with informed consent documented in the chart, or documented refusal by the client. (y) Prenatal Education wiII include docmentation in the record of 1. All patients will receive individual education about their identified risk conditions(s) 2. B��ssio prenatal education may be provided in an individual or group format and provision of this education must be clearly documented in the medical record. Any appropriately trained members of the maternal health team can provide the education component$. These�ncludeNurse Nutritionist, Social Worker, MCC,MD, CNM, Nurse?ractitigner, Physician Assistant, Health Educator, etc. For example, if the MCC or the nutritionist provides education n a given topic, this education need not be repeated by another member orr the health team. (a) Required educational components 1. First trimester; • nutrition/weight gain • over-the-counter medications • substance abuse • bleeding • severe headaches • visual changes DEHNR 3300(Revised 2/90) eviewed by General Services Division(Review 1/95) N.C.Department of Environment,Health,and Natural Resources Page 11 of 11 Division of General Services FY 97-98 CONTRACT ADDENDUM DMCH/wHS/Maternal Health 98 51010 068 Office,Section,or Branch Contract Number Grane Maternal Health Contractor Activity ,S—!"TT0N Tl. QIT A T TTV A CSTTT2 A NCF DFT TUFT?A T2T F C (rentind) 2. First or Second trimester: • preterm labor • ruptured/leaking membranes • change in fetal activity 3. Third trimester: • signs of labor • contraception • car seat instructions • basic techniques with infant feeding • immunizations (b) Additional educational components: Any of the following components which are clinically relevant will be provided: • clinical routines • anatomy/physiology • prenata postnatal exercises - • sex during pregnancy • labor and delivery/cesarean delivery • postpartum period • dental care during pregnancy • early parenting/inf int care 3. Pregnant women who have participated in a prenatal education series in a past pregnancy will be provided an educational review and update which: • is conducted either by class or by individual sessions, • is planned and carried out according to procedures for this review as set forth in written clinic policy, and • includes the following required components, at a minimum: ! preterm labor ! ruptured/leaking membranes ! severe headaches ! visual changes ! bleeding ! changesin fetal activity ! over-the-counter medications ! substance abuse ! nutrition/weight gain ! signs of labor ! contraception ♦ car seat use ! immunizations Reviewed by ___nT7TJWR 1100(Revised 2/90) li r MATERNAL HEALTH CONTRACT ADDENDA SECTION A BASELINE DATA Orange Count DEHNR Year County Region State 1. Percentage of all resident five births to women CY 195 79.8 78 81.1 who received adequate prenatal care 2. Percentage of all resident live births to women CY 195 5.5 9 9.2 who experienced pregnancy weight gain < 15 lbs 3. Percentage of all resident live births to women CY 195 12 11.3 15.9 who smoked tobacco during pregnancy. 4. Percentage of all Medicaid enrolled pregnant FY 9495 51.2 57.8 61.7 women who received MCC services 5. Percentage of all Medicaid enrolled pregnant CY 195 67.7 74.1 76.2 women who received WIC Program Services 6. Percentage of infants enrolled in WIC who FY 94-95 26.3 14.1 15.7 were breastfeeding at 6 weeks of age 7. Percentage of Medicaid enrolled women who CY 195 13.5 24.6 30.6 delivered and received a postpartum home visit LOCAL HEALTH DEPARTMENT BUDGET N.C.Department of Environment, `�� Health, and Natural Resources 11j7 Revision Number_— Division of General Services /� ? Division of Maternal and Child Health SFy 1 P.O.Number 7 / 97 6 / 98 9 8 5 2 5 15 0 —6-—3- Effective Date Termination Date Contrar_Number Contractor: Orange County Health Department - Acriviry: Family Planning Project Director: Daniel B. Reimer Total Budget: $ 141,227 ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT E STATE EXPENDITURES: X Salaries & Fringe Benefits SA/FR 1000 1109105 Operating Expenses OP EX? 2000 P Purchase of Equipment _EQUIP 5000 E General Contracted or Purchased Services GENERAL 6100 N School Health x�.�'l'R D Clinician CLN 6863 Laboratory a37 2hya 5 x c T Pharmacy Services UTransfer TXIX {�:. . ....... . . >.{. .. . 5..=. . .: ,.. . R Subtotal State Expend. $ 110,105 E LOCAL EXPENDITURES: --TLOCAL EXP 9000 31,122 S TOTAL EXPENDITURES—equal to Total Receipts $ 141,227 LOCAL FUNDS: R Appropriation APPROP 101 0 E TXIX TXE{ 102 19,086 Other Receipts OTHR REC 103 12,036 C 31,122 Subtotal Loral Funds $ E STATE/FEDERAL/SPECIAL FUNDS: I FF $ 40,081 T WHSr $ 1601 5369 6111 151 5515 x x x x RgjC s 70,024 S 110,105 Subtotal State/Federal/Special -S ecial $ TOTAL RECEIPTS—equal to Total Expenditures $ 141,227 Local Authorized Official Signature Mte BMWI,Hed Division/Searan Signature Date Finance Officer Signature , ' Elate ` Acaxau= Fiscal Management Signature Date Wdal 0F74-NR 2948(Revised 2/93) JUL 1997 N.C.Department of Environment.Health.and Natural Resources page 1 of 2 Division of General Services FY 1997-98 CONTRACT ADDENDUM '7'.Tomen's Preventive Health I. 98 51510 068 Office, Section, or Branch -, Contract Number Oranze Family Planning Contractor Activity GOAL To improve pregnancy outcomes; to improve the health status of women before pregnancy,and to assure all pregnancies are intended. SECTION A: PROCESS/OUTCOME OBJECTIVES 1. The pregnancy rate will not exceed 23 pregnancies per 1,000 females age 10 to 17. 2. The percentage of repeat pregnancies to teens ages 17 and under will not exceed 18 %. 3. The percentage of women with short birth intervals will not exceed G C K NOTE: Decreases in these rates and percentages will constitute improvement. Reviewed by DEHNR 3300(Revised 2/97) �-//h J o ✓, General Services Division(Review 1/98) "-M lo 1Lo Initials 6ate N.C.Department of Environment,Health,and Natural Resources Page 2 of 2 Division of General Services FY 1997-98 CONTRACT ADDENDUM , Women's Preventive Health 98 51510 068 Office, Section, or Branch Contract Number Orange Family Planninlz Contractor Activity SECTION B: NON-MEDICAID SERVICE DELIVERABLES Instructions: In the ESTIMATED NUMBER column, enter the projected number of non-Medicaid reimbursable services that the local agency plans to provide during the contract period. Multiply the ESTIMATED NUMBER for each service by the reimbursement rate for that service and enter the amount in the ESTIMATED COST column. If the projected number for a service type is zero, enter"0" in both ESTIMATED NUMBER and ESTIMATED COST columns. ESTIMATED ESTIMATED SERVICE TYPE NUMBER X RATE = COST FP Initial Visit 245 x $190.24 = $46,608.8 FP Complete Physical/Annual Exam 620 x $149.63 = $92,770.6 FP Limited Revisit 775 x $63.68 = $49,352.00 FP Extended Revisit 22 x $106.90 = $ 20-351 .8 Depo Injection 475 x $23.74 = $11 Norplant Insertion 0 x $504.90 = $ 0 Norplant Removal 6 x $197.11 $ 1,182.66 Norplant Removal and Reinsertion 0 x $645.91 — $ - '0 IUD Device and Insertion 0 x $177.35 = $ 0 IUD Removal 0 x $89.71 = $ 0 Pregnancy Test(not associated with a family planning visit) 0 x $10.51 = $ 0 Psychosocial Counseling 0 x $63.59 — $ 0 Medical Nutrition Therapy 0 x $56.97 — $ 0 ' Colposcopy without Biopsy 0 x $48.85 = $ 0 Colposcopy with Biopsy 0 x $73.37 = $ 0 _ Cryosurgery 0 x $78.90 = $ 0 TOTAL ESTIMATED COST OF SECTION B SERVICE DELIVERABLES $203,542-36 Instruction: If the TOTAL ESTIMATED COST OF SECTION B SERVICE DELIVERABLES is equal to or greater than the total amount of DEHNR funds budgeted in the ACTIVITY BUDGET for this program, then skip to SECTION D. If lest than the total amount of DEHNR funds budgeted, then continue on to SECTION C. Reviewed by DEHNR 3300(Revised 2/97) General Services Division(Review 1798) Initials Date N.C.Department of Environment.Health.and Natural Resources Page_of • Division of General Services FY 1997-98 CONTRACT ADDENDUM Women's Preventive Health Office,Section,or Branch Contract Number Family Plannin,2 Contractor Activity • . SECTION D:QUALITY ASSURANCE DELIVERABLES 1. The local health agency has written policies in place for family planning services: a. Description of local family planning services,including local protocols, standing orders and components of Initial,Complete,Limited and Extended Revisits. b. Tracking mechanisms for follow-up of abnormal clinical and laboratory findings. c. Follow-up of family planning patients with positive pregnancy tests to assure patient has access to health care provider. d. Protocol for clients wanting permanent contraception. e. There is a written plan/protocol which addresses education,counseling,and referral regarding:HIV/AIDS,Hepatitis B-infection and immunization. f. Identification of clients at risk for contraceptive failure and clients at high medical risk for complications of contraceptive use. g. Counseling family planning postpartum clients to delay pregnancy for at least 12 months after delivery. Reviewed by DEHNR 3300(Revised 2/97) General Services Division(Review 1/98) Initials Date N.C.Department of Environment.Health,and Natural Resources Page_of_ Division of General Services FY 1997-98 CONTRACT ADDENDUM Women's Preventive Health Of.ice,Section,or Branch Contract Number Family Planning Contractor Activity SECTION D: QUALITY ASSURANCE DELIVERABLES(continued) 6. Method specific consent form was reviewed with client,dated,signed by client,and copy given to client. a. A new consent form is signed with any change in method. b. Risks specific to the individual due to her/his use of the chosen contraceptive method were identified. c. Minors under 18 years of age were counseled about the importance of discussing birth control needs with parent(s)and minor signs forms. d. Information about emergency and after-hour services was provided. 7. Screening,Diagnosis,Treatment and Follow-Up Services There is evidence in the record that: a. Significant problems were identified and documented. b. Significant abnormal clinical and laboratory findings were discussed with the client. c. Problems,conditions,and abnormal findings are appropriately followed. 8. Service Providers a. Certain low risk clients may receive designated services from public health nurses that have received special Family Planning Enhanced Role Training. See Enhanced Role specifications for detailed criteria. Reviewed by DEHNR 3300(Revised 2/97) General Services Division(Review 1/98) Initials Date LOCAL HEALTH DEPARTMENT BUDGET N.C. Department of Environment, - Health,and Natural Resources kc, ,RECEIVED . Revision Number Division of General Services ,?/r2b� . ��9� lZj�� SFY vision of Maternal and Child Heal. P.O.Number 7 / 97 6 / 98 Children &you* S%Uric 1 8 0 0 6 8 Effective Date Termination Date Contract Number Contractor: Orange County Health Department Activity: Child Service Coordination Project Director: Daniel B. Reimer Total Budget:$ 172,213 ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT E STATE EXPENDITURES: X Salaries & Fringe Benefits SA/FR 1000 57 876 Operating Expenses OP EXP 2000 P Purchase of Equipment EQUIP 5000 E General Contracted or N Purchased Services GENERAL 6100 School Health SCH HLTH 6200 D Clinician CLN 6863 :2}'+ '3*E.+ti�'\.,}.`'r ,.ih'1<YT,X; ti<'; v.•y+;WMR ':;y£;.ro:..,\„+. <i L;-:, �:•, :r fix+ <�" ::.e.« ..w*q�:�ia;°;<Sp;.,. :.,§ale'£ »• ::,.�'.7c:;: -;:a�.".<�ka`:. �<d;:o .,{r. ;8FS��;t:;>.; .:g�:.:,<;%ct>5'<:'�ai T Laboratory LAB 6862 Pharmacy Services RX SERV 6865 Z.T Transfer T?CX ><.:...�ssk.:.;. <<;,,,:>.�;;;,::��...: . '� in:;: z<. R Subtotal State Expend. $ 51,876-T E LOCAL EXPENDITURES: LOCAL EXP 9000 120,337 S TOTAL EXPENDITURES—equal to Total Receipts $ 172,213 LOCAL FUNDS: R Appropriation APPROP 101 0 E TXIX TXIX 102 _ 120,337 Other Receipts OTHR REC 103 0 C 120,337 E Subtotal Local Funds $ STATE/FEDERAL/SPECIAL FUNDS: I P T S Subtotal State/Federal/Special $ 51,876 TOTAL RECEIPTS—equal to Total Expenditures $ 172,213 -97 Local Authorized Official Signature ba B..h xnd ` ivision/Section Si Date finance Officer Signature Date Tiscal Management SigngZA!0J-- Date DEHNR 2948(Revised 2/93) , General Services Division(Review 2/94) N.C.Department of Environment,Health,and Natural Resources Page 1 of 4 • Division of General Services FY 97 - 98 CONTRACT ADDENDUM Specialized Services Branch 98 53180 068 Office, Section, or Branch Contract Number Child Service Orange __ :; Coordination Contractor Activity GOAL To cooperate and collaborate with families to assure identification of and access to preventative, specialized and support services for themselves and their children .... and children with special needs will have maximum opportunity to reach their developmental potential. SECTION A: NON-MEDICAJID SERVICE L E Instructions: In the ESTIMATED NUMBER column, enter the projected number of non-Medicaid reimbursable services that the local agency plans to provide during the contract period. Multiply the ESTIMATED NUMBER of each service by the reimbursement rate for that service and enter the amount in the ESTIMATED COST column. If the projected number for a service type is zero, enter "0" in both ESTIMATED NUMBER and ESTIMATED COST columns. The estimated number for each service type should at least equal the previous fiscal year's non-Medicaid service level. If declines in service levels are projected, attach a written explanation. ESTIMATED ESTIMATED SERVICE TYPE NUMBER X RATE = COST Number of active service months* 558 $103.79 $ . 76 * Number of active months: This number should include the estimated number of months of CSCP services that your agency intends to provide to non-Medicaid eligible clients. This does not refer to the number of clients. Reviewed by DEHNR 3300 (Revised 2/90) General Services Division (Review 1/95) f` '© �� Initials Date N.C.Department of Environment, Health,and Natural Resources Page 2 of 4 Division of General Services FY 97 - 98 CONTRACT ADDENDUM Specialized Services Branch 98 53180 068 Office, Section, or Branch Contract Number Child Service Orange Coordination Contractor Activity SECTION B: QUALITY ASSURANCE AND OTHER DELIVERABLES CONTRACT ADDENDUM 1. All children enrolled in the Child Service Coordination Program will have demographic information in their client file. a. Name b. Date of Birth c. Race d. Medicaid number, if applicable e. County of residence f. Address g. Phone number h. Primary care physician 2. All children enrolled will have a completed Identification and Referral Form (DEHNR 3748). 3. All children enrolled will have a completed and signed Letter of Agreement between the designated Child Service Coordinator and family. 4. All children enrolled will have.signed Release(s) of Information as appropriate for exchange of information between agencies identified on the forms. 5. All children enrolled will have a completed Child and Family Strengths and Needs Assessment at specified intervals. 6. All children enrolled will have a completed Status Report Form (DEHNR 3750) at specified intervals. 7. All children enrolled will have a care coordination plan for problems identified by,the family and child Service Coordinator. 8. All children enrolled will have documentation of a referral for Intermediate Assessments at: a. 15 - 18 months b. 30 - 36 months c. 48 - 54 months Reviewed by DEHNR 3300(Revised 2/90) General Services Division (Review 1/95) - 1,ej66 -9 7 Initials Date N.C.Department of Environment, Health,and Natural Resources Page 3 of 4 Division of General Services FY 97 - 98 CONTRACT ADDENDUM Specialized Services Branch 98 53180 068 Office, Section, or Branch Contract Number Child Service Orange Coordination Contractor Activity SECTION B: QUALITY ASSURANCE AND OTHER DELIVERABLES (continued) 9. 61 % of all enrolled children will receive WIC Program Services. CSCP and WIC staff must jointly decide on estimated % to be used on both WIC and CSCP contract addenda. (The percentage for this item must be the same as for the corresponding item on the WIC Contract Addendum.) Projections for CSCP clinical objectives #10 through #16 should range from 90 to 100 percent. If the performance level is below 90 percent, a written explanation by the health department must be attached. 10. 95 % of all enrolled children will have an assessment of parent-child interaction at mandated face-to- face contacts. 11. 95 % of all enrolled children will have a review of immunizations and referral and follow-up as necessary. 12. 93 % of all enrolled children will receive at least mandated minimum contacts by the designated Child Service Coordinator including: a. Review and update of risk indicators b. Assessment of current needs c. Update of care coordination plan d. Monitoring of the provision of services by referral sources. 13. 95 % of all enrolled children will have documentation of and their families will receive assistance regarding transfer to a new service coordination agency when indicated. 14.95 % of all enrolled children will have documentation of and their families will receive assistance regarding closure to the Child Service Coordination Program when indicated. 15.95 % of all children enrolled will have the provision for appropriate referrals, follow-up and support services as specified in the care coordination plan. 16.95 % of all children enrolled will receive education and counseling about the importance and value of parenting, nutrition, WIC services and immunization. Reviewed by DEHNR 3300(Revised 2/90) General Services Division (Review 1/95) IA _1-r Initials Date • N.C. Department of Environment, Health,and Natural Resources Page 4 of 4 Division of General Services 97 - 98 FY CONTRACT ADDENDUM Specialized Services Branch 98 53180 068 Office, Section, or Branch Contract Number Child Service Orange Coordination Contractor Activity SECTION B: QUALITY ASSURANCE AND OTHER DELIVERABLES (continued) 17. All enrolled children, regardless of Child Service Coordination Provider Agency, will have Identification and Referral Forms (DEHNR 3748) and Status Report Forms (DEHNR 3750) entered into the Health Services Information System (HSIS) at the local health department in a timely manner upon receipt from outside agencies. 18. Signed Provider Agreements for Child Service Coordination Agencies will be maintained for all county providers participating in the program. Agreements will be updated annually. 19. Child Service Coordination staff must meet the minimum staff qualifications as specified in the Child Service Coordination Program Technical Manual. 20. Child Service Coordinators working full-time in the Child Service Coordination Program will have no more than 75 families in their caseload at a given time. Employees working part-time in Child Service Coordination will have a number less than 75 prorated for the time spent in Child Service Coordination activities. 21. List each position number and the percent of time spent in providing Child Service Coordination activities. POSITION # % OF TIME POSITION # % OF TIME 328 10% 603 5% 332 20% 642 95f 336 100% 646 357- 343 5% 720 1 007- 351 70% t pMpjQra r7 5(l�la 326 5% 356 12% 640 gf 74 5% 732 100% Reviewed by DEHNR 3300(Revised 2/90) General Services Division (Review 1/95) Initials Date LOCAL HEALTH DEPARTMENT BUDGET N.C.Department of Environment, Revision Number—_ Health,and Natural Resources Division of General Services Division of Health Promotion SFY L7 Y P, / 7 / 97 6 / 98 Activity: COMP. Breast & Cervical Cancer Control Effective Date Termination D ate Contractor: Orange County Health Department ProjectDirector: Daniel B. Reimer TOTALBUDGET: $ 24,364 $ Screening Outreach 3,311 1 0.Number P. O.Number �— 5452 C) (j 5453 --- ITEMDESCRIPTION CLASSIFICATION ITEM Contract Number Contract Number STATE EXPENDITURES: E Salaries&Fringe Benefits SA/FR 1000 14,729 X Operating Expenses OP EX? 2000 677 P Purchase of Equipment EQUIP 5000 E General Contracted or N Purchased Services GENERAL 6100 :.. School Health SCH HL TH 6200 i:' ..: �.:.. ...; s.. D ».... k � k \r I Clinician CLN 6863 ,I I r{ mom Laboratory LAB 6862 :wx U RX SERV 6865 `� Pharmacy Services R Transfer TXIX 6864 4,� fi �.,�{ T Su;%•.:w:3.:�.m E Subtotal State Expend. 24,364 S LOCAL EXPENDITURES: LOCALEXP 9000 0 TOTAL EXPENDITURES—equal to Total Receipts 24,364 LOCAL FUNDS: Appropriation APPROP 101 0 R TXLY TXIX 102 0 E OtherReceipts OTHR REC 103 0 C Subtotal Local Funds 0 E STATE/FEDERAL/SPECIAL tree g _~i•.�?lrl 5.� � L:�, P FUND OBJ RCC PROG T Outreach S FUND OBJ RCC PROG Subtotal State/Federal/Special 24,364 TOTAL RECEIPTS—equal to Total Expenditures 24,364 //77 x W U. �P 1 Local Authorized Official Signature Date BUA it.ad Divi o Se&ionSignatu ate Finance Officer Signature �* _ D to Accountant Fiscal Management Signature Oate tai , Initial DERNR 2948(Revised 7/94) General Services Division(Review L9C j 697 Revised 02 112197 Orange County NORTH CARD INA COMPREHENSIVE B FAST ND CERVICA—L CANCER CONTROL. PROGRAM CONTRACT ADDENDUM For the i2efiod Jab 1 1997- June 30, 1998 STATEMENT OF NEED CERVICAL CANCER: Between 1988 and 1992, 690 women in North Carolina died of preventable cervical cancer. The age-adjusted mortality rates for the period was 4.0/100,000. However the death rate among Native Americans is twice that of whites, while mortality among blacks is three times higher than whites.Cervical cancer deaths are preventable in most cases through early detection and treatment. North Carolina ranks ninth in the nation for cervical cancer deaths; twelfth in the nation for related deaths among white women, and fourth highest for black women. In 1997, 460 new cases of invasive cervical cancer are expected with as many as 150 projected deaths. BREAST CANCER: Breast cancer is the most commonly diagnosed cancer and the second leading cause .of cancer deaths among women in the United States. In 1992, 1127 women died of breast cancer in North Carolina making it the second leading cause of cancer deaths among women in the state. North Carolina's age- adjusted mortality rate for 1988-1992 was 29.2/100,000. Black women have higher mortality than white women from breast cancer. Women over age 50 years have a mortality rate from breast cancer about fifteen times greater than women under age 50. In North Carolina in 1997, more than 5140 new cases of breast cancer are expected and nearly 1250 projected deaths from breast cancer will occur. I. TARGET POPULATION A. All women provided services through this program will have gross incomes that are less than or equal to 200% of the federal poverty level according to schedules in effect at the beginning of the contract term. B. At least 75% of the women provided services will be aged 50 years or older. C. Services should be targeted to women of ethnic minorities, those uninsured or underinsured, or without a usual source of health care. 11. SERVICES TO BE PROVIDED A. The following comprehensive screening services will be provided to all age-eligible women in the BCCCP: 1. Clinical Breast Examination; 2. Screening Mammogram; 3. Pelvic Examination; 4. Pap Smear; and 5. Instruction in Self Breast Examination. Page 2 Contract Addendum B. Breast Screening and Follow-Up: 1. Protocols Protocols for breast screening and follow-up will be in accordance with Breast Health: A Guide for Health Departments, (DEHNR, October, 1994). 2. Screening a. All women will receive instruction in self breast examination (SBE). b. All women aged 20 - 39 years will receive a clinical breast examination (CBE) every three years. Women in the high risk group for breast cancer, beginning at age 30, may receive a CBE screening every year.** c. All women aged 40 -49 years will receive a CBE every year and a screening mammogram every other year.** d. All women aged 50 years and older will receive a CBE and screening mammogram every year. ** A woman at high risk for breast cancer may receive a screening mammogram every year. High risk definitions are found in Breast Health- A Guide for Health Departments, page 3. 3. Follow-Up Women having an abnormal breast screening result will be referred for additional evaluation. BCCCP funds may be.used for the following diagnostic services: a. Repeat or diagnostic mammogram (including cone-down view); b. Consultation Visits for Surgical Evaluation; c. Fine needle aspiration (FNA) and pathology, if needed; d. Office visits for surgical evaluation and/or FNA; and e. Breast ultrasound, when preceded by a screening mammogram and in accordance with the Breast Health_guidelines. The contractor will assure that a referral system for the diagnosis and treatment of all abnormal findings is in place. The contractor will designate a person who will be responsible for implementing a protocol which ensures, to the best of its ability, that all patients receive follow-up services or medical treatment when required. For all abnormal mammogram and clinical breast examination results the following information will be documented and reported to the BCCCP within 60 days of the initial screening date: a. Follow-up appointment information (date and follow-up location); b. Patient contact information (number and date of attempts made to follow-up); and c. Referral information (date and referral source). Page 3 Contract Addendum 4. Rescreening The contractor will assure that a system is in place for contacting women screened previously through the BCCCP for the purpose of scheduling repeat screening for the appropriate age and risk intervals. C. Cervical Screening and Follow-Up: 1. Protocols Protocols for cervical screening and follow-up will be in accordance with Pap_. Smear Screening: A Guide for Health Dcpartmen s (DEHNR, January, 1994). 2. Screening All women aged 18 years and older will receive a Pap smear and bimanual pelvic examination every year. After three consecutive satisfactory normal Pap smears, the following schedule will be used: High risk - continue to screen every year (See Pa Smear Screening: A Guide for Health Dellartments, page 1-8 for definition of high risk); Low risk - screen every 2-3 years if all Pap smear results continue to be normal. 3. Follow-Up Women having an abnormal cervical screening result will be referred for additional evaluation. BCCCP funds may be used for the following diagnostic services: a. Repeat Pap smear; b. Colposcopy; c. Colposcopy-directed biopsy and pathology; and d. Office visits for repeat Pap smear and Colposcopy. The contractor will assure that a referral system for the diagnosis and treatment of all abnormal findings is in place. The contractor will designate a person who will be responsible for implementing a protocol which ensures, to the best of its ability, that all patients receive follow-up services or medical treatment when required. For all abnormal Pap smear and biopsy results the following information will be documented and reported to the BCCCP within 60 days of the initial screening date: a. Follow-up appointment information (date and follow-up location); b. Patient contact information (number and date of attempts made to follow-up); and c. Referral information (date and referral source). 4. Rescreening The contractor will assure that a system is in place for contacting women screened previously through the BCCCP for the purpose of scheduling repeat screening for the appropriate age and risk intervals. Page 4 Con.&aet Addendum III. QUALITY ASSU ANC'E A. Cervical Screening_and follow-ua: Laboratories must be certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88). The Bethesda System is required for reporting the results of Pap smears. (See Pap Smear Screening- A Guide for Health Departmt ents, page 1-5). A report of all screening and follow-up results will be placed in the patient's medical record. B. Breast Screening and follow-=: Federal Food and Drug Administration (FDA) certification is required for all mammography facilities. When contracting with any mammography facility, the contractor will take into consideration that mammography facility's prior performance under the Mammography Quality Standards Act (MQSA) regulations. Reporting of results of mammograms from all contractors and all sub-contractors will be made on the Mammography and Billing Report supplied by the BCCCP which utilizes the American College of Radiology Breast Imaging Reporting and Database System, final categories for mammogram assessment (See Appendix VII, Breast Health: A Cmj& for Health Departments). Any substitute report form requires prior BCCCP approval. A report of all screening and follow-up results will be placed in the patient's medical record. C. Freauc= of Screenings- The frequency of screenings will follow the protocols noted in Section II.B. and II.C. of this Contract Addendum. D. Program Audits: s: The contractor will provide or assure the provision of high quality services for all the program components. Audits will be conducted by the BCCCP staff in order to evaluate the program components as specified in this Contract Addendum for the purposes of quality assurance. Prior notification will be given as to the date and time of the audit. W. DATA AND PROGRAM REPORTING A. Minimum Data Elements (MDEs)for every woman provided screening and follow-up services will be reported to the BCCCP in one of two ways: L Enter aFelectronically in the state HSIS (and the Enhanced System when available) or through a compatible system; or 2. Provided in hard copy if the HSIS is not available. B. All data will be entered or sent no later than the 15th of the month following the month the service was provided. Page 5 Contract Addendum _ V. P11BI iC�,AND PROFFSSIONAL. EDIT.A('ION A. Public Education: The contractor will provide education to the targeted population as appropriate. B. Community Outreach: If awarded special outreach funds, 1. The contractor will submit a performance report in a standardized format to be supplied by the BCCCP no later than 15 days from the end of the first and third quarters of this fiscal year; 2. New outreach contractors will participate in one training session on community outreach to be conducted by the BCCCP` during the fiscal year. C. Professional Education: The contractor will participate in educational opportunities provided or recommended by the BCCCP as appropriate. VI. PAYMENT FOR SERVICES A. BCCCP funds may not be used to reimburse for treatment services. Payment to a subcontractor(s) is limited to those screening and follow-up services listed in Section II, pages 1-3 of this Contract Addendum. B. The payment to a subcontractor(s) for any service described in Section II may notes the prexafling M i ar llowable fee for the service. C. BCCCP funds may only be used for payment after all other third party payment sources (including Medicare, Medicaid, and private insurance) provide evidence of partial or non-payment for qualified services. BCCCP funds may be used to reimburse for a deductible and/or co-payment (except for Medicaid) required of the patient, provided that the total payment (including the deductible and copayment) to the subcontractor(s) does not exceed the prevailing Medicare- allowable fee. D. Women whose gross incomes are less than or equal to 100% of the federal poverty level will not be charged for any services covered through BCCCP. VII. CONTRACTRUDGMT ADJUSTMENTS A. Performance and Budget Based Ad' ctm n Increases or decreases in the baseline budget for fiscal year 1997-98 will be made according_to c�rPP ins performance indicators, with consideration given to county/district size, local service delivery methods, and average cost of services. Those performance indicators are: the total number of women screened in relation to target levels; the number and percent of women over 50 years of age who are screened; the percent of women screened who receive comprehensive services..In addition, total expenditures in relation to baseline budgets will be evaluated when determining contractor performance. Performance indicators pertaining to rescreening and follow-up activities will not be used to determine adjustments to the baseline budget for fiscal year 1997-98. They will be included in your notification of results for information purposes. Page 6 Orange County Contract Addendum Contractors will be notified of performance-based adjustments in January 1998. Decreases to the budget will not exceed ten percent. The resulting adjusted budget will be the baseline for the following fiscal year. Performance will be based on the latest screening data available on December 31,1997, for the prior fiscal year (FY 1996-97). If additional funds are available, eligible contractors will be notified in February 1998. Performance-based adjustments to restore decreased fiscal year 1997- 98 budgets will be made in September 1997. Restoration of funds will be based on updated performance indicators using data reported through September 1997, for fiscal year 1996-97. B. Voluntary Adjustments: Midyear, voluntary increases or decreases may be made in the baseline budget of contractors. Those whose pattern of expenditures predict a surplus of funds in the contract year may be asked to approve a one-time, voluntary budget rev..on (decrease) to free up excess funds which may be allocated to another contractor. By the same token, contractors whose pattern of expenditures predict a shortage of funds in the contract year may be asked to approve a one-time, voluntary budget revision (increase) to cover anticipated needs. In either event, the allocation for the baseline budget for the following fiscal year will be restored to the adjusted levels determined in accordance with Section VII. A., above. VIII. SUMMARY OF D_ FL.IVERABLES A. Breast and Cervical Cancer Screenings will be provided to at least a total of= women during the contract period. Performance indicators will apply to the total women screened by the contractor, regardless of the established target levels. The contractor will assure age- and risk- appropriate breast and cervical cancer screenings and follow-up in the following manner: At least 75% X122) of the total women screened during the contract period will be 50 years of age or older. No more than 25%(43) of the total women screened during the contract period may be age 49 years or younger, of w ich 7% (12). of the total women screened may be under age 40 years. Appropriate to the age and risk status of the women, and consistent with the cervical and breast health protocols issued by the DEHNR, 100% of the women screened will receive both cervical cancer and breast cancer screening services. B. 100% of women having abnormal breast or cervical screening results will be followed up and documentation of final diagnostic disposition will be made and reported to the BCCCP within 60 days of the initial screening date. G--Documentation of the treatment disposition for 100% of those women diagnosed with breast or pre-invasive/invasive cervical cancer will be made and reported to the BCCCP within 30 days of the final diagnostic disposition. D. Data entry and/or submission of data will be made no later than the 15th of each month for the previous month's services. E. A system for contacting women for annual rescreening will be in place with an emphasis on rescreening women over 50 years of age. ealth Departme t Signature-Health Director Date LOCAL IMALTH DEPARTMENT BUDGET -i.C.Depar-mezt of Environment, — Health,and Revision Number Natural Resources � � Sly ion of General Services �' Division of Maternal and Child Healtb, !` P.O.Number 7 / 97 6 / 98 9 8 5 7 1 5. 0 0, 6 8 Effective Date Termination Date Contract Number Contraaor. Orange County Health De artment Activity: Immunization Action Plan - Project Direc_or: Daniel B. Reimer Total Budget:$ 24,369 ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT E STA-y EXPENDITURES: 1-7,560 Sajaries Sc Fringe Benefits SA/FR 1000 Y Operating Expenses OP EXP 2000 6,809 P PL:chase of Equipment EQUIP 7000 E Gt-neral Contracted or Purchased Services GENERAL 6104 N Scaool Health Clinician I - - Laboratory . T Piarmacy Services U Transfer TXIX 5f R Subtotal State Expend $ 24,369 E LOC_-,L EXPENDITURES: LOCAL EXP 9000 0 S TOTAL EXPENDITURES—equal to Total Receipts $ 24 369 LOC.-.L FUNDS: R Appropriation APPROP 101 0 E 7/DC Tm 102 0 C seer Receipts OTHR REC 103 0 C Subtotal Local Funds $ - E STAit:/FEDERAL/SP1:r 1 AT t1.mc. I P 1570-5715-1097 $ 8,593.00 ,I 1570-5701-0098 $ 7,183.00 1570-5715-1098 $ 8,593.00 S Subtotal Scat. $ - - 24,369 TOTAL RECEIPTS—equal to Total Expenditures / $ 24 369 2J19 7 Local Auu'7orized Official Signature Date a D' ' ion/S on Signature ate w� Finance Officer Signature a, D to A=,*��. Fiscal Management Si Lure ate DEIR,M 29+s fRrvised 2/93) N.C.Department of Environment,Health,and Natural Resources Page 1 of 2 + Division of General Services FY 97_98 CONTRACT ADDENDUM IMMUNIZATION SECTION 98 57150 068 Office, Section, or Branch Contract Number Orange IMMUNIZATION Contractor Activity GOAL To eliminate cases of vaccine-preventable disease in North Carolina by raising the age-appropriate immunization levels of two-year old children to 90 percent or more by the year 2000. SECTION A: PROCESS/OUTCOME OBJECTIVES 1. At least 62 % of all children 24-35 months of age served by the local health department will be age- appropriately immunized by 24 months of age. This rate will be measured either through a North Carolina Immunization Registry (NCIR) report or by a CASA review conducted by a regional immunization consultant during FY 97/98. In future fiscal years, when the North Carolina Immunization Registry (NCIR) is operational in the private provider sector, a community- wide age-appropriate immunization rate will be measured, in addition to the local health department-specific rate. 2. No more than 5 % of all children 12-13 months old, served by the health department, will have one or more documented missed opportunity(ies). During FY 97/98 a missed opportunity review (minimum of 20 charts) will be conducted for health department patients. SECTION B: PROGRAMMATIC DELIVERABLES 1. Administrative Immunization Services To eliminate barriers that delay or prevent delivery of immunizations and to assure the safe delivery of vaccines,the health department agrees to: a) Provide walk-in immunizations during all hours the health department and satellite locations are open. b) Make on-site immunization appointment times available in all immunization clinic locations. c) Integrate immunization screening and referral within WIC and other child health services. d) Provide immunizations on demand and without prerequisites such as county residence,a physical exam, well child check, or a note from a physician, etc. e) Assess patients for contraindications and will not accept invalid contraindications. f) Administer simultaneously at time of visit all immunizations for which a child is eligible. g) Refer, as needed, clients being seen only for immunization services to the following staff WIC Staff,Maternity Care Coordinators, Child Service Coordinators, Health Check Outreach Workers or Private Provider. 'Revi �d by DEHNR 3300(Revised 2/90) General Services Divisidn(Review 1/95) Initials ate i N.C.Department of Environment,Health,and Natural Resources Page 2 of 2 Division of General Services FY 9797_98 CONTRACT ADDENDUM IMMUNIZATION SECTION 98 57150 068 Office, Section, or Branch Contract Number Orange IMMUNIZATION Contractor Activity h) Maintain current signed standing orders that provide for appropriate immunizations and physician referrals when contraindications exist. The standing orders should contain temporary and permanent contraindications as outlined in the North Carolina Administrative Code. The standing orders must comply with the immunization schedule recommended by the Immunization Section and must require simultaneous administration of needed vaccines. i) Document all vaccine administered in the patient's permanent medical record, including vaccine type, date, dose,manufacturer and lot number, and record, report and submit adverse events to the Immunization Section. j) Enter data on all vaccines administered into Health Services Information System(HSIS), or other local health department computerized data system by name, date, dose, contraindication,VFC eligibility status, and provider identifier. k) Facilitate implementation of the North Carolina Immunization Registry (NCIR), when available,for your county's private health care providers and facilities, such as hospitals. 2. Monitoring and Follow-up Services To assure quality of community-wide immunization service delivery,the health department agrees to: a) Maintain a system or use the North Carolina Immunization Registry (NCIR)to identify children due or past due for immunizations. b) Conduct tracking and follow-up activities to ensure that patients are age-appropriately immunized. Mail,telephone, autodialers, and home visits are acceptable follow-up techniques. 3. Parental Education and Outreach To help teach parents the value of immunizations and to ensure that they are aware of required immunizations,the health department agrees to: a) Conduct appropriate community-based outreach and education activities. b) Present and review appropriate Vaccine Information Statement(s) (VIS)with each parent\guardian, person standing in loco parentis, or adult presenting the child for immunizations each time a patient presents for the administration of any vaccine covered by the NC Universal Childhood Vaccine Distribution Program. c) Incorporate immunization education in prenatal, parenting and other health education curriculum. "viewed by DEHNR 3300(Revised 2190) General Services Division(Review 1/95) 4/7,)zt� L 5 IMMUNIZATION CONTRACT ADDENDA SECTION A BASELINE DATA Orange County DEHNR Year Co—� Region State 1. Percentage of all children 24-35 months CY '96 52 73 73 of age served by the local health department who were age-appropriately immunized by 24 months of age 2. Percentage of all children 12-13 months CY '95 15 26 30 served by the local health department who had one or more documented missed opportunities LOCAL HEALTH DEPARTMENT BUDGET N.C.'Dep'art rent of Environment. J 7 Health,and Natural Resources , ! Revisio Number Division of General Services SFY 98 Division of Epidemiology P. O.Number 7 97 6 / 98 9 8 4 -- 5 3- 3 () 0 6 8 Effective Dare Termination Date Contract Number Consacmr: Orange County Health Department Activity: AID-TO-COUNTY (FEDERAL) Project Director: Daniel B. Reimer Total Budget:$ 31,000 ITEM DESCRIFZTON I CLASSIFICATION ITEM AMOUNT E STATE EXPENDITURES: X Salaries & Fringe Benefits SA/FR 1000 29,750 Operating Expenses OP EXP 2000 1, P Purchase of Equipment EQUIP 5000 E General Contracted or Purchased Services GENERAL 6100 School Health SCII.:HLTFI u.., lrZ£ 1 ::: : .. :... D Clinician CF .. 686 x .. ;:. Laboratory LB 6662 T Pharmacy Services R :SERZI u .:.::666 U Transfer TXIX 6664 . R Subtotal State E_r„end. $ 31,000 E LOCAL EXPENDITURES: ( LOCAL EXP 9000 0 S TOTAL EXPENDITURES—equal to Total Receipts $ 31,000 LOCAL FUNDS: R Appropriation APPROP 101 0 E TXIX TXIX 102 0 Other Receipts OTHR REC 103 0 C Subtotal Local Funds o E $ STATE/FEDERAL/SPECIAL FUNDS: I P DEHNR 31,000 T 1601-1450-536961-4533-1177 S 31,000 Subtotal Snte./Feaeral/S ecial $ i TOTAL RECEIPTS—equal to Total Expenditures $ 31,000 —� 1" L Local Authorized Official Signature Date, amt,Had Division/Section Signature Date t� Finance Officer Signature Date ��= Fis Manageme t Signature Date ►tilt )E NP.2948(Revised 2/93) 3enerai Scrvices Division(Rcvicw 2/94) N.C.Department of Environment,Heald-i,and Natural Resources' Page 1 of Division of General Services FY 197 - 1998' CONTRACT ADDENDUM HIV/STD Control Branch 9845331068 Office,Section,or Branch Contract Number Orange County Health Department AIDS Federal Contractor Activiry HIV COUNSELING AND TESTING PROGRAM PLAN 1.A. All staff with primary responsibility for HIV antibody counseling and testing will receive training and continuing education by the HN/STD Control Branch; all other staff will be trained by local staff who were trained by Branch staff. I.B. Pre and post-test counseling will be conducted as specified below: 1) All persons provided HIV counseling and testing services will receive individual pre- and post-test counseling. 2) All pre-test counseling will include risk assessment, personalized risk reduction guidelines, the advantages and disadvantages of testing, and the accuracy and limitations of the test. Informed consent is obtained prior to testing. 3) All post-test counseling will include test results, interpretation of test results, and personalized risk reduction counseling. 4) If the client is infected, HIV control measures will be given, including information on the legal responsibility to notify sex and needle-sharing partners. 5) If a client is infected, a referral will be made for a follow-up interview with an HIV/STD Control Branch Regional Disease Intervention Specialist. For clients tested confidentially, the referral will be made within three to seven days after post-test counseling. A telephone report may be given; however, a Communicable Disease Report Card will also be completed within seven days. 6) If the client is infected, appropriate referrals for medical and psychosocial services will be made. 7) If the client is tested confidentially and is seropositive, a Communicable Disease Report Card will be filled out and forwarded to the Communicable Disease Coordinator for submission to HIV/STD Control Surveillance Unit. 8) If the client is tested anonymously and is seropositive, reporting is accomplished through submission of the correctly completed laboratory report form. I.C. HIV antibody test results will be opened only by trained HIV counselor, nurse practitioners and public health nurses. Written release of information is required before confidential HIV test results will be released except as required by law. All HIV test records and patient records will be stored in locked facilities. I.D. Plan of Operation 1)_Informing clients of availability of service: posters; bulletin boards; brochures; individual risk assessment during STD/FP/Maternal Health/TB interviews (especially women of childbearing age, adolescents, minorities,drug users and gay/bisexual men). Advertising will occur through periodic public service announcements. Contact will be maintained with local AIDS services organizations, drug treatment centers and other local agencies serving populations who are at increased risk. Contact is also maintained with student and university organizations at UNC-Chapel Hill, religious and human service organizations. The health department will participate in the AIDS Service Agency of Orange County. �4w Reviewed by DEI-INR 33CO(Revised 2/90) General Services Division(Review Initials Date N.C. Department of Environme-ric,Health, and Natural Resources' Page 2 of 2 Division of General Services FY 1997-1998 CONTRACT ADDENDUM HIV/STD Control Branch Office,Section,or Branch Contract Number Orange County Health Departm n� t _ AIDS Federal Contractor Activity 2) Providers of services are appropriately trained HIV counselor, public health nurses and nurse practitioners. 3) Anonymous (as long as this option is available) and confidential HIV counseling and testing, are available by appointment, with walk-ins seen as time allows, in our Carr Mill site Monday through Friday from 8:00am- 12:00 noon and l:00pm-4:00pm. Confidential testing is available during OCHD prenatal, family planning, STD and TB clinical hours. 4) HIV counseling and testing policies, procedures and information are located in a procedure manual in each site. 2. We will comply with efforts of the 11IV/STD Control Branch to develop and implement a quality assurance system. 3. Blood samples for HIV serology are submitted to the State Laboratory on properly completed scannable serology forms. 4. Patients who receive STD/FP/Maternal/TB services will receive basic.HIV and STD information, with special emphasis placed on educating pregnant patients about the prevention of congenital syphilis. Patients whose behaviors place them at increased risk for HIV infection are advised of HIV counseling and testing options and are offered confidential testing. Patients who refuse confidential testing will be referred for anonymous testing until this option is no longer available. Written informed consent is obtained with confidential testing. All clients who receive testing are encouraged to return for their test results and post-test counseling. Letters and phone calls will be used for follow-up of patients who do not return for results. 5. Individual counseling is provided. 6. The health department will place a strong emphasis on its HIV/STD education and testing efforts on reaching persons at highest risk for HIV and STD's. 7.A. Funds will be used solely for HIV counseling.and testing and HIV/STD education. 7.B. All applicable state and federal cost accounting procedures and principles for the disbursement and accounting of funds will be followed. 7.C. State approved educational materials will be used. When new CDC guidelines-are available, OCHD will incorporate those educational guidelines in selecting educational materials. Reviewed by DEHNR 33CC(Revised 2/90) ' General Services Division(Review 1/95 ' " 'J J Initials Dace