HomeMy WebLinkAbout2014-206 Health - NC Dept. of Health and Human Services Division of Public Health - FY 2015 Consolidated Agreement / 1 / y- 15:'
y —Please return this copy to the Clerk to the Board's —
Consolidated Agreement FY15 office for permanent agenda file. Page 1 of 28
FY 2015 CONSOLIDATED AGREEMENT RECT MAY 12 2014
This Agreement is made between the North Carolina Department of Health and Human Services, Division of
Public Health ("State") and the Orange County Health Department("Department") for the purpose of
maintaining and promoting the advancement of public health in North Carolina. This Agreement shall cover a
period from July 1, 2014 to June 30, 2015 and shall remain in force until the next Fiscal Year Agreement is
signed except as provided for in Section J. Termination.
Now, therefore, the State and the Department agree that the provisions and clauses herein set forth shall be
incorporated in and constitute the terms and conditions applicable for activities involving State funding. (State
funding or funds means State, federal, and/or special funding or funds throughout this Agreement.)
A. RESPONSIBILITIES OF THE DEPARTMENT
1. The Department shall perform activities in compliance with applicable program rules contained in
the North Carolina Administrative Code, as well as all applicable Federal and State laws and
regulations.
2. The Department shall perform the activities specified in the Agreement Addenda for State-funded
budgets. The Department must negotiate these Agreement Addenda in good faith to the satisfaction
of State representatives as part of the agreement execution. The Department will meet or exceed the
Agreement Addenda levels unless extenuating circumstances prevail and are explained in writing to
the state section, branch or program.
3. The Department shall report client, service, encounter, and other data as specified by applicable
program rules, Agreement Addenda for State-funded budgets, and by North Carolina Administrative
Code.
4. The Department shall provide access to patient records to authorized staff from the Division of
Public Health for technical consultation, program monitoring, and program evaluation, as specified
by applicable program rules, Agreement Addenda for State-funded budgets, and by North Carolina
Administrative Code.
5. The Department shall provide client, service, encounter, and other data through the State's
centralized automated systems for claims creation and submission for processing to the State's
Medicaid agency except as allowed by NCGS 130A—45.13 and SB245 passed in the 2011 session.
To ensure that such data is accurately linked to the specific client served in a manner that results in a
unique identifier from the DHHS Common Name Data Service except as allowed by SB245 passed
in the 2011 session, the Department shall allow the State to submit(on its behalf)the Social Security
Numbers of all clients to the Social Security Administration for verification.
6. The Department shall share data to support efforts of the public health system, represented by the
local health departments, local health programs, and the State (the parties), in order to meet public
health objectives while respecting the confidentiality and integrity of each party's data and protecting
the privacy of individual client health information. Sharing data includes providing client
information allowed as permitted disclosures under the Health Insurance Portability and
Accountability Act of 1996,Public Law 104-91, HIPAA Administration Simplification Provisions
Sections 261 through 264, 45 CFR 164.512.
C �
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7. The Department shall administer and enforce all rules that have been adopted by the Commission for
Public Health, ratified by the North Carolina General Assembly, or adopted by the Local Board of
Health.
8. The Department shall provide to the State a copy of any rules adopted by the Local Board of Health
pursuant to G.S. 130A-39 and Public Health Ordinances adopted by the County Commissioners,
within 30 days of adoption. These rules and ordinances are to be sent to the Local Technical
Assistance and Training Branch(LTAT).
9. The Department shall have policies related to conflict of interest, and policies and procedures for
Human Subjects Clearance. Each staff member shall receive a copy of these policies.
10. The Department shall provide to the State, for each county, a comprehensive community health
assessment(CHA) at least every four years and a State of the County's Health Report each of the
interim years. North Carolina Division of Public Health will administer this. The CHA should be a
collaborative effort with local partners such as hospitals and community partnerships or the local
Healthy Carolinians Partnership (if such exists), and shall include collection of primary data at the
county level and secondary data from the State and other sources. The CHA shall include a list of
community health problems based on the findings and a narrative of the assessment findings and
priorities chosen(refer to accreditation activities regarding CHA or SOTCH). The CHA or SOTCH
is due by the first Monday of December. The Department is required to submit community action
plans to address the selected priority issues. These plans are due by the first Friday in June following
the December submission of the CHA. For action plans, the Department shall include a minimum of
two new evidence-based strategies (or expand current evidence-based strategies to new target
populations)to address at least two Healthy North Carolina 2020 objectives from different focus
areas. There are a total of 13 focus areas and 40 objectives within Healthy North Carolina 2020. The
evidence-based strategies (EBS) shall be highlighted in the Action Plan and shall include a plan for
staffing, training, implementation and monitoring/evaluation for each EBS.Action Plans shall be
submitted by the Department for every CHA priority selected. The CHA will include data analysis of
those indicators that are listed in the accreditation self-assessment.
11. The Department shall provide formal training for their Board of Health(BOH). The LTAT Branch
shall notify the Department no later than April 30 of the name of the contractor who can provide this
training during the upcoming fiscal year. First priority should be given to training newly appointed
members with the ultimate goal of having all BOH members trained as time and resources allow.
Continuing education updates on topics of special interest are strongly encouraged after general
board member orientation has been provided for all BOH Members.
12. The Department shall provide Network and Internet access at its facilities (or to the county network
where desired) at a minimum speed of a full T1 line in order to:
• Connect with the North Carolina Health Alert Network(HAN), North Carolina Electronic
Disease Surveillance System(NCEDSS), North Carolina Immunization Registry(NCIR), Health
Information System(HIS)
• Rapidly communicate e-mail alerts to and from the North Carolina Division of Public Health
regarding bioterrorism and public health topics (outbreaks, emergency alerts, etc.)
• Access NCDPH training material and information used for training staff, including access to
webinars
• Build steps of a secure infrastructure for remote data entry in the local health departments
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• Report electronically all required Environmental Health Section inspection data in the format and
frequency specified by the Division. Paper copies of inspection data are no longer accepted.
The Department will maintain the above-described minimum connection. The Department may
choose any provider(ISP) that they wish. The Department will also ensure security of a minimum of
a T1 connection at the Department location. The Department may utilize security products (i.e.,
firewalls) of their choosing to maintain network connectivity and security integrity. The Department
network configuration and security practices must allow communication with systems within the
state network.
13. The Department shall incorporate basic elements of the North Carolina Public Health logo and theme
line(slogan) into communication materials developed for programs and services that depend, in
whole or in part, upon State funding. Such communication materials could include letterhead,
business cards, brochures, pamphlets, advertisements or announcements, signs and
marketing/promotional materials. The Department is encouraged to incorporate its own name with
the logo.
14. The Department shall notify the Local Technical Assistance and Training Branch any time there is a
legal name change to the Department; in addition, if the Department becomes part of a consolidated
human services agency, the Department shall send to the Local Technical Assistance and Training
Branch an organization chart reflecting the new structure so that the state health department will
know who to contact related to public health issues.
B. FUNDING STIPULATIONS
1. Funding for this Agreement is subject to the availability of State, Federal, and Special Funds for the
purpose set forth in this Agreement.
2. During the period of this Agreement, the Department shall not use State, Federal or Special Project
funds received under this Agreement to reduce locally appropriated funds as reflected in the Local
Appropriations Budget(see item C.2. below.)
3. The Department shall not use personal health program funds to support environmental health
programs nor use environmental health program funds to support personal health programs.
4. Fees generated by the Food and Lodging Fees Collection Program may only be used to support State
and Local food, lodging, and institution sanitation programs and activities.
5. The county shall submit monthly reports of On-Site Wastewater activities to the On-Site Wastewater
Branch in the Environmental Health Section of the Division of Public Health in the format provided
by the Section.
6. The Department shall comply with Standards for Mandated Public Health Services, 10A NCAC 46,
Section .0200; and Administrative Procedures Manual for Federal Block Grant Funds, 1 NCAC 33,
Sections .0100 - .1502.
7. The Department shall maintain signed employee time records to document the actual work activity of
each employee on a daily basis. The percentage of time each employee spends in each activity shall
be converted to dollars based upon the employee's salary and benefits at least on a monthly basis.
The computation shall support the charges for salaries and benefits to all federal and State grants (as
required in OMB Circular A87) as well as provide the documentation of detailed labor cost per
activity for preparation of Medicaid Cost Report.
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8. For Departments participating in Medicaid Reimbursement, the Department shall:
a. Execute a Provider Participation Agreement with the Division of Medical Assistance. Selected
health departments receiving at least$5,000,000 in Medicaid receipts annually, as identified by
the Division of Medical Assistance, must sign, as part of their continuing participation as a
Medicaid provider, a Letter of Attestation affirming that: 1) detailed information is provided to
employees, contractors and agents about the Federal and State False Claims Acts and 2)written
policies and procedures are in place to detect and prevent fraud, waste and abuse.
b. Make every reasonable effort to collect its cost in providing services, for which Medicaid
reimbursement is sought, through public or private third party payors except where prohibited by
Federal regulations or State law; however, no one shall be refused services solely because of an
inability to pay.
c. Establish one charge per clinical/support service for all payors (including Medicaid)based on
their costs. All Payors must be billed the same established charge, but the Department may
accept negotiated or other agreed upon lower amounts (e.g., the Medicaid reimbursement rate) as
payment in full.
9. Subject to the approval of the appropriate Section, the Department may seek reimbursement for
services covered by a program operating under 10A NCAC 45 rules, Purchase of Medical Care
Services (POMCS), when those services are not supported by other State or federal funds. All
payment program rules and procedures as specified in the Purchase of Medical Care Services Manual
must be followed.
10. Provision of Interpreter Services: As required by Title VI of the Civil Rights Act, the Department,
because it receives federal funds, must provide interpreter services at no charge to Limited English
Proficiency clients in all programs and services offered by the Department.
11. The Department may not require a client to present identification that includes a picture of the client
for at least immunization, pregnancy prevention, sexually transmitted disease and communicable
disease services.
12. Subject to the availability of funds and approval of the Public Health Nursing and Professional
Development Unit, the Department may request reimbursement for:
a. Nursing service personnel participating in the Introduction to Principles and Practices of Public
Health and Public Health Nursing course. Reimbursement is $400.00 per participant upon
successful completion of the course. Reimbursement requests must be filed by the Department
within one year of completion.
b. Health Department Management/Supervision level staff participating in the Management and
Supervision for Public Health Professionals course. Reimbursement is $600.00 per participant
upon successful completion of the course. Reimbursement requests must be filed by the
Department within one year of completion.
13. Audits/Monitoring:
a. The Department shall have an annual audit performed in accordance with The Single Audit Act of
1984 as implemented by OMB Circular A-133. The audit report shall be submitted to the Local
Government Commission(LGC)by the County Administration(if single county health
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department)or the District Health Department or Public Health Authority(if so organized)
within six months following the close of the Agreement. Audit findings referred to the DHHS
Controller's Office by LGC will be investigated and findings verified by the DHHS Controller's
Office staff with assistance of the Division of Public Health Program Staff.
b. The Department, if it is a District Health Department or a Public Health Authority, must
complete quarterly a Fiscal Monitoring Report and submit to the DHHS Controller's Office
based on the schedule published by the DHHS Controller's Office.
14. Equipment is a type of fixed asset consisting of specific items of property that: (1) is tangible in
nature; (2)has a life longer than one year; and (3)has a significant value.
a. For Inventory Purposes
1) Equipment must be accounted for in accordance with the North Carolina Department of State
Treasurer Policies Manual, Chapter 20, and Fixed Assets Policy.
2) All equipment with an acquisition cost of$500.00 or more which is purchased with Women,
Infants and Children(WIC) Program Funds, must be inventoried with the Women's and
Children's Health Section.
b. For Prior Approval Purposes
1) All equipment purchased or leased with an acquisition cost exceeding $2500.00 (except in
WIC; see subparagraph 2)below for WIC requirements), where there is an option to purchase
with State/Federal funds, the purchase or lease must receive prior written approval from the
appropriate Branch/Section. For those purchased with Public Health Preparedness &
Response Grant funds only, any purchase exceeding $2500 per invoice(e.g., if the
Department is purchasing a computer, monitor, printer, etc. totaling more than $2500 or
purchasing six computers at$500 each)should be treated as one purchase for purposes of
prior approval.
2) For WIC, all computer and medical equipment purchased or leased, must receive prior
written approval from the Branch regardless of cost. In addition, all other tangible assets
(non-computer/medical) with an acquisition cost exceeding$500.00 must receive prior
approval.
c. For Accounting Purposes: The Department must utilize the depreciation schedule provided by
the State for all assets with an acquisition cost of$5,000 or greater. The accumulated
depreciation should be recorded in the general fixed assets account group.
15. Prior approval required for purchases other than equipment.
a. For Public Health Preparedness &Response grant funds, purchases for meals and refreshments
must receive prior written approval from the PHP&R Branch.
b. The use of Women's and Children's Health Medicaid fees for capital improvements requires
prior written approval from the Women's and Children's Health Section.
16. The Department agrees to execute the following Consolidated Federal Certifications attached to this
Agreement as applicable when receiving Federal funds:
a. Certification regarding Lobbying
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b. Certification regarding Debarment
c. Certification regarding Drug-Free Workplace Requirements
d. Certification regarding Environmental Tobacco Smoke.
17. When administering the Women, Infants, and Children's Program(WIC), the Department must
adhere to the requirements set forth in Section 361 of the Healthy Hunger-Free Kids Act of 2010
which amended Section 12(b) of the Richard B. Russell National School Lunch Act (NSLA), 42
USC 1760(b). This Act requires the Department to support full use of the Federal administrative
funds provided for the WIC program. The Federal administrative funds are specifically excluded
from budget restrictions or limitations including, at a minimum, hiring freezes, work furloughs and
travel restrictions.
18. Pursuant to the Federal Funding Accountability and Transparency Act (FFATA), the Department is
required to submit to the Division information that is reportable by the Division for all qualified
subawardees of federal funds. The Department will complete and submit the Federal Funding
Accountability and Transparency Act(FFATA)Data Reporting Requirement form provided by the
Division to determine the eligibility as a subawardee for reporting purposes. Information provided by
the Department will be used by the Division to report subawards (funding authorizations) equal to or
greater than$25,000 from each federal grant.
The Department shall maintain an active registration in the federal government's System for Award
Management(SAM). The SAM registration must be updated no less than annually in order to
maintain an active status. To update the registration, the Department must log in at the SAM home
page, www.sam.gov, and follow the instructions found there.
19. Subject to the availability of funds and approval of the Environmental Health Section, the
Department may request reimbursement for Centralized Intern Training (CIT) and a one-time
mileage allocation.
a. For Interns attending CIT sessions, reimbursement amounts are based on the session attended:
• Food Protection&Facilities Track—$280
• On-Site Wastewater Protection Track—$560
• Tier 2 General EH Module—$280
b. For Cross-training Registered Environmental Health Specialists (REHS) attending CIT sessions,
reimbursement amounts are based on the session attended:
• Food, Lodging, & Institutions—$170
• Child Care & School Sanitation—$62
• On-site Water Protection—$450
• Private Drinking Water Wells—$62
• Public Swimming Pools—$62
• Tattoo—$62
c. A one-time mileage allocation per two REHS per training session based on which of four
geographical areas they are employed. Reimbursement requires successful completion of the
course and requests must be filed by the Department within one year of the course completion.
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• Area 1 —$57: Alamance, Caswell, Chatham, Cumberland, Duplin, Durham, Edgecombe,
Franklin, Granville, Greene, Guilford, Halifax, Harnett, Hoke, Johnston, Lee, Lenoir,
Montgomery, Moore, Nash, Orange, Person, Randolph, Sampson, Vance, Wake, Warren,
Wayne, Wilson.
• Area 2—$170: Alexander, Alleghany, Anson, Ashe, Beaufort, Bertie, Bladen, Brunswick,
Cabarrus, Camden, Carteret, Catawba, Chowan, Columbus, Craven, Currituck, Dare,
Davidson, Davie, Forsyth, Gaston, Gates, Hertford, Hyde, Iredell,Jones, Lincoln, Martin,
Mecklenburg, New Hanover, North Hampton, Onslow, Pamlico, Pasquotank,Pender,
Perquimans,Pitt,Richmond, Robeson, Rockingham, Rowan, Scotland, Stanly, Stokes, Surry,
Tyrell, Union, Washington, Watauga, Wilkes, Yadkin.
• Area 3 —$283: Avery, Buncombe, Burke, Caldwell, Cleveland, Haywood, Henderson,
Jackson, Madison, McDowell, Mitchell, Polk, Rutherford, Transylvania, Yancey.
• Area 4—$396: Cherokee, Clay, Graham, Macon, Swain.
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.
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. Exceptions may be permitted in cases where the
patient has a preference for a non-contracted provider and that provider verbally agrees to abide
by program requirements and to accept program payment as payment in full.
c. The Department, when subcontracting, must meet the following conditions:
1) The Department is not relieved of any of the duties and responsibilities provided in this
agreement.
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) Upon request, the Department will make available to the State a copy of subcontracts
supported with State/Federal funds.
d. The Department must receive prior written approval from the State to subcontract when any of
the following conditions exist:
1) The Department proposes to subcontract to a single entity 50 percent or more of the total
State and federal funds made available through this Agreement.
2) The Department proposes to subcontract 50 percent or more, or$50,000, whichever is
greater, of the total State and federal funds made available through this Agreement for any
Agreement Addendum for any single public health Activity.
Consolidated Agreement FY 15 Page 8 of 28
3) The Department proposes to subcontract for services in the Women, Infants and Children
(WIC) Program.
e. The Department shall mail a signed copy of all final public health Funding Authorizations to the
DPH Budget Office, 1931 Mail Service Center, Raleigh, NC 27699-1931. The Department shall
retain a copy of all Funding Authorizations, the monthly certified electronic printed screen of the
Expenditure Reports with any amendments (via the Aid-to-Counties Database), Consolidated
Agreement, Agreement Addenda, Revisions and other financial records in accordance with the
current Records Disposition Schedule for County and District Health Departments issued by the
NC Division of Archives and History, Department of Cultural Resources and located on their
website at: http://www.ah.dcr.state.nc.us/records/local/default.htm.
2. The Department shall prepare and maintain a Local Appropriations Budget(reflecting the plans to
use local appropriations or earned fees)for each activity covered by this Agreement in a manner
consistent with instructions provided in general budgetary guidance from the Division and the
specific guidance from the respective programs and enter that budget information into the Aid-to-
Counties Database for each activity funded under this Agreement.
a. The Department shall prepare budget revisions to their Local Appropriation budgets when
appropriations will be increased or decreased and enter that information in the Aid-to-Counties
Database.
3. (Local Earned Revenues)The Department shall observe the following conditions when budgeting
and reporting earned revenues:
a. Locally appropriated funds may not be supplanted by earned revenues from persons, or public or
private third-party payors.
b. All earned revenue(officially classified as local funds) must be budgeted and spent in the
program that earned it except:
1) Revenue generated by WCH Section Programs, except WIC, may be budgeted and expended
(consequently reported) in any WCH Section Program activity.
2) Revenue generated by a local clinic or program that has no State-funded activity budget(no
State/federal funds) should be budgeted and associated expenditures reported in a State
program activity that most closely matches the deliverables of the respective State program.
This process will enable the collection of total expenditures in public health per program.
c. All fees collected shall be used in the current year or succeeding fiscal years.
d. Use of program income generated by the expenditure of Federal categorical funds will be
governed by applicable Federal regulations, including, but not limited to, 45 CFR 4.
e. Local Budgets for DHHS Reporting:
1) After preparing Local Budgets the Department must use the Allocation/County Line on the
Aid-to-Counties Database to show the approved local funding.
i Line item 101 on the Aid-to-Counties Database must be used to budget local
appropriations for each program activity, if applicable.
ii Line item 102 on the Aid-to-Counties Database must be used to budget Title XIX
Medicaid earned revenues for each program activity, if applicable.
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iii Line item 103 on the Aid-to-Counties Database must be used to budget other earned
revenues (e.g., Home Health fees, patient fees (cash), other insurance payments, and other
grants and donations) for each program activity, if applicable.
iv Line item 104 on the Aid-to-Counties Database must be used to budget Local funding
associated with Teen Pregnancy activities, if applicable.
v Line item 106 on the Aid-to-Counties Database must be used to budget Local funding for
bioterrorism activities, if applicable.
vi Line item 107 on the Aid-to-Counties Database must be used to budget Temporary Food
Establishment(TFE) fees collected, if applicable.
Note: The Department shall report Local expenditures in the appropriate category(e.g., 101,
102, 103, 104, or 106) in the ZZZZ line item in the Aid-to-Counties Database and TFE fees
collected in Category 107 in the ZZZZ line item in the Aid-to-Counties Database.
f. When reporting local expenditures (local appropriations, Medicaid or other earned revenues)the
Department must use the electronic Aid-to-Counties Database to report the pertinent month's
actual expenditures. (Note that an"actual expenditure" is one for which the item has been
ordered,received, invoiced and the check has been issued) or if the Agreement Addendum allows
for drawing down funds based on number of individuals screened or provided services, the actual
number screened or served multiplied by the per capita rate specified in the Agreement
Addendum. The Expenditure Reports must be submitted monthly in the website format and
certified in the website to the DHHS Controller's Office.
1) Line item 101 on the Aid-to-Counties Database must be used to report local appropriations
that were expended on a monthly basis.
2) Line item 102 on the Aid-to-Counties Database must be used to report Title XIX(Medicaid)
earned revenues that were expended on a monthly basis.
3) Line item 103 on the Aid-to-Counties Database must be used to report other earned revenues
that were expended on a monthly basis.
4) Local funding for Teen Pregnancy Prevention Initiatives (104) and Bioterrorism(106)must
be reported on the Aid-to-Counties Database on a monthly basis.
5) Line item 107 must be used to report Temporary Food Establishment fees collected on a
monthly basis.
g. A local account shall be maintained for unexpended earned revenues [i.e., Title XIX fees, private
insurance or private pay {cash I]. Accounts shall be maintained in sufficient detail to identify the
program source generating the fees.
h. The amount of Title XIX fees budgeted and expended in FY 2013-2014 must equal or exceed the
amount of Title XIX revenues earned during FY 2012-2013. The State will not approve program
activity budgets that do not include an amount of Title XIX fees sufficient to meet the
requirements of this section. The State may waive this requirement if the Department provides
sufficient justification.
4. (State/Federal Revenues only)The Department shall submit a monthly report of actual expenditures
(State and/or Federal)to the DHHS Controller's Office in the Aid-to-Counties Database as
referenced in 3.f. above—all reported in one system,but separated here for clarity of instructions.
Consolidated Agreement FY15 Page 10 of 28
a. The Department shall submit a monthly Expenditure Report of the pertinent month's actual
expenditures for all programs via the Aid-to-Counties Database to the DHHS Controller's Office
no later than the dates published annually in November or December for the next calendar year.
The schedule reflects a general period of 15-20 days from the end of the reporting month for
submission of the Aid-to-Counties Database report, based on weekends and holidays, to allow
processing time for the payment. Failure to meet the reporting deadline, as published in the
Controller's Office Aid-to-Counties E-Payment Schedule, WILL result in the exclusion of those
expenditures for that month. Early submission may result in earlier payment to the Department.
The Department must submit these monthly Expenditure Reports, via the Aid-to-Counties
Database, consecutively throughout the agreement period.
The health director and the finance officer will approve the monthly Expenditure Report in the
Aid-to-Counties Database and the system will alert the staff in the DHHS Controller's Office that
expenditures have been approved and certified. The"Certification"verifies that the total State
and Federal expenditures reported are valid for the pertinent month's actual expenditures. Local
expenditures are part of the Expenditure Report,but are not included in the amount verified in
the"Certification."Local appropriations must be reported monthly along with the State and
Federal expenditures.
b. Departments shall keep expenditure reporting current and submit their certification of
expenditures per the published DHHS Controller's Office Schedule. Funding is based on an
allocation method, not a contract method, and counties receive reimbursement for services
provided during one month in the following month. Therefore, the last service month to be paid
in the SFY will be May services which are reported and paid in June.
c. Expenditures of federal funds must be reported according to the funding period for a grant. Care
must be taken to be attentive to the service month/payment months for each grant as well as the
ending liquidation date for a grant. For each grant, the budgetary estimate, funding authorization
and Agreement Addendum will have service and payment month dates listed.
d. The Department shall submit the final Expenditure Report (via the Aid-to-Counties Database) for
all programs to the DHHS Controller's Office according to the schedule published annually in
November or December for the next Calendar Year by the DHHS Controller's Office. The
Expenditure Report for May Services,which is paid in June,will be the final report period
paid from the SFY. Services provided in June and reported in July will be paid out of the
next SFY.
e. The Department shall have the opportunity to submit amended expenditure reports in the month
following discovery of the error. The Department should not wait to submit all adjustments with
the invoice submitted to the Controller's Office at the end of May as that will not allow sufficient
time for verification of the adjustments before the last payment in the State Fiscal Year.
1) In accordance with item 4.c, above, the Department must keep current on reporting
adjustments against federal funds to ensure such adjustments are received in time to be paid
within the grant's payment period.
2) The Department shall review their prior reimbursement claims against payments monthly.
3) Amended expenditure reports must be submitted no later than the next reporting date after the
grant period ends in order to be paid unless an exception is approved by the DPH Budget
Office.
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4) Any overpayments identified by either the State or the Department will be adjusted out of the
next month's claim for reimbursement by the DHHS Controller's Office or by submitting a
check to DHHS for payment if it is the last month of the fiscal year or the federal grant is
closed. There is no provision to carry forward funds from one State Fiscal Year to another;
therefore, any adjustment not included in the June payment (or earlier if the grant period
expires during the State Fiscal Year) should be paid from local funds.
f. The Department shall submit requests for reimbursement for training per Section B. Funding
Stipulations, Paragraph 12, to the Public Health Nursing and Professional Development Unit.
Form 3300—Public Health Nurse Training Activity must be used as the invoice for payment.
g. The Department shall submit requests for reimbursement for training per Section B. Funding
Stipulations, Paragraph 19, to the Environmental Health Section. Form DHHS 4125—
Centralized Intern Training Funds Reimbursement Request must be used as the invoice for
payment.
5. The Department shall maintain expenditures for maternal health, child health and family planning
programs per General Statute 130A-4.1(a). The amount of expenditures shall be calculated by the
State and provided to the Department as described in section G.19 of this Agreement.
D. PERSONNEL POLICIES
1. The Department shall adhere to and fully comply with State or county personnel policies as
applicable.
2. Environmental Health Specialists employed by the Department shall be delegated authority by the
State to administer and enforce State environmental health rules and laws as directed by the State
pursuant to G.S. 130A-4(b). This delegation shall be done according to 15A NCAC 10 .0100.
a. The Department is responsible for sending their newly employed environmental health specialists
(interns)to centralized training within 180 days from date of employment.
b. Arrangements for centralized training for newly-employed environmental health specialists will
be handled by the Education and Training Staff, Division of Public Health.
c. The Department, when contracting with an environmental health specialist employed by another
entity shall be responsible for ensuring that all original documents, correspondence, and other
public records be maintained in the health department using the contractor and all contracts shall
stipulate that the contractor shall be available for consultation to the public being served.
3. The Department shall comply with Minimum Standard Health Department Staffing 10A NCAC
Section 46 .0301(c), and shall ensure that all nursing staff who provide public health services funded
by this Agreement comply with this rule.
E. CONFIDENTIALITY
All information as to personal facts and circumstances obtained by Department personnel in connection
with the provision of services or other activity under this Agreement shall be privileged communication,
shall be held confidential, and shall not be divulged without the client's or responsible person's written
consent, except as may be otherwise required or allowed by law or regulation. Such information may be
disclosed in summary, statistical, or other form which does not directly or indirectly identify particular
individuals. Department employees must sign confidentiality pledges documenting the knowledge of,
and the agreement to maintain, personal and medical confidentiality.
Consolidated Agreement FYI Page 12 of 28
F. CIVIL RIGHTS
1. The Department shall assure that no person, on the grounds of race, color, age,religion, sex, marital
status, immigration status,national origin or otherwise qualified handicapped individual, solely by
reason of his or her handicap (unless otherwise medically indicated),be excluded from participation
in,be denied the benefits of, or be subjected to discrimination under any program or activity covered
by this Agreement.
2. The Department shall complete the attached Federal Certifications: Nondiscrimination; Drug-Free
Workplace Requirements; Environmental Tobacco Smoke; Debarment, Suspension, Ineligibility and
Voluntary Exclusion Lower Tier Transactions; and Lobbying.
3. The American with Disabilities Act 1990 (ADA) makes it unlawful to discriminate in employment
against a qualified individual with a disability and outlaws discrimination against individuals with
disabilities in State and local government services and public accommodations. The Department
certifies that it and its principals and subcontractors will comply with regulations in ADA Title I
(Employment),Title II(Public Services), and Title III(Public Accommodations) in fulfilling the
obligations under this agreement.
G. RESPONSIBILITIES OF THE STATE
1. The State shall provide to the Department regular training, and, upon request, technical assistance in
the preparation of the Consolidated Agreement and Agreement Addenda.
2. The State shall conduct liaison activities with local health departments for general problem solving
and technical support.
3. The State shall provide high-level consultation,technical assistance, and advice to local health
directors. Broad content areas include,but are not limited to:
• Board Relations
• Management Teams/Staffing
• Policy Development
• Program Planning and Implementation
• Quality/Performance Improvement
• General Administrative Consultation, including consultation and technical assistance in
budgeting, fiscal, administrative and management support topic areas.
4. The State shall provide coordination and support for the education and training for the public health
workforce.
5. The State shall provide technical assistance and consultant services, as required, for specific health
program areas, including providing guidance and consultation about specific patient clinical issues,
when requested.
6. The State shall provide course coordination, consultation, and technical assistance on nursing
practice and standards, policies and procedures that cross programs.
7. The State shall provide support and consultation to the public health workforce in local health
departments, including regional public health consultants who offer technical assistance and training
on professional development; program planning, program evaluation and quality assurance; data
collection; and community assessment.
Consolidated Agreement FY15 Page 13 of 28
8. The State shall act as the principal liaison between the public health system and the State's Medicaid
agency on issues related to Medicaid reimbursed services provided by the State and the Department
and shall cooperate with the State Medicaid agency to provide technical assistance, guidance, and
consultation to local health programs to ensure compliance with Medicaid policies and procedures.
9. The State shall design and implement annual cost studies to ensure appropriate cost-based Medicaid
reimbursement.
10. The State shall work with the North Carolina Division of Information Resource Management to
provide automated systems and facilities via the Health Information System(HIS). HIS is currently
used to create and submit Medicaid claims, perform accounts receivables, and to collect other DPH
program-related data from client, service, encounter and other data on behalf of the local health
departments and other public health programs. The State shall provide business and technical support
for the automated systems to the users of this system.
11. The State,shall provide support and consultation to ensure that the Health Information System(HIS)
can generate standard transactions for public health Medicaid claims and for public health claims to
all insurers submitted on behalf of the Department per HIPAA [the Administrative Simplification
provisions of the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-91) subparts
I through N, which define the standards for specific transactions.]
12. The State shall responsibly use data reviewed and received in its role as a public health authority and
health oversight agency while respecting the confidentiality and integrity of the data and securing
and protecting the privacy of individual client health information(see Business Associate Addendum
to this Consolidated Agreement)
13. The State shall provide to the Department"Budgetary Estimates of Funding Allocations"no later
than February 14 of each year to use in preparation of their local budget proposals per current
General Statute. An exception is the Food&Lodging distributions required by G.S. 130A-248(d).
The State shall provide the Food&Lodging funding allocation on the Distribution Spreadsheet
which will accompany the Food& Lodging Agreement Addendum.
14. The Food &Lodging Local Health Department Request for Payment Form(DPH EH 2948) will
accompany the Agreement Addendum and will be provided to the Department no later than
March 30 for the State Fiscal Year in which payment will be made. The State shall disperse Food &
Lodging funds to the Department upon receipt of the executed Agreement Addendum and the signed,
completed, and approved Food &Lodging Local Health Department Request for Payment Form.
15. The State shall provide a"Funding Authorization"to the Department after the receipt of the Certified
State Budget. If funds are restricted through quarterly allotments, the initial Funding Authorization
will only include one-quarter of the annual amount for each specific activity involving State funds.
16. The State shall provide funds to the Department upon receipt of this executed Agreement, the
executed Agreement Addenda, and timely submissions of Expenditure Reports. Payment will be
made to the Department according to the DHHS Controller's Office E-Payment Schedule issued
November or December of each year for the following calendar year.
17. The State shall assist the Department to comply with all applicable laws, regulations, and standards
relating to the activities covered in this Agreement.
Consolidated Agreement FY 15 Page 14 of 28
18. The State reserves the right to conduct reviews, audits, and program monitoring to determine
compliance with the terms of this Agreement and its associated Agreement Addenda.
19. The State shall be assured that the Department maintains expenditures of locally appropriated funds
(MOE) for maternal health, child health, and family planning program activities equal to, or greater
than,that reported on the Staff Time Activity Report for the period beginning July 1, 1984, and
ending June 30, 1985. This figure will be increased annually based on a federally accepted inflation
index (first updated FY 2000-2001 Agreement.)This revised baseline figure will be calculated and
provided to Departments for use in budget preparation.
20. For services of the State Laboratory, the State shall:
a. Provide free or at cost mailers that meet the US Postal Service/DOT UN3373 Biologic substance
shipping and packaging regulations for samples submitted to the State Laboratory only as ordered
via the web-based mailroom ordering system;
b. Assure qualified personnel to process, analyze and report test results;
c. Assure that the State Laboratory maintains CLIA certification;
d. Submit invoices to the local health departments via electronic means; and
e. Collect interest(per N.C.G.S. 147-86.23 and 150-241.1) and a 10% late fee as appropriate;
H. DISBURSEMENT OF FUNDS
1. The State shall disburse funds to the Department on a monthly basis; monthly disbursements for each
program activity will be based on monthly expenditures reported.
2. The State shall disburse Food and Lodging funds in accordance with NCAC TI5A:18A . 2900—
"Restaurant and Lodging Fee Collection and Inventory Program" in the month following receipt of
the signed, completed, and approved Food&Lodging Local Health Department Request for
Payment Form(DPH EH 2948). The exception is that Temporary Food Establishment(TFE) fees
MUST be collected by the Department and must be expended to support the food, lodging, and
institution sanitation programs and activities. Such fees shall be deemed to have been disbursed to
the Department upon their collection and shall be reported in the Aid to County Database on the
ZZZZ line for Activity 874, Category 107—Local Temporary Food Establishment(TFE—State).
3. Total payment by program activity is limited to the total amount of the Funding Authorization and
any revisions received after the initial Funding Authorization notification.
4. Final payments for the State Fiscal Year will be made based on the final monthly Expenditure Report
which is due as delineated per the Controller's Office's Aid-to-Counties Payment Schedule.
I. AMENDMENT OF AGREEMENT
Amendments, modifications, or waivers of this Agreement may be made at any time by mutual consent
of all parties. Amendments shall be in writing and signed by appropriate authorities.
J. PROVISION OF TERMINATION
Either party may terminate this Agreement for reasons other than non-compliance upon 60 days written
notice. If termination should occur, the Department shall receive payment only for allowable
expenditures.
Consolidated Agreement FYI Page 15 of 28
The State may withhold payment to the Department until the State can determine whether the
Department is entitled to further payment or whether the State is entitled to a refund.
K. COMPLIANCE
1. The State shall respond to non-compliance with all terms of this agreement as follows:
a. Upon determination of non-compliance, the State shall give the Department 60 days written
notice to come into compliance. If the deficiency is corrected, the Department shall submit a
written report to the State that sets forth the corrective action taken.
b. If the above deficiencies should not be corrected to the satisfaction of the State after the 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 30 days following temporary suspension of
funding, program funds may be permanently suspended until the Department can provide
evidence that the deficiencies have been corrected.
"d. In the event of the Department's non-compliance with clauses of this Agreement, the State may
cancel, terminate, or suspend this agreement in whole or in part and the Department 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 through K.1.c have been
followed, documented, and have failed to provide a resolution, and (2) all other reasonable
administrative remedies have been exhausted.
2. Monitoring—OMB Circular A-133 (Audits of States, Local Government, and Non-Profit
Organizations) as revised on June 27, 2003 requires that pass-through entities monitor the activities
of their subcontractors as necessary to ensure that federal awards are used for authorized purposes in
compliance with laws, regulations and the provision of contracts or grant agreements and that
performance goals are achieved. North Carolina establishes comparable monitoring requirements for
State funds received by subrecipients in N.C.G.S.158-34,Annual independent audit. rules and
regulations, for local units of government. Also, the State must perform monitoring as required in
the DHHS Policy and Procedure Manual entitled"Monitoring of Programs" dated August 1, 2002
and its Monitoring Plan dated January 2006.
Additionally, the Department is required under Circular A-133, N.C.G.S.143-6.2 and N.C.G.S.159-
34 to perform monitoring of its subrecipients and to maintain records to support such monitoring
activities and results. Accordingly, the Department shall participate fully in monitoring by the State
and shall appropriately monitor its subrecipients to the extent necessary based on the assessed level
of risk.
3. If the Department or the State should be determined out of compliance with the provisions of the
agreement, either party may file a formal appeal with the Office of Administrative Hearings.
L. RECORD RETENTION
In accordance with the State's basic records retention policy, records resulting from these Services shall
not be destroyed, purged or disposed of without the express written consent of the Division during the
period specified in the State's records retention policy and in accordance with state and federal law.
State basic records retention policy requires all grant records to be retained for a minimum of five years
or until all audit exceptions have been resolved, whichever is longer. If the contract is subject to Federal
Consolidated Agreement FY 15 Page 16 of 28
policy and regulations,record retention may be longer than five years since records must be retained for
a period of three years following submission of the final Federal Financial Status Report, if applicable,
or three years following the submission of a revised final Federal Financial Status Report. Also, if any
litigation, claim, negotiation, audit, disallowance action, or other action involving this Contract has been
started before expiration of the five-year retention period described above, the records must be retained
until completion of the action and resolution of all issues which arise from it, or until the end of the
regular five-year period described above, whichever is later. Records for Temporary Assistance for
Needy Families (TANF) and Medicaid and Medical Assistance grants and programs must be retained for
a minimum of ten years.
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.
Orange County Health Department North Carolina Department
of Health and Human Services,Division of
YPubli Health
IL
Health or Human Services Dir or Date Division irector ate
Finance Officer Date
County Official Date
(when locally required)
Consolidated Agreement FYI Page 17 of 28
NORTH CAROLINA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
BUSINESS ASSOCIATE ADDENDUM TO CONSOLIDATED AGREEMENT
This Agreement is made effective July 1, 2014, by and between Orange County Health Department
("Covered Entity") and the North Carolina Department of Health and Human Services,Division of Public
Health ("Business Associate") (collectively the"Parties").
1. BACKGROUND
a. Covered Entity and Business Associate are parties to a Memorandum of Understanding, entitled
"FY 2015 Consolidated Agreement" (the"MOU"), whereby Business Associate agrees to perform
certain services for or on behalf of Covered Entity.
b. Covered Entity is a local health department in the State of North Carolina that has been designated in
whole or in part by as a"covered entity" for purposes of the HIPAA Privacy Rule.
c. The relationship between Covered Entity and Business Associate is such that the Parties believe
Business Associate is or may be a"business associate" within the meaning of the HIPAA Privacy Rule.
d. The Parties enter into this Business Associate Addendum to the MOU with the intention of complying
with the HIPAA Privacy Rule provision that a covered entity may disclose protected health information
to a business associate, and may allow a business associate to create or receive protected heath
information on its behalf, if the covered entity obtains satisfactory assurances that the business associate
will appropriately safeguard the information.
2. DEFINITIONS
Unless some other meaning is clearly indicated by the context, the following terms shall have the following
meaning in this Agreement:
a. "Electronic Protected Health Information" shall have the same meaning as the term"electronic protected
health information" in 45 C.F.R. § 160.103.
b. "HIPAA" means the Administrative Simplification Provisions, Sections 261 through 264, of the federal
Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, as modified and
amended by the Health Information Technology for Economic and Clinical Health("HTTECH")Act,
Title XIII of Division A and Title IV of Division B of the American Recovery and Reinvestment Act of
2009, Public Law 111-5.
c. "Individual" shall have the same meaning as the term"individual" in 45 C.F.R. § 160.103 and shall
include a person who qualifies as a personal representative in accordance with 45 C.F.R. § 164.502(g).
d. "Privacy Rule" shall mean the Standards for Privacy of Individually Identifiable Health Information at
45 C.F.R. Part 160 and Part 164.
e. "Protected Health Information" shall have the same meaning as the term"protected health information"
in 45 C.F.R. § 160.103, limited to the information created or received by Business Associate from or on
behalf of Covered Entity.
f. "Required By Law" shall have the same meaning as the term"required by law" in 45 C.F.R. § 164.103.
g. "Secretary" shall mean the Secretary of the United States Department of Health and Human Services or
the person to whom the authority involved has been delegated.
h. Unless otherwise defined in this Agreement, terms used herein shall have the same meaning as those
terms have in the Privacy Rule.
3. OBLIGATIONS OF BUSINESS ASSOCIATE
a. Business Associate agrees to not use or disclose Protected Health Information other than as permitted or
required by this Agreement or as Required By Law.
M
Consolidated Agreement FY15 Page 18 of 28
b. Business Associate agrees to use appropriate safeguards and comply, where applicable, with subpart C
of 45 C.F.R. Part 164 with respect to electronic protected health information, to prevent use or disclosure
of the Protected Health Information other than as provided for by this Agreement.
c. Business Associate agrees to mitigate,to the extent practicable, any harmful effect that is known to
Business Associate of a use or disclosure of Protected Health Information by Business Associate in
violation of the requirements of this Agreement.
d. Business Associate agrees to report to Covered Entity any use or disclosure of the Protected Health
Information not provided for by this Agreement of which it becomes aware, including breaches of
unsecured protected health information as required by 45 C.F.R. § 164.410.
e. Business Associate agrees, in accordance with 45 C.F.R. § 164.502(e)(1) and § 164.308(b)(2), to ensure
that any subcontractors that create, receive, maintain, or transmit protected health information on behalf
of Business Associate agree to the same restrictions and conditions that apply to Business Associate with
respect to such information.
f. Business Associate agrees to make available protected health information as necessary to satisfy
Covered Entity's obligations in accordance with 45 C.F.R. § 164.524.
g. Business Associate agrees to make available Protected Health Information for amendment and
incorporate any amendment(s)to Protected Health Information in accordance with 45 C.F.R. § 164.526.
h. Unless otherwise prohibited by law, Business Associate agrees to make internal practices,books, and
records relating to the use and disclosure of Protected Health Information received from, or created or
received by Business Associate on behalf of, Covered Entity available to the Secretary for purposes of
the Secretary determining Covered Entity's compliance with the Privacy Rule.
i. Business Associate agrees to make available the information required to provide an accounting of
disclosures of Protected Health Information in accordance with 45 C.F.R. § 164.528.
4. PERMITTED USES AND DISCLOSURES
a. Except as otherwise limited in this Agreement or by other applicable law or agreement, if the MOU
permits, Business Associate may use or disclose Protected Health Information to perform functions,
activities, or services for, or on behalf of, Covered Entity as specified in the MOU, provided that such
use or disclosure:
1) would not violate the Privacy Rule if done by Covered Entity; or
2) would not violate the minimum necessary policies and procedures of the Covered Entity.
b. Except as otherwise limited in this Agreement or by other applicable law or agreements, if the MOU
permits, Business Associate may disclose Protected Health Information for the proper management and
administration of the Business Associate or to carry out the legal responsibilities of the Business
Associate, provided that:
1) the disclosures are Required By Law; or
2) Business Associate obtains reasonable assurances from the person to whom the information is
disclosed that it will remain confidential and will be used or further disclosed only as Required By
Law or for the purpose for which it was disclosed to the person, and the person notifies the Business
Associate of any instances of which it is aware in which the confidentiality of the information has
been breached.
c. Except as otherwise limited in this Agreement or by other applicable law or agreements, if the MOU
permits, Business Associate may use Protected Health Information to provide data aggregation services
to Covered Entity as permitted by 45 C.F.R. § 164.504(e)(2)(i)(B).
d. Notwithstanding the foregoing provisions, Business Associate may not use or disclose Protected Health
Information if the use or disclosure would violate any term of the MOU or other applicable law or
agreements.
Cothsolidated Agreement FY15 Page 19 of 28
5. TERM AND TERMINATION
a. Term.This Agreement shall be effective as of the effective date stated above and shall terminate when
the MOU terminates.
b. Termination for Cause. Upon Covered Entity's knowledge of a material breach by Business Associate,
Covered Entity may, at its option:
1) Provide an opportunity for Business Associate to cure the breach or end the violation, and terminate
this Agreement and services provided by Business Associate, to the extent permissible by law, if
Business Associate does not cure the breach or end the violation within the time specified by
Covered Entity;
2) Immediately terminate this Agreement and services provided by Business Associate, to the extent
permissible by law; or
3) If neither termination nor cure is feasible, report the violation to the Secretary as provided in the
Privacy Rule.
c. Effect of Termination.
1) Except as.:provided in paragraph(2) of this section or in the MOU or by other applicable law or
agreements,upon termination of this Agreement and services provided by Business Associate,for
any reason,Business Associate shall return or destroy all Protected Health Information received from
Covered Entity,or created or received by Business Associate on behalf of Covered Entity. This
provision shall apply to Protected Health Information that is in the possession of subcontractors or
agents of Business Associate.Business Associate shall retain no copies of the Protected Health
Information.
2) In the event that Business Associate determines that returning or destroying the Protected Health
Information is not feasible,Business Associate shall provide to Covered Entity notification of the
conditions that make return or destruction not feasible. Business Associate shall extend the
protections of this Agreement to such Protected Health Information and limit further uses and
disclosures of such Protected Health Information to those purposes that make the return or
destruction infeasible,for so long as Business Associate maintains such Protected Health
Information.
6. GENERAL TERMS AND CONDITIONS
amends and is
a. This Agreement amen p art of the MOU.
b. Except as provided in this Agreement, all terms and conditions of the MOU shall remain-in force and
shall apply to this Agreement as if set forth fully herein.
c. In the event of a conflict in terms between this Agreement and the MOU,the interpretation that is in
accordance with the Privacy Rule shall prevail. In the event that a conflict then remains,the MOU terms
shall prevail so long as they are in accordance with the Privacy Rule.
d. A breach of this Agreement by Business Associate shall be considered sufficient basis for Covered
Entity to terminate the MOU for cause.
Orange County Health Department North Carolina Department
of Health and Human Services,Division of
Public Health
Zw
Health or Human Services ector Date Divisi Da Director e
Consolidated Agreement FY15 Page 20 of 28
STATE CERTIFICATION
Contractor Certifications Required by North Carolina Law
Instructions: The person who signs this document should read the text of the statutes listed below and consult with
counsel and other knowledgeable persons before signing.
• The text of Article 2 of Chapter 64 of the North Carolina General Statutes can be found online at:
http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDFByArticle/Chapter_64/Article_2.pdf
• The text of G.S. 105-164.8(b) can be found online at:
http://www.nega.state.nc.us/EnactedLegislation/Statutes/PDFBySection/Chapter_105/GS_105-164.8.pdf
• The text of G.S. 143-48.5 (S.L. 2013-418, s. 2.(d))can be found online at:
http://www.nega.state.nc.us/Sessions/2013Bills/House/PDF/H786v6.pdf
• The text of G.S. 143-59.1 can be found online at:
http://www.nega.state.nc.us/EnactedLegislation/Statutes/PDFBySection/Chapter_143/GS_143-59.l.pdf
• The text of G.S. 143-59.2 can be found online at:
http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDFBySection/Chapter_143/GS_143-59.2.pdf
• The text of G.S. 147-33.95(g) (S.L. 2013-418, s. 2.(e))can be found online at:
http://www.ncga.state.nc.us/Sessions/2013Bills/House/PDF/H786v6.pdf
Certifications
(1) Pursuant to G.S. 143-48.5 and G.S. 147-33.95(8), the undersigned hereby certifies that the Contractor
named below, and the Contractor's subcontractors, complies with the requirements of Article 2 of Chapter 64
of the NC General Statutes,including the requirement for each employer with more than 25 employees in
North Carolina to verify the work authorization of its employees through the federal E-Verify system."E-
Verify System Link: www.uscis.gov
(2) Pursuant to G.S. 143-59.1(b),the undersigned hereby certifies that the Contractor named below is not an
"ineligible Contractor" as set forth in G.S. 143-59.1(a) because:
(a) Neither the Contractor nor any of its affiliates has refused to collect the use tax levied under Article 5 of
Chapter 105 of the General Statutes on its sales delivered to North Carolina when the sales met one or
more of the conditions of G.S. 105-164.8(b); and
(b) [check one of the following boxes]
PNeither the Contractor nor any of its affiliates has incorporated or reincorporated in a"tax haven
country" as set forth in G.S. 143-59.1(c)(2) after December 31, 2001; or
❑ The Contractor or one of its affiliates has incorporated or reincorporated in a"tax haven country" as
set forth in G.S. 143-59.1(c)(2) after December 31, 2001 but the United States is not the principal
market for the public trading of the stock of the corporation incorporated in the tax haven country.
.*(3)- Pursuant to G.S. 143-59.2(b),the undersigned hereby certifies that none of the Contractor's officers,
directors, or owners (if the Contractor is an unincorporated business entity) has been convicted of any
violation of Chapter 78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act
of 1934 within 10 years immediately prior to the date of the bid solicitation.
Consolidated Agreement FY15 Page 21 of 28
(4) The undersigned hereby certifies further that:
(a) He or she is a duly authorized representative of the Contractor named below;
(b) He or she is authorized to make, and does hereby make,the foregoing certifications on behalf of the
Contractor; and
(c) He or she understands that any person who knowingly submits a false certification in response to the
requirements of G.S. 143-59.1and-59.2 shall be guilty of a Class I felony.
Orange County Health Department
Contractor's Name ff
Signature of Contractor's orized Agent Date
'
C( '( l _, � C'
Printed Name of Contractor's Authorized Agent Title
KZ'Yrl
Signature of Witness Title
i
Printed Name of Witness Date
The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and
date this document immediately thereafter.
Consolidated Agreement FY 15 Page 22 of 28
FEDERAL CERTIFICATIONS
The undersigned states that:
1. He or she is the duly authorized representative of the Contractor named below;
2. He or she is authorized to make,and does hereby make,the following certifications on behalf of the Contractor,as set
out herein:
a. The Certification Regarding Nondiscrimination;
b. The Certification Regarding Drug-Free Workplace Requirements;
c. The Certification Regarding Environmental Tobacco Smoke;
d. The Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier
Covered Transactions; and
e. The Certification Regarding Lobbying;
3. He or she has completed the Certification Regarding Drug-Free Workplace Requirements by providing the addresses
at which the contract work will be performed;
4. [Check the applicable statement]
❑ He or she has completed the attached Disclosure of Lobbying Activities because the Contractor has made,or
has an agreement to make, a payment to a lobbying entity for influencing or attempting to influence an officer
or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with a covered Federal action;
OR
He or she has not completed the attached Disclosure of Lobbying Activities because the Contractor has not
made, and has no agreement to make, any payment to any lobbying entity for influencing or attempting to
influence any officer or employee of any agency,any Member of Congress,any officer or employee of Congress,
or any employee of a Member of Congress in connection with a covered Federal action.
5. The Contractor shall require its subcontractors, if any, to make the same certifications and disclosure.
_/)I)fCt
Signature Title
Orange County Health Department l
Contractor[Organization's] Legal Name Date
[This Certification must be signed by a representative of the Contractor who is authorized to sign contracts.]
I. Certification Regarding Nondiscrimination
The Contractor certifies that it will comply with all Federal statutes relating to nondiscrimination.These include but are not
limited to:(a)Title VI of the Civil Rights Act of 1964(P.L.88-352)which prohibits discrimination on the basis of race,color or
national origin; (b)Title IX of the Education Amendments of 1972, as amended(20 U.S.C. §§1681-1683,and 1685-1686),
which prohibits discrimination on the basis of sex;(c)Section 504 of the Rehabilitation Act of 1973,as amended(29 U.S.C.
§794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42
U.S.C. §§6101-6107),which prohibits discrimination on the basis of age;(e)the Drug Abuse Office and Treatment Act of 1972
(P.L.92-255),as amended,relating to nondiscrimination on the basis of drug abuse;(f)the Comprehensive Alcohol Abuse and
Alcoholism Prevention,Treatment and Rehabilitation Act of 1970(P.L.91-616),as amended,relating to nondiscrimination on
the basis of alcohol abuse or alcoholism;(g)Title VIII of the Civil Rights Act of 1968(42 U.S.C. §§3601 et seq.),as amended,
relating to nondiscrimination in the sale, rental or financing of housing; (h) the Food Stamp Act and USDA policy, which
prohibit discrimination on the basis of religion and political beliefs; and(i)the requirements of any other nondiscrimination
statutes which may apply to this Agreement.
Consolidated Agreement FY15 Page 23 of 28
II. Certification Regarding Drug-Free Workplace Requirements
1. . The Contractor certifies that it will provide a drug-free workplace by:
a. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession or use of a controlled substance is prohibited in the Contractor's workplace and specifying the
actions that will be taken against employees for violation of such prohibition;
b. Establishing a drug-free awareness program to inform employees about:
(1) The dangers of drug abuse in the workplace;
(2) The Contractor's policy of maintaining a drug-free workplace;
(3) Any available drug counseling,rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;
c. Making it a requirement that each employee be engaged in the performance of the agreement be given a copy
of the statement required by paragraph (a);
d. Notifying the employee in the statement required by paragraph(a)that,as a condition of employment under
the agreement, the employee will:
(1) Abide by the terms of the statement; and
(2) Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no
later than five days after such conviction;
e. Notifying the Department within ten days after receiving notice under subparagraph(d)(2)from an
employee or otherwise receiving actual notice of such conviction;
f. Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(2), with
respect to any employee who is 'so convicted:
(1) taking appropriate personnel action against such an employee, up to and including
termination; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program
approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate
agency;and
g. Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs (a), (b), (c), (d), (e), and(f).
2. The sites for the performance of work done in connection with the specific agreement are listed below(list all sites; add
additional pages if necessary):
Street Address No. 1:
City, State,Zip Code:
Street Address No. 2: "76 ji &—(J
City, State,Zip Code: j i d, li 2 1
3. Contractor will inform the Department of any additional sites for performance of work under this agreement.
4. False certification or violation of the certification maybe grounds for suspension of payment,suspension or termination of
grants, or government-wide Federal suspension or debarment. 45 C.F.R. 82.510.
Consolidated Agreement FY15 Page 24 of 28
III. Certification Regarding Environmental Tobacco Smoke
Public Law 103-227,Part C-Environmental Tobacco Smoke,also known as the Pro-Children Act of 1994(Act),requires that
smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely
or regularly for the provision of health,day care,education,or library services to children under the age of 18,if the services are
funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan
guarantee.The law does not apply to children's services provided in private residences,facilities funded solely by Medicare or
Medicaid funds,and portions of facilities used for inpatient drug or alcohol treatment.Failure to comply with the provisions of
the law may result in the imposition of a civil monetary penalty of up to $1,000.00 per day and/or the imposition of an
administrative compliance order on the responsible entity.
The Contractor certifies that it will comply with the requirements of the Act.The Contractor further agrees that it will require
the language of this certification be included in any subawards that contain provisions for children's services and that all
subgrantees shall certify accordingly.
IV. Certification Regarding Debarment,Suspension,Ineligibility and Voluntary Exclusion Lower Tier
Covered Transactions
Instructions
[The phrase"prospective lower tier participant"means the Contractor.]
1. By signing and submitting this document,the prospective lower tier participant is providing the certification set out below.
2. The certification in this clause is a material representation of the fact upon which reliance was placed when this transaction
was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous
certification,in addition to other remedies available to the Federal Government,the department or agency with which this
transaction originate may pursue available remedies, including suspension and/or debarment.
3. The prospective lower tier participant will provide immediate written notice to the person to whom this proposal is
submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or
has become erroneous by reason of changed circumstances.
4. The terms"covered transaction," "debarred,""suspended,""ineligible," "lower tier covered transaction,""participant,"
"person,""primary covered transaction,""principal,""proposal,"and`voluntarily excluded,"as used in this clause,have
the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549,45 CFR Part
76.You may contact the person to whom this proposal is submitted for assistance in obtaining a copy of those regulations.
5. The prospective lower tier participant agrees by submitting this proposal that,should the proposed covered transaction be
entered into, it shall not knowingly enter any lower tier covered transaction with a person who is debarred, suspended,
determined ineligible or voluntarily excluded from participation in this covered transaction unless authorized by the
department or agency with which this transaction originated.
6. The prospective lower tier participant further agrees by submitting this document that it will include the clause titled
"Certification Regarding Debarment,Suspension,Ineligibility and Voluntary Exclusion--Lower Tier Covered Transaction,"
without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered
transaction that it is not debarred,suspended,ineligible,or voluntarily excluded from covered transaction,unless it knows
that the certification is erroneous.A participant may decide the method and frequency by which it determines the eligibility
of its principals. Each participant may,but is not required to,check the Nonprocurement List.
8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in
good faith the certification required by this clause.The knowledge and information of a participant is not required to exceed
that which is normally possessed by a prudent person in the ordinary course of business dealings.
9. Except for transactions authorized in paragraph 5 of these instructions,if a participant in a covered transaction knowingly
enters into a lower tier covered transaction with a person who is suspended,debarred, ineligible,or voluntarily excluded
from participation in this transaction,in addition to other remedies available to the Federal Government,the department or
agency with which this transaction originated may pursue available remedies, including suspension, and/or debarment.
4
Consolidated Agreement FYI Page 25 of 28
Certification
a. The prospective lower tier participant certifies, by submission of this document, that neither it nor its principals is
presently debarred,suspended,proposed for debarment,declared ineligible,or voluntarily excluded from participation in
this transaction by any Federal department or agency.
b. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such
prospective participant shall attach an explanation to this proposal.
V.Certification Regarding Lobbying
The Contractor certifies,to the best of his or her knowledge and belief,that:
1. No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person for
influencing or attempting to influence an officer or employee of any agency,a Member of Congress,an officer or employee
of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract,
continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency,a Member of Congress,an officer or employee of Congress,
_ or an employee of:a Member of Congress in connection with this Federally funded contract, grant, loan, or cooperative
agreement, the undersigned shall complete and submit Standard Form SF-LLL, "Disclosure of Lobbying Activities," in
accordance with its instructions.
3. The undersigned shall require that the language of this certification be included in the award document for subawards at all
tiers(including subcontracts,subgrants,and contracts under grants,loans,and cooperative agreements)who receive federal
funds of$100,000.00 or more and that all subrecipients shall certify and disclose accordingly.
4. This certification is a material representation of fact upon which reliance was placed when this transaction was made or
entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by
Section 1352,Title 31,U.S.Code.Any person who fails to file the required certification shall be subject to a civil penalty
of not less than$10,000.00 and not more than $100,000.00 for each such failure.
VI.Disclosure of Lobbying Activities
Instructions
This disclosure form shall be completed by the reporting entity,whether subawardee or prime Federal recipient,at the initiation
or receipt of a covered Federal action,or a material change to a previous filing,pursuant to title 31 U.S.C. section 1352.The
filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting
to influence an officer or employee of any agency,a Member of Congress,an officer or employee of Congress,or an employee
of a Member of Congress in connection with a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional
information if the space on the form is inadequate.Complete all items that apply for both the initial filing and material change
report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome
of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the
information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last
previously submitted report by this reporting entity for this covered Federal action.
4. Enter the full name,address,city,state and zip code of the reporting entity.Include Congressional District,if known.Check
the appropriate classification of the reporting entity that designates if it is,or expects to be,a prime or sub-award recipient.
Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1 st tier. Subawards include but are not
limited to subcontracts, subgrants and contract awards under grants.
Consolidated Agreement FY15 Page 26 of 28
5. If the organization filing the report in Item 4 checks"Subawardee",then enter the full name,address,city,state and zip code
of the prime Federal recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment.Include at least one organizational level below
agency name, if known. For example,Department of Transportation,United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action(Item 1).If known,enter the full Catalog of
Federal Domestic Assistance(CFDA)number for grants,cooperative agreements, loans, and loan commitments.
8. Enter the most appropriate Federal Identifying number available for the Federal action identified in Item 1(e.g.,Request for
Proposal(RFP)number,Invitation for Bid(IFB)number,grant announcement number,the contract grant,or loan award
number,the application/proposal control number assigned by the Federal agency).Include prefixes,e.g.,"RFP-DE-90-001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency,enter the Federal
amount of the award/loan commitment for the prime entity identified in Item 4 or 5.
10. (a) Enter the full name,address,city,state and zip code of the lobbying entity engaged by the reporting entity identified in
Item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s)performing services,and include full address if different from 10(a).Enter Last
Name,First Name and Middle Initial(MI).
11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity(Item 4)to the lobbying
entity (Item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that
apply. If this is a material change report,enter the cumulative amount of payment made or planned to be made.
12. Check the appropriate boxes. Check all boxes that apply.If payment is made through an in-kind contribution,specify the
nature and value of the in-kind payment.
13. Check the appropriate boxes. Check all boxes that apply. If other, specify nature.
14. Provide a specific and detailed description of the services that the lobbyist has performed,or will be expected to perform,
and the date(s)of any services rendered. Include all preparatory and related activity,not just time spent in actual contact
with Federal officials.Identify the Federal official(s)or employee(s)contacted or the officer(s),employee(s),or Member(s)
of Congress that were contacted.
15. Check whether or not a SF-LLL-A Continuation Sheet(s) is attached.
16. The certifying official shall sign and date the form,print his/her name,title,and telephone number.
Consolidated Agreement FY 15 Page 27 of 28
Disclosure of Lobbying Activities
(Approved by OMB 0348-0046)
Complete this form to disclose lobbying activities pursu ant to 31 U.S.C. 1352
1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:
❑ a. contract ❑ a. Bid/offer/application ❑ a. initial filing
❑ b. grant ❑ b. Initial Award ❑ b. material change
❑ c. cooperative agreement ❑ c. Post-Award
❑ d. loan For Material Change Only:
❑ e. loan guarantee
❑ f. loan insurance Year Quarter
Date of Last Report:
4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is Subawardee, Enter Name
❑ Prime and Address of Prime:
❑ Subawardee Tier ,(if known)
Congressional District if known Congressional District if known
6. Federal Department/Agency: 7. Federal Program Name/Description:
CFDA Number(if applicable)
8. Federal Action Number(if kno Award Amount(if known) :
10. a. Name and Address of Lobt b. Individuals Performing Services(including address if
(if individual, last name, firs, different from No. 10a.)(last name, first name, MP:
attach Continuation Sheet(s attach Continuation Sheets SF-LLL-A,if necessary)
11. Amount of Payment(check all i Type of Payment(check all that apply):
$ a. retainer
❑ b. one-time fee
12. Form of Payment(check all that apply): ❑ c. commission
❑ d. contingent fee
❑ a. cash ❑ e. deferred
❑ b. In-kind;specify: Nature ❑ f. other; specify:
Value
14. Brief Description of Services Performed or to be Performed and Date(s)of Services, including officer(s),employee(s),or
Member(s)contacted,for Payment Indicated in Item 11(attach Continuation Sheet(s)SF-LLL-A, if necessary):
15. Continuation Sheet(s)SF-LLL-A attached: ❑Yes ❑ No
16. Information requested through this form is authorized by Signature:
title 31 U. S.C. section 1352.This disclosure of lobbying
activities is a material representation of fact upon which
reliance was placed by the tier above when this transaction Print Name:
was made or entered into.This disclosure is required
pursuant to 31 U.S. C. 1352.This information will be Title:
reported to the Congress semi-annually and will be
available for public inspection.Any person who fails to file Telephone No: Date:
the required disclosure shall be subject to a civil penalty of
not less than$10,000 and not more than$100,000 for
each such failure.
Authorized for Local Reproduction
mm 1 11 � I I: 1-m-, Standard Form-LLL
Public reporting burden for this collection of information is estimated to average 30 minutes per response,including time for reviewing instructions,searching existing data
sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.Send comments regarding the burden estimate or any other
aspect of this collection of information,including suggestions for reducing this burden,to the Office of Management and Budget,Paperwork Reduction Project(0348-0046),
Washington,D.C.20503
Consolidated Agreement FY15 Page 28 of 28
Maintenance of Effort Schedule- local health departments Citation: 130A-4.1; Consolidated Agreement clause G(19)
Updated Updated
Local Health MOE Baseline Baseline Local Health MOE Baseline Baseline
Department 1985 CPI *2014-15 Department 1985 CPI*2014-15
Alamance $215,751 $468,181 Jackson $11,822 $25,653
Albemarle District $47,803 $103,733 Johnston $196,475 $426,351
Alexander $33,308 $72,278 Jones $22,851 $49,587
Anson $27,096 $58,798 Lee $57,470 $124,710
Appalachian District $56,663 $122,958 Lenoir $120,667 $261,847
Beaufort $63,029 $136,772 Lincoln $78,475 $170,291
Bladen $19,564 $42,453 Macon $27,277 $59,191
Brunswick $122,285 $265,358 Madison $55,718 $120,909
Buncombe $166,104 $360,445 MTW District $97,748 $212,113
Burke $83,689 $181,606 Mecklenburg, $375,712 $815,295
Cabarrus $250,406 $543,381 Montgomery $24,389 $52,924
Caldwell $59,226 $128,520 Moore $36,243 $78,648
Carteret $16,843 $36,549 Nash $124,412 $269,974
Caswell $31,809 $69,026 New Hanover $128,664 $279,200
Catawba $127,542 $276,766 Northampton $71,678 "$155,541
Chatham $50,121 $108,763 Onslow $63,147 $137,029
Cherokee $11,705 $25,400 Orange $258,834 $561,670
Clay $1,580 $3,428 Pamlico $11,162 $24,222
Cleveland $243,917 $529,300 Pettder $
Columbus $85,858 $186,312 Person $42,878 $93,045
Craven $113,647 $246,614 Pitt $164,404 $356,757
Cumberland $458,294 $994,497 Randolph $81,302 $176,425
Dare $22,597 $49,036 Richmond $50,348 $109,256
Davidson $100,199 $217,431 Robeson $225,422 $489,165
Davie $38,546 $83,646 Rockingham $157,370 $341,493
Duplin $84,922 $184,280 Rowan $178,268 $386,841
Durham $439,506 $953,728 RPM District $48,315 $104,845
Edgecombe $157,941 $342,732 Sampson $37,229 $80,786
Forsyth $508,138 $1,102,660 Scotland $12,388 $26,881
Franklin $65,012 $141,076 Stanly $23,625 $51,266
Gaston $342,765 $743,800 Stokes $41,687 $90,461
Graham $3,949 $8,569 Surry $49,658 $107,758
Granville-Vance District $170,160 $369,247 Swain $10,674 $23,162
Greene $78,527 $170,404 Toe River District $49,658 $107,758
Guilford $1,605,509 $3,483,955 Transylvania $66,417 $144,125
Halifax $118,024 $256,113 Union $25,573 $55,493
Harnett $69,651 $151,142 Wake $758,321 $1,645,557
Haywood $82,684 $179,424 Warren $8,551 $18,555
Henderson $109,750 $238,158 Wayne $271,847 $589,908
Hertford $3,517 $7,631 Wilkes $73,909 $160,382
Hoke $25,698 $55,765 Wilson $59,617 $129,370
Hyde $12,355 $26,810 Yadkin $20,687 $44,891
Iredell $36,698 $79,636
TOTAL: $10,583,276 $22,965,709
Notes: Adjusted for inflation, 1985 through 2013, based upon changes in Consumer Price Index(CPI).
Adjustment factor equals 217%.
Reference for calculating CPI changes: http://www.bis.gov/data/inflation calculator.htm