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Home My WebLink About1995 S Amendment to Consolidated Contract between The State of North Carolina and Orange County Health Department vra - t_ State of North Carolina Department of Environment, Health and Natural Resources 4 • • General Services Division James B. Hunt,Jr., r Jonathan B. Howes,, Secretary C C F1 Laird Davison, Director AMENDMENT NO. 2 ORANGE COUNTY DECEMBER 5, 1995 MEMORANDUM TO: Local Health Directors FROM: Laird A. Davison, Director Division of General Services SUBJECT: Activity Budgets - FY 96 Enclosed please find your copies of the approved activity budgets) listed below, which are to be included as part of your original consolidated contract. This notification not only serves as a transmittal for the activity budget(s) but also as an amendment to the consolidated contract. Note that all provisions and clauses set forth in the consolidated contract apply to these activities. Please call Dianna Wentz at (919) 715-3898 if you have any questions. ACTIVITIES ' FAMILY PLANNING Enclosures P.O. Box 27687,Raleigh,North Carolina 27611-7687 Telephone 919-733-9746 LOCAL HEALTH DEPARTMENT BUDGET Revision Number N.C.Department of Environment _ � D Health,and Natural Resources v 1�G Division of General Services 14 Division of Maternal and Child Health P.O.Number SFY 1996 7 / 95 6 / 96 96 5151 068 Effective Date Termination Date Contract Number Contractor: Orange County Health Department Activity Family Planning Project Director. Daniel B.Reimer Total Budget. S $574,659 Item Description CLASSIFICATION ITEM AMOUNT STATE EXPENDITURES: E Salaries and Fringe Benefits SA/FR 1000 122,262 X Operating Expenses OP EXP 2000 P Purchase of Equipment EQUIP 5000 E General Contracted or N Purchased Services GENERAL 6100 D School Health �1t* I Clinician CLN 6863 T ` U Laboratory R Pharmacy Services 1-01 W 'mills'loll II '1 S Transfer TXIX Subtotal State Expenditures: $ 122,262 LOCAL EXPENDITURES: LOCAL EXP 9000 452,397 TOTAL EXPENDITURES-Equal to Total Receipts $ 574,659 LOCAL FUNDS: R Appropriation APPROP 101 407,039 E TXIX T= 102 33,118 C Other Receipts OTHR REC 103 12,240 E Subtotal Local Funds $ 452,397 STATE/FEDERAL/SPECIAL FUNDS: 16C 1 536900100 1515515 x x x x P ————— [22,162 T HMHC FUNDS: 1515-6100-5151-XXXX S NON HMHC FUNDS: r 00,100 �k�� a Subtotal State/Federal/Special $ �1 122,262 TOTAL RECEIPTS-E to Total Expenditures $ 574,659 :De� �L cal Authorized Official Signature BmchHnd Divisi n/Section Signature Date lr.27 Finance Officer Signature ate Ao ftnt Fiscal Management Signature Date wor DEHNR 2943(Revised 1'93) 0--I 5e .Di—n)R-"1194) N.C. Department of Environment, Health and Natural Resources Page 1 of 5 Division of General Services FY 1995-96 CONTRACT ADDENDUM Women's Preventive Health Branch 96 51510 068 Office, Section, or Branch Contract Number Orange Family Planning Contractor Activity Suggested order of completion of data items: 1.a., I.b., I.c., 1., 2., 3., and 4. 1, 1300 Total persons will be served (sum of 1.a., I.b., and 1.c.). HSIS Report, IBS 085, Pat. Char., Row "P, " "Total" column. a. 380 Persons will be served, aged 19 or less. HSIS Report, HBS 085, Pat. Char. Report, Row "P, " third through fifth columns. b, 660 Persons will be served, at or below 150% of poverty, aged 20-44. HSIS Report, HBS 085, Pat. Char. Report, Rows "H.1. and H.2., " sum of sixth through tenth columns. C. 260 Other persons will be served. HSIS Report, HBS 085, Row "H.3., " sum of sixth through tenth columns. 2. 13 % Percent of persons aged 19 or less will be served. (See attached need table for figure to use as denominator, item La., as numerator). HSIS Report HBS 084, Evaluation Report, Item "I.A. " 3. 12 % Percent of persons at or below 150% of poverty, aged 20-44, will be served. (See attached need table for figure to use as denominator, item Lb., as numerator). HSIS Report HBS 084, Evaluation Report, Item "I.B. " 4, 80 Percent of caseload from target population (item 1.a. + item 1.b., divided by item 1). HSIS Report, HBS 084, Evaluation Report, Item "XI. " 5. 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. Reviewed by DEHNR 3300 (Revised 2195) ` -- 3 General Services Division (Review 9%95) Initials Date N.C. Department of Environment, Health and Natural Resources Page 1 of 5 Division of General Services FY 1995-96 CONTRACT ADDENDUM Women's Preventive Health Branch 96 51510 068 Office, Section, or Branch Contract Number Orange Family Planning Contractor Activity Suggested order of completion of data items: La., Lb., I.c., 1., 2., 3., and 4. 1. 1300 Total persons will be served (sum of 1.a., 1.b., and 1.c.). HSIS Report, HBS 085, Pat. Char., Row "P, " "Total" column. a. 380 Persons will be served, aged 19 or less. HSIS Report, HBS 085, Pat. Char. Report, Row "P, " third through fifth columns. b. 660 Persons will be served, at or below 150% of poverty, aged 20-44. HSIS Report, HBS 085, Pat. Char. Report, Rows "H.1. and H.2., " sum of sixth through tenth columns. C. 260 Other persons will be served. HSIS Report, HBS 085, Row "H.3., " sum of sixth through tenth columns. 2. 13 % Percent of persons aged 19 or less will be served. (See attached need table for figure to use as denominator, item 1.a., as numerator). HSIS Report HBS 084, Evaluation Report, Item "I.A. " 3. 12 % Percent of persons at or below 150% of poverty, aged 20-44, will be served. (See attached need table for figure to use as denominator, item 1.b., as numerator). HSIS Report HBS 084, Evaluation Report, Item "I.B. " 4, 80 Percent of caseload from target population (item 1.a. + item 1.b., divided by item 1). HSIS Report, HBS 084, Evaluation Report, Item "XI. " 5. 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. Reviewed by DEHNR 3300 (Revised 2/95) "'L'57 3 J-- General Services Division (Review 9/95) Initials Date N.C. Department of Environment, Health and Natural Resources Page 2 of 5 Division of General Services FY 1995-96 CONTRACT ADDENDUM Women's Preventive Health Branch 96 51510 068 Office, Section, or Branch Contract Number Orange Family Planning Contractor Activity b. Tracking mechanism 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. Follow-up of missed appointments. e. Follow-up and protocol for clients wanting permanent contraception. f. Offering HIV-STD and Hepatitis B prevention method (condoms and spermicide) to clients who have high-risk behaviors (use high-risk behaviors for HIV as defined by HIV/STD Prevention Program). g. Identification of high risk contraceptors. h. Counseling family planning postpartum clients to delay pregnancy for at least 12 months after delivery. 6. Persons enrolled in the local agency's family planning program will be provided the following services as documented in their medical records: a. All patients will receive an initial or updated history which includes: medical; social; family; surgical, menstrual, douching, genetics, contraception, drugs/medication, obstetrical and immunization (Td, Rubella) on initial or complete visits. b. All patients will receive a physical examination on initial or complete visits which includes: weight, height (if growth not complete), blood pressure, breasts, heart, lungs, abdomen, extremities, complete pelvic examination and rectal examination, if indicated. c. Limited revisits include reason for visit, method specific history, weight, blood pressure and education and counseling if indicated. i jReviewed-by DEHNR 3300 (Revised 2!95) 0) —.S 7—/ 5 S General Services Division (Review 9!95) Initials Date N.C. Department of Environment,Health and Natural Resources Page 3 of 5 Division of General Services FY 1995-96 CONTRACT ADDENDUM Women's Preventive Health Branch 96 51510 068 Office, Section, or Branch Contract Number Orange Family Planninq Contractor Activity 7. The following tests will be obtained on all initial or complete visits and documented in the medical record unless a normal result has been obtained in the last six months: a. Hematocrit or hemoglobin b. Urinalysis for sugar and protein c. Pap smear d. Gonorrhea culture e. Syphilis Serology (required on initial visits, required on complete visits in the presence of a positive gonorrhea culture or on other visits as indicated by the clinician). Note: HIV testing is recommended in the presence of a positive syphilis serology. 8. Immunity Assessment for Rubella & Tetanus-diphtheria will be documented in the patient's record on all initial and complete visits: a. Rubella assessment includes documentation of Rubella vaccine or laboratory test indicating immunity. Once immunity is documented, no future assessments are needed. If no documentation of vaccine or immunity, Rubella vaccine is given to non-pregnant clients (see Medical Guidelines). b. Tetanus-diphtheria assessment includes documentation of Tetanus-diphtheria vaccine. Assessment on annual visits is not required if Td vaccine was given and documented within the last ten years. If no documentation, Td vaccine should be given (See Medical Guidelines). 9. Education and Counseling: a. Client received information on all contraceptive methods and their risks and benefits (including natural family planning and abstinence for teens). See Medical Guidelines. Reviewed by DEHNR 3300 (Revised 2/95) General Services Division (Review 9/95) Initials ' Date N.C. Departrnent of Environment,Health and Natural Resources Page 4 of 5 Division of General Services FY 1995-96 CONTRACT ADDENDUM Women's Preventive Health Branch 96 51510 068 Office, Section, or Branch Contract Number ' Orange Family Planning Contractor Activity b. Client received additional information specific to the contraceptive method(s) to be used. c. Education in HIV infection and AIDS including counseling on risk assessment, HIV prevention and how to get tested (on site or referral) was provided. d. Breast self examination was taught or education reviewed. e. Required education offered outside the family planning clinic is assessed and documented and updated as appropriate according to the needs of the individual family planning patient. f. There is evidence that significant abnormal clinical and laboratory findings were discussed with client. 10. 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. Any individual risk to contraceptive method was identified on the method specific consent form. c. Minors under 18 years of age were counseled about the importance of discussing birth control needs with parent(s) and minor signs form. d. Information about emergency and after-hour services was provided. 11. Screening, Diagnosis, Treatment and Follow-up Services There is evidence in the record that: a. Significant problems are identified and documented. j b. Problems, conditions and abnormal findings are appropriately followed. Reviewed by DEHNR 3300 (Revised 2/95) r —S �' /3_ �7 3 General Services Division (Review 9195) Initials Date N.C. Department of Environment,Health and Natural Resources Page 5 of 5 Division of General Services FY 1995-96 CONTRACT ADDENDUM Women's Preventive Health Branch 96 51510 068 Office, Section, or Branch Contract Number Orange Family Planning Contractor Activity 12. The lowest level provider of care on all Initial and Complete Visits for oral contraceptive, IUD, Norplant and Depo Provera users was a physician or physician extender (nurse practitioner, CNM or physician assistant). Reviewed by DEHNR 3300 (Revised 2/95) a o;, Initials Date