HomeMy WebLinkAboutAgenda - 04-20-1993 - III-A I
ORANGE COUNTY
BOARD OF COMMISSIONERS
Action Agenda
Item No. _/°,
ACTION AGENDA ITEM ABSTRACT
Meeting Date: April 20, 1993
SUBJECT: 1993-94 Contract Between orange County Health Department and the N. C.
Department of Environment Health and Natural Resources
DEPARTMENT: HEALTH PUBLIC HEARING: Yes X No
ATTACHMENT(S) : INFORMATION CONTACT:
HEALTH DIRECTOR'S OFFICE X2411
12-Page Contract
Federal Assurance Agreements
Local Health Department Budget Pages TELEPHONE NUMBER:
Hillsborough - 732-8181
Chapel Hill - 968-4501
Mebane - 227-2031
Durham - 688-7331
PURPOSE: The attached contract stipulates the State grant support in the
amount of four hundred and thirty two thousand, and seven hundred
and seventy-seven dollars ($432,777.00) , a 2.5% increase over the
previous year, for the following programs in FY 1993-94:
General Child Health
Transfer of Escrow Child Service Coordination
AIDS (federal) MCH Block Grant Nutrition
Tuberculosis Adult Health
Communicable Disease Health Promotion
Maternal Health Breast and Cervical Cancer
Family Planning
CSHS Orthopedic
The above-mentioned programs, and associated revenue, have been
included in the proposed budget.
BACKGROUND: Each year the State contracts with the Health Department to render
specified, mandated services. The attached contract outlines the
terms and dollar amounts of grant support for each program
activity as well as local allocations and revenues which support
these mandated services. Minor changes in the contract terms are
acceptable and do not substantially alter the working
relationship.
RECOMMENDATION(S) : Approve the contract, subject to-the endorsement of the
County Attorney and County Purchasing Director, and
authorize the Chair to sign the contracts, assurances, and
budget pages.
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Page 1 of 12
1993 1994
CONSOLIDATED CONTRACT
BETWEEN
THE STATE OF NORTH CAROLINA
AS REPRESENTED BY
THE DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
(Hereinafter called the "State")
AND
ORANGE COUNTY HEALTH DEPARTMENT
(Name of Local Health Department)
(Hereinafter called the "Department")
FOR THE PURPOSE OF
MAINTAINING AND STIMULATING THE ADVANCEMENT OF HEALTH IN NORTH CAROLINA
This Contract Shall Cover a Period From
July 01, 1993 to June 30, 1994
NOW, THEREFORE, the State and the Department agree that the provisions and clauses
herein set forth shall be incorporated in and constitute the terms and conditions
applicable for the following activities involving State funding. (State funding
or funds means state, federal, and/or special funding or funds throughout this
contract.)
ACTIVITY ACTIVITY
General Adult Health
Transfer of Escrow Health Promotion
AIDS (federal) Breast and Cervical Cancer
Tuberculosis
Communicable Disease
Maternal Health
Family Planning
Child Service Coordination
CSHS Orthopedic
Child Health
NCH Block Grant Nutrition
DEHNR 2946 (Revised 02/93)
Division of General Services (Review 02/94)
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Page 2 of 12
•
A. WORK TO BE PERFORMED
1. The Department shall perform activities in compliance with applicable
program rules contained in the North Carolina Administrative Code as
well as all applicable Federal and State laws and regulations.
2. The Department shall submit for approval the required Program Contract
Addenda for State funded budgets.
3. The Department shall submit completed reports as required by budgeted
funding criteria and as specified in Listing of Required Fiscal and
Statistical Reports (Addenda 1) .
4. The Department shall administer and enforce all rules which have been
adopted by the Commission for Health Services or approved by the State
and adopted by the Local Board of Health.
5. The Department shall provide to the State copies of rules adopted by the
Local Board of Health pursuant to G.S. 130A-39 and Public Health
Ordinances adopted by the County Commissioners. Copies of existing
rules and ordinances shall be submitted to the State Health Director
within 45 days. Thereafter, copies of rules adopted shall be submitted
within 30 days of adoption.
6. The Department shall provide to the State a Community Diagnosis
Prioritization of Problems every biennium. The Department shall also
provide a Community Diagnosis narrative, if completed.
B. FUNDING STIPULATIONS
1. Funding for this contract is subject to the availability of State,
Federal, and special funds for the purpose set forth in this Contract.
2. During the period of this Contract, the Department shall not use State.
Federal or Special Project funds received under this Contract to reduce
locally appropriated funds as reflected in the Local Health Department
Budgets.
3. The Department shall not use personal health program funds to support
environmental health personnel nor use environmental health program
funds to support personal health programs. Fees generated by the Food
and Lodging fees collection program may only be used to support
Environmental Health activities.
4. The Department shall comply with Standards for Mandated Public Health
Services, 15A NCAC 25, Section .0200; and Administrative Procedures
Manual for Federal Block Grant Funds, 1 NCAC 33, Sections .0100 - .1502.
5. The Department shall maintain employee • time records for the contract
period documenting the portion of time that each employee attributes to
each activity when State funds are budgeted for the support of employee
salaries and fringe benefits. The percentage of time each employee
spends in each activity shall be converted to dollars based upon the
employees' salary and benefits. These records will Serve to document
salary and benefit expenditures reported on Forms DEHNR 2949 and DEHNR
2950, and compliance with Chapter 479, Section 99 of the 1985 Session
Laws.
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Page 3 of 12
6. The Department participating in Medicaid Reimbursement shall:
a. Comply with the terms of the Interagency Agreement between the
Division of Medical Assistance, Department of Human Resources and
the Department of Environment, Health, and Natural Resources and
the Provider Participation Agreement effective October 1, 1992 and
any subsequent approved addenda or new Agreement approved and
established during the period of this contract.
b. Make every reasonable effort to collect its cost in providing
services, for which Medicaid reimbursement is sought, through
public or private third party payors except where prohibited by
Federal regulations or State law. No one shall be refused services
solely because of an inability to pay. All payments from persons.
and public or private third party payors. shall be utilized for the
activity that generated the revenue and shall not reduce or replace
locally appropriated funds during the period of this Contract. All
fees collected shall be used in the current year or succeeding
fiscal years. Use of program income generated by the expenditure
of Federal categorical funds will be governed by applicable Federal
regulations, including but not limited to, 45 CFR 74.
7. The Department agrees to match the expenditure of Adolescent Pregnancy
Prevention Project grant funds with any in-kind source or newly
generated funds, public or private available to the project. Payment
from the State shall be in accordance with Chapter 689, Section 174 of
the 1991 Session Laws.
8. Funds budgeted for Adolescent Health Activities shall not be expended
for dues or out-of-state travel unless prior approval is received from
the program.
9. Subject to the approval of the appropriate Division, a local health
department may seek reimbursement for services covered by a program
operating under 15A NCAC 24A rules when those services are not supported
by other state or federal funds. All payment program rules and
procedures as specified in the Purchase of Medical Care Services manual
must be followed.
10. Subject to the availability of funds and approval of the Office of
Public Health Nursing, a local health department may request
reimbursement for:
a. Nursing service personnel participating in the Introduction to
Principles and Practices of Public Health and Public Health Nursing
course (2 week course) and the Public Health Nurse Supervisors
Training Course (4 week course) . Reimbursement is limited to no
more than $200.00 per week per participant upon successful
completion of the course.
b. Community Health Assistants and Staff Nurse attending certain
pre-approved Continuing Education courses offered by the Office of
Public Health Nursing. Reimbursement is limited to $25.00 per
participant per event.
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Page 4 of 12
11. The Department shall have an annual audit performed in accordance with
The Single Audit Act of 1984 as implemented by OMB Circular A-128.
Audit findings and resolution of said findings shall be handled by the
Division of Fiscal Management, Budget & Analysis Section.
12. Equipment is a type of fixed asset consisting of specific items of
property that: (1) are tangible in nature; (2) have a life longer than
one year; and (3) have a significant value.
a. For Budgeting and Reporting Purposes
1. Equipment purchases meeting the above definition and having an
acquisition cost of $500 or more must be budgeted and reported
in Line Item 5000.
b. For Inventory Purposes
1. Equipment must be accounted for in accordance with Local
Government Accounting System Procedure No. 15.
2. Women, Infants and Children Program
All equipment with an acquisition cost of $500.00 or more must
be inventoried with the Division of Maternal and Child Health.
c. For Prior Approval Purposes
1. Equipment purchased or equipment leased where there is an
option to purchase with State/Federal funds must receive prior
written approval from the appropriate Division, Section, or
Branch when the acquisition cost exceeds $500.00.
2. Women, Infants and Children Program
All medical equipment and computer equipment, regardless of
cost and all other equipment with an acquisition cost of
$500.00 or more must receive prior approval from the program
office. '
3. Equipment purchased with program income generated by the
expenditure of Title X Family Planning Funds with an
acquisition cost of $500.00 or more must receive prior written
approval from-the program.
C. FISCAL CONTROL
1. The Department shall comply with the Local Government Budget and Fiscal
Control Act, North Carolina General Statute Chapter 159, Article 3.
a. The Department shall maintain a purchasing and procurement system
in accordance with generally accepted accounting practices and
procedures set forth by the Local Government Commission.
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Page 5 of 12
b. The Department shall execute written agreements with all parties
who invoice the Department for payment for the provision of
services to patients.
c. When subcontracting, the following conditions must be met:
1. The Department is not relieved of any of the duties and
responsibilities provided in this contract.
2. The subcontractor will agree to abide by the standards
contained herein or to provide such information as to allow
the Department to comply with these standards.
3. The subcontractor will agree to allow state and federal
authorized representatives access to any records pertinent to
its role as a subcontractor of the Department.
4. The Department will make available to the State upon request a
copy of subcontracts supported with State/Federal funds.
d. The Department shall receive prior approval from the State when
subcontracting for services in the Women, Infants and Children
Program.
e. The . Department shall retain all budgets, budget revisions,
contracts, contract addenda, and financial records in accordance
with the current Records Disposition Schedule for County and
District Health Departments issued by the Division of Archives and
History, Department of Cultural Resources.
2. The Department shall prepare and maintain a budget for each activity
covered by this contract in a manner consistent with instructions
provided with Forms DEHNR 3370 (Revised 2/93) and DEHNR 2948 (Revised
2/93) .
a. The Department shall prepare budget revisions for prior approval of
the State when those revisions are in the School Health Program
(Line Item 6200) .
b. The Department shall prepare budget revisions for prior approval of
the State when State funds will be increased or decreased.
c. The Department shall prepare an informational copy for the State of
all other budget revisions when proposed expenditures exceed the
line amount budgeted.
d. The Department shall submit all revisions prior to the end of the
term specified in this Contract. Budget revisions received by the
State after the end of to contract period will be returned without
action.
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Page 6 of 12
3. The Department shall observe the following conditions when budgeting and
reporting earned income revenues (escrow) :
a. All earned income must be budgeted in the program where earned,
except that income earned by a program which has no activity budget
can be budgeted in a program approved by the State.
b. Line Item 9000 in the program budget shall be used to budget TXIX
fees.
c. Line Item 102 in the program budget shall be used to report TXIX
fees received which are used to support TXIX expenditures shown in
Line Item 9000.
d. Activity budgets that do not include an amount of TXIX funds
sufficient to meet the requirements of 3g. will not be approved by
the State.
e. Line Item 6864 in Activity 4125, Transfer of Escrow Funds, only
shall be used to show anticipated TXIX earnings.
f. A local account shall be maintained for unbudgeted/unreported TXIX
fees transferred to the Department. Accounts shall be maintained
in sufficient detail to identify the program source generating the
fees.
g. Funds carried forward to fiscal year 1994 may not exceed Title XIX
funds earned during fiscal year 91-92 or $10,000.00 whichever is
greater.
4. The Department shall submit a quarterly report of actual receipts and
expenditures of the Department according to instructions provided with
Expenditure Reports, Form DEHNR 2949 (Revised 8/92) and Form DEHNR 2950
(Revised 2/93) .
a. The Department shall submit quarterly expenditure reports to the
State within 45 days from the end of the reporting quarter.
b. The Department shall submit the final Expenditure Report to the
State within 45 days after the end of the contract period.
c. The Department shall submit amended or corrected expenditure
reports within six -(6) months after the end of the contract period.
Any such reports must be prepared for the specific quarter to be
amended or corrected. Reports received after December 31 will be
returned without action.
d. The Department shall refund to the State all State funds not
supported by expenditures within 45 days after notification of
overpayment. When payment is not received by the State within 45
days, future payments to the Department may be reduced by the
amount due or payments may be suspended until the refund is
received by the State.
e. The Department shall follow Women, Infants and Children Program and
other Federal program reporting requirements when they differ from
those stated above.
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Page 7 of 12
f. The Department shall submit monthly WIC expenditure reports to the
State no later than the 8th of the following month.
g. Reimbursement of WIC approved expenditures for July, August, and
September cannot exceed one-fourth of the total budget for the
contract period.
h. The Department shall submit monthly Maternal Outreach expenditure
reports to the state no later than the 15th of the following month.
i. The Department shall submit expenditure reports for Mosquito
Control activity in accordance with 15A NCAC 18B, Sections .0104
and .0107.
j . The Department shall submit request for payment for services
provided under 1SA NCAC 24 A rules to the Claims Processing Unit,
DEHNR Division of Fiscal Management.
k. The Department shall submit request for reimbursement for nurse
training to the Office of Public Health Nursing. Form DEHNR 3300 -
Public Health Nurse Training Activity must be used as the invoice
for payment.
5. The Department shall submit on an annual basis Staff Time Activity
Report, DEHNR_ 3389. The report shall accompany the final expenditure
report and must be received by the State within 45 days after the end of
the contract period.
6. For Adolescent Health Activity, the Department agrees to (1) have
responsibility for the immediate direction, supervision and evaluation
of the activities supported through the contract, which will be
conducted in accordance with the amended plan/update submitted by the
Department; (2) submit any media material in writing to the Division of
Maternal and Child Health for approval prior to release to the public;
(3) submit a mid-year report on progress in meeting project objectives
by February 1, 1994; (4) submit an evaluation report demonstrating
achievement of stated goals no later than August 16, 1994.
D. PERSONNEL POLICIES
The Department shall adhere to and fully comply with State personnel
policies as found in North Carolina General Statute, Chapter 126, and 1
NCAC 8. Such policies include, but are not limited to, the following:
1. Equal employment opportunity;
2. Affirmative action;
3. Policies for local government employment subject to the State Personnel
Act;
4. "Local Classification and Salary Range";
5. "Compensation Policy for Local Competitive Services Employees"; and
6. "Recruitment and Selection Policy and Procedures";
Page 8 of 12 9
7. Environmental Health Specialists employed by the Department shall be
delegated authority by the State to administer and enforce State
environmental health rules and laws as directed by the State pursuant to
G.S. 130A-4(b) . This delegation shall be done according to 15A NCAC 18A
.2300.
a. Local health departments are responsible for sending their
newly-employed environmental health specialists (interns) to 40
days of initial field training/orientation at designated training
centers within 90 days from date of employment.
b. Arrangements for initial field training/orientation including
designation of the training center for newly-employed environmental
health specialists will be handled by the Environmental Health
Services Section, Division of Environmental Health.
E. CONFIDENTIALITY
All information as to personal facts and circumstances obtained by Department
personnel in connection with the provision of services or other activity .
under this Contract shall be privileged communication, shall be held
confidential, and shall not be divulged without the responsible person's
written consent except as may be otherwise required by applicable law or
regulation. Such information may be disclosed in summary, statistical, or
other form which - does not directly or indirectly identify particular
individuals.
F. CIVIL RIGHTS
1. The Department shall assure that no person, on the grounds of race,
color, age, religion, sex, marital status, or national origin (unless
otherwise medically indicated) or otherwise qualified handicapped
individual solely by reason of his/her handicap be excluded from
participation in, be denied the benefits of, or be subjected to
discrimination under any program or activity covered by this Contract.
2. The Department shall complete HHS Form 441, Assurance of Compliance with
the Department of Health and Welfare regulations, under Title VI of the
Civil Rights Act of 1964; for the Women, Infants and Children Program,
FNS-64, Assurance of Compliance with the Department of Agriculture Food
and Nutrition Service, under Title VI of the civil Rights Act of 1964;
and HHS Form 641, Assurance of Compliance with Section 504 of the
Rehabilitation Act of 1973.
3. The American with Disabilities Act 1990 (ADA) makes it unlawful to
discriminate in employment against a qualified individual with a
disability and outlaws discrimination against individuals with
disabilities in State and local government services and public
accommodations. The Department certifies that it and its principals and
subcontractors will comply with regulations in A.D.A. Title I
(Employment) , Title II (Public Services) , and Title III (Public
Accommodations) in fulfilling the obligations under this agreement.
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Page 9 of 12
G. RESPONSIBILITIES OF THE STATE
1. The State shall provide to the Department upon request technical
assistance in the preparation of the Consolidated Contract/Activity
Budgets and Contract Addenda.
2. The State shall specify those administrative forms/reports and their
respective revision dates that are required by particular activities
pertaining to the Department's budget with the State in Listing of
Required Fiscal and Statistical Reports (Addendum 1) for the contract
period. New forms/reports not listed in Required Fiscal and Statistical
Reports shall be implemented during a contract period only with the
approval of the State Health Director.
3. The State shall provide to the Department within thirty (30) days after
receiving an activity budget from the Department an approved signed copy
of the budget.
4. The State shall provide funds to the Department upon approval of the
Contract Addenda, activity budgets, and signing of this contract.
5. The State shall assist the Department to comply with all applicable
laws, regulations, and standards relating to the activities covered in
this contract.
6. The State .reserves the right to conduct reviews to determine compliance
with the terms of this contract.
7. The State shall be assured that the Department maintains expenditure of
locally appropriated funds for maternal health, child health, and family
planning activities equal to or greater than that reported on the Staff
Time Activity Report for the period beginning July 1, 1984, and ending
June 30, 1985. This maintenance of effort shall be measured by salary
equivalencies which are to be maintained in accordance with Section
B . 5. of this contract.
H. DISBURSEMENT OF FUNDS
The State shall disburse funds to, the Department as follows:
1. For departments selecting monthly payments through the GMTS option --
3
Provided the Consolidated Contract is properly executed and all
quarterly expenditure reports are filed within the established time
frames, payments equal to 1/12 of the total program approved budget
shall be made in the following months:
July October February
August November April
September January May
Based on expenditures reported for the first, second, and third
quarters, payments shall be adjusted either upward. or downward, in
payments made in the following months:
December March June
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2. For Departments selecting monthly payments through the check option --
Provided the Consolidated Contract is properly executed and all
quarterly expenditure reports are filed within the established time
frames, payments equal to 1/12 of the total program approved budget
shall be made each month as follows:
July October March
August December April
September January June
Based on expenditures reported for the first, second, and third
quarters, payments shall be adjusted either upward or downward, in
payments made in the following months:
November February May
3. For departments selecting quarterly reimbursement option, payments shall
be made when the quarterly expenditure report is received.
4. For departments receiving Rural Obstetrical Care Incentive funds,
payment of such funds shall be made in one lump sum the month following
receipt and approval of the activity budget.
5. For departments receiving Maternal Outreach project funds, payment will
be based on actual reported expenditures. Monthly payments will be made
provided that expenditure reports are received as required in C. 4. h.
6. Food and lodging fees will be disbursed to the department in one sum the
month following receipt and approval of the activity budget and any
subsequent budget revisions.
7. Funds for injury prevention projects will be disbursed in one lump sum
during the first quarter of the project budget approval.
8. Quarterly payment for reported expenditures in Line Item 1000 shall be
limited to one-fourth of the budgeted amount in that line item.
9. Increased or decreased payments necessitated by changes in the total
budgeted amount will be reflected in the monthly payments subsequent to
approval of the budget revision.
10. Payments shall be suspended when expenditure reports are not received by
the time specified in 4 a and f. Payments will resume in the months
subsequent to receipt of the expenditure reports.
11. Payment is limited to the total amount of the budget by line item.
12. Final payments will be made based on the-4th quarter expenditure report.
Final payments will be equal to the difference between approved reported
expenditures and the sum of previous payments. Final payments should be
made not later than September provided that an original signed copy of
an expenditure report for each quarter has been received by the office
of fiscal management. Final payment will be made only after the Staff
Time Activity Report, DEHNR 3389, is received by the State.
Page 11 of 12 12
13. Transfer of Title XIX Fees:
a. Title XIX fees received from Medicaid will be transferred to the
Department as soon as possible following receipt of payment to the
State.
b. When fees received exceed the amount shown by program in Activity
4125 an internal adjustment will be made to increase the amount
shown.
I. AMENDMENT OF CONTRACT
Amendments, modifications, or waivers of this contract may be made at any
time by mutual agreement of all parties. Amendments shall be in writing and
signed by appropriate authorities.
J. PROVISION OF TERMINATION
This contract may be terminated for reasons other than non-compliance upon
sixty (60) days written notice by either party. If termination should occur,
the Department shall receive payment only for allowable expenditures.
The State may withhold payment to the Department until the State can
determine whether the Department is entitled to further payment or whether
the State is entitled to a refund.
K. COMPLIANCE
1. The State shall assure compliance with all terms of this contract.
a. Upon determination of non-compliance, the State shall give the
Department sixty (60) days written notice to come into compliance.
If the deficiency is corrected, the Department shall submit a
written report to the State which sets forth the corrective action
taken.
b. If the above deficiencies should not be corrected to the
satisfaction of the State after the sixty (60) day period,
disbursement of funds for the particular activity may be
temporarily suspended pending negotiation of a plan of corrective
action.
c. If the deficiency is still not corrected within the next thirty
(30) days following temporary suspension of funding, program funds
may be permanently suspended until the Department can provide
evidence that the deficiencies have been corrected.
d. In the event of the Department's non-compliance with clauses of
this contract, the State may cancel, terminate, or suspend this
contract in whole or in part and the Department may be declared
ineligible for further State contracts or agreements. Such
terminations for non-compliance shall not occur until: (1) the
provisions of Section K-1 (a-c) have been followed, documented, and
have failed to provide a resolution, (2) all other reasonable
administrative remedies have been exhausted.
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Page 12 of 12
2. If the Department or the State should be determined out of compliance
with the provisions of the contract, either party may file a formal
appeal with the Office of Administrative Hearings.
IN WITNESS WHEREOF, the Department and the State have executed this
agreement in duplicate originals, one of which is retained by each of the parties.
LOCAL SIGNATURES DEPARTMENT OF ENVIRONMENT, HEALTH,
AND NATURAL RESOURCES
Jonathan B. Howes, Secretary
Health Director Date
By
Finance Officer Date Department Head's Signature
or Authorized Agent
Chairman of County Date
Commissioners
(when required)
14
ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF
HEALTH AND HUMAN SERVICES REGULATION UNDER
TITLE VI OF THE CIVIL RIGHTS ACT OF 1964
Orange County Health Department (hereinafter called the "Applicant")
tame of Applicant (type or print)
HEREBY AGREES THAT it will comply with Title VI of the Civil Rights Act of 1964 (P.L.
38-352) and all requirements imposed by or pursuant to the Regulation of the Department
of Health and Human Services (45 C.F.R. Part 80) issued pursuant to that title, to the end
that, in accordance with Tide VI of that Act and the Regulation, no person in the United
States shall, on the ground of race, color, or national origin, be excluded from participation
in, be denied the benefits of, or be otherwise subjected to discrimination under any program
or activity for which the Applicant receives Federal financial assistance from the Depart-
ment; and HEREBY GIVES ASSURANCE THAT it will immediately take any measures
necessary to effectuate this agreement.
If any real property or structure thereon is provided or improved with the aid of Federal
financial assistance extended to the Applicant by the Department, this Assurance shall obligate
the Applicant, or in the case of any transfer of such property, any transferee, for the period
during which the real property or structure is used for a purpose for which the Federal financial
assistance is extended or for another purpose involving the provision of similar services or
benefits. If any personal property is so provided, this Assurance shall obligate the Applicant
for the period during which it retains ownership or possession of the property. In all other
cases, this Assurance shall obligate the Applicant for the period during which the Federal
financial assistance is extended to it by the Department.
THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and
all Federal grants, loans, contracts, property, discounts or other Federal financial assistance
extended after the date hereof to the Applicant by the Department, including installment
payments after such date on account of applications for Federal financial assistance which
were approved before such date. The Applicant recognizes and agrees that such Federal finan-
cial assistance will be extended in reliance on the representations and agreements made in
this Assurance, and that the United States shall have the right to seek judicial enforcement
of this Assurance. This Assurance is binding on the Applicant, its successors, transferees,
and assignees, and the person or persons whose signatures appear below are authorized to
sign this Assurance on behalf of the Applicant.
Date orb r„o,■±, real rh incparirsant
Applicant itype or pruul
By
• Signature and Title of Authorised Official
Moses Carey, Jr., Chairman
Board of County Ccamissioners
•
•
ttHS-141 (Rev. 12112)
•
•
�`"• •"'-'• 6.S. DEPARTMIX OF AGR:CLL JRE .00k..ok •oker[o o•••«o••
i1-711 Food and Nutrition Service ��Me
15
ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF AGRICULTURE,
FOOD AND NUTRITION SERVICE, UNDER TITLE VI OF THE CIVIL RIGHTS ACT OF 1964
fr-Ange County Health Department
tName of Applicant)
(Hereinafter called the "Applicant.")
HEREBY AGREES THAT it will comply with Title VI any improvements made with Federal financial
of the Civil Rights Act of 1964 (P.L. 88-352) assistance extended to the Applicant by the
and all requirements imposed by the Regulations Department. This includes any Federal agreement,
of the Department of Agriculture (7 CFR Part 15), arrangement, or other contract which has as one
Department of Justice (28 CFR Parts 42 & 50), of its purposes the provision of assistance such
and FNS directives or regulations issued as food, food stamps, cash assistance for the
pursuant to that Act and the Regulations, to the purchase of food, and cash assistance for purchase
effect that, no person in the United States shall, or rental of food service equipment or any other
on the ground of race, color, or national origin, financial assistance extended in reliance on the
be excluded from participation in, be denied the representations and agreements made in this
benefits of, or be otherwise subject to discrimi- assurance.
nation under any program or activity for which the
Applicant received Federal financial assistance BY ACCEPTING THIS ASSURANCE, the applicant agrees
from the Department; and HERESY GIVES ASSURANCE to compile data, maintain records and submit
THAT it will immediately take any measures reports as required, to permit effective enforce-
necessary to effectuate this agreement. ment of Title VI and permit authorized USDA
personnel during normal working hours to review
THIS ASSURANCE is given in consideration of and
for the purpose of obtaining any and all Federal ascertain rcompliance awith cTitle sVI. nIfdthere are
financial assistance, grants and loans of Federal any violations of this assurance, the Department
funds, reimbursable expenditures, .grant or of Agriculture, Food and Nutrition Service, shall
donation of Federal property and interest in have the right to seek judicial enforcement of
property, the detail of Federal personnel, the this assurance.
sale and lease of, and the permission to use,
Federal property or interest in such property or This assurance is binding on the applicant, its'
the furnishing of services without consideration successors, transferees, and assignees as long as
or at a nominal consideration, or at a consider- it receives assistance or retains possession of
ation which is reduced for the purpose of assist- any assistance from the Department. The person
ing the recipient, or in recognition of the or persons whose signatures appear below are
public interest to be served by such sale, lease, authorized to sign this assurance on the behalf of
or furnishing of services to the recipient, or the applicant.
Dated Orange County Health Department
(Applicant)
By
(Title of authorized official)
Moses Carey, Jr., (iai_rman
Board of County Commissioners
P.O. Box 8181
•
Hillsborough, N.C. 27278-6181
(Address of Applicant)
No further monies or other benefits may be paid out under Food and Nutrition Service Federal assistance
programs unless this Assurance is completed and filed as required by existing regulations (7 CFR 15).
•o•1,CU
16
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ASSURANCE OF COMPLIANCE WITH SECTION SO4 OF THE
REHABILITATION ACT OF 1973, AS AMENDED
The undersigned(hereinafter called the "recipient")HER.EEY AGREES THAT it will comply
with Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C.794), all require-
ments imposed by the applicable HHS regulation(45 C.F.R. Part 84),and all guidelines and
interpretations issued pursuant thereto.
Pursuant to §84.5(a)of the regulation [45 C.F.R. 84.5(a)j, the recipient gives this Assurance
in consideration of and for the purpose of obtaining any and a l Federal grants, loans, con-
tracts (except procurement contracts and contracts of insurance or guaranty), property, dis-
counts, or other Federal financial assistance extended by the Department of Health and Human
Services after the date of this Assurance, including payments or other assistance made after
such date on applications for Federal financial assistance that were approved before such
date.The recipient recognizes and agrees that such Federal financial assistance will be extended
in reliance on the representations and agreements made irrthis Assurance and that the United
States will have the right to enforce this Assurance through lawful means. This Assurance
is binding on the recipient, its successors, transferees, and assignees, and the person or persons
whose signatures appear below are authorized to sign this Assurance on behalf of the recipient.
This Assurance obligates the recipient for the period during which Federal financial assistance
is extended to it by the Department of Health and Human Services or, where the assistance
is in the form of real or personal property, for the period provided for in §84.5(b) of the
regulation [45 C.F.R. 84:5(b)j.
The recipient: [Check (a) or (b)]
a. ( ) employs fewer than fifteen persons;
b. ( x ) employs fifteen or more persons and, pursuant to §84.7(a) of the regulation
[45 C.F.R. 84.7(a)j, has designated the following person(s) to coordinate its
efforts to comply with the HHS regulations:
Daniel B. RPimar
Name of Designee(s) (Type or Print)
Orange County Health Department P.O. Box 8181
Name of Recipient-(Type or Print) Street Address or P.O. Box
56-6000327 Hillsborough
(IRS) Employer Identification Number City
North Carolina 27278-8181
State Zip
I certify that the above information is complete and correct to the best of my knowitdge.
Date Signature and Title of Authorized Official
If there has been a change in name or ownership within the last year, please PRINT the former
name below:
HHS-641 (itcv.42/521
cc..
ap
P1
State of North Carolina �: � Kc
Department of Environment, ' Src,
Health and Natural Resources 4 • •
General Services Division
James B. Hunt,Jr., Governor
Jonathan B. Howes, Secretary ED EE NJ
Laird Davison, Director
V,74/93
77X, -
July 19, 1993 DATE ITEM .3--/9
MEMORANDUM
To: Local Health Directors
From: John L. Perkinson," Chief
Purchase and Contract Section
Subject: Transmittal of Approved FY 93-94 Consolidated Contract
Enclosed you will find a fully executed copy of the Consolidated
Contract for your department for FY 93-94.
Any budget sent in with the original consolidated contract but
not included with this package will be returned under separate
cover when approved.
If new programs ( activities) are added during the year, it will
be necessary to amend the contract.
Please remember that budgets, budget revisions and amendments
are sent to the Purchase and Contract Section and expenditure
reports to the Division of Fiscal Management, P.O. Box 27687 ,
Raleigh, N.C. 27611-7687 .
Should you have questions about budgets, budget revisions or
amendments, call us at ( 919) 733-3131 .
/rew
Enclosures
P.O. Box 27687,Raleigh,North Carolina 27611-7687 Telephone 919-733-9746
An Equal Opportunity Affirmative Action Employer 50%recycled/10%post-consumer paper
Page 1 of 12
1993 - 1994
CONSOLIDATED CONTRACT
BETWEEN
THE STATE OF NORTH CAROLINA
AS REPRESENTED BY
THE DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
(Hereinafter called the "State")
AND
ORANGE COUNTY HEALTH DEPARTMENT -
(Name of Local Health Department)
(Hereinafter called the "Department")
FOR THE PURPOSE OF
MAINTAINING AND STIMULATING THE ADVANCEMENT OF HEALTH IN NORTH CAROLINA
This Contract Shall Cover a Period From
July 01, 1993 to June 30, 1994
NOW, THEREFORE, the State and the Department agree that the provisions and clauses
herein set forth shall be incorporated in and constitute the terms and conditions
applicable for the following activities involving State funding. (State funding
or funds means .state, federal, and/or special funding or funds throughout this
contract. )
ACTIVITY ACTIVITY
General Adult Health
Transfer of Escrow Health Promotion
AIDS (federal) Breast and Cervical Cancer
Tuberculosis
uuCommunicable Disease
Family Planning
Child Service Coordination
CSHS Orthopedic
MCH Block Grant Nutrition
DEHNR 2946 (Revised 02/93)
Division of General Services (Review 02/94)
Page 2 of 12
A. WORK TO BE PERFORMED
1. The Department shall perform activities in compliance with applicable
program rules contained in the North Carolina Administrative Code as
well as all applicable Federal and State laws and regulations.
2. The Department shall submit for approval the required Program Contract
Addenda for State funded budgets.
3. The Department shall submit completed reports as required by budgeted
funding criteria and as specified in Listing of Required Fiscal and
Statistical Reports (Addenda 1) .
4. The Department shall administer and enforce all rules which have been
adopted by the Commission for Health Services or approved by the State
and adopted by the Local Board of Health.
5. The Department shall provide to the State copies of rules adopted by the
Local Board of Health pursuant to G.S. 130A-39 and Public Health
Ordinances adopted by the County Commissioners. Copies of existing
rules and ordinances shall be submitted to the State Health Director
within 45 days. Thereafter, copies of rules adopted shall be submitted
within 30 days of adoption.
6. The Department shall provide to the State a Community Diagnosis
Prioritization of Problems every biennium. The Department shall also
provide a Community Diagnosis narrative, if completed.
B. FUNDING STIPULATIONS
1. Funding for this contract is subject to the availability of State,
Federa-1, and special funds for the purpose set forth in this Contract.
2 . During the period of this Contract, the Department shall not use State,
Federal or Special Project funds received under this Contract to reduce
locally appropriated funds as reflected in the Local Health Department
Budgets.
3. The Department shall not use personal health program funds to support
environmental health personnel nor use environmental health program
funds to support personal health programs. Fees generated by the Food
and Lodging fees collection program may only be used to support
Environmental Health activities.
4. The Department shall comply with Standards for Mandated Public Health
Services, 15A NCAC 25, Section .0200; and Administrative Procedures
Manual for Federal Block Grant Funds, 1 NCAC 33, Sections .0100 - .1502.
5 . The Department shall maintain employee time records for the contract
period documenting the portion of time that each employee attributes to
each activity when State funds are budgeted for the support of employee
salaries and fringe benefits. The percentage of time each employee
spends in each activity shall be converted to dollars based upon the
employees' salary and benefits. These records will serve to document
salary and benefit expenditures reported on Forms DEHNR 2949 and DEHNR
2950, and compliance with Chapter 479, Section 99 of the 1985 Session
Laws.
Page 3 of 12
6. The Department participating in Medicaid Reimbursement shall:
a. Comply with the terms of the Interagency Agreement between the
Division of Medical Assistance, Department of Human Resources and
the Department of Environment, Health, and Natural Resources and
the Provider Participation Agreement effective October 1, 1992 and
any subsequent approved addenda or new Agreement approved and
established during the period of this contract.
b. Make every reasonable effort to collect its cost in providing
services, for which Medicaid reimbursement is sought, through
public or private third party payors except where prohibited by
Federal regulations or State law. No one shall be refused services
solely because of an inability to pay. All payments from persons,
and public or private third party payors, shall be utilized for the
activity that generated the revenue and shall not reduce or replace
locally appropriated funds during the period of this Contract. All
fees collected shall be used in the current year or succeeding
fiscal years. Use of program income generated by the expenditure
of Federal categorical funds will be governed by applicable Federal
regulations, including but not limited to, 45 CFR 74.
7. The Department agrees to match the expenditure of Adolescent Pregnancy
Prevention Project grant funds with any in-kind source or newly
generated funds, public or private available to the project. Payment
from the State shall be in accordance with Chapter 689, Section 174 of
the 1991 Session Laws.
8. Funds budgeted for Adolescent Health Activities shall not be expended
for dues or out-of-state travel unless prior approval is received from
the program.
9 . Subject to the approval of the appropriate Division, a local health
department may seek reimbursement for services covered by a program
operating under 15A NCAC 24A rules when those services are not supported
by other state or federal funds. All payment program rules and
procedures as specified in the Purchase of Medical Care Services manual
must be followed.
10. Subject to the availability of funds and approval of the Office of
Public Health Nursing, a local health department may request
reimbursement for:
a. Nursing service personnel participating in the Introduction to
Principles and Practices of Public Health and Public Health Nursing
course (2 week course) and the Public Health Nurse Supervisors
Training Course (4 week course) . Reimbursement is limited to no
more than $200.00 per week per participant upon successful
completion of the course.
b. Community Health Assistants and Staff Nurse attending certain
pre-approved Continuing Education courses offered by the Office of
Public Health Nursing. Reimbursement is limited to $25.00 per
participant per event.
Page 4 of 12
11. The Department shall have an annual audit performed in accordance with
The Single Audit Act of 1984 as implemented by OMB Circular A-128.
Audit findings and resolution of said findings shall be handled by the
Division of Fiscal Management, Budget & Analysis Section.
12. Equipment is a type of fixed asset consisting of specific items of
property that: (1) are tangible in nature; (2) have a life longer than
one year; and (3) have a significant value.
a. For Budgeting and Reporting Purposes
1. Equipment purchases meeting the above definition and having an
acquisition cost of $500 or more must be budgeted and reported
in Line Item 5000.
b. For Inventory Purposes
1. Equipment must be accounted for in accordance with Local .
Government Accounting System Procedure No. 15.
2. Women, Infants and Children Program
All equipment with an acquisition cost of $500.00 or more must
be inventoried with the Division of Maternal and Child Health.
c. For Prior Approval Purposes
1. Equipment purchased or equipment leased where there is an
option to purchase with State/Federal funds must receive prior
written approval from the appropriate Division, Section, or
Branch when the acquisition cost exceeds $500.00.
2. Women, Infants and Children Program
All medical equipment and computer equipment, regardless of
cost and all other equipment with an acquisition cost of
$500.00 or more must receive prior approval from the program
office.
3. Equipment purchased with program income generated by the
expenditure of Title X Family Planning Funds with an
acquisition cost of $500.00 or more must receive prior written
approval from the program.
C. FISCAL CONTROL
1. The Department shall comply with the Local Government Budget and Fiscal
Control Act, North Carolina General Statute Chapter 159, Article 3.
a. The Department shall maintain a purchasing and procurement system
in accordance with generally accepted accounting practices and
procedures set forth by the Local Government Commission.
Page 5 of 12
b. The Department shall execute written agreements with all parties
who invoice the Department for payment for the provision of
services to patients.
c. When subcontracting, the following conditions must be met:
1. The Department is not relieved of any of the duties and
responsibilities provided in this contract.
2. The subcontractor will agree to abide by the standards
contained herein or to provide such information as to allow
the Department to comply with these standards.
3. The subcontractor will agree to allow state and federal
authorized representatives access to any records pertinent to
its role as a subcontractor of the Department.
4. The Department will make available to the State upon request a
copy of subcontracts supported with State/Federal funds.
d. The Department shall receive prior approval from the State when
subcontracting for services in the Women, Infants and Children
Program.
e. The Department shall retain all budgets, budget revisions ,
contracts, contract addenda, and financial records in accordance
with the current Records Disposition Schedule for County and
District Health Departments issued by the Division of Archives and
History, Department of Cultural Resources .
2. The Department shall prepare and maintain a budget for each activity
covered by this contract in a manner consistent with instructions
provided with Forms DEHNR 3370 (Revised 2/93) and DEHNR 2948 (Revised
2/93) .
a. The Department shall prepare budget revisions for prior approval of
the State when those revisions are in the School Health Program
(Line Item 6200) .
b. The Department shall prepare budget revisions for prior approval of
the State when State funds will be increased or decreased.
c. The Department shall prepare an informational copy for the State of
all other budget revisions when proposed expenditures exceed the
line amount budgeted.
d. The Department shall submit all revisions prior to the end of the
term specified in this Contract. Budget revisions received by the
State after the end of the contract period will be returned without
action.
Page 6 of 12
3. The Department shall observe the following conditions when budgeting and
reporting earned income revenues (escrow) :
a. All earned income must be budgeted in the program where earned,
except that income earned by a program which has no activity budget
can be budgeted in a program approved by the State.
b. Line Item 9000 in the program budget shall be used to budget TXIX
fees.
c. Line Item 102 in the program budget shall be used to report TXIX
fees received which are used to support TXIX expenditures shown in
Line Item 9000.
d. Activity budgets that do not include an amount of TXIX funds
sufficient to meet the requirements of 3g. will not be approved by
the State.
e. Line Item 6864 in Activity 4125, Transfer of Escrow Funds , only
shall be used to show anticipated TXIX earnings.
f. A local account shall be maintained for unbudgeted/unreported TXIX
fees transferred to the Department. Accounts shall be maintained
in sufficient detail to identify the program source generating the
fees .
g. Funds carried forward to fiscal year 1994 may not exceed Title XIX
funds earned during fiscal year 91-92 or $10,000.00 whichever is
greater.
4. The Department shall submit a quarterly report of actual receipts and
expenditure's of the Department according to instructions provided with
Expenditure Reports, Form DEHNR 2949 (Revised 8/92) and Form DEHNR 2950
(Revised 2/93) .
a. The Department shall submit quarterly expenditure reports to the
State within 45 days from the end of the reporting quarter.
b. The Department shall submit the final Expenditure Report to the
State within 45 days after the end of the contract period.
c. The Department shall submit amended or corrected expenditure
reports within six (6) months after the end of the contract period.
Any such reports must be prepared for the specific quarter to be
amended or corrected. Reports received after December 31 will be
returned without action.
d. The Department shall refund to the State all State funds not
supported by expenditures within 45 days after notification of
overpayment. When payment is not received by the State within 45
days , future payments to the Department may be reduced by the
amount due or payments may be suspended until the refund is
received by the State.
e. The Department shall follow Women, Infants and Children Program and
other Federal program reporting requirements when they differ from
those stated above.
Page 7 of 12
f. The Department shall submit monthly WIC expenditure reports to the
State no later than the 8th of the following month.
g. Reimbursement of WIC approved expenditures for July, August, and
September cannot exceed one-fourth of the total budget for the
contract period.
h. The Department shall submit monthly Maternal Outreach expenditure
reports to the state no later than the 15th of the following month.
i. The Department shall submit expenditure reports for Mosquito
Control activity in accordance with 15A NCAC 18B, Sections .0104
and .0107.
j . The Department shall submit request for payment for services
provided under 15A NCAC 24 A rules to the Claims Processing Unit,
DEHNR Division of Fiscal Management.
k. The Department shall submit request for reimbursement for nurse
training to the Office of Public Health Nursing. Form DEHNR 3300 -
Public Health Nurse Training Activity must be used as the invoice
for payment.
5. The Department shall submit on an annual basis Staff Time Activity
Report, DEHNR 3389. The report shall accompany the final expenditure
report and must be received by the State within 45 days after the end of
the contract period.
6. For Adolescent Health Activity, the Department agrees to (1) have
responsibility for the immediate direction, supervision and evaluation
of the activities supported through the contract, which will be
conducted in accordance with the amended plan/update submitted by the
Department; (2) submit any media material in writing to the Division of
Maternal and Child Health for approval prior to release to the public;
(3) submit a mid-year report on progress in meeting project objectives
by February 1, 1994; (4) submit an evaluation report demonstrating
achievement of stated goals no later than August 16, 1994.
D. PERSONNEL POLICIES
The Department shall adhere to and fully comply with State personnel
policies as found in North Carolina General Statute, Chapter 126, and 1
NCAC 8. Such policies include, but are not limited to, the following:
1. Equal employment opportunity;
2. Affirmative action;
3. Policies for local government employment subject to the State Personnel
Act;
4. "Local Classification and Salary Range" ;
5. "Compensation Policy for Local Competitive Services Employees" ; and
6. "Recruitment and Selection Policy and Procedures" ;
Page 8 of 12
7. Environmental Health Specialists employed by the Department shall be
delegated authority by the State to administer and enforce State
environmental health rules and laws as directed by the State pursuant to
G.S. 130A-4(b) . This delegation shall be done according to 15A NCAC 18A
.2300.
a. Local health departments are responsible for sending their
newly-employed environmental health specialists (interns) to 40
days of initial field training/orientation at designated training
centers within 90 days from date of employment.
b. Arrangements for initial field training/orientation including
designation of the training center for newly-employed environmental
health specialists will be handled by the Environmental Health
Services Section, Division of Environmental Health.
E. CONFIDENTIALITY
All information as to personal facts and circumstances obtained by Department
personnel in connection with the provision of services or other activity
under this Contract shall be privileged communication, shall be held
confidential, and shall not be divulged without the responsible person's
written consent except as may be otherwise required by applicable law or
regulation. Such information may be disclosed in summary, statistical, or
other form which does not directly or indirectly identify particular
individuals.
F. CIVIL RIGHTS
1. The Department shall assure that no person, on the grounds of race,
color, age, religion, sex, marital status , or national origin (unless
otherwise medically indicated) or otherwise qualified handicapped
individual solely by reason of his/her handicap be excluded from
participation in, be denied the benefits of, or be subjected to
discrimination under any program or activity covered by this Contract.
2. The Department shall complete HHS Form 441, Assurance of Compliance with
the Department of Health and Welfare regulations , under Title VI of the
Civil Rights Act of 1964; for the Women, Infants and Children Program,
FNS-64, Assurance of Compliance with the Department of Agriculture Food
and Nutrition Service, under Title VI of the civil Rights Act of 1964;
and HHS Form 641, Assurance of Compliance with Section 504 of the
Rehabilitation Act of 1973.
3. The American with Disabilities Act 1990 (ADA) makes it unlawful to
discriminate in employment against a qualified individual with a
disability and outlaws discrimination against individuals with
disabilities in State and local government services and public
accommodations. The Department certifies that it and its principals and
subcontractors will comply with regulations in A.D.A. Title I
(Employment) , Title II (Public Services) , and Title III (Public
Accommodations) in fulfilling the obligations under this agreement.
Page 9 of 12
G. RESPONSIBILITIES OF THE STATE
1. The State shall provide to the Department upon request technical
assistance in the preparation of the Consolidated Contract/Activity
Budgets and Contract Addenda.
2. The State shall specify those administrative forms/reports and their
respective revision dates that are required by particular activities
pertaining to the Department's budget with the State in Listing of
Required Fiscal and Statistical Reports (Addendum 1) for the contract
period. New forms/reports not listed in Required Fiscal and Statistical
Reports shall be implemented during a contract period only with the
approval of the State Health Director.
3. The State shall provide to the Department within thirty (30) days after
receiving an activity budget from the Department an approved signed copy
of the budget.
4. The State shall provide funds to the Department upon approval of the
Contract Addenda, activity budgets, and signing of this contract.
5. The State shall assist the Department to comply with all applicable
laws, regulations, and standards relating to the activities covered in
this contract.
6. The State reserves the right to conduct reviews to determine compliance
with the terms of this contract.
7. The State shall be assured that the Department maintains expenditure of
locally appropriated funds for maternal health, child health, and family
planning activities equal to or greater than that reported on the Staff
Time Activity Report for the period beginning July 1, 1984, and ending
June 30, 1985. This maintenance of effort shall be measured by salary
equivalencies which are to be maintained in accordance with Section
B . 5 . of this contract.
H. DISBURSEMENT OF FUNDS
The State shall disburse funds to the Department as follows:
1. For departments selecting monthly payments through the GMTS option --
Provided the Consolidated Contract is properly executed and all
quarterly expenditure reports are filed within the established time
frames, payments equal to 1/12 of the total program approved budget
shall be made in the following months:
July October February
August November April
September January May
Based on expenditures reported for the first, second, and third
quarters, payments shall be adjusted either upward or downward, in
payments made in the following months:
December March June
Page 10 of 12
2. For Departments selecting monthly payments through the check option --
Provided the Consolidated Contract is properly executed and all
quarterly expenditure reports are filed within the established time
frames, payments equal to 1/12 of the total program approved budget
shall be made each month as follows:
July October March
August December April
September January June
Based on expenditures reported for the first, second, and third
quarters, payments shall be adjusted either upward or downward, in
payments made in the following months:
November February May
3. For departments selecting quarterly reimbursement option, payments shall
be made when the quarterly expenditure report is received.
4. For departments receiving Rural Obstetrical Care Incentive funds,
payment of such funds shall be made in one lump sum the month following
receipt and approval of the activity budget.
5. For departments receiving Maternal Outreach project funds, payment will
be based on actual reported expenditures. Monthly payments will be made
provided that expenditure reports are received as required in C. 4. h.
6. Food and lodging fees will be disbursed to the department in one sum the
month following receipt and approval of the activity budget and any
subsequent budget revisions.
7. Funds for injury prevention projects will be disbursed in one lump sum
during the first quarter of the project budget approval.
8. Quarterly payment for reported expenditures in Line Item 1000 shall be
limited to one-fourth of the budgeted amount in that line item.
9. Increased or decreased payments necessitated by changes in the total
budgeted amount will be reflected in the monthly payments subsequent to
approval of the budget revision.
10. Payments shall be suspended when expenditure reports are not received by
the time specified in 4 a and f. Payments will resume in the months
subsequent to receipt of the expenditure reports.
11. Payment is limited to the total amount of the budget by line item.
12. Final payments will be made based on the 4th quarter expenditure report.
Final payments will be equal to the difference between approved reported
expenditures and the sum of previous payments. Final payments should be
made not later than September provided that an original signed copy of
an expenditure report for each quarter has been received by the office
of fiscal management. Final payment will be made only after the Staff
Time Activity Report, DEHNR 3389, is received by the State.
Page 11 of 12
13. Transfer of Title XIX Fees:
a. Title XIX fees received from Medicaid will be transferred to the
Department as soon as possible following receipt of payment to the
State.
b. When fees received exceed the amount shown by program in Activity
4125 an internal adjustment will be made to increase the amount
shown.
I. AMENDMENT OF CONTRACT
Amendments, modifications, or waivers of this contract may be made at any
time by mutual agreement of all parties. Amendments shall be in writing and
signed by appropriate authorities.
J. PROVISION OF TERMINATION
This contract may be terminated for reasons other than non-compliance upon
sixty (60) days written notice by either party. If termination should occur,
the Department shall receive payment only for allowable expenditures.
The State may withhold payment to the Department until the State can
determine whether the Department is entitled to further payment or whether
the State is entitled to a refund..
K. COMPLIANCE
1. The State shall assure compliance with all terms of this contract.
a. Upon determination of non-compliance, the State shall give the
Department sixty (60) days written notice to come into compliance.
If the deficiency is corrected, the Department shall submit a
written report to the State which sets forth the corrective action
taken.
b. If the above deficiencies should not be corrected to the
satisfaction of the State after the sixty (60) day period,
disbursement of funds for the particular activity may be
temporarily suspended pending negotiation of a plan of corrective
action.
c. If the deficiency is still not corrected within the next thirty
(30) days following temporary suspension of funding, program funds
may be permanently suspended until the Department can provide
evidence that the deficiencies have been corrected.
d. In the event of the Department's non-compliance with clauses of
this contract, the State may cancel, terminate, or suspend this
contract in whole or in part and the Department may be declared
ineligible for further State contracts or agreements. Such
terminations for non-compliance shall not occur until: (1) the
provisions of Section K-1 (a-c) have been followed, documented, and
have failed to provide a resolution, (2) all other reasonable
administrative remedies have been exhausted.
Page 12 of 12
2. If the Department or the State should be determined out of compliance
with the provisions of the contract, either party may file a formal
appeal with the Office of Administrative Hearings.
IN WITNESS WHEREOF, the Department and the State have executed this
agreement in duplicate originals, one of which is retained by each of the parties.
LOCAL SIGNATURES DEPARTMENT OF ENVIRONMENT, HEALTH,
AND NATURAL RESOURCES
57/219 3
/ Jonathan B. Howes, Secretary
Health Director Date ;
Director
LAY. of General ('c``rvic:s
Finance Officer Date Department Head's Signature
or Authorized Agent
Chairman of Count / Da e
Commissioners
(when require.
ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF
HEALTH AND HUMAN SERVICES REGULATION UNDER
TITLE VI OF THE CIVIL RIGHTS ACT OF 1964
Orange County Health Department (hereinafter called the "Applicant")
Name of Applicant (type or print)
HEREBY AGREES TEAT it will comply with Title VI of the Civil Rights Act of 1964 (P.L.
38-352) and all requirements imposed by or pursuant to the Regulation of the Department
of Health and Human Services (45 C.F.R. Part 80) issued pursuant to that title, to the end
that, in accordance with Title VI of that Act and the Regulation, no person in the United
States shall, on the ground of race, color, or national origin, be excluded from participation
in, be denied the benefits of, or be otherwise subjected to discrimination under any program
or activity for which the Applicant receives Federal financial assistance from the Depart-
ment; and HEREBY GIVES ASSURANCE THAT it will immediately take any measures
necessary to effectuate this agreement.
If any real property or structure thereon is provided or improved with the aid of Federal
financial assistance extended to the Applicant by the Department, this Assurance shall obligate
the Applicant, or in the case of any transfer of such property, any transferee, for the period
during which the real property or structure is used for a purpose for which the Federal financial
assistance is extended or for another purpose involving the provision of similar services or
benefits. If any personal property is so provided, this Assurance shall obligate the Applicant
for the period during which it retains ownership or possession of the property. In all other
cases, this Assurance shall obligate the Applicant for the period during which the Federal
financial assistance is extended to it by the Department.
THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and
all Federal grants, loans, contracts, property, discounts or other Federal financial assistance
extended after the date hereof to the Applicant by the Department, including installment
payments after such date on account of applications for Federal financial assistance which
were approved before such date. The.Applicant recognizes and agrees that such Federal finan-
cial assistance will be extended in reliance on the representations and agreements made in
this Assurance, and that the United States shall have the right to seek judicial enforcement
of this Assurance. This Assurance is binding on the Applicant, its successors, transferees,
and assignees, and the person or persons whose signatures appear below are authorized to
sign this Assurance on behalf of the Applicant.
Date
37
_.._ . ma . _ • rr- rt,r,e„t
Applicant (ty• or pnnt)
By _ (2; i
Signature and Title of Auth•t . •ffinal
Moses Carey, Jr., .irman
Board of County In ssioners
HHS-411 (Rev. 12142)
•
•
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ASSURANCE OF COMPLIANCE WITH SECTION SO4 OF THE
REHABILITATION ACT OF 1973, AS AMENDED
The undersigned(hereinafter called the "recipient") HEREBY AGREES THAT it will comply
with Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794), all require-
ments imposed by the applicable HHS regulation (45 C.F.R. Put 84),and all guidelines and
interpretations issued pursuant thereto.
Pursuant to §84.5(a)of the regulation [45 C.F.R. 84.5(a)), the recipient gives this Assurance
in consideration of and for the purpose of obtaining any and all Federal grants, loans, con-
tracts (except procurement contracts and contracts of insurance or guaranty), property, dis-
counts, or other Federal financial assistance extended by the Department of Health and Human
Services after the date of this Assurance, including payments or other assistance made after
such date on applications for Federal financial assistance that were approved before such
date.The recipient recognizes and agrees that such Federal financial assistance will be extended
in reliance on the representations and agreements made irrthis Assurance and that the United
States will have the right to enforce this Assurance through lawful means. This Assurance
is binding on the recipient, its successors, transferees, and assignees, and the person or persons
whose signatures appear below are authorized to sign this Assurance on behalf of the recipient.
This Assurance obligates the recipient for the period during which Federal financial assistance
is extended to it by the Department of Health and Human Services or, where the assistance
is in the form of real or personal property, for the period provided for in §84.5(b) of the
regulation [45 C.F.R. 84.5(b)).
The recipient: [Check (a) or (b))
a. ( ) employs fewer than fifteen persons;
b. ( x ) employs fifteen or more persons and, pursuant to §84.7(a) of the regulation
[45 C.F.R. 84.7(a)J, has designated the following person(s) to coordinate its
efforts to comply with the HHS regulations:
Daniel B. Reimer
Name of Designee(s) (Type or Print)
Orange County Health Department P.O. Box 8181
Name of Recipient4Type or Print) Street Address or P.O. Box
56-6000327 Hillsborough
(IRS) Employer Identification Number City
North Carolina 27278-8181
State Zip
I certify t at the above information is -/.plete and corre the best of my knowledge.
Date Signature and Title of Authorized 1,rcial
If there has been a change in name or ownership within the last ye; , please PRINT the former
name below:
HH5441 (acv. 42/112)
r0w14 1,141-44 U.S. DEPART?0EN7 OF AGRICULTURE row..•••worco e.+•..o.•o,w•o40
Food and Nutrition Service
ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF AGRICULTURE,
FOOD AND NUTRITION SERVICE, UNDER TITLE VI OF THE CIVIL RIGHTS ACT OF 1964
Orang County Health Department
kName of Applicant)
(Hereinafter called the "Applicant.")
HEREBY AGREES THAT it will comply with Title VI any improvements made with Federal financial
of the Civil Rights Act of 1964 (P.L, 58-352) assistance extended to the Applicant by the
and all requirements imposed by the Regulations Department. This includes any Federal agreement,
of the Department of Agriculture (7 CFR Part 15), arrangement, or other contract which has as one
Department of Justice (28 CFR Parts 42 & 50), of its purposes the provision of assistance such
and FNS directives or regulations issued as food, food stamps, cash assistance for the
pursuant to that Act and the Regulations, to the purchase of food, and cash assistance for purchase
effect that, no person in the United States shall, or rental of food service equipment or any other
on the ground of race, color, or national origin, financial assistance extended in reliance on the
be excluded from participation in, be denied the representations and agreements made in this
benefits of, or be otherwise subject to discrimi- assurance.
nation under any program or activity for which the
Applicant received Federal financial assistance BY ACCEPTING THIS ASSURANCE, the applicant agrees
from the Department; and BEREBY GIVES ASSURANCE to compile data, maintain records and submit
THAT it will immediately take any measures reports as required, to permit effective enforce-
necessary to effectuate this agreement. ment of Title VI and permit authorized USDA
personnel during normal working hours to review
THIS ASSURANCE is given in consideration of and such records, books and accounts as needed to
for the purpose of obtaining any and all Federal ascertain compliance with Title VI. If there are
financial assistance, grants and loans of Federal any violations of this assurance, the Department
funds, reimbursable expenditures, grant or of Agriculture, Food and Nutrition Service, shall
donation of Federal property and interest in have the right to seek judicial enforcement of
property, the detail of Federal personnel, the this assurance.
sale and lease of, and the permission to use,
Federal property or interest in such property or This assurance is binding on the applicant, its
the furnishing of services without consideration successors, transferees, and assignees as long as
or at a nominal consideration, or at a consider- it receives assistance or retains possession of
ation which is reduced for the purpose of assist- any assistance from the Department. The person
ing the recipient, or in recognition of the or persons whose signatures appear below are
public interest to be served by such sale, lease, authorized to sign this assurance on the behalf of
or furnishing of services to the recipient, or the applicant.•
Dated /��/k3 • Orange County P HPa1 th Department
(Applicant)
• /L di
(title of authorized offi�.
Moses Carey, Jr., Chai
Board of County . t ioners
p.n. Box 8181
Hillsborough, N.C. 27278-8181
(Address of Applicant)
No further monies or other benefits may be paid out under Food and Nutrition Service Federal assistance
programs unless this Assurance is completed and filed as required by existing regulations (7 CFR 15).
4r o,2S ++1
LOCAL HEALTH DEPARTMENT BUDGET
N.C. Department of Environment,
Health, and Natural Resources Revision Number
Division of General Services �' /
SFY Division of General Services
P. O. Number
07 / 93 06 / 94 / ai 3 9 4 4 1 1 0 0 0 6 8
Effective Date Termination Date c,lu^ x(11 Contract Number
t!�
Contractor: nrangp Colmty Health Department Activity: General
Project Director: Daniel B. Reimer Total Budget: $_44L,659
ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT
E STATE EXPENDITURES:
Salaries (Si. Fringe Benefits SA/FR 1000 531523
X Operating Expenses OP EXP 2000
E Purchase of Equipment EQUIP 5000
E General Contracted or
N Purchased Services GENERAL 6100
e
School Health
D
Clinician
I
Laboratory
Pharmacy Services
rvices
i3Et'4z:Yi i` '�ii f �:'•..>:ff3itiisi2:>`t:i::SS ?i
Transfer r TXIX
R Subtotal State Expend. $53,523
E LOCAL EXPENDITURES: LOCAL EXP 9000 438,136
S TOTAL EXPENDITURES— equal to Total Receipts $491,659
LOCAL FUNDS: •
R Appropriation APPROP 101 359,376
E TXIX TXIX 102 16,013
Other Receipts OTHR REC 103 62,747
E Subtotal Local Funds $ 438,136
STATE/l±DERAL/SPECIAL FUNDS:
I
P
General Aid–To–Counties 53,523 L-
T
S
Subtotal State/Federal/Special $ 53,523
TOTAL RECEIPTS— equal to Total Expenditures $491,659
Jji /� // hrf - ;.s 6 -!0--97• s�t
Local Authorized Official Si g fr. Date BranchHnd t Division/Section Signature Date •
-9 Init al
3 f
�.
Finance Officer Signature Date Ac • .unt Or'. Ma�. 4yj1�'.-',u-.ture Date
DEHNR 2948(Revised 2/93)
General Services Division(Review 2/94)
LOCAL HEALTH DEPARTMENT BUDGET
N.C. Department of Environment,
Health, and Natural Resources Revision Number
Division of General Services
SFY Division of General Services
P. O. Number
07 / 93 06 / 94 9 4 4 1 2 5 0 0 6 8
Effective Date Termination Date Contract Number
Contractor: Orange County Health Dept. Activity: Transfer of Escrow
Project Director: Darnel B. Reimer Total Budget: $ 208,668
ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT
ESTATE EXPENDITURES:
S
S •es
Salaries & Fringe
Benefits
.INII:. 1:H. 't l , Ililll 111
Operating Expenses . :....................:::::.::.::::....................................:.:€:::>s
Purchase o
Pu of Equipment
:.................. ii !1{I� 1111111 C.::.:................' ....i 11NI Il,t}:a•::x::::•: ....
E Contracted Con acted or
Purchased Services
N
School Heal th
•:.::� .;,?:>:J ? .::�..:...:.:.>�.'<.;..s....:>:<::..:>::.::.>:.'s.::>iiii:.•s.:.::::::>v::;:<:i:,1,.>;:)1:,)1:I<1.1:w1<:r>:::v:::.�•.::::::.•::.::<::::::::.::?.:•
D
cl
Clini '
an ?'' Y+i3�'.'♦� ? r� i?a?3i?� £'>:'?� 't� ?< �'�`2£?> y t ' �?k`
I
Laboratop
ry
T
Pharmacy Services
t ' ::: ':�it: ' st `:i2:': `iiS>'i�£i:�s>i��i2::'.•';::C; :!:� :
U Transfer TXIX 6864 208,668 —,
R Subtotal State Expend. $ 208,668
E LOCAL EXPENDITURES: LOCAL EXP 9000
S TOTAL EXPENDITURES—equal to Total Receipts $ 208,668
LOCAL FUNDS:
R Appropriation APPROP 101
E TXIX TXIX 102
Other Receipts OTHR REC 103
C
E Subtotal Local Funds $
STATE/1-EDERAL/SPECIAL FUNDS:
I
Transfer of DX1X 208,668
T
S
Subtotal State/Federal/Special $ 208,688
TOTAL RECEIPTS—equal to Total Expenditures $ 208,688
, (Yad/Aiadli / : o �. 33Z b-ZS-mot 3
Lou'Authorized Official Signatur ' Date s.t xna S ivision/Section Signature Date
Initial
—93
Finance Officer Signature Date Accountant Fiscal Management Signature Date
lnirial
DEHNR 2948(Revised 2/93) fib
General Services Division(Review 2/94)
Pagc 1 of 1
N.C.Department of Environment,Health,and Natural Resources
Division of General Services FY 94
CONTRACT ADDENDUM
PURCHASE & CONTRACTS 94 41'25 068
Office,Section,or Branch Contract Number
Orange co. Health Degts TRANSFER OF ESCROW
Contractor Activity
4125 TB CONTROL 0 4151 NEUROMUSCULAR.
4126 VD CONTROL 5,935 4152 ULTRASOUND
4127 ADULT HEALTH 0 4153 OBSTERIC CARE
4128 BLOOD PRESSURE 0 4154 CAESAREAN DELIV
4129 CANCER DETECTION 0 4155 HYSTERECTOMY
4131 HEART/RH FEVER 4156 CHILD SERV COORD 5/1,77Q (16--
4132 NEUROLOGY 4157 FAMILY PLANNING 8,215
4133 CLI-SPCH/HEAR 4158 EPSDT 17,015
4134 ORTHOPEDIC 4159 IMMU UPDATE
4135 SPCH THERAPY 4160 DEC
4136 CLI-PHYS THER 4161 DEC SPEECH-HEAR
4137 CHILD HLTH TREAT 8,289 ' 4162 HEPATITIS CHILD
4138 MAT HLTH TREAT 40,460 -/ 4163 HEPATITIS ADULT
4139 INTRA PARTUM CARE 4168 HYPERTENSION
4140 DENTAL M,n13 6 r9 4169 DIABETES
4141 NON STRESS 0 4170 GLAUCOMA •
4142 REFUGEE HEALTH 4171 EYE CARE
4143 PAP SMEAR 4172 ADULT SCREENING
4144 MAT CARE INITIAL 19,957 CQ 4173 GONORRHEA
4145 MAT CARE SUBSEQ 31 ,nRA 4174 AUDIOMETRY
4146 CHILDBIRTH CLASS 4175 BLOOD CHEM SMA-6
4147 MAT HOME VISIT 4176 BLOOD CHEM SMA-12
4148 PARENTING CLASS 4177 ARTHRITIS ASSES /�_ /
4149 VAG DELIV ONLY 4178 NORPLANT 13,980 / /�
4150 TOT OBSTET VAG ( �L
TOTAL 208,668
Reviewed by
•
DEHNR 3300(Revised 2/90)
General Services Division (Review 1/95) Initials Date
LOCAL HEALTH DEPARTMENT BUDGET
N.C. Department of Environment,
Health, and Natural Resources Revision Number
Division of General Services 4_/ O R 1
SFY Division of Epidemiology
P. O. Number
07 / 98 06 / 94 / 9 4 4 5 4 5 0 0 6 8
Effective Date Termination Date I Contract Number
Contractor: Orange County Health Department A ctivity : Aids (Federal)
Project Director: Daniel B.Reimer Total Budget:$ 28,000
ITEM DESCRIPTION CLASSIFICATION I'1bM AMOUNT
E STATE EXPENDITURES:
X Salaries & Fringe Benefits SA/FR 1000 2R MC)
Operating Expenses OP EXP 2000
P
Purchase
of
Equipment
nt
E General al
Contracted
0
r
Purchased
Services
ices
School Health �,,��
D
Clinician
I _
Laboratory
Pharmacy Services
U
Transfer r TXIX
iiiy` iy i%'i' ; 'i2i�t� >��i'?c ># ; f`>%:S '•a > :i: f�?-t��:'•.
R Subtotal State Expend. $28,000
E LOCAL EXPENDITURES: LOCAL EXP 9000
S
TOTAL EXPENDITURES—equal to Total Receipts $28,000
LOCAL FUNDS:
R Appropriation APPROP 101
E TX( TXIX 102
Other Receipts OTHR REC 103
C
E Subtotal Local Funds $
STATE/FEDERAL/SPECIAL FUNDS:
I
E Federal Funding • 28,000
T
S
-
Subtotal State/Federal/Special $28,000
TOTAL RECEIPTS—equal to Total Expenditu $28,000
Lo . Authorized Official Signature ' Date Br d • Di'is'on/Section Signa re Date
inance Officer Signature Date Accountant Fiscal Management S'• ature Date
DEHNR 2948(Revised 2/93)
General Services Division(Review 2/94)
North Carolina Department of Environment, Health, Page 1 of 4'
and Natural Resources FY 93-94
Division of Epidemiology
CONTRACT ADDENDUM
HIV/STD Control Branch 94-4545-068
Office, Section or Branch
Contract Number
Orange County Health Department
Contractor HIV/STD Control
Activity
Local Health Department HIV/STD Control Objectives
1. By June 30, 1994, 95 % of the staff hired with HIV/STD Control Branch,
FY 93-94 aid-to-county funds for HIV antibody counseling and testing .
will have received training provided by the HIV/STD Control Branch or
by others trained by the Branch. (Statewide objective = 95%)
2 . By June 30; 1994 , 100% of persons receiving confidential HIV antibody
testing will have signed an informed consent form.
3 . By June 30, 1994, 950 of the HIV serology forms designated by the
Division of Epidemiology will have all items answered completely and
accurately. (Statewide objective = 95%)
4 . By June 30, 1994, 100% of all patients testing positive for HIV
will be referred to the HIV/STD Control Branch Regional •
Supervisor within three to seven days of post-test counseling.
5 . By June 30, 1994, 90 % of patients seen in Family Planning and TB
clinics will receive basic information about HIV and other sexually
transmitted diseases. (Statewide objective = 85%)
6 . By June 30, 1994, 95 %. of patients seen in family planning and TB
clinics who receive basic information about HIV/STDs and those whose
behaviors place them at risk for HIV/STDs will be offered HIV
counseling and testing. (Statewide objective = 95%)
7 . By June 30, 1994 , confidential HIV counseling and testing will be
recommended to 15% of all patients seen in STD clinic. (Statewide
objective = 95%)
8 . By June 30, 1994 , 95 % of maternity patients will receive information
about HIV/STDs and be offered HIV counseling and testing. (Statewide
objective = 95%)
Page 2 of 4
FY 93-94
9 . By June 30, 1994 , 90 % of persons tested for HIV return for results
within 3 weeks. (State objective = 90%)
10 . By June 30, 1994 , 9n % of the staff involved in HIV/STD education
activities will have received specific training on HIV/STD
information and education issues. (Statewide objective = 90%)
11. By June 30, 1994 , 80 % of HIV/STD education efforts will target
communities/individuals at risk or potentially at risk for HIV and
other sexually transmitted diseases (e. g. , minorities, gay and
bisexual men, drug users, . women of childbearing age, and
adolescents) . This can include direct educational services to the
targeted population and/or consultation/collaboration with other
agencies serving these populations . (Statewide objective = 80%)
•
•
LOCAL HEALTH DEPARTMENT BUDGET
N.C. Department of Environment,
Health, and Natural Resources Revision Nun)b
Division of General Services /LT
Ste' Division of Epidemiology
P. O. Number
07 / 93 06/ 94 A ) 9 4 4 5 5 1 0 0 6 8
Effective Date Termination Date i)i.A1 Contract Number
Contractor: Oran 8e County Health t)Ppar-traent Activity: Tuberculosis
Project Director: 11anip1 R RPimr Total Budget: $ 13,27-8
II EM DESCRIPTION CLASSIFICATION ITEM AMOUNT
E STATE EXPENDITURES:
Salaries & Fringe Benefits SA/FR 1000 13,218
Operating Expenses OP EXP 2000
p Purchase of Equipment EQUIP 5000
E General Contracted or
N
Purchased Services GENERAL 6100
School choo Health
D
Clinician
I
Laboratory
Pharmacy Services
U
Transfer TXIX
R Subtotal State Expend. $13,218
E LOCAL EXPENDITURES: LOCAL EXP 9000
S
TOTAL EXPENDITURES—equal to Total Receipts $ 13( 2 i 2
LOCAL FUNDS:
R Appropriation APPROP 101
E TXIX TXIX 102
Other Receipts OTHR REC 103
C
E Subtotal Local Funds $
STATE/1EDERAL/SPECIAL FUNDS:
I
P
TB Control 13,218
T /'/55 -6/00 -S/s5 -atv95'
S
Subtotal State/Federal/Special $ 13,218
TOTAL RECEIPTS— equal to Total Expenditures $ 13,218
/ g / i u �� ti�
cal Authorized Official Si atur ,
. z ,2" /3
Date BranchHad Di ion/Section Signature Date
idal
Finance Officer Signature Date A...um Fisca Management Si nnaure Date
I,Itii
DE:-NR 2948(Revised 2/93)
r__—_I¢______n:..:_:__ (11_ -, :n.,
N.C. Department Re-
sources of Environment, Health, and Narural Rources Page 1 of 1
Division of General Services
FY 93-94
CONTRACT ADDENDUM
TB C NTROL BRktiCE 94-4551-068
Office, Section, or Branch Contract Number
TUBERCULOSIS CONTROL
Orange County Health Department
Contractor Activity
1. By June 30, 1994, 90 percent of newly diagnosed cases of TB will complete
treatment within nine months. (State goal = 90%) _
2. By June 30, 1994, 85 percent of newly reported sputum positive TB cases on
treatment will convert their sputum to negative within three months. (State goal
= 850)
3. By June 30, 1994, 75 percent of TB cases are on directly-observed therapy
(DOT) . (State goal = 90%)
4. By June 30, 1994, 90 percent of contacts to infectious TB cases will be
examined within seven days -of recognition of the suspected case. (State goal =
95%)
5. By June 30, 1994, 90 percent of persons eligible for preventive therapy
according to American Thoracic Society (ATS) guidelines will complete a minimum
of 6 continuous months of preventive therapy. (State goal = 90% )
•
Reviewed by
DEHNR 3300(Revised 2/90) ij51
f;vn,rai Servirec 17ivicir',n (Rrvipw I/951 Initials Da e
LOCAL HEALTH DEPARTMENT BUDGET
N.C,. Depainnent of Environment,
Health, and Natural Resources Revision Number
Division of General Services efv6 , (P ,
SFY _ Division of Epidemiology --P. O. Number
07 / 93 06 /94 'o X1.10 9 4 4 5 1 0 0 0 6 8
Effective Date Termination Date 1�' Contract Number
Contractor: _9 nge_ Colmty Health Deapartir nt Activity: Communicable Disease
Project Director: Daniel B. Reimer Total Budget: $ 179 11'1
ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT
E STA'I E EXPENDITURES:
Salaries & Fringe Benefits SA/FR 1000 3,800
Operating Expenses OP EXP 2000
P Purchase of Equipment EQUIP 5000
E General Contracted or
N Purchased Services GENERAL 6100
School Health
D Clinician _ CLN 6863
I
Laboratory ... ................. .. .._......... ........_....... .. ...................... .................... ...
T y LAB 6862
Pharmacy Services RX SERV 6865
U
Tr ansfer TXIX
R Subtotal State Expend. $ 3,800
E LOCAL EXPENDITURES: LOCAL EXP 9000 175,313
S
TOTAL EXPENDITURES —equal to Total Receipts $
LOCAL FUNDS:
R Appropriation APPROP 101 164,878
E IX TXIX 102
5,935
Other Receipts OTHR REC 103 4,500
C
E Subtotal Local Funds 175,313
STATE/FEDERAL/SPECIAL FUNDS:
I
P Corm nzicable Diseasee 3,800
Aid-to-County
T /X0 - ,S-// - C4/OO -,9
S
Subtotal State/Federal/Special $3,800
I TOTAL RECEIPTS—equal to Total Expenditures $ 179,113
/ qV0 -adiCALLIK 5 77" 9 s 60\4'' I a,,,, 6, 't v-/- Z -- --3-- -3
.cal Authorized Official Signature Date sr., od D v'sion/Section Si: .cure Date
.. ,.. .. 200‹.-. 40i \ 6--t 2-33 /8;://12VV ._74',/,,_3 '
Finance Officer Signature Date A��„m,t Fiscal Management Signature Date
in��
DEHNR 2943(Revised 2/93)
.r,tr-.1 CY...,.�..n:.1-:__ I'D-._ , ,f,I,
.-ReG• -415\93 35
• N. C. Department cf Environment, Health, and Natural Resources Pace 1 c`
Division of General Services FY
CONTRACT ADDENDUM
Communicable Disease Control Section 93 4510 068
Office, Section or :Branch Contract Number
Orange County Health Department Communicable Disease
Contractor Activity
I. Negotiable Objectives and Required Items:
1) By June 30, 1993 80 % of the communicable disease reports are
evaluated within 24 hours of receipt by a staff member knowledoeable
about investigation and control of communicable diseases; cases are
confirmed; and appropriate investigations are initiated. (State goal=
90%)
2) • By June 30, 1993 the immunization status of children who receive
- immunization services in-the local health- department is tracked-
and 75 % of 2 year olds are age-appropriately vaccinated. (State
goal=90%)
3) By June 30, 1993 95 % of household contacts of and infants born to
chronic hepatitis B carriers complete prophylaxis within 9 months.
(State goal=95%)
• 4) By June 30, 1993 90 % of patients eligible for preventive •treatment
for TB complete treatment. (State goal=90%)
5) By Dune 30, 1993 90 %' of TB cases complete treatment within 9
months. (State goal=90%)
6) By June- 3D, 1993 95• % of hepatitis A and B cases reported meet case
definitions. (State goal=95%)
• 7) By June 30, 1993 85 % of persons tested for HIV return for results •
within 3 weeks. (State goal=90%)
8) By June 30, 1993 65 % of TB cases are on directly-observed therapy.
(State goal=90%)
9) By July 1, 1992 the local health department will submit a brief plan to
the Communicable Disease Section which outlines their activities to
- provide outreach for individuals and groups at high risk for
communicable diseases (STD, TB, HIV, HBV) or for failure to be
immunized.
10) By July 1, 1992 the local health department will have a written
confidentiality policy consistent with G.S... 130A-143 which all staff
are required to sign and .comply ;with and an annual training session for
• all staff.
II. Basic Local Communicable Disease Control Services:
A. To eliminate organizational barriers which delay or prevent delivery of
communicable disease control services, local health departments should:
1) make no charges to clients for TB & STD diagnosis and treatment,
immunization, HIV testing and counseling;
2) provide STD diagnosis and treatment for uncomplicated GC, Syphilis,
Chlamydia, and NCD on site; patients will be seen within 1 working day
of request, including on a" walk-in basis;
3) provide HIV counseling ..and testing and STD diagnosis and treatment
f._ services to patients as an integral part of STD, prenatal, TB, and
family planning clinics without referral or rescheduling;
Reviewed by
DEHNR 230D (Revised 2/90) • 4-1(1 C'S
General 5e_-vices Division (Review 1/95) Initials Date
36
N.C. Department of Environment, Health, and Natural Resources Page 2 of
_ _ Division of General Services- FY 03
CONTRACT ADDENDUM
Communicable Disease Control Section 93 4510 068
Office, Section or Branch Contract Number
Orange County Health Department Communicable Disease
Contractor Activity
4) provide HIV counseling and testing services to 90% of those requesting
testing within one week of request;
5) provide immunizations as an integral part of child health and family
planning clinics without referral or rescheduling;
6) provide required immunizations within one week by appointment and on a
walk-in basis;
7) -physical exams will not be required prior to immunization unless there
is an acute illness or a neurologic condition that is evolving or has
not been fully evaluated;
8) provide communicable disease control services regardless of patients'
county of residence;
9) suspected TB cases should be evaluated within one working day and
started on therapy within 72 hours;
• 10) contacts of suspected TB cases should be interviewed for
symptoms and screened within 7 days of recognition of
suspected case.
j B. Quality of Services: .
1) local health departments should have current standing orders which are
consistent with control measures for:
a) giving immunizations and avoiding inappropriate contraindications;
b) diagnosing and testing for uncomplicated gonorrhea, syphilis,
. chlamydia, and NGU on-site;
c) beginning preventive therapy for tuberculosis for patients at low
risk for side effects;
d) investigation and management of cases and contacts of reportable
communicable diseases;
e) providing HIV counseling, testing, and .referral.
2) Staff at local health departments who routinely provide communicable
disease services should have sufficient training to:
• a) conduct an investigation to:identify the source of infection and
those at risk for spread of all reportable communicable diseases;
b) conduct STD evaluation, including performance of physical
examinations and laboratory work (gram stain, wet prep,
*- urinalysis, stat RPR, and "stat" or "dry" dark field) , and provide
treatment under standing orders; .
c) monitor TB patients on medications, recognize and provide initial
management for side effects or complications of TB disease;
3) local health departments- should have:
a) back-up from a physician knowledgeable about public health
communicable disease control needs for each facet of its
communicable disease control Program; and
rJ • . Reviewed by
r 1
Dec 33D0 (Revised 2/90) (� 0 - t;, c(�
General Services Division (Review 1/95) Initials Date
•
' N.C. Department of Environment, Health, and Natural Resources Page 3 of7
. Division of General Services FY 93
CONTRACT ADDENDUM
Communicable Disease Control 'Section '
` 93 4510 068 -
Office, Section or Branch Contract Number
Orange County Health Department Communicable Disease
Contractor Activity
b) a plan for making medical and psychosocial referrals when services
needed for conmmunicable disease (STD, TB, HIV, vaccine-preventable
disease) clients are not provided at the local health department.
4) local health departments should have an infection control policy,
including:
a) management of clients so that airborne diseases (measles, TB) are
not transmitted in the clinic;
b). blood and body fluid precautions are followed .with -all patients;
c) routine aseptic technique is followed to prevent nosocomial
infection and infection of staff;
d) staff with direct patient contact are required to be immunized
against measles, mumps, rubella, and influenza, and, those at high
risk, against hepatitis B;
e) • management of blood exposures for patients or staff;
5) local health departments assures that protocols for jail inmates health
care include appropriate screening, and treatment and reporting for TB,
STDs, and other communicable diseases are consistent with control
measures.
JO .
Reviewed by
D DiR 3300 (Revised 2/90) (7L) i-{-)(y, c4?)
General Services Division (Review 1/95) Initials Date
•
•
•
REC4,` t . •_;
APR,P1) _ ,93
OCHD Communicable Disease
Outreach Activities
Activities to provide outreach for individuals and groups at risk
for communicable diseases (STD, TB, HIV, HBV or for failure to be
immunized) will include:
1 . Regularly submitted PSA's and news releases to local
radio stations and newspapers on services available.
2 . - Distribution of OCHD services brochure to local agencies
such as DSS, Cooperative Extension, IFC, Homeless
Shelter, OCIM, OPC Mental Health, JOCCA.
3 . Maintain working relationship with agencies who serve
individuals from at risk groups such as AIDS Service
Organizations, local private medical providers , OCCHS,
UNC Hospitals, schools, UNC-CH, Commission for Women,
Coalition for Battered Women as well as those listed in
#2 .
4 . Provide information through OCHD's Minority AIDS
Education Project, "In ' the Know" (targets minority
youth) .
5 . Provide information through screenings and programs in
targeted community settings such as public housing,
homeless shelter, churches, community center, women's
groups , worksites.
6. Information provided by home visiting staff (nurses,
social workers, maternal outreach workers and community
health assistants ) to clients, household and friends.
7 . Health education classes on HIV/STD done in the schools
by OCHD nurses and health educators .
8 . One-on-one counseling, group education, educational
materials, displays to clients who attend OCHD clinics.
LOCAL HEALTH DEPARTMENT BUDGET
N.C. Depaitment of Environment,
Health, and Natural Resources Revision Number_
Division of General Services a/,.. _7 jJ 9
SFY Division of Maternal and Child Health
P. O. Number
07/ 93 06 / 94 cet 4;12 5 1 5_1 Q 0 6 8
Effective Date Termination Date 1/II Contract Number
Contractor: Prange Cnnnty Health Department Activity: Family Planning
Project Director: TlaniP1 B.Reimer Total Budget: $ 487-,997
ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT
E STATE EXPENDITURES:
X Salaries & Fringe Benefits SA/FR 1000 98,342
Operating Expenses OP EXP 2000
p Purchase of Equipment EQUIP 5000
E General Contracted or
N Purchased Services GENERAL 6100 5,777
School Health SC1-I::HLT
D Clinician CLN 6863
I i
Z, Laboratory AB L 6862
Pharmacy Services 4.J S .. 6$65 ;:
U Transfer TXIX
R Subtotal State Expend. $ 104,119
E LOCAL EXPENDITURES: LOCAL EXP 9000 383,878
S
TOTAL EXPENDITURES —equal to Total Receipts $ 487,997
LOCAL FUNDS:
R Appropriation APPROP 101 351,583
E TXIX TXIX 102 22,195
Other Receipts OTHR REC 103 10,100
C
E Subtotal Local Funds $383,878
STATE/FEDERAL/SPECIAL FUNDS:
I
p 13111C Ftmds . DENtiR
l515 .- 6(0 0 - 5151 - 7XXx £ 22162 }3.
T
Non-HII3C Funds , 81,957
S
Subtotal State/Federal/Special $ 104.A 119
TOTAL RECEIPTS—equal to Total Expenditures $ 487,997
' iA° , )
"ca'Authorized Official Signature , D to Branch xod Division/Section Signature Date
/ Initial
�G �--is_q3
F".."---
i ante Officer Signature Date Accountant Fiscal Management Signature Date
DEHNR 2948(Revised 2/93)
General Services Division(Review 2/94)
N.C. Department of Environment. Health, and Natural Resources Page 1 of 4
Division of General Services FY 1993-94
CONTRACT ADDENDUM •
Women's Preventive Health Branch 94-5151-068
Office, Section, or Branch Contract Number
Orange County Health Department Family Planning •
Contractor Activity •
1. 265 new patients age 20 and above will be served.
110 new patients age 19 and under will be served.
3. 915 total persons age 20 and above will be served.
4. 370 total persons age 19 and under will be served.
5. 12 % of low income women (age 20 and over) at or below 150% of federal
poverty level will be served: •
6. 80 % of the total caseload at or below 150% of the federal poverty level will
be served.
7. 13 % of sexually active teens (age .19 and under) will be served.
8. The local health agency has written policies in place for family planning services:
(a) Description of local family planning services, including local
protocols, standing orders and components of Initial, Complete,
Limited and Extended Revisits.
(b) Tracking mechanism for follow-up of abnorulaI tests,
referrals and other indicators.
•
(c) Follow-up of family planning patients with positive pregnancy tests to
assure patient has access to health care provider. (N0'1 E: An
intermediate sensitivity urine pregnancy test which can reliably detect
pregnancy within 14 days of conception should be used.)
(d) Follow-up of missed appointments.
(e) Follow-up and protocol for clients wanting permanent
contraception.
Reviewed by
DEHNR 3300 (Revised 2/93)
General Services Division (Review 1/95) Initials Date
N.C. Department of Environment, Health, and Natural Resources Page 2 of 4
Division of General Services FY 1993-94
CONTRACT ADDENDUM
Women's Preventive Health Branch 94-5151-068
Office, Section, or Branch Contract Number
Orange County Health Department Family Planning
•
Contractor Activity
(f) Offering HIV-SID prevention method (condoms and
spermicide) to clients who have high-risk behaviors (use high-
risk behaviors for HIV as defined by HIV/SID Prevention
Program).
(g) Identification of high risk contraceptors.
(h) Counseling family planning postpartum clients to delay
pregnancy for at least 12 months after delivery.
9. 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
consists of: medical; social; family; surgical; menstrual;
douching; contraception; drugs/medication; obstetrical and
immunization (Td, Rubella) on initial or complete visits.
(b) All patients will receive an annual physical examination on
initial or complete visits which consists of: 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.
10. The following tests will be obtained on all initial or complete visits and
documented in the medical record:
(a) Hematocrit or hemoglobin
(b) Urinalysis for sugar and protein
(c) Pap smear
(d) Gonorrhea culture
Reviewed by
DEHNR 3300 (Revised 2/93) 2
General Services Division (Review 1/95) Initials Date
N.C. Department of Environment, Health, and Natural Resources Page 3 of 4
Division of General Services FY 1993-94
CONTRACT ADDENDUM •
Women's Preventive Health Branch 94-5151-068
Office, Section, or Branch Contract Number
Orange Co. Health Department Family Planning
Contractor Activity
(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. •
11. 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 immune,
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 complete visits is not required if '11.) vaccine was
given and documented within the last ten years. If-no
documentation, Td vaccine should be given (See Medical
Guidelines).
12. 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.
(b) Client received additional information on 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.
Reviewed by
DEHNR 3300 (Revised 2/93) C ��3�/�-
General Services Division (Review 1/95) Initials Date
N.C. Department of Environment, Health, and Natural Resources Page 4 of 4
Division of General Services FY 1993-94
CONTRACT ADDENDUM
Women's Preventive Health Branch 94-5155-068
Office, Section, or Branch Contract Number
Orange Co. Health Department Family Planning
Contractor Activity
(d) Breast self examination was taught or education reviewed.
(e) Minors under 18 years of age were counseled about the
importance of discussing birth control needs with parent(s)
and minor signs foul'.
(f) Information about emergency and after-hour services was provided.
13. Method specific consent form was reviewed with client, dated, signed by
client, and copy given to client.
(a) Consent forms are updated and resigned with any change in
method, or change in prescription of same method.
(b) Any individual risk to contraceptive method was identified on
the method specific consent form.
14. Screening, Diagnosis, Treatment and Follow-up Services
There is evidence in the record that:
(a) Significant problems are identified and documented.
(b) Problems, conditions and abnormal findings are appropriately
followed.
(c) There is evidence that clinical and laboratory findings were
discussed with client.
15. The highest level provider of care on all Initial and Complete Visits for
oral contraceptive, IUD, NorpIant and Depo Provera users was a physician
or physician extender (nurse practitioner, CNM or physician assistant).
Reviewed by
DEHNR 3300 (Revised 2/93) C7 4---)3/ .3
LOCAL HEALTH DEPARTMENT BUDGET
N.C. l5epartmenc of Environment,
Health, and Natural Resources Revision Number_
Pivision of General Services F�f//
SFy Division of Maternal and Child Health
P. O. Number
07 / 93 06 / 94 1 q� 5 3 1 8 0 0 6 8
Effective Date Termination Date W Alin Contract Number
1'
Contractor: Orange County Health Department Activity: Child Service Coordination
Project Director: Daniel B. Reimer Total Budget: $ 133,413
ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT
E STATE EXPENDITURES:
X Salaries & Fringe Benefits SA/FR 1000 51,377
Operating Expenses OP EXP 2000
P Purchase of Equipment EQUIP 5000
E General Contracted or
N Purchased Services GENERAL 6100
School Health SCH HLTH 6200
D Clinician CLN 6863
I
T Laboratory LAB 6862
Pharmacy Services RX SERV 6865
LJ Transfer TXIX
R Subtotal State Expend. $51,377
E LOCAL EXPENDITURES: LOCAL EXP 9000 82,036
S
TOTAL EXPENDITURES—equal to To Receipts $133,413
LOCAL FUNDS:
R Appropriation APPROP 101 27,316
E TXIX TXIX 102 54,770
Other Receipts OTHR REC 103
C
E Subtotal Local Funds $ 82,036
STA'i h/FEDERAL/SPECIAL FUNDS:
I
P Child Service Coordination 51,377
T
IS
Subtotal State/Federal/Special $ 51,377
I
TOTAL RECEIPTS—equal to Total Expenditures $ 133,413
i ' X��i 2/ 3
� ,/ � 7,,;t7,1-61,,, ,e_)- 7/ /L3
• . Authorized Official Si atur- , Date a �off�' Division/Section Signaturec
Date
.�� • _am* ��7 -7 3 r ).-',,y— 3
Finance Officer Signature Date A.W,.t Fiscal Management Signatgr Date
wt;.1
DE} R 2948(Revised 2/93)
General Services Division(Review 2/94)
N.C. Department of Environment, Health, and Natural Resources Page 1 of 1
Division of General Services
FY 1993-1994
CONTRACT ADDENDUM
Children and Youth Section 93-5356-068
Office, Section, or Branch Contract Number
Orange County Health Department Child Service Coordination
Contractor
Activity
•
CHILD SERVICE COORDINATION
1. An estimated 200 (number) eligible children birth through age five will receive Child
Service Coordination through the local health department.
2_ All enrolled children will receive the following minimum program components:
- client file containing full demographic information;
- complete Identification and Referral Form (DEHNR 3748) ;
- signed Letter of Agreement between CSC and family;
- signed release of information as appropriate for exchange of records between appropriate
providers;
- strengths/needs assessment and complete assessment of parent-child interaction;
- mandated minimum contact by designated Child Service Coordinator including
1. review and update of risk indicators,
2. assessments and care coordination plan and
3 . monitoring of the provision of services by referral sources;
- documentation of referral and follow up of the Intermediate Assessment or Denver II
screening for appropriate children-at indicated times;
- provision of or arrangement for appropriate educational materials and counseling/support
services as specified in the Care Coordination Plan;
- completion of Status Report Forms (DEHNR 3750) at specified intervals;
- documentation and appropriate assistance regarding transfer of families to new service
coordination agency when appropriate;
- documentation and appropriate assistance regarding closure of families to the Child
Service Coordination Program;
- records organized according to MCH program requirements.
3. Enter Identification and Referral Forms and Status Report Forms for all enrolled children
regardless of CSC agency into the computer system' at the health department.
Maintain signed Provider Agreement for Child Service Coordination with all county
providers participating in the Child Service Coordination Program. (Attach Agreements for
FY 1993-94)
_. Child Service Coordination staff must meet the qualifications as specified in the manual.
H_intain roster of health department staff, professional discipline and hours per week
roviding CSC.
List Child Service Coordinator or contact person:
Rebekah Hermann (919 )732-8181, ext. 2400
Name Phone
Reviewed by
DEHNR 3300(Revised 2/90) � y�'
General Services Division (Review 1/95) Initials Date
LOCAL HEALTH DEPARTMENT BUDGET
N.C. DepaiunLent of Environment, /3 .
Health, and Natural Resources 1 Revision Number_r.
Division of General Services ✓, •
sF ( , Division of Maternal and Child He lth P. 0. Number
07 / 93 06/ 94 5 3 2 3 0 0 6. 8
Effective Date Termination Date Contract Number
Contractor: Orange Cnnty Heal th Department Activity: CSHS Orthopedic
m
Project Director: Tani e1 R. Reiner Total Budget: $ 628
ITEM DESCRIPTION CLASSIFICATION I't"EM AMOUNT
E STATE EXPENDITURES:
X Salaries & Fringe Benefits SA/FR 1000 388
Operating Expenses OP EXP 2000
P Purchase of Equipment EQUIP 5000
E General Contracted or -
N Purchased Services GENERAL 6100 75
School Health ';SCI '; II..TI-I . >6200$;. .w
D Clinician CLN 6863 165
I
T Laboratory LAB 6862
Pharmacy Services RX SERV 6865
U Transfer TXIX 6864
R Subtotal State Expend. $628
E LOCAL EXPENDITURES: LOCAL EXP 9000
S TOTAL EXPENDITURES —equal to Total Receipts $ -0-
LOCAL FUNDS:
R Appropriation APPROP 101
E TXIX TXIX 102
Other Receipts OTHR REC 103
C
Subtotal Local Funds $
E STA'1 E/FEDERAL/SPECIAL FUNDS:
I
P Scoliosis Clinic 628
T
S
Subtotal State/Federal/Special $ 628
TOTAL REC • S — equal to Total Expenditures $ 628
ii, `g661/i/.dee )1/27 ') G}u> \Y �. 7/.- e�.�>,te ) . 7/7/ ',
Local Authorized Official Signa , Date aR'a;H � Division/Section Signature Date Inical
// ( c- iI--q'S
/9-/2/1/1,;.-(71- �%77-1 -2/51195
Finance Officer Signature • Date accou ur Fiscal Management Signatur Date
wiixl
rrtnrn -,nAo m _.___I-I inoN •
•
N.C. Department of Environment, Health, and Natural Resources Page 1 of 2
Division of General Services
FY 1993-1994
CONTRACT ADDENDUM
Children and Youth Section 93-5323-068
Office, Section, or Branch Contract Number
Orange County Health Department Children's Special
Scoliosis Clinic ADMINISTRATIVE SECTION Health Services
Contractor Activity
An estimated . _35 (total number) of clients will be served through this clinic.
Refer to HSIS Report: HBS 124 II.
3. An estimated 25 (number) of new clients will be admitted to this clinic.
Refer to HSIS Report: HBS 124 II.
3. An estimated 35 (number) of client visits will be made to this clinic.
Refer to HSIS Report: HBS 124 III. •
An estimated N/A (number) of eligible* clients will receive speech therapy.
Refer to HSIS Report: HBS 124 IIIB. Applies only to Speech and Hearing Clinics.
5. List counties which are served by this clinic.
1. Orange 3. 5.
2. 4. 6.
List all services funded through this contract, such as laboratory and diagnostic services,
casting, therapy, etc.
1. x-rays 2. 3..
4. 5. 6.
7. Attach a copy of the eligibility criteria used in this clinic.
CSHS Criteria
3. Do you bill individuals above poverty for diagnostic services? Yes' J NoJT If yes, attach
copy of fee schedule.
3. When do you complete a financial eligibility foim?
]1st visitflonce diagnosis is made Uwhen a cost service is needed[ they Please
explain none completed
3. Do you bill private insurance? Yes[1 No 71
1. Attach a list of subcontractors funded by this contract stating name, address and discipline,
e.g. identify the physicians who staff the clinic, sources of x-rays, therapists, etc.
N.C. Spine Center, Dr. Stephen Grubb, 101 Conner Dr. , Suite 200, Chapel Hill, NC 27514
2. Who are the durable medical equipment suppliers? Applies to Orthopedic, Neuromuscular, and
Myelodysplasia Clinics.
Name: N/A Company: Phone:
3. Who is the clinic coordinator or contact person? 14. Name of person who completed the contra
addendum:
Name: Leigh McFalls Phone: (919) Name Leigh McFalls Phone: (919)
732-8181 d 732-8181 ext. .2400
2lients not covered by Medicaid or other thi€4tpatfQ9 Reviewed y
DEHNR 3300 (Revised 2/90) `� �� J�3
General Services Division (Review 1/95) Initials J Date
•
N.C. Department of Environment, Health, and Natural Resources page 2 of 2
Division of General Services
FY 1993-1994 -
CONTRACT ADDENDUM
Children and Youth Section 93-5323-068
Office, Section, or Branch Contract Number
Orange County Health Department Children's Special
Scoliosis Clinic Health Services
Contractor Activity
CLINICAL SECTION
Persons enrolled in a CSHS Clinic will be provided the following services as documented in
their medical records and in accordance with CSHS Clinical Guidelines.
1. An estimated * % will receive a health history which includes the following components:
present problem, past medical history, developmental history, caregiving history/status,
nutrition history and family history.
2a. An estimated * % will receive at each visit a review of systems pertinent to the
problem which includes the following components: head, skin, eyes, ears, mouth, throat,
neck, respiratory, cardiovascular, gastrointestinal, skeletal and neuromuscular.
Applies to Orthopedic, Neurology, Cardiology, Neuromuscular, and Myelodysplasia Clinics.
2b. An estimated N/A % will receive at each visit a review of systems pertinent to the
problem which includes the following components: head, ears, mouth, throat and neck.
Applies only to Speech and Hearing Clinics.
3. An estimated * % will receive the following health related assessments: behavior,
medications, immunization, and nutrition/growth.
4. An estimated 100 % will receive at each visit a pertinent physical examination and blood
pressure as indicated. One-time per year year scoliosis clinic, 100% of patients will
receive a pertinent examination without blood pressure.
5. An estimated N/A % of children who have special needs related to appliances, equipment
and supplies will be assessed and these needs will be addressed in the plan of care.
6. An estimated 100 % will have a written diagnosis.
7. An estimated 100 % will have a plan of care.
8. An estimated N/A % will receive diagnostic tests as indicated in the plan of care.
9. An estimated N/A % will receive treatment services as indicated in the plan of care.
All patients are referred for treatment.
10. An estimated 100 % will receive follow-up of missed appointments.
11. An estimated 100 % will receive follow-up of treatment and referral recommendations.
12. An estimated 100 % will have documentation of summary clinic notes sent to referral
sources and appropriate providers.
13. An estimated 100 % will have education and counseling provided for each diagnosis and for
prescribed treatment.
_N/A, one time per year scotinsisclinic.
it corthract addendum for Children's Special Health Serivices includes information pertaining to the annual scoliosis clinic.
are unable to complete the form in its entirety due to the uniqueness of our one-time per Reviewed by
ar clinic and have made notations when necessary. Please callus if you have any questions,,,,yy�l '
DEHNR 3300 (Revised 2/90) on our submitted addendum. It�1 A ����3
General Services Division (Review 1/95) Initials Date
N.C. Department of Environment, Health, and Natural Resources Page 1 of 2
Division of General Services
FY 1993-1994
CONTRACT ADDENDUM
Children and Youth Section 93-5323-068
Office, Section, or Branch Contract Number
Orange County Health Department Children's Special
Scoliosis Clinic • ADMINISTRATIVE SECTION ' Health Services
Contractor Activity
1. An estimated . 35 (total number) of clients will be served through this clinic.
Refer to HSIS Report: HES 124 II.
•
2. An estimated 25 (number) of new clients will be admitted to this clinic.
Refer to HSIS Report: HBS 124 II.
3. An estimated 35 (number) of client visits will be made to this clinic.
Refer to HSIS Report: HBS 124 III.
1. An estimated N/A (number) of eligible* clients will receive speech therapy.
Refer to HSIS Report: HBS 124 IIIB. Applies only to Speech and Hearing Clinics.
5. List counties which are served by this clinic.
. 1. Orange 3. 5.
2. 4. 6.
List all services funded through this contract, such as laboratory and diagnostic services,
casting, therapy, etc.
1. x-rays 2. 3.
4. 5. 6.
7. Attach a copy of the eligibility criteria used in this clinic.
CSHS Criteria
Do you bill individuals above poverty for diagnostic services? Yes' ' Non If yes, attach
copy of fee schedule.
R. When do you complete a financial eligibility form?
Elst visit)—hnce diagnosis is made' Iwhen a cost service is neededEother Please
explain none completed
D. Do you bill private insurance? Yes i--1 No n
_. Attach a list of subcontractors funded by this contract stating name, address and discipline,
e.g. identify the physicians who staff the clinic, sources of x-rays, ttherapists, etc.
N.C. Spine Center, Dr. Stephen Grubb, 101 Conner Dr. , Suite 200, Chapel Hill, NC 27514
2. Who are the durable medical equipment suppliers? Applies to Orthopedic, Neuromuscular, and
Mvelodysplasia Clinics.
Name: N/A Company: Phone:
3. Who is the clinic coordinator or contact person? 14. Name of person who completed the contr.,
addendum:
Name: Leigh McFalls Phone: (919) Name Leigh McFalls Phone: (919)
732-8181 732-8181 ext. :2400
_li ents not covered by Medicaid or other'thi€ paQ? �Ryeview y
DEHNR 3300 (Revised 2/90) `� /-0 tri �
General Services Division (Review 1/95) initials Date
LOCAL HEALTH DEPARTMENT BUDGET
N.C. Depaitnent of Environment,
Health, and Natural Resources Revision Number_
Division of General Services
SFY Division of Maternal and Child Health
P. O. Number
07 / 93 06 / 94 9 4 5 4 0 2 0 0 6 8
Effective Date Termination Date Contract Number
Contractor: Orange Cnrn.ty Health LIpar-nent Activity; MCH Block Grant Nutrition
Project Director: lbni el B, Reimer Total Budget: $ 2,450
I'IEM DESCRIPTION CLASSIFICATION I"l'hM AMOUNT
E STA'I E EXPENDITURES:
X Salaries & Fringe Benefits SA/FR 1000 2,450
Operating Expenses OP EXP 2000
P Purchase of Equipment EQUIP 5000
E General Contracted or
N
Purchased Services GE ,'ERA;j 6I00
School Health SCH .FILTH .. X6200
D Clinician Ch 1 6863 .
I
Laboratory LA:B 6862
T Pharmacy Services RX SERV'> :6865
U Transfer TXIX
R Subtotal State Expend. $2,450
E LOCAL EXPENDITURES: LOCAL EXP 9000
S
TOTAL EXPENDITURES—equal to Total Receipts $2,450
LOCAL FUNDS:
R Appropriation APPROP 101
E TXIX TXIX 102
Other Receipts OTHR REC 103
C
E Subtotal Local Funds $
STA I E/FEDERAL/SPECIAL FUNDS:
I
P MCH Block Grant Nutrition 2,450
T
S
Subtotal State/Federal/Special $2,450
TOTAL RECEIPTS — equal to Total Expenditures $2,450 .
littd /AO -. 5/ .2/53
•cal A.thorize. Official Signa �, Date sr„d,H d Division/Section Sig attire Date
w�
/ /
_ � 42-i_ ,/:?...i'LL 6/1„0-w--yt.... 1 -2
Finance Officer Signature Date A r,rn Fiscal Management Signature Date
1114¢21
r,rvwm 'In A /n_.___.,-,roes
N.C. Department of Environment, Health, and Natural Resources Page 1 of 1
Division of General Services
- Fl 94
CONTRACT ADDENDUM
Nutrition Services Section 93-5402-068
Office, Section, or Branch Contract Number
Orange County MOH Block Grant Nutrition
Contractor Activity
1. 70 hours of MCH Block Grant Nutrition Services will be provided to
the target population.
2. The following individuals who are registered dietitians (or registry
eligible) or licensed dietitians/nutritionists will provide the nutrition
services for this agency. **
Name Credentials
LAUREL ELLZEY REGISTERED DIETICIAN
** Documentation of credentials should be on file in local agency.
Revie by
DEHNR 3300 (Revised 2/9C ;2/ Y--3
r r
)
LOCAL HEALTH DEPARTMENT BUDGET
N.C. Department of Environment, /,7 IL-Health, and Natural Resources , lC 3 Revision Number
Division of General Services ( /''c21/4- Q
SFY Division of Adult Health °-' `
P. O.Number
07 / 93 06 / 94 9 4 5 4 _5__2___0__0_ L 8
Effective Date Termination Date Contract Number
Contractor: Orange County_Health Depart-mm rnt Activity: COMP. Breast & Cancer Control
_ ttn
Project Director: Daniel B. Reimer Total Budget: $-n-r-9-42- 3.2 1 q S--1
ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT
E STA'I E EXPENDITURES:
Salaries & Fringe Benefits SA/FR 1000 14,422
X Operating Expenses OP EXP 2000
P Purchase of Equipment EQUIP 5000 642
E General Contracted or
Purchased Services GENERAL 6100 9,650
N School Health : IH; Th; :.
D Clinician CLN 6863
Laboratory LAB 6862
Pharmacy Services
xRa hRY ntinSISM` ` ::
U
Transfer TXIX >< 1` ........ 481:<.::.:,.::::::: _ ;:
R Subtotal State Expend. $24,714
E 8,23 8
LOCAL EXPENDITURES: LOCAL EXP 9000 -9,ttI
S 32_, gS-2"
TOTAL EXPENDITURES —equal to Total Receipts $337$
LOCAL FUNDS:
R Appropriation APPROP 101
E TXIX TXIX 102 -g-7-3-
Other Receipts OTHR REC 103 t n k i Rd 8;738
C
E Subtotal Local Funds $ 9,11i 8
E STA'I E/FEDERAL/SPECIAL FUNDS:
I
Breast and Cervical Cancer 24,714
P Control Program
T 154-S- (060 - 5462 - 0/344
S
Subtotal State/Federal/Special $24,714
3-1, qs .
TOTAL RECEIPTS— equal to Total Expenditures $33-gr-
i i� • £'IM C•--7 `/ q3
Local Authorized Official Signia Date MB7 i '�d3 Division/Section Signature Date
•
, .--a,.-4D<- 7, . .5--/2-if) Ar .4' 1 : ; i Z/787 -3
Finance Officer Signature Date AcInitiacounl �'
tant Fiscal Management Signal Date
DEHNR 2948(Revised 2/93)
General Services Division(Review 2/94) i.
NORTH CAROLINA
COMPREHENSIVE BREAST AND CERVICAL CANCER CONTROL PROGRAM
CONTRACT ADDENDUM
•
NEEDS
CERVICAL CANCER: Between 1980 and 1987 , 1400 women in North
Carolina died of preventable cervical cancer. The age-adjusted
mortality rates for the white population are 3 . 5/100, 000 and 10 . 6
for the black population. For Native Americans, the rate is twice
as high as for whites.
The mortality percentage for women age 35 and older has
increased from 91% in 1985 to 94% in 1989 .
BREAST CANCER: In 1989 , 1099 women died of breast cancer in
North Carolina making it the leading cause of cancer deaths in
women in the state. North Carolina's mortality rate of
26 .4/100, 000 ranks twenty third iii ' the United States . In race-
adjusted mortality rates, white women are 25 . 6/100, 000 and black
women are 30 . 7/100 , 000 . For both races, mortality rates are much
higher among older women. In 1986-1987, for example, the mortality
for women less than 50 years was 6 . 4 while that for those 50 and
older was 91.4/100 , 000.
TARGET POPULATION: Older and minority women in North Carolina
are least likely to be screened and most likely to die. The target
population includes women who are at or below 200% of poverty, are
older, are un-/underinsured and are minorities, including Native
Americans. Women who are or have been sexually active, or have
reached the age of 18 years are eligible for cervical cancer
screening. Women who are 40 years and older are eligible for
breast cancer screening.
INTERVENTIONS
BREAST SCREENING AND FOLLOW UP: A Clinical Breast Examination
(CBE) and instruction on Self Breast Examination will be provided
to each woman screened. Clinical Breast Examination (CBE) will be
performed every three years for women 20 - 40 years old and yearly
thereafter. Between the ages of 40 and 49 one screening mammogram
is allowed every other year, unless the woman is high risk. For
women 50 years and older, screening mammograms are provided
annually. The woman is considered to be at high risk for breast
cancer if one or more of the following conditions apply:
Page 2
Contract Addendum •
i. Personal history of breast cancer;
2 . Personal history of biopsy-proven benign breast
disease;
3 . A mother, sister or daughter had breast cancer; or
4 . Not having given birth prior to age 30 .
If these American Cancer Society (ACS) guidelines are updated,
the BCCCP will abide by the new ones .
Diagnostic mammographies are performed when medically
appropriate.
CERVICAL SCREENING AND FOLLOW UP: For women who are or have
been sexually active and are 18 years old or older, the screening
includes a bimanual pelvic exam, and a Papanicolaou smear every
year. After a woman has had three or more consecutive satisfactory
normal annual examinations , the pap test may be performed less
frequently at the discretion of her physician. Repeat pap tests
and colposcopy directed biopsies will be provided as medically
indicated.
Breast and Cervical Cancer Screenings will be provided to 191
women during the contract period:
1.78 of these women are 40 years and older and will receive
breast cancer screenings and follow-up.
178 of these women are 40 years and older and receive
cervical cancer screenings and follow-up.
13 of these women are under the age of 40 and receive
cervical cancer screenings and follow-up.
QUALITY ASSURANCE AND CONTINUOUS QUALITY IMPROVEMENT: The
contractor must provide or assure the provision of high quality
services throughout the program's components. For laboratories,
this means Clinical Laboratory Improvement Amendments of 1988 (CLIA
' 88) certification. The Bethesda System of reporting will be
required for results of pap tests.
For mammography facilities, American College of Radiology
(ACR) accreditation must be obtained. Any facility that provides
screening services to this program must apply for ACR creditation
prior to January 1, 1993 . Reporting results will be, in accordance
with the Categories from the ACR Breast Imaging Reporting and
Database System.
ACS guidelines must be followed regarding the frequency of
screenings. The contractor will assure compliance with the
certifications, accreditations and guidelines.
Page 3
Contract Addendum
PROTOCOLS : The local contractor will follow the medical
protocols provided by the State. Pap Smear Screening: A Guide for
Health Departments will be used for cervical cancer screening and
follow-up guidelines will be developed by the Program by
December 15, 1992 .
PUBLIC AND PROFESSIONAL EDUCATION: The local contractor will
participate in educational opportunities provided by the North
Carolina Comprehensive Breast and Cervical Cancer Control Program
and other continuing education as appropriate.
SURVEILLANCE: Minimum data elements (MDE's) are required by
the Centers for Disease Control in order to amass the statistics to
provide to the Congress for the research component of this program.
The contractor will submit the MDE' s to the state on a quarterly
basis according to the schedule provided.
FUNDING: There is a 3 : 1 Federal : non-Federal matching
requirement; therefore, the local contractor will provide the non-
Federal match on the funding received from the State under this
contract. If a sliding fee scale is used, it will be the same as
the Family Planning fee scale. No woman at or below 100% of the
• federal poverty level may be charged for services provided by this
program. The sliding fee scale must be posted in order for the
clients being served to view it. The BCCCP is the payor or last
resort after Medicare, Medicaid, Title X, and private insurance.
REFERRAL: ' The contractor will assure that a referral system
for the diagnosis and treatment of all abnozuial findings is
developed and a written protocol is available. The contractor will
designate a person who will be responsible for implementing a
follow-up protocol which ensures, to the best of their ability,
that no patient who receives program reimbursement services or
requires follow-up or medical treatment is lost to follow-up. For
all abnozlual results the following information will be documented:
1) follow-up appointment information (date and follow-up
location) -
2) patient contact information (number and date of attempts
made to follow-up)
3) referral information (date and referral source) .
This contract addendum will cover the period from July_ 1, 1993
to June 30 , 1994.
4,410", _5/7179_3
Local Health Director Date
Orange County Health Department
Health Department
LOCAL HEALTH DEPARTMENT BUDGET
'?.C. Department of Environment,
Health, and Natural Resources `- Revision Number
Division of General Services 133 6
\F`f Division of Adult Health 1y,i.)/93
P. O. Number
07/ 93 06 / 94 9 4 5 5 0 2 0 0 6 8
Effective Date Termination Date Contract Number
ontractor: Orange County Health Department Activity: Adult Health
Project Director: Daniel B. EZeimer Total Budget: $ 94,846
ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT
E STA I.E.EXPENDITURES:
Salaries & Fringe Benefits SA/FR 1000 5,446
X Operating Expenses OP EXP 2000
P Purchase of Equipment EQUIP 5000
E General Contracted or
N Purchased Services GENERAL 6100
School Health SCH iHLTIt :` 6200.::. ... . ;: . 444`4.
D Clinician CLN 6863
I
Laboratory LAB 6862
T Pharmacy Services RX SERV 6865
IJ Transfer TXIX
R Subtotal State Expend. $5,446
E LOCAL EXPENDITURES: LOCAL EXP 9000 89,400
S
TOTAL EXPENDITURES —equal to Total Receipts $94,846
LOCAL FUNDS:
R Appropriation APPROP 101 89,400
E TXIX TXIX 102
Other Receipts OTHR REC 103
C
E Subtotal Local Funds $89,400
STATE/FEDERAL/SPECIAL FUNDS:
I -
P Adult Health 5,446
T
S
Subtotal State/Federal/Special $ 5,446
TOTAL RECEIPTS —equal to Total Expenditures $ 94 846
i1 ' . / ' / SC,(•(,
Local Authorized Official Signat; 'e Date Branch xod Division/Section Signature Date
initial
- -- 6--/7.—?3 kill ' /
Finance Officer Signature Date Accountant Fiscal Management Signature Date
Initul
DEI-LNR 2948(Revised 2/93)
r---.1 s..,,;,-.<n;t„<;,,n rR—A.,,,7 boa\
N.C. Department of Health Environment, Health, and Narnrai Resources
Page 1 of 5
CONTRACT ADDENDUM
• FY 93-94
Adult Health Promotion 94-5502-068
Office, Section, or Branch Contract Number
Orange County Health Department Adult Health
Contractor Activity
A. Adult Health Problems/Needs, Program Area/Focus
1. Problems/Needs in Communities
Identify the most important adult health problems/needs in your communities.
Cardiovascular disease is the leading cause of mortality and shows
a disproportional risk for minority populations based on 1986-1990
race-sex-specific age-adjusted rates.
Total white male Non-white male White female Non-white female
183.8 227 .7 275.5 124.1 218.3
Estimated percentage for adult prevalence of selected risks
factors based on 1990 Behavioral Risk Factor Survey .
Total White male Non-white male White female None-white female
overweight 29% 29% 34% 25% 48%
hypertension 19% 16% 17% 19% 29%
2. Program Area/Focus Reducing cardiovascular disease through focusing
on hypertension and weight control activities.
a. Identify the problem(s) you will address in this contract by placing a check mark(s)
beside the appropriate item.
Heart Disease/Hypertension/Stroke X Cancer:
Diabetes Breast •
Glaucoma Cervical
Arthritis Colorectal
Renal Disease Prevention Lung
Sedentary Lifestyle Prostate
Cholesterol Tobacco Use:
Nutrition Smoking
Obesity X Smokeless
Other, Specify:
b. Does your contract address the following:
1. Adult Health Physical
Assessment No
2. Primary Care No
Reviewed by
DEt3NR 3300 (Revised 2/90)
General Services Division (Review 1/95) Initials Date
N.C. Department of Health Environment, Health, and Natural Resources
Page 2 of 5
CONTRACT ADDENDUM
• Fy 93-94
Adult Health Promotion 94-5502-068
Office, Section, or Branch Contract Number
Orange County Health Department Adult Health
Contractor Activity
B. Target Group(s)
First name your target group(s), then refer to the attached "Target Group Descriptors" sheet
to complete this section. From each category, select the descriptor(s) that best describes your
target group(s). You may choose one(1) or more descriptors per category. Example of
category: Age. Example of descriptor: young adults 18-34 years.
Complete as many categories as is possible.
1. Target Grp. Name Black community members2. Target Grp. Name local primary care physicia:
Age. . 18 and over Age 25 plus
Race black Race all
Gender both Gender both
Occupation varies Occupation physicians
Education varies Education Doctor of Medicine-
Income varies Income Unknown
Underserved yes .Underserved No
Site churches Site Multiple MD offices
Other (specify) Other (specify)
Total number 100 Total number 25
Number expected to'reach 50 Number expected to reach 12
Explain why you chose this target group. Explain why you chose this target group.
disproportionate risk for . provide weight control resources to
cardiovascular disease assist their clients in weight control
•
3. Target Grp. Name Senior citizens 4. Target Grp. Name
Age 55 and older Age
Race black Race
Gender both Gender
Occupation mostly retired or disabled Occupation
Education varies Education
Income less than 19,000 Income
Underserved yes Underserved • ,
Site Senior sites Site
Other (specify) Other (specify)
Total number 240 Total number
Number expected to reach 120 Number expected to reach
Explain why you chose this target group. Explain why you chose this target group.
disproportinate risk of minority
population for cardiovascular disease
DEBNR 3300 (Revised 2/90)
General Services Division (Review 1/9S) •
Page 3 of 5
C. Community Organizations
•
List the community organizations that you will work with on this program (i.e., American
Cancer Society, Cooperative Extension)
UNC-CH School of Public Health Department on Aging
American Heart Association Orange County Kellogg Coalition
Cooperative Extension
D./E. Goals and Objectives
All health departments are expected to use the Goal Oriented Evaluation format. Select goals
and objectives from Model Objectives as they relate to your program. Use the format on the
following page to describe your program's goals and objectives. It is expected that the Goals,
Objectives, Terms in Objectives, Method of Measures, and Measure columns will be completed
as part of the Contract Addendum. Results and Analysis are completed as part of the
Performance Report. Complete a separate form for each Program Goal.
Note: Health Promotion Program contracts must include a training objective. For example, "staff
will attend at least one health promotion training endorsed by the Division of Adult Health
within the contract year."
F. Quality Assurance
This program must have a Quality Assurance (QA) plan which includes at least the following
components: Please indicate the components that you have in your Quality Assurance plan by
placing a check,mark after the appropriate item.
• YES
1. Quality Assurance plan is written and on file. X
2. Regular QA meetings are planned. X
3. Appropriate methods of collecting and reviewing program information
will be used (e.g., adult health clinical record review, direct
• observation of program activities, review hypertension.program
policies and procedures, etc.) X
4. Quality assurance findings and corrective actions taken will be
documented. X
•
5. Protocols for screening, education, referral/treatment and
follow-up, etc., are established. X
In the appropriate space below, please give the name, title, and degree of person(s)
implementing this contract:
Name Degree
Jerry Ann Gregory, RN Health Promotion Coordinator BSN
Laurel Ellzey, RD Nutrition Program Coordinator MS
Page 4 of 5
CONTRACT ADDENDUM
Funded Program Adult Health FIT 9'�-94 Target Group Black senior ci .ize s
and church members
Goal: To reduce cardiovascular disease risk factors (hypertension and overweight) in black adults in Orange County by
June, 1996.
IV
otdoc es.
. esults;:and:An st
_ ..:::::::.:.:...............::.:.:.....,:.:..:..... .. Te s ..tn:....:............. ... ... .:.......................::::::..:..:.......,. .........::::.:::.:::,..::................... ......:::::.:::.:..:.............._..:.::.::.::..... .. ............:,::::::.:.:.:..........
1a. By June 30, 1994, screen OCHD adult health percent of
50% of black clients at records, logs and target population
selected church and computer printouts screened for
senior sites for high high blood
blood pressure. pressure
percent
proposed (50%)
1b. By June '30, 1994, provid OCHD adult health percent of targ t
education, counseling, records, logs and population who
referral and follow-up computer printouts received
to 60% of the black education,
clients at Senior Center counseling,
and church screenings referral and
identified with high follow-up.
blood pressure. percent
proposed (60%)
LOCAL HEALTH DEPARTMENT BUDGET
N.C. Department of Environment,
Health, and Natural Resources Revision umber
Division of General Services
cpy Division of Adult Health @
R O. Number
07/ 93 06/ 94 9 4 5 5 0 0 6 8
Effective Date Termination Date Contract Number
Contractor: Orange County He 1 th Department Activity: Health Promotion
Project Director: Daniel B. Reimer Total Budget: $ 57.818
I'fbM DESCRIPTION CLASSIFICATION I'i'EM AMOUNT
E STA'1 E EXPENDITURES:
Salaries & Fringe Benefits SA/FR 1000
X Operating Expenses OP EXP 2000
P Purchase of Equipment EQUIP 5000
E General Contracted or
N Purchased Services GENERAL 6100
School Health SCH; LTH < . 5200:
D Clinician OL�T 68Es .
•Laboratory b862-
T Pharmacy Services
U Transfer TXIX
R Subtotal State Expend. $22,053
E LOCAL EXPENDITURES: LOCAL EXP 9000 35,765
IS
TOTAL EXPENDITURES—equal to Total Receipts $57,818
LOCAL FUNDS:
R Appropriation APPROP 101 33,765
E TXIX TXIX • 102
Other Receipts OTHR REC 103 2,000
C
E Subtotal Local Funds $35,765
STA'1 E/I±DERAL/SPECIAL FUNDS:
I
Heal th Prarotion 22,053
T
S
Subtotal State/Federal/Special $
TOTAL RECEIPTS— equal to Total Expenditures $57,818
4.13Thca 4&31-1U1 V-93
Local Authorized Official Signatu , Date BMd Hod Division/Section Signature Date
Ar
/2—R'3
t417- .,-, 12(1///Y t'47.-
inance Officer Signature Date Accountant Fiscal Management Signa`fure Date
DERMA 2948(Revised 2/93)
General Services Division(Review 2/94)
N.C. Department of Health Environment, Health, and Natural Resources
Page 1 of 7
CONTRACT ADDENDUM,
FY 93-94
Adult Health Promotion 94-5503-068
Office, Section, or Branch Contract Number
Orange County Health Department Health Promotion
Contractor Activity
A. Adult Health Problems/Needs, Program Area/Focus
1. Problems/Needs in Communities
Identify the most important adult health problems/needs in your communities.
Cardiovascular disease is the leading cause of mortality in Orange
county with a rate of 183.8. Recent screenings of 578 employees of
worksites in Orange county revealed the following percentage levels
of modifiable risk factors: Overweight 33%, current smoker 19%,
sedentary lifestyle 40%, current hypertension 8%, and cholesterol
200 or greater 28%.
2. Program Area/Focus Reduction of these modifiable risk factors for
cardiovascular disease.
a. Identify the problem(s) you will address in this contract by placing a check mark(s)
beside the appropriate item.
Heart Disease/Hypertension/Stroke X Cancer:
Diabetes Breast
Glaucoma Cervical
Arthritis Colorectal
Renal Disease Prevention Lung
Sedentary Lifestyle X Prostate
Cholesterol X Tobacco Use:
Nutrition Smoking X
Obesity X Smokeless
Other, Specify:
b. Does your contract address the following:
•
1. Adult Health Physical
Assessment No
2. Primary Care No
Reviewed by
DEENR 3300 (Revised 2/90) (o- Y—93
General Services Division (Review 1/95) Initials Date
N.C. Department of Health Environment, Health, and Natural Resources
Page 2 of 7
CONTRACT ADDENDUM
• FY 93-94
Adult Health Promotion 94-5503-068
Office, Section, or Branch Contract Number
Orange County Health Department Health Promotion
Contractor Activity
B. Target Group(s)
First name your target group(s), then refer to the attached "Target Group Descriptors" sheet
to complete this section. From each category, select the descriptor(s) that best describes your
target group(s). You may choose one(1) or more descriptors per category. Example of
category: Age. Example of descriptor: young adults 18-34 years.
Complete as many categories as is possible.
1. Target Grp. NameOrange Co. Government 2. Target Grp. Name Three Service Oriented.
Age 18-64 Age • worksiLe 18-64
Race All Race All
Gender Both Gender Both
Occupation Government Occupation Services
Education Less than to greater than gradeEducation less than to greater than grade 12
Income Varies 12 Income Varies
Underserved generally no but some are Underserved Yes
underinsured
Site place of employment Site place of employment
Other (specify) Other (specify)
Total number 660 Total number 1085
Number expected to reach 280 Number expected to reach 415
Explain why you chose this target group. Explain why you chose this target group.
Modifiable risk factors for cardiovascular Modifiable risk factors for
disease cardiovascular disease
3. Target Grp. Name 4. Target Grp. Name
Age Age
Race Race
Gender Gender
Occupation Occupation
Education Education
Income Income
Underserved Underserved •
Site Site
Other (specify) Other (specify)
Total number Total number
Number expected to reach Number expected to reach
Explain why you chose this target group. Explain why you chose this target group.
DEHNR 3300 (Revised 2/90)
General Services Division (Review 1/95)
•
Page 3 of 7
C. Community Organizations
List the community organizations that you will work with on this program (i.e., American
Cancer Society, Cooperative Extension)
American Heart Association AmPriran CanrPr Society
Cooperative Extension Parks and Recreation
City and County Schools Personnel Departments of selected
worksites
D./E. Goals and Objectives
All health departments are expected to use the Goal Oriented Evaluation format. Select goals
and objectives from Model Objectives as they relate to your program. Use the format on the
following page to describe your program's goals and objectives. It is expected that the Goals,
Objectives, Terms in Objectives, Method of Measures, and Measure columns will be completed
as part of the Contract Addendum. Results and Analysis are completed as part of the
Performance Report. Complete a separate form for each Program Goal.
Note: Health Promotion Program contracts must include a training objective. For example, "staff
will attend at least one health promotion training endorsed by the Division of Adult Health
within the contract year."
F. Quality Assurance
This program must have a Quality Assurance (QA) plan which includes at least the following
components: Please indicate the components that you have in your Quality Assurance plan by
placing a check mark after the appropriate item.
YES
1. Quality Assurance plan is written and on file. x
2. Regular QA meetings are planned. X
3. Appropriate methods of collecting and reviewing program information
will be used (e.g., adult health clinical record review,direct
• observation of program activities, review hypertension program
policies and procedures, etc.) X
4. Quality assurance findings and corrective actions taken will be
documented. • • X
•
5. Protocols for screening, education, referral/treatment and
follow-up, etc., are established. X
In the appropriate space below, please give the name, title, and degree of person(s)
implementing this contract:
Name Title DeIree
Jerry Ann Gregory, RN Health Promotion Coordinator BSN
Laurel Ellzey, RD Nutrition Program Coordinator MS
Page 4 of L
CONTRACT ADDENDUM
Funded Program Health Promotion 1'Y g'�-ga Target Group Government and Service
Oriented Worksites
Goa[: To reduce cardiovascular disease risk factors in employees in the Orange County workforce
by June, 1996.
Ob 1::.::::..::.::.:::.::.::..:.....:.......................:........:...,:_:..:...:.:..: ..::.:.....
:.:
ec ._.. :.S...P
.:::: .:::::..... : . ....i....f...Y:.....T.......e.t..7.m.... s. .:.�.::�........:....:.:..........:.:.....:.:... :......:.=mom
.
;..::.:.
...,...:.:.:::::.:.::.:.:.:.::....:...............
1a. By June 30, 1994, screen Documentation in percent of
32% of selected worksite client records, employees
employees for high blood health promotion screened for
pressure. logs and OCHD high blood
computer printouts pressure
percent propos d
(32%)
1b. By June 30, 1994, provid Documentation in percent of
education, counseling, client records, employees
referral and follow-up health promotion receiving
to 75% of employees logs and OCHD education,
identified with high computer printouts counseling,
blood pressure. referral and
follow-up
percent propose
(80%).
Page 5 of 7
CONTRACT ADDENDUM
Foodmd Program Health Promotion FY e
Oriented Workaita
Goal: To reduce cardiovascular disease risk factors in employees in the Orange County
workforce by June, 1896.
mys
VV
Opj
2a. By June 30, 1994, assist Technical assistance Log of technical Number of
Orange County Government to County Managers assistance and department
in developing a smoking office. Serve on meetings attended buildings
policy for 5 department committee for and community provided
buildings within County developing recommendat -on resources assistance
Government on smoking policy for made available - -Number pr.oposec
County Managers office
2b. By June 30, 1994, provid ) Log of technical Number of
smoking cessation assistance and department
resource/referral lists meetings attended buildings receiving
for 5 department and community resource list
�uildings within County resources made Number proposed
government available
3a. By June 30, 1994, four Fresh Start Smoking Maintain log of Number of group
Fresh Start smoking Cessation .Program group programs, dat.�, programs
cessation group programs site, facilitator, offered
will be offered to program outline, Number proposed
selected government-and number of partibipaits
service-oriented worksitEs. and their attendanc ..
,
Page_6 of 7
CONTRACT ADDENDUM
Fuuded Program Health Promotion FY 93-94 Target Group Government and Service-
Oriented Worksites
Goal: To reduce cardiovascular disease risk factors in employees in the Orange County workforce
by June, 1996.
><>=<
.. : : ::::;:;::.:::..�:::: ..a�Seth.o�l:.oF:;Measures:: ..:.I�easu�re:.:::::,..:..... .::.: �tesul�s..��nd,..�. .. ....................:.........::::..::::.:,:....
.::::.::.:.:::::.:::.:............................ ..... .5 x� ..Tenn s ..tn................. .. .. .................................: ............... ....................... . . ... .......................... ............................ .
rives.. . ......................._............. .. Y....................................,.....::.:.:.
_.. 1. ....................................................:...:...:.._..... . .. _............................:.:.:::::.. .. _....................... .
3b. By June 30, 1994, 12 Participate by Log of participants Number of
identified smokers will attending all 4 as outlined in 3a. identified
participate in a Fresh =sessions. smokers
Start group smoking participating
cessation program. Number propose
3c. By June 30, 1994, 8 Smart Move program by Log of persons Number of identified
identified smokers will American Cancer receiving self- smokers -
participate in a smoking Society; participate b help program, title,participating
cessation self help accepting material and date, site and Number propose
program. agreeing for 1 month follow-up on
follow-up to see if contract.
implemented'.a: contract
4. By June 30, 1994, promote Articles in employee Log of each event Number of event
knowledge & awareness of newsletters, employee noting dates, size, held
the risks of overweight, health fairs, lunch ba brief description Number proposed
sedentary lifestyle, seminars, special day of event & particip nt
hypertension, high blood events like Great number and descript on
cholesterol & smoking as American Smokeout,
they relate to cardio- walking days, group
vascular disease through presentations
18 worksite campaign even is
among employees of select d
worksites.
Page_1.•_of
CONTRACT ADDENDUM
Funded Program Health Promotion FY 93-94 Target Group Government and-Sari-ice-
Oriented Worksites
Goal: To reduce cardiovascular disease risk factors in employees in the Orange County workforce.
by June, 1996.
. ............
:::........:... >: ...:..<...:...::..:.:.:.:,: :.::.....:::::: .., ea res::.. .::Measure....._.........:...:.: :..Results.. d..An.. ......................................:.........
:......::.:::.:.:::.::::.::.:............. 5 Tenn S .:.try:.:....::..:....... ..N�etftc?d...: ,M..:.... . .....:.. ................._....._.................... ......................:..::.::.:,::..:.... ........................................:.....:.:..
... .... ............ ................... : ..............Y............................................. .
5. Health Promotion staff Log of training, Number of
will attend at least one objectives and trainings
health promotion training persons attending. attended
endorsed by the Division Number proposed
of Adult Health