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Home My WebLink About2021-308-Health-Melynee Falk-Regional audiology consulting serviceRevised 07/20 1 [Departmental Use Only] TITLE Falk, Melynee EDHI FY 2021-2022 NORTH CAROLINA SERVICES AGREEMENT NO RFP/RFQ ORANGE COUNTY This Services Agreement (hereinafter “Agreement”), made and entered into this 2nd day of June, 2021, (“Effective Date”) by and between Orange County, North Carolina a political subdivision of the State of North Carolina (hereinafter, the "County") and Melynee Falk, (hereinafter, the "Provider"). WITNESSETH: That the County and Provider, for the consideration herein named, do hereby agree as follows: 1. Services a. Scope of Work. i) This Agreement is for services to be rendered by Provider to County with respect to (insert type of project): Audiology consulting services. ii) By executing this Agreement, the Provider represents and agrees that Provider is qualified to perform and fully capable of performing and providing the services required or necessary under this Agreement in a fully competent, professional and timely manner. iii) Time is of the essence with respect to this Agreement. iv) The services to be performed under this Agreement consist of Basic Services, as described and designated in Section 3 hereof. Compensation to the Provider for Basic Services under this Agreement shall be as set forth herein. 2. Responsibilities of the Provider a. Services to be provided. The Provider shall provide the County with all services required in Section 3 to satisfactorily complete the Project within the time limitations set forth herein and in accordance with the highest professional standards. b. Standard of Care. i) The Provider shall exercise reasonable care and diligence in performing services under this Agreement in accordance with the highest generally accepted standards of this type of Provider practice throughout the United States and in accordance with applicable federal, state and local laws and regulations applicable to the performance of these services. Provider is solely responsible for the professional DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Revised 07/20 2 quality, accuracy and timely completion and submission of all work related to the Basic Services. ii) Provider shall be responsible for all errors or omissions of its agents, contractors, employees, or assigns in the performance of the Agreement. Provider shall correct any and all errors, omissions, discrepancies, ambiguities, mistakes or conflicts at no additional cost to the County. iii) The Provider shall not, except as otherwise provided for in this Agreement, subcontract the performance of any work under this Agreement without prior written permission of the County. No permission for subcontracting shall create, between the County and the subcontractor, any contract or any other relationship. iv) Provider is an independent contractor of County. Any and all employees of the Provider engaged by the Provider in the performance of any work or services required of the Provider under this Agreement, shall be considered employees or agents of the Provider only and not of the County, and any and all claims that may or might arise under any workers compensation or other law or contract on behalf of said employees while so engaged shall be the sole obligation and responsibility of the Provider. v) If activities related to the performance of this Agreement require specific licenses, certifications, or related credentials Provider represents that it or its employees, agents and subcontractors engaged in such activities possess such licenses, certifications, or credentials and that such licenses certifications, or credentials are current, active, and not in a state of suspension or revocation. vi) In determining the Basic Services to be provided, should any documents be referenced in this Agreement, the terms of this Agreement shall have priority in any conflict between the terms of referenced documents and the terms of this Agreement. vii) Should this Agreement involve project designs, the construction or creation of which is to be bid out or fulfilled by other contractors, and bidding or negotiation with contractors produce prices which, when added to the other elements of the approved total project cost, produce a cost that is in excess of the approved total project cost, the Provider shall participate with the County in negotiation and design adjustments to the extent such are necessary to obtain prices within the approved total project cost. All activity of the Provider with respect to these matters shall constitute Basic Services and shall be performed by the Provider without additional compensation. If negotiation and design adjustments fail to bring costs within the total project cost the County may reject all bids and Provider will redesign or reduce portions of the project in an effort to reduce the bid prices to within the total project cost and rebid the project. One such redesign is included within Basic Services. If this second letting for bids does not produce bids that are within the approved total project cost initially or after negotiations with the contractor the cost is not reduced to an amount within the total project cost, the Provider is not obligated to engage in further redesign. DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Revised 07/20 3 3. Basic Services a. Basic Services. The Services to be rendered pursuant to this Agreement are as follows (fully describe services to be provided): Provide regional audiology consulting services for the NC Early Hearing Detection and Intervention (EHDI) program to hospitals and other public and private agencies. Follow the work plan developed by State EHDI Program staff as stated in subsection B under section III of the Division of Public Health Agreement Addendum FY 21-22: 324 Speech and Hearing attached as Exhibit A and any amendments thereto, both of which are attached and hereby incorporated by reference. Attend all DPH, C&Y Branch EHDI program training events and staff meetings. Attend conferences and workshops as directed by the DPH C&Y Branch EHDI program and supported by Agreement Addendum funds. Perform duties in subsection A under section IV of Exhibit A. i) The Provider shall perform as Basic Services the work and services described herein. ii) The Basic Services will be performed by the Provider in accordance with the following schedule: (Insert milestones task list, dates and fees. If milestones are not established mark N/A under Milestone Task 1.) Milestone Task Milestone Date Milestone Fee 1. N/A 2. 3. 4. 5. 6. 7. 8. 9. 10. iii) Should County reasonably determine that Provider has not met the Milestone Dates established in Section 3(a)(ii), County shall notify Provider of the failure to meet the Milestone Date. The County, at its discretion may provide the Provider seven (7) days to cure the breach. County may withhold the accompanying payment without penalty until such time as Provider cures the breach. In the alternative, upon Provider’s failure to meet any Milestone Date the County may modify the Milestone Date schedule. Should Provider or its representatives fail to cure the breach within seven (7) days, or fail to reasonably agree to such modified schedule, County may immediately terminate this Agreement in writing, without penalty or incurring further obligation to Provider. This section shall not be interpreted to limit the definition of breach to the failure to meet Milestone Dates. 4. Duration of Services a. Term. The term of this Agreement shall be from June 1, 2021 to May 31, 2022. DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Revised 07/20 4 b. Scheduling of Services. i) The Provider shall schedule and perform its activities in a timely manner. ii) Should the County determine that the Provider is behind schedule, it may require the Provider to expedite and accelerate its efforts, including providing additional resources and working overtime, as necessary, to perform its services in accordance with the approved project schedule at no additional cost to the County. iii) The Commencement Date for the Provider's Basic Services shall be June 1, 2021. 5. Compensation a. Compensation for Basic Services. Compensation for Basic Services shall include all compensation due the Provider from the County for all services satisfactorily (as determined by the County) performed pursuant to this Agreement. The maximum amount payable for Basic Services shall not exceed Seventy Seven Thousand Five Hundred Ninety Seven Dollars ($77,597). Payment for satisfactorily performed Basic Services shall become due and payable within thirty (30) days of Provider properly invoicing County. Payment shall be subject to provisions of Section 5(b). b. Disputes. In the event the amount stated on an invoice is disputed by the County, the County may withhold payment of all or a portion of the amount stated on an invoice until the parties resolve the dispute. Should Provider fail to perform its duties under the terms of this Agreement, County may, without fault or penalty, withhold any payment associated with the work to be performed until such time as said work is completed. c. Additional Services. County shall not be responsible for costs related to any services in addition to the Basic Services performed by Provider unless County requests such additional services in writing and such additional services are evidenced by a written amendment to this Agreement. 6. Responsibilities of the County a. Cooperation and Coordination. The County has designated (Rebecca Crawford) to act as the County's representative with respect to the Project who shall have the authority to render decisions within guidelines established by the County Manager or the County Board of Commissioners and who shall be available during working hours as often as may be reasonably required to render decisions and to furnish information. 7. Insurance a. General Requirements. Provider shall obtain, at its sole expense, Commercial General Liability Insurance, Automobile Insurance, Workers’ Compensation Insurance, and any additional insurance as may be required by County’s Risk Manager as such insurance requirements are described in the Orange County Risk Transfer Policy and Orange County Minimum Insurance Coverage Requirements (each document is incorporated herein by reference and may be viewed at DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Revised 07/20 5 http://www.orangecountync.gov/departments/purchasing_division/contracts.php). If County’s Risk Manager determines additional insurance coverage is required such additional insurance shall consist of N/A (if no additional insurance required mark N/A as being not applicable). Provider shall not commence work until such insurance is in effect and certification thereof has been received by the County's Risk Manager. 8. Indemnity a. Indemnity. To the extent authorized by North Carolina law the Provider agrees, without limitation, to defend, indemnify and hold harmless the County from all loss, liability, claims or expense, including attorney's fees, arising out of or related to the Project and arising from property damage or bodily injury including death to any person or persons caused in whole or in part by the negligence or misconduct of the Provider except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this provision to require the Provider to indemnify the County to the fullest extent permitted under North Carolina law. 9. Amendments to the Agreement a. Changes in Basic Services. Changes in the Basic Services and entitlement to additional compensation or a change in duration of this Agreement shall be made by a written Amendment to this Agreement executed by the County and the Provider. The Provider shall proceed to perform the Services required by the Amendment only after receiving a fully executed Amendment from the County. 10. Termination a. Termination for Convenience of the County. This Agreement may be terminated without cause by the County and for its convenience upon seven (7) days’ prior written notice to the Provider. b. Other Termination. The Provider may terminate this Agreement based upon the County's material breach of this Agreement; provided, the County has not taken all reasonable actions to remedy the breach. The Provider shall give the County seven (7) days' prior written notice of its intent to terminate this Agreement for cause. Either party may terminate this Agreement upon notice to the other party that obligations pursuant to this Agreement are made impractical due to declarations of emergency by Orange County or by North Carolina due to events directly impacting Orange County. Both parties shall remain responsible for all payment and performance due up to the receipt of such notice, but shall have no further obligation or responsibility beyond that date provided the terminating party has taken all reasonable steps to complete the performance of its obligations. c. Compensation After Termination. i) In the event of termination, the Provider shall be paid that portion of the fees and expenses that it has earned to the date of termination, less any costs or expenses incurred or anticipated to be incurred by the County due to errors or omissions of the Provider. Upon request of the County, the Provider shall submit to County all DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Revised 07/20 6 relevant documentation, including but not limited to, job cost records, to support its claims for final compensation. ii) Should this Agreement be terminated, the Provider shall deliver to the County within seven (7) days, at no additional cost, all deliverables including any electronic data or files relating to the Project. d. Waiver. The payment of any sums by the County under this Agreement or the failure of the County to require compliance by the Provider with any provisions of this Agreement or the waiver by the County of any breach of this Agreement shall not constitute a waiver of any claim for damages by the County for any breach of this Agreement or a waiver of any other required compliance with this Agreement. e. Suspension. County may suspend the Basic Services and this Agreement at any time for County’s convenience and without penalty to County upon three (3) days’ notice to Provider. Upon any suspension by County, Provider shall discontinue work on the Basic Services and shall not resume the Basic Services until notified to proceed by County. 11. Additional Provisions a. Limitation and Assignment. The County and the Provider each bind themselves, their successors, assigns and legal representatives to the terms of this Agreement. Neither the County nor the Provider shall assign or transfer its interest in this Agreement without the written consent of the other. b. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.58. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.81. c. Non-Discrimination. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal non-discrimination laws, policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php.) Any violation of the Orange County Non-Discrimination Policy is a breach of this Agreement and County may immediately terminate this Agreement without further obligation on the part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. d. Dispute Resolution. Any and all suits or actions to enforce, interpret or seek damages with respect to any provision of, or the performance or non-performance of, this DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Revised 07/20 7 Agreement shall be brought in the General Court of Justice of North Carolina sitting in Orange County, North Carolina. It is agreed by the parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding arbitration may not be initiated by either Party, however, the Parties may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. e. Entire Agreement. This Agreement represents the entire and integrated agreement between the County and the Provider and supersedes all prior negotiations, representations or agreements, either written or oral. This Agreement may be amended only by written instrument signed by both parties. Modifications may be evidenced by facsimile signatures. f. Severability. If any provision of this Agreement is held as a matter of law to be unenforceable, the remainder of this Agreement shall be valid and binding upon the Parties. g. Ownership of Work Product. Should Provider’s performance of this Agreement generate documents, items or things that are specific to this Project such documents, items or things shall become the property of the County and may be used on any other project without additional compensation to the Provider. The use of the documents, items or things by the County or by any person or entity for any purpose other than the Project as set forth in this Agreement shall be at the full risk of the County. h. Non-Appropriation. Provider acknowledges that County is a governmental entity, and the validity of this Agreement is based upon the availability of public funding under the authority of its statutory mandate. In the event that public funds are unavailable and not appropriated for the performance of County’s obligations under this Agreement, then this Agreement shall automatically expire without penalty to County immediately upon written notice to Provider of the unavailability and non-appropriation of public funds. It is expressly agreed that County shall not activate this non-appropriation provision for its convenience or to circumvent the requirements of this Agreement, but only as an emergency fiscal measure during a substantial fiscal crisis. In the event of a change in the County’s statutory authority, mandate or mandated functions, by state or federal legislative or regulatory action, which adversely affects County’s authority to continue its obligations under this Agreement, then this Agreement shall automatically terminate without penalty to County upon written notice to Provider of such limitation or change in County’s legal authority. i. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the consent of the Parties to utilize electronic signatures and the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. j. Notices. Any notice required by this Agreement shall be in writing and delivered by certified or registered mail, return receipt requested to the following: DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Revised 07/20 8 Orange County Provider’s Name Attention:Kimberlee Quatrone Melynee Falk P.O. Box 8181 1406 Valleymede Rd. Hillsborough, NC 27278 Greensboro, NC 27410 [SIGNATURE PAGE TO FOLLOW] DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Revised 07/20 9 IN WITNESS WHEREOF, the Parties, by and through their authorized agents, have hereunder set their hands and seal, all as of the day and year first above written. ORANGE COUNTY: PROVIDER: By: _________________________________ By: __________________________________ Melynee M. Falk, M.A., CCC-A Printed Name and Title DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Revised 07/20 10 ORANGE COUNTY—DEPARTMENT USE ONLY ______________________________________________________________________________ Party/Vendor Name: Melynee Falk Party/Vendor Contact Person: Melynee Falk Contact Phone: 336-402-1025 Party/Vendor Address: 1406 Valleymede Rd. City Greensboro State: NC Zip: 27410 Department: Health Amount: $77,597 Purpose: Regional audiology consulting service Budget Code(s): 10414020-630000-71423 Vendor # 64366 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date 6-1-21 Approved by Board Yes No Agenda Date: This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this project has not been initiated prior to execution of the agreement: Department Director’s Signature ________________________________________ Date: ________ Agreements for emergency services or repair are not subject to the above affirmation. If services related to this agreement have already begun or been completed please briefly describe the nature of the emergency condition that was addressed: orgot the agreement was on the State addendum fiscal year (June - May). Required contract for State addendum. Reimbursed by State for services; renewed yearly. Information Technologies (Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer___________________________________ Date: ________ Risk Management This agreement is approved for sufficiency of insurance standards, specifications, and requirements: Office of the Risk Management Officer___________________________________ Date: _________ Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer ____________________________________ Date: _________ Legal Services This agreement is approved as to legal form and sufficiency: Office of the County Attorney __________________________________________Date: ________ Clerk to the Board Received for record retention: All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board __________________________________________Date:_________ DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA 6/2/2021 6/2/2021 6/22/2021 6/22/2021 Revised 07/20 11 DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Division of Public Health Agreement Addendum FY 21-22 Page 1 of 5 _____________________________________________ ____________________________________ Health Director Signature (use blue ink) Date Local Health Department to complete: (If follow-up information is needed by DPH) LHD program contact name: Phone number with area code: Email address: Signature on this page signifies you have read and accepted all pages of this document.Template rev. July 2020 Orange County Health Department Women’s and Children’s Health / Children and Youth Local Health Department Legal Name DPH Section / Branch Name 324 Speech and Hearing Marcia Fort, 919-707-5630, Marcia.Fort@dhhs.nc.gov Activity Number and Description DPH Program Contact (name, phone number, and email) 06/01/2021 – 05/31/2022 Service Period DPH Program Signature Date (only required for a negotiable agreement addendum) 07/01/2021 – 06/30/2022 Payment Period Original Agreement Addendum Agreement Addendum Revision # I. Background: Hearing loss is the most common congenital birth defect, affecting as many as three infants per thousand born. Left undetected, hearing loss in infants can negatively impact speech and language acquisition, academic achievement, and social and emotional development. If detected, however, these negative impacts can be diminished and even eliminated through early intervention. Infants who fail the initial newborn hearing screening are at a higher risk than the general population of having a hearing loss. The most recent data from the Centers for Disease Control (CDC), for infants born in 2018, shows that 25.9% of infants in the United States and 25.3% in the state of North Carolina with a failed newborn hearing screen are subsequently “lost to follow up.” The primary goal of the Children and Youth Branch’s North Carolina Early Hearing Detection and Intervention (EHDI) Program is to ensure that all infants are screened for hearing loss by one month of age; that children with congenital hearing loss are identified by three months of age; and that all are provided access to appropriate audiological, educational, and medical intervention by six months of age. Regional staffing is needed to support hospital universal newborn hearing screening programs in order to: 1) ensure that infants receive additional hearing screening when needed, 2) support families through the diagnostic and/or intervention processes, if necessary, and 3) provide consultation, technical assistance and resources to public and private agencies for the development and implementation of effective Early Hearing Detection and Intervention programs. Regional staffing is also needed to provide support and assistance to parents and families whose children have hearing loss and to provide assistance to other professionals working with these families. rcrawford@orangecountync.gov 919-245-2414 Rebecca Crawford Exhibit A DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Page 2 of 5 Template rev. July 2020 II. Purpose: This Agreement Addendum provides support for maintaining and improving the EHDI program by identifying and designating no more than 0.75 FTE Audiologist to act as a Child Health Audiology Consultant (CHAC) in the north central part of North Carolina. This CHAC shall act as part of the DPH EHDI Team, with oversight of his or her EHDI program responsibilities carried out by State EHDI Program staff. III. Scope of Work and Deliverables: A. The Local Health Department shall: 1. Provide one three-quarter-time (0.75 FTE) audiologist to perform as the Child Health Audiology Consultant (CHAC) on the Division of Public Health (DPH) EHDI team. The CHAC must have a master’s degree in Audiology and must maintain current certification and licensure from the American Speech-Language-Hearing Association and the North Carolina Board of Speech Language Pathologists and Audiologists. 2. Collaborate with the DPH Genetics and Newborn Screening Unit Manager to ensure that all responsibilities of the CHAC work plan, as described in Paragraph B below, meets the standards set by the Local Health Department and the EHDI program. The CHAC will be expected to meet the program requirements as determined by the DPH EHDI Program. 3. Ensure that the CHAC provides direct and indirect services to identify and assist children with hearing loss in the following counties: Forsyth, Guilford, and Orange. For these counties, the estimated number of births for the state fiscal year 2020-2021 is 12,602. An estimated 24 to 36 (2 to 3 per 1,000 births) of these infants will have some form of hearing loss, and an additional 504 infants will need follow-up from newborn hearing screening to determine their hearing status. 4. Within five working days, notify the EHDI Program of any staff changes as a result of employment termination of the person designated as the CHAC. 5. Agree not to bill families or third parties for services provided under this Agreement Addendum. 6. Ensure that the CHAC attends: a. All DPH EHDI Program training events and staff meetings as requested. b. Conferences and workshops as directed by the program and supported by Agreement Addendum funds. c. The National Early Hearing Detection and Intervention Meeting in February/March 2021 in Cincinnati, Ohio. 7. Ensure that the CHAC submits the reports and monthly service logs as required by the EHDI Program. 8. Provide adequate workspace for the CHAC. 9. Serve as the purchasing agent for newborn hearing screening disposable testing supplies used within the catchment area for this Agreement Addendum. 10. Serve as purchasing agent for maintenance, replacement or purchase of equipment used for hearing screening and rescreening to the extent possible with the funds provided with this Agreement Addendum. B. The Local Health Department’s Child Health Audiology Consultant (CHAC) shall follow the individual work plan developed annually (SFY) consistent with the plan for all other DPH EHDI Consultants by the DPH Genetics and Newborn Screening Unit Manager which will include, but is not limited to, the following activities: DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Page 3 of 5 Template rev. July 2020 1. Provide technical assistance to birthing facilities for hearing screening, rescreening and tracking of infants born at each facility. 2. Provide consultation and technical assistance to public and private agencies (other stakeholders) focusing on identification and intervention for children with hearing loss or communication delays. 3. Provide technical assistance regarding the WCSWeb Hearing Link, North Carolina’s direct data entry and tracking system. 4. Coordinate regional educational and networking meetings about newborn hearing screening for personnel from birthing facilities and other involved stakeholders. 5. Keep track of data concerning the efficiency and effectiveness of each birthing facility in the region and intervene when a facility appears to be missing hearing screenings on children or has an excessive number of children who fail the screening. 6. Identify community resources and systems that identify and refer infants and children with suspected late onset or progressive hearing loss or communication deficits. 7. Collaborate with care managers, private providers, local health departments, and others for the tracking of infants and children with or at risk for hearing loss. 8. Supply educational materials about hearing loss and communication delays to agencies working with families of young children. 9. Collaborate with community resources to screen children as part of special health promotion events or part of Head Start or other community mass screening initiatives. 10. Provide support to individual families whose children have not had a newborn hearing screening or have failed a hearing screening to ensure that they obtain the needed repeat hearing screenings or diagnostic evaluations to determine the absence or presence of hearing loss. 11. Provide support to individual families whose children have been diagnosed with hearing loss to ensure that they obtain the needed intervention services and family support services. 12. Promote public awareness related to the benefits of early hearing detection and intervention. 13. Identify and develop resources for provision of services to families in a culturally appropriate setting and in their own language. 14. Educate private providers regarding the benefits of early hearing detection and intervention and the reporting requirements of the State. 15. Coordinate with professionals in the DPH, Children and Youth Branch’s Early Intervention Program regarding service delivery and transition issues for children with hearing loss. 16. Collaborate with other regional consultants to identify and develop appropriate communication- related practices, skills and techniques. 17. Consult with public and private agencies and families in the selection and procurement of communication-related equipment and/or other assistive devices/technology. 18. Collaborate with local audiologists in the expansion and development of audiology services for children birth to 21 years. 19. Collaborate with academia to provide training opportunities for students. 20. Screen each child served directly for health insurance status and refers and assists each child’s parents or guardians to obtain needed health insurance coverage. DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Page 4 of 5 Template rev. July 2020 IV. Performance Measures/Reporting Requirements: A. Electronic submission of service logs is required monthly of the CHAC and are due to State EHDI Program staff by the fifth day of the following month. The monthly services logs shall include: 1. Performance Measure #1: Evidence of having provided a total of at least 25 instances each month of consultations, technical assistance, or training sessions for hospitals and other EHDI stakeholders. 2. Performance Measure #2: Evidence of timely interventions with 95% of families whose children need follow-up from a newborn hearing screening. Entries will be made in the WCSWeb Hearing Link notes section to document counseling and education provided to families of children who failed the newborn hearing screening, and to document consultation with their direct service providers. 3. Performance Measure #3: Evidence of timely coordination of service delivery for children with or at risk of hearing loss. This will include: a. At least four in-service sessions provided to community collaborators or private providers per year b. At least three public awareness activities per year. V.Performance Monitoring and Quality Assurance: A. The Local Health Department shall adhere to the following Quality Assurance measures: 1. Ensure that the CHAC is board certified and is licensed in North Carolina. 2. Ensure that services are provided in a culturally and linguistically appropriate manner. B. The state EHDI Program staff will monitor the CHAC’s work plan progress through: 1. Monthly reviews of electronic service logs. 2. Quarterly contacts (phone and email) with the CHAC. 3. An annual site visit with the Local Health Department, and with additional visits if needed. 4. Semi-annual in-person review of CHAC's work on the same schedule as VIP performance reviews for DPH employees. 5. Quarterly reviews of data from the WCSWeb Hearing Link data tracking system on hospitals served by the CHAC. 6. Meetings with the CHAC during DPH EHDI Team Meetings and other DPH required activities. C. Should the performance of the CHAC be deemed inadequate because of non-completion of expected activities, poor communication with team members or community collaborators, or insufficient documentation, a meeting will be convened with the Local Health Department supervisor to develop a corrective action plan which will define next steps. VI. Funding Guidelines or Restrictions: 1. Requirements for pass-through entities: In compliance with 2 CFR §200.331 – Requirements for pass-through entities, the Division of Public Health provides Federal Award Reporting Supplements to the Local Health Department receiving federally funded Agreement Addenda. a. Definition: A Supplement discloses the required elements of a single federal award. Supplements address elements of federal funding sources only; state funding elements will not be included in the Supplement. Agreement Addenda (AAs) funded by more than one federal award will receive a disclosure Supplement for each federal award. DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Page 5 of 5 Template rev. July 2020 b. Frequency: Supplements will be generated as the Division of Public Health receives information for federal grants. Supplements will be issued to the Local Health Department throughout the state fiscal year. For federally funded AAs, Supplements will accompany the original AA. If AAs are revised and if the revision affects federal funds, the AA Revisions will include Supplements. Supplements can also be sent to the Local Health Department even if no change is needed to the AA. In those instances, the Supplements will be sent to provide newly received federal grant information for funds already allocated in the existing AA. DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA Federal Award Reporting Requirements for Pass-Through Agencies, 2 CFR § 200.331 DPH v3.1 10-5-20 FY22 Activity: 324 CSHS Speech & Hearing Supplement 1 Supplement reason: ܈ In AA+BE or AA+BE Rev –OR– ܆ – CFDA #: 93.778 Fed awd date: NGA date Is award R&D? no FAIN: Unknown Total amount of fed awd: $ Unknown CFDA name: Medical Assistance Program (Medicaid:Title XIX Fed award project description: Medical Adminstrtive Payments Fed awarding agency: DHHS, Health Resources and Services Administration Federal award indirect cost rate: n/a % % Subrecipient Subrecipient DUNS Fed funds for This Supplement Total of All Fed Funds for This Activity Subrecipient Subrecipient DUNS Fed funds for This Supplement Total of All Fed Funds for This Activity Alamance 965194483 = = Jackson 019728518 = = Albemarle 130537822 18623 18623 Johnston 097599104 = = Alexander 030495105 = = Jones 095116935 = = Anson 847163029 = = Lee 067439703 = = Appalachian 780131541 = = Lenoir 042789748 = = Beaufort 091567776 = = Lincoln 086869336 = = Bladen 084171628 = = Macon 070626825 = = Brunswick 091571349 = = Madison 831052873 = = Buncombe 879203560 = = MTW 087204173 = = Burke 883321205 = = Mecklenburg 074498353 = = Cabarrus 143408289 = = Montgomery 025384603 = = Caldwell 948113402 = = Moore 050988146 = = Carteret 058735804 = = Nash 050425677 = = Caswell 077846053 = = New Hanover 040029563 = = Catawba 083677138 = = Northampton 097594477 = = Chatham 131356607 = = Onslow 172663270 = = Cherokee 130705072 = = Orange 139209659 18623 18623 Clay 145058231 = = Pamlico 097600456 = = Cleveland 879924850 = = Pender 100955413 = = Columbus 040040016 = = Person 091563718 = = Craven 091564294 = = Pitt 080889694 = = Cumberland 123914376 = = Polk 079067930 = = Dare 082358631 = = Randolph 027873132 = = Davidson 077839744 = = Richmond 070621339 = = Davie 076526651 = = Robeson 082367871 = = Duplin 095124798 = = Rockingham 077847143 = = Durham 088564075 = = Rowan 074494014 = = Edgecombe 093125375 = = Sampson 825573975 = = Foothills 782359004 = = Scotland 091564146 = = Forsyth 105316439 = = Stanly 131060829 = = Franklin 084168632 = = Stokes 085442705 = = Gaston 071062186 = = Surry 077821858 = = Graham 020952383 = = Swain 146437553 = = Granville-Vance 063347626 = = Toe River 113345201 = = Greene 091564591 = = Transylvania 030494215 = = Guilford 071563613 = = Union 079051637 = = Halifax 014305957 = = Wake 019625961 = = Harnett 091565986 = = Warren 030239953 = = Haywood 070620232 = = Wayne 040036170 = = Henderson 085021470 = = Wilkes 067439950 = = Hoke 091563643 = = Wilson 075585695 = = Hyde 832526243 = = Yadkin 089910624 = = Iredell 074504507 = = DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA DPH-Aid-To-Counties For Fiscal Year: 21/22 Budgetary Estimate Number : 0 Activity 324 Service Period Payment Period AA 1332 5390 99 06/01-05/31 07/01-06/30 Proposed Total New Total 01 Alamance 000 D1 Albemarle * 0 77,597 77,597 77,597 02 Alexander 000 04 Anson 000 D2 Appalachian 000 07 Beaufort 000 09 Bladen 000 10 Brunswick 000 11 Buncombe 000 12 Burke 000 13 Cabarrus 000 14 Caldwell 000 16 Carteret 000 17 Caswell 000 18 Catawba 000 19 Chatham 000 20 Cherokee 000 22 Clay 000 23 Cleveland 000 24 Columbus 000 25 Craven 000 26 Cumberland 000 28 Dare 000 29 Davidson 000 30 Davie 000 31 Duplin 000 32 Durham 000 33 Edgecombe 000 D7 Foothills 000 34 Forsyth 000 35 Franklin 000 36 Gaston 000 38 Graham 000 D3 Gran-Vance 000 40 Greene 000 41 Guilford 000 42 Halifax 000 43 Harnett 000 44 Haywood 000 45 Henderson 000 46 Hertford 000 47 Hoke 000 48 Hyde 000 49 Iredell 000 50 Jackson 000 Page 1 of 2WicGridPrint 12/3/2020https://atc.dhhs.state.nc.us/WICGridPrint.aspx DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA 51 Johnston 000 52 Jones 000 53 Lee 000 54 Lenoir 000 55 Lincoln 000 56 Macon 000 57 Madison 000 D4 M-T-W 000 60 Mecklenburg 000 62 Montgomery 000 63 Moore 000 64 Nash 000 65 New Hanover 000 66 Northampton 000 67 Onslow 000 68 Orange * 0 77,597 77,597 77,597 69 Pamlico 000 71 Pender 000 73 Person 000 74 Pitt 000 75 Polk 000 76 Randolph 000 77 Richmond 000 78 Robeson 000 79 Rockingham 000 80 Rowan 000 D5 R-P-M 000 82 Sampson 000 83 Scotland 000 84 Stanly 000 85 Stokes 000 86 Surry 000 87 Swain 000 D6 Toe River 000 88 Transylvania 000 90 Union 000 92 Wake 000 93 Warren 000 96 Wayne 000 97 Wilkes 000 98 Wilson 000 99 Yadkin 000 Totals 155,194 155,194 155,194 Sign and Date - DPH Program Administrator Sign and Date - DPH Section Chief Sign and Date - DPH Contracts Office Sign and Date - DPH Budget Officer Page 2 of 2WicGridPrint 12/3/2020https://atc.dhhs.state.nc.us/WICGridPrint.aspx Sign and Date - DPH Program Adm Si 12/4/2020 12/4/2020 gn and Date - DPH Section Ch ign and Date - DPH Contracts Office ign and Date - DPH Contracts Of 12/22/2020 ign and Date - DPH Budget Officer gn and Date - DPH Budget Off 12/29/2020 DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA MEMORANDUM OF INSURANCE Date Issued Prod ucer coverages afforded by the Certificate listed below. Company Afford ing Coverage Insured This is to certify that the Certificate listed below has been issued to the insured named above for the policy period indicated, not withstanding any requirement, term or condition of any contract or other document with respect to which this memorandum may be issued or may pertain, the insurance afforded by the Certificate described herein is subject to all the terms, exclusions and conditions of such Certificate. The limits shown may have been reduced by paid claims. The Memorandum of Insurance and verification of payment are your evidence of coverage. No coverage is afforded unless the premium is successfully paid in full. Type of Insuran ce Certificat e Number Effective Date Expirati on Date Limits Pro fessional Liability Per Incident/ Occurrence Annual Aggregate PROOF OF INSURANCE Memorandum Holder:Should the above describe of any kind up representatives. Authorized Representative Joan O’Sullivan Client # 2271544 02/15/2021 Melynee M Falk 1406 Valleymede Road Greensboro, NC 27410 SpeechLangH SE Speech Language Pathologist AHY-860875005 04/01/2021 04/01/2022 $1,000,000 $3,000,000 Mercer Consumer, a service of Mercer Health & Benefits Administration LLC. In CA d/b/a Mercer Health & Benefits Insurance Services LLC. CA License #0G39709 PROOF OF COVERAGE ONLY Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box 14576 Des Moines, IA 50306-3576 1-800-375-2764 Liberty Insurance Underwriters Inc. Mark Brostowitz DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA