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HomeMy WebLinkAboutResolution - 2019-R0185 - Department Of State Health Services - Immunization/Locals Grant Program - 05/28/2019Resolution No. 2019-RO185 Item No. 6.11 May 28, 2019 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for and on behalf of the City of Lubbock, Amendment No.1 to Contract No. HHS000109800001, the Immunization/Locals Grant Program Contract, by and between the City of Lubbock and the State of Texas' Department of State Health Services, and all related documents. Said Amendment is attached hereto and incorporated in this resolution as if fully set forth herein and shall be included in the minutes of the City Council. Passed by the City Council on May 28, 2019 DANIEL M. POPE, MAYOR ATTEST: Reb cca Garza, City Secr tar APPRO ED AS TO CONTENT: I(Atherine Wells, Director of Public Health APPROVED AS TO FORM: Ry Br ke, A. sistant City Attorney RES.Amend No.I Contract No. HHS000109800001 DSHS 5.9.19 DocuSign Envelope ID: ED1D9DAA-F953-45C7-9B27-C890EF3615DA Resolution No. 2019-RO185 TEXAS DEPARTMENT OF STATE HEALTH SERVICES CONTRACT No. HHS000109800001 AMENDMENT No. 01 The Department of State Health Services ("DSHS" or "System Agency"), an administrative agency within the executive branch of the State of Texas, and City of Lubbock ("Grantee"), who are collectively referred to herein as the "Parties," to that certain Immunization/Locals Grant Program Contract effective September 1, 2018, and denominated DSHS Contract No. HHS000109800001 (the "Contract"), now desire to amend the Contract. Whereas, the Parties desire to allot additional funds, revise the Statement of Work, add a Guidance Document_, and extend the term of the Contract to allow for successful completion of the Project; and Whereas, the Parties have chosen to exercise their option to amend the Contract in accordance with Section 9.01 of Attachment C to the Contract. Now, therefore, the Parties hereby amend and modify the Contract as follows: I . Section III of the Contract, Duration, is hereby amended to reflect a revised termination date of August 31, 2020, unless renewed, extended, or terminated earlier pursuant to the terms and conditions of the Contract. 2. Section IV of the Contract, Budget, is hereby amended to add funding for state fiscal year 2020 in the amount of $232,115.00, which is based on $128,839.00 state funds and $103,276.00 federal fiends. The total not -to -exceed amount of this Contract is increased to $489,230.00. All expenditures under the Contract will be in accordance with Attachment B- 1, Fiscal Year 2020 Budget. 3. Attachment A of the Contract, Statement of Work, is hereby amended and replaced with Attachment A-1, Revised Statement of Work. Attachment A-1 is applicable to the period beginning on the effective date of this Amendment. 4. Attachment B of the Contract, Budget, is hereby supplemented with the addition of Attachment B-1, Fiscal Year 2020 Budget. 5. Attachment F of the Contract, Federal Funding Accountability and Transparency Act, is hereby supplemented for state fiscal year 2020 with the addition of Attachment F-1, Federal Funding Accountability and Transparency Act. 6. Attachment H, Immunization/Locals Program Guidance Document, is attached hereto and incorporated into the Contract as if fully set forth therein. 7. Grantee may not begin work or incur any expenses prior to the date on the System Agency's Notice to Proceed ("NTP"). This Notice to Proceed may include an Amended or Ratified Budget which will be incorporated into this Contract by a subsequent amendment, if amended. Any work performed prior to the date on the NTP shall be at Grantee's sole risk. System Agenc} Contract No. 11115000109800001 Page I of 32 DocuSign Envelope ID- EDID9DAA-F953-45C7-9827-C890EF3616DA 8. This Amendment No. 01 shall be effective as of September 1, 2019. 9. Except as amended and modified by this Amendment No. 01, all terms and conditions of the Contract shall remain in full force and effect. 10. Any further revisions to the Contract shall be by written agreement of the Parties. Signature Page Follows System Agency Contract No. III 1S000109800001 Page 2 of 32 DocuSign Envelope ID EDID9DAA-F953-45C7-9827-C890EF3616DA Signature Page for Amendment No. 01 DSHS Contract No. HHS000109800001 Department of State of Health City of Lubbock Services By:_ _ By: Name: Title: Name: Daniel Pope Title: Mayor Date of Execution: Date of Execution: May 28, 2019 The following attachments are attached and incorporated as part of the Contract: Attachment A-1 Revised Statement of Work Attachment B-1 Fiscal Year 2020 Budget Attachment F-1 Federal Funding Accountability and Transparency Act (FFATA) Attachment H Immunization/Locals Program Guidance Document System Agency Contract No. 1-11IS000109800001 Page 3 o£32 DocuSign Envelope ID EDID9DAA-F95345C7-9B27-C890EF3616DA Attachment A-1 Revised Statement of Work 1. GRANTEE RESPONSIBILITIES Grantee will: A. Implement and operate an immunization program for children, adolescents, and adults, with special emphasis on accelerating interventions to improve the immunization coverage of children three (3) years of age or younger (birth to 35 months of age). Grantee shall incorporate traditional and non-traditional systematic approaches designed to eliminate barriers, expand immunization capacity, and establish uniform operating policies, as described herein. B. Be enrolled as a provider in the Texas Vaccines for Children ("TVFC") and the Adult Safety Net (ASN) Programs by the effective date of this Contract. This includes a signed Depuliza ion Addendum Form (EF11-13999). C. Comply with written policies and procedures provided by DSHS in managing vaccines supplied through the ASN and TVFC Programs, including guidelines for proper storage, handling, and safeguarding of vaccines in the event of natural disaster. D. Adhere to DSHS Immunization updated guidance according to Attachment H, Immunization/Locals Program Guidance Document. E. Maintain staffing levels to meet required activities of the Contract and ensure staff funded by this Contract attend required training. F. Report all notifiable conditions as specified in Texas Administrative Code ("TAC") Title 25, Part I §§ 97.1-97.6, as amended, and as otherwise required by law. G. Report all vaccine adverse event occurrences in accordance with the 1986 National Childhood Vaccine Injury Act ("NCVIA") 42 U.S.C. § 300aa-25 (located at htt :1lvaers.hhs. gov.' or 1-800-822-7967), as amended. H. Sustain a network of TVFCIASN providers to administer vaccines to program -eligible populations by conducting the following activities: I . Ensuring New Provider Checklist is completed; 2. Conducting quality assurance reviews; 3. Ensuring annual influenza pre -book survey is completed; 4. Conducting compliance site visits; 5. Conducting unannounced storage and handling visits; and 6. Ensuring providers adhere to the vaccine borrowing procedure. I. Participate in audits and assessments through the following activities: System Agency Contract No. 11HS000109800001 Page 4 of 32 DocuSign Envelope ID: EDID9DAA-F953-45C7-9B27-CB90EF3616DA I . Completing and submitting through Child Health Reporting System ("CHRS") all audits and assessments conducted on childcare facilities and Head Start Centers; 2. Completing audits, assessments and retrospective surveys of public and private schools; 3. Reviewing monthly reports to ensure data quality; 4. Reviewing the monthly Provider Activity Reports; S. Reviewing the quarterly Consent Accepted Rate Evaluations; and 6. Conducting quality improvement assessments of Texas Immunization Registry organizations. J. Provide education and outreach activities regarding vaccines and vaccine -preventable diseases, Texas Immunization Registry, and TVFC and ASN Programs to the following: 1. American Indian Tribes; 2. Schools and childcare facilities; 3. Healthcare workers; and 4. Community and general public. K. Not deny vaccinations to recipients because they do not reside within Grantee's jurisdiction or because of an inability to pay an administration fee. L. Be responsible for identification and case management of all hepatitis B surface antigen ("HBsAg")-positive pregnant women. Grantee shall ensure timely newborn post - exposure prophylaxis ("PEP") with hepatitis B vaccine and hepatitis B immune globulin ("HBIG"), timely completion of doses two and three of hepatitis B vaccine, and timely completion of post -vaccination serologic testing ("PVST"). M. Be responsible for assessing and/or auditing coverage rates and/or compliance with vaccine requirements at assigned schools and childcare facilities in accordance with the Population Assessment Manual, which is distributed annually from DSHS. N. Transfer (which may include shipping) overstocked vaccines and vaccines approaching expiration to alternate providers for immediate use when instructed to do so by the DSHS Public Health Region ("PHR") Immunization Program Manager to avoid vaccine waste. Grantee is responsible for covering the cost to ship overstocked vaccines and vaccines approaching expiration. O. Receive written approval from DSHS before varying from applicable policies, procedures, protocols, and/or work plans, and must update and disseminate its implementation documentation to its staff involved in activities under this Contract within forty-eight (48) hours of making approved changes. P. Review monthly Contract funding expenditures and salary savings from any Contract - paid staff vacancies and revise spending plan to ensure that all funds will be properly expended under this Contract before the end of the Contract term. Q. Submit out-of-state travel requests to the ImmttlilZatioll Unit for approval when utilizing Contract funds or program income. System Agcncy Conuact No I IHS000109800001 Page 5 of32 DocuSign Envelope ID- ED1 D9DAA-F953-45C7-9B27-CB90EF3616DA R. Report the number of doses administered to underinsured children monthly, as directed by DSHS. S. Report the number of unduplicated underinsured clients served, as directed by DSHS. T. Complete and submit Immunization Inter -Local Agreement Quarterly Report form, utilizing the format provided by the DSHS Immunization Unit and available at littps://dslis.texas.gov/immunize/lhd.shtm, by the report due date. If the due date falls on a weekend or state -approved holiday, the report is due the next business day. Report Type Reporting Period Report Due Date Programmatic 09/01/2019 to 11/30/2019 12/31/2019 Programmatic I2/01/2019 to 02/29/2020 03/31/2020 Programmatic 03/01/2020 to 05/30/2020 06/30/2020 Programmatic 06/01/2020 to 08/31/2020 10/31/2020 Submit quarterly reports electronically through Survey Gizmo following instructions provided by the DSHS Immunization Unit and according to the time frames stated above. Supplemental report documents (PEAR and AFIX reports, vacancy letters, etc.) should be sent to dshsilnlnunizationcontracts2.dshs.texas.f4ov__ II. PERFORMANCE MEASURES The System Agency will monitor the Grantee's performance of the requirements in this Attachment A-1 and compliance with the Contract's terms and conditions. Ili. INVOICE AND PAYMENT A. Grantee shall request monthly payments using the State of Texas Purchase Voucher (Form 13-13) at http:,`/w,.�-w.dshs.texas.gov,'grants.'forms.shtm and submitting acceptable supporting documentation for reimbursement of the required services/deliverables. Vouchers and supporting documentation shall be submitted to System Agency no later than thirty (30) days after the last day of each month. Documentation shall be submitted in a format approved by DSHS Immunization Unit. At a minimum vouchers should include: 1. Grantee name, address, email address, vendor identification number or Social Security number, and telephone number; 2. DSHS Contract or Purchase Order number; 3. Dates services were completed and/or products were delivered; and 4. The total invoice amount. 5. Supporting documentation must include: a. Receipts with a zero balance for items such as hotel, rental car and fuel, taxi, airline or mileage as documented by a readily available online mapping service; b. Receipts for supplies, registration fees and other items ordered and paid for; System Agenc) Contract No. 111 IS000109800001 Page 6 of 32 DocuSign Envelope ID ED1D9DAA-F953-45C7-9827-Ci390EF3616DA c. A copy of the Personnel and Temporary Staff General Ledger for the period which supports the budget items requesting reimbursement; and d. Paid invoices to contractors for services received. Receipts for meals are not required. B. Voucher and supporting documentation shall be mailed or submitted by fax or electronic mail to DSHS Claims Processing Unit at the address/number below, and also sent via email to Tray Kirkpatrick, DSHS Contract Management Section, at tray.kirkpatrickf7dshs.texas.gov, and to the Immunization Unit at dshsimmunizationContracts(a'dshs.texas. gov. Department of State Health Services Claims Processing Unit, MC 1940 P.O. Box 149347 Austin, Texas 78714-9347 Fax: (512) 458-7442 Email: invoices,, r dshs.texas_gL and to CMSinvoicesndshs.texas. 7ov C. Grantee will be paid on a cost reimbursement basis and in accordance with the established state fiscal year Budget of this Contract. (Remainder of Page Intentionally Lef Blank) System Agency Conti -act No. I IHS000109800001 Page 7 of 32 DocuSign Envelope ID: EDID9DAA-F953-45C7-9827-0890EF3616DA Attachment B-1 Fiscal Year 2020 Budget Organization Name: City of Lubbock Program ID: IMMILOCALS Contract Number: HHS000109800001 Budget Categories Budget for FY 2020 Personnel $141,861.00 Fringe Benefits $57,454.00 Travel $14,640.00 Equipment $0.00 Supplies $5,958.00 Contractual $12,202.00 Other $0.00 Total Direct Costs $232,115.00 Indirect Costs $0.00 Total $232,115.00 (Renrainrle-r of Page Intentionally Left Blank) System Agcncy Contract No. 111 IS000109800001 Page 8 of 32 DocuSign Envelope ID. ED1 D9DAA-F953-45C7-9B27-C890EF3616DA Attachment H Immunization/Locals Program Guidance Document GRANTEE RESPONSIBILITIES Instructions related to each required and suggested activity below can be found in the Ininiutlization Program Contractor's Guide. 1. PROGRAM & CONTRACT MANAGEMENT I.I. PROGRAM MANAGEMENT 1.1.01 implement and operate an Immunization Program as a Standard Responsible Entity (Universal) 1.1.02 Identify at least one individual to act as the program Required contact in the following areas: Activity I. Immunization Program Manager, 2. RE Contract Coordinators, 3. RE School Compliance Coordinators, 4, RE Perinatal Hepatitis B Case Manager, 5. RE Disease Surveillance Coordinators, 6. RE Clinical Coordinators, 7. RE Texas Immunization Registry Coordinators, 8. RE TVFC & ASN Coordinators, and 9. RE Communications Coordinators 1.1.03 Attend all required trainings for each Area of Work as Required specified in the Immunization Program Contractor's Activity Guide. Ensure that the Immunization Program Manager and TVFC and ASN Coordinator attend the annual Immunization Unit mandatory in -person meeting__ 1.1.04 Comply with the DSHS Immunization Contractor's Guide Standard for Local Health Departments which includes all (Universal) immunization grant objectives and required activities. The Immunization Contractor's Guide is Attachment A of the ILA and will be attached to the executed contract 1.1.05 Annually complete one LHD Deputization Addendum Required Form (EF11-13999) for all Provider Identification Activity Numbers (PIN) associated with the LHD Grantee to ensure eligibility to provide immunization services to ttnderinsured children _ 1.1.06 Maintain staffing levels adequate to meet the required Standard activities of this contract and to assure expenditure of all (Universal) contract funds 1.1.07 Develop and implement an employee immunization policy for Grantee's immunization program staff according to CDC recommendations Required Activity System Agency Contract No. I111S000109800001 Page 9 of 32 DocuSign Envelope ID: EDID9DAA-F953-45C7-9B27-Ca9oE=F3616DA 1.1.08 Maintain a record of orientation (new staff) and ongoing Required training for existing contract-fiinded staff involved in the Activity provision of immunization services 1.1.09 Inform DSHS (in writing) of any changes (both departures Required and arrivals) in LHD Medical Director, Immunization Activity Program Manager and all other positions listed under activity I.1.02 within 30 days of staffing changes 1.1.10 Submit a written notification for contract -funded staff Required positions that remain vacant more than 90 days Activity 1.1.11 Have a standard method to document all work time spent Standard performing immunization activities for staff who are (Universal) partially funded with immunization contract fiends 1.1.12 Use the results of the community assessment conducted in Suggested activity 4.7.01 to review and address an immunization need Activity within the LHD jurisdiction System Agency Contract No. I IIIS000109800001 Page 10 of 32 DocuSign Envelope ID. E01D9DAA-F953-45C7-9B27-CB90EF3616DA 1.2. PROGRAM COMPLIANCE 1.2.01 Comply with all applicable federal and state regulations Standard and statutes as amended, (Universal) including but not limited to: L Human Resources Code §42.043, VTCA; 2. Education Code §§38.001-38.002, VTCA; 3. Health and Safety Code §§ 12.032. 81.023, and 161.001- 161.009, VTCA; 4. TAC Title 25, Chapter 97; 5. TAC Title 25, Chapter 96; 6. TAC Title 25, Chapter 100; 7.42 USC §§247b and 300 as-25; 8.Omnibus Budget Reconciliation Act of 1993, 26 USC §4980B 1.2.02 Ensure compliance with Health and Human Services Standard (HHS) Deputization Guidance. Activities under this (Universal) requirement shall be conducted in accordance with the DSHS Immunization Contractor's Guide for Local Health Departments 1.3. FINANCIAL MANAGEMENT 1.3.01 Agree DSHS reserves the right, where allowed by legal Standard authority, to redirect funds in the event of financial (Universal) shortfalls 1.3.02 Submit monthly invoices with appropriate supplemental Required documentation and request monthly payments using the Activity State of Texas Purchase Voucher (Form B-13) and in accordance with the DSHS Immunization Contractor's Guide for Local Health Dements _ 1.3.03 Agree DSHS will pay Grantee on a cost reimbursement Standard basis (Universal) 1.3.04 Adhere to travel rates set by the State of Texas TexTravel Standard _ (Universal) 1.3.05 Review monthly contract funding expenditures to ensure Standard that all funds will be properly expended before the end of (Universal) the contract period 1.3.06 Lapse no more than 5 percent of total funded amount of the Required contract Activity 1.3.07 Submit requests to move more than 25% of the total Standard contract amount between direct budget categories in writing (When to the DSHS Contract Management Section (CMS) in Applicable) Austin and obtain approval before monies can be transferred_ _ 1.3.08 Expend funds consistently throughout the contract term, Suggested approximately 25% per quarter � Activity System Agency ConVact No. I If ISOOO 109800001 Page I I of 32 DocuSign Envelope ID: EDID9DAA-F953-45C7-9B27-C890EE3616DA 1.4. CONTRACT MANAGEMENT 1.4.01 Initiate the purchase of approved equipment purchases in Standard the first quarter of the Contract term. Requests to purchase (When previously approved equipment after the first quarter must Applicable) be submitted to the contract manager. Changes to the approved equipment budget category must be approved by DSHS prior to the purchase of equipment. If a Grantee would like to deviate from the approved equipment budget, a written request to amend the budget is required 1.5. CONTRACT QUALITY ASSURANCE 1.5.01 Participate in remote and on -site technical assistance Required Activity 1.5.02 Participate in on -site contract evaluation visits Required -Activity _ 1.6. CONTRACT ACCot NTARILITY 1.6.01 Submit Corrective Action Plan (CAP) letter to Public Required Health Region Program Manager and DSHS Contract Activity Management Section (CMS) within 30 days after the date of the written notification from DSHS CMS of the on -site evaluation findings (if applicable} 1.6.02 Maintain property records for property and equipment Standard funded or property provided b+ grant funds (Universal) 1.7. REQUIRED REPORTING 1.7.01 Complete and submit Immunization Inter -Local Agreement Required (ILA) Quarterly Report and supplemental documents Activity according to the formats, mechanisms, and timefratnes specified in the DSHS Immunization Contractor's Guide for Local Health Departments _ 1.7.02 Report program income (PI) generated as a result of the Required DSHS immunization contract activities on the quarterly Activity financial status report (FS) 1.7.03 Ensure all program income (PI) generated as a result of the Standard DSHS immunization contract activities is expended in (Universal) accordance with the DSHS Immunization Contractor's Guide for Local Health Departments 1.7.04 Submit quarterly FSRs to Accounts Payable by the last Required business day of the month following the end of each quarter Activity for review and financial assessment. Submit the final FSR no later than forty-five (45) calendar days following the end of the applicable term System Agene). Contract No. I11-IS000109800001 Page 12 of 32 DocuSign Envelope ID: ED1090AA-F95345C7-9B27-C890EF3616DA 2. FACILITY IMMUNIZATION ASSESSMENTS 2.1. CHILDCARE & SCHOOL COMPLIANCE 2.1.01 2.1.03 Assess and/or audit coverage rates and/or compliance with vaccine requirements at assigned schools and childcare facilities Complete 100% of assigned childcare facility and Head Start center audits and assessments. By July 15 of contract year, local health department staff will complete and submit into CHRS 100% of assigned childcare audits Complete 100% of assigned public and private school audits, assessments, retrospective surveys, and validation surveys in accordance with the DSHS Immunization Contractor's Guide for Local Health Departments • By January 15 of contract year, local health department staff will complete and submit to PHR 50,0' of assigned validation Surveys • By February 15 of contract year (end of 2nd Q), local health department staff will complete and submit to PHR 100% of assigned validation surveys • By June 30 of contract year, local health department staff will complete 100% of assigned school audits and submit to PHR 2.2. C111LDCARE & SUIIOOL COMPLIANCE QA 2.2.01 Provide education to school and childcare facilities with high provisional, delinquency, and/or exemption rates at time of audit or when noncompliant records are identified. Report education provided to school or childcare staff in accordance with the DSHS Immunization Contractor's Guide for Local Health Departments 2.2.02 Provide feedback to DSHS ACE Group regarding trends/issues for school, college, and childcare vaccine requirements in accordance with the DSHS Immunization Contractor's Guide for Local Health Departments 2.2.03 Contact schools/districts to remind them to report during the Annual School Survey reporting period in accordance with the DSHS Immunization Contractor's Guide for Local Health Departments 2.3. FIRST RESPONDER IMMUNIZATION ASSESSMENTS Standard (Universal) Required Activity Required Activity Required Activity Required Activity Required Activity 2.3.01 Educate and inform first responder facilities on the use of Suggested the Texas Immunization Registry to assess first responder Activity immunization records and forecast any future immunization needs. Use the First Responder Immunization Toolkit (FRIT) to drive these activities System Agency Contract No. 111ISO00109800001 Page 13 of 32 DocuSign Envelope ID: EDID90AA-F953-45C7-9B27-C890EF3616DA 3. MANAGING TVFC AND ASN PROVIDERS 3.1. PROVIDER RECRUITMENT 3.1.01 Recruit additional TVFC providers to administer vaccines Suggested to program -eligible populations. The goal is to increase Activity each local health department's provider enrollment by a minimum of 5% 3.1.02 Ensure New Provider Checklist (I 1-15016) is completed Required for all clinics that join the TVFC/ASN Program Activity 3.1.03 Collaborate with medical societies and/or local health Suggested provider organizations to identify providers to recruit and Activity enroll 3.2. PROVIDER RETENTION 3.2.01 Sustain a network (through re -enrollment) of TVFC Required providers to administer vaccines to program -eligible Activity populations 3.2.02 Promote TVFC and ASN Provider achievements: Suggested - Implement incentives for provider sites that reach Activity vaccination coverage rate goals - Implement incentives to recognize sites during national observances (i.e. NIIW, NIAM, and NIVW) System Agency Contlwt No. I ItIS000109800001 Page 14 of 32 DocuSign Envelope ID: EDiD9DAA-F953-45C7-9B27-C890EF3616DA 3.3. PROVIDER EDE CATION 3.3.01 Provide a training for TVFC and ASN providers within the Suggested LHD Grantee's jurisdiction on the policies outlined in the Activity TVFC and ASN Provider Manual and recommended procedures for implementing them. These include: - procedures for following storage and handling guidelines - procedures for vaccine management - procedures for using the DSHS vaccine management system (EVI) - procedures for vaccine borrowing - procedures for other compliance guidelines - appropriate reporting of vaccine adverse events - appropriate routine and emergency vaccine storage and handling plans - meeting the federal requirement that the most current Vaccine Information Statements (VIS) (available at (http:.`iwww.cdc.gov./vaccines'Iicp/vise'index.html) must be distributed to patients prior to patient vaccination 3.3.02 Notify providers of TVFC and ASN updates and changes Standard to program policies and procedures. (Universal) Notify TVFC/ASN providers of the following: - CDC and DSHS Announcements - TVFC/ASN Trainings - Vaccine storage and handling policy updates - Vaccine ordering changes - Vaccine choice _ 3.3.03 Educate and assist TVFC and ASN providers on a Standard quarterly basis with Provider Choice, as necessary (Universal' 3.3.04 Inform TVFC and ASN providers of the most up-to-date, Standard DSHS-produced immunization information for their (Universal) offices 3.3.05 Identify TVFC and ASN providers experiencing high Required volumes of vaccine loss and develop process Activity improvements/trainings aimed at reducing the amount of vaccine loss (including wasted and expired) in their clinics 3.4. PROVIDER VACCINE MANAGEMENT 3.4.01 Utilize the DSHS Inventory Tracking Electronic Asset Required Management System (iTEAMS) reports and other provider Activity submitted reports to perform 100% of quality assurance reviews on the following TVFC and ASN: - monthly biological reports (doses administered and current inventory), - vaccine orders, System Agency Contract No. I114S0001098000Q I Page 15 of 32 DocuSign Envelope ID: EDID9DAA-F953-45C7-9B27-C890EF3616DA - temperature logs and - clinic hours of operation from TVFC and ASN providers in LHD Grantee's jurisdiction. Address all issues identified during review 3.4.02 Transfer vaccines that cannot be stored within provider Standard offices (ex. accidental large orders) and vaccines (Universal) approaching expiration between providers in LHD Grantee's 'urisdiction for immediate use 3.4.03 Ensure provider participation in vaccine ordering and Standard inventory management using the Electronic Vaccine (Universal) Inventory (EVI) system -Educate providers regarding vaccine ordering policies -Train providers to use the EVI system for inventory and order entry 3.4.04 Assist TVFC and ASN providers in LHD Grantee's Standard jurisdiction on the maintenance of appropriate vaccine (Universal) stock levels. Activities under this requirement shall be conducted in accordance with the DSHS Immunization Contractor's Guide for Local Health Departments and the current TVFC and ASN Program Operations Manual for Responsible Entities 3.4.05 Train TVFC and ASN providers within LHD Grantee's Standard jurisdiction to ensure that expired and spoiled/wasted (Universal) vaccines are appropriately identified and entered into the electronic Vaccine Inventory (EVI) system Train providers to complete returns to CDC's centralized distributor within six months of product expiration _ 3.4.06 Ensure that 100% of TVFC providers within the LHD Required Grantee's jurisdiction complete the annual influenza pre- Activity book survey 3.5. PROVIDER QUALITY AssURANC E 3.5.01 Utilize the CDC Provider Education Assessment and Reporting Required (PEAR) system to document TVFC compliance site visits for all Activity subcontracted clinics and non-LHD Grantee's clinics (as applicable) 3.5.02 Utilize the CDC PEAR system and directly enter data into Required PEAR to document TVFC unannounced storage and handling Activity visits to a minimum of 10% of providers within the LHD Grantee's iurisdiction 3.5.03 Utilize the CDC PEAR system and directly enter data into Required PEAR to document TVFC contacts and other visits conducted at Activity TVFC provider offices 3.5.04 Complete and document 100% of the follow-up activities for Required TVFC quality assurance visits within required timeframes Activity Systcm Agency Contract No. I II I5000109800001 Page 16 of 32 DocuSign Envelope ID• ED1 D9DAA-F95345C7-9627-C890EF3616DA 3.5.05 Utilize the CDC assessment visit online tool and methodology to assess immunization practices and coverage rates for all subcontracted entities and non-LHD Grantee's clinics (as applicable) 3.5.06 Review 100% of re -enrollment applications from TVFC and ASN providers in your jurisdiction by the DSHS specified deadline _ 3.5.07 Ensure that expired, wasted, and unaccounted-for vaccines (excluding flu) do not exceed 5% in TVFC provider clinics within the LHD Grantee's jurisdiction 3.5.08 Review monthly reports to ensure data quality. This includes: - Identify sites that have not administered or ordered vaccine in the previous six months. Conduct a discussion and develop a plan of action - Identify sites that are suspended to ensure 90 days is not exceeded - Ensure enrollment and withdrawal forms are submitted correctly and on time to the PHR staff 3.5.09 Review submitted reports to ensure data quality. This includes: - Quarterly, review 25% of enrolled sites to ensure contacts are listed correctly in EVI - Quarterly, review 25% of enrolled sites and provide education for the Vaccine borrowing and Vaccine transfer forms 3.5.10 Review monthly data logger reports for 25% of providers in LHD Grantee's jurisdiction to validate the accuracy of provider - submitted monthly temperature reporting forms f 3.5.11 Review monthly data logger reports to validate the accuracy of provider -submitted monthly temperature reporting forms for all providers within LHD Grantee's jurisdiction who experience a vaccine loss as a result of temperature excursions 3.5.12 Conduct a monthly review of 10% of randomly selected providers in LHD Grantee's jurisdiction to identify vaccine loss report forms that were completed in FNI but were not submitted 3.5.13 Conduct a quarterly review of 25% of providers in LHD Grantee's jurisdiction to identify those that have adjusted more than 10% of their vaccine inventory 3.5.14 Conduct a quarterly review of 25% of providers in LHD Grantee's jurisdiction to ensure the reported patient population matches the number of doses ordered 3.6. PROVIDER ACCOUNTABILITY Required Activity Required Activity Standard (Universal) Required Activity Suggested Activity Suggested Activity Standard (Conditional) Suggested Activity Suggested Activity Suggested Activity 3.6.01 Track, report and follow up on vaccine fraud and abuse Standard cases Universal System Agency Contract No. I111S000109900001 Page 17 of 32 DocuSign Envelope ID: EDID9DAA-F953-45C7-9B27-C890EF3616DA 3.6.02 Complete program evaluation activities with TVFC and ASN providers to address issues identified as noncompliance issues For all TVFC providers, document corrective action plans in the CDC PEAR system as a contact 3.7. RE STAFF EDUCATION 3.7.01 3.7.02 3.7.03 Train LHD Grantee's staff to follow the policies and procedures outlined in the TVFC & ASN Program Operations Manual for Responsible Entities. Provide training on TVFC and ASN requirements and updates (as described in the TVFC & ASN Program Operations Manual for Responsible Entities) annually at a minimum _ For personnel identified by DSHS, attend andfor complete the following trainings: - CDC Immunization Trainings - TVFC/ASN Annual Trainings - Annual Responsible Entity Training - Public Health Region (PHR) Trainings Ensure that the TVFC & ASN Coordinator conducts quality assurance on 10% of the temperature recording logs that were reviewed by their staff each quarter 3.8. RE COMPLIANCE Required Activity Required Activity Required Activity Suggested Activity 3.8.01 Comply with the current DSHS Immunization Standard Contractor's Guide for Local Health Departments and the (Universal) TVFC and ASN Operations Manual for Responsible Entities 3.8.02 Receive regional approval for any vaccine transfers and Standard document those transfers in EVI within 24 hours of the (Universal) transfer occurring 3.8.03 Address general inquiries by providers about the Standard TVFC/ASN Program, and ensure timely follow-up on (Universal) requests for information 3.8.04 Ensure that providers within LHD Grantee's jurisdiction Required Activity are adhering to the vaccine borrowing procedures outlined in the TVFC and ASN Provider Manual Report the number of borrowing forms submitted by quarter in the Immunization Inter -Local Agreement (ILA) Euarterly Report ... System Agency Contract No I11I5000109800001 Page 18 of 32 DocuSign Envelope IDED1 D9DAA-F953-45C7 9B27-C890EF3616DA 3.9 RE EMERGENCY RESPONSE 3.9.01 3.9.02 3.9.03 Communicate the importance of an Emergency Vaccine Storage and Handling Plan to all clinics in the LHD Grantee's jurisdiction. Provide technical assistance to support the successful activation of each clinic's Emergency Vaccine Storage and Handling Standard (Universal) Plan Transfer, accept, and store TVFC and ASN vaccines Standard from clinics in the LHD Grantee's jurisdiction if there (Universal) is a failure in the clinic's Emergency Vaccine Storage and Handling Plan _ Be prepared to pack and ship vaccine to other sites, Required Activity as directed by the DSHS Immunization Unit S}stem Agency Contract No. Ill IS000109800001 Page 19 of 32 DocuSign Envelope ID. EDID90AA-F953-45C7-9B27-C890EF3616DA 4. EPIDEMIOLOGY & SURVEILLANCE 4.1. PERINATAL HEPATITIS B CASE IDENTIFICATION 4.1.01 Conduct identification and case management of Required Activity erinatal hepatitis B cases 4.1.02 Determine the number of newborns that do not receive Required Activity the first dose of the hepatitis B vaccine and/or HBIG and work with those facilities to ensure all at -risk infants receive the hepatitis B vaccine series and HBIG within 12 hours of birth 4.1.03 Develop a surveillance system that includes prenatal Suggested Activity care providers, obstetrical and gynecological care providers, family practitioners, and labor and delivery facilities to ensure all HBsAg-positive pregnant women are reported to the DSHS Immunization Unit within one week of diabnosis 4.1.04 Ensure timely follow-up and reporting of case status of Required Activity possible moms as reported by DSHS within 2 weeks of recei t of report 4.2. PERINATAL HEPATITIS B CASE MANAGEMENT 4.2.01 Contact and provide case management to 100% of the Required Activity number of hepatitis B surface antigen -positive pregnant women identified 4.2.02 Ensure timely newborn post -exposure prophylaxis Required Activity (PEP) with hepatitis B vaccine and hepatitis B immune globulin (HBIG) and report to DSHS within 2 weeks of identification 4.2.03 _ Ensure timely completion of doses two and three of Required Activity hepatitis B vaccine and report to DSHS within 2 weeks of identification after each dose 4.2.04 Ensure timely completion of post -vaccination Required Activity serologic testing (PVST) and report to DSHS within 2 weeks of identification 4.2.05 Case manage and report all household contacts under Required Activity 24 months of age in accordance with the DSHS Immunization Contractor's Guide for Local Health Departments and Perinatal Hepatitis B Prevention Manual (including serologic testing and completion of the full hep B vaccination series) _ 4.2.06 Refer all household contacts over 24 months of age Standard and sexual partners of reported HBsAg-positive (Universal) women for serologic testing to determine susceptibility status in accordance with the DSHS Immunization Contractor's Guide for Local Health Departments and Perinatal Hepatitis B Prevention Manual Systcm Agency Contract No. I IHS000109800001 Page 20 of 32 DocuSign Envelope ID EDID9DAA-F953-45C7-9B27-C890EF3616DA 4.3. PERINATAL HEPATITIS B REPORTING 4.3.01 For all cases documented as'lost-to-follow-up' on the Required Activity Perinatal Hepatitis B case management form, report the number and types of attempted activities performed in locating the mother or guardian of the infant to the DSHS Immunization Unit on the Perinatal Hepatitis B case management form 4.3.02 Report to the DSHS Immunization Unit all infants Required Activity born to HBsAg-positive women within 2 weeks of the event 4.3.03 Report to the DSHS Immunization Unit the case status Required Activity of possible exposed infants (born to women of unknown or unconfirmed HBsAg status) as reported by DSHS within 2 weeks of receipt of report 4.3.04 Ensure timely reporting of updates in case Required Activity management as requested by DSHS within 2 weeks of inquire 4.4. PERINAT,AL HEPATITIS B EDUCATION 4.4.01 Require Perinatal Hepatitis B Case Manager to attend Required Activity the biannual conference 4.4.02 Conduct educational training for hospital and T Required Activity healthcare providers within the Grantee's jurisdiction, to increase mandatory screening and reporting of hepatitis B surface antigen (HBsAg)-positive women 4.4.03 Educate delivery hospitals to ensure they verify Required Activity prenatal HBsAg test results of pregnant women on admission for delivery and test for HBsAg at delivery, regardless of prenatal test results, as required by law _ 4.4.04 Educate prenatal care providers to ensure they are Required Activity screening pregnant women for HBsAg status during each pregnancy, implementing procedures for documenting HBsAg screening results in prenatal care records, and forwarding original laboratory results to the delivery facility 4.4.05 Ensure all labor and delivery facilities develop Required Activity standing orders and policies to administer the first dose of the hepatitis B vaccine and HBIG to at -risk infants within 12 hours of birth 4.4A6 Identify labor and delivery facilities that do not have Required Activity standing orders and/or policies and educate providers to establish standing orders and policies to administer Sv%tcm Agency Contract No. I IHS000109800001 Page 21 of 32 DocuSign Envelope ID: EDID9DAA-F953-45C7-9827-C890EF3616DA to at -risk infants the first dose of the hepatitis B vaccine and HBIG within 12 hours of birth 4.4.07 Promote the TVFC Program to birthing hospitals and Suggested Activity encourage TVFC program enrollment 4.4.08 Provide training on the prevention of perinatal Required Activity hepatitis B through vaccination and PVST to pediatric care providers within the Grantee's jurisdiction 4.4.09 Provide trainings to delivery hospitals on reporting Suggested Activity HBsAg-positive test results for women who have delivered at their facilities using the LHD Grantee - developed surveillance system _ 4.4.10 Work with partners, as appropriate, to ensure Standard coordination of activities aimed at preventing (Universal) perinatall hepatitis B transmission 4.5. DISEASE SURvrILLANCE 4.5.01 Complete investigation and document at least 90% of Required Activity confirmed or probable reportable vaccine -preventable disease (VPD) cases within thirty (30) days of initial report to public health 4.5.02 Adhere to the DSHS Emerging and Acute Infectious Standard Disease Guidelines and current Epi Case Criteria (Universal) Guide in conducting all activities _ 4.5.03 Ensure all new VPD surveillance staff attend Required Activity `Introduction to NBS' training and complete the certification process in order to gain access to the NBS system 4.5.04 Complete all data entry into the Texas National Standard Electronic Disease Surveillance System (NEDSS) (Universal) Base System (NBS) following the NBS Data Entry Guidelines 4.5.05 Routinely review and follow up on all VPD Standard laboratory reports received, including electronic lab (Universal) reports (ELRs) generated through NBS in a timely fashion 4.5.06 Verify and enter complete vaccination history in NBS Required Activity on all VPD investigations with case status of confirmed or probable. Complete vaccination history can be assessed through the Texas Immunization Registry, provider offices, school records, and/or patient records 4.5.07 Initiate vaccine -based disease control activities by Standard identifying population in need of a vaccination (Universal) response and requesting vaccination services for that population by contacting the DSHS Vaccine - Preventable Disease (VPD) Surveillance Team Lead System Agcncy Contract No. I I HS000 109800001 Page 22 of 32 DocuSign Envelope ID: EDID9DAA-F953-4507-9B27-C890EF3616DA 4.6, DISEASE SURWILLANCE EDUCATION 4.6.01 Educate physicians, laboratories, hospitals, schools, Suggested child-care staff, and other health providers on VPD Activity reporting requirements 4.7. NEEDS ASSESSMENT 4.7.01 Community Assessment: Each LHD immunization Suggested Grantee will conduct a community needs assessment Activity System Agency Contract No. III ISo00109800001 Page 23 of 32 DocuSign Envelope ID• EDID9DAA-F953-45C7-9827-C890EF36160A 5. PROVIDING A VACCINE SAFETY NET 5.1. CLINIC ENROLLMENT 5.1.01 Enroll all eligible LHD clinics into the TVFC and ASN Required Programs as providers Activity 5.1.02 Provide immunization services according to national Standard standards for immunization practices for infants, (Universal) children, adolescents, adults, and healthcare workers. LHD clinics will comply with the National Childhood Vaccine Iq uj+ Act of 1986 5.2. CLINIC STAFF TRAINING 5.2.01 Train all clinic staff on the policies outlined in the TVFC Required and ASN Provider Manual and LHD procedures for Activity implementing them. These include: - procedures for following storage and handling guidelines - procedures for vaccine management - procedures for using the DSHS vaccine management system (EVI) - }procedures for other compliance guidelines 5.2.02 Develop clinic staff education requirements. Ensure that Required persons who administer vaccines and staff that are Activity involved in the vaccine administration process (including those who screen immunization records and administer vaccines) to follow Advisory Committee on Immunization Practices (ACIP) standards for children and adults and are knowledgeable on immunizations and immunization practices This can be accomplished by having staff complete the most current CDC Pink Book (Epidemiology and the Prevention of Vaccine Preventable Diseases) training and appropriate Vaccine Education Online (VEO) modules 5.2.03 Develop eligibility screening and documentation policy Required for all LHD clinics. Provide training to all staff on Activity appropriate screening and documentation for TVFC eligibility to ensure TVFC vaccine is administered only to TVFC-eligible children. Implement policy and plan for routine adherence to eligibility policies 5.2.04 Develop and implement a policy on the use of the Texas Required Immunization Registry. Train LHD staff on conducting Activity client searches in the Texas Immunization Registry and how to effectively enter client demographic and immunization information 5.3. CLINIC IMMUNIZATION PRACTICES System Agency Contract No. H11S000109800001 Page 24 of 32 DocuSign Envelope ID- EDID90AA-F95345C7-9B27-C890EF3616DA 5.3.01 Comply with current applicable state and federal standards, Standard policies and guidelines for clinics (Universal) 5.3.02 Provide vaccines regardless of residency or ability to pay Standard _ (Universal) 5.3.03 Adhere to clinical records retention schedule Standard _ Universall 5.3.04 Explain the benefits of a "medical home" and assist the Standard parent/guardian in obtaining or identifying the child's (Universal) medical home 5.3.05 Discuss the next ACIP-recommetided vaccines and refer Standard the client to a medical home to complete the vaccination (Universal) series 5.3.06 Maintain a list of current providers within the LHD's Standard jurisdiction who accept children on Medicaid or CHIP and (Universal) make this list available to clinic clients and families as needed 5.3.07 Refer uninsured clients to Medicaid or the Children's Standard Health Insurance Program (CHIP) as appropriate (Universal) 5.3.08 Ensure that all ACIP-recommended vaccines are routinely Standard available and offered to TVFC patients (Universal) 5.3.09 Ensure that all vaccines listed on the ASN vaccine Standard formulary are available and offered to eligible adult (Universal) patients 5.3.10 Establish "standing orders" for vaccination in LHD Required Grantee's clinics that are consistent with legal Activity requirements for standing orders (including, but not limited to, those found in the Texas Medical Practice Act) 5.3.11 Search for the client's immunization history at every client Standard encounter. Compare all immunization histories (Texas (Universal) Immunization Registry, TWICES or EMR system, validated patient -held records, clinic medical record) and enter into the Texas Immunization Registry all historical immunizations not in the Registry at every client encounter Review the client's record for vaccines due and overdue according to the CDC recommended schedules at: 5.3.12 -littps://8N,ww.cdc.gov/vacciiiesi,schedulesiiiidex.htjiii Offer updated Immunization History Report to the client or Standard client's parent or guardian at every client encounter (Universal) 5.3.13 Follow and explain recommended guidelines for obtaining Standard and submitting ImmTrac2 consent forms according to the (Universal) instructions found at htt ://Nvww.dshs.texas.gov/immunize/immtrac/forms.shtm System Agency Contract No_ I-II•IS00O109800001 Pape 25 of 32 DocuSign Envelope ID EDID9DAA-F953-45C7-9B27-C890EF3616DA 5.3.14 5.3.15 5.3.16 5.3.17 5.3.18 5.3.19 5.3.20 5.3.21 5.3.22 5.3.23 5.3.24 5.3.25 5.3.26 Report to the Texas Immunization Registry all immunizations administered to consented children (younger than 18 years of age) and consented adults in LHD Grantee's clinics, either by entering data directly into the Registry or through electronic data exchange via TWICES or an electronic medical record (EMR) system Verbally and with DSHS-produced literature, inform parents at LHD Grantee's clinics about the Texas Immunization Registry, the benefits of inclusion in the Registry, and the importance of maintaining a complete immunization history in the Registry Update all demographic information, including address, email, and telephone number, at every client encounter in HMR and the Texas Immunization Registry Verbally educate patients and parents/guardians about the benefits and risks of vaccination and distribute DSHS educational materials, as applicable, as part of this Standard (Universal) Standard (Universal) Standard (Universal) Standard (Universal) conversation Follow only medically supportable contraindications to Standard vaccination (Universal) Provide immunization services at times other than 8 am to Required 5 pm, Monday through Friday, at least once per month Activity Institute infection control practices, including effective Standard hand washing and management of hazardous waste (Universal) Maintain confidentiality of client information Standard (Universal) Recommend the simultaneous administration of all needed Standard vaccines for the patient (Universal) Implement clinic policy on screening and documentation Standard of eligibility for TVFC vaccines. The policy must be (Universal) consistent with the TVFC requirements outlined in the current TVFC and ASN Provider Manual Participate in public health emergencies and exercises that Suggested may require vaccine administration to the public or first Activity responders Conduct outreach activities to raise the immunization Suggested coverage levels of uninsured adults by visiting sites such as Activity homeless shelters, halfway houses, day labor sites or other locations _ Coordinate with community vaccinators to conduct annual Suggested employee -based vaccination clinics for influenza vaccine Activity administration 5.4. CLINIC VACCINE MANAGEMENT Systcm Agency Contract No. 1111S000109800001 Page 26 of 32 DocuSign Envelope ID: EDID9DAA-F953-45C7-9B27-C890EF3616DA 5.4.01 5.4.02 Ensure that all expired and spoiled/wasted vaccines are appropriately identified and entered into the Electronic Vaccine Inventory (EVI) system for the LHD Grantee's clinics _ Submit returns for all vaccines distributed via CDC's centralized distributor back to the centralized distributor for returns processing 5.5. CLINIC QUALITY ASSURANCE Required Activity Standard (Universal) 5.5.01 Ensure that appropriate routine and emergency vaccine Required storage and handling plans are in place at each of the LHD Activity Grantee clinic locations 5.5.02 Ensure that expired, wasted, and unaccounted-for vaccines Standard (excluding flu) do not exceed 5 percent in LHD Grantee's (Universal) clinics 5.5.03 Participate in all TVFCfASN extended PEAR visits for Required quality assurance Activity___ 5.6. CLINIC REPORTING 5.6.01 Conduct timely reporting of monthly clinic activities Required Activity by recording vaccine inventory, doses administered, temperature logs and other reportable activities by the 5`' of each month as described in the TVFCIASN Provider Manual 5.6.02 Report all notifiable conditions as specified in the Standard DSHS Immunization Contractor's Guide for Local (Universal) Health Departments 5.6.03 Report all vaccine adverse events as specified in the Standard DSHS Immunization Contractor's Guide for Local (Universal) Health Departments 5.6.04 Report the number of unduplicated underinsured clients Required Activity and the number of doses administered to underinsured children monthly as specified in the DSHS Immunization Contractor's Guide for Local Health Departments 5.6.05 Conduct monthly reporting of doses administered to Required Activity women veterans, as required in the ASN Program System Agency Contract No. 11Ii5000109800001 Page 27 of 32 DocuSign Envelope ID EDID9DAA-F953-45C7-9B27-C890EF36t6DA 6. INCREASING USE OF THE TEXAS IMMUNIZATION REGISTRY 6.1. TEXAS IMMUNIZATION REGISTRY OUTREACH FOR IMMUNIZATION RECORDS 6.1.01 Conduct Texas Immunization Registry outreach to Suggested organizations regarding missing vaccinations for children Activity and adults for whom consent has been granted but who do not have complete immunization records 6.2. TEXAS IMMUNIZATION REGISTRY OUTREACH FOR PATIENT CONSENTS 6.2.01 Conduct activities aimed at increasing the consent rate Suggested for all age groups, including adults and individuals Activity identified as recently moved in -state 6.2.02 Conduct at least twelve (12) outreach and educational Required activities focused on 18-year-olds in high schools and Activity colleges/universities in LHD Grantee's jurisdiction 6.3. TEXAS IMMUNIZATION REGISTRY OUTREACH TO USERS 6.3.01 Conduct outreach to existing Registry users whohaveRequired not logged into the Registry in the last 90 dabs Activity 6.3.02 Provide orientation to all new Texas Immunization Suggested Registry organizations within the LHD Grantee's Activity jurisdiction at least once a year and maintain documentation of all technical assistance provided (e.g., telephone logs) Provide education and training on the effective use of the Texas Immunization Registry according to the Guidelines for Increasing the Use of the Texas Immunization Registry Identify and assist newly registered providers and new users reporting to the Texas Immunization Registry 6.4. TEXAS IMMUNIZATION REGISTRY USER EDUCATION 6.4.01 Provide education, training, and technical assistance to promote the effective use of the Texas Immunization Rgisja by organizations 6.4.02 Identify and assist providers to establish electronic affirmation of consent 6.5. TEXAS IMMUNIZATION REGISTRY PROMOTION Suggested Activity Required Activity Systcm Agency Contract No IIH5000109800001 Page 28 of 32 DocuSign Envelope ID• EDID9DAA-F95345C7-9B27-C890EF3616DA 6.5.01 6.5.02 6.5.03 Promote the use of the Texas Immunization Registry to Required organizations within the LHD Grantee's jurisdiction that are Activity not currently enrolled in the Registry. Identify all providers who administer vaccine in awardee's jurisdiction, including both pediatric and adult immunization providers. Educate them on their statutory requirement to report immunizations and on the enrollment process _ Provide education and technical assistance to birth Suggested registrars on the effective use of the Texas Immunization Activity Registry Collaborate with prenatal healthcare providers, birth Suggested registrars, hospital staff, pediatricians, and other entities to Activity educate parents, expectant parents, and providers about the Texas Immunization Registry and the benefits of participation. This includes the dissemination of DSHS educational materials as appropriate _ 6.6. TEXAS IMMUN17ATIoN REGISTRI PROGRAM QUALITI IM'1PROVEMENT 6.6.01 6.6.02 6.6.03 Review the monthly Provider Activity Report (PAR) to Required identify organizations who are inactive or not routinely Activity submitting immunization data or adding consented clients. Prioritize these organizations for outreach activities Review the quarterly Consent Accepted Rate Evaluation Required (CARE) report to target organizations with largest client Activity volume and/or lowest consent acceptance rate. Prioritize these organizations for outreach activities Conduct a Ininilnum of60 Texas immunization Registry Required organization quality improvement assessments per FTE Activity each year as described in the Guidelines for Increasing the Use of the Texas Immunization Registry. (For jurisdictions with less than 60 orgs, conduct quality improvement assessment visits to 100% of your orgs) System Agency Contract No. I IHS000109800001 Page 29 of 32 DocuSign Envelope ID- EDID9DAA-F95345C7-9B27-C890EF3616DA 7. EDUCATION AND PARTNERSHIPS 7.1 PUBLIC EDUCATION 7.1.01 Inform and educate the public about vaccines and vaccine- Required preventable diseases _Activity 7.1.02 Inform the general public about the TVFC and ASN Programs Required and the eligibility criteria for qualifying for theprograms Activity 7.2 PROVIDER EDUCATION 7.2.01 Educate and update providers on the most current ACIP Suggested recommendations for all age groups Activity 7.2.02 inform and highly recommend to the medical community and Suggested local providers within the LHD Grantee's jurisdiction the most Activity current Centers for Disease Control and Prevention (CDC) Epidemiology and Prevention of Vaccine -Preventable Disease (EPl-VAC) training (https:,I/www.cdc.gov.ivaceines/ed/webinar-epv/index.html). The most current "Pink Book," titled Epidemiology and Prevention of Vaccine -Preventable Diseases, can be found on the CDC website at htt p://www.cdc.gov/vaceines/p ubs/ inkbook/index.lttml 7.2.03 Provide information to community healthcare employers Suggested (hospitals, clinics, doctor offices, long-term care facilities) Activity about the importance of vaccination of healthcare workers 7.2.04 Provide training relating to Standards for Child and Adolescent Suggested Immunization Practices and Standards for Adult Immunization Activity Practices to all immunization providers within LHD Grantee's _ jurisdiction 7.2.05 Provide training opportunities and/or resources to assist Required immunization providers in communicating with patients and/or Activity parents (e.g., making a strong recommendation, addressing vaccine hesitancy, etc.) 7.3 STAFF EDUCATION 7.3.01 Work to ensure that all Immunization Program Grantee staff Standard _ are knowledgeable about vaccines and VPDs _ (Universals_ 7.3.02 Develop and implement a written communications and Required customer service plan for Grantee's staff to ensure customers Activity receive consistent, correct immunization information and services in a courteous and friendly manner on a timely basis 7.3.03 Educate healthcare workers on the importance of keeping Required themselves up-to-date with the vaccine schedule Activity 7.4 COALITION BUILDING System Agency Contract No. HH5000109800001 Page 30 of 32 DocuSign Envelope ID: ED1D9DAA-F953-45C7-9027-C890EF3616DA 7.4.01 Appoint an immunization coalition coordinator Suggested Activity 7.4.02 Attend and participate in required coalition trainings Suggested sponsored by DSHS Activity 7.4.03 Develop and maintain a planning group with the goal of Suggested sustaining a coalition Activity 7.4.04 Engage and recruit community groups and immunization Suggested stakeholders into a coalition Activity 7.4.05 Facilitate and host coalition meetings Suggested Activity 7.4.06 Participate in monthly calls to provide updates on coalition Suggested collaboration activities Activity _ 7.4.07 Provide signed letters of agreement and other documentation Suggested of commitment to articipate in coalition Activity 7.4.08 Document communications, group meetings, and planning of Suggested activities that promote the best practices identified in contract Activity agreement (documents are to be accessible during site visits) 7.5 COMMUNITY PARTNERSHIP 7.5.01 Plan and implement community education activities and Required partnerships aimed at improving and sustaining Activity immunization coverage levels 7.5.02 Conduct outreach and collaborative activities with American Required Indian tribes, if applicable _ Activity 7.5.03 Participate in at least one collaborative meeting concerning Required tribal health issues, concerns, or needs with American Indian Activity tribal members, if applicable 7.5.04 Coordinate educational and other activities with local Women, Infants, and Children (WIC) programs to ensure that children participating in WIC are screened and referred to their "medical home" for vaccination using a documented immunization history in accordance with the Standards for Child and Adolescent Immunization Practices 7.5.05 Offer educational opportunities to all WIC Programs in the service area, including information about online and satellite -broadcast continuing education opportunities from the CDC Continuing Education website at https:lfwww.cdc.govfvaccinesledlindex.html 7.5.06 Engage in education and partnerships aimed at reducing or eliminating coverage disparities by race, ethnicity, and socioeconomic status Suggested Activity Suggested Activity Requ i red Activity 7.5.07 Maintain a contact list of providers, hospitals, schools, child- Required care facilities, social service agencies, and community Activity groups involved in promoting immunizations and reducing vaccine -preventable diseases System Agency Contract No. 1-11-IS000109800001 Page 31 of 32 DocuSign Envelope ID: EDID9DAA-F953-45C7-9B27-C890EF3616DA 7.5.0 7.5.0 8 Participate in special initiatives as directed by the DSHS Required Immunization Unit Activity 9 Implement the DSHS Immunization Ambassador Program Required throughout Grantee's jurisdiction Activity 7.6 STAKEHOLDER ENGAGEIvtENT 7.6.01 Attend all Texas Immunizers and Stakeholders Working Required Activity Groups (TIS WG) and other designated stakeholder ' meetings (these meetings can be attended remotely) 7.6.02 Host at least l immunization stakeholder meeting per Suggested quarter (4 per contract),ear) Activity 7.7 MEDIA CAMPAIGNS 7.7.01 Distribute ASN information and educational materials at Required Activity venues and clinics that serve eligible adults _ 7.7.02 Distribute TVFC information and educational materials at Required Activity venues that parents of TVFC-eligible children might Frequent 7.7.03 Participate, when directed, in statewide media campaigns Required Activity by distributing DSHS-developed and produced public service announcements and materials to local television and radio stations, newspapers, parent publications, university newspapers, high school newspapers, and neiShborhood newspapers 7.7.04 Promote www.imnnuiizeTexas.com, the Immunization Required Activity Unit's website; and any other Immunization Unit newsletters to providers in the LHD Grantee's jurisdiction 7.7.05 Use national immunization observances as opportunities to Required Activity 4r conduct specific education and promotional activities to give emphasis to the importance and benefits of vaccines: National Infant Immunization Week (N1IW), National Immunization Awareness Month (NIAM), and National Influenza Immunization Week 11W 7.7.06 Share available federal, state, and/or local adolescent Required Activity vaccination coverage and/or vaccine -uptake -related data with partner organizations; adolescent immunization roviders, and other stakeholders (Remainder of Page Intentionalljr Left Blank) System Agency Contract No. IikiS000109800001 Page 32 of 32