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HomeMy WebLinkAboutResolution - 2002-R0312 - Contract Pertaining To HIV Surveillance - TX Dept. Of Health - 08/29/2002Resolution No. 2002-RO312 August 29, 2002 Item No. 42 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 a Contract (TDH Document No. 7560005906 2003, Attachments No. 03, 04, 05 and 06) pertaining to HIV surveillance, AC Family Health, OPHP-Local Public Health System and Immunization Division and any associated documents between the City of Lubbock and the Texas Department of Health, a copy of which contract is attached hereto and which shall be spread upon the minutes of this Council and as spread upon the minutes of this Council shall constitute and be a part hereof as if fully copied herein in detail. Passed by the City Council this 29th day of August '2002. MARC McD Af,, MAYOR 11 ATTEST: Rebecca Garza, City Secretary APPROVED AS TO CONTENT: Tommy CaInden, Health Director APPROVED AS TO FORM: Dd�ald G. V Attorney DDresfrDH-gen. con..res August 1, 2002 m � a TEXAS DEPARTMENT OF HEALTH 1100 WEST 49TH STREET AUSTIN, TEXAS 78756-3199 STATE OF TEXAS COUNTY OF TRAVIS Resolution No. 2002—RO312 August 29, 2002 Item No. 42 TDH Document No. 7560005906 2003 Contract Change Notice No. 02 The Texas Department of Health, hereinafter referred to as RECEIVING AGENCY, did heretofore enter into a contract in writing with LUBBOCK CITY HEALTH DEPARTMENT hereinafter referred to as PERFORMING AGENCY. The parties thereto now desire to amend sucn contract attactunent(s) as tonows: SUMMARY OF TRANSACTION: ATT NO. 03 HIV - SURVEILLANCE ATT NO. 04 AC FAMILY HEALTH - POPULATION BASED ATT NO. 05 OPHP - LOCAL PUBLIC HEALTH SYSTEM ATT NO. 06 IMMUNIZATION DIVISION - LOCALS All terms and conditions not hereby amended remain in full force and effect. EXECUTED IN DUPLICATE ORIGINALS ON THE DATES SHOWN. CITY OF LUBBOCK HEALTH DEPARTMENT Authorized Contracting Entity (type above if different from PERFORMING AGENCY) for and in behalf of: PERFORMING AGENCY: IM of person 4thorized to sign) Marc mal, NY Ior (Name and Title) Date: August 29, 2002 RECOMMENDE By: (PERFORMING A E CY Director, if different from person authorized to sign contract Tam1y Carden, Health Director V`'f-• Yt AS 10 M RECEIVING AGENCY: TEXAS UE RTMENT OF HEALTH By: � a, Z:��fA (Signature of person authorized to sign Melanie A. Doyle, Director Grants Management Division (Name and Title) Date: [14Z602, J V GMD - Rev. 12100 1?, 0,- � Z �S� 0, Cover Page 1` Rebecca Garza, City Secre DETAILS OF ATTACHMENTS Att/ Amd No. TDH Program ID Term Financial Assistance Direct Assistance Total Amount (TDH Share) Begin End Source of Funds* Amount 01 HIV/PREV 01/01/02 12/31/02 93.940 46,350.00 0.00 46,350.00' 02 OPHP/BIO-LAB 06/01/02 08/31/03 93.283 737,908.00 0.00 737,908.00 03 HIV/SURV 09/01/02 08/31/03 State 50,251.00 0.00 50,251.00 04 ACFH/POP 09/01/02 08/31/03 State 93.994 51,181.00 0.00 51,181.00 05 OPHP/LPHS 09/01/02 08/31/03 State 93.991 93,162.00 25,392.00 118,554.00 06 IMM/LOCALS 09/01/02 08/31/03 State 107,153.00 0.00 107,153.00 TDH Document No.7560005906 2003 Totals Change No. 02 $1,086,005.00 $ 25,392.00 $1,111,397.00 *Federal funds are indicated by a number from the Catalog of Federal Domestic Assistance (CFDA), if applicable. REFER TO BUDGET SECTION OF ANY ZERO AMOUNT ATTACHMENT FOR DETAILS. Cover Page 2 DOCUMENT NO. 7560005906-2003 ATTACHMENT NO. 03 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: BUREAU OF HIV AND STD PREVENTION TERM: September 01, 2002 THRU: August 31, 2003 SECTION I. SCOPE OF WORK: PERFORMING AGENCY shall conduct active surveillance and reporting activities for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). PERFORMING AGENCY shall comply with all applicable federal and state laws, rules, regulations, standards, and guidelines in effect on the beginning date of this contract Attachment unless amended. The following documents are incorporated by reference and made a part of this contract Attachment. 0 Chapters 81 and 85 of the Health and Safety Code; • Relevant portions of Chapter 6A (Public Health Service) of Title 42 (The Public Health and Welfare) of the United States Code, as amended; • 25 TAC Chapter 97, Subchapter F; and, • RECEIVING AGENCY Quality Care: Client Services Standards for Public Health and Community Clinics, revised June 1997. PERFORMING AGENCY shall perform all activities in accordance with PERFORMING AGENCY'S application, activities work plan and any revisions, and detailed budget as approved by RECEIVING AGENCY Program. All of the above-named documents are incorporated herein by reference and made a part of this contract Attachment. All revisions to these documents shall be approved by RECEIVING AGENCY Program and transmitted in writing to PERFORMING AGENCY. The activities required to carry out these projects are outlined in the Centers for Disease Control and Prevention (CDC) Guidelines for HIV/AIDS Surveillance, April 1996, and RECEIVING AGENCY Program's grant applications and awards by CDC which are the basis for this contract Attachment. Copies have been provided to RECEIVING AGENCY Program. Within thirty (30) days of receipt of an amended standard(s) or guideline(s), PERFORMING AGENCY shall inform RECEIVING AGENCY Program, in writing, if it will not continue performance under this contract Attachment in compliance with the amended standard(s) or guideline(s). RECEIVING AGENCY may terminate the contract Attachment immediately or within a reasonable period of time as determined by RECEIVING AGENCY. ATTACHMENT — Page 1 PERFORMING AGENCY shall immediately comply with all applicable policies adopted by RECEIVING AGENCY Program. PERFORMING AGENCY shall be responsible to RECEIVING AGENCY Program for the design, maintenance and evaluation of an active surveillance system for AIDS cases. For the purpose of this contract Attachment, HIV infection and AIDS are as defined by the Centers for Disease Control and Prevention of the United States Public Health Service in accordance with the Health and Safety Code §81.101. The publication designating the most current definition may be requested from RECEIVING AGENCY. PERFORMING AGENCY shall perform the following: 1. REPORTING a. Establish and maintain communications with key community and medical groups, individuals, and laboratories within PERFORMING AGENCY'S geographic area. b. Collect reports of HIV infections and AIDS cases diagnosed and/or treated within PERFORMING AGENCY'S geographic area. C. Report cases to RECEIVING AGENCY Program on a weekly basis. 2. REGISTRY MAINTENANCE a. Maintain a case file on all confirmed and suspected cases of HIV infections and AIDS diagnosed and/or treated within PERFORMING AGENCY'S geographic area. b. Maintain a current list of key reporting sources. 3. SYSTEM EVALUATION a. Review and provide thorough follow-up on a minimum of eighty percent (80%) of suspected cases identified by RECEIVING AGENCY Program's alternate record review systems in order to enhance case ascertainment and validate the effectiveness of local surveillance efforts. b. Track reporting by local sources in order to monitor the level of compliance to reporting laws and level of case ascertainment. 4. EPIDEMIOLOGIC INVESTIGATIONS ATTACHMENT — Page 2 a. Initiate epidemiologic investigations on newly reported No Identified Risk (NIR) cases within five (5) days of receipt of case report through contact with appropriate health care provider or the review of medical records. b. Assist RECEIVING AGENCY Program with other epidemiologic investigations as deemed necessary by RECEIVING AGENCY Program or CDC. 5. CONFIDENTIALITY a. Store all case files and computer diskettes containing patient information in a locked file cabinet when not in use. The locked file cabinet and surveillance computer shall be kept in a locked room with limited, controlled access. b. Utilize passwords to access computer databases containing HIV/AIDS case data. Passwords shall be changed monthly and known only to surveillance personnel. C. Limit the number of persons who have keys to registry files to persons directly involved in case reporting. d. Require a statement of confidentiality to be signed by all personnel having access to HIV/AIDS case files and computer diskettes and kept on file by PERFORMING AGENCY. e. PERFORMING AGENCY may release demographic analyses of local data as public information as long as it cannot lead to the identity of an individual. RECEIVING AGENCY Program will monitor PERFORMING AGENCY'S expenditures on a semi-annual basis. If expenditures are above or below those projected in SECTION III: BUDGET, PERFORMING AGENCY'S contract Attachment amount may be subject to increase or decrease for the remainder of the contract Attachment period. PERFORMING AGENCY shall authorize its staff to attend training, conferences, and meetings for which funds were budgeted and approved by RECEIVING AGENCY Program. PERFORMANCE MEASURES The following performance measure(s) will be used to assess, in part, PERFORMING AGENCY'S effectiveness in providing the services described in this contract Attachment, without waiving the enforceability of any of the other terms of the contract: 1. PERFORMING AGENCY shall collect case information for an estimated 50 cases and information shall be entered into the computerized HIV/AIDS Reporting System (HARS). PERFORMING AGENCY shall transfer the collected information on a weekly basis to RECEIVING AGENCY Program. ATTACHMENT — Page 3 PERFORMING AGENCY may request RECEIVING AGENCY Program to extend the timetable for transferring data to monthly. Any agreement shall be in writing and signed by both parties. 2. RECEIVING AGENCY Program will provide HIV/AIDS case reporting activities for cases diagnosed in the following geographic area(s): Lubbock. 3. PERFORMING AGENCY shall complete and submit semi-annual activity reports demonstrating PERFORMING AGENCY'S conduct of HIV/AIDS case -finding activities. These reports shall be submitted to RECEIVING AGENCY Program on the 20th day of February and September 2003 in a format provided by RECEIVING AGENCY Program, SECTION II. SPECIAL PROVISIONS: General Provisions, Assurances Article, is revised to include the following: PERFORMING AGENCY shall comply with all federal and state non-discrimination statutes, regulations, and guidelines. PERFORMING AGENCY shall provide services without discrimination on the basis of race, color, national origin, age, disability, ethnicity, gender, religion, or sexual orientation. General Provisions, Records Retention Article, is revised to include the following: All records pertaining to this contract Attachment shall be retained by PERFORMING AGENCY and made available to RECEIVING AGENCY, the Comptroller General of the United States, the Texas State Auditor, or any of their authorized representatives, and in accordance with RECEIVING AGENCY'S General Provisions. General Provisions, Patient or Client Records Article, is revised to include the following: RECEIVING AGENCY shall have access to a client or patient record in the possession of PERFORMING AGENCY, or any subrecipient, under authority of the Health and Safety Code, Chapters 81 and 85, and the Medical Practice Act, Texas Occupations Code, Chapter 159. In such cases, RECEIVING AGENCY shall keep confidential any information obtained from the client or patient record, as required by the Health and Safety Code, Chapter 81, and Texas Occupations Code, Chapter 159. Due to the sensitive and highly personal nature of HIV/AIDS-related information, PERFORMING AGENCY shall require its personnel to adhere strictly to the General Provisions, Confidentiality Article. ATTACHMENT — Page 4 SECTION III. BUDGET: PERSONNEL $31,844.00 FRINGE BENEFITS 11,973.00 TRAVEL 2,500.00 EQUIPMENT 0.00 SUPPLIES 750.00 CONTRACTUAL 0.00 OTHER 0.00 TOTAL DIRECT CHARGES $47,067.00 INDIRECT CHARGES $3,184.00 TOTAL $50,251.00 Total reimbursements will not exceed $50,251.00. Financial status reports are due the 30th of December, 30th of March, 30th of June, and the 30th of November. Based on UGMS, indirect cost may be recovered up to 10% of the direct salary and wage costs of providing the service (excluding overtime, shift premiums, and fringe benefits). ATTACHMENT — Page 5 DOCUMENT NO. 7560005906-2003-_ ATTACHMENT NO. 04 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: ASSOCIATE COMMISSIONER FOR FAMILY HEALTH TERM: September 01, 2002 THRU: August 31, 2003 SECTION I. SCOPE OF WORK: PERFORMING AGENCY shall perform public health preventive services related to women, children, and their families in order to address local health needs; to build the local public health infrastructure; and to improve the health status of women, children, and families. PERFORMING AGENCY shall comply with all applicable federal and state laws, rules, regulations, standards, and guidelines in effect on the beginning date of this contract Attachment unless amended. The following documents are incorporated by reference and made part of this contract Attachment: • RECEIVING AGENCY Title V FY 03 Continuation Request for Proposal (RFP); • PERFORMING AGENCY FY 03 Continuation Application and any revision; • RECEIVING AGENCY Family & Community Health Services Grants Fiscal Year 02 Competitive Request for Proposal (RFP) for Title V Population -Based projects; • PERFORMING AGENCY FY 02 Component II, Attachment B Application, and any revisions; • Client Services Standards for Public Health and Community Clinics, revised June, 1997; • RECEIVING AGENCY'S Quality Assurance (QA) Title V - Population Based On -Site Evaluation Report (designed to be used with QA Core Tool), which requires monthly time sheets to document staff time on work plan activities, invoices of all expenditures, logs of dated activities with sign -in sheets for public presentations; and, • Title V Policy and Procedures Manual revised for FY 02. Within thirty (30) days of receipt of an amended standard(s) or guideline(s), PERFORMING AGENCY shall inform RECEIVING AGENCY Program, in writing, if it will not continue performance under this Attachment in compliance with the amended standard(s) or guideline(s). RECEIVING AGENCY may terminate the Attachment immediately or within a reasonable period of time as determined by RECEIVING AGENCY. PERFORMING AGENCY shall implement its approved work plan in consultation with RECEIVING AGENCY'S Public Health Region (PHR) Title V Manager and Central Office Coordinator for public health preventive services. ATTACHMENT — Page 1 RECEIVING AGENCY'S PHR Director, as coordinator of regional services, will assist RECEIVING AGENCY staff in providing direction to PERFORMING AGENCY. RECEIVING AGENCY personnel will provide technical assistance and training to PERFORMING AGENCY, as needed. PERFORMING AGENCY shall cooperate with RECEIVING AGENCY staff to attain the goals of unified community health assessment, policy development, coordinated services, and quality assurance and to prevent unnecessary duplication of services. PERFORMANCE MEASURES The following performance measures will be used to assess, in part, PERFORMING AGENCY'S effectiveness in providing the services described in this contract Attachment, without waiving the enforceability of any of the other terms of this contract. • PERFORMING AGENCY shall submit quarterly reports on project activities to RECEIVING AGENCY'S PHR Title V Manager for review, assessment, and transmission to Central Office Coordinator within thirty (30) days of the end of each quarter. Quarterly reports shall describe accomplishments, challenges, barriers, impact, and progress in achieving the goals and objectives contained in PERFORMING AGENCY'S FY 03 Title V Application work plan, and any revisions. • The quarterly progress report shall be in the format specified by RECEIVING AGENCY in the Title V Policy and Procedures Manual and through any amended guidelines. • PERFORMING AGENCY shall provide public health preventative services to women, children, and their families who live or receive services in the following counties/area: Lubbock. • PERFORMING AGENCY shall submit a comprehensive final report on FY 03 work plan activities on or before September 30, 2003. This final report shall include the findings of an evaluation to determine the effectiveness of project activities in addressing local health needs, in building the local public health infrastructure, and in improving public health status. SECTION II. SPECIAL PROVISIONS: General Provisions, Reports Article, is revised to include the following: PERFORMING AGENCY shall submit quarterly and year-end financial reports, in the format specified by RECEIVING AGENCY Program, within thirty (30) days of the end of each quarter and within ninety (90) days of the end of the contract Attachment term detailing the activities performed and the objectives achieved with the funding provided ATTACHMENT — Page 2 under this contract Attachment. PERFORMING AGENCY shall submit other reports as deemed necessary by RECEIVING AGENCY Program. General Provisions, Inspections Article, is revised to include the following: In addition to the site visits authorized by the Inspections Article of the General Provisions, PERFORMING AGENCY shall allow RECEIVING AGENCY to conduct on-site quality assurance reviews as deemed necessary by RECEIVING AGENCY. Unsatisfactory review findings may result in implementation of General Provisions, Sanctions Article. PERFORMING AGENCY shall notify RECEIVING AGENCY Program immediately in the event of any significant change affecting PERFORMING AGENCY'S identity, ownership or control, name, governing board membership, vendor identification, medical or program director, or address. Failure to disclose the required information or inaccurate disclosure by PERFORMING AGENCY may be treated as a material breach of this contract Attachment and may be grounds for termination. ATTACHMENT -- Page 3 SECTION III. BUDGET: PERSONNEL FRINGE BENEFITS TRAVEL EQUIPMENT SUPPLIES CONTRACTUAL OTHER TOTAL DIRECT CHARGES INDIRECT CHARGES TOTAL $32,556.00 11,720.00 2,318.00 0.00 4,587.00 0.00 0.00 $51,181.00 $0.00 $51,181.00 Total reimbursements will not exceed $51,181.00 . Financial status reports are due the 30th of December, 30th of March, 30th of June, and the 30th of November. ATTACHMENT — Page 4 DefArtment of Health and Human Services Form Approved I-I61th Care Financing Administration OMB 0938-0086/HCFA-1513 INSTRUCTIONS FOR COMPLETING DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT (HCFA -1513) Completion and submission of this form is a condition of participation, certification, or recertification under any of the programs established by titles V, XVIII, XIX, and XX, or as a condition of approval or renewal of a contractor agreement between the disclosing entity and the secretary of appropriate state agency under any of the above titled programs, a full and accurate disclosure of ownership and financial interest is required. Failure to submit requested information may result in a refusal by the Secretary or appropriate State agency to enter into an agreement or contract with any such institution or in termination of existing agreements. SPECIAL INSTRUCTIONS FOR TITLE XX PROVIDERS All Title XX providers must complete Part II(a) and (b) of this form. Only those Title XX providers rendering medical, remedial, or health-related homemaker services must complete Parts II and III. Title V providers must complete Parts II and III. GENERAL INSTRUCTIONS For definitions, procedures and requirements, refer to the appropriate Regulations: Title V 42CFR 51a.144 Title XVIII 42CFR 420.200-206 Title XIX 42CFR 455.100-106 Title XX 45CFR 228.72-73 Please answer all questions as of the current date. If the yes block for any item is checked, Iist requested additional information under Remarks on Page 2, referencing the item. If additional space is needed use an attached sheet. Return the original to the State agency; retain a copy for your files. This form is to be completed annually. Any substantial delay in completing the form should be reported to the State survey agency. DETAILED INSTRUCTION These instructions are designed to clarify certain questions on the form. Instructions are listed in question order for easy reference. No instructions have been given for questions considered self-explanatory. IT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE ANSWERED ACCURATELY AND THAT ALL INFORMATION BE CURRENT. Item I (a) Under identifying information specify in what capacity the entity is doing business as (DBA), example, name of trade or corporation. Item I (b) For Regional Office Use Only. If the yes box is checked for Item VII the Regional Office will enter the 5 -digit number assigned by HCFA to chain organizations. Item II Self-explanatory. Item III List the names of all individuals and organizations having direct or indirect ownership interests, or controlling interest separately or in combination, amounting to an ownership interest of 5% or more in the disclosing entity. Direct ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of the disclosing entity. A disclosing entity is defined as a Medicare provider or supplier, or other entity that furnishes services or arranges for furnishing services under Medicaid or the Maternal and Child Health Department of Health and Human Services Health Care Financing Administration program, or health related services under the social service program. Indirect ownership interest is defined as ownership interest in an entity that has direct or indirect ownership interest in the disclosing entity. The amount of indirect ownership in the disclosing entity that is held by any other entity is determined by multiplying the percentage of ownership interest at each level. An indirect ownership interest must be reported if it equates to an ownership interest of 5 % or more in the disclosing entity. Example: If A owns 10% of the stock in a corporation that owns 80% of the stock of the disclosing entity, A's interest equates to an 8% indirect ownership and must be reported. Controlling interest is defined as the operational direction or management of a disclosing entity which may be maintained by any or all of the following devices: the ability or authority, expressed or reserved, to amend or change the corporate identity (i.e. joint venture agreement, unincorporated business status) of the disclosing entity; the ability or authority to nominate or name members of the Board of Directors or Trustees of the disclosing entity; the ability or authority, expressed or reserved, to amend or change the by-laws, constitution, or other operating or management direction of the disclosing entity; the right to control any or all of the assets or other property of the disclosing entity upon the sale or dissolution of that entity; the ability or authority, expressed or reserved, to control the sale of any or all of the assets, to encumber such assets by way of mortgage or other indebtedness, to dissolve the entity, or to arrange for the sale or transfer of the disclosing entity to new ownership or control. Items IV -VII Changes in Provider Status Change in provider status is defined as any change in management control. Examples of such changes would include: a change in Medical or Nursing Director, a new Administrator, contracting the operation of the facility to a management corporation, a change in the composition of the owning partnership which under applicable State law is not considered a change in ownership, or the hiring or dismissing of any employees with 5 % or more financial interest in the facility or in an owning corporation, or any change of ownership. Items IV -VII If the yes box is checked, list additional information requested under Remarks. Clearly identify which item is being continued. Form.Approved OMB 0938-00861HCpA-1513 Item IV (a and b) If there has been a change in ownership within the last year or if you anticipate a change, indicate the date in the appropriate space. Item V If the answer is yes, list name of the management firm and employer identification number (EIN), or the name of the leasing organization. A management company is defined as any organization that operates and manages a business on behalf of the owner of that business, with the owner retaining ultimate legal responsibility for operation of the facility. Item VI If the answer is yes, identify which has changed (Administrator, Medical Director, or Director of Nursing) and the date the change was made. Be sure to include name of the new Administrator, Director of Nursing or Medical Director, as appropriate. Item VII A chain affiliate is any free-standing health care facility that is either owned, controlled, or operated under lease or contract by an organization consisting of two or more free-standing health care facilities organized within or across State lines which is under the ownership, or through any other device, control and direction of a common party. Chain affiliates include such facilities whether public, private, charitable or proprietary. They also include subsidiary organizations and holding corporations. Provider -based facilities, such as hospitaI- based home health agencies, are not considered to be chain affiliates. Item VIII If yes, list the actual number of beds in the facility now and the previous number. DgmUnedt of Health and Human Servlces Health Cao Financing Adraldstradon proved OMB No. 0938-00 6/HCpA_1513 A-1513 DISCLOSURE OF OWNERSI-HP AND CONTROL INTEREST STATEMENT I. IDENTIFYING INFORMATION (a) Name of Entity DBA Provider No. Vendor No. Phone Street Address City County State Zip (To be completed by HCFA Regional Office) Chain Affiliate No. II. Answer the following questions by marking "Yes" or "No." If any of the questions are answered "Yes," list names and addresses of individuals or corporations under Remarks on Page 2. Identify each item number to be continued. (a) Are there any individuals or organizations having a direct or indirect ownership or control interest of 5% or more in the institution, organization, or agency that have been convicted of a criminal offense related to the involvement of such persons, or organizations in any of the programs established by Titles XVIII, XIX, or XX? Yes No (b) Are there any directors, officers, agents, or managing employees of the institution, agency or organization who have ever been convicted of a criminal offense related to their involvement in such programs established by Title XVIII, XIX, or XX? Yes No (c) Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar capacity who were employed by the institution's, organization's, or agency's fiscal intermediary or carrier within the previous 12 months? itle XVIII providers only.) Yes No M. (a) List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. (See instructions for definition of'ownership and controlling interest.) List any additional names and addresses under Remarks on Page 2: If more than one individual is reported and any of these persons are related to each other, this must be reported under Remarks on Page 2. NAME; ADDRESS EIN (b) Type of Entity: _ Sole Proprietorship _ Partnership _ Unincorporated Associations _ Corporation Other (specify) (c) If the disclosing entity is a corporation, list names, addresses of the Directors, and EINS for corporations under Remarks on Page 2. Mark appropriate answer for each of the following questions: (d) Are any owners of the disclosing entity also owners of Medicare/Medicaid facilities? (Example, sole proprietor, partnership or members of Board of Directors)Yes No _ If cs, list names, addresses of individuals and rovider numbers. _ NAME ADDRESS PROVIDER NUMBER y .. 1 Department of Health and Human Services Health Ciro Financing Administration i OMB No. 0938-00FA Or1P roved IS13 IV. (a) Has there been a change in ownership or control within the last year? Yes No If Yes, give date. (b) Do you anticipate any change of ownership or control within the year? Yes No If yes, when? (c) Do you anticipate fling for bankruptcy within the year? Yes No If yes, when? V. Is this facility operated by a management company, or leased in whole or part by another organization? Yes No If yes, give date of chane in o eration. VI. Has there been a change in Administrator. Director of Nursing or Medical Director within the last ear? Yes No VII. (a) Is this facility chain affiliated? If yes, list name, address of Corporation, and EIN. Name EIN Address (b) If the answer to question VII (a) is No, was the facility ever affiliated with a chain? If Yes, list name, address of Corporation, and EIN. Name EIN Address VIII. Have you increased your bed capacity by 10% or more or by 10 beds, whichever is greater, within the last 2 years: Yes No If yes, give year of change: Current beds ace: Prior beds ace: Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be prosecuted under applicable federal or state Iaws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of a request to participate or where the entity already participates, a termination of its agreement or contract with the state agency or the secretary, asappropriate. Name of Authorized Representative (Typed) Title Signature Date Remarks: DOCUMENT NO. 7560005906-2003 ATTACHMENT NO. 05 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: OFFICE OF PUBLIC HEALTH PRACTICE TERM: September 01, 2002 THRU: August 31, 2003 SECTION I. SCOPE OF WORK: LOCAL PUBLIC HEALTH SUPPORT FUNDS PERFORMING AGENCY shall use direct assistance and/or financial assistance, as specified in SECTION III., BUDGET, from RECEIVING AGENCY to develop local public health systems and infrastructure through carrying out one or more of the following essential public health services as specified in PERFORMING AGENCY'S FY 03 Service Delivery Plan, which is adopted by reference: • Monitor the health status of individuals in the community to identify community health problems; • Diagnose and investigate community health problems and community health hazards; • Inform, educate, and empower the community with respect to health issues; • Mobilize community partnerships to identify and solve, community health problems; • Develop policies and plans that support individual and community efforts to improve health; • Enforce laws and rules that protect the public health and ensure safety in accordance with those laws and rules; • Link individuals who have a need for community and personal health services to appropriate community and private providers; • Ensure a competent workforce for the provision of essential public health services; • Research for new insights and innovative solutions to community health problems; and • Evaluate the effectiveness, accessibility and quality of personal and population based health services in a community. For the purpose of these grant funds Local Public Health Systems are defined as the human, informational, financial and organizational resources, including public, private and voluntary organizations that contribute to the public's health [Source: Mobilizing for Action through Planning and Partnerships (MAPP) from the National Association of County and City Health Officials]. Two types of support are available under this program: ATTACHMENT — Page 1 (1) Direct assistance in the form of state -paid positions and/or (2) Financial assistance from a. General Revenue funds; and, b. Federal Preventive Health and Health Services Block Grant. DIRECT ASSISTANCE State -paid positions under this contract Attachment shall perform activities as specified in PERFORMING AGENCY'S FY 03 Service Delivery Plan. FINANCIAL ASSISTANCE PERFORMING AGENCY shall direct funds toward developing a functional and effective public health system(s) with the specific goal of improving public health capacity to respond to both emergency and continuing public health threats. PERFORMANCE MEASURES The following performance measure(s) will be used to assess, in part, PERFORMING AGENCY'S effectiveness in providing the services described in this contract Attachment, without waiving the enforceability of any of the other terms of the contract. For the General Revenue and/or Preventive Health and Health Services Block Grant funds the PERFORMING AGENCY must: 1. Base all activities on the PERFORMING AGENCY'S approved Worksheet for Local Public Health Preparedness and Response for Bioterrorism. This worksheet (www.tdh.state.tx.us/ophp/pubs/plan.pdf) should have been completed prior to August 31, 2002. 2. Identify local public health system members critical to improving public health capacity to respond to both emergency and continuing public health threats (i.e. hospitals, EMS, fire, police, first responders). 3. Identify a small, but representative group of stakeholders who contribute to or benefit from public health to help guide the LPHS development process. 4. Convene members of the LPHS for the purpose of developing and carrying out a (3-6 page) LPHS strategic plan for improving public health capacity to respond to both emergency and continuing public health threats. ATTACHMENT — Page 2 Targets & Deliverables by Quarter: Quarter 1 Target: Identification of LPHS partners and stakeholders (i.e. those organizations and individuals critical to improving public health capacity to respond to both emergency and continuing public health threats). Quarter 2 Target: Identification of existing LPHS assets and needs; Quarter 3 Target: Development of an LPHS strategic plan [goal(s); objectives; strategies/activities; timelines]. Quarter 4 Target: Finalized LPHS strategic plan [goals(s); objectives; strategic/activities; timelines] with evidence of progress on implementing the plan. Deliverable November _15, 2002: A database (name, address, phone number and e-mail address) of LPHS partners and stakeholders submitted to the TDH Regional Director. Deliverable February 15, 2003: A short (3-4 page ) summary report of the assets and needs of the LPHS submitted to the TDH regional director. Deliverable May 15, 2003: A draft (3-6 page) LPHS strategic plan that improves public health capacity to respond to both emergency and continuing public health threats submitted to the TDH regional director. Deliverable August 30, 2003: A final (3-6 page) LPHS strategic plan that improves public health systems capacity to respond to both emergency and continuing public health threats submitted to the TDH regional director. A resource http://w-ww.phppo.cdc.gov/docum.e.nts/local.inventory.PDF SECTION II. SPECIAL PROVISIONS: General Provisions, Reports Article, is revised to include the following paragraph: PERFORMING AGENCY shall submit an Annual Budget and Expenditures Report to the appropriate RECEIVING AGENCY Regional Director by October 31, 2003. ATTACHMENT — Page 3 SECTION III. BUDGET: DIRECT ASSISTANCE Direct assistance involves the assignment of state funded positions in lieu of cash. State salary warrants for net earnings will be issued in accordance with state regulations. PERSONNEL $25,392.00 TRAVEL 0.00 LABORATORY SUPPORT 0.00 OTHER 0.00 TOTAL $25,392.00 Financial status reports (FSRs) are not required on direct assistance. Program income generated from activities supported with direct assistance will be reported on FSRs required for financial assistance provided through this Attachment, if applicable, or through other program Attachments(s) benefitting from this assistance. RECEIVING AGENCY direct assistance will not exceed $ 25,392-00. ATTACHMENT — Page 4 FINANCIAL ASSISTANCE Financial assistance involves payment of funds to Performing Agency for costs incurred in carrying out approved activities. PERSONNEL FRINGE BENEFITS TRAVEL EQUIPMENT SUPPLIES CONTRACTUAL OTHER TOTAL RECEIVING AGENCY financial assistance will not exceed $ 93,162.00. TOTAL RECEIVING AGENCY assistance will not exceed $ 118,554.00. 78,453.00 14,709.00 0.00 0.00 0.00 0.00 0.00 $93,162.00 Financial status reports are due the 30th of December, 30th of March, 30th of June, and the 30th of November. ATTACHMENT — Page 5 ' CERTIFICATION REGARDING LOBBYING CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS The undersigned certifies, to the best of his or her knowledge and belief that: (1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or an employee of any agency, a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. (2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form -111, "Disclosure Form to Report Lobbying," in accordance with it's instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Signature Date Tamy Carden Print Name of Authorized Individual 7560005906 2003-05 Application or Contract Number LUBBOCK CITY HEALTH DEPARTMENT Organization Name and Address 1902 TEXAS AVENUE LUBBOCK, TX 79457-0000 DOCUMENT NO. 7560005906-2003 ATTACHMENT NO. 06 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: IMMUNIZATION DIVISION TERM: September 01, 2002 THRU: August 31, 2003 SECTION I. SCOPE OF WORK: The goal of RECEIVING AGENCY Program is to prevent, control, and eliminate vaccine - preventable diseases by providing and administering biologicals, promoting immunizations; conducting vaccine -preventable disease surveillance, assessing vaccine coverage levels, and applying principles of epidemiology and outbreak control measures within budgetary constraints. PERFORMING AGENCY shall implement an immunization program for children, adolescents, and adults, with special emphasis on accelerating interventions to improve the immunization coverage of children two years of age or younger (less than 36 months of age). PERFORMING AGENCY shall incorporate traditional and non-traditional, systematic approaches designed to eliminate barriers, expand immunization delivery, and establish uniform policies. PERFORMING AGENCY shall provide services as outlined in PERFORMING AGENCY'S Fiscal Year (FY) 2003 Contract Renewal Budget and Work Plan and revisions, if any, as agreed to and approved by RECEIVING AGENCY Program. These documents are adopted by reference and made a part of this contract Attachment. Any revisions to these documents shall be approved by RECEIVING AGENCY Program and transmitted in writing to PERFORMING AGENCY. PERFORMING AGENCY shall report all reportable conditions as specified in 25 TAC Part I §§97.1 - 97.6 and 97.101 - 97.102. PERFORMING AGENCY shall report all vaccine adverse event occurrences in accordance with the National Childhood Vaccine Injury Act of 1986. PERFORMING AGENCY shall inform and educate the public about vaccines and vaccine - preventable diseases. PERFORMING AGENCY shall develop policies and plans that support individual and community-based immunization strategies and evaluate effectiveness, accessibility, and quality of personal and population -based immunization services and program activities. ATTACHMENT — Page PERFORMING AGENCY shall ensure a health care workforce that is knowledgeable about vaccines, vaccine -preventable diseases, and delivery of vaccination services. PERFORMING AGENCY shall comply with written policies and procedures provided by RECEIVING AGENCY Program in managing state -supplied vaccines, including guidelines for proper storage and handling of vaccines. PERFORMING AGENCY shall not deny vaccinations to recipients because they do not reside within PERFORMING AGENCY'S jurisdiction. PERFORMING AGENCY shall maintain an accurate, up-to-date list of clinics and sites where public sector (free or low cost) immunization services are offered in PERFORMING AGENCY'S local area. No fee may be charged for vaccines provided by RECEIVING AGENCY Program. All vaccines obtained from RECEIVING AGENCY Program shall be used solely for purposes of this contract Attachment and shall not be sold to agencies or individuals. PERFORMING AGENCY shall not collect vaccine administration fees from Medicaid recipients. Vaccine administration fees collected from non -Medicaid patients shall be kept within guidelines established by RECEIVING AGENCY. In accordance with 25 TAC §1.91, no one shall be denied immunization services in public clinics because of inability to pay the administration fee. Fee schedules shall not be based on vaccine type, formulation, or dose in series. A copy of PERFORMING AGENCY'S fee schedule shall be submitted to RECEIVING AGENCY Program by October 15th. All equipment and vaccine used by PERFORMING AGENCY which are provided by RECEIVING AGENCY Program, shall be accounted for as public property. RECEIVING AGENCY Program will investigate equipment or vaccine loss, destruction, spoilage, or other waste and may require PERFORMING AGENCY to replace or reimburse RECEIVING AGENCY Program. PERFORMING AGENCY shall provide the parent, managing conservator, or guardian of each patient with a form that is approved by RECEIVING AGENCY Program in compliance with 25 TAC, Chapter 100 to authorize participation in the statewide immunization registry (ImmTrac). PERFORMING AGENCY shall provide RECEIVING AGENCY Program weekly data transfers of all vaccines administered in a format that is compatible for inclusion in the statewide immunization registry (ImmTrac). PERFORMING AGENCY shall comply with all applicable federal and state laws, rules, regulations, standards, and guidelines in effect on the beginning date of this contract Attachment ATTACHMENT — Page 2 y unless amended. The following documents are incorporated by reference and made a part of this contract Attachment. • PERFORMING AGENCY'S FY 2003 Contract Budget and Work Plan, and any revisions; • Human Resources Code §42.043, VTCA; • Education Code §§38.001-38.002, VTCA; • Health and Safety Code §§81.023 and 161.001-161.009, VTCA; • 25 TAC Chapter 97; • 25 TAC, Chapter 96; • 25 TAC, Chapter 100; • 42 USC §§247b and 300 as -25; • Omnibus Budget Reconciliation Act of 1993, 26 USC §4980B; • RECEIVING AGENCY'S Client Services Standards for Public Health and Community Clinics, revised June 1997; • RECEIVING AGENCY'S Vaccine -Preventable Disease Surveillance guidelines, http://www.tdh.state.tx.us/immunize/does/guide.htm; • RECEIVING AGENCY'S Pharmacy guidelines; • Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) guidelines, including the statement: "Immunization of Health -Care Workers"; and • Standards for Pediatric Immunization Practices, February 1996, recommended by the National Vaccine Advisory Committee, approved by the United States Public Health Service, and endorsed by the American Academy of Pediatrics. Within thirty (30) days of receipt of an amended standard(s) or guideline(s), PERFORMING AGENCY shall inform RECEIVING AGENCY Program, in writing, if it will not continue performance under this Attachment in compliance with the amended standard(s) or guideline(s). RECEIVING AGENCY may terminate the Attachment immediately or within a reasonable period of time as determined by RECEIVING AGENCY. PERFORMANCE MEASURES The following performance measure(s) will be used, in part, to assess PERFORMING AGENCY'S effectiveness in providing the services described in this contract Attachment to the service area, without waiving the enforceability of any of the terms of the contract. PERFORMING AGENCY shall investigate 100% of all reported vaccine -preventable diseases in accordance with RECEIVING AGENCY'S Vaccine -Preventable Disease Surveillance Guidelines. PERFORMING AGENCY shall investigate 100% of suspected hepatitis B infections in pregnant women to assure appropriate treatment and follow-up as directed by Health and ATTACHMENT Page 3 Safety Code §81.090 and RECEIVING AGENCY'S Vaccine -Preventable Disease Surveillance Guidelines. PERFORMING AGENCY shall submit to RECEIVING AGENCY Program the monthly reports of doses administered by the fifteenth calendar day of each month for the previous calendar month, in a format approved by RECEIVING AGENCY Program. The monthly vaccine biologicals order form must be submitted in accordance with the schedule provided to PERFORMING AGENCY by RECEIVING AGENCY Program. PERFORMING AGENCY shall implement an immunization reminder and/or recall system to notify parents or guardians of children less than 36 months of age when immunizations are due. The notifications may be automated or manual and may consist of mail or telephone contacts. PERFORMING AGENCY shall conduct immunization audits in childcare facilities and registered family homes as assigned by RECEIVING AGENCY Program. PERFORMING AGENCY shall conduct immunization audits and surveys in public and private schools as assigned by RECEIVING AGENCY. PERFORMING AGENCY shall conduct annual assessments in 100% of sub -contracted entities and WIC clinics using the Assessment, Feedback, Incentives, and eXchange (AFIX) methodology. PERFORMING AGENCY shall submit assessment results to RECEIVING AGENCY Program within two (2) weeks after completion. PERFORMING AGENCY shall conduct follow-up monitoring visits of Texas Vaccines for Children Program (TVFC)-enrolled provider sites using the RECEIVING AGENCY'S monitoring tool and methodology. PERFORMING AGENCY shall submit monitoring report to RECEIVING AGENCY Program within two (2) weeks after completion of visit. PERFORMING AGENCY shall recruit and enroll providers into the TVFC program. SECTION II. SPECIAL PROVISIONS General Provisions, Reports Article, is revised to include the following: PERFORMING AGENCY shall submit quarterly program reports to RECEIVING AGENCY Program according to the following timelines and in the formats provided by RECEIVING AGENCY Program. ATTACHMENT — Page 4 NAME OF REPORT APPLICABLE QUARTERS DUE DATES Immunization Program - September, October, November December 30 Performance Measure December, January, February March 30 Quarterly Report March, April, May June 30 June, July, August September 30 Immunization Program - September, October, November December 30 Recruitment Quarterly Report December, January; February March 30 March, April, May June 30 June, July, August September 30 For immunization activities performed under this contract Attachment, General Provisions, Overtime Compensation Article is not applicable. In addition, PERFORMING AGENCY shall comply with the following paragraphs: PERFORMING AGENCY is authorized to pay employees who are not exempt under the Fair Labor Standards Act (FLSA), 29 USC, Chapter 8, §201 et seq., for overtime or compensatory time at the rate of time and one-half per FLSA. PERFORMING AGENCY is authorized to pay employees who are exempt under FLSA on a straight time basis for work performed on a holiday or for regular compensatory time hours when the taking of regular compensatory time off would be disruptive to normal business operations. Authorization for payment under this provision is limited to work directly related to immunization activities and shall be in accordance with the amount budgeted in this contract Attachment. PERFORMING AGENCY shall document proper authorization or approval for any work performed by exempt or non-exempt employees in excess of forty (40) hours per work week. ATTACHMENT — Page 5 t SECTION III. BUDGET: PERSONNEL FRINGE BENEFITS TRAVEL EQUIPMENT SUPPLIES CONTRACTUAL OTHER TOTAL DIRECT CHARGES INDIRECT CHARGES TOTAL Total reimbursements will not exceed $107,153.00. $77,705.00 29,448.00 0.00 0.00 0.00 0.00 0.00 $107,153.00 $0.00 $107,153.00 Financial status reports are due the 30th of December, 30th of March, 30th of June, and the 30th of November. ATTACHMENT — Page 6 ' 4 CERTIFICATION REGARDING LOBBYING CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS The undersigned certifies, to the best of his or her knowledge and belief that: (1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or an employee of any agency, a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. (2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form -111, "Disclosure Form to Report Lobbying," in accordance with it's instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Signature Tamiy Cmc Print Name of Authorized Individual 7560005906 2003-06 Application or Contract Number LUBBOCK CITY HEALTH DEPARTMENT Organization Name and Address 1902 TEXAS AVENUE LUBBOCK, TX 79457-0000 Date Resolution No. 2002—RO312 August 29, 2002 Item No. 42 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 a Contract (TDH Document No. 7560005906 2003, Attachments No. 03, 04, 05 and 06) pertaining to HIV surveillance, AC Family Health, OPHP-Local Public Health System and Immunization Division and any associated documents between the City of Lubbock and the Texas Department of Health, a copy of which contract is attached hereto and which shall be spread upon the minutes of this Council and as spread upon the minutes of this Council shall constitute and be a part hereof as if fully copied herein in detail. Passed by the City Council this 29th day of August 2002. &M,kRC'McD- , MAYOR ATTEST: a NXRebecca Garza, City Secretary APPROVED AS TO CONTENT: 1Y Tommy C den, Health Director APPROVED AS TO FORM: Dd ald G. Vandiver First Ass`1 Attorney DDres/TDH-gen. con.. res August 1, 2002 No Text STATE OF TEXAS COUNTY OF TRAVIS Resolution No. 2002—RO312 August 29, 2002 Item No. 42 TEXAS DEPARTMENT OF HEALTH 1100 WEST 49TH STREET AUSTIN, TEXAS 78756-3199 TDH Document No. 7560005906 2003 Contract Change Notice No. 02 The Texas Department of Health, hereinafter referred to as RECEIVING AGENCY, did heretofore enter into a contract in writing with LUBBOCK CITY HEALTH DEPARTMENT hereinafter referred to as PERFORMING AGENCY. The parties thereto now desire to amend such contract attachment(s) as follows: SUMMARY OF TRANSACTION: ATT NO. 03 HIV - SURVEILLANCE ATT NO. 04 AC FAMILY HEALTH - POPULATION BASED ATT NO. 05 OPHP - LOCAL PUBLIC HEALTH SYSTEM ATT NO. 06 IMMUNIZATION DIVISION LOCALS All terms and conditions not hereby amended remain in full force and effect. EXECUTED IN DUPLICATE ORIGINALS ON THE DATES SHOWN. CITY OF LUBBOCK HEALTH DEPARTMENT Authorized Contracting Entity (type above if different from PERFORMING AGENCY) for and in behalf of: PERFORMING AGENCY: LUBBOCK ITY HEAL D.-P2TMENT ByASigature of person tiorized to sign) Hm:c NhDaigal, Mayor (Name and Title) Date: August 29, 2002 RECOMMENDE By: (PERFORMING AGENCY Director, if different from person authorized to sign contract TmW c ardor, t-Iealth Director RECEIVING AGENCY: TEXASRT#qdau,'j MNT OF HEALTH By: (Signature of person authorized Ntosign�4 Melanie A. Doyle, Director Grants Management Division (Name and Title) Date: l 2— 7V GMD - Rev. 12/00 No Text DETAILS OF ATTACHMENTS Att/ Amd No. TDH Program ID Term Financial Assistance Direct Assistance Total Amount (TDH Share) Begin g End Source of Amount Funds* 01 HIV/PREV 01/01/02 02 OPHP/BIO-LAB 06/01/02 03 HIV/SURV 09/01/02 04 ACFH/POP 09/01/02 05 OPHP/LPHS 09/01/02 06 IMM/LOCALS 09/01/02 TDH Document No.7560005906 2003 Chane No. 02 12/31/02 08/31/03 08/31/03 08/31/03 08/31/03 08/31/03 93.940 93.283 State State 93.994 State 93.991 State Totals 46,350.00 737,908.00 50,251.00 51,181.00 93,162.00 107,153.00 $1,086,005.00 0.00 0.00 0.00 0.00 25,392.00 0.00 $ 25,392.00 46,350.00 737,908.00 50,251.00 51,181.00 118,554.00 107,153.00 $1,111,397.00 *Federal funds are indicated by a number from the Catalog of Federal Domestic Assistance (CFDA), if applicable. REFER TO BUDGET SECTION OF ANY ZERO AMOUNT ATTACHMENT FOR DETAILS. Cover Page 2 No Text DOCUMENT NO. 7560005906-2003 ATTACHMENT NO. 03 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: BUREAU OF HIV AND STD PREVENTION TERM: September 01, 2002 THRU: August 31, 2003 SECTION I. SCOPE OF WORK: PERFORMING AGENCY shall conduct active surveillance and reporting activities for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). PERFORMING AGENCY shall comply with all applicable federal and state laws, rules, regulations, standards, and guidelines in effect on the beginning date of this contract Attachment unless amended. The following documents are incorporated by reference and made a part of this contract Attachment. • Chapters 81 and 85 of the Health and Safety Code; Relevant portions of Chapter 6A (Public Health Service) of Title 42 (The Public Health and Welfare) of the United States Code, as amended; 25 TAC Chapter 97, Subchapter F; and, • RECEIVING AGENCY Quality Care: Client Services Standards for Public Health and Community Clinics, revised June 1997. PERFORMING AGENCY shall perform all activities in accordance with PERFORMING AGENCY'S application, activities work plan and any revisions, and detailed budget as approved by RECEIVING AGENCY Program. All of the above-named documents are incorporated herein by reference and made a part of this contract Attachment. All revisions to these documents shall be approved by RECEIVING AGENCY Program and transmitted in writing to PERFORMING AGENCY. The activities required to carry out these projects are outlined in the Centers for Disease Control and Prevention (CDC) Guidelines for HIV/AIDS Surveillance, April 1996, and RECEIVING AGENCY Program's grant applications and awards by CDC which are the basis for this contract Attachment. Copies have been provided to RECEIVING AGENCY Program. Within thirty (30) days of receipt of an amended standard(s) or guideline(s), PERFORMING AGENCY shall inform RECEIVING AGENCY Program, in writing, if it will not continue performance under this contract Attachment in compliance with the amended standard(s) or guideline(s). RECEIVING AGENCY may terminate the contract Attachment immediately or within a reasonable period of time as determined by RECEIVING AGENCY. ATTACHMENT — Page 1 No Text PERFORMING AGENCY shall immediately comply with all applicable policies adopted by RECEIVING AGENCY Program. PERFORMING AGENCY shall be responsible to RECEIVING AGENCY Program for the design, maintenance and evaluation of an active surveillance system for AIDS cases. For the purpose of this contract Attachment, HIV infection and AIDS are as defined by the Centers for Disease Control and Prevention of the United States Public Health Service in accordance with the Health and Safety Code §81.101. The publication designating the most current definition may be requested from RECEIVING AGENCY. PERFORMING AGENCY shall perform the following: 1. REPORTING a. Establish and maintain communications with key community and medical groups, individuals, and laboratories within PERFORMING AGENCY'S geographic area. b. Collect reports of HIV infections and AIDS cases diagnosed and/or treated within PERFORMING AGENCY'S geographic area. C. Report cases to RECEIVING AGENCY Program on a weekly basis. 2. REGISTRY MAINTENANCE a. Maintain a case file on all confirmed and suspected cases of HIV infections and AIDS diagnosed and/or treated within PERFORMING AGENCY'S geographic area. b. Maintain a current list of key reporting sources. 3. SYSTEM EVALUATION a. Review and provide thorough follow-up on a minimum of eighty percent (80%) of suspected cases identified by RECEIVING AGENCY Program's alternate record review systems in order to enhance case ascertainment and validate the effectiveness of local surveillance efforts. b. Track reporting by local sources in order to monitor the level of compliance to reporting laws and level of case ascertainment. 4. EPIDEMIOLOGIC INVESTIGATIONS ATTACHMENT — Page 2 No Text a. Initiate epidemiologic investigations on newly reported No Identified Risk (NIR) cases within five (5) days of receipt of case report through contact with appropriate health care provider or the review of medical records. b. Assist RECEIVING AGENCY Program with other epidemiologic investigations as deemed necessary by RECEIVING AGENCY Program or CDC. 5. CONFIDENTIALITY a. Store all case files and computer diskettes containing patient information in a locked file cabinet when not in use. The locked file cabinet and surveillance computer shall be kept in a locked room with limited, controlled access. b. Utilize passwords to access computer databases containing HIV/AIDS case data. Passwords shall be changed monthly and known only to surveillance personnel. C. Limit the number of persons who have keys to registry files to persons directly involved in case reporting. d. Require a statement of confidentiality to be signed by all personnel having access to HIV/AIDS case files and computer diskettes and kept on file by PERFORMING AGENCY. e. PERFORMING AGENCY may release demographic analyses of local data as public information as long as it cannot lead to the identity of an individual. RECEIVING AGENCY Program will monitor PERFORMING AGENCY'S expenditures on a semi-annual basis. If expenditures are above or below those projected in SECTION III: BUDGET, PERFORMING AGENCY'S contract Attachment amount may be subject to increase or decrease for the remainder of the contract Attachment period. PERFORMING AGENCY shall authorize its staff to attend training, conferences, and meetings for which funds were budgeted and approved by RECEIVING AGENCY Program. PERFORMANCE MEASURES The following performance measure(s) will be used to assess, in part, PERFORMING AGENCY'S effectiveness in providing the services described in this contract Attachment, without waiving the enforceability of any of the other terms of the contract: 1. PERFORMING AGENCY shall collect case information for an estimated 50 cases and information shall be entered into the computerized HIV/AIDS Reporting System (HARS). PERFORMING AGENCY shall transfer the collected information on a weekly basis to RECEIVING AGENCY Program. ATTACHMENT — Page 3 No Text PERFORMING AGENCY may request RECEIVING AGENCY Program to extend the timetable for transferring data to monthly. Any agreement shall be in writing and signed by both parties. 2. RECEIVING AGENCY Program will provide HIV/AIDS case reporting activities for cases diagnosed in the following geographic area(s): Lubbock. 3. PERFORMING AGENCY shall complete and submit semi-annual activity reports demonstrating PERFORMING AGENCY'S conduct of HIV/AIDS case -finding activities. These reports shall be submitted to RECEIVING AGENCY Program on the 20th day of February and September 2003 in a format provided by RECEIVING AGENCY Program. SECTION II. SPECIAL PROVISIONS: General Provisions, Assurances Article, is revised to include the following: PERFORMING AGENCY shall comply with all federal and state non-discrimination statutes, regulations, and guidelines. PERFORMING AGENCY shall provide services without discrimination on the basis of race, color, national origin, age, disability, ethnicity, gender, religion, or sexual orientation. General Provisions, Records Retention Article, is revised to include the following: All records pertaining to this contract Attachment shall be retained by PERFORMING AGENCY and made available to RECEIVING AGENCY, the Comptroller General of the United States, the Texas State Auditor, or any of their authorized representatives, and in accordance with RECEIVING AGENCY'S General Provisions. General Provisions, Patient or Client Records Article, is revised to include the following: RECEIVING AGENCY shall have access to a client or patient record in the possession of PERFORMING AGENCY, or any subrecipient, under authority of the Health and Safety Code, Chapters 81 and 85, and the Medical Practice Act, Texas Occupations Code, Chapter 159. In such cases, RECEIVING AGENCY shall keep confidential any information obtained from the client or patient record, as required by the Health and Safety Code, Chapter 81, and Texas Occupations Code, Chapter 159. Due to the sensitive and highly personal nature of HIV/AIDS-related information, PERFORMING AGENCY shall require its personnel to adhere strictly to the General Provisions, Confidentiality Article. ATTACHMENT — Page 4 No Text SECTION III. BUDGET: PERSONNEL $31,844.00 FRINGE BENEFITS 11,973.00 TRAVEL 2,500.00 EQUIPMENT 0.00 SUPPLIES 750.00 CONTRACTUAL 0.00 OTHER 0.00 TOTAL DIRECT CHARGES $47,067.00 INDIRECT CHARGES $3,184.00 TOTAL $50,251.00 Total reimbursements will not exceed $50,251.00. Financial status reports are due the 30th of December, 30th of March, 30th of June, and the 30th of November. Based on UGMS, indirect cost may be recovered up to 10% of the direct salary and wage costs of providing the service (excluding overtime, shift premiums, and fringe benefits). ATTACHMENT — Page 5 JL I DOCUMENT NO. 7560005906-2003-= ATTACHMENT NO. 04 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: ASSOCIATE COMMISSIONER FOR FAMILY HEALTH TERM: September 01, 2002 THRU: August 31, 2003 SECTION I. SCOPE OF WORK: PERFORMING AGENCY shall perform public health preventive services related to women, children, and their families in order to address local health needs; to build the local public health infrastructure; and to improve the health status of women, children, and families. PERFORMING AGENCY shall comply with all applicable federal and state laws, rules, regulations, standards, and guidelines in effect on the beginning date of this contract Attachment unless amended. The following documents are incorporated by reference and made part of this contract Attachment: • RECEIVING AGENCY Title V FY 03 Continuation Request for Proposal (RFP); • PERFORMING AGENCY FY 03 Continuation Application and any revision; • RECEIVING AGENCY Family & Community Health Services Grants Fiscal Year 02 Competitive Request for Proposal (RFP) for Title V Population -Based projects; • PERFORMING AGENCY FY 02 Component II, Attachment B Application, and any revisions; • Client Services Standards for Public Health and Community Clinics, revised June, 1997; • RECEIVING AGENCY'S Quality Assurance (QA) Title V - Population Based On -Site Evaluation Report (designed to be used with QA Core Tool), which requires monthly time sheets to document staff time on work plan activities, invoices of all expenditures, logs of dated activities with sign -in sheets for public presentations; and, • Title V Policy and Procedures Manual revised for FY 02. Within thirty (30) days of receipt of an amended standard(s) or guideline(s), PERFORMING AGENCY shall inform RECEIVING AGENCY Program, in writing, if it will not continue performance under this Attachment in compliance with the amended standard(s) or guideline(s). RECEIVING AGENCY may terminate the Attachment immediately or within a reasonable period of time as determined by RECEIVING AGENCY. PERFORMING AGENCY shall implement its approved work plan in consultation with RECEIVING AGENCY'S Public Health Region (PHR) Title V Manager and Central Office Coordinator for public health preventive services. ATTACHMENT — Page 1 No Text RECEIVING AGENCY'S PHR Director, as coordinator of regional services, will assist RECEIVING AGENCY staff in providing direction to PERFORMING AGENCY. RECEIVING AGENCY personnel will provide technical assistance and training to PERFORMING AGENCY, as needed. PERFORMING AGENCY shall cooperate with RECEIVING AGENCY staff to attain the goals of unified community health assessment, policy development, coordinated services, and quality assurance and to prevent unnecessary duplication of services. PERFORMANCE MEASURES The following performance measures will be used to assess, in part, PERFORMING AGENCY'S effectiveness in providing the services described in this contract Attachment, without waiving the enforceability of any of the other terms of this contract. • PERFORMING AGENCY shall submit quarterly reports on project activities to RECEIVING AGENCY'S PHR Title V Manager for review, assessment, and transmission to Central Office Coordinator within thirty (30) days of the end of each quarter. Quarterly reports shall describe accomplishments, challenges, barriers, impact, and progress in achieving the goals and objectives contained in PERFORMING AGENCY'S FY 03 Title V Application work plan, and any revisions. The quarterly progress report shall be in the format specified by RECEIVING AGENCY in the Title V Policy and Procedures Manual and through any amended guidelines. • PERFORMING AGENCY shall provide public health preventative services to women, children, and their families who live or receive services in the following counties/area: Lubbock. • PERFORMING AGENCY shall submit a comprehensive final report on FY 03 work plan activities on or before September 30, 2003. This final report shall include the findings of an evaluation to determine the effectiveness of project activities in addressing local health needs, in building the local public health infrastructure, and in improving public health status. SECTION II. SPECIAL PROVISIONS: General Provisions, Reports Article, is revised to include the following: PERFORMING AGENCY shall submit quarterly and year-end financial reports, in the format specified by RECEIVING AGENCY Program, within thirty (30) days of the end of each quarter and within ninety (90) days of the end of the contract Attachment term detailing the activities performed and the objectives achieved with the funding provided ATTACHMENT — Page 2 No Text under this contract Attachment. PERFORMING AGENCY _shall submit other reports as deemed necessary by RECEIVING AGENCY Program. General Provisions, Inspections Article, is revised to include the following: In addition to the site visits authorized by the Inspections Article of the General Provisions, PERFORMING AGENCY shall allow RECEIVING AGENCY to conduct on-site quality assurance reviews as deemed necessary by RECEIVING AGENCY. Unsatisfactory review findings may result in implementation of General Provisions, Sanctions Article. PERFORMING AGENCY shall notify RECEIVING AGENCY Program immediately in the event of any significant change affecting PERFORMING AGENCY'S identity, ownership or control, name, governing board membership, vendor identification, medical or program director, or address. Failure to disclose the required information or inaccurate disclosure by PERFORMING AGENCY may be treated as a material breach of this contract Attachment and may be grounds for termination. ATTACHMENT — Page 3 No Text SECTION III. BUDGET: PERSONNEL FRINGE BENEFITS TRAVEL EQUIPMENT SUPPLIES CONTRACTUAL OTHER TOTAL DIRECT CHARGES INDIRECT CHARGES TOTAL Total reimbursements will not exceed $51,181.00 . $32,556.00 11,720.00 2,318.00 0.00 4,587.00 0.00 0.00 $51,181.00 $0.00 $51,181.00 Financial status reports are due the 30th of December, 30th of March, 30th of June, and the 30th of November. ATTACHMENT — Page 4 No Text De(*rtment of Health and Human Services 1-161th Care Financing Administration Form Approved OMB 0938-0086/HCFA-1513 INSTRUCTIONS FOR COMPLETING DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT (HCFA -1513) Completion and submission of this form is a condition of participation, certification, or recertification under any of the programs established by titles V, XVIII, XIX, and XX, or as a condition of approval or renewal of a contractor agreement between the disclosing entity and the secretary of appropriate state agency under any of the above titled programs, a full and accurate disclosure of ownership and financial interest is required. Failure to submit requested information may result in a refusal by the Secretary or appropriate State agency to enter into an agreement or contract with any such institution or in termination of existing agreements. SPECIAL INSTRUCTIONS FOR TITLE XX PROVIDERS All Title XX providers must complete Part II(a) and (b) of this form. Only those Title XX providers rendering medical, remedial, or health-related homemaker services must complete Parts II and III. Title V providers must complete Parts II and III. GENERAL INSTRUCTIONS For definitions, procedures and requirements, refer to the appropriate Regulations: Title V 42CFR 51a.144 Title XVIII 42CFR 420.200-206 Title XIX 42CFR 455.100-106 Title XX 45CFR 228.72-73 Please answer all questions as of the current date. If the yes block for any item is checked, list requested additional information under Remarks on Page 2, referencing the item. If additional space is needed use an attached sheet. Return the original to the State agency; retain a copy for your files. This form is to be completed annually. Any substantial delay in completing the form should be reported to the State survey agency. DETAILED INSTRUCTION These instructions are designed to clarify certain questions on the form. Instructions are listed in question order for easy reference. No instructions have been given for questions considered self-explanatory. IT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE ANSWERED ACCURATELY AND THAT ALL INFORMATION BE CURRENT. Item I (a) Under identifying information specify in what capacity the entity is doing business as (DBA), example, name of trade or corporation. Item I (b) For Regional Office Use Only. If the yes box is checked for Item VII the Regional Office will enter the 5 -digit number assigned by HCFA to chain organizations. Item II Self-explanatory. Item III List the names of all individuals and organizations having direct or indirect ownership interests, or controlling interest separately or in combination, amounting to an ownership interest of 5% or more in the disclosing entity. Direct ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of the disclosing entity. A disclosing entity is defined as a Medicare provider or supplier, or other entity that furnishes services or arranges for furnishing services under Medicaid or the Maternal and Child Health No Text Department of Health and Human Services Health Care Financing Administration program, or health related services under the social service program. , Indirect ownership interest is defined as ownership interest in an entity that has direct or indirect ownership interest in the disclosing entity. The amount of indirect ownership in the disclosing entity that is held by any other entity is determined by multiplying the percentage of ownership interest at each level. An indirect ownership interest must be reported if it equates to an ownership interest of 5% or more in the disclosing entity. Example: If A owns 10% of the stock in a corporation that owns 80% of the stock of the disclosing entity, A's interest equates to an 8 % indirect ownership and must be reported. Controlling interest is defined as the operational direction or management of a disclosing entity which may be maintained by any or all of the following devices: the ability or authority, expressed or reserved, to amend or change the corporate identity (i.e. joint venture agreement, unincorporated business status) of the disclosing entity; the ability or authority to nominate or name members of the Board of Directors or Trustees of the disclosing entity; the ability or authority, expressed or reserved, to amend or change the by-laws, constitution, or other operating or management direction of the disclosing entity; the right to control any or all of the assets or other property of the disclosing entity upon the sale or dissolution of that entity; the ability or authority, expressed or reserved, to control the sale of any or all of the assets, to encumber such assets by way of mortgage or other indebtedness, to dissolve the entity, or to arrange for the sale or transfer of the disclosing entity to new ownership or control. Items IV -VII Changes in Provider Status Change in provider status is defined as any change in management control. Examples of such changes would include: a change in Medical or Nursing Director, a new Administrator, contracting the operation of the facility to a management corporation, a change in the composition of the owning partnership which under applicable State law is not considered a change in ownership, or the hiring or dismissing of any employees with 5% or more financial interest in the facility or in an owning corporation, or any change of ownership. Items IV -VII If the yes box is checked, list additional information requested under Remarks. Clearly identify which item is being continued. Form Approved OMB 0938-0086/HCFA-1513 Item IV (a and b) If there has been a change in ownership within the last year or if you anticipate a change, indicate the date in appropriate space. Item V If the answer is yes, list name of the management firm and employer identification number (EIN), or the name of the leasing organization. A management company is defined as any organization that operates and manages a business on behalf of the owner of that business, with the owner retaining ultimate legal responsibility for operation of the facility. Item VI If the answer is yes, identify which has changed (Administrator, Medical Director, or Director of Nursing) and the date the change was made. Be sure to include name of the new Administrator, Director of Nursing or Medical Director, as appropriate. Item VII A chain affiliate is any free-standing health care facility that is either owned, controlled, or operated under lease or contract by an organization consisting of two or more free-standing health care facilities organized within or across State lines which is under the ownership, or through any other device, control and direction of a common party. Chain affiliates include such facilities whether public, private, charitable or proprietary. They also include subsidiary organizations and holding corporations. Provider -based facilities, such as hospital- based home health agencies, are not considered to be chain affiliates. Item VIII If yes, list the actual number of beds in the facility now and the previous number. Department of Health and Human Services Health Care Financing Administration Form Approved OMB 0938-0086/HCFA-1513 INSTRUCTIONS FOR COMPLETING DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT (HCFA -1513) Completion and submission of this form is a condition of participation, certification, or recertification under any of the programs established by titles V, XVIII, XIX, and XX, or as a condition of approval or renewal of a contractor agreement between the disclosing entity and the secretary of appropriate state agency under any of the above titled programs, a full and accurate disclosure of ownership and financial interest is required. Failure to submit requested information may result in a refusal by the Secretary or appropriate State agency to enter into an agreement or contract with any such institution or in termination of existing agreements. SPECIAL INSTRUCTIONS FOR TITLE XX PROVIDERS All Title XX providers must complete Part II(a) and (b) of this form. Only those Title XX providers rendering medical, remedial, or health-related homemaker services must complete Parts II and III. Title V providers must complete Parts II and III. GENERAL INSTRUCTIONS For definitions, procedures and requirements, refer to the appropriate Regulations: Title V 42CFR 51a.144 Title XVIII 42CFR 420.200-206 Title XIX 42CFR 455.100-106 Title XX 45CFR 228.72-73 Please answer all questions as of the current date. If the yes block for any item is checked, list requested additional information under Remarks on Page 2, referencing the item. If additional space is needed use an attached sheet. Return the original to the State agency; retain a copy for your files. This form is to be completed annually. Any substantial delay in completing the form should be reported to the State survey agency. DETAILED INSTRUCTION These instructions are designed to clarify certain questions on the form. Instructions are listed in question order for easy reference. No instructions have been given for questions considered self-explanatory. IT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE ANSWERED ACCURATELY AND THAT ALL INFORMATION BE CURRENT. Item I (a) Under identifying information specify in what capacity the entity is doing business as (DBA), example, name of trade or corporation. Item I (b) For Regional Office Use Only. If the yes box is checked for Item VII the Regional Office will enter the 5 -digit number assigned by HCFA to chain organizations. Item II Self-explanatory. Item III List the names of all individuals and organizations having direct or indirect ownership interests, or controlling interest separately or in combination, amounting to an ownership interest of 5% or more in the disclosing entity. Direct ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of the disclosing entity. A disclosing entity is defined as a Medicare provider or supplier, or other entity that furnishes services or arranges for furnishing services under Medicaid or the Maternal and Child Health Dcparimedt d Health and Human Services 11Wth Cate fr=ncing Administration OMB No.r'Ornlved 0938-00 '51HCgArIS 3 DISCLOSURE Or OWNERSIilP AND coNTROL UMREST STATEMENT 1. IDENTIFYING INFORMATION (a) Name of Entity Provider No. Vendor No. Phone DBA Street Address City County State Zip (To be completed by HCFA Regional Office) Chain Affiliate No. II, Answer the following questions by marking "Yes" or "No." If any of the questions are answered "Yes," list names and addresses of individuals or corporations under Remarks on Page 2. Identi each item number to be continued. (a) Are there any individuals or organizations having a direct or indirect ownership or control interest of 5% or more in the institution, organization, or agency that have been convicted of a criminal offense related to the involvement of such persons, or organizations in any of the programs established by Titles XVIII. XIX, or XX7 Yes No (b) Are there any directors, officers, agents, or managing employees of the institution, agency or organization who have ever been convicted of a criminal offense related to their involvement in such programs established by Title XVIII, XIX, or XX? Yes No (c) Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar capacity who were employed by the institution's, organization's, or agency's fiscal intermediary or carrier within the previous 12 months? itle XVIII providers only.) Yes No M. (a) List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. (See instructions for definition of'ownership and controlling interest.) List any additional names and addresses and any of these persons are related to each other, this under Remarks on Page 2. If more than one individual is reported must be reported under Remarks on Page 2. NAME ADDRESS BIN (b) Type of Entity: _ Sole Proprietorship _ Partnership _ Unincorporated Associations _ Corporation _ Other (specify) (c) If the disclosing entity is a corporation, list names, addresses of the Directors, and EINS for corporations under Remarks on Page 2. Mark appropriate answer for each of the following questions: of Medicare/Medicaid facilities? (Example, sole proprietor, partnership (d) Are any owners of the disclosing entity also owners list addresses of individuals and rovider numbers. or members of Board of Directors. Yes _ No _ If es, names, ADDRESS PROVIDER NUMBER NAME tt Y 1 No Text Department of Health wO Human Services Health Care Financing Administration Form Approved OMS No. 0938-0086/HCFA-1513 iV. (a) Has there been a change in ownership or control within the last year? Yes No If yes, give date. (b) Do you anticipate any change of ownership or control within the year? Yes No If yes, when? (c) Do you anticipate filing for bankruptcy within the year? Yes No If yes, when? V. Is this facility operated by a management company, or leased in whole or part by another organization? Yes No If yes, give date of chane in operation. c,r rs.... 0-- r1;—t— of M—Cino nr Medical Director within the last Year? Yes No VII. (a) Is this facility chain affiliated? If yes, list name, address of Corporation, and EIN. Name EIN Address (b) If the answer to question VII (a) is No, was the facility ever affiliated with a chain? If Yes, list name, address of Corporation, and EIN. Name EIN Address VIII. Have you increased your bed capacity by 10% or more or by 10 beds, whichever is greater, within the last 2 years: Yes No If yes, give year of change: Current beds ace: Prior beds ace: Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of a request to participate or where the entity already participates, a termination of its agreement or contract with the state agency or the secretary, as appropriate. Name of Authorized Representative (Typed) Title Signature Date Remarks: ra Departmerit of Health and Human Services Health Cane Financing Administration i OMB No. 0938-0086/H FAroved 1513 DISCLOSURE OF OWNERS -HP AND CONTROL INTEREST STATEMENT (a) Name of Entity Provider No. Vendor No. Phone DBA Street Address City County State Zip (To be completed by HCFA Regional Office) Chain Affiliate No. II. Answer the following questions by marking "Yes" or *No." If any of the questions are answered "Yes," list names and addresses of individuals or co orations under Remarks on Page 2. Identify each item number to be continued. (a) Are there any individuals or organizations having a direct or indirect ownership or control interest of 5 % or more in the institution, organization, or agency that have been convicted of a criminal offense related to the involvement of such persons, or organizations in an of the ro rams established by Titles XVIII, XIX, or XX? Yes No (b) Are there any directors, officers, agents, or managing employees of the institution, agency or organization who have ever been convicted of a criminal offense related to their involvement in such programs established by Title XVIII, XIX, or XX? Yes No (c) Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar capacity who were employed by the institution's, organization's, or agency's fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only.) Yes No III. (a) List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. (See instructions for definition of'ownership and controlling interest.) List any additional names and addresses under Remarks on Page 2: If more than one individual is reported and any of these persons are related to each other, this must be reported under Remarks on Pae 2. NAME ADDRESS EIN (b) Type of Entity: _ Sole Proprietorship _ Partnership _ Unincorporated Associations _ Corporation —Other (s eci (c) If the disclosing entity is a corporation, list names, addresses of the Directors, and EINS for corporations under Remarks on Page 2. Mark appropriate answer for each of the following questions: (d) Are any owners of the disclosing entity also owners of Medicare/Medicaid facilities? (Example, sole proprietor, partnership or members of Board of Directors.) Yes _ No _ If yes, list names, addresses of individuals and provider numbers. NA11>E ADDRESS PROVIDES_ NUMBER I DOCUMENT NO. 7560005906-2003 ATTACHMENT NO. 05 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: OFFICE OF PUBLIC HEALTH PRACTICE TERM: September 01, 2002 THRU: August 31, 2003 SECTION I. SCOPE OF WORK: LOCAL PUBLIC HEALTH SUPPORT FUNDS PERFORMING AGENCY shall use direct assistance and/or financial assistance, as specified in SECTION III., BUDGET, from RECEIVING AGENCY to develop local public health systems and infrastructure through carrying out one or more of the following essential public health services as specified in PERFORMING AGENCY'S FY 03 Service Delivery Plan, which is adopted by reference: • Monitor the health status of individuals in the community to identify community health problems; • Diagnose and investigate community health problems and community health hazards; • Inform, educate, and empower the community with respect to health issues; • Mobilize community partnerships to identify and solve community health problems; • Develop policies and plans that support individual and community efforts to improve health; • Enforce laws and rules that protect the public health and ensure safety in accordance with those laws and rules; • Link individuals who have a need for community and personal health services to appropriate community and private providers; • Ensure a competent workforce for the provision of essential public health services; • Research for new insights and innovative solutions to community health problems; and • Evaluate the effectiveness, accessibility and quality of personal and population based health services in a community. For the purpose of these grant funds Local Public Health Systems are defined as the human, informational, financial and organizational resources, including public, private and voluntary organizations that contribute to the public's health [Source: Mobilizing for Action through Planning and Partnerships (MAPP) from the National Association of County and City Health Officials]. Two types of support are available under this program: ATTACHMENT — Page 1 No Text (1) Direct assistance in the form of state -paid positions and/or (2) Financial assistance from a. General Revenue funds; and, b. Federal Preventive Health and Health Services Block Grant. DIRECT ASSISTANCE State -paid positions under this contract Attachment shall perform activities as specified in PERFORMING AGENCY'S FY 03 Service Delivery Plan. FINANCIAL ASSISTANCE PERFORMING AGENCY shall direct funds toward developing a functional and effective public health system(s) with the specific goal of improving public health capacity to respond to both emergency and continuing public health threats. PERFORMANCE MEASURES The following performance measure(s) will be used to assess, in part, PERFORMING AGENCY'S effectiveness in providing the services described in this contract Attachment, without waiving the enforceability of any of the other terms of the contract. For the General Revenue and/or Preventive Health and Health Services Block Grant funds the PERFORMING AGENCY must: 1. Base all activities on the PERFORMING AGENCY'S approved Worksheet for Local Public Health Preparedness and Response for Bioterrorism. This worksheet (www.tdh.state.tx.us/ophp/pubs/plan.pdf) should have been completed prior to August 31, 2002. 2. Identify local public health system members critical to improving public health capacity to respond to both emergency and continuing public health threats (i.e. hospitals, EMS, fire, police, first responders). 3. Identify a small, but representative group of stakeholders who contribute to or benefit from public health to help guide the LPHS development process. 4. Convene members of the LPHS for the purpose of developing and carrying out a (3-6 page) LPHS strategic plan for improving public health capacity to respond to both emergency and continuing public health threats. ATTACHMENT — Page 2 No Text Targets & Deliverables by Quarter: Quarter 1 Quarter 2 Quarter 3 Quarter 4 Target: Identification of LPHS partners and stakeholders (i.e. those organizations and individuals critical to improving public health capacity to respond to both emergency and continuing public health threats). Target: Identification of existing LPHS assets and needs; Target: Development of an LPHS strategic plan [goal(s); objectives; strategies/activities; timelines]. Target: Finalized LPHS strategic plan [goals(s); objectives; strategic/activities; timelines] with evidence of progress on implementing the plan. Deliverable November 15, 2002: A database (name, address, phone number and e-mail address) of LPHS partners and stakeholders submitted to the TDH Regional Director. Deliverable February 15, 2003: A short (3-4 page ) summary report of the assets and needs of the LPHS submitted to the TDH regional director. Deliverable May 15, 2003: A draft (3-6 page) LPHS strategic plan that improves public health capacity to respond to both emergency and continuing public health threats submitted to the TDH regional director. Deliverable August 30, 2003: A final (3-6 page) LPHS strategic plan that improves public health systems capacity to respond to both emergency and continuing public health threats submitted to the TDH regional director. A resource http://www.phppo.cd.c.gov/documents/local.inventoTy.PDF SECTION II. SPECIAL PROVISIONS: General Provisions, Reports Article, is revised to include the following paragraph: PERFORMING AGENCY shall submit an Annual Budget and Expenditures Report to the appropriate RECEIVING AGENCY Regional Director by October 31, 2003. ATTACHMENT — Page 3 No Text SECTION III. BUDGET: DIRECT ASSISTANCE , Direct assistance involves the assignment of state funded positions in lieu of cash. State salary warrants for net earnings will be issued in accordance with state regulations. PERSONNEL $25,392.00 TRAVEL 0.00 LABORATORY SUPPORT 0.00 OTHER 0.00 TOTAL $25,392.00 Financial status reports (FSRs) are not required on direct assistance. Program income generated from activities supported with direct assistance will be reported on FSRs required for financial assistance provided through this Attachment, if applicable, or through other program Attachments(s) benefitting from this assistance. RECEIVING AGENCY direct assistance will not exceed $ 25,392.00. ATTACHMENT — Page 4 No Text FINANCIAL ASSISTANCE Financial assistance involves payment of funds to Performing Agency for costs incurred in carrying out approved activities. PERSONNEL FRINGE BENEFITS TRAVEL EQUIPMENT SUPPLIES CONTRACTUAL OTHER TOTAL RECEIVING AGENCY financial assistance will not exceed $ 93,162.00. TOTAL RECEIVING AGENCY assistance will not exceed $ 118,554.00. 78,453.00 14,709.00 0.00 0.00 0.00 0.00 0.00 $93,162.00 Financial status reports are due the 30th of December, 30th of March, 30th of June, and the 30th of November. ATTACHMENT — Page 5 No Text CERTIFICATION REGARDING LOBBYING CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS The undersigned certifies, to the best of his or her knowledge and belief that: (1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or an employee of any agency, a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. (2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form -111, "Disclosure Form to Report Lobbying," in accordance with it's instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Signature Date Tarmy Cardw Print Name of Authorized Individual 7560005906 2003-05 Application or Contract Number LUBBOCK CITY HEALTH DEPARTMENT Organization Name and Address 1902 TEXAS AVENUE LUBBOCK, TX 79457-0000 tj DOCUMENT NO. 7560005906-2003 ATTACHMENT NO. 06 PERFORMING AGENCY: LUBBOCK CITY HEALTH DEPARTMENT RECEIVING AGENCY PROGRAM: IMMUNIZATION DIVISION TERM: September 01, 2002 THRU: August 31, 2003 SECTION I. SCOPE OF WORK: The goal of RECEIVING AGENCY Program is to prevent, control, and eliminate vaccine - preventable diseases by providing and administering biologicals, promoting immunizations, conducting vaccine -preventable disease surveillance, assessing vaccine coverage levels, and applying principles of epidemiology and outbreak control measures within budgetary constraints. PERFORMING AGENCY shall implement an immunization program for children, adolescents, and adults, with special emphasis on accelerating interventions to improve the immunization coverage of children two years of age or younger (less than 36 months of age). PERFORMING AGENCY shall incorporate traditional and non-traditional, systematic approaches designed to eliminate barriers, expand immunization delivery, and establish uniform policies. PERFORMING AGENCY shall provide services as outlined in PERFORMING AGENCY'S Fiscal Year (FY) 2003 Contract Renewal Budget and Work Plan and revisions, if any, as agreed to and approved by RECEIVING AGENCY Program. These documents are adopted by reference and made a part of this contract Attachment. Any revisions to these documents shall be approved by RECEIVING AGENCY Program and transmitted in writing to PERFORMING AGENCY. PERFORMING AGENCY shall report all reportable conditions as specified in 25 TAC Part I §§97.1 - 97.6 and 97.101 - 97.102. PERFORMING AGENCY shall report all vaccine adverse event occurrences in accordance with the National Childhood Vaccine Injury Act of 1986. PERFORMING AGENCY shall inform and educate the public about vaccines and vaccine - preventable diseases. PERFORMING AGENCY shall develop policies and plans that support individual and community-based immunization strategies and evaluate effectiveness, accessibility, and quality of personal and population -based immunization services and program activities. ATTACHMENT — Page 1 No Text PERFORMING AGENCY shall ensure a health care workforce that is knowledgeable about vaccines, vaccine -preventable diseases, and delivery of vaccination services. PERFORMING AGENCY shall comply with written policies and procedures provided by RECEIVING AGENCY Program in managing state -supplied vaccines, including guidelines for proper storage and handling of vaccines. PERFORMING AGENCY shall not deny vaccinations to recipients because they do not reside within PERFORMING AGENCY'S jurisdiction. PERFORMING AGENCY shall maintain an accurate, up-to-date list of clinics and sites where public sector (free or low cost) immunization services are offered in PERFORMING AGENCY'S local area. No fee may be charged for vaccines provided by RECEIVING AGENCY Program. All vaccines obtained from RECEIVING AGENCY Program shall be used solely for purposes of this contract Attachment and shall not be sold to agencies or individuals. PERFORMING AGENCY shall not collect vaccine administration fees from Medicaid recipients. Vaccine administration fees collected from non -Medicaid patients shall be kept within guidelines established by RECEIVING AGENCY. In accordance with 25 TAC §1.91, no one shall be denied immunization services in public clinics because of inability to pay the administration fee. Fee schedules shall not be based on vaccine type, formulation, or dose in series. A copy of PERFORMING AGENCY'S fee schedule shall be submitted to RECEIVING AGENCY Program by October 15th. All equipment and vaccine used by PERFORMING AGENCY which are provided by RECEIVING AGENCY Program, shall be accounted for as public property. RECEIVING AGENCY Program will investigate equipment or vaccine loss, destruction, spoilage, or other waste and may require PERFORMING AGENCY to replace or reimburse RECEIVING AGENCY Program. PERFORMING AGENCY shall provide the parent, managing conservator, or guardian of each patient with a form that is approved by RECEIVING AGENCY Program in compliance with 25 TAC, Chapter 100 to authorize participation in the statewide immunization registry (ImmTrac). PERFORMING AGENCY shall provide RECEIVING AGENCY Program weekly data transfers of all vaccines administered in a format that is compatible for inclusion in the statewide immunization registry (ImmTrac). PERFORMING AGENCY shall comply with all applicable federal and state laws, rules, regulations, standards, and guidelines in effect on the beginning date of this contract Attachment ATTACHMENT — Page 2 No Text unless amended. The following documents are incorporated by reference and made a part of this contract Attachment. • PERFORMING AGENCY'S FY 2003 Contract Budget and Work Plan, and any revisions; • Human Resources Code §42.043, VTCA; • Education Code §§38.001-38.002, VTCA; • Health and Safety Code §§81.023 and 161.001-161.009, VTCA; • 25 TAC Chapter 97; • 25 TAC, Chapter 96; • 25 TAC, Chapter 100; • 42 USC §§247b and 300 as -25; • Omnibus Budget Reconciliation Act of 1993, 26 USC §4980B; • RECEIVING AGENCY'S Client Services Standards for Public Health and Community Clinics, revised June 1997; • RECEIVING AGENCY'S Vaccine -Preventable Disease Surveillance guidelines, http://www.tdh.state.tx.us/immunize/docs/guide.htm; • RECEIVING AGENCY'S Pharmacy guidelines; • Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) guidelines, including the statement: "Immunization of Health -Care Workers"; and • Standards for Pediatric Immunization Practices, February 1996, recommended by the National Vaccine Advisory Committee, approved by the United States Public Health Service, and endorsed by the American Academy of Pediatrics. Within thirty (30) days of receipt of an amended standard(s) or guideline(s), PERFORMING AGENCY shall inform RECEIVING AGENCY Program, in writing, if it will not continue performance under this Attachment in compliance with the amended standard(s) or guideline(s). RECEIVING AGENCY may terminate the Attachment immediately or within a reasonable period of time as determined by RECEIVING AGENCY. PERFORMANCE MEASURES The following performance measure(s) will be used, in part, to assess PERFORMING AGENCY'S effectiveness in providing the services described in this contract Attachment to the service area, without waiving the enforceability of any of the terms of the contract. PERFORMING AGENCY shall investigate 100% of all reported vaccine -preventable diseases in accordance with RECEIVING AGENCY'S Vaccine -Preventable Disease Surveillance Guidelines. PERFORMING AGENCY shall investigate 100% of suspected hepatitis B infections in pregnant women to assure appropriate treatment and follow-up as directed by Health and ATTACHMENT — Page 3 No Text Safety Code §81.090 and RECEIVING AGENCY'S Vaccine -Preventable Disease Surveillance Guidelines. PERFORMING AGENCY shall submit to RECEIVING AGENCY Program the monthly reports of doses administered by the fifteenth calendar day of each month for the previous calendar month, in a format approved by RECEIVING AGENCY Program. The monthly vaccine biologicals order form must be submitted in accordance with the schedule provided to PERFORMING AGENCY by RECEIVING AGENCY Program. PERFORMING AGENCY shall implement an immunization reminder and/or recall system to notify parents or guardians of children less than 36 months of age when immunizations are due. The notifications may be automated or manual and may consist of mail or telephone contacts. PERFORMING AGENCY shall conduct immunization audits in childcare facilities and registered family homes as assigned by RECEIVING AGENCY Program. PERFORMING AGENCY shall conduct immunization audits and surveys in public and private schools as assigned by RECEIVING AGENCY. PERFORMING AGENCY shall conduct annual assessments in 100% of sub -contracted entities and WIC clinics using the Assessment, Feedback, Incentives, and eXchange (AFIX) methodology. PERFORMING AGENCY shall submit assessment results to RECEIVING AGENCY Program within two (2) weeks after completion. PERFORMING AGENCY shall conduct follow-up monitoring visits of Texas Vaccines for Children Program (TVFC)-enrolled provider sites using the RECEIVING AGENCY'S monitoring tool and methodology. PERFORMING AGENCY shall submit monitoring report to RECEIVING AGENCY Program within two (2) weeks after completion of visit. PERFORMING AGENCY shall recruit and enroll providers into the TVFC program. SECTION II. SPECIAL PROVISIONS General Provisions, Reports Article, is revised to include the following: PERFORMING AGENCY shall submit quarterly program reports to RECEIVING AGENCY Program according to the following timelines and in the formats provided by RECEIVING AGENCY Program. ATTACHMENT — Page 4 No Text NAME OF REPORT APPLICABLE QUARTERS DUE DATES Immunization Program - September, October, November December 30 Performance Measure December, January, February March 30 Quarterly Report March, April, May June 30 June, July, August September 30 Immunization Program - September, October, November December 30 Recruitment Quarterly Report December, January; February March 30 March, April, May June 30 June, July, August September 30 For immunization activities performed under this contract Attachment, General Provisions, Overtime Compensation Article is not applicable. In addition, PERFORMING AGENCY shall comply with the following paragraphs: PERFORMING AGENCY is authorized to pay employees who are not exempt under the Fair Labor Standards Act (FLSA), 29 USC, Chapter 8, §201 et seq., for overtime or compensatory time at the rate of time and one-half per FLSA. PERFORMING AGENCY is authorized to pay employees who are exempt under FLSA on a straight time basis for work performed on a holiday or for regular compensatory time hours when the taking of regular compensatory time off would be disruptive to normal business operations. Authorization for payment under this provision is limited to work directly related to immunization activities and shall be in accordance with the amount budgeted in this contract Attachment. PERFORMING AGENCY shall document proper authorization or approval for any work performed by exempt or non-exempt employees in excess of forty (40) hours per work week. ATTACHMENT — Page 5 No Text SECTION III. BUDGET: PERSONNEL $77,705.00 FRINGE BENEFITS 29,448.00 TRAVEL 0.00 EQUIPMENT 0.00 SUPPLIES 0.00 CONTRACTUAL 0.00 OTHER 0.00 TOTAL DIRECT CHARGES $107,153.00 INDIRECT CHARGES $0.00 TOTAL $107,153.00 Total reimbursements will not exceed $107,153.00. Financial status reports are due the 30th of December, 30th of March, 30th of June, and the 30th of November. ATTACHMENT — Page 6 No Text •t CERTIFICATION REGARDING LOBBYING CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS The undersigned certifies, to the best of his or her knowledge and belief that: (1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or an employee of any agency, a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. (2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form -111, "Disclosure Form to Report Lobbying, in accordance with it's instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Signature C TaW Carden Print Name of Authorized Individual 7560005906 2003-06 Application or Contract Number LUBBOCK CITY HEALTH DEPARTMENT Organization Name and Address 1902 TEXAS AVENUE LUBBOCK, TX 79457-0000 Date y.J v I 'v, 'v