N. C. DHHS Confirmation Reports:

APRIL 2015 93.576 REFUGEE AND ENTRANT ASSISTANCE DISCRETIONARY GRANTS State Project/Program: NC REFUGEE HEALTH PROGRAM U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Federal Authorization: State Authorization: P.L. 96-212; Section 412C(3) of the Immigration and Nationality Act G.S. 130A-223 N. C. Department of Health and Human Services Division of Public Health Agency Contact Person Program: Jennifer Morillo (919) 733-7286, ext. 106 Jennifer.Morillo@dhhs.nc.gov Agency Contact Person Financial: Allen Hawks Business Director (919) 707-5076 Allen Hawks@dhhs.nc.gov N. C. DHHS Confirmation Reports: SFY 2015 audit confirmation reports for payments made to Counties, Local Management Entities (LMEs), Boards of Education, Councils of Government, District Health Departments and NC DHHS/Division of Health Service Regulation Grant Subrecipients will be available by mid September at the following web address: http://www.ncdhhs.gov/control/auditconfirms.htm. At this site, click on the link entitled Audit Confirmation Reports (State Fiscal Year 2014-2015). Additionally, audit confirmation reports for Nongovernmental entities receiving financial assistance from the DHHS are found at the same website except select Non-Governmental Audit Confirmation Reports (State Fiscal Years 2013-2015). The Auditor should not consider the Supplement to be safe harbor for identifying audit procedures to apply in a particular engagement, but the Auditor should be prepared to justify departures from the suggested procedures. The Auditor can consider the Supplement a safe harbor for identification of compliance requirements to be tested if the Auditor performs reasonable procedures to ensure that the requirements in the Supplement are current. The grantor agency may elect to review audit working papers to determine that audit tests are adequate. Brief Description of Program: The NC Refugee Health Program receives a federal grant from the Office of Refugee Resettlement to assist the Division of Public Health in assuring that the State s newly arrived refugees receive a timely health screening and examination to identify and treat any communicable diseases as well as any health conditions that might affect the successful resettlement of the refugee. The State Program establishes health screening protocols; assists in notifying local health departments of new arrivals; provides technical consultation on refugee health issues; collects and reports health data on newly arrived refugees; and provides contract funds to seven county health departments with the largest number of refugee arrivals. Allocations to local health departments are based on the number of prior year refugee arrivals and anticipated refugee arrivals in each county as well as the proportion of arrivals reported receiving timely health assessments. Health departments can generally bill Medicaid or Refugee Medical Assistance (RMA) through Medicaid for the cost of providing the health assessment. Contract funds can be used for a variety of program administrative B-4 93.576-4 1

expenses associated with providing the refugee health screening. This includes support for salaries of key staff involved in refugee clinical services and data collection; interpreters, training for interpreters, and outreach services; to purchase bilingual health education materials, bilingual medical dictionaries, vaccines, and over-the-counter medications not covered by insurance; to provide enhanced follow up services for refugees receiving treatment for latent tuberculosis (TB) infection; for travel and other costs associated with staff attending refugee health-related conferences/meetings and training; to purchase bus/taxi vouchers to ensure refugees are able to get to their health assessment appointments; and to purchase necessary laboratory equipment and supplies that will be used for refugee health screenings. I. PROGRAM OBJECTIVES FEDERAL OBJECTIVES: (A) To assure that an adequate number of trained staff are available at the location at which the refugees enter the United States to assure that all necessary medical records are available and in proper order; (B) To provide for the identification of refugees who have been determined to have medical conditions affecting the public health and requiring treatment; (C) Assure that state or local health officials at the resettlement site are promptly notified of the refugee s arrival and provided with all applicable medical records; and (D) To provide for such monitoring of refugees identified in B above, to ensure that they receive appropriate and timely treatment. STATE OBJECTIVES: The NC Refugee Health Program s mission is to ensure that the Refugee Health Assessment is provided soon after arrival to identify any communicable diseases of public health concern and any health conditions that might impede resettlement and achieving self-sufficiency. At least 95% of refugee arrivals are informed in their own language within 30 days of arrival in the U.S. regarding the availability, importance, and content of the health screening. At least 60% of refugee arrivals within 30 days will initiate care at local health departments for a health assessment based on the NC Refugee Health Protocol. At least 95% of refugee arrivals within 90 days will have initiated the health screening based on the NC Refugee Health Protocol. 80% of refugee arrivals will be provided treatment for any conditions of public health concern by local health departments within 14 days of diagnosis and will be treated or referred for other health conditions identified during the health screening assessment. II. PROGRAM PROCEDURES The NC Refugee Health Program receives a federal grant from the Office of Refugee Resettlement (ORR) in the Administration for Children and Families (ACF). The Program applied for the funding in March 2011 and was approved for a 5 year project period; however, the grant projected period was subsequently reduced to three years. The NC Refugee Health Program disburses funds to the county health departments that receive and serve the greatest number of new refugee arrivals. The health departments must report health screening data on a quarterly basis. The NC Refugee Health Program provides semi-annual and final project period reports to ORR. The NC Refugee Health Program establishes health screening protocols; assists in notifying local health departments of new arrivals; provides technical consultation on refugee health issues; collects and reports health data on newly arrived refugees; and provides contract funds to certain health departments. The funded health departments are monitored through telephone and email correspondence, tracking quarterly reporting, as well as site visits. Contract funds can be used for a variety of program administrative expenses associated with providing the refugee health screening. This includes support for salaries of staff involved in refugee clinical services, data collection and reporting; interpreter and outreach services; to purchase bilingual B-4 93.576-4 2

materials; to provide enhanced follow up services for refugees on Tuberculosis treatment; to provide training for interpreters; to purchase over-the-counter medications or other related supplies not covered by Medicaid; and for travel and other costs associated with staff attending refugee health-related conferences/meetings and training. STATE PROGRAM The NC Refugee Health Program is administered in the Communicable Disease Branch in the Division of Public Health that oversees the management of the federal Refugee Health Grant award. AGREEMENTS SYSTEM NC Refugee Health funds are allocated as part of the North Carolina Division of Public Health s Consolidated Agreement with local health departments. Seven local NC county health departments receive refugee health funds. GENERAL AGREEMENT GUIDANCE The Consolidated Agreement provides general guidelines regarding approved policies and procedures related to the implementation of public health programs and describes requirements of the funding relationship between the State and local public health agencies. These requirements are detailed under the following headings: Work to Be Performed; Funding Stipulations; Fiscal Control; Responsibilities of the State; and Compliance. Budgetary Guidance is sent annually by each of the Divisions to all local health departments. The Budgetary Guidance document specifies the amount of funds allocated and the respective sources. PROGRAM GUIDANCE The NC Refugee Health Program Agreement Addendum to the Consolidated Agreement provides guidance to local health departments regarding specific requirements for local programs receiving Refugee Health funds. Health departments also receive a Technical Assistance Guide for Local Refugee Health Programs from the State program that provides detailed information on the requirements for providing health assessments to newly arrived refugees. III. COMPLIANCE REQUIREMENTS A. ACTIVITIES ALLOWED OR UNALLOWED Federal Statutory Authority: PL 96-212; Section 412C (3) of the Immigration and Nationality Act allows that funds may be used to assure that newly arrived immigrants with refugee status receive a health assessment after resettlement in the United States. State Statutory Authority: G. S. 130A-223 provides that the Department shall establish and administer a program for the prevention of disease, disabilities, and accidents that contribute significantly to mortality and morbidity among adults. The program may also provide for the treatment of persons with diseases and disabilities. PROGRAM REQUIREMENTS As a recipient of Refugee Health funds, local health departments have agreed to: Designate a Refugee Health Liaison to coordinate refugee health assessments. Inform newly arrived refugees in the county about availability of the assessment services and schedule assessment ideally within 30 days but no later than 90 days after arrival or eligibility. Exams must be completed within 90 days to assure reimbursement through Medicaid or Refugee Medical Assistance (RMA). Provide the assessment based on NC Refugee Health Assessment Protocol guidelines as well as Center for Disease Control (CDC) and the Office of Refugee Resettlement (ORR) recommendations. The assessment includes a Communicable Disease Screening and a Physical Exam. The Local Health Department should be able to provide at least the communicable disease portion of the assessment. If the Local Health Department cannot provide the physical exam portion, the refugee must be referred to a private B-4 93.576-4 3

clinic/physician (preferably to a medical home) for the physical exam. (In this situation, the Local Health Department is not eligible to bill Medicaid/RMA for the complete refugee health assessment.) Use a qualified interpreter for clinical encounters. Telephone interpretation may be appropriate. Provide language-appropriate health education based on individual refugee s needs and risk factors. Provide treatment for Class A or B conditions, tuberculosis and other communicable diseases within 30 days of arrival or 14 days of domestic diagnosis. Provide follow up care or referral(s) for any conditions identified in the health assessment. Conditions of public health concern must be followed up within 14 days. Provide vaccination upgrades based on the North Carolina and the CDC s Advisory Committee on Immunization Practices (ACIP) immunization guidelines. Complete the refugee health Data Collection Form for each refugee arrival. Allow key refugee health staff to attend trainings and conferences sponsored by the North Carolina Refugee Assistance Program or the North Carolina Refugee Health Program; to meet regularly with voluntary resettlement agencies to coordinate local refugee services; and to attend North Carolina Refugee Advisory Council meetings. Not assess the refugee any fees for this screening. Each health department can provide the auditor with a copy of the Consolidated Agreement for the particular year being audited, as well as, copies of the Budgetary Guidance, the Refugee Health Program Agreement Addendum, expenditure reports, and a summary of quarterly reports of health screening assessments provided to newly arrived refugees. If the health department cannot provide these documents, they are available from the Refugee Health Program in the Division of Public Health. Suggested Audit Procedure: Review the Consolidated Agreement Addendum for Refugee Health and expenditure reports to determine the appropriateness of activities paid by these funds. B. ALLOWABLE COSTS/COST PRINCIPLES Although OMB Circular A-87 is not applicable to Preventive Health Grant funds, the North Carolina Department of Health and Human Services has adopted this circular as its standard for determining allowable costs. E. ELIGIBILITY Eligibility is limited to newly arrived immigrants with refugee status. This eligibility for health assessment services includes refugees, Cuban/Haitian Entrants (including Cuban parolees), Asylees, certain Amerasians, Certified Victims of a Severe Form of Trafficking, and Iraqi and Afghan Special Immigrants. These individuals present the local health department with U.S. Citizenship and Immigration Services documentation of their status. (45 CFR 400.43 Requirements for documentation of refugee status) B-4 93.576-4 4

Suggested Audit Procedure: Review the local health department eligibility criteria for assuring that health assessments are provided to newly arrived immigrants with refugee status. H. PERIOD OF AVAILABILITY OF FEDERAL FUNDS Funds are available to the subgrantee for the period delineated by the effective dates of the contract with the Division of Public Health. I. PROCUREMENT AND SUSPENSION AND DEBARMENT Funds can be used for a variety of purposes to support the health departments' capacity to provide health assessments to newly arrived refugees as well as to collect and report health assessment data to the state. This includes support for salaries of key staff involved in refugee clinical services and data collection; interpreters, training for interpreters, and outreach services; to purchase bilingual health education materials, bilingual medical dictionaries, vaccines, and over-the-counter medications not covered by insurance; to provide enhanced follow up services for refugees receiving treatment for latent tuberculosis (TB) infection; for travel and other costs associated with staff attending refugee health-related conferences/meetings and training; to purchase bus/taxi vouchers to ensure refugees are able to get to their health assessment appointments; and to purchase necessary laboratory equipment and supplies that will be used for refugee health screenings. J. PROGRAM INCOME The refugee should not be assessed any fees for the provision of the communicable disease portion of the health assessment as described in the NC Refugee Health Protocol. An exception is that adult refugees may be charged by local health departments for immunizations required by U. S. Citizenship and Immigration Services and not available through the state vaccine programs or through Medical Assistance. These funds remain part of the health department fees for immunization services and need not be reported to the Program. L. REPORTING Statutory Authority: 10A NCAC 39A.0506: Local health departments must prepare health assessment data reports as referenced in the Agreement Addendum. Programs must provide quarterly electronic reports of this refugee health assessment data to the state Program using the EpiInfo database unless they are given an exemption to be permitted to submit hard copies. Statutory Authority: 10A NCAC 39A.0506: Local health departments are required to submit Expenditure Reports (through an electronic Aid to County website) on a schedule set out in the Consolidated Agreement between the parties. Suggested Audit Procedure: Review the files for evidence of activity reports. M. SUBRECIPIENT MONITORING The subgrantee shall not subcontract any of the work contemplated under this financial assistance contract without prior written approval from the Division of Public Health. Any approved subcontract shall be subject to all conditions of this contract. Only the subcontractors specified in the contract documents are to be considered approved upon award B-4 93.576-4 5

of the contract. The Division shall not be obligated to pay for any work performed by any unapproved subcontractor. The Contractor shall be responsible for the performance of all of its subcontractors and will monitor said performance to ensure compliance with performance standards. N. SPECIAL TESTS AND PROVISIONS Consolidated Agreement System The DHHS Division of Public Health is made up of five major sections: Chronic Disease and Injury Prevention; Epidemiology; Women s and Children s Health Services; Oral Health; and Administrative, Local & Community Support Sections. The Division utilizes a single written agreement to manage all funds, that is, State, federal or private grant funds, that the Division allocates to local health departments across the State. This document, as amended, is called the Consolidated Agreement. The Agreements set forth the more general requirements of the funding relationship between the State and local public health agencies. The respective requirements are detailed under the headings: Responsibilities of the Department (Local Public Health Unit); Funding Stipulations; Fiscal Control; Responsibilities of the State; and Compliance. More specific information related to Program activity is set out in a document called the Agreement Addenda which detail outcome objectives and may or may not be negotiable at the beginning of each fiscal year that each health department must achieve in exchange for the funding. A third part of the system is the Budgetary Authorization which is sent annually from each of the Sections or Branches of the Division to all health departments being allocated funds from specific sources, i.e., State appropriations or other federal grant funds for specific activities. This estimate indicates the amount of the allocated funds and their respective sources. Each health department should be able to provide an auditor with a copy of the Consolidated Agreement for the particular year being audited, as well as copies of the Budgetary Authorization and any revisions, Agreement Addenda, expenditure reports and any activity reports for each source of money received. If the health department cannot provide these documents, they may contact the State Division of Public Health Budget Office for assistance. Suggested Audit Procedures The auditor should review Section B. FUNDING STIPULATIONS of the Consolidated Agreement before beginning an audit. The fourteen items of this Section describe much of the detailed information the auditor may be seeking during a review of these programs. Conflicts of Interest and Certification Regarding No Overdue Tax Debts All non-state entities (except those entities subject to the audit and other reporting requirements of the Local Government Commission) that receive, use or expend State funds (including federal funds passed through the N. C. Department of Health and Human Services) are subject to the financial reporting requirements of G. S. 143C-6-23 for fiscal years beginning on or after July 1, 2007. These requirements include the submission of a Notarized Conflict of Interest Policy (see G. S. 143C-6-23(b)) and a written statement (if applicable) completed by the grantee's board of directors or other governing body that the entity does not have any overdue tax debts as defined by G. S. 105-243.1 at the federal, State or local level (see G. S. 143C-6-23(c)). All non-state entities that provide State funding to a non-state entity (except any non-state entity subject to the audit and other reporting requirements of the Local Government Commission) must hold the subgrantee accountable for the legal and appropriate expenditure of those State grant funds. B-4 93.576-4 6