Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696597323269.pdf (United States)
Title V Reproductive Health/Family Planning Program Policies and Procedures Manual Rev.
April 2020 ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL Table of Contents _____________________________________________________________________________________________ CHAPTER 1: INTRODUCTION ........................................................................................................................................ 4 1.1 Program Background and Description ......................................................................................................... 5 1.2 Authority for the Program ............................................................................................................................ 5 1.3 Mission Statement........................................................................................................................................ 5 1.4 1.5 1.6 1.7 Reproductive Health/Family Planning and Maternal and Child Health Block Grant .................................... 5 Other Reproductive Health/Family Planning Programs ............................................................................... 5 Program Goals and Objectives ..................................................................................................................... 7 The Purpose of this Manual ......................................................................................................................... 7 CHAPTER 2: GLOSSARY ................................................................................................................................................. 9 CHAPTER 3: PROGRAM MANAGEMENT AND ADMINISTRATION .............................................................................. 13 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Role of the Bureau of Women’s and Children’s Health ............................................................................. 13 Role of the Contractor in Program Management
 ...................................................................................... 13 Contractor Oversight of Medical Management Component ..................................................................... 14 Sub-contracts .............................................................................................................................................. 14 Contractor’s Personnel Policy Standards ................................................................................................... 14 Staff Training and Orientation .................................................................................................................... 15 Continuous Quality Improvement (CQI) ..................................................................................................... 16 Internal Policy and Procedure for Reproductive Health/Family Planning ................................................. 17 Clinic Facility Standards .............................................................................................................................. 17 3.10 Availability and Accessibility of Clinic Services ........................................................................................... 18 3.11 Program Eligibility ....................................................................................................................................... 18 3.12 Nondiscrimination ...................................................................................................................................... 19 3.13 Voluntary Participation .............................................................................................................................. 19 3.14 Confidentiality ............................................................................................................................................ 19 3.15 Client Medical Records
 ............................................................................................................................... 19 3.16 Informed Consent ....................................................................................................................................... 21 3.17 Program Promotion .................................................................................................................................... 21 3.18 Community Education ................................................................................................................................ 22 1 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 3.19 Establishing Referral and Communication Networks ................................................................................. 22 3.20 Developing Partnerships and Establishing Collaborative Efforts .................................................................. 23 CHAPTER 4: PROGRAM SERVICES .............................................................................................................................. 24 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 Required Services ....................................................................................................................................... 24 History ........................................................................................................................................................ 24 Client Education/Counseling ...................................................................................................................... 25 Physical Assessment ................................................................................................................................... 27 Laboratory Testing
 ...................................................................................................................................... 27 Fertility Regulation Referral ....................................................................................................................... 29 Infertility Services Referral ......................................................................................................................... 29 Pregnancy Screening, Counseling, and Referrals ....................................................................................... 29 Adolescent Services .................................................................................................................................... 30 4.10 Sexually Transmitted Infection Screening .................................................................................................. 31 4.11 Referral and Follow-up ............................................................................................................................... 32 4.12 Recommended Services ............................................................................................................................. 32 4.13 Excluded Services ....................................................................................................................................... 34 CHAPTER 5: MONTHLY, QUARTERLY AND ANNUAL REPORTS ................................................................................... 35 5.1 Monthly Reports ......................................................................................................................................... 35 5.2 Monthly Report Requirements ................................................................................................................... 35 5.3 Monthly Performance Report Instructions ................................................................................................ 35 5.4 Quarterly Expenditure Report
 .................................................................................................................... 37 5.5 Quarterly Expenditure Report Requirements ............................................................................................ 38 5.6 Contractor’s Quarterly Expenditure Report Instructions ........................................................................... 38 5.7 5.8 BWCH Program Manager’s Role in Quarterly Expenditure Report Review ............................................... 38 Annual Report ............................................................................................................................................. 39 5.9 Annual Report Requirements ..................................................................................................................... 39 CHAPTER 6: MONTHLY BILLING ................................................................................................................................. 40 6.1 Contractor Reimbursement and CER ......................................................................................................... 40 6.2 Monthly Submission Requirements ........................................................................................................... 40 6.3 Submission Location ................................................................................................................................... 40 2 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 6.4 BWCH Program Manager’s Role in CER Approval ...................................................................................... 40 6.5 Supporting Documentation ........................................................................................................................ 41 CHAPTER 7: PROGRAM MONITORING AND EVALUATION
 ........................................................................................ 42 7.1 Annual Review ............................................................................................................................................ 42 7.2 Multiple Sites .............................................................................................................................................. 42 7.3 Consultative Site Visit ................................................................................................................................. 42 7.4 Purpose of the Site Review:........................................................................................................................ 42 7.5 7.6 7.7 7.8 Review Guidelines ...................................................................................................................................... 42 Annual Review Draft Report ....................................................................................................................... 43 Annual Review Final Report and Corrective Action ................................................................................... 43 Failure to Comply ....................................................................................................................................... 44 CHAPTER 8: APPENDICES and OPTIONAL DOCUMENTS ........................................... 42Error!
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3 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL CHAPTER 1: INTRODUCTION 1.1 Program Background and Description The mission of the Bureau of Women’s and Children’s Health (BWCH) is to “strengthen the family and community by promoting and improving the health status of women, infants, and children.” This is accomplished through the provision of community-based services and the facilitation of systems development.
The Bureau of Women’s and Children’s Health administers the federal Maternal Child Health Title V Block Grant and other federally funded programs, as well as private and state supported programs.

The Bureau of Women’s and Children’s Health, Reproductive Health/Family Planning Program is a statewide, clinic-based, program that provides comprehensive family planning and reproductive health services to promote optimal health to Arizona’s men and women.
Services include education, screening, counseling, and medical and referral services that enable people to make voluntary and informed decisions.

Program services are preventive health services that enhance maternal and infant health, and the emotional and social health of the individual and the family.

Reproductive health and family planning is a cost effective intervention that plays a key role in health care delivery.
Clinics are often the entry point into the health care system, and may be the only source of health care for the low income, for the young, and for the underinsured and the uninsured.

Program services promote responsible and healthy lifestyles by providing accurate information, education, and counseling to people regarding their reproductive health and family planning options.
Program services provide individuals with the information and means to exercise personal choice in determining the number and the spacing of their children.

Research indicates that women who can plan and space their pregnancies are likely to have healthier babies.

The reduction of unplanned pregnancy increases the likelihood that women will receive early and continuous prenatal care.
Improved birth outcomes include a reduction of birth defects, decreases in infant mortality, and decreases in the incidence of low birth weight babies.

An important social statistic indicates that children born to individuals who are prepared for them are less likely to be abused and/or neglected.

Clients receive initial or annual exams which include a choice of a family planning method, cancer and Sexually Transmitted Infection (STI) screenings.
Clients also receive treatment as indicated, pregnancy testing, counseling, education, and referrals to other medical services as needed.

It is vital that reproductive health and family planning services be available, accessible, and linked to other types of necessary medical, social, educational, and financial resources in communities throughout Arizona.
4 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 1.2 Authority for the Program Arizona Revised Statutes, ARS §36-104(1)(c)(i), authorizes the Director of the Arizona Department of Health Services (ADHS) to administer community health services which are to include medical service programs for family planning.
1.3 Mission Statement The mission of the Reproductive Health/Family Planning Program is: A.

To provide preventive health services to enhance the emotional, physical, and social health and well-being of mother’s, children, and the whole family unit.
B. C. To enable individuals to make and implement educated personal decisions regarding the quantity and spacing of their children 1.4 Reproductive Health/Family Planning, Maternal and Child Health Block Grant To make reproductive health and family services available and easily accessible to all who seek such assistance To assure that mothers and children (in particular, those with low income or with limited access to health services) receive quality maternal and child health services, the United States Congress enacted Title V of the Social Security Act.
Title V provides funds via the federal Maternal and Child Health Services Block Grant for the health promotion of mothers and children, particularly through preventive and primary care services for the low-income population.

Title V also provides support for prenatal care, delivery assistance, and postpartum care for low-income mothers.
Recognizing that reproductive health and family planning services are important components of maternal and child health care, the Bureau of Women’s and Children’s Health contributes a portion of this block grant to address various reproductive health and family planning needs.

The funding for reproductive health and family planning services administered by the Bureau of Women’s and Children’s Health is supported entirely by dollars received from the federal Maternal Child Health Title V Block Grant.
1.5 Other Reproductive Health/Family Planning Programs A.

5 | P a g e Infertility Prevention Project (IPP) Referrals infections are considered major cause of pelvic Gonorrhea and chlamydia inflammatory disease (PID), ectopic pregnancy and related infertility among women in Arizona and in the United States.

ADHS Sexually Transmitted Disease Control Program (STDCP) manages the IPP component of the CDC Comprehensive STD Prevention Services (CSPS) Cooperative Agreement grant.
The overall goal of the IPP is to assess and reduce the prevalence of chlamydial and gonococcal infection, and associated complications through increased education and training, targeted screening, timely, and effective treatment, effective partner referral and treatment, and dissemination of chlamydia-related information to providers and policy makers ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL in order to reduce infertility among women through the screening and treatment of chlamydia.
Should the contractor choose to participate in this program, the Contractor agrees to: Provide universal chlamydia and gonorrhea screening for all women at Title V 1.

Health Clinics, during the first visit and annually thereafter.

Prevalence requirements may change as funds for testing dictates.

Provide client level services including treatment, education and counseling, as well as partner elicitation and services.
Provide staff training in the process for collecting specimens, client education, referral, confidentiality, reporting, and requisition of laboratory supplies.

Provide comprehensive reports in a timely manner as dictated 2.

3.

4.

Contingent upon the availability of IPP funds, ADHS’ contracted laboratory will provide Contractor testing collection kits for the target population of women 25 years of age and younger at no cost.
Failure to adhere to Region IX Infertility Prevention Chlamydia Clinical Guidelines may result in elimination of Chlamydia testing funds.

Contingent upon availability, IPP agrees to provide Contractor with dosages of azithromycin at no charge for treatment of Title V patients.

If azithromycin is no longer available, Contractor will provide treatment at Contractor’s expense or provide appropriate referrals for target population for treatment of a positive Chlamydia test result.
Contractor agrees to submit the IPP Azithromycin Usage Report on a monthly basis to IPP.

Title X, Public Health Service Act Congress enacted the Family Planning Service and Population Research Act, which added Title X, Population Research, and Voluntary Family Planning Programs, to the Public Health Service Act.

Title X is administered by the Office of Population Affairs, a department within the U.S. Department of Health and Human Services.
The regulations governing Title X are contained in the Code of Federal Regulations, (CFR), (42 CFR, Subsection A, Part 59).

These regulations govern the provision of family planning services nationwide.

In Arizona, The Arizona Family Health Partnership (AFHP) administers these funds and services.

All clinics provide basic medical, educational, and counseling services related to contraception and pregnancy testing.

These services are targeted for low-income women and men.
Title XIX Title XIX of the Social Security Act funds federal Medicaid programs.

Arizona’s version of the Medicaid program is the Arizona Health Care Cost Containment System (AHCCCS).

AHCCCS acts as the health insurer for low income Arizonans who qualify for various state and federal programs.

Enrollees are entitled to receive health care benefits, including family planning services through prepaid managed care health plans.
Family planning services are covered services for Title XIX enrollees, but B. C. 6 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL AHCCCS health plans may elect at the time of contract negotiations not to provide family planning services directly.

In those cases, services must be made available on a fee-for-service basis through referrals to AHCCCS registered providers.
1.6 Program Goals and Objectives A.

The overall goal of the Reproductive Health/Family Planning Program is to provide comprehensive health services to promote optimal health, outcomes, and wellness for all Arizonans.

1.

2.

Promoting safe sexual behaviors Related goals include: a. b.

Improving access to quality health care c. Improving maternal and infant health The related Bureau of Women’s and Children’s strategic plan priority is to improve the health of women prior to pregnancy.

B.
B.

The objectives of the Reproductive Health/Family Planning Program are to: 1.

Decrease the teen pregnancy rate by providing reproductive health and family planning education, counseling, medical care, and referral services to adolescents statewide Ensure access to health care by providing reproductive health and family planning education, counseling, medical care, and referral services to low- income individuals living in rural and other underserved areas 2.
By meeting these objectives, Program services aim to improve birth outcomes by reducing birth defects, decreasing infant mortality, and decreasing the incidence of low birth weight babies.

These services also aim to improve the emotional and social health of the individual and the family by decreasing the stress that can be caused by an unplanned pregnancy.
1.7 The Purpose of this Manual The purpose of this manual is to document the Reproductive Health/Family Planning policy and procedures for the Maternal and Child Health Title V Block Grant Contractors to use in development, implementation, and management of the Program.

The manual is to be used to supplement terms of the contracts as indicated in the Scope of Work (SOW).
Program Contractors, Department Administration, and other interested parties are to use this manual for reference and to provide more detailed information than contained in the contract.

Reproductive health and family planning Contractors are required to adhere to the requirements and guidelines set forth in this manual, and are also responsible for incorporating any policy changes into their operations.
Revisions to the manual will be distributed to all Contractors at least thirty days prior to the effective date of any change, when appropriate.

Contractors may consider keeping relevant correspondence and program updates as an Appendix to this document.
If this reference 7 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL does not answer a question or concern, or if Contractors have suggestions for additional information that might be included in the policy manual, please contact the Reproductive Health/Family Planning Program Manager via any of the information below: Physical Address : Attention: Family Planning Program Manager Arizona Department of Health Services Bureau of Women’s and Children’s Health 150 N. 18th Avenue, Suite 320 Phoenix, Arizona 85007-3242 Office Number: 602-542-8953 Preferably E-mail:desiree.fields@azdhs.gov 8 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL CHAPTER 2: GLOSSARY “ACOG” means the American College of Obstetricians and Gynecologists.
ACOG establishes 1. and promotes standards for women’s health care.

2.

“ADHS” means the Arizona Department of Health Services.

The Department is the Arizona state agency that is mandated to promote, protect and improve the health of the people of the state of Arizona.

The Department is responsible for administering public health services and a variety of community health programs, including the Reproductive Health/Family Planning Program.

“AHCCCS” means the Arizona Health Care Cost Containment System.
AHCCCS is the Arizona 3. state agency that administers health care benefits and services for persons who are eligible for Title XIX services (Medicaid) or other low-income medical assistance programs.

4.

“Annual Review” means compliance-based site visits that are conducted to ensure that services are delivered pursuant to the terms and conditions of the contract and in accordance with the Reproductive Health/Family Planning Program Policy and Procedure Manual.
All Contractors will have at least one compliance-based site visit at least every two years, either virtually or in person, as circumstances dictate.

“Annual Visit” means an established client’s yearly comprehensive well-woman preventive 5. visit.

visits: Please https://www.womenspreventivehealth.org/recommendations/well-woman-preventive-visits/.

A client may only have one annual visit in a twelve month period.
for updated guidelines annual click link this the for “BWCH” means the Bureau of Women’s and Children’s Health at the Arizona Department of 6.

Health Services.

7.

“CDC” means the Centers for Disease Control and Prevention, a federal public health agency.

The CDC is recognized as the lead federal agency for protecting the health and safety of people in the United States and abroad, providing credible information to enhance health decisions, and promoting health through strong partnerships.
The CDC serve as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and education activities designed to improve the health of the people of the United States.

“Client” means an individual who receives reproductive health/family planning services 8. through the Program.

“Clinic Site” means an outpatient facility, or part of a facility, devoted to diagnosis and 9. treatment of patients.
“Clinical Staff” means a designated physician or nurse practitioner who is licensed and board 10. certified in the State of Arizona who administers clinical care for the Reproductive Health/Family 9 | P a g e Planning Program.

ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 11.
“Continuous Quality Improvement” (CQI) means the combination of activities traditionally referred to as quality assurance, quality management, utilization review, and risk management.

CQI encompass any and all plans, actions, and evaluation practices used to monitor and improve services and service provision.

“Contractor” means the organization awarded by ADHS to provide services; also known as 12. the Grantee.

13.

“DES” means the Arizona Department of Economic Security.
DES is the Arizona state agency that is responsible for determining eligibility for federal assistance programs for low income persons.

14.

“Encounter” means an episode of contact or single unit of service provided to an eligible reproductive health/family planning client.

An initial or annual visit is an example of a client encounter.

A visit for contraceptive supplies is another example of a client encounter.
“Family Planning” means the process by which individuals and couples exercise their ability 15. to make personal choices in the spacing and quantity of their children.

16.

“FDA” means the Food and Drug Administration.

The FDA is the federal agency that promotes and protects the public health by helping safe and effective products reach the market and by monitoring products for continued safety after they are in use.
The FDA reviews clinical research and takes action on the marketing of foods, human and veterinary drugs, devices intended for human use, and cosmetics.

“HPHC IGA” means Healthy People Healthy Communities Intergovernmental Agreement, 17. funding Arizona County Health Departments to provide family planning services.
“Informed and Written Consent” means that the client has provided written consent to 18. participate in receiving Family Planning services after having been properly educated about the medical facts and risks involved.

“Initial Visit” means a client’s first comprehensive visit.

It will normally include a physical 19. exam, a pap smear, if indicated, and issuing of a birth control method.

“Infertility Prevention Program (IPP)” is a program established by the CDC and the Office of 20.
Population Affairs to reduce the incidence of sexually transmitted diseases that can lead to infertility (primarily chlamydia and gonorrhea).

21.

“Logic Model” is a diagram that shows the relationship between the program components and activities and desired process and outcome objectives.
It is a visual way to present and share understanding of the relationships among the resources available to implement the proposed intervention, the strategies/activities planned for implementation, and the outputs and outcomes 10 | P a g e expected.

Logic Models should typically be one (1) to three (3) pages in length.
ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL “Low-Income/Low-Income Family” means an individual or family meeting the official 22. poverty guideline, as revised annually by Health and Human Services.

25.
25.

“Network” means a collection of service resources or information pathways that have been developed to assist clients in accessing appropriate information, education, medical, social, and financial services.

26.

“Nurse Practitioner” means a registered nurse with a graduate degree in advanced practice nursing.

She/he must be certified by the Arizona State Board of Nursing to function as a nurse practitioner in the extended role under the provisions of ARS Title 32, Chapter 15, Nursing.

See 27.
See 27.

“Outpatient Treatment Center” means a class of health care institution without inpatient beds which provides medical services for the diagnosis and treatment of persons on an outpatient basis.

ARS §36-421.01.

“Outreach” means any method used to provide information and education to the community 28. regarding Reproductive Health Family Planning Program, services, benefits, etc.
“Preconception Health” the physical, emotional, social well-being and economic stability of a 29. man or woman during their reproductive years, before conception.

30.

“Preconception Care” the provision of education and/or services to men or women related to the impact of their physical, emotional, social well-being and economic stability on their health status prior to conception.

“Primary Care Physician” means a main doctor who manages most of a patient’s medical 31. issues.
“Program” refers to the Title V Reproductive Health/Family Planning Program as outlined in 32. the Policy and Procedure manual.

33.

“Program Manager” means the Department employee who is responsible for the implementation and oversight of the Reproductive Health/Family Planning Program.

The Program Manager coordinates activities among Contractors and among Reproductive Health Team members, receives and reconciles invoices, handles budget issues, and provides technical support.
The Program Manager is responsible for negotiating contracts, requesting contract amendments to be processed by the Procurement Office, conducting site visits, and monitoring Contractor compliance with the provisions of the contract.

34.

“Recommended Services” are those services that are not required by contract or Program policy, but may be provided by the Contractor in order to promote the general reproductive-related health care needs of the client.
11 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL “Related Services” are those services which are not authorized or paid for by the Department 35. but may be provided by the Contractor in order to meet the general health care needs of the client.
“Reproductive Health/Family Planning Services” means the cost effective and preventative 36. care provided to participants designed to help promote responsible and healthy lifestyles.
Family planning services may include but are not limited to education, confidential counseling, comprehensive health history, physical exams, provision and maintenance of safe and effective contraceptive methods, health screenings and follow up for breast and cervical cancer, screening, testing, and treatment of sexually transmitted diseases, pre-pregnancy counseling, pregnancy testing and counseling, infertility screening, sterilization services for men and women, intimate partner violence and reproductive life planning screening and education, and referrals to other medical or social services.
Abortion is not a family planning service.

“Required Services” means those services which are stipulated either by law, in rules, by 37. contract, or by Program policy which are otherwise considered essential to the provision of high quality reproductive health services.

“SOW” means Scope of Work, which is the area in an agreement where the work to be 38. performed is described.
The SOW should contain any milestones, reports, deliverables, and end products that are expected to be provided by the performing party.

39.

“Shall” means mandatory program policy.

“Site Visit” means any visit to the Contractor’s or Sub-contractor’s business location by ADHS 40.

Reproductive Health/Family Planning Program staff or a designee, at least every two years.

41.

“Title V” means Title V of the Social Security Act.
At the national level the Maternal and Child Health Bureau administers Title V. The bureau is a segment of the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services.

Title V funds programs that promote the health of women, infants, and children.

Title V funding and services are administered in Arizona by the Arizona Department of Health Services, Bureau of Women’s and Children’s Health.

42.
42.

“Title X” means the National Family Planning Program created by the Public Health Service Act (P.L.910572).

Title X is administered by the Office of Population Affairs, the U.S. Department of Health and Human Services.

The regulations governing Title X are contained within the Code of Federal Regulations (CFR), (42 CFR, Subsection A, Part 59).

In Arizona, Title X funding and services are administered by the Arizona Family Health Partnership.

43.
43.

“TITLE XIX” means Title XIX of the Social Security Act.

Title XIX funds federal Medicaid programs.

Arizona’s version of the Medicaid program is the Arizona Health Care Cost Containment System (AHCCCS).

AHCCCS acts as the health insurer for low income Arizonans who qualify for various state and federal programs.
12 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL CHAPTER 3: PROGRAM MANAGEMENT AND ADMINISTRATION 3.1 Role of the Bureau of Women’s and Children’s Health The Bureau of Women’s and Children’s Health (BWCH) administers the federal Maternal Child Health Title V Block Grant.
Recognizing that reproductive health and family planning services are important components of maternal and child health care, BWCH contributes a portion of this block grant specifically to address reproductive health and family planning needs.

BWCH provides the criteria, policies, funding, and requirements for developing and implementing the Reproductive Health and Family Planning Program at the community level.

BWCH contracts with local public and private agencies.
Contractors may use a variety of strategies and/or service delivery systems to achieve program standards and desired outcomes.

Within the framework of the Reproductive Health and Family Planning Program is the flexibility for Contractors to implement clinical programs and provide reproductive health services in a manner that suits the needs of their community.

BWCH provides technical assistance to the Contractor, monitors contract compliance, and authorizes payment of contracted deliverable services.

A.
A.

B. C. BWCH provides two annual summits each year for Contractors, the Family Planning Nurse Summit and the Healthy People Healthy Communities Intergovernmental Agreement (HPHC IGA) Annual Fall Summit.

Each Annual Summit provides comprehensive training, education, and technical assistance support on reproductive health and family related topics.

Continuing education credits may be available.


3.2 Role of the Contractor in Program Management Contractors are required to achieve and maintain certain minimum standards.

Contractors must provide services of high quality and must be efficiently administered.

The Contractor must develop administrative, management, and organizational systems that meet all Reproductive Health/Family Planning Program requirements.
The Contractor must also have adequate staff and support services to implement the program at each clinic site.

The Contractor’s personnel shall meet all certification and licensure requirements.

At a minimum, the following personnel are required: A.

Administrator: The Contractor is required to have a qualified Program Administrator who is responsible and accountable for overall Program planning, implementation, and evaluation at each contracted site.
The Administrator’s allocation of time to this position must be sufficient to ensure that program objectives are met.

Clinical Staff: The clinical care component of the program must be under the supervision and responsibility of a designated physician or nurse practitioner who is licensed and board certified in the State of Arizona.

If a nurse practitioner is overseeing the Program, she or he must work collaboratively with a physician for consultation or B.
13 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL C. D. A.

B. C. D. referral on an as-needed basis.

Training or experience in reproductive health services is preferred.
Nursing Coordinator: The nursing care component of the Reproductive Health/Family Planning Program must be under the supervision and responsibility of a Nursing Coordinator who is a registered nurse licensed in the State of Arizona with special training or experience in reproductive health and family planning services.

The Nursing Coordinator must maintain compliance with the Arizona State Board of Nursing regulations.
The Nursing Coordinator must be committed to obtaining reproductive and family health training.

Please see the Family Planning National Training Center www.fpntc.org for more information.

Other Support Staff: Other support staff for the Contractor may include registered nurses, licensed practical nurses, nurse’s aides, health educators, nutrition counselors, family planning counselors, and other administrative personnel required to support business and clinical operations.
3.3 Contractor Oversight of Medical Management Component All medical functions for the Contractor’s Reproductive Health/Family Planning Program are performed under protocols, or standing orders approved by the designated physician or nurse practitioner.

The standing orders and protocols must be in compliance with state rules and laws.
Sub-contracts 3.4 The Contractor must not enter into any subcontract under this contract without the advance written approval of the Arizona Department of Health Services Procurement Officer.

In the event that family planning services are sub-contracted, the Contractor will remain responsible for ensuring that the subcontractor provides service in accordance with all specifications within the contract and the policy and procedure manual.
Contractors must have a written and signed agreement with the sub-contractor.

Contractor must monitor the sub-contractor’s performance annually and provide a written evaluation for the Bureau of Women’s and Children’s Health Program Manager to review during the Contractor’s annual site review.

3.5 Contractor’s Personnel Policy Standards Contractors must establish and maintain written personnel policies that comply with federal and state requirements and Title VI of the Civil Rights Act.
These policies shall include, but need not be limited to: staff recruitment and selection, performance evaluation, promotion, 14 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL termination, compensation, benefits, orientation to the agency and the Program, in-service training, and grievance procedures.

At a minimum, Contractors must require and ensure that: A.
Personnel records are kept confidential in a secured place.

An organizational chart and personnel policies are available to all personnel.

Job descriptions (specifying training, formal education, experience, and licensure) are available for all positions, and that these are reviewed annually and updated as necessary to reflect changes in duties.

A performance appraisal system is in place for all employees.
An evaluation and review of the job performance of all program personnel must be conducted annually, at a minimum.

B. C. D. E. It is the responsibility of all sub-recipients and Contractors to be aware of, and monitor their staff and volunteers to be in compliance with protection of minors receiving Family Planning services.

3.6 Staff Training and Orientation A.

B. C. 15 | P a g e Contractors must provide an orientation to all Program personnel and must include the following: 1.

2.
2.

Orientation on the agency, or clinical site where the employee is employed.

Orientation on reproductive and family health services, federal and state Program protocols, policies and procedures.

Note* This Family Planning Policy and Procedure Manual must be reviewed by ALL staff and readily available for staff if applicable.

Introductory call with the ADHS Family Planning Program Manager.

Overview of the HPHC IGA and how the family planning program fits within the IGA.

3.

4.
3.

4.

Contractors must provide for the in-service training of all Program personnel.

Contractors must also develop and implement plans for promoting and offering continuing education programs as needed.

Contractors are required to attend the HPHC IGA Annual Fall Summit and Family Planning Nurse Summit.
Furthermore, all program personnel must participate in continuing education related to their activities, including on-the-job training, workshops, institutes, and courses Documentation of attendance at in-service trainings and of having received orientation must be kept in the Program’s records or the staff’s personnel record.

Documentation of training and orientation will be used in evaluating the scope and effectiveness of the staff training program.
ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 3.7 Continuous Quality Improvement (CQI) Contractors must develop an ongoing, systematic process to monitor and evaluate the quality, efficiency, effectiveness, and appropriateness of client service and program operations.

Required CQI: 1.
Required CQI: 1.

Resolving Client Problems The Contractor and its subcontractors must develop and implement a process by which clients may present grievances about the operation and management of the program and services received.

When developing grievance policy and procedure the following must be included: a. b. c. d. e. Contractors must inform the client of the right to grieve and must assist the client with the grievance process.

Client grievances must be addressed in a timely manner.
Client problems and issues must be tracked to identify potential trends.

Contractors must incorporate findings and feedback into a plan to identify and correct future problems.

The Contractor must include in the grievance process, contact information for the Bureau of Women’s and Children’s Health Program Manager and cooperate in the resolution of any client problems brought to the attention of the BWCH.

2.

3.
2.

3.

Client Satisfaction Surveys Contractors must develop a client satisfaction survey to facilitate client input into clinic operations and services.

Survey results must be considered when identifying areas for improvement.

Medical Record Review Medical records should be reviewed periodically for accuracy, completeness, quality of care, and compliance with policy and contract obligations.
Examples include but should not be limited to: a. b. Counseling and education provided to the client Client receives and is assisted as needed with referrals for services that are not provided by the clinic Notification and follow up of abnormal lab results Follow up by staff of client self-reported risk factors Informed consent Medical record documentation is signed and dated Staff certifications and licenses are current Staff has been fingerprinted as required by law c. d. e. f. g. h. A.

B.
B.

Recommended CQI 1.

Monitoring Service Availability and Accessibility: a.

Determine the time interval between the request for an appointment and the date the appointment is scheduled.

Determine the time interval between the client’s scheduled appointment and the time the client sees the care provider.

Determine if there are any clients with unmet needs.
16 | P a g e b. c. ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 2.

3.

4.

2.

3.

4.

5.

6.

7.

Timeliness of Deliverables Contractors should monitor the performance reports, CERs, and the annual reports for accuracy and for timely submission to the ADHS FP Program Manager.
Monitoring Referral Networks Contractors should periodically evaluate the accessibility, availability, and quality of service provided by the outside agencies, providers, and organizations to which they are referring clients.

CQI projects can be initiated by the County Contractors or started by ADHS.

3.8 Internal Policy and Procedure for Reproductive Health/Family Planning A.

B.
B.

Contractors must maintain an internal policy and procedure manual to be used to provide staff with guidelines for client care and Program management.

When developing policy, procedure, and protocols the Contractor must consider the contract requirements as further detailed in this manual.

The internal manual should include but not limit policy to: 1.
Management and administrative functions as detailed in Chapter 3 of this manual All required services as detailed in Chapter 4 of this manual Any recommended services detailed in Chapter 4 that are adopted by the Contractor Monthly reporting Monthly billing Reporting physical, sexual, emotional abuse, and neglect to the protective agencies Procedure for management of on-site medical emergencies 3.9 Clinic Facility Standards A.
B. C. Clinic sites and client care facilities for the Reproductive Health/Family Planning Program shall be licensed by the ADHS as Outpatient Treatment Centers.

Facilities must meet applicable federal, state, and local government standards, i.e.

: fire codes, building codes, Occupational Safety and Health Administration (OSHA) requirements, Clinical Laboratory Improvement Amendments (CLIA) Licensure, etc.
Facilities must meet the accessibility standards as established by the American’s with Disabilities Act (ADA).

The current ADA recommendations can be found here: https://www.ada.gov/2010_regs.htm.

17 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 3.10 Availability and Accessibility of Clinic Services A.

B.
B.

Reproductive health and facilities and services must be geographically accessible to the population served and should be available at times that are convenient to persons seeking services.

family planning Facilities should be adequate to provide the required services and should be designed for the comfort and privacy for clients.

3.11 Program Eligibility C. Facilities must have a written plan and procedure for management of emergencies.

A.

Income Eligibility: 1.

2.

3.

4.

5.

6.

7.


Reproductive health and family planning services are to be provided to persons from low income households as the highest priority.

Low income for the purpose of this Program is defined as at or below 150% of the Federal Poverty Level (FPL).

The FPL is determined by the Office of Management and Budget and is revised annually.

Contractors must maintain and use current information regarding the FPL.
The current information for the FPL can be found here: https://aspe.hhs.gov/poverty-guidelines.

A client’s self-declaration of income may be considered sufficient to receive services.

Eligibility for minors seeking services shall be based on the financial resources of the minor.

Client income must be reevaluated annually.

Clients at or below 150% FPL shall receive services free of charge.
Voluntary donations from clients are permissible within the following guidelines: a. b. c. d. Clients who are above 150% of FPL can be provided services on a sliding fee scale within the following guidelines: a. b. c. Clients must not be pressured to make donations The amount of the donation cannot be specified Those not donating cannot be refused service Those not donating must not be subjected to any variation in services The scale must be adjusted to reflect income and family size The scale must be posted in a visible public place Clients who do not pay the sliding scale rate must not be subjected to any variation in quality of services B. C. 18 | P a g e Program services are to be provided to clients who are reproductive; i.e., not to clients who are post-menopausal, have had a hysterectomy, and/or who have been sterilized.
Program services are to be provided without the imposition of any duration residency requirement.
ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 3.12 Nondiscrimination Contractors must provide program services without regard to religion, race, color, national origin, creed, disability, gender, sexual orientation, and number of pregnancies, marital status, age, ability to pay, and contraceptive preference.

3.13 Voluntary Participation A.

B.


Use of program services by any individual must be solely on a voluntary basis.

Individuals must not be coerced to accept services or to use any particular method of family planning.

Acceptance of reproductive health services must not be a prerequisite to eligibility for or receipt of any other service or assistance from or participation in any other programs.
Program personnel should be informed that it is an illegal action to coerce or attempt to coerce any person to undergo a sterilization procedure or an abortion procedure, (Arizona Revised Statutes, Section 36-2153).

3.14 Confidentiality Every Contractor must assure client confidentiality and provide safeguards for individuals against the invasion of personal privacy as required by Arizona Revised Statute (ARS) and by Public Law 104-191, the Health Insurance Portability and Accountability Act (HIPAA).

A.
A.

All information obtained and records prepared in the course of providing service to clients shall be considered to be confidential information.

No information obtained by the provider’s staff about individuals receiving services may be disclosed without the client’s written consent, except as required by law.

The client’s statement of written consent must be included in the client’s medical record.
Information may otherwise be disclosed only in summary, statistical, or other form that does not identify the individual.

B.

Clients transferring care to other providers may be provided with a copy of their medical record to expedite continuity of care.

3.15 Client Medical Records A.

B. C. 19 | P a g e Contractors must establish a medical record for every client who obtains clinical services.

Clinic staff members are required to document all pertinent information about client interaction.
Entries in the medical record are to reflect professional, nonjudgmental statements of fact.

Records must be legible, dated, and are to be signed in ink with the initial and last name of the clinician providing the service.

Records must be complete, accurate, and follow standard practice for medical record documentation.

ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL D. 10.

E. F. G. H. I. J.
E. F. G. H. I. J.

Medical records must contain the following information: Personal identifying information about the client 1.
Medical history, physical examination, laboratory tests, results, and follow-up, 2. diagnosis, orders, allergies Treatment and instructions Informed and written consent Documentation of telephone contact of a clinical nature Documentation of attempts to contact client Refusal of service Documentation of counseling, referrals, and education; both written and verbal provided Financial information 3.

4.

5.

6.

7.

8.

9.


Procedures Clients must be informed that a medical record will be maintained and that this information is confidential information to be divulged only upon their written permission, or as otherwise required by law.

Clients shall have access to their own medical record at all times, and shall have the right to correct any inaccurate information included in the records.

Clients will have signed an informed consent statement prior to receiving reproductive health services.
The Contractor is responsible for maintaining the client's case file record in a confidential manner, and ensuring that information contained in the records is released only to authorized parties.

The BWCH Program Manager may have access to client records without client consent in order to conduct necessary evaluations or programmatic review.
The client's case file record is not available to other governmental agencies, except for the Auditor General, without specific prior written consent by the client for the release of information in the client record.

The Contractor shall store and maintain client records in a safe, secure location.

Except for non-identifiable demographic characteristics, records shall be destroyed six (6) years after the client's last participation in the Reproductive Health/Family Planning Program.
Minors’ records must be maintained until the age of majority plus three (3) years.
20 | P a g e To learn more about how to handle HIPAA Related client records, please review the Custom Records Retention Schedule Issued to: All State and Local Agencies Administrative and Management Records document, page 12, Record Series Number ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 10283 schedules_2019-12-16.pdf.
here: https://azlibrary.gov/sites/default/files/arm-all-general- For more information on Permanent and Historical records, please see here: https://azlibrary.gov/sites/default/files/arm_permanent_and_historical_records_20 19.pdf.

3.16 Informed Consent A.

B. C. A written, signed, informed consent statement must be received from the client prior to receiving family planning services or medical treatment.

This statement documents the client’s voluntary consent to receive program services.
The form must be written in the primary language of the client or witnessed by an interpreter the client knows and/or trusts.

The form must cover all procedures and medications to be provided.
To give informed consent for contraception, the client must receive education about the benefits, risks and limitations of the various contraceptive alternatives, and details on the safety, effectiveness, potential side effects, complications, discontinuation issues, and danger signs of the contraceptive methods of choice.

The consent statement shall include at least the following: 1.
A clear description of the services or procedures to be performed, including medical treatments and interventions, counseling, or other client contact The right of the client to terminate treatment or refuse services at any time Any responsibilities of the client Any other information that is necessary to convey to the client a clear understanding of the Program All consent forms must contain a statement that the client has been counseled, has read the appropriate informational material, and has understood the content of both.
The signed informed consent must be a part of the client’s record The form must be renewed and updated when there is a major change in the client’s health status or a change to a different prescriptive contraceptive method 2.

3.

4.

5.

6.

3.17 Program Promotion A.

B.

21 | P a g e Contractors must establish and implement planned activities whereby family planning services are made known to the community.
In planning for Program promotion, providers should review and utilize a range of strategies to gain community acceptance.

Program promotion activities should be updated periodically and be responsive to the needs of the community.
ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 3.18 Community Education Contractors must develop written material for distribution to clients, the community, and to other agencies and organizations.

When developing materials, the Contractor must follow the guidelines below: 1.
Materials must be medically accurate and culturally suitable for the population and community to which they are being distributed.

Program materials must be printed in a size and type style that is easy to read.

The materials must be language and literacy level appropriate.
All marketing, or education materials shall bear the following “Funded in part by the Bureau of Women’s and Children’s Health, Arizona Department of Health Services as made available through the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau, Title V Maternal and Child Health Services Block Grant Program.” All written materials should be reviewed periodically to be certain that the information remains timely, correct, inclusive, and medically accurate.
2.

3.

4.

5.

To enhance understanding of the objectives of the Program and to make known the availability of services to potential clients, Contractors must provide education to the community about the Reproductive Health/Family Planning Program services.

Community education should be directed toward identifying local agencies and organizations that are likely to serve significant numbers of individuals in need of family planning care.
Programs should offer in-service training sessions for the staff of these agencies and organizations in order to help them provide better counsel and to offer reference options to potential clients.

C. A.

B. C. Education directed toward the general community should employ a variety of approaches.

Education must be designed to meet the educational, cultural, and language needs of the community to be served.

3.19 Establishing Referral and Communication Networks A.
B. C. 22 | P a g e Contractors must develop a comprehensive listing of available local resources to assist clients with obtaining services not provided by the Reproductive Health/Family Planning Program.

The resource information should be reviewed and updated periodically to ensure continued availability, accessibility, and quality of the services recommended to clients.
In circumstances where resources or necessary services do not exist within the local community, Contractors will provide the client with information to obtain access to equivalent services in another community.

ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL The Contractor must network with those agencies and organizations most frequently used as referrals for clients.
An established informal network helps to ensure acceptance of the client for services and can provide a smoother transition for the client.

Networking also helps to ensure that the client did receive the services as referred or recommended.

The Contractor is encouraged to develop a community based Reproductive Health and Family Planning Advisory Committee to aid in the identification of communities’ reproductive health needs and resources, and to help develop strategies to meet the needs.
D. E. F. The Contractor shall make uninsured clients aware of the possibility of coverage through the Arizona Health Care Cost Containment System (AHCCCS) and shall provide referrals to AHCCCS as appropriate.

3.20 Developing Partnerships and Establishing Collaborative Efforts A.

To avoid duplication of effort and to maximize resources, Contractors must develop partnerships, or collaborate with existing agencies providing family planning services in their local communities.
Contractors will be familiar with the AHCCCS eligibility criteria and refer clients who B. meet those criteria to an AHCCCS provider to receive services.

If the Contractor identifies that a number of individuals seeking services at their clinic are eligible for AHCCCS, the Contractor will consider becoming an AHCCCS provider to maximize the state resources to serve all populations in need of services.
23 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL CHAPTER 4: PROGRAM SERVICES 4.1 Required Services A.

B. C. Contractors must provide clinical, informational, educational, social, and referral services to Program clients who want such services.
Contractors must offer a broad range of acceptable and effective medically approved family planning methods and services either on site or by referral.

Programs should make all methods of contraception approved by the Federal Food and Drug Administration (FDA) available to all clients.

Contractors must provide the following services as part of initial and annual exams, and at other times as deemed medically appropriate: 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.


Client Education/Counseling Physical Assessment Laboratory Testing, as medically indicated Fertility Regulation Infertility Services Referral Pregnancy Diagnosis and Counseling Adolescent Services Sexually Transmitted Infection Screening/Assessment, as medically indicated Referral and Follow-up Preconception Health and Reproductive Life Planning Screening for intimate partner violence (IPV) and reproductive coercion Education on 4.2 History A.

B.
B.

A comprehensive personal, medical, and social history must be obtained on all clients at the initial medical visit and must be updated at subsequent visits.

The medical history must address but not be limited to the following areas: 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.


Allergies Immunizations, including rubella and TDAP Current use of prescription and over-the-counter medications Chronic and acute medical conditions Significant hospitalization Surgeries Review of systems Extent of use of tobacco, alcohol and other drugs Genetic conditions or disorders that affect the client or her family Pertinent medical history of immediate family members 24 | P a g e 11.
Partner history, including: Injectable drug use a. ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL b. c. d. Multiple partners Risk history for STI’s and HIV Bisexuality C. History of reproductive function must include but not be limited to the following: 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.


Menstrual history Sexual history Obstetrical history Gynecological conditions Sexually transmitted infections (Chlamydia, Gonorrhea, and Syphilis) HIV Pap smear history (date of last pap, any abnormal pap, treatment) Contraceptive use, past and present, and any adverse reactions Pregnancies Genetic risk assessment 4.3 Client Education/Counseling A.

Contractors must provide clients with education needed to make informed decisions about family planning choices.
Contractors must provide this information both orally and in writing.

Furthermore, client education must be appropriate to the client’s age, level of knowledge, language, and culture.

Any instruction and other client education offered or provided must be documented in the client’s medical record.

Contractors must also provide education to assist clients in reaching informed decisions regarding the choice and continued use of contraceptive methods.
Education is designed to help clients resolve uncertainty, ambivalence, and anxiety in relation to their reproductive health.

Education should be provided in a private environment in which the client feels comfortable and in a manner that protects the dignity of the individual.

Documentation of all education provided, must be included in the client’s medical record.

B. C. 25 | P a g e Client education must include but not be limited to the information needed to: 1.

2.

3.

4.

5.

6.

7.


Make informed decisions about care Choose specific methods of contraception Perform breast self-exam Reduce the risk of infection or transmission of STIs and HIV Understand intimate partner violence and reproductive coercion Understand the procedures involved in the clinic visit Understand the services offered at the clinic Clients must also be offered the following information/education, as appropriate: 1.

2.

3.
2.

3.

Achieving optimal preconception/inter-conception health Basic female and male reproductive anatomy Benefits of Folic Acid ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 4.

5.

6.

7.

8.

9.

10.

11.

12.


Fertility regulation referral Developing an individualized reproductive life plan Health promotion/disease prevention MMR & TDAP information and/or referrals Exercise Nutrition Smoking cessation Alcohol and drug abuse Sexual abuse D. E. F. G. H. 26 | P a g e Persons who provide education must be knowledgeable, objective, non-judgmental, culturally aware, and sensitive to the rights and differences of clients as individuals.
The counselor’s knowledge must be sufficient to provide information regarding the risks, benefits, limitations, contraindications, and effective use of any method, procedure, treatment, or option being considered by the client.

Pre-examination counseling must be provided to clients to explain the Program, clinical procedures, eligibility requirements, and to allow the client the opportunity to ask questions, express concerns, etc.

3.
3.

Post-examination counseling should be provided to assure that the client: Knows results of the physical examination and laboratory studies 1.
Knows how to use and is comfortable with the contraceptive method selected 2. and prescribed Knows the common side effects and possible complications of the method selected and what to do if complications occur Knows how to discontinue the contraceptive method and has information regarding a backup method Receives appropriate referrals for additional services as needed Knows an emergency 24-hour number and a location where emergency services can be obtained Knows when to schedule a return visit 5.

6.

4.
6.

4.

7.

Sexually Transmitted Disease and HIV Counseling: 1.

Contractors must provide clients with thorough and medically accurate counseling on STI’s, HIV infection, and AIDS.

Contractors must also offer information on risk and infection prevention, and referral services.

Other Counseling: 1.

Clients should receive special counseling regarding future planned pregnancies, assistance with current pregnancy, and other individual concerns as indicated i.e.
substance use and abuse, sexual abuse, sexual concerns, domestic violence, nutrition, etc.

Preconception counseling and a reproductive life plan must also be provided.

ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 3.

4.4 Physical Assessment 2.

Referral systems should be in place for those who require genetic counseling and evaluation.
Contractors should counsel clients about health promotion and disease prevention and make referrals as appropriate.

Clients must have a general physical examination at each initial and annual medical visit.

The physical examination must include but not be limited to the following: 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.


Height Weight Blood pressure Thyroid Heart Lungs Extremities Breast Abdomen Pap smear as medically indicated A client’s refusal or deferral of a service, including the reason for refusal and/or deferral must be documented in the client’s medical record.

Clients who decline or defer a service must be counseled regarding any possible health risks associated with declining and/or deferring the screening test or procedure.
Counseling regarding any associated risk must be documented in the client’s medical record.

Physical examinations and laboratory testing should not be deferred beyond 3 months after the client’s visit unless in the clinician’s judgment there is a compelling reason to extend the deferral.

All deferrals and the reason for the deferral must be documented in the client’s medical record.

A.
A.

B. C. D. E. Revisit schedules must be individualized, based upon the client’s need for education, counseling, and medical care.

Younger clients and clients initiating a new contraceptive method may need to be scheduled for a revisit to reinforce proper use, check for side effects, and to provide additional information or clarification.

4.5 Laboratory Testing A.

The following laboratory procedures must be provided as medically indicated for all clients at the initial and annual visit: 1.

2.
Hemoglobin (Hgb) or Hematocrit (Hct), as indicated Pap smear/Guidelines: 27 | P a g e First Age 21, regardless of the age or onset of sexual activity ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL Pap Smear Until Age 30 Should be avoided before age 21 Screen every 3 years instead of annually, using either the standard pap or liquid-based cytology Ages 30 – 65 Contractors are required to follow the American College of Obstetricians and Gynecologists (ACOG) Clinical Guidance, found here:https://www.acog.org/Clinical-Guidance-and- Publications/Search-Clinical-Guidance?IsMobileSet=false Note: Contractors are required to follow the ACOG Clinical Guidelines for women who have a history of cervical cancer, are infected with HIV, have a weakened immune system, or who were exposed to diethylstilbestrol (DES) before birth.
3.

4.

5.

6.

7.

8.

9.

Pregnancy testing Wet mounts, as indicated Urine Dip Stick/ Urinalysis Syphilis serology, as indicated Gonorrhea and Chlamydia tests HIV testing, as medically indicated or upon client request Other procedures and laboratory testing may be indicated for some clients and may be provided on-site or by referral Laboratory procedures or services that cannot be performed on site must be made available through a referral when indicated.
Contractors must assure that laboratory tests performed by or for the clinic are of high quality.

The Contractor must assess the credentials of the laboratories with which it contracts.

Laboratories must be CLIA certified.

If laboratory testing is performed on-site, written protocols for quality control and proficiency testing are necessary.

The Contractor must establish a procedure for timely client notification and adequate follow up of all abnormal laboratory results.

1.

2.
1.

2.

The procedure must respect the client’s request to maintain confidentiality When initial contact of the client is not successful, a reasonable further effort must be made to notify the client, this shall consist of at least three attempts, the means having been discussed during the visit.

A client who has had a negative Pap smear done at another facility within 6 months of the visit and has written test results, may have these procedures waived during the initial/annual visit.
B. C. D. E. 28 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 4.6 F. Fertility Regulation Referral Annual history updates, exams, and laboratory tests are required for all clients.

A.

Contractors must make available through referral, all of the FDA approved methods of reversible contraception.

1.
1.

Non-hormonal Methods Hormonal Methods Long-Term Contraception Emergency Contraception Reversible Contraception: a. b. c. d. Permanent Contraception Referral: a.

2.

Clients who request information regarding sterilization procedures must be counseled with regard to the permanence, risks, and benefits of this procedure.

Contractors should be aware of federal sterilization regulations, (42 CFR Part 50, Subpart B).
More information can be found here: https://www.hhs.gov/opa/sites/default/files/42-cfr-50-c_0.pdf.

b.

B. Infertility Services Referral More than one method of contraception can be used simultaneously by a client and may be indicated to minimize risk of STI, HIV, and pregnancy.

4.7 A.

Providers are required to make basic (level 1) infertility services available to clients who request such service.
Level I service includes initial infertility interview, education, physical examination, appropriate laboratory testing, counseling, and appropriate referral.

4.8 Pregnancy Screening, Counseling, and Referrals A.

B. C. 29 | P a g e Programs must provide pregnancy diagnosis and counseling to all clients in need or requesting this service.

Pregnancy testing is one of the most frequent reasons for the initial visit to the family planning facility, particularly by adolescents.
It is therefore important to use this occasion as an entry point for providing education and counseling about family planning.

Pregnancy screening consists of: Pregnancy History 1.

Pregnancy test 2.

Referrals to supportive programs 3.

Programs providing pregnancy testing on-site should have available at least one test of high specificity.
For those clients with positive pregnancy tests results who elect to ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL continue the pregnancy, the examination may be deferred, but should be performed within 30 days.

D. For clients with a negative pregnancy diagnosis and abnormal menstrual history, the cause of the abnormal menstruation should be investigated.
Pregnant women planning to carry their pregnancy to term must be offered information and education regarding their pregnancy.

Clients must be given information about good health practices during early pregnancy, especially those practices that serve to protect the fetus during the first three months, and referral for prenatal care.
Women requesting information on options for the management of an unintended pregnancy must be given non-directive counseling on alternative courses of action and referral upon request.

E. F. H. Clients who are found to be not pregnant must be offered information about the availability of contraceptive, or infertility services, depending on the client’s wishes.

Anticipatory guidance regarding good health practices prior to pregnancy, including avoidance of teratogens should also be provided.
4.9 Adolescent Services A.

B. C. D. 30 | P a g e Contractors must offer age appropriate information and skilled services to adolescents.

Contractors must take steps to assure the adolescent that all information learned during any encounter is confidential information and that every effort will be made to ensure privacy in any encounter or any necessary follow-up contact.

(See G. below regarding Duty to Report) Adolescent clients require skilled counseling and detailed information.
Program staff should have a comprehensive understanding of the following: a. b. c. d. e. Adolescent growth and development Psychosocial growth and development Nutritional needs Risk and resiliency factors Communication skills When providing services to adolescents Contractors must: a. b. c. d. Inform the adolescent about all methods of contraception Make every attempt to schedule appointments for them on short notice Encourage the young person to participate in the full range of medical services Evaluate the adolescents understanding about the contraceptive method selected ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL E. F. G. e. f. Inquire about symptoms and exposure to STI’s Encourage examination and treatment either directly or by referral to those at risk for STI’s It should not be assumed that all adolescents are sexually active.
Many teenagers are seeking assistance in reaching this decision.

Abstinence as an option should be discussed.

Contractors do not need the consent of parent or guardian for provision of service to minors.

Therefore, Contractors must not notify the parent or guardian before or after an adolescent has requested and/or received service.

Staff should encourage young clients to involve a parent or guardian in their family planning decisions.
Discussion of encouraging family involvement should be documented in the client’s medical record.

Contractors must be knowledgeable regarding Department of Child Safety (DCS) reporting laws e.g.

ARS § 13-3620, “Duty to report abuse, physical injury, neglect and denial or deprivation of medical or surgical care or nourishment of minors…” Contractors are advised to consult with their legal counsel regarding any clarification they may need regarding this and other related statutes.
Adolescents seeking services who the staff member believes may meet DCS reporting requirements must be advised prior to any service provision that they will not be refused service but due to their particular circumstance, a report to DCS will need to be filed.

4.10 Sexually Transmitted Infection Screening Fees for minors seeking services must be based on the income of the minor.

G. A.

B. C. D. E. 31 | P a g e Contractors must have a process for identification of high-risk behavior for STIs and HIV/AIDS.
Appropriate education and preventive measures must be provided to discourage continuation of risk behaviors and to help prevent the client from contracting or spreading an infection.

The Contractor must offer Gonorrhea, Syphilis, Chlamydia, and HIV screening for clients and their partners with probable or definite exposure, signs, and symptoms suggesting an infection.

The client may also request screening.


The Contractor must offer at risk clients either treatment or referral for treatment for clients and partners testing positive for an STI and/or HIV.

Contractors must establish a procedure for timely client notification and adequate follow up of all positive results: a.

The procedure must respect the client’s request to maintain confidentiality.

F. A.
F. A.

B. C. D. E. ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL b.

When initial contact of the client is not successful, a reasonable further effort must be made to notify the client; this shall consist of at least three attempts, one of which is a certified letter.
The Contractor must comply with Arizona Administrative Code, Article 2, R9-6-202, Communicable Disease and Infestation Reporting, and any other local reporting requirements.

4.11 Referral and Follow-up Contractors must assure that clients requiring services indicated to be medically necessary but beyond the scope of the Contractor, are referred to other providers for care.
Contractors must establish and maintain a comprehensive and current list of available quality health care providers and community resources.

The Contractor must assure that: 1.
The client is able to follow through with contacting the referred provider; if the client is unable to follow through independently, the Contractor must offer assistance or find support for the client Arrangements are made for the provision of pertinent information regarding client care and services to the referral provider with the prior written consent of the client The client’s confidentiality and privacy are always maintained The client is advised of the importance of complying with the referral The client is advised of their responsibility in complying with the referral 2.
3.

4.

5.

The Contractor must, whenever possible, give clients a choice of providers from whom to select.

The Contractor must have a procedure to prioritize referrals and follow-up.

For example: 1.
Referrals considered by the clinician to be emergencies should be made immediately Referrals considered by the clinician to be urgent should be followed up with the client within two weeks Referrals considered by the clinician to be important and necessary but not urgent, may be followed up at the discretion of the provider but prior to the next clinic visit Referral requests made by the client and not considered to be urgent or of immediate need may be followed up with the client at the next clinic visit 2.
3.

4.

4.12 Recommended Services 32 | P a g e A.

Minor Gynecologic Problems: ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL B. C. D. Contractors may provide for the diagnosis and treatment of minor gynecologic problems so as to avoid fragmentation of services or lack of medical care for clients with these conditions.
Problems such as vaginitis or urinary tract infection may be amenable to on-the-spot diagnosis and treatment.

More complex procedures may be offered providing the clinician has had the necessary training and has demonstrated proficiency.

Genetic Screening and Referral: Contractors may provide basic counseling to clients who are at risk for transmission of genetic abnormalities.

More complete genetic screening and counseling may be offered by referral to a comprehensive genetic service program.
If feasible, training in genetics should be arranged to enable Program staff to provide simple genetic screening.

Health Promotion and Disease Prevention: For many clients the family planning program services are their only continuing source of health information and medical care.

The Contractor may whenever possible, provide health maintenance services such as screening, immunization, and general health education and counseling directed toward health promotion and disease prevention.
These additional services enhance the client’s general state of health, and in turn, the health of their families and children.

Programs are therefore encouraged to assess the health problems prevalent among the populations they serve, and to develop services or referral mechanisms to address them.
Preconception Education and Reproductive Life Planning: Couples and prospective mothers may receive preconception education from the Contractor to obtain an overview of the responsibilities of pregnancy and parenting.

Preconception health helps women think about how their behaviors, lifestyles, and medical conditions affect their ability to live healthy lives and to have healthy children.
It gives women the opportunity to be assessed for risks, to be counseled about healthy living and to be offered treatment if needed.

The education may include but not be limited to: 1.

2.

3.

4.

5.

6.

7.


Fertility awareness/menstrual cycle A review of family genetic history Immunizations (MMR & TDAP) Spacing of children Nutritional needs, including folic acid supplements Effects of medications on maternal health and pregnancy Current contraceptive method, when to stop using it, and the waiting to conceive timeframe Substance use and abuse 8.
E. 33 | P a g e Intimate Partner Violence and Reproductive Coercion: Definitions: ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL a. b.

Birth Control Sabotage: Active interference with contraceptive methods (flushing pills, poking holes in condoms, refusing to wear condoms).
Pregnancy Coercion: Threats or acts of violence if the partner does not comply with the perpetrator’s wishes to continue or terminate a pregnancy.

Intimate partner violence and coercion have long been linked to negative health outcomes.

In 2011, the National Academy of Medicine formerly named the Institute of Medicine, recommended screening patients for current and past domestic and sexual violence as part of basic preventative care.
The Bureau of Women’s and Children’s Health (BWCH) recognizes the negative impact of domestic and sexual abuse on reproductive health, and funded a program to assist communities in addressing it through Futures Without Violence (formerly the Family Violence Prevention Fund): https://www.futureswithoutviolence.org/.

Future Without Violence, along with ACOG created a comprehensive document with guidelines on how to handle intimate partner violence.
In a nationally competitive application process, Arizona was selected to receive funding to implement a statewide public health initiative.

Since the spring of 2010, Project Connect Arizona has trained over 300 health care providers on the links between abuse and reproductive health and has worked diligently to make positive changes in policies and procedures related to screening and response to abuse.
Please see more on Project Connect Arizona here: https://vsuw.org/what-we- do/fight-for-families/project-connect.

Health care providers are in a unique position to assist victims of domestic and sexual violence by providing validation, education, and resources.

This simple process can be easily integrated into reproductive health appointments.

Domestic violence and reproductive coercion screening should include, at a minimum, three questions from the following sample screening questions: 1.
Has your partner ever messed with your birth control or tried to get you pregnant when you didn’t want to be?

Does your partner refuse to use condoms when you ask?

Has he/she ever tried to force or pressure you to become pregnant when you didn’t want to be?

Are you afraid your partner will hurt you if you tell him/her you have an STI and he/she needs to be treated?

Do you feel controlled or isolated by your partner?

Do you feel safe in your current relationship?

2.

3.

4.

5.

6.
2.

3.

4.

5.

6.

4.13 Excluded Services Programs funded by Title V may not provide abortion services to clients as a method of family planning.
34 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL CHAPTER 5: MONTHLY, QUARTERLY AND ANNUAL REPORTS 5.1 Monthly Reports The contractor must submit a monthly Family Planning Database Report in a format approved by the Bureau of Women’s and Children’s Health (BWCH).

5.2 Monthly Report Requirements A.


B. C. Contractors must have procedures in place to review the completeness, accuracy, integrity, and timely submission of the information required on the Monthly Family Planning Database Report.

Under the HPHC IGA, the Family Planning Contractor’s Expenditure Reports (CERs) are due quarterly to the ADHS Family Planning Program manager.
Beginning in March 2020, along with submitting the quarterly reports and CERS, Contractors are to also submit the following supporting documents: Certificates of Completion for training and conferences, and conference registration receipts.
The ADHS Family Planning Program Manager will access the Family Planning database to verify the services provided are reflective of the narrative in the quarterly reports and document in the ADHS Program Procedure Tool 5.3 Monthly Performance Report Instructions The Monthly Performance Report form is to be used to document encounters occurring during the calendar month.

Documentation will be based on each individual client versus aggregate data.
Here is what the Client and Visit key looks like: 35 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL This document is provided to each Contractor, along with an Excel database document for the data to be listed.

A.

Contractor will populate the 3 fields in the header with: 1.

2.

3.
2.

3.

Name of contractor Month reporting Date submitted to ADHS Family Planning Program Manager B. C. D. E. F. 36 | P a g e Complete the form as follows for each qualifying Title V funded client: Client ID number.

(Column 1) This is an identification number assigned by the Contractor.

No two clients may have the same client identification number.

Client ID numbers must not exceed nine characters.

Date of visit.

(Column 2) Must be recorded as mm/dd/yyyy.

Date of birth.
Date of birth.

(Column 3) Must be recorded as mm/dd/yyyy.

Age.

(Column 4) This column will self-populate with correct date of visit and date of birth.

# Type of visit.

(Columns 5-7) Visit type 3 Medical captures all visits excluding initial follow-up, complaints, re-pap and/or follow ups, etc.

Initial and annual visits will be unduplicated.

ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL Gender.
(Column 8) Determined by observation or medical records.

Race.

(Columns 9-13) Based on Federal requirements; race is different than ethnicity.

Ethnicity.

(Columns 14-15) Ethnicity should be provided through client self- declaration not through observation.

Income.

(Columns 16-24) Record client’s income, following the Federal Poverty Guidelines; update the income as necessary.

Family size and monthly income are used to determine eligibility requirements for the Federal Poverty Level (FPL).
The FPL is determined by the Federal Office of Management and Budget (OMB) and is revised annually.

Contractors must stay current with OMB information regarding the FPL.

The FPL was discussed earlier in this manual and the OMG website was provided.

When determining the client’s income, the Contractor must: a.

Determine the family size, which is the number of people in the client’s household, including spouse, and any other dependents.
If the client is less than 18 years of age, do not include parents or siblings.
Include only the teen and any children the teen reports If the client is single use the total gross monthly household income (before taxes) If the client is married, use the amount of gross income (before taxes), including any spousal income If the client is a teen, include only the teen’s income, not the parent’s income If income varies, or is seasonal, use an average of the annual income, i.e., annual income divided by 12 months b. c. d. e. Services Provided.
(Columns 25-33) Select all tests performed and record all positive results.

Emergency Contraception.

(Column 34) G. H. I. J. K. L. M. Pre Visit Contraceptive Method: (Columns 35-36) The method a client is using the majority of time prior to the visit.

Post Visit Contraceptive Method: The method the client intends to use after the visit.

Record both methods when possible using the contraceptive method coding numbers 1 – 26.
5.4 Quarterly Expenditure Report Per the HPHC IGA, the Contractor shall submit a Quarterly Expenditure Report in a format approved by the Bureau of Women’s and Children’s Health (BWCH).

37 | P a g e A.

B.

A.


B. ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 5.5 Quarterly Expenditure Report Requirements The Quarterly Expenditure Report shall accurately reflect the Contractor’s expenditures for each quarter (every three months).

For the HPHC IGA, the quarters are: July-September, October-December, January-March, and April-June.
5.6 Contractor’s Quarterly Expenditure Report Instructions The Quarterly Expenditure Report must be submitted to the Program Manager by the 30th of October, January, April, and July.

The Quarterly Expenditure Report form is to be used to document expenditures for Title V Reproductive Health/Family Planning funds only.

Complete the form as follows: 1.

2.

3.

4.


Contract Number: Write in your contract number Contractor’s Name: Write in your agency name Title of Program: Healthy People Healthy Communities IGA Reporting Period Covered: Quarterly Expenditure Reports are submitted after each quarter (every three months) of the year and are to report expenditures occurring during that period.

For example, a report submitted for the quarter of January 2010 thru March 2010 would read, Reporting Period From 1/1/10 to 3/31/10.
Contractor’s Detailed Statement of Expenditures: a.

5. b. c. d. Budget: Next to each line item, e.g.

Personnel Salaries, Professional and Outside, Travel Expenses, etc.
write the dollar amount that was budgeted or planned for in the quarter Prior Report Period Year to Date Expenditures: This amount is taken from the Total Year to Date Expenditures from the Contractor’s Quarterly Expenditure Report from the previous quarter Current Reporting Period Expenditures: Write the actual expenditures for each line item for the quarter Total Year to Date Expenditures: Add the dollar amount in the Prior Report Period Year to Date Expenditures and the amount in the Current Reporting Period Expenditures.
This amount is equal to the Total Year to Date Expenditures Signature of Authorized Person: The authorized person that completed or reviewed the report must sign and date the report 5.7 BWCH Program Manager’s Role in Quarterly Expenditure Report Review 6.

A.

The Program Manager in BWCH will review all Quarterly Expenditure Reports when received and will compare expenditures budgeted for the quarter, actual expenditures, and contracted amounts.
38 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL B.

The Contractor will be contacted to discuss any discrepancies found or for any expenditure concerns.

C. 5.8 Annual Report If there are expenditure concerns, the Program Manager in BWCH and the Contractor will agree to a resolution.
The Contractor shall prepare an annual report that will summarize program activities 5.9 Annual Report Requirements .

A.

The Annual Report must be submitted within 45 days of the end of the contract year.. A blank Annual Report template is provided to all County Contractors that are B. participating in the HPHC IGA.
39 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL CHAPTER 6: BILLING 6.1 Contractor Reimbursement and Contractor’s Expenditure Report (CER) Contractor reimbursement provisions and methods are specified in the Contractor's written contract agreement with the Arizona Department of Health Services.
Reimbursement for services and any other program expenditures are made in accordance with these contract specifications, and upon approval of BWCH Program Manager.

The CER is a multi-purpose form for use by agencies that have a Negotiated Service Contract with the Arizona Department of Health Services.

The CER must be completed, signed by an authorized person, and e-mailed to the Program Manager.
It is the responsibility of the Chief Executive Officer/Health Officer/Authorized Signer of the reporting agency to insure valid representation of the agency’s expenditures or units reported on Fixed Rate Contracts.

Once satisfied, this person must sign and date the report.
Submission Requirements Per the contractual language within the HPHC IGA, the contractor must submit a complete and accurate (CER) and narrative report (including all programs within the HPHC IGA), quarterly to the HPHC IGA Program Manager for payment for contracted services provided.

For Family Planning specifically, the Contractor must submit the Family Planning Database of each month.
The CERs Report for the ADHS Family Planning Program Manager by the 15 will be submitted with the other programs within the HPHC IGA quarterly.

If there is an unavoidable delay in submission of any part of the report, the Contractor must notify the ADHS Family Planning Program Manager in a timely fashion.
Submission Location th Contractors are to submit the quarterly CER, supporting documentation, and the monthly Family Planning Database Reports to: Physical Mail 6.2 6.3 : Attention: Family Planning Program Manager Arizona Department of Health Services Bureau of Women’s and Children’s Health 150 N. 18th Avenue, Suite 320 Phoenix, Arizona 85007-3242 Office Number: 602-542-8953 Preferably E-mail:desiree.fields@azdhs.gov 6.4 BWCH Program Manager’s Role in CER Approval A.
The BWCH Program Manager will review the CER and supporting documents for errors, or omissions B.

The Contractor will be contacted to discuss any discrepancies found.

40 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL C. CER’s not meeting specification may either be amended by the Contractor or by the BWCH Program Manager.
If the CER is amended by the BWCH Program Manager, a copy of the amended document will be sent to the Contractor for their records.

D. Partial or no payment of CER’s submitted may be authorized by the Program Manager when: 1.

2.

3.

Deliverables are billed but not submitted Insufficient funds exist to fully reimburse the Contractor for services provided Reports and FP databases are blank or if they are not properly filled out (i.e.

missing information, data, etc.)


E. Supporting Documentation Once the BWCH Program Manager approves the CER, it will be forwarded for payment.

6.5 The Contractor must maintain adequate supporting documentation to verify that units of service billed match units of service provided, and to verify that services were provided to eligible clients.
41 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL CHAPTER 7: PROGRAM MONITORING AND EVALUATION 7.1 Annual Review All Contractors shall have at least one compliance-based site visit at least every two years.

This site visit is also referred to as the site review.
7.2 Multiple Sites To the extent practical, annual reviews will include a visit to all Contractor site locations, if the Contractor is providing services at multiple sites.

7.3 Consultative Site Visit In addition to the site review, additional consultative site visits will be conducted if Contractor performance or other circumstances deem it necessary.
7.4 Purpose of the Site Review: A. Compliance-based site visits are provided to ensure that services were delivered pursuant to the terms and conditions of the contract and in accordance with the Reproductive Health/Family Planning Program Policy and Procedure Manual.

B.

Other purposes for annual review include but are not limited to: Evaluation of State and Community Resource Utilization 1.

Investigation of areas in question 2.

Identification of strengths and accomplishments 3.


Identification of weaknesses or areas of needed focus 4.

Providing consultation and technical assistance 5.

Facilitation of communication between the Contractor and BWCH 6.

Follow-up on previous site visit findings 7.

7.5 Review Guidelines The review, which will take place at least every two years, will be conducted in accordance with the following guidelines: Contractor Notification: A.

1.
1.

The ADHS Family Planning Program Manager will notify the Contractor of the scheduling of annual review site visits.

The ADHS Family Planning Program Manager will send an email to the Contractor which will: Confirm the date and the time of the visit a.

Review the purpose of the visit b.


Identify the reviewer c. Discuss activities to expect as part of the review process d. e. Provide the Contractor with a copy of the site review monitoring tool(s) The visit with the Contractor will be scheduled a minimum of 30 days in advance of the review.

The reviewer will work with the Contractor as much as 2.

3.
3.

42 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL possible to assist in minimizing interruptions to the staff's normal workload during the course of the review.

B.

Review Process 1.
Contractors and Sub-contractors must cooperate fully with the reviewer during the review process by making records and information available, allowing interviews, and providing a tour of the facilities The reviewer will hold an entrance interview to obtain a current overview of clinic operations, clarify the review process, meet staff, answer any questions, and discuss completion of corrective action from any past review Examples of activities included in site visits may include, but are not limited to: a.
Any materials to be distributed to clients Medical records Management reports Job descriptions, personnel files, etc.

Review of Contractor Documentation i. ii.

iii.

iv.

Meeting with or interviewing program personnel to discuss program successes and potential problems Work unit observation c. Exit Conference: The reviewer will provide feedback to the Contractor regarding preliminary findings, the Contractors will have the opportunity to clarify and provide any input they deem necessary b.

2.

3.

4.
2.

3.

4.

7.6 Annual Review Draft Report A.

B.

The Program Manager will write findings in a draft report and e-mail the draft with a cover letter to the Contractor for review and comment.

The cover letter will include instructions for review of the draft report.

The Contractor must respond to the draft report within fourteen (14) days of receipt.

7.7 Annual Review Final Report and Corrective Action The ADHS Family Planning Program Manager will be available to provide technical assistance as needed.
A.

B.

43 | P a g e Within (5) five days of receipt and review of the Contractor’s comments, the Program Manager will prepare a final report.

The final report will identify areas of strength and a request for a written plan of corrective action, if required.

The final report will be sent with a cover letter that will include instructions for completion of the written plan of correction.
The Contractor will prepare the plan of corrective action addressing each finding included in the current year’s annual review.

This plan must be returned within 14 days of receipt of the final report.
ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL C. Once the written plan of corrective action has been reviewed and approved by the Program Manager, it will be included as part of the final report 7.8 D. Failure to Comply The final report will be maintained in the Program files for future review.
Concerns of compliance failure or major contract performance issues will be reported to the Procurement Administrator.

The Procurement Administrator will notify the Contractor within (7) seven days of receipt of the concern regarding further recourse.
44 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL CHAPTER 8: APPENDICES AND OPTIONAL DOCUMENTS 45 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 46 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL 47 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL ARIZONA DEPARTMENT OF HEALTH SERVICES - FAMILY PLANNING PROGRAM CLIENT REGISTRATION FORM - ALL INFORMATION IS CONFIDENTIAL Date of Visit:_____/______/_______Social Security Number______/____ /_______Clinic Site: _____________________ Personal Data: Please provide the following information.
Last Name:_______________________ First_________________________ Middle Initial___________ Birth Date: ____/____/_____ Sex: (___) Female (F) (___) Male (M) Marital Status: (___) Never Married (N) (___) Married (M) (___) Divorced (D) (___) Living Together (L) (___) Separated (S) (___) Widowed (W) Race: (___) Asian (A) (___) Black (B) (___) White (W) (___) Other (O) (___) Native American (I) Tribe:__________________ Are you of Hispanic origin such as Mexican American, Latin American, Puerto Rican or Cuban?
(___) Yes (H) (___) No Primary Language: (___) English (01) (___) Spanish (02) (___) Other_____ Years of Education Completed: ___________ Maiden Name: ___________________ Mother’s Maiden Name: ____________________ Residential Address:_______________________________________________________________APT#_________CITY_______________________ZIP___ ____ Mailing Address:________________________________________________________________APT#_________CITY______________________ZIP___ ____ Home #:(_______)______________________ Work #:(_______)________________________Cell Phone #:(_______)______________________ Check all the ways we may contact you for Follow-up: _____Mail only _____Home Phone ____Work Phone _____Cell Phone ____Mail or Phone Special Instructions/Other:___________________________________________________________________________________________________ In case of EMERGENCY: Phone # (_____)______________ Relationship:___________ NAME (Last, First)___________________________________ What is your PRIMARY work status?
(please check one) _____ Unemployed _____ Working Full-Time ____ Working Part-Time ____ Student Are you a: _____ Seasonal Worker _____ Migrant Worker _____ Not Seasonal or Migrant Worker Have you seen a doctor in the last 3 months?

____ Yes ____No If yes, why?_______________________________________________________ Who do you usually go to for health care?
(___) Doctor (___) Clinic (___) Other (___) None Name:______________________________ If you are single, what is your total monthly income before taxes: OR If you are married, what is your total combined monthly income before taxes: $______________ per month Number of people (including yourself) who are supported by this income: ________________________ How many children have you given birth to?
(Parity) _______________________________________ FOR CLINIC USE ONLY FEDERAL GUIDELINE %________________ FEE SCALE: ___ No Fee ___ Partial Fee ___ Full ASSIGNED SOURCE OF PAYMENT: ___ Title V ___ Title X ___ Other:____________________________ Authorization:____________________________ ___ Title XX ___ AHCCCS ___ Private Insurance ___ Self Are you enrolled in AHCCCS?

Yes: _____ AHCCCS ID #: ______________________ No:_____ 48 | P a g e Do you ANY have Health Insurance?
Yes ______ No______ If Yes, does the insurance cover Family Planning services?

Yes:_____ No:_____ How did you hear about this Clinic?
______ Friend _____ Family Member ______ Flyer/Pamphlet ______ TV/Radio/Newspaper _____ Referred by other agency ______ I am a regular patient ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL HIPPA / Patient Rights ACKNOWLEDGEMENT I acknowledge that I have been given the opportunity to view or receive a copy of the notice of Health Information Practices describing how medical information may be used and disclosed under the Health Insurance portability and Accountability Act (HIPAA), as well as a copy of Patient Rights.
_______________________________________ Name ________________________________ Date _______________________________________ Signature ADVANCE DIRECTIVES (LIVING WILL OR POWER OF ATTORNEY) IF you have an advanced directive you may provide us with a copy.

If you do not, we can give you information on how you can obtain one.

PLEASE CHECK ONE OF THE FOLLOWING STATEMENTS: ____ I have an ADVANCE DIRECTIVE (Living Will or Power of Attorney) for health care.
____ I do not have an ADVANCE DIRECTIVE (Living will or Power of Attorney) for health care.

____ I would like to have information on obtaining an Advanced Directive.
____________________________ Witness/Staff Signature 49 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL HIPPA RECONOCIMIENTO Yo reconozco que se me ha dado la oportunidad de ver o recibir una copia del aviso de Prácticas de Información de Salud que describe cómo su información médica puede ser utilizada y divulgada en virtud de la Ley de portabilidad y Responsabilidad de Seguros Médicos (HIPAA), igualmente copia de los derechos de paciente.
_____________________________________ Nombre ___________________________ Fecha __________________________ ___________ Firma LAS INSTRUCCIONES POR ADELANTADO (TESTAMENTO) Si tiene una directiva avanzada puede proporcionarnos una copia.

Si no, podemos darle información sobre cómo puede obtener uno.

POR FAVOR MARQUE UNA DE LAS SIGUIENTES AFIRMACIONES: _______ YO tener una directriz anticipada (Testamento) para el cuidado de la salud.
_______ No tengo una directriz anticipada (Testamento) para el cuidado de la salud.

_______ ME gustaría tener información sobre la obtención de una Directiva Avanzada.

50 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL DOMESTIC/SEXUAL VIOLENCE SCREENING FORM Completing this form is voluntary.

You do not have to fill out this form to receive services.
Anything you disclose, including your relationship with the person, who has abused you, will be kept confidential, with the exception of child abuse and neglect.

You may complete this form and request counseling services regardless of your gender, sexual orientation, or marital status.

You do not have to have children or have left the abusive situation.

You are not required to provide any information or details about the abusive situation to anyone before you are referred to see a counselor.
Are you in danger of a family member, your partner, or ex-partner doing any of the following to you?

: Isolating you, making you feel like a prisoner, or controlling what you can do?

• Hitting, slapping, kicking, choking, or in any way hurting you physically?

• • Threatening to harm you, your children, or someone close to you?

• Stalking you, following you, or checking up on you?

• Shaming or belittling you, constantly putting you down, or telling you that you are worthless?
• Forcing you to have sex, or into sexual acts that you do not want to participate in?

• Making you feel afraid?

_____YES: I would like to meet with a domestic/sexual violence case worker to discuss my situation.

_____YES: But I do not want to meet with anyone at this time.

_____NO: None of the situations described above apply to me or I do not wish to answer these questions at this time.

In signing this form I affirm that the information above is correct.
Signature:_________________________________________________________________________________ 51 | P a g e Revised 03/10/2020 ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL VOLUNTARY CONSENT FORM I voluntarily agree to receive Family Planning services from the Graham County Health Department, and further state that I have not been coerced, forced, threatened with physical violence, or otherwise received any undue influence to compel me to receive these services.
I understand that as a part of the overall services, I may be expected to have a physical exam, as well as a Pap smear if deemed necessary by the medical provider.

These services will be conducted either by clinicians on contract with, or staff of, the Graham County Health Department.

I also agree to participate in any administrative or consultation process that may be necessary to provide the identified services.
I understand that Graham County Health Department provides a teaching environment to students in the health care field.

If I have any questions or concerns about this I will speak to a nurse.

I understand that family planning services are available to all females aged 14 years or older regardless of marital status, sexual orientation, religious affiliation, race, ethnicity, or national origin.
If I feel I have been discriminated against by any contractor or staff member of the Graham County Health Department I will speak with the Health Director.

I have received and read my Patient Bill of Rights.

I have read the above information and hereby consent to and authorize the staff and contracted clinicians of the Graham County Health Department to conduct the identified Family Planning services.
______________________________ _____________________ Signature of Client Date _______________________________ _____________________ Signature of Witness Date Please Note: This is an example of language that can be used.
52 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL FORMULARIO DE CONSENTIMIENTO VOLUNTARIO Estoy de acuerdo voluntariamente recibir servicios de planificación familiar del Departamento de salud del Condado ____________ y más estado que yo he no sido coaccionado, obligado, amenazados con violencia física, o de lo contrario recibe cualquier influencia indebida para obligarme a recibir estos servicios.
Entiendo que como parte de los servicios generales se espera tener un examen físico, así como una prueba de Papanicolaou o sangre dibuja si se considera necesario por el médico.

Estos servicios se llevará a cabo por los médicos por contrato con, o de personal, el Departamento de salud del Condado.

También estoy de acuerdo en participar en alguna administrativo o proceso de consultas que sea necesaria para proveer los servicios identificados.
Entiendo que ____________ Graham Departamento de Salud proporciona un entorno de enseñanza a los estudiantes en el campo de la salud.

Si tengo alguna pregunta o inquietud acerca de esto voy a hablar con una enfermera.

Entiendo que servicios de planificación familiar están disponibles para todas las mujeres de 14 años de edad o mayores independientemente del estado civil, orientación sexual, afiliación religiosa, raza, etnia o nacionalidad de origen.
Si siento que he sido discriminado por cualquier contratista o miembro del personal del Departamento de salud del Condado voy a hablar con el Director de salud.

Haber leído la información anterior y por la presente consiente y autorizar al personal y los médicos contratados del Departamento de salud del Condado para llevar a cabo los servicios de planificación familiar identificados.
_____________________________ _____________________ Firma del cliente fecha _______________________________ _____________________ Firma del testigo fecha 53 | P a g e ARIZONA DEPARTMENT OF HEALTH SERVICES BUREAU OF WOMEN’S AND CHILDREN’S HEALTH REPRODUCTIVE HEALTH/FAMILY PLANNING PROGRAM POLICIES AND PROCEDURES MANUAL Optional Documents Electronic copies of the following documents will be shared with each County: Consent for Birth Control Patch Consent for Birth Control Ring Consent for Depo-Provera Consent for NuvaRing Consent for Oral Contraceptive ECP Informed Consent 54 | P a g e