Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696597191762.pdf (United States)
Maryland Family Planning and Reproductive Health Program Administrative Guidelines Maryland Department of Health and Mental Hygiene Maternal Child Health Bureau Issued May 2015 I. Maryland Family Planning and Reproductive Health Program Information A.

Family Planning in Maryland Table of Contents B. Maryland Health Codes and Other Rules C. Maryland Family Planning and Reproductive Health Minimum Program Requirements 1.

Definition 2.
Definition 2.

Minimum Program Requirements D. Maryland Family Planning and Reproductive Health Minimum Reporting Requirements E. Needs Assessment and Annual Plan Instructions 1.

Program Specific Assurances and Requirements 2.

Needs Assessment II.

Program Standards and Guidelines A.

Introduction to Program Guidelines 1.

Definitions B.

The Law, Regulations and Guidelines C. Application Process 1.

Needs Assessment 2.

Project Requirements D. Grant Administration E. Legal Issues 1.
Voluntary Participation 2.

Confidentiality 3.

Conflict of Interest 4.

Liability Coverage 5.

Human Subjects Clearance (Research) 6.

Limited English Proficiency (LEP) F. Project Management 1.

Overview 2.

Planning and Evaluation 3.

Financial Management 4.

Charges, Billing and Collections 5.

Facilities and Accessibility of Service 6.


Personnel The Maryland Family Planning and Reproductive Health Administrative Guidelines – 2015 Table of Contents Training and Technical Assistance 8.

Reporting Requirements 9. Review and Approval of Informational and Educational Materials 10.

Community Participation, Education and Project Promotion 11.

Community Education 12.

Project Promotion III.


Client Services, Required Services and Clinic Management A.

Client Services 1.

Overview 2.

Service Plans and Protocols 3.

Procedural Outline 4.

Emergencies 5.

Referrals and Follow-Up B.

Required Services Overview Client Education Informed Consent Counseling History, Physical Assessment and Laboratory Testing Fertility Regulation (Contraception) Emergency Contraception Permanent Contraception (Sterilization) Tubal Ligation Referral 1.

2.

3.

4.

5.
2.

3.

4.

5.

6.

7.

8.

9.

10.

Infertility Service 11.

Pregnancy Diagnosis and Counseling 12.

Adolescent Services 13.

Identification of Estrogen-Exposed Offspring C. Related Services 1.

Gynecological Services 2.

Sexually Transmitted Infections (STIs) and HIV/AIDS 3.

Genetic Information and Referral 4.

Health Promotion/Disease Prevention 5.

Postpartum Care 6.

Family and Intimate Partner Violence 7.

Mandated Reporting of Child Abuse and Neglect 8.

Human Trafficking 9.


Reproductive Life Plan D. Clinic Management 1.

Equipment and Supplies 2.

Pharmaceuticals 3.

Medical Records 4.

Quality Assurance and Audit 5.

Maryland Family Planning Customer Satisfaction Survey The Maryland Family Planning and Reproductive Health Administrative Guidelines – 2015 Table of Contents V. Program Monitoring Site Reviews A.
Program Monitoring Site Reviews 1.

Methodology 2.

Process B.

Monitoring and Technical Assistance 1.

Monitoring Visits 2.

Technical Assistance (Consultation Visits 64 64 64 66 66 66 The Maryland Family Planning and Reproductive Health Administrative Guidelines – 2015 Table of Contents 3 I. Maryland Title X Family Planning and Reproductive Health Program Information The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 1 A.
Family Planning in Maryland The mission of the Maryland State Title X Family Planning and Reproductive Health Program (MFPRH) is to reduce unintended pregnancies and to improve pregnancy outcomes by assuring that comprehensive, quality family planning services are available and accessible to Maryland citizens in need.
This is consistent with the Title X Federal Family Planning Program mission "to provide individuals the information and means to exercise personal choice in determining the number and spacing of their children."

Family Planning is a preventive health measure which positively impacts the health and well- being of women, children and families.
Effective family planning programs are essential health care delivery interventions that correlate with decreased high-risk pregnancy and decreased maternal and infant mortality and morbidity.

Services provided through family planning clinics allow women and men to make well-informed reproductive health choices.
Maryland Title X funded family planning clinics are specifically created to address the unmet family planning needs of women and men below poverty, and those slightly above poverty, but still considered low-income, and to provide access to those with special needs.

No one is denied services because of inability to pay.

The Maternal and Child Health Bureau is responsible for carrying out federal and state mandates for improving the health of women, newborns, children, and adolescents.
A major goal is to reduce maternal, infant, and child mortality and morbidity, with a focus on low income populations.

Integral to this process is the development and implementation of a plan to assure statewide availability and accessibility to high quality comprehensive reproductive health care.

The fundamental belief underlying the Maryland State Family Planning and Reproductive Health Program is that every pregnancy should be a planned and wanted one.
The guiding principle of the Program is that all men and women should be able to have the number of children they want, when they want to have them.

Consistent with this principle are the following expectations:  No one is denied family planning services because of the inability to pay and that priority is given to individuals who are at or below 250% of the federal poverty level.
 Services are provided to individuals regardless of religion, race, color, national origin, disabling condition, age, sex, number of pregnancies, or marital status.

 Family planning counseling includes all methods of contraception and is conducted in a supportive and non-coercive manner that protects the dignity of the individual.

 Counseling specifically includes information on the prevention of HIV/AIDS and other sexually transmitted infections.
 Adolescents are specifically provided counseled on abstinence and resisting sexual coercion and encouragement of parental involvement.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 2  Health care providers from both the public and private sectors work in partnership to address the reproductive health and family planning issues within their community.
 Community members are consulted in the design and implementation of the local family planning and reproductive health program.

B. Maryland Health Codes and Other Rules The following health codes and other rules that provide crucial information to Title X program implementation can be found in Appendix A.

Domestic Violence Annotated Code of Maryland, Family Law Article, §4-501 to§ 4-530 Md.

FAMILY LAW Code Ann.

§ 4-501 Mandated Child Abuse Reporter Legislation Family Law Article: Md.
FAMILY LAW Code Ann.

§ 5-704 Criminal Law Article: Md.

CRIMINAL LAW Code Ann.

§ 3-304 Md.

CRIMINAL LAW Code Ann.

§ 3-306 Md.

CRIMINAL LAW Code Ann.

§ 3-307 Md.

CRIMINAL LAW Code Ann.

§ 3-308 Minor Consent: Md.

HEALTH-GENERAL Code Ann.

§ 20-102 Nurse Dispensing in Local Health Departments The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 3 C. Maryland Title X Family Planning Minimum Program Requirements 1.
DEFINITION Family Planning services offer comprehensive preventive reproductive health care that includes: general health assessment and examination; screening and treatment for sexually transmitted diseases, HIV infections, cervical and breast cancer, high blood pressure, anemia, infertility problems and selected infections; contraception, pregnancy testing and counseling services; client and community educations; and follow-up and referrals for medical or socioeconomic problems.
The primary mission is to provide individuals the information and means to exercise personal choice in determining the number and spacing of their children.

2.

MINIMUM PROGRAM REQUIREMENTS a.

Provide a broad range of acceptable and effective medically approved family planning methods (including natural family planning methods) and services (including infertility services and services for adolescents).

Reference: 42 CFR CH.

1 (10-1-00 Edition) §59.5 (a)(1).

b.


Provide services without subjecting individuals to any coercion to accept services or to employ or not to employ any particular methods of family planning.

Acceptance of services must be solely on a voluntary basis and may not be made a prerequisite to eligibility for, or receipt of, any other services, assistance from or participate in any other program.

Reference: 42 CFR CH.

1 (10-1-00 Edition) §59.5 (a)(2).


c. Provide services in a manner which protects the dignity of the individual.

Reference: 42 CFR CH.

1 (10-1-00 Edition) §59.5 (a)(3).

d. Provide services without regard to religion, race, color, national origin, handicapping condition, age, sex, number of pregnancies, or marital status.

Reference: 42 CFR CH.

1 (10-1-00 Edition) §59.5 (a)(4).

e. Not provide abortion as a method of family planning.
Offer pregnant women the opportunity to be provided information and counseling regarding each of the following options: (A) Prenatal care and delivery; (B) Infant care, foster care, or adoption; and (C) Pregnancy termination.

Reference: 42 CFR CH.

1 (10-1-00 Edition) §59.5 (a)(5) and (i).

f. Provide that priority in the provision of services will be given to persons from low- income families.

Reference: 42 CFR CH.

1 (10-1-00 Edition) §59.5 (a)(6).


The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 4 g. Provide that no charge will be made for services provided to any persons from a low income family except to the extent that payment will be made by a third party (including a government agency) which is authorized to or is under legal obligation to pay this charge.

Reference: 42 CFR CH.

1 (10-1-00 Edition) §59.5 (a)(7).


h. Provide that charges will be made for services to persons other than those from low- income families in accordance with a schedule of discounts based on ability to pay, except that charges to persons from families whose annual income exceeds 250 percent of the levels set forth in the most recent Poverty Guidelines will be made in accordance with a schedule of fees designed to recover the reasonable cost of providing services.

Reference: 42 CFR CH.


1 (10-1-00 Edition) §59.5 (a)(8).

i.

If a third party (including a government agency) is authorized or legally obligated to pay for services, all reasonable efforts must be made to obtain the third-party payment without application of any discounts.

Where the cost of services is to be reimbursed under title XIX, XX, or XXI of the Social Security Act, a written agreement with the specific title agency is required.

Reference: 42 CFR CH.

1 (10-1-00 Edition) §59.5 (a)(9).

j.


Provide for an advisory committee as required.

Reference: 42 CFR CH.

1 (10-1-00 Edition) §59.6 (a)(11).

k. Provide for medical services related to family planning (including physician's consultation, examination prescription, and continuing supervision, laboratory examination, contraceptive supplies) and necessary referral to other medical facilities when medically indicated, and provide for the effective usage of contraceptive devices and practices.
Reference: 42 CFR CH.

1 (10-1-00 Edition) §59.5 (b)(1).

l. Provide for social services related to family planning including counseling, referral to and from other social and medical services agencies, and any ancillary services which may be necessary to facilitate clinic attendance.

Reference: 42 CFR CH.

1 (10-1-00 Edition) §59.5 (b)(2).


m. Provide for informational and educational programs designed to: achieve community understanding of the objectives of the program; inform the community of the availability of services; and promote continued participation in the project by persons to whom family planning services may be beneficial.

Reference: 42 CFR CH.

1 (10-1-00 Edition) §59.5 (b)(3).

n. Provide for orientation and in-service training for all project personnel.
Reference: 42 CFR CH.1 (10-1-00 Edition) §59.5 (b)(4).

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 5 o.

Provide services without the imposition of any durational residency requirement or requirement that the patient be referred by a physician.

Reference: 42 CFR CH.

1 (10-1- 00 Edition) §59.5 (b)(5).


p. Provide that the family planning medical services will be performed under the direction of a physician with special training or experience in family planning.

Reference: 42 CFR CH.1(10-1-00 Edition) §59.5 (b)(6).

q.

Provide that all services purchased for project participants will be authorized by the project director or his/her designee on the project staff.

Reference: 42 CFR CH.

1 (10- 1-00 Edition) §59.5 (b)(7).


r. Provide for coordination and use of referral arrangements with other providers of health care services, local health and welfare departments, hospitals, voluntary agencies, and health services projects support by other federal programs.

Reference: 42 CFR CH.

1 (10-1-00 Edition)§59.5 (b)(8).


s. Provide that if family planning services are provided by contract or other similar arrangements with actual providers of services, services will be provided in accordance with a plan which establishes rates and method of payment for medical care.

These payments must be made under agreements with a schedule of rates and payment procedures maintained by the agency.

The agency must be prepared to substantiate that these rates are reasonable and necessary.
Reference: 42 CFR CH.

1 (10-1-00 Edition) §59.5 (b)(9).

t. Provide, to the maximum feasible extent, an opportunity for participation in the development, implementation, and evaluation of the project by persons broadly representative of all significant elements of the population to be served, and by others in the community knowledgeable about the community's needs for family planning services.

Reference: 42 CFR CH.

1(10-1-00 Edition) §59.5 (b)(10).

u.


Any funds granted shall be expended solely for the purpose of delivering Title X Family Planning Services in accordance with an approved plan and budget, regulations, terms and conditions and applicable cost principles prescribed in 45 CFR Part 74 or Part 92, as applicable.

Reference: 42 CFR CH.

1 (10-1-00 Edition) §59.9.


These Minimum Program Requirements (MPR’s) are used as indicators for the Maryland Title X Family Planning and Reproductive Health Program site review process to determine program compliance.

They are based on the Title X Family Planning Program statute (Appendix B), the Office of Population Affairs (OPA) Family Planning Standards and Guidelines (Appendix B), and the Maryland Title X Family Planning and Reproductive Health Guidelines.
The Site Review Tool identifies the minimum program requirements and references to the above documents in the review tool.

Each indicator refers to a minimum standard that must be The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 6 in place to be in compliance with the Maryland Title X Family Planning and Reproductive Health Program for grant status as a Family Planning Delegate Agency.
The Site Review Tool identifies the measurements used to determine compliance with each MPR indicator.

These indicators are used in the site review process to evaluate compliance with grant requirements.

Any indicator determined to be out of compliance must to be corrected.
Minimum Program Requirements and site review tools are reviewed annually as part of an ongoing quality improvement process, working toward optimal clarity and objective measurement of required program components and compliance with those components.
The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 7 D. Maryland Family Planning and Reproductive Health Minimum Program Reporting Requirements (MFPRR) The federally mandated minimum program reporting requirements for delegate agencies are explained here.

It is mandatory that agencies submit these documents and do so by the deadlines set forth within.

These requirements are subject to change as legislative, fiduciary and other aspects of the program change.
These documents include the:  Family Planning Data Requirement  Family Planning Needs Assessment The Maternal and Child Health Bureau, Family Planning and Reproductive Health Program also requires that delegate agencies report performance measures [unduplicated number of clinic users, number of clinic visits, and number of clients receiving long acting reversible contraceptives (LARC)].

It is crucial that these reports are submitted accurately and timely.
The information is used for essential activities not limited to legislative reporting, federal reporting requirements for the State, budgeting, funding, and other aspects of financial management.

In addition, this data provides statistical information needed for program evaluation, assessment of need, and other activities required of Title X Family Planning Projects.
The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 8 E. Needs Assessment and Annual Plan Instructions The Maternal and Child Health Bureau, Family Planning and Reproductive Health Program must have every delegate agency develop and submit a needs assessment and annual grant as described below: 1.

PROGRAM SPECIFIC ASSURANCES AND REQUIREMENTS a.

Each delegate agency annual performance measure is determined by taking 100% of the most recent three years.

b.
b.

Each delegate agency will be required to adhere to Maryland Title X Family Planning and Reproductive Health Program Minimum Program Requirements (MPRs).

The MPRs are written based on the Federal Regulations for Title X Family Planning Programs (the law) and the Office of Population Affairs (OPA) Family Planning Standards and Guidelines.

2.
2.

NEEDS ASSESSMENT a. Demographic description of the service delivery area including objective data pertaining to individuals in need of family planning services (Examples include but are not limited to maternal and infant mortality/morbidity rates, estimates of women/teens in need of services, teen birth rates and pregnancy rates, rates of unintended pregnancy, STI and HIV rates/prevalence and indicators of the poverty status of the populations to be served).
Also discuss cultural and linguistic barriers to service.

b.

Geographic description of the service area including any geographic, topographic, and other barriers to service.

c. Identification and discussion of high priority populations and target areas, with special emphasis on low-income women and men.

d. Identify other major health care providers and agencies providing similar services in your service delivery area, and the existing need for additional services.
e. Describe linkages or possible linkages with other health and social agencies related to reproductive health.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 9 II.

Program Standards and Guidelines The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 10 A.

Introduction to Program Guidelines Reference is made throughout the document to specific sections of the Title X law and implementing regulations.
(Reference to specific sections of the regulations will appear in brackets, e.g.

[45 CFR Part 74, Subpart C]).

Selected materials that provide additional guidance are classified as Resource Documents.

The format used in this document follows the Program Requirements for Title X Funded Family Planning Projects, 2014, authorized by Title X of the PHS Act (42 U.S.C.

300 et seq.)

.

1.

DEFINITIONS Throughout this document, the words required or must indicate mandatory program requirements.
Standards refer to minimally required services.

The word should indicates recommended program guidelines and policies.

These guidelines and policies reflect current acceptable medical or professional practices and are highly recommended by the Maryland Title X Family Planning Program in order to fulfill the intent of Title X.

The words can and may indicate suggestions for consideration by individual projects.
MFPRH refers to the Maryland Family Planning and Reproductive Health Program as the entity that receives a Federal grant and assumes legal and financial responsibility and accountability for the awarded funds and for the performance of the activities approved for funding.
The project consists of those statewide activities described in the Maternal and Child Health Bureau, Title X Family and Reproductive Health Program grant application submitted to the Office of Population Affairs (OPA), Family Planning Program and supported under the approved budget.

For more information about the OPA Family Planning Program, go to www.hhs.gov/opa .

Delegate agencies are those entities that provide family planning services with Federal Title X funds.
Service sites are those locations where Title X family planning services are provided by the delegate agency.

References made throughout this document to Title X law and Federal policy can be explored in Appendix B and Appendix C. The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 11 B.

The Law, Regulations and Guidelines The philosophy of the Maryland Title X Family Planning and Reproductive Health (MFPRH) Program is consistent with that of Title X.
Family planning is a preventive health measure which positively impacts the health and wellbeing of women, children and families.

Effective family planning programs are essential health care delivery interventions that correlate with decreased high-risk pregnancy and decreased maternal and infant morbidity and mortality.

Services provided through family planning clinics allow women and men to make well- informed reproductive health choices.
Title X family planning clinics are specifically created to address the unmet family planning needs of women and men living below or slightly above poverty, but still considered low income, and to provide access to those with special needs (including teens).

No one is denied services because of inability to pay.

1.
1.

To enable persons voluntary access to family planning services, Congress enacted the Family Planning Services and Population Research Act of 1970 (Public Law 91-571), which added Title X, "Population Research and Voluntary Family Planning Program," to the Public Health Services Act.
Section 1001 of the Act (as amended by Public Laws 94-63 and 95-613), "The Secretary is authorized to make grants to and enter into contracts with public and nonprofit private entities to assist in the establishment and operation of voluntary family planning projects which shall offer a broad range of acceptable and effective family planning methods and services (including natural family planning methods, infertility services and services to adolescents)."
The mission of Title X is to provide individuals the information and means to exercise personal choice in determining the number and spacing of their children.
The regulations governing Title X (42 CFR, Part 59, Subpart A), published in the Federal Register on June 3, 1980, amended on February 2, 1988, July 3, 2000, and again on August 10, 2000, are the requirements of the Secretary, Department of Health and Human Services, for the provision of family planning services funded under Title X, and implement the statute as authorized under Section 1001 of the Public Health Services Act.

2.
2.

The Maryland Department of Health and Mental Hygiene, Maternal and Child Health Bureau is the Title X Program Grantee and has the primary responsibility in Maryland to receive and administer State and Federal funds for family planning services.

Guidelines for MFPRH Program administration of the federal program are based on requirements as cited in the document Program Requirements for Title X Funded Family Planning Projects available at the following website: http://www.hhs.gov/opa/.
Additional guidelines may be required through either the federal or state annual funding process, or as MFPRH Program deems necessary.

3.

The program guidelines found in this document interpret the law and regulations in the form of standards and provide a general orientation to the federal and state perspective on family planning.

This manual is written to define minimum standards (requirements) and give recommendations for quality care.
This manual is designed to be used for the: The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 12 a. Orientation of all new family planning staff members b.

Annual quality assurance review procedures required of all delegate agencies The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 13 C. Application Process 1.
NEEDS ASSESSMENT An assessment of the need for family planning services in the service area must be conducted prior to applying for a grant award and supplied in the annual plan thereafter.

The information will be used to ensure that services are being delivered in areas under-served by other medical and/or social welfare facilities.

At a minimum, the needs assessment must include the following: a.
Description of the geographic area including a discussion of potential geographic, topographic, and other related barriers to service; b. Demographic description of the service delivery area including objective data pertaining to individuals in need of family planning services (Examples include but are not limited to maternal and infant mortality/morbidity rates, estimates of women/teenagers in need of services, teen birth rates and teen pregnancy rates, rates of unintended pregnancy by age groups, and indicators of the poverty status of the populations to be served).
Also discuss cultural and linguistic barriers to services; c. Description of existing services and the need for additional family planning services to meet community/cultural needs; d. Rates and/or prevalence of STIs and HIV (including perinatal infection rates) in the service delivery area; e. Identification and description of linkages with other resources related to reproductive health; and f. Identification and discussion of high priority populations and target areas and an estimate of the number of clients to be served, with special emphasis on low-income women and men.
2.

PROJECT REQUIREMENTS All delegate agencies providing family planning services must assure the following requirements.

a.

Provision of a broad range of effective medically approved family planning methods and services including natural family planning methods, infertility services and services for adolescents.

(Sections 9.8) b.

Services will be provided to clients (Section 8.1): 1.)

On a voluntary basis 2.)


Without coercion to accept services or any particular method of family planning The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 14 3.)

Without making acceptance of services a prerequisite to eligibility for any other service or assistance in other programs c. Provide services in a manner that will protect each individual's dignity and will respect the diverse cultural and social practices of the service area population.
(Section 9.2) d. Provide services impartially to all without regard to religion, race, color, national origin, handicapping condition, age, sex, number of pregnancies or marital status in accordance with Title VI of the Civil Rights Act of 1996.

(Section 9.30) In addition, all delegate agencies must have a policy that assures meaningful access to family planning services for persons with limited English proficiency.
This means that language assistance must be provided that results in accurate and effective communication at no cost to the client.

e. Not provide abortions as a method of family planning.

A project must offer pregnant women the opportunity to be provided information and counseling on prenatal care and delivery; infant care, foster care, or adoption; and pregnancy termination.

Information on any of these options must be factual, neutral and nondirective.
(Section 8.2) f. Persons from low-income families are given priority in the provision of services.

Agencies must strive to increase use of services by historically under-served segments of the population (people of color, non-English speaking persons, persons abusing substances, homeless persons, etc.)

(Section 9.1).

g. Low-income individuals (below 100% of poverty) are not charged except where third party payment is authorized (Section 8.4.1).
h. Clients must not be denied services or be subjected to any variation in quality of service because of inability to pay.

Charges will be made to persons other than low-income individuals (at or below 100% poverty) based on the following (Section 8.4.2): 1.)

Current Federal Department of Health and Human Services (DHHS) Poverty Guidelines 2.)

Sliding fee scale schedule 3.)

Periodic cost analysis of all services provided i.


Individuals from families with an annual income above 250% poverty will be charged to recover the reasonable cost of providing services (Section 8.4.4).

j.

Reasonable effort is made to recover third party payment from all sources (Section 8.4.6).

k. Provide for medical services related to family planning including (Section 9): 1.)

Physician's consultation 2.)

Examination 3.)


Prescription The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 15 4.)

Continuing supervision of clients 5.)

Laboratory examination 6.)

Contraceptive supplies 7.)

Referral to other medical facilities when medically indicated 8.)

Effective usage of contraceptive devices and practices l. Provide for social services related to family planning including (Section 9): 1.)

Counseling 2.)
Counseling 2.)

Referral to and from other social and medical services agencies 3.)

Referral to any ancillary services which may be necessary to facilitate clinic attendance m. Provide informational and educational programs designed to (Section 12): 1.)

Achieve community understanding of program objectives 2.)

Inform community of availability of services 3.)


Promote continued participation in the project by persons to whom family planning services may be beneficial n. Orientation and in-service training are provided for all project personnel (Section 8.6).

o.

Services are provided without residency requirement or physician referral (section 9.9).

p. Medical services that are provided by delegate agencies are done so under the direction of a physician (8.5.4).

q.
q.

All services purchased for the project participants are authorized by the project director or director's designee.

r. Provide for coordination and use of referral arrangements with other appropriate providers supported by other federal programs (Section 9.5).

s. Agreements on methods and rates of payments for medical care by contracted or referral providers are in place and are reasonable and necessary.
t. Provide an opportunity for a broadly based representation from the service population and those in the community knowledgeable about family planning needs, to participate in the development, implementation and evaluation of the project (Section 11.1).

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 16 D. Grant Administration 1.

All delegate agencies must comply with MFPRH Program and federal grants administration requirements, including the following: a.
All Family Planning Directors must be familiar with the MFPRH Program Administrative Guidelines and the Title X law and regulations.

b.

All delegate agencies receiving Title X funds must provide services of high quality which meet minimum program standards.

c. Delegate agencies must have an Information and Education Committee which reviews all educational materials.
The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 17 E. Legal Issues Written protocols and operating procedures are required to meet the standards of the legal issues described in sections 8, 9, 10, and13.4).

Services must be provided without regard to religion, race, color, national origin, creed, handicap, sex, number of pregnancies, marital status, age, sexual orientation, and contraceptive preference in a manner that protects the dignity of the individual.
1.

VOLUNTARY PARTICIPATION Use by any individual of delegate agency services must be solely on a voluntary basis.

Individuals must not be subjected to coercion to receive services or to use or not to use any particular method of family planning.

Acceptance of family planning services must not be a prerequisite to eligibility for, or receipt of, any other service or assistance from or participation in any other programs of the applicant [59.5(a)(2)].
Personnel must be informed that they may be subject to prosecution under Federal law if they coerce or endeavor to coerce any person to undergo an abortion or sterilization procedure.

A statement acknowledging the staff member’s awareness and understanding of the voluntary participation policy must be maintained in his or her personnel file.

2.
2.

CONFIDENTIALITY Every delegate agency must assure client confidentiality and provide safeguards for individuals against the invasion of personal privacy, as required by the Privacy Act.

No information obtained by the project staff about individuals receiving services may be disclosed without the individual's written consent, except as required by law or as necessary to provide services to the individual, with appropriate safeguards for confidentiality.
Information may otherwise be disclosed only in summary, statistical, or other form that does not identify the individual [59.11].

Confidentiality under Title X cannot be invoked to circumvent Maryland mandated reporting requirements for Child Abuse and Neglect.

Health care providers are required to report suspected child abuse or neglect.
When they make a report of suspected maltreatment in good faith, they are protected under the law from civil or criminal liability pertaining to abrogation of confidentiality a.

Under Maryland law, an individual under the age of 18 may consent on his or her own behalf to confidential family planning services and certain other medical treatment; however, a doctor providing the treatment, or his or her designee, may notify the minor’s parents.
For example, a doctor in a family planning clinic may decide it is necessary to notify a minor’s parents when the minor has been found to have a serious health problem and the minor does not return to the clinic for treatment.

b.
b.

When serving an adolescent or adult client who does not wish to be contacted by phone or by mail at home or at other stipulated locations, providers should ask the client to sign The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 18 an Individualized Contact Plan found in the MFPP Program Clinical Guidelines or an equivalent local form.

This form, provides a space where the client can identify a special contact plan.
The client must be informed that, in the event that a serious health problem is identified, the clinic will make every attempt possible to contact the client, which could mean abrogating confidentiality.

c. Every effort should be made to have all written and verbal exchanges between clients and office/clerical staff kept private, so that other clients in the waiting room or other uninvolved staff do not know who is visiting the clinic or the reason for the visit.
An example would be keeping the sign-in sheet from being inappropriately read by other people.

3.

CONFLICT OF INTEREST Delegates must establish policies to prevent employees, consultants, or members of governing or advisory bodies from using their positions for purposes of private gain for themselves or for others.

4.

LIABILITY COVERAGE Liability insurance coverage must be assured for all segments of the program funded under the Title X grant, including all personnel providing direct patient services.
5.

HUMAN SUBJECTS CLEARANCE (RESEARCH) a.

Delegates considering clinical or sociological research using Title X clients as subjects must adhere to the legal requirements governing human subjects research at 45 CFR Part 46, as applicable.

b.

All DHMH facilities must comply with DHMH requirements for research.

Information on DHMH requirements can be found at http://www.dhmh.state.md.us/oig/irb.
c. Delegate must send written notification of any planned research activities to the MFPP Program, State Family Planning Administrator prior to the initiation of activities.

This notification must include the following: 1.)

A description of the project, including plans to comply with legal requirements pertaining to human subjects of research, especially the method for obtaining informed consent; 2.)
Documentation of approval by an Institutional Review Board (IRB); and/or Indication of when the researcher(s) plan to submit an application to the DHMH IRB.

All applications to the DHMH IRB must be processed through the Maternal and Child Health Bureau d. The State Family Planning Administrator will inform the federal Region III office in The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 19 writing of all planned research with IRB approval.
e. Information concerning rights of people who participate in research and federal regulations on using humans in medical or behavioral research may be obtained by calling 1-866-447-4777 or by writing: Office for Human Research Protections (OHRP), 1101 Wootton Parkway, Room 200, Rockville, MD 20852 f. Any provider planning to publish materials based upon activities conducted under funding from the Maternal and Child Health Bureau should contact the State Family Planning Administrator or his/her designee to ensure that the publication complies with all relevant federal and DHMH requirements.
6.

LIMITED ENGLISH PROFICIENCY (LEP) a.

All delegate agencies must ensure meaningful access to services for persons with limited English proficiency.

b.

All delegate agencies must develop and implement a written plan regarding the process for providing language assistance to LEP clients.

Guidance can be found in Federal Register/Vol.

76, No 74/Monday, April 18, 2011/Notices.

c. The scope and complexity of the plan must consider: 1.)
Size of the LEP population eligible to be served or likely to be encountered.

2.)

Frequency of contact with the LEP population.

d. All LEP plans must include: 1.)

Statement of the agency’s commitment to provide meaningful access for LEP persons.

2.)

Statement that services will not be denied to a client because s/he is limited English proficient.

3.)

Statement that clients will not be asked or required to provide their own interpreter.
Because of the concerns for confidentiality and the sensitive nature of the information that clients may disclose during services, the use of family and friends as interpreters is strongly discouraged.

If the client chooses to use family or friends, first inform the client of the right to receive free interpreter services and permit the use of family/friends only after the offer has been declined and documented.
e. At minimum, delegate agencies must include and address the following within their LEP Plans: 1.)

Identify LEP individuals who need language assistance 2.)

Language assistance measures 3.)

Oral interpretation The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 20 4.)

Written translation 5.)

Training staff 6.)

Providing notice to LEP persons 7.)

Monitoring and updating the LEP plan.


f. MFPRH Program will provide technical assistance for the development of the LEP plan.

g. MFPRH Program will review delegate agencies’ LEP practices and policies during site review.

F. Project Management 1.


OVERVIEW Structure of the Maryland Title X Family Planning and Reproductive Health Program family planning services under Title X grant authority are offered by delegate/contract agencies, however MFPRH Program is responsible for the quality, cost, accessibility, acceptability, reporting, and performance of the grant-funded activities provided by delegate/contract agencies.
MFPP must therefore have a negotiated, written agreement with each delegate/contract agency and establish written standards and guidelines for all delegated project activities consistent with the appropriate section(s) of the Program Requirements for Title X Funded Family Planning Projects, as well as other applicable requirements such as Subpart C of 45 CFR Part 74, or Subpart C of 45 CFR Part 92.
If a delegate/contract agency wishes to subcontract any of its responsibilities or services, a written negotiated agreement that is consistent with Title X requirements must be established.

It is the responsibility of the delegate to ensure that, given the necessary information, every effort is directed to total compliance with regulations.

a. MFPRH Program must provide each delegate agency with an updated MFPRH Program Administrative manual.
This manual will be routinely provided online through the MFPRH Program website.

A hard copy will be provided upon request.

b. MFPRH Program must perform a program review on individual delegate agencies a minimum of every three years.

c. MFPRH Program is responsible for providing technical assistance and consultation as needed to ensure that the delegate agencies are in compliance with all applicable state/federal regulations and laws.
All requests for technical assistance should be forwarded to MFP RH Program in writing.

2.

PLANNING AND EVALUATION The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 21 All projects receiving Title X funds must provide services of high quality and be competently and efficiently administered.

To meet these requirements, each delegate agency must provide a plan which identifies overall goals and specific measurable objectives for the project period.
The objectives may be directed to all clients or to specific groups of clients and must be consistent with Title X objectives and Title X annual priorities.

The plan must include an evaluation component that addresses and defines indicators by which the project intends to evaluate itself.

3.
3.

FINANCIAL MANAGEMENT Delegates must maintain a financial management system that meets the standards specified in Subpart C of 45 CFR Part 74or Subpart C of 45 CFR Part 92, as applicable, as well as any other requirements imposed by the Notice of Grant Award, and which complies with Federal standards to safeguard the use of funds.

Documentation and records of all income and expenditures must be maintained as required.

4.
4.

CHARGES, BILLING AND COLLECTIONS A delegate is responsible for the implementation of policies and procedures for charging, billing, and collecting funds for the services provided by the project.

a.

Clients must not be denied family planning services or be subjected to any variation in quality of services because of the inability to pay.

b.

Charges must be based on a cost analysis of all services provided by the project.
At the time of services, clients who are responsible for paying any fee for their services must be given bills directly.

In cases where a third party is responsible, bills must be submitted to that party.

c. A schedule of discounts must be developed and implemented with sufficient proportional increments so that inability to pay is never a barrier to service.

A schedule of discounts is required for individuals with family incomes between 101% and 250% of the Federal poverty level.
Fees may be waived for individuals with family incomes above this amount who, as determined by the service site project director, are unable, for good cause, to pay for family planning services.

d. Clients whose documented income is at or below 100% of the Federal poverty level must not be charged, although projects must bill all third parties authorized or legally obligated to pay for services.
e. Along with these Guidelines, refer to the current DHMH Non-Chargeable Services List (updated each fiscal year) at http://dhmh.maryland.gov/dca for information on family planning services that are non-chargeable except, in certain cases, to Medicaid or other third party insurers.

f. Individual eligibility for a discount must be documented in the client's record/file.
The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 22 g. Bills to third parties must show total charges without applying any discount.

h. Bills to clients must show total charges less any allowable discounts.

i.

Eligibility for discounts for minors who receive confidential services must be based on the income of the minor.

j.

Reasonable efforts to collect charges without jeopardizing client confidentiality must be made.
k. A method for the "aging" of outstanding accounts must be established.

l. DHMH Policy 3205 establishes certain requirements for collection by local health departments of accounts declared by the Health Officer to be delinquent.

Once an account has been designated delinquent, it must be transferred to the Central Collection Unit, Department of Budget and Fiscal Planning (CCU).
However, Title X precludes any practice that may constitute a barrier to the receipt of services, such as the assignment of the account of a service recipient to a collection agency.

m. In order to refer an account to Central Collection Unit the following procedures must be in place: 1.)

The Family Planning Clinic must make the expectation of payment known to the client when the client schedules the appointment.

2.)
2.)

The Family Planning Clinic must bill all third party payors (medical assistance and private insurance) as well as self-pay.

3.)

The Family Planning Clinic must be able to accept cash, credit/debit and checks at time service is provided.

4.)

The Family Planning Clinic must be able to provide a payment plan to the client at the time of the fee assessment.

5.)
5.)

An invoice must be given to every client at the time of service showing the actual charge of the visit, the discount based on the approved sliding fee schedule, and the amount the client owes for the services performed that day and any previous unpaid balance.

6.)

A client can not be sent to the Central Collection Unit if a partial payment has been made towards the outstanding charge within 90 days.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 23 7.)
A client, excluding confidential clients, must be sent three (3) invoices at least 30 days apart before a client can be sent to the Central Collection Unit.

Each invoice must include the following: a) A statement stating the Clinic accepts cash, credit/debit and check payments.

b) A copy of the payment plan and details on how the client can participate in the payment plan.
c) A notice that states after the third invoice a client will be referred to the Central Collection Unit if payment or partial payment is not received.

8.)

A quarterly summary will be sent to the Family Planning Fiscal Coordinator at the Maryland Department of Health and Mental Hygiene’s Family Planning Program.

A worksheet developed by the Family Planning Fiscal Coordinator will be used to capture the following information: a) Client ID# b) Client’s Age c) Type of birth control method used by client.
d) Amount due n. Voluntary donations from clients are permissible.

However, clients must not be pressured to make donations, and donations must not be a prerequisite to the provision of services or supplies.

Donations from clients do not waive the billing/charging requirements set out above.

o.

Client income should be re-evaluated at least annually.

5.

FACILITIES AND ACCESSIBILITY OF SERVICES a.


Facilities in which project services are provided should be geographically accessible to the population served and should be available at times convenient to those seeking services, i.e., they should have evening and/or weekend hours in addition to daytime hours.

b.

The facilities should be adequate to provide the necessary services and should be designed to ensure comfort and privacy for clients and to expedite the work of the staff.
Facilities must meet applicable standards established by the Federal, state and local governments (e.g., local fire, building and licensing codes).

c. Projects must comply with [45 CFR Part 84], which prohibits discrimination on the basis of handicap in Federally assisted programs and activities, and which requires, among other things, that recipients of Federal funds operate their Federally assisted programs so that, when viewed in their entirety, they are readily accessible to people with disabilities.
A copy of Part 84 may be obtained from the Regional office.

Projects must also comply with any applicable provisions of the Americans with Disabilities Act (Public Law 101-336).

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 24 d. All delegate agencies must have a written policy and plan pertaining to services for disabled clients.
The plan should include information on referral to the closest facility offering the necessary accommodation when a clinic cannot serve a particular individual for any reason.

At a minimum, the plan should address service delivery to the following clients: 1.)

Clients who are wheelchair dependant or who have any special needs due to physical disability.

2.)

Clients who are hearing impaired: Clinics should make an effort to provide interpreters who know sign language.
Another source of help may be the Maryland Relay Service (MRS), which is a telephone service that gives people with hearing and/or speech impairments the ability to communicate by telephone.

The number is 1-800-735-2258.

There is no additional fee for local calls and long distance calls are billed at reduced rates.

For more information call the Customer Service Center at 1- 800-676-3777. e. Questions about services for the disabled may be addressed to the DHMH Office of Equal Opportunity Programs (OEOP).
OEOP information may be found on-line at http://dhmh.state.md.us/oeop/ or by calling 410-767-6600. f. If sterilizations are performed on-site by the delegate, they must conform to facility standards as established by federal Title X guidelines.

g. In an effort to assure accessible and acceptable client services, it is strongly encouraged that each delegate agency offer late afternoon, evening, and/or weekend clinic hours.

Emergency situations may occur at any time.


All projects must therefore have written plans and procedures for the management of medical and non medical emergencies.

(Section 13) 6.

PERSONNEL Delegates, or their organizing body, must establish and maintain written personnel policies that comply with federal and state requirements and Title VI of the Civil Rights Act, Section 504 of the Rehabilitation Act of 1973, and Title 1 of Americans with Disabilities Act (Public Law 101-336).

a.
a.

These policies must cover the following items: [59.5(b)(10)].

1.)

Staff recruitment and selection methods.

2.)

Methodology for performance evaluation.

3.)

Staff promotion.

4.)

Staff termination.

5.)

Compensation and benefits.

6.)

Grievance procedures.

7.)

Staff orientation.

8.)

Nondiscrimination in hiring employees.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 25 9.)

Patient confidentiality issues.

10.)


Duties, responsibilities, and qualifications of each staff position.

11.)

Licenses for those positions requiring licensure.

b.

Policies should cover the following items as appropriate: 1.)

A system for replacing key staff members in case of illness, vacation or unexpected absence.

2.)

Use of volunteer employees.

3.)

Use of contractual consultants in providing service.

4.)
4.)

Project personnel should reflect racial and ethnic diversity of population being served and be sensitive to the cultural needs of the client population.

c. Delegates must ensure that: 1.)

The medical care component of the project operates under the supervision of a medical director who is a licensed and qualified physician.

It is recommended that the medical director has training or experience in family planning.
If colposcopy and related services are provided, the supervising physician must be trained in colposcopy/cryotherapy as part of an OB/GYN residency or provide documentation of a minimum two-day training course or its equivalent.

2.)

Clinicians other than physicians performing medical functions do so under protocols and/or standing orders approved by the delegate medical director.

d. Personnel records must be kept confidential.


e. Organizational chart and personnel policies must be available to all personnel.

f. Job descriptions must be available for all positions, reviewed annually, and updated as needed.

g. Annual evaluation of all project personnel must be conducted.

1.)

The written evaluations are discussed with the employee and are kept in the employee's personnel files.

2.)

Annual peer reviews must be conducted of all project clinicians/providers.
h. All clinicians employed in the family planning program must agree to follow the clinic protocols and procedures and/or standing orders.

i.

Personnel policies should be reviewed and updated as needed.

j.

The agency must have written policies and procedures to ensure compliance with OSHA regulations regarding transmission of blood borne disease (e.g.

HIV, Hepatitis B, etc.).

7.


TRAINING AND TECHNICAL ASSISTANCE The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 26 a.

Delegates must provide for orientation and in-service training for all project personnel.

1.)

The agency should document attendance at training and continuing education programs.

2.)
2.)

All staff should be offered the opportunity to attend training programs, particularly Region III training programs, MFPRH training programs, and the annual family planning update at least once per year.

3.)

All staff, including administrative and support staff, as well as direct service providers, must be trained regarding prevention, transmission and infection control in the health care setting of sexually transmitted infections including HIV (See Section 8.8).

4.)
4.)

Funding for training and continuing education should be included in each year’s operating budget.

5.)

Staff must be trained in the unique social practices, customs and beliefs of under- served populations of their service area.

b.

Delegates should conduct an annual assessment of the training needs of their staff; and an evaluation of the scope and effectiveness of all educational programs offered.

1.)

Educational opportunities should be developed to assist in meeting identified needs.

2.)
2.)

Regular training topics should include Mandated Reporting and Human Trafficking (inclusive of Intimate Partner Violence).

3.)

These training needs should be shared with MFPRH Program.

c. Delegates should have appropriate clinical resource books available for staff such as: 1.)

Family Planning Perspectives (AGI) 2.)

The most current annual edition of Contraceptive Technology and monthly editions of Contraceptive Technology Update.

3.)

Drug Facts and Comparisons, or current PDR 8.


REPORTING REQUIREMENTS a.

All delegate agencies must comply with MFRPH minimum reporting requirements, b. Sterilization reporting requirements must be met.

All projects must be in compliance with Title X regulations on minimum age, waiting period between signing of consent and surgical procedure and informed consent.
Documentation that these requirements have been met should be found in the client’s chart and/or the sterilization log (42 CFR, Part 50, sub-part B) (50.210) 9. REVIEW AND APPROVAL OF INFORMATIONAL AND EDUCATIONAL MATERIALS (I & E) An advisory committee of five to nine members who are broadly representative of the community must review and approve all informational and educational materials developed or made available under the project prior to their distribution to assure that the materials are suitable for the population and community for which they are intended and to assure their consistency with the purposes of Title X.
Whether materials have been obtained from an outside source or created in-house, they are subject to informational and educational review The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 27 procedures established under Title X. a.

When reviewing educational materials the I&E Committee should consider the following: 1.)

The educational and cultural backgrounds of the individuals to whom the materials are addressed; 2.)
The standards of the population or community to be served with respect to such materials; 3.)

The content of the material to assure that the information is factually correct; 4.)

Whether the material is suitable for the population or community to which it is to be made available; and 5.)

Establish a written record of its determinations [59.6].

The Informational & Educational Materials Review Evaluation Worksheet should be used for this purpose.
The Worksheet is available on the Family Planning and Reproductive Health, Administrative Guidelines section of the MCHB website at http://phpa.dhmh.maryland.gov/mch b.

The committee(s) may delegate responsibility for the review of the factual, technical, and clinical accuracy to appropriate project staff.

However, final approval of information and education materials rests with the committee(s).
c. After the local I&E Review Committee has completed its work, a packet containing the following items must be submitted to the MFP Program I&E Program Coordinator: 1.)

A list of local committee members; 2.)

A copy of each of the print materials reviewed and a listing of any videos and/or DVDs; 3.)

Photocopies of each Informational & Educational Materials Review Evaluation Worksheet completed by committee members during the review; and 4.)

A copy of the sign-in sheet for the review.


d. Packets containing materials reviewed during the previous 12 month period should be submitted to the MFPRH Program Chief of Perinatal & Reproductive Health, MCHB, 201 West Preston Street, Baltimore, MD 21201, no later than March 31.

Also, please keep a copy of the packet submitted on file, as the Nurse Consultant will review it during the scheduled site visit.

10.
10.

COMMUNITY PARTICIPATION, EDUCATION AND PROJECT PROMOTION Agencies typically have diverse ways of connecting within their communities to assess needs and promote family planning services.
Delegate agencies must convene an informational and educational (I&E) materials review committee at least annually consisting The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 28 of diverse members of the community to advise family planning staff on the suitability of materials provided to or viewed by clients.
Ideally, these committees link the agency with others who are knowledgeable about the needs of the community for affordable family planning and reproductive health services.

A record should be kept, at the delegate agency, of all community education and outreach efforts, as the Nurse Consultant will review it during the scheduled site visit.

Staff should evaluate the effectiveness of the efforts.
Delegate agencies must submit a Health Education Report to MFPRH Program Chief of Perinatal & Reproductive Health, MCHB, 201 West Preston Street, Baltimore, MD 21201, no later than March 31, each year describing education and outreach activities for the preceding 12 months.

Reports should follow the Community Health Education Annual Report Format, which can be found in the Family Planning and Reproductive Health, Administrative Guidelines section of the MCHB website at http://phpa.dhmh.maryland.gov/mch 11.
COMMUNITY EDUCATION a.

Each family planning project must provide for community education programs [59.5(b)(3)].

This should be based on an assessment of the needs of the community and should contain an implementation and evaluation strategy.

b.

Community education programs should enhance community understanding of the family planning project, make known the availability of services to potential clients, and encourage participation by persons to whom family planning may be beneficial.
c. A written plan inclusive of goals, objectives, and measurement criteria must be submitted with the agency’s annual grant application.

The plan should be based on an assessment of the needs of the service delivery area.

d. A variety of strategies used in community education programming may include: 1.)

Distribution of educational materials 2.)

Educational sessions to schools, community groups, agencies and professionals 3.)
Assisting community groups in the development of family health related curricula 4.)

A system for handling community requests for information and materials 12.

PROJECT PROMOTION a.

To facilitate community acceptance of and access to the delegate's family planning services, delegates must establish and implement planned activities whereby their services are made known to the community.

[59.5(b)(3)].
[59.5(b)(3)].

Projects should review a range of strategies and assess the availability of existing resources and materials.

b.

Delegates must have a formal, written plan for program promotion.

This plan must be submitted with the annual needs assessment and health care plan.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 29 1.)

Low income women and teens must be included in the target groups the agency has identified for program promotion activities.

2.)
2.)

Promotional activities should be reviewed annually and updated in response to the changing needs of the community.

c. A variety of approaches may be used for promotional activities based on the goals of the program and the intended audience, such as: 1.)

Distribution of posters and brochures 2.)

Distribution of a newsletter to clients, board members, community leaders, etc.

3.)

Providing information to the public through mass media 4.)
Participation in community fairs, speakers bureaus, community organizations 5.)

Assisting community schools and groups in developing curricula in family life and human sexuality, reproductive health, pregnancy prevention, etc.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 30 III.

Client Services, Required Services and Clinic Management The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 31 A.
Client Services All family planning delegate agencies funded under Title X must provide clinical, informational, educational, social and referral services, relating to family planning, to clients who want such services.

All delegate agencies must offer a broad range of acceptable and effective medically approved family planning methods and services either on-site or by referral [59.5(b)(1)].
Delegate agencies should make available to clients all methods of contraception approved by the Federal Food and Drug Administration.

Section III of this document has been developed to assist delegate agencies in determining those services which will be provided to fulfill the mission of Title X.

Delegate agencies must provide services stipulated in the law or regulations of which are required by these guidelines for the provision of high quality family planning services.
Delegate agencies may also provide those services that are intended to promote the reproductive and general health care of the family planning client population.

1.

OVERVIEW a.

Family Planning services must be provided under a clinical operations plan with approved protocols and procedures.

1.)

The clinic staff must use approved protocols for the provision of all family planning services.

2.)
2.)

Emergency arrangements must be available for after hours and weekend care and should be posted, given to, and/or explained to clients.

3.)

Clinic hours should be convenient for the target population.

4.)

The staffing level of providers should be appropriate for the size and complexity of the project.

5.)

Procedures to be followed in case of fire, disaster, or other emergency should be posted.

6.)

The clinic should have adequate space and lighting, and should be clean and attractive.

b.
b.

The clinic facility must provide for the confidentiality and privacy of the client.

The traffic flow pattern in the clinic should be organized to promote privacy and confidentiality.

c. The agency must assure client confidentiality.

1.)

A confidentiality assurance statement must appear in the client's record.

2.)

Delegate agencies must assure confidentiality in policy and procedures.

3.)

Delegate agency personnel must assure confidentiality, such as in a confidentiality statement.

4.)
4.)

Confidentially should be assured in the following ways: a) Inclusion of consent forms b) Verbalized to clients c) Posted in the clinic The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 32 d. Clients should be informed of their rights and responsibilities as related to the delivery of family planning services.

Suggested approaches include: 1.)

Use of a consent form delineating these rights and responsibilities.

2.)

A poster on the wall.

3.)


An informational brochure.

e. Clinic scheduling should be efficient and promote the delivery of high quality services.

1.)

The agency should have a written procedure for scheduling client appointments.

2.)

Clients should be able to make appointments for specific times.

3.)

Clients should be able to schedule appointments within two weeks.

4.)

Teens should be able to schedule appointments within 2-4 days.

5.)
5.)

The agency should make supply visits available at various times of the day and week for convenience to the client and clinic efficiency.

6.)

Where possible, clients should be scheduled for all needed services in one visit.

f. The agency should have written procedures for handling service delivery to walk-ins, urgent problems and emergencies.

g. The no-show and walk-in rates should not exceed 30% of total appointments.

2.
2.

SERVICE PLANS AND PROTOCOLS The service plan is the component of the delegate agency’s health care plan which is developed by staff and the medical director and which identifies those services to be provided to clients under Title X.

All delegate agencies must have written clinical protocols and client education plans, signed by the agency’s Medical Director, which outline procedures for the provision of each service offered.
Delegate agencies must have the written protocols available at each clinical site.

Clinical protocols must be written in accordance with Title X program requirements, Maryland Title X Family Planning and Reproductive Health Program requirements, State of Maryland laws and nationally recognized standards for medical care.

Clinical Protocols must be reviewed and signed annually by the Medical Director.

The MFPRH Program Administrative and Clinical Guidelines Manual must be available at each clinical site.
According to the Office of Population Affairs Program Instruction, OPA 09-01, acceptable recommendations and standards of care include those of the following nationally recognized health agencies or professional organizations:  American Cancer Society  Agency for Health Care Policy and Research, U.S. Preventive Services Task Force  Centers for Disease Control and Prevention  American College of Obstetricians and Gynecologists  North American Society of Pediatric and Adolescent Gynecology  American Society for Colposcopy and Cervical Pathology The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 33  Agency for Healthcare Research and Quality  Partners in Information Access for Public Health Resources (Department of Health and Human Services) Protocols should outline the services provided at initial visits, annual revisits, and other revisits, including supply and problem revisits.
3.

PROCEDURAL OUTLINE The services provided to family planning clients, and the sequence in which they are provided will depend upon the type of visit and the nature of the service requested.

However, the following components must be offered to and documented on all clients at the initial visit: a.

Service delivery to all clients must include the following: 1.)

Assuring clients are treated courteously and with dignity and respect.

2.)

Assurance of confidentiality.

3.)


The opportunity to participate in planning their own medical treatment.

4.)

Encouraging clients to voice any questions or concerns they may have.

5.)

Materials and/or interpreter available for those with limited ability to read or understand English and for those who may be blind or hearing impaired.

6.)

Explanation of all procedures, range of available services, and agency fees and financial arrangements.

b.
b.

Client education, including use of relevant educational materials such as pamphlets, audiovisuals, and brochures, must be offered.

1.)

Education must include information about all contraceptive methods and may include information about basic male and female reproductive anatomy and physiology.

2.)

HIV/STI education and information must be offered to clients.

3.)

Client education should be individualized as much as possible based upon client needs and knowledge.
c. Individual counseling, an interactive process to assist the client in making an informed choice must be offered.

1.)

Must be done prior to client making informed choice regarding a contraceptive method.

2.)

Clients must be provided HIV/STI risk assessment, counseling regarding risk reduction and offered testing or referral for testing.

d. A signed general consent covering examination and treatment, and where applicable a method specific informed consent, must be obtained.
e. A personal, family, medical and social history must be obtained.

f. A physical examination, including necessary clinical procedures, must be provided.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 34 1.)

New clients may defer the required initial physical exam.

2.)

Clients must be counseled about the importance of preventive services, and the dangers and health risks involved if they defer or decline them.

3.)
3.)

Physical exam and other related prevention services should not be deferred more than 3 months and must not be deferred beyond 6 months, unless the clinician documents a compelling reason.

4.)

If the client decides to decline or defer a service, both the counseling that took place and the reason for the deferral must be documented in the client record.

5.)

On future visits, these clients should be encouraged to have a physical exam and appropriate laboratory testing performed.
g. Laboratory testing must be provided, as indicated.

h. Medications and/or supplies must be provided, as indicated/requested.

1.)

Must provide written specific instructions on how to use chosen birth control method 2.)

Must include danger signs and when, where, and how to obtain emergency care, return schedule and follow-up i.

Follow-up and Referral must be provided, as indicated.

1.)
1.)

Planned mechanism of client follow-up a) Suggested return visit date b) Contact information for emergencies after hours 2.)

Performance of any necessary clinical procedures 3.)

Provision of referrals as needed Return visits, with the exception of routine supply visits, should include an assessment of the client’s health status, current complaints, and evaluation of the birth control method as well as an opportunity to change methods.

4.
4.

EMERGENCIES Emergency situations involving clients and/or staff may occur any time; therefore, all agencies must have written plans and protocols/ operating procedures for the management of on-site medical and non-medical emergencies.

a.

At a minimum, written protocols must address: 1.)

Vaso-vagal reactions/Syncope (fainting) 2.)

Anaphylaxis 3.)

Cardiac arrest 4.)

Shock 5.)

Hemorrhage 6.)


Respiratory difficulties The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 35 b. Protocols must also be in place for emergencies requiring EMS transport, after-hours management of contraceptive emergencies and clinic emergencies.

c. All staff should be trained in emergency procedures and must be familiar with the plans.
Licensed medical staff providing direct patient care services must be trained in CPR and hold current certification.

d. There must be a procedure in place for maintenance of emergency resuscitative drugs, supplies, and equipment.

e. Protocols must also be in place for non-medical emergencies including: 1.)

Fire 2.)

Natural disaster 3.)

Robbery 4.)

Power failure 5.)

Harassment 5.


REFERRALS AND FOLLOW-UP Written protocols and operating procedures for referrals and follow-up must be in place for the following: referrals that are made as a result of abnormal physical exam or laboratory findings, referrals for required services, and referrals for services determined to be necessary but beyond the scope of family planning.

a.

Referral procedures must be sensitive to clients’ concerns for confidentiality and privacy.

b.
b.

Client consent for release of information to providers must be obtained, except as may be necessary to provide care or as required by law.

c. Protocols and operating procedures for referrals and follow-up made as a result of abnormal physical examination or laboratory test findings within the scope of Title X that impact contraceptive management must include the following: 1.)

A system to document referrals and follow up procedures must be in place.

2.)
2.)

Follow-up procedures must include the following: a) A method to identify clients needing follow-up b) A method to track follow-up results on necessary referrals (such as Pap and breast follow-up) c) Documentation in the client record of contact and follow-up d) Documentation of reasons, actions and follow-up where recommendations were not followed and/or protocols not acted upon 3.)
Referral procedures should include that the client be given an explanation of the referral and need for follow-up including: a) Reason and importance of the referral b) Services to be received from the referral agency The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 36 c) Address of the referral provider/agency d) Any instructions needed to follow through with the referral e) When to return to the family planning clinic d. Delegate agencies must provide all family planning services listed in Section 9.0 of the Federal Program Requirements for Title X Funded Family Planning Projects, under “Project Services and Clients” either on-site or by referral.
When required services are provided by referral, the agency must have in place formal arrangements with a referral provider that includes a description of the services provided and includes cost reimbursement information.

e. For services determined to be necessary but which are beyond the scope of the project (such as thyroid abnormalities), clients must be referred to other providers for care.

When a client is referred for non family planning or emergency clinical care, agencies must: 1.)
Make arrangements for the provision of pertinent client information to the referral provider (client may hand carry referral information).

2.)

Obtain the client consent for referral arrangements, except as necessary to provide care or as required by law.

3.)

Document that the client was advised of the referral and the importance of follow- up.

4.)

Document that the client was advised of their responsibility to comply with the referral.

5.)

Maintain appropriate safeguards for confidentiality.
f. Agencies must maintain a current list of providers including health care providers, local health and human service departments, hospitals, voluntary agencies, and health service projects supported by other federal programs to be used for referral purposes.

1.)

Referral lists must be current and updated annually.

2.)

Providers should be selected by procedures which assure fairness in selection and identify providers of acceptable quality.

3.)
3.)

When possible, clients should be given a choice of providers.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 37 B.

REQUIRED SERVICES 1.

OVERVIEW The services contained in this section must be provided by all Title X funded projects.

The client’s written informed voluntary general consent must be obtained prior to receiving any clinical services.
In addition, if a client chooses a prescription method of contraception, a method-specific consent must be obtained and updated at subsequent visits to reflect a change to a different method or significant changes in information regarding the method.

2.

CLIENT EDUCATION a.

Delegate agencies must have written client education plans that include goals and content outlines to ensure the consistency and accuracy of the education.
The education must provide clients with the information needed to make informed decisions about their reproductive health.

Client education must be documented in the client record.

The education provided must be appropriate to the client’s age, level of knowledge, language, socio-cultural background and be presented in an unbiased manner.

The education plan should include content on the educational focus for initial, annual, other revisits and supply visits.

b.
b.

Following are educational topic areas that must be provided: 1.)

Birth control methods: a) Hormonal Contraceptives (oral, injectable, implant, patch, ring) b) Abstinence c) Natural family planning d) Barrier Methods (male & female condoms, diaphragm, sponge, cervical cap, spermicide) e) Intrauterine Devices f) Sterilization (tubal surgery, tubal implant, vasectomy) g) Emergency Contraception 2.)

Instruction in breast self awareness and testicular self-exam 3.)
Education on reducing the risk of Sexually Transmitted Infections (STIs), including Human Immunodeficiency Virus (HIV) 4.)

Information on the range of available services, purpose and sequence of clinic procedures.

5.)

Information on the importance of recommended screening tests and other procedures involved in the family planning visit.

6.)

Information around Intimate Partner Violence (IPV), and available resources.

c. Following educational topic areas should be provided as indicated: 1.)
Clients should be offered information about basic male and female anatomy and physiology and the value of fertility regulation in maintaining individual and family health.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 38 2.)

Information on reproductive health and health promotion, disease prevention, including nutrition, exercise, smoking cessation and alcohol and drug abuse, domestic violence and sexual abuse.

3.)
3.)

Education should include information on clinical services that are available and what to expect during clinic appointments.

4.)

Individualized educational needs should be identified and addressed during the visit.

5.)

The client should receive information about routine screening tests and other procedures involved in the family planning visit.

6.)
6.)

A variety of teaching methods may be used, for example: (i) One-on-one instruction with the client (ii) Videotape or DVD (iii)Pamphlets or other written media (iv) Group education 3.
INFORMED CONSENT Delegate agencies may need to obtain multiple types of written informed consent, depending on the services a client will receive: a general consent must be obtained prior to receiving clinical services; a second, method-specific informed consent must be obtained for prescription birth control; and a third federally required consent for sterilization.

In addition, consent to release information may be required before client information is released.

a.
a.

A written consent for general family planning services must be obtained at the initial visit.

It should be obtained again every four years for continuing clients or if there is a break in service of one year or greater.

b.

Each consent form must be signed and dated by the client and witnessed and signed and dated by a staff member after thorough counseling and review of the information on the form.
c. A written consent for a specific procedure (such as IUD/IUS insertion) needs to be obtained only at the time of the procedure.

d. The FDA-approved and manufacturer-supplied pamphlet must be given to the client for all hormonal methods and the IUD.

This action should be documented.

e. The client may be given a copy of each consent, if requested.
f. If the clinician believes that a client is unable to give informed consent (for example, because of mental disability), then written informed consent must be given by the parent or legal guardian if the client is a minor, or a legal guardian if the client is an adult.

g. Local programs may use additional consent forms.
The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 39 h. Templates for method specific consent forms can be found on the MFPRH Program website http://phpa.dhmh.maryland.gov/mch/SitePages/fp_home.aspx 4.

COUNSELING The main reason for counseling is to assist clients to reach informed choices about their reproductive health and continued use of family planning methods and services.
The counseling process should be designed to help clients resolve uncertainty, ambivalence, and anxiety about their reproductive health and increase their ability to make decisions that fit their lifestyle.

The counseling process involves mutual sharing of information.

It must be provided by someone who is knowledgeable, objective, non-judgmental, sensitive to the rights and differences of clients as individuals, culturally aware and able to make the client comfortable while sharing personal information.
The counselor must have the knowledge to provide accurate information about the benefits and risks, safety, effectiveness, potential side effects, complications, discontinuation issues and danger signs of various contraceptive methods.

The counselor should be aware of other services and referral agencies.

Documentation of counseling must be in the client’s record.

a.

Method Counseling is an individualized discussion that includes the following: 1.)
The results of the history, physical exam, and lab testing 2.)

How to use contraceptive methods, including natural family planning (NFP), and the benefit and efficacy of the methods 3.)

Possible side effects and complications 4.)

How to discontinue the method selected and information regarding back up method use 5.)

Protection against STI/HIV with the method selected 6.)

Return visit schedule 7.)

Emergency 24-hour telephone number 8.)

Location where emergency services can be obtained 9.)
Appropriate referral for additional services as needed b. Sexually-Transmitted Infection (STI) and HIV (Human Immunodeficiency Virus) Counseling 1.)

All clients must receive accurate counseling on STIs and HIV.

Counseling refers to an individualized discussion with a client that involves personal risks for STIs and HIV and the steps to be taken by the individual to reduce their risks.
Clients with at- risk behaviors for STIs and HIV must be advised about risk reduction and if clinical evaluation is needed.

2.)
2.)

All delegate agencies must offer the following HIV components: a) Education about HIV infection and Acquired Immune Deficiency Syndrome (AIDS) b) Individualized risk assessment and risk reduction counseling The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 40 c) If the delegate agency does not provide HIV testing on-site, they must provide the client with a referral list of health care providers who can provide this service.

3.)
3.)

All delegate agencies must follow the most current Centers for Disease Control and Prevention (CDC) Sexually Transmitted Diseases Treatment Guidelines (CDC Guidelines) and their local health department or Maryland Department of Health and Mental Hygiene’s Infectious Disease and Environmental Health Administration.

4.)
4.)

Information on reportable disease is available on the Infectious Disease and Environmental Health Administration’s (IDEHA) website at http://ideha.dhmh.maryland.gov/SitePages/reportable-diseases.aspx The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 41 5.

HISTORY, PHYSICAL ASSESSMENT AND LABORATORY TESTING a.

History 1.)

At the initial comprehensive clinical visit, a complete medical history must be obtained on female and male clients.
At minimum, the history must include the following: a) Significant illnesses; hospitalizations; surgery; blood transfusion (prior to 1984) or exposure to blood products; and chronic or acute medical conditions b) Allergies c) Current use of prescription and over-the-counter medications d) Extent of use of tobacco, alcohol, and other drugs e) Immunizations and Rubella status (use of MCIR is encouraged) f) Review of systems g) Pertinent history of immediate family members h) Partner history of: (i) injectable drug use (ii) multiple partners (iii)risk history for STIs and HIV (iv) sex with men, sex with women or both i) Intimate Partner Violence (IPV) 2.)
Female reproductive history must include at least the following: a) Contraceptive use, past and current (including any adverse effects); reasons for stopping past method b) Menstrual history, including last menstrual period (LMP) c) Sexual history d) Obstetrical history e) Gynecological conditions f) Sexually transmitted infections, including Hepatitis B Virus (HBV) (i) HIV infection (ii) Pap test history (date of last Pap, abnormal Pap, treatment) (iii)In-utero exposure to diethylstilbestrol (DES).

3.)
3.)

Male reproductive history must include at least the following: a) Sexual history b) Sexually transmitted infections, including HBV c) HIV infection d) Urological conditions b.

Physical Assessment (female) For many clients, Family Planning programs are the only continuing source of health information and clinical care.
Therefore, an initial complete physical exam, including height and weight, examination of the thyroid, heart, lungs, extremities, breasts, abdomen, pelvis, and rectum, should be performed.

The primary reason for family The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 42 planning visits is fertility regulation, but other health maintenance screening is important and should be encouraged.

1.)
1.)

Clinics must provide and stress the importance of the following to all clients: a) Blood pressure evaluation b) Clinical breast exam (CBE) as age appropriate, including instruction in breast self awareness c) Pelvic examination including vulvar evaluation and bimanual exam, beginning at age 21 and only as indicated for 13-20 years of age d) Pap testing as indicated e) Colo-rectal cancer screening, beginning at age 50 f) STI and HIV risk assessment and screening or referral, as indicated 2.)
Clients must be counseled about the importance of the above preventive services, and the dangers and health risks involved if they defer or decline them.

If a service is deferred or declined, both the counseling that took place and the reason for the deferral must be documented in the client record.

3.)
Delegate agencies protocols must be developed to ensure that: a) All physical exams and laboratory tests required for specific methods of contraception must be followed b) Physical exam and related preventive services should not be deferred more than 3 months after the initial visit, and in no case be deferred beyond 6 months, unless in the clinician documents a compelling reason to do so c) All deferrals and reason for deferral must be documented in the client record c. Physical Assessment (male) Family planning clinics are an important source of reproductive health care for male clients.
A physical exam should be provided that includes: height and weight, examination of the thyroid, heart, lungs, breasts, abdomen, extremities, genitals and rectum.

Examination should also include palpation of the prostate, as appropriate, and instructions in self-examination of the testes.

Clinics should stress the importance of the following to male clients: 1.)

Blood pressure evaluation 2.)

Colo-rectal cancer screening, beginning at age 50 3.)
STI and HIV risk assessment and screening or referral, as indicated d. Laboratory Testing Written laboratory protocols and operating procedures must be in place that meets the following required standards: 1.)

Specific laboratory tests are required for the provision of specific methods of contraception.

These tests are also indicators of health status and are useful for The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 43 diagnostic reasons.
These tests are provided to the client unless written results of the test done within 12 months are obtained and placed in the medical record.

a) Pregnancy testing must be provided on site as indicated.

b) Laboratory testing must be provided if indicated for a specific method of contraception.

c) Pap testing must be provided on site as indicated.

d) HIV testing, or referral for testing, as indicated.
e) Colo-rectal cancer screening, beginning at age 50. f) The following laboratory testing must be provided if required in the provision of a specific contraceptive method.

They may be provided, either on site or by referral, for health maintenance and/or for diagnostic purposes as indicated.
(i) Anemia assessment (ii) Gonorrhea and Chlamydia testing (iii) Vaginal wet mount (iv) Diabetes testing (v) Cholesterol and lipids (vi) Hepatitis B testing (vii) Genital Herpes testing (viii) Syphilis serology (VDRL, RPR) (ix) Rubella titer (x) Urinalysis g) The following testing may be provided either on site or by referral for health maintenance and/or diagnostic purposes as indicated.
(i) Condylomata Acuminata (HPV) (ii) Trichomonas (iii)Candidiasis (iv) Bacterial Vaginosis h) Quality control, equipment maintenance and proficiency testing for on-site lab testing must be in place.

i) Assurance of high quality lab testing for off-site labs must include: (i) Compliance with Clinical Laboratory Improvement Amendments (CLIA) regulations.
Following is a CLIA website for more information: http://www.cms.hhs.gov/clia (ii) A system for assessing credentials of contracting labs should be in place (iii)Cytology services must be provided by laboratories compliant with state licensure regulations j) A procedure must be established for referral and follow-up for abnormal tests that includes the following: (i) Documentation of the appropriate management for abnormalities (ii) Notification of the client The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 44 (iii)Protection of the client’s confidentiality (iv) Follow-up with the client of significant lab results (v) Referral for necessary services if not provided on-site (vi) When initial contact is not successful, a reasonable further effort should be made, consistent with the severity of the abnormality.
e. Agencies should provide testing for a variety of STIs as indicated.

If testing is provided, delegate agencies must have STI treatment protocols and follow-up procedures in place that are consistent with current CDC guidelines.

f. When indicated, the following lab tests and procedures may be provided or referred: 1.)

Microscopic exam of vaginal smears and wet mounts.

2.)

Microscopic exam and/or culture and sensitivity of urine.

3.)
3.)

Selected blood tests including fasting and/or random blood sugar, cholesterol, and other lipid panels.

g. Written protocols for abnormal Pap testing follow-up must be in place.

1.)

Follow-up contact must be noted in the client’s medical record.

2.)

Results of the follow-up must be noted in the client’s medical record.

3.)

If unable to contact client, a certified letter should be sent to those clients who have any high grade lesions or cancer on their Pap test result.

h. Revisits 1.)
h. Revisits 1.)

Revisit schedules must be individualized based on the client’s need for education, counseling, and clinical care beyond that provided at the initial and annual visits.

2.)

Clients selecting hormonal contraceptives, implants, intrauterine devices (IUD/IUS), or diaphragms for the first time may be scheduled for a revisit, if needed, to reinforce proper use, check fit, side effects, and provide additional information.

3.)
3.)

A new or established client who chooses to continue a method already in use need not return for a revisit unless a need for reevaluation is determined on the basis of findings at the initial visit.

4.)

Pertinent history must be updated at subsequent physical exam visits.

6.

FERTILITY REGULATION (CONTRACEPTION) a.

Written protocols and operating procedures must be in place that meet the following standards: 1.)
A broad range of Federal Drug Administration (FDA) approved methods of contraception must be made available on site or through referral.

2.)

Current FDA guidelines as to relative and absolute contraindications should be followed when prescribing contraceptives.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 45 3.)

More than one method may be used simultaneously by the client.
Clients with high- risk sexual behavior patterns should be encouraged to use condoms correctly and consistently in addition to any other chosen method to reduce the risks of STIs/HIV and pregnancy.

b.

Methods of contraception that must be provided and for which written protocols must be in place include: 1.)

Reversible contraception a) Hormonal Contraceptives b) At least two delivery methods of combined hormonal contraceptives must be available on site.
c) At least one delivery method of progestin-only contraceptives must be available on site.

d) At least a second type of progestin-only method must be made available on site within two weeks of client request.

2.)

Condoms a) At least male condoms must be available on site.

3.)

Implants and Intrauterine Devices (IUD/IUS) must be provided, either on site or by paid referral.

4.)
4.)

Education materials and information regarding all methods, including hormonal contraceptives, abstinence, natural family planning, barrier methods, intrauterine devices, sterilization, and emergency contraception.

5.)

The agency formulary must indicate: a) Methods maintained and available on site.

b) Methods available on site within two weeks of client request.

c) Methods available by paid referral.

d) Methods available by unpaid referral.

6.)


Agencies are encouraged to review current practice and the needs of their client population and maintain the most frequently used methods where feasible.

7.)

Agencies are strongly encouraged to provide emergency contraception and maintain supplies on site.

7.
7.

EMERGENCY CONTRACEPTION Certain oral contraceptive regimens have been found by the FDA to be safe and effective for use as post-coital emergency contraception when initiated after unprotected intercourse, including 1 and 2 pill formulations of progestin-only emergency contraceptive pills.

Emergency Contraception education and referral must be provided to all female clients.
The The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 46 provision of pre-placement emergency contraception is strongly encouraged, but not required for delegate agencies.

Where delegate agencies provide this method the following must occur: a.

Written protocol must be in place.

b.

The client requesting emergency contraception should have a negative, highly sensitive pregnancy test to exclude a pre-existing pregnancy if indicated by the client’s history.
c. Birth control counseling should accompany or follow any method used for emergency contraception.

8.

PERMANENT CONTRACEPTION (STERILIZATION) Clinical guidance on sterilization for males and for females can be found in the Maryland Title X Family Planning and Reproductive Health Program Clinical Guidelines.
The guidance that follows pertains to the process of counseling and referring the client, obtaining informed consent where appropriate, processing the consent form and assisting in scheduling the procedure.

a. Vasectomy Since 1994, the Maryland Family Planning and Reproductive Health Program has funded vasectomy procedures for a limited number of Maryland men aged 21 or older who desire this method of contraception but cannot afford it.

The procedures are performed at the Planned Parenthood of Maryland.
Counseling and consent, which must be completed at least 30 days prior to the procedure, may be provided either at Planned Parenthood of Maryland or at any other Maryland State Family Planning and Reproductive Health Program clinic site.

To obtain information about vasectomy services offered by Planned Parenthood of Maryland and funded by the Maryland State Family Planning and Reproductive Health Program, go to www.plannedparenthoodmd.org or call 410-665-9775.

1.)
1.)

Counseling a) The client may receive vasectomy counseling at any delegate agency.

When the counseling is performed locally, the prospective vasectomy patient signs the consent form at the conclusion of the session and hand-carries the original to Planned Parenthood of Maryland on the day of the procedure.

b) Patient education tools may be used in order to assist with vasectomy counseling.
Vasectomy counseling will include information about the “no-scalpel” procedure, advantages, disadvantages, permanency, the availability of other contraceptive options for the client and his partner and the post-operative semen analysis.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 47 2.)
Consent a) The Federal Sterilization Consent (OMB 0937-0166) must be used when a client chooses sterilization through the MFPRH Program partnership with Planned Parenthood of Maryland.

It is available in English or Spanish for from the OPA Clearinghouse (http://www.hhs.gov/opa/pdfs/consent-for-sterilization-english- updated.pdf).

It must be signed by the client and witnessed by staff.
If the client signed the consent at a local clinic, he must bring the original with him to the Planned Parenthood of Maryland facility on the day of the procedure.

b) It is important to remember that vasectomies funded through federal government programs such as the Title X program and Medicaid or Medicare require that there be a 30-day waiting period between the date the consent was signed and the date of the vasectomy.
Once signed, the consent form is effective for 180 days from the date of the signature.

3.)

Release of Medical Information If the local provider wants vasectomy information returned, the provider must forward a release of information form, signed by the client to Planned Parenthood of Maryland.
The INDIVIDUAL’S AUTHORIZATION form which can be found by staff or local health departments on the DHMH Intranet at http://indhmh/hipaa/html/guideandforms.html or an alternative HIPAA-compliant release form is acceptable.

4.)

Financial Eligibility Determination The contact person at Planned Parenthood of Maryland will explain the fee assessment eligibility process when the client calls to make the vasectomy appointment.

9.

TUBAL LIGATION REFERRAL The MFPRH Program does not fund tubal ligation surgeries.
However, clients seeking information about sterilization should be counseled by staff regarding the advantages and disadvantages of tubal ligation, its permanency, and the availability of other contraceptive options.

Patient education tools may be used in order to assist with tubal ligation counseling.

The Office of Population Affairs (OPA) Clearinghouse offers the information on female sterilization (http://www.hhs.gov/opa/reproductive-health/contraception/female- sterilization/).
Clinics should have a current list of local providers for referral.

Women who are in the Maryland Medical Assistance Family Planning (Purple and White Card) Program are eligible for tubal ligation if they are 21 years or older.

The women can choose any doctor or clinic that accepts Medical Assistance.

10.
10.

INFERTILITY SERVICES The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 48 All clinics must offer at least basic (Level I) infertility services, which include an initial infertility interview, education, physical examination, counseling, and appropriate referral.

However, Level II and Level III infertility services are beyond the scope of services offered by the Maryland State Family Planning and Reproductive Health Program.
The following centers are referral resources for infertility: a.

University of Maryland Hospital Gynecology, Endocrinology and Infertility Clinic 410-328-6640 b. Johns Hopkins Hospital Gynecologic, Infertility and Endocrine Clinic 410-955-5191 11.

PREGNANCY DIAGNOSIS AND COUNSELING Delegate agencies must provide pregnancy diagnosis and counseling to all clients in need of this service.

Pregnancy testing is one of the most common reasons for a first visit to a family planning agency.
It is therefore important to use this occasion as an entry point for providing education and counseling about family planning services.

a.

Written protocols and procedures must meet the following standards: 1.)

Pregnancy diagnosis services include: a) Informed consent b) History c) Pregnancy testing with high sensitivity d) Physical exam, including pelvic exam b.
When a physical exam is not performed at the time of the pregnancy test, the client must be counseled about the importance of a physical assessment, preferably within 15 days.

This physical exam can be done on-site, by a provider of the client’s choice, or through a referral.
c. If the pregnancy test is positive, all of the following counseling options to manage the pregnancy must be offered, except with respect to any option(s) about which the pregnant woman indicates she does not wish to receive such information and counseling.

1.)

Prenatal care and delivery 2.)

Infant care, foster care, or adoption 3.)

Pregnancy termination d. Pregnancy options counseling must be provided in a non-directive, unbiased manner.
When requested to provide such information and counseling, agencies must provide neutral, factual information and nondirective counseling on each of the options, and referrals upon request, except with respect to any options about which the pregnant woman indicates she does not wish to receive information and counseling.

[59.5(a)(5)].
[59.5(a)(5)].

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 49 e. Clients with positive pregnancy tests who elect to continue the pregnancy should receive a referral for early prenatal care and information about the importance of early prenatal care.
Clients planning to carry their pregnancies to term should be given information about good health practices during early pregnancy, especially those which serve to protect the fetus during the first three months (e.g., good nutrition, avoidance of smoking, drugs, alcohol and exposure to x-rays).

f. Clients with a negative pregnancy diagnosis should be given information about the availability of contraceptive and infertility services and offered an appointment, as appropriate.
If the pregnancy test is negative, but other indicators are present for pregnancy, the client should be encouraged to have a repeat pregnancy test within the appropriate time frame.

Clients with a negative pregnancy test should have the cause of their delayed menses investigated.

g. If an ectopic pregnancy is suspected, the client must be referred for immediate diagnosis and treatment.

Clients with a history of pelvic inflammatory disease (PID) are at high risk for ectopic pregnancies.
Follow-up with these clients must occur and all contact must be documented in the medical record.

h. Personnel involved in pregnancy diagnosis and counseling must have knowledge of: 1.)

Pregnancy testing procedures 2.)

Prenatal care and delivery 3.)

Infant care, foster care and adoption 4.)

Pregnancy termination 5.)

Local availability of referral services 6.)

Methods of contraception 7.)

Federal and state requirements regarding mandatory reporting, options counseling, and abortion laws 8.)
Non-directive counseling skills and techniques 9.)

Documentation needed for the client record 12.

ADOLESCENT SERVICES Adolescent clients require skilled counseling and age-appropriate information.

An atmosphere in which the adolescent is comfortable asking questions should be created.

The agency must address in their annual plan service delivery to adolescents, including the total number of adolescents the agency anticipates serving.
Appointments should be available to them for counseling and clinical services as soon as possible.

Adolescents seeking contraceptive services must be informed about all methods of contraception.

It is important not to assume that the adolescent is sexually active because they came for family planning services.

As the contraceptive needs of adolescents frequently change, counseling should prepare them to use a variety of methods effectively.
The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 50 a.

The agency must have protocols and operating procedures that address the following requirements related to adolescent health: 1.)

Adolescent counseling services must consist of: a) Assurance of confidentiality of services b) An atmosphere in which the adolescent is comfortable in asking questions.
c) Information on all methods of contraception, including abstinence d) Discussion of sexually transmitted infections, including HIV infection, and safer sex practices to reduce risks for STI/HIV.

2.)

Encourage participation in the agency’s medical services, including physical exam, laboratory testing, and treatment as indicated 3.)

Encourage family participation in the decision of minors to seek family planning services.

4.)
4.)

Provide counseling on how to resist attempts to coerce adolescents into engaging in sexual activities.

5.)

Inform adolescents that in special cases, (e.g.

suspected child abuse) that reporting to authorities is required.

b.

The delegate should have specialized projects or services for adolescents.

These may include the following: 1.)

Peer counselors 2.)

Special clinic hours for adolescents 3.)

School/community education programs 4.)

Priority appointments to schedule within 2-4 days 13.
IDENTIFICATION OF ESTROGEN-EXPOSED OFFSPRING Women born between 1940 and 1970 must be assessed for in-utero DES exposure.

The children of women who received DES or similar hormones during pregnancy may have abnormalities of their reproductive systems or other fertility related risks.

Clients exposed to exogenous estrogen must receive information, education and special screening either onsite or by referral.

C. Related Services 1.


GYNECOLOGICAL SERVICES Family planning delegate agencies should provide for the diagnosis and treatment of minor gynecologic problems to avoid fragmentation or lack of health care for clients with these conditions.

Problems such as vaginitis or urinary tract infection may be amenable to on-the- spot diagnosis and treatment, following microscopic examination of vaginal secretions or urine dip stick testing.

These services should be provided.


More complex procedures, such as colposcopy, may be offered, provided that clinicians performing these services have specialized training.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 51 2.
SEXUALLY TRANSMITTED INFECTIONS (STIS) AND HIV/AIDS The increasing incidence and prevalence of STIs, particularly among adolescents, requires that family planning delegate agencies increase their efforts to provide education and information about the more common STIs and HIV/AIDS.

Delegate agencies should make available detection and treatment of the more common STIs.

At-risk clients should be urged to undergo examination and treatment as indicated, either directly or by referral.
When treatment is provided on-site, appropriate follow-up measures must be undertaken.

Gonorrhea and chlamydia tests must be available for clients requesting IUD insertion, if indicated.

Tests for gonorrhea, chlamydia, syphilis, and HIV should be available as indicated by client request or evidence of increased risk.

a.

Written protocols and operating procedures for sexually transmitted infections must be in place when STI services are provided by the delegate agency and must include the following: 1.)
Screening should follow current Centers for Disease Control and Prevention STI Treatment Guidelines: a) Chlamydia tests should be provided annually for sexually active females 24 and under.

Clients who test positive should be re-tested 3 months following treatment for early detection of re-infection.

Clients who do not present at 3 months for re- test should be re-tested the next time they present for services in the 12 months following treatment of the initial infection.
Females over 24 should be tested only if other risk factors are present (infected partner, symptoms, history of STI or multiple partners in the last year).

b) CDC screening recommendations indicate targeted chlamydia screening for men only when resources permit and do not hinder chlamydia screening efforts in young women 24 and under.

2.)

Gonorrhea testing should be offered annually to high risk clients 24 and under who reside in high prevalence areas.
Females over 24 should be tested only if other risk factors are present (infected partner, symptoms, history of STI or multiple partners in past year).

3.)

Routine Gonorrhea screening of males at low risk is not recommended.

4.)

When treatment for any STI is provided on-site, the delegate must follow current Centers for Disease Control and Prevention STI Treatment Guidelines and ensure appropriate follow-up measures are taken with all persons treated.

5.)
5.)

Delegate agencies must comply with state and local STI reporting requirements.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 52 6.)

Providers should encourage their clients with STIs to notify their sex partners and urge them to seek medical evaluation and treatment.

7.)

Test for syphilis as indicated.

8.)

Test for other STIs as indicated.


b. HIV/AIDS written protocols and operating procedures must be in place to meet the following required HIV/AIDS services: 1.)

Education on HIV infection and AIDS 2.)

HIV risk assessment, counseling regarding risk reduction and referral services 3.)

Testing or referral for testing 4.)


All clinical staff must receive in-service training regarding: a) HIV infection and its prevention b) Transmission and infection control in a health care setting c) Education on HIV infection should be included in appropriate community educational sessions 3.

GENETIC INFORMATION AND REFERRAL Information gathered when completing the family planning initial record may assist in assessing the client’s need for genetic counseling and evaluation.
The clinician and other staff members should be alert to any indication of genetic disorders or conditions in a client that may lead to birth defects.

Extensive genetic counseling and evaluation are beyond the scope of the MFPRH Program; therefore, a referral systems should be in place for those that require such services.

The Office for Genetics and Children with Special Health Care Needs at DHMH can facilitate referral for in-depth personalized counseling.
You may call the Office for Genetics and Children with Special Health Care Needs at 410-767-6730 or 1-800-638-8864.

Additionally, the following centers are referral resources: a.

University of Maryland Hospital Prenatal Diagnostic Center 410-328-3335 b. Johns Hopkins Hospital Prenatal Diagnostic Center 410-955-3091 c. Sinai Hospital Prenatal Diagnostic Center 410-601-5853 4.
HEALTH PROMOTION/DISEASE PREVENTION The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 53 Family planning programs should, whenever possible, provide or coordinate access to services intended to promote health and prevent disease.

Delegate agencies are encouraged to assess the health problems prevalent in the populations they serve and to develop strategies to address them.
For many clients, family planning programs are their only continuing source of health information and medical care.

Delegate agencies should, whenever possible, provide or coordinate access to services intended to promote health and prevent disease.

Health promotion/disease prevention information should include the following: a.

Cancer detection - breast, cervical, testicular and colon b.
Harmful effects of smoking and smoking cessation resources c. Automobile safety, including seat belt and child car seat resources d. Sexual risk behaviors e. Substance abuse f. Mental health problems g. Weight control h. Regular exercise i.

Violence prevention: including domestic assault, relationship abuse, and human trafficking 5.

POSTPARTUM CARE Family planning programs may provide postpartum care in collaboration with local agencies or institutions which provide prenatal and/or intrapartum care.
If a family planning program assumes responsibility for postpartum care, such care should be directed toward: a.

Assessment of the woman’s physical health b. Initiation of contraception, if desired c. Counseling and education related to: 1.)

Parenting 2.)

Breast-feeding 3.)

Infant care 4.)

Post-partum depression 5.)

Family adjustment 6.

INTIMATE PARTNER VIOLENCE Intimate partner violence (IPV) is a pattern of assaultive or coercive behaviors perpetrated by a current or former intimate partner.
It is also known as domestic violence.

It often includes physical abuse, psychological abuse and/or sexual violence.

The goal of this behavior is achieving compliance from or control over the victim.
The prevalence of IPV in Maryland is significantly higher than the national rate with 42% of Maryland women reporting a lifetime history of rape, physical violence and/or stalking by an intimate partner.1 It is most prevalent in women of childbearing age and is associated with unintended pregnancy, repeat abortions, sexually transmitted infections, gynecological The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 54 disorders and pregnancy complications.
IPV is also linked to chronic diseases, behavioral health issues and alcohol and drug use.

Most violence toward a partner is perpetrated by a male against a female; however, male-to-male, female-to-male and female-to-female violence is known to occur as well.

Many women who experience IPV also experience reproductive coercion.

Reproductive coercion is characterized by an intimate partner’s attempt to maintain power and control through behaviors that impact reproductive health.
It may involve birth control sabotage and interference, pregnancy pressure and/or coercing a partner to have unprotected sex.

IPV negatively impacts family planning program outcomes.
Women who experience intimate partner violence are more likely to have partners who refuse to use condoms or prevent them from using contraception and are three times more likely to have an STI.2 Adolescent girls who are currently involved in physically abusive relationships are over three times more likely to become pregnant than non-abused girls.3 Family planning clinic clients have high rates of violence.4,5 This makes family planning settings an ideal place to offer education, screening and interventions for IPV and reproductive coercion.
Family planning clinics that implemented an intervention promoting awareness of IPV, harm-reduction counseling and referrals saw a 71% reduction in pregnancy pressure and coercion in women who experienced IPV.6 The women were also 60% more likely to end a relationship they perceived as unsafe or unhealthy.6 Across health care settings, women who talked to their health care providers were four times more likely to seek help and two times more likely to end an abusive relationship.7 The American College of Obstetricians and Gynecologists (ACOG) recommends routinely screen women and adolescent girls for intimate partner violence including reproductive and sexual coercion.8 This is further supported by the U.S. Preventative Service Task Force recommendation that all women of childbearing age be screened for IPV.9 The Institute of Medicine also recommends IPV screening and counseling at women’s health visits.10 The CDC and the U.S. Office of Family Planning suggests the provider consider current and past IPV when providing contraceptive services as it may interfere with the correct and consistent use of contraception.11 ACOG recommends counseling patients on harm- reduction strategies and safety planning for women experiencing reproductive or sexual coercion.12 Harm reduction counseling should include information about less detectable long-acting contraceptive methods like IUDs, implants and injections as well as offering emergency contraception when appropriate.
Clients should be counseled on the need to receive regular STI testing and offered alternate methods of partner notification for positive STI screenings.

In addition, if a client screens positive for IPV, the health care provider should assess immediate safety, and offer a referral to community resources.

Offering support to facilitate the referral process increases the likelihood that a client will follow through with seeking help.
Clinics should create connections with advocates from local domestic and sexual violence organizations.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 55 The goal of screening is not to get the woman to disclose abuse or to leave her partner.

The goal is to help her stay safe and reduce her risk of harm.

Your recognition and validation of her situation is important.

Many women who have been victimized are reluctant or unable to get help.
Some are literally held captive, and others may not have the money or means of transportation to leave.

Cultural, ethnic and/or religious influences may affect a woman’s response to violent behavior and her awareness of viable options.

Some victims are at greatest risk when they try to leave the situation or have separated from the abuser.
Creating a safe environment for assessment and disclosure begins with displaying educational materials that address IPV and reproductive coercion in the clinic and providing discreet take-home materials like relationship safety cards in the waiting room.

This helps to educate clients, plant seeds for those who are experiencing abuse but not ready to disclose and lets victims know they are not alone.
These educational materials also serve as primary prevention by helping clients recognize unsafe or unhealthy relationships and educating them on how to assist a friend or family member who may be experiencing IPV.

Maryland does not have mandatory reporting requirements for domestic violence.

In Maryland, mandatory reporting is required only for abuse or neglect of a child or abuse, neglect or exploitation of a vulnerable adult.
A vulnerable adult is defined as a person aged 18 or older who lacks the physical or mental capacity to provide for his or her daily needs.

In other situations involving interpersonal violence, it is the responsibility of the victim to report the abuse to the proper authorities, OR the victim may provide consent to a healthcare provider to report the abuse.
However, whenever any health care provider treats a person for an injury that was caused by or shows evidence of having been caused by any type of gunshot or moving vessel, or by an auto accident or a lethal weapon (only in the following counties: Allegany, Anne Arundel, Charles, Kent, Montgomery, Prince George’s, Somerset, Talbot and Wicomico) the police must be notified.

a. IPV guidelines for providers are as follows: 1.)
All clients should be educated to increase their awareness of violence as a health problem.

This information should be part of their health care education and counseling.

2.)

Family planning clients should be screened for current or previous IPV during initial visits.

Screening should be updated at least annually thereafter.

Information about a person’s prior experience of physical, psychological or sexual violence may have bearing upon current or future health and wellbeing.
Clients should also be screened when showing signs of depression or mental health issues, substance abuse, repeat pregnancy tests, and new or recurring STIs.

3.)

Normalize the conversation by letting the client know IPV screening is a standard of care.

For example, say “Because violence is so common and help is available, I now ask every patient if they are being hurt by a current or former partner.” The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 56 4.)
Clients should be informed about the level of confidentiality they may expect in response to any disclosure they may make.

Requirements for mandated reporting of child abuse or neglect should be clearly stated, including the requirement that maltreatment be reported even when it occurred when an adult was still a child.

5.)

Screening should be carried out alone and in private.
Avoid stigmatizing language like “rape,” “battering” and “violence.” Direct, specific questions should be phrased in order to make them nonjudgmental and as non-threatening as possible.

For example, “Has your current or former partner threatened you or made you feel afraid?” 6.)

Health care providers should accurately document any problems or complaints of abuse, or physical evidence of violence.

7.)
7.)

The possibility of IPV should be considered when a client’s explanation for an injury does not seem plausible, when there has been a delay in seeking medical care or when an individual presents with vague complaints for which there is no other plausible explanation.

8.)

Cultural competency is important, and questions should be asked in the client’s primary language when possible.

Do not use a friend, family member or partner as a translator.

9.)
9.)

Upon learning of an incident or pattern of domestic violence, a provider needs to assess the current safety of the client.

If the client was victimized in the past and is no longer at risk, a referral for counseling may be indicated.

If there is violence in a current relationship, a provider should attempt to establish a safety plan with the client and make referrals to community resources.
Each clinic should maintain listings with contact information for local law enforcement, shelters and other agencies that serve victims of domestic violence and counselors.

The Maryland Network Against Domestic Violence (MNADV) and the Maryland Coalition Against Sexual Assault (MCASA) can provide statewide information on laws as well as national and local resources.

To contact MNADV, go to www.MNADV.org or call 1-800-MD HELPS.

To contact MCASA, go to www.mcasa.org or call 1- 800-983 RAPE.
Providers should maintain respect for the right of each individual to determine his or her own course of action.

If a client does not wish to seek counseling or involve the authorities, it may be helpful to promote the importance of a social support system.

b.

Women are sometimes under the mistaken impression that violence will stop during pregnancy.

It is important to advise such clients that research has not shown this to be true.

In fact, abusive behavior is likely to continue unabated or increase.
Women often underestimate their level of danger.

Homicide is the leading cause of pregnancy- The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 57 associated mortality in the U.S.13 All pregnant women should be encouraged to create a safety plan.

c. Women who screen positive for IPV and/or reproductive coercion should be offered less-detectable methods of contraception like IUDs, implants and injections.
Education on emergency contraception should also be provided.

d. When a provider suspects or is told that an adolescent client has experienced violence, sexual coercion and/or assault that is not reportable to Child Protective Services or law enforcement, the provider should seek to engage the young person in safety planning.

Counseling may also be appropriate on ways to avoid sexual coercion.
The client should be given information about ways to contact local victims’ services programs, emergency medical facilities and law enforcement.

e. Details about the laws concerning Domestic Violence can be found in the Annotated Code of Maryland, Family Law Article, §4-501 to §4-530.

f. Details about the laws concerning sexual assault and rape can be found in the Annotated Code of Maryland, Criminal Law Article, §3-304.

§3-305, §3-306, §3-307 and §3-308.

2.


MANDATED REPORTING OF CHILD ABUSE AND NEGLECT All health care workers acting in their professional capacity are mandated to report information that otherwise would be confidential when they suspect child abuse or neglect.

In Maryland, reports are required even when a previously maltreated child is now an adult.

All mandated reporters must have an updated training every two years and documentation of this training must be maintained.
Workers are protected from civil liability and criminal penalty when making a report in good faith.

Alternatively, they could be subject to sanctions from their professional licensing boards if they knowingly fail to report.

A child is defined as an individual under the age of 18.
Child abuse includes physical injury or mental injury under circumstances indicating that a child’s health or welfare is harmed or at substantial risk of harm and sexual abuse, with or without physical injury, perpetrated upon a child by a family or household member or someone with temporary or permanent, current or past care, custody or responsibility for supervision of the child.
Child neglect means the failure to provide proper care and attention to the child under circumstances that the child’s health or welfare is harmed or placed at substantial risk of harm.

It includes leaving the child unattended and mental injury or substantial risk of mental injury that is caused by failure to provide proper care and attention to the child.
The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 58 When the perpetrator of a physical or sexual assault is an individual other than a family or household member or someone with temporary or permanent, current or past care, custody or responsibility for the supervision of the child, the mandated reporting requirement does not apply.
In fact, a provider could risk licensing or criminal penalties or civil liability for violating the confidentiality of a client were the provider to make a report in a situation that falls outside the mandated reporting law.

In Maryland, statutory rape is not reportable unless the perpetrator is a family or household member or someone with temporary or permanent, current or past care, custody or responsibility for the supervision of the minor.
However, even when it is not reportable, a sexual relationship between an adolescent and an older adolescent or adult may raise concerns that sexual coercion is occurring.

Family planning providers are required to counsel minors about ways to resist attempts to coerce them into engaging in sexual activities.

In addition to counseling, referrals to sexual assault programs or other types of assistance may be offered.

a.

Guidelines for mandated reporters are as follows: 1.)
Under Maryland’s mandated reporting law, after a health care provider has learned about a suspected incident or incidents of child maltreatment, a report to the appropriate authorities is required.

2.)

An oral report of child physical or sexual abuse must be made as soon as possible to Child Protective Services (CPS) or the appropriate law enforcement agency.

3.)

An oral report of neglect or mental injury must be made as soon as possible to CPS.

4.)
4.)

The head of the public health agency in which the provider is employed should be informed of an abuse or neglect report immediately.

5.)

Within 48 hours, a written report of abuse or neglect must be sent to CPS and, if the report concerns child abuse, a copy must also be sent to the State’s Attorney.

Information on how to report to CPS can be found at www.dhr.state.md.us/cps.

6.)
6.)

When the mandated reporting law does not apply in cases of statutory rape, dating violence or sexual assault, a young person may need assistance in accessing a variety of medical, including mental health, and community services.

At a minimum, the client should be counseled about safety, parental involvement and ways to resist sexual coercion.

The youth should be urged to take advantage of local victims’ services programs.
Referral to emergency medical facilities and/or local law enforcement authorities may also be appropriate.

b.

Details about the laws concerning Domestic Violence can be found in the Annotated Code of Maryland, Family Law Article, §4-501 to §4-530.

The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 59 c. Details about the laws concerning sexual assault and rape can be found in the Annotated Code of Maryland, Criminal Law Article, §3-304.
§3-305, §3-306, §3-307 and §3-308.

3.

HUMAN TRAFFICKING Human trafficking is a form of modern-day slavery and is a federal crime since the passage of the Trafficking Victims Protection Act of 2000.

This act applies to both U.S. citizens and foreign born nationals.

All delegate agency staff must have an updated training every two years on human trafficking and documentation of this training must be maintained.
Regular training topics should include Mandated Reporting and Human Trafficking (inclusive of Intimate Partner Violence).

There are three categories of human trafficking:  Those over 18 involved in commercial sex via force, fraud or coercion.

 Minors involved in commercial sex  Adults or minors involved in forced labor services or involuntary servitude via force, fraud, or coercion.
a. Identifying Trafficking Victims Human trafficking is a hidden industry and many clients do not self-report being victims of trafficking because of shame, fear, or distrust.

When conducting an assessment to identify if someone is a victim, use the existing protocols for sexual coercion, intimate partner violence, and child abuse.

Ensure that the client is seen individually if they are accompanied by another person, including individuals that present themselves as interpreters.
It is important to provide the client with interpreter services.

Human trafficking is a significant public health and human rights issue.

Providers can assist victims through heightened awareness, provision of care for the health consequences of human trafficking, and client counseling, which may include referrals to government and/or assistance agencies.

Providers must discuss possible options with the client, provide referral resources, help facilitate referrals (i.e.
offer to make the first call, ask advocates if they can meet clients at the clinic), and assist the client with safety planning.

Maryland does not have mandatory reporting requirements for human trafficking.

In Maryland, mandatory reporting is required only for abuse or neglect of a child or abuse, neglect or exploitation of a vulnerable adult.

A vulnerable adult is defined as a person aged 18 or older who lacks the physical or mental capacity to provide for his or her daily needs.
In other situations involving interpersonal violence, it is the responsibility of the victim to report the abuse to the proper authorities, OR may provide consent to a healthcare provider to report the abuse.

However, if you suspect a client is a victim of trafficking, call the National Human Trafficking Resource Center (www.acf.hhs.gov/trafficking) 24 Hour National Hotline at 1-888-3737-888 for information on how to report.
The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 60 4.

REPRODUCTIVE LIFE PLAN A reproductive life plan is a set of personal goals about having or not having children.

It also states how to achieve those goals.

All clients need to make a reproductive life plan based on their own values, goals, and resources.

Clients need to think about when and under what conditions they want to become pregnant.
If they do not plan to have children, they need to think about how they will prevent pregnancy.

A reproductive life plan allows for preconception counseling.

Preconception counseling offers women an ideal time to plan their pregnancies and establish good health habits.

Certain congenital anomalies and complications of pregnancy may be prevented if intervention occurs prior to conception.
Promoting positive health behaviors and eliminating medical risks are most effective when initiated well before a woman becomes pregnant.

Since approximately 50% of all pregnancies are unintended, targeting only self-referred women who are planning their next conception will result in a significant number of missed opportunities for primary prevention.

Counseling women of childbearing age allows for an identification of women with risk factors.
As an example, we can educate women to avoid any teratogenic medications, to update their immunizations, and take folic acid supplements to decrease their risk of neural tube defects.

The active planning of pregnancy will maximize the benefits of appropriate interventions and adherence to good health habits to help insure a reduction of maternal and perinatal morbidity and mortality.

D. Clinic Management 1.


EQUIPMENT AND SUPPLIES Equipment and supplies must be appropriate to the type of care offered by the project.

Projects are expected to follow applicable Federal and state regulations regarding infection control.
An Exposure Control Plan must be developed by each delegate agency in accordance with the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030, the Maryland Occupational Safety and Health Act, Title 09, Subtitle 12, 09.12.31, and DHMH Policy 03.02.01, The HIV Policy for DHMH Facilities, version effective August 13, 2013.

All staff included in the Exposure Control Plan are considered to be affected staff.
Affected staff should be aware of the location of the written Exposure Control Plan at each clinic site.

They are required to follow Plan requirements, use personal protective equipment as directed by their employer and attend an annual Exposure Control Plan training update.

Documentation of staff attendance at the annual update must be kept on file.

In addition: a.

Equipment and supplies must be safe, adequate, and appropriate to the type of care offered by the project.
The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 61 b.

It is the responsibility of the project coordinator, in consultation with the medical director, to assure proper selection and maintenance of equipment and supplies.

c. Equipment maintenance and calibration must be performed and documented based on manufacturer instructions.

2.

PHARMACEUTICALS a.


Agencies must operate in accordance with Federal and state laws relating to security and record keeping for drugs and devices.

The inventory, supply, and provision of pharmaceuticals must be conducted in accordance with state pharmacy laws and professional practice regulations.

b.

It is essential that each facility maintain an adequate supply and variety of drugs and devices to effectively manage the contraceptive needs of its clients.
Projects should also ensure access to other drugs or devices that are necessary for the provision of other medical services included within the scope of the Title X project.

Agencies are allowed to write prescriptions for Title X clients who choose and can conveniently obtain their contraceptives and medications from a pharmacy.

To preserve the principal of equality, prescriptions may be written only for items on the approved formulary.
c. The medical director of the family planning program is responsible for all policies and procedures pertaining to the general handling of pharmaceuticals.

d. All clients must receive verbal and written instructions for each drug.

Medication education sheets should be kept current, annually reviewed and revised as needed.

The nature of drug education should be documented in the medical records.
e. There must be documentation that in-service education pertaining to the nature and safety aspects of pharmaceuticals is provided to staff involved in the provision of medications to clients.

f. Safeguards must be in place for assuring that supplies purchased through the 340B program are provided only to clients of the family planning program.

g. A system for silent notification in case of drug recall must be in place.
h. A current formulary, listing all drugs available for Title X clients, must be maintained and reviewed at least annually.

Formularies should be retained for three years.

3.

MEDICAL RECORDS a.

General Policy 1) A medical record must be established for each client who receives clinical services, including all pregnancy testing/counseling clients and emergency contraception clients.
The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 62 2) Medical records are maintained in accordance with the accepted medical standards and state laws with regard to record retention.

Records must be: a) Complete, legible, and accurate.
b) Signed and dated by the clinician health professional making each entry i) Each entry includes date, name and title of the clinician/health professional ii) Each entry is a permanent part of the record c) Readily accessible d) Systematically organized to facilitate retrieval and compilation of information e) Confidential f) Safeguarded against loss or use by unauthorized persons g) Secured by lock when not in use h) Available upon request to the client 3) HIPPA regulations regarding personal health information must be followed.
b.

Record Contents The client’s medical record must contain sufficient information to identify the client, indicate where and how the client can be contacted, justify the clinical diagnosis, and warrant the treatment and end results.
Records must include the following: 1) Personal data a) Name b) Address, phone number(s), and how to contact c) Age d) Sex e) Income Assessment f) Unique client number g) Race and ethnicity (as required for FPAR) 2) Medical history a) Allergies recorded in a prominent, consistent location 3) Physical exam a) Documentation of clinical findings, diagnostic/therapeutic orders i) Laboratory test results and follow-up done for abnormal results ii) Treatments and special instructions iii) Documentation of continuing care, referral and follow-up iv) Documentation of scheduled revisits b) Contraceptive method chosen by the client c) Informed consents d) Documentation of all counseling, education, and social services given The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 63 e) Documentation of deferrals, reason for deferral, and refusal of services f) Date and signature of clinician or health professional for each entry, including documentation of telephone encounters of a clinical nature.
i) Signature includes name and title of provider ii) A signature log, if full name and title are not used in medical record g) A confidentiality assurance statement in the client's record.

h) A problem list should be maintained at the front of the chart listing identified problems to facilitate continuing evaluation and follow-up.

c. Confidentiality and Release of Records 1) A system must be in place to maintain confidentiality of client records.
2) A confidentiality assurance statement must appear in the client's record.

3) HIV, mental health, and substance use information must be handled according to state law.

4) The written consent of the client is required for the release of personally identifiable information, except as may be necessary to provide services to the client or as required by law, with appropriate safeguards for confidentiality.
a) Consent form for release of information, signed by the client, specifies to whom information may be disclosed.

b) Only the specific information requested may be released.

5) Information collected for reporting purposes must be disclosed only in summary, statistical, or other form which does not identify individuals.

6) Upon request, clients transferring to other providers must be provided with a copy or summary of their record to expedite continuity of care.
7) Upon request, clients must or be given access to their medical record.

4.

QUALITY ASSURANCE AND AUDIT a.

Delegate agencies must have a quality assurance system in place that provides for the ongoing evaluation of family planning personnel and services.

The quality assurance system should include an established set of clinical, administrative and programmatic standards by which conformity is maintained.

b.
b.

Delegate agencies must have a quality assurance system in place that includes the following elements: The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 64 1) A tracking system that identifies clients in need of follow up and/or continuing care must be in place (Section 7.4 Referrals and Follow-up).

2) A system to assure that professional licenses and CPR certifications are current must be in place (Sections 6.5 Personnel & 7.3 Emergencies).
3) Medical Audits to determine conformity with agency protocols, current standards, and acceptable medical practices must be conducted monthly by the medical director.

A minimum of two to three charts per clinician must be reviewed by the medical director monthly.

4) Chart Audits/ Record Monitoring to determine completeness and accuracy of the medical record must be conducted monthly by the quality assurance committee or identified personnel.
a) Chart audits must represent a minimum of three percent (3%) of the agency’s monthly caseload, randomly selected and reviewed by staff.

b) All clinical sites should be represented in the sampling.

c) Topic audits are strongly suggested.

5) Annual performance evaluations must be performed for all family planning program staff, including the medical director (Section 6.5 Personnel).

6) Annual peer review of all clinician/providers must be conducted (Section 6.5 Personnel).
7) Clinical Protocols and procedures must be reviewed and signed annually by the medical director (Section 7.1 Service Plans and Protocols).

8) Infection control policies and procedures reflecting current CDC recommendations and OSHA regulations must be in place (Sections 6.5 Personnel & 6.6 Training and technical Assistance).

9) Laboratory audits to assure quality and CLIA compliance must be in place (Section 8.3.

D. 8 & 9).
D. 8 & 9).

10) Equipment maintenance and calibration must be documented (Section 10.1 Equipment and Supplies).

11) Review and approval of all educational materials used by the delegate agency must be conducted by the I & E Committee prior to distribution (6.8 Education).

12) A process to implement corrective actions when deficiencies are noted must be in place.
The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 65 c. Delegate agency quality assurance systems should include the following: 1) Regularly scheduled staff meetings to update and/or review medical or service delivery topics.

Minutes should be kept of these meetings.

2) Routine check of emergency drugs and supplies.

3) A process to elicit consumer feedback should be in place.

4) Periodic review of forms used by the agency for completeness and applicability.
5) Routine monitoring of critical incident/occurrence reports.

6) Periodic review of credentials of contracted laboratories.

7) Periodic patient flow analysis.

8) Periodic review of provider liability insurance coverage.

9) Periodic monitoring for reliability and accuracy of the client data system to assure program performance, reporting, quality care, and generation of revenues.
The following components should be monitored: a) Missing user data b) Coding errors c) Data outcome d. A Quality Assurance Committee should be in place.

This committee should meet at least quarterly to discuss quality assurance issues and to make recommendations for corrective action when deficiencies have been noted.

1) If a formal Quality Assurance Committee is in place, minutes should be kept of all Quality Assurance Committee meetings.
2) The function of the Quality Assurance Committee may be assumed by an in-house nursing or medical advisory committee with ongoing documentation of quality assurance activities.

5.

MARYLAND FAMILY PLANNING CUSTOMER SATISFACTION SURVEY Two types of customer satisfaction surveys are conducted in the Maryland State Family Planning Program: The Family Planning Report Card and the Internal Customer Satisfaction Survey.
The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 66 a.

The Family Planning Client Survey The Family Planning Client Survey is the name given to a brief client satisfaction measure administered on an on-going basis in family planning clinics, and aggregated and reported to the Office of Family Planning & Home Visiting annually.

The Family Planning Client Survey is distributed to providers and is also available in English and Spanish on the MCHB website.
It is short (taking no more than 7-10 minutes to complete) and easy to read.

All questions are simple and direct, and the format is designed with data processing in mind.

Providers using the Family Planning Client Survey are instructed that they may insert questions of local interest on the form following the questions that are standard for all facilities.
In jurisdictions with significant populations of clients who speak neither English nor Spanish, providers should furnish translations in accordance with the DHMH Policy on Limited English Proficiency.

Reports on findings from local customer satisfactions surveys are maintained with other quality assurance materials at sites and will be reviewed during scheduled site visit by the Nurse Consultant.

Insights gained through the surveys should inform quality improvement efforts.

b.
b.

Customer Satisfaction Survey One way in which MFPRH Program staff is able to evaluate the effectiveness of family planning services is by inviting providers to respond to a survey designed especially for internal customers.

The survey, which is brief and user-friendly, is posted periodically on the Internet on Survey Monkey.

Results from the survey are evaluated and used to improve program quality and enhance communication.
The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 67 IV.

Program Monitoring Site Reviews The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 68 A.

Program Monitoring Site Reviews The MFPRH Program staff conduct site reviews to determine whether MFPRH Program supported family planning delegate agencies are managed effectively and comply with the Federal Title X regulations [42 CFR Part 59,Subpart A].
All Title X Delegate Agency Family Planning Programs in Maryland are required to have this comprehensive site visit by the MFPRH Program every three years as part of the Family Planning Grant monitoring process.

All program areas are reviewed: Administration, Finance, Clinical Services and Community Outreach and Information.

The Minimum Program Requirements developed from the Federal Regulations are used to evaluate both Health Department and Non-Health Department Title X agencies.

1.

METHODOLOGY a.
1.

METHODOLOGY a.

Delegate Agencies are reviewed by the same standards of performance, called Minimum Program Requirements (MPRs).

MPRs are program regulatory mandates based on the Federal Register, and the Federal Office of Population Affairs (OPA) Title X Program Guidelines.

The MFPRH Program Administrative Guidelines is a resource that specifically outlines what is needed to meet the program mandates.

b.

The Federal Register, being law, reads as legislation.
The Office of Population Affairs Program Requirements for Title X Funded Family Planning Projects, is guidance taken from the Federal Register, used to assist delegate agencies with their implementation.

The Federal Register is the family planning statute itself.

It outlines the policy that must be in place, but allows for interpretation by the MCHB MFPRH Program to determine what will be required to carry out the policy.
The MFPRH Program Guidelines provide the most detail and specific expectations for the individual Title X Family Planning Delegate Agencies.

The requirements in the MFPRH Program Guidelines supercede the information in the OPA Title X Standards and Guidelines.
The MFPP Guidelines do not contradict the OPA – Program Requirements for Title X Funded Family Planning Projects, they provide clarity, specific direction and in some cases additional information or requirements that may exceed those in the OPA document as determined by the State.

c. Agencies will receive a letter 4 weeks prior to their review from MFPP indicating when their review is scheduled, where to find needed documents to prepare for the site review and who to consult for technical assistance.
d. The Delegate Family Planning Coordinator will be contacted by the MFPRH Program Staff for scheduling.

Agencies must have a clinic scheduled during the visit to facilitate the accurate evaluation of this clinical component of the program.

Sites at any location a delegate agency has may be visited during this process.

2.

PROCESS The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 69 The following are steps in the site review process: a.
Prepare from the list of “Pre-Assessment Required Materials” for the scheduled site review.

b. Pre-Conference The preconference is the opportunity for MFPRH Program staff to meet the agency personnel and get acquainted with the physical aspects of the building, schedules, and so on.

It is likewise a time for the agency staff to meet the program reviewers, and let them know the individual characteristics of the program and agency lay-out.
A sample plan follows: 1) Introductions and Overview a) Expected time in facility and brief summary of the process b) Identify resource persons and pertinent staff 2) Discussion of Clinical times and Expectations a) The MFPRH Program staff will need access to the clerical staff (intake process, etc.)

and the financial staff.

b) The reviewer will follow a client through her entire clinical experience.

c) Request specific client charts.


d) Request any additional materials that may not have been provided in advance.

3) Logistics a) Working Room b) Computer terminal access for laptops 4) Questions and wrap-up c. Exit Conference An exit conference is an opportunity for discussion between the reviewers and the delegate agency staff regarding the general findings of the review.

d. Completed Report Delegate Agencies can expect a written report within 30 days.
Any indicator that was not met will be identified in the Site Review Summary as a Compliance Issue.

e. Corrective Plans of Action The Submission of Corrective Plans of Action will be developed by the delegate agency to correct all Compliance Issues identified in the Site Review Summary.

Technical Assistance from MFPRH Program Staff is available to assist with developing plans that will meet program regulations.
f. MFPRH Program Response to Plan The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 70 The Corrective Plans of Action will be evaluated by MFPRH Program staff.

1) Plans may be approved with no further action needed.

2) Plans may be approved with conditions such as a site revisit or submission of materials to the state agency.
3) Plans may be rejected in which case instructions will be included advising the delegate agency about what revisions are needed for acceptance of the plan.

4) If for any reason an agency is not going to meet the timelines, they should notify the MFPP Program as soon they are aware that this situation is apparent.

B.

Monitoring and Technical Assistance 1.


MONITORING VISITS Delegate agencies may be visited during the year prior to a Site Review (3 year review) and will be visited during the year following a Site Review.

These visits will be specifically to monitor progress on improving areas needing improvement which were identified during the previous Site Review.

Programs will have a follow-up review if there were any unmet indicators identified during their Site Review.
This is done to assure that those areas have been corrected to confirm Title X compliance.

In addition, additional topics that were not discussed during the Site Review process may be reviewed.

The list below is not inclusive.

Each Title X Family Planning Delegate Agency has individual needs, and monitoring with technical assistance is provided on that basis.

a.
a.

Following are examples of some topics that may be covered during a monitoring visit: 1) Methodology used for consumer input (review of satisfaction surveys, etc.).

2) Policies and procedures will be reviewed to assure accurate application of the sliding fee scale, no charge or donation is required for clients with income below 100% of poverty, charges are distributed proportionally across all services and supplies.
Policies that reflect that clients are never rejected because of inability to pay, and staff performance also indicates compliance.

3) Agency policies that reflect assurance that service provision does not require any residency or referral requirements, without subjecting individuals to any coercion to accept services or employ or not employ any particular method of family planning, and that priority of services goes to low income persons.
4) Financial monitoring by clinical observation for accurate application of the sliding fee scale, the donation, and billing process, and application of the poverty guidelines.

5) Reassessment of any indicators submitted on a Corrective Plan of Action (CPA).

2.

TECHNICAL ASSISTANCE (CONSULTATION VISITS) Consultation visits for technical assistance are available as needed.
Technical assistance is provided for areas needing improvement that have been identified through the local agency plan, a site review, monitoring visit, per the request of the agency or other mechanisms.

The The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 71 content and timing of the visit is mutually determined between the agency representative and the MFPRH Program staff.
Follow-up on any areas requiring change found in the Site Review process is considered routine.

Below are examples of areas where technical assistance is available.

This list is not inclusive and delegate agencies may call for technical assistance on any aspect of their operation requiring regulatory clarification.

a.
a.

Assistance with the application of billing and collections procedures (total charges less discount); third party payer billing instructions (total charges no discount); charges are determined by cost analysis; and clients are not denied services based on inability to pay.

b.

Assisting with the orientation of project staff to Title X regulations, new staff must receive specific orientation about confidentiality of services, Title X history, regulations and guidelines.
c. Guidance about the development and implementation of method-specific consent forms with follow-up and assurance of compliance.

d. Support and information about the Family Planning Data System.
The Maryland Family Planning and Reproductive Health Program Administrative Guidelines – 2015 72 APPENDIX A FEDERAL LEGISLATION AND REQUIREMENTS Title X Statute - Federal Regulations To enable persons who want to obtain family planning care to have access to such services, Congress enacted the Family Planning Services and Population Research Act of 1970 (Public Law 91-572), which added Title X, "Population Research and Voluntary Family Planning Programs" to the Public Health Service Act.
Section 1001 of the Act (as amended) authorizes grants "to assist in the establishment and operation of voluntary family planning projects which shall provide a broad range of acceptable and effective medically approved methods (including natural family planning methods) and services (including infertility services and services for adolescents)."

The mission of Title X is to provide individuals the information and means to exercise personal choice in determining the number and spacing of their children.
The regulations governing Title X [42 CFR Part 59, Subpart A] set out the requirements of the Secretary, Department of Health and Human Services, for the provision of family planning services funded under Title X and implement the statute as authorized under Section 1001 of the Public Health Service Act.

See Program Guidelines for Family Planning Project Grants, which interprets the law and regulations in operational terms and provides a general orientation to the Federal perspective on family planning.
Title X Statute TITLE X - POPULATION RESEARCH AND VOLUNTARY FAMILY PLANNING PROGRAMS PROJECT GRANTS AND CONTRACTS FOR FAMILY PLANNING SERVICES SEC.
1001 [300] (a) The Secretary is authorized to make grants to and enter into contracts with public or nonprofit private entities to assist in the establishment and operation of voluntary family planning projects which shall offer a broad range of acceptable and effective family planning methods and services (including natural family planning methods, infertility services, and services for adolescents).
To the extent practicable, entities which receive grants or contracts under this subsection shall encourage family1 participation in projects assisted under this subsection.

(b) In making grants and contracts under this section the Secretary shall take into account the number of patients to be served, the extent to which family planning services are needed locally, the relative need of the applicant, and its capacity to make rapid and effective use of such assistance.
Local and regional entities shall be assured the right to apply for direct grants and contracts under this section, and the Secretary shall by regulation fully provide for and protect such right.

(c) The Secretary, at the request of a recipient of a grant under subsection (a), may reduce the amount of such grant by the fair market value of any supplies or equipment furnished the grant recipient by the Secretary.
The amount by which any such grant is so reduced shall be available for payment by the Secretary of the costs incurred in furnishing the supplies or equipment on which the reduction of such grant is based.

Such amount shall be deemed as part of the grant and shall be deemed to have been paid to the grant recipient.
(d) For the purpose of making grants and contracts under this section, there are authorized to be appropriated $30,000,000 for the fiscal year ending June 30, 1971; $60,000,000 for the fiscal year ending June 30, 1972; $111,500,000 for the fiscal year ending June 30, 1973, $111,500,000 each for the fiscal years ending June 30, 1974, and June 30, 1975; $115,000,000 for fiscal year 1976; $115,000,000 for the fiscal year ending September 30, 1977; $136,400,000 for the fiscal year ending September 30, 1978; $200,000,000 for the fiscal year ending September 30, 1979; $230,000,000 for the fiscal year ending September 30, 1980; $264,500,000 for the fiscal year ending September 30, 1981; $126,510,000 for the fiscal year ending September 30, 1982; $139,200,000 for the fiscal year ending September 30, 1983; $150,030,000 for the fiscal year ending September 30, 1984; and $158,400,000 for the fiscal year ending September 30, 1985.
1 So in law.

See section 931(b)(I) of Public Law 97-35 (95 Stat.

570).

Probably should be “family”.

FORMULA GRANTS TO STATES FOR FAMILY PLANNING SERVICES SEC.

1002 [300a] (a) The Secretary is authorized to make grants, from allotments made under subsection (b), to State health authorities to assist in planning, establishing, maintaining, coordinating, and evaluating family planning services.
No grant may be made to a State health authority under this section unless such authority has submitted, and had approved by the Secretary, a State plan for a coordinated and comprehensive program of family planning services.

(b) The sums appropriated to carry out the provisions of this section shall be allotted to the States by the Secretary on the basis of the population and the financial need of the respective States.
(c) For the purposes of this section, the term ''State'' includes the Commonwealth of Puerto Rico, the Northern Mariana Islands, Guam, American Samoa, the Virgin Islands, the District of Columbia, and the Trust Territory of the Pacific Islands.

(d) For the purpose of making grants under this section, there are authorized to be appropriated $10,000,000 for the fiscal year ending June 30, 1971; $15,000,000 for the fiscal year ending June 30, 1972; and $20,000,000 for the fiscal year ending June 30, 1973.
TRAINING GRANTS AND CONTRACTS; AUTHORIZATION OF APPROPRIATIONS SEC.

1003 [300a-1] (a) The Secretary is authorized to make grants to public or nonprofit private entities and to enter into contracts with public or private entities and individuals to provide the training for personnel to carry out family planning service programs described in section 1001 or 1002 of this title.
(b) For the purpose of making payments pursuant to grants and contracts under this section, there are authorized to be appropriated $2,000,000 for the fiscal year ending June 30, 1971; $3,000,000 for the fiscal year ending June 30, 1972; $4,000,000 for the fiscal year ending June 30, 1973; $3,000,000 each for the fiscal years ending June 30, 1974 and June 30, 1975; $4,000,000 for fiscal year ending 1976; $5,000,000 for the fiscal year ending September 30, 1977; $3,000,000 for the fiscal year ending September 30, 1978; $3,100,000 for the fiscal year ending September 30, 1979; $3,600,000 for the fiscal year ending September 30, 1980; $4,100,000 for the fiscal year ending September 30, 1981; $2,920,000 for the fiscal year ending September 30, 1982; $3,200,000 for the fiscal year ending September 30, 1983; $3,500,000 for the fiscal year ending September 30, 1984; and $3,500,000 for the fiscal year ending September 30, 1985.
RESEARCH SEC.

1004 [300a-2] The Secretary may: (1) conduct, and (2) make grants to public or nonprofit private entities and enter into contracts with public or private entities and individuals for projects for, research in the biomedical, contraceptive development, behavioral, and program implementation fields related to family planning and population.

INFORMATIONAL AND EDUCATIONAL MATERIALS SEC.


1005 [300a-3] (a) The Secretary is authorized to make grants to public or nonprofit private entities and to enter into contracts with public or private entities and individuals to assist in developing and making available family planning and population growth information (including educational materials) to all persons desiring such information (or materials).
(b) For the purpose of making payments pursuant to grants and contracts under this section, there are authorized to be appropriated $750,000 for the fiscal year ending June 30, 1971; $1,000,000 for the fiscal year ending June 30, 1972; $1,250,000 for the fiscal year ending June 30, 1973; $909,000 each for the fiscal years ending June 30, 1974, and June 30, 1975; $2,000,000 for fiscal year 1976; $2,500,000 for the fiscal year ending September 30, 1977; $600,000 for the fiscal year ending September 30, 1978; $700,000 for the fiscal year ending September 30, 1979; $805,000 for the fiscal year ending September 30, 1980; $926,000 for the fiscal year ending September 30, 1981; $570,000 for the fiscal year ending September 30, 1982; $600,000 for the fiscal year ending September 30, 1983; $670,000 for the fiscal year ending September 30, 1984; and $700,000 for the fiscal year ending September 30, 1985.
REGULATIONS AND PAYMENTS SEC.

1006 [300a-4] (a) Grants and contracts made under this subchapter shall be made in accordance with such regulations as the Secretary may promulgate.
The amount of any grant under any section of this title shall be determined by the Secretary; except that no grant under any such section for any program or project for a fiscal year beginning after June 30, 1975, may be made for less than 90 per centum of its costs (as determined under regulations of the Secretary) unless the grant is to be made for a program or project for which a grant was made (under the same section) for the fiscal year ending June 30, 1975, for less than 90 per centum of its costs (as so determined), in which case a grant under such section for that program or project for a fiscal year beginning after that date may be made for a percentage which shall not be less than the percentage of its costs for which the fiscal year 1975 grant was made.
(b) Grants under this title shall be payable in such installments and subject to such conditions as the Secretary may determine to be appropriate to assure that such grants will be effectively utilized for the purposes for which made.
(c) A grant may be made or contract entered into under section 1001 or 1002 for a family planning service project or program only upon assurances satisfactory to the Secretary that: (1) Priority will be given in such project or program to the furnishing of such services to persons from low-income families; and (2) no charge will be made in such project or program for services provided to any person from a low-income family except to the extent that payment will be made by a third party (including a government agency) which is authorized or is under legal obligation to pay such charge.
For purposes of this subsection, the term ''low-income family'' shall be defined by the Secretary in accordance with such criteria as he may prescribe so as to insure that economic status shall not be a deterrent to participation in the programs assisted under this title.
(d) (1) A grant may be made or a contract entered into under section 1001 or 1005 only upon assurances satisfactory to the Secretary that informational or educational materials developed or made available under the grant or contract will be suitable for the purposes of this title and for the population or community to which they are to be made available, taking into account the educational and cultural background of the individuals to whom such materials are addressed and the standards of such population or community with respect to such materials.
(2) In the case of any grant or contract under section 1001, such assurances shall provide for the review and approval of the suitability of such materials, prior to their distribution, by an advisory committee established by the grantee or contractor in accordance with the Secretary's regulations.

Such a committee shall include individuals broadly representative of the population or community to which the materials are to be made available.

VOLUNTARY PARTICIPATION SEC.


1007 [300a-5] The acceptance by any individual of family planning services or family planning or population growth information (including educational materials) provided through financial assistance under this title (whether by grant or contract) shall be voluntary and shall not be a prerequisite to eligibility for or receipt of any other service or assistance from, or to participation in, any other program of the entity or individual that provided such service or information.
PROHIBITION OF ABORTION SEC.

1008 1 [300a-6] None of the funds appropriated under this title shall be used in programs where abortion is a method of family planning.

1 Section 1009 was repealed by section 601(a)(1)(G) of Public Law 105-362 (112 Stat.

3285).

59.1 To what programs do these regulations apply?

59.2 Definitions.

59.3 Who is eligible to apply for a family planning services grant?

59.4 How does one apply for a family planning services grant?
59.5 What requirements must be met by a family planning project?

59.6 What procedures apply to assure the suitability of informational and educational material?

59.7 What criteria will the Department of Health and Human Services use to decide which family planning services projects to fund and in what amount?

59.8 How is a grant awarded?

59.9 For what purposes may grant funds be used?

59.10 What other HHS regulations apply to grants under this subpart?

59.11 Confidentiality.


59.12 Additional conditions.

Subpart B [Reserved] Subpart C—Grants for Family Planning Service Training 59.201 Applicability.

59.202 Definitions.

59.203 Eligibility.

59.204 Application for a grant.

59.205 Project requirements.

59.206 Evaluation and grant award.

59.207 Payments.

59.208 Use of project funds.

59.209 Civil rights.

59.210 Inventions or discoveries.

59.211 Publications and copyright.

59.212 grantee accountability.


59.213 [Reserved] 59.214 Additional conditions.

59.215 Applicability of 45 CFR part 74.

Subpart A—Project Grants for Family Planning Services AUTHORITY: 42 U.S.C.

300a–4.

SOURCE: 65 FR 41278, July 3, 2000, unless otherwise noted.

§ 59.1 To what programs do these regulations apply?

The regulations of this subpart are applicable to the award of grants under section 1001 of the Public Health Service Act (42 U.S.C.

300) to PUBLIC HEALTH SERVICE HHS PT.


59 (2) The trainee is not eligible or able to continue in attendance in accordance with its standards and practices.

[45 FR 73658, Nov. 6, 1980.

Redesignated at 61 FR 6131, Feb. 16, 1996] § 58.232 What additional Department regulations apply to grantees?

Several other Department regulations apply to grantees.
They include, but are not limited to: 42 CFR part 50, subpart D—Public Health Service grant appeals procedure 45 CFR part 16—Procedures of the Departmental Grant Appeals Board 45 CFR part 46—Protection of human subjects 45 CFR part 74—Administration of grants 45 CFR part 80—Nondiscrimination under programs receiving Federal assistance through the Department of Health and Human Services effectuation of title VI of the Civil Rights Act of 1964 45 CFR part 81—Practice and procedure for hearings under part 80 of this title 45 CFR part 83—Regulation for the administration and enforcement of sections 794 and 855 of the Public Health Service Act 45 CFR part 84—Nondiscrimination on the basis of handicap in programs and activities receiving or benefiting from Federal financial assistance 45 CFR part 86—Nondiscrimination on the basis of sex in education programs and activities receiving or benefiting from Federal financial assistance 45 CFR part 91—Nondiscrimination on the basis of age in HHS programs or activities receiving Federal financial assistance 45 CFR part 93—New restrictions on lobbying [49 FR 38116, Sept. 27, 1984.
Redesignated and amended at 61 FR 6131, Feb. 16, 1996] § 58.233 What other audit and inspection requirements apply to grantees?

Each entity which receives a grant under this subpart must meet the requirements of 45 CFR part 74 concerning audit and inspection.

[61 FR 6131, Feb. 16, 1996; 61 FR 51020, Sept. 30, 1996] § 58.234 Additional conditions.
The Secretary may impose additional conditions in the grant award before or at the time of the award if he or she determines that these conditions are necessary to assure or protect the advancement of the approved activity, the interest of the public health, or the conservation of grant funds.

[45 FR 73658, Nov. 6, 1980.

Redesignated at 61 FR 6131, Feb. 16, 1996] Subparts E–F [Reserved] PART 59—GRANTS FOR FAMILY PLANNING SERVICES Subpart A—Project Grants for Family Planning Services Sec.
assist in the establishment and operation of voluntary family planning projects.

These projects shall consist of the educational, comprehensive medical, and social services necessary to aid individuals to determine freely the number and spacing of their children.

[65 FR 41278, July 3, 2000; 65 FR 49057, Aug. 10,2000] § 59.2 Definitions.

As used in this subpart: Act means the Public Health Service Act, as amended.
Family means a social unit composed of one person, or two or more persons living together, as a household.

Low income family means a family whose total annual income does not exceed 100 percent of the most recent Poverty Guidelines issued pursuant to 42 U.S.C.

9902(2).

‘‘Low-income family’’ also includes members of families whose annual family income exceeds this amount, but who, as determined by the project director, are unable, for good reasons, to pay for family planning services.
For example, unemancipated minors who wish to receive services on a confidential basis must be considered on the basis of their own resources.

Nonprofit, as applied to any private agency, institution, or organization, means that no part of the entity’s net earnings benefit, or may lawfully benefit, any private shareholder or individual.
Secretary means the Secretary of Health and Human Services and any other officer or employee of the Department of Health and Human Services to whom the authority involved has been delegated.

State includes, in addition to the several States, the District of Columbia, Guam, the Commonwealth of Puerto Rico, the Northern Mariana Islands, the U.S. Virgin Islands, American Samoa, the U.S. Outlying Islands (Midway, Wake, et al.
), the Marshall Islands, the Federated State of Micronesia and the Republic of Palau.

[65 FR 41278, July 3, 2000; 65 FR 49057, Aug. 10,2000] § 59.3 Who is eligible to apply for a family planning services grant?

Any public or nonprofit private entity in a State may apply for a grant under this subpart.

§ 59.4 How does one apply for a family planning services grant?

(a) Application for a grant under this subpart shall be made on an authorized form.
(b) An individual authorized to act for the applicant and to assume on behalf of the applicant the obligations imposed by the terms and conditions of the grant, including the regulations of this subpart, must sign the application.
(c) The application shall contain— (1) A description, satisfactory to the Secretary, of the project and how it will meet the requirements of this subpart; (2) A budget and justification of the amount of grant funds requested; (3) A description of the standards and qualifications which will be required for all personnel and for all facilities to be used by the project; and (4) Such other pertinent information as the Secretary may require.

§ 59.5 what requirement s must be met by a family planning project?
(a) Each project supported under this part must: (1) Provide a broad range of acceptable and effective medically approved family planning methods (including natural family planning methods) and services (including infertility services and services for adolescents).

If an organization offers only a single method of family planning, it may participate as part of a project as long as the entire project offers a broad range of family planning services.
(2) Provide services without subjecting individuals to any coercion to accept services or to employ or not to employ any particular methods of family planning.

Acceptance of services must be solely on a voluntary basis and may not be made a prerequisite to eligibility for, or receipt of, any other services, assistance from or participation in any other program of the applicant.

(3) Provide services in a manner which protects the dignity of the individual.
(4) Provide services without regard to religion, race, color, national origin, handicapping condition, age, sex, number of pregnancies, or marital status.

(5) Not provide abortion as a method of family planning.

A project must: (i) Offer pregnant women the opportunity to be provided information and counseling regarding each of the following options: (A) Prenatal care and delivery; (B) Infant care, foster care, or adoption; and (C) Pregnancy termination.
(ii) If requested to provide such information and counseling, provide neutral, factual information and nondirective counseling on each of the options, and referral upon request, except with respect to any option(s) about which the pregnant woman indicates she does not wish to receive such information and counseling.

(6) Provide that priority in the provision of services will be given to persons from low income families.
(7) Provide that no charge will be made for services provided to any persons from a low-income family except to the extent that payment will be made by a third party (including a government agency) which is authorized to or is under legal obligation to pay this charge.
(8) Provide that charges will be made for services to persons other than those from low income families in accordance with a schedule of discounts based on ability to pay, except that charges to persons from families whose annual income exceeds 250 percent of the levels set forth in the most recent Poverty Guidelines issued pursuant to 42 U.S.C.

9902(2) will be made in accordance with a schedule of fees designed to recover the reasonable cost of providing services.
(9) If a third party (including a Government agency) is authorized or legally obligated to pay for services, all reasonable efforts must be made to obtain the third-party payment without application of any discounts.

Where the cost of services is to be reimbursed under title XIX, XX, or XXI of the Social Security Act, a written agreement with the title XIX, XX or XXI agency is required.
(10)(i) Provide that if an application relates to consolidation of service areas or health resources or would otherwise affect the operations of local or regional entities, the applicant must document that these entities have been given, to the maximum feasible extent, an opportunity to participate in the development of the application.

Local and regional entities include existing or potential subgrantees which have previously provided or propose to provide family planning 1 Section 205 of Pub.
L. 94–63 states: ‘‘Any (1) officer or employee of the United States,(2) officer or employee of any State, political subdivision of a State, or any other entity, which administers or supervises the administration of any program receiving Federal financial assistance, or (3) person who receives, under any program receiving Federal assistance, compensation for services, who coerces or endeavors to coerce any person to undergo an abortion or sterilization procedure by threatening such person with the loss of, or disqualification for the receipt of, any benefit or service under a program receiving Federal financial assistance shall be fined not more than $1,000 or imprisoned for not more than one year, or both.’’ services to the area proposed to be served by the applicant.
(ii) Provide an opportunity for maximum participation by existing or potential sub-grantee in the ongoing policy decision making of the project.

(11) Provide for an Advisory Committee as required by § 59.6.

(b) In addition to the requirements of paragraph (a) of this section, each project must meet each of the following requirements unless the Secretary determines that the project has established good cause for its omission.
Each project must: (1) Provide for medical services related to family planning (including physician’s consultation, examination prescription, and continuing supervision, laboratory examination, contraceptive supplies) and necessary referral to other medical facilities when medically indicated, and provide for the effective usage of contraceptive devices and practices.
(2) Provide for social services related to family planning, including counseling, referral to and from other social and medical services agencies, and any ancillary services which may be necessary to facilitate clinic attendance.
(3) Provide for informational and educational programs designed to— (i) Achieve community understanding of the objectives of the program; (ii) Inform the community of the availability of services; and (iii) Promote continued participation in the project by persons to whom family planning services may be beneficial.

(4) Provide for orientation and inservice training for all project personnel.
(5) Provide services without the imposition of any durational residency requirement or requirement that the patient be referred by a physician.

(6) Provide that family planning medical services will be performed under the direction of a physician with special training or experience in family planning.

(7) Provide that all services purchased for project participants will be authorized by the project director or his designee on the project staff.
(8) Provide for coordination and use of referral arrangements with other providers of health care services, local health and welfare departments, hospitals, voluntary agencies, and health services projects supported by other federal programs.

(9) Provide that if family planning services are provided by contract or other similar arrangements with actual providers of services, services will be provided in accordance with a plan which establishes rates and method of payment for medical care.
These payments must be made under agreements with a schedule of rates and payment procedures maintained by the grantee The grantee must be prepared to substantiate that these rates are reasonable and necessary.
(10) Provide, to the maximum feasible extent, an opportunity for participation in the development, implementation, and evaluation of the project by persons broadly representative of all significant elements of the population to be served, and by others in the community knowledgeable about the community’s needs for family planning services.

[65 FR 41278, July 3, 2000; 65 FR 49057, Aug. 10, 2000] § 59.6 What procedures apply to assure the suitability of informational and educational material?
(a) A grant under this section may be made only upon assurance satisfactory to the Secretary that the project shall provide for the review and approval of informational and educational materials developed or made available under the project by an Advisory Committee prior to their distribution, to assure that the materials are suitable for the population or community to which they are to be made available and the purposes of title X of the Act.
The project shall not disseminate any such materials which are not approved by the Advisory Committee.

(b) The Advisory Committee referred to in paragraph (a) of this section shall be established as follows: (1) Size.

The Committee shall consist of no fewer than five but not more than nine members, except that this provision may be waived by the Secretary for good cause shown.

(2) Composition.
(2) Composition.

The Committee shall include individuals broadly representative (in terms of demographic factors such as race, color, national origin, handicapped condition, sex, and age) of the population or community for which the materials are intended.

(3) Function.
In reviewing materials, the Advisory Committee shall: (i) Consider the educational and cultural backgrounds of individuals to whom the materials are addressed; (ii) Consider the standards of the population or community to be served with respect to such materials; (iii) Review the content of the material to assure that the information is factually correct; (iv) Determine whether the material is suitable for the population or community to which is to be made available; and (v) Establish a written record of its determinations.
§ 59.7 What criteria will the Department of Health and Human Services use to decide which family planning services projects to fund and in what amount?
(a) Within the limits of funds available for these purposes, the Secretary may award grants for the establishment and operation of those projects which will in the Department’s judgment best promote the purposes of section 1001 of the Act, taking into account: (1) The number of patients, and, in particular, the number of low-income patients to be served; (2) The extent to which family planning services are needed locally; (3) The relative need of the applicant; (4) The capacity of the applicant to make rapid and effective use of the federal assistance; (5) The adequacy of the applicant’s facilities and staff; (6) The relative availability of nonfederal resources within the community be served and the degree to which those resources are committed to the project; and (7) The degree to which the project plan adequately provides for the requirements set forth in these regulations.
(b) The Secretary shall determine the amount of any award on the basis of his estimate of the sum necessary for the performance of the project.

No grant may be made for less than 90 percent of the project’s costs, as so estimated, unless the grant is to be made for a project which was supported, under section 1001, for less than 90 percent of its costs in fiscal year 1975.

In that case, the grant shall not be for less than the percentage of costs covered by the grant in fiscal year 1975.
(c) No grant may be made for an amount equal to 100 percent for the project’s estimated costs.

§ 59.8 How is a grant awarded?

(a) The notice of grant award specifies how long HHS intends to support the project without requiring the project to recompete for funds.

This period, called the project period, will usually be for three to five years.

(b) Generally the grant will initially be for one year and subsequent continuation awards will also be for one year at a time.
A grantee must submit a separate application to have the support continued for each subsequent year.

Decisions regarding continuation awards and the funding level of such awards will be made after consideration of such factors as the grantee’s progress and management practices,and the availability of funds.

In all cases, continuation awards require a determination by HHS that continued funding is in the best interest of the government.
(c) Neither the approval of any application nor the award of any grant commits or obligates the United States in any way to make any additional, supplemental, continuation, or other award with respect to any approved application or portion of an approved application.

§ 59.9 For what purpose may grant funds be used?


Any funds granted under this subpart shall be expended solely for the purpose for which the funds were granted in accordance with the approved application and budget, the regulations of this subpart, the terms and conditions of the award, and the applicable cost principles prescribed in 45 CFR Part 74 or Part 92, as applicable.

§ 59.10 What other HHS regulations apply to grants under this subpart?
Attention is drawn to the following HHS Department-wide regulations which apply to grants under this subpart.
These include: 37 CFR Part 401—Rights to inventions made by nonprofit organizations and small business firms under government grants, contracts, and cooperative agreements 42 CFR Part 50, Subpart D—Public Health Service grant appeals procedure 45 CFR Part 16—Procedures of the Departmental Grant Appeals Board 45 CFR Part 74—Uniform administrative requirements for awards and subawards to institutions of higher education, hospitals, other nonprofit organizations, and commercial organizations; and certain grants and agreements with states, local governments and Indian tribal governments 45 CFR Part 80—Nondiscrimination under programs receiving Federal assistance through the Department of Health and Human Services effectuation of Title VI of the Civil Rights Act of 1964 45 CFR Part 81—Practice and procedure for hearings under Part 80 of this Title 45 CFR Part 84—Nondiscrimination on the basis of handicap in programs and activities receiving or benefitting from Federal financial assistance 45 CFR Part 91—Nondiscrimination on the basis of age in HHS programs or activities receiving Federal financial assistance 45 CFR Part 92—Uniform administrative requirements for grants and cooperative agreements to state and local governments § 59.11 Confidentiality.
All information as to personal facts and circumstances obtained by the project staff about individuals receiving services must be held confidential and must not be disclosed without the individual’s documented consent, except as may be necessary to provide services to the patient or as required by law, with appropriate safeguards for confidentiality.

Otherwise, information may be disclosed only in summary, statistical, or other form which does not identify particular individuals.
§ 59.12 Additional conditions.

The Secretary may, with respect to any grant, impose additional conditions prior to or at the time of any award, when in the Department’s judgment these conditions are necessary to assure or protect advancement of the approved program, the interests of public health, or the proper use of grant funds.

[65 FR 41278, July 3, 2000; 65 FR 49057, Aug. 10, 2000] Subpart B [Reserved] Subpart C—Grants for Family Planning Service Training AUTHORITY: Sec.

6(c), 84 Stat.
6(c), 84 Stat.

1507, 42 U.S.C.

300a–4; sec.

6(c), 84 Stat.

1507, 42 U.S.C.

300a–1.

SOURCE: 37 FR 7093, Apr.

8, 1972, unless otherwise noted.

§ 59.201 Applicability.

The regulations in this subpart are applicable to the award of grants pursuant to section 1003 of the Public Health Service Act (42 U.S.C.

300a–1) to provide the training for personnel to carry out family planning service programs described in sections 1001 and 1002 of the Public Health Service Act (42 U.S.C.

300, 300a).
300, 300a).

§ 59.202 Definitions.

As used in this subpart: (a) Act means the Public Health Service Act.

(b) State means one of the 50 States, the District of Columbia, Puerto Rico, Guam, the Virgin Islands, American Samoa, or the Trust Territory of the Pacific Islands.

(c) Nonprofit private entity means a private entity no part of the net earnings of which inures, or may lawfully inure, to the benefit of any private shareholder or individual.
(d) Secretary means the Secretary of Health and Human Services and any other officer or employee of the Department of Health and Human Services to whom the authority involved has been delegated.

(e) Training means job-specific skill development, the purpose of which is to promote and improve the delivery of family planning services.

§ 59.203 Eligibility.

(a) Eligible applicants.

Any public or nonprofit private entity located in a State is eligible to apply for a grant under this subpart.
(b) Eligible projects.
Grants pursuant to section 1003 of the Act and this subpart may be made to eligible applicants for the purpose of providing programs, not to exceed three months in duration, for training family planning or other health services delivery personnel in the skills, knowledge, and attitudes necessary for the effective delivery of family planning services: Provided, That the Secretary may in particular cases approve support of a program whose duration is longer than three months where he determines (1) that such program is consistent with the purposes of this subpart and (2) that the program’s objectives cannot be accomplished within three months because of the unusually complex or specialized nature of the training to be undertaken.
[37 FR 7093, Apr.

8, 1972, as amended at 40 FR 17991, Apr.

24, 1975] § 59.204 Application for a grant.

(a) An application for a grant under this subpart shall be submitted to the Secretary at such time and in such form and manner as the Secretary may prescribe.
1 The application shall contain a full and adequate description of the project and of the manner in which the applicant intends to conduct the project and carry out the requirements of this subpart, and a budget and justification of the amount of grant funds requested, and such other pertinent information as the Secretary may require.
(b) The application shall be executed by an individual authorized to act for the applicant and to assume for the applicant the obligations imposed by the regulations of this subpart and _________________________ 1 Applications and instructions may be obtained from the Program Director, Family Planning Services, at the Regional Office of the Department of Health and Human Services for the region in which the project is to be conducted, or the Office of Family Planning, Office of the Assistant Secretary for Health, Washington, DC 20201. any additional conditions of the grant.
(Sec.

6(c), Public Health Service Act, 84 Stat.

1506 and 1507 (42 U.S.C.

300, 300a–1, and 300a–4)) [37 FR 7093, Apr.

8, 1972, as amended at 49 FR 38116, Sept. 27, 1984]§ 59.205 Project requirements.

An approvable application must contain each of the following unless the Secretary determines that the applicant has established good cause for its omission: (a) Assurances that: (1) No portion of the Federal funds will be used to train personnel for programs where abortion is a method of family planning.
(2) No portion of the Federal funds will be used to provide professional training to any student as part of his education in pursuit of an academic degree.

(3) No project personnel or trainees shall on the grounds of sex, religion, or creed be excluded from participation in, be denied the benefits of, or be subjected to discrimination under the project.
(b) Provision of a methodology to assess the particular training (e.g., skills, attitudes, or knowledge) that prospective trainees in the area to be served need to improve their delivery of family planning services.

(c) Provision of a methodology to define the objectives of the training program in light of the particular needs of trainees defined pursuant to paragraph (b) of this section.
(d) Provision of a method for development of the training curriculum and any attendant training materials and resources.

(e) Provision of a method for implementation of the needed training.

(f) Provision of an evaluation methodology, including the manner in which such methodology will be employed, to measure the achievement of the objectives of the training program.

(g) Provision of a method and criteria by which trainees will be selected.

§ 59.206 Evaluation and grant award.
(a) Within the limits of funds available for such purpose, the Secretary may award grants to assist in the establishment and operation of those projects which will in his judgment best promote the purposes of section 1003 of the Act, taking into account: (1) The extent to which a training program will increase the delivery of services to people, particularly low-income groups, with a high percentage of unmet need for family planning services; (2) The extent to which the training program promises to fulfill the family planning services delivery needs of the area to be served, which may include, among other things: (i) Development of a capability within family planning service projects to provide pre- and inservice training to their own staffs; (ii) Improvement of the family planning services delivery skills of family planning and health services personnel; (iii) Improvement in the utilization and career development of paraprofessional and paramedical manpower in family planning services; (iv) Expansion of family planning services, particularly in rural areas, through new or improved approaches to program planning and deployment of resources; (3) The capacity of the applicant to make rapid and effective use of such assistance; (4) The administrative and management capability and competence of the applicant; (5) The competence of the project staff in relation to the services to be provided; and (6) The degree to which the project plan adequately provides for the requirements set forth in § 59.205.
(b) The amount of any award shall be determined by the Secretary on the basis of his estimate of the sum necessary for all or a designated portion of direct project costs plus an additional amount for indirect costs, if any, which will be calculated by the Secretary either: (1) On the basis of his estimate of the actual indirect costs reasonably related to the project, or (2) on the basis of a percentage of all, or a portion of, the estimated direct costs of the project when there are reasonable assurances that the use of such percentage will not exceed the approximate actual indirect costs.
Such award may include an estimated provisional amount for indirect costs or for designated direct costs (such as travel or supply costs) subject to upward (within the limits of available funds) as well as downward adjustments to actual costs when the amount properly expended by the grantee for provisional items has been determined by the Secretary.

(c) Allowability of costs shall be in conformance with the applicable cost principles prescribed by Subpart Q of 35 CFR part 74.
(d) All grant awards shall be in writing, shall set forth the amount of funds granted and the period for which support is recommended.

(e) Neither the approval of any project nor any grant award shall commit or obligate the United States in any way to make any additional, supplemental, continuation, or other award with respect to any approved project or portion thereof.

For continuation support, grantee must make separate application annually at such times and in such form as the Secretary may direct.
[37 FR 7093, Apr.

8, 1972, as amended at 38 FR 26199, Sept. 19, 1973] § 59.207 Payments.

The Secretary shall from time to time make payments to a grantee of all or a portion of any grant award, either in advance or by way of reimbursement for expenses incurred or to be incurred in the performance of the project to the extent he determines such payments necessary to promote prompt initiation and advancement of the approved project.

§ 59.208 Use of project funds.


(a) Any funds granted pursuant to this subpart as well as other funds to be used in performance of the approved project shall be expended solely for carrying out the approved project in accordance with the statute, the regulations of this subpart, the terms and conditions of the award, and, except as may otherwise be provided in this subpart, the applicable cost principles prescribed by subpart Q of 45 CFR part 74.
(b) Prior approval by the Secretary of revision of the budget and project plan is required whenever there is to be a significant change in the scope or nature of project activities.

(c) The Secretary may approve the payment of grant funds to trainees for: (1) Return travel to the trainee’s point of origin.

(2) Per diem during the training program, and during travel to and from the program, at the prevailing institutional or governmental rate, whichever is lower.

[37 FR 7093, Apr.
[37 FR 7093, Apr.

8, 1972, as amended at 38 FR 26199, Sept. 19, 1973] § 59.209 Civil rights.

Attention is called to the requirements of Title VI of the Civil Rights Act of 1964 (78 Stat.

252, 42 U.S.C.

2000d et seq.)


and in particular section 601 of such Act which provides that no person in the United States shall, on the grounds of race, color, or national origin be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.
A regulation implementing such title VI, which applies to grants made under this part, has been issued by the Secretary of Health and Human Services with the approval of the President (45 CFR part 80).

§ 59.210 Inventions or discoveries.

Any grant award pursuant to § 59.206 is subject to the regulations of the Department of Health and Human Services as set forth in 45 CFR parts 6 and 8, as amended.
Such regulations shall apply to any activity for which grant funds are in fact used whether within the scope of the project as approved or otherwise.

Appropriate measures shall be taken by the grantee and by the Secretary to assure that no contracts, assignments or other arrangements inconsistent with the grant obligation are continued or entered into and that all personnel involved in the supported activity are aware of and comply with such obligations.
Laboratory notes, related technical data, and information pertaining to inventions and discoveries shall be maintained for such periods, and filed with or otherwise made available to the Secretary, or those he may designate at such times and in such manner, as he may determine necessary to carry out such Department regulations.

§ 59.211 Publications and copyright.


Except as may otherwise be provided under the terms and conditions of the award, the grantee may copyright without prior approval any publications, films or similar materials developed or resulting from a project supported by a grant under this part, subject, however, to a royalty free, nonexclusive, and irrevocable license or right in the Government to reproduce, translate, publish, use, disseminate, and dispose of such materials and to authorize others to do so.
§ 59.212 Grantee accountability.

(a) Accounting for grant award payments.

All payments made by the Secretary shall be recorded by the grantee in accounting records separate from the records of all other grant funds, including funds derived from other grant awards.
With respect to each approved project the grantee shall account for the sum total of all amounts paid by presenting or otherwise making available evidence satisfactory to the Secretary of expenditures for direct and indirect costs meeting the requirements of this part: Provided, however, That when the amount awarded for indirect costs was based on a predetermined fixed-percentage of estimated direct costs, the amount allowed for indirect costs shall be computed on the basis of such predetermined fixed-percentage rates applied to the total, or a selected element thereof, of the reimbursable direct costs incurred.
(b) [Reserved] C Bonding and Insurance.

D Retention and Custodial Requirements for Records.

F Grant-Related Income.

G Matching and Cost Sharing.

K Grant Payment Requirements.

L Budget Revision Procedures.

M Grant Closeout, Suspension, and Termination.

O Property.

Q Cost Principles.

[38 FR 26199, Sept. 19, 1973] PART 59a—NATIONAL LIBRARY OF MEDICINE GRANTS Subpart A—Grants for Establishing, Expanding, and Improving Basic Resources Sec.

59a.1 Programs to which these regulations apply.


59a.2 Definitions.

59a.3 Who is eligible for a grant?

59a.4 How are grant applications evaluated?

59a.5 Awards.

59a.6 How may funds or materials be used?

59a.7 Other HHS regulations that apply.

Subpart B—Establishment of Regional Medical Libraries 59a.11 Programs to which these regulations apply.

59a.12 Definitions.

59a.13 Who is eligible for a grant?

59a.14 How to apply.

59a.15 Awards.

59a.16 What other conditions apply?


59a.17 Other HHS regulations that apply.

SOURCE: 56 FR 29189, June 26, 1991, unless otherwise noted.

Subpart A—Grants for Establishing, Expanding, and Improving Basic Resources AUTHORITY: 42 U.S.C.

286b–2, 286b–5.

§ 59a.1 Programs to which these regulations apply.


(a) The regulations of this subpart apply to grants of funds, materials, or both, for establishing, expanding, and improving basic medical library resources as authorized by section 474 of the Act (42 U.S.C.

286b–5).

(b) This subpart also applies to cooperative agreements awarded for this purpose.

In these circumstances, references to ‘‘grant(s)’’ shall include ‘‘cooperative agreements(s).’’ (c) Accounting for grant-related income—(1) Interest.
Pursuant to section 203 of the Intergovernmental Cooperation Act of 1968 (42 U.S.C.

4213), a State will not be held accountable for interest earned on grant funds, pending their disbursement for grant purposes.
A State, as defined in section 102 of the Intergovernmental Cooperation Act, means any one of the several States, the District of Columbia, Puerto Rico, any territory or possession of the United States, or any agency or instrumentality of a State, but does not include the governments of the political subdivisions of the State.

All grantees other than a State, as defined in this subsection, must return all interest earned on grant funds to the Federal Government.
(d)Grant closeout—(1) Date of final accounting.

A grantee shall render, with respect to each approved project, a full account, as provided herein, as of the date of the termination of grant support.

The Secretary may require other special and periodic accounting.

(2) Final settlement.


There shall be payable to the Federal Government as final settlement with respect to each approved project the total sum of: (i) Any amount not accounted for pursuant to paragraph (a) of this section; (ii) Any credits for earned interest pursuant to paragraph (c)(1) of this section; (iii) Any other amounts due pursuant to subparts F, M, and O of 45 CFR part 74.
Such total sum shall constitute a debt owed by the grantee to the Federal Government and shall be recovered from the grantee or its successors or assignees by setoff or other action as provided by law.

[36 FR 18465, Sept. 15, 1971, as amended at 38 FR 26199, Sept. 19, 1973] § 59.213 [Reserved] § 59.214 Additional conditions.
The Secretary may with respect to any grant award impose additional conditions prior to or at the time of any award when in his judgment such conditions are necessary to assure or protect advancement of the approved project, the interests of public health, or the conservation of grant funds.

§ 59.215 Applicability of 45 CFR part 74.


The provisions of 45 CFR part 74, establishing uniform administrative requirements and cost principles, shall apply to all grants under this subpart to State and local governments as those terms are defined in subpart A of that part 74.

The relevant provisions of the following subparts of part 74 shall also apply to grants to all other grantee organizations under this subpart.

45 CFR PART 74 Subpart: A General.

B Cash Depositories.

§ 59a.2 Definitions.


Undefined terms have the same meaning as provided in the Act.

As used in this subpart: Act means the Public Health Service Act, as amended (42 U.S.C.

201 et seq.).

Project period—See § 59a.5(c).

Related instrumentality means a public or private institution, organization, or agency, other than a medical library, whose primary function is the acquisition, preservation, dissemination, and/ or processing of information relating to the health sciences.
Secretary means the Secretary of Health and Human Services and any other official of the Department of Health and Human Services to whom the authority involved is delegate Health Insurance Portability and Accountability Act of 1996 Many aspects of this law impact the Maryland Family Planning and Reproductive Health Program and its delegate agencies.

Much information is available on implementation and compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA.)
The websites listed below will provide comprehensive information.

The following is a summary of the HIPPA statute: Administrative Simplification To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, included Administrative Simplification provisions that required HHS to adopt national standards for electronic health care transactions and code sets, unique health identifiers, and security.
At the same time, Congress recognized that advances in electronic technology could erode the privacy of health information.

Consequently, Congress incorporated into HIPAA provisions that mandated the adoption of Federal privacy protections for individually identifiable health information.

HHS published a final Privacy Rule in December 2000, which was later modified in August 2002.
This Rule set national standards for the protection of individually identifiable health information by three types of covered entities: health plans, health care clearinghouses, and health care providers who conduct the standard health care transactions electronically.

Compliance with the Privacy Rule was required as of April 14, 2003 (April 14, 2004, for small health plans).

HHS published a final Security Rule in February 2003.
This Rule sets national standards for protecting the confidentiality, integrity, and availability of electronic protected health information.

Compliance with the Security Rule was required as of April 20, 2005 (April 20, 2006 for small health plans).

All of the HIPAA Administrative Simplification Rules are located at 45 CFR Parts 160, 162, and 164.
The Privacy Rule The Office of Civil Rights administers and enforces the HIPAA Privacy Rule which establishes national standards to protect individuals’ medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically.
The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization.

The Rule also gives patients rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections.
The Privacy Rule is located at 45 CFR Part 160 and Subparts A and E of Part 164. http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/index.html The Security Rule The HIPAA Security Rule establishes national standards to protect individuals’ electronic personal health information that is created, received, used, or maintained by a covered entity.
The Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information.
The Security Rule is located at 45 CFR Part 160 and Subparts A and C of Part 164. http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/index.html Other HIPAA Administrative Simplification Rules are administered and enforced by the Centers for Medicare & Medicaid Services, and include: Transactions and Code Sets Standards On January 16, 2009, HHS published two final transactions and code set rules to adopt updated HIPAA standards; these rules are available at the Federal Register.
Transactions are electronic exchanges involving the transfer of information between two parties for specific purposes.

For example, a health care provider will send a claim to a health plan to request payment for medical services.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) named certain types of organizations as covered entities, including health plans, health care clearinghouses, and certain health care providers.
HIPAA also adopted certain standard transactions for Electronic Data Interchange (EDI) of health care data.

These transactions are: claims and encounter information, payment and remittance advice, claims status, eligibility, enrollment and disenrollment, referrals and authorizations, and premium payment.

Under HIPAA, if a covered entity conducts one of the adopted transactions electronically, they must use the adopted standard.
This means that they must adhere to the content and format requirements of each standard.

HIPAA also adopted specific code sets for diagnosis and procedures to be used in all transactions.
The HCPCS (Ancillary Services/Procedures), CPT-4 (Physicians Procedures), CDT (Dental Terminology), ICD-9 (Diagnosis and hospital inpatient Procedures), ICD-10 (As of October 1, 2013) and NDC (National Drug Codes) codes with which providers and health plan are familiar, are the adopted code sets for procedures, diagnoses, and drugs.
To view these rules and information sheets for both sets of standards see the following link on the CMS website: http://www.cms.gov/TransactionCodeSetsStands/01_Overview.asp#TopOfPage Finally, HIPAA adopted standards for unique identifiers for Employers and Providers, which must also be used in all transactions, as required by the standard.
Employer Identifier Standard The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires that employers have standard national numbers that identify them on standard transactions.

The Employer Identification Number (EIN), issued by the Internal Revenue Service (IRS), was selected as the identifier for employers and was adopted effective July 30, 2002.
For more information, see the following CMS webpage: http://www.cms.gov/EmployerIdentifierStand/01_overview.asp National Provider Identifier Standard The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard.

The NPI is a unique identification number for covered health care providers.
Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA.

The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).

This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty.

The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.
As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.
For more information, see the following CMS webpage: http://www.cms.gov/NationalProvIdentStand/ Additional HIPAA Internet Resources http://www.hhs.gov/ocr/hipaa/ This site from the Office of Civil Rights covers a variety of issues and includes the HIPAA Statute, as well as a number of links that provide more specific information.
http://www.cms.hhs.gov/HIPAAGenInfo/ The site includes the HIPAA statute, related materials, compliance information and downloads prepared by Centers for Medicare and Medicaid Services (CMS.)
Civil Rights Act of 1964 The Civil Rights Act of 1964, is an act to enforce the constitutional right to vote, to confer jurisdiction upon the district courts of the United States to provide injunctive relief against discrimination in public accommodations to authorize the Attorney General to institute suits to protect constitutional rights in public facilities and public education, to extend the Commission on Civil Rights, to prevent discrimination in federally assisted programs, to establish a Commission on Equal Employment Opportunity, and for other purposes.
This law has had significant impact on our lives and operations.

The following websites provide detailed information on civil rights that can be used in conjunction with family planning programs.
The following links provide further information on civil right for use in conjunction with your family planning program: http://www.eeoc.gov/policy/vii.html http://www.eeoc.gov/laws/guidance/compliance.cfm APPENDIX B Maryland Health Codes and Other Rules Mandated Child Abuse Reporter Legislation Article - Family Law § 5-704.
(a) Notwithstanding any other provision of law, including any law on privileged communications, each health practitioner, police officer, educator, or human service worker, acting in a professional capacity in this State: (1) (i) who has reason to believe that a child has been subjected to abuse, shall notify the local department or the appropriate law enforcement agency; or (ii) who has reason to believe that a child has been subjected to neglect, shall notify the local department; and (2) if acting as a staff member of a hospital, public health agency, child care institution, juvenile detention center, school, or similar institution, shall immediately notify and give all information required by this section to the head of the institution or the designee of the head.
(b) (1) An individual who notifies the appropriate authorities under subsection (a) of this section shall make: (i) an oral report, by telephone or direct communication, as soon as possible: 1. to the local department or appropriate law enforcement agency if the person has reason to believe that the child has been subjected to abuse; or 2. to the local department if the person has reason to believe that the child has been subjected to neglect; and (ii) a written report: 1. to the local department not later than 48 hours after the contact, examination, attention, or treatment that caused the individual to believe that the child had been subjected to abuse or neglect; and 2. with a copy to the local State's Attorney if the individual has reason to believe that the child has been subjected to abuse.
(2) (i) An agency to which an oral report of suspected abuse is made under paragraph (1) of this subsection shall immediately notify the other agency.

(ii) This paragraph does not prohibit a local department and an appropriate law enforcement agency from agreeing to cooperative arrangements.
(c) Insofar as is reasonably possible, an individual who makes a report under this section shall include in the report the following information: (1) the name, age, and home address of the child; (2) the name and home address of the child's parent or other person who is responsible for the child's care; (3) the whereabouts of the child; (4) the nature and extent of the abuse or neglect of the child, including any evidence or information available to the reporter concerning possible previous instances of abuse or neglect; and (5) any other information that would help to determine: (i) the cause of the suspected abuse or neglect; and (ii) the identity of any individual responsible for the abuse or neglect.
Minor Consent Maryland's Minor Consent Law (Article 20-102 of the Maryland Annotated Code) This law permits minors to receive contraceptive services on a confidential basis.
The law states that “a minor has the same capacity as an adult to consent to treatment for or advice about drug abuse, alcoholism, venereal disease, pregnancy, and contraception other than sterilization.” This means minors can get the following services without parental knowledge or consent: Pregnancy testing Birth control Exams Testing and treatment of sexually transmitted infections (STIs) Planned Parenthood encourages adolescents to communicate with their parents and guardians when seeking contraceptive health care, but does not require that they do so.
According to a report in the Journal of the American Medical Association (JAMA), most adolescents already inform parents about their use of reproductive health services.

Definition of a Minor: In Maryland, a minor is anyone under the age of 18 years who is not married or the parent of a child.

Maryland's Parental Notification for Abortion Law (Article 20-103 of the Maryland Annotated Code) Maryland law requires that one parent or guardian be notified before a minor has an abortion.
The parent/guardian does not need to consent (agree) with the minor's choice, but does need to know the minor is planning to have an abortion.
Maryland's parental notification law says specifically that no notification is required if, in the judgment of the doctor performing the abortion: The minor is mature and capable of giving her informed consent to the procedure, OR Notification would not be in the minor's best interest, OR Notice may lead to physical or emotional abuse of the minor, OR The minor patient does not live with her parent or guardian, OR A reasonable effort to give notice has been unsuccessful.
Article - Health - General § 20-102.

(a) A minor has the same capacity as an adult to consent to medical treatment if the minor: (1) Is married; or (2) Is the parent of a child.

(b) A minor has the same capacity as an adult to consent to medical treatment if, in the judgment of the attending physician, the life or health of the minor would be affected adversely by delaying treatment to obtain the consent of another individual.
(c) A minor has the same capacity as an adult to consent to: (1) Treatment for or advice about drug abuse; (2) Treatment for or advice about alcoholism; (3) Treatment for or advice about venereal disease; (4) Treatment for or advice about pregnancy; (5) Treatment for or advice about contraception other than sterilization; (6) Physical examination and treatment of injuries from an alleged rape or sexual offense; (7) Physical examination to obtain evidence of an alleged rape or sexual offense; and (8) Initial medical screening and physical examination on and after admission of the minor into a detention center.
(c-1) The capacity of a minor to consent to treatment for drug abuse or alcoholism under subsection (c)(1) or (2) of this section does not include the capacity to refuse treatment for drug abuse or alcoholism in an inpatient alcohol or drug abuse treatment program certified under Title 8 of this article for which a parent or guardian has given consent.
(d) A minor has the same capacity as an adult to consent to psychological treatment as specified under subsection (c)(1) and (2) of this section if, in the judgment of the attending physician or a psychologist, the life or health of the minor would be affected adversely by delaying treatment to obtain the consent of another individual.
(e) A physician, psychologist, or an individual under the direction of a physician or psychologist who treats a minor is not liable for civil damages or subject to any criminal or disciplinary penalty solely because the minor did not have capacity to consent under this section.
(f) Without the consent of or over the express objection of a minor, the attending physician, psychologist or, on advice or direction of the attending physician or psychologist, a member of the medical staff of a hospital or public clinic may, but need not, give a parent, guardian, or custodian of the minor or the spouse of the parent information about treatment needed by the minor or provided to the minor under this section, except information about an abortion.
Nurse Dispensing in Local Health Departments: http://www.mbp.state.md.us/forms/dr_nurse.pdf Intimate Partner Violence and Sexual Coercion: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health- Care-for-Underserved-Women/Intimate-Partner-Violence http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health- Care-for-Underserved-Women/Reproductive-and-Sexual-Coercion http://www.iom.edu/Reports/2011/Clinical-Preventive-Services-for-Women-Closing-the- Gaps.aspx http://www.guideline.gov/content.aspx?id=39425 http://phpa.dhmh.maryland.gov/mch/SitePages/IPV.aspx http://phpa.dhmh.maryland.gov/mch/Documents/IPV%20Guide%20for%20providers.January.pd f