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["Disclaimer: The CATT Tool was not developed and is not maintained by the NC Local Health Department Accreditation (NCLHDA) program. It is provided as an example of a resource that can be adapted by local health departments to support their accreditation efforts. The user is responsible for ensuring the validity and accuracy of all information in the document. "]
["Note: Use the most recent version of the HDSAI Interpretation Document as the standard for preparing evidence for the accreditation audit.  "]
["Standard, Function & Essential Service Number","Benchmark Number","Benchmark Description","Activity","Activity Description"," Timeframe                              Evidence is Needed for          HDSAI in the 48 Months","Minimum Total Number of Evidence Required for HDSAI                                               ","Documentation","Category (section/division/program where evidence will come from)","Person Responsible"," Initial when     2+ people are Responsible for Submissions","Year 1         10/24/14 - 10/23/15  ","Year 2     10/24/15 - 10/23/16        ","Year 3            10/24/16 - 10/23/17 ","Past 24 Months Prior to HDSAI Due Date                                                                6/1/16 - 6/1/18 ","Past 12 Months Prior to HDSAI Due Date                     6/1/17 - 6/1/18","Year 4                                          10/24/17 - 6/1/18,                        when HDSAI due.                              Can submit evidence until day of audit, only where needed.","Note from AAC for evidence improvement prior to final accreditation use.  ","Note from responsible person to AAC."]
["Standard: Agency Core Functions and Essential Services, Function: Assessment, Essential Service 1",1,"A local health department shall conduct and disseminate results of regular community health assessments.",1.1000000000000001,"Activity 1.1:  The local health department shall conduct a comprehensive community health assessment every 48 months.    The community health assessment must fulfill each of the following requirements:                                                                                                              \n• Provide evidence of community collaboration in planning and conducting the assessment.\n• Reflect the demographic profile of the population.\n• Describe socioeconomic, educational and environmental factors that affect health.\n• Assemble and analyze secondary data (collected by someone other than the health department) to describe the health status of the community.\n• Collect and analyze primary data (collected by the health department) to describe the health status of the community.\n• Compile and analyze trend data to describe changes in community health status and in factors affecting health.\n• Use scientific methods for collecting and analyzing data.\n• Identify population groups at risk for health problems\n• Identify existing and needed health resources.\n• Compare selected local data with data from other jurisdictions (e.g., local to state, local to local).\n• Identify leading community health problems. ","Any 1 or 2 Years","1 or 2"," A. Copy of Community Health Assessment (CHA)                                                                              Note: Might need 2 CHAs if submitting every three years. ","Health Education","Donald Duck  Mickey Mouse","DD  MM","c","c","s"]
[null,null,null,null,null,"Any 1 or 2 Years","1 or 2"," B. Letter(s) from N.C. Division of Public Health stating CHA meets content requirements described above (include the attached checklist) Note: Might need 2 CHAs if submitting every 3 years   ",null,null,null,"I","M"]
[null,null,null,null,null,"Any 1 or 2 Years","1 or 2                                   (if applicable) "," C.  If applicable, a letter from OHC/HE stating that Corrective Action Plan (CAP) has been accepted.                                                                           Note: Might need 2 CHAs if submitting every 3 years  "]
[null,null,null,1.2,"Activity 1.2: The local health department shall update the community health assessment with an interim \"State of the County's Health\" report (or equivalent) annually. The report shall demonstrate that the local health department is tracking priority issues identified in the community health assessment, identifying emerging issues, and shall identify any new initiatives.","Any 2 or 3 Years","2 or 3","A.  Copies of each annual State of the County’s Health (SOTCH) reports produced  Note: Might need only 2 SOTCHs if submitting CHA every 3 years                                                                         "]
[null,null,null,null,null,"Any 2 or 3 Years","2 or 3","B. Letters from NCDPH stating each SOTCH meets content requirements  Note: Might need only 2 SOTCHs if submitting CHA every 3 years      "]
[null,null,null,null,null,"Any 2 or 3 Years","2 or 3                                    if applicable","C. Letter from NCDPH stating CAP(s) have been accepted                                                       Note: Might need only 2 SOTCHs if submitting CHA every 3 years      "]
[null,null,null,1.3,"Activity 1.3: The local health department shall disseminate results of the most recent community health assessment and \"State of the County's Health\" reports to the local health department's stakeholders, community partners and the general population.","Any 1 or 2 Year(s)                  Most Recent Needed",2,"A.  Evidence of most recent CHA dissemination efforts  (e.g., website, newsletters, news releases, meeting minutes describing a presentation) directed to stakeholders/community partners \nNote: Need to reflect 2 different methods\n"]
[null,null,null,null,null,"Any 1 or 2 Year(s)                 (Most Recent Needed)",2,"B. Evidence of most recent CHA dissemination efforts  (e.g., website, newsletters, news releases, meeting minutes describing a presentation) directed  to the general population. Note: 2 different methods"]
[null,null,null,null,null,"Any 2 or 3 Year(s)                  Most Recent Needed",2,"C. Evidence of most recent SOTCH dissemination efforts  (e.g., website, newsletters, news releases, meeting minutes describing a presentation) directed  to the stakeholders/community partners. Note: 2 different methods"]
[null,null,null,null,null,"Any 2 or 3 Year(s)                  Most Recent Needed",2,"D. Evidence of most recent SOTCH  dissemination efforts  (e.g., website, newsletters, news releases, meeting minutes describing a presentation) directed  to the general population. Note: 2 different methods"]
[null,2,"The local health department shall work with health care providers in the community to report reportable diseases and other health-related events and data.",2.1,"Activity 2.1: The local health department shall collect local vital records of births and deaths and transmit them to the Division.","Since Previous Site Visit ","As many as needed to demonstrate solid evidence                        Note: 4","A. Evidence of vital record keeping (births and deaths) & transmit records to NCDPH.  Note: Submit evidence for each accreditation year.  However, evidence of record keeping, since previous site visit, will need to be available upon request during the audit and may be requested during facility tour. "]
[null,null,null,2.2000000000000002,"Activity 2.2: The local health department shall report annual childhood immunization data as required by statute and rule."," Most Recent Needed                      ",1," A. Annual Immunization Assessment conducted by the N.C Division of Public Health.\n(This activity is only assuring report is complete not looking at level or rate)  Note: Auditors will be specifically looking at Most Recent"]
[null,null,null,2.2999999999999998,"Activity 2.3: The local health department shall collect reports of communicable diseases and other reportable health conditions from community health care providers and transmits them to the Division.","Past 12 months",1,"A. Evidence of reporting via NCEDSS all reports received by LHD  Note: For evidence, use the \"de-identified event line list\"  from NCEDSS converting the past 12 months                                              "]
[null,null,null,2.4,"Activity 2.4: The local health department shall analyze and note reportable events occurring within the community and shall report atypical incidence, if any, to the Division and the local board of health.","Annually",4,"A. Evidence of an annual internal process reflecting analysis                                                                     "]
[null,null,null,null,null,"Since Previous Site Visit                         ",1," B. Evidence of having reported atypical incidences to NCDPH (note what was sent and how it was sent)                                                                     "]
[null,null,null,null,null,"Annually",4," C. Evidence of  annual report to the board of health on local disease incidence and trends. Note: Need BOH minutes & copy of report."]
[null,3,"The local health department shall maintain skills and capacity to collect, manage, integrate and display health-related data",3.1,"Activity 3.1: The local health department shall assure agency staff has expertise and training to collect, manage, integrate and display health-related data."," Since Previous Site Visit  ","<4"," A.  Evidence of relevant expertise and/or training on collecting, managing, integrating and displaying health-related data for at least one individual. (e.g. transcript or certificate(s) of course completion) Note: Less evidence is needed if 1 training/course meets more than 1 of the 4 required components."]
[null,null,null,3.2,"Activity 3.2: The local health department shall conduct an annual evaluation of the agency’s data system (hardware and software) and plans for upgrades to improve the accessibility, quality and utilization of health data.","Annually",4," A. Since the previous site visit, evidence of annual evaluation of the data system                                                        "]
[null,null,null,null,null," Since Previous Site Visit",1," B. Evidence of an updated plan for improving the accessibility, quality and utilization of health data.   Note: Plan for improving how  IT improvements produce better health data and easier access to health data? Examples: Hardware, software, access to Internet improvements                                                                                                          "]
[" Standard: Agency Core Functions and Essential Services, Function: Assessment, Essential Service 2",4,"The local health department shall engage in surveillance activities and assess, investigate and analyze health problems, threats and hazards, maintaining and using epidemiological expertise.",4.0999999999999996,"Activity 4.1: The local health department shall assure that a surveillance system is in place for identifying health problems, threats and hazards that occur in the community.","  Past 12 Months ",1," A. Policies and procedures describing the agency’s community surveillance system                                                             "]
[null,null,null,null,null,"  Past 12 Months ",1,"B. A list of internal and external surveillance system participants (individuals & positions) If list an agency then list the contact there.                                                                "]
[null,null,null,null,null,"Past 12 months",3,"C. Evidence of communication with surveillance participants.  Note: Examples: email, fax, newsletter, notice, or other evidence of agency communication to surveillance participants concerning the surveillance."]
[null,null,null,4.2,"Activity 4.2: The local health department shall monitor exposure to environmental health risks.","Annually",4,"A.   Individual or Summary report monitoring exposure to environmental health risks including 1) evidence of notification,  and 2) actions taken as required by General Statute.                                                                                        For three of the following: Well sample, on-site wastewater survey, childhood blood lead levels, meth lab investigation, food and lodging, general inspection data, FDA Standard 9 Risk Factor Study,  water quality monitoring, or air quality monitoring.     Note:  Need 4 reports representing 1 from each year representing different environmental risks.  Make sure to submit  evidence of any required actions that were taken based on the report. "]
[null,null,null,4.3,"Activity 4.3: The local health department shall have access to, and consult with a Masters or Doctoral level epidemiologist when necessary to fully investigate and diagnose health problems and hazards within the community.","Since Previous Site Visit",1,"A.   Current contract and/or job description for local personnel OR evidence of availability of consultation with state epidemiologist.                                                              Note: If we use consulting with a state-level professional then we also need in the same folder evidence of that person has a Masters or Doctoral level degree."]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Evidence of consultation with an epidemiologist     Note: outbreak assistance, training & expenses, "]
[null,5,"The local health department shall establish and maintain a system to receive and provide health alerts and public health response for health care providers, emergency responders, and communities on a 24-hour-a-day, 7-day-a-week basis.",5.0999999999999996,"Activity 5.1: The local health department shall have a system in place to receive reports of communicable diseases or other public health threats on a 24-hour-a-day, 7-day-a-week basis.","Past 12 Months",1,"A. Copy of Notification Protocol from local Public Health Preparedness and Response Plans (or equivalent), OR written policies and procedures regarding after-hours calls Note: Evidence should also explain how this agency receives reports after normal business hours                                                              "]
[null,null,null,null,null,"Past 12 Months",1,"B. Current after-hours call list                                               Note: Need names and contact information for employees who will receive, act on, or forward any reports or information received that describes a PH threat of some kind.   Person on list should know his/her role in a call down list.  Some employees/roles will be defined by the Incident Command System assignments and for some the answer to this could be \"Based on the situation, I understand that I will do anything within my scope of practice.                                                           "]
[null,null,null,null,null,"Annually",4,"C. Evidence of distribution and education of partners to the most current notification protocol.\nNote: Place current information for A, B &C in Year 4  so will have most current items."]
[null,null,null,5.2,"Activity 5.2: The local health department shall use two or more methods to disseminate health alerts and other advisories on real or potential disease threats, as they occur, to the local medical community, including pharmacists and veterinarians.","Past 12 Months",1,"A. Health Alert communication plan                                                                Note: Looking for process. Use most recent version with date. "]
[null,null,null,null,null,"Past 12 Months",1,"B.  Medical provider contact list (to include pharmacists and veterinarians)    Note: Need current contact list with contact information (phone, fax and/or email that works with Health Alert Communication system.                                                         "]
[null,null,null,null,null,"Since Previous Site Visit",4,"C. Evidence of disseminations of alerts by multiple methods.  If no alerts or advisories have been distributed, present evidence that system has been tested.  Note:  The use of multiple methods must be documented for each alert dissemination provided as evidence. "]
[null,null,null,5.3,"Activity 5.3: The local health department shall provide health alerts or advisories to the news media to inform the public when disease outbreaks or other potential public health threats occur.","Past 24 months ",1,"A. Agency crisis communication plan, or communication/media plan                                                     Local Note: Update contact lists in communication plan each year but other sections of the communication plan once per 24 months.                                                        "]
[null,null,null,null,null,"Since Previous Site Visit",2,"B. Evidence of two or more alerts or advisories to the news media. If no alerts or advisories have been distributed, present evidence that system has been tested."]
[null,6,"The local health department shall be able to respond to a public health emergency on a 24-hour-a-day, 7-day-a-week basis.",6.1,"Activity 6.1: The local health department shall be involved in a local emergency planning committee.","Past 12 months",1,"A.  Minutes or documents confirming agency involvement in Local Emergency Planning (LEP) Committee (or equivalent).                                                                                  Note: Activity 7.5 will reflect that the health director must be involved in the LEPC so it would be good if minutes here reflect that as well."]
[null,null,null,6.2,"Activity 6.2: The local health department shall have a defined role in the county emergency operations plan to protect the public’s health.","Past 24 months ",1,"A. Copy of County/Counties Emergency Operations Plan(s) with the local health department role defined and current.  Note: If county emergency operations plan has not been revised since the previous site visit to reflect the health department’s current role, provide evidence which indicates efforts have been made to request such updates, within past 24 months. "]
[null,null,null,6.3,"Activity 6.3: The local health department shall participate in regional emergency preparedness exercises and activities.","  Since Previous Site Visit",1,"A.  Records of local agency participation in regional or multi-county trainings, planning meetings, or exercises."]
[null,7,"The local health department shall maintain and implement epidemiological case investigation protocols providing for rapid detection and containment of communicable disease outbreaks; environmental health hazards; potential biological, chemical and radiological threats.",7.1,"Activity 7.1: The local health department shall have epidemiological case investigation protocols in place."," Most Recent Needed",1," A. Current policies & procedures for epidemiological case investigation protocols                                                            "]
[null,null,null,null,null,"  Most Recent Needed",1," B. Written protocols and/or guidelines to guide epidemiological practice.                                                            Note: All aspects of the protocols must be clearly and fully defined in writing. Protocols address the specified investigation practices for individual diseases and conditions.  "]
[null,null,null,7.2,"Activity 7.2: The local health department shall conduct communicable disease investigations, follow-up, documentation and reporting activities.","  Since Previous Site Visit",1,"A.   Evidence of an appropriately conducted, documented and reported outbreak investigation.                                   Note: Can be a single report or multiple documents for one event. Note:  If no activity, demonstrate knowledge by providing policy. Note: Examples should follow policies and procedures in 7.1.\n"]
[null,null,null,7.3,"Activity 7.3: The local health department shall investigate and respond to environmental health complaints or referrals.","Annually","On-Site Review","A. Since the previous site visit, annual complaint logs (with the following required:  complaint reported, date reported, action taken in accordance with policy (including names of staff who responded), date of action taken and referral information if referred to another agency) Logs can be kept for calendar year of FY.                                                           "]
[null,null,null,null,null,"Annually","On-Site Review","B. Lab/investigation reports (where applicable)"]
[null,null,null,null,null," Most Recent Needed",1," C. EH Policy defining timely and appropriate action."]
[null,null,null,7.4,"Activity 7.4: The local health department shall have a public health preparedness and response plan that:                                                                                      · corresponds to existing local and state emergency and Bioterrorism plans;                                   ·establishes roles and responsibilities of plan participants;                                                                             · identifies training for participants in those roles;         · establishes a chain of command among plan  participants;                                                                             · describes a system of emergency notification to local and state public health staff and other key decision makers based upon the nature of the event;                                                                                   · is available to staff on site"," Since Previous Site Visit                    Most Recent Needed","1+"," A. Copy of the local public health preparedness and response work plan  Note: See specific details in HDSAI."]
[null,null,null,null,null," Since Previous Site Visit                    Most Recent Needed",1,"B. Letter from Office of Public Health Preparedness and Response indicating that the plan is accepted.                                                           "]
[null,null,null,null,null,"  Since Previous Site Visit                    Most Recent Needed",1,"C. Evidence of availability to all staff.                                               \n"]
[null,null,null,7.5,"Activity 7.5:  The local health director shall maintain periodic communication with local emergency managers.","At Least 2 Per Year                   ","8+","A. Evidence of on-going communication with Local Emergency Manager (LEM).                                                   ",null,null,null,"s"]
[null,null,null,null,null,"  Past 24 Months Needed ","2+","B. Evidence that Health Director, or designee, is an active member of Local Emergency Preparedness Committee (LEPC), or equivalent.  Note:  If an LEPC does not exist or is currently inactive, provide evidence which indicates efforts have been made to request an LEPC be formed or become active."]
[null,null,null,7.6,"Activity 7.6: The local health department shall annually test or implement the local public health preparedness and response plan.","Annually","4+"," A. Record of preparedness and response exercises or execution of plan  "]
[null,null,null,7.7,"Activity 7.7: The local health department shall have one of the following: public health preparedness and response coordination team with an environmental health member and a public health preparedness response coordinator, or an epidemiology team with an environmental health member and an epidemiology team coordinator.","Past 12 Months ",1,"A. Team member names, titles (day-to- day title)  and designated roles (responsibility as a team member)                                                    "]
[null,null,null,null,null," Since Previous Site Visit  ","2+","B. Evidence team is active.  Note: Can use agenda & minutes, reports, outbreak investigation reports, presentation to BOH recorded in minutes."]
[null,null,null,8.1,"Activity 8.1: The local health department shall have written policies and procedures for handling clinical and environmental laboratory samples.","Most Recent Needed",1,"A.  Policies and procedures for handling clinical and environmental laboratory samples. Note: If testing is done by a reference laboratory then we need a copy of any handling processes required by the reference lab. Note: Requesting 1 from Clinical and 1 from Environmental Health.  "]
[]
[null,8,"The local health department shall provide or have access to laboratory capacity capable of providing for rapid detection and containment of communicable disease outbreaks; environmental health hazards; potential biological, chemical and radiological threats."]
[null,null,null,8.1999999999999993,"Activity 8.2: The local health department laboratory and external laboratories utilized by the local health department shall comply with all applicable federal regulations for clinical and environmental laboratory testing.  This activity ensures the labs used are properly certified.  "," Most Recent Needed",1,"A. List of laboratories used and their areas of certification, if other than the NC State Laboratory.   Note: For clinical and environmental laboratory testing"]
[null,null,null,8.3000000000000007,"Activity 8.3: The local health department shall provide or have access to laboratory services capable of meeting routine diagnostic and surveillance needs. Note: lab services that supports normal program and services delivered day-to-day. ","Past 12 Months","1+","A. Current CLIA or other appropriate certificate for each laboratory used (MSVL too).  Note: Examples:  Child health, lead, well-water and …"]
[null,null,null,null,null,"Past 12 Months","1+","B. Current contract(s) or evidence of agreement with external laboratories, if other than the North Carolina State Laboratory.  Note:  Certificates and contracts should correlate to labs listed in 8.2 & 8.4)"]
[null,null,null,8.4,"Activity 8.4: The local health department shall provide or have access to laboratory services to support investigations of public problems, hazards, and emergencies.  Note: this is access to lab services that support problems, hazards and emergencies  like an outbreak or response situation. ","Past 12 Months","1+","A.  Current protocols and guidelines regarding access to laboratory services. "]
["Standard: Agency Core Functions and Essential Services, Function: Policy Development, Essential Service 3",9,"The local health department shall provide the general public and elected and appointed officials with information on health risks, health status, and health needs in the community as well as information on policies and programs that can improve community health.",9.1,"Activity 9.1: The local health department shall publish and disseminate data and information on current local health issues to the general public, community partners, and elected and appointed officials.","Annually",4," A. Evidence of dissemination of information on current local issues to public.      Note: more general approach like newspaper article to inform and educate.                                                    "]
[null,null,null,null,null,"Annually",4,"B. Evidence of dissemination of information on current local issues to policy leaders. Note: More targeted approach like personal correspondence to inform, educate and advocate for action.  "]
[null,null,null,9.1999999999999993," Activity 9.2: The local health department shall have a mechanism by which the public can access community data and health status information maintained in the agency in accordance with applicable laws and rules.","     Most Recent Needed",1,"A. Policies and procedures regarding access to data and lists of accessible information.                                                           "]
[null,null,null,null,null,"      Most Recent Needed ",1,"B.  Lists of accessible information  Note: This is  information regarding health risks, health status and health needs that can be provided to members of the community upon their request.                                                                 "]
[null,null,null,null,null,"      Most Recent Needed ","2+"," \nC. Evidence of current modes of communication (e.g., agency website, brochures, press releases).    \n"]
[null,null,null,9.3000000000000007,"Activity 9.3: The local health department shall provide information to the public on the availability and location of health data that are accessible in the public domain.","      Most Recent Needed",1,"•A.   Agency website with web links, brochures, press releases, etc. Note: Show links to other health data websites but make sure links work and the links are related to most recent data.  "]
[null,null,null,9.4,"Activity 9.4: The local health department shall have written guidelines that it follows in responding to requests for information.","Most Recent Needed","1+","A. Policies and procedures for responding to written requests for information. Note: Policy to reflect information to be given timely, accurately, appropriately, & designate a position (PIO) and describe responsibilities for staff positions that may interact with news media and the public (related to requests for information). The policy should define specific methods whereby requests will or will not be accepted.                  "]
[null,null,null,null,null,"Since Previous Site Visit","1+","B.  If information has been requested, evidence showing adherence to guidelines. Note: Evidence that information was provided following policy timelines and etc…)"]
[null,null,null,9.5,"Activity 9.5: The local health department shall inform affected community members of changes in department policies or operations.","Since Previous Site Visit",2,"A. Announcement related to departmental change appearing in two of the following:  news article, posting on web site, signage within the agency, recording from radio or TV, etc., (can be blog) Note: Note: Two separate methods for the same change.                                 "]
[null,null,null,null,null,"Since Previous Site Visit",1,"B.  Evidence of opportunity for public comment demonstrated by one of the following:  meeting minutes, record of scheduled event, questionnaire and results.  If no changes, show policy and procedure. Note: Staff, leadership team, or BOH meeting notes.  "]
[null,null,null,9.6,"Activity 9.6: The local health department shall assure that information disseminated by the agency reflects the cultural and linguistic character of the local population as required by Title VI of the Civil Rights Act.","Most Recent Needed",1," A. Policies that acknowledge compliance with Title VI of the Civil Rights Act                                                          "]
[null,null,null,null,null,"Since Previous Site Visit",2," B. Evidence of two examples of information disseminated in accordance with policy."]
[null,10,"The local health department shall provide, support, and evaluate health promotion activities designed to influence the behavior of individuals and groups.",10.1,"Activity 10.1: The local health department shall develop, implement and evaluate population-based health promotion/disease prevention programs and educational materials for the general public. Note: The focus of this activity is population based program that targets the community at large.  ","Since Previous Site Visit",3,"A. Evidence of planning, implementation, and evaluation of health promotion/disease prevention programs targeted to the general public.                                                          "]
[null,null,null,null,null," Since Previous Site Visit",3,"B. Evidence of planning, implementing and evaluating educational materials targeted to the general public.\n Note: Evidence can come from different programs for each part (planning, implementing and evaluating)"]
[null,null,null,10.199999999999999,"Activity 10.2: The local health department shall carry out or assist other agencies in the development, implementation and evaluation of health promotion/disease prevention programs and educational materials targeted to groups identified as at-risk in the community health assessment.","Since Previous Site Visit",3,"A. Evidence of planning, implementation and evaluation of health promotion/disease prevention programs targeted to at-risk group identified in CHA.  "]
[null,null,null,null,null,"Since Previous Site Visit",3,"B.  Educational materials targeted to an at-risk group identified in the community health assessment.\nNote: Evidence can come from different programs for each part (planning, implementing and evaluating)     Note: For this we can assist or take the lead for targeted program and materials. Note in the evidence how partners were used in fulfilling this activity."]
[null,null,null,10.3,"Activity 10.3: The local health department shall employ evidence-based health promotions/disease prevention strategies, when such evidence exists."," Since Previous Site Visit",1,"A. One of the following: meeting minutes, correspondence, report, or research summary citing agency exploration and employment of evidence-based strategies                                                             "]
[null,null,null,null,null,"Since Previous Site Visit",1," B. External evidence that indicates strategy as effective (e.g. professional journal, research study). Need to research before implementation date of program or services where strategies were used."]
[null,null,null,10.4,"Activity 10.4: The local health department shall promote and support the use of evidence-based health promotion/disease prevention strategies by other community agencies and organizations.","Since Previous Site Visit",1,"A. One of the following: meeting minutes, correspondence discussing evidence based health promotion/disease prevention strategy, research summary citing agency promotion and support of evidence-based strategies by other community partners.                                  "]
[null,null,null,null,null," Since Previous Site Visit",1,"B.  External evidence that indicates strategy as effective (e.g. professional journal, research study). Need to research before implementation date of program or services where strategies were used. Note: Do not have to prove outside agency is using the EB Strategy just that LPH promoted it."]
["Standard: Agency Core Functions and Essential Services, Function: Policy Development, Essential Service 4",11,"The local health department shall convene key constituents and community partners to identify, analyze, and prioritize community health problems/issues.",11.1,"Activity 11.1: The local health department shall participate in a collaborative community steering committee to identify health issues and needs.   Note: Try to show evidence other than the Healthy Carolinian's Partnership if possible. ","  Since Previous Site Visit",1," A. List of participants (by organization or group represented) in a collaborative process to identify health issues and needs."]
[null,null,null,null,null," Since Previous Site Visit",1," B. Evidence of department's active participation in a collaborative process.   Note: Show role of health department in the group related to identifying health needs.   Evidence can be meeting minutes, action plan, or report from steering committee demonstrating the local health department’s role."]
[null,null,null,11.2,"Activity 11.2: The local health department shall involve community members in assessing, setting priorities and establishing desired outcomes for addressing community health issues and needs. Note: Can use Community Health Assessment material, along with developed action plans, in developing the evidence for the activity. "," Since Previous Site Visit",3,"A.  Community Member input on 1) assessing,                  2) prioritizing, and 3) establishing desired outcomes for community health issue or needs. Note: Evidence ideas -  recommendations from a community survey, focus group or community forum. Can use meeting minutes of the group with participants listed and community input noted in the record, or any committee report concerning community input in the process.  "]
[null,12,"The local health department shall develop strategies in collaboration with community partners to solve existing community health problems.",12.1,"Activity 12.1: The local health department shall participate in a collaborative process to identify strategies for addressing community health problems."," Since Previous Site Visit",1," A. List of participants (by organization or group represented) in a collaborative process to identify strategies for addressing community health problems.  Note: Evidence can come from list of participants (this may be in collaborative records such as a membership list, minutes or a list of those who signed in to a recent meeting, or other evidence of who participated)  showing that the health department is represented in the group."]
[null,null,null,null,null," Since Previous Site Visit",1,"B. Evidence of the department's active participation in this collaboration process.  Note: Evidence of current intervention and how the strategy was developed in a collaborative effort. Minutes can be used where there is discussion of strategies by the group. Written reports can be used where there it documents the strategies considered by the group.   Any evidence provided must include discussion, consideration and/or identification of potential strategies and demonstrate participation by the partners or members involved in the effort. "]
[null,null,null,12.2,"Activity 12.2: The local health department shall participate in a collaborative process to assess resources needed, including personnel, funding, policy changes, and system change, to address community health problems.","  Since Previous Site Visit",1,"A.  Evidence of participation in a collaborative process to assess resources needed to address community health problems.  Note:  The evidence must demonstrate collaboration  of assessment of resources for all of the following 1) personnel, 2) funding, 3) policy changes,  and 4) system changes. Change is defined as a way of doing things to achieve desired outcomes) . "]
[null,null,null,12.3,"Activity 12.3: The local health department shall participate in a collaborative process to implement population-based programs to address community health problems.","Since Previous Site Visit",1,"A.  Evidence of a collaborative process on the implementation of a population-based program to address community health problems. Note: Can be minutes recording collaborative efforts and program implementation. Can be a media release and must mention members involved, program information and indicate what has been implemented.  Website, brochure flyers or other program material must also indicate partners involved and show program implementation. If using a grant report, then would need to include partners, implementation roles and demonstrate program implementation. "]
[null,13,"The local health department shall identify and build upon community assets and direct them toward resolving health problems.",13.1,"Activity 13.1: The local health department shall broaden existing partnerships by cultivating innovative and new community contacts, such as businesses and industries, healthcare practitioners, faith communities, and grassroots organizations, and increasing their awareness of public health through outreach and training."," Since Previous Site Visit",2,"A.  Documentation of two targeted outreach and training activities with two community partners or contacts. Note: Partners or contacts should be new or a new contact within an existing partner organization or company. Show awareness of public health through outreach from and training by the health department."]
["Standard: Agency Core Functions and Essential Services, Function: Policy Development, Essential Service 5",14,"The local health department shall work with local, state and federal policymakers to enact policies, laws, rules, and ordinances that support individual and community health efforts.",14.1,"Activity 14.1: The local health department shall disseminate information relative to public health needs to elected and appointed officials."," Since Previous Site Visit",2,"A.  Information dissemination to local, state and/or federal elected and appointed officials that are in a policy or law-making role for two different public health needs.  Note: Presentations can be directed toward elected and appointed officials, can be a public forum if can show if officials were attending, A memo, e-mail or letter naming the elected or appointed official can be used too.  Meeting minutes are valid if a public health need is noted and officials are present. "]
[null,null,null,14.2,"Activity 14.2: The local health department shall provide information and recommendations to support the local board of health and the board(s) of county commissioners in setting public health priorities and planning public health programs.  This activity show health department involvement while 34.5 shows BOH involvement. Note: 1 Example if BOCC assumes BOH powers/duties)  Otherwise, will need 1 evidence for the BOH and 1 evidence for the BOCC. ","Since Previous Site Visit",2,"A.   Evidence of LHD provision of information/recommendations to the BOH/Human Services Board and Board of County Commissioners regarding public health priority setting and program planning. Note:  Evidence should show sharing of information to help the boards set priorities and plan programming. Evidence can be written correspondence or board meeting minutes if they reflect the HD has provided input in public health priority setting and program planning.   Can share information, data, statistics of rankings, results of reports of task forces and recommendations. Evidence cannot be related to CHA activities."]
[null,null,null,14.3,"Activity 14.3: The local health department shall evaluate, with the local board of health, the need for additional rules or ordinances to protect the health of the public.","  Since Previous Site Visit",1,"A.  Evidence of agency evaluation with the BOH, of the need for additional rules/ordinances or amendment of current rules/ordinances. Note: Can use BOH minutes to show efforts, involvement, discussion or responsibilities for both the BOH an  health department. A section of the strategic plan from the BOH, the health department or a combined plan.  Notes, summary or report from public hearings on a proposed rule, ordinance or the investigation of the need for or amendment of a rule can be used.  "]
[null,null,null,14.4,"Activity 14.4: The local health department shall assist the local board of health in drafting local ordinances and rules as needed and presenting them to elected officials in order to implement or enforce needed local public health prevention and protection activities.  Note: This activity does not require that a rule or ordinance to pass because the focus in on the evidence of the health department assistance in drafting or amending a rule or ordinance. "," Since Previous Site Visit","0-1 (if applicable)","A. Board of health minutes or BOH memo referencing input of agency in drafting/amending rule or ordinance impacting the public's health.                                                          "]
[null,null,null,null,null,"  Since Previous Site Visit","0-1 (if applicable)","B.  Minutes of meeting of BOCC citing new rule/amended rule or ordinance as a presentation and/or discussion item."]
[null,null,null,null,null,"Since Previous Site Visit","0-1 (if applicable)","C.  If no work towards rules or ordinances has been done, the health department shall provide a signed statement, from the BOH chair, indicating that no local rules/ordinances have been drafted/amended by the BOH.  "]
[null,15,"The local health department shall develop plans to guide its work.",15.1,"Activity 15.1: The local health department shall develop or update annually an agency strategic plan that: includes a review and analysis of factors influencing the health department’s ability to improve the community’s health, uses local health status data and information to set goals and objectives, uses community input where applicable, states desired outcomes for each element, sets priorities, and uses community collaborations to implement activities."," Most Recent Needed",1,"A. Copy of current strategic plan that includes the 6 core requirements included in the HDSAI. \n"]
[null,null,null,null,null,"Most Recent Needed",1,"B. Evidence that CHA results were used in most recent agency strategic planning."]
[null,null,null,null,null,"Since Previous Site Visit","3 - 4 (depending on timeframe of agency plan)","C. Evidence of implementation of the strategic plan                     "]
[null,null,null,15.2,"Activity 15.2: The local health department shall develop and adopt program policies and procedures that meet the following criteria: refer to the federal and state legislation, rules or regulations, or local rules or ordinances that provide the authority to carry out agency programs and activities, and delineates desired outcomes.","Since Previous Site Visit",3,"A.  Examples of three program policies and procedures that include reference to applicable laws, rules or ordinance and identify purpose/outcome. Note: This is not Administrative b/c those policies are covered in Benchmark 31.\n"]
[null,null,null,15.3,"Activity 15.3: The local health department shall have a written procedure providing for annual review, and revision if necessary, of all policies.","Most Recent Needed",1,"A. Policy on policies \n"]
[null,null,null,null,null,"Most Recent Needed",1," B. Evidence of annual review of all policies                   "]
[null,null,null,null,null,"  Since Previous Site Visit","On-Site Review","C.  Evidence of revision, if applicable, of all policies.                                                      "]
[null,null,null,null,null,"Since Previous Site Visit","On-Site Review","D. If revised, evidence that policy on policies has been followed regarding current staff notification."]
[null,null,null,15.4,"Activity 15.4: The local health department shall assess the internal and external resources that are available or needed to implement proposed new or updated policies and procedures.","Since Previous Site Visit",1,"A.  Evidence of assessment of resources that are available or needed to implement proposed new or updated policies and procedures. Note (Iredell): Towards the back of each policy notes some of this information."]
[null,null,null,15.5,"Activity 15.5: The local health department shall ensure that new staff is oriented to program policies and procedures and existing staff receives training on any updated or revised program policies and procedures."," Most Recent Needed",1," A. Program orientation policy for new staff based on role"]
[null,null,null,null,null,"Past 12 Months",1,"B.  A list of all new employees hired in the past 12 months Note: Will submit list with HDSAI and then have most recent available on first day of audit.  "]
[null,null,null,null,null,"Past 12 months","0+","C. Evidence indicating each new employee has completed policy training for the program(s), in which he/she work  Note: Relates to new employees only                                                 "]
[null,null,null,null,null,"Most Recent Needed",1,"D. Procedure for distributing policy changes to existing/current staff"]
[null,null,null,null,null,"Most Recent Needed","0+","E.  Evidence that appropriate staff have been notified of policy updates/revisions, related to their role. Note: Relates to new employees only  "]
[null,null,null,15.6,"Activity 15.6: The local health department shall ensure that policies and procedures are accessible to all staff."," Most Recent Needed",1,"A. Program Policies Note: Will be part of on-site review. Place most recent program policies in evidence. \n"]
[null,null,null,null,null,"Most Recent Needed","Narrative +                     On-Site Review","B.  Evidence demonstrating accessibility by all health department staff. Note 1: Write narrative where we keep accessible program policies and can take pictures of where the accessible policies are located for HDSAI. Note 2: Policies need to be accessible 24/7, not locked in an office where program person may not be able to access to a program team member if supervisor is out or needed after working hours.  Program policies should be at each location where the services are provided and all policies at all sites should be the same version.  Any accessible electronic versions should be the same version as well."]
["Standard: Agency Core Functions and Essential Services, Function: Assurance, Essential Service 6",16,"The local health department staff shall have knowledge of public health law and an understanding of the relationship between the law and public health practice.",16.100000000000001,"Activity: 16.1: The local health director and unit directors, such as directors of communicable disease, nursing, clinical services and environmental health, shall receive ongoing training in current public health law and its application.","Most Recent Needed",1,"A. List of appropriate directors who require training Note: Must include health director, directors of communicable disease, nursing, and environmental health "]
[null,null,null,null,null,"Once per each accreditation   24 months","8+","B. Evidence of at least two trainings since the previous site visit for appropriate directors in relation to applicable laws and their application to public health practice. Note:  Required for each director. Evidence can be a webinar, self-study course, web-based trainings, workshops,  in-house presentation or staff meeting, and conferences (including legal conference).  The evidence must show PH law and its application to practice. Can use dated agendas, meeting minutes, logs, certificates. "]
[null,null,null,16.2,"Activity 16.2: Local health department new employee orientation shall address public health laws and rules.","   Most Recent Needed",1,"A. New employee orientation addresses public health laws and rules.   Note: Can be new employee orientation checklist, orientation materials used for orientation. Evidence will need to prove general orientation to public health law and rules.   "]
[null,null,null,16.3,"Activity 16.3: Environmental health staff shall be trained in the implementation of laws, rules and ordinances that they enforce and shall have access to copies of the laws, rules and ordinances.","Most Recent Needed",1,"A. List of Environmental Health Specialists (EHS) currently employed and the programs for which they are enforcing.                                                        "]
[null,null,null,null,null," Most Recent Needed  ","1+"," B. Evidence that registered EHS are maintaining training requirements of RS Board and programs for which they are enforcing.  Note: Evidence may be thorough Centralized Intern Training, continuing education sessions, RS hours, public health meetings, and internal trainings. Can use a log or individual records. Need to show each EHS is currently properly trained.  Any accreditation year may be audited.                                                "]
[null,null,null,null,null,"Most Recent Needed",1,"C. Evidence demonstrating accessibility to laws, rules and ordinances that they enforce.  Note: If team members have links to statutes, rules, regulations and ordinances they there will need to be proof that team members know where to find links and have computer and Internet access. Team members will need to have access in offices and in the field. "]
[null,17,"The local health department shall monitor compliance with public health laws and rules.",17.100000000000001,"Activity 17. 1: The local health department shall conduct inspection and permitting activities for state mandated environmental health regulatory programs.","Past 12 Months",1,"A. Completion of 17.1 and 22.2 Division of Public Health State Programs Section of the Iredell County HDSAI Program List.   Note:  1) Answer \"Yes\" or \"No\" to all programs on this tool 2) Note if program letter was received and if so provide evidence. 3) Note date of most recent review for the program. 4) Note \"Met\" requirements or \"CAP\" needed. 5) Last line note status of CAP - Submitted, accepted or closed. "]
[null,null,null,null,null,"Past 12 Months","1+","B.  Letters from appropriate monitoring offices of NC Division of Public Health verifying environmental health program compliance Note: Letters must at least be electronically signed by creator. Environmental Health Section Head may create one letter and may address more than one program in that letter. "]
[null,null,null,null,null,"Past 12 Months","0+","C.  Evidence of performance improvement activities, as indicated by corrective action plan(s) (CAP) or program letter(s). Note: If there is a CAP then evidence should show progress towards fulfilling the CAP. If CAP was approved, there should be a letter indicating this and if the CAP is closed one will need to see the letter indicating this.  If CAP has deadlines for progress to be made then provide proof that you are meeting goals in the set timelines.  "]
[null,null,null,17.2,"Activity 17.2: The local health department shall conduct inspection and permitting activities assigned to the local health department by local rules, ordinances, or policies.","Past 12 Months",1,"A.  Completion of Activity 17.2 Summary of Locally Mandated Regulatory Programs Environmental Health section of the Iredell County HDSAI Program List. \n"]
[null,null,null,null,null," Since Previous Site Visit","0+","B. Evidence of local program activities including copy of local rules, ordinances, or policies Note: Attach local rules, ordinances or policies. Only submit if applicable. "]
[null,null,null,null,null,"Just Before HDSAI Submission","0 or 1","C.  If no local rules, ordinances or policies have been adopted, a signed statement from the board of health chair is needed indicating this.   "]
[null,null,null,17.3,"Activity 17.3: The local health department shall monitor compliance with communicable disease control laws and rules.","Most Recent Needed",1,"A.   Annual summary of implemented control measures, isolation/quarantine orders, arrest orders. Note: Auditors looking for one annual summary report. As support, the department may need to show individual case documents. Do Not Submit PHI so black our names and identifying information before submitting/sharing.  If no activity in the past 24 months, provide an example of control measures that would be used to comply with laws and rules."]
[null,null,null,null,"Activity 18.1: The local health department shall have written policies and procedures addressing enforcement of public health laws, rules and ordinances.","   Most Recent Needed","1 or 3+","A.  Policies and procedures that define how the  enforcement of public health laws, rules and ordinances will be done. Note: All health department programs with some type of legal authority should have written policies and procedures addressing enforcement. "]
[null,18,"The local health department shall enforce public health laws, rules and ordinances.",18.100000000000001]
[null,null,null,18.2,"Activity 18.2: The local health department shall take enforcement action for violations of public health laws, rules and ordinances.","Since Previous Site Visit",3,"A.  Examples of enforcement actions taken (e.g. notices of violations (NOV’s), letters of intent to suspend or revoke or other legal actions, permit actions, criminal actions, inspections, warrants, quarantine and isolation orders). Note: Examples should come from different programs, where possible, to show range of enforcement actions.  "]
[null,null,null,18.3,"Activity 18.3: The local health department shall have written policies and procedures for handling complaints related to enforcement of laws, rules and ordinances.","       Most Recent Needed","1+","A. Policies and procedures for handling complaints. Note: Any program that has enforcement actions that the health department is responsible for must have a component in policy that defines how complaints are handled.  Put related evidence of adherence to these policies in 18.4A."]
[]
[]
[null,null,null,18.399999999999999,"Activity 18.4: The local health department shall address complaints in accordance with its policies and procedures.","Since Previous Site Visit",3,"A. Evidence of review of three complaint reports demonstrating  adherence to policies and procedures. Note: Evidence should relate to different programs and should relate to how we respond to complaints and how does our response to complaints lead to performance improvement within the agency.  Also, auditors will be looking at related policies and procedures so consider put related policies in 18.3A. "]
[]
["Standard: Agency Core Functions and Essential Services, Function: Assurance, Essential Service 7",19,"The local health department shall identify populations that are not receiving preventive services or are otherwise underserved with respect to health care.",19.100000000000001,"Activity 19.1: The local health department shall assess use of public health programs and health care services by underserved, at-risk and vulnerable populations identified in the community health assessment process. Note: The intent of the assessment is to show that, through both the LHD and outside providers, access for the identified populations are being met.  ","Since Previous Site Visit",1,"A. Data on utilization of agency services by underserved populations. Note: Reference the CHA. Underserved: Do not access health care because there is a lack of services or providers available or because of limitations of income, literacy or understanding on how to access services. \n"]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Data on utilization of agency services by at-risk populations. Note: Reference the CHA. At-risk are likely to, or have the potential to get a specified health condition. This could be from engaging in behavior that could cause a specified health condition or having an indicator or precursor that could lead to a specified health condition.  "]
[null,null,null,null,null,"Since Previous Site Visit",1,"C. Data on utilization of agency services by vulnerable populations. Note: Reference the CHA. Vulnerable:  More susceptible than the general population to risk factors that lead to poor health outcomes. Vulnerable populations, a type of at-risk population, can be classified by such factors as race/ethnicity, socio-economic status cultural factors and age group."]
[null,null,null,null,null,"Annually",4,"D. Evidence of annual review of utilization data. Note: Reference the CHA. The purpose of this is to assess services used by these populations and what changes could be made to improve access. "]
[null,null,null,19.2,"Activity 19.2: The local health department shall take actions to include linguistically and culturally representative persons in planning and implementing programs intended to reach underserved population groups.","Since Previous Site Visit",1," A. Evidence of participation by such persons in a  planning activity (e.g., focus groups, interviews, planning meeting)                                               "]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. One implementation activity (e.g., media/promotional campaign, program delivery) targeted at that population."]
[null,null,null,null,"Activity 20.1: The local health department shall collaborate with community health care providers to provide personal and preventive health services.","Since Previous Site Visit",1,"A. Evidence of collaboration with community health care providers to provide personal health services. Note:  Disease management and primary care. Can be newsletters, newspaper articles, MOA and more.  Evidence needs to reflect collaborative work. "]
[null,20,"The local health department shall mobilize the community to address health care resource needs.",20.100000000000001,null,"Since Previous Site Visit",1,"B. Evidence of collaboration with community health care providers to provide preventive health services. Note: Screenings.  Can be newsletters, newspaper article, MOA and more.  Evidence needs to reflect collaborative work. "]
[null,null,null,null,"Activity 20.2: The local health department shall collaborate with community health care providers and agencies to reduce barriers to access to care.","Since Previous Site Visit",2,"A.  Collaborations with community healthcare providers to reduce barriers to access to care.  Note: Meeting minutes, report, written report, correspondence, collaborative grant application, letter of support for grants, ."]
[null,null,null,20.2]
[null,21,"The local health department shall lead efforts in the community to link individuals with preventive, health promotion, and other health services.",21.1,"Activity 21.1: The local health department shall make available to the general public a current, comprehensive list of community health and wellness resources.","Most Recent Needed",1,"A. Copy of current resource list or directory \n\n"]
[null,null,null,null,null,"Most Recent Needed",1,"B. Policy or mechanism for dissemination of community health and wellness resource list. Note: This can be part of another policy or a stand alone policy.                              "]
[null,null,null,null,null,"Since Previous Site Visit",3,"C. Examples of dissemination of health and wellness resource list  (e.g., website, brochures, flyers, media reports). Note:  Need 3 examples demonstrating dissemination of list. "]
[null,null,null,21.2,"Activity 21.2: The local health department shall make available complete and up-to-date information about local health department programs, services and resources.","Since Previous Site Visit",3,"A.  Three examples of linguistically and culturally appropriate information about agency programs, services, and resources (e.g., signage, brochures, flyers, websites, newsletter, health fair promotions, media articles)."]
[null,null,null,21.3,"Activity 21.3: The local health department shall develop and implement strategies to increase use of public health programs and services."," Most Recent Needed",1,"A. Plans or policies for increasing utilization of public health programs and services. Note: Show the development and implementation of strategies for increasing use of services for those that use some but not all is available to them. Make sure there is a culturally and linguistic component to the plan or policy. "]
[null,null,null,null,null,"Since Previous Site Visit",2,"B.  Evidence of culturally and linguistically appropriate implementation of those plans or policies."]
[null,null,null,21.4,"Activity 21.4: The local health department shall assure that the program planning and implementation involve community health advocates that represent populations being served in the local health department.","Since Previous Site Visit",1,"A. Evidence of program planning that shows involvement of community health advocates."]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Evidence of program implementation that shows involvement of community health advocates. "]
[null,22,"The local health department shall serve as a health care provider when local needs and authority exist, and the agency capacity and resources are available.",22.1,"Activity 22.1: When the local health department determines that there are compelling unmet health care needs in the community, the local health department shall develop a plan with community leaders and providers to meet the unmet needs, which may include the establishment and provision of such services by the local health department if the department has the authority, capacity and resources to address the unmet needs.","Since Previous Site Visit",4," A. Community Action Plans from most recent Community Health Assessment (CHA), with approval notice from NCDPH.  Note: Assuming there are at least three action plans and the approval notice. \n"]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Evidence of implementation and results of community health action plans. Note: Community Action Plans can include a newly developed plan that is not yet fully implemented. If the community action plans are new, there should be some evidence of implementation within the year due.  If plans have been in place for less than one year, results from implementation of community health action plan generated from previous CHA should be provided. Meeting minutes, logs or reports can be used as evidence."]
[null,null,null,22.2,"Activity 22.2: The local health department shall comply with laws, rules and contractual requirements for programs and services provided pursuant to the local health department’s consolidated agreement and agreement addenda, including requirements for corrective action.","Most Recent Needed",1,"A. Completion of 17.1 and 22.2 Division of Public Health State Programs Section of the Iredell County HDSAI Program List.  "]
[null,null,null,null,null," Most Recent Needed","1+","B. Letters from appropriate monitoring offices of NC Division of Public Health verifying program compliance.  Note: One letter may address all programs for each section or can be individual program letters.  Letters must be dated one year of the 90 day HDSAI notification date.  Letters must have signature of person generating letter (written or electronic). Letterhead, name and title of  person signing must be on letter. Letter should indicate when audit was held. Letter should indicate if corrective action plans are needed. "]
[null,null,null,null,null,"Most Recent Needed","1+                                          ","C.  Evidence of performance improvement activities, as indicated by corrective action plan(s) or program letter(s).  (See accompanying table in HDSAI)."]
[null,null,null,22.3,"Activity 22.3: The local health department shall comply with laws and rules relating to programs and services offered by local health department but not covered by the consolidated agreement and agreement addenda.        Note:  If the HD serves only as pass through for funds and is NOT involved in the activities or administration of the funded program they do NOT need to list the program or provide any other type of oversight for accreditation purposes.  ","Most Recent Needed",1,"A. Policies and procedures for each program not covered by the Agreement Addenda. "]
[null,null,null,null,null,"Most Recent Needed","1+                                         ","B. Evidence of program oversight or monitoring (See accompanying table in HDSAI)   Note:  This can be a program and/or chart audit, on-site monitoring, quality improvement program, self-audit or internal audit.                                                   "]
[null,null,null,null,null,"Since Previous Site Visit","1+                                         ","C. Evidence of performance improvement activities resulting from oversight or monitoring, as indicated, since the previous site visit. "]
[null,null,null,23.1,"Activity 23.1:The local health department shall have, or be recruiting, a health director who meets the legal requirements for the position.","Most Recent Needed"," 1+                                        ","A. Evidence that the current health director has credentials  Note: Proof of Health Director’s credentials (e.g. copy of diploma, transcript stating degree awarded or Division of Public Health qualification letter) OR board of health minutes describing plan to seek a Health Director with appropriate credentials."]
["Standard: Agency Core Functions and Essential Services, Function: Assurance, Essential Service 8",23,"The local health department staff shall meet statutory and regulatory qualifications for their positions.",null,null,"Most Recent Needed","1+                                         (if applicable)","B. Evidence that the BOH is seeking a health director with required credentials. Note: If the health director position is not filled at the time of the HDSAI due date, evidence of the BOH is seeking a health director with appropriate credentials is needed.  Evidence can be minutes, job posting, or any other form of documentation that demonstrates the board is seeking a qualified candidate.   "]
[null,null,null,23.2,"Activity 23.2: The local health department staff shall meet all registration, certification or licensure requirements for positions held and duties assigned.","Annually","Number required based on number of HD staff.","A.  Evidence of up-to-date registration, certification or licensure for staff as required for each staff position. All records reviewed must meet the documentation required.   Site Visitors will review randomly selected personnel records based on health department size: \n\nHealth Dept. Staff    Personnel Records Accessed                                                                                               30 or fewer               Up to 10 records \n31-100                        Up to 15 records\n101 or more              Up to 15% of total staff's records\n\nSite visitors will review at least one individual in each of the following roles: public health nursing, environmental health, health educator and member of the management team.  If the randomly selected personnel records do not reflect these roles, additional personnel records may be requested.\nNote: This includes any continuing education related to credentials. Site visitors will not review or assess documentation for licensure when license is granted by a legal entity such as a professional board. Site Visitors will record their findings in the table following Activity 24.3. \n"]
[null,null,null,23.3,"Activity 23.3: The local health department shall employ or contract with one or more physicians licensed to practice in North Carolina to serve as medical director.","Most Recent Needed",1,"• A. Evidence of a medical director’s M.D. or D.O. license                                                                                  AND"]
[null,null,null,null,null,"  Most Recent Needed ",1,"• B. Job description or contract for medical director.  Note: These must reflect duties of the medical director, credentials that must be held to serve in the capacity,  These can be annual but if not an annual contract, the contract should have a time period for services specified in some way.  If the MD is a contract placement then a contract and evidence of proper MD credentials.  If the MD is an employee, proper credentials, job description and records for required continuing education are reviewed. "]
[null,24,"The local health department shall regularly evaluate staff training and development needs and provide opportunities for continuing education, training and leadership development.",24.1,"Activity 24.1: The local health department shall have policies that promote and provide staff access to training.","Most Recent Needed",1,"A. Policies regarding staff training opportunities \n"]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Evidence that policies have been implemented.      Note: Evidence must tie back to the policy and can be related documentation, minutes, summaries, logs, reports, or etc.  "]
[null,null,null,24.2,"Activity 24.2: The local health department shall have a staff development plan that includes identifying and addressing the training and continuing education needs of the staff.","Most Recent Needed",1,"A. Staff development plan Note: Plan should clearly show that an assessment of needs was conducted and how the department will provide training or continuing education in response to the needs.  This can be a health department plan or part of a larger plan (such as a county plan).\n"]
[null,null,null,null,null,"Most Recent Needed",1,"B.  Evidence of plan implementation.  Note: Examples can be minutes, logs, staff development forms/templates, records for trainings, continuing education or coursework, QI documents, or other documents used to track progress of the plan. "]
[null,null,null,24.3,"Activity 24.3: The local health department staff shall participate in orientation and on-going training and continuing education activities required by law, rule or contractual obligation.","Annually","Number required based on number of HD staff.","A.  Evidence that health department staff have participated in orientation and ongoing training and continuing education activities required by law, rule or contractual obligation; and that the training is up-to-date.                                                                                                                                               Site Visitors will review randomly selected personnel records based on health department size:\n\nHealth Dept. Staff  Personnel  Records Accessed\n30 or fewer              Up to 10 records\n31-100                      Up to 15 records \n101 or more            Up to 15% of total staff's records\n\nSite visitors should review at least one individual in each of the following roles: public health nursing, environmental health, health educator and member of the management team.  If the randomly selected personnel records do not reflect these roles, additional personnel records may be requested.\nNote: Site Visitors will record their findings in the table that is in the HDSAI.\nPut in this file the person the site visit team would talk to regarding personnel records. Shonna to work with division managers.  See HDSAI for details per some disciplines."]
[null,25,"The local health department shall build relationships with entities that conduct education or research to enrich public health practice.",25.1,"Activity 25.1: The local health department shall work with academic institutions and other programs such as universities, colleges, community colleges, Area Health Education Centers, CDC and professional associations to provide training opportunities for current staff and future public health practitioners.","Since Previous Site Visit",2,"• A. Evidence from at least two  programs or institutions demonstrating the provision of training opportunities. Note: Documentation can be through enrollment documents, grade reports, transcripts, or certificates, a section of the staff development plan defining how it will use academic public health resources in educating and training staff or in providing training opportunities. Evidence can also be a formal agreement between the department and an educational institution where the agency will serve as a training site for a student in a clinical rotation, an internship or for a field practicum.   Evidence can be from universities, colleges, community colleges, AHECs, CDC and public health professional associations.      "]
[null,null,null,25.2,"Activity 25.2: The local health department shall work with at least two academic institutions and other programs such as universities, colleges, community colleges and Area Health Education Centers to facilitate research and evaluation of public health programs and issues.","Since Previous Site Visit",2,"A.  Evidence from institutions demonstrating research and evaluation of public health programs and issues. Note: Evidence that research or evaluation of an issue or program. Evidence can be a research grant proposal, agreement, contract or memorandum of understanding for research or evaluation, description of internship related to research or evaluation projects, list of agency staff serving as adjunct faculty but work must be related to facilitation research and evaluation of public health programs and issues, not just teaching an occasional class. The health department cannot work with the same group on two topics.                                                                                                                                                                                                                                         "]
[null,26,"The local health department shall promote diversity in the public health workforce.",26.1,"Activity 26.1: The local health department shall have and implement a non-discrimination policy as required by state and federal law and train staff in its application.","Most Recent Needed",1,"A. Policy for non-discrimination  Note: This policy may be part of another policy such as personnel policies or may be an administrative policy of the department. The policy should include training expectations, training schedule, identify staff that must be trained, and must reflect any state or federal requirements on non-discrimination.\n"]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Evidence of implementation of non-discrimination policy.  Note: Site visitors will be looking for the non-discrimination verbiage on materials during facilities tour and need to submit in evidence recently produced materials with the non-discrimination verbiage on it too.   "]
[null,null,null,null,null,"Since Previous Site Visit",1,"C.  Evidence of training on non-discrimination policy.  Note: New employee orientation is required and the agency should note in the policy the timeline for ongoing training.  Evidence can be training log, roster, or sign in sheet. "]
[null,null,null,26.2,"Activity 26.2: The local health department shall develop and implement a plan consistent with the health department’s non-discrimination policy to recruit and retain a management team and staff that reflects the population of the service area.","Most Recent Needed",1,"A. A plan to recruit and retain a management team and staff that reflects the population of the service area which supports the non-discrimination policy (in the workforce development plan)\n"]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Evidence of plan implementation.  Note: Evidence can be efforts made to recruit and retain. "]
[null,null,null,26.3,"Activity 26.3: The local health department shall assure that agency staff receives training in cultural sensitivity and competency.","Most Recent Needed",1,"A. Cultural sensitivity and Competency policy Note: This can be a stand alone policy or part of another  policy.   \n"]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Training records for each year since the previous site visit, to be verified by the Site Visitors upon examination of personnel records and staff training logs.  Note:  All new employees should be trained during orientation.  Annual training is not required, but should be conducted at least once since last site visit.   "]
["Standard: Agency Core Functions and Essential Services, Function: Assurance, Essential Service 9",27,"The local health department shall evaluate all services it provides for effectiveness in achieving desired outcomes.",27.1,"Activity 27.1: The local health department shall have in place a process for assessing consumer and community satisfaction with its services.","  Most Recent Needed",1,"A. Policy and procedure related to seeking consumer and community input with its services\nNote:  Reflect how community members be informed about ways to provide input. "]
[null,null,null,null,null,"Since Previous Site Visit","1+","B. Copies of tools used for both consumer and community input with its services  Note: Tools should match the language and linguistic needs of the customers served and that is present in the community. "]
[null,null,null,null,null,"Since Previous Site Visit","2+","• C. Examples of data collected from both consumer and community input with its services"]
[null,null,null,27.2,"Activity 27.2: The local health department shall use data from the consumer and community satisfaction assessment to make changes to improve its services.","Since Previous Site Visit",1,"A. Meeting minutes or records describing how consumer/community satisfaction data was used in planning or decision-making to improve services.\n\n"]
[null,null,null,null,null,"Since Previous Site Visit",1,"B.  Current Documentation of changes made (e.g., a copy of “old” and “revised” policy or procedure). If no changes indicated from data collected, provide policy/protocol for how community satisfaction data would be used to improve services."]
[null,null,null,27.3,"the local health department shall implement a performance appraisal system for all staff.","Most Recent Needed",1,"A. Quality assurance policies and procedures \n"]
[null,null,null,null,null,"Most Recent Needed ",1,"B. Quality improvement policies and procedures"]
[null,null,null,null,null,"Since Previous Site Visit",2,"C. Evidence of policy implementation for one quality assurance effort and one quality improvement effort.  Note: Evidence can be QI team or the name of a staff member responsible for or designated to lead quality improvement efforts, minutes from a quality team meeting, reports or records of efforts as defined by plan or policy, pre and post records, photo records, project narratives, logs & worksheets, and other documents that demonstrate that the department's quality assurance/improvement work.  "]
["Standard: Agency Core Functions and Essential Services, Function: Assurance, Essential Service 10  ",28,"The local health department shall use research to develop and evaluate public health programs.",28.1,"Activity 28.1: Before implementing a proposed public health program, the local health department shall review, when available, research evaluating the potential effectiveness of the program.","Since Previous Site Visit","1 (or the below instead)"," A.  Evidence of Internet or library search Note: To use the evidence the research should be conducted prior to the implementation of a proposed program or service not after. "]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Record of consultation with academic institution, professional organization, state consultant, regarding information about evidence-based best practices.  Note: To use the evidence the research should be conducted prior to the implementation of a proposed program or service not after. "]
[null,29,"The local health department shall ensure that its participation in research meets ethical standards.",29.1,"Activity 29.1: The local health department shall develop and implement policies ensuring that state and federal requirements are followed regarding the rights of participants in local public health research programs and requiring that any requests to access health department clients have Institution Review Board approval obtained by the host research organization.","Most Recent Needed",1,"A. Research policies \n"]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Evidence of implementation for activities conducted since the previous site visit."]
[null,null,null,29.2,"Activity 29.2: The local health department shall develop and implement policies for participation in research activities that impact its clients or community members.  Note: This activity speaks primarily to research programs that are based outside the health department but may involve the health department, specific programs, data or individuals affiliated with the department in some aspect of the research.   Also, if there has been no research conducted since the previous site visit, provide a statement declaring such. ","  Most Recent Needed",1,"A. Research policies Note: If the policy used in 20.1 is used for 29.2 then the policy must have a clear distinction between research directed by a host organization and research directed by the agency. Policy must refer to client's rights when the LHD is conducting research. The focus of the policy is the health department is the primary sponsor of the research and will be involving its own clients or customers. "]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Evidence of implementation if participated in research activities. Note: Show that all state or federal requirements regarding the rights of participants were followed, The host research organization had IRB approval for the project if it will request access to health department clients, and any specified practices defined by policy were followed.  Evidence can be release forms from participants in the study, a Memorandum of Understanding or Memorandum of Agreement with another entity that will be conducting  the research, an IRB document showing approval for the project, project criteria and guidelines, or a combination of these documents. "]
["Standard: Facilities and Administrative Services",30,"The local health department shall provide safe and accessible physical facilities and services.",30.1,"Activity 30.1: The local health department shall have facilities that are clean, safe and secure for the specific activities being carried out in the facility or any area of the facility, such as laboratory analyses or patient examinations.","During Audit","On Site Review","A.  Visit to facilities and observations by Site Visitors (refer to \"Activities that Require Visual Observation\" sheet). Note: Put a note in folder stating the ICHD person responsible or who manages facilities. "]
[null,null,null,30.2,"Activity 30.2: The local health department shall have facilities that are accessible to persons with physical disabilities and services that are accessible to persons with limited proficiency in the English language.","  Most Recent Needed",1,"A.  Policies/Protocols that address accessibility for persons with physical disabilities and Limited English Proficiency"]
[null,null,null,null,null,"During Audit ","On Site Review","B.  Interior and exterior signage that facilitates access to persons with physical disabilities and Limited English Proficiency (e.g. ramps, handicapped-accessible restrooms and examination rooms, Braille signage)                 Note: Photos to prove in folder.                                                 "]
[null,null,null,null,null,"During Audit","On Site Review +"," C. Facilities that are accessible to persons with physical disabilities.  If not fully accessible, evidence of performance improvement (such as seeking funding or short-term solution). Note: Photos to prove in folder. "]
[null,null,null,30.3,"Activity 30.3: The local health department shall have examination rooms and direct client service areas that are configured in a way that protects client privacy.","  Most Recent Needed",1,"A, Policies and procedures addressing client privacy"]
[null,null,null,null,null,"During Audit","On Site Review","B. Agency floor plan/layout conducive to privacy. To be verified through observations by Site Visitors (refer to \"Activities that Require Visual Observation\" sheet). Place photos in file from various sites."]
[null,null,null,30.4,"Activity 30.4: The local health department shall ensure privacy and security of records containing privileged patient medical information or information protected by the federal Health Insurance Portability and Accountability Act.","Most Recent Needed ",1,"A.  Medical records policies (HIPAA Related policies) Note: This should address such areas like HIPAA, Business Associate Agreements, Record Retention, Information Release, Confidentiality, Components of the Medical Records, Acronyms/Abbreviations, Medical Record Access, whether flash drives may be used, security of computers taken to client's homes, parental access to children's records, off site records access, etc. This can be one policy or many.  If records are accessed electronically off-site, policies should specifically address secure access off site. \n"]
[null,null,null,null,null,"During Audit","On Site Review"," B. Proper handling, storage and transport of medical records. To be verified through observations by Site Visitors (refer to \"Activities that Require Visual Observation\" sheet).  Show picture of transport units too."]
[null,null,null,30.5,"Activity 30.5: The local health department shall comply with OSHA regulations.","Most Recent Needed",1," A. OSHA Compliance policies and procedures \n"]
[null,null,null,null,null,"Since Previous Site Visit",2,"B.  Documents indicating utilization of policies."]
[null,null,null,30.6,"Activity 30.6: The local health department shall ensure cleaning, disinfection and maintenance of clinical and laboratory equipment and service areas and shall document all cleanings, disinfections and maintenance.","Most Recent Needed ",1,"A. Policies and procedures, supported by evidence-based practice, related to cleaning, disinfection, and maintenance of equipment Note: Add the evidence-based infection control research reference in policy and procedure. Policy to include: WHAT items are to be cleaned, WHO is responsible to clean these items, WHAT products are to be used to clean the items, HOW cleaning will be performed (the steps to be taken and the order in which they should be done), WHEN (frequency) cleaning will occur and any \"special circumstances\" (such as outbreaks of norovirus.)  The policy should also clearly define training requirements (for what staff and how) and address equipment maintenance and calibration. Policy should also address:  Autoclaves/medical or dental washers, BP cuff calibrations, scale calibrations, X-Ray equipment permits/license, audiometer calibrations, thermometer calibrations including those used in EH Lab equipment maintenance and calibration, dental equipment maintenance and calibration including x-ray inspection certification, documents to show that eye wash station(s) have been inspected/checked to ensure they are working properly (includes free standing eye wash stations and/or eye wash attachments for CLEAN sinks), crash cart logs - equipment lists and expiration dates, vision testing equipment depending on the type, toys in patient play area or therapeutic toys or props (must be disinfected after each use). Consult your Regional Child Health Consultant for recommendations for alternatives to toys such as the evidence-based Reach Out and Read Program.  "]
[null,null,null,null,null," Only Most Recent Needed ","1+","B. Training records showing where staff were trained on policies and procedures related to cleaning, disinfection and maintenance of clinical and laboratory equipment and service areas.                             "]
[null,null,null,null,null," Previous 24 Months ","On Site Review; however,  Submit Samples of Evidence ","C. Maintenance records.  To be verified through observations by Site Visitors , who will randomly select a month for review from the previous 24 months records (refer to \"Activities that Require Visual Observation\" sheet)."]
[null,null,null,30.7,"Activity 30.7: The local health department shall have and comply with policies and procedures for infection control required by law in providing clinical services.","   Most Recent Needed ",1,"A. Policies and procedures regarding infection control required by law in providing clinical services \n"]
[null,null,null,null,null,"Since Previous Site Visit",2,"B. Evidence of compliance with infection control laws. Note: Examples: wearing latex gloves in appropriate clinical areas, hand sanitizer dispensers for use by staff and public and proper disposal of medical waste.  Other compliance can be demonstrated by records, such as showing that staff requirements for Hepatitis B vaccination are being met by appropriate clinical personnel. "]
[null,null,null,30.8,"Activity 30.8: The local health department’s hours of operation shall be based on documented community need.","Since Previous Site Visit",1,"A. Evidence of consumer and community input related to service needs (Customer Satisfaction Results can be used for this)  Note: This activity is related to input regarding hours of operation b/c hours of operation gets at issues of access. "]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Record of response. Note: Also show evidence of  documentation that reflects how the agency evaluates the consumer and community input and makes adjustments as needed based on the responses. Management team or staff minutes reflecting record of response and how the input will help guide the agency's actions to hours of operation can be used as evidence. "]
[null,null,null,30.9,"Activity 30.9: The local health department shall prohibit the use of tobacco in its facility.","During Audit","On-Site Review                 1+","A.  Verification of signage at all health department facilities (refer to \"Activities that Require Visual Observation\" sheet). Note: Place pictures from all health department internal and external signage in evidence.  This activity refers to tobacco use so a \"no smoking\" signage will not suffice. English and Spanish signage is needed. Mobile Units: Tobacco free signage is needed at other locations where health department services are provided and where there are no tobacco free campus policies.  Otherwise, signage is needed where there is a full-time or permanent presence and where equipment, furniture, materials/or records remain at the site when the health department is not seeing clients or customers.  "]
[null,null,null,30.1,"Activity 30.10: The local health department shall make efforts to prohibit the use of tobacco in all areas and grounds within fifty (50) feet of the health department facility.","Since Previous Site Visit",1,"A. Evidence that the agency may prohibit the use of tobacco use within 50 feet by vote of the Board of Health or the Board of County Commissioners for ALL health department facilities;\n                                                                                                                          Note: This A. OR B. (below) is required. "]
[null,null,null,null,null,"Since Previous Site Visit",1,"B.  Evidence that a request to prohibit the use of tobacco within 50 feet was made to the Board of Health, County Commissioners or property owner for ALL health department facilities with a response from the Board of Health, County Commissioners or property owner."]
[null,31,"The local health department shall develop and implement administrative policies and procedures.",31.1,"Activity 31.1: The local health department shall develop and implement policies and procedures regarding the administration of the local health department and shall assure policies and procedures are accessible to staff.","Most Recent Needed ",1,"A. Administrative policies and procedures (not program policies)\n"]
[null,null,null,null,null,"During Audit","On-Site Review","B. Accessibility of policies and procedures by staff, to be verified through observations by Site Visitors Note: Add into evidence screen shots of Intranet access, where health departments have that capacity. "]
[null,null,null,31.2," Activity 31.2: The local health department shall have a current organizational chart showing lines of authority.","Most Recent                             Just Before HDSAI is Submitted  ",1," A.  Current organizational chart with identifiable lines of authority.  Note: If organizational chart changes between the time the HDSAI is submitted and the audit day then a revised version will be provided to the audit team during the visit. "]
[null,null,null,31.3,"Activity 31.3: The local health department shall have written personnel policies that address disciplinary, grievance and harassment issues.","Most Recent Needed",1,"A.  Personnel policies that address disciplinary, grievance and harassment issues.  Note: Three components must be covered in the policies 1) Disciplinary,    2) Grievance and 3) Harassment.  "]
[null,null,null,31.4,"Activity 31.4: The local health department shall have current written position descriptions and qualifications for each staff position.","Most Recent Needed ",1,"A. Policy requiring annual review of position descriptions."]
[null,null,null,null,null,"During Audit","On-Site Review","A. Position descriptions on file that have been signed, dated, and reviewed annually by both employee and supervisor, to be verified through observations by Site Visitors.  Site Visitors will review a written position description for each individual selected for review from one of the previous years since the last site visit.\nSite Visitors will review randomly selected personnel records based on health department size: \n\nHealth Dept. Staff     Personnel  Records Accessed\n30 or fewer                  Up to 8 records\n31-100                          Up to 15 records\n101 or more                 Up to 15% of total staff's records\n\nAt least 85% of the records reviewed must meet the documentation required.                                                          Site visitors should review at least one individual in each of the following roles: public health nursing, environmental health, and member of the management team.  If the randomly selected personnel records do not reflect these roles, additional personnel records may be requested.\nNote: Site Visitors will record their findings in the table following Activity 24.3. See HDSAI for table.\nNote in evidence folder who will be the contact person for this activity during the site visit.  "]
[null,null,null,31.5,"The local health department shall implement a performance appraisal system for all staff.","Most Recent Needed",1,"A. Performance appraisal policies and procedures "]
[null,null,null,null,null,"During Audit","On-Site Review","B.  Signed and dated annual performance appraisal, to be verified through observations by Site Visitors.  To be accepted as valid documentation, the performance appraisal should have been conducted within a randomly selected year since the last accreditation site visit, and is to be signed and dates by the employee and the supervisor conducting the appraisal, to be verified through observations by Site Visitors\nSite Visitors will review randomly selected personnel records based on health department size: \n\nHealth Dept. Staff  Personnel Records Accessed\n30 or fewer            Up to 8 records\n31-100                    Up to 15 records\n101 or more           Up to 15% of total staff\nAt least 85% of the records reviewed must meet the documentation required. \nSite visitors will review at least one individual in each of the following roles: public health nursing, environmental health, and member of the management team.  If the randomly selected personnel records do not reflect these roles, additional personnel records may be requested.\nNote: Site Visitors will record their findings in the table following Activity 24.3."]
[null,null,null,31.6,"Activity 31.6: The local health department shall have an inventory of equipment that includes a plan for replacement.","Most Recent Needed",1,"A. Inventory list of equipment Note: Equipment will include any type of laboratory, clinical, medical or home health equipment, audio/visual, computers and servers, environmental health equipment, animal control equipment (if part of the health department), and vehicles.  For single county health departments, the county inventory list will meet this activity. For districts and authorities, a list that follows guidelines that the board of health has established will meet this activity.  "]
[null,null,null,null,null,"Most Recent Needed",1,"B. Replacement plan for equipment Note: This plan must include a description of how and when the department will assess the need for replacement of equipment owned or assigned to the department and evidence that the plan has been followed, since the previous site visit or that attempts have been made to follow the plan (i.e. budget request, grant application, etc.).  "]
[null,null,null,null,null,"Most Recent Needed",1,"C. Evidence of efforts to implement plan.  Note: At least one example of  plan implementation must be provided. "]
[null,32,"The local health department shall operate a secure and effective management information system.",32.1,"Activity 32.1: The local health department shall have computer equipment and software needed to interface with state data management systems.","Since Previous Site Visit",2,"A. Evidence of data exchange between LHD and two different state systems. Note: Examples can be HIS, NCIR, NCEDSS, VRAS, BETS, Crossroads, CSDW, etc.)\n"]
[]
[null,null,null,32.200000000000003,"Activity 32.2: The local health department shall ensure that staff are able to use the management information system to participate in electronic communications and public health program implementation.","Most Recent Needed",1,"A. Policy on training staff on management information systems (MIS)"]
[null,null,null,null,null,"Since Previous Site Visit",2,"B. Examples of evidence of implementation of the policy                                                                                                                                                                                                                                                                                                                                                                                         Note: B or C.   The department will need to provide a list or spreadsheet to define the relevant staff that use any MIS and this most likely will include anyone who logs onto a computer that is a part of a network.  This will include staff using NCIR, NCEDSS, VRAS, BETS, Crossroads, CSDW, the department billing system and any other MIS program. This will include any staff that must provide state reports through some type of web-based system or specialized software.  Just because a staff member has an assigned login and uses a system does not provide the evidence of training.  Also, documentation of training must be provided like an orientation checklist, checklist specific to MIS training that is provided, or a completed outline of training topics signed by a supervisor or a county or department/district MIS department. "]
[null,null,null,null,null,"Since Previous Site Visit",1,"C. A statement signed by the health director that no new staff have been hired and no new information systems have been implemented since the last site visit. "]
[null,null,null,32.299999999999997,"Activity 32.3: The local health department shall have a written policy regarding authorized and prohibited use of computer equipment, email and Internet.","Most Recent Needed",1,"A.  Computer/technology use policy.  Note: The policy must specifically address three areas - general use of computer equipment, use of email, and use of the internet,  The authorized and prohibited uses of MIS may be for any use of the MIS including the three specified. \n"]
[null,null,null,32.4,"Activity 32.4: The local health department shall have policies and procedures to assure management information system security, and use passwords and screensavers to safeguard the privacy of electronic information.","Most Recent Needed",1,"A. Policies and procedures assuring management information system security, and use passwords and screensavers to safeguard the privacy of electronic information.  Note: This policy should be a comprehensive look at MIS security and not just specific segments or regulations, such as HIPAA. Include how staff, visitors and clients/customers would not view or use information on MIS where access is not allowed. "]
[null,null,null,null,null,"During Audit ","On-Site Review                 ","B.  Evidence that policies and procedures have been implemented, to be verified through observations by Site Visitors"]
[null,33,"The local health department shall assure its financial accountability.",33.1,"Activity 33.1: The local health department shall demonstrate that it receives financial support from a local taxing authority.","Since Last Site Visit   ",1,"A. Evidence reflecting local appropriations for local health department for every year Note: Need the completed Budget Summary Template that, in part, breaks out actual allocation of local dollars in each year's approval budget.  "]
[null,null,null,33.200000000000003,"Activity 33.2: The local health department shall operate under a budget approved by the appropriate authority under state statute.","Most Recent Needed",1,"A. Current budget \n"]
[null,null,null,null,null,"Most Recent Needed",1,"B. Evidence that it has received official approval from the appropriate authority.  Note:  For single county agencies, need evidence that the budget was recommended by the BOH and BOCC.  For authorities and districts need evidence the budget has been approved by the BOH. "]
[null,null,null,33.299999999999997,"Activity 33.3: The local health department shall follow generally accepted accounting principles.","Most Recent Needed",1,"A. Findings of most recent audit Note: Will need the full audit document during the site visit; however, electronic evidence can be a compilation of pages from the audit.  \n"]
[null,null,null,null,null,"Most Recent  Needed","1+","B. Evidence of corrective actions taken based on any health department related findings.  Note: Need B or C "]
[null,null,null,null,null,"Most Recent Needed",1,"C. If there were no findings, need a statement from the audit report indicating such "]
[null,null,null,33.4,"Activity 33.4: The local health department shall have policies that assure segregation of financial management duties and accountability for funds.","Most Recent Needed",1,"A. Policies referencing segregation of financial management duties and accountability for funds.     Note: This policy will include content regarding segregation of financial management duties (referring to collecting fees, preparing daily deposit, making the deposit, preparing invoices, accounts payable, travel reimbursement, processing paper checks received by mail and etc.) and the accountability for funds (referring to handling large receipts, for example from grants and electronic deposits, defines protocols for handling of cash receipts, reconciliation of collections to charges (such as encounter forms or master bills), protocols for collections off site, daily deposit cut-offs, petty cash, and other sections to define the department's overall proper handling of funds).   "]
[null,null,null,33.5,"Activity 33.5: The local health department shall determine the cost of services in setting fees.  Note:  This activity focuses on the information used to determine the fees that will be proposed. ","Since Previous Site Visit",1,"A. Minutes of agency meetings where cost of services are determined and fees  are proposed. Note: This can be staff workgroups, management team, or meeting convened by the health department. There is not prescribed method that the department must use to determine costs. Internal cost analysis can be done, cost settlement reports can be used, or another data analysis process that looks at the cost of providing a service or program can be used. The external pricing guides and market surveys can be done, these should be secondary and, if used, should include some accepted guidelines for a cost breakdown versus simply being used for a comparison of fees. "]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Board of Health or advisory committee on health minutes reflecting discussion of service costs.  Note: Discussion should be on the information that is provided by the health department and will be a guide in setting fees.  "]
[null,null,null,null,null,"Since Previous Site Visit",1,"C. Data or methodology used to determine costs. Note: The data would include any reports, statistics, utilization numbers, etc. used in the analysis to determine costs of services.  The methodology used refers to the actual process of analysis of the data to arrive at costs of services amounts that will be used to develop proposed fees.  There is no data that must be included or methodology that must be used.  The department, in collaboration with the BOH, should use a process that helps determine the most accurate and valid numbers for both cost and fees.  "]
[null,null,null,33.6,"Activity 33.6: The local health department shall develop and present periodic budget, expenditure and other financial tracking reports to the board of health for its review.","Since Previous Site Visit",3,"A. Three different financial reports. Note: The reports can't be the three different reports of the same kind. Examples can be a budget report showing current expenditures and revenue, including year to date summaries.  Annual budget summary, quarterly or monthly report of expenditures and/or revenues or a report detailing a specific program, billing or accounts receivable reports, accounts payable reports, collections reports, and state expenditure reports (WIRM).  Reports can reflect data for any time period.  Bad debt reports can be used but not the bad debt write-off amount or summary should not be used in this activity since it will be used for activity 33.7.     \n"]
[null,null,null,null,null,"Since Previous Site Visit",3,"B. Board of Health minutes reflecting discussion of those reports."]
[null,null,null,33.700000000000003,"Activity 33.7: The local health department shall have a financial risk management system in place to address uncollected fees and bad debt.","Most Recent Needed",1," A. Policies and procedures defining financial risk management for uncollected fees and bad debt  Note: The focus is on how the department maximizes the collection of fees and minimizes bad debt. \n"]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Evidence of implementation of policies and procedures defining financial risk management for uncollected fees and bad debt.  Note: This can be shown through BOH minutes with attachments, commissioner meeting minutes, correspondence with county finance offices and records of bad debt write-offs that have occurred since the previous site visit.  Evidence can be records showing how the department works to maximize the collection of fees and to minimize bad debt (such as the use of payment plans and debt setoff programs)."]
["Standard: Governance",34,"The local board of health shall exercise its authority to adopt and enforce rules necessary to protect and promote the public’s health.",34.1,"Activity 34.1: The local board of health shall have operating procedures which shall comply with state law.","Most Recent Needed","1`"," A.  Current BOH operating procedures consistent with the content in the Operating Procedures document located on the Accreditation website that is based on guidance found in the Institute of Government's Suggested Rules of Procedure for Small Local Government Boards.   Note: By simply having a set Bylaws will not meet the requirements. All items included in the bylaws should comply with state statutes. The Institute of Government recommends that the BOH have operating procedures instead of Bylaws. Many BOHs will usually repeal their Bylaws and replace them with the Operating Procedures. A board can't avoid using Robert's Rules. There is an exception where BOCC have assumed powers and duties of the BOH. "]
[null,null,null,34.200000000000003,"Activity 34.2: The local board of health shall have access to legal counsel.","Most Recent Needed",1,"A. Copy of contract, letter of agreement, correspondence, or other evidence verifying access to legal counsel.  Note:  Evidence can be a contract process, a letter of agreement, correspondence with legal counsel, or other evidence presented to the BOH. Any copy of a contract or letter of agreement with an attorney may be provided and should be dated or renewed within the past 24 months. There may be current correspondence of some type - written, email or by telephone - that will demonstrate access.  Single county health departments may present documentation that a county attorney is employed by or under contract to the county and that the board of health has access to this counsel.  The use of legal council is not required, only that the BOH has access. However, Documentation showing use of legal counsel would imply that the BOH has access.   "]
[null,null,null,34.299999999999997,"Activity 34.3: The local board of health shall follow the procedures for adopting rules in G.S. 130A-39.","Most Recent Needed",1,"A.  Policy/procedures for rule-making Note: A or B"]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. If rule has been adopted since previous site visitor, evidence policy/procedure was followed.   Note: B or C Evidence can be a rule notice signed by the BOH chair. A policy and procedure manual which defines how the BOH adopts rules or correspondence with legal counsel referencing BOH's legal procedures in adopting rules. "]
[null,null,null,null,null,"Since Previous Site Visit",1,"C.  If a rule has not been adopted, since the previous site visit, evidence of signed board of health statement to that effect.  "]
[null,null,null,34.4,"Activity 34.4: The local board of health shall evaluate the need for the adoption or amendment of local rules or ordinances.","Since Previous Site Visit",1,"A. Evidence of implementation of rules/ordinance adoption or amendment. Note:  A or B   BOH minutes reflecting discussion or decision. "]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. BOH Minutes indicating that the BOH has done an evaluation and feels no new or amended rules or ordinances are needed.  Note: BOH minutes should record a discussion or decision on assessing the need for adoption or amendment of local rules. "]
[null,null,null,35.1,"Activity 35.1: The local board of health shall assure it follows the procedures for adjudications in G.S. 130A-24.","Most Recent Needed",1,"A. Policies and/or procedures for adjudications, specific to G.S. 130A-24  "]
[null,35,"The local board of health shall assure a fair and equitable adjudication process.",null,null,"Since Last Site Visit   ",1," B.  If an adjudication has occurred since the previous site visit, evidence that policy/procedure was followed                 Note: B or C   Can submit any correspondence with a citizen regarding a BOH rule, BOH minutes recording discussion of a potential appeal or actual appeal, report of BOH actions after a hearing, or documentation referencing involvement of legal counsel to the BOH related to the adjudication of an appeal.                                                   "]
[null,null,null,null,null,"Since Last Site Visit   ",1,"C.  If no adjudication since last site visit, evidence of signed BOH statement to that effect."]
[null,36,"The local board of health members shall be trained regarding their service on the board.",36.1,"Activity 36.1: The local health department shall provide board of health members with a written board handbook developed or updated within the past 12 months.","Past 12 Months",1,"A.  Dated board of health handbook developed or updated within the last 12 months. Note:  There are no specific or required contents but the information should be regularly updated and information replaced as appropriate.  Can include BOH specific information and health department specific information.\n"]
[null,null,null,36.200000000000003,"Activity 36.2: The local health department shall assure new board of health members receive training and reference materials on the authorities and responsibilities of the local board of health within the first year after appointment to the board.","Most Recent Needed",1,"A. Policies and Procedures on BOH Members receiving training and referencing materials on the authorities and responsibilities of the local board of health, within the first year of appointment. Note: Policy can be in the operating procedures or a separate policy. \n"]
[null,null,null,null,null,"Most Recent Needed","1+","B. Training materials used.  Note: Training can be conducted at one time, may be done as modules, and can be done as a group and/or as individuals.  A self-guided training which includes each board member documenting their completion of the training on a specific date is acceptable.  Training should be focused on the authorities and responsibilities of the local board of health. "]
[null,null,null,null,null,"Annually","1+","C. Dated evidence of new board of health members’ participation in orientation training activities during their first year of service.  Note: Should have evidence for all BOH members appointed since the last site visit and currently serving on the board."]
[null,null,null,36.299999999999997,"Activity 36.3: The local health department shall assure on-going training for board of health members related to the authorities and responsibilities of local boards of health.","Most Recent Needed",1,"A.  Policies and/or Procedures for BOH ongoing training Note: This policy can be in the operating procedures or may be in a separate policy.  The same policy can be used for 36.2 but there must be a separate section that addresses ongoing training. Policy should specify when and how training is conducted.  At minimum, on-going training should be at least once during a 4-year cycle. The topics may be related to any relevant or emerging public health topic such as isolation/quarantine authorities as related to an emerging infectious disease or updates to state environmental health rules, so long as the training includes/highlights the BOH rule-making or other authority as it relates to the topic. A self-guided training is acceptable."]
[null,null,null,null,null,"Most Current Needed","1+","B. Training materials used Note: Materials should be related to their authorities and responsibilities."]
[null,null,null,null,null,"Since Previous Site Visit","1+","C.  Dated Evidence of all BOH members' participation in on-going training activities related to authorities and responsibilities of BOH since previous site visit. "]
[null,37,"The local board of health shall assure the development, implementation and evaluation of local health services and programs to protect and promote the public’s health.",37.1,"Activity 37.1: The local board of health shall assure that a qualified local health director, in accordance with G.S. 130A-40 or 40.1, is in place to lead the agency. Note: 27.3 focuses on assuring the BOH/Consolidated human services director assures it is meeting statutory/regulatory qualifications for the health director position. ","Most Current Needed",1,"A.  Evidence the current Health Director has required credentials   Note: A or B                                                Note: Evidence can be a copy of a diploma showing degree awarded, a copy of the transcript stating the degree awarded, or a letter from the Division of Public Health stating that the division has determined that the person is qualified to be in the position of health director.  \n"]
[null,null,null,null,null,"Most Current Needed",2,"B. If the position is currently vacant, evidence that the former health director was qualified and a letter from the BOH noting a new qualified director is being sought. Note: Information on the former health director should include dates of employment as well as qualification information. "]
[null,null,null,37.200000000000003,"Activity 37.2: The local board of health shall approve policies for the administration of local public health programs.","Since Previous Site Visit",1,"A.  Board of health minutes approving policies in compliance with the organizations policy on policies. \n"]
[null,null,null,37.299999999999997,"Activity 37.3: The local board of health shall describe and define the knowledge, skills, and abilities that must be met by the local health director, consistent with the requirements in G.S. 130A-40.","Since Previous Site Visit",1,"A. If the local board of health or the consolidated human services director has hired a Health Director since the previous site visit or if a search is presently underway, evidence that BOH or consolidated human services director sought or is seeking a health director with the knowledge, skills, and abilities that must be met by a local health director.  Note: A or B                              Note: This evidence is not related to legal qualifications, which are covered in Activity 37.1"]
[null,null,null,null,null,"Since Previous Site Visit",1,"B.    If the health director has been in place since the previous site visit, evidence of signed board of health/consolidated human services director statement indicating that the local health department director has been in his/her position for __ __ number of years; therefore, the local board of health or consolidated human services director has not needed to define the knowledge, skills and abilities needed for this position.    "]
[null,null,null,37.4,"Activity 37.4: The local board of health shall review and approve the job description of the local health director.","Past 12 Months",1,"A. Current Health Director job description that has been signed, dated and reviewed within the past 12 months  "]
[null,null,null,null,null,"Since Previous Site Visit","1                                           (O if done by a consolidated human service director)","B.  Board of Health review and approved the Health Director job description at least once since previous site visit. Note: Only the most recent job description is needed here.  However, 31.4 will prove LHD staff (including the HD) has annually signed job descriptions.  "]
[null,null,null,37.5,"Activity 37.5: The local board of health shall conduct an annual performance review of the health director.","Past 12 Months",1,"A.  Signed and dated annual health director performance review by board of health within the last 12 months.  \nNote:  The review should include an assessment related to the Health Director's job description and any expected performance indicators identified by the BOH or the consolidated human services director.  For evidence, the LHD does not need to provide the completed performance review of the director, including any ratings or comments.  Site visitors only need to verify that an appraisal was conducted and can do so by viewing a copy of the tool uses, along with the signature page of the performance appraisal that includes the health director's signature. "]
[null,null,null,null,null,"Past 12 Months","1                                           (O if done by a consolidated human service director)","B. Evidence the BOH had input in the most recent health director's performance review.  Note: The full BOH does not have to participate fully in the process; however, it may choose to do so. The key here is the full board had the opportunity for input and final approval as appropriate and as evidenced by e-mails, minutes, or other correspondence and that final results were reported back to the full BOH."]
[null,null,null,37.6,"Activity 37.6: The local board of health shall approve policies for the recruitment, retention and workforce development for agency staff.","Most Recent Needed",1,"A.  Board of health minutes or consolidated human services director correspondence indicating approval of policies, plans, or allocations through budget process to provide for recruitment, retention and workforce development for agency staff. Note: This is to show the BOH or consolidated human service director has a role in supporting the department’s workforce by working with the health director to approve policies related to 1) recruitment,     2) retention activities, and 3) development. It is a good idea to include the minutes and the document that was considered and approved; however, the document is not a requirement.  "]
[null,38,"The local board of health shall participate in the establishment of public health goals and objectives.",38.1,"Activity 38.1: The local board of health shall annually review reports provided by the local health department on the community’s health.","Annually",8,"A. Board of Health minutes reflecting review of two annual reports related to the community's health.  Note: This refers to reports that contain information and statistics on the health of the communities served by the health department. Need two reports for each year since the previous site visit that are reviewed by the BOH. Examples could be an environmental health report, an agency annual report if it contains information on the community's health, an annual report on flu incidence or vaccine distribution, an update on county health rankings, etc...  An annual report on local disease incidence and trends can't be submitted as it is covered in Activity 2.4. Likewise, SOTCH and CHA reports cannot be submitted as they are covered in Activity 38.2.     "]
[null,null,null,38.200000000000003,"Activity 38.2: The local board of health shall review community health assessment data and citizen input used to plan and monitor progress toward health-related goals.","Since Previous Site Visit","2 or 3","A.  Evidence of BOH or advisory committee on health review of SOTCH reports for each year a CHA was not conducted.  Note: Reviews should be prompt after completion. "]
[null,null,null,null,null,"Since Previous Site Visit","1 or 2","B. Board of health or advisory committee on health review of specific aspects of CHA data (or each year CHA was conducted).  Note: Reviews should be prompt after completion. "]
[null,null,null,38.299999999999997,"Activity 38.3: The local board of health shall assure that individuals, agencies, and organizations have the opportunity to participate in the development of goals, objectives and strategies for community health improvement.","Since Previous Site Visit",1,"A. Board of health/advisory committee on health policy regarding broad community collaboration in the development of goals, objectives and strategies for community health improvement.  Note: This can be a policy regarding public participation and may be part of the BOH/advisory committee on health operational procedures or it may be a separate policy adopted by the board.                                                               "]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Board of health/advisory committee on health minutes reflecting that public participation occurred.   Note: Public comments may be through individual comments given at a BOH/Advisory committee on health meeting, may be by individual correspondence or by a survey or questionnaire.  If not delivered in person, any written comments must be reported to the BOH/advisory committee on health.  Comments that are shared with or received by the Director or staff may also be relayed to the BOH/advisory committee on health and used in planning and in the development of goals and strategies."]
[null,39,"The local board of health shall assure the availability of resources to implement the essential services described in G.S. 130A-34.1(e)(2).",39.1,"Activity 39.1: The local board of health shall communicate with the board of county commissioners, units of government and private foundations in support of local health department efforts to secure national, state and local financial resources.","Since Previous Site Visit",1,"A.  Board of Health or advisory committee on health correspondence to board of county commissioners about efforts to secure financial resources. Note: It is expected that there be some type of link back to the BOH or advisory committee on health showing that the BOH or advisory committee on health supports, discussed, and/or approved the communication. Note: It is preferable when feasible to have the chair or the BOH or advisory committee on health sign the correspondence.  It may also be a joint signature between the chair and the health director.  Funding sources can be national, state and local financial resources."]
[null,null,null,null,null,"Since Previous Site Visit",1,"B.   Board of health or advisory committee on health correspondence with other units of government or private foundations in regards to efforts to secure financial resources.  Note: It is expected that there be some type of link back to the BOH or advisory committee on health showing that the BOH or advisory committee on health supports, discussed, and/or approved the communication.  Note: It is preferable when feasible to have the chair or the BOH or advisory committee on health sign the correspondence.  It may also be a joint signature between the chair and the health director.  Funding sources can be national, state and local financial resources."]
[null,null,null,39.200000000000003,"Activity 39.2: The local board of health shall review fiscal reports to assure essential services of public health are being provided in accordance with local, state and federal requirements.","Since Previous Site Visit","1+","A. Board of Health minutes demonstrating review of fiscal reports that assure essential services of public health are being provided. Note: This activity complements 33.6 where the BOH reviews to assure financial accountability of the agency. This activity focuses on financial reports as an assurance of essential services. The focus of this activity is to assure that resources are being provided to provide the essential services. Essential services like but not limited to communicable disease services, health education/promotion programs, environmental health services and other regulatory programs, workforce development, evaluation services and policy development. "]
[null,null,null,39.299999999999997,"Activity 39.3: The local board of health shall annually review and approve the local health department budget and approve fees in accordance with G.S. 130A-39(g).","Since Previous Site Visit",1,"A. Board of health minutes reflecting review and approval of department budget and fees.  Note: The BOH should be knowledgeable about and involved in the budget process for the LHD and has a role in the financial health of the agency and in the efficient use of funds.  G.S. 130A-39(g) authorizes the BOH to impose a fee for services rendered by the health department, except where prohibited by statute. It further states that the fees shall be based on a plan recommended by the health director and approved by both the BOH and the BOCC, where required.  Changing of the fees may be addressed by the BOH annually or as changes to individual fees occur. Each department will determine the process whereby the BOH participates in approving the fee lists. This may be accomplished in a single meeting or extended over several meetings. "]
[null,null,null,39.4,"Activity 39.4: The local board of health shall communicate with the board of county commissioners, units of government and private foundations in support of the development, implementation and evaluation of public health programs and a community health improvement process.","Since Previous Site Visit",1," A. BOH or advisory committee on health communication with BOCC in support of public health programs and improvement.  Note: The communication must be about the support of the development, implementation and evaluation of public health programs and a community health improvement process. A community improvement process is a method by which, on a community-wide basis, the health of the population might be improved.  It is a long-term, systematic effort to address health problems based on the results of assessment activities. It will involve community partners and stakeholders in the assessment, planning, development and implementation of strategies to address identified needs. It is understood that the  health director may serve, or be directed by the board to serve, as the designee for the BOH or advisory committee on health in writing and presenting the correspondence for this activity and that much communicati9on will be form the health director.  There should be some kind of tie back to the BOH or advisory committee on health (i.e. minutes).  It is preferable when feasible to have the chair of the BOH or advisory committee on health sign the correspondence.  It may also be a joint signature between the chair and the health director."]
[null,null,null,null,null,"Since Previous Site Visit",1," B. BOH or advisory committee on health communication with other units of government or private foundations in support of public health programs and improvement. Note: See above notes."]
[null,null,null,39.5,"Activity 39.5: The local board of health shall assure that the proposed budget for the local health department meets maintenance of effort requirement in the consolidated agreement between the Division of Public Health and local health department.","Most Recent Needed",1,"A. Signed copy of current Consolidated Agreement    Note: This is the document that is signed by representatives of the local agency and by the NC Division of Public Health.                   "]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. A Web Identity Role Management (WIRM) report that the local health department sends to the Division of Public Health.  Note: Print-out of the monthly (Web Identity Role Management or WIRM) report that the local health department sends to the Division of Public Health.  This report usually will show the amount of fees or local appropriation, in addition to state and federal provided funds, used to support program expenses.  Not required by HDSAI - but a more recent report would be requested for evidence.      "]
[null,40,"The local board of health shall advocate in the community on behalf of public health.",40.1,"Activity 40.1: The local board of health shall inform elected officials and community boards about community health issues.","Since Previous Site Visit",2,"A.  Evidence that demonstrates the BOH or advisory committee on health informed elected officials and community boards about community health issues.    Note: All evidence should show that the board is sharing appropriate information regarding community health issues.  This relates to members being advocates for both the health department and its needs and for public health and the needs of the community. Examples can be:  Letter, e-mail or memo correspondence between BOH/health director or advisory committee on health/health director and an elected official - BOCC minutes reflecting a presentation by BOH/health director or advisory committee on health/health director (presentation should be attached) -  Media articles (i.e. printed press release) showing BOH or advisory committee on health support for community health issues - Documentation (i.e. agenda, participant list, minutes, copy of presentation) of BOH/health director or advisory committee on health/health director presenting at meetings with other boards or commissions related to community health issues. "]
[null,null,null,40.200000000000003,"Activity 40.2: The local board of health shall communicate support for the enactment and retention of laws and rules and the development of public health interventions that protect health and ensure safety.","Since Previous Site Visit",2,"A. Evidence that demonstrate that the BOH or advisory committee or health communicated support for laws, rules, or public health interventions to elected officials and community boards.  "]
[null,41,"The local board of health shall promote the development of public health partnerships.",41.1,"Activity 41.1: The local board of health shall take actions to foster community input regarding public health issues.","Since Previous Site Visit",1,"A. Evidence of BOH or advisory committee on health taking actions to foster community input regarding a public health issue. Note: Examples can be notice of town meeting, public forum, public hearing, media article, web posting, etc. The issue can be any kind of public health topic including hazards, programmatic-related issues, diseases or outbreaks. The evidence should show that the input is requested by the BOH or advisory committee on health or that the BOH or advisory committee on health is involved in the process. For example, a public forum may be sponsored by the department; however, the BOH or advisory committee on health should be present to hear input for the public.  Other documentation can be through board minutes, a letter of response to a citizen or group, a report or white paper, an action of the board as documented in the minutes, or media, such as newspaper articles.  Simply including a public input item on regular board meeting agendas is not sufficient evidence for meeting this activity."]
[null,null,null,41.2,"Activity 41.2: The local board of health shall take actions to foster local health department partnership-building efforts and staff interactions with the community.","Since Previous Site Visit",1,"A. Evidence of agency partnership efforts  Note: This may be the development of a new partner, maintaining or developing a current partnership or support for staff interactions/involvement in the community.   The type of evidence is not specified and can be materials from a partnership building effort, including meeting agenda's and minutes, joint statements, news articles, participants lists showing involvement of department staff and brochure or flyers.                   "]
[null,null,null,null,null,"Since Previous Site Visit",1,"B. Evidence of BOH or advisory committee on health support of the partnership efforts. Note: The department must also submit BOH or advisory committee on health minutes that record discussion of partnership building efforts or letters of support that are from the BOH or advisory committee on health in support of the partnership effort described in the first piece of evidence. If letters of support are submitted for this activity, they should be signed by that BOH or advisory committee on health, such as by the chair.  It may jointly be signed by the health director.   The letters my support involvement with the partner in a community effort, in support of a proposed project, to support a request for funding by the partner, to acknowledge efforts within the partnership to achieve defined objectives, staff using work time to serve on a partner’s board, or sharing of staff resources. "]
[null,null,null,41.3,"Activity 41.3: The local board of health shall take actions to foster the coordination of resources to enhance partnerships and collaboration to achieve public health objectives.","Since Previous Site Visit",1,"A. Evidence showing BOH or advisory committee on health action to foster the coordination of resources. Note:  This can be BOH or advisory committee on health minutes reflecting discussion evidence of BOH or advisory committee on health member participation on a community coalition, steering committee, or advisory committee.  Evidence of BOH member participation could be documented through a report or discussion in the BOH minutes, or can be an agenda, participation list or minutes of the coalition or committee that demonstrates involvement by a BOH member."]

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["Board of Health - Accreditation Items"]
["Standard & Essential Service Number","Activity","Activity Description","Documentation","Responsible","2009 Evidence",null,"2010 Evidence",null,"2011 Evidence",null,"2012 Evidence"]
[]
[]
[" 1.  Monitor health status to identify and solve community health problems.",2.4,"The local health department shall analyze and note reportable events occurring within the community and shall report atypical incidence, if any, to the Division and the local board of health.","Evidence of an internal process reflecting analysis (e.g., policies and procedures, Epidemiology (Epi) Team minutes, agency management team minutes) and  Evidence of having reported analysis findings to state (e.g., emails/logs of phone calls to DPH and DEH consultants, Health Alert Network (HAN) postings) and Evidence of annual report to board of health on local disease incidence and trends and Since the previous site visit, evidence of an internal process reflecting analysis (e.g., policies and procedures, Epidemiology (Epi) Team minutes, agency management team minutes) and Evidence of having reported analysis findings to state and Evidence of presentation to the board of health."]
[]
[" 3.  Inform, educate, and empower people about health issues.",9.1,"The local health department shall publish and disseminate data and information on current local health issues to the general public, community partners, and elected and appointed officials.","Evidence of dissemination of information on current local issues (e.g., methamphetamine labs, water quality problems, emerging health threats) to public AND policy leaders, in each case by one of the following: community presentation, press release, report to BOH or County Commission or other method of dissemination.  Re-Accreditation Documentation:  For each year since the previous site visit, evidence of dissemination of information on current local issues to public AND policy leaders, in each case by one of the following: community presentation, press release, report to board of health or County Commission or other method of dissemination."]
[]
["5.  Develop policies and plans that support individual and community health efforts.",14.2,"The local health department shall provide information and recommendations to support the local board of health and the board(s) of county commissioners in setting public health priorities and planning public health programs.","One of the following: minutes from BOH or County Commissioner’s board meeting, or written correspondence or report provided to BOH and/or County Commissioners reflecting agency input in public health priority setting and program planning"]
[null,14.3,"The local health department shall evaluate, with the local board of health, the need for additional rules or ordinances to protect the health of the public.","One of the following: BOH minutes, strategic plan, or notes from public hearing referencing need for additional rules or ordinances"]
[null,14.4,"The local health department shall assist the local board of health in drafting local ordinances and rules as needed and presenting them to elected officials in order to implement or enforce needed local public health prevention and protection activities.","BOH minutes or BOH memo referencing input of agency in drafting rule or ordinance and Minutes of meeting of elected officials citing new rule or ordinance as a discussion item (if applicable)."]
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["Standard 1:  Facilities and Administrative Services",33.1,"The local health department shall demonstrate that it receives financial support from a local taxing authority.","Board of health minutes reflecting discussion of budget and County Commission minutes reflecting discussion of budget and Evidence of passage of budget"]
[]
[null,33.5,"The local health department shall determine the cost of services in setting fees.","Minutes of agency meetings and Board of health minutes reflecting discussion of service costs.  Re-Accreditation Documentation:  Minutes of agency meetings and Board of health minutes reflecting discussion of service costs and Data or methodology used to determine costs."]
[null,33.6,"The local health department shall develop and present periodic budget, expenditure and other financial tracking reports to the board of health for its review.","Examples of three kinds of financial reports and BOH minutes reflecting discussion of those reports."]
[]
["  Standard 2: Governance",34.1,"The local board of health shall have operating procedures which shall comply with state law.","Operating procedures consistent with the content in the Operating Procedures document located on the Accreditation website."]
[null,34.200000000000003,"The local board of health shall review its operating procedures annually.","Board of health meeting minutes indicating review of operating procedures within the last 12 months.  Re-Accreditation Documentation:  Board of health meeting minutes indicating annual review of operating procedures."]
[null,"Activity","Activity Description","Documentation","Responsible","2009 Evidence",null,"2010 Evidence",null,"2011 Evidence",null,"2012 Evidence"]
[null,34.299999999999997,"The local board of health shall have access to legal counsel.","Copy of contract, letter of agreement, correspondence, or other evidence verifying access to legal counsel."]
[null,34.4,"The local board of health shall follow the procedures for adopting rules in G.S. 130A-39.","If a rule has been adopted in the last 48 months, one of the following: rules notice signed by BOH chair, policy/procedure manual, correspondence with legal counsel referencing BOH’s legal procedures."]
[null,34.5,"The local board of health shall evaluate the need for the adoption or amendment of local rules or ordinances.","Copy of state public health statutes available to the BOH and One of the following: BOH minutes, policy/procedure manual, correspondence with legal counsel referencing BOH’s legal authority for adopting rules."]
[null,35.1,"The local board of health shall assure it follows the procedures for adjudications in G.S. 130A-24.","Policies and/or procedures for adjudications, specific to G.S. 130A-24 and One of the following, if applicable within the past 48 months: correspondence, BOH minutes, report of BOH actions, document referencing involvement of legal counsel re: adjudication."]
[null,36.1,"The local health department shall provide board of health members with a written board handbook developed or updated within the past 12 months.","Dated BOH handbook."]
[null,36.200000000000003,"The local health department shall assure new board of health members receive training and reference materials on the authorities and responsibilities of the local board of health within the first year after appointment to the board.","Training materials used and Dated evidence of all BOH members’ participation in orientation training activities during their first year after appointment."]
[null,36.299999999999997,"The local health department shall assure on-going training for board of health members related to the authorities and responsibilities of local boards of health.","Training materials used and Dated evidence of BOH members’ participation in on-going training activities related to the authorities and responsibilities of local boards of health."]
[null,37.1,"The local board of health shall assure that a qualified local health director, in accordance with G.S. 130A-40 or 40.1, is in place to lead the agency.","BOH minutes reflecting discussion completed within the past 24 months."]
[null,37.200000000000003,"The local board of health shall approve policies for the administration of local public health programs.","BOH minutes reflecting discussions of administrative issues with Health Director."]
[null,37.299999999999997,"The local board of health shall describe and define the knowledge, skills, and abilities that must be met by the local health director, consistent with the requirements in G.S. 130A-40.","If the Board has hired a Health Director within the past 48 months or if a search is presently underway: BOH minutes reflecting discussion of knowledge, skills, and abilities that must be met by the Health Director candidate."]
[null,37.4,"The local board of health shall review and approve the job description of the local health director.","Health Director job description that has been signed, dated and reviewed annually and BOH minutes reflecting discussion of Health Director job description."]
[null,37.5,"The local board of health shall conduct an annual performance review of the health director.","Signed and dated annual health director performance review by BOH within the last 12 months."]
[null,37.6,"The local board of health shall approve policies for the recruitment, retention and workforce development for agency staff.","BOH minutes indicating discussion and approval of policies, plans, or allocations through the budget process to provide for recruitment, retention and workforce development for agency staff."]
[null,38.1,"The local board of health shall annually review reports provided by the local health department on the community’s health.","Minutes reflecting BOH’s review of annual reports related to the community’s health."]
[null,38.200000000000003,"The local board of health shall review community health assessment data and citizen input used to plan and monitor progress toward health-related goals.","BOH minutes reflecting discussion of specific aspects of CHA data and The approval of action plans to address health related goals"]
[null,38.299999999999997,"The local board of health shall assure that individuals, agencies, and organizations have the opportunity to participate in the development of goals, objectives and strategies for community health improvement.","BOH policy regarding public participation in the development of goals, objectives and strategies for community health improvement and BOH minutes reflecting that public participation occurred or agenda indicating allocated time to encourage public participation."]
[null,39.1,"The local board of health shall communicate with the board of county commissioners, units of government and private foundations in support of local health department efforts to secure national, state and local financial resources.","Evidence of County Commissioner serving on BOH and BOH minutes reflecting BOH endorsement for a grant application, or a request for additional public health funding."]
[null,39.200000000000003,"The local board of health shall review fiscal reports to assure essential services of public health are being provided in accordance with local, state and federal requirements.","BOH minutes demonstrating receipt of AND discussion of reports that assure essential services of public health are being provided."]
[null,39.299999999999997,"The local board of health shall annually review and approve the local health department budget and approve fees in accordance with G.S. 130A-39(g).","BOH minutes reflecting discussion and approval of department budget and fees."]
[null,39.4,"The local board of health shall communicate with the board of county commissioners, units of government and private foundations in support of the development, implementation and evaluation of public health programs and a community health improvement process.","Correspondence with board of county commissioners and Two or more correspondences with units of government or private foundations."]
[null,39.5,"The local board of health shall assure that the proposed budget for the local health department meets maintenance of effort requirement in the consolidated agreement between the Division of Public Health and local health department.","Signed copy of current Consolidated Agreement and A Web Identity Role Management (WIRM) report that the local health department sends to the Division of Public Health."]
[null,40.1,"The local board of health shall inform elected officials and community boards about community health issues.","One of the following related to community health issues: correspondence between BOH/Health Director and an elected official, County Commission minutes reflecting a presentation by the BOH/Health Director, media articles showing BOH support for community health issues, or documentation of BOH/Health Director presenting at meetings with other boards or commissions related to community health issues."]
[null,40.200000000000003,"The local board of health shall communicate support for the enactment and retention of laws and rules and the development of public health interventions that protect health and ensure safety.","One of the following related to communicating support for laws, rules, and public health interventions: correspondence between BOH/Health Director and an elected official, County Commission minutes reflecting a presentation by the BOH/Health Director, media articles showing BOH support for laws, rules, and public health interventions, or documentation of BOH/Health Director presenting at meetings with other boards or commissions."]
[null,41.1,"The local board of health shall take actions to foster community input regarding public health issues.","One of the following: notice of town meeting, public forum, public hearing, media article, web posting, etc., which demonstrates actions to foster community input regarding public health issues."]
[null,41.2,"The local board of health shall take actions to foster local health department partnership-building efforts and staff interactions with the community.","Evidence of agency partnership efforts and One of the following: BOH minutes reflecting discussion of partnership OR letters of support from BOH for partnership efforts."]
[null,41.3,"The local board of health shall take actions to foster the coordination of resources to enhance partnerships and collaboration to achieve public health objectives.","One of the following relating to partnerships and the coordination of resources: BOH minutes reflecting discussion; evidence of BOH member participation on community coalition, steering committee, or advisory committee; BOH minutes reflecting a decision that the Health Director was the best representative to such a group and Evidence of the Health Director’s participation."]

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[null,null,null,null,null,null,null,null,null,null,"Double click anywhere in the document on the left to open full Instructions\n\n\n(In 2007 or earlier versions, after clicking twice on the document to the left, the pdf may not automatically open up in the screen.  You will find it as a tab on the bottom of your screen (Acrobat Document).  Click that tab to open the pdf document.)"]

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