IGA ADHS DENTAL SEALANT SERVICES AMD 1.PDF
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INTERGOVERNMENTAL AGREEMENT (IGA) Amendment ARIZONA DEPARTMENT OF HEALTH SERVICES 150 18th Ave Suite 530 Phoenix, Arizona 85007 Contract No.: ADHS18-175153 IGA Amendment No: 1 Procurement Officer Anthony Beckum Page 1 of 14 Oral Health Dental Sealant Services 1. Effective upon signature by all parties and pursuant to the Terms and Conditions, Provision Six (6), Contract Changes, Section 6.1, Amendments, Purchases Orders and Change Orders, it is mutually agreed that the Intergovernmental Agreement referenced is amended as follows under this Amendment One (1): 1.1 The Scope of Work is hereby revised and replaced by the Scope of Work of this Amendment One (1); 1.2 The Price Sheet is hereby revised and replaced; and 1.3 Exhibit A is added. ALL CHANGES ARE IDENTIFIED BELOW IN RED. All other provisions of this Agreement remain unchanged. Maricopa County Public Health Contractor Name: Authorized Signature 4041 North Central Avenue Address: Print Name Phoenix AZ 85012 City State Zip Title Pursuant to A.R.S. § 11-952, the undersigned public agency attorney has determined that this Intergovernmental Agreement is in proper form and is within the powers and authority granted under the laws of Arizona This Intergovernmental Agreement Amendment shall be effective the date indicated. The Public Agency is hereby cautioned not to commence any billable work or provide any material, service or construction under this IGA until the IGA has been executed by an authorized ADHS signatory. State of Arizona Signature Date Signed this day of . Print Name Procurement Officer Contract No.: ADHS18-175153, which is an Agreement between public agencies, has been reviewed pursuant to A.R.S. § 11-952 by the undersigned Assistant Attorney, who has determined that it is in proper form and is within the powers and authority granted under the laws of the State of Arizona. Signature Date Assistant Attorney General Print Name ATTEST: ________________________ Juanita Garza, Clerk of the Board _____________ Date Anne Longo, Attorney for Maricopa County Bill Gates Chairman, Board of Supervisors Date INTERGOVERNMENTAL AGREEMENT (IGA) Amendment ARIZONA DEPARTMENT OF HEALTH SERVICES 150 18th Ave Suite 530 Phoenix, Arizona 85007 Contract No.: ADHS18-175153 IGA Amendment No: 1 Procurement Officer Anthony Beckum Page 2 of 14 SCOPE OF WORK 1. BACKGROUND 1.1. The mission of the Arizona Department of Health Services (ADHS) Office of Oral Health (OOH) is to promote oral health for the well-being of all Arizona residents. The United States Surgeon General’s report in the year 2000 identified dental caries (tooth decay) as one of the most common childhood chronic diseases. Tooth decay is also one of the most common preventable diseases seen in children, preventable through preventive dental services such as the use of fluoride and the application of dental sealants. 1.2. Children who are at greatest risk for caries are those from low income and minority populations and are least likely to have access to dental care. The American Academy of Pediatric Dentistry and the American Dental Association recommends the first dental visit occur no later than twelve (12) months of age. Children can get cavities as young as twelve (12) to eighteen (18) months, which can cause pain and prevent them from being able to eat, speak, sleep, and learn properly. Children do not lose all their baby teeth until they are about twelve (12) to thirteen (13) years old. Of the decay found in children’s teeth, approximately ninety percent (90%) occurs in tooth surfaces with pits and fissures, and almost two-thirds are found in the chewing surfaces alone. Tooth decay can often be reversible or arrested in the earliest stages through a variety of proven preventive methods. Once the decay progresses and the longer the decay remains untreated, it becomes more difficult and costlier to repair. As a result, early intervention and prevention is easier for both the child and the dental professional, less expensive, and more successful than treatment at a later time. 1.3. Health education and promotion can be an important piece of any public health initiative as many low income people do not understand the importance of seeking care or preventive services. The knowledge that tooth decay is a transmissible disease caused by bacteria or that simple behavior changes can limit the risk of decay, is not widespread among the general population, let alone low income people. According to the National Institute of Dental and Craniofacial Research National Institutes of Health (NIDCR-NIH) fewer than one-quarter of U.S. adults know that dental sealants prevent dental decay. Collaborative efforts with agencies or groups such as Head Start centers, Women Infant and Children (WIC) centers or coalition groups can play a significant role in improving the education and awareness of community members. 1.4. National objectives help guide States in promoting health and wellness through such guidelines as the Healthy People 2020 oral health objectives. These objectives include: 1.4.1. OH–2: Reduce the proportion of children with untreated dental decay in their primary teeth. 1.4.2. OH–7: Increase the proportion of children, adolescents, and adults who used the oral health care system. 1.4.3. OH–8: Increase the proportion of low-income children and adolescents who received any preventive dental service during the past year. 1.4.4. OH–9: Increase the proportion of school-based health centers with an oral health component that includes dental sealants, dental care and topical fluoride. 1.4.5. OH–10: Increase the proportion of local health departments that have oral health prevention or care programs. 1.4.6. OH–12: Increase the proportion of children and adolescents who have received dental sealants on one (1) or more of their molar teeth. INTERGOVERNMENTAL AGREEMENT (IGA) Amendment ARIZONA DEPARTMENT OF HEALTH SERVICES 150 18th Ave Suite 530 Phoenix, Arizona 85007 Contract No.: ADHS18-175153 IGA Amendment No: 1 Procurement Officer Anthony Beckum Page 3 of 14 1.5. Prevention services provided through collaboration with the OOH can help to address some, if not all of the above mentioned oral health objectives. Some of the services may include (but are not be limited to) implementation of a dental sealant program, fluoride varnish program, or an early childhood oral health program. 1.6. The Arizona School-based Sealant Program is a school-based preventive dental program targeting schools with greater than fifty percent (50%) of the children participating in the free and reduced school meal program. Second (2nd) and sixth (6th) grade children without private dental insurance are eligible to participate. Children in other grades may receive services upon determination by OOH. Children shall have parental consent and a clinical need for sealants. Screenings, sealants, and/or fluoride varnish are provided by OOH trained dentists, Affiliated Practice (AP) dental hygienists, dental hygienists, and dental assistants. OOH training ensures specified guidelines are used to ensure successful sealant retention. Additionally, every effort is made to ensure that participating children receive information and referral to establish a dental home in or near their community. 1.7. Pit and fissure sealants, defined as plastic (resin) coatings applied to susceptible tooth surfaces, are an evidence-based preventive service, and have been approved and recommended for use for many years by professional health associations and public health agencies. The purpose of sealants is to prevent the growth of bacteria present in the pits and grooves of molar teeth, which lead to the breakdown of tooth structure, resulting in decay. When properly placed, dental sealants can prevent up to seventy percent (70%) of tooth decay on the chewing surfaces of first and second permanent molar teeth. 1.8. Fluoride varnish application is a safe, cost-effective procedure to prevent tooth decay. Bacteria that build up on tooth surfaces produce acids that de-mineralize enamel. Left unchecked, the bacteria continue to destroy tooth structure. Fluoride varnishes are applied directly to the tooth surface and provide immediate "re-mineralization", interfere with bacterial build- up, and reduce acid production. According to an Association of State and Territorial Dental Directors (ASTDD) Research Brief (2007.) http://www.astdd.org/state-of-the-science/ studies on fluoride varnish have demonstrated that at least two (2) fluoride applications per year for a period of two (2) years are necessary to demonstrate effective reductions in tooth decay. Fluoride varnish is an adjunct to community water fluoridation. Children may receive fluoride varnish application after sealant application as part of the school-based dental sealant program, consistent with Medicaid reimbursement policies, which may be subject to change. 1.9. Community health assessments are included in the core set of population-based elements outlined as essential in all communities by the Essential Public Health Services Work Group, (1994) http://www.cdc.gov/nphpsp/essentialServices.html. Periodic dental surveys and data gatherings are conducted by OOH to determine the oral health status of Arizona’s children and for reporting and monitoring Healthy People 2020 Objectives. Numerous screeners are needed to participate in various surveys which follow strict calibration set on national standards. Such calibration training would be provided by OOH for each type of survey. 1.10. OOH uses a community-based approach and will target children at higher risk for dental caries, operate efficiently, ensure quality, and maximize the use of public funding to meet these objectives. 1.11. Silver Diamine Fluoride (SDF) is a colorless liquid containing silver, fluoride and ammonia. In clinical trials, SDF was more effective than fluoride varnish or other fluoride agents at halting the caries process and at arresting decay when applied directly to cavitated lesions. Several clinical trials revealed that SFD is a safe, efficient, and effective method of controlling caries. SDF is an agent that prevents cavitated lesions from further progressing into the dentin of a tooth. It is recommended for use in people who are unable to access dental treatment or tolerate conventional dental care. SDF included in the Arizona school-based sealant program is a great alternative for preventing tooth decay in children residing in low income communities, especially those that lack access to dental care and those that are afraid of going to the dentist. SDF has been proven to be effective at not only arresting active decay but also at reducing the risk of cavities in the permanent first molars of children. Children participating in the school-based sealant program will benefit greatly from having access to this very innovative approach to treating and preventing tooth decay. INTERGOVERNMENTAL AGREEMENT (IGA) Amendment ARIZONA DEPARTMENT OF HEALTH SERVICES 150 18th Ave Suite 530 Phoenix, Arizona 85007 Contract No.: ADHS18-175153 IGA Amendment No: 1 Procurement Officer Anthony Beckum Page 4 of 14 2. OBJECTIVE 2.1. To reduce dental decay in primary and permanent teeth in children; 2.2. Provide dental sealants and fluoride varnish to at-risk children; 2.3. Monitor oral health status of children; 2.4. Assist children in obtaining dental care; 2.5. Provide educational training for children, teachers, parents, health professionals; and 2.6. Provide technical assistance on dental public health issues. 3. SCOPE OF SERVICES The Contractor shall provide the services necessary to promote oral health and provide OOH authorized preventive dental services. Provision of each type of preventive service will be based on availability of funding and at the discretion of OOH. Services shall include those necessary to coordinate and implement the Arizona School-based Sealant Program using portable equipment, OOH approved dental sealant materials, and following the protocols outlined in the Arizona School-based Sealant Program Manual http://www.azdhs.gov/phs/owch/ooh/schools/sealant.htm. At the request of the Chief of the OOH, the Contractor shall provide services necessary to coordinate and implement a Fluoride Varnish Program using materials and protocols outlined by OOH. At the request of the OOH, the Contractor shall provide services necessary to gather data for dental surveys following strict calibration in accordance with training provided by the OOH. 4. TASKS The Contractor shall provide: 4.1. Coordination/Administration 4.1.1. Distribute, collect, and analyze annual school applications for the Arizona School-based Sealant Program in accordance with Arizona School-based Sealant Program Provider Manual guidelines (reference Provision Seven (7) Reference Documents), 4.1.2. Coordinate preventive dental services with OOH identified school and community sites, 4.1.3. Procure and manage dental supply inventory. Dental sealant fluoride varnish and/or silver diamine fluoride (SDF) material shall have American Dental Association (ADA) seal of acceptance and/or comply with Center for Disease Control (CDC) guidelines, 4.1.4. Monitor equipment, maintain an inventory list, provide maintenance and perform basic repairs, 4.1.5. Assure instrument sterilization, and 4.1.6. Provide clerical procedures, including but not limited to: 4.1.6.1. Maintaining program schedules to include school screening and application dates; 4.1.6.2. Maintaining inventories of supplies and equipment; 4.1.6.3. Planning as related to the dental sealant and/or fluoride varnish program; INTERGOVERNMENTAL AGREEMENT (IGA) Amendment ARIZONA DEPARTMENT OF HEALTH SERVICES 150 18th Ave Suite 530 Phoenix, Arizona 85007 Contract No.: ADHS18-175153 IGA Amendment No: 1 Procurement Officer Anthony Beckum Page 5 of 14 4.1.6.4. Preparing and submitting accurate and complete records of program activities; and 4.1.6.5. Preparing and submitting accurate and complete forms and reports required by OOH; 4.1.7. Develop, solicit, and maintain program provider contracts and provide a copy of each contract to OOH; 4.1.8. Notify ADHS in writing within thirty (30) days of any change in personnel; 4.1.9. Maintain a current Provider List to include name, address, phone number, and license number of each provider, and submit to OOH once (1) each year thirty (30) days prior to beginning the program each school year; 4.1.10. Maintain files containing the following information for each provider and staff member: 4.1.10.1. Arizona current licenses to practice dentistry or dental hygiene; 4.1.10.2. Resumes or curriculum vitae; 4.1.10.3. Certificates for dental assisting, or affiliated practice (AP), if applicable; 4.1.10.4. A copy of the Standing Orders of the AP, if applicable; 4.1.10.4.1. A Standing Order is an agreement that the Dentist and hygienist signs which allows the AP hygienist or Dental Hygienist to screen and diagnose sealants without the dentist being present. 4.1.10.4.2. An AP (hygienist) is allowed to provide dental screenings without a dentist present. 4.1.10.5. Current Cardiopulmonary Resuscitation (CPR) certificate, 4.1.10.6. Copy of fingerprint clearance, 4.1.10.7. Malpractice insurance; including, but not limited to, sexual molestation and abuse coverage, 4.1.10.8. Copy of Arizona Driver’s License, 4.1.10.9. Signed confidentiality agreement from all dentists, hygienists, and dental assistants providing service in the sealant program to comply with Health Insurance Portability and Accountability Act (HIPAA), 4.1.10.10. Provide the date and verification of most recent in-service training for all individuals providing service in the sealant and/or fluoride varnish program, 4.1.10.11. Provide other insurance and documentation as needed, 4.1.10.12. Provide storage of the above mentioned documents and must follow HIPAA compliance and be available for audit by ADHS Sealant Program Manager or designated person, 4.1.10.13. Coordinate the collection of all information required by Arizona Health Care Cost Containment System (AHCCCS) and AHCCCS health plans for enrollment of dentists and/or AP dental hygienists into the program. This AHCCCS Provider Information shall be submitted to OOH thirty (30) days prior to a dentist and/or AP dental hygienist providing service in the sealant program. The information shall include the following: INTERGOVERNMENTAL AGREEMENT (IGA) Amendment ARIZONA DEPARTMENT OF HEALTH SERVICES 150 18th Ave Suite 530 Phoenix, Arizona 85007 Contract No.: ADHS18-175153 IGA Amendment No: 1 Procurement Officer Anthony Beckum Page 6 of 14 4.1.10.13.1. State of Arizona Substitute W-9 & Vendor Authorization form, 4.1.10.13.2. Completed AHCCCS Provider Registration form, 4.1.10.13.3. Completed AHCCCS Provider Participation Agreement, 4.1.10.13.4. Completed AHCCCS Group Authorization form, 4.1.10.13.5. Copy of Drug Enforcement Administration (DEA) Card, and 4.1.10.13.6. Social Security number. 4.1.10.14. Coordinate training for preventive dental program providers, at a minimum annually, 4.1.10.15. Assure that all employed and contracted preventive dental program providers complete any ADHS required training prior to providing services, and receive annual training on program updates and reviews. Reimbursement to the program provider for attending training is the responsibility of the contractor and should be considered part of the unit price, 4.1.10.16. Prepare and submit OOH preventive dental program Data Forms as contained in the Arizona Dental Sealant Provider Training Manual (reference Provision Seven (7) Reference Documents) after completion of each school or community site which may include the following: 4.1.10.16.1. School application forms, 4.1.10.16.2. Completed Preventive Dental Program Consent/Health History Forms, 4.1.10.16.3. Encounter Forms using standard protocols, and 4.1.10.16.4. Completed Summary Forms. 4.1.10.17. Ensure all children screened are provided information regarding AHCCCS health plans as provided by AHCCCS and receive appropriate dental referral, 4.1.10.18. Assure accurate data collection and reporting, using standard guidelines as stated in the Arizona Dental Sealant Provider Training Manual (see Provision 7, Reference Documents), 4.1.10.19. Correct and return forms deemed unacceptable by OOH, within ten (10) calendar days of receipt by the Contractor, 4.1.10.20. Prepare and submit an Annual Activity Plan to include: 4.1.10.20.1. A list of schools and/or community sites to be scheduled for screenings, fluoride varnish, and/or sealant placement, and 4.1.10.20.2. A schedule of any in-service trainings and/or scheduled quality assurance checks. 4.1.10.21. Prepare and submit a Monthly Activity Report to include: 4.1.10.21.1. The number of children by site who received preventive dental services in the previous month, outlining which type of service was received, and 4.1.10.21.2. Quality Assurance activities, including a training attendance list. INTERGOVERNMENTAL AGREEMENT (IGA) Amendment ARIZONA DEPARTMENT OF HEALTH SERVICES 150 18th Ave Suite 530 Phoenix, Arizona 85007 Contract No.: ADHS18-175153 IGA Amendment No: 1 Procurement Officer Anthony Beckum Page 7 of 14 4.1.10.22. Prepare and submit a Contractor's Expenditure Report (CER) and supporting documents, provided by OOH, to be signed by the Chief of the OOH or designee before submitting to ADHS Accounting Office for payment. Payment shall be made in monthly payments based on the number of hours screened (for specified survey activities), the number of children treated, or the service provided multiplied by the contract rate. Payment for the number of children sealed shall be based on the number of approved sealant encounter forms received by OOH during the month that indicates sealants were placed. A month shall be defined as a calendar month, e.g. March 1st – March 31st, 4.1.10.23. Utilize the OOH Quality Assurance Plan, or, develop or update, and implement, a Quality Assurance (QA) Plan to include: 4.1.10.23.1. Sealant retention, goal of eighty-five percent (85%) or better, 4.1.10.23.2. Infection control, Occupational Safety and Health Administration (OSHA) compliant, 4.1.10.23.3. QA monitoring forms, 4.1.10.23.4. Schedule of QA checks and equipment maintenance, 4.1.10.23.5. Equipment Maintenance log, 4.1.10.23.6. Protocol to be followed if acceptable performance measures are not being met, 4.1.10.23.7. Training agenda, and 4.1.10.23.8. Other topics determined necessary by ADHS and/or the Contractor. 4.1.10.24. Prepare and submit an Annual Report to include: 4.1.10.24.1. Identification of any barriers, or recommendations for, achieving program goals; 4.1.10.24.2. Annual budget narrative and justification of expenditures by January 15th of each year; and 4.1.10.24.3. A summary of the progress made toward accomplishing the tasks set forth in the QA Plan. 4.2. Dental Assistant(s) shall: 4.2.1. Transport equipment and supplies, 4.2.2. Provide chair-side dental assisting, 4.2.3. Record dental findings as instructed by dentists and dental hygienists, 4.2.4. Adhere to infection control protocols, 4.2.5. Educate clients and families, and 4.2.6. Distribute referral and health insurance information. INTERGOVERNMENTAL AGREEMENT (IGA) Amendment ARIZONA DEPARTMENT OF HEALTH SERVICES 150 18th Ave Suite 530 Phoenix, Arizona 85007 Contract No.: ADHS18-175153 IGA Amendment No: 1 Procurement Officer Anthony Beckum Page 8 of 14 4.3. Dental Hygienist(s), Public Health or AP Dental Hygiene (s) shall: 4.3.1. Follow standing orders as provided by affiliated practice agreement, 4.3.2. Transport equipment and supplies, 4.3.3. Collect oral health data using OOH standardized protocol, 4.3.4. Provide OOH authorized dental prevention services, 4.3.5. Apply dental sealants and/or fluoride varnish, 4.3.6. Adhere to infection control protocols, 4.3.7. Educate clients and families, 4.3.8. Distribute referral and health insurance information, and 4.3.9. Provide program consultation, as requested. 4.4. Dentist(s) shall: 4.4.1. Serve as AP dentist if applicable, 4.4.2. Transport equipment and supplies, 4.4.3. Collect oral health data using OOH standardized protocol, 4.4.4. Provide OOH authorized dental prevention services, 4.4.5. Adhere to CDC infection control protocols, 4.4.6. Educate clients and families, 4.4.7. Distribute referral and health insurance information, 4.4.8. Provide program consultation, as requested, 4.4.9. Maintain AHCCCS enrollment, and 4.4.10. Provide standing orders for public health dental hygienists to apply sealants and fluoride varnish to children enrolled in the program. 5. REQUIREMENTS The Contractor shall: 5.1. Maintain confidentiality; 5.1.1. All data, forms, and supporting documentation for the program-related activities shall remain the ownership of ADHS, 5.1.2. All materials containing information that could identify an individual shall be kept confidential including but not limited to, paper, electronic documents, databases, and audio/visual tapes, INTERGOVERNMENTAL AGREEMENT (IGA) Amendment ARIZONA DEPARTMENT OF HEALTH SERVICES 150 18th Ave Suite 530 Phoenix, Arizona 85007 Contract No.: ADHS18-175153 IGA Amendment No: 1 Procurement Officer Anthony Beckum Page 9 of 14 5.1.3. Confidential information shall be kept in an inaccessible location at all times except when being worked on during business hours, 5.1.4. Confidential information shall not be released to or discussed with anyone other than authorized individuals, 5.1.5. All confidential information shall be disposed of by either shredding or incineration, and 5.1.6. All employees and subcontractors must sign a confidentiality form to be kept on file for the duration of their affiliation with the Contractor. 5.2. Obtain approval from OOH for any marketing, educational, and/or referral materials to be used in the program; 5.3. Adhere to the policies and procedures as set forth in the appropriate dental prevention program Provider Manual/Protocol (reference Provision Seven (7) Reference Documents); 5.4. Utilize all dental prevention program forms as provided by OOH. No alterations shall be permitted without authorization from OOH Prevention Program Manager or designated person; 5.5. Ensure correspondence with schools, parents, and/or partners (including, but not limited to, county governments, sub-recipients and other agencies) includes the following statement: “The Arizona School-based Sealant Program is funded by the Arizona Department of Health Services, Office of Oral Health”; and 5.6. Special Programmatic Requirements 5.6.1. Schools shall be chosen on the basis of participation: and prioritized from highest to lowest. There shall be a minimum of fifty (50) children with signed consent forms to schedule the school for a screening. At least twenty-five (25) children shall be eligible for sealants. Any services provided to schools with fewer than fifty (50) signed consents shall be approved by the Chief of the OOH prior to providing services. 6. STATE PROVIDED ITEMS OOH will provide: 6.1. Dental Prevention Program Provider Manual/ Protocol for each provider as related to each prevention program the provider is participating; 6.2. Contractor Expenditure Report (CER); 6.3. Master copies of forms, report templates, protocols, and polices required to be used in the particular prevention Program; 6.4. Portable dental equipment, unless provided by the Contractor. All portable equipment is to be returned in working condition, to OOH upon termination of contract. 6.5. Sealant Program Guidelines and Communications Manual; 6.6. Market the Arizona School-based Sealant Program and/or other dental prevention programs to qualified sites; 6.7. Provide a list of eligible sites; 6.8. Monitor sealant retention results; 6.9. Provide annual sealant retention checklist to Contractor; INTERGOVERNMENTAL AGREEMENT (IGA) Amendment ARIZONA DEPARTMENT OF HEALTH SERVICES 150 18th Ave Suite 530 Phoenix, Arizona 85007 Contract No.: ADHS18-175153 IGA Amendment No: 1 Procurement Officer Anthony Beckum Page 10 of 14 6.10. Provide standardized training for program implementation and data collection; 6.11. Provide periodic Technical Assistance Meetings for Contractors; 6.12. Conduct random quality assurance checks, including site visits; and 6.13. Ensure dental providers are linked to appropriate health plans. 7. REFERENCE DOCUMENTS 7.1. Arizona Sealant Program Provider Manual (reference Provision Six (6) State Provided Items); 7.2. ADHS Fluoride Varnish Program protocol (reference Provision Six (6) State Provided Items); 7.3. ADHS Surveillance protocol (reference Provision Six (6) State Provided Items); 7.4. ADHS Education protocol (reference Provision Six (6) State Provided Items); 7.5. OOH Guidelines and Communications Manual; and 7.6. OOH Waterline Testing Manual. 8. APPROVALS 8.1. The Chief of the OOH or designated Program Manager shall have the final approval of all items submitted by the Contractor. 9. DELIVERABLES Any required lists or reports may be submitted electronically. Any correspondence including Protected Health Information (PHI) shall adhere to HIPAA security rules. The Contractor shall submit: 9.1. A Provider List, due ten (10) days after Arizona School-based Sealant Program provider training; 9.2. AHCCCS Provider Information, due thirty (30) days prior to a dentist/AP dental hygienist providing service in the Arizona School-based Sealant Program; 9.3. Data Forms within ten (10) business days after completion of each school or community site; 9.4. Monthly Activity Reports by the tenth (10th) business day of the following month to include: 9.4.1. Health fairs attended, 9.4.2. Community outreach activities, and 9.4.3. List of schools included on CER. 9.5. Monthly Planning Reports by the twenty-fifth (25th) of each month for the upcoming month; 9.6. Quality Assurance Plan along with Annual Report, due thirty (30) days after the end of each school year; INTERGOVERNMENTAL AGREEMENT (IGA) Amendment ARIZONA DEPARTMENT OF HEALTH SERVICES 150 18th Ave Suite 530 Phoenix, Arizona 85007 Contract No.: ADHS18-175153 IGA Amendment No: 1 Procurement Officer Anthony Beckum Page 11 of 14 9.7. Completed CER with supporting documents due by the fifteen (15th) of the month following the calendar month that the services were provided; 9.8. Annual Report within thirty (30) days after the end of each Contract year; 9.9. Copies of school applications to OOH within thirty (30) days of receipt. Copies may be transmitted electronically, or hard copies are also acceptable; and 9.10. A log to the OOH within thirty (30) days of a completed Waterline test. 10. NOTICES, CORRESPONDENCE, REPORTS, INVOICES/CERs AND PAYMENT 10.1. Notices, Correspondence and Reports from the Contractor to ADHS shall be sent to: Arizona Department of Health Services Bureau of Women’s and Children’s Health (BWCH) Office of Oral Health 150 North 18th Avenue, Suite #320 Phoenix, Arizona 85007 Phone: (602) 364-1431 Email: polar.akoi@azdhs.gov 10.2. Invoices/CERs shall be sent to invoices@azdhs.gov. 10.3. Notices, Correspondence and Payments from the ADHS to the Contractor shall be sent to: Maricopa County Public Health Department Attn: Cheryl Rentscheler 4041 North Central Avenue, Suite #1400 Phoenix, Arizona 85012 Phone: (602) 506-6886 Fax: (602) 506-6885 Email: cherylrentscheler@mail.maricopa.gov INTERGOVERNMENTAL AGREEMENT (IGA) Amendment ARIZONA DEPARTMENT OF HEALTH SERVICES 150 18th Ave Suite 530 Phoenix, Arizona 85007 Contract No.: ADHS18-175153 IGA Amendment No: 1 Procurement Officer Anthony Beckum Page 12 of 14 ORAL HEALTH DENTAL SEALANT SERVICES LINE ITEM DESCRIPTION OF SERVICE UOM TOTAL 1 DENTAL SEALANT SERVICES Total cost per sealant to include the following: Sealant dental staff and services including travel, supplies, training, indirect/direct costs. Administrative personnel coordination of Sealant program and participation in an External Advisory Group. Cost of Dentist providing standing orders for public health hygienist. Sealant applied per Child $75.00 2 FLUORIDE VARNISH SERVICES Per fluoride application $8.00 3 ORAL HEALTH DATA COLLECTION, DENTAL HYGIENIST Per hour per Provider $30.00 4 ORAL HEALTH DATA COLLECTION, DENTAL ASSISTANT Per hour per Provider $18.00 5 COST EFFECTIVENESS EVALUATION Each $13,324.00 6 CUSTOMER SASTIFICATION SURVEY AND ASSESSMENT RESULTS Each 13,324.00 7 PROGRAM IMPLEMENTATION ANAYLSIS AND ASSESSMENT Each 13,324.00 8 SILVER DIAMINE FLUORIDE Per Child $50.00 9 PROGRAM OUTREACH Time spent on program outreach activities, participation in workgroups and all administrative duties listed under the coordinator tasks Per Hour $18.00 Authorization for Provision of Services: Authorization for purchase of services under this Contract shall be made only upon ADHS issuance of a Purchase Order that is signed by an authorized agent. The Purchase Order will indicate the Contract number and the dollar amount of funds authorized. The Contractor shall only be authorized to perform services up to the amount of the Purchase Order. No further obligation shall exist on behalf of ADHS unless: a) The Purchase Order is changed or modified with an official ADHS Procurement Change Order, and/or b) An additional Purchase Order is issued for purchase of services under this Contract. INTERGOVERNMENTAL AGREEMENT (IGA) Amendment ARIZONA DEPARTMENT OF HEALTH SERVICES 150 18th Ave Suite 530 Phoenix, Arizona 85007 Contract No.: ADHS18-175153 IGA Amendment No: 1 Procurement Officer Anthony Beckum Page 13 of 14 EXHIBIT A - 2 CFR 200.332 § 200.332 Requirements for pass-through entities. All pass-through entities must: (a) Ensure that every subaward is clearly identified to the subrecipient as a subaward and includes the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass-through entity must provide the best information available to describe the Federal award and subaward. Prime Awardee: Arizona Department of Health Services DUNS # 804745420 Federal Award Identification (Grant Number): T12HP28879 Subrecipient name (which must match the name associated with its unique entity identifier): Maricopa County Public Health Subrecipient's unique entity identifier (DUNS #): 602062515 Federal Award Identification Number (FAIN, sometimes it’s the same as the Grant Number): T12HP28879 Federal Award Date (see the definition of Federal award date in § 200.1 of this part) of award to the recipient by the Federal agency; 9/1/2018 Subaward Period of Performance Start and End Date; 1/1/2022 - 09/30/2022 Subaward Budget Period Start and End Date: 1/1/2022 - 09/30/2022 Amount of Federal Funds Obligated by this action by the pass-through entity to the subrecipient (this is normally the contract amount): N/A Total Amount of Federal Funds Obligated to the subrecipient by the pass-through entity including the current financial obligation (how much is available for contracts): $ 20,000 Total Amount of the Federal Award committed to the subrecipient by the pass-through entity N/A Federal award project description, as required to be responsive to the Federal Funding Accountability and Transparency Act (FFATA) Oral Health Workforce Activities INTERGOVERNMENTAL AGREEMENT (IGA) Amendment ARIZONA DEPARTMENT OF HEALTH SERVICES 150 18th Ave Suite 530 Phoenix, Arizona 85007 Contract No.: ADHS18-175153 IGA Amendment No: 1 Procurement Officer Anthony Beckum Page 14 of 14 Name of Federal awarding agency, pass-through entity, and contact information for awarding official of the Pass-through entity Human Resources and Services Administration (HRSA) Assistance Listings number and Title; the pass- through entity must identify the dollar amount made available under each Federal award and the Assistance Listings Number at time of disbursement: 93.994 Identification of whether the award is R&D No Indirect cost rate for the Federal award (including if the de minimis rate is charged) per § 200.414