FY15 SRC Title IIID Evidenced Based Health Promotion application1919
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Refer to NC Division of Aging and Adult Services
Health Promotion Disease Prevention (11113)
Service Standards located • the website
btip://www.nedhhs.gov/aging(svcstd/iiid.pdf
NARRATIVE
EVIDENCE • HEALTH PROMOTION
r = •
Title IIID of the Older Americans Act (OAA) was established in 1987. It provides grants for
education and activities that support healthy lifestyles and behaviors for those 60 and older. In
2012, Congress mandated that Title IIID funding be used only for programs and activities that
have been demonstrated to be evidence - based. Evidence -based Health Programs are those
which have been developed, researched, and rigorously tested in order to yield consistent,
desired results. They reduce the need for more costly medical interventions and enable older
adults to live independently longer.
Funding support is provided to states under Health Promotion and Disease Prevention
Services (Title IIID), to empower older adults to take control of their health. Through these
programs, seniors learn to maintain a healthy lifestyle through increased self - efficiency and
self - management behaviors. Classes are provided to older adults in their own communities,
in familiar non - clinical settings, such as community centers, and in peer learning groups which
provide support, socialization and reinforcement of positive behavior changes.
Priority is given to seniors living in medically underserved areas of the State or who are in
greatest economic and social need.
Evidence -based disease prevention and health promotion programs have been an aging
network priority in North Carolina for several years; and again this year, requirements
demonstrate a commitment to these programs.
FY 14115 HPDP FUNDING CHART
County
Health Promotion HP Funds
HP match
Grand Total
Brunswick
7,000
778
7,778
Columbus
7,000
778
7,778
New Hanover
2,000
222
2,222
Pender
8,000
889
8,889
Rr-M +;
The Administration for Community Living, (formally The U.S. Administration on Aging), uses
graduated criteria known as "tiers" to define evidence -based interventions. Health promotion
programs fall within one of three tiers; Minimum Criteria, Intermediate Criteria, and Highest -
level criteria. See below for descriptions.
Page 3 of 6
Minimum Criteria
Intermediate Criteria
Highest -level Criteria
DESCRIPTION
Demonstrates through evaluation to be
Programs published in peer-
Programs have undergone
effective for improving the health & well-
review journal AND are proven
experimental design AND are
being or reducing disease, disability Wor
effective with older adult
ready to be presented &
injury among older adults AND are ready
population, using some type of
implemented at the
for translation, implementation Wor
control condition (for example
community level
broad dissemination by community-
pre and post study) AND have
based organizations using appropriate
some basis in translation for
credentialed practitioners
implementation in the community
EXAMPLES
Programs related to the prevention &
Dining with Diabetes
A Matter of Balance (MOB)
mitigation of the effects of chronic
disease, including osteoporosis,
Eat Better Move More
Arthritis Foundation Tai Chi
hypertension, obesity, diabetes, &
cardiovascular disease
Laughter Yoga
Chronic Disease Self-Mgt.
Program
Most health screenings, when
administered by an appropriately
Diabetes Self- Management
credentialed professional
Program
NC Senior Games providing funding is
Fit and Strong
used for events themselves (for example,
equipment) & not for items such as tee
Geri -Fit
shirts & food
Powerful Tools for Caregivers
Walk with Ease
Page 3 of 6
• has the option to conduct at least one Minimum Criteria program, or utilize a portion of
funds for NC Senior Games (Refer to Division of Aging and Adult Services (DAAS)
Administrative Letter No. DAAS -12 -05 (April 23, 2012) Title IIID Revision for information
regarding NC Senior Games.
1 - Complete Attachment B. EBHP Data Spreadsheet found on page 6.
2. Consumer Contributions Requirement
a) Describe how your agency will notify participants and solicit consumer contributions
for participants of EBHP.
b) Provide a copy of your Agency Policy and Procedures governing the collection of
voluntary contributions.
The NC DAAS Health Promotion and Disease Prevention Program Standards,
(Section VII. B. Records, Reports and Reimbursement, page 8) states. "Voluntary
Contributions: In accordance with the requirements of the Older Americans Act,
agencies must provide individuals receiving service the opportunity to contribute to the
cost of the service. Eligible persons receiving Health Promotion and Disease
Prevention services are subject to these requirements. Agencies must estab h written
policies and procedures governing the collection of voluntary cont►ibutions. "
➢ Agencies providing EBHP services with Title IIID funding cannot charge
participants for classes or services.
3. Sign the Standard Assurances — Attachment
4. Sign the Conflict of Interest Policy (for non - profits only) — Atta ch nt
5. Reporting — Providers shall submit to the AAA each quarter the number of unduplicated
persons served for each program or activity offered with Title IIID funds.
Title IIID funds cannot be used for:
• Services covered under Medicare or Medicaid
• Indirect costs or administrative salaries
• Purchase of pill boxes, night lights, line- dancing, exercise videos or health fairs
Title IIID funds can be used to
• support staff salary when they conduct training or attend meetings where they are
sharing information about Evidence Based Programs
Page 4of6
Helpful References
Page 5 of 6
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Chronic C; • • • l
DIRECTIVES
1. Should you elect to conduct CDSMP and/or DSMP, please advise AAA under
whose license you will be working.
2. Each class is required to have 2 Lay - Leaders to teach each class. (Must teach
in pairs.)
3. Fidelity checks, by your licensee, are required for all first - time - teaching Lay
Leaders - usually 2nd or 3'd class session
4. 6 weeks of classes — 2 Y2 hours each class
5. Provide 1 book to each participant — 2 CDs for each class site
6. Supplies needed: 2 flip charts, markers, name tags
7. Must provide, to your licensee, copies of Class & Participant Information Forms:
Class Information Sheet, Attendance Sheet, Participant Information Forms, Class
Evaluation Forms and Class Survey Forms. All forms should be completed and
returned to your licensee within 2 weeks of class completion.
Matter of Balance
. AAA must be contacted when class is scheduled along with the following
information: Identify Coaches teaching class, Begin date and end date of
classes, time and location.
2. Each class must have 2 coaches to teach each class. (Must teach in pairs.)
3. New teaching coaches will be monitored 1 time during the course of class
sessions. Usually 2nd or 3rd class.
4. 8 weeks of classes —1 class per week/2 hours per class or 4 weeks of classes —
2 classes per week/2 hours each class.
5. Must provide handout packets for each participant.
6. Supplies needed: 2 flip charts, markers, name tags
7. Must provide copies of Class & Participant Information Forms: Class Information
Sheet, Attendance Sheet, Participant Information Forms, Class Evaluation Forms
and Class Survey Forms. All forms must be completed and returned to AAA for
data entry and reporting purposes within 2 weeks of class completion.
8. Provide Healthy Refreshments
9. Coaches will need the use of a TV/VCR for 2 of the class sessions. Videos may
be borrowed from AAA office.
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NEW HANOVER COUNTY SENIOR RESOURCE CENTER
GENERAL SERVICE STANDARDS
. CONTRIBUTION POLICY
The Senior Resource Center follows all Title III and State guidelines for contribution from participants.
The state cost sharing policy has been adopted as the guide for each service area. These guidelines
include, but are not limited to:
All participants are informed of the total cost of service during enrollment into the program.
Suggested donations are established annually in each service area. Participants are asked to
contribute toward cost of service based on their ability to pay. Service is not withheld because of
inability to contribute.
See Appendix for copies of packet information. See Appendix B "Recommended Consumer
Contribution Schedule" which is based on US poverty Guidelines for additional recommendations.
Each Congregate nutrition participant is provided with an envelope at the time meal is received.
Contributions are collected and deposited daily. Home Delivered Meal participants are provided with
an envelope on Mondays and envelopes are picked up on each day of the week. All monies /checks
are deposited daily.
Transportation contributions are received via mail and /or direct from client. Monies are collected by
the Transportation Coordinator and given to Finance for daily deposit.
Case Management contributions are received via mail and /or given to Case Manager. Monies /checks
are given to Finance for daily deposit.
All contributions are viewed as confidential.
Signs are placed in the Senior Resource Center stating, the Senior Center welcomes contributions to
enhance the activity programs.
The Grants Coordinator and NHC Budget Office monitor the collection of program income. Annual
monitoring is conducted on all services.
2. CONSUMER CONTRIBUTIONS:
The Senior Resource Center has adopted the NC Division of Aging policy on cost sharing as the policy
and procedure for collection of donations for all service areas. Materials describing the suggested cost
for each service are provided during enrollment into the program. These information processes
include:
• Signage in nutrition site, Social Worker offices, and Support Group Sessions
• Letters to home delivered meals clients
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2
• Letter to medical transportation clients
• Annual cost sharing presentation in nutrition site
• Cost sharing explanation at time of enrollment and bi- annual reassessments
The Senior Resource Center maintains records of all costs related to the collection of contributions.
3. CONFIDENTIALITY:
All client records are viewed as the property of the Senior Resource Center and are confidential. Each
client is asked to sign a release of information form when enrolled into Senior Resource Center
Programs. This release allows Senior Resource Center staff to share information that is critical to the
well -being of the client with appropriate agencies. The Senior Resource Center has signed agreements
of understanding with these agencies. Information may also be shared with other employees of the
agency for the purpose of making referrals and for reporting purposes, with the service provider, Area
Agency on Aging and the NC Division of Aging. Client records are stored in a secure place and are
available to service provider and authorized staff. All information is held for five (5) years and then
destroyed. Client is informed that contents may be released for definite purpose, client may withhold
consent for release, and there are statutes and regulations protecting the confidentiality of the
information in his /her files. Client may alter the release form to contain other information which
would restrict usage of the information, such as specifying the date or specific purpose of the releases.
The client is informed as to how information is to be released, with whom the information will be
shared and that all data will not be used without client's consent.
Clients may have access to view their own information within a period of five days from date of
request. An authorized staff person must be present during the viewing. Record of client's review of
his /her file is maintained and included as part of client confidential file. Any correction of information
(as related to client contest)shall become a part of the client file.
The Senior Resource Center has the right to withhold information from a client. The client will be
informed that information is being withheld. A record of the choice to withhold information will be
documented in the client file.
A client may contest the accuracy, completeness, or relevancy of the information in his /her files. A
correction of the contested information, but not a deletion of the original information if it is required
to support receipt of state or federal financial participation, shall be inserted in the file when the
director or his /her designee concurs that such correction is justified.
All automated files are located in the Client -X computer program, ServTracker, and the State Division
of Aging ARMS (Automated Resource Management System) program. All programs are password and
firewall protected.
4. STAFF TRAINING:
Training of staff, senior aides, and volunteers is documented in personal and training files.
Area Agency on Aging Workshops
Aging Conference
Safety
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• Staff Development
• Service Excellence
5. ELIGIBILITY:
All persons 60+ and their spouses are eligible to participate in the Senior Resource Center Programs.
Target groups will be elderly, at risk of institutionalization, and /or referral for protective services, and
those with the greatest socio - economic needs.
Special eligibility (see HCCBG manual)
Salaried SRC staff are discouraged from participation in grant funded programs to extend funds
to those with greatest need (i.e. Congregate Nutrition) Handled on a case -by -case basis.
6. INFORMATION REFERRAL AND CASE ASSISTANCE:
Information, Referral, and Case Assistance is a part of each of the service areas and is conducted by all
staff within his /her program. For persons contacting the Senior Center via telephone or walk -in, the
following plan is utilized:
A. Questions pertaining to the activities /classes /general of the Senior Center (recreational and
social events) are transferred to the SRC Ambassadors Desk or to the Senior Center Activities
Program Manager or his assistant.
B. Questions, other than above, are referred to the Case Worker and handled in the following
manner:
y Simple question requiring no assessment
• Provide requested information (pamphlet, etc.)
• No follow -up required
r- Questions requiring assessment
• Assessment is conducted via telephone, office interview, or home visit
• Referrals are arranged
• Follow -up conducted to assure resolution
• Documented in ServTracker
The Senior Resource Center Case Worker maintains a comprehensive file on community /referral
agencies. This information includes names of contact persons, telephone numbers, and addresses of
each agency. Information is made available to elderly persons, their families, and other staff members.
The Senior Resource Center has developed a firm working relationship with the community and is
committed to simplification of service entry for all seniors. This is accomplished by sharing information
and complete understanding and knowledge of community resources.
7. DATA:
Monthly reports and other pertinent data, programmatic reports, financial history, support, and
statistical data are maintained on file by the department for five (5) years. Current and past years are
maintained in the Administrative Office of the SRC, or secured in a locked out - building on -site.
8. UNITS OF SERVICE:
A clear definition of a unit of service is based on type of service rendered and available for explanation
on request.
9/17/2014
Ll
9. COORDINATION /OUTREACH:
Coordination is on -going with local community agencies as well as providers in Region 0. Letters from
local churches describes transportation linkages. Monthly meetings with in -home service providers,
medical organizations, and other contractors offer opportunity to share and expand ideas, thus
increasing effectiveness of services to seniors.
10. LICENSURE & SAFETY REQUIREMENTS:
The Senior Resource Center follows licensure and safety requirements of New Hanover County policies.
Linkage established with the fire & health departments meet all Area Agency on Aging requirements.
Fire drills and inspections are monitored on an annual basis.
11. GRIEVANCE PROCEDURE:
Denial Procedure is:
Informal complaint to service provider, discussion and resolution being the goal.
• Written statement of complaint to service provider.
• Formal response from the service provider.
+ Written statement of complaint to County Commissioners,
12. TRAVEL:
Out of state travel must be approved by the: 1) Department Head, 2) County Commissioners, 3) Area
Agency on Aging. Only one staff member may attend out of state meeting.
13. VIEWS OF PARTICIPANTS:
Participants are encouraged to participate in suggestions pertaining to policies and procedures.
Informal site councils are organized when need is obvious to address issues within the immediate site.
14. FISCAL OPERATIONS:
The day to day fiscal operations are conducted by the Financial Specialist staff in the Senior Resource
Center. These include preparation of purchase orders, payment vouchers, deposits of contributions,
data entry into ARMS (Aging Resource Management System), and general bookkeeping responsibilities.
The Grants Coordinator, located in the county finance office, is responsible for the monitoring of grants
and the preparation of all fiscal reports related to the grants.
All contributions for Nutrition Programs, Transportation, Case Assistance, and Senior Center are
received by the Senior Resource Center Financial Specialist /Bookkeeper. Deposits are made daily.
Contributions are collected from the nutrition site boxes by the Financial Specialist and one other staff
member. All monies are counted and deposits made in accordance to the guidelines established by the
C Finance Department.
15. POLICY OF REIMBURSEMENT:
Staff reimbursement may be requested for mileage at the current State rate. This request will be
submitted with record of odometer supported mileage with the staff time sheet.
9/17/2014
5
Volunteer reimbursements are made monthly for volunteer drivers in the home delivered meal
program. Written request and odometer readings are required.
16. LIABILITY INSURANCE:
Insurance is in compliance with New Hanover County policies. Liability and accident insurance covers
volunteers with the department.
17. FISCAL RECORDS:
Fiscal records are maintained by the County Finance Office. Bookkeeping records are maintained
within the department.
18. DENIAL POLICY:
Clients are denied service for the following reasons:
• Ineligible (under 60 years of age)
• Inappropriate behavior
• Lack of local /federal /state monies to operate the programs
• Does not meet eligibility (i.e. not homebound for HDM, resides outside NHC)
19. PRIORITY
Priority is given to those clients 60+ in the following order:
• Adult Protective Services Referral
• At risk of institutionalization. Referral to DSS for abuse is suspected.
• Most needy economically
20. UNEXPLAINED ABSENCE POLICY
Client receives and signs a letter upon registration explaining this policy. In the event a client is absent
from their home when the meal is delivered:
• a staff member will contact the client or emergency contact person to ensure client's safety
• on second occurrence of absence without notification, meal service will be suspended until the
absences are resolved.
• Three or more unexplained absences will result in termination of service
• Clients are notified by mail of service termination date and reason for termination
21. TERMINATION POLICY:
Clients may be terminated for the following reasons:
• Under age 60
• Lack of Local /State /Federal funds to operate program
• Undesirable behavior
• Medical /Health reasons
• Services no longer needed
• a staff member will contact the client or emergency contact person to notify of termination
• Clients are notified by mail of service termination date and reason for termination
22. EMERGENCY POLICY:
9/17/2014
If an incident occurs in the Senior Resource Center, Nutrition site, or County Van, the following
procedure is followed:
• If the emergency incident involves the health of the client, the Senior Resource Center staff is
instructed to:
(a) Call 911
(b) Stay with client until help arrives
(c) Notify client's emergency contact and inform of incident
(d) Client is to be evaluated by EMS and MAY accept /decline transport to the hospital
If client's emergency is related to food, housing, utilities, medication, client is referred to a
Social Worker Case Worker. Case Worker will make appropriate referral to resolve emergency
issue.
In case of inclement weather /other emergency situation, the Senior Resource Center follows
the Disaster Plan as developed by the NHC Emergency Management Department. Clients are
contacted by the NHC Special Needs Telephone Response Team and referred to the Special
Needs Task Force if additional assistance is needed. Once the weather /emergency event is
over, the Senior Center staff makes contact with all participants to confirm re- establishment of
services.
23. SAFETY PROCEDURE
Regular inspection by the Fire and Health Department are conducted and reports retained by
the Department Director
• Written EXIT plans are clearly displayed inside the Senior Center in case of fire or emergency.
• First Aid Kit /cart is located in the Case Worker's Office.
Safety Training manual is on First Aid Cart
• "Call 911— then notify Center Staff member" signs are posted by each telephone
• All staff and volunteers that may be handling food read and sign the State "Senior Nutrition
Program Employee Health Policy Agreement" (see Attached). Signed form is maintained in
individual record.
24. POLICY REGARDING RETENTION OF RECORDS
All records of current and previous year are maintained in the SRC office, records 2 -5 years prior are
stored in exterior locked storage building. After five years, Department Director is notified and records
are destroyed.
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7
Senior Nutrition Program Employee Health Policy Agreement
Reporting: Symptoms of Illness
I agree to report to the manager when I have:
1. Diarrhea and /or vomiting
2. Jaundice (yellowing of the skin and /or eyes)
3. Sore throat with fever
4. Infected cuts or wounds, or lesions containing pus on the hand, wrist, an exposed body part (such as boils and infected
wounds, however small).
Reporting: Diagnoses! Illnesses
I agree to report to the manager when I have:
1. Norovirus
2. Salmonella Typhi (typhoid fever)
3. Shigella spp. infection
4. E. coil infection (Escherichia coli O157:1-17 or other EHEC /STEC infection)
5. Hepatitis A
Note: The manager must report to the Health Department when an employee has one of these illnesses.
Reporting: Exposure of Illness
I agree to report to the manager when I have been exposed to any of the illnesses listed above
through:
1. An outbreak of Norovirus, typhoid fever, Shigella infection, E. coil infection, or Hepatitis A.
2. A household member with Norovirus, typhoid fever, Shigella spp. infection, E. coil infection, or Hepatitis A.
3. A household member attending or working in a setting with an outbreak of Norovirus, typhoid fever, Shigella spp.
infection, E. coil infection, or Hepatitis A.
Exclusion and Restriction from Work
If you have any of the symptoms or illnesses listed above, you may be excluded* or restricted ** from work.
*If you are excluded from work you are not allowed to come to work.
* *If you are restricted from work you are allowed to come to work, but your duties may be limited.
Returning to Work
If you are excluded from work for having diarrhea and /or vomiting, you will not be able to return to work until more
than 24 hours have passed since your last symptoms of diarrhea and /or vomiting.
If you are excluded from work for exhibiting symptoms of a sore throat with fever or for having jaundice
(yellowing of the skin and/or eyes), Norovirus, Salmonella Typhii (typhoid fever), Shigella spp. infection, E.
coli infection, and/or Hepatitis A, you may return to work after receiving 24 hours of antibiotic therapy;
negative for Strep or determined by health professional Mthout Strep.
Agreement
I understand that I must: -
1. Report when I have or have been exposed to any of the symptoms or Illnesses listed above; and
2. Comply with work restrictions and /or exclusions that are given to me.
I understand that if I do not comply with this agreement, it may put my job at risk.
Food Employee Name (please print)
Signature of Employee Date
9/17/2014
H.
Manager Name (please print)
Signature of Manager Date
These are some of the Bacterium and Viruses spread from Food Handlers to Food
E. Coli
Overview: A bacterium that can produce a deadly toxin and causes an estimated 70,000 cases of foodborne illnesses each year in the
U.S.
Sources: Meat, especially undercooked or raw hamburger, produce and raw milk.
Incubation period: 2 -10 days
Symptoms: Severe diarrhea, cramping, dehydration
Prevention: Cook implicated food to 155F, wash hands properly and frequently, correctly wash rinse and sanitize food contact
surfaces.
Shigella
Overview: Shigella is a bacterium that causes an estimated 450,000 cases of diarrhea illnesses each year. Poor hygiene causes
Shigella to be easily passed from person to person.
Sources: Salad, milk, and dairy products, and unclean water.
Incubation period: 1 -7 days
Symptoms: Diarrhea, stomach cramps, fever, chills and dehydration
Prevention: Wash hands properly and frequently, especially after using the restroom, wash vegetables thoroughly.
Salmonella
Overview: Salmonella is a bacterium responsible for millions of cases of foodborne illnesses a year. Elderly, infants and individuals
with impaired immune systems are at risk to severe illness and death can occur if the person is not treated promptly with antibiotics.
Sources: raw and undercooked eggs, undercooked poultry and meat, dairy products, seafood, fruits and vegetables
Incubation period: 5 -72 hours (up to 16 days has been documented for low doses)
Symptoms: Nausea, vomiting, cramps, and fever
Prevention: Cook all food to proper temperatures, chill food rapidly, and eliminate sources of cross contamination (i.e. proper meat
storage, proper wash, rinse, and sanitize procedure)
Hepatitis A
Overview: Hepatitis A is a liver disease caused by the Hepatitis A virus. Hepatitis A can affect anyone. In the United States, Hepatitis A
can occur in situations ranging from isolated cases of disease to widespread epidemics.
Incubation period: 15 -50 days
Symptoms: Jaundice, nausea, diarrhea, fever, fatigue, loss of appetite, cramps
Prevention: Wash hands properly and frequently, especially after using the restroom.
orvirs
Overview: This virus is the leading cause of diarrhea in the United States. Any food can be contaminated with norovirus if handled by
someone who is infected with the virus. This virus is highly infectious.
Incubation period: 648 hours
Symptoms: Nausea, vomiting, diarrhea, and cramps
Prevention: Wash hands properly and frequently, especially after using the restroom: obtain food from a reputable food source: and
wash vegetables thoroughly.
Staph (Staphylococcus aureus)
Overview: Staph food poisoning is a gastrointestinal illness. It is caused by eating foods contaminated with toxins produced by
Staphylococcus aureus. Staph can be found on the skin, in the mouth, throat, and nose of many employees. The hands of employees
can be contaminated by touching their nose, infected cuts or other body parts. Staph produces toxins that are extremely heat stable
and are not inactivated by normal reheating temperatures. It is important that food contamination be minimized.
Incubation period: Staph toxins are fast acting, sometimes causing illness in as little as 30 minutes after eating contaminated foods,
but symptoms usually develop within one to six hours.
Sources: Ready -to -eat foods touched by bare hands. Foods at highest risk of producing toxins are those that are made by hand and
require no cooking.
Symptoms: Patients typically experience several of the following. nausea, vomiting, stomach cramps, and diarrhea. The illness lasts
one day to three days. In a small minority of patients the illness may be more severe.
Prevention: No bare hand contact with ready -to -eat foods. Wash hands properly. Do not prepare food if you have a nose or eye
infection. Do not prepare or serve food for others if you have wounds or skin infections on your hands or wrists. If food is to be stored
longer than two hours, keep hot foods hot (over 135 °F) and cold foods cold (41'F or under). Properly cool all foods.
9/17/2014
Reference: NC Food Code Manual; Employee Health, 2 -201.
September 2012
Senior Nutrition Program Volunteer Health Policy Agreement
Reporting: Symptoms of Illness
I agree to report to the manager when I have:
1. Diarrhea and /or vomiting
2. Jaundice (yellowing of the skin and /or eyes)
3. Sore throat with fever
4. Infected cuts or wounds, or lesions containing pus on the hand, wrist, an exposed body part (such as boils and infected
wounds, however small).
Reporting: Diagnosed Illnesses
I agree to report to the manager when I have:
1. Norovirus
2. Salmonella Typhi (typhoid fever)
3. Shigella spp. infection
4. E. coli infection (Escherichia coil 0157 :H7 or other EHEC /STEC infection)
5. Hepatitis A
(Vote: The manager must report to the Health Department when an employee or volunteer has one of these illnesses.
Reporting: Exposure of Illness
I agree to report to the manager when I have been exposed to any of the illnesses listed above
through:
1. An outbreak of Norovirus, typhoid fever, Shigella infection, E. toll infection, or Hepatitis A.
2. A household member with Norovirus, typhoid fever, Shigella spp. infection, E. coli infection, or Hepatitis A.
3. A household member attending or working in a setting with an outbreak of Norovirus, typhoid fever, Shigella spp.
infection, E. coil infection, or Hepatitis A.
Exclusion and Restriction from Work
If you have any of the symptoms or illnesses listed above, you may be excluded* or restricted ** from volunteering.
*If you are excluded from volunteering you are not allowed to come in.
* *If you are restricted from volunteering you are allowed to come in, but your duties may be limited.
Returning to Work
If you are excluded from volunteering for having diarrhea and /or vomiting, you will not be able to return to volunteer
until more than 24 hours have passed since your last symptoms of diarrhea and /or vomiting.
If you are excluded from volunteering for exhibiting symptoms of a sore throat with fever or for having
jaundice (yellowing of the skin and/or eyes), Norovirus, Salmonella Typhii (typhoid fever), Shigella spp.
infection, E. coli infection, and/or Hepatitis A, you may return to volunteer after receiving 24 hours of antibiotic
therapy; negative for Strep or determined by health professional without Strep.
Agreement
I understand that I must:
1. Report when I have or have been exposed to any of the symptoms or illnesses listed above; and
2. Comply with restrictions and /or exclusions that are given to me.
understand that if I do not comply with this agreement, I may not be able to volunteer at the Center.
Food Volunteer Name (please print)
Signature of Volunteer
9/17/2014
I
N
1A
Manager Name (please print)
Signature of Manager Date
These are some of the Bacterium and Viruses spread from Food Handlers to Food
E. Coli
Overview: A bacterium that can produce a deadly toxin and causes an estimated 70,000 cases of foodborne illnesses each year in the
U.S.
Sources: Meat, especially undercooked or raw hamburger, produce and raw milk.
Incubation period: 2 -10 days
Symptoms: Severe diarrhea, cramping, dehydration
Prevention: Cook implicated food to 155F, wash hands properly and frequently, correctly wash rinse and sanitize food contact
surfaces.
Shigella
Overview: Shigella is a bacterium that causes an estimated 450,000 cases of diarrhea illnesses each year. Poor hygiene causes
Shigella to be easily passed from person to person.
Sources: Salad, milk, and dairy products, and unclean water.
Incubation period: 1 -7 days
Symptoms: Diarrhea, stomach cramps, fever, chills and dehydration
Prevention: Wash hands properly and frequently, especially after using the restroom, wash vegetables thoroughly.
Salmonella
Overview: Salmonella is a bacterium responsible for millions of cases of foodborne illnesses a year. Elderly, infants and individuals
with impaired immune systems are at risk to severe illness and death can occur if the person is not treated promptly with antibiotics.
Sources: raw and undercooked eggs, undercooked poultry and meat, dairy products, seafood, fruits and vegetables
Incubation period: 5 -72 hours (up to 16 days has been documented for low doses)
Symptoms: Nausea, vomiting, cramps, and fever
Prevention: Cook all food to proper temperatures, chill food rapidly, and eliminate sources of cross contamination (i.e. proper meat
storage, proper wash, rinse, and sanitize procedure)
Hepatitis A
Overview: Hepatitis A is a liver disease caused by the Hepatitis A virus. Hepatitis A can affect anyone. In the United States, Hepatitis A
can occur in situations ranging from isolated cases of disease to widespread epidemics.
Incubation period: 15 -50 days
Symptoms: Jaundice, nausea, diarrhea, fever, fatigue, loss of appetite, cramps
Prevention: Wash hands properly and frequently, especially after using the restroom.
Norovirus
Overview: This virus is the leading cause of diarrhea in the United States. Any food can be contaminated with norovirus if handled by
someone who is infected with the virus. This virus is highly infectious.
Incubation period: 6-48 hours
Symptoms: Nausea, vomiting, diarrhea, and cramps
Prevention: Wash hands properly and frequently, especially after using the restroom: obtain food from a reputable food source: and
wash vegetables thoroughly.
Staph (Staphylococcus aureus)
Overview: Staph food poisoning is a gastrointestinal illness. It is caused by eating foods contaminated with toxins produced by
Staphylococcus aureus. Staph can be found on the skin, in the mouth, throat, and nose of many employees. The hands of employees
can be contaminated by touching their nose, infected cuts or other body parts. Staph produces toxins that are extremely heat stable
and are not inactivated by normal reheating temperatures. It is important that food contamination be minimized.
Incubation period: Staph toxins are fast acting, sometimes causing illness in as little as 30 minutes after eating contaminated foods,
but symptoms usually develop within one to six hours.
Sources: Ready -to -eat foods touched by bare hands. Foods at highest risk of producing toxins are those that are made by hand and
require no cooking.
Symptoms: Patients typically experience several of the following: nausea, vomiting, stomach cramps, and diarrhea. The illness lasts
one day to three days. In a small minority of patients the illness may be more severe.
Prevention: No bare hand contact with ready -to -eat foods. Wash hands properly. Do not prepare food if you have a nose or eye
infection. Do not prepare or serve food for others if you have wounds or skin infections on your hands or wrists. If food is to be stored
longer than two hours, keep hot foods hot (over 135 °F) and cold foods cold (41'F or under). Properly cool all foods.
9/17/2014
Reference: NC Food Code Manuel, Employee Health, 2 -201.
September 2012
9/17/2014
IF
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9/17/2014
12
NC Di4isiorn of Aging and Adult Services Manual
:', Division (i Agin? and Adult Servixs
Recommended Contribution Scheduie
Barad on the 2013 U5 Poverty Guidciinc3
Sen ice Recipients Namc:_
&rvice NI_ Rrte-. - &" ,viec 02 Rot-'N-
Rate
�`of
Y y Percentage of oPService mount per Chit
the Cwt Pavers
° o oath ncame at: Su es:ed Recammendecl Contribution A
Individual �C' le Scrvice Service { ] Service #2 f Service #.'3
100% $958 -$1 ;96 $1,2. - $]L615 JO°u
I?5�ra $1,197- !;1,535 $1616 — $1.938 2A5v i
T54S: x1.436- $1.675 $1039- ,;2261 30`'•.
26 ' - $2.5x4 io° • �I
204 °, $i 91,- a°,IS3 I 1250 -$190 3C
- o _. _ -1 - -
2 ^.5'. L I 52 -I Si - 393 $2 908 - X3,230
'..50° o $2,394 - $2,632 $3.231- x3,553
'75% $2 633 - $2 Ery_! $7,554 • ;13,877 80CII
W 300 °. 0 52.873 - $3.350 33878 44-521 905' 1
350, 3,351 -- abovc $4 57!4 -- abo a 100 °% ._.._
Tha Rscomme.ided C.an„ umcr Contribution Schedule may only b ::lief d with s�rviae re ipient" rho are Abu::: �c� e rh
and receiv.; a Type I s.:rvicc {s). VolLntary contribution rnz.ie towaW tl__ ccsc of :nx: =ices rec eivad ar_ no. te:x
deductible,
C oo.amer Cvntributiot s Policy and Procedures Page t3 - I
Effc.stive Date: 01/2.4/2013
Last I rpdate: 2/5/2413
9/17/2014
13
a a
Services wilf be provided in accordance with requirements set forth in:
a. Cape Fear Area Agency on Aging Procedures Manual
b. The North Carolina Division of Aging and Adult Services Policies and
Procedures.
c. The Older Americans Act of 1965.
2. Priority will be given to older persons with the greatest economic or social needs, with
particular attention to low- income minority individuals.
3. All licenses, permits, bonds, and insurance necessary for carrying out services will be maintained by
the Community Service Provider and any contracted providers.
4, Certification, State Grants compliance reporting. If the contractor is a governmental entity, such entity
is subject to the provisions of the requirements of OMB Circular A -133 and the NC Single Audit
Implementation Act of 1987. Non- government agencies must comply with GS 143C -6 -23 as outlined in
the chart below.
NON- PROFIT ONLY
Required State Grants Reporting
$1-$24,999
$25,000 - $499,999
$500,000 and 'more
Certification Form
Certification Form
Certificai#. n Form
Brief accounting and program
More detailed accounting
AudiVIand
activities and accomplishments
(schedule of receipts and
Schedule Wf Awards
expenditures)
(usually included in audit
Due within six (6) months of
Due within six (6) months of
Due within nine (9) months of
entity's fiscal year to Cape Fear
entity's fiscal year to Cape Fear
entity's fiscal year to Cape Fear
and Office of the State Auditor
NIA
Separate program activities and
Program activities and
accomplishments
accomplishments
5. Compliance with Equal Employment Opportunity requirements shall be followed.
6. The Community Service Provider will be monitored through on -site visits by the Area Agency on Aging
to assure that services are being provided in compliance with the provisions of the contract.
7. The Community Service Provider will submit both monthly financial (ARMS) and quarterly program
reports as required by the Area Agency on Aging and the NC DAAS.
8. The Community Service Provider assures that the required 10% match will be provided.
9. The Community Service Provider assures that all consumer contributions collected will be used to
expand EBHP Services.
10. The Community Service Provider assures that all terms and conditions as required by the Older
Americans Act of 1965, the North Carolina Division of Aging and Adult Services, and Cape Fear Area
Agency on Aging will be adhered to.
• i 1
Date
Sign A ,, %%� yiAIfc-, pfe'sisial-�V C04.%4 V%r
ATTACHMENT D
CONFLICT OF INTEREST POLICY
In accordance with G.S. 143 -6.1 and related legislation, we, the undersigned entity, have
adopted the following policy regarding conflicts of interest:
The undersigned entity is aware that in the process of fund allocation by its
management, employees, members of the board of directors or other governing
body, instances may arise which have the appearance of a conflict of interest or
appearance of impropriety.
In order to avoid conflicts of interest or the appearance of impropriety, should
instances arise where a conflict may be perceived, any individual who may
benefit, directly or indirectly, from the entity's disbursement of funds shall abstain
from participating in any decisions or deliberation by the entity regarding the
disbursement of funds.
The undersigned entity recognizes the possibility that it may be the recipient of
funds which are allocated consistent with the purpose and goals of its programs.
If such allocations are made, the undersigned entity will strive to ensure that funds
are expended in such a manner that no individual will benefit, directly or
indirectly, from the expenditure of such funds in a manner inconsistent with its
programs.
NHC Senior Resource Center
Name of Agency