pplm grant application for title x 2011

Table Of Contents

Applicant:

Application Number:

Planned Parenthood League of Massachusetts

FPH2011005026

Project Title 2011 Family Planning SeNices Announcement (Region 1 - New

Hampshire, Vermont, Maine, Rhode Island, Connecticut, Central

Massachusetts)

Status: Awarded

Statute/Regulations

1. 42CFR50 SubPart B - Policies of General Applicability (10/01/2003)

2. Title X Family Planning Regulations - 42CFR59 - Grants for Family Planning Services

(10/01/2000)

3. Title X of the Public Health Service Act

Information for the Applicant

1. 2009 OPHS non-compete submission policies

2. 2010 OPA Program Priorities

3. Family Planning Services Non Competing Grant Application Checklist, Revised July 2009

4. Notification of Project Management

5. Title X Assurances

6. Guidelines for Family Planning SeNices Non Competing Application Preparation, Revised July

2009

Online Forms

1. Key Personnel Form

2. SF-424 Application for Federal Assistance (Version 2.0)

• (Upload #1): PPLM List of Congressional Districts

3. SF-424A - Budget Information for Non-Construction Programs

4. SF-424B - Assurances for Non-Construction Programs

5. SF-LLL Disclosure of Lobbying Activities

• (Filing Detail): PPLM does not conduct any lobbying activities as part of our Title X project.

6. Standard Certifications

Program Narrative

1. Budget Narrative

• (Upload #2): PPLM Budget Narrative

2. Program Narrative Upload

• (Upload #3): PPLM Program Narrative

• (Upload #4): PPLM Exhibit A - Family Planning Program Service Site Information

• (Upload #5): PPLM Exhibit B - Family Planning Site Services Provided

• (Upload #6): PPLM Attachment A - Map of Title X Health Centers

• (Upload #7): PPLM Attachment B - Floor Plans

• (Upload #8): PPLM Attachment C - Community Partnerships

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• (Upload #9): PPLM Attachment D - Position Descriptions and Biographical Sketches

• (Upload #10): PPLM Attachment E - Clinical Policy and Procedures Manual

• (Upload #11): PPLM Attachment F - Information and Education Committee

• (Upload #12): PPLM Attachment G - Schedule of Charges and Sliding Fee Scale

• (Upload #13): PPLM Attachment H - IRS Certification of 501 c3 Status

• (Upload #14): PPLM Attachment I - Project Administration Policy and Procedures Manual

Additional Information to be Submitted

1. Miscellaneous Information

• (Upload #15): PPLM Notification of Project Management

• (Upload #16): PPLM OPHS Checklist

• (Upload #17): PPLM Title X FPS Grant Applicant Checklist

• (Upload #18): PPLM Public Health Impact Statement

• (Upload #19): PPLM Assurance of Compliance

Note: Upload document(s) printed in order after online forms.

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(b) (4)

K P ey ersonne

Name Position Title Annual Salary No.Months % Fed Non-Fed Total Amount Budget Time Amount Amount Requested

Karen Caponi Health Services Director, Cent 17,920 41 ,816 59,736

Dianne Luby President/CEO 13,160 39,483 52,643

Chad Ellis CFO 13,500 13,500 27,000

Susan Wood VP, Clinical Operations 30,399 45,600 75,999

Anne Dixon Medical Director 20,733 62,200 82,933

Gretchen Landwehr Quality Assurance Manager 9,189 15,316 24,505

Elizabeth Poitras Quality Assurance Manager 8,767 14,611 23,378

Aaron Caine Chief Information Officer 5,739 17,217 22,956

Jackie Mansfield-Marcoux Regional Director 11,437 26,688 38,125

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Application for Federal Assistance SF-424

• 1. Type of Submission: • 2. Type of Application: • If Revision, select appropriate letter(s):

DPreapplication DNew I I (gJApp Ii cation Dcontinuation • Other (Specify)

DChanged/Corrected Application DRevision I • 3. Date Received: 4. Applicant Identifier:

110101/2010 II I 5a. Federal Entity Identifier: • 5b. Federal Award Identifier:

I II State Use Only:

6. Date Received by State: 110101/2010 11 7. State Application Identifier: I 8, APPLICANT INFORMATION:

• a. Legal Name: IPlanned Parenthood League of Massachusetts

• b. Employer/Taxpayer Identification Number (EINITIN): • c. Organizational DUNS:

11042698497 A 1 1103-081-2648 1

d. Address:

• Street1: 11055 Commonwealth Ave Street2:

I • City: IBoston 1

County: 1 I * State: I Massachusetts

Province: I I * Country: IUNITED STATES * Zip 1 Postal Code: /02215-1001 I

e. Organizational Unit:

Department Name: Division Name:

1 1

f. Name and contact information of person to be contacted on matters involving this application:

Prefix: I 1 * First Name: IDianne Middle Name: I I * Last Name: ILub~ Suffix: I I

Title: 1 PresidenUCEO 1 Organizational Affiliation:

IPresidenUCEO

* Telephone Number: 1617 -616-1651 IFax Number: 1617-616-1665

* Email: Idlub~@~~lm.or9

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I

OMS Number: 4040-0004

Expiration Date: 07/31/2006

Version 02

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9. Type of Applicant 1: Select Applicant Type:

INonprofit with 501C3 IRS Status (Other than Institution of Higher Education) Type of Applicant 2: Select Applicant Type:

1 Type of Applicant 3: Select Applicant Type:

1 • Other (specify):

I I • 10. Name of Federal Agency:

IPA-Family Planning

11. Catalog of Federal Domestic Assistance Number:

193.217 1 CFDATitle:

IFamily Planning Services

·12. Funding Opportunity Number:

I I • Title:

I 13. Competition Identification Number:

I I Title:

I 14. Areas Affected by Project (Cities, Counties, States, etc.):

OMB Number: 4040-0004


Version 02

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Worcester, Fitchburg, Milford (Worcester County) and Framingham and Marlborough (Middlesex County), MA

·15. Descriptive Title of Applicant's Project:

2011 Family Planning Services Announcement (Region 1 - New Hampshire, Vermont, Maine, Rhode Island, Connecticut, Central Massachusetts)

Attach supporting documents as specified in agency instructions.

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Application for Federal Assistance SF-424 Version 02

16. Congressional Districts Of:

" a. Applicant 108 I " b. Program/Project!01

I

Attach an additional list of Program/Project Congressional Districts if needed.

17. Proposed Project:

" a. Start Date: 112/31/2009 1 " b. End Date: 112/30/2011 I

18. Estimated Funding ($):

"a. Federal 7935481

" b. Applicant 01

"c. State 2500001

"d. Local 01

"e. Other 16659831

" f. Program Income 01

"g. TOTAL 27095311

* 19. Is Application Subject to Review By State Under Executive Order 12372 Process?

Oa. This application was made available to the State under the Executive Order 12372 Process for review on I I

Db. Program is subject to E.O. 12372 but has not been selected by the State for review.

IEIc. Program is not covered by E.O. 12372.

* 20. Is the Applicant Delinquent On Any Federal Debt? (If "Ves", provide explanation.)

DVes lEI No

21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances*" and agree to com-ply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)

IBl *" I AGREE

"" The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions.

Authorized Representative:

Prefix: I I

" First Name: IDianne I Middle Name:

I I "Last Name: ILuby I Suffix:

I I

" Title: 1 President/CEO 1

"Telephone Number: 1617-616-1651 IFax Number: 1617-616-1665 1

" Email: Idlub~@~~lm.or9 1

" Signature of Authorized Representative: I I " Date Signed: 1 I Authorized for Local Reproduction Standard Form 424 (Revised 10/2005)

Prescribed by OMS Circular A-102

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• Applicant Federal Debt Delinquency Explanation



Version 02

The following field should contain an explanation if the Applicant organization is delinquent on any Federal Debt. Maximum number of characters that can be entered is 4,000. Try and avoid extra spaces and carriage returns to maximize the availability of space.

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(b) (4)

(b) (4)

Grant Program Catalog of Federal Function Domestic Assistance

or Activity Number (a) (b)

1. Family Planning Services 93.217

2. 93.217

3. 93 .217

4. 93 .217

5. Totals

6. Object Class Categories

a. Personnel

b. Fringe Benefits

c. Travel

d. Equipment

e. Supplies

f. Contractual

g. Construction

h. Other

i. Total Direct Charges (sum of6a-6h)

j. Indirect Charges

k. TOTALS (sum of 6; and 6j)

7. Program Income

Previous Edition Usable

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BUDGET INFORMATION - Non-Construction Programs OMB Approval No. 0348-0044

SECTION A - BUDGET SUMMARY

Estimated Unobligated Funds

Federal Non-Federal Federal (c) (d) (e)

$793,548.00

$793,548.00

SECTION B - BUDGET CATEGORIES GRANT PROGRAM, FUNCTION OR ACTIVITY

(1) Family Planning (2) (3)

$964,496.00

I $6,700.00

$851,022.00

$45,000.00

$637,005.00

$2,709,53 1.00

Authorized for Local Reproduction

New or Revised Budget

(4)

Non-Federal Total (f) (g)

$1,915,983.00 $2,709,531.00

$1,915,983.00 $2,709,531.00

Total

(5)

$964,496.00

$6,700.00

$851,022.00

$45,000.00

$637,005.00

$2,709,531.00

Standard Form 424A (Rev. 7-97) Prescribed by OMS Circular A-102

(b) (4) (b) (4)

SECTION C - NON-FEDERAL RESOURCES (a) Grant Program (b) Applicant (c) State (d) Other Sources (e) TOTALS

8. Family Planning Services $250,000.00 $ $1,665,983.00 $1,915,983.00

9.

10.

11 .

12. TOTAL (sum of lines 8-11) $250,000.00 $1,665,983.00 $1,915,983.00

SECTION D - FORECASTED CASH NEEDS

Total for 1st Year 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

13. Federal $793,548.00 $198,387.00 $198,387.00 $198,387.00 $198,387.00

14. Non-Federal $1,915,983.00 $478,996.00 $478,996.00 $478,996.00 $478,995.00

15. TOTAL (sum oflines 13 and 14) $2,709,531.00 $677,383.00 $677,383.00 $677,383.00 $677,382.00

SECTION E - BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT

(a) Grant Program FUTURE FUNDING PERIODS (Years) (b) First (c) Second (d) Third (e) Fourth

16. Family Planning Services $844,545.00 $920,554.00 $1,003,403.00 $1,093,709.00

17.

18.

19.

20. TOTAL (sum oflines 16-19) $844,545.00 $920,554.00 $1,003,403.00 $1,093,709.00

SECTION F - OTHER BUDGET INFORMATION r. Direct Charqes:1

1122. Indirect Charqes:1

23. Remarks:

Authorized for Local Reproduction Standard Form 424A (Rev. 7-97) Page 2

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Project Title:

Project Period:

Application Organization

Authorized Certifying Official:

Title:

SF4248 Assurances

2011 Family Planning Services Announcement (Region 1 - New Hampshire, \

12/31/2009 to 12/30/2011


Dianne Luby

PresidenUCEO

o I DO NOT agree with the tenns of the Signing Agreement

[8] I agree with the tenns of the signing Agreement

Page 1 0 of 155

DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352

(See reverse for public burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: ~ a. contract

b. grant Da. bid/offer/application

b. initial award D a. initial filing

b. material change c. cooperative agreement c. post-award For Material Change Only: d.loan year quarter e. loan guarantee date of last report f. loan insurance

Approved by OMS

0348-0046

4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is a Subawardee, Enter Name D Prime D Subawardee and Address of Prime:

Tier , ifknown:

Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description:

CFDA Number, if applicable: 93.217

8. Federal Action Number, if known: 9. Award Amount, if known:

$

10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (if individual, last name, first name, M/): different from No. 10a)

(last name, first name, M/):

11 Informalion requested through this form is authorized by title 31 U.S.C. section • 1352. This disclosure of lobbying activities is a material representation of fact Signature:

upon which reliance was placed by the tier above when this transaction was made Print Name: or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be available for public inspection. Any person who fails to file the

Title: required disclosure shall be subject to a civil penalty of not less than $10.000 and not more than $100.000 for each such failure.

Telephone No.: Date:

Federal Use Only: I Authorized for Local Reproduction

Standard Form LLL (Rev. 7-97)

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Reporting Entity:

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DISCLOSURE OF LOBBYING ACTIVITIES CONTINUATION SHEET

Page 2 of

Approved by OMB

0348-0046

2

Authorized for Local Reproduction Standard Form - LLL-A

OPHS-1 Certifications

Project Title: 2011 Family Planning Services Announcement (Region 1 - New Hampshire, \

Project Period: 12/31/2009 to 12/30/2011

Application Organization Planned Parenthood League of Massachusetts

Authorized Certifying Official: Dianne Luby

Title: PresidenUCEO

D I DO NOT agree with the terms of the Signing Agreement

[8] I agree with the terms of the signing Agreement

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Applicant:

Application Number:

Project Title

Status:

Document Title:

of 155

Upload #1


FPH2011005026

2011 Family Planning Services Announcement (Region 1 - New


Massachusetts)

Awarded

PPLM List of Congressional Districts

Pl'OjectfProgl'am Congressional Districts - Full List

01 02 03 07

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Applicant:

Application Number:

Project Title

Status:

Document Title:

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Upload #2


FPH2011005026



M assach usetts)

Awarded

PPLM Budget Narrative

(b) (4)

(b) (4) (b) (4)

(b) (4)

(b) (4) (b) (4)

Budget Information See Budget summary, SF 424A.

1. Personnel $355,813

This covers [)f overall staffing costs associated with operating PPLM's Title X project sites. The

Title X allocation is calculated by taking of clinical staff expense Df key personnel expense, "------'

and of administrative staff expense. All amounts are based upon PPLM's budget for January-

December 2011.

Summary

Following is a staffing summary, including total to be funded with Title X dollars. Detail for each line

item appears below.

Staff type Budgeted Expense Title X allocation Clinicians $333,876 $150,243

Key Personnel $407,275 $130,884 Administrative Staff $223,345 $74,686

Total $964,496 $355813

Clinical Personnel

Includes Nurse Practitioners (NPs), Clinic Coordinators and Healthcare Assistants (HCAs) who

perform exams and tests, prescribe medication, offer birth control options counseling, take medical

histories, and oversee day-to-day operations of the clinics.

% of Budgeted FTEs Annual wages effort expense %of

Staff type effort Title X allocation

Nurse Practitioners (NPs) $151,994 $68,397

Clinic Coordinators $92,150 $41,467 Healthcare Assistants (HCAs) $89,732 $40,379 Total $333,876 $150,343

Key Personnel

Organizational leadership involved in the oversight and administration ofPPLM's Title X program.

We allocated a percentage of each individual's annual salary to the Title X program overall, and then

allocated a smaller percentage to Title X for funding assistance.

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(b) (4) (b) (4)

(b) (4) (b) (4)

Annual I %of Budget

% alloca::~.J Name Position Salary effort allocation I_ tn TJ tl X Title X allocation

Dianne Luby President/CEO $52,643 $13,160

Chad Ellis CFO $27,000 $13,500

Susan Wood VP, Clinical Operations $75,999 $30,399

Anne Dixon Medical Director $82,933 $20,733

Aaron Caine ChiefInfonnation Officer $22,956 $5,739

Jackie Mansfield- Regional Director (Central Marcoux MAl $38,125 $11,437

Health Services Director Karen Caponi (Central MA) $59,736 $17,920

Gretchen Quality Assurance Landwehr Manager $24,505 $9,189

Quality Assurance Elizabeth Poitras Manager $23,378 $8,767

Total I $407,275 $130,884

Administrative

Administrative staff in the areas of the Call Center, Finance, Outreach and Information Technology

departments who are needed to support PPLM's Title X program.

Annual %of Budget % allocated Name Position Salary effort allocation to Title X Title X allocation Call Center Ana Mioline Call Center Manager $19,175 $4,793

Patient Services $35,263 Representatives

7.5 FTEs (appointment scheduling) $22,039 Sarah Fuller Hotline Coordinator I $12,937 $3,234 Finance Christa Chandler Accounting_ Man'!Ker $27,670 $6,917 Amit Gupta Finance Coordinator j $9,880 $2,470 Amy Wei Purchasing Coordinator $9,751 $2,437

Trainin~ ,

Liz Cohen Training Manager $25,294 $6,323 Casey Dunton Training Manager , $17,830 $4,457

Outreach Central MA Outreach $33,173 $9,951

Christina Vogeley Coordinator Information Technolo~

Sarah Buzanowski IT Associate j $16,720 $6,688

TlMcAndrew IT Associate $5,858 $2,929

Executive Office , Jessica Saunders Executive Assistant $9,794 $2,448

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(b) (4)

(b) (4)

I Total $223,345 $74,686

2. Fringe benefits

3. Travel $6,700

This category covers 100% of the cost of travel for Title X - related trainings/conferences, including

regional/state conferences and national conferences. Staff is reimbursed for mileage at the

government-approved reimbursement rate, which as of January 1, 2010 was $0.50/mile.

No/Cost of Meeting Trips Location Staff Traveling Purpose of Travel Total Cost TBD VP, Clinical Regional Grantee Meeting

Operations Hotel: $300; RT Airfare: $500; Per Diem (for 1.5 days): $100; Other (e.g., shuttle, taxis, parking, etc.): $100 $1,000

TBD Mid-Level Clinician Title X Clinical Conference Hotel: $750; RT Airfare: $1,500; Per Diem (for 2.5 days): $150; Other (e.g., shuttle, taxis, parking, etc.): $100 $2,500

TBD VP, Clinical National Grantee Meeting Operations Hotel: $750; RT Airfare: Medical Director $2,000; Per Diem (for 2.5 CFO days) : $150; Other (e.g.,

shuttle, taxis, parking, etc.): $100 $3,000

TBD Quality Assurance Delegate Site Evaluation Managers Visits $200

Total $6,700

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4. Equipment $0

5. Supplies $212,755

Supplies include contraceptive methods, clinic disposables, medications, lab services and fees, lab

supplies, and office supplies. Examples of supplies include pregnancy tests, Pap test, blood tests and

STD tests. The amount charged to Title X represents 25% of the budgeted expense for Title X-funded

centers and was calculated based on PPLM's budget for January-December, 2011.

Bud2eted expense Title X allocation Contrac~tives $670,185 $167,546 Clinic disposables $32,976 $8,244 Medications $46,753 $11,688 Lab Services & Fees $77,705 $19,426 Lab SUPJ~lies $14,893 $3,723 Office & Program Supplies $8,510 $2,128 Total $851,022 $212,755

6. Contractual $45,000

Includes 100% of funds allocated to delegate/contractual agencies for family planning programs.

PPLM's Title X project includes granting $45,000 to Framingham Community Health Center to fund

costs associated with having a Family Planning Counselor on site.

Dele2ate/Contractuai A2ency Title X aUoca tion Framingham CRC $45,000 Total $45,000

7. Other $103,221

Includes additional costs of operating PPLM's Title X program. The amount charged to the Title X grant is 16% of the overall cost of these items, which are as follows:

Annual Budgeted Type of E~ense Amount Federal Non-Federal

Printing $1,017 $300 $717 Telephone $5,126 $2,000 $3,126 Rent $52,849 $16,000 $36,849 Depreciation $182,668 $12,000 $170,668 Repairs/Maintenance $65,910 $12,000 $53,910 Security $45,109 $12,000 $33,109 Utilities/Office Expense $30,198 $5,000 $25,198 Educational Materials /

Literature $675 $300 $375 Contracted Services $102,658 $11,821 $90,837 Translation Services $23,220 $8,000 $15,220

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Computer Services $28,081 $8,000 $20,081 Subscriptions / Publications $1,251 $300 $951 Dues and Fees (inc!. PPFA) $25,920 $9,000 $16,920

Postage, Shipping, Freight $4,902 $1,500 $3,402

Insurance & Malpractice $67,421 $5,000 $62,421 Total $637,005 $103,221 $533,784

Rent breakdown:

Includes rent expense for operating PPLM's Title X program sites. (Depreciation in lieu of rent expense for PPLM's Worcester site is factored into the "Other" category.) The amount charged to the Title X grant is 30% of the overall rent expense, which is as follows:

Annual budgeted Average Title X allocation PPLM Clinic exp_ense monthly rent (of annual rent) Worcester $0 $0 $0 Marlborough $22,849 $1,904 $6,000 Milford $12,000 $1,000 $5,000 Fitchburg $18,000 $1,500 $5,000

TOTAL $52,849 $4,404 $16,000

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Applicant:

Application Number:

Project Title

Status:

Document Title:

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Upload #3


FPH2011005026



Massachusetts)

Awarded

PPLM Program Narrative

TABLE OF CONTENTS

A. UPDATED CLINICAL SERVICES INFORMATION .......................................... 1

B. PROGRESS REPORT •................................................................................. 4

C. FAMILY PLANNING SERVICE DELIVERY PLAN ......................................... 12

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A. UPDATED CLINICAL SERVICES INFORMATION

In December 2009, Planned Parenthood League of Massachusetts (PPLM) became the new

provider of Title X family planning services for Central Massachusetts. In order to assure access

to the highest-quality family planning services in this high-need area, our plan consisted of three

parts: expand family planning services at our Worcester health center; open three new health

centers in Fitchburg, Marlborough, and Milford, MA; and partner with Framingham Community

Health Center to provide family planning services in that community.

PPLM has had a health center in Worcester since 1982. In November 2009 we completed

construction on our new, state-of-the-art health center, and we began seeing patients

immediately.

In December 2009 we began searching for ideal locations for our three new health centers. We

wanted to find locations that were not only adequately sized to meet our need for exam rooms,

patient counseling rooms, waiting area, and lab space; but also centrally located and easily

accessible within the communities. By March we had signed leases on three locations (see

Attachment A: Map of Title X Health Centers). We then had to go through the process of

completing renovations, permitting, and obtaining licensure from the Massachusetts Department

of Public Health. Cutler Construction, the same contractor that worked with PPLM on our new

Worcester health center, designed all three of our new health centers. (See Attachment B: Floor

Plans.) Cutler also completed the build-out for Milford; Division Seven built out Fitchburg and

Keystone Development built out Marlborough. We opened our Marlborough Health Center on

May 20th, our Milford Health Center on June 16th

, and our Fitchburg health center on August

24th, 2010. In August 2010, PPLM also became the first of89 Planned Parenthood affiliates

nationwide to implement the NextGen Electronic Health Records (ERR) system at all of our

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health center sites. The system has already helped us to monitor outcomes as part of our Title X

project.

When we first opened in Marlborough and Milford, we were staffed one day per week. We

opened for a second day at both locations in mid-July. In early August, we added a third day at

both health centers. We are now open for over 17 hours per week in Marlborough (Mon 9AM -

4:30 PM, Weds 2-7 PM, Thurs 2-7 PM) and over 20 hours per week in Milford (Tues 11AM-

7PM; Weds 2-7PM; Thurs 11-7PM). In Fitchburg, we are currently open 17 hours per week

(Tues lOAM - 7 PM; Fri 8AM - 4PM). Demand has been strong in all of our new health center

service areas. We expect to expand each of our new health centers to 20 hours per week by

October 2010, with significant evening hours available at each center. Our health center hours in

Worcester remain unchanged from our previous health center at 47 to 53 hours, every other

week, and continues to book at full capacity. We offer walk-in and same-day appointments at all

of our health centers, in addition to pre-scheduled appointments.

In early January 2010 we began our partnership with Framingham Community Health Center

(FCHC). We worked with the organization to help secure a family planning counselor. As part of

our partnership with FCHC as our delegate agency, we are helping FCHC to subsidize expenses

related to family planning services, including facilitating visits with the counselor, sending her to

clinical service training, and supporting the organization overall so that they can continue to

offer family planning services. (For more information about patient volume and hours at PPLM's

Title X health centers, see Exhibit A: Family Planning Service Site Information and Exhibit B:

Family Planning Site Services Provided.)

Finally, we've been working on building our partnerships within our new communities, so that

we have an extensive list not only of referral partners, but also community organizations that we

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can partner with for our outreach programs (see Attachment C: Community Partnerships for a

complete list). Our Central Massachusetts Outreach Coordinator (see Attachment D: Position

Descriptions and Biographical Sketches) will continue to build relationships with our partners in

2011 (see Family Planning Service Delivery Plan Goal 2 - EducatiOn/Outreach, page 15).

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B. PROGRESS REPORT

Goal: Provide family planning clinical services in Central Massachusetts to reduce unplanned pregnancy and STD/HIV infection.

Objective Outcome Data Progress Narrative

Ensure medical protocols are in Complete Susan Wood, PPLM's VP of Clinical Operations, worked with PPLM's compliance with state law and (reviewed Health Services Operations Team to review PPLM policies and update them Title X guidelines. annually) according to Title X guidelines prior to the opening of our new health

centers. Policies and procedures are reviewed annually (see Attachment E: Clinical Policy and Procedures Manual). I

Increase awareness of 2,233 total users During visits to PPLM's Title X health centers, Health Care Assistants contraceptive methods; (HCAs) and mid-level clinicians (nurse practitioners, certified nurse emergency contraception; midwives, physicians' assistants) provided information about contraceptive !

HIV ISTD prevention, testing methods, emergency contraception, HIV/STD prevention, testing and and treatment; cancer treatment, and cancer screening (including Pap tests, clinical breast exam, prevention screenings; and the and testicular exam); to 2,233 patients from January-June 2010. Each HPV vaccine. patient that comes into a PPLM has their first in-person point of contact in

our health center waiting rooms, where they find educational brochures addressing many of these topics in English, Spanish and Portuguese.

Each patient who visits a PPLM Title X health center for the first time fills out a general history form. When the patient meets with a mid-level clinician, the clinician reviews the patient's history, answers questions, and discusses contraception, emergency contraception, HIV ISTD prevention, testing, and treatment, cancer screening, and the HPV vaccine. As the HPV vaccine is not available at all Title X sites, if necessary patients are referred to a different site within PPLM's network. Clinicians are prompted to have this discussion through the patient's Electronic Health Record (EHR). This past spring, PPLM became the first of 89 Planned Parenthood affiliates nationwide to have the NextGen EHR system implemented at all of our locations. Periodically, PPLM's Quality Assurance Managers review EHR to ensure that clinicians are raising these issues with all Title X patients.

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Assist patients with their 654 total users At all ofPPLM's Title X health centers we offer male and female condoms, reproductive life plans by oral contraceptives, the Ortho-Evra contraceptive patch, Nuvaring, IUD, offering a broad range of Depo-Provera injection and emergency contraception. The breakdown of contraceptive methods and contraceptive use by our patients is as follows: emergency contraception to meet patient needs. Condoms: 89

Depo Provera: 209 IUD: 125 Nuva Ring: 21 Ortho Evra Patch: 4 Oral Contraceptives: 195 Abstinence: 11 Emergency Contraception: 24

PPLM utilizes a contraceptive visit model, a standard for Planned Parenthood affiliates nationwide. Patients coming to PPLM for a contraceptive visit are able to meet with a clinician and obtain contraception without a full gynecological exam. PPLM's Purchasing Associate reviews

I inventory at all Title X sites on a weekly basis to ensure that all contraceptive methods are available.

Improve patient outcomes by 302 total users PPLM offered HIV testing and referrals to 302 total patients at our Title X offering HIV testing and timely health centers. Patients who tested positive and were referred to one of referral of patients with positive PPLM's referral partners (see Attachment C) for treatment. PPLM also results for treatment. integrates HIV testing and risk-reduction information into routine visits.

PPLM's EHR reporting system helps ensure that HIV is offered to all Title X patients as a part of routine care; PPLM's Quality Assurance Managers periodically review charts to ensure that this is taking place. EHR also prompts clinicians to follow-up from HIV tests and refer patients in a timely manner.

Per CDC guidelines, encourage 1 , 13 8 total users Of the 2,233 total patients PPLM reached through Title X, more than 50% women under 25 to be tested for (1,138) were females under the age of25. Chlamydia testing is offered at all Chlamydia and ensure proper of our Title X health centers, both as a part of routine care and as standalone follow-up and treatment. visits. 731 patients received a Chlamydia test. PPLM's Quality Assurance

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Managers periodically review EHR charts to ensure that Chlamydia testing is offered to all female patients under 25. PPLM remains committed improving patients' lives by preventing STDs, in alliance with the State STD and CDC Infertility Prevention Project (IPP).

Improve patient outcomes by 689 total users PPLM provided cancer screenings to 689 Title X patients during January-offering cancer screenings (Pap June 2010. We offer Pap tests, clinical breast exams, and testicular exams at tests, clinical breast exams, all of our Title X health centers and all are included as part of a patient's testicular exams) at all clinics. routine exam. Patients who had abnormal exams were referred to our

partners for follow-up exams, or colposcopy or LEEP procedures. Patients who have had an abnormal Pap test are informed through at least one phone call and two written letters. PPLM's Quality Assurance Managers review all EHR records on a quarterly basis to ensure that follow-up is taking place.

Achieve patient volume goals of: Women: 1,993 We are pleased about our progress towards our patient volume goals, which Women: 3,935; Men: 285; 19 Men: 240 we have adjusted as we were unable to open our health centers until mid-years and under: 1,482; ::; 100% 19 years and 2010. We were able to achieve 53% of our overall patient goaL However, FPL: 855; 101-300% FPL: 285; under: 539 our main goal for Title X was to increase accessibility of family planning Medicaid: 685; Medicaid ::S100% FPL: services to those who are most in need, and on that metric - patients who managed care: 912; Latinos: 1,966 are at or under 100% of the federal poverty level- we far exceeded our 1,140; Blacks 570; Asians: 285. 101-250% FPL: patient goaL

144 Medicaid! For FY11 we have many public awareness initiatives planned in order to Medicaid drive traffic to all of our Title X centers. See Family Planning Service managed care: 741 Delivery Plan - Goal 2: Education/Outreach, page 15. Latinos: 385 Blacks: 161 Asians: 61

OPA Priorities Addressed Assuring the delivery of quality family planning and related preventive health services Expanding access to a broad range of acceptable and effective family planning methods and related preventive health services Providing preventive health care services in accordance with nationally recognized standards of care

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I Emphasizing the importance of coUnseling family planning clients . I

Goal: Provide community education and outreach in Central Massachusetts to educate the public about the importance of family planning; to publicize the availability of Title X services; and to reach vulnerable, hard-to-reach and at-risk populations (low-income, non-English speakers, adolescents and teens).

Objective Outcome Data Proeress Narrative Provide education about 215 patients PPLM has expanded our Facebook and MySpace pages; the PPLM abstinence, birth control, surveyed, over Advocacy Fund, our 501c4 organization, also began a Twitter feed in FYI0. emergency contraception, 100 community We ran radio ads on several popular local stations, and advertised on the HIV /STD prevention, cancer members reached Worcester Regional Transit Authority bus system when our new Worcester screenings, and HPV and through outreach health center opened in November. PPLM's Central MA Family Planning publicize the availability of Title events Outreach Coordinator and Grassroots Organizers also participated in tabling !

X family planning services in and outreach events at colleges and community health fairs in Central Central MA. Massachusetts, including the Plumley Village Health Fair in Worcester in

June 2010, where we anticipate that we reached at least 100 attendees.

In March and April, PPLM surveyed 215 patients at our Worcester Health Center to determine the best ways to reach patients via public awareness initiatives. Patients were asked about the radio, print, and online media outlets where they obtain the majority of their information. "Word of mouth" was the most popular answer when patients were asked how they heard about PPLM's services, followed by the Internet (including outlets such as Facebook, Yahoo, Google AdWords, and online earned media such as the Worcester Telegram and Gazette). The information gained from these patient surveys helped our Director of Public Awareness develop an outreach plan for 2011 (see Family Planning Service Delivery Plan - Goal 2: Education/Outreach, page 15).

Implement targeted outreach 31 new PPLM's Central MA Family Planning Outreach Coordinator and Grassroots activities to low-income community and Organizers reached out to 19 new community partners in Marlborough, individuals and families in coalition partners Framingham, Milford, Fitchburg, Worcester, and surrounding communities Central MA. in FY10 (see Attachment C). Each organization has become a referral

- .- ---'partner for PPLM's Title X health centers, and received a PPLM health

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services brochure, postcards, and magnets to distribute to community members. PPLM also currently sits on three regional coalitions - including Common Pathways, Worcester's Community Health Network Area (CHNA) - and we have been invited to join 12 additional coalitions, including the South and North Central MA CHNAs.

Ensure materials available in Complete PPLM's Information and Education Committee (1&E) was formed and had clinics are medically accurate, their annual meeting in May 2010. I&E consists offive representatives from culturally relevant, age- Worcester, Milford, and Fitchburg (see Attachment F: Information and appropriate and multi-lingual, Education Committee for bios). At their meeting, members reviewed and as necessary. approved the content, layout, confidentiality, and accessibility of all PPLM

materials. The committee also discussed the best methods and locations to distribute materials in Worcester, Fitchburg, Milford, Marlborough and the surrounding communities.

OPA Priorities Addressed Assuring the delivery of quality family planning and relate preventive health services Providing preventive health care services in accordance with nationally recognized standards of care Encouraging participation of families, parents, and/or legal guardians Addressing the comprehensive family planning and other health needs of individuals, families, and communities through outreach to vulnerable populations

-- - - - - -

Goal: Ensure the operational quality of PPLM's clinical and educational programs through administrative procedures and oversight.

Objective Outcome Data Progress Narrative Expand PPLM in Central Complete PPLM identified locations, completed renovations, purchased equipment Massachusetts by opening clinics and inventory, hired staff, and began providing services at our Marlborough in Marlborough, Milford and health center in May 2010, at Milford in June 2010, and in Fitchburg in Fitchburg and increasing hours August 2010. Currently, we are providing comprehensive family planning of operation. services in Marlborough and Fitchburg for 17 hours per week and in

Milford for 20 hours/week, with evening hours available in all three locations. We expect to start offering services at all three locations 20 hours

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per week b~ October 2010. (See Exhibit A). Ensure compliance with aU Title Complete PPLM's VP of Clinical Operations, Quality Assurance Managers and X regulations at PPLM Central (reviewed Regional Director used a review tool to ensure that our Title X health MA locations. annually) centers were in compliance with federal Title X clinical, administrative,

educational and financial regulations prior to their opening in the spring of 2010. Health centers will be reviewed for compliance on an annual basis.

Ensure compliance with all Title Complete PPLM's VP of Clinical Operations, Quality Assurance Managers, and X regulations by Framingham (reviewed Regional Director works with the Framingham Community Health Center Community Health Center. quarterly) (FCHC) to review Title X clinical, administrative, educational and financial

regulations. Our VP visits FCHC to document the site's compliance with Title X clinical regulations.

Ensure accessibility of services Ongoing Currently, more than 50% ofPPLM's centralized call center staff is to non-English speakers at all bilingual (English/Spanish). The majority of our forms and educational health centers. materials - including health center brochures, contact information,

educational pamphlets about topics such as birth control, STDs, and HIV / AIDS, and all intake forms - are available in English, Spanish, and Portuguese. Portions ofPPLM's website are also available in Spanish, and the site interfaces with Planned Parenthood Federation of America (PPFA's) website to provide additional information. For our patients who have limited English proficiency and who need an interpreter, we have relationships with several medical interpreters around the Central MA area. We also have a language line that staff can contact to help translate in real-time to facilitate health care needs for our Portuguese-speaking and other bilingual patients.

Staff at each of our Title X health centers represent a diverse array of language and cultures, and our ongoing recruitment for open positions is focused on continuing to hire staff that represent the diversity of the surrounding communities.

Provide accessible services to the Complete PPLM is currently offering 15 hours of clinical services per week at our greatest number of users at all Marlborough and Milford health centers, and 17 hours per week at our sites. Fitchburg health center; we expect to offer 20 hours per week of services at

~ll three of these centers by October. At our Worcester health center we

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offer family planning services at least 47 hours per week (53 hours every other week). At FCHC, family planning services are offered 43 hours per week. At all four of our Title X centers we have evening hours and accept walk-in and same-day appointments; at our Worcester health center we offer Saturday hours every other week. All ofPPLM's Title X health centers and our delegate agency are accessible to people with disabilities and have handicapped parking and curb cuts, ramps, and/or step-free exits, as well as accessible exam rooms and washrooms.

Share population-based data Ongoing PPLM's VP of Clinical Operations, Quality Assurance Managers, and with public and community Regional Director utilize Electronic Health Records (EHR) to collect groups to better understand population data about Title X patients' age, income, ethnicity, geography, family planning needs in Central referral source, new and returning patients, types of services rendered, and MA. other factors. We are currently in the process of synthesizing this

anonymous data to share with Title X using the Family Planning Annual Report structure. In 20 10 PPLM also began a partnership with the Massachusetts Department of Public Health, to provide family planning services in Central Massachusetts, so we will be working to share outcomes at the state level as well.

OPA Priorities Addressed Assuring the delivery of quality family planning and related preventive health services Expanding access to a broad range of acceptable and effective family planning methods and related preventive health services Providing preventive health services in accordance with nationally recognized standards of care Assuring compliance with State laws requiring notification or the reporting. of child abuse, molestation, sexual abuse, rape, or incest Addressing the comprehensive family planning and other health needs of individuals, families, and communities through outreach to vulnerable populations

Goal: Continuous, rigorous financial management and control of the Title X project and related PPLM programs and services.

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Objective Outcome Data Progress Narrative I

Ensure access to family planning Complete PPLM's utilizes a sliding fee schedule at all of our Title X health centers. services regardless of income by (reviewed All patients who are aged 19 and under or are living under 151 % of the offering discounted and free annually) Federal Poverty Level (FPL) are eligible to receive services using the family planning services in sliding scale. Patients who are at or below 100% of the FPL slide to 0 for all Central MA clinics. services. PPLM's VP of Clinical Operations, Quality Assurance Managers,

and Regional Director perform a quarterly audit ofPPLM's billing files to ensure that no one is turned away for service due to inability to pay. PPLM's CFO and VP of Clinical Operations worked to update the sliding fee scale in early FY11, and will continue to do so on an annual basis. (See Attachment G: Schedule of Charges and Sliding Fee Scale).

Make efficient use of public and Ongoing PPLM's overall collection rate for individual payers at our Title X centers organizational resources by in FYI0 was 94.4%. While we had some challenges collecting from three ensuring collection from 3rd different private insurers, we have mostly resolved these challenges by party payers following up on outstanding claims and working with the carriers to

identify and correct issues. Make efficient use of public Will be complete PPLM's CFO undertakes a monthly review of our Title X allowable resources through management as of January 2011 expenditures against the amount we had originally budgeted, documenting of Title X allowable expenses (reviewed variances and corrective action to stay within the budget. We expect to

annually) submit a full financial report of our 2010 expenditures to Title X by January 2011. A final 2010 budget will be submitted by November 1, 2010.

Ensure compliance with Title X Complete During visits to FCHC, PPLM's VP for Clinical Operations documents that financial management and (reviewed site's compliance with Title X financial management and control control regulations by quarterly) regulations. Framingham Community Health Center (delegate agency) Ensure compliance with Title X 2011 As PPLM has not been a Title X site for a full year, we currently do not regulations regarding financial qualify for a federal audit. Our CFO and finance staff are prepared to audits complete federal audits necessary beginning in 2011. Ensure appropriate Complete PPLM's CFO performs an annual negotiation of our reimbursement rates reimbursement rates from 3rd (reviewed with third party payers, including private insurance companies, Medicaid, party payers to make efficient annually) MassHealth and other subsidized insurance plans. use of public and organizational

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resources Ensure timely reporting of data Will be complete PPLM's VP for Clinical Operations is responsible for submitting our to Title X (Family Planning as of February 15, patient data for the Family Planning Annual Report on a monthly basis. We Annual Report and Region 1 2011 expect that our submission of data through September 30 will be complete .reporting) by October 10,2010, and that our final patient data for 2010 will be

submitted by February 15, 2011. She has also worked with our Quality Assurance Managers to ensure that PPLM's monthly dashboard indicators, EHR, and other reporting tools are mapped to Title X data reporting requirements and created a reporting tickler system.

OPA Priority Addressed Assuring the delivery of quality family planning and related preventive health services Expanding access to a broad range of acceptable and effective family planning methods and related preventive services Providing preventive health care services in accordance with nationally recognized standards of care Assuring compliance with State laws requiring notification or the reporting of child abuse, sexual abuse, rape or incest Addressing the comprehensive family planning and other health needs of individuals, families, and communities through outreach to hard-to-reach and/or vulnerable populations

C. FAMILY PLANNING SERVICE DELIVERY PLAN

T fGoal/Ob· Clinical NEED: To increase access to comprehensive family planning services - including a choice of contraceptive methods - in order I

to prevent unintended pregnancy (which may lead to school drop-out and poverty) and disease (which may cause infertility, fetal and perinatal health problems, cancer, serious illness, and death) among low-income women, diverse populations, adolescents, and teens who are disproportionately affected in Central Massachusetts. Goal 1: Provide family planning clinical services in Central MA to reduce unplanned pregnancy and STDIHIV infection. Objective 1.1: Ensure medical protocols are in compliance with state law and Title X guidelines. Objective 1.2: Increase awareness of contraceptive methods; emergency contraception; HIV/STD prevention, testing and treatment; and cancer prevention screenings. Ob.iective 1.3: Assist patients with their reproductive life plans by offering a broad range of contraceptive methods and

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emergenc], contraception to meet patient needs. Objective 1.4: Improve patient outcomes by offering HIV testing and timely referral of patients with positive results for treatment. Objective 1.5: Per CDC guidelines, encourage women under 25 to be tested for Chlamydia and ensure proper follow-up and treatment. Objective 1.6: Improve patient outcomes by offering cancer screenings (Pap tests, clinical breast exams, testicular exams) at all clinics. Objective 1:7: Achieve patient volume goals of Women: 10,150; Men: 1,255; 19 years and under: 2,965; ::;100% FPL: 1,710; 101-250% FPL: 570; Medicaid: 1,369; Medicaid mana2ed care: 1,825; Latinos: 2,281; Blacks: 1,141; Asians: 570. TIME LINE ACTIVITIES/ACTION STEPS RESPONSIBILITY EVALUATION Bi-weekly Monitor PPLM's compliance to state laws and VP, Clinical Bi-weekly Health Services Operations

Title X guidelines by reviewing evidence-based Operations Team; reviews protocols and updates protocols against state and federal regulations as necessary

Ongoing 1) During clinic visits, provide information about Regional Director, 1) Periodic chart review as part of contraceptive methods; emergency contraception; Quality Assurance Quality Assurance program to monitor HIV /STD prevention, testing and treatment; and Managers content of clinician/patient discussion cancer screening (Pap test, clinical breast exam, 2) Ensure ongoing capability of EHR testicular exam) 2) Utilize Electronic Bealth to prompt clinicians Records to prompt clinicians to provide this information, especially with patients of a certain age and with certain risk factors

Ongoing Offer male and female condoms, pill, patch, ring, Regional Director, Periodically review contraceptive IUD, injection and emergency contraception at all Quality Assurance inventory at all health centers health centers Managers

Ongoing 1) Offer HIV testing (including rapid HIV) to Health Services 1) Utilize reporting system in EHR patients within routine care visits and as Director and triage systems to ensure HIV standalone visits 2) Ensure consistent and timely testing is offered as part of routine follow-up with patients testing positive to refer care 2) Utilize reporting system in for appropriate treatment and support EHR and triage systems to ensure

timely follow-up and referral Ongoing 1) Offer Chlamydia testing to patients within Health Services 1) Periodic chart review to ensure

routine care and as standalone visits 2) Continue Director Chlamydia testing is part of routine

'----- -- -participation in CDC Infertility Prevention

-- - -- ---_ care for womel!_under 25 2)_

-

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Ongoing

JanuaryDecember 2011

Project (IPP)

1) Offer cancer screenings to patients as part of routine care 2) Identify patients with abnormal screenings needing follow-up 3) Follow protocols for abnormal screening follow-up 4) Provide education about importance of colposcopy 5) Provide colposcopy services to improve access and compliance with follow-up care

Align public awareness and outreach activities to reach targeted populations and achieve patient volume goals specified in Objective 1.7 (page 13)

Health Services Director

Director of Public Awareness

Documentation of existing relationship with IPP 1) Utilize reporting in EHR and triage systems to ensure all patients receive Pap tests and cancer screenings and abnormal screenings are identified 2-3) Quarterly audit of abnormal screenings to ensure compliance with a) reminder phone calls and b) reminder letters sent to all patients needing follow-up 4-5) Quarterly audit to track patients needing and receiving colposcopy to measure effectiveness of our education and follow-up p~ograms Review public awareness and outreach plans to ensure target populations will be reached (see also Education and Outreach, page 15)

OP A Priorities: Assuring the delivery of quality family planning and related preventive health services Expanding access to a broad range of acceptable and effective family planning methods Providing preventive health care services in accordance with nationally recognized standards of care Emphasi~ng the importance of counseling family pla!!11ing clients on establishing a r~roductive life plan

T f GoallObiective: Ed dO h - '.-- - - - - - --- _.- - - -- . - - - - -- - -- -- - -- ---- - - -- -- - -- ---

NEED: To increase access to family planning information and services to individuals and families in Central Massachusetts through targeted outreach activities to certain demographic groups. GOAL 2: To provide community education and outreach in Central Massachusetts to educate the public about the importance of family planning; to publici~e the availability of Title X services; and to reach vulnerable, hard-to-reach and at-risk popUlations (low-income, non-English speakers, adolescents and teens). Objective 2.1: Provide education about abstinence, birth control, emergency contraception, HIV/STD prevention, cancer screenings, and HPV and publicize the availability of Title X family~lannin~ services in Central MA. Ob.jective 2.2: Implement targeted outreach activities to low-income individuals and families in Central MA.

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Objective 2.3: Ensure materials available in health centers are medically accurate, culturally relevant, age-appropriate and multi-lin2ual, as necessary. TIMELINE ACTIVITIES/ACTION STEPS RESPONSIBILITY EVALUATION Ongoing Reach community through traditional marketing Director of Public Ask how patients heard of services

and social media strategies, including: Awareness and utilize tracking system to capture 1) Radio ads 2) Bus ads (Worcester Regional this information Transportation Authority) 3) Online media including Facebook, MySpace, Twitter, Google, and WickedLocal (Marlborough and Milford) 4) Print media including Pulse Magazine, Vocero, Siglo 21, and Bate Papo 5) TV such as Bate Papo's local cable show 6) Table tents in the Solomon Pond and Greendale Mall food courts 7) Participation in outreach events such as college and community health fairs (including the Gaston Institute's statewide policy fair, the Investing in Girls fair at YWCA, Heywood Hospital's community health fair, Fitchburg State's college fair, the Blackstone Valley Health Expo, and the Centro Las Americas Latino festival) 8) Community referral partnerships

Ongoing Continue partnerships with nearly 90 Central MA Director of Public Track patients that came to clinics as a shelters, social services agencies, coalitions, and Awareness result of partnership activities, and others to inform low-income individuals about utilize tracking system to capture this Title X services available, including distributing information marketing materials aimed at low literacy individuals and continuing referral partnerships

January 2011 Working with the Information and Education Director of Public Document Committee meetings. Review Committee, ensure that educational Awareness Monitor need and availability of materials are reviewed and updated on a yearly materials basis

OPA Priorities: Assuring the delivery of quality family planning and relate preventive health services Providing preventive health care services in accordance with nationally recognized standards of care

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Encouraging participation of families, parents, and/or legal guardians in the decision of minors to seek family planning services Addressing the comprehensive family planning and other health needs of individuals, families, and communities through outreach to vulnerable populations

Tvoe of Goal/Objective: Administraf - .-- -- - ---- - -- ---_. -- -----------------_.-

NEED: To comply with all Title X requirements and other professional standards that help to ensure high quality patient care and prudently managed resources. Goal 3: To ensure the operational quality of PPLM's clinical and educational programs through administrative procedures and oversight. Ob.iective 3.1: Ensure compliance with all Title X re2ulations at PPLM Central MA locations. Objective 3.2: Ensure compliance with all Title X regulations by Framingham Community Health center (delegate agency). Objective 3.3: Ensure accessibility of services to non-English speakers at all clinics. Ob.iective 3.4: Provide accessible services to the 2reatest number of users at all sites. Objective 3.5: Share population-based data with public and community groups to better understand family planning needs in Central MA. TIMELINE ACTIVITIES/ACTION STEPS RESPONSIBILITY EVALUATION January- Review Title X clinical, administrative, Quality Assurance Documentation of compliance with December 2011 educational and financial regulations annually Managers Title X clinical regulations January- Review Title X clinical, administrative, Quality Assurance Documentation of compliance with December 2011 educational and financial regulations during Managers Title X clinical regulations

quarterly site visits to delegate agency Ongoing 1) Maintain 50% bilingual (English/Spanish) Health Services I) Quarterly review of call center

staff in centralized call center for appointment Director staffing 2) Ongoing inventory of scheduling 2) Continue to offer forms and forms and educational materials 3) educational materials in English, Spanish and Quarterly review of patient Portuguese 3) Add forms and education demographics and language needs 4) materials in additional languages based on Quarterly review of staffing patient demographics 4) Maintain a representative number of staff at each site to reflect the diversity of our client base

January- 1) Offer 20 hours of clinical services per week, VP, Clinical 1) Monthly review of hours of December 2011 evening and/or weekend hours, and walk-in Operations operation and patient usage 2) Annual

services 2) Ensure clinics are handicapped review of handicapped-accessible

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accessible features of clinics January- I) Collect population-based data on age, VP, Clinical 1) Utilize ERR to report relevant December 2011 income, ethnicity, geography, referral source, Operations family planning data, analysis, and

new and returning patients, types of services trends 2) Share data through Family rendered, and other factors 2) Synthesize and Planning Annual Report structure and share anonymized data with Title X, MA DPH, document other uses of data/analysis and other community stakeholders 3) Document outcomes from

collaboration OPA Priorities: Assuring the delivery of quality family planning and related preventive health services Expanding access to a broad range of acceptable and effective family planning methods and related preventive health services Providing preventive health services in accordance with nationally recognized standards of care Assuring compliance with State laws requiring notification or the reporting of child abuse, molestation, sexual abuse, rape, or incest Addressing the comprehensive family planning and other health needs of individuals, families, and communities through outreach to vulnerable populations

T f Goal/Objective: E· . I

NEED: To ensure financial management and control in order to utilize public and organizational resources effectively and efficiently, to provide high-quality programs to populations in need of family planning services. Goal 4: Continuous, rigorous financial management and control of the Title X project and related PPLM programs and services. Objective 4.1: Ensure access to family planning services regardless of income by offering discounted and free family planning services in Central MA health centers. Ob.iective 4.2: Make efficient use of public and organizational resources by ensuring collection from 3rd party payers. Objective 4.3: Make efficient use of public resources through management of Title X allowable expenses. Objective 4.4: Ensure compliance with Title X financial management and control regulations by Framingham Community Health Center (delegate agency). Objective 4.5: Ensure compliance with Title X regUlations regarding financial audits. Objective 4.6: Ensure appropriate reimbursement rates from 3rd party payers to make efficient use of public and organizational resources. Ob.iective 4.7: Ensure timely reporting of data to Title X (Family Planning Annual Report and Region 1 reporting) TIMELINE ACTIVITIES/ACTION STEPS RESPONSIBILITY EVALUATION Ongoing 1) Annual review, development and CFO 1) Documentation of annual

implementation of sliding fee schedule 2) review 2) Quarterly audit of

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Ensure patients are not turned away for inability client billing files to ensure no to pay one is turned away for selVice

due to inability to~ay Ongoing 1) Collect data on collection rate for individual CFO 1) Utilize PPLM's monthly

payers (overall goal is 95%) 2) Identify problem dashboard indicators to track areas and corrective action to ensure collections collections 2) Document

corrective actions Ongoing 1) Monitor Title X allowable expenditures CFO 1) Monthly review of

versus budgeted amount 2) Make course expenditures vs. budgeted corrections as necessary amount 2) Document variances

and corrective action to stay within budget

Ongoing Review Title X financial management and CFO Documentation of compliance control regulations during quarterly site visits to with Title X financial delegate agency management and control

regulations ,

1) Ongoing 1) Undertake annual financial audit 2) Review CFO 1) Documentation of annual 2) January 2011 procedure for responding to audits financial audit 2) I

Documentation of procedure for responding to audits

January- Perform annual negotiation of reimbursement CFO Documentation of negotiated December 2011 . h 3rd rates with 3rd party payers rates WIt party payers January 2011 1) Ensure ERR, dashboard indicators and other CFO 1) Review and document

PPLM reporting tools are mapped to Title X alignment between ERR and data reporting requirements 2) Create a dashboard indicator fields to reporting tickler system Title X data needs 2) Document

implementation of reporting tickler system

OPA Priorities: Assuring the delivery of quality family planning and related preventive health selVices Expanding access to a broad range of acceptable and effective family planning methods and related preventive selVices Providing preventive health care selVices in accordance with nationally recognized standards of care Assuring compliance with State laws requiring notification or the reporting of child abuse, sexual abuse, rape or incest Addressing the comprehensive family planning and other health needs of individuals, families, and communities through outreach to

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FPH2011005026



Massachusetts)

Awarded

PPLM Exhibit A - Family Planning Program Service Site Information

,

Family Planning Program Service Site Information

SUB-RECIPIENT LOCATION SERVICE AREA OFFICE HOURS FAMILY PLANNING AGENCY and *1 CLINIC HOURS

SERVICE SITES *2

Worcester Health 470 Pleasant Street, Greater Worcester Office hours same as Monday, 8AM-5PM Center (PPLM) Worcester, MA clinic hours. Call Tuesday, 8:30AM-4PM

Center: Monday - Wednesday, 8:30AM-Friday 8AM - 6PM, 7PM Saturday 8AM - 2PM. Thursday, 7:30AM-Sexual Health 7:30PM Counseling & Referral Friday, 8AM-4PM Hotline hours: Every other Saturday, Monday, Tuesday, and 8AM-2PM Thursday 9AM-8PM, Wednesday, Friday 9AM-6PM

Marlborough Health 91 Main Street, Suite Greater Marlborough Same as above. Monday 9AM-4:30 PM Center (PPLM) 103, Marlborough, MA Wednesday 2PM-7PM

Thursday 2PM-7PM Milford Health Center 208 Main Street, Suite Greater Milford Same as above. Tuesday 11AM-7PM (PPLM) 101, Milford, MA Wednesday 2PM-7PM

Thursday 11AM-7PM Fitchburg Heath Center 391 Main Street, Greater Fitchburg Same as above. Tuesday 10AM-7PM (PPLM) Fitchburg, MA Friday 8AM-4PM Framingham 19 Concord Street Greater Framingham 24 hour answering M-W,F 8AM-5PM Community Health 72 Union Avenue service. Thurs 8AM-3PM Center Framingham, MA (DELEGATE)

, -- -- -- - - - - - - ~- - ~-

*1 - Times of day/days of month that the office is open to clients, such as to receive phone calls, make appointments, etc. *2 - Times of day/days of month that family planning clinical/medical services are provided.

NUMBER OF USERS FYI0/ NUMBER

PROJECTED FYll *3

l,823/5,405

33/1,000

14/1,000

2,500 (New site) 363/1,500

*3 - Number of users as reported on the last FP ARlprojected on the next FP AR at the sub-recipient/delegate agency level.

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Upload #5


FPH2011005026



Massachusetts)

Awarded

PPLM Exhibit B - Family Planning Site Services Provided

Family Planning Site Services Provided

SERVICES PROVIDED within the Title X Pro.iect Informed Method History Physical Lab Pap Client Pregnancy STD STD Consent Specific Assessment Testing Testing Education! Diagnosis/ Testing Treatment

Consent Counseling Counseling Worcester I 1 1 1 1 1 1 1 1 1 Marlborough 1 1 1 1 1 1 1 1 1 1 Milford 1 1 1 1 1 1 1 1 I 1 Fitchburg 1 1 1 1 1 1 1 1 1 1 Framingham 1

--1 1 1 1 1 1 1 1 1

SERVICES PROVIDED within the Title X Project Male HN Identification Levell Minor Health Special Emergency Services Services of Estrogen- Infertility GYN Promotion! GYN Contraception

Exposed Services Problems Disease Procedures Offspring Prevention

Worcester 1 1 1 1 1 1 4 1 Marlborough 1 1 1 1 1 1 4 1 Milford 1 1 1 1 1 1 4 1 Fitchburg 1 1 1 1 1 1 4 1 Framingham 1 1 1 1 1 1 4 1

-

Legend 1 = Provided on-site at all delegate sites T 3 = Referral outside delegate system, but paid for by Title X 2 = Provided within delegate system, but not at all sites I 4 = Not Provided

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SERVICES PROVIDED within the Title X Project Female IUD/IUS Honnonal 3 Month Oral Honnonall Vaginal Cervical Contraceptive Sterilization Implant Honnonal Contracepti ves Contraceptive Ring Cap/ Sponge

Injection Patch Diaphragm Worcester 4 1 1 1 1 1 1 I 1 Marlborough 4 1 1 1 1 1 1 1 1 Milford 4 1 1 1 1 1 1 1 1 Fitchburg 4 1 I 1 1 I I 1 I Framingham 4 I 1 1 1 1 1 1 1

~-- -

Female Spennicidal Fertility Abstinence Vasectomy Male Other Methods Condom Methods or Awareness Education Condom (HPV vaccine)

Products Method (FAM)

Worcester 1 1 1 1 4 1 4 Marlborough 1 1 1 1 4 1 4 Milford 1 1 I 1 4 I 4 Fitchburg 1 1 1 1 4 1 4 Framingham 1 1 I 1 4 1 4

1 = Provided on-site at all dele ate sites 3 = Referral outside dele 2 = Provided within delegate system, but not at all sites 4 = Not Provided

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PPLM Attachment A - Map of Title X Health Centers

, , , , ,

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Fitchburg Health Center

Map of Title X Health Centers

391 Main Street, Fitchburg, MA 01420

Marlborough Health Center 91 Main Street, Suite 103, Marlborough, MA 01752

Worcester Health Center 470 Pleasant Street, Worcester, MA 01609

Framingham Community Health Center (delegate agency) 19 Concord Street, Framingham, MA 01702

Milford Health Center 208 Main Street, Suite 101, Milford, MA 01757

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PPLM Attachment B - Floor Plans

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RECEPTION/WAITI NG [ill]

ARE".::!61 SF

OFFICE ~

AREA::1l9 SF

CORRIDOR Oill

ARE.~7';:.sF

Floor Plans

,t,

Milford Health Center

RECEPTIOflllWAITING [§]

.~>':212SF !-

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Fitchburg Health Center

VE8-TlBUL5

~,

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PPLM Attachment C - Community Partnerships

* indicates new partner in 2010 Organization Name AIDS Project Worcester Assabet Valley Area Family Network ATF - Westborough Bancroft School Boys and Girls Clubs of Marlborough Centro Las Americas* Children Across America *

Community Partnerships

Children's Aid and Family Services - Seven Hills Foundation* Christa McAuliffe Regional Charter Public School Cleghorn Neighborhood Center* Community Health Network of North Central MA (CRNA-9)* Common Pathways (CRNA-8) Community Partners for Health (CHNA-6)* Coordinated Community Response Network (CCRN)* DARE Family Services David Prouty High School Department of Transitional Authority* Dynamy First Unitarian Universalist Church of Milford* First Unitarian Universalist Church of Worcester Fitchburg Community Connections Coalition (FCCC)* Framingham Boys and Girls Club FraminghamlWaltham WIC Program* Framingham State University Franklin Community Health Council Franklin Public Schools Gardner Area Interagency Team* Ginny's Thrift Shop and Food Pantry* Girls Inc. Glenhaven Academy Grafton Girls Grafton High School Great Brook Valley Health Center Great Brook Valley Regional Teen Pregnancy Prevention Group* Healthy Families FraminghamlMilford* Hudson High School Investing in Girls Alliance Juvenile Advocacy Group/Community Impact* KEY Outreach and Tracking Key-Norton St. Key-Oakes D Lincoln Square Girls Lutheran Social Services - Teen Parent Apt. program Marlborough Community Services, Inc. * Marlborough Department of Human Services* Marlborough Human Services Coalition* Marlborough Resource Center (South Middlesex Opportunity Council) * Milford Public Library*

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Community Worcester

Marlborough Westborough

Worcester Marlborough

Worcester Milford

Fitchburg Framingham

Fitchburg Fitchburg

Worcester Milford

Worcester Worcester

Spencer Milford

Worcester Milford

Worcester Fitchburg

Framingham Marlborough Framingham

Franklin Franklin Gardner

Leominster Worcester

Marlborough Grafton Grafton

Worcester Worcester

Milford Hudson

Worcester Milford

Worcester Worcester Worcester Worcester Worcester

Marlborough Marlborough Marlborough

Marlborough Milford

Milford Regional Medical Center* Milford Regional Teen Pregnancy Prevention Group* Milford Youth Center* Mothers & More National Council of Jewish Women North Central Charter Essential School North Central WIC Program* Nichols College Pelletier Center Perkins School Pregnant & Parenting Teen Program of Southern Worcester County Rape Crisis Center Rehabilitated Resources, Inc. School Aged Mothers Program (part of Worcester Public Schools) Service Coordination Collaborative (SCC) for South Central MA * Shirley Public Schools Shrewsbury High School Shriver Jobs Corps* Sigourney House Social Services and Multicultural Services at Heywood Hospital * South Central WIC* South Worcester Neighborhood Center Southbridge CPM Spanish American Center* Spectrum Youth Academy Spectrum-Worcester Day Reporting Center St. Mark's High School Temple Emanuel The Bridge of Central Mass The Salter School Training Resources of America United Way Women's Initiative Voice with Choices Westborough Reception (DYS program) Westborough Public Schools Worcester Academy Worcester Mothers Group Worcester Poly Tech Parent Exchange Worcester Public Schools Worcester Secure Treatment Facility Worcester State College YOU, Inc. - Family Resources Services YOU, Inc. - Foster Parent Program YOU, Inc. - GEDlEducation for Employment Program* YOU, Inc. - Oxford House YOU, Inc. - Teen Parent Apt. Program YOU, Inc. - YMD (Youth Making a Difference) YWCA - Young Parents Program YWCA of Worcester YWCA-STPC Program

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Milford Milford Milford

Northborough Leominster

Fitchburg Fitchburg

Dudley Westborough

Lancaster Oxford

Worcester Sturbridge Worcester Worcester

Shirley Shrewsbury

Devens·

Worcester Gardner Milford

Worcester Southbridge Leominster

North Grafton Worcester

Southborough Worcester Worcester Worcester Worcester Worcester

Oxford Westborough Westborough

Worcester Worcester Worcester Worcester Worcester Worcester Worcester Worcester

Milford Oxford

Worcester Worcester Worcester Worcester Worcester

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PPLM Attachment D - Position Descriptions and Biographical Sketches

Position Descriptions and Biographical Sketches

Dianne Luby, President/CEO

Dianne Luby is the President/CEO of the Planned Parenthood League of Massachusetts. She has held this position since 1999. In her role, Dianne administers the programs of PPLM by managing the professional staff in carrying out the policies of the Board of Directors. She is responsible for overseeing PPLM's Title X program. Dianne is also very closely involved with PPFA's efforts at a national level. Prior to joining PPLM, Ms. Luby served as the Director of Public Health for the State of New Hampshire. She spent 10 years in senior management positions in managed care firms in California, Pennsylvania and Tennessee. She was the founding Executive Director of the Manet Community Health Center in Quincy, MA. In August 2009, Dianne received a Champions in Health Care award from the Boston Business Journal, for

, her community outreach work.

Susan Wood, Vice President, Clinical Operations

Susan joined PPLM in March 2010. Susan has over 10 years of health care management experience all focused within large integrated healthcare systems and group practice management. Prior to joining PPLM, she served as Administrative Director of Clinical Services for Lahey Clinic and prior to moving to New England, served as Practice Manager for two surgical departments at Henry Ford Health System based in Detroit, Michigan. Susan received her Master in Health Care Administration from Washington University in St. Louis School of Medicine and has a Bachelor of Science degree in Public Policy from Michigan State University.

Chad Ellis, MBA, Chief Financial Officer

Chad joined PPLM in May 2010, having worked with PPLM as a volunteer consultant. Chad is responsible for the oversight ofPPLM's Title X program. Prior to joining PPLM, Chad ran the Product Marketing position for a business unit of Siemens Mobile and founded and ran a small game publishing company. He received his MBA from Harvard Business School with High Distinction where he was designated a Baker Scholar and awarded the Charles M. Williams research fellowship in Finance. Prior to business school, Chad was an international equity analyst with HSBC Securities.

Anne Dixon, M.D., Medical Director

Dr. Dixon joined Planned Parenthood League of Massachusetts as the Medical Director in August of2008. As Medical Director, Dr. Dixon provides leadership, oversight and direction for PPLM's medical services. Dr. Dixon maintains clinical standards as established by the PPFA National Medical Committee through oversight of the Quality Assurance Program. Dr. Dixon will be providing medical oversight for PPLM's Title X program. Dr. Dixon received her MD degree from the University of Connecticut Medical School and completed residency training in Obstetrics and Gynecology at the University of Colorado Health Sciences Center in Denver, Colorado. Prior to joining PPLM, she was in a general OB/GYN practice with Harvard Vanguard Medical Associates in Medford, Massachusetts.

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Jackie Mansfield-Marcoux, Regional Director

As Regional Director, Jackie is the senior on-site clinical services manager at PPLM's Worcester Health Center. She supervises Clinic Coordinators handling day-to-day logistical operations at the new Marlborough, Milford, and Fitchburg health centers. Jackie joined Planned Parenthood in July, 2001. She has held multiple positions at PPLM including Data Project Coordinator and Worcester Health Center Manager. Jackie holds a BA in Studio Art and French Language and Literature from Smith College.

Karen Y. Caponi WHNP, BC, Health Services Director

Karen Caponi, Women's Health Nurse Practitioner, joined Planned Parenthood in March, 1986. As Health Services Director, Karen is the senior on-site medical services manager supervising Nurse Practitioners at PPLM's Worcester Health Center. She supervises Nurse Practitioners at the new Marlborough, Milford, and Fitchburg health centers. She works with the Medical Director in developing and implementing clinical protocols. Karen also provides patient care in all the medical services programs. Prior to working for PPLM, Karen worked as a Manager and Nurse Practitioner for a Title X program in North Central Massachusetts for 4 years.

Gretchen Landwehr, CNM, Quality Assurance Manager

Gretchen is responsible for all quality assurance issues from the perspective of the electronic medical records system, as part ofPPLM's Title X project. She has worked as a clinician in the GYN clinic at PPLM since 2008. Before coming to PPLM, she worked as a nurse-midwife at several institutions including the Fort Defiance Indian Hospital in Fort Defiance, AZ and the Cambridge Health Alliance in Cambridge, MA. Gretchen received her MSN in nurse-midwifery from Yale University School of Nursing, her MDiv from Harvard Divinity School, and her BA from Grinnell College.

Beth Poitras, RN, NP, WHNP-BC, Quality Assurance Manager

In her role as Quality Assurance Manager, Beth is responsible for reviewing and implementing new policies and procedures based on PPF A requirements. Beth will also be heavily involved with Title X accreditation in January and with PPLM accreditation due next year. Beth comes from her role as a Triage Nurse at PPLM and more recently a Nurse Practitioner working at the Boston and Somerville locations. She started her nursing career in Labor and Delivery at Caritas Good Samaritan in Brockton and then worked at Beth Israel Deaconess Medical Center in Boston. She spent 8 years at BIDMC working as a staff nurse in Labor and Delivery and then working as a nurse in a busy OB/GYN practice. Beth graduated from UPENN with her Bachelors degree in Nursing and from the University of Cincinnati with her Masters degree in Nursing.

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Christina Vogeley, Central Massachusetts Outreach Coordinator

As Central Massachusetts Outreach Coordinator, Christina is responsible for educational outreach activities designed to increase awareness of, and access to, Title X family planning services in the region .. Christina began her work with sexual health during her undergraduate years at the University of Georgia as a Peer Sexuality Educator. She was very involved with the Northeast Georgia AIDS Coalition and the Northeast Georgia Sexual Assault Center. She also organized students to participate in multiple women's rights and reproductive rights activities on campus. After six years as an educator both in the United States and abroad, Christina decided to return to her passion for sexual health matters.

Family Planning Counselor, Framingham Community Health Center

The Family Planning Counselor provides confidential, unbiased, nonjudgmental family planning education and information to patients at the Framingham Community Health Center. Working with NPs/mid-level clinicians, the Family Planning Counselor provides basic information about birth control options, the importance of cancer screenings and HIV/STD tests, and general health and safety issues as dictated by the patient's history (nutrition, smoking, substance abuse, etc).

Melanie Lown, Director of Communications and Public Awareness

As Director of Public Awareness, Melanie is responsible for PPLM's statewide educational outreach activities and supervises the Central Massachusetts Outreach Coordinator. Melanie came to PPLM in June 2002 after graduating with a liberal arts degree from Sarah Lawrence College. During her college career, Melanie was published in Extra! the magazine of Fairness and Accuracy in Reporting (FAIR) in New York City. After college she moved back to Boston to pursue freelance journalism and wrote for The Boston Globe and The South End News. Melanie opened PPLM's first express health center in Davis Square, Somerville called Plan, managed PPLM's 80th anniversary events, and produced a gala for 600 guests and an educational conference for 300 educators and clinicians.

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PPLM Attachment E - Clinical Policy and Procedures Manual

Clinical Policy and Procedures Manual

E-mail Communication with Patients

I. Policy: PPLM does not send protected health information via e-mail. PPLM may use e-mail to follow up on services requested by a patient via e-mail. These communications do not include protected health information.

II. Purpose: To ensure patient health information is protected and to document appropriate use of email in health center operations.

III. Scope: All PPLM patients and staff responsible for patient communication or involved in marketing.

IV. Procedure: If a patient sends an e-mail to PPLM requesting information, the PPLM staff

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person receiving the e-mail will respond to the patient and ask her/him to call a PPLM Health Center during business hours to obtain requested information. If a PPLM staff person receives a general inquiry about health information from a patient or non-patient, s/he will direct the patient to PPLM's website or the Sexual Health Matters Hotline.

Appropriate forms of e-mail contact include confirmation e-mails sent for on-line appointment requests and refills online. These emails do not contain any protected health information.

There is a space on PPLM intake forms for patients to provide their e-mail address. The form clearly indicates that providing the e-mail address is voluntary and will only be used for marketing and advocacy purposes.

Policy # 06-05 Date: Al'proved: Leadership Team 2/28/06 Approved: Health Services Quality Committee 1113105 Originator: Revised: 8/2009

Emergency Contraception Standing Orders with Pharmacists

I. Policy: PPLM's Medical Director may issue standing orders to Massachusetts' pharmacists to dispense emergency contraception as directed in M.G.L c.94C.

II. Purpose: PPLM wishes to reduce the number of unintended pregnancies in the Commonwealth of Massachusetts by partnering with qualifying pharmacists to ensure that emergency contraception is accessible in a timely manner.

III. Scope: PPLM's Medical Director and qualifying pharmacists

IV. Procedure: The Department of Public Health, the Board of Registration in Pharmacy, the

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Board of Registration in Medicine and the Drug Control Program under authority ofM.G.L. c. 94C, have adopted Guidelines (Pharmacy Board Policy No. 2006-1) that describe the requirements for pharmacists to dispense emergency contraception. It is described in M.G.L. c. 94C, subsection 19A in accordance with a written standardized procedure or protocol (i.e., Standing Order) developed by an actively practicing physician registered with the Commissioner to distribute or dispense a controlled substance in the course of professional practice pursuant to M.G.L. c. 94C, subsection 7. The Standing Order must include written, standardized procedures and protocols, the printed name and signature of the physician and the entity(ies) authorized by the Physician. The Standing Order may be issued for a pharmacist, pharmacy or group of pharmacies under common ownership or control of one entity. A pharmacist may dispense EC pursuant to a Standing Order of an actively practicing physician who is registered with the Commissioner provided that: • The pharmacist is currently licensed by the Pharmacy Board; • The pharmacist has completed training accredited by the Accreditation

Council on Pharmacy Education (ACPE) or offered by an Approved College or School of Pharmacy (247 CMR 2.00), which training shall include instruction on:

• Referring patient for additional service and follow-up; • Quality assurance; and • Proper documentation

• The Standing Order is maintained on file at the pharmacy; and • A copy of the Standing Order has been filed with the Pharmacy Board.

PPLM's Medical Director will issue Standing Orders (Form #) to pharmacists willing to dispense emergency contraception upon receipt of a copy of the pharmacist's license and documentation that s/he has completed the required training. PPLM will provide referral materials to all pharmacists to whom the Medical Director issues standing orders. The Medical Director's Executive Assistant will update the information obtained from the pharmacists every two years.

Policy Number 06-07.1 Effective Date 9/1/2006 Date(s) of Revision 9/1/2006

Escorts for Patients Receiving Mild or Moderate Sedation

I. Policy: PPLM provides patients with the option of receiving mild or moderate sedation (see PPFA Medical Standards and Guidelines for definitions) in addition to local anesthesia for surgical procedures. In order to be eligible for sedation, a patient must have an escort to take them home.

II. Purpose: The purpose of this policy is to ensure the safety ofPPLM patients who have received sedation medications.

III. Scope: All Health Center staff

IV. Procedure: PPLM operates in accordance with PPFA Medical Standards and Guidelines. According to these guidelines, one criteria for patients receiving mild or moderate sedation is that the patient have a responsible person to take them home. As well, the patient should be instructed not to drive or operate heavy machinery on the day of her procedure. In order to make sure that patients receiving mild and moderate sedation have an appropriate escort the following steps should be taken

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1. The patient is notified of this policy at the time of scheduling her appointment.

2. The day of her procedure the patient verifies that she has a responsible person to take her home. The name and contact information for that person should be collected at the time that the consents for sedation are signed.

3. Handoff of the patient from PPLM staff must be directly to the patient's escort.

In the event that a patient's escort is not available at the time the patient is ready to be discharged home, the following steps should be taken

Policy #

1. Reasonable attempts should be made by the patient and PPLM staff to reach her escort or to secure another responsible person to act as her escort.

2. If an escort cannot be secured, there are 2 options available. The patient can be transported to her horne via a licensed Medical Transport company or the patient can be transported to the local hospital with whom PPLM has a transfer agreement. In either case, the cost of the transfer will be billed to the patient.

A taxi cab driver or the driver of public transportation is not considered

an escort and does not fulfill the requirements of this policy.

Date: 08/10 A2proved: HSOT 8116110 Approved: M. Gallagher, COO 8/17110 Originator: A. Dixon, MD 8116110 Replaces: N/A

External Distribution of Clinical Data

I. Policy: PPLM provides limited aggregate clinical data at PPLM's discretion to entities not covered by a valid Business Associate Agreement.

II. Purpose: Ensure that entities not covered by a Business Associate Agreement receive limited aggregate clinical data at PPLM's discretion.

III. Scope: This policy is for all clinical data related to PPLM's patients or Health Center operations.

IV. Procedure: PPLM produces clinical and patient data for internal use and for distribution

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to entities with a valid Business Associate Agreement. Please see policy on Minimum Necessary Disclosure for guidelines around distribution of data to covered entities and business associates.

Entities such as donors, supporters, media, interns, volunteers and referrers may request clinical data on an ad hoc basis. All requests for data are reviewed for appropriateness at the time of the request.

The Director of Communications and Public Awareness or her designee reviews all requests by the media. The Vice President of Development or her designee reviews requests by donors and volunteers. The Chief Operating Officer or her designee reviews all other requests.

Limited aggregate clinical data can be shared with non-business associates at PPLM's discretion. PPLM does not provide Personal Health Information (data that identifies an individual patient in any way) to non-business associates.

Policy # 06-09 Date: Approved: Leadership Team 2/28/06 Approved: Health Services Quality Committee 11/3/05 Originator: Revised: 8/2009

Forms Translation

I. Policy: PPLM engages a professional company to translate all Clinic Medical and/or Patient Education forms and material.

II. Purpose: The purpose of this policy is to ensure that a professional translation company translates all translated forms.

III. Scope: This policy is for all PPLM clinical printed material.

IV. Procedure: The forms database houses all of the PPLM forms used for clinical patient

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care and education. The forms database is located on the Intranet. This database is updated and maintained by the Administrative Assistant - Health Services.

Staff members identify forms or educational material that need to be translated and what languages they need to be translated to. The staff brings a request for translation to the Center Director. The Center Director verifies that PPF A does not offer translations of the form and approves the request, in consultation with the other Center Directors and the Vice President of Clinical Operations, based on priority of the translation request and resources available.

The Administrative Assistant - Health Services contacts the current vendor and requests a quote for translating the formes) into the designated language(s). The Administrative Assistant - Health Services obtains the quote and gives it to the Vice President of Clinical Operations for approval.

If the formes) is/Care) translated, the revision date on the form is updated. The form is uploaded to the Forms Database for future copying/use.

If the formes) is/Care) not translated, the requestor is notified of the decision.

Policy # 06-] 0 Date: Approved: Leadership Team 2/28/06 Approved: Health Services Quality Committee 11/3/05 Originator: Revised: 8/2009

I. Policy:

Hand Washing Policy

All health center staff must wash their hands before and after each patient contact.

II. Purpose: The purpose of this policy is to minimize the risk of patients acquiring an infection at PPLM.

III. Scope: Health Center Personnel

IV. Procedure: Hand washing before and after each patient is required. Proper hand washing techniques are documented below. Proper hand washing signs will be posted throughout the health center as a reminder to all staff. See Appendix A below.

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Proper Hand Washing Technique using soap and water:

ALWAYS use soap and water if hands are visibly soiled

• Place hands under warm water • Add soap • Rub hands together thoroughly including all surfaces and between

fingers • Continue washing for 20 seconds • Rinse with warm water thoroughly • Use paper towel to dry hands • Use paper towel to turn off water.

Proper Hand Washing Technique using hand sanitizer:

Policy # Approved: Approved: Originator: Replaces:

• Place drop of hand sanitizer in palm • Rub hands together thoroughly including all surfaces and between

fingers

• Let air dry

Date: HSOT 8/16/10 M. Gallagher 8/17110

PLEASE REMEMBER TO WASH YOUR HANDS OR USE HAND SANITIZER

Always use soap and water if hands are visibly dirty/soiled

When washing hands with soap and water:

Wet your hands with warm water and apply soap.

Rub hands together and scrub all areas including between your fingers.

Rub hands together for 20 seconds (sing Happy Birthday twice)

Rinse hands well with warm water and dry thoroughly

When using an alcohol-based hand sanitizer:

Apply product to the palm of one hand and rub together

Let hands air dry

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I. Policy:

II. Purpose:

III. Scope:

IV. Procedure:

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Handling Patients Requiring Care Once Doors Are Locked

PPLM is committed to providing the highest quality care and best customer service to our patients. Between the time the doors close and the clinician leaves, a patient might show up requesting to be seen emergently. This policy is to be disseminated to all relevant clinic staff, including security so that these patients are given the best care possible.

The purpose of this policy is to establish a safe plan for patients who show up at PPLM after the doors close, but when the guard and some clinic staff are still on site.

All PPLM Health Services Staff

Any PPLM patient who appears at the door, once the doors are locked, requesting/requiring immediate care should be let into the building. If a clinician or triage nurse is available on site, she should use her clinical judgment to determine the urgency of care needed for that patient.

If the patient appears stable, the clinician/triage nurse should determine if she can be seen the following day and clinic staff should make an appointment as needed.

If the patient does not appear stable, or the clinician/triage nurse does not feel it is safe or within her scope of practice to see the patient, then the patient should be strongly encouraged to go to the emergency room. The clinic staff should call 911 and the patient should be transferred to the hospital (preferably Brigham and Women's Hospital).

The clinician should document her interaction with the patient and recommended plan clearly in the patient's medical record.

Ifthe patient arrives when the clinician and triage staff has gone, security or reception should page the on-call nurse who should speak with the patient and determine if the patient requires emergent care. If, to the best of the on-call nurses ability it is determined that the patient requires emergent care, the on-call nurse should instruct the clinic staff to call 911 and the patient should be sent to the hospital (preferably Brigham and Women's Hospital).

If the patient requires emergent care, but refuses to go to the hospital, the on-call nurse should inform the patient that deciding not to go to the hospital is against our medical advice. The patient does have the right to make her own medical decision even if it is against medical advice.

If the on-call nurse determines that the patient does not require emergent care, then she should be instructed to return to the clinic in the morning to be seen. The clinic staff should make the appointment for the patient.

The on-call nurse should document clearly the phone conversation with the patient and the follow-up plan and this documentation should be placed in the patients chart the following day-per on-call nurse protocol.

Policy # 06-11 Date: Approved: Approved: Originator: R~laces:

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Health Policy for Patient Care Staff in PPLM Health Centers

I. Policy: PPLM assures that employees are free of communicable disease in compliance with Department of Public Health Clinic Licensure regulation l05CMR140.301.

II. Purpose: To document compliance with state regulations.


IV. Procedure: 1. TB Testing

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Within one month date of hire, PPLM staff shall submit result of a Mantoux test done within the previous year (unless the individual has a history of positive skin tests). Tests should be updated annually thereafter. If a test becomes positive, a chest x-ray is indicated and annual skin testing is no longer necessary. Mantoux testing is available at each Health Center site to facilitate this procedure for Health Center personnel.

2. Rubella/measles Within one month of their date of hire, all personnel shall submit documentation of a positive Rubella titer or MMR immunization.

3. Hepatitis B All personnel having contact with blood products are encouraged to have Hepatitis B vaccination. PPLM makes this available to all personnel at risk for exposure at no cost to the employee. All personnel are required to sign a waiver if they choose not to have the vaccine or have previously received vaccination. See Hepatitis B vaccination policy

4. Physical Examination Routine physical examinations are not required. However, PPLM reserves the right to request documentation of a physical examination if it is deemed necessary by the Medical Director.

Policy # Approved: Approved: Originator:

a. Documentation of the above immunizations and examinations should be submitted to the Employee Health nurse at the site the employee works. Physicians operating as contractors can submit this information directly to the Medical Director.

b. This policy covers all paid and unpaid personnel including physicians operating as independent contractors can submit this information directly to the Medical Director.

06-12 Date: Leadership Team 2/28/06 Health Services Quality Committee 1113105

I Replaces:

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I. Policy:

II. Purpose:

III. Scope:

IV. Procedure:

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Identification Badges Policy

All persons who examine, observe or treat a patient at PPLM must wear an identification badge, which indicates the person's name, licensure status, if any, and position. All Physician identification badges will include the Physician's first and last name and licensure.

The purpose of this policy is to ensure compliance with Massachusetts General Law, Chapter 111: Section 70E.

PPLM Health Center Staff, Students, Observers, or Volunteers observing in Health Centers.

In accordance with Massachusetts General Law, Chapter 111: Section 70E Patients' Rights, all persons who examine, observe or treat a patient at a PPLM Health Center will wear an identification badge which readily discloses the first name, licensure status, if any, and staff position of the person so examining, observing or treating a patient or resident.

Policy # 06-12.1 Effective Date: 12/1106 Date(s) of Revision: 11106

I. Policy:

II. Purpose:

III. Scope:

IV. Procedure:

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Income Verification Policy

PPLM receives funding from the Department of Public Health Family Planning Program. This funding enables PPLM to provide patients with family planning services on a sliding fee scale based on the patient's income that is verified by PPLM staff.

The purpose of this policy is to ensure that the sliding fee subsidy is provided only to patients who qualify for the subsidy.

This policy is for all PPLM health center patients.

PPLM subsidizes family planning services based on a patient's income. Patients that are middle or high school students and patients with incomes equal to or below 100% of the Federal Poverty Level (FPL) receive family planning services and most contraceptive supplies for free or at a discounted rate according to the level 1 fee schedule; patients with income greater than 101 % but less than 150% of the Federal Poverty Level (FPL) receive services supplies at a discounted rate according to the level 2 fee schedule; patients with income greater than 151 % but less than 200% of the Federal Poverty Level (FPL) receive services supplies at a discounted rate according to the level 3 fee schedule; and patients with income greater than 201 % but less than 300% of the Federal Poverty Level (FPL) receive services supplies at a discounted rate according to the level 4 fee schedule.

If PPLM has to change the fee schedule for these patients, the fees will be published on a revised fee schedule 30 days in advance of being implemented. PPLM's fee schedule is located on the Intranet.

Patients must be residents of Massachusetts to receive this subsidy. PPLM first-visit patients who state they have no ability to pay but have no income verification may be approved to a Slide Level 2 upon approval from the Clinical Operations Manager, Patient Services Manager, Surgical Services Manager or Center Director.

PPLM will require one of the following proofs of income every three months if a patient is refilling a contraception prescription or on an annual basis if not. • Wages, 4 consecutive pay stubs • Wages, 1 pay stub and letter from employer stating annual gross

income • Self-employed, 1040 Form and Profit and Loss • Unemployed, 4 consecutive stubs, computer claim history printout • Workers comp - Copy of check, letter from source • None. Households with "0" income - inquire about how patient is

supported, approval from Center Director.

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For teens, PPLM will use the best estimate of the parents' income if the teen's parents know they are there.

Staffwill inquire whether the patient's status has changed when a patient calls to schedule an appointment or request contraceptive pick-up. Changes will be noted in the practice management system and patients will be required to bring in new proof of income.

Patients will be informed that sliding scale can be applied to office visits, contraceptive supplies, medication, labs provided on the same date of service and gyn procedures.

Contraceptive supplies are dispensed as follows for patients eligible for the sliding fee scale:

-3 months if income is verified -13 months for teens

Policv # 06-\3 Date: Approved: Leadership Team 2/28/06 Approved: Health Services Quality Committee 1113105 Originator: Revised: 8/2009

Physician Licensing and Credentialing

I. Policy: All physicians must have an active Massachusetts medical license, StateControlled Substances registration number, DEA registration number, and CPR certification to work at PPLM. PPLM maintains a current copy in the Licensing and Credentialing Database as well as a copy of the above in each physicians file.

II. Purpose: To comply with state and federal regulations and to assure that all PPLM physicians meet licensing and credentialing standards.

III. Scope: All contract and employed physicians.

IV. Procedure: A. New Hire

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Physicians are required to submit a copy of their current Massachusetts medical license, Massachusetts Controlled Substances registration, DEA registration, and CPR certification to the Assistant to Health Services prior to being scheduled in the Health Center. The copy will be stored in the physicians file as well as in the licensing and credentialing database (maintained by the Assistant to Health Services).

B. Active Physicians • One month prior to the expiration date of any of the above items, a

letter, e-mail or fax will be sent to the physician reminding him or her to send a copy of the new certificate or license to PPLM upon receipt. A copy of this letter will be sent to the Surgical Services Manager.

• One week prior to the expiration date, a second letter, fax or e-mail will be sent to the physician notifying him/her that he/she will need to be taken off of the schedule if the updated information is not received. A copy of this will go to the Medical Director, the Surgical Services Manager and to the Health Services Director or Center Director.

• As of the expiration date, the physician will be called, or paged, if a copy has not been received. The Medical Director will be notified at this point if slhe has not been previously notified. The physician will be taken off of the schedule pending receipt of the missing document.

Policy # 06-14 Date: Apgroved: Approved: HSQC 1113/05 Originator: Heather Sankey 6.30.03 Replaces: N/a

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BCBS Policy for Non- Credentialed Mid-Level Clinicians

I. Policy: PPLM begins the BCBS credentialing process immediately after hire for new clinicians at all sites. This process can take 1-6 months to complete. Clinicians who are not credentialed through BCBS cannot see patients with this insurance or PPLM will not be reimbursed if they do.

II. Purpose: The purpose of this policy is to establish a plan for communicating with appropriate staff and scheduling patients with BCBS during times when clinicians are not credentialed.

III. Scope: All PPLM Health Services Staff

IV. Procedure: New clinicians will begin the credentialing process on hire. Appropriate staff will be notified that specific clinicians are not yet credentialed with BCBS.

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Every effort will be made to have those clinicians work with a credentialed clinician. In this case, if at all possible the credentialed clinician should see the BCBS patients. The non-credentialed clinician may see the BCBS patient as long as the credentialed clinician reviews the visit documentation, says hello to the patient and co-signs the chart.

If the non-credentialed clinician is scheduled when no credentialed clinician is scheduled or when they are scheduled to work alone, the lead clinician or Reproductive Health Services Director will let the site management teams know. The appropriate managers will notify the call center and reception staff. The call center will make every effort not to schedule patients with BCBS insurance during those days/times that a non-credentialed clinician is scheduled to work. The call center will ask the patient for their insurance information per standard protocol. The patient will be informed that if they have BCBS, there is a possibility that we will not be able to accept their insurance and they will have to pay for their visit. If the patient arrives at a site and the front desk staff notice they have BCBS and are aware that only a non-credentialed staff is working, they should inform the patient that we are unable to accept their insurance today and would they like to reschedule or self-pay.

If a BCBS patient makes it into the exam room and a non-credentialed clinician is the only person available to see them, we will see the patient for their visit. Reception will notify the billing department of this situation so that we can keep track of how many BCBS patients we are seeing by non credentialed clinicians despite our communication efforts. Once the clinician is credentialed, the site management teams should be notified and the staff should be made aware by their appropriate manager.

Policy"# 6.15 Date: 1/13/2010 Approved: Approved: Originator: Replaces:

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I. Policy:

II. Purpose:

III. Scope:

IV. Procedure:

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Lab Coat Policy

Physicians, Nurse Practitioners, Physician Assistants, Nurses, Managers/Coordinators, and Day Supervisors can (optional) wear white lab coats.

The purpose of this policy is to ensure that the attire of Health Center staff appropriately represents the role that the staff has in the Health Center.

Health Center staff

The above-designated staff can wear white lab coats. All other staff must wear street clothes or scrubs according to their job function and the dress code policy outlined in the employee manual.

Policy # 06-16 Date: Approved: Leadership Team 2/28/06 Approved: Health Services Quality Committee 1113105 Originator: Replaces:

MDPH Family Planning Program Standards Compliance

I. Policy: PPLM maintains compliance with all MDPH Family Planning Program Standards.

II. Purpose: The purpose of this policy is to insure and document compliance with MDPH Family Planning program standards.

III. Scope: This policy is for all providers and patients of PPLM.

IV. Procedure: All PPLM sites will maintain a copy of the MDPH Family Planning

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Program Standards which address the following topics and comply with the requirements set forth by these standards:

Health Assessment/History Client Education/Counseling Clinical Issues Laboratory Testing F ollow-uplReferrals Clinic-based Quality Improvement Programs Medical Records Essential Community Education/Outreach Access/Availability of Services Governance Board Facility/Risk Management Fiscal Issues Data Collection/Reporting Personnel Policies Staff Training

Center Directors are responsible for ensuring that their sites are compliant with the Family Planning standards set forth in the Self Assessment Tool. Annually PPLM will submit one Self-Assessment Tool for PPLM to MDPH for review along with the Annual Report.

PPLM's Accounting Manager will submit monthly bills; PPLM's Vice President of Clinical Operations will submit semi-annual and annual reports and performance measures to MDPH based on the schedule set forth.

PPLM's VP Clinical Operations is responsible for oversight of the MDPH family planning contract.

Policy # 06-18 Date: Approved: Leadership Team 2/28/06 Approved: Health Services Quality Committee 1113105

1 Originator: Revised: 18/2009

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Medical Protocols Policy

I. Policy: PPLM protocols are for internal use only, by PPLM staff, Advanced Practice Nurses, Physician Assistants, and Physicians, in the care of PPLM patients.

II. Purpose: To document the procedure for development, use, access, distribution and maintenance ofPPLM medical protocols.

III. Scope: All PPLM employees, contract physicians, volunteers, and Board members.

IV. Procedure: A. Development

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PPLM staff develop the medical protocols in accordance with the PPF A Manual of Standards and Guidelines, current accepted medical practice, evidence-based medicine, Massachusetts Board of Registration in Medicine Regulations, and State and Federal laws. The Medical Director must approve Medical Protocols before taking effect. Each page of the protocol will contain the following: the date of last PPF A revision and last PPLM revision as well as the formatting including PPLM header and footer which includes "Planned Parenthood League of Massachusetts - for Internal Use Only."

B. Use & Access Current Medical Protocols will be maintained on the PPLM Intranet, an online format that is accessible from all PPLM computers. All PPLM staff has access to PPLM Medical Protocols. Health Center staff is required to be up-to-date on all protocol changes. Volunteers and interns will have access to the Medical Protocols with supervisor approval when necessary for projects in which they are involved. Board members have access to the Medical Protocols when necessary to fulfill board duties.

C. Distribution PPLM Medical Protocols may be shared freely with PPF A Affiliates in response to a specific request, with the understanding that they were not developed for external use, and must not be adopted verbatim. In general, PPLM Medical Protocols should not be shared in their entirety, or with external organizations or individuals. The Medical Director may make exceptions.

D. Maintenance The PPLM Medical Protocols should be updated as often as necessary to respond to changes in medical information, but no less than with each set of changes to the PPF A Manual of Standards and Guidelines. When changes are made to any section of the protocols, the old version shall be kept in an electronic archive for 30 years. Updates will be distributed to

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physicians by the Medical Director, and to Health Center staff through the Health Services Director and Center Director at each site.

Policy # 06-19 Date: Approved: Health Services Quality Committee 9/29/03 Approved: Management Team Originator: Heather Sankey, Medical Director 4/8/03 Revised: 8/2009

I.

II.

III. IV.

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Policy:

Purpose:

Scope: Procedure:

Medical Records and Health Information

PPLM creates a record of the care provided to all patients and ensure that this information is only accessed by authorized individuals and is maintained in a manner that reduces the risk of damage by fire or water. This record is the property ofPPLM. PPLM recognizes that patients have an interest in the health information contained in this record and make this information available to patients. The purpose of this policy is to ensure that all records of medical care provided are created and maintained in a consistent manner. PPLM Health Center Staff Medical records are the property ofPPLM. Patients, however, have a legally recognized interest in the Health Information contained in their medical record and PPLM has policies and procedures in place to allow patients to access their medical records. All medical records are strictly confidential and the right to authorize release of health information contained in the medical record belongs to the patient, not PPLM. Medical records serve as a permanent written record of treatment and advice given to a patient by PPLM staff. They provide a means of communicating instructions and observations among members of the health care team at PPLM. In a setting like ours where a different staff member may see a patient at each visit and/or by several staff members in the course of one visit, a well-documented, legible record is essential in providing consistent and appropriate treatment. A well-documented, accurate and legible medical record is our best defense in the event of legal action. The best care and the finest intentions are worthless in a legal action if the record is not properly documented. The medical record also provides an essential reference in locating a patient in the event of necessary follow-up.

1. Health Information: The term "Health Information," as used herein, means any information, whether oral or recorded in any form or medium, including demographic information, that:

a) Is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and

b) Relates to the past, present or future physical or mental health or condition of any individual, the provision of healthcare to an individual, or the past, present, or future payment for the provision of health care to an individual; and

1. That identifies the individual; or 11. With respect to which there is a reasonable basis to believe

the information can be used to identify the individual.

2. Contents:

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One complete medical record is maintained for each patient. Every patient encounter, including telephone and mail contacts must be documented in the patient's record. Each patient's record is assigned a unique number on the patients first visit to PPLM. This number remains the same throughout the patient's history of care with PPLM. Each page of the medical record must include the patient's full name, date of birth, unique record number and date of service/contact. Every entry in the medical record should be legible, written in ink (preferably black ink) dated and signed with the staff member's full name (or, first initial and last name and title. The use of pre-printed signature stamps fro clinicians are encouraged but must be used IN ADDITION to the clinician's hand-written signature. A perpetual signature log containing the signatures, initials and titles of all personnel who's chart will be kept by the Health Center or her designee. All written, signed consents will be filed permanently in the medical record. Contents of the medical record should be kept in chronological order with the most recent visit/contact on top. Record of treatment, laboratory reports, advice, and telephone communication should be filed on the righthand side of the chart. Consents, emergency contact information, and any other non-treatment related forms are filed on the left-hand side of the chart. The problem alert from is always filed on the top, left-hand side of the chart. No loose papers or post-it-type notes should be part of the permanent record.

3. Record Retention: According to Massachusetts's law for licensed Health Center, medical records will be kept for fifteen (15) years from the date of service in the case of adults. Medical records for minors must be kept for thirty (15) years beyond the age of majority. Financial records related to patient care will be kept for six (6) years from the date of service. Patients medical records shall be considered active and will be maintained in the Health Center's active files if a patient has received services within the past two years. Patient medical records shall be considered inactive and will be stored in inactive record storage if the patient has not received services within the last two years. Inactive medical records must be purged at least once a year. Inactive records will be boxed and the box clearly marked for ease in retrieval.

4. Record Security: All patient records are confidential. Only authorized personnel are permitted in the medical records area. All patient records and logbooks containing patient names must be returned to the medical records room at the close of the Health Center day. The medical records room must be

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locked at the close of the Health Center and/or when no authorized personnel are in attendance. Charts in use during clinic sessions should never be left unattended. Care must be taken to position patient records in chart racks, etc. so that Health Information is not visible to unauthorized individuals. The Privacy Officer is ultimately responsible for the security of the Health Information.

5. Removal and Re-filing of Charts: Charts removed for clinic sessions should be reviewed, processed and refiled within 72 hours of the clinic session.

Charts removed from active files for a purpose other than a clinic session, pill dispensing or quick review, should be replaced with a plastic place holder containing a charged-out slip indicating the date taken, person removing chart and current location of chart. Charts removed from follow-up slots in records room should also be replaced with plastic placeholders.

Policy # 06-20 Date: Approved: ApQfoved: Originator: Revised:

Medical Referral, Recommendation and Follow-Up Policy

I. Policy: This policy outlines the procedures that PPLM follows when clients require a referral outside of the affiliate.

II. Purpose: The purpose of this policy is to ensure that clients obtain appropriate referrals and recommendations and that all PPF A and PPLM protocols are adhered to in terms of follow-up.

III. Scope: All PPLM Health Center Staff

IV. Procedure: Referrals are categorized by PPFA as 'recommendations', 'emergent',

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'very serious', and 'other.' Required follow-up depends on the category of referral. Each year, the PPF A protocols include specific information and requirements on following up with referrals. PPLM updates its' protocols and this policy accordingly.

Recommendations do not require specific documentation. Recommendations DO NOT need to be placed in the follow-up system. Whether a client follows up with a recommendation is their choice and responsibility. If, however, results from a recommendation come back to PPLM, a licensed provider should review the results and follow-up on any abnormals as needed.

Referral Process: The table below is taken from the PPF A protocols and describes in detail the level of referral and required follow-up needed for the client. 1. The letters required for follow-up are standard letters and are located on the Intranet. The letters are updated annually as needed. All forms and letters that are sent to clients are identified on the triage follow-up progress note (i.e 'combined letter' sent) or in the client's medical record. A copy of the letter/form can also be placed in the medical record. If a unique letter/form is sent to the client, a copy MUST be placed in the medical record.

2. The letter notifying the client must contain the following information: • the nature of the abnormal findings • the implications of the findings • the possible consequences of not receiving additional diagnosis

and/or treatment • an explanation of management options and provision of

appropriate referral sources, as indicated • informing client that it is her responsibility to obtain follow-up

care

3. A Reminder Letter must be sent within 30 days of the recommended referral unless there is documentation that the client already received care. A confirmation of care letter is NO LONGER REQUIRED.

Staff Training In addition to following these requirements, all staff involved in this referral process are required, each year, to read and sign a description of this referral process.

EMERGENT

Acute Condition

e.g., suspected ectopic, acute abdomen, thromboembolic event, hemorrhage

Malignancy

e.g., Birads 5 on mammogram, adenocarcinoma, squamous cell carcinoma, invasive cancer of vulva or vagina

VERY SERIOUS

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Acute Condition

For acute condition suspected or found at visit or by client report on telephone, must notify client of need for immediate medical attention.

Note: IfhCG is indicated for suspected ectopic, must communicate all results to client immediately upon receipt.

Any client sent to the emergency room or hospital must be followed up. One telephone contact must be attempted within 24 hours (72 hours if on a Friday), followed by one letter if the client is not reached by phone.

Malignancy on Result / Report

Must make three attempts at notification, two of which must be in writing within 14 days of receiving results.

First attempt: call client at least once within 72 hours of receiving result / report.

If no response to telephone attempt, must send first letter within seven days of receiving result / report.

If no response to first letter, must send second letter within 14 days of receiving result / report.

If no response, follow up when client returns to health center.

, ,,> .. c',c

CONDITION

Potential Malignancy, HIV

(e.g., AGC, ASC-H, HSIL, carcinoma in situ, CIN 2-3; VIN 2-3, VAIN 2-3, Birads 4 on mammogram, breast mass, suspicious adnexal mass)

OTHER

Other referrals, abnormal test results, or findings

(e.g., +HPV, ASCUS, LSIL, CIN 1, VIN 1, VAIN 1, STI except HIV)

Policy # Approved: Approved: Originator: Revised:

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Very Serious Condition

For very serious condition, suspected or found at visit, or by client report on telephone, must notify client of need for referral at that time.

Potential Malignancy / HIV on Report / Result

If not otherwise designated by specific standard, must make three attempts at notification, two of which must be in writing, within six weeks of receiving results.

Other Findings Requiring Referral

For other conditions found at visit that require a referral, must notify client of need for referral at that time.

Abnormal Test Results / Reports

If not otherwise designated per specific standard * * or state law / health department, must make three attempts at notification, two of which must be in writing, within six weeks of receiving results.

**Notification requirements for STIs are specified in sections IX-A - General STI Standards, IX-C - Genital Ulcers, IX-D - Cervicitis & Urethritis, IX-F - Vulvar Infections, IX-HFemale UTI

06-21 Date:

8/2009

I. Policy:

Observers in the PPLM Health Centers

PPLM shall make clinical areas available for observation to students in clinical training (Nursing/Medicine) in order to facilitate their education in the area of reproductive health.

II. Purpose: The purpose of this policy is to establish standards for those interested in observing in the clinical areas.

III. Scope: This policy is for all patients and staff at Planned Parenthood League of Massachusetts.

IV. Procedure: Nursing, medical school, medical residency, or nursing graduate programs

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with students interested in observing family planning at PPLM may contact the placement coordinator. If a student contacts PPLM directly, the placement coordinator will confirm the student's participation in the program with the program contact. The program must have an agreement in place with PPLM and is responsible for ensuring that the student has been appropriately screened and has had HIP AA training. The placement coordinator will send out a packet of information including the contract, the appropriate contact persons, an overview of the observation experience, appropriate behavior/attire as well as other information necessary for an observation visit. The student will contact the appropriate person at PPLM and arrange a visit at the convenience of the clinical area.

The student will arrive and be screened by the security guard upon entering the building. The student will be greeted by his/her contact person and escorted to the clinic. The student will read and sign a confidentiality statement as well as receive an evaluation form to be completed at the end of his/her visit.

The student will be asked to wait until he/she can be matched with a patient willing for a student to accompany her through her entire visit for gyn services. This would include accompanying the patient through lab, ultrasound, information session and procedure if the patient is comfortable. The patient has the right to decline observation in any part of her visit. For family planning visits, the student will observe the gyn intake by the clinic assistant as well as the exam/visit with the clinician. Again any patient has the right to decline observation in any part of the visit.

The patient will be introduced to the observer by his/her title (MD, NP, nursing or medical student). Additionally, the clinician who is performing the procedure will be introduced to the observer and has the right to decline having the student in the procedure room.

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The student will negotiate with the contact person as to the length of the observation and notify the contact person when he/she needs to leave the b °ld

o

U1 mgo Policy # 06-22 Date: AJlQIoved: Leadership Team 2128/06 Approved: Health Services Quality Committee 1113/05 Originator: Replaces:

I.

II.

III.

On Call Service Policy

Purpose: Planned Parenthood League of Massachusetts provides 24 hour on call emergency telephone contact for clients who may be experiencing complications from a procedure done at PPLM. Telephone advice and triage is in place to provide continuity of care to our clients. When the on call employee is uncertain of how to triage a situation the on call person must contact the medical director or designee immediately for consultation.

Scope:

Policy:

a. b. c.

This policy is for all patients and staff at PPLM.

All RNs and some clinicians at each site rotate through the call schedule. A schedule is provided to all on call personnel. For schedule changes please call the Boston Surgical Services Manager at (617) 616-1621 or contact via email. If changes need to be made and a schedule cannot be electronically delivered to the answering service, you must contact the answering service directly.

d. The on call employee must be available by phone or pager. A telephone or pager will be provided to you.

e. The on call employee is expected to respond to a call/page within 20 minutes. f. It is the responsibility of the on call employee to be sure their phone/pager is

working order. g. PPLM has a contract with an answering service that will call/page an on call RN

when the health center is closed. h. Staff is reimbursed $40/weeknight and $75/Saturday, Sunday, and holidays

Call Center Hours Monday 8:00AM-6 PM Tuesday 8:00AM-6PM

Wednesday 8:00 AM-5:00 PM Thursday_ 8:00 AM-6:00 PM

Friday 8:00 AM-5:00 PM Saturday 8:00 AM-2:00 PM Sunday Closed

IV. Procedure:

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a. The answering service receives a copy of the on call schedule b. During agency in services or when the call center is closed the Boston Surgical

Services Manager will take call. In the event of an absence the Call Center Manager will contact the person on call.

c. Call begins when the call center closes and ends when the call center reopens. d. You are responsible for receiving calls from medication and surgical services

(Essure, IUD insertion, colposcopy, and LEEP) patients seen at PPLM.

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e. The answering service will page for any medical emergency but will not page on call personnel for the following

1. Directions to the health center 11. Emergency Contraception/Refill requests

111. Cancelling or scheduling an appointment iv. Hours of operation

f. Each affiliate has a cell phone available for use during on call hours and the phones are to be rotated between employees taking call. These items are property of PPLM.

g. The answering service will calVpage your primary contact number first. In the event the answering service cannot contact you, they will attempt to contact you at the alternative number given. If the answering service cannot reach you, the answering service has instructions to contact each person on the list, if unable to reach on call personnel the answering service will contact the Vice President of Clinical Services.

h. The on call service functions to relay calls from patients needing or requesting urgent medical advice. Answering service personnel have no medical training and should not act as an intermediary once the nurse has been called.

1. Document your on call hours on the on call time sheet template. This must be submitted to Human Resources/Payroll.

J. If you are unable to reach a patient after two attempts, call to alert the answering service.

k. You must fill out an "Emergency Telephone Contact" form completely. 1. Maintain patient confidentiality when returning patient calls.

Policy # 06-23 Effective Date: 12/1/06 Date(s) of Revision: 712009

Patient Escorts in Exam Rooms

I. Policy: PPLM will consider a patient's request for her escort to accompany her into the exam or procedure room. The clinician and health center supervisor will determine if allowing the patient escort into the exam or procedure room is appropriate in the circumstances of each request.

II. Purpose: The purpose of this policy is to ensure the safety ofPPLM staff, patients and patient escorts.

III. Scope: Health Center staff and patients

IV. Procedure: Generally, patients are unaccompanied in exam, information

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session and procedure rooms for the safety of patients, partners and staff. However, if a patient requests that her partner or escort accompany her throughout her visit, a health center supervisor, in conjunction with the provider, will decide the appropriateness of this on a case-by-case basis. If a partner or escort is permitted to accompany the patient, PPLM staff will always meet with the patient alone to confirm the patient's comfort with the person accompanying her for her visit.

Policy # 06-24 Date: Approved: Leadership Team 2/28/06 Approved: Health Services Quality Committee 11/3/05 Originator: Replaces: NA

Patient Termination

I. Policy: PPLM terminates patients who are non-compliant with medical advice or plan of care or who exhibit unacceptable or threatening behavior towards PPLM staff members or other patients.

II. Purpose: The purpose of this policy is to define the reasons for terminating a patient and the process for terminating a patient from the PPLM practice.

III. Scope: This policy applies to all PPLM patients.

IV. Procedure: Due to a patient's non-compliance with medical advice or a care plan; or unacceptable/threatening behavior towards a PPLM staff member, it may be necessary to terminate the patient clinician relationship. Each of these cases is reviewed with the Medical Director and Center Director prior to the patient being notified.

The following are reasons to terminate a patient:

• Patient refuses to follow medical advice or care plan after three contacts with PPLM staff member

• Patient exhibits aggressive, threatening, or demeaning behavior towards a PPLM staff member or other patient

A Patient Termination letter is sent to the patient telling them that effective 30 days from the receipt of the letter PPLM will no longer be able to provide medical care for them. PPLM will be available to the patient in case of emergencies until 30 days from the receipt of the letter. The letter should refer them to the Massachusetts Medical Society's referral line - 781-893-3800, extension 5515 Monday through Friday from 8:00 a.m. - 4:00 p.m. The letter should also state that we would transfer their medical records to their new physician upon receipt of a signed authorization.

The termination is documented in the patient's chart with the effective date of the termination.

A note is recorded in Medical Manager that no further medical care will be provided for this patient.

Policy # 06-25 Date: Approved: Leadership_ Team 2/28/06 Approved: Health Services Quality Committee 1113105 Originator: Revised 8/2009

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I. Policy:

II. Purpose:

III. Scope:

IV. Procedure:

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Social Service Referral Policy

In order to facilitate continuity of care, PPLM maintains an agency referral list to establish referral networks with community organizations and services.

The purpose of this policy is to ensure PPLM patients have access to a full range of social services.

This policy is for all PPLM health care centers.

Patients seen at PPLM may require referrals to outside providers of social services. PPLM maintains a list of referrals in the following areas:

• Primary healthcare; • Adolescent programs including primary care, school based health

centers, youth development and others; • Pregnancy and parenting programs, including Healthy Families,

FirstLINK, and Early Intervention Partnerships; • Adoption; • Prenatal care services, including Healthy Start; • MDPH Sexually Transmitted Disease clinics; • HIV/AIDS services, including counseling and testing, Comprehensive

HIV/STDlHepatitis C sites, and perinatal clinical specialty services such as MassCare;

• MDPH Women's Health Network; • Mental health services; • Substance abuse services; • Tobacco cessation programs; • Domestic violence, abuse prevention and rape crisis; • WIC and other nutritional programs; • Gay, Lesbian, Bisexual, Transgender and Questioning services; • Disabilities/special health care needs programs; • Housing services and homeless shelters; • Mutual assistance organizations and refugee resettlement agencies; • Social services.

Referrals may be provided following the guidelines below: • A list of local providers of the above listed services will be maintained

at each PPLM center and updated annually by the Quality Assurance Director and/or Hot Line Coordinator or Health Services Director

• A referral may be provided to a patient only if listed on the approved providers list updated annually and maintained at each center.

• A referral may be made to an organization on the approved list but not to an individual employed within an organization.

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• Referrals may be provided to individual mental health care providers, if the provider has been screened and added to the list by PPLM's Hot Line Coordinator

• No employee of PPLM will refer patients to providers based on their personal experience or personal knowledge of a provider.

• In the event that patients inquire about health and human service needs that are beyond the scope ofPPLM services, PPLM staff will refer the patient to the comprehensive information and referral agency serving the patient's community.

• PPLM staff will document any and all referrals provided to a patient in the patient's medical record.

Policy # 06-27 Date: Approved: Leadership Team 2/28/06 Approved: Health Services Quality Committee 11/3/05

I. Policy:

Reporting on Communicable Diseases

PPLM reports to DPH regarding communicable diseases in accordance with current state regulations (see Attachment A below).

II. Purpose: The purpose of this policy and procedure is to specify which communicable diseases are reportable and to whom they should be reported.

III. Scope: This policy applies to all ofPPLM's Health Center sites.

IV. Procedure: 1. Communicable diseases should be reported to the local health department or the

Attachment A

Massachusetts Department of Public Health in a time frame specified in the schedule included in Attachment A.

2. The list will be updated whenever PPLM is notified of a change in the regulation, in addition to the annual review of all policies.

3. The Health Services Director and Center Director at each site are responsible for keeping staff informed of updates, for creating a system for reporting in a timely manner, and for ensuring that the system functions appropriately.

4. Diagnosed diseases must be reported with each occurrence, with the exception of vaginal warts, which should only be reported with the initial diagnosis.

Policy # 06-28 Date: Approved: Leadership Team 2/28/06 Approved: Health Services Quality Committee 11/3/05 Originator: Revised:

Policy regarding the Reporting of Communicable and other Infectious Diseases by Health Care Providers

Communicable And Other Infectious Disease Reportable In Massachusetts By Healthcare Providers 105 CMR 300.000 Report immediately by phone!

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This includes both suspect and confirmed cases. All cases should be reported to your local health department; if unavailable call the Massachusetts Department of Public Health: Telephone (617) 983-6800 Confidential Fax: (617) 983-6813

Any cluster/outbreak of illness (e.g. food borne) Anthrax Botulism Brucellosis Diphtheria Encephalitis (any case) Haemophilus Influenzae (invasive infection) Hemolytic Uremic Syndrome Hepatitis A (acute [lgM +]) Measles Meningitis (bacterial) Meningococcal Disease (N. meningitides, invasive) Poliomyelitis Rabies (humans only) Rubella (humans only) Tetanus Tularemia

In addition, the MDPH requests the voluntary reporting of Plague and Viral Hemorrhagic Fevers

Report Promptly (within 24 hours)

Amebiasis Babesiosis Campylobacter Enteritis Chickenpox (Varicella) Cholera Cryptosporidiosis E. coli 0157:H7 Food Poisonings (includes poisoning by ciguatera, scombrotoxin, mushroom toxin, tetrodoxin, paralytic shellfish and amnesic shellfish) Giardiasis Hansen's Disease (Leprosy) Hepatitis B (acute or chronic) Hepatitis C (acute or chronic) Kawasaki Syndrome Legionellosis Leptospirosis Literiosis Lyme Disease Malaria

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Meningitis (viral) Mumps Pertussis (Whooping cough) Psittacosis Reye Syndrome Rheumatic Fever Rocky mountain Spotted Fever Salonellosis (including typhoid) Shigellosis Toxic Shock Syndrome Toxoplasmosis Teichinosis Yersiniosis

Report Promptly within (24 hours)

Report all cases directly to the Massachusetts Department of Public Health, Bureau of Communicable Disease Control.

HIV/AIDS: Call (617) 983-6950 Sexually Transmitted Disease: Call (617) 983-6952

Chancroid Chlamydial Infections (genital) Genital Warts Gonorrhea Granulome Inguinale Herpes, Neonatal (onset within 30 days after birth) Lymphogranuloma Venereum Ophthalmia Neonatorum a) Gonococcal b) Other agents Pelvic Inflammatory Disease a) Gonococcal b) Other agents Syphilis Tuberculosis: Call1-88-MASSMTB Rabies Post-Exposure Prophylaxis: Call (617) 983-6800

MDPH, its authorized agents, and local boards of health have the authority to collect pertinent information on all reportable diseases, including those not listed on the listing, related to epidemiological investigations (M.G.L. c. Ill, s. 7).

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Policy Regarding Separation of Title X Services and Abortion Services

I. Policy: It is PPLM's policy that no funds from the federal Title X program are used to provide abortion services or to provide other prohibited abortionrelated activities.

II. Purpose: The purpose of this policy is to document guidelines and regulations that provide the generally accepted principles for separating Title X and abortion services and to document PPLM's compliance with the federal regulations regarding provision of Title X services.

III. Scope: PPLM's Title X facilities (Worcester, Marlborough, Fitchburg, Milford), Administration and Finance Department.

IV. Procedure: PPLM's policy regarding separation of Title X and abortion services is

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based on the federal guidelines, which requires Title X sites ensure that federal Title X funds are not used to provider abortion services or other prohibited abortion-related activities.

PPLM acknowledges that:

1. A Title X project must preserve sufficient separation between Title Xfunded program activities and abortion-related activities. PPLM's Title X funded activities do not include services that directly facilitate the use of abortion as a method of contraception. The following activities are specifically prohibited in PPLM's Title X program:

a. Providing transportation for abortion b. Obtaining consent forms from clients interested in abortion c. Scheduling an abortion or arranging for the performance of an

abortion d. Advocating abortion within Title X program activities.

2. To comply with Title X rules (as outlined in the DHHS notice, "Provision of Abortion-Related Services in Contraceptive Service Projects" July 3,2000.) PPLM Title X funded centers that also offer medication or surgical abortion will separate prohibited abortion

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related activities from Title X funded activities through the following systems:

a. Separate cost centers so that shared costs can be properly allocated between Title X and non-Title activities;

b. Procedures to allocate time and other costs related to staff that perform non-Title X activities at Title X funded centers;

c. Counseling and service protocols that reinforce the distinction between Title X funded and non-Title X services;

d. A centralized call center that handles all appointment making for abortion services that is separate from Title X-funded activities;

e. A system to exclude all abortion related services from the monthly upload of utilization data to the Region I Title X data system.

PPLM Procedures to Ensure Abortion Separation:

1. Fees

a. Patients who seek medication abortion at a Title X-funded center will be informed that no Title X funds are used to provide or promote abortion. Staff will inform patients that medication abortion is not subsidized by any state or federal grant. Non-Title X services are designated on PPLM's fee schedule.

2. Allocation of Time

Surgical abortion services are provided on set days and at set times. Medication abortion and laminaria insertion appointments may be planned in the schedule throughout the day. Abortion and abortionrelated appointments will have separate schedules in the appointmentmaking system.

a. For health centers that receive Title X funds, staff must charge the time spent providing abortion services to the abortion program according to the agency's guidelines (see detail below under Administrative Guidelines, Forms, Time sheets).

b. All time spent on abortion-related activities such protocol preparation and revision, quality assurance, training, service coordination will be coded to the Program department's abortion cost center (in effect 1/1/2010).

3. Appointment making

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Abortion appointments are made through the PPLM centralized call center. The call center has its own, separate cost center. None of the staff expenses or other expenses for this service are charged to the Title X grant. All patients at Title X sites who request abortion appointments with PPLM will be referred to the Call Center.

4. Patient Counseling

a. Patients at a Title X center who, after being provided with a variety of options, express interest in making an appointment for an abortion at a PPLM center will be referred to the PPLM call center and will be told that abortion services are not part of the Title X program. Patients who opt to have any abortion service at a Title X-funded center will be informed that no Title X funds are used to provide or promote abortion.

b. Title X sites must offer pregnant women the opportunity to be provided information and education regarding each of the following options;

1. Prenatal care and delivery; 11. Infant care, foster care, or adoption; and

111. Pregnancy termination

c. If requested to provide such information and education, PPLM will provide neutral, factual i,nformation and nondirective education on each of the options, and referral on request, except with respect to any options about which the pregnant women indicates she does not wish to receive such information and counseling.

d. A Title X site may provide referral for abortion, which may include providing the patient with the name, address, telephone number, and other factual information (charges, insurance coverage) about an abortion provider. PPLM will provide at least 2 referrals for patients requesting this service.

5. Title X Reporting

PPLM uploads a file with all of its Title X visits to the Region I Title X reporting system monthly. Any visit with an abortion related ICD-9 code (63S.x) is excluded from the file. This includes medication abortion and post abortion follow up visits. Health center staff has been instructed to use the abortion ICD-9

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codes for any visit related to providing an abortion.

6. Program Clarifications

At times, patient visits or patient problems may not clearly be related to either the contraceptive or abortion programs. At times, some judgment is needed. When in doubt, always charge time and expense to the abortion program and include the appropriate abortion diagnosis code on the encounter form.

7. Administrative Guidelines

The methodology for determining cost allocation in assigning expenses to the abortion program is based on the visit volume of the center with a minimum of 5% of shared costs assigned to the abortion program. This percentage is reviewed annually to account for the growth of the program over time.

a. Staff Time Sheets

All staff are required to document the time spent in each cost center; the format of the time sheet is based upon assignment of time by cost center.

All staff must record the time spent in the abortion program using the appropriate cost center number. Personnel at Title X centers that co-site abortion and Title X contraceptive services are expected to code their timesheets at the end of a defined work period to show time actually spent on abortion related activity during that time period. This includes both staff providing direct clinical services and administrative and support staff.

h. Check Requests and Invoices

Expenses for the abortion program must be coded directly to the abortion program. When shared costs exist that are not directly attributable to the abortion program they will be allocated on the basis of pre-determined formulas.

c. General center expenses

Center expenses are allocated between a center's contraceptive cost center and its abortion cost center. These expenses include occupancy, telephone, utilities, office expense, miscellaneous, depreciation, insurance, telephone, repairs, maintenance and

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security, telephone, outside printing, and rental of minor equipment. The allocation is based on the square footage of the center devoted to use for abortion services. No medications purchased through the 340B program are used in the abortion servIce program.

Worcester Title X - 120200 - 50% Worcester Abortion Services - 120100 - 50%

d. Lab/Pathology Expense

All lab tests and pathology for the care related to a surgical or medication abortion should be coded 100% to the appropriate abortion cost center.

e. Other Clinic Supplies

Medical supplies used exclusively in the abortion program are coded 100% to that program number.

1. All medical supplies used by both the contraceptive and the abortion programs should be allocated between those programs according to historical visit percentages.

11. Medical supplies used exclusively by the Title X program are coded to the Title X expense codes.

111. Medical supplies used exclusively in the abortion program are stored in dedicated abortion program areas.

f. Physicians

All costs for contracted physician abortion providers are coded 100% to the abortion program. Consulting physician time should be allocated to both the contraceptive program and the abortion program according to historical visit percentages.

g. Travel Expenses

All expenses for mileage, meals, lodging, and seminars related to providing abortion services are coded 100% to the abortion program. This includes internal training sessions related to abortion (both for staff trainers and center staft); meetings of internal task force groups or committees, such as Abortion Providers Committee, as well as travel within and outside of Massachusetts to meetings related to abortion provision or training, such as CAPS or NAF.

Policy # AQProved: Approved: Originator: Replaces:

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h. Forms/Publications

Forms or other printed materials used specifically by the abortion program are coded to the outside printing line of the appropriate abortion cost center.

i. Malpractice Insurance

Malpractice Insurance expense is allocated to the appropriate abortion cost centers based on the following formula: the total of the procedures (CPT codes) provided multiplied by the current rate per procedure, as established annually by ARMS.

j. Miscellaneous Expense

Any costs related to the abortion program that does not fit into an expense category detailed above will be expensed to "miscellaneous" in the appropriate abortion cost center.

Date:

I. Policy:

II. Purpose:

III. Scope:

Services for Mentally Incompetent Individuals

PPLM provides medical or surgical services to individuals who are able to consent for treatment or have the consent of a legal guardian.

The purpose of this policy is to ensure that all of our patients are able to consent to any treatment and are able to understand the treatment.

All PPLM Health Center Staff

IV. Procedure:

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A person who is mentally incompetent cannot legally consent to medical or surgical treatment. When there has been a judicial determination of mental incompetence, the consent of the patient's legal guardian must be obtained. The mentally incompetent person should also sign consent form if she understands the form and is capable of signing. With respect to persons who have not been adjudged legally incompetent, if the physician or interviewer doubts a patient's capacity to consent, the consent of the nearest relative should be obtained in addition to the consent of the patient. If there are no relatives to consult, application should be made for a court order.

Policy # 06-29 Date: Approved: Leadership Team 2/28/06 Approved: Health Services Quality Committee 1113105 Originator: R(!Q1aces:

I. Policy:

Transfer & Transient Patients

Inter-affiliate transfer and transient patients are accepted at PPLM without requiring that the patient be considered a new patient and without routine examinations and laboratory tests unless due to be repeated.

II. Purpose: The purpose of this policy is to ensure that inter-affiliate transfer and transient patients are not considered a new patient and are not required routine examinations and laboratory tests unless due to be repeated.


IV.

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Procedure: A. affiliate and who

Transient patients (e.g. persons who are registered with the local

will be in the area no longer than three (3) months): If the person is an active patient at another Planned Parenthood affiliate and her current medical status is confirmed, a prescription method and other management and treatment may be provided.

B. Transfer patients: If the patient is an inter-affiliate transfer and her current medical status is confirmed, a prescription method and other medical services may be provided. Upon completion of the transfer of the medical record, the person will be categorized as an active patient.

C. Current medical status must be confirmed and documented.

Policy # Approved: Approved: Originator: Revised:

Records ofvisit(s) must be maintained. "The Medical Information Form for Inter-Affiliate Transfer/Transient Patients" should be used.

06-30 Date: Leadership Team 2/28/06 Health Services Quality Committee 1113105

Pills by Mail

I. Policy: PPLM will mail contraceptive refills to existing PPLM patients with current prescriptions.

II. Purpose: The purpose of this policy and procedure is to ensure that our patients are able to access their birth control more conveniently and to ensure that are staff are following the proper guidelines when filling the prescriptions.


IV. Procedure: Patient Eligibility

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The Pills by Mail service is available to any existing PPLM patient who has a current/active prescription for a contraceptive method with refills remaining, with the exception of patients using MassHealth.

Fees

Most patients will be required to pay the full (self-pay) price for each cycle of contraception. If she requests 12 cycles, PPLM will honor the "buy 12, get the 13th cycle free" policy. All patients must pay a shipping and handling fee of $4.50. This fee is variable and PPLM is at liberty to modify the charge as necessary.

Patients who generally receive a sliding scale discount for other PPLM services and who are required to provide income verification will not receive such discounts for Pills by Mail orders. Patients who receive sliding scale discounts and who are not required to provide income verification (such as middle and high school students) may receive discounts on up to 13 cycles at the appropriate sliding fee scale level.

Contraceptive supplies are non-refundable.

Quantity

Patients may request up to the full amount of refills remaining on their prescription, up to 13 cycles, with the exception of Nuva Ring. If the patient has 3 or more refills remaining, she must request a minimum of 3 cycles. If the patient only has 1 or 2 refills remaining, she may request the remaining number of cycles. PPLM will only ship up to 3 cycles of Nuva Ring at a time.

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Operations

Pills by Mail requests must be made by the patient directly, not via a third party, with exceptions in the case of translation. Patients will place requests by speaking with a PPLM staff person over the phone or by leaving the required information on a voicemail.asindicated in the phone script. At a minimum, the patient must leave her name and phone number to be called back by a staff person. The patient may also choose to leave her full order on the voicemail, and if all necessary information is provided, the request will be processed as usual. If any piece of information is not provided or is unclear, PPLM staff will call the patient back.

PPLM staff will verify patient and prescription information in the practice management system. For each Pills by Mail request, the Pills by Mail Order Foro1 will be completed, including the names of each staff person involved in the order with dates.

The patient chart and request form will be given to a licensed staff person for review.

The licensed staff person will review the order, confirm the prescription, and package supplies in the appropriate envelope, making notes on the order form as needed. The envelope and the order form are then given to PPLM staff to complete the transaction. .

To complete the order, the PPLM staff person will process the credit card transaction and enter the charges into the practice management system according to current policy. The CPT codes "CTSHIP" and "CTMAIL" will be entered for each transaction, in addition to deducting the number of cycles requested from the prescription as a result of the order. "CTSHIP" is associated with the shipping and handling fee; "CTMAIL" is a zerocharge tracking code used to differentiate Pills by Mail transactions with in-person supplies sales.

PPLM staff will complete the patient receipt at the bottom of the form and include both this and the customer copy of the credit card receipt in the packing envelope. Sealed and addressed packages will be shipped the next business day.

The top portion of the Pills by Mail order form will be filed in the patient chart.

Payment and Billing

The patient is quoted the total price of supplies plus shipping and

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handling. An active debit or credit card is required to request Pills by Mail. PPLM will not ship supplies in the event of a declined card.

PPLM staff will verify the billing address of the card, and that the name on the card is the patient's name. In the case where the patient absolutely cannot use a card with her name, PPLM will accept a credit or debit card with a name other than the patient's only with a complete and signed authorization form. PPLM will direct the patient to the website to obtain a copy of the form, or will fax a copy to the patient. Pills by Mail requests will not be processed until the authorization form has been received.

In the case of a declined debit or credit card, PPLM staff will attempt to reach the patient via phone a minimum of three times. Packaged supplies will be held for up to one week in the event of waiting for a patient call back.

Postage and Shipping

PPLM staff will inform the patient that her order may take up to 10 business days to arrive. It will also be recommended that she place her next order at least 2 weeks in advance.

Requests will be processed and packaged Monday through Friday and are generally shipped the next business day. All packaged and sealed orders kept at PPLM overnight will be stored in a locked cabinet.

PPLM will ship Pills by Mail requests using U.S. Postal Service, First Class. PPLM will use padded mailing envelopes and return address labels with the street address of the site only.

Pills by Mail requests may be shipped in the continental U.S. Pills by Mail requests may be shipped to a P.O. box.

Patients may choose a shipping address that is different from the one listed in the practice management system. If applicable, PPLM staff will prompt the patient to verify and/or update the address fields in the practice management system.

Inventory and Supplies

All office supplies required for Pills by Mail will be ordered by the Facilities and Purchasing Manager or designee and integrated into the existing inventory system. Pills by Mail supplies will be accounted for with a unique department code.

Budget / Financial Plan

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Please review the Pills by Mail Financial Plan for detailed infonnation regarding the costs of the service.

Legality

PPLM has been advised in regards to Pills by Mail by legal personnel and by the Massachusetts Department of Public Health. Please review the following documents for more infonnation.

Foley Hoag Legal Memo, 1/04 DPH Approval Email, 6/04

Service Evaluation

The progress of Pills by Mail will be evaluated on a monthly basis via PPLM's monthly clinic statistics report. Detailed reports may be run on an as-needed basis. At the six-month mark of the service, a workgroup will convene to review the service and make modifications as necessary.

Other AffIliates

Several Planned Parenthood affiliates offer services similar to Pills by Mail, including:

Planned Parenthood of Northern New England Planned Parenthood of San Diego and Riverside Counties Planned Parenthood of East Central Iowa Planned Parenthood of Indiana Planned Parenthood of Southern New England Planned Parenthood of Central Ohio

Policy # 06-31 Date: Approved: Leadership Team 2/28/06 Approved: Health Services Quality Committee 1113105 Originator: Revised: 8/2009

Pills Now Pay Later Policy

I. Policy: Patients can pick up a year's worth of contraception and pay for it over the course of the year.

II. Purpose: To provide patients with a convenient way to get a full year of birth control.

III. Scope: Non-slide 1 self-pay patients and insured patients who choose to self-pay for the patch, the ring or pills at all health centers.

IV. Procedure: Patients will be able to access the PNPL program at a visit or when

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requesting refills. The patient must pay for her visit and one month's supply of birth control at the time of her visit. PPLM accepts Visa, Mastercard and Discover for payment. The credit card must be in the patient's name, and the patient must use the same credit card for PNPL that she uses to pay for her visit and one month's supply of birth control at the time of her visit. When using the PNPL program, the 13th month of birth control is not free. Patients can only cancel a PNPL contract if it is medically indicated by a PPLM clinician or physician.

For patients using Nuva Ring, a bright orange Refrigeration Required sticker must be affixed to each Nuva Ring box dispensed as well as the outer bag. The patient must be reminded that the Nuva Ring has to be refrigerated.

At a Visit

Patients must pick up a full year of birth control to sign up for the PNPL program at a visit. The PNPL Credit Card Agreement will be included in the HOPE and GYN packets. If at any point during a visit, a patient clearly expresses that she is not interested in PNPL, staff should remove the PNPL materials from the patient's information. The PNPL materials can be returned to reception to be used again. Clinic assistants and recovery room staff should remind patients about the program if they plan to get birth control during their visit. If a patient expresses interest in the program, she should complete the grey sections of the Credit Card Agreement. The nurse or clinician packaging the birth control should document the number of packs of pills dispensed in the Pills Now section of the Credit Card Agreement. The PNPL code on the encounter form should be darkened in addition to the usual codes. The staff person checking the patient out should complete the remaining sections of the Credit Card Agreement, verify the credit card information that the patient entered, ask the patient to sign the Agreement, and make a copy of the agreement for the patient. Patients can pay for as many cycles as they

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want on the day of their visit and pay for the remaining cycles over the course of a year. The billing start date is the 5th or the 20th (based on patient's selection) of the next month.

Picking up refills

PNPL is described in the refill voicemail and in the online refill request system, and patients are asked to indicate in their message or online if they would like to sign up for PNPL. If they indicate that they would like to sign up for PNPL, the nurse will package their remaining refills and indicate on the label that they would like to sign up for PNPL. When the patient picks up the refills, the patient should complete the Credit Card Agreement. The staff person checking the patient out should complete the remaining sections of the Credit Card Agreement, verify the credit card information that the patient entered, ask the patient to sign the Agreement, verify that the signature is consistent with the signature on the back of the card and make a copy of the Agreement for the patient.

Billing

Reception staff should set PNPL patient's primary insurance to self-payor slide 2 and set her secondary insurance to PNPL. If the patient has insurance and is choosing to self-pay for birth control, her primary insurance should be set to her insurance carrier. Visit payments are posted to self-pay/slide 2 and birth control payments are posted to PNPL.

Paper clip the Credit Card Agreement to the encounter form, separate the encounter forms with Credit Card Agreements and send to the Billing Department. The Credit Card Agreements will go to the PNPL biller to enter into the PNPL software.

Reed, Inc. will process the credit cards transactions on the 5th and 20th of each month. PPLM will receive a transaction report from Reed. The PNPL biller will post each PNPL payment to each patient account. The PNPL biller will review the payments received for unsuccessful credit card transactions. A one time administrative fee of $15 will be charged to the patient account for a denied credit card. Card declines will be resubmitted up to 3 times within 7 days. In the event that the card does not successfully process, the remaining amount of the contract will be due immediately and will be transferred to the patient and billed to her through PPLM's collections process.

On a monthly basis, the PNPL biller will query Medical Manager for the number of PNPL transactions, compare that number to the number of

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Credit Card Agreements processed, and investigate any differences. This reconciliation will be reviewed by the Patient Accounts Manager. The Credit Card Agreements will be kept in the Patient Accounts Manager's locked drawer. Each month, accounting will compare the total amount received in the bank account to the total of the two transaction reports received from Reed, Inc.

Birth Control Returns

If a patient does not like the birth control method that she is prescribed, she can return her remaining supply and get a replacement method for the same number of cycles. Patients can ONLY get a replacement method if they return their originally prescribed method. The birth control returned by the patient should be put in the designated location to be destroyed. On a monthly basis, each site should count the number of cycles of birth control to be destroyed and report that number to the Center Director. If a patient selects a replacement method that is more expensive than her original method, the patient needs to complete a new credit card agreement.

Incentive Program

Staff members will receive $6 for each patient that they are responsible for enrolling in the Pills Now Pay Later program for the first time. Staff members will receive $6 for each patient that renews her contract. Staff members should write their name legibly on the agreement to receive credit for signing the patient up.

Policy # 06-31.2 Effective Date: 12/18/06 Revised: 8/2009

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Disposal of Expired Medication

I. Policy: PPLM maintains an inventory of both prescription and non prescription medications. These medications may expire before they are dispensed to patients. When medications expire, they should be disposed of in hazardous waste containers and given to PPLM's hazardous waste vendor.

II. Purpose: The purpose of this policy is to establish a policy for safe, legal disposal of expired prescription and non-prescription medications that meets all regulations.


IV. Procedure: All expired prescription or non prescription medications must be disposed of in a red biohazard sharps container and then given to our Waste Management vendor for disposal.

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Only individuals authorized to dispense (i.e. MD, NP, RN) may dispose of expired or returned medications. The method of disposal must be in accordance to applicable Federal, State, and local regulations for disposal of chemicals and potentially dangerous or hazardous substances. Disposal of stock, samples, and client medications will be documented on a Medication Destruction Log which should include the following information: 1. Name of medication, strength, quantity 2. Date of disposal 3. Appropriate signatures (two signatures for controlled substances).

All narcotics will be disposed of according to this policy and the disposal will be recorded in the narcotics log. All narcotics that are disposed of will be disposed of with a witness present. Both the person disposing of the medication and the witness will initial the narcotics log and note that the expired medication was disposed of. The narcotics count should be redone to ensure that the narcotics inventory and the log balance.

After the medications have been placed in the red biohazard sharps container, the empty plastic bottles may be placed in the regular trash. Any glass ampules must be placed in the red biohazard sharps container.

Policy # 32 Date: Approved: Approved: Originator: Replaces:

I.

II.

III.

IV.

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Interpreter Policy for Limited English Proficiency (LEP) Patients

Policy:

Purpose:

Scope:

Procedure:

PPLM provides interpreter services for LEP patients when a provider is not available that speaks the patients' native language through one of four means: staff that is fluent in the patient's spoken language, friends and/or family of the patient, volunteer interpreters, or paid interpreter services, either in person or via a language line. This meets CLAS standards (National Standards on Culturally and Linguistically Appropriate Services).

The purpose of this policy is to document the policies and procedures that are in place to ensure that LEP patients understand the medical care that is provided to them and that informed consent is obtained for all services and provided in a manner compatible with their preferred language.

Health center staff and volunteers, and LEP patients

When a LEP patient schedules an appointment, PPLM determines which interpreter service the patient will have and schedules accordingly. PPLM follows the procedures for each of the approved means of providing LEP patients with interpreter services:

Staff that is fluent in the patient's spoken language In order to qualify for the bilingual pay differential and to be allowed to interpret for patients, the staff person must pass a language proficiency test. Testing will be completed by an outside testing service.

If the position requires bilingual proficiency, Human Resources will coordinate the testing as part of the interview process. If the position does not require bilingual proficiency, but rather bilingual preferred, the new staff member will be tested by their 90 day evaluation and coordinated by their supervisor/manager.

Current staff that is receiving the differential will be tested on an annual basis. Supervisors are responsible for scheduling language proficiency testing for any existing staff.

PPLM staff must document that interpretation services were provided by completing the Interpreter Consent Form (Form GEN 12). The completed form will be placed in the patient's chart.

Friends and/or Family If a patient requests that a friend or family interpret for him/her the family/friend interpreter must be 18 years or older and show proof of ill if between the ages of 18-21. The patient and friend or family member must also complete the Interpreter Consent Form (Form GEN 12) documenting her/his desire to have a friend or family member interprets for her/him. A PPLM staff member must witness the patient's signature. The ability for the friend/family member to interpret is at the discretion of PPLM staff.

Volunteer interpreter services PPLM uses volunteer interpreters who are certified medical interpreters. The volunteer must provide documentation verifying certification. PPLM must have

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signed, completed paperwork including a confidentiality agreement and documentation of HIP AA training, with the volunteer before scheduling services. PPLM staff must document that the volunteer provided interpretation services for each patient by completing the Interpreter Consent Form (Form GEN 12) and placing the completed form in the patient's chart.

Paid interpreter services PPLM uses interpreter companies that are affiliated with the American Translation Association and the Massachusetts Medical Interpreters Association. PPLM must have a signed Business Associate agreement with a company before scheduling services. PPLM staff must document interpretation services for each patient by completing the Interpreter Consent Form (Form GEN 12) and placing the completed form in the patient's chart.

Policy # 06-33 Effective Date: 12/1/06 Date(s) of Revision: 7/2009, 8/2010

I. Policy:

Comment Card Policy

PPLM values patient feedback and solicits feedback through comment cards. PPLM analyses all comments and makes operational changes as necessary.

II. Purpose: The purpose of this policy is to ensure that PPLM offers clients the opportunity to have their comments heard. PPLM is always looking for ways to improve our services and welcomes feedback from our clients regarding services they would like us to continue as well as suggestions for improvement.

III. Scope: PPLM Health Centers

IV. Procedure: PPLM has placed comment cards and receptacles in our client waiting

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areas at all three health centers. Center Directors check the receptacles on a regular basis and respond directly to patients who request further contact. All feedback is recorded on a spreadsheet which Center Directors from all three health centers review on a quarterly basis. Based on this review Center Directors will present any recommendations for change to the Health Services Operational Team for final approval.

Policy # 06-34 Date: Approved: Leadership Team 2/28/06 Approved: Health Services Quality Committee 1113105 Originator: Revised: 8/20090

Sharing Arrangement

I. Policy: PPLM will refer all patients, both in person and over the phone, who have a gestational age greater than 18 weeks and 6 days to the Access Coordinator.

II. Purpose: The purpose of this policy is to ensure eligible patients get access to services that are not available at PPLM.

III. Scope: This policy is for all patients and staff at PPLM.

IV. Procedure: After an ultrasound, if the patient dates farther than 18w6d, PPLM staff

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should page the Access Coordinator. If the patient is in Boston, and the Access Coordinator is also working in the building that day, the Access Coordinator will meet with the patient in person to discuss options and make appropriate referrals. If the patient is in Worcester or Springfield, or if the patient is in Boston and Access Coordinator is accessible by mobile phone, staff will place the patient in a room with a phone and the Access Coordinator will discuss options with the patient over the phone. Every attempt should be made to reach the Access Coordinator while the patient is still at PPLM. If the Access Coordinator is not available or the patient does not want to stay, patients should be given a card with the Access Coordinator's contact information and asked to call her as soon as possible. Staff should also leave a message with the Access Coordinator that contains the patient's name, gestational age by ultrasound and medical record number, and should fax the ultrasound to the Access Coordinator.

If a patient calls to schedule an appointment or calls the Sexual Health Counseling and Referral Hotline, and by LMP or a previous ultrasound the patient dates farther than 18w6d, or the patient dates under 18w6d but cannot be accommodated at a PPLM clinic in a timely fashion, staff should transfer the call to the Access Coordinator, who will provide options counseling and appropriate referrals over the phone.

Providers in Massachusetts refer the following patients directly to the Hotline and Access Coordinator for assistance in accessing services: Patients whose gestational age is greater than 18w6d and who also • Are Massachusetts residents • Have MassHealth or no health insurance • Have private health insurance and are medically ineligible to be seen in a clinic

Policy # 06-35 Date: Approved: Leadership Team 2/28/06 AQQfoved: Health Services Qualgy Committee 1113/05 iginator:

I Replaces:

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Reporting Thefts/Loss of Controlled Substances

I. Policy: PPLM will report the theft or loss of controlled substances to the Drug Control Program immediately upon discovery by telephone, followed up in writing within 7 days of the incident.

II. Purpose: To document compliance with Department of Public Health regulation 105 CMR 700.00SCA) that requires every licensed health care facility to report the theft of loss of a controlled substance to the Drug Control Program.

III. Scope: PPLM Health Centers

IV. Procedure: Upon discovery of the theft or loss of a controlled substance, the site

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Center Director will call the Drug Control Program at 617.983.6700 to report the loss. The Center Director will report the loss in writing to the Drug Control Program within 7 days of the identification of the loss to the following address:

Drug Control Program 305 South Street, 2nd Floor Jamaica Plain, MA 02130

Policy # 06-36 Approved: Leadership Team Approved: Health Services Quality Committee Originator: Re_~laces:

Date: 2128/06 1113/05

Vaccine Storage

I. Policy: PPLM maintains an inventory of vaccines from the Department of Public Health and vendors. All vaccines should be stored according to the vaccine manufacturer's instructions and the instruction ofDPH.

II. Purpose: The purpose of this policy is to establish a policy for the storage of vaccines at each clinic site that meets all regulations.


IV. Procedure: PPLM will maintain an accurate record of all vaccines received, including

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type of vaccine, manufacturer, lot number, expiration date and total number of doses. All vaccines, with the exception of varicella, must be stored at 2°_8° C (35°-46° F). The refrigerator temperature should be recorded twice daily (AM and PM) on the temperature log. This log should include a space for the temperature and the staffs initials who documented that temperature. The log should be reviewed regularly for completeness and out of range temperatures. A copy of the log should be kept in the Lab Manual. Temperature logs must be maintained, according to MA DPH, for 3 years.

Thermometers should be placed in a centra110cation in each compartment near the vaccine. A number of thermometers can be used. A chart comparing these thermometers is available through MMWR vol.551N0.RR-15.

If the temperature is out of range, a supervisor should be notified. The supervisor should contact the Vaccines Management Unit at 617-983-6828 for instructions. The vaccines should be moved to a working refrigerator. The vaccine should be marked clearly "DO NOT USE." Call the vaccine manufacturer or MA DPH to explain the situation and ask about specific vaccines usability.

State-supplied vaccines that are damaged or expired MUST be returned to DPH. PPLM MUST call the MDPH Vaccine Management Unit at 617-983-6828 for instructions on returning the vaccines. A completed Vaccine Return Request Form must be completed and faxed to MDPH Vaccine Management Unit at 617-983-6924. See attached document. Vaccines coming directly from the manufacturer that have expired, can be disposed of per PPLM expired medication disposal policy.

Policv # 06-39 Date: Approved: Approved: Originator: Replaces:

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Massachusetts)

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PPLM Attachment F - Information and Education Committee

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

Information and Education Committee

Worcester Representative

Fitchburg/Leominster Area RepresentatIve

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PPLM Attachment G - Schedule of Charges and Sliding Fee Scale

sim VISIT DESCRIPTION Planned Paren

11981 IMPLANON INSERTION

11982 IMPLANON REMOVAL o 75 150 225 300

11983 IMPLANON REMOVAL WI RE-INSERTION o 113 225 338 450

36415 VENIPUNCTURE o o o o o 57170 DIAPHRAGM, CAP FIT o 38 75 112 149

58300 IUD INSERTION o 50 100 150 200

58301 IUD REMOVAL o 34 68 102 135

80051 ELECTROLYTES o 2 3 5 6 80061 LIPID PROFILE o 3 6 9 12

80076 LIVER PROFILE o 3 6 9 12

81002 URINE DIPSTICK o 2 4 6 7 81025,N NON-SENSITIVE UCG o o o o o 81025,S SENSITIVE UCG (PREG. TEST) o 3 5 8 10

81025,WI WALK-IN PREGNANCY TEST o 5 10 15 20

82670 ESTRADIOL o 6 13 19 25

82947 GLUCOSE o 3 4 5 83001 FSH o 5 10 15 20

83986 PH TESTING o o o o o 84146 PROLACTIN o 4 9 13 17

84443 TSH o 4 8 11 15 ·84702 HCG QUANT BSU o 4 8 11 15

84702,MAB HCG QUANT BSU o 4 8 11 15 85018 HEMOGLOBIN o 2 3 4 85025 CBC WIDIFFERENTIAL o 2 3 4 5 85595 PLATELET COUNT o 3 4 5 85610 PT o 3 4 5 85651 lLESR) SEDIMENTATION RATE o 3 4 5 85730 PTT o 2 5 7 9 86592 RPR WITH REFLEX o 3 4 5 86695 HSV TYPE I ANTIBODY o 3 5 8 10

86696 HSV TYPE II ANTIBODY o 4 8 12 16

86701 HIV I ANTIBODY o 6 13 19 25

86702 HIV II ANTIBODY o 25 50 75 100

86790 HSVTYPE I & II o 7 13 20 26

86901 RH TYPING o o o o o 87070 GENITAL CULTURE o 3 5 8 10

87081 GC Culture Rectal or Throat o 3 6 9 12

87086 URINE CULTURE & SENSITIVITY o 8 15 23 30

87102 YEAST CULTURE o 4 8 11 15 87164 GRAM STAIN o o o o o 87210 WET MOUNT o 2 3 4 5 87252 HERPES CULTURE o 6 12 17 23

87255 HERPES CULTURE WI REFLEX o 19 38 56 75

87491 CHLAMYDIA, AMPLIFIED DNA o 6 13 19 25

87491,IH CHLAMYDIA, AMPLIFIED DNA o 6 13 19 25

87591 GONORRHEA, AMPLIFIED DNA o 6 13 19 25 87591,IH GONORRHEA, AMPLIFIED DNA o 6 13 19 25

87621 HPV, HIGH RISK o 14 28 41 55 88142 PAP, THIN PREP REFLEX o 10 20 29 39

96372 1M INJECTION o 5 10 15 20

99000 LAB COLLECTION FEE o 3 4 5 99070,L LUBRICANT -DPH o o o o o 99070,V VAGINAL CONTRACEPTIVE FILM (3) o 2 99201 LEVEL 1 o 17 33 49 65

99202 LEVEL 2 o 23 45 68 90 99203 LEVEL 3 o 30 60 90 120

99204 LEVEL 4 o 40 80 120 160

99205 LEVEL 5 o 50 100 150 200

99211 LEVEL 1 o 15 30 45 60

99212 LEVEL 2 o 15 30 45 60 99213 LEVEL 3 o 22 43 64 85

Page 1 of 2

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Slidl!1g Scale 1

S~lr ~!~il~ , ,~mc!ing Scale 4 , ~,Self Ray,

~-<100 0> 109",1;1 FPL, ,~,:~01 ~0.2% j:Pl '_ ,- ,'>300% FPL " -- " 5c- " ' Level 75 ' , Level 100 _

" - - -. "~-- ~ ___ ~_ _ ~ __ ~~:_-_- ~ T~ ~ , ,-

Planned Paren ~', - -

- • ,r "~~-2~ ~-'- ~ "'"' :.. - -.:-sim VISIT DESCRIPTION

-~=-- " - -'L~~ ~ -- - , ' , -

, , , , ,

99214 LEVEL 4 0 33 65 98 130 99215 LEVEL 5 0 44 88 132 175 99384 AGE12-17 0 38 75 113 150 99385 AGE 18 - 39 0 38 75 113 150 99386 AGE 40 - 64 0 44 88 132 175 99394 AGE12-17 0 34 68 102 135 99395 AGE 18 - 39 0 35 70 105 140 99396 AGE 40 - 64 0 44 88 132 175 A4266 DIAPHRAGM 0 6 13 19 25 A4267,C CONDOMS (6 units) 0 0 1 1 1

A4269 CONTRACEPTIVE JELLY 0 2- 3 5 6 ACYC Acyclovir 0 5 10 15 20 AZIT Azithromicin 0 5 10 15 20

IUDCHK IUD CHECK (AT 6 WEEKS~ 0 0 0 0 0 J0696 Rocephin (Injection) 0 3 5 26 35 J1055 DEPO PROVERA 0 10 20 30 40 J3490,OTC PLANB/Next Choice - OTC (+ 5% Sales tax) 0 10 17 25 32 J3490,P PLANB/Next Choice - Prescription Only 0 8 15 23 30 J7300 PARAGARD IUD 0 125 250 375 500 J7302 MIRENA IUD 0 225 450 675 900 J7303 NUVARING 0 15 30 45 60 J7304 EVRA PATCH (1 box = 3 patches) 0 15 30 45 60 J7307 IMPLANON 0 75 150 225 300 LEVOR LEVORA 0 8 15 23 30 LUT LUTERA 0 8 15 23 30 MC1,5 MICROGESTIN 1,5/30 0 8 15 23 30 MC20 MICROGESTIN 1/20 0 8 15 23 30 MICRO MICRONOR 0 8 15 23 30 ORCYC ORTHOCYCLEN 0 8 15 23 30 ORTRI ORTHOTRICYCLEN 0 8 15 23 30 ZITHROMAX Zithromax 0 7 14 20 27

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Massachusetts)

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PPLM Attachment H - IRS Certification of 501c3 Status.

t~~ ."RS Devmtlllent of the Tl'easmy ~ifll"JJ'. IlItnnllJ R,,"clluf.' Scn'le." .

000169

P.O. Box 2508 '. Cincinnati 'OH 45201

PLANNED PARENTHOOD LEAGUE OF MASSACHUSETTS INC

1055 COMMONWEALTH AVE BOSTON MA 02215-1001

In reply refer to: 0248162365 July 29, 2010 LTR 4168C EO 04-2698497 000000 00

00021329 BODC: TE

Employer Identification Number: 04-2698497 Person to Contact: Robert C Voss

Toll Free Telephone Number: 1-877-829-5500

Dear Taxpayer:

This is in resporise to your July 20, 2010, request for information regarding your tax-exempt status.

Our ·records indicate that your organization was recognized as exempt under section 501Cc)C3) of the Internal Revenue Code in a determination letter issued in May 1980.

Our records also indicate that YOU are not a private foundation within the meaning of ~ection 509(a) of the Code because YOU are described in sectionCs) 509(a)(I) and 170(b)(I}(A)(vi).

Donors may deduct contributions to yoU as provided in section 170 of the Code. Bequests, legacies, deVises, transfers, or gifts to yOU or for your use are deductible for Federal estate and gift tax purposes if they meet th~ applicable provisions of sections 2055, 2106, and 2522 of .the Code.

Beginning with the organization's sixth taxable year and all succeeding year~, it must meet one of the public support tests under section 170(b)(I)(A)(vi) or section 509(a)(2} as reported on Schedule A of the Form 990. If your organization does not meet the public support test for two cons~cutive' years, it is required to file Form 990-PF~ Return o~ Private Foundation, for the second tax year that the organization failed to meet the support test and will be reclassified as a private foundation.

If you have any Questions, please call us at the telephone number shown in the heading of this letter.

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PLANNED PARENTHOOD LEAGUE OF MASSACHUSETTS INC

1055 COMMONWEALTH AVE BOSTON MA 02215-1001

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0248162365 July 29, 2010 LTR 4168C EO 04-2698497 000000 00

00021330

Sincerely yours,

Michele M. Sullivan, Oper. Mgr. Accounts Management Operations I

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Massachusetts)

Awarded

PPLM Attachment I - Project Administration Policy and Procedures

Manual

Project Administration Policy and Procedures Manual

Scope of Title X Project:

With Title X funding, PPLM is leveraging 27 years of experience as a family planning provider in Central Massachusetts to increase access to Title X family planning services throughout the region. Between May and August 2010, we opened three new clinics in Marlborough, Milford, and Fitchburg. In January 2010 we also converted our Worcester Health Center to our largest Title X site, and begin a partnership with the Framingham Community Health Center. Between January-June 2010 we reached 2,233 patients at these five sites, including 1,993 females, 240 males, and 539 adolescents aged 19 and younger. During 2011 we expect to reach a total of 11,405 patients at these five Title X centers, including 10,150 women, 1,255 men, and 2,965 adolescents and teens aged 19 and younger.

TITLE X SERVICE SITE LOCATION FAMILY PLANNING CLINIC HOURS

Worcester Clinic (PPLM) 470 Pleasant Street, Worcester, MA Monday, 8AM-5PM Tuesday, 8:30AM-4PM Wednesday, 8:30AM-7PM Thursday, 7:30AM-7:30PM Friday, 8AM-4PM Every other Saturday, 8AM-2PM

Marlborough Clinic (PPLM) 91 Main Street, Suite 103, Marlborough, Monday 9AM-IPM MA Tuesday 9AM-12PM

Thursday 2PM-7PM Milford Clinic (PPLM) 208 Main Street, Suite 101, Milford, MA Tues-Thurs, 2PM-7PM

Fitchburg Clinic (PPLM) TBD Tuesday IOAM-7PM Friday 8AM-4PM

Framingham Community Health Center 19 Concord Street M-W,F 8AM-5PM (DELEGATE) 72 Union Avenue Framingham, MA Thurs 8AM-3PM

Allocation of Funds to Delegate Agencies:

Through discussions with Toni Maguire at Great Brook Valley and Paula Kaminow at the Framingham Community Health Center (FCHC - a federally qualified health center), PPLM identified the need for an on-site Family Planning Counselor to enable it to serve at least 300 more patients (a 25% increase), by enhancing the capacity of two new family planning providers at FCHC. In addition to providing primary care, including family planning services, FCHC also provides services to homeless popUlations, youth in transition, and recently released prisoners from MCl Framingham. The delegate agency will sign a subcontract each year with PPLM, outlining their obligations under the Title X family planning program.

In future years, as we see demand in high need populations, we will conduct a thorough review to determine ifthere are other local community based organizations we could partner with or if PPLM needs to develop additional service location capacity ourselves to meet the need in Central MA. We envision this as a competitive process which would include a formal Request for Proposal procedure.

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(b) (4) (b) (4)(b)

(4)

(b) (4)

(b) (4)

Allocation of Funds for Title X Grant Administration

PPLM's total allocation to our Title X project for 2011 is $793,548.

PPLM plans to allocate $355,813 in personnel costs for our Title X urogram in 2011. The Title X allo ation is calculated by taking of clinical staff expense, of key personnel expense, and of administrative staff expense. All amounts are based upon PPLM's budget for January - December 2011.

Clinical Personnel include Nurse Practitioners (NPs), Clinic Coordinators and Healthcare Assistants (HCAs) who perfonn exams and tests, prescribe medication, offer birth control options counseling, take medical histories, and oversee day-to-day operations of the clinics. Key personnel include organizational leadership involved in the oversight and administration of PPLM's Title X program.

Administrative staff are also needed to support PPLM's Title X program. In addition to administrative staff in the areas of the Call Center, Finance, Infonnation Technology, Training, and Executive Office, our Title X allocation for administrative staff includes $9,951 for a Central Massachusetts Outreach Manager, who is responsible for increasing awareness of, and access to, Title X family planning services for adolescents and teens.

in fringe benefits for our Title X rogram.

PPLM also plans to allocate $6,700 for travel costs. This includes 100% of the cost of travel for Title X - related trainings/conferences, including regional/state conferences and national conferences.

In 2010, PPLM allocated funds from our Capital budget and Sexual Health Matters Campaign donations for the purchase of equipment necessary to outfit each of our three new Title X health centers (Marlborough, Milford and Fitchburg) with reception areas, waiting rooms, exam rooms, a small lab, and office (see Attachment B: Floor Plans). No amount was charged to the Title X grant for these expenses.

PPLM will allocate $212,755 for supplies. Supplies include contraceptive methods, clinic disposables, medications, lab services and fees, lab supplies, and office supplies. Examples of supplies include pregnancy tests, Pap test, blood tests and STD tests. The amount charged to Title X represents 25% of the budgeted expense for Title X-funded centers and was calculated based on PPLM's budget for January-December, 2011.

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PPLM's Contractual allocation for our Title X program in 2011 is $45,000. This includes 100% of funds allocated to delegate/contractual agencies for family planning programs. PPLM's Title X project includes granting $45,000 to Framingham Community Health Center to fund costs associated with having a Family Planning Counselor on-site. Framingham Community Health Center estimates a 25% increase in the number of patients they can serve as a result of this subgrant.

PPLM will allocate $103,221 to its Title X program for "other" expenses, which include computer services, dues and fees, postage, and shipping. The amount charged to the Title X grant is 16% of the overall cost of these items.

Finally, PPLM is allocating $16,000 for rent expense at our Title X program sites. The amount charged to the Title X grant is 30% of the overall rent expense.

Please see SF-424A, "Budget Information," and the Budget Narrative for further information about PPLM's allocation of Title X funds for 2011.

Preparation of Title X Grant Application

Laura Katz Leacu, PPLM's Senior Manager, Institutional Support, is primarily responsible for the preparation of our Title X budget and grant application. She is overseen by Dianne Luby, PPLM's President/CEO, and Susan Wood, VP, Clinical Operations.

Management of Grant Award

Chad Ellis, PPLM's Chief Financial Officer, is responsible for overseeing PPLM's Title X grant award. He oversees Title X financial management working closely with Christa Chandler, Accounting Manager.

Determining Patient Eligibility for Discounted Family Planning Services

Clients who do not have insurance coverage are eligible for discounted family planning services based on their (or their families') income. PPLM's fee schedule has five levels of discount for patients with incomes up to 300% of the Federal Poverty Level, including a no-fee level for patients at or below 150% of the Federal Poverty Level.

When considering charges to minors (men and women under the age of 18) the following conditions are taken into account.

• If the minor is unemancipated and confidentiality of services is not a concern, the family's income is considered in determining the charge. If, however, the minor does not know hislher family's income, PPLM and its delegate agency assign an estimated income to determine charges. The estimated family income is based on information about the parents' jobs and financial situation obtained from the patient.

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• If the minor requests confidential services - without the consent or knowledge of a principle family member - charges are based on the minor's income alone.

• A minor's income includes wages from employment, stipends, allowances, or grants paid directly to the minor.

When considering charges to men and women 18 years of age and older, the following conditions are taken into account:

• If the young man or woman is living at horne, the family's income is used in determining charges. If the patient does not know his/her family's income, an estimated amount is assigned to the patient to determine charges. The estimated family income is based on information about the parents' jobs and financial situation obtained from the patient.

• If the young man or woman is a student at a college or university, and his/her parents are paying for most of the cost of tuition and room and board, the family's income is used in determining charges. If the patient does not know his/her family's income, an estimated amount is assigned to the patient to determine charges. The estimated family income is based on information about the parents' jobs and financial situation obtained from the patient.

• If the young man or woman is a student at a college or university and he/she is paying for most of the cost of tuition and room and board, the patient's income alone is used in determining charges. The patient's income includes wages from employment, stipends, allowances, or grants paid directly to the minor.

Income, family size, as well as any other eligibility for discount, will be maintained in each patient's financial record and will be updated annually. Uninsured clients with documented incomes less than 100% of Federal Poverty Level are not charged for services. A Health Center Manager can waive fees for clients with incomes above 300% of poverty if she determines that the client is unable, for good cause, to pay for the family planning services.

Sliding Fee Scale

PPLM performs a cost analysis of its services on an annual basis. This analysis involves allocating costs to CPT codes using the following methodology:

• Direct labor costs are allocated to CPT codes based on actual time spent on each visit type. This information is obtained from PPLM's Health Center Log System that tracks each patient's visit length;

• Direct materials costs are allocated based on actual usage; • Overhead and malpractice costs are allocated based on the appropriate relative value unit

component promulgated by Medicare. • To verify cost per CPT code, the cost of each CPT code is multiplied by the CPT code's

volume. These values are then summed to ensure they match the health center's total costs.

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Self-pay charges for patients above 300% of poverty approximate the cost of providing the service. Patients between 151 % and 300% of poverty receive a 50% discount off full self-pay charges (sliding scale 4); patients between 101 % and 150% of poverty receive a 75% discount for visits and a 60% discount for supplies (sliding scale 3); teens receive a 75% discount for visits and a 100% discount for supplies (sliding scale 2); patients under 100% of poverty receive a 100% discount for visits and supplies (sliding scale 1).

With Title X funding, no one will be refused services based on an inability to pay. PPLM's Reimbursement Group reviews the sliding fee scale on a semi-annual basis and updates poverty levels annually. Members of the Reimbursement Group include the President/CEO, CFO, VP, Clinical Operations, Medical Director, Patient Accounts Manager, Center Directors and Government Relations Director. The Reimbursement Group reviews the fee schedule and visit volume to ensure that all financial targets are being met. The Framingham Community Health Center also employs a sliding scale when determining charges to clients; their scale slides to $0 for patients below 100% of the Federal Poverty Level.

Please see Attachment G: Schedule of Charges and Sliding Fee Scale in the Appendix for further detail.

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FPH2011005026



Massachusetts)

Awarded

PPLM Notification of Project Management

NOTIFICATION OF PROJECT MANAGEMENT

1. Please provide us with the Name, Title and Address of the Project Director if not the same as the Authorized Representative signing the application.

NAME, _____ tA_~~~~~uu~~~ ________________ __ T1TLE __ ...;..~_rtS-.:o:Id::....:~----=--...!..../~c£~(J __ ---,-____ _

ADDRESS \(955 ~1\UJtt1' fV\ A~ CITY ~ S?$ teA STATE ,N)A NINE·DlGIT ZIP CODE DfiJP?, IS' - (OC\ PHONE # e?.1-Gl{? ... lbSJ FAX # (OlCJ-Gl6- (bb5"' E.MAIL_~d.....,\0~bo&..f~;.....o@-.,........", -F'rPF-'=-M~ . ..=.C!)~r:g+--____ _

2. Please provide us with the Name, Title and Address of your Business Manager.

NAME aro.A @ltS TITLE C,fO ADDRESS \ t:J55" C,c,JV'\~tih M()ve.. CITY lSe£kcr\ STATE MA NINE·DlGIT ZIP CODE CG\?215'" [CC))

PHONE # G\2- bt~ - I rO%'-! FAX # (0\1) ~ 6Ui ... ·(66S" E·MAIL c...e...1\iS e.- p~I(\I\. O.cg

3. Please provide us with the Name, Title and Address (other than the Project address) of the higher level "authorized official."

NAME, _____ ~~~~~~~ ________________ ___

\h~, PrtSJ~Qj\t; O~ C\;()j co.\ OpC?ro.·EiOIlS ADDRESS tD:SS= C('YY\IY'lY\wf?(lJ 61\ AJ€.I\ve. CITY ~ STATE MA

TITLE

NINE·DIGIT ZIP CODE oae?J5' ." 00 \ PHONE # 6l C") ",b\(; ... \ b l)c;r FAX # Gt"l-Gr b'~ {bGS'

E-MAIL Sw~O @ 'fl?\M.O~~

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PPLM OPHS Checklist

~O~P~H~S~-1~(~3/~2_00~~~ _______________________________________________________________________________ P~age22

OMB App"roval No. 0920-0428 CHECKLIST

Public Burdell Statement: Public reporting burden of this collection of infol1nation is estimated to avol'llge 4 hours per response, including the time for reviewing instructions, searching e;t.isting data sources, gathering and maintaining the data needed, and completing and reviewing the collectioll of infol1nntion. An agency may not conduct 01'

sponsor, Ilnd a person is not required to respond to n collection of infom1lltion tmless it displays a currently valid OMB control number. Send comments I'cgnrding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this

blu'den to os Reports Clearance Officer, ASMBlBudgetJPIOM, Room 503H, HHH Bldg., 200 Independence Ave., S.W .• Washingtoll. DC 2020 I. Do not send the completed fonn to this address.

NOTE TO APPLICANT: This fonn must be completed and sl\bmitted with the original of your application. Bo sure to cCIlnplete both sides of Ihis fOl1n, Check the appropriate boxes alld provide the informatioll requested. This fCllm should be attached as the last page of the signed original of the application. This page is reselved for PHS staff use only.

Type of Appllcalion: DNEW )'Joncompeting ~ Conlinuatlon

Competing o Continuation D Supplemental

PART A: The followIng checklist Is provided to assure that proper signatures, assurances, and certifications have been submitted.

1. Proper Signature and Dale on the SF 424 (FACE PAGE) ..................................... .. ./lfluded

2. Human Subjects CerUfication. when applicable (45 CFR 46) ............................................ . o PART B: This part Is provided to assuro thai portlnont Information has been addressed and Included In the appllcation.

1. Has a Public Health System Impact Statemenl for the proposed program/project been completed and distributed as required? ............................................................... ..

2. Has the appropriate box been checked on the SF-424 (FACE PAGE) regarding intergovemmental review under E.O. 12372? (45 CFR Part 100) ........................ .

3. Has the enlire proposed project period been Identified on the SF-424 FACE PAGE? ................................................................................. , ............................... .

4. Have biographical sketch(es) with job descrlptlon(s) been attached, when required? .............. , ... , .. ,' .............. , .................................. , ................. , ................. , ...

5. Has Ihe "Budgellnformalion" page, SF-424A (Non-Construction Programs) been completed and included? .......................................................................................... ..

6. Has Ihe 12 month detalled budget been provided? ......................................................... .. 7. Has the budget for the entire proposed project period with sufficient detail been

provided? ............................................................................................................... .. 8. For a Supplemental application, does the detailed budget address only the

addilional funds requested? ...................................... _ ................................................. .. 9. For Competing ContinuaHon and Supplemental applications. has a progress report

been Included? .............. , .......................................................................................... .

PART C; In tho spaces providod below. please provide tho requested Information.

NOT Applicable

NOT Applicable

o

o

D

o

~ Business Ofnclallo be noll ned If an award Is to be made. Program Director/ProJect Olractor/Prlnctpallnvestlgator designated to

direct the proposed project or program.

Name ChM 'E\ \~~ Name Oi 0Nle. LokH Title ~~ {) Title ~cW\t-/CEO Organization ?PL..M -'o:..:.r ... 9"'an"'l:::za:..:t:..::loc:..:n--'YL...?lAV\-'--'--=-___________ _ Address \ ~5'5 CJ::,roro A.Je, 1&~-\CIA ~IS'" Address I C)65' CONW"\ A~ 1?~" Q5Cl1&"' E-mail Address ut\\-IS @:W\M.D'S E-mail Address ci lU\of @<~~ (\1\ ,C(9 Telephone Number (Q\!J ... G\ b ~ ',seq Telephone Number (Pl')~ 61 ~...(~

Fax Number 6n-~\~-Irs;; " Fax Number bt ? .. to\G~fQ~ SOCIAL SECURITY NUMBER HIGHEST DEGREE EARNED

I I I I-I I I I I I I I I }/I. A. I (OVER)

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_O_P_II_S_-l_(~3_/2_0_06~) ________________________________________________________________________________ P'~lgCl3

PART D: A private, nonprofit organization must Include evidence of lis nonprofit s1atus with the application. Any of the following is acceptable evidence. Check the appropriate box or complete the "Previously Fllod" section, whichever Is applicable.

rita)

B (b) (c)

A reference to the organization's listing in the Internal Revenue Service's (IRS) most recent list of tax·exempt organizations described In section 501 (c)(3) of the IRS Code. A copy of a currently valid Internal Revenue Service Tax exemption certificate.

o (d)

A statement from a State taxing body, State Attorney General, or other appropriate State official certifying that the applicant organization has a nonprofit status and that none of the net earnings accrue to any private shareholders or individuals.

o (e)

A certified copy of the organization's certificate of Incorporation or similar document If it clearly esteblishes the nonprofit status of the organization. Any of the above proof for a State or national parent organization, and a statement signed by the parent organization that the applicant organization is a local nonprofit affiliate. "

.' If an applicant has evidence of current nonprofit status on file with an agency of PHS, 11 will not be necessary to file similar papers again, but the place and date of filing must be Indicated.

Previously Filed with: (Agency) on (Datel

INVENTIONS

If this Is an application for continued support, include: (1) the report of inventions conceived or reduced to practice required by the terms and conditions of the grant; or (2) a list of Inventions already reported, or (3) a negative certilication.

EXECUTIVE ORDER 12372'

Effective September 30, 1983, Executive Order 12372 (Intergovernmental Review of Federal Programs) directed OMB to abolish OMB Circular A-95 and establish a new process for conSltlting with State and local elected officials on proposed Fedeml financial assistance. The Department of Health and Human Services imptelnented the Executive Order through regulations at 45 CFR Part 100 (Inter-governmental Review of Department of Health and Human Services Programs and ActIvities). The objectives of the Executive Order nre to (I) increase State flexibility to design a consultation process and select tile programs it wishes to review, (2) increase the ability of State a!}d local elected officials to influence Federal decisions and (3) compel Federal officials to be responsive to State concerns, or explnin the reasons.

The regulations at 45 CFR PSli 100 were published in the Federal Register on June 24, 1983, along with a notice identifying the

Department's programs that are subject to the provisions of Excc~ltive Order 12372. Infol1untion regarding PHS programs subject to Executive Order 12372 is also IIvaiioble from the appropriate llwarding office.

States participating in this program establish State Single Points of Contact (SPOCs) to coordinate and manage the review and comment on proposed Federal financial assistllncc. Applicants should contact the Governor's office for information regarding the SPOC, programs selected for roview, and the consultation (review) process designed by their State.

Applicants are to certify on the fnce page of the SF-424 (attached) whether the request is for n progrnm covered under Executive Order 12372 Dnd, where approptiate, whether tho State has been given nn opportunity to comment.

BY SIGNING THE FACE PAGE OF THIS APPLICATION. THE APPLICANT ORGANIZATION CERTIFIES THAT THE STATEMENTS IN THtS APPLICATION ARE TRUE. COMPLETE, AND ACCURATE TO THE BEST OF THE SIGNER'S KNO.wLEDGE, AND THE ORGANIZATION ACCEPTS THE OBLIGATION TO COMPLY WITH PUBLIC HEALTH SERVICE TERMS ·AND CONDITIONS IF AN AWARD IS MADE AS A RESULT OF THE APPLICATION. THE SIGNER IS ALSO AWARE THAT ANY FALSE, FICTITIOUS, OR FRAUDULENT STATEMENTS OR CLAIMS MAY SUBJECT THE SIGNER TO CRIMINAL, CIVIL. OR ADMINISTRATIVE PENAt,TIES.

THE FOLLOWING ASSURANCES/CERTIFICATIONS ARE MADE AND VERIFIED BY THE SIGNATURE OF THE OFFICIAL SIGNING FOR THE APPLICANT ORGANIZATION ON THE FACE PAGE OF THE APPLICATION:

Civil Rights -TItle VI of th~ Civil Rights Act of 1964 (Pub.l. 68-352), as amended, and ali the requirements imposed by or pursuant 10 the DHHS regulation (45 CFR 80). Handicapped Individuals - Section. 504 of the Rehabilitation Act of 1973 (pub.L. 93-112), as amended, and all requirements Imposed by or pursuant to the DHHS regulation (45 CFR 64). Sex Discrimination - Hie IX of the Educational Amendments of 1972 (Pub.L. 92-318), as amended, and all require men Is imposed by or pursuant to the DHHS regulation (45 CFR 66). Age Discrimination - The Age Dlscrlmintaion Act of 1975 (Pub.L. 94·135), as amended, and ali requirements Imposed by or pursuant to the DHHS regulation (45 CFR 91). Debarment and Suspension - TItle 45 CFR Part 76. Certlflca1ion Regarding Drug-Free Workplace Requirements - Tille 45 CFR Part 76. Certification Regarding Lobbying - TiUe 32, United States Code, Section 1352 and all requirements imposed by or pursuant to the DHHS regulation (45 CFR 93). Environmental Tobacco Smoke - Public Law 103·227. Program Fraud Clvll Remedies Act (PFCRA)

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Applicant:

Application Number:

Project Title

Status:

Document Title:

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Upload #17


FPH2011005026



Massachusetts)

Awarded

PPLM Title X FPS Grant Applicant Checklist

TO:

Dept. of Health and Human Services OPHS Office of Grants Management 1101 Wootton Parkway Suite 550 Rockville MD 20852

For assistance in preparation of this contact: Program Office:

Grants Office: 240·453·8822

APPLICATION SUBMISSION REQUIREMENTS Mail-in Hardcopy Submissions: 1. Submit the hardcopy SIGNED ORIGI NAL and two complete copies of your application.

2. Due Date: 5:00 PM Eastern Time 90 days prior to the current budoet period end date. OR

Electronic Submissions: it Application electronicallv (http:// www.qrantsolutions.qov) AND

hardcopy SIGNED ORIGINAL required forms and mail-in items.

Due Date: 11 :00 PM Eastern Time 90 days prior to the current budget period end date for the application 5:00 PM Eastern Time on the next business day after the due date for the mail-in signature items.

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Title X FPS Grant Application Checklist (Non-Competing) Revised: July 2009

Applicant:

Application Number:

Project Title

Status:

Document Title:

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Upload #18


FPH2011005026



Massachusetts)

Awarded

PPLM Public Health Impact Statement

PUBLIC HEALTH IMPACT STATEMENT

Description of Population to be Served and Summary of Services to Be Provided

With Title X funding, Planned Parenthood League of Massachusetts (PPLM) has leveraged 27-years of experience as a family planning provider in Central Massachusetts to increase access tot Title X services throughout Central MA. In January 2010 we began a partnership with the Framingham Community Health Center and converted our Worcester Health Center to our largest Title X site. Between May and August 2010 we opened three new health centers in Marlborough, Milford and Fitchburg.

With PPLM as the Title X grantee in Central MA, we expect that in 2011 the number of family planning patients served in this area will increase substantially due to increased operations and successful marketing of Title X services available. By the end of201O, PPLM expects to have added 61 hours of family planning health center time per month. PPLM will also leverage our sophisticated public awareness, marketing, and outreach infrastructure to reach low-income, uninsured and underinsured women, Latinos, Asians, Blacks, immigrants, adolescents and teens. This will lead to a 150% increase in patients served overall (11,405 to be served by PPLM, versus 4,540 served by the previous Title X provider), including a 76% increase in patients served in Marlborough, Milford and Fitchburg (2,500 served by the previous provider vs. 4,500 by PPLM) and a 25% increase at the Framingham Community Health Center.

PPLM's goal is to provide patients with unbiased, medically-accurate, culturally- and ageappropriate information which they can use to create a reproductive life plan that meets their unique needs. We provide client information/education, including abstinence information; pregnancy testing and options information; Chlamydia, gonorrhea, and syphilis testing; HIV testing; cancer screening (breast exams and pap smears); birth control methods (male and female condoms, pill, patch, ring, IUD, diaphragm, hormonal injection), emergency contraception, inhouse lab services for quicker turnaround, and referrals for treatment of HIV and health care and social service needs beyond the scope of our family planning health centers.

Coordination with State and Local Health Agencies

PPLM is pleased that the State Department of Public Health has also lent their support to this project. We have conformed to all appropriate Massachusetts and local DPH licensing requirements.

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• 1. Type of Submission: • 2. Type of Application: • If Revision, select appropriate letter(s):

DPreapplication DNew I I [gJApplication DContinuation • Other (Specify)

DChanged/Corrected Application DRevision I • 3. Date Received: 4. Applicant Identifier:

I II I Sa. Federal Entity Identifier: • 5b. Federal Award Identifier:

I II State Use Only:

6. Date Received by State: I 117. State Application Identifier: I

8. APPLICANT INFORMATION:

• a. Legal Name: IPlanned Parenthood Lea9ue of Massachusetts

• b. EmployerlTaxpayer Identification Number (EINITIN): • c. Organizational DUNS:

11042698497 A 1 1103-081-2648 1 d. Address:

• Street1: 11055 Commonwealth Ave

Street2: I • City: I Boston I

County: I I

• State: 1 Massachusetts

Province: I 1 • Country: IUNITED STATES

• Zip 1 Postal Code: 102215-1001 1 e. Organizational Unit:

Department Name: Division Name:

1 1 f. Name and contact information of person to be contacted on matters involving this application:

Prefix: 1 1 • First Name: IDianne

Middle Name: I 1 • Last Name: ILub~ Suffix:

I 1 Title: IPresident/CEO 1 Organizational Affiliation:

I President/CEO

• Telephone Number: 1617-616-1651 IFax Number: 1617-616-1665

• Email: [email protected]!

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I



Version 02

I

I

1

I 1

1

1

I

1

1

I 1

1


9. Type of Applicant 1: Select Applicant Type:

INonprofit with 501 C3 IRS Status (Other than Institution of Higher Education) Type of Applicant 2: Select Applicant Type:

1 Type of Applicant 3: Select Applicant Type:

1 * Other (specify):

I I

·10. Name of Federal Agency:

IPA-Family Planning

11. Catalog of Federal Domestic Assistance Number:

193.21 7 1 CFDATitle:

IFamil~ Planning Services

·12. Funding Opportunity Number:

I I * Title:

I 13. Competition Identification Number:

I I Title:

I 14. Areas Affected by Project (Cities, Counties, States, etc.):



Version 02

1

1

1

I

I

I

I Worcester, Fitchburg, Milford (Worcester County) and Framingham and Marlborough (Middlesex County), MA

·15. Descriptive Title of Applicant's Project:

2011 Family Planning Services Announcement (Region 1 - New Hampshire, Vermont, Maine, Rhode Island, Connecticut, Central Massachusetts)

Attach supporting documents as specified in agency instructions.

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Application for Federal Assistance SF-424 Version 02

16. Congressional Districts Of:

* a. Applicant 108 I * b. program/Projectl01

I

Attach an additional list of Program/Project Congressional Districts if needed.

17. Proposed Project:

* a. Start Date: 112/3112009 I * b. End Date: 112/30/2011 I

18. Estimated Funding ($):

* a. Federal 7935481

* b. Applicant 01

* c. State 2500001

* d. Local 01

* e. Other 16659831

* f. Program Income I 01

* g. TOTAL I 27095311

• 19. Is Application Subject to Review By State Under Executive Order 12372 Process?

Da. This application was made available to the State under the Executive Order 12372 Process for review on I I

Db. Program is subject to E.O. 12372 but has not been selected by the State for review.

IEIc. Program is not covered by E.O. 12372 .

• 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes", provide explanation.)

DYes lEI No

21. 'By signing this application, I certify (1) to the statements contained in the list of certifications" and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances" and agree to com-ply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)

lEI" I AGREE

** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions.

Authorized Representative:

Prefix: I I

* First Name: IDianne I Middle Name:

I I 'Last Name: ILuby I Suffix:

I I

'Title: IPresident/CEO I

* Telephone Number: 1617-616-1651 IFax Number: 1617-616-1665 1

, Email: [email protected] 1

* Signature of Authorized Representative: I I * Date Signed: I 1

Authorized for Local Reproduction Standard Form 424 (Revised 10/2005)

Prescribed by OMS Circular A-102

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• Applicant Federal Debt Delinquency Explanation



Version 02

The following field should contain an explanation if the Applicant organization is delinquent on any Federal Debt. Maximum number of characters that can be entered is 4,000. Try and avoid extra spaces and carriage returns to maximize the availability of space.

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Applicant:

Application Number:

Project Title

Status:

Document Title:

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Upload #19


FPH2011005026



Massachusetts)

Awarded

PPLM Assurance of Compliance

TITLE X ASSURANCE OF COMPLIANCE

V\~~~ \'(},H)l\tY\()Co. L-.e~r~s\hCt'}ttih: .PP&M) (Name of Organization)

Grants Process Policy Notice 2001-03 Page -22-

EXHIBIT C Revised 03/98

1. Provide services without subjecting individuals to any coercion to accept services or coercion to employ or not to employ any particular methods of family planning. Acceptance of services must be solely on a voluntary basis and may not be made a prerequisite to eligibility for, or receipt of, any other services.

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

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

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

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

Furthe r: ____ lS'-+--IP--'c, ..... }/\'----L_____ certifies that it will: (Name of Organization)

1. Encourage family participation in the decision of the minor seeking family planning services.

2. Provide counseling to minors on how to resist coercive attempts to engage in sexual activities.

From Part 59~~Grants for Family Planning Servic s, Subpart A, Sect" n 59.5(a) 2, 3, 4, 5, and 6.

(Title)

9/3~ ! 2..tJ ro (Date)

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pplm grant application for title x 2011

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