CHAPTER 48 - LOCAL HEALTH DEPARTMENT ACCREDITATION

Subchapter 48A - Local Health Department Accreditation –Administration

SECTION .0100 - General Provisions

10A NCAC 48A .0101 PURPOSE

The rules of this Subchapter establish the process for local health departments to become accredited pursuant to G.S. 130A-34.1.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48A .0102 DEFINITIONS

The following definitions shall apply throughout this Subchapter:

(1) "Board" is defined in G.S 130A-2(1).

(2) "Institute" means the North Carolina Institute for Public Health in the UNC School of Public Health.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

SECTION .0200 - Accreditation Process

10A NCAC 48A .0201 SELF-ASSESSMENT

Each local health department shall complete a self-assessment based on the standards adopted in this Chapter. The local health department shall submit the self-assessment to the Institute within 90 days after notification by the Institute that the accreditation process for the department has begun.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48A .0202 SITE VISIT

(a) The Institute shall select a site visit team composed of not fewer than four individuals with expertise or experience in local public health, including experience or expertise in environmental health, public health nursing, public health administration or policy development/governance.

(b) The site visit team shall visit the local health department, review the self-assessment and supporting documentation, interview local health department staff and other persons necessary to evaluate compliance with the standards and inspect the facilities in accordance with the standards. The team may request additional supporting documentation or other evidence as necessary to evaluate compliance with the standards.

(c) The site visit team shall prepare a report that makes a determination as to whether the standards have been met and shall submit the report to the Board and the local health department within 14 days of the end of the site visit. The site visit team shall make a recommendation regarding accreditation status to the Board.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48A .0203 BOARD ACTION

The site visit team shall present the report to the Board and the local health department shall have the opportunity to respond to the presentation. Upon the local health department’s request, the Board shall grant the local health department an additional 21 calendar days to submit additional written information to the Board. If no such request is made, the Board may take action on the site visit team’s recommendation or may request additional information from the local health department and defer action on the recommendation to a later meeting. The action shall be taken within 90 days of the presentation of the site visit team to the Board.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48A .0204 INFORMAL REVIEW PROCEDURES

If the Board assigns a status of "conditionally accredited" or "unaccredited," the local health department may make a written request within 10 calendar days for reconsideration of the decision. The written request shall state the specific objections to the decision and the basis for those objections. The Board shall act on the request within 60 calendar days.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48A .0205 RE-ACCREDITATION

A local health department shall submit the self-assessment required by Rule .0201 no later than six months before the expiration date of its accreditation. The Board shall initiate a site visit in accordance with Rule .0202 and take action in accordance with Rule .0203 before the local health department's accreditation expires. If the Board re-accredits a local health department, accreditation is extended for an additional four years. The local health department may utilize the informal review procedures of Rule .0204 of this Section.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

Subchapter 48B - Local Health Department Accreditation Standards

SECTION .0100 - General Provisions

10A NCAC 48B .0101 PURPOSE

The rules in this Subchapter establish the accreditation standards for local health departments pursuant to G.S. 130A-34.1.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0102 DEFINITIONS

The following definitions shall apply throughout this Subchapter:

(1) "Activities" means specific, documentable actions taken by a local health department or a local board of health.

(2) "Consolidated agreement and agreement agenda" means the contract used by the Division to distribute state and federal public health funds to local health departments.

(3) "Division" means the North Carolina Division of Public Health.

(4) "Evidence-based health promotions/disease prevention strategies" means endeavors in which there is an informed and explicit use of evidence that has been derived from any of a variety of science and social science research and evaluation methods.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0103 ACCREDITATION REQUIREMENTS

(a) To receive an accreditation status of "accredited," a local health department must satisfy all of the accreditation standards contained in this Subchapter. In order to satisfy the accreditation standards, the local health department shall satisfy activities under the standards according to the following proportions:

(1) Standard 1. Agency core functions and essential services:

(A) The local health department must satisfy at least 26 of the 29 activities listed in the benchmarks contained in Sections .0200 and .0300 of this Subchapter;

(B) The local health department must satisfy at least 23 of the 26 activities listed in benchmarks contained in Sections .0400 through .0600 of this Subchapter;

(C) The local health department must satisfy at least 34 of 38 activities listed in the benchmarks contained in Sections .0700 through .1100 of this Subchapter;

(2) Standard 2. Facilities and administrative services: The local health department must satisfy at least 24 of the 27 activities listed in the benchmarks contained in Section .1200 of this Subchapter; and

(3) Standard 3. Board of health: The local health department must satisfy at least 24 of the 27 activities listed in the benchmarks contained in Section .1300 of this Subchapter.

(b) In order to satisfy an activity, the local health department must satisfy all of the requirements prescribed for that activity. Failure to complete any activity requirement associated with an activity means that the activity is not satisfied.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Amended Eff. April 1, 2015; February 1, 2013;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

SECTION .0200 - Monitor Health Status

10A NCAC 48B .0201 BENCHMARK 1

(a) Benchmark: A local health department shall conduct and disseminate results of regular community health assessments:

(b) Activities:

(1) The local health department shall conduct a comprehensive community health assessment every 48 months. The community health assessment must fulfill each of the following requirements:

(A) Provide evidence of community collaboration in planning and conducting the assessment

(B) Reflect the demographic profile of the population

(D) Assemble and analyze secondary data (collected by someone other than the health department) to describe the health status of the community

(E) Collect and analyze primary data (collected by the health department) to describe the health status of the community

(F) Compile and analyze trend data to describe changes in community health status and in factors affecting health

(G) Use scientific methods for collecting and analyzing data

(H) Identify population groups at risk for health problems

(I) Identify existing and needed health resources

(J) Compare selected local data with data from other jurisdictions (e.g., local to state, local to local)

(K) Identify leading community health problems

(2) The local health department shall update the community health assessment with an interim "State of the County's Health" report (or equivalent) annually. The report shall demonstrate that the local health department is tracking priority issues identified in the community health assessment, identifying emerging issues, and shall identify any new initiatives.

(3) The local health department shall disseminate results of the most recent community health assessment and "State of the County's Health" report to individuals and groups that participated in the community health assessment process, community partners and the general population.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0202 BENCHMARK 2

(a) Benchmark: The local health department shall work with health care providers in the community to report reportable diseases and other health-related events and data.

(b) Activities:

(1) The local health department shall collect local vital records of births and deaths and transmit them to the Division.

(2) The local health department shall report annual childhood immunization data as required by statute and rule.

(3) The local health department shall collect reports of communicable diseases and other reportable health conditions from community health care providers and transmits them to the Division.

(4) The local health department shall analyze and note reportable events occurring within the community and shall report atypical incidence, if any, to the Division and the local board of health.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0203 BENCHMARK 3

(a) Benchmark: The local health department shall maintain skills and capacity to collect, manage, integrate and display health-related data.

(b) Activities:

(1) The local health department shall assure agency staff has expertise and training to collect, manage, integrate and display health-related data.

(2) The local health department shall conduct an annual evaluation of the agency's data system (hardware and software) and plans for upgrades to improve the accessibility, quality and utilization of health data.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

SECTION .0300 - Diagnose and Investigate Health Problems and Health Hazards in the Community

10A NCAC 48B .0301 BENCHMARK 4

(a) Benchmark: The local health department shall engage in surveillance activities and assess, investigate and analyze health problems, threats and hazards, maintaining and using epidemiological expertise.

(b) Activities:

(1) The local health department shall assure that a surveillance system is in place for identifying health problems, threats and hazards that occur in the community.

(2) The local health department shall monitor exposure to environmental health risks.

(3) The local health department shall have access to, and consult with a Masters or Doctoral level epidemiologist when necessary to fully investigate and diagnose health problems and hazards within the community.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0302 BENCHMARK 5

(a) Benchmark: The local health department shall establish and maintain a system to receive and provide health alerts and public health response for health care providers, emergency responders, and communities on a 24-hour-a-day, 7-day-a-week basis.

(b) Activities:

(1) The local health department shall have a system in place to receive reports of communicable diseases or other public health threats on a 24-hour-a-day, 7-day-a-week basis.

(2) The local health department shall use two or more methods to disseminate health alerts and other advisories on real or potential disease threats, as they occur, to the local medical community, including pharmacists and veterinarians.

(3) The local health department shall provide health alerts or advisories to the news media to inform the public when disease outbreaks or other potential public health threats occur.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0303 BENCHMARK 6

(a) Benchmark: The local health department shall be able to respond to a public health emergency on a 24-hour-a-day, 7-day-a-week basis.

(b) Activities:

(1) The local health department shall be involved in a local emergency planning committee.

(2) The local health department shall have a defined role in the county emergency operations plan to protect the public's health.

(3) The local health department shall participate in regional emergency preparedness exercises and activities.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0304 BENCHMARK 7

(a) Benchmark: The local health department shall maintain and implement epidemiological case investigation protocols providing for rapid detection and containment of communicable disease outbreaks; environmental health hazards; potential biological, chemical and radiological threats.

(b) Activities:

(1) The local health department shall have epidemiological case investigation protocols in place.

(2) The local health department shall conduct communicable disease investigations, follow-up, documentation and reporting activities.

(3) The local health department shall investigate and respond to environmental health complaints or referrals.

(4) The local health department shall have a public health preparedness and response plan that:

(A) corresponds to existing local and state emergency and bioterrorism plans

(B) establishes roles and responsibilities of plan participants

(D) establishes a chain of command among plan participants

(E) describes a system of emergency notification to local and state public health staff and other key decision makers based upon the nature of the event

(F) is available to staff on site

(5) The local health director shall maintain periodic communication with local emergency managers.

(6) The local health department shall annually test or implement the local public health preparedness and response plan.

(7) The local health department shall have one of the following:

(A) public health preparedness and response coordination team with an environmental health member and a public health preparedness response coordinator, or

(B) an epidemiology team with an environmental health member and an epidemiology team coordinator.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0305 BENCHMARK 8

(a) Benchmark: The local health department shall provide or have access to laboratory capacity capable of providing for rapid detection and containment of communicable disease outbreaks; environmental health hazards; potential biological, chemical and radiological threats.

(b) Activities:

(1) The local health department shall have written policies and procedures for handling clinical and environmental laboratory samples.

(2) The local health department laboratory and external laboratories utilized by the local health department shall comply with all applicable federal regulations for clinical and environmental laboratory testing.

(3) The local health department shall provide or have access to laboratory services capable of meeting routine diagnostic and surveillance needs.

(4) The local health department shall provide or have access to laboratory services to support investigations of public problems, hazards, and emergencies.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

SECTION .0400 - Inform, Educate, and Empower People About Health Issues

10A NCAC 48B .0401 BENCHMARK 9

(a) Benchmark: The local health department shall provide the general public and elected and appointed officials with information on health risks, health status, and health needs in the community as well as information on policies and programs that can improve community health.

(b) Activities:

(1) The local health department shall publish and disseminate data and information on current local health issues to the general public, community partners, and elected and appointed officials.

(2) The local health department shall have a mechanism by which the public can access community data and health status information maintained in the agency in accordance with applicable laws and rules.

(3) The local health department shall provide information to the public on the availability and location of health data that are accessible in the public domain.

(4) The local health department shall have written guidelines that it follows in responding to requests for information.

(5) The local health department shall inform affected community members of changes in department policies or operations.

(6) The local health department shall assure that information disseminated by the agency reflects the cultural and linguistic character of the local population as required by Title VI of the Civil Rights Act.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0402 BENCHMARK 10

(a) Benchmark: The local health department shall provide, support, and evaluate health promotion activities designed to influence the behavior of individuals and groups.

(b) Activities:

(1) The local health department shall develop, implement and evaluate population-based health promotion/disease prevention programs and educational materials for the general public.

(2) The local health department shall carry out or assist other agencies in the development, implementation and evaluation of health promotion/disease prevention programs and educational materials targeted to groups identified as at-risk in the community health assessment.

(3) The local health department shall employ evidence-based health promotions/disease prevention strategies, when such evidence exists.

(4) The local health department shall promote and support the use of evidence-based health promotion/disease prevention strategies by other community agencies and organizations.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

SECTION .0500 - Mobilize Community Partnerships to Identify and Solve Health Problems

10A NCAC 48B .0501 BENCHMARK 11

(a) Benchmark: The local health department shall convene key constituents and community partners to identify, analyze, and prioritize community health issues.

(b) Activities:

(1) The local health department shall participate in a collaborative community steering committee to identify health issues and needs.

(2) The local health department shall involve community members in assessing, setting priorities and establishing desired outcomes for addressing community health issues and needs.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0502 BENCHMARK 12

(a) Benchmark: The local health department shall develop strategies in collaboration with community partners to solve existing community health problems.

(b) Activities:

(1) The local health department shall participate in a collaborative process to identify strategies for addressing community health problems.

(2) The local health department shall participate in a collaborative process to assess resources needed, including personnel, funding, policy changes, and system change, to address community health problems.

(3) The local health department shall participate in a collaborative process to implement population-based programs to address community health problems.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0503 BENCHMARK 13

(a) Benchmark: The local health department shall identify and build upon community assets and direct them toward resolving health problems.

(b) Activity: The local health department shall broaden existing partnerships by cultivating innovative and new community contacts, such as businesses and industries, healthcare practitioners, faith communities, and grassroots organizations, and increasing their awareness of public health through outreach and training.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

SECTION .0600 - Develop Policies and Plans That Support Individual and Community Health Efforts

10A NCAC 48B .0601 BENCHMARK 14

(a) Benchmark: The local health department shall work with local, state and federal policymakers to enact policies, laws, rules, and ordinances that support individual and community health efforts.

(b) Activities:

(1) The local health department shall disseminate information relative to public health needs to elected and appointed officials.

(2) The local health department shall provide information and recommendations to support the local board of health and the board(s) of county commissioners in setting public health priorities and planning public health programs.

(3) The local health department shall evaluate, with the local board of health, the need for additional rules or ordinances to protect the health of the public.

(4) The local health department shall assist the local board of health in drafting local ordinances and rules as needed and presenting them to elected officials in order to implement or enforce needed local public health prevention and protection activities.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0602 BENCHMARK 15

(a) Benchmark: The local health department shall develop plans to guide its work.

(b) Activities:

(1) The local health department shall develop or update annually an agency strategic plan that:

(A) includes a review and analysis of factors influencing the health department's ability to improve the community's health,

(B) uses local health status data and information to set goals and objectives,

(D) states desired outcomes for each element,

(E) sets priorities, and

(F) uses community collaborations to implement activities.

(2) The local health department shall develop and adopt program policies and procedures that meet the following criteria:

(A) refer to the federal and state legislation, rules or regulations, or local rules or ordinances that provide the authority to carry out agency programs and activities, and

(B) delineate desired outcomes.

(3) The local health department shall have a written procedure providing for annual review, and revision if necessary, of all policies.

(4) The local health department shall assess the internal and external resources that are available or needed to implement proposed new or updated policies and procedures.

(5) The local health department shall ensure that new staff is oriented to program policies and procedures and existing staff receives training on any updated or revised program policies and procedures.

(6) The local health department shall ensure that program policies and procedures are accessible to all staff.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

SECTION .0700 - Enforce Laws and Regulations That Protect Health and Ensure Safety

10A NCAC 48B .0701 BENCHMARK 16

(a) Benchmark: The local health department staff shall have knowledge of public health law and an understanding of the relationship between the law and public health practice.

(b) Activities:

(1) The local health director and unit directors, such as directors of communicable disease, nursing, clinical services and environmental health, shall receive ongoing training in current public health law and its application.

(2) Local health department new employee orientation shall address public health laws and rules.

(3) Environmental health staff shall be trained in the implementation of laws, rules and ordinances that they enforce and shall have access to copies of the laws, rules and ordinances.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0702 BENCHMARK 17

(a) Benchmark: The local health department shall monitor compliance with public health laws and rules.

(b) Activities:

(1) The local health department shall conduct inspection and permitting activities for state mandated environmental health regulatory programs.

(2) The local health department shall conduct inspection and permitting activities assigned to the local health department by local rules, ordinances, or policies.

(3) The local health department shall monitor compliance with communicable disease control laws and rules.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0703 BENCHMARK 18

(a) Benchmark: The local health department shall enforce public health laws, rules and ordinances.

(b) Activities:

(1) The local health department shall have written policies and procedures addressing enforcement of public health laws, rules and ordinances.

(2) The local health department shall take enforcement action for violations of public health laws, rules and ordinances.

(3) The local health department shall have written policies and procedures for handling complaints related to enforcement of laws, rules and ordinances.

(4) The local health department shall address complaints in accordance with its policies and procedures.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

SECTION .0800 - Link People to Needed Personal Health Services to Assure the Provision of Health Care When Otherwise Unavailable

10A NCAC 48B .0801 BENCHMARK 19

(a) Benchmark: The local health department shall identify populations that are not receiving preventive services or are otherwise underserved with respect to health care.

(b) Activities:

(1) The local health department shall assess use of public health programs and health care services by underserved, at-risk and vulnerable populations identified in the community health assessment process.

(2) The local health department shall take actions to include linguistically and culturally representative persons in planning and implementing programs intended to reach underserved population groups.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0802 BENCHMARK 20

(a) Benchmark: The local health department shall mobilize the community to address health care resource needs.

(b) Activities:

(1) The local health department shall collaborate with community health care providers to provide personal and preventive health services.

(2) The local health department shall collaborate with community health care providers and agencies to reduce barriers to access to care.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0803 BENCHMARK 21

(a) Benchmark: The local health department shall lead efforts in the community to link individuals with preventive, health promotion, and other health services.

(b) Activities:

(1) The local health department shall make available to the general public a current, comprehensive list of community health and wellness resources.

(2) The local health department shall make available complete and up-to-date information about local health department programs, services and resources.

(3) The local health department shall develop and implement strategies to increase use of public health programs and services.

(4) The local health department shall assure that the program planning and implementation involve community health advocates that represent populations being served in the local health department.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0804 BENCHMARK 22

(a) Benchmark: The local health department shall serve as a health care provider when local needs and authority exist, and the agency capacity and resources are available.

(b) Activities:

(1) When the local health department determines that there are compelling unmet health care needs in the community, the local health department shall develop a plan with community leaders and providers to meet the unmet needs, which may include the establishment and provision of such services by the local health department if the department has the authority, capacity and resources to address the unmet needs.

(2) The local health department shall comply with laws, rules and contractual requirements for programs and services provided pursuant to the local health department's consolidated agreement and agreement addenda, including requirements for corrective action.

(3) The local health department shall comply with laws and rules relating to programs and services offered by local health department but not covered by the consolidated agreement and agreement addenda.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

Section .0900 - Assure a Competent Public Health Workforce and Personal Health Workforce

10A NCAC 48B .0901 BENCHMARK 23

(a) Benchmark: The local health department staff shall meet statutory and regulatory qualifications for their positions.

(b) Activities:

(1) The local health department shall have, or be recruiting, a health director who meets the legal requirements for the position.

(2) The local health department staff shall meet all registration, certification or licensure requirements for positions held and duties assigned.

(3) The local health department shall employ or contract with one or more physicians licensed to practice in North Carolina to serve as medical director.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0902 BENCHMARK 24

(a) Benchmark: The local health department shall regularly evaluate staff training and development needs and provide opportunities for continuing education, training and leadership development.

(b) Activities:

(1) The local health department shall have policies that promote and provide staff access to training.

(2) The local health department shall have a staff development plan that includes identifying and addressing the training and continuing education needs of the staff.

(3) The local health department staff shall participate in orientation and on-going training and continuing education activities required by law, rule or contractual obligation.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0903 BENCHMARK 25

(a) Benchmark: The local health department shall build relationships with entities that conduct education or research to enrich public health practice.

(b) Activities:

(1) The local health department shall work with academic institutions and other programs such as universities, colleges, community colleges, Area Health Education Centers, CDC and professional associations to provide training opportunities for current staff and future public health practitioners.

(2) The local health department shall work with at least two academic institutions and other programs such as universities, colleges, community colleges and Area Health Education Centers to facilitate research and evaluation of public health programs and issues.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .0904 BENCHMARK 26

(a) Benchmark: The local health department shall promote diversity in the public health workforce.

(b) Activities:

(1) The local health department shall have and implement a non-discrimination policy as required by state and federal law and train staff in its application.

(2) The local health department shall develop and implement a plan consistent with the health department’s non-discrimination policy to recruit and retain a management team and staff that reflects the population of the service area.

(3) The local health department shall assure that agency staff receives training in cultural sensitivity and competency.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

SECTION .1000 - Evaluate Effectiveness, Accessibility and Quality of Personal and Population-Based Health Services

10A NCAC 48B .1001 BENCHMARK 27

(a) Benchmark: The local health department shall evaluate all services it provides for effectiveness in achieving desired outcomes.

(b) Activities:

(1) The local health department shall have in place a process for assessing consumer and community satisfaction with its services.

(2) The local health department shall use data from the consumer and community satisfaction assessment to make changes to improve its services.

(3) The local health department shall employ a quality assurance and improvement process to assess the effectiveness of services and improve health outcomes.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

SECTION .1100 - Research for New Insights and Innovative Solutions to Health Problems

10A NCAC 48B .1101 BENCHMARK 28

(a) Benchmark: The local health department shall use research to develop and evaluate public health programs.

(b) Activity: Before implementing a proposed public health program, the local health department shall review, when available, research evaluating the potential effectiveness of the program.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .1102 BENCHMARK 29

(a) Benchmark: The local health department shall ensure that its participation in research meets ethical standards.

(b) Activity:

(1) The local health department shall develop and implement policies ensuring that state and federal requirements are followed regarding the rights of participants in local public health research programs and requiring that any requests to access health department clients have Institution Review Board approval obtained by the host research organization.

(2) The local health department shall develop and implement policies for participation in research activities that impact its clients or community members.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

section .1200 - Provide Facilities and Administrative Services

10A NCAC 48B .1201 BENCHMARK 30

(a) Benchmark: The local health department shall provide safe and accessible physical facilities and services.

(b) Activities:

(1) The local health department shall have facilities that are clean, safe and secure for the specific activities being carried out in the facility or any area of the facility, such as laboratory analyses or patient examinations.

(2) The local health department shall have facilities that are accessible to persons with physical disabilities and services that are accessible to persons with limited proficiency in the English language.

(3) The local health department shall have examination rooms and direct client service areas that are configured in a way that protects client privacy.

(4) The local health department shall ensure privacy and security of records containing privileged patient medical information or information protected by the federal Health Insurance Portability and Accountability Act.

(5) The local health department shall comply with OSHA regulations.

(6) The local health department shall ensure cleaning, disinfection and maintenance of clinical and laboratory equipment and service areas and shall document all cleanings, disinfections and maintenance.

(7) The local health department shall have and comply with policies and procedures for infection control required by law in providing clinical services.

(8) The local health department’s hours of operation shall be based on documented community need.

(9) The local health department shall prohibit the use of tobacco in its facility.

(10) The local health department shall make efforts to prohibit the use of tobacco in all areas and grounds within 50 feet of the health department facility.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .1202 BENCHMARK 31

(a) Benchmark: The local health department shall develop and implement administrative policies and procedures.

(b) Activities:

(1) The local health department shall develop and implement policies and procedures regarding the administration of the local health department and shall assure policies and procedures are accessible to staff.

(2) The local health department shall have a current organizational chart showing lines of authority.

(3) The local health department shall have written personnel policies that address disciplinary, grievance and harassment issues.

(4) The local health department shall have current written position descriptions and qualifications for each staff position.

(5) The local health department shall implement a performance appraisal system for all staff.

(6) The local health department shall have an inventory of equipment that includes a plan for replacement.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .1203 BENCHMARK 32

(a) Benchmark: The local health department shall operate a secure and effective management information system.

(b) Activities:

(1) The local health department shall have computer equipment and software needed to interface with state data management systems.

(2) The local health department shall ensure that staff are able to use the management information system to participate in electronic communications and public health program implementation.

(3) The local health department shall have a written policy regarding authorized and prohibited use of computer equipment, email and Internet.

(4) The local health department shall have policies and procedures to assure management information system security, and use passwords and screensavers to safeguard the privacy of electronic information.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .1204 BENCHMARK 33

(a) Benchmark: The local health department shall assure its financial accountability.

(b) Activities:

(1) The local health department shall demonstrate that it receives financial support from a local taxing authority.

(2) The local health department shall operate under a budget approved by the appropriate authority under state statute.

(3) The local health department shall follow generally accepted accounting principles.

(4) The local health department shall have policies that assure segregation of financial management duties and accountability for funds.

(5) The local health department shall determine the cost of services in setting fees.

(6) The local health department shall develop and present periodic budget, expenditure and other financial tracking reports to the board of health for its review.

(7) The local health department shall have a financial risk management system in place to address uncollected fees and bad debt.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

section .1300 – governance

10A NCAC 48B .1301 BENCHMARK 34

(a) Benchmark: The local board of health shall exercise its authority to adopt and enforce rules necessary to protect and promote the public's health.

(b) Activities:

(1) The local board of health shall have operating procedures which shall comply with state law.

(2) The local board of health shall have access to legal counsel.

(3) The local board of health shall follow the procedures for adopting rules in G.S. 130A-39.

(4) The local board of health shall evaluate the need for the adoption or amendment of local rules or ordinances.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Amended Eff. April 1, 2015;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .1302 BENCHMARK 35

(a) Benchmark: The local board of health shall assure a fair and equitable adjudication process.

(b) Activity: The local board of health shall assure it follows the procedures for adjudications in G.S. 130A-24.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .1303 BENCHMARK 36

(a) Benchmark: The local board of health members shall be trained regarding their service on the board.

(b) Activities:

(1) The local health department shall provide board of health members with a written board handbook developed or updated within the past 12 months.

(2) The local health department shall assure new board of health members receive training and reference materials on the authorities and responsibilities of the local board of health within the first year after appointment to the board.

(3) The local health department shall assure on-going training for board of health members related to the authorities and responsibilities of local boards of health.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .1304 BENCHMARK 37

(a) Benchmark: The local board of health shall assure the development, implementation, and evaluation of local health services and programs to protect and promote the public's health.

(b) Activities:

(1) The local board of health or the consolidated human services director shall assure that a qualified local health director has been appointed in accordance with G.S. 130A-40 or G.S. 130A-40.1.

(2) The local board of health shall approve policies for the administration of local public health programs.

(3) The local board of health or the consolidated human services director shall describe and define the knowledge, skills, and abilities that must be met by the local health director, consistent with the requirements in G.S. 130A-40.

(4) The local board of health or the consolidated human services director shall review and approve the job description of the local health director.

(5) The supervisor shall conduct an annual performance review of the health director.

(6) The local board of health or the consolidated human services director shall approve policies for the recruitment, retention and workforce development for agency staff.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Amended Eff. April 1, 2015;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .1305 BENCHMARK 38

(a) Benchmark: The local board of health shall participate in the establishment of public health goals and objectives.

(b) Activities:

(1) The local board of health shall annually review reports provided by the local health department on the community's health.

(2) The local board of health or the advisory committee on health shall review community health assessment data and citizen input used to plan and monitor progress toward health-related goals.

(3) The local board of health or the advisory committee on health shall assure that individuals, agencies, and organizations have the opportunity to participate in the development of goals, objectives and strategies for community health improvement.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Amended Eff. April 1, 2015;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .1306 BENCHMARK 39

(a) Benchmark: The local board of health shall assure the availability of resources to implement the essential services described in G.S. 130A-34.1(e)(2).

(b) Activities:

(1) The local board of health or the advisory committee on health shall communicate with the board of county commissioners, units of government and private foundations in support of local health department efforts to secure national, state and local financial resources.

(2) The local board of health shall review fiscal reports to assure essential services of public health are being provided in accordance with local, state and federal requirements.

(3) The local board of health shall annually review and approve the local health department budget and approve fees in accordance with G.S. 130A-39(g).

(4) The local board of health or the advisory committee on health shall communicate with the board of county commissioners, units of government and private foundations in support of the development, implementation and evaluation of public health programs and a community health improvement process.

(5) The local board of health shall assure that the proposed budget for the local health department meets maintenance of effort requirement in the consolidated agreement between the Division of Public Health and local health department.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Amended Eff. April 1, 2015;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .1307 BENCHMARK 40

(a) Benchmark: The local board of health or the advisory committee on health shall advocate in the community on behalf of public health.

(b) Activities:

(1) The local board of health or the advisory committee on health shall inform elected officials and community boards about community health issues.

(2) The local board of health or the advisory committee on health shall communicate support for the enactment and retention of laws and rules and the development of public health interventions that protect health and ensure safety.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Amended Eff. April 1, 2015;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.

10A NCAC 48B .1308 BENCHMARK 41

(a) Benchmark: The local board of health or the advisory committee on health shall promote the development of public health partnerships.

(b) Activities:

(1) The local board of health or the advisory committee on health shall take actions to foster community input regarding public health issues.

(2) The local board of health or the advisory committee on health shall take actions to foster local health department partnership-building efforts and staff interactions with the community.

(3) The local board of health or the advisory committee on health shall take actions to foster the coordination of resources to enhance partnerships and collaboration to achieve public health objectives.

History Note: Authority G.S. 130A-34.1;

Temporary Adoption Eff. January 1, 2006;

Eff. October 1, 2006;

Amended Eff. April 1, 2015;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 5, 2016.