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
Page 1 of 155
(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.
Page 2 of 155
(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
Page 3 of 155
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:

Suffix:
I I
Title:
1 PresidenUCEO
1
Organizational Affiliation:
IPresidenUCEO
* Telephone Number: 1617 -616-1651 IFax Number:
1617-616-1665
* Email:

Page 4 of 155
I
OMS Number: 4040-0004
Expiration Date: 07/31/2006
Version 02
I
I
1
I
I
I
1
I
I
1
I
1
1
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
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
1
1
1
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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.
Page 5 of 155
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:

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
Page 6 of 155
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.
Page 7 of 155
(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
Page 8 of 155
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)
(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:
Standard Form 424A (Rev. 7-97) Page 2
Page 9 of 155
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)
Page 11 of 155
Reporting Entity:
Page 12 of 155
DISCLOSURE OF LOBBYING ACTIVITIES
CONTINUATION SHEET
Page
2
of
Approved by OMB
0348-0046
2
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
Page 13 of 155
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 14 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
Page 15 of 155
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 16 of 155
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.
Page 17 of 155
(b) (4)
(b) (4)
(b) (4)
(b) (4)
Annual
I %of
Budget
%
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

,
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

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
Page 18 of 155
(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
Page 19 of 155
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
$670,185 $167,546
Clinic disposables $32,976 $8,244
Medications $46,753 $11,688
Lab Services & Fees $77,705 $19,426
Lab $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 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
Page 20 of 155
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
Page 21 of 155
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 22 of 155
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
Page 23 of 155
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 20
th
, our Milford Health Center on June 16
th
, and our Fitchburg health center on August
24
th
, 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
1
Page 24 of 155
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
2
Page 25 of 155
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).
3
Page 26 of 155
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
6
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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
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.
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
8
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I
I
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
~ l l 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
planning methods and related preventive health services
Providing preventive health services in accordance with nationally
Assuring compliance with State laws requiring notification or the reporting.
of child abuse, molestation, sexual abuse, rape, or incest
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.
10
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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 3
rd
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 3
rd
(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
planning methods and related preventive services
Assuring compliance with State laws requiring notification or the reporting
of child abuse, sexual abuse, rape or incest
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
12
Page 35 of 155
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
January-
December 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
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
the importance of counseling family pla!!11ing clients on establishing a 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 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 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
15
Page 38 of 155
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.
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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I
I
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
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 3
rd
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 3
rd
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)
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 t o ~ a y
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 3
rd
rates with 3
rd
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
18
Page 41 of 155
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Application Number:
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Page 43 of 155
Upload #4
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.
Page 44 of 155
I
I
I
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 45 of 155
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
Page 46 of 155
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
Page 47 of 155
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 48 of 155
Upload #6
FPH2011005026
Massachusetts)
Awarded
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
Page 49 of 155
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 50 of 155
Upload #7
FPH2011005026
Massachusetts)
Awarded
PPLM Attachment B - Floor Plans
Page 51 of 155
RECEPTION/WAITI NG
[ill]
ARE".::!61 SF
OFFICE

AREA::1l9 SF
CORRIDOR
Oill

Floor Plans
,t,
Milford Health Center
RECEPTIOflllWAITING
[]

!-
Page 52 of 155
Fitchburg Health Center
VE8-TlBUL5
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Page 53 of 155
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 54 of 155
Upload #8
FPH2011005026
Massachusetts)
Awarded
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*
Page 55 of 155
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
Page 56 of 155
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
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 57 of 155
Upload #9
FPH2011005026
Massachusetts)
Awarded
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.
Page 58 of 155
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.
Page 59 of 155
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 80
th
anniversary events, and produced a gala for 600 guests and an educational
conference for 300 educators and clinicians.
Page 60 of 155
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Project Title
Status:
Document Title:
Page 61 of 155
Upload #10
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Massachusetts)
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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
Page 62 of 155
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
Page 63 of 155
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
Page 64 of 155
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
Page 65 of 155
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.
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
Page 66 of 155
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:
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.
Page 67 of 155
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
Page 68 of 155
PPLM Appendix A
06/08/2006
I. Policy:
II. Purpose:
III. Scope:
IV. Procedure:
Page 69 of 155
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.
Approved:
Approved:
Originator:

Page 70 of 155
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
Page 71 of 155
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:
Page 72 of 155
I. Policy:
II. Purpose:
III. Scope:
IV. Procedure:
Page 73 of 155
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:
Page 74 of 155
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.
Page 75 of 155
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:
Originator:
Revised: 8/2009
Physician Licensing and Credentialing
I. Policy: All physicians must have an active Massachusetts medical license, State-
Controlled 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
Page 76 of 155
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.
Apgroved:
Approved: HSQC 1113/05
Originator: Heather Sankey 6.30.03
Replaces: N/a
Page 77 of 155
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.
Page 78 of 155
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:
Page 79 of 155
I. Policy:
II. Purpose:
III. Scope:
IV. Procedure:
Page 80 of 155
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.
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
Page 81 of 155
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.
1 Originator:
Revised: 18/2009
Page 82 of 155
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
Page 83 of 155
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
Page 84 of 155
physicians by the Medical Director, and to Health Center staff through the
Health Services Director and Center Director at each site.
Approved: Management Team
Originator: Heather Sankey, Medical Director 4/8/03
Revised: 8/2009
I.
II.
III.
IV.
Page 85 of 155
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:
Page 86 of 155
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 right-
hand 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
Page 87 of 155
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 re-
filed 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.
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',
Page 88 of 155
'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
Page 89 of 155
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:
Page 90 of 155
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-H-
Female 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
Page 91 of 155
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.
Page 92 of 155
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
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.
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.
Approved: Leadership_ Team 2/28/06
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.
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.
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 abortion-
related 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 X-
funded 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 abortion-
related appointments will have separate schedules in the appointment-
making 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
Page 1 04 of 155
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.
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 13
th
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 zero-
charge 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
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
Page114of155
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 13
th
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
Page 115 of 155
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 5
th
or the 20
th
(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 5
th
and 20
th
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
Page 116 of 155
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
Revised: 8/2009
Page 117 of 155
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.
Page 118 of 155
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 re-
done 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.
Page 119 of 155
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
Page 120 of 155
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
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
Page 121 of 155
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.
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
Page 122 of 155
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
AQQfoved: Health Services Qualgy Committee 1113/05
iginator:
I Replaces:
Page 123 of 155
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
Page 124 of 155
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:

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
Page 125 of 155
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:
Page 126 of 155
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 127 of 155
Upload #11
FPH2011005026
Massachusetts)
Awarded
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
Page 128 of 155
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 129 of 155
Upload #12
FPH2011005026
Massachusetts)
Awarded
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
Page 130 of 155
Slidl!1g Scale 1

, Scale 4 , Ray,
0> 109",1;1 FPL, j:Pl '_
,- ,'>300% FPL "
-- " 5c-
" ' Level 75 ' , Level 100 _
" -
- -.
___ _ __
, ,-
Planned Paren
- -
- ,r
"'"' :.. - -.:-
sim VISIT DESCRIPTION
" - -
- - , ' ,
-
,
, , , ,
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 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
Page 2 of 2
Page 131 of 155
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 132 of 155
Upload #13
FPH2011005026
Massachusetts)
Awarded
PPLM Attachment H - IRS Certification of 501c3 Status.
."RS Devmtlllent of the Tl'easmy
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 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 applicable provisions of sections 2055, 2106, and
2522 of .the Code.
Beginning with the organization's sixth taxable year and all
succeeding 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 years, it is required to file Form
Return 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.
Page 133 of 155
PLANNED PARENTHOOD LEAGUE OF
MASSACHUSETTS INC
1055 COMMONWEALTH AVE
BOSTON MA 02215-1001
Page 134 of 155
0248162365
July 29, 2010 LTR 4168C EO
04-2698497 000000 00
00021330
Sincerely yours,
Michele M. Sullivan, Oper. Mgr.
Accounts Management Operations I
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 135 of 155
Upload #14
FPH2011005026
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.
Page 136 of 155
(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.
Page 137 of 155
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 sub-
grant.
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.
Page 138 of 155
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.
Page 139 of 155
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.
Page 140 of 155
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 141 of 155
Upload #15
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, _____ ________________ __
T1TLE __ __ ---,-____ _
ADDRESS \(955 fV\
CITY S?$ teA STATE ,N)A
NINEDlGIT ZIP CODE DfiJP?, IS' - (OC\
PHONE # e?.1-Gl{? ... lbSJ FAX # (OlCJ-Gl6- (bb5"'
. ____ _
2. Please provide us with the Name, Title and Address of your Business
Manager.
NAME aro.A @ltS
TITLE C,fO
ADDRESS \ t:J55" M()ve..
CITY lSekcr\ STATE MA
NINEDlGIT ZIP CODE CG\?215'" [CC))
PHONE # G\2- - I rO%'-! FAX # (0\1) 6Ui ... (66S"
EMAIL c...e...1\iS e.- O.cg
3. Please provide us with the Name, Title and Address (other than the Project
address) of the higher level "authorized official."
NAME, _____ ________________ ___
C\;()j co.\ OpC?ro.EiOIlS
ADDRESS tD:SS= C('YY\IY'lY\wf?(lJ 61\ AJ.I\ve.
CITY STATE MA
TITLE
NINEDIGIT ZIP CODE oae?J5' ." 00 \
PHONE # 6l C") ",b\(; ... \ b l)c;r FAX # Gt"l-Gr {bGS'
E-MAIL @
Page 142 of 155
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 143 of 155
Upload #16
FPH2011005026
Massachusetts)
Awarded
PPLM OPHS Checklist
_______________________________________________________________________________
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
Organization ?PL..M -'o:..:.r ... 9"'an"'l:::za:..:t:..:: loc:..: n--'YL...?lAV\-'--'--=-___________ _
Address \ CJ::,roro A.Je, Address I C)65' CONW"\ 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 61
Fax Number " Fax Number bt ? ..
SOCIAL SECURITY NUMBER HIGHEST DEGREE EARNED
I I I I-I I I I I I I I I }/I. A. I
(OVER)
Page 144 of 155
________________________________________________________________________________
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
taxexempt 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
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 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. 94135), 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 103227.
Program Fraud Clvll Remedies Act (PFCRA)
Page 145 of 155
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 146 of 155
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: 2404538822
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.
Page 147 of 155
Title X FPS Grant Application Checklist (Non-Competing)
Revised: July 2009
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 148 of 155
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 age-
appropriate 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, in-
house 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.
Page 149 of 155
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:

Suffix:
I 1
Title:
IPresident/CEO
1
Organizational Affiliation:
I President/CEO
Telephone Number: 1617-616-1651 IFax Number:
1617-616-1665
Email:

Page 150 of 155
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)
1
1
* Other (specify):
I I
10. Name of Federal Agency:
IPA-Family Planning
11. Catalog of Federal Domestic Assistance Number:
1
93
.
21
7
1
CFDATitle:
I F a m i l ~ 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.
Page 151 of 155
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:

1
* Signature of Authorized Representative: I
I
* Date Signed:
I 1
Authorized for Local Reproduction Standard Form 424 (Revised 10/2005)
Page 152 of 155
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.
Page 153 of 155
Applicant:
Application Number:
Project Title
Status:
Document Title:
Page 154 of 155
Upload #19
FPH2011005026
Massachusetts)
Awarded
PPLM Assurance of Compliance
TITLE X ASSURANCE OF COMPLIANCE
\'(},H)l\tY\()Co. .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 for Family Planning Servic s, Subpart A, Sect" n 59.5(a) 2,
3, 4, 5, and 6.
(Title)
! 2..tJ ro
(Date)
Page 155 of 155

PPLM Grant Application For Title X 2011

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