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Michigan Local Public Health Accreditation Program
Guidance Document
SECTION Q:
FAMILY PLANNING
Q1. The local health department had protocols at assure
client confidentiality and provide safeguards for
individuals against the invasion of personal privacy, as
required by the Privacy Act. [Michigan Department of
Community Health Standards and Guidelines, 2001 5.2]
Q1.1 The local health department had protocols at assure client confidentiality
and provide safeguards for individuals against the invasion of personal
privacy, as required by the Privacy Act.
To fully meet this indicator:
a. No information obtained by the project staff about individuals receiving
services may be disclosed without the individual’s consent, except as
required by law or as necessary to provide services to the individual,
with appropriate safeguards for confidentiality; AND
b. Information may otherwise be disclosed only in summary, statistical, or
other form that does not identify the individual.
Q2. The local health department has protocols and
operating procedures for emergency situations.
[Michigan Family Planning Standards and Guidelines,
2001: 7.3 A1--9; State of Michigan MPR 20,2001]
Q2.1 The local health department has protocols and operating procedures for
medical emergencies.
To fully meet this indicator:
The local health department maintains on file emergency protocols and
operating procedures which indicate appropriate recognition of the
specific emergency and medical interventions for:
a. Medical emergencies, this includes a policy specific to transportation
ambulance service; AND
b. Fainting and shock; AND
c. Cardiac arrest; AND
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d. Respiratory distress; AND
e. Vasovagal response; AND
f. Hemorrhage; AND
g. The local health department clinic staff are trained to handle
cardiopulmonary arrest, anaphylactic shock and the local health
department maintains appropriate drugs and equipment to handle
anaphylactic and vasovagal shock; AND [Michigan Family Planning
Standards and Guidelines, 2001 10.2A7a-b)
h. All medical staff Must be trained in CPR and hold current certification
[Michigan Family Planning Standards and Guidelines ;2001: 7.3B;
AND
i. Emergency arrangements must be available for after hours
management of contraceptive emergencies and weekend care and
must be either posted, given to and/or explained to clients. [7.0C1];
AND
j. Maintenance and monitoring of appropriate emergency resuscitative
drugs, supplies and equipment for the services provided. [Michigan
Family Planning Standards and Guidelines, 2001: 7.3 C]
Q2.2 The local health department has protocols and operating procedures for
non-medical emergencies. [Michigan Family Planning Standards and
Guidelines, 2001: 7.3 A10]
To fully meet this indicator:
The local health department maintains on file emergency protocols and
operating procedures to address:
a. Fire. Fire routes or exit signs should be clearly posted in the facility
and routine fire drills must be performed; AND [Michigan Family
Planning Standards and Guidelines, 2001: 6.4 A2]
b. There is documentation that drills are held at least annually; AND
c. Natural disaster; AND
d. Robbery; AND
e. Power failure; AND
f. Harassment.
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Q3. The local health department has financial management
policies and procedures that comply with allowable
costs of Title X projects and adheres to reporting
requirements. [Michigan Family Planning Standards
and Guidelines, 2001: 6.7; State of Michigan MPR 20,
2001; Title X]
Q3.1 The local health department is in compliance with State and Federal
financial management guidelines for allowable costs of Title X projects.
[Michigan Family Planning Standards and Guidelines, 2001: 6.3]
To fully meet this indicator:
The local health department’s policies and procedures comply with the
following:
a. Charge, billing, and collection policies and procedures are in place,
which include evidence that efforts to collect do not violate
confidentiality; AND
b. Charges are based on a cost analysis of all services, provided by the
program; AND
c. A schedule of discounts must be developed and implemented with
sufficient proportional increments so that inability to pay is never a
barrier to service. A schedule of discounts based on a current copy of
the CSA Poverty Income Guidelines is required for individuals with
family incomes between 101% and 250% of the Federal Poverty level.
AND
d. Clients whose documented income is at or below 100% of the Federal
Poverty level must no be charged; although projects must bill all third
parties authorized or legally obligated to pay for services; AND
e. Third party payers are billed total charges; AND
f. Financial eligibility is documented in each client’s chart and is
reassessed at least annually; AND
g. Clients who are responsible for paying any fee for their services must
be given a statement of charges (bill) directly; AND
h. Client bills show total charges less any allowable discounts; AND
i. Charges to minors requesting confidential services are based on the
resources of the minor; AND
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j. Charges to unemancipated minors, where confidentiality is not a
concern, is based on family income; AND
k. Clients services are not denied or limited in any way because of
inability to pay; AND
l. Client may make voluntary donations; however clients must not be
pressured to make donations, and donations must not be a
prerequisite for the provision of services and supplies. Donations from
clients do not waive the billing/charging requirements set out above;
AND
m. Reasonable effort is made to collect bills without jeopardizing
confidentiality; AND
n. Charges to persons whose family income exceeds 250 percent of the
poverty guidelines recover the reasonable cost of providing service;
AND
o. A method for aging accounts is in place; AND
p. Payment agreements with contracted or referral providers are in place.
[Michigan Family Planning Standards and Guidelines, 2001: 7.4 A1]
Q3.2 The local health department adheres to reporting requirements. [Michigan
Family Planning Standards and Guidelines, 2001: 6; State of Michigan
MPR’s 22 and 26, 2001]
To fully meet this indicator:
The local health departments:
a. Family Planning Annual Report (FPAR B formerly known as BCCR)
meets all of the following requirements:
1) Financial tables are completed accurately and on time using
current financial data.
2) Tables 1, 1a, 2, 3, 4, 5, and 6 are complete.
3) Income for Title X and Medicaid are shown on Table 6.
4) Thirty (30) percent of the caseload is less than 19 years of age
OR the local health department is maintaining its percentage of
adolescents and has included an objective to increase teen
numbers.
5) Eighty (80) percent of the caseload is women at less than 200
percent of poverty.
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6) Males users are reported only if they meet the user definition for
family planning patients.
7) Donations are reported separately from patient fees and are
reported on Line 16, Table 6.
8) Pap-smear follow-up is in 100 percent compliance or an
approved corrective action plan is in place; AND
b. Reliability and accuracy of data systems are monitored for missing
user data, coding error editing, and data outcome; AND
c. Quarterly sterilization reports are completed and submitted, if
sterilizations are performed; AND
d. Hepatitis B reports are submitted following vaccine administration;
AND
e. The program provides MICR information and registers clients under 20
if they consent following Hepatitis B vaccine administration; AND
f. If sterilization’s are performed, the local health department also
maintains on file protocols for performing sterilization’s, assuring that
requirements are met for age, voluntary informed consent, and waiting
period.
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Q4. The local health department’s family planning clinic (s)
adequately schedule appointments for family planning
services. [Michigan Family Planning Standards and
Guidelines, 1998: 6.4; State of Michigan MPR 21, 1999]
I Q4.1 The family planning clinic’s individual appointment system complies with
Title X requirements and Michigan Department of Community Health
standards. [Michigan Family Planning Standards and Guidelines, 2001
7.0 D]
To fully meet this indicator:
a. The local health department maintains on file operating procedures for
scheduling client appointments; servicing walk-ins, urgent problems
and emergencies; and following-up on no-shows; AND
b. A review of the appointment scheduling system reveals that:
1) Clients are scheduled for an appointment within two weeks of
calling; AND
2) Clients may make appointments for specific times for all types
of exams and when feasible, clients are scheduled for all
needed services on one visit; AND
3) Teens are scheduled for an appointment within two (2) to four
(4) days; AND
4) Clients receiving an initial exam receive service in less than two
(2) hours; AND
5) Clients receiving an annual exam receive service in less than
one and a half (1 ½) hours; AND
6) Supply clients receive services in less than half an hour; AND
7) Clients with positive pregnancy tests receive services in less
than one and a half (1 1/2) hours; AND
8) Supply pickup times are scheduled at various times of the day
and week; AND
9) Evening, or Saturday appointments are available; AND
10) Patients needing urgent care and emergency contraception are
scheduled immediately or accommodated by walking in; AND
11) The no show rate is 30% or less; AND
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12) It is recommended that periodic Patient Flow Analysis (PFA) is
done at least every 3 years and modifications in the schedule
are made based on PFA results. [Michigan Family Planning
Standards and Guidelines, 2001: 10.4 B7]
Q5. The local health department assesses community need
related to family planning and develops a plan to
address community need. [Michigan Family Planning
Standards and Guidelines, 2001: 3.2; State of Michigan
MPR 18, 2001]
Q5.1 The local health department assesses community need related to family
planning and develops a plan to address community need.
To fully meet this indicator:
a. The local health department maintains on file an annual plan which
includes the results from a needs assessment (the methodology for
assessment should be detailed in the plan), a progress report on
the previous year’s goals, annual goals and objectives, services to
be provided, and projected caseload. Michigan Department of
Community Health Family Planning Standards and Guidelines,
2001: 3.2A1-6.
The plan must include:
i. A description of the geographic area including a
discussion of potential geographic, topographic and other
related barriers to service; AND
ii. Demographic description of the service area including
objective data pertaining to individuals in need of family
planning services, maternal and infant mortality/morbidity
rates, birth rates and percentages of unintended
pregnancies by age groups, poverty status of the
populations to be served, cultural and linguistic barriers
to service, etc.; AND
iii. Description of existing services and need for additional
family planning services to meet community/cultural
needs; AND
iv. Need indicators that include rates of STDs and HIV
prevalence (Including perinatal infection rates) in the
service area; AND
v. Identification and description of linkage with other
resources related to reproductive health; AND
vi. Identification and discussion of high priority populations
and target areas.
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b. Goals and objectives must be clearly stated, listed in order of
priority, be specific, realistic, measurable, and have a time frame
for completion, be compatible with Title X requirements and
Michigan Department of Community Health standards, and reflect
state and federal objectives. Objectives must include community
participation, program promotion, community education, and
evidence that low-income individuals are given services priority and
that low-income women, teens, minorities, and other underserved
populations are included in the target group.
Q6. The local health department educates and promotes
the community related to family planning services and
promotes family planning services in the community.
Q6.1 The local health department has a community-based family planning
advisory and/or education committee, representative of the population
served, that meets at least twice a year and provides general direction for
the family planning program and provides education on family planning
services to the community. [Michigan Family Planning Standards and
Guidelines, 2001: 4.0; State of Michigan MPR 8, 2001]
To fully meet this indicator:
The local health department maintains on file:
a. Agencies provide an opportunity for participation in the development,
implementation and evaluation of the project by (1) persons broadly
represented of all significant elements of the population to be served
and (2) persons in the community knowledgeable about the
community’s need for family planning services [Michigan Department
of Community Health Family Planning Standards; 2001: 3.4A20
b. An advisory committee of five to nine members who are broadly
representative of the community must review and approve all
informational and education materials developed of made available
under the project prior to their distribution; AND
c. The I&E advisory committee may serve the community participation
functions if it meets the above requirements, or a separate group may
be identified; AND
d. Minutes of committee(s) meetings which document recommendations,
actions taken, meetings dates, and attendance; AND
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e. Evidence, such as meeting minutes, that the committee(s) has
reviewed and concurred with the local health department’s family
planning program, and methods and that educational materials are
approved by the local health department’s Information and Education
Advisory or Family Planning Advisory Committee prior to
disbursement. This can be evidenced through meeting minutes; AND
[Michigan Family Planning Standards and Guidelines, 2001: 4.0A3]
f. By-laws or description of the committee(s) duties and responsibilities
that include a statement of purpose; AND
g. A written community education plan evidenced in the annual plan that
defines the local health department’s implementation and evaluation
strategy. The community education objectives must include
identification of specific target groups, such as teens, migrants, and
homeless individuals, and HIV/AIDS education and at least one of the
following: developing and maintaining a positive community climate for
program activities; coordination with other agencies to avoid gaps in
and duplication of services; outreach to clients of agencies likely to
provide services to those in need of family planning services; or
orientation of professional staff of agencies likely to counsel or refer
clients for family planning services; AND [Michigan Department of
Community Health Family Planning Standards and Guidelines
;2001A: 6.10A]
h. A written plan that details how the local health department will promote
community awareness of the agency’s family planning goals, inform
the community of services provided, promote continued participation in
the program by persons to whom family planning services may be
beneficial, and yearly caseload and outreach targets. The plan must
specifically delineate outreach strategies targeted at low-income
women, teens, minority groups, and other underserved populations
(i.e., HIV carriers, IV drug users, prostitutes, lesbians); AND [Michigan
Family Planning Standards and Guidelines, 2001: 6.11 A]
i. Evidence that all staff received training regarding the unique socio-
cultural practices, beliefs and customs of the under-served populations
of their service area; AND [Michigan Family Planning Standards and
Guidelines, 2001: 6.6 A6]
j. Brochures, agendas or outlines from promotional meetings/sessions,
or public service announcements used in program promotion. This
could include evidence that peer counselors, teen theater, or
community health advocates are used and documentation of
community education activities such as outreach logs or evaluations of
education activities, speakers provided by the local health department,
and program effectiveness.
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Q6.2 The local health department has operating procedures for providing
medical client education about contraceptives, HIV/AIDS, and STIs that
comply with federal Title X requirements and Michigan Department of
Community Health. [State of Michigan MPR’s 20, 23, 25, 2001; Michigan
Department of Community Health Family Planning Standards and
Guidelines 2001:7.2A(7) a-b.]
To fully meet this indicator:
The local health department’s materials acknowledge federal grant
support in any publication and are subject to royalty free, non-exclusive,
and irrevocable license or right to the Government to reproduce, translate,
publish, use, disseminate, and dispose of such materials and to authorize
others to do so. The work “publication is defined to include computer
software. [Michigan Family Planning Standards and Guidelines 2001:
6.10A] AND Informational and educational materials:
a. Reflect Title X requirements and Michigan Department of Community
Health standards policies regarding discrimination, coercion, client
eligibility, education about all methods of contraception, provision of
services which do not include abortion as a method of family planning,
options of managing unplanned pregnancies, confidentiality, client
charges, the Americans with Disabilities Act, and do not contain
information that is contrary to accepted medical practice; AND
[Michigan Family Planning Standards and Guidelines, 2001: 6.8 B2,
6.13 C]
b. The local health department maintains on file client education
procedures for providing information on all contraceptive methods,
including the birth control pill, emergency contraception, condoms,
diaphragm, cervical caps, IUD, natural family planning, spermicides,
injectible contraceptives, contraceptive implants, abstinence, and
sterilization. Information on newly available methods must be
available. Contraceptive information must include detail on the safety,
effectiveness, benefits, risks, side effects, complications, protection
against STI’s and correct usage of all contraceptives; AND [Michigan
Family Planning Standards and Guidelines, 2001: 8.1 A1]
c. The local health department provides educational opportunities to
clinic clients through group discussion, film or videotape, pamphlets, or
one-to-one discussion; AND [Michigan Family Planning Standards
and Guidelines, 2001: 8.1 A6]
d. Client education must be documented in the client’s chart. The
education provided should be appropriate to the client’s age, level of
knowledge, language and sociocultural background and be presented
in an unbiased manner; AND [Michigan Family Planning Standards
and Guidelines, 2001: 6.8 B4 and 5]
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e. changes or selected based on client input. The local health
department maintains on file evidence of client review of materials
prior to distribution, such as client questionnaires; AND [Michigan
Family Planning Standards and Guidelines, 2001: 6.10 A1]
f. Are reviewed periodically to assure that information is factually correct
and up to date. [Michigan Family Planning Standards and Guidelines,
2001: 6.8 B3]; AND
g. A review process is in place to insure currency and accuracy of
information.
Q7. The local health department assures the quality of the
clinical and educational components of the family
planning program. [Michigan Family Planning Standards
and Guidelines, 2001: 10.4 A; State of Michigan MPR 20,
2001]
Q7.1 The local health department has a quality assurance system in place to
evaluate the quality of the clinical and educational components of the
family planning program.
To fully meet this indicator:
a. Written and annually updated plans and operating procedures,
including a system to implement corrective action when deficiencies
are noted, and Quality Assurance activities assure that all
requirements of the family planning program are met; AND [Michigan
Family Planning Standards and Guidelines, 2001: 10.4 B]
b. Minutes of quality assurance meetings; AND [Michigan Family
Planning Standards and Guidelines, 2001: 10.4 B3]
c. A tracking system to identify clients in need of follow-up, such as a
computer or tickler system. [Michigan Family Planning Standards and
Guidelines, 2001: 10.4 B3]; AND
d. Staff evaluations occur annually as part of the quality assurance
system [Michigan Family Planning Standards and Guidelines;
2001:6.5B6]
Q7.2 The local health department monitors client satisfaction with Title X
services provided by both the local health department and referred
services.
I
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To fully meet this indicator:
The local health department maintains on file:
a. Copies of completed client satisfaction surveys, client surveys of
needed services or results from focus groups conducted to determine
potential improvements in services; AND [Michigan Family Planning
Standards and Guidelines, 2001: 10.4 B8]
b. Documentation of changes made in response to client input, where
indicated, and with input from the Advisory Council. [Michigan Family
Planning Standards and Guidelines, 2001: 10.4 B8a]
Q7.3 The local health department evaluates the quality of family planning
counseling services. [Michigan Family Planning Standards and
Guidelines, 2001: 8.1]
To fully meet this indicator:
a. The local health department maintains on file written procedures for
evaluating the quality of its counseling. The evaluation must include
consideration of whether staff are knowledgeable, objective,
nonjudgmental, sensitive to individual rights and differences, and able
to create an environment conducive to discussing personal
information; AND
b. Accompanying a client through the clinic reveals that staff members
introduce themselves to client; the client is treated with courtesy and
respect; the client is given opportunity to participate in planning her/his
own treatment; and service delivery promotes an atmosphere in which
clients feel free to ask questions and voice concerns; AND
c. The local health department has specific protocols and operating
procedures for providing education and information on services such
as HIV, pregnancy, infertility and, preconceptional health counseling
are on file.
Q8. The local health department has protocols and
operating procedures for equipment and supplies.
[Michigan Family Planning Standards and Guidelines,
2001: 10.4 B10;10.1 A and B; State of Michigan MPR’s 9
and 20, 2001]
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Q8.1 The local health department’s protocols and operating procedures for
equipment and supplies comply with Title X requirements and Michigan
Department of Community Health standards guidelines.
To fully meet this indicator:
Direct observation, review of records, and/or written protocols and
operating procedures indicate:
a. Equipment and supplies are kept in a safe and secured area,
adequate to meet service demands, appropriate to the type of service
offered, maintained in good working order, records of equipment
purchased with grant related funds are verified during inventory,
inventoried annually by one designated individual; AND
b. A specific individual at each site is responsible for maintenance and
selection of equipment and supplies; AND
c. A log is maintained to document equipment maintenance; AND
d. Disposition of equipment and supplies is in compliance with federal
and state regulations; AND [Michigan Family Planning Standards and
Guidelines, 2001: 6.3A]
e. A system is in place to safeguard against loss, theft or damage of
equipment or supplies.
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Q9. The local health department has protocols and
operating procedures for pharmaceutical distribution.
[Michigan Family Planning Standards and Guidelines,
2001:10.2; State of Michigan MPR’s 9 and 20, 2001;
P.A.368 as amended under the Pharmacy Practice and
Drug Control 333.17745)]
Q9.1 The local health department has protocols and operating procedures for
the distribution, security and record keeping of pharmaceuticals that
adhere to all applicable federal and state regulations.
To fully meet this indicator:
The local health department:
a. Maintains on file written protocols and operating procedures for the
distribution, security and record keeping of pharmaceuticals that
adhere to all applicable federal and state regulations; AND
b. The medical director of dispensing physician maintains a Drug Control
License AND
c. All medications except prepackaged and prelabled oral contraceptives
are distributed by a nurse or physician; AND
d. The label must contain the following information:
1. The name and address of the location from which the prescription
drug is dispensed.
2. The patient’s name and record number.
3. The date the prescription drug was dispensed.
4. The prescriber’s name.
5. The directions for use.
6. The name and strength of the prescription drug.
7. The quantity dispensed.
8. The expiration date of the prescription drug or the statement
“discard this medication one year after the date it is dispensed”;
9. Lot number AND
e. Vaccines for immunizations are stored according to manufacturer’s
recommendations; AND
f. Maintains on file a listing (formulary) of all drugs stocked that is revised
annually; AND
g. Maintains on file and additional listing of pharmaceuticals that may be
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ordered, but are not stocked; AND
h. Purchases and uses generic drugs based on therapeutic equivalence
as published by the Federal Drug Administration or in the Formularies
of Therapeutic Equivalence accepted by the State Board of Pharmacy;
AND
i. A system is in place to monitor the expiration date on drugs and
ensure disposal of all expired drugs; AND
j. Double locks and separates from other drugs narcotics or tranquilizers,
and takes a count of controlled substances at the beginning and end
of each day or clinic session; AND
k. Has a system for silent notification in case of drug recall; AND
l. Has documented that in-service training on the nature and safety of
pharmaceuticals has been provided to staff involved in the provision of
medications to clients.
Q9.2 Each of the local health department’s clinics maintained an adequate
supply and variety of drugs and devices to meet the contraceptive needs
of clients.
To fully meet this indicator:
A review of the supply of contraceptives in stock include:
a. Hormonal contraceptives in a variety of dosages, routes and
combinations; including DMPA, Lunelle, oral contraceptives
and emergency contraception; AND
b. IUDs and Implants if provided on site; AND
c. Diaphragms/cervical caps in various types and sizes; AND
d. Male and female condoms; AND
e. Spermicidal agents such as foams, creams, jellies, film.
Q10. The local health department has protocols and
operating procedures for maintaining medical records.
[Michigan Family Planning Standards and Guidelines,
2001: 10.3; State of Michigan MPR’s 9 and 20, 2001]
Q10.1 The local health department maintains medical records in accordance with
Title X requirements, Michigan Department of Community Health
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standards and accepted medical standards for all clients receiving
medical services.
To fully meet this indicator:
A review of randomly selected medical records indicate:
a. All male and female clients receiving medical services have a medical
record, including pregnancy testing, HIV and other counseling clients;
AND [Michigan Family Planning Standards and Guidelines, 2001:
10.3 A1]
b. Entries on client records are uniform as to format and content, in
chronological order, and signed and dated. Entries must be written in
black ink or typed and must be legible and accurate; AND [Michigan
Family Planning Standards and Guidelines, 2001: 10.3 A2]
c. A signature log is used if full name is not written on entries; AND
d. All telephone calls from clients with medical concerns are accurately
documented; AND [Michigan Family Planning Standards and
Guidelines, 2001: 10.3 B16]
e. Signed and dated consent forms covering examination and treatment,
including, as applicable, General Treatment (must be signed by all
clients); Prescriptive Contraception (method specific); Pregnancy
Testing; Sterilization; or Release of Information. Consent forms must
cover all procedures and medications and contain statements that
consent was given voluntarily, education and counseling was provided,
questions were answered, and client understands the content of
information given. Consent must be written in the primary language of
the client or an interpreter must be used. If the client is mentally
incompetent, a special consent form must be used and a parent or
guardian must also sign; AND [Michigan Family Planning Standards
and Guidelines, 2001: 8.1 B]
f. Individual counseling occurs before client makes choice of method or
signs consent; AND [Michigan Family Planning Standards and
Guidelines, 2001: 8.1 B1]
g. Consent must be updated in response to change in health status or to
new prescriptive method and must reflect current knowledge relating to
the methods of birth control; AND [Michigan Family Planning
Standards and Guidelines, 2001: 8.1 B4]
h. Parental or partner consent is not required for services; AND
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i. For teens, family involvement is encouraged and documented in the
chart; AND [Michigan Family Planning Standards and Guidelines,
2001: 8.1 B4]
j. Assurances of confidentiality statement appear on history forms or
another place within the medical record; AND [Michigan Family
Planning Standards and Guidelines, 2001: 10.3 B10]
k. Medical history; AND [Michigan Family Planning Standards and
Guidelines, 2001: 10.3 B1e]
l. Results of physical exam; AND [Michigan Family Planning Standards
and Guidelines, 2001: 10.3 B10]
m. Results of clinical findings, diagnostic and therapeutic orders, including
documentation of clinical information that justifies treatment or end
result; AND [Michigan Family Planning Standards and Guidelines,
1998: 10.3 B1e]
n. Lab test results and follow-up of abnormal results is documented; AND
[Michigan Family Planning Standards and Guidelines, 2001: 10.3 B1h]
o. Documentation of all treatments initiated or contraceptive methods
provided; AND [Michigan Family Planning Standards and Guidelines,
2001: 11.3 B1m]
p. Documentation of all special instructions; AND [Michigan Family
Planning Standards and Guidelines, 2001: 11.3 B1I]
q. Documentation of all continuing care, counseling, referral, education,
social services, and follow-up services (including scheduled revisits).
Education provided related to contraceptives, HIV/AIDS, and STI’s
must be documented. For referrals, documentation in medical records
indicates the client was allowed to select referral provider; consent was
obtained prior to release of pertinent information to referral provider;
reason for referral, services to be received from the referral agency
and directions to the referral agency were explained; and a date to
return to the family planning clinic was scheduled; AND [Michigan
Family Planning Standards and Guidelines, 2001: 7.2 D, 7.4 A2]
r. Documentation of emergency referrals; AND [Michigan Family
Planning Standards and Guidelines, 2001: 11.3 B1i]
s. An optional problem list at the front of chart; AND [Michigan Family
Planning Standards and Guidelines, 2001: 11.3 B1p]
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t. For transfer clients, history is completed and a method-specific
consent form is signed and a breast exam is offered if the woman is
over 30 and choosing a hormonal method of contraception. If the
client's last exam occurred over 12 months, the client is treated as a
new client. [Michigan Family Planning Standards and Guidelines,
2001: 10.2 B]
u. HIV, mental health and substance abuse information is handled
according to law, and kept
Q10.2 The local health department maintains a system for filing, retrieving, and
storing medical records. [Michigan Family Planning Standards and
Guidelines, 2001: 11.3 A2]
To fully meet this indicator:
The local health department maintains:
a. The client’s family planning chart separate from the client’s other
service charts; AND
b. An efficient system for filing and retrieving charts. Records must be
available to clients upon request and locked when not in use, and
access to records must be limited on a need-to-know basis; AND
c. A system for storage and destruction of records. This must include a
system for identifying inactive clients and purging inactive files.
Q10.3 The local health department has a system for performing a medical audit.
[Michigan Family Planning Standards and Guidelines, 2001: 10.4 B]
To fully meet this indicator:
a. The local health department’s Medical Director or designee reviews a
reasonable number of randomly selected charts at least quarterly for
completeness and accurateness; AND [Michigan Family Planning
Standards and Guidelines, 2001:10.4B3]
b. The local health department has evidence that client records are
periodically monitored. This must include post clinic medical record
review where problems are logged and resolved. Additionally, periodic
or intermittent random chart audit must be performed by category or
combination of categories: [Michigan Family Planning Standards and
Guidelines, 2001: 10.4B3
1. New users
2. Continuing users
3. Specific topics (e.g., methods, problem diagnosis)
4. Age group (e.g., teen, over 35); AND
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c. A system is in place to identify documentation or clinical practice
problems and resolution or follow-up of problems identified above.
Q11. The local health department’s General Clinic
Procedures and Clinician Service Protocols are in
compliance with Title X requirements, and Michigan
Department of Community Health standards.
Q11.1 The local health department has General Clinic Procedures and Clinician
Service Protocols in compliance with Title X requirements and Michigan
Department of Community Health standards.
To fully meet this indicator:
a. The local health department maintains current clinical practice
resources, such as the text of Contraceptive Technology or CT
Update Newsletter or the NP journal AND [Michigan Family Planning
Standards and Guidelines, 2001: 6.6 D]
b. The local health department maintains on file, at each site, a General
Clinic Procedure Manual [See Appendix E at the end of Section Q] and
Clinician Service Protocol Manual(s) that are in compliance with Title X
requirements, Michigan Department of Community Health standards;
AND [Michigan Family Planning Standards and Guidelines, 2001: 7.0
B]
c. Voluntary participation by clients and acceptance of family planning
services is not a prerequisite to receiving other services; AND
[Michigan Family Planning Standards and Guidelines, 2001: 3.4 A2]
d. Access to persons with limited English proficiency is assured and
assistance is provided that results in accurate and effective
communication with the client with no financial cost to the client; AND
[3.4A3-4]
e. Provide services in a manner that will protect individual dignity and
respect diverse social and cultural practices of the population to be
served; AND
f. Services are provided without residency requirement or physician
approval; AND [Michigan Family Planning Standards and Guidelines,
2001: 3.4 A5, 5.2 A]
g. Sterilization services provided on-site comply with standards for out-of-
hospital sterilization’s; AND [Michigan Family Planning Standards and
Guidelines, 2001: 6.7 C]
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h. Services do not include abortion as a method of birth control; AND
[Michigan Family Planning Standards and Guidelines, 2001: 3.4 A5]
i. Signatures by the medical director and clinicians indicating procedures
and protocols are updated annually and evidence of training if changes
in protocol occur between annual reviews; AND [Michigan Family
Planning Standards and Guidelines, 2001: 6.5 B2]
j. Practitioner signature on all established protocols or on cover sheet;
AND [Michigan Family Planning Standards and Guidelines, 2001: 6.5
B7]
k. As applicable, copy of waiver requests submitted for exemption from a
particular requirement and documentation, such as a letter or
memorandum, from the Michigan Department of Community Health
indicating approval of the waiver request; AND [Michigan Family
Planning Standards and Guidelines, 2001: 7.1 C]
l. A patient rights and responsibilities poster is displayed or given to the
patient. [Michigan Family Planning Standards and Guidelines, 2001:
7.0 E]
Q12. The local health department has protocols and
operating procedures for providing services to
adolescents. [State of Michigan MPR 26, 2001]
Q12.1 The local health department has specific protocols and operating
procedures for providing services to adolescents. [Michigan Family
Planning Standards and Guidelines, 2001: 8.7]
To fully meet this indicator:
a. The local health department addresses service delivery to adolescents
in their annual plan; AND
b. A review of medical records, direct observation and written protocols
and operating procedures related to adolescents demonstrate all the
following items are assured:
1) Written consents of parents or guardians is not required for the
provision of services; AND
2) Parents are not notified before of after services are requested
or received AND
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3) Specialized, confidential counseling and follow-up services are
provided. [Michigan Family Planning Standards and Guidelines,
2001: 8.7 B1]
4) Adolescent are encouraged to participate in decisions related to
receiving medical services. This is mandatory prior to
dispensing any prescriptive methods. [Michigan Family
Planning Standards and Guidelines, 2001: 8.7 C1e]
5) Documentation of encouragement of parental involvement.
[Michigan Family Planning Standards and Guidelines, 2001: 8.1
B4]
6) Information on all methods of contraception is given and
abstinence is discussed as an option. [Michigan Family
Planning Standards and Guidelines, 2001: 8.7 C1F]
7) An atmosphere conducive to questions, discussion is created.
[Michigan Family Planning Standards and Guidelines, 2001: 8.7
B1E]
8) Teens are asked about symptoms and exposures to STI’s or
HIV and high-risk teens are encouraged to be tested and
treated, as indicated. [Michigan Family Planning Standards and
Guidelines, 2001: 8.7 B1F]
I Q12.2 The local health department has specialized services for teens. [Michigan
Family Planning Standards and Guidelines, 2001: 8.7 C]
To fully meet this indicator:
a. The local health department maintains on file a list of the type of
specialized services available such as:
1) Teen peer counselors; OR
2) Special walk in or scheduled clinic hours for teens; OR
3) Teen focused community education programs; OR
4) Opportunity for priority clinic scheduling within 2-4 days; OR
5) Delegate agency staff represent the program on teen
pregnancy task forces, or other community initiatives focused
on adolescents.
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Q13. The local health department has protocols and
operating procedures for performing initial and annual
visits. [State of Michigan MPR 9, 1999]
Q13.1 The protocols for conducting an initial medical visit comply with Title X
requirements and Michigan Department of Community Health standards.
[Michigan Family Planning Standards and Guidelines, 2001: 8.3]
To fully meet this indicator:
A chart review or observation of clinicians conducting an initial medical
visit indicates that during a medical visit, clients provide or receive the
following information:
a. Personal and family history. At a minimum, the woman’s medical
history must include information on: [Michigan Family Planning
Standards and Guidelines, 2001: 8.3.1A 1,2]
1) Allergies
2) Immunizations, esp. rubella and Hepatitis B
3) Current medications
4) Hospitalizations
5) Cancer
6) Cardiovascular disease
7) Gynecological history, including date of last menstrual period, in
utero exposure to DES, and any problems
8) Pregnancies
9) Sexual risk behavior
10) History of blood transfusion prior to 1984 or exposure to
substance abuse
11) Drug/substance abuse
12) Current or previous methods of birth control, including reasons
for discontinuing use
13) Major illnesses
14) Sexually transmitted infections
15) High cholesterol/early coronary artery disease
16) Hyperlipidemia
17) Blood clots
18) Hepatitis
19) Epilepsy
20) Migraine headaches
21) Diabetes
22) Hypertension
23) Partner history (indictable drug use, multiple partners,
bisexuality, risk history for STIs and HIV)
b. For females, an examination of height and weight, blood pressure,
thyroid, heart and lungs, extremities, breast (including instruction in
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self-exam), abdomen, and pelvic (speculum) and bimanual should be
included. Colo-rectal screening for individuals over 40 must be
provided ; AND [Michigan Family Planning Standards and Guidelines,
2001: 8.3.2 A1]
c. For males, medical history should include sexual activity, risk for STIs
and HIV/AIDS, fertility, and in utero exposure to DES. An examination
of height and weight, blood pressure, thyroid, heart and lungs,
extremities, genitals and rectum, including palpation of the prostate,
and instruction in self-exam of the testes should be included. ;
Colorectal screening must be provided for individuals over 40; AND
[Michigan Family Planning Standards and Guidelines, 2001: 8.3.3 A2]
d. Physical examination and related prevention services should not be
deferred beyond three months after the initial visit and in no case may
be deferred beyond six months, unless if in the clinicians’ judgement,
there is compelling reasons for extending the deferral; AND [Michigan
Family Planning Standards and Guidelines 2001: 8.3.2 A3a]
e. All deferrals, including the reason(s) for deferral must be documented
in the client chart AND [Michigan Family Planning Standards and
Guidelines 2001:8.3.2A3b]
f. Protocols are available regarding deferrals AND
g. A presentation of relevant educational materials including information
about the value of fertility regulation, all contraceptive methods, male
and female reproductive anatomy, reproductive health, health
promotion/disease prevention, and AIDS/HIV; AND [Michigan Family
Planning Standards and Guidelines, 2001: 8.1 A]
h. Is prior to IUD insertion if indicated by history or prior exam findings;
AND [Michigan Family Planning Standards and Guidelines, 2001:
8.3.5A1
i. Necessary medical procedures; AND
j. Medication and/or supplies; AND
k. Exit counseling which includes written, specific instructions on chosen
method, including instructions on danger signs and actions to take in
case of emergency. [Michigan Family Planning Standards and
Guidelines, 2001:8.2 B1]
Q14. The local health department has protocols and
operating procedures for providing counseling services.
[State of Michigan MPR 10, 24, 2001]
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Q14.1 The local health department provides counseling services in compliance
with Title X requirements and Michigan Department of Community Health
standards.
To fully meet this indicator:
A review of protocols and operating procedures indicate that:
a. During a visit the client is informed of confidential treatment of
information and medical records and their right to refuse release of
information to any individual except as required by law or third party
payor contract; right to voice grievances and of agency's procedure for
handling grievances; and right to refuse to participate in research, if
applicable; AND [Michigan Family Planning Standards and
Guidelines, 1998: 7.0 E, 7.0 H, 7.1 B4]
b. Clinical staff give accurate and up to date information on risks,
benefits, contraindications and effective use of any method,
procedure, treatment or option being considered; AND [Michigan
Family Planning Standards and Guidelines, 2001: 8.1 A1]
c. Client-centered counseling is provided to all clients on HIV/AIDS and
offers testing; AND [Michigan Family Planning Standards and
Guidelines, 2001: 8.1A8]
d. Substance abuse history is taken, education, and referral is provided
and appropriate follow-up is conducted. The local health department
maintains on file evidence of collaboration with community substance
abuse centers for referral of clients; AND
e. Post-exam (exit) counseling assures the client knows results of
physical exam; results of lab tests; how to use chosen method.
(Should be given written instruction); method specific common side
effects, possible complications and what to do if they occur; when to
return for revisit; emergency phone number and/or location where
emergency services can be obtained; information on referrals and
follow-up, if appropriate; AND [Michigan Family Planning Standards
and Guidelines, 2001: 9.6]
f. Special counseling services, such as preconceptional, management of
current pregnancy, sterilization, infertility, genetic, nutritional, and
adolescent, are provided on-site or are available by referral; AND
[Michigan Family Planning Standards and Guidelines, 2001: 9.3]
g. Male counseling services include a brief description of contraceptive
methods, including sterilization; where to obtain contraceptive
supplies; written and verbal instructions for use of spermicides and
condoms; information regarding HIV/AIDS and STIs; and responsibility
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as a partner. [Michigan Family Planning Standards and Guidelines,
2001: 8.1]
Q15. The local health department has protocols and
operating procedures for providing clinical services.
[State of Michigan MPR 9, 2001]
Q15.1 Specific laboratory tests are required for the provision of specific methods
of contraception. [Michigan Family Planning Standards and Guidelines,
2001: 8.3 .5A1]
To fully meet this indicator:
a. Pregnancy tests must be provided on site; AND [Michigan Family
Planning Standards and Guidelines, 2001; 2001: 8.61A]
b. The following laboratory procedures must be provided if required in the
provision of a contraceptive method and may be provided for the
maintenance of health status and/or diagnostic purposes, either on
site of by referral; AND [Michigan Family Planning Standards and
Guidelines, 2001 8.3.5 A1b,
(1) Anemia assessment
(2) Gonorrhea and chlamydia test
(3) Vaginal wet mount
(4) Diabetes testing
(5) Cholesterol and lipids
(6) Hepatitis B testing
(7) Syphilis serology (VDRL, RPR)
(8) Rubella titer
(9) Urinalysis HIV testing
c. A procedure which addressed client confidentiality must be established
to allow for client notification and adequate follow-up of abnormal
laboratory results AND [Michigan Family Planning Standards and
Guidelines, 2001; 2001:8.3.5A4c]
d. The local health department maintains on file written policies and
operating procedures for laboratory services performed on-site.
[Michigan Family Planning Standards and Guidelines, 2001: 8.3 A]
e. Lab services are performed in accordance with accepted medical
practice and CLIA regulations. [Michigan Family Planning Standards
and Guidelines, 2001: 8.3.5, A3]
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Q15.2 The local health department provides revisit services in compliance with
Title X requirements and Michigan Department of Community Health
standards.
To fully meet this indicator:
Written protocols and operating procedures indicate that:
a. Annual revisits are required for all clients using prescriptive methods;
AND [Michigan Family Planning Standards and Guidelines, 2001: 8.3
A1]
b. Annual revisits include, at a minimum, a history update and a physical
exam. Hormonal contraceptive users are asked about symptoms of
embolic disease; pain in arms, chest, abdomen; headaches, visual
problems; mood changes; leg complaints; irregular bleeding; and date
and nature of the last menstrual period. Intrauterine device users are
asked about abdominal complaints; irregular bleeding; fever; problems
with device; vaginal discharge; and date and nature of the last
menstrual period; AND [Michigan Family Planning Standards and
Guidelines, 2001: 8.3.4]
c. Medical revisits are individualized based on a client's need; AND
[Michigan Family Planning Standards and Guidelines, 2001: 8.3 .4]
d. The local health department maintains on file written protocols and
operating procedures for revisit services. All procedures to be
routinely repeated must be listed; AND [Michigan Family Planning
Standards and Guidelines, 2001: 8.3 A]
e. Annual revisits are recommended to all clients. The medical director ,
per protocol, determines the frequency with which specific procedures
are to be routinely repeated. [Michigan Family Planning Standards
and Guidelines, 2001: 8.3.4 A1]
f. Urinalysis is performed as medically indicated or per the request of a
client. Serology, Hemagglutination test for Rubella, and pregnancy
testing are administered if indicated or requested; AND [Michigan
Family Planning Standards and Guidelines, 2001: 8.3.51b )]
g. Return visits lab tests minimally performed for hormonal contraceptive
users is an annual pap smear and for IUD users is an annual pap
smear and hemoglobin or hematocrit; AND [Michigan Family Planning
Standards and Guidelines, 2001: 8.3 A1c (1-2)]
h. Medical, initial, annual and revisit clients receive the appropriate lab
tests unless written results done within the last 12 months are
available; AND [Michigan Family Planning Standards and Guidelines,
2001: 10.2B2]
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i. When medically indicated, assessment/screening for condylomata
acuminata (HPV), chlamydia, trichomonas, genital herpes, bacterial
vaginosis, candidiasis, syphilis, and gonorrhea is provided; AND
[Michigan Family Planning Standards and Guidelines, 2001: 8.3.5A1b]
j. Microscopic examination is available at each clinic site; AND
[Michigan Family Planning Standards and Guidelines, 2001: 8.3 C]
k. Microscopic exam of vaginal or urethral smears and wet mounts for
diagnosis of some sexually transmitted infections, vaginitis, and
urethritis provided when indicated; AND [Michigan Family Planning
Standards and Guidelines, 2001: 8.35 C1]
l. Microscopic exam and/or culture and sensitivity of urine is provided;
AND [Michigan Family Planning Standards and Guidelines, 2001:
8.3.5 C2]
m. Selected blood tests including blood sugar, triglycerides/cholesterol,
and HIV testing (if the local health department is a designated HIV
Counseling and Testing Center) are conducted; AND [Michigan
Family Planning Standards and Guidelines, 2001: 8.3.5 C3]
n. Quality control and equipment maintenance procedures, including
proficiency testing, are in place for on-site lab testing. Quality Control
logs are maintained; AND [Michigan Family Planning Standards and
Guidelines, 2001: 8.3.5 Aa]
o. There are lab log(s) and a system to identify, treat and follow-up
abnormal results and selected conditions. Referral and follow-up
procedures for abnormal test results include documentation of the
appropriate management for abnormalities; client notification;
confidentiality; referral of client for necessary services if not provided
on site; AND [Michigan Family Planning Standards and Guidelines,
2001: 8.3 A4,
p. Abnormal or unsatisfactory Pap Smear readings result in client
notification within six weeks if further diagnostic study or repeat test is
needed; follow-up contact noted in medical record; result of follow-up
noted in medical record, the sending of a certified letter to unreachable
clients if Pap Smear indicates dysplasia. AND
q. A registered certified letter is sent to the patient for results of a HGSlL
or worse; AND [Michigan Family Planning Standards and Guidelines,
2001: 8.3.5 B]
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r. For positive gonorrhea, syphilis, chlamydia and HIV tests, state and
local reporting requirements and follow-up procedures are followed.
[Michigan Family Planning Standards and Guidelines, 2001: 8.8 A2]
Q15.3 Local health departments using off-site laboratories are of high reliability
and quality. [Michigan Family Planning Standards and Guidelines, 2001:
8.3 A4]
To fully meet this indicator:
a. Labs reading Pap Smears must comply with their state licensing
regulations; AND [Michigan Family Planning Standards and
Guidelines, 2001: 8.3.5 A3d]
b. Has a system to assure lab tests performed by off-site laboratories are
of high reliability and quality; AND [Michigan Family Planning
Standards and Guidelines, 2001: 8.3.5 A3]
c. Competitively bids lab services contracts prior to award of contract.
[Michigan Family Planning Standards and Guidelines, 2001: 8.3.5 A3c]
Q16. The local health department has protocols and
operating procedures for providing referrals and follow-
up. [State of Michigan MPR’s 9 and 10, 2001]
Q16.1 The local health department has policies for providing referrals for
services not provided by the local health department. [Michigan Family
Planning Standards and Guidelines, 2001: 7.4 A]
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To fully meet this indicator:
The local health department maintains on file:
a. A referral list of providers, reviewed and updated periodically, that
includes health care providers, local health and welfare departments,
hospitals, voluntary agencies, and federally supported health services
projects; AND [Michigan Family Planning Standards and Guidelines,
2001: 7.4 A3]
b. Policies and procedures, contracts, or operating agreements, that
indicate formal arrangements for off-site required services are in place.
If minimally required services are not offered at the local health
department, referral arrangements must include a provision regarding
reimbursement of cost; AND [Michigan Family Planning Standards
and Guidelines, 2001: 7.4 A1]
c. Procedures for referral must include fairness in selection of providers.
[Michigan Family Planning Standards and Guidelines, 2001: 7.4 A3a]
Q16.2 The local health department has specific protocols for follow-up or
emergency, urgent, essential, and discretionary referrals. [Michigan
Family Planning Standards and Guidelines, 2001: 7.4 A4]
To fully meet this indicator:
a. The local health department maintains on file policies for follow-up on
emergency, urgent, essential, and discretionary referrals.
b. When a client is referred for non-family planning or emergency
clinical care the local health department must
c. Make arrangements for the provision of pertinent client information to
the referral provider. Agencies must obtain client consent to such
arrangements, except as my be necessary to provide services as
required by law with appropriate safeguards for confidentiality; AND
(1) Advise clients on their responsibility in complying with the
referral; AND
(2) Counsel clients on the importance of such referral and agreed
upon method of follow-up AND
(3) Efforts may be made to aid the client in identifying potential
resources for reimbursement of the referral provider, but health
departments are not responsible for the cost of the care, unless
the referral is a mandated minimum service AND
(4) Agencies must maintain a current list of health care providers,
local health a social services departments, hospitals and local
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health agencies and health services projects supported by other
Federal programs to be used for referral purposed. Whenever
possible, the clients should be given a choice of providers.
[Michigan Family Planning Standards and Guidelines
2001:7.4A3]
Q17. The local health department has protocols that meet
current standards of care for identifying, treating, and
reporting sexually transmitted infections and HIV/AIDS.
[State of Michigan MPR 20, 2001 Michigan Family
Planning Standards and Guidelines 2001:9.2]
Q17.1 The local health department has protocols that meet current standards of
care for identifying, treating, and reporting sexually transmitted infections.
To fully meet this indicator:
a. The local health department maintains on file written protocols and
operating procedures for identifying, treating, and reporting sexually
transmitted infections; AND [Michigan Family Planning Standards and
Guidelines, 2001: 9.2 A]
a. A review of medical records and STI written protocols and
operating procedures indicate that:
b. Chlamydia and Gonorrhea testing is provided to all women
requesting an IUD, clients with exposure to and/or symptoms of
gonococcal infection, and high risk populations; AND [Michigan
Family Planning Standards and Guidelines, 2001: 9.2 A1]
c. VDRL/RPR test is provided as needed; AND [Michigan Family
Planning Standards and Guidelines, 2001: 8.8 A5]
d. Screening and treatment for STI's is provided as needed; AND
[Michigan Family Planning Standards and Guidelines, 2001: 9.2
A6]
e. State and local STI reporting requirements are met; AND
[Michigan Family Planning Standards and Guidelines, 2001: 9.2
A2]
b. Appropriate treatment and follow-up for STIs is conducted, including
arrangements or referral for partner treatment; AND [Michigan Family
Planning Standards and Guidelines, 2001: 9.2 A3]
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Q17.2 Local health department provides HIV/AIDS services related to individual
client risk assessment, pre and posttest counseling and testing. [Michigan
Family Planning Standards and Guidelines, 2001: 9.2B]
To fully meet this indicator:
a. Discussion with staff and review of credentials and training indicate
that clinic staff are trained in HIV infection and AIDS and its prevention
and transmission and infection control in a health care setting; AND
[Michigan Family Planning Standards and Guidelines, 2001: 9.2B1e]
b. Prevention counseling activities should assist clients in identifying risk
of acquiring or transmitting disease by documenting acknowledged risk
behaviors, negotiating and reinforcing plans to reduce or eliminate
behavioral risk, and referring for medical and/or psychosocial services
and follow-up; AND [Michigan Family Planning Standards and
Guidelines, 2001: 9.2 B]
c. Policies and procedures for early medical intervention and referrals for
all HIV infected clients to ensure psychosocial and medical care.
Polices and procedures must reflect the local health department
complies with the Quality Assurance Standards and Guidelines for HIV
Counseling, Testing and Referrals, 1996; AND
d. An intensive counseling and referral system is in place with on going
monitoring for quality assurance indicators.
Q18. The local health department has protocols for providing
contraceptive services that meet current standard of
practice. [Michigan Family Planning Standards and
Guidelines, 2001: 8.4; State of Michigan MPR’s 1, 2, 3, 9,
19, 20, and 21, 2001]
Q18.1 The local health department has specific protocols for contraceptive
management that meet current standard of practice.
To fully meet this indicator:
a. The local health department maintains on file written protocols for
contraceptive management services provided either on site or by
referral and protocols and procedures reflect current standards of care;
AND [Michigan Family Planning Standards and Guidelines, 2001: 8.4
A]
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b. The local health department has established letters of agreement for
services provided by referral; AND [Michigan Family Planning
Standards and Guidelines, 2001: 3.4 A18 and 19]
c. The protocols must assure all Department of Health and Human
Services approved contraceptive methods are provided on-site or by
referral; that current medical guidelines related to relative and absolute
contraindications for prescriptive methods are followed; and that
education is provided regarding use of condoms/spermicides alone or
in combination with other methods to decrease risk of HIV/AIDS and
sexually transmitted infections; OR [Michigan Family Planning
Standards and Guidelines, 2001: 8.4 A1]
d. The local health department requested and was granted a waiver for
those services not available on-site. [Michigan Family Planning
Standards and Guidelines, 2001: 7.1 C]
Q18.2 The local health department provides contraceptive services in
compliance with Title X requirements and Michigan Department of
Community Health standards. [Michigan Family Planning Standards and
Guidelines, 2001: 8.4 B]
To fully meet this indicator:
The local health department’s protocols include UP TO DATE and method
specific instruction for use of:
a. Diaphragms and cervical caps, including contraindications and
procedures. Instruction must provide information on types available,
how to choose the proper type, and fitting. Additionally, the procedure
for at-home care of diaphragm, use instructions, and revisit schedule
must also be included; AND [Michigan Family Planning Standards and
Guidelines, 2001: 8.4 B1a]
b. Condoms and spermicides, including dispensing and
contraindications. Instruction must provide information on types
available and use instructions; AND [Michigan Family Planning
Standards and Guidelines, 2001: 8.4 B1a]
c. Intrauterine devices, including indications and contraindications.
Instruction must provide information on types available, use
instructions, and revisit schedule. Additionally, the procedures for
insertion, removal, and missing IUD string must be included.
Information on complications such as PID, perforation, pregnancy,
expulsion, missing string; AND [Michigan Family Planning Standards
and Guidelines, 2001: 8.4 B1b]
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d. Norplant, or other implants, including contraindications, insertion and
removal procedure, side effects, and revisit schedule. Possible
complications such as inflammation at insertion site must be
addressed; AND [Michigan Family Planning Standards and
Guidelines, 2001: 8.4 B1c]
e. Oral contraceptives, including indications and determining the start
date for the pill, provision to high-risk women, and contraindications.
Information must be provided on use, supply visits, and revisit
schedule. Additionally, the procedures for available pills and
managing side effects must be included. Complications such as
embolic disease must be addressed; AND [Michigan Family Planning
Standards and Guidelines, 2001: 8.4 A1c]
f. Injectible contraceptives, including indications and contraindications,
visit frequency, and side effects. Complications such as decreased
bone density and adverse lipid changes must be addressed; AND
[Michigan Family Planning Standards and Guidelines, 2001: 8.4 A1c]
g. Natural family planning, including instructions, contraindications, and
revisit schedule; AND [Michigan Family Planning Standards and
Guidelines, 2001: 8.4 A1d]
h. Abstinence; AND [Michigan Family Planning Standards and
Guidelines, 2001: 8.4 A1e]
i. Sterilization, including contraindications. If services are provided on-
site, information on types of surgical procedures and male and female
sterilization must be provided. Additionally, complications such as
post-op bleeding, paralytic ileus, and allergic reaction to pre-operative
medications or to anesthesia must be addressed. A review of 10
randomly selected charts of clients receiving sterilization’s
demonstrates that the local health department is in compliance with
Federal regulations related to age, minimum to maximum time period
for consent, client is mentally competent, informed consent,
regulations for out-of-hospital surgery, referral process in place if
sterilization not offered on-site, and follow-up/revisits; AND [Michigan
Family Planning Standards and Guidelines, 2001: 8.4 B2]
j. Emergency Contraception, including compliance with Federal Drug
Administration guidelines for use of postcoital medication; DES is not
used; birth control counseling is conducted; and a pregnancy test is
performed if indicated prior to treatment; AND [Michigan Family
Planning Standards and Guidelines, 2001: 8.4, B1c]
k. Each of the local health department’s clinics maintains on-site an
adequate supply and variety of drugs and devices to meet the
contraceptive needs of clients. A review of the supply of
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contraceptives in stock includes: [Michigan Family Planning Standards
and Guidelines, 2001: 10.2 A5]
1. Oral contraceptives in a variety of dosages and combinations;
AND
2. IUDs, Norplant systems, and injectible contraceptives if
provided on site; AND
3. Diaphragms/cervical caps in various types and sizes; AND
4. Male and female condoms; AND
5. Spermicidal agents such as foams, creams, jellies, film; AND
6. Emergency contraceptive pills AND
l. Method counseling is conducted and includes the following: [Michigan
Family Planning standards and Guidelines 2001:8.3B3]
1. Results of physical exam and lab studies AND
2. Effective use of contraceptive methods, including natural family
planning (NFP), and the benefits and efficacy of the methods
AND
3. Location where emergency services can be obtained AND
4. Appropriate referral for additional services as needed.
Q19. The local health department has protocols and
operating procedures for pregnancy diagnosis and
counseling services. [State of Michigan MPR’s 9, 10,
and 20, 2001]
Q19.1 The local health department provides pregnancy diagnosis and
counseling services in compliance with Title X requirements and Michigan
Department of Community Health standards. [Michigan Family Planning
Standards and Guidelines, 2001: 8.6 A]
To fully meet this indicator:
a. The local health department’s protocols and operating procedures for
pregnancy diagnosis and counseling assure that:
1) Pregnancy diagnosis and counseling is provided to all clients in
need of this service or at clients request (7-10 days after
possible conception); AND [Michigan Family Planning
Standards and Guidelines, 2001: 8.6 A1, 8.3 A2]
2) A client chart is maintained; AND
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3) Pregnancy diagnosis services consist of a signed consent form,
comprehensive history, physical exam, including pelvic exam,
when indicated, pregnancy test, and repeat testing of those with
negative tests whose history and physical exam are indicative of
pregnancy; AND [Michigan Family Planning Standards and
Guidelines, 2001: 8.6 A2]
4) Pregnancy counseling consists of information provided in a non-
directive, unbiased manner; AND [Michigan Family Planning
Standards and Guidelines, 1998: 8.6 A3]
5) Information on all options is provided, if requested by the client;
AND [Michigan Family Planning Standards and Guidelines
2001: 8.6A3.a]
6) For a positive test, information and counseling must be offered
and appropriate referral information are provided on pregnancy,
prenatal care and delivery, infant care and adoption, pregnancy
termination, family planning, especially with women having
unplanned pregnancies, and good health practices during early
pregnancy; AND [Michigan Family Planning Standards and
Guidelines, 2001: 8.6 3A1]
7) For a negative test counseling is provided on retesting and
revisit appointments, as indicated and available contraceptive
and infertility services; AND [Michigan Family Planning
Standards and Guidelines, 2001: 8.6 3A2]
8) If a medical exam is not done at the time of testing, the client is
counseled as to the importance of receiving a physical exam as
soon as possible, preferably within 15 days; AND [Michigan
Family Planning Standards and Guidelines, 2001: 8.6 3A3]
9) Suspected ectopic pregnancies are referred for immediate
diagnosis and treatment and follow-up process is in place.
[Michigan Family Planning Standards and Guidelines, 2001: 8.6
B]; AND
10) STI/HIV education is given and testing offered and documented
in the chart; AND [Michigan Family Planning Standards and
Guidelines, 2001: 8.0A11, 9.2.1, 8.1A12]
11) Condoms are offered; AND [Michigan Family Planning
Standards and Guidelines, 2001: 8.1 C3]
b. Discussions with clinic staff and by observation of patient-client
interaction and review of credentials and training indicate that clinic
staff have knowledge of the above standards.
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Q20. The local health department has protocols and
operating procedures for infertility services. [State of
Michigan MPR’s 9, 10, and 20, 2001]
Q20.1 The local health department has specific protocols for providing infertility
services.
To fully meet this indicator:
a. The local health department maintains on file written protocols that
identify the services to be provided, criteria for diagnosis of infertility,
identification of referral sites, follow-up, fee schedules and payment
mechanisms; AND [Michigan Family Planning Standards and
Guidelines, 2001: 8.5 A2]
b. The local health department’s protocols for infertility services assure
that at a minimum Level I services are offered, including: [Michigan
Family Planning Standards and Guidelines, 2001: 8.5 A1]
1) Initial interview or assessment
2) Education/Counseling
3) Physical Examination
4) Lab testing including Hgb/Hct, Pap smear, Gonorrhea testing,
and other STI's, especially Chlamydia
5) Optional testing within the scope of the local health
department’s program, i.e., basal body temperature charting
6) Referral services; AND
c. Clients are encouraged to have her/his partner participate in decisions
related to infertility services; AND [Michigan Family Planning
Standards and Guidelines, 2001: 8.5 D]
d. If applicable, for any Level II services offered (semen analysis,
assessment of ovulatory function and post-coital testing) protocols are
in place that meet minimum requirements; AND [Michigan Family
Planning Standards and Guidelines, 2001: 8.5 B]
e. If applicable, for any Level III services offered protocols are in place
that meet minimum requirements. [Michigan Family Planning
Standards and Guidelines, 1998: 8.5 C]
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Q21. The local health department has protocols and
operating procedures for identifying and assuring
treatment of estrogen-exposed offspring.
I Q21.1 The local health department identifies and assures treatment of estrogen-
exposed offspring born between 1940 and 1970. [Michigan Family
Planning Standards and Guidelines, 2001: 8.8 A]
To fully meet this indicator:
a. The local health department maintains on file written protocols and
operating procedures to identify estrogen-exposed offspring. The
protocols and procedures must use the following methods to identify
and treat estrogen-exposed offspring:
1) Clients with prenatal exposure to estrogen receive special
screening either on-site or by referral. [Michigan Family
Planning Standards and Guidelines, 2001: 8.8A]
2) Females with prenatal exposure are given appropriate
counseling, and a referral for colposcopy is made. [Michigan
Family Planning Standards and Guidelines, 20018.8B2]
3) Males with prenatal exposure are given appropriate counseling.
[Michigan Family Planning Standards and Guidelines,
2001:8.8B3]
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THIS SECTION TO BE COMPLETED ONLY IF SERVICES ARE OFFERED ON-SITE
Q22. The local health department has protocols and
operating procedures for screening for minor
gynecologic problems.
I Q22.1 The local health department has up to date protocols for screening for
breast conditions and minor gynecologic problems. [Michigan Family
Planning Standards and Guidelines, 2001: 9.2]
To fully meet this indicator:
The local health department:
a. Maintains on file written protocols and operating procedures for
screening for breast conditions and minor gynecologic problems; AND
b. Diagnosis and treatment of minor gynecologic problems are provided
on-site (e.g. vaginitis, dysmenorrhea, secondary amenorrhea).
Q23. The local health department has operating procedures
for genetic screening with referral if indicated.
I Q23.1 The local health department provides screening and referral procedures
for genetic conditions. [Michigan Family Planning Standards and
Guidelines, 2001: 9.4]
To fully meet this indicator:
The local health department:
a. Offers initial genetic screening and referral services that are supported
by a program of public information and education sensitive to concerns
of local ethnic and religious groups and upholds the dignity of
individuals with congenital physical or mental limitations; AND
[Michigan Family Planning Standards and Guidelines, 1998: 9.3 A, 9.3
A4a]
b. Refers to a genetic counselor if more complete genetic screening and
counseling offered and has linkage with a genetic service program and
other referral providers; AND [Michigan Family Planning Standards
and Guidelines, 1998: 9.3 A1a]
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c. Documentation that staff have been trained to provide basic genetic
information; AND [Michigan Family Planning Standards and
Guidelines, 2001: 9.4 A2]
d. Literature and informational materials, including information on
Michigan Department of Community Health’s state-wide genetic
screening program, are available for all clients if requested. [Michigan
Family Planning Standards and Guidelines, 2001: 9.4A3]
Q24. The local health department has protocols and
operating procedures for providing special gynecologic
procedures.
I Q24.1 The local health department has protocols and operating procedures for
providing special gynecologic procedures. [Michigan Family Planning
Standards and Guidelines, 2001: 10.0]
To fully meet this indicator:
The local health department:
a. Maintains on file up to date written protocols and operating procedures
for providing special gynecologic procedures, such as colposcopy,
biopsy, and cryosurgery; AND [Michigan Family Planning Standards
and Guidelines, 2001: 10.0 A]
b. Maintains on file evidence, such as letters or memoranda, that such
services provided on-site have been approved by the Michigan
Department of Community Health; AND [Michigan Family Planning
Standards and Guidelines, 2001: 10.0 B]
c. If colposcopy or related services are provided the supervising
physician must have training and according to MDCH standards and
maintains current affiliation with a JCAHO accredited back-up hospital;
AND [Michigan Department of Community Health Colposcopy
Guidelines (1997)]
d. Midlevel clinicians have completed a preceptorship under the direct
supervision of an approved preceptor and a course outline,
preceptorship requirements and faculty are available for review; AND
e. A physician colposcopist is available by phone whenever patients are
seen, evaluates problem cases referred by midlevel practitioners,
reviews each chart and countersigns prior to treatment and at least
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annually, and evaluates and documents the skills of the midlevel
practitioner; AND
f. All practitioners maintain evidence of continuing education course
within the last 10 years with cervical disease and
colposcopy/cryotherapy as its main focus; AND
g. Up to date policies and procedures are in place describing the agency
philosophy related to colposcopy/cryotherapy, staffing and staff
responsibility, patient selection criteria, absolute contraindications to
patient eligibility, fact sheets and educational materials, informed
consent, counseling, documentation and use of the medical record,
refusal of colposcopy after counseling, documentation in the medical
record, informed refusal signed by the client, set up and clean up of
examination room and aseptic technique; AND
h. Colposcopic exam procedures include endocervical curettage,
colposcopic punch biopsy, hemostatic agents/instruments and
handling of biopsy specimens; AND
i. Cryotherapy procedures include prior review of pathology report,
management of intra-procedure complications, management of post
procedure complications and referral management and follow-up; AND
j. Medical records are maintained in accordance with accepted medical
standards and a system exists for retrieving records of patients by the
date of service, clinician or complications; AND
k. Correlation data for pap smear, colposcopic diagnosis and histologic
diagnosis are gathered and maintained; AND
l. Complication logs and summaries are maintained; AND
m. The physician director and quality assurance committee routinely
monitors individual rates. Patient care audits are conducted at least
annually; AND
n. Policies and procedures exist for the management of complications,
emergencies and adverse outcomes which include the management of
after hours problems and complications, the management of out of
town patients and the documentation of emergencies and adverse
outcomes; AND
o. Clients are counseled about Hepatitis B and vaccination is offered on-
site for clients at risk.
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APPENDIX E
General Clinic Procedures and Clinician Service Protocol
SECTION 7.0 CLIENT SERVICES
EVALUATION CRITERIA
7.1 Service Plans and Protocols YES NO COMMENTS
Review General Clinic Procedures and Clinician
Service Protocols for compliance to Title X and
MDCH requirements look at personnel file of
medical director and/or clinician’s for
documentation of annual review of manual and
follow at least one client through clinic to assess
compliance of staff to regulations.
A. General Clinic Procedures and Clinician Service
Protocol and Clinician Service Protocol Manual(s)
are in place and reviewed annually. ___ ___
1. General clinic procedures and clinician
protocols are in compliance with Title X and
accepted medical practice. ___ ___
2. General clinic procedures and clinician
protocols are reviewed annually, updated as
indicated and signed by medical director and
clinicians. ___ ___
3. Any change/addition in protocol occurring
between annual reviews is signed and dated
by affected staff members at time change
occurs. ___ ___
4. Clinical staff members function according to
established protocols outlining qualifications
and responsibilities. ___ ___
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YES NO COMMENTS
B. General Clinic Procedure and Clinician Protocol
Manual(s) includes details on:
1. Specific procedures performed for:
a. Initial visit ___ ___
b. Annual visit ___ ___
c. Revisits, including supply visit,
pregnancy testing and counseling. ___ ___
d. Clinical procedures and clinical
protocols reviewed annually ___ ___
2. The frequency with which procedures are to
be routinely repeated. ___ ___
3. History and physical exam requirements for
each visit type. ___ ___
4. Permanent, temporary and emergency
contraception. ___ ___
5. Informed consent. ___ ___
6. Client eligibility ___ ___
7. Supply distribution. ___ ___
8. Client education and counseling ___ ___
9. Service to minor’s. ___ ___
10. Pregnancy diagnosis and counseling ___ ___
11. Medical follow-up. ___ ___
12. Laboratory testing. ___ ___
13. Referral procedures. ___ ___
14. Infertility services. ___ ___
15. Emergencies ___ ___
16. HIV/AIDS education and counseling. ___ ___
17. Equipment and supplies. ___ ___
18. Medical records. ___ ___
19. Confidentiality and release of records. ___ ___
20. Quality assurance ___ ___
21. Standing orders. ___ ___
22. Job description; responsibilities of Clinic
personnel. ___ ___
23. Medical supervision. ___ ___
24. Pharmaceuticals ___ ___
25. Any other services provided ___ ___
26. Clinic flow for client visit. ___ ___
27. Management of reproductive diseases/
disorders. ___ ___
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YES NO COMMENTS
28. Sexually transmitted infections ___ ___
29. Management of high risk contraceptive
clients. ___ ___
C. Waiver request has been submitted for
exemption from a particular requirement. ___ ___
1. If yes, what requirement
2. Waiver was approved by MDCH ___ ___
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