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					NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
Date Submitted by LME: _______/_______/_______ Name & Phone # of Assigned LME Staff Member Responsible for SAPTBG Report Submission:

1.8.1.4. System Monitoring: LME Semi-Annual SAPTBG Compliance Report

For Division Use Only: Date Received from LME:

Insert Name of LME
(Name of LME)

_______/________/________

___________________

SFY 08-09 Local Management Entity (LME) Semi-Annual Substance Abuse Prevention and Treatment Block Grant (SAPTBG) Compliance Report for the Division Performance Contract/Performance Agreement
Mid-Year Report

Report Period: July 1, 2008 through December 31, 2008

Due Date: January 20, 2009 Due Date: July 20, 2009

Year-End Report Report Period: January 1, 2009 through June 30, 2009

Quality Management Team Community Policy Management Section Division of Mental Health, Developmental Disabilities, and Substance Abuse Services North Carolina Department of Health and Human Services Revision: October 1, 2008
DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 1 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993

Revised: October 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

Section I: Report of LME SAPTBG 20% Set-Aside Fund Expenditures and Recipients by CSAP Prevention Strategy for SA Primary Prevention Programs
The Local Management Entity (LME) is required to ensure the expenditure of no less than its designated allocation amount of the SAPTBG 20% Prevention Set-Aside Funding that is detailed in the SFY 06 Final Continuation Allocation Letter. This amount is detailed in the Substance Abuse Federal Non-UCR Child SA Prevention Account Number 536915, Fund Code 1491, for the provision of substance abuse primary prevention services, to be reimbursed through the regular FSR process. The LME agrees to ensure the maintenance of adequate provider records, including consumer records with individual consumer prevention outcomes, programmatic data, and fiscal records to provide full details of such recipients, activities, and expenditures for SAPTBG monitoring, reporting, and audit purposes, in accordance with the requirements of the SAPTBG, as contained in 45 CFR, Part 96, and as highlighted in the Summary of Significant Federal Funding Requirements as outlined on the Division’s web page. See Page 6 for definitions of CSAP Prevention Strategies. A1. List Name of LME Staff, Position Title, and Phone No. Who is Responsible for SAPTBG Prevention Compliance, Monitoring, and Quality Mgt.

A2. First Six Months Report of Expenditures to be Completed at Mid-Year for Period of July 1, 2008 – December 31, 2008: (1a) Information Dissemination Child SA Adult SA Total SA $ $ $ $ $ $ (2a) Education (3a) Alternatives (4a) Problem Identification and Referral $ $ $ $ $ $ (5a) CommunityBased Process $ $ $ (6a) Environmental (7a) Combined Total $ $ $ $

$ $ $

A3. Second Six Months Report of Expenditures to be Completed at Year-End for Period of January 1, 2009 – June 30, 2009: (1a) Information Dissemination Child SA Adult SA Total SA $ $ $ $ $ $ (2a) Education (3a) Alternatives (4a) Problem Identification and Referral $ $ $ $ $ $ (5a) CommunityBased Process $ $ $ (6a) Environmental (7a) Combined Total $ $ $ $

$ $ $

A4. Combined First and Second Six Months Reports of Expenditures to be Completed at Year-End for Period of July 1, 2008 – June 30, 2009: (1a) Information Dissemination Child SA Adult SA $ $ $ $ (2a) Education (3a) Alternatives (4a) Problem Identification and Referral $ $ $ $ (5a) CommunityBased Process $ $ (6a) Environmental (7a) Combined Total $ $ $

$ $

DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 2 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993

Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

Total SA

$

$

$

$

$

$

$

B.

ALL OTHER LME SA PP ANNUAL (12 MO.) GRANT FUNDING BY SOURCE: List all other LME funds in SFY 2008-2009 for SA PP by source.
(2b) DPI/LEA Grant(s) From Safe and Drug-Free Schools and Communities Act (3b) Community-Based Alternatives (CBA) or Other OJJ Grant(s) for SA Primary Prevention Programs (4b) Center for Substance Abuse Prevention State Incentive Grant (SIG) or Other SAMHSA Grant (5b) Other Federal, State, Local, Private or Foundation Funds (Describe): (6b) Other (Describe): (7b) Combined Total $

(1b) DHHS/Governor's Substance Abuse And Violence Primary Prevention Project Grant(s)

$ 

$

$

$

$

$

$

SA PRIMARY PREVENTION RECIPIENTS TARGETED BY CHILD/ADULT PRIMARY HIGH RISK FACTOR:

Comprehensive primary prevention programs should give priority to target population sub-groups that are at risk of developing a pattern of substance abuse. Programs should include activities and services provided in a variety of settings, that address specific risk factors, and that may be broken down by age, race/ethnicity, gender, and other characteristics of the population being served. (Summary of Significant Federal Funding Requirements, SAMHSA, 45 CFR Part 96, March 31, 1993). C. First Six Months Report of Recipient Groups Targeted to be Served to be Completed at Mid-Year for Period of July 1, 2008 – December 31, 2008: Check () recipient groups to be served in non-treatment services provided by LME or contract agency staff staff through Substance Abuse Primary Prevention Programs to individual and group recipients in SFY 2008-2009 by Recipient Age and Primary High Risk Factor.
RECIPIENT PRIMARY HIGH RISK FACTOR

(0c)
R000 Genera l Group with No Identifi ed Risk Factor

(1c)
R001 School DropOut (<18)

(2c)
R002 Repeat -ed Failure in School (<18)

(3c)
R003 Pregna nt: Teen or Woma n

(4c)
R004 Econo mically Disadvantaged

(5c)
R005 Child of a Drug or Alcoho l Abuser (<18)

(6c)
R006 Victim of Physical, Sexual , or Psych ological Abuse (<18)

(7c)
R007 Has Commi t-ted a Violent Or Delinquent Act (<18)

(8c)
R008 Has Had Past Mental Health Problems

(9c)
R009 Has Attempted Suicid e in the Past

(10c)
R010 Has Had Longterm Physic al Pain Due to Injury

(11c)
R011 Is a Juvenil e within a Detention Facility within the State (<18)

(12c)
R012 Other (Describe):

(13c)
R013 Is Physically Disabled

(14c)
R014 Legally Uses Alcoho l or Prescribe d Drugs withou t Evidence of Abuse

(15c)
R015 Is a Homeless and/or Runaway Youth (<18)

(16c)

Child SA Adult SA

DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 3 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993

Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

CSAP PREVENTION FORM P1:

NUMBER OF PERSONS SERVED IN LME AND CONTRACT AGENCY SAPTBG PREVENTION PROGRAMS

D. Annual Report of Persons Served to be Completed at Year-End for Period of July 1, 2008 – June 30, 2009:
Age 0-4 5-9 10-11 12 13 14 15 16 17 18-20 21-24 25-44 45-64 65+ Total* DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 4 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993 Total Single Services Recurring Services Race, Ethnicity, and Gender Total Single Services Recurring Services *Note: The same “Total” is repeated for description of the population served by: o Age o Race o Ethnicity o Gender Single Services: Single Services are those services that are provided to an individual in a single session such as a group presentation or community event. Recurring Services:

American Indian/Alaska Native Asian Black/African American Native Hawaiian/Other Pacific Islander White More than One Race Unknown Total* Not Hispanic or Latino Hispanic or Latino Total* Male Female Total*

Recurring Services are those services that are provided to an individual through a continuing multi-session event such as participation in an evidencebased curriculum.

Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

SAPTBG PRIMARY PREVENTION NUMBER OF CONSUMERS SERVED BY PROGRAM STRATEGY: See Page 6 for definitions of CSAP Prevention Strategies. E1. First Six Months Report of Number of Consumers Served to be Completed at Mid-Year for Period of July 1, 2008 – December 31, 2008: (1a) Information Dissemination
Child SA Adult SA Total SA

(2a) Education

(3a) Alternatives

(4a) Problem Identification and Referral

(5a) CommunityBased Process

(6a) Environmental

(7a) Combined Total

E2. Second Six Months Report of Number of Consumers Served to be Completed at Year-End for Period of January 1, 2009 – June 30, 2009: (1a) Information Dissemination
Child SA Adult SA Total SA

(2a) Education

(3a) Alternatives

(4a) Problem Identification and Referral

(5a) CommunityBased Process

(6a) Environmental

(10a) Combined Total

E3. Combined First and Second Six Months Number of Consumers be Completed at Year-End for Period of July 1, 2008 – June 30, 2009:
(1a) Information Dissemination Child SA Adult SA Total SA (2a) Education (3a) Alternatives (4a) Problem Identification and Referral (5a) CommunityBased Process (6a) Environmental (10a) Combined Total

DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 5 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993

Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

Section II: Local Management Entity and Contract Agency(ies) SAPTBG Primary Prevention Strategies and Activities Checklist
A. SA PRIMARY PREVENTION PROGRAM DEFINITION AND STRATEGIES FOR PURPOSES OF SA PREVENTION AND TREATMENT BLOCK GRANT Substance Abuse Primary Prevention Programs are those directed at individuals who do not require treatment for substance abuse. Such programs are aimed at educating and counseling individuals on such abuse and providing for designated non-treatment activities to reduce the risk of such abuse. Early intervention activities which were previously counted as part of the Block Grant's 20% Prevention Set-Aside may not be counted towards the required 20% Primary Prevention Program Set-Aside in the new Block Grant regulations, nor may primary prevention services include any activity designed to determine if a person is in need of treatment. Check () all activities and methods supported for applicable six month period through SFY 2008-2009 actual SAPTBG expenditures.
(1) Information Dissemination: This strategy provides awareness and knowledge of the nature and extent of alcohol, tobacco, and drug use, abuse and addiction and their effects on individuals, families and communities. It also provides knowledge and awareness of available prevention programs and services. Information dissemination is characterized by one-way communication from the source to the audience, with limited contact between the two. Examples include: Clearinghouse/information resource center(s); Resource directories; Media campaigns; Brochures; Radio/TV public service announcements; Speaking engagements; Health fairs/other health promotion, e.g., conferences, meetings, seminars; Information lines/Hot lines; and Other (Specify):______________________ Education: This strategy involves two-way communication and is distinguished from the Information Dissemination strategy by the fact that interaction between the educator/facilitator and the participants is the basis of its activities. Activities under this strategy aim to affect critical life and social skills, including decision-making, refusal skills, critical analysis (e.g. of media messages) and systematic judgment abilities. Examples include: Ongoing classroom and/or small group sessions (all ages); Parenting and family management classes; Mentors; Peer leader/helper programs; Education programs for youth groups; Children of substance abusers groups; Preschool ATOD prevention programs; and Other (Specify):______________________ Alternatives: This strategy provides for the participation of the target populations in activities that exclude alcohol, tobacco, and other drug use. The assumption is that constructive and healthy activities offset the attraction to, or otherwise meet the needs usually filled by alcohol, tobacco and other drugs and would, therefore, minimize or obviate resort to the latter. Examples include: Drug free dances and parties; Outward Bound; Youth/adult leadership activities; Recreation activities; Community drop-in centers; Community service activities; and Other (Specify):______________________ (4) Problem Identification and Referral: This strategy aims at identification of those youth who have indulged in illegal/age-inappropriate use of tobacco or alcohol and those individuals who have indulged in the first use of illicit drugs in order to assess if their behavior can be reversed through education. It should be noted, however, that this strategy does not include any activity designed to determine if a person is in need of treatment. Examples include: Marketing Only of Employee Assistance Programs; (Division of MH/DD/SAS policy prohibits the payment of federal or state funds through UCR or Non-UCR funding to support EA Programs) Student assistance programs; Other (Specify):______________________ NA Driving while under the influence/while intoxicated education programs; (Division of MH/DD/SAS policy prohibits the payment of federal or state funds through UCR or Non-UCR funding to support DWI Assessments or ADETS Programs) (5) Community-Based Process: This strategy aims to enhance the ability of the community to more effectively provide prevention and treatment services for alcohol, tobacco and other drug abuse disorders. Activities in this strategy include organizing, planning, enhancing efficiency and effectiveness of services implementation, inter-agency collaboration, coalition building and networking. Examples include: Community and volunteer training, e.g., neighborhood action training, Impacted training (key people in the system), staff/officials training; Systematic planning; Community team-building; Multi-agency coordination and collaboration/coalition; Accessing services and funding; and Other (Specify):_____________________ Environmental: This strategy establishes or changes written and unwritten community standards, codes and attitudes, thereby influencing incidence and prevalence of alcohol, tobacco and other drugs used in the general population. This strategy is divided into two subcategories to permit distinction between activities which center on legal and regulatory initiatives and those that relate to service and action-oriented initiatives. Examples include: Promoting establishment/review of alcohol/tobacco/other drug policies in schools; Guidance and technical assistance to communities to monitor and maximize local enforcement procedures governing availability and distribution of alcohol, tobacco and other drug use; Modifying alcohol and tobacco advertising practices; Product pricing strategies; and Other (Specify):______________________

(2)

(3)

(6)

DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 6 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993

Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

Section III: SAPTBG Primary Prevention Program Staff and Written Program Plan (APSM 30-1, T10: 14 V .4200 and .6900) A. SAPTBG PREVENTION PROGRAM STAFF BY NAME, POSITION TITLE, PROVIDER AGENCY, FTE, AND PREVENTION CERTIFICATION STATUS:
Name and Position Title of SAPTBG Primary Prevention Program Staff Name of Provider Agency (LME Provider or Contract Agency Provider) Date Staff Began Work in this SAPTBG Primary Prevention Program Initiative % of FTE Position Dedicated to SAPTBG Primary Prevention NC Substance Abuse Professional Practice Board Certified as Prevention Specialist?

WITH STAFF MEMBER’S PRIMARY PRACTICE COUNTY(IES)*

TOTAL FTE =

* Additional information requested to be included is in response to the NC Institute of Medicine Task Force on Substance Abuse Services:12-10-07. B. WRITTEN PROGRAM PLAN for CONSULTATION AND EDUCATION SERVICES (10 NCAC 27G .6900) In order to strengthen SAPT Block Grant planning and accountability for the 20% Set-Aside for Substance Abuse Primary Prevention Services, the LME is requested to provide a brief summary below of Written Program Plan highlights pertaining to substance abuse populations, objectives, and activities. This Plan should specify substance abuse populations that will be targeted in the coming fiscal year (including those High-Risk groups identified in Page 3) and
DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 7 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993 Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

evidence-based programs to be implemented (as described on Page 8). This Plan should include activities and services in each of the six Substance Abuse Primary Prevention Strategies as described in Licensure Rule 10 NCAC 27G, Section .4200. (APSM 30-1) [FOR REPORT DUE IN JANUARY ONLY] 1. Please provide a brief summary below of Written Plan highlights pertaining to substance abuse at risk target populations, objectives, and activities.

CSAP PREVENTION FORM P2:

NUMBER OF NREPP EVIDENCE-BASED PROGRAMS IMPLEMENTED THROUGH LME AND CONTRACT AGENCIES THROUGH SAPTBG FUNDING

B1. Annual Report of No. of Programs Provided & No. of Consumers Served to be Completed at Year-End for Period of July 1, 2008 – June 30, 2009: Provide a listing of the number of SAPTBG programs provided, and the number of consumers served, through evidence–based substance abuse prevention programs that are listed on the SAMHSA National Registry of Evidence-based Programs and Practices (NREPP). NREPP web address is <http://modelprograms.samhsa.gov/template.cfm?page=nreppover>.

Name of NREPP Evidence-Based Substance Abuse Prevention Program Implemented WITH IDENTIFICATION OF FACILITATING STAFF MEMBER(S) AND COUNTY AND HOST AGENCY LOCATION WHERE PROGRAM HAS BEEN PROVIDED*

Universal Population: No. of Times Program Was Provided to Universal Populations and No. of Consumers Served

Selective Population: No. of Times Program Was Provided to Selective Populations and No. of Consumers Served

Indicated Population: No. of Times Program Was Provided to Indicated Populations and No. of Consumers Served

Total

# of Times Program Provided

# of Consumers Served

# of Times Program Provided

# of Consumers Served

# of Times Program Provided

# of Consumers Served

# of Times Programs Provided

Unduplicated # of Consumers Served

DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 8 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993

Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

Name of NREPP Evidence-Based Substance Abuse Prevention Program Implemented WITH IDENTIFICATION OF FACILITATING STAFF MEMBER(S) AND COUNTY AND HOST AGENCY LOCATION WHERE PROGRAM HAS BEEN PROVIDED*

Universal Population: No. of Times Program Was Provided to Universal Populations and No. of Consumers Served

Selective Population: No. of Times Program Was Provided to Selective Populations and No. of Consumers Served

Indicated Population: No. of Times Program Was Provided to Indicated Populations and No. of Consumers Served

Total

# of Times Program Provided

# of Consumers Served

# of Times Program Provided

# of Consumers Served

# of Times Program Provided

# of Consumers Served

# of Times Programs Provided

Unduplicated # of Consumers Served

* Additional information requested to be included is in response to the NC Institute of Medicine Task Force on Substance Abuse Services:12-10-07.

Section IV: SAPTBG Activities for Reducing Youth Access to Tobacco Products Initiative (Synar Amendment) A. List Name of LME Staff, Position Title, and Phone No. Who is Responsible for Synar Amendment Services Compliance, Monitoring, and Quality Mgt.

DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 9 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993

Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

B. SFY 08 - 09 LME Synar Performance Measure: Demonstrate Local Management Entity (LME) leadership to insure local community implementation of
Synar Amendment provisions towards Reducing Youth Access to Tobacco Products and provide a minimum of 8 hours per month of Substance Abuse Primary Prevention Services specifically directed towards Youth Access Community Collaboration, Merchant Education, Law Enforcement-Related, and Media and Public Relations activities. Ensure the maintenance of appropriate event documentation through a standardized reporting format for program monitoring audit purposes, including event date, time, provider(s), target audience, methods, and results.

_____________________________

SAPTBG SYNAR AMENDMENT ACTIVITIES COMPLETED IN SFY 08-09
(The Local Management Entity is encouraged to attach a narrative of additional information regarding specific activities).

Jul 2008

Aug 2008

Sep 2008

Oct 2008

Nov 2008

Dec 2008

1 Six Mo. SubTotal

st

Jan 2009

Feb 2009

Mar 2009

Apr 2009

May 2009

Jun 2009

2 Six Mo. SubTotal

nd

12 Mo. Total

1.

COMMUNITY COLLABORATION

a. Identification of Community Partners: Identified and determined the level of interest and involvement of community partners who share the goal of reducing youth access to tobacco products. b. Community Leadership: Took the lead in pulling together community partners to develop strategies to reduce access in the area(s) your program(s) served. c. Group Participation: Participated with an existing group that is collaborating on the issue of reducing youth access to tobacco products in the area(s) served. d. Community Education: Provided information on youth access (i.e. laws, penalties) to youth organizations and community groups to educate and actively involve them in efforts to reduce youth access to tobacco products.

2.

MERCHANT EDUCATION

a. Identification of Tobacco Retail Outlets: Determined the number and location of all tobacco retail outlets including over-the-counter and vending machines in the area(s) served. b. Merchant Education: Contacted tobacco retail outlets in your area(s) to ensure that they have received specific information on their responsibilities and on the penalties for violation of state and federal youth access laws.
DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 10 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993 Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

SAPTBG SYNAR AMENDMENT ACTIVITIES COMPLETED IN SFY 08-09
(The Local Management Entity is encouraged to attach a narrative of additional information regarding specific activities). with community/youth groups to visit tobacco retail outlets in your area(s) to provide information and materials (i.e. brochures, signs) on state youth access law.

Jul 2008

Aug 2008

Sep 2008

Oct 2008

Nov 2008

Dec 2008

1 Six Mo. SubTotal

st

Jan 2009

Feb 2009

Mar 2009

Apr 2009

May 2009

Jun 2009

2 Six Mo. SubTotal

nd

12 Mo. Total

c.

3.

LAW ENFORCEMENT-RELATED

a. Promote Local Law Enforcement: Contacted officers from your local police or sheriffs’ departments to promote increased enforcement of youth access laws. b. Promote Model for Success: Encouraged local law enforcement to implement the Model for Success Program incorporating merchant education and enforcement of the state youth access law. c. Assistance in Implementation of Model for Success: Assisted local law enforcement/ALE officers in the implementation of the Model for Success Program by participating in any of the following tasks: (Note: SAPT Block Grant Funds may not be used for actual enforcement activities.)  Development of a comprehensive list of all retail tobacco outlets  Recruitment and age testing of youth for an enforcement operation  Serving as an adult observer or monitor during an enforcement operation  Provision of incentives for clerks who don’t sell tobacco products to minors during enforcement operations  Provision of refreshments and/or incentives to youth volunteers  Assisting in coordination of a merchant
DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 11 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993 Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

SAPTBG SYNAR AMENDMENT ACTIVITIES COMPLETED IN SFY 08-09
(The Local Management Entity is encouraged to attach a narrative of additional information regarding specific activities). education workshop with local retailers

Jul 2008

Aug 2008

Sep 2008

Oct 2008

Nov 2008

Dec 2008

1 Six Mo. SubTotal

st

Jan 2009

Feb 2009

Mar 2009

Apr 2009

May 2009

Jun 2009

2 Six Mo. SubTotal

nd

12 Mo. Total

4.

MEDIA AND PUBLIC RELATIONS

a. Collaborated with community partners to include news stories, letters to the editor, etc. to heighten awareness of youth access to tobacco products. b. Collaborated with community/youth organizations to conduct a Merchant Pledge Campaign and publicized results to recognize merchants and clerks who have pledged not to sell tobacco products to minors. TOTAL

C. As needed, please explain any discrepancy in successful achievement of the LME Synar Performance Measure of an average minimum of 8 hours per month (48 hours per six month reporting period) on Synar related activities and actual hours reported above.

Section V: Priority Admission Preference for Pregnant Injecting Drug Users, Pregnant Women and Injecting Drug Users A. List Name of LME Staff, Position Title, and Phone No. Who is Responsible for SAPTBG Priority Admission Compliance, Monitoring, and Quality Mgt.

DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 12 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993

Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

B.

Describe your LME adult and child program policies and practices assuring priority admission preference for all substance abuse individuals who meet federally defined special population criteria in all LME programs and contract agencies. Describe the LME’s contract management and monitoring, training, technical assistance, and quality management practices that ensure that all LME and contract agency direct services staff provide Priority Admission Preference for all pregnant injecting drug users, pregnant women, and injecting drug users.

C.

Document evidence of satisfactory efforts of the LME and contract agencies to advertise and publicize priority admission policies in the current fiscal year assuring admission to all pregnant injecting drug users, pregnant women, and injecting drug users.

Section VI: Universal TB Screening, Testing, Referral & Case Management Services, & Health Department MOA

A. List Name of LME Staff, Position Title, and Phone No. Who is Responsible for SAPTBG TB Services Compliance, Monitoring, and Quality Management

B.

Describe the LME’s adult and child substance abuse universal TB screening policies. Describe the LME’s contract management and monitoring, training, technical assistance, and quality management practices that ensure that all LME and contract agency direct services staff provide universal TB screening for all adult and child substance abuse consumers. Indicate the specific type of screening services that are provided by direct services staff and indicate the standard location for documentation in each consumer’s record for program monitoring and audit purposes.

DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 13 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993

Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

C.

Describe the LME’s adult and child substance abuse policies related to TB Testing, Referral, and Case Management or Community Support Services for individuals identified as high-risk for TB. Describe the LME’s contract management and monitoring, training, technical assistance, and quality management practices that ensure that all LME and contract agency direct services staff provide appropriate TB Testing, Referral and Case Management or Community Support Services for individuals identified as high-risk for TB. Indicate the specific criteria for TB Testing and Referral Services and the standard location for documentation in each consumer’s record for program monitoring and audit purposes.

D.

Does your Local Management Entity (LME) have a current Memorandum of Agreement with the local health department pertaining to TB Services? Yes No

If “No”, please describe your LME’s planning and commitment to address this requirement.

Section VII: Injecting Drug Use (IDU) Programs and Services Required To be completed only by the following programs that receive specialized funding for:  Injecting Drug Use (IDU): Federal SA UCR-IV Drug Account 536952, Fund 1491 or Non-UCR IV Drug Account 536962, Fund 1491 2) Mecklenburg 3) Piedmont 4) CenterPoint 5) Guilford 6) Durham
Rev.: October 1, 2008

1) Western Highlands

DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 14 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

7) Wake

8) Eastpointe

9) East Carolina Behavioral Health

10)Onslow

11) Southeastern Area

12) Sandhills

A. List Name of LME Staff, Position Title, and Phone No. Who is Responsible for SAPTBG IDU Services Compliance, Monitoring, and Quality Management

B.

Describe your LME’s policies and practices that ensure that all LME and contract agency staff provide IDU consumer admission within 14 days of request for services, or if at capacity, within 120 days of request for services, and provision of interim services within 48 hours of request for services.

Section VIII: HIV Programs and Services Required To be completed only by th e following programs that receive specialized funding for:  HIV:Federal SA UCR HIV Account 536913, Fund 1491 or Non-UCR HIV Account 536914, Fund 1491 2) CenterPoint 3) Durham 4) Sandhills 5) Eastpointe 9 Mecklenburg 6) East Carolina Behavioral Health 10) Guilford

1) Wake

7) Alamance-Caswell-Rockingham

8) Southeastern Area

A. List Name of LME Staff, Position Title, and Phone No. Who is Responsible for SAPTBG HIV Services Compliance, Monitoring, and Quality Mgt.

LMEs and contract agencies that receive SAPTBG HIV Set-Aside Funds are required to provide HIV Early Intervention Services to substance abuse treatment clients who are at risk for HIV disease. These services are defined in the SAPTBG regulations as listed below. Such programs
DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 15 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993 Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

are required to submit documentation of the number of substance abuse treatment clients who have received the designated HIV Early Intervention Services, and the number of hours provided of HIV Early Intervention Services in each of these services.
B. Describe the LME’s adult and child substance abuse policies for HIV referral, pre-test counseling, testing, and post-test counseling services. Describe the LME’s contract management and monitoring, training, technical assistance, and quality management practices that ensure that all LME and contract agency direct services staff provide appropriate HIV referral, pre-test counseling, testing, and post-test counseling for all adult and child substance abuse consumers. Indicate the standard location for documentation in the consumer’s record for program monitoring and audit purposes.

C. Provide a listing of the number of substance abuse treatment clients served with HIV/AIDS-related services and the number of hours of these HIV/AIDS-related services provided to clients enrolled in substance abuse treatment services in the following four areas of service:
First Six Months Report of SA Treatment Clients Served and Hours of HIV/AIDS-Related Services Provided: July 1, 2008 to Dec. 31, 2008 Second Six Months Report of SA Treatment Clients Served and Hours of HIV/AIDS-Related Services Provided: Jan. 1, 2008 to June 30, 2008 Combined First and Second Six Months Reports of Unduplicated SA Treatment Clients Served and Hours of HIV/AIDS-Related Services Provided: July 1, 2008 to June 30, 2008

TYPE OF SERVICE 1) 2) Appropriate pretest counseling for HIV and AIDS. Testing individuals with respect to such HIV/AIDS disease, including tests to confirm the presence of the disease, tests to diagnose the extent of the deficiency in the immune system, and tests to provide information on appropriate therapeutic measures for preventing and treating the deterioration of the immune system and for prevention and treating conditions arising from the disease. Appropriate post-test counseling. Providing the therapeutic measures for preventing and treating the deterioration of the immune system and for preventing and treating conditions arising from the disease.

No. of Clients Served

No. of Hours Provided

No. of Clients Served

No. of Hours Provided

No. of Clients Served

No. of Hours Provided

3) 4)

DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 16 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993

Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

TOTAL CLIENTS SERVED AND HOURS PROVIDED

D.

Does your LME have a current Memorandum of Agreement with the local health department pertaining to HIV Services?

Yes

No

If “No”, please describe your LME’s planning and commitment to address this requirement.

Section IX: Names and Signatures of LME Personnel Responsible for SAPTBG Compliance Note regarding Federal Prohibition on the Use of SAPT Block Grant Funds for Financial Assistance to a For-Profit Entity: The specific federal statutory reference (US Code TITLE 42, CHAPTER 6A, SUBCHAPTER XVII, Part B, subpart ii, §300x–31) in the Substance Abuse Prevention and Treatment Block Grant (SAPTBG), and referenced in the Summary of Significant Federal Funding Requirements in the Division’s Performance Agreement, outlines the restriction on the expenditure of the SAPTBG funds to provide financial assistance to any entity other than a public of nonprofit private entity. The Division’s allocates Non-UCR SAPTBG prevention set-aside funds to an LME in a financial assistance arrangement in which the recipient/subrecipient receives the funding to carry out or administer a program in which the recipient/subrecipient is responsible for:  Determining who is eligible for participation in a program by applying pre-determined eligibility requirements. (These eligibility requirements are those contained in the Division’s CSA Target Populations of Selected Prevention or Indicated Prevention.)  Determining the type of services to be delivered / rendered to a specific individual who meet eligibility requirements. (These are based on a consumer screening and assessment.)  Determining whether or not the services to be provided are suitable for a particular consumer. (These are based on the application of evidence-based prevention programs).  Making programmatic decisions and its performance is measured against meeting the program’s objectives. (These include the National Outcome Measures).  Ensuring that the program activities are carried out in accordance with the rules, regulations and criteria established by federal, state and local funding authorities; and  Requiring the provider to incur costs of operating a program and subsequently to receive reimbursement upon submission of a properly completed cost report.

DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 17 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993

Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

The undersigned persons hereby attest to the accuracy and completeness of the information provided in this report:

A1. LME Director Name (Printed)

_____________

Signature

__________

_____ Date

___

A2. LME Finance Officer Name (Printed)

_______

Signature

_______________ Date

___

A3. LME Adult SA Director Name (Printed)

_______

Title _____ _______

___ Phone No.

___

A4. LME Child and Adolescent SA Name (Printed)

_____

Title

_____

_______

___ Phone No.

___

We would appreciate your report submissions with original signatures either via a hard copy or through electronic submission with appropriate signatures by January 20, 2009 and July 20, 2009. Please send to Terrie Qadura, Quality Management Team, Community Policy Management Section, DMH/DD/SAS, 3004 Mail Service Center, Raleigh, NC 27699-3004 or E-Mail to Terrie Qadura at terrie.qadura@ncmail.net. Items sent by Federal Express or UPS must be addressed to 325 North Salisbury Street, Suite 634, Albemarle Building, Raleigh, NC 27603, telephone (919) 733-0696. For any Local Management Entity that is interested, a WORD format version is located on the Division website at http://www.ncdhhs.gov/mhddsas/performanceagreement/ or of this report can be sent to you electronically as an E-Mail attachment. Please address any such requests to Terrie Qadura at (919) 733-0696. If you have any questions about the report content, format, or requirements, please do not hesitate to have your staff contact Terrie Qadura at (919) 733-0696, or Spencer Clark at (919) 733-4670 or E-mail to Terrie.Qadura@ncmail.net or Spencer.Clark@ncmail.net. Thank you in advance for your assistance in completing this request.

THE END

DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 18 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993

Rev.: October 1, 2008

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

1.8.1.4. System Monitoring: SFY 08-09 LME Semi-Annual SAPTBG Compliance Report for
Check () One applicable 6 Month Report Period Below:
______Mid-Year Report: July 1, 2008 through December 31, 2008 - Due Date: 1/20/2009

_____

Name of LME

_

____________

______Year-End Report: Jan. 1, 2009 through June 30, 2009: Due Date: 7/20/2009

Section VIII: DMHDDSAS Review (For Division Use Only) Position Title Name of Division Staff Date Reviewed Corrective Action Recommended? If “Yes”, describe actions needed and follow-up planned or implemented.

CPM SAPTBG Coordinator

CPM Prevention Team Staff

CPM State Synar Staff

CPM State TB/STD/HIV/AIDS Staff

CPM Director of Operations and Clinical Services

Other

DMH/DD/SAS – Community Policy Management Section – Quality Management Team – 8326b7c5-d0b3-42a0-81f6-7667240210ed.doc Page 19 of 19 SAMHSA: 45 CFR Part 96, March 31, 1993

Rev.: October 1, 2008


				
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