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Task <br />Task! ActivitylDescription Number <br />Housing. If the child is Medicaid enrolled collect the <br />Provider One number <br />f) Provide educational material to the child's caregivers in <br />the family's primary language <br />g) (Optional) If warranted, contact DOH to request <br />technical or environmental investigation assistance <br />with an X-ray fluorescent (XRF) analyzer <br />Have the child retested following the Pedi atric <br />Environmental Health Specialty Units (PEHSU) medical <br />management guidelines. If the lead level remains ~5 flg/dL <br />the LHJ will conduct a second home visit to connect the <br />family to other service providers as needed. <br />PEHSU medical management guidelines: <br />htms :llwww.oehSU .netl L ibrarv/fuctslmedical-mtmlllt- <br />childhood-lead-exQosure-lune-2013 .odf <br />If the second lead level drops to <5 llg/dL, the LHJ has the <br />option to : 1) Mail the child's caregivers a letter <br />recommending a developmental and nutritional screening, <br />the letter will include providers in the child's residential <br />area. The LHJ may then close the case . (DOH will provide a <br />template letter.); or 2) proceed to Task 2 and conduct a <br />second home visit. <br />2 The purpose of the second home vi sit is to connect the <br />family to other service providers as needed: <br />a) LHJ staff will facilitate and guide the child 's caregiver <br />in completing the WithinReach Developmental <br />Screening Questionnaire online <br />ht!R:/1 www.I!arenthelI!123.org/. The LHJ must provide <br />a hard copy of the developmental screening in case it <br />cannot be submitted online. In unusual, and DOH <br />approved cases, in which the WithinReach assessment <br />cannot be performed, the LHJ may refer the family to <br />the child's physician or to another entity that is trained <br />to administer developmental screening tests <br />b) Encourage blood lead testing of other children less than <br />72 months of age and pregnant or nursing caregivers in <br />the home <br />c) If appropriate, refer the child's caregivers to the <br />Exhibit A, Statements of Work <br />Revised as of January 16 ,2018 <br />*May Support PHAB <br />StandardsIMeasures <br />I <br />I <br />Page 4 of6 <br />AMENDMENT #1 --. Payment <br />Due DatelTime Information Deliverables/Outcomes Frame and/or <br />Amount <br />g) (If applicable) If the LHJ opts to <br />close the case after verifying <br />that the second lead level has <br />dropped to <5 Ilg/dL, it must I <br />submit a copy of the letter I <br />mailed to the family <br />Submit a written report summarizing I <br />the environmental assessment lab test <br />results and a Plan of Care that lists <br />recommendations on how to remove <br />and remediate lead exposure. Include <br />the educational material provided to <br />the family that addresses the child's <br />needs. (DOH will provide a generic <br />template .) The LHJ will provide a <br />copy of the report to DOH, the . <br />child's caregivers and provider. <br />Submit an updated Plan of Care to Monthly, by the $500 per home <br />DOH, the child's caregivers and 30th of the visit, up to two <br />provider that includes: following month (2) home visits <br />a) Completion date and results of per child <br />the online WithinReach <br />Developmental Screening <br />Questionnaire <br />b) Ifblood lead testing of at-risk <br />family members was <br />recommended, list the <br />individuals <br />c) The referral date and provider of <br />the nutritional assessment, <br />include all other referrals <br />d) The members of the case <br />management team, their <br />Contract Number CLH18249-1