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Consolidated Agreement FY23 Page 4 of 28 LHD shall reimburse NCDHHS or otherwise be held responsible for the costs associated with giving affected persons written notice of a privacy or security incident, as required by any applicable federal or state law, when the privacy or security incident arises out of LHD's performance under this Consolidated Agreement or Agreement Addenda. C. Assessments and Plans 1. LHD shall provide to the Director of Community Health Assessment, State Center for Health Statistics or designee: a. A comprehensive community health assessment (CHA) at least every four years for each county or health district as follows: 1) The CHA report is due on the first Monday in March following the year of community health assessment. 2) The CHA report shall be submitted as an attachment via the web-based software, Clear Impact Scorecard. The executive summary and community priorities will appear in the note fields. 3) The CHA shall be a collaborative effort with local partners inclusive of hospitals, businesses, community partners, and local community health coalitions, and the CHA report shall identify a list of community health problems based on the assessment. 4) The CHA report shall include primary and secondary data that is collected and analyzed. 5) Secondary data shall be obtained from published statistical tables and reports from the State Center for Health Statistics (SCHS) or other official sources. 6) Primary data needs and methodologies shall be determined once secondary data have been reviewed and gaps in knowledge about the community are identified. 7) After analyzing primary and secondary data, the CHA report shall describe available community resources and resource needs for the identified community health problems. 8) Each identified community health problem shall be prioritized and described in the narrative. The CHA report shall include data analysis of those indicators listed in the Accreditation Self-Assessment Inventory, Benchmark 1, Activity 1.1. b. A Community Health Improvement Plan (CHIP) no later than six months after the completion of the comprehensive community health assessment as follows. 1) The CHIP is due by the first Monday in September following the year of assessment. 2) The CHIP shall be submitted via the web-based software, Clear Impact Scorecard. 3) The CHIP shall address a minimum of two priorities identified in the most recent community health assessment. 4) The CHIP shall be data driven and derived by using results-based accountability to focus on both population and program accountability. Results, indicators, programs, and performance measures must be included. 5) The CHIP shall be aligned with one or more of the Healthy North Carolina 2030 indicators and use best evidence interventions targeting health behaviors, the physical environment, social and economic factors, and/or clinical care. 6) The CHIP shall be aligned with the current N.C. State Health Improvement Plan and consider policy recommendations as a best practice opportunity. 7) The CHIP shall be updated at least annually, and LHD must monitor its performance against the CHIP annually.