HomeMy WebLinkAbout020711_ca09~` ~ Consent Agenda
~_ ~z-- JEFFERSON COUNTY PUBLIC HEALTH
`~,,, ° ~~~ - 615 Sheridan Street • Port Townsend • Washington • 98368
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www. jeffersoncountypublichealth.org
e 9, 2010
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: Jean Baldwin, Director
DATE: ~rt~~? U ~p ~ ~ , ~ ~ 1 i
SUB7ECT: Agenda Item -Agency Agreement -Early Intervention Program (EIP)
#1063-93588, Amendment #1 with Department of Social and Health
Services; January 1, 2011- June 30, 2011; Decreased $2,456.96 total
compensation $36,623.04
STATEMENT OF ISSUE:
Jefferson County Public Health is requesting Board approval of the Agency Agreement -Early Intervention
Program (EIP) #1063-93588, Amendment #1 with Department of Social and Health Services;
January 1, 2011- June 30, 2011; Decreased $2,456.96 total compensation $36,623.04
ANALYSIS/STRATEGIC GOALS/PRO'S and CON'S:
This amendment represents across the board state budget reductions at 6.287%.
JCPH will continue to provide services for families that are screened by Child Protective Services (CPS) to be
low risk to moderately low risk of abuse or neglect. Services include direct services to families or link
families to community resources.
FISCAL IMPACT/COST BENEFIT ANALYSIS:
This amendment represents across the board state budget reductions at 6.287%. This will cause minimal
service level decreases over the next six months.
RECOMMENDATION:
JCPH management request approval of the Agency Agreement -Early Intervention Program (EIP)
#1063-93588, Amendment #1 with Department of Social and Health Services; January 1, 2011 -
June 30, 2011; Decreased $2,456.96 total compensation $36,623.04
REV WED BY:
~.__
ilip rl CountyAdminist for
1~~~~~~
Date
DEOVELOPMENTALLD SABILITIES PUBLIC HEALTH ENVIRONwATERLOUALITY
MAIN: (360) 385-9400 ALWAYS WOR!(IN~ FeIR A SAFEN AN® MAIN: (360) 385-9444
FAX: (360) 385-9401 HEALTHIER COMMUHITY FAX: (360) 379-4487
DSHS CONTRACT NUMBER:
CONTRACT AMENDMENT 1063-93588
Wash;xgton Stare
7, uEPA RTMENT OF
SOCIALE>HEALTH
Amendment No. 1063-93588-01
SERVICES Early Intervention Program (EIP)
This Contract Amendment is between the State of Washington Department of Program Contract Number
Social and Health Services (DSHS) and the Contractor identified below. 0603-
Contractor Contract Number
CONTRACTOR NAME CONTRACTOR doing business as (DBA)
Jefferson County
CONTRACTOR ADDRESS WASHINGTON UNIFORM BUSINESS DSHS INDEX NUMBER
IDENTIFIER (UBI)
615 Sheridan St
161-001-169 1223
Part Townsend, WA 98368-
CONTRACTOR CONTACT CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS
Julia Danskin 360 385-9420 Ext: 360 385-9401 ~danskin co.~efferson.wa.us
DSHS ADMINISTRATION DSHS DIVISION DSHS CONTRACT CODE
Childrens Administration Division of Children and Family 2048CS-63
Services
DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS
Ann Polanco 6840 Capital Blvd Bidg 3
Contracts Manager P.O. Bax 45714
OI m ia, WA 98504-
DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS
360 725-6760 Ext: 360 725-6769 ann300 dshs.wa. av
IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? CFDA NUMBERS
NO
AMENDMENT START DATE CONTRACT END DATE
.0110112011 06/3012011
PRIOR MAXIMUM CONTRACT AMOUNT AMOUNT OF INCREASE OR DECREASE TOTAL MAXIMUM CONTRACT AMOUNT
$39,080.00 $-2,456.96 $36,623.04
REASON FOR AMENDMENT;
CHANGE OR CORRECT MAXIMUtvI CONTRACT AMOUh1T
ATTACHMENTS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into
this Contract Amendment by reference:
^ Additional Exhibits s eci
This Contract Amendment, including all Exhibits and other documents incorporated by reference,. contains all of the terms
and conditions agreed upon by the parties as changes to the original Contract. No other understandings or
representations, oral or otherwise, regarding the subject matter of this Contract Amendment shall be deemedto exist or
bind the parties. All other terms and conditions of the original Contract remain'in full force and effect. The parties signing
below warrant that they have read and understand this Contract Amendment, and have authority to enter into this Contract
Amendment.
CONTRACTOR SIGNATURE PRINTED NAME AND TITLE DATE SIGNED
DSHS SIGNATURE PRINTED NAME AND TITLE DATE SIGNED
Ann Polanco, Contracts Manager/Monitor
DSHS Children's Administration Re ion 6
DSHS Central Contract Services ~ ~. 11 1 a ~ 1 1 Page 1
2048CS Contract Amendment (11-19-10)
_.,.
44~i. ICI EJ ~'3~C~t1 s.L51~g4 ors
This Contract between the State of Washington Department of Social and Health Services (DSHS) and the
Contractor is hereby amended as follows:
1. Purpose. The purpose of this Amendment is to reduce the maximum consideration payable under the
Contract in order to implement budget reductions pursuant to Executive Order 10-04 issued by the
Governor requiring across-the-board reductions of 6.287% in spending authority for all agencies with
General Fund-State (GF-S) appropriations.
2. Effective Date of Amendment. This Amendment shall be effective as of the start date indicated on
page 1 under "Amendment Start Date."
The Special Terms and Conditions are amended as follows:
3. Section 5. Budget Exhibit is amended as follows:
If payment for services is based on actual costs or equal monthly payments and the Contractor's
budget for providing services under this contract is attached as an exhibit to the original Contract, it is
prorated accordingly to reflect the above stated Vendor Rate Decrease of 6.287%.
Contractors, who require revisions to specific individual line items, may submit a revised Budget for
consideration to the DSHS contact stated on page 1 of this Amendment. If approved by DSHS, the
revised Budget will be signed and dated by both parties and incorporated into this Contract by an
additional Amendment.
All contract references to the Budget Exhibit are hereby amended to refer to the revised Budget.
4. Section 6. Consideration, subsections a. and c. are amended as follows:
a. Maximum Contract Amount. The maximum amount of total consideration payable to the Contractor
for satisfactory performance of work under this Contract is reduced by the amount shown on page 1
of this Amendment under "Amount of Increase or Decrease" for the new "Total Maximum Contract
Amount" shown on page 1 of this Amendment.
c. Vendor Rate Increase or Decrease. In the event of a legislatively mandated vendor rate increase or
decrease for the services under this Contract, the rates under this Contract shall be adjusted
accordingly and incorporated into this Contract as of the date the new rate becomes effective.
5. Section 6. Consideration, subsection d. "Rate of Payment" is amended as follows, depending
on the Contractor's payment type as identified in the original Contract as actual costs, equal
monthly payments or hourly rate:
Actual Costs. DSHS will pay the Contractor a reduced amount, according to the Contractor's revised
budget for actual costs related to services provided during the period of this Amendment.
Equal Monthly Payment. DSHS will pay the Contractor a revised equal monthly payment, calculated by
subtracting the total dollar amount of the equal monthly payments paid and/or scheduled through
DSHS Central Contract Services Page 2
2048CS Contract Amendment (11-19-10)
November 30, 2010 from the new Total Maximum Contract Amount and dividing that subtotal by the
number of months remaining in the contract period.
• The number of families to be served under this contract is
Hourly. DSHS will pay the Contractor at the rate stated in the original Contract within the reduced
maximum consideration stated on page 1 of this Amendment.
All other terms and conditions of this Contract remain in full force and effect.
DSHS Central Contract Services Page 3
2048CS Contract Amendment (11-19-10)
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This Program Agreement is by and between the State of Washington Department of Program Agreement Number
and is issued in
Social and Health Services {DSHS) and the County identified below 0603-
,
conjtartction with a County and DSHS Agreement on General Terrns and Conditions, County Agreement Number
which is inco ra#ed b reference. Famt_ink # 125316
DSHS ADAAINISTi2ATlON DSHS DIViSlON DSHS INDEX NUMBER DSHS CONTRACT CODE
Childrens Administration Division of Children and Family 1223 2048CS-63
Services
t)SHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS
Ann Poianco 6840. Capital Blvd Bldg 3P.O. Box 43714
Contracts Mana er fliympia, WA 98504-
DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL
{360 725-6760 Ext: 360 725-67fi9 ann300 shs.wa. ov
COUNTY NAME COUNTY ADDRESS
Jefferson County 615 Sheridan St
Port Townsend, WA 98368-
COUNTY FEDERAL EMPLOYER IDENTIFICATION NUMBER COUNTY CONTACT NAME
916001322 Julia Danskin
COUNTY CONTACT TELEPHONE COUNTY CONTACT FAX . COUNTY CONTACT E-MAIL
360 385-9420 Ext: 360 385-9401 'danskin co.'efferson.wa.us
1S THE COUNTY A SUBRECIPlENT FflR PURPOSES OF THIS PROGRAM CFDA NUMBERS
AGREEMENT?
No 93.556
PROGRAM AGREEMENT START DATE PROGRAM AGREEMENT END DATE MAXIMUM PROGRAM AGREEMENT AMOUNT
07!01/2014 06/30/2011 $39,080.00
1~XHIBiTS. When the box below is marked with an X, the following EXhibits are attached and are incorporated into this
County Program Agreement by reference:
Exhibits (specify}: Exhibit A -Statement of Work; Exhibit B -Program Requirements; and [] Exhibit C --
bud et
Contract Purpose: The purpose of these services is is control threats to child safety so children can remain safely in their
own homes, whi{e continuing to suppart families. These services at a minimum will:
• Place the child and their safety as the center of focus for service delivery
• Assess the child's safety to remain in the home on an ongoing basis
• Engage families in the focus to reduce safety #hreats
• Work to increase safe parenting skills; and
Re wire immediate communication with the Children's Adminis#ration about safe threats to the child.
By thetrsiga?ta#ures below, the parties agree to the terms anti conditions oiT,f#~s County. Pit~g~arri'Agreemehtand all
documents incorporated by reference, No other understandings or represeltafrons; oral" or otherwise, rega>'ding the
subject matterof this Program Agreement shall b~ deemed to exist or•bind ttie,parties. The"parties `signing below certify
tha# the are authoriz to si n this Prp cam.A reement., , .
COUNTY SIGNATUR ) PRINTED NAME(S) RND TITLE(S) DATE(S) SIGNED
pSHS SIGNATURE PRINTED NAME AND TITLE DATE SIGNED
Ann Potanco. Contracts ManagerlMonitor
DSHS Children's Administration Re ion 6
t' - ,~
'_;~;~ro~.'n~ as to form ox.~;
DSHS Central Contract Services
20481/S EIP County (5-28.10) ~ ~ ~ Page 1
4.~
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Special Terms and Conditions
Definitions. The words and phrases listed below, as used in this Contract, shall each have the
following definitions:
a. "Abuse of Client" means the injury, sexual abuse or exploitation, negligent treatment or
maltreatment of a client by any person under circumstances which indicate that the client's health,
welfare or safety is harmed thereby.
b. "Agency" means a public or private agency or other organization providing services to DSHS
clients.
c. "Authorized" means approved by a CA social worker as evidenced by receipt of an SSPS Social
Services notice or other written notice.
d. "Case" means a family for which a risk of abuse or neglect has been determined and the family is
open to CA services.
e. "CA" means Children's Administration, which is an Administration within DSHS.
f. "CA/ EIP Liaison" means the CA staff person who is responsible for maintaining contact with the
Contractor and coordinating EIP services in the region.
g. "CFWS" means Children and Family Welfare Services, a program under CA.
h. "Child Abuse or Neglect" means the injury, sexual abuse, sexual exploitation, negligent treatment,
or maltreatment of a child under circumstances, which indicate that the child's health, welfare, and
safety is harmed. An abused child is a child who has been subjected to child abuse or neglect.
i. "Client" means any child or adult who is authorized services by DSHS.
j. "Community Resources" means community supports and concrete services.
k. "Community Resource Directory" means a list of local resource agencies or individuals that provide
supports for families.
I. "Community Supports" means services that are offered to families by community providers that may
include but are not limited to: housing assistance, mental health services, public health services,
alcohol and drug treatment, family and social support connections, financial assistance, domestic
violence counseling and treatment, educational and employment assistance, parent education,
legal services and cultural and language assistance.
m. "Contract" means the entire written County Program Agreement between DSHS and the Contractor,
including any Exhibits, documents, and materials incorporated by reference.
n. "Contractor" means the individual or entity performing services pursuant to this Contract and
includes. the Contractor's owners, members, officers, directors, partners, employees, and/or agents,
unless otherwise stated in this Contract. For purposes of any permitted Subcontract, "Contractor"
includes any Subcontractor and its owners, members, officers, directors, partners, employees,
and/or agents.
o. "Corporal Punishment" means any act that willfully inflicts or causes the infliction of physical pain on
a child.
p. "CPS" means Child Protection Services, a program under CA.
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2048CS EIP County (5-26-10) Page 2
Special Terms and Conditions
q. "CPS Intake" is the process designated to record all referral reports concerning instances of
suspected child abuse and neglect, determine if the referral meets referral screening criteria and
make a disposition concerning the referral.
r. "DCFS" means the Division of Children and family Services, which is a division of CA.
s. "DLR" means the Division of Licensed Resources, which is a division of CA.
t. "EFSS" means the CA program called Early Family Support Services.
u. "EIP" means Early Intervention Program. A program provided by County Public Health
Departments.
v. "Face to Face Contact" means an in-home visit or visit at an alternative location with the referred
family which is visual contact within the same room not to include any form of electronic contact,
e.g., telephone or computer, with the exception of the use of such equipment as reasonable
accommodation for a client with a disability.
w. "FVS" means Family Voluntary Services, a program under CA.
x. "KBS" means Knowledge, Behavior, and Status which is the problem rating scale for outcomes
within the Omaha System.
y. "LEP" means Limited English Proficiency, and indicates an individual's need for additional support
and assistance in comprehending the English language.
z. "Omaha System" is the comprehensive classification rating and outcome tool used for EFSS and
EIP. The Omaha System consists of the Problem Classification Scheme, Intervention Scheme, and
Problem Rating Scale for Outcomes.
aa. "Participation" means family participation in one or more of the services outlined in the Family
Service Plan.
bb. "Service Plan" means a plan written with input from the EIP nurse and family to address family
needs and strengths, behaviorally directed goals, specific interventions and community referrals.
cc. "Staffing" means a formal or informal meeting, conducted by a CA social worker or CA staff
member with one or more of the following persons: other CA staff, Contractor and/or other
provider, consultants, parents or others, for the purpose of reviewing or discussing, or for making
decisions concerning, a client or case.
2. Previous Contract Superseded. In the event any previous contract between the Contractor and CA
for these services should be in effect upon execution of this Contract, this Contract shall terminate and
supersede that previous contract.
3. Statement of Work -Exhibit A. The Contractor shall provide services and staff as described in the
Statement of Work attached as Exhibit A.
4. Program Requirements -Exhibit B. The Contractor shall comply with all program and other
requirements for providing services under this Contract, as stated in the Program Requirements
attached as Exhibit B.
DSHS Central Contract Services
2048CS EIP County (5-26-10} Page 3
Special Terms and Conditions
5. Budget -Exhibit C. If Exhibit C-Budget is checked on page 1 of the Contract, and Consideration
Section 6.d. indicates payment for either service based on actual costs or in monthly payments then the
Contractor's budget for providing services under this Contract is attached as Exhibit C.
Consideration.
a. Maximum Contract Amount. The maximum amount of total compensation payable to the Contractor
for satisfactory performance of the work under this Contract is $39,080.00.
b. Allotted Funds. Allotted funds not expended during the period ending on June 30, 2011 shall not be
carried forward into the following fiscal year.
c. Vendor Rate Increase. In the event of a legislatively mandated vendor rate increase for the
services under this Contract, the rates under this Contract shalt be adjusted accordingly and
incorporated into this Contract as of the date the new rate becomes effective.
d. Rate of Payment. DSHS will pay Contractor for actual costs related to services provided to CA
referred families during the period of this Contract.
7. Billing. The Contractor shall submit the following documents, prepared in the manner prescribed by
DSHS, to invoice services performed under this Contract:
a. A-19 Invoice. The Contractor shall submit a monthly invoice for services performed under this
Contract on State of Washington Invoice Voucher forms (Form A-19), prepared in the manner
prescribed by DSHS.
(1) The A-19 invoice shall state the amount of each cost or expense incurred by Contractor in the
preceding calendar month that is based on the items listed in the Budget Exhibit.. Costs or
expenses listed in the A-19 invoice must match the corresponding items listed in the Budget
Exhibit for costs or expenses that will be incurred by the Contractor.
(2) The cost or expense billed for each such item shall be charged against the total amount listed
for that item in the Budget Exhibit. The cumulative dollar amount for each such item, for all
invoices submitted by Contractor, shall not exceed the total dollar amount stated for that item in
the Budget Exhibit.
(3) The A-19 invoice shall clearly indicate that it is:
"FOR SERVICES RENDERED IN PERFORMANCE UNDER DSHS CONTRACT NO. 1063-
93588FOR THE MONTH OF , 20 "
(4) The A-19 invoice shall be submitted to:
Ann Polanco, Contracts Manager/Monitor
Children's Administration
Region 6 -Contracts
P.O. Box 45714
Olympia, WA 98504-5714
(5) The Contractor shall contact Pamela Mahan at (360) 725-6811 concerning billing questions.
(6) The Contractor shall bill for each month of service on a separate A-19 invoice. The A-19 invoice
shall state the month services were provided.
DSHS Central Contract Services
2048CS EIP County (5-26-10} Page 4
Special Terms and Conditions
8. Payment.
a. Claims for payment must be received by DSHS no later than sixty (60) days from the date services
were rendered.
b. DSHS will make payment within thirty (30) days of receipt of a properly completed invoice for
services.
c. DSHS may stop payment to the Contractor if reports required under this Contract are delinquent,
i.e., not submitted within 10 days of the due date, or incomplete.
d. DSHS may, at its sole discretion, withhold or deny payment claimed by the Contractor for services
rendered if Contractor fails to satisfactorily comply with any term or condition of the Contract.
9. Payment Only for Authorized Services.
DSHS shall pay the Contractor only for authorized services provided in accordance with this Contract.
If this Contract is terminated for any reason, DSHS shalt pay only for services authorized and provided
through the date of termination.
10. Funding Stipulations.
a. Information for Federal Funding. The Contractor shall cooperate in supplying any information to
DSHS that may be needed to determine DSHS or the client's eligibility for federal funding.
b. Duplicate Billing. The Contractor must not bill other funding sources for services rendered under
this Contract which would result in duplicate billing to different funding sources for the same service.
Furthermore, the Contractor shall ensure that no subcontractor bills any other funding sources for
services rendered under this Contract, which would result in duplicate billing to different funding
sources for the same service.
c. No Federal Match. The Contractor shall not use funds payable under this Contract as match toward
federal funds without the prior written permission of DSHS.
d. Supplanting. The Contractor shall use these funds to supplement, not supplant the amount of
federal, state and local funds otherwise expended for services provided under this Contract.
11. Recovery of Fees for Noncompliance.
In the event the Contractor bills for services provided and is paid fees for services that DSHS later finds
were either (a) not delivered or (b) not delivered in accordance with applicable standards or the
requirements of this Contract, DSHS shall have the right to recover the fees for those services from the
Contractor, and the Contractor shall fully cooperate during the recovery process.
12. Overpayments.
In the event that DSHS establishes overpayments or erroneous payments made to the Contractor
under this Contract, DSHS may secure repayment, plus interest, if any, by requiring the posting of a
bond, assignment of deposit, or some other form of security acceptable to DSHS.
13. Prohibition of Use of Funds for Lobbying Activities.
The Contractor shall not use funds payable under the Contract for lobbying activities of any nature. The
Contractor certifies that no state or federal funds payable under this Contract shall be paid to any
DSHS Central Contract Services
2048CS EIP County (5-26-10) Page 5
Special Terms and Conditions
person or organization to influence, or attempt to influence, either directly or indirectly, an officer or
employee of any state or federal agency, or an officer or member of any state or federal legislative body
or committee, regarding the award, amendment, modification, extension, or renewal of a state or
federal contract or grant.
Any act by the Contractor in violation of this prohibition shall be grounds for termination of this Contract,
at the sole discretion of DSHS, and shall subject Contractor to such monetary and other penalties as
may be provided by law.
14. Contract Suspension.
DSHS may, without prior notice, suspend the Contractor's performance of the Contract if the.
Contractor, or any partner, officer or director of the Contractor or a subcontractor, or any staff or
employee of the Contractor or a subcontractor, is investigated by a local, county, state or federal
agency regarding any matter that, if ultimately established, could either:
a. Result in a conviction for violating a local, state or federal law,. or
b. In the sole judgment of DSHS, adversely affect the delivery of services under this Contract or the
health, safety or welfare of DSHS clients.
DSHS may also take other lesser action, including, but not limited to, disallowing a staff member,
employee, or other person associated with the Contractor or a subcontractor, from providing services,
or from having contact with DSHS clients, until the investigation is concluded and a final determination
made by the investigating agency.
15. Insurance. For purposes of this Contract:
a. DSHS certifies that it is self-insured under the State's self-insurance liability program, as provided
by RCW 4.92.130, and shall pay for losses for which it is found liable.
b. The Contractor certifies, by checking the appropriate box below, initialing to the left of the box
selected, and signing this Contract, that:
® The Contractor is self-insured or insured through a risk pool and shall pay for losses
for which it is found liable; or
^ The Contractor maintains the types and amounts of insurance identified below and
shall, prior to the execution of this Contract by DSHS, provide certificates of insurance to
that effect to the DSHS Contact on Page 1 of this Contract.
(1} Commercial General Liability Insurance
The Contractor shall maintain Commercial General Liability Insurance, or Business Liability
Insurance, including coverage for bodily injury, property damage, and contractual liability, with
the following minimum limits: Each Occurrence - $1,000,000; General Aggregate - $2,000,000.
The policy shall include liability arising out of premises, operations, independent contractors.,
products-completed operations, personal injury, advertising injury, and liability assumed under
an insured contract. The State of Washington, Department of Social & Health Services (DSHS),
and elected and appointed officials, agents, and employees of the state, shall be named as
additional insured.
(2) Business Automobile Liability Insurance
If a Contractor transports DSHS clients, the Contractor shall maintain a Business Automobile
DSHS Central Contract Services
2048CS EIP County (5-26-10) Page 6
Special Terms and Conditions
Policy on all vehicles used to transport clients, including vehicles hired by the Contractor or
owned by the Contractor's employees, volunteers or others, with the following minimum limits:
$1,000,000 per accident combined single limit. The Contractor's carrier shall provide DSHS
with a waiver of subrogation or name DSHS as an additional insured.
(3} Professional Liability Insurance
The Contractor shall maintain Professional Liability Insurance or Errors & Omissions insurance,
including coverage for losses caused by errors and omissions, with the following minimum
limits: Each Occurrence - $1,000,000; Aggregate - $2,000,000.
16. Resolution of Differences.
In the event of any differences between the parties on matters related to the interpretation and
implementation of this Contract, the parties shall first attempt to resolve the difference informally
between themselves at the local or regional level, by following the regional conflict resolution process.
If the parties are unable to resolve their difference as stated above, then either party may submit a
request for dispute resolution as provided in Section 18, Disputes.
A copy of the regional conflict resolution process is available from the DSHS Contact person listed on
Page 1 of this contract.
17. Disputes.
a. Either party who has a dispute concerning this Contract. may submit a written request for dispute
resolution. The amount of any rate set by law, regulation, or DSHS policy is not disputable. A
party's written request for dispute resolution must include:
(1) A statement identifying the issue(s) in dispute; and
(2) Contractor's name, address and contract number.
b. The request must be mailed to the following address within thirty (30) calendar days after the party
could reasonably be expected to have knowledge of the issue, which is disputed.
c. A copy of the current CA dispute resolution process is available at any time by written request.
d. Requests for dispute resolution or for a copy of the current CA's dispute resolution process should
be sent to:
DSHS/Children's Administration
Attention Contracts Management Unit
P.O. Box 45710
Olympia, WA 98504-5710
This dispute resolution process is the sole administrative remedy available under this Contract
18. Addressing Diversity.
In providing services to DSHS clients under this Contract, the Contractor shall adhere to the principles
of the CA Diversity Charter, which principles include but are not limited to the following:
• Non-discrimination;
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2048CS EIP County (5-26-10) Page 7
Special Terms and Conditions
• Exceptional customer service;
• Diversified, individualized, responsive and inclusive services;
• Services that meet the cultural and ethnic needs of clients;
• Equal opportunity for the workforce.
To ensure compliance with the above requirement, the Contractor shall be familiar with the CA Diversity
Charter, which can be accessed at http://www1.dshs.wa.gov/pdf/publications/22-1108.pdf
19. Braam Considerations.
In the event that CA should need to include additional requirements relating to the services provided
under this. Contract, as part of CA's obligation to meet the requirements of Braam v. State of
Washington, the parties agree to negotiate in good faith the incorporation of such additional
requirements in this Contract, either by an amendment to this Contract or by a revised contract that
would replace this Contract.
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2048CS EIP County (5-26-10) Page 8
EXH181T A
STATEMENT OF WORK
Early Intervention Program (EIP)
ORGANIZATION OF STATEMENT OF WORK
1. Intent of Services
2. Philosophical Principals used in the Delivery. of EIP Services
3. Client Eligibility and Referral for Services
4. Referral Procedures
5. Service Coordination with CA
6. Dual Case Management with Another Agency
7. Family Centered Practice Model
8. Provision of Services
a. Face to Face Contact
b. Initial Screen
c. Service Delivery
d. Brief Intervention Path
e Assessment and Comprehensive Service Path
f. Service Plan
g. 90-Day Reviews
h. Exit from the EIP Program
i. Exit Summary
9. Reports
10. Program Improvements
The Contractor shall provide services under the Contract as described in this Statement of Work.
Intent of Services.
Early Intervention Services is a home visiting nurse program which shaA address health conditions,
physical growth, child development, social-emotional health, caretaking/parenting, and home safety
issues for children served by CA. EIP nurses shall provide assessments, education/counseling, care
management, and linkage into community programs for identified concerns.
The Contractor shall provide EIP services through direct services to families and/or by linking families
to community resources to accomplish the following goals for families:
• Reduce risk of abuse or neglect of children in the home;
• Enhance parenting skills, family and personal self-sufficiency, and family functioning;
• Reduce stress on the family;
• Reduce the likelihood of additional referrals to CPS;
• Enhance the health and well being of children and their families; and
• Facilitate linkages to health and community services.
2. Philosophical Principles used in the Delivery of EIP services
• Individualized, tailored intervention;
• Empowerment approaches;
• Community support building approach;
DSHS Central Contract Services
2048CS EIP County (5-26-10) Page 9
• Strengths perspective;
• Cultural competence;
• Developmental appropriateness; and
• Outcome driven service plans.
3. Client Eligibility and Referral for Services
a. Eligibility. Families are eligible for EIP services who meet the following criteria:
(1) Have a child ages birth to six who has issues related to hislher:
(a) Nutrition,
(b) Physical growth,
(c) Social-emotional health,
(d) Hygiene,
(e) Developmental patterns,
(f} Medical conditions,
(g) Access to health care,
(h) Attachment with caregiver, or
(i) Risks for injuries from home safety hazards
OR
(2} Have a school aged child or youth who has medical neglect or problems with chronic health
conditions.
Infants and young children under three are of highest priority and should be served first
whenever possible
b. Referrals. EIP services are designed to be a cooperative service between CA and the contracted
nurse. Both CA and the EIP nurse shall work together to provide service delivery in a coordinated
approach. All EIP service plans should be developed in consultation with the CA social worker. All
families must be referred to EIP by a CA social worker. Families may be referred from CPS, Family
Voluntary Services, or Child and Family Welfare Services as follows:
(1) Omen Child Protective Services (CPS) Cases: Includes children who have been investigated by
CPS and are residing with their biological parent or legal caregiver. Referral can be made to
-EIP:
(a} CPS social worker has interviewed the family and has identified an issue relating to the
child's health, growth, development, caretaking/parenting, or home safety.
(b) Families are opened for brief assessment and must be closed when the CPS social worker
closes their case. The EIP Nurse links family to needed community resources and services.
(2) Open Family Voluntary Service (FVS) Cases: Includes children who are opened to FVS
services and have an active service plan in place.
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(a) FVS social worker has interviewed the family and has identified an issue relating to the
child's health, growth, development, caretaking/parenting, or home safety.
(b) The CA family's service plan indicates a goal related to the child's health, growth,
development, caretaking/parenting, or home safety and the family would benefit from having
an EIP nurse home visitor to address these issues in the CA service plan.
(c} Priority for EIP eligibility is given to child(ren) in home or returning to the home within 60
days.
(3) Omen Child and Family Welfare Service (CFWS) Cases: Includes children who are in relative
placement, .foster care, or in-home dependencies:
(a) CFWS social worker has interviewed the family and has identified an issue relating to the
child's health, growth, development, parenting, or home safety.
(b} An EIP referral may be appropriate for a brief nurse consultation when the child enters foster
care or out-of home placement and has an immediate health care management problem
that requires health assessment, case coordination, care management education, and
linkage into health care services.
(c) A child in out-of home placement and who is being returned to a caregiver or permanent
placement within 60 days and has a health care management problem. The home visiting
nurse is to provide health assessment, case coordination, caregiver care management
education, and linkage into health care services.
(d) Priority for EIP eligibility is given to child(ren) in home or returning to the home within 60
days.
4. Referral Procedures.
a. CA shall have sole responsibility for referring clients to the Contractor under this Contract. All
referrals. must be initiated in writing. by CA. CA will not pay for any families served under this
Contract who were not referred by CA.
b. CA shall submit a written EIP referral to the Contractor which will authorize services.
c. The. Contractor shall adhere to the referral procedures set forth in the CA regional/local protocol.
d. Referral review.
(1) The Contractor shall review the EIP referral to ensure:
(a) The referral meets the eligibility criteria and the family and has identified an issue relating to
the child's health, growth, development, caretaking/parenting, or home safety concern that
necessitates nursing interventions;
(b) The reasons for requested EIP intervention are clear and are appropriate for nursing
services;
(c} Clients case numbers, clients names and dates of births, and client contact information are
provided; and
(d) Assigned CA social worker names and contact information is provided.
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(2) If the referral does not have the above information or the information is unclear, the Contractor
shall contact the referring CA social worker, or their agency EIP program leads, or the CA EIP
liaison to obtain the needed information.
(3) Upon receipt of the referra{, the EIP nurse shall telephone the referring CA social worker to
inform them of their assignment to the case and discuss coordination of services for the family.
5. Service Coordination with CA. The Contractor shall ensure that the assigned EIP nurse:
a. Works col{aboratively with the CA SW to determine the EIP nurse's role in working with the needs
of children in order to coordinate, but not overlap, service delivery;
b. Reviews the CA's family assessment, if services have warranted its development; and
c. Develops a family assessment, if CA has not developed one.
6. Dual Case Management with Another Agency.
a. If the Contractor and another agency are performing case management services for the same
family, the Contractor shall facilitate a staffing with the other agency to assure that the family's
needs are met in a coordinated approach.
b. The Contractor shall ensure services being provided under this Contract are not being charged to
another funding source which would result in duplicate payment.
7. Family Centered Practice Model.
The Contractor shall provide services consistent with the "Washington State Division of Children and
Family Services Family Centered Practice Model." It shall be the Contractor's responsibility to obtain
information on the Family Centered Practice Model from CA. The Family Centered Practice Model may
be accessed at: http://www1.dshs.wa.gov/pdf/ca/FCPModel.pdf
8. Provision Of Services.
The Contractor shall deliver services as follows for CA referred families:
Face to Face Contact. The Contractor shall:
(1) Attempt to make initial contact with the family within three (3} working days of acceptance of the
referral from CA. Initial contact may be via a telephone contact or face to face contact.
(2) Notify the CA social worker in writing within 10 working days if the family is unavailable or
unwilling to meet with the Contractor for an initial face to face home visit.
(3) Make, at a minimum, two home visit attempts before closing a case. If a second home visit
attempt is not completed, the Contractor shall document on the Exit Summary the reason a
second attempt for a home visit was not completed.
(4) Immediately notify the referring social worker and complete an Exit Summary if the family has
moved from the service area and is not available for any face-to-face contact.
b. Initial Screen.
(1) The EIP nurse shall conduct an initial screening to determine the family or child's:
(a) Health care needs, to include physical and developmental health, social-emotional health,
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and dental health; and
(b) Issues relating to home safety, basic needs, parenting skills, parental delays, and home
environment.
(2) Based on the initial screening, the EIP nurse, family, and CA social worker will determine the
service path for the family. The service path will be either a Brief Intervention Path or an
Assessment and Comprehensive Service Path.
c. Service Defivery.
(1) Schedule services at the family's convenience and tailor to accommodate a family's work
schedule whenever possible.
(2) Make EIP nurses available to testify at court hearings when subpoenaed. When. requested by
CA staff, EIP nurses shall participate in CA EIP meetings, Child Protective Team (CPT) or case
staffings, and child fatality reviews for EIP involved families. If EIP nurses are not able to attend
in person, the Contractor shall provide a written summary of the family's progress.
(3) Length of Service.. EIP services shall be provided only while the case is open to CA.
d. Brief Intervention Path
(1) The Brief Intervention Path is a short-term intervention designed to:
(a) Provide health and developmental assessments. for the identified child;
(b) Assist the CA social worker with case planning information;
(c) Connect the family with community services; and
(d) Provide brief and focused teaching and guidance in areas identified in the screening
process.
(2) The Brief Intervention shall be completed within 90 days and an Exit summary completed within
10 days of case closure.
e. Assessment and Comprehensive Service Path
(1) Assessment. The Contractor shall work with the assigned CA social worker and family so that a
complete family assessment is created that identifies or addresses the family's:
(a) Current protective factors;
(b) Current strengths and successes of the family that can be built upon to address need;
(c} Current safety or health risk factors;
(d) Natural support systems, such as friends, family, community members, and groups;
(e) Physical health and social-emotional health care needs;
(f) Attainment of developmental milestones and physical growth;
(g) Service and/or support needs of the children; and
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(h) Circumstances that led to the crisis.
(2) Identified Priorities. After the assessment is completed, the EIP nurse shall utilize the Omaha
System for identified priorities.
(a) The EIP nurse shall identify the top two to three Omaha problems that are of priority for EIP
interventions.
(b) The EIP nurse shall score each selected Omaha problem using the Knowledge, Behavior,
and Status (KBS) scoring system as defined by the Omaha System in conjunction with the
CA KBS manual.
(c) The results of the Omaha scores shall be recorded on 90 day reports and Exit summary
reports.
f. Service Plan. The EIP nurse may contribute to the CA service plan by assisting the social worker in
the identification of:
(1) The top two to three Omaha priorities for the client. The nurse, in conjunction with the family and
CA social worker, shall develop specific behaviorally driven goals and objectives that support
the target areas identified through the family assessment process and supported by the Omaha
priorities.
(2} The client's individualized interventions designed to increase protective factors, decrease risk
factors, and target child safety and well-being outcomes. The Contractor shall focus on the
following:
(a} Physical health;
(b) Wellness;
(c} Social-emotional health;
(d) Home safety;
(e} Caretaking/parenting; and
(f) Developmental issues.
(3) The family's internal and external support networks and service providers and plans for
utilization.
g. 90-Day Reviews
(1) The Contractor shall complete a 90 day review using a report form provided by CA
(2) Contractor shall submit reports at 90 day service intervals or when CA requires service reports
for court proceedings.
h. Exit from the EIP Program. The Contractor shall staff with CA to determine whether to close an
EIP case if one or more of the following occurs:
(1) Family refused service
(2) Children removed from parenUcaregiver
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(3) Family moved from contractor service area
(4) Family was referred to another program or service that is more appropriate than the EIP
intervention
(5) CA is closing the case
(6} Services were completed
i. Exit Summary. The Contractor shall complete an Exit Summary:
(1) When closing the case, on forms provided by CA;
(2) Within 10 working days of case closure and shall submit to the CA social worker.
9. Reports
a. The Contractor shall submit the following monthly reports, in a format prescribed by CA as
instructed below, unless specified differently in the regional protocol:
EIP Contractor Re orts Submit to: Due Date
• EIP Monthly Report 1 copy to EIP regional liaison By the 15 of the month for
services provided in the
[Attention: Peggy Lopez (regional previous month
liaison} Children's Administration
P.O. Box 45714
Olympia, WA 98504-5714)
1 copy to the regional billing person
[mail with A-1 S to address under Billing
Section)
1 copy to CA HQ Program Manager
[Attention: EIP Program Manager
P O Box 45710
OI m ia, WA 98504-5710
• 90 Day Review 1 copy of each to the assigned CA social By the 15t of the month for
• Exit Summary worker services provided in the
revious month
b. DSHS may stop payment to the Contractor if reports required under this Contract are
delinquent or incomplete.
c. Additional Data
DSHS may request additional measurable service and outcome data for services provided. In the
event DSHS so requests, DSHS commits to work with the Contractor to develop data elements. If
so requested, the Contractor agrees to provide data collection in a manner prescribed by DSHS.
10. Program Improvements.
The Contractor agrees to collaborate with CA to develop and implement program changes which may
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EXHIBIT B
PROGRAM REQUIREMENTS.
Early Intervention Program (EIP}
ORGANIZATION OF PROGRAM REQUIREMENTS
1. Qualification Requirements
2. Licensing or Statutory Requirements
3. Required License in Good Standing
4. Degree Requirements
5. Staff and Subcontractor Training
6. Annual EIP Provider Meetings
7. Evaluation of Contractor
8. Background Checks
9. Health and Safety of DSHS Clients
10. Corporate Punishment Prohibited
11. Smoking Prohibited in Presence of Client Children and Foster Youth
12. No Transportation of DSHS Clients
13. Culturally Relevant Services
14. Interpretation and Translation
15. Confidentiality -Additional Requirements
16. Records
a. Client Records
b. Administrative Records
c. Personnel and Subcontractor Records
17. Auditing and Monitoring
18. Operating Procedures
19. Office of the Family and Children's Ombudsman
The Contractor shall comply with all program and other requirements for providing services under this Contract,
as set forth below.
1. Qualification Requirements.
a. The Contractor shall ensure that employees, subcontractors, and/or volunteers providing services to
DSHS clients under this Contract have the following minimum qualifications:
(1) Holds a current license to practice as a registered nurse by the State of Washington;
(2} Has a minimum of two years working with children and families; and
(3} Has experience providing a home visitation model of service delivery.
OR
(4) Has completed a Bachelor of Nursing Program and currently is serving as a Public Health Nurse in
a t_ocal Health Jurisdiction.
b. Exceptions. for Required Staff Qualifications
If the preferred candidate does not meet the requirements for the minimum home visiting experience,
the Contractor shall request an exception by submitting the following information to the CA
headquarters program manager for EIP:
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• Documentation of the individual's credentials and work experiences
• Documentation of related coursework, conferences, and other training
• Reasons why applicant was chosen
• How the Contractor plans to supervise the applicant
• Training plan
• Position description for which the exception is being requested.
DSHS/Children's Administration
Attention: EIP Program Manager
PO Box 45710
Olympia, WA 98504-5710
2. Licensing or Statutory Requirements
a. The Contractor shall meet or exceed all minimum licensing, certification or registration requirements or
other requirements as required by statute.
b. When licensing, certification, registration or other statutory requirements differ from contract
requirements, the Contractor shall meet whichever requirement imposes the higher standard. Any
variance from such requirements shall require a licensing waiver from the issuing agency.
3. Required License in Good Standing.
a. If the Contractor or any of the Contractor's staff are required to be licensed to provide any of the
services under this Contract, the required license must be in good standing at all times during the term
of the Contract.
b. In the event that a required license is suspended, or if any limitations or restrictions are placed on the
license, the Contractor shall notify the DSHS Contact person listed on Page 1 of this contract
4. Degree Requirements.
The Contractor shall ensure that any degrees required of the Contractor or the Contractor's staff under this
Contract, or by statute, shall meet the following requirements before the Contractor shall provide services
under this Contract:
a. The degree must be awarded following successful completion of a required course of instruction
undertaken by the recipient of the degree;
b. The degree must be awarded by a public or private 4-year or 2-year college, university, community
college, trade or vocational school, or other institution of higher education in the United States that is
accredited by the Council for Higher Education Accreditation (CHEA) or an accreditation organization
recognized by the Council for Higher Education Accreditation, or by one of the following regional
accreditation boards for the United States:
(1 } MSA - Middle States Association
(2) NASG -Northwest Association of Schools and Colleges
(3) NCA - North Central Association of Colleges and Schools
(4) NEASC -New England Association of Schools and Colleges
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(5) SACS -Southern Association of Colleges and Schools
(6) WASC -Western Association of Schools and Colleges
c. If the degree has been awarded by a tribal college, university, community college, trade or vocational.
school, it must be accredited by one of the above regional accreditation boards or other accreditation
organization recognized by the American Indian Higher Education Consortium, which may be
accessed at: www.aihec.org.
d. If the degree has been awarded by a foreign educational institution outside of the United States, it
must be qualified in the country in which it is located to provide the course of instruction leading to that
degree, and must be accredited by an accreditation organization recognized as such in the country. in
which it is located or recognized by the Council for Higher Education Accreditation.
The Council for Higher Education Accreditation (CHEA) is located at One Dupont Circle NW, Suite
510, Washington, DC 20036-1135 acrd may be accessed at: www.chea.org.
e. Failure to comply with the degree requirements of this section shall be grounds for termination of this
Contract.
5. Staff and Subcontractor Training.
Mandated Reporter Training. The Contractor shall ensure that all current staff view the video "Making a
CPS Referral: A Guide for Mandated Reporters" within 30 days of the effective date of this Contract and
that all future employees view the video within two (2) weeks of initial employment. After viewing, each
employee shall sign and date a statement acknowledging his or her duty to report child maltreatment, and
the Contractor shall retain the signed statement in the employee's personnel file. If staff have viewed the
video within the last three (3) years, they shall be considered as having satisfied this requirement provided
the Contractor has the employee's signed statement on file. The Contractor shall either obtain a copy of
the video from DSHS, or access the video online at the following address:
http://www1.dshs.wa.gov/ca/pubs/pubcats.asp?cat=Multi-Media.
6. Annual EIP Provider Meetings.
It is expected under this Contract that, at a minimum, one Contractor representative shall attend CA's EIP
provider meetings.
7. Evaluation of Contractor.
a. DSHS may evaluate the Contractor's performance during the term of the Contract. Areas of review
may include, but are not limited to, the following:
(1} Reports required under this contract are complete and submitted in a timely manner;
(2) Families are referred to appropriate community resources; and
(3) EIP direct service staff participate in all EIP program meetings and trainings as required by CA.
b. ff the Contractor fails to meet any of the performance measures, DSHS may terminate this Contract.
8. Background Checks.
a. This requirement applies to any employees, volunteers and subcontractors who may have
unsupervised access to children served under this Contract.
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b. This requirement does not apply to currently licensed foster parents who are affiliated with the
Contractor. Licensed foster parents are subject to the criminal history background provisions
associated with obtaining and maintaining a current foster license.
c. The Contractor shall ensure a criminal history background check pursuant to RCW 43.43.832,
43.43.834, RCW 43.20A.710 and WAC 388-06 has been completed through DSHS for all current
employees, volunteers, and subcontractors, and that a criminal history background check shall be
initiated for all prospective employees, volunteers and subcontractors who may have unsupervised
access to children served under this contract.
d. The Contractor shall assist in obtaining additional state or national criminal history and/or child
abuse/neglect history, if requested by DSHS.
e. The Contractor shall ensure that no employee, volunteer or subcontractor, including those
provisionally hired pursuant to RCW 43.43.832(7), has unsupervised access to children served under
this contract, until a full and satisfactory background check is completed and documentation, qualifying
the individual for unsupervised access, is returned to the Contractor.
9. Health and Safety of DSHS Clients.
In the delivery of services under this Contract, children's health, safety and well-being shalt always be the
first concern of the Contractor.
a. If the Contractor determines that there are additional health. and safety concerns, suspected substance
abuse, or other presenting problems which were not stated in the CA referral, the Contractor shall
immediately report this information to the referring CA social worker and, if appropriate to CPS Intake.
The Contractor shall follow such verbal notification by written notification within 24 hours to the CA
social worker and to CPS Intake.
b. Contractors are mandated reporters under Chapter 26.44.030 RCW. The Contractor shall immediately
report all instances of suspected child abuse and neglect to (1 }Child Protective Services (CPS) Intake
and (2) the referring CA social worker. The Contractor shall follow verbal notification by written
notification within 24 hours to the CA social worker and to CPS Intake.
c. CPS Intake shall make the determination of whether the referral constitutes an allegation of child
abuse or neglect that shall be accepted for investigation, as a possible licensing compliance issue, or
as a matter of "information only".
d. Written notification required by the Contractor shall include notification by fax or by a-mail.
10. Corporal Punishment Prohibited.
Corporal punishment of children in the Department's care or custody is prohibited. Corporal punishment is
any act which willfully inflicts or causes the infliction of physical pain on a child. The Contractor, and the
Contractor's agents and employees, shall not administer corporal punishment to children served under this
Contract.
11. Smoking Prohibited in Presence of Client Children and Foster Youth.
Smoking in the presence of client children is prohibited including, but not limited to whenever there is
direct contact with client children under age 18 and foster youth 18 to 21 years of age, such as talking with
a child or accompanying a child, even when in a public place where smoking may otherwise be permitted.
12. No Transportation of DSHS Clients. The Contractor shall not provide transportation to DSHS clients
under this Contract
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13. Gutturally Relevant Services.
The Contractor shall provide appropriate, accessible, and culturally relevant services to clients and their
families. Service delivery shall be culturally competent and responsive to each client's cultural beliefs and
values, ethnic norms, language needs, and individual differences. Contractors are encouraged to employ
a diverse workforce that reflects the diversity of their clientele and the community. The Contractor shall
have a written recruitment policy which demonstrates that the Contractor is an equal opportunity employer.
14. Interpretation and Translation.
a. The Contractor shall provide Limited English Proficient (LEP) clients with certified or otherwise
qualified interpreters and translated documents.
b. The Contractor shall provide deaf, deaf-blind, or hard of hearing clients with the services of a certified
sign language interpreter..
c. Interpreter and translation services shall be provided at no cost to the client. All interpreter and
translation costs shall be the financial responsibility of the Contractor. These costs are included in the
contracted rate.
d. Extraordinary costs, which create an undue hardship for the Contractor in providing interpretation
and/or translation services to an individual client, may be reviewed and addressed for supplemental
reimbursement by the CA Regional Administrator or designee on a case by case basis.
15. Confidentiality -Additional Requirements
This Contract. imposes the following additional requirements to the section titled Confidentiality, set forth
as one of the General Terms and Conditions of this Contract:
a. Consent by Minor. The Contractor shall not use, publish, transfer, sell or otherwise disclose any
Confidential Information of a minor except as provided by law or with the prior written consent of the
minor's parent, legal representative or guardian. If a child is a dependent of Washington State, then
prior written consent must be obtained from DSHS.
b. Encrypted Email Account. The Contractor shall use an encrypted email account for electronic
submissions which contain Confidential, and Personal Information, as defined in the General Terms
and Conditions. Information regarding encrypted email accounts can be obtained at CA's website,
located at: http:/Jwww.dshs.wa.gov/ca/partners/intro asp.
16. Records.
a. Client Records
The Contractor shall maintain individual client records and shall promptly submit to DSHS a copy of
such records upon request. At a minimum, individual client records must include:
(1) CA Intake Referral Summary Report;
(2} Additional referral information, if applicable;
(3) Client Assessment;
(4) Client Screenings;
(5) Family Service Plan;
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(6) 90 Day Reviews;
(7) Exit Summary;
(8) KBS scores and supporting documentation;
(9) Contacts with the family to include: date of contact, name(s) of member(s) present, and charting
notes;
(10) Contacts with CA social worker and service providers.
b. Administrative Records
The Contractor shall retain the following administrative records:
(1) Community Resource Directory that lists: name of agency, address, telephone number, description
of available resources and supports for families;
(2) Monthly Reports;
(3) Fiscal records that shall substantiate costs charged to DSHS under this contract;
(4) Audits., License review, contract monitoring and corrective actions required and action taken;
(5) Documentation of all audits, license reviews, contract monitoring reports, and corrective action
reports and actions taken. Documentation of all costs associated with service provided under this
Contract;
(6) Recruitment policy which demonstrates that Contractor is an equal opportunity employer;
(7) Personnel policy reflecting CA policy requirements re "Smoking Prohibited in Presence of Client
Children and Foster Youth", as stated above in Section 11;
(8} A copy of any subcontract or other agreement for subcontracted services and the provider's
qualifications;
(9) Copy of the Certificate of Insurance for each subcontractor; and
(10} Protected group data:
(a) A list of current staff by position that addresses date of birth, sex, and identified protected
group status, including race, Vietnam Era Veteran, Disabled Veteran, and person of disability.
(b) A list of all clients served that addresses date of birth, sex, and race.
When collecting protected groups data, the Contractor shall inform staff and clients that (1) the
furnishing of the information is entirely voluntary; (2) the refusal to furnish the data shall not have
adverse effects.
c. Personnel and Subcontractor Records
The Contractor shall retain the following records on (1) all of Contractor's staff and employees,
whether full-time or part-time, (2} volunteers, and (3) any subcontractor's staff and employees who
may have contact with DSHS clients in performing duties or providing services under this Contract:
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(1 } DSHS criminal history background check approval;
(2) Any other criminal history background checks;
(3) Current license(s), registration(s), or certification(s) to practice in the state of Washington and/or in
the state in which services are provided, as applicable;
(4) Proof of degrees}, if required, and transcripts from college or other school awarding any degree(s)
required under this Contract for service provision;
(5) Documentation of academic history and credentials, as applicable;
(6} Employment and experience history;
(7} Job description;
(8) Annual performance evaluations;
(9) Training records, as applicable;
(10} Hours worked and payment records;
(11} Staff training fog;
(12) Signed statements to adhere to confidentiality of client information;
(13) Signed statements acknowledging duty to report child maltreatment; and
(14) Copy of each signed subcontract or other agreement for any subcontractors.
17. Auditing and Monitoring.
a. If the Contractor is required to have an audit or if an audit is performed, the Contractor shall forward a
copy of the audit report to the DSHS Contact listed on Page 1 of this Contract.
b. If federal. or state audit exceptions are made relating to this Contract, the Contractor must reimburse
the amount of the audit exception, and any other costs including, but not limited to, audit fees, court
costs, and penalty assessments.
c. The Contractor shall be financially responsible for any overpayments by DSHS/CA to the Contractor.
The Contractor shall be financially responsible for any audit disallowances resulting from a federal or
state audit which resulted from an action., omission or failure to act on the part of the Contractor.
d. DSHS may schedule monitoring visits with the Contractor to evaluate performance of the program.
The Contractor shall provide at no further cost to DSHS reasonable access to all program-related
records and materials, including financial records in support of billings, and records of staff and/or
subcontractor time.
18. Operating Procedures.
a. In collaboration with CA, the Contractor shall develop written operating procedures, which set forth
procedures for the day-to-day operation and conduct of activities under this Contract. Such
procedures must be in accord and consistent with, and shall not conflict. with, the provisions of this
Contract. The written operating procedures shall address:
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(1) Referral process steps;
(2} Communication links (contact persons};
(3) Case updating requirements;
(4) Case termination and extension procedures;
(5) Scheduling process;
(6) Training collaboration, if any;
(7) Report and feedback process;
(8) Emergency procedures.
b. The Contractor shall submit a copy of the written operating procedures to the DSHS Contact identified
on Page 1 of this Contract.
c. The Contractor and CA shalt each retain a copy of the written operating procedures.
19. Office of the Family and Children's Ombudsman.
a. The Office of the Family and Children's Ombudsman (OFCO) shat( have the same right of access to
clients as DSHS.
b. The Contractor shall release records relating to services provided to youth that are dependent under
Chapter 13.34 RCW to the OFCO. The Contractor can release records for dependent youth under
Chapter 13.34 without the consent of a dependent youth's parent or guardian or the youth if the youth
is under the age of 13 years, unless law otherwise specifically prohibits such release.
c. The Contractor shall notify the CA headquarters Program Manager when the OFCO makes a request
for records.
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Exhibit C
Budget
Early Intervention Program (EIP}
AGENCY: Jefferson County Public Health
PROGRAM: EIP
PERIOD OF PERFORMANCE:1uly 1, 201.0 -June 30, 2011
ACTIVITY (not limited to the items below) Please add FTEs - Budget Request
footnotes to the budget section as needed. Percent for FYil
PERSONNEL (Direct Admin Costs}
Names:
Quen Zorrah $26,460
Fringe $6,871.
TRAVEL (registration, ferry) $440
LODGING (hotel) $286
PER DIEM (food) $150
OTHER DIRECT COSTS MUST BE PROGRAM SPECIFIC
Equipment
Supplies (includes curricula) $600
Professional services $720
Other (use as many lines as needed)
TOTAL DIRECT CHARGES $35,527
INDIRECT CHARGES (NOT TO EXCEED 10%) $3,553
(see attachment & use as many -ines as needed)
TOTAL INDIRECT CHARGES $3,553
GRAND TOTAL $39,080
DSHS Central Contract Services
2048CS EIP County (5-26-10) Page 25