HomeMy WebLinkAbout121613_ca10JEFFERSON COUNTY PUBLIC HEALTH Consent Agenda
615 Sheridan Street o Port Townsend o Washington 0 98368
www.jeffersoncountypublichealth.org
December 2, 2013
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: Jean Baldwin, Director
DATE:
CUB3ECT: Agenda Item — Contract Agreement with Public Health of King Countw.
for Breast Cervical & Colon Health Program Services, Amendment #1;
November 8, 2013— June 30, 2014; addl $8,125 total $13,328
STATEMENT OF ISSUE-'
Jefferson County Public Health, Community Health, is requesting Board approval of the Contract Agreement
with Public Health of King County for Breast Cervical & Colon Health Program Services, Amendment #1;
November 8, 2013— June 30, 2014; add'l $8,125 total $13,328
ANALYSIS STRATEGIC GOALS P'RO'S and COWS:
This amendment adds funding to continue services providing Breast and Cervical Health Care, (Screening &
Referral Services) to a specific segment of the population, Services are available to women who lack
insurance to pay for preventive services such as health exams, mammograms and pap tests. This includes
breast screening and annual exam for women age 40-64 with incomes at or below 250% of Federal Poverty
Level and mammography and breast diagnostics available to women below 300% of FPL. These services
will also be available to women who may not be eligible for Medicare. JCPH will continue to do outreach.
FISCAL IT ANALYSIS:
The agreement provides add'l funding of $8,125 to the current $5,203 for a total of $13,328 in State and
Federal funding The original contract funded approximately six months funding to provide BCHP services,
This funding represents additional anticipated funding for the remaining seven months of the contract. No
general fund dollars support this program.
The amendment provides:
$4,500 in Public Education/Outreach
$3,375 for Clinical Services (Fee-for-Service)
$250 for Client Support Services
COMMUNITY HEALTH ENVIRONMENTAL HEALTH
DEVELOPMENTAL DISABILI I'IES PUBLIC HEALTH WATER QUAUTY
MAIN: (360) 385-9400 A WORKINO 0GR A SAFER AND MAIN: (360) 385-9444
FAk (360) 385-9401 HEALTHIER COMMUNITY FAX: (360) 379-4487
Consent A,,0 enda
RECOMMENDATION:
JCPH management request approval of the Contract Agreement with Public Health of King County for Breast
Cervical & Colon Health Program Services, Amendment #1; November 8, 2013— June 30, 2014; add'I $8,125
total $13,328
REVI ED BY
P ;` 11p Morlei��ount-y- Administ-r6tor Date
CONTRACT AMENDMENT / CHANGE ORDER
PROJECT NAME: Breast, Cervical and Colon Health Program
PHS,KC PROGRAM MONITOR: Amber Roche
Cori'TRACTORI Jefferson County Public Health
615 Sheridan
Port Townsend, WA 98368
CONTRACT #PREV3163
AMENDIMENT#1
ORIGINAL CONTRACT START DATE., 7/1/2013 AMENDMENT EFFECTIVE DATE: 11/812013
This amendment adds $8,125 additional funding to continue providing breast and cervical services and
outreach to BCCHP program clients.
CHANGES To CONTRACT _BOILERPI-ATE
r-nm-rDArT ARAOI INT CHANGES TO READ: THIRTEEN THOUSAND THREE HUNDRED TWENTY-EIGHT
DOLLARS ANCD ERCD CENTS.
CONTRACT FUNDING BOX CHANGES AS FOLLOWS:
FUNDING SOURCES FUNDING LEVELS EFFECTIVE DATES
fFEDERAL
Federal Catalo ue No. 93.283 $ 6,750.00 7/1/2013 to 6/1412014
,;TAT E $ 6,578.00 1 7111/2013 to 6/14/2014
1
TOTAL $13,328.00 1 7/1/2013 to 6/1412014::1
THE FOLLOWING EXHIBITS ARE TO BE REPLACED IN THEIR ENTIRETY AS ATTACHED HERETO:
• EXHIBIT B —BUDGET —AMENDMENT 1
• EXHIBIT C —INVOICE —AMENDMENT 1
All other terms and conditions of the referenced contract, including any amendments, shall remain
unchanged,
IN WITNESS HEREOF, the parties hereto have caused this amendment to be executed and instituted on the
date first written,
KING COUNTY
PREM163 — Jefferson COUnty Public 11ealth -- Amendment I
Exhibit B : B', udget
Jefferson County Public Health
615 Sheridan
Port Townsend, WA 98368
The budget is based on ave ra ed yyeights Ler CPT coded procedures
Anticipated #s
Ori;inal Ai:i:;endI I
BCHP
25
2�
:BCHP Services Average $1351clilent
25
25
Dient. Support Services at $IUY—Rent
Outreach an Recruitment Cat
12
0
MontM Outreacli reports, at $200 each
"BCD
TB
New contacts at $30 each
TBD
---fB—D
-�c—,,tu—rning Oents, at $5 each
TBD
TBD
Referrals, at $50 each
Prev3163 - Jefferson County Public Health - Amendment 1
Breast, Cervical, and colon Health Program
401 Fifth Avenue, Suite 900
Seattle, WA 98104-1818
206-263-8205 Fax 206-296-0208
TTY Relay: 711
_Qv/h ga Itt
Jefferson County Public Health
615 Sheridan Port Townsend, WA 98368
Prev # 3163 CPA# 5600181
Contract Period: 71112013 thru 6/1412014
rtirrest Billing Period Oct. 2013
Public Health
IL I& M
Seattle & King County em
Please review, sign, and MAIL this invoice
within 10 days of receipt
Attention Amber Roche Address Above
Call wl questions: T # 206-263-8205
,ArnLL
,be Roche@.E�9,unt ., -g9-y-
-
._
Exhibit C - Invoice
Year 7-2013 thru 6-2014 Contract Status
I certify that the expenses itenlizecl above were incurred for the period: Oct. 2013
and that the reimbursement amount reflects as reasonably as possible, the contractual value of the expenses
being charged.
x
Jefferson CO. Public Health authorized signature
Please Print flame Below Si nature
X
Date
7:7' 777::Tor BCCHP Health Uepartrnent use
921
Expense summary
Current
Contracted
Accumulated
Available
Contracted Line Items 7
Expenses
Budget
Expense
Balance —
... . ....... I
O' Clinical 1111S ............ Kes c6g contract
$
$
$
$ 3,375.00
Services Amend 1
$
I . . ...3,375.00
$ 3,375-00
$
$ 3,375. 0
'HP Clinical
HP Dent SUP ort ServiceEEontract
$
$ 250.00
$
$ MOM
SupporFs--r?—rvices Arriend
$
$ 250.00
$
$ 250.'00mm
HP 'Client
$
$ 1,500.00
$
$ 1,500.00
4,500.00
$
$ 4,5010.00
78.00
.... .......
$
$ 78,00
13,328.00
$ m
$ 13,328.0/0
I certify that the expenses itenlizecl above were incurred for the period: Oct. 2013
and that the reimbursement amount reflects as reasonably as possible, the contractual value of the expenses
being charged.
x
Jefferson CO. Public Health authorized signature
Please Print flame Below Si nature
X
Date
7:7' 777::Tor BCCHP Health Uepartrnent use
921
Expense summary
-Ur—g7TTro�jec
8001051
Pay Current
Contracted
Budget
7
Accumulated
Expense
Available
Balance
-'ed orig. contract
101562
$
$ 3,375M
$ -
$ 3,375.00
CHP -
IP - --1017b6-2
Pnd I
I' Am�endj
A""'nd 1
- ��7, '
$
$ 3,375,00
$
$ 3,3,75,00
0 -
contract
[E 0 ntract
or c
Bc�.jp - on
tL BC!
101614
101614
$
$ 1,82b.UO
$
$ 1,828.00
Sttat ,
1
mend 1
AE e
PE
101614
101 6 1 4
$
$ 41750-00
—
$
$ 4,750,00
_
Slate BE��CHP-
St
Total OK-to-Pay --
$
13,328-00
7$
L$ 13,328-00
Date
Invoice # Prev # 3163
Invoice Date
P.O. # Receipt #
Prev3163 - Jefferson County Public Healffi - Amendment 1
Public HealthIZA
Seattle & KIng County
King County Contract No, PREV3163
Federal Taxpayer ID No. 91-6001322
This form'is available in alternate formats for people with disabilities upon request.
KING COUNTY CONTRACT FOR MEDICAL/HEALTH PROFESSIONAL SERVICES – 2013
. .. .........
Seattle-King County Dept. of Public Health (a.k.a. Public Health – Seattfe'
c�4m'ent
,sion U Lna County) PREV . . . ........
.2M.—
hero Public unfired hree IBollars and
nt a ct Am nt,_ Start t e 0�02 01 C0ntra t _ ro
_
THIS CONTRACT is entered into by KING COUNTY (the "County"), and Jefferson County Public Health
(the "Contractor"), whose address is 615 Shericlan,Port Townsend,WA , 98368.
WHEREAS, the County has been advised that the following are the current funding sources, funding
levels and effective dates:
FUNDING SOURCES FUNDING LEVELS EFFECTIVE DATES
FEDERAL Catalo ue Na, 93-283 $3,375.00 711112013 to 6114/2014
Federal STATE $1,828,00 71112013 to 611412014
TOTAL $5,203.00 71112013 to 611412014
and
WHEREAS, the County desires to have certain services performed by the Contractor as described in this
Contract, and as authorized by the 2013 Annual Budget,
NOW THEREFORE, in consideration of payments, covenants, and agreements hereinafter mentioned,
to be made and performed by the parties hereto, the parties mutually agree as follows:
CONTRACT DOCUMENT
The Contractor shall provide services and comply with the requirements set forth herein, The Contract
shall consist of the following documents and attached exhibits, each of which are made a part hereof by
this reference in the following order of precedence:
1, Contract Amendments executed pursuant to Section XV herein.
2. Contract for Medical/Health Professional Services, which includes:
Scope of Services ...... ........... Attached hereto as Exhibit A
Budget .... ___ ........ - . ......... .......... ....................... Attached hereto as Exhibit B
Invoice . . . . ...... .......... ....... Attached hereto as Exhibit C
Certificate(s) of lnsurance and Policy Endorsement....... Attached hereto as Exhibit D
Special Terms & Conditions
Contract # PREV3163
....... 111 ........ .. Attached hereto as Exhibit
Page # 1 of 10
TERM AND "TERMINATION
A This Contract shall commence on July 1, 2013, and shall terminate on June 14, 2014, unless
extended or terminated earlier, pursuant to the terms and conditions of the Contract,
B This Contract may be terminated by the County without cause, in whole or in part, upon providing
the Contractor ten (10) calendar days advance written notice of the termination,
If the Contract is terminated pursuant to this Section 11, paragraph B: (1) the County will be liable
only for payment in accordance with the terms of this Contract for services rendered prior to the
effective date of termination; and (2) the Contractor shall be released from any obligation to
provide further services pursuant to the Contract.
C The County may terminate this Contract, in whole or in part, upon five (5) calendar days' advance
written notice in the event: (1) the Contractor materially breaches any duty, obligation, or services
required pursuant to this Contract, or (2) the duties, obligations, or services required herein
become impossible, illegal, or not feasible.
If the contract is terminated by the County pursuant to this Subsection 11 (C) (1), the Contractor shall be liable for damages, including any additional costs of procurement of similar services from
another source,
If the termination results from acts or omissions of the Contractor, including but not limited to
misappropriation, nonperformance of required services or fiscal mismanagement, the Contractor
shall return to the County immediately any funds, misappropriated or Unexpended, which have
been paid to the Contractor by the County,
D If expected or actual funding is withdrawn, reduced or limited in any way prior to the termination
date set forth above in Section 11 or in any amendment hereto, the County may, upon written notice
to the Contractor, immediately terminate this Contract in whole or in part,
if the Contract is terminated pursuant to this Section 11, paragraph D: (1) the County will be liable
only for payment in accordance with the terms of this Contract for services rendered prior to the
effective date of termination; and (2) the Contractor shall be released from any obligation to
provide further services pursuant to the Contract.
Funding under this Contract beyond the current appropriation year is conditional upon
appropriation by the County Council of sufficient funds to support the activities described in this
Contract. Should such an appropriation not be approved, this contract will terminate at the close of
the current appropriation year.
E Nothing herein shall limit, waive, or extinguish any right or remedy provided by this Contract or law
that either party may have in the event that the obligations, terms and conditions set forth in this
Contract are breached by the other party.
lIl COMPENSATION AND METHOD OF PAYMENT
A The County shall reimburse the Contractor for satisfactory completion of the services and
requirements specified in this Contract in an amount not to exceed Five Thousand Two Hundred
Three Dollars and Zero Cents, payable in the following manner:
Upon receipt and approval of a signed invoice as set forth in Exhibit C that corresponds to the
budget set forth in Exhibit B.
B The Contractor shall submit an invoice and all accompanying reports as specified in the attached
exhibits not more than 15 working days after the close of each indicated reporting period. The
County shall make payment to the Contractor not more than 30 days after a complete and
accurate invoice is received
C If the Contractor fails to comply with any terms or conditions of this Contract or to provide in any
manner the work or services agreed to herein, the County may withhold any payment due the
Contractor until the County is satisfied that corrective action, as specified by the County, has been
Contract # PREV3163 Page# 2 of 10
IV
completed, This right is in addition to and not in lieu of the County's right to terminate this Contract
as provided in section 11,
D If travel costs are contained in the attached budget, reimbursement of Contractor travel, lodging,
and meat expenses are limited to the eligible costs based on the following rates and criteria.
The mileage rate allowed by King County shall not exceed the current Internal Revenue
Service (IRS) rates per mile as allowed for business related travel, The IRS mileage rate
shall be paid for the operation, maintenance and depreciation of individually owned vehicles
for that time which the vehicle is used during work hours. Parking shall be the actual cost.
When rental vehicles are authorized, governent rates shall be requested. If the Contractor
does not request government rates, the Contra ctor shall be personally responsible for the
difference. Please reference the federal web site for current rates: http://www,gsa.gov,
2 Reimbursement for meals shall be limited to the per them rates established by federal travel
requisitions for the host city in the Code of Federal Regulations, 41 CFR § 301, App.A.
3 Accommodation rates shall not exceed the federal lodging limit plus host city taxes. The
Contractor shall always request government rates.
4 Air travel shall be by coach class at the lowest possible price available at the time the
County requests a particular trip. In general, a trip is associated with a particular work activity
of limited duration and only one round-trip ticket, per person, shall be billed per trip.
MAINTENANCE OF RECORDS/EVALUATIONS AND INSPECTIONS
A The Contractor shall maintain accounts and records, including personnel, property, financial, and
programmatic records and other such records as may be deemed necessary by the County to
ensure proper accounting for all Contract funds and compliance with this Contract.
B, in accordance with the nondiscrimination and equal employment opportunity requirements set forth
in Section XJV. below, the Contractor shall maintain the following:
I Records of employment, employment advertisements, application forms, and other pertinent
data, records and information related to employment, applications for employment or the
administration or delivery of services or any other benefits under this Contract; and
2 Records, including written quotes, bids, estimates or proposals submitted to the Contractor
by all businesses seeking to participate on this Contract, and any other information
necessary to document the actual use of and payments to subcontractors and suppliers in
this Contract, including employment records,
The County may visit the site of the work and the Contractor's office to review the foregoing
records, The Contractor shall provide every assistance requested by the County during
such visits and make the foregoing records available to the County for inspection and
,copying upon request, The Contractor shall provide right of access to its facilities including
those of any subcontractor assigned any portion of this Contract pursuant to Section XIII to
the County, the state, and/or federal agencies or officials at all reasonable times in order to
monitor and evaluate the services provided under this Contract. The County will give
advance notice to the Contractor in the case of fiscal audits to be conducted by the County.
The Contractor shall comply with all record keeping requirements set forth in any federal
rules, regulations or statutes included or referenced in the contract documents. The
Contractor shall inform the County in writing of the location, if different from the Contractor
address listed on page one of this Contract, of the aforesaid books, records, documents, and
other evidence and shall notify the County in writing of any changes in location within ten
(10) working days of any such relocation,
C The records listed in A and B above shall be maintained for a period of six (6) years, after
termination of this Contract. The records and documents with respect to all matters covered by
this Contract shall be subject at all time to inspection, review, or audit by the County and/or
Contract # PREV3163
Page # 3 of 10
federal/state officials so authorized by law during the performance of this Contract and six (6)
years after termination hereof, unless a longer retention period is required by law.
D Medical records shall be maintained and preserved by the Contractor in accordance with state and
federal medical records statutes, including but not limited to RCW 70.41.190, 70.02,160, and
standard medical records practice. If the Contractor ceases operations under this Contract, the
Contractor shall be responsible for the disposition and maintenance of such medical records.
E The Contractor agrees to cooperate with the County or its agent in the evaluation of the
Contractor's performance under this Contract and to make available all information reasonably
required by any such evaluation process. The results and records of said evaluations shall be
maintained and disclosed in accordance with RCW Chapter 42.56,
F The Contractor agrees that all information, records, and data collected in connection with this
Contract shall be protected from unauthorized disclosure in accordance with applicable state and
federal law.
V AUDIT
A If the Contractor or subcontractor is a non-profit organization as defined in OMB Circular A -133,
and expends a total of $500,000 or more in federal financial assistance and has received federal
financial assistance from the County during its fiscal year, then the Contractor or subcontractor
shall meet the respective A-133 requirements described in subsections V.B. and V,C.
B If the Contractor is a non-profit organization, it shall have an independent audit conducted of its
financial statement and condition, which shall comply with the requirements of GAAS (generally
accepted auditing standards); GAO's Standards for Audits of Governmental Organizations,
Programs, Activities, and Functions; and OMB Circular A-133, as amended, and as applicable.
The, Contractor shall provide a copy of the audit report to each County division providing financial
assistance to the Contractor no later than six (6) months subsequent to the end of the Contractor's
fiscal year. The Contractor shall provide to the County its response and corrective action plan for
all findings and reportable conditions contained in its audit. When reference is made in its audit to
a "Management Letter" or other correspondence made by the auditor, the Contractor shall provide
copies of those communications and the Contractor's response and corrective action plan.
Submittal of these documents shall constitute compliance with subsection V.A.
C If the Contractor is a municipal entity or other government institution or jurisdiction, it shall submit
to the County a copy of its annual report of examination/ audit, conducted by the Washington State
Auditor, within thirty (30) days of receipt, which submittal shall constitute comp�liance with
subsection V.X
D if the Contractor, for-profit or non-profit, receives in excess of $100,000 in funds during its fiscal
year from the County, it shall provide a fiscal year financial statement prepared by an independent
Certified Public Accountant or Accounting Firm within six (6) months subsequent to the close of the
Contractor's fiscal year.
E Additional audit or review requirements which may be imposed on the County will be passed on to
the Contractor and the Contractor will be required to comply with any such requirements.
vl PUBLIC RECORDS REQUESTS
This Contract shall be considered a public document and will be available for inspection and copying by
the public in accordance with the Public Records Act, chapter 42.56 RCW (the "Act").
If the Contractor considers any portion of any record provided to the County under this Contract, whether
in electronic or hard copy form, to be protected under law, the Contractor shall clearly identify each such
portion with words such as "CONFIDENTIAL," "PROPRIETARY" or "'BUSINESS SECRET," If a request
is made for disclosure of such portion, the County will determine whether the material should be made
available under the Act. If the County determines that the material is subject to disclosure, the County
will notify the Contractor of the request and allow the Contractor ten (10) business days to take whatever
action it deems necessary to protect its interests. If the Contractor fails or neglects to take such action
Contract # PREV3163 Page # 4 of 10
within said period, the County will release the portions of record(s) deemed by the County to be subject
to disclosure. The County shall not be liable to the Contractor for inadvertently releasing records
pursuant to a disclosure request not clearly identified by the Contractor as "CONFIDENTIAL,"
°IPRCPRIETARY" or "BUSINESS SECRET,"
vil CORRECTIVE ACTION
if the County determines that a breach of contract has occurred, that is the Contractor has failed to
comply with any terms or conditions of this Contract or the Contractor has failed to provide in any
manner the work or services agreed to herein, and if the County deems said breach to warrant corrective
action, the following sequential procedure will apply:
M1
Ix
A The County will notify the Contractor in writing of the nature of the breach;
6 The Contractor shall respond in writing within three (3) working days of its receipt of such
notification, which response shall indicate the steps being taken to correct the specified
deficiencies. The corrective action plan shall specify the proposed completion date for bringing the
Contract into compliance, which date shall not be more than ten (10) days from the date of the
Contractor's response; unless the County, at its sole discretion, specifies in writing an extension in
the number of days to complete the corrective actions;
C The County will notify the Contractor in writing of the County's determination as to the sufficiency
of the Contractor's corrective action plan. The determination of sufficiency of the Contractor's
corrective plan shall be at the sole discretion of the County-,
D In the event that the Contractor does not respond within the appropriate time with a corrective
action plan, or the Contractor's corrective action plan is determined by the County to be
insufficient, the County may commence termination of this Contract in whole or in part pursuant to
Section ll-C;
E In addition, the County may withhold any payment owed the Contractor or prohibit the Contractor
from incurring additional obligations of funds until the County is satisfied that corrective action has
been taken or completed; and
F Nothing herein shall be deemed to affect or waive any rights the pates may have pursuant to
Section 11, Subsections B, C, D, and E.
ASSIGNMENT/SuBCONTRACTING f this Contract or transfer or assign
A The Contractor shall not assign or subcontract any portion o
any claim arising pursuant to this Contract without the written consent of the County. Said consent
must be sought in writing by the Contractor not less than fifteen (15) calendar days prior to the
date of any proposed assignment
"'Subcontract`" shall mean any agreement between the Contractor and a Subcontractor or between
Subcontractors that is based on this Contract, provided that the term "subcontract" does not
include the purchase of (i) support services not related to the subject matter of this contract, or (ii)
supplies.
HOLD HARMLESS AND INDEMNIFICATION
In providing services under this Contract, the Contractor is an independent contractor, and neither
the Contractor nor its officers, agents or employees are employees of the County for any purpose,
The Contractor,shall be responsible for all federal and/or state tax, industrial insurance and Social
Security liability that may result from the performance of and compensation for these services and
shall make no claim of career service or civil service rights which may accrue to a County
employee under state or local law.
The County assumes no responsibility for the payment of any compensation, wages, benefits, or
taxes by or on behalf of the Contractor, its employees and/or others by reason of this Contract.
The Contractor shall protect, indemnify, defend and save harmless the County and its officers,
agents and employees from and against any and all claims, costs, and/or losses whatsoever
A
Contract # PREV3163 Wage # 5 of 10
occurring or resulting from (1) the Contractor's failure to pay any such compensation, wages,
benefits or taxes, and/or (2) the Supplying to the Contractor of work, services, materials, and/or
supplies by Contractor employees or other suppliers in connection with or in support of the
performance of this Contract,
E3 The Contractor further agrees that it is financially responsible for and will repay the County all
indicated amounts following an audit exception which occurs due to the negligence, intentional act
and/or failure for any reason to comply with the terms of this Contract by the Contractor, its
officers, employees, agents, and/or representatives. This duty to repay shall not be diminished or
extinguished by the prior termination of the Contract pursuant to the Term and Termination
section.
C The contractor shall protect, defend, 'indemnify, and save harmless the County, [and the State of
Washington (when any funds for this Contract are provided by the State of Washington)], their
officers, employees, and agents from any and all costs, fees (including attorney fees), Claims,
actions, lawsuits, judgments, awards of damages or liability of any kind, arising out of or in any
way resulting from the negligent acts or omissions of the Contractor, its officers, employees, sub-
contractors of any tier and/or agents. The Contractor agrees that its obligations under this
paragraph extend to any claim, demand, and/or cause of action brought by or on behalf of any of
its employees, sub-contractors of any tier or agents,
In addition to injuries to persons and damage to property, the term "claims," for purposes of this
paragraph C, shall include, but not be limited to, assertions that the use or transfer of any software,
book, document, report, film, tape, or sound reproduction or material of any kind, delivered
hereunder, constitutes an infringement of any copyright, patent, trademark, trade name, and/or
otherwise results in an unfair trade practice.
D For purposes of paragraphs A and C above, the Contractor, by mutual negotiation, hereby waives,
as respects the County only, any immunity that would otherwise be available against such claims
under the Industrial Insurance provisions of Title 51 RCW.
E In the event the County incurs attorney fees and/or costs in the defense Of claims within the scope
of paragraph A and C above, such attorney fees and costs shall be recoverable from the
Contractor. In addition King County shall be entitled to recover from the Contractor its attorney
fees, and costs incurred to enforce the provisions of this section..
The indemnification, protection, defense and save harmless obligations contained here in shall
survive the expiration, abandonment or termination of this Contract.
G Nothing contained within this provision shall affect and/or alter the application of any other
provision contained within this agreement.
Contract # PR EV3163 Page #/ 6 of 10
X INSURANCE REQUIREMENTS
By the date of execution of this Contract, the Contractor shall procure and maintain for the duration of
this Contract„ insurance against claims for injuries to persons or damages to property which may arise
from, or in connection with, the performance of work hereunder by the Contractor, its agents,
representatives, employees, and/or subcontractors. The costs of such insurance shall be paid by the
c a I
Contractor or subcontractor. The Contractor may furnish separate certificates of insurance and policy
endorsements for each subcontractor as evidence of compliance with the insurance requirements of this
Contract. The Contractor is responsible for ensuring compliance with all of the insurance requirements
stated herein. Failure by the Contractor, its agents, employees, officers, subcontractors, providers,
and/or provider subcontractors to comply with the insurance requirements stated, herein shall constitute a
material breach of this Contract. Specific coverages and requirements are at
http://www.king, county,gov/healthserv'ices/health/partnerships/contracts„ contractors shall read and
certify compliance.
X1 CONFLICT OF INTEREST, NONCOMPETITIVE PRACTICES AND DISCLOSURE
A Confli—&O-1interest
y entering into this Contract to perform work , the Contractor represents that it has no interest and
B
shall not acquire any interest that conflicts in any manner or degree with the work required to be
performed under this Contract. The Contractor shall not employ any person or agent having any
conflict of interest. In the event that the Contractor or its agents, employees or representatives
hereafter acquires such a conflict of interest, it shall immediately disclose such conflict to the
County. The County shall require that the Contractor take immediate action to eliminate the
conflict Up to and including termination for default.
B 922kn ent Peas and Gratuities
By entering into this Contract to perform Work, the Contractor represents that:
I No person except as designated by Contractor has been employed or retained to solicit or
secure this Contract with an agreement or understanding that a commission, percentage,
brokerage, or contingent fee would be paid.
2 No gratuities, in the form of entertainment, gifts or otherwise, were offered or given by the
Contractor or any of its agents, employees or representatives, to any official, member or
employee of the County or other governmental agency with a view toward securing this
Contract or securing favorable treatment with respect to the awarding or amending, or the
making of any determination with respect to the performance of this Contract,
3 Any person having an existing Contract with the County or seeking to obtain a Contract who
willfully attempts to secure preferential treatment in his or her dealings with the County by
offering any valuable consideration, thing or promise, in any form to any County official or
employee shall have his or her current Contracts with the County canceled and shall not be
able to enter into any other Contracts with King County for a period of two (2) years.
Disclosure of Current an F ormer Count F m 'o
ee s D i sclosure
of Interests under �CCI,0�,120
To avoid a ny actual or potential confl ict of cond uct.
I County employees or former County employees are prohibited from assisting with the
preparation of proposals or contracting with, influencing, advocating, advising or consulting
with a third party, including Contractor, while employed by the County or within one (1) year
after leaving County employment if he/she participated in determining the Work to be done
or processes to be followed while a County employee,
2 Contractor shall identify at the time of offer current or former County employees involved in
the preparation of proposals or the anticipated performance of Work if awarded the Contract.
Failure to identify current or former County employees involved in this transaction may result
in the County's termination of this Contract.
Page 7 of 1 0
Contract # PREV3163 #
3 After Contract award, the Contractor is responsible for notifying the County of current or
former County employees who may become involved in the Contract at any time during the
term of the Contract.
XII NONDISCRIMINATION AND EQUAL EMPLOYMENT OPPORTUNITY
The Contractor shall comply with all applicable federal, state and local laws regarding discrimination,
including those set forth in this Section.
During performance of the Contract, the Contractor agrees that it will not discriminate against any
employee or applicant for employment because of the employee or applicant's sex, race, color, marital
status, national origin, religious affiliation, disability, sexual orientation, gender identity or expression or
age except by minimum age and retirement provisions, unless based upon a bona fide occupational
qualification. The Contractor will make equal employment opportunity efforts to ensure that applicants
and employees are treated, without regard to their sex, race, color, marital Status, national origin,
religious affiliation, disability, sexual orientation, gender identity or expression or age. Additional
requirements are at http://www.kingcounty.gov/healthsery ces/liealth/partnerships/contraicts; contractors
shall read and certify compliance.
X111 INTELLECTUAL PROPERTY
,a, Patents ,-006 hts and Fri h�tsin Sub ect Data
Any patentable result or materials suitable for copyright arising out of this Contract shall be owned
and retained by the County. The County in its sole discretion shall determine whether it is in the
public's interest to release or make available any patent or copyright,
"The Contractor agrees that the ownership of any plans, drawing, designs, Scope of Work,
computer programs, technical reports, operating manuals, calculations, notes and other work
submitted or which '1$ specified to be delivered under this Contract, whether or not complete
(referred to in this subsection as "Subject Data") shall be vested in the County.
All such Subject Data furnished by the Contractor pursuant to this Contract, other than documents
exclusively for internal use by the County, shall carry such notations on the front cover Or a title
page (or in Such case of maps, in the name block), as may be requested by the County. The
Contractor shall also Place its endorsement on all Contractor-furnished Subject Data. All such
identification details shall be subject to approval by the County prior to printing,
The Contractor shall ensure that the substance of foregoing subsections is included in each
subcontract for the Work under this Contract.
B Non Disclosure of Data
Data provided by the County either before or after Contract award shall only be used for its
intended purpose. Contractors and Subcontractors shall not utilize nor distribute the County data in
any form without the prior express written approval of the County.
C Non - Disclosure Obligation
While performing the Work under this Contract, the Contractor may encounter personal
information, licensed technology, drawings, schematics, manuals, data and other materials
described as "Confidential", "Proprietary" or "Business Secret". The Contractor shall not disclose or
publish the information and material received or used in performance of this Contract. This
obligation is perpetual, The Contract imposes no obligation upon the Contractor with respect to
confidential information which the Contractor can establish that: a) was in the possession of, or
was rightfully known by the Contractor without an obligation to maintain its confidentiality prior to
receipt from the County or a third party; b) is or becomes generally known to the public without
violation of this Contract; c) is obtained by the Contractor in good faith from a third party having the
right to disclose it without an obligation of confidentiality, or, d) is independently developed by the
Contractor without the participation of individuals who have had access to the County's or the third
party's confidential information, If the Contractor is required by law to disclose confidential
information the Contractor shall notify the County of such requirement prior to disclosure,
Contract # PREV,3163 Page # 8 of 10
X1V ENVIRONMENTAL. PURCHASING POLICY
In accordance with King County Code 10.16, Contractors are required to use recycled and recyclable
products, and both sides of paper sheets for printed and photocopied materials, whenever practicable, in
fulfilling contractual obligations to the County.
XV ENTIRE CONTRACT I WAIVER OF DEFAULT
The parties agree that this Contract is the complete expression of the terms hereto and any oral or
written representations or understandings not incorporated herein are excluded Both parties recognize
that time is of the essence in the performance of the provisions of this Contract. Waiver of any default
shall not be deemed to be a waiver of any subsequent default. Waiver or breach of any provision of the
Contract shall not be deemed to be a waiver of any other or subsequent breach and shall not be
construed to be a modification of the terms of the Contract unless stated to be such through written
approval by the County, which shall be attached to the original Contract,
XVI NOTICES vides for notice to be provided by one party to another such notice shall be in
Whenever this Contract pro
writing.. time within which a party must take some action shall be computed from the date that the notice is
ny
r eceived by said party. Notice shall be provided to: CONTRACTOR:
KING COUNTY: Jefferson County Public Health
PHsKC
Roche Veronica K Shaw
401 'Fifth th Avenue, Suite 615 Sheridan
WA 98104 Port Townsend, 98368
Seattle,
Phone: (206) 263-8205 Phone: (360) 385 - 9437
XVII CONTRACT AMENDMENTS
Either party may request changes to this contract. Proposed changes, which are mutually agreed upon,
shall be incorporated by written amendments to this contract.
xVjII DEBARMENT AND SUSPENSION CERTIFICATION
Agencies receiving federal funds that are debarred, suspended, or proposed for debarment are excluded
if a
from contracting with the County, The Contractor, by signature to this Contract, certifies that the
Contractor is not presently debarred, suspended, or proposed for debarment by any Federal department
or agency. The Contractor also agrees that it will not enter into a subcontract with a contractor that is
debarred, suspended, or proposed for debarment. The Contractor agrees to notify King County in the
event it, or a subcontractor, is debarred, suspended, or proposed for debarment by any Federal
department or agency. For more information on suspension and debarment, see Federal Acquisition
Regulation 9*
)(jX COMPLIANCE WITH THE HEALTH INSURANCE PORTABILITY ACCOUNTABILITY ACT OF 1996
(HiPAA)
The Contractor shall not use protected health information created or shared under this Contract in any
manner that would constitute a violation of HIPAA and any regulations enacted pursuant to its
provisions. www Contractor shall read and certify compliance with all HIPAA requirements at
c t a
http1j . kingcounty,gov/healthservices/health/partnerships/ on r cts
XX APPLICABLE LAW AND FORUM
This Contract shall be governed by and construed according to the laws of the State of Washington,
including, but not limited to, the Uniform Commercial Code, Title 62A RCVS. Any claim or suit concerning
this Contract may only be filed and prosecuted in either the King County Superior Court or U.S. District
for the Western District of Washington, in Seattle.
Contract # PREV3163 Page# 9 of 10
XXI NO THIRD PARTY BENEFICIARIES
Except for the parties to whom this Contract is assigned in compliance with the terms of this
Contract, there are no third party beneficiaries to this Contract, and this Contract shall not impart
any rights enforceable by any person or entity that is not a party hereto.
KING cOUNTY: CONTRACTOR:
FOR
... _. ......... . . . ...... Co�rnt Executive Sign at e
i—L 1�i
.... .. .. ...
__N._a.m.e {Type
bate
Title Type 6r Print)
Xg
Date (Type or Print)
A prov d as to form only
'a
C
David Alvarez, Chief Civil"
Contract # PREV3163 Page # 10 of 1 0
Exhibit A
Scope of Work
JEFFERSON COUNTY PUBLIC HEALTH
PP
CLINICAL and CLC-I�NT 'SUORT SERVICES, OUTREACH & RECRUITMENT
July 1, 2013 through June 14, 2014
BACKGROUND
The Breast, Cervical, and Colon Health Program (BCCHP) helps eligible clients get
screened for breast, cervical, and colorectal cancers, and connects clients with diagnostic
services and treatment when needed. The program serves clients with low incomes and
who lack health insurance coverage for cancer screening, BCCHP improves access to
services, especially for people who face extra barriers to getting health care.
PURPOSE
Jefferson County Public Health will enroll BCCHP eligible clients and provide
recommended cancer screening services. They will refer BCCHP enrolled clients with
abnormal cancer screening results to other BCCHP contracted providers for appropriate
follow-up services. They will also use outreach activities outlined below to recruit clients
for the BCCHP.
SERVICES
Enrollment. Sjte-
Annual exam with Clinical Breast Exam (CBE)
Problem - focused visit
Pap tests
HPV tests
-LIGIBLE FVPT-L"A"7'�"'
�;omen - all services;
l
Breast screenipg & 9—�nua exam
--.---
or
35-39, if being seen for breast
symptoms, or
64+ if ineligible for Medicare
Priorit I for Mammo ra
Ages 50 or older, and last
mammogram -`f 2 years
Suspicious breast findings
Strong family history or other
high risk
At or below 250% of FE
Uninsured or Ulnderins
Washington
Cervical"
If last Pap normal & > 3 years or co-
testing (Pap normal and HPV
negative) > 5 years:
* 40-64
0 35-39, if being seen for breast
symptoms
"As per USPSTF 2012 Cervical Cancer
Screening Guidelines, If not eligible for Pap
Test, pelvic exam paid only if done as part of
visit for breast scirreninglannual eXan7
�l Poverty Level (FPL)*
(deductible over $500)
e Residents
*rr�ar rruograPh `aid breast �diagnosfic-sav—aOable to clients at or below 300% FPL
pRE'V3163 -- Ji0flef"airu (,ownty Pubfic Ideallh Paige 1 of 5
Some populations have lower screening and/or higher morbidity or mortality rates.
Jefferson will focus outreach and enrollment efforts on clients who'.
• Have never or rarely received breast or cervical services
• Are ages 50 or older (breast services) or 40-49 (cervical services)
• Are new to BCCHP
• Are from a racial or ethnic minority population, including African American, Asian,
Pacific Islander, American Indian/Alaskan Native, and Hispanic/Latina
• Are lesbian, gay, bisexual, or transgender
• Have a disability (as defined by the client)
• Have a strong family history or other high risk, including ages 40-49 for breast services
The contractor will obtain informed consent before performing services, and mail
completed enrollment and consent forms to BCCHP (within the timeframe listed below
under "reimbursement process").
#UTREACH and RECRUITMENT
Efforts should:
• Target clients who have never or rarely been screened
• Increase the percent of BCCHP clients from priority populations (described below)
• Reduce barriers to getting screening and primary care services
• Include cancer prevention messages
• Educate women about Medicaid support for treating breast and cervical cancer
• Raise community awareness about the importance of breast and cervical health
screening and prevention. Provide information about how and where to get these
services.
The contractor will:
Identify women eligible for BCCHP, especially in priority populations, and refer them
to providers for services. Motivate, assist and follow-up with clients who are rarely
screened or haven't seen a provider in years to help them obtain screening
services.
2 Work with clinic screening coordinators to schedule client appointments. Follow-up
to check that clients receive services and return for their next scheduled exam.
3 Provide information and referral about Medicaid programs, services and eligibility
requirements
4. Maintain HIPAA-regulated confidentiality of all BCCHP client data and medical
records concerning outreach clients.
5. Collect data about outreach activities.
6. Submit monthly data reports detailing outreach and education activities, using the
form provided by BCCHP. Include samples of any promotional materials for
activities performed, and write a descriptive paragraph including qualitative and
quantitative outcomes and challenges.
To recruit clients, the contractor may use strategies such as*
PREV31 63 __ Jefferson C
,()tjg�ty puraik Health Page 2 of 5
1 Identify communication networks for people in priority populations to find those who
may benefit from breast or cervical screening services. Refer them to appropriate
providers.
, Use a combinatio n of small group, one-to-one education, and media to educate,
2
encourage, and assist people in obtaining BCCHP services.
3. Use outreach & recruitment techniques appropriate for priority populations that are
developed with community input, including one-on-one education, group education,
and motivational interviewing. (Specific example: the BCCHP video presentation,
"Mammogram Screening -faking Care of Ourselves & Each Other.") Use these
strategies encourage and assist clients in obtaining appropriate cancer screening
tests or prevention education.
4. Work with Pubic Health to develop a local media plan targeting priority groups.
5, Assist Public Health in designing community awareness activities that are
appropriate for priority populations that encourage people to seek out
mammography, Pap tests, and other health care services.
clinical Services
The Contractor will: OH Performance Indicators:
Make best efforts to comply with CDC and D
Assist the client to complete the diagnostic work-up within 60 days of a
documented abnormal breast finding.
Assist the client to start breast cancer treatment within SO days of a
documented diagnosis of breast cancer or breast pre-cancer.
0 Assist the client to start cervical cancer treatment within 90 days of a
documented diagnosis of cervical cancer or pre-cancer.
Document attempts to contact each client for follow-up services per BCCHP
protocol. it is the contractor's rtan2n.�jbility to get clients in for timely follow-up.
Review and follow instructions in the Contractor's Procedure Manual, available at:
tiiaj/wwV. ki nqcou ntyAio v,/nh _ceaolthse, rvi ce s/h ea Ith/ch ro n icJbc hp /d own I oad s. asp)�
�
Document that administrative and health care personnel who work with BCCHP
clients review the DOH online BCCHP training modules that correspond to their
r/dolhmediia.d Lgb]L/
work, See: hjtR�..//d
��tjgI�.wa
Maintain HIPAA regulated confidentiality of all BCCHP client data and medical
records.
Provide effective, understandable, and respectful care to clients in their preferred
language, Make reasonable efforts to provide care that is compatible with clients'
cultural health beliefs and practices, and/or certificatio for all
Maintain documentation of current WA State ficensu re n
health care professionals who perform medical procedures under this contract.
Present documentation to BCCHP staff upon request.
Send a representative to the annual BCCHP mandatory meeting and a minimum of
two other meetings and/or trainings as scheduled by the DOH or Public Health.
Work with BCCHP staff to distribute educational materials, upon request.
PREV3163 — jefferson coumy Public Heafth Page 3 of 5
Client Support Services at Jefferson
T!je contractor WLIL
H
Track BCC P clients tO make sure they receive timely follow-up after abnormal breast
or cervical cancer findings. Monitor clients until they receive a diagnosis.
2, implement a re-screening reminder system for BC� Hl3, Document scheduling for appopriate followp tess and return appointments.
4. Review and give test results to clients in a timely manner,
5. Document all findings and send to Public Health,
outreach and Recruitment:
The Contractor will:
• Record outreach activities and report to BCCHP using the monthly outreach data form.
Complete the entire form each month.
• Provide written summaries on the data form to describe outreach efforts outside of the
clinic, including a list of educational materials, used and copies of any new materials
created (i.e. materials not created by BCCHP).
Clinical Services:
The Contra-ctOlwill.
Complete exam and reimbursement forms and, if applicable, diagnostic forms. Forms
•
are available online at: -j�galth/chronic/b �p
jLq ds.asp
ri c _/downloa
_j�ounjy, healthst[v
qov� �tces/l .0 .x
• Make best efforts to submit reimbursement forms to BCCHP at Public Health within 10
business �da s from the date of service. current BCCHP Fee
• Accept the amounts for CPT-coded services listed on the
Schedule.
• Certify that work to be performed under this contract does not duplicate any work to be
charged against any other contract, subcontract, or other funding source,
• Monitor funds spent and clients scheduled, to stay within the total budget.
In the case of any overpayment, contact BCCHP staff before taking any action to
discuss how to correct the error,
Review BCCHP-generated invoices promptly, and approve by mailing a signed original to
BCCHP.
BCCHP will not pay for services if we receive reimbursement forms later than 45 days from
the service date. We will evaluate exceptions on a case-by-case basis. We may impose
an earlier deadline to submit forms for June services, to achieve timely fiscal year-end
close out.
PV),EV3163 —jefferS,C)rl COLVIty pubhc� Heafth Page 4 cat :5
REIMBURSEMENT LIMITS:
not exceed the total bud eted contract amountI.Exhibit Bj,,
Pa' merit D-�
Exhibit B shows the t4a ticipated number of clients" (sometimes called "slots") that the
clinical funding may cover for each type of service. These are estimates based on
average historical costs per type of clinical service. Since costs may vary, these estimates
-Jeline to show a possible mix of services that the Contractor could provide
are only A-V wine w Exhibit B.
with total available funds, ELe���e
it 171
.%EIMBURSEMENT�,
outreach and Recruitment:
BCCHP at public Health will,
Pay the Contractor based on deliverables, as reported on the monthly outreach data
report,
0 $30 per new contact
o $5 per returning client
$50 per referral
$200 per completed monthly outreach data report, including narrative section
Limit payment to the amount of funding in the Contractor's budget (Exhibit B).
Reimbursement is Contingent upon BCCHP review and approval of deliverables.
Clinical Services:
BCCHP at public Health will:
provided within the corresponding contract period.
• Pay for services
• Send the current Fee Schedules for Breast an d Cervical Cancer Screening to the
Contractor, as well as any subsequent revisions. Revisions will replace earlier
versions.
0 pay for CPT-coded services at rates listed on the Fee Schedule. When applicable,
payment will include facility fee costs, as described on the Fee Schedule, We
reimburse clinic services at "Professional non-facility office" rates.
0 Pay for Client Support Services (case management) based on the BCCHP rate per
client enrolled and screened (Exhibit B).
• Monitor contracted funds.
• Generate monthly clinical services billing reports for the contractor, based on forms the
contractor submits. The reports will detail client names, dates of service, CPT codes,
and fees.
Create a monthly in voice from the billing reports and send to the Contractor to review
and approve. based on the approved invoice,
Pay the 'Contractor
The Contractor will not bill BCCHP clients for any differences between service
charges and BCCHP reimbursement.
Page 5 of 5
pj�EV3163 ,Unty pLIDIfic HeDith
Exhibit B: Budget
Jefferson County Public Health
615 Sheridan
Port Townsend, WA 98368
FTTII = =
2a BGHP
........... ....
Client
—N-7—T--
outreach and RecrtfilmenlCalegories
12
Monthly outreach reports, at $200 each
TBD
New contacts at $30 each
TBD
Returning clients, at $5 each
TBD
Referrals, at $50 each
Prev3163
reast l, and colon Health Progra
B I Cervical, m
Publ ic Health
401 Fifth Avenue, Suite 900
WA 93104-1818
Seattle & King County
Seattle,
Fax 206-296-0208
206-263-8206
Please review, sign, and MAIL this invoice
TTY Relay: 711
within 10 days of receipt
g 09—DIL-cLo�Llhg-a—llh
�_�I,pw kin -c
county public Health
Attention Scott Feet @ Address Above
Jefferson
Townsend, WA 98368
Call wl questions: TEL# 206-263-8175
615 Sheridan Port
CPA#
L i Mc cLu-D1Y=0 v
sq.ott.feest,@kir
Prev # 3163
Contract Period: 71112013 thru 6M412014
Exhibit C - Invoice
Period July 2013
Year 7 -2013 th ru 6.2014 Contract Status
Current Billing
Current
Contracted
Accumulated
Available
,Contracted LinelteMs
Ex2enses
Budget
Expense
Balance
$
$ 3,375.00
$ -
$ 3,375.00
B CHP clinical Services
BcCHP Client Support services
$
$
250M
$ —
$ 1,500.00
$ -
$ -
$ 250M
$ 1,500M -
�crujtrnent
Outreach and Re
D Annual M,eetin
BCCHF
$
$ 78.00 '
$ -
$ 78.00
1
Travel to
$
$ 5,203,001
$ -
$ 5,203.001
dotal
itemized above were incurred
for the period, July 22,013
I certify that the expenses
amount reflects as reasonably as possible, the contractual value of the expenses
and that the reimbursement
being charged.
X
Date
Co. fferson Public Health authorized signature
L-- 1print borne Below Siqnaturo
lease
011 �!! 1 111 P Health Department Use Only BELOW THIS LINE ---- - ----------------- - - - - --
B -
Org I project
Pay Current
Contracted
Accumulated Available
Expense summary 80010511045158
Budget
Expense Balance
101562
$
$ 3,375,00
$ $ 3,375.00
Federal BCCNP 101614
$
$ 1,828.00
$ $ 1,828.00
State BCCHP
$
$ $ -
Total OK-to-PaY
$ $ 5,203.00 $ $ 5,203=00
H SKC 8CCHP Monitor
............
Date
Contract 1 CPA 0
Invoice # Prev # 3163
Invoice Date
Total to Pa
P.O. # Receipt #
I#
E29-u����
PREV3163 - Jefferson County Public Health
.-AY/65i 7"
. .................
..........
. ................. .............
...................
..........
CONFERS NO RIGHTS 7 "ON THE CRIUDFICkrE HOLDSK
GE AFFORDED 13Y THE POLICY BEWW
r1ty Washington
Jefferson W son C , �
At= Lcslic LOCIce
PO Box 1.220
Port Townsend, WA 98368
Washington Counties Risk Pool
2558 R,W, Johnson Road SW, Suite 106
Tun titer, Washington 98512-6103
LL&J3TI-,ITY POLICY LISTED BELOW HAS BEEN ISSUEDTOTHE PARTICIPATING MEVBE,R,
THIS Is TO CER:ITFY'rHKr THE
NAIME�D ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR,
CONDITION 01., ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WI IC CERTIFICATE MAY BE
JS,SUFD OR MAY pE.RTAIN, THE COVERAGES AFFORDED BY THE POLICY DESCRIBED HEREIN 13 SUBJECTTOALI.
THE'rERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY.
PoTicy NumnRz
pol,ICY EFFECTIVE DATE:
pol,lCy FXPIRATION DAM
LE91TS OF LIABILM EACH OCCURRENCE
BI ANT) PD CONIBLNED,
Imludiftg�
Including:
201.22013-R,ISKPOOL-JFCO
October 1, 2012
October 1, 2013
10'000MOM
General Liability
Bodily lqjury
Personal Injury
Property Damage
Errors and 0mmissions/Professional
Advertising Injury
Contractual
Automobile Liability
Owned, nonowned and hired autos
ianr�n ...... I .........
X
SHOULD THE ABOVF DESCRIBED POLICY BE CANCELED
Covers ail JefTcrson County Employees BEFORE THE EXPIRATION DATE TI o I TIM IS SUFM WITA,
E MEAVOR TO MAII, 30 DAYS WRITTLN N011CRTO THE
Agreement to provide breast and cervical health CERTMCATE HOLDER, BUT FAILURE TO MAIL, SUCII NOTICE
care prograrm: Kilig County SKOUL IMPOSE Na OHLIGATION OR 11ABILITY OF ANY KIND
I)uring th . 0 policy period 10/01/12- 10/01113
Seattle-Kirtg County Dept ()f Public Health
alca Public Health - Seattle & King County
...........
Claims Assistant
f_,,xhibit E — Special Ternis and Conditions
This Contract is funded in whole or in part by the LIS Government, throiigh the Wash inglon State
Department of Health �5 COM50jida-ted Contract with Public Health-Seattle & Kind County, D011 Contract
I'Ve), 06898. In addition to King County's general terms and conditions, the Contractor shall also comply
with the terms and conditions of theftinder and the federal certffleettions and assurances in this Exhibit.
STANDARD FEDERM, CERTIFICATIONS AND ASSURANCES
hollowing are the Assurances, certifications, and Special Conditions that apply to all federally funded (in whole or in
part) agreernents adniinistered by the Washington State Department of fiealth.
I. FEI)ERAI., CIRCULARS' The following compliance rnatrix identifies the Office of Managernent and Budget's
Circulars that contain the requirements which govern expenditure of federal funds. These requirements apply to
the I)epartnient of I-lealth and then follow the funds to the subrecipient. "I'lle, federal Circulars which provide the
applicable administrative requirements, cost principles and audit requirements are identified by subrecipient
organization type-
C'C' ,VP L 1A NCE IWA TR IX
. ........ — — -----
OMB CIRCULAR
... ..... . ..... . .
. ....
....... .... . .......
..... .
ADMINISTRA,rivE
COST PRINCIPUS
AUDIT REQUIREMENTS
ENTITY TYPE ICE -',qj�lR..l`1MENTS
. . . .... ........
State, I-ocal and Indian
A-102 & Cornrnon Rule
A�
A-87
A-133
. Rr
Tribal (10vernn"ellts
(jovernnAerltal 1-10spitals
. .. . ......
. ..... . . . ......
�"Ons
Non-Profit Organizations A-] 10
A-122
A-133
s
& N,cji.-Profil hospitals
oiluges or Universities A-1 10
A-21
A-133
& Affiliated Hospitals . . . . . ........
. . ..... – — --------
. . .......... .
2. CERTIFICATION RE, GARDING DRUG -'FREE W ORKPI.AC E R EQUIREMEN'rs
j,he contractor certifies that the Contractor will, or will continue to, provide a drUg-free workplace in accordance
,,,vith 45 Cl" p- Par, 76 by:
a) Publishing a statement notifying ernployees that the unlawful rnanUfaCtUre, distribution, dispensing, possession
or use of a controlled substance is prohibited in the grantee's workplace and specifying the actions that will be
taken against el,111)joyees for violation ofI 'such prohibition;
b) J.sstabhsl-jing an ongoing drug-free awareness prograrn to inforrn ernployees about
(1) The dangers of drug abuse in the workplace;
(2) The contractor's policy of niaintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance prograrns; and
(4) "rhe penalties that nlay be irnposed Up0fj eniployees for drug abuse violations occurring in the workplace;
c) Making it a requ rern I ent that each ernployee to be engaged in the perforaiance of the contract be given a copy
of tyre statellient requwed by paragraph (a) above;
N f;V3l63 jefferSon COU11ty Public Health
F'xhlbit E ... Special Ternis and Conditions
d) Notifying the employee in the statement required by paragraph (a), above, that, as a condition of employment
Under the contract, the employee will—
(1) Abide by the terrns of the statement; and
(2) Notify the employer in writing of his or her conviction for a violation of a criffinnal drug statute occurring
in tile v,vorkplace no later than five calendar days after such conviction;
C) Notifying the agency in writing within ten calendar days after receiving notice tinder paragraph (d)(2) from an
ernployee or otherwise receiving actual notice of such conviction. Employers of convicted employees must
provide notice, jjjclLndijjg position title, to every contract officer or other designee on whose contract activity
tile convicted employee was working, unless the Federal agency has designated a central point for the receipt
01, such notices. Notice shall include the identification number(s) of each affected grant;
f) Taking one Of the following actions, within 30 calendar days of receiving notice under paragraph (d) (2), with
respect to any employee Who is so convicted
(1) 'Taking appropriate personnel action against such an employee, up to and including termination, consistent with
the requireincllts of the Rehabilitation Act of 1973, as amended; or
(2) Requiring such ernployee to participate satisfactorily in a drug abuse assistance or rehabilitation program
.Hach purposes by a Federal, State, or local health, law enforcement, or other appropriate
,jpprovcd for s
agency;
910 Making a good faith effort lo continue to maintain a drug-free workplace through irnplementatioll of
paragraplls ([,), (b), (c), (d), (e), and (f),
For purposes of paragraph (e) regarding agency notification of criminal drug convictions, D01-I has designated
tine following central point for receipt of such notices:
Compliance and Internal Control Officer
()free of Grants Manager rent
WA State I)epartnient Of Healtli
PO Box 47905
()lynipia, WA 98504-7905
3. Cj�R'VIFICNTION REGARDING LOBBYING ,
Title 31, United Slates Code, Section 1352, entitled "Limitation On use of appropriated funds to influence certain
Federal contracting and financial transactions," generally prohibits recipients of Federal grants and cooperative
agreernents front using Federal (appropriated) funds for lobbying the Executive or Legislative Branches of the
l-'cderal Govel-11ment ill connection with a SPECIFIC grant or cooperative agreement. Section 1352 also requires
that each person who requests or receives a Federal grant or cooperative agreement must disclose lobbying
Lill dertake n with non-Federal (nonappropriated) funds, These requirements apply to grants and cooperative
` XCEEj-
agreements I )ING $joo,000 in total costs (45 CFI Part 93).
The Contraclor certifies, to the best of Ills or her knowledge and belief, that:
m No Federal appropriated funds have been paid or will be paid, by or on behalf of the Contractor, to ally person
for influencing or afternPling to influence an officer or employee of any agency, a Member of (,ongrerss, all
officer or employee of Congress, Or an employee of Member of Congress in connection with the awarding of'
any Federal contract, the making of any Federal grant, the making ofany Federal loan, the entering into ofany
cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal
corltrac 't, grant loan, 0,1 - cooperative agreement.
,
1) JUEV3 163 - Jefferson COL"ItY ic Health
t�xhibit E — Special Terms arid Conditions
(2) if any funds other than Federally appropriated funds have been paid or will be paid to any person for
ii-iflLLencing or attempting to influence an officer or ernployee of any agency, a Member of Congress, an officer
or ernPl0Y'ee of Congress, or an employee of a Member of Congress in corujectiolj with this Federal contract,
grant, loan, o cooperative agreement, the Contractor shall complete and subrnit Standard Forrn-LLL,
r
"Disclosure of Lobbying Activities," in accordance with its instructions. (If needed, Standard Forril-LU,
11� � . 1 10 . a
"Disclosure of Lobbying Activitles, Its instructions, and continuation sheet are included at the end of this
applicatioll foam.)
or shall require that the language of this certification be included in the award documents for all
(3) The Contract at all tiers (including subcontracts, subcontracts, and contracts Linder grants, loan,,, and
cooperative agreements) and that all subrecipients shall certify arid disclose accordingly.
,,,his - a] representation of fact upon which reliance was placed when this
certification is a materi
made or entered into. Submission of this certification prerequisite for making or
transaction was ails to F
entering into this transaction imposed by Section 1352, US. Code. Any person who f, Ile the
required certification shall be subJect to a civil penalty of not less than $10,000 and not more than
$ 100,00,0 for each such failure.
4. CERTIFICATION REGARDING PROGRAM FRAIJD CIVIL REMEDIES ACT (PFCRA)
The Contractor certifies that the staterrients herein are true, complete, statements bhoknow'ledge, and that lie or she is aware that any false, fictitious, or fraudulent or clainis may subject hirn
nal civil, or administrative penalties, The Contractor agrees that the contracting organization will
or her to crl"n! , Ith Service terms arid conditions of award if a contract is awarded.
comply with the Public Hea
5. CERTIFICATION REGARDING ENVIRONMENTAL, TOBACCO SMOKE
public Law 103-227, also known as the Pro-Children Act of 1994 (Act), requires that smoking not be permitted in
any portion of any indoor facility owned or ]eased or contracted for by an entity and used routinely or regularly for
the provision (
)fhealth, (Jay care, early childhood development services, education or library services to children
of, I g, if tile services are funded by Federal prograrns either directly or through State or local
tinder tile age
g by Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that
�'oVer nrnents� 001' facilities that are constructed, operated, or rnaintained with such Federal funds. The law
are provided in indoor s provided in private residence, portions of facilities used for inpatient drug or
does not apply to children's services
alcohol treatment, service providers whose sole source of applicable Fe cleral funds is Medicare or Medicaid, or
facilities where WIC COtIP011 s are redeemed,
F,a,lure to comply' with the provisions of the law may result in the imposition of a civil monetary penalty of Lip to
S1,000 for each violation and/or tile imposition of an administrative compliance order on the responsible entity.
Contractor certifies that tjje contracting organization will comply with the requirements of the Act and will not
allow sliloknIg within any portion of any indoor facility used for the provision of services for children as definecl
by tile Act,
Contraeting, organization agrees that it will require that the language of this certification be included in any
g -
ibconlracts \vInch contam provisions for children's services and that all subrecipients shall certify accordingly.
Services (pl-IS) strongly enCOUrages all recipients to provide a snloke-free workplace and
-File Public Health ProduCt strongly is consistent with the PHS mission to protect and advance the
Promote tile rjon-use of tobacco S .
pilysical and mental ,call[, of tile American people.
1'REV3 163 — Jefferson County Public Health
E Special Terrns and Conditions
ASSURANCES — NON CONSTRUCTION PROGRAMS
Public reporting burden for tins collection of information is estimated to average 15 minutes per response„ including
time for reviewing instructions. searching! existing data sources, gathering and maintaining the data needed, and
completing, and reviewing the Collection of information. Send cornments regarding the burden estimate or any other
nJspect, Of this collection of infc)rrnation, includin1g, suggestions for reducing this burden, to the Office of Nianagement
and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503
PLEASE DO NOT RETURN YOUR COMPLE TED FORM TO THE OFFICE OF MANAGEMENT AND
BIJI)GIJ.
Note: Certain of these assurances may not be applicable to your project or prograrn. if you have questions, please
contact the awarding, agency. Further, certain Federal awarding agencies may require applicants to certify to
additional assurances, If sLich is the case, you will be notified,
As the Chfly authorized representative of the contractor, I certify that the Contractor:
1, Has the legal authority to apply for Federal assistance, arid the institutional, managerial arid 11nancial capability
(including funds sUfflCient to pay the non Federal share of project cost) to ensure proper planning, management, and
completion of tile project described in this application.
2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State., through
any lauthOri'zed representative, access to and the right to examine all records, books, papers, or documents related to
the award; and will establish a proper accounting system in accordance with generally accepted accounting standards
or agency directives.
3. Will establish safeguards to prohibit eMployees from using their positions for a PLIrPOSe that constitute-5 or presents
the appearance of personal or organizational conflict 011 interest, or personal gain.
4. WHi initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.
5. Will cornply will, tile Intergovernmental Personnel Act of 1970 (42 U.S.C. 4728-4763) relating to prescribed
standards for merit systems for programs funded Linder one of the 19 statutes or regulations specified in Appendix A
of OpM,s Standard-, for a MCI-it System of Personnel Administration (5 CT,R. 90'0, Subpart F),
6. Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title V1
of tile (,ivil Rights Act Of 1964 (P,I,, 88-352) which prohibits discrimination on the basis of race., color or national
origin, (b) Title IX of tile Education Amendments of 1972, as amended (20 U.S.C. 1681-1683, and 1685-1686),
which prohibits di sci,i nli nati,oll on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as arnended (29
tj,S.C. 794), wilich prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as
-6107), which prohibits discrimination oil the basis of age; (e) the Drug Abuse Office arid
ainended (42 US 6101 1 o nondiscrimination on the basis of drug abuse; (f) the
`l-reatinent Act of 1972 (11,L 92-25-55), as amended, relating t
Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1.970 (Rl— 91-61(r),
as amended, relating to nondiscriniination on the basis of alcohol abuse or alcoholism; (g) 523 and 527 of the Public
1-lealth Service Act of 1912 (42 JJ.S.C. 290 dd-3 and 290 ee 3), as amended, relating to confidentiality of alcohol and
drug abuse patient records; (it) J'itle Vill of the Civil Rights Act of 1968 (42 U.S.C. 3601 et seq.), as amended,
relating to nondiscripriiination ill the sale, rental or financing of'housing; (i) any other nondiscrimination provisions in
the specific StatLitC(s) under which application for Federal assistance is being made; and 0) the requirements of any
riondiscriftli"MiOn st,atute(S) which rllay apply to the application,
pl� F'N3163 _,lefferSon (,oUnty Public Health
i�;xhlbit ' -.,- Special Terrns and Conditions
7, will comply, 01' has already conlplied.� with the requirements of Titles 11 and III of tile uniform Relocation
Assistarice and Real property Acquisition Policies Act of' 1970 (P,I,, 91-646) which provide for fair and equitable
treatrilent of persons displaced or whose property is acquired as a result of Federal or federally assisted programs.
'I'hese requirements apply to all interests in real property acquired for project purposes regardless of' Federal
participation in purchases.
Will comply, as applicable, with the provisions of the 1 -latch Act (5 U.S.C. 1501-1508 and 7324-7328) which lirnit
tile political activities of employees whose principal employment activities are funded in whole or in part with
Federal fundsa
9. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. 276a to 276a-7), the Copeland
Act (40 U.S.C, 276c and 18 U SC. 874) and the Contract Work Hours and Safety Standards Act (40 U-S-C, 327-
333), regarding labor standards for federally assisted construction subagreernents.
10, will Comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (11.1— 93--234) which requires recipients in a special flood hazard area to participate in the
program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or
more.
11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of
environmental quality control Measures, tinder the National Environmental Policy Act of 1969 (RI.- 91-190) and
F. O) 11514; (b) notification of violatifig facilities pursuant to EO 11738; (c) protection of
', ectitive Order (F
wetlands pursuant to EO 1 199x; (d) evaluation of flood hazards in floodplains it) accordance with EO 11.988; (e)
a,ssurance Of Project consistency with the approved State management program developed under tile Coastal Zone
6 U.S.(". 1451 et seq.); (f) conformity of" Federal actions to .State (Clear Air)
tvianagernent Act of 1972 (1 1
linplementati011 plans under Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. 7401 et seq.);
(g,) p rotection o f underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended,
(P.L 93-523); and (11) protection of` endangered species under the Endangered Species Act of 1973, as amended,
(p,1_ 93-205),
12 NV,ll comply with thc Wild and Scenic Rivers Act of 1968 (16 U&C. 1721 et seq.) related to protecting,
components or potential contpolleylts of the national wild and scenic rivers system.
13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act
of 1966, as amended (16 U.S.C. 470), EO 11593 (identification arid protection of historic properties), and the
Archaeological and I-lis�tol-ic Preservation Act of 1974 (16 l,J,S,C. 469a-I et seg.).
With P,L 93-348 regarding the protection of human sub�pects involved in research, development, arid
M Will Comply I
related activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L 89-544, as amended, 7 U.S.C, 2131 et seq,)
pertaining to tile care, handling, and treatment of warm blooded animals held for research, teaching, or other
activities supported by this award of assistance.
Will comply with the Lead-Based Paint poisoning Prevention Act (42 US.C, 4801 et seq.) which prohibits the use
16, or rehabilitation of" residence Structures,
of lead- based paint in coils
1?, \Vill cause to be ped'ormed the required financial and compliance audits in accordance with tile Single Audit Act
Amendments of 1.996 and OMB Circular No. A-133, Audits of' States, Local Governments, and Non-Profit
Organizat ions.
1ap,FV3 163 .- Jeffersoll County Ptl )"c I I ealth
i,"xhibit E — Spfcial TerMs and Conditions
IS. Will comply with all applicable requirerneiits of all other F'ederal IaWS, eXeCLJtiVC orders, regulatius mid policies
governing this program.
I)R[",'V31 63 - - Jeffersor, Courity Public I lealth