HomeMy WebLinkAbout071414_ca06Consent Agenda
JEFFERSON COUNTY PUBLIC HEALTH
` 615 Sheridan Street o Port Townsend o Washington o 98368
�'SHir�1°
www.jeffersoncountypublichealth.org
14
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: Jean Baldwin, Director
DATE: -7 //�
SUBJECT: Agenda Item — Agency Agreement — Early Intervention Program (EIP)
#1463 -15228 with Department of Social and Health Services; July 1,
2014 — June 30, 2015; $36,623.04
STATEMENT OF ISSUE:
Jefferson County Public Health is requesting Board approval of the Agency Agreement — Early Intervention
Program (EIP) #1463 -15228 with Department of Social and Health Services; July 1, 2014 — June 30, 2015;
$36,623.04
ANALYSIS/ STRATEGIC GOALS /PRO'S and CON'S:
Jefferson County Public Health has contracted with Department of Social & Health Services, Division of
Children & Family Services, to provide Early Intervention Services since 1990. This contract provides
services to families referred by Children's Administration, Child Protective Services, for public health nurse
interventions. Under this agreement, DSHS contracts with JCPH to provide services for families at
moderately low risk of abuse or neglect. Services include direct services to families or link families to
community resources to accomplish the following goals: reduce risk by enhancing parenting skills and self-
sufficiency; reduce stress on the family; enhance the health status of families through linkages to health
services, through assessment and identification of risk factors, through education, through information
sharing and referrals, and through other public health services.
FISCAL IMPACT /COST BENEFIT ANALYSIS:
The funding covers all program costs. There is no general fund support in this program.
RECOMMENDATION:
JCPH management request approval of the Agency Agreement — Early Intervention Program (EIP)
#1463 -15228 with Department of Social and Health Services; July 1, 2014 — June 30, 2015; $36,623.04
REVIEWED BY.
Philip Morley, C unty Administrator
Date
661:�A'
COMMUNITY HEALTH PUBLIC HEALTH ENVIRONMENTAL HEALTH
DEVELOPMENTAL DISABILITIES WATER QUALITY
MAIN: (360) 385 -9400 ALWAYS WORKING FOR A SAFER AND MAIN: (360) 385 -9444
FAX: {360) 385 -9401 HEALTHIER COMMUNITY FAX: (360) 379 -4487
Appro as form only.
DSHS Central Contract Services
2048CS EIP County (5- 13 -14) k � 3o I Page 1
JCI'ferson Co. PTOSCCIItOt� we
David Alvarez, Chief Civil DPA
DSHS Agreement Number
COUNTY PROGRAM AGREEMENT
1463 -15228
Washiry ion SWIG
'A'e, E A H
lRr7�P"_3' SE R 10ESTH
Early Intervention Program (EIP)
This Program Agreement is by and between the State of Washington Department of
Program Agreement Number
Social and Health Services (DSHS) and the County identified below, and is issued in
0603 -
conjunction with a County and DSHS Agreement on General Terms and Conditions,
County Agreement Number
which is incorporated by reference.
DSHS ADMINISTRATION
DSHS DIVISION
DSHS INDEX NUMBER
DSHS CONTRACT CODE
Childrens Administration
Division of Children and Family
1223
2048CS -63
Services
DSHS CONTACT NAME AND TITLE
DSHS CONTACT ADDRESS
Dianne Thompson
11949SO. State St., MS: N27- 33Tacoma, WA 98405 -
Regional Contracts Manager
DSHS CONTACT TELEPHONE
DSHS CONTACT FAX
DSHS CONTACT E -MAIL
253 983 -6266
(253)983-6433
thompdi@dshs.wa.gov
COUNTY NAME
COUNTY ADDRESS
Jefferson County
615 Sheridan St
Port Townsend, WA 98368 -
COUNTY FEDERAL EMPLOYER IDENTIFICATION NUMBER
COUNTY CONTACT NAME
Julia Danskin
COUNTY CONTACT TELEPHONE
COUNTY CONTACT FAX
COUNTY CONTACT E -MAIL
360 385 -9420
360 385 -9401
jdanskin@co.jefferson.wa.us
IS THE COUNTY A SUBRECIPiENT FOR PURPOSES OF THIS PROGRAM
CFDA NUMBERS
AGREEMENT?
No
PROGRAM AGREEMENT START DATE
PROGRAM AGREEMENT END DATE
MAXIMUM PROGRAM AGREEMENT AMOUNT
07101/2014
1 06/30/2015
$36,623.04
EXHIBITS. 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 — Data Security Requirements; Exhibit B— Statement of Work; Exhibit C — Program
Requirements; Exhibit D— Exit Code Definition; and ❑- Exhibit E — Budget
Contract Purpose; The purpose of these services is to control threats to child safety so children can remain safely in their
own homes, while continuing to support 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 threats
• Work to increase safe parenting skills; and
• Require immediate communication with the Children's Administration about safety threats to the child.
By their signatures below, the parties agree to the terms and conditions of this County Program Agreement and all
documents incorporated by reference. No other understandings or representations, oral or otherwise, regarding the
subject matter of this Program Agreement shall be deemed to exist or bind the parties. The parties signing below certify
that they are authorized to sign this Program Agree nt,
COUNTY SIGNATURE(S)
PRINTED NAME(S) AND TITLE(S)
DATE(S) SIGNED
DSHS SIGNATURE
PRINTED NAME AND TITLE
DATE SIGNED
Dianne E. Thompson, Contracts Manager /Monitor
Appro as form only.
DSHS Central Contract Services
2048CS EIP County (5- 13 -14) k � 3o I Page 1
JCI'ferson Co. PTOSCCIItOt� we
David Alvarez, Chief Civil DPA
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. "Authorized User(s)" means an individual or individuals with an authorized business requirement to
access DSHS Confidential Information.
e. "Case" means a family for which a risk of abuse or neglect has been determined and the family is
open to CA services.
"CA" means Children's Administration, which is an Administration within DSHS.
g. "CA/ EIP Liaison" means the CA staff person who is responsible for maintaining contact with the
Contractor and coordinating EIP services in the region.
h. "CFWS " means Children and Family Welfare Services, a program under CA.
i. "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.
j. "Client" means any child or adult who is authorized services by DSHS.
k. "Community Resources" means community supports and concrete services.
I. "Community Resource Directory" means a list of local resource agencies or individuals that provide
supports for families.
m. "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.
n. "Contract" means the entire written County Program Agreement between DSHS and the Contractor,
including any Exhibits, documents, and materials incorporated by reference.
o. "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.
p. "Corporal Punishment" means any act that willfully inflicts or causes the infliction of physical pain on
a child.
DSHS Central Contract Services
204SCS EIP County (5- 13 -14) Page 2
Special Terms and Conditions
q. "Corrective Action Plan" means a written plan approved by DSHS which identifies deficiencies in
Contractor's performance, describes the steps Contractor must take to correct the deficiencies, and
sets forth timeframes within which such steps must be taken to return Contactor to compliance with
the terms of the Contract.
r. "CPS" means Child Protection Services, a program under CA.
s. "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.
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. "Hardened Password " means a string of at least eight characters containing at least one alphabetic
character, at least one number and at least one special character such as an asterisk, ampersand
or exclamation point.
y. "KBS" means Knowledge, Behavior, and Status which is the problem rating scale for outcomes
within the Omaha System.
z. "LEP" means Limited English Proficiency, and indicates an individual's need for additional support
and assistance in comprehending the English language.
aa. "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.
bb. "Participation" means family participation in one or more of the services outlined in the Family
Service Plan.
cc. "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.
dd. "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.
ee. "Unique User ID" means a string of characters that identifies a specific user and which, in
conjunction with a password, passphrase or other mechanism, authenticates a user to an
information system.
DSHS Central Contract Services
2048CS EIP County (5- 13 -14) Page 3
Special Terms and Conditions
2, Data Security Requirements — Exhibit A. The Contractor shall protect, segregate, and dispose of
data from Children's Administration as described in Exhibit A, as required in the Section below entitled
Secure Management of Confidential Information.
3. Statement of Work — Exhibit B. The Contractor shall provide services and staff as described in the
Statement of Work attached as Exhibit B.
4. Program Requirements -- Exhibit C. 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 C.
S. Exit Code Definitions — Exhibit D. The Contractor shall utilize the Exit Code Definitions when
documenting case closure with a family, attached as Exhibit D.
6. Budget — Exhibit E. If Exhibit E— Budget is checked on page 1 of the Contract, and Consideration
Section 8 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 E. Funds may be
transferred between budget line items of the Contractor's Budget subject to the following conditions:
a. Transfer of funds up to 10% of the budget line item must be requested in writing by the Contractor
and may be made without amending this Contract;
b. Transfer of funds that exceeds 10 %Q of the budget line item shall require a written amendment to
this Contract for to the transfer of funds between budget line items.
7. Secure Management of Confidential Information
The Contractor shall ensure that all Confidential Information (also referred to as Personal
Information) as defined in the General Terms and Conditions Section 1, acquired under this contract is
used only for the provision of services under this contract and is handled with the utmost confidentiality
as described in the General Terms and Conditions, Section 6, Confidentiality. In addition:
a. Contractors have permission to use mobile devices under this contract and shall ensure that mobile
devices and data are accessed and protected as described in Exhibit A- Data Security
Requirements.
b. Failure to comply with applicable requirements may result in termination of this contract.
8. 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 $36,623.04.
b. Allocated Funds. Allocatted funds not expended during the period ending on June 30, 2015 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 shall be adjusted accordingly and
incorporated into this Contract as of the date the new rate becomes effective,
d. Rate of Pa ment. DSHS will pay Contractor:
(1) DSHS will pay Contractor for actual costs related to services provided to CA referred families
during the period of this Contract.
DSHS Central Contract Services
2048CS EIP County (5- 13 -14) Page 4
Special Terms and Conditions
9. Billing. The Contractor shall submit the following documents, prepared in the manner prescribed by
DSHS, to invoice services performed under this Contract:
DSHS may choose to pay the Contractor for services under this Contract through FamLink as an
alternative method to the invoice billing process, described below. The Contractor shall be notified in
writing of any change in the billing process.
a. A -19_ Imo• 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, 1463-
15228 FOR THE MONTH OF , 20
(4) The A -19 invoice shall be submitted to:
Veronica Hinojosa, EBP Program Manager
Children's Administration
Region 3
1949 South State Street, MS: N27 -1
Tacoma, WA 98405-
(5) The Contractor shall contact Veronica Hinojosa at (253) 983 -6324 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.
10. Payment
a. Claims for payment must be received by DSHS no later than sixty (60) days from the date services
were rendered.
b. CA will not be obligated to pay for services submitted more than three (3) months after the calendar
month in which the services were performed.
c. DSHS will make payment within thirty (30) days of receipt of a properly completed invoice for
services.
d. 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.
e. DSHS may, at its sole discretion, withhold or deny payment claimed by the Contractor for services
DSHS Central Contract Services
2048CS EIP County (5- 13 -14) Page 5
Special Terms and Conditions
rendered if Contractor fails to satisfactorily comply with any term or condition of the Contract.
11. Subcontracting.
Except as otherwise provided in this Contract, the Contractor shall not subcontract any of the
contracted services without the prior approval of DSHS. Contractor is responsible to ensure that all
terms, conditions, assurances and certifications set forth in this Contract are included in any and all
Subcontracts. Any failure of Contractor or its subcontractors to perform the obligations of this Contract
shall not discharge the Contractor from its obligations hereunder or diminish DSHS's rights or remedies
available under this Contract.
12. 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 shall pay only for services authorized and provided
through the date of termination.
13. 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 Billin . 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. aqppLantinq. 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.
14. 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.
15. 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.
16. 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
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
DSHS Central Contract services
2048CS EIP County (5- 13 -14) Page 6
Special Terms and Conditions
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.
17. Investigations of Contractor or Related Personnel
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 employee or
volunteer of the Contractor or a subcontractor, is investigated by DSHS or 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 the subject of the
investigation, whether an employee, volunteer, 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.
18. Removal of Individuals from performing Services
a. In the event that any of Contractor's employees, subcontractors, or volunteers who provide services
under this Contract do not meet qualifications required by this Contract or do not perform the
services as required in this Contract, DSHS may require that Contractor assure DSHS that such
individual will not provide services to DSHS clients under this Contract.
b. DSHS shall notify the Contractor of this decision verbally and in writing and the Contractor shall,
within 24 hours, disallow that person from providing direct services to DSHS clients. Failure to do so
may result in a Corrective Action Plan and possible suspension or termination of this Contract.
19. Compliance with Corrective Action Plan
In the event that DSHS identifies deficiencies in Contractor's performance under this Contract, DSHS
may , at its option, establish a Corrective Action Plan. When presented with a Corrective Action Plan,
Contractor agrees to undertake the actions specified in the plan within the timeframes given to correct
the deficiencies. Contractor's failure to do so shall be grounds for termination of this Contract.
20. 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
F-1 The Contractor maintains the types and amounts of insurance identified below and
shall, upon request, provide certificates of insurance to that effect to the DSHS Contact
on Page 1 of this Contract.
DSHS Central Contract Services
2048CS EIP County (5- 13 -14) Page 7
Special Terms and Conditions
c. The Contractor shall ensure that all subcontractors providing client services under this Agreement
meet the insurance requirements specified below.
21. Insurance Requirements
For the purpose of this section, the term "Contractor" as used in the following provisions shall mean the
Contractor and its subcontractors, and the term "Contract" shall mean this Agreement and the
Contractor's subcontract with a subcontractor.
The Contractor shall ensure that all subcontractors have and maintain insurance with the following
types and limits of coverage. The Contractor shall maintain copies of Certificates of Insurance for each
subcontractor as evidence that each subcontractor has and maintains insurance as required by this
Agreement.
a. 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), its elected
and appointed officials, agents, and employees of the state, shall be named as additional insureds.
In lieu of general liability insurance mentioned above, if the contractor is a sole proprietor
with less then three contracts, the contractor may choose one of the following three general
liability policies but only if attached to a professional liability policy, and if selected the
policy shall be maintained for the life of the contract:
Supplemental Liability Insurance, including coverage for bodily injury and property damage that will
cover the contractor wherever the service is performed with the following minimum limits: Each
Occurrence - $1,000,000; General Aggregate - $2,000,000. The State of Washington, Department
of Social & Health Services (DSHS), its elected and appointed officials, agents, and employees
shall be named as additional insureds.
or
Workplace Liability Insurance, including coverage for bodily injury and property damage that
provides coverage wherever the service is performed with the following minimum limits: Each
Occurrence - $1,000,000; General Aggregate - $2,000,000. The State of Washington, Department
of Social & Health Services (DSHS), its elected and appointed officials, agents, and employees of
the state, shall be named as additional insureds.
or
Premises Liability Insurance and provide services only at their recognized place of business,
including coverage for bodily injury, property damage with the following minimum limits: Each
Occurrence - $1,000,000; General Aggregate - $2,000,000. The State of Washington, Department
of Social & Health Services (DSHS), its elected and appointed officials, agents, and employees of
the state, shall be named as Additional Insured.
b. Business Automobile Liability Insurance
If a Contractor transports DSHS clients, the Contractor shall maintain a Business Automobile Policy
DSHS Central Contract Services
2048CS EIP County (5- 13 -14) Page 8
Special Terms and Conditions
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.
c. 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.
d. Worker's Com ensation
The Contractor shall comply with all applicable Worker's Compensation, occupational disease, and
occupational health and safety laws and regulations. The State of Washington and DSHS shall not
be held responsible for claims filed for Worker's Compensation under RCW 51 by the Contractor or
its employees under such laws and regulations.
e. Employees and Volunteers
Insurance required of the Contractor under the Contract shall include coverage for the acts and
omissions of the Contractor's employees and volunteers. In addition, the Contractor shall ensure
that all employees and volunteers who use vehicles to transport clients or deliver services have
personal automobile insurance and current driver's licenses.
f. Subcontractors
The Contractor shall ensure that all subcontractors have and maintain insurance with the same
types and limits of coverage as required of the Contractor under the Contract.
g. Separation of Insureds
All insurance policies shall include coverage for cross liability and contain a "Separation of
Insureds" provision.
h. Insurers
The Contractor shall obtain insurance from insurance companies identified as an admitted
insurertcarrier in the State of Washington, with a Best's Reports' rating of B + +, Class VII, or better.
Surplus Lines insurance companies will have a rating of A -, Class VII, or better.
i. Evidence of Coverage
The Contractor shall, upon request by DSHS, submit a copy of the Certificate of Insurance, policy,
and additional insured endorsement for each coverage required of the Contractor under this
Contract. The Certificate of Insurance shall identify the Washington State Department of Social and
Health Services as the Certificate Holder. A duly authorized representative of each insurer,
showing compliance with the insurance requirements specified in this Contract, shall execute each
Certificate of Insurance.
The Contractor shall maintain copies of Certificates of Insurance, policies, and additional insured
endorsements for each subcontractor as evidence that each subcontractor maintains insurance as
required by the Contract.
DSHS Central Contract Services
2048CS UP County (5- 13 -14) Page 9
Special Terms and Conditions
j. Material Changes
The insurer shall give the DSHS point of contact listed on page one of this Contract 45 days
advance written notice of cancellation or non - renewal. If cancellation is due to non - payment of
premium, the insurer shall give DSHS 10 days advance written notice of cancellation.
k. General
By requiring insurance, the State of Washington and DSHS do not represent that the coverage and
limits specified will be adequate to protect the Contractor. Such coverage and limits shall not be
construed to relieve the Contractor from liability in excess of the required coverage and limits and
shall not limit the Contractor's liability under the indemnities and reimbursements granted to the
State and DSHS in this Contract. All insurance provided in compliance with this Contract shall be
primary as to any other insurance or self - insurance programs afforded to or maintained by the
State.
1. Waiver
The Contractor waives all rights, claims and causes of action against the State of Washington and
DSHS for the recovery of damages to the extent said damages are covered by insurance
maintained by Contractor
22. 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 below, in the section titled "Disputes ".
A copy of the regional conflict resolution process is available from the DSHS Contact person listed on
Page 1 of this Contract.
23. 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
DSHS Central Contract Services
2048CS EIP County (5-13-14) Page 10
Special Terms and Conditions
P.O. Box 45710
Olympia, WA 98504 -5710
This dispute resolution process is the sole administrative remedy available under this Contract.
24. 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;
• 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:llwww1.dshs.wa.govlpdf /publications /22- 1108.pdf"
25. 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.
DSHS Central Contract Services
2048CS EIP County (5- 13 -14) Page 1 t
Exhibit A — Data Security Requirements
1. Definitions. The words and phrases listed below, as used in this Exhibit, shall each have the following
definitions:
a. "Authorized User(s)" means an individual or individuals with an authorized business requirement to
access DSHS Confidential Information.
b. "Hardened Password" means a string of at least eight characters containing at least one alphabetic
character, at least one number and at least one special character such as an asterisk, ampersand
or exclamation point.
c. "Unique User ID" means a string of characters that identifies a specific user and which, in
conjunction with a password, passphrase or other mechanism, authenticates a user to an
information system.
Data Transport. When transporting DSHS Confidential Information electronically, including via email,
the Data will be protected by:
a. Transporting the Data within the (State Governmental Network) SGN or Contractor's internal
network, or;
b. Encrypting any Data that will be in transit outside the SGN or Contractor's internal network. This
includes transit over the public Internet.
3, Protection of Data. The Contractor agrees to store Data on one or more of the following media and
protect the Data as described:
a. Hard disk drives. Data stored on local workstation hard disks. Access to the Data will be
restricted to Authorized User(s) by requiring logon to the local workstation using a Unique User ID
and Hardened Password or other authentication mechanisms which provide equal or greater
security, such as biometrics or smart cards.
b. Network server disks. Data stored on hard disks mounted on network servers and made available
through shared folders. Access to the Data will be restricted to Authorized Users through the use of
access control lists which will grant access only after the Authorized User has authenticated to the
network using a Unique User ID and Hardened Password or other authentication mechanisms
which provide equal or greater security, such as biometrics or smart cards. Data on disks mounted
to such servers must be located in an area which is accessible only to authorized personnel, with
access controlled through use of a key, card key, combination lock, or comparable mechanism.
For DSHS Confidential Information stored on these disks, deleting unneeded Data is sufficient as
long as the disks remain in a Secured Area and otherwise meet the requirements listed in the
above paragraph. Destruction of the Data as outlined in Section 5. Data Disposition may be
deferred until the disks are retired, replaced, or otherwise taken out of the Secured Area.
optical discs (CDs or DVDs) in local workstation optical disc drives. Data provided by DSHS
on optical discs which will be used in local workstation optical disc drives and which will not be
transported out of a Secured Area. When not in use for the contracted purpose, such discs must be
locked in a drawer, cabinet or other container to which only Authorized Users have the key,
combination or mechanism required to access the contents of the container. Workstations which
access DSHS Data on optical discs must be located in an area which is accessible only to
authorized personnel, with access controlled through use of a key, card key, combination lock, or
comparable mechanism.
DSHS Central Contract Services
204SCS EIP County (5- 13 -14) Page 12
d. Optical discs (CDs or DVDs) in drives or jukeboxes attached to servers. Data provided by
DSHS on optical discs which will be attached to network servers and which will not be transported
out of a Secured Area. Access to Data on these discs will be restricted to Authorized Users through
the use of access control lists which will grant access only after the Authorized User has
authenticated to the network using a Unique User ID and Hardened Password or other
authentication mechanisms which provide equal or greater security, such as biometrics or smart
cards. Data on discs attached to such servers must be located in an area which is accessible only
to authorized personnel, with access controlled through use of a key, card key, combination lock, or
comparable mechanism.
e. Paper documents. Any paper records must be protected by storing the records in a Secured Area
which is only accessible to authorized personnel. When not in use, such records must be stored in
a locked container, such as a file cabinet, locking drawer, or safe, to which only authorized persons
have access.
Remote Access. Access to and use of the Data over the State Governmental Network (SGN) or
Secure Access Washington (SAW) will be controlled by DSHS staff who will issue authentication
credentials (e.g, a Unique User ID and Hardened Password) to Authorized Users on Contractor
staff. Contractor will notify DSHS staff immediately whenever an Authorized User in possession of
such credentials is terminated or otherwise leaves the employ of the Contractor, and whenever an
Authorized User's duties change such that the Authorized User no longer requires access to
perform work for this Contract.
g. Data storage on portable devices or media.
(1) Except where otherwise specified herein, DSHS Data shall not be stored by the Contractor on
portable devices or media unless specifically authorized within the terms and conditions of the
Contract. if so authorized, the Data shall be given the following protections:
(a) Encrypt the Data with a key length of at least 128 bits
(b) Control access to devices with a Unique User ID and Hardened Password or stronger
authentication method such as a physical token or biometrics.
(c) Manually lock devices whenever they are left unattended and set devices to lock
automatically after a period of inactivity, if this feature is available. Maximum period of
inactivity is 20 minutes.
Physically Secure the portable device(s) and/or media by
(d) Keeping them in locked storage when not in use
(e) Using check -in /check -out procedures when they are shared, and
(f) Taking frequent inventories
(2) When being transported outside of a Secured Area, portable devices and media with DSHS
Confidential Information must be under the physical control of Contractor staff with authorization
to access the Data.
(3) Portable devices include, but are not limited to; smart phones, tablets, flash memory devices
(e.g. USB flash drives, personal media players), portable hard disks, and
laptopinotebooklnetbook computers if those computers may be transported outside of a
Secured Area.
DSHS Central Contract Services Page 13
2048CS EIP County (5- 13 -14)
(4) Portable media includes, but is not limited to; optical media (e.g. CDs, DVDs), magnetic media
(e.g. floppy disks, tape), or flash media (e.g. CompactFlash, SD, MMC).
h. Data stored for backup purposes.
(1) DSHS data may be stored on portable media as part of a Contractor's existing, documented
backup process for business continuity or disaster recovery purposes. Such storage is
authorized until such time as that media would be reused during the course of normal backup
operations. If backup media is retired while DSHS Confidential Information still exists upon it,
such media will be destroyed at that time in accordance with the disposition requirements in
Section 5. Data Disposition
(2) DSHS Data may be stored on non - portable media (e.g. Storage Area Network drives, virtual
media, etc.) as part of a Contractor's existing, documented backup process for business
continuity or disaster recovery purposes. If so, such media will be protected as otherwise
described in this exhibit. If this media is retired while DSHS Confidential Information still exists
upon it, the data will be destroyed at that time in accordance with the disposition requirements in
Section 5. Data Disposition.
4. Data Segregation.
a. DSHS Data must be segregated or otherwise distinguishable from non -DSHS data. This is to
ensure that when no longer needed by the Contractor, all DSHS Data can be identified for return or
destruction. It also aids in determining whether DSHS Data has or may have been compromised in
the event of a security breach. As such, one or more of the following methods will be used for data
segregation.
b. DSHS Data will be kept on media (e.g. hard disk, optical disc, tape, etc.) which will contain no
non -DSHS data. And /or,
c. DSHS Data will be stored in a logical container on electronic media, such as a partition or folder
dedicated to DSHS Data. And /or,
d. DSHS Data will be stored in a database which will contain no non -DSHS data. And /or,
e, DSHS Data will be stored within a database and will be distinguishable from non -DSHS data by the
value of a specific field or fields within database records.
f. When stored as physical paper documents, DSHS Data will be physically segregated from non -
DSHS data in a drawer, folder, or other container,
g. When it is not feasible or practical to segregate DSHS Data from non -DSHS data, then both the
DSHS Data and the non -DSHS data with which it is commingled must be protected as described in
this exhibit.
5. Data Disposition. When the contracted work has been completed or when no longer needed, except
as noted in Section 3. Protection of Data b. Network Server Disks above, Data shall be returned to
DSHS or destroyed. Media on which Data may be stored and associated acceptable methods of
destruction are as follows:
Data stored on:
Will be destroyed by:
Server or workstation hard disks, or
Using a "wipe" utility which will overwrite the Data at
least three (3) times using either random or single
Removable media (e.g. flo ies, USB flash drives,
character data, or
DSHS Central Contract Services Page 14
2048CS EIP County (5- )3 -14)
portable hard disks) excluding optical discs
Degaussing sufficiently to ensure that the Data cannot
be reconstructed, or
Physically destroying the disk
Paper documents with sensitive or Confidential
Information
Recycling through a contracted firm provided the
contract with the recycler assures that the
confidentiality of Data will be protected.
Paper documents containing Confidential Information
requiring special handling (e.g. protected health
information
On -site shredding, pulping, or incineration
Optical discs (e,g. CDs or DVDs)
Incineration, shredding, or completely defacing the
readable surface with a coarse abrasive
Magnetic tape
De aussin , incineratin or crosscut shredding
6. Notification of Compromise or Potential Compromise. The compromise or potential compromise of
DSHS shared Data must be reported to the DSHS Contact designated in the Contract within one (1)
business day of discovery. If no DSHS Contact is designated in the Contract, then the notification must
be reported to the DSHS Privacy Officer at dshsprivacyofficer @dshs.wa.gov. Contractor must also
take actions to mitigate the risk of loss and comply with any notification or other requirements imposed
by law or DSHS.
T. Data shared with Subcontractors. If DSHS Data provided under this Contract is to be shared with a
subcontractor, the Contract with the subcontractor must include all of the data security provisions within
this Contract and within any amendments, attachments, or exhibits within this Contract. If the
Contractor cannot protect the Data as articulated within this Contract, then the contract with the sub -
Contractor must be submitted to the DSHS Contact specified for this contract for review and approval.
DSHS Central Contract Services
2048CS EIP County (5- 13 -14) Page 15
EXHIBIT B
STATEMENT OF WORK
Early Intervention Program (EIP)
ORGANIZATION OF STATEMENT OF WORK
1. Intent of Services
2, Philosophical Principles 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 ensure that services provided under this Contract at all times meet the specifications
described in this Statement of Work Exhibit.
Intent of Services
a. Early Intervention Services is a home visiting nurse program which shall 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.
b. 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:
(1) Reduce risk of abuse or neglect of children in the home;
(2) Enhance parenting skills, family and personal self- sufficiency, and family functioning;
(3) Reduce stress on the family;
(4) Reduce the likelihood of additional referrals to CPS;
(5) Enhance the health and well being of children and their families; and
(6) Facilitate linkages to health and community services.
DSHS Central Contract Services Page 16
2048CS EIP County (5- 13 -14)
2. Philosophical Principles used in the Delivery of EIP services
a. Individualized, tailored intervention;
b. Empowerment approaches;
c. Community support building approach;
d. Strengths perspective;
e. Cultural competence;
f. Developmental appropriateness; and
g. Outcome driven service plans.
3. Client Eligibility and Referral for Services
a. Eli ibilit . Families are eligible for EIP services who meet the following criteria:
(1) Have a child ages birth to six who has issues related to his/her:
OR
(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.
(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) Open 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:
DSHS Central Contract Services Page 17
2048CS EIP County (5- 13 -14)
(a) CPS social worker has interviewed the family and has identified an issue relating to the
child's health, growth, development, caretakinglparenting, 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.
(a) FVS social worker has interviewed the family and has identified an issue relating to the
child's health, growth, development, caretakinglparenting, or home safety.
(b) The CA family's service plan indicates a goal related to the child's health, growth,
development, ca retaking/pa renting, 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) Open 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 children) 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;
DSHS Central Contract Services Page t 8
2048CS EIP County (5- 13 -14)
(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.
(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 referral, 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 collaboratively with the CA social worker 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.
Family Centered Practice Model
The Contractor shall provide services consistent with Solution Based Casework, the family- centered
practice model used by the Children's Administration. It shall be the Contractor's responsibility to
obtain information on Solution Based Casework from CA. Information about Solution Based Casework
is available at http:Ifwww.dshs.wa..qov /ca /about /sbc.asp
8. Provision of Services
The Contractor shall deliver services as follows for CA referred families:
a. 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.
DSHS Central Contract Services Page 19
2048CS EIP County (5- 13 -14)
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,
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 Delivery
(1) Schedule services at the family's convenience and tailor to accommodate a family's work
schedule whenever possible.
(2) Make EIP nurses availabie 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
DSHS Central Contract Services Page 20
2048CS EIP County (5- 13 -14)
(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 the EIP 90 Day Review form when providing services to families
up to and beyond 90 days. The 90 Day Review form is #10 -479 and may be accessed at:
http:l t .dshs.wa.gov /forms /eform_s-_shtml
(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 parent/caregiver;
DSHS Central Contract Services Page 21
2048CS EIP County (5- 13 -14)
(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; or
(6) Services were completed.
Exit Summary
(1) The Contractor shall complete the EIP Exit Summary on completion of services with families
served under the EIP Contract. The EIP Exit Summary form is #10 -475 and may be accessed
at: http: www.dshs.wa.gov /forms /eforms.shtmi
(2) The Contractor shall submit the Exit Summary to the CA social worker within 10 working days
of case closure.
Reports
a. Written reports must be submitted by secure email to the DSHS contacts identified below. The
DSHS Secure E -mail User Guide is available at http: / /www.dshs.wa.gov /ca /partners /intro.asp
b. 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 Reports
Submit to:
Due Date
EIP Monthly Report
1 electronic copy to the EIP CA
By the 15 of the month
regional liaison
for services provided in
Name: Veronica Hinojosa
the previous month
Email:
veronica.hinojosa @dshs.wa.gov
1 electronic copy to the EIP CA
headquarters liaison
Mireya Beltre, MSW
HQ Family Voluntary Services
Program Manager
beltrMA @dshs.wa.go
90 Day Review
1 copy of each to the assigned CA social
By the 15` of the month
Exit Summary
worker
for services provided in
the previous month
Annual (Contract period) roll-
1 electronic copy to the EIP CA
By the 1 Sth of the
up report to include:
regional liaison (as above)
month of July each
o # of referrals
year of contract.
o # of unduplicated children
1 electronic copy to the EIP
served
headquarters liaison (as above)
o # of unduplicated families
(cases) served
o # of families (cases) exited
from EIP for:
DSHS Central Contract Services
2048CS EIP County (5- 13 -14) Page 22
■ # of families- Provider
U nable to make contact
■ # of families- Provider
determined family does
nvt need EIP
■ # of families - Family
refused services
■ # of families - Family was
referred to another
program within CA
■ # of families - Service
were completed
■ # of families - Provider
referred EIP case back
to CPS as higher risk
■ # of families — re- referral
and accepted for
investigation
o # of cases with another CPS
referral received while family
was participating in EIP
o # of families enrolled in
community resource and
referral services
o # of families enrolled in
Family Engagement
Services
o Of total # of families, what %
improved KBS scores in
caretaking and parenting
over time
c. DSHS may stop payment to the Contractor if reports required under this Contract are
delinquent or incomplete.
d. 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
include: a standardized assessment tool, performance measures, and service standards.
DSHS Central Contract Services
2048CS EIP County (5- 13 -14) Page 23
EXHIBIT C
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. Staff and Subcontractor Training
5. Annual EIP Provider Meetings
6. Evaluation of Contractor
7. No Transportation of DSHS Clients
8. Records
a. Client Records
b. Administrative Records
c. Personnel and Subcontractor Records
9, Operating Procedures
10. Degree Requirements
11. Background Checks
12. Health and Safety of CA Clients
13. Corporal Punishment Prohibited
14, Smoking Prohibited in Presence of Client Children and Foster Youth
15. Culturally Relevant Services
16. Interpretation and Translation
17. Confidentiality — Additional Requirements
18. Auditing and Monitoring
19. Office of the Family and Children's Ombudsman (OFCO)
The Contractor shall ensure that all qualifications for employees, volunteers, or subcontractors, performance
expectations and program requirements for services provided under this Contract at all times meet the
specifications described in this Program Requirement Exhibit.
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 Local Health Jurisdiction.
b. Exceptions for Required Staff Qualifications
DSHS Central Contract Services Page 24
2048CS EIP County (5- 13 -14)
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:
(1) Documentation of the individual's credentials and work experiences;
(2) Documentation of related coursework, conferences, and other training;
(3) Reasons why applicant was chosen;
(4) How the Contractor plans to supervise the applicant;
(5) Training plan; and
(6) 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 or certification requirements or other
requirements as required by statute.
b. When licensing, certification, 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. Staff and Subcontractor Training.
a. Omaha S stem
The Contractor shall ensure that all direct service staff have completed the Omaha Training. The
Omaha training can be obtained through Ding County Health Department or the Tacoma - Pierce
County Health Department. Training is to be paid by the Contractor through the allotted Contract
dollars.
b. Mandated Reporter Trainin
(1) The Contractor shall ensure that all current employees and volunteers, who are mandated
reporters or who have access to children, read and/or view the materials in CA's Mandated
Reporter Toolkit within 30 days of the effective date of a first time CA Contract and annually
thereafter; and that all newly hired employees and volunteers who are mandated reporters or who
have access to children read and /or view the materials in the Mandated Reporter Toolkit within two
DSHS Central Contract Services Page 25
2048CS EIP County (5- 13 -14)
(2) weeks of initial employment After reading and reviewing the materials, each employee shall
sign and date a statement acknowledging his or her duty to report child maltreatment and affirming
that he or she understands when and how to report suspected child abuse or neglect. The
Contractor shall retain the signed statement in each individual's personnel file.
(2) The Contractor shall either obtain a copy of the Mandated Reporter Toolkit from DSHS, or access
the Mandated Reporter Toolkit online at the following
address: http:llwww dshs. wa.gov /calsafetylabuseReport.as ?2
EIP Provider Meetings
It is expected under this Contract that, at a minimum, one Contractor representative shall attend any
scheduled CA's EIP provider meetings.
6. 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. If the Contractor fails to meet any of the performance measures, DSHS may terminate this Contract.
7. No Transportation of DSHS Clients. The Contractor shall not provide transportation to DSHS clients
under this Contract.
B. 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;
(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; and
DSHS Central Contract Services Page 26
2o48CS EIP County (5- 13 -14)
(10) Contacts with CA social worker and service providers.
b. Adminlstrative 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:
(1) DSHS criminal history background check approval;
(2) Any other criminal history background checks;
(3) Current license(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 degree(s), if required, and transcripts from college or other school awarding any degree(s)
required under this Contract for service provision;
DSHS Central Contract Services Page 27
2048CS EIP County (5- 13 -14)
(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 log;
(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.
9. 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:
(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 shall each retain a copy of the written operating procedures.
10. 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
DSHS Central Contract Services Page 28
2048CS EIP County (5- 13 -14)
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) VISA — Middle States Association
(2) NWCCU — Northwest Commission on Colleges and Universities
(3) NCA — North Central Association of Colleges and Schools
(4) NEASC — New England Association of Schools and Colleges
(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.
Cl. 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.
e. The Council for Higher Education Accreditation (CHEA) is located at One Dupont Circle NW, Suite
510, Washington, DC 20036 -1135 and may be accessed at: www.chea.orq.
f. Failure to comply with the degree requirements of this section shall be grounds for termination of this
Contract.
11. Background Checks
a. This requirement applies to any employees, volunteers and subcontractors who may have
unsupervised access to children served under this Contract.
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, or successor statutes 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), or successor statute, 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.
DSHS Central Contract Services Page 29
2048CS EIP County (5- 13 -14)
12. Health and Safety of CA Client Children
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 e-mail.
13. 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.
14. Smoking Prohibited in Presence of Client Children and Foster Youth
Smoking in the presence of client children, including the use of e- cigarettes, is prohibited. This prohibition
extends to, but is not limited to, the following circumstances:
a. When transporting client children under age 18 and foster youth 18 to 21 years of age;
b. When 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.
15. Culturally 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.
16. 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
DSHS Central Contract Services
2048CS EIP County (5- 13 -14) Page 30
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.
17. 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://www,dshs.wa-qov/ca/partners/intro.asp.
18. 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 park 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.
19. Office of the Family and Children's Ombudsman (OFCO)
a. 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.
b. The Contractor shall notify the CA headquarters Program Manager when the OFCO makes a request
for records.
DSHS Central Contract Services Page 31
2048CS EIP County (5- 13 -14)
EXHIBIT D
Page 1 of 2
Exit Code Definitions
Early Family Support and Early Intervention
Exit Summary Code Definitions
Code Definition
la, Family Engagement The family has engaged in ongoing services with a provider and has identified
and Assessment Services goals and priorities for services. The family has engaged in interventions or
Completed services outlined in the service plan to address risk factors for child abuse and
neglect and support family strengths and protective factors.
11b. Community Resource The family has initiated community services.
and Referral Completed
2. Initial Screening Visit The family engaged in the initial screening visit with the provider and declined
Only further services either directly or by agreeing to services and then failing to
show for appointments.
3. Participated in Services
but did not complete
service plan due to:
a. Change in
Circumstance
b. Refused
Family has reached the
service limit and is not
longer eligible for services.
4a. Family has transferred
to other community
services.
3a. The family engages in services to a level the provider believes will benefit
the family to some degree, but further services are discontinued due to change
in circumstances.
3b. The family engages in services to a level that the provider believes the
children will benefit to some degree from the changes that will occur, but the
family refuses to further engage in services prior to addressing all
risk/protective factors for child abuse and neglect. (The provider MUST write
the activities the family participated in on the exit summary.)
The family continues to participate in services and is no longer eligible for
EFSS services.
4a. The Family has transferred to other community services.
4b.No other community
services are available.
4b. The community does not have appropriate services for the family.
5.AII services declined
Provider contacts family b hone or in person and the family declines to
participate in services.
6.Unable to locate family
The provider is not able to physically locate the address or the family at the
address provided.
7.Unable to contact
Family does live at the identified address but the provider is not able to contact
the family through at least 2 attempted home visits; and phone calls and/or
letters.
QSHS Central Contract Services
2048CS EIP County (5- 13 -14)
Page 32
EXHIBIT D
Page 2 of 2
8,Services not needed
Family was contacted in person and is already engaged in community services
that address the allegations, thus services would be duplicative and would not
be necessary.
8a. Self Report
$a. Client self reported, unable to verify
8b. Verification received
8b. Provider verified other service involvement
9.Returned to CPS due
Prior to contact with the family CPS receives additional information accepts the
to high level of risk
case for investigation or after further discussion with CA results in accepted
investigation.
EFSS Only
10. New CPS referral.
Anytime after the first face -to -face visit, an additional referral is made to CPS
Assigned for
and the case is accepted for investigation.
investigation
EFSS Only
11. Participated in
Family no longer in EFSS service area and cannot receive services.
Services then family
moved.
12. Child Placed in out
Child has been placed in out of home care through a dependency or court
of home care
intervention
DSHS Central Contract Services
2048CS EIP County (5- 13 -14) Page 33
Exhibit E
Budget
Early Intervention Program (EIP)
July 1, 2014 -June 30, 2015
ACTIVITY (not limited to the items below)
Please add footnotes to the budget section as FTEs -
needed Percent Budget Request for FY15
PERSONNEL
Names:
Denis Langlois 39% $33,193.67
$
°l° $
Fringe $100
TRAVEL (itemize) $
LODGING (itemize) $
PER DIEM (itemize) $
OTHER DIRECT COSTS
Equipment $
Supplies (includes curricula) $
Professional services $
Other (use as many lines as needed) $
TOTAL DIRECT CHARGES $33,294
INDIRECT CHARGES $3,329
(see ati chment & use as many lines as needed)
TOTAL INDIRECT CHARGES $3,329
GRAND TOTAL $36,623
DSHS Central Contract Services
2048CS EIP County (5- 13 -14) Page 34