HomeMy WebLinkAbout081715_ca05615 Sheridan Street
Port Townsend, WA 98368
www.JeffersonCountyPublicHealth.org
JEFFERSON COUNTY
BOARD OF COUNTY COMM
TO:
FROM:
DATE:
SUBJECT:
AGENDA REQUEST
Board of County Commissioners
Philip Morley, County Administrator
RS
Consent Agenda
June 27, 2014
Jean Baldwin, Director
6
ZcA«
Agenda Item — Agency Agreement with Department of Social and
Health Services for Developmental Disabilities Administration,(DDA)
#1563 - 45217; July 1, 2015 — June 30, 2016; $267,820
STATEMENT OF ISSUE:
Jefferson County Public Health, Developmental Disabilities Division, is requesting Board approval of the
Agency Agreement with Department of Social and Health Services for Developmental Disabilities
Administration, (DDA) #1563 - 45217; July 1, 2015 —June 30, 2016; $267,820
ANALYSIS /STRATEGIC GOALS /PRO'S and CON'S:
This contract is a continuation of services with DSHS for services to clients with developmental disabilities in
Jefferson County. The contract covers a variety of services. The services include administration, training
expenses (volunteers, board members, and staff), community information activities, consumer support
(Early intervention services for Child development services for Birth to 3), Group Supported Employment,
Pre Vocational Services, Individual Supported Employment, Individual Technical Assistance, Community
Access, and other activities (special projects). The statement of work requires a qualified coordinator,
advisory board, Intermediate Care Facilities agreement (where applicable), working knowledge of
DSHS /DRW Access Agreement, Feb. 27, 2001, and assignment of Medicaid billing rights under Title XIX.
Jefferson County has professional service subcontracts with agencies or organizations representing each
group.
The developmental disabilities program services provide educational opportunities for life -long learning and
training to a specific workforce that allows interactions, equal opportunity, and integrated participation with
non- disabled community members. These program services also support strategic efforts toward a
sustainable economic base by recognizing the need for integrated employment opportunities for persons
with disabilities. DDA program services undergird the economic reach of the disabled community by
supporting programs that emphasize and address prevention, early intervention, and recovery; and provide
opportunities to overcome community complexity by providing community outreach and activities that
recognize the significant health issues the disabled community confronts.
Community Health
Developmental Disabilities
360 -385 -9400
360- 385 -9401 (f1
Always working for a safer and healthier community
Environmental Health
Water Quality
360 -385 -9444
(tJ 364379 -4487
FISCAL IMPACT /COST BENEFIT ANALYSIS:
This is a contract with the Department of Social and Health Services and includes both State and Waiver
revenue. This revenue will be used to support programs in the Developmental Disabilities Programs.
RECOMMENDATION:
JCPH management request approval of the Agency Agreement with Department of Social and Health
Services for Developmental Disabilities Administration, (DDA) #1563- 45217; July 1, 2015 — June 30, 2016;
$267,820
RE BY:
Philip Morle my AdmiNstr for Date
DSHS Central Contract Services
1769CS County Agreement 7 -14 -2015
X A form
7 7C g
Jcfrec„n (-n P- 01 Office
Davin Alvarez, �-hwl Civil DPA
Page 1
DSHS Agreement Number
AL
COUNTY
wj� atofSOal
1563 -45217
cepeRmServicocial
Depar
PROGRAM AGREEMENT
& ttcalth Services
DDA County Services
Transforming lives
This Program Agreement is by and between the State of Washington Department of
Administration or Division
Social and Health Services (DSHS) and the County identified below, and is issued in
Agreement Number
conjunction with a County and DSHS Agreement On General Terms and Conditions,
which is incorporated by reference.
County Agreement Number
DSHS ADMINISTRATION
DSHS DIVISION
DSHS INDEX NUMBER
DSHS CONTRACT CODE
Developmental Disabilities
Division of Developmental
I
1223
1769CS -63
Admin
Disabilities
DSHS CONTACT NAME AND TITLE
DSHS CONTACT ADDRESS
Luise Frank
6860 Capital Blvd
Program Specialist II
Olympia, WA 98501 -
DSHS CONTACT TELEPHONE
DSHS CONTACT FAX
DSHS CONTACT E -MAIL
(360) 725 -4252
360 586 -6502
frank) dshs.wa. ov
COUNTY NAME
COUNTYADDRESS
Jefferson County
615 Sheridan St
Jefferson County DDA County Services
Port Townsend, WA 98368 -
COUNTY FEDERAL EMPLOYER IDENTIFICATION
COUNTY CONTACT NAME
NUMBER
Anna McEnery
916001322
COUNTY CONTACT TELEPHONE
COUNTY CONTACT FAX
COUNTY CONTACT E -MAIL
360 385 -9410
360) 385 -9401
amcenery@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
07/01/2015
06/30/2016
$267,820.00
EXHIBITS. The following Exhibits are attached: Exhibit A — Data Security Requirements; Exhibit B — Program
Agreement Bud et; Exhibit C— Local Match Certification
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 ent.
COUNTY SIGNATURE(S)
PRINTED NAME(S) AND TITLE(S)
DATE(S) SIGNED
DSHS SIGNATURE
PRINTED NAME AND TITLE
DATE SIGNED
Melissa Diebert, Contract Manager
DSHS Central Contract Services
1769CS County Agreement 7 -14 -2015
X A form
7 7C g
Jcfrec„n (-n P- 01 Office
Davin Alvarez, �-hwl Civil DPA
Page 1
Special Terms and Conditions
Definitions Specific to Program Agreement: The words and phrases listed below, as used in this
Program Agreement, shall each have the following definitions:
a. "Acuity Level" means the level of an individual's abilities and needs as determined through the DDA
assessment.
b. "AWA" means ADSA Web Access also referred to as the CMIS.
c. "Additional Consumer Services' refers to indirect Client service types as follows:
(1) "Community Information and Education ": Activities to inform and /or educate the general public
about developmental disabilities and related services. These may include information and
referral services; activities aimed at promoting public awareness and involvement; and
community consultation, capacity building and organization activities.
(2) "Training ": To increase the job related skills and knowledge of staff, providers, volunteers, or
interning students in the provision of services to people with developmental disabilities. Also to
enhance program related skills of board or advisory board members.
(3) "Other Activities" reserved for special projects and demonstrations categorized into the following
types:
(a) Infrastructure projects: Projects in support of Clients (services not easily tracked back to a
specific working age Client) or that directly benefit a Client(s) but the Client is not of working
age. Examples include planning services like benefits planning and generic job
development e.g. "Project Search."
(b) Start-up projects: Projects that support an agency or directly benefit the agency. Examples
include equipment purchases and agency administrative support.
(c) "Partnership Project ": Collaborative partnerships with school districts, employment
providers, DVR, families, employers and other community collaborators needed to provide
the employment supports and services young adults with developmental disabilities require
to become employed during the school year they turn twenty -one (21).
d. 'ADSK means Aging & Disability Services Administration.
e. "Authorized User(s)" means an individual or individuals with an authorized business requirement to
access DSHS Confidential Information.
f. "BARS" means DDA Budget and Accounting Reporting System.
g. "CSA" means County Service Authorization.
h. "CMIS" means the Case Management Information System also referred to as AWA.
i. "Client" means a person with a developmental disability as defined in Chapter 388 -823 WAC who is
currently eligible and active with the Developmental Disabilities Administration or is an identified
PASRR Client.
j. "County' means the county or counties entering into this Program Agreement.
k. "Confidential Information" means information that is exempt from disclosure to the public or other
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Special Terms and Conditions
unauthorized persons under RCW 42.56 or other federal or state laws. Confidential information
includes, but not limited to, Personal information.
I. "Consumer Support" refers to direct Client service types as follows:
(1) "Community Access' or "CA ": services are individualized services provided in typical integrated
community settings for individuals in retirement. Services will promote individualized skill
development, independent living and community integration for persons' to learn how to actively
and independently engage in their local community. Activities will provide opportunities to
develop relationships and to learn, practice and apply skills that result in greater independence
and community inclusion. These services may be authorized instead of employment support
(Individual Employment, Group Supported Employment or Pre - Vocational services) for working
age individuals who have received nine months of employment support, have not found a job
and decide not to continue looking for work.
(2) "Child Development Services" or "CDS ": Birth to three services are designed to meet the
developmental needs of each eligible child eligible and the needs of the family related to
enhancing the child's development. Services may include specialized instruction, speech -
language pathology, occupational therapy, physical therapy, assistive technology, and vision
services. Services are provided in natural environments to the maximum extent appropriate.
(3) "Individual Supported Employment" or "IE ": services are a part of an individual's pathway to
employment and are tailored to individual needs, interests, and abilities to, and promote career
development. These are individualized services necessary to help persons with developmental
disabilities obtain and continue integrated employment at or above the state's minimum wage in
the general workforce. These services may include intake, discovery, assessment, job
preparation, job marketing, job supports, record keeping and support to maintain a job.
(4) "Individualized Technical Assistance" or "ITA ": services are a part of an individual's pathway to
individual employment. This service provides assessment and consultation to the employment
provider to identify and address existing barriers to employment. This is in addition to supports
received through supported employment services or pre - vocational services for individuals who
have not yet achieved their employment goal.
(5) "Group Supported Employment" or "GSE ": services are a part of an individual's pathway to
integrated jobs in typical community employment. These services are intended to be short term
and offer ongoing supervised employment for groups of no more than eight (8) workers with
disabilities in the same setting. The service outcome is sustained paid employment leading to
further career development in integrated employment at or above minimum wage. Examples
include enclaves, mobile crews, and other business models employing small groups of workers
with disabilities in integrated employment in community settings.
(6) "Pre- Vocational Services" or "PVS ": services are a part of an individual's pathway to integrated
jobs in typical community employment. These services and supports are intended to be short
term and should be designed to further habilitation goals that will lead to greater opportunities
for competitive and integrated employment and career advancement at or above minimum
wage. Services are provided by agencies established to provide services to people with
disabilities and offer training and skill development for groups of workers with disabilities in the
same setting as well as individual support. Participants are provided at least monthly
opportunities to experience typical community settings in support of their pursuit to integrated
employment.
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m. "CRM" means the DDA Case Resource Manager.
n. "DD" means developmental disabilities.
o. "DDA" means the Developmental Disabilities Administration within DSHS.
p. "DDA Region" means the DDA Regional office.
q. "DVR" means the Division of Vocational Rehabilitation.
r. "Encrypt" means to encode Confidential Information into a format that can only be read by those
possessing a "key ": a password, digital certificate or other mechanism available only to authorized
users. Encryption must use a key length of at least 128 bits.
s. "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.
t. "HCBS" means the Medicaid Home and Community Based Services.
u. "ISP" means the Individual Support Plan, a document that authorizes and identifies the DDA paid
services to meet a Client's assessed needs.
v. "PASRR" means Preadmission Screening and Resident Review.
w. "Personal Information" means information identifiable to any person including, but not limited to,
information that relates to a person's name, health, finances, education, business, use or receipt of
governmental services or other activities, addresses, telephone numbers, Social Security Numbers,
driver's license numbers, other identifying numbers, and any financial identifiers.
x. "Physically Secure" means that access is restricted through physical means to authorized
individuals only.
y. "Quality Assurance" means an adherence to all Program Agreement requirements, including DDA
Policy 6.13, Employment/Day Program Provider Qualifications, County Guidelines and the Criteria
for Evaluation, as well as a focus on reasonably expected levels of performance, quality, and
practice.
z. "Quality Improvement" means a focus on activities to improve performance above minimum
standards and reasonably expected levels of performance, quality and practice.
aa. "Secured Area" means an area to which only authorized representatives of the entity possessing
the Confidential Information have access. Secured Areas may include buildings, rooms or locked
storage containers (such as a filing cabinet) within a room, as long as access to the Confidential
Information is not available to unauthorized personnel.
bb. "Service Provider" is a qualified Client service vendor who is contracted to provide Employment and
Day Program services.
cc. "Subcontractor" is the service provider contracted by the County to provide consumer services.
dd. "Tracking" means a record keeping system that identifies when the sender begins delivery of
Confidential Information to the authorized and intended recipient, and when the sender receives
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confirmation of delivery from the authorized and intended recipient of Confidential Information.
ee. "Trusted Systems" include only the following methods of physical delivery: (1) hand - delivery by a
person authorized to have access to the Confidential Information with written acknowledgement of
receipt; (2) United States Postal Service ( "USPS ") first class mail, or USPS delivery services that
include Tracking, such as Certified Mail, Express Mail or Registered Mail; (3) commercial delivery
services (e.g. FeclEx, UPS, DHQ which offer tracking and receipt confirmation; and (4) the
Washington State Campus mail system. For electronic transmission, the Washington State
Governmental Network (SGN) is a Trusted System for communications within that Network.
ff. "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.
2. Purpose: This Program Agreement is entered into between DDA and the County in accordance with
Chapter 71A.14 RCW. Its purpose is to advance the state legislative policy to provide a coordinated
and comprehensive state and local program of services for persons with developmental disabilities.
3. Confidentiality:
a. The County shall not use, publish, transfer, sell or otherwise disclose any Confidential Information
gained by reason of this Program Agreement for any purpose that is not directly connected with the
performance of the services contemplated hereunder, except:
(1) As provided by law; or,
(2) In the case of Personal Information, as provided by law or with the prior written consent of the
person or personal representative of the person who is the subject of the Personal Information.
b. The County shall protect and maintain all Confidential Information gained by reason of this Program
Agreement against unauthorized use, access, disclosure, modification or loss. This duty requires
the County to employ reasonable security measures, which include restricting access to the
Confidential Information by:
(1) Allowing access only to staff that have an authorized business requirement to view the
Confidential Information;
(2) Physically Securing any computers, documents, or other media containing the Confidential
Information;
(3) Ensuring the security of Confidential Information transmitted via fax (facsimile) by verifying the
recipient phone number to prevent accidental transmittal of Confidential Information to
unauthorized persons;
(4) When transporting six (6) to one hundred forty nine (149) records containing Confidential
Information outside a Secure Area, one or more of the following as appropriate:
(a) Using a Trusted System, or
(b) Encrypting the Confidential Information, including:
i. Email and /or email attachments.
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ii. Confidential Information when it is stored on portable devices or media, including but not
limited to laptop computers and flash memory devices.
(5) When transporting one hundred fifty (150) records or more containing Confidential Information
outside a Secure Area, referring to the requirements in Exhibit A — Data Security Requirements;
and
(6) Sending paper documents containing Confidential Information via a Trusted System.
c. To the extent allowed by law, at the end of the Program Agreement term or when no longer needed,
the parties shall return Confidential Information or certify in writing the destruction of Confidential
Information upon written request by the other party.
d. Paper documents with Confidential Information may be recycled through a contracted firm, provided
the contract with the recycler specifies that the confidentiality of information will be protected and
the information destroyed through the recycling process. Paper documents containing Confidential
Information requiring special handling (e.g. protected health information) must be destroyed through
shredding, pulping, or incineration.
e. The compromise or potential compromise of Confidential Information must be reported to the DSHS
Contact designated on this Program Agreement within five (5) business days of discovery for
breaches of less than one hundred fifty (150) persons' protected data, and one (1) business day of
discovery of breaches of over one hundred fifty (150) persons' protected data. The parties must
also take actions to mitigate the risk of loss and comply with any notification or other requirements
imposed by law.
4. Client Eligibility: Client eligibility and service referral are the responsibility of the DDA pursuant to
Chapter 388 -823 WAC (Eligibility) and Chapter 388 -825 WAC (Service Rules). Only persons referred
by DDA shall be eligible for direct Client services under this Program Agreement. It is DDA's
responsibility to determine and authorize the appropriate direct service(s) type. Direct Client services
provided without authorization are not reimbursable under this Program Agreement.
5. Credentials and Minimum Requirements:
a. Administration of the developmental disabilities County program cannot be subcontracted.
b. Qualified DD Program Coordinator: A qualified DD program coordinator has a minimum of five
years training and experience in the administration and /or the delivery of developmental disabilities
services to a community. For a county where the coordinator administers more than one program
area (e.g. Chemical Dependency, Mental Health, Developmental Disabilities), training and
experience in administration and /or a related Human or Social service may be considered.
c. Fiscal Responsibility: The County must demonstrate the ability to safeguard public funds including
maintaining books, records, documents and other materials relevant to the provision of goods and
services.
d. Sufficient Policies and Procedures for Establishment and Maintenance of adequate internal control
systems: The County will maintain written policy procedural manuals for information systems,
personnel, and accounting /finance in sufficient detail such that operations can continue should
staffing change or absences occur.
e. Background /Criminal History Check: A background /criminal history clearance is required every
three years for all employees (including DD program County staff), subcontractors, and /or
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volunteers who may have unsupervised access to vulnerable DSHS Clients, in accordance with
RCW 43.43.830 -845, RCW 74.15.030, and Chapter 388 WAC. If the entity reviewing the application
elects to hire or retain an individual after receiving notice that the applicant has a conviction for an
offense that would disqualify the applicant from having unsupervised access to vulnerable adults as
defined in Chapter 7434 RCW, then DDA shall deny payment for any subsequent services
rendered by the disqualified individual provider. The DSHS Background Check Central Unit (BCCU)
must be utilized to obtain background clearance.
f. Qualified Advisory Board Members: A Developmental Disabilities advisory board shall include
members knowledgeable about developmental disabilities. No board member shall have a contract
with the County to provide Training, Community Information Activities, Consumer Support as
defined in this agreement , and shall not be aboard member, officer, or employee of an agency
subcontracting with the County to provide such services.
g. Qualified Service Providers: The County assures that all service providers meet qualifications as
outlined in the DDA Policy 6.13, Program Provider Qualifications.
h. Home and Community Based Waiver Services Assignment of Medicaid Billing Rights: The County
assures that each subcontractor has agreed to assign to DDA its Medicaid billing rights for services
to DDA Clients eligible under Title XIX programs in this agreement. Written documentation shall be
available to DSHS on request.
i. Reporting Abuse and Neglect: The County staff and its subcontractors who are mandated reporters
under RCW 74.34.020(l 1) must comply with reporting requirements described in RCW 74.34.035,
.040 and Chapter 26.44 RCW. If the County is notified by DSHS that a subcontractor staff member
is cited or on the registry for a substantiated finding, then that associated staff will be prohibited
from providing services under this Program Agreement.
j. Counties who provide Child Development Services (birth to three early intervention services), must
provide those services under the regulations implementing the Individuals with Disabilities
Education Act (IDEA), Part C, and Washington State's Early Support for Infant and Toddler
Federally Approved Plan.
k. The County staff who perform on -site evaluations of subcontractor work sites will promptly report to
DSHS per DDA Policy 5.13, Protection from Abuse: Mandatory Reporting, if:
(1) They have reasonable cause to believe that abandonment, abuse, financial exploitation or
neglect (as defined in RCW 74.34.020) of a person who has a developmental disability (as
defined in RCW 71A.10.020) has occurred, and,
(2) If they have reason to suspect that sexual or physical assault of such a person has occurred,
they shall also immediately report to the appropriate law enforcement agency.
6. Duty to Disclose: Pursuant to 42 CFR §455.104, the Administration must obtain certain disclosures
and complete required screenings to ensure the State does not pay federal funds to excluded person or
entities. The County is required to provide disclosures from managing employees, specifically the
persons in the positions of Developmental Disabilities Director and Fiscal /Budget Director, i.e. the
person who authorizes expenditures. A completed Medicaid Provider Disclosure Statement, DSHS
Form 27 -094, should be submitted to the Administration to complete the required screenings.
Disclosures must be provided at contract renewal and within thirty -five (35) days whenever there is a
change in the staff holding these management positions [42 CFR 455.104 (c)(1)].
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Statement of Work: The County shall provide the services and staff, and otherwise do all things
necessary for or incidental to the performance of work, as set forth below. Working collaboratively, the
parties shall administer DD services within the county as set forth below:
a. The DDA region shall:
(1) Review subcontractors and shall immediately notify the County of any disapproval of the
subcontractors identified by the County;
(2) Inform and include the County in the discharge planning of individuals leaving institutions and
returning to the community who will need program funding;
(3) Inform the County of individuals who have had their waiver status changed;
(4) Work with the County when referring individuals for services;
(5) Inform Clients of service changes through Planned Action Notice(s);
(6) Work with the County to document planned services in the Individual's Support Plan including
notification of assessment dates;
(7) Work with the County when terminating services;
(8) Work with the County on Spending Plan adjustments; and
(9) Work with the County in participating in on -site evaluation of direct service providers.
b. The County shall:
(1) Work with the DDA Region when individuals are referred for services;
(2) Work with the DDA Region to document planned services in the Individual's Support Plan;
(3) Assist with informing the DDA Region of any potential service level changes not documented in
the individual's DD Assessment prior to any changes;
(4) Work with the DDA Region regarding service termination;
(5) Work with the DDA Region on Spending Plan adjustments;
(6) Inform the DDA Region of new providers to be included on the CMIS system;
(7) Notify the DDA Region of any intent to terminate a subcontractor who is serving a DDA referral;
(8) Provide a copy of each subcontractor's contract upon written request from the DDA Region; and
(9) Notify and work with the DDA Region when performing on -site evaluations of direct service
providers.
c. Compliance with BARS Policies: The County shall take any necessary and reasonable steps to
comply with BARS.
d. The County shall comply with the following referenced documents found at DDA Internet site
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hftps://www.dshs.wa.gov/dda/county-best-practices under "Counties ":
(1) DDA Policy 4.11, County Services for Working Age Adults;
(2) WAC 388 -850, WAC 388 -828, WAC 388 - 845 -0001, 0030, 0205,0210, 0215, 0220, 0600 -0610,
1200 -1210, 1400 -1410, 2100, 2110;
(3) Criteria for Evaluation;
(4) County Guidelines; and
(5) Disability Rights Washington (formerly Washington Protection and Advocacy System) Access
Agreement.
e. The County shall develop and submit a comprehensive plan for the County DD Services as
required by WAC 388 - 850 -020.
Conveyance of The Estimated Number of People to be Served and Targeted Outcomes: The
County shall submit the Service Information Forms (SIF's) (provided by DDA at Internet site
https: / /www.dshs.wa,gov /dda /county- best - practices to indicate the estimated number of people to
be served, targeted outcomes, and identified goal(s) that focus on quality improvement within the
categories of Training, Community Information, Direct Client Services, and Other Activities within 30
days of execution of the Program Agreement. Once approved, the SIF outcomes may be modified
only by mutual agreement of the County and the DDA Region.
g. Solicitation for Qualified Employment and Day Program Service Providers: Requests for Information
(RFI's) and /or Requests for Proposals (RFPs), Requests for Qualifications (RFQ's) for direct
services will be issued at a minimum of once every four years for new providers. If a Client's needs
cannot be met by the current qualified providers or there is a capacity issue, then the County shall
issue an RFQ prior to the four year cycle.
h. Qualified Providers: A qualified provider must be a county or an individual or agency contracted
with a county or DDA.
I. Regional Approval of Subcontractors: The DDA Region shall review new subcontractors and shall
immediately notify the County of any disapproval of the subcontractors identified by the County.
Subcontractors: The County will pass on all applicable contractual requirements that are between
DDA and the County to the subcontractor. The County shall immediately notify the DDA Region of
the County's intent to terminate a subcontractor who is serving a DDA referral.
k. The County shall provide or contract with qualified Employment and Day Program Service
Providers for consumer support services that include the following program outcomes:
(1) Monthly Community Access service support hours will be based on the Client's community
access service level per WAC 388 - 828 -9310 for all Clients who began receiving community
access services July 1, 2011 and forward.
(a) To ensure health and safety, promote positive image and relationships in the community,
increase competence and individualized skill - building, and achieve other expected benefits
of Community Access, services will occur individually or in a group of no more than two (2)
or three (3) individuals with similar interests and needs.
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(b) Community Access services will focus on activities that are typically experienced by the
general public. Support to participate in segregated activities and/or specialized activities
will not be reimbursed.
(c) A Client receiving Community Access services will not receive employment support
simultaneously.
(d) A Client receiving Community Access services may at any time choose to leave Community
Access to pursue work and receive employment support.
(2) Clients in an employment program will be supported to work towards a living wage. A living
wage is the amount needed to enable an individual to meet or exceed his/her living expenses.
Clients should average twenty (20) hours of community work per week or eighty -six (86) hours
per month. The amount of service a Client receives will be based on his /her demonstrated need,
acuity level and work history per WAC 388 -828.
(3) Prior to beginning service or prior to an expected change in service, the provider will clearly
communicate to the Client and the County the maximum service hours per month the Client can
expect to receive. Service changes will not occur until the Client has received proper
notification from DDA.
(a) The Client's DDA ISP is the driver for service. The CMIS County Service Authorization and
updated Planned Rates information will not exceed the Client's DDA ISP.
(b) The amount of service the Client receives should match with the CMIS County Service
Authorization and updated Planned Rates information
(4) All Clients will have an individualized plan to identify Client's preferences. Minimum plan
elements are outlined in the reference document "Criteria for an Evaluation." A copy of the
Client's individualized plan will be provided to their CRM, guardian and others as appropriate.
(5) Semi - annual progress reports that describe the outcomes of activities will be provided by the
provider or the County to the CRM, guardian and others as appropriate. The report will
summarize the progress made towards the Client's individualized goals.
(6) All Clients will be contacted by their service provider according to Client need and at least once
per month.
(7) If Clients in Individual Employment, Group Supported Employment, or Prevocational services
have not obtained paid employment at minimum wage or better within six (6) months, the
County will assure the following steps are taken:
(a) Review the progress toward employment goals;
(b) Provide evidence of consultation with the family /Client; and
(c) Develop additional strategies with the family /Client, county staff, employment support staff
and the case manager. Strategies may include providing technical assistance, changing to
a new provider, and /or providing additional resources as needed to support the individual's
pursuit of employment. The additional strategies will be documented for each Client and
kept in the Client's file(s).
(8) If after twelve (12) months the Client remains unemployed, an additional review will be
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conducted. The provider will address steps outlined in the previous six month progress report in
the next six month progress report. The Client may request to participate in Community Access
activities or the Client may choose to remain in an employment program. When requesting to
participate in Community Access services, the Client shall communicate directly with his or her
DDA Case Manager. The DDA Case Manager is responsible for authorizing Community
Access services.
(9) For Individual Employment where the service provider is also the Client's employer long term
funding will remain available to the service provider / employer for six months after the
employee / DDA Client's date of hire. At the end of the six month period, if the DDA Client
continues to need support on the job, another service provider who is not the employer of record
must provide the support unless the County issues prior written approval for the service provider
to continue to provide long -term supports if needed.
(10) For Group Supported Employment, Clients must have paid work or paid training. The total
number of direct service staff hours provided to the group should be equal to or greater than the
group's collective amount of individual support monthly base hours. If the direct service staff
hours are less than the collective amount, then the provider will be reimbursed only for the
number of hours staff actually provided.
(11) For Prevocational services, Clients will receive training and skill development in groups as well
as individual support in the community. The total number of direct service staff hours provided
to the group should be equal to or greater than the group's collective amount of individual
support monthly base hours. If the direct service staff hours are less than the collective amount,
then the provider will be reimbursed only for the number of hours staff actually provided.
(12) Employment and day services must adhere to the Home and Community Based settings
(HCBS) requirements of 42CFR 441 530(a)(1), including that:
(a) The setting is integrated in the greater community and supports individuals to have full
access to the greater community;
(b) Ensures the individual receives services in the community to the same degree of access as
individuals not receiving Medicaid HCBS;
(c) The setting provides opportunities to seek employment and work in competitive integrated
settings; and
(d) The setting facilitates individual choice regarding services and supports, and who provides
them.
Quality Assurance and Service Evaluation: The County shall develop and have available an
evaluation system to review services. The evaluation system must have both a Quality Assurance
and a Quality Improvement component, and both must include objective measures. The County's
service evaluation system shall serve as the method by which current providers demonstrate that
they continue to be qualified providers. A copy of such evaluation system shall be provided upon
request to DDA for review and approval.
m. On -Site Evaluation: The County shall evaluate and review services delivered to reasonably assure
compliance and quality. The County shall conduct at least one on -site visit to each subcontractor
during the biennium. The County shall maintain written documentation of all evaluations,
recommendations and corrective action plans for each subcontractor. Copies of such
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Special Terms and Conditions
documentation will be provided to the DDA upon request.
The County shall work with local developmental disability advisory groups to plan for and coordinate
services.
o. The County shall participate in regularly scheduled bi- monthly meetings between County
developmental disability staff and DDA staff to remain updated and current.
p. CMIS Data System: The County shall use the CMIS data system for all billing requests, service
provider address and phone number maintenance, evaluation dates and to provide employment
outcome information.
(1) Monthly provide all data described in the Billing Instructions and in the Employment Outcomes
Instructions, which is hereby incorporated by reference.
(2) Assure the integrity of data submitted to the State. When data is submitted and rejected due to
errors or an error is later identified, the County will correct and resubmit the data within thirty
(30) days.
8. Consideration:
a. County Millage Funds: Per RCW 71.20.110, a County may elect to declare all or part of millage
funds to the state of Washington, Department of Social and Health Services, for the purpose of
obtaining federal matching funds to coordinate and provide community services for individuals with
developmental disabilities. Millage funds that are matched with federal dollars must comply with
federal requirements. Counties electing to make such a declaration of Millage funds will:
(1) Ensure that services provided using millage and matching funds meet HCBS Waiver
requirements. Additionally, millage and matching funds shall not be used when the same
services are paid for under the Rehabilitation Act of 1973 or Public Law 94 -142.
(2) Each Month complete a separate A -19 identifying the amount of total expenditures by category,
the amount of millage contributed, and the expected amount of federal match. Additionally
enter this information into AWN CARE County billing summary.
(3) Submit a Local Match Certification (Exhibit C) with the final contract billing.
b. Fees:
(1) Approval of fees is the responsibility of the DDA. The DDA Region reserves the right to approve
fees /rates for the services being provided. The County will submit a fee /rate schedule with the
initial Program Agreement. The County will submit updated fee/rate schedules to the DDA
Region for approval as changes occur. The rate schedule will include the following information:
(a) County(s) name;
(b) Time period for which the schedule is applicable; and
(c) Each contracted direct service (IE, GSE, PVS, CA, ITA, CDS) and its associated rate.
(2) Fee Limitations: The DDA will set limitations on the Hourly Rate for each direct service. Hourly
rates must be divisible by four. The current rates are as follows:
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Special Terms and Conditions
(a) Employment services.
i. Individual Employment services will not exceed $75.00 /hour.
ii. Group Supported Employment services will not exceed $65.00 /hour.
iii. Prevocational services will not exceed $55.00 1hour.
(b) Community Access services will not exceed an hourly rate of $30.00.
(c) Child Development services will not exceed a monthly rate of $500.00.
c. Budget and Spending Plan, attached as Exhibit B:
(1) Budget amount listed in Exhibit B: The County may not exceed the state only revenue dollar
amount or the total revenue dollar amount indicated on the Program Budget Agreement
included in Exhibit B. The waiver revenue dollar amount may be exceeded to accommodate
Clients moving from state -only employment and day services to waiver employment and day
services.
(2) Spending Plan: DDA will provide the initial Spending Plan. Funding shall be distributed under
planned expenditures as well as allocated under State and Medicaid shall function as a line item
budget for expenditures under this agreement. The planned expenditures for Consumer
Support are based on Client numbers as well as planned additional consumer services
expenditures. The spending plan may only be modified by mutual agreement of the parties in
writing and shall not require a contract amendment.
d. If a County provides Community Information and Education services under additional consumer
services, then activities must include outreach efforts to federally recognized local tribes.
e. Funds Designated for Adult Day Care Consumers: Funds designated for Adult Day Care
Consumers are available to Clients who were served between December 1996 and December 2003
in Adult Day Health agencies and were subsequently determined ineligible for Level II or III services
(Adult Day Health). Level II and III services are licensed rehabilitation and skilled nursing services
along with socialization. Level I services (Adult Day Care) are supervised day programs where frail
and disabled adults can participate in social, educational, and recreational programs without the
need for skilled nursing. These Clients may be referred to services defined in the statement of
work, or to an Adult Day Care service other than Level II or III. If a Client no longer needs and
wants services, the funds are available for other Clients who are not part of the group of original
Clients identified between December 1996 and 2003. An Adult Day Care service shall only be
provided by Adult Day Care agencies certified by the local Area Agency on Aging. Adult Day Care
service is not a waiver approved service.
f. Exemptions: The DDA Assistant Secretary may approve in writing an exemption to a specific
program agreement requirement.
9. Billing and Payment:
a. Program Agreement Budget: DSHS shall pay the County all allowable costs, which are defined by
DDA as:
(1) Administration: Costs of the County Human Services Department or similar county office,
responsible for administration of the Developmental Disabilities Program. Allowable costs
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Special Terms and Conditions
include personnel and overhead costs directly related to the administration and coordination of
the program, including such activities as program planning, budgeting, contracting, monitoring,
and evaluation. Also included are departmental and county indirect and /or direct administrative
costs, to the extent that such costs are appropriately allocated to the program using an
established methodology consistent with grants management guidelines.
(2) Additional Consumer Services:
(a) Training:
i. Staff Training: Costs incurred by the program for planned, structured activities for the
purpose of providing, or improving, or enhancing job - related knowledge and skills of
staff, providers, volunteers, or interning students in the provision of developmental
disabilities services.
ii. Board Training: Costs incurred by the program for planned, structured activities
designed to provide, improve, or enhance program - related skills of board and advisory
committee members.
(b) Community Information and Education: to inform and /or educate the general public about
developmental disabilities and related services. These may include information and referral
services; activities aimed at promoting public awareness and involvement; and community
consultation, capacity building and organization activities.
(c) Other Activities
i. Infrastructure projects: Projects in support of Clients (services not easily tracked back to
a specific working age Client) or that directly benefit a Client(s) but the Client is not of
working age. Examples include planning services like benefits planning and genericjob
development e.g. "Project Search"
ii. Start-up projects: Projects that support an agency or directly benefit the agency.
Examples include equipment purchases and agency administrative support.
iii. Partnership project: Collaborative partnerships with school districts, employment
providers, DVR, families, employers and other community collaborators needed to
provide the employment supports and services young adults with developmental
disabilities require to become employed during the school year they turn twenty -one
(21).
(3) Consumer Support
(a) Adult Day Care services are available to Clients who were served between December 1996
and December 2003 in Adult Day Health agencies and were subsequently determined
ineligible for Level II or III services (Adult Day Health). Level 11 and III services are licensed
rehabilitation and skilled nursing services along with socialization. Level I services (Adult
Day Care) are supervised day programs where frail and disabled adults can participate in
social, educational, and recreational programs without the need for skilled nursing.
(b) Community Access services are individualized services provided in typical integrated
community settings for individuals in retirement. Services will promote individualized skill
development, independent living and community integration for persons to learn how to
actively and independently engage in their local community. Activities will provide
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Special Terms and Conditions
opportunities to develop relationships and to learn, practice and apply skills that result in
greater independence and community inclusion. These services may be authorized instead
of employment support (Individual Employment, Group Supported Employment or Pre -
Vocational services) for working age individuals who have received nine (9) months of
employment support, have not found a job and decide not to continue looking for work.
(c) Child Development Services are designed to meet the developmental needs of each eligible
child and the needs of the family related to enhancing the child's development. Services
may include specialized instruction, speech - language pathology, occupational therapy,
physical therapy, assistive technology, and vision services. Services are provided in natural
environments to the maximum extent appropriate.
(d) Individual Supported Employment services are a part of an individual's pathway to
employment and are tailored to individual needs, interests, and abilities to promote career
development. These are individualized services necessary to help persons with
developmental disabilities obtain and continue integrated employment at or above the
state's minimum wage in the general workforce. These services may include intake,
discovery, assessment, job preparation, job marketing, job supports, record keeping and
support to maintain a job.
(e) Individualized Technical Assistance services are a part of an individual's pathway to
employment. This service provides assessment and consultation to the employment
provider to identify and address existing barriers to employment. This is in addition to
supports received through supported employment services or pre - vocational services for
individuals who have not yet achieved their employment goal.
(f) Group Supported Employment services are a part of an individual's pathway to integrated
jobs in typical community employment. These services are intended to be short term and
offer ongoing supervised employment for groups of no more than eight (8) workers with
disabilities in the same setting. The service outcome is sustained paid employment leading
to further career development in integrated employment at or above minimum wage.
Examples include enclaves, mobile crews, and other business models employing small
groups of workers with disabilities in integrated employment community settings.
(g) Pre - Vocational Services are a part of an individual's pathway to integrated jobs in typical
community employment. These services and supports are intended to be short term and
should be designed to further habilitation goals that will lead to greater opportunities for
competitive and integrated employment and career advancement at or above minimum
wage. Services are provided by agencies established to provide services to people with
disabilities and offer training and skill development for groups of workers with disabilities
in the same setting as well as individual support. Participants are provided at least
monthly opportunities to experience typical community settings in support of their pursuit
to integrated employment.
b. Reimbursement for the Fiscal Year shall not exceed the total amount listed in Exhibit B to this
Program Agreement. However, with a Program Agreement amendment, the parties may increase
or decrease the Program Agreement amount.
c. Monthly Invoice with Documentation: All requests for reimbursement amounts must be entered and
posted into the CMIS system. The Contractor may post a combined claim of all programs /services
covered by this agreement. DSHS shall make all payments due to the Contractor for all invoices
submitted pursuant to this section within sixty (60) days following posting of required information.
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Special Terms and Conditions
d. It is an expectation that all Clients access DVR funding as a resource. Client services shall not be
reimbursed under this Program Agreement when the same services are paid for under the
Rehabilitation Act of 1973 by DVR, Public Law 94 -142 or any other source of public or private
funding.
e. Reimbursement of Client Services: A claim for each individual is made on the CMIS system by
indicating the number of service units delivered to each individual listed and the fee per unit. Units
are defined as:
(1) An "Hour" is at least fifty (50) minutes of direct service. Partial hour to the quarter may be
recorded.
(2) A "Day" is at least four (4) hours of direct service and will only be used in connection with Adult
Day Care (ADC) reimbursement.
(3) A "Month" represents a minimum of one service visit which is at least fifty (50) minutes of direct
service for Child Development Services (CDS) reimbursement.
Program Administration : The County will provide program administration and may bill for
administrative costs as identified in Exhibit B. Administrative costs will not exceed 7% of the total
combined allocation for Consumer Support and Other Consumer Support services unless millage
has been declared or the Assistant Secretary of DDA approves a request for an exception under
Chapter 388 -850 WAC. Monthly claims for administrative costs will be 1/12 of the maximum
Administration amount identified in Exhibit B.
g. The Employment Phases & Billable Activities document defines the individual Client services that
DDA reimburses. That document is located on the DSHS DDA County Best Practices Web site at
http://www.dshs.wa.gov/ddd/counties.shtm,
h. The Community Access Billable Activities document defines the individual Client services DDA
reimburses. That document is located on the DSHS DDA County Best Practices Web site at
http://www.dshs.wa.gov/ddd/counties.shtm.
Timeliness of and Modification to Billings: All initial invoices with documentation must be received
by the DDA Region within sixty (60) calendar days following the last day of the month in which the
service is provided. Corrected invoices and documentation including re- posted billing information
will be accepted throughout the fiscal year as long as they are received within sixty (60) calendar
days of the associated fiscal year unless an extension is approved by the DDA Regional
Administrator or designee. Payment will not be made on any invoice submitted past sixty (60)
calendar days after the Program Agreement fiscal year.
j. Recovery of Fees: If the County bills and is paid fees for services that DSHS later finds were (a)
not delivered or (b) not delivered in accordance with Program Agreement standards, DSHS shall
recover the fees for those services and the County shall fully cooperate during the recovery.
10. Intermediate Care Facilities for Intellectual Disabilities (ICF /ID) Agreement. If applicable per 42
CFR 483.410, the County shall assure that all county- operated or subcontracted programs serving
persons living in ICF /ID facilities develop a plan and coordinate their services with the facility on behalf
of the ICF /ID resident. DDA will supply to the County a list of ICF /ID residents who attend a day
program.
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Special Terms and Conditions
11. Single State Medicaid Agency — Health Care Authority (HCA): HCA, as the single state Medicaid
Agency, has administrative authority for Title XIX coverage per 42 CFR 431.10. DSHS is the operating
agency for the Home and Community Based Waivers for services for people with developmental
disabilities. The County only has responsibility for services covered in this agreement.
12. DSHS /DRW Access Agreement: The DRW February 27, 2001 Access Agreement with DDA is
incorporated by reference. The County assures that it and its subcontractors have reviewed the
Access Agreement. The agreement covers DRW's access to individuals with developmental
disabilities, Clients, programs and records, outreach activities, authority to investigate allegations of
abuse and neglect, and other miscellaneous matters and is binding for all providers of DDA contracted
services.
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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.
2. 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.
c. 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.
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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.
f. 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
laptop /notebook/netbook computers if those computers may be transported outside of a
Secured Area.
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(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 destro ed 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
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Removable media (e.g. floppies, USB flash drives,
portable hard disks) excluding optical discs
character data, or
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 tae
Degaussing, incinerating or crosscut shredding
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.
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.
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EXHIBIT B
Program Agreement Budget
X Original Budget Budget Revision
REVENUES
Fiscal
Year
Fund Source
Original
15f Revision
2nd Revision
3rd Revision
2016
State
143,243
Waiver
Local
Medicaid Match to Local
Total Rev.
$267,820
$
$
$
Fiscal
Year
Fund Source
Original
1" Revision
2nd Revision
3`d Revision
2017
State
Waiver
Local
Medicaid Match to Local
Total Rev.
$
$
$
$
COUNTY FY SPENDING PLAN
Planned Expenditures
Local II PASRR
BARS 11)
OTHER CONSUMER SUPPORTS
(CMIS /AWA Code 31, 32,41, 92,
CONSUMER SUPPORT
STATE -ONLY
MEDICAID CLIENTS
ROADS to COMMUNITY LIVING
I7 -41
TOTAL
r�
II TOTAL II NA II NA II 143,243 1 124,577 1 267,820 II
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Exhibit C
Local Match
f [s „;;,;hS I, Local Match Certification
71.F I,;, (This form must be submitted with final contract billing.)
I certify that local funds and /or in -kind items
PRINT NAME
were provided in the amount of
TYPE AND SOURCE OF FUNDS /ITEMS
of
and were used to match federal funds paid during the time period
TYPE OF SERVICE /CONTRACT
for
NAME OF ENTITY
NAME OF AUTHORIZED AGENT
CONTRACTNENDOR NUMBER
AUTHORIZED REPRESENTATIVE'S SIGNATURE DATE
TITLE OR POSITION
PRINTED NAME OF AUTHORIZED REPRESENTATIVE
TELEPHONE NUMBER
Instructions
Name: Printed name of the local entity's agent authorized to complete certification form.
Type and source of funds: The type and source of local funds used. In -kind sources need specific identification
showing who donated the item(s) (e.g., volunteers, building use, etc.).
Dollar amount: Dollars that were used to match federal funds paid during the time period. Dollars
reported must agree with amount on the final billing.
Time frame: Period of time the services were provided.
Type of service /contact: Services eligible for FFP.
Name of entity: Name of local entity that is providing the local funding match.
Name of authorized agent: Name of local entity that is authorized to act in behalf of local entity.
Contract/vendor number: The contract or vendor number of the local entity.
Authorized representative's signature: The signature of the local entity authorized representative.
Date: Date when form was completed.
Title or position: Title or position of local entity authorized representative
Printed name: Printed name of authorized representative.
Telephone number: Telephone number of authorized representative. Include the area code.
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