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Home My WebLink AboutWashington State Department of Social & Health Services, Amendment No. 1 - 050916a Approved as tA form only P)"A_ 41 DSHS Central Contract Services J/4//4eerso Co. Prosecutor s Oe Page 1 6046 LF Long -Term Payable Amendment (3-13-14) David Alvarez, Chief Civil EWA DSHS CONTRACT NUMBER: COUNTY PROGRAM or INTERLOCAL 1563-32718 RR DEPART�ivIENT OF 7�OCIALEHEALTH Amendment No. 01 ` SERVICES LONG-TERM PAYABLE AGREEMENT AMENDMENT This Amendment is between the State of Washington Department of Social and Program Contract Number Health Services (DSHS) and the Contractor identified below. Click here to enter text. Contractor Contract Number CONTRACTOR NAME CONTRACTOR doing business as (DBA) Jefferson County Jefferson Count CONTRACTOR ADDRESS WASHINGTON UNIFORM BUSINESS DSHS INDEX NUMBER IDENTIFIER (UBI) 615 Sheridan St Port Townsend, WA 98368- 161-001-169 1223 CONTRACTOR CONTACT CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS Susan Parke (360) 385-9400 360 385-9401 1 sparke@co.jefferson.wa.us DSHS ADMINISTRATION DSHS DIVISION DSHS CONTRACT CODE Executive Administration Financial Services 8030CS-63 DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS David Erickson PO Box 45842 Financial Coordinator Olympia, WA 98504-5842 DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS (360)664-5757 (360)664-5775 erickdd@dshs.wa.gov IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? I CFDA NUMBERS No AMENDMENT START DATE CONTRACT END DATE 07/01/2016 06/30/2017 PRIOR MAXIMUM CONTRACT AMOUNT AMOUNT OF INCREASE OR DECREASE TOTAL MAXIMUM CONTRACT AMOUNT $0.00 N/A Based on Annual Review REASON FOR AMENDMENT; CHANGE OR CORRECT PERIOD OF PERFORMANCE ATTACHMENTS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into this Amendment by reference: ❑ Additional Exhibits (specify): This Amendment, including all Exhibits and other documents incorporated by reference, contains all of the terms and conditions agreed upon by the parties as changes to the original County Program Agreement or Interlocal Agreement. No other understandings or representations, oral or otherwise, regarding the subject matter of this Amendment shall be deemed to exist or bind the parties. All other terms and conditions of the original County Program Agreement or Interlocal Agreement remain in full force and effect. The parties signing below warrant that they have read and understand this Amendment, and have authority to enter into this Amendment. CONTRACTOR SIGNATURE PRINTED NAME AND TITLE DATE SIGNED Ka-} h leen J(Jec (',hair, CC— 5 - 9 2014 DSHS SIGNATURE PRINTED NAME AND TITLE DATE SIGNED Angela Williams, Contract Manager DSHS Central Contract Services a Approved as tA form only P)"A_ 41 DSHS Central Contract Services J/4//4eerso Co. Prosecutor s Oe Page 1 6046 LF Long -Term Payable Amendment (3-13-14) David Alvarez, Chief Civil EWA This Agreement between the State of Washington Department of Social and Health Services (DSHS) and the Contractor is hereby amended as follows: DSHS extends the Agreement End Date twelve months from July 1, 2016, to June 30, 2017, as stated on Page One of this Amendment. 2. DSHS revises the DSHS Contact Name and Contact Address to David Erickson as stated on Page One of this Amendment. All other terms and conditions of this Agreement remain in full force and effect. DSHS Central Contract Services Page 2 6046 LF Long -Term Payable Amendment (3-13-14) DSHS Central Contract Services 8030CS County Long -Term Payable (1-27-15) roved to form only 3� IS efferson Co. Prosec is Offict David Alvarez, Chie Civil DPA Page 1 DSHS Agreement Number COUNTY (((��()))) stare 1563-32718 .��,� ^}L—wash�ng�on ♦1 /, DEPARTMENT OF Jl`' /'S�"sER 1�T" PROGRAM AGREEMENT Long -Term Payable 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 with a County and DSHS Agreement On General Terms and Conditions, conjunction County Agreement Number which is incorporated by reference. DSHS ADMINISTRATION DSHS DIVISION DSHS INDEX NUMBER DSHS CONTRACT CODE Executive Administration Financial Services 1223 8030CS-63 DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS Donna Corcoran 1115 Washington St SE Financial Coordinator Olvmi3ia WA 98504 DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL (360)664-5769 360 664-5775 corcodl dshs.wa. ov COUNTY`NAME COUNTY ADDRESS Jefferson County 615 Sheridan St Port Townsend WA 98368 - COUNTY CONTACT NAME Susan Parke COUNTY CONTACT TELEPHONE COUNTY CONTACT FAX COUNTY CONTACT E MAIL (360) 385-9400 360) 385-9401 s arke 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 Based on Annual Review The terms and conditions of this Contract are an integration and representation of the final, entire and exclusive understanding between the parties superseding and merging all previous agreements, writings, and communications, oral or otherwise, regarding the subject matter of this Contract. The parties signing below represent that they have read and understand this Contract, and have the authority to execute this Contract. This Contract shall be binding on DSHS only upon signature by DSHS. DATE(S) SIGNED COUNTY SIGNATURE(S) PRINTED NAME(S) AND TITLE(S) f,. C,/ a DSHS SIGNATURE PRINTED NAME AND TITLE DATE SIGNED Andrea Goff, 3( ZJr/ 1S CC Contracts Consultant jr!4= v7� DSHS Central Contract Services 8030CS County Long -Term Payable (1-27-15) roved to form only 3� IS efferson Co. Prosec is Offict David Alvarez, Chie Civil DPA Page 1 SPECIAL TERMS AND CONDITIONS Definitions a. "Commingle" is the act of mixing the funds and/or Long -Term Payables for one program with the funds of another program. b. "Documentation of Funds Form" (DFF) is a form provided to the County each year by DSHS on which the County records qualifying previous year expenditures from which DSHS can appraise and evaluate the amount of the existing Long -Term Payable or appropriate adjustments. c. "Long -Term Payable" means funds provided by DSHS to the County in anticipation of specific client services provided by the County. The County shall not be allowed to retain any overage of the Long -Term Payable funds if the County does not actually provide the anticipated services during the given timeframe. Long -Term Payable funds are to be reconciled by April 30 of each year and any funds not fully utilized shall be refunded to DSHS by May 31 of each year. d. "Prepaid Inpatient Health Plan" is an entity that contracts with the Behavioral Health and Service Integration Administration (BHSIA) to administer mental health services for people who are eligible for the Title XIX Medicaid program in accordance with WAC 388-865-0300. 2. Purpose a. It is the purpose of this Agreement to specify the procedure by which DSHS will assess and, if necessary, adjust the Long -Term Payable it provides to the County. b. Funds to support contracts for the following DSHS programs may be included in a Long -Term Payable: Behavioral Health and Service Integration Administration (BHSIA) Mental Health (MH) and/or Alcohol and Substance Abuse (ASA); Developmental Disabilities Administration (DDA); Aging and Long -Term Support Administration (ALTSA); and/or Children's Administration (CA) operated during the term of this Agreement. 3. Statement of Work a. County Responsibilities (1) The County shall submit to DSHS, on forms provided by DSHS and by a date determined by DSHS, a completed Documentation of Funds Form (DFF) from which DSHS shall assess whether or not an adjustment to the amount of the Long -Term Payable provided to the County is warranted. (2) The County shall exclude all amounts related to its Prepaid Inpatient Health Plan expenditures from its DFF. (3) The County shall repay to DSHS all of the Long -Term Payable funds received from DSHS that exceed the amount that DSHS determines is warranted. Repayment requirements shall be based upon DSHS assessment of the most recent annual DFF submitted by the County to DSHS. Any Long -Term Payable funds not fully utilized by the County, as determined by DSHS through the DFF process, shall be refunded to DSHS by May 31 of each year. (4) The County shall only utilize Long -Term Payable funds for the DSHS program or service for which the funds were originally designated. Long -Term Payable funds may not be commingled between or among programs or services. (5) Any interest the County earns on the Long -Term Payable funds shall only be utilized for the DSHS Central Contract Services 8030CS County Long -Term Payable (1-27-15) Page 2 SPECIAL TERMS AND CONDITIONS DSHS programs or services for which the funds were originally designated. Long -Term Payable interest shall not be used for programs or services unrelated to the client services anticipated by this Agreement. (6) The County shall record the Long -Term Payables in its financial records. 4. DSHS Responsibilities a. DSHS shall assess the DFF submitted by the County to determine if, during the term of this Agreement, any adjustment to the original two month Long -Term Payable provided to the County is warranted. b. Adjustment may include DSHS request for repayment by County of any Long -Term Payable amounts previously paid to County that are in excess of the amount currently warranted. Termination In the event that this Agreement, or a program contract listed in 2.b. above, is terminated prior to completion, DSHS shall take all available steps to recover any Long -Term Payable determined to be an overpayment and the County shall fully cooperate during the recovery process. DSHS Central Contract Services 8030CS County Long -Term Payable (1-27-15) Page 3 615 Sheridan Street Port Townsend, WA 98368 Aff,' on www.JeffersonCountyPublicHealth.org Public Ha"Itt Consent Agenda April 7, 2016 JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS AGENDA REQUEST TO: Board of County Commissioners Philip Morley, County Administrator FROM: Veronica Shaw, Deputy Director Susan Parke, Financial Operations Coordinator DATE: 5—' c7 za / SUBJECT: Agenda Item – Long-term Payables A-1; July 1, 2016—June 30, 2017 STATEMENT OF ISSUE: Jefferson County Public Health requests Board approval of the Long-term Payables A-1; July 1, 2016 - June 30, 2017; ANALYSIS/ STRATEGIC GOALS/PRO'S and CON'S: This contract advances funds in anticipation of the actual approval of spending plans filed by the Contractor (JCPH) with DSHS for the Division of Developmental Disabilities, (DDD) and Substance Abuse prevention programs operated during the contract period. This agreement is governed by terms in accordance with the General Terms and Conditions between DSHS and the Contractor. This amendment changes the contact name to David Erickson, and extends the contract by one year. FISCAL IMPACT/COST BENEFIT ANALYSIS: This contract has no fiscal impact. This contract represents a method by which DSHS approves JCPH spending plans for monies received by the Developmental Disabilities and Substance Abuse programs. RECOMMENDATION: JCPH management request approval of Long -Term Payables A-1; July 1, 2016 – June 30, 2017. Community Health Developmental Disabilities 360-385-9400 360-385-9401 (f) Date Always working for a safer and healthier community Environmental Health Water Quality 360-385-9444 (f) 360-379-4487 615 Sheridan Street Port Townsend, WA 98368 �ee�hson www.JeffersonCountyPublicHealth.org is Hea AD -15-15-A1 CONTRACT REVIEW FORM PR 0 8. CONTRACT WITH: Long-term Payables( NL& - a �016 �Ck CONTRACT FOR: General Terms and Conditions TERM: July 1, 2016—June 30, 2017 COUNTY DEPARTMENT: Jefferson County Public Health For More Information Contact: Susan Parke Contact Phone #: X437 RETURN TO: Denise Banker RETURN BY: ASAP AMOUNT: Revenue: Expenditure: Matching Funds Required: Source(s) of Matching Funds PROCESS: ❑ Exempt from Bid Process ❑ Consultant Selection Process ❑ Cooperative Purchase ❑ Competitive Sealed Bid ❑ Small Work Roster ❑ Vendor List Bid ❑ RFP or RFQ x Other: DSHS Step 1: REVIEW BY RI M Review pyl Date Revi APPROVED FORM EILRdturned f6rrevision (See Comments) Comments: Step 2: REVIEW BY PR Q U I G AT EY Review by: 1 Date Reviewed: APPROVED AS TO FORM Returned f lsl evo a Comments) Comment (This form to stay with contract throughout the contract review process) R"IRCE� V LE0 APR 2 6 2016 Community Health JEFFERSON COUNTY PROSE6WTINOMMRNEY Developmental Disabilities Water Quality 360-385-9400 360-385-9444 360-385-9401 (f) Always working for a safer and healthier community (f) 360-379-4487