HomeMy WebLinkAbout072417_ca04615 Sheridan Street
Port Townsend, WA 98368
www.JeffersonCountyPublicHealth.org
Public zHeailt Consent Agenda
June 29, 2017
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: Vicki Kirkpatrick, Director
Anna McEnery
DATE: -4 /.q 41 X 11 -4 -
SUBJECT: Agenda Item — Program Agreement with Department of Social and
Health Services for Developmental Disabilities Administration, (DDA)
#1763-96185; July 1, 2017 — June 30, 2018; $291,930
STATEMENT OF ISSUE:
Jefferson County Public Health, Developmental Disabilities Division, is requesting Board approval of the
Program Agreement with Department of Social and Health Services for Developmental Disabilities
Administration, (DDA) #1763-96185; July 1, 2017 — June 30, 2018; $291,930
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,
Individual Supported Employment, Individual Technical Assistance, Community Access, and other activities
(special projects). The statement of work requires a qualified developmental disabilities 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 people with developmental
disabilities by supporting programs that emphasize and address early intervention, integrated employment,;
while providing opportunities for community information and education for citizens with and without
disabilities.
Community Health
Developmental Disabilities
360-385-9400
360-385-9401 (f)
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
www.JeffersonCountyPublicHealth.org
coo
Public Healt
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 Program Agreement with Department of Social and Health
Services for Developmental Disabilities Administration, (DDA) #1763-96185; July 1, 2017 — June 30, 2018;
$291,930
REVIEWED BY:
p Mori y, C unty Admini for
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
ApgFgWedt fa
-C Dake:
Philip C. Hunsucker, Chief Civil Deputy Prosecuting Attorney
Jefferson County Prosecuting Attorney's Office
DSHS Central Contract Services
1769CS County Agreement 6-15-2017
Page 1
DSHS Agreement Number
COUNTY
wiaeinploe Vile
1763-96185
Department of Social
a Health Services
PROGRAM AGREEMENT
Transforming lives
DDA County Services
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
1223
1769CS-63
Admin
Disabilities
DSHS CONTACT NAME AND TITLE
DSHS CONTACT ADDRESS
Wendi Winchel
PO BOX 45315
Regional Business Manager
Olympia, WA 98504-5315
DSHS CONTACT TELEPHONE
DSHS CONTACT FAX
DSHS CONTACT E-MAIL
(360) 725-4264
(360) 586-6502
winchwa(o)dshs.wa.gov
COUNTY NAME
COUNTY ADDRESS
Jefferson County
615 Sheridan St
Jefferson County DDA County Services
Port Townsend, WA 98368
COUNTY FEDERAL EMPLOYER IDENTIFICATION
COUNTY CONTACT NAME
NUMBER
Anna McEnry
916001322
L
COUNTY CONTACT TELEPHONE
COUNTY CONTACT FAX
COUNTY CONTACT E-MAIL
(360) 385-9410
(360) 385-0073
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
07/01/2017
06/30/2018
$291,930.00
EXHIBITS. The following Exhibits are attached: Exhibit A — Data Security Requirements; Exhibit B — Budget and
Spending Plan; Exhibit C-Fund 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 thev are authorized to sian this Proaram Agreement.
COUNTY SIGNATURE(S)
PRINTED NAME(S) AND TITLE(S)
DATE(S) SIGNED
DSHS SIGNATURE
PRINTED NAME AND TITLE
DATE SIGNED
Melissa Diebert, Contracts Manager
ApgFgWedt fa
-C Dake:
Philip C. Hunsucker, Chief Civil Deputy Prosecuting Attorney
Jefferson County Prosecuting Attorney's Office
DSHS Central Contract Services
1769CS County Agreement 6-15-2017
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 ALTSA Web Access also referred to as the CMTS.
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. "BARS" means DDA Budget and Accounting Reporting System.
e. "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.
f. "CMIS" means the Case Management Information System also referred to as AWA.
g. "County" means the county or counties entering into this Program Agreement.
h. "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
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Special Terms and Conditions
(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 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, 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.
"CRM" means the DDA Case Resource Manager.
j. "CSA" means County Service Authorization.
k. "DD" means developmental disabilities.
"DDA" means the Developmental Disabilities Administration within DSHS.
m. "DDA Region" means the DDA Regional office.
n. "DVR" means the Division of Vocational Rehabilitation.
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Special Terms and Conditions
o. "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.
p. "HCBS" means the Medicaid Home and Community Based Services.
q. "ISP" means the Individual Support Plan, a document that authorizes and identifies the DDA paid
services to meet a Client's assessed needs.
r. "PASRR" means Preadmission Screening and Resident Review.
s. "PCSP" means Person Centered Service Plan, a document that authorizes and identifies the DDA
paid services to meet a Client's assessed needs. Formerly referred to as the Individual Support
Plan.
t. "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.
u. "Quality Improvement" means a focus on activities to improve performance above minimum
standards and reasonably expected levels of performance, quality and practice.
v. "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.
w. "Service Provider" is a qualified Client service vendor who is contracted to provide Employment and
Day Program services.
x. "Subcontractor" is the service provider contracted by the County to provide services.
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. 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.
4. 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.
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Special Terms and Conditions
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
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 74.34 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, and Consumer Support as
defined in this Program Agreement, and shall not be a board 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 Program 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(13) 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.
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,
DSHS Central Contract Services Page 5
1769CS County Agreement 6-15-2017
Special Terms and Conditions
they shall also immediately report to the appropriate law enforcement agency.
5. Duty to Disclose: Under 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)].
6. 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;
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1769CS County Agreement 6-15-2017
Special Terms and Conditions
(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
ottps://www-dshs.wa.gov/dda/COLjnty-best-practices under "County Best Practices":
(1) DDA Policy 4.11, County Services for Working Age Adults;
(2) WAC 388-850, WAC 388-828, WAC 388-845-0001, 0030, 0210, 0215, 0220, 0600-0610, 1030-
1040, 1400-1410, 2100, 2110;
(3) Criteria for Evaluation;
(4) DDA Guiding Values
(5) County Guide to Achieve Developmental Disability Administration's Guiding Values;
(6) 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, excluding Child Development, will be open continuous enrollment.
h. Qualified Providers: A qualified provider must be a county or an individual or agency contracted
with a county or DDA.
i. Technical Assistance: DDA contracts with Technical Assistance providers that may be utilized by
Counties with prior written approval.
j. 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.
k. 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
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1769CS County Agreement 6-15-2017
Special Terms and Conditions
the County's intent to terminate a subcontractor who is serving a DDA referral. Individuals or
agencies contracted with a county or DDA may not subcontract for services with the exception of
Technical Assistance providers.
I. 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.
(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 PCSP is the driver for service. The CMIS CSA and updated Planned
Rates information will not exceed the Client's DDA PCSP.
(b) The amount of service the Client receives should match with the CMIS CSA 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.
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Special Terms and Conditions
(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
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
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Special Terms and Conditions
(d) The setting facilitates individual choice regarding services and supports, and who provides
them.
m. 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 objective
measures at a minimum will include performance indicators, by acuity, that include the number of
new jobs; job loss and reasons for job loss; the percentage employed earning minimum wage or
better; and the average number of hours worked. 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.
n. 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
documentation will be provided to the DDA upon request.
o. The County shall work with local developmental disability advisory groups to plan for and coordinate
services.
p. The County shall participate in regularly scheduled meetings between County DD staff and DDA
staff to remain updated and current including ACHS and Regional Meetings.
q. 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.
7. 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 AWA/ CARE County billing summary.
(3) Submit a Funds Match Certification (Exhibit C) with the final contract billing.
DSHS Central Contract Services Page 10
1769CS County Agreement 6-15-2017
Special Terms and Conditions
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:
(a) Employment services.
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/hour.
(b) Community Access services will not exceed an hourly rate of $35.00.
(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
DSHS Central Contract Services Page 11
1769CS County Agreement 6-15-2017
Special Terms and Conditions
work, or to an Adult Day Care service other than Level I I 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.
8. 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
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 generic job
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
DSHS Central Contract Services Page 12
1769CS County Agreement 6-15-2017
Special Terms and Conditions
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 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.
(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
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
DSHS Central Contract Services Page 13
1769CS County Agreement 6-15-2017
Special Terms and Conditions
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 Signed 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 Program 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.
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 reimbursement.
(3) A "Month" represents a minimum of one service visit which is at least fifty (50) minutes of direct
service for CDS reimbursement.
f. 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
https://www.dshs.wa.gov/dda/county-best-pi'actices.
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
https://www-dshs,wa.gov/dda/coLinty-best-practices.
i. Timeliness of and Modification to Billings: All initial invoices with signed documentation must be
DSHS Central Contract Services Page 14
1769CS County Agreement 6-15-2017
Special Terms and Conditions
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.
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.
k. PASRR Administration: The County may bill for administration costs as identified in Exhibit B.
Monthly claims for administration cost will be based on the actual PASRR expenditures multiplied
by 7%.
9. 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.
10. 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.
11. 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.
DSHS Central Contract Services Page 15
1769CS County Agreement 6-15-2017
Exhibit A
Data Security Requirements
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. All Electronic Data must be encrypted using at least an encryption
standard of AES 128 bit. Electronic Data can be on desktops, laptops and other portable devices,
servers, and external media:
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.
DSHS Central Contract Services Page 16
1769CS County Agreement 6-15-2017
Exhibit A
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.
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
DSHS Central Contract Services Page 17
1769CS County Agreement 6-15-2017
Exhibit A
(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.
(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.
DSHS Central Contract Services Page 18
1769CS County Agreement 6-15-2017
Exhibit A
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:
Server or workstation hard disks, or
Removable media (e.g. floppies, USB flash drives,
portable hard disks) excluding optical discs
Paper documents with sensitive or Confidential
Information
Will be destroyed by:
Using a "wipe" utility which will overwrite the Data at
least three (3) times using either random or single
character data, or
Degaussing sufficiently to ensure that the Data
cannot be reconstructed, or
the disk
Recycling through a contracted firm provided the
contract with the recycler assures that the
confidentialitv of Data will be protected.
Paper documents containing Confidential Information On-site shredding, pulping, or incineration
requiring special handling (e.g. protected health
information)
Optical discs (e.g. CDs or DVDs) Incineration, shredding, or completely defacing the
readable surface with a coarse abrasive
Magnetic tape Degaussing, incinerating 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.
7. 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 Page 19
1769CS County Agreement 6-15-2017
Exhibit B
Program Agreement Budget
XXX Original Budget Budget Revision
REVENUES
Fiscal
Year
Fund Source
Oriqinal 1St Revision
2nd Revision
3rd Revision
2018
State onlv
Waiver
155,562
0
0
9,817
8.032
17,849
Waiver
Local
Local
Medicaid Match to Local
0
Child Development
Total Rev,
$291,930 $
$
$
Total Rev.
$
$
Fiscal
Year
Fund Source
Oriqinal
1St Revision
2nd Revision
3rd Revision
2019
State
0
0
9,817
8.032
17,849
Waiver
Local
0
15,499
0
Child Development
Medicaid Match to Local
Total Rev.
$
$
$
$
COUNTY FY 18 SPENDING PLAN
DSHS Central Contract Services Page 20
1769CS County Agreement 6-15-2017
Planned Expenditures
Local PASRR Medicaid
Funds Funds State Funds Funds TOTAL
ADMINISTRATION (CMIS/AWA
BARS 11)
OTHER CONSUMER SUPPORTS
(CMIS/AWA Code 31, 32, 41, 92,
93.94)
0
0
10,504
8,594
19,098
0
0
9,817
8.032
17,849
CONSUMER SUPPORT
STATE -ONLY
0
15,499
0
Child Development
15,499
MEDICAID CLIENTS
0 119,742
119,742
239,484
ROADS to COMMUNITY LIVING
0
0
0
TOTAL
0
0
155,562
136,368
291,930
DSHS Central Contract Services Page 20
1769CS County Agreement 6-15-2017
Exhibit C
Funds Match Certification
(This form must be submitted with final contract billing.)
I,
PRINT NAME
TYPE AND SOURCE OF PRIVATE / LOCAL FUNDS / ITEMS
TYPE AND SOURCE OF NON-PROFIT FUNDS / ITEMS
TYPE AND SOURCE OF FEDERAL FUNDS / ITEMS
and were used to match funds paid during the time period
TYPE OF SERVICE/CONTRACT
certify that local funds and/or in-kind items
- were provided in the amount of I
- were provided in the amount of I
- were provided in the amount of _$
through
NAME OF ENTITY
NAME OF AUTHORIZED AGENT CONTRACT/ VENDOR NUMBER
AUTHORIZED REPRESENTATIVE'S SIGNATURE DATE TITLE OR POSITION
PRINTED NAME OF AUTHORIZED REPRESENTATIVE TELEPHONE NUMBER
Name:
Type and source of funds:
Dollar amount:
Time frame:
Type of service/Contract:
Name of entity:
Name of authorized agent:
Contract/vendor number:
Authorized representative's signature:
Date:
Title or position:
Printed name:
Instructions
Printed name of the entity's agent authorized to complete certification form.
The type and source of funds used. Please break out different types of funding sources. Not
all funding sources will be necessary to complete each certification. In-kind sources need
specific identification showing who donated the item(s) (e.g., volunteers, building use, etc.).
Dollars that were used to match funds paid during the time period. Dollars reported must
agree with amount on the final billing.
Period of time the services were provided.
Services eligible for matching.
Name of entity that is providing the funding match.
Name of agent, if different than "name of entity" above, that is authorized to act on behalf of
entity.
The contract or vendor number of the entity.
The signature of the entity authorized representative.
Date when form was completed.
Title or position of entity authorized representative
Printed name of authorized representative.
Telephone number: Telephone number of authorized representative. Include the area code
for
DSHS Central Contract Services Page 21
1769CS County Agreement 6-15-2017