Loading...
HomeMy WebLinkAboutWashington State, Department of Social and Health Services, Developmental Disabilities Adminstration (DSHS), Amendment No. 1 -112017Ap/B,�-e has — �L-� - Date: /I / Philip C. Hunsucker, Chief Civil Deputy Prosecuting Attorney Jefferson County Prosecuting Attorney's Office DSHS Central Contract Services Page 1 6024PF Contract Amendment (3-31-06) DSHS CONTRACT NUMBER: CONTRACT AMENDMENT 1763-961 //��MMington Scate �, UCIARTMENTOf DDA Count Services SUCIALRVICES H y SERVICES -� Amendment No. 01 This Contract Amendment is between the State of Washington Department of Program Contract Number Social and 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 County DDA County Services 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 Anna McEnr 360 385-9410 360 385-0073 amcenery@co.jefferson.wa.us DSHS ADMINISTRATION DSHS DIVISION DSHS CONTRACT CODE Developmental Disabilities Admin Division of Developmental 1769CS-63 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 ADDRESS 360 725-4264 360 586-6502 winchwa@dshs.wa.gov IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? CFDA NUMBERS No AMENDMENT START DATE CONTRACT END DATE 07/01/2017 06/30/2018 PRIOR MAXIMUM CONTRACT AMOUNT AMOUNT OF INCREASE OR DECREASE TOTAL MAXIMUM CONTRACT AMOUNT $291,930.00 $5,342.00 $297,272.00 REASON FOR AMENDMENT; CHANGE OR CORRECT MAXIMUM CONTRACT AMOUNT ATTACHMENTS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into this Contract Amendment by reference: ® Additional Exhibits (specify): Exhibit B1 -Pro ram Agreement Budget This Contract 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 Contract. No other understandings or representations, oral or otherwise, regarding the subject matter of this Contract Amendment shall be deemed to exist or bind the parties. All other terms and conditions of the original Contract remain in full force and effect. The parties signing below warrant that they have read and understand this Contract Amendment, and have authority to enter into this Contract Amendment. CONTRACTOR SIGNATURE PRINTED NAM AND TITLF=, DATE SIGNED � -� ZoI DSHS SIGNATUREPRINTED NAME AND TITLE DATE SIGNED JOU a�' 17 Melissa Diebert, Contracts Manager Ap/B,�-e has — �L-� - Date: /I / Philip C. Hunsucker, Chief Civil Deputy Prosecuting Attorney Jefferson County Prosecuting Attorney's Office DSHS Central Contract Services Page 1 6024PF Contract Amendment (3-31-06) This Contract between the State of Washington Department of Social and Health Services (DSHS) and the Contractor is hereby amended as follows: A. Contract maximum amount is increased by $5,342 for a new contract maximum total of $297,272. B. Exhibit B, Program Agreement Budget, is revised and replaced by Exhibit B-1, Program Agreement Budget, which is attached hereto and incorporated herein. All other terms and conditions of this Contract remain in full force and effect. DSHS Central Contract Services Page 2 6024PF Contract Amendment (3-31-06) Exhibit B1 Program Agreement Budget Original Budget XXX Budget Revision REVENUES Fiscal Year Fund Source Original 1st Revision 2nd Revision 3rd Revision 2018 State only $155,562 $158,421 Local PASRR Medicaid Waiver Funds Funds State Funds Funds TOTAL Local BARS 11) Medicaid Match to Local $10,696 $8,752 $19,448 OTHER CONSUMER SUPPORTS Total Rev. $291,930 $297,272 $ $ 93,94) Fiscal Year Fund Source Original 1st Revision 2nd Revision 3rd Revision 2019 State Local PASRR Medicaid Waiver Funds Funds State Funds Funds TOTAL Local BARS 11) Medicaid Match to Local $10,696 $8,752 $19,448 OTHER CONSUMER SUPPORTS Total Rev. $ $ $ $ 93,94) TOTAL DSHS Central Contract Services 6024PF Contract Amendment (3-31-06) $158,421 1 $138,851 1 $297,2 Page 3 COUNTY FY 18 SPENDING PLAN Planned Expenditures Local PASRR Medicaid Funds Funds State Funds Funds TOTAL ADMINISTRATION (CMIS/AWA BARS 11) $10,696 $8,752 $19,448 OTHER CONSUMER SUPPORTS (CM IS/AWA Code 31, 32, 41, 92, 93,94) $9,996 $8,179 $18,175 CONSUMER SUPPORT STATE -ONLY Child Development $15,809 $15,809 $243,84 MEDICAID CLIENTS $121,920 $121;,920 0 ROADS to COMMUNITY LIVING TOTAL DSHS Central Contract Services 6024PF Contract Amendment (3-31-06) $158,421 1 $138,851 1 $297,2 Page 3 DEC 012017 DDA REG 3 Tumwater RECEIVED NOV 2 7 2017 DDA REG 3 Tumwater 615 Sheridan Street Port Townsend, WA 98368 www.JeffersonCountyPublicHealth.org Public Health Consent Agenda November 1, 2017 JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS AGENDA REQUEST TO: Board of County Commissioners Philip Morley, County Administrator FROM: Vicki Kirkpatrick, Director Anna McEnery, Developmental Disabilities Coordinator DATE: I � _x—_X' I— SUBJECT: Agenda Item — Amendment No. 1 with Department of Social and Health Services for Developmental Disabilities Administration, (DDA); July 1, 2017 — June 30, 2018; additional $5,342 for a total of $297,272 STATEMENT OF ISSUE: Jefferson County Public Health, Developmental Disabilities Division, is requesting Board approval of amendment No. 1 with Department of Social and Health Services for Developmental Disabilities Administration, (DDA); July 1, 2017 — June 30, 2018; additional $5,342 for a total of $297,272 ANALYSIS/ STRATEGIC GOALS/PRO'S and CON'S: This amendment adds funding for the continuation of services with DSHS for services to clients with developmental disabilities in Jefferson County. 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. 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. There is no impact to the general fund. RECOMMENDATION: JCPH management request approval of t amendment No. 1 with Department of Social and Health Services for Developmental Disabilities Administration, (DDA); July 1, 2017 — June 30, 2018; additional $5,342 for a total of $297,272 REVIEWED BY: Philip Morley, County inistre-or� Date Community Health Environmental Health 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 615 Sheridan Street Port Townsend, WA 98368 Mown www.JeffersonCountyPublicHealth.org Hek'1 • �As' CONTRACT REVIEW FORM CONTRACT WITH: Developmental Disabilities Administration DSHS NOV 0 2 2017 CONTRACT FOR: Proves ancoordination of local program TERMj, ' / b1t L ti, 8 services to persons with developmental disabilities. COUNTY DEPARTMENT: Jefferson County Public Health For More Information Contact: Anna McEnery Contact Phone #: X410 RETURN TO: Jenny Matter RETURN BY: ASAP AMOUNT: Add'I $5,342 for a total of $297,272 Revenue: $297,272 Expenditure: Matching Funds Required: Source(s): PROCESS: ❑ Exempt from Bid Process Fully Funded Inter -local agreement Step 1: REVIEW BY RI Review by: Date Revie APPROVED FORM mments: ❑ Consultant Selection Process ❑ Cooperative Purchase ❑ Competitive Sealed Bid ❑ Small Work Roster ❑ Vendor List Bid ❑ RFP or RFQ 0 Other: DSHS funding rned for revision (See Comments) Step 2: REVIEW BY PROS TING A T Y Review by: Date Reviewed: P APPROVED AS TO FORM Returned for revision (See Comments) Comments: O -AA 1014,,K (This form to stay with contract throughout the contract review process) Community Health Developmental Disabilities 360-385-9400 360-385-9401 (t) Environmental Water Always working for a safer and healthier community (t) Ap _Mvedd a tc f Philip C. Hunsucker, Chief Civil Deputy Prosecuting k Jefferson County Prosecuting Attorney's Office DSHS Central Contract Services 1769CS County Agreement 6-15-2017 Page 1 DSHS Agreement Number COUNTY WW"gion Vift 1763-96185 merA of Social all1kal"Ith Services . ... .... 11-1.1 PROGRAM AGREEMENT Transforming lives - --11111- 1 1-1 1 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 I RNional Business Manager Olympia, WA 98504-5315 DSHS CONTACT TELEPHONE T—DSHS CONTACT FAX DSHS CONTACT E-MAIL (360) 725-4264 (36 ) 586-6502 winchwa@dshs.wa.aov 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 COUNTY CONTACT TELEPHONE COUNTY CONTACT FAX COUNTY CONTACT E-MAIL 1 (360) 385-9410 (361385-0073 amcenecojefferson.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 $2911,930.00. 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 they are authorized to sign this Program Acireement. COUNTY SIGNATURE(S) PRINTED NAME(S) AND TITLE(S) DATE(S) SIGNED I<IE?r al r) r-�&yl 0) UNV—obw Kt Ss I �y feV' S DSHS SIGNATURE PRINTED NAME AND TITLE DATE SIGNED LaMelissa Diebert, Contracts Manager Ap _Mvedd a tc f Philip C. Hunsucker, Chief Civil Deputy Prosecuting k Jefferson County Prosecuting Attorney's Office DSHS Central Contract Services 1769CS County Agreement 6-15-2017 Page 1 Special Terms and Conditions 1.. 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 385-323 WAC who is currently eligible and active with the Developmental Disabilities Administration or is an identified PASRR Client. f. "CMTS" 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 DSHS Central Contract Services Page 2 1769CS County Agreement 6-15-2017 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. i. "CRM" means the DDA Case Resource Manager. j. "CSA" means County Service Authorization. k. "DD" means developmental disabilities. I. "DDA" means the Developmental Disabilities Administration within DSHS. m. "DDA Region" means the DDA Regional office. n. "DVR" means the Division of Vocational Rehabilitation. DSHS Central Contract Services Page 3 1769CS County Agreement 6-15-2017 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. DSHS Central Contract Services Page 4 1769CS County Agreement 6-15-2017 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. 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, 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 CMTS system; DSHS Central Contract Services Page 6 176905 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 https://www,dshs.WA.gov/dda/county-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.aov/dda/countv-best-Dra,ctippli) 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 DSHS Central Contract Services Page 7 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 CMTS 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. DSHS Central Contract Services Page 8 1769CS County Agreement 6-15-2017 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 DSHS Central Contract Services Page 9 1769CS County Agreement 6-15-2017 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. 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/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 Ill 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 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. 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 CMTS 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. 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 aoy/ da/count best -practices. 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 httr)s://www.dshs.MLa.gov/ddalcountv-best-oractices. 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, 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. 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 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. 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: Will be destroyed by: Server or workstation hard disks, or Using a "wipe" utility which will overwrite the Data at least three (3) times using either random or single Removable media (e.g. floppies, USB flash drives, character data, or portable hard disks) excluding optical discs Degaussing sufficiently to ensure that the Data cannot be reconstructed, or Physically destroving the disk Paper documents with sensitive or Confidential Recycling through a contracted firm provided the Information contract with the recycler assures that the confidentiality 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 Ma netic tape.,,,,,,.,,___ De aussin , 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 Original 18t Revision 2nd Revision 3rd Revision 2018 State only 155,562 Waiver Local Medicaid Match to Local Total Rev. $291,930 $ $ $ Fiscal Year Fund Source Ori final 1gt Revision 2"d Revision 3rd Revision 2019 State Waiver Local Medicaid Match to Local Total Rev, $ $ $ $ CONSUMER SUPPORT TOTAL NE am 1 1 i�T� . .: * • 1 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, certify that local funds and/or in-kind items PRINT NAME - were provided in the amount of I TYPE AND SOURCE OF PRIVATE / LOCAL FUNDS / ITEMS - were provided in the amount of I TYPE AND SOURCE OF NON-PROFIT FUNDS / ITEMS - were provided in the amount of I TYPE AND SOURCE OF FEDERAL FUNDS / ITEMS and were used to match funds paid during the time period of through for TYPE OF SERVICE/CONTRACT 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 Instructions Name: Printed name of the entity's agent authorized to complete certification form. Type and source of funds: 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;), Dollar amount: Dollars that were used to match 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/Contract: Services eligible for matching. Name of entity: Name of entity that is providing the funding match. Name of authorized agent: Name of agent, if different than "name of entity" above, that is authorized to act on behalf of entity. Contract/vendor number: The contract or vendor number of the entity. Authorized representative's signature: The signature of the entity authorized representative. Date: Date when form was completed. Title or position: Title or position of entity authorized representative Printed name: Printed name of authorized representative. Telephone number: Telephone number of authorized representative. Include the area code DSHS Central Contract Services Page 21 1769CS County Agreement 6-15-2017