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Home My WebLink AboutWashington State Department of Social and Health Services, Amendment No. 1 - 052118 aialr9 .... .(1-1,E--it S -al-if •Wk,k -, 93Ji3,, AV W a s h l n p f a n State COUNTY PROGRAM Or INTERLOCAL 1763-88836 Department of Social DSHS CONTRACT NUMBER: &Health Services Amendment No. 01 LONG-TERM PAYABLE AGREEMENT Transforming lives AMENDMENT This Amendment is between the State of Washington Department of Social and Program Contract Number Health Services(DSHS)and the Contractor identified below. Click here to enter text. Contractor Contract Number CONTRACTOR NAME CONTRACTOR doing business as(DBA) Jefferson County 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 i s Susan Parke (360)385-9400 (360)385-9401 _sparke@co.jefferson.wa.us DSHS ADMINISTRATION DSHS DIVISION DSHS CONTRACT CODE Services and Enterprise Support Central Contracts&Legal 8030CS-63 r Administration Services DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS William Taplin 1111 Washington St South Contracts Manager I Olympia.WA 98504-5811 DSHS;CONTACT TFI FPHONE DSHS CONTACT FAX DSHS CONTACT EMAIL ADDRESS (360)664-6046 Click here to enter text. tapliwh(c dshs.wa.gov IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES QF THIS CONTRACT? CFDA NUMBERS i No l AMENDMENT START DATE CONTRACT END DATE r t 07/01/2018 06/30/2019 I PRIOR MAXIMUM CONTRACT AMOUNT AMOUNT OF INCREASE OR DECREASE TOTAL MAXIMUM CONTRACT AMOUNT $0.00 N/A Based on Annual Review i 5 REASON FOR AMENDMENT; CHANGE OR CORRECT PERIOD OF PERFORMANCE r ATTACHMENTS. When the box below is marked with an X,the following Exhibits are attached and are incorporated into I this Amendment by reference: I El Additional Exhibits(specify)'- i This Amendment,including all Exhibits and other documents incorporated by reference,contains all of the terms and I conditions agreed upon by the parties as changes to the original County Program Agreement or Interlocal Agreement. No other understandings or representations,oral or otherwise,regarding the subject matter of this Amendment shall be deemed to exist or bind the parties. All other terms and conditions of the original County Program Agreement or Interlocal Agreement remain in full force and effect. The parties signing below warrant that they have read and understand this Amendment,and -ve authority to enter into this Amendment. CONTRACTOR - R.E. PRIN I tO NAME AND TITLE DATE SIGNED t bVi[I crilll[Ii�l'sf4+fl Ona r . Qtd 14e- )eiNAMA tcrnm ton (N 5/71 t h Y i DSHS SIGNATURE PRINTED NAME AND TITLE DATESIGNED Laura Wood,Contract Manager /fg#.,11.,(A"it- � DSHS Central Contracts and Legal Services 5/g 9: Cs, Date:, il . 1 Phifip C.`Hunsucker,Chief Civil Deputy Prosecuting arney Jefferson County Prosecuting Attorney's Office DSHS Central Contracts and Legal Services Page 1 6046 LF Long-Term Payable Amendment —1//tfil O'rlitAl 46A7r a aP-11 VW 104014,L , i This Agreement between the State of Washington Department of Social and Health Services(DSHS) and the Contractor is hereby amended as follows: 1. DSHS extends the Agreement End Date twelve months from June 30,2018,to June 30, 2019, as stated on Page One of this Amendment. All other terms and conditions of this Agreement remain in full force and effect. DSHS Central Contracts and Legal Services Page 2 8046 LF Long-Term Payable Amendment(5-2-18) DSHS CONTRACT NUMBER: Washington State COUNTY PROGRAM or INTERLOCAL 1763-88836 At Department of Social &Health Services Amendment No. 01 LONG-TERM PAYABLE AGREEMENT Transforming lives AMENDMENT This Amendment is between the State of Washington Department of Social and Program Contract Number Health Services (DSHS) and the Contractor identified below. Click here to enter text. Contractor Contract Number CONTRACTOR NAME CONTRACTOR doing business as(DBA) Jefferson County CONTRACTOR ADDRESS WASHINGTON UNIFORM BUSINESS DSHS INDEX NUMBER IDENTIFIER(UBI) 615 Sheridan St Port Townsend, WA 98368- 161-001-169 1223 CONTRACTOR CONTACT CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS Susan Parke (360) 385-9400 (360) 385-9401 sparke@co.jefferson.wa.us DSHS ADMINISTRATION DSHS DIVISION DSHS CONTRACT CODE Services and Enterprise Support Central Contracts & Legal 8030CS-63 Administration Services DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS William Taplin 1111 Washington St South Contracts Manager Olympia, WA 98504-5811 DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS (360)664-6046 Click here to enter text. tapliwh@dshs.wa.gov IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? CFDA NUMBERS No AMENDMENT START DATE CONTRACT END DATE 07/01/2018 06/30/2019 PRIOR MAXIMUM CONTRACT AMOUNT AMOUNT OF INCREASE OR DECREASE TOTAL MAXIMUM CONTRACT AMOUNT $0.00 N/A Based on Annual Review REASON FOR AMENDMENT; CHANGE OR CORRECT PERIOD OF PERFORMANCE ATTACHMENTS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into this Amendment by reference: Er Additional Exhibits (specify): This Amendment, including all Exhibits and other documents incorporated by reference, contains all of the terms and conditions agreed upon by the parties as changes to the original County Program Agreement or Interlocal Agreement. No other understandings or representations, oral or otherwise, regarding the subject matter of this Amendment shall be deemed to exist or bind the parties. All other terms and conditions of the original County Program Agreement or Interlocal Agreement remain in full force and effect. The parties signing below warrant that they have read and understand this Amendment, and ve authority to enter into this Amendment. CONTRACTOR SI NA URE . PRINTED NAME AND TITLE DATE SIGNED bQ,ViCCA 146a'LCy-saivMCLt� b2alet o. jE. 1 CAA nealtrn,ssiDoc r5 / `/O DSHS SIGNATURE PRINTED NAME AND TITLE DATE SIGNED Laura Wood, Contract Manager DSHS Central Contracts and Legal Services Aprproved y o fo tr. Date: 5.//i /� ` Philip C. Hunsucker,Chief Civil Deputy Prosecuting ttorney Jefferson County Prosecuting Attorney's Office DSHS Central Contracts and Legal Services Page 1 6046 LF Long-Term Payable Amendment(5-2-18) This Agreement between the State of Washington Department of Social and Health Services (DSHS) and the Contractor is hereby amended as follows: 1. DSHS extends the Agreement End Date twelve months from June 30, 2018, to June 30, 2019, as stated on Page One of this Amendment. All other terms and conditions of this Agreement remain in full force and effect. DSHS Central Contracts and Legal Services Page 2 6046 LF Long-Term Payable Amendment(5-2-18) 615 Sheridan Street 4( Port Townsend, WA 98368 , Almon www.JeffersonCountyPublicHealth.org Public Healt Consent Agenda May 10, 2018 JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS AGENDA REQUEST TO: Board of County Commissioners Philip Morley, County Administrator FROM: Vicki Kirkpatrick, Director Susan Parke, Financial Operations Coordinator DATE: ike( 01 ( i SUBJECT: Agenda Item – Amendment No. 1 to program agreement with DSHS for Long-term Payables; July 1, 2018—June 30, 2019 STATEMENT OF ISSUE: Jefferson County Public Health requests Board approval of Amendment No. 1 to the program agreement with DSHS for Long-term Payables; July 1, 2018 - June 30, 2019. ANALYSIS/STRATEGIC GOALS/PRO'S and CON'S: This amendment extends the agreement date twelve months from June 30, 2018 to June 30, 2019. The purpose of the original agreement is to advances funds, in anticipation of the actual approval of those plans filed by the Contractor (JCPH) with DSHS for the Division of Developmental Disabilities (DDD) program operated during the contract period. FISCAL IMPACT/COST BENEFIT ANALYSIS: This contract has no fiscal impact. RECOMMENDATION: Jefferson County Public Health requests Board approval of Amendment No. 1 to the program agreement with DSHS for Long-term Payables; July 1, 2018 - June 30, 2019. REVIEWED BY: t 6 P 37/7/ Philia.Morley, Cou, ty Administrator 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 ff A Port Townsend, WA 98368 �. �eehson www.JeffersonCountyPublicHealth.org Public Heat AD-17-14-A1 CONTRACT REVIEW FORM *a 1 7 2C18 CONTRACT WITH: DSHS CONTRACT FOR: Long-term payables TERM: July 1, 2018—June 30, 2019 COUNTY DEPARTMENT: Jefferson County Public Health For More Information Contact: Susan Parke Contact Phone #: X437 RETURN TO: Jenny Matter RETURN BY: ASAP AMOUNT: PROCESS: 0 Exempt from Bid Process 0 Consultant Selection Process Revenue: 0 Cooperative Purchase Expenditure: 0 Competitive Sealed Bid Matching Funds Required: 0 Small Work Roster Source(s) of Matching Funds: 0 Vendor List Bid 0 RFP or RFQ x Other: DSHS Step 1: REVIEW BY RISK MANAGI ' N Review by: ,� ' P Atat ll 7 2 Date Reviewe6:- ` ) p APPROVED FORM 0 Re urned for revision (See Comments) Comments: Step . REVIEW BY PROSTING TT S R Review by: V):71: Date Revie ed: APPROVED AS TO FORM /eturned for revision (See Comments) Comments: *0.414.441)4f.672444 ` a ,n,1 f.6 .i/_ _ they;eiA,444,44, (This form to stay with contract throughout the contract review process) 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 DSHS Agreement Number COUNTY 1763-88836 )''''-k 4`7a,,,, ,;,,si,„ gF �rsftv;C `TH PROGRAM AGREEMENT Working Advance Long-Term Payable This Program Agreement is by and between the State of Washington Department of Administration or Division Social and Health Services(DSHS) and the County identified below, and is issued in Agreement Number 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 Executive Administration Operation Support and 1223 8030CS-63 Services Division DSHS CONTACT NAME AND TITLE -DSHS CONTACT ADDRESS Angela Williams 1115 S Washington St Contracts Supervisor Olympia WA 98504-5811 DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL (360)664-6046 (3601664-6184 williah@dshs.wa.gov COUNTY NAME COUNTY ADDRESS Jefferson County 615 Sheridan St Port Townsend WA 98368 COUNTY CONTACT NAME Susan Parke COUNTY CONTACT TELEPHONE COUNTY CONTACT FAX COUNTY CONTACT E-MAIL (360) 385-9400 (360) 385-9401 sparkeco.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 Based on Annual Review The terms and conditions of this Contract are an integration and representation of the final, entire and exclusive understanding between the parties superseding and merging all previous agreements, writings, and communications, oral or otherwise, regarding the subject matter of this Contract. The parties signing below represent that they have read and understand this Contract, and have the authority to execute this Contract. This Contract shall be binding on DSHS only upon signature by DSHS. COUNTY SIGNATURE(S) PRINTED NAME(S)AND TITLE(S) DATE(S)SIGNED -9I -Zi-/-C-e'Vt-- -62,, Icon (er- S l ctlictie, e DSHS SIGNATURE PRINTED NAME AND TITLE DATE SIGNED IlkAngie Williams, Contract Manager DSHS Central Contracts and Legal Services 1''�"'j _) DSHS Central Contract Services 8030CS County Long-Term Payable(3-28-2017) Page 1 SPECIAL TERMS AND CONDITIONS 1. Definitions a. "Commingle" is the act of mixing the funds and/or Long-Term Payables for one program with the funds of another program. b. "Documentation of Funds form" (DOF) is a form provided to the County each year by DSHS on which the County records qualifying previous year expenditures from which DSHS can appraise and evaluate the amount of the existing Long-Term Payable or appropriate adjustments. c. "Long-Term Payable" means funds provided by DSHS to the County in anticipation of specific client services provided by the County. The County shall not be allowed to retain any overage of the Long-Term Payable funds if the County does not actually provide the anticipated services during the given timeframe. Long-Term Payable funds are to be reconciled by April 30 of each year and any funds not fully utilized shall be refunded to DSHS by May 31 of each year. 2. Purpose a. It is the purpose of this Agreement to specify the procedure by which DSHS will assess and, if necessary, adjust the Long-Term Payable it provides to the County. b. Funds to support contracts for the following DSHS programs may be included in a Long-Term Payable: Developmental Disabilities Administration (DDA) and/or Aging and Long-Term Support Administration (ALTSA). 3. Statement of Work a. County Responsibilities (1) The County shall submit to DSHS, on forms provided by DSHS and by a date determined by DSHS, a completed Documentation of Funds form (DOF) from which DSHS shall assess whether or not an adjustment to the amount of the Long-Term Payable provided to the County is warranted. (2) The County shall exclude all amounts related to its Prepaid Inpatient Health Plan expenditures from its DOF. (3) The County shall repay to DSHS all of the Long-Term Payable funds received from DSHS that exceed the amount that DSHS determines is warranted. Repayment requirements shall be based upon DSHS assessment of the most recent annual DOF submitted by the County to DSHS. Any Long-Term Payable funds not fully utilized by the County, as determined by DSHS through the DOF process, shall be refunded to DSHS by May 31 of each year. (4) The County shall only utilize Long-Term Payable funds for the DSHS program or service for which the funds were originally designated. Long-Term Payable funds may not be commingled between or among programs or services. (5) Any interest the County earns on the Long-Term Payable funds shall only be utilized for the DSHS programs or services for which the funds were originally designated. Long-Term Payable interest shall not be used for programs or services unrelated to the client services anticipated by this Agreement. (6) The County shall record the Long-Term Payables in its financial records. DSHS Central Contract Services 8030CS County Long-Term Payable(3-28-2017) Page 2 SPECIAL TERMS AND CONDITIONS b. DSHS Responsibilities (1) DSHS shall assess the DOF submitted by the County to determine if, during the term of this Agreement, any adjustment to the original two month Long-Term Payable provided to the County is warranted. (2) Adjustment may include DSHS request for repayment by County of any Long-Term Payable amounts previously paid to County that are in excess of the amount currently warranted. 4. Termination In the event that this Agreement, or a program contract listed in 2.b. above, is terminated prior to completion, DSHS shall take all available steps to recover any Long-Term Payable determined to be an overpayment and the County shall fully cooperate during the recovery process. DSHS Central Contract Services 8030CS County Long-Term Payable(3-28-2017) Page 3