HomeMy WebLinkAbout021621_ca09JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: David Fortino, Jail Superintendent
DATE: February 16, 2021
SUBJECT: AGREEMENT re: K4821- Medication Project; In the Amount
of $25,000; Jefferson County Sheriffs Office/Jail; Washington State
Health Care Authority
STATEMENT OF ISSUE:
AGREEMENT re: K4821 - Medication Project; In the Amount of $25,000; Jefferson County Sheriff's
Office/Jail; Washington State Health Care Authority.
ANALYSIS:
This agreement with WA State Health Care Authority provides supplemental funding for Medications for
the Opioid Treatment Network at the Jefferson County Jail.
FISCAL IMPACT:
Maximum reimbursement allowed is $25,000.
RECOMMENDATION:
Approve AGREEMENT re: K4821 - Medication Project; In the Amount of $25,000; Jefferson County
Sheriff's Office/Jail; Washington State Health Care Authority.
V� W y•
/�12t
P orley, mistrator Date
Washington StateINTERAGENCY
AGREEMENT
HCA Contract Number: K4821
Health CareAu"t-h-oriW7
for
Medication Project
Contractor Contract Number:
THIS AGREEMENT is made by and between Washington State Health Care Authority (HCA) and Jefferson
County, Contractor, pursuant to the authority granted by Chapter 39.34 RCW.
CONTRACTOR NAME
CONTRACTOR DOING BUSINESS AS (DBA)
Jefferson County
Sheriff's Office
CONTRACTOR ADDRESS I Street
City
State
Zip Code
79 Elkins Road;
Port Hadlock
WA
98339-9700
CONTRACTOR CONTACT
CONTRACTOR TELEPHONE
CONTRACTOR E-MAIL ADDRESS
David Fortino
360-344-9734
dfortino[cD-coJefferson.wa.us
Is Contractor a Subrecipient under this Contract?
CFDA NUMBER: 93.788
FFATA Form Required
®YES [NO
DUNs NUMBER: 619143741
®YES ONO
HCA PROGRAM
State Opioid Response
HCA CONTACT NAME AN
Amy Dura, State Opioid Response Treatment Manager
HCA DIVISION/SECTION
DBHR/SUD Treatment
HCA CONTACT ADDRESS
Health Care Authority
626 8th Avenue SE
PO Box 42730
Olympia, WA 98504-2730
HCA CONTACT TELEPHONE HCA CONTACT E-MAIL ADDRESS
(360) 725-2019 amy.duraLa-)tg@.wa.gov
CONTRACT START DATE CONTRACT END DATE TOTAL MAXIMUM CONTRACT AMOUNT
09/30/2020 09/29/2021 $25, 000
PURPOSE OF CONTRACT:
No cost extension state opioid response grant, medication project with the OTN jails and fire department in order to
cover cost of medication prior to release and immediately following release from jails. It also includes Naloxone.
The parties signing below warrant that they have read and understand this Contract, and have authority to execute this
Contract. This Contract will be binding on HCA only upon signature by both parties.
CONTRACTOR SIGNATURE
PRINTED NAME AND TITLE
DATE SIGNED
HCA SIGNATURE
PRINTED NAME AND TITLE
DATE SIGNED
Approve as to roan:
(9. G February 12, 2021
Philip C. Hunsucker,
Chief Civil Deputy Prosecuting Attorney
Washington State
Health Care Authority
Page 1 of 28
HCA IAA K4821
1. DEFINITIONS
"Authorized Representative" means a person to whom signature authority has been delegated in
writing acting within the limits of the person's authority.
"CFR" means the Code of Federal Regulations. All references in this Contract to CFR chapters or
sections include any successor, amended, or replacement regulation. The CFR may be accessed at
http://www.eefr.goy/cai-bin/ECFR?Pape=browse.
"Confidential Information" means information that may be exempt from disclosure to the public or
other unauthorized persons under chapter 42.56 RCW or chapter 70.02 RCW or other state or
federal statutes or regulations. Confidential Information includes, but is not limited to, any information
identifiable to an individual that relates to a natural person's health, finances, education, business,
use or receipt of governmental services, names, addresses, telephone numbers, social security
numbers, driver license numbers, financial profiles, credit card numbers, financial identifiers and any
other identifying numbers, law enforcement records, HCA source code or object code, or HCA or
State security information.
"Contract" or "Agreement" means the entire written agreement between HCA and the contractor,
including any exhibits, documents, or materials incorporated by reference. The parties may execute
this contract in multiple counterparts, each of which is deemed an original and all of which constitute
only one agreement. E-mail (electronic mail) or fax (facsimile) transmission of a signed copy of this
contract shall be the same as delivery of an original. Contract and Agreement may be used
interchangeably.
"Contractor" means Jefferson County, its employees and agents. Contractor includes any firm,
provider, organization, individual or other entity performing services under this Agreement. It also
includes any Subcontractor retained by Contractor as permitted under the terms of this Agreement.
"Data" means information disclosed, exchanged or used by Contractor in meeting requirements
under this Agreement. Data may also include Confidential Information as defined in this Contract.
"DBHR" means the Division of Behavioral Health and Recovery, a division of the Washington
State Health Care Authority.
"Health Care Authority" or "HCA" means the Washington State Health Care Authority, any
division, section, office, unit or other entity of HCA, or any of the officers or other officials lawfully
representing HCA.
"Services" means all work performed or provided by Contractor pursuant to this Contract.
"Statement of Work" or "SOW" means a detailed description of the work activities the Contractor is
required to perform under the terms and conditions of this Contract, including the deliverables and
timeline, and is attached as Schedule A.
"Subcontractor" means a person or entity that is not in the employment of the Contractor, who is
performing all or part of the business activities under this Agreement under a separate contract with
Contractor. The term "Subcontractor' means subcontractor(s) of any tier.
Washington State Page 2 of 28 HCA IAA K4821
Health Care Authority
"Subrecipient" shall have the meaning given in 45 C.F.R. 75.2, or any successor or replacement to
such definition, for any federal award from HHS; or 2 C.F.R. 200.93, or any successor or
replacement to such definition, for any other federal award.
2. STATEMENT OF WORK
Contractor will furnish the necessary personnel, equipment, material and/or service(s) and otherwise
do all things necessary for or incidental to the performance of work set forth in Schedule "A"
3. PERIOD OF PERFORMANCE
Subject to its other provisions, the period of performance of this Contract will commence on
September 30, 2020, and be completed on September 29, 2021, unless terminated sooner or
extended upon written agreement between the parties.
4. PAYMENT
4.1. Compensation for the work provided in accordance with this Agreement has been established
under the terms of RCW 39.34.130. The parties have determined that the cost of accomplishing
the work herein will not exceed $25,000. Payment for satisfactory performance of the work will
not exceed this amount unless the parties mutually agree to a higher amount. Compensation for
services will be based on the following rates or in accordance with the following terms, or as set
forth in accordance with Schedule "A".
4.2. Federal funds disbursed through this Contract were received by HCA through OMB Catalogue
of Federal Domestic Assistance (CFDA) Number: 93.788, SAMHSA Center for Substance
Abuse Treatment, 61-179TI081705-021-001, Washington State Opioid Response (SOR) Grant.
Contractor agrees to comply with applicable rules and regulations associated with these federal
funds and has signed Attachment 2: Federal Compliance, Certification and Assurances,
attached.
5. OVERPAYMENTS TO CONTRACTOR
In the event that overpayments or erroneous payments have been made to the Contractor
under this Contract, HCA will provide written notice to Contractor and Contractor will refund the
full amount to HCA within thirty (30) calendar days of the notice. If Contractor fails to make
timely refund, HCA may charge Contractor one percent (1%) per month on the amount due,
until paid in full. If the Contractor disagrees with HCA's actions under this section, then it may
invoke the dispute resolution provisions of Section 12. Disputes.
6. BILLING PROCEDURE
6.1. Contractor must submit accurate invoices to the following address for all amounts to be paid by
HCA via e-mail to amy.dura@hca.wa.gov. Include the HCA Contract number in the subject line
of the email.
6.2. Invoices must describe and document to HCA's satisfaction a description of the work performed,
the progress of the project, and fees. If expenses are invoiced, invoices must provide a detailed
Washington State Page 3 of 28 HCA IAA K4821
Health Care Authority
breakdown of each type. Any single expense in the amount of $50.00 or more must be
accompanied by a receipt in order to receive reimbursement. All invoices will be reviewed and
must be approved by the Contract Manager or designee prior to payment.
6.3. Contractor must submit properly itemized invoices to include the following information, as
applicable:
6.3.1 HCA Contract number K4821;
6.3.2 Contractor name, address, phone number;
6.3.3
Description of Services;
6.3.4
Date(s) of delivery;
6.3.5
Net invoice price for each item;
6.3.6
Applicable taxes;
6.3.7
Total invoice price; and
6.3.8 Payment terms and any available prompt payment discount.
6.4. Contractor will return incorrect or incomplete invoices for correction and reissue. The Agreement
number must appear on all invoices, bills of lading, packages, and correspondence relating to
this Agreement.
6.5. Payment will be considered timely if made within thirty (30) calendar days of receipt of properly
completed invoices. Payment will be directly deposited in the bank account or sent to the
address Contractor designated in this Agreement.
6.6. Upon expiration or termination any claims for payment for costs due and payable under this
Agreement that are incurred prior to the expiration date must be submitted by Contractor within
sixty (60) calendar days after the expiration date. There will be no obligation to pay any claims
that are submitted -sixty-one (61) or more calendar days after the expiration date ("Belated
Claims"). Belated Claims will be paid at HCA's sole discretion, and any such potential payment
is contingent upon the availability of funds.
7. AGREEMENT CHANGES MODIFICATIONS AND AMENDMENTS
This Agreement may be amended by mutual agreement of the parties. Such amendments are not
binding unless they are in writing and signed by an Authorized Representative of each party.
8. SUBCONTRACTING
Neither the Contractor nor any Subcontractor shall enter into subcontracts for any of the work
contemplated under this Agreement without obtaining HCA's prior written approval. HCA shall have
no responsibility for any action of any such Subcontractors.
9. ASSIGNMENT
Washington State Page 4 of 28 HCA IAA K4821
Health Care Authority
The work to be provided under this Agreement, and any claim arising thereunder, is not assignable
or delegable by either party in whole or in part, without the express prior written consent of the other
party, which consent will not be unreasonably withheld.
10. CONTRACT MANAGEMENT
The Contract Manager for each of the parties, named on the face of this Contract, will be responsible
for and will be the contact person for all communications and billings regarding the performance of
this Agreement. Either party must notify the other party within thirty (30) days of change of Contract
Management. Changes in Contract Management shall require an amendment.
11. DISALLOWED COSTS
The Contractor is responsible for any audit exceptions or disallowed costs incurred by its own
organization or that of its Subcontractors.
12. DISPUTES
In the event that a dispute arises under this Agreement, it will be determined by a Dispute Board in
the following manner: Each party to this Agreement will appoint one member to the Dispute Board.
The members so appointed will jointly appoint an additional member to the Dispute Board. The
Dispute Board will review the facts, Agreement terms and applicable statutes and rules and make a
determination of the dispute. The Dispute Board will thereafter decide the dispute with the majority
prevailing. The determination of the Dispute Board will be final and binding on the parties hereto. As
an alternative to this process, either of the parties may request intervention by the Governor, as
provided by RCW 43.17.330, in which event the Governor's process will control.
13. GOVERNANCE
13.1 This Agreement is entered into pursuant to and under the authority granted by the laws of the
state of Washington and any applicable federal laws. The provisions of this Agreement will be
construed to conform to those laws.
13.2 In the event of an inconsistency in the terms of this Agreement, or between its terms and any
applicable statute or rule, the inconsistency will be resolved by giving precedence in the
following order:
13.2.1 Applicable federal and state statutes and regulations
13.2.2 Attachment 1: Confidential Information Security Requirements;
13.2.3 Attachment 2: Federal Compliance, Certifications and Assurances
13.2.4 Attachment 3: Federal Funding Accountability and Transparency Act Data Collection
Form
13.2.5 Attachment 4: Substance Abuse and Mental Health Services Administration
(SAMHSA) Award Terms;
Washington State Page 5 of 28 HCA IAA K4821
Health Care Authority
13.2.6 Attachment 5: Federal Award Table;
13.2.7 Schedule A: Statement of Work;
13.2.8 Schedule B: Special Terms Definitions; and
13.2.9 Any other provisions of the agreement, including materials incorporated by reference.
14. FEDERAL FUNDING ACCOUNTABILITY & TRANSPARENCY ACT (FFATA)
14.1 This Contract is supported by federal funds that require compliance with the Federal Funding
Accountability and Transparency Act (FFATA or the Transparency Act). The purpose of the
Transparency Act is to make information available online so the public can see how federal
funds are spent.
14.2 To comply with the act and be eligible to enter into this Contract, Contractor must have a Data
Universal Numbering System (DUNS®) number. A DUNS® number provides a method to
verify data about your organization. If Contractor does not already have one, a DUNS® number
is available free of charge by contacting Dun and Bradstreet at www.dnb.com.
14.3 Information about Contractor and this Contract will be made available on
www.uscontractorregistration.com by HCA as required by P.L. 109-282. HCA's Attachment 3:
Federal Funding Accountability and Transparency Act Data Collection Form, is considered part
of this Contract and must be completed and returned along with the Contract.
15. INDEPENDENT CAPACITY
The employees or agents of each party who are engaged in the performance of this Agreement will
not be considered for any purpose to be employees or agents of the other party.
16. RECORDS MAINTENANCE
14.4 The parties to this Agreement will each maintain books, records, documents and other
evidence which sufficiently and properly reflect all direct and indirect costs expended by either
party in the performance of the services described herein. These records will be subject to
inspection, review or audit by personnel of both parties, other personnel duly authorized by
either party, the Office of the State Auditor, and federal officials so authorized by law. All
books, records, documents, and other material relevant to this Agreement will be retained for
six years after expiration and the Office of the State Auditor, federal auditors, and any persons
duly authorized by the parties will have full access and the right to examine any of these
materials during this period.
14.5 Records and other documents, in any medium, furnished by one party to this Agreement to
the other party, will remain the property of the furnishing party, unless otherwise agreed. The
receiving party will not disclose or make available this material to any third parties without first
giving notice to the furnishing party and giving it a reasonable opportunity to respond. Each
party will use reasonable security procedures and protections to assure that records and
documents provided by the other party are not erroneously disclosed to third parties.
Washington State Page 6 of 28 HCA IAA K4821
Health Care Authority
17. RIGHTS IN DATA
Unless otherwise provided, data which originates from this Agreement will be "works for hire" as
defined by the U.S. Copyright Act of 1976 and will be owned by HCA. Data will include, but not be
limited to, reports, documents, pamphlets, advertisements, books, magazines, surveys, studies,
computer programs, films, tapes and/or sound reproductions. Ownership includes the right to
copyright, patent, register and the ability to transfer these rights.
18. CONFIDENTIALITY
Each party agrees not to divulge, publish or otherwise make known to unauthorized persons
confidential information accessed under this Agreement. Contractor agrees that all materials
containing confidential information received pursuant to this Agreement, including, but not limited to
information derived from or containing patient records, claimant file and medical case management
report information, relations with HCA's clients and its employees, and any other information which
may be classified as confidential, shall not be disclosed to other persons without HCA's written
consent except as may be required by law.
19. CONFIDENTIAL INFORMATION SECURITY
The federal government, including the State of Washington all maintain security requirements
regarding privacy, data access, and other areas. Contractor is required to comply with the
Confidential Information Security Requirements set out in Attachment 1 to this Contract and
appropriate portions of the Washington OCIO Security Standard, 141.10
(hftps.//ocio.wa.aov/policies/141-securing-information-technology-assets/14110-securing-
information-technolog)-assets).
20. SEVERABILITY
If any provision of this Agreement or any provision of any document incorporated by reference will be
held invalid, such invalidity will not affect the other provisions of this Agreement, which can be given
effect without the invalid provision if such remainder conforms to the requirements of applicable law
and the fundamental purpose of this agreement, and to this end the provisions of this Agreement are
declared to be severable.
21. SUBRECIPIENT
20.1 General
20.1.1 If the Contractor is a subrecipient (as defined in 45 CFR 75.2 and 2 CFR 200.93) of
federal awards, then the Contractor, in accordance with 2 CFR 200.501 and 45 CFR
75.501, shall:
20.1.1.1 Maintain records that identify, in its accounts, all federal awards received and
expended and the federal programs under which they were received, by
Catalog of Federal Domestic Assistance (CFDA) title and number, award
Washington State Page 7 of 28 HCA IAA K4821
Health Care Authority
number and year, name of the federal agency, and name of the pass -through
entity;
20.1.1.2 Maintain internal controls that provide reasonable assurance that the
Contractor is managing federal awards in compliance with laws, regulations,
and provisions of contracts or grant agreements that could have a material
effect on each of its federal programs;
20.1.1.3 Prepare appropriate financial statements, including a schedule of expenditures
of federal awards;
20.1.1.4 Incorporate OMB Super Circular 2 CFR 200.501 and 45 CFR 75.501 audit
requirements into all agreements between the Contractor and its
Subcontractors who are subrecipients;
20.1.2 Comply with any future amendments to OMB Super Circular 2 CFR 200.501 and 45
CFR 75.501 and any successor or replacement Circular or regulation;
20.1.3 Comply with the applicable requirements of OMB Super Circular 2 CFR 200.501 and
45 CFR 75.501 and any future amendments to OMB Super Circular 2 CFR 200.501
and 45 CFR 75.501, and any successor or replacement Circular or regulation; and
20.1.4 Comply with the Omnibus Crime Control and Safe streets Act of 1968, Title VI of the
Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title II of the
Americans with Disabilities Act of 1990, Title IX of the Education Amendments of 1972,
The Age Discrimination Act of 1975, and The Department of Justice Non -
Discrimination Regulations, 28 C.F.R. Part 42, Subparts C.D.E. and G, and 28 C.F.R.
Part 35 and 39. (Go to http://oop.gov/about/officestocr.htm for additional information
and access to the aforementioned Federal laws and regulations.)
20.2 Single Audit Act Compliance
20.2.1 If the Contractor is a subrecipient and expends $750,000 or more in federal awards
from any and/or all sources in any fiscal year, the Contractor will procure and pay
for a single audit or a program -specific audit for that fiscal year. Upon completion
of each audit, the Contractor will:
20.2.2 Submit to the Authority contact person the data collection form and reporting
package specified in OMB Super Circular 2 CFR 200.501 and 45 CFR 75.501,
reports required by the program -specific audit guide (if applicable), and a copy of
any management letters issued by the auditor;
20.2.3 Follow-up and develop corrective action for all audit findings; in accordance with
OMB Super Circular 2 CFR 200.501 and 45 CFR 75.501, prepare a "Summary
Schedule of Prior Audit Findings."
20.3 Overpayments
Washington State Page 8 of 28 HCA IAA K4821
Health Care Authority
20.3.1 If it is determined by HCA, or during the course of a required audit, that Contractor
has been paid unallowable costs under this or any Program Agreement, Contractor
will refund the full amount to HCA as provided in Section 5. Overpayments to
Contractors.
22. FUNDING AVAILABILITY
HCA's ability to make payments is contingent on funding availability. In the event funding from state,
federal, or other sources is withdrawn, reduced, or limited in any way after the effective date and
prior to completion or expiration date of this Agreement, HCA, at its sole discretion, may elect to
terminate the Agreement, in whole or part, or to renegotiate the Agreement subject to new funding
limitations and conditions. HCA may also elect to suspend performance of the Agreement until HCA
determines the funding insufficiency is resolved. HCA may exercise any of these options with no
notification restrictions.
23. TERMINATION
Either party may terminate this Agreement upon 30-days' prior written notification to the other party. If
this Agreement is so terminated, the parties will be liable only for performance rendered or costs
incurred in accordance with the terms of this Agreement prior to the effective date of termination.
24. TERMINATION FOR CAUSE
If for any cause, either party does not fulfill in a timely and proper manner its obligations under this
Agreement, or if either party violates any of these terms and conditions, the aggrieved party will give
the other party written notice of such failure or violation. The responsible party will be given the
opportunity to correct the violation or failure within 15 working days. If failure or violation is not
corrected, this Agreement may be terminated immediately by written notice of the aggrieved party to
the other.
25. WAIVER
A failure by either party to exercise its rights under this Agreement will not preclude that party from
subsequent exercise of such rights and will not constitute a waiver of any other rights under this
Agreement unless stated to be such in a writing signed by an Authorized Representative of the party
and attached to the original Agreement.
26. ALL WRITINGS CONTAINED HEREIN
This Agreement contains all the terms and conditions agreed upon by the parties. No other
understandings, oral or otherwise, regarding the subject matter of this Agreement will be deemed to
exist or to bind any of the parties hereto.
27. SURVIVORSHIP
The terms, conditions and warranties contained in this Agreement that by their sense and context are
intended to survive the completion of the performance, expiration or termination of this Agreement
shall so survive. In addition, the terms of the sections titled Rights in Data, Confidentiality, Disputes
and Records Maintenance shall survive the termination of this Agreement.
Washington State Page 9 of 28 HCA IAA K4821
Health Care Authority
ATTACHMENT 1
Confidential Information Security Requirements
Definitions
In addition to the definitions set out in Section 1 of this Contract, the definitions below apply to
this Attachment.
a. "Hardened Password" means a string of characters containing at least three of the following
character classes: upper case letters; lower case letters; numerals; and special characters,
such as an asterisk, ampersand or exclamation point.
Passwords for external authentication must be a minimum of 10 characters long.
ii. Passwords for internal authentication must be a minimum of 8 characters long.
iii. Passwords used for system service or service accounts must be a minimum of 20
characters long.
b. "Portable/Removable Media" means any Data storage device that can be detached or
removed from a computer and transported, including but not limited to: optical media (e.g.
CDs, DVDs); USB drives; or flash media (e.g. CompactFlash, SD, MMC).
c. "Portable/Removable Devices" means any small computing device that can be transported,
including but not limited to: hand helds/PDAs/Sm artphones; Ultramobile PC's, flash memory
devices (e.g. USB flash drives, personal media players); and laptops/notebook/tablet
computers. If used to store Confidential Information, devices should be Federal Information
Processing Standards (FIPS) Level 2 compliant.
d. "Secured Area" means an area to which only Authorized Users 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.
e. "Transmitting" means the transferring of data electronically, such as via email, SFTP,
webservices, AWS Snowball, etc.
"Trusted System(s)" means the following methods of physical delivery: (1) hand -delivery by
a person authorized to have access to the Confidential Information with written
acknowledgement of receipt; (2) United States Postal Service ("USPS") first class mail, or
USPS delivery services that include Tracking, such as Certified Mail, Express Mail or
Registered Mail; (3) commercial delivery services (e.g. FedEx, UPS, DHL) which offer
tracking and receipt confirmation; and (4) the Washington State Campus mail system. For
electronic transmission, the Washington State Governmental Network (SGN) is a Trusted
System for communications within that Network.
Washington State Page 10 of 28 HCA IAA K4821
Health Care Authority Attachment 1: Confidential Information Security Requirements
g. "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.
Confidential Information Transmitting
a. When transmitting HCA's Confidential Information electronically, including via email, the
Data must be encrypted using NIST 800-series approved algorithms
(http://csrc.nist.gov/publications/PubsSPs,html). This includes transmission over the public
internet.
b. When transmitting HCA's Confidential Information via paper documents, the Receiving Party
must use a Trusted System.
Protection of Confidential Information
The Contractor agrees to store Confidential Information as described:
a. Data at Rest:
Data will be encrypted with NIST 800-series approved algorithms. Encryption keys will
be stored and protected independently of the data. Access to the Data will be
restricted to Authorized Users through the use of access control lists, a Unique User
ID, and a Hardened Password, or other authentication mechanisms which provide
equal or greater security, such as biometrics or smart cards. Systems which contain or
provide access to Confidential Information must be located in an area that is
accessible only to authorized personnel, with access controlled through use of a key,
card key, combination lock, or comparable mechanism.
Data stored on Portable/Removable Media or Devices:
• Confidential Information provided by HCA on Removable Media will be encrypted
- . with NIST 800-series approved algorithms. Encryption -keys will be stored and
protected independently of the Data.
HCA's data must not be stored by the Receiving Party on Portable Devices or
Media unless specifically authorized within the Data Share Agreement. If so
authorized, the Receiving Party must protect the Data by:
1. Encrypting with NIST 800-series approved algorithms. Encryption keys will
be stored and protected independently of the data;
2. Control access to the devices with a Unique User ID and Hardened
Password or stronger authentication method such as a physical token or
biometrics;
3. Keeping devices in locked storage when not in use;
Washington State Page 11 of 28 HCA IAA K4821
Health Care Authority Attachment 1: Confidential Information Security Requirements
4. Using check-in/check-out procedures when devices are shared;
5. Maintain an inventory of devices; and
6. Ensure that when being transported outside of a Secured Area, all devices
with Data are under the physical control of an Authorized User.
b. Paper documents. Any paper records containing Confidential Information must be protected
by storing the records in a Secured Area that is accessible only 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.
Confidential Information Segregation
HCA Confidential Information received under this Contract must be segregated or otherwise
distinguishable from non-HCA data. This is to ensure that when no longer needed by the
Contractor, all HCA Confidential Information can be identified for return or destruction. It also
aids in determining whether HCA Confidential Information has or may have been compromised
in the event of a security Breach.
a. The HCA Confidential Information must be kept in one of the following ways:
on media (e.g. hard disk, optical disc, tape, etc.) which will contain only HCA Data;
or
in a logical container on electronic media, such as a partition or folder dedicated to
HCA's Data; or
iii. in a database that will contain only HCA Data; or
iv. within a database and will be distinguishable from non-HCA Data by the value of a
specific field or fields within database records; or
V. when stored as physical paper documents, physically segregated from non-HCA
Data in a drawer, folder, or other container.
b. When it is not feasible or practical to segregate HCA Confidential Information from non-
HCA data, then both the HCA Confidential Information and the non-HCA data with which it
is commingled must be protected as described in this Attachment.
Confidential Information Shared with Subcontractors
If HCA Confidential Information provided under this Contract is to be shared with a
Subcontractor, the contract with the Subcontractor must include all of the Confidential
Information Security Requirements.
Washington State Page 12 of 28 HCA IAA K4821
Health Care Authority Attachment 1: Confidential Information Security Requirements
Confidential Information Disposition
When the Confidential Information is no longer needed, except as noted below, the Confidential
Information must be returned to HCA or destroyed. Media are to be destroyed using a method
documented within NIST 800-88 (http://csrc.nist.gov/publications/PubsSPs.html).
a. For HCA's Confidential Information stored on network disks, deleting unneeded
Confidential Information is sufficient as long as the disks remain in a Secured Area and
otherwise meet the requirements listed in Section 03, above. Destruction of the
Confidential Information as outlined in this section of this Attachment may be deferred until
the disks are retired, replaced, or otherwise taken out of the Secured Area.
Washington State Page 13 of 28 HCA IAA K4821
Health Care Authority Attachment 1: Confidential Information Security Requirements
ATTACHMENT 2 — Federal Compliance, Certifications, and Assurances
FEDERAL COMPLIANCE - The use of federal funds requires additional compliance and
control mechanisms to be in place. The following represents the majority of compliance
elements that may apply to any federal funds provided under this contract. For clarification
regarding any of these elements or details specific to the federal funds in this contract,
contact: Amy Dura.
a. Source of Funds SOR: This Contract is being funded partially or in full through Cooperative
Contract number 61-179TI081705-021-001, the full and complete terms and provisions of which
are hereby incorporated into this Contract. Federal funds to support this Contract are identified
by the Catalog of Federal Domestic Assistance (CFDA) number 93.788, in the amount of
$25,000 The Contractor or Subrecipient is responsible for tracking and reporting the cumulative
amount expended under HCA Contract K4821.
b. Period of Availability of Funds SOR: Pursuant to 45 CFR 92.23, Contractor or Subrecipient may
charge to the award only costs resulting from obligations of the funding period specified in
61-179TI081705-021-001 unless carryover of unobligated balances is permitted, in which case the
carryover balances may be charged for costs resulting from obligations of the subsequent
funding period. All obligations incurred under the award must be liquidated no later than 90 days
after the end of the funding period.
c. Single Audit Act. This section applies to subrecipients only. Subrecipient (including
private, for -profit hospitals and non-profit institutions) shall adhere to the federal Office
of Management and Budget (OMB) Super Circular 2 CFR200.501 and 45 CFR 75.501.
A Subrecipient who expends $750,000 or more in federal awards during a given fiscal
year shall have a single or program -specific audit for that year in accordance with the
provisions of OMB Super Circular 2 CFR 200.501 and 45 CFR 75.501.
d. Modifications: This Contract may not be modified or amended, nor may any term or
provision be waived or discharged, including this particular Paragraph, except in writing,
signed upon by both parties.
1. Examples of items requiring Health Care Authority prior written approval
include, but are not limited to, the following:
i. Deviations from the budget and Project plan.
ii. Change in scope or objective of the Contract.
iii. Change in a key person specified in the Contract.
iv. The absence for more than one (1) months or a 25% reduction in time by
the Project Manager/Director.
v. Need for additional funding.
vi. Inclusion of costs that require prior approvals as outlined in the
appropriate cost principles.
vii. Any changes in budget line item(s) of greater than twenty percent (20%) of
the total budget in this Contract.
2. No changes are to be implemented by the Sub-awardee until a written notice
of approval is received from the Health Care Authority.
e. Sub -Contracting: The Contractor or Subrecipient shall not enter into a sub -contract for
any of the work performed under this Contract without obtaining the prior written
approval of the Health Care Authority. If sub -contractors are approved by the Health
Care Authority, the subcontract, shall contain, at a minimum, sections of the Contract
pertaining to Debarred and Suspended Vendors, Lobbying certification, Audit
requirements, and/or any other project Federal, state, and local requirements.
Washington State Page 14 of 28 HCA IAA K4821
Health Care Authority Attachment 2: Federal Compliance, Certifications, and Assurances
f. Condition for Receipt of Health Care Authority Funds: Funds provided by Health Care
Authority to the Contractor or Subrecipient under this Contract may not be used by the
Contractor or Subrecipient as a match or cost -sharing provision to secure other federal
monies without prior written approval by the Health Care Authority.
g. Unallowable Costs: The Contractor or Subrecipient's expenditures shall be subject to
reduction for amounts included in any invoice or prior payment made which determined
by HCA not to constitute allowable costs on the basis of audits, reviews, or monitoring of
this Contract.
h. Supplanting Compliance: SABG: If SABG funds support this Contract, the Block Grant
will not be used to supplant State funding of alcohol and other drug prevention and
treatment programs. (45 CFR section 96.123(a)(10)).
i. Citizenship/Alien Verification/Determination: The Personal Responsibility and Work
Opportunity Reconciliation Act (PRWORA) of 1996 (PL 104-193) states that federal
public benefits should be made available only to U.S. citizens and qualified aliens.
Entities that offer a service defined as a "federal public benefit" must make a
citizenship/qualified alien determination/ verification of applicants at the time of
application as part of the eligibility criteria. Non -US citizens and unqualified aliens are
not eligible to receive the services. PL 104-193 also includes specific reporting
requirements.
j. Federal Compliance: The Contractor or Subrecipient shall comply with all applicable
State and Federal statutes, laws, rules, and regulations in the performance of this
Contract, whether included specifically in this Contract or not.
k Civil Rights and Non -Discrimination Obligations: During the performance of this
Contract, the Contractor or Subrecipient shall comply with all current and future federal
statutes relating to nondiscrimination. These include but are not limited to: Title VI of the
Civil Rights Act of 1964 (PL 88-352), Title IX of the Education Amendments of 1972 (20
U.S.C. §§ 1681-1683 and 1685-1686), section 504 of the Rehabilitation Act of 1973 (29
U.S.C. § 794), the Age Discrimination Act of 1975 (42 U.S.C. §§ 6101- 6107), the Drug
Abuse Office and Treatment Act of 1972 (PL 92-255), the Comprehensive Alcohol
Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL 91-
616), §§523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. §§290dd-3
and 290ee-3), Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), and
the Americans with Disability Act (42 U.S.C., Section 12101 et seq.)
hftp://www.hhs.gov/ocr/civilrights.
HCA Federal Compliance Contact Information
Federal Grants and Budget Specialist Health Care Policy
Washington State Health Care Authority
Post Office Box 42710
Olympia, Washington 98504-2710
CIRCULARS `COMPLIANCE MATRIX' - The following compliance matrix identifies the
OMB Circulars that contain the requirements which govern expenditure of federal funds.
These requirements apply to the Washington State Health Care Authority (HCA), as the
primary recipient of federal funds and then follow the funds to the sub-awardee, Jefferson
County, dba Sherriff's Office. The federal Circulars which provide the applicable
administrative requirements, cost principles and audit requirements are identified by sub-
awardee organization type.
OMB CIRCULAR
Washington State Page 15 of 28 HCA IAA K4821
Health Care Authority Attachment 2: Federal Compliance, Certifications, and Assurances
ENTITY TYPE
ADMINISTRATIVE
COST
AUDIT REQUIREMENTS
REQUIREMENTS
PRINCIPLES
State. Local and Indian
OMB Super Circular 2 CFR 200.501 and 45 CFR 75.501
Tribal Governments and
Governmental Hospitals
Non -Profit
Organizations and Non -
Profit Hospitals
Colleges or Universities
and Affiliated Hospitals
For -Profit Organizations
III. STANDARD FEDERAL CERTIFICATIONS AND ASSURANCES - Following are the
Assurances, Certifications, and Special Conditions that apply to all federally funded (in
whole or in part) Contracts administered by the Washington State Health Care Authority.
1. CERTIFICATION REGARDING DEBARMENT AND SUSPENSION: The
undersigned (authorized official signing for the contracting organization) certifies to
the best of his or her knowledge and belief, that the contractor, defined as the
primary participant in accordance with 45 CFR Part 76, and its principals: are not
presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from covered transactions by any Federal Department or
agency have not within a 3-year period preceding this contract been convicted of or
had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State, or local) transaction or contract under a public transaction; violation
of Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving
stolen property; are not presently indicted or otherwise criminally or civilly charged
by a governmental entity (Federal, State, or local) with commission of any of the
offenses enumerated in Section 2 of this certification; and have not within a 3-year
period preceding this contract had one or more public transactions (Federal, State,
or local) terminated for cause or default.
Should the Contractor or Subrecipient not be able to provide this certification, an explanation
as to why should be placed after the assurances page in the contract.
The contractor agrees by signing this contract that it will include, without modification, the
clause above certification in all lower tier covered transactions (i.e., transactions with sub -
grantees and/or contractors) and in all solicitations for lower tier covered transactions in
accordance with 45 CFR Part 76.
2. CERTIFICATION REGARDING DRUG -FREE WORKPLACE REQUIREMENTS: The
undersigned (authorized official signing for the contracting organization) certifies that the
contractor will, or will continue to, provide a drug -free workplace in accordance with 45 CFR
Part 76 by:
1. Publishing a statement notifying employees that the unlawful manufacture,
distribution, dispensing, possession or use of a controlled substance is prohibited in
the grantee's workplace and specifying the actions that will be taken against
Washington State Page 16 of 28 HCA IAA K4821
Health Care Authority Attachment 2: Federal Compliance, Certifications, and Assurances
employees for violation of such prohibition; Establishing an ongoing drug -free
awareness program to inform employees about
i. The dangers of drug abuse in the workplace;
ii. The contractor's policy of maintaining a drug -free workplace;
iii. Any available drug counseling, rehabilitation, and employee assistance
programs; and
iv. The penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace;
2. Making it a requirement that each employee to be engaged in the performance of the
contract be given a copy of the statement required by paragraph (1) above;
3. Notifying the employee in the statement required by paragraph (1), above, that, as a
condition of employment under the contract, the employee will—
i. Abide by the terms of the statement; and
ii. Notify the employer in writing of his or her conviction for a violation of a
criminal drug statute occurring in the workplace no later than five (5) calendar
days after such conviction;
4. Notifying the agency in writing within ten calendar days after receiving notice under
paragraph (lll)(b) from an employee or otherwise receiving actual notice of such
conviction. Employers of convicted employees must provide notice, including position
title, to every contract officer or other designee on whose contract activity the
convicted employee was working, unless the Federal agency has designated a central
point for the receipt of such notices. Notice shall include the identification number(s)
of each affected grant;
5. Taking one of the following actions, within thirty (30) calendar days of receiving notice
under paragraph (III) (b), with respect to any employee who is so convicted—
i. Taking appropriate personnel action against such an employee, up to and
including termination, consistent with the requirements of the Rehabilitation
Act of 1973, as amended; or
ii. Requiring such- employee to_ participate satisfactorily in a drug abuse
assistance or rehabilitation program approved for such purposes by a
Federal, State, or local health, law enforcement, or other appropriate agency;
6. Making a good faith effort to continue to maintain a drug -free workplace through
implementation of paragraphs (1) through (V).
For purposes of paragraph (V) regarding agency notification of criminal drug convictions, Authority
has designated the following central point for receipt of such notices:
Legal Services Manager
WA State Health Care Authority
PO Box 42700
Olympia, WA 98504-2700
3. CERTIFICATION REGARDING LOBBYING: Title 31, United States Code, Section 1352,
entitled "Limitation on use of appropriated funds to influence certain Federal contracting and
financial transactions," generally prohibits recipients of Federal grants and cooperative
Washington State Page 17 of 28 HCA IAA K4821
Health Care Authority Attachment 2: Federal Compliance, Certifications, and Assurances
Contracts from using Federal (appropriated) funds for lobbying the Executive or Legislative
Branches of the Federal Government in connection with a SPECIFIC grant or cooperative
Contract. Section 1352 also requires that each person who requests or receives a Federal
grant or cooperative Contract must disclose lobbying undertaken with non -Federal
(nonappropriated) funds. These requirements apply to grants and cooperative Contracts
EXCEEDING $100,000 in total costs (45 CFR Part 93).
The undersigned (authorized official signing for the contracting organization) certifies, to the
best of his or her knowledge and belief, that:
No Federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or
employee of any agency, a Member of Congress, an officer or employee of Congress,
or an employee of a Member of Congress in connection with the awarding of any
Federal contract, the making of any Federal grant, the making of any Federal loan,
the entering into of any cooperative Contract, and the extension, continuation,
renewal, amendment, or modification of any Federal contract, grant, loan, or
cooperative Contract.
2. If any funds other than Federally appropriated funds have been paid or will be paid to
any person for influencing or attempting to influence an officer or employee of any
agency, a Member of Congress, an officer or employee of Congress, or an employee
of a Member of Congress in connection with this Federal contract, grant, loan, or
cooperative Contract, the undersigned shall complete and submit Standard Form-
LLL, "Disclosure of Lobbying Activities," in accordance with its instructions. (If needed,
Standard Form-LLL, "Disclosure of Lobbying Activities," its instructions, and
continuation sheet are included at the end of this application form.)
3. The undersigned shall require that the language of this certification be included in the
award documents for all subcontracts at all tiers (including subcontracts,
subcontracts, and contracts under grants, loans and cooperative Contracts) and that
all sub -recipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when
this transaction was made or entered into. Submission of this certification is a prerequisite
for making or entering into this transaction imposed by Section 1352, U.S. Code. Any person
who fails to file the required certification shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.
4. CERTIFICATION REGARDING PROGRAM FRAUD CIVIL REMEDIES ACT (PFCRA): The
undersigned (authorized official signing for the contracting organization) certifies that the
statements herein are true, complete, and accurate to the best of his or her knowledge, and
that he or she is aware that any false, fictitious, or fraudulent statements or claims may subject
him or her to criminal, civil, or administrative penalties. The undersigned agrees that the
contracting organization will comply with the Public Health Service terms and conditions of
award if a contract is awarded.
5. CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE: Public Law 103-
227, also known as the Pro -Children Act of 1994 (Act), requires that smoking not be
permitted in any portion of any indoor facility owned or leased or contracted for by an entity
and used routinely or regularly for the provision of health, day care, early childhood
development services, education or library services to children under the age of 18, if the
services are funded by Federal programs either directly or through State or local
governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to
Washington State Page 18 of 28 HCA IAA K4821
Health Care Authority Attachment 2: Federal Compliance, Certifications, and Assurances
children's services that are provided in indoor facilities that are constructed, operated, or
maintained with such Federal funds. The law does not apply to children's services provided
in private residence, portions of facilities used for inpatient drug or alcohol treatment, service
providers whose sole source of applicable Federal funds is Medicare or Medicaid, or
facilities where WIC coupons are redeemed.
Failure to comply with the provisions of the law may result in the imposition of a civil
monetary penalty of up to $1,000 for each violation and/or the imposition of an
administrative compliance order on the responsible entity.
By signing the certification, the undersigned certifies that the contracting organization will
comply with the requirements of the Act and will not allow smoking within any portion of any
indoor facility used for the provision of services for children as defined by the Act.
The contracting organization agrees that it will require that the language of this certification be
included in any subcontracts which contain provisions for children's services and that all sub -
recipients shall certify accordingly.
The Public Health Services strongly encourages all recipients to provide a smoke -free
workplace and promote the non-use of tobacco products. This is consistent with the
PHS mission to protect and advance the physical and mental health of the American
people.
6. CERTIFICATION REGARDING OTHER RESPONSIBILITY MATTERS
The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The
prospective contractor shall submit an explanation of why it cannot provide the
certification set out below. The certification or explanation will be considered in
connection with the department or agency's determination whether to enter into this
transaction. However, failure of the prospective contractor to furnish a certification or
an explanation shall disqualify such person from participation in this transaction.
2. The certification in this clause is a material representation of fact upon which
reliance was placed when the department or agency determined to enter into this
transaction. If it is later determined that the prospective contractor knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause of default.
3. The prospective contractor shall provide immediate written notice to the department
or agency to whom this contract is submitted if at any time the prospective
contractor learns that its certification was erroneous when submitted or has become
erroneous by reason of changed circumstances.
4. The terms covered transaction, debarred, suspended, ineligible, lower tier covered
transaction, participant, person, primary covered transaction, principal, proposal,
and voluntarily excluded, as used in this clause, have the meanings set out in the
Definitions and Coverage sections of the rules implementing Executive Order
12549. You may contact the person to whom this contract is submitted for
assistance in obtaining a copy of those regulations.
5. The prospective contractor agrees by submitting this contract that, should the
proposed covered transaction be entered into, it shall not knowingly enter into any
lower tier covered transaction with a person who is debarred, suspended, declared
Washington State Page 19 of 28 HCA IAA K4821
Health Care Authority Attachment 2: Federal Compliance, Certifications, and Assurances
ineligible, or voluntarily excluded from participation in this covered transaction,
unless authorized by Authority.
6. Nothing contained in the foregoing shall be construed to require establishment of a
system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed
that which is normally possessed by a prudent person in the ordinary course of
business dealings.
7. Except for transactions authorized under paragraph 6 of these instructions, if a
participant in a covered transaction knowingly enters into a lower tier covered
transaction with a person who is suspended, debarred, ineligible, or voluntarily
excluded from participation in this transaction, in addition to other remedies
available to the Federal Government, HCA may terminate this transaction for cause
or default.
CONTRACTOR SIGNATURE REQUIRED
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL I TITLE
Please also print or type name:
ORGANIZATION NAME: (if applicable) I DATE
Washington State Page 20 of 28 HCA IAA K4821
Health Care Authority Attachment 2: Federal Compliance, Certifications, and Assurances
ATTACHMENT 3
Federal Funding Accountability and Transparency Act (FFATA) Data Collection Form
This Contract is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency
Act (FFATA or the Transparency Act). The purpose of the Transparency Act is to make information available online so the public
can see how federal funds are spent.
To comply with the act and be eligible to enter into this contract, your organization must have a Data Universal Numbering
System (DUNS®) number. A DUNS® number provides a method to verify data about your organization. If you do not already
have one, you may receive a DUNS® number free of charge by contacting Dun and Bradstreet at www.dnb.com.
Required Information about your organization and this contract will be made available on USASpending.gov by HCA as required
by P.L. 109-282. As a tool to provide the information, HCA encourages registration with the Central Contractor Registry (CCR)
because less data entry and re-entry is required by both HCA and your organization. You may register with CCR on-line at
httos://www.uscontractorregistration.com/.
CONTRACTOR
Legal Name
DUNS Number
Principle Place of Performance
Congressional District
3b. City
State
3d. Zip+4
Country
Are you registered in CCR (httys://www.uscontractorreaiWarbon,coMb? []YES (skip to page 2. Sign, date and return) []NO
In the preceding fiscal year did your organization:
Receive 80% or more of annual gross revenue from procurement federal contracts, Subcontracts, grants, loans, sub -grants, and/or
cooperative agreements; and
$25,000,000 or more in annual gross revenues from federal procurement contracts, Subcontracts, grants, loans, subgrants, and/or
cooperative agreements; and
The public does not have access to information about the compensation of the executives through periodic reports filed with the IRS
or the Security and Exchange Commission per 2 CFR Part 170.330
❑ NO (skip the remainder of this section - Sign, date and return)
❑ YES (You must report the names and total compensation of the top 5 highly compensated officials of your organization).
Name Of Official
Total Compensation
1.
2.
3.
4.
5.
Note: "Total compensation" means the cash and noncash dollar value earned by the executive during the sub -recipient's past fiscal
year of the following (for more information see 17 CFR 229.402 (c) (2))
By signing this document, the Contractor Authorized Representative attests to the information.
Signature of Contractor Authorized Representative Date
Washington State Page 21 of 28 HCA IAA K4821
Health Care Authority Attachment 3: Federal Funding and Accountability and Transparency Act
HCA will not endorse the Contractor's sub -award until this form is completed and returned.
FOR HEALTH CARE AUTHORITY USE ONLY
HCA Contract Number: K4821
Sub -award Project Description (see instructions and examples below)
Instructions for Sub -award Project Description:
In the first line of the description provide a title for the sub -award that captures the main purpose of
the Subrecipients work. Then, indicate the name of the Subrecipient and provide a brief description
that captures the overall purpose of the sub -award, how the funds will be used, and what will be
accomplished.
Example of a Sub -award Project Description:
Increase Healthy Behaviors: Educational Services District XYZ will provide training and technical
assistance to chemical dependency centers to- assist the centers to integrate tobacco -use into their
existing addiction treatment programs. Funds will also be used to assist centers in creating tobacco
free treatment environments.
Washington State Page 22 of 28 HCA IAA K4821
Health Care Authority Attachment 3: Federal Funding and Accountability and Transparency Act
ATTACHMENT 4
Substance Abuse and Mental Health Services Administration (SAMHSA) Award Terms
If the funding for this Contract work should fall under the Substance Abuse and Mental Health Services
Administration (SAMHSA) Award Terms outlined below the Contractor must comply with the requirements of
those terms as they would apply to HCA.
1. SAMHSA Award Terms.
1.1 This grant is subject to the terms and conditions, included directly, or incorporated by reference on
the Notice of Award (NoA).
1.2 Grant funds cannot be used to supplant current funding of existing activities.
1.3 By law, none of the funds awarded can be used to pay the salary of an individual at a rate in excess
of the Executive Level 1, which is $197,300 annually.
1.4 Awardees and sub -recipients must maintain records which adequately identify the source and
application of funds provided for financially assisted activities. These records must contain
information pertaining to grant or sub -grant awards and authorizations, obligations, unobligated
balances, assets, liabilities, outlays or expenditures, and income. SAMHSA or its designee may
conduct a financial compliance audit and on -site program review of grants with significant amounts of
Federal funding.
1.5 Per 45 Code of Federal Regulations (CFR) 74.36 and 45 CFR 92.34 and the US Department of
Health and Human Services Grants Policy Statement, any copyrighted or copyrightable works
developed under this cooperative agreement/grant shall be subject to royalty -free, nonexclusive and
irrevocable license to the government to reproduce, publish, or otherwise use them and to authorize
others to do so for General Government purposes. Income earned from any copyrightable work
developed under this grant must be used as program income.
1.6 Program income accrued under this award must be used in accordance with the additional costs
alternative described in 45 CFR 74.24(b) (1) or 45 CFR 92.25(g) (2) as applicable. Program income
must be used to further the grant objectives and shall only be used for allowable costs as set forth in
the applicable Office of Management and Budget circulars A-102 and A-110.
1.7 No part of an appropriation contained in this Act shall be used, other than for normal and recognized
- executive -legislative relationships, for publicity or propaganda purposes, for the preparation,
distribution, or use of any kit, pamphlet, booklet, publication, radio, television, or video presentation
designed to support or defeat legislation pending before the Congress, except in presentation to the
Congress itself or any State legislature.
1.8 No part of any appropriation contained in this Act shall be used to pay the salary or expenses of any
grant or contract recipient, or agency acting for such recipient, related to any activity designed to
influence legislation or appropriations pending before the Congress or any State legislature.
1.9 Where a conference is funded by a grant or cooperative agreement the recipient must include the
following statement on all conference materials (including promotional materials, agenda, and internet
sites): "Funding for this conference was made possible (in part) by Grant H79TI081705 from
SAMHSA. The views expressed in written conference materials or publications and by speakers and
moderators do not necessarily reflect the official policies of the Department of Health and Human
Services; nor does mention of trade names, commercial practices, or organizations imply
endorsement by the U.S. Government."
Washington State Page 23 of 28 HCA IAA K4821
Health Care Authority Attachment 4: SAMHSA Award Terms
1.10 If federal funds are used by the Contractor to attend a meeting, conference, etc. and meal(s) are
provided as part of the program, then the per diem applied to the Federal travel costs (Meal and
Incidental Expenses allowance) must be reduced by the allotted meal cost(s).
1.11 Marijuana Attestation. The primary award recipient and all sub -recipients (contractor & sub-awardee)
will not use funds, directly or indirectly, to purchase, prescribe, or provide marijuana or treatment
using marijuana. Treatment in this context includes the treatment of opioid use disorder. Grant funds
also will not be provided to any individual who or organization that provides or permits marijuana use
for the purposes of treating substance use or mental disorders (45 CFR. § 75.300(a); 21 United
States Code §§ 812(c) (10) and 8410). This prohibition does not apply to those providing such
treatment in the context of clinical research permitted by the Drug Enforcement Administration and
under a US Food and Drug Administration -approved investigational new drug application where the
article being evaluated is marijuana or a constituent thereof that is otherwise a banned controlled
substance under federal law.
1.12 SABG Block Grant Attestation: SABG Block grant funds will not be used to supplant State funding of
alcohol and other drug prevention and treatment programs. (45 CFR section 96.123(a)(10)).
Washington State Page 24 of 28 HCA IAA K4821
Health Care Authority Attachment 4: SAMHSA Award Terms
ATTACHMENT 5
Federal Award Identification for Subrecipients (reference 2 CFR 200.331)
Washington State Opioid Response (SOR) Grant
(i)
Subrecipient name (which must match the name
Jefferson County dba. SherrifPs Office
associated with its unique entity identifier);
(ii)
Subrecipient's unique entity identifier; (DUNS)
619143741
(iii)
Federal Award Identification Number (FAIN);
H79TIO81705
(iv)
Federal Award Date (see §200.39 Federal award
09/03/2018
date);
(v)
Subaward Period of Performance Start and End
9/30/2020 — 9/29/2021
Date;
(vi)
Amount of Federal Funds Obligated by this action;
$25,000
(vii)
Total Amount of Federal Funds Obligated to the
$25,000
subrecipient;
(xiii) Total Amount of the Federal Award;
$21,573,093
(ix)
Federal award project description, as required to be
Washington State Opioid Response (SOR)
responsive to the Federal Funding Accountability
Grant
and Transparency Act (FFATA);
(x)
Name of Federal awarding agency, pass -through
SAMHSA
entity, and contact information for awarding official,
WA State Health Care Authority
Keri Waterland, Assistant Director DBHR
626 8th Ave SE; Olympia, WA 98504-5330
Keri.waterland0_)hca.wa.gov
(xi)
CFDA Number and Name; the pass -through entity
93.788
must identify the dollar amount made available
under each Federal award and the CFDA number at
time of disbursement;
(xii)
. Identification -of whether the award is R&D; -and
EI_Yes 0 No _
(xiii)
Indirect cost rate for the Federal award (including if
de minimus (10%)
the de minimis rate is charged per §200.414 Indirect
(F&A) costs).
Washington State Page 25 of 28 HCA IAA K4821
Health Care Authority Attachment 5: Federal Award Identification
Schedule A
Statement of Work
1. Purpose:
1.1 SITE HERE shall purchase medications (one agonist and one antagonist) for the purpose of
providing Medication for Opioid Use Disorder (MOUD) within their site for individuals with
Opioid Use Disorder (OUD) and Opioid overdose reversal medication to individuals with
OUD prior to release from jail.
The site will make available one agonist and one antagonist medication.
a. The site shall provide a quarterly report submitted to the HCA Contract Manager using
an approved data report, to include:
i. number of individuals served
ii. type medication distributed
iii. induction or maintenance
iv. overdose reversal kits distributed
v. number of overdose reversals documented through individual notification
b. A total of $25,000 may be used for the purchase of the above medications for induction,
maintenance and overdose reversal. The site will bill HCA with an A-19 quarterly as
outlined in the deliverable table.
2. Budget and Deliverables:
Deliverables Table — SOR No Cost Extension
- September 30, 2020 through September 29, 2021
Deliverable
Due Date
Payment
1.
Purchasing and Distribution
December 31, 2020
Four (4) quarterly
Medications (overdose reversal,
March 30, 2021
payments of $6,250
agonist and antagonist medication) —
June 30, 2021
for a total of
Quarterly reports number of
September 29, 2021
$25,000
individuals served by medication type
and reversals reported
TOTAL
$25,000
Washington State Page 26 of 28 HCA IAA K4821
Health Care Authority Schedule A: Statement of Work
Schedule B
Definitions Specific to Special Terms
The words and phrases listed below, as used in this Contract, shall each have the following
definitions:
a. "Agonist" means an FDA -approved opioid agonist medication (e.g., methadone,
buprenorphine products including buprenorphine/naloxone combination formulations and
buprenorphine mono -product formulations) for the maintenance treatment of opioid use
disorder.
b. "Antagonist" means the FDA -approved opioid antagonist medication (e.g., naltrexone products
including extended -release and oral formulations) to prevent relapse to opioid use.
C. "Culturally and Linguistically Appropriate Services" or "CLAS" means the national standards in
health and health care intended to advance health equity, improve quality, and help eliminate
health disparities by establishing a blueprint for health and health care organizations
d. "Data Universal Numbering System" or "DUNS" means a unique identifier for businesses.
DUNS numbers are assigned and maintained by Dun and Bradstreet (D&B) and are used for
a variety of purposes, including applying for government contracting opportunities.
e. "DBHR" means the HCA Division of Behavioral Health and Recovery, and its employees and
authorized agents.
"Electronic Health Records" or "EHR" means a certified electronic health record system that
has been tested and certified by an approved Office of National Coordinator for Health
Information Technology's (ONC) certifying body.
g. "FDA" means the U.S. Food and Drug Administration.
"HCA" means the Washington State Health Care Authority and its employees and authorized
agents.
i. "Medication Assisted Treatment" or "MAT" (now MOUD) means the use of FDA -approved
opioid agonist medications (e.g., methadone, buprenorphine products including
buprenorphine/naloxone combination formulations and buprenorphine mono -product
formulations) for the treatment of opioid use disorder and the use of opioid antagonist
medication (e.g. naltrexone products including extended -release and oral formulations) to
prevent relapse to opioid use.
j. "Medication for Opioid Use Disorder" or "MOUD" means the use of FDA -approved opioid
agonist medications (e.g., methadone, buprenorphine products including
buprenorphine/naloxone combination formulations and buprenorphine mono -product
formulations) for the maintenance treatment of opioid use disorder and the use of opioid
antagonist medication (e.g., naltrexone products including extended -release and oral
formulations) to prevent relapse to opioid use.
"Naloxone" means a medication designed to rapidly reverse opioid overdose. The brand name
is Narcan.
Washington State Page 27 of 28 HCA IAA K4821
Health Care Authority Schedule B: Definitions Specific to Special Terms
"Opioid Use Disorder' or "OUD" is defined by a pattern of problematic use of opioids, whether
prescription painkillers, or heroin, or other illicit synthetic opioids. Practitioners use criteria
from the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) to diagnose opioid
use disorder.
M. "Prescription Monitoring Drug Program" or "PMDP" means a law that the Washington State
Legislature passed in 2007 requiring the Department of Health to create a prescription
monitoring program. The law directs the Department to design the program to improve
healthcare quality and effectiveness by: Reducing abuse of controlled substances, reducing
duplicative prescribing and overprescribing; and improving prescribing practices.
n. "Report" or "Monthly Report" means and refers to a report that the Contractor will complete
and submit to DBHR on a monthly basis prior to monthly reimbursement.
o. "SAMHSA" means the U.S. Department of Health and Human Services, Substance Abuse
and Mental Health Services Administration, and its employees and authorized agents.
p. "Substance Use Disorder Professional" or "SUDP" means an individual certified in substance
use disorder counseling by the Washington Department of Health Licensing.
q. "SUD" means substance use disorder. Practitioners use criteria from the Diagnostic and
Statistical Manual of Mental Disorders 5 (DSM-5).
Washington State Page 28 of 28 HCA IAA K4821
Health Care Authority Schedule B: Definitions Specific to Special Terms