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Consent Agenda
Public Healt
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Mark McCauley, County Administrator
FROM: Apple Martine, JCPH Director
Veronica Shaw, JCPH Deputy Director
DATE:
SUBJECT: Agenda Item — Consolidated Contracts Amendment #10 with the Department
of Health; January 12022 — December 31, 2024; additional $205,027 for a
total of $4,330,576
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH) requests Board approval of Consolidated Contract Amendment #10
between JCPH and State of Washington Department of Health (DOH); January 1, 2022 — December 31, 2024;
additional $205,027 for a total of $4,330,576.
ANALYSIS/STRATEGIC GOALS/PRO'S and CONS:
The purpose of this agreement is to provide public health services to the people of Washington State. This
Amendment amends statements of work and funding for the following programs:
• Foundational Public Health Services — updates allocation of funds to match actual funds requested and
distributed for SFY22 (plus additional funding of$32,681)
• Office of Immunization COVID-19 Vaccine — modifies activities, deliverables and deliverable due dates
for COVID-19 vaccine activities
• Sexual & Reproductive Health Program — extends funding period, minor edits to deliverables (additional
$40,357)
• WIC Nutrition Program — women, infants and children nutrition services, additional training requirement
(additional $131,989)
FISCAL IMPACT/COST BENEFIT ANALYSIS
Total consideration for this Contract Amendment is an increase of $205,027 for a total of $4,330,576. The
Consolidated Contract is funded by DOH, and comprises both Federal and State funds.
Community Health
Developmental Disabilities Environmental Public Health
360-385-9400 360-385-9444
360-385-9401 (f) (f)360-379-4487
CC 22-002-A10 Always working for a safer and healthier community
RECOMMENDATION:
JCPH Management recommends BOCC approval of Consolidated Contract Amendment #10; January 12022 —
December 31, 2024; additional $205,027 for a total of $4,330,576.
REVIEWED BY:
Mark McCauley, CountUdministrator Date
Community Health Environmental Public Health
Developmental Disabilities 360-385-9444
360-385-9400 Always working for a safer and healthier community (f) 360-379-4487
360-385-9401 (f)
Page 1 of 26
JEFFERSON COUNTY PUBLIC HEALTH
2022-2024 CONSOLIDATED CONTRACT
CONTRACT NUMBER: CLH31013 AMENDMENT NUMBER: 10
PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HEALTH hereinafter referred to as
"DOH",and JEFFERSON COUNTY PUBLIC HEALTH,a Local Health Jurisdiction,hereinafter referred to as"LHJ",
pursuant to the Modifications/Waivers clause,and to make necessary changes within the scope of this contract and any
subsequent amendments thereto.
IT IS MUTUALLY AGREED: That the contract is hereby amended as follows:
1. Exhibit A Statements of Work, includes the following statements of work,which are incorporated by this reference
and located on the DOH Finance SharePoint site in the Upload Center at the following URL:
https•//stateofwa sharer)oint com/sites/doh-ofsfundingresources/siteaages/home.aspx?=el:9a94688da2d94d3ea8Oac7fbc32e4d7c
❑ Adds Statements of Work for the following programs:
® Amends Statements of Work for the following programs:
Foundational Public Health Services(FPHS)-Effective January 1, 2022
Office of Immunization COVID-19 Vaccine-Effective January 1, 2022
Sexual&Reproductive Health Program -Effective January 1, 2022
WIC Nutrition Program-Effective January 1,2022
❑ Deletes Statements of Work for the following programs:
2. Exhibit B-10 Allocations,attached and incorporated by this reference, amends and replaces Exhibit B-9 Allocations
as follows:
® Increase of$205,027 for a revised maximum consideration of$4,330,576.
❑ Decrease of for a revised maximum consideration of
❑ No change in the maximum consideration of__
Exhibit B Allocations are attached only for informational purposes.
Unless designated otherwise herein,the effective date of this amendment is the date of execution.
ALL OTHER TERMS AND CONDITIONS of the original contract and any subsequent amendments remain in full force
and effect.
IN WITNESS WHEREOF,the undersigned has affixed his/her signature in execution thereof.
JEFFERSON COUNTY WASHINGTON STATE OF WASHINGTON
BOARD OF COUNTY COMMISSIONERS DEPARTMENT OF HEALTH
Greg Brotherton,Chair Date Date
APPROVED AS TO FORM ONLY APPROVED AS TO FORM ONLY
January 19, 2023 Assistant Attorney General
Philip C. Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
cc-22-002-A 10 Page I of I
EXHIBIT B-10 Page 2 of 26
Jefferson County Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: December 1,2022
Indirect Rate January 1,2022 through December 31,2022:29.23%Public Health
DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue LHJ Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# List#* Code** Start Date End Date Start Date End Date Amount SubTotal Total
FFY23 USDA BFPC Prog Mgmt NGA Not Received Amd 10 10.557 333.10.55 10/O1/22 09/30/23 10/O1/22 09/30/23 $28,238 $37,651 $81,040
FFY23 USDA BFPC Prog Mgmt NGA Not Received Amd 8,10 10.557 333.10.55 10/01/22 09/30/23 10/01/22 09/30/23 $9,413
FFY22 USDA BFPC Prog Mgmt 7WA700WAI Amd 1 10.557 333.10.55 01/01/22 09/30/22 10/01/21 09/30/22 $43,389 $43,389
FFY24 USDA WIC Client Svs Contracts NGA Not Received Amd 10 10.557 333.10.55 10/O1/23 12/31/23 10/01/23 12/31/23 $25,238 $25,238 $211,077
FFY23 USDA WIC Client Svs Contracts NGA Not Received Amd 10 10.557 333.10.55 10/O1/22 09/30/23 10/01/22 09/30/23 $75,713 $99,463
FFY23 USDA WIC Client Svs Contracts NGA Not Received Amd 1 10.557 333.10.55 10/01/22 09/30/23 10/01/22 09/30/23 $23,750
FFY22 USDA WIC Client Svs Contracts 7WA700WA7 Amd 7 10.557 333.10.55 01/01/22 09/30/22 10/01/21 09/30/22 $5,600 $86,376
FFY22 USDA WIC Client Svs Contracts 7WA700WA7 Amd 5 10.557 333.10.55 01/01/22 09/30/22 10/01/21 09/30/22 $6,726
FFY22 USDA WIC Client Svs Contracts 7WA700WA7 Amd 1 10.557 333,10.55 01/01/22 09/30/22 10/01/21 09/30/22 $74,050
FFY23 USDA WIC Prog Mgmt CSS :VGA Not Received Amd 10 10.557 333.10.57 01/O1/23 09/30/23 10/01/22 09/30/23 $2,800 $2,800 $2,800
FFY22 USDA FMNP Prog Mgmt 7WA810WA7 Amd 4 10.572 333.10.57 05/01/22 09/30/22 10/01/21 09/30/22 $516 $516 $516
PS SSI 1-5 OSS Task 4 OIJ18001 Amd 7 66.123 333.66.12 01/01/22 06/30/23 07/01/17 06/30/23 ($1,654) $233,844 $233,844
PS SSI 1-5 OSS Task 4 OIJ18001 Amd 2,5 66.123 333.66.12 01/01/22 06/30/23 07/01/17 06/30/23 $235,498
FFY22 Swimming Beach Act Grant IAR(ECY) NGA Not Received Amd 2 66.472 333.66.47 03/01/22 10/31/22 01/01/22 11/30/22 $15,000 $15,000 $15,000
FFY22 PHEP BP4 LHJ Funding NU90TP922043 Amd 7 93.069 333.93.06 07/01/22 06/30/23 07/01/22 06/30/23 $34,384 $34,384 $48,138
FFY21 PHEP BP3 LHJ Funding NU90TP922043 Amd 2 93.069 333.93.06 01/01/22 06/30/22 07/01/21 06/30/22 $13,754 $13,754
FFY22 Title X Dire Needs FPHPA006495 Amd 2 93.217 333.93.21 01/14/22 03/31/22 01/14/22 03/31/22 $4,066 $4,066 $4,066
FFY22 Title X Family Planning FPRPA006560 Amd 5 93.217 333.93.21 04/01/22 03/31/23 04/01/22 03/31/23 $27,137 $27,137 $27,137
COVID19 Vaccines NH231P922619 Amd 4 93.268 333.93.26 01/01/22 06/30/24 07/01/20 06/30/24 $278,114 $278,114 $278,114
COVID19 Vaccines R4 NH231P922619 Amd 4 93.268 333.93,26 01/01/22 06/30/24 07/01/20 06/30/24 $354,803 $709,606 $709,606
COVID19 Vaccines R4 NH231P922619 Amd 1 93.268 333.93.26 01/01/22 06/30/24 07/01/20 06/30/24 $354,803
FFY23 VFC Ops NH231P922619 Amd 5 93.268 333.93.26 07/01/22 06/30/23 07/01/22 06/30/23 $5,600 $5,600 $11,200
FFY22 VFC Ops NH231P922619 Amd 3 93.268 333.93.26 01/01/22 06/30/22 07/01/21 06/30/22 $5,600 $5,600
FFY19 COVID CARES NU50CK000515 Amd 2 93.323 333.93.32 01/01/22 04/22/22 04/23/20 07/31/24 $14,664 $14,664 $14,664
FFY19 ELC COVID Ed LHJ Allocation NU50CK000515 Amd 7 93.323 333.93.32 01/01/22 10/18/22 05/19/20 10/18/22 ($2,281) $1,737 $1,737
FFY19 ELC COVID Ed LHJ Allocation NU50CK000515 Amd 4 93.323 333.93.32 01/01/22 10/18/22 05/19/20 10/18/22 ($78,694)
FFY19 ELC COVID Ed LHJ Allocation NU50CK000515 Amd 2 93.323 333.93.32 01/01/22 10/18/22 05/19/20 10/18/22 $82,712
Pagel of 3
EXHIBIT B-10 Page 3 of 26
Jefferson Countv Public Health ALLOCATIONS Contract Number: CLH31013
Contract Term:2022-2024 Date: December 1,2022
Indirect Rate.January 1,2022 through December 31,2022:29.23%Public Health
DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue LHJ Funding Period Funding Period Period Accounts
Chart of Accounts Program Title Identification# Amend# List#* Code** Start Date End Date Start Date End Date Amount SubTotal Total
FFY20 ELC EDE LHJAllocation NU50CK000515 Amd9 93.323 333.93.32 01/01/22 07/31/23 01/15/21 07/31/24 ($6,375) $341,822 $341,822
FFY20 ELC EDE LHJ Allocation NU50CK000515 Anxi 4,9 93.323 333.93.32 01/01/22 07/31/23 01/15/21 07/31/24 ($90,842)
FFY20 ELC EDE LHJ Allocation NU50CK000515 Amd 2,9 93.323 333.93.32 01/01/22 07/31/23 01/15/21 07/31/24 $439,039
FFY22 NEHA Climate&Health Grant NU380T000300 Amd 9 93.421 333.93.42 04/11/22 12/31/22 04/01/22 12/31/22 $11,000 $22,000 $22,000
FFY22 NEHA Climate&Health Grant NU380T000300 Amd 5 93.421 333.93.42 04/11/22 12/31/22 04/01/22 12/31/22 $11,000
FFY23 MCHBG LHJ Contracts NGA Not Received Amd 7 93.994 333.93.99 10/01/22 09/30/23 10/01/22 09/30/23 $36,700 $36,700 $64,225
FFY22 MCHBG LHJ Contracts B04MC45251 Amd 1 93.994 333.93.99 01/01/22 09/30/22 10/01/21 09/30/22 $27,525 $27,525
SFY23 School Based Health Centers Amd 5 N/A 334.04.90 07/01/22 06/30/23 07/01/22 06/30/23 $150,000 $150,000 $150,000
SFY23 Sexual&Rep Hith Cost Share Amd 10 N/A 334.04.91 07/01/22 06/30/23 07/01/22 06/30/23 $40,357 $80,009 $124,109
SFY23 Sexual&Rep Filth Cost Share Amd 7,10 N/A 334.04.91 07/01/22 06/30/23 07/01/22 06/30/23 $39,652
SFY22 Sexual&Rep Mth Cost Share And 5 N/A 334.04.91 01/01/22 06/30/22 07/01/21 06/30/22 $5,880 $44,100
SFY22 Sexual&Rep Mth Cost Share Amd 1 N/A 334.04.91 01/01/22 06/30/22 07/01/21 06/30/22 $38,220
State Drug User Health Program Amd 5 N/A 334.04.91 07/01/22 06/30/23 07/01/21 06/30/23 $15,000 $15,000 $22,500
State Drug User Health Program Amd I N/A 334.04.91 01/01/22 06/30/22 07/01/21 06/30/23 $7,500 $7,500
RecShellfishBiotoxin Amd9 N/A 334.04.93 01/01/22 06/30/23 07/01/21 06/30/23 $7,000 $17,500 $17,500
Rec ShellfishBiotoxin Amd 1 N/A 334.04.93 01/01/22 06/30/23 07/01/21 06/30/23 $10,500
Small Onsite Management(ALEA) Amd 1 N/A 334.04.93 07/01/22 06/30/23 07/01/21 06/30/23 $15,000 $15,000 $37,500
Small Onsite Management(ALEA) Amd 1 N/A 334.04.93 01/01/22 06/30/22 07/01/21 06/30/23 $22,500 $22,500
Wastewater Management-GFS Amd I N/A 334.04.93 07/01/22 06/30/23 07/01/21 06/30/23 $30,000 $30,000 $30,000
SFY23 FPHS-LHJ-GFS Amd 6,9 N/A 336.04,25 07/01/22 06/30/23 07/01/21 06/30/23 $1,433,000 $1,433,000 $1,433,000
FPHS-LHJ-Proviso(YR2) Amd 7 N/A 336.04.25 07/01/22 06/30/23 07/01/21 06/30/23 ($550,000) $0 $445,181
FPHS-LHJ-Proviso(YR2) Amd I N/A 336.04.25 07/01/22 06/30/23 07/01/21 06/30/23 $550,000
FPHS-LHJ-Proviso(YRI) Amd 10 N/A 336.04.25 01/01/22 06/30/22 07/01/21 06/30/23 $32,681 $445,181
FPHS-LHJ-Proviso(YRl) Amd4 N/A 336.04.25 01/01/22 06/30/22 07/01/21 06/30/23 ($137,500)
FPHS-LHJ-Proviso(YRI) Amd 1 N/A 336.04.25 01/01/22 06/30/22 07/01/21 06/30/23 $550,000
YR24 SRF-Local Asst(15%)(FO-SW)SS Amd 1 N/A 346.26.64 01/01/22 12/31/22 07/01/21 06/30/23 $1,400 $1,400 $1,400
Sanitary Survey Fees(FO-SW)SS-State AmdI N/A 346.26.65 01/01/22 12/31/22 07/01/21 06/30/23 $1,400 $1,400 $1,400
YR24 SRF-Local Asst(15%)(FO-SW)TA AmdI N/A 346.26.66 01/01/22 12/31/22 07/01/21 06/30/23 $1,000 $1,000 $1,000
Page 2 of 3
EXHIBIT B-10 Page 4 of 26
Jefferson County Public Health ALLOCATIONS Contract Number: C1.1131013
Contract Term:2022-2024 Date: December I,2022
Indirect Rate January 1,2022 through December 31,2022:29.23%Public Health
DOH Use Only
BARS Statement of Work Chart of Accounts Funding Chart of
Federal Award Assist Revenue LHJ Funding Period Funding Period Period Accounts
Chart of Accounts Program"Title Identification# Amend# List#* Code** Start Date End Date Start Date End Date Amount SubTotal Total
TOTAL. $4,330,576 $4,330,576
Total consideration: $4,125,549 GRAND TOTAL $4,330,576
$2059027
GRAND TOTAL $4,330,576 Total Fed $2,0669986
Total State $2,263,590
*Catalog of Federal Domestic Assistance
"Federal revenue codes begin with"333". State revenue codes begin with"334".
Page 3 of 3
Page 5 of 26
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Foundational Public Health Services(FPHS)- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1.2022
Contract Number: CLH31013
SOW Type: Revision Revision#(for this SOW) 3 Funding Source Federal Compliance Type of Payment
❑ Federal<Select One> (check if applicable) ❑ Reimbursement
Period of Performance: January 1,2022 through June 30,2022 El Other® State El FFATA(Transparency Act)
® Periodic Distribution
❑Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to specify how state funds for Foundational Public Health Services(FPHS)will be used for the
period of performance. Per RCW 43.70.512,these funds are for the governmental public health system to deliver FPHS services statewide in the most effective,efficient and
equitable manner possible with the funds available.
The FPHS Steering Committee with input from FPHS Subject Matter Expert(SME)Workgroups and the Tribal Technical Workgroup is the decision making body for FPHS. For
SFY22,the Steering Committee is using an iterative approach to decision making. Determining investments for SFY22(July 1, 2021 —June 30,2022). This means that additional
tasks and/or funds may be added to an LHJ's FPHS SOW as these decisions are made.
These funds are to be used as directed and allocated by the FPHS Steering Committee. As the global COVID-19 pandemic and the public health response to it continues and
begins to abate,these FPHS funds can be braided with and used to supplement other short-term pandemic response funding as needed for FPHS activities during this period of
performance through 06/30/22. Responding to pandemics,epidemics and public health emergencies are foundational services of the governmental public health system.
Note:
The total SFY22 funding allocation is for the period of July 1,2021 through June 30,2022. The funding allocations will be divided into two six-month lump sum amounts that
will be disbursed at the beginning of each six month period as follows:July 1,2021;January 1,2022. The July payment will be disbursed upon completion of the FPHS Annual
Report.
The SFY22 July 1,2021 disbursement of funds was completed in the 2018-2021 consolidated contract and is included in this statement of work for informational purposes only.
FPHS funds must be spent in the state fiscal year(SFY)in which they are appropriated by the legislature,allocated,and disbursed.Legislative appropriations lapse at the end of
each state fiscal year. (RCW 43.88.140)
Spending and spending projections must be reported as required by the FPHS Steering Committee. Funds that are projected to be unspent by the close of the state fiscal year must
be reallocated per the process developed by the FPHS Steering Committee to assure that all funds appropriated by the legislature can be spent by the governmental public health
system to deliver FPHS within the year that the funds are appropriated. Unspent funds revert to the state treasury and must be returned to DOH by July 15th of each year for
return to the Office of Financial Management.
Revision Purpose: The purpose of this revision is to update allocation to match actual funds requested and distributed for SFY22.
Exhibit A, Statement of Work Page 1 of 5 Contract Number CLH31013-Amendment 10
Page 6 of 26
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FPHS-LHJ-PROVISO(YR1) 99202111 N/A 336.04.25 01/01/22 06/30/22 412,500 32,681 445,181
Note:Total YRl allocation is for SFY22 07/01/21-06/30/22
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 412,500 32,681 445,181
BARS un s to' rovi i MRS in
Expenditure. FPHS Tasks/Activities/Short Description Your Other SFY22
Code 562.xx Jurisdiction- jurisdictions
10-17, All—CD,
20,21,23-29 EPH,CCC, Reinforcing Capacity(Assessment,CD,EPH,CCC) X 192,000
40-53 93 Assessment
10 Assessment CHA/CHIP X 30,000
20,21,23-29, CD Communicable Disease(CD) X 138,000
93
40-53,93 EPH Environmental Public Health(EPH) X 190,000
Funding Adjustment -137,500
32,681
$4M,389
TOTAL $445,181
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
In coordination with FPHS Steering Committee and Subject Routine reporting of spending and TBD
Matter Expert(SME)workgroups FPHS funds are to be used to spending projections. Process and
increase delivery of FPHS services statewide as measured reporting template TBD and provided by
through FPHS annual reporting,indicators,metrics and other the FPHS Steering Committee via DOH.
data compiled and analyzed by contractors,DOH and Subject
Matter Expert(SME)Workgroups. Resuts are published in the FPHS annual reporting(template provided For SFY22(07/01/21— Each year,the July
annual FPHS Investment Report. FPHS indicator metrics by the FPHS Steering Committee via 06/30/22)due by 08/15/22 payment will be disbursed
available here. DOH) upon completion of the
FPHS Annual Report.
Exhibit A,Statement of Work Page 2 of 5 Contract Number CLH31013-Amendment 10
Page 7 of 26
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1 Reinforcing Capacity—These funds are to each LHJ to deliver FPHS in their own jurisdiction—In coordination with the FPHS Steering Committee and Subject
Matter Expert(SME)Workgroups,provide FPHS Communicable Disease(CD),Environmental Public Health(EPH),Assessment(Surveillance&Epidemiology)and/
or any or all of the other FPHS,Cross-cutting Capabilities(CCC)as defined in the most current version of the FPHS definitions.
Suggested BARS expenditure codes:652.xx- 10-17,20,21,23-29,40-53.
2 Assessment—CHA/CHIP(FPHS definitions G.3)—These funds are to each LHJ to deliver FPHS in their own jurisdiction—In coordination with the FPHS Steering
Committee and Subject Matter Expert(SME)Workgroups,conduct and complete a comprehensive community health assessment and identify health priorities arising
from that assessment,including analysis of health disparities and the social determinants of health as defined in the most current version of the FPHS definitions.
• Conduct a local and/or regional comprehensive community health assessment(CHA)every three to five years in conjunction with community partners.
• Develop a local and/or regional community health improvement plan(CHIP)in conjunction with community partners.
These funds can be used for any CHA/CHIP activity or service(e.g.,data analysis,focus groups,report writing,process facilitation)and may be used to contract with
other LHJs for staff time or services. Coordinate with the Spokane Regional Health District to participate in County Health Insights.
Suggested BARS expenditure codes:562.11.
3 Communicable Disease(CD)(FPHS definitions C.1,2,3,4,6)—These funds are to each LHJ to deliver FPHS in their own jurisdiction— In coordination with the
FPHS Steering Committee and Subject Matter Expert(SME)Workgroups,provide FPHS CD services as defined in the most current version of the FPHS definitions.
These funds can(and actually are intended to)be braided with temporary pandemic emergency funding such that when those funds run out,FPHS funds can be used to
retain staff there were hived with pandemic emergency funds if the jurisdictions desires to retain them and/or to hire additional staff if needed and/or contract with other
LHJs for staff time or services for delivering FPHS CD. As the pandemic response wains,staff funded with FPHS funds are to shift focus to providing some or all or the
FPHS CD services. This includes maintaining access to and use of data systems created during the pandemic and others under development and case investigation and
contact tracing for sexually transmitted disease and other communicable and notifiable conditions within the mandated timeframes. Emphasis should be placed on
addressing syphilis and gonorrhea cases.
1. Provide timely,statewide,locally relevant and accurate information statewide and to communities on prevention and control of communicable disease and other
notifiable conditions.
2. Identify statewide and local community assets for the control of communicable diseases and other notifiable conditions,develop and implement a prioritized
control plan addressing communicable diseases and other notifiable conditions and seek resources and advocate for high priority prevention and control policies
and initiatives regarding communicable diseases and other notifiable conditions.
3. Promote immunization through evidence-based strategies and collaboration with schools,health care providers and other community partners to increase
immunization rates.
4. Ensure disease surveillance,investigation and control for communicable disease and notifiable conditions in accordance with local,state and federal mandates and
guidelines.
Suggested BARS expenditure codes:562.xx—20,21,23-29.
4 Environmental Public Health(EPH)(FPHS definitions B.3&4)—These funds are to each LHJ to deliver services in their own jurisdiction.In coordination with the
FPHS Steering Committee and Subject Matter Expert(SME)Workgroups,these funds are for each LHJ to deliver FPHS EPH services in their jurisdiction as defined in
the most current version of the FPHS definitions and supplement existing funding specifically for:
• Develop,implement and enforce laws,rules,policies and procedures for maintaining the health and safety of retail food service inspections and shellfish
monitoring,that address environmental public health concerns.(B.3.b)
Exhibit A, Statement of Work Page 3 of 5 Contract Number CLH31013-Amendment 10
Page 8 of 26
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
• Develop, implement and enforce laws,rules,policies and procedures for ensuring the health and safety of wastewater and facilities, including onsite septic
design and inspections,wastewater treatment and reclaimed water,that address environmental public health concerns. (B.3.e)
• Develop, implement and enforce laws,rules,policies and procedures for ensuring the health and safety of solid waste and facilities,including hazardous waste
streams(e.g.animal waste,solid waste permitting and solid waste inspections),that address environmental public health concerns.(B.3.f)
• Develop, implement and enforce laws,rules,policies and procedures for ensuring the health and safety of schools, including through education and plan review
that address environmental public health concerns. (B.3.g)
These funds can be used to retain,hire and/or contract with other LHJs for staff time or services and for staff training as needed to provide the following FPHS EPH
services that are not appropriately funded with fees. Each LHJ will be responsible to report on their progress on FPHS deliverables even if contracted with other LHJs
(FPHS funds are intended to build capacity and not intended to justify the reduction of existing fee revenue):
• Food Safety(FPHS definitions B.3.b.)—Respond to food safety concerns that are not appropriately funded such as foodbome illness threats,requests for
technical assistance and addressing new and emerging business models. Every local jurisdiction in Washington is expected to respond to foodbome illness
outbreaks,food safety inquiries and provide preventative education for the general public and technical assistance.
• Sewage Safety(FPHS definitions B.3.e-f)—Respond to sewage concerns and public health threats and provide technical assistance that are not appropriately
funded to ensure that sewage is handled appropriately to limit potential exposure to sewage. Every local jurisdiction in Washington is expected to ensure
sewage is properly managed.On-Site Septic(OSS)permitting,enforcement and providing technical assistance and education to OSS owners are fee funded
activities and should be funded through fees or local government who sets the fees. These FPHS funds provide resources to support activities for which a fee
cannot be charged such as: responding to OSS failures, surfacing sewage,OSS safety concerns,and similar issues. These funds can also be used for concerns
related to large on-site sewage systems,other OSS-related concerns that do not involve locally permittable systems,and other sewage-related issues,regardless
of whether they are related to a fee-for-service activity.Examples of activities FPHS funds can be used for:
o Work with partners to educate and inform public on OSS monitoring and maintenance
o Work with the public,policy makers and partners to assess needs and develop plans and solutions for wastewater management in their communities.
o Respond to complaints,act as needed,and assure that failing OSS are identified and promptly repaired.
o Conduct Pollution Identification and Correction(PIC)investigations where water quality is impaired to identify failing septic systems and other pollution
sources.
o Ensure that sewage from both OSS and other sources is adequately handled to create barriers to potential exposure to sewage.
o Adequate qualified staff to evaluate proposals, inspect new installations and repairs,assess cause of OSS failure,and comply with requirements in state
law.
• Schools Safety(FPHS definition B.3.g)—Assure safe and effective learning environments for children attending K-12 schools—public,private and parochial.
Every local jurisdiction in Washington is expected to work collaboratively with DOH,ESDs and local school districts and use the model program to assure
consistency to regularly evaluate each K-12 for health and safety concerns and provide mandated services per WAC 246-366. Initial priorities include:
o Build partnerships with school officials,local boards of education,parent teacher associations,education service districts,and other school focused entities.
o Participate with statewide public health groups to standardize school program implementation.
o Focus on schools that have not previously been inspected to assess current conditions
o Focus on existing elementary schools for first phase of inspections program
■ Indoor Air Quality
■ Classroom
■ Healthy cleaning and indoor environments
■ Playground
■ Drinking water lead
Exhibit A, Statement of Work Page 4 of 5 Contract Number CLH31013-Amendment 10
Page 9 of 26
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Suggested BARS expenditure codes: 562.xx—40-53.
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to financeAdoh.wa.gov.
Program Specific Requirements
Program Manual,Handbook,Policy References:
All FPHS Resources—www.doh.wa.gov/fphs or FPHS I Powered by Box
Special References(i.e.,RCWs,WACs,etc.):
Link to RCW 43.70.512—RCW 43.70.512:Public health system—Foundational public health services—Intent.(wa.gov)
Link to RCW 43.70.515—RCW 43.70.515:Foundational public health services—Funding.(wa.gov)
Definitions:
FPHS Definitions—https://wsalpho.box.com/s/gb6ssI Omxbrajx0fla742lw6zcfxzohk
Special Instructions:
There are two different BARS Revenue Codes for"state flexible funds"to be tracked separately and reported separately on your annual BARS report. These two BARS Revenue
Codes and definitions from the State Auditor's Office(SAO's)are listed below along with a link to the BARS Manual. 336.04.25 is the new BARS Revenue Code to use for the
Foundational Public Health Services(FPHS)funds included in this statement of work.
336.04.24—County Public Health Assistance
Use this account for the state distribution authorized by the 2013 2ESSB 5034,section 710.The local health jurisdictions are required to provide reports regarding expenditures
to the legislature from this revenue source.
336.04.25—Foundational Public Health Services
Use this account for the funding designated for the local health jurisdictions to provide a set of core services that government is responsible for in all communities in the WA
state. This set of core services provides the foundation to support the work of the broader public health system and community partners.At this time the funding from this
account is for delivering ANY or all of the FPHS communicable disease services(listed above)and can also be used for the FPHS capabilities that support FPHS communicable
disease services as defined in the most current version of FPHS Definitions.
Public Health Budgeting,Accounting and Reporting System(BARS)Resources: www.doh.wa.gov/lhjfunding
DOH Program Contact
Marie Flake, Special Projects,Foundational Public Health Services,Washington State Department of Health
Mobile Phone 360-951-7566/marie.flakeAdoh.wa.gov
Exhibit A,Statement of Work Page 5 of 5 Contract Number CLH31013-Amendment 10
Page 10 of 26
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Office of Immunization COVID-19 Vaccine- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2022
Contract Number: CLH31013
SOW Type: Revision Revision#(for this SOW) 2 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2022 through June 30,2024 El Other❑ State ® FFATA(Transparency Act)
El Fixed Price
❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to provide funding to conduct COVID-19 vaccine activities.
Revision Purpose: The purpose of this revision is to modify activities,deliverables,and deliverable due dates.
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation None Allocation
COVID19 Vaccines R4 74310230 93.268 333.93.26 01/01/22 06/30/24 709,606 0 709,606
COVIDI9 Vaccines 74310229 93.268 333.93.26 01/01/22 06/30/24 278,114 0 278,114
0 0 0
0 0 0
0 0 0
0 0 0
TOTALS 987,720 0 987,720
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
The purpose of this statement of work is to identify activities and provide funding to support COVID vaccine response outreach,education,and operations. The activities may
include other vaccines recommended for the audience population,as long as COVID vaccine is the primary focus and references to other vaccines are secondary.
3.A Identify activity/activities to support COVID vaccine response Summary of the engagement strategies to January 31,Annually Reimbursement for actual
in your community,using the examples below as a guideline. be used with health care providers and costs incurred,not to
other partners,and the locally identified exceed total funding
Example 1: Develop and implement communication strategies population to be reached. consideration amount.
with health care providers,community,and/or other partners to
help build vaccine confidence broadly and among groups
anticipated to receive early vaccination,as well as dispel
vaccine misinformation.Document and provide a plan that
shows the communication strategies used with health care
providers and other partners and the locally identified
population anticipated to reach.
Exhibit A,Statement of Work Page 1 of 3 Contract Number CLH31013-Amendment 10
Page 11 of 26
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Example 2: Engage in other vaccination planning activities
such as partnership development,provider education,
vaccination point of dispensing(POD)planning,tabletop
exercises,engagement with communities,leaders,non-
traditional provider,or vulnerable populations to develop
strategies to ensure equitable access to vaccination services
3.13 Implement the communication strategies or other activities, Mid term written report describing June 30,Annually Reimbursement for actual
working with health care providers and other partners to reach activity/activities and progress made to- costs incurred,not to
the locally identified population,support providers in date and strategies used(template to be exceed total funding
vaccination plans,and support equitable access to vaccination provided) consideration amount.
services.
3.0 Catalog activities and conduct an evaluation of the strategies Final written report,showing the Deeembeo-31 Reimbursement for actual
used strategies used and the final progress of June 30,annually costs incurred,not to
the reach(template to be provided) exceed total funding
consideration amount.
3.13 As needed to meet community needs,expand operations to Qwwferly reports summarizing quantity, �kkreh December 31; Reimbursement for actual
increase vaccine throughput(i.e.,providing vaccinations during type,and frequency of activities annually costs incurred,not to
evenings,overnight,and on weekends). Activities may include June 30,annually exceed total funding
vaccine strike teams,mobile vaccine clinics,satellite clinics, consideration amount.
temporary,or off-site clinics to travel and provide vaccination
services in non-traditional settings,or to supplement the work
of local health departments in underserved communities,and
may include administration costs for other vaccines co-
administered at the events.These activities may be done by the
local health department or in collaboration with community
partners. see Restrictions on Funds below
3.E At the LHJ discretion,provide incentives to persons receiving a. LHJ Incentive Plan Proposal a. Prior to implementing Reimbursement for actual
COVID vaccine,adhering to LHJ Guidance for COVID b. Quarterly report that summarizes b. Afareh 31,AnnuaRy costs incurred,not to
Initiatives Application requirements and allowable/unallowable quantity of incentives purchased and June 30,Annually exceed total funding
use of federal funds. distributed consideration amount.
3.F As needed to meet community needs,perform as a vaccine a. Complete a redistribution agreement. a. Submit upon Reimbursement for actual
depot to provide COVID vaccine. Duties include ordering and b. Report inventory reconciliation page. completion costs incurred, not to
redistributing of COVID-19 vaccine, assure storage space for c. Report lost(expired, spoiled, wasted) b. Reconcile and submit exceed total funding
minimum order sizes, initiating transfer in the Immunization vaccine to the IIS. inventory once consideration amount.
Information System(IIS), coordinate with providers for d. Report transfer doses in the IIS and monthly in the IIS.
physical transport of doses, and maintaining inventory of VaccineFinder. c. Report lost vaccine
COVID vaccine by manufacturer. e. Monitor and maintain vaccine within 72 hours in the
temperature logs from digital data IIS.
Immunization COVID-19 funding is specifically required to logger andlor the temperature d. Update within 24
address COVID-19 vaccination activities. However, the monitoring system for a minimum of 3 hours from when
funding can be leveraged to also address and incorporate other years. transfers occur.
non-COVID vaccination activities concurrent to COVID-19
Exhibit A, Statement of Work Page 2 of 3 Contract Number CLH31013-Amendment 10
Page 12 of 26
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
vaccination activities. For example, COVID vaccine storage e. Download as needed
and distribution may also support monkeypox vaccine storage (retain temperature
and distribution, concurrently data on site for 3
ears
DOH Program and Fiscal Contact Information for all ConCon SOWs can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to financeadoh.wa.gov.
Federal Funding Accountability and Transparency Act(FFATA)
This statement of work 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 the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpendinggov by DOH as required by P.L. 109-282.
Program Specific Requirements
Restrictions on Funds(i.e.,disallowed expenses or activities,indirect costs,etc.):
Coverage of co-administration costs for other vaccines administered at vaccination events does NOT apply to the FEMA Mass Vaccination funding. Coverage of co-
administration costs only applies to the vaccine funding(COVID19 Vaccine R4,MI 74310230)allocated for Task 3 of the consolidated contract. FEMA Mass Vaccination
funding is only available to cover the costs for COVID vaccine administration and cannot be used for co-administration costs of other vaccines.
Exhibit A,Statement of Work Page 3 of 3 Contract Number CLH31013-Amendment 10
Page 13 of 26
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: Sexual&Reproductive Health Program- Local Health Jurisdiction Name: Jefferson County Public Health
Effective January 1,2022
Contract Number: CLH31013
SOW Type: Revision Revision#(for this SOW) 4 Funding Source Federal Compliance Type of Payment
® Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2022 through December 31,2024 ® State ® FFATA(Transparency Act) ❑ Fixed Price
❑ Other ❑ Research&Development
Statement of Work Purpose: The purpose of this statement of work(SOW)is to provide sexual and reproductive health services(SRH)to Washington State residents.These
services will comply with all state,federal,and DOH SRHP Manual requirements. It highlights specific requirements,but all must be complied with. Budgets are based on an
approved allocation formula with funds available.
This Statement of Work spans Year 1 and Year 2 of the contract,which runs January 1,2022—March 31,2024
For state funding,due dates after June 30,2023 are for reporting only.LHJs may not bill under this contract for work done after June 30,2023.
Revision Purpose: The purpose of this revision is to extend the funding period for FFY23 Sexual&Rep Hlth Cost Share from 12/31/22 to 06/30/23 and add$40,357,extend the
period of performance from March 31,2023 through December 31,2024,and make minor edits to task deliverables and due dates.
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
SFY22 Sexual&Rep Hlth Cost Share 78430120 N/A 334.04.91 01/01/22 06/30/22 44,100 0 44,100
FFY22 Title X Dire Needs 78430222 93.217 333.93.21 01/14/22 03/31/22 4,066 0 4,066
FFY22 Title X Family Planning 78430225 93.217 333.93.21 04/01/22 03/31/23 27,137 0 27,137
SFY23 Sexual&Rep Hlth Cost Share 78430130 N/A 334.04.91 07/01/22 06/30/23 39,652 40,357 80,009
0 0 0
0 0 0
TOTALS 114,955 40,357 155,312
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
1. Sexual and Reproductive Health Program . A19 invoice vouchers submitted in a timely manner No more than monthly Billing must be based
(SRHP)&Title X(TX)Services—excluding accompanied by an R&E workbook showing revenue and no less than on a current cost
abortion and other surgical procedures related to and expenses for the month billed and any other quarterly. methodology approved
SRHP. required back up documentation per DOH policy. by DOH(see Reporting
A. Comply with Washington State 2022 SRHP Requirements table).
Manual, federal Title X requirements and all
state and federal laws. Also see Program
Exhibit A, Statement of Work Page 1 of 8 Contract Number CLH31013-Amendment 10
Page 14 of 26
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
Manual,Handbook,Policy References under 3. DOH reserves the right
Reporting Requirements below. to withhold payment
until:
B. Complete required Agency Information • Compliance issues
Dashboard that includes Title X Assurance of related to this or a
Compliance previous SOW are
resolved in a way
1. Compile all National Provider accepted by DOH
Identifier(NPI)billing numbers for • Current data is
SRHP services and submit to DOH. submitted to,and
DOH will compile and send to Health accepted by,
Care Authority(HCA)in order for Ahlers.
LHJ to qualify for the Medicaid • A19 back up
Enhanced rate documentation
required by DOH
C. Provide medical services,community education • All reports described in Reporting Requirements table As described in has been submitted
and outreach,and staff training,consistent with below. Reporting and approved.
state requirements: Requirements table • Other deliverables
1. LHJ is responsible for making sure all staff below. have been met.
have the knowledge to carry out the
requirements of the SOW. • Other data and documentation in format requested by As requested by DOH Payment is limited to
2. Medical,laboratory,and other services DOH.(Includes copies of program and financial the maximum funds
related to abortion are not covered by this audits and reviews including summaries conducted by available for funding
task. other entities.) source.
3. Community education services must be
based on the needs of the community.LHJ . To facilitate DOH/TX desk reviews—requested DOH will reimburse
must have an Information&Education documentation available to DOH in requested format. for:
(I&E)committee with no fewer than five • Actual allowable
(5)members and up to as many members • To facilitate DOH/TX site-visits—appropriate staff costs according to
as the LHJ determines;be broadly and documentation readily available prior to and your approved cost
representative of the population or during review. methodology(see
community for which materials are Reporting
intended; review all educational materials DOH performs site visits.Follow-up site visits are As requested by DOH Requirements
for clients;meet at least annually and performed until identified issues are resolved. table).
establish a written record of its
or
determination.(42 CFR 59[59.6]) • The amount
4. Outreach is to ensure all populations in remaining in the
your community understands the services
available.Focus your outreach efforts on SOW divided by
the number of
increasing equity. months remaining
Washington State Sexual and Reproductive Health in the funding
Network priority populations are: source,plus one,
whichever is less.
Exhibit A,Statement of Work Page 2 of 8 Contract Number CLH31013-Amendment 10
Page 15 of 26
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
• Teens
• People who are uninsured or underinsured, Payment will be
and/or low-income(at or below 250%of calculated by R&E
the federal poverty line) provided by DOH(see
• Rural communities Reporting Requirements
• Hispanic table).
• Black,Indigenous,People of Color
Extra efforts should be made to provide information All services through
and services to people who intersect with multiple 03 31-23 06-30-23
priority population categories. must be billed by
04 30 23 07-30-23
Provide all services in accordance with:
• DOH SRHP&Title X Manual
• Other state and federal requirements
• LHJ's Current Scope Report(defined under
3.Reporting Requirements below)
D. Collect,maintain,and provide data about each CVR data submitted to DOH data contractor(Ahlers& The last day of the next
family planning clinic visit as defined in the Associates)electronically in a format compatible with month.
SRH CVR Manual. Ahlers software. Within thirty(30)days
1. Maintain a computer system that includes of receiving
normal safety precautions against loss of 0 Data for each month error/rejection report or
information.
2. Ensure data entry personnel protect request from DOH
confidentiality of CVR data. • Corrected CVR data Sexual and
3. Have ability to retrieve all information for Reproductive Health
auditing and monitoring by DOH or its data manager.
designee.
E. Notify DOH contract manager of all:
• Key staff and organizational changes. in Email briefly describing change. needed to keep
information current.
• Proposed clinic site additions.New clinic
sites must be approved by DOH before
offering services supported by SOW
funding.
• Expected clinic site closures.Note:DOH
may,at its sole discretion,recalculate
LHJ's funding allocation if it closes a clinic
site.
• Any other change that might affect LHJ's
ability to provide the sexual and
Exhibit A,Statement of Work Page 3 of 8 Contract Number CLH31013-Amendment 10
Page 16 of 26
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
reproductive services described in this
SOW.
2. Abortion and other surgical procedures related Surgical A19 accompanied by Surgical Services Summary No more than six(6) DOH will only
to SRHP and Health Insurance Claim Forms form for each visit months after date reimburse LHJ for these
A. LHJ may choose to use up to 3%of its total billed. service was provided. services if this SOW
SOW state funds for medical and surgical includes state surgical
abortions and other SRHP related surgical DOH will provide Surgical Services Summary forms and funds outside of the
procedures. surgical A19s as part of R&E workbook for all LHJs who Title X Project.
B. LHJ must notify the DOH contract manager receive surgical funds.
prior to providing services with SOW state DOH will pay for
funds. DOH will move the appropriate amount services at Health Care
to the appropriate funding source.This may or Authority(HCA)
may not require an amendment. Medicaid
C. Comply with Washington State 2022 SRHP reimbursement
requirements and all state laws.Also see amounts.
Program Manual,Handbook,Policy References • This will be
section below. considered payment
D. Eligible clients are those with incomes at or in full.
below 250%FPL. LHJ will not seek
additional payment
If LHJ bills for services provided by someone from the client or any
outside their organization the outside provider must other person or
agree to accept DOH payment as payment in full. organization.
LHJ is responsible for ensuring that the outside
provider does not seek additional payment from the
client or any other person or organization.(Also see
Payment column.)
3. Reporting Requirements
1. Agency Information Dashboard This information must be reported using the template '^�204-30-23
or format provided by DOH.All signatures and forms
Information required at the beginning of this must be completed by 10 31 22 04-30-23 It will include: AND
SOW period.This information ensures that
DOH has accurate information about LHJ's Information about your agency contacts and your As needed or requested
organization and the services it provides. organization's staffing to maintain accuracy of
A. Head of Organization
information.
Exhibit A,Statement of Work Page 4 of 8 Contract Number CLH31013-Amendment 10
Page 17 of 26
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
In addition,elements of this report allow DOH B. Head of Finance
to ensure that SRHP&Title X requirements C. Medical Director
regarding client fees,required services, D. The following(one person might fill more than one
requirements are met.It also provides other role)
information to assist DOH to manage this SOW a. Contract Coordinator
and the Sexual&Reproductive Health Network b. Clinical representative
as a whole. c. Billing contact
d. Outreach and education contact
e. Contact for CVR data
f. Contact for EHR information
E. NP1 numbers used to bill Medicaid
Information regarding sexual and reproductive health
related services offered at each clinic site:
A. Cost analysis:How LHJ determines what it costs to
provide services. LHJ uses this to help construct its
fee schedule. A cost analysis must be performed by
LHJ no more than three years prior to the start date of
this SOW.
B. Sliding fee schedule that includes all services required Submit DO sliding`==
in the SRH Manual. Additional Task 1 SRH-related sea30le DOH i
^�z 2023 income
services may also be included on LHJ's sliding fee conversion chart by
schedule. 03-15-23
a. Sliding fee schedule must be based on cost
analysis described above.
b. LHJ may use the last fee schedule approved prior
to this SOW as long it was approved later than
04-01-24-2. LHJ must email the DOH contract
manager letting them know it is using a prior
approved fee schedule.
c. LHJ must not implement a revised fee schedule
until it has been approved in writing by DOH.
d. Income conversion tables must be updated
annually and approved by DOH
Information related to current Community Outreach Plan:
LHJ's community outreach plan follows a 5-year cycle.In
the first year LHJ must assess,document and disseminate
community health needs assessment,this process must
include the following steps:
A. Define the populations LHJ serves and identify
opportunities to expand reach within those
Exhibit A,Statement of Work Page 5 of 8 Contract Number CLH31013-Amendment 10
Page 18 of 26
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
populations and to unreached populations in each
community it serves.
B. Identify organizations and people representing the
broad interests of the community and identify
opportunities for partnership and collaboration.
C. Gather available data and current assessments
(secondary data)
D. Seek community perspectives by gathering input
from the various populations in LHJ's community
(collect primary data)
E. Aggregate secondary and primary data and analyze
aggregated data
F. Prioritize health issues,define areas of unmet need,
and incorporate both in plans for outreach and
education materials and activities
G. Document and disseminate the community health
needs assessment to LHJ's SRH consultant and
appropriate stakeholders
Information related to billing and client fees
Cost methodology:How LHJ determines appropriate
expenses for the purpose of billing DOH.
If LHJ cost methodology was approved by DOH after
04-01-202,LHJ does not have to resubmit unless changes
were made. LHJ does need to email DOH contract
manager informing them that no changes were made.
2. Family Planning Annual Report(FPAR) Organization-level data on clinical services emailed to Data to be collected
DOH SRH data manager annually through the
Information DOH is requesting to develop trend end of the contract
data. All information is for calendar year 2022 Number of: period(03 31 23).
(January through December 2022).The A. Pap tests with an ASC or higher result
subsequent agreements sent to the agency will B. Pap tests with an HSIL or higher result
request that these data be collected and reported C. HIV Positive confidential tests
on within the statement of work period of D. HIV Anonymous tests
performance. E. FTE required to provide sexual and reproductive
health services:
• Physicians
• Physician assistants+nurse practitioners+
certified nurse midwives
• Registered nurses with expanded scope of practice
who are trained and permitted by statespecific
Exhibit A,Statement of Work Page 6 of 8 Contract Number CLH31013-Amendment 10
Page 19 of 26
Task Activity Deliverables/Outcomes Due Date/Time Frame Payment Information
# and/or Amount
regulations to perform all aspects of the physical
assessment.
Financial data emailed to DOH Contract Manager
R&E showing Other Revenue through 6-30 2212-31-23 as
described in item 5,below.
Subsequent agreements will request that data be collected
and reported on during the appropriate contract period of
performance.(FPAR due 01 31 23 01-31 annually through
202 7)
3. Clinic Visit Reports(CVRs) Clinic visit records must include all elements specified The last day of the next
in the Clinic Visit Record(CVR)Manual available at: month
httt)s://www.doh.wa.eov/Portals/l/Documents/Pubs/930- Within thirty(30)days
139-CVRManual.pdf. of receiving error or
rejection report or
CVR data must be submitted to DOH data contractor request from DOH
(Ahlers&Associates)electronically in a format compatible SRH data manager.
with Ahlers software.
- Each month's CVR data
- Corrected CVR data
4. Revenue and Expense Reports(R&E) Completed R&E for time period that shows all revenue Submitted with each
(including program income)that support Task 1 SRH invoice(A19).No
Services and all expenses related to providing those more than monthly and
services. R&E workbook will be provided by DOH. no less than quarterly.
A. Expenses must match General Ledger. R&E showing all
B. Other revenue/program income must reflect revenue sources of revenue that
actually received in the reporting month.
All entries on"Other"rows must be accompanied by a support services for:
January June
2023 due within description of the revenue source or expense,including any within 30
calculations uses. days after 0'o '�3
06-30-23
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance(a-doh.wa.gov_.
Federal Fundine Accountability and Transparency Act(FFATA)
This statement of work 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 the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpendinggov by DOH as required by P.L. 109-282.
Exhibit A, Statement of Work Page 7 of 8 Contract Number CLH31013-Amendment 10
Page 20 of 26
Program Specific Requirements
Program Manual,Handbook,Policy References:
LHJ must comply with all state and DOH SRH requirements,policies,and regulations and with their DOH approved Current Scope Report.
Reference documents include:
• DOH SRHP Manual(DOH publication 930-122,available at https://www.doh.wa. og_v/portals/l/Documents/Pubs/930-122-FPRHManualComplete.pdf). Some provisions
of this manual are highlighted in this SOW,but all provisions of the manual must be complied with.
• Clinic Visit Record Manual(https://www.doh.wa.2ov/Portals/l/Documents/Pubs/930-139-CVRManual.pdf)
• LHJ's approved Current Scope Report
Billing Requirements:
See Payment column of Tasks and Deliverables table and R&E report description in Reporting Requirements table
Special Instructions:
Accessibility of Services
• Clients must not be denied services or subjected to variation in quality of services because of inability to pay.
• LHJ must make sure their communities are informed of the services available.
• LHJ must make sure that all services provided are accessible to target populations.
o Facilities must be geographically accessible to the populations served.
o As much as possible,services will be available at times convenient to those seeking services.
o Clinics must comply with the Americans with Disabilities Act.
o Facilities must meet applicable standards established by the Federal, State,and local governments,including local fire,building,and licensing codes.
o Clinic settings must ensure respect for the privacy and dignity of the individual.
• Clients must be accepted on referral from any source.
• Services must be provided solely on a voluntary basis. Acceptance of SRH services must not be a prerequisite to eligibility for,or receipt of, services in any non-SRH
programs of the LHJ.
Availability of Emergency Services
The LHJ must have written plans and procedures for the management of on-site medical emergencies,including emergencies that require transport and after-hours management of
contraceptive emergencies.(See DOH SRH Manual)
Exhibit A,Statement of Work Page 8 of 8 Contract Number CLH31013-Amendment 10
Page 21 of 26
Exhibit A
Statement of Work
Contract Term: 2022-2024
DOH Program Name or Title: WIC Nutrition Program-Effective January 1,2022 Local Health Jurisdiction Name: Jefferson County Public Health
Contract Number: CLH31013
SOW Type: Revision Revision#(for this SOW) 5 Funding Source Federal Compliance Type of Payment
®Federal Subrecipient (check if applicable) ® Reimbursement
Period of Performance: January 1,2022 through December 31,2024 ❑ State❑ Other ®FFATA(Transparency Act)
El Fixed Price
[IResearch&Development
Statement of Work Purpose: The purpose is to provide Women,Infants,and Children(WIC)Nutrition Program services by following WIC federal regulations, WIC state office
policies and procedures, WIC directives,and other rules. Refer to the Program Specific Requirements section of this document.
Revision Purpose: To add FFY23 and FFY24 USDA WIC Client Services Contracts funds,FFY23 USDA WIC Program Management CSS funds and a special requirement,
FFY23 USDA BFPC Program Management funds,and to update the caseload.
Master Assistance BARS Allocation
LHJ Funding Period Chan e
Index Listing Revenue Current g Total
DOH Chart of Accounts Master Index Title Code Number Code Start Date End Date Allocation Increase(+) Allocation
FFY22 USDA WIC CLIENT SVS CONTRACTS 76101234 10.557 333.10.55 07/01/22 09/30/22 86,376 0 86,376
FFY23 USDA WIC CLIENT SVS CONTRACTS 76101244 10.557 333.10.55 10/01/22 09/30/23 23,750 75,713 99,463
FFY22 USDA BFPC PROG MGMT 76214231 10.557 333.10.55 01/01/22 09/30/22 43,389 0 43,389
FFY22 USDA FMNP PROG MGMT 76540237 10.572 333.10.57 05/01/22 09/30/22 516 0 516
FFY23 USDA BFPC PROG MGMT 76214241 10.557 333.10.55 10/01/22 09/30/23 9,413 28,238 37,651
FFY23 USDA WIC PROG MGMT CSS 76101242 10.557 333.10.55 01/01/23 09/30/23 0 2,800 2,800
FFY24 USDA WIC CLIENT SVS CONTRACTS TBD 10.557 333.10.55 10/01/23 12/31/23 0 25,238 25,238
0 0 0
TOTALS 163,444 131,989 295,433
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
See"Billing
I WIC Nutrition Program Requirements"
below.
1.1 Maintain authorized participating caseload at 100%based on Outcomes based on monthly participation Authorized participating
quarterly average as determined from monthly caseload data from state WIC caseload management caseload for January 2022
management reports generated at state WIC office. reports. through December 2024=
The Department of Health(Department)State WIC Nutrition 250
Program has the option of reducing authorized participating
caseload and corresponding funding when:
1. Unanticipated funding situations occur.
Exhibit A, Statement of Work Page I of 6 Contract Number CLH31013-Amendment 10
Page 22 of 26
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
2. Reallocations are necessary to redistribute caseload Revised authorized
statewide. participating caseload for
3. Caseload declines. January 2023 through
December 2024=265
1.2 Submit the annual Nutrition Services Plan for each year of the Nutrition Services Plan First year due 9/30/22 Payment withheld if
contract. Second year due 9/30/23 not received by due
date.
1.3 Submit the annual Nutrition Services Expenditure Report for each Nutrition Services Expenditure Report 11/30/22 Payment withheld if
year of the contract. 11/30/23 not received by due
date.
Tell participants about other health services in the agency. If Documentation must be available for review
1.4 needed,develop written agreements with other health care agencies by WIC monitor staff. Biennial WIC Monitor
and refer participants to these services.
Provide nutrition education services to participants and caregivers Documentation must be available for review
1.5 in accordance with federal and state requirements. by WIC monitor staff. Biennial WIC Monitor
Issue WIC benefits while assuring adequate WIC card security and Documentation must be available for review
1.6 reconciliation. by WIC monitor staff. Biennial WIC Monitor
Collect data,maintain records,and submit reports to effectively Documentation must be available for review
1.7 enforce the non-discrimination laws(Refer to Civil Rights by WIC monitor staff. Biennial WIC Monitor
Assurances below).
Submit entire WIC and Breastfeeding Peer Counseling Budget Budget Workbook First year due 9/30/22
1.8a Workbook for each year of the contract
Second year due 9/30/23
Submit Rev-Exp Report spreadsheet from the WIC Budget Revenue and Expense Report and A-19 First year due monthly
1.8b Workbook monthly with A-19 through December 31,2022
Second year due monthly
through December 31,2023
See"Billing
2 Breastfeeding Promotion Requirements"
below.
Provide breastfeeding promotion activities in accordance with Status report of chosen activities in First year due 11/30/22
federal and state requirements. Nutrition Services Plan. Second year due 11/30/23
2.1
Documentation must be available for review Biennial WIC Monitor
by WIC monitor staff.
Work with community partners to improve practices that affect Status report of chosen activities in First year due 8/30/22
breastfeeding. Choose one or more of the following projects: Nutrition Services Plan. Second year due 8/30/23
2.2 Provide staff,health care providers and community partners
virtual breastfeeding training resources. Documentation must be available for review Biennial WIC Monitor
■ Work with employers who likely employ low-income people by WIC monitor staff.
to create worksite environments that support breastfeeding.
Exhibit A, Statement of Work Page 2 of 6 Contract Number CLH31013-Amendment 10
Page 23 of 26
Task Payment
# Activity Deliverables/Outcomes Due Date/Time Frame Information and/or
Amount
■ Work with birthing hospitals to improve maternity care
practices that affect WIC participant breastfeeding rates.
■ Provide participants access to lactation consultants.
Other projects will need pre-approval from the State WIC Office
See"Billing
3 Breastfeeding Peer Counseling Program(BFPC) Requirements"
below.
Provide Breastfeeding Peer Counseling Program activities in Breastfeeding Peer Counseling Annual First year due 12/31/22
accordance with federal and state requirements.The WIC Report and expenditures from the previous Second year due 12/31/23
3.1 Breastfeeding Peer Counseling Program is meant to enhance,not federal fiscal year.
replace,WIC Breastfeeding promotion and support activities. Biennial WIC Monitor
Documentation must be available for review
by WIC monitor staff.
Track Breastfeeding Peer Counseling Program expenditures and Documentation must be available for review Biennial WIC Monitor
3.2 bill separately from the WIC grant. by WIC monitor staff.
See"Billing
4 Farmers Market Nutrition Program(FMNP) Requirements"
below.
Distribute all Farmers Market Nutrition Program checks to eligible Send completed readable copy of FMNP Weekly June-Sept. 2022 and
WIC participants between June and September 30 of current year. check registers to State WIC office on a June-Sept. 2023
weekly basis following FMNP procedures.
4.1 All sent by Oct. 1,2022 and
Documentation must be available for review by Oct. 1,2023
by WIC monitor staff.
Biennial WIC Monitor
DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site.Questions related to this SOW,or any other
finance-related inquiry,may be sent to finance(a,doh.wa.gov.
Federal Funding Accountability and Transparency Act(FFATA)(Applies to federal grant awards.)
This statement of work 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 the federal funds are spent.
To comply with this act and be eligible to perform the activities in this statement of work,the LHJ must have a Unique Entity Identifier(UEI)generated by SAM.gov.
Information about the LHJ and this statement of work will be made available on USASpendingeov by DOH as required by P.L. 109-282.
Program Specific Requirements
Program Manual,Handbook,Policy References:
The LHJ shall be responsible for providing services according to rules,regulations and other information contained in the following:
• WIC Federal Regulations,USDA,and FNS 7CFR Part 246.
• Washington State WIC Nutrition Program Policy and Procedure Manual
Exhibit A,Statement of Work Page 3 of 6 Contract Number CLH31013-Amendment 10
Page 24 of 26
• Office of Management and Budget, Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards,2 CFR 200
• Farmers Market Nutrition Program Federal Regulations,USDA,FNS 7CFR Part 248
• Other directives issued during the term of the contract
Staffing Requirements:
The LHJ shall:
• Use Competent Professional Authority staff, as defined by WIC policy,to determine participant eligibility,prescribe an appropriate food package and offer nutrition
education based on the participants' needs.
• Use a Registered Dietitian(RD)or other qualified nutritionist to provide nutrition services to high risk participants,to include development of a high-risk care plan. The
RD is also responsible for quality assurance of WIC nutrition services. See WIC Policy for qualifications for a Registered Dietitian and other qualified nutritionist.
• Assign a qualified person to be the Breastfeeding Coordinator to organize and direct local agency efforts to meet federal and state policies regarding breastfeeding
promotion and support. The Breastfeeding Coordinator must be an International Board-Certified Lactation Consultant or attend an intensive lactation management
course,or other state approved training.
Restrictions on Funds:
The LHJ shall follow the instructions found in the Policy and Procedure Manual under WIC Allowable Costs and 2 CFR Part 200 Uniform Administrative Requirements,Cost
Principles,and Audit Requirements for Federal Awards.
Special References:
What is the WIC program?
1. The WIC program in the state of Washington is administered by the Department of Health.
2. The WIC program is a federally funded program established in 1972 by an amendment to the Child Nutrition Act of 1966.The purpose of the program is to provide nutrition
and health assessment; nutrition education;nutritious food;breastfeeding counseling;and referral services to pregnant,breastfeeding,and postpartum women, infants,and
young children in specific risk categories.
3. Federal regulations governing the WIC program(7 CFR Part 246)require implementation of standards and procedures to guide the state's administration of the WIC program.
These regulations define the rights,responsibilities,and legal procedures of WIC employees,participants,persons acting on behalf of a participant,and retailers.They are
designed to promote:
a. High quality nutrition services;
b. Consistent application of policies and procedures for eligibility determination;
c. Consistent application of policies and procedures for food benefit issuance and delivery;and
d. WIC program compliance.
4. The WIC program implements policies and procedures stated in program manuals, handbooks,contracts,forms,and other program documents approved by the USDA Food
and Nutrition Service.
5. The WIC program may impose sanctions against WIC participants for not following WIC program rules stated on the WIC rights and responsibilities.
6. The WIC program may impose monetary penalties against persons who misuse WIC benefits or WIC food but who are not WIC participants.
Monitoring Visits:
Program and fiscal monitoring are done on a biennial(every two years)basis and are conducted onsite.
The LHJ must maintain on file and have available for review,audit and evaluation:
• All criteria used for certification, including information on income,nutrition risk eligibility and referrals
• Program requirements
• Nutrition education
• All financial records
Exhibit A,Statement of Work Page 4 of 6 Contract Number CLH31013-Amendment 10
Page 25 of 26
Assurances/Certifications:
1. Computer Equipment Loaned by the Department of Health WIC Nutrition Program
In order to perform WIC program activities,the Department requires computer equipment,such as computers,signature pads,document scanners,card readers and printers to
be in local WIC clinics or to be transported to mobile clinics. This equipment("Loaned Equipment")is owned by the Department and loaned to the local agency(Contractor).
The Loaned Equipment is supported by the Department. This equipment shall be used for WIC business only or according to WIC Policy and Procedures.
An inventory of Loaned Equipment is kept by the Department. Each time Loaned Equipment is changed,the parties shall complete the Equipment Transfer Form and the
Department updates the inventory. A copy of the Transfer Form will be provided to the contractor. Copies of the updated inventory list may be requested at any time.
The LHJ agrees to:
a. Defend,protect and hold harmless the Department or any of its employees from any claims,suits or actions arising from the use of this Loaned Equipment.
b. Assume responsibility for any loss or damage from abnormal wear or use,or from inappropriate storage or transportation. The Department may enforce this by:
1) Requiring reimbursement from the LHJ of the value of the Loaned Equipment at the time of the loss or damage.
2) Requiring the LHJ to replace the Loaned Equipment with equipment of the same type,manufacturer,and capabilities(as pre-approved by the Department),or
3) Assertion of a lien against the Contractor's property.
c. Notify the Department immediately of any damage to Loaned Equipment.
d. Notify the Department prior to moving or replacing any Loaned Equipment.
The Department recommends Contractors carry insurance against possible loss or theft.
2. Civil Rights Assurance
a. The LHJ shall perform all services and duties necessary to comply with federal law in accordance with the following Civil Rights Assurance.
b. "The Program applicant hereby agrees that it will comply with Title VI of the Civil Rights Act of 1964(42 U.S.C. 2000d et seq.),Title IX of the Education Amendments
of 1972(20 U.S.C. 1681 et seq.), Section 504 of the Rehabilitation Act of 1973(29 U.S.C. 794),Age Discrimination Act of 1975(42 U.S.C.6101 et seq.); all provisions
required by the implementing regulations of the Department of Agriculture;Department of Justice Enforcement Guidelines,28 CFR 50.3 and 42;and FNS directives and
guidelines,to the effect that,no person shall,on the ground of race,color,national origin,sex, age or handicap,be excluded from participation in,be denied benefits of,or
otherwise be subject to discrimination under any program or activity for which the Program applicant receives Federal financial assistance from FNS; and hereby gives
assurance that it will immediately take measures necessary to effectuate this agreement.
c. `By accepting this assurance,the Program applicant agrees to compile data,maintain records and submit reports as required,to permit effective enforcement of the
nondiscrimination laws and permit authorized USDA personnel during normal working hours to review such records,books and accounts as needed to ascertain
compliance with the nondiscrimination laws. If there are any violations of this assurance,the Department of Agriculture,Food and Nutrition Service,shall have the right
to seek judicial enforcement of this assurance. This assurance is binding on the Program applicant, its successors,transferees,and assignees,as long as it receives
assistance or retains possession of any assistance from the Department. The person or persons whose signatures appear on the contract are authorized to sign this
assurance on behalf of the Program applicant."
3. 2CFR 200
The LHJ shall comply with all the fiscal and operations requirements prescribed by the state agency as directed by Federal WIC Regulations(7CFR part 246.6),2CFR part
200,the debarment and suspension requirements of 2CFR part 200.213, if applicable,the lobbying restrictions of 2CFR part 200.245,and FNS guidelines and instructions and
shall provide on a timely basis to the state agency all required information regarding fiscal and program information.
Billing Requirements:
1. Definitions
Contract Period: January 1,2022-December 31,2024
Contract Budget Period: The time period for which the funding is budgeted.
• There are four federal budget periods
January 1,2022 through September 30,2022;
October 1,2022 through September 30,2023;
Exhibit A, Statement of Work Page 5 of 6 Contract Number CLH31013-Amendment 10
Page 26 of 26
October 1,2023 through September 30,2024;
October 1,2024 through December 31,2024.
2. Billing Information:
a. Billings are submitted on an A-19-IA invoice. These invoices are provided by the Department in the WIC Budget Workbook and include accounting codes for different
budget categories.
b. A-19s are submitted monthly and must be received by the Department within 60 days following the close of each calendar month. Additional A-19s may be submitted at
any time,but must be received within 90 days of the close of the federal budget period.
c. Funds are allocated by budget categories and by federal budget periods(refer to the budget spreadsheet).
d. Funds are encumbered or spent only during the budget period;no carry forward from previous time periods or borrowing from future time periods is allowed.
e. Payments are limited to the amounts allocated for the budget period for each budget category.
f. Billings are based on actual costs for completed activities.Advance payments are not allowed. Back up documentation must be retained by the LHJ and available for
inspection by the Department or other appropriate authorities.
g. Payments will be made only for WIC approved expenditures. Refer to the Washington State WIC Nutrition Program Policy and Procedure Manual Volume 2,Chapter 4—
Allowable Costs and 2 CFR Part 200 Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards.
h. If billing for indirect costs,a Cost Allocation Plan or Federal Indirect Cost Agreement must be submitted prior to payment.
Special Instructions:
The LHJ shall:
1. Maintain complete,accurate,and current accounting of all local,state,and federal program funds received and expended.
2. Provide,as necessary,a single audit in accordance with the provisions of 2 CFR Part 200 Uniform Administrative Requirements,Cost Principles,and Audit Requirements for
Federal Awards. This circular requires all recipients and sub-recipients of federal funds to have a single audit performed should they spend$750,000 or more of federal grants
or awards from all sources. Contractors spending less than$750,000 in federal grants or awards may also be subject to audit.
3. Use Breastfeeding Peer Counseling(BFPO)Program funds only to support the peer counseling program. Once the program is established and peer counselors are trained,the
majority of the salary costs must be paid to peer counselors to provide direct services to WIC participants. For a list of allowable costs see Volume 2,Chapter 4—Allowable
Costs. The priority use of BFPC funds is to hire and train peer counselors to provide breastfeeding peer counseling services to WIC participants.
SPECIAL REQUIREMENTS
Contract Funding Period Time Period special Amount Special Requirement Description
requirement funds are available
January 2022 to September 2024 January 2022 to September 2022 $29800 Added in the USDA WIC Client Services Contracts category to cover training and travel
expenses for all local WIC staff to participate in WIC-related trainings.
January 2023-September 2023 January 2023-September 2023 $2,800 This funding is for all WIC staff to participate in WIC-related training.Added in the USDA
WIC Client Services Contracts category to cover training registrations, travel expenses,
staff time to participate in training(salary/benefits or contractor), and other approved WIC
training expenses.
Other:
Any program requirements that are not followed may be subject to corrective action and may result in monetary fines or repayment of funds.
Exhibit A, Statement of Work Page 6 of 6 Contract Number CLH31013-Amendment 10