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HomeMy WebLinkAboutca4_050310 Consent Agenda JEFFERSON COUNTY PUBLIC HEALTH 615 Sheridan Street · Port Townsend · Washington · 98368 www.jeffersoncountypublichealth.org April 12, 2010 JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS AGENDA REQUEST TO: Board of County Commissioners Philip Morley, County Administrator FROM: DATE: Jean Baldwin, Director MA'f 3, 9.010 SUBJECT: Agenda Item - Consolidated Contract, Amendment #23 with the Department of Health; January 1, 2007 - December 31, 2011; add'l $82,846 total $2,355,063 STATEMENT OF ISSUE: Jefferson County Public Health is requesting Board approval of the Consolidated Contract, Amendment #23 with the Department of Health; January 1, 2007 - December 31, 2011; add1 $82,846 total $2,355,063 ANALYSIS/STRATEGIC GOALS/PRO'S and CON'S: This agreement with the Department of Health is a 5 year agreement containing both State & Federal Funds. This amendment adds $82,846 to the existing contract. The affected programs are as follows: . $4,000; BEACH Program; March 2007 - December 2010 Revenue will be utilized by testing several swimming beaches in Jefferson County through the summer season. . $70,000; Public Health Emergency Preparedness & Response (PHEPR) - July 2009 - August 2010 Revenue for this program aided H1N1 vaccine distribution and pandemic response during the Pan Flu outbreak . $8,846; WIC Nutrition Program -January 2007 - December 2010; This revenue will pay for two staff to attend lactation management training, including travel costs. Funds in the amount of $171 will be added to the WIC Farmers Market Nutrition Program. COMMUNITY HEALTH DEVELOPMENTAL DISABILITIES MAIN: (360) 385-9400 FAX: (360) 385-9401 PUBLIC HEALTH ALWAYS WORKING FOR A SAFER AND HEALTHIER COMMUNI" ENVIRONMENTAL HEALTH WATER QUALITY MAIN: (360) 385-9444 FAX: (360) 379-4487 Consent Agenda . ARRA Immunization Reaching More Children; March 2010 - February 2011 This amendment corrects the BARS revenue code and adds fraud reporting information . ARRA Immunization Reimbursement Project; March 2010 - February 2011 This amendment corrects the BARS revenue code and adds fraud reporting information . On-Site LMP Implementation; July 2009 - June 30, 2011; Language added in program specific narrative to ensure consistency with the puget Sound Action Agenda and statute. FISCAL IMPACT I COST BENEFIT ANALYSIS: This amendment through the Department of Health adds $82,846 in revenue for a total of $2,355,063. Revenue from this amendment is reflected in the JCPH 2010 budget. RECOMMENDATION: JCPH management request approval of the Consolidated Contract, Amendment #23 with the Department of Health; January 1, 2007 - December 31, 2011; add'l $82,846 total $2,355,063 Lf~:;; 1(0 Date (Routed to all Public Health Managers) JEFFERSON COUNTY PUBLIC HEALTH 2007-2011 CONSOLIDATED CONTRACT CONTRACT NUMBER: C14950 AMENDMENT NUMBER: 23 PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HEALTH hereinafter referred to as "DOH", and JEFFERSON COUNTY PUBLIC HEALTH 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, attached and incorporated by this reference, is amended as follows: D Adds Statements of Work for the following programs: [8J Amends Statements of Work for the following programs: . ARRA Immunization Reaching More Children Project - Effective March 1,2010 . ARRA Immunization Reimbursement Project - Effective March 1, 2010 · BEACH Program - Effective March 1,2007 · On-Site LMP Implementation - Effective July 1, 2009 . Public Health Emergency Preparedness & Response (PHEPR) - Effective July 31, 2009 · WIC Nutrition Program - Effective January 1,2007 D Deletes Statements of Work for the following programs: 2. Exhibit B-23 Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-22 Allocations as follows: [8J D D Increase of $82.846 for a revised maximum consideration of $2.355.063. Decrease of $ for a revised maximum consideration of $ No change in the maximum consideration of $ 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 PUBLIC HEALTH STATE OF WASHINGTON DEPARTMENT OF HEALTH (Date) (Date) ~lS IO Icrriii (,.:~~ APPROVED AS TO FORM ONLY Assistant Attorney General .. G)~ C~;/Jq);" - - -:;'1 I}......_;,.{..'~f<:--;..;,.-" :-.!c)ij .l'!,.,P,y\,c."",-.",,:.or')s (~,/" Page] of 28 tI1 & 8: ...... 10 I::H:H::H::I 10 000000 =::r::===::r:: "'C"'C"'C"'C"tl"tl "'I "'I "'I "'I "'I "'I o 0 000 0 (JQ(JQ(JQ(JQ(JQ(JQ "'I "'I "'I "'I "'I "'I ~ ~ ~ ~ ~ ~ 8 8 8 8 8 8 ZZZZZZ ~ ~ ~ ~ ~ ~ 8 8 8 888 ~ ~ ~ ~ ~ ~ o 0 0 000 "'I "'I "'I "'I "'I "'I 0-30-30-30-30-30-3 ... ...... ..... ... -. -. ....... ,.... .... ....... .... .... 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"0 (1) ..... o' Po EXHIBIT B-23 Contract Number: CI4950 Jefferson County Pnblic Health ALLOCA nONS Date: March 15, 2010 CONTRACT TERM: 2007-2011 rD9no~~,,~ BARS Funding Chart of Revenue Period Accounts Chart of Accounts Program Title Amendment Code* CFDA ** Amount Sub Total Total WIC USDA Farmers Market Admin Amend 2 333.10.52 10572 $121 $121 WIC USDA Fanners Market Admin Amend 9 333.10.52 10.572 $135 $135 WIC USDA Fanners Market Admin Amend \5 333.10.52 10.572 $139 $139 WJC USDA Farmers Market Admin Amend 23 333,]0,52 10,572 $171 $171 $566 WIC USDA Breastfeeding 333.10.57 10557 $804 $804 WIC USDA Breastfeeding 333.10.57 10.557 $1,073 $1,073 WIC USDA Breastfeeding Amend 13 333.10.57 10557 $268 WIC USDA Breastfeedmg Amend \3 333.10.57 10557 $898 $1,166 WIC USDA Breastfeeding Amend 13 333.10.57 10.557 $\,\97 $1,197 WIC USDA Breastfeeding Amend 13 333.10.57 10.557 $299 $299 $4,539 WJC USDA Breastfeeding Peer Counsel Amend 23 333.10.57 10.557 $8,675 $8,675 $8,675 WIC USDA NLS 333.10.57 10.557 $39,150 $39,150 WIC USDA NLS 333.10.57 10.557 $52,200 WIC USDA NLS Amend 4 333.1057 10.557 $1,350 WIC USDA NLS Amend 10 333. I 057 10.557 $1,000 WIC USDA NLS Amend I I 333.1057 10.557 $650 $55,200 WIC USDA NLS Amend 13 333.10.57 10.557 $13,050 WIC USDA NLS Amend 13 333.10.57 10.557 $338 WIC USDA NLS Amend 13 333.10.57 10 557 $450 WIC USDA NLS Amend 13 333.\ 0.57 10557 $41,513 WIC USDA NLS Amend 14 333.10.57 10557 $1,794 WIC USDA NLS Amend 16 333 10.57 10557 $1,894 $59,039 WIC USDA NLS Amend 13 333.1057 10557 $55,350 WIC USDA NLS Amend 14 333.10.57 10557 $3,075 WIC USDA NLS Amend 16 333 10.57 10.557 $7,575 WIC USDA NLS Amend 19 333 10.57 10557 $1,480 WIC USDA NLS Amend 22 333 10.57 10.557 $735 $68,215 WIC USDA NLS Amend 13 333.1057 10.557 $13,838 WIC USDA NLS Amend 14 333.10.57 10.557 $769 WIC USDA NLS Amend 16 333 10.57 10557 $1,894 $16.501 $238, 105 Swimming Beach JAR (Ecol) Amend 15 333.66.47 66.472 $4,2 19 Swimming Beach JAR (Ecol) Amend 23 333,66,47 66.472 $4,000 $8,219 $8,219 Water Rec Beach IAR Amend 2 333.66.47 66.472 $1,600 $1,600 Water Rec Beach IAR Amend 9 333.6647 66.472 $2,400 Water Rec Beach IAR Amend 9 333.66.47 66.472 $5,000 Water Rec Beach IAR Amend 15 333.66.47 66.472 $3,281 $10,681 $12,281 Drinking Water Group A - SS Amend 15 33366.48 66.468 $4,000 $4,000 $4,000 Drinking Water Group A - TA Amend I 5 333.66 48 66.468 $3,000 $3,000 $3,000 EH Drinking Water SS 333.66 48 66 468 $1,250 EH Drinking Water SS Amend 8 333.6648 66.468 ($1,250) $0 EH Drinking Water SS Amend 8 333.66 48 66 468 $5,000 $5,000 EH Drinking Water SS 333.6648 66 468 $3,750 EH Drinking Water SS Amend 8 33366 48 66.468 ($3,750) $0 EH Drinking Water SS Amend 13 333.66.48 66 468 $5,500 EH Drinking Water 55 Amend 1 5 333.6648 66 468 ($4,000) EH Drinking Water 55 Amend 22 333.66.48 66 468 ($250) $1,250 $6,250 lof5 EXHIBIT B-23 Contract Number: C14950 Jefferson County Public Health ALLOCATIONS Date: March 15,2010 CONTRACT TERM: 2007-2011 BARS Fnnding Chart of Revenue Period Accounts Chart of Accounts Program Title Amendment Code. CFDA .. Amount Sub Total Total EH Drinking Water T A 333.66.48 66.468 $2,000 EH Drinking Water T A Amend 5 333.66.48 66.468 ($1,500) (Correction to Amend 4 . Moved from EH - Drinking Water SS) EH Drinkmg Water TA Amend 8 333.66.48 66.468 ($500) $0 EH Drinking Water TA Amend 8 3336648 66.468 $6,500 EH Drinking Water T A Amend 13 333 66.48 66.468 ($500) EH Drinking Water TA Amend 15 333.66.48 66.468 ($2,500) $3,500 EH Drinking Water T A 333.66.48 66.468 $6,000 EH Drinking Water T A Amend 8 333.66.48 66.468 ($6,000) $0 EH Drinking Water TA Amend 13 33366.48 66.468 $4,000 EH Dnnking Water TA Amend 15 333.66.48 66.468 ($3,000) EH Drinking Water T A Amend 22 333.66.48 66.468 ($500) $500 $4,000 PHEPR - LHJ Funding Amend 18 33390.69 93.069 $31,274 $31,274 $31,274 PHER HINl Pan Flu Focus I Amend 18 333.90.69 93.069 $12,500 PHER H1N1 Pan Flu Focus I Amend 19 333.90.69 93.069 $18,559 $31,059 $31,059 PHER HINI Pan Flu Focus 2 Amend 19 333.9069 93.069 $1,233 $1,233 $1,233 PHER HINI Pan Flu Ph III Mass Vac Amend 20 333.90.69 93.069 $57,432 PHER HINl Pan Flu Ph 111 Mass Vac Amend 23 333.90.69 93,069 $70,000 $127,432 $127,432 FPRH TX RX Contraceptives Amend 5 333.92.17 93.217 $600 $600 FPRH TX RX Contraceptives Amend 12 333.92.17 93.217 $1,000 $],000 FPRH TX RX Contraceptives Amend 2] 333.92.17 93.217 $1,000 $1,000 $2,600 FPRH Title X Contracts 333.92.17 93.217 $21 ,400 FPRH Title X Contracts Amend 5 333.92.17 93.217 $700 $22,100 FPRH Title X Contracts Amend 5 333.92.]7 93.217 $21,000 FPRH Title X Contracts Amend ] 2 333.92.]7 93.217 $540 $21 ,540 FPRH Title X Contracts Amend 13 333.92 17 93.2] 7 $]8,664 FPRH Title X Contracts Amend 21 33392 J7 932J7 $373 $]9,037 FPRH Title X Contracts Amend 21 333 92 17 93.217 $23,750 $23,750 $86,427 FPRH Title X Expansion Amend 12 333 92. I 7 93217 $2,764 $2,764 FPRH Title X Expansion Amend 13 333.92.17 93.2]7 $2,764 $2,764 FPRH Title X Expansion Amend 21 33392. I 7 93.217 $500 $500 $6,028 UW Workforce Development YR9 Amend 13 333.92.49 93.249 $1,090 $1,090 $1,090 AFIX ]mmun ConCon Fed Amend 1 333.92.68 93.268 $9,389 $9,389 AF1X ]mmun Con Con Fed Amend I 333.92.68 93.268 $9,389 $9,389 AF]X ]mmun ConCon Fed Amend 13 333.92.68 93.268 $9,353 $9,353 $28,131 Child Immun ActIvities Fed Amend 2] 333.92.68 93.268 $9,827 $9,827 $9,827 FA3] 7 Immun ConCon Fed 3339268 93 268 $4,]59 FA317 Immun ConCon Fed Amend I 333.92.68 93.268 ($2,379) $ I ,780 F A3 I 7 Immun ConCon Fed 333.92.68 93.268 $4,159 FA317 [mmun ConCon Fed Amend 1 333.92.68 93.268 ($2,379) $1,780 F A3 I 7 Immun ConCon Fed Amend I 3 333.92.68 93.268 $],573 $1,573 FA317 Immun ConCon Fed Amend 21 333.9268 93 268 $1,573 $ I .573 $6,706 VFC Immun ConCon Fed 333.92.68 93.268 $4,047 VFC Immun ConCon Fed Amend 1 33392.68 93.268 ($3,815) $232 VFC Immun ConCon Fed 333.92.68 93.268 $4,047 VFC Immun Con Con Fed Amend ] 33392.68 93.268 ($3,8] 5) $232 VFC ]mmun ConCon Fed Amend 13 333.92.68 93.268 $474 $474 $938 20f5 EXHIBIT B-23 Contract Number: CI4950 Jefferson County Public Health ALLOCA nONS Date: March 15,2010 CONTRACT TERM: 2007-2011 BARS Funding Chart of Revenue Period Accounts Chart of Accounts Program Title Amendment Code' CFDA .. Amount Sub Total Total CDC Tobacco Prevention 333.92.83 93.283 $2,550 $2,550 CDC Tobacco Prevention Amend 3 333.92.83 93.283 $5,100 $5,100 CDC Tobacco Prevention YR5 Amend 10 333.92.83 93.283 $3,825 $3,825 CDC Tobacco Prevention YRI Amend 16 333.92.83 93.283 $1,000 CDC Tobacco PreventIOn YRI Amend 16 333.92.83 93.283 $3,090 $4,090 $15,565 PHEPR - LHJ Funding 333.92.83 93.283 $13,901 $13,901 PHEPR - LHJ Funding Amend 5 333.9283 93.283 $5,442 PHEPR - LHJ Fundmg Amend 8 333.9283 93 283 $12,699 $18,141 PHEPR - LHJ Funding Amend 12 333.9283 93 283 $18,774 $18,774 $50,816 PHEPR-Pandemic Influenza 33392 83 93 283 $10,986 $10,986 PHEPR-Pandemic Influenza Amend 5 333.92 83 93.283 $4,020 PHEPR.Pandemic Influenza Amend 8 33392 83 93.283 $9,381 $13,401 $24,387 PHEPR-Prog E Amend 3 33392 83 93.283 $730 $730 $730 HCCW Infant Toddler JAR 333.95.75 93575 $5,767 $5,767 HCCW Infant Toddler JAR Amend 4 333.95.75 93.575 $11,534 $11,534 HCCW Infant Toddler JAR Amend 11 333.95.75 93.575 $11,534 $11 ,534 HCCW Infant Toddler IAR Amend 17 333.95.75 93 575 $11,660 $11,660 $40,495 PHEPR HC Systems - Prep Amend 12 333.98.89 93.889 $1,800 $1,800 PHEPR HC Systems. Prep Amend 18 333.98.89 93.889 $1,612 $1,612 $3,412 PHEPR Hospital - Prep 333.98.89 93.889 $ I ,340 $1 ,340 PHEPR Hospital - Prep Amend 5 333.9889 93.889 $2,000 $2,000 $3,340 PHBG - LHD Amend 2 333.99.91 93.991 $2,500 $2,500 $2,500 MCHBG CSHCN Spec Prog Amend 1 333.99.94 93.994 $18,916 $18,916 MCHBG CSHCN Spec Prog Amend 5 333.99.94 93 994 $25,221 MCHBG CSHCN Spec Prog Amend 5 333.9994 93994 ($18,916) $6,305 MCHBG CSHCN Spec Prog Amend 1 333.99.94 93.994 $6,305 MCHBG CSHCN Spec Prog Amend 5 333.99.94 93 994 ($6,305) $0 $25,221 MCHBG MCH ConCon fed 333.99.94 93.994 $32,180 $32,180 MCHBG MCH ConCon fed 333.99.94 93.994 $42,907 $42,907 MCHBG MCH ConCon fed 33399.94 93.994 $10,727 $10,727 MCHBG MCH ConCon fed Amend 12 333.9994 93.994 $28,990 $28.990 MCHBG MCH ConCon fed Amend 12 333.9994 93994 $38,653 $38,653 MCHBG MCH ConCon fed Amend 12 3339994 93.994 $9,663 $9,663 $163,120 ARRA LHJ Billable Project Amend 22 339.47,12 93.712 $175,000 $175,000 $175,000 ARRA Reaching Children & Adults Amend 22 339,47,12 93.712 $1,397 $ I ,397 $1,397 Adult Viral Hepatitis Strategic Plan Amend 19 334.04.91 N/A $5,000 $5,000 $5,000 FPRH State Clinical-HP-Surg-Aud Amend 21 33404.91 N/A $53,890 $53,890 $53,890 FPRH State Contracts 33404.91 N/A $17,400 $17,400 FPRH State Contracts Amend 3 334.04.91 N/A $17,400 $17,400 FPRH State Contracts Amend 5 3340491 N/A $37,800 FPRH State Contracts Amend 10 334.04.91 N/A $3,300 $41,100 FPRH State Contracts Amend 13 334.0491 N/A $24,683 $24,683 FPRH State Contracts Amend 1 3 334.0491 N/A $24,683 $24,683 $125,266 FPRII State Enhancement Amend 16 33404.91 N/A $12,220 $12,220 $12,220 ) of\ EXHIBIT B-23 Contract Number: C14950 Jefferson County Public Health ALLOCA nONS Date: March 15,2010 CONTRACT TERM: 2007-2011 ~~,OO!h~~.Q~~k:~ BARS Funding Chart of Revenue Period Accounts Chart of Accounts Program Title Amendment Code" CFDA"" Amount Sub Total Total Group B Systems Amend I 334.0491 N/A $3,000 Group B Systems Amend 2 3340491 N/A $3,015 Group B Systems Amend 3 334.0491 N/A $3,590 $9,605 Group B Systems Amend 5 334.04.91 N/A $6,875 $6,875 Group B Systems Amend 10 334.04.91 N/A $10,500 $10,500 $26,980 Oral Health State 334.04.91 N/A $4,500 $4,500 Oral Health State 33404.91 N/A $9,000 $9,000 Oral Health State 334.04.91 N/A $4,500 $4,500 Oral Health State Amend 13 334.04.91 N/A $5,783 $5,783 Oral Health State Amend 13 334.04.91 N/A $11,567 $] 1,567 Oral Health State Amend 13 334.04.91 N/A $5,784 $5,784 $41,134 PHEPR - Pandemic Influenza 334.04.91 N/A $5,083 $5,083 $5,083 Correction in Amendment # I of an addition of$8 (previously $5,075) Hepatitis C Awareness Amend ] 4 3340492 N/A $8,500 $8,500 $8,500 Local Capacity Dev Funds - GFS & HSA 334.04.92 N/A $19,142 $19,142 Local Capacity Dev. Funds - GFS & HSA 3340492 N/A $19,142 $19,142 Local Capacity Dev. Funds - GFS & HSA Amend 6 33404.92 N/A $]9,105 $19,105 Local Capacity Dev. Funds - GFS & HSA Amend 6 33404.92 N/A $]9,105 $19,105 Local Capacity Dev. Funds - GFS & HSA Amend 13 33404.92 N/A $]9,016 $19,0]6 Local Capacity Dev. Funds - GFS & HSA Amend 13 334.04.92 N/A $19,016 Local Capacity Dev. Funds - GFS & HSA Amend 21 3340492 N/A $37,920 $56,936 $152,446 Local Capacity HSA Partnership Amcnd 3 33404 92 N/A $2,550 $2,550 $2,550 Child Death Review (Proviso) Amend ] 2 334.04.93 N/A $750 $750 $750 DOH-3 Shellfish CN/CN.Proviso 334.04.93 N/A $1,400 $1,400 DOH-3 Shellfish CN/CN-Proviso 33404.93 N/A $2,800 DOH-3 Shellfish CN/CN-Proviso Amend 13 334.04.93 N/A ($2,800) $0 DOH-3 Shellfish CN/CN-Provlso Amend 1 334.04.93 N/A $1,400 DOH-3 Shellfish CN/CN-Proviso Amend 13 334.04.93 N/A ($1,400) $0 DOH-3 Shelltish CN/CN-Proviso Amend 13 334.04.93 N/A $4,200 DOH-3 Shellfish CN/CN.Proviso Amend 15 334.04.93 N/A $800 $5,000 $6,400 DOH-6 PSAP Onsite -Proviso Amend 6 334.04.93 N/A $34,500 $34,500 DOH-6 PSAP Onsite .Proviso Amend 6 334.04.93 N/A $17,000 $17,000 $51 ,500 DOH-7 PSAP Onsite Sys Spt CN/CN-Prov Amend 5 334.04.93 N/A $]00,000 DOH-7 PSAP Onsite Sys Spt CN/CN-Prov Amend 6 334.04.93 N/A ($100,000) $0 DOH-7 PSAP Onsite Sys Spt CN/CN-Prov Amend 6 334.04.93 N/A $20,125 $20,\ 25 DOH-7 PSAP Onsite Sys Spt CN/CN-Prov Amend 6 334.04.93 N/A $8,500 $8,500 $28,625 DOH-7 PSAP Onsite Sys Spt eN/CN-ALE Amend 6 33404.93 N/A $19,875 $19,875 $19,875 FPRH Proviso Contracts Amend 5 33404 93 N/A $19,800 $19,800 FPRH Proviso Contracts Amend 10 33404.93 N/A $29,600 FPRH Proviso Contracts Amend 10 334.04.93 N/A $13,600 $43,200 FPRH Proviso Contracts Amend 13 334.0493 N/A $13,600 $13,600 $76,600 On Site GFS Proviso Amend 2 334.04.93 N/A $31,000 $31 ,000 $31,000 Rec Shellfish/Biotoxin (PSAA) Amend 17 334 04 93 N/A $6,400 Rec Shellfish/Biotoxin (PSAA) Amend ] 9 334.04.93 N/A ($1,400) $5,000 $5,000 Small On-Site LHJ Contracts Amend 16 334 04 93 N/A $100,000 $100,000 $100,000 40fS EXHIBIT B-23 Contract Number: C14950 Jefferson County Public Health ALLOCATIONS Date: March 15,2010 CONTRACT TERM: 2007-2011 BARS Funding Chart of Revenue Period Accounts Chart of Accounts Program Title Amendment Code" CFDA ** Amount Sub Total Total Youth Tobacco Prevention 334.04.93 N/A $2,400 $2,400 Youth Tobacco Prevention Amend 3 334.0493 N/A $4,100 $4,100 Youth Tobacco Prevention Amend 10 334.04.93 N/A $4,100 $4,100 Youth Tobacco Prevention Amend 16 334.04.93 N/A $8,200 $8,200 $18,800 TPC Account 334.04.97 N/A $19,125 $19,125 TPC Account Amend 3 334.04.97 N/A $38,250 $38,250 TPC Account Amend 10 334.04.97 N/A $38,250 $38,250 TPe Account Amend 16 334.0497 N/A $61,200 $61,200 $156,825 Drinking Water Group A - SS State Amend 13 334.0498 N/A $4,000 $4,000 $4,000 EHP - Drinking Water - SS State Amend 4 334.04.98 N/A $1,250 $1,250 EHP - Drinking Water - SS State Amend 13 334.04.98 N/A $3,750 EHP - Drinking Water - SS State Amend 13 334.04.98 N/A $1,500 EHP - Drinking Water - SS State Amend 15 334.04.98 N/A ($4,000) HIP - Drinking Water - SS State Amend 16 334.04.98 N/A $4,000 EHP - Drinking Water - SS State Amend 22 334.04.98 N/A ($250) $5,000 $6,250 Blue Ribbon Local Health Funds Amend 7 334.04.99 N/A $103,008 $103,008 Blue Ribbon Local Health Funds Amend I 3 334.04.99 N/A $102,901 $102,901 Blue Ribbon Local Health Funds Amend 21 334.04.99 N/A $82,097 $82,097 $288,006 TOTAL $2,355,063 $2,355,063 GRAND TOTAL $2,355,063 Total consideration prior to this amendment: $2,272,217 Change in consideration in this amendment: $82,846 Total Fed $ J ,128,363 GRAND TOTAL $2,355,063 Total State $1,226,700 *Federal revenue codes begm with "333" State revenue codes begin with "334". ** Catalog of Federal Domestic Assistance Sofs ~ ~~WaslriIfgtO"S"'(e <\ . DEPARTMENT OF SOClAL&HEALTH SERViCES COUNTY PROGRAM or INTERLOCAL DSHS CONTRACT NUMBER: 0863-38313 LONG-TERM PAYABLE AGREEMENT Amendment No, 0863-38313-01 AIVIENDMENT This Amendment is between the State of Washington Department of Social and Health Services (DSHS) and the Contractor identified below. Program Contract Number Contractor Contract Number CONTRACTOR NAME CONTRACTOR doing business as (DBA) Jefferson County CONTRACTOR ADDRESS WASHINGTON UNIFORM BUSINESS DSHS INDEX NUMBER IDENTIFIER (UBI) Castle Hill Center 615 Sheridan 161-001-169 1223 Port Townsend, WA 98368-2476 CONTRACTOR CONTACT CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS (360 385-9400 Ext: (360 385-9401 DSHS DIVISION Financial Services DSHS CONTACT ADDRESS Antoinette Renshaw Financial Coordinator Blake Office Pari< West 4450 10th Ave SE Lace , WA 98504- DSHS CONTACT TELEPHONE DSHS CONTACT FAX 360 664-5759 Ext: 360 664-5775 IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? No AMeNBMENT stART BATE 10 OF INCREASE OR oe~ AMOUNT 7/1/2009 PR10RMAX1MUliilOONlAACT AMOUNT Based on Annual Review REA~ CHANGE OR . ATTACHMENTS. When the box below is marked with an X, the this Amendment by reference: o Additional Exhibits s eci : This Amen~ntr in~ ilIf.IE)(tlib~'&.~4Gcuments I conditions agtee.d t.1fi)OO by the part~s as changes to the original other lmae.r$lam!lff1Jg&or rep~h . GtafGr otherwise, rega ... deemed to ~ist or bind the parties. ~ t.erms: and conditio County Progr .. fnteriocai Agreement remain in full force and effect. the parties signing below warrant that they nave reaBand liItlderstand this Amendment,Eilnd y~alJJh!?rl to .!er .into thi.$ AmEJndm~t. CONTRACTOR 81 URE PRINTED NAME AND TITLE Sheila R. Anderson, CCS Contracts Mana er DSHS Central Contract Services 6046 LF Long-Term Payable Amendment (2-4-09) Page 1 as This Agreement between the State of Washington Department of Social and Health Services (DSHS) and the Contractor is hereby amended as follows: 1. DSHS extends the Agreement End Date twelve months from June 30, 2009, to June 30, 2010, as stated on Page One of this Amendment. 2. DSHS revises the DSHS Contact Name and Contact Address to Antoinette Renshaw, DSHS Financial Coordinator, as stated on Page One of this Amendment. All other terms and conditions of this Agreement remain in full force and effect. DSHS Central Contract Services 6046 LF Long-Term Payable Amendment (2-4-09) Page 2 ~7~Woshi"KfOn StRte 7~<-\.. DEPARTlYlENT OF SOCIAL&HEALTH SERVICES DSHS Agreement Number COUNTY 0863-38313 PROGRAM AGREEMENT Long-Term Payable This Program Agreement is by and between the State of Washington Department of Social and Health Services (DSHS) and the County identified below, and is issued in conjunction with a County and DSHS Agreement On General Terms and Conditions, which is incorporated by reference, Administration or Division Agreement Number County Agreement Number DSHS ADMINISTRATION DSHS DIVISION DSHS INDEX NUMBER DSHS CONTRACT CODE Executive Management and o erations DSHS CONTACT NAME AND TITLE Financial Services 1223 6030CS-63 DSHS CONTACT ADDRESS D, Holly Medlrn Financial Coordinator PO Box 45842 Jefferson Cou nty Castle Hill Center 615 Sheridan Port Townsend W A 98368-2476 COUNTY CONTACT NAME COUNTY FEDERAL EMPLOYER IDENTIFICATION NUMBER ... 916001322 COUNTY CONTACT TELEPHONE 360 385-9400 Ext: IS THE COUNTY A SUBRECIPIENT FOR PURPOSES OF THIS PROGRAM AGREEMENT? Susan Parke COUNTY CONTACT FAX No PROGRAM AGREEMENT START DATE 7/1/2008 PROGRAM AGREEMENT END DATE 6/30/2009 MAXIMUM PROGRAM AGREEMENT AMOUNT Based on Annual Review COUNTY SIGNATURE(S) PRINTED NAME(S) AND T1TLE(S) /.----x ~ ! , ,II \'~ 'F LA iJ ~ I t/.,_,i;;,{ I. ""'V~ \ / -' "'" iJ- '\' yh~\ 'JDh n:D1\ C htl \ rV~'\O.{\ y 111()~ PRINTED NAME AND TITLE DATE SIGNED Angie Wifliams, Contracts Consultant L(J II J tit "{is 3 hi} DSHS Central Contract Services County Long-Term Payable #6030CS (4-20-07) Page 1 SPECIAL TERMS AND CONDITIONS 1. Definitions a. "Commingle" is the act of mixing the funds and/or Long-Term Payables for one program with the funds of another program. b. "Documentation of Funds Form" (OFF) is a form provided to the County each year by DSHS on which tl1~. County records qualifying previous year expenditures from which DSH$.can appraise and evaluate the amount of the existing Long-Term Payable or appropriate adjustments. c. "Long-Term Payable" means funds provided by DSHS to the County in anticipation of specific client services provided by the County. The County shall not be allowed to retain any overage of the Long-Term Payable funds if the County does not actually provide the anticipated services during the given timeframe. Long-Term Payable funds are to be reconciled by April 30 of each year and any funds not fully utilized shall be refunded to DSHS by May 31 of each year. d. "Prepaid Inpatient Health Plan" is an entity that contracts with the Mental Health Division (MHO) to administer mental health services for people who are eligible for the Title XIX Medicaid program in accordance with WAC 388-865-0300, 2. Purpose a. It is the purpose of this Agreementto specify the procedure by which DSHS will assess and, if necessary, adjust the Long-Term Payable it provides to the Gounty. b. Funds to support contracts for the following DSHS programs may be included in a Long-Term Payable: Health & Recovery Services Administration (Mental Health Division and Division of Alcohol and Substance Abuse) and Aging & Disability Services Administration (Long Term Care and Division of Developmental Disabilities) operated during the term of this Agreement. 3. Statement of Work a. County Responsibilities (1) The County shall submit to DSHS, on forms provided by DSHS and by a date determined by DSHS, a completed Documentation of Funds Form from which OSHS shall assess whether or not an adjustment to the amount of the Long-Term Payable provided to the County is warranted. (2) The County shall exclude all amounts related to its MHO Prepaid Inpatient Health Plan expenditures from its OFF, (3) The County shall repay to OSHS all of the Long-Term Payable funds received from OSHS that exceed the amount that OSHS determines is warranted. Repayment requirements shall be based upon OSHS assessment of the most recent annual OFF submitted by the County to OSHS. Any Long-Term Payable funds not fully utilized by the County, as determined by OSHS through the OFF process, shall be refunded to DSHSby May 31 of each year. (4) The County shall only utilize Long-Term Payable funds for the DSHS program or service for which the funds were originally designated. Long-Term Payable funds may not be commingled between or among programs or services, (5) Any interest the County earns on the Long-Term Payable funds shall only be utilized for the DSHS Central Contract Services County Long-Term Payable #6030CS (4-20-07) Page 2 OSHS programs or ~'ryices for which the funds were originc . iesignated. Long-Term Payable interest sh... :lOt be used for programs or services Ul..elated to the client services anticipated by this Agreement. (6) The County shall record the Long-Term Payables in its financial records. b. OSHS Responsibilities (1) OSHS shall assess the OFF submitted by the County to determine if, during the term of this Agreement, any adjustment to the original two month Long-Term. Payable provided to the County is warranted. (2) Adjustment may include OSHS request for repayment by County of any Long-Term Payable amounts previously paid to County that are in excess of the amount currently warranted. 4. Termination In the event that this Agreement. or a program contract listed in 2,b, above, is terminated prior to completion, DSHS shall take all available steps to recover any Long-Term Payable determined to be an overpayment and the County shall fully cooperate during the recovery process, APPROVED AS TO FORM BY THE OFFICE OF THE ATTORNEY GENERAL DSHS Central Contract Services County Long-Term Payable #6030CS (4-20-07) Page 3