HomeMy WebLinkAbout2016-08-02-public-health-amendment2DSHS CONTRACT NUMBER:
CONTRACT AMENDMENT 1563-44899 ."~"II.."'." County Day Program OEf'or ENT OF Amendment No . 02 soc I\' &~W'rH 5 RV .
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This Contract Amendment is between the State of Washington Department of Program Contract Number
Social and Health Services (DSHS) and the Contractor identified below. Click here to enter text .
Contractor Contract Number
CONTRACTOR NAME CONTRACTOR doing business as (DBA)
Kittitas County Kittitas County DDA County Services
CONTRACTOR ADDRESS WASHINGTON UNIFORM DSHS INDEX NUMBER
BUSINESS IDENTIFIER (UBI)
507 North Nanum Street Suite 102
Ellensburg , WA 98926-192-002-673 1225
CONTRACTOR CONTACT CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS
DSHS ADMINISTRATION DSHS DIVISION DSHS CONTRACT CODE
Developmental Disabilities Admin Division of Developmental 1769CS-63
Disabilities
DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS
Roger Van Allen 1611 W Indiana Ave
Operations ManaQer Spokane, WA 99205-
DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS
(509) 329-2952 (509) 568-3037 vanalrl@dshs .wa.gov
IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? CFDA NUMBERS
No
AMENDMENT START DATE CONTRACT END DATE
07/01/2016 06/30/2017
PRIOR MAXIMUM CONTRACT AMOUNT AMOUNT OF INCREASE OR DECREASE TOTAL MAXIMUM CONTRACT AMOUNT
$738,941 .00 $762,332.00 $1,501,273.00
REASON FOR AMENDMENT;
CHANGE OR CORRECT PERIOD OF PERFORMANCE AND MAX CONTRACT AMOUNT
ATTACHMENTS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into
this Contract Amendment by reference :
[g] Additional Exhibits (specify): Program AQreement Budget and Spending Plan
This Contract Amendment, including all Exhibits and other documents incorporated by reference, contains all of the terms
and conditions agreed upon by the parties as changes to the original Contract. No other understandings or
representations , oral or otherwise, regarding the subject matter of this Contract Amendment shall be deemed to exist or
bind the parties. All other terms and conditions of the original Contract remain in full force and effect. The parties signing
below warrant that they have read and understand this Contract Amendment, and have authority to enter into this Contract
Amendment.
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DSHS Central Contract Services
6024PF Contract Amendment (3-31-06)
PRINTED NAME AND TITLE
~o b,·~H ,~{tC~l AvtWU~i~ :5!8"f~ (Q
PRINTED NAME AND TITLE DATE SIGNED
Melissa Diebert, Contract Manager J''-/:5i-/b
RECEIVED RECEIVED
AUG 1 02016 AUtb 2 A 2016
DDA SPOKIffffA SPOKANE
This Contract between the State of Washington Department of Social and Health Services (DSHS) and the
Contractor is hereby amended as follows:
1. The Total Maximum Contract Amount is hereby increased in the amount of $762,332 for a new Contract
Amount of $1,501,273 . This amount is for services provided during the added fiscal year.
2. The Program Agreement end date is extended to June 30, 2017 .
3. Section 7. Statement of Work, sub-paragraph h. Qualified Providers . Will add the following paragraph :
DDA contracts with Technical Assistance providers that maybe utilized by Counties with prior written
approval. .
4. Section 8. Consideration sub-paragraph b. Fees, item (2) Fee Limitations, sub-section (b) will be replaced
in its entirety with .the following:
(b) Community Access services will not exceed and hourly rate of $35.00 .
5. Section 9. Billing and Payment, will add sub-paragraph (k) as follows :
(k) PASRR Administration: The County may bill for administration costs as identified in Exhibit B. Monthly
claims for administration cost will be based on the actual PASRR expenditures multiplied by 7%.
6. Exhibit B. Program Agreement Budget is hereby replaced with the following Budget Revision:
DSHS Central Contract Services
6024PF Contract Amendment (3-31-06)
RECEIVED
AUG 102016
DDA SPOKANE
RECEIVED
AUG 262016
DDA SPOKANE
Page 2
Fiscal
Year Fund Source
2016 State Funds
Medical Funds
Total
2017 State Funds
Federal Funds
Total
I
ADMINISTRATION
(CMIS/AWA BARS 11)
OTHER CONSUMER
SUPPORTS
(CMIS/AWA Code 31,32,41, n . 93, 94)
CONSUMER SUPPORT
STATE-ONLY
Child Development
MEDICAID CLIENTS
ROADS to COMMUNITY
LIVING
TOTAL
DSHS Central Contract Services
6024PF Contract Amendment (3-31-06)
EXHIBIT B
Program Agreement Budget
X Budget Revision
REVENUES
Original 1st Revision 2nd Revision 3rd Revision
$
389360
762332
.
COUNTY FY 2017 SPENDING PLAN
Local
Funds
Planned Expenditure s
PASRR Medica id
Funds State Funds Funds TOTAL
403 27208 22261 49872
22180 18148 40328
l ~i]I~0';-:~~.-;-, .. ~ :~~~"~~~ 1 -·'·I~t ~
13572 ~~W J~ 13572
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,.e.:: -!,:: ;,:.._ ;l< I~ 'i,;;.:>. ~ i~·r--~i~ :.~J ·'i,.~~;;..;,.'1
5760 326400 326400 658,560
Iii "1'..-~.\~~-:':Ul:l T~· ~:-fjl !;;.r -.~:!iIi~;:f;~ I?!E; -~-'~~
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~ "I~ ~: ..c~~" jJ
6163 389360 366809
RECE\VEO
~UG 1020'6
DDA SPOKANE
762332
RECEIVED
AUG 262016
Page 3
ODASPOKANE