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Home My WebLink AboutAmendment 2KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT 2018 -2020 CONSOLIDATED CONTRACT CONTRACT NUMBER: CLH18249 AMENDMENT NUMBER: 2 PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HEALTH hereinafter referred to as "DOH", and KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT 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, are amended as follows : D Adds Statements of Work for the following programs: [gl Amends Statements of Work for the following programs: • Maternal & Child Health Block Grant -Effective January 1, 2018 • Office of Emergency Preparedness & Response -Effective January 1, 2018 • Supplemental Nutrition Assistance Program-Education -Effective January 1, 2018 D Deletes Statements of Work for the following programs: 2. Exhibit B-2 Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-1 Allocations as follows: [gl Increase of $12,483 for a revised maximum consideration of $93,521. • Decrease of for a revised maximum consideration of __ D No change in the maximum consideration of __ . Exhibit B Allocations are attached only for informational purposes. 3. Exhibit C-2 Schedule of Federal Awards, attached and incorporated by this reference, amends and replaces Exhibit C-1. 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. KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT STATE OF WASHINGTON DEPARTMENT OF HEALTH APPROVED AS TO FORM ONLY Assistant Attorney General Page 1 of 18 2018-2020 CONSOLIDATED CONTRACT EXHIBIT A STATEMENTS OF WORK TABLE OF CONTENTS AMENDMENT #2 DOH Program Name or Title: Maternal & Child Health Block Grant -Effective January 1, 2018 ................................................................ , ................................... 3 DOH Program Name or Title: Office of Emergency Preparedness & Response -Effective January 1, 2018 .................. ····-············ .. ·····-·················· .. ·····"·"···--··· .. 7 DOH Program Name or Title: Supplemental Nutrition Assistance Program-Education -Effective January 1, 2018 .................................... , ............ __ ...... _. ........... 12 Exhibit A, Statements of Work Revised as of March 15, 2018 Page 2 of 18 Contract Number CLH18249-2 DOH Program Name or Title: Maternal & Child Health Block Grant - Effective January 1, 2018 SOW Type: Revision Revision # (for this SOW) l Period of Performance: January 1, 2018 through September 30, 2018 Exhibit A Statement of Work Contract Term: 2018-2020 AMENDMENT #2 Local Health Jurisdiction Name: Kittitas County Public Health Department Contract Number: CLH18249 Funding Source Federal Compliance ~pe of Payment ~ Federal Subrecipient (check if applicable) Reimbursement D State ~ FF AT A (Transparency Act) D Fixed Price D Other D Research & Development Statement of Work Purpose: The purpose of this statement of work is to support local interventions that impact the target population of the Maternal and Child Health Block Grant. Revision Purpose: The purpose of this revision is to shift unspent FFY18 funds from October-December 2017 to the Consolidated Contract that began in January 2018 . Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Revenue Index (LHJ Use Only) Code Code Start Date End Date FFYl 8 MCHBG LHJ CONTRACTS 93.994 333.93.99 78120281 01101/18 l 09/30/18 TOTALS Task *May Support PHAB Number Task/ Activity/Description Standards/Measures Deliverables/Outcomes Maternal and Child Health Block Grant (MCHBG) Administration . la Participate in calls, at a minimum of every Designated LHJ staff will quarter, with DOH contract manager. Dates and partic ipate in contract management time for calls are mutually agreed upon between calls. DOH and LHJ lb Report actual expenditures for October 1, 2017 Submit actual expenditures using through March 31, 2018 the MCHBG Budget Workbook to DOH contract manager le Develop 2018-2019 MCHBG Budget Workbook Submit MCHBG Budget for October 1, 2018 through September 30, 2019 Workbook to DOH contract using DOH provided template. manager Exhibit A, Statements of Work Revised as of March 15, 2018 Page 3 of 18 Current Change !Total Consideration Increase(+) Consideration 33,147 893 34,040 33,147 893 34,040 Payment Due Date/Time Frame Information and/or Amount September 30, 2018 Reimbursement for actual costs, not to exceed total funding consideration. May 26, 2018 Action Plan and Progress Reports must only reflect September 5, 2018 activities paid for with funds provided in this statement of work for the specified funding period. See Pro_gram Contract Number CLH18249-2 Task Number Task/ Activity/Description MCHBG Assessment and Evaluation 2a Participate in project evaluation activities developed and coordinated by DOH, as requested. 2b Report program level strategy measure data (CSHCN, UDS, ACEs). MCHBG Implementation 3a Develop 2018-2019 MCHBG Action Plan for October 1, 2018 through September 30, 2019 using DOH~provided template. 3b Report activities and outcomes of 2017-2018 MCHBG Action Plan using DOH-provided template. Exhibit A, Statements of Work Revised as of March 15, 2018 *May Support PHAB Standards/Measures Deliverables/Outcomes Documentation using report template provided by DOH Documentation using report template provided by DOH Submit MCHBG Action Plan to DOH contract manager Submit Action Plan monthly reports to DOH contract manager Page 4 of 18 AMENDMENT #2 Payment Due Date/Time Frame Information and/or Amount Specific Requirements and Special Billing Requirements. September 30, 2018 Reimbursement for actual costs, not to exceed total funding January 15, 2018 consideration. April 15, 2018 July 15, 2018 See Program Specific Requirements and Special Billing Requirements. Draft August 17, 2018 Reimbursement for Final September 5, 2018 actual costs, not to , exceed total funding Monthly, on or before consideration. the 15 th of the following Action Plan and month Progress Reports must only reflect activities paid for with funds provided in this statement of work for the specified funding period. See Program Specific Requirements and Special Billing Req uirements. Contract Number CLH18249-2 AMENDMENT #2 Task *May Support PHAB Payment Number Task/Activity/Description Standards/Measures Deliverables/Outcomes Due Date/Time Frame Information and/or Amount Children with Special Health Care Needs (CSHCN) 4a Complete Child Health Intake Form (CHIF) Submit CHIF data into Secure File January 15 , 2018 Reimbursement for using the CHIF Automated System on all infants Transport (SFT) website: April 15, 2018 actual costs, not to and children served by the CSHCN Program as https://sft. wa.gov July 15 , 2018 exceed total funding referenced in CSHCN Program Manual. consideration. Ensure client data is collected on all children Action Plan and served by CSHCN contractors, including Progress Reports neurodevelopmental centers, regional must only reflect maxillofacial coordinators, and the DOH activities paid for Newborn Screening Program. with funds provided 4b Administer requested DOH Diagnostic and Submit completed Health Services 30 days after forms are in this statement of Treatment funds for infants and children per Authorization forms and Central completed. work for the CSHCN Program Manual when funds are used . Treatment Fund requests directly specified funding to the CSHCN Pro_gram as needed. period. 4c Participate in the CSHCN Regional System and Submit Action Plan monthly Monthly, on or before quarterly meetings as described in the CSHCN reports including number of the 15 th of the following See Program Program Manual. regional meetings attended to the month Specific DOH contract manager. Requirements and Special Billing Requirements. *For Information Only: Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at: bnp J/www.phaooard .org/wo-cop 1en rl up'loads/P H AB-Standards-and-Measures-Versie n-1 . 0: pdj: Program Specific Requirements/Narrative Special Requirements Federal Funding Accountabilirv and 'fra.nsparenc,, Ad {FFATA) This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFAT A 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 Data Universal Numbering System (DUNS®) number. Information about the LHJ and this statement of work will be made available on USASpending .gov by DOH as required by P.L. 109-282 . Program Manual, Handbook, Policy References Exhibit A, Statements of Work Revised as ofMarch 15, 2018 Page 5 of 18 Contract Number CLH18249-2 Children with Special Health Care Needs Manual -bup://www.dgb _wa.aovi Porta:l sJ l/Documents/Pubs /970 ,209-CSHCN-ManuaLpdf Health Services Authorization (HSA) Form http://www:doh.wa .gov/Portals/llDotuments/Pubs/9l0,-002-AoprovedHSA.docx. Restrictions on Funds (what funds can be used for which activities, not direct payments, etc.) AMENDMENT #2 1. At least 30% of federal Title V funds must be used for preventive and primary care services for children and at least 30% must be used services for children with special health care needs. [Social Security Law, Sec. 505(a)(3)]. 2. Funds may not be used for: a. Inpatient services, other than inpatient services for children with special health care needs or high risk pregnant women and infants, and other patient services approved by Health Resources and Services Administration (HRSA). b. Cash payments to intended recipients of health services. c. The purchase or improvement of land, the purchase, construction, or permanent improvement of any building or other facility, or the purchase of major medical equipment. d. Meeting other federal matching funds requirements. e. Providing funds for research or training to any entity other than a public or nonprofit private entity. f. payment for any services furnished by a provider or entity who has been excluded under Title XVIII (Medicare), Title XIX (Medicaid), or Title XX (social services block grant).[Social Security Law, Sec 504(b)]. 3. If any charges are imposed for the provision of health services using Title V (MCH Block Grant) funds, such charges will be pursuant to a public schedule of charges; will not be imposed with respect to services provided to low income mothers or children; and will be adjusted to reflect the income, resources, and family size of the individual provided the services. [Social Security Law, Sec. 505 (l)(D)]. Monitoring Visits (frequency, type) Telephone calls with contract manager at least one every quarter, and annual site visit. Special Billing Requirements Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable Al 9-1 A invoice voucher. Payment to completely expend the "Total Consideration" for a specific funding period will not be processed until all deliverables are accepted and approved by DOH. Invoices must be submitted monthly by the 30th of each month following the month in which the expenditures were incurred and must be based on actual allowable program costs. Billing for services on a monthly fraction of the "Total Consideration" will not be accepted or approved. DOH Program Contact Mary Dussol Community Consultant Office of Family and Community Health Improvement Washington State Department of Health Street Address: 310 Israel Rd SE, Tumwater, WA 98501 Mailing Address: PO Box 4 7848, Olympia, WA 98504 Telephone: 360-236-3781 / Fax: 360-236-3646 Email: Mary.Dussol@doh.wa.gov Exhibit A, Statements of Work Revised as of March 15, 2018 Page 6 of 18 Contract Number CLH18249-2 Exhibit A Statement of Work Contract Term: 2018-2020 AMENDMENT #2 DOH Program Name or Title: Office of Emergency Preparedness & Response - Effective January L 2018 Local Health Jurisdiction Name: Kittitas County Public Health Department Contract Number: CLH18249 SOW Type: Revision Revision# (for this SOW) 1 Period of Performance: Jiu.Nary 1, 2018 through June 30, 2018 Funding Source Federal Compliance Type of Pa y ment ~ Federa l Subrecipient {check if applicable) ~ R-e imbm'seinent D S1a1e ~ FF AT A (Transparency Act) D Fixed Price D Other D Research & Development Statement of Work Purpose: The purpose of this statement of work is to establish the funding and tasks for the Public Health Emergency Preparedness and Response program for the 201 7 grant period. Revision Purpose: The purpose of this revision is to add unspent funds from the prior contract period July-December 2017. Chart of Accounts Program Name or Title FFYl 7 EPR PHEP BPI LHJ FUNDING TOTALS Task Number Task/ Activity/Description 1 Attend emergency preparedness events, (e.g. trainings, meetings, conference calls, and conferences) as necessary to advance LHJ preparedness or complete the deliverables in this statement of work. 2 Complete reporting templates as requested by DOH to comply with program and federal grant requirements ( e.g. performance measures, gap analysis, mid-year and end-of-year reporting templates, etc.) 3 Develop or update written procedures to activate a comprehensive emergency response plan within the jurisdiction. Include: • Describe how the command structure is utilized to manage emergency response • Describe the relationship between the LHJ and the county Emergency Operations Center (EOC) during a response. Exhibit A, Statements of Work Revised as of March 15, 2018 CFDA# BARS Master Funding Period Revenue Index (LHJ Use Only) Code Code Start Date End Date 93.069 333.93.06 18101380 01;01;1s I o6/30/1s *May Support PHAB Standards/Measures Deliverables/Outcomes Complete the end of year progress report. Submit completed templates to DOH Submit end of year progress report. Submit the most recent Emergency Response Plan (ERP). Page 7 of 18 Current Change tfotal Consideration Increase(+) Consideration 19,833 565 20,398 19,833 565 20,398 Due Date/Time Payment Frame Information and/or Amount June 30, 2018 Reimbursement for actual costs not to exceed total funding consideration amount. June 30, 2018 June 30, 2018 Contract Number CLH 18249-2 Task Number Task/ Activity/Description • Identify an EOC location from which public health will coordinate the Emergency Support Function #8 (ESF#8) response • Describe the process for notifying and mobilizing staff during an incident. 3.1) Provide training for appropriate staff who serve in the EOC and the ESF#8 role on the Incident Command System, ESF#8 response plans and policies. 3.2) Train appropriate public health emergency response staff on Web EOC or applicable information management system utilized by local emergency management in the county. 4 Develop a decision making protocol to support the Local Health Officer and the Public Health Administrator in making policy level decisions during an emergency. 4.1 Document that Public Health, Medical and Mortuary Response is identified in the Public Health Emergency Plan and is integrated with the City and County Emergency Plans. 5 Maintain Washington Secure Electronic Communication, Urgent Response and Exchange System (W ASECURES) program as the primary emergency notification system within the LHJ and include all critical LHJ positions as registered users. 5.1) Conduct a notification drill using WASECURES. Notes: Registered users must log in quarterly at a minimum. DOH will provide on-site technical assistance to LHJs, as needed, on utilizing WASECURES. LHJs may choose to utilize other notification systems in addition to W ASECURES to alert staff during incidents. Exhibit A, Statements of Work Revised as of March 15, 2018 AMENDMENT #2 *May Support PHAB Due Date/Time Payment Standards/Measures Deliverables/Outcomes Frame Information and/or Amount Provide agenda and sign-in sheets of trainings conducted. Provide sign-in sheets of trainings conducted, with attendee signatures and contact information, or registrations if training is not conducted by the LHJ Submit end of year progress report. June 30, 2018 Submit completed protocol to DOH Submit written Public Health, Medical and Mortuary Response documentation showing inclusion in city and county plans. Submit end of year progress report. June 30, 2018 A list ofregistered users to include their title and role in the emergency response plan. Results of notification drill. Page 8 of 18 Contract Number CLH18249-2 Task Number Task/ Activity/Description 6 Update and maintain procedures for defining how your LHJ will request assistance from the local Emergency Operations Center (EOC), neighboring LHJs, and DOH during disasters. • Identify how resources are coordinated with the local EOC. • Identify how to coordinate the logistical issues to receive resources from DOH and other partners. (IfLHJs rely on local Emergency Management (EM) or other partners to coordinate logistical issues for receiving resources, and the local EM plan documents this fact, that documentation will suffice.) Note: DOH will provide technical assistance to LHJs, as requested, on updating plans to address resource requests. 7 Update or develop procedures and tools to inform the public of threats to health and safety by various means. Include a list of the various mechanisms used by your LHJ for releasing information to the public during drills, exercises or incident response. 7.1) Create and maintain templates for news releases for categories of public health hazards. 8 Participate in evaluation ofresponse capabilities based on a standard evaluation tool created by DOH. 9 Develop and maintain procedures and forms to gain and maintain situational awareness during an incident to include the following key data elements: • The functionality of critical public health operations • The functionality of critical healthcare facilities and the services they provide (hospitals, skilled nursing facilities, blood centers, dialysis centers) • The functionality of critical infrastructure serving oublic health and healthcare facilities Exhibit A, Statements of Work Revised as of March 15, 2018 AMENDMENT #2 *May Support PHAB Due Date/Time Payment Standards/Measures Deliverables/Outcomes Frame Information and/or Amount Submit end of year progress report. June 30, 2018 The most current procedures for requesting assistance during disasters to DOH Submit end of year progress report. June 30, 2018 Submit the most current procedures used to inform the public during drills, exercise or incident response. Include a summary of how communication tools were used. Submit sample templates. Submit end of year progress report. June 30, 2018 Submit end of year progress report. June 30, 2018 Submit procedures and situational awareness form templates that include the data elements listed. Page 9 of 18 Contract Number CLH 18249-2 Task Task/ Activity/Description Number (roads, water, sewer, power, communications) • Number of disease cases • Number of fatalities attributed to an incident • If key elements are collected by others, such as local EM or Health Care Coalition (HCC), describe how the LHJ gains access to that information. 9.1) Create an ESF#8 situation report form based on an established planning cycle to include, at a minimum, the data elements listed above 9.2) Develop procedures for disseminating situation reports to ESF#8 response partners 9.3) Train staff on all procedures established to maintain situational awareness during an incident. 10 Update or develop procedures to request, receive and dispense medical countermeasures. 11 Develop or update a continuity of operations plan (COOP) plan for your jurisdiction. Plan shall include: • Definition and identification of essential services to sustain LHJ mission and operations • Line of succession and written delegation of authority for select critical positions in the LHJ, including LHO. • Plans for temporarily discontinuing select LHJ functions to sustain critical services 12 Provide notification to DOH for all instances involving a public health response by the LHJ to an emergency utilizing emergency response plans and structures. Exhibit A, Statements of Work Revised as of March 15, 2018 AMENDMENT #2 *May Support PHAB Due Date/Time Payment Standards/Measures Deliverables/Outcomes Frame Information and/or Amount Submit an ESF#8 situation report template. Submit procedures for disseminating a situation report. Submit agendas and sign-in sheets that include attendee signatures and contact information for trainings conducted. Submit end of year progress report. June 30, 2018 Submit up to date procedure to request, receive and dispense medical countermeasures. Submit end of year progress report. June 30, 2018 The most current COOP plan which includes the elements listed. An AAR documenting COOP implementation demonstrating the elements listed. Submit end of year progress report. June 30, 2018 Submit Incident Action Plans, Situation Reports and After Action Reports produced for each response. Page 10 of 18 Contract Number CLH18249-2 AMENDMENT #2 Task *May Support PHAB Due Date/Time Payment Number Task/ Activity/Description Standards/Measures Deliverables/Outcomes Frame Information and/or Amount 13 Provide LHJ situation reports to DOH during all Submit end of year progress report. June 30, 2018 incidents involving an emergency response by the LHJ. Submit Situation Reports . 14 Submit essential elements of information (EE Is) Submit end of year pro gress report. June 30, 201 8 during incident response upon request by DOH. I Provide information upon request. 15 Participate in the regional healthcare coalition and Submit end of year progress report June 30, 2018 I attend coalition meetings as necessary with a summary of participation in coalition activities. *For Information Only: Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a Standard/Measure . More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at: http :ll www .phab oar<l .or g/wo-co nt ent/u_p I oads/PHAB -Standards-and-Mea.sures-V ersion -1.0 .pdf Special Requirements Federal F unding Accountabjlitv and Transparcncv Act. (FF AT A) This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFAT A 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 Data Universal Numbering System (DUNS®) number. Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P .L. 109-282. DOH Program Contact: Jennifer Albertson, Contract and Finance Specialist Department of Health P O Box 47960, Olympia, WA 98504-7960 j ennifer.albertson@doh. wa. gov PHEP/HPP Deliverable Submission email address : concondeliverables @doh.wa.gov Exhibit A, Statements of Work Revised as of March 15 , 201 8 Page 11 ofl8 Contract Number CLH18 249-2 Exhibit A Statement of Work Contract Term: 2018-2020 AMENDMENT #2 DOH Program Name or Title: fu!ppl e mental Nutriti on Assis cance Program- Education -Effective January 1, 2018 Local Health Jurisdiction Name: Kitt itas Coumv Publ ic Health Departmen t Contract Number: CLH18249 SOW Type: Revision Revision# (for this SOW) 1 Funding Source Federal Compliance Type of Payment Period of Performance: January 1, 2018 through September 30, 2020 ~ Federal Subrecipient (check if applicable) ~ Reimbursement 0 State ~ FF AT A (Transparency Act) D Fixed Price D Other D Research & Development Statement of Work Purpose: The purpose of this statement of work is to provide Supplemental Nutrition Assistance Program-Education (SNAP-Ed) to improve the likelihood that persons eligible for SNAP (Food Stamps) will make healthy food choices within a limited budget and choose active lifestyles consistent with the current USDA dietary guidance system. Revision Purpose: The purpose of this revision is to adjust funding based on the first quarter expenditures and add additional funding to cover DSHS sponsored trainings and meetings. Chart of Accounts Program Name or Title FFY18 CSS IAR SNAP ED PROG MGNT FFY17 CSS IAR SNAP ED PROG MGNT CF TOTALS Task Number Task/ Activity/Description 1.0 For SNAP-Ed, the LHJ will perform work as described in LHJ's approved FFY18 SNAP-Ed project description and work plans approved by Department of Health (DOH), Department of Social and Health Services (DSHS), and United States Department of Agriculture (USDA) that was submitted to them via DOH email. Exhibit A , Statements of Work Revised as ofMarch 15 , 2018 CFDA# BARS Master Funding Period Current Change 'rota! Revenue Index (LHJ Use Only) Consideration Increase(+) Consideration Code Code Start Date End Date 10.561 333.10.56 76211981 01101118 I 09130118 8,830 11,025 19,855 10.561 333.10.56 76211971 01 101118 I 09130118 1,472 0 1,472 10,302 11 ,025 21 ,327 *May Support PHAB Payment Standards/Measures Deliverables/Outcomes Due Date/Time Frame Information and/or Amount • Project qualified target For the Period: Reimbursement upon audiences reached. 0 l /01/18-09/30/20 receipt and approval • Project activities completed Due: per the approved work of deliverables for the (# direct education, PSE, plan and no later than funding period will etc.) noted in project plans 09/30 /20 . not exceed $10,302 and workbook. $21 ,32 7. • Required demographic data collected. Kittitas County • Evaluation activities Public Health completed per the state Department will be evaluation team (pre and paid the allowable post survey s , PSE tracking, costs incurred based success stories etc.). on their approved budget and program allowability . See Page 12 of 18 Contract Number CLH18249-2 Task Task/ Activity/Description Number 2.0 Quarterly Progress Reports The following data is to be collected and submitted within DOH provided form /system: 1. Project major achievements 2. Project major challenges 3. If projects are running on time with original timeline? If not, why, and how will LHJ correct the timeline? 4. Any policy, system, and environment (PSE) progress 5. Any success stories to date 2.1 Education and Administrative Reporting System (EARS) Data and Reports The following EARS data is required for each project and in order to count clients toward unduplicated direct reach. Required entry for the PEARS Database includes but is not limited to: • Unduplicated number of clients served per project. • # unduplicated clients served per oroject based on the following: Exhibit A, Statements of Work Revised as of March 15, 2018 *May Support PHAB Standards/Measures Deliverables/Outcomes Submit Quarterly Progress Report for all SNAP-Ed projects within the DOH approved form/system. Submit EARS data for all project(s). LHJs are required to collect and submit EARS data electronically or within a template provided by DOH. This must be done in real time. Real time = As you provide services and no later than one Page 13 ofl8 AMENDMENT #2 Payment Due Date/Time Frame Information and/or Amount special billing requirements section. **NOTE: The SNAP-Ed program will deny payment for any costs not submitted by the due date and without prior DOH approval in writing. Quarterly Progress Reports See payment due: information as referenced in task • 2nd quarter report for the number 1.0. work completed during 01/01/18 to 03/31/18. Final Due: COB 04/06/18. • 3rd quarter report for the work completed during 04/0 l /18 to 06/3 0/18. Final Due: COB 07 /06/18. • Final report for all work not already reported. Final Due: COB 09/21/18. Data should be collected in See payment real time and submitted to the information as state office by the following referenced in task dates: number 1.0. • EARS data collected 01/01/18 to 09/13/18. Due: In real time and no later than one week after services are provided. Contract Number CLH18249-2 Task Number Task/ Activity/Description 0 Race/ethnicity 0 Gender 0 Age • % SNAP eligible per site • Setting type -school, church, etc . • Top Key Messages delivered per project LHJs are required to submit data electronically or within the template provided by DOH. 2.2 Evaluation Data and Reports The following evaluation activities* and information is required for all projects based on your approved project/plan • Formative • Process • PSE • Outcome • Qualitative *Please Note: the deliverables may change based on state evaluation team requirements . Exhibit A, Statements of Work Revised as of March 15, 2018 I AMENDMENT #2 *May Support PHAB Payment Standards/Measures Deliverables/Outcomes Due Date/Time Frame Information and/or Amount week after data is collected. I l. Collect and report any 1. Due: Submit within See payment formative and process data Quarterly reporting listed information as completed based on above in task 2.0 . referenced in task approved project plan. number 1.0. 2. Submit PSE progress and 2. Due: quarterly outcomes based on approved • 2nd quarter due by project plan. 04/06/18 • 3rd quarter due by 07/06/18 • Final report for all other work due 09/21/18. 3. Conduct and submit/mail 3. Due: Within 30 days after pretest surveys for each completed. Submit all project class series. pretests surveys/data when they are completed for a specific project. 4. Conduct and submit/mail 4. Due: Within 30 days after posttest surveys for each completed. Submit all project class series. posttest surveys/data when they are completed for a specific project. 5. Capture and submit 5. Due: Submit within qualitative (success stories, Quarterly reporting listed pictures) information per above in task 2.0 along with your approved work plan. photo releases. Page 14 of 18 Contract Number CLH18249-2 I Task Number Task/ Activity/Description 3.0 Civil Rights Training All staff must be trained each fiscal year in civ il rights . 3.1 Other Agency Training The following trainings are required for all agencies: • Fiscal -fiscal lead and coordinator I • Data collection and reporting - coordinator and program staff who are reporting data *It is required that all staff making any SNAP- Ed purchases or reporting data be trained. 4.0 SNAP-Ed Inventory List Keep an up-to-date inventory list that includes all non-capital equipment, purchased curriculum, and other SNAP-Ed paid items that are not disposable . This list should include items purchased in prior fiscal years and be updated yearly . 5.0 SNAP-Ed A19 Invoices Use the Al9-1A specific to SNAP-Ed program. This document was sent to all LHJ's prior to October 2017. *For Information Only: Exhibit A, Statements of Work Revised as ofMarch 15 , 2018 *May Support PHAB Standards/Measures Deliverables/Outcomes Submit documentation showing Civil Rights training was completed for all SNAP-Ed paid staff Documentation must include: • Training and source • Who attended • Date completed Fiscal and Data reporting training completed. SNAP-Ed inventory list. Submit SNAP-Ed Al9 invoices and detailed ledger supporting the costs to be reviewed by SNAP-Ed program before approval of payment. Documentation of all costs incurred shall be accompanied by an agenc y financial system report. IfLHJ does not have a financial reporting system, LHJ must check with the DOH SNAP-Ed program for further guidance . Page 15 of 18 AMENDMENT #2 Payment Due Date/Time Frame Information and/or Amount Due: 12/31/18 See payment information as referenced in task number 1.0 . Due: New staff trained See payment within 30 days of starting information as SNAP-Ed activities and again referenced in task at least once every five years . number 1.0 . If the data collection system changes in FFY18 every staff member entering data into the electronic system will be required to take training on the new system . Due: Yearly , at the time ofa See payment fiscal monitoring and/or site information as visit. referenced in task number 1.0 . Due: Monthly -Submit See payment in voices to DOH no later information as than 30 days after the end of referenced in task the preceding month. number 1.0 . ( e.g. October Al 9 invoice submitted no later than November 30 and so on ... ) Final invoice is due 10/30/18 Contract N umber CLH18249 -2 AMENDMENT #2 Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at: http://www.pbahoard. orn:/wp -content/uploads/PH AB-'Sta!'ldards -a.nd-Meas ures-V ersio n-1 . 0. o df Program Specific Requirements/Narrative Special Requirements: 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 (FFAT A 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 Data Universal Numbering System (DUNS ®) number. Information about the LHJ and this statement of work will be made available on USASpending .gov by DOH as required by P.L. 109-282. Travel The LHJ is expected to comply with the Office of Financial Management's Travel Management Requirement and Restrictions as found in policy 10 .10 . hnn://www:ofin.wa.gov/po licy/10.htm Curriculum Requirements Agencies are expected to communicate with, respond to , and comply with all state curriculum team requests, sites visits, approved curriculum list , and curriculum fidelity findings . Program Manual, Handbook, Policy References: Records -Record Retention and Management-State Agency and All Sub-grantees 7CFR 272.2 SNAP-Ed regulations require that all records be retained for six years from fiscal closure. This requirement applies to fiscal records, reports and client information. Supporting documentation may be kept at the sub-grantee level, but shall be available for review for six years from the date of quarterly claim submittal. Any costs that cannot be substantiated by source documents will be disallowed as charges to SNAP. Staffing Requirements: Upon request by DOH, LHJ must demonstrate that SNAP-Ed staff meet requirements appropriate to their positions including but not limited to : background checks, food handlers' permits , and training required by DOH . Annual Civil Rights Training Requirement (see FNS Instruction Number 113-1 Chapter XI) -http ://www .fns.usda .gov/sites/defaul t/files /l 13-l.pdf "Training is required so that people involved in all levels of administration of programs that receive Federal financial assistance understand ci vil rights related laws, regulations, procedures, and directives. The local governmental agency, Indian Tribal Organization or non-Governmental Agency are responsible for training their subrecipients , including 'frontline staff.' 'Frontline staff who interact with program applicants or participants, and those persons who supervise 'frontline st aff must be provided civil rights trainin g on an annual basis ." Restrictions on Funds: Amendments Agencies must submit a request to DOH to amend a project plan and/or budget for prior approval whenever they wish to change the USDA-approved scope of activities and/or budget. All requests for amendments must be submitted no later than April 1, 2018. *Please Note: • No changes may be incorporated into the project plan until an amendment request is approved by DOH and/or USDA. • Any requests submitted after April 1, 2018 will NOT be approved. Exhibit A, Statements of Work Revised as of March 15, 2018 Page 16 of 18 Contract Number CLH 18249 -2 AMENDMENT #2 Overtime Overtime is not billable in the DOH SNAP-Ed program unless it has been reviewed and preapproved by the state DOH SNAP-Ed program in advance and was approved in writing. Budget Revisions All changes to the budget must be pre-approved in writing by DOH SNAP-Ed . Special Funding Requirements Payment for deliverables as specified herein is dependent on receipt of funding from the USDA funding sources. In the event funding is not received, DOH is under no obligation to make payments for the deliverables as specified. If funding is reduced or limited in any way after the effective date of this contract and prior to normal completion DOH may terminate task(s), remove funds, or reallocate funds at DO H's discretion under new funding limitations and conditions . DOH will make payments only upon the receipt of the funding. DOH will notify the LHJ within seven working days upon notice by the funding source of funding availability. Indirect Rate All indirect rates must be submitted and preapproved by DOH and the DOH SNAP-Ed program. The LHJ is responsible for ensuring that indirect costs included in the LHJ's SNAP-Ed plan are supported by an indirect cost agreement and/or cost allocation plan approved by the appropriate agency . The LHJ cannot bill indirect costs that are determined to be unacceptable and will be disallowed. Monitoring Visits (frequency, type): Audits The LHJ must make State financial and program audits or reviews conducted by other entities available to the DOH, DSHS , USDA, or its designee . Monitoring expectations The LHJ's premises and records will be made available upon request to DOH, DSHS, and USDA staff for the purposes of observing nutrition education activities and reviewing for program and fiscal compliance. All non-capital equipment and reusable educational materials should be tracked in an inventory list and available for review upon request. SNAP-Ed Assurances: The following assurances must be followed (see program Guidance https://snaped.fos.usda.gov/natitmal-snap-ed/snap-ed-plan-guidance-and-templates) • The LHJ is fiscally responsible for nutrition education activities funded with Supplemental Nutrition Assistance Program Education funds and is liable for repayment of unallowable costs. • Efforts are made to target SNAP-Ed to the SNAP-Ed target audience . • Only expanded or additional coverage of those activities funded under the Expanded Food and Nutrition Education Program (EFNEP) may be claimed under the SNAP-Ed grant. Approved activities are those designed to expand the State's current EFNEP coverage in order to serve additional SNAP-Ed targeted individuals. In no case may activities funded under the EFNEP grant be included in the budget for SNAP-Ed. • Contracts are procured through competitive bid procedures governed by State procurement regulations . • Program activities are conducted in compliance with all applicable Federal laws , rules, and regulations including Civil Rights and 0MB circulars governing cost issues. • Program activities do not supplant existing nutrition education and obesity prevention programs, and where operating in conjunction with existing programs, enhance as well as supplement them. This applies to all activities and costs under the Federal budget. • Program activities are reasonable and necessary to accomplish SNAP-Ed objectives and goals. • All materials developed or printed with SNAP-Ed funds include the appropriate USDA non-discrimination statement and credit SNAP as a funding source in standard font that is easily readable . Special Billing Requirements: Exhibit A, Statements of Work Revised as of March 15, 2018 Page 17 of 18 Contract Number CLH18249-2 AMENDMENT #2 1. All invoices, billing and reimbursements must be in compliance with all applicable Federal laws, rules, regulations including the FFY18 SNAP-Ed Guidance and 0MB circulars governing cost issues. 2. Total costs billed will not exceed the USDA-approved budget amount listed in the box below. a. Bills must be for only SNAP-Ed specific activities, using a DOH Al9-1A Invoice voucher b. A SNAP-Ed specific Al 9-lA must be submitted to the agency's designated DOH SNAP-Ed contract manager within 30 days of the last day of the month for which the work is being billed, OR c. An agency may request pre-approval to bill every two months instead, in which case, that agency is required to adhere to the billing due dates listed in Task 5 (see above) 3. NOTE: In FFY18 the SNAP-Ed program will deny payment for any costs not submitted by the due date without prior approval. If for ANY reason a LHJ is unable to submit the SNAP-Ed A-19-1 A on the due date, the LHJ is required to submit a request for an exception to the DOH no later than seven days prior to due date to the DOH SNAP-Ed program. The SNAP-Ed program reserves the right and responsibility to either approve or deny the request for an exception and will reply to the request. 4. Supporting documentation for each month must be submitted with each SNAP-Ed Al9-1A. a. At the very least this means a copy of an agency's financial expanded/detailed general ledger level report. b. Additionally, all receipts, timecards and other supporting documentation, as noted by USDA, must be available upon request. 5. PLEASE NOTE: If an agency is a new SNAP-Ed LHJ or has had a fiscal finding, or does not submit adequate and/or accurate backup documentation within the last year, all SNAP-Ed backup documentation must be submitted with each bill and this requirement will continue until further notice by DOH SNAP-Ed program. BUDGET Source USDA DOH Program Contact Jamie Wells, SNAP-Ed Contract Manager Department of Health PO Box47886 Olympia, WA 98504-7886 Jamie.Wells@doh.wa.gov 360-236-3668 Exhibit A, Statements of Work Revised as of March 15, 2018 Amount $-1-{}-d#Z $21,327 DOH Fiscal Contact Kim Henderson, Fiscal Analyst Department of Health PO Box 47886 Olympia, WA 98504-7886 Kim.Henderson@doh. wa. gov 360-236-3491 Page 18 of 18 Contract Number CLH18249-2 EXHIBITB-2 Kittitas County Public Health Department ALLOCATIONS Contract Number: CLHl8249 Contract Term: 2018-2020 Date: March 15, 2018 Indirect Rate as of January 2018: 12.50% County Central Svcs & 29.50% Public Health Dept DOU Use Only BARS Statement of Work Chart of Accounts Funding Chart of Federal Award Revenue Funding Period Funding Period Period Accounts Chart of Accounts Pros.ram Title Identification # Amend# CFDA* Code** Start Date End Date Start Date End Date Amount Sub Total Total FFY18 CSS lAR SNAP ED Program Mgnt NGA Not Received Amd2 10.561 333 .10.56 01101/18 09130/18 10101117 09130/18 $11,025 $19,855 $21,327 FFY18 CSS IAR SNAP ED Program Mgnt NGA Not Received NIA 10.561 333 .10 .56 01 /01/18 09/30/18 I0/01117 09/30/18 $8,830 FFYI 7 CSS !AR SNAP ED Program Mgnt CF NGA Not Received NIA 10.561 333 .10.56 01 101 118 09130118 10/01/17 09130118 $1 ,472 $1 ,472 FFYl 7 EPR PHEP BPI LBJ Funding NU90TP921889-0l Amd2 93.069 333.93.06 01 /01/18 06 130/18 07/01/17 07/02/18 $565 $20,398 $20,398 FFYl7 EPR PHEP BPI LHJ Funding NU90TP92!889-01 NIA 93.069 333 .93.06 01/01 /18 06130118 07101/17 07102/18 $19,833 FFYl7317 Ops 5NH23!P000762-05-00 NIA 93.268 333.93 .26 0l/01 i l8 06130/18 04101117 06130118 $616 $616 $616 FFY17 AFIX 5NH231P000762-05-00 NIA 93.268 333 .93.26 0\101 118 06130/18 04101/17 06130/18 $2,226 $2 ,226 $2,226 FFY\7 VFC Ops 5NH231P000762-05-00 NIA 93.268 333.93.26 01/01 /18 061301\8 04/01/17 06/30/18 $1,114 $1,114 $1 ,114 FFY18 MCHBG LHJ Contracts 804MC31524 Amd2 93.994 333.93.99 01/01 118 09130/18 I0/01/17 09/30/18 $893 $34,040 $34,040 FFYI8 MCHBG LHJ Contracts B04MC31524 NIA 93 .994 333.93.99 01/01/18 09130/18 10/01117 09130118 $33,147 GFS -Group B (FO-E) NIA NIA 334.04.90 0l/01 118 06130/18 07/01/17 06/30/19 $5,000 $5,000 $5,000 SFYI Lead Environments of Children Amdl NIA 334.04.93 01101/\8 06/30/18 07101117 06130/18 $2,000 $2,000 $2,000 YR 20 SRF -Local Asst (15%) (FS) SS NIA NIA 346.26.64 01 101/18 12/31/20 07/01115 12/31120 $2 ,400 $2,400 $2 ,400 Sanitary Survey Fees (FO -E) SS-State NIA NIA 346.26.65 01 101/18 12/31 120 07101/17 12/31120 $2,400 $2,400 $2 ,400 YR 20 SRF-Local Asst (15%) (FS) TA NIA NIA 346.26.66 01/01/18 \2/31120 07101115 12131120 $2,000 $2,000 $2,000 TOTAL $93,521 $93,521 Total consideration: $81,038 GRAND TOTAL $93,521 $12,483 GRAND TOTAL $93,521 Total Fed $79,721 Total State $13,800 *Catalog of Federal Domestic Assistance **Federal revenue codes begin with "333". State revenue codes begin with "334". Page I of l Exhibit C-2 Schedule of Federal Awards KITTITAS COUNTY HEALTH DEPT-SWV001047!>-07 CONTRACT CLH18249-Kittitas County Public Health Department CONTRACT PERIOD: 01/01/2018-12/31/2020 DOH Federal Chart of Accounts Program Title BARS Award Date NGA Not FFY18 CSS IAR SNAP-ED PROGRAM MGNT 333.10.56 Received NGA Not FFY17 CSS IAR SNAP-ED PROGRAM MGNT CF 33310 56 Received FFY17 EPR PHEP BPI LHJ FUNDING 333 93 ,06 07118117 FFY17 VFC OPS 333.93.26 03/03/17 FFY17 AFIX 333_93 26 03103/17 FFY17 317 OPS 333.93.26 03/03/17 FFY18 MCHBG LHJ CONTRACTS 333 93_99 10120/17 ,otai Amt Allocation Peri od Federal Start End Award Date Date NGA_Not 01101/18 Rcca,ved 09/30/18 NGA_Not 01/01/18 Reca,ved 09/30/18 $11,062,782 01101/18 06130118 $1,201,605 01/01/18 06/30/18 $1,672,289 01/01/18 06130/18 $575,969 01/01118 06130/18 $1,650,528 01/01/18 09/30/18 TOTAL Contract Amt $19,855 $1,472 $20,398 $1,114 $2,226 $616 $34,040 $79,721 AMENDMENT #2 Date: March 15, 2018 CFDA CFDA Program Title Federal Agency Name Federal Award Federal Grant Award Name Identification "lumber S\l!lll Min/Ol~~•ll·MalChing 10 561 Grants for the Supplemental Nutrition Assistance Program Department of Agriculture Food and NGA Not Received NGA Not Received Nutrition Service State Administrative rvtatching 10.561 Grants for the Supplemental Nutrition Assistance Program Department of Agriculture Food and NGA Nol Received NGA Not Received Nutrition Service 93 069 Public Health Emergency Preparedness Department of Health and Human HPP AND PHEP COOPERATIVE Services Centers for Disease Control NU90TP921889-01 and Prevention AGREEMENT 93,268 Immunization Cooperative Agreements Department of Health and Human IMMUNIZATION GRANT AND Services Centers for Disease Control 5NH231P000762-05-00 VACCINES FOR CHILDREN'S and Prevention PROGRAM 93 .268 Immunization Cooperative Agreements Department of Health and Human IMMUNIZATION GRANT AND Services Centers for Disease Control 5NH231P000762-05-00 VACCINES FOR CHILDREN'S and Prevention PROGRAM 93.268 Immunization Cooperative Agreements Department of Health and Human IMMUNIZATION GRANT AND Services Centers for Disease Control 5NH231P000762-05-00 VACCINES FOR CHILDREN'S and Prevention PROGRAM Maternal and Child Health 93.994 Services Block Grant to the Department of Health and Human MATERNAL AND CHILD HEAL TH Services Health Resources and B04MC31524 SERVICES States Services Administration Page 1 of 1 Kittitas County Review Form Grants & Contract Agreement Today's Date 05/08/2018 Fund/Department 116-Public Health Contract/Grant Information Agenda Date Contract /Grant Agency: Consolidated Contract Amendment 2 Period Begin Date: January 1, 2018 j I Period End Date: 12/31/2020 Total Grant/Contract Amount: Increase of $12,483 for a revised maximum consideration of $93,521.00 Grant/Contract Number: CLH18249 Contract/Grant Summary: The Consolidated Contract Amendment 2 amends Statements of Work for the following programs Maternal and Child Health Block Grant, Office of Emergency Preparedness and Response, and Supplemental Nutrition Assistance Program Education. Recommendation for Board of Health and Board of Health Review on Department Head Signatu re ~ , Administrator Date :~ Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment: APPRO\tEO AS TO FORM: i '. '\) Date Signature of Board of Health member Date Financial Information Total Amount$ 12,483 State Funds $ 0 Federal Funds$ 12,483 Percentage County Funds Matching Funds$ CFDA# 93.994 MCHGB; In-Kind$ 93.069 PHER; 10.561 SNAP ED Explain Grant/Contract Review Page 1 Is Equipment being purchased? no Who owns equipment? New Personnel being hired? no Contact HR hiring -reporting requirements Future impacts or liability to Kittitas County: Budget Information Budget Amendment Needed? Yes D attach budget form No • Why not amended funding New Division Created? no Revenue Code 612.22.333.93.99 MCHBG $ 893 612.88.3.333.93.06 PHER $ 565 612.94.333.10.56 SNAP ED $11,025 Pass Through Information Agency to Pass Through Amount to Pass Through $ Sub-Contract Approved Date: Prosecutor Review I Has the Prosecutor reviewed this agreement? j Yes • No D County Departments Impacted Auditor Facilities Maintenance Information Services Human Resource Prosecutor Treasurer Submitted I: Siitn atu re: Department: I Date: Assignment of Tracking Information Auditor's Office Human Resource Prosecutor's Office Who Signed the grant application I Reviewer I Date Grant/Contract Review Page 2