HomeMy WebLinkAboutPS Contract ABCD DentalWashington State
Health Care .
PROFESSIONAL SERVICES
CONTRACT
for
ABCD DENTAL SERVICES
Kittitas County
HCA Contract Number: K2747
Contractor/Vendor Contract Number:
THIS CONTRACT is made by and between Washington State Health Care Authority, (HCA) and the
(Contractor).
CONTRACTOR NAME CONTRACTOR DOING BUSINESS AS (DBAl
Kittitas County Public Health Network
CONTRACTOR ADDRESS [ Street City State Zip Code
507 NORTH NANUM STREET, SUITE 201, ELLENSBURG, WA
98926
CONTRACTOR CONTACT I CONTRACTOR TELEPHONE I CONTRACTOR E-MAIL ADDRESS
Kasey Knutson 509-962-7029 kasey.knutson@co.kittitas.wa.us
Is Contractor a Subrecioient under this Contract? I CFDA NUMBER(S): I FFATA Form Required •YES ~NO 93.778 ~YES •NO
HCA PROGRAM HCA DIVISION/SECTION
ABCD Dental Program Clinical Quality and Care Transformation (CQCT)
HCA CONTACT NAME AND TITLE HCA CONTACT ADDRESS
Janice Tadeo, Dental Program Manager
Health Care Authority
626 8th Avenue SE
Health Services and Management PO Box 42702
Clinical Quality and Care Transformation (CQCT)
Olympia, WA 98504
Health Care Services
HCA CONTACT TELEPHONE HCA CONTACT E-MAIL ADDRESS
(360) 725-1583 Janice. Tadeot@hca .wa .gov
CONTRACT START DATE CONTRACT END DATE TOTAL MAXIMUM CONTRACT AMOUNT
July 1, 2018 June 30, 2020 $19,000.00
PURPOSE OF CONTRACT:
Provide 'Access to Baby and Child Dentistry' (ABCD) services to detect and prevent early childhood dental decay by
engaging dentists in seeing birth to six (6) year old Medicaid eligible children and engaging local public health
departments in outreach and case management.
The parties signing below warrant that they have read and understand this Contract, and have authority to
execute this Contract. This Contract will be binding on HCA only upon signature by HCA.
Washington State
Health Care Authority
PRINTED NAME AND TITLE
Robin Read
Administrator
PRINTED NAME AND TITLE
James W. Gayton
Contracts Administrator
Page 1 of 53
DATE SIGNED
{e(:?7{
OA,TE Sl f NED
, 2~\1.t,>
Contract# 2747
TABLE OF CONTENTS
Recitals ............................................................................................................................................... 4
1. STATEMENT OF WORK (SOW) ................................................................................................. 4
2. DEFINITIONS .............................................................................................................................. 4
3. SPECIAL TERMS AND CONDITIONS .................... ,. .......................................................................... 6
3.1 PERFORMANCE EXPECTATIONS ...................................................................................... ?
3.2 TERM .................................................................................................................................... 8
3.3 COMPENSATION .................................................................................................................. 8
3.4 INVOICE AND PAYMENT ..................................................................................................... 9
3.5 CONTRACTOR and HCA CONTRACT MANAGERS .......................................................... 10
3.6 KEY STAFF .............................................................................................. -........................... 11
3. 7 LEGAL NOTICES ................................................................................................................ 11
3.8 INCORPORATION OF DOCUMENTS AND ORDER OF PRECEDENCE ........................... 12
3.9 INSURANCE ........................................................................................................................ 12
4. GENERAL TERMS AND CONDITIONS ..................................................................................... 13
4.1 ACCESS TO DATA .............................................................................................................. 13
4.2 ADVANCE PAYMENT PROHIBITED .................................................................................. 14
4.3 AMENDMENTS .................................................................................................................... 14
4.4 ASSIGNMENT .................................................................................................................... 14
4.5 ATTORNEYS' FEES .............................................................................................. _ ......... u •• 14
4.6 CHANGE IN STATUS ......................................................................................................... 14
4.7 CONFIDENTIAL INFORMATION PROTECTION ................................................................ 14
4.8 CONFIDENTIAL INFORMATION SECURITY ..................................................................... 15
4.9 CONFIDENTIAL INFORMATION BREACH -REQUIRED NOTIFICATION ........................ 15
4.10 CONTRACTOR'S PROPRIETARY INFORMATION ............................................. ,. .............. 16
4.11 COVENANT AGAINST CONTINGENT FEES ..................................................................... 16
4.12 DEBARMENT ................................................................................................... , ................. 17
4.13 DISPUTES .......................................................................................................................... 17
4.14 ENTIRE AGREEMENT ....................................................................................................... 18
4.15 FEDERAL FUNDING ACCOUNTABILITY & TRANSPARENCY ACT (FFATA) .................... 18
4.16 FORCE MAJ EURE ............................................................................................................. 18
4.17 FUNDING WITHDRAWN, REDUCED OR LIMITED .......................................... ,, ................ 18
4.18 GOVERNING LAW ............................................................................................................. 19
4.19 HCA NETWORK SECURITY .............................................................................................. 19
4.20 INDEMNIFICATION ......................................................................................................... -.... 19
4.21 INDEPENDENT CAPACITY OF THE CONTRACTOR ........................................................ 20
Washington State
Health Care Authority Page 2 of 53 Contract# 2747
4.22 INDUSTRIAL INSURANCE COVERAGE ..............................•..................................• ., ......... 20
4.23 LEGAL AND REGULATORY COMPLIANCE ...................................................................... 20
4.24 LIMITATION OF AUTHORITY ............................................................................................. 20
4.25 NO THIRD-PARTY BENEFICIARIES .................................................................................. 20
4.26 NONDISCRIMINATION ....................................................................................................... 21
4.27 OVERPAYMENTS TO CONTRACTOR ......................... -............................................... -.... -.. 21
4.28 PAY Equity .......................................................................................................................... 21
4.29 PUBLICITY ......................................................................................................................... 22
4.30 RECORDS AND DOCUMENTS REVIEW ............................................................ ; .............. 22
4.31 REMEDIES NON-EXCLUSIVE ........................................................................................... 22
4.32 RIGHT OF INSPECTION .................................................................................................... 23
4.33 RIGHTS IN DATA/OWNERSHIP .......................................................................................... 23
4.34 RIGHTS OF STATE AND FEDERAL GOVERNMENTS ...................................................... 24
4.35 SEVERABILITY ............................................................... , ................................ .-................. 24
4.36 SITE SECURITY ................................................................................................................. 24
4.37 SUBCONTRACTING ....................................................... , ................................. , ................. 24
4.38 SUBRECIPIENT .................................................................. _ ............. _ .... _ ............................... 25
4.39 SURVIVAL ...................................................................................•....................................... 26
4.40 TAXES ................................................................................................................................ 27
4.41 TERMINATION ................................................................................................................... 27
4.42 TERMINATION PROCEDURES ......................................................................................... 28
4.43 WAIVER .............................................................................................................................. 29
4.44 WARRANTIES .................................................................................................................... 29
Attachments
Attachment 1: Federal Compliance, Certifications and Assurances
Attachment 2 : Federal Funding Accountability and Transparency Act (FFATA} Data
Collection Form
Schedules
Schedule A: Statement of Work (SOW) ABCD Dental Services
Exhibit A:
Exhibit B:
Exhibit C:
Washington State
Health Care Authority
Exhibits
ABCD Quarterly Outreach and Case Management Report
ABCD Quarterly Outreach and Coordination of Care Report
ABCD Yearly Budget Tool
Page 3 of 53 Contract# 2747
Contract K2747 for ABCD Dental Services
Recitals
The state of Washington, acting by and through the Health Care Authority (HCA), is entering
into a contract that is exempt from procurement.
HCA has determined that entering into a contract with Kittitas County Public Health Network
in accordance with its authority under chapters 39.26 and 41 .05 RCW.
HCA has determined that entering into a Contract with Kittitas County Public Health
Network will meet HCA's needs and will be in the State's best interest.
NOW THEREFORE, HCA awards to Kittitas County Public Health Network this Contract,
the terms and conditions of which will govern Contractor's providing to HCA the services to
detect and prevent early childhood dental decay by engaging dentists in seeing birth to six (6)
year old Medicaid eligible children and engaging local public health departments or
organizations in outreach and case management.
IN CONSIDERATION of the mutual promises as set forth in this Contract, the parties agree as
follows:
1. STATEMENT OF WORK (SOW)
The Contractor will provide the services and staff as described in Schedule A: Statement of
Work.
2. DEFINITIONS
"Authorized Representative" means a person to whom signature authority has been
delegated in writing acting within the limits of his/her authority.
"Breach" means the unauthorized acquisition, access, use, or disclosure of Confidential
Information that compromises the security, confidentiality, or integrity of the Confidential
Information.
"Business Associate" means a Business Associate as defined in 45 CFR 160.103, who
performs or assists in the performance of an activity for or on behalf of HCA, a Covered Entity,
that involves the use or disclosure of protected health information (PHI). Any reference to
Business Associate in this DSA includes Business Associate's employees, agents, officers,
Subcontractors, third party contractors, volunteers, or directors.
"Business Days and Hours" means Monday through Friday, 8:00 a.m. to 5:00 p.m., Pacific
Time, except for holidays observed by the state of Washington.
"Centers for Medicare and Medicaid Services" or "CMS" means the federal office under
the Secretary of the United States Department of Health and Human Services, responsible for
the Medicare and Medicaid programs.
Washington State
Health Care Authority Paae 4 of 53 Contract# 2747
"CFR" means the Code of Federal Regulations. All references in this Contract to CFR
chapters or sections include any successor, amended, or replacement regulation. The CFR
may be accessed at http://.www.ecfr.gov/cgi-bin/ECFR?page=browse.
"Confidential Information" means information that may be exempt from disclosure to the
public or other unauthorized persons under chapter 42.56 RCW or chapter 70.02 RCW or
other state or federal statutes or regulations. Confidential Information includes, but is not
limited to, any information identifiable to an individual that relates to a natural person's health,
(see also Protected Health Information); finances, education, business, use or receipt of
governmental services, names, addresses, telephone numbers, social security numbers,
driver license numbers, financial profiles, credit card numbers, financial identifiers and any
other identifying numbers, law enforcement records, HCA source code or object code, or HCA
or State security information.
"Contract" means this Contract document and all schedules, exhibits, attachments,
incorporated documents and amendments.
"Contractor" means its employees and agents. Contractor includes any firm, provider,
organization, individual or other entity performing services under this Contract. It also includes
any Subcontractor retained by Contractor as permitted under the terms of this Contract.
"Covered entity" means a health plan, a health care clearinghouse or a health care provider
who transmits any health information in electronic form to carry out financial or administrative
activities related to health care, as defined in 45 CFR 160.103.
"Data" means information produced, furnished, acquired, or used by Contractor in meeting
requirements under this Contract.
"Effective Date" means the first date this Contract is in full force and effect. It may be a
specific date agreed to by the parties; or, if not so specified, the date of the last signature of a
party to this Contract.
"HCA Contract Manager" means the individual identified on the cover page of this Contract
who will provide oversight of the Contractor's activities conducted under this Contract.
"Health Care Authority" or "HCA" means the Washington State Health Care Authority, any
division, section, office, unit or other entity of HCA, or any of the officers or other officials
lawfully representing HCA.
"Overpayment" means any payment or benefit to the Contractor in excess of that to which
the Contractor is entitled by law, rule, or this Contract, including amounts in dispute.
"Proprietary Information" means information owned by Contractor to which Contractor
claims a protectable interest under law. Proprietary Information includes, but is not limited to,
information protected by copyright, patent, trademark, or trade secret laws.
Washington State
Health Care Authority Page 5 of 53 Contract# 2747
"Protected Health Information" or "PHI" means individually identifiable information that
relates to the provision of health care to an individual; the past, present, or future physical or
mental health or condition of an individual; or past, present, or future payment for provision of
health care to an individual, as defined in 45 CFR 160.103. Individually identifiable information
is information that identifies the individual or about which there is a reasonable basis to
believe it can be used to identify the individual, and includes demographic information. PHI is
information transmitted, maintained, or stored in any form or medium. 45 CFR 164.501. PHI
does not include education records covered by the Family Educational Rights and Privacy Act,
as amended, 20 USC 1232g(a)(4)(b)(iv).
"RCW" means the Revised Code of Washington. All references in this Contract to RCW
chapters or sections include any successor, amended, or replacement statute. Pertinent
RCW chapters can be accessed at: http://apps.leq .wa.gov/rcw/.
"Statement of Work" or "SOW" means a detailed description of the work activities the
Contractor is required to perform under the terms and conditions of this Contract, including the
deliverables and timeline, and is Schedule A hereto.
"Subcontractor" means a person or entity that is not in the employment of the Contractor,
who is performing all or part of the business activities under this Contract under a separate
contract with Contractor. The term "Subcontractor" means subcontractor(s) of any tier.
"Subrecipient" means a contractor operating a federal or state assistance program receiving
federal funds and having the authority to determine both the services rendered and disposition
of program. See 0MB Super Circular 2 CFR 200.501 and 45 CFR 75.501, "Uniform
Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards for
additional detail.
"USC" means the United States Code. All references in this Contract to USC chapters or
sections shall include any successor, amended, or replacement statute. The USC may be
accessed at http://uscod.e.house.gov/
"WAC" means the Washington Administrative Code. All references to WAC chapters or
sections will include any successor, amended, or replacement regulation. Pertinent WACs
may be accessed at: http:1/app.leq.wa.gov/wac/.
3. SPECIAL TERMS AND CONDITIONS
a) "ABCD" means Access to Baby and Child Dentistry, a program designed to
detect and prevent early childhood dental decay by engaging dentists in seeing
birth to six (6) year old Medicaid eligible children and engaging local public
health departments in outreach and case management.
b) "ABCD Coordinators Group" means the Contractors.
c) "ABCD Dental Champion" means a participating dentist(s) who has/have been
identified by the University of Washington in each local program to deliver the
University of Washington designed training to newly recruited dentists and assist
Washington State
Health Care Authority Page 6 of 53 Contract# 2747
the local ABCD coordinator and the local dental society in recruiting dentists to
participate.
d) "Case Management" means identifying barriers to early oral health care for
Medicaid eligible children and assisting families in addressing those barriers;
preparing families for their child's first visit to the dentists by providing a family
orientation and assisting them in making that first appointment; and following-up
to insure that appointments were made and kept, and that the families
understand the need for future visits and home care.
e) "Client" means Medicaid eligible Clients ages birth through six (6) years of age.
f) "CMS" means the Centers for Medicare and Medicaid Services of the United
States Department of Health and Human Services.
g) "Confidential Information" means information that is exempt from disclosure
to the public or other unauthorized persons under Chapter 42.56 RCW or other
federal or state laws. Confidential information includes, but is not limited to,
Personal Information.
h) "Family Orientation" means educating the family of Medicaid children on the
need for early, preventive dental care, and dental office etiquette, including the
need to make and keep dental appointments.
i) "Health Care Authority or "HCA" means the agency designated by the
Washington Legislature as the Single State Agency that oversees Washington
State's medical assistance programs, including Medicaid, and its employees and
authorized agents.
j) "Health Coalition" means a group of health care providers and community
organizations that meet to collaborate for a common cause.
k) "Local Programs" means the constellation of local partners who deliver this
program in a county or group of counties.
I) "Outreach" means identifying families with Medicaid eligible children and
linking them with dental care through a variety of methods, including but not
limited to partnerships with other organizations who work with low-income
families, earned media, and referral services.
m) "Personal Information" means information identifiable to any person,
including, but not limited to, information that relates to a person's name, health,
finances, education, business, use or receipt of governmental services or other
activities, addresses, telephone numbers, Social Security Numbers, driver
license numbers, other identifying numbers, and any financial identifiers.
n) "Steering Committee" means a smaller subset of the bigger Health Coalition
tasked with working on specific causes that identified by the Health Coalition.
3.1 PERFORMANCE EXPECTATIONS
Expected performance under this Contract includes, but is not limited to, the following :
Washington State
Health Care Authority Page 7 of 53 Contract# 2747
3.1.1 Knowledge of applicable state and federal laws and regulations pertaining to subject
of contract;
3.1.2 Use of professional judgment;
3.1.3 Collaboration with HCA staff in Contractor's conduct of the services;
3.1.4 Conformance with HCA directions regarding the delivery of the services;
3.1.5 Timely, accurate and informed communications;
3.1.6 Regular completion and updating of project plans, reports, documentation and
communications;
3.1. 7 Regular, punctual attendance at all meetings; and
3 .1.8 Provision of high quality services .
Prior to payment of invoices, HCA will review and evaluate the performance of Contractor
in accordance with Contract and these performance expectations and may withhold
payment if expectations are not met or Contractor's performance is unsatisfactory.
3.2 TERM
3.2.1 The initial term of the Contract will commence on July 1, 2018, or date of last
signature, whichever is later, and continue through June 30, 2020, unless
terminated sooner as provided herein .
3.2.2 This Contract may be extended through June 30, 2028 in whatever time increments
HCA deems appropriate. No change in terms and conditions will be permitted during
these extensions unless specifically agreed to in writing.
3.2.3 Work performed without a contract or amendment signed by the authorized
representatives of both parties will be at the sole risk of the Contractor. HCA will not
pay any costs incurred before a contract or any subsequent amendment(s) is fully
executed .
3.3 COMPENSATION
3.3.1 The Maximum Compensation payable to Contractor for the performance of all things
necessary for or incidental to the performance of work as set forth in Schedule A:
Statement of Work is $19,000.00, and includes any allowable expenses.
Source(s} of Funds. The above maximum amount payable under this Contract,
for the service to be provided is based on the amounts(s) of funding from the
following sources:
Washington State
Health Care Authority Page 8 of 53 Contract# 2747
a) 50% is allotted under this Contract from federal funds received by HCA under
the United States Department of Health & Human Services Medical
Assistance Program, Title XIX of the Social Security Act, Catalog of Federal
Domestic Assistance #93. 778 ; and
b) 50% is allotted under this Contract from GF-S (General Fund-State) funds.
If indicated on page one (1) of this Agreement the Contractor is a sub-recipient for
purposes of this Contract, and as such, shall comply with the terms and conditions
listed in Section 4.37, Sub-recipients.
Funding Stipulations.
a) The Contractor shall cooperate in supplying any information to HCA that may
be needed to verify accuracy of reimbursable billings.
b) The Contractor shall not use funds payable under this Contract for lobbying
activities of any nature. The Contractor certifies that no state or federal funds
payable under this Contract shall be paid to any person or organization to
influence, or attempt to influence, either directly or indirectly, an officer or
employee of an state or federal agency, or an officer or member of any state
or federal legislative body or committee, regarding the award, amendment,
modification, extension, or renewal of a state or federal contract or grant.
c) The Contractor shall not pay Consultants and/or Billing Agents, or
Subcontractors on either a contingent, or percentage basis, for work
performed as a result of this Contract.
3.3.2 Contractor's compensation for services rendered will be based on the rates in
accordance with the Exhibits.
3.3.3 Federal funds disbursed through this Contract were received by HCA through 0MB
Catalogue of Federal Domestic Assistance (CFDA) Number: 93. 788, Contractor
agrees to comply with applicable rules and regulations associated with these federal
funds and has signed Attachment 1: Federal Compliance, Certification and
Assurances, attached.
3.4 INVOICE AND PAYMENT
3.4.1 Contractor must submit accurate invoices to the following address for all amounts to
be paid by HCA via e-mail to: Acctspay@hca.wa .gov. Include the HCA Contract
number in the subject line of the email.
3.4.2 Invoices must describe and document to HCA's satisfaction a description of the
work performed, the progress of the project, and fees. All invoices will be reviewed
and must be approved by the Contract Manager or his/her designee prior to
payment.
Washington State
Health Care Authority Page 9 of 53 Contract# 2747
3.4.3 Contractor must submit properly itemized invoices to include the following
information, as applicable:
3.4.3.1 HCA Contract number K2747;
3.4.3.2 Contractor name, address, phone number;
3.4.3.3 Description of Services;
3.4 .3.4 Date(s) of delivery;
3.4.3.5 Net invoice price for each item;
3.4.3.6 Applicable taxes;
3.4.3.7 Total invoice price; and
3.4.3.8 Payment terms and any available prompt payment discount.
3.4.4 HCA will return incorrect or incomplete invoices to the Contractor for correction and
reissue . The Contract Number must appear on all invoices, bills of lading, packages,
and correspondence relating to this Contract.
3.4.5 In order to receive payment for services or products provided to a state agency,
Contractor must register with the Statewide Payee Desk at
http:Ndes .wa .gov/services/ContractingPurchasingJBusinessNendorPay/Pages/defa
ult.aspx. Payment will be considered timely if made by HCA within thirty (30)
calendar days of receipt of properly completed invoices. Payment will be directly
deposited in the bank account or sent to the address Contractor designated in its
registration .
3.4.6 Upon expiration of the Contract, any claims for payment for costs due and payable
under this Contract that are incurred prior to the expiration date must be submitted
by the Contractor to HCA within sixty (60) calendar days after the Contract
expiration date. HCA is under no obligation to pay any claims that are submitted
sixty-one (61) or more calendar days after the Contract expiration date ("Belated
Claims"). HCA will pay Belated Claims at its sole discretion, and any such potential
payment is contingent upon the availability of funds.
3.5 CONTRACTOR AND HCA CONTRACT MANAGERS
3.5.1 Contractor's Contract Manager will have prime responsibility and final authority for
the services provided under this Contract and be the principal point of contact for
the HCA Contract Manager for all business matters, performance matters, and
administrative activities.
3.5.2 HCA's Contract Manager is responsible for monitoring the Contractor's performance
and will be the contact person for all communications regarding contract
performance and deliverables. The HCA Contract Manager has the authority to
accept or reject the services provided and must approve Contractor's invoices prior
to payment.
Washington State
Health Care Authority Page 10 of 53 Contract# 2747
3.5.3 The contact information provided below may be changed by written notice of the
change (email acceptable) to the other party.
CONTRACTOR Health Care Authority
Contract Manager Information Contract Manager Information
Name : Kasey Knutson Name; Janice Tadeo
Title: Title: Dental Program Manager
Address: 507 North Nanum Street, Suite Address: P.O. Box 45506
201, Ellensburg, WA 98926 Olympia, WA 98504-5506
Phone : 509-962-7029 Phone : 360/725-1583
Email : kasey.knutson@co.kittitas.wa.u Email : janice.tadeo@hca.wa.gov s
3.6 KEY STAFF
3.6.1 Except in the case of a legally required leave of absence, sickness, death,
termination of employment or unpaid leave of absence, Key Staff must not be
changed during the term of the Statement of Work (SOW) from the people who
were described in the Response for the first SOW or those Key Staff initially
assigned to subsequent SOWs, without the prior written approval of HCA until
completion of their assigned tasks.
3.6.2 During the term of the Statement of Work (SOW), HCA reserves the right to approve
or disapprove Contractor's Key Staff assigned to this Contract, to approve or
disapprove any proposed changes in Contractor's Key Staff, or to require the
removal or reassignment of any Contractor staff found unacceptable by HCA,
subject to HCA's compliance with applicable laws and regulations. Contractor must
provide a resume to HCA of any replacement Key Staff and all staff proposed by
Contractor as replacements for other staff must have comparable or greater skills
for performing the activities as performed by the staff being replaced.
3. 7 LEGAL NOTICES
Any notice or demand or other communication required or permitted to be given under
this Contract or applicable law is effective only if it is in writing and signed by the
applicable party, properly addressed, and either delivered in person, or by a recognized
courier service, or deposited with the United States Postal Service as first-class mail,
postage prepaid certified mail, return receipt requested, to the parties at the addresses
provided in this section.
3.7.1 In the case of notice to the Contractor:
Kittitas County Public Health Network
507 North Nanum Street, Suite 201, Ellensburg, WA 98926
Washington State
Health Care Authority Page 11 of 53 Contract# 2747
3.7.2 In the case of notice to HCA:
Attention: Contracts Administrator
Health Care Authority
Division of Legal Services
Post Office Box 42702
Olympia, WA 98504-2702
3.7.3 Notices are effective upon receipt or four (4) Business days after mailing, whichever
is earlier.
3. 7.4 The notice address and information provided above may be changed by written
notice of the change given as provided above.
3.8 INCORPORATION OF DOCUMENTS AND ORDER OF PRECEDENCE
Each of the documents listed below is by this reference incorporated into this Contract. In
the event of an inconsistency, the inconsistency will be resolved in the following order of
precedence:
3.8.1 Applicable Federal and State of Washington statutes and regulations;
3.8.2 Recitals
3.8.3 Special Terms and Conditions;
3.8.4 General Terms and Conditions;
3.8.5 Attachment 1: Federal Compliance, Certifications and Assurances;
3.8.6 Attachment 2: Federal Funding Accountability and Transparency Act (FFATA) Data
Collection Form
3.8. 7 Schedule A: Statement of Work;
3.8.8 Exhibits A: ABCD Quarterly Outreach and Case Management Report, Exhibit B:
ABCD Quarterly Outreach and Coordination of Care Report and Exhibit C: ABCD
Yearly Budget Tool; and
3.8.9 Any other provision, term or material incorporated herein by reference or otherwise
incorporated.
3.9 INSURANCE
Contractor must provide insurance coverage as set out in this section . The intent of the
required insurance is to protect the State should there be any claims, suits, actions, costs,
damages or expenses arising from any negligent or intentional act or omission of
Washington State
Health Care Authority Page 12 of 53 Contract# 2747
Contractor or Subcontractor, or agents of either, while performing under the terms of this
Contract. Contractor must provide insurance coverage that is maintained in full force and
effect during the term of this Contract, as follows:
3.9.1 Commercial General Liability Insurance Policy -Provide a Commercial General
Liability Insurance Policy, including contractual liability, in adequate quantity to
protect against legal liability arising out of contract activity but no less than $1 million
per occurrence/$2 million general aggregate. Additionally, Contractor is responsible
for ensuring that any Subcontractors provide adequate insurance coverage for the
activities arising out of subcontracts.
3.9.2 Business Automobile Liability. In the event that services delivered pursuant to this
Contract, involve the use of vehicles, owned, either hired, or non-owned by the
Contractor, automobile liability insurance is required covering the risks of bodily
injury (including death} and property damage, including coverage for contractual
liability. The minimum limit for automobile liability is $1,000,000 per occurrence,
using a Combined Single Limit for bodily injury and property damage.
3.9.3 Professional Liability Errors and Omissions -Provide a policy with coverage of not
less than $1 million per claim/$2 million general aggregate.
3.9.4 The insurance required must be issued by an insurance company/ies authorized to
do business within the state of Washington, and must name HCA and the state of
Washington, its agents and employees as additional insured's under any
Commercial General and/or Business Automobile Liability policy/ies. All policies
must be primary to any other valid and collectable insurance. In the event of
cancellation , non-renewal, revocation or other termination of any insurance
coverage required by this Contract, Contractor must provide written notice of such
to HCA within one (1} Business day of Contractor's receipt of such notice. Failure to
buy and maintain the required insurance may, at HCA's sole option, result in this
Contract's termination.
Upon request, Contractor must submit to HCA a certificate of insurance that outlines the
coverage and limits defined in the Insurance section. If a certificate of insurance is
requested, Contractor must submit renewal certificates as appropriate during the term of
the contract.
4. GENERAL TERMS AND CONDITIONS
4.1 ACCESS TO DATA
In compliance with RCW 39.26.180 (2) and federal rules, the Contractor must provide
access to any data generated under this Contract to HCA, the Joint Legislative Audit and
Review Committee, the State Auditor, and any other state or federal officials so
authorized by law, rule, regulation, or agreement at no additional cost. This includes
access to all information that supports the findings, conclusions, and recommendations of
the Contractor's reports, including computer models and methodology for those models.
Washington State
Health Care Authority Page 13 of 53 Contract# 2747
4.2 ADVANCE PAYMENT PROHIBITED
No advance payment will be made for services furnished by the Contractor pursuant to
this Contract.
4.3 AMENDMENTS
This Contract may be amended by mutual agreement of the parties. Such amendments
will not be binding unless they are in writing and signed by personnel authorized to bind
each of the parties.
4.4 ASSIGNMENT
4.4.1 Contractor may not assign or transfer all or any portion of this Contract or any of its
rights hereunder, or delegate any of its duties hereunder, except delegations as set
forth in Section 4.37, Subcontracting , without the prior written consent of HCA. Any
permitted assignment will not operate to relieve Contractor of any of its duties and
obligations hereunder, nor will such assignment affect any remedies available to
HCA that may arise from any breach of the provisions of this Contract or warranties
made herein, including but not limited to, rights of setoff. Any attempted assignment,
transfer or delegation in contravention of this Subsection 4.4.1 of the Contract will
be null and void.
4.4.2 HCA may assign this Contract to any public agency, commission, board, or the like,
within the political boundaries of the State of Washington , with written notice of thirty
(30) calendar days to Contractor.
4.4.3 This Contract will inure to the benefit of and be binding on the parties hereto and
their permitted successors and assigns.
4.5 ATTORNEYS' FEES
In the event of litigation or other action brought to enforce the terms of this Contract, each
party agrees to bear its own attorneys' fees and costs.
4.6 CHANGE IN STATUS
In the event of any substantive change in its legal status, organizational structure, or
fiscal reporting responsibility, Contractor will notify HCA of the change. Contractor must
provide notice as soon as practicable, but no later than thirty (30) calendar days after
such a change takes effect.
4.7 CONFIDENTIAL INFORMATION PROTECTION
4.7.1 Contractor acknowledges that some of the material and information that may come
into its possession or knowledge in connection with this Contract or its performance
may consist of Confidential Information. Contractor agrees to hold Confidential
Information in strictest confidence and not to make use of Confidential Information
Washington State
Health Care Authority Page 14 of 53 Contract# 2747
for any purpose other than the performance of this Contract, to release it only to
authorized employees or Subcontractors requiring such information for the purposes
of carrying out this Contract, and not to release, divulge, publish, transfer, sell,
disclose, or otherwise make the information known to any other party without HCA's
express written consent or as provided by law.
Contractor agrees to implement physical, electronic, and managerial safeguards to
prevent unauthorized access to Confidential Information.
4.7.2 Contractors that come into contact with Protected Health Information may be
required to enter into a Business Associate Agreement with HCA in compliance with
the requirements of the Health Insurance Portability and Accountability Act of 1996,
Pub. L. 104-191, as modified by the American Recovery and Reinvestment Act of
2009 ("ARRA"), Sec. 13400-13424, H.R. 1 (2009) (HITECH Act) (HIPAA).
4.7.3 HCA reserves the right to monitor, audit, or investigate the use of Confidential
Information collected, used, or acquired by Contractor through this Contract.
Violation of this section by Contractor or its Subcontractors may result in termination
of this Contract and demand for return of all Confidential Information, monetary
damages, or penalties.
4.7.4 The obligations set forth in this Section will survive completion, cancellation,
expiration, or termination of this Contract.
4.8 CONFIDENTIAL INFORMATION SECURITY
The federal government, including the Centers for Medicare and Medicaid Services
(CMS), and the State of Washington all maintain security requirements regarding privacy,
data access, and other areas. Contractor is required to comply with the Confidential
Information Security Requirements set out in this Contract and appropriate portions of the
Washington OCIO Security Standard, 141.1 O (https://ocio. wa .gov/pollcies/141 -securing-
informatlon-technology-assets/14110-securinq-iriformation-technology-assets).
4.9 CONFIDENTIAL INFORMATION BREACH -REQUIRED NOTIFICATION
4.9.1 Contractor must notify the HCA Privacy Officer (HCAPrlvacyOfficer@hca .wa .gov)
within five Business days of discovery of any Breach or suspected Breach of
Confidential Information.
4.9.2 Contractor will take steps necessary to mitigate any known harmful effects of such
unauthorized access including, but not limited to, sanctioning employees and taking
steps necessary to stop further unauthorized access. Contractor agrees to
indemnify and hold HCA harmless for any damages related to unauthorized use or
disclosure of Confidential Information by Contractor, its officers, directors, and
employees, Subcontractors or agents.
Washington State
Health Care Authority Page 15 of 53 Contract# 2747
4.9.3 If notification of the Breach or possible Breach must (in the judgment of HCA) be
made under the HIPM Breach Notification Rule, or RCW 42.56.590 or RCW
19.254.010, or other law or rule, then:
4.9.3.1 HCA may choose to make any required notifications to the
individuals, to the U.S. Department of Health and Human
Services Secretary (DHHS) Secretary, and to the media, or
direct Contractor to make them or any of them.
4.9.3.2 In any case, Contractor will pay the reasonable costs of
notification to individuals, media, and governmental agencies
and of other actions HCA
4.9.3.3 Reasonably considers appropriate to protect HCA Clients (such
as paying for regular credit watches in some cases).
4.9.3.4 Contractor will compensate HCA Clients for harms caused to
them by any Breach or possible Breach.
4.9.4 Any breach of this clause may result in termination of the Contract and the demand
for return or disposition of all Confidential Information.
4.9.5 Contractor's obligations regarding Breach notification survive the termination of this
Contract and continue for as long as Contractor maintains the Confidential
Information and for any breach or possible breach at any time.
4.10 CONTRACTOR'S PROPRIETARY INFORMATION
Contractor acknowledges that HCA is subject to Chapter 42.56 RCW, the Public Records
Act, and that this Contract will be a public record as defined in chapter 42.56 RCW. Any
specific information that is claimed by Contractor to be Proprietary Information must be
clearly identified as such by Contractor. To the extent consistent with Chapter 42.56
RCW, HCA will maintain the confidentiality of Contractor's information in its possession
that is marked Proprietary. If a public disclosure request is made to view Contractor's
Proprietary Information, HCA will notify Contractor of the request and of the date that
such records will be released to the requester unless Contractor obtains a court order
from a court of competent jurisdiction enjoining that disclosure. If Contractor fails to obtain
the court order enjoining disclosure, HCA will release the requested information on the
date specified.
4.11 COVENANT AGAINST CONTINGENT FEES
Contractor warrants that no person or selling agent has been employed or retained to
solicit or secure this Contract upon an agreement or understanding for a commission,
percentage, brokerage or contingent fee, excepting bona fide employees or bona fide
established agents maintained by the Contractor for the purpose of securing business.
HCA will have the right, in the event of breach of this clause by the Contractor, to annul
this Contract without liability or, in its discretion, to deduct from the contract price or
Washington State
Health Care Authority Page 16 of 53 Contract# 2747
consideration or recover by other means the full amount of such commission, percentage,
brokerage or contingent fee.
4.12 DEBARMENT
By signing this Contract, Contractor certifies that it is not presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded in any Washington
State or Federal department or agency from participating in transactions (debarred).
Contractor agrees to include the above requirement in any and all subcontracts into which
it enters, and also agrees that it will not employ debarred individuals. Contractor must
immediately notify HCA if, during the term of this Contract, Contractor becomes debarred.
HCA may immediately terminate this Contract by providing Contractor written notice, if
Contractor becomes debarred during the term hereof.
4.13 DISPUTES
The parties will use their best, good faith efforts to cooperatively resolve disputes and
problems that arise in connection with this Contract. Both parties will continue without
delay to carry out their respective responsibilities under this Contract while attempting to
resolve any dispute. When a genuine dispute arises between HCA and the Contractor,
regarding the terms of this Contract or the responsibilities imposed herein and it cannot
be resolved between the parties' Contract Managers, either party may initiate the
following dispute resolution process.
4 .13.1 The initiating party will reduce its description of the dispute to writing and deliver it to
the responding party (email acceptable). The responding party will respond in
writing within five (5) Business days (email acceptable). If the initiating party is not
satisfied with the response of the responding party, then the initiating party may
request that the HCA Director review the dispute. Any such request from the
initiating party must be submitted in writing to the HCA Director within five (5)
Business days after receiving the response of the responding party. The HCA
Director will have sole discretion in determining the procedural manner in which he
or she will review the dispute. The HCA Director will inform the parties in writing
within five (5) Business days of the procedural manner in which he or she will review
the dispute, including a timeframe in which he or she will issue a written decision.
4.13.2 A party's request for a dispute resolution must:
4.13.2.1 Be in writing;
4.13.2.2 Include a written description of the dispute;
4 .13.2.3 State the relative positions of the parties and the remedy sought;
4.13.2.4 State the Contract Number and the names and contact
information for the parties;
4.13.3 This dispute resolution process constitutes the sole administrative remedy available
under this Contract. The parties agree that this resolution process will precede any
action in a judicial or quasi-judicial tribunal.
Washington State
Health Ca re Aulhority Page 17 of 53 Contract# 2747
4.14 ENTIRE AGREEMENT
HCA and Contractor agree that the Contract is the complete and exclusive statement of
the agreement between the parties relating to the subject matter of the Contract and
supersedes all letters of intent or prior contracts, oral or written, between the parties
relating to the subject matter of the Contract, except as provided in Section 4.44
Warranties.
4.15 FEDERAL FUNDING ACCOUNTABILITY & TRANSPARENCY ACT (FFATA)
4.15.1 This Contract is supported by federal funds that require compliance with the Federal
Funding Accountability and Transparency Act (FFATA or the Transparency Act).
The purpose of the Transparency Act is to make information available online so the
public can see how federal funds are spent.
4 .15.2 To comply with the act and be eligible to enter into this Contract, Contractor must
have a Data Universal Numbering System (DUNS®) number. A DUNS® number
provides a method to verify data about your organization. If Contractor does not
already have one, a DUNS® number is available free of charge by contacting Dun
and Bradstreet at www.dnb.com.
4.15.3 Information about Contractor and this Contract will be made available on
www.uscontractorregistration .com by HCA as required by P.L. 109-282. HCA's
Attachment 1: Federal Funding Accountability and Transparency Act Data
Collection Form, is considered part of this Contract and must be completed and
returned along with the Contract.
4.16 FORCE MAJEURE
A party will not be liable for any failure of or delay in the performance of this Contract for
the period that such failure or delay is due to causes beyond its reasonable control,
including but not limited to acts of God, war, strikes or labor disputes, embargoes,
government orders or any other force majeure event.
4.17 FUNDING WITHDRAWN, REDUCED OR LIMITED
If HCA determines in its sole discretion that the funds it relied upon to establish this
Contract have been withdrawn, reduced or limited, or if additional or modified conditions
are placed on such funding after the effective date of this contract but prior to the normal
completion of this Contract, then HCA, at its sole discretion, may:
4.17. 1 Terminate this Contract pursuant to Section 4.41.3, Termination for Non-Allocation
of Funds ;
4.17 .2 Renegotiate the Contract under the revised funding conditions; or
4.17.3 Suspend Contractor's performance under the Contract upon five (5) Business days'
advance written notice to Contractor. HCA will use this option only when HCA
Washington State
Health Care Authority Page 18 of 53 Contract# 2747
determines that there is reasonable likelihood that the funding insufficiency may be
resolved in a timeframe that would allow Contractor's performance to be resumed
prior to the normal completion date of this Contract.
4.17.3.1 During the period of suspension of performance, each party will
inform the other of any conditions that may reasonably affect the
potential for resumption of performance.
4.17.3.2 When HCA determines in its sole discretion that the funding
insufficiency is resolved, it will give Contractor written notice to
resume performance. Upon the receipt of this notice, Contractor
will provide written notice to HCA informing HCA whether it can
resume performance and, if so, the date of resumption. For
purposes of this subsection, "written notice" may include email.
4.17.3.3 If the Contractor's proposed resumption date is not acceptable to
HCA and an acceptable date cannot be negotiated, HCA may
terminate the contract by giving written notice to Contractor. The
parties agree that the Contract will be terminated retroactive to
the date of the notice of suspension. HCA will be liable only for
payment in accordance with the terms of this Contract for
services rendered prior to the retroactive date of termination.
4.18 GOVERNING LAW
This Contract is governed in all respects by the laws of the state of Washington, without
reference to conflict of law principles. The jurisdiction for any action hereunder is
exclusively in the Superior Court for the state of Washington, and the venue of any action
hereunder is in the Superior Court for Thurston County, Washington. Nothing in this
Contract will be construed as a waiver by HCA of the State's immunity under the 11th
Amendment to the United States Constitution.
4.19 HCA NETWORK SECURITY
Contractor agrees not to attach any Contractor-supplied computers, peripherals or
software to the HCA Network without prior written authorization from HCA's Chief
Information Officer. Unauthorized access to HCA networks and systems is a violation of
HCA Policy and constitutes computer trespass in the first degree pursuant to RCW
9A.52.110. Violation of any of these laws or policies could result in termination of the
contract and other penalties.
Contractor will have access to the HCA visitor Wi-Fi Internet connection while on site.
4.20 INDEMNIFICATION
Contractor must defend, indemnify, and save HCA harmless from and against all claims,
including reasonable attorneys' fees resulting from such claims, for any or all injuries to
persons or damage to property, or Breach of its confidentiality and notification obligations
under Section 4. 7 Confidential Information Protection and Section 4.8 Confidentiality
Washington State
Health Care Authority Page 19 of 53 Contract# 2747
Breach-Required Notification, arising from intentional or negligent acts or omissions of
Contractor, its officers, employees, or agents, or Subcontractors, their officers,
employees, or agents, in the performance of this Contract.
4.21 INDEPENDENT CAPACITY OF THE CONTRACTOR
The parties intend that an independent contractor relationship will be created by this
Contract.
Contractor and its employees or agents performing under this Contract are not
employees or agents of HCA. Contractor will not hold itself out as or claim to be an officer
or employee of HCA or of the State of Washington by reason hereof, nor will Contractor
make any claim of right, privilege or benefit that would accrue to such employee under
law. Conduct and control of the work will be solely with Contractor.
4.22 INDUSTRIAL INSURANCE COVERAGE
Prior to performing work under this Contract, Contractor must provide or purchase
industrial insurance coverage for the Contractor's employees, as may be required of an
"employer" as defined in Title 51 RCW, and must maintain full compliance with Title 51
RCW during the course of this Contract.
4.23 LEGAL AND REGULATORY COMPLIANCE
4.23.1 During the term of this Contract, Contractor must comply with all local, state, and
federal licensing, accreditation and registration requirements/standards, necessary
for the performance of this Contract and all other applicable federal, state and local
laws, rules, and regulations.
4.23.2 While on the HCA premises, Contractor must comply with HCA operations and
process standards and policies (e.g ., ethics, Internet I email usage, data, network
and building security, harassment, as applicable). HCA will make an electronic copy
of all such policies available to Contractor.
4.23.3 Failure to comply with any provisions of this section may result in Contract
termination .
4.24 LIMITATION OF AUTHORITY
Only the HCA Authorized Representative has the express, implied, or apparent authority
to alter, amend, modify, or waive any clause or condition of this Contract. Furthermore,
any alteration, amendment, modification, or waiver or any clause or condition of this
Contract is not effective or binding unless made in writing and signed by the HCA
Authorized Representative.
4.25 NO THIRD-PARTY BENEFICIARIES
HCA and Contractor are the only parties to this contract. Nothing in this Contract gives or
is intended to give any benefit of this Contract to any third parties.
Washington State
Health Care Authority Page 20 of 53 Contract# 2747
4.26 NONDISCRIMINATION
During the performance of this Contract, the Contractor must comply with all federal and
state nondiscrimination laws, regulations and policies, including but not limited to: Title VI I
of the Civil Rights Act, 42 U.S.C. §12101 et seq.; the Americans with Disabilities Act of
1990 (ADA), 42 U.S.C. §12101 et seq., 28 CFR Part 35; and Title 49 .60 RCW,
Washington Law Against Discrimination .
In the event of Contractor's noncompliance or refusal to comply with any
nondiscrimination law, regulation or policy, this Contract may be rescinded, canceled, or
terminated in whole or in part under the Termination for Default sections, and Contractor
may be declared ineligible for further contracts with HCA.
4.27 OVERPAYMENTS TO CONTRACTOR
In the event that overpayments or erroneous payments have been made to the
Contractor under this Contract, HCA will provide written notice to Contractor and
Contractor shall refund the full amount to HCA within thirty (30) calendar days of the
notice. If Contractor fails to make timely refund, HCA may charge Contractor one percent
(1 %) per month on the amount due, until paid in full. If the Contractor disagrees with
HCA's actions under this section, then it may invoke the dispute resolution provisions of
Section 4.13 Disputes.
4.28 PAY EQUITY
4.28. 1 Contractor represents and warrants that, as required by Washington state law
(Laws of 2017, Chap . 1, § 147), during the term of this Contract, it agrees to
equality among its workers by ensuring similarly employed individuals are
compensated as equals. For purposes of this provision, employees are similarly
employed if (i) the individuals work for Contractor, (ii) the performance of the job
requires comparable skill, effort, and responsibility, and (iii) the jobs are performed
under similar working conditions. Job titles alone are not determinative of whether
employees are similarly employed.
4.28.2 Contractor may allow differentials in compensation for its workers based in good
faith on any of the following : (i) a seniority system; (ii) a merit system; (iii) a system
that measures earnings by quantity or quality of production; (iv) bona fide job-
related factor(s); or (v) a bona fide regional difference in compensation levels.
4.28.3 Bona fide job-related factor(s)" may include, but not be limited to,
education, training, or experience, that is: (i) consistent with business necessity;
(ii) not based on or derived from a gender-based differential; and (iii) accounts for
the entire differential.
4.28.4 A "bona fide regional difference in compensation level" must be (i) consistent with
business necessity; (ii) not based on or derived from a gender-based differential;
and (iii) account for the entire differential.
Washington State
Health Care Authority Page 21 of 53 Contract# 2747
4.28.5 Notwithstanding any provision to the contrary, upon breach of warranty and
Contractor's failure to provide satisfactory evidence of compliance within thirty (30)
days of HCA's request for such evidence, HCA may suspend or terminate this
Contract.
4.29 PUBLICITY
4.29.1 The award of this Contract to Contractor is not in any way an endorsement of
Contractor or Contractor's Services by HCA and must not be so construed by
Contractor in any advertising or other publicity materials.
4.29.2 Contractor agrees to submit to HCA, all advertising, sales promotion, and other
publicity materials relating to this Contract or any Service furnished by Contractor in
which HCA's name is mentioned, language is used, or Internet links are provided
from which the connection of HCA's name with Contractor's Services may, in HCA's
judgment, be inferred or implied. Contractor further agrees not to publish or use
such advertising, marketing, sales promotion materials, publicity or the like through
print, voice, the Web, and other communication media in existence or hereinafter
developed without the express written consent of HCA prior to such use.
4.30 RECORDS AND DOCUMENTS REVIEW
4.30.1 The Contractor must maintain books, records, documents, magnetic media,
receipts, invoices or other evidence relating to this Contract and the performance of
the services rendered, along with accounting procedures and practices, all of which
sufficiently and properly reflect all direct and indirect costs of any nature expended
in the performance of this Contract. At no additional cost, these records, including
materials generated under this Contract, are subject at all reasonable times to
inspection, review, or audit by HCA, the Office of the State Auditor, and state and
federal officials so authorized by law, rule, regulation, or agreement [See 42 USC
1396a(a)(27)(B); 42 USC 1396a(a)(37)(B); 42 USC 1396a(a)(42(A); 42 CFR 431,
Subpart Q; and 42 CFR 447.202].
4.30.2 The Contractor must retain such records for a period of six (6) years after the date
of final payment under this Contract.
4.30.3 If any litigation, claim or audit is started before the expiration of the six (6) year
period, the records must be retained until all litigation, claims, or audit findings
involving the records have been resolved.
4.31 REMEDIES NON-EXCLUSIVE
The remedies provided in this Contract are not exclusive, but are in addition to all other
remedies available under law.
Washington State
Health Care Authority Page 22 of 53 Contract# 2747
4.32 RIGHT OF INSPECTION
The Contractor must provide right of access to its facilities to HCA, or any of its officers,
or to any other authorized agent or official of the state of Washington or the federal
government, at all reasonable times, in order to monitor and evaluate performance,
compliance, and/or quality assurance under this Contract.
4.33 RIGHTS IN DATA/OWNERSHIP
4.33.1 HCA and Contractor agree that all data and work products (collectively "Work
Product") produced pursuant to this Contract will be considered a work for hire
under the U.S. Copyright Act, 17 U.S.C. §101 et seq, and will be owned by HCA.
Contractor is hereby commissioned to create the Work Product. Work Product
includes, but is not limited to, discoveries, formulae, ideas, improvements,
inventions, methods, models, processes, techniques, findings, conclusions,
recommendations, reports, designs, plans, diagrams, drawings, Software,
databases, documents, pamphlets, advertisements, books, magazines, surveys,
studies, computer programs, films, tapes, and/or sound reproductions, to the extent
provided by law. Ownership includes the right to copyright, patent, register and the
ability to transfer these rights and all information used to formulate such Work
Product.
4.33.2 If for any reason the Work Product would not be considered a work for hire under
applicable law, Contractor assigns and transfers to HCA, the entire right, title and
interest in and to all rights in the Work Product and any registrations and copyright
applications relating thereto and any renewals and extensions thereof.
4.33.3 Contractor will execute all documents and perform such other proper acts as HCA
may deem necessary to secure for HCA the rights pursuant to this section.
4.33.4 Contractor will not use or in any manner disseminate any Work Product to any third
party, or represent in any way Contractor ownership of any Work Product, without
the prior written permission of HCA. Contractor shall take all reasonable steps
necessary to ensure that its agents, employees, or Subcontractors will not copy or
disclose, transmit or perform any Work Product or any portion thereof, in any form,
to any third party.
4.33.5 Material that is delivered under this Contract, but that does not originate therefrom
("Preexisting Material"), must be transferred to HCA with a nonexclusive, royalty-
free, irrevocable license to publish, translate, reproduce, deliver, perform, display,
and dispose of such Preexisting Material, and to authorize others to do so.
Contractor agrees to obtain, at its own expense, express written consent of the
copyright holder for the inclusion of Preexisting Material. HCA will have the right to
modify or remove any restrictive markings placed upon the Preexisting Material by
Contractor.
Washington State
Health Care Authority Page 23 of 53 Contract# 2747
4.33.6 Contractor must identify all Preexisting Material when it is delivered under this
Contract and must advise HCA of any and all known or potential infringements of
publicity, privacy or of intellectual property affecting any Preexisting Material at the
time of delivery of such Preexisting Material. Contractor must provide HCA with
prompt written notice of each notice or claim of copyright infringement or
infringement of other intellectual property right worldwide received by Contractor
with respect to any Preexisting Material delivered under this Contract.
4.34 RIGHTS OF STATE AND FEDERAL GOVERNMENTS
In accordance with 45 C.F.R. 95.617, all appropriate state and federal agencies, including
but not limited to the Centers for Medicare and Medicaid Services (CMS), will have a
royalty-free, nonexclusive, and irrevocable license to reproduce, publish, translate, or
otherwise use, and to authorize others to use for Federal Government purposes: (i)
software, modifications, and documentation designed, developed or installed with Federal
Financial Participation (FFP) under 45 CFR Part 95, subpart F; (ii) the Custom Software
and modifications of the Custom Software, and associated Documentation designed,
developed, or installed with FFP under this Contract; (iii) the copyright in any work
developed under this Contract; and (iv) any rights of copyright to which Contractor
purchases ownership under this Contract.
4.35 SEVERABILITY
If any provision of this Contract or the application thereof to any person(s) or
circumstances is held invalid, such invalidity will not affect the other provisions or
applications of this Contract that can be given effect without the invalid provision, and to
this end the provisions or application of this Contract are declared severable.
4.36 SITE SECURITY
While on HCA premises, Contractor, its agents, employees, or Subcontractors must
conform in all respects with physical, fire or other security policies or regulations. Failure
to comply with these regulations may be grounds for revoking or suspending security
access to these facilities. HCA reserves the right and authority to immediately revoke
security access to Contractor staff for any real or threatened breach of this provision.
Upon reassignment or termination of any Contractor staff, Contractor agrees to promptly
notify HCA.
4.37 SUBCONTRACTING
4.37.1 Neither Contractor, nor any Subcontractors, may enter into subcontracts for any of
the work contemplated under this Contract without prior written approval of HCA.
HCA has sole discretion to determine whether or not to approve any such
subcontract. In no event will the existence of the subcontract operate to release or
reduce the liability of Contractor to HCA for any breach in the performance of
Contractor's duties.
Washington State
Health Care Authority Page 24 of 53 Contract# 2747
4.37.2 Contractor is responsible for ensuring that all terms, conditions, assurances and
certifications set forth in this Contract are included in any subcontracts.
4.37.3 If at any time during the progress of the work HCA determines in its sole judgment
that any Subcontractor is incompetent or undesirable, HCA will notify Contractor,
and Contractor must take immediate steps to terminate the Subcontractor's
involvement in the work.
4.37.4 The rejection or approval by the HCA of any Subcontractor or the termination of a
Subcontractor will not relieve Contractor of any of its responsibilities under the
Contract, nor be the basis for additional charges to HCA.
4.37.5 HCA has no contractual obligations to any Subcontractor or vendor under contract
to the Contractor. Contractor is fully responsible for all contractual obligations,
financial or otherwise, to its Subcontractors.
4.38 SUBRECIPIENT
4.38.1 General
If the Contractor is a subrecipient (as defined in 45 CFR 75.2 and 2 CFR 200.93)
of federal awards, then the Contractor, in accordance with 2 CFR 200.501 and 45
CFR 75.501, shall:
Washington State
Health Care Authority
4.38.1.1 Maintain records that identify, in its accounts, all federal awards
received and expended and the federal programs under which
they were received, by Catalog of Federal Domestic Assistance
(CFDA) title and number, award number and year, name of the
federal agency, and name of the pass-through entity;
4.38.1.2 Maintain internal controls that provide reasonable assurance that
the Contractor is managing federal awards in compliance with
laws, regulations, and provisions of contracts or grant
agreements that could have a material effect on each of its
federal programs;
4.38.1.3 Prepare appropriate financial statements, including a schedule of
expenditures of federal awards;
4.38.1.4 Incorporate 0MB Super Circular 2 CFR 200.501 and 45 CFR
75.501 audit requirements into all agreements between the
Contractor and its Subcontractors who are subrecipients;
4.38.1.5 Comply with any future amendments to 0MB Super Circular 2
CFR 200.501 and 45 CFR 75.501 and any successor or
replacement Circular or regulation;
4 .38.1.6 Comply with the applicable requirements of 0MB Super Circular
2 CFR 200.501 and 45 CFR 75.501and any future amendments
Page 25 of 53 Contract# 2747
to 0MB Super Circular 2 CFR 200.501 and 45 CFR 75.501, and
any successor or replacement Circular or regulation; and
4.38.1. 7 Comply with the Omnibus Crime Control and Safe streets Act of
1968, Title VI of the Civil Rights Act of 1964, Section 504 of the
Rehabilitation Act of 1973, Title 11 of the Americans with
Disabilities Act of 1990, Title IX of the Education Amendments of
1972, The Age Discrimination Act of 1975, and The Department
of Justice Non-Discrimination Regulations, 28 C.F.R. Part 42,
Subparts C.D.E. and G, and 28 C.F.R. Part 35 and 39. (Go to
http://ojp.gov/about/offices/ocr.htm for additional information and
access to the aforementioned Federal laws and regulations.)
4.38.2 Single Audit Act Compliance
If the Contractor is a subrecipient and expends $750,000 or more in federal
awards from any and/or all sources in any fiscal year, the Contractor shall procure
and pay for a single audit or a program-specific audit for that fiscal year. Upon
completion of each audit, the Contractor shall:
4.38.2.1 Submit to the Authority contact person the data collection form
and reporting package specified in 0MB Super Circular 2 CFR
200.501 and 45 CFR 75.501, reports required by the program-
specific audit guide (if applicable), and a copy of any
management letters issued by the auditor;
4.38.2.2 Follow-up and develop corrective action for all audit findings; in
accordance with 0MB Super Circular 2 CFR 200.501 and 45
CFR 75.501, prepare a "Summary Schedule of Prior Audit
Findings."
4.38.3 Overpayments
4.39 SURVIVAL
4.38.3.1 If it is determined by HCA, or during the course of a required
audit, that Contractor has been paid unallowable costs under this
or any Program Agreement, Contractor shall refund the full
amount to HCA as provided in Section 4.27 Overpayments to
Contractors.
The terms and conditions contained in this Contract that, by their sense and context, are
intended to survive the completion, cancellation, termination, or expiration of the Contract
will survive. In addition, the terms of the sections titled Confidential Information
Protection, Confidential Information Breach -Required Notification, Contractor's
Proprietary Information, Disputes, Overpayments to Contractor, Publicity, Records and
Documents Review, Rights in Data/Ownership, and Rights of State and Federal
Governments will survive the termination of this Contract. The right of HCA to recover
any overpayments will also survive the termination of this Contract.
Washington State
Health Care Authority Page 26 of 53 Contract# 2747
4.40 TAXES
HCA will pay sales or use taxes, if any, imposed on the services acquired hereunder.
Contractor must pay all other taxes including, but not limited to, Washington Business
and Occupation Tax, other taxes based on Contractor's income or gross receipts, or
personal property taxes levied or assessed on Contractor's personal property. HCA, as
an agency of Washington State government, is exempt from property tax.
Contractor must complete registration with the Washington State Department of Revenue
and be responsible for payment of all taxes due on payments made under this Contract.
4.41 TERMINATION
4.41.1 TERMINATION FOR DEFAULT
In the event HCA determines that Contractor has failed to comply with the terms
and conditions of this Contract, HCA has the right to suspend or terminate this
Contract. HCA will notify Contractor in writing of the need to take corrective action.
If corrective action is not taken within five (5) Business days, or other time period
agreed to in writing by both parties, the Contract may be terminated. HCA
reserves the right to suspend all or part of the Contract, withhold further
payments, or prohibit Contractor from incurring additional obligations of funds
during investigation of the alleged compliance breach and pending corrective
action by Contractor or a decision by HCA to terminate the Contract.
In the event of termination for default, Contractor will be liable for damages as
authorized by law including, but not limited to, any cost difference between the
original Contract and the replacement or cover Contract and all administrative
costs directly related to the replacement Contract, e.g., cost of the competitive
bidding, mailing, advertising, and staff time.
If it is determined that Contractor: (i) was not in default, or (ii) its failure to perform
was outside of its control, fault or negligence, the termination will be deemed a
"Termination for Convenience."
4.41.2 TERMINATION FOR CONVENIENCE
When, at HCA's sole discretion, it is in the best interest of the State, HCA may
terminate this Contract in whole or in part by providing ten (10) calendar days'
written notice. If this Contract is so terminated, HCA will be liable only for payment
in accordance with the terms of this Contract for services rendered prior to the
effective date of termination. No penalty will accrue to HCA in the event the
termination option in this section is exercised.
4.41.3 TERMINATION FOR NONALLOCATION OF FUNDS
If funds are not allocated to continue this Contract in any future period, HCA may
immediately terminate this Contract by providing written notice to the Contractor.
Washington State
Health Care Authority Page 27 of 53 Contract# 2747
The termination will be effective on the date specified in the termination notice.
HCA will be liable only for payment in accordance with the terms of this Contract
for services rendered prior to the effective date of termination. HCA agrees to
notify Contractor of such non-allocation at the earliest possible time. No penalty
will accrue to HCA in the event the termination option in this section is exercised .
4.41.4 TERMINATION FOR WITHDRAWAL OF AUTHORITY
In the event that the authority of HCA to perform any of its duties is withdrawn,
reduced, or limited in any way after the commencement of this Contract and prior
to normal completion, HCA may immediately terminate this Contract by providing
written notice to the Contractor. The termination will be effective on the date
specified in the termination notice. HCA will be liable only for payment in
accordance with the terms of this Contract for services rendered prior to the
effective date of termination. HCA agrees to notify Contractor of such withdrawal
of authority at the earliest possible time. No penalty will accrue to HCA in the
event the termination option in this section is exercised.
4.41.5 TERMINATION FOR CONFLICT OF INTEREST
HCA may terminate this Contract by written notice to the Contractor if HCA
determines, after due notice and examination, that there is a violation of the Ethics
in Public Service Act, Chapter 42.52 RCW, or any other laws regarding ethics in
public acquisitions and procurement and performance of contracts. In the event
this Contract is so terminated, HCA will be entitled to pursue the same remedies
against the Contractor as it could pursue in the event Contractor breaches the
contract.
4.42 TERMINATION PROCEDURES
4.42.1 Upon termination of this Contract, HCA, in addition to any other rights provided in
this Contract, may require Contractor to deliver to HCA any property specifically
produced or acquired for the performance of such part of this Contract as has been
terminated.
4.42.2 HCA will pay Contractor the agreed-upon price, if separately stated, for completed
work and services accepted by HCA and the amount agreed upon by the Contractor
and HCA for (i) completed work and services for which no separate price is stated;
(ii) partially completed work and services; (iii) other property or services that are
accepted by HCA; and (iv) the protection and preservation of property, unless the
termination is for default, in which case HCA will determine the extent of the liability.
Failure to agree with such determination will be a dispute within the meaning of
Section 4.13 Disputes. HCA may withhold from any amounts due the Contractor
such sum as HCA determines to be necessary to protect HCA against potential loss
or liability.
Washington State
Health Care Authority Page 28 of 53 Contract# 2747
4.42.3 After receipt of notice of termination, and except as otherwise directed by HCA,
Contractor must:
4.41.3.1 Stop work under the Contract on the date of, and to the extent specified
in, the notice;
4.42.3.2 Place no further orders or subcontracts for materials, services, or
facilities except as may be necessary for completion of such portion of
the work under the Contract that is not terminated ;
4.42 .3.3 Assign to HCA, in the manner, at the times, and to the extent directed
by HCA, all the rights, title, and interest of the Contractor under the
orders and subcontracts so terminated; in which case HCA has the
right, at its discretion, to settle or pay any or all claims arising out of the
termination of such orders and subcontracts;
4.42.3.4 Settle all outstanding liabilities and all claims arising out of such
termination of orders and subcontracts , with the approval or ratification
of HCA to the extent HCA may require, which approval or ratification will
be final for all the purposes of this clause;
4.42.3 .5 Transfer title to and deliver as directed by HCA any property required to
be furnished to HCA;
4.42.3.6 Complete performance of any part of the work that was not terminated
by HCA; and
4.42.3.7 Take such action as may be necessary, or as HCA may direct, for the
protection and preservation of the records related to this Contract that
are in the possession of the Contractor and in which HCA has or may
acquire an interest.
4.43 WAIVER
Waiver of any breach of any term or condition of this Contract will not be deemed a
waiver of any prior or subsequent breach or default. No term or condition of this Contract
will be held to be waived, modified, or deleted except by a written instrument signed by
the parties. Only the HCA Authorized Representative has the authority to waive any term
or condition of this Contract on behalf of HCA.
4.44 WARRANTIES
4.44.1 Contractor represents and warrants that it will perform all services pursuant to this
Contract in a professional manner and with high quality and will immediately re-
perform any services that are not in compliance with this representation and
warranty at no cost to HCA.
4.44.2 Contractor represents and warrants that it shall comply with all applicable local,
State, and federal licensing, accreditation and registration requirements and
standards necessary in the performance of the Services.
Washington State
Health Care Authority Page 29 of 53 Contract# 2747
4.44.3 Any written commitment by Contractor within the scope of this Contract will be
binding upon Contractor. Failure of Contractor to fulfill such a commitment may
constitute breach and will render Contractor liable for damages under the terms of
this Contract.
For purposes of this section, a commitment by Contractor includes: (i) Prices,
discounts, and options committed to remain in force over a specified period of
time; and (ii) any warranty or representation made by Contractor to HCA or
contained in any Contractor publications, or descriptions of services in written or
other communication medium, used to influence HCA to enter into this Contract.
Approved as to Form:
This contract format was approved by
the Office of the Attorney General.
Approval on file.
Washington State
Health Care Authority Page 30 of 53 Contract# 2747
ATTACHMENT 1 FEDERAL COMPLIANCE, CERTIFICATIONS, AND ASSURANCES
In the event federal funds are included in this agreement, the following sections apply: I. Federal Compliance
and II. Standard Federal Assurances and Certifications. In the instance of inclusion of federal funds, the
Contractor may be designated as a sub-recipient and the effective date of the amendment shall also be the
date at which these requirements go into effect.
I. FEDERAL COMPLIANCE -The use of federal funds requires additional compliance and control
mechanisms to be in place. The following represents the majority of compliance elements that may
apply to any federal funds provided under this contract. For clarification regarding any of these elements
or details specific to the federal funds in this contract, contact the Health Care Authority.
a. Source of Funds: This agreement is being funded partially or in full through Cooperative Agreement
number, the full and complete terms and provisions of which are hereby incorporated into this
agreement can be found by reference. Federal funds to support this agreement are identified by the
Catalog of Federal Domestic Assistance (CFDA) number 93.778. The sub-awardee is responsible
for tracking and reporting the cumulative amount expended under HCA Contract No.K2747
b. Period of Availability of Funds: Pursuant to 45 CFR 92 .23, Sub-awardee may charge to the award
only costs resulting from obligations of the funding period specified, unless carryover of unobligated
balances is permitted, in which case the carryover balances may be charged for costs resulting from
obligations of the subsequent funding period. All obligations incurred under the award must be
liquidated no later than 90 days after the end of the funding period.
c. Single Audit Act: A sub-awardee (including private, for-profit hospitals and non-profit institutions)
shall adhere to the federal Office of Management and Budget (0MB) Super Circular 2 CFR 200.501
and 45 CFR 75.501. A sub-awardee who expends $750,000 or more in federal awards during a
given fiscal year shall have a single or program-specific'audit for that year in accordance with the
provisions of 0MB Super Circular 2 CFR 200.501 and 45 CFR 75.501 .
d. Modifications: This agreement may not be modified or amended, nor may any term or provision be
waived or discharged, including this particular Paragraph, except in writing, signed upon by both
parties.
1. Examples of items requiring Health Care Authority prior written approval include, but are not
limited to, the following:
i. Deviations from the budget and Project plan.
ii. Change in scope or objective of the agreement.
iii. Change in a key person specified in the agreement.
iv. The absence for more than three months or a 25% reduction in time by the Project
Manager/Director.
v. Need for additional funding.
vi. Inclusion of costs that require prior approvals as outlined in the appropriate cost principles.
vii. Any changes in budget line item(s) of greater than twenty percent (20%) of the total
budget in this agreement.
2. No changes are to be implemented by the Sub-awardee until a written notice of approval is
received from the Health Care Authority.
e. Sub-Contracting: The sub-awardee shall not enter into a sub-contract for any of the work performed
under this agreement without obtaining the prior written approval of the Health Care Authority. If
sub-contractors are approved by the Health Care Authority, the subcontract, shall contain, at a
minimum, sections of the agreement pertaining to Debarred and Suspended Vendors, Lobbying
certification, Audit requirements, and/or any other project Federal, state, and local requirements.
f. Condition for Receipt of Health Care Authority Funds: Funds provided by Health Care Authority to
the sub-awardee under this agreement may not be used by the sub-awardee as a match or cost-
sharing provision to secure other federal monies without prior written approval by the Health Care
Authority.
Washington State
Health Care Authority Page 31 of 53 Contract# 2747
g. Unallowable Costs: The sub-awardees' expenditures shall be subject to reduction for amounts
included in any invoice or prior payment made which determined by HCA not to constitute allowable
costs on the basis of audits, reviews, or monitoring of this agreement.
h. Citizenship/Alien Verification/Determination: The Personal Responsibility and Work Opportunity
Reconciliation Act (PRWORA) of 1996 (PL 104-193) states that federal public benefits should be
made available only to U.S. citizens and qualified aliens . Entities that offer a service defined as a
"federal public benefit" must make a citizensh ip/qualified al ien determination/ verification of
applicants at the time of application as part of the eligibility criteria. Non-US cit izens and unqualified
aliens are not eligible to receive the services. PL 104-193 also includes specific reporting
requirements.
i. Federal Compliance: The sub-awardee shall comply with all applicable State and Federal statutes,
laws, rules, and regulations in the performance of this agreement, whether included specifically in
this agreement or not.
). Civil Rights and Non-Discrimination Obligations During the performance of this agreement, the
Contractor shall comply with all current and future federal statutes relating to nondiscrimination .
These include but are not limited to: Title VI of the Civil Rights Act of 1964 (PL 88 -352), Title IX of
the Education Amendments of 1972 (20 U.S.C . §§ 1681 -1683 and 1685-1686), section 504 of the
Rehabilitation Act of 1973 (29 U.S.C. § 794), the Age Discrimination Act of 1975 (42 U.S.C. §§ 6101-
6107), the Drug Abuse Office and Treatment Act of 1972 (PL 92-255), the Comprehensive Alcohol
Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL 91-616), §§523 and
527 of the Public Health Service Act of 1912 (42 U.S .C. §§290dd-3 and 290ee-3), Title VIII of the
Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), and the Americans with Disability Act (42
U.S.C., Section 12101 et seq.) http://www.hhs.gov/ocr/civil riqhls
HCA Federal Compliance Contact Information
Federal Grants and Budget Specialist
Health Care Policy
Washington State Health Care Authority
Post Office Box 42710
Olympia, Washington 98504-2710
I. CIRCULARS 'COMPLIANCE MATRIX' -The following compliance matrix identifies the 0MB Circulars
that contain the requirements which govern expenditure of federal funds. These requirements apply to
the Washington State Health Care Authority (HCA), as the primary recipient of federal funds and then
follow the funds to the sub-awardee, x. The federal Circulars which provide the applicable administrative
requirements, cost principles and audit requirements are identified by sub-awardee organization type.
II.
OM B CIRCULAR
ENTITY TYPE ADMINISTRATIVE I COST I AUDIT REQUIREMENTS
REQUIREMENTS PRINCIPLES
State. Local and Indian Tribal 0MB Super Circular 2 CFR 200.501 and 45 CFR 75 .501
Governments and
Governmental Hosoitals
Non-Profit Organizations and
Non-Profit Hospitals
Colleges or Universities and
Affiliated Hosoitals
For-Profit Oraan izations
Definitions:
"Sub -recipient"; means the legal entity to which a sub -award is made and which is accountable to the State tor the
use of the funds provided in carrying out a portion of the State's programmatic effort under a sponsored project. The
term may include institutions of higher education, tor-profit corporations or non-U .S. Based entities.
Washington State
Health Care Authority Page 32 of 53 Contract# 2747
"Sub-award and Sub-granf' are used interchangeably and mean a lower tier award of financial support from a prime awardee
(e.g., Washington State Health Care Authority) to a Sub-recipient for the performance of a substantive portion of the
program. These requirements do not apply to the procurement of goods and services for the benefit of the Washington
State Health Care Authority .
IV. STANDARD FEDERAL CERTIFICATIONS AND ASSURANCES • Following are the Assurances,
Certifications, and Special Conditions that apply to all federally funded (in whole or in part) agreements
administered by the Washington State Health Care Authority.
CERTIFICATIONS
1. CERTIFICATION REGARDING
DEBARMENT AND SUSPENSION
The undersigned (authorized official signing for the
contracting organization) certifies to the best of his
or her knowledge and belief, that the contractor,
defined as the primary participant in accordance
with 45 CFR Part 76 , and its principals:
a) are not presently debarred, suspended,
proposed for debarment, declared ineligible, or
voluntarily excluded from covered transactions
by any Federal Department or agency;
b) have not within a 3-year period preceding this
contract been convicted of or had a civil
judgment rendered against them for
commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain ,
or performing a public (Federal, State , or local)
transaction or contract under a public
transaction; violation of Federal or State
antitrust statutes or commIssIon of
embezzlement, theft, forgery, bribery ,
falsification or destruction of records, making
false statements, or receiving stolen property;
c) are not presently indicted or otherwise
criminally or civilly charged by a governmental
entity (Federal, State, or local) with commission
of any of the offenses enumerated in paragraph
(b) of this certification; and
d) have not within a 3-year period preceding this
contract had one or more public transactions
(Federal, State, or local) terminated for cause
or default.
Should the contractor not be able to provide this
certification, an explanation as to why should be
placed after the assurances page in the contract.
The contractor agrees by signing this contract that
it will include, without modification, the clause titled
"Certification Regarding Debarment, Suspension ,
In eligibility, and Voluntary Exclusion--Lower Tier
Covered Transactions" in all lower tier covered
transactions (i.e., transactions with sub-grantees
and/or contractors) and in all solicitations for lower
tier covered transactions in accordance with 45
CFR Part 76.
2 . CERTIFICATION REGARDING DRUG-FREE
WORKPLACE REQUIREMENTS
The undersigned (authorized official signing for the
contracting organization) certifies that the
contractor will, or will continue to, provide a drug-
free workplace in accordance with 45 CFR Part 76
by:
a) Publishing a statement notifying employees
that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled
substance is prohibited in the grantee's
workplace and specifying the actions that will
be taken against employees for violation of
such prohibition;
b) Establishing an ongoing drug-free awareness
program to inform employees about
(1) The dangers of drug abuse in the
workplace;
(2) The contractor's policy of maintaining a
drug-free workplace;
(3) Any available drug counseling,
rehabilitation, and employee assistance
programs; and
(4) The penalties that may be imposed upon
employees for drug abuse violations
occurring in the workplace;
c) Making it a requirement that each employee to
be engaged in the performance of the contract
be given a copy of the statement required by
paragraph (a) above;
d) Notifying the employee in the statement
required by paragraph (a), above, that, as a
condition of employment under the contract,
the employee will-
Washington State
Health Care Authority Page 33 of 53 Contract# 2747
(1) Abide by the terms of the statement; and
(2) Notify the employer in writing of his or her
conviction for a violation of a criminal drug
statute occurring in the workplace no later than
five calendar days after such conviction;
e) Notifying the agency in writing within ten
calendar days after receiving notice under
paragraph (d)(2) from an employee or
otherwise receiving actual notice of such
conviction. Employers of convicted employees
must provide notice, including position title, to
every contract officer or other designee on
whose contract activity the convicted employee
was working, unless the Federal agency has
designated a central point for the receipt of
such notices. Notice shall include the
identification number(s) of each affected grant;
f} Taking one of the following actions , within 30
calendar days of receiving notice under
paragraph (d) (2), with respect to any employee
who is so convicted-
( 1) Taking appropriate personnel action
against such an employee, up to and
including termination, consistent with
the requirements of the Rehabilitation
Act of 1973, as amended; or
(2) Requiring such employee to participate
satisfactorily in a drug abuse
assistance or rehabilitation program
approved for such purposes by a
Federal, State, or local health, law
enforcement, or other appropriate
agency ;
g) Making a good faith effort to continue to
maintain a drug-free workplace through
implementation of paragraphs (a), (b), (c), (d),
( e ), and (f).
For purposes of paragraph (e) regarding agency
notification of criminal drug convictions, Authority
has designated the following central point for
receipt of such notices :
Legal Services Manager
WA State Health Care Authority
PO Box 42700
Olympia, WA 98504-2700
3 . CERTIFICATION REGARDING LOBBYING
Washington State
Health Care Authority Page 34 of 53
Title 31, United States Code , Section 1352, entitled
"Limitation on use of appropriated funds to
influence certain Federal contracting and financial
transactions," generally prohibits recipients of
Federal grants and cooperative agreements from
using Federal (appropriated) funds for lobbying the
Executive or Legislative Branches of the Federal
Government in connection with a SPECIFIC grant
or cooperative agreement. Section 1352 also
requires that each person who requests or receives
a Federal grant or cooperative agreement must
disclose lobbying undertaken with non-Federal
(nonappropriated) funds . These requirements
apply to grants and cooperative agreements
EXCEEDING $100,000 in total costs (45 CFR Part
93).
The undersigned (authorized official signing for the
contracting organization) cert ifies, to the best of his
or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid
or will be paid, by or on behalf of the
undersigned, to any person for influencing or
attempting to influence an officer or employee
of any agency, a Member of Congress, an
officer or employee of Congress, or an
employee of a Member of Congress in
connection with the awarding of any Federal
contract, the making of any Federal grant, the
making of any Federal loan, the entering into
of any cooperative agreement, and the
extension, continuation, renewal, amendment,
or modification of any Federal contract, grant,
loan, or cooperative agreement.
(2) If any funds other than Federally appropriated
funds have been paid or will be paid to any
person for influencing or attempting to
influence an officer or employee of any
agency, a Member of Congress, an officer or
employee of Congress , or an employee of a
Member of Congress in connection with this
Federal contract , grant , loan, or cooperative
agreement, the undersigned shall complete
and submit Standard Form-LLL, "Disclosure of
Lobbying Activities ," in accordance with its
instructions. (If needed , Standard Form-LLL,
"Disclosure of Lobbying Activities," its
instructions, and continuation sheet are
included at the end of this application form .)
(3) The undersigned shall require that the
language of this certification be included in the
Contract# 2747
award documents for all subcontracts at all tiers
(including subcontracts, subcontracts, and
contracts under grants, loans and cooperative
agreements) and that all sub-recipients shall
certify and disclose accordingly.
This certification is a material representation of fact
upon which reliance was placed when this
transaction was made or entered into. Submission of
this certification is a prerequisite for making or
entering into this transaction imposed by Section
1352, U.S. Code. Any person who fails to file the
required certification shall be subject to a civil penalty
of not less than $10,000 and not more than $100,000
for each such failure.
4. CERTIFICATION REGARDING PROGRAM
FRAUD CIVIL REMEDIES ACT (PFCRA)
The undersigned (authorized official signing for the
contracting organization) certifies that the
statements herein are true, complete, and accurate
to the best of his or her knowledge, and that he or
she is aware that any false, fictitious, or fraudulent
statements or claims may subject him or her to
criminal, civil, or administrative penalties. The
undersigned agrees that the contracting
organization will comply with the Public Health
Service terms and conditions of award if a contract
is awarded .
5. CERTIFICATION REGARDING
ENVIRONMENT AL TOBACCO SMOKE
Public Law 103-227, also known as the Pro-
Children Act of 1994 (Act), requires that smoking
not be permitted in any portion of any indoor facility
owned or leased or contracted for by an entity and
used routinely or regularly for the provision of
health, day care, early childhood development
services, education or library services to children
under the age of 18, if the services are funded by
Federal programs either directly or through State or
local governments, by Federal grant , contract, loan,
or loan guarantee. The law also applies to
children's services that are provided in indoor
facilities that are constructed, operated, or
maintained with such Federal funds. The law does
not apply to children's services provided in private
residence, portions of facilities used for inpatient
drug or alcohol treatment, service providers whose
sole source of applicable Federal funds is Medicare
or Medicaid, or facilities where WIC coupons are
redeemed.
Washington State
Health Care Authority Page 35 of 53
Failure to comply with the provisions of the law
may result in the imposition of a civil monetary
penalty of up to $1,000 for each violation and/or
the imposition of an administrative compliance
order on the responsible entity.
By signing the certification, the undersigned
certifies that the contracting organization will
comply with the requirements of the Act and will not
allow smoking within any portion of any indoor
facility used for the provision of services for children
as defined by the Act.
The contracting organization agrees that it will
require that the language of this certification be
included in any subcontracts which contain
provisions for children's services and that all sub-
recipients shall certify accordingly.
The Public Health Services strongly
encourages all recipients to provide a smoke-
free workplace and promote the non-use of
tobacco products. This is consistent with the
PHS mission to protect and advance the
physical and mental health of the American
people.
6 . CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS
INSTRUCTIONS FOR CERTIFICATION
1) By signing and submitting this proposal, the
prospective contractor is providing the
certification set out below.
2) The inability of a person to provide the
certification required below will not necessarily
result in denial of participation in this covered
transaction. The prospective contractor shall
submit an explanation of why it cannot provide
the certification set out below. The certification
or explanation will be considered in connection
with the department or agency's determination
whether to enter into this transaction. However,
failure of the prospective contractor to furnish a
certification or an explanation shall disqualify
such person from participation in this
transaction.
3) The certification in this clause is a material
representation of fact upon which reliance was
placed when the department or agency
determined to enter into this transaction. If it is
later determined that the prospective contractor
knowingly rendered an erroneous certification,
in addition to other remedies available to the
Contract# 2747
Federal Government, the department or
agency may terminate this transaction for
cause of default.
4) The prospective contractor shall provide
immediate written notice to the department or
agency to whom this contract is submitted if at
any time the prospective contractor learns that
its certification was erroneous when submitted
or has become erroneous by reason of
changed circumstances.
5) The terms covered transaction, debarred,
suspended, ineligible, lower tier covered
transaction, participant, person, primary
covered transaction, principal, proposal, and
voluntarily excluded, as used in this clause,
have the meanings set out in the Definitions
and Coverage sections of the rules
implementing Executive Order 12549. You may
contact the person to whom this contract is
submitted for assistance in obtaining a copy of
those regulations.
6) The prospective contractor agrees by
submitting this contract that, should the
proposed covered transaction be entered into,
it shall not knowingly enter into any lower tier
covered transact ion with a person who is
debarred, suspended , declared ineligible, or
voluntarily excluded from participation in this
covered transact ion , unless authorized by
Authority.
7) The prospective contractor further agrees by
submitting this contract that it will include the
clause titled "Certification Regarding
Debarment, Suspension, Ineligibility and
Voluntary Exclusion --Lower Tier Covered
Transaction," provided by HHS, without
modification, in all lower tier covered
transactions and in all solicitations for lower tier
covered transactions.
8) A participant in a covered transaction may rely
upon a certification of a prospective participant
in a lower tier covered transaction that it is not
debarred, suspended, ineligible, or voluntarily
excluded from the covered transaction, unless
it knows that the certification is erroneous. A
participant may decide the method and
frequency by which it determines the eligibility
of its principals. Each participant may, but is not
required to, check the Non-procurement List (of
excluded parties).
9) Nothing contained in the foregoing shall be
construed to require establishment of a system
of records in order to render in good faith the
certification required by this clause . The
Washington State
Health Care Authority Page 36 of 53
knowledge and information of a participant is
not required to exceed that which is normally
possessed by a prudent person in the ordinary
course of business dealings.
10) Except for transactions authorized under
paragraph 6 of these instructions, if a
participant in a covered transaction knowingly
enters into a lower tier covered transaction with
a person who is suspended, debarred,
ineligible, or voluntarily excluded from
participation in this transaction, in addition to
other remedies available to the Federal
Government, Authority may terminate this
transaction for cause or default.
7. CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS •· PRIMARY
COVERED TRANSACTIONS
1) The prospective contractor certifies to the best
of its knowledge and bel ief, that it and its
principals:
a) Are not presently debarred, suspended,
proposed for debarment, declared
ineligible, or voluntarily excluded from
covered transactions by any Federal
department or agency;
b) Have not within a three-year period preceding
this contract been convicted of or had a civil
judgment rendered against them for
commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain,
or performing a public (Federal, State or local)
transaction or contract under a public
transaction; violation of Federal or State
antitrust statutes or commIssIon of
embezzlement, theft , forgery, bribery,
falsification or destruction of records, making
false statements, or receiving stolen property;
c) Are not presently indicted for or otherwise
criminally or civilly charged by a
governmental entity (Federal, State or
local) with commission of any of the
offenses enumerated in paragraph (1 )(b) of
this certification ; and
d) Have not within a three-year period
preceding this contract had one or more
public transactions (Federal, State or local)
terminated for cause or default.
2) Where the prospective contractor is unable to
certify to any of the statements in this certification ,
such prospective contractor shall attach an
explanation to this proposal.
Contract# 2747
CONTRACTOR SIGNATURE REQUIRED
SI GNAT URE OF AUTHORIZED
C F . NG OFFICIAL
ORGANIZATION NAME: (If applicable)
Kittitas County Health
Washington State
Health Care Authority
TITLE
Administrator
Robin Read
DATE
June 9, 2018
Page37of53 Contract# 2747
Attachment 2 Federal Funding Accountability and Transparency Act (FFATA) Data Collection Form
This Contract is supported by federal funds that require compliance with the Federal Funding Accountability and
Transparency Act (FFATA or the Transparency Act). The purpose of the Transparency Act is to make information
available online so the public can see how federal funds are spent.
To comply with the act and be eligible to enter into this contract, your organization must have a Data Universal
Numbering System (DUNS®) number. A DUNS® number provides a method to verify data about your
organization. If you do not already have one, you may receive a DUNS® number free of charge by contacting
Dun and Bradstreet at www.dnb.com .
Required Information about your organization and this contract will be made available on USASpending.gov by
the Washington State Health Care Authority (HCA) as required by P.L. 109-282. As a tool to provide the
information, HCA encourages registration with the Central Contractor Registry (CCR) because less data entry
and re-entry Is required by both HCA and your organization. You may register with CCR on-line at
111 s:l/www.u onu-ac torr ls tralio1 1.corn/.
Contractor must complete this form and return it to the Health Care Authority (HCA).
CONTRACTOR
1. Legal Name 2. DUN S Number
Kittitas Count y Health J:?e p artment tJ /~ O 2-0 · 25Gf '"i-
3. Principle Place of Performance
3a. City 3b. State
Ellensburq WA
3c. Zip+4 3d. Country
98926 Kittitas
4. Are you ~lslered in CCR (htlos:l/www .uscon trac torreoislratlon.com l )? LJYES (skip to page 2. Sign, date and
return) NO
5. In the preceding fiscal year did your organization:
a. Receive 80% or more of annual gross revenue from federal contracts, subcontracts, grants, loans, subgrants,
and/or cooperative agreements; and
b. $25,000,000 or more in annual gross revenues from federal contracts, subcontracts, grants, loans,
subgrants, and/or cooperative agreements; and
c. The public does not have access to information about the compensation of the executives through periodic
reports filled with the IRS or the Security and Exchange Commission per 2 CFR Part 170.330
"g NO (skip the remainder of this section -Sign, date and return)
D YES (You must report the names and total compensation of the top 5 highly compensated officials of your
organization).
Name Of Official Total Compensation
1.
2.
3.
4.
5.
Note: "Total compensation" means the cash and noncash dollar value earned by the executive during the
sub-recipient's past fiscal vear of the followina (for more information see 17 CFR 229.402 (c)(2)) .
.Washington State
Health Care Authority Page38 of 53 Contract# 2747
Schedule A:
Statement of Work (SOW)
The Contractor shall provide the services and staff, and otherwise do all things necessary for or
incidental to the performance of work, as set forth below:
A. In accordance with deadlines in Exhibit A, ABCD Quarterly Outreach and Case
Management Report, develop and implement an ABCD action plan in accordance with
the ABCD program principles and submit corresponding budget, using Exhibit C, ABCD
Yearly Budget Tool. The ABCD program principles are outlined below.
1. Provide outreach and recruitment of Apple Health/Medicaid-eligible Clients, ages birth
to six (6), in collaboration with other organizations, including, but not limited to:
a) Contact no less than ten (10%} of Client list provided by HCA to the Contractor;
i. HCA shall provide the Contractor's contact name identified on page 1, a list
that shall include the following data elements: Client ID, Name, Address,
and Telephone Number of Clients who have not gone to the dentist, as well
the Client's caregiver name and preferred spoken language. HCA shall
securely transmit Client information and the Contractor shall be responsible
for notifying the Dental Program Manager within five (5) business days prior
to the beginning of the quarter if they have not received this information.
b) Provide outreach by attending, visiting or working with the below, but not limited to
the following:
i. County Health Fairs;
ii. SmileMobile locations (a mobile clinic serving dental needs to children
by the Washington Dental Service Foundation);
iii. Women, Infants, and Children WIC offices (a federal assistance
program of the Food and Nutrition Services of the United States
Department of Agriculture;
iv. Head Start facilities (a federal program that promotes the school
readiness of children under five from low-income families);
v. Early Learning Regional Coalitions (that are a not-for-profit alliance of
employers and community subsidized before and after school child
care); and
vi. Day Care facilities throughout the state of Washington.
c) Provide care coordination, including:
Washington State
Health Care Authority
i. Provide family orientation; including but not limited to, sharing information
about the value of a child going to the dentist, what activities will occur in the
dentist's office;
Page 39 of 53 Contract# 2747
ii. Connect families with an ABCD certified dentist who accepts Apple
Health/Medicaid, and providing information including, but not limited to,
names and referrals to dentists, sharing information about interpreters and
transportation benefits, and following up after an appointment, if appropriate;
iii. Assisting in scheduling dental appointments for eligible children and council
on the importance of keeping the appointment; and
iv . Identify and address family barriers to accessing oral health care.
2. Convene Health Coalition/ABCD Steering Committee or participate in a Coalition or
Steering Committee focused on health care, access or early learning with ABCD semi-
annually.
a) Invite the ABCD program manager with ARCORA Foundation and the Health
Care Authority Dental program administrator.
3. Coordinate with the local ABCD Dental Champions to :
a) Identify and recruit dental providers who will take Apple Health/Medicaid Clients
through the ABCD Program;
b) Maintain a list of active ABCD providers who accept Apple Health/Medicaid
Clients birth to six (6) years and monitor provider availability to accept new
Clients birth to six (6) years into their practice;
c) Support current ABCD providers by communicating program changes and policy
updates through in-person meetings and written communication;
d) Provide or assist in providing new ABCD provider trainings to providers as
needed;
e) Assure certification process is completed;
f) Provide Apple Health/Medicaid billing training assistance to ABCD offices/or
providers or arrange for billing assistance;
g) Update dental society ( or local dentists/study clubs in counties without a society)
on the ABCD Program and encourage their continued recruitment of new Apple
Health/Medicaid providers; and
h) Support the Dental Champion(s) participation in meetings and activities
necessary to effectively conduct Apple Health/Medicaid provider outreach,
recruitment and training, including financial support of attendance in development
day.
4. Identify and recruit primary care medical providers to participate in Apple
Health/Medicaid, secure their training in preventive oral health techniques and build
their role in referring Apple Health/Medicaid-eligible children to the ABCD Program.
This may include oral health education, fluoride treatments, etc.
Washington State
Health Care Authority Page 40 of 53 Contract# 2747
5. Participate in all three (3) statewide ABCD Coordinators group meetings to remain
current with ABCD policies, practices and opportunities.
6. Participate in statewide ABCD Champion Development Day meeting to remain current
with any new clinical practices and opportunities. As well as meeting and networking
with other champions to discuss roadblocks and program success stories.
7 . Identify an ABCD Coordinator within the contracting organization who will develop and
maintain a desk manual that outlines the expected ABCD contractual deliverables and
how the contractor meets each deliverable. The Coordinator will utilize this manual to
fulfill the contractual requirements.
If the Contractor's Coordinator leaves, the contractor is responsible to notify the Health
Care Authority within two weeks, of the coordinators departure or as soon as possible
and share the Contractor's developed work plan that outlines how the expected
contract deliverables will be met. The Contractor will share with HCA the contact
information of the newly hired or appointed Coordinator and coordinate with HCA to
assure a smooth transition of the expected contracted work deliverables.
8. Each quarter complete and submit the following via email:
1) Community Outreach and Coordination Care summary which shall include;
a) Exhibit A, ABCD Quarterly Outreach and Case Management Report for the
specific quarter; and
b) Exhibit B, ABCD Quarterly Outreach and Coordination of Care Report.
2) Each year complete and submit via email the Exhibit C, ABCD Yearly Budget Tool, as
applicable to the requirements, contained in Exhibit A.
3) A fully completed invoice that correlates with dollar values for completed deliverables
outlined in Exhibit A:
a) Exhibit templates are available on the ABCD website http://abcd-dental.org/for-
coordinators/: and
b) Reports and billing must be submitted no later than one month after each quarter
end date, unless otherwise mutually agreed by both parties.
Washington State
Health Care Authority Page 41 of 53 Contract# 2747
Exhibit A ABCD Quarterly Outreach & Case Management Report
Year One 2018 -2019 • 1st Quarter Report
Please complete and submit report electronically to:
Janice Tadeo, Dental Program Administrator
Division of Health Care Services, Washington State Health Care Authority
PO Box 45506, Olympia, WA 98504-5506
Phone: (360) 725-1583 Email: Ja nice .T a d eo@ H C A .W A .G OV
Organization: Kittitas County Public Health Network
ABCD Contact Person: Kasey Knutson
Phone: 509-962-7029 kasey. knutson(@co. kittitas. wa. us
1st
Quarter
Report Due: 10/31/18 7/1/18-
9/30/18
Performance Category Yes/No
Allocate staff and review contract to plan and
create the vear 1 action plan.
Community and Provider Outreach
Coordinate Care
Convene Health Coalition/ABCD Steering
committee or participate in a Coalition or
Steering Committee Focused on Health Care ,
Access or Early Learning with ABCD as a
Quarterly Agenda Item.
Washington State
Health Care Authority Page 42 of 53
Brief description (for events, provide date
Maximum held/attended/ for staff assignments, provide name
$$ available and title) -no more than 100 words (complete Exhibit
for this A and attach supporting document if providing
deliverable additional detail)
Include attached budget (Exhibit C) and copy of your
$470 plan.
$940 Complete Exhibit B
$465 Complete Exhibit B
Provide outcome information such as minutes, copies of
information provided or list of items provided, examples of
type of Organizations attended, what were outcomes or
next steps for ABCD .
*Send invitation and report back any concerns/issues to
HCA Dental Program Administrator & ABCD
$500 Administrator
Contract# 2747
I
Exhibit A ABCD Quarterly Outreach & Case Management Report
Year One 2018 -2019 • 2nd Quarter Report
Please complete and submit report electronically to:
Janice Tadeo, Dental Program Administrator
Division of Health Care Services, Washington State Health Care Authority
PO Box 45506, Olympia, WA 98504-5506
Phone: (360) 725-1583 Email: Janice.Tadeo@HCA.WA.GOV
Organization : Kittitas Countv Public Health Network
ABCD Contact Person: Kasev Knutson
Phone: 509-962-7029 kasev. knutson®co. kittitas. wa. us
2nd
Quarter
Report Due: 01/30/19 10/1/18-
12/31/18
Performance Cateaorv Yes/No
Attend and participate in ABCD
Coordinator/Program Meeting
Community and Provider Outreach
Coordinate Care
Convene Health Coalition/ABCD Steering
committee or participate in ·a Coalition or
Steering Committee Focused on Health Care,
Access or Early Learning with ABCD as a
Quarterly Agenda Item.
Washington Stale
Health Care Authority Page 43 of 53
Brief description (for events, provide date
Maximum held/attended/ for staff assignments, provide name
$$ available and title) -no more than 100 words (complete Exhibit
for this A and attach supporting document if providing
deliverable additional detail)
$450
$500 Complete Exhibit B
$960 Complete Exhibit B
Provide outcome information such as minutes, copies of
information provided or list of items provided, examples of
type of Organizations attended, what were outcomes or
next steps for ABCD.
*Send invitation and report back any concerns/issues to
HCA Dental Program Administrator & ABCD
$465 Administrator
Contract# 2747
Exhibit A ABCD Quarterly Outreach & Case Management Report
Year One 2018 -2019 • 3rd Quarter Report
Please complete and submit report electronically to:
Janice Tadeo, Dental Program Administrator
Division of Health Care Services, Washington State Health Care Authority
PO Box 45506 , Olympia, WA 98504-5506
Phone: (360) 725-1583 Email : Janice.Tadeo@HCA.WA.GOV
Organization : Kittitas County Public Health Network
ABCD Contact Person: Kasey Knutson
Phone : 509-962-7029 kasey.knutson@co .kittitas.wa.us
3rd
Quarter
Report Due: 04/30/19 1/1/19-
3/31/19
Performance Category Yes/No
Attend and participate in ABCD
Coordinator/Program Meeting
Community and Provider Outreach
Coordinate Care
Convene Health Coalition/ABCD Steering
committee or participate in a Coalition or
Steering Committee Focused on Health Care,
Access or Early Learning with ABCD as a
Quarterly Agenda Item.
Washington State
Health Care Authority Page 44 of 53
Brief description (for events, provide date
Maximum held/attended/ for staff assignments, provide name
$$ available and title) -no more than 100 words (complete Exhibit
for this A and attach supporting document if providing
deliverable additional detail)
$500
$910 Complete Exhibit B
$465 Complete Exhibit B
Provide outcome information such as minutes, copies of
information provided or list of items provided, examples of
type of Organizations attended, what were outcomes or
next steps for ABCD.
*Send invitation and report back any concerns/issues to
HCA Dental Program Administrator & ABCD
$500 Administrator
Contract# 2747
Exhibit A ABCD Quarterly Outreach & Case Management Report
Year One 2018 -2019 • 4th Quarter Report
Please complete and submit report electronically to:
Janice Tadeo, Dental Program Administrator
Division of Health Care Services, Washington State Health Care Authority
PO Box 45506 , Olympia , WA 98504-5506
Phone: (360) 725-1583 Email: Janice.Tadeo@HCAWA.GOV
Organization : Kittitas County Public Health Network
ABCD Contact Person :
Phone :
Report Due: 07/31/2019
Performance Category
Contact at least 10% of client list
Attend and participate in ABCD
Coordinator/Program Meeting
Community and Provider Outreach
Coordinate Care
Washington State
Health Care Authority
Kasey Knutson
509-962-7029 kasey. knutsonc'@co . kittitas . wa. us
4th
Quarter
4/1/19-
6/30/19
Brief description (for events, provide date
Maximum held/attended/ for staff assignments, provide name
$$ available and title) -no more than 100 words (complete Exhibit
for this A and attach supporting document if providing
Yes/No deliverable additional detail)
$450 Complete Exhibit B
$500
$960 Complete Exhibit B
$465 Complete Exhibit B
Page 45 of 53 Contract# 2747
Exhibit A ABCD Quarterly Outreach & Case Management Report
Year Two 2019 -2020 • 1st Quarter Report
Please complete and submit report electronically to:
Janice Tadeo , Dental Program Administrator
Division of Health Care Services, Washington State Health Care Authority
PO Box 45506 , Olympia , WA 98504-5506
Phone: (360) 725-1583 Email: Janice.Tadeo@ HCA.WA.GOV
Organization : Kittitas County Public Health Network
ABCD Contact Person: Kasey Knutson
Phone : 509-962-7029 kasey. knutson<@co . kittitas . wa. us
1st
Quarter
Report Due: 10/31/19 7/1/19-
9/30/19
Performance Category Yes/No
Allocate staff and review contract to plan and
create the vear 2 action plan.
Community and Provider Outreach
Coordinate Care
Convene Health Coalition/ABCD Steering
committee or participate in a Coalition or
Steering Committee Focused on Health Care,
Access or Early Learning with ABCD as a
Quarterly Agenda Item.
Washington Stale
Health Care Authority Page 46 of 53
Brief description (for events, provide date
Maximum held/attended/ for staff assignments, provide name
$$ available and title) -no more than 100 words (complete Exhibit
for this A and attach supporting document if providing
deliverable additional detail)
Include attached budget (Exhibit C) and copy of your
$470 plan.
$940 Complete Exhibit B
$465 Complete Exhibit B
Provide outcome information such as minutes , copies of
information provided or list of items provided , examples of
type of Organizations attended, what were outcomes or
next steps for ABCD.
*Send invitation and report back any concerns/issues to
HCA Dental Program Administrator & ABCD
$500 Administrator
Contract # 27 4 7
Exhibit A ABCD Quarterly Outreach & Case Management Report
Year Two 2019 -2020 • 2 nd Quarter Report
Please complete and submit report electronically to:
Janice Tadeo, Dental Program Administrator
Division of Health Care Services, Washington State Health Care Authority
PO Box 45506, Olympia, WA 98504-5506
Phone: (360) 725-1583 Email: Jan!ce.Tadeo@HCAWAGOV
Oroanization : Kittitas County Public Health Network
ABCD Contact Person :
Phone:
Report Due: 01/31/2020
Performance Category
Contact at least 10% of client list
Attend and participate in ABCD
Coordinator/Program Meeting
Community and Provider Outreach
Coordinate Care
Washington State
Health Care Authority
Kasey Knutson
509-962-7029 kasey.knutson@co.kittitas.wa.us
2nd
Quarter
10/1/19-
12/31/19
Brief description (for events, provide date
Maximum held/attended/ for staff assignments, provide name
$$ available and title) -no more than 100 words (complete Exhibit
for this A and attach supporting document if providing
Yes/No deliverable additional detail)
$450 Complete Exhibit B
$500
$960 Complete Exhibit B
$465 Complete Exhibit B
Page 47 of 53 Contract# 2747
Exhibit A ABCD Quarterly Outreach & Case Management Report
Year Two 2019 -2020 • 3rd Quarter Report
Please complete and submit report electronically to:
Janice Tadeo, Dental Program Administrator
Division of Health Care Services, Washington State Health Care Authority
PO Box 45506, Olympia, WA 98504-5506
Phone: (360) 725-1583 Email: Janice.Tadeo@HCAWAGOV
Oroanization : Kittitas County Public Health Network
ABCD Contact Person : Kasey Knutson
Phone: 509-962-7029 kasey.knutsoncafco.kittitas.wa.us
3rd
Quarter
Report Due: 04/30/20 1/1/20-
3/31/20
Brief description (for events, provide date
Maximum held/attended/ for staff assignments, provide name
$$ available and title) -no more than 100 words (complete Exhibit
for this A and attach supporting document if providing
Performance Category Yes/No deliverable additional detail)
Attend and participate in ABCD
Coordinator/Prooram Meetino $500
Community and Provider Outreach $910 Comolete Exhibit B
Coordinate Care $465 Complete Exhibit B
Provide outcome information such as minutes, copies of
Convene Health Coalition/ABCD Steering information provided or list of items provided, examples of
committee or participate in a Coalition or type of Organizations attended, what were outcomes or
Steering Committee Focused on Health Care, next steps for ABCD.
Access or Early Learning with ABCD as a *Send invitation and report back any concerns/issues to
Quarterly Agenda Item. HCA Dental Program Administrator & ABCD
$500 Administrator
Washington State
Health Care Authority Page 48 of 53 Contract# 2747
Exhibit A ABCD Quarterly Outreach & Case Management Report
Year Two 2019 -2020 • 4th Quarter Report
Please complete and submit report electronically to:
Janice Tadeo, Dental Program Administrator
Division of Health Care Services, Washington State Health Care Authority
PO Box 45506, Olympia, WA 98504-5506
Phone: (360) 725-1583 Email: Janice.Tadeo@HCA.WAGOV
O rg anization : Kittitas Countv Public Health Network
ABCD Contact Person :
Phone:
Report Due: 07/31/2020
Performance Category
Contact at least 1 0% of client list
Attend and participate in ABCD
Coordinator/Program Meeting
Community and Provider Outreach
Coordinate Care
Washington State
Health Care Authority
Kasey Knutson
509-962-7029 kasey.knutson@co.kittitas.wa.us
4th
Quarter
4/1/20-
6/30/20
Brief description (for events, provide date
Maximum held/attended/ for staff assignments, provide name
$$ available and title} -no more than 100 words (complete Exhibit
for this A and attach supporting document if providing
Yes/No deliverable additional detail)
$450 Complete Exhibit B
$500
$960 Complete Exhibit B
$465 Complete Exhibit B
Page 49 of 53 Contract# 2747
Exhibit B ABCD Quarterly Outreach and Coordination of Care Report
COORDINATE CARE
Family Orientation
How provided: in-person/phone/email/mail/etc.
I
Clients Contacted from List (10%)
How provided: in-person/phone/email/mail/etc.
Assisted Client w/lnitial Dental Appts.
& Provided Follow-Up
If applicable
Referrals To Dental Home
Barriers to Care Identified
interpreter services/transportation/etc.
Washington State
Health Care Authority Page 50 of 53
How
I
How Many
How
Many
How
Many
How
Many
How
Many
Contract# 2747
Location & Date
COMMUNITY OUTREACH
Type of Outreach/Place ~ I Date ·· "' How many reached ~
I Examples: County health fairs/coordination w/Smile Mobile/WIG offices/Headstart/Early Learning Centers/Day Cares .
WORK WITH CHAMPION/RECRUIT PROVIDERS
Activit}'
New Providers Certified
Provider Trainings Held
Provider Recruitment
Wai;hl,:191.0n State
Health Care Authority
How Many
How Many
How Many
Page 51 of 53
' Notes 11
Place and Date
Place and Date ,1
11
Contract# 2747
"
Exhibit C
EXPENSES
-
ABCD Yearly Budget Tool
2018-2020 Yearly Expenses (estimated)
Staffing/Salary & Benefits-add a column to identify % and hours per week for each year
Program Coordinator (x hrs/week = .X FTE}
Outreach Staff (x hrs/week= .X FTE)
Program Manager (x hrs/week = .X FTE)
Support Staff (clerical, IT, finance, communications/per staff, other x hrs/week= .X FTE )
Administration (x hrs/ week (.X FTE)
Salary & Benefits Subtotal
Operating Expenses
Advertising/Marketing (print, broadcast ads; cable TV time , movie ads, weekly newspaper,
billboards , social media)
Office Equipment (Copier, Fax)
Meeting Expenses (steering committee room , food, etc.)
Postaae
Printing (Outside Vendors)
Professional Services
Office Supplies
Ooeratina Supplies
Telephone
ABCD Certification Training/dentists and staff (room, audiovisuals , food, thank you to
participating families, promotion , etc .)
Washington State
Health Care Authority Page 52 of 53 Contract# 2747
Year One Year Two
July 1, 2018 July 1, 2019
to To
June 30, 2019 June 30._ 2020
Travel (Per Diem, Transportation, Mileage/airfare, accommodations as required) for 3x
annual ABCD Coordinators meeting -2 Seattle, 1 Central WA; and for 1x annual Dental
Cont.
Champion(s) travel/expenses to Development Day, Seattle (Coordinator participation in this
meetina ootio nal but recommended ),
Computer Support/Tech Services
RenUI nsu ranee/ Janitorial/Maintenance
Utilities
Operating Expenses Subtotal
Indirect Costs
TOTAL EXPENSES
FUNDING SOURCES
Other Funding (United Way, Grants, Community Development Block Grant, etc.)
Agency Funds and/or In-Kind
Current Health Care Authority Contract
Washington State
Health Care Authority
TOTAL FUNDING
Page 53 of 53 Contract# 2747
. i -
Year One Year Two
.
In-Kind$
Explain
Is Equipment being purchased? Who owns equipment?
New Personnel being hired? Contact HR hiring -reporting requirements
Future impacts or liability to Kittitas County:
Budget Information
Budget Amendment Needed? Yes D attach budget form No []I Why not-previously included in
New Division Created? budgeting process
Revenue Code Federal 116.612.24.1.333.93778 $9,500
State 116.612.24.1.334.06.901 $9,500
Pass Th rough Information
Agency to Pass Through
Amount to Pass Through $
Sub-Contract Approved Date :
Prosecutor Review ! Has the Prosecutor reviewed this agreement? I Yes • No D
County Departments Impacted
Auditor Facilities Maintenance
-
Information Services Human Resource
Prosecutor Treasurer
Submitted I Signature:
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
Kittitas County
Review Form
Grants & Contract Agreement
Today's Date
06/05/2018
Fund/Department
116-Public Health
Contract/Grant Information
Agenda Date
Contract /Grant Age ncy: Professional Services Contract for ABCD Dental Services
Period Begin Date: July 1, 2018 I j Period End Date: June 30, 2020
Total Grant/Contract Amount: $19,000.00
Grant/Contract Number: K2747
Contract/Grant Summary:
The Professional Services Contract for ABCD Dental Services is established to allow Kittitas County to
provide Access to Baby and Child Dentistry' (ABCD) services to detect and prevent early childhood dental
decay by engaging dentists in seeing birth to six year old Medicaid eligible children and engaging local
public health departments in outreach and case management.
Recommendation for Board of Health and Board of Health Review on
~-f\ .t ' .,
Department Head Signature:~7__7'::: , Administrator Date: lf, {a-QJ{l~
Signature of Prosecutor's Offi Date
---~~
Date
Signature of Board of Health member Date
Financial Information
Total Amount$ 19,000 State Funds $ 9,500 Federal Funds $ 9,500
Percentage County Funds Matching Funds$ CFDA# 93. 778
Grant/Contract Review Page 1