HomeMy WebLinkAboutDSHS Behavioral Health AgreementCOUNTY DSHS Agreement Number mi1t .,,.,.,,,. '""
Department of Social PROGRAM AGREEMENT 1863-28733
& Health Services
Transforming lives Prevention Services
This Program Agreement is by and between the State of Washington Administration or Division
Department of Social and Health Services (DSHS) and the County identified Agreement Number
below, and is issued in conjunction with a County and DSHS Agreement On TM010056 / SP020155
General Terms and Conditions, which is incorporated by reference. County Agreement Number
DSHS ADMINISTRATION DSHS DIVISION DSHS INDEX NUMBER DSHS CONTRACT CODE
Behavioral Health Division of Behavioral Health 1225 1644CS-63
Administration and Recovery
DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS
Sarah Mariani 4500 Tenth Ave SE
Program Administrator PO Box45330
Olympia. WA 98504-5330
DSHS CONTACT TELEPHONE I DSHS CONTACT FAX I DSHS CONTACT E-MAIL
(360)725-377 4 (360)725-2253 mariaseCWdshs.wa.gov
COUNTY NAME COUNTY ADDRESS
Kittitas County 507 North Nanum Street Suite 102
Kittitas County Health Department Ellensburq, WA 98926-2886
COUNTY FEDERAL EMPLOYER IDENTIFICATION COUNTY CONTACT NAME
NUMBER
Kasey Knutson
COUNTY CONTACT TELEPHONE I COUNTY CONTACT FAX I COUNTY CONTACT E-MAIL
(509) 962-7515 (509) 962-7581 kasey. knutson@co. kittitas. wa. us
IS THE COUNTY A SUBRECIPIENT FOR PURPOSES OF THIS PROGRAM CFDA NUMBERS
AGREEMENT?
93.959
Yes
.PROGRAM AGREEMENTSTARTOAlc I PROGRAM AGREEMENT END DATE MAXIMUM PROGRAM AGREEMENT AMOUNT
04/01/2018 06/30/2019 $158 ,037 .00
EXHIBITS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into this
County Program Agreement by reference:
!ZI Exhibits (specify): Exhibit A: Data Security; Exhibit B: Awards and Revenue; Exhibits C-K
0 No Exhibits.
The terms and conditions of this Contract are an integration and representation of the final, entire and exclusive
understanding between the parties superseding and merging all previous agreements, writings, and communications , oral
or otherwise, regarding the subject matter of this Contract. The parties signing below represent that they have read and
understand this Contract, and have the authority to execute this Contract. This Contract shall be binding on DSHS only
upon signature by DSHS .
COUNTY SIGNATURE(S) PRINTED NAME(S) AND illLE (S) DATE(S) SIGNED
<fflVVVV-fzD~r~ l(ijaJ_,, 1/JVl 1'6 ·-~tlwu 11Jl ~1vfbtlv
DSHS SIGNATURE PRINTED NAME AND TITLE DATE SIGNED r Sv01 _,~(~ 014/&~~ 1]~,l11 BHA Contracts
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DSHS Central Contract Services
1644CS Prevention Services -County (6-26-2015) Page 1
Federal Award Identification for Subrecipients (reference 2 CFR 200.331)
Substance Abuse Block Grant
(i) Subrecipient name (which must match the Kittitas County
name associated with its unique entity
identifier);
(ii) Subrecipient's unique entity identifier; (DUNS) 010202547
(iii) Federal Award Identification Number (FAIN); SM010056
(iv) Federal Award Date (see §200.39 Federal 04/17/2015
award date);
(v) Subaward Period of Performance Start and 4/1/18 to 6/30/19
End Date;
(vi) Amount of Federal Funds Obligated by this $89,101
action;
(vii) Total Amount of Federal Funds Obligated to $89,101
the subrecipient;
(xiii) Total Amount of the Federal Award; FY14 $37,271,989
FY15 $37,296,186
FY16 $38,042,110
(ix) Federal award project description, as required Substance Abuse Prevention and Treatment Block
to be responsive to the Federal Funding Grant
Accountability and Transparency Act (FFATA);
(x) Name of Federal awarding agency, pass-SAMHSA,
through entity, and contact information for Washington State DSHS,
awarding official, Chris Imhoff, Director
PO Box 45330
Olympia, WA 98504-5330
lmhofc@dshs.wa.gov
(xi) CFDA Number and Name; the pass-through 93.959
entity must identify the dollar amount made
available under each Federal award and the
CFDA number at time of disbursement;
(xii) Identification of whether the award is R&D; and [gl Yes D No
(xiii) Indirect cost rate for the Federal award 5%
(including if the de minimis rate is charged per
§200.414 Indirect (F&A) costs).
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1644CS Prevention Services -County (6-26-2015) Page 2
Federal Award Identification for Subrecipients (reference 2 CFR 200.331)
Strategic Prevention Framework Partnerships for Success
(i) Subrecipient name (which must match the Kittitas County
name associated with its unique entity
identifier);
(ii) Subrecipient's unique entity identifier; (DUNS) 010202547
(iii) Federal Award Identification Number (FAIN); SP020155
(iv) Federal Award Date (see §200.39 Federal 06/12/2015
award date);
(v) Subaward Period of Performance Start and 4/1/18 to 6/30/19
End Date;
(vi) Amount of Federal Funds Obligated by this $33,932
action;
(vii) Total Amount of Federal Funds Obligated to $33,932
the subrecipient;
(viii) Total Amount of the Federal Award; $2,207,505 FY16 (09/30/15 -09/29/16)
(ix) Federal award project description, as required Strategic Prevention Framework Partnerships for
to be responsive to the Federal Funding Success (PFS)
Accountability and Transparency Act (FFATA);
(x) Name of Federal awarding agency, pass-SAMHSA,
through entity, and contact information for Washington State DSHS,
awarding official, Chris Imhoff, Director
PO Box 45330
Olympia, WA 98504-5330
I MHOFC@dshs.wa.gov
(xi) CFDA Number and Name; the pass-through 93.243
entity must identify the dollar amount made
available under each Federal award and the
CFDA number at time of disbursement;
(xii) Identification of whether the award is R&D; and •Yes [:8J No
(xiii) Indirect cost rate for the Federal award de minimis (10%)
(including if the de minimis rate is charged per
§200.414 Indirect (F&A) costs).
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1644CS Prevention Services -County (6-26-2015) Page 3
Federal Award Identification for Subrecipients (reference 2 CFR 200.331)
WA-STR addresses the Opiate Epidemic by increasing treatment and prevention activities
(i) Subrecipient name (which must match the name Kittitas County
associated with its unique entity identifier);
(ii) Subrecipient's unique entity identifier; (DUNS) 010202547
(iii) Federal Award Identification Number (FAIN); TI080249
(iv) Federal Award Date (see §200.39 Federal award 5/1/2017
date);
(v) Subaward Period of Performance Start and End 4/1 /18 -6/30/19
Date;
(vi) Amount of Federal Funds Obligated by this action; $0
(vii) Total Amount of Federal Funds Obligated to the $0
subrecipient;
(viii) Total Amount of the Federal Award; $11,790,256 (5/1/17-4/30/18)
(ix) Federal award project description, as required to be WA-STR addresses the Opiate Epidemic by
responsive to the Federal Funding Accountability increasing treatment and prevention activities
and Transparency Act (FFATA);
(x) Name of Federal awarding agency, pass-through SAMHSA,
entity, and contact information for awarding official, Washington State DSHS,
Chris Imhoff, Director
PO Box 45330
Olympia, WA 98504-5330
imhofc@dshs.wa.gov
(xi) CFDA Number and Name; the pass-through entity 93.788
must identify the dollar amount made available
under each Federal award and the CFDA number at
time of disbursement;
(xii) Identification of whether the award is R&D; and •Yes [gl No
(xiii) Indirect cost rate for the Federal award (including if de minimis (10%)
the de minimis rate is charged per §200.414 Indirect
(F&A) costs).
DSHS Central Contract Services
1644CS Prevention Services -County (6-26-2015) Page 4
1. Definitions.
a. "Awards and Revenues" or "A&R" details the Contractor's Awards and Revenues attached as
Exhibit 8.
b. "Awards" means the total funding of all individual awards DSHS allocates to the Contractor, and the
total of all awards in this Contract's Maximum Amount, which is itemized, per service, in Exhibit 8.
c. "BARS" means -"Fiscal/Program Requirements", see below, which replaces BARS document.
d. "BHA" means Behavioral Health Administration .
e. "Boilerplate Language" means the standard Contract language, including General and Special
terms, which will be common to all subcontracts issued by the Contractor for provision of the
services required by this Contract.
f. "Calibration Scoring" means scoring between Observer 3, Observer 2, and Observer 1 to prevent
scorer drift from the standards and methods established in the Washington Codebook. Calibration
Scoring happens on a frequency of approximately ten percent (10%) of entries in the CCB or
semiannually to ensure reliability.
g. "CCB" means the Community Check Box, an on-line documentation support system project.
h. "Certified Prevention Professional" or "CPP" means the Prevention Specialist certification
recognized by the International Credentialing and Reciprocity Consortium (IC&RC) and supported
by the Prevention Specialist Certification Board of Washington, www.pscbw.com .
i. "Community Prevention and Wellness Initiative" or "CPWI" means the DSHS substance abuse
prevention delivery system that focuses prevention services in high-need communities in
Washington State as selected by Contractor and approved by DSHS.
j . "Contract Coordinator" means the person designated to carry out administrative and oversight
responsibilities of the prevention programs .
k. "Contract Manager" means the DSHS contact identified on page one (1) of this Contract.
I. "Data" means information that is disclosed or exchanged as described by this Contract.
m. "DEA" means United States Drug Enforcement Agency.
n. "Dedicated Marijuana Account" or "OMA" means revenue generated by the taxation of retail
marijuana as a result of the implementation of Initiative 502 (1-502) as authorized by the
Washington State Legislature in 2E2SHB 2136.
o. "DBHR" means the Division of Behavioral Health and Recovery or its successor.
p. "DSHS Contact" means the DSHS Contact staff identified on page 1 of this Contract.
q. "DUNS" or "Data Universal Numbering System" means a unique identifier for businesses. DUNS
numbers are assigned and maintained by Dun and Bradstreet (D&B) and are used for a variety of
purposes, including applying for government contracting opportunities.
r. "Ensure" as to this Contract means to make sure that something will happen or will be available
within the resources identified in the Consideration.
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1644CS Prevention Services -County (6-26-2015) Page 5
s. "EPA" means Environmental Protection Agency .
t. "Fiscal/Program Requirements" means the Supplementary Instructions and Fiscal Policy Standards
for Reimbursable Costs as used by DSHS, located at:
https://www.dshs.wa.gov/sites/defaultJfiles/BHS IA/dbh/Substance%20Use/FY14%20Fiscal%20Prcog
ram%20Req ulreinents%20for%20SUD. pdf
u. "Media materials and publications" means:
(1) News Release: A brief written announcement the agency provides to reporters highlighting key
events, research, results, new funding and programs, and other news.
(2) Paid Media: Any advertising space/time that is purchased for prevention/coalition messages
(printed publications/newspapers, online, outdoor, on-screen, TV and radio).
(3) Earned Media: Published news stories (print, broadcast or online) resulting from the
Contractor's contacts with reporters.
(4) Donated Media, including public service announcements: Any free advertising space or time
from broadcast, print, outdoor, online, and other advertising vendors.
(5) Social Media: Also referred to as new media: messages posted online on Facebook, Twitter,
YouTube, lnstagram, Snapchat and similar sites.
v. "Monitoring and Participatory Evaluation" or "M&E" means the CCB project data collection and
evaluation process for coalitions to measure community impact of coalition activity.
w. "Observer 1" means the CCB project Primary Scorer(s), the Coalition Coordinator(s) and Coalition
Member(s).
x. "Observer 2" means the CCB project Reliability scorer at DSHS .
y. "Observer 3" means the CCB project Calibration scorer at Work Group for Community Health and
Development at the University of Kansas (KU Work Group).
z. "Partnerships for Success" also known as "Partnerships for Success 2013" or "PFS" means the
Federal grant funded by the Substance Abuse and Mental Health Services Administration
(SAMHSA), CFDA number 93.243.
aa. "Prevention Activity Data" means information input to the "Substance Use Disorder Prevention
Mental Health Promotion Online Reporting System" or "Minerva" to record all active prevention
services including outcome measures. This information will be used to verify services identified in
A-19 invoices prior to payment and must be entered into Minerva by the close of business of the
fifteenth (15 th ) of each month for prevention activities provided during the previous month.
bb. "Prevention System Manager" (PSM) means the designee assigned to manage day to day
responsibilities associated with this Contract.
cc. "Reliability Scoring" means CCB project scoring between Observer 2 and Observer 1 to ensure the
standardizing of methods, times, and other aspects of the observation to be accurate and
consistent, and therefore more useful to an overall evaluation. Reliability scoring happens on a
monthly frequency with DSHS to ensure reliability and consistency of entries with the Washington
Codebook.
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1644CS Prevention Services -County (6-26-2015) Page 6
dd. "Regular annual schedule" means consistent, reliable services with a pattern of implementation
intervals throughout the year.
ee. "Substance Abuse Block Grant" or "SABG" means Federal Substance Abuse Block Grant funded by
the Substance Abuse and Mental Health Services Administration (SAMHSA), CFDA number
93.959.
ff. "Substance Use Disorder Prevention and Mental Health Promotion Online Reporting System" or
"Minerva" means the management information system maintained by DSHS that collects planning,
demographic, and prevention service data.
2. Applicable Law .
This Contract contains links to both DSHS and Federal websites to provide references, information and
forms for the Contractor's use. Links may break or become inactive if a website is reorganized; DSHS
is not responsible for links that do not respond as expected.
These legal resources identified below are incorporated by reference and include but are not limited to
the following:
a. 21 CFR Food and Drugs
Chapter 1, Subchapter C, Drugs: General
https://www. law.cornell .ed u/cfr/text/21 /chapter-1/subcha pter-C
b. 42 CFR Subchapter A--General Provisions
Part 2 Confidentiality of Alcohol and Drug Abuse Patient Records
https://www.law.cornell.edu/cfr/text/42/chapter-l/subchapter-A
45 CFR Public Welfare, Part 96 Block Grants, Subpart L Substance Abuse Block Grant
https://wwwJaw.cornell.edu/cfr/text/45!part-96/subpart-L
c. Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards 2
CFR Part 200 in 45 CFR Part 75 https://www.law.cornell.edu/cfr/text/2/pa rt-200
https://www.law.cornell.edu/cfr/text/45/part-75
d. Fiscal/Program Requirements (Formerly BARS)
https://www,dshs.wa.gov/sites/default/files/BHSI A/dbh/Substance%20Use/FY14%20Fiscal%20Prog
ram%20Requlrements%20for%20SUD.pdf
3. Purpose.
The purpose of this contract is to coordinate and implement prevention programs and strategies
designed to prevent or delay the misuse and abuse of alcohol, marijuana, tobacco, and other drugs,
increase mental health promotion, and prevent suicide. Program target populations and focus areas are
dependent on funding source and specific funded exhibits.
4. Performance Statement of Work.
The Contractor shall ensure services, and staff, and otherwise do all things necessary for or incidental
to the performance of work, as set forth below. Prevention programs and services include, but are not
limited to:
a. Coordination of Prevention Services.
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1644CS Prevention Services -County (6-26-2015) Page 7
The Contractor shall ensure:
(1) Provision of CPWI services in accordance with the CPWI Community Coalition Guide located on
the Athena Forum website www.TheAthenaForum.org/quide which outlines the minimal
standards to participate in the CPWI. Contractor shall plan to reach the ideal benchmarks
related to the community coalition's efforts and staffing.
(2) Contractor shall ensure that a regular annual schedule of direct prevention services for public
dissemination is established.
(a) Regular annual schedule shall take into account items including, but not limited to:
implementation times that maximize participation and service outcomes; local needs and
gaps; leveraged resources; and, other locally identified factors that influence service delivery
throughout the year.
(b) Regular annual schedule and community dissemination plan shall be identified as part of the
CPWI Action Plan Update and submitted to Contract Manager or designee for DSHS review
in accordance with the timeline in the CPWI Community Coalition Guide.
(3) Submit an annual Action Plan and Budget with projected expenditures, including salary and
benefits for DSHS funded prevention staff, program costs, training and travel to the Contract
Manager or designee, by June 15, 2018 and June 15, 2019 according to the CPWI Community
Coalition Guide, or within thirty (30) days upon request. A template will be provided.
(4) Budget adjustments that total ten percent (10%) or more from the approved Contractor and/or
CPWI coalition budget shall submit a budget revision for approval to CM or designee at least
fifteen (15) days prior to expending adjusted budget items. Approval must be granted prior to
expending funds.
(5) Ensure new hire Community Coalition Coordinators meet required position qualifications and
workstation requirements found in the CPWI Community Coalition Guide.
(a) Contractor shall submit a completed Community Coalition Coordinator Qualification
Checklist to Contract Manager or designee for review.
DSHS shall review and respond within forty-eight (48) business hours .
(b) DSHS reserves the right to require Contractor to develop a Community Coalition
Coordinator training plan if candidate does not meet required qualifications.
(6) Contractor contact on page one of this Contract and primary fiscal staff or their designee(s) shall
attend annual contractor training that will be scheduled for four (4) hours in duration. Date and
location will be announced by DBHR at least 30 days prior to the training.
(7) Ensure Community Coalition Coordinators are Certified Prevention Professionals (CPP).
(a) Ensure currently certified Community Coalition Coordinator(s) maintain CPP credential
status, and
(b) Ensure Certified Prevention Professional (CPP) certification within eighteen ( 18) months of
new Community Coalition Coordinator start date.
(8) Enter approved programs, based on the priorities, goals and objectives described in the
approved Strategic Plan, into the Minerva within thirty (30) days of Strategic Action Plan
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1644CS Prevention Services -County (6-26-2015) Page 8
approval.
(9) Ensure sixty percent (60%) of programs supported by DSHS funds will be replications or
adaptations of "Evidence-based Practice" substance abuse prevention programs as identified in
the Excellence In Prevention Strategies List webpage on the Athena Forum website:
www.TheAthenaForum .org/learning library/ebp . Ensure that all of the programs supported by
DSHS meet the Center for Substance Abuse Prevention's (CSAP) Principles of Substance
Abuse Prevention, found on the Athena Forum Website.
W\/1/W . TheAthena Forum.org/CSAPprinciples
(10) Food costs are generally unallowable during program implementation except within the
following parameters:
(a) Light refreshment costs for training events and meetings lasting longer than two (2) hours in
duration are allowable.
(b) Ensure that light refreshment costs do not exceed $2.50 per person.
(c) Meals may be provided for participants using SABG and DMA funds only if:
i. The training is four (4) hours or more in duration; or
ii. The program is a recurring, direct service family domain program and must be approved
in strategic plan.
(d) Meals are not allowable costs with Partnerships for Success (PFS) funds.
(e) Contractor shall adhere to current state per-diem rates for meals found online at
www.ofm .wa ,qov/policy/10 .90.htm.
(f) No more than a total of $1,000 may be spent on food or light refreshments per CPWI
Coalition per year.
(11) Dedicated Marijuana Account Funds (DMA) shall be used for program and strategy training
and implementation.
(a) All programs planned and implemented with DMA shall be programs selected from the
current DBHR provided youth marijuana use prevention and reduction program list.
www. TheAthena Forum .org/I502Prevention Plan Impleme ntation
i. No less than eighty-five percent (85%) of DMA funds shall be expended on evidence-
based or research-based programs on the identified program list.
ii. Up to fifteen percent (15%) of DMA funds may expended on Promising programs on the
identified program list.
(12) Contractor is encouraged to collaborate and partner with community-based organizations that
operate within or serve the CPWI community.
b. Coordination of Prevention Services.
If funding permits the Contractor to provide Community Based Coordination services in addition to
meeting CPWI requirements, (i.e., Counties with communities that each have at least $110,000 per
community of DSHS funding budgeted for CPWI implementation, annually) services may be
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1644CS Prevention Services -County (6-26-2015) Page 9
provided at the County level. Services shall reflect work of the Contractor staff coordinating,
organizing, building capacity, providing education and information related to prevention initiatives at
the County level with a goal to expand CPWI communities.
If applicable to Contractor, develop plan for services listed above and submit to Contract Manager
or designee for review and approval within sixty (60) days of contract execution.
c. Prevention Training .
(1) The Contractor shall participate in all required training events identified by DSHS and listed in
the CPWI Community Coalition Guide.
(2) Non-Required Training in CPWI
(a) In the absence of trainings identified in the approved strategic plan, all additional (non-
required) training paid for by DSHS shall be approved by Contract Manager or designee
prior to training and meet the approved goals and objectives in approved Strategic Plan
(b) The Contractor shall ensure any requests for training in addition to the approved training in
the Strategic plan are requested in writing and sent directly to the Contract Manager or
designee, a minimum of ten (10) working days before the date of the proposed training.
Trainings shall relate to one ( 1) of the following four ( 4) categories:
i. Coalition building and community organization .
ii. Capacity building regarding prevention theory and practice .
iii. Capacity building for Evidence-based Practice and environmental strategy
implementation, related to the goals and objectives of the coalition's approved strategic
plan.
iv. Capacity building in non-CPWI communities to expand CPWI efforts and meets overall
goals and objectives of CPWI may be approved by Contract Manager or designee upon
request.
(3) The Contractor shall ensure training paid for by DSHS that requires travel follows state travel
reimbursement guidelines and rates accessible at www.ofm.wa .gov/policy/10.90.htm .
( 4) The Contractor shall bill for training events on an A-19 per billing code (BARS) 566 .22(7) and
record training events in the DSHS Substance Use Disorder Prevention and Mental Health
Promotion Online Reporting Systems or Minerva in accordance with the monthly reporting
requirements described in Section 5.d., Prevention Report Schedule/Due Dates.
d. Media Materials.
(1) Media materials and publications developed with DSHS funds shall be submitted to the Contract
Manager or designee for approval prior to publication (DSHS will respond within five (5) working
days). DSHS must be cited as the funding source in news releases, publications, and
advertising messages created with or about DSHS funding. The funding source shall be cited
as: Washington State Department of Social and Health Services. The DSHS logo may also be
used in place of the above citation.
Messaging specifically directed to youth does not require DSHS logo or funding credit.
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(2) Exceptions: The Contractor does not need to submit the following items to Contract Manager or
designee:
(a) Newsletters and fact sheets.
(b) News coverage resulting from interviews with reporters. This includes online news
coverage .
(c) Newspaper editorials or letters to the editor.
(d) Posts on Facebook, YouTube, Tumblr, Twitter, lnstagram, Snapchat and other social media
sites.
(e) When a statewide media message is developed by DSHS is localized.
(f) When the current SAMHSA-sponsored media campaign is localized. (As of October 2014,
this is the "Talk. They Hear You." campaign. https:/iwww.samhsa.gov/under-age.-drinking )
5. Reporting Requirements.
a. Prevention Reporting Requirements
The Contractor shall report on all requirements as identified in the DSHS Substance Use Disorder
Prevention and Mental Health Promotion Online Reporting System or Minerva. DSHS reserves the
right to add reporting requirements based on requirements of grants.
b. Prevention Activity Data Reports
The Contractor shall:
Ensure that monthly prevention activities are reported in the DSHS Minerva in accordance with the
requirements and timelines set forth in Section 5.d.
(1) Ensure accurate and unduplicated reporting.
(2) Ensure proper training of staff and designated staff for back-up Minerva data entry to meet
report due dates.
c . If special circumstances arise and Contractor is unable to enter the data by the reporting
deadline(s), the Contractor shall ensure any requests for extensions to reporting deadlines are
requested in writing and sent directly to the PSM via email five (5) working days before the report
due date.
The maximum extension request permitted is ten (10) working days.
(1) Monthly Invoices submitted with active data entry extensions will be denied and may be re-
submitted by Contractor once data for the month(s) in question is complete.
(2) Contractors with three (3) or more consecutive months of data entry extensions or late reporting
or four (4) or more program data entry extensions or late reporting within a six (6) month period
shall be required to submit a Corrective Action Plan to DSHS.
Extensions granted due to Minerva technical issues will be excluded from this count.
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d. Complete prevention reporting, according to the Schedule/Due Dates below:
Reporting Period Report(s) Report Due Dates Reporting
System
Enter programs listed on Within 30 days of
Annually approved Strategic Action Strategic Action Plan Minerva
Plan by DSHS into Minerva. approval
As requested GPRA Measures. As requested Minerva
Prevention activity data input
for all active services including
community coalition 1 5th of each month Monthly coordination staff hours and for activities from the Minerva efforts, services, participant previous month information, training,
evaluation tools and
assessments .
Quarterly CPWI Quarterly Reporting . October 15, January Minerva 15, April 15, July 15
Bi-annually (for PFS Community Level Instrument -November 1 , 2017
funded Contractor only). Revised (CLI-R). As required May 1, 2018 Pep-C MRT
by SAMHSA. November 1 , 2018
( 1) Ensure all required demographic information is provided for individual participant; population
reach; aggregate; environmental and mentoring or 1-to-1 services in Minerva.
(2) Report Community Coalition Coordination Staff Hours in Minerva for each month of the calendar
year.
e. Outcome Measures
(1) The Contractor shall report on all required evaluation tools (i.e., pre/post-tests) identified in
Minerva that measure primary program objective.
Special situations and exceptions regarding evaluation tools identified in the Minerva include,
but are not limited to, the following:
(a) The Contractor may negotiate with the Contract Manager or designee to reduce multiple
administrations of surveys to individual participants.
(b) Participants in recurring program groups in which the majority of participants are younger
than ten (10) years old on the date of that group's first service.
f. Performance Work Statement/ Evaluation .
(1) The Contractor shall ensure program results show positive outcomes for at least half of the
participants in each program group as determined by Activity Log with individual participant
sessions.
(a) "Positive outcomes" means that at least half of the participants in a group report positive
improvement or maintenance as determined by the program measurable objective between
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1644CS Prevention Services -County (6-26-2015) Page 12
pre and post-tests.
(b) Positive outcomes will be determined using the pre-test and post-test data reported in
Minerva.
( c) Evaluation of Minerva data will occur on the 15th of the month following the final date of
service for each group.
(2) DSHS shall use the following protocol for evaluation :
(a) Matched pre-test and post-test pairs will be used in the analysis .
(b) To allow for normal attendance drop-off, a 20% leeway will be given for missing post-tests.
(c) If there are missing post-tests for entered pre-tests in excess of 20% of pre-tests, missing
post-test will be counted as a negative outcome.
Example: there are ten (10) pre-tests and seven (7) post-tests. The denominator would be
eight (8) and the maximum numerator would be seven (7).
(3) Different groups, as determined by Activity Logs, receiving the same program will be clustered
by school district.
(a) In cases where multiple providers are serving the same school district, groups will be
clustered by school district and provider.
(b) The results of one (1) provider in a given school district will not impact another provider in
the same district.
i. In cases where the survey instrument selected for a given program includes more than
one scale, the scale that is most closely aligned with the measurable objective linked to
the program in Minerva will be used.
ii. Results for groups, as determined by Activity Logs, with services that span two (2)
contracting periods will be analyzed in the contracting period that the post-test was
administered.
(c) If fewer than half of the participants in a group, as determined by Activity Log, within a given
school district, report positive change in the intended outcome:
i. The Contractor shall submit a Performance Improvement Plan (PIP) for the non-
compliant program to the Contract Manager or designee or designee within forty-five
(45) days of notice by DSHS.
ii. Reimbursement for the CSAP Category row on the A-19 for that program will be held
until the PIP is approved by the Contract Manager or designee or their designee.
iii. If a second group, as determined by Activity Log, within that same school district has
fewer than half of the participants report positive change in the intended outcome, then
the following steps will be taken:
(A) In cases where there is no active non-compliant program, the Contractor shall
discontinue implementation of that program within the specified geography.
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(B) In cases where the same programs as the non-compliant program are active and
continuing in the same school district, those groups, as determined by Activity Logs,
will be allowed to complete the expected number of sessions. No new groups, as
determined by Activity Logs, will be started.
(C) Following the conclusion of all groups, as determined by Activity Logs, completing
the program, results will be reviewed for those groups.
(D) If the results do not show positive change for each groups, as determined by Activity
Logs, the Contractor shall take the following action:
• In cases where the program is being delivered by a single provider in the
specified geography, the Contractor shall discontinue implementation of that
program in the specified geography.
• In cases where the program is being delivered by multiple providers in the
specified geography, the Contractor shall discontinue implementation of that
program by the underperforming provider in the specified geography.
(4) A program that resulted in the need for a Performance Improvement Plan and Plan was
approved during the July 1, 2015 to June 30, 2017 contract period will not carry that record
forward into the July 1, 2017 -June 30, 2019 contract period.
(5) Implement and monitor prevention programs and reporting to assure compliance with these
guidelines.
6. Requirements.
a . Background Checks. (RCW 43.43, WAC 388-877 & 388-877B).
(1) The Contactor shall ensure a criminal background check is conducted for all staff members,
case managers, outreach staff members, etc. or volunteers who have unsupervised access to
children, adolescents, vulnerable adults, and persons who have developmental disabilities.
(2) When providing services to youth, the Contractor shall ensure that requirements of WAC 388-
877-0500(1) are met.
b. Services and Activities to Ethnic Minorities and Diverse Populations.
The Contractor shall:
(1) Ensure all services and activities provided by the Contractor or subcontractor under this
Contract shall be designed and delivered in a manner sensitive to the needs of all diverse
populations.
(2) Initiate actions to ensure or improve access, retention, and cultural relevance of prevention or
other appropriate services, for ethnic minorities and other diverse populations in need of
prevention services as identified in their needs assessment.
(3) Take the initiative to strengthen working relationships with other agencies serving these
populations. The Contractor shall require its subcontractors to adhere to these requirements.
c. Continuing Education .
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Ensure that continuing education is provided for employees of any entity providing prevention
activities. (42 USC 300x-28{b) and 45 CFR 96.132(b)).
d. Single Source Funding.
(1) The Contractor shall ensure all subcontractors that Single Source Funding means that a
subcontractor can use only one source of funds at any given time.
(2) Each cost reimbursement Prevention service provided must be billed only one (1) time through
the source selected for funding this expense. At no time may the same expense be billed
through more than one (1) funding source.
e. Contract termination notice.
The Contractor shall provide a minimum of one hundred-twenty (120) days written notice to DSHS
to terminate contract.
f. Subrecipients.
(1) General. If the Contractor is a subrecipient of federal awards under any Program Agreement as
defined by 2 CFR Part 200, the Contractor shall:
(a) 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;
(b) 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;
(c) Prepare appropriate financial statements, including a schedule of expenditures of federal
awards;
(d) Incorporate 2 CFR Part 200, Subpart F audit requirements into all agreements between the
Contractor and its Subcontractors who are subrecipients;
(e) Comply with the applicable requirements of 2 CFR Part 200, including any future
amendments to 2 CFR Part 200, and any successor or replacement Office of Management
and Budget (0MB) Circular or regulation; and
(f) 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
at 28 CFR Part 42, Subparts C, D, E, and G, and 28 CFR Parts 35 and 39. (Go to
www~o.jp.usdoj.gov/ocr/ for additional information and access to the aforementioned Federal
laws and regulations.)
(2) Single Audit Act Compliance. If the Contractor is a subrecipient under a Program Agreement
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:
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(a) Submit to the DSHS contact person, listed on the first page of the Program Agreement, the
data collection form and reporting package specified in 2 CFR Part 200, Subpart F, reports
required by the program-specific audit guide (if applicable), and a copy of any management
letters issued by the auditor;
(b) Follow-up and develop corrective action for all audit findings, in accordance with 2 CFR Part
200, Subpart F; prepare a "Summary Schedule of Prior Audit Findings" reporting the status
of all audit findings included in the prior audit's schedule of findings and questioned costs.
(3) Overpayments. If it is determined by DSHS, or during the course of a required audit, that the
Contractor has been paid unallowable costs under any applicable Program Agreement, DSHS
may require the Contractor to reimburse DSHS in accordance with 2 CFR Part 200.
(4) Subcontractor Audit
(a) If a Contractor subcontractor is subject to 2 CFR, Part 200, Subpart F, the Contractor shall
require a copy of the completed Single Audit and ensure corrective action is taken for any
audit finding, per 2 CFR, Part 200, Subpart F requirements.
(b) If a Contractor subcontractor is not subject to 2 CFR, Part 200, Subpart F, the Contractor
shall perform subrecipient monitoring in compliance with federal requirements .
g. Federal Block Grant Funding Requirements.
The Contractor shall comply with the following:
Charitable Choice (42 USC 300x-65 and 42 CFR Section 54)
( 1) The Contractor shall ensure that Charitable Choice Requirements of 42 CFR Part 54 are
followed and that Faith-Based Organizations (FBO) are provided opportunities to compete with
traditional alcohol/drug abuse prevention providers for funding.
(2) If the Contractor subcontracts with FBOs, the Contractor shall require the FBO to meet the
requirements of 42 CFR Part 54 as follows:
(a) Applicants/recipients for/of services shall be provided with a choice of prevention providers .
(b) The FBO shall facilitate a referral to an alternative provider within a reasonable time frame
when requested by the recipient of services.
(c) The FBO shall report to the Contractor all referrals made to alternative providers.
(d) The FBO shall provide recipients with a notice of their rights.
(e) The FBO provides recipients with a summary of services that includes any inherently
religious activities.
(f) Funds received from the federal block grant must be segregated in a manner consistent with
Federal regulations.
(g) No funds may be expended for religious activities.
h. Notice of Federal Block Grant Funding Requirement.
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The Contractor shall :
(1) Notify subcontractors in writing of the federal funds, when federal block grant funds are
allocated by the Contractor to subcontractors for the delivery of services and activities under this
Contract.
(2) Ensure all subcontractors comply with all conditions and requirements for use of federal block
grant funds within any subcontracts or other agreements. 0MB 2 CFR, Part 200, Subpart F (A-
133).
(3) A portion of the funding for this contract may be from the federally funded Substance Abuse
Block Grant (SABG) CFDA #93.959. The amount allocated will be detailed in the Contractor's
authorization for service.
7. Subcontracts.
The Contractor shall obtain prior approval before entering into any subcontracting arrangement. In
addition, the Contractor shall submit the proposed subcontract to ensure it meets all DSHS
requirements to the Contract Manager or designee for review and approval purposes.
a. Subcontract Language .
(1) The Contractor shall include in its boilerplate language all requirements and conditions in this
Contract that the Contractor is required to meet when providing services to patients, clients, or
persons seeking assistance, which include but are not limited to:
(a) Identification of funding sources
(b) DUNS number and Zip code +4 of subcontractor
( c) How eligibility will be determined
(d) That subcontracts shall be fee-for-service, cost related, or price related as defined in
Fiscal/Program Requirements
(e) That termination of a subcontract shall not be grounds for a fair hearing for the service
applicant or a grievance for the recipient if similar services are immediately available in the
County.
(f) What actions the Contractor will take in the event of a termination of a subcontractor to
ensure all prevention data on services provided have been entered into the Substance Use
Disorder Prevention and Mental Health Promotion Online Reporting System also called
"Minerva".
(g) How service applications and recipients will be informed of their right to a grievance in the
case of:
i. Denial or termination of service
ii. Failure to act upon a request for services with reasonable promptness
(h) Audit requirements -0MB 2 CFR, Part 200, Subpart F (A-133) audit requirements if
applicable to the subcontractor
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(i) Authorizing facility inspection
U) Background Checks
(k) Conflict of interest
(I) Debarment and suspension certification
(m)HIPAA Business Associate Agreement and Compliance adherence as outlined in the
Contract
(n) Indemnification
(o) Nondiscrimination in employment
(p) Nondiscrimination in prevention activities
(q) Performance Based Contracts
(r) Providing data
(s) Records and reports
(t) Requirements outlined in the Data Sharing provision in the Contract
(u) Services provided in accordance with law and rule and regulation
(v) Minerva data input and reconciliation
(w) Treatment of assets
(x) Unallowable use of federal funds
b. Subcontract Inspection.
DSHS reserves the right to inspect any subcontract document.
c. Subcontractor Monitoring.
(1) Contractor shall submit subcontract monitoring protocol to Contract Manager or designee fifteen
(15) days prior of entering into first subcontract during contract period for review and DSHS
approval.
(2) On-Site Monitoring:
The Contractor shall
(a) Conduct a subcontractor review which shall include at least one (1) on-site visit, annually, to
each subcontractor site providing services to monitor fiscal and programmatic compliance
with subcontract performance criteria for the purpose of documenting that the
subcontractors are fulfilling the requirements of the subcontract.
(b) Submit written documentation of each on-site visit to Contract Manager or designee. A
copy of the full report shall be kept on file by the Contractor.
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(3) Minerva Monitoring
The Contractor shall ensure that subcontractors have entered services funded under this
Contract in the Minerva.
(a) Ensure accurate and unduplicated reporting .
Contractor may not require subcontractor to enter duplicate prevention service data that is
entered into Minerva into an additional system.
(b) Ensure proper training of staff and designated back-up staff for Minerva data entry to meet
report due dates.
(4) Additional Monitoring Activities
The Contractor shall maintain records of additional monitoring activities in the Contractor's
subcontractor file and make them available to DSHS upon request including any audit and any
independent documentation.
d. Subcontractor Termination Requirements .
When terminating a subcontract, the Contractor shall withhold the final payment of any subcontract
until all required Minerva reporting is complete . This also applies to all subcontractor closures.
8. Applicable Exhibits.
The following table lists the included exhibits in the Contract and the Contractors to which they apply.
Exhibit Title of Exhibit Applicable to the Following
Contractors
Exhibit A Data Security Requirements All Contractors
Exhibit B Awards and Revenue (A&R) All Contractors
Exhibit C PFS Advanced Community King County, San Juan County,
Surveillance Project -Year 5 City of Prosser, Tekoa School
September 30, 2017 to September 29, District
2018
Exhibit D PFS Secure Medicine Take-Back City of Prosser, Garfield County,
Year 5 September 30, 2017 to King County, Lewis County,
September 29, 2018 Tekoa School District; Grant
County
Exhibit E PFS Community Coalition Sector City of Prosser, Garfield County
Sharing Project -Year 5 September
30 , 2017 to September 29, 2018
Exhibit F PFS Increase Capacity, Outreach, and King County, City of Prosser
Programming to LGBTQ Community -
Project Year 5 September 30, 2017 to
September 29, 2018
Exhibit G State Targeted Response to the Opioid Whatcom County, Pacific County,
Crisis (STR) Community Prevention Spokane Tribal Network, Cape
and Wellness Initiative (CPWI) Flattery School District, Skagit
Expansion Community -August 15, County
2017 -April 30, 2019*
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Exhibit H PFS Community Coalition Mentoring ESD 112
Project -Year 5 September 30, 2017 to
September 29, 2018
Exhibit I PFS Secure Medicine Take-Back ESD 112
Year 5 September 30, 2017 to
September 29, 2018
Exhibit J PFS Carryover Funds Enhance San Juan County, Wapato
Prevention Services Carryover ending: School District
September 29, 2017
Exhibit K PFS Carryover Funds for NPN City of Prosser, Clark County,
Conference Support Carryover ending : Grant County; Mt. Adams School
September 29, 2017 District
9. Consideration.
Total consideration payable to the Contractor for satisfactory performance of the work under this
Contract is, up to a maximum of $158,037, including any and all expenses, and shall be based on the
following and outlined in Exhibit B: Awards and Revenue
a. Reimbursable Costs.
The Contractor shall ensure all expenditures for services and activities under this Contract are
submitted on the A-19 invoice appropriate for Minerva data entry.
(1) Administrative costs shall be billed separately from direct prevention services as indicated on
the A-19 invoice.
(a) Administrative costs are defined in the Fiscal/Program Requirements .
https://www.dshs.wa.gov/slles/default/files/BHS INdbh/Substance%20Use/FY 14 %20Fiscal%
2 0Program%20Reguirem ents%20for%20SUD.pdf.
(b) The allocation of General Fund State funds in this contract shall be used for administrative
costs.
(c) The Contractor shall use no more than eight percent (8%) of the OMA and PFS allocation
for administrative costs.
(d) No SABG funds allocated in this contract shall be used for administrative costs.
b . Funding Allocation .
The Contractor shall manage the Contract to ensure that services are provided in a manner that
allocates the available resources over the life of the Contract.
c. Period of Performance Service Costs .
The Contractor shall ensure that service costs incurred are within the period of performance of this
Contract.
d . DSHS reserves the right to reduce the Prevention funds awarded in the Contract if the Contractor
expenditures are below 60% of expected levels during the fiscal quarter. Expenditures will be
reviewed quarterly.
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Appropriate rate is defined as the percentage of expenditures being roughly equal to the
percentage of time in the Contract that has passed.
e. Based on Exhibit B -Awards and Revenue, the source of funds in this contract may include the
Substance Abuse Block Grant (SABG) CFDA 93.959, the Washington State Dedicated Marijuana
Account Fund (DMA), General Fund -State (GF-S), the Partnerships for Success (PFS) Grant
CFDA 93.243 (Year 4 is September 30, 2016 to September 29, 2017, Year 5 is September 30,
2017 to September 29, 2018), and the State Targeted Response to the Opioid Crisis (STR) CFDA
93. 788 (Year 1 is May 1, 2017 to April 30, 2018 and Year 2 is May 1, 2018 to April 30, 2019).
(1) PFS, GF-S, and DMA funds are not carried forward from year to year.
(2) SABG funds may be carried forward from year to year.
10. Billing and Payment.
a. Invoice System .
The Contractor shall submit invoices using State Form A-19 Invoice Voucher, or such other form as
designated by DSHS. Consideration for services rendered shall be payable upon receipt of properly
completed invoices which shall be submitted to A-19DBHR@dshs.wa.gov., by the Contractor, not
more often than monthly. The invoices shall describe and document to DSHS' satisfaction a
description of the work performed, activities accomplished, the progress of the project, and fees.
The rates shall be in accordance with those set forth in the Consideration Section of this Contract.
If the limitation to not more often than monthly billing presents a fiscal hardship, the Contractor may
submit a written request of exception to this limitation to Contract Manager or designee.
b. Timely Payment.
Payment shall be considered timely if made by DSHS within thirty (30) days after receipt and
acceptance by the Contract Manager or designee of the properly completed invoices. Payment
shall be sent to the address designated by the Contractor on page 1 of this Contract. DSHS may,
at its sole discretion, withhold payment claimed by the Contractor for services rendered if
Contractor fails to satisfactorily comply with any term or condition of this Contract.
c. DSHS Obligation for Payment.
DSHS shall not be obligated to reimburse the Contractor for any services or activities, performed
prior to having a fully executed copy of this Contract.
d. Duplication .
The Contractor assures that work performed and invoiced does not duplicate work to be charged to
the State of Washington under any other Contract or agreement with the Contractor.
e. Claims for Payment.
The Contractor shall:
(1) Submit invoices for costs due and payable under this agreement that were incurred prior to the
expiration date within ninety (90) days of the date services were provided.
(2) Submit final billing for services provided within sixty (60) days after the end of the State Fiscal
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Year.
(a) Final PFS billing shall be submitted within sixty (60) days of end of each Federal Fiscal
Year.
(b) Final STR billing shall be submitted by June 30 th , annually for each fiscal year.
f. Non-Compliance.
Failure to Maintain Reporting Requirements.
In the event the Contractor or a subcontractor fails to maintain its reporting obligations under this
Contract, DSHS reserves the right to withhold reimbursements to the Contractor until the
obligations are met.
g. Recovery of Costs Claimed in Error.
If the Contractor claims and DSHS reimburses for expenditures under this Contract which DSHS
later finds were one (1) claimed in error or two (2) not allowable costs under the terms of the
Contract, DSHS shall recover those costs and the Contractor shall fully cooperate with the
recovery.
11. Miscellaneous Items.
a. Complete the Contractor Self-Assessment Monitoring Tool and submit to Contract Manager or
designee.
b. Update Contractor Intake form within thirty (30) days of Contractor changes and submit to Contract
Manager or designee for processing.
c. Provide DUNs number and Zip Code + 4 for Contractor.
(1) The DUNs number is 010202547.
(2) Zip Code + 4 is 98926-2886.
12. SAMHSA Award Terms.
a. This grant is subject to the terms and conditions, included directly, or incorporated by reference on
the Notice of Award (NoA).
b. Grant funds cannot be used to supplant current funding of existing activities .
c. By law, none of the funds awarded can be used to pay the salary of an individual at a rate in excess
of the Executive Level 1, which is $199,700 annually.
d. Awardees and sub-recipients must maintain records which adequately identify the source and
application of funds provided for financially assisted activities. These records must contain
information pertaining to grant or sub-grant awards and authorizations, obligations, unobligated
balances, assets, liabilities, outlays or expenditures, and income. SAMHSA or its designee may
conduct a financial compliance audit and on-site program review of grants with significant amounts
of Federal funding.
e. Per 45 CFR 74.36 and 45 CFR 92.34 and the HHS Grants Policy Statement, any copyrighted or
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copyrightable works developed under this cooperative agreement/grant shall be subject to royalty-
free, nonexclusive and irrevocable license to the government to reproduce, publish, or otherwise
use them and to authorize others to do so for General Government purposes. Income earned from
any copyrightable work developed under this grant must be used as program income.
f. Program income accrued under this award must be used in accordance with the additional costs
alternative described in 45 CFR 74.24(b)(1) or 45 CFR 92.25(g)(2) as applicable. Program income
must be used to further the grant objectives and shall only be used for allowable costs as set forth
in the applicable 0MB circulars A-102 and A-110.
g. No part of any appropriation contained in this Act shall be used, other than for normal and
recognized executive-legislative relationships, for publicity or propaganda purposes, for the
preparation, distribution, or use of any kit, pamphlet, booklet, publication, radio, television, or video
presentation designed to support or defeat legislation pending before the Congress, except in
presentation to the Congress itself or any State legislature.
h. No part of any appropriation contained in this Act shall be used to pay the salary or expenses of any
grant or contract recipient, or agency acting for such recipient, related to any activity designed to
influence legislation or appropriations pending before the Congress or any State legislature.
i. Where a conference is funded by a grant or cooperative agreement the recipient must include the
following statement on all conference materials (including promotional materials, agenda, and
internet sites): "Funding for this conference was made possible (in part) by Grant SP020155 and/or
TI010056 from SAMHSA. The views expressed in written conference materials or publications and
by speakers and moderators do not necessarily reflect the official policies of the Department of
Health and Human Services; nor does mention of trade names, commercial practices, or
organizations imply endorsement by the U.S. Government."
j. If federal funds are used by the Contractor to attend a meeting, conference, etc. and meal(s) are
provided as part of the program, then the per diem applied to the Federal travel costs (M&IE
allowance) must be reduced by the allotted meal cost(s).
13. Subrecipients.
a. General. !f the Contractor is a subrecipient of federal awards under any Program Agreement as
defined by 2 CFR Part 200, the Contractor shall:
(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;
(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;
(3) Prepare appropriate financial statements, including a schedule of expenditures of federal
awards;
(4) Incorporate 2 CFR Part 200, Subpart F audit requirements into all agreements between the
Contractor and its Subcontractors who are subrecipients;
(5) Comply with the applicable requirements of 2 CFR Part 200, including any future amendments
to 2 CFR Part 200, and any successor or replacement Office of Management and Budget
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(0MB) Circular or regulation; and
(6) 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 II 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 at 28 CFR Part 42,
Subparts C, D, E, and G, and 28 CFR Parts 35 and 39. (Go to www.olp.usdoj.gov/ocr/ for
additional information and access to the aforementioned Federal laws and regulations.)
b. Single Audit Act Compliance. If the Contractor is a subrecipient under a Program Agreement 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:
( 1) Submit to the DSHS contact person, listed on the first page of the Program Agreement, the
data collection form and reporting package specified in 2 CFR Part 200, Subpart F, reports
required by the program-specific audit guide (if applicable), and a copy of any management
letters issued by the auditor;
(2) Follow-up and develop corrective action for all audit findings, in accordance with 2 CFR Part
200, Subpart F; prepare a "Summary Schedule of Prior Audit Findings" reporting the status of all
audit findings included in the prior audit's schedule of findings and questioned costs.
HIPAA Compliance
Preamble: This section of the Contract is the Business Associate Agreement as required by HIPAA.
14. Definitions.
a. "Business Associate," as used in this Contract, means the "Contractor'' and generally has the same
meaning as the term "business associate" at 45 CFR 160.103. Any reference to Business
Associate in this Contract includes Business Associate's employees, agents, officers,
Subcontractors, third party contractors, volunteers, or directors.
b. "Business Associate Agreement" means this HIPAA Compliance section of the Contract and
includes the Business Associate provisions required by the U.S. Department of Health and Human
Services, Office for Civil Rights.
c. "Breach" means the acquisition, access, use, or disclosure of Protected Health Information in a
manner not permitted under the HIPAA Privacy Rule which compromises the security or privacy of
the Protected Health Information, with the exclusions and exceptions listed in 45 CFR 164.402.
d. "Covered Entity" means DSHS, a Covered Entity as defined at 45 CFR 160.103, in its conduct of
covered functions by its health care components.
e. "Designated Record Set" means a group of records maintained by or for a Covered Entity, that is:
the medical and billing records about Individuals maintained by or for a covered health care
provider; the enrollment, payment, claims adjudication, and case or medical management record
systems maintained by or for a health plan; or Used in whole or part by or for the Covered Entity to
make decisions about Individuals.
f. "Electronic Protected Health Information (EPHI)" means Protected Health Information that is
transmitted by electronic media or maintained in any medium described in the definition of
electronic media at 45 CFR 160.103.
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g. "HIPAA" means 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).
h. "HIPAA Rules" means the Privacy, Security, Breach Notification, and Enforcement Rules at 45 CFR
Parts 160 and Part 164.
i. "lndividual(s)" means the person(s) who is the subject of PHI and includes a person who qualifies
as a personal representative in accordance with 45 CFR 164.502(9).
j. "Minimum Necessary" means the least amount of PHI necessary to accomplish the purpose for
which the PHI is needed.
k. "Protected Health Information (PHI)" means individually identifiable health information created,
received, maintained or transmitted by Business Associate on behalf of a health care component of
the Covered Entity 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 the past, present, or future payment
for provision of health care to an Individual. 45 CFR 160.103. PHI includes demographic
information that identifies the Individual or about which there is reasonable basis to believe can be
used to identify the Individual. 45 CFR 160.103. PHI is information transmitted or held in any form
or medium and includes EPHI. 45 CFR 160.103. PHI does not include education records covered
by the Family Educational Rights and Privacy Act, as amended, 20 USCA 1232g(a)(4)(B)(iv) or
employment records held by a Covered Entity in its role as employer.
I. "Security Incident" means the attempted or successful unauthorized access, use, disclosure,
modification or destruction of information or interference with system operations in an information
system.
m. "Subcontractor" as used in this HIPAA Compliance section of the Contract (in addition to its
definition in the General Terms and Conditions) means a Business Associate that creates, receives,
maintains, or transmits Protected Health Information on behalf of another Business Associate.
n. "Use" includes the sharing, employment, application, utilization, examination, or analysis, of PHI
within an entity that maintains such information.
15. Compliance. Business Associate shall perform all Contract duties, activities and tasks in compliance
with HIPAA, the HIPAA Rules, and all attendant regulations as promulgated by the U.S. Department of
Health and Human Services, Office of Civil Rights.
16. Use and Disclosure of PHI. Business Associate is limited to the following permitted and required uses
or disclosures of PHI:
a. Duty to Protect PHI. Business Associate shall protect PHI from, and shall use appropriate
safeguards, and comply with Subpart C of 45 CFR Part 164 (Security Standards for the Protection
of Electronic Protected Health Information) with respect to EPHI, to prevent the unauthorized Use or
disclosure of PHI other than as provided for in this Contract or as required by law, for as long as the
PHI is within its possession and control, even after the termination or expiration of this Contract.
b. Minimum Necessary Standard. Business Associate shall apply the HIPAA Minimum Necessary
standard to any Use or disclosure of PHI necessary to achieve the purposes of this Contract. See
45 CFR 164.514 ( d)(2) through ( d)(5).
c. Disclosure as Part of the Provision of Services. Business Associate shall only Use or disclose PHI
as necessary to perform the services specified in this Contract or as required by law, and shall not
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Use or disclose such PHI in any manner that would violate Subpart E of 45 CFR Part 164 (Privacy
of Individually Identifiable Health Information) if done by Covered Entity, except for the specific uses
and disclosures set forth below.
d. Use for Proper Management and Administration. Business Associate may Use PHI for the proper
management and administration of the Business Associate or to carry out the legal responsibilities
of the Business Associate.
e. Disclosure for Proper Management and Administration. Business Associate may disclose PHI for
the proper management and administration of Business Associate or to carry out the legal
responsibilities of the Business Associate, provided the disclosures are required by law, or
Business Associate obtains reasonable assurances from the person to whom the information is
disclosed that the information will remain confidential and used or further disclosed only as required
by law or for the purposes for which it was disclosed to the person, and the person notifies the
Business Associate of any instances of which it is aware in which the confidentiality of the
information has been Breached.
f. Impermissible Use or Disclosure of PHI. Business Associate shall report to DSHS in writing all
Uses or disclosures of PHI not provided for by this Contract within one (1) business day of
becoming aware of the unauthorized Use or disclosure of PHI, including Breaches of unsecured
PHI as required at 45 CFR 164.410 (Notification by a Business Associate), as well as any Security
Incident of which it becomes aware. Upon request by DSHS, Business Associate shall mitigate, to
the extent practicable, any harmful effect resulting from the impermissible Use or disclosure.
g. Failure to Cure. If DSHS learns of a pattern or practice of the Business Associate that constitutes a
violation of the Business Associate's obligations under the terms of this Contract and reasonable
steps by DSHS do not end the violation, DSHS shall terminate this Contract, if feasible. In addition,
If Business Associate learns of a pattern or practice of its Subcontractors that constitutes a violation
of the Business Associate's obligations under the terms of their contract and reasonable steps by
the Business Associate do not end the violation, Business Associate shall terminate the
Subcontract, if feasible.
h. Termination for Cause. Business Associate authorizes immediate termination of this Contract by
DSHS, if DSHS determines that Business Associate has violated a material term of this Business
Associate Agreement. DSHS may, at its sole option, offer Business Associate an opportunity to
cure a violation of this Business Associate Agreement before exercising a termination for cause.
l. Consent to Audit. Business Associate shall give reasonable access to PHI, its internal practices,
records, books, documents, electronic data and/or all other business information received from, or
created or received by Business Associate on behalf of DSHS, to the Secretary of DHHS and/or to
DSHS for use in determining compliance with HIPAA privacy requirements.
j . Obligations of Business Associate Upon Expiration or Termination. Upon expiration or termination
of this Contract for any reason, with respect to PHI received from DSHS, or created, maintained, or
received by Business Associate, or any Subcontractors, on behalf of DSHS, Business Associate
shall:
(1) Retain only that PHI which is necessary for Business Associate to continue its proper
management and administration or to carry out its legal responsibilities;
(2) Return to DSHS or destroy the remaining PHI that the Business Associate or any
Subcontractors still maintain in any form;
(3) Continue to use appropriate safeguards and comply with Subpart C of 45 CFR Part 164
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(Security Standards for the Protection of Electronic Protected Health Information) with respect to
Electronic Protected Health Information to prevent Use or disclosure of the PHI, other than as
provided for in this Section, for as long as Business Associate or any Subcontractors retain the
PHI;
(4) Not Use or disclose the PHI retained by Business Associate or any Subcontractors other than
for the purposes for which such PHI was retained and subject to the same conditions set out in
the "Use and Disclosure of PHI" section of this Contract which applied prior to termination; and
(5) Return to DSHS or destroy the PHI retained by Business Associate , or any Subcontractors,
when it is no longer needed by Business Associate for its proper management and
administration or to carry out its legal responsibilities.
k. Survival. The obligations of the Business Associate under this section shall survive the termination
or expiration of this Contract.
17. Individual Rights .
a. Accounting of Disclosures .
(1) Business Associate shall document all disclosures, except those disclosures that are exempt
under 45 CFR 164.528, of PHI and information related to such disclosures.
(2) Within ten (10) business days of a request from DSHS, Business Associate shall make available
to DSHS the information in Business Associate's possession that is necessary for DSHS to
respond in a timely manner to a request for an accounting of disclosures of PHI by the Business
Associate. See 45 CFR 164.504(e)(2)(ii)(G) and 164.528(b)(1).
(3) At the request of DSHS or in response to a request made directly to the Business Associate by
an Individual, Business Associate shall respond, in a timely manner and in accordance with
HIPAA and the HIPAA Rules , to requests by Individuals for an accounting of disclosures of PHI.
(4) Business Associate record keeping procedures shall be sufficient to respond to a request for an
accounting under this section for the six (6) years prior to the date on which the accounting was
requested.
b. Access
(1) Business Associate shall make available PHI that it holds that is part of a Designated Record
Set when requested by DSHS or the Individual as necessary to satisfy DSHS's obligations
under 45 CFR 164.524 (Access of Individuals to Protected Health Information).
(2) When the request is made by the Individual to the Business Associate or if DSHS asks the
Business Associate to respond to a request, the Business Associate shall comply with
requirements in 45 CFR 164.524 (Access of Individuals to Protected Health Information) on
form, time and manner of access. When the request is made by DSHS, the Business Associate
shall provide the records to DSHS within ten (10) business days .
c. Amendment.
( 1) If DSHS amends, in whole or in part, a record or PHI contained in an Individual's Designated
Record Set and DSHS has previously provided the PHI or record that is the subject of the
amendment to Business Associate, then DSHS will inform Business Associate of the
amendment pursuant to 45 CFR 164.526(c)(3) (Amendment of Protected Health Information).
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(2) Business Associate shall make any amendments to PHI in a Designated Record Set as directed
by DSHS or as necessary to satisfy DSHS's obligations under 45 CFR 164.526 (Amendment of
Protected Health Information).
18. Subcontracts and other Third Party Agreements. In accordance with 45 CFR 164.502(e)(1)(ii),
164.504(e)(1)(i), and 164.308(b)(2), Business Associate shall ensure that any agents, Subcontractors,
independent contractors or other third parties that create, receive, maintain, or transmit PHI on
Business Associate's behalf, enter into a written contract that contains the same terms, restrictions,
requirements, and conditions as the HIPM compliance provisions in this Contract with respect to such
PHI. The same provisions must also be included in any contracts by a Business Associate's
Subcontractor with its own business associates as required by 45 CFR 164.314(a)(2)(b) and
164.504(e)(5).
19. Obligations. To the extent the Business Associate is to carry out one or more of DSHS's obligation(s)
under Subpart E of 45 CFR Part 164 (Privacy of Individually Identifiable Health Information), Business
Associate shall comply with all requirements that would apply to DSHS in the performance of such
obligation(s).
20. Liability. Within ten (10) business days, Business Associate must notify DSHS of any complaint,
enforcement or compliance action initiated by the Office for Civil Rights based on an allegation of
violation of the HIPM Rules and must inform DSHS of the outcome of that action. Business Associate
bears all responsibility for any penalties, fines or sanctions imposed against the Business Associate for
violations of the HIPM Rules and for any imposed against its Subcontractors or agents for which it is
found liable.
21. Breach Notification.
a. In the event of a Breach of unsecured PHI or disclosure that compromises the privacy or security of
PHI obtained from DSHS or involving DSHS clients, Business Associate will take all measures
required by state or federal law.
b. Business Associate will notify DSHS within one (1) business day by telephone and in writing of any
acquisition, access, Use or disclosure of PHI not allowed by the provisions of this Contract or not
authorized by HIPM Rules or required by law of which it becomes aware which potentially
compromises the security or privacy of the Protected Health Information as defined in 45 CFR
164.402 (Definitions).
c. Business Associate will notify the DSHS Contact shown on the cover page of this Contract within
one (1) business day by telephone or e-mail of any potential Breach of security or privacy of PHI by
the Business Associate or its Subcontractors or agents. Business Associate will follow telephone or
e-mail notification with a faxed or other written explanation of the Breach, to include the following :
date and time of the Breach, date Breach was discovered, location and nature of the PHI, type of
Breach, origination and destination of PHI, Business Associate unit and personnel associated with
the Breach, detailed description of the Breach, anticipated mitigation steps, and the name, address,
telephone number, fax number, and e-mail of the individual who is responsible as the primary point
of contact. Business Associate will address communications to the DSHS Contact. Business
Associate will coordinate and cooperate with DSHS to provide a copy of its investigation and other
information requested by DSHS, including advance copies of any notifications required for DSHS
review before disseminating and verification of the dates notifications were sent.
d. If DSHS determines that Business Associate or its Subcontractor(s) or agent(s) is responsible for a
Breach of unsecured PHI:
(1) requiring notification of Individuals under 45 CFR § 164.404 (Notification to Individuals),
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Business Associate bears the responsibility and costs for notifying the affected Individuals and
receiving and responding to those Individuals' questions or requests for additional information;
(2) requiring notification of the media under 45 CFR § 164.406 (Notification to the media), Business
Associate bears the responsibility and costs for notifying the media and receiving and
responding to media questions or requests for additional information;
(3) requiring notification of the U.S. Department of Health and Human Services Secretary under 45
CFR § 164.408 (Notification to the Secretary), Business Associate bears the responsibility and
costs for notifying the Secretary and receiving and responding to the Secretary's questions or
requests for additional information; and
(4) DSHS will take appropriate remedial measures up to termination of this Contract.
22. Miscellaneous Provisions.
a . Regulatory References. A reference in this Contract to a section in the HIPAA Rules means the
section as in effect or amended.
b. Interpretation. Any ambiguity in this Contract shall be interpreted to permit compliance with the
HIPAA Rules.
23. Insurance ..
a. DSHS certifies that it is self-insured under the State's self-insurance liability program, as provided
by RCW 4.92.130, and shall pay for losses for which it is found liable.
The Contractor certifies that it is self-insured or insured through a risk pool and shall pay for losses
for which it is found liable.
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Exhibit A-Data Security Requirements
1. Definitions. The words and phrases listed below, as used in this Exhibit, shall each have the following
definitions:
a . "Authorized User(s)" means an individual or individuals with an authorized business requirement to
access DSHS Confidential Information.
b. "Hardened Password" means a string of at least eight characters containing at least one alphabetic
character, at least one number and at least one special character such as an asterisk, ampersand
or exclamation point.
c. "Unique User ID" means a string of characters that identifies a specific user and which, in
conjunction with a password, passphrase or other mechanism, authenticates a user to an
information system.
2. Data Transport. When transporting DSHS Confidential Information electronically, including via email,
the Data will be protected by:
a . Transporting the Data within the (State Governmental Network) SGN or Contractor's internal
network, or;
b. Encrypting any Data that will be in transit outside the SGN or Contractor's internal network. This
includes transit over the public Internet.
3 . Protection of Data. The Contractor agrees to store Data on one or more of the following media and
protect the Data as described:
a . Hard disk drives. Data stored on local workstation hard disks. Access to the Data will be
restricted to Authorized User(s) by requiring logon to the local workstation using a Unique User ID
and Hardened Password or other authentication mechanisms which provide equal or greater
security, such as biometrics or smart cards.
b. Network server disks. Data stored on hard disks mounted on network servers and made available
through shared folders. Access to the Data will be restricted to Authorized Users through the use of
access control lists which will grant access only after the Authorized User has authenticated to the
network using a Unique User ID and Hardened Password or other authentication mechanisms
which provide equal or greater security, such as biometrics or smart cards. Data on disks mounted
to such servers must be located in an area which is accessible only to authorized personnel , with
access controlled through use of a key, card key, combination lock, or comparable mechanism.
For DSHS Confidential Information stored on these disks, deleting unneeded Data is sufficient as
long as the disks remain in a Secured Area and otherwise meet the requirements listed in the
above paragraph. Destruction of the Data as outlined in Section 5. Data Disposition may be
deferred until the disks are retired, replaced, or otherwise taken out of the Secured Area.
c . Optical discs (CDs or DVDs) in local workstation optical disc drives. Data provided by DSHS
on optical discs which will be used in local workstation optical disc drives and which will not be
transported out of a Secured Area . When not in use for the contracted purpose, such discs must be
locked in a drawer, cabinet or other container to which only Authorized Users have the key ,
combination or mechanism required to access the contents of the container. Workstations which
access DSHS Data on optical discs must be located in an area which is accessible only to
authorized personnel, with access controlled through use of a key, card key, combination lock, or
comparable mechanism .
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d. Optical discs (CDs or DVDs) in drives or jukeboxes attached to servers. Data provided by
DSHS on optical discs which will be attached to network servers and which will not be transported
out of a Secured Area. Access to Data on these discs will be restricted to Authorized Users through
the use of access control lists which will grant access only after the Authorized User has
authenticated to the network using a Unique User ID and Hardened Password or other
authentication mechanisms which provide equal or greater security, such as biometrics or smart
cards. Data on discs attached to such servers must be located in an area which is accessible only
to authorized personnel, with access controlled through use of a key, card key, combination lock, or
comparable mechanism.
e. Paper documents. Any paper records must be protected by storing the records in a Secured Area
which is only accessible to authorized personnel. When not in use, such records must be stored in
a locked container, such as a file cabinet, locking drawer, or safe, to which only authorized persons
have access.
f. Remote Access. Access to and use of the Data over the State Governmental Network (SGN) or
Secure Access Washington (SAW) will be controlled by DSHS staff who will issue authentication
credentials (e.g. a Unique User ID and Hardened Password) to Authorized Users on Contractor
staff. Contractor will notify DSHS staff immediately whenever an Authorized User in possession of
such credentials is terminated or otherwise leaves the employ of the Contractor, and whenever an
Authorized User's duties change such that the Authorized User no longer requires access to
perform work for this Contract.
g. Data storage on portable devices or media .
(1) Except where otherwise specified herein, DSHS Data shall not be stored by the Contractor on
portable devices or media unless specifically authorized within the terms and conditions of the
Contract. If so authorized, the Data shall be given the following protections:
(a) Encrypt the Data with a key length of at least 128 bits
(b) Control access to devices with a Unique User ID and Hardened Password or stronger
authentication method such as a physical token or biometrics.
(c) Manually lock devices whenever they are left unattended and set devices to lock
automatically after a period of inactivity, if this feature is available. Maximum period of
inactivity is 20 minutes.
Physically Secure the portable device(s) and/or media by
(d) Keeping them in locked storage when not in use
(e) Using check-in/check-out procedures when they are shared, and
(f) Taking frequent inventories
(2) When being transported outside of a Secured Area, portable devices and media with DSHS
Confidential Information must be under the physical control of Contractor staff with authorization
to access the Data.
(3) Portable devices include, but are not limited to; smart phones, tablets, flash memory devices
(e.g. USB flash drives, personal media players), portable hard disks, and
laptop/notebook/netbook computers if those computers may be transported outside of a
Secured Area.
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(4) Portable media includes, but is not limited to; optical media (e.g. CDs, DVDs), magnetic media
(e.g. floppy disks, tape), or flash media (e.g. CompactFlash, SD, MMC).
h. Data stored for backup purposes .
(1) DSHS data may be stored on portable media as part of a Contractor's existing, documented
backup process for business continuity or disaster recovery purposes. Such storage is
authorized until such time as that media would be reused during the course of normal backup
operations. If backup media is retired while DSHS Confidential Information still exists upon it,
such media will be destroyed at that time in accordance with the disposition requirements in
Section 5. Data Disposition
(2) DSHS Data may be stored on non-portable media (e.g. Storage Area Network drives, virtual
media, etc.) as part of a Contractor's existing, documented backup process for business
continuity or disaster recovery purposes. If so, such media will be protected as otherwise
described in this exhibit. If this media is retired while DSHS Confidential Information still exists
upon it, the data will be destroyed at that time in accordance with the disposition requirements in
Section 5. Data Disposition.
4. Data Segregation .
a. DSHS Data must be segregated or otherwise distinguishable from non-DSHS data. This is to
ensure that when no longer needed by the Contractor, all DSHS Data can be identified for return or
destruction. It also aids in determining whether DSHS Data has or may have been compromised in
the event of a security breach. As such, one or more of the following methods will be used for data
segregation.
b. DSHS Data will be kept on media (e.g. hard disk, optical disc, tape, etc.) which will contain no
non-DSHS data. And/or,
c. DSHS Data will be stored in a logical container on electronic media, such as a partition or folder
dedicated to DSHS Data. And/or,
d. DSHS Data will be stored in a database which will contain no non-DSHS data. And/or,
e. DSHS Data will be stored within a database and will be distinguishable from non-DSHS data by the
value of a specific field or fields within database records.
f. When stored as physical paper documents, DSHS Data will be physically segregated from non-
DSHS data in a drawer, folder, or other container.
g. When it is not feasible or practical to segregate DSHS Data from non-DSHS data, then both the
DSHS Data and the non-DSHS data with which it is commingled must be protected as described in
this exhibit.
5. Data Disposition. When the contracted work has been completed or when no longer needed, except
as noted in Section 3. Protection of Data b. Network Server Disks above, Data shall be returned to
DSHS or destroyed. Media on which Data may be stored and associated acceptable methods of
destruction are as follows:
Data stored on: I Will be destroyed by:
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1644CS Prevention Services -County (6-26-2015) Page 32
Server or workstation hard disks, or Using a "wipe" utility which will overwrite the Data at
least three (3) times using either random or single
Removable media (e.g. floppies, USB flash drives, character data, or
portable hard disks) excluding optical discs
Degaussing sufficiently to ensure that the Data
cannot be reconstructed, or
Physically destroying the disk
Paper documents with sensitive or Confidential Recycling through a contracted firm provided the
Information contract with the recycler assures that the
confidentiality of Data will be protected.
Paper documents containing Confidential Information On-site shredding, pulping, or incineration
requiring special handling (e .g. protected health
information)
Optical discs (e.g. CDs or DVDs) Incineration, shredding, or completely defacing the
readable surface with a coarse abrasive
Magnetic tape Degaussing, incinerating or crosscut shredding
6. Notification of Compromise or Potential Compromise. The compromise or potential compromise of
DSHS shared Data must be reported to the DSHS Contact designated in the Contract within one (1)
business day of discovery. If no DSHS Contact is designated in the Contract, then the notification must
be reported to the DSHS Privacy Officer at dshsprivacyofficer@dshs.wa .gov. Contractor must also
take actions to mitigate the risk of loss and comply with any notification or other requirements imposed
by law or DSHS.
7. Data shared with Subcontractors. If DSHS Data provided under this Contract is to be shared with a
subcontractor, the Contract with the subcontractor must include all of the data security provisions within
this Contract and within any amendments, attachments, or exhibits within this Contract. If the
Contractor cannot protect the Data as articulated within this Contract, then the contract with the sub-
Contractor must be submitted to the DSHS Contact specified for this contract for review and approval.
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1644CS Prevention Services -County (6-26-2015) Page 33
AWARD AND REVENUES
2017-2019 Biennium
CONTRACTOR NAME
CONTRACT NUMBER
COUNTY
Kittitas County Public Health
CAC 1863-28733
Kittitas
The above named Contractor is hereby awarded the following amounts for the purposes listed.
REVENUE
OURCE
CODE:
333.99.59
334.04.6X
334.04.6X
333.92.43
333.37.88
Total Federal Funds
Total State Funds
TYPE OF SERVICE
SABG Prevention (7.1.17-6.30.19)
GF-State-Admin (for SABG Prevention)
SFY 18 (7.1 .17-6.30.18}
SFY 19 (7.1 .18-6.30-19)
Dedicated Marijuana Account-Fund 315-State
SFY 18 (7.1 .17-6.30.18}
SFY 19 (7.1 .18-6.30-19)
PFS-Total
Year 4 FFY16 (7.1.17-9.29.17)
Year 5 FFY17 (9.30.17-9.29.18}
STR-Total
FFYl 7 {8.15.17-4.30.18)
FFY18 {5 .1.18-4.30.19}
!TOTAL ALL AWARDS
Federal CFDA:
SFY 18
$17,548
$1,261
$1 ,261
$7,614
$7,614
$21,614
$9,296
$12,318
$0
$39,162
$8,875
$48,037
AWARD AMOUNTS
fil.12
$71,553
$3,009
$3,009
$23,120
$23,120
$12,318
$12,318
$0
$83,871
$26,129
$110,000
SABG-Substance Abuse Block Grant -CFDA 93 ,959 Substance Abuse and Mental Health Services Administration (SAMHSA)
.5ABG Prevention:
Funding pcri od!s l: 7.1 ,17-6.30.19
Funds may be used in SFY 18 or SFY 19; up to the Total 17-19 Biennium award, as indicated above .
GF-Stote-Admin (for .5ABG Prevention):
Fundln · erred .s : 7.1.17-6.30.18 and 7.1.18-6.30.19
Funds must be used only in the SFY in which they are awarded, as indicated above .
Dedicated Morijuono Account-Fund 315 State :
FundJnu _i:~ 7.1.17-6.30,18 and 7.1.18-6.30.19
Funds must be used only in the SFY in which they are awarded, as indicated above .
PFS-Partnerships for Success-CFDA 93.243 Substance Abuse and Mental Health Services Administration (SAMHSA)
PFS:
7.1.17-9.29 .17
9.30.17-9 .29 .18
Funds must be used in the FFY in which they are awarded, as indicated above ,
Beginning 9.30 .17, funds for Year 5 may be used i n SFY 18 or SFY 19 , until 9.29 .18.
Total 17-19
Biennium
$89,101
$4,270
$30,734
$33,932
$9,296
$24,636
$0
$123,033
$35,004
$158,037
STR -State Targeted Response to the Oplod Crlsis-CFDA 93.788 Substance Abuse and Mental Health Services Administration (SAMHSA)
STR:
8 .15 .17-4.30.18
5.1.18-4.30.19
Funds must be used in the FFY in which they are awarded, as indicated above .
Beginning 5 ,1.18, funds for FFY18 may be used in SFY 18 or SFY 19, until 4.30.19 .
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1644CS Prevention Services -County (6-26-2015)
Exhibit B
Page 34
Partnerships for Success (PFS) Advanced Community Surveillance Project
Year 5 September 30, 2017 to September 29, 2018
1. Definitions. The following definitions are added in this Exhibit:
Exhibit C
a. "Community Check Box Evaluation System Codebook" means is the CCB System Codebook in
which coding definitions are defined and described, both for Community Accomplishments and
Capacity Building Accomplishments.
b. "Community Surveillance" means data collection and evaluation process for coalitions to measure
community impact of coalition activity.
c. "Reliability Scoring" means scoring between Observer 2 and Observer 1 to ensure the
standardizing of methods, times, and other aspects of the observation to be accurate and
consistent, and therefore more useful to an overall evaluation. Reliability scoring happens on a
monthly frequency between the Coalition Coordinator(s) and Coalition Member(s) to ensure
reliability and consistency of entries with the Community Check Box Evaluation System Codebook.
2. Purpose. The purpose of the Year 5 Partnerships for Success Community Surveillance Targeted
Enhancement Project is to continue to provide support to Community Prevention and Wellness Initiative
(CPWI) communities that have the need, capacity and readiness to build community capacity to
evaluate community-level impact of coalition activity. This amendment applies to the "Advanced
Community Surveillance Pilot Year 5 PFS Targeted Enhancement Project".
3. Statement of Work.
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. Coalition Coordinator and a minimum of one (1) Coalition Member participate in the following :
(1) Enter a target of 40-100 quarterly data entries into the CCB Evaluation System. The Contractor
is responsible for inputting a minimum of 40 complete data entries into the CCB Evaluation
System per quarter (20 Community Accomplishments and 20 Capacity Building
Accomplishments).
(2) Work collaboratively with DSHS to become Primary and Secondary Observers; scoring shall
take place on a monthly basis between Coalition Coordinator(s) and Coalition Member(s). This
partnership will develop and pilot data collection methods which document and evaluate
coalition contributions to community-level change, including developing methods to track
prevention outputs as defined in the current version of the Community Check Box Evaluation
System Codebook for the pilot project that will be input in the Community Check Box Evaluation
System:
(a) Community Accomplishments
i. Community Change
ii. Services Provided
iii. Media
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iv. Resources Generated
v. Community Action
vi. Other Important Event
(b) Capacity Building Accomplishments
i. Organizational Capacity Change
ii . Training
iii. Implementation Support
iv. Coalition Development
v. Technical Assistance
vi. Internal Coalition Meeting
vii. Other Important Event
b. Coalition Coordinator(s) and Coalition Member(s) complete quarterly reliability scoring. Each
quarter, reliability scoring must be completed for Community Accomplishments and Capacity
Building Accomplishments. This will result in a total of 8 individual reliability scoring events
throughout the year.
c. Coalition Coordinator(s) and Coalition Member(s) participate in quarterly reliability scoring technical
assistance (TA) calls provided by DSHS Reliability Scorer (Observer 3) on dates to be determined.
d. Participate and present in annual DBHR Summer Institute Community Surveillance Pilot Project
Presentation in June 2018.
e. Complete and submit two supplemental DBHR CCB Evaluation Mini-Reports (due November 30,
2017 and April 30, 2018) on the coalition's use of the CCB data outputs. This shall be completed by
the Coalition Coordinator(s) and the acting Coalition Member(s) who have implemented the CCB
Community Surveillance Pilot Project.
Contractor shall use provided funds to
(1) Purchase a one year data collection software application license for use until expiration of the
license:
(a) The identified software is Community Check Box Evaluation System (CCB) which is a
product owned by the University of Kansas.
(b) Contractor shall purchase the software license through :
Community Systems Group LLC
3115 S. Grand Blvd, Suite 600
St. Louis MO, 63118
(314) 287-5161
www.commun tysystemsgroup .com
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1644CS Prevention Services -County (6-26-2015) Page 36
(2) Contract directly for expert consultation from Community Systems Group for a minimum of 10
hours during contract period to include:
(a) Consultation and technical assistance for uploading the coalition's logic model into the CCB .
(b) Designing and maintain the Coalition's CCB page for specific data entry related to the logic
model activities.
(c) Training and consultation to become Primary Observers to identify the local activities related
to the coalition's logic model and strategies in the coalition's action plan that should be
coded and entered into the ODSS.
(d) Quarterly calibration scoring calls between Primary Observer(s), DSHS Reliability Scorer,
and CSG Calibration Scorer.
4. Reporting.
The Contractor Primary Observers shall:
a. Enter data monthly into the CCB System by the 15th of the month for previous month's services.
(1) Report quarterly a minimum of 40 complete data entries (20 Community Accomplishments and
20 Capacity Building Accomplishments) into the Community Check Box Evaluation System
(CCB) using the current Community Check Box Evaluation System Codebook that reflect the
work of the coalition for the previous month. A target of 100 complete data entries is strongly
encouraged to enhance use of the CCB system.
(2) Complete entries into the CCB are defined as entries per Community Accomplishment and
Capacity Building Accomplishment which critically reflect the impact made in the community by
the respective Coalition. Entries into the CCB will demonstrate the Coalition's efforts toward
accountability, self-evaluation, continuous improvement, and ongoing monitoring of progress
against the work identified in the Coalition's Action Plan. Outputs from the CCB should be used
in analysis of Coalition efforts and used in the Strategic Planning process, as well as a parallel
compliment to the outputs from the Minerva MIS Reporting System.
b. Participate and present in annual DBHR Summer Institute Community Surveillance Pilot Project
Presentation in June 2018.
c. Complete and submit two supplemental DBHR CCB Evaluation Mini-Reports (due November 30,
2017 and April 30, 2018) on the coalition's use of the CCB data outputs. This shall be completed by
the Coalition Coordinator(s) and the acting Coalition Member(s) who have implemented the CCB
Community Surveillance Pilot Project.
5. Performance Work Statement.
Due to the nature of this project's potential contribution to statewide prevention system development, if
the Contractor shall fail to report services in the CCB data collection software application by the 15th of
the month for two or more consecutive months during the contract period, the resulting penalty may be
exclusion from future opportunities to continue participation in the Community Surveillance Pilot
Targeted Enhancement Project.
6. Consideration. Total consideration payable to Contractor for timely and satisfactory performance of
the work under this Exhibit is $4,800 including any and all expenses, and shall be based on the
following:
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1644CS Prevention Services -County (6-26-2015) Page 37
a. The source of funds for this project is the Partnerships for Success (PFS) Grant CFDA 93.243
(Year 5 September 30, 2017 to September 29, 2018).
b. Administrative expenses are limited to a maximum of 8% of the total.
c. If funding permits after the software license acquisition and required consultation and training are
allocated, project funds may be used to support or enhance approved substance abuse prevention
action plan strategies.
d. Administrative expenses are limited to a maximum of 8% of the total Targeted Enhancement
Project funds.
e. Honorariums for guests and participants are not allowed .
f. Meals are not allowed with these funds.
Light refreshments totaling $2.50 per person or less are permitted with these funds if training lasts
more than two (2) hours in duration.
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Partnerships for Success (PFS) Secure Medicine Take-Back
Year 5 September 30, 2017 to September 29, 2018
1. Definitions. The following definitions are added in this Exhibit:
a. "Rx" means prescription drugs and medications.
2 . Purpose.
Exhibit D
The purpose of the Year 5 Partnerships for Success Targeted Enhancement Project is to provide
support to the Community Prevention and Wellness Initiative (CPWI) community to implement a Secure
Medicine Take-back Project. The project aligns with the community needs assessment and will
increase local capacity to address prescription drug misuse and abuse by reducing social availability of
prescriptions in the community.
3. Statement of Work.
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. Enhance community capacity to practice safe disposal of medications by promoting permanent
secure drop box in the location where community readiness has been established. (Installation and
disposal must follow all DEA rules and all federal and state laws and regulations.)
(1) Collaborate with community partners to maintain and/or enhance policies and procedures
necessary to maintain a permanent secure medicine take-back drop box.
(2) Overtime wages for law enforcement officers and staff as outlined in strategic plan and outside
of normal duties and other real costs (including mileage reimbursement) associated with
transporting and properly disposing of collected medicines at EPA approved locations shall be
permitted.
b. Create, utilize and disseminate public education information materials to increase awareness of the
secure medicine take-back project, local treatment resources, naloxone information and medical
response (Good Samaritan law) cards.
( 1 ) Collaborate with community partners to develop and adopt policies and procedures necessary
to maintain a permanent secure medicine take-back drop box.
(2) Disseminate public information including information on local treatment resources, naloxone
information and medical response cards and posters. (Print ready materials are available online
at www.stopoverdose.org).
Utilize publications already available through DSHS and other websites. (i.e., SAMHSA Opioid
Overdose Toolkit, and downloadable/printable materials on
http://www.dshs .wa .gov/dbhr/dapreventionpub.shtrnl#dbhr, www.stopoverdose.org and
www . takebackyourmeds.orq .
(3) Submit locally-developed educational and informational materials to DBHR for approval at least
ten (10) business days prior to publication.
DSHS Central Contract Services
1644CS Prevention Services -County (6-26-2015) Page 39
c. Ensure at least three (3) news publications to increase community awareness of secure medicine
take-back project.
(1) Publications are locally determined with the expectation of reaching community members.
(2) Acceptable examples of publications include but are not limited to newspapers, newsletters,
payroll stuffers, flyer inserts in bags distributed by pharmacy, printing on paper grocery bags,
public service announcements (radio or television), and social media.
d. Coalition members provide education at one (1) public forum on topics related to safe home
medicine storage, safe medicine disposal, local resources, and ways to reduce youth access to
prescription medication for misuse and abuse before September 29, 2018.
e. Coalition coordinator or coalition representative participate in at least one (1) project learning
community meeting/ webinar lasting up to two (2) hours in duration (date and time to be
determined) with secure medicine take-back project DBHR staff lead during contract period.
f. If identified in project plan, purchase and distribute home medication lock boxes or bags to
distribute to community members in consultation with DSHS.
Prior to purchasing home medication lock boxes or bags the Contractor will submit to DSHS in
writing a plan for the purchase and distribution of home mediation storage devices.
(1) This plan will include the cost and source of the home storage devices, the number of devices to
be purchased, a clear plan for distribution and method for tracking the use of the devices.
(2) The Contractor must also demonstrate how the distributed home medication devices will be
altered (by engraving, indelible ink, or other means) to have no cash value
4. Reporting. The Contractor shall :
a . Create and submit Secure Medicine Tack-back Project as an "Environmental Program" in the
Minerva reporting system within 30 days following the availability to enter Environmental Strategies
in the Minerva System.
(1) Report all project efforts into Minerva by the 15th of each month following month of service.
Contractor may bill for cost reimbursement for month of service if appropriate service data is
provided in Minerva.
(2) Track and report the following in Minerva:
(a) Number of new policies developed and adopted to support sustained drop box;
(b) Number of educational and or informational materials developed;
(c) Number of outreach materials developed and distributed including news publications;
(d) Number of pharmacies involved in information dissemination efforts;
(e) Number of health care providers involved in information dissemination efforts; and
(f) Pounds of medicine collected, monthly; once secure medicine take-back box is in place .
(g) The number of home medication storage devices purchased and distributed, including a
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pre/posttest survey for those that receive the log bags/boxes to be determined by DSHS
(3) Report Coalition Coordinator time spent on project in the "direct" and "indirect" staff time related
to the project.
5. Performance Work Statement.
If the Contractor shall fail to enter the Secure Medicine Take-back program in Minerva (Section 4.) and
submit to DSHS for review within 30 days of contract execution, the resulting penalty of a deduction in
the amount of $10.00 for each business day late will be made no more than $300. The penalty shall be
reflected on the A-19 invoice.
6. Consideration.
Total consideration payable to Contractor for timely and satisfactory performance of the work under this
Exhibit is modified as follows including any and all expenses, and shall be based on the following:
a. The source of funds for this project is the Partnerships for Success (PFS) Grant CFDA 93.243
(Year 5 September 30, 2017 to September 29, 2018).
b. The current maximum of Exhibit D is $2,000 .
c. Administrative expenses are limited to a maximum of 8% of the total Targeted Enhancement
Project funds.
d. Honorariums for guests and participants are not allowed .
e. Meals are not allowed with these funds.
Light refreshments totaling $2.50 per person or less are permitted with these funds if training lasts
more than two (2) hours in duration.
DSHS Central Contract Services
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Exhibit E
Partnerships For Success (PFS) Community Coalition Sector Sharing Project
Year 5 September 30, 2017 to September 29, 2018
1. Purpose.
This purpose of the project is to increase the capacity for coalitions to develop strategies on share with
other coalitions on how they can engage identified sectors of their communities through community
sector sharing in a cross site sharing format. The Sector Sharing Project aligns with the needs of the
community and will increase local capacity and strengthen the Coalition as well as other coalitions in
the areas as identified in the application.
2. Statement of Work.
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:
Coalition Sharing Incentive Project:
a. Facilitate at least two (2) Sector Sharing meetings, whereas each meeting focuses on inviting
sector group representatives from other CPWI coalitions (or other community coalitions focused on
substance abuse prevention) to gather and share experiences and ideas for community level
change within their sphere of influence. (for example, a Sector Sharing meeting could invite Law
Enforcement for the first meeting and the second meeting could invite the Faith-based sectors.)
Meetings may be in-person or conducted virtually using webinar technology. A phone conference
will not be sufficient.
b. Coalition coordinator and chairperson shall visit at least one (1) peer CPWI coalition (recommended
by DBHR) during that other coalition's monthly full-membership coalition meeting for the purpose of
cross-site sharing.
(1) Submit Sector Sharing meeting dates and agenda to DBHR at least fifteen (15) days before the
meeting is to occur.
(2) Submit summary of meeting notes and attendance within two (2) weeks of the meeting
completion.
(3) Write an article focused on tips and lessons learned from the meeting and post on Athena
Forum website .
3. Reporting.
Sector Sharing Project: Enter each Sector Sharing meeting as a new "Log" under the Coalition Program
in the Minerva.
Report all project efforts into the Minerva by the 15th of each month following month of service .
a. Enter two (2) sector sharing dates as aggregate entries into Minerva that includes dates,
attendance, and demographic information of attendees.
b. Enter one (1) peer coalition meeting as an individual entry that incudes date of meeting and
attendance.
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4. Performance Work Statement.
Sector Sharing Project payment penalty: For each business day the list of registered participants in
Section 2. b. (2) is late, there will be a $50 deduction reflected on the next available A-19. Maximum
penalty for this Exhibit shall be $500.
5. Consideration. Total consideration payable to Contractor for timely and satisfactory performance of
the work under this Exhibit is modified as follows including all expenses and shall and shall be based
on the following:
a. The source of funds for this project is the Partnerships for Success (PFS) Grant CFDA 93.243
(Year 5 September 30, 2017 to September 29, 2018).
b. The current maximum of Exhibit E is $2,000.
c. Administrative expenses are limited to a maximum of 8% of the total Targeted Enhancement
Project funds.
d. Honorariums for guests and participants are not allowed .
e. Meals are not allowed with these funds.
Light refreshments totaling $2.50 per person or less are permitted with these funds if training lasts
more than two (2) hours in duration.
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Exhibit F
Partnerships For Success (PFS) Increase Capacity, Outreach, and Programming to LGBTQ Community
Project Year 5 September 30, 2017 to September 29, 2018
1. Purpose.
This purpose of the Year 5 Partnerships for Success Targeted Enhancement Project is to provide
support to the Community Prevention and Wellness Initiative (CPWI) community to increase the
capacity for coalitions to increase prevention programing to the LGBTQ community and their families
and provide dedicated outreach efforts to recruit LGBTQ Community participants in at least one (1)
prevention program identified in the coalition's strategic plan.
2. Statement of Work.
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:
Increase prevention programming to the LGBTQ community and their families by deliverable outlined
as follows:
a. Increase outreach efforts to focus on LGBTQ community members and their families
Increase community collaboration by engaging new prevention partners that will enhance services,
increase capacity, or conduct more effective outreach to the LGBTQ community in local prevention
services.
b. Increase coalition capacity to engage members of the LGBTQ community in local prevention
services by receiving consultation or host at least one (1) training for coordinators/coalition on how
to increase prevention programming to focus population.
Submit consultation/training dates and agenda to DBHR fifteen (15) days prior to date of event.
c. Increase the number of LGBTQ community members and their families receiving prevention
services.
d. Document recruitment efforts and hours, document coalition involvement in the recruitment of focus
population. When applicable, utilize pre and posttest in program implementation to assess group
outcomes.
3. Reporting.
Increase capacity, outreach, and/or programming to LGBTQ Community: Enter outreach efforts,
increased prevention programming, and training/consolation events as a new program in the Minerva .
Report all project efforts into the Minerva by the 15th of each month following month of service.
a. Enter new program into the Minerva under project title within thirty (30) days of contract execution .
(1) Report direct program in the Minerva System as an "Individual" log, including participant
demographic data.
(2) Report outreach efforts including recruitment efforts and hours in Minerva as an "Aggregate" log
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1644CS Prevention Services -County (6-26-2015) Page 44
including .
b. Enter one (1) training/consultation events under the program as an "Aggregate" log including
number of participants and general participant demographic data.
4. Performance Work Statement.
If the Contractor shall fail to enter the Increase Capacity, Outreach and/or Programming to LGBTQ
Community in Minerva (Section 3.) and submit to DSHS for review within 30 days of contract
amendment execution, the resulting penalty of a deduction in the amount of $10.00 for each business
day late will be made. The penalty shall be reflected on the A-19 invoice.
5. Consideration. Total consideration payable to Contractor for timely and satisfactory performance of
the work under this Exhibit is modified as follows including all expenses and shall and shall be based
on the following:
a. The source of funds for this project is the Partnerships for Success (PFS) Grant CFDA 93.243
(Year 5 September 30, 2017 to September 29, 2018).
b. The current maximum of Exhibit F is $5,000.
c. Administrative expenses are limited to a maximum of 8% of the total Targeted Enhancement
Project funds.
d. Honorariums for guests and participants are not allowed .
e. Meals are not allowed with these funds .
Light refreshments totaling $2.50 per person or less are permitted with these funds if training lasts
more than two (2) hours in duration.
DSHS Central Contract Services
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State Targeted Response to the Opioid Crisis (STR)
Community Prevention and Wellness Initiative (CPWI) Expansion Community
August 15, 2017 -April 30, 2019*
*Pending federal award for Year 2 of grant (May 1, 2018 to April 30, 2019).
1. Definitions. The following definitions are added in this amendment:
Exhibit G
a. "State Targeted Response to the Opioid Crisis", "Opioid STR" or "STR" means the Federal
Substance Abuse and Mental Health Services Administration (SAMHSA) Grants Funding. CFDA #
93.788.
2. Purpose. The purpose of this Exhibit is to implement additional Community Prevention and Wellness
Initiative (CPWI) services in the community and school district identified in selected Washington Opioid
STR Grant for CPWI Expansion RFA # 18/19-001 application.
3. Performance Statement of Work.
The Contractor shall ensure services, and staff, and otherwise do all things necessary for or incidental
to the performance of work, as set forth below. Prevention programs and services include, but are not
limited to:
a. In addition to the CPWI Community Coalition Guide, Contractor shall follow the unique timeframes
for STR CPWI Expansion below:
(1) Implement at least one (1) service by August 31, 2017. Service selected shall be negotiated
with DBHR.
(2) Hire or identify 0.5 FTE Community Coalition Coordinator within thirty (30) days of executed
contract.
(3) First coalition meeting must occur by September 30, 2017 .
(4) Contractor shall ensure provision of the following three (3) community activities by December
30, 2017:
(a) Host at least one (1) local Town Hall meeting to educate community members about local
youth substance use issues identified in needs assessment and engage expanded
participation in coalition activities.
(b) Provide one ( 1) Key Leader Orientation with community leaders to gain feedback and
support.
(c) Provide at least one (1) Medicine Take-Back event with local law enforcement.
i. Collection and disposal must follow all United States Drug Enforcement Agency (DEA)
rules and all federal and state laws and regulations
ii. Overtime wages for law enforcement officers and staff outside of normal duties and
other real costs (including mileage reimbursement) associated with transporting and
properly disposing of collected medicines at EPA approved locations shall be permitted .
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1644CS Prevention Services -County (6-26-2015) Page 46
iii. Disseminate public information including prevention messages, local treatment
resources, naloxone information and medical response cards and posters. (Print ready
materials are available online at www.StopOverdose.org ,www.TheAthenaForum.org/rx ,
and www.StartTalkingNow.org/parentslfind -resources/prescription-drugs).
(5) Contractor shall participate in planning meetings to meet service confirmation deadlines with
identified school district and Educational Service District (ESD) staff for the provision of
Prevention and Intervention services as outlined in the successful application.
b. Contractor shall ensure that a regular annual schedule of direct prevention services for public
dissemination is established.
(1) Regular annual schedule shall take into account items including, but not limited to:
implementation times that maximize participation and service outcomes; local needs and gaps;
leveraged resources; and, other locally identified factors that influence service delivery
throughout the year.
(2) Regular annual schedule and community dissemination plan shall be identified as part of the
CPWI Action Plan and submitted to Contract Manager or designee for DSHS review in
accordance with the timeline in section 3.c. of Exhibit G.
c. Submit a completed Strategic Plan, including an annual Action Plan and Budget with projected
expenditures, including salary and benefits for DSHS funded prevention staff, program costs,
training and travel to the Contract Manager or designee, by January 3, 2018 according to the CPWI
Community Coalition Guide.
d. Budget adjustments that total ten percent (10%) or more from the approved Contractor and/or
CPWI coalition budget shall submit a budget revision for approval to CM or designee at least fifteen
(15) days prior to expending adjusted budget items. Approval must be granted prior to expending
funds.
e. Ensure new hire Community Coalition Coordinators meet required position qualifications and
workstation requirements found in the CPWI Community Coalition Guide.
(1) Contractor shall submit a completed Community Coalition Coordinator Qualification Checklist to
Contract Manager or designee for review.
DSHS shall review and respond within forty-eight (48) business hours.
(2) DSHS reserves the right to require Contractor to develop a Community Coalition Coordinator
training plan if candidate does not meet required qualifications.
f. Contractor contact on page one of this Contract and primary fiscal staff or their designee(s) shall
attend annual contractor training that will be scheduled for four (4) hours in duration. Date and
location will be announced by DBHR.
g. Ensure Community Coalition Coordinators are Certified Prevention Professionals (CPP).
(1) Ensure currently certified Community Coalition Coordinator(s) maintain CPP credential status,
and
(2) Ensure Certified Prevention Professional (CPP) certification within eighteen (18) months of new
Community Coalition Coordinator start date.
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h. Enter approved programs, based on the priorities, goals and objectives described in the approved
Strategic Plan, into the Minerva within thirty (30) days of Strategic Action Plan approval.
Community Coalition, Medicine Take-Back and Training Program Profiles shall be entered into the
Minerva system by October 10, 2017 for on-time data entry.
i. Ensure sixty percent (60%) of programs supported by DSHS funds will be replications or
adaptations of "Evidence-based Practice" substance abuse prevention programs as identified by
DBHR. Ensure that all of the programs supported by DSHS meet the Center for Substance Abuse
Prevention's (CSAP) Principles of Substance Abuse Prevention, found on the Athena Forum
Website. www.TheAthenaForum.org/CSAPprinciples
j. Food costs are generally unallowable during program implementation except within the following
parameters:
(1) Light refreshment costs for training events and meetings lasting longer than two (2) hours in
duration are allowable.
Ensure that light refreshment costs do not exceed $2.50 per person.
(2) Meals are not allowable costs.
(3) No more than a total of $1,000 may be spent on food or light refreshments per CPWI Coalition
per year.
k. Contractor is encouraged to collaborate and partner with community-based organizations that
operate within or serve the CPWI community.
4. Consideration .
Total consideration payable to the Contractor for satisfactory performance of the work under this Exhibit
G is, up to a maximum of $200,000 including any and all expenses.
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Exhibit H
Partnerships For Success (PFS)
Community Coalition Mentoring Project
Year 5 September 30, 2017 to September 29, 2018
1. Purpose.
This purpose of the project is to increase the capacity for coalitions to mentor another coalition. The
community mentoring project should be focused on providing another coalition with technical
assistance and guidance on the topics related to prevention theory, Strategic Prevention Framework,
and implementation of approved prevention programs.
2. Statement of Work.
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:
Coalition Mentoring Incentive Project:
Coalition coordinator and chairperson visit at least one (1) peer coalition (by request or recommended
by DBHR) during that other coalition's monthly full-membership coalition meeting for the purpose of
cross-site sharing.
a. Spend four (4) hours each month mentoring another coalition.
Each meeting should be focused on providing another coalition with technical assistance and
guidance on the topics related to prevention theory, Strategic Prevention Framework, and
implementation of approved prevention programs.
Meetings may be in-person or conducted virtually using webinar technology. A phone conference
will not be sufficient.
b. Coalition coordinator and chairperson shall visit at least one (1) mentee coalition meeting during
that other coalition's monthly full-membership coalition meeting for the purpose of providing
technical assistance.
(1) Submit coalition mentor meeting dates and agenda to DBHR at least five (5) days before the
meeting is to occur.
(2) Submit final report on how mentor activities have increased the capacity and coalition activities
for both the mentor coalition and the coalition mentee on June 23, 2018.
(3) Attend at least one (1) peer coalition meeting (on-site) to visit and share experiences and submit
dates and meeting agenda to PSM.
3. Reporting.
Enter each mentoring activities as a new "Log" under the Coalition Program in the Minerva.
Report all project efforts into the Minerva by the 15th of each month following month of service.
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a. Dates and attendance of mentoring meetings that equal four (4) hours each month .
b. Dates and attendance of visit to another coalition's meeting .
4. Performance Work Statement.
Coalition Mentoring Project payment penalty: For each business day the final report Section 1. b. (2) is
late, there will be a $50 deduction reflected on the next available A-19. Maximum penalty for this
Exhibit shall be $500.
5. Consideration. Total consideration payable to Contractor for timely and satisfactory performance of
the work under this Exhibit is as follows including all expenses and shall and shall be based on the
following:
a. The source of funds for this project is the Partnerships for Success (PFS) Grant CFDA 93.243
(Year 5 September 30, 2017 to September 29, 2018).
b. The current maximum of Exhibit H is $4,000.
c. Administrative expenses are limited to a maximum of 8% of the total Targeted Enhancement
Project funds.
d. Honorariums for guests and participants are not allowed .
e. Meals are not allowed with these funds.
Light refreshments totaling $2.50 per person or less are permitted with these funds if training lasts
more than two (2) hours in duration.
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Exhibit I
Partnerships for Success (PFS)
Secure Medicine Take-Back
Year 5 September 30, 2017 to September 29, 2018
1. Definitions. The following definitions are added in this amendment:
a. "CPWI" means Community Prevention and Wellness Initiative.
b. "DEA" means United States Drug Enforcement Agency .
c. "EPA" means Environmental Protection Agency
d. "Rx" means prescription drugs and medications.
2. Purpose ,
The purpose of the Year 5 Partnerships for Success Targeted Enhancement Project is to provide
support to the Community Prevention and Wellness Initiative (CPWI) community to implement a Secure
Medicine Take-back Project. The project aligns with the community needs assessment and will
increase local capacity to address prescription drug misuse and abuse by reducing social availability of
prescriptions in the community.
3. Statement of Work.
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. Enhance community capacity to practice safe disposal of medications by promoting permanent
secure drop box in the location where community readiness has been established. (Installation and
disposal must follow all DEA rules and all federal and state laws and regulations.)
(1) Collaborate with community partners to maintain and/or enhance policies and procedures
necessary to maintain a permanent secure medicine take-back drop box.
(2) Overtime wages for law enforcement officers and staff as outlined in strategic plan and outside
of normal duties and other real costs (including mileage reimbursement) associated with
transporting and properly disposing of collected medicines at EPA approved locations shall be
permitted.
b. Create, utilize and disseminate public education information materials to increase awareness of the
secure medicine take-back project, local treatment resources, naloxone information and medical
response (Good Samaritan law) cards.
(1) Collaborate with community partners to develop and adopt policies and procedures necessary
to maintain a permanent secure medicine take-back drop box.
(2) Disseminate public information including information on local treatment resources, naloxone
information and medical response cards and posters. (Print ready materials are available online
at www.stopoverdose.org).
Utilize publications already available through DSHS and other websites. (i.e., SAMHSA Opioid
Overdose Toolkit, and downloadable/printable materials on
DSHS Central Contract Services
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http://www.dshs.wa.gov/dbhr/dapreventionpub .shtm l#dbhr, www.sfopoverdose.org and
wiNw .takebackyoum,eds.org .
(3) Submit locally-developed educational and informational materials to DBHR for approval at least
ten (10) business days prior to publication.
c . Ensure at least three (3) news publications to increase community awareness of secure medicine
take-back project.
(1) Publications are locally determined with the expectation of reaching community members.
(2) Acceptable examples of publications include but are not limited to newspapers, newsletters,
payroll stuffers, flyer inserts in bags distributed by pharmacy, printing on paper grocery bags,
public service announcements (radio or television), and social media.
d. Coalition members provide education at one (1) public forum on topics related to safe home
medicine storage, safe medicine disposal, local resources, and ways to reduce youth access to
prescription medication for misuse and abuse before September 29, 2018.
e. Coalition coordinator or coalition representative participate in at least one (1) project learning
community meeting/ webinar lasting up to two (2) hours in duration (date and time to be
determined) with secure medicine take-back project DBHR staff lead during contract period.
f. If identified in project plan, purchase and distribute home medication lock boxes or bags to
distribute to community members in consultation with DSHS.
Prior to purchasing home medication lock boxes or bags the Contractor will submit to DSHS in
writing a plan for the purchase and distribution of home mediation storage devices.
(1) This plan will include the cost and source of the home storage devices, the number of devices to
be purchased, a clear plan for distribution and method for tracking the use of the devices.
(2) The Contractor must also demonstrate how the distributed home medication devices will be
altered (by engraving, indelible ink, or other means) to have no cash value
4. Reporting .
The Contractor shall :
a. Create and submit Secure Medicine Tack-back Project as an "Environmental Program" in the
Minerva reporting system within 30 days following the availability to enter Environmental Strategies
in the Minerva System.
( 1) Report all project efforts into Minerva by the 15th of each month following month of service.
Contractor may bill for cost reimbursement for month of service if appropriate service data is
provided in Minerva.
(2) Track and report the following in Minerva :
(a) Number of new policies developed and adopted to support sustained drop box;
(b) Number of educational and or informational materials developed;
(c) Number of outreach materials developed and distributed including news publications;
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1644CS Prevention Services -County (6-26-2015) Page 52
(d) Number of pharmacies involved in information dissemination efforts;
(e) Number of health care providers involved in information dissemination efforts; and
(f) Pounds of medicine collected, monthly; once secure medicine take-back box is in place .
(g) The number of home medication storage devices purchased and distributed, including a
pre/posttest survey for those that receive the log bags/boxes to be determined by DSHS
(3) Report Coalition Coordinator time spent on project in the "direct" and "indirect" staff time related
to the project.
5. Performance Work Statement.
If the Contractor shall fail to enter the Secure Medicine Take-back program in Minerva (Section 4.) and
submit to DSHS for review within 30 days of contract execution, the resulting penalty of a deduction in
the amount of $10.00 for each business day late will be made no more than $300. The penalty shall be
reflected on the A-19 invoice.
6. Consideration .
Total consideration payable to Contractor for timely and satisfactory performance of the work under this
Exhibit is as follows including any and all expenses, and shall be based on the following:
a. The source of funds for this project is the Partnerships for Success (PFS) Grant CFDA 93.243
(Year 5 September 30, 2017 to September 29, 2018).
b. The current maximum of Exhibit I is $3,500 .
c. Administrative expenses are limited to a maximum of 8% of the total Targeted Enhancement
Project funds .
d. Honorariums for guests and participants are not allowed .
e. Meals are not allowed with these funds.
(1) Light refreshments totaling $2.50 per person or less are permitted with these funds if training
lasts more than two (2) hours in duration .
DSHS Central Contract Services
1644CS Prevention Services -County (6-26-2015) Page 53
ExhibitJ
Partnerships For Success (PFS)
Carryover Funds To Enhance Prevention Services
Carryover ending: September 29, 2017
This Exhibit add funds in the amount of $0 for enhancing prevention services.
Contractor will bill on an A-19 and call out PFS Carryover as the funding source in the program description.
The source of funds for this project is the Partnerships for Success (PFS) Grant CFDA 93.243 (PFS Carryover
ending September 29, 2017).
DSHS Central Contract Services
1644CS Prevention Services -County (6-26-2015) Page 54
Exhibit K
Partnerships For Success {PFS)
Carryover Funds for NPN Conference Support
Carryover ending: September 29, 2017
This Exhibit add funds in the amount of $0 to attend the National Prevention Network Conference as outlined in
the approved application.
Training to support registration and lodging costs only following state travel reimbursement guidelines and
rates stated in Section 4. c. (3).
Contractor will bill on an A-19 and call out PFS Carryover as the funding source in the program description.
Bill for training as stated in Section 4. c. ( 4 ).
Report training in the Minerva System by October 15, 2017 as outlined in Section 5.
The source of funds for this project is the Partnerships for Success (PFS) Grant CFDA 93.243 (PFS Carryover
ending September 29, 2017).
DSHS Central Contract Services
1644CS Prevention Services -County (6-26-2015) Page 55
Kittitas County
Review Form
Grants & Contract Agreement
Today's Date
04/12/2018
Fund/Department
116-Public Health
Contract/Grant Information
Agenda Date
Contract /Grant Agency: Agreement between Department of Social and Health Services Division of
Behavioral Health and Recovery and KCPHD
Period Begin Date: April 1, 2018 I I Period End Date: June 30, 2019
Total Grant/Contract Amount: $158,037.00
Grant/Contract Number:
Contract/Grant Summary:
The purpose of this contract is to coordinate and implement prevention programs and strategies
designed to prevent or delay the misuse and abuse of alcohol, marijuana, tobacco, and other drugs,
increase mental health promotion, and prevent suicide. Program target populations and focus area are
dependent on funding source and specific funded exhibits.
Recommendation for Boar f Health and Board of Health Review on
Date :tll/?S
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPROVED AS TO FORM:
Date
Signature of Board of Health member Date
Financial Information
Total Amount$ 158,037.00 State Funds$ 35,004 Federal Funds$ 123,033
Percentage County Funds Matching Funds$ CFDA# 93.959(SABG), 93.243(PFS)
In-Kind$
Explain
Grant/Contract Review Page 1
Is Equipment being purchased? yes Who owns equipment? KCPHD
New Personnel being hired? yes Contact HR hiring-reporting requirements
Future impacts or liability to Kittitas County :
Budget Information
Budget Amendment Needed? Yes[] attach budget form
1
New Division Created? yes
Revenue Code 116.612.47 Behavioral Health & Recovery
GL REVENUE DESCRIPTION
612.47.1.333.93.959 SABG SUBSTANCE ABUSE BLOCK GRANT
612.47.2.333.93.243 PFS PARTNERSHIP FOR SUCCESS
612.47.3.334.04.6X GFS GENERAL FUND STATE ADMIN
612.47.4.334.04.6X DMA DEDICATED MARIJUANA ACCOUNT
TOTAL
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub-Contract Approved Date:
Prosecutor Review
) Has the Prosecutor reviewed this agreement?
County Departments Impacted
No O Why not
SFY-18 SFY-19
17,548 71,553
21,614 12,318
1,261 3,009
7,614 23,120
48,037 110,000
I Yes • No D
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
J Reviewer I Date
Grant/Contract Review
TOTAL
89,101 (FED)
33,932 (FED)
4,270 (STATE)
30,734 (STATE)
158,037 (TOTAL)
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