HomeMy WebLinkAboutDSHS Contract Amend 3Washingtorr State
Department of Social
& Health Services
Transforming lives
CONTRACT AMENDMENT
DSHS CONTRACT NUMBER:
1763-98187
Amendment No. 03
This Contract Amendment is between the State of Washington Department of
Social and Health Services (DSHS) and the Contractor identified below.
Program Contract Number
Click here to enter tex t.
Contractor Contract Number
CONTRACTOR NAME
Kittitas County
CONTRACTOR ADDRESS
507 North Nanum Street Suite 102
Elle nsbur , WA 98926-2886
CONTRACTOR CONTACT
Joann Schaan ·
' DSHS A DMINISTRATION
Developmental Disabilities Admin
DSHS GONTACT NAME AND TiTLE
Seanna Woodard
Operations Manager
DSHS CONTACT TELEPHONE
509 329-2952
CONTRACTOR doing business as (DBA)
Kittitas County DDA County Services
WASHINGTON UNIFORM BUSINESS DSHS INDEX NUMBER
IDENTIFIER (UBI) 1225
192-002-673
CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS
509 933-8233 Click here to enter tex t. Click here to enter text.
DSHS DIVISION DSHS CONTRACT CODE
Division of Developmental 1769CS-63
Disabilities
DSHS CONTACT ADDRESS
1611 W Indiana Ave
S okane, WA 99205
DSHS CONTACT FAX
509 568-3037
IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT?
No
AMENDMENT START DATE
07/01/2018
PRIOR MAXIMUM CONTRACT AMOUNT
$826,847.00
REASON FOR AMENDMENT;
CONTRACT END DATE
06/30/2019
AMOUNT OF INCREASE OR DECREASE
$801,577.00
TOTAL MAXIMUM CONTRACT AMOUNT
$1,628,424.00
CHANGE OR CORRECT PERIOD OF PERFORMANCE AND MAX CONTRACT AMOUNT
ATTACHMENTS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into
this Contract Amendment by reference:
D Additional Exhibits speci ):
This Contract Amendment, including all Exhibits and other documents incorporated by reference, contains all of the terms
and conditions agreed upon by the parties as changes to the original Contract. No other understandings or
representations, oral or otherwise, regarding the subject matter of this Contract Amendment shall be deemed to exist or
bind the parties. All other terms and conditions of the original Contract remain in full force and effect. The parties signing
below warrant that they have read and understand this Contract Amendment, and have authority to enter into this Contract
Amendment.
CONTRACTOR SIGNATURE
DSHS Central Contract Services
6024PF Contract Amendment (1-26-2018)
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DAT E S IGNED
Page 1
This Contract between the State of Washington Department of Social and Health Services (DSHS) and the
Contractor is hereby amended as follows :
1. The Total Maximum Contract Amount is hereby increased in the amount of $801,577 for a new
Contract Amount of $1,628,424.
2. The Program Agreement end date is extended to June 30, 2019 .
3. Special Terms and Conditions, Section 8, Billing and Payment is amended as follows:
a . Program Agreement Budget: DSHS shall pay the County all allowable costs, which are defined by
DOA as costs incurred by the program for:
f. Program Administration : The County will provide program administration and may bill for
administrative costs up to the identified amount in Exhibit B. Administrative costs reimbursement
will not exceed 7% of the total combined allocation for Consumer Support and Other Consumer
Support services unless millage has been declared or the Assistant Secretary of ODA approves a
request for an exception under Chapter 388-850 WAC. Monthly claims for administrative costs will
be for allowable expenditures incurred or 1/12 of the maximum Administration amount identified in
Exhibit B, or the lessor of the two.
4. Exhibit B. Program Agreement Budget is hereby replaced with the following Budget Revision :
All other terms and conditions of this Contract remain in full force and effect.
EXHIBITB
Program Agreement Budget
D Original Budget X Budget Revision
REVENUES
Fiscal
Year Fund Source Original 1st Revision 2nd Revision
2018 State Only 413,416 421,051
Waiver
Local
Medicaid Match to
Local
Total Rev. $820,341 $835,289 $826,847
Fiscal
Year Fund Source Original 1st Revision 2nd Revision
2019 State Only 408A62
Waiver
Local
Medicaid Match to
Local
Total Rev . $801,577
DSHS Central Contract Services
6024PF Contract Amendment (1-26-2018)
3rd Revision
3rd Revision
Page 2
' .
COUNTY FY 2019 SPENDING PLAN
I Planned Expenditures
Local PASRR Medicaid
Funds Funds State Funds Funds TOTAL
ADMINISTRATION 76
(CMIS/AWA BARS 11) 28800 23S64 52440
OTHER CONSUMER
SUPPORTS
(CMIS/AWA Code 31, 32 , 41 ,
92, 93, 94) 26916 22022 48938
CONSUMER SUPPORT ---
STATE-ONLY 6372 6372
Child Development -
MEDICAID CLIENTS 1079 346374 346374 693827
ROADS to COMMUNITY
LIVING
TOTAL
1155 408462 391960 801,577
DSHS Central Contract Services Page 3
6024PF Contract Amendment (1-26-2018)
Kittitas County
Review Form
Grants & Contract Agreement
Today's Date
06/19/2018
Fund/Department
116-Public Health
Contract/Grant Information
Agenda Date
7
Contract /Grant Agency: Kittitas County DDA Coun t y Services Amendment 3
Period Begin Date: 07/01/2018 I I Period End Date: 06/30/2019
Total Grant/Contract Amount :$ 1,628.424.00
Gran t/Contract Number: 1763-98187
Contract/Grant Summary:
Change or correct period of performance and max contract amount.
Contract amendment end date 06/30/2019; increased fund +$801.577 .
Recommendation for Board of Health and Board of Health Review on
Department Head Signature· k~Ll , Administrator Date:~¥
Signature of Board of Health member Date
Financial Information
Total Amount$ 801,577 State Funds$ 801,577 Federal Funds$
Percentage County Funds Matching Funds $ CFDA#
In-Kind$
Explain
Is Equipment being purchased? Who owns equipment?
New Personnel being hired? Contact HR hiring -reporting requirements
Grant/Contract Review Page 1
Future impacts or liability to Kittitas County :
Budget Information
Budget Amendment Needed? Yes D attach budget form No D Why not
New Division Created?
Revenue Code Amount Increase New Total
105.568.334.04.68 +$801,577 $1,628,424
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub -Contract Approved Date:
Prosecutor Review I Has the Prosecutor reviewed this agre ement? I Yes • No 0
County Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted
!~Signature:
Department:
I Date:
Assignment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
I Reviewer j Date
Grant/Contract Review Page 2