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HomeMy WebLinkAboutC10-154 Family Planning Program Rtg 11-16393DEPARTMENT OF PUBLIC HEALTH AND E~]VIRONMENT ROUTING NO. 11 FLA 16393 APPROVED TASK ORDER CONTRACT -WAIVER #154 Tttis Task Order Contract is issued pursuant to Master Contract made on 01/23/2007, with routing number O8 FAA 00016 STATE: State of Colorado for the use & benefit of the Department of Public Health and Environment Prevention Services Division -WHU Family Planning Program 4300 Cherry Creek Drive South Denver, Colorado 80246 CONTRACTOR: Board of County Commissioners of Eagle County 500 Broadway • Eagle, CO 816331-0608 For the use and benefit of the Eagle County Public Health Agency 551 Broadway Eagle, CO 81631 TASK ORDER MADE DATE: 3/15/2010 PO/SC ENCUMBRANCE NUMBER: PO FLA PSD1116393 TERM: This Task Order shall be effective upon approval by the State Controller, or designee, or on 07/01 /2010, whichever is later. The Task Order shall end on 06/30/2011. PRICE STRUCTURE: Cost Reimbursement PROCUREMENT METHOD: Sole Source BID/RFP/LIST PRICE AGREEMENT NUMBER: Not Applicable LA\V SPECIFIED VENDOR STATUTE: Not Applicable CONTRACTOR ENTITY TYPE: Colorado BILLING STATEMENTS RECEIVED: Monthly STATUTORY AUTHORITY: Not Applicable Political Subdivision CONTRACT PRICE NOT TO ERCEED: $47,505.00 FEDERAL FUNDING DOLLARS: $32,412.00 STATE FUNDING DOLLARS: $1 S,O93.00 MA~iIMUM AMOUNT AVAILABLE PER FISCAL YEAR: FY 11: $47,505.00 FY 12: $ FY 13: $ FY 14: $ FY 15: $ STATE REPRESENTATIVE: CONTRACTOR REPRESENTATIVE: Judith Crotser Tammy Brunk Department of Public Health and Environment Eagle County Public Health Agency Prevention Services Division -WHU 551 Broadway Family Planning Program Eagle, CO 81631 4300 Cherry Creek Drive South Denver, CO 80246 SCOPE OF \Y/ORI<: Contractor shall provide a comprehensive family planning program in accordance with section 1001 of the Public Health Service Act, 42 U.S.C., 300 et seq., and all applicable federal regulations, as amended, contained in Title X, 42 C.F.R., Subpart A, Part 59, as well as all State Regulations and with the terms of this contract. Page 1 of 5 Rev 6/25/09 ESHIBITS: The following exhibits are hereby incorporated: Exhibit A - Additional Provisions (and its attachments if any - e.g., A-1, A-2, etc.) Exhibit B - Statement of Work and Budget (and its attachments if any - e.g., B-1, B-2, etc.) Exhibit C - Grant Funding Change Letter GENERAL PROVISIONS The following clauses apply to this Task Order Contract. These genera] clauses may have been expanded upon or made more specific in some instances in exhibits to this Task Order Contract. To the extent that other provisions of this Task Order Contract provide more specificity than these general clauses, the more specific provision shall control. This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract including, but not limited to, Exhibit One thereto. The total teen of this Task Order Contract, including any renewals or extensions, may not exceed five (5) years. The parties intend and agree that all work shall be performed according to the standards, terms and conditions set forth in the Master Contract. 2. In accordance with section 24-30-202(1), C.R.S., as amended, this Task Order Contract is not valid until it has been approved by the State Controller, or an authorized delegee thereof. The Contractor is not authorized to, and shall not; commence performance under this Task Order Contract until this Task Order Contract has been approved by the State Controller or delegee. The State shall have no financial obligation to the Contractor whatsoever for any work or'services or, any costs or expenses, incurred by the Contractor prior to the effective date of this Task Order Contract. If the State Controller approves this Task Order Contract on or before its proposed effective date, then the Contractor shall commence performance under this Task Order Contract on the proposed effective date. If the State Controller approves this Task Order Contract after its proposed effective date, then the Contractor shall only commence performance under this Task Order Contract on that later date. The initial term of this Task Order Contract shall continue through and including the date specified on page one of this Task Order Contract, unless sooner terminated by the parties pursuant to the ternls and conditions of this Task Order Contract and/or the Master Contract. Contractor's conunencement of perfom~ance under this Task Order Contract shall be deemed acceptance of the teens and conditions of this Task Order Contract. The Master Contract and its exhibits and/or attachments are incorporated herein by this reference and made a part hereof as if fully set forth herein. Unless otherwise stated, all exhibits and/or attachments to this Task Order Contract are incorporated herein and made a part of this Task Order Contract. Unless otherwise stated, the terms of this Task Order Contract shall control over any conflicting ternis in any of its exhibits. In the event of conflicts or inconsistencies between the Master Contract and this Task Order Contract (including its exhibits and/or attachments), or between this Task Order Contt~act and its exhibits and/or attachments, such conflicts or inconsistencies shall be resolved by reference to the documents in the following order of priority: 1) the Page 2 of 5 Rev 6/25/09 Special Provisions of the Master Contract; 2) the Master Contract (other than the Special Provisions) and its exhibits and attachments in the order specified in the Master Contract; 3) this Task Order Contract; 4) the Additional Provisions -_Exhibit A, and its attachments if included, to this Task Order Contract; 5) the Scope/Statement of Work -Exhibit B, and its attachments if included, to this Task Order Contract; 6) other exhibits/attachments to this Task Order Contract in their order of appearance. The Contractor, in accordance with the terms and conditions of the Master Contract and this Task Order Contract, shall perform and complete, in a timely and satisfactory manner, all work items described in the Statement of Work and Budget, which are incorporated herein by this reference, made a part hereof and attached hereto as "Exhibit B". The State, with the concurrence of the Contractor, may, among other things, prospectively renew or extend the term of this Task Order Contract, subject to the limitations set forth in the Master Contract, increase or decrease the amount payable under this Task Order Contract, or add to, delete from, and/or modify this Task Order Contract's Statement of Work through a contract amendment. To be effective, the amendment must be signed bythe State and the Contractor, and be approved by the State Controller or an authorized delegate thereof. This contract is subject to such modifications as may be required by changes in Federal or State law, or their implementing regulations. Any such required modification shall automatically be incorporated into and be part of this Task Order Contract on the effective date of such change as if fully set forth herein. The conditions, provisions, and terms of any RFP attached hereto, if applicable, establish the minimum standards of performance that the Contractor must meet under this Task Order Contract. If the Contractor's Proposal, if attached hereto, or any attachments or exhibits thereto, or the Scope/Statement of Work - Exhibit B, establishes or creates standards of performance greater than those set forth in the RFP, then the Contractor shall also meet those standards of performance under this Task Order Contract. STATEWIDE CONTRACT MANAGEMENT SYSTEM (This section shall apply when the Effective Date is on or after July 1, 2009 and the maxinnrm an2ount payable to Contractor herezrnder is $100, 000 0~ higher) By entering into this Task Order Contract, Contractor agrees to be governed, and to abide, by the provisions of CRS §24-102-205, §24-102-206, §24-103-601, §24-103.5-101 and §24-105-102 concerning the monitoring of vendor performance on state contracts and inclusion of contract perfornlance information in a statewide contract management system. Contractor's performance shall be evaluated in accordance with the terms and conditions of this Task Order Contract, State law, including CRS §24-103.5-101, and State Fiscal Rules, Policies and Guidance. Evaluation of Contractor's performance shall be part of the normal contract administration process and Contractor's performance will be systematically recorded in the statewide Contract Management System. Areas of review shall include, but shall not be limited to quality, cost and timeliness. Collection of information relevant to the performance of Contractor's obligations under this Task Order Contract shall be determined by the specific requirements of such obligations and shall include factors tailored to match the requirements of the Statement of Project of this Task Order Contract. Such performance information shall be entered into the statewide Contract Management System at intervals established in the Statement of Project and a final review and rating shall be rendered within 30 days of the end of the Task Order Contract term. Contractor shall be notified following each perfornlance and shall address or correct any identified problem in a timely manner and maintain work progress. Should the final performance evaluation determine that Contractor demonstrated a gross failure to meet the performance measures established under the Statement of Project, the Executive Director of the Colorado Department of Personnel and Administration (Executive Director), upon request by the Colorado Department of Public Health and Environment and showing of good cause, may debar Contractor and Page 3 of 5 Rev 6/25/09 prohibit Contractor from bidding on future contracts. Contractor may contest the final evaluation and result by: (i) filing rebuttal statements, which may result in either removal or correction of the evaluation (CRS §24-105-102(6)), or (ii) under CRS §24-105-102(6), exercising the debarment protest and appeal rights provided in CRS §§24-109-106, 107, 201 or 202, which may result in the reversal of the debarment and reinstatement of Contractor, by the Executive Director, upon showing of good cause. Page 4 of 5 Rev 6/25/09 THE PARTIES HERETO HAVE EXECUTED THIS CONTRACT * Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's behalf and acknowledge that the State is relying on their representations to that effect. CONTRACTOR: STATE OF COLORADO: EAGLE COUNTY PUBLIC HEALTH AGENCY. BILL BITTER, JR. GOVERNOR (apolitical subdivision of the state of Colorado) Legal Name of Contracting Entity By For Executive Director Department of Public Health and Environment Signahire of Auth zed Officer ~•~ ~ ~~ 7 ~r/~ ~'l/Y n Print Name of Authorized Officer ('~i1 ~' ~ Cl.h Print Title of Authorized Officer _ By Department Program Approval: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS §24-30-202 requires the State Controller to approve all State Contracts. This Contract is not valid until signed and dated below by the State Controller or delegate. Contractor is not authorized to begin performance until such time. If Contractor begins performing prior thereto, the State of Colorado is not obligated to pay Contractor for such performance or for any goods and/or services provided hereunder. STATE CONTROLLER: David J. McDermott, CPA By Date Page 5 of 5 Rev 6/25/09 EYHIBIT A ADDITIONAL PROVISIONS To Task Order Contract Dated 3/15/2010 -Contract Routing Number 11 FLA 16393 1. This Task Order Contract contains federal fiends (see Catalog of Federal Domestic Assistance (CFDA) number 93.217) 2. The United State Department of Health and Human Services ("US DHHS"), through the Colorado General Assembly has awarded federal funds, hereinafter."Award", to perform - a comprehensive family planning ro ram. The State has formulated a comprehensive State plan, with associated budgets, to disburse these funds tlu-oughout the state of Colorado. Under this comprehensive State plan, the State shall allocate these funds to qualified entities to provide comprehensive family planning services to the citizens of the state of Colorado on behalf of the State. If the underlying Award authorizes the State to pay all allowable and allocable expenses of a contractor as of the effective date of that Award, then the State shall reimburse the Contractor for any allowable and allocable expenses of the Contractor that have been incurred by the Contractor since the proposed effective date of this Task Order Contract. If the underlying Award does not authorize the State to pay all allowable and allocable expenses of a contractor as of the effective date of that Award, then the State shall only reimburse the Contractor for those allowable and allocable expenses of the Contractor that are incurred by the Contractor on or after the effective date of this Task Order Contract, with such effective date being the later of the date specified in this Task Order Contract or the date the Task Order Contract is signed by the State Controller or delegate. To receive compensation under this Task Order Contract, the Contractor shall submit a signed Monthly Family Planning Program (FPP) Cost Reimbursement Statement in a forniat acceptable to the State. A FPP Cost Reimbursement Statement is incorporated and made part hereof by reference. This document is located at: http:%hvww.cdphe.state.co.us/pp/womenslFPNursinEConsntsForms.html?colt=open. A FPP Cost Reimbursement Statement must be submitted within sixty (60) calendar days of the end of the billing period for which services were rendered. FPP Cost Reimbursement Statements must be accompanied by detailed cost ledger to reflect all purchases being invoiced under that contract and should include date of payment, payee name and amount, and check or voucher number, when available. Expenditures shall be in accordance with Fiscal Year 2011 Funding Amounts attached hereto as Attachment A-1 and the Statement of Work attached hereto as Exhibit B. These items may include, but are not limited to, the Contractor's salaries, fringe benefits, supplies, travel, operating, indirect costs which are allowable, and other allocable expenses related to its performance under this Task Order Contract. FPP Cost Reimbursement Statements shall: 1) reference this Task Order Contract by its contract routing number, which is located on page one of this Task Order Contract; 2) state the applicable performance dates; 3) state the names of payees; 4) include a brief description of the services performed during the relevant performance dates; and, 5) show the total requested payment. Payment during the initial, and any renewal or extension, term of this Task Order Contract shall be conditioned upon affirniation by the State that all services were rendered by the Contractor in accordance with the terms of this Task Order Contract. FPP Cost Reimbursement Statements shall be sent to: Fiscal Officer Family Planning Program Prevention Services Division Colorado Department of Public Health and Environment PSD - A4 4300 Cherry Creek Drive South Denver, CO 80246 To be attached to CDPHE Page 1 of 3 Revised: 12/19/06 Task Order v1.0 (11/OS) contract template EXI3IBIT.a Final billings under this Task Order Contract must be received by the State within a reasonable time after the expiration or termination of this Task Order Contract; but in no event no later than sixty (60) calendar days from the effective expiration or termination date of this Task Order Contract. 4. The Contractor is authorized to make limited transfers of funds from one line item in its budget to another line item in its budget, but must notify the Program Director by email prior to the transfer. A transfer from one line item to another line item may not exceed ten percent (10%) or one thousand dollars ($1,000), which ever amount is more, of the total amount of the line item from which the transfer is made unless prior written approval is received from the Program Director. The Contractor is not authorized to add project staff without prior written approval from the Program Director. If the Contractor desires to transfer more than ten percent (10%) or one thousand dollars ($1,000), which ever amount is more from one line item in its budget to another line item in its budget, then the contractor shall request and receive prior written approval from the program Director by completing and submitting a budget revision request form incorporated and made part of hereof by reference. This document is located at: http:%/w~vw.cdphe.state.co.us/pp/womens/FPNursineCousntsFonns.htrnl`?colt=open. The services or activities under this Contract may be carried out by the Contractor, or through subcontracts with other providers or, through collaborative partnerships with other community partners. The State authorizes the Contractor to subcontract some, or all, or the services that are to be performed under this Contract. However, a subcontractor is subject to all of the terms and conditions of this Contract. Additionally, the contractor remains ultimately responsible for the timely and satisfactory completion of all work performed by any subcontractor(s) under this Contract. If the Contractor desires to subcontract some, or all, of the services that are to be perforn~ed under this Conh•act, the Contractor shall obtain the prior, express, written consent of the State before entering into any subcontract. The Contractor shall maintain, at a minimum a Memorandum of Understanding or other binding contractual agreement, and provide a copy to the Family Planning Program Director fifteen (15) calendar days from the date the agreement is executed. The Contractor shall maintain records of any subcontractors for a minimum of three years. 6. The Contractor shall comply with section 1001 of the federal Act and all applicable federal regulations, as amended, contained in Title X, 42 C.F.R., Subpart A, Part 59, as well as all applicable state regulations. 7. Health Insurance Portability and Accountability Act (HIPAA) Business Associate Determination. The State has determined that this contract does hot constitute a Business Associate relationship under HIPAA. 8. Under this Task Order Contract, the Contractor shall refer families participating in any and all programs in its agency such as WIC, Early and Periodic Screening, Diagnosis and Treatment (EPSDT), Immunization Clinics, HCP, Prenatal Plus (PNP), etc. to appropriate enabling and direct care service programs in the community. All pregnant women in need of resources for prenatal medical care are provided with information about programs such as WIC, PNP, etc. as needed; all children ages birth through two years who may be eligible for early intervention services are referred to Early Intervention Colorado. 9. Under this Task Order Contract, the Contractor shall assure clients age twenty (20) and under and families with children in need of EPSDT care coordination are referred to county Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Medicaid Navigators via written or telephone referral. 10. The State may require fornls attached to this contract and incorporated herein by reference be updated during the term of this contract. The Contractor will be informed of the new forms as they are developed. Forms may be sent to contractors or will be available on the Family Planning Administrative Manual website: http:/hvww.cdphe.state. co.us/pu%womens/famplan. html. 11. Notwithstanding anything herein to the contrary, the parties understand and agree that all teams and conditions of this Task Order Contract and the exhibits and attachments hereto which may require continued performance, compliance or effect beyond the termination date of this Task Order Contract shall survive such termination date and shall be enforceable by the State as provided herein in the event of such failure to perform or comply by the Contractor. To be attached to CDPHE Page 2 of 3 Revised: 12/19/06 Task Order v 1.0 (1 I /OS) contract template EXHIBIT A 12. Funding adjustments may be made during the term of this contract. The State makes funding adjustments on this contract using a Funding Letter substantially equivalent to Exhibit C and bearing the approval of the State Controller or his designee; the funding letter shall not be deemed valid until the State Controller or his designee has approved it. 13. Contractor agrees to provide services to all Program participants and employees in a smoke-free environment in accordance with Public Law 103-227, also known as "the Pro-Children Act of 1994", (Act). Public Law 103-227 requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, early childhood development services, education or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable Federal funds is Medicare or Medicaid; or facilities where Women Infant and Children (WIC) coupons are redeemed. Failure to comply with the provision of Public Law 103-227 may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. By signing this Contract, the Contractor certifies that the Contractor will comply with the requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act. The Contractor agrees that it will require that the language of the Act be included in any subcontracts which contain provisions for children's services and that all contractors shall sign and agree accordingly. 14. Contractor shall ensure that the provisions of Section 601 of Title VI of the Civil Rights Act of 1964 are carried out. That Act states that "no person in the United States shall on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." The Office of Civil Rights has concluded that it is the responsibility of any program which is a recipient of funds from the Department of Health and Human Services to ensure that clients who do not speak or understand English well, be provided interpretation services to ensure that the service provider and the client can communicate effectively. The Contractor shall have policies and procedures to ensure that interpretation services are available for clients with Limited English Proficiency and will advise such clients that an interpreter will be provided for them. If a client has their own interpreter, they shall be advised that the Contractor will provide an interpreter if the client so chooses. To be attached to CDPHE Page 3 of 3 Revised: 12/19/06 Task Order vl .0 (11/OS) contract template Attachment A-i FISCAL YEAR 2011 FUNDING AMOUNTS TITLE X FAMILY PLANNING Agency Name Eagle County Public Health Agency Contact Name Tamm Brunk Phone # 970-328-8820 FUNDING SOURCE AMOUNT FUNDING PERIOD Federal Title X Federal $32,412 June 30 1, 2010 -June 29, 2011 Title X, State CDPHE-WH-STATE $15,093 July 1, 2010 -June 29, 2011 TOTAL TITLE X FEDERAL & STATE. $47,505 # of Target Clients 595 EYHIBIT B STATEMENT OF WORK To Task Order Contract Dated 03!15/2010 -Contract Routing Number 11 FLA 16393 The Contractor shall conduct a comprehensive family planning program ("the program") in Eagle County. This program shall comply with section 1001 of the federal Act and all applicable federal regulations, as amended, contained in Title X, 42 C.F.R., Subpart A, Part 59, as well as all applicable state regulations. (Federal funding from HHS, CFDA #93.217 FP Services). The funding for this program will be spent in accordance with the FAMILY PLANNING BUDGET and FAMILY PLANNING BUDGET NARRATIVE attached hereto and referred to as Attachment B-1 and Attachment B-2. 2. The Contractor shall make its program available to men and women in their reproductive years and shall offer the following services, as appropriate: A. Outreach services and/or other program efforts designed to improve client recruitment; B. Nursing and medical services, which shall include a comprehensive health and social history and physical examination administered in accordance with all applicable Title X regulations and, all applicable nursing-medical policies or procedures which have been, or may be, established by the State's Women's Health Unit ("WH"); C. Contraceptive information, education, and supplies regarding all family planning methods; D. Education and counseling services regarding family planning, family planning methods, child spacing, infertility, sterilization, nutrition, sexually transmitted diseases, HIV/AIDS, adolescent counseling and other related health issues, as outlined in the Nursing and Administrative Manual; E. Follow-up and/or referral services, as appropriate. The services provided by the Contractor to the clients it serves shall be performed pursuant to law in accordance with prevailing medical standard of care for the same or similar medical, nursing and professional services. The services provided shall also comply with applicable Title X regulations, WHU nursing-medical policies and procedures, and any applicable fiscal or administrative policies of the State or Federal government which can be located at http•i%www cdphe state co us/pp/womens/f~mulan html'~col2=oven. Contractor acknowledges that it has reviewed these policies and procedures. 4. The services provided by the Contractor must be deemed acceptable, in good faith, by WH. For a service to be "acceptable" it must comply with all applicable: Title X regulations, WH nursing-medical policies and procedures, and any applicable fiscal and administrative policies and procedures of the State and Federal government. All applicable Title X regulations, WHmsrsing-medical policies and procedures, and all applicable fiscal or administrative policies of the State have been provided to the Contractor by the State as of the effective date of this Contract. The Contractor shall provide the State's family planning program consultants and administrators with reasonable access to its operations to perform: periodic site reviews, data reviews, fiscal reviews or other evaluations of the Contractor's family planning program. Evaluations of the Contractor's program shall be based on established standards and policies of the State or the Federal government. The Contractor shall cooperate during all periodic site visits, data reviews, fiscal reviews or other evaluations conducted by the State. The established standards and policies for the Family Planning Program can be located in the Family Planning Administrative Manual and the Family Plam~ing Nursing Manual located on the Family Planning website at http•//www cdphe state co us/up/womens/famplan html. To be attached to CDPHE Page 1 of 3 Revised: 12/19/06 Task Order v1.0 (11/OS) contract template h~xHlarr ~ If necessary, the Contractor shall comply with all recommendations including development of a performance improvement plan made by the State's family planning program consultants and/or administrators after a periodic site visit, data review, fiscal review or other evaluations that are necessary to bring its program into compliance with all applicable program requirements, federal and state laws, policies and regulations. The Contractor shall be in full compliance with a recommendation, if any, within three (3) months of the date a recommendation is made by the State. If the Contractor camlot obtain full compliance within this three (3) month period, then on or before the expiration date of that three (3) month period the Contractor shall present sufficient written evidence to the State: to show that continuing progress is being made towards full compliance; and, the date when full compliance shall occur. 1n no event, however, shall full compliance with a recommendation occur any later than six (6) months after the date that a recommendation was initially made by the State. If the Contractor fails to correct such deficiencies, the Contractor shall be in default of its obligations under this Task Order Contract and the State, at its option, may elect to withhold payment or terminate this Task Order Contract or the Master Contract and all Task Order Contracts entered into pursuant to the Master Contract. Notwithstanding the foregoing provisions, the State may disregard these cure periods and immediately terminate the contract without liability if it has solely determined that Contractor's noncompliance places the health, safety or welfare of persons receiving services in jeopardy. On a monthly basis, the Contractor shall collect and provide to the State, by the fifteenth calendar day of the following month unless otherwise specified by CDPHE, all pertinent data as defined by CDPHE regarding all services offered, and all family planning clients served, by its program during the preceding month, submitted through the IRIS data system. This data shall be verified on a quarterly basis to help assure accuracy. The Contractor must adhere to the Data Security, Use and Confidentiality Agreement, incorporated and made part hereof by reference. This document is located at: http•//~~-ww.cdphe state co usippiwomens/FPNursineConsntsFornls html'~col~=oven. 8. Within thirty (30) calendar days of receipt of a written request from the State, the Contractor shall submit nursing-medical chart audits, client satisfaction surveys, FTE reports and other documentation required for the Family Planning Annual Report (FPAR) to the State. The Contractor shall only use program income generated from client fee collections and donations for family planning purposes that further the objectives of the legislation under which this Contract is entered into.. In accordance with Title X guidelines, the Contractor shall not charge for any Title X required services provided to clients who are at or below 100% of the official poverty line as defined by the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902 (2). A copy of this guideline has been posted at http:i/www.cdphe.state.co.us/pp,womens/Federall'overtyUuidelines html by the State as of the effective date of this Contract. If the State receives new poverty guidelines during the term of this Contract, then the State shall immediately notify the Contractor. The Contractor shall use these new poverty guidelines, if any, upon receipt of notification thereof from the State. 10. The Contractor's charges for services to clients who are above 100% of poverty level shall be based on a sliding fee scale that takes into account a client's family size and/or individual income and is approved by CDPHE. These charges and the sliding fee scale shall be made available to all clients of the Contractor, the general public, and the State. This most current version the approved sliding fee scale templates are available on the Family Planning website (http:ihvww.cd~~hestate.co.us/pphvomenslFederalPovertyGuidelines htmll Charges shall be based upon the Contractor's actual costs to provide these services as determined by a cost analysis. The Contractor and the State shall review these costs annually. The Contractor shall insure that all clients understand that they will not be denied services because of an inability to pay any of the Contractor's sliding fee charges. All money received by the Contractor from the State under this Contract shall be used by the Contractor to provide contraceptive services to qualified family planning clients (fertile clients receiving contraceptive services including approximately 595 tarset family planning clients. To be attached to CDPHE Page 2 of 3 Revised: 12/19/06 Task Order v1.0 (11/OS) contract template EYHIBIT B 11. The Contractor shall either use a cytology laboratory chosen by the State or, a laboratory proposed by the Contractor and approved by the State. 12. During the term of this Contract, the Contractor agrees to provide the State with the semi-annual Family Planning Expenditure/Revenue Reports, incorporated and made part hereof by reference. This document is located at: http://www.cdphe.state co us!pphvomens/FPNursinaConsutsFonns html'?colt=open. The first report is for the months of July through December; the second report is for the months of January through June. These reports will be due on dates specified by CDPHE. 13. During the term of this Contract, the Contractor agrees to provide the State with an Amlual Family Planning Work Plan and to submit semi-annual work plan progress reports by dates specified by CDPHE on forms located at http://www.cdphe.state.co.us/pphvomenslFPNursingConsntsForms.html?co12=off 14. The Contractor shall protect the confidentiality of all client records and other materials that are obtained, created, or maintained by the Contractor under this contract. Except for purposes directly related to the administration of this contract, no information about, or obtained from, any client shall be disclosed by the Contractor in any form that would identify that client without the prior written consent of that client. As of the acceptance date of this contract by the Contractor, the Contractor shall have written policies governing the access to and, the duplication and dissemination of, all such information. The Contractor shall advise its directors, officers, employees, agents, servants, and subcontractors, if any, that they are subject to these confidentiality requirements. 15. The Contractor shall participate in meetings or trainings as requested by the State. 16. The Contractor shall require any new staff working on Family Planning program services to participate in Fiscal Orientation within forty-five (45) days of employment. To be attached to CDPHE Page 3 of 3 Revised: 12/19/06 Task Order v1.0 (11/OS) contract template FAMILY PLANNING BUDGET Attachment B-1 APPLICANT: Eagle County Yublic Health Agency Federal Title X & Title X Expansion July i, 2010 -June 29, 2011 _ FOR THE BUDGET PERIOD: State Title X July 1, 2010 -June 29, 2011 - _ _ -- Chlalnydia July 1, 2010 -December 31, 2010 Salary % Time CDPHE-WFIU CDPHE-WHU NON-CDPHE TOTALS SEE ABOVE Family Planning -_ - FOR BUDGET JULY 1, 2010 - Program JUNE 30, 2010 PLEASE ROUND ALL FIGURES PERIODS BY JUNE 30, 2011 Funding JULY 1, _ JUNE 30, TO THE NEAREST DOLLAR FTE GRANT ZO10 - JUNF. 30, 2011 FEDERAL & STATE TITLE X CFPI NON-CDPHE CDPHE PLUS & CHLAMYDIA N'ON-CDPHE PERSONNEL EXPENSES: (Include name & title for each employee charged to CDPHE funding. You do not need to list the name and title for employees charged only to Non-CDPHE finding) $0 Tamm Brunk, FP Coordinator $85,010 100% $47;505 $37,505 $85,010 _ __ Clinic Assistant $35,340 70% $24,373 $24,373 Clinic Assistant $36,400 30% $10920 $10,920 Ntu'se Manager $73,507 10".0 ~ $7.351 $7,351 _ Sub-total Sala Ex enses $47,505 SO $80,149 $127,654 Fringe Benefit Rate and Expenses $0 _ _ Total Personnel Expenses $230,257 $47,505 $0 $80.149 $127,654 _ __ CONTRACTUAL: (btdependent contractor for tuba) ligation, Ensure, vasectomy, physicians, nurse practitioners, etc. In CFPI portion ONLY, add referral fee in this section. $0 Rocky Mountain Urology -Vasectomy X24 procedures I $16,200 $16,200 Ensure Contractor TBD i10 procedures $26,000 $26,000 Medical Officer I i1 year's contract $6,575 $6,575 __ Total Contractual Ex enses $0 $42,200 $6,575 $48,775 OPERATING: $0 - _ --- - - '~Contraceptive Methods (for CFPI portion ONLY, 10°o admin fee eau be - --- --- - included in this line.) $17,800 $20,000 $37,800 ;Trauting costs -which includes registration fees, travel $1,500 $921 $2,421 ~Chlamydia tests ([fyou do not use the state lab, please make sure this line equals or exceeds the amount listed on your FY 2011 Estimated Funding worksheet for Chlamydia) $2,000 $2,000 (Other Lab tests ~ $7,000 $7,000 (,Educational materials (brochures, etc) ~I $SSO $S50 _____ ___ ;Clinical supplies ~ $569 $569 __ ~I Office operatingsupplies (papers, charts, pens, etc) $0 OtTice expense (rent, utilities, maintenance) $0 U I7IEA (Specify) ~ $Q Total Operating Ex enses $0 $19,300 $31,040 $50,340 EQUIPMENT: (Con uters, Office furniture.) $0 $0 --- Total Equi ment ExJenses $0 50 $0 $0 TOTAL DIRECT EXPENSES $47,505 $61 S(10 $1 17,764 $226,769 INDIRECT: _ Indirect rate: Indirect Expense $0 $0 $0 ADMINISTRA'PIVE (10°io CFt'1 Expansion Grant. Do NOT calculate the 0% admin rate on one-time expenes, contraceptive methods, training, or t:ontractors for htbals, [sure, vasectonry, etc) 50 $0 ONE-TIME EXPENSE (For CFPI Expansion Grant only) $0 'roTAL AMOUNT REQUESTED $47,505 $61,500 $117,764 $226,769 - - Page 1 FAMILY PLANNING BUDGET NARRATIVE Attachment B-2 BUDGET NARRATIVE FYll Federal Titte X & State Family Planning Grants APPLICANT: Eagle County Public Health Agency FOR THE PERIOD: June 30, 2010 -June 29, 2011 For Personnel category list title of position How is the total amount required Relationship to project Total For all other categories list the line calculated? item from the budget PERSONNEL EXPENSES: $47,505.00 Tammy Brunk, C\lVt Family Planning Coordinator Annual Salary (58,010) ~ ~S.S~`i~ S47,505.00 Page 1 Exhibit C GRANT FUNDING CHANGE LETTER Date: State Fiscal Year: Grant Fundin Chan a Letter # CMS Routin # TO: Insert Grantee's name In accordance with Section of the Original Contract routing number , [insert the following language here if previous amendment(s), renewal(s) have been processed] as amended by [include all previous amendment(s), renewal(s) and their routing numbers], [insert the following word here if previous amendment(s), renewal(s) have been processed] between the State of Colorado, Department of Public Health and Environment and Contractor's Name beginning Insert start date <insert start date of original contract> and ending on Insert ending date <insert ending date of current contract amendment>, the undersigned commits the following funds to the Grant: The amount of grant funds available and specified in Section of <insert contract amendment number and routin number> is ^ increased or ^ decreased by $amount of change to a new total funds available of ~ <insert new cumulative total> for the following reason: .Section is hereby modified accordingly. This Grant Funding Change Letter does not constitute an order for services under this Grant. The effective date of hereof is upon approval of the State Controller or ,whichever is later. STATE OF COLORADO Bill Ritter, Jr. GOVERNOR Department of Public Health and Environment PROGRAM APPROVAL: By: Lisa Ellis, Purchasing & Contracts Unit Director BY~ Date: ALL GRANTS REQUIRE APPROVAL BY THE STATE CONTROLLER CRS §24-30-202 requires the State Controller to approve all State Grants. This Grant is not valid until signed and dated below by the State Controller or delegate. Grantee is not authorized to begin performance until such time. If Grantee begins performing prior thereto, the State of Colorado is not obligated to pay Grantee for such performance or for any goods and/or services provided hereunder. STATE CONTROLLER David J. McDermott, CPA By: Donald Rieck Date: Page 1 of 1 Effective Date: 1/6/09-Rev 8/25/09 DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Psn-CFPI DEPARTMENT OR AGENCY NUMBER FLA CONTRACT ROUTING NUMBER 11-15888 AMENDMENT FOR TASK ORDERS #4 This Amendment is made this 1st day of March, 2010, by and between the State of Colorado, acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose address or principal place of business is 4300 Cherry Creek Drive South, Denver, Colorado 80246, hereinafter referred to as the "State"; and, BOARD OF COUNTY COMMISSIONERS OF EAGLE COUNTY, whose principle place of business is 500 Broadwav, Eagle, Colorado 81631 for the use and benefit of the EAGLE COUNTY PUBLIC HEALTH AGENCY , (a political subdivision of the state of Colorado), whose address or principal place of business is 551 Broadwav, Eagle, Colorado 81631, hereinafter referred to as the "Contractor". FACTUAL RECITALS The parties entered into a Master Contract, dated January 23, 2007, with contract routing number 08 FLA 00016. Pursuant to the terms and conditions of the Master Contract, the parties entered into a Task Order Contract, dated Ausust 15, 2008, with contract encumbrance number PO FLA FPP0900663, and contract routing number 09-FLA- 00663, as amended by Contract Amendment #1, contract routing number 09-FLA-00854, Contract Amendment #2, contract routing number 10-FLA-00227, Contract Amendment #3, contract routing number 10-FLA-9455 and Grant Funding Letter #2, contract routing number 10-FLA-13357 collectively referred to herein as the "Original Task Order Contract, whereby the Contractor was to provide to the State the following: Contractor will provide a comprehensive family planning program with an emphasis on increasing the total number of men and women accessing services and increasing utilization of long acting reversible methods of contraception (LARC) among existing clients. The State promises to pay the Contractor the sum of Sixty-One Thousand Five Hundred Dollars, ($61,500.00) in exchange for the promise of the Contractor to continue to perform the work identified in the Original Task Order Conri•act for the renewal term of 12 months, ending on June 30, 2011. NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as follows: 1. Consideration for this Amendment to the Original Task Order Contract consists of the payments and services that shall be made pursuant to this Amendment, and promises and agreements herein set forth. 2. It is expressly agreed to by the parties that this Amendment is supplemental to the Original Task Order Contract, contract routing number 09-FLA-00663, as amended by Contract Amendment #1 contract routing number 09-FLA-00854,. Contract Amendment #2, contract routing number 10-FLA-00227, Contract Amendment #3, contract routing number 10-FLA-9455 and Grant Funding Letter #2, contract routing number 10-FLA-13357 collectively referred to herein as the Original Contract, which is by this reference incorporated herein. All teens, conditions, and provisions thereof, unless specifically modified herein, are to apply to this Amendment as though they were expressly rewritten, incorporated, and included herein. It is expressly agreed to by the parties that the Original Task Order Contract is and shall be modified, altered, and changed in the following respects only: Page 1 o~f 1 Rev 3/16/2010 A. This Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number 09 FLA 00663. This Amendment is for the renewal term of July 1, 2010, through and including June 30, 2011. The maximum amount payable by the State for the work to be perfornied by the Contractor during this renewal term is Sixty-One Thousand Five Hundred Dollars, ($61,500.00) for an amended total financial obligation of the State of TWO HUNDRED TWENTY-NINE THOUSAND FIVE HUNDRED SEVENTY-EIGHT DOLLARS, ($229,578.00). This is an increase of Sixty-One Thousand Five Hundred Dollars, ($61,500.00) of the amount payable from the previous term. The revised Additional Provisions and Statement of Work is incorporated herein by this reference and identified as "Exhibit J" and "Exhibit K". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaft7rmed. The effective date of this Amendment is ,lulu 1, 2010, or upon approval of the State Controller, or an authorized delegate thereof, whichever is later. Except for the Special Provisions and other terms and conditions of the Master Contract and the General Provisions of the Original Task Order Contract, in the event of any conflict, inconsistency, variance, or contradiction between the terms and provisions of this Amendment and any of the terms and provisions of the Original Task Order Contract, the terms and provisions of this Amendment shall in all respects supersede, govern, and control. The Special Provisions and other terms and conditions of the Master Contract shall always control over other provisions of the Original Task Order Contract or any subsequent amendments thereto. The representations in the Special Provisions to the Master Contract concerning the absence of personal interest of state of Colorado employees and the certifications in the Special Provisions relating to illegal aliens are presently reaffi~n~ed. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND OTHERWISE MADE AVAILABLE. Page 2 oft Rev 3/16/2010 IN WITNESS WHEREOF, the parties hereto have executed this Amendment on the day first above written. x Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's behalf and acknowledge that the State is relying on their representations to that effect. CONTRACTOR: BOARD OF COUNTY COMMISSIONERS OF EAGLE COUNTY for the use and benefit of EAGLE COUNTY PUBLIC HEALTH AGENCY (a political subdivision of the state of Colorado) STATE: STATE OF COLORADO Bill Ritter, Jr. Governor Signature of Authorized Officer Print Name of Authorized Officer Print Title of Authorized Off cer By: For the Executive Director DF,PARTMF,NT OF PUBLIC HEALTH AND ENVIRONMENT PROGRAM APPROVAL: By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS §24-30-202 requires the State Controller to approve all State Contracts. This Contract is not valid until signed and dated below by the State Controller or delegate. Contractor is not authorized to begin performance until such time. If Contractor begins performing prior thereto, the State of Colorado is not obligated to pay Contractor for such performance or for any goods and/or services provided hereunder. STATE CONTROLLER David J. McDermott, CPA By: Date: Page 3 of 3 Rev 3/16/2010 E\HIBIT .J ADDITIONAL PROVISIONS To Contract Dated 03/01/2010 -Contract Routing Number 11 FLA 15888 These provisions are to be read and interpreted in conjunction with the provisions of the contract specified above. The revised Additional Provisions are effective July 1, 2010. 1. Health Insurance Portability and Accountability Act (HIPAA) Business Associate Deternlination. The State has determined that this contract does not constitute a Business Associate relationship under HIPAA. 2. To receive compensation under this Task Order Contract, the Contractor shall submit a signed Monthly Colorado Family Planning Initiative (CFPI) Cost Reimbursement Statement in a format acceptable to the State. A CFPI Cost Reimbursement Statement is incorporated and made part hereof by reference. This document is located at: httpa~www.cdphe.state.co.us/p~hvomeus/FPNursingConsntsForms.hhnl?colt=open. A Cost Reimbursement Statement must be submitted within sixty (60) calendar days of the end of the billing period for which services were rendered. CFPI Cost Reimbursement Statements must be accompanied by detailed cost ledger to reflect all purchases being invoiced under that contract and should include date of payment, payee name and amount, and check or voucher number, when available. Expenditures shall be in accordance with the Statement of Work attached hereto as Exhibit K and in accordance with allocable expenses outlined in Cost Reimbursement Guidelines attached hereto as Attachment J-1. These items may include, but are not limited to, the Contractor's salaries, fringe benefits, supplies, travel, operating, administrative costs which are allowable, and other allocable expenses related to its performance under this Task Order Contract. CFPI Cost Reimbursement Statements shall: 1) reference this Task Order Contract by its contract routing number, which is located on page one of this Task Order Contract; 2) state the applicable performance dates; 3) state the names of payees; 4) include a brief description of the services performed during the relevant performance dates; and, 5) show the total requested payment. Payment during the initial, and any renewal or extension, term of this Task Order Contract shall be conditioned upon affirmation by the State that all services were rendered by the Contractor in accordance with the terms of this Task Order Contract. CFPI Cost Reimbursement Statements shall be sent to: Fiscal Oftlcer Family Planning Program Prevention Services Division Colorado Department of Public Health and Environment PSD - A4 4300 Cherry Creek Drive South Denver, CO 80246 Final billings under this Task Order Contract must be received by the State within a reasonable time after the expiration or termination of this Task Order Contract; but in no event no later than sixty (60) calendar days from the effective expiration or termination date of this Task Order Contract. The Contractor is authorized to make limited transfers of funds from one line item in its Budget to another line item in its Budget but must notify the Program Director by email prior to the transfer. A transfer from one line item to another line item may not exceed ten percent (10%) or One Thousand Dollars ($1000), which ever amount is more, of the total arnount of the line item from which the transfer is made unless prior written approval is received from the Program Director. If the Contractor desires to transfer more than ten percent (10%) or One Thousand Dollars ($1000), which ever amount is more, from one line item in its budget to another line item in its budget then the Contractor shall request and receive prior written approval from the Program Director by completing and submitting a Budget Revision Request Form, To be attached to CDPHE Page 1 of 3 Revised: 4/1/04 Version 1.0 (4104) contract template EXEIIBIT J incorporated and made part hereof by reference. This document is located at: http://www.cdphe.state.co.us/pp/womens/FPNursin~ConsntsFornls.html?colt=open. The services or activities under this Contract may be carried out by the Contractor, or through subcontracts with other providers or, through collaborative partnerships with other community partners. The State authorizes the Contractor to subcontract some, or all, or the services that are to be performed under this Contract. However, a subcontractor is subject to all of the terms and conditions of this Contract. Additionally, the contractor remains ultimately responsible for the timely and satisfactory completion of all work performed by any subcontractor(s) under this Contract. If the Contractor desires to subcontract some, or all, of the services that are to be performed under this Contract, the Contractor shall obtain the prior, express, written consent of the State before entering into any subcontract. The Contractor shall maintain, at a minimum a Memorandum of Understanding or other binding contractual agreement, and provide a copy to the Family Planning Program Director fifteen (15) calendar days from the date the agreement is executed. The Contractor shall maintain records of any subcontractors for a minimum of three years. 6. Contractor agrees to provide services to all Program participants and employees in a smoke-free environment in accordance with Public Law 103-227, also known as "the Pro-Children Act of 1994", (Act). Public Law 103-227 requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, early childhood development services, education or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable Federal funds is Medicare or Medicaid; or facilities where Women Infant and Children (WIC) coupons are redeemed. Failure to comply with the provision of Public Law 103-227 may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. By signing this Contract, the Contractor certifies that the Contractor will comply with the requirements of the Act and will not allow smoking within an}~ portion of any indoor facility used for the provision of services for children as defined by the Act. The Contractor agrees that it will require that the language of the Act be included in any subcontracts which contain provisions for children's services and that all contractors shall sign and agree accordingly. 7. Contractor shall ensure that the provisions of Section 601 of Title VI of the Civil Rights Act of 1964 are carried out. That Act states that "no person in the United States shall on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." The Office of Civil Rights has concluded that it is the responsibility of any program which is a recipient of funds from the Department of Health and Human Services to ensure that clients who do not speak or understand English well, be provided interpretation services to ensure that the service provider and the client can communicate effectively. The Contractor shall have policies and procedures to ensure that interpretation services are available for clients with Limited English Proficiency and will advise such clients that an interpreter will be provided for them. If a client has their own interpreter, they shall be advised that the Contractor will provide an interpreter if the client so chooses. 8. The State may require fornls attached to this contract and incorporated herein by reference by updated during the term of this contract. The Contractor will be informed of the new forms as they are developed. Forms may be sent to contractors or will be available on the Family Planning Administrative Manual website: http://«-ww.cdphe.state.co.us/pp/woinenslfamplan.htmt. 9. Notwithstanding anything herein to the contrary, the parties understand and agree that all terms and conditions of this Task Order Contract and the exhibits and attachments hereto which may require continued performance, compliance or effect beyond the termination date of this Task Order Contract shall survive such termination date and shall be enforceable by the State as provided herein in the event of such failure to perform or comply by the Contractor. To be attached to CDPHE Page 2 of 3 Revised: 4/1/04 Version 1.0 (4/04) contract template EYHIBIT,J Funding adjustments maybe made during the terns of this contract. The State makes funding adjustments on this contract using a Funding Letter substantially equivalent to Exhibit D of Original Contract and bearing the approval of the State Controller or his designee; the funding letter shall not be deemed valid until the State Controller or his designee has approved it. To be attached to CDPNE Page 3 of 3 Revised: 4/1/04 Version I.0 (4/04) contract template ti a d ~ ~"~ ~ ~ b ..- '~ ~ cOi ..f,. C/~ 6". ~ ..r ~~ s. ~ O ~ ~ ~ O ~ ^d ~ i. ~o U U O O s .~ ti~ O N O i N .~ ~' U ~~ o ~ ~ x ~ ~ U O ~ ~ ~ ~ .~f. ~n. ~ cd t. ~' O ~ c~.., O > ~ O p, o > ~ ~ ~ O ~~ LZ. A O ~ O U ~ «S 'O Q".~ ~ ~ ~ '~ ~ ~ ~•O 3-i ~' o ~ o 'd o ~ ~ U 4 p ~ .V.~ O ~ ~ O _~ Q ~ '~ .~ ~ ~ +~+ S." N ~ ~ ~ ~ ~ .~ ~ ~ O ~ bA ~w •~ U o ~.fl-o ~ ~ ~ .fl -o ~ o O ~ ~ ~ ~ ~~ `..G . O ,a ~ ~ ~ ~ Q ~ ~ •~ ~ ~ ~ ~ ~ ~~ ~ ~ ~' ~ ~ ~ ,~ 1: ~ U U ~ O ~ '~ j ~ ~ ,~ ~ 4 y a' ~ ." i ~ i "' i u v ~ v u ~ ~ v '~ y ~ y y ~ m v ~ ~ ~ ~ ~ ~ ~ ~ ~ "O ~ ^O ~ b p ti ~i ~ ~ 0. O ~ v 0. 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"'C7 ~ ,,., ~ cd ~ !'1 ra a O Q•~ ' ~ ~ r, E-~ F ; ~ ~ ~ bA p ~ ~~ rr N w 0 N ti E 0 o ° 0 0 0 ~ ^" ~ _ ~ o sg ~ _ ~ ~ ca >> .5 L o ~ ° ~ F ° ~ >, a~ ' ~ ~ S c . ~ ~' C ue ~' ~ ~ ~ , + s + ~ ~ ~ U] `~ ~ .r V ~ c U •~ ~ ~ ~. w ~ ~ o U . ~, ~o ~ ~ ;~? ~ U ~ `~ [ o y~ ~ ~ ~ ~ ~ ~ ~ a ~ ~ ~ ~ ~~ w o ~ s ~ .~ , ~ .~ ~ o ^J s ~ H u d ~, w ~.. .o ~=. w w ~ U U U w 0 M EXHIBIT K STATEMENT OF WORK To Contract Dated 03/01/2010 -Contract Routing Number 11 FLA 15888 1) The Contractor, in accordance with the terms and conditions of this contract, shall perform and complete, in a timely and satisfactory manner, all activities described in this approved Statement of Work and incorporated in accordance with the associated COLORADO FAMILY PLANNING INIATIVE BUDGET and COLORADO FAMILY PLANNING INIATIVE BUDGET NARRATIVE, which is attached hereto as Attachment K-1 and Attachment K-2. 2) The Contractor shall continue to conduct a comprehensive family planning program ("the program"). This program shall comply with section 1001 of the federal Act and all applicable federal regulations, as amended, contained in Title X, 42 C.F.R., Subpart A, Part 59, as well as all applicable state regulations. (Federal funding from HHS, CFDA #93.217 FP Services). The program shall offer the following under the Title X family planning program: A. Out•each services and/or other program efforts designed to improve client recruitment. B. Nursing and medical services, which shall include a comprehensive health and social history and physical examination administered in accordance with all applicable Title X regulations and, all applicable nursing-medical policies or procedures which have been, or may be, established by the State's Women's Health Unit (WHU). C. Contraceptive information, education, and supplies regarding all family planning methods. D. Education and counseling services regarding family planning, family planning methods, child spacing, infertility, sterilization, nutrition, sexually transmitted diseases, Human immunodeficiency virus (HIV)/ Acquired immunodeficieny syndrome (AIDS), adolescent counseling and other related health issues, as outlined in the Nursing and Administrative Manual. E. Follow-up and/or refen-al services, as appropriate. 3) All money received by the Contractor from the State under the Colorado Family Plamling Initiative (CFPI) shall be used by the Contractor to provide contraceptive services. The Contractor shall make its program available to men and women in their reproductive years and shall offer the following services under the CFPL A. Utilize CFPI funding to purchase long acting reversible methods of contraception and contraceptive rings. These are limited to Intrauterine Devices (IUD) Mirena and Paraguard, contraceptive implants and contraceptive rings. B. Utilize CFPI funding to provide the referral process and cover the actual costs of tubal ligation and vasectomy procedures. C. Utilize CFPI funding for Family Planning staff to attend reproductive health related training with preference to those related to long acting reversible methods of contraception. 4) The services provided by the Contractor to the clients it serves shall be performed pursuant to law in accordance with prevailing medical standard of care for the same or similar medical, nursing and professional services. The services provided shall also comply with applicable Title X regulations, WHU nursing-medical policies and procedures, and any applicable fiscal or administrative policies of the State or Federal government which can be located at http:/iwww.cdphe.state.co.us/pp/womens/famplan.html?colt=open. Contractor acknowledges that it has reviewed these policies and procedures. To be attached to CDPHE Page 1 of 3 Revised: 4/1/04 Version 1.0 (4/04) contract template EXHIBIT K 5) The Contractor shall provide the State's family planning program consultants and administrators with reasonable access to its operations to perfoml: periodic site reviews, data reviews, fiscal reviews or other evaluations of the Contractor's family planning program. Evaluations of the Contractor's program shall be based on established standards and policies of the State or the Federal government. The Contractor shall cooperate during all periodic site visits, data reviews, fiscal reviews or other evaluations conducted by the State. The established standards and policies for the Family Planning Program can be located in the Family Planning Administrative Manual and the Family Planning Nursing Manual located on the Family Planning website at http://www. cdphe. state.co.us/pp/womens/famplan.html. 6) If necessary, the Contractor shall comply with all recommendations, including development and implementation of a Performance Improvement Plan, made by the State's family planning program consultants and/or administrators after a periodic site visit, data review, fiscal review or other evaluations that are necessary to bring its program into compliance with all program requirements and applicable federal and state laws, policies and regulations. The Contractor shall be in full compliance with a recommendation, if any, within three (3) months of the date a recommendation is made by the State. If the Contractor cannot obtain full compliance within this three (3) month period, then on or before the expiration date of that tlu•ee (3) month period the Contractor shall present sufficient written evidence to the State: to show that continuing progress is being made towards full compliance; and, the date when full compliance shall occur. In no event, however, shall full compliance with a recommendation occur any later than six (6) months after the date that a recommendation was initially made by the State. Notwithstanding the foregoing provisions, the State may disregard these cure periods and immediately terminate the contract without liability if it has solely determined that Contractor's noncompliance places the health, safety or welfare of persons receiving services in jeopardy. 7) On a monthly basis, the Contractor shall collect and provide to the State, by the fifteenth calendar day of the following month unless otherwise specified by CDPHE, all pertinent data as defined by CDPHE regarding all services offered, and all family planning clients served, by its program during the preceding month, submitted through the IRIS data system. This data shall be verified on a quarterly basis to help assure accuracy. The Contractor must adhere to the Data Security, Use and Confidentiality Agreement, incorporated and made part hereof by reference. This document is located at: http:!,~~~vw.cdphe.state,co.uslpp/womens/FPNursingConsntsForms html`~col2=open. Contractor also agrees to respond to other data requests required by the program. 8) During the term of this Contract, the Contractor agrees to provide the State with the semi-annual Family Planning Expenditure/Revenue Reports. The Expenditure/Revenue Report (ERR) is located on pages 19-21 in the Financial Management Section of the Family Plamiing Administrative Manual, this information can also be accessed online on the CDPHE Family Planning website at http://www.cdphe.state.co.us!pp/womens/famplau.html. The first report is for the months of October through December will be due in February. January through June and will be due in August. Final due dates will be specified by CDPHE. 9) The Contractor shall protect the confidentiality of all client records and other materials that are obtained, created, or maintained by the Contractor under this contract. Except for purposes directly related to the administration of this contract, no information about, or obtained from, any client shall be disclosed by the Contractor in any form that would identify that client without the prior written consent of that client. As of the acceptance date of this contract by the Contractor, the Contractor shall have written policies governing the access to and, the duplication and dissemination of, all such information. The Contractor shall advise its directors, officers, employees, agents, servants, and subcontractors, if any, that they are subject to these confidentiality requirements. 10) Maintenance of Effort (MOE) Colorado Family Planning Initiative funding is expected to provide new funding for providing services to additional family planning clients and increasing the total number of clients utilizing efficacious methods of contraception. This is a temporary funding source, and therefore shall not be used to supplant other traditional funding sources. Therefore, the contractor shall show Maintenance of Effort (MOE) for revenue provided by local government as documented on the required family planning program Expenditure Revenue Reports To be attached to CDPHE Page 2 of 3 Revised: 4/1/04 Version 1.0 (4/04) contract template EXHIBIT K (ERR), for the three years previous to any year in which funding from the Colorado Family Planning Initiative is received. This revenue, provided by local government (county and city grants and contracts) shall be equal to, or in excess of, 90% of the average of the last 3 year's Expenditure Revenue Reports. Definition: Maintenance of Effort (MOE) - A measure intended to preserve funding for the base program. This ensures that fiscal resources are not supplanted and that new funding creates an expansion in the program. MOE shall be determined by averaging the revenue provided by local government in the last 3 years' Expenditure/Revenue Reports (ERR) for the entity's family planning program, and then multiplying by ninety percent (90%). The result is the minimum amount that the entity must spend in order to illustrate MOE. In an instance where there is not three years' data, MOE shall be 90% of previous two years' local government revenues from the ERR, or 95% of the last year's results, as applicable. In the case of an anomaly where local government revenue level from the previous three years' ERR varies more than 30% in any two of the three years, an explanation of the variance must be provided by the Contractor. The Family Planning Director shall use this information to decide if the anomaly should be eliminated from the calculation of the MOE level. In any year in which the Contractor will not attain MOE, according to the fornlula described in the definition the Contractor shall notify the Family Planning Director. Should MOE not be obtained, in special hardship cases, a Maintenance of Effort Waiver to this clause may be requested from the CDPHE Family Planning Director, in conjunction with the Women's Health Director, attached hereto as Attachment B-2 of Original Contract. Should a Maintenance of Effort Waiver not be granted, the Colorado Family Planning Initiative funding maybe reduced. 11. The services provided by the Contractor must be deemed acceptable, in good faith, by WH. For a service to be "acceptable" it must comply with all applicable: Title X regulations, WH nursing-medical policies and procedures, and any applicable fiscal and administrative policies and procedures of the State and Federal government. All applicable Title X regulations, WH nursing-medical policies and procedures, and all applicable fiscal or administrative policies of the State have been provided to the Contractor by the State as of the effective date of this Contract. 12. During the term of this Contract, the Contractor agrees to provide the State with quarterly reports to the Family Planning Program Coordinator. 13. The Contractor shall require any new staff working on Family Planning program services to participate in Fiscal Orientation within forty-five (45) days of employment. To be attached to CDPHE Page 3 of 3 Revised: 4/1/04 Version 1.0 (4/04) contract template COLORADO FAMILY PLANNING INIATIVE BUDGET Attachment K-1 APPLICANT: Eagle County Public Health Agency __ _ FOR THE BUDGET PERIOD: CFPI July 1, 2010 - Junc 30, 2011 Salary % Time - -- ------ CDPHE-WHU CDPHE-WHU CDPHE-WHU NON-CDPHE TOTALS PLEASE ROUND ALL FIGURES TO THE NEAREST DOLLAR - TE _ JUNE 30, 2010 JUNE 29, 2011 SEE ABOVF, FOR BUDGET PERIODS BY JULY 1, 2010 - JUNE 30, 2011 Family Planning program Funding JULY 1, 2010 - .111, zn- zntn ,TUNE 30, 2010 -JUNE 30, 2011 _ _ _ FEDERAL TITLE X FEDF,RAL & STATE TITLE X CFPI NON-CDPHE CDPHE PLUS NON-CDPHE ___ PERSONNEL EXPENSES: (Include name & title for each employee charged to CDPHE CUnding. You do not need to list the name and title for employees charged only to Non-CDPHE fundin) Q Tatum Bnmlc, FP Coordinator $85,010 100°/n $47,505 $37,505 $85,010 Clinic Assistant $35,340 70% $24,373 $24,373 CGnicAssistant $36,400 30% $10,920 $10,920 Nutse Manager $73,507 10°/ $?,351 $7,35] $0 _ $0 __ Sub-total Sala Ex enses $0 $47,505 $0 $80,149 $127,654 Fringe Benefit Rate and Ex enses $0 Total Personnel Ex enses $230,257 $0 $47,505 $0 $80,149 $127,654 CONTRACTUAL: (Independent contractor (or tuba) ligafioq Essure, vasectomy, physicians, nurse practitioners, etc. [n CFPf portion ONLY, add referral fee in this section. $Q Rocky Mountain Urology -Vasectomy 124 procedures $ ] 6,200 $16,200 Essure ContractorTBD 10 procedures ~ $26,000 $26,000 Medical Offcer lyear'scontract j $6,575 $6,575 ______ Total Contractual Ex enses SO $0 $42,200 $6,575 $48,775 OPERATING: $0 ____ ontracepnve , et [o< s ar por on o a mm ee can a includcd in this line.) $17,800 $20,000 $37,800 ------ jTraining costs -which includes registration fees, travel $ ],500 $921 $2,421 Chlamydia tests ([f you do not use the stale lab, please make sure th6 line jequa6 or exceeds the amount listed on your FY 2011 Estimated Funding jworksheet for Chlamydia) $2,000 $2,000 other Lab tests j I $7,000 $7,000 jEducational materials (brochures, etc) $S50 $550 _____ __ !Clinical supplies $569 5569 _ Office operatingsupplies (papers, charts, pens, etc) ~ $Q Office expense (rent, utilities, mam[enance) ~ $0 jOTHER (Specify) $0 $0 $0 ---- Total O eratin Ex enses 50 $0 $19,300 $31,040 550,340 EQUIPMENT: (Com uters, Office furnitures) $p $0 $0 Total E ui ment Ex enses $0 $0 $0 $0 $0 TOTAL DIRECT EXPENSES $0 $47,505 $61,500 $117,76# $226,769 Indirect rate: Indirect Ex ease m 'SO $0 $0 ADiN1INISTRATIVE (10°'o CFPI Expansion Grant. Do NOT calculate the 10% adnun late on one-time cxpenes, conhaceptive methods, training, or contractors for tubals, Essure, vascctom ,etc) $0 50 ONE-TIME EXPENSE For CFPI Ex ansion Grant onl ( }) $0 TOTAL .4f~ioUNT REQUESTED $0 $47,505 $61,500 $I 17,764 $226,769 I _.._. -- Page 1 COLORADO FAMILY PLANNING INIATIVE BUDGET NARRATIVE Attachment K-2 13UDGET NARRATIVE FYll CFPI Regular Grant, with Expansion Grant if applicable, APPLICANT: Eagle County Public Health Agency FOR THE PERIOD: July 1, 2010 -June 30, 2011 For Personnel category list title of position Relationship to project How is the total amount required Total For all other categories list the line calculated? item from the budget Rocky Mountain Urology Provide vasectomy services Contract is for 24 procedures I $16,200.00 Contractor TBD Provide Essure services Contract is for 10 procedures 526,000.00 Contraceptive Methods - LARC I I I $17,800.00 (Training FP Coordinator training In-state training $ ] ,500.00 Page 1