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Home My WebLink AboutC2018-629 - 7/17/2018 - Approved DocuSign Envelope ID:4371AF1C-960D-4298-9225-324F051596BB DEPARTMENT OF STATE HEALTH SERVICES CONTRACT No.2016-003808 AMENDMENT No. 5 THE DEPARTMENT OF STATE HEALTH SERVICES ("DSHS") AND CORPUS CHRISTI-NUECES COUNTY PUBLIC HEALTH DISTRICT(CITY) ("Contractor"), each a"Party"and collectively the "Parties,"to that certain grant contract effective October 1,2015 and denominated DSHS Contract No. 2016-003808 ("Contract"), now desire to further amend the Contract. WHEREAS, the System Agency has chosen to exercise its option to renew the Contract in accordance with Contract Section 4,Term of the Contract; WHEREAS, the Parties desire to revise the Budget to add funds for the period beginning October 1, 2018 through September 30, 2019 (hereinafter referred to as "Fiscal Year 2019" or "FY2019"); WHEREAS,this revision will result in an addition of funds in the amount of FIFTY THOUSAND DOLLARS($50,000.00);and WHEREAS, the Parties desire to revise the Statement of Work. Now,THEREFORE, the Parties hereby amend and modify the Contract as follows: 1. SECTION 2 of the Contract, TOTAL AMOUNT, is amended to increase the total amount of the contract to TWO HUNDRED THOUSAND DOLLARS($200,000.00). 2. SECTION 4 of the Contract, TERM OF THE CONTRACT, is hereby amended to reflect a new end date of September 30, 2019. 3. Section 7 of the Contract, STATEMENT OF WORK,is amended to add the following: For FY 19 Contractor shall: a. Develop, complete and submit a Project Work Plan in conjunction with DSHS. The Project Work plan must include objectives with supporting activities that address indicators identified in the FY 2018 TXHC assessment as needing improvement. A Project Work Plan Draft must be submitted,reviewed and approved by DSHS prior to the final version submission date. The Project Work Plan draft must be submitted to DSHS on or before October 17, 2018 and the final Project Work Plan submission is due to DSHS on or before October 31, 2018. b. Develop and submit an Evaluation Plan to DSHS. An Evaluation Plan Draft must be reviewed and approved by DSHS prior to the final version submission date. The Evaluation Plan Draft must be submitted on or before November 16,2018 and the final Evaluation Plan version is due to DSHS on or before November 30, 2018. C2018-629 7/17/18 Ord. 031474 TX Dept of State Health Services SCANNED DocuSign Envelope ID:4371AF1C-960D-4298-9225-324F051596BB c. Submit an Interim Progress Report Draft to DSHS for review on or before March 19, 2019. The Report will include summary of all items/activities conducted to date; detailed description of progress toward achieving objectives and activities; and barriers. Submission of the final Interim Report must fully address any feedback from DSHS based on the draft Interim Report and must be submitted on or before March 29, 2019. d. Conduct, complete and submit the Texas Healthy Communities Assessment Draft in the Performance Management and Tracking System (PMATS) by May 16, 2019. DSHS will review and approve Draft submission prior to submission of final report in PMATS on or before May 31, 2019. Delinquent Assessments will not be accepted. e. Designate a member of the TXHC program to attend, in person, the TXHC Annual Meeting during the Contract term. If the member or designee is unable to attend the meeting in person, then the Contractor must notify DSHS in writing as to the reason for non-compliance. f. Submit a Final Progress Report Draft to DSHS for review and approval on or before August 30,2019.Report will include summary of all items/activities conducted to date; detailed description of progress toward achieving objectives and activities; plans for sustaining activities once funding has ended; and barriers/lessons learned. Submission of Final Report must fully address any feedback from DSHS based on draft final report and must be submitted on or before September 13, 2019. g. Participate in twelve (12) monthly feedback calls (monthly project status reports)with DSHS Program to be conducted on or before the following dates: October 31St, November 28th,December 31st,January 30th,February 28th,March 29th,April 30th,May 29th,June 28th, July 31St, August 30th, and September 30th. h. Inform DSHS of delinquent submission within five (5) business days of the due date including a detailed justification and proposed submission date. i. Submit written monthly reports as directed by DSHS. DSHS will monitor the Contractor's financial performance on a monthly basis to insure that the Contractor will not lapse more than 5% of the allotted funding for FY19. Contractor certifies that it has adopted and enforces a Tobacco-Free Workplace Policy that meets or exceeds all of the following minimum standards of: a) Prohibiting the use of all forms of tobacco products, including but not limited to cigarettes, cigars, pipes, water pipes (hookah), bidis, kreteks, electronic cigarettes, smokeless tobacco, snuff and chewing tobacco; b) Designating the property to which this Policy applies as a "designated area," which must at least comprise all buildings and structures where activities funded under this Contract are taking place, as well as Grantee owned, leased, or controlled sidewalks, parking lots, walkways, and attached parking structures immediately adjacent to this designated area; c) Applying to all employees and visitors in this designated area; and Page 2 of 5 DocuSign Envelope ID:4371AF1C-960D-4298-9225-324F051596BB d) Providing for or referring its employees to tobacco use cessation services. If Contractor cannot meet these minimum standards, it must obtain a waiver from the System Agency. 4. SECTION 7 of the Contract,STATEMENT OF WORK,BILLING INSTRUCTIONS, is amended to reflect the following changes in financial documentation submission: Department of State Health Services Claims Processing Unit, MC 1940 P.O. Box 149347 Austin, TX 78714-9347 FAX: (512)458-7442 EMAIL: invoices(aAshs.texas.gov &CMSinvoices@dshs.texas.gov B-13 and supporting documentation should be sent to: invoices@dshs.texas.gov & CMSinvoices@dshs.texas.gov FSRs should be sent to: invoices@dshs.texas.gov, CMSinvoices@dshs.texas.gov & FSRGrants@dshs.texas.gov 5. SECTION 11 of the Contract, RENEWALS, is hereby amended to reflect that there are no renewals remaining under the Contract. 6. The categorical budget is deleted in its entirety and replaced with the following budget table: Budget FY16 FY17 FY18 FY19 Category Categories Allocation Allocation Allocation Allocation Total Personnel $0.00 $32,328.00 $32,442.00 $33,253.00 $98,023.00 Fringe $0.00 $9,537.00 $13,892.00 $14,239.00 $37,668.00 Benefits Travel $1,790.00 $2,529.00 $1,465.00 $1,147.00 $6,931.00 Equipment $0.00 $0.00 $0.00 $0.00 $0.00 Supplies $2,400.00 $5,606.00 $2,201.00 $1,361.00 $11,568.00 Contractual $15,000.00 $0.00 $0.00 $0.00 $15,000.00 Other $30,810.00 $0.00 $0.00 $0.00 $30,810.00 Total Direct $50,000.00 $50,000.00 $50,000.00 $50,000.00 $200,000.00 Costs Indirect $0.00 $0.00 $0.00 $0.00 $0.00 Costs Totals $50,000.00 $50,000.00 $50,000.00 $50,000.00 $200,000.00 7. This Amendment No. 5 shall be effective as of the date upon which both Parties have signed this Amendment. Page 3 of 5 DocuSign Envelope ID:4371 AF1 C-960D-4298-9225-324F051596BB 8. Except as amended and modified by this Amendment No. 5, all terms and conditions of the Contract, as amended, shall remain in full force and effect. 9. Any further revisions to the Contract shall be by written agreement of the Parties. SIGNATURE PAGE FOLLOWS Page 4 of 5 DocuSign Envelope ID:4371AF1 C-960D-4298-9225-324F051596BB SIGNATURE PAGE FOR AMENDMENT No.5 DSHS CONTRACT No.2016-003808 DEPARTMENT OF STATE HEALTH SERVICES CORPUS CHRISTI-NUECES COUNTY PUBLIC HEALTH DISTRICT(CITY) DocuSigned by: DocuSigned by: CittiOA4 /.�4L1 By: tA Nt,.O. a .tA.t,f t, lee�l iev a,y 202CEA5A9C164E2... 4FC9D92742CE414... Associate Commissioner Name:Annette Rodriquez Community Health Improvement Title:Health Di rector Date of Execution: July 24, 2018 Date of Execution:3uly 23, 2018 THE FOLLOWING ATTACHMENTS ARE ATTACHED TO THIS AMENDMENT AND INCORPORATED INTO THE CONTRACT: ATTACHMENT A: FFATA Page 5 of 5 DocuSign Envelope ID:4371AF1C-9600-4298-9225-324F0515968B SIGNATURE PAGE FOR AMENDMENT NO.5 DSHS CONTRACT No.2016-003808 DEPARTMENT OF STATE HEALTH SERVICES CORPUS CHRISTI-NUECES COUNTY PUBLIC HEALTH DISTRICT(CITY) By: L^ u4k 1- _o • Associate Commissioner Name: Community Health Improvement Title: Date of Execution: Date of Execution: THE FOLLOWING ATTACHMENTS ARE ATTACHED TO THIS AMENDMENT AND INCORPORATED INTO THE CONTRACT: ATTACHMENT A: FFATA Approved as to form: . 5 18 4 ,ssistant City Atto .. ejaFeoLy Attrly. fel ATTEST: REB CCA HUERTA - - CITY SECRETARY \+1 L4 0Vd l D3 0"1"1"-- sY CONN. . r.I ) SECRETARY Page 5 of 5 DocuSign Envelope ID:4371AF1 C-960D-4298-9225-324F051596BB Fiscal Federal Funding Accountability and Transparency Act (FFATA) CERTIFICATION The certifications enumerated below represent material facts upon which DSHS relies when reporting information to the federal government required under federal law. If the Department later determines that the Contractor knowingly rendered an erroneous certification, DSHS may pursue all available remedies in accordance with Texas and U.S. law. Signor further agrees that it will provide immediate written notice to DSHS if at any time Signor learns that any of the certifications provided for below were erroneous when submitted or have since become erroneous by reason of changed circumstances. if the Signor cannot certify all of the statements contained in this section, Signor must provide written notice to DSHS detailing which of the below statements it cannot certify and why. Legal Name of Contractor: FFATA Contact#1 Name,Email and Phone Number: Corpus Christi-Nueces County Public Health Constance Sanchez District constancep@cctexas.com 361-826-3227 Primary Address of Contractor: FFATA Contact#2 Name, Email and Phone Number: 1702 Horne Road Blandina Costley Corpus Christi , Texas 78416 blandinac@cctexas.com 361-826-7252 ZIP Code:9-digits Required www.usps.com DUNS Number:9-digits Required www.sam.gov 78416-1902 - O69457786 State of Texas Comptroller Vendor Identification Number(VIN) 14 Digits 07460005741027 Printed Name of Authorized Representative Signature of Authorized Representative DocuSigned by: Annette Rodriquez I rp` I.� Il 0.1FCOD02742CIEw41Q4...'l Title of Authorized Representative Date Health Director July 23, 2018 - 1- Department of State Health Services Form 4734—June 2013 DocuSign Envelope ID:4371AF1 C-960D-4298-9225-324F051596BB Fiscal Federal Funding Accountability and Transparency Act (FFATA) CERTIFICATION As the duly authorized representative(Signor)of the Contractor, I hereby certify that the statements made by me in this certification form are true, complete and correct to the best of my knowledge. Did your organization have a gross income, from all sources, of less than $300,000 in your previous tax year?❑Yes Q No If your answer is "Yes", skip questions "A", "B", and "C" and finish the certification. If your answer is "No", answer questions "A" and "B". A. Certification Regarding%of Annual Gross from Federal Awards. Did your organization receive 80% or more of its annual gross revenue from federal awards during the preceding fiscal year? ❑Yes x❑ No B. Certification Regarding Amount of Annual Gross from Federal Awards. Did your organization receive $25 million or more in annual gross revenues from federal awards in the preceding fiscal year? ❑Yes x❑ No If your answer is "Yes" to both question "A" and "B", you must answer question "C". If your answer is "No" to either question "A" or "B", skip question "C" and finish the certification. C. Certification Regarding Public Access to Compensation Information. Does the public have access to information about the compensation of the senior executives in your business or organization (including parent organization, all branches, and all affiliates worldwide) through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986? ❑Yes ❑ No If your answer is"Yes"to this question,where can this information be accessed? If your answer is "No" to this question, you must provide the names and total compensation of the top five highly compensated officers below. Provide compensation information here: -2- Department of State Health Services Form 4734—June 2013 Docu�i�,►,; ■ SECURED Certificate Of Completion Envelope Id:4371AF1C960D42989225324F051596BB Status:Completed Subject:Amending$200,000;2016-003808 Corpus Christi-Nueces County Public Health District A-5;DSHS/CMS Source Envelope: Document Pages: 16 Signatures:3 Envelope Originator: Certificate Pages:2 Initials:0 Texas Health and Human Services Commission AutoNav:Enabled 1100 W.49th St. Envelopeld Stamping:Enabled Austin,TX 78756 Time Zone:(UTC-06:00)Central Time(US&Canada) PCS_DocuSign@hhsc.state.tx.us IP Address: 167.137.1.16 Record Tracking Status:Original Holder:Texas Health and Human Services Location:DocuSign May 18,2018 Commission PCS_DocuSign@hhsc.state.tx.us Signer Events Signature Timestamp Annette Rodriquez DocaSiane°by I�_ Sent:May 18,2018 annetter@cctexas.com t lebA�l @ °VI"tiy Resent:May 18,2018 '-4FC9D92742CE414. Health Director Viewed:June 26,2018 City of Corpus Christi Signed:July 23,2018 Security Level:Email,Account Authentication Using IP Address:64.201.138.47 (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign Manda Hall,M.D. �D°`uS1ynad°�YL' nn Sent:July 23,2018 Manda.Hall@dshs.texas.gov Ma' Nal At.V, Viewed:July 24,2018 Associate Commissioner,Community Health —202°En5n9c164E2 Signed:July 24,2018 Improvement Texas Health and Human Services Commission Using IP Address: 107.77.220.186 Security Level:Email,Account Authentication Signed using mobile (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign In Person Signer Events Signature Timestamp Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Intermediary Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp Margaret Schmidt COPIED Sent:May 18,2018 margaret.schmidt@hhsc.state.tx.us Viewed:May 18,2018 Security Level:Email,Account Authentication (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign Carbon Copy Events Status Timestamp Jason Adams COPIED Sent:May 18,2018 jason.adams@dshs.state.tx.us Viewed:May 18,2018 Contract Manager Texas Health and Human Services Commission Security Level:Email,Account Authentication (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign CMU Contract Inbox COPIED Sent:May 18,2018 cmucontracts@dshs.texas.gov Viewed:May 23,2018 Security Level:Email,Account Authentication (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign William Uhlarik COPIED Sent:May 18,2018 williamu2@cctexas.com Viewed:May 22,2018 Security Level:Email,Account Authentication (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign Notary Events Signature Timestamp Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted July 23,2018 Certified Delivered Security Checked July 24,2018 Signing Complete Security Checked July 24,2018 Completed Security Checked July 24,2018 Payment Events Status Timestamps