HomeMy WebLinkAboutAgreements/Contracts - New Hope DV/SAAnnual Contract Compliance Self -Assessment
Part A — Contractor Profile
Instructions:
The Annual Contract Compliance Self -Assessment, Part A — Contractor Profile is one of several
documents DSHS reviews to gauge contractor compliance with applicable state and federal laws and
rules, program guidelines, and the contract. This form is not a contract.
Please review and answer the following questions.
• The form has been set up to be completed on your computer.
• If you have any questions, contact the Program Manager for your contract.
Program Administration
1. Contractor maintains documentation to substantiate its organizational structure and tax status (i.e.,
Articles of Incorporation, Bylaws, Washington State Business License).
® Yes ❑ No ❑ N/A Explain if "No":
2. Contractor maintains all insurance coverage required by the contract.
® Yes ❑ No Explain if "No":
3. DSHS contractors for emergency DV shelter and supportive service shall comply with guidance
prohibiting discrimination issued by the federal Office for Civil Rights within the Office of Justice
Programs.
• Cited laws collectively prohibit discrimination based on race, color, national origin, disability,
religion, sex, gender, gender identity, and sexual orientation in both the delivery of services
and employment practices
• The Age Act also prohibits discrimination on the basis of age in the delivery of services or
benefits.
• The Equal Treatment Regulation prohibits recipients from using federal financial assistance
to engage in explicitly religious activities.
• Eligibility for direct services is not dependent on the victim's immigration status.
Contractor complies with non-discrimination requirements stated above: ® Yes ❑ No
4. The complete VOCA rule is available at:
httos•//www federairegister.gov/documents/2016/07/08/2016-16085/victims-ofcrime-act-victim-
assistance-program
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5. For civil rights compliance, the Contractor collects and maintains a list of current staff by positions
(not names) that includes date of birth, gender, and identified protected group status, including
race, Vietnam Era Veteran, Disabled Veteran, and person of disability. For protected group data,
Contractor must inform staff that furnishing the information is voluntary. This is a state, federal,
and Contract requirement.
® Yes ❑ No Explain if "No":
6. Is the Contractor currently, or within the past one (1) year, involved in any litigation or
administrative dispute resolution proceeding, including civil rights complaints, by current or past
employees or service recipients?
❑ Yes ® No
a. If "Yes", explain:
b. Please provide the status of any pending litigation or administrative proceedings.
c. Please attach a copy of any related findings of discrimination (i.e. court/administrative
order) issued.
7. In the past one (1) year, has the Contractor received any findings or a corrective action plan as a
result of any financial audit, license review, administrative proceeding, or contract monitoring
review?
❑ Yes® No If "Yes", explain:
8. Has the contracted program undergone any major restructuring with the past one (1) year?
❑ Yes ® No Explain if "Yes":
9. Has there been turnover in the program's management" within the past one (1) year?
("Management includes executive director, program director, accounting/fiscal staff, etc.)
Attach a copy of the Contractor's current organizational chart that includes staff names and job
titles.
❑ Yes ® No Explain if "Yes":
10. If the Contractor is required to have and maintain a Board of Directors, what are the minimum and
maximum numbers of boardmembers required, in accordance with the Contractor by-laws.
Minimum: 3 Maximum: 3 N/A: ❑ (skip to question 9)
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a. How many boardmembers are on the Contractor's current Board of Directors? Three (3)
b. In accordance with the Contractor by-laws, what constitutes a quorum for the purpose of
taking board action? Two (2)
c. In the past 12 months, has the board taken any action without having the required quorum
present?
❑ Yes ® No Explain if "Yes":
d. Does the board schedule and conduct meetings on a regular basis and in accordance with
Contractor bylaws? Attach copies of the minutes from the four (4) most recent meetings
of the Board of Directors.
® Yes ❑ No Explain if "No":
e. How frequently do the Contractor bylaws require that the board of directors meet?
Weekly, per resolution
11. Contractor verifies that criminal history background checks (CHBC) have been conducted on all
employees, volunteers, subcontractors, and other persons who may have unsupervised access to
children, developmentally disabled persons, or vulnerable adults, prior to these individuals providing
services under the contract.
® Yes ❑ No Explain if "No":
12. Contractor verifies that it has documentation of the CHBC on file for all staff described in question 9
above.
® Yes ❑ No Explain if "No":
13. Contractor has personnel files on all staff and volunteers providing contracted services and verifies
that each file includes at least the following documents:
Yes No
® ❑ Employment application or resume
® ❑ Current job description
® ❑ Signed dated statement acknowledging a duty to report child abuse/neglect in
accordance with RCW 26.44 (if staff/volunteer is a mandated reporter)
Explain any "No" responses:
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14. Contractor verifies that it has written policies/procedures on the following:
Yes No
® ❑ Confidentiality and protection of Contractor and service recipient records
(both hard copy and electronic)
® ❑ Nondiscrimination in employment
Complete Section A (non -profits) or B (local government) of the EEOP Certification
form; sign, date and include a copy of the ESOP Certification form with your
application.
® ❑ Nondiscrimination in the provision of services
® ❑ Provision of bilingual and interpreter services for service recipients
® ❑ Reporting of child abuse/neglect as required by law, if contractor is a mandated
reporter
® ❑ Service recipient access to their file
® ❑ Grievance procedure for service recipients
® ❑ Grievance procedure for staff
® ❑ Policy prohibiting harassment of service recipients based on race, sexual
orientation, gender identity (or expression), religion, and national origin
® ❑ Procedures to address violations of the anti -harassment policy
® ❑ InfoNet security procedures
® ❑ Written accounting procedures
® ❑ Written personnel policies
Explain any "No" responses:
15. Contractor verifies that it has the following written forms that comply with WAC 388-61A:
Yes No
® ❑ Release of confidential information (waiver) that complies with the requirements
of WAC 388-61A
® ❑ Notice of Rights that complies with the requirements of WAC 388-61A
16. Contractor maintains a fixed assets log that identifies all equipment assets purchased with
contracted funds that includes at least the following information: description, serial number,
acquisition date, invoice/cost; location; disposition data (date of disposal and sale price).
® Yes ❑ No Explain if "No":
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17. Contractor anticipates subcontracting certain services/activities required to be performed by the
contract statement of work.
❑ Yes ® No
If yes, identify which services/activities the Contractor anticipates it will subcontract. Sub -contracts
for services identified in the contract statement of work require prior written approval by DSHS
whether or not you are expending contract funds for the services.
18. If Contractor anticipates subcontracting for services, Contractor will obtain and maintain a written
subcontract between the parties.
❑ Yes ❑ No ❑ N/A
19. Describe how the Contractor provides, or arranges for the provision of, qualified interpreters for all
persons provided services pursuant to the DSHS contract, when interpreter services are necessary.
New Hope employs 6 bi-lingual Spanish speaking personnel. For the most part, they are
available to provide services to our mono -lingual Spanish speaking population of our service area. If a
bi-lingual staff isn't available, or a client speaks a language other than Spanish, we reach out to an
interpreter service (Pacific Interpreters or Language Line).
20. Contractor enters each NEW domestic violence client (and any dependent children of the client)
served by the DSHS contract into InfoNet. NEW client is defined as an individual that has never
before received services from the Contractor.'
® Yes ❑ No Explain if "No":
21. Describe the Contractor's protocol for issuing NEW client ID numbers for entry into InfoNet.
New clients are given a unique client ID after checking the agency data base to see if the client has
been entered previously. All client ID numbers are created in the following fashion: 3 letters (the
first letter represents the county, the second two letters represent the city), followed by 4 or more
digits as a unique identifier. New client ID shall be assigned within 24 hours or the next business day
from date of intake.
1 NEW client means someone that has never received services before from the agency, including sexual assault and
general crimes services. If an individual that previously received domestic violence services from the agency
returns at a later time to again receive services, the agency does not issue a new client ID number. Rather, the
agency issues a new case number if the individual is seeking sexual assault or general crimes services. One
individual = one client ID number irrespective of the program from which the individual is receiving services.
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22. Describe how the Contractor ensures that multiple client ID numbers are not issued to the same
client.
New Hope uses a very unique combination of letters and numbers to create a client ID. The letters
in the client ID number are chosen by New Hope advocates, but not commonly known by anyone
viewing a list of the client IDs. The numbers following the letters are in a sequence based upon the
identified advocate who completed intake and the unduplicated numbers following that are
representative of the advocate's caseload number. No client ID has been duplicated with this
system, ensuring each ID number is unique to each client.
23. Contractor enters/updates the services provided to new and returning clients in InfoNet at least
quarterly.
® Yes ❑ No Explain if "No":
24. Describe how the Contractor verifies the accuracy of the client and service data in InfoNet at least
quarterly, and makes any necessary corrections.
InfoNet reports (staff services, client intakes and service summaries) are pulled and compared to the
reports of services entered in the agency database (staff caseload, staff services). Those
numbers/hours are matched to within a small margin of error on a monthly basis. If the margin of
error is exceeded, corrections will be made.
25. Does the Contractor enter any personally identifying information of domestic violence clients into
any other database that can be accessed by another entity or organization, such as HMIS, Safe
Harbors, Washington Family Funds, etc.z
[:]Yes ® No Explain if "Yes":
Z Personally identifying information includes, but is not limited to, first and last name, home or other physical
address, telephone number, social security number, date of birth, nine -digit postal (ZIP) code, physical appearance
of, case file or history of, and other information that would personally identify a victim of domestic violence who
seeks or has received services from a domestic violence agency, or such other information which, taken
individually or together with other identifying information, could identify a particular individual.
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Fiscal Administration
Describe how the Contractor's accounting system identifies the receipt and expenditures of program
funds separately for each contract/grant.
New Hope is a county department with the Grant County governmental umbrella. Grant County
has an automated accounting system that allows for accounts to be established under "projects". Each
"project" is a separate funding source. Within each project are a full range of revenue and expense
codes established in accordance with BARS. As revenues are received, accounting staff determines
which project the funding should be applied to. This procedure assures that revenues and expenditures
are specific to each funding source.
2. How does the Contractor accurately document allocation of time when employees are paid from
multiple contracts/grants/fund sources?
New Hope employees are expected to account accurately for their work time on their
timesheet, turned in for review by a supervisor twice monthly. Timesheets allow for the breakout of
time to be documented for work on each grant/contract/funding source. Targets are given to staff
that match the amount of time written on the grant budget sheet; knowing that is just a target. Hours
must be documented according to work done. Include a copy of the contractor's time sheet.
3. Contractor has —and follows —a written cost allocation plan.
® Yes ❑ No Explain if "No":
4. In the preceding fiscal year, did the Contractor receive 80% or more of its annual gross revenues in
U.S. federal contracts, subcontracts, loans, grants, subcontracts, and/or cooperative agreements
AND $25,000,000 or more in annual gross revenues from U.S. federal contracts, subcontracts, loans,
grants, subcontracts, and/or cooperative agreements?
❑ Yes ® No If "Yes", DSHS will contact you for further information.
5. Contractor understands that DSHS contract funds cannot be expended for lobbying activities. Sign,
date and include a copy of the Certification Regarding Lobbying with your application.
® Yes ❑ No Explain if "No":
6. Is the Contractor presently debarred, suspended, proposed for disbarment, declared ineligible, or
voluntarily excluded from covered transactions by any Federal department or Contractor? Sign,
date and attach a copy of the Certification Regarding Debarment to your application.
❑ Yes ® No Explain if "Yes":
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7. Does the Contractor own or rent its business office?
❑ Own ® Rent If you rent, who is the lessor/landlord: Mario Padilla
8. Does the Contractor own or rent the location where it provides non-residential community-based
advocacy and supportive services?
❑ Own ® Rent
If you rent, name of lessor/landlord: Mario Padilla
9. Does the Contractor own or rent its emergency domestic violence shelter building(s)/units?
❑ Own ® Rent
If you rent, name of lessor/landlord: Eric Kornblit
10. Does the Contractor have a federally negotiated indirect cost rate (NICR)?
❑ Yes ® No
If yes, attach a copy of the NICR approval letter from the cognizant federal Contractor.
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Miscellaneous Federal Funding Requirements
1. Contractor agrees that prior to using any federal funds in your contract to renovate, alter, or
otherwise improve the exterior or interior of a building, you will establish identification,
recordkeeping, reporting, consulting and decision-making processes within your programs or
procedures for administering contract funds. Contractor also agrees that proposed renovation
work, as it relates to the National Historic Preservation Act (NHPA), includes work not specifically
funded with VOCA or FVPSA funds but funded by the Contractor or any third party as a prerequisite
to accommodate the proposed use of contract funds. Contractor shall contact the DSHS Program
Manager for additional implementation guidance before deciding on any renovation work for which
Contractor is unsure of the application of the NHPA.
® Yes ❑ No Explain if "No":
2. Contractor must utilize at least one volunteer directly supporting your direct service and/or service
outreach activities. This does not include volunteer board members.
a. Your program funded by this contract uses volunteers. ® Yes ❑ No
b. How many volunteers do you have that directly support your direct service and/or service
outreach activities funded by this contract? 5
c. Briefly describe how volunteers are used in your program. Community awareness events,
miscellaneous tasks/repairs at the shelter, transportation, child care, data entry,
reception desk fill-in, and project focused internships (prevention and support group).
d. If you do not use volunteers, have you received a written waiver from the DSHS Program
Manager? ❑ Yes ❑ No ® N/A
3. Contractor provides information to, and assists service recipients in applying for crime victim
compensation benefits with the Washington State Department of Labor and Industries.
® Yes ❑ No Explain if "No":
4. Contractor prohibits smoking in any portion of any indoor area routinely owned or leased or
contracted for by the contractor and used routinely or regularly for the provision of health, day care,
education, or library services to children under the age of 18 years.
® Yes ❑ No Explain if "No":
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5. Contractor understands that federal VOCA funding cannot be used to maintain or establish a
computer network unless such network blocks the viewing, downloading, and exchanging of
pornography.
® Yes ❑ No
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