HomeMy WebLinkAboutAgreement A-13-313-1 with WestCare California Inc..pdf Agreement No. 13-313-1
1 AMENDMENT I TO AGREEMENT
2 THIS AMENDMENT is made and entered into this 24th day of May ,2016, by
3 and between the COUNTY OF FRESNO, a political subdivision of the State of California, hereinafter
4 referred to as "COUNTY", and WESTCARE CALIFORNIA, INC., whose service address is 2772 South
5 Martin Luther King Jr. Boulevard, Fresno, California, 93706, and whose remit to address is P.O.Box
6 12107, Fresno, California, 93776, hereinafter referred to as"CONTRACTOR"
7 (collectively the"parties").
8 WHEREAS, the parties entered into that certain Agreement, identified as COUNTY Agreement
9 No. 13-313, effective July 1, 2013, hereafter referred to as the Agreement; and
10 WHEREAS, CONTRACTOR has agreed to provide perinatal residential alcohol and substance
11 use disorder treatment services to Fresno County residents; and
12 WHEREAS the parties desire to amend the Agreement, regarding changes as stated below and
13 restate the Agreement in its entirety.
14 NOW, THEREFORE, in consideration of their mutual promises, covenants and conditions,
15 hereinafter set forth, the sufficiency of which is acknowledged, the parties agree as follows:
16 1. That the following text in the Agreement, Page Sixteen (16), beginning with Paragraph
17 Twenty-One (21), Line Ten (10) with the word"COMPREHENSIVE" and ending on Page Seventeen
18 (17), Line Fifteen (15) with the link"(http://www.kenminkoff.com/ccisc.html)" be deleted in its
19 entirety. The remaining paragraphs (Paragraph Twenty-Two (22) REFERENCES TO LAWS AND
20 RULES to Paragraph Forty-Five (45) ENTIRE AGREEMENT) shall be renumbered sequentially to read
21 as Paragraphs Twenty-One (21) through Forty-Four(44).
22 2. That the following text in the Agreement, Page Twenty-Three (23), beginning with
23 Paragraph Twenty-Five (25), Line Eleven (11) with the word "CULTURAL" and ending on Page
24 Twenty-Four(24), Line Nineteen (19)with the word "accordingly"be deleted and the following
25 inserted in its place:
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1 - COUNTY OF FRESNO
Fresno, CA I
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1 "25. CULTURAL COMPETENCY
2 As related to Cultural and Linguistic Competence,CONTRACTOR shall comply
3 with:
4 A. Title 6 of the Civil Rights Act of 1964 (42 U.S.C. section 2000d, and 45
5 C.F.R.Part 80)and Executive Order 12250 of 1979 which prohibits recipients of federal financial
6 assistance from discriminating against persons based on race, color,national origin, sex, disability or
7 religion. This is interpreted to mean that a limited English proficient(LEP) individual is entitled to equal
8 access and participation in federally funded programs through the provision of comprehensive and quality
9 bilingual services.
10 B. Policies and procedures for ensuring access and appropriate use of trained
11 interpreters and material translation services for all LEP consumers, including, but not limited to,assessing
12 the cultural and linguistic needs of its consumers,training of staff on the policies and procedures,and
13 monitoring its language assistance program.The CONTRACTOR's procedures must include ensuring
14 compliance of any sub-contracted providers with these requirements.
15 C. CONTRACTOR shall not use minors as interpreters.
16 D. CONTRACTOR shall provide and pay for interpreting and translation
17 services to persons participating in CONTRACTOR's services who have limited or no English language
18 proficiency, including services to persons who are deaf or blind. Interpreter and translation services shall be
19 provided as necessary to allow such participants meaningful access to the programs, services and benefits
20 provided by CONTRACTOR. Interpreter and translation services, including translation of
21 CONTRACTOR's "vital documents"(those documents that contain information that is critical for
22 accessing CONTRACTOR's services or are required by law) shall be provided to participants at no cost to
23 the participant. CONTRACTOR shall ensure that any employees, agents, subcontractors, or partners who
24 interpret or translate for a program participant,or who directly communicate with a program participant in a
25 language other than English, demonstrate proficiency in the participant's language and can effectively
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26 communicate any specialized terms and concepts peculiar to CONTRACTOR's services.
27 E. In compliance with the State mandated Culturally and Linguistically
28 Appropriate Services standards as published by the Office of Minority Health, CONTRACTOR must
2 COUNTY OF FRESNO
Fresno, CA
1 submit to COUNTY for approval,within 60 days from date of contract execution,CONTRACTOR's plan
2 to address all fifteen national cultural competency standards as set forth in the"National Standards on
3 Culturally and Linguistically Appropriate Services(CLAS)"attached hereto as Exhibit D and incorporated
4 herein by reference. COUNTY's annual on-site review of CONTRACTOR shall include collection of
5 documentation to ensure all national standards are implemented. CONTRACTOR may solicit
6 complementary assistance from OnTrack Consulting(http://ontrackconsulting.org/news/culturally-
7 linguistically-appropriate-services for training in plan development. As the national competency
8 standards are updated, CONTRACTOR'S plan must be updated accordingly."
9 3. That the following text in the Agreement, Page Twenty-Four(24), beginning with
10 Paragraph Twenty-Six (26), Line Twenty(20) with the word "SINGLE" and ending on Page Twenty-
11 Five (25), Line Four(4) with the word "Collector" be deleted and the following inserted in its place:
12 "26. SINGLE AUDIT CLAUSE
13 A. If CONTRACTOR expends Seven Hundred Fifty Thousand Dollars
14 ($750,000.00) or more in Federal and Federal flow-through monies, CONTRACTOR agrees to conduct
15 an annual audit in accordance with the requirements of the Single Audit Standards as set forth in Office
16 of Management and Budget(OMB) Circular A-133. CONTRACTOR shall submit said audit and
17 management letter to COUNTY. The audit must include a statement of findings or a statement that
18 there were no findings. If there were negative findings, CONTRACTOR must include a corrective
19 action plan signed by an authorized individual. CONTRACTOR agrees to take action to correct any
20 material non-compliance or weakness found as a result of such audit. Such audit shall be delivered to
21 COUNTY's Human Services Finance for review within nine(9) months of the end of any fiscal year in
22 which funds were expended and/or received for the program. Failure to perform the requisite audit
23 functions as required by this Agreement may result in COUNTY performing the necessary audit tasks,
24 or at COUNTY's option, contracting with a public accountant to perform said audit, or, may result in the
25 inability of COUNTY to enter into future agreements with CONTRACTOR. All audit costs related to
26 this Agreement are the sole responsibility of CONTRACTOR.
27 B. A single audit report is not applicable if CONTRACTOR's Federal
28 contracts do not exceed the Seven Hundred Fifty Thousand Dollars ($750,000.00) requirement or
3 - COUNTY OF FRESNO
Fresno, CA
1 CONTRACTOR'S only funding is through Drug related Medi-Cal. If a single audit is not applicable, a
2 program audit must be performed and a program audit report with management letter shall be submitted
3 by CONTRACTOR to COUNTY as a minimum requirement to attest to CONTRACTOR's solvency.
4 Said audit report shall be delivered to COUNTY's Human Services Finance for review, no later than
5 nine (9) months after the close of the fiscal year in which the funds supplied through this Agreement are
6 expended. Failure to comply with this Act may result in COUNTY performing the necessary audit tasks
7 or contracting with a qualified accountant to perform said audit. All audit costs related to this
8 Agreement are the sole responsibility of CONTRACTOR who agrees to take corrective action to
9 eliminate any material noncompliance or weakness found as a result of such audit. Audit work
10 performed by COUNTY under this section shall be billed to the CONTRACTOR at COUNTY's cost, as
11 determined by COUNTY's Auditor-Controller/Treasurer-Tax Collector.
12 C. CONTRACTOR shall make available all records and accounts for
13 inspection by COUNTY, the State of California, if applicable, the Comptroller General of the United
14 States, the Federal Grantor Agency, or any of their duly authorized representatives, at all reasonable
15 times for a period of at least three (3) years following final payment under this Agreement or the closure
16 of all other pending matters, whichever is later."
17 4. That the following text in the Agreement, Page Twenty-Five (25), beginning with
18 Paragraph Twenty-Eight (28) , Section A, Line Twenty-Eight(28), with the word "CONTRACTOR"
19 and ending on Page Twenty-Six (26), Line Four(4) with the word "COUNTY" be deleted in its entirety.
20 The remaining Sections (Section B through Section G) in the Agreement shall be re-lettered sequentially
21 to read as Sections A through F.
22 5. That the following section be inserted into the existing COUNTY Agreement No. 13-313
23 as Paragraph Forty-Four(44). The remaining sections Paragraph Forty-Four(44) and Forty-Five(45)
24 shall be renumbered sequentially to read as Paragraph Forty-Five (45) and Forty-Six (46).
25 1144. TRAFFICKING IN PERSONS PROVISIONS—PRIVATE ENTITY
26 CONTRACTOR shall conform to all Federal statutes and regulations prohibiting
27 trafficking in persons, as well as trafficking-related activities, including, but not limited to the trafficking
28 of persons provisions in Section 106(g) of the Trafficking Victims Protection Act of 2000 (TVPA).
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Fresno, CA
1 CONTRACTOR, CONTRACTOR's employees, subrecipients, and subrecipients'
2 employees may not:
3 A. Engage in severe forms of trafficking in person during the period of time
4 that the award is in effect;
5 B. Procure a commercial sex act during the period of time that the award is in
6 effect; or
7 C. Use forced labor in the performance of the award or subawards under the
8 award.
9 This agreement may be unilaterally terminated, without penalty, if
10 CONTRACTOR or a subrecipient that is a private entity is determined to have violated a prohibition of
11 the TVPA or has an employee who is determined by the DBH Director or her designee to have violated
12 a prohibition of the TVPA through conduct that is either associated with performance under the award or
13 imputed to the CONTRACTOR or their subrecipient using the standards and due process for imputing
14 the conduct of an individual to an organization that are provided in 2 C.F.R. Part 180, "OMB Guidelines
15 to Agencies on Government-wide Debarment and Suspension (Nonprocurement).
16 CONTRACTOR must inform the DBH Director or her designee immediately of
17 any information received from any source alleging a violation of a prohibition of the TVPA."
18 6. That all references in the Agreement to "Exhibit A"shall be changed to read "Revised
19 Exhibit A", which is attached hereto and incorporated herein by reference.
20 7. That all references in the Agreement to"Exhibit D" shall be changed to read "Revised
21 Exhibit D", which is attached hereto and incorporated herein by reference.
22 8. COUNTY and CONTRACTOR agree that this Amendment I is sufficient to amend
23 Agreement No. 13-313 and Amendment I together with the Agreement shall be considered the
24 Agreement.
25 9. The Agreement, as hereby amended, is ratified and continued. All provisions,terms,
26 covenants, conditions, and promises contained in the Agreement and not amended herein shall remain in
27 frill force and effect. This Amendment I shall be effective upon execution.
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Fresno, CA
1 IN WITNESS WHEREOF, the parties hereto have executed this Amendment I to Agreement No.
2 13-313 as of the day and year first hereinabove written.
3
4 ATTEST:
5
6 CONTRACTOR
7 WESTCARE CALIFORNIA,INC. COUNTY OF FRESNO
8
By St:7:M 01C16 By
10 Ernest Buddy Mendes, airman
Board of Supervisors
11 Print Name: }rIf
12 �� �.
Title:_s Date: a'�6
13 Chairman of the Board, or
19
President, or any Vice President
15
16 `` �" '����J �� �� BERNICE E. SEIDEL, Clerk
-yv wec—A aO)1 d� Board of Supervisors
17 �f
18 By �— ( � —�- By
19
20 ultName�1��� ��1 Date: '(`�Q,I �y. �Dl t' o
.- ---
21 Title:
Secretary of Corporation,
22 any Assistant Secretary, or
23 Chief Financial Officer,or
Assistant Treasurer
24
5 Mailing Address:
26 WestCare California, Inc.
P.O. Box 12107
27 Fresno, CA 93776
Attn: ShaA- n Jenkins, Senior Vice President
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Fresno, CA
1 APPROVED AS TO LEGAL FORM:
2 DANIEL C. CEDERBORG, COUNTY COUNSEL
3 s
.._ ,
4 By f
5
6 Date: _ /
7
8 APPROVED AS TO ACCOUNTING FORM:
VICKI CROW, C.P.A., AUDITOR-CONTROLLER/
9 TREASURER-TAX COLLECTOR
10
11
By
=`� -�-
12
Date:
13
14 REVIEWED AND RECOMMENDED FOR
15 APPROVAL:
16 f�
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18 Dawan Utecht, Director
19 Department of Behavioral Health
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Date: �' ''�
21
22
23
Fund/Subclass: 0001/10000
24 Account/Program: 7294/0
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Fresno, CA
REVISED EXHIBIT A
SCOPE OF WORK
Page 1 of 6
SCOPE OF WORK
Perinatal Residential Substance Use Disorders Treatment Services
ORGANIZATION: WestCare California, Inc.
MAILING ADDRESS: P.O. Box 12107, Fresno, CA 93776
SERVICE ADDRESS: 2772 South Martin Luther King Boulevard, Fresno, CA 93706
SERVICES: Perinatal Residential Substance Use Disorders Treatment Services
Director, Lynn Pimentel, MA, CRC 659) 265-4800
:Re��anat;Vice°Prresittent _ . .Sh�wn:A.Jenkins' . ... __ .. .
Clinical Director: Brenda Kent, LMFT
1T-Suppprt: fT Bra ) 28
'.(559. 3.�141;5 email_Jitiri;.6[at irrcare co "
. ..., r... m,
County Division Department of Behavioral Health, Substance Abuse Services
County Contact.' Ike;G'rewal;;Staff ArialysEa'(559�'60 -"
CONTRACT PERIOD: July 1, 2013 through June 30, 2018
CONTRACT AMOUNT: $1,750,000
Term Total Budget
FYI 3-14 $350,000
FY14-15 $350,000
FYI 5-16 $350,000
FYI 6-17 $350,000
FY17.18 $350,000
REVISED EXHIBIT A
SCOPE OF WORK
Page 2of6
Perinatal Residential Treatment Services
PROGRAM DESCRIPTION
The Perinatal Residential Substance Use and Co-occurring Treatment program is a 180-day
intensive inpatient program that offers an intensive treatment experience with a minimum of 26 hours
of core curriculum (Core curriculum does not include 12-step group participation, daily chores, peer
led groups, or other activities not facilitated by program staff). In order to progress through treatment
and earn additional privileges (and Phase Up), clients must complete 32 hours per week of
curriculum. The women's schedule makes up an average of 55-59 hours of gender-specific,
culturally relevant Substance Use Disorder treatment services.
SCHEDULE OF SERVICES
CONTRACTOR staff shall be available to provide Perinatal Residential Substance Use Disorder
and Co-occurring treatment services to a ten (10) clients at one time. CONTRACTOR shall be
available 24 hours a day, 7 days a week.
TARGET POPULATION
The target population that will participate in the program is:
1) pregnant and/or parenting women;
2) residents of Fresno County;
3) 18 years or older;
4) meeting the DSM IV-TR criteria for substance abuse or dependence.
Admission priority approved by Fresno County falls in the following order:
1) Women 18 years and older who are pregnant or who have a child younger than 1 year of age
and are using/abusing illicit drugs;
2) Women 18 years and older who have children under 17 and are using/abusing illicit drugs;
and
3) Women 18 years and older who have children under 17 and are using/abusing a►cohol or
drugs
STAFFING REQUIREMENTS
1. CONTRACTOR shall implement and support the use of a team delivery method, which shall
be the unified team approach with a family centered focus. Implementation and oversight of
the project, including operations, strategic planning/development, and direct services include
the Program Director, Residential Director, Clinical Services Director, a Program
Coordinator, and a Family Services Specialist.
2. Clinical Treatment Staff: The Family Services Specialist works as part of a Multi-disciplinary
Casework team that includes an AOD Counselor, a Child Development Specialist, Childcare
Workers, a Nurse, a Psychiatrist or Mental Health Clinician, to deliver direct services in the
key clinical treatment areas, including AOD counseling, mental health services, education
and instruction. According to CCR Title 9, by October 1, 2005 or within six months of the
date of hire, whichever is later, all non-licensed or non-certified individuals providing
counseling services in an AOD program are required to register to obtain certification as an
REVISED EXHIBIT A
SCOPE OF WORK
Page 3 of 6
AOD counselor by one of the certifying organizations specified in the regulation. Further,
registrants shall complete certification as an AOD counselor within five years of the date of
registration. In addition, according to CCR Title 9, by April 2010, at least 30% of staff
providing counseling services in AOD programs shall be licensed or certified.
3. The Perinatal Residential Treatment staff will be available on-site 24 hours a day, 7 days a
week. Participants may access crisis intervention through the main facility telephone
number(559) 265-4800.
CONTRACTOR'S RESPONSIBILITIES
CONTRACTOR shall provide:
(1) a 24-hour residential facility for women and children;
(2) a gender-specific, culturally and linguistically sensitive, substance use disorder and co-
occurring treatment program for pregnant and parenting women to include up to two
children;
(3) a 180-day residential program (90 days extension when clinically appropriate) incorporating
a variety of innovative, and evidence-based treatment methods;
(4) an extensive home management and parenting program;
(5) linkages to legal services (domestic violence, child custody, adoption, divorce);
(6) services related to psychological, financial, physical, and social survival of women and their
children once released form the treatment program;
(7) management of a waitlist, including documented referrals to other treatment providers, and
priority admissions according to the COUNTY approved priority admissions criteria;
(8) age-appropriate, licensed', child care resulting in improved developmental outcomes and
overall well-being among children;
(9) adherence to the Perinatal Services Network Guidelines(2009), Title 9 Department of
Alcohol and Drug Programs licensing requirements for treatment facilities, and models for
implementing trauma-specific services;
(10) a cultural and linguistic competency plan to address the 15 Cultural and Linguistically
Appropriate Services (CLAS)
(11) a Program Fidelity plan to ensure proper integration and adherence to the Evidence-Based
practices adopted by the program.
"A cooperative arrangement that has received a Waiver by California Department of Health and Human Services
qualifies as licensed child care.
MANAGED WAITLIST
WestCare California, Inc. follows the recognized state protocol procedures: FIRST priority is injection
drug users who are pregnant. SECOND priority is injection drug users who are parenting. THIRD
priority is substance abusers who have children.WestCare California makes every effort to place
priority applicants.
REVISED EXHIBIT A
SCOPE OF WORK
Page 4 of 6
In the event that the program is at full capacity, the Intake Specialist will immediately make telephone
contact with other County funded Perinatal provider(s) to see if a referral can be made. In addition,
email correspondence will be sent and returned to be used as documentation for the file. If an opening
exists, every effort will be made to place clients and correspondence will be filed as documentation for
the purpose of review by the County during annual site visits for compliance.
PROGRAM REPORTS AND OUTCOMES
1. Certification and Licensing Standards:
a. CONTRACTOR shall maintain at all times current and applicable licensure and
certifications for residential facilities.
b. CONTRACTOR shall ensure at all times that staff maintain at all times all applicable
licensure and certifications as required by regulations, this agreement, and County
Policies.
c. CONTRACTOR shall ensure that Child Care facilities maintain at all times current
and applicable licensure and certifications as required by regulations, this agreement,
and County Policies.
d. CONTRACTOR shall ensure that all paid Child Care workers are qualified, meeting
and maintaining minimum qualification as outlined in the WestCare job description:
i. Essential Qualifications:
1. Two years teaching, experienced in providing developmental
intervention to children or teaching in a licensed child care center is
preferred;
2. Two years supervisory and administrative experience is preferred;
3. Must meet all standards of the local licensing board;
4. Knowledge of substance abuse and treatment is desired; and
5. Infant-child CPR Certification, First Aid Certification and an Annual
Tuberculosis test.
ii. Education:
1. High School Diploma or equivalent is required; and
2. Graduation from an accredited four-year college with applicable
experience in early childhood education is preferred.
3. Indemnity
a. CONTRACTOR shall maintain valid and current insurance coverage at or above the
minimum requirements of Paragraph 14 of this agreement.
b, CONTRACTOR shall provide a Certificate of Commercial General Liability naming
the County of Fresno as additional insured.
c. CONTRACTOR shall provide a Certificate of Automobile Liability naming the County
of Fresno as additional insured.
d. CONTRACTOR shall provide a Certificate of Professional Liability naming the County
of Fresno as additional insured.
e. CONTRACTOR shall provide a Certificate of Worker's Compensation insurance.
REVISED EXHIBIT A
SCOPE OF WORK
Page 5 of 6
3. Culturally and Linguistically Appropriate Services
a. CONTRACTOR shall submit to COUNTY for approval, within 60 days from date of
contract execution, a plan to address all fifteen national cultural competency
standards, as identified in Exhibit D of this agreement.
b. CONTRACTOR shall review and document adherence to the plan.
c. CONTRACTOR shall modify and update the plan in response to deficiencies sited in
COUNTY site reports, or in response to updates to the national competency
standards.
4. Program Fidelity
a. CONTRACTOR shall submit to COUNTY for approval, within 60 days from date of
contract execution, a plan to address Program Fidelity to address adherence to the
evidence-based practices as approved by the Substance Abuse and Mental Health
Services Administration (SAMSHA). For more information refer to
http://www.nrepp.samhsa.gov/.
b. CONTRACTOR shall modify and update the plan in response to deficiencies found in
self-audits, COUNTY site reports, or in the case of implementing other evidence-
based practices.
5. Report Delivery and Content Requirements
CONTRACTOR shall deliver all Department of Behavioral Health, Substance Abuse Services
Division required reporting in approved data collection format in a timely and accurate
manner.
6. Billable Services
CONTRACTOR shall ensure billable Substance Use Disorder treatment services meet
any/all County, State, Federal regulations including any utilization review and quality
assurance standards, and provide all pertinent and appropriate information in a timely
manner to County for services rendered.
7. Outcome Measurements and Reporting
Outcomes to be measured are:
1. 40% of clients admitted for Perinatal Residential Treatment services will be engaged
in treatment for 60 days or more.
2. 60% of clients receiving treatment will have satisfactory progress at discharge.
COUNTY'S RESPONSIBILITIES
COUNTY shall:
1. Provide oversight through the County Department of Behavioral Health (DBH), Substance
Abuse Services Division
2. Assist CONTRACTOR in making linkages with Mental Health Services.
REVISED EXHIBIT A
SCOPE OF WORK
Page 6 of 6
3. Participate in evaluating the progress of the overall program and the efficiency of
collaboration with the CONTRACTOR staff and will be available to the CONTRACTOR for
ongoing consultation.
4. Receive and analyze statistical data outcome information from CONTRACTOR throughout
the term of contract on a monthly basis. DBH will notify the CONTRACTOR when additional
participation is required. The performance outcome measurement process will not be limited
to survey instruments but will also include, as appropriate, client and staff interviews, chart
reviews, and other methods of obtaining required information.
5. Recognize that program competency is a goal toward which professionals, agencies, and
systems should strive. To assist the CONTRACTOR's efforts towards program
competency, DBH shall provide the following at no cost to CONTRACTOR:
a. Technical assistance to CONTRACTOR regarding County, State, and Federal
requirements for Substance Use Disorder treatment services.
b. Technical assistance for CONTRACTOR in translating behavioral health and
substance abuse services information into DBH's threshold languages (Spanish,
Laotian, Cambodian and Hmong). Translation services and costs associated will be
the responsibility of CONTRACTOR.
Revised Exhibit D
Page Iof1
National Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health and Health Care
The National CLAS Standards are intended to advance health equity, improve quality,and help eliminate health care
disparities by establishing a blueprint for health and health care organizations to:
Principal Standard:
1. Provide effective,equitable,understandable,and respectful quality care and services that are responsive to diverse
cultural health beliefs and practices, preferred languages, health literacy,and other communication needs.
Governance, Leadership, and Workforce:
2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy,
practices,and allocated resources.
3. Recruit, promote,and support a culturally and linguistically diverse governance, leadership, and workforce that are
responsive to the population in the service area.
4. Educate and train governance,leadership,and workforce in culturally and linguistically appropriate policies and
practices on an ongoing basis.
Communication and Language Assistance:
5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs,at
no cost to them,to facilitate timely access to all health care and services.
6. Inform all individuals of the availability of language assistance services dearly and in their preferred language,
verbally and in writing.
7. Ensure the competence of individuals providing language assistance,recognizing that the use of untrained individuals
and/or minors as interpreters should be avoided.
8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the
populations in the service area.
Engagement, Continuous Improvement,and Accountability:
9. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them
throughout the organization's planning and operations.
10. Conduct ongoing assessments of the organization's CLAS-related activities and integrate CLAS-related measures into
measurement and continuous quality improvement activities.
11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health
equity and outcomes and to inform service delivery.
12. Conduct regular assessments of community health assets and needs and use the results to plan and implement
services that respond to the cultural and linguistic diversity of populations in the service area.
13, Partner with the community to design,implement,and evaluate policies, practices,and services to ensure cultural
and linguistic appropriateness.
14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify,prevent,
and resolve conflicts or complaints.
15. Communicate the organization's progress in implementing and sustaining CLAS to all stakeholders, constituents,and
the general public.
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