STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES PO Box 45811, Olympia WA 98504-5811
DATE: October 22, 2020
TO: RFP #2034-765 – ALTSA-DDA - Translation Auto Systems
FROM: James O'Brien, Solicitation Coordinator DSHS Central Contracts and Legal Services
SUBJECT: Amendment No. 1 – Questions and Answers
DSHS amends RFP #2034-765 solicitation document to include:
- Bidders' Questions and Answers - Updated Attachment G - List of Language Names and Codes - Template for LTC Service Summary - Temple of a Client Specific Service Summary Document (redacted) - Samples of a Form in Large Print (LP)
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Bidder’s Questions and Answers RFP #2034-765
Question #1: Can companies from Outside USA can apply for this solicitation? (like from India or Canada)
A: The Contractor must be located within the United States.
Question #2: Would the selected Company be required to come to DSHS offices for meetings?
A: Meetings can be conducted remotely, especially in the current world pandemic situation.
Question #3: Can we perform the tasks (related to RFP) outside USA? (like from India or Canada)
A: The Contractor must be located in the United States. With respect to the translators'/reviewers’ locations, DSHS prefers to use linguists residing: a. within our state when possible, b. then within the country, c. and only in rare instances when no qualified linguists for the languages of lesser diffusion are available in a. and b. would the Contractor use the outside resources.
Question #4: Can we submit the proposals via email?
A: Yes. Electronic submittal of the proposals is acceptable. Please send to the Solicitation Coordinator, James O'Brien, at [email protected].
Question #5: Regarding Section E. 7. Bidder’s References: Once the written evaluations are completed, DSHS may contact the references provided by the top-ranked Bidder(s) in order to investigate past performance and validate information in Bidder Responses.
Please specify the Form and Section where references should be included.
A: DSHS will seek references from the top-ranked bidders once the written evaluations have been completed. Please see page 27 of the RFP document under section 7. Bidder's References.
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Question #6: Regarding Section 4. Bidder Minimum Qualifications Note: Currently there are 25 different templates in use.
Are the 25 templates references already translated into each of the Primary Languages?
A: Yes.
Question #7: Please indicate the anticipated volume (total number of pages) of orders for Large Print per year. Alternately, please indicate the historic volume (total number of pages) of orders for Large Print per year.
A: Not to exceed 100 pages per quarter. Last year DSHS ALTSA/DDA requested 263 pages of documents for LP formatting.
Question #8: Please indicate the anticipated volume (total number of words) of orders of each of the Primary Languages per year. Alternately, please indicate the historic volume (total number of words) of orders of each of the Primary Languages per year.
A: DSHS ALTSA and DDA do not have this information.
Question #9: Can you provide samples or access to the 25 templates?
A: DSHS will include a couple of templates and will attach them to the end of this Amendment #1. All pre-translated templates will be provided to the Apparent Successful Bidder.
Question #10: Can you be more specific about the average number of words to be requested for translation and inserted into the foreign language templates?
A: This information is not available, as it differs from client to client.
Question #11: Are these entire paragraphs of text, or pages of text to be translated?
A: Mostly paragraphs and words, also checking the boxes.
Question #12: Of the 25 existing templates, how many are 10 or more pages?
A: Currently 10 templates are 10 or more pages long 3
.
Question #13: Please provide a sample order that includes new translation with the template and English text to be translated.
A: We will provide some samples and will attach to the end of this Amendment #1.
Question #14: Do you anticipate extending the bid due date?
A: No.
Question #15: What additional details are you willing to provide, if any, beyond what is stated in bid documents concerning how you will identify the winning bid?
A: All relevant information for the RFP process has been listed in the RFP document.
Question #16: Please let us know whether you have received this email, and when and how answers will be provided.
A: All questions received by the solicitation coordinator will be acknowledged with a return email confirmation to the sender. All answers to all of the questions will be posted in Amendment #1 to this solicitation.
Question #17: Other than your own website, where was this bid posted?
A: This RFP was posted, in addition to DSHS website, on the Washington Electronic Business Solution (WEBS) page https://pr-webs- vendor.des.wa.gov/Search_BidDetails.aspx?ID=44495 as required by state regulations.
Question #18: What is the minimum and maximum amount of documents the DSHS expects to be translated/formatted per week?
A: This information is not available, as it depends on many individual factors.
Question #19: Will the vendor be provided with any previously translated templates?
A: Yes, the selected Contractor will receive pre-translated templates.
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Question #20: Can samples be provided of the templates to be processed under this contract? Or do they exist in a publicly accessible online repository?
A: Samples will be provided as a part of the responses to the questions and will be attached to the end of this Amendment #1.
Question #21: Can examples be provided of a client letter for which large print formatting has been applied?
A: We will provide DSHS form in large print as an example and will be attached to the end of this Amendment #1.
Question #22: Will the client letters submitted by the requestor be scanned from physical paper?
A: Most of the documents will be in PDF created from the electronic written documents. In very rare cases the document may be a scanned one.
Question #23: What is the estimated daily volume of letters?
A: This information is not available, as it has not been tracked under previous contract.
Question #24: What is the approximate percentage of the total requests that are Translation-related, and what approximate percentage are Large Print Formatting-related?
A: Ratio of translations vs LP requests is unknown. Annual number of requests for formatting as LP documents did not exceed 300 pages. Please see the answer to Q #7.
Question #25: Regarding Section 3. Project Scope b. Service Requirements ‒ ii. Translation Quality Requirements. To ensure and promote translation accuracy, the Contractor must: • Use Translators who are certified, authorized or qualified by one or more of the following authorities: • American Translators Association (ATA). • DSHS Language Testing and Certification program. • Approved Contractor Translator testing programs.
-What information will you need in order to approve a Contractor’s Translator testing program?
A: Description of process applied to determine translator/reviewer qualifications.
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-The firm in question is a member of the American Translator Association (ATA) since 1995 and employs a pre-approved linguist testing and vetting process as documented in their ISO 9001:17100 certification. They also have a robust Quality Management System established with ISO 9001:2017 certification. Would this qualify as an “Approved Contractor Translator testing program”?
A: The firm will need to provide the mentioned documentation and the description of their Quality Management System.
Question #26: What are the primary 15 languages?
A: Please see the definition on page 19 of Attachment A; list of languages in the first table of worksheet - Question 7 on “Bidder Response Form Management Response” Attachment D1.
Question #27: We have a database of over 4,000 linguists. It would not be possible to send a comprehensive list of all the translators and reviewers that could be working the DSHS contract. Would it be possible to provide the names of a few translators we may use?
A: Please respond to the Q7 on abovementioned “Bidder Response Form Management Response” (Attachment D1) as you deem appropriate.
Question #28: In regards to Large Print, does DSHS require the documents to be 508 compliant, or simply to have larger font size?
A: Please see the requirements for Large Print formatting description in the Statement of Work of Sample Contract (Attachment A, pages 34-35) and Attachment H documents.
Question #29: Can a rush fee be adding to the cost work sheet for expedited turnaround times?
A: 4, 8, and 10 workdays turnaround time frames will be sufficient under this contract.
Question #30: Can we provide rates for translation memory?
A: Software programs that use Translation Memories are broadly used by the translation service industry. DSHS will not be responsible for purchasing, maintaining or reimbursing for these products.
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Question #31: 508 compliance/large print is charged per hour, can we change the pricing to per hour?
A: No, we use the pricing per page.
Question #32: Keying and formatting I also charged per hour as it changes per document. Can we also price this per hour?
A: No, per word charge must be applied.
Question #33: Can we price translation per word differently for differently languages. For example, Spanish is much cheaper than Somali and we want to give the most competitive pricing.
A: No.
Question #34: Are you able to provide the name of the current incumbent and their prices?
A: Please refer to current contract 01714 information on the Department of Enterprise Services (DES) website: https://apps.des.wa.gov/DESContracts/Home/ContractSummary/01714 and refer all additional questions to DES contracts specialists.
Question #35: Have you experienced any difficulties with the current incumbent?
A: No.
Question #36: What is the anticipated volume of translations per month and in which languages, i.e., 20,000 words of Spanish and 8,000 word Vietnamese per month?
A: We do not have this information.
Question #37: How does the DSHS currently organize their requests – do they all go through one team or is it decentralized?
A: This is described in Attachment A, page 35.
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Question #38: Is DSHS open to using a technology solution to centralize translation projects?
A: This question does not pertain to this RFP document.
Question #39: Do all translators have to be located in the United States, or can they be qualified linguists from around the world?
A: Please see the answer to a similar Question #3.
Question #40: How many letters on average per day?
A: We do not have this information.
Question #41: What is the average length of a letter?
A: It varies.
Question #42: Are the letters sent in editable format (Word or other)?
A: Systems generate client specific documents from templates that are filled by case managers. Those documents get saved as PDFs and sent for translation.
Question #43: Are the letters sent in pdf format?
A: Yes.
Question #44: In what format do the translated files need to be delivered?
A: PDF
Question #45: For question 7: Capacity, can we give last initial for the translator names?
A: Yes.
Question #46: Where has the incumbent contractor been successful during the current contract (01714)?
A: Current contractor provided timely services adhering to the terms and conditions of the expiring contract.
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Question #47: What has been the biggest challenge with the incumbent contractor during the current contract (01714)?
A: N/A
Question #48: Do you anticipate that the incumbent will bid in this solicitation?
A: Unknown
Question #49: Do you have any preference for awarding the contract to an incumbent contractor?
A: This is an open procurement process and the current Contractor will need to submit the bid document as all other bidders. No preference is given to an incumbent.
Question #50: What has the current vendor billed under contract 01714 in the last 12 months?
A: For the period from July 2019 through June 2020 the billed amount was $1,667,093.00
Question #51: What is the total spend so far under contract 01714?
A: Annual cost was between $891,936.00 and $1,509,813.00
Question #52: What was the annual spend under contract 01714 for the last 3 calendar years?
A: 2017 – $1,318,108.00 2018 – $1,134.956.00 2019 - $1,509.813.00
Question #53: Will there be any handwriting to be translated?
A: No
Question #54: Is translation only from English to foreign language?
A: Yes
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Question #55: Is the translation sometimes from foreign language to English?
A: No
Question #56: What is the average distribution per language of letters to be translated?
A: For the top 5 languages (Spanish, Russian, Chinese/Traditional, Vietnamese, and Korean) the number of documents translated are between 80 and 489 a month. For the next 10 primary languages monthly number of requested translations was between 3 and 80 per language.
Question #57: What is the distribution of files requiring rekeying/translation vs large print?
A: Please see the answer to the Questions #7 and #24.
Question #58: Is large print required for English documents or also for translated versions?
A: Mostly for English language documents, but could be a need for providing the document in foreign language/font as large print.
Question #59: The RFP mentions the following under section 3.b.i “Use only the approved DSHS Language Codes as language identifiers (see Attachment H)”, however attachment H refers to large print guidelines. Attachment G has languages but no codes. Are we missing an attachment?
A: New attachment with language names and codes will be provided. This will be an attachment located at the end of this Amendment #1.
Question #60: How are files transferred to the translation provider? Eg. Does each email contain documents as separate attachments or all in one zip file?
A: Each request for translation will contain separate documents as attachments.
Question #61: And are files submitted once per day or multiple times per day? And at what time are files submitted?
A: Requests will be coming from different requestors via secure email, as they encounter the need for translation. 10
Question #62: Does a submission email contain letters for all languages or are they sent separately by language pair, or is it a separate email for each individual document?
A: Requests will be language specific.
Question #63: Are the files accompanied by any information that does NOT require translation and needs to be separated from the file and/or later combined with the translated file?
A: Documents for specific clients will be templates with filled in client specific information. Please see Service Summary document (redacted and its template) at the end of this Amendment #1.
Question #64: Will the vendor awarded with the contract have access to the repository of templates prior to the start of the work?
A: Contractor will be provided with the translated templates.
Question #65: In what file format are the templates in the repository?
A: MSWord and corresponding PDF. Templates for translation will be in MSWord format.
Question #66: How many words need to be rekeyed in average per letter?
A: We do not have this information.
Question #67: How many words need to be translated in average per letter?
A: We do not have this information.
Question #68: Can we see a sample of documents coming from ALTSA, DDA and AAA?
A: Samples will be provided as attachments to this document. These documents will be attached to the end of this Amendment #1.
Question #69: Will this be a new service provided to DSHS, or is there an existing contract in place?
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A: The current contract administered by DES expires and must be re-procured. The administration of this contract is given to the DSHS ALTSA/DDA.
Question #70: In the case that there are current contractors who provide translation for DSHS, will we have access to the contractors to add to our system?
A: This question does not pertain to this RFP document.
Question #71: #3, Project Scope, item b.ii.,Translation Quality Requirements. There may be some languages (Attachment G: List of Client Languages 2020) where it is challenging to find people who have the certifications. In the event that a certified linguist (ATA/DSHS) is not available, will you accept an alternative qualification process?
A: Bidders will need to describe the process for determining translators/reviewers qualification when answering non-cost questions.
Question #72: #3, Project Scope, item b.iv. Workflow and Procedures - Requirements. It mentions that a secure email with a PDF will be attached. In the case that the file requires formatting, will we have access to the source file? (i.e. .docx)? Will we need to format the PDF?
A: Contractor will have access to the templates and available translations in MSWord and PDF. Client specific documents will be sent for translation in PDF format.
Question #73: #3, Project Scope, item b.iv. Workflow and Procedures - Requirements. Also, in relation to the workflow, will we have access to examples of the typical documents that need translation or large format printing.
A: Yes, please see attachments to this document. They will be attached to the end of this Amendment #1.
Question #74: #4, Bidder Minimum Qualifications. Is there somewhere we can review the "electronic file transfer standards" as mentioned in paragraph (g)?
A: SFTP is industry standard. Here is the website https:// www.techopedia.com/definition/1879/secure-file-transfer-protocol-sftp
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A: No. There will be only one contract awarded to one company.
Question #76: Attachment E: Translation Review Guidelines. Is there an explanation/example on the intent and use of these procedures?
Attachement F: Translations Correction Procedures. Is there an explanation/example on the intent and use of these procedures?
A: These are the procedures to be used when 1) discrepancy is found by the ALTSA/DDA/AAA staff in the translation provided by the Contractor – Attachment E document; and 2) Attachment F is for the Translator and Reviewer of the allegedly incorrectly translated document.
Question #77: To preserve confidentiality for our translators, will DSHS accept initials (i.e., “J.D.” instead of “John Doe”), partial names (i.e., “John D.” instead of “John Doe”), or unique identifiers instead of full names?
A: Yes. However, the contractor will be required to provide a list of actual names of the linguists for verification.
Question #78: Instead of negotiating with each Requestor, can we negotiate one or more of the generally applicable turnaround time frames (particularly for languages of lesser diffusion) now?
A: This is not possible as ALTSA and DDA are under obligation to provide information to clients within certain time frames. When this is not possible, the decision on next step must be made in the local office.
Question #79: What is the threshold number of rejected (non-primary language and non-Large Print) requests which may be considered grounds for breach of contract?
A: The Contractor will be held to the requirement of providing translations into 15 primary languages and formating documents into LP font. The Contractor will also be held to the answers to the Management Questions – Attachment D1: “Recruitment and Retention” (Question3) and “Capacity” (Question 7) they provide as a part of their bid.
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Question #80: The RFP references "automatic system generated documents" does this mean that ALTSA-DDA is looking for documents translated/generated by software instead of manually by hand?
A: No
Question #81: Under the qualifications for translators, what does "Approved Contractor Translator testing programs" mean and entail?
A: Bidders will need to describe their process of determining translator/reviewer qualifications – answer to Q4 in Attachment D1.
All other terms and conditions in this Solicitation remain the same.
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Attachment G (revised 10.22) - LIST OF LANGUGE NAMES and CODES (CARE 2020)
Albanian (AL) Kakwa (KK) Slovene/Slovenian (SE) Amharic (AM) Karen (KA) Somali (SM) Anuak (AN) Kashmiri (KH) Soninke (SO) Arabic (AR) Kayah (KL) Spanish (SP) Armenian (AE) Kinaray-a (KN) Swahili (SI) Assyrian/Syriac (AS) Kinyarwanda/Rwanda (RW) Swedish (SW) Azeri (AZ) Kikuyu (KY) Tagalog (TA) Balochi (BA) Kirundi/Rundi (KI) Tajik (TJ) Bambara (BM) Kmhmu/Khmu (KM) Tamil (TM) Bengali (BN) Korean (KO) Telugu (TE) Bikol (BK) Kosrean (KS) Thai (TH) Bosnian (BO) Kunama (KB) Tibetan (TB) Bulgarian (BL) Kurdish/ Sorani (KU) Tigrinya (TI) Burmese (BS) Lao (LA) Tongan (TN) Cambodian/Khmer (CA) Large Print (LP) Trukese/Chuukese (TR) Cebuano/Visayan (CB) Latvian (LV) Turkish (TK) Cham (CM) Lebanese Arabic (LE) Turkmen (TU) Chamorro (CR) Limba (LI) Ukrainian (UK) Chin (CI) Lingala (LG) Urdu (UR) Chinese (Traditional or Lithuanian (LT) Uzbek (UZ) Simplified) (CH) Luganda/Ganda (LU) Vietnamese (VI) ChiuChow (CC) Macedonian (MC) WarayWaray (WW) Creole (Haitian, French) (CE) Malay (ML) Wolof (WO) Croatian (CT) Malayalam (MM) Yapese (YA) Czech (CZ) Mam (MU) Yoruba (YR) Danish (DN) Mandinka (MN) Yupik (YP) Dinka (DI) Marathi (MR) Zulu (ZU) Dutch (DU) Marshallese (MS) Dzongkha (Bhutan) (DZ) Mien (MI) English (EN) Mixteco (MX) Esan (EA) Moldavian/Romanian (RO) Estonian (ES) Mongolian (MO) Ewe (EW) Navajo (NA) Farsi/Persian/Dari (FA) Nepali (NE) Fijian (FJ) Norwegian (NO) Finnish (FI) Nuer (NU) French (FR) Oromo (OM) Fulani (FU) Other (OT) Georgian (GN) Palauan (PL) German (GE) Pangasinan (PN) Greek (GR) Pastu (PA) Gujarati (GJ) Pohnpeian (PH) Hakha Chin (HA) Polish (PO) Hebrew (HE) Portuguese (PG) Hindi (HI) Punjabi (PJ) Hmong (HM) Romanian/Moldavian (RO) Hungarian (HU) Russian (RU) Ibo/Igbo (IB) Salish (SH) Ilocano (IL) Samoan (SA) Ilongo/Hiligaynon (HL) Serbo-Croatian (SC) Indonesian (IN) Shona (SN) Italian (IT) Sinhalese (SL) Japanese (JA) Slovak (SV)
RFP NO.2034-765 – ALTSA/DDA TRANSLATION SERVICES, SYSTEM GENERATED DOCUMENTS (ATTACHMENT G - REVISED) 1
CARE-DT Forms LTC Service Summary Template Service Summary Form Header
LTC Service Summary Form <
Service Summary Document Footer Client Name:
Client Information Client Name:
Gender:
Contacts
Emergency Contacts Name:
Name:
Backup Caregiver:
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Name:
Primary Physician:
Services Client is functionally eligible for:
Recommended Living Situation:
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Monthly Hours After Adjustments
Your IP cannot work more hours than their work week limit unless: DSHS has approved this ahead of time; or You had an unplanned health or safety need and your IP had to stay with you until help arrived. If this happens, your IP must report the emergency to your case manager the next business day or as soon as possible. It is up to your IP to tell you if she or he is also working for another client because that may change the number of hours your IP can work for you.
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Monthly Hours After Adjustments
Your IP cannot work more hours than their work week limit unless: DSHS has approved this ahead of time; or You had an unplanned health or safety need and your IP had to stay with you until help arrived. If this happens, your IP must report the emergency to your case manager the next business day or as soon as possible. It is up to your IP to tell you if she or he is also working for another client because that may change the number of hours your IP can work for you.
Provider Information The following schedule(s), if identified, are based on the consumer's preference at the time of the assessment.
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Formal Providers Provider:
Provider:
Informal Providers Provider:
Provider:
Environment/Equipment Plan Environment Concerns List: Concern Who Acts Act By
Equipment/Supplies:
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Referrals/Indicators
Nursing Service Indicators Indicator:
Indicator:
My Goals and Plans My skills and gifts:
My relationships and interest:
How to best support me:
My perfect day:
What does/doesn’t work for me:
My favorite things/what makes me happy:
What’s important to me:
In the next year, I really want to:
Topics of Interest Category:
Comments:
Necessary Supplemental Accommodation
Worker Information Assessor:
The role of the Case Manager is to: 1 Determine program eligibility, complete assessments identifying your preferences, strengths and needs, and reassess annually or as needs change; 2. Assist you to develop a plan of care that documents your choice of services and qualified providers; 3. Authorize payment for services identified in your plan of care; 4. Monitor that services are provided according to your plan of care.
Clients have the right to waive case management services other than those listed in items 1, 2, 3, and 4 above.
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I understand that participation in all ALTSA/LTC paid services is voluntary and I have a right to decline or terminate services at any time. I understand that I must notify my case manager if I have a change in my living situation. By signing this plan, I agree that I have been included in creating it and I agree to receive the services listed in it. I understand that agreeing to receive the services in this plan does not waive any hearing rights I have.
______Client/Representative Signature Date
Social Service Specialist/Case Manager Signature
______Social Service Specialist/Case Manager Signature Date
Signature of Provider responsible for implementing the Plan of Care
______Provider Signature Provider Printed Name Date
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The exception is in the interest of the overall economy and your welfare; and Your situation is different from most other people in your classification group; and The request would not break any federal or state laws; and either You are at serious risk of going to a nursing home, hospital, or other institution, or The exception increases your opportunities to function effectively, or You have a limitation that significantly interferes with the usual way we decide eligibility and payment.
You may ask for an ETR by calling or writing your care consultant or his/her supervisor. If your request is denied, you may ask for a review by the Exception to Rule Committee in Olympia. You can ask for a review by contacting your care consultant or his/her supervisor. You can also ask for a review by writing to Aging and Disability Services.
Aging and Disability Services ETR Committee PO Box 45600 Olympia, WA 98504.
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• Activities of Daily Living (ADLs) – how you perform basic activities like getting dressed, moving around, and eating. • Cognitive Performance – how you communicate with other people, make decisions, and remember recent things. • Clinical complexity – if you have medical conditions or need treatments that make it harder for you to do your ADLs. • Moods and behaviors – if you have certain types of Moods or Behaviors. When they last occurred. In some cases, how often the moods or behavior occurred and if a caregiver can assist in some way. • Exceptional care – whether you have exceptional conditions that make it harder for you to do your ADLs.
We will also look at whether you have other help currently available.
Whether or not you ask for an ETR, you may still challenge the results of your assessment, including its accuracy, through an administrative appeal.
If you have already asked for a personal care ETR, you can ask for more hours if: • You have received our decision on your ETR, or • It has been more than 30 days since you asked for an ETR and we have not made a decision yet.
You have to ask for more hours: • In writing, and • Within 90 days of getting notice about your ETR.
You will have to show us that you need more hours for your ADLs and IADLs. More information about ADLs and IADLs is available:
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• In the letter about your assessment that came with the “Planned Action Notice”. • At https://www.dshs.wa.gov/node/2337. Or • From your case manager.
If we approve some or all of the hours you asked for, we call this a Limitation Extension.
We want you to be able to give us the information we need to make a decision. Ask your case manager for information or visit https://www.dshs.wa.gov/node/5806.
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CLIENT NAME
ACES ID NUMBER
Your Rights and Responsibilities When You Receive Services Offered by Aging and Long-Term Support Administration and Developmental Disabilities Administration Services Available You have the right to choose from the services that you are eligible to receive. Services are voluntary. The services that Aging and Long-Term Support Administration (ALTSA) and Developmental Disabilities Administration (DDA) can pay for may not help you with all of your needs. ALTSA and DDA offer services in: • An Adult Family Home, Assisted Living Facility, Enhanced Services Facility, Nursing Facility, Companion Home, Children’s Foster Home, Children’s Licensed Staffed Residential Home; DDA Group Homes, Group Training Homes, ICF/IDs; OR • A person’s own home. Note: ALTSA and DDA do not provide paid 24 hour/day personal care services in a person’s own home. If 24 hour care is desired then other service options may be considered. Your AAA Case Manager, DDA Case Resource Manager, or HCS Social Service Specialist is called a case worker in this document. • Make a complaint without fear of harm even if you have requested an administrative hearing; • Talk with an advocate by calling 1-888-201-1014; • Refuse all services;
YOUR RIGHTS AND RESPONSIBILITIES WHEN YOU RECEIVE SERVICES OFFERED BY ALTSA AND DDA DSHS 16-172 (REV. 05/2018)
YOUR RIGHTS AND RESPONSIBILITIES WHEN YOU RECEIVE SERVICES OFFERED BY ALTSA AND DDA
DSHS 16-172 (REV. 05/2018) • Have interpreter services provided to you free of charge if you cannot speak or understand English well; • Choose, fire or change a qualified provider; and • Receive the results of the background check for any individual provider you choose. Your Responsibilities You have the responsibility to: • Let the case worker complete your assessment at least annually in a location convenient to you; • Let the case worker view your living environment at least annually; • Give us enough information to complete your assessment; • Tell your case worker if someone else makes medical or financial decisions for you; • Participate in the development of your care or support plan, and sign it; • Understand your provider cannot be paid for services or hours that are not authorized; • Choose your own health care; • Choose a qualified provider; • Provide a safe work place; • Keep provider background checks private; • Tell your case worker if you are having problems with your provider or if you are not getting the hours claimed by your provider; • Pay your provider every month if you help pay for your care; YOUR RIGHTS AND RESPONSIBILITIES WHEN YOU RECEIVE SERVICES OFFERED BY ALTSA AND DDA DSHS 16-172 (REV. 05/2018)
• Not act in a way that puts anyone in danger; and • Tell your case worker if there is a change in: Your medical condition; The help you get from family or other agencies; Where you live; or Your financial situation. Case Worker Responsibilities Your case worker is responsible to: • Treat you with dignity and respect; • Maintain your privacy; • Tell you what ALTSA and DDA can, or cannot, do for you; Get information from you and others to do an assessment to determine your level of assistance and decide what services you can choose from The assessment will include your strengths, limitations, goals, and preferences. The assessment will include the help you are already getting or can get from family or other agencies and how you want the services to be done; • Assist you to develop a care plan or support plan that addresses assistance with personal care and includes your personal goals, preferences, and choices; • Get information from you and others to update your care plan or support plan every year or when your condition changes; • Give you enough time to provide the information that is needed; • Address problems with your care plan or support plan as they arise; • Respect your rights and provide more help in accessing services if you have mental, neurological, sensory, or physical
YOUR RIGHTS AND RESPONSIBILITIES WHEN YOU RECEIVE SERVICES OFFERED BY ALTSA AND DDA DSHS 16-172 (REV. 05/2018)
impairments; and • Help you find a qualified provider if you are not able to find one.
Advance Directives You have the right to make advance directives. Advance directives may include a living will or durable power of attorney for your healthcare. Advance directives summarize your wishes about medical and/or mental health care, including the right to accept or refuse medical, mental health, or surgical treatment, when you do not have the mental ability to make those decisions. You can revoke your advance directives at any time. Voter Registration Service The National Voter Registration Act of 1993 requires all states to provide voter registration assistance through their public assistance offices. Applying to register or declining to register to vote will not affect the services or amount of benefits that you will be provided by this agency. If you would like help in filling out the voter registration form, we will help you. Your decision to register or to decline to register will be kept confidential and only used for voter registration purposes. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with: Washington State Elections Office PO Box 40229 Olympia WA 98504-0229 1-800-448-4881
Your Signature
YOUR RIGHTS AND RESPONSIBILITIES WHEN YOU RECEIVE SERVICES OFFERED BY ALTSA AND DDA DSHS 16-172 (REV. 05/2018)
Sign on the line below if you understand your rights and responsibilities and understand the responsibilities of your case worker.
CLIENT SIGNATURE
DATE
LEGAL REPRESENTATIVE SIGNATURE
DATE
Notice for customers and employees (Title VI and VII) Washington State Department of Social and Health Services is an equal opportunity employer and does not discriminate in any area of employment, its programs or services on the basis of age, sex, sexual orientation, gender, gender identity/expression, marital status, race, creed, color, national origin, religion or beliefs, political affiliation, military status, honorably discharged veteran, Vietnam Era, recently separated or other protected veteran status, the presence of any sensory, mental, physical disability or the use of a trained dog guide or service animal by a person with a disability, equal pay or genetic information.
YOUR RIGHTS AND RESPONSIBILITIES WHEN YOU RECEIVE SERVICES OFFERED BY ALTSA AND DDA DSHS 16-172 (REV. 05/2018)
Your Rights and Responsibilities When You Receive Services Offered by Aging and Long-Term Support Administration and Developmental Disabilities Administration INSTRUCTIONS 1. Present this form to the client when completing the initial CARE assessment and reviewing the care plan or support plan. If the client is already receiving services and did not previously sign this version of the form, present the form to the client at the next assessment. Review the form with the client to answer any questions about the client‘s rights and responsibilities. 2. Have the client or the client’s representative sign two copies of the form to indicate his/her understanding of the client’s rights and responsibilities when receiving services offered by Aging and Long-Term Support Administration and Developmental Disabilities Administration. 3. File one copy in the hard file or Document Management System (DMS) and give the other copy to the client.
YOUR RIGHTS AND RESPONSIBILITIES WHEN YOU RECEIVE SERVICES OFFERED BY ALTSA AND DDA DSHS 16-172 (REV. 05/2018)