DCYF Form 10-521 Comprehensive Review: Compliance Agreement - Washington

DCYF Form 10-521 or the "Comprehensive Review: Compliance Agreement" is a form issued by the Washington State Department of Children, Youth, and Families.

Download a PDF version of the DCYF Form 10-521 down below or find it on the Washington State Department of Children, Youth, and Families Forms website.

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DEPARTMENT OF CHILDREN, YOUTH AND FAMILIES (DCYF)
CONTRACTED PERIOD DATE
DATE OF VISIT
CONTRACT MANAGER’S NAME
LICENSING DIVISION (LD)
BEHAVIORAL REHABILITATION SERVICES (BRS)
CONTRACTS AND PROCUREMENT OFFICE
EMAIL
TELEPHONE NUMBER (AREA CODE)
Comprehensive Review:
Compliance Agreement
CONTRACT NUMBER
PROVIDER NUMBER
CONTRACTED SERVICES
REGIONAL LICENSOR’S NAME
EMAIL
TELEPHONE NUMBER (AREA CODE)
NAME OF CONTRACTED AGENCY
ADMINISTRATOR / DIRECTOR / OWNER
ADDRESS
CITY
STATE
ZIP CODE
EMAIL
TELEPHONE NUMBER (AREA CODE)
WA
CONTRACT, BRS,
NONCOMPLIANCE DESCRIPTION / SUMMARY: WHEN
DATE
AND/OR WAC
IDENTIFYING AREAS OF NON-COMPLIANT, BE SPECIFIC TO THE
PLAN OF CORRECTION
COMPLETE BY
COMPLETED
CITATION
ACTUAL NUMBER OF FILES (I.E., THREE FILES DID NOT HAVE?)
Program Review; LD and BRS Contracts (Agency Policies / Procedures)
Site Inspection
Client File Review; Number Reviewed:
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COMPREHENSIVE REVIEW: COMPLIANCE AGREEMENT
DCYF 10-521 (01/2019)) INT
DEPARTMENT OF CHILDREN, YOUTH AND FAMILIES (DCYF)
CONTRACTED PERIOD DATE
DATE OF VISIT
CONTRACT MANAGER’S NAME
LICENSING DIVISION (LD)
BEHAVIORAL REHABILITATION SERVICES (BRS)
CONTRACTS AND PROCUREMENT OFFICE
EMAIL
TELEPHONE NUMBER (AREA CODE)
Comprehensive Review:
Compliance Agreement
CONTRACT NUMBER
PROVIDER NUMBER
CONTRACTED SERVICES
REGIONAL LICENSOR’S NAME
EMAIL
TELEPHONE NUMBER (AREA CODE)
NAME OF CONTRACTED AGENCY
ADMINISTRATOR / DIRECTOR / OWNER
ADDRESS
CITY
STATE
ZIP CODE
EMAIL
TELEPHONE NUMBER (AREA CODE)
WA
CONTRACT, BRS,
NONCOMPLIANCE DESCRIPTION / SUMMARY: WHEN
DATE
AND/OR WAC
IDENTIFYING AREAS OF NON-COMPLIANT, BE SPECIFIC TO THE
PLAN OF CORRECTION
COMPLETE BY
COMPLETED
CITATION
ACTUAL NUMBER OF FILES (I.E., THREE FILES DID NOT HAVE?)
Program Review; LD and BRS Contracts (Agency Policies / Procedures)
Site Inspection
Client File Review; Number Reviewed:
Page 1 of 3
COMPREHENSIVE REVIEW: COMPLIANCE AGREEMENT
DCYF 10-521 (01/2019)) INT
Personnel File Review; Number Reviewed:
Information from Other Sources; Number:
Per the contract’s Special Terms and Conditions: In the event that DCYF identifies deficiencies in the Contractor’s performance under this Contract, DCYF may,
at its option, establish a Corrective Action Plan (a.k.a., Compliance Agreement). When presented with a Compliance Agreement, the Contractor agrees to
undertake the actions specified in the plan within the timeframes given to correct the deficiencies. Contractor’s failure to do so shall be grounds for termination of
this Contract.
I agree to correct the issues of noncompliance cited above as outlined in the plan of correction by the dates indicated. I further agree to send written notification
to the licensor and/or contracts manager no later than
declaring the extent to which each deficiency has been corrected.
CONTRACTED AGENCY’S ADMINISTRATOR’S OR OTHER AUTHORIZED PERSON’S SIGNATURE
DATE
CONTRACT MANAGER’S SIGNATURE
DATE
LICENSOR’S SIGNATURE
DATE
BEHAVIORAL REHABILITATION SERVICES PROGRAM MANAGER SIGNATURE
DATE
Comments, any other feedback supporting documentation or other information to share about the Agency’s practice (either from the Contracted Agency or the
DCYF Contract Manager.
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COMPREHENSIVE REVIEW: COMPLIANCE AGREEMENT
DCYF 10-521 (01/2019)) INT
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COMPREHENSIVE REVIEW: COMPLIANCE AGREEMENT
DCYF 10-521 (01/2019)) INT
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