Okaloosa County BOCC — October 7, 2014 — AH105 OKALOOSA BCC amendment #7 renewal Fully Executed — reading text

approve the release of more than the monthly prorated amount when the provider submits a written request justifying the release of additional funds, if funds are available and services have been provided. 3. Invoice Requirements a. The provider shall request payment monthly through submission of a properly completed invoice, Exhibit E-Invoice within ten (10) days following the end of the month for which payment is being requested for the delivery of service. b. The provider's final invoice must reconcile actual service units provided during the contract period with the amount paid by BBCBC. The provider shall submit their fiscal year final invoice to BBCBC within ten (10) days after the end of each state fiscal year in the contract period. c. The total number of monthly service units paid under this contract cannot exceed the total amount of funding as specified on Exhibit G, Funding by Program. 4. Supporting Documentation a. The provider agrees to maintain service documentation for each service billed Rev.09/3/14 OKBOCC Contract No.AH105 9/12/14 EXHIBIT B Client Non-Specific Performance Contract SAMH Service Program to BBCBC pursuant to this contract. b. The provider shall maintain documentation to support all units billed to BBCBC. c. BBCBC and the State’s Chief Financial Officer reserve the right to request supporting documentation at any time after actual units have been delivered. Rev.09/3/14 OKBOCC Contract No.AH105 EXHIBIT C REQUIRED REPORTS Report Delivery Format Frequency/Due Date Send to: Required Y/N Deaf and Hard of Hearing E-mail confirmation of Monthly by the 3rd business . electronic submission mecontracts@bigbendcbc.org N Li Report/Auxiliary Aid di Comipiance: Report/ Auxiliary A) see Section 6 for details ay E-mail i f Agency Single-Point of Contact mallet confirmation 9 Within 14 days of contract ‘ name and contact 5 mecontracts@bigbendcbc.org N for DHH 3 7 begin date information eat 3 A Response to Monitoring Reports E-Mail 0 days post receipt of final mecontracts@bigbendcbc.or y and Corrective Action Plans report mecontracls@bigbendebc.org zi Within 30 days of contract Program Description 4 . * E-Mail execution and upon request mecontracts@bigbendcbc.org ¥ CF-MH1045 by BBCBC Financial Audit and Compliance d to BBCBC admini i Report and 4 additional ., | Annually within 180 days of Hard copy to a rninistrative % Hard Copy and E-mail ; offices and electronic to Y schedules as required by Rule Provider's fiscal year end fecontracts@blebendebe.oF 65E-14.003(2)(a). F.A.C. 8 “OTB ie Within 15 days of contract Civil Rights Compliance Checklist P ; execution and annually mecontracts@bigbendcbc.org ¥. Department website thereafter by May 20th www.dcf.state.fl.us yay Within 15 days of contract Emergency Preparedness Plan E-Mail execution and annually by mecontracts@bigbendcbc.ory Y May 1 bef tract General Liability Insurance + Upon or . erore contrac . gs E-Mail execution and upon mecontracts@bigbendcbc.org Y Certificate A insurance renewal Within 30 days of contract Proof of Accreditation E-Mail execution and upon renewal mecontracts@bigbendcbc.org N of certification ification of Crimi Notification ° finainial E-Mail Within 15 days of notice mecontracts@bigbendcbc.org Y Investigation involving Agency Electronic to IRAS In Accordance with DCF’ Incident Report -Incident Reporting and nace! ' s IRAS Y ; CFOP 215-6 Analysis System Within 15 days of contract Current Agency Licenses E-Mail execution and upon license mecontracts@bigbendcbc.org N renewal Quarterly by Ocotber 30, Mi 5E-14.005 . atch Reports per . E-Mail January 30, April 30 and July mecontracts@bigbendcbc.org Y with supporting docuementation 15 Within 30 days of contract Sliding Fee Scale E-Mail execution and annually on mecontracts@bigbendcbc.org N May 1, Waiting List Electronic to SAMHIS_ | As required in PAM-155-2 SAMHIS N i id Monthly Forensic Report eu E-Mail Monthly with Invoice mecontracts@bigbendcbc.org y supporting narrative Quarterly Conditional Release E-Mail Quarterly within 15 days of niecontrads@blsbandebeae y Forensic Report end of quarter meson tracts @biebendcbs.org Staff Recruitment Plan for racial ithi f tract and ethnic parity with client E-Mail Within 20 days of contrac mecontracts@bigbendcbc.org N base execution EXHIBIT C REQUIRED REPORTS Report Delivery Format Frequency/Due Date Send to: Required Y/N Alternative Projected Operating and Capital Budget Report E-Mail Annually by March 31 mecontracts@bigbendcbc.org Y CF-MH 1042 Agency Service Capacity Report F : | A i CF-MH 1043 E-Mail nnually by March 31 mecontracts@bigbendcbc.org Y Within 30 d f List of Assisted Living Facility Fi ine A ays of contract , . E-Mail execution and annually by mecontracts@bigbendcbc.org N Cooperative Agreements July 1 Subcontracts E-Mail Prlor:to:exeaution of mecontracts@bigbendcbc.org N subcontract ion-P ; Prevention = Program Evaluation Electronic Within 5 business days KIT Solutions N Instrument Level | and Level 2 Prevention — Invoice Support E-Mail Submitted with monthly mecontracts@blebendebe.on N Report invoice mecontracts@bigbendchc.org Annual Report for HIV Early Intervention Services, SAPT " E-Mail Upon Ri t tracts @ big! .Org Block GrantSet Aside Funded ai jpon Reques' mecontracts@bigbendcbc.ory N Services Only Annual Report for Evidenced- based Injection Drug User Outreach Services, SAPT Block E-Mail Upon Request mecontracts@bigbendcbc.org N Grant Mandate, Designated Providers Only Annual Report for Pregnant Women and Women With Dependent Children SAPT Block E-Mail Upon Request mecontracts@bigbendcbc.org N Grant Set Aside Funded Services Only 7 ‘ TANE Prograr es and Senvice E-Mail/Hard Copy Monthly with Invoice Monthly with Invoice N . As directed by DCF/SAMH As di by DCF/SAMH PATH Annual Report E-Mail sidjretted BY DCE Headquarters and N Headquarters " mecontracts@bigbendcbc.org No | than 90 di directed Aggregate Payor Class Report for E-Mail in Required ° ater: an ays Asditected by DEF/SAMH designated receiving facilities Report Format following the end of the Headquarters and N e 6 e facility's fiscal year mecontracts@bigbendcbc.org Client Trust Fae Represents Within 30 days of contract ae M amas E-Mail execution/amendment and mecontracts@bigbendcbc.org N Determination/Certification annually by July 15 Letter MOU(s) with local Federally Within 15 days of MOU . E-Mail if MOU Par econtracts@bigbendcbc.org Qualified Health Centers (FQHCs)| al-copy'o (s) signing mecontracts@bigbendchc.or N FACT Enhancement E-Mail Quarterly within 15 days of mecontracts@bigbendcbc.or; N Reconciliation Report end of quarter mecontracts@bigbendebc.org rterly within 15 d: f FACT Ad Hoc Report E-Mail Quarterly within ays o mecontracts@bigbendcbc.org N end of quarter FACT. Monthly Enrollment E-Mail Monthly with Invoice mecontracts@bigbendcbc.org N Report FACT Monthly Vacant Position E-Mail Monthly with Invoice mecontracts@bigbendcbc.org N Report EXHIBIT C REQUIRED REPORTS Report Delivery Format Frequency/Due Date Send to: Required Y/N BNET Alternative Services Provision, Pharmaceuticals Only E-Mail Monthly with Invoice mecontracts@bigbendcbc.org BNET Alternative Services Provision, Other than Pharmaceuticals E-Mail Monthly with Invoice mecontracts @bigbendcbc.org BNET Statement of Program Cost E-Mail Annually by September 1 mecontracts @bigbendcbc.org BNET Discreet Service Events E-Mail Monthly with Invoice mecontracts@bigbendcbc.org Pregnant and Post-Partum High Risk Women Report E-Mail Monthly with Invoice mecontracts@bigbendcbc.org Drug Court Caseload and Service Report E-Mail Monthly with Invoice mecontracts@bigbendcbc.org Forensic Status Report E-Mail Monthly with Invoice mecontracts@bigbendcbc.org Monthly/YTD Unduplicated Client Outcome Summary E-Mail Monthly with Invoice mecontracts@bigbendcbc.org Provider Name: Performance Contract SAMH Services Program Exhibit D Substance Abuse and Mental Health Required Performance Outcomes and Outputs 2014-2015 Okaloosa County Board of County Commissioners. Contract #: AH105_ Date: 9/1/14 Revision #: __ I. Mental Health Contracted Services A. Required Performance Output Standards for Each Target Population Include all clients paid for ‘ANF, PTS, Local Match, an oy this SAMH contract only, Contract funding includes SAMH, Title XXI payments.) *Please explain in the comment section below if a target population is indicated in the section below, but there is no corresponding outcome standard for that population. 1. 2. Adult Mental Health a. Adults with Severe and Persistent Mental Illness (SPMI) (M0016)/(MHO016) b. Adults with Serious and Acute Episodes of Mental Illness (IM05301)/(MH5301) c. Adults with Mental Health Problems (M05302)/(MH5302) d. Adults with Forensic Involvement — Maximum case load Drug Court MH Court Case Management Pretrial Services Minimum Numbers to be Served N/A N/A N/A 50 30 60 Total 140 Children’s Mental Health a. Children with Serious Emotional Disturbances (SED) (M0031)/(MH031) b. Children with Emotional Disturbances (ED) (M0032)/(MH032) c. Children at-risk of Emotional Disturbances (M0033)/(MH033) B. Required Performance Outcome Standards for Each Target Population *Please explain in the comment section below if there is an Outcome Standard but there is no corresponding target population indicated. 1. Adult Mental Health - Adults with Severe and Persistent Mental Illness a. Percent of adults with severe and persistent mental illnesses who live in stable housing environment will be at least (MO0742)/MH742) - (Statewide Target - 93%) b. Average annual number of days (post admission assessments) worked for pay for adults with severe and persistent mental illness will be at least (M0003)/(MHO003) — (Statewide Target - 30) Adult Mental Health - Adults in Mental Health Crisis, including Adults with Serious and Acute Episodes of Mental Illness and Adults with Mental Health Problems a. Percent of adults in mental health crisis who live in stable housing environment will be at least (M0744)/MH744) — (Statewide Target - 90%) Adult Mental Health — Adults with Serious Mental Illness (SPMI, MH Crisis, Forensic) a. Percent of adults with serious mental illness who are competitively employed will be at least (M0703)/MH703) — (Statewide Target - 15%) Adult Mental Health - Forensic Involvement a. Percent of adults in forensic involvement who live in stable housing environment will be at least (MO743)/MH743) — (Statewide Target - 70%) Children’s Mental Health - Seriously Emotionally Disturbed a. Percent of children with serious emotional disturbance who live in stable housing environment will be at least (MO0779)/(MH779) — (Statewide Target - 95%) b. Percent of children with serious emotional disturbance who improve their level of functioning will be at least (M0378)/MH378) — (Statewide Target - 65%) c. Percent of school days seriously emotionally disturbed children attended will be at least (M0012)/(MHO012) — (Statewide Target - 86%) Children’s Mental Health - Emotionally Disturbed a. Percent of children who live in stable housing environment will be at least (M0778)/(MH778) — (Statewide Target - 95%) b. Percent of children who improve their level of functioning will be at least (M0377)(MH377) — N/A N/A N/A Minimum Contract Standard N/A N/A N/A N/A N/A N/A N/A N/A N/A Performance Contract SAMH Services Program Exhibit D Substance Abuse and Mental Health Required Performance Outcomes and Outputs 2014-2015 Provider Name: Okaloosa County Board of County Commissioners Contract #: AH105 Date: 9/1/14 Revision #: __ (Statewide Target - 64%) 7. Children’s Mental Health — At-Risk of Emotional Disturbance a. Percent of children who live in stable housing environment will be at least (M0780) (MH780) — (Statewide Target - 90%) C. Required Internal Measures 1. Data Submission Outcomes for Mental Health a. Percent of persons receiving state-contracted