ESBD_File_296114_HHS0012375 Application and Required Forms.docx

7. TREATMENT FAMILY FOSTER CARE (TFFC) OPEN ENROLLMENT APPLICATION, ATTACHMENTS and

REQUIRED FORMS

INSTRUCTIONS

1. Applicant must read all of the Open Enrollment posted on the ESBD or HHS Enrollment Sites before completing this Application.

2. The Application must be completed and signed in Section V (Certification) for it to be accepted by DFPS.

3. The Application must be complete for it to be accepted by DFPS, and all questions and forms are required to be answered or submitted. Responding with “Not Applicable” is only an appropriate response when a question or form does not apply to the Applicant. Do not leave any section of the Application blank.

4. Applicant will provide the information in the body of the Application unless otherwise instructed to include it as an Attachment (See File Folder 2 in Appendix A).

5. Applicant will complete the forms listed see Required Forms (See File Folder 3 in Appendix A).

6. Applicant will provide the information listed in Service Level Monitor Attachments (See File Folder 4 in Appendix A).

7. Applicant will submit all contract application files and documents to: DFPS24HourResidentialApplications@dfps.texas.gov.

8. If DFPS has difficulty accessing the Applicant’s documents, the Applicant will be required to re-submit documents as directed by DFPS.

SECTION I – APPLICANT INFORMATION

Doing Business As Name (DBA) or Parent Organization- Indicate if different from Legal Name above

Attach a copy of Assumed Name Certificate

If an Applicant has a Parent Organization, attach a copy of the agreement between the Applicant and the Parent Organization

Mailing Address - If different from Office Address above

Applicant:

Parent Organization:_

Federal ID Number – If different from Vendor ID Applicant:

Parent Organization:

Social Security Number - If applying as Individual/Sole Proprietor

Name of Person Authorized to Sign Contract:

Title:

Phone Number:

Email:

Name of Person Responsible for Billing:

Title:

Phone Number:

Email:

Type of Applicant – Check appropriate box(es) and attach documentation as indicated

Are you applying to provide services to DFPS? |_|Yes |_|No

Charter Number:

Attach a copy of Certificate of Incorporation

Attach a list of names, addresses and Social Security numbers for each partner If Partnership – Do you have:

|_|Yes |_|No Partnership Agreement |_|Yes |_|No Signatory Assignment

If Yes is checked above, attach a copy

Provide date of birth:

Submit an HHS CCL License for the CPA and services that Applicant is applying to provide TFFC services.

SECTION II – SERVICE AREA

DFPS will only accept Applications from HHS CCR Licensed Applicants as a CPA providing treatment services must (see Section 1.6 of the Open Enrollment).

Select the appropriate DFPS Region(s) for each question.

1. Indicate which DFPS Region your administrative headquarter is located:

2. Indicate which DFPS Regions you will be providing TFFC services.

*For Active CBC Catchment Areas - DFPS will not accept applications for RCC CPA Contractors whose entire placement capacity is located solely in a CBC catchment area. If you provide CPA treatment services in part of a CBC area, review Section 1.6.3 of the Open Enrollment before completing this Section of the Application.

3. If you are a CPA proposing to provide multiple treatment and/or programmatic services:

· The identified multiple programmatic services must be listed on your CPA's HHS Child Care License (CCL);

· You must identify the multiple programmatic services on your CCL License that your CPA intends to provide through this Application; and

· Select all the following services that apply to this Application:

|_| Child-Care Services

|_| Treatment Services for Children with:

|_| Emotional Disorders |_| Intellectual developmental disabilities (ICFIDD)(Mental Retardation) |_| Pervasive Developmental Disorders |_| Primary Medical Needs

|_| Programmatic Services Provided:

|_| Transitional Living Program |_| Assessment Services |_| Intermittent Alternative Care (Respite Child Care)

4. Requested Service Level Information. Is your CPA authorized to provide Intense Level of Care Services?

|_|Yes |_|No

SECTION III – INSURANCE

Review Section 1.5.4 of this Open Enrollment, Section II (G) of the DFPS Supplemental, Special & Programmatic Conditions for TFFC, and Section I (H) of the DFPS Vendor Uniform Terms and Conditions (see Section 1.7) and indicate in the table below if requirements are met.

Commercial General Liability or equivalent insurance: |_|Yes |_|No

Professional Liability Insurance or equivalent insurance if CPA intends to employ staff to provide professional services: |_|Yes |_|No

Commercial Crime Insurance or equivalent insurance with 3rd Party endorsement & Employee Dishonesty endorsement: |_|Yes |_|No

Business Automobile Liability (Owned & Hired Endorsements and Non-owned Auto): |_|Yes |_|No

If "No" is checked for any insurance named above, Contractor must submit insurance coverage documentation with the signed contract. DFPS will not execute a Contract if this documentation is not provided or is found to not meet the insurance requirements.

If “Yes” is checked for any insurance named above, Contractor must submit insurance coverage documentation prior to contract execution.

SECTION IV - APPLICANT’S ORGANIZATION

1. Describe your organizational history with contracting, including:

a. Has your organization been contracting with DFPS as a CPA for at least one year?

|_|Yes |_|No

b. Your past experience working with residential child-care services for the last five years. Also include information specific to working with children requiring therapeutic and/or treatment services.

6. Have you had a contract for residential child-care services that was non-renewed or terminated by any private party or governmental entity within the last five years?

|_| Yes |_| No

If yes, please answer the following:

a. Provide the name of the entity that you contracted with, contract service type, date of the non-renewal/termination, and list the factors that contributed to that action; and

b. Describe in detail the actions taken by your agency to remedy each factor that contributed to that non-renewal/termination.

7. Provide a list of all current contracts held by your organization. List must at a minimum include if applicable:

a. Type of Contract (Private, federal, state or county);

b. Contract number;

c. Contact person at the contract entity;

d. Contact phone number;

e. Type of service;

f. Dollar value of the contract;

g. Begin and end date of the contract;

h. Any corrective actions put into place by the contracting agency; and

i. Copies of contract monitoring reports during the last five years.

8. Does your CPA place geographical limitations on accepting admissions?

|_| Yes |_| No

If yes, specify the following:

|_| Specific Region/City

TARGETED CHARACTERISTICS

Check the characteristics and behaviors of children you propose to serve specified for each category found in the table below.

Characteristic

Victims of Human Trafficking

Verbal Aggression – threaten, bully or other coercing, including threats of physical harm

|_|Yes |_|No

*Special Needs - means a Child with medical, mental, emotional, behavioral or educational needs that could require extra on-going attention.

CHILDREN’S RECORDS

9. Identify where Children’s current and archived records will be maintained and backed up.

ORGANIZATIONAL STRUCTURE OF PROFESSIONAL, KEY MANAGEMENT, DIRECT CARE STAFF, AND FOSTER PARENTS

10. Attach a copy of your CPA's Board of Directors including:

a. Full names;

b. Titles;

c. Addresses;

d. Email addresses; and

e. Phone numbers.

11. Attach a copy of your CPA's Person(s) in a Key Position including:

a. Full names;

b. Titles, if applicable;

c. Addresses;

d. Email addresses; and

e. Phone numbers.

See definition of Person in a Key Position in the Requirements at http://www.dfps.state.tx.us/Doing_Business/Purchased_Client_Services/Residential_Child_Care_Contracts/documents/24_Hour_RCC_Requirements.pdf.

12. Attach a copy of your CPA's professional organizational chart that clearly depicts lines of authority.

13. Attach a copy of your CPA's professional staffing plan, which must contain:

a. Minimum qualifications for the position; and

b. The primary roles of that position.

PROFESSIONAL AND KEY MANAGEMENT STAFF

14. What is the level of experience (in months or years) with fiscal and/or programmatic components of federal or state programs? If some positions are not applicable, indicate as such.

President/CEO

Executive Director

Administrator

Chief Operating Officer

15. Attach current resumes and Professional Licenses for the President/CEO, Executive Director, Administrator, Chief Operating Officer, Comptroller/CFO, Program Director, Clinical Director, and Licensed Child-Care Administrator for the CPA for which you are submitting an Application.

a. Attach copies of licenses of any professional licensed employee of the organization, including licensed professional therapists.

16. What is the annual turnover rate for professional and key management Staff within the last 12 months?

Direct Care Staff and Foster Parents

17. In what region(s) does your CPA plan to develop new TFFC homes?

An Applicant must submit Form 9077RCC Internal Control Structure Questionnaire (ICSQ) and all applicable attachments (Appendix A File Folder 3) to confirm accounting systems and procedures in in place that support fiscal responsibility.

SECTION V – CERTIFICATION

I certify that the information provided in this Application is to the best of my knowledge, complete and accurate, that the named legal entity has authorized me, as its representative, to submit this Application, and that the legal entity complies with all requirements of this Open Enrollment and accept them without alteration.

Name of Authorized Representative (Printed)

Title of Authorized Representative (Printed)

APPENDIX A - APPLICATION, ATTACHMENTS, REQUIRED FORMS and SERVICE LEVEL MONITOR ATTACHEMENTS FILE FOLDER 1: Application

Document Location

ELECTRONIC FILE NAME

Document Is Document Required Yes/No

Applicant Provides

Insurance

Insurance Documents Yes, if currently insured. Insurance is not required at the time of application.

FILE FOLDER 2: Attachments

Document Is Document Required Yes/No

Applicant Provides

Resume/ Professional Licenses/Work History

Resumes, Professional Licenses Work History with any other Residential Provider for Key Management Staff (Label applicable additional resumes accordingly, e.g. 02.F, 02.G, etc.)

Yes

FILE FOLDER 3: Required Forms

Document Location

ELECTRONIC FILE NAME

Document Is Document Required Yes/No

Signature Authority Designation

Yes

If no, submit current financial position Yes

Management letter (Only applicable to operations that have conducted annual audits) Yes, if applicable.

FILE FOLDER 4: Service Level Monitor Attachments The following information needs to be organized in File Folder 4 as provided below.

Document Location

ELECTRONIC FILE NAME

Document Is Document Required Yes/No

a. Rules, Rewards, Consequences and/or

b. Orientation Manual/Handbook Yes

a. School Year,

b. Summer and

c. Weekends Yes

a. Direct, Continuous Observation of a Child Who May Be at Risk for Harming Self or Others, and

b. Awake Night Staff Based on the Child’s Needs Yes

a. Responsibility for Developing Diagnostic Assessments and

b. Treatment Plans Yes

a. Medical,

b. Dental and

c. Therapy Services Yes

a. Psychotropic Medication Training and

b. Medication Monitoring, and

c. On-Call/Emergency Services Yes

a. 72-Hour Treatment Plan,

b. Diagnostic Assessment,

c. Treatment Plan or Plan of Service;

d. Individual, Group and/or family Therapy notes;

e. Progress Reports;

f. School reports;

g. Medication Monitoring reports;

h. Serious Incidents reports,

i. Case Management Notes, daily logs or Documentation by Foster Parents Yes

DFPS TFFC Open Enrollment HHS0012375