ESBD_File_344253_HHS0014286 CPA 6.1 New Applicant OE Application (App 11-15).docx

6.1 CPA NEW APPLICANT OPEN ENROLLMENT APPLICATION

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. DFPS considers a complete answer to be a written response. Responding with “Not Applicable” is only an appropriate response when a question or form does not apply to the Applicant.

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 License for the CPA and services for which the Applicant is submitting an Application or a letter from CCR stating that an application for such a License is complete and has been accepted.

SECTION II – SERVICE AREA

A separate Application must be submitted for each License (or letter from CCR stating that an application for such a License is complete and has been accepted) and service type you propose to provide in accordance with the information in this section.

For In-State Applicants: Select the appropriate DFPS Region/s for each question.

APPLICATIONS NOT ACCEPTED – New applications for CPAs with all capacity located within a CBC catchment area will not be accepted. For a list of CBC catchments, see the Community-Based Care page on the DFPS website.

For Out-of-State Applicants: Enter the city and state in “Other” for both questions below.

1. Select the DFPS Region below where your administrative headquarter is located:

Other: (City and State)

2. Please mark the DFPS Region/s where you will be developing capacity and providing services outside of CBC catchment areas.

Does your Operation intend to provide treatment services to victims of Human Trafficking? |_| Yes |_| No

Other: (City and State) Does your Operation intend to provide treatment services to victims of Human Trafficking? |_| Yes |_| No

3. If you are a CPA proposing to provide multiple programmatic services:

|_| Child-Care Services

|_| Treatment Services for Children with:

|_| Emotional Disorders |_| Intellectual Developmental Disabilities (ICFIDD) |_| Autism Spectrum Disorder |_| Primary Medical Needs |_| Determination as a Trafficking Victim

|_| Transitional Living Program |_| Assessment Services |_| Intermittent Alternative Care

4. Requested Service Level Information. Select the Authorized Service Level(s) your CPA is requesting to serve.

Requested Service Levels (check all that apply):

|_| Basic |_| Moderate |_| Specialized |_| Intense

Refer to 2.3 of this Open Enrollment for Service Level Monitor and see Appendix A - File Folder 4, if applicable to your CPA.

SECTION III – INSURANCE

Review Subsection 1.5.5 of this Open Enrollment, II(G) of Subsection 1.8.1c, and I(G) of 6.3.1 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. Performance under government contracts and other private party contracts in Texas or any other state for the last five years.

b. Your past experience working with residential child-care services for the last five years.

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

|_| Yes |_| No

If yes, please answer the following:

a. Provide the name of the CPA, date of the non-renewal, the contract number, and list the factors that contributed to DFPS or any other private party or governmental entity taking that action; and

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

7. Have you had a contract for residential child-care services terminated by DFPS or any other private party or governmental entity within the last five years?

|_| Yes |_| No

If yes, please answer the following:

a. Provide the date of the termination and the contract number, and list the factors cited that contributed to DFPS or any other private party or governmental entity taking that action.

b. Describe in detail the actions taken by your CPA to remedy each factor that contributed to that termination.

8. Have you applied for a contract to provide residential child-care services, and not been awarded a contract by DFPS or any other private party or governmental entity within the last five years?

|_| Yes |_| No

If yes, please answer the following:

a. List the factors that contributed to DFPS or any other private party or governmental entity taking that action; and

b. Describe in detail the actions taken by your CPA to remedy each factor that contributed to that denial.

9. Provide a list of all current contracts with DFPS or any other private or governmental entity (federal, state or county). 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; and

g. Begin and end date of the contract.

10. For the contracts listed in question #5 above, briefly describe your compliance with program requirements, and any corrective actions put into place by the contracting agency. Include copies of contract monitoring reports and letters from the contracting entity to the Applicant during the last five years.

a. Identify the referral sources that make up Applicant’s child population by estimating the percentage (%) for each placement source (for example):

DFPS

Texas Juvenile Justice Department

Texas Youth Commission

Out of State

Other – (List Individually)

Add additional rows to table, if needed, to list “Other” referral sources individually. Total should equal 100%.

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

|_| Yes |_| No

If yes, specify the following:

|_| Specific Region/City

TARGETED CHARACTERISTICS

12. In accordance with the service levels you are proposing to serve, check the characteristics and behaviors of Children specified for each category in the table below.

Characteristic

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.

13. If you propose to primarily provide services to any population of Children listed above;

a. Identify the population(s) you propose to serve; and

b. Submit your program description(s) providing detailed information regarding treatment modalities and treatment services extended to this population(s) of Children.

14. Check the appropriate box, if your CPA intends to serve any of the listed groups of Children.

|_| N/A

BEHAVIORAL HEALTH SERVICES

15. Identify the name(s) of the individual(s) providing behavioral health services and state the relationship that this person has with your Organization by indicating if they are a subcontractor, employee or neither of these. All therapists are required to be STAR Health providers.

16. 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

17. 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.

18. 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 https://www.dfps.texas.gov/Doing_Business/Purchased_Client_Services/Residential_Child_Care_Contracts/documents/24_Hour_RCC_Requirements.pdf.

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

20. 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

21. What is the level of experience (in months and/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

Comptroller/CFO

Program Director

Treatment/ Clinical Director

LCCA or LCPAA

22. 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.

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

Direct Care Staff and Foster Parents

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

25. Provide the number and type of currently verified foster homes and/or homes pending verification for your CPA effective as of the date of this Application.

Foster Family Home Providing Residential Child-Care Services and Programmatic Services Only

Foster Family Home Providing Treatment Services

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.

Attach the following additional financial documents:

Bank statements for the most recent 3 months Projected 12-month budget Balance sheet (statement of financial position) Income statement

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.

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

01.E-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

Yes, if applicable.

Yes, if applicable.

FILE FOLDER 3: Required Forms

To complete the below, see definition of Principal in the Requirements at https://www.dfps.texas.gov/Doing_Business/Purchased_Client_Services/Residential_Child_Care_Contracts/documents/24_Hour_RCC_Requirements.pdf

Document Location Electronic File Name

Document Is Document Required Yes/No

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.

1. A valid HHS License or CCR acceptance letter.

2. Complete set of program policies and procedures, model and philosophy, including a substance abuse policy that indicates the Applicant will ensure substance abuse services will be provided for the Child, if needed. Substance abuse services can include referrals to outpatient/inpatient programs in the community, or substance abuse services provided through the Applicant's CPA.

Submit all of your CPA’s Policies and Procedures.

3. Description of all program components to include behavioral and therapeutic interventions.

4. Children’s rules, rewards, consequences and/or orientation manual/handbook.

5. Example of daily schedules for school year, summer and weekends.

6. Example of recreation schedule.

7. Description of recreational program including its therapeutic value.

8. Written description of the relationship with the school system or a written agreement between the Applicant and the school district.

Information needed includes an outline of the Applicant's responsibilities including procedures for resolving conflicts occurring during school activities.

9. Written plan to provide direct, continuous observation of a Child who may be at risk for harming self or others and to provide awake night staff if indicated based on the needs of the Child.

10. Professional staffing plan to include responsibility for developing diagnostic assessments and treatment plans.

11. Training schedule for foster parents to complete annual training requirements.

12. Contracts, agreements or plans for professionals providing medical, dental and therapy services.

13. Contracts, agreements or plans for professionals to provide psychotropic medication training and medication monitoring and on-call/emergency services.

14. Example of a Child’s Record to include a sample of:

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 and school reports;

f. Medication monitoring reports;

g. Serious incidents reports;

h. Case management notes; and

i. Daily logs or documentation by foster parents.

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 and School reports;

f. Medication Monitoring reports;

g. Serious Incidents reports,

h. Case Management Notes;

i. Daily logs or Documentation by Foster Parents Yes

DFPS CPA New Applicant Open Enrollment Application HHS0014286 image1.wmf