Supervised Visitation Provider Packet.xlsx

XLSX spreadsheet 130 KB Posted Sep 23, 2026

Attached to: Supervised Visitation Services
Solicitation number: RFA - 10A - 202608134
Issued by: York County, Maine

About this file

Written by GovTribe AI · Sep 28, 2026

This is a provider packet for supervised visitation services submitted to the Maine Department of Health and Human Services, Office of Child and Family Services (DHHS/OCFS). The packet serves as a quarterly reporting and attestation document for contracted supervised visitation providers delivering family visitation program services. Providers must complete all sections of the packet and submit within 30 days of each quarter end. Required quarterly submissions include a Performance Measure Report, Staff Report, and Supervised Visitation Narratives, with monthly invoice reports submitted alongside invoices and an Annual TANF Report submitted yearly. The contract term spans two years with eight reporting quarters, each with specific performance metrics tracked across four key measures: scheduling referrals within required timeframes, safety interventions, service authorization compliance, and in-home visitation provision.

The Performance Measure Report tracks four primary metrics with defined targets: 90 percent of completed referrals must offer at least three available visit times within three business days of referral; 100 percent safety intervention when visits are compromised; 100 percent of appropriate referrals receiving services up to authorized units; and 70 percent of department-requested referrals provided in the home. Providers must report numerators, denominators, and actual percentages for each quarter. The packet requires detailed documentation of supervised visitation activities including visit narratives with client information, visitor engagement observations, teaching prompts, safety interventions, and post-visit feedback. Direct service hours are billed in quarter-hour increments and include face-to-face contact, case conferences, court time, documentation, and service coordination. No-show visits cancelled by parties other than the provider within 24 hours may be billed for one hour plus additional time based on scheduled length. The Annual TANF Report requires program description, internal control verification procedures, and reconciliation of expenditures, with a threaded comment questioning continued TANF funding allocation for this service.

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Other files

File	Type	Posted
SV Application Response Form.docx	DOCX document	Sep 23, 2026
RFA 202608134 Supervised Visitation_FINAL.docx	DOCX document	Sep 23, 2026

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1. Attestation & Signature Page

DHHS/OCFS PROVIDER PACKET
*Do not create additional tabs to this document*
PROVIDER NAME:		QUARTER BEING REPORTED:
AGREEMENT #:		DATE COMPLETED:
VENDOR CODE:
SERVICE GROUP:	FAMILY VISITATION PROGRAM - SUPERVISED VISITATION

Dear Provider, This Provider Packet collects information that is required as part of your Agreement with OCFS. Please complete all shaded gray areas of this form before submitting. You will also complete each tab with the requested information and submit any other required material listed below in the supplemental information area. A list of due dates has been provided below. This information must be reported no later than 30 days from the end of each quarter.

Once complete, you will submit by email to the Contract Administrator listed in your Agreement along with the following: OCFS-PMR.DHHS@maine.gov and Program Manager. We thank you for your efforts in providing this information to ensure compliance with your OCFS contract.

	QUARTERS REPORTED:	DUE BY:
Y1-Q1:	MM/DD/YYYY to MM/DD/YYYY	MM/DD
Y1-Q2:	MM/DD/YYYY to MM/DD/YYYY	MM/DD
Y1-Q3:	MM/DD/YYYY to MM/DD/YYYY	MM/DD
Y1-Q4:	MM/DD/YYYY to MM/DD/YYYY	MM/DD
Y2-Q1:	MM/DD/YYYY to MM/DD/YYYY	MM/DD
Y2-Q2:	MM/DD/YYYY to MM/DD/YYYY	MM/DD
Y2-Q3:	MM/DD/YYYY to MM/DD/YYYY	MM/DD
Y2-Q4:	MM/DD/YYYY to MM/DD/YYYY	MM/DD

REQUIRED REPORTS:	WHEN TO PROVIDE:
Performance Measure Report	QUARTERLY
Staff Report	QUARTERLY
Supervised Visitation Narrative	Within 5 business days of Visit
Supervised Visitation Monthly Invoice Report	MONTHLY WITH INVOICE
Annual TANF Report	ANNUALLY

I,	the undersigned on behalf of	0
attest the information included is true to the best of my abilities and knowledge. I do attest to the agency being in compliance with all Federal and State rules and regulations and adherence to all agency established policies and procedures.

Electronic Signature:

Date:

2. Performance Measure Report

0	QUARTER BEING REPORTED:	0
0	DATE COMPLETED:		MM/DD/YYYY to MM/DD/YYYY	MM/DD/YYYY to MM/DD/YYYY	MM/DD/YYYY to MM/DD/YYYY	MM/DD/YYYY to MM/DD/YYYY	MM/DD/YYYY to MM/DD/YYYY	MM/DD/YYYY to MM/DD/YYYY	MM/DD/YYYY to MM/DD/YYYY	MM/DD/YYYY to MM/DD/YYYY
			YEAR 1 - QUARTER 1	YEAR 1 - QUARTER 2	YEAR 1 - QUARTER 3	YEAR 1 - QUARTER 4	YEAR 2 - QUARTER 1	YEAR 2 - QUARTER 2	YEAR 2 - QUARTER 3	YEAR 2 - QUARTER 4

Performance Measure

Numerator Definition

Denominator Definition

Target %

District

Q3 Numerator

Q3 Denominator

Actual %

Q4 Numerator

Q4 Denominator

Actual %

Q4 Numerator

Q4 Denominator

Actual %

Q4 Numerator

Q4 Denominator

Actual %

Q3 Numerator

Q3 Denominator

Actual %

Q4 Numerator

Q4 Denominator

Actual %

Q4 Numerator

Q4 Denominator

Actual %

Q4 Numerator

Q4 Denominator

Actual %

Ninety percent 90% of completed Supervised Visitation referrals must have offered within 3 business days at least three (3) available times for a Visit to be conducted within seven (7) calendar days.

The number of visits that were scheduled within seven (7) calendar days this quarter.

The total number of referrals completed this quarter.

90%

ERROR:#DIV/0!

Supervised Visitation workers must intervene one hundred percent (100%) of the time when Safety is compromised to ensure Visits are emotionally and physically Safe.

The number of safety interventions used by a worker during visits this quarter.

The total number of safety issues, that require safety intervention, during visits this quarter.

100%

ERROR:#DIV/0!

100% of appropriate referrals will receive services up to the maximum number of authorized units.

The total number of appropriate referrals who receiced services up to the maximum number of authorized units this quarter.

The total number of appropriate referrals received this quarter.

100%

ERROR:#DIV/0!

70% of all Supervised Visitation, when requested by the Department, will be provided in the home.

The total number of Department requested referrals to be provided in the home that were provided in the home this quarter.

The total number of Department referrals requested to be provided in the home this quarter.

70%

ERROR:#DIV/0!

4. Staff Report

PROVIDER NAME:	0			QUARTER BEING REPORTED:	0
AGREEMENT #:	0			DATE COMPLETED:
STAFF REPORT
STAFF MEMBER NAME:	POSITION TITLE:	DEGREE:	VALID

STATE

DRIVERS LICENSE

Y/N (If applicable to position) YEARS OF EXPERIENCE WORKING WITH YOUTH: STAFF

CONTACT

PHONE: STAFF CONTACT EMAIL: NOTES REGARDING ANY CHANGES IN INFORMATION FROM PREVIOUS QUARTER:

Narrative

SUPERVISED VISITATION NARRATIVE
CLIENT CASE ID:	DATE OF VISITATION:
AGENCY CASE ID #:	AGENCY:
SCHEDULED START TIME:	SCHEDULED END TIME:
ACTUAL START TIME:	ACTUAL END TIME:
LOCATION:	VISIT SUPPORT WORKER (VSW):
IF VISIT DID NOT OCCUR, STATE REASON:
ADULTS IN ATTENDANCE AND ROLE:
CHILD(REN) IN ATTENDANCE:
PRE-VISIT PLANNING DISCUSSION:
DESCRIBE THE INTERACTIONS BETWEEN VISITORS AND CHILD(REN) AT THE START AND END OF THE VISIT:

DESCRIBE THE LEVEL OF ENGAGEMENT BETWEEN VISITORS AND CHILD(REN) THROUGHOUT THE VISIT:

NUMBER OF TEACHING PROMPTS DURING THE VISIT:

DESCRIBE TEACHING PROMPTS:

NUMBER OF SAFETY INTERVENTIONS:

DESCRIBE INTERVENTIONS NEEDED TO ENSURE CHILD(REN)'S PHYSICAL OR EMOTIONAL SAFETY:

DESCRIBE VISITOR'S PARTICIPATION IN AND RESPONSE TO IN THE MOMENT AND POST VISIT FEEDBACK:

IF THE VISIT WAS TERMINATED, EXPLAIN THE CIRCUMSTANCES RESULTING IN TERMINATION:

NOTES REGARDING ANY ADDITIONAL COMMUNICATION WITH PARENTS OUTSIDE OF THE ACTUAL VISIT:

NEW INFORMATION ABOUT THE PARENTS AND/OR CHILD(REN) THAT MAY BE HELPFUL FOR FUTURE VISITS:

				Pg 2
CLIENT CASE ID:	0	DATE OF VISITATION:	12/31/1899
AGENCY CASE ID #:	0	AGENCY:	0

5. Mnthy Supervised Invoice Rep

PROVIDER NAME:	MONTH BEING REPORTED
AGREEMENT #:

Definition of Direct Service Staff Hours:
	Direct service hours are reported as Units of service in one-quarter hour (15 minute) increments and include:
	1.	Actual time spent working with the family (i.e. face to face and telephone contacts, and collateral contacts, as needed to arrange visitation). The nature of telephone and collateral contacts will be documented in writing and maintained in the client file;
	2.	Actual time spent in case conferences with Department staff;
	3.	Actual time spent participating in multi-disciplinary telephone conferences scheduled by Department staff;
	4.	Actual time spent in court, as well as the actual travel time to and from court;
	5.	Actual time spent preparing and submitting video documentation (approximately fifteen [15] minutes/visit);
	6.	Actual time spent attempting to provide service (waiting for client for prearranged visit, rescheduling visits, etc.);
	7.	Actual time spent documenting reportable incidents and interventions;
	8.	A no-show or visit cancelled by someone other than the Provider in less than twenty-four (24) hours of the scheduled start time may be billed for one (1) hour and half of any additional time over one (1) hour based on the length of the scheduled visit. (In addition to the time billed for attempting to provide the service, as defined above.)

SUPERVISED VISITATION

MONTHLY INVOICE REPORT

	District	Child/ren Name(s)	KatahdinCase ID#	Referral
Date	Who visited with (mother, father, etc.)	Date of first visit
	Total

Billable

Units	Visit
Hours	Initials of Staff

During

Visit	Visitor Role	Number of Interventions	NO SHOW
(X)	Cancelled

by Other (List Reason) Cancelled by Client

(X) Cancelled by Provider

(X) Cancelled by Dept.

(X)	Documentation
TIME in UNITS	Other

Admin

TIME in UNITS	Coordination with Other
TIME in UNITS	FTM
TIME in UNITS	Court Prep
TIME in UNITS	Court Testimony
TIME in UNITS	Transportation
(PARENT)	Transportation

(CHILD/REN)

6. Annual TANF Report

Contract #	0
Vendor Name	0
Funding Source
CFDA Number
Program/Service Description and Use of Funds

tc={748A5335-A21E-41F7-AA74-73B0EB218186}: [Threaded comment]

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Comment:

Are we still using TANF funds for this?

A. Please provide a desciription of the program/service this grant will fund and how these funds will be used.

B. Please provide a description of your internal controls that you will use to verify accuracy of data collected then subsequently reported.

C. Please provide a description of how you anticipate the use of funds to meet the federal block grant's purpose, and parameters.

Additional information needed per quarter	Y1 Q1	Y1 Q2	Y1 Q3	Y1 Q4	Y2 Q1	Y2 Q2	Y2 Q3	Y2 Q4
Total Expenditures:
Expenditures spent on clothing:
Expenditures spent on food:

Are we still using TANF funds for this?

File details come from the government source that posted it. Updated Sep 28, 2026.