Agreement with Starlight Adolescent Center, Inc.
AGREEMENT BETWEEN THE COUNTY OF SANTA CLARA
AND STARLIGHT ADOLESCENT CENTER,INC.,
FOR PROVISION OF MENTAL HEALTH SERVICES
FOR FISCAL YEAR JULY 1,2000, THROUGH JUNE 30,2001
THIS AGREEMENT("Agreement'*)is entered into at San Jose, California, between County
of Santa Clara ("County"), a political subdivision ofthe State of California, and Starlight Adolescent
Center,Inc., a for-profit corporation ("Contractor"). The purpose ofthis Agreement is the provision
of mental health services to residents of County,pursuant to statutes and agreements-with the State
of California. The parties agree as follows:
1.
OBLIGATIONS OF CONTRACTOR
1.1.
Services and Standards. Contractor agrees to supply the services described
in Exhibit A,in the amounts detailed in Exhibit B, which are incorporated herein by reference.
Contractor agrees that services shall be provided throughout the year as indicated in Exhibit A.
Contractor shall provide services to the patient population described in Exhibit A. The parties agree
that any distribution of services between the client categories set forth in Exhibit A i
is
programmatically significant. Contractor further agrees to maintain, at a minimum, the staffing
necessary to meet government licensing and certification requirements and to fulfill program
obligations under this Agreement.
1.2.
Space and Supplies. Contractor will furnish all space, utilities, equipment,
and furniture necessary to provide the services described in this Agreement(including Exhibit A)
at iic v)va.5 expense, except as may be approved by the Mental Health Director. Contractor agrees to
cie.ii! and maintain such space in an appropriate manner.
1.3.
Compliance With Law.
1.3.1.
Licensure. Contractor agrees that all facilities and staff
including, but not limited to, all professional and paraprofessional staff used to provide services will
maintain throughout the term of this Agreement and any extensions thereof, such qualifications,
licenses and/or permits as are required by State or local law or are necessaiy to receive payment from
the Federal government under the Medicare or Medicaid programs. The parties agree that failure
to comply with this provision shall be considered a material breach of this Agreement.
1.3.2.
Compliance with Medicare Rules. Contractor agrees to
comply with the requirements of the Medicare Act,42 U.S.C. section 1395 et sea, and regulations
and niles promulgated by the Health Care Financing Administration,as they relate to conditions of
certification, coverage and reimbursement. To the extent that County develops procedures for
implementing these requirements. Contractor shall follow such procedures. Contractor shall become
responsible for compliance with any changes or new procedures developed by County thirty days ;
after the date of notice ofthe terms ofsuch changes or new procedures, provided however that if an
earlier compliance date is required by federal, state or local regulation, Contractor shall be
responsible for compliance on the date specified in the federal, state or local regulation.
1.3.3.
Compliance with Medi-Cal Rules. Contractor agrees to
comply with the requirements imposed by statutes, regulations and rules governing certification,
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1
■^4
coverage and reimbursement by Medi-Cal, including but not limited to the applicable provisions of
the California Welfare and Institutions Code, Title 22 of the California Code of Regulations, the
Federal Medicaid Act, Title XJX of the Social Security Act, 42 U.S.C. section 1396 ets^., and any
applicable regulations promulgated thereunder. To the extent that County develops procedures for
implementing these requirements. Contractor shall follow such procedures. Contractor shall become
responsible for compliance with any changes or new procedures thirty days after the date of notice
of the terms of such changes or new procedures, provided however that if an earlier compliance date
is required by federal, state or local regulation. Contractor shall be responsible for compliance
the date specified in the federal, state or local regulation.
1.3.4.
—
on
Compliance With Other Laws. Contractor agrees to provide
services under this Agreement in accordance with the Bronzan-McCorquodale Act (Welfare and
Institutions Code section 5600 etseq.) and any regulations promulgated thereunder; the applicable
provisions of the Welfare and Institutions Code, Health and Safety Code, and Titles 9 and 22 of the
California Code of Regulations; the ordinances and resolutions of the County of Santa Clara Board
of Supervisors and the applicable policies, procedures and guidelines of County of Santa Clara,
Health and Hospital Systems, Mental Health Department; any State policies as identified in the State
Department of Mental Health or Department of Health Services Letters and in the Cost
Reporting/Data Collection Manual, and any other applicable provision of law or regulation. This
obligation specifically includes an agreement by Contractor to honor the patient's rights set forth in
the above referenced statutes and regulations.
Compliance with Grant Agreements. Contractor shall comply
with the terms of federal and State funding contracts in which the County is a Grantee, and said
1.3.5.
contract provisions shall be deemed a part of this Agreement as if fully set forth herein. ’
1.3.6.
Debarment and Exclusion Provisions. Contractor certifies that
Contractor or its employees, subcontractors or agents have not been convicted of a criminal offense
related to health care nor is Contractor or its employees, subcontractors or agents listed by any
federal or state agency as debarred, excluded or otherwise ineligible for participating in federal or
slate funded health care programs. Contractor agrees that if criminal charges are brought or
debarment or exclusion sought of Contractor or its employees, subcontractors or agents providing
services under this Agreement, the same shall be removed from any responsibility for or involvement
in the provision of services under this Agreement during the pendency of such proceedings and that
Contractor shall notify the County of the pendency of such charges or proposed debarment or
exclusion. Contractor shall indemnify, defend, and hold harmless County for any loss or damage
resulting from Contractor or its employees, subcontractors or agents’ debarment or exclusion.
1.3.7.
Prohibitions on Conflict of Interest and Referrals. In addition
to County's and Contractor’s obligations to comply with applicable federal, state and local laws
respecting the conduct of their respective business and profession. County and Contractor
acknowledge that they are subject to certain federal and state laws governing Conflict of Interest and
Referral of Patients which are in effect or will become effective during the term of this Agreement.
Contractor shall comply with such laws. These laws include prohibitions on:
(1)
Payments for referral or to induce the referral of patients (Cal.
Business and Professions Code section 650; Cal. Labor Code section 3215; and section 1128B of
the Social Security Act); and
(2)
The referral of patients by a Contractor or its employees,
subcontractors or agents for certain designated health care services to an entity with which the
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2
Contractor or its employees, subcontractors or agents (or the referring party’s immediate family)
have a financial relationship (Cal. Labor Code sections 139.3 and 139.31, applicable to referrals for
workers' compensation services; Cal. Business and Professions Code sections 650.01 and 650.02
applicable to all other patient referrals within the State; and section 1877 ofthe Social Security Act,
applicable to referrals of Medicare and Medi-Cal patients.)
1.4.
Staff Training. Contractor shall implement and maintain an in-service
training program in which all of the personnel designated on Exhibit A as "professional" shall
participate. Such in-service training program will, at a minimum, cover: (a)treatment review,
(b) case conferences, and (c) confidentiality of client information. In addition, all personnel
providing social services or mental health services will receive training regarding the special needs
and circumstances of persons with disabilities including Acquired Immune Deficiency Syndrome
("AIDS") or AIDS Related Complex ("ARC").
1.5.
Admission Procedures. Contractor shall maintain its client admissions
procedures and eligibility criteria in writing and shall make such procedures and eligibility criteria
available to the public upon request. Such procedures shall be in conformance with the Welfare and
Institutions Code section 5600 et seq.
1.6.
Consent for Treatment. Contractor agrees to obtain a consent to treat each
client covered by this Agreement using a legally adequate consent forai in a specific form or format
pursuant to California Welfare and Institutions Code section 5326.2 or any other statute or
regulation.
1.7.
Maintenance and Confidentiality of Records.
1.7.1.
Maintenance of Records. Contractor shall maintain adequate
-’mical and/or rehabilitation records on each client as indicated by program type. Such
.'.ii, at a minimum, include (a) diagnostic studies, if applicable,(b)a description of the
: ior each patient's care, (c) documentation describing services provided by various
protessionals and paraprofessionals, and (d) documentation regarding client interviews and/or
progress notes. Contractor agrees to maintain such records in the form determined or approved by
the State of California or by the County Director of Mental Health (“Director”). Moreover,
'
t -1 .-
O'
Contractor commits that such records shall be in sufficient detail to facilitate evaluation of the
sewices provided pursuant to this Agreement and shall contain all data necessary to prepare any
reports required by the State Department of Mental Health.
1.7.2.
Record Retention. Contractor shall maintain Client medical
and or clinical records as required by the California Code of Regulations or any other applicable
statuies or regulations. At a minimum,records shall be retained for adult clients for a period often
years from the date of discharge, and records of persons who are under the age of 18 at the time of
treatment shall be retained until either (a) one year beyond the patient's 18th birthday or (b) for a
period often years from the date of discharge, whichever is later. Contractor shall maintain the
rec:>rds longer if required by law.
1.7.3.
Confidentiality. Contractor shall maintain the confidentiality
of die medical and psychiatric records of clients as required by State or Federal law including, but
not inniied to, California Welfare and Institutions Code section 5328 et seq.. California Evidence
Cod
e section 1010 et.. seq. and 45 C.F.R. section 205.50. Contractor shall only disclose such
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3
information as authorized by law. Within the confines ofthe foregoing. Contractor agrees to provide
information regarding particular clients to qualified professional persons having medical or
psychological responsibility for a client’s care, or for use in conservatorship proceedings.
1.7.4.
Access to Records At Conclusion of Agreement. When this
Agreement expires or is terminated by either party, and is not immediately renewed or extended all
client records shall be delivered by Contractor to County within fifteen (15)working days ofthe ite
of termination upon County’s request. Client records for this purpose shaft include all
medical/clmical records, utilization and peer review records, medication monitoringTecords, and all
fiscal records related to funding received under this Agreement unless Contractor is otherwise
required by law to retain such records. If Contractor is required to retain such records, Contractor
agrees to supply copies of the records to County and to allow inspection ofthe original records by
County upon request. .Although Contractor shall, in this event, have possession of client records and
information. County shall own all such information and records notwithstanding the provisions of
paragraph 1.11.2 below.
1.8.
Financial and Statistical Records. Contractor shall maintain all financial
statistical or accounting records, associated with the provision of each type of service described in
Exhibit A of this Agreement, necessary to support the cost report prepared pursuant to paragraph
2.11 ofthis Agreement. Moreover, Contractor shall maintain
all statistical data necessary to support
the allocation of such costs among programs or types of programs and/or among payers, and shall
maintain auditable records, in accordance with generally accepted accounting principles, reflecting
the methods and calculations used to make such allocations, and such other statistical data as shall
be necessary to satisfy the requirements of State or Federal law. Contractor agrees to maintain such
data in a format specified by the State of California or by the Director.
1.8.1.
Maintenance ofFinancial Records. Contractor shall maintain
such financial records for a period of seven years from the later of the following events;(a) the
termination or expiration of this Agreement, (b)the audit or final settlement of County's
Contractor’s claim for payment by Medi-Cal, if the results of such audit or settlement are not
or
appealed, or(c)the completion of an appeal by County of any adjustments or disallowance made by
a third-party payer on audit. If there is a dispute, audit, or inspection, records must be retained
beyond seven years until the dispute, audit, or inspection is resolved. Contractor shall be responsible
for any disallowances related to inadequate documentation.
1.8.2.
Access to Records, Facilities and ProCTams. Contractor agrees
to allow the Director, and/or any designated auditor of County, the State of California, including but
not limited to officials from the State Department of Mental Health or the. State Department of
Health Services, or any designated official ofDepartment of Health and Human Services or the fiscal
intermediary, or the Comptroller General of the United States, the right to inspect or otherwise
evaluate the cost, quality, appropriateness, and timeliness ofservices performed,to audit and inspect
any books and records of Contractor which pertain to services performed and/or determination of
the amounts payable under this Agreement, and the right to have reasonable access to facilities,
programs, staff, clients/patients, or other material
or
persons such officials deem necessary to
monitor or audit services rendered. Except as otherwise provided in state or federal law, such access
shall be provided during Contractor's normal business hours upon proper notice. (See also paragraph
1.14. below.) ■
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4
1.8.3.
Retention and Disclosure of Records. For the purposes of
implementing Section 1861(v)(l)(I) ofthe Social Security Act, as amended, and any written
regulations thereto. Contractor agrees to comply with the following statutory requirements
governing the maintenance of documentation to verify the cost ofservices rendered under this
Agreement, (a) Until the expiration offive years after the furnishing of such services pursuant to
this Agreement, Contractor shall make available.. upon written request to the Secretary of the
Department of Health and Human Services (the "Secretary") or upon request to the Comptroller
General, or any oftheir duly authorized representatives, the contract, and Contractor's books,
documents and records that are necessary to certify the nature and extent ofsuch costs, and (b)If
Contractor cames out any of the duties of this Agreement through a subcontract with a value or
cost of $10,000 or more over a tM'elve month period with a related organization, such subcontract
shah contain a clause to the effect that until the expiration offive years after the furnishing of
such services pursuant to such subcontract, the related organization shall make available, upon
written request to the Secretary, or upon request to the Comptroller General, or any oftheir duly
authonzed representatives, the subcontract, and books, documents and records of such
organization that are necessary to verify the nature and extent of such costs.
1.9.
.
..
Disclosure of Violations and Unu.sual Incidents.
. ^-9-1- Contractor shall notify the Director, by telephone, ofthe violation
of any provision ofthis Agreement within 24 hours ofobtaining reasonable cause to believe that a
violation occurred. Notice ofsuch violation shall be confiimed by delivery to the Director within
72 hom-s ofobtainmg reasonable cause to believe that such violation occurred, a written notice which
.shall describe the violation in detail.
1.9.2. Contractor shall comply with County policies and requirements
reporting of unusual occurrences and incidents.
1.10.
,
.
Treatment of Unsponsored Clients.
1.10.1.
Pursuit of Sponsorship. Contractor shall determine
at or
aooui the time a new client is accepted for services, the existence ofany third party which is or may
become responsible for paying for all or part of the client's services including, but not limited to
Medicare, Medi-Cal or private insurance. Contractor shall make reasonable and consistent efforts
to deienmne possible sponsorship by a third party and shall document such efforts. In the event that
Contractor determines that the client is potentially eligible to have a third party pay for services
Conu-actor shall assist the client in applying for such benefits and in diligently pursuing such
appncation. Failure to comply with the provisions ofthis section shall be deemed a material breach
of th.i3 Agreement.
1.10.2.
Definition of Unsponsored Clients. An individual will not be
considered an eligible unsponsored client for purposes of reimbursement under this Agreement
unle.ss the provisions ofparagraph 1.10.1 have been met in his or her particular case. A patient who
IS gtijerally eligible to have a tlurd party pay for his or her care but who receives services which are
the scope of coverage of such third party may be considered unsponsored. Moreover, if
Contractor can demonstrate, through adequate documentation, that a client is unwilling to cooperate
out.
with the application for benefits from a third party payer, such client will also be considered
unsponsored.
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1.11.
CountY Client Tracking and Services System1.11.1.
Use of County Client Tracking and Services System. In
recognition of the fact that County's electronic client tracking and services system ("OSCAR
System )is a critical source ofinformation for purposes of monitoring the provision of services and
for obtaining payment for such services. County shall provide Contractor access to such system at
Contractor’s expense. Contractor shall supply such data as the Director may periodically designate,
and input such data into the OSCAR System. Data regarding each client service shall be input within
two (2)business days ofthe date that such services are rendered. The parties agree that, in the event
Contractor cannot satisfy this requirement because the OSCAR system is malfhnctioning, Contractor
shall not be in breach of this Agreement.
1.11.2.
Ownership. County shall be deemed the owner of all data
processing procedures for the OSCAR System including, but not limited to, the computer program,
documentation ofthe programs, computer manuals, and computer program descriptions. Client data
and information entered by Contractor into the OSCAR System and any statistical reports generated
from such system utilizing such information shall be co-owned by Contractor and County during the
term of this Agreement. Upon termination. Contractor may retain a copy of records but will no
longer have access to the OSCAR system or programs. Contractor shall own all original client charts
and other individual client documentation not duplicated in the OSCAR System, except as provided
in paragraph 1.7.4 of this Agreement. Contractor agrees to make available to County, upon its
request, electronic or hard copies of any records or statistical reports generated by Contractor from
the OSCAR System.
1.11.3.
Limitations On Access To Information. Contractor shall not
access client specific information in the OSCAR System except in the following instances:
(a) where the information pertains to a client for whom Contractor has medical or psychological
responsibility for care;(b) where the information pertains to a client for whom or concerning whom
Contractor has obtained consent to access information from the client or his or her guardian or
conservator, or substituted consent in the case of a minor, except when otherwise limited by law; and
(c)information which Contractor is otherwise entitled to access under California Welfare'and
Institutions Code section 5328 ejseq. and section 5510 et seq. For purposes ofsubparagraph (b).
Contractor agrees to utilize a legally adequate consent form and to make available to County any
completed forms upon request. Notwithstanding any other provisions of this Agreement, it is
understood that Contractor shall not use the OSCAR System for services provided outside of this
Agreement.
1.11.4.
Limits on Persons With Access. Contractor shall restrict use
of the OSCAR System to employees of Contractor who have completed County's confidentiality
training program and have been issued individual passwords for the system. Nothing in these
provisions shall be construed to prevent an employee who has properly obtained information from
the OSCAR System from making such information available to another employee of Contractor who
is entitled to receive information under paragraph 1.11.3.
1.12.
Certified Audit.
Within one hundred and twenty (120) days of the
termination date of this Agreement, and within one hundred and twenty (120)days of any June 30
occurring during the period of this Agreement, Contractor shall frimish to Director the report of an
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6
audit of Contractors financial records for the period covered since the commencement of the
Agreement or the last audited period, whichever is later, as well as a financial statement for that
_
period, prepared by a Certified Public Accountant, or with the Director's wTitten permission, a Public
Accountant. Extensions of this Agreement shall not extend the date by which this material must be
submitted. Extensions of time to submit the certified audit report and financial statement will be
given where such audit is delayed by County's failure to provide necessary information and may be
granted in other instances at the sole discretion of the Director. Contractor requests for such
extensions must be made,in writing, at least 10 working days prior to the date on which the certified
audit report is due.
1.13.
—’
Performance Outcomes and Client Satisfaction. All Contractors will
comply with State Department of Mental Health performance outcome measurement requirements
and County performance indicators for each mode ofservice as specified in Exhibit E.
1.14.
Contracting Principles. This contract is a Type II service contract subject
to the Resolution of Contracting Principles (Resolution) adopted by the Board of Supervisors on
October 28, 1997. Accordingly, Contractor shall comply with all ofthe following during the term
of this contract:
(a) Contractor shall comply with all applicable federal, state, and local
rules, regulations, and laws.
(b) Contractor shall maintain financial records adequate to show that
County funds paid under the contract were used for purposes consistent with the terms of the
contract. These records shall be maintained during the term ofthis contract and for a period defined
in paragraph 1.8.1.
>1.-
(c) To enable County to determine compliance with the requirements of
i iion and this contract Contractor shall, through its designated representatives, provide to
s designated agents reasonable access to facilities, records, and employees used and
j -n conjunction with the provision ofservices under the contract, except where such access
IS prohibited by federal or state laws, regulations, or rules,
(d) Contractor shall provide to the County Department/Agency
responsible for monitoring the contract, within a reasonable amount of time from receipt by
Contractor of the County’s request for information, with copies of any and all financial audits
completed dunng the term ofthe contract. For the purposes ofthis section, financial audit includes
any final audit report transmitted to Contractor by the auditor, but does not include draft reports,
(e) Contractor shall use County funds paid under this contract for County
services and .shall not use County funds for general employer costs that do not support or otherwise
directly relate to the scope of contracted services. Consistent with the legal and financial provisions
of this contract, this requirement shall not preclude the realization of profit or savings.
^
(f) Contractor shall promptly advise the County DepartmentyAgency
responsible for monitoring the contract of:(1)the issuance of any legal complaint by an enforcement
agency, or of any enforcement proceedings by any Federal, State or Local agency for alleged
violations of federal, state or local rules, regulations or laws, and/or (2) the issuance of citations,
court findings or administrative findings for violations of applicable federal, state or local rules,
regulations, or laws.
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7
(g) As required under the Resolution and the County’s implementing
procedures. Contractor provided to County as a part of the selection process certain information
pertaining to the provision of services under this contract and/or expenditures to be charged under
the contract, including information concerning wages and benefits for Contractor’s employees,
length of service, staff turnover and training, complaints (if any) regarding legal violations, and
collective bargaining agreements and/or personnel policies. Contractor warrants and represents that
the information so provided was complete and accurate.
The failure of Contractor to comply with this Section or any portion thereof, and/or the
breach of Contractor’s warranty thereunder, may be considered a material breach oftills contract and
may, at the option of the County, constitute grounds for the termination and/or non-renewal of the
contract. Contractor shall be provided reasonable notice of any intended termination or non-renewal
on the grounds of noncompliance with this Section, and the opportunity to respond and discuss the
County’s intended action.
2.
COMPENSATION AND BILLINGS
2.1.
Client Financial Responsibility2.1.1.
Determination of Client Financial Responsibility. Contractor
shall determine the personal fmancial liability ofeach client for whom services are provided pursuant
to the Uniform Method of Determining Ability to Pay ("UMDAP") established by the State
Department of Mental Health. Contractor may make therapeutic adjustments to the amount of
client's liability provided that they are consistent with County guidelines. However,in no event shall
the client's fmancial responsibility exceed the actual cost of providing services as determined in the
cost report submitted pursuant to paragraph 2.11 below.
2.1.2.
Entering Client Financial Information Into OSCAR Sv.stem
Contractor shall complete a Payer Financial Form, developed by the State Department of Mental
Health, for each client and shall maintain such form with the client's records and shall enter such
information into the OSCAR system as the Director prescribes.
Collection of Client Financial Responsibility. Based on information input
by Contractor into the OSCAR System on the amount of each client’s liability as determined under
UMDAP,including any therapeutic adjustments consistent with paragraph 2.1.1, Contractor shall
generate a bill for such liability and deliver it to the client or appropriate third party (parent,
2.2.
representative payee, conservator, etc.). Contractor will assist the client or third party in
understanding such bill and in remitting payment. If Contractor has been reimbursed by County for
services for which UMDAP payments have been collected. Contractor shall deduct the
amounts
collected from Contractor’s claim for reimbursement submitted to County.
2.3.
Billings to Medicare for Patient Services. Notwithstanding the provisions
of paragraph 2.2, Contractor shall bill the Medicare program for those services rendered by
Contractor to Medicare beneficiaries which are within Medicare’s scope of covered
services.
Contractor agrees not to charge beneficiaries for such services. Contractor shall bill Medicare
beneficiaries for their personal fmancial liability detemiined under UMDAP. Contractor will make
reasonable efforts in collecting such UMDAP amounts.
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8
2.4.
Bliiingltojvledi-Cal. County will bi]] the Medi-Cal program on behalf of
Contractor for services rendered to
. Medi-Cal beneficiaries which- are within the scope of Medi-Cal
covered services,
using tne provider number assigned by the Medi-Cal program
Contractor shall make eveiy reasonable effort
services.
r
to Contractor,
to maximize billing to Medi-Cal program for eligible
2.5.
•n
Third-Party_^aygrs. Contractor will bill any entitv
financially responsible for all or part ofthe client’s
health care services(third-party payers) and may
m am any amounts collected as a result ofsuch billing. However,if Contract^h^ren pald^y
amn
^ collected ffom Contractor’s
^h^ch third-party
are collected, Contractor shall deduct the
mounts
claim payments
for reimbursement
from County. To the extent that
County reimburses Contractor for services covered and paid by a third party payer. County shall
recoup such reimbursement or offset from amounts owed to Contractor.
,
, ,
Contractor agrees to retain documentation relating to billines to and
payments, whether full or partial, from third party payers and to make such information amiable
County upon reasonable request, in the marmer specified by County.
2.6.
■ u
^
to
Compensation for Serviee.s
^
2.6.1.
Maximizing FTP Reimbursement. In order to maximize
reimbmsement from Federal Financial Participation / Medi-Cal(FFP), the parties agree that ftmds
be used first to match for services
toto Medi-Cal
Med^rf""
County’s
Obligation
patients
andMaximum
only thenFinancial
will be used
to pay will
for the care of patients determined to be
Fo^P-POsesofthi-s Agreement, unitsofsei^iL
Reporting Data Collectic^(cS^DQ 1110^
tom “
Cost
Total
to
P , ,,
,
Maximum Medi-Cal Revenue Pa.ss-fhmnpt. Obligation
Contractor s pass-through revenue frciiTMedi-Cal
m County s Total Financial Obligation; provided, however, that the Director ofMental Health shall
P
2.7.
^ 1 r u,
AcceptanctypfJ^. Contractor acknowledges that, in no event shall
Trerarf'
'°f7"'°7
Obligation as set forth on Exhibit B
The parties acknowledge
and agree that Contractor remains obligated
to provide the level ofservices
ignaled“Exhibits A and B,regardless of whether County's Total Financial Obligation has been
fully exhausted. No guarantee, express or implied,
by County to lent ae tofo
reimbursement for services perforated in excess ofthe unitsisofmade
services set forth in Exhibit B, or for
services provided after the termination date of this Agreement.
2.8.
Contractor’s Submission of Service Reports
’•
Direct Patient Care Sendees. As a condition for pavment for
tor
patient care services regardless of payer source:
payment
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August 21,2000
9
County will transmit to Contractor a Preliminary Report generated by
the third business day of each month based on information input by Contractor into the OSCAR
System, listing the services provided to Medi-Cal, and unsponsored clients since the date of last
report.
(b) Contractor shall make such adjustments as are necessary to the report
supplied by County pursuant to subparagraph (a) and transmit such adjustments to County by the
second business day following transmission ofthe report. County will supply to Contractor, on the
next business day after transmission of the adjustments,a final adjusted report. Such jeport shall be
submitted by Contractor on or before the fourth business day ofeach month following transmission
by County of a final adjusted report, on such forms or in such other format as the Director may
periodically specify. All reports shall provide clear and detailed information regarding the services
provided by Contractor.
2.9.
Reimbursement.
2.9.1.
Delay ofPayment When Cost Report Information is T ,atp. The
submission of Cost Report information to the State is critical for the County and all contractors to
be fully reimbursed. Ifthe Contractor is late in submitting cost report information, the Director shall
^^bmission of the Contractor’s monthly payment documents to the
SLVHHS Finance Department. Once the cost report information is provided,the monthly payment
documents will be released to Finance for regular processing of a check.
2.9.2.
.
Reimbursement For FY2000-2001. During Fi^riil
2001 the following provisions shall apply as final reimbursement to Contractor;
following table:
onnn.
(a) The reimbursement for each month shall be in accordance with the
$0
Aug-00
Dec-00 $420,082
Apr-01 $389,861
Nov-00 $366,517
Mar-01 $389,861
,
Sep-00 $763.790
Jan-01 $392,154
May-01 $379,543
Oct-00
$0
Feb-01
$389,861
Jun-01
$379,543'
Total Financial Oblieation = ,S.1.871.21 ?.
Payments do not mclude DFCS AFDC payments, which will be made directly to the provider.
The payment schedule and total financial obligation is based on 12
months of program operation. If program operation is less than 12 months, then at the discretion of
the Mental Health Director, the payment schedule and Total Financial Obligation may be
appropriately prorated.
(b)
Contractor shall submit
an invoice based on the above payment
schedule to the County 10 working days prior to the end ofthe month. County agrees to pay on
an
interim basis, subject to the provisions of this Agreement, within 30 days of receipt of the invoice
submitted by Contractor.
County’s Total Financial Obligation to Contractor shall not exceed
verified expenditures incurred by the Contractor. If actual costs as identified in quarterly expense
^atements are significantly below or above projections, then at the discretion of the Mental Health
Director, the payment schedule and the County’s Total Financial Obligation will be modified
accordingly. The parties recognize that the Mental Health Director’s authority is limited to this
G:\MHEALTH\SHRTDYL\SDLBLR\FY2001\2001BLRSTARLIGHT.DOC
August 21,2000
10
amount and, if it is anticipated that costs will exceed the sum of $4,062,548, the Board of
Supervisors’ approval will be required for any additional modifications or additions offunds to this
contract. Exhibit B-1 and B-2 summarizes funding sources and payment schedule.
(d)
Contractor shall submit quarterly expense statements with substantial
detail. The quarterly statements shall be due according to the following: E'quarter due by October
30,2000; 2"'' quarter due by January 30, 2001; 3'‘' quarter due by April 30, 2001; and 4* quarter due
by July 30, 2001.
(e) The Agreement Budget for FY2000-2001 includes County payment
for certain startup costs. Therefore the following provisions shall apply:
(1)
Contractor may incur start-up costs in support of the services
described in the attached Exhibit A, Reporting Unit Grouping #13 (Reporting Unit 43AGJ.
Contractor shall be reimbursed in accordance with paragraph 2.9.2(a)-(d).
(2)
Except as may be otherwise provided in the Agreement,
Contractor shall furnish and be responsible for all supplies, furniture, telephones, and equipment
necessary for the performance ofthis Agreement.
(3)
All personal property, supplies and equipment purchased in
full or in part from payments received under this Agreement shall become the property of County,
unless otherwise agreed in writing by Contractor and Director.
(4)
All personal property, supplies and equipment purchased by
Contractor in whole or in part under this Agreement shall be so identified and marked by Contractor,
on^'-actor
and
shall maintain a separate detailed list identifying all such items, together with the name
ddress of seller, total cost, and the amount of payment requested, and shall make such list
':fj ^he Director upon request.
(5)
Upon termination of this Agreement, Contractor shall
immediately return all personal property, supplies and equipment purchased in whole or in part with
County funds to County, except as may be specified and approved by the Director.
(6)
Contractor shall prepare and submit an annual inventory of all
personal property, equipment, and supplies purchased in whole or in part with County funds pursuant
to this and previous mental health services Agreements with County. This inventory shall be
provided to County in conjunction with the Annual Fiscal Report.
(7)
Donated personal property, including supplies and equipment,
shall become the property of Contractor or such other person or entity specified by donor.
Contractor shall keep accurate records of all such donations, as well as any donations of services.
Such records shall include the identification of the donors and an estimate of value. Such records
shall be made available to Director upon written request.
2.10.
Advance Payment. Payments in advance of those due may be made to
Contractor to facilitate cash flow, where requested by Contractor, and where approved by the
Director, at his or her sole discretion based on the existence of unusual circumstances. Such requests
for advance payment shall be made in writing and submitted to the Director.
G:\MHE.VLTH\SHRTDYL\SDLBLR\FY2001\200IBLRSTARLIGHT.DOC August 21,2000
2.11.
Cost Report. Contractor shall submit annually a cost report for the period
beginning July 1, through the close of County’s fiscal year, or the termination of this Agreement
whichever occurs first, in accordance with the format required by the State Department of Mental
Health, within 30 days from the date of receipt from County of all information within County's
control which is required for the completion of the cost report. This obligation shall sur\dve the
termination of this Agreement. In addition, the Contractor shall submit a six-month cost report
statement, as specified by the County, which will be diie by January 31, 2001. Tlje cost report
submissions shall be used to adjust the payment schedule and total financial obligation due to
Contractor.
2.12.
Subsequent Adjustments. The parties acknowledge that federal and state
funds, as well as County money will be used to compensate Contractor and that the use and
expenditure of such fiinds may be audited by either state, federal or county agencies Contractor
agrees to cooperate with such audits, to make available all data or documents reasonably requested
by auditors including any documents related to parts of Contractor's organization which are not
directly involved in providing services under this Agreement to the extent necessary to validate costs
or allocations under this Agreement. Contractor shall respond to any audit inquiries or exceptions
made by such officials. Contractor further agrees to take whatever corrective action may be required
to comply with applicable state or federal law.
Contractor shall pay to County the amount of any liability determined on audit and
attributable to unallowable service costs rendered by Contractor or County may offset that amount
from any momes due to Contractor for services rendered. Ifthe audit reflects that additional amounts
are owed for services rendered by Contractor, County shall pay such amounts to Contractor provided
however, that County’s obligation shall not exceed the Total Financial Obligation.
In the event that Contractor disagrees with the determinations made in a state or federal audit.
such determinations. Contractor’s request shall
,County may appeal
^ or allow Contractor to appeal
--
be considered by County unless it believes in good faith that the appeal is without merit or not in
County’s interest. The decision to appeal is within County’s sole discretion. Contractor will bear
the cost of any appeal. Contractor agrees to cooperate frilly in the prosecution ofsuch appeals. If
such appeal results in additional payments to County and if Contractor has already reimbursed
County for its share of the initial audit liability. County shall return to Contractor its pro rata share
of the additional amounts received as a result of the
appeal.
2.13.
Early Termination. If, for any reason,this Agreement is terminated by either
party prior to its expiration date, the total compensation paid to Contractor shall be equal to a
prorated portion of County’s Total Financial Obligation set forth in Exhibit B, based on actual
verified costs incurred; provided however that such amount shall not exceed one tenth of County's
Maximum Financial Obligation for each month or
portion of a month during which this
Agreement is m effect. Final payment of any amounts due shall not occur until after Contractor has
submitted Its cost report in accordance with paragraph 2.11 above, and such cost report has been
audited by the applicable County, State or federal governmental agency. County agrees to complete
Its audit, within twelve months from (a)the end ofthe period oftime to which the cost report relates,
or (b) the end of County’s fiscal year, whichever is later.
2-13.1.
Transfer of Funds. If Contractor wishes to transfer funds
among modes of services, different provider numbers, different reporting units, reporting unit
G.\MHEALTH\SHRTDVL\SDLBLR\Fy2001\2001BLRStarlight.doc Aucjst 21, 2000
12
groupings or service clusters, Contractor must obtain the prior written approval ofthe Director To
receive such approval, Contractor shall provide to the Director, a ^^Titten notice ofa desire to transfer
hinds which shall include a complete and full justification for the proposed transfer Where the
^ount to be transferred exceeds ten percent (10%) of the particular line item amount stated in
Exhibit B, such notice must be provided at least thirt)'(30) days prior to such transfer. Where the
amount is less than ten percent, shorter notice will be accepted. Except as provided in paragraph
2.13.2 below, where the requested transfer will allow the receipt of higher amounts ofFFP, and is
not inconsistent with County goals and objectives, such request shall not be unreasonably clenied.
2.13.2.
..
State and County Funds - Transfers Among Program
County and Contractor hereby acknowledge that State and County funds are allocated
to meet the needs of targeted age groups. Therefore State and County Finding allocations to
individual program divisions may not be transferred from one division to another except under
extraordinary circumstances. Requests for such transfers must be made in writing to the Director;
and the Director must approve such transfers, in writing, prior to the effective date ofsuch transfer’
2.14.
State and Federal Funding Approval. The parties acknowledge and agree
that this Agreement is contingent on the availability of State and Federal funds for the services
described in Exhibit A. In addition, if the State Department of Mental Health disapproves this
Agreement, it will be null and void.
2.15
Change in Exhibits A and B, and Medi-Cal Revenues
With the
Contractor’s wntten consent, the Director of Mental Health shall have the authority to revise or add
to Exhibit A and B provided that such change does not increase the County’s Maximum Financial
Obligation. The Director of Mental Health shall have the authority to revise or add to Exhibits A
and B to rrovide for increased or decreased Medi-Cal/Medicaid revenues.
2.16.
,
Early and Periodic Screening, Diagnosis and Treatment(EPSDTI Prom-am
. - has EPSDT funding included in its budget the following applies; The availability of
^
EPSDT program under this Agreement is contingent upon the State reimbursing
the County under the EPSDT program.
3.
term and termination
3.1.
Ehe term of this Agreement shall commence on July 1,2000 and
shall continue through June 30, 2001, unless otherwise extended by the parties.
3.2.
Extensions. The term of this Agreement may be automatically extended for
an additional period not to exceed twelve (12) calendar months, provided all of the following
conditions are satisfied;
^
(a) Director notifies Contractor in writing that;
(I)
Contractor has been selected to continue to perform services
pursuant to a Request for Proposals or Request for Bids (if any);
(2)
detailed timetable is contained in
Contractor's detailed timetable for performance (if any such
this Agreement) has been adjusted to cover the extension period;
G:\MHEALTH\SHRTDYL\SDLBLR\FY200I\200IBLRSTARLIGHT.r
August 21, 2000
13
(3)
The County Board of Supervisors has appropriated sufficient
funds for the extension of this Agreement.
(4)
Any changes to rate of payment or the amount or kind of
services to be performed by Contractor during the period ofthe extension are specifically identified.
(b) Said extension is approved in writing by Contractor including any
changes stated in the Director's notice.
3.2.1.
Termination for Cause. The Director may terminate this
Agreement, effective as provided in paragraph 3.2.2 below, for good cause after providing written
notice to Contractor. For purposes ofthis Agreement, good cause includes, but is not limited to, any
of the following: (a) material breach of this Agreement,(b) material violation of any applicable
County ordinance or State or Federal law, (c)filing by Contractor for protection under the
bankruptcy laws, or receivership,(d)assignment ofthis Agreement without the written consent of
County,(e)failure to maintain any license or permit required to provide the services specified
Exhibit A or failure to utilize licensed personnel where required by law,(1) failure to maintain
certification by Medi-Cal, where such certification is required, or (g)failing to provide services
under this Agreement in a satisfactoiy manner. The notice oftermination shall specify, in detail, the
basis for County’s decision to terminate the Agreement and shall specify the steps, if any, which
Contractor may take to cure the breach and the time period for compliance. Such notice shall
m
indicate the effective date of such termination.
3.2.2.
Effective Date of Termination For Cause. Such termination
shall be effective on tlie date ofthe notice provided pursuant to paragraph 3.2.1 of this Agreement
or such other date as the Director may specify in such notice. If a violation of this Agreement
provides tlie basis for this termination, and Contractor failed to give notice ofsuch violation pursuant
to paragraph 1.9 ofthis Agreement,the Director may, at his or her discretion, make the termination
effective as ofthe date ofthe violation. Where,however, a violation ofthis Agreement provides the
basis for the termination, and Contractor gave proper notice ofthe violation pursuant to paragraph
1.9 ofthis Agreement, such termination shall not be effective until thirty(30)days after the date of
the notice of termination, or such later date as that notice may provide, except that any violation
which could result in substantial harm to any client may provide grounds for immediate termination
regardless of whether such violation was reported.
3.3.
Termination without Cause. Either party may terminate this Agreement
without cause upon thirty(30) days written notice to the other party.
3.4.
Transition Plan. Upon the termination of this contract for
any reason,
Contractor shall participate in and make arrangements for the orderly transition of client services.
4.
NON-DISCRJMINATION
4.1.
Non-discrimination in Services. Benefits And Facilities. Contractor shall
not discriminate in the admission of patients, assignment of accommodations, treatment, evaluation,
any other respect, on any invidious ground including race, color, religion, creed, national origin
or ancestry, seX', marital status, sexual orientation, age, HIV status, or physical or mental disability,
or in
condition, or impairment as defined in applicable local, State, and Federal laws and regulations!
including the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973
G:\MH EALTH\SHRTDYL\SDLBLR\FY2001\2001BLRSTARLIGHT
'
August 21, 2000
14
amended, and implementing regulations. Unlawful discrimination includes, but is not limited to,
the following; providing clients a different level of care than is provided to all other clients;
discrimination in admission practices, such as placement in special wings or rooms or provision of
as
,
separate meals; denying persons any service or benefit; providing to persons any service or benefit
which is different, or is provided in a different manner, place or time from that provided to other
persons under this Agreement; subjecting persons to segregation or separate treatment in any manner
related to their receipt of any service; restricting persons in any manner in the enjoyment of any
advantage or pnvilege enjoyed by others receiving any service or benefit; treating persons differently
from others in determining whether they satisfied any admission criteria, enrollment quota,
eligibility, membership, or other requirement or condition which individuals must meet in order to
be provided any service or benefit; and the assignment oftimes or places for the provision ofservices
on the basis of prohibited discrimination.
4.2.
Appropriate Facilities. Contractor agrees that its facilities will have access
for the disabled to the extent required by Section 504 of the Rehabilitation Act of 1973, the
Americans With Disabilities Act of 1990, and any federal or state provision requiring such access.
4.3.
Non-discrimination in Employment. The County of Santa Clara is an equal
opportunity employer. Contractor shall comply with all apphcable Federal, State, and local laws and
regulations including Santa Clara County’s equal opportunity requirements. Such laws include but
are not limited to the following: Title VII ofthe Civil Rights Act of 1964 as amended; Americans
with Disabilities Act of 1990, the Rehabilitation Act of 1973(sections 503 and 504); California Fair
Employment and Housing Act(Government Code sections 12900, et seq.); and California Labor
Code sections 1101 and 1102.
Contractor shall not discriminate against any subcontractor,
employee, or applicant for employment because of age,race, color, national origin, ancestry, religion,
sexual onentation, mental disability, physical disability, medical condition, political
• TPizational affiliations, or marital status in the recruitment, selection for training
ipprenticeship, hiring, employment, utilization, promotion, layoff, rates of pay or other
iijpensation. Contractor shall give written notice ofits obligations under this clause.
4.3.1.
Notices. Contractor shall post in a conspicuous place such
notices to potential applicants and to employees, setting forth their right to be treated in conformity
with the non-discrimination provisions of this Agreement.
4.3.2.
for employees placed by
Opportunity Employer.
4.4.
or
Position Advertisements. All solicitations or advertisements
on behalf of Contractor shall provide that Contractor is an Equal
Non-compliance. Failure to comply with any of the requirements of
paragraph 4 shall be considered a material breach ofthis Agreement. Such failure shall be grounds
for suspension ofthis Agreement in whole or in part. Nothing in this Agreement shall be deemed
a limitation on the right of County to take any other action with respect to Contractor as a means of
enforcing the anti-discrimination provisions ofthis Agreement as the State may require.
5.
RELATIONSHIP OF THE PARTIES
Contractor shall perform all work and services described herein as an independent
contractor and not as an officer, agent, servant or employee of County. None of the provisions of
this Agreement is intended to create, nor shall be deemed or construed to create, any relationship
between the parties other than that of independent parties contracting with each other for purpose
G:\MHEALTH\SHRTDYL\SDLBLR\FY2001\2001BLRSTARLIGHT.'
August 21, 2000
15
of effecting the provisions ofthis Agreement. The parties are not, and shall not be construed to be.
in a relationship ofjoint venture, partnership or employer-employee. Neither party shall have the
authority to make any statements, representations or commitments of any kind on behalf ofthe other
party, except with the written consent ofthe other party. Contractor shall be solely responsible for
the acts and omissions of its officers, agents, employees, contractors and subcontractors, if any.
r
Contractor’s personnel rendering services under this Agreement shall not have any of the rights
privileges of County or State employees. Contractor and its agents, employees and subcontractors
shall not have any claim against the County or State for any employment privileges and benefits,
including but not limited to vacation pay, sick leave,retirement benefits. Social Security, workers
compensation, unemployment benefits, disability benefits, etc. Notwithstanding any reference to a
managed care plan or system of care. Contractor shall act as an entity separate and apart from the
County, and shall be considered an independent contractor for all purposes, including liability and
or
litigation.
6.
INDEMNIFICATION AND INSURANCE
Contractor shall indemnify, defend, and hold harmless the County,its officers, agents
and employees fom any claim, liability, loss, injury or damage arising out of, or in connection with,
performance of this Agreement by Contractor and/or its agents, employees or sub-contractors,
excepting only loss, injury or damage caused solely by the sole negligence or willful misconduct of
personnel employed by the County. It is the intent of the parties to this Agreement to provide the
broadest possible coverage for the County. The Contractor shall reimburse the County for all costs,
attorneys' fees, expenses and liabilities incurred with respect to any litigation in which the Contractor
is obligated to indemnify, defend and hold harmless the County under this Agreement.
Contractor agrees to comply with the provisions involving indemnification and
insurance as set forth in Exhibit C hereto which is incorporated by this reference.
7.
AMENDMENT
The terms of this Agreement, such as units of service to be provided, nature of
services rendered, the rates per unit of service, or any other provision may be modified upon the
execution by Contractor and the Director on behalfof County of a written amendment specifying the
precise changes to be made. Contractor may submit a written request for amendment at any time;
however, Contractor acknowledges that requests for modification ofthe total units of service, types
of services, rates per unit of services, or other change to the financial or service provisions of this
Agreement shall be approved by County only upon receipt ofevidence ofunanticipated costs or other
appropriate justification for such change. County will act within a reasonable period oftime given
the nature of the requested amendment in determining whether to agree to an amendment.
8.
GENEITAL PROVISIONS
8.1.
Assignment. Rights and obligations under this Agreement may not be
assigned or delegated, in whole or in part, without the prior written consent of the other party.
Contractor shall give County a minimum of 30 days to consider any request to assign, prior to the
proposed effective date of such assignment. Approval for assignment may be granted by the
Director. Failure to obtain prior, written consent to an assignment shall be deemed a material breach
of this Agreement. Upon an authorized assignment. Contractor shall ensure that the terms and
conditions of this Agreement shall inure to the benefit of County and be binding upon the successor
and assignees, except such terms and conditions as may be expressly waived, in writing, by County.
G;\MHEALTH\SHRTDYL\SDLBLR\FY2001\2001BLRSTARL1GHT.DOC August 21, 2000
16
8.2.
, „, .
..
Notices. All notices required to be given under the terms ofthis Agreement
sha 1 be m witmg and shall be delivered in person, transmitted by electronic facsimile, or deposited
inbelow:
the United States mail, certified mail, return receipt requested, addressed to the parties as set forth
County:
Director of Mental Health
Santa Clara County Mental Health Department
828 South Bascom Avenue
San Jose, California 95128
Copy to:
County of Santa Clara, Board of Supervisors
Administration Building
70 West Hedding Street
San Jose, California 95110
Contractor:
Mary Jane Gross, RN, MN
President
Starlight Adolescent Center, Inc.
7700 Edgewater Drive
Oakland, CA 94621
510-635-9705 / FAX 510-635-9716
8.3.
Miscellaneou.s.
(^) This Agreement shall be binding upon the successors, assigns, heirs,
neljciaries of the parties hereto, subject to the provisions of paragraph 8.1 above,
(b) The paragraph headings used in this Agreement are intended solely
■ " - n ee ofreference and shall not in any way or manner amplify, limit, modify or othenvise
> e interpretation of any of the provisions of this Agreement,
(c) As used herein, the masculine, feminine, or neuter gender and the
singular
r Of plural number shall be deemed to include the others whenever the context so dictates.
8.4.
Entirety. This Agreement,including its exhibits, contains the sole and entire
agreement between County and Contractor with respect to the subject matter hereof and shall
sujK.a-- de all prior agreements between the parties as of the effective date hereof The parties
ackiiowledge and agree that they have not made any representations with respect to the subject matter
of this Agreement, or any representations inducing its execution and delivery except such
repic wntations as are specifically set forth herein.
/
/
/
/
/
/
/
/
/
G:\MHf AL T 1 I\SHRTDYL\SDLBLR\Fy2001\2001 BLRStarIight.doc Au:;
21. 2000
17
Severability. In the event any one or more of the provisions contained in
8.5.
this Agreement shall, for any reason, be held to be invalid, illegal or unenforceable in any respect,
it shall not affect any other provision of this Agreement. This Agreement shall be construed as if
such invalid, illegal or unenforceable provision had never been contained herein.
IN WITNESS WHEREOF,the parties have executed this Agreement as of the date set forth below.
COUNTY OF SANTA CLARA
CONTRACTOR
^ bsL jro
^
Date
Date
BY:
Nancy Pena, Ph.D.
0^
BY:
•OL
7
T
/,
Interim Director, Mental Health Department
NAME: />[qrM Jq
TITLE:
ATTEST: Phyllis Perez, Clerk
Board of Supervisors
Date
APPROVED AS TO FORM AND LEGALITY
60
Rima H. Singh i
Deputy County Counsel
D
T ate
AGREEMENT BETWEEN THE COUNTY OF SANTA CLARA
AND STARLIGHT ADOLESCENT CENTER,INC.,
FOR PROVISION OF MENTAL HEALTH SERVICES
EOR FISCAL YEAR JULY 1, 2000, THROUGH JUNE 30, 2001
G:\MHEALTmSHRTDYL\SDLBLR\FY2001\200IBLRSTAJRl
7
August 21,2000
18
STARLIGHT Adolescent Center, Inc.
FY2001
Page 1
August 21, 2000
Exhibit A; Reporting Unit Grouping #13
Family and Children’s Division
FY 2000-2001
Provider Name:
STARLIGHT Adolescent Center, Inc.
Address:
455 Silicon Valley Blvd, San Jose, CA 95138
Provider Number #;
43AG
Reporting Unit #:
Santa Clara 43AG1, 43AG2; Alameda 43AG3,43AG4
Contact Person:
Mary Jane Gross, RN, MN
Program Title:
Program Type:
STARLIGHT Adolescent Center, Inc.
Intensive Day Treatment, Mental Health Services, Med Support,
Therapeutic Behavioral Services, Case Management, Crisis
Intervention Services
Program Address:
455 Silicon Valley Blvd
Telephone:
(510)428-2240
San Jose, CA 95138
Contractor has submitted a response to a State of California Request for Proposal(RFP) dated
r. sj ■ ■
-■.j
0, 1S99 A brief synopsis of the RFP submission is attached to the Exhibit A. Contractor
sria!! pmvide the services set forth in its RFP response, including the services outlined below.
I
DESCRIPTION OF SERVICE INTENT & GOALS
A.
MISSION AND GOALS:
1.
System-wide Service Intent and Goals:
a.
To treat and ameliorate the mental health symptoms and dysfunction
of children and adolescents requiring intensive daily intervention, so
they may be transitioned to a less restrictive and less intrusive level
of care at the earliest possible point.
b.
To provide day treatment and related outpatient services within the
context of the individual’s family, culture, language, and community;
and according to developmental age-appropriate needs.
c.
To deliver individualized intensive day treatment and intensive
outpatient services in the community treatment facility (CTF), clinic,
home, school, and community, as appropriate to the treatment needs
and service goals of the child and family;
d.
To promote coordination and collaboration in care planning efforts
G;\MHEALTH\SHRTDYL\ExA FY01\SlarlightExA.doc
STARLIGHT Adolescent Center Inc
FY2001
Page 2
August 21, 2000
with other child-serving agencies and institutions involved in delivering
services to the child and their family, to insure comprehensive and
consistent care;
e.
To direct service objectives towards achieving the ipdividual. family
and system desired results as identified in the Mental Health Service
Plan and to move the child to less intensive service.
2.
Program Specific Description of Service Intent & Goals:
a.
To provide intensive day treatment services 7 days/week for children
residing in the STARLIGHT Community Treatment Facility (CTF)
program as well as those who have graduated from the residential
program and are transitioning to lower levels of care.
b.
To reduce the need for Out-of-State Placements
or more acute
psychiatric care services.
c.
To provide case management services, coordinated precare and
aftercare services for children who are being considered for
admission and who
STARLIGHT CTF.
d.
are approaching and/or discharged from
To facilitate admission and discharge as well as to assure continued
coordination of care and resources for all clients.
e.
To provide medication support services by providing appropriate
medication services to ameliorate or stabilize the psychiatric
conditions of the clients in the STARLIGHT CTF
f.
program.
To provide Therapeutic Behavioral Services (TBS), a one-on-one
therapeutic program, designed to maintain the child/youth’s residential
placement in the least restrictive environment. (TBS Procedures
Attached.)
g-
To provide 24 hour/7day/week secure residential treatment services
in a CTF for up to 36 adolescents.
h.
To adhere to the philosophy of providing quality mental health
services within a context of the clienfs culture and in the client's
language. Because of this commitment all efforts will be made to hire,
train and maintain staff who are capable of providing services in a
linguistically and culturally meaningful manner.
G:\MHEALTH\SHRTDYL\ExA FY01\StarlightExA,doc
STARLIGHT Adolescent Center, Inc
FY2001
Page 3
August 21, 2000
B.
DESCRIPTION OF SERVICES
1.
System-wide Description of Services and Treatment Methods:
Family and Children's Outpatient programs will provide services according
to the MediCal Rehabilitation Option. Available treatment methods will
include intensive day treatment (full day), assessments, medication
evaluation and support services, crisis intervention, individual, group,
collateral and family therapy; and rehabilitation and case management
brokerage services. Services will be provided in a variety of settings,
including the CTF, clinic, school, and community as described in the agency
day treatment program, and as needed by the clients served. Services will
be individualized and take into account each person’s age, maturational
level, culture, family values and structure, educational functioning level and
physical health.
2.
Program Specific Description of Services and Treatment Methods;
a.
Day Treatment
The STARLIGHT Day Treatment Program will serve up to 44 students
and their families. Up to 36 of the students will be residents of
STARLIGHT CTF and 8 will be graduates of the STARLIGHT CTF
who are transitioning from the CTF program. The Day Treatment
Program is distinct and in addition to the School Program provided.
Intensive day treatment services will be provided 7 days/week for
children residing in the STARLIGHT CTF program and 5 days/week
for those who have graduated from the residential program and are
transitioning to lower levels of care. The intent of these services will
be to reduce the need for State Hospital, Out of State Placement or
more acute psychiatric care services.
b.
Therapeutic Behavioral Services(TBS)
The STARLIGHT TBS program will provide an on-site, individualized,
one-to-one behavioral assistance program. It will provide short term
immediately available interventions to clients under age 21 meeting
state requirements. It will provide children/youth with skills to
effectively manage the behavior(s) or symptoms that are a barrier to
achieving and/or maintaining their placement at the STARLIGHT CTF
program.
c.
Community Treatment Facility(CTF) Services
The STARLIGHT CTF program will provide residential treatment
services for clients under the age of 18 on a 24-hr/7day/week basis
to youngsters requiring a secured treatment facility due to their mental
G:\MHEALTH\SHRTDYL\ExA FY01\StarlightExA.doc
STARLIGHT Adolescent Center, Inc
FY2001
Page 4
August 21, 2000
disorder. Seoyices will include 24 hour nursing care, activity program
treatment and rehabilitation and psychiatric services.
d.
Case Management Sen/ices
STARLIGHT case management services will provide coordinated
precare and aftercare services for children who are being considered
for admission and who are approaching and/or discharged from
STARLIGHT CTF. With these services, STARLIGHT will facilitate
admission and discharge as well as assure continued coordination of
care and resources for all clients.
e.
Medication Support Services
STARLIGHT medication support services will provide appropriate
medication services to ameliorate or stabilize the psychiatric
conditions of the clients in the STARLIGHT CTF program.
f.
Crisis Intervention Services
STARLIGHT crisis intervention services will provide emergency
intervention to STARLIGHT graduates to reduce the likelihood of their
needing to return to placement.
POPULATION SERVED
A.
ACTIVE CASELOAD AND LENGTH OF SERVICE
TARGET %(+/- 5%)
Active Caseload;
Day Treatment Intensive
44
Medication Support Services
Case Management Services
44
44
TBS Services
CTF Services
36
Total Clients Served/Year;
88
36
Service Duration:
0-2 months
05%
3-6 months
30%
7-12 months
60%
over 13 months
05%
The length or duration of service will depend on individual needs. The average
length of service will be 9 months.
B.
ETHNIC PROFILE
White
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TARGET %
40%
STARLIGHT Adolescent Center Inc
FY2001
Page 5
August 21, 2000
Hispanic
Asian
40%
10%
Black
5%
American Indian
2%
Other
3% ^
STARLIGHT intensive outpatient services include children from diverse cultural
backgrounds from through out Santa Clara County. We have an on-going multi
cultural emphasis and are v/orking with our referral sources to address the under
served diverse populations.
C.
AGE
0- 5
6-12
13-17
18-59
60+
D.
SERVICE REGION
i <orth
Louth
East
'est
E.
TARGET %
0%
5%
93%
2%
0%
TARGET %
10%
30%
50%
10%
DIAGNOSTIC SPECTRUM & FUNCTIONAL IMPAIRMENT
Provider will serve youth clients whose problems fall within a broad range of both
diagnostic and functioning categories. Contractor's estimated caseload diagnostic
profile is listed below;
DIAGNOSTIC PROFILE
DISTRIBUTION OF DIAGNOSES
TARGET %(+/- 5%)
Psychotic
PTSD
Major Depressions/Mood Disorders
Disorders of Bodily Functions
5%
15%
20%
3%
Behavioral Disorders
48%
Anxiety
Adjustment Disorders
15%
Other
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8%
10%
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Page 6
August 21, 2000
FUNCTIONAL IMPAIRMENT
In addition to diagnostic assessment, Contractor will assess youth clients and
families with respect to impairments in functioning in seven ar@as. Estimated
targets in each functional area are listed below. Numbers represent the percent of
clients served who will have scores of 1 or 2 (most impaired) on the Functional
Assessment Scale.
TARGET %(+/- 5%)
Self care
0%
School/job performance
90%
Moods/emotions
70%
Behavior towards others
70%
Substance abuse
20%
Family Functioning
Cultural Adjustment
70%
15%
SERVICE FREQUENCY
0-5 hours per week
6-10 hours per week
over 10 hours per week
0%
5%
95%
PROGRAM PERFORMANCE STANDARDS
A.
REFERRALS;
All referrals to providers in the Family and Children’s services for mental health
services will be documented and summarized according to procedures developed
and agreed to by the provider system.
STARLIGHT Adolescent Center will accept referrals only through the County
Resource and Intensive Services Committee (RISC) Team. Adolescents who are
deemed appropriate for admission by RISC will not be refused or discharged by
STARLIGHT absent substantial good cause. Substantial good cause may include
violation of licensing regulations.
B.
ASSESSMENTS;
All referrals for services will be assessed for eligibility according to the following
criteria:
1
Evidence of symptoms of mental health problems which meet the criteria for
diagnosis in the DSM IV; and
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2.
Evidence of impaired functioning in one or more of the areas of self-care
behavior towards others, family functioning, school performance’
moods/emotions, substance abuse, and/or cultural adjustment, as measured
by the Functional Assessment Scale; and/or,
3.
Approved AB3632 eligibility through the Family and Children’s Division
AB3632 Program.
4.
TBS services will be provided to Agency clients only and will follow the
guidelines established by the State Department of Mental Health and the
Santa Clara County Mental Health TBS Program Draft Procedure (Attached).
At the time of intake, the clinician will begin a comprehensive youth and family
assessment, consistent with the guidelines provided by the MediCal Rehabilitation
Option. These details are described more fully in the next section. The clinician will
formulate a DSM IV diagnosis for the youth, a description of the systemic family
dynamics, and a family and child strength assessment using information gathered
from family meetings, individual interviews, observations, and input from the
teacher, aide, and adolescent specialist.
Within 30 days after admission, the clinician will present the initial assessment of
the youth at a staffing attended by the interdisciplinary treatment team. At this time
the assembled group will develop initial long and short-term treatment goals for the
youth. The long-term goals will include the return of the child to a less restrictive
setting. The short term goals will address current behavioral difficulties, and are
ntten in measurable behavioral terms and stated in positive language. The goals
ill be updated by the whole team every six months or earlier, if needed.
The clinician will be responsible for maintaining clinical records and seeing that the
necessary clinical and management information forms are completed on schedule.
C.
HOURS OF OPERATION PLAN;
1.
System-wide Requirements:
STARLIGHT Adolescent Center operates on a 24-hour/7day/week basis.
2.
Specific Hours of Operation Plan;
Intensive Day Treatment occurs daily from 3pm - 8pm seven days/week
TBS services are available on a 24 hr/7day/week basis; Case Management
and Med Support are typically provided M-F from Bam - 5pm
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FY2001
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August 21.2000
D.
DISCHARGE:
Clients shall be discharged: 1) Upon mutual agreement (client and therapist) that
the goals of treatment have been met; 2) Upon parent or gua/dian refusal of
services
or refusal to comply with objectives outlined in the Mental Health Services
Plan; 3) Upon parent or guardian's unilateral decision to terminate treatment; 4)
Upon a determination that the individual is a substantial danger to other youth or
staff; or 5) Upon transfer out of the County or to another region. Appropriate follow
up or other service linkage will be made.
E.
ADMINISTRATIVE PARTICIPATION:
A suitable representative of the Provider shall attend provider meetings regularly,
training sessions, seminars or other meetings as scheduled by the Director of
Mental Health or his/her designee.
IV.
STAFFING
A.
MINIMUM STAFFING REQUIREMENTS:
Staffing shall be provided at least at the minimum licensing requirements of ShortDoyle Medi-Cal Rehabilitation Option regulations to the extent they are applicable
to this program; and consistent with any applicable regulations contained in Titles
IX, XIX and XXII.
B.
ADDITIONAL STAFFING REQUIREMENTS:
The following additional experience, training and skills will be required of staff in this
program:
1.
Understanding of psychopathology within the ethnically diverse clients’ cultural
context.
2.
3.
Knowledge of the values of the ethnically diverse client population.
Knowledge of the socio-historical situation of the ethnically diverse client
population.
4.
Capability for addressing the diverse levels of client acculturation and
5.
Knowledge of the multicultural experience.
biculturality.
6.
Knowledge of the local community resources, within the county’s ethnic
communities available to the client population and their families.
7.
Ability to engage the families of the ethnically diverse client population.
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FY2001
Page 9
August 21, 2000
c.
PROJECTED STAFF LISTING:
m
;-i
OF
m
y-r'
.’KiY
LICE^
•A
Trf'
■r.
W:
8S
1.0
7.5
m§
-s
5
Director of Social
Services
LCSW/MFT
QMHP’s
QMHP’s
0.5
Psychiatrist/M. D.
6.0
Support Counselors
6.0
Clinicians
M.D.
LCSW/MFT
STARLIGHT will make every reasonable effort to recruit staff so that there will be
language coverage in the two threshold languages for Santa Clara County of Spanish and
iii.,'.® ..u.uion® a reasonable
there willgood
be staff
are knowledgeable
of African American culture
faithwhoeffort
will be
made to recruit staff who are
s I
"^hnic groups in the client
CULTURAL KNOWLEDGE SKILLS:
Contractor shall attempt to provide culturally competent services as set forth in the
description provided by Contractor to the Director.
G;\MHEALTH\SHRTDYL\ExA FY01\StarlightExA.doc
t AniB1 I
continued
STARLIGHT Adolescent Center, Inc,
Synopsis Of The RFP Submission
FY2001
Page 10
August 18, 2000
STARLIGHT Adolescent Center, INC.
Program Overview
—
STARLIGHT Adolescent Center, Inc. will offer a comprehensive approach to providing a full spectrum
of mental health services for clients residing at STARLIGHT Community Treatment Facility (CTF),
Inc., a nonprofit 36 bed Community Treatment Facility licensed through the State Department of Social
Sciences, Community Care Licensing and certified by the State Department of Mental Health. The
Community Care Licensed CTF equivalent to an RCL level 14 residential treatment program provides
care for both male and female clients. The residents of this CTF will utilize the STARLIGHT
Adolescent Center, onsite, seven day per week intensive Short/Doyle Medi-Cal certified day treatment
program and attend an onsite certified non-public school. The goal will be reduce acute inpatient
care
for adolescents in the County. The model presented will utilize 24 hour/7 day/week nursing supervision,
psychiatric services and daily comprehensive treatment intervention provided by STARLIGHT CTF,
Inc.. An Intensive Day Treatment Program will be provided by STARLIGHT Adolescent Center, Inc.,
as well as a nonpublic certified High School, STARS High School, Inc.. A comprehensive program
with a rehabilitative and resiliency based model of groups and services will be stressed offering
extensive work in the areas of self-sufficiency, skills development, problem oriented treatment, and
independent living skills. The program will strive for complete cultural competency with regard to
staff, program and community involvement.
Aftercare services will begin prior to discharge from the CTF and are designed to assure the highest
likelihood of successful community reintegration possible. Exiting youngsters will have opportunities for
gradual transition with space for participation for eight clients in the intensive day treatment program and/or
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STARLIGHT Adolescent Center, Inc.
Synopsis Of The RFP Submission
FY2001
Page 11
August 18, 2000
Non-Public school until smooth transitions to community schools can be made. Two dedicated staff
members will be available to work with the child, family, school and community to, provide
services
assisting the child and family in their transition from the program to the community. These services will
be delivered in the child’s home, school or wherever the services are needed.
1. Philosophy and Mission Statement
STAJILIGHT Adolescent Center and STARLIGHT CTF will be committed to offering and maintaining the
highest quality ofcare and life to each ofthe children entrusted to their care. Programs will stress self-reliance,
positive youth development, and enhancement of the quality oflife and achievement ofindependence. The
goal of each program will be to prepare each child for future success, including mental health,independent
d effective social and vocational achievement. The approach in managing programs will be to provide
an extensive program of orientation and on-going staff education with a focus on teamwork, ongoing quality
achievement, and a responsive management team to ensure that the program provided has solid results, and
is easily able to adapt to changing client and consumer concerns in a culturally sensitive atmosphere. A special
focus will be placed on providing specific treatment programs and pathways for youngsters with specific
clinical syndromes. Program offerings will include group and individual therapies, skills training, behavior
modification, a variety of activity therapies and one-to-one interactions through an approach that is solidly
anchored in a well supervised therapeutic milieu. All activities and interactions are processed through this
therapeutic rehabilitative milieu, so that everyday activities of daily living can be a source of therapeutic
stabilization, impact and change.
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STARLIGHT Adolescent Center, Inc.
Synopsis Of The RFP Submission
FY2001
Page 12
August 18, 2000
The psychiatric treatment programs reflect the belief that children benefit from community placement versus
state hospital, that positive peer culture is a powerful source of adolescent influence and persuasion, and that
all staff need to be trained to “catch the child doing something right”. The goal of treatment is to return
children to their natural family setting(or alternative family setting) as soon as they achieve an appropriate level
of personal responsibility. STARLIGHT Adolescent Center and STARLIGHT CTF will utilize staff
experienced in providing psychiatric treatment for male and female adolescents from many ethnic or cultural
groups, religions, and national origins. All of its programs will reflect the demographics of the County and
community both in clients and staff. The population served will be County contracted and gate-kept by the
County. Approximately 70% of the population will be of minority backgrounds. Contractor will conduct
regular cultural awareness programs for both clients and staffto dispel ignorance, shape values and behaviors,
and heighten acceptance and sensitivity in responding to cultural and ethnic differences. The Programs will
be proactive in efforts to recruit staff who reflect the culture and values of the clients and their families.
Although Contractor will recognize cultural differences. Contractor will also recognize and strongly support
cultural similarities and stresses these similarities in its work with children and their families
The STARLIGHT program philosophy reflects a philosophy of“positive youth development”. The programs
will be composed of a unique combination of clinical and strength based programs, focusing on skills building,
transition to adulthood, and resiliency support. The program goals will be to return the adolescent to their
community setting with family or other caregiver and within the public school system.
• Global Collaboration will be practiced in each of the Contractor’s programs. The importance of
integrating all available resources into an individual’s treatment will be recognized in
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STARLIGHT Adolescent Center, Inc.
Synopsis Of The RFP Submission
FY2CJ'!
.Page
Rugu - 18, 2000
comprehensive interdisciplinary treatment plans which involve the adolescents, their families and
all the significant people and agencies which intersect with the adolescents’s lives.
*
Equally important will be an emphasis on Family involvement. Families are an integral aspect of
assessment, intervention, and evaluation. Families are considered to be equal partners in the
formulation, execution and evaluation oftreatment plans. The Contractor’s interventions will be
family driven.
Consumer participation -Youngsters and their families will be partners and colleagues in not
only the treatment processes, but also in the focus, design and refinement of the program.
Consumer surveys will occur biannually with clients, family, referral sources and other members
of the system of care and these will be used in fine tuning the program.
Serfices will be results oriented and committed to realizing specific short and long-term goals
+ - 'oungsters and their families. Specific measurable and time limited goals and objectives will
■ formulated for each child. Program effectiveness will be regularly monitored internally using
untion analysis and standardized psychiatric, behavioral and achievement measurement tools.
*
Culturally competent services will include services to any ethnic/ancestral group, race, sex,
sexual orientation, religion, or national origin. Contractor will actively strive to have its staff
reflect the cultural & linguistic backgrounds ofthe clients and the community. English and Spanish
language services will be available routinely in the program. Contractor will practice mutual
understanding and respect and teach the children and staff to be proud of their culture, and see
diversity as an opportunity to know and understand each other.
s
Comprehensiveness in Contractor’s programs will be demonstrated by offering a full array of
sc: vices for the child and family and by recognizing and utilizing the full network of services within
•ihe community system of care.
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STARLIGHT Adolescent Center, Inc.
Synopsis Of The RFP Submission
FY2001
Page 14
August 18, 2000
• Transitional services which assist the adolescent and family to move from a highly structured
system of treatment and intervention to a family setting with outpatient resources will be a key to
Contractor’s success. This is where all factors including collaboration, family involvement,
cultural competence and coordination of care become more critical than at any time. Significant
time and energy will be spent in interagency planning and coordination to make this step work as
all outcomes depends on its success.
The Program will demonstrate its ability to collaborate and coordinate its services with the system of care of
each individual commumty by participation in interagency teams, community forums, coordination with the
County mental health program, social services, probation and schools. STARLIGHT Adolescent Center will
utilize EPSDT funding, Short/Doyle Medi-Cal, and various creative funding techniques to offer not only
services which are reimbursed by Medi-Cal, but also nontraditional services which enhance commuraty
functioning, family cohesiveness and community reintegration. Examples ofthese activities include childcare,
fishing trips,family picnics,job coaching and other supportive services which support the child and family
on
their “turf’.
2. Target Population To Be Served
A. Age Range
Minors between the ages of 11 years and 18 years are eligible for admission to STARLIGHT CTF and to
receive treatment by STAILLIGHT Adolescent Center, Inc.. It is expected, however, that the vast
majority of the referrals will be in the age range between 13 and 16 years.
B. Gender
Both males and females are eligible for admission to STARLIGHT CTF and to receive services from
STARLIGHT Adolescent Center Inc..
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STARLIGHT Adolescent Center Inc
Synopsis Of The RFP Submission
FY2001
—•
Page 15
August 18, 2000
C Ethnicity
Youngsters of all races and cultures are eligible for admission to STARLIGHT CTF ajid to receive
services from STARLIGHT Adolescent Center, Inc.. It is expected that the bulk ofthe youngsters will
be Caucasian, Vietnamese/Asian, or Hispanic, and that smaller numbers of youngsters will be of other
ethnicity. However, ethnicity will not be a factor in admissions.
D. Degree ofLevel ofImpairment
Youngsters are expected to have significant impairments in all areas of adaptive functioning including
symptom management, interpersonal relationships, social functioning, educational functioning, and
recreational functioning.
ii I S expected that the bulk of the youngsters served will have scores below 40 on the CGAS(Children’s
Global Assessment Scale).
E. Diagnosis as listed in the most current edition ofDSM
All youngsters admitted will have diagnosable mental disorders according to the diagnostic criteria
specified in DSM-IV. The youngsters are expected to have a wide range of different DSM-IV psychiatric
diagnoses. However, the most common diagnoses are expected to be forms of: '
a) Conduct and Behavioral disorders(Conduct Disorder, Disruptive Behavior Disorder, Attention
Deficit Hyperactivity Disorder, diagnosis codes = 312.8; 312.9, 314.xx, 314.9).
b) Depressive and Mood disorders (e.g.. Major Depressi Disorder, Dysthymic Disorder; Bipolar I
ive
Disorder, diagnosis codes = 296.xx; 300.4; 311)
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STARLIGHT Adolescent Center, Inc
FY2001
Synopsis Of The RFP Submission
Page 16
August 18, 2000
c) Psychotic Disorders (e.g., Schizophrenia, Schizoaffective Disorder, codes = 295.xx)
No youngsters who have primary diagnoses of chemical dependencies(substance related diagnoses)
eating disorders will be admitted for treatment. However, substance related disorders (e.g., alcohol
or
use
disorders, amphetamine use disorders, cannabis use disorders, cocaine use disorders, hallucinogen related
disorders etc.) are expected to be common secondary(DSM-Axis I) diagnoses. Learning, communication,
and other specific developmental disorders diagnoses are expected to be common secondary diagnoses
on
Axis II.
F. Number ofyoungsters to be served
STARLIGHT CTF is designed to serve 36 youngsters at a time, however, STARLIGHT Adolescent
Center will serve not only the current residents of STARLIGHT CTF, but also up to 8 of it’s graduates.
G. Identification ofthe particular needs ofthe population
The referred youngsters are expected to have major psychiatric illnesses (often with secondary substance
related disorders) resulting in numerous behavioral, emotional and cognitive symptoms and problems.
The adaptive functioning ofthese youngsters is expected to be impaired across all areas(including
interpersonal relationships, social/recreational, and educational/vocational).
Each of the youngsters is expected to have their own unique complex of symptoms and problems.
However,there are expected to be a large number of symptoms and problems that are shared by many of
the youngsters.
Description of services designed to meet the identified needs
STARLIGHT CTF will provide a variety of individual, group, school, and therapeutic milieu activities
within a highly structured schedule. The initial focus of treatment will be to address major presenting
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STARLIGHT Adolescent Center, Inc.
FY2001
Synopsis Of The RFP Submission
Page 17
August 18, 2000
psychiatric problems,focusing on symptom remission or control; to provide a consistent, predictable, and
behaviorally focused milieu; and to assist youngsters in the acquisition of skills necessary Tor successful
interpersonal functioning.
Specific treatment components will differ across the different youngsters referred to STAJfiLlGHT CTF.
Upon admission, each youngster will receive a comprehensive assessment by all disciplines ofthe facility
(e.g., psychiatry, nursing, rehabilitation, diet, social worker). Based on this assessment, an Interdisciplinary
Treatment Plan/Plan of Service will be developed with the active participation ofthe youngster.
Method and Frequency ofEvaluating Youngster Progress & Program Effectiveness
STARLIGHT CTF and STARLIGHT Adolescent Center will establish specific, measurable goals for
c acn
ngster, as well as for the overall facility program. Youngster progress and effectiveness of the
program will be regularly monitored using a variety oftools, including clinical reviews, utilization
analyses, satisfaction surveys, and standardized psychiatric measurement instruments.
Rigorous treatment planning, evaluation, and modification will be employed to gauge program and
treatment responsiveness. Frequent and regular modifications will be made ofprogram components in
order to provide flexible, effective, and creative approaches to seemingly chronic psychiatric problems.
Regular monitoring of each youngster's progress, reassessments for continued stay, and coordination of
discharge/ aftercare services will be coordinated with the assigned County program liaison and individual
case workers. To ensure that both program objectives and County goals are satisfied, a close working
relationship is expected.
Youngster progress will be continuously documented in writing in each youngster’s record. Weekly
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STARLIGHT Adolescent Center, Inc
Synopsis Of The RFP Submission
FY2001
Page 18
August 18, 2000
progress notes will be written for each youngster by the program staff or interdisciplinary professional
staff who are providing the rehabilitation services. There will be a physician’s/psychiatrist’s progress note
whenever the youngster is seen by the physician. There will be a documented review of each youngster’s
treatment plan by treatment team staff and the youngster at least monthly. Treatment Team progress notes
will be signed by the attending disciplines whenever the Treatment Plans are reviewed and approved.
Plans of service will be reviewed and updated any time there is a change in condition.
Treatment outcomes will be evaluated in relation to the current status or level of the youngster, the
objectives achieved, and the potential for discharge. Specific psychiatric outcome measures that have been
proven in the scientific literature to be reliable and valid will also be used to mom’tor youngster progress
in specific areas. Such measures include; nurses ratings, Achenbach Child Behavior Checklist(CBCL),
Achenbach Teacher Behavior Rating Scale, Achenbach Youth Selfrating scale (YSR), Skills assessment
forms, Children’s Global Assessment Scale(CGAS), standardized achievement tests, quarterly academic
assessments and report cards, tracking of discharge locations, case management monitoring. Family
Satisfaction Survey and Mental Health Agency Satisfaction Survey.
In addition, overall program outcomes (across all youngsters for each fiscal year) will be analyzed and
documented in a written Aimual Report, which will be presented to the County. The report will include
the results of youngster, family, and agency Satisfaction Surveys which will be conducted periodically to
assess outside perception of the program and obtain valuable input for ongoing evaluation and program
adjustment.
Basic Services dnd Staffing
STARLIGHT CTF and STARLIGHT Adolescent Center will provide the following basic services to the
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FY2001
Synopsis Of The RFP Submission
Page 19
August 18, 2000
referred youths; residential services, physician (psychiatrist) services, nursing services, pharmaceutical
services, and dietary services. In addition to these basic services, the following rehabilkation/treatment
services will be provided: comprehensive interdisciplinary assessments, evaluation, and treatment planning;
quality residential care stabilization services in a highly stmctured and supervised setting; continuous daily
therapeutic interventions in a “therapeutic milieu” environment; brokerage/linkages with juvenile courts.
Department of Probation, Department of Social Services, Department of Mental Health, and community
schools; educational services (nonpublic school); discharge planning/aftercare including active
participation with the County Department of Mental Health, the youngsters and their families and/or
caregivers.
Clinical s
taffing will consist of: Registered Nurses(4.5 FTE’s), Licensed Vocational Nurses(6.0 FTE’s),
Youth Counselors (36.0 FTE’s), Social Workers(5.0 FTE’s), Rehab Therapist(7.5 FTC),a unit
clerk/transport aid. In addition, there will be a Program Mental Health (Licensed LCSW,MFCC
or
Ph.D. with three years experience) overseeing the youths’ clinical, special rehabilitation, and activity
services.
Overall, there will be a minimum ratio of child care staffto clients of 1 ;5 during awake hours.
Appropriate supervisory staff will be employed to assume responsibility for supervision of youth
counselors, rehabilitation aides, nursing staff, and facility operations. On-call administrative. nursing,
youth counseling, and rehabilitation staff will be available at all times for emergency coverage and
intervention.
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Synopsis Of The RFP Submission
FY2O01
Page 20
August 18, 2000
STARLIGHT CTF will have a qualified psychiatrist to review/approve treatment plans and services; to
perform and document a psychiatric assessment and mental status on all youngsters upon admission to
monitor any progress of all adolescents and to assess the need for or reactions to psychotropic
medications and their ongoing progress; to see each youngster weekly until discharged; and to be
available on a 24 hour basis for emergencies.
All of the professional treatment staff will be degreed, licensed ,waivered, and/or registered and will meet
CTF requirements per Section 1921 for Social Workers, RN’s, LVN’s, Mental Health Workers,
psychologists and psychiatrists. All staff will be trained in both appropriate medical and psychiatric
interventions and behavioral management techniques.
The Medical Director/Physician will be responsible for medical care standards, coordination.
surveillance (oversight to ensure treatment is carried out as directed in treatment plans), and
improvement planning for in the facility. The Medical Director will be a trained psychiatrist who will
also be responsible for psychiatric services. Counseling services will be provided by licensed clinical
social workers, or licensed marriage, family and child counselors.
Nursing sendees will be under the supervision of a registered nurse with experience in psychiatric
nursing who will be employed for 40 hours a week. In addition, there will be not less than two full time
equivalent(FTE)of nursing staff per 40 clients on each 8-hour shift, during each 24 hour period, on a 7
day (weekly) basis. There will be at least one registered nurse, and a licensed psychiatric technician or
licensed vocational nurse, awake and on duty, in the facility at all times, day and night.
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Synopsis Of The RFP Submission
FY2001
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August 18, 2000
Nursing services will include: planning of client care including an initial written evaluation commencing
at time of admission and completed within 7 days of admission; implementing each client’s care plan;
and notifying physicians promptly regarding admissions, sudden changes in condition, unusual
occurrences involving clients, weight changes, untoward reactions to treatment, medication errors, or
problems. Nursing services will be individualized for each client, designed specifically to meet the
objectives of each client’s interdisciplinary treatment plan.
The nursing staff will provide 24 hour supervision in such matters as eating, personal hygiene, dressing and
undressing, and taking prescribed medications. Nursing staff will also orient the client to the personnel
_ and to the unit and will complete a personal property inventory.
Registered Nurses and Licensed Vocational Nurses will administer medications (either orally or
intramuscularly) as prescribed by the physician. These nursing professionals will be specifically trained to
administer psychoactive medications. Should the administering nurse question a medication order or the
appropriateness ofthe medication, or observe any untoward effect, the prescribing physician or the Medical
Director will be notified immediately before further administration ofthe medication.
Additionally, the nursing staff will be responsible for follow up and monitoring of lab work, X-rays and
other medical needs as prescribed by the attending physician.
Dietary and food services at STARLIGHT CTF are considered an integral part of a youngster’s treatment
program. Special protocols for dietary services will be used that interface with the psychotherapeutic needs
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Synopsis Of The RFP Submission
FY2001
Page 22
August 18, 2000
of youth. These services include special activities such as barbecues, ethnic and cultural food service, and
meal preparation skills training activities.
Close consultation between the dietary and clinical staff will occur surrounding the issues of medication
interactions on appetite and nutrition intake. In order to provide the extensive support necessary for
ensuring adequate dietary compliance, the "family style" of dining will be used, with assigned staff
eating with the youngsters and serving as role models and supervisors.
STARLIGHT CTF will be in operation 24 hours a day, seven days a week. Special treatment
programming will be available each day, 7 days a week and provided by STARLIGHT Adolescent
Center in addition to school programming. The non-public school will be in operation Monday through
Friday for six hours per day, including summer school. Clerical and administrative services will be
available 8:30 am to 5:00 p.m., Monday through Friday.
Specific Services Offered
The average length of participation in the program will be six months, although some students may
participate longer if indicated. Aftercare case management, wrap-around, and other services can be
provided by the contractor up to six months beyond discharge from the Program for those adolescents
eligible to continue to receive these services (based on medical necessity, eligibility for EPSDT, Healthy
Families, or other funding sources). Services to be provided by the Counseling staff include:
1. Weekly individual counseling
2. Daily group therapy (topic focused, such as substance abuse, life skills, anger
management, etc.)
3. Family therapy up to twice monthly
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4. Crisis intervention as needed
5. Collateral and/or case management services as needed
6. Family support groups
7. Coordinated Treatment Planning and linkage to other mental health, health,
substance abuse, vocational and other service providers.
8. Child and Family Team facilitation
Groups will be structured so as to be appropriate to the developmental and cognitive levels of the
youngsters. A schedule of all activities and groups will be posted daily in the facility during both the day
and evening shifts.
Educational Services
^ Educational services will be provided for youngsters at STARLIGHT through a State-certified on-site
Nonnublic School with educational programming that is designed specifically for emotionally disturbed
youngsters.
In this school program, an Individual Educational Plan(lEP) will be developed for each seriously
emotionally disturbed yoimgster in cooperation with the parents or guardians and the youngster's home
school district. This lEP will be integrated into the child's treatment program by the multidisciplinary
treatment team (which will include teachers from the school program). STARLIGHT CTF and
STARLIGHT Adolescent Center staff will work closely with school staff to ensure that the child’s
educational experience is appropriate to his or her emotional needs.
All referred youngsters will receive an educational evaluation, including recommendations for
educational readiness.
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The Staff of STARLIGHT CTF ,STARLIGHT Adolescent Center, and the High School will also work
closely with parents or guardians and the youngsters themselves to facilitate educational progress
through the use of behavioral contracts. In compliance with the Hughes Bill, a written Functional
Behavior Analysis Assessment will be made prior to instituting any behavioral interventions. The roles
of the adolescents, teachers, and parents will be specified in writing in the form of behavioral contracts.
The process of educational services will be initiated within at least seven days after a youngster’s
admission to STARLIGHT CTF. lEP's Avill be completed as soon as possible, preferably prior to or
shortly after admission.
Medications
In order to provide stabilization, psychopharmacology may be necessary for some ofthe youngsters at
STARLIGHT CTF. However, psychoactive medications will be used as sparingly as possible. Staff will
be thoroughly trained in crisis intervention and de-escalation techniques in order to preclude the use of
most psychotropic medications, except in the more extreme behavioral problems, psychosis, or well
documented medical justification.
If medications are used, they will be prescribed by the treating physician and monitored closely by program
staff for therapeutic or untoward effects. The youngster will be informed ofthe medications to be
employed, the expected result of the medication and any significant side effects of medications, especially
psychotropic medications. Consent forms will be signed by the adolescent and the parent or responsible
party; these will become part of the medical record. All psychotropic medications will be administered in
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compliance with Patients Rights procedures and State and County guidelines for such administration.
Medications will be available from a contract service pharmacy on a 24-hour basis. A licensed pharmacist
will review medication administration, policy and procedure, and perform a drug regimen review monthly.
The Medical Director will be responsible for monitoring medication for appropriateness and effectiveness
on a regular basis. All licensed nursing staff will be trained in the administration and monitoring of all
medications, especially psychotropic medications through the use of medication tests and simulated
practices. Medications may be given either orally or intramuscularly. Clients on medication will be
reviewed by the Psychiatrist at least once every thirty(30)days.
— Admissions Process and Criteria
Adrnis.sions Criteria
SI ARLIGHT CTF will accept referrals of seriously emotionally disturbed minors who have been
screened and evaluated for appropriateness for admission by the County Mental Health Department and
Interagency Council reviewing out of home placements. STARLIGHT CTF reserves the right for the
ultimate decision for admission, and will give written reasons for the rejection of any referred youngster.
Admissions Process including Assessment & Treatment Planning
Prior to admission, a Resident Admission Packet will be completed by the STAJRLIGHT CTF Mental
Health admissions designee. The admissions packet must include a signed written statement from the
^ placing county’s or the parent’s county of residence interagency placement committee must certily that:
“The child is in need ofthe level of care provided by a CTF to implement the proposed treatment program
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Synopsis Of The RFP Submission
_FY2001
'’age 26
August 18, 2000
and has been found, by a licensed mental health professional to require periods of containment to
participate in and benefit from mental health treatment.” The admissions designee will review all contents
for completeness. Upon completion, the resident admission packet will be reviewed by and approved by
the facility’s Program Director, Psychiatrist, or licensed clinical social worker, and, whenever possible,
one of these individuals will interview the youngster. Upon acceptance for admission, the youngster will
be admitted as soon as required legal documentation for admission is completed. An Intake Report will
be completed and typed prior to admission and signed by a licensed member of the staff and placed into
the youngster’s medical record.
^Adolescents will only be admitted if the following criteria can be met: (See Policy and Procedure
Attachment #3 for specific details of each situation).
1. They are on LPS Conservatorship and the Conservator has authorized the admission and signed the
Admission Agreement.
2. They have applied to the juvenile court and the court’s consent to treatment is documented by a copy
of the juvenile court’s ruling per Welfare and Institutions Code 6552.
3. The parents of an adolescent under the age of fourteen have both given consent for admission (unless
sole custody is established - in which case the consent of one parent will suffice).
4. The parents of an adolescent between the age of fourteen and seventeen years of age have given
consent as above and;
i. The adolescent has waived a pre-admission “Roger S.” hearing; or
ii. The adolescent has had his due process right by way of a “Roger S.” hearing and the
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FY2001
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decision to admit was upheld
Upon arrival at the facilit}', the youngster will have the facility and services explained to him by the
admissions designee and will receive orientation on his rights, the program rules and expectations, etc.
An admission record containing all identification data required by relevant codes and statutes, as well as
physician and practitioner data will be completed. The youngster will be screened for tuberculosis, and
his personal possessions, equipment, and valuables will be inventoried and identified. The youngster or
his representative will sign an admission agreement describing the services to be provided and the
expectations and rights of the youngster regarding program rules, client empowerment, and involvement
in the program and fees. The youngster will receive a copy of the signed admission agreement. At the
time of admission, the youngster’s preferences will be solicited to aid in determining whether
medication, restraint or seclusion is the least restrictive method for controlling injurious behaviors.
Each admission will result in a comprehensive assessment by all disciplines of STARLIGHT CTF. The
admission assessment is completed within five(5 jdays of admission and a typed copy will be provided
to the adolescent’s parents, conservator or the person designated by the court to manage the placement
within(10) working days of assessment completion. A comprehensive Needs and Service Plan
fTreatment Planl is completed within 15 days of admission. The Needs and Service Plan is developed
by a licensed mental health professional together with the adolescent and his/her parent or conservator.
The admission assessment and needs and services plan both becomes a part of the clients’ medical
record. A written report of a physical examination is provided within 72 hours following the admission
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The referred youngsters will be given comprehensive assessments and evaluations by a multidisciplinary
team. All areas of functioning will be included (e.g., social, emotional and behavioral^pducational;
physical; and psychosocial). A nursing or social service clinician will enter an imtial admission problem
onto the youngster’s treatment plan within 24 hours. Other evaluations will include a psychosocial
assessment ofthe child and the family including an assessment of the level of psychosocial functioning,
the self-care potential, the support network availability, and the needs and strengths of family members
and of the family as a whole.
Initial evaluation, including assessments by a multidisciplinary treatment team including a psvcniatnsi,
social worker, licensed nurse, dietitian and a rehabilitation therapist with a specialty in physn aL art,
dance, music, vocational, or recreational therapy, will be completed within five (5) days of admission.
However,assessment and evaluation will be an ongoing process, and written re-evaluations will be dorie
on a
regular basis and at least monthly. Within days of admission the written assessment (including, at
a minimum: health and psychiatric histories, psychosocial skills, social support skills, current
psychological, educational, vocational and other functional needs or limitations, medical needs, selfcontrol & symptom management)is signed by a licensed mental health professional.
These evaluations form the basis of a comprehensive treatment plan/plan of service. The treatment plan
will include long term goals, current status/level of the adolescent, short term objectives, the specific,
his
measurable process to achieve the objectives, and a discharge plan. Participation of the youngster and
^ or her family or guardian(s) will be encouraged in treatment planning. The treatment plan will document
all psychotherapeutic modalities, the adjunctive therapies, and medications that are to be employed.
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Close monitoring ofthe child’s functioning and offamily functioning will be a part o^ontinuing
planning. Biweekly case oriented meetings will be conducted to discuss treatment planning, discharge
planning and referral and placement needs. The biweekly case staffing will review the progress or
problems of the youngsters in the facility, and staff will discuss the treatment approaches to be utilized.
This meeting will be attended by the supervising youth counselor, therapist, and nursing staff. This
meeting is in addition to the daily roster/case review to occur at least once per shift. Participation of the
clinical staff, including the County DMH case managers will ensure that treatment approaches are
consistent with the documented treatment plans discussed in the clinical case conference.
Evaluation and assessment is a continuing process and takes place not only in treatment planning
meetings, but also in case conferences, staff meetings,supervision meetings, consultative meetings, chart
audits, peer review and utilization review meetings. Treatment outcomes are evaluated in relation to the
current status/level of the adolescent, the objectives achieved, and the potential for discharge. There
will be a physician's progress note whenever the Treatment Plan is reviewed and approved. Should
medication be employed to ameliorate the psychiatric or behavioral symptomatology, the physician will
describe the medication used, the side effects and the response of the adolescent to the medication. If no
medication is being employed, that will be stated in the treatment plan and the physician's progress note.
Continuing Stay Criteria
Each youngster will be evaluated by the Psychiatrist for continuing to meet admission criteria at least
every
ninety (90) days. The outcome of this review will be documented in the clients’ medical record.
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Continued need for stay within the CTF will also be verified by the placing agency’s case manager or
interagency placement committee.
Discharge Planning & Processes
Discharge Planning & Case Management Services
Discharge planning shall be an integral part of each youngster’s treatment program at STARLIGHT CTF.
Discharge planning will start from the day of admission, and continue throughout the course of treatment.
Continued assessment of the child's discharge planning status will occur through review by the facility
Program Director, the multidisciplinary treatment team, and the County DMH case manager
In add'tmn
active participation of the referred youngster and the parent(s) or legal guardian will be songhi toi
discharge planning. Discharge recommendations will be made jointly among the primar>’ therapist and
the DMH case manager.
The objective is to provide long range planning to meet the needs ofthe youngster and his/her family as
well as to take preventative measures to avoid the necessity for repeated crisis intervention and to allow the
youngster and family to appropriately utilize community resources.
Discharge planning will include an evaluation ofthe youngster’s needs for aftercare services to assure
smooth and lasting transition into the community. The discharge program is based on a highly
individualized case management approach in which multifaceted plans are devised by an
interdisciplinary team directed by the resident. These plans coordinate medical and psychological care
and address the specific concerns of the youngster and his family or guardian. The team members meet
frequently with the youngsters in order to assist them in identifying their major strengths and weaknesses
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and in establishing changing transition goals. Although input will be obtained from various sources, the
youngsters’ own personal goals are always the primary focus.
The youngster’s discharge and aftercare plans will be documented in his health record. Complete and
accurate youngster information, in sufficient detail to provide for continuity of care, will be transferred
with the youngster at the time of transfer or discharge. When a youngster is transferred to another
facility, the youngster’s record will be updated to include: the date, time, and youngster’s condition at
the time of transfer; a written statement of the reason for the transfer; and written or telephone
acknowledgment of the youngster, youngster’s guardian or legal representative, except in an emergency.
The staff of STARLIGHT CTF and STARLIGHT Adolescent Center will be familiar with and
knowledgeable about other agencies, organizations, and individuals involved, either directly or
indirectly, in providing mental health services in both the public and private sectors. Contacts will be
made and maintained with significant persons in the referred youngsters’ lives (e.g., family members.
educators, service agency representatives, peer group members, physicians, etc.). Services will include,
but not be limited to, helping significant support persons understand the referred child’s condition and
gaining their input and assistance in implementing plans of service. Due to the high levels of stress that
severely emotionally disturbed youngsters, and especially adolescents, bring to their family members,
family counseling and/or therapy is expected to be an important part of the collateral services provided
by our program.
From day one, identified clients who are referred to the program will benefit from a planning approach
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that is both realistic and adaptable. Plans will have clear paths to success, and be adaptable, so that the
plans can be revised to address the changing needs ofthe clients and their families. The program will
strive to develop effective Child and Family support teams. These teams, which include any positive
support persons in the clients’ and families’ lives (friends, neighbors, co-workers, etc.) as well as
professionals working with family members, will work together to develop a plan that is strength-based
and is focused on continued progress after discharge from the program. Parent participation is seen as a
key element ofthe program to insure each clients success in meeting their individual goals.
Although all members ofthe team have equal input, the initial task of bringing the team together rests on
the program staff, and specifically the Social Workers and Case Managers,
These facilitators will meet
each family in their place of residence or other agreed-upon place, assisting the family in assessing their
strengths, assets, needs and identification of potential members ofthe Child and family Team. Program
staff will also be responsible for 24-hour on-call coverage (by pager or cellular phone), to handle after
hour emergencies. The size and composition of the Community-Based team and the Child and Family
support teams will vary, but program staff will work to establish consistent meeting times, phone
contact, mailed minutes of meetings, e-mail correspondence, and/or internet and web-based sites, to keep
everyone on the team up to date on an ongoing basis. Once again emphasizing the full participation of
the family, facilitators will work with them to rally people who are committed to the overall success of
the clients. The Child and family Team will work toward viewing situations from a strength-based
model, which emphasizes the positive qualities inherent in the clients. With these assets in hand, the
^team can then assess the specific needs of the families and then begin to develop a creative and concrete
plan of action. With a matching of goals and responsible persons to carry out those goals, and accolades
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for progress made along the way, a powerful tool for desired change is produced. These tools, which are
self-sustaining by design, can be utilized while the clients are in the program and after discharge, hence a
full circle of care is created. This wrap around process empowers family members to master challenges
they face and builds their capacity for solving problems.
In order to ensure that the adolescent and her family are linked with the System of Care and all providers
delivering services to or on behalf of the adolescent, case management services will be provided by the
program. School linkage, medical care, dental care, nutritional and other therapeutic care are seen as the
primary linkages before, during and after placement in the CTF. Case Management services continue even
after the adolescent completes the program or as they are mainstreamed into regular classes as long as they
are clinically indicated.
Prior to admission, in home crisis stabilization services are available to the client and their family for up to
72 hours. The client may enter directly into the CTF after appropriate approvals and legal paper work is
completed or enter through the acute psychiatric service. After discharge, the Community Services division
continues with the comprehensive circle of care described above for as long as necessary. These services
are funded through EPSDT MediCal as Mental Health Services, Case Management and Therapeutic
Behavioral services when they become available.
Aftercare services and Re-admission Policy
Aftercare services may include: assessing the youngster’s and family’s needs; exploring available
community resources; making recommendations; arranging for placement; arranging for medication
supervision if indicated; and facilitating referrals to community social, vocational and educational
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FY2001
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services if appropriate, as well as following each child and family in the community to deliver and
ensure appropriate and continued case management and mental health services.
When a youngster is discharged, an agreement will be made with the community resource anchor
,i}e
family receiving the youngster that will enable them to contact STARLIGHT CTF should any problem.^
arise relative to the continuing care of the youngster. Thus, STARLIGHT CTF will have the capability
and make the commitment to serve as a consulting resource to any placement institution or family
member needing assistance in the difficult task of caring for the discharged youth. STAR!I( / I . ‘ • n
follow all children in aftercare through providing necessary services which the child may need fcr
mental health, case management and other needed services.
Although, every effort is made to avoid the need for re-admission, STARLIGHT CTF nonetheless has a
policy of unconditional care to its youngster. This means that STARLIGHT CTF is always willing
readmit youngsters who seek treatment.
Client and Health Records
Health records shall be maintained for each youngster and shall include the following information:
admissions and discharge records identifying data; mental status; medical history and physical
examination results; dated and signed observations and daily progress notes; legal admission
authorization; consultation reports; medication and dietary orders; other applicable evaluations; dated
and signed patient care notes; rehabilitation evaluation; interdisciplinary treatment plan; progress noe.:,'-;
redication records; ti'eatment records of groups and counseling; other reports if applicable (e.g. (i i-.ed
records, lab tests, cardiology/ encephalographic tests, x-ray exams), documentation of patient riglrt;- .nd
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discharge summary. Monthly clinical review reports will be completed by the clients’ licensed clinician.
All documentation will be in compliance of requirements of CTF regulations per Sec^on 1927 of these
regulations.
Client records are kept for all youngsters admitted to or accepted for care at STARLIGHT CTF and
STARLIGHT Adolescent Center. These records are permanent documents, either typewritten or legibly
written in ink, and capable of being photocopied.
The bulk of the youngsters’ records will consist of a comprehensive written Interdisciplinary Treatment
Plan. This plan includes: admission records; an individual plan of service including specific goals.
measurable objectives and treatment responsibilities; daily progress notes by professional and program
staff; at least monthly documentation of reviews by staff and the youngster; monthly reevaluations of the
treatment plan and progress; licensed mental health professionals’ signatures; and the discharge plan.
Information contained in youngster records is confidential and is disclosed only to authorized persons in
accordance with federal, state, and local laws.
All current clinical information pertaining to youngsters’ stays are centralized in the youngsters’ records.
Youngster records are filed in an accessible manner, providing for prompt retrieval when needed for
continuity of care. Young.ster records will not be removed from the facility, except for storage after the
youngster is discharged, unless expressly authorized by the Department.
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Client Rights & Empowerment
STARLIGHT CTF and STARLIGHT Adolescent Center believes that rehabilitation is best achieved by
empowering youngsters and their families to the maximal extent possible. The STARLIGHT CTF and
STARLIGHT Adolescent Center program will use a pro-active, consumer-oriented approach in which
youngsters(and, whenever possible, families) are considered as equal partners and colleagues in the
treatment process.
The input of the youngsters will be encouraged in the formulation, execution, and evaluation or
- treatment and discharge plans. Whenever possible, treatment will be driven by the goals and priorities of
the youngsters. The youngsters’ responsibility in making important decisions for themselves will be
emphasized.
A list of Client Rights will be posted prominently at STARLIGHT CTF in English, Spanish and other
languages representing at least 5% of the County population. Youngsters shall not be subjected to verbal
or
physical abuse of any kind. In addition, youngsters will have the rights: to wear their own clothes; to
keep and use personal possessions; to keep and spend reasonable sums of their own money; to have
access to individual storage for private use; to see visitors; to have reasonable access to telephones to
make and receive confidential calls; to have access to letter writing materials, stamps and mail; to refuse
shock treatment; to refuse lobotomy services.
The youngster has the right to revoke their W & 1 Code 6552 by informing staff who in turn will inform
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the child’s court worker who will then schedule a hearing with the court on this matter.
The preferences of the youngsters will be solicited regarding the use of medication, restraint or seclusion
for controlling injurious behavior. Youngsters will be informed regarding the nature of procedures to be
used in treatment, and will have the right to accept or refuse treatment.
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D A n i D 1 1
H
Exhibit A-1
SANTA CLARA COUNTY MENTAL HEALTH TBS PROGRAM
Draft Procedures:
Therapeutic Behavioral Services (TBS)
Purpose
I.
The purpose of this procedure is to define Therapeutic Behavioral Services
(TBS), outline eligibility for TBS. Clarify service delivery requirements, and
explain authorization for these services.
Definition
Therapeutic behavioral services are a one-to-one therapeutic contact between a
mental health provider and a child/youth plan member for a short-term period of
time. These services are designed to maintain the child'g/youth’s residential
placement at the lowest appropriate level by resolving target behaviors and
achieving short-term goals. A contact is considered therapeutic if it is intended to
provide the child/youth with skills to effectively manage the beh3V!0'(s)
symptom(s)that impedes achieving residence in the lowest appropriate iev.-i
,oi
III.
Service Description
Ic
The person providing therapeutic behavioral services is available on
and
one-to-one
provide individualized one-to-one behavioral assistance
interventions to accomplish outcomes specified in the written treatment plan.
The critical distinction between therapeutic behavioral services and other
rehabilitative Mental Health services is that a significant component of this
service activity is having the staff person on-site and immediately available to
intervene for a specified period of time. The expectation is that the staff person
would be with the child/youth for a designated time period and the entire time the
mental health provider spends with the child/youth in accordance with the
treatment plan would be reimbursable. These designated time periods may vary
in length and may be up to 24 hours a day. depending upon the needs of the
child/youth.
IV.
TBS Eligibility Criteria
The ChildAfouth
1.
Must be full scope MediCal under 21 years old.
2.
Must meet Mental Health Program medical necessity criteria
(attachment 1).
3.
Must be a member of certified class by meeting one of the
following criteria:
TBS/Emergency Procedures
06/05A)0
1
Exhibit A-]
a.
Is Placed in a group home facility. RCL12 or above and/or
a locked treatment facility for treatment of mental health
needs which is not an institution for mental health disease,
or
b.
Has undergone at least one emergency
i
psychiatric
hospitalization related to his/her current
presenting
disability with the preceding 24 months, or
c.
Is being considered by the county for placement in a group
home facility, RCL 12 or above and/or a locked treatment
facility, or
d.
Previously received therapeutic behavioral services while a
member of the certified class.
4.
5.
Is receiving other specialty mental health services.
Without these additional short-term services it is highly likely that
in the clinical judgement of the mental health provider;
a.
The child/youth will need to be placed in a higher level of
residential care, including acute care because of a change
in the child/youth’s behaviors or symptoms which
jeopardize continued placement in current facility, or
b.
The child/youth needs additional support to transition to a
lower level of residential placement. Although the
child/you^ may be stable in the current placement, change
in behavior or symptoms are expected and therapeutic
behavioral services are needed to stabilize the child/youth
in the new environment,
v:
Conditions under
Reimbursable:
1.
which Therapeutic
Behavioral
Servicer:
are
not
Where the need for TBS are solely;
a.
b.
for
the convenience of the family, or other caregivers, physician,
or teacher,
to provide supervision or to assure compliance with -terms and
conditions of probation,
c.
to ensure the child/youth's physical safety or the safety of others,
e.g., suicide watch or
d.
TBS/Emergency Procedures
to
address conditions that arb not part of the child/youth’s mental
health condition.
oe/osAX)
2
Exhibit A-1
2.
For children/youth who can sustain non-impulsive self-directed behavior,
handle themselves appropriately in social situations with peers, and who
are
able to appropriately handle transitions during the day probably do not
need these services.
3.
For children/youth who will never be able to sustain non-impulsive self-
directed behavior and engage in appropriate community activities without
full-time supervision.
4.
VI.
When the child/youth is an inpatient of a hospital, psychiatric health
facility, nursing facility, IMD, or crisis residential program
Service Delivery Requirements
This sen/ice activity is focused on'resolution of target behaviors or symptoms
which jeopardize existing placements or which are a barrier to transitioning to a
lower level of residential placement and completion of specific treatment goals.
Therapeutic behavioral services must be expected, in the clinical judgement of
the MHP provider, to be effective in addressing the above focus to meet the
goals of the treatment plan. Therapeutic behavioral sen/ices are to be decrec-sed
when indicated and discontinued when the identified behavioral benchmarks
have been reached or when reasonable progress towards the behavioral
benchmarks are not being achieved and are not reasonably expected in the
clinical judgement of the MHP provider to be achieved. They are intended to be
short-term, time-limited services and not appropriate to maintain a child/youth at
a specified level for the long-term.
Examples of activities, interventions may include but are not limited to
• Assisting the child/youth to engage in, or remain engaged in, appropriate
activities
• Helping to minimize the child/youth’s impulsive behavior
• Helping to increase the child/youth’s social and community competencies by
building or reinforcing those daily living skills that will assist the child/youth in
living successfully at home and in the community
• Providing immediate behavior reinforcements
• Providing time-structuring activities
•
Preventing inappropriate responses
• Providing appropriate time-out strategies
• Providing cognitive behavioral approaches, such as cognitive restructuring,
use of hierarchies, and graduated exposure
. Collaboration with and support for the family caregiver's efforts to provide a
positive environment for the child
TBS/Emergency Procedures
oe/osAX)
3
Exhibit A-1
Therapeutic behavioral services must be provided by a Licensed Practitioner of
the Healing Arts (LPHA)^ or trained staff members who are under the direction of
a LPHA.
Staff providing therapeutic behavioral services will follow requirements regarding
restraint, which are applicable to the child/youth’s setting or prograrp. Seclusion
is not allowable as a component of therapeutic behavioral services—
VII.
Treatment Plan and Documentation Requirements
There must be a written plan for therapeutic behavioral services, as a component
of an overall treatment plan for specialty mental health services, which identifies
all of the following;
1.
Specific target behaviors or symptoms that are jeopardizing the current
placement or presenting a .barrier to transitions, e.g=, tantrums, property
destruction, assaultive behavior in school.
2.
Specific interventions to resolve the behaviors or symptoms, such
as
anger management techniques.
3.
Specific outcome measures that can be used to demonstrate the
frequency of targeted behaviors has declined and has been replaced with
adaptive behaviors.
The treatment plan that includes therapeutic behavioral services should be based
on a comprehensive assessment of the child/youth and family, if applicable,
strengths and needs. It should be developed with the family, if available, and
appropriate. The therapeutic behavioral services component of the plan should
be: 1) adjusted to identify new target behaviors interventions and outcomes
necessary and appropriate; and
as
2) reviewed and updated as necessary
whenever there is a change in the child/youth's residence.
There must be a written transition plan for TBS from their inception. This
-•v..
transition plan must outline the decrease and/or discontinuance of TBS when
they are no longer needed or appear to have reached a plateau in effectiveness,
and when applicable, a plan for transition to adult services when the child/youth
turns 21 years old and is no longer eligible for TBS. This plan should address
strategies and skills for parents/caregivers to provide continuity of care when
TBS are discontinued.
A progress note is required for each time period that a mental health provider
spends with the child/youth. Significant inten/entions that address'the goals of
the treatment plan must be documented. The progress notes do not have to
justify staff intervention or activities for all billed minutes.
' LPHA are: Physicians, Psychologists, Licensed Clinical Social Workers, Marriage and
Family Therapists and Registered Nurses.
TBS/Emergency Procedures
06A)5AX)
4
Exhibit A-1
The progress notes must be recommended in minutes,
Service time noted in
parenthesis by contract/shift, e.g., 8:00 a.m. to 1:30 p.m. may be included in the
note.
Staff travel and documentation time is MediCal Billable. On-Call time for the staff
person providing therapeutic behavioral services is not MediCal billable. TBS are
not billed as mental health services.
VIII.
Authorization
Therapeutic Behavioral Services will be initially reviewed and authorized by the
respective Rehabilitation Option (R70) Coordinators for a period of 30 calendar
days. The RIO Coordinator may authorize TBS semces by completing a TBS
packet and sending it in to the Mental Health TBS Coordinator within 7 days of
the initial authorization.
The TBS packet must include; 1) the TBS
Authorization/Service Plan and 2) the Notification to DMH Form. See the
attached forms. The packets must be faxed, mailed or hand carried to:
TBS Coordinator,
Family and Children's Service Division
see Mental Health Department
650 South Bascom Avenue
San Jose, California 95128
408.299.6262 Phone
408.971.6932 FAX
Reauthorization must occur every thirty days. Reauthorization will occur if TBS
continues to be effective for the child/youth. The child/youth must be making
A request for
progress towards the specified measurable outcomes.
TBS
Coordinator
5 full
reauthorization, (TBS packet) must be received by the
business days prior to the current authorization expiration and the Coordinators
must notify the Agency of the receipt of the requests.
All inquires regarding TBS should be made to the TBS administrative support
staff person at 408.299.6262. Identify the nature of the inquiry. If it is procedural
in nature, the TBS support staff person will assist the caller. If it is clinical in
nature, the call will be forwarded to the TBS Coordinator.
IX.
Claiming
Billing procedures, reimbursement amounts, cost reporting and cost settlement
Services. Service
procedures are identical to those used for the Mental Health
will
be
notified
of the new
delivery must be recommended in minutes. Providers
treatment codes as soon as they are available. Since this is an EPSDT funded
service, claims will be denied for services, which do not have MediCal eligibility.
This includes assuring that share of cost MediCal has been fully billed for the
months services were delivered. The OSCAR Procedure Code for TBS Services
is 380.
TBS/Emergency Procedures
06A)5/00
5
Exhibit A-1
NOTIFICATION TO DMH
REGARDING PROVISION OF THERAPEUTIC BEHAVIORAL SERVICES
TODAY’S DATE
CHILD/YOUTH’S NAME,
GENDER; □ Male
AGE
SOCIAL SECURJTY NO.
/
Is this a TBS Renewal?
BEGINNING DATE OF TBS
/
□ Female
No
Yes
TBS PROVIDER AGENCY
COUNTY: SANTA CLARA
FORM COMPLETED BY (name);
PRIMARY RESIDENCES FOR CHILDA^OUTH WHILE RECEIVING TBS (check all that apply)
□ Foster Home
Full Address
Name of FH & full address _
□ Foster Family Agency
Name of FFA & full address
□ Family Home
□ Children’s Shelter
□ Juvenile Hall Awaiting Placement
Name of GH & full address
□ Group Home RCL
□ Other (specify & give full address)
CLASS MEMBERSHIP (check one)
□ In RCL 12 of Above
□ Being Considered for RCL 12 or Above
by (name o f placement agency):
□ One Psychiatric Hospitaluadon in proceeding 24 months
Name of Hospital and dates:
□
Previously Received TBS while Class Member?
Where?
When?
SERVICE NEED (check one)
□ To Prcvcrit'Placement in a ITighcr Level of Care
O To EnablcTransition to a Lower Level of Care
TBS SERVICE PLAN
Planned Average Hours of TBS per week
Estimated # of Weeks of TBS
PLACEMENT WORKER (Name)
(Agency)
(Phone)
Submit this form upon initial TBS authorization and upon all requests for renewal authorization to ;
TBS Coordinator
FSeC Administration
Santa Clara Co. Mental Health Department
650 So. Bascom Avenue
San Jose, Ca 95128
Ph: 408.299.6262
Fax: 408.971.6932
FSeC AdministraUon will submit this form to the State Department of Mental Health
If this form is handwrittem please make sure the handwriting is legible.
6
Exhibit A-1
□ Initial □ Reauthorization
Is this request an
/
/
'ate of Referral
Agency Name
r'^'ral Information;
Fax;
Phone number
.inlclan_
Chlldrirouths DOB:
Child/Youth's Age;
That Jepardize Placement or Present Barriers to Transitions_
/
/
Specihc Target Behaviors & Symptoms
Specirtc Interventions To Resolve the Behvaviors or Symptoms:
Specific interventions
That Will Be Used to Demonstrate That the
Specific Outcome Measures
Frequency of Targeted Behaviors Have Declined
Hav
Been Replaced With Adapative Behaviors:
Transition Plan
3au
SVOr Discontinue TBS When They Are No Longer Needed Or Appear to Have Reached a
To Decrease
In Benefit Effectiveness, or A Plan
Reauthorlratlon Request
For Transition To Adutt Services;
Justify need for additiorral TBS, Include
_
progress to date, ongoing
Signatures
need, and IMihood of father Improvement
Date
Disipline
Provider _
Date
Disipline
LPHA;
□
TBS Authorization; pyes
Sen/ice Dates
From
I
No
Reason for Denial:
/
To
I
/
Next Review
Date
I
I
/
I
Authorization Signature^
effective & the child Is making progres
• ReauthorUalion must occur every 30 days,
Note:
toward the t|
Reauth^^Si^l'occur only If TBS conUnuet to be loc lo luthortzatlon e
outcornes. A reouest for Reauthoriratiopn^
SANTA ClARA COUNTY MbN 1AL HbALTH
Therapeutic Behaviors Services
Service Plan
be received 6 full business days pd
Iratkxi.
Individual Name
sm
Provider
-
T
EXHIBITS SUMMARY PAGE
FISCAL YEAR 2001
AGENCY NAME: STARLIGHT ADOLESCENT CENTER, INC.
REPORTING UNIT GROUPING: #13 SCHOOL/CLINIC DAY TREATMENT/OP
SUBMISSION DATE :
08/18/2000
DIVISION: FAMILY AND CHILDREN
MAXIMUM FINANCIAL OBLIGATION
TOTAL
FEDERAL MEDI-CAL AMOUNT(FFP= 51.67 % of Total Medi-Cai Service Costsi
COUNTY GENERAL FUi^
STATE EPSDT REVENUE
$560,241
$280,121
$3,871,212
OTHER
MAXIMUM FINANCIAL OBLIGATION
g:\mhealth\shr1dyl\fy01exhb\fy01 Starlight ALS
)
$898,438
$2,132,412
08/18/2000 1:44 PM
)
)
)
)
SUBMISSION DATE:
EXHIBIT B • ESTIMATE OF PROGRAM FINANCIAL DATA
FISCAL YEAR 2001
REPORTING UNIT GROUPING: #13 School/CHnic Day Troatment/OP
AGENCY NAME: Starlight Adolescent Center, Inc.
July 1. 2000-June 30. 2001
08/18/2000
MODE/
SERVICE
RATE
MEDI-CAL
BASE
REPORTING
SERVICE
FUNCTION
PROGRAM
UNITS OF
PER
FFP
COUNTY
EPSDT
UNIT
FUNCTION
NAME
NAME
SERVICE
UNIT
CONTRIBUTION
REVENUE
43AG2
10:8S-89
Starlight CTF
Santa Clara County
Day Treatment/Full
Medl-Cal/ FFP, County Match. EPSDT
Other/County
Total Day Treatment/Full
43AG1
15:01-09
43AG1
15:60-69
15:70-79
Santa Clara County
Medication Support
Medi-Cal/ FFP, County Match. EPSDT
Other/County
Starlight CTF
Santa Clara County
Starlight CTF
Santa Clara County
Other/County
Total Crisis Intervention
TBS Mental Health Services
15:30-59
Medi-Cal/ FFP, County Match, EPSDT
Other/County
$1.60
0
$1.60
15,126
$3.70
0
$3.70
1,623
$3.08
0
$3,06
1,623
$389,713
$0
$364,521
TOTAL
PROGRAM
COSTS
$0
$754,234
$0
$0
$389,713
$0
$364,521
$0
$764,234
$39,097
$0
$36,570
$0
$75,667
$0
$0
$39,097
$0
$36,570
$0
$75,667
$28.918
$0
$27,048
$0
$55,966
$0
$0
$28,918
$0
$27,048
$0
$55,966
$2,584
$0
$2,417
$0
$5,000
$0
$0
$2,584
$0
$2,417
$0
$5,000
$138,648
$0
$129,686
$0
$268,333
Starlight CTF
Santa Clara County
Total TBS Mental Health Services
130,694
$2.05
0
$2.05
130,894
TOTAL ESTIMATE
43AG2
47,292
15,126
Crisis Intervention
15:10-19
$160.18
47,292
Medi-Cal/ FFP, County Match. EPSDT
43AG1
$160.18
0
OTHER
REVENUE
Starlight CTF
Case Management \ Brokerage
Medl-Cal/ FFP, County Match, EPSDT
Other/County
Total Medication Support
43AG1
4,709
4,709
Total Mental Health Services
Mental Health Program Supplement
County Match
Starlight CTF
Santa Clara County
Total Supplement
I
)
$138,648
199,644
5,092
$0
$0
$0
$598,959
$114,00
5,092
43AG2 I
Mental Health Startup Budget
Slarlup Budget: In FY2000-2001 the Contractor will require startup funds which will be prorated to the users of beds.
$129,686
$560,241
$0
$0
$580,541
$0
I
$0
$580,541
I
$1,261,600 T
$268,333
$1,159,200
$580,541
$0
$0
$580,541
$1,261,600
In FY2000-2001. Contractor's reimbursement up to the Total Maximum Financial Obligation amount is not strictly dependent on the number of units provided or the actual rates as detemlned In their cost report, per
Agreement section 2.9.
Program Start Date: July 2000 / Admission Start: October 2000
dg
TOTAL MAXIMUM FINANCIAL OBLIGATION
FEDERAL MEDI-CAL AMOUNT (FFP« 51.67 % of Total Medi-Cal Service Costs)
COUNTY GENERAL FUND
STATE EPSDT REVENUE
OTHER
TOTAL MAXIMUM FINANCIAL OBLIGATION
g:\mheallh\snr1dyl\fy01exhb\fy01 Starlight ALS
TOTAL
$598,959
$1,842.141
$560,241
$0
$3,001,341
INDEX 4434
08/23/2000 3:47 PM
EXHIBIT B - ESTIMATE OF PROGRAM FINANCIAL DATA
FISCAL YEAR 2001
REPORTING UNIT GROUPING:#13 School/Cllnic Day Treatment/OP
July 1, 2000-June 30, 2001
08/18/2000
SUBMISSION DATE:
AGENCY NAME: Starlight Adolescent Center, Inc.
MODE/
SERVICE
RATE
MEDI-CAL
BASE
REPORTING
SERVICE
FUNCTION
PROGRAM
UNITS OF
PER
FFP
COUNTY
EPSDT
UNIT
FUNCTION
NAME
NAME
SERVICE
UNIT
CONTRIBUTION
REVENUE
A 3AG 3
10:05-89
Day Treatment/Full
Medi-Cal/ FFP, County Match, EPSDT
Other/County
Starlight CTF
Alameda County
15:01-09
Caae Management \ Brokerage
Medi-Cal/ FFP, County Match, EPSDT
Other/County
Starlight CTF
Alameda County
Total Mental Health Services
43AG4
15:60-69
Medication Support
Medl-Cal/ FFP, County Match, EPSDT
Other/County
15:70-79
Crisis Intervention
Medi-Cal/ FFP, County Match, EPSDT
Other/County
Starlight CTF
Alameda County
15:10-19
TBS Mental Health Services
15:30-59
Medi-Cal/ FFP, County Match, EPSDT
Olher/County
Starlight CTF
Alameda County
Starlight CTF
Alameda County
$1.60
7,563
$3,70
0
$3,70
1,623
$3.06
0
$3.08
64,228
$2.05
0
$2,05
Starlight CTF
Alameda County
Total Supplement
2,546
2,546
$182,261
$377,117
$0
$0
$194,856
$0
$19,548
$0
$0
$182,261
$377,117
$18,285
$37,833
$0
$0
$19,548
$0
$14,459
$0
$0
$18,285
$37,833
$13,524
$27,983
$0
$14,459
$0
$2,584
$0
$0
$0
$13,524
$27,983
$2,417
$5,000
$0
$0
$0
$0
$0
$68,032
$2,417
$5,000
$63,635
$131,667
$0
$63,635
$280,121
$131,667
$579,600
$0
$0
$68,032
$299,479
99,414
TOTAL
PROGRAM
COSTS
$0
$194,856
$2,684
64,228
TOTAL ESTIMATE
Mental Health Program Supplement
County Match
CTF Rate Supplement
County Match
$1,60
0
1,623
Total TBS Mental Health Services
43AG3
23,646
7,663
Total Crisis Intervention
43AG4
$160.18
23,646
Total Medication Support
43AG4
$160,18
0
2,354
Total Day Treatment/Full
43AG 4
2,354
OTHER
REVENUE
$114.00
$0
$0
$0
$290,271
$0
$290,271
$290,271
$0
$0
$290,271
In FY2000-2001, Contractor's reimbursement up to the Total Maximum Financial Obligation amount is not strictly dependent on the number of units provided or the actual rates as detemined In their cost report, per
Agreement section 2,9.
Program Start Dale: July 2000 / Admission Start: October 2000
I.
dg
TOTAL M/\XIMUM FINANCIAL OBLIGATION
FEDERAL MEDI-CAL AMOUNT (FFP= 51.67 % of Total Medi-Cal Service Costs)
TOTAL
$299,479
COUNTY GENERAL FUND
STATE EPSDT REVENUE
$290,271
$0
OTHER
$280,121
TOTAL MAXIMUM FINANCIAL OBLIGATION
$869,871
g:\mhealth\shr1dyl\fy01 exhb\fy01 Starlight ALS
)
INDEX 4434
08/23/2000 3:48 PM
)
)
Exhibit B-1
r
Community Treatment Facility Mental Health Funding Sou rces(Summary)
FUNDING SOURCE
FY 00/01
ANNUAL
Medi-Cal FFP
$
898,438
STATE MATCH
$
840,362
1,508,601
MENTAL HEALTH PROGRAM SUPPLEMENT(CGF)
$
870,812
1,423,062
$
1,261,600
S
3,871,212
COUNTY START-UP COSTS(CGF)
$
1,612,857
$
4,544,520
Community Treatment Facility Mental Health Contract(Detailed)
FUNDING SOURCE
FY 00/01
ANNUAL
Medi-Cal FFP
S
898,438
$
1,612,857
State Match
$
840,362
S
1,508,601
Santa Clara County
Alameda County
$
560,241
$
1,010,762
280,121
$
497,838
MENTAL HEALTH PROGRAM SUPPLEMENT
$
870,812
$
1,423,062
Santa Clara County(CGF)
Alameda County(CGF)*
$
580,541
$
290,271
$
1,261,600
$
841,066
$
420,533
$
S
3,871,212
$
COUNTY START-UP COSTS
Santa Clara County(CGF)
Aameda County(CGF)
Actual Estimated Day Rate by County’
Santa Clara County(24 beds)
Aameda County (12 beds)
FY 01
$
948,708
$
474,354
4,544,520
ANNUAL
177:35
108.30
177.35
108.30
'' Based on Mental Health Program Supplement and Start-up Costs for 334 days in FY01 and 365 Annually
...Behavioral Health Center\Budget\CTF Budget Final
08/17/2000
Proposed Payment and Fiscal Monitoring Schedule
For Services Delivered in FY 00-01
Amount
Month^
Amount
Excluded
Amount to
Actual
Budgeted
(AFDC)^
be Paid
Expense^
Jul/Aug-00 $
Sep-00
185,178
$
$ 185,178
$
269,113
$
$ 269,113
$
(48,722) $ 309,499
$
Oct-00
$
358,221
$
Nov-00
$
469,693
$
(103,176) $ 366,517 $
Dec-00
$
580,578
$
(160,496) $ 420,082
$
Jan-01
$
575,578
$
(183,424) $ 392,154
$
Feb-01
$
575,578
$
(185,717) $ 389,861
$
575,578
$
(185,717) $ 389,861
$
575,578
$
(185,717) $ 389,861
$
575,578
$
(196,034) $ 379,543 $
575,578
$
(196,034) $ 379,543 $
Mar-Ol
Apr-Ql
$
May-01
Jun-01
Total
$
ss:316a249“' t
Expense
VARIANCE
Statement
S/DCost
Report
Qtrly 10-30-00
Qtrly 01-30-011 Mini 01-31-01
Qtrly 04-30-0111
Final 07-30-01 Final 10-31-01
1
Assumes 12 months of program operation (first admission 10/02/00)
^ AFDC revenue shortfalls will be reimbursed as start-up costs by the Mental Health Department
^ Contractor will receive the 4 months(Jul-Oct) of costs upfront and subsequently invoice monthly after incurring costs.
...Behavioral Health Center\Budget\CTF Budget Final
08/17/2000
EXHIBIT C
INSURANCE REQUIREMENTS FOR PROFESSIONAL SERVICES CONTRACTS
Insurance
Without limiting the Contractor's indemnification of the County and State, the Contractor shall
provide and maintain at its own expense, during the term of this Agreement, or as may be further
required herein, all insurance coverages and provisions;
A.
Evidence of Coverage:
Prior to commencement of this Agreement, the Contractor shall provide a Certificate of
Insurance certifying that coverage as required herein has been obtained and remains in
force for the period required by the Agreement. The County's Special Endorsement
(Exhibit C-1,see last page of this document)form shall accompany the certificate
Individual endorsements executed by the insurance carrier may be substituted for the
County's Special Endorsement form if they provide the coverage as required. In addition
a certified copy of the policy or policies shall be provided by the Contractor upon request.
This verification of coverage shall be sent to the following address: Santa Clara County
Mental Health Department,645 South Bascom Avenue, San Jose, CA 95128; c/o
Contracts Unit. The Contractor shall not receive a Notice to Proceed with the work
under the Agreement until it has obtained all insurance required and such insurance lias
been approved by the County. This approval of insurance shall neither relieve noi
decrease the liability ofthe Contractor.
B.
Qualifying Insurers:
All coverages, except surety, shall be issued by companies which hold a current policy
holder's alphabetic and financial size category rating of not less than A V,according to
the current Best's Key Rating Guide or a company of equal financial stability that is
approved by the County's Insurance/Risk Manager.
C.
Insurance Required
Commercial General Liability Insurance - for bodily injury (including death)
and property damage which provides limits as follows;
a. Each occurrence
b. General aggregate
c. Products/Completed Operations aggregate
d. Personal Injury
$1,000,000
$2,000,000
$2,000,000
$1,000,000
A minimum of50% of each of the aggregate limits must remain available at all
times unless coverage is project specific.
G.\MHEALTH\lNSURANC\EXH-C-lns-only.doc July 2000
1
2.
General liability coverage shall include:
a.
b.
c.
Premises and Operations
Products/Completed
Contractual liability, expressly including liability assumed under this
Agreement.
d.
e.
f.
3.
Personal Injury liability
Owners’ and Contractors’ Protective liability
Severability of interest
General liability coverage shall include the following endorsements, copies of
which shall be provided to the County
a.
Additional Insured Endorsement:
Insurance afforded by this policy shall also apply to the County of Santa
Clara, and members ofthe Board of Supervisors of the County of Santa
Clara, and the officers, agents, and employees of the County of Santa
Clara, individually and collectively, as additional insureds. Such
insurance shall also apply to any municipality in which the work occurs
and it shall be named on the policy as additional insured (if applicable).
b.
Primary Insurance Endorsement:
Insurance afforded by the additional insured endorsement shall apply as
primary insurance, and other insurance maintained by the County of Santa
Clara, its officers, agents, and employees shall be excess only and not
contributing with insurance provided under this policy.
c.
Notice of Cancellation or Change of Coverage Endorsement:
Insurance afforded by this policy shall not be canceled or changed so as to
no longer meet the specified Coimty insurance requirements without 30
days’ prior written notice of such cancellation or change being delivered to
the County of Santa Clara
d.
Contractual Liability Endorsement:
Insurance afforded by this policy shall apply to liability assumed by the
insured under written contract with the County of Santa Clara.
4.
Automobile Liability Insurance:
For bodily injury (including death) and property damage which provides total
limits of not less than one million dollars ($1,000,000) combined single limit per
occurrence applicable to all owned, non-owned and hired vehicles.
G;\MHEALTH\INSURANC\EXH-C-lns-only.doc August 17, 2000
2
4a.
AircraftAVatercraft Liability Insurance (Required if Contractor or any of its
agents or subcontractors will operate aircraft or watercraft in the scope of the
Agreement)
For bodily injury (including death) and property damage which provides total
limits of not less than one million dollars ($1,000,000) combined single limit per
occurrence applicable to all owned, non-owned and hired aircraft/watercraft.
5.
Workers’ Compensation and Employer's Liability Insurance
a.
Statutory California Workers’ Compensation coverage including broad
form all-states coverage.
6.
b.
Employer's Liability coverage for not less than one million dollars
($1,000,000) per occurrence.
c.
Coverage under the United States Longshoremen’s and Harbor Workers’
Act shall be provided when applicable.
Professional Errors and Omissions Liability Insurance
a.
Coverage shall be in an amount of not less than one million dollars
($1,000,000) per occurrence/aggregate.
b.
If coverage contains a deductible or self-retention, it shall not be greater
than twenty-five thousand dollars ($25,000) per occurrence/event.
7.
Claims Made Coverage
If coverage is written on a claims made basis, the Certificate ofInsurance shall
clearly state so. In addition to coverage requirements above, such policy shall
provide that:
a.
Policy retroactive date coincides with or precedes the Contractor’s start of
work (including subsequent policies purchased as renewals or
replacements).
b.
Contractor will make every effort to maintain similar insurance during the
required extended period of coverage following project completion,
including the requirement of adding all additional insureds.
c.
If insurance is terminated for any reason, Contractor agrees to purchase
extended reporting provision of at least two years to report claims arising
an
from work performed in connection with this Agreement or Permit.
a.
Policy allows for reporting of circumstances or incidents that might give
rise to future claims.
G:\MHEALTH\lNSURANC\EXH-C-lns-only,doc August 17, 2000
3
D.
Special Provisions:
The following provisions shall apply to this Agreement:
The foregoing requirements as to the types and limits of insurance coverage to be
maintained by the Contractor and any approval of said insurance by the County or
its insurance consultant(s) are not intended to and shall not in any manner limit or
qualify the liabilities and obligations otherwise assumed by the Contractor
pursuant to this Agreement, including but not limited to the provisions concerning
indemnification.
E.
2.
The County acknowledges that some insurance requirements contained in this
Agreement may be fulfilled by self-insurance on the part of the Contractor.
However, this shall not in any way limit liabilities assumed by the Contractor
under this Agreement. Any self-insurance shall be approved in writing by the
County upon satisfactory evidence of financial capacity. Contractor’s obligation
hereunder may be satisfied in whole or in part by adequately funded self-insurance
programs or self-insurance retentions.
3.
Should any ofthe work under this Agreement be sublet, the Contractor shall
require each ofits subcontractors of any tier to carry the aforementioned
coverages, or Contractor may insure subcontractors under its own policies.
4.
The County reserves the right to withhold payments to the Contractor in the event
of material noncompliance with the insmance requirements outlined above.
Fidelity Bonds (Required only if contractor will be receiving advanced funds or
payments)
Before receiving any monetary advances under this Agreement, Contractor will furnish
County with evidence that all officials, employees, and agents handling or having access
to funds received or disbursed under this Agreement, or authorized to sign or countersign
checks, are covered by a BLANKET FIDELITY BOND in an amount of AT LEAST
fifteen percent(15%)of the maximum financial obligation of the County cited herein. If
such bond is canceled or reduced. Contractor will notify County immediately, and County
may withhold further payment to Contractor until proper coverage has been obtained.
Failure of Contractor to give such notice may be cause for termination of this Agreement
at the option of County.
G:\MHEALTH\INSURANC\EXH-C-lns-only.doc August 17, 2000
4
Exhibit C-1
SANTA CLARA COUNTY SPECIAL ENDORSEMENT TO BE MADE A PART OF
REQUIRED POLICIES
Unless specifically excluded, the following endorsements are issued to, and form a part of, the policy
number(s) shown below, and are effective on the date indicated at 12:01 am. Standard Time as
stated in the policy.
Endorsements
1.
Additional Insured Endorsement; Insurance afforded by this policy shall also apply to the
County of Santa Clara, and members of the Board of Supervisors of the County of Santa
Clara, and the officers, agents, and employees ofthe County of Santa Clara, individually and
collectively, as additional insured. Such insurance shall also apply to any municipality in
which the work occurs and it shall be named on the policy as additional insured (if
applicable).
2.
Primary Insurance Endorsement:
Insurance afforded by the additional insured
endorsement shall apply as primary insurance, and other insurance maintained by the County
of Santa Clara, its officers, agents, and employees shall be excess only and not conU ibi
with insurance provided under this policy.
3.
Notice of Cancellation or Change of Coverage Endorsement; Insurance affoiucd ov l us
policy shall not be canceled or changed so as to no longer meet the specified Courity
insurance requirements without 30 days’ prior written notice ofsuch cancellation or change
being delivered to the County of Santa Clara at the address shown on the Agreement.
4.
Contractual Liability Endorsement; Insurance afforded by this policy shall apply to
liability assumed by the insured under written contract with the County of Santa Clara.
Name of
Effective Date
Insured
of Endorsement
Insuring
Company
Policy
Insuring
Company
Policy
Signature of Authorized
Insurance Company Representative:
Please print Name/Title/Company
G;\MHEALTH\INSURANC\EXH-C-1.DOC / July 2000
Number
Number
The California Insurance Code, Section 384, specifies that a statement made on a certificate of
insurance does not amend the insurance policy that it describes. This means that if the certificate
IS not accurate, or if an error is made in describing the policy, or the coverages, the insurer is not
required to conform to the certificate. It also means that any statements made on the certificate, such
as the cancellation notice, do not affect the actual policy. If the insurer fails to issue the required
endorsements, the insurance company is not responsible to provide coverage. Therefore, the County
requires actual submission ofendorsements that do implement the required coverages, as well as the
completed certificates. This arrangement materially reduces the potential for
error.
If endorsements issued by the Insurance Company are to be accepted, they must accompany the
certificate and provide for all the clauses shown on the County’s special endorsement.
G:\MHEALTH\INSURANC\EXH-C-I DOC / July 2000
Comprehensive Evaluation Plan
Exhibit E: Legal Entity
FY 2000 - 2001
The Mental Health Department is committed to an evaluation monitoring proc_eSs in the spirit of
program excellence. The clients and families who seek services from the County Mental Health
System must receive services that are of the highest quality, effective, and respectful of their
needs. This exhibit reflects the implementation of the plan and is a provider/legal entity exhibit.
A.
Intent of the Comprehensive Evaluation Plan;
In September of 1998, the Mental Health Department began a stakeholder involvement
process which produced this comprehensive plan for program evaluation. The
Department also conducted an extensive assessment of its current program monitoring
Md program evaluation activities. The proposed plan integrates the Board’s requirements
for performance-based information collection and establishes the basis for an information
and outcome dnven mental health system of care. In addition, the proposed activities
meet the requirements of the State Department of Mental Health and Federal funding
agencies, and account for an ongoing mental health needs assessment of the service gans
in our communities. It is expected that the Plan will;
1.
Create an equitable system for process and performance outcome monitoring of
mental health programs delivered by both contract and county operated providers.
2.
Establish performance-based programs throughout our system.
3.
Develop a comprehensive system for program evaluation to provide the Board of
Supervisors, the Health and Hospital system, the Mental Health Department, the
Mental Health Board and other stakeholders with a concise evaluation and
performance outcome report on each mental health provider.
4.
Establish a program evaluation system that is adaptable, efficient, and accountable.
5.
Integrate information sharing with Comprehensive Performance Management and
Cross Systems Evaluation.
B.
Provider Expectations:
In FY 2000 - 2001,each provider will comply with the following specifications as they
relate to the programs for which they have contracted. It is the responsibihty of the care
coordinator to ensure that the appropriate State evaluation instruments are completed
within the specified time frames. Furthermore, for each treatment program that an
individual chent/consumer enters and exits, a Santa Clara County Functional Assessment
Scale(SCCFAS) will be completed. The SCCFAS is not required at entry and exit from
homeless shelter, supported housing (expect PATH funded Supported Housing) and Day
Socialization programs. The State Performance Outcome Instruments will be
implemented as stated below:
1. Evaluation and Performance Outcome instruments as specified by the California State
Department of Mental Health, the Mental Health Department and as specified in the
"Comprehensive Plan" will be administered at the required time intervals as specified
the Santa Clara County Mental Health Department Policy and Procedure Manual
(policy #249) and as specified below.
in
A. The time frames for collection of Children’s instruments are; intake (to
Mental Health System), sixty (60) days, annually, and at discharge (from
Mental Health System). Children’s instruments required to be collected are:
Child and Adolescent Functional Assessment Scale (CAFAS), Client Living
Environment Profile(CLEP), Child Behavior Checklist(CBCL), Youth Self-
Report Form (YSR), Client Satisfaction Questionnaire(CSQ-8), Youth
Satisfaction Questionnaire(YSQ), and Santa Clara County Functional
Assessment Scale(SCC-FAS).
B. Time frames for collection of Adult instruments arc: intake (to Mental
Health System), annually, and discharge(from Mental Health System).
Instruments required for the Adult data collection are: Client Identification
Face Sheet, Supplemental Client Information Face Sheet, MHSIP Consumer
Survey, Behavior and Symptom Identification Scale(BASIS-32), California
Quality of Life(CA-QOL),and Santa Clara County Functional Assessment
Scale(SCC-FAS).
C. Time frames for collection of Older Adult instruments are: intake (to
Mental Health System),annually, and discharge(from Mental Health
System).Instruments required for the Older Adult data collection are: Older
Adult Pilot Project Face Sheet, Mini-Mental State Examination, MHSIP
Mental Health Survey,SF-12 Health Survey, and Santa Clara County
Functional Assessment Scale(SCC-FAS).
D. Completed instruments shall be provided to Program Evaluation and
Services Research staff in a timely manner.
2. Each provider will submit unaudited financial information to the Department on a
quarterly basis similar to the required cost report information provided at the end of
each contract year beginning 30 days after the end of the second quarter(due dates:
January 30, April 30, July 30)(Exhibit E-1). Additionally, an audited financial
statement will be submitted per contract requirements. Staff information by reporting
unit will be submitted on the revised Personnel Action Request Form.Contract
Agencies(Section 504 - Attachment A,B)-(PARCA)beginning July'l, 2000. A full
staff report by agency and reporting unit will be completed by January 1,2001.
Electronic submissions of quarterly information is acceptable.
D.
Department Responsibilities
I. The Department will provide training on the required instrumentation.
2. Technical assistance will be provided in the preparation, delivery and interpretation of
the required instruments, staffing patterns and financial information.
2
3.
The Department will provide aggregated reports to providers regarding the data
submitted and train agency personnel in the interpretation of said reports. Reports
will be provided to the provider on a semi - annual basis.
4.
The Department will produce summary reports which are not traceable to individual
clients.
3
Exhibit E-1
Info Sheet-Sch A
A
Santa Clara County Mental Health
Medi-Cal/Short-Doyle Cost Report
FYE 6/30/98
Organization Information
egal Entity Name
egal Entity No.:
Enter Name Here
illing Names and Nos.:
Enter Name/Location Here
Enter Legal Entity Number Here
Provider ft
erson Completing Cost Report:
f
ame
Enter Person to call with questions here
Their Title
ddress
Agency Office Address
'hone No.
Enter
ax No.
Enter
tertlfication:
certify, that to the best of my knowledge, the Information provided in the following worksheets is true, correct and
onslstent with applicable instructions and regulations. I will maintain all supporting Information, documentation
nd wort<sheets for review and audit by the Department of Health Services or County of Santa Clara.
tame
Itle
CFO or Director for Agency
>ate
Page 1
Total cost
)
Santa Clara County Mental Hec
1B
)
)
.. I
B
Medl-Cal/Short-Doyle Cost Report
FYE 6/30/98
Ota/ Cost Worksheet:
e^al Entity Name:
Enter Name Here
egal Entity No.:
Enter Legal Entity Number Here
leconciliation of Total Reported Costs To Audited Financial Statements:
Salaries and Benefit
otal Cost Per Audited Financial Statements
Enter
Other
Enter
Total
0 FromAFS
otal Medi-Cal Adjustments
otal Other Adjustments
0_ From Worksheet C - Line 14
0 From Worksheet D - Line 14
otal Mode Cost Reported
0 Worksheet E Total Cost
m
X
ID'
CT
m
Page
I
c
Santa Clara County Mental Health
Medl-Cal/Short-Doyle Cost Report
FYE 6/30/98
Medi-Cal Adjustments Worksheet:
Enter Name Here
Legal Entity Name;
Legal'Entity No.:
Enter Legal Entity Number Here
Summary of Medi-Cal Adjustments:
Salaries and
Enter
1 Enter
Other
Benefits
Description/Purpose'.
Total
Enter
2
4
5
6
8
9
10
11
12
13
To Worksheet B
14 Total
The adjustments on
1.
this worksheet result only from program regulations. The following are typical adjustments:
Reduce Interest Expense by interest income
2. Reduce related organlatlon costs to actual cost
3, Eliminate equipment expenditures and add depreciation expense
4, Eliminate fundraising expense
m
X
5. Offset Other Operating Income
ZT
cr
and reference to the corresponding line
Attach copies of documentation used to compute these adjustments
m
Page 3
)
)
)
wuici nuj• »
Santa Clara County Mental Health
Medl-Cal/Short-Doyle Cost Report
D
)
FYE mom
Other Adjustments Worltsheet:
Legal Entity Name:
Enter Name Here
Legal Entity No.:
Enter Legal Entity Number Here
Summary of Other Adjustments:
Salaries and
Description
Benefits
Other
Total
1 Enter
2
3
4
5
6
7
8
9
10
11
12
13
14 Total
To Worksheet B
The adjustments on this worksheet result only from program regulations. The following are typical adjustments:
1. Eliminate Non Program Costs
2. Miscellaneous Adjustments
m
Attach copies of documentation used to compute these adjustments and reference to the corresponding line.
Page
X
cr
m
Exhibit E-1
Mode & SF Summary - Sch E
E
Santa Clara County Mental Health
Medl-Cal/Short-Doyle Cost Report
FYE 6/30/98
Mode and Service Function Summary:
Legal Entity Name
Enter Name Here
Legal Entity No.:
Enter Legal Entity Number Here
Mode 5 - Inpatient Hospital Services
Description
Mode
Enter
Enter
Total
Neg
Service
Total
Total
Charge
Rate
Cost
Punction
Cost
Units
Per Unit
Per Unit
Per Unit
Enter
Enter
Enter
Enter
Enter
Total For Mode 5
Mode 5 - Other 24hr Sep/ices
Total
Service
Description
Mode
Enter
nter
Cost
Function
Enter
Total
Units
Enter
Enter
Total
Neg
Charge
Rate
Cost
Per Unit
Per Unit
Per Unit
Enter
Enter
Total For Mode 5
Mode 10 - Day Services
Total
Service
Description
Enter
Total For Mode 10
Mode
Enter
Cost
Function
Enter
Enter
Total
Units
Enter
Total
Neg
Charge
Per Unit
Rate
Per Unit
Enter
Enter
Cost.
Per Unit
Exhibit E-1
Mode & SF Summary - Sch E
Santa Clara County Mental Health
Medi-Cal/Short-Doyle Cost Report
E
FYE 6/30/98
Mode and Service Function Summary:
Legal Entity Name;
Legal Entity No.:
Enter Name Here
Enter Legal Entity Number Here
Mode 15 - Outpatient Services
Total
Description
Enter
Mode
Enter
Service
Total
Total
Function
Cost
Units
Enter
Enter
Enter
Charge
Neg
Rate
Per Unit
Per Unit
Enter
(Enter
Cost
Per Unit
Total For Mode 15
Mode 45 - Outreach Services
Description
Enter
Mode
Enter
Total
Neg
Service
Total
Total
Charge
Rate
Cost
Function
Cost
Units
Per Unit
Per Unit
Per Unit
Enter
Enter
Enter
Enter
Enter
Total For Mode 45
Mode 55 - Medi-Cal Administrative Services
Description
Enter
'"oj-it For Mode 55
Mode
Enter
Total
Neg
Service
Total
Total
Change
Rate
Cost
Function
Cost
Units
Per Unit
Per Unit
Per Unit
Enter
Enter
Enter
Enter
Enter
Exhibit E-1
Mode & SF Summary - Sch E
Santa Clara County Mental Health
Medi-Cal/Short-Doyle Cost Report
E
FYE 6/30/98
Mode and Service Function Summary:
Legal Entity Name;
Legal Entity No.;
Enter Name Here
Enter Legal Entity Number Here
Mode 60 - Support Services
Description
Enter
Mode
Enter
Total
Neg
Service
Total
Total
Charge
Rate
Cost
Function
Cost
Units
Per Unit
Per Unit
Per Unit
Enter
Enter
Enter
Enter
Total For Mode 60
]Worksheet B
Grand Tola!- Total Ail Modes
OK
Pane 7
Enter
)
Expense V\ )heet
)
Enter Name Here
Expense Worksheet
FYE 6/30/98
Description
Expense
Allocated
Medi-Cal
Other
Total
Per Trial Balance
Overhead
Adjustments
Adjustment
Cost
Total
Enter Name Here
Expense Worksheet
FYE 6/30/98
Mode / Service Function
Allocated
Total Units
Charge Per Unit
Relative Value
Cost
+
Total
m
X
or
cr
Page"
m
1
Pt Paymei.._ - Sch F
F
Santa Clara County Mental Health
Medl-Cal/Short-Doyle Cost Report
FYE 6/30/98
MedhCal Share of Cost Payments Summary:
Legal Entity Name:
Legal Entity No,:
Enter Name Here
Enter Legal Entity Number Here
Report Payments Collected From Patients or Other Insurance For Medl-Cal Units Only.
Mode
Patient Payments Other Ins. Pmt Medicare Pmts.
Enter
Enter
Enter
Enter
Total
m
X
rr
cr
m
Page 9
)
)
)
Exhibit E-1
Cost Allocation
Santa Clara County Mental Health
Medi-Cal/Short-Doyle Cost Report
FYE 6/30/98
Cost Allocation Description:
Legal Entity Name: Enter Name Here
Legal Entity No.:
Enter Legal Entity Number Here
Method Used To Assign Costs To Mode and Service Functions
1 Relative Value Units Method
2 Time Study
S
3 Direct Assignment in general ledger
4 Other(Describe below)
&
140
m
v-
Attach copies of worksheets used to allocate costs to mode and service functions
Page 10
Section 504 - Attachment A
personnel action requestform
—CONTRACT AGENCIES - tPARCA^
To:
Mental Health Administration
645 South Bascom Avenue
San Jose, Ca 95128
From:
Agency:
Contact Person
Telephone #:
Fax #:
Today’s Date:
Effective Date:
Purpose for PARCA: □ New Hire
□
Leaving Agency
□ Status Change (Indicate change only)
Staff Name:
Sex:
Staff ID #:
□ Male
□ Female
Birthdate:.
SSN #:
Index Code (4-digits; Where staffs time is billed, i.e. F&C, Adult, O/A, etc.):
Ethnicity: □ White
□ African American □ Native American
a Latin American □ Other Spanish
□ Cambodian
□ Japanese
□ Chinese
□ Filipino
Position Title:
□ Mexican American/Chicano
Q Viemamese
o Laotian
□ Other Asian
□ Other Non-White
(i.e. Psychiatrist, Psychiatric Social Worker, MFCQ
Crcdential(s); □ M.D.
□ R.N.
□ DEA Registration □ Clinical Psychologist
□ LPT
GLVN OOTR
License/Registration #:.
write n/a if no license
“
□ LCSW
□ RT □ BBSE Registration
□ MFCC
□ Paraprofession al
Expiration Date:
Last Date Will WorkAVorked:
Langnages:
Certified Bilingual:^
^ary Reporting Unit(s) & FTE for each RU (a provider
can be assigned to multiple units such as .5
FTE in outpatient, .25 day treatment & .25 residential do not
include temporary assignments as a result
of vacation/illncss coverage):
RU#
Additional Information:
FTE
RU#
FTE
RU#
FTE
Section 504 - Attachment B
PARAPROFESSIONAL EMPLOYEE STATUS AND MHRS REQUEST
NAME:
DEGREE:
□
Ph.D. in
□
Master’s in
□
Bachelor’s in
□
Associate’s in
□
None
Years experience in a Mental Health field:
(Provide a work history, from monthlyear to monthlyear)
Mental Health related: If holder of a degree, submit copy with this form.
Rev. 3/00
AND STARLIGHT ADOLESCENT CENTER,INC.,
FOR PROVISION OF MENTAL HEALTH SERVICES
FOR FISCAL YEAR JULY 1,2000, THROUGH JUNE 30,2001
THIS AGREEMENT("Agreement'*)is entered into at San Jose, California, between County
of Santa Clara ("County"), a political subdivision ofthe State of California, and Starlight Adolescent
Center,Inc., a for-profit corporation ("Contractor"). The purpose ofthis Agreement is the provision
of mental health services to residents of County,pursuant to statutes and agreements-with the State
of California. The parties agree as follows:
1.
OBLIGATIONS OF CONTRACTOR
1.1.
Services and Standards. Contractor agrees to supply the services described
in Exhibit A,in the amounts detailed in Exhibit B, which are incorporated herein by reference.
Contractor agrees that services shall be provided throughout the year as indicated in Exhibit A.
Contractor shall provide services to the patient population described in Exhibit A. The parties agree
that any distribution of services between the client categories set forth in Exhibit A i
is
programmatically significant. Contractor further agrees to maintain, at a minimum, the staffing
necessary to meet government licensing and certification requirements and to fulfill program
obligations under this Agreement.
1.2.
Space and Supplies. Contractor will furnish all space, utilities, equipment,
and furniture necessary to provide the services described in this Agreement(including Exhibit A)
at iic v)va.5 expense, except as may be approved by the Mental Health Director. Contractor agrees to
cie.ii! and maintain such space in an appropriate manner.
1.3.
Compliance With Law.
1.3.1.
Licensure. Contractor agrees that all facilities and staff
including, but not limited to, all professional and paraprofessional staff used to provide services will
maintain throughout the term of this Agreement and any extensions thereof, such qualifications,
licenses and/or permits as are required by State or local law or are necessaiy to receive payment from
the Federal government under the Medicare or Medicaid programs. The parties agree that failure
to comply with this provision shall be considered a material breach of this Agreement.
1.3.2.
Compliance with Medicare Rules. Contractor agrees to
comply with the requirements of the Medicare Act,42 U.S.C. section 1395 et sea, and regulations
and niles promulgated by the Health Care Financing Administration,as they relate to conditions of
certification, coverage and reimbursement. To the extent that County develops procedures for
implementing these requirements. Contractor shall follow such procedures. Contractor shall become
responsible for compliance with any changes or new procedures developed by County thirty days ;
after the date of notice ofthe terms ofsuch changes or new procedures, provided however that if an
earlier compliance date is required by federal, state or local regulation, Contractor shall be
responsible for compliance on the date specified in the federal, state or local regulation.
1.3.3.
Compliance with Medi-Cal Rules. Contractor agrees to
comply with the requirements imposed by statutes, regulations and rules governing certification,
G:\MHEALTH\SHRTDYL\SDLBLR\FY2001\2001BLRSTARLIGHT.DOC August 21.2000
1
■^4
coverage and reimbursement by Medi-Cal, including but not limited to the applicable provisions of
the California Welfare and Institutions Code, Title 22 of the California Code of Regulations, the
Federal Medicaid Act, Title XJX of the Social Security Act, 42 U.S.C. section 1396 ets^., and any
applicable regulations promulgated thereunder. To the extent that County develops procedures for
implementing these requirements. Contractor shall follow such procedures. Contractor shall become
responsible for compliance with any changes or new procedures thirty days after the date of notice
of the terms of such changes or new procedures, provided however that if an earlier compliance date
is required by federal, state or local regulation. Contractor shall be responsible for compliance
the date specified in the federal, state or local regulation.
1.3.4.
—
on
Compliance With Other Laws. Contractor agrees to provide
services under this Agreement in accordance with the Bronzan-McCorquodale Act (Welfare and
Institutions Code section 5600 etseq.) and any regulations promulgated thereunder; the applicable
provisions of the Welfare and Institutions Code, Health and Safety Code, and Titles 9 and 22 of the
California Code of Regulations; the ordinances and resolutions of the County of Santa Clara Board
of Supervisors and the applicable policies, procedures and guidelines of County of Santa Clara,
Health and Hospital Systems, Mental Health Department; any State policies as identified in the State
Department of Mental Health or Department of Health Services Letters and in the Cost
Reporting/Data Collection Manual, and any other applicable provision of law or regulation. This
obligation specifically includes an agreement by Contractor to honor the patient's rights set forth in
the above referenced statutes and regulations.
Compliance with Grant Agreements. Contractor shall comply
with the terms of federal and State funding contracts in which the County is a Grantee, and said
1.3.5.
contract provisions shall be deemed a part of this Agreement as if fully set forth herein. ’
1.3.6.
Debarment and Exclusion Provisions. Contractor certifies that
Contractor or its employees, subcontractors or agents have not been convicted of a criminal offense
related to health care nor is Contractor or its employees, subcontractors or agents listed by any
federal or state agency as debarred, excluded or otherwise ineligible for participating in federal or
slate funded health care programs. Contractor agrees that if criminal charges are brought or
debarment or exclusion sought of Contractor or its employees, subcontractors or agents providing
services under this Agreement, the same shall be removed from any responsibility for or involvement
in the provision of services under this Agreement during the pendency of such proceedings and that
Contractor shall notify the County of the pendency of such charges or proposed debarment or
exclusion. Contractor shall indemnify, defend, and hold harmless County for any loss or damage
resulting from Contractor or its employees, subcontractors or agents’ debarment or exclusion.
1.3.7.
Prohibitions on Conflict of Interest and Referrals. In addition
to County's and Contractor’s obligations to comply with applicable federal, state and local laws
respecting the conduct of their respective business and profession. County and Contractor
acknowledge that they are subject to certain federal and state laws governing Conflict of Interest and
Referral of Patients which are in effect or will become effective during the term of this Agreement.
Contractor shall comply with such laws. These laws include prohibitions on:
(1)
Payments for referral or to induce the referral of patients (Cal.
Business and Professions Code section 650; Cal. Labor Code section 3215; and section 1128B of
the Social Security Act); and
(2)
The referral of patients by a Contractor or its employees,
subcontractors or agents for certain designated health care services to an entity with which the
G:\MHEALTH\SHRTDYL\SDLBLR\FY2001\2001BLRSTARL1GHT.DOC August 21,2000
2
Contractor or its employees, subcontractors or agents (or the referring party’s immediate family)
have a financial relationship (Cal. Labor Code sections 139.3 and 139.31, applicable to referrals for
workers' compensation services; Cal. Business and Professions Code sections 650.01 and 650.02
applicable to all other patient referrals within the State; and section 1877 ofthe Social Security Act,
applicable to referrals of Medicare and Medi-Cal patients.)
1.4.
Staff Training. Contractor shall implement and maintain an in-service
training program in which all of the personnel designated on Exhibit A as "professional" shall
participate. Such in-service training program will, at a minimum, cover: (a)treatment review,
(b) case conferences, and (c) confidentiality of client information. In addition, all personnel
providing social services or mental health services will receive training regarding the special needs
and circumstances of persons with disabilities including Acquired Immune Deficiency Syndrome
("AIDS") or AIDS Related Complex ("ARC").
1.5.
Admission Procedures. Contractor shall maintain its client admissions
procedures and eligibility criteria in writing and shall make such procedures and eligibility criteria
available to the public upon request. Such procedures shall be in conformance with the Welfare and
Institutions Code section 5600 et seq.
1.6.
Consent for Treatment. Contractor agrees to obtain a consent to treat each
client covered by this Agreement using a legally adequate consent forai in a specific form or format
pursuant to California Welfare and Institutions Code section 5326.2 or any other statute or
regulation.
1.7.
Maintenance and Confidentiality of Records.
1.7.1.
Maintenance of Records. Contractor shall maintain adequate
-’mical and/or rehabilitation records on each client as indicated by program type. Such
.'.ii, at a minimum, include (a) diagnostic studies, if applicable,(b)a description of the
: ior each patient's care, (c) documentation describing services provided by various
protessionals and paraprofessionals, and (d) documentation regarding client interviews and/or
progress notes. Contractor agrees to maintain such records in the form determined or approved by
the State of California or by the County Director of Mental Health (“Director”). Moreover,
'
t -1 .-
O'
Contractor commits that such records shall be in sufficient detail to facilitate evaluation of the
sewices provided pursuant to this Agreement and shall contain all data necessary to prepare any
reports required by the State Department of Mental Health.
1.7.2.
Record Retention. Contractor shall maintain Client medical
and or clinical records as required by the California Code of Regulations or any other applicable
statuies or regulations. At a minimum,records shall be retained for adult clients for a period often
years from the date of discharge, and records of persons who are under the age of 18 at the time of
treatment shall be retained until either (a) one year beyond the patient's 18th birthday or (b) for a
period often years from the date of discharge, whichever is later. Contractor shall maintain the
rec:>rds longer if required by law.
1.7.3.
Confidentiality. Contractor shall maintain the confidentiality
of die medical and psychiatric records of clients as required by State or Federal law including, but
not inniied to, California Welfare and Institutions Code section 5328 et seq.. California Evidence
Cod
e section 1010 et.. seq. and 45 C.F.R. section 205.50. Contractor shall only disclose such
G:\M1 ir.ALTH\SHRTDYL\SDLBLR\FY200I\2001BLRSTARLIGHT.DOC August 21, 2000
3
information as authorized by law. Within the confines ofthe foregoing. Contractor agrees to provide
information regarding particular clients to qualified professional persons having medical or
psychological responsibility for a client’s care, or for use in conservatorship proceedings.
1.7.4.
Access to Records At Conclusion of Agreement. When this
Agreement expires or is terminated by either party, and is not immediately renewed or extended all
client records shall be delivered by Contractor to County within fifteen (15)working days ofthe ite
of termination upon County’s request. Client records for this purpose shaft include all
medical/clmical records, utilization and peer review records, medication monitoringTecords, and all
fiscal records related to funding received under this Agreement unless Contractor is otherwise
required by law to retain such records. If Contractor is required to retain such records, Contractor
agrees to supply copies of the records to County and to allow inspection ofthe original records by
County upon request. .Although Contractor shall, in this event, have possession of client records and
information. County shall own all such information and records notwithstanding the provisions of
paragraph 1.11.2 below.
1.8.
Financial and Statistical Records. Contractor shall maintain all financial
statistical or accounting records, associated with the provision of each type of service described in
Exhibit A of this Agreement, necessary to support the cost report prepared pursuant to paragraph
2.11 ofthis Agreement. Moreover, Contractor shall maintain
all statistical data necessary to support
the allocation of such costs among programs or types of programs and/or among payers, and shall
maintain auditable records, in accordance with generally accepted accounting principles, reflecting
the methods and calculations used to make such allocations, and such other statistical data as shall
be necessary to satisfy the requirements of State or Federal law. Contractor agrees to maintain such
data in a format specified by the State of California or by the Director.
1.8.1.
Maintenance ofFinancial Records. Contractor shall maintain
such financial records for a period of seven years from the later of the following events;(a) the
termination or expiration of this Agreement, (b)the audit or final settlement of County's
Contractor’s claim for payment by Medi-Cal, if the results of such audit or settlement are not
or
appealed, or(c)the completion of an appeal by County of any adjustments or disallowance made by
a third-party payer on audit. If there is a dispute, audit, or inspection, records must be retained
beyond seven years until the dispute, audit, or inspection is resolved. Contractor shall be responsible
for any disallowances related to inadequate documentation.
1.8.2.
Access to Records, Facilities and ProCTams. Contractor agrees
to allow the Director, and/or any designated auditor of County, the State of California, including but
not limited to officials from the State Department of Mental Health or the. State Department of
Health Services, or any designated official ofDepartment of Health and Human Services or the fiscal
intermediary, or the Comptroller General of the United States, the right to inspect or otherwise
evaluate the cost, quality, appropriateness, and timeliness ofservices performed,to audit and inspect
any books and records of Contractor which pertain to services performed and/or determination of
the amounts payable under this Agreement, and the right to have reasonable access to facilities,
programs, staff, clients/patients, or other material
or
persons such officials deem necessary to
monitor or audit services rendered. Except as otherwise provided in state or federal law, such access
shall be provided during Contractor's normal business hours upon proper notice. (See also paragraph
1.14. below.) ■
G:\MHEALTH\SHRTDYL\SDLBLR\FY2001\200)BLRSTARL1GHT.DOC August 21.2000
4
1.8.3.
Retention and Disclosure of Records. For the purposes of
implementing Section 1861(v)(l)(I) ofthe Social Security Act, as amended, and any written
regulations thereto. Contractor agrees to comply with the following statutory requirements
governing the maintenance of documentation to verify the cost ofservices rendered under this
Agreement, (a) Until the expiration offive years after the furnishing of such services pursuant to
this Agreement, Contractor shall make available.. upon written request to the Secretary of the
Department of Health and Human Services (the "Secretary") or upon request to the Comptroller
General, or any oftheir duly authorized representatives, the contract, and Contractor's books,
documents and records that are necessary to certify the nature and extent ofsuch costs, and (b)If
Contractor cames out any of the duties of this Agreement through a subcontract with a value or
cost of $10,000 or more over a tM'elve month period with a related organization, such subcontract
shah contain a clause to the effect that until the expiration offive years after the furnishing of
such services pursuant to such subcontract, the related organization shall make available, upon
written request to the Secretary, or upon request to the Comptroller General, or any oftheir duly
authonzed representatives, the subcontract, and books, documents and records of such
organization that are necessary to verify the nature and extent of such costs.
1.9.
.
..
Disclosure of Violations and Unu.sual Incidents.
. ^-9-1- Contractor shall notify the Director, by telephone, ofthe violation
of any provision ofthis Agreement within 24 hours ofobtaining reasonable cause to believe that a
violation occurred. Notice ofsuch violation shall be confiimed by delivery to the Director within
72 hom-s ofobtainmg reasonable cause to believe that such violation occurred, a written notice which
.shall describe the violation in detail.
1.9.2. Contractor shall comply with County policies and requirements
reporting of unusual occurrences and incidents.
1.10.
,
.
Treatment of Unsponsored Clients.
1.10.1.
Pursuit of Sponsorship. Contractor shall determine
at or
aooui the time a new client is accepted for services, the existence ofany third party which is or may
become responsible for paying for all or part of the client's services including, but not limited to
Medicare, Medi-Cal or private insurance. Contractor shall make reasonable and consistent efforts
to deienmne possible sponsorship by a third party and shall document such efforts. In the event that
Contractor determines that the client is potentially eligible to have a third party pay for services
Conu-actor shall assist the client in applying for such benefits and in diligently pursuing such
appncation. Failure to comply with the provisions ofthis section shall be deemed a material breach
of th.i3 Agreement.
1.10.2.
Definition of Unsponsored Clients. An individual will not be
considered an eligible unsponsored client for purposes of reimbursement under this Agreement
unle.ss the provisions ofparagraph 1.10.1 have been met in his or her particular case. A patient who
IS gtijerally eligible to have a tlurd party pay for his or her care but who receives services which are
the scope of coverage of such third party may be considered unsponsored. Moreover, if
Contractor can demonstrate, through adequate documentation, that a client is unwilling to cooperate
out.
with the application for benefits from a third party payer, such client will also be considered
unsponsored.
G:\MHEAL.TH\SHRTDYL\SDLBLR\FY2001\200IBLRSTARL1GHT.DOC August 21,2000
1.11.
CountY Client Tracking and Services System1.11.1.
Use of County Client Tracking and Services System. In
recognition of the fact that County's electronic client tracking and services system ("OSCAR
System )is a critical source ofinformation for purposes of monitoring the provision of services and
for obtaining payment for such services. County shall provide Contractor access to such system at
Contractor’s expense. Contractor shall supply such data as the Director may periodically designate,
and input such data into the OSCAR System. Data regarding each client service shall be input within
two (2)business days ofthe date that such services are rendered. The parties agree that, in the event
Contractor cannot satisfy this requirement because the OSCAR system is malfhnctioning, Contractor
shall not be in breach of this Agreement.
1.11.2.
Ownership. County shall be deemed the owner of all data
processing procedures for the OSCAR System including, but not limited to, the computer program,
documentation ofthe programs, computer manuals, and computer program descriptions. Client data
and information entered by Contractor into the OSCAR System and any statistical reports generated
from such system utilizing such information shall be co-owned by Contractor and County during the
term of this Agreement. Upon termination. Contractor may retain a copy of records but will no
longer have access to the OSCAR system or programs. Contractor shall own all original client charts
and other individual client documentation not duplicated in the OSCAR System, except as provided
in paragraph 1.7.4 of this Agreement. Contractor agrees to make available to County, upon its
request, electronic or hard copies of any records or statistical reports generated by Contractor from
the OSCAR System.
1.11.3.
Limitations On Access To Information. Contractor shall not
access client specific information in the OSCAR System except in the following instances:
(a) where the information pertains to a client for whom Contractor has medical or psychological
responsibility for care;(b) where the information pertains to a client for whom or concerning whom
Contractor has obtained consent to access information from the client or his or her guardian or
conservator, or substituted consent in the case of a minor, except when otherwise limited by law; and
(c)information which Contractor is otherwise entitled to access under California Welfare'and
Institutions Code section 5328 ejseq. and section 5510 et seq. For purposes ofsubparagraph (b).
Contractor agrees to utilize a legally adequate consent form and to make available to County any
completed forms upon request. Notwithstanding any other provisions of this Agreement, it is
understood that Contractor shall not use the OSCAR System for services provided outside of this
Agreement.
1.11.4.
Limits on Persons With Access. Contractor shall restrict use
of the OSCAR System to employees of Contractor who have completed County's confidentiality
training program and have been issued individual passwords for the system. Nothing in these
provisions shall be construed to prevent an employee who has properly obtained information from
the OSCAR System from making such information available to another employee of Contractor who
is entitled to receive information under paragraph 1.11.3.
1.12.
Certified Audit.
Within one hundred and twenty (120) days of the
termination date of this Agreement, and within one hundred and twenty (120)days of any June 30
occurring during the period of this Agreement, Contractor shall frimish to Director the report of an
G:\MHEALTH\SHRTDYL\SDLBLR\FY200I\2001BLRSTARL1GHT.DOC August 21,2000
6
audit of Contractors financial records for the period covered since the commencement of the
Agreement or the last audited period, whichever is later, as well as a financial statement for that
_
period, prepared by a Certified Public Accountant, or with the Director's wTitten permission, a Public
Accountant. Extensions of this Agreement shall not extend the date by which this material must be
submitted. Extensions of time to submit the certified audit report and financial statement will be
given where such audit is delayed by County's failure to provide necessary information and may be
granted in other instances at the sole discretion of the Director. Contractor requests for such
extensions must be made,in writing, at least 10 working days prior to the date on which the certified
audit report is due.
1.13.
—’
Performance Outcomes and Client Satisfaction. All Contractors will
comply with State Department of Mental Health performance outcome measurement requirements
and County performance indicators for each mode ofservice as specified in Exhibit E.
1.14.
Contracting Principles. This contract is a Type II service contract subject
to the Resolution of Contracting Principles (Resolution) adopted by the Board of Supervisors on
October 28, 1997. Accordingly, Contractor shall comply with all ofthe following during the term
of this contract:
(a) Contractor shall comply with all applicable federal, state, and local
rules, regulations, and laws.
(b) Contractor shall maintain financial records adequate to show that
County funds paid under the contract were used for purposes consistent with the terms of the
contract. These records shall be maintained during the term ofthis contract and for a period defined
in paragraph 1.8.1.
>1.-
(c) To enable County to determine compliance with the requirements of
i iion and this contract Contractor shall, through its designated representatives, provide to
s designated agents reasonable access to facilities, records, and employees used and
j -n conjunction with the provision ofservices under the contract, except where such access
IS prohibited by federal or state laws, regulations, or rules,
(d) Contractor shall provide to the County Department/Agency
responsible for monitoring the contract, within a reasonable amount of time from receipt by
Contractor of the County’s request for information, with copies of any and all financial audits
completed dunng the term ofthe contract. For the purposes ofthis section, financial audit includes
any final audit report transmitted to Contractor by the auditor, but does not include draft reports,
(e) Contractor shall use County funds paid under this contract for County
services and .shall not use County funds for general employer costs that do not support or otherwise
directly relate to the scope of contracted services. Consistent with the legal and financial provisions
of this contract, this requirement shall not preclude the realization of profit or savings.
^
(f) Contractor shall promptly advise the County DepartmentyAgency
responsible for monitoring the contract of:(1)the issuance of any legal complaint by an enforcement
agency, or of any enforcement proceedings by any Federal, State or Local agency for alleged
violations of federal, state or local rules, regulations or laws, and/or (2) the issuance of citations,
court findings or administrative findings for violations of applicable federal, state or local rules,
regulations, or laws.
G;\MHEALTH\SHRTDYL\SDLBLRVFY2001\2001BLRSTARL1GHT.DOC August 21, 2000
7
(g) As required under the Resolution and the County’s implementing
procedures. Contractor provided to County as a part of the selection process certain information
pertaining to the provision of services under this contract and/or expenditures to be charged under
the contract, including information concerning wages and benefits for Contractor’s employees,
length of service, staff turnover and training, complaints (if any) regarding legal violations, and
collective bargaining agreements and/or personnel policies. Contractor warrants and represents that
the information so provided was complete and accurate.
The failure of Contractor to comply with this Section or any portion thereof, and/or the
breach of Contractor’s warranty thereunder, may be considered a material breach oftills contract and
may, at the option of the County, constitute grounds for the termination and/or non-renewal of the
contract. Contractor shall be provided reasonable notice of any intended termination or non-renewal
on the grounds of noncompliance with this Section, and the opportunity to respond and discuss the
County’s intended action.
2.
COMPENSATION AND BILLINGS
2.1.
Client Financial Responsibility2.1.1.
Determination of Client Financial Responsibility. Contractor
shall determine the personal fmancial liability ofeach client for whom services are provided pursuant
to the Uniform Method of Determining Ability to Pay ("UMDAP") established by the State
Department of Mental Health. Contractor may make therapeutic adjustments to the amount of
client's liability provided that they are consistent with County guidelines. However,in no event shall
the client's fmancial responsibility exceed the actual cost of providing services as determined in the
cost report submitted pursuant to paragraph 2.11 below.
2.1.2.
Entering Client Financial Information Into OSCAR Sv.stem
Contractor shall complete a Payer Financial Form, developed by the State Department of Mental
Health, for each client and shall maintain such form with the client's records and shall enter such
information into the OSCAR system as the Director prescribes.
Collection of Client Financial Responsibility. Based on information input
by Contractor into the OSCAR System on the amount of each client’s liability as determined under
UMDAP,including any therapeutic adjustments consistent with paragraph 2.1.1, Contractor shall
generate a bill for such liability and deliver it to the client or appropriate third party (parent,
2.2.
representative payee, conservator, etc.). Contractor will assist the client or third party in
understanding such bill and in remitting payment. If Contractor has been reimbursed by County for
services for which UMDAP payments have been collected. Contractor shall deduct the
amounts
collected from Contractor’s claim for reimbursement submitted to County.
2.3.
Billings to Medicare for Patient Services. Notwithstanding the provisions
of paragraph 2.2, Contractor shall bill the Medicare program for those services rendered by
Contractor to Medicare beneficiaries which are within Medicare’s scope of covered
services.
Contractor agrees not to charge beneficiaries for such services. Contractor shall bill Medicare
beneficiaries for their personal fmancial liability detemiined under UMDAP. Contractor will make
reasonable efforts in collecting such UMDAP amounts.
G:\MHEALTH\SHRTDYL\SDLBLR\FY2001\2001BLRSTARJLIGHT.DOC August 21.2000
8
2.4.
Bliiingltojvledi-Cal. County will bi]] the Medi-Cal program on behalf of
Contractor for services rendered to
. Medi-Cal beneficiaries which- are within the scope of Medi-Cal
covered services,
using tne provider number assigned by the Medi-Cal program
Contractor shall make eveiy reasonable effort
services.
r
to Contractor,
to maximize billing to Medi-Cal program for eligible
2.5.
•n
Third-Party_^aygrs. Contractor will bill any entitv
financially responsible for all or part ofthe client’s
health care services(third-party payers) and may
m am any amounts collected as a result ofsuch billing. However,if Contract^h^ren pald^y
amn
^ collected ffom Contractor’s
^h^ch third-party
are collected, Contractor shall deduct the
mounts
claim payments
for reimbursement
from County. To the extent that
County reimburses Contractor for services covered and paid by a third party payer. County shall
recoup such reimbursement or offset from amounts owed to Contractor.
,
, ,
Contractor agrees to retain documentation relating to billines to and
payments, whether full or partial, from third party payers and to make such information amiable
County upon reasonable request, in the marmer specified by County.
2.6.
■ u
^
to
Compensation for Serviee.s
^
2.6.1.
Maximizing FTP Reimbursement. In order to maximize
reimbmsement from Federal Financial Participation / Medi-Cal(FFP), the parties agree that ftmds
be used first to match for services
toto Medi-Cal
Med^rf""
County’s
Obligation
patients
andMaximum
only thenFinancial
will be used
to pay will
for the care of patients determined to be
Fo^P-POsesofthi-s Agreement, unitsofsei^iL
Reporting Data Collectic^(cS^DQ 1110^
tom “
Cost
Total
to
P , ,,
,
Maximum Medi-Cal Revenue Pa.ss-fhmnpt. Obligation
Contractor s pass-through revenue frciiTMedi-Cal
m County s Total Financial Obligation; provided, however, that the Director ofMental Health shall
P
2.7.
^ 1 r u,
AcceptanctypfJ^. Contractor acknowledges that, in no event shall
Trerarf'
'°f7"'°7
Obligation as set forth on Exhibit B
The parties acknowledge
and agree that Contractor remains obligated
to provide the level ofservices
ignaled“Exhibits A and B,regardless of whether County's Total Financial Obligation has been
fully exhausted. No guarantee, express or implied,
by County to lent ae tofo
reimbursement for services perforated in excess ofthe unitsisofmade
services set forth in Exhibit B, or for
services provided after the termination date of this Agreement.
2.8.
Contractor’s Submission of Service Reports
’•
Direct Patient Care Sendees. As a condition for pavment for
tor
patient care services regardless of payer source:
payment
G:\MHEALTH\SHRTDYL\SDLBLR\FY200I\200IBLRSTARLIGHT.DOC
August 21,2000
9
County will transmit to Contractor a Preliminary Report generated by
the third business day of each month based on information input by Contractor into the OSCAR
System, listing the services provided to Medi-Cal, and unsponsored clients since the date of last
report.
(b) Contractor shall make such adjustments as are necessary to the report
supplied by County pursuant to subparagraph (a) and transmit such adjustments to County by the
second business day following transmission ofthe report. County will supply to Contractor, on the
next business day after transmission of the adjustments,a final adjusted report. Such jeport shall be
submitted by Contractor on or before the fourth business day ofeach month following transmission
by County of a final adjusted report, on such forms or in such other format as the Director may
periodically specify. All reports shall provide clear and detailed information regarding the services
provided by Contractor.
2.9.
Reimbursement.
2.9.1.
Delay ofPayment When Cost Report Information is T ,atp. The
submission of Cost Report information to the State is critical for the County and all contractors to
be fully reimbursed. Ifthe Contractor is late in submitting cost report information, the Director shall
^^bmission of the Contractor’s monthly payment documents to the
SLVHHS Finance Department. Once the cost report information is provided,the monthly payment
documents will be released to Finance for regular processing of a check.
2.9.2.
.
Reimbursement For FY2000-2001. During Fi^riil
2001 the following provisions shall apply as final reimbursement to Contractor;
following table:
onnn.
(a) The reimbursement for each month shall be in accordance with the
$0
Aug-00
Dec-00 $420,082
Apr-01 $389,861
Nov-00 $366,517
Mar-01 $389,861
,
Sep-00 $763.790
Jan-01 $392,154
May-01 $379,543
Oct-00
$0
Feb-01
$389,861
Jun-01
$379,543'
Total Financial Oblieation = ,S.1.871.21 ?.
Payments do not mclude DFCS AFDC payments, which will be made directly to the provider.
The payment schedule and total financial obligation is based on 12
months of program operation. If program operation is less than 12 months, then at the discretion of
the Mental Health Director, the payment schedule and Total Financial Obligation may be
appropriately prorated.
(b)
Contractor shall submit
an invoice based on the above payment
schedule to the County 10 working days prior to the end ofthe month. County agrees to pay on
an
interim basis, subject to the provisions of this Agreement, within 30 days of receipt of the invoice
submitted by Contractor.
County’s Total Financial Obligation to Contractor shall not exceed
verified expenditures incurred by the Contractor. If actual costs as identified in quarterly expense
^atements are significantly below or above projections, then at the discretion of the Mental Health
Director, the payment schedule and the County’s Total Financial Obligation will be modified
accordingly. The parties recognize that the Mental Health Director’s authority is limited to this
G:\MHEALTH\SHRTDYL\SDLBLR\FY2001\2001BLRSTARLIGHT.DOC
August 21,2000
10
amount and, if it is anticipated that costs will exceed the sum of $4,062,548, the Board of
Supervisors’ approval will be required for any additional modifications or additions offunds to this
contract. Exhibit B-1 and B-2 summarizes funding sources and payment schedule.
(d)
Contractor shall submit quarterly expense statements with substantial
detail. The quarterly statements shall be due according to the following: E'quarter due by October
30,2000; 2"'' quarter due by January 30, 2001; 3'‘' quarter due by April 30, 2001; and 4* quarter due
by July 30, 2001.
(e) The Agreement Budget for FY2000-2001 includes County payment
for certain startup costs. Therefore the following provisions shall apply:
(1)
Contractor may incur start-up costs in support of the services
described in the attached Exhibit A, Reporting Unit Grouping #13 (Reporting Unit 43AGJ.
Contractor shall be reimbursed in accordance with paragraph 2.9.2(a)-(d).
(2)
Except as may be otherwise provided in the Agreement,
Contractor shall furnish and be responsible for all supplies, furniture, telephones, and equipment
necessary for the performance ofthis Agreement.
(3)
All personal property, supplies and equipment purchased in
full or in part from payments received under this Agreement shall become the property of County,
unless otherwise agreed in writing by Contractor and Director.
(4)
All personal property, supplies and equipment purchased by
Contractor in whole or in part under this Agreement shall be so identified and marked by Contractor,
on^'-actor
and
shall maintain a separate detailed list identifying all such items, together with the name
ddress of seller, total cost, and the amount of payment requested, and shall make such list
':fj ^he Director upon request.
(5)
Upon termination of this Agreement, Contractor shall
immediately return all personal property, supplies and equipment purchased in whole or in part with
County funds to County, except as may be specified and approved by the Director.
(6)
Contractor shall prepare and submit an annual inventory of all
personal property, equipment, and supplies purchased in whole or in part with County funds pursuant
to this and previous mental health services Agreements with County. This inventory shall be
provided to County in conjunction with the Annual Fiscal Report.
(7)
Donated personal property, including supplies and equipment,
shall become the property of Contractor or such other person or entity specified by donor.
Contractor shall keep accurate records of all such donations, as well as any donations of services.
Such records shall include the identification of the donors and an estimate of value. Such records
shall be made available to Director upon written request.
2.10.
Advance Payment. Payments in advance of those due may be made to
Contractor to facilitate cash flow, where requested by Contractor, and where approved by the
Director, at his or her sole discretion based on the existence of unusual circumstances. Such requests
for advance payment shall be made in writing and submitted to the Director.
G:\MHE.VLTH\SHRTDYL\SDLBLR\FY2001\200IBLRSTARLIGHT.DOC August 21,2000
2.11.
Cost Report. Contractor shall submit annually a cost report for the period
beginning July 1, through the close of County’s fiscal year, or the termination of this Agreement
whichever occurs first, in accordance with the format required by the State Department of Mental
Health, within 30 days from the date of receipt from County of all information within County's
control which is required for the completion of the cost report. This obligation shall sur\dve the
termination of this Agreement. In addition, the Contractor shall submit a six-month cost report
statement, as specified by the County, which will be diie by January 31, 2001. Tlje cost report
submissions shall be used to adjust the payment schedule and total financial obligation due to
Contractor.
2.12.
Subsequent Adjustments. The parties acknowledge that federal and state
funds, as well as County money will be used to compensate Contractor and that the use and
expenditure of such fiinds may be audited by either state, federal or county agencies Contractor
agrees to cooperate with such audits, to make available all data or documents reasonably requested
by auditors including any documents related to parts of Contractor's organization which are not
directly involved in providing services under this Agreement to the extent necessary to validate costs
or allocations under this Agreement. Contractor shall respond to any audit inquiries or exceptions
made by such officials. Contractor further agrees to take whatever corrective action may be required
to comply with applicable state or federal law.
Contractor shall pay to County the amount of any liability determined on audit and
attributable to unallowable service costs rendered by Contractor or County may offset that amount
from any momes due to Contractor for services rendered. Ifthe audit reflects that additional amounts
are owed for services rendered by Contractor, County shall pay such amounts to Contractor provided
however, that County’s obligation shall not exceed the Total Financial Obligation.
In the event that Contractor disagrees with the determinations made in a state or federal audit.
such determinations. Contractor’s request shall
,County may appeal
^ or allow Contractor to appeal
--
be considered by County unless it believes in good faith that the appeal is without merit or not in
County’s interest. The decision to appeal is within County’s sole discretion. Contractor will bear
the cost of any appeal. Contractor agrees to cooperate frilly in the prosecution ofsuch appeals. If
such appeal results in additional payments to County and if Contractor has already reimbursed
County for its share of the initial audit liability. County shall return to Contractor its pro rata share
of the additional amounts received as a result of the
appeal.
2.13.
Early Termination. If, for any reason,this Agreement is terminated by either
party prior to its expiration date, the total compensation paid to Contractor shall be equal to a
prorated portion of County’s Total Financial Obligation set forth in Exhibit B, based on actual
verified costs incurred; provided however that such amount shall not exceed one tenth of County's
Maximum Financial Obligation for each month or
portion of a month during which this
Agreement is m effect. Final payment of any amounts due shall not occur until after Contractor has
submitted Its cost report in accordance with paragraph 2.11 above, and such cost report has been
audited by the applicable County, State or federal governmental agency. County agrees to complete
Its audit, within twelve months from (a)the end ofthe period oftime to which the cost report relates,
or (b) the end of County’s fiscal year, whichever is later.
2-13.1.
Transfer of Funds. If Contractor wishes to transfer funds
among modes of services, different provider numbers, different reporting units, reporting unit
G.\MHEALTH\SHRTDVL\SDLBLR\Fy2001\2001BLRStarlight.doc Aucjst 21, 2000
12
groupings or service clusters, Contractor must obtain the prior written approval ofthe Director To
receive such approval, Contractor shall provide to the Director, a ^^Titten notice ofa desire to transfer
hinds which shall include a complete and full justification for the proposed transfer Where the
^ount to be transferred exceeds ten percent (10%) of the particular line item amount stated in
Exhibit B, such notice must be provided at least thirt)'(30) days prior to such transfer. Where the
amount is less than ten percent, shorter notice will be accepted. Except as provided in paragraph
2.13.2 below, where the requested transfer will allow the receipt of higher amounts ofFFP, and is
not inconsistent with County goals and objectives, such request shall not be unreasonably clenied.
2.13.2.
..
State and County Funds - Transfers Among Program
County and Contractor hereby acknowledge that State and County funds are allocated
to meet the needs of targeted age groups. Therefore State and County Finding allocations to
individual program divisions may not be transferred from one division to another except under
extraordinary circumstances. Requests for such transfers must be made in writing to the Director;
and the Director must approve such transfers, in writing, prior to the effective date ofsuch transfer’
2.14.
State and Federal Funding Approval. The parties acknowledge and agree
that this Agreement is contingent on the availability of State and Federal funds for the services
described in Exhibit A. In addition, if the State Department of Mental Health disapproves this
Agreement, it will be null and void.
2.15
Change in Exhibits A and B, and Medi-Cal Revenues
With the
Contractor’s wntten consent, the Director of Mental Health shall have the authority to revise or add
to Exhibit A and B provided that such change does not increase the County’s Maximum Financial
Obligation. The Director of Mental Health shall have the authority to revise or add to Exhibits A
and B to rrovide for increased or decreased Medi-Cal/Medicaid revenues.
2.16.
,
Early and Periodic Screening, Diagnosis and Treatment(EPSDTI Prom-am
. - has EPSDT funding included in its budget the following applies; The availability of
^
EPSDT program under this Agreement is contingent upon the State reimbursing
the County under the EPSDT program.
3.
term and termination
3.1.
Ehe term of this Agreement shall commence on July 1,2000 and
shall continue through June 30, 2001, unless otherwise extended by the parties.
3.2.
Extensions. The term of this Agreement may be automatically extended for
an additional period not to exceed twelve (12) calendar months, provided all of the following
conditions are satisfied;
^
(a) Director notifies Contractor in writing that;
(I)
Contractor has been selected to continue to perform services
pursuant to a Request for Proposals or Request for Bids (if any);
(2)
detailed timetable is contained in
Contractor's detailed timetable for performance (if any such
this Agreement) has been adjusted to cover the extension period;
G:\MHEALTH\SHRTDYL\SDLBLR\FY200I\200IBLRSTARLIGHT.r
August 21, 2000
13
(3)
The County Board of Supervisors has appropriated sufficient
funds for the extension of this Agreement.
(4)
Any changes to rate of payment or the amount or kind of
services to be performed by Contractor during the period ofthe extension are specifically identified.
(b) Said extension is approved in writing by Contractor including any
changes stated in the Director's notice.
3.2.1.
Termination for Cause. The Director may terminate this
Agreement, effective as provided in paragraph 3.2.2 below, for good cause after providing written
notice to Contractor. For purposes ofthis Agreement, good cause includes, but is not limited to, any
of the following: (a) material breach of this Agreement,(b) material violation of any applicable
County ordinance or State or Federal law, (c)filing by Contractor for protection under the
bankruptcy laws, or receivership,(d)assignment ofthis Agreement without the written consent of
County,(e)failure to maintain any license or permit required to provide the services specified
Exhibit A or failure to utilize licensed personnel where required by law,(1) failure to maintain
certification by Medi-Cal, where such certification is required, or (g)failing to provide services
under this Agreement in a satisfactoiy manner. The notice oftermination shall specify, in detail, the
basis for County’s decision to terminate the Agreement and shall specify the steps, if any, which
Contractor may take to cure the breach and the time period for compliance. Such notice shall
m
indicate the effective date of such termination.
3.2.2.
Effective Date of Termination For Cause. Such termination
shall be effective on tlie date ofthe notice provided pursuant to paragraph 3.2.1 of this Agreement
or such other date as the Director may specify in such notice. If a violation of this Agreement
provides tlie basis for this termination, and Contractor failed to give notice ofsuch violation pursuant
to paragraph 1.9 ofthis Agreement,the Director may, at his or her discretion, make the termination
effective as ofthe date ofthe violation. Where,however, a violation ofthis Agreement provides the
basis for the termination, and Contractor gave proper notice ofthe violation pursuant to paragraph
1.9 ofthis Agreement, such termination shall not be effective until thirty(30)days after the date of
the notice of termination, or such later date as that notice may provide, except that any violation
which could result in substantial harm to any client may provide grounds for immediate termination
regardless of whether such violation was reported.
3.3.
Termination without Cause. Either party may terminate this Agreement
without cause upon thirty(30) days written notice to the other party.
3.4.
Transition Plan. Upon the termination of this contract for
any reason,
Contractor shall participate in and make arrangements for the orderly transition of client services.
4.
NON-DISCRJMINATION
4.1.
Non-discrimination in Services. Benefits And Facilities. Contractor shall
not discriminate in the admission of patients, assignment of accommodations, treatment, evaluation,
any other respect, on any invidious ground including race, color, religion, creed, national origin
or ancestry, seX', marital status, sexual orientation, age, HIV status, or physical or mental disability,
or in
condition, or impairment as defined in applicable local, State, and Federal laws and regulations!
including the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973
G:\MH EALTH\SHRTDYL\SDLBLR\FY2001\2001BLRSTARLIGHT
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August 21, 2000
14
amended, and implementing regulations. Unlawful discrimination includes, but is not limited to,
the following; providing clients a different level of care than is provided to all other clients;
discrimination in admission practices, such as placement in special wings or rooms or provision of
as
,
separate meals; denying persons any service or benefit; providing to persons any service or benefit
which is different, or is provided in a different manner, place or time from that provided to other
persons under this Agreement; subjecting persons to segregation or separate treatment in any manner
related to their receipt of any service; restricting persons in any manner in the enjoyment of any
advantage or pnvilege enjoyed by others receiving any service or benefit; treating persons differently
from others in determining whether they satisfied any admission criteria, enrollment quota,
eligibility, membership, or other requirement or condition which individuals must meet in order to
be provided any service or benefit; and the assignment oftimes or places for the provision ofservices
on the basis of prohibited discrimination.
4.2.
Appropriate Facilities. Contractor agrees that its facilities will have access
for the disabled to the extent required by Section 504 of the Rehabilitation Act of 1973, the
Americans With Disabilities Act of 1990, and any federal or state provision requiring such access.
4.3.
Non-discrimination in Employment. The County of Santa Clara is an equal
opportunity employer. Contractor shall comply with all apphcable Federal, State, and local laws and
regulations including Santa Clara County’s equal opportunity requirements. Such laws include but
are not limited to the following: Title VII ofthe Civil Rights Act of 1964 as amended; Americans
with Disabilities Act of 1990, the Rehabilitation Act of 1973(sections 503 and 504); California Fair
Employment and Housing Act(Government Code sections 12900, et seq.); and California Labor
Code sections 1101 and 1102.
Contractor shall not discriminate against any subcontractor,
employee, or applicant for employment because of age,race, color, national origin, ancestry, religion,
sexual onentation, mental disability, physical disability, medical condition, political
• TPizational affiliations, or marital status in the recruitment, selection for training
ipprenticeship, hiring, employment, utilization, promotion, layoff, rates of pay or other
iijpensation. Contractor shall give written notice ofits obligations under this clause.
4.3.1.
Notices. Contractor shall post in a conspicuous place such
notices to potential applicants and to employees, setting forth their right to be treated in conformity
with the non-discrimination provisions of this Agreement.
4.3.2.
for employees placed by
Opportunity Employer.
4.4.
or
Position Advertisements. All solicitations or advertisements
on behalf of Contractor shall provide that Contractor is an Equal
Non-compliance. Failure to comply with any of the requirements of
paragraph 4 shall be considered a material breach ofthis Agreement. Such failure shall be grounds
for suspension ofthis Agreement in whole or in part. Nothing in this Agreement shall be deemed
a limitation on the right of County to take any other action with respect to Contractor as a means of
enforcing the anti-discrimination provisions ofthis Agreement as the State may require.
5.
RELATIONSHIP OF THE PARTIES
Contractor shall perform all work and services described herein as an independent
contractor and not as an officer, agent, servant or employee of County. None of the provisions of
this Agreement is intended to create, nor shall be deemed or construed to create, any relationship
between the parties other than that of independent parties contracting with each other for purpose
G:\MHEALTH\SHRTDYL\SDLBLR\FY2001\2001BLRSTARLIGHT.'
August 21, 2000
15
of effecting the provisions ofthis Agreement. The parties are not, and shall not be construed to be.
in a relationship ofjoint venture, partnership or employer-employee. Neither party shall have the
authority to make any statements, representations or commitments of any kind on behalf ofthe other
party, except with the written consent ofthe other party. Contractor shall be solely responsible for
the acts and omissions of its officers, agents, employees, contractors and subcontractors, if any.
r
Contractor’s personnel rendering services under this Agreement shall not have any of the rights
privileges of County or State employees. Contractor and its agents, employees and subcontractors
shall not have any claim against the County or State for any employment privileges and benefits,
including but not limited to vacation pay, sick leave,retirement benefits. Social Security, workers
compensation, unemployment benefits, disability benefits, etc. Notwithstanding any reference to a
managed care plan or system of care. Contractor shall act as an entity separate and apart from the
County, and shall be considered an independent contractor for all purposes, including liability and
or
litigation.
6.
INDEMNIFICATION AND INSURANCE
Contractor shall indemnify, defend, and hold harmless the County,its officers, agents
and employees fom any claim, liability, loss, injury or damage arising out of, or in connection with,
performance of this Agreement by Contractor and/or its agents, employees or sub-contractors,
excepting only loss, injury or damage caused solely by the sole negligence or willful misconduct of
personnel employed by the County. It is the intent of the parties to this Agreement to provide the
broadest possible coverage for the County. The Contractor shall reimburse the County for all costs,
attorneys' fees, expenses and liabilities incurred with respect to any litigation in which the Contractor
is obligated to indemnify, defend and hold harmless the County under this Agreement.
Contractor agrees to comply with the provisions involving indemnification and
insurance as set forth in Exhibit C hereto which is incorporated by this reference.
7.
AMENDMENT
The terms of this Agreement, such as units of service to be provided, nature of
services rendered, the rates per unit of service, or any other provision may be modified upon the
execution by Contractor and the Director on behalfof County of a written amendment specifying the
precise changes to be made. Contractor may submit a written request for amendment at any time;
however, Contractor acknowledges that requests for modification ofthe total units of service, types
of services, rates per unit of services, or other change to the financial or service provisions of this
Agreement shall be approved by County only upon receipt ofevidence ofunanticipated costs or other
appropriate justification for such change. County will act within a reasonable period oftime given
the nature of the requested amendment in determining whether to agree to an amendment.
8.
GENEITAL PROVISIONS
8.1.
Assignment. Rights and obligations under this Agreement may not be
assigned or delegated, in whole or in part, without the prior written consent of the other party.
Contractor shall give County a minimum of 30 days to consider any request to assign, prior to the
proposed effective date of such assignment. Approval for assignment may be granted by the
Director. Failure to obtain prior, written consent to an assignment shall be deemed a material breach
of this Agreement. Upon an authorized assignment. Contractor shall ensure that the terms and
conditions of this Agreement shall inure to the benefit of County and be binding upon the successor
and assignees, except such terms and conditions as may be expressly waived, in writing, by County.
G;\MHEALTH\SHRTDYL\SDLBLR\FY2001\2001BLRSTARL1GHT.DOC August 21, 2000
16
8.2.
, „, .
..
Notices. All notices required to be given under the terms ofthis Agreement
sha 1 be m witmg and shall be delivered in person, transmitted by electronic facsimile, or deposited
inbelow:
the United States mail, certified mail, return receipt requested, addressed to the parties as set forth
County:
Director of Mental Health
Santa Clara County Mental Health Department
828 South Bascom Avenue
San Jose, California 95128
Copy to:
County of Santa Clara, Board of Supervisors
Administration Building
70 West Hedding Street
San Jose, California 95110
Contractor:
Mary Jane Gross, RN, MN
President
Starlight Adolescent Center, Inc.
7700 Edgewater Drive
Oakland, CA 94621
510-635-9705 / FAX 510-635-9716
8.3.
Miscellaneou.s.
(^) This Agreement shall be binding upon the successors, assigns, heirs,
neljciaries of the parties hereto, subject to the provisions of paragraph 8.1 above,
(b) The paragraph headings used in this Agreement are intended solely
■ " - n ee ofreference and shall not in any way or manner amplify, limit, modify or othenvise
> e interpretation of any of the provisions of this Agreement,
(c) As used herein, the masculine, feminine, or neuter gender and the
singular
r Of plural number shall be deemed to include the others whenever the context so dictates.
8.4.
Entirety. This Agreement,including its exhibits, contains the sole and entire
agreement between County and Contractor with respect to the subject matter hereof and shall
sujK.a-- de all prior agreements between the parties as of the effective date hereof The parties
ackiiowledge and agree that they have not made any representations with respect to the subject matter
of this Agreement, or any representations inducing its execution and delivery except such
repic wntations as are specifically set forth herein.
/
/
/
/
/
/
/
/
/
G:\MHf AL T 1 I\SHRTDYL\SDLBLR\Fy2001\2001 BLRStarIight.doc Au:;
21. 2000
17
Severability. In the event any one or more of the provisions contained in
8.5.
this Agreement shall, for any reason, be held to be invalid, illegal or unenforceable in any respect,
it shall not affect any other provision of this Agreement. This Agreement shall be construed as if
such invalid, illegal or unenforceable provision had never been contained herein.
IN WITNESS WHEREOF,the parties have executed this Agreement as of the date set forth below.
COUNTY OF SANTA CLARA
CONTRACTOR
^ bsL jro
^
Date
Date
BY:
Nancy Pena, Ph.D.
0^
BY:
•OL
7
T
/,
Interim Director, Mental Health Department
NAME: />[qrM Jq
TITLE:
ATTEST: Phyllis Perez, Clerk
Board of Supervisors
Date
APPROVED AS TO FORM AND LEGALITY
60
Rima H. Singh i
Deputy County Counsel
D
T ate
AGREEMENT BETWEEN THE COUNTY OF SANTA CLARA
AND STARLIGHT ADOLESCENT CENTER,INC.,
FOR PROVISION OF MENTAL HEALTH SERVICES
EOR FISCAL YEAR JULY 1, 2000, THROUGH JUNE 30, 2001
G:\MHEALTmSHRTDYL\SDLBLR\FY2001\200IBLRSTAJRl
7
August 21,2000
18
STARLIGHT Adolescent Center, Inc.
FY2001
Page 1
August 21, 2000
Exhibit A; Reporting Unit Grouping #13
Family and Children’s Division
FY 2000-2001
Provider Name:
STARLIGHT Adolescent Center, Inc.
Address:
455 Silicon Valley Blvd, San Jose, CA 95138
Provider Number #;
43AG
Reporting Unit #:
Santa Clara 43AG1, 43AG2; Alameda 43AG3,43AG4
Contact Person:
Mary Jane Gross, RN, MN
Program Title:
Program Type:
STARLIGHT Adolescent Center, Inc.
Intensive Day Treatment, Mental Health Services, Med Support,
Therapeutic Behavioral Services, Case Management, Crisis
Intervention Services
Program Address:
455 Silicon Valley Blvd
Telephone:
(510)428-2240
San Jose, CA 95138
Contractor has submitted a response to a State of California Request for Proposal(RFP) dated
r. sj ■ ■
-■.j
0, 1S99 A brief synopsis of the RFP submission is attached to the Exhibit A. Contractor
sria!! pmvide the services set forth in its RFP response, including the services outlined below.
I
DESCRIPTION OF SERVICE INTENT & GOALS
A.
MISSION AND GOALS:
1.
System-wide Service Intent and Goals:
a.
To treat and ameliorate the mental health symptoms and dysfunction
of children and adolescents requiring intensive daily intervention, so
they may be transitioned to a less restrictive and less intrusive level
of care at the earliest possible point.
b.
To provide day treatment and related outpatient services within the
context of the individual’s family, culture, language, and community;
and according to developmental age-appropriate needs.
c.
To deliver individualized intensive day treatment and intensive
outpatient services in the community treatment facility (CTF), clinic,
home, school, and community, as appropriate to the treatment needs
and service goals of the child and family;
d.
To promote coordination and collaboration in care planning efforts
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STARLIGHT Adolescent Center Inc
FY2001
Page 2
August 21, 2000
with other child-serving agencies and institutions involved in delivering
services to the child and their family, to insure comprehensive and
consistent care;
e.
To direct service objectives towards achieving the ipdividual. family
and system desired results as identified in the Mental Health Service
Plan and to move the child to less intensive service.
2.
Program Specific Description of Service Intent & Goals:
a.
To provide intensive day treatment services 7 days/week for children
residing in the STARLIGHT Community Treatment Facility (CTF)
program as well as those who have graduated from the residential
program and are transitioning to lower levels of care.
b.
To reduce the need for Out-of-State Placements
or more acute
psychiatric care services.
c.
To provide case management services, coordinated precare and
aftercare services for children who are being considered for
admission and who
STARLIGHT CTF.
d.
are approaching and/or discharged from
To facilitate admission and discharge as well as to assure continued
coordination of care and resources for all clients.
e.
To provide medication support services by providing appropriate
medication services to ameliorate or stabilize the psychiatric
conditions of the clients in the STARLIGHT CTF
f.
program.
To provide Therapeutic Behavioral Services (TBS), a one-on-one
therapeutic program, designed to maintain the child/youth’s residential
placement in the least restrictive environment. (TBS Procedures
Attached.)
g-
To provide 24 hour/7day/week secure residential treatment services
in a CTF for up to 36 adolescents.
h.
To adhere to the philosophy of providing quality mental health
services within a context of the clienfs culture and in the client's
language. Because of this commitment all efforts will be made to hire,
train and maintain staff who are capable of providing services in a
linguistically and culturally meaningful manner.
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STARLIGHT Adolescent Center, Inc
FY2001
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August 21, 2000
B.
DESCRIPTION OF SERVICES
1.
System-wide Description of Services and Treatment Methods:
Family and Children's Outpatient programs will provide services according
to the MediCal Rehabilitation Option. Available treatment methods will
include intensive day treatment (full day), assessments, medication
evaluation and support services, crisis intervention, individual, group,
collateral and family therapy; and rehabilitation and case management
brokerage services. Services will be provided in a variety of settings,
including the CTF, clinic, school, and community as described in the agency
day treatment program, and as needed by the clients served. Services will
be individualized and take into account each person’s age, maturational
level, culture, family values and structure, educational functioning level and
physical health.
2.
Program Specific Description of Services and Treatment Methods;
a.
Day Treatment
The STARLIGHT Day Treatment Program will serve up to 44 students
and their families. Up to 36 of the students will be residents of
STARLIGHT CTF and 8 will be graduates of the STARLIGHT CTF
who are transitioning from the CTF program. The Day Treatment
Program is distinct and in addition to the School Program provided.
Intensive day treatment services will be provided 7 days/week for
children residing in the STARLIGHT CTF program and 5 days/week
for those who have graduated from the residential program and are
transitioning to lower levels of care. The intent of these services will
be to reduce the need for State Hospital, Out of State Placement or
more acute psychiatric care services.
b.
Therapeutic Behavioral Services(TBS)
The STARLIGHT TBS program will provide an on-site, individualized,
one-to-one behavioral assistance program. It will provide short term
immediately available interventions to clients under age 21 meeting
state requirements. It will provide children/youth with skills to
effectively manage the behavior(s) or symptoms that are a barrier to
achieving and/or maintaining their placement at the STARLIGHT CTF
program.
c.
Community Treatment Facility(CTF) Services
The STARLIGHT CTF program will provide residential treatment
services for clients under the age of 18 on a 24-hr/7day/week basis
to youngsters requiring a secured treatment facility due to their mental
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STARLIGHT Adolescent Center, Inc
FY2001
Page 4
August 21, 2000
disorder. Seoyices will include 24 hour nursing care, activity program
treatment and rehabilitation and psychiatric services.
d.
Case Management Sen/ices
STARLIGHT case management services will provide coordinated
precare and aftercare services for children who are being considered
for admission and who are approaching and/or discharged from
STARLIGHT CTF. With these services, STARLIGHT will facilitate
admission and discharge as well as assure continued coordination of
care and resources for all clients.
e.
Medication Support Services
STARLIGHT medication support services will provide appropriate
medication services to ameliorate or stabilize the psychiatric
conditions of the clients in the STARLIGHT CTF program.
f.
Crisis Intervention Services
STARLIGHT crisis intervention services will provide emergency
intervention to STARLIGHT graduates to reduce the likelihood of their
needing to return to placement.
POPULATION SERVED
A.
ACTIVE CASELOAD AND LENGTH OF SERVICE
TARGET %(+/- 5%)
Active Caseload;
Day Treatment Intensive
44
Medication Support Services
Case Management Services
44
44
TBS Services
CTF Services
36
Total Clients Served/Year;
88
36
Service Duration:
0-2 months
05%
3-6 months
30%
7-12 months
60%
over 13 months
05%
The length or duration of service will depend on individual needs. The average
length of service will be 9 months.
B.
ETHNIC PROFILE
White
G:\MHEALTH\SHRTDYL\ExA FY01\SlarlightExA.doc
TARGET %
40%
STARLIGHT Adolescent Center Inc
FY2001
Page 5
August 21, 2000
Hispanic
Asian
40%
10%
Black
5%
American Indian
2%
Other
3% ^
STARLIGHT intensive outpatient services include children from diverse cultural
backgrounds from through out Santa Clara County. We have an on-going multi
cultural emphasis and are v/orking with our referral sources to address the under
served diverse populations.
C.
AGE
0- 5
6-12
13-17
18-59
60+
D.
SERVICE REGION
i <orth
Louth
East
'est
E.
TARGET %
0%
5%
93%
2%
0%
TARGET %
10%
30%
50%
10%
DIAGNOSTIC SPECTRUM & FUNCTIONAL IMPAIRMENT
Provider will serve youth clients whose problems fall within a broad range of both
diagnostic and functioning categories. Contractor's estimated caseload diagnostic
profile is listed below;
DIAGNOSTIC PROFILE
DISTRIBUTION OF DIAGNOSES
TARGET %(+/- 5%)
Psychotic
PTSD
Major Depressions/Mood Disorders
Disorders of Bodily Functions
5%
15%
20%
3%
Behavioral Disorders
48%
Anxiety
Adjustment Disorders
15%
Other
G:\MHEALTH\SHRTDYL\ExA FY01\StarlightExA.doc
8%
10%
STARLIGHT Adolescent Center Inc
FY2001
Page 6
August 21, 2000
FUNCTIONAL IMPAIRMENT
In addition to diagnostic assessment, Contractor will assess youth clients and
families with respect to impairments in functioning in seven ar@as. Estimated
targets in each functional area are listed below. Numbers represent the percent of
clients served who will have scores of 1 or 2 (most impaired) on the Functional
Assessment Scale.
TARGET %(+/- 5%)
Self care
0%
School/job performance
90%
Moods/emotions
70%
Behavior towards others
70%
Substance abuse
20%
Family Functioning
Cultural Adjustment
70%
15%
SERVICE FREQUENCY
0-5 hours per week
6-10 hours per week
over 10 hours per week
0%
5%
95%
PROGRAM PERFORMANCE STANDARDS
A.
REFERRALS;
All referrals to providers in the Family and Children’s services for mental health
services will be documented and summarized according to procedures developed
and agreed to by the provider system.
STARLIGHT Adolescent Center will accept referrals only through the County
Resource and Intensive Services Committee (RISC) Team. Adolescents who are
deemed appropriate for admission by RISC will not be refused or discharged by
STARLIGHT absent substantial good cause. Substantial good cause may include
violation of licensing regulations.
B.
ASSESSMENTS;
All referrals for services will be assessed for eligibility according to the following
criteria:
1
Evidence of symptoms of mental health problems which meet the criteria for
diagnosis in the DSM IV; and
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STARLIGHT Adolescent Center Inc
FY2001
Page 7
August 21, 2000
2.
Evidence of impaired functioning in one or more of the areas of self-care
behavior towards others, family functioning, school performance’
moods/emotions, substance abuse, and/or cultural adjustment, as measured
by the Functional Assessment Scale; and/or,
3.
Approved AB3632 eligibility through the Family and Children’s Division
AB3632 Program.
4.
TBS services will be provided to Agency clients only and will follow the
guidelines established by the State Department of Mental Health and the
Santa Clara County Mental Health TBS Program Draft Procedure (Attached).
At the time of intake, the clinician will begin a comprehensive youth and family
assessment, consistent with the guidelines provided by the MediCal Rehabilitation
Option. These details are described more fully in the next section. The clinician will
formulate a DSM IV diagnosis for the youth, a description of the systemic family
dynamics, and a family and child strength assessment using information gathered
from family meetings, individual interviews, observations, and input from the
teacher, aide, and adolescent specialist.
Within 30 days after admission, the clinician will present the initial assessment of
the youth at a staffing attended by the interdisciplinary treatment team. At this time
the assembled group will develop initial long and short-term treatment goals for the
youth. The long-term goals will include the return of the child to a less restrictive
setting. The short term goals will address current behavioral difficulties, and are
ntten in measurable behavioral terms and stated in positive language. The goals
ill be updated by the whole team every six months or earlier, if needed.
The clinician will be responsible for maintaining clinical records and seeing that the
necessary clinical and management information forms are completed on schedule.
C.
HOURS OF OPERATION PLAN;
1.
System-wide Requirements:
STARLIGHT Adolescent Center operates on a 24-hour/7day/week basis.
2.
Specific Hours of Operation Plan;
Intensive Day Treatment occurs daily from 3pm - 8pm seven days/week
TBS services are available on a 24 hr/7day/week basis; Case Management
and Med Support are typically provided M-F from Bam - 5pm
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STARLIGHT Adolescent Center, Inc.
FY2001
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August 21.2000
D.
DISCHARGE:
Clients shall be discharged: 1) Upon mutual agreement (client and therapist) that
the goals of treatment have been met; 2) Upon parent or gua/dian refusal of
services
or refusal to comply with objectives outlined in the Mental Health Services
Plan; 3) Upon parent or guardian's unilateral decision to terminate treatment; 4)
Upon a determination that the individual is a substantial danger to other youth or
staff; or 5) Upon transfer out of the County or to another region. Appropriate follow
up or other service linkage will be made.
E.
ADMINISTRATIVE PARTICIPATION:
A suitable representative of the Provider shall attend provider meetings regularly,
training sessions, seminars or other meetings as scheduled by the Director of
Mental Health or his/her designee.
IV.
STAFFING
A.
MINIMUM STAFFING REQUIREMENTS:
Staffing shall be provided at least at the minimum licensing requirements of ShortDoyle Medi-Cal Rehabilitation Option regulations to the extent they are applicable
to this program; and consistent with any applicable regulations contained in Titles
IX, XIX and XXII.
B.
ADDITIONAL STAFFING REQUIREMENTS:
The following additional experience, training and skills will be required of staff in this
program:
1.
Understanding of psychopathology within the ethnically diverse clients’ cultural
context.
2.
3.
Knowledge of the values of the ethnically diverse client population.
Knowledge of the socio-historical situation of the ethnically diverse client
population.
4.
Capability for addressing the diverse levels of client acculturation and
5.
Knowledge of the multicultural experience.
biculturality.
6.
Knowledge of the local community resources, within the county’s ethnic
communities available to the client population and their families.
7.
Ability to engage the families of the ethnically diverse client population.
G;\MHEALTH\SHRTDYL\ExA FY01\StarlightExA.doc
STARLIGHT Adolescent Center Inc
FY2001
Page 9
August 21, 2000
c.
PROJECTED STAFF LISTING:
m
;-i
OF
m
y-r'
.’KiY
LICE^
•A
Trf'
■r.
W:
8S
1.0
7.5
m§
-s
5
Director of Social
Services
LCSW/MFT
QMHP’s
QMHP’s
0.5
Psychiatrist/M. D.
6.0
Support Counselors
6.0
Clinicians
M.D.
LCSW/MFT
STARLIGHT will make every reasonable effort to recruit staff so that there will be
language coverage in the two threshold languages for Santa Clara County of Spanish and
iii.,'.® ..u.uion® a reasonable
there willgood
be staff
are knowledgeable
of African American culture
faithwhoeffort
will be
made to recruit staff who are
s I
"^hnic groups in the client
CULTURAL KNOWLEDGE SKILLS:
Contractor shall attempt to provide culturally competent services as set forth in the
description provided by Contractor to the Director.
G;\MHEALTH\SHRTDYL\ExA FY01\StarlightExA.doc
t AniB1 I
continued
STARLIGHT Adolescent Center, Inc,
Synopsis Of The RFP Submission
FY2001
Page 10
August 18, 2000
STARLIGHT Adolescent Center, INC.
Program Overview
—
STARLIGHT Adolescent Center, Inc. will offer a comprehensive approach to providing a full spectrum
of mental health services for clients residing at STARLIGHT Community Treatment Facility (CTF),
Inc., a nonprofit 36 bed Community Treatment Facility licensed through the State Department of Social
Sciences, Community Care Licensing and certified by the State Department of Mental Health. The
Community Care Licensed CTF equivalent to an RCL level 14 residential treatment program provides
care for both male and female clients. The residents of this CTF will utilize the STARLIGHT
Adolescent Center, onsite, seven day per week intensive Short/Doyle Medi-Cal certified day treatment
program and attend an onsite certified non-public school. The goal will be reduce acute inpatient
care
for adolescents in the County. The model presented will utilize 24 hour/7 day/week nursing supervision,
psychiatric services and daily comprehensive treatment intervention provided by STARLIGHT CTF,
Inc.. An Intensive Day Treatment Program will be provided by STARLIGHT Adolescent Center, Inc.,
as well as a nonpublic certified High School, STARS High School, Inc.. A comprehensive program
with a rehabilitative and resiliency based model of groups and services will be stressed offering
extensive work in the areas of self-sufficiency, skills development, problem oriented treatment, and
independent living skills. The program will strive for complete cultural competency with regard to
staff, program and community involvement.
Aftercare services will begin prior to discharge from the CTF and are designed to assure the highest
likelihood of successful community reintegration possible. Exiting youngsters will have opportunities for
gradual transition with space for participation for eight clients in the intensive day treatment program and/or
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Non-Public school until smooth transitions to community schools can be made. Two dedicated staff
members will be available to work with the child, family, school and community to, provide
services
assisting the child and family in their transition from the program to the community. These services will
be delivered in the child’s home, school or wherever the services are needed.
1. Philosophy and Mission Statement
STAJILIGHT Adolescent Center and STARLIGHT CTF will be committed to offering and maintaining the
highest quality ofcare and life to each ofthe children entrusted to their care. Programs will stress self-reliance,
positive youth development, and enhancement of the quality oflife and achievement ofindependence. The
goal of each program will be to prepare each child for future success, including mental health,independent
d effective social and vocational achievement. The approach in managing programs will be to provide
an extensive program of orientation and on-going staff education with a focus on teamwork, ongoing quality
achievement, and a responsive management team to ensure that the program provided has solid results, and
is easily able to adapt to changing client and consumer concerns in a culturally sensitive atmosphere. A special
focus will be placed on providing specific treatment programs and pathways for youngsters with specific
clinical syndromes. Program offerings will include group and individual therapies, skills training, behavior
modification, a variety of activity therapies and one-to-one interactions through an approach that is solidly
anchored in a well supervised therapeutic milieu. All activities and interactions are processed through this
therapeutic rehabilitative milieu, so that everyday activities of daily living can be a source of therapeutic
stabilization, impact and change.
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The psychiatric treatment programs reflect the belief that children benefit from community placement versus
state hospital, that positive peer culture is a powerful source of adolescent influence and persuasion, and that
all staff need to be trained to “catch the child doing something right”. The goal of treatment is to return
children to their natural family setting(or alternative family setting) as soon as they achieve an appropriate level
of personal responsibility. STARLIGHT Adolescent Center and STARLIGHT CTF will utilize staff
experienced in providing psychiatric treatment for male and female adolescents from many ethnic or cultural
groups, religions, and national origins. All of its programs will reflect the demographics of the County and
community both in clients and staff. The population served will be County contracted and gate-kept by the
County. Approximately 70% of the population will be of minority backgrounds. Contractor will conduct
regular cultural awareness programs for both clients and staffto dispel ignorance, shape values and behaviors,
and heighten acceptance and sensitivity in responding to cultural and ethnic differences. The Programs will
be proactive in efforts to recruit staff who reflect the culture and values of the clients and their families.
Although Contractor will recognize cultural differences. Contractor will also recognize and strongly support
cultural similarities and stresses these similarities in its work with children and their families
The STARLIGHT program philosophy reflects a philosophy of“positive youth development”. The programs
will be composed of a unique combination of clinical and strength based programs, focusing on skills building,
transition to adulthood, and resiliency support. The program goals will be to return the adolescent to their
community setting with family or other caregiver and within the public school system.
• Global Collaboration will be practiced in each of the Contractor’s programs. The importance of
integrating all available resources into an individual’s treatment will be recognized in
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comprehensive interdisciplinary treatment plans which involve the adolescents, their families and
all the significant people and agencies which intersect with the adolescents’s lives.
*
Equally important will be an emphasis on Family involvement. Families are an integral aspect of
assessment, intervention, and evaluation. Families are considered to be equal partners in the
formulation, execution and evaluation oftreatment plans. The Contractor’s interventions will be
family driven.
Consumer participation -Youngsters and their families will be partners and colleagues in not
only the treatment processes, but also in the focus, design and refinement of the program.
Consumer surveys will occur biannually with clients, family, referral sources and other members
of the system of care and these will be used in fine tuning the program.
Serfices will be results oriented and committed to realizing specific short and long-term goals
+ - 'oungsters and their families. Specific measurable and time limited goals and objectives will
■ formulated for each child. Program effectiveness will be regularly monitored internally using
untion analysis and standardized psychiatric, behavioral and achievement measurement tools.
*
Culturally competent services will include services to any ethnic/ancestral group, race, sex,
sexual orientation, religion, or national origin. Contractor will actively strive to have its staff
reflect the cultural & linguistic backgrounds ofthe clients and the community. English and Spanish
language services will be available routinely in the program. Contractor will practice mutual
understanding and respect and teach the children and staff to be proud of their culture, and see
diversity as an opportunity to know and understand each other.
s
Comprehensiveness in Contractor’s programs will be demonstrated by offering a full array of
sc: vices for the child and family and by recognizing and utilizing the full network of services within
•ihe community system of care.
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• Transitional services which assist the adolescent and family to move from a highly structured
system of treatment and intervention to a family setting with outpatient resources will be a key to
Contractor’s success. This is where all factors including collaboration, family involvement,
cultural competence and coordination of care become more critical than at any time. Significant
time and energy will be spent in interagency planning and coordination to make this step work as
all outcomes depends on its success.
The Program will demonstrate its ability to collaborate and coordinate its services with the system of care of
each individual commumty by participation in interagency teams, community forums, coordination with the
County mental health program, social services, probation and schools. STARLIGHT Adolescent Center will
utilize EPSDT funding, Short/Doyle Medi-Cal, and various creative funding techniques to offer not only
services which are reimbursed by Medi-Cal, but also nontraditional services which enhance commuraty
functioning, family cohesiveness and community reintegration. Examples ofthese activities include childcare,
fishing trips,family picnics,job coaching and other supportive services which support the child and family
on
their “turf’.
2. Target Population To Be Served
A. Age Range
Minors between the ages of 11 years and 18 years are eligible for admission to STARLIGHT CTF and to
receive treatment by STAILLIGHT Adolescent Center, Inc.. It is expected, however, that the vast
majority of the referrals will be in the age range between 13 and 16 years.
B. Gender
Both males and females are eligible for admission to STARLIGHT CTF and to receive services from
STARLIGHT Adolescent Center Inc..
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C Ethnicity
Youngsters of all races and cultures are eligible for admission to STARLIGHT CTF ajid to receive
services from STARLIGHT Adolescent Center, Inc.. It is expected that the bulk ofthe youngsters will
be Caucasian, Vietnamese/Asian, or Hispanic, and that smaller numbers of youngsters will be of other
ethnicity. However, ethnicity will not be a factor in admissions.
D. Degree ofLevel ofImpairment
Youngsters are expected to have significant impairments in all areas of adaptive functioning including
symptom management, interpersonal relationships, social functioning, educational functioning, and
recreational functioning.
ii I S expected that the bulk of the youngsters served will have scores below 40 on the CGAS(Children’s
Global Assessment Scale).
E. Diagnosis as listed in the most current edition ofDSM
All youngsters admitted will have diagnosable mental disorders according to the diagnostic criteria
specified in DSM-IV. The youngsters are expected to have a wide range of different DSM-IV psychiatric
diagnoses. However, the most common diagnoses are expected to be forms of: '
a) Conduct and Behavioral disorders(Conduct Disorder, Disruptive Behavior Disorder, Attention
Deficit Hyperactivity Disorder, diagnosis codes = 312.8; 312.9, 314.xx, 314.9).
b) Depressive and Mood disorders (e.g.. Major Depressi Disorder, Dysthymic Disorder; Bipolar I
ive
Disorder, diagnosis codes = 296.xx; 300.4; 311)
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c) Psychotic Disorders (e.g., Schizophrenia, Schizoaffective Disorder, codes = 295.xx)
No youngsters who have primary diagnoses of chemical dependencies(substance related diagnoses)
eating disorders will be admitted for treatment. However, substance related disorders (e.g., alcohol
or
use
disorders, amphetamine use disorders, cannabis use disorders, cocaine use disorders, hallucinogen related
disorders etc.) are expected to be common secondary(DSM-Axis I) diagnoses. Learning, communication,
and other specific developmental disorders diagnoses are expected to be common secondary diagnoses
on
Axis II.
F. Number ofyoungsters to be served
STARLIGHT CTF is designed to serve 36 youngsters at a time, however, STARLIGHT Adolescent
Center will serve not only the current residents of STARLIGHT CTF, but also up to 8 of it’s graduates.
G. Identification ofthe particular needs ofthe population
The referred youngsters are expected to have major psychiatric illnesses (often with secondary substance
related disorders) resulting in numerous behavioral, emotional and cognitive symptoms and problems.
The adaptive functioning ofthese youngsters is expected to be impaired across all areas(including
interpersonal relationships, social/recreational, and educational/vocational).
Each of the youngsters is expected to have their own unique complex of symptoms and problems.
However,there are expected to be a large number of symptoms and problems that are shared by many of
the youngsters.
Description of services designed to meet the identified needs
STARLIGHT CTF will provide a variety of individual, group, school, and therapeutic milieu activities
within a highly structured schedule. The initial focus of treatment will be to address major presenting
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psychiatric problems,focusing on symptom remission or control; to provide a consistent, predictable, and
behaviorally focused milieu; and to assist youngsters in the acquisition of skills necessary Tor successful
interpersonal functioning.
Specific treatment components will differ across the different youngsters referred to STAJfiLlGHT CTF.
Upon admission, each youngster will receive a comprehensive assessment by all disciplines ofthe facility
(e.g., psychiatry, nursing, rehabilitation, diet, social worker). Based on this assessment, an Interdisciplinary
Treatment Plan/Plan of Service will be developed with the active participation ofthe youngster.
Method and Frequency ofEvaluating Youngster Progress & Program Effectiveness
STARLIGHT CTF and STARLIGHT Adolescent Center will establish specific, measurable goals for
c acn
ngster, as well as for the overall facility program. Youngster progress and effectiveness of the
program will be regularly monitored using a variety oftools, including clinical reviews, utilization
analyses, satisfaction surveys, and standardized psychiatric measurement instruments.
Rigorous treatment planning, evaluation, and modification will be employed to gauge program and
treatment responsiveness. Frequent and regular modifications will be made ofprogram components in
order to provide flexible, effective, and creative approaches to seemingly chronic psychiatric problems.
Regular monitoring of each youngster's progress, reassessments for continued stay, and coordination of
discharge/ aftercare services will be coordinated with the assigned County program liaison and individual
case workers. To ensure that both program objectives and County goals are satisfied, a close working
relationship is expected.
Youngster progress will be continuously documented in writing in each youngster’s record. Weekly
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progress notes will be written for each youngster by the program staff or interdisciplinary professional
staff who are providing the rehabilitation services. There will be a physician’s/psychiatrist’s progress note
whenever the youngster is seen by the physician. There will be a documented review of each youngster’s
treatment plan by treatment team staff and the youngster at least monthly. Treatment Team progress notes
will be signed by the attending disciplines whenever the Treatment Plans are reviewed and approved.
Plans of service will be reviewed and updated any time there is a change in condition.
Treatment outcomes will be evaluated in relation to the current status or level of the youngster, the
objectives achieved, and the potential for discharge. Specific psychiatric outcome measures that have been
proven in the scientific literature to be reliable and valid will also be used to mom’tor youngster progress
in specific areas. Such measures include; nurses ratings, Achenbach Child Behavior Checklist(CBCL),
Achenbach Teacher Behavior Rating Scale, Achenbach Youth Selfrating scale (YSR), Skills assessment
forms, Children’s Global Assessment Scale(CGAS), standardized achievement tests, quarterly academic
assessments and report cards, tracking of discharge locations, case management monitoring. Family
Satisfaction Survey and Mental Health Agency Satisfaction Survey.
In addition, overall program outcomes (across all youngsters for each fiscal year) will be analyzed and
documented in a written Aimual Report, which will be presented to the County. The report will include
the results of youngster, family, and agency Satisfaction Surveys which will be conducted periodically to
assess outside perception of the program and obtain valuable input for ongoing evaluation and program
adjustment.
Basic Services dnd Staffing
STARLIGHT CTF and STARLIGHT Adolescent Center will provide the following basic services to the
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referred youths; residential services, physician (psychiatrist) services, nursing services, pharmaceutical
services, and dietary services. In addition to these basic services, the following rehabilkation/treatment
services will be provided: comprehensive interdisciplinary assessments, evaluation, and treatment planning;
quality residential care stabilization services in a highly stmctured and supervised setting; continuous daily
therapeutic interventions in a “therapeutic milieu” environment; brokerage/linkages with juvenile courts.
Department of Probation, Department of Social Services, Department of Mental Health, and community
schools; educational services (nonpublic school); discharge planning/aftercare including active
participation with the County Department of Mental Health, the youngsters and their families and/or
caregivers.
Clinical s
taffing will consist of: Registered Nurses(4.5 FTE’s), Licensed Vocational Nurses(6.0 FTE’s),
Youth Counselors (36.0 FTE’s), Social Workers(5.0 FTE’s), Rehab Therapist(7.5 FTC),a unit
clerk/transport aid. In addition, there will be a Program Mental Health (Licensed LCSW,MFCC
or
Ph.D. with three years experience) overseeing the youths’ clinical, special rehabilitation, and activity
services.
Overall, there will be a minimum ratio of child care staffto clients of 1 ;5 during awake hours.
Appropriate supervisory staff will be employed to assume responsibility for supervision of youth
counselors, rehabilitation aides, nursing staff, and facility operations. On-call administrative. nursing,
youth counseling, and rehabilitation staff will be available at all times for emergency coverage and
intervention.
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STARLIGHT CTF will have a qualified psychiatrist to review/approve treatment plans and services; to
perform and document a psychiatric assessment and mental status on all youngsters upon admission to
monitor any progress of all adolescents and to assess the need for or reactions to psychotropic
medications and their ongoing progress; to see each youngster weekly until discharged; and to be
available on a 24 hour basis for emergencies.
All of the professional treatment staff will be degreed, licensed ,waivered, and/or registered and will meet
CTF requirements per Section 1921 for Social Workers, RN’s, LVN’s, Mental Health Workers,
psychologists and psychiatrists. All staff will be trained in both appropriate medical and psychiatric
interventions and behavioral management techniques.
The Medical Director/Physician will be responsible for medical care standards, coordination.
surveillance (oversight to ensure treatment is carried out as directed in treatment plans), and
improvement planning for in the facility. The Medical Director will be a trained psychiatrist who will
also be responsible for psychiatric services. Counseling services will be provided by licensed clinical
social workers, or licensed marriage, family and child counselors.
Nursing sendees will be under the supervision of a registered nurse with experience in psychiatric
nursing who will be employed for 40 hours a week. In addition, there will be not less than two full time
equivalent(FTE)of nursing staff per 40 clients on each 8-hour shift, during each 24 hour period, on a 7
day (weekly) basis. There will be at least one registered nurse, and a licensed psychiatric technician or
licensed vocational nurse, awake and on duty, in the facility at all times, day and night.
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Nursing services will include: planning of client care including an initial written evaluation commencing
at time of admission and completed within 7 days of admission; implementing each client’s care plan;
and notifying physicians promptly regarding admissions, sudden changes in condition, unusual
occurrences involving clients, weight changes, untoward reactions to treatment, medication errors, or
problems. Nursing services will be individualized for each client, designed specifically to meet the
objectives of each client’s interdisciplinary treatment plan.
The nursing staff will provide 24 hour supervision in such matters as eating, personal hygiene, dressing and
undressing, and taking prescribed medications. Nursing staff will also orient the client to the personnel
_ and to the unit and will complete a personal property inventory.
Registered Nurses and Licensed Vocational Nurses will administer medications (either orally or
intramuscularly) as prescribed by the physician. These nursing professionals will be specifically trained to
administer psychoactive medications. Should the administering nurse question a medication order or the
appropriateness ofthe medication, or observe any untoward effect, the prescribing physician or the Medical
Director will be notified immediately before further administration ofthe medication.
Additionally, the nursing staff will be responsible for follow up and monitoring of lab work, X-rays and
other medical needs as prescribed by the attending physician.
Dietary and food services at STARLIGHT CTF are considered an integral part of a youngster’s treatment
program. Special protocols for dietary services will be used that interface with the psychotherapeutic needs
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of youth. These services include special activities such as barbecues, ethnic and cultural food service, and
meal preparation skills training activities.
Close consultation between the dietary and clinical staff will occur surrounding the issues of medication
interactions on appetite and nutrition intake. In order to provide the extensive support necessary for
ensuring adequate dietary compliance, the "family style" of dining will be used, with assigned staff
eating with the youngsters and serving as role models and supervisors.
STARLIGHT CTF will be in operation 24 hours a day, seven days a week. Special treatment
programming will be available each day, 7 days a week and provided by STARLIGHT Adolescent
Center in addition to school programming. The non-public school will be in operation Monday through
Friday for six hours per day, including summer school. Clerical and administrative services will be
available 8:30 am to 5:00 p.m., Monday through Friday.
Specific Services Offered
The average length of participation in the program will be six months, although some students may
participate longer if indicated. Aftercare case management, wrap-around, and other services can be
provided by the contractor up to six months beyond discharge from the Program for those adolescents
eligible to continue to receive these services (based on medical necessity, eligibility for EPSDT, Healthy
Families, or other funding sources). Services to be provided by the Counseling staff include:
1. Weekly individual counseling
2. Daily group therapy (topic focused, such as substance abuse, life skills, anger
management, etc.)
3. Family therapy up to twice monthly
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4. Crisis intervention as needed
5. Collateral and/or case management services as needed
6. Family support groups
7. Coordinated Treatment Planning and linkage to other mental health, health,
substance abuse, vocational and other service providers.
8. Child and Family Team facilitation
Groups will be structured so as to be appropriate to the developmental and cognitive levels of the
youngsters. A schedule of all activities and groups will be posted daily in the facility during both the day
and evening shifts.
Educational Services
^ Educational services will be provided for youngsters at STARLIGHT through a State-certified on-site
Nonnublic School with educational programming that is designed specifically for emotionally disturbed
youngsters.
In this school program, an Individual Educational Plan(lEP) will be developed for each seriously
emotionally disturbed yoimgster in cooperation with the parents or guardians and the youngster's home
school district. This lEP will be integrated into the child's treatment program by the multidisciplinary
treatment team (which will include teachers from the school program). STARLIGHT CTF and
STARLIGHT Adolescent Center staff will work closely with school staff to ensure that the child’s
educational experience is appropriate to his or her emotional needs.
All referred youngsters will receive an educational evaluation, including recommendations for
educational readiness.
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The Staff of STARLIGHT CTF ,STARLIGHT Adolescent Center, and the High School will also work
closely with parents or guardians and the youngsters themselves to facilitate educational progress
through the use of behavioral contracts. In compliance with the Hughes Bill, a written Functional
Behavior Analysis Assessment will be made prior to instituting any behavioral interventions. The roles
of the adolescents, teachers, and parents will be specified in writing in the form of behavioral contracts.
The process of educational services will be initiated within at least seven days after a youngster’s
admission to STARLIGHT CTF. lEP's Avill be completed as soon as possible, preferably prior to or
shortly after admission.
Medications
In order to provide stabilization, psychopharmacology may be necessary for some ofthe youngsters at
STARLIGHT CTF. However, psychoactive medications will be used as sparingly as possible. Staff will
be thoroughly trained in crisis intervention and de-escalation techniques in order to preclude the use of
most psychotropic medications, except in the more extreme behavioral problems, psychosis, or well
documented medical justification.
If medications are used, they will be prescribed by the treating physician and monitored closely by program
staff for therapeutic or untoward effects. The youngster will be informed ofthe medications to be
employed, the expected result of the medication and any significant side effects of medications, especially
psychotropic medications. Consent forms will be signed by the adolescent and the parent or responsible
party; these will become part of the medical record. All psychotropic medications will be administered in
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compliance with Patients Rights procedures and State and County guidelines for such administration.
Medications will be available from a contract service pharmacy on a 24-hour basis. A licensed pharmacist
will review medication administration, policy and procedure, and perform a drug regimen review monthly.
The Medical Director will be responsible for monitoring medication for appropriateness and effectiveness
on a regular basis. All licensed nursing staff will be trained in the administration and monitoring of all
medications, especially psychotropic medications through the use of medication tests and simulated
practices. Medications may be given either orally or intramuscularly. Clients on medication will be
reviewed by the Psychiatrist at least once every thirty(30)days.
— Admissions Process and Criteria
Adrnis.sions Criteria
SI ARLIGHT CTF will accept referrals of seriously emotionally disturbed minors who have been
screened and evaluated for appropriateness for admission by the County Mental Health Department and
Interagency Council reviewing out of home placements. STARLIGHT CTF reserves the right for the
ultimate decision for admission, and will give written reasons for the rejection of any referred youngster.
Admissions Process including Assessment & Treatment Planning
Prior to admission, a Resident Admission Packet will be completed by the STAJRLIGHT CTF Mental
Health admissions designee. The admissions packet must include a signed written statement from the
^ placing county’s or the parent’s county of residence interagency placement committee must certily that:
“The child is in need ofthe level of care provided by a CTF to implement the proposed treatment program
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August 18, 2000
and has been found, by a licensed mental health professional to require periods of containment to
participate in and benefit from mental health treatment.” The admissions designee will review all contents
for completeness. Upon completion, the resident admission packet will be reviewed by and approved by
the facility’s Program Director, Psychiatrist, or licensed clinical social worker, and, whenever possible,
one of these individuals will interview the youngster. Upon acceptance for admission, the youngster will
be admitted as soon as required legal documentation for admission is completed. An Intake Report will
be completed and typed prior to admission and signed by a licensed member of the staff and placed into
the youngster’s medical record.
^Adolescents will only be admitted if the following criteria can be met: (See Policy and Procedure
Attachment #3 for specific details of each situation).
1. They are on LPS Conservatorship and the Conservator has authorized the admission and signed the
Admission Agreement.
2. They have applied to the juvenile court and the court’s consent to treatment is documented by a copy
of the juvenile court’s ruling per Welfare and Institutions Code 6552.
3. The parents of an adolescent under the age of fourteen have both given consent for admission (unless
sole custody is established - in which case the consent of one parent will suffice).
4. The parents of an adolescent between the age of fourteen and seventeen years of age have given
consent as above and;
i. The adolescent has waived a pre-admission “Roger S.” hearing; or
ii. The adolescent has had his due process right by way of a “Roger S.” hearing and the
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decision to admit was upheld
Upon arrival at the facilit}', the youngster will have the facility and services explained to him by the
admissions designee and will receive orientation on his rights, the program rules and expectations, etc.
An admission record containing all identification data required by relevant codes and statutes, as well as
physician and practitioner data will be completed. The youngster will be screened for tuberculosis, and
his personal possessions, equipment, and valuables will be inventoried and identified. The youngster or
his representative will sign an admission agreement describing the services to be provided and the
expectations and rights of the youngster regarding program rules, client empowerment, and involvement
in the program and fees. The youngster will receive a copy of the signed admission agreement. At the
time of admission, the youngster’s preferences will be solicited to aid in determining whether
medication, restraint or seclusion is the least restrictive method for controlling injurious behaviors.
Each admission will result in a comprehensive assessment by all disciplines of STARLIGHT CTF. The
admission assessment is completed within five(5 jdays of admission and a typed copy will be provided
to the adolescent’s parents, conservator or the person designated by the court to manage the placement
within(10) working days of assessment completion. A comprehensive Needs and Service Plan
fTreatment Planl is completed within 15 days of admission. The Needs and Service Plan is developed
by a licensed mental health professional together with the adolescent and his/her parent or conservator.
The admission assessment and needs and services plan both becomes a part of the clients’ medical
record. A written report of a physical examination is provided within 72 hours following the admission
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The referred youngsters will be given comprehensive assessments and evaluations by a multidisciplinary
team. All areas of functioning will be included (e.g., social, emotional and behavioral^pducational;
physical; and psychosocial). A nursing or social service clinician will enter an imtial admission problem
onto the youngster’s treatment plan within 24 hours. Other evaluations will include a psychosocial
assessment ofthe child and the family including an assessment of the level of psychosocial functioning,
the self-care potential, the support network availability, and the needs and strengths of family members
and of the family as a whole.
Initial evaluation, including assessments by a multidisciplinary treatment team including a psvcniatnsi,
social worker, licensed nurse, dietitian and a rehabilitation therapist with a specialty in physn aL art,
dance, music, vocational, or recreational therapy, will be completed within five (5) days of admission.
However,assessment and evaluation will be an ongoing process, and written re-evaluations will be dorie
on a
regular basis and at least monthly. Within days of admission the written assessment (including, at
a minimum: health and psychiatric histories, psychosocial skills, social support skills, current
psychological, educational, vocational and other functional needs or limitations, medical needs, selfcontrol & symptom management)is signed by a licensed mental health professional.
These evaluations form the basis of a comprehensive treatment plan/plan of service. The treatment plan
will include long term goals, current status/level of the adolescent, short term objectives, the specific,
his
measurable process to achieve the objectives, and a discharge plan. Participation of the youngster and
^ or her family or guardian(s) will be encouraged in treatment planning. The treatment plan will document
all psychotherapeutic modalities, the adjunctive therapies, and medications that are to be employed.
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STARLIGHT Adolescent Center, Inc.
Synopsis Of The RFP Submission
FY2001
Page 29
August 18, 2000
Close monitoring ofthe child’s functioning and offamily functioning will be a part o^ontinuing
planning. Biweekly case oriented meetings will be conducted to discuss treatment planning, discharge
planning and referral and placement needs. The biweekly case staffing will review the progress or
problems of the youngsters in the facility, and staff will discuss the treatment approaches to be utilized.
This meeting will be attended by the supervising youth counselor, therapist, and nursing staff. This
meeting is in addition to the daily roster/case review to occur at least once per shift. Participation of the
clinical staff, including the County DMH case managers will ensure that treatment approaches are
consistent with the documented treatment plans discussed in the clinical case conference.
Evaluation and assessment is a continuing process and takes place not only in treatment planning
meetings, but also in case conferences, staff meetings,supervision meetings, consultative meetings, chart
audits, peer review and utilization review meetings. Treatment outcomes are evaluated in relation to the
current status/level of the adolescent, the objectives achieved, and the potential for discharge. There
will be a physician's progress note whenever the Treatment Plan is reviewed and approved. Should
medication be employed to ameliorate the psychiatric or behavioral symptomatology, the physician will
describe the medication used, the side effects and the response of the adolescent to the medication. If no
medication is being employed, that will be stated in the treatment plan and the physician's progress note.
Continuing Stay Criteria
Each youngster will be evaluated by the Psychiatrist for continuing to meet admission criteria at least
every
ninety (90) days. The outcome of this review will be documented in the clients’ medical record.
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Synopsis Of The RFP Submission
FY2001
*vPage 30
\ugust 18. 2000
Continued need for stay within the CTF will also be verified by the placing agency’s case manager or
interagency placement committee.
Discharge Planning & Processes
Discharge Planning & Case Management Services
Discharge planning shall be an integral part of each youngster’s treatment program at STARLIGHT CTF.
Discharge planning will start from the day of admission, and continue throughout the course of treatment.
Continued assessment of the child's discharge planning status will occur through review by the facility
Program Director, the multidisciplinary treatment team, and the County DMH case manager
In add'tmn
active participation of the referred youngster and the parent(s) or legal guardian will be songhi toi
discharge planning. Discharge recommendations will be made jointly among the primar>’ therapist and
the DMH case manager.
The objective is to provide long range planning to meet the needs ofthe youngster and his/her family as
well as to take preventative measures to avoid the necessity for repeated crisis intervention and to allow the
youngster and family to appropriately utilize community resources.
Discharge planning will include an evaluation ofthe youngster’s needs for aftercare services to assure
smooth and lasting transition into the community. The discharge program is based on a highly
individualized case management approach in which multifaceted plans are devised by an
interdisciplinary team directed by the resident. These plans coordinate medical and psychological care
and address the specific concerns of the youngster and his family or guardian. The team members meet
frequently with the youngsters in order to assist them in identifying their major strengths and weaknesses
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STARLIGHT Adolescent Center, Inc.
Synopsis Of The RFP Submission
FY2001
Page 31
August 18, 2000
and in establishing changing transition goals. Although input will be obtained from various sources, the
youngsters’ own personal goals are always the primary focus.
The youngster’s discharge and aftercare plans will be documented in his health record. Complete and
accurate youngster information, in sufficient detail to provide for continuity of care, will be transferred
with the youngster at the time of transfer or discharge. When a youngster is transferred to another
facility, the youngster’s record will be updated to include: the date, time, and youngster’s condition at
the time of transfer; a written statement of the reason for the transfer; and written or telephone
acknowledgment of the youngster, youngster’s guardian or legal representative, except in an emergency.
The staff of STARLIGHT CTF and STARLIGHT Adolescent Center will be familiar with and
knowledgeable about other agencies, organizations, and individuals involved, either directly or
indirectly, in providing mental health services in both the public and private sectors. Contacts will be
made and maintained with significant persons in the referred youngsters’ lives (e.g., family members.
educators, service agency representatives, peer group members, physicians, etc.). Services will include,
but not be limited to, helping significant support persons understand the referred child’s condition and
gaining their input and assistance in implementing plans of service. Due to the high levels of stress that
severely emotionally disturbed youngsters, and especially adolescents, bring to their family members,
family counseling and/or therapy is expected to be an important part of the collateral services provided
by our program.
From day one, identified clients who are referred to the program will benefit from a planning approach
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Synopsis Of The RFP Submission
FY2001
Page 32
'\ugust 18, 2000
that is both realistic and adaptable. Plans will have clear paths to success, and be adaptable, so that the
plans can be revised to address the changing needs ofthe clients and their families. The program will
strive to develop effective Child and Family support teams. These teams, which include any positive
support persons in the clients’ and families’ lives (friends, neighbors, co-workers, etc.) as well as
professionals working with family members, will work together to develop a plan that is strength-based
and is focused on continued progress after discharge from the program. Parent participation is seen as a
key element ofthe program to insure each clients success in meeting their individual goals.
Although all members ofthe team have equal input, the initial task of bringing the team together rests on
the program staff, and specifically the Social Workers and Case Managers,
These facilitators will meet
each family in their place of residence or other agreed-upon place, assisting the family in assessing their
strengths, assets, needs and identification of potential members ofthe Child and family Team. Program
staff will also be responsible for 24-hour on-call coverage (by pager or cellular phone), to handle after
hour emergencies. The size and composition of the Community-Based team and the Child and Family
support teams will vary, but program staff will work to establish consistent meeting times, phone
contact, mailed minutes of meetings, e-mail correspondence, and/or internet and web-based sites, to keep
everyone on the team up to date on an ongoing basis. Once again emphasizing the full participation of
the family, facilitators will work with them to rally people who are committed to the overall success of
the clients. The Child and family Team will work toward viewing situations from a strength-based
model, which emphasizes the positive qualities inherent in the clients. With these assets in hand, the
^team can then assess the specific needs of the families and then begin to develop a creative and concrete
plan of action. With a matching of goals and responsible persons to carry out those goals, and accolades
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Synopsis Of The RFP Submission
FY2001
Page 33
August 18, 2000
for progress made along the way, a powerful tool for desired change is produced. These tools, which are
self-sustaining by design, can be utilized while the clients are in the program and after discharge, hence a
full circle of care is created. This wrap around process empowers family members to master challenges
they face and builds their capacity for solving problems.
In order to ensure that the adolescent and her family are linked with the System of Care and all providers
delivering services to or on behalf of the adolescent, case management services will be provided by the
program. School linkage, medical care, dental care, nutritional and other therapeutic care are seen as the
primary linkages before, during and after placement in the CTF. Case Management services continue even
after the adolescent completes the program or as they are mainstreamed into regular classes as long as they
are clinically indicated.
Prior to admission, in home crisis stabilization services are available to the client and their family for up to
72 hours. The client may enter directly into the CTF after appropriate approvals and legal paper work is
completed or enter through the acute psychiatric service. After discharge, the Community Services division
continues with the comprehensive circle of care described above for as long as necessary. These services
are funded through EPSDT MediCal as Mental Health Services, Case Management and Therapeutic
Behavioral services when they become available.
Aftercare services and Re-admission Policy
Aftercare services may include: assessing the youngster’s and family’s needs; exploring available
community resources; making recommendations; arranging for placement; arranging for medication
supervision if indicated; and facilitating referrals to community social, vocational and educational
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STARLIGHT Adolescent Center, Inc.
Synopsis Of The RFP Submission
FY2001
Page 34
^^ugust 18, 2000
services if appropriate, as well as following each child and family in the community to deliver and
ensure appropriate and continued case management and mental health services.
When a youngster is discharged, an agreement will be made with the community resource anchor
,i}e
family receiving the youngster that will enable them to contact STARLIGHT CTF should any problem.^
arise relative to the continuing care of the youngster. Thus, STARLIGHT CTF will have the capability
and make the commitment to serve as a consulting resource to any placement institution or family
member needing assistance in the difficult task of caring for the discharged youth. STAR!I( / I . ‘ • n
follow all children in aftercare through providing necessary services which the child may need fcr
mental health, case management and other needed services.
Although, every effort is made to avoid the need for re-admission, STARLIGHT CTF nonetheless has a
policy of unconditional care to its youngster. This means that STARLIGHT CTF is always willing
readmit youngsters who seek treatment.
Client and Health Records
Health records shall be maintained for each youngster and shall include the following information:
admissions and discharge records identifying data; mental status; medical history and physical
examination results; dated and signed observations and daily progress notes; legal admission
authorization; consultation reports; medication and dietary orders; other applicable evaluations; dated
and signed patient care notes; rehabilitation evaluation; interdisciplinary treatment plan; progress noe.:,'-;
redication records; ti'eatment records of groups and counseling; other reports if applicable (e.g. (i i-.ed
records, lab tests, cardiology/ encephalographic tests, x-ray exams), documentation of patient riglrt;- .nd
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STARLIGHT Adolescent Center, Inc.
Synopsis Of The RFP Submission
FY2001
Page 35
August 18, 2000
discharge summary. Monthly clinical review reports will be completed by the clients’ licensed clinician.
All documentation will be in compliance of requirements of CTF regulations per Sec^on 1927 of these
regulations.
Client records are kept for all youngsters admitted to or accepted for care at STARLIGHT CTF and
STARLIGHT Adolescent Center. These records are permanent documents, either typewritten or legibly
written in ink, and capable of being photocopied.
The bulk of the youngsters’ records will consist of a comprehensive written Interdisciplinary Treatment
Plan. This plan includes: admission records; an individual plan of service including specific goals.
measurable objectives and treatment responsibilities; daily progress notes by professional and program
staff; at least monthly documentation of reviews by staff and the youngster; monthly reevaluations of the
treatment plan and progress; licensed mental health professionals’ signatures; and the discharge plan.
Information contained in youngster records is confidential and is disclosed only to authorized persons in
accordance with federal, state, and local laws.
All current clinical information pertaining to youngsters’ stays are centralized in the youngsters’ records.
Youngster records are filed in an accessible manner, providing for prompt retrieval when needed for
continuity of care. Young.ster records will not be removed from the facility, except for storage after the
youngster is discharged, unless expressly authorized by the Department.
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STARLIGHT Adolescent Center, Inc.
Synopsis Of The RFP Submission
FY2001
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vugust 18, 2000
Client Rights & Empowerment
STARLIGHT CTF and STARLIGHT Adolescent Center believes that rehabilitation is best achieved by
empowering youngsters and their families to the maximal extent possible. The STARLIGHT CTF and
STARLIGHT Adolescent Center program will use a pro-active, consumer-oriented approach in which
youngsters(and, whenever possible, families) are considered as equal partners and colleagues in the
treatment process.
The input of the youngsters will be encouraged in the formulation, execution, and evaluation or
- treatment and discharge plans. Whenever possible, treatment will be driven by the goals and priorities of
the youngsters. The youngsters’ responsibility in making important decisions for themselves will be
emphasized.
A list of Client Rights will be posted prominently at STARLIGHT CTF in English, Spanish and other
languages representing at least 5% of the County population. Youngsters shall not be subjected to verbal
or
physical abuse of any kind. In addition, youngsters will have the rights: to wear their own clothes; to
keep and use personal possessions; to keep and spend reasonable sums of their own money; to have
access to individual storage for private use; to see visitors; to have reasonable access to telephones to
make and receive confidential calls; to have access to letter writing materials, stamps and mail; to refuse
shock treatment; to refuse lobotomy services.
The youngster has the right to revoke their W & 1 Code 6552 by informing staff who in turn will inform
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Synopsis Of The RFP Submission
FY2001
Page 37
August 18, 2000
the child’s court worker who will then schedule a hearing with the court on this matter.
The preferences of the youngsters will be solicited regarding the use of medication, restraint or seclusion
for controlling injurious behavior. Youngsters will be informed regarding the nature of procedures to be
used in treatment, and will have the right to accept or refuse treatment.
G;\MHEALTH\SHRTDYL\ExA FY01\StarlightExA.doc
D A n i D 1 1
H
Exhibit A-1
SANTA CLARA COUNTY MENTAL HEALTH TBS PROGRAM
Draft Procedures:
Therapeutic Behavioral Services (TBS)
Purpose
I.
The purpose of this procedure is to define Therapeutic Behavioral Services
(TBS), outline eligibility for TBS. Clarify service delivery requirements, and
explain authorization for these services.
Definition
Therapeutic behavioral services are a one-to-one therapeutic contact between a
mental health provider and a child/youth plan member for a short-term period of
time. These services are designed to maintain the child'g/youth’s residential
placement at the lowest appropriate level by resolving target behaviors and
achieving short-term goals. A contact is considered therapeutic if it is intended to
provide the child/youth with skills to effectively manage the beh3V!0'(s)
symptom(s)that impedes achieving residence in the lowest appropriate iev.-i
,oi
III.
Service Description
Ic
The person providing therapeutic behavioral services is available on
and
one-to-one
provide individualized one-to-one behavioral assistance
interventions to accomplish outcomes specified in the written treatment plan.
The critical distinction between therapeutic behavioral services and other
rehabilitative Mental Health services is that a significant component of this
service activity is having the staff person on-site and immediately available to
intervene for a specified period of time. The expectation is that the staff person
would be with the child/youth for a designated time period and the entire time the
mental health provider spends with the child/youth in accordance with the
treatment plan would be reimbursable. These designated time periods may vary
in length and may be up to 24 hours a day. depending upon the needs of the
child/youth.
IV.
TBS Eligibility Criteria
The ChildAfouth
1.
Must be full scope MediCal under 21 years old.
2.
Must meet Mental Health Program medical necessity criteria
(attachment 1).
3.
Must be a member of certified class by meeting one of the
following criteria:
TBS/Emergency Procedures
06/05A)0
1
Exhibit A-]
a.
Is Placed in a group home facility. RCL12 or above and/or
a locked treatment facility for treatment of mental health
needs which is not an institution for mental health disease,
or
b.
Has undergone at least one emergency
i
psychiatric
hospitalization related to his/her current
presenting
disability with the preceding 24 months, or
c.
Is being considered by the county for placement in a group
home facility, RCL 12 or above and/or a locked treatment
facility, or
d.
Previously received therapeutic behavioral services while a
member of the certified class.
4.
5.
Is receiving other specialty mental health services.
Without these additional short-term services it is highly likely that
in the clinical judgement of the mental health provider;
a.
The child/youth will need to be placed in a higher level of
residential care, including acute care because of a change
in the child/youth’s behaviors or symptoms which
jeopardize continued placement in current facility, or
b.
The child/youth needs additional support to transition to a
lower level of residential placement. Although the
child/you^ may be stable in the current placement, change
in behavior or symptoms are expected and therapeutic
behavioral services are needed to stabilize the child/youth
in the new environment,
v:
Conditions under
Reimbursable:
1.
which Therapeutic
Behavioral
Servicer:
are
not
Where the need for TBS are solely;
a.
b.
for
the convenience of the family, or other caregivers, physician,
or teacher,
to provide supervision or to assure compliance with -terms and
conditions of probation,
c.
to ensure the child/youth's physical safety or the safety of others,
e.g., suicide watch or
d.
TBS/Emergency Procedures
to
address conditions that arb not part of the child/youth’s mental
health condition.
oe/osAX)
2
Exhibit A-1
2.
For children/youth who can sustain non-impulsive self-directed behavior,
handle themselves appropriately in social situations with peers, and who
are
able to appropriately handle transitions during the day probably do not
need these services.
3.
For children/youth who will never be able to sustain non-impulsive self-
directed behavior and engage in appropriate community activities without
full-time supervision.
4.
VI.
When the child/youth is an inpatient of a hospital, psychiatric health
facility, nursing facility, IMD, or crisis residential program
Service Delivery Requirements
This sen/ice activity is focused on'resolution of target behaviors or symptoms
which jeopardize existing placements or which are a barrier to transitioning to a
lower level of residential placement and completion of specific treatment goals.
Therapeutic behavioral services must be expected, in the clinical judgement of
the MHP provider, to be effective in addressing the above focus to meet the
goals of the treatment plan. Therapeutic behavioral sen/ices are to be decrec-sed
when indicated and discontinued when the identified behavioral benchmarks
have been reached or when reasonable progress towards the behavioral
benchmarks are not being achieved and are not reasonably expected in the
clinical judgement of the MHP provider to be achieved. They are intended to be
short-term, time-limited services and not appropriate to maintain a child/youth at
a specified level for the long-term.
Examples of activities, interventions may include but are not limited to
• Assisting the child/youth to engage in, or remain engaged in, appropriate
activities
• Helping to minimize the child/youth’s impulsive behavior
• Helping to increase the child/youth’s social and community competencies by
building or reinforcing those daily living skills that will assist the child/youth in
living successfully at home and in the community
• Providing immediate behavior reinforcements
• Providing time-structuring activities
•
Preventing inappropriate responses
• Providing appropriate time-out strategies
• Providing cognitive behavioral approaches, such as cognitive restructuring,
use of hierarchies, and graduated exposure
. Collaboration with and support for the family caregiver's efforts to provide a
positive environment for the child
TBS/Emergency Procedures
oe/osAX)
3
Exhibit A-1
Therapeutic behavioral services must be provided by a Licensed Practitioner of
the Healing Arts (LPHA)^ or trained staff members who are under the direction of
a LPHA.
Staff providing therapeutic behavioral services will follow requirements regarding
restraint, which are applicable to the child/youth’s setting or prograrp. Seclusion
is not allowable as a component of therapeutic behavioral services—
VII.
Treatment Plan and Documentation Requirements
There must be a written plan for therapeutic behavioral services, as a component
of an overall treatment plan for specialty mental health services, which identifies
all of the following;
1.
Specific target behaviors or symptoms that are jeopardizing the current
placement or presenting a .barrier to transitions, e.g=, tantrums, property
destruction, assaultive behavior in school.
2.
Specific interventions to resolve the behaviors or symptoms, such
as
anger management techniques.
3.
Specific outcome measures that can be used to demonstrate the
frequency of targeted behaviors has declined and has been replaced with
adaptive behaviors.
The treatment plan that includes therapeutic behavioral services should be based
on a comprehensive assessment of the child/youth and family, if applicable,
strengths and needs. It should be developed with the family, if available, and
appropriate. The therapeutic behavioral services component of the plan should
be: 1) adjusted to identify new target behaviors interventions and outcomes
necessary and appropriate; and
as
2) reviewed and updated as necessary
whenever there is a change in the child/youth's residence.
There must be a written transition plan for TBS from their inception. This
-•v..
transition plan must outline the decrease and/or discontinuance of TBS when
they are no longer needed or appear to have reached a plateau in effectiveness,
and when applicable, a plan for transition to adult services when the child/youth
turns 21 years old and is no longer eligible for TBS. This plan should address
strategies and skills for parents/caregivers to provide continuity of care when
TBS are discontinued.
A progress note is required for each time period that a mental health provider
spends with the child/youth. Significant inten/entions that address'the goals of
the treatment plan must be documented. The progress notes do not have to
justify staff intervention or activities for all billed minutes.
' LPHA are: Physicians, Psychologists, Licensed Clinical Social Workers, Marriage and
Family Therapists and Registered Nurses.
TBS/Emergency Procedures
06A)5AX)
4
Exhibit A-1
The progress notes must be recommended in minutes,
Service time noted in
parenthesis by contract/shift, e.g., 8:00 a.m. to 1:30 p.m. may be included in the
note.
Staff travel and documentation time is MediCal Billable. On-Call time for the staff
person providing therapeutic behavioral services is not MediCal billable. TBS are
not billed as mental health services.
VIII.
Authorization
Therapeutic Behavioral Services will be initially reviewed and authorized by the
respective Rehabilitation Option (R70) Coordinators for a period of 30 calendar
days. The RIO Coordinator may authorize TBS semces by completing a TBS
packet and sending it in to the Mental Health TBS Coordinator within 7 days of
the initial authorization.
The TBS packet must include; 1) the TBS
Authorization/Service Plan and 2) the Notification to DMH Form. See the
attached forms. The packets must be faxed, mailed or hand carried to:
TBS Coordinator,
Family and Children's Service Division
see Mental Health Department
650 South Bascom Avenue
San Jose, California 95128
408.299.6262 Phone
408.971.6932 FAX
Reauthorization must occur every thirty days. Reauthorization will occur if TBS
continues to be effective for the child/youth. The child/youth must be making
A request for
progress towards the specified measurable outcomes.
TBS
Coordinator
5 full
reauthorization, (TBS packet) must be received by the
business days prior to the current authorization expiration and the Coordinators
must notify the Agency of the receipt of the requests.
All inquires regarding TBS should be made to the TBS administrative support
staff person at 408.299.6262. Identify the nature of the inquiry. If it is procedural
in nature, the TBS support staff person will assist the caller. If it is clinical in
nature, the call will be forwarded to the TBS Coordinator.
IX.
Claiming
Billing procedures, reimbursement amounts, cost reporting and cost settlement
Services. Service
procedures are identical to those used for the Mental Health
will
be
notified
of the new
delivery must be recommended in minutes. Providers
treatment codes as soon as they are available. Since this is an EPSDT funded
service, claims will be denied for services, which do not have MediCal eligibility.
This includes assuring that share of cost MediCal has been fully billed for the
months services were delivered. The OSCAR Procedure Code for TBS Services
is 380.
TBS/Emergency Procedures
06A)5/00
5
Exhibit A-1
NOTIFICATION TO DMH
REGARDING PROVISION OF THERAPEUTIC BEHAVIORAL SERVICES
TODAY’S DATE
CHILD/YOUTH’S NAME,
GENDER; □ Male
AGE
SOCIAL SECURJTY NO.
/
Is this a TBS Renewal?
BEGINNING DATE OF TBS
/
□ Female
No
Yes
TBS PROVIDER AGENCY
COUNTY: SANTA CLARA
FORM COMPLETED BY (name);
PRIMARY RESIDENCES FOR CHILDA^OUTH WHILE RECEIVING TBS (check all that apply)
□ Foster Home
Full Address
Name of FH & full address _
□ Foster Family Agency
Name of FFA & full address
□ Family Home
□ Children’s Shelter
□ Juvenile Hall Awaiting Placement
Name of GH & full address
□ Group Home RCL
□ Other (specify & give full address)
CLASS MEMBERSHIP (check one)
□ In RCL 12 of Above
□ Being Considered for RCL 12 or Above
by (name o f placement agency):
□ One Psychiatric Hospitaluadon in proceeding 24 months
Name of Hospital and dates:
□
Previously Received TBS while Class Member?
Where?
When?
SERVICE NEED (check one)
□ To Prcvcrit'Placement in a ITighcr Level of Care
O To EnablcTransition to a Lower Level of Care
TBS SERVICE PLAN
Planned Average Hours of TBS per week
Estimated # of Weeks of TBS
PLACEMENT WORKER (Name)
(Agency)
(Phone)
Submit this form upon initial TBS authorization and upon all requests for renewal authorization to ;
TBS Coordinator
FSeC Administration
Santa Clara Co. Mental Health Department
650 So. Bascom Avenue
San Jose, Ca 95128
Ph: 408.299.6262
Fax: 408.971.6932
FSeC AdministraUon will submit this form to the State Department of Mental Health
If this form is handwrittem please make sure the handwriting is legible.
6
Exhibit A-1
□ Initial □ Reauthorization
Is this request an
/
/
'ate of Referral
Agency Name
r'^'ral Information;
Fax;
Phone number
.inlclan_
Chlldrirouths DOB:
Child/Youth's Age;
That Jepardize Placement or Present Barriers to Transitions_
/
/
Specihc Target Behaviors & Symptoms
Specirtc Interventions To Resolve the Behvaviors or Symptoms:
Specific interventions
That Will Be Used to Demonstrate That the
Specific Outcome Measures
Frequency of Targeted Behaviors Have Declined
Hav
Been Replaced With Adapative Behaviors:
Transition Plan
3au
SVOr Discontinue TBS When They Are No Longer Needed Or Appear to Have Reached a
To Decrease
In Benefit Effectiveness, or A Plan
Reauthorlratlon Request
For Transition To Adutt Services;
Justify need for additiorral TBS, Include
_
progress to date, ongoing
Signatures
need, and IMihood of father Improvement
Date
Disipline
Provider _
Date
Disipline
LPHA;
□
TBS Authorization; pyes
Sen/ice Dates
From
I
No
Reason for Denial:
/
To
I
/
Next Review
Date
I
I
/
I
Authorization Signature^
effective & the child Is making progres
• ReauthorUalion must occur every 30 days,
Note:
toward the t|
Reauth^^Si^l'occur only If TBS conUnuet to be loc lo luthortzatlon e
outcornes. A reouest for Reauthoriratiopn^
SANTA ClARA COUNTY MbN 1AL HbALTH
Therapeutic Behaviors Services
Service Plan
be received 6 full business days pd
Iratkxi.
Individual Name
sm
Provider
-
T
EXHIBITS SUMMARY PAGE
FISCAL YEAR 2001
AGENCY NAME: STARLIGHT ADOLESCENT CENTER, INC.
REPORTING UNIT GROUPING: #13 SCHOOL/CLINIC DAY TREATMENT/OP
SUBMISSION DATE :
08/18/2000
DIVISION: FAMILY AND CHILDREN
MAXIMUM FINANCIAL OBLIGATION
TOTAL
FEDERAL MEDI-CAL AMOUNT(FFP= 51.67 % of Total Medi-Cai Service Costsi
COUNTY GENERAL FUi^
STATE EPSDT REVENUE
$560,241
$280,121
$3,871,212
OTHER
MAXIMUM FINANCIAL OBLIGATION
g:\mhealth\shr1dyl\fy01exhb\fy01 Starlight ALS
)
$898,438
$2,132,412
08/18/2000 1:44 PM
)
)
)
)
SUBMISSION DATE:
EXHIBIT B • ESTIMATE OF PROGRAM FINANCIAL DATA
FISCAL YEAR 2001
REPORTING UNIT GROUPING: #13 School/CHnic Day Troatment/OP
AGENCY NAME: Starlight Adolescent Center, Inc.
July 1. 2000-June 30. 2001
08/18/2000
MODE/
SERVICE
RATE
MEDI-CAL
BASE
REPORTING
SERVICE
FUNCTION
PROGRAM
UNITS OF
PER
FFP
COUNTY
EPSDT
UNIT
FUNCTION
NAME
NAME
SERVICE
UNIT
CONTRIBUTION
REVENUE
43AG2
10:8S-89
Starlight CTF
Santa Clara County
Day Treatment/Full
Medl-Cal/ FFP, County Match. EPSDT
Other/County
Total Day Treatment/Full
43AG1
15:01-09
43AG1
15:60-69
15:70-79
Santa Clara County
Medication Support
Medi-Cal/ FFP, County Match. EPSDT
Other/County
Starlight CTF
Santa Clara County
Starlight CTF
Santa Clara County
Other/County
Total Crisis Intervention
TBS Mental Health Services
15:30-59
Medi-Cal/ FFP, County Match, EPSDT
Other/County
$1.60
0
$1.60
15,126
$3.70
0
$3.70
1,623
$3.08
0
$3,06
1,623
$389,713
$0
$364,521
TOTAL
PROGRAM
COSTS
$0
$754,234
$0
$0
$389,713
$0
$364,521
$0
$764,234
$39,097
$0
$36,570
$0
$75,667
$0
$0
$39,097
$0
$36,570
$0
$75,667
$28.918
$0
$27,048
$0
$55,966
$0
$0
$28,918
$0
$27,048
$0
$55,966
$2,584
$0
$2,417
$0
$5,000
$0
$0
$2,584
$0
$2,417
$0
$5,000
$138,648
$0
$129,686
$0
$268,333
Starlight CTF
Santa Clara County
Total TBS Mental Health Services
130,694
$2.05
0
$2.05
130,894
TOTAL ESTIMATE
43AG2
47,292
15,126
Crisis Intervention
15:10-19
$160.18
47,292
Medi-Cal/ FFP, County Match. EPSDT
43AG1
$160.18
0
OTHER
REVENUE
Starlight CTF
Case Management \ Brokerage
Medl-Cal/ FFP, County Match, EPSDT
Other/County
Total Medication Support
43AG1
4,709
4,709
Total Mental Health Services
Mental Health Program Supplement
County Match
Starlight CTF
Santa Clara County
Total Supplement
I
)
$138,648
199,644
5,092
$0
$0
$0
$598,959
$114,00
5,092
43AG2 I
Mental Health Startup Budget
Slarlup Budget: In FY2000-2001 the Contractor will require startup funds which will be prorated to the users of beds.
$129,686
$560,241
$0
$0
$580,541
$0
I
$0
$580,541
I
$1,261,600 T
$268,333
$1,159,200
$580,541
$0
$0
$580,541
$1,261,600
In FY2000-2001. Contractor's reimbursement up to the Total Maximum Financial Obligation amount is not strictly dependent on the number of units provided or the actual rates as detemlned In their cost report, per
Agreement section 2.9.
Program Start Date: July 2000 / Admission Start: October 2000
dg
TOTAL MAXIMUM FINANCIAL OBLIGATION
FEDERAL MEDI-CAL AMOUNT (FFP« 51.67 % of Total Medi-Cal Service Costs)
COUNTY GENERAL FUND
STATE EPSDT REVENUE
OTHER
TOTAL MAXIMUM FINANCIAL OBLIGATION
g:\mheallh\snr1dyl\fy01exhb\fy01 Starlight ALS
TOTAL
$598,959
$1,842.141
$560,241
$0
$3,001,341
INDEX 4434
08/23/2000 3:47 PM
EXHIBIT B - ESTIMATE OF PROGRAM FINANCIAL DATA
FISCAL YEAR 2001
REPORTING UNIT GROUPING:#13 School/Cllnic Day Treatment/OP
July 1, 2000-June 30, 2001
08/18/2000
SUBMISSION DATE:
AGENCY NAME: Starlight Adolescent Center, Inc.
MODE/
SERVICE
RATE
MEDI-CAL
BASE
REPORTING
SERVICE
FUNCTION
PROGRAM
UNITS OF
PER
FFP
COUNTY
EPSDT
UNIT
FUNCTION
NAME
NAME
SERVICE
UNIT
CONTRIBUTION
REVENUE
A 3AG 3
10:05-89
Day Treatment/Full
Medi-Cal/ FFP, County Match, EPSDT
Other/County
Starlight CTF
Alameda County
15:01-09
Caae Management \ Brokerage
Medi-Cal/ FFP, County Match, EPSDT
Other/County
Starlight CTF
Alameda County
Total Mental Health Services
43AG4
15:60-69
Medication Support
Medl-Cal/ FFP, County Match, EPSDT
Other/County
15:70-79
Crisis Intervention
Medi-Cal/ FFP, County Match, EPSDT
Other/County
Starlight CTF
Alameda County
15:10-19
TBS Mental Health Services
15:30-59
Medi-Cal/ FFP, County Match, EPSDT
Olher/County
Starlight CTF
Alameda County
Starlight CTF
Alameda County
$1.60
7,563
$3,70
0
$3,70
1,623
$3.06
0
$3.08
64,228
$2.05
0
$2,05
Starlight CTF
Alameda County
Total Supplement
2,546
2,546
$182,261
$377,117
$0
$0
$194,856
$0
$19,548
$0
$0
$182,261
$377,117
$18,285
$37,833
$0
$0
$19,548
$0
$14,459
$0
$0
$18,285
$37,833
$13,524
$27,983
$0
$14,459
$0
$2,584
$0
$0
$0
$13,524
$27,983
$2,417
$5,000
$0
$0
$0
$0
$0
$68,032
$2,417
$5,000
$63,635
$131,667
$0
$63,635
$280,121
$131,667
$579,600
$0
$0
$68,032
$299,479
99,414
TOTAL
PROGRAM
COSTS
$0
$194,856
$2,684
64,228
TOTAL ESTIMATE
Mental Health Program Supplement
County Match
CTF Rate Supplement
County Match
$1,60
0
1,623
Total TBS Mental Health Services
43AG3
23,646
7,663
Total Crisis Intervention
43AG4
$160.18
23,646
Total Medication Support
43AG4
$160,18
0
2,354
Total Day Treatment/Full
43AG 4
2,354
OTHER
REVENUE
$114.00
$0
$0
$0
$290,271
$0
$290,271
$290,271
$0
$0
$290,271
In FY2000-2001, Contractor's reimbursement up to the Total Maximum Financial Obligation amount is not strictly dependent on the number of units provided or the actual rates as detemined In their cost report, per
Agreement section 2,9.
Program Start Dale: July 2000 / Admission Start: October 2000
I.
dg
TOTAL M/\XIMUM FINANCIAL OBLIGATION
FEDERAL MEDI-CAL AMOUNT (FFP= 51.67 % of Total Medi-Cal Service Costs)
TOTAL
$299,479
COUNTY GENERAL FUND
STATE EPSDT REVENUE
$290,271
$0
OTHER
$280,121
TOTAL MAXIMUM FINANCIAL OBLIGATION
$869,871
g:\mhealth\shr1dyl\fy01 exhb\fy01 Starlight ALS
)
INDEX 4434
08/23/2000 3:48 PM
)
)
Exhibit B-1
r
Community Treatment Facility Mental Health Funding Sou rces(Summary)
FUNDING SOURCE
FY 00/01
ANNUAL
Medi-Cal FFP
$
898,438
STATE MATCH
$
840,362
1,508,601
MENTAL HEALTH PROGRAM SUPPLEMENT(CGF)
$
870,812
1,423,062
$
1,261,600
S
3,871,212
COUNTY START-UP COSTS(CGF)
$
1,612,857
$
4,544,520
Community Treatment Facility Mental Health Contract(Detailed)
FUNDING SOURCE
FY 00/01
ANNUAL
Medi-Cal FFP
S
898,438
$
1,612,857
State Match
$
840,362
S
1,508,601
Santa Clara County
Alameda County
$
560,241
$
1,010,762
280,121
$
497,838
MENTAL HEALTH PROGRAM SUPPLEMENT
$
870,812
$
1,423,062
Santa Clara County(CGF)
Alameda County(CGF)*
$
580,541
$
290,271
$
1,261,600
$
841,066
$
420,533
$
S
3,871,212
$
COUNTY START-UP COSTS
Santa Clara County(CGF)
Aameda County(CGF)
Actual Estimated Day Rate by County’
Santa Clara County(24 beds)
Aameda County (12 beds)
FY 01
$
948,708
$
474,354
4,544,520
ANNUAL
177:35
108.30
177.35
108.30
'' Based on Mental Health Program Supplement and Start-up Costs for 334 days in FY01 and 365 Annually
...Behavioral Health Center\Budget\CTF Budget Final
08/17/2000
Proposed Payment and Fiscal Monitoring Schedule
For Services Delivered in FY 00-01
Amount
Month^
Amount
Excluded
Amount to
Actual
Budgeted
(AFDC)^
be Paid
Expense^
Jul/Aug-00 $
Sep-00
185,178
$
$ 185,178
$
269,113
$
$ 269,113
$
(48,722) $ 309,499
$
Oct-00
$
358,221
$
Nov-00
$
469,693
$
(103,176) $ 366,517 $
Dec-00
$
580,578
$
(160,496) $ 420,082
$
Jan-01
$
575,578
$
(183,424) $ 392,154
$
Feb-01
$
575,578
$
(185,717) $ 389,861
$
575,578
$
(185,717) $ 389,861
$
575,578
$
(185,717) $ 389,861
$
575,578
$
(196,034) $ 379,543 $
575,578
$
(196,034) $ 379,543 $
Mar-Ol
Apr-Ql
$
May-01
Jun-01
Total
$
ss:316a249“' t
Expense
VARIANCE
Statement
S/DCost
Report
Qtrly 10-30-00
Qtrly 01-30-011 Mini 01-31-01
Qtrly 04-30-0111
Final 07-30-01 Final 10-31-01
1
Assumes 12 months of program operation (first admission 10/02/00)
^ AFDC revenue shortfalls will be reimbursed as start-up costs by the Mental Health Department
^ Contractor will receive the 4 months(Jul-Oct) of costs upfront and subsequently invoice monthly after incurring costs.
...Behavioral Health Center\Budget\CTF Budget Final
08/17/2000
EXHIBIT C
INSURANCE REQUIREMENTS FOR PROFESSIONAL SERVICES CONTRACTS
Insurance
Without limiting the Contractor's indemnification of the County and State, the Contractor shall
provide and maintain at its own expense, during the term of this Agreement, or as may be further
required herein, all insurance coverages and provisions;
A.
Evidence of Coverage:
Prior to commencement of this Agreement, the Contractor shall provide a Certificate of
Insurance certifying that coverage as required herein has been obtained and remains in
force for the period required by the Agreement. The County's Special Endorsement
(Exhibit C-1,see last page of this document)form shall accompany the certificate
Individual endorsements executed by the insurance carrier may be substituted for the
County's Special Endorsement form if they provide the coverage as required. In addition
a certified copy of the policy or policies shall be provided by the Contractor upon request.
This verification of coverage shall be sent to the following address: Santa Clara County
Mental Health Department,645 South Bascom Avenue, San Jose, CA 95128; c/o
Contracts Unit. The Contractor shall not receive a Notice to Proceed with the work
under the Agreement until it has obtained all insurance required and such insurance lias
been approved by the County. This approval of insurance shall neither relieve noi
decrease the liability ofthe Contractor.
B.
Qualifying Insurers:
All coverages, except surety, shall be issued by companies which hold a current policy
holder's alphabetic and financial size category rating of not less than A V,according to
the current Best's Key Rating Guide or a company of equal financial stability that is
approved by the County's Insurance/Risk Manager.
C.
Insurance Required
Commercial General Liability Insurance - for bodily injury (including death)
and property damage which provides limits as follows;
a. Each occurrence
b. General aggregate
c. Products/Completed Operations aggregate
d. Personal Injury
$1,000,000
$2,000,000
$2,000,000
$1,000,000
A minimum of50% of each of the aggregate limits must remain available at all
times unless coverage is project specific.
G.\MHEALTH\lNSURANC\EXH-C-lns-only.doc July 2000
1
2.
General liability coverage shall include:
a.
b.
c.
Premises and Operations
Products/Completed
Contractual liability, expressly including liability assumed under this
Agreement.
d.
e.
f.
3.
Personal Injury liability
Owners’ and Contractors’ Protective liability
Severability of interest
General liability coverage shall include the following endorsements, copies of
which shall be provided to the County
a.
Additional Insured Endorsement:
Insurance afforded by this policy shall also apply to the County of Santa
Clara, and members ofthe Board of Supervisors of the County of Santa
Clara, and the officers, agents, and employees of the County of Santa
Clara, individually and collectively, as additional insureds. Such
insurance shall also apply to any municipality in which the work occurs
and it shall be named on the policy as additional insured (if applicable).
b.
Primary Insurance Endorsement:
Insurance afforded by the additional insured endorsement shall apply as
primary insurance, and other insurance maintained by the County of Santa
Clara, its officers, agents, and employees shall be excess only and not
contributing with insurance provided under this policy.
c.
Notice of Cancellation or Change of Coverage Endorsement:
Insurance afforded by this policy shall not be canceled or changed so as to
no longer meet the specified Coimty insurance requirements without 30
days’ prior written notice of such cancellation or change being delivered to
the County of Santa Clara
d.
Contractual Liability Endorsement:
Insurance afforded by this policy shall apply to liability assumed by the
insured under written contract with the County of Santa Clara.
4.
Automobile Liability Insurance:
For bodily injury (including death) and property damage which provides total
limits of not less than one million dollars ($1,000,000) combined single limit per
occurrence applicable to all owned, non-owned and hired vehicles.
G;\MHEALTH\INSURANC\EXH-C-lns-only.doc August 17, 2000
2
4a.
AircraftAVatercraft Liability Insurance (Required if Contractor or any of its
agents or subcontractors will operate aircraft or watercraft in the scope of the
Agreement)
For bodily injury (including death) and property damage which provides total
limits of not less than one million dollars ($1,000,000) combined single limit per
occurrence applicable to all owned, non-owned and hired aircraft/watercraft.
5.
Workers’ Compensation and Employer's Liability Insurance
a.
Statutory California Workers’ Compensation coverage including broad
form all-states coverage.
6.
b.
Employer's Liability coverage for not less than one million dollars
($1,000,000) per occurrence.
c.
Coverage under the United States Longshoremen’s and Harbor Workers’
Act shall be provided when applicable.
Professional Errors and Omissions Liability Insurance
a.
Coverage shall be in an amount of not less than one million dollars
($1,000,000) per occurrence/aggregate.
b.
If coverage contains a deductible or self-retention, it shall not be greater
than twenty-five thousand dollars ($25,000) per occurrence/event.
7.
Claims Made Coverage
If coverage is written on a claims made basis, the Certificate ofInsurance shall
clearly state so. In addition to coverage requirements above, such policy shall
provide that:
a.
Policy retroactive date coincides with or precedes the Contractor’s start of
work (including subsequent policies purchased as renewals or
replacements).
b.
Contractor will make every effort to maintain similar insurance during the
required extended period of coverage following project completion,
including the requirement of adding all additional insureds.
c.
If insurance is terminated for any reason, Contractor agrees to purchase
extended reporting provision of at least two years to report claims arising
an
from work performed in connection with this Agreement or Permit.
a.
Policy allows for reporting of circumstances or incidents that might give
rise to future claims.
G:\MHEALTH\lNSURANC\EXH-C-lns-only,doc August 17, 2000
3
D.
Special Provisions:
The following provisions shall apply to this Agreement:
The foregoing requirements as to the types and limits of insurance coverage to be
maintained by the Contractor and any approval of said insurance by the County or
its insurance consultant(s) are not intended to and shall not in any manner limit or
qualify the liabilities and obligations otherwise assumed by the Contractor
pursuant to this Agreement, including but not limited to the provisions concerning
indemnification.
E.
2.
The County acknowledges that some insurance requirements contained in this
Agreement may be fulfilled by self-insurance on the part of the Contractor.
However, this shall not in any way limit liabilities assumed by the Contractor
under this Agreement. Any self-insurance shall be approved in writing by the
County upon satisfactory evidence of financial capacity. Contractor’s obligation
hereunder may be satisfied in whole or in part by adequately funded self-insurance
programs or self-insurance retentions.
3.
Should any ofthe work under this Agreement be sublet, the Contractor shall
require each ofits subcontractors of any tier to carry the aforementioned
coverages, or Contractor may insure subcontractors under its own policies.
4.
The County reserves the right to withhold payments to the Contractor in the event
of material noncompliance with the insmance requirements outlined above.
Fidelity Bonds (Required only if contractor will be receiving advanced funds or
payments)
Before receiving any monetary advances under this Agreement, Contractor will furnish
County with evidence that all officials, employees, and agents handling or having access
to funds received or disbursed under this Agreement, or authorized to sign or countersign
checks, are covered by a BLANKET FIDELITY BOND in an amount of AT LEAST
fifteen percent(15%)of the maximum financial obligation of the County cited herein. If
such bond is canceled or reduced. Contractor will notify County immediately, and County
may withhold further payment to Contractor until proper coverage has been obtained.
Failure of Contractor to give such notice may be cause for termination of this Agreement
at the option of County.
G:\MHEALTH\INSURANC\EXH-C-lns-only.doc August 17, 2000
4
Exhibit C-1
SANTA CLARA COUNTY SPECIAL ENDORSEMENT TO BE MADE A PART OF
REQUIRED POLICIES
Unless specifically excluded, the following endorsements are issued to, and form a part of, the policy
number(s) shown below, and are effective on the date indicated at 12:01 am. Standard Time as
stated in the policy.
Endorsements
1.
Additional Insured Endorsement; Insurance afforded by this policy shall also apply to the
County of Santa Clara, and members of the Board of Supervisors of the County of Santa
Clara, and the officers, agents, and employees ofthe County of Santa Clara, individually and
collectively, as additional insured. Such insurance shall also apply to any municipality in
which the work occurs and it shall be named on the policy as additional insured (if
applicable).
2.
Primary Insurance Endorsement:
Insurance afforded by the additional insured
endorsement shall apply as primary insurance, and other insurance maintained by the County
of Santa Clara, its officers, agents, and employees shall be excess only and not conU ibi
with insurance provided under this policy.
3.
Notice of Cancellation or Change of Coverage Endorsement; Insurance affoiucd ov l us
policy shall not be canceled or changed so as to no longer meet the specified Courity
insurance requirements without 30 days’ prior written notice ofsuch cancellation or change
being delivered to the County of Santa Clara at the address shown on the Agreement.
4.
Contractual Liability Endorsement; Insurance afforded by this policy shall apply to
liability assumed by the insured under written contract with the County of Santa Clara.
Name of
Effective Date
Insured
of Endorsement
Insuring
Company
Policy
Insuring
Company
Policy
Signature of Authorized
Insurance Company Representative:
Please print Name/Title/Company
G;\MHEALTH\INSURANC\EXH-C-1.DOC / July 2000
Number
Number
The California Insurance Code, Section 384, specifies that a statement made on a certificate of
insurance does not amend the insurance policy that it describes. This means that if the certificate
IS not accurate, or if an error is made in describing the policy, or the coverages, the insurer is not
required to conform to the certificate. It also means that any statements made on the certificate, such
as the cancellation notice, do not affect the actual policy. If the insurer fails to issue the required
endorsements, the insurance company is not responsible to provide coverage. Therefore, the County
requires actual submission ofendorsements that do implement the required coverages, as well as the
completed certificates. This arrangement materially reduces the potential for
error.
If endorsements issued by the Insurance Company are to be accepted, they must accompany the
certificate and provide for all the clauses shown on the County’s special endorsement.
G:\MHEALTH\INSURANC\EXH-C-I DOC / July 2000
Comprehensive Evaluation Plan
Exhibit E: Legal Entity
FY 2000 - 2001
The Mental Health Department is committed to an evaluation monitoring proc_eSs in the spirit of
program excellence. The clients and families who seek services from the County Mental Health
System must receive services that are of the highest quality, effective, and respectful of their
needs. This exhibit reflects the implementation of the plan and is a provider/legal entity exhibit.
A.
Intent of the Comprehensive Evaluation Plan;
In September of 1998, the Mental Health Department began a stakeholder involvement
process which produced this comprehensive plan for program evaluation. The
Department also conducted an extensive assessment of its current program monitoring
Md program evaluation activities. The proposed plan integrates the Board’s requirements
for performance-based information collection and establishes the basis for an information
and outcome dnven mental health system of care. In addition, the proposed activities
meet the requirements of the State Department of Mental Health and Federal funding
agencies, and account for an ongoing mental health needs assessment of the service gans
in our communities. It is expected that the Plan will;
1.
Create an equitable system for process and performance outcome monitoring of
mental health programs delivered by both contract and county operated providers.
2.
Establish performance-based programs throughout our system.
3.
Develop a comprehensive system for program evaluation to provide the Board of
Supervisors, the Health and Hospital system, the Mental Health Department, the
Mental Health Board and other stakeholders with a concise evaluation and
performance outcome report on each mental health provider.
4.
Establish a program evaluation system that is adaptable, efficient, and accountable.
5.
Integrate information sharing with Comprehensive Performance Management and
Cross Systems Evaluation.
B.
Provider Expectations:
In FY 2000 - 2001,each provider will comply with the following specifications as they
relate to the programs for which they have contracted. It is the responsibihty of the care
coordinator to ensure that the appropriate State evaluation instruments are completed
within the specified time frames. Furthermore, for each treatment program that an
individual chent/consumer enters and exits, a Santa Clara County Functional Assessment
Scale(SCCFAS) will be completed. The SCCFAS is not required at entry and exit from
homeless shelter, supported housing (expect PATH funded Supported Housing) and Day
Socialization programs. The State Performance Outcome Instruments will be
implemented as stated below:
1. Evaluation and Performance Outcome instruments as specified by the California State
Department of Mental Health, the Mental Health Department and as specified in the
"Comprehensive Plan" will be administered at the required time intervals as specified
the Santa Clara County Mental Health Department Policy and Procedure Manual
(policy #249) and as specified below.
in
A. The time frames for collection of Children’s instruments are; intake (to
Mental Health System), sixty (60) days, annually, and at discharge (from
Mental Health System). Children’s instruments required to be collected are:
Child and Adolescent Functional Assessment Scale (CAFAS), Client Living
Environment Profile(CLEP), Child Behavior Checklist(CBCL), Youth Self-
Report Form (YSR), Client Satisfaction Questionnaire(CSQ-8), Youth
Satisfaction Questionnaire(YSQ), and Santa Clara County Functional
Assessment Scale(SCC-FAS).
B. Time frames for collection of Adult instruments arc: intake (to Mental
Health System), annually, and discharge(from Mental Health System).
Instruments required for the Adult data collection are: Client Identification
Face Sheet, Supplemental Client Information Face Sheet, MHSIP Consumer
Survey, Behavior and Symptom Identification Scale(BASIS-32), California
Quality of Life(CA-QOL),and Santa Clara County Functional Assessment
Scale(SCC-FAS).
C. Time frames for collection of Older Adult instruments are: intake (to
Mental Health System),annually, and discharge(from Mental Health
System).Instruments required for the Older Adult data collection are: Older
Adult Pilot Project Face Sheet, Mini-Mental State Examination, MHSIP
Mental Health Survey,SF-12 Health Survey, and Santa Clara County
Functional Assessment Scale(SCC-FAS).
D. Completed instruments shall be provided to Program Evaluation and
Services Research staff in a timely manner.
2. Each provider will submit unaudited financial information to the Department on a
quarterly basis similar to the required cost report information provided at the end of
each contract year beginning 30 days after the end of the second quarter(due dates:
January 30, April 30, July 30)(Exhibit E-1). Additionally, an audited financial
statement will be submitted per contract requirements. Staff information by reporting
unit will be submitted on the revised Personnel Action Request Form.Contract
Agencies(Section 504 - Attachment A,B)-(PARCA)beginning July'l, 2000. A full
staff report by agency and reporting unit will be completed by January 1,2001.
Electronic submissions of quarterly information is acceptable.
D.
Department Responsibilities
I. The Department will provide training on the required instrumentation.
2. Technical assistance will be provided in the preparation, delivery and interpretation of
the required instruments, staffing patterns and financial information.
2
3.
The Department will provide aggregated reports to providers regarding the data
submitted and train agency personnel in the interpretation of said reports. Reports
will be provided to the provider on a semi - annual basis.
4.
The Department will produce summary reports which are not traceable to individual
clients.
3
Exhibit E-1
Info Sheet-Sch A
A
Santa Clara County Mental Health
Medi-Cal/Short-Doyle Cost Report
FYE 6/30/98
Organization Information
egal Entity Name
egal Entity No.:
Enter Name Here
illing Names and Nos.:
Enter Name/Location Here
Enter Legal Entity Number Here
Provider ft
erson Completing Cost Report:
f
ame
Enter Person to call with questions here
Their Title
ddress
Agency Office Address
'hone No.
Enter
ax No.
Enter
tertlfication:
certify, that to the best of my knowledge, the Information provided in the following worksheets is true, correct and
onslstent with applicable instructions and regulations. I will maintain all supporting Information, documentation
nd wort<sheets for review and audit by the Department of Health Services or County of Santa Clara.
tame
Itle
CFO or Director for Agency
>ate
Page 1
Total cost
)
Santa Clara County Mental Hec
1B
)
)
.. I
B
Medl-Cal/Short-Doyle Cost Report
FYE 6/30/98
Ota/ Cost Worksheet:
e^al Entity Name:
Enter Name Here
egal Entity No.:
Enter Legal Entity Number Here
leconciliation of Total Reported Costs To Audited Financial Statements:
Salaries and Benefit
otal Cost Per Audited Financial Statements
Enter
Other
Enter
Total
0 FromAFS
otal Medi-Cal Adjustments
otal Other Adjustments
0_ From Worksheet C - Line 14
0 From Worksheet D - Line 14
otal Mode Cost Reported
0 Worksheet E Total Cost
m
X
ID'
CT
m
Page
I
c
Santa Clara County Mental Health
Medl-Cal/Short-Doyle Cost Report
FYE 6/30/98
Medi-Cal Adjustments Worksheet:
Enter Name Here
Legal Entity Name;
Legal'Entity No.:
Enter Legal Entity Number Here
Summary of Medi-Cal Adjustments:
Salaries and
Enter
1 Enter
Other
Benefits
Description/Purpose'.
Total
Enter
2
4
5
6
8
9
10
11
12
13
To Worksheet B
14 Total
The adjustments on
1.
this worksheet result only from program regulations. The following are typical adjustments:
Reduce Interest Expense by interest income
2. Reduce related organlatlon costs to actual cost
3, Eliminate equipment expenditures and add depreciation expense
4, Eliminate fundraising expense
m
X
5. Offset Other Operating Income
ZT
cr
and reference to the corresponding line
Attach copies of documentation used to compute these adjustments
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Page 3
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wuici nuj• »
Santa Clara County Mental Health
Medl-Cal/Short-Doyle Cost Report
D
)
FYE mom
Other Adjustments Worltsheet:
Legal Entity Name:
Enter Name Here
Legal Entity No.:
Enter Legal Entity Number Here
Summary of Other Adjustments:
Salaries and
Description
Benefits
Other
Total
1 Enter
2
3
4
5
6
7
8
9
10
11
12
13
14 Total
To Worksheet B
The adjustments on this worksheet result only from program regulations. The following are typical adjustments:
1. Eliminate Non Program Costs
2. Miscellaneous Adjustments
m
Attach copies of documentation used to compute these adjustments and reference to the corresponding line.
Page
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m
Exhibit E-1
Mode & SF Summary - Sch E
E
Santa Clara County Mental Health
Medl-Cal/Short-Doyle Cost Report
FYE 6/30/98
Mode and Service Function Summary:
Legal Entity Name
Enter Name Here
Legal Entity No.:
Enter Legal Entity Number Here
Mode 5 - Inpatient Hospital Services
Description
Mode
Enter
Enter
Total
Neg
Service
Total
Total
Charge
Rate
Cost
Punction
Cost
Units
Per Unit
Per Unit
Per Unit
Enter
Enter
Enter
Enter
Enter
Total For Mode 5
Mode 5 - Other 24hr Sep/ices
Total
Service
Description
Mode
Enter
nter
Cost
Function
Enter
Total
Units
Enter
Enter
Total
Neg
Charge
Rate
Cost
Per Unit
Per Unit
Per Unit
Enter
Enter
Total For Mode 5
Mode 10 - Day Services
Total
Service
Description
Enter
Total For Mode 10
Mode
Enter
Cost
Function
Enter
Enter
Total
Units
Enter
Total
Neg
Charge
Per Unit
Rate
Per Unit
Enter
Enter
Cost.
Per Unit
Exhibit E-1
Mode & SF Summary - Sch E
Santa Clara County Mental Health
Medi-Cal/Short-Doyle Cost Report
E
FYE 6/30/98
Mode and Service Function Summary:
Legal Entity Name;
Legal Entity No.:
Enter Name Here
Enter Legal Entity Number Here
Mode 15 - Outpatient Services
Total
Description
Enter
Mode
Enter
Service
Total
Total
Function
Cost
Units
Enter
Enter
Enter
Charge
Neg
Rate
Per Unit
Per Unit
Enter
(Enter
Cost
Per Unit
Total For Mode 15
Mode 45 - Outreach Services
Description
Enter
Mode
Enter
Total
Neg
Service
Total
Total
Charge
Rate
Cost
Function
Cost
Units
Per Unit
Per Unit
Per Unit
Enter
Enter
Enter
Enter
Enter
Total For Mode 45
Mode 55 - Medi-Cal Administrative Services
Description
Enter
'"oj-it For Mode 55
Mode
Enter
Total
Neg
Service
Total
Total
Change
Rate
Cost
Function
Cost
Units
Per Unit
Per Unit
Per Unit
Enter
Enter
Enter
Enter
Enter
Exhibit E-1
Mode & SF Summary - Sch E
Santa Clara County Mental Health
Medi-Cal/Short-Doyle Cost Report
E
FYE 6/30/98
Mode and Service Function Summary:
Legal Entity Name;
Legal Entity No.;
Enter Name Here
Enter Legal Entity Number Here
Mode 60 - Support Services
Description
Enter
Mode
Enter
Total
Neg
Service
Total
Total
Charge
Rate
Cost
Function
Cost
Units
Per Unit
Per Unit
Per Unit
Enter
Enter
Enter
Enter
Total For Mode 60
]Worksheet B
Grand Tola!- Total Ail Modes
OK
Pane 7
Enter
)
Expense V\ )heet
)
Enter Name Here
Expense Worksheet
FYE 6/30/98
Description
Expense
Allocated
Medi-Cal
Other
Total
Per Trial Balance
Overhead
Adjustments
Adjustment
Cost
Total
Enter Name Here
Expense Worksheet
FYE 6/30/98
Mode / Service Function
Allocated
Total Units
Charge Per Unit
Relative Value
Cost
+
Total
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Page"
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1
Pt Paymei.._ - Sch F
F
Santa Clara County Mental Health
Medl-Cal/Short-Doyle Cost Report
FYE 6/30/98
MedhCal Share of Cost Payments Summary:
Legal Entity Name:
Legal Entity No,:
Enter Name Here
Enter Legal Entity Number Here
Report Payments Collected From Patients or Other Insurance For Medl-Cal Units Only.
Mode
Patient Payments Other Ins. Pmt Medicare Pmts.
Enter
Enter
Enter
Enter
Total
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Page 9
)
)
)
Exhibit E-1
Cost Allocation
Santa Clara County Mental Health
Medi-Cal/Short-Doyle Cost Report
FYE 6/30/98
Cost Allocation Description:
Legal Entity Name: Enter Name Here
Legal Entity No.:
Enter Legal Entity Number Here
Method Used To Assign Costs To Mode and Service Functions
1 Relative Value Units Method
2 Time Study
S
3 Direct Assignment in general ledger
4 Other(Describe below)
&
140
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v-
Attach copies of worksheets used to allocate costs to mode and service functions
Page 10
Section 504 - Attachment A
personnel action requestform
—CONTRACT AGENCIES - tPARCA^
To:
Mental Health Administration
645 South Bascom Avenue
San Jose, Ca 95128
From:
Agency:
Contact Person
Telephone #:
Fax #:
Today’s Date:
Effective Date:
Purpose for PARCA: □ New Hire
□
Leaving Agency
□ Status Change (Indicate change only)
Staff Name:
Sex:
Staff ID #:
□ Male
□ Female
Birthdate:.
SSN #:
Index Code (4-digits; Where staffs time is billed, i.e. F&C, Adult, O/A, etc.):
Ethnicity: □ White
□ African American □ Native American
a Latin American □ Other Spanish
□ Cambodian
□ Japanese
□ Chinese
□ Filipino
Position Title:
□ Mexican American/Chicano
Q Viemamese
o Laotian
□ Other Asian
□ Other Non-White
(i.e. Psychiatrist, Psychiatric Social Worker, MFCQ
Crcdential(s); □ M.D.
□ R.N.
□ DEA Registration □ Clinical Psychologist
□ LPT
GLVN OOTR
License/Registration #:.
write n/a if no license
“
□ LCSW
□ RT □ BBSE Registration
□ MFCC
□ Paraprofession al
Expiration Date:
Last Date Will WorkAVorked:
Langnages:
Certified Bilingual:^
^ary Reporting Unit(s) & FTE for each RU (a provider
can be assigned to multiple units such as .5
FTE in outpatient, .25 day treatment & .25 residential do not
include temporary assignments as a result
of vacation/illncss coverage):
RU#
Additional Information:
FTE
RU#
FTE
RU#
FTE
Section 504 - Attachment B
PARAPROFESSIONAL EMPLOYEE STATUS AND MHRS REQUEST
NAME:
DEGREE:
□
Ph.D. in
□
Master’s in
□
Bachelor’s in
□
Associate’s in
□
None
Years experience in a Mental Health field:
(Provide a work history, from monthlyear to monthlyear)
Mental Health related: If holder of a degree, submit copy with this form.
Rev. 3/00
Document
Agreement between the County of Santa Clara and Starlight Adolescent Center, Inc., for provision of mental health services for fiscal year July 1, 2000 through June 30, 2001
Initiative
Collection
James T. Beall, Jr.
Content Type
Agreement
Resource Type
Document
Date
08/22/2000
Language
English
Rights
No Copyright: http://rightsstatements.org/vocab/NoC-US/1.0/