TEXAS HEALTH AND HUMAN SERVICES COMMISSION



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Home and Community-Based Services - Adult Mental Health Services Provider Agreement

Procurement Number: HHS0000075

|Addendum #7 |

|Revised on August 4, 2020 |

|Item |Purpose of Change |Previous |Revision |

|1. |Update Enrollment |August 31, 2020 |August 31, 2021 |

| |Period Close Date | | |

| |on pg. 1 | | |

|Addendum #6 |

|Revised on March 9, 2020 |

|Item |Purpose of Change |Previous |Revision |

|1. |How to Obtain |The last paragraph in Article I, Letter A, Introduction, |The last paragraph in Article I, Letter A, Introduction, |

| |Technical |Currently States: |Revised to State: |

| |Assistance with | | |

| |this OE |Respondents may seek technical assistance in completing |SYSTEM AGENCY recommends Respondents seek technical assistance|

| | |this OE and HCBS-AMH program implementation support via |in completing this OE and HCBS-AMH program implementation |

| | |Texas Institute for Excellence in Mental Health. For more|support via The University of Texas Health Science Center- San|

| | |details on the specific assistance available, email |Antonio (UTHSCSA). For more details on the specific |

| | |txinstitute4mh@austin.utexas.edu. |assistance available, email Dr. Matt Brown at |

| | | |brownma@uthscsa.edu. |

| | | | |

| | | |Dr. Matt Brown is a subject matter expert on the HCBS-AMH OE |

| | | |document and process, and can provide comprehensive, no-cost |

| | | |technical assistance to OE Respondents. Dr. Matt Brown and |

| | | |UTHSCSA are prepared to assist Respondents with completing all|

| | | |aspects of the OE. |

| | | | |

| | | |Respondents that are unsuccessful in three attempts to submit |

| | | |a complete and acceptable application will be restricted from |

| | | |reapplying for 365 days from the date of the last rejected |

| | | |application. |

|2. |Update OE Point of |Article VI, Letter A, OE Point of Contact Currently |Article VI, Letter A, OE Point of Contact is now: |

| |Contact |States: | |

| | | |For purposes of submitting questions concerning this OE, the |

| | |For purposes of submitting questions concerning this OE, |only contact is the Mental Health Contract Management Unit |

| | |the only contact is Tracie Deloach unless otherwise |unless otherwise delegated by the OE Point of Contact. All |

| | |delegated by the OE Point of Contact. All communications |communications concerning this OE must be submitted by email |

| | |concerning this OE must be submitted by email to: |to: |

| | | | |

| | |OE Point of Contact Email: |OE Point of Contact Email: MHContracts@hhsc.state.tx.us |

| | |Tracie.DeLoach01@hhsc.state.tx.us |Ref: OE# HHS0000075 |

| | |Ref: OE# HHS0000075 | |

|Addendum #5 |

|Revised on May 31, 2019 |

|Item |Purpose of Change |Previous |Revision |

|1. |Update Enrollment |August 31, 2019 |August 31, 2020 |

| |Period Close Date | | |

| |on pg. 1 | | |

|2. |Update Open |Article VI, Letter A, OE Point of Contact was: |Article VI, Letter A, OE Point of Contact is now: |

| |Enrollment Point of| | |

| |Contact |Christopher Dickinson |Tracie Deloach |

| | |Christopher.Dickinson@hhsc.state.tx.us |Tracie.DeLoach01@hhsc.state.tx.us |

|3. |URL Updates | |

| |throughout Open | |ral-health-services-providers/home-community-based-services-adult|

| |Enrollment | |-mental-health |

|4. |Update Enrollment |The enrollment period begins December 18, 2014, and |The enrollment period begins December 18, 2014, and will remain |

| |Period Close Date |will remain open through August 31, 202019. |open through August 31, 2020. Respondents deemed qualified to |

| |and initial award |Respondents deemed qualified to provide services shall |provide services shall be awarded a Contingency Contract which |

| |period in Section |be awarded a Contingency Contract which shall be |shall be effective on the day of execution through 8/31/2022. |

| |I. A. |effective on the day of execution through 8/31/2019. |SYSTEM AGENCY may, at its sole discretion, extend the closing |

| | |SYSTEM AGENCY may, at its sole discretion, extend the |date of this OE. As stated in Sec. II, SYSTEM AGENCY may also, |

| | |closing date of this OE. As stated in Sec. II, SYSTEM |at its sole discretion, withdraw this OE before the stated date |

| | |AGENCY may also, at its sole discretion, withdraw this |the enrollment period ends. |

| | |OE before the stated date the enrollment period ends. | |

|5. |Update Enrollment |Contingency contracts awarded under this OE will be |Contingency contracts awarded under this OE will be effective on |

| |Period Close Date |effective on the date of execution through August 31, |the date of execution through August 31, 2022. |

| |and initial award |2019. SYSTEM AGENCY may, at its sole discretion, renew| |

| |period in Section |a contingency contract after the initial term. | |

| |III. C. |Contracts may be renewed up to three additional one- | |

| | |year period contract terms. Renewal is contingent upon| |

| | |the availability of funds and the satisfactory | |

| | |performance of the contractor during the prior contract| |

| | |period. | |

|6. |Update Appendix D |Region 16 was: |Region 16 is now: |

| | | | |

| | |Dallas |Dallas, Ellis, Navarro, Kaufman, Rockwall, Hunt |

|7. |Update Appendix D |Region 25 was: |Region 25 is now: |

| | | | |

| | |Ellis, Navarro, Kaufman, Rockwall, Hunt, Hopkins, |Hopkins, Lamar, Delta, Franklin, Titus, Camp, Morris |

| | |Lamar, Delta, Franklin, Titus, Camp, Morris | |

|Addendum #4 |

|Revised on March 26, 2019 |

|Item |Purpose of Change |Previous |Revision |

|1. |Update Open |Article VI, Letter A, OE Point of Contact was: |Article VI, Letter A, OE Point of Contact is now: |

| |Enrollment Point of| | |

| |Contact |Amy Hess |Christopher Dickinson |

| | |Amy.Hess@hhsc.state.tx.us |Christopher.Dickinson@hhsc.state.tx.us |

|Addendum #3 |

|Revised on January 13, 2017 |

|Item |Purpose of Change |Previous |Revision |

|1. |Update enrollment |Enrollment Cover Page read in part as follows: |Enrollment Cover Page now reads in part as follows: |

| |Cover Page | | |

| |including |Notice of Open Enrollment (OE) |Notice of Open Enrollment (OE) |

| |enrollment title | | |

| |and agency name |Home and Community Based Services - Adult Mental |Home and Community Based Services – Adult Mental Health Provider |

| | |Health Services Provider Agreement (MH/HCBS-AMH PA) |Agency |

| | | | |

| | |Department of State Health Services |Health and Human Services Commission |

|2. |To update agency |Department of State Health Services or DSHS |All references to Department of State Health Services, DSHS or |

| |name | |Department are replaced with Health and Human Services |

| | | |Commission(HHSC) or System Agency |

|3. |To add language to|Section I. A. Introduction read in part as follows: |Section I. A. Introduction is revised to read in part as follows: |

| |the Introduction | | |

| | |The Department of State Health Services (DSHS or |The Health and Human Services Commission (“SYSTEM AGENCY”), Home and|

| | |Department), Home and Community Based Services-Adult |Community Based Services-Adult Mental Health (HCBS-AMH) Services |

| | |Mental Health (HCBS-AMH) Services Program announces |Program announces this notice of Open Enrollment (OE) requesting |

| | |this notice of Open Enrollment (OE) requesting |applications to enter into a contingency contract with SYSTEM |

| | |applications to enter into a contingency contract with|AGENCY. Respondents are hereby notified that the HCBS-AMH Services |

| | |DSHS. The contingency contract will require the |Program and all functions associated with the HCBS-AMH Services |

| | |contractor to provide home and community-based |Program have been transferred by the Department of State Health |

| | |services to adults with extended tenure in psychiatric|Services to the SYSTEM AGENCY with all rights, responsibilities and |

| | |hospitals in lieu of remaining as long term residents |obligations thereto, as provided in Texas Government Code, Section |

| | |of those facilities. The contingency contract will |531.0201. |

| | |provide an array of services, appropriate to each | |

| | |individual’s needs, to enable these individuals to |The contingency contract will require the contractor to provide home|

| | |live and experience successful tenure in their |and community-based services to adults with a diagnosis of serious |

| | |community. |mental illness and have a history of at least one of the following |

| | | |additional criteria: |

| | | | |

| | | |Long-term psychiatric hospitalization(s); |

| | | |Frequent arrests and psychiatric crisis; |

| | | |Frequent emergency department (ED) visits and psychiatric crisis. |

| | | | |

| | | |The contingency contract will provide an array of services, |

| | | |appropriate to each individual’s needs, to enable these individuals |

| | | |to live and experience successful tenure in their community. |

| | | |Contractor will select the population(s) they will serve. |

|4. |To revise language|Section I. A. Introduction read in part as follows: |Section I. A. Introduction is revised to read in part as follows: |

| |in the | | |

| |introduction |The enrollment period begins December 18, 2014, and |The enrollment period begins December 18, 2014, and will remain open|

| | |will remain open through August 31, 2018. Contingency|through August 31, 2018. Respondents deemed qualified to provide |

| | |contracts awarded under this OE will begin on the day |services shall be awarded a Contingency Contract which shall be |

| | |of execution through 8/31/2018. DSHS may, at its sole|effective on the day of execution through 8/31/2018. SYSTEM AGENCY |

| | |discretion, extend the closing date of this OE. As |may, at its sole discretion, extend the closing date of this OE. As|

| | |stated in Sec. II, DSHS may also, at its sole |stated in Sec. II, SYSTEM AGENCY may also, at its sole discretion, |

| | |discretion, withdraw this OE before the stated date |withdraw this OE before the stated date the enrollment period ends. |

| | |the enrollment period ends. | |

|5. |To revise language|Section I. A. Introduction read in part as follows: |Section I. A. Introduction is revised to read in part as follows: |

| |in the | | |

| |introduction |Respondents may seek technical assistance in |Respondents may seek technical assistance in completing this OE and |

| | |completing this OE and HCBS-AMH program implementation|HCBS-AMH program implementation support via Texas Institute for |

| | |support thru 8/31/2016 via Texas Institute for |Excellence in Mental Health. For more details on the specific |

| | |Excellence in Mental Health (TIEMH). For more details|assistance available, email txinstitute4mh@austin.utexas.edu. |

| | |on the specific assistance available, email | |

| | |txinstitute4mh@austin.utexas.edu. | |

| | | | |

|6. |To add or revise |Section I. B. Definitions is revised in part to add or|Section I. B. Definitions, is revised in part to add or revise the |

| |Definitions |revise definitions. |following definitions: |

| | | | |

| | | |Center for Medicare and Medicaid Services – The Federal agency |

| | | |within the United States Department of Health and Human Services |

| | | |that administers the Medicare program and works collaboratively with|

| | | |state governments to administer Medicaid. |

| | | | |

| | | |Contingency Contract – Also called a “contract” in this OE, a |

| | | |written agreement referring to promises or agreements for which the |

| | | |law establishes enforceable duties and remedies between a minimum of|

| | | |two parties and which is contingent on one or more factors. A |

| | | |SYSTEM AGENCY contract is assembled using a core contract (base), |

| | | |one or more program attachments, and other required exhibits |

| | | |(general provisions, etc.). |

| | | |Contract Term – The period of time during which the contract or |

| | | |program attachment will be effective from execution date to end, or |

| | | |renewal date. The contract term may or may not be the same as the |

| | | |budget period. |

| | | | |

| | | |Cost Reimbursement- A payment mechanism in which funds are provided |

| | | |to carry out approved contract activities. Reimbursement is based on|

| | | |actual allowable costs incurred that comply with contractual |

| | | |requirements. |

| | | | |

| | | |Entity- A person, business, organization, or LLC that submits a |

| | | |response to solicitation. For purposes of this document, “entity” is|

| | | |intended to include such phrases as “offeror”, “respondent”, |

| | | |“bidder”, “responder”, or other similar terminology employed by |

| | | |SYSTEM AGENCY to describe the person, business, organization or LLC |

| | | |that responds to a solicitation. |

| | | | |

| | | |Fee For Service – Payment mechanism for services that are reimbursed|

| | | |on an agreed rate per unit of service. Rates are available through |

| | | |SYSTEM AGENCY’s website at |

| | | | |

| | | | |

| | | |Individual Recovery Plan – A written, individualized plan, developed|

| | | |in consultation with the individual and legally authorized |

| | | |representative, if applicable, which identifies the necessary HCBS |

| | | |to be provided to the individual and also serves as the treatment |

| | | |plan or recovery plan. |

| | | | |

| | | |Medicaid Management Information System – Automated management and |

| | | |control system for Medicaid payments. |

| | | | |

| | | |Provider of Last Resort – An entity that is the only willing and |

| | | |qualified entity in a geographic area that the individual chooses to|

| | | |provide the service. |

| | | | |

| | | |Unit Rate – Payment mechanism for services that are reimbursed at a |

| | | |set rate per unit of service; for example, treatment services at a |

| | | |prescribed rate per hour. Also known as fee-for-service. Rates are |

| | | |available through SYSTEM AGENCY’s website at |

| | | |. |

| | | | |

| | | | |

|7. |To add language to|Section II. Limitations read as follows: |Section II. Limitations is revised to read as follows: |

| |Section II. | | |

| |Limitations |Issuance of this OE in no way constitutes a commitment|Issuance of this OE in no way constitutes a commitment by SYSTEM |

| | |by DSHS or the State of Texas to execute a contract or|AGENCY or the State of Texas to execute a contract or to pay any |

| | |to pay any costs incurred by any provider who may |costs incurred by any Respondent who may submit an enrollment |

| | |submit an enrollment application. |application. |

| | | | |

| | |The resulting contingency contract will be subject to |The resulting contingency contract will be subject to the |

| | |the availability of state and federal funds. |availability of State and Federal funds and the need for HCBS-AMH |

| | |Contingency contracts awarded under this OE and any |services. Contingency contracts awarded under this OE and any |

| | |anticipated contract renewals are contingent upon the |anticipated contract renewals are contingent upon the continued |

| | |continued availability of funding. DSHS reserves the |availability of funding. SYSTEM AGENCY reserves the right to alter,|

| | |right to alter, amend or withdraw this OE at any time |amend or withdraw this OE at any time prior to the execution of a |

| | |prior to the execution of a contingency contract. If |contingency contract. If a contingency contract has been fully |

| | |a contingency contract has been fully executed and |executed and this OE is altered, amended, or withdrawn, SYSTEM |

| | |this OE is altered, amended, or withdrawn, DSHS and |AGENCY and contractor’s obligations and rights will be determined in|

| | |contractor’s obligations and rights will be determined|accordance with the provisions of the contract. |

| | |in accordance with the provisions of the contract. | |

|8. |To revise language|Section III. Use of Funds read in part as follows: |Section III. Use of Funds is revised in part as follows: |

| |to Use of Funds | | |

| | |DSHS will provide a one-time disbursement of $40,000 |SYSTEM AGENCY will provide a one-time disbursement of $40,000 for |

| | |for infrastructure development to the contractor. |infrastructure development to eligible contractors for as long as |

| | |Infrastructure development is demonstrated by |allocated funds are available. Infrastructure development is |

| | |enrollment of and HCBS-AMH service provision to an |demonstrated by an executed contract and enrollment of and HCBS-AMH |

| | |individual prior to August 31, 2016. Service provision|service provision to an individual. Service provision will be |

| | |will be validated through HCBS-AMH service claims |validated through HCBS-AMH service claims submission on the HCBS-AMH|

| | |submission on the HCBS-AMH invoice template located at|invoice template located at |

| | |. |. There is a maximum of |

| | | |one disbursement per Respondent allowed regardless of the number of |

| | | |contracts the Respondent may hold under this OE. |

|9. |To Add language in|Section IV. A. Eligibility Requirements and |Section IV. A. Eligibility Requirements and Affirmations are revised|

| |Eligibility |Affirmations reads in part as follows: |to read in part as follows: |

| |Requirements and | | |

| |Affirmations |Respondent must be a Medicaid provider prior to the |Respondent must meet the following: |

| | |provision of HCBS-AMH services. |Have at least 2 years of experience working with individuals with |

| | |Respondent must be established as an appropriate legal|serious mental illness; or |

| | |entity as described in the paragraph above, under |Currently is a provider of a HCBS Waiver program. |

| | |state statutes and must have the authority and be in |Prior to receiving referrals for the provision of HCBS-AMH services,|

| | |good standing to do business in Texas and to conduct |Respondent must be authorized as an active Medicaid Provider.  |

| | |the activities described in the OE. |Respondent must be established as an appropriate legal entity as |

| | |Respondent must have a Texas address. A post office |described in the paragraph above, under state statutes and must have|

| | |box may be used when the enrollment application is |the authority and be in good standing to do business in Texas and to|

| | |submitted, but the respondent must conduct business at|conduct the activities described in the OE. |

| | |a physical location in the service area prior to the |Respondent must have an encrypted e-mail extension that is |

| | |date that the contract is awarded. |exclusively associated with the respondent’s organization and have |

| | |Respondent must be in good standing with the U.S. |capacity to assign employees an e-mail address with the exclusive |

| | |Internal Revenue Service. |e-mail extension. |

| | |Respondent is ineligible to apply for funds under this|Respondent must have a Texas address. A post office box may be used|

| | |OE if currently debarred, suspended, or otherwise |when the enrollment application is submitted, but the respondent |

| | |excluded or ineligible for participation in Federal or|must conduct business at a physical location in the service area or |

| | |State assistance programs. |within 30 miles of an adjacent service area. This physical location|

| | |Respondent’s staff members, including the executive |must be zoned to conduct business, be compliant with property |

| | |director, must not serve as voting members on their |agreements, and be obtained prior to the site review as well as |

| | |employer’s governing board. |prior to date the contract is awarded. If respondent’s business |

| | |In compliance with Comptroller of Public Accounts and |address is their home respondent shall attach proof that the |

| | |Texas Procurement and Support Services rules, a name |building is approved to be zoned for business or if leased that the |

| | |search will be conducted using the websites listed in |building owner approves the space to be used for business purposes. |

| | |this section prior to the development of a contract.  |Respondent shall provide SYSTEM AGENCY, upon request, with the |

| | |A respondent is not considered eligible to contract |personnel files of any or all HCBS-AMH staff (including |

| | |with DSHS if a name match is found on any of the |administration, owners and board members) prior to the commencement |

| | |following lists: |of HCBS-AMH services and at the request of SYSTEM AGENCY. Personnel |

| | |The System for Award Management (SAM) is an official |files shall include: |

| | |U.S. Government system that consolidated the | |

| | |capabilities of CCR/Fed Reg, ORCA and EPLS. Search | |

| | |the federal excluded list at the following website: |Credentialing for employees and subcontractors (including |

| | |; and |verification of licensure, qualifications, training requirements, |

| | |Texas Comptroller of Public Accounts (CPA) Debarment |certification records; and |

| | |List located at |Criminal History Background and all Abuse Registry checks |

| | | and all administrative staff shall complete HCSB-AMH |

| | |performance/debarred/. |Pre-application modules located at the following website: |

| | |Respondent must have established organizational |

| | |policies and procedures. Topics include, but are not |ased-services-adult-mental-health-2/ prior to completion of the OE |

| | |limited to the following. Please refer to the Manual |application. Respondents shall submit Pre-application certificates |

| | |located at |with the OE application to verify completion of all HCBS-AMH |

| | |for guidance on how topics below shall meet the |Pre-application modules. |

| | |minimum standards). |Respondent must be in good standing with the U.S. Internal Revenue |

| | |Confidentiality and retention of client records and |Service. |

| | |progress notes; |Respondent is ineligible to apply for funds under this OE if |

| | |Provision of services / coordination of care |currently debarred, suspended, or otherwise excluded or ineligible |

| | |(including routine and emergency appointment |for participation in Federal or State assistance programs. |

| | |availability, and assurance that all HCBS-AMH services|Respondent’s staff members, including the executive director, must |

| | |will be available to individuals in each service area.|not serve as voting members on their employer’s governing board. |

| | |This includes notification of DSHS when HCBS-AMH |In compliance with Comptroller of Public Accounts and Texas |

| | |service is unavailable for any period of time); |Procurement and Support Services rules, a name search will be |

| | |Quality management plan; |conducted using the websites listed in this section prior to the |

| | |Utilization management; |development of a contract.  |

| | |Determination of respondent’s capacity to serve |A respondent is not considered eligible to contract with SYSTEM |

| | |individuals; |AGENCY if a name match is found on any of the following lists: |

| | |Notification to DSHS of respondent’s capacity to serve|The System for Award Management (SAM) is an official U.S. Government|

| | |individuals; |system that consolidated the capabilities of CCR/Fed Reg, ORCA and |

| | |Housing and placement policies and procedures |EPLS. Search the federal excluded list at the following website: |

| | |(monitoring and tracking placement, expansion of |; and |

| | |community housing relationship plan, and other |Texas Comptroller of Public Accounts (CPA) Debarment List located at|

| | |procedures identified on Form H); |

| | |Compliance with 1915(i) federal regulations, including|barred/. |

| | |settings requirements for provider owned and operating|Please refer to the Manual located at |

| | |settings; | for guidance on how |

| | |Managing Conflicts of Interest; |topics below shall meet the minimum standards. Respondent must have |

| | |Personnel recordkeeping / management; |established organizational policies and procedures. Topics include,|

| | |Critical incident reporting; |but are not limited to the following: |

| | |Personnel and client safety (behavior management, |Confidentiality and retention of client records and progress notes; |

| | |restraint, suicide precaution/prevention); |Provision of services / coordination of care (including routine and |

| | |Personnel credentialing and training (including |emergency appointment availability, and assurance that all HCBS-AMH |

| | |verification of licensure, qualifications, training |services will be available to individuals in each service area. This|

| | |requirements, and certification records for employees |includes notification of SYSTEM AGENCY when HCBS-AMH service is |

| | |and subcontractors); |unavailable for any period of time); |

| | |Medication safety; |Quality management plan; |

| | |Payment of employees and subcontractors; |Utilization management; |

| | |Process to submit reports and billing invoices to DSHS|Determination of respondent’s capacity to serve individuals; |

| | |(including verification of the individual’s Medicaid |Notification to SYSTEM AGENCY of respondent’s capacity to serve |

| | |for a billing period); |individuals; |

| | |Medicaid fair hearing; |Housing and placement policies and procedures (monitoring and |

| | |Consumer rights and grievances; |tracking placement, expansion of community housing relationship |

| | |Reporting abuse, neglect, and exploitation; |plan, and other procedures identified on Form H); |

| | |Critical incidents; |Compliance with 1915(i) federal regulations, including settings |

| | |Transfer of individual’s to another HCBS-AMH provider;|requirements for provider owned and operating settings; |

| | |and |Managing Conflicts of Interest if applying for both Open Enrollment |

| | |Discharge of individuals from HCBS-AMH. |Applications: Provider Agency Agreement and Recovery Management |

| | |Respondent must affirm audit and financial statements |Agreement (include organizational chart that clearly defines |

| | |are complete and accurate, and demonstrate financial |separation between Recovery Manager and Provider functions, audit |

| | |solvency or sufficient cash balances to operate for a |process for managing conflicts of interest, employee training and |

| | |minimum of two months. |attestation that no conflict of interest exists, reporting of |

| | |Respondent must affirm they have not violated federal |conflicts of interest to SYSTEM AGENCY such as a change in |

| | |law in connection with any contract awarded by the |administrative structure, billing practice and invoice submission). |

| | |federal government for relief, recovery or |Personnel recordkeeping / management; |

| | |reconstruction efforts as a result of Hurricanes |Critical incident reporting; |

| | |Katrina or Rita or any other disaster occurring after |Personnel and client safety (behavior management, restraint, suicide|

| | |September 25, 2005, in accordance with Texas |precaution/prevention); (Including but not limited to: TAC Title 25,|

| | |Government Code §§2155.006 and 2261.053. |Part 1, CH-415 Rules 415.259-415.273) |

| | |Respondent affirm they will comply with Human |Personnel credentialing and training (including verification of |

| | |Resources Code, Section 48.253, requiring a provider |licensure, qualifications, training requirements, and certification |

| | |to: |records for employees and subcontractors); |

| | |Cooperate completely with an investigation of alleged |Medication safety; |

| | |abuse, neglect, or exploitation conducted by the |Process to submit reports and billing invoices to SYSTEM AGENCY |

| | |Department of Family and Protective Services. |(including verification of the individual’s Medicaid for a billing |

| | |Provide complete access to the Department of Family |period); |

| | |and Protective Services during an investigation to: |Medicaid fair hearing; |

| | |All sites owned, operated, or controlled by the |Consumer rights and grievances; |

| | |provider; and |Reporting abuse, neglect, and exploitation; |

| | |Clients and client records. |Critical incidents; |

| | |Respondents who are local mental health authorities |Transfer of individual’s to another HCBS-AMH provider; and |

| | |shall affirm they and their subcontractors will comply|Discharge of individuals from HCBS-AMH. |

| | |with the Texas Administrative Code, Chapter 414, |Respondent must affirm audit and financial statements are complete |

| | |Subchapter L. This includes, but is not limited to: |and accurate, and demonstrate financial solvency or sufficient cash |

| | |Amending contracts to ensure contractors’ compliance |balances to operate for a minimum of two months. |

| | |with this subchapter. |Respondent must affirm they have not violated federal law in |

| | |Implementing policies and procedures addressing |connection with any contract awarded by the federal government for |

| | |disciplinary and other action in confirmed cases of |relief, recovery or reconstruction efforts as a result of Hurricanes|

| | |abuse, neglect, and exploitation involving employees |Katrina or Rita or any other disaster occurring after September 25, |

| | |and agents, in accordance with Section 414.557. |2005, in accordance with Texas Government Code §§2155.006 and |

| | |Ensuring that a Client Abuse and Neglect Reporting |2261.053. |

| | |form (AN-1-A) is completed within 14 calendar days of |Respondent affirm they will comply with Human Resources Code, |

| | |the receipt of the investigative report from the |Section 48.253, requiring a provider to: |

| | |Department of Family and Protective Services or a |Cooperate completely with an investigation of alleged abuse, |

| | |decision made after review or appeal using the CANRS |neglect, or exploitation conducted by the Department of Family and |

| | |Definitions and the CANRS Classifications, when the |Protective Services. |

| | |perpetrator or alleged perpetrator is an employee or |Provide complete access to the Department of Family and Protective |

| | |agent of the local mental health authority, community |Services during an investigation to: |

| | |center, or contractor, or if the perpetrator is |All sites owned, operated, or controlled by the provider; and |

| | |unknown. |Clients and client records. |

| | |Ensuring, within one working day after completion of |Respondents who are local mental health authorities shall affirm |

| | |the AN-1-A form, that: |they and their subcontractors will comply with the Texas |

| | |The information contained in the completed AN-1-A form|Administrative Code, Chapter 414, Subchapter L. This includes, but |

| | |is entered into the Client Abuse and Neglect Reporting|is not limited to: |

| | |System (CANRS); or |Amending contracts to ensure contractors’ compliance with this |

| | |If access to CANRS is unavailable, a copy of the |subchapter. |

| | |completed AN-1-A form is forwarded for data entry to |Implementing policies and procedures addressing disciplinary and |

| | |the Office of Consumer Services and Rights |other action in confirmed cases of abuse, neglect, and exploitation |

| | |Protection–Ombudsman, P.O. Box 12668, Austin, TX |involving employees and agents, in accordance with Section 414.557. |

| | |78711-2668. |Ensuring that a Client Abuse and Neglect Reporting form (AN-1-A) is |

| | |Respondent must affirm a contract or Provider |completed within 14 calendar days of the receipt of the |

| | |Agreement has not been suspended or terminated, |investigative report from the Department of Family and Protective |

| | |license has not been surrendered, or license has not |Services or a decision made after review or appeal using the CANRS |

| | |been suspended or revoked by any local, state or |Definitions and the CANRS Classifications, when the perpetrator or |

| | |federal department or agency or non-profit entity. |alleged perpetrator is an employee or agent of the local mental |

| | |Respondent must affirm all pending or threatened |health authority, community center, or contractor, or if the |

| | |litigation has been disclosed to DSHS. |perpetrator is unknown. |

| | |Respondent must affirm identification to DSHS of any |Ensuring, within one working day after completion of the AN-1-A |

| | |related party transactions involving parties that may |form, that: |

| | |perform part of the work under the Provider Agreement.|The information contained in the completed AN-1-A form is entered |

| | |Respondent must affirm identification to DSHS whether |into the Client Abuse and Neglect Reporting System (CANRS); or |

| | |any person who has an ownership, controlling interest |If access to CANRS is unavailable, a copy of the completed AN-1-A |

| | |in the organization, employee, or volunteer of the |form is forwarded for data entry to the Office of Consumer Services |

| | |organization has pending criminal charges, been placed|and Rights Protection–Ombudsman, P.O. Box 12668, Austin, TX |

| | |on community supervision (probation or parole), |78711-2668. |

| | |received deferred adjudication or convicted of a |Respondent must affirm a contract or Provider Agreement has not been|

| | |criminal offense. |suspended or terminated, license has not been surrendered, or |

| | |All respondents must have general liability insurance.|license has not been suspended or revoked by any local, state or |

| | | |federal department or agency or non-profit entity. |

| | |Minimum eligibility requirements for direct service |Respondent must affirm all pending or threatened litigation has been|

| | |providers of HCBS-AMH services are set forth in the |disclosed to SYSTEM AGENCY. |

| | |Manual. |Respondent must affirm identification to SYSTEM AGENCY of any |

| | | |related party transactions involving parties that may perform part |

| | | |of the work under the Provider Agreement. |

| | | |Respondent must affirm identification to SYSTEM AGENCY whether any |

| | | |person who has an ownership, controlling interest in the |

| | | |organization, employee, or volunteer of the organization has pending|

| | | |criminal charges, been placed on community supervision (probation or|

| | | |parole), and received deferred adjudication or convicted of a |

| | | |criminal offense. |

| | | |Respondent must affirm they have a history of compliance with the |

| | | |laws relating to the respondent’s business operations and the |

| | | |affected services and whether the respondent is currently in |

| | | |compliance; |

| | | |All respondents must have general liability insurance (Form N) |

| | | |All documents submitted must be numbered in numerical sequence in |

| | | |the lower right corner. Any additions to the original submission may|

| | | |be added, but the application must be renumbered to ensure the final|

| | | |packet is sequentially numbered and the entire packet resubmitted. |

| | | |If a contingency contract has been fully executed and the Respondent|

| | | |requests to contract to serve additional service region(s) or |

| | | |additional target population(s), Respondent will complete the |

| | | |following: |

| | | |Updated Form-A-Face Page |

| | | |Updated Form-C-Contact Person Information |

| | | |Updated Form G-Organizational Chart |

| | | |Updated Form-J-Proof of General Liability Insurance |

| | | |Updated Form-K-Organizational Brochure or Biographical Information |

| | | |Updated electronic Policy and Procedure Manual from the Respondent |

| | | |to reflect the additional proposed service region(s), target |

| | | |population(s), or programmatic changes due to expansion. |

| | | |Provide addresses to physical locations within the requested |

| | | |expansion service region(s). |

| | | |On site reviews of Respondent offices and residential setting in |

| | | |requested service region(s) designated for individuals enrolled in |

| | | |HCBS-AMH will be conducted at the discretion of SYSTEM AGENCY. |

| | | |Onsite reviews for additional service regions are subject to the |

| | | |terms identified in Section VI.C.4. |

| | | | |

| | | |Minimum eligibility requirements for direct service providers of |

| | | |HCBS-AMH services are set forth in the Manual. |

|10. |To revise language|Section IV. B. Required Activities for Contractors |Section IV. B. Required Activities for Contractors Receiving and |

| |in Required |Receiving and Award under This OE reads in part as |Award under This OE is revised to read in part as follows: |

| |Activities for |follows: | |

| |Contractors | | |

| |Receiving an award|Respondent must directly or indirectly, through |Respondent must directly or indirectly, through subcontractor, |

| |under This OE |subcontractor, provide the following HCBS-AMH |provide the following HCBS-AMH services. Services shall be delivered|

| | |services. Services shall be delivered according to the|according to the individual’s IRP approved by SYSTEM AGENCY. |

| | |individual’s IRP approved by DSHS. Respondent must |Respondent must provide at a minimum one of the services demarcated |

| | |provide one of the services demarcated by (*) |by (*) directly. A minimum of one directly provided service shall |

| | |directly……… |not also be provided through a subcontractor…….. |

|11. |To revise language|Section IV. B. Required Activities for Contractors |Section IV. B. Required Activities for Contractors Receiving and |

| |in Required |Receiving and Award under This OE reads in part as |Award under This OE is revised to read in part as follows: |

| |Activities for |follows: | |

| |Contractors | |10. Respondent shall provide SYSTEM AGENCY, upon request, with the |

| |Receiving an award|10. Respondent shall provide DSHS, upon request, with |personnel files of any or all HCBS-AMH staff (including |

| |under This OE |the personnel files of any or all HCBS-AMH staff |administration, owners and board members) prior to the commencement |

| | |(including administration) prior to the commencement |of HCBS-AMH services and at the request of SYSTEM AGENCY. Personnel |

| | |of HCBS-AMH services and at the request of DSHS. |files shall include: |

| | |Personnel files shall include: |Credentialing (including verification of licensure, qualifications, |

| | |Credentialing (including verification of licensure, |training requirements, and certification records for employees and |

| | |qualifications, training requirements, and |subcontractors) and |

| | |certification records for employees and |Criminal History Background and Abuse Registry checks |

| | |subcontractors); and |11. Respondent shall receive approval from SYSTEM AGENCY on their |

| | |Criminal History Background and Abuse Registry checks |determined capacity to serve prior to the provision of HCBS-AMH |

| | |11.Respondent shall receive approval from DSHS on |services. |

| | |their determined capacity to serve prior to the | |

| | |provision of HCBS-AMH services. |12. Respondent shall affirm they have a history of compliance with |

| | | |the laws relating to the respondent’s business operations and the |

| | |12. Respondent shall maintain appropriate |affected services and whether the respondent is currently in |

| | |documentation of all HCBS-AMH services in the format |compliance. |

| | |prescribed by DSHS. Information shall be collected, | |

| | |maintained, and reported by Respondent in accordance |13. Respondent shall maintain appropriate documentation of all |

| | |with the following specifications: |HCBS-AMH services in the format prescribed by SYSTEM AGENCY. |

| | |All reports shall be submitted to DSHS within the time|Information shall be collected, maintained, and reported by |

| | |frame and formats, and including subject matter, |Respondent in accordance with the following specifications: |

| | |specified in this Provider Agreement. |a. All reports shall be submitted to SYSTEM AGENCY within the time |

| | |Respondent shall respond within five working days to |frame and formats, and including subject matter, specified in this |

| | |requests for ad hoc reports by DSHS. |Provider Agreement. |

| | |Respondent shall submit all Critical Incident |b. Respondent shall respond within five working days to requests for|

| | |Reporting Forms to the Recovery Manager within 72 |ad hoc reports by SYSTEM AGENCY. |

| | |hours of notification of an incident report, in |c. Respondent shall submit all Critical Incident Reporting Forms |

| | |accordance with DSHS policy. |within 72 hours of notification of an incident report, in accordance|

| | | |with SYSTEM AGENCY policy. |

|12. |To correct Civil |Section V., C. Program Requirements reads in part as |Section V., C. Program Requirements is revised to read in part as |

| |Rights Office |follows: |follows: |

| |website address |Contractors are required to conduct Project activities| |

| | |in accordance with federal and state laws prohibiting |Contractors are required to conduct Project activities in accordance|

| | |discrimination. Guidance for adhering to |with federal and state laws prohibiting discrimination. Guidance |

| | |non-discrimination requirements can be found on the |for adhering to non-discrimination requirements can be found on the |

| | |HHSC Civil Rights Office website at: |SYSTEM AGENCY Civil Rights Office website at: |

| | | |

| | | | |

|13. |To add language in| |Section V., C. Program Requirements is revised to add the following:|

| |Program | | |

| |Requirements | |SYSTEM AGENCY reserves the right to perform a Quality Management |

| | | |review at SYSTEM AGENCY’s sole discretion. |

| | | | |

|14. |To add Form O to |Section VI., C. Evaluation Process reads in part as |Section VI., C. Evaluation Process is revised to reads in part as |

| |the evaluation |follows: |follows: |

| |process | | |

| | |2. Other preliminary screening criteria as needed and |2. Other preliminary screening criteria as needed and appropriate, |

| | |appropriate, including: |including: |

| | |FORM A: Face Page; |a. FORM A: Face Page; |

| | |FORM B: Open Enrollment Application checklist; |b. FORM B: Open Enrollment Application checklist; |

| | |FORM C: Contact Person Information; |c. FORM C: Contact Person Information; |

| | |FORM D: Board Member Information (if applicable); |d. FORM D: Board Member Information (if applicable); |

| | |FORM E: Vendor Information; |e. FORM E: Vendor Information; |

| | |FORM F: Plan of HCBS-AMH service provision; |f. FORM F: Plan of HCBS-AMH service provision; |

| | |FORM G: Subcontracted Providers (if applicable); |g. FORM G: Subcontracted Providers (if applicable); |

| | |FORM H: Access to Housing; |h. FORM H: Access to Housing; |

| | |FORM I: Articles of Incorporation and Bylaws, |i. FORM I: Articles of Incorporation and Bylaws, including amendment|

| | |including amendment (if applicable); |(if applicable); |

| | |FORM J: Organizational Overview, Philosophy, or |j. FORM J: Organizational Overview, Philosophy, or Mission |

| | |Mission Statement; |Statement; |

| | |FORM K: Organizational Chart/Structure; |k. FORM K: Organizational Chart/Structure; |

| | |FORM L: Policies and Procedures; and |l. FORM L: Policies and Procedures; and |

| | |FORM M: Job Descriptions. |m. FORM M: Job Descriptions. |

| | |FORM N: Proof of General Liability Insurance |n. FORM N: Proof of General Liability Insurance |

| | | |o. FORM O: Organization Brochure or Biographical Information |

| | | | |

|15. |To add language | |Section VI., C. Evaluation Process is revised to add the following |

| |regarding onsite | |paragraph: |

| |reviews. | | |

| | | |On site reviews of Respondent offices and residential setting in |

| | | |requested service region(s) designated for individuals enrolled in |

| | | |HCBS-AMH will be conducted at the discretion of SYSTEM AGENCY. |

| | | |Respondents will provide addresses to physical locations within the |

| | | |requested service region(s). |

| | | | |

|16. |To add language to|Section VI. D. Rejection of Enrollment Applications |Section VI. D. Rejection of Enrollment Applications is revised to |

| |Rejection of |reads in part as follows: |reads in part as follows: |

| |Enrollment | | |

| |Applications |5. If a Respondent wishes to re-apply for the Open |5. If a Respondent wishes to re-apply for the Open Enrollment after |

| | |Enrollment after receiving a rejection letter: |receiving a rejection letter: |

| | |Respondent is not permitted to re-apply for 6 months |Respondent is not permitted to re-apply for 6 months from the date |

| | |from the date of the rejection letter; and |of the rejection letter; |

| | |Respondent must correct the item(s) identified in the |Respondent must correct the item(s) identified in the rejection |

| | |rejection letter. |letter prior to re-applying: and |

| | | |Respondent must complete and submit a new OE PA Application. |

|17. |To add Form O. as |Section VII. Application Instructions and Criteria For|Section VII. Application Instructions and Criteria For Acceptance is|

| |a required |Acceptance read in part as follows: |revised to read in part as follows: |

| |document | | |

| | |The following application documents are required: |The following application documents are required: |

| | |FORM A: Face Page; |FORM A: Face Page; |

| | |FORM B: Open Enrollment Application Checklist; |FORM B: Open Enrollment Application Checklist; |

| | |FORM C: Contact Person Information; |FORM C: Contact Person Information; |

| | |FORM D: Board Member Information (if applicable); |FORM D: Board Member Information (if applicable); |

| | |FORM E: Vendor Information Form; |FORM E: Vendor Information Form; |

| | |FORM F: Plan of HCBS-AMH Service Component Provision; |FORM F: Plan of HCBS-AMH Service Component Provision; |

| | |FORM G: Subcontracted Providers (if applicable); |FORM G: Subcontracted Providers (if applicable); |

| | |FORM H: Access to Housing; |FORM H: Access to Housing; |

| | |FORM I: Articles of Incorporation and Bylaws, |FORM I: Articles of Incorporation and Bylaws, including amendment |

| | |including amendment (if applicable); |(if applicable); |

| | |FORM J: Organizational Overview, Philosophy, or |FORM J: Organizational Overview, Philosophy, or Mission Statement; |

| | |Mission Statement; |FORM K: Organizational Chart/Structure; |

| | |FORM K: Organizational Chart/Structure; |FORM L: Policies and Procedures; and |

| | |FORM L: Policies and Procedures; and |FORM M: Job Descriptions |

| | |FORM M: Job Descriptions |FORM N: Proof of General Liability Insurance |

| | |FORM N: Proof of General Liability Insurance |FORM O: Organization Brochure or Biographical Information |

|18. |To add Form O | |Section VIII. Blank Forms and Instructions is revised to add Form O:|

| | | |Organization Brochure or Biographical Information |

|Addendum #2 |

|Revised on January 15, 2016 |

|Item |Purpose of Change |Previous |Revision |

|1. |To add language regarding|New language added to the end of Section I. A. Introduction. |Language was added as follows: |

| |technical assistance | | |

| |completing the Open | |Respondents may seek technical assistance in completing |

| |Enrollment | |this OE and HCBS-AMH program implementation support thru |

| | | |8/31/2016 via Texas Institute for Excellence in Mental |

| | | |Health (TIEMH). For more details on the specific |

| | | |assistance available, email |

| | | |txinstitute4mh@austin.utexas.edu. |

|2. |To add language regarding|New language added to Section III. A, Use of Funds |Language was added as follows: |

| |the use of funds and | | |

| |funding methodology. | |DSHS, at its sole discretion, may adjust the funding |

| | | |amount of a Program Attachment based on performance |

| | | |measures, outcome measures, waitlist, and/or other |

| | | |criteria determined by DSHS, and contingent on |

| | | |availability of funds allocated for the adjustments DSHS |

| | | |may implement an alternative reimbursement methodology |

| | | |using the rates set forth herein (or using the rates that|

| | | |exist at the time a contract is executed). This |

| | | |alternative methodology may include the use of a case |

| | | |rate based on expected lengths of stay. |

|3. |To extend the date for |Section III. A, Use of Funds, contained language that read, |Said language was changed as follows: |

| |one-time disbursements |in part, as follows: | |

| |for infrastructure | |DSHS will provide a one-time disbursement of $40,000 for |

| |development. |DSHS will provide a one-time disbursement of $40,000 for |infrastructure development to the contractor. |

| | |infrastructure development to the contractor. Infrastructure|Infrastructure development is demonstrated by enrollment |

| | |development is demonstrated by enrollment of and HCBS-AMH |of and HCBS-AMH service provision to an individual prior |

| | |service provision to an individual prior to January 1, 2016. |to August 31, 2016. |

|4. |To add funding obligation|Section III. B. Term of Contract, contained language that |Section III. B. is now Funding Obligation and reads as |

| |language |read, in part, as follows: |follows: |

| | | | |

| | |Contingency contracts awarded under this OE will begin on the|This Contract is contingent upon the availability of |

| | |date of execution through August 31, 2018. DSHS may, at its |funding. If funds become unavailable through lack of |

| | |sole discretion renew a contingency contract after the |appropriations, budget cuts, transfer of funds between |

| | |initial term |programs or health and human services agencies, amendment|

| | | |of the Appropriations Act, Health and Human Services |

| | | |agency consolidation, or any other disruptions of current|

| | | |appropriated funding for this Contract, DSHS may |

| | | |restrict, reduce or terminate funding under this |

| | | |Contract. Notice of any restriction or reduction shall |

| | | |include instructions and detailed information on how DSHS|

| | | |shall fund the services and/or goods to be procured with |

| | | |the restricted or reduced funds |

|5. |To inform that Section |Section III. B. Term of Contract is now located in Section |Section III. C. Term of Contract |

| |III. B. Term of Contract |III. C | |

| |is now Section III. C | |Contingency contracts awarded under this OE will begin on|

| | | |the date of execution through August 31, 2018. DSHS may,|

| | | |at its sole discretion renew a contingency contract after|

| | | |the initial term….. |

|6. |To revise language in |Section IV. A. Eligibility Requirements and Affirmations, |Said language was changed as follows: |

| |eligibility requirements |contained language that read, in part, as follows: | |

| |and affirmations | |Eligible respondents include organizations established as|

| | |Eligible respondents include organizations established as a |a legal entity under state statutes and have the |

| | |legal entity under state statutes and have the authority to |authority to do business in Texas. Eligible respondents |

| | |do business in Texas. Eligible respondents must comply with |must comply with the criteria listed below. |

| | |the criteria listed below. | |

| | | |1. Respondent must be a Medicaid provider prior to the |

| | |1. Respondent must be a Medicaid provider of the necessary |provision of HCBS-AMH services. |

| | |provider type for HCBS-AMH services. | |

|7. |To revise language in |Section IV. A Eligibility Requirements and Affirmations, |Said language was changed as follows: |

| |eligibility requirements |contained language that read, in part as follows: | |

| |and affirmations | |9. Respondent must have established organizational |

| | |9. Respondent must have established organizational policies |policies and procedures. Topics include, but are not |

| | |and procedures. Topics include, but are not limited to the |limited to the following. Please refer to the Manual |

| | |following. Please refer to the Manual for guidance on how |located at for|

| | |topics below shall meet the minimum standards). |guidance on how topics below shall meet the minimum |

| | |a. Confidentiality and retention of client records and |standards). |

| | |progress notes; |a. Confidentiality and retention of client records and |

| | |b. Provision of services / coordination of care (including |progress notes; |

| | |routine and emergency appointment availability, and assurance|b. Provision of services / coordination of care |

| | |that all HCBS-AMH services will be available to individuals |(including routine and emergency appointment |

| | |in each service area. This includes notification of DSHS when|availability, and assurance that all HCBS-AMH services |

| | |HCBS-AMH service is unavailable for any period of time); |will be available to individuals in each service area. |

| | |c. Quality management plan; |This includes notification of DSHS when HCBS-AMH service |

| | |d. Utilization management; |is unavailable for any period of time); |

| | |e. Determination of respondent’s capacity to serve |c. Quality management plan; |

| | |individuals; |d. Utilization management; |

| | |f. Notification of DSHS of respondent’s capacity to serve |e. Determination of respondent’s capacity to serve |

| | |individuals; |individuals; |

| | |g. Housing and placement policies and procedures (monitoring |f. Notification to DSHS of respondent’s capacity to serve|

| | |and tracking placement, expansion of community housing |individuals; |

| | |relationship plan, and other procedures identified on Form |g. Housing and placement policies and procedures |

| | |H); |(monitoring and tracking placement, expansion of |

| | |h. Compliance with 1915(i) federal regulations, including |community housing relationship plan, and other procedures|

| | |settings requirements for provider owned and operating |identified on Form H); |

| | |settings; |h. Compliance with 1915(i) federal regulations, including|

| | |i. Personnel recordkeeping / management; |settings requirements for provider owned and operating |

| | |j. Critical incident reporting; |settings; |

| | |k. Personnel and client safety (behavior management, |i. Managing Conflicts of Interest; |

| | |seclusion and restraint); |j. Personnel recordkeeping / management; |

| | |l. Personnel credentialing and training (including |k. Critical incident reporting; |

| | |verification of licensure, qualifications, training |l. Personnel and client safety (behavior management, |

| | |requirements, and certification records for employees and |restraint, suicide precaution/prevention); |

| | |subcontractors); |m. Personnel credentialing and training (including |

| | |m. Medication safety; |verification of licensure, qualifications, training |

| | |n. Payment of employees and subcontractors; |requirements, and certification records for employees and|

| | |o. Process to submit invoices to DSHS (including verification|subcontractors); |

| | |of the individual’s Medicaid for a billing period); |n. Medication safety; |

| | |p. Medicaid fair hearing; |o. Payment of employees and subcontractors; |

| | |q. Consumer rights and grievances; |p. Process to submit reports and billing invoices to DSHS|

| | |r. Reporting abuse, neglect, and exploitation; |(including verification of the individual’s Medicaid for |

| | |s. Critical incidents; |a billing period); |

| | |t. Transfer of individual’s to another HCBS-AMH provider; and|q. Medicaid fair hearing; |

| | |u. Discharge of individuals from HCBS-AMH. |r. Consumer rights and grievances; |

| | | |s. Reporting abuse, neglect, and exploitation; |

| | | |t. Critical incidents; |

| | | |u. Transfer of individual’s to another HCBS-AMH provider;|

| | | |and |

| | | |v. Discharge of individuals from HCBS-AMH. |

|8. |To revise language and |Section IV. A Eligibility Requirements and Affirmations, |Said language and numbering was changed as follows: |

| |numbering in eligibility |contained language that read, in part as follows: | |

| |requirements and | |11. Respondent must affirm they have not violated federal|

| |affirmations |11. Respondent must affirm they have not violated federal law|law in connection with any contract awarded by the |

| | |in connection with any contract awarded by the federal |federal government for relief, recovery or reconstruction|

| | |government for relief, recovery or reconstruction efforts as |efforts as a result of Hurricanes Katrina or Rita or any |

| | |a result of Hurricanes Katrina or Rita or any other disaster |other disaster occurring after September 25, 2005, in |

| | |occurring after September 25, 2005, in accordance with Texas |accordance with Texas Government Code §§2155.006 and |

| | |Government Code §§2155.006 and 2261.053. |2261.053. |

| | |12. Respondent must affirm a contract or Provider Agreement |12. Respondent affirm they will comply with Human |

| | |has not been suspended or terminated, license has not been |Resources Code, Section 48.253, requiring a provider to: |

| | |surrendered, or license has not been suspended or revoked by |a. Cooperate completely with an investigation of alleged |

| | |any local, state or federal department or agency or |abuse, neglect, or exploitation conducted by the |

| | |non-profit entity. |Department of Family and Protective Services. |

| | |13. Respondent must affirm all pending or threatened |b. Provide complete access to the Department of Family |

| | |litigation has been disclosed to DSHS. |and Protective Services during an investigation to: |

| | |14. Respondent must affirm identification to DSHS of any |i. All sites owned, operated, or controlled by the |

| | |related party transactions involving parties that may perform|provider; and |

| | |part of the work under the Provider Agreement. |ii. Clients and client records. |

| | |15. Respondent must affirm identification to DSHS whether any|13. Respondents who are local mental health authorities |

| | |person who has an ownership, controlling interest in the |shall affirm they and their subcontractors will comply |

| | |organization, employee, or volunteer of the organization has |with the Texas Administrative Code, Chapter 414, |

| | |been placed on community supervision (probation or parole), |Subchapter L. This includes, but is not limited to: |

| | |received deferred adjudication or convicted of a criminal |a. Amending contracts to ensure contractors’ compliance |

| | |offense. |with this subchapter. |

| | |16. All respondents must have general liability insurance. |b. Implementing policies and procedures addressing |

| | | |disciplinary and other action in confirmed cases of |

| | | |abuse, neglect, and exploitation involving employees and |

| | | |agents, in accordance with Section 414.557. |

| | | |c. Ensuring that a Client Abuse and Neglect Reporting |

| | | |form (AN-1-A) is completed within 14 calendar days of the|

| | | |receipt of the investigative report from the Department |

| | | |of Family and Protective Services or a decision made |

| | | |after review or appeal using the CANRS Definitions and |

| | | |the CANRS Classifications, when the perpetrator or |

| | | |alleged perpetrator is an employee or agent of the local |

| | | |mental health authority, community center, or contractor,|

| | | |or if the perpetrator is unknown. |

| | | |d. Ensuring, within one working day after completion of |

| | | |the AN-1-A form, that: |

| | | |i. The information contained in the completed AN-1-A form|

| | | |is entered into the Client Abuse and Neglect Reporting |

| | | |System (CANRS); or |

| | | |ii. If access to CANRS is unavailable, a copy of the |

| | | |completed AN-1-A form is forwarded for data entry to the |

| | | |Office of Consumer Services and Rights |

| | | |Protection–Ombudsman, P.O. Box 12668, Austin, TX |

| | | |78711-2668. |

| | | |14. Respondent must affirm a contract or Provider |

| | | |Agreement has not been suspended or terminated, license |

| | | |has not been surrendered, or license has not been |

| | | |suspended or revoked by any local, state or federal |

| | | |department or agency or non-profit entity. |

| | | |15. Respondent must affirm all pending or threatened |

| | | |litigation has been disclosed to DSHS. |

| | | |16. Respondent must affirm identification to DSHS of any |

| | | |related party transactions involving parties that may |

| | | |perform part of the work under the Provider Agreement. |

| | | |17. Respondent must affirm identification to DSHS whether|

| | | |any person who has an ownership, controlling interest in |

| | | |the organization, employee, or volunteer of the |

| | | |organization has pending criminal charges, been placed on|

| | | |community supervision (probation or parole), received |

| | | |deferred adjudication or convicted of a criminal offense.|

| | | |18. All respondents must have general liability |

| | | |insurance. |

|9. |To revise language and |Section IV. B. Required Activities for Contractors Receiving |Said language and numbering was changed as follows: |

| |numbering in Required |an Award Under This OE, contained language that read, in part| |

| |Activities for |as follows: |9. Respondent shall have and maintain HIPAA compliant |

| |Contractors Receiving an | |encrypted email to provide the department with reporting |

| |Award Under this OE |9. Respondent shall have and maintain HIPAA compliant |data that includes HIPAA-related information. |

| | |encrypted email to provide the department with reporting data|10. Respondent shall provide DSHS, upon request, with the|

| | |that includes HIPAA-related information. |personnel files of any or all HCBS-AMH staff (including |

| | |10. Respondent shall maintain appropriate documentation of |administration) prior to the commencement of HCBS-AMH |

| | |all HCBS-AMH services in the format prescribed by DSHS. |services and at the request of DSHS. Personnel files |

| | |Information shall be collected, maintained, and reported by |shall include: |

| | |Respondent in accordance with the following specifications: |a. Credentialing (including verification of licensure, |

| | |a. All reports shall be submitted to DSHS within the time |qualifications, training requirements, and certification |

| | |frame and formats, and including subject matter, specified in|records for employees and subcontractors); and |

| | |this Provider Agreement. |b. Criminal History Background and Abuse Registry checks |

| | |b. Respondent shall respond within five working days to |11. Respondent shall receive approval from DSHS on their |

| | |requests for ad hoc reports by DSHS. |determined capacity to serve prior to the provision of |

| | |c. Respondent shall submit all Critical Incident Reporting |HCBS-AMH services. |

| | |Forms to the Recovery Manager within 72 hours of notification|12. Respondent shall maintain appropriate documentation |

| | |of an incident report, in accordance with DSHS policy. |of all HCBS-AMH services in the format prescribed by |

| | | |DSHS. Information shall be collected, maintained, and |

| | | |reported by Respondent in accordance with the following |

| | | |specifications: |

| | | |a. All reports shall be submitted to DSHS within the time|

| | | |frame and formats, and including subject matter, |

| | | |specified in this Provider Agreement. |

| | | |b. Respondent shall respond within five working days to |

| | | |requests for ad hoc reports by DSHS. |

| | | |c. Respondent shall submit all Critical Incident |

| | | |Reporting Forms to the Recovery Manager within 72 hours |

| | | |of notification of an incident report, in accordance with|

| | | |DSHS policy. |

|10. |To revise language and |Section VI. C. Evaluation Process, contained language that |Said language and numbering was changed as follows: |

| |numbering in Evaluation |read, in part as follows: | |

| |Process | |4. The respondent may be subject to an Onsite Review |

| | |4. The respondent may be subject to an Onsite Review which |which may include, but is not limited to, the review and |

| | |may include, but is not limited to, the review and |verification of: |

| | |verification of: |a. Information submitted as a part of the OE application;|

| | |a. Information submitted as a part of the OE application; |b. Policies and Procedures Manuals or Operational |

| | |b. Policies and Procedures Manuals or Operational Handbooks |Handbooks to include the following policies and |

| | |to include the following policies and procedures: |procedures: |

| | |i. Confidentiality and retention of client records and |i. Confidentiality and retention of client records and |

| | |progress notes; |progress notes; |

| | |ii. Provision of services / coordination of care (including |ii. Provision of services / coordination of care |

| | |routine and emergency appointment availability, and assurance|(including routine and emergency appointment |

| | |that all HCBS-AMH services will be available to individuals |availability, and assurance that all HCBS-AMH services |

| | |in each service area. This includes notification of DSHS when|will be available to individuals in each service area. |

| | |HCBS-AMH service is unavailable for any period of time); |This includes notification of DSHS when HCBS-AMH service |

| | |iii. Quality management plan; |is unavailable for any period of time); |

| | |iv. Utilization management; |iii. Quality management plan; |

| | |v. Determination of respondent’s capacity to serve |iv. Utilization management; |

| | |individuals; |v. Determination of respondent’s capacity to serve |

| | |vi. Housing and placement policies and procedures (monitoring|individuals; |

| | |and tracking placement, expansion of community housing |vi. Housing and placement policies and procedures |

| | |relationship plan, and other procedures identified on Form |(monitoring and tracking placement, expansion of |

| | |H); |community housing relationship plan, and other procedures|

| | |vii. Compliance with 1915(i) federal regulations, including |identified on Form H); |

| | |settings requirements for provider owned and operating |vii. Compliance with 1915(i) federal regulations, |

| | |settings; |including settings requirements for provider owned and |

| | |viii. Personnel recordkeeping / management; |operating settings; |

| | |ix. Critical incident reporting; |viii. Managing Conflicts of Interest; |

| | |x. Personnel and client safety (behavior management, |ix. Personnel recordkeeping / management; |

| | |seclusion and restraint); |x. Critical incident reporting; |

| | |xi. Personnel credentialing and training (including |xi. Personnel and client safety (behavior management, |

| | |verification of licensure, qualifications, training |restraint, suicide precaution/prevention); |

| | |requirements, and certification records for employees and |xii. Personnel credentialing and training (including |

| | |subcontractors); |verification of licensure, qualifications, training |

| | |xii. Medication safety; |requirements, and certification records for employees and|

| | |xiii. Payment of employees and subcontractors; |subcontractors); |

| | |xiv. Process to submit invoices to DSHS (including |xiii. Medication safety; |

| | |verification of the individual’s Medicaid for a billing |xiv. Payment of employees and subcontractors; |

| | |period); |xv. Process to submit reports and billing invoices to |

| | |xv. Medicaid fair hearing; |DSHS (including verification of the individual’s Medicaid|

| | |xvi. Consumer rights and grievances; |for a billing period); |

| | |xvii. Reporting abuse, neglect, and exploitation; |xvi. Medicaid fair hearing; |

| | |xviii. Critical incidents; |xvii. Consumer rights and grievances; |

| | |xix. Transfer of individual’s to another HCBS-AMH provider; |xviii. Reporting abuse, neglect, and exploitation; |

| | |and |xix. Critical incidents; |

| | |xx. Discharge of individuals from HCBS-AMH. |xx. Transfer of individual’s to another HCBS-AMH |

| | | |provider; and |

| | | |xxi. Discharge of individuals from HCBS-AMH. |

|11. |To add language on |Section VI.D of the open enrollment, Rejection of Enrollment |Language was added as follows: |

| |re-applying for the open |Applications, adds item number 5. | |

| |enrollment. | |5. If a Respondent wishes to re-apply for the Open |

| | | |Enrollment after receiving a rejection letter: |

| | | |a. Respondent is not permitted to re-apply for 6 months |

| | | |from the date of the rejection letter; and |

| | | |b. Respondent must correct the item(s) identified in the |

| | | |rejection letter |

|Addendum #1 |

|Revised on April 24, 2015 |

|Item |Purpose of Change |Previous |Revision |

| |To add a one-time |Section III. Funding and Term, of the open enrollment, A. |Said language was changed as follows: |

| |disbursement for |Use of Funds, contained language that read, in part, as | |

| |infrastructure |follows: |“Contingency contracts will be awarded for the purpose |

| |development. | |specifically defined in this OE. DSHS will review |

| | |“Contingency contracts will be awarded for the purpose |applications in the order in which they are received. The |

| | |specifically defined in this OE. DSHS will review |Medicaid rates will be the payment methodology for services |

| | |applications in the order in which they are received. The |provided by a contractor under this contingency contract. |

| | |Medicaid rates will be the payment methodology for services| |

| | |provided by a contractor under this contingency contract. |DSHS will provide a one-time disbursement of $40,000 for |

| | | |infrastructure development to the contractor. Infrastructure|

| | |DSHS does not guarantee a minimum amount to be paid to a |development is demonstrated by enrollment of and HCBS-AMH |

| | |contractor pursuant to a contingency contract awarded |service provision to an individual prior to January 1, 2016. |

| | |through this OE." |Service provision will be validated through HCBS-AMH service |

| | | |claims submission on the HCBS-AMH invoice template located at|

| | | |. |

| | | | |

| | | |DSHS does not guarantee a minimum amount to be paid to a |

| | | |contractor pursuant to a contingency contract awarded through|

| | | |this OE. |

| |To extend the enrollment|Cover Page read, in part, as follows: |Said language was changed as follows: |

| |closing date to | | |

| |08/31/2018. |Enrollment Period Opens: 12/18/2014 |Enrollment Period Opens: 12/18/2014 |

| | |Enrollment Period Closes: 08/31/2015 |Enrollment Period Closes: 08/31/2018 |

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