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Department Family & Protective ServicesOpen Enrollment Number: HHS0000071

FORM A - Applicant and Contract Information

DFPS uses the PEN Application and Contract (2280PEN) to create a contract between DFPS and a Contractor for the performance of services that were solicited using the Provider Enrollment (PEN) procurement method. The PEN Application and Contract, Form 2280PEN is included as an attachment to the PEN solicitation.

Under §5 of the 2280PEN, DFPS must indicate where the services will be provided. The Contractor will be required to provide services in the geographical area specified in the solicitation, most frequently consistent with a DFPS region.

Department of Family & Protective ServicesOpen Enrollment HHS0000071

Attachment A-3APPLICATION AND CONTRACT

Evaluation & Treatment HHS0000071

1. Identification Information

Legal Name of Applicant Doing Business As (DBA) Name

If different from Legal Name Attach a copy of Assumed Name Certificate

Vendor ID Number

Federal ID Number – If different from Vendor ID

2. Type of Applicant – Check “√” appropriate box(es) and attach documentation as indicated

Individual/Sole Proprietor Limited Liability Company (LLC) Attach a copy of the Articles of Formation Corporation

Type of Corporation: For Profit Non-ProfitState of Incorporation: Charter Number:

Attach a copy of Certificate of Incorporation Partnership

Type of Partnership: Limited GeneralAttach a copy of Partnership Agreement.

If applicable, also attach a copy of the Signatory Assignment

3. Contact InformationOffice Address (Street-Suite #)

Office Address (City, State, Zip)

Mailing Address (P.O. Box)If different from Office Address above

Mailing Address (City, State, Zip)If different from Office Address above

Phone- Primary Office

Fax- Primary Office

E-Mail- Primary Office

Name-Primary Contact Person

Title-Primary Contact Person

Phone-Primary Contact Person

Alternate Phone-Primary Contract Person

E-Mail- Primary Contract Person


Name- Person Authorized to Sign Contract

Title- Person Authorized to Sign Contract

Phone- Person Authorized to Sign Contract

Alternate Phone- Person Authorized to Sign Contract

E-Mail- Person Authorized to Sign Contract

Name-Person Responsible for Billing

Title- Person Responsible for Billing

Phone- Person Responsible for Billing

Alternate Phone- Person Responsible for Billing

E-Mail- Person Responsible for Billing

DFPS will send contract-related communications to the primary contact listed above. The Contractor must maintain and monitor at least one active e-mail address for the receipt of contract-related communications from DFPS.

4. Services to Be Provided

Contractor may provide Psychological Evaluation and Testing and/or Psychosocial Assessment and Treatment Services specified in Provider Enrollment HHS0000071. Contractor must provide all Support Services specified in HHS0000071 upon DFPS request.

Evaluation and Treatment ServicesService Service Type Applying For

Evaluation ServicesTreatment Services

Psychological Evaluation and Testing Yes No

Psychosocial Assessment, Individual, Group and Family Counseling

Yes No

Support ServicesCourt Related ServicesDiagnostic ConsultationTranslator & Interpreter

As requested by DFPS

Battering Intervention and Prevention Program (BIPP) ServicesService Service Type Applying For

Evaluation andIntervention Services

Domestic Violence Assessment and BIPP Group Intervention (Providers must be TDCJ-CJAD accredited BIPP program providers who are either an LMSW,

Yes No


LCSW, LPC, LMFT or a TDCJ-CJAD funded BIPP Provider)

Support ServicesCourt Related ServicesDiagnostic ConsultationTranslator & Interpreter

As requested by DFPS

5. Service Delivery Locations

a. You must determine which counties will be served and mark them in Attachment A-4 Service Delivery Areas. Contractor must provide services within each county selected.

b. Will you, your staff, or subcontractors be delivering services from established office sites other than the location listed in Section C of this application?

Yes No

If yes, services from these satellite locations are to be billed as In-Office. Designate any satellite office on Attachment A-4 Service Delivery Areas.

c. Indicate locations in which the Contractor is willing to provide services.

In-Office Out-of-Office Home-Based (client's home) (not allowable for BIPP)

d. Will you, your staff, or subcontractors be delivering services in any of the CPS Designated Underserved Counties identified on Attachment A-4 Service Delivery Areas?

Yes No

6. Contractor Background

a. Does the Contractor have contracts with DFPS or other State Agencies?

Yes No

If yes, is the Contractor's organization currently under any corrective action plan for any of the contracts with DFPS or State Agencies?

Yes No

b. Have any contracts been terminated for cause in the last five (5) years?

Yes (Provide copy of termination notice) No

7. Insurance

7.1 Review the minimum insurance requirements in PEN §2.16. Applicants must meet all requirements as outlined. Indicate in the table below, if requirement is met:


Commercial General Liability

Yes No

Applicant does not have required Commercial General Liability insurance, but will obtain within the timeframe defined in the PEN:

Yes No

Professional Liability Insurance

Yes No N/A*

Applicant does not carry Professional Liability Insurance for its employees or subcontractors, but will obtain within the timeframe defined in the PEN:

Yes No

Commercial Crime

Yes No N/A*

Applicant does not have required commercial crime insurance, but will obtain within the timeframe defined in the PEN:

Yes No

Attach a copy of the Form 4736, Certificate of Insurance (COI) or equivalent (ACORD Certificate of Insurance, or a copy of the policy) for each policy currently in force and referenced in the table above. Form 4736 has been approved by the Texas Department of Insurance and is the preferred form of insurance verification.

*Business entities with no employees and hospitals are exempt from crime policy insurance requirement.

7.2 For Employees and Subcontractors

Applicant’s organization requires individual professional employees and subcontractors to secure their own Professional Liability Insurance:

Yes No N/A

8. Incorporation by Reference

The following documents are incorporated into the Contract for all purposes:

8.1.1. DFPS Vendor Uniform Terms & Conditions, Form 5645V8.1.2. DFPS General Affirmations, Form 56478.1.3. DFPS Vendor Special Conditions, Form 5622V8.1.4. Provider Enrollment HHS0000071, including all addenda and attachments8.1.5. Attachment A-3 and A-4, as completed by the Contractor, including all addenda

and attachments8.1.6. Each Service Authorization Form 2054, prepared by DFPS

9. Order of Precedence

The Contractor will provide the services and deliverables described and required by all the documents listed in this Section. In the event of conflicts or inconsistencies between documents, such conflicts or inconsistencies will be resolved by reference to the documents in the following order of precedence:

9.1.1. This PEN Application and Contract, 2280PEN, and any amendments thereto;


9.1.2. DFPS Vendor Uniform Terms & Conditions, Form 5645V9.1.3. DFPS General Affirmations, Form 56479.1.2. DFPS Special Conditions, Form 5622V9.1.3. Provider Enrollment HHS0000071 and any amendments thereto; 9.1.4. Each Service Authorization Form 2054 prepared by DFPS; and 9.1.5. Attachment A-3 and A-4, as completed by the Contractor, including all addenda

and attachments, and any amendments thereto.

10.Certification and Signature

I certify that the information provided in this application is, to the best of my knowledge, complete and accurate; that the named legal entity has authorized me, as its representative, to submit this application; and that the legal entity complies with all terms of this Provider Enrollment.

By signing this PEN Application and Contract, applicant certifies that if a Texas address is shown as the address of the applicant, applicant qualifies as a Texas Resident Bidder as defined in Texas Administrative Code, Title 34, Part 1, Chapter 20.

DFPS will post all official communication regarding this PEN on the Electronic State Business Daily (ESBD). DFPS reserves the right to revise the PEN at any time. Contractors must comply with any changes, amendments, or clarifications posted to ESBD. It is the responsibility of the Contractor to periodically check the ESBD for updates to the procurement. The Contractor’s failure to periodically check the ESBD will not release the Contractor from “addenda or additional information” resulting in additional costs to meet the requirements of the PEN.

The undersigned representative agrees to all the terms and conditions specified in the Contract and by signing below agrees to execute the terms and conditions of the Contract upon receipt of a 2054 from the Department.

Signature of Authorized Representative

Date

Name of Authorized Representative (Printed)

Title of Authorized Representative (Printed)

DFPS Approval Signature:Signature of Authorized DFPS Representative

Date

Name of Authorized DFPS Representative (Printed)

Title of Authorized DFPS Representative (Printed)

http://esbd.cpa.state.tx.us/

http://esbd.cpa.state.tx.us/


11.Contract Information – For DFPS Use ONLY

DFPS will complete the information below once Application is screened, reviewed, and accepted for contract.

11.1. Notices

Any notice required or permitted under this contract by the Contractor to DFPS must be in writing and submitted to the DFPS address below:

DFPS Office Address (Street;-Suite #; or P.O. Box)

11.2. Contract Term

Contract Number (DFPS staff will complete)

The initial contract period will begin on the effective date stated below, with the total contract term not to exceed sixty (60) months.

Effective Date of Contract

End Date of Contract


FORM B - Attachment A-4 Service Delivery Area

Service Delivery AreaCounties To Be Served – Region 1

Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.

***CPS Designated Underserved County

Regional Counties☐ Armstrong*** ☐ Hockley***☐ Bailey*** ☐ Hutchinson***☐ Briscoe*** ☐ King***☐ Carson*** ☐ Lamb***☐ Castro*** ☐ Lipscomb***☐ Childress*** ☐ Lubbock☐ Cochran*** ☐ Lynn***☐ Collingsworth*** ☐ Moore***☐ Crosby*** ☐ Motley***☐ Dallam*** ☐ Ochiltree***☐ Deaf Smith*** ☐ Oldham***☐ Dickens*** ☐ Parmer***☐ Donley*** ☐ Potter☐ Floyd*** ☐ Randall☐ Garza*** ☐ Roberts***☐ Gray*** ☐ Sherman***☐ Hale*** ☐ Swisher***☐ Hall*** ☐ Terry***☐ Hansford*** ☐ Wheeler***☐ Hartley*** ☐ Yoakum***☐ Hemphill***





Regional Counties☐ Archer*** ☐ Kent***☐ Baylor*** ☐ Knox***☐ Brown*** ☐ Mitchell***☐ Callahan*** ☐ Montague***☐ Clay*** ☐ Nolan***☐ Coleman*** ☐ Runnels***☐ Comanche*** ☐ Scurry***☐ Cottle*** ☐ Shackelford***☐ Eastland*** ☐ Stephens***☐ Fisher*** ☐ Stonewall***☐ Foard*** ☐ Taylor***☐ Hardeman*** ☐ Throckmorton***☐ Haskell*** ☐ Wichita***☐ Jack*** ☐ Wilbarger***☐ Jones*** ☐ Young***





Regional Counties☐ Collin ☐ Johnson***☐ Cooke*** ☐ Kaufman***☐ Dallas ☐ Navarro***☐ Denton ☐ Palo Pinto***☐ Ellis*** ☐ Parker***☐ Erath*** ☐ Rockwall***☐ Fannin*** ☐ Somervell☐ Grayson*** ☐ Tarrant☐ Hood*** ☐ Wise***☐ Hunt***





Regional Counties☐ Anderson ☐ Marion☐ Bowie ☐ Morris***☐ Camp*** ☐ Panola***☐ Cass*** ☐ Rains***☐ Cherokee ☐ Red River***☐ Delta ☐ Rusk☐ Franklin*** ☐ Smith☐ Gregg ☐ Titus☐ Harrison ☐ Upshur☐ Henderson ☐ Van Zandt☐ Hopkins ☐ Wood***☐ Lamar





Regional Counties☐ Angelina ☐ Polk***☐ Hardin ☐ Sabine***☐ Houston*** ☐ San Augustine***☐ Jasper*** ☐ San Jacinto***☐ Jefferson ☐ Shelby***☐ Nacogdoches ☐ Trinity***☐ Newton*** ☐ Tyler***☐ Orange





Regional Counties☐ Austin*** ☐ Liberty***☐ Brazoria*** ☐ Matagorda***☐ Chambers*** ☐ Montgomery☐ Colorado*** ☐ Walker***☐ Fort Bend ☐ Waller***☐ Galveston*** ☐ Wharton☐ Harris





Regional Counties☐ Bastrop*** ☐ Hill***☐ Bell ☐ Lampasas***☐ Blanco*** ☐ Lee***☐ Bosque*** ☐ Leon***☐ Brazos*** ☐ Limestone***☐ Burleson*** ☐ Llano***☐ Burnet*** ☐ Madison***☐ Caldwell ☐ McLennan☐ Coryell*** ☐ Milam***☐ Falls*** ☐ Mills☐ Fayette*** ☐ Robertson***☐ Freestone*** ☐ San Saba***☐ Grimes*** ☐ Travis☐ Hamilton*** ☐ Washington***☐ Hays ☐ Williamson





Regional Counties☐ Atascosa ☐ Karnes☐ Bandera ☐ Kendall☐ Bexar ☐ Kerr☐ Calhoun*** ☐ Kinney☐ Comal ☐ La Salle☐ De Witt*** ☐ Lavaca***☐ Dimmit ☐ Maverick***☐ Edwards ☐ Medina***☐ Frio*** ☐ Real☐ Gillespie ☐ Uvalde***☐ Goliad ☐ Val Verde***☐ Gonzales*** ☐ Victoria***☐ Guadalupe ☐ Wilson***☐ Jackson ☐ Zavala***





Regional Counties☐ Andrews*** ☐ Mason***☐ Borden*** ☐ McCulloch***☐ Coke*** ☐ Menard***☐ Concho*** ☐ Midland☐ Crane*** ☐ Pecos***☐ Crockett*** ☐ Reagan***☐ Dawson*** ☐ Reeves***☐ Ector ☐ Schleicher***☐ Gaines*** ☐ Sterling***☐ Glasscock*** ☐ Sutton***☐ Howard*** ☐ Terrell***☐ Irion*** ☐ Tom Green☐ Kimble*** ☐ Upton***☐ Loving*** ☐ Ward☐ Martin*** ☐ Winkler***





Regional Counties☐ Brewster*** ☐ Hudspeth***☐ Culberson*** ☐ Jeff Davis***☐ El Paso*** ☐ Presidio***





Regional Counties☐ Aransas*** ☐ Live Oak***☐ Bee*** ☐ McMullen***☐ Brook***s ☐ Nueces☐ Cameron ☐ Refugio***☐ Duval*** ☐ San Patricio***☐ Hidalgo ☐ Starr***☐ Jim Hogg*** ☐ Webb***☐ Jim Wells*** ☐ Willacy***☐ Kenedy ☐ Zapata***☐ Kleberg***


:Satellite Offices and Additional Office Information:

Please provide a schedule in the table(s) below indicating days and times routinely available to provide services at each service location. These represent only routine days and times. Applicant will be expected to adjust schedule to accommodate the needs of clients and DFPS. Refer to PEN Section 2.5 for additional information. Use additional copies of this section, as necessary, to provide complete information.

Name of Applicant/Contractor

1.

Service Delivery Address

City, State, Zip

Phone Fax

Contact Person E-mail

HOURSDAY From To From To

Example 7 AM Noon 2 PM 7 PMMonday Tuesday Wednesday Thursday Friday Saturday Sunday

2.


City, State, Zip

Phone Fax



Monday Tuesday Wednesday Thursday Friday Saturday



Sunday

3.


City, State, Zip

Phone Fax



Monday Tuesday Wednesday Thursday Friday Saturday Sunday


FORM C - Attachment A-5 Required Forms

Applicants must complete and submit all forms in the format and order listed below.

A complete answer includes a written response and any supporting documents required by the form. In addition, “Not Applicable” is only an appropriate response when a given question or form does not apply to an Applicant’s organization.

Notes

1. The application can be accessed via the link or embedded document provided in the Required Forms table below. (Hold down the "Ctrl" key while clicking on the link). Save the form on your computer, and complete the saved form as instructed.

2. Forms must be completed and signed.Note: Review each form in its entirety to ensure that applicable sections are completed.

3. Forms requiring an original signature must be signed and saved in the electronic (Adobe Acrobat Files (.pdf)) copies and, if requested, submit hard copies of these forms to DFPS with original signatures.

4. Some forms may include special instructions or clarification provided under the name of the form in the column titled "Name."

5. If a form does not apply to you or your organization, mark "N/A" on the form, include your operation's name, signature (if required) and date, and save in the electronic copies.


Number Name Purpose Form Location

2970C

Disclosure and Consent to Release of Information Regarding Criminal or Abuse/Neglect History For Applicants, Employees or Volunteers of DFPS Contractors and Subcontractors

Release of information regarding criminal history or DFPS abuse and neglect history

Form D

2971CRequest for Criminal History and DFPS History Check

Application for requesting criminal history and DFPS abuse or neglect history Form E

4108x Vendor Direct Deposit Authorization

For vendor to receive direct deposit Form F

4109x

Application for Texas Identification Number/Additional Mailing Address

Application for identification number

Form G

PCS-102ET

Contracting Entity and List of Staff, Subcontractors, and Volunteers – Must include Medicaid Number

List the contracting entity, all service providers, and requested provider information on this form.

Form H

9007FFSInternal Control Structure Questionnaire (ICSQ) for Fee for Service Contracts

Contractor's disclosure of internal controls. Instructions included

Form I

4736 Certificate of InsuranceDocuments the Contractor's Insurance Coverage Form J

5627 Evaluation & Treatment Experience Summary

Documents the Contractor's Professional Experience

Form K


FORM M - BIPP Application Checklist

STEP 1: Read the Evaluation & Treatment Open Enrollment for details of the terms and conditions of this contract. Focus on the sections that apply to BIPP Applicants. http://esbd.cpa.state.tx.us/bid_show.cfm?bidid=126949

STEP 2: Organization of Electronic Submission of ApplicationApplicant must organize its scanned and signed Application packet in the following order and format. Each flash drive or compact disc submission of the Application packet must include the following three (3) file folders with the respective listed documents included, and the documents must be in the following order, and numbered and labeled accordingly. Refer to Section 5, Information and Submission Instructions in the Open Enrollment and Section 8, Attachments and Forms (p.94).

Items to include in Application Packet Yes No

File Folder 1: ApplicationExhibit 1 - Application and Contract (Form 2280PEN) Exhibit 2 - Attachment A-4 Service Delivery Areas

File Folder 2: Supporting DocumentationExhibit 1 - Verification of Business Entity (Copy of: Certificate of Incorporation, Articles of Formation, Partnership Agreement, or Assumed Name Certificate)Exhibit 2 - BIPP Providers will have a 2-hour Child Welfare Trauma Informed Training Certificate from the completion of webinar http://www.dfps.state.tx.us/training/trauma_informed_care/

Exhibits 3 - 7 do not apply to BIPP Applicants

Exhibit 8 - Copy of Professional Licenses of direct providers listed on PCS-102ET (2.15.2) if applicable http://www.dfps.state.tx.us/PCS/Regional_Contracts/forms.asp#Evaluation_Treatment

Exhibit 9 - Verification of Required Insurance coverage including A.M. Best rating (subsection 2.16)

File Folder 3: Required Forms Applicants may also access the list of Required Forms at the following alternative link: http://www.dfps.state.tx.us/PCS/Regional_Contracts/forms.asp

Exhibit 1 – Form 2970c Disclosure and Consent to Release of Information --background checkExhibit 2 – Form 2971c Request for Criminal History & DFPS History Check--background checkExhibit 3 – Form 4108x Vendor Direct Deposit --allows DFPS to pay your bank accountExhibit 4 – Form 4109x Application of Texas Identification Number -- needed to identify contracted provider for paymentExhibit 5 – PCS-102ET Contracting Entity - lets us know who is working under your contractExhibit 6 – 9007FFS Internal Control Structure Questionnaire - lets us know how you manage your business financesExhibit 7 – 4736 Certificate of Insurance- or applicant can submit the Certificate

http://www.dfps.state.tx.us/PCS/Regional_Contracts/forms.asp

http://www.dfps.state.tx.us/PCS/Regional_Contracts/forms.asp#Evaluation_Treatment

http://www.dfps.state.tx.us/training/trauma_informed_care/

http://esbd.cpa.state.tx.us/bid_show.cfm?bidid=126949


of Insurance - ACCORD form in place of this form.NOTE: Each individual document requested in File Folders 1, 2, and 3 must be collated; in sequential order; labeled; and submitted as delineated in this subsection.

FORM N - PERFORMANCE MEASURES Evaluation and Treatment Services - BIPP Services

Contract Outcomes and Outputs

Pursuant to Texas Human Resources Code §40.058 all contracts for client services must include clearly defined goals and outcomes that can be measured to determine whether the objectives of the program are being achieved. Measures, indicators, targets, data sources, or methodologies are subject to change during the Contract period or at renewal.

Performance Measures for Treatment Services (BIPP Services):

OUTCOME MEASURE # 4

OUTCOME # 1: By the end of an entire BIPP program, clients have achieved their treatment goals.

PERFORMANCE PERIOD: Contractor performance for this Outcome is determined for one or more of the following Performance Periods, wholly or partially, depending on the contract start and end dates: September 1 through November 30 (Quarter 1); December 1 through February 28/29 (Quarter 2); March 1 through May 31 (Quarter 3); and June 1 through August 31 (Quarter 4).

INDICATOR: Percent of unduplicated clients who completed their BIPP program during the Performance Period who have achieved all or at least over 50% of the goals identified in their Individualized Plan.

TARGET: A baseline will be established from data reported during FY17.

PURPOSE: To evaluate the Contractor’s effectiveness in facilitating clients' progress in controlling their behavior.

DATA SOURCE: Self-reported by Contractor.

METHODOLOGY: The numerator is the total number of unduplicated clients who completed their BIPP program during the Performance Period and who achieved all or at least over 50% of the goals identified in their Individualized Plan. The denominator is the total number of unduplicated clients who completed their BIPP program during the Performance Period. The numerator is divided by the denominator, multiplied by 100, and stated as a percentage.



OUTCOME MEASURE # 5OUTCOME # 2: Clients show improvement in their attitudes and behaviors regarding family relationships.


INDICATOR: Percent of clients who show an improvement in their scores on the BIPP Client Questionnaire (Hamby, 1996).


PURPOSE: To evaluate the Contractor’s effectiveness in facilitating clients' progress in controlling their behavior.


METHODOLOGY: The numerator is the number of clients who completed the 18-week BIPP program during the Performance Period who showed an improvement in their scores on the BIPP Client Questionnaire. (NOTE: "improvement" will be shown in increments of 1-25 points; 26-50; 51-75, 76-100, and over 100 points). The denominator is the number of clients who completed the 18-week BIPP program during the Performance Period. The numerator is divided by the denominator, multiplied by 100, and stated as a percentage.


OUTCOME MEASURE # 6


OUTCOME # 3: Authorized services provided by the Contractor are viewed positively by Clients.


INDICATOR: Percent of aggregated favorable responses made to items in the BIPP Client Satisfaction Survey Questionnaires

TARGET: A baseline will be established from data reported during FY17

PURPOSE: To evaluate the Contractor’s overall quality of service, as perceived by their Clients.



METHODOLOGY: The numerator is the aggregated number of favorable responses to the BIPP Client Satisfaction Survey Questionnaires obtained from all the unduplicated clients who completed their 18-week BIPP program during the Performance Period. The denominator is the aggregated number of all responses, excluding Not Applicable (NA) or Blank responses, to the BIPP Client Satisfaction Survey Questionnaires obtained from all the unduplicated clients who completed their 18-week BIPP program during the Performance Period. The numerator is divided by the denominator, multiplied by 100, and stated as a percentage.

BIPP Performance Measure Reporting (NOTE: The directions below are only for the collection and reporting of Performance Measure data, and do not replace or supersede directions for reporting to CPS Program elsewhere in this contract.) DFPS has developed PMET [Performance Management Evaluation Tool], an Internet-based data collection and reporting system for Contractors to self- report performance measure data. The Contractor will be responsible for supporting the collection and reporting of performance measure data. The Contractor must:

1. Register an account in PMET following the provision of the first Treatment Service provided under this contract. The Contractor TIN (Texas Identification Number) and the Contract Number are needed to register. Instructions can be found at https:/www.dfps.state.tx.us/application/PCSPMET. Select Help>PMET User Guide.

2. Report the results for each Performance Period in the format specified by DFPS.

3. Comply with report date time frames. Performance Measure reporting is to be entered into PMET within 30 days of the end of the Performance Period in accordance with the table below:

Performance Period Reporting PeriodSeptember 1 – November 30 (Quarter 1) December 1 to December 30December 30 - February 28/29 (Q2) March 1 to March 30March 1 – May 31 (Q3) June 1 to June 30June 1 – August 31 (Q4) September 1 to September 30

4. Keep all records (physical or electronic) for each client documenting the goals in their Individualized Plan; the service provider conducting their sessions; their progress in meeting their BIPP goals; client surveys; and the performance results which were )reported in PMET. All records must be kept on file and available to DFPS upon request for the time period specified by DFPS for supporting documentation purposes. These documents must be maintained in a manner to allow for testing the validity of the results being reported in PMET.

5. Outcome # 4; PMET Question 3 Tally and report all clients who completed an entire BIPP program during the Performance Period.


Services may have been initiated for some clients during a previous Performance Period. They should still be counted in the tally of "all clients who completed an entire BIPP program" during the Performance Period being reported.

Some clients may no longer be receiving services, but did not "complete" an entire BIPP program. For example, they may simply stop attending sessions, or move, or the CPS Caseworker may discontinue services for various reasons. Those clients will NOT be counted as part of the total who completed an entire BIPP program.

6. Outcome # 4; PMET Question 4 Tally and report all clients who completed an entire BIPP program during a Performance Period and who achieved over 50% of the goals identified in their Individualized Plan. All of the goals that were achieved during the program should be counted, even if some of them were achieved in a previous Performance Period.

Do not report achieved goals of any clients who have not yet completed the entire course of treatment.

If no clients have completed a course of treatment, report zeros.

7. Outcome #5 Distribute copies of the BIPP Client Questionnaire (Hamby, 1996) during Orientation prior to initiating services, and ensure clients fill it out completely. Save the completed Questionnaire as part of the client record. Compile a TOTAL of all 32 questions. Prior to closing the case, have clients take the Questionnaire again and compare the score pre-service and after-service. Save the pre and post-service Questionnaire as part of the client record.

IMPORTANT SCORING INFORMATION FOR BIPP CLIENT QUESTIONNAIRE (HAMBY, 1996)

Each question has a value from 1 to 4. The higher the score on most questions, the more controlling the client, and the more likely the client is to be a DV perpetrator. HOWEVER, in 9 of the 32 questions, a higher score indicates a more egalitarian attitude.

The scoring for the following questions should be reversed as shown below. Question Strongly

AgreeAgree Disagre

eStrongly Disagree

1; 10; 12; 18; 20; 22; 24; 26; 28 4 3 2 1

8. Outcome #5; PMET Question 8 In how many of the closed cases reported above in PMET question #3 was there an improvement from 1 to 25 points in the clients' scores between the Pre-Service administration and the Post-Service administration of the BIPP Client Questionnaire? NOTE: improvement is indicated by a LOWER score on the questionnaire.

9. Outcome #54; PMET Question 9 In how many of the closed cases reported above in PMET question #3 was there an improvement from 26 to 50 points in the clients' scores between


the Pre-Service administration and the Post-Service administration of the BIPP Client Questionnaire? NOTE: improvement is indicated by a LOWER score on the questionnaire.

10. Outcome # 5; PMET Question 10 In how many of the closed cases reported above in PMET question #3 was there an improvement from 51 to 75 points in the clients' scores between the Pre-Service administration and the Post-Service administration of the BIPP Client Questionnaire? NOTE: improvement is indicated by a LOWER score on the questionnaire.

11. Outcome # 5; PMET Question 11 In how many of the closed cases reported above in PMET question #3 was there an improvement from 76 to 100 points in the clients' scores between the Pre-Service administration and the Post-Service administration of the BIPP Client Questionnaire? NOTE: improvement is indicated by a LOWER score on the questionnaire.

12. Outcome # 5; PMET Question 12 In how many of the closed cases reported above in PMET question #3 was there an improvement of over 100 points in the clients' scores between the Pre-Service administration and the Post-Service administration of the BIPP Client Questionnaire? NOTE: improvement is indicated by a LOWER score on the questionnaire.

13. Outcome # 6 Distribute and collect the BIPP Client Satisfaction Survey Questionnaire just

prior to closing out services. As much as possible, all clients should have the opportunity to fill out the survey, whether they completed the entire 18-week course, or services were discontinued prior to completion. Participation in the survey is voluntary, and clients should not be required to give their names.

A sample copy of the survey may be offered early in the program so clients will know they will be asked for feedback. Any surveys distributed prior to closing out services will be clearly marked as a sample, and will not be collected nor reported for the Performance Measure.

14. Outcome #6; PMET Question 5 Report the total number of BIPP Client Satisfaction Survey Questionnaires collected during the Performance Period.

15. Outcome # 6; PMET Question 6 Compile and report the aggregate number combined sum) of responses, excluding NAs and Blanks, in all the Surveys collected. Example: there are 8 questions in the Survey. If 8 Surveys are collected, there are 64 possible responses. If one Survey is completely Blank, and one has 2 NA responses, and a third has 4 Blanks, the AGGREGATE response is 48 (64 -10 Blanks - 2 NAs - 4 Blanks = 48). That is the number to be reported.

16. Outcome # 6; PMET Question 7 Compile and report the aggregate number of POSITIVE responses in the Surveys collected.

The Survey may be used by the Provider to collect additional data, including additional comments. Any additions or revisions to the DFPS developed Survey must be in a SEPARATE section. ONLY responses to questions 1 - 8 in the Survey provided by DFPS are to be reported to DFPS.


FORM O - ATTACHMENT A-1PERFORMANCE MEASURES

Contract Outcomes and OutputsPursuant to Texas Human Resources Code §40.058 all contracts for client services must include clearly defined goals and outcomes that can be measured to determine whether the objectives of the program are being achieved. Measures, indicators, targets, data sources, or methodologies are subject to change during the Contract period or at renewal.

Performance Measures for Evaluation and Treatment Services:OUTPUT MEASURE # 1

OUTPUT # 1: Client goals in the initial or revised Contractor-developed Treatment Plan address all of the worries identified by the referring CPS Caseworker.

PERFORMANCE PERIOD: Contractor performance for this Outcome is determined for one or more of the following Performance Periods, wholly or partially, depending on the contract start and end dates: September 1 through February 28/29 (Performance Period 1); March 1 through August 31 Performance Period 2).

INDICATOR: Percent of Contractor-developed client Treatment Plans which include goals that address all of the Caseworker-identified worries for each unduplicated client.

TARGET: At least 90%

PURPOSE: To evaluate the Contractor’s responsiveness to CPS Caseworker concerns.

DATA SOURCE: Self-reported by the Contractor.

METHODOLOGY: The numerator is the number of initial or revised Treatment Plans developed by the Contractor during the Performance Period which have client goals that address every worry identified by the referring CPS Caseworker. The denominator is the number of initial or revised Treatment Plans developed by the Contractor during the Performance Period. The numerator is divided by the denominator, multiplied by 100, and stated as a percentage.


Performance Measures for Treatment Services:OUTCOME MEASURE # 1

OUTCOME # 1: By the end of an entire course of treatment, clients have achieved their treatment goals.

PERFORMANCE PERIOD: Contractor performance for this Outcome is determined for one or more of the following Performance Periods, wholly or partially, depending on the contract start and end dates: September 1 through February 28/29 (Performance Period 1); March 1 through August 31 (Performance Period 2).

INDICATOR: Percent of unduplicated clients who completed their course of treatment during the Performance Period who have achieved all or at least over 50% of the goals identified in their initial or revised Treatment Plan. (NOTE: treatment goals may be revised after the initial Treatment Plan. The duration of treatment may be changed based on client progress. Performance Measure reporting will use the most current Treatment Plan as the entire "course of treatment".)


PURPOSE: To evaluate the Contractor’s ability to facilitate clients' progress in protecting their child(ren).


METHODOLOGY: The numerator is the total number of unduplicated clients who completed their course of treatment during the Performance Period and who achieved all or at least over 50% of the goals identified in their initial or revised Treatment Plan. The denominator is the total number of unduplicated clients who completed their course of treatment during the Performance Period. The numerator is divided by the denominator, multiplied by 100, and stated as a percentage.


Performance Measures for Evaluation and Treatment Services:OUTCOME MEASURE # 2

OUTCOME # 2: Authorized services provided by the Contractor meet Caseworkers’ expectations.

PERFORMANCE PERIOD: Contractor performance for this Outcome is determined for one or more of the following Performance Periods, wholly or partially, depending on the contract start and end dates: September 1 through November 30; December 1 through February 28/29; March 1 through May 31; and June 1 through August 31.

INDICATOR: Percent of aggregated favorable responses made to items in the Caseworker Satisfaction Survey Questionnaires.

TARGET: At least 90%

PURPOSE: To evaluate the Contractor’s overall quality of service, as perceived by CPS Caseworkers.

DATA SOURCE: Caseworker Satisfaction Survey Questionnaires obtained by DFPS from CPS Caseworkers.

METHODOLOGY: The numerator is the aggregated number of favorable responses to the Caseworker Satisfaction Survey Questionnaires obtained from Caseworkers for the Outcome Performance Period. The denominator is the aggregated number of all responses, excluding Not Applicable (NA) or blank responses, to the Caseworker Satisfaction Survey Questionnaires obtained from Caseworkers for the Outcome Performance Period. The numerator is divided by the denominator, multiplied by 100, and stated as a percentage.


Performance Measures for Evaluation and Treatment Services:OUTCOME MEASURE # 3

OUTCOME # 3: Authorized services provided by the Contractor are viewed positively by Clients.

PERFORMANCE PERIOD: Contractor performance for this Outcome is determined for one or more of the following Performance Periods, wholly or partially, depending on the contract start and end dates: September 1 through February 28/29 (Performance Period 1); March 1 through August 31 (Performance Period 2).

INDICATOR: Percent of aggregated favorable responses made to items in the Client Satisfaction Survey Questionnaires

TARGET: A baseline will be established from data reported during FY17

PURPOSE: To evaluate the Contractor’s overall quality of service, as perceived by their Clients.


METHODOLOGY: The numerator is the aggregated number of favorable responses to the Client Satisfaction Survey Questionnaires obtained from all the unduplicated clients who completed their course of treatment during the Performance Period. The denominator is the aggregated number of all responses, excluding Not Applicable (NA) or Blank responses, to the Client Satisfaction Survey Questionnaires obtained from all the unduplicated clients who completed their course of treatment during the Performance Period. The numerator is divided by the denominator, multiplied by 100, and stated as a percentage.

Performance Measure Reporting (NOTE: The directions below are only for the collection and reporting of Performance Measure data, and do not replace or supersede directions for reporting to CPS Program elsewhere in this contract.) DFPS has developed PMET [Performance Management Evaluation Tool], an Internet-based data collection and reporting system for Contractors to self- report performance measure data. The Contractor will be responsible for supporting the collection and reporting of performance measure data. The Contractor must:

17. Register an account in PMET following the provision of the first Treatment Service provided under this contract. The Contractor TIN (Texas Identification Number) and the Contract Number are needed to register. Instructions can be found at https:/www.dfps.state.tx.us/application/PCSPMET. Select Help>PMET User Guide.

18. Report the results for each Performance Period in the format specified by DFPS.

19. Comply with report date time frames. Performance Measure reporting is to be entered into PMET within 30 days of the end of the Performance Period in accordance with the table below:


Performance Period Reporting PeriodSeptember 1 – February 28/29 March 1 to March 30

March 1 – August 31 September 1 to September 30

20. Keep all records (physical or electronic) for each client documenting the CPS Caseworker concerns; the goals in their Treatment Plan; the treatment service provider conducting their sessions; their progress in meeting their treatment goals; client surveys; and the performance results which were reported in PMET. All records must be kept on file and available to DFPS upon request for the time period specified by DFPS for supporting documentation purposes. These documents must be maintained in a manner to allow for testing the validity of the results being reported in PMET.

21. Output # 1; PMET Question 1 Tally and report initial or revised Treatment Plans for Clients receiving services during the Performance Period. A Treatment Plan should be counted only one time during a Performance Period for each client.

If a client has both an initial and a revised Treatment Plan during a Performance Period, only ONE Treatment Plan (the revised one) is counted.

If a client's Treatment Plan is revised during the NEXT Performance Period after the initial Plan was developed, that Client's Treatment Plan should be counted again, in the following Performance Period.

A client's Treatment Plan does not need to be revised if the only change is that the client achieved one or more of the identified goals. Goals that have been achieved should remain in the revised Treatment Plan as documentation of client progress.

22. Output # 1; PMET Question 2 Tally and report all initial or revised Treatment Plans that include goals which address all the worries identified by the referring CPS Caseworker. (NOTE: this does not preclude the service provider from identifying and including additional goals for the client.)

23. Outcome # 1; PMET Question 3 Tally and report all clients who completed an entire course of treatment during the Performance Period. The duration of treatment may be changed based on client progress. Performance Measure reporting will use the most current Treatment Plan as the entire "course of treatment".)

Services may have been initiated for some clients during a previous Performance Period. They should still be counted in the tally of "ALL clients who completed an entire course of treatment" during the Performance Period being reported.

Some clients may no longer be receiving services, but did not "complete" an entire course of treatment. For example, they may simply stop attending sessions, or move, or the CPS Caseworker may discontinue services for various reasons. Those clients will NOT be counted as part of the total who completed an entire "course of treatment".


24. Outcome # 1; PMET Question 4 Tally and report all clients who completed an entire course of treatment during a Performance Period and who achieved over 50% of the goals identified in their most recent Treatment Plan. All of the goals that were achieved during the course of treatment should be counted, even if some of them were achieved in a previous Performance Period.

Do not report achieved goals of any clients who have not yet completed the entire course of treatment.

If no clients have completed a course of treatment, report zeros.

25. Outcome # 3 Distribute and collect the Client Satisfaction Survey Questionnaire just prior to closing out services. As much as possible, all clients should have the opportunity to fill out the survey, whether they completed a course of treatment, or services were discontinued prior to completion. Participation in the survey is voluntary, and clients should not be required to give their names.

A sample copy of the survey may be offered early in therapy so clients will know they will be asked for feedback. Any surveys distributed prior to closing out services will be clearly marked as a sample, and will not be collected nor reported for the Performance Measure.

26. Outcome # 3; PMET Question 5 Report the total number of Client Satisfaction Survey Questionnaires collected during the Performance Period.

27. Outcome # 3; PMET Question 6 Compile and report the aggregate number combined sum) of responses, excluding NAs and Blanks, in all the Surveys collected. Example: there are 10 questions in the Survey. If 8 Surveys are collected, there are 80 possible responses. If one Survey is completely Blank, and one has 2 NA responses, and a third has 4 Blanks, the AGGREGATE response is 64 (80 -10 Blanks - 2 NAs - 4 Blanks = 64). That is the number to be reported.

28. Outcome # 3; PMET Question 7 Compile and report the aggregate number of POSITIVE responses in the Surveys collected.

The Survey may be used by the Contractor to collect additional data, including additional comments. Any additions or revisions to the DFPS developed Survey must be in a SEPARATE section. ONLY responses to questions 1 - 10 in the Survey provided by DFPS are to be reported to DFPS.


PMET QuestionsService Procurement # Reports PMET Questions

CPS ET Psychological & Treatment Services

HHS0000071 Semi-annually 1. Tally and report all initial and revised Treatment Plans that were developed for each UNDUPLICATED client during the Performance Period. If a client had both an initial and a revised Treatment Plan during the Performance Period, count only the revised Treatment Plan. If no Treatment Plans have been developed during the Performance Period, report zeros.

2. Of the total number of Treatment Plans reported in PMET Question #1, report the total number of Treatment Plans which include goals that address all the worries identified by the referring CPS Caseworker.

3. Tally and report the total number of clients who completed an entire course of treatment during the Performance Period. If no clients have completed a course of treatment, report zeroes. (Do not count clients who did not complete treatment, but are no longer receiving services.)

4. Enter the total number of clients reported in PMET Question # 3 who achieved at least 50% of the goals identified in their Treatment Plan.

5. Report the total number of Client Satisfaction Survey Questionnaires collected during the Performance Period.

6. Compile and report the aggregate number (combined sum) of all responses from all Client Satisfaction Survey Questionnaires returned during the Performance Period, excluding Blank and NA responses.

7. Enter the total number of responses reported in PMET Question # 6 that were favorable.

8. Comments

ATTACHMENT A-1PERFORMANCE MEASURES

September 1, 2016


EVALUATION AND TREATMENT CASEWORKER SURVEYContracts not meeting 90% Target Outcome #1

Caseworker Survey Responses FY15Q2

Strongly Agree Agree Disagree Strongly

Disagree NA

1. I was satisfied with the efforts the Contractor made to schedule appointments. The Contractor was flexible in scheduling to accommodate clients' school/work/personal commitments.

2. Reports (i.e., Evaluation Report; Treatment Plan; Psychosocial Assessment; or any other written report requested by DFPS) were individualized, complete, and useful in the development of the client service plan, for making case decisions and/or for use in court. Reports were legible and easy to understand (free of acronyms or arcane technical language).

3. If client was referred for ongoing treatment, monthly summaries were submitted by the 10th business day of the month following the month of service. Respond NA if Contractor does not provide Treatment.

4. If client was referred for ongoing treatment, monthly summaries were individualized, with sufficient detail to support the client's progress, or lack thereof, in meeting goals identified in the Treatment Plan and were useful in making decisions and/or for use in court. Respond NA if Contractor does not provide Treatment.

5. Contractor treated client(s) with respect and cultural sensitivity. Contractor offered translation or interpreter services if needed.

6. Contractor was prepared and willing to appear in court; and testimony was consistent with information reported to DFPS.

7. I would recommend this Contractor to other DFPS Caseworkers.


Date: Facilitator:Agency:

Client Satisfaction Survey Questionnaire

Put an X in the box for your answer to each question. If the question does not apply to you, mark the NA box for Not Applicable.

Stro

ngly

A

gree

Agr

ee

Dis

agre

e

Stro

ngly

D

isag

ree

NA

1. My therapist believes that I can change and grow. My therapist helps me find my own solutions.

2. My therapist encourages me to be responsible for the safety of my kids. My therapist helped me find relatives and friends who care about the safety of my kids.

3. My therapist understands my problems and worries and makes me feel comfortable talking about my life and my family.

4. I learned new ways to parent my kids and I have been using my new skills at home.

5. I learned a lot about how kids grow and develop. I learned how abuse and neglect hurts kids and how it makes them act. I learned about my children's needs and how I can meet them.

6. I understand the problems that caused CPS to open a case and most of the problems are getting better.

7. My therapist encourages me to attend other classes or join other support groups or participate in community activities. I found other agencies or groups that could help me with my life and my kids.

8. My therapist is respectful of my culture and how we raise our kids.9. If I had other choices, I would still get services from this therapist10 This therapy made positive changes in my life and in how I parent

my kids and I would tell someone to try this kind of therapy if they had problems like mine.

Comments (What did you like most about therapy? Like least? Is there anything you wanted that was not part of the therapy?)

Client Signature Date Signed


FORM P - ATTACHMENT A-2 –TABLE AFEE SCHEDULE – EVALUATION SERVICES

Payment is based on “unit of service." The allowable unit rate for the type of service delivered is the rate consistent with the highest credential held by the service provider.LICENSED PSYCHOLOGIST (LP), PROVISIONAL LICENSED PSYCHOLOGIST (PLP)

Psychological Evaluation & Testing

Category Service - Service CodeLocation & Unit Rate

In Office Home Based Out of Office

Psychological Evaluation Psychological Testing-86A $113.91 $159.25

Psychological Evaluation by Licensed Psychological Associate (LPA)

Psychological Testing (LPA)-86A $79.74 $111.48

Incomplete Psychological Evaluation1

Psychological Testing-86AMaximum 2 hours $113.91 $159.25

Incomplete Psychological Evaluation by Licensed Psychological Associate1

Psychological Testing (LPA)-86AMaximum 2 hours $79.74 $111.48

Court Related ServicesCourt Testimony-86HDeposition-86HMediation-86H

$157.57 $157.57

Diagnostic Consultation Diagnostic Consultation - 81H $112.70 $157.57

Translator/Interpreter Services Service Code 98L Cost Reimbursement-Requires Contract Manager prior authorization

1NOTE: Incomplete Psychological Evaluations are defined as after conducting a private individualized face-to-face clinical interview, extenuating circumstances impacted the ability to complete the testing.

Additional reimbursement for services provided in CPS DESIGNATED UNDERSERVED COUNTIES: Missed Appointments: Refer to Section 2.13.1 Travel: Refer to Section 2.13.3


ATTACHMENT A-2 - TABLE BFEE SCHEDULE –TREATMENT SERVICES

LICENSED PSYCHOLOGIST (LP), PROVISIONAL LICENSED PSYCHOLOGIST (PLP)Psychological Counseling Services



Psychosocial Psychosocial Assessment – 86U $79.74 $111.48 $111.48

IndividualIndividual Counseling - 86C $95.93 $134.11

Home Based Counseling - Individual - 88K $134.11

FamilyFamily Counseling - 86F $79.93 $111.75

Home Based Counseling - Family - 88K $111.75

Group Group Counseling - 86E $23.52 $32.88

Court Related Services

Court Testimony - 86H $91.19

Deposition - 86H $91.19

Mediation – 86H $91.19

Diagnostic Consultation Diagnostic Consultation - 81H $65.22 $91.19

Translator/Interpreter Services Service Code 98L Cost Reimbursement-Requires Contract

Manager prior authorization

Additional reimbursement for services provided in CPS DESIGNATED UNDERSERVED AREAS: Missed Appointments: Refer to Section 2.13.1

Travel to Underserved County: Refer to Section 2.13.3


FORM Q - ATTACHMENT A-2 –TABLE CFEE SCHEDULE – EVALUATION AND TREATMENT SERVICES

Payment is based on “unit of service." The allowable unit rate for the type of service delivered is the rate consistent with the highest credential held by the service provider.

LCSW, LMFT, LPC & LSOTP – Psychosocial Assessment & Counseling



Psychosocial Psychosocial Assessment – 86U $67.15 $93.88 $93.88

IndividualIndividual Counseling – 86C $67.15 $93.88

Home Based Counseling-Individual – 88K $93.88

FamilyFamily Counseling – 86F $55.95 $78.22

Home Based Counseling-Family – 88K $78.22

Group Group Counseling – 86E $16.46 $23.01

Court Related ServicesCourt Testimony – 86HDeposition – 86HMediation – 86H

$63.82

Diagnostic Consultation Diagnostic Consultation – 81H $63.82



Additional reimbursement for services provided in CPS DESIGNATED UNDERSERVED COUNTIES: Missed Appointments: Refer to Section 2.13.1

Travel: Refer to Section 2.13.3


FORM R - ATTACHMENT A-2 –TABLE DATTACHMENT A-2 –TABLE D

FEE SCHEDULE – EVALUATION AND TREATMENT SERVICESBATTERING INTERVENTION PREVENTION PROGRAM (BIPP)

Payment is based on “unit of service." The allowable unit rate is based on information in the Unit Rate column in the table below.The identified BIPP provider types must maintain accreditation through TDCJ-CJAD.

LMSW, LCSW, LMFT & LPC or a TDCJ-CJAD funded BIPP


In Office Out-of-Office

Domestic Violence Assessment Report 1 unit = 1 assessment

Domestic Violence Assessment Report – 86K $75.00

Group1 unit = 1 hour sessions are 2 hours long (2 units)

Orientation and Battering Intervention Prevention Program (BIPP) – 86L

$16.46(2 units = $32.92)

$23.01(2 units = $46.02)

Court Related ServicesCourt Testimony – 86HDeposition – 86HMediation – 86H

$63.82

Diagnostic Consultation Diagnostic Consultation – 81H $63.82



Additional reimbursement for services provided in CPS DESIGNATED UNDERSERVED COUNTIES: Refer to Billing Requirements in Sections 2.9.6.3.1.4.2 and 2.9.7.2.5.10. Out-of-Office rate applies in accordance with Section 2.5 and is payable when travel exceeds 60 miles and

travel to underserved areas has not been claimed. Refer to Section 2.13.3 for details.