HomeMy WebLinkAbout031918_ca05615 Sheridan Street
Port Townsend, WA 98368
�etm www.JeffersonCountyPublicHealth.org
Public Health January 17,Consent 82018
,JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: Vicki Kirkpatrick, Director
Anna McEnery, DD & 1/10th County Coordinator
DATE: j, �q I ZZ71
SUBJECT: Agenda Item — Contract Amendment #2 with Jumping Mouse
Children's Center; January 1, 2018 — March 31, 2018; Additional
$22,284.00 for a total of $92,409.00
STATEMENT OF ISSUE:
Jefferson County Public Health, as the fund manager of the Mental Health and Substance Abuse sales tax
treatment funds, is requesting Board approval of a contract amendment with the Jumping Mouse Children's
Center, to provide mental health services for young children, (along with support for their parents/care-
givers), who have suffered trauma, including loss, abuse, neglect, and exposure to violence, mental illness,
and substance abuse; January 1, 2018 —March 31, 2018; additional $22,284.00 for a total of $92,409.00 in
funding.
ANALYSIS/ STRATEGIC GOALS/PRO'S and CON'S:
This contract amendment is for clinical and care management services for children, (ages 2-12 living in East
Jefferson County) for a total of 45 children and their caregivers. This service may include long-term therapy
to children affected by and/or with risk factors for mental illness or substance abuse at home and/or in the
community. Jumping Mouse will utilize promising and/or evidence based models of treatment, referrals for
mental health medication, provide parental support and education to the adults of the children served and
monitoring as required.
RFP Panel members of the Substance Abuse Mental Health Advisory Committee are still deliberating about
2018 1/10th of 1% funding recommendations. Public Health is recommending a three month amendment
to maintain continuity of services.
FISCAL IMPACTICOST BENEFYT ANALYSIS:
This is sales tax revenue raised by the County in the 1/10th of 1% Fund; is allocated by the BOCC with
advice from Mental Health and Substance Abuse Sales Tax Advisory Committee. The contract states if the
sales tax revenue decreases, the vendor will be contacted and the contract may be renegotiated.
RECOMMENDATION:
JCPH management request approval of the contract amendment with Jumping Mouse Children's Center;
January 1, 2018 — March 31, 2018; additional $22,284.00 for a total of $92,409.00 in funding.
REVIEWED B
_ 2-//i
Philip MorleX�1 County Ad* trator Date
commu�ii y 1•iealth Environmental Health
Developmental Disabilities Water Quality
360-385-9400 360-385-9444
360-385-9401 (f) Always working for a safer and healthier community (f) 360-379-4487
CONTRACT AMENDMENT 42
For Professional Services
Between
Jefferson County
And
Jumping Mouse Children's Center
For Expanded Mental Health (MH) & Chemical Dependency (CD) Treatment
WHEREAS, Jumping Mouse Children's Center (Contractor) and Jefferson County (County)
entered into an agreement on January 1, 2017 for Professional Services to be provided in
connection with the provision of mental health services to individuals impacted by mental
health/substance abuse issues in Jefferson County, Washington.
WHEREAS, the parties desire to amend the terms of that agreement.
IT IS AGREED BETWEEN BOTH PARTIES AS NAMED HEREIN AS FOLLOWS:
1. The term of the above referenced agreement ends March 31, 2018.
Jumping Mouse Children's Center will continue to provide mental health therapy for young
children ages 2-12 living in east Jefferson County, (along with support for their
parents/caregivers), who have suffered trauma, including loss, abuse, neglect, and exposure
to violence, mental illness, and substance abuse. Along with funding operations,'
utility/insurance payments and necessary supplies in order for children affected by
substance abuse disorders and mental health issues to be served as stated in Exhibit A,
Statement of Work and Attachment A, Match Policy.
2. Jumping Mouse Children's Center will adhere to the new reporting date listed in Exhibit
A, Number 23, Section B of this amendment.
3. This amendment adds $22,284.00 in funding as stated in Exhibit B, Fee Schedule, to be
used specifically for clinical and care management services children affected by and/or with
risk factors for mental illness or substance abuse at home and/or in the community.
4. The contract, including this amendment, shall not exceed $92,409.00 without express
written amendment signed by both parties. Work performed between January 1, 2018 and the
execution of this Amendment that is consistent with the provisions of this Agreement is hereby
ratified.
5. All other terms and conditions of the agreement will remain the same.
Dated this day of , 2018.
By: -
David Sullivan, Chairman
Jefferson County Board of Commissioners
By:
Contractor
ATTEST:
Carolyn Avery, Deputy Clerk of the Board
APPROVED AST FORM ON
• LY:
By: C. 3//JF
Philip Hunsucker, Chief Civil, Delfutytrosecuting
Attorney
EXHIBIT A
Scope of Work
RESPONSIBILITIES:
The Jumping Mouse Children's Center Services agency as a contracted provider, agrees
to:
1. Clinical and care management services for up to 45 children and their caregivers per
billing period.
2. All employees or subcontractors of the Contractor undertaking the performance of mental
health/substance abuse services under this agreement are required to be professionally
licensed or certified by the State.
3. Background checks are required for all employees; to be redone for every employee
every 3 years. The names of licensed therapists will be given to the County upon request.
4. Provide long-term therapy to children affected by and/or with risk factors for mental
illness or substance abuse at home and/or in the community.
5. Provide parent support and education to the adults of the children covered in this
contract.
6. Work with social services or other agencies as needed for dually served families with
mental health or chemical dependency issues.
7. Provide care coordination with other involved agencies, and referral to supportive
services such as housing, transportation and vocational services; tracking of client
involvement in recommended services, including 12 -step or comparable support.
8. Maintain a secure records system guaranteeing the confidentiality of PHI pursuant to
HIPPA.
9. Bill other revenues whenever they exist.
10. Quarterly data template on client utilization, referrals, outcomes, and required reporting,
in standard form as specified by Jefferson County Health.
11. Individual therapy, using promising and/or evidence based models of treatment.
Applicant will identify the number of clients seen, how often each week and the number
of hours per week and per month for treatment enrollment.
12. Referral for mental health medication and monitoring as needed.
13. Collection and preparation of data for internal and external evaluation purposes,
providing a monthly invoice to JCPH and a quarterly data report. Use forms supplied by
JCPH for data.
14. Preparation of progress reports if needed, e.g. for care coordination purposes.
15. Staffed by 4 master's level Licensed Mental Health Counselors, 3 master's level Licensed
Mental Health Counselor Associates, 4 master's level intern therapists (supervised by
Washington State Approved Clinical Supervisors), and support staff to include billing
and administration.
16. Clerical, billing, and general office support.
17. Operations, utility/insurance payments and necessary supplies in order for children
affected by substance abuse disorders and mental health issues to be served.
18. Agency oversight regarding record keeping, data collection, legal and ethical issues and
standards of care are updated and meet State of Washington standards.
19. Services are available throughout Jefferson County.
20. Provide data including:
• Number of intakes, individual sessions, psychiatric visits, and adult education visits
provided
• Age, sex, drug of choice, psychiatric diagnosis of clients.
• Referrals to other agencies.
• Client satisfaction form indicating client's view of how program helped in their life.
21. Opportunities for regular clinical supervision and consultation are available for staff on a
regular basis. Supervision for all therapists, including interns and externs, consists of
minimum one hour per week in individual consultation, one hour per week in group
consultation and three hours per month in a clinical staff meeting. Additional individual
support and supervision to interns is also provided on a continual, as -needed basis.
22. Attend and report to the Mental Health and Substance Abuse Sales Tax Advisory
Committee once during the duration of this contract period, ata regularly scheduled
meeting, with progress evaluation reports for children and their families.
23. For clinical and care management services for up to 45 children and their caregivers per
billing period, Jumping Mouse will provide quarterly statistics in an electronic form,
which may be revised by Jefferson County Public Health in consultation with Jumping
Mouse, for statistical and program data collection.
a) Jumping Mouse Children's Center will ensure that quarterly electronic reports are
sent to Siri Kushner of Kitsap County Health District, 345 6th Street, Suite 300,
Bremerton WA 98337 and/or and that a
copy of each electronic report is also sent to Anna McEnery of Jefferson County
Public Health at wneenery6(ijccr.jef_rson.NN a.us.
b) Due dates for reports are as follows: 4/27 for January through March of 2018,
c) Quarterly reports will be reviewed by Public Health and Siri Kushner for
accuracy. Any questions will be referred back to the Jumping Mouse.
EXHIBIT B
Fee Schedule
January — March 2018: Therapy and Care Management by three intern therapists @ $366.67
each per month, for a total of $1100.00 per month. Clinical supervision @ $1234.5 8 per month
and Administration @ $341.67 per month.
In addition: January — March 2018: Therapy and Care Management by two licensed therapists @
$3609.75 per month. Clinical supervision @ $324.88 per month, Administration @ $408.62 per
month, and Operations (supplies, utilities, insurance, etc) @ $408 per month.
Not to exceed $7,428.00 per month.
Not to exceed for $92,409.00 in completion of services for the duration of this contract
without express written amendment.
ATTACHMENT A
JEFFERSON COUNTY MH/SA TREATMENT TAX FUNDING -
MATCH POLICY
Definitions:
Match: is a requirement for the grantee to provide contributions of a specified amount or
percentage to match funds provided by another grantor. Matching can be in the form of
cash or in-kind contributions.
Regulations: The specific requirements for matching funds are unique to each federal or
state program. The A-102 Common Rule provides criteria for acceptable costs and
contributions in regard to snatch.
Jefferson County Policy:
In 2005, the Washington State Legislature created an option for counties to raise the local sales
tax by 0.1 percent, (the 1/10th of 1% sales tax initiative) to augment state funding for mental
liealth and chemical dependency treatment. Jefferson County collects and distributes the Mental
Health/Chemical Dependency (MH/SA) tax. Services purchased by the County are allocated
through a formal Request for Proposal (RFP) process, review and contracting; staffed by
Jefferson County Public Health, overseen by Jefferson County Mental Health Substance Abuse
Fund Advisory Committee and adopted by the Board of County Commissioners, (BOCC).
BOCC does not assume any fiscal responsibility/liability for any of the Contractors they contract
for services with.
Jefferson County reserves the first right to use as match the chemical dependency mental health
tax funds and the services funded by them for purposes of qualifying for additional funding and
grants. County may make available to the Contractor the chemical dependency mental health tax
funds for the Contractor to propose as match to state, federal or other entities, at the County's
sole discretion. Contractor shall not use chemical dependency mental health County tax funds
for match without prior authorization by the Jefferson County Administrator and County fiscal
team. To request authorization of availability of the funds for match, Contractor must apply to
the County Administrator in writing, and include their match formula and allocation plan and
may include other documentation to support their request. The County Administrator will
authorize or deny the availability of match funds in writing within 30 days of the application.
If the County informs the Contractor of the availability of chemical dependency mental health
County tax funds for match, then the Contractor shall be solely responsible for compliance with
all state and federal laws and regulations, including, but not limited to DSHS, CMS and DBHR
funding rules, applicable to the use of MH/SA sales tax monies as match. Following state,
federal and local guidelines for match is the responsibility of the Contractor.
For example, if a Contractor provides Title XIX Medicaid services (the Policy 19.50.02 or
42CFR 430.30) they are required by those rules to actually bill Medicaid for the services at the
same time. If no Medicaid billing exists, the match would not comply with state and federal
guidelines for match.
Concurrent with its request for authorization of the availability of match, Contractor shall
document it has met its responsibility to follow state, federal and local guidelines for match by
submitting in writing to the County Administrator their match formula, allocation plan, and
other documentation made mandatory pursuant to this Agreement and this Attachment A. At a
minimum, the Contractor shall also provide the following to the County Administrator:
1. DSHS requires contractors to complete and submit a "Local Match Certification"
form (DSHS 06-155) or a form that has equivalent data elements prior to any
agreement for DSHS services. Submit a copy of this application and form when
requesting match availability from the County and at each monthly billing.
2. Submit the current administrative policy within WA State regulating your services
and the use of local match.
3. Submit to the County your last financial audit showing your use of match,
County funds and tracking systems.
4. Submit to the County the terms of the agreement showing the MH/SA allocation
is an allowable source of match.
5. Provide documentation that your financial reporting system tracks matching funds
at a level that meets the level of documentation required by federal or state
statutes.
The County may reject permission for Contractor to utilize the MH/SA sales tax monies as
match.
g (66�
CONTRACT AGREEMENT ��\-k
By and Between
Jumping Mouse Children's Center
And
Jefferson County
For Expanded Mental Health (MH) & Chemical Dependency (CD) Treatment 2017
Section 1: PURPOSE:
THIS AGREEMENT for Professional Services is entered into between Jefferson County herein
referred to as the "County" and Jumping Mouse Children's Center, herein referred to as the
"Contractor" to provide mental health services to individuals impacted by mental
health/substance abuse issues in Jefferson County, Washington.
Section 2: TERMS:
This Agreement sliall commence on January 1, 2017 and continue through December 31, 2017,
unless terminated as provided herein.
Section 3: SCOPE OF AGREEMENT:
Contractor will increase mental health treatment options to Jefferson county residents as outlined
in Exhibit A, herein incorporated by reference. Through the use of these funds the provider will
increase the number of citizens receiving Mental Health services. The goal of this funding and
sales tax increase is to improve the quality of life for Jefferson County citizens by improving
access to mental health and substance abuse treatment.
A. CONTRACT REPRESENTATIVES:
Jefferson County and Jumping Mouse Children's Center will each have a contract representative
who will have responsibility to administer the contract for that party. A party may change its
representative upon providing written notice to the other party. The parties' representatives are as
follows:
.IC1111-1 Contract Re msent tlivr;
Anna McEnery
Jefferson County Public Health
615 Sheridan St.
Port Townsend, WA 98368
(360) 385-9400
PAGE 1
catill a ive
Kris Becker, Executive Director
Jumping Mouse Children's Center
1809 Sheridan St.
Port Townsend, WA 98368
(360) 379-5109
Section 4: COMPENSATION:
The total amount payable under this Contract by County to CONTRACTOR, shall not exceed
$32,115.00 as outlined in Exhibit B- Fee Schedule, in completion of this project without express
written amendment signed by both parties to this Agreement. The parties acknowledge that
funding for this contract is contingent on the continuation of sales tax revenue in 2017. If the
sales tax revenue decreases by ten percent (10%) when applicable sales tax revenues are
compared between the most recently completed quarter year and the same quarter year revenues
for 2016, then this contract may be renegotiated. The parties acknowledge the funding connected
to this contract is revenue of last resort and therefore Contractor will bill all other sources of
revenue first.
A. Contractor shall be paid for services as outlined in Exhibit A — Scope of Work.
B. CONTRACTOR shall submit monthly invoices to JCPH, 615 Sheridan St., Port
Townsend, WA 98368, Attn: Finance Department, for payment of work actually
completed to date.
C. Invoices must be submitted by the 3rd Monday of the month for the previous month's
expenses. The County will review such invoices, and upon approval thereof, payment will
be made to the Contractor in the amount approved. Failure to submit timely invoices may
result in a denial of reimbursement.
D. Contractor shall provide invoices and necessary backup documentation for all invoices
including timesheets and statements. Any indirect charges require the submittal of an
indirect cost methodology and rate using OMB Circular's A-87 and A-122.
E. County reserves first right to use as match the chemical dependency mental health tax
funds and the services funded by them for purposes of qualifying for additional funding
and grants. County may allow Contractor to use the chemical dependency mental health
tax funds as match, at the County's sole discretion. Should the County decline to use
chemical dependency mental health tax funds as match for additional funding and/or
grants, then the County may authorize the Contractor to use such funds for match. (See
Attachment A).
F. Where Contractor proposes to use chemical dependency mental health County tax funds
for match, Contractor shall be solely responsible for compliance with all state and federal
laws and regulations, including, but not limited to DSHS, CMS and DBHR funding rules,
applicable to the use of MH/SA sales tax monies as match. Contractor shall document
they have met this responsibility by submitting to the County Administrator, in writing,
their match formula, allocation plan and any other documentation required of them
pursuant to Attachment A, attached hereto and incorporated in this Agreement.
G. Contractor records and accounts pertaining to this agreement are to be kept available for
inspection by representatives of the County and state for a period of six (6) years after
final payments. Copies shall be made available upon request.
H. An audit will be submitted to the County annually.
PAGE 2
a. Contractor will submit the most recent financial audit or recent compiled financial
statements to accompany our annual 990 tax form filing within 30 days from the
beginning of this agreement.
b. The audit or recent compiled financial statements to accompany our annual 990 tax
form filing shall be completed by the WA State Auditor's Office or a mutually agreed
upon entity. Upon request the County shall have the option of performing an onsite
review of all records, statements, and documentation.
c. If the County finds indications of potential non-compliance during the monitoring
process, the County shall notify Contractor within ten (10) days. County and
Contractor shall meet to discuss areas of contention in an attempt to resolve issues.
d. Audit or recent compiled financial statements to accompany our annual 990 tax form
filing will provide statements consistent with the guidelines of Reporting for Other
Non -Profit Organizations AICPA SOP 78-10, and is performed in accordance with
generally accepted auditing standards and with Federal Standards for Audit of
Governmental Organizations, Programs, Activities and Functions, and meeting all
requirements of OBM Circular A-133 or A-128, as applicable.
Section 5: INDEMNIFICATION:
The Contractor shall indemnify, defend and hold harmless the County, its officers, agents and
employees, from and against any and all claims, lawsuits, demands for money damages, losses or
liability, or any portion thereof, including attorney's fees and costs, arising from any injury to
person or persons (including the death or injury of the Contractor or darnage to personal property)
if said injury or damage was caused by the negligent acts or omissions of the Contractor.
Section 6: INSURANCE:
The Contractor shall obtain and keep in force during the terms of this Agreement, or as otherwise
required:
A. Commercial Automobile Liability Insurance is waived based on the fact that Jumping
Mouse does not own a fleet of vehicles that are titled in their name.
B. General Liability (1) — with a minimum limit per occurrence of one million dollars
($1,000,000) and an aggregate of not less than two million dollars ($2,000,000) for
bodily injury, death and property damage unless otherwise specified in the contract
specifications. This insurance coverage shall contain no limitations on the scope of
the protection provided and indicate on the certificate of insurance the following
coverage:
PAGE 3
1. Broad Form Property Damage with no employee exclusion;
2. Personal Injury Liability, including extended bodily injury;
3. Broad Form Contractual/Commercial Liability including completed operations
(contractors only);
4. Premises — Operations Liability (M&C)
5. Independent Contractors and Subcontractors; and
6. Blanket Contractual Liability.
(1) Note: The County shall be named as an additional insured party under
this policy.
C. Professional Liability Insurance providing $2,000,000 per incident; $3,000,000
aggregate. Contractor shall name Jefferson County Public Health as additional
insured.
D. The Contractor shall participate in the Worker's Compensation and Employer's
Liability Insurance Program as may be required by the State of Washington.
E. It is agreed by the parties that insurers shall have no right of recovery or subrogation
against the County (including its employees and other agents and agencies) it being
the intention of the parties that the insurance policies listed above shall protect both
parties and be primary coverage for any and all losses covered by the above -listed
insurance policies. It is further agreed by the parties that any and all deductibles
made part of the above -listed insurance policies shall be assumed by, paid for and at
the risk of the Contractor.
F. Any coverage for third party liability claims provided to the County by a
"Risk Pool" created pursuant to Ch. 48.62 RCW shall be non-contributory with
respect to any policy of insurance the Contractor must provide to comply with this
Agreement.
G. If the proof of insurance or certificate indicating the County is an "additional
insured" to a policy obtained by the Contractor refers to an endorsement (by number
or naive) but does not provide the full text of that endorsement, then it shall be the
obligation of the Contractor to obtain the full text of that endorsement and forward
that full text to the County.
H. The County may, upon the Contractor's failure to comply with all provisions of this
contract relating to insurance; withhold payment or compensation that would
otherwise be due to the Contractor.
Section 7: CONFIDENTIALITY:
Contractor, its employees, subcontractors and their employees will maintain the confidentiality
of all information provided by JCPH or acquired in performance of this Agreement as required
by HIPAA and other privacy laws. This Contract, once executed by the parties, is and remains a
Public Record subject to the provision of Ch. 42.56 RCW, the Public Records Act.
PAGE 4
Section 8: ASSIGNMENTS AND SUBCONTRACTING:
The Contractor shall not sublet or assign any of the services covered by this agreement without
the express written consent of the County.
Section 9: INDEPENDENCE:
The Contractor and the County agree that the Contractor is an independent Contractor with
respect to the services provided pursuant to this agreement. Noticing in this agreement shall be
considered to create the relationship of employer and employee between the parties hereto. The
Contractor shall not be entitled to any benefits accorded County employees by virtue of the
services provided under this agreement. The County shall not be responsible for withholding or
otherwise deducting federal income tax or social security or for contributing to the state
industrial insurance program, otherwise assuming the duties of an employer with respect to
employee.
Section 10: REPORTING:
The Contractor will collect and prepare data for internal and external evaluation purposes and
provide a quarterly statistics data report in an electronic form. Due dates for quarterly reports are
as follows: 4/28 for Jan -Mar, 7/28 for Apr -June, 10/31 for July -Sept, and 1/31 of the next year
for Oct -Dec.
In addition, monthly service summary reports will be provided to the County at the same time as
invoices and must be submitted by the 3rd Monday of the month for the previous month's work.
The monthly report shall contain the report of services and the total hours worked by which staff`
The monthly report shall be submitted to Jefferson County Public Health in care of Anna
McEnery, 615 Sheridan, Port Townsend, and WA 98368. The County will review such reports,
and upon approval thereof, payment will be made to the Contractor in the amount approved.
Failure to submit timely reports may result in a denial of reimbursement.
Section 11: TERMINATION:
The County reserves the right to terminate this contract in whole or in part, with 30 days' notice,
in the event that expected or actual funding from any funding source is withdrawn, reduced, or
limited in airy way after the effective date of this agreement. In the event of termination under
this clause, the County shall be liable for only payment for services rendered prior to the
effective date of termination.
A. This agreement may also be terminated as provided below:
1. With 30 days' notice by the Board of County Commissioners for any
reason, or
2. With 30 days' notice by the Board of County Commissioners for non-
performance of the specific job duties in Exhibit A
3. With 30 days' notice by the Contractor by voluntary resignation.
Section 12: MODIFICATION:
This professional services agreement may be modified at any time by written agreement of either
party and may be modified if tax revenue decreases.
PAGE 5
Section 13: DISPUTE .RESOLUTION:
Any dispute or disagreement concerning the terr�ts and obligations of this Contract shall initially
be brought to the attention of the Public Health Director via a written document. The Public
Health Director shall make a determination with reasonable promptness, i.e., a decision within
ten business days shall be deemed to have been rnade with reasonable promptness. If the
aggrieved party is not happy with that decision, then the Jefferson County Administrator (or as
may hereafter be amended), will decide the appeal of the Director's decision.
Section 14: INTEGRATED AGREEMENT:
This Agreement together with attachments or addenda represents she entire and integrated
iat i ns,
agreement between the County and the Contractor and supersedes all prior negotiations,
representations, or agreements written or oral between the parties. This agreement may be
arnended only by written instrument sighed by both County and Contractor.
Approved this clay 01'_ ( , 2017
BOARD OF COUNTY COMMISSIONERS
JEFFERSON COUNTY, WASHINGTON
Chairperson 1� NNrV�g.Y'
-tbu-�!Aouu—L
Jumping Mouse Children's Center
A"I I'1•'ST:
+ ss
Deputy Cle of the Bo:ir
f
2/Z 3141(l
PAGE 6
EXHIBIT A
Scope of Work
RESPONSIBILITIES:
The Jumping Mouse Children's Center Services agency as a contracted provider, agrees
to:
1. Clinical and care management services for up to 21 children and their caregivers per
billing period.
2. All employees or subcontractors of the Contractor undertaking the performance of mental
health/substance abuse services under this agreement are required to be professionally
licensed or certified by the State.
Background checks are required for all employees; to be redone for every employee
every 3 years. The names of licensed therapists will be given to the County.
4. Provide long-term therapy to children affected by and/or with risk factors for mental
illness or substance abuse at home and/or in the community.
5. Provide parent support and education to the adults of the children covered in this
contract.
6. Work with social services or other agencies as needed for dually served families with
mental health or chemical dependency issues.
7. Provide care coordination with other involved agencies, and referral to supportive
services such as housing, transportation and vocational services; tracking of client
involvement in recommended services, including 12 -step or comparable support.
S. Maintain a secure records system guaranteeing the confidentiality of PHI pursuant to
HIPPA.
9. Bill other revenues whenever they exist.
10. Quarterly data template on client utilization, referrals, outcomes, and required reporting,
in standard form as specified by Jefferson County Health.
11. Individual therapy, using promising and/or evidence based models of treatment.
Applicant will identify the number of clients seen, how often each week and the number
of hours per week and per month for treatment enrollment.
12. Referral for mental health medication and monitoring as needed.
13. Collection and preparation of data for internal and external evaluation purposes,
providing a monthly invoice to JCPH and a quarterly data report. Use forms supplied by
JCPH for data.
14. Preparation of progress reports if needed, e.g. for care coordination purposes
PAGE 7
15. Staffed by 4 master's level, Licensed Mental Health Counselors, 3 master's level Licensed
Mental Health Counselor Associates, 3 master's level intern therapists (supervised by
Washington State Approved Clinical Supervisors), and one social worker, with support
staff to include billing and administration.
16. Clerical, billing, and general office support.
17. Agency oversight regarding record keeping, data collection, legal and ethical issues and
standards of care are updated and meet State of Washington standards.
18. Services are available throughout Jefferson County.
19. Provide data including:
*Number of intakes, individual sessions, psychiatric visits, and adult education visits
provided
• Age, sex, drug of choice, psychiatric diagnosis of clients.
*Referrals to other agencies.
• Client satisfaction form indicating client's view of how program helped in their life.
20. Opportunities for regular clinical supervision and consultation are available for staff on a
regular basis. Supervision for all therapists, including interns and externs, consists of
minimum one hour per week in individual consultation, one hour per week in group
consultation and three hours per month in a clinical staff meeting. Additional individual
support and supervision to interns is also provided on a continual, as -needed basis.
21. Attend and report to the Mental Health Substance Abuse Sales Tax Advisory Committee
once during the duration of this contract period, at regularly scheduled meetings, with
progress evaluation reports.
22. For clinical and care management services for up to 21 children and their caregivers per
billing period, Jumping Mouse will provide quarterly statistics in an electronic form, an
illustrative example of which is shown in EXHIBIT B of this contract, as will be
developed and may be revised by Jefferson County Public Health in consultation with
Jumping Mouse, for statistical and program data collection.
Jumping Mouse Children's Center will ensure that quarterly electronic reports are
sent to Siri Kushner of Kitsap County Health District, 345 6t11 Street, Suite 300,
Bremerton WA 98337 and/or siri:l1.�11r�7�r+rr;kits€31��rlllirl1c111117.1?i, and that a
copy of each electronic report is also sent to Anna McEnery of Jefferson County
Public Health at rami-etrcry ir)ccl jeL ierson.wa.us.
Due dates for reports are as follows: 4/28 for Jan -Mar, 7/28 for Apr -June, 10/31
for July -Sept, and 1/31 of the next year for Oct -Dec.
Quarterly reports will be reviewed by Public Health and Siri Kushner for
accuracy. Any questions will be referred back to the Jumping Mouse.
PAGE 8
EXHIBIT B
Jefferson County 1/10111 of l % for Mental Health & Substance Abuse
2017 Quarterly Evaluation Reporting Template
For clinical and care management services for up to 21 children and their caregivers, Jumping
Mouse will provide quarterly statistics in an electronic form, an illustrative example of which is
shown below, that will be developed, and may be revised, by Jefferson County Public Health in
consultation with Jumping Mouse.
Jefferson County 1/10th of 1% for
?_017 Evaluation Reporting Template (Version 2;
Renortina Atxencv : Jumolnu Mouse
& Substance Abuse
Total Individuals (unduplicated) I
I
Roport Quarter:
Service Inquiries
Service Inquiry Disposition: Enrollments by Client Status:
I:ar mllod
New client
Wait list: some service
Existing client _
Wait list: no service
_
Previous client
Closed prior: some service
Client refused
Agency denied out of service
area/waitllst closed
Referred to other
Lost to follow-up
Service Counts:
Total clients served:
Total clients eligible for 1/10th 1%: a portion
ineligible due to paperwork status
Tolal caregivers of all clients served:
Clients by Opeode of Residence
98325
98365
lUnknown due to naoerwork status I
ther
Session Counts:
Child
Parent
Length of Participation at Close of Quarter
0-4 weeks (less than 1 month)
5-8 weeks (1 month)
9-12 weeks (2 months)
13-16 weeks (3 months)
17-20 weeks (4 months)
21-24 weeks (5 months)
25..-28 weeks ((3 months)
6 months - 1 year
1 year or more
PAGE 9
lousing Status at Intake
tent/own apartment or house
)oubled up/Couch surfing
Insheltered
Inknown
otal 0
Parent/Carogiver Employment Status
Not in the work force
_
Employed work full time
Oto6
Employed work part time
7to9
Unknown
10 to 12" may be >12 @ close
Total
0
Parenticaregker requesting
employment support
_
Generalized Anxiety
Referral to DVIU
Homeless at any
time during the
quarter
Other cr,rebnr€es JM does riot collect:
Sheller Live in cal/tenUry
Transitional (inrlurlirf[ (Iot0Urrt nt/ E
Insurance StatuE Child -billable
Private insurance
Medicaid
Medicare
Uninsured _
Other
Unknown
Total 0 0
Clients by Age and Gender:
Second
Age Range Male Female
Total
Oto6
0
7to9
0
10 to 12" may be >12 @ close
0
1 otal 0 0
0
Client Mental Health no mental health
Cis fi fic•
known unknown
own
by Parent)
Intem - Caregiver
paperwork
status
Diagnosis Primary
Second
Third
Total
ADHD
0
Adjustment Disorder
0
_
Generalized Anxiety
0
Attachment Disorder
0
Mgjor Depression
0
PTSD
0
Z or T code: 0
0
0
0
abuse/neglect
0
sexualabuse
0
family or relational problem
0
foster child problem
0
bereement
m�
0
academic problem
_...
0
phase of life pi cihlc111
0
NT giPie�lse T1? 610 q
Ci
0
Trauma
--
---
0 ---..
_ 0
Mood Disorder
Separation Anxiety".
Learning Disability
Other Depress€%e w]Anxlety
PAGE 10
C:
Adverse Chi dhood Experiences - historical known l
Parent/Household Mental Illness Ij
PArAT1f1Hr3 ltahnId Alnnhnliem nr Drun Aridintinn
Drug/Alcchol Exposure in Utero
Count/Reporting
t :intfiy L-k1wria nce
Loss: D[varce or Separation
_
historical .
Loss: Death
0 _
single parent
Loss: Abandonment
0
foster care
Loss: Poster Care of Adoption
0
adoptive care
Loss: Other
0
0
kinship care
House: umoucnai
Abuse: Physical
Abuse: Sexual
Neglect Physical
Neglect: Emotional
Domestic Violence
Incarceration of ParentlHousehotd Member
i [omelessness
Any (undufttr..it�[l1
Any (unduplicated)
Experience Count
Count/Reporting
yes
Non -Reporting
_
#DIV/01
,0 Experiences
0 _
1 Experiences
2 Experiences
3 Experiences
0
#DIV101
4 Experiences
0
#DIV/01
5 Experiences
0
0
#DIV/01
6 or more Experiences
due to paperwork status (different
than reporting # due to 0 count
reporters)
% of Reporting
% of Total
Successful completion
#DIV/01
#DIV101
#DIV/01
#DIV/01
#DIV101
#DIVI014DIV101
fully participate in
#DIV/01
#DIV101
#DIV/01
#DIV101
#DIV/01
#DIV101
4DIV/01
#DIV/01
SECTIONTHIS •- All CLIENTS WHO CLOSED DURING
Client Discharge Outcome:
Successful completion
Other (please specs : # and type)
Disappeared/Left services
Not yet repoiled
Dro pad out/Quit
Hospitalized
fully participate in
Deceased
What did client die from?
Moved out of County
1;,,hildrensuccess
successfully
ANNUAL OUTCOMES
SMART Objective Type of Measure Source Numerator Denominator 96 auto ca
90% of children served will
#children
fully participate in
rTiedium/long
1;,,hildrensuccess
successfully
patic[pating
#VALUEI
therapy
term outcome
participating
80% of parents served will
# parents
successfully
a
# p rents
#VALUEI
successfullvdevclop intended
medium/long
develuping
participating
3ki115/behaviors of ro�ram
term outcome
# pa rti ci pa nts
# partici pants
X% of participants report
reporting program
completing
program has helped them
has helped
parenting skills
#VALUEI
Improve parenting skills (4 or
satisfaction
improve parent
question
5)
outcome
survev
skills
# participants
# participants
X% of participants report
PAGE II
reporting program
helped reach
comp letinghas
#VALUEI
program has helped them
go sfor family
family and self
reach goals for family and self
satisfaction
andd self
goals question
r4 or S)
nutcnme
survev
EXHIBIT C
Fee Schedule
Therapy and Care Management by three intern therapists @ $366.67 each per month, for a total
of $1100.00 per month. Clinical supervision @ $1234.58 per month and Administration @
$341.67 per month.
Not to exceed $32,115.00 in completion of services for the duration of this contract without
express written amendment.
PAGE 12
EXHIBIT D
.11:1 1 `1tSQN COUNTY MI IICD TREATM1N'1 TAX FLINDINtr-
MATCH POLICY
On October 14, 2013 Jefferson County Board of County Commissioners (BOCC) adopted the
following language in the allocation of the Mental Health Chemical Dependency treatment
dollars.
Agencies may not use Jefferson County mental health county/ chemical dependency
treatment tax funds for match, without prior authorization of their match, formula and
allocation use, approved by the Jefferson County Administrator and fiscal team. The
match may not be used without written permission.
Definitions:
Match: is a requirement for the grantee to provide contributions of a specified amount or
percentage to match funds provided by another grantor. Matching can be in the form of
cash or in-kind contributions.
Auditors Objective: To determine whether the match amount or percentage of
contributions from JC is an allowable source of funding and that the vendor has an
accurate accounting system to track the match.
Regulations: The specific requirements for matching funds are unique to each federal or
state program. The A-102 Common Rule provides criteria for acceptable costs and
contributions in regard to match.
Jefferson County Policy:
In 2005, the Washington State Legislature created an option for counties to raise the local sales
tax by 0.1 percent, (the 1/10th of 1% sales tax initiative) to augment state funding for mental
health and chemical dependency treatment. Jefferson County collects and distributes the Mental
IIealth/Chemical Dependency (MH/CD) tax. Services purchased by the County are allocated
through a formal Request for Proposal (RFP) process, review and contracting; staffed by
Jefferson County Public Health, overseen by Jefferson County Mental Health Substance Abuse
Fund Advisory Committee and adopted by the Board of County Commissioners, (BOCC). The
BOCC does not assume any fiscal responsibility/liability for any of the vendors they contract for
services with. Services leveraged by a vendor using MH/CD tax as match have no oversight or
agency relationship to Jefferson County; funding cannot be used without prior authorization of
the vendor's match formula and allocation by the Jefferson County Administrator and fiscal
team.
PAGE 13
Following state, federal and local guidelines for match is the responsibility of the vendor.
Jefferson County will follow all administrative policies in authorizing that use. If a vendor is
disallowed the use of funds for match according to the State of Washington or the federal
government, Jefferson County funds will not be available as matching funds.
For example, if a vendor provides Title XIX Medicaid services (the Policy
19.50.02 or 42CFR 430.30) they will not be allowed the use of match without
actually billing Medicaid for the services at the same time. If no Medicaid billing
exists, the match cannot be applied.
• The County shall verify that the local entity's financial reporting system tracks
matching funds at a level to support the use of funds; that meets the level of
documentation required by federal or state statutes.
The verification and application process for Match use within the County will include the
following steps:
1. DSHS requires contractors to complete and submit a "Local Match Certification"
form (DSHS 06-155) or a form that has equivalent data elements prior to any
agreement for DSHS services. The County must review a copy of this application
and form prior to granting match authorization of MH/CD funds for Match and at
each monthly billing.
2. Submit the current administrative policy within WA State regulating your services
and the use of local match.
3. Submit to the County your last financial audit showing your use of match,
County funds and tracking systems.
4. Submit to the County the terms of the agreement to ascertain the MH/CD
allocation is an allowable source of match.
5. The County Administrator will authorize or deny the use of snatch in writing
within 30 days of the application.
PAGE 14