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HomeMy WebLinkAboutJumping Mouse Children's Center - 031918CONTRACT AMENDMENT #2 i For Professional Services Between • Jefferson County f V V �� 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. 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 / da of , 2018. ,f By: Da I Sullivan, Chairman Jefferson Count Board of Commissioners By: Contractor ATTEST: By: CQ4' ov&�,, — Car yn Ate, Deputy lerk of the Board 6AIIAW"I APPROVEDAS ��ONLY: By: U C. 3 /7 Philip Hunsucker, Chief Civil, Defity4lrosecuting 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, at 'a regularly scheduled meeting, with progress evaluation reports for children and their fan -lilies. 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 siri.kushner r��kitsappublichealth.or,-,and that a copy of each electronic report is also sent to Anna McEnery of Jefferson County Public Health at aineenerN,,,'ii'co.{e:fferson_wa.Lis. 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 @ $1234.58 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 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 I/ 10th of I% sales tax initiative) to augment state funding for mental health 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. 615 Sheridan Street Port Townsend, WA 98368 www.JeffersonCountyPublicHealth.org Public He� Consent Agenda January 17, 2018 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: jI )q I Z )I 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 COWS: 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 IMPACT/COST BENEFIT 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' Philip Morlex�// County Acltrator _ Date Commur5i�y i 'Health 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 +, . 615 Sheridan Street Port Townsend, WA 98368 V eihson www.JeffersonCountyPublicHealth.org ew Public He9allt N -17-109-A2 CONTRACT REVIEW FORM JAN 19 2010 CONTRACT WITH: Jumping Mouse Children's Center CONTRACT FOR: Mental Health Treatment Services TERM: January 1, 2018 - March 31, 2018 COUNTY DEPARTMENT: For More Information Contact Contact Phone #: RETURN TO: Jenny Matter Jefferson County Public Health Anna McEnery X410 RETURN BY: ASAP Additional $22,284 for a total of AMOUNT: $92,409 Revenue: Expenditure: $22,284 Matching Funds Required: Source(s) of Matching Funds: 1/10th of 1% PROCESS: ❑ Exempt from Bid Process ❑ Consultant Selection Process ❑ Cooperative Purchase ❑ Competitive Sealed Bid ❑ Small Work Roster ❑ Vendor List Bid ❑x RFP or RFQ ❑ Other: Step 1: REVIEW BY RISK MA ��/// Review by: (1 ' Date Reviewed: APPROVED FORM ❑ eturned for revision (See Comments) Comments: /APPROVED p 2: REVIEW BY PROS TINGXTrCjRNV Review by: !' Date Reviewed: 3 / AS TO FORM Returned for revision (See Comments) Comments: (This form to stay with contract throughout the contract review process) Community Health Developmental Disabilities 360-385-9400 360-385-9401 (t) Always working for a safer and healthier community Environmental Health Water Quality 360-385-9444 (f) 360-379-4487 MEMORANDUM Philip Morley 1820 Jefferson Street PO Box 1220 Port Townsend, WA 98368 TO: File FROM: Philip Morley, County Administrat 1 `� DATE: February 21, 2018 SUBJECT: Disclosure of Interest As Risk Manager, I review all agreements for risk, including all agreements with organizations recommended by the Hargrove Committee to receive an allocation 1/10th of 1% Mental Health Substance Abuse funds to provide services. Among these agreements, I have reviewed and approved for Risk, a Contract Amendment No. 2 with Jumping Mouse Children's Center, extending an existing agreement and providing funding in 2018 for mental health treatment services. The Amendment with Jumping Mouse is like five other agreements with other service providers that I have reviewed in the same Hargrove Committee funding round. All of these agreements are also reviewed by Legal after my review. Jefferson County's Code of Ethics is adopted as Appendix B of the County's Personnel Administration Manual. Section 4.0 of the Code of Ethics reads in part, If an employee or someone, with whom the employee has a close personal relationship, has a financial or employment relationship with a vendor, potential vendor, or any person or business entity doing business or wishing to do business with the County, then the employee has an "interest," as that term is defined in Section 2.0. In such circumstances the employee is considered to have an "interest" that mandates disclosure of that "interest" and eventual resolution in accordance with this Code. Starting November 1, 2017, my spouse has been employed by Jumping Mouse as a Staff Therapist, working part time 22 hours per week. She is one of approximately eleven full- and part-time staff. County funding from Amendment No. 2 is $22,284, while Jumping Mouse's most recent annual financial report shows revenues from all sources in 2016 were $528,222, used to fund Jumping Mouse's operations. As such, there is not a direct correlation or benefit between Amendment No. 2 and my spouse's employment. In conclusion, in disclosing my spouse's part time employment at Jumping Mouse, I believe my ability to professionally conduct routine Risk review of this agreement on behalf of the County is unaffected. Phone (360) 385-9100 Fax (360) 385-9382 pmorley@co.jefferson.wa.us CONTRACT AGREEMENT 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 shall 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: .K.1111 Contract RCDresentative Anna McEnery Jefferson County Public Health 615 Sheridan St. Port Townsend, WA 98368 (360) 385-9400 PACE t Contractor's Contract Representative 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 damage 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 name) 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. Nothing 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 any 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 terms 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 made 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 the entire and integrated 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 amended only by written instrument signed by both County and Contractor. Approved this —13V—� day of , 2017. BOARD OF COUNTY COMMISSIONERS JEFFERSON COUNTY, WASHINGTON Chairperson Nr►�Cr Jumping Mouse Children's Center ATT1 ST: ---C V Deputy Cie of the Boer ` �-V 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. 8. Maintain a secure records system guaranteeing the confidentiality of PHI pursuant to HIPPA. 4. 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 6t" Street, Suite 300, Bremerton WA 98337 and/or 4iri ktFshi�t'i�iits4tplul�licl�c t�Etl7.r, and that a copy of each electronic report is also sent to Anna McEnery of Jefferson County Public Health at --irlfe.rscin,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 I% 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. xfferson County 1/10th of 1% for M 17 Evaluation Reporting Template (Version 2: Portina Anencv : Jurn'uina Mouse ealth & Substance [Total Individuals (unduplicated) 1 iries t list: some service t list: no service ,ed prior: some service nt refused ncy denied out of service dwaitlist closed ,rred to other to follow-up is call/walk-in Service Counts: Session Counts: Total clients served: Child Total clients eligible for 1110th 1 %: a portion Parent ineligible due to paperwork status otai caregivers of all clients served: Clients by apcode of Resid4 !Unknown due to paperwork status I 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 (6 months) 6 months - 1 year 1 year or more PAGE 9 ousing Status at Intake Homeless at any time during the qupef Other rategodes JPd does rUt collect: ShefteF '. Livel; cdtlif�r3tlry �rarsi6emai {inciudmc lteUtlzC Child -served by Parent/ Insurance State Child -billable intern Caregiver ent/own apartment or house oubled up/Couch `surfing nsheltered nkllOWn Dtai 0 10 to 12' may be >12 @ close ar iiar gi a Ip ent tatus of in the work force 0 Private insurance mployed work full time Medicaid ; mployed work part time Medicare nknown Uninsured :)tal 0 Other — arent/caregiver requesting -nploymentsupport Unknown Referral to DVR Total 0 0 10 Clients by Age and Gunder: Age Range Male Female Total 0to6 6 7to9 0 10 to 12' may be >12 @ close 0 Tatal 0 0 0 PAGE, 10 Aaverse (;nillanooa 4=xpenences - nlstoricai «nc Parent/Household Mental Illness Parent/Household Alcoholism or Drug Addiction Drug/Alcohol Exposure in Utero Lass: Morce or �aeparation I ncc nAnth Loss: Abandonment foster`care Loss: Foster Care 'ofAdoption Other (please specify # and type) adoptive care Loss: Other Yes kinship care buse: Emotional buse: Physical buse: Sexual onai Homelessness due to paperwork status (different than reporting # due to 0 count reporters) ,� !^ Other (please specify # and type) Any (unduplicated) Experience Count Count/Reporting Yes % of Reporting % of Total Non -Reporting Dropped out/Quit #DIV/01 0 Experiences Hospitalized 0 #DIVJOI #DIV/01 1 Experiences 0 #DIV/01 #DIV/01 2 Experiences 0 #DIV/OI #DIV/01 3 Experiences 0 #DIVI01 #DIV/01 4 Experiences 0 #DIVI01 #DIV/O1 5 Experiences 0 If children #DIVI01 #DIV/01 5 or more Experiences 0 r #DIV/01 #DIV/01 Client Discharge Outcome: Successful completion Other (please specify # and type) Disappeared/Left services Not yet reported _ Dropped out/Quit Hospitalized Deceased What did client die from? Moved out of County ANNUAL OUTCOMES SMART Objective 'rype of Measure Srrurce tvurtterrsttor D rta it c 90% of children served will #children If children successfully participate in rnedium/long successfully participating #VALUE! therapy term outcome ciarticioating 80% of parents served will # pa rents successfully #parents #VALUE! successfullydevelop intended medium /long Bevel upi ng participating skills/behaviors of 2rograrn term outcome # partici pants #participants X% of participants report reporti no program completing program has helped them has helped parenting s kills #VALUE! mprove parenting skills (4 or satisfaction improve parent question 5 outcome survey skills # participants # participants %of participants report PAGE 11 reporting program has helped reach completing #VALUE! )rogram has helped them sforfam(ly family and self -each goals for family and self satisfaction and self a and goals question 4 or 5) outcome survey 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 Jt-, VI,12:SON COUNTY Ml1 J/CD TREA`I'Ml`N'T''l'AX FUNDING - 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-1.02 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 Health/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 i� 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 match in writing within 30 days of the application. PAGE 14 CONTRACT �� For Professional Services Between Jefferson County And Jumping Mouse Children's Center For Expanded Mental Health (MH) & Chemical Dependency (CD) Treatment 2017 WIIEREAS, 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 December 31, 2017, 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, 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. This amendment adds $38,010,00 in funding as stated in Exhibit C, Fee Schedule, to be used specifically for clinical and care management services for up to 45 children affected by and/or with risk factors for mental illness or substance abuse at home and/or in the community. 3. This contract shall not exceed $70,125.00 without express written amendment signed by both parties. All other terms and conditions of the agreement will remain the same. Dated thisday of 'fit. 1,,,1 , 2017. By:C� Kathleen Kier, Chair Jefferson 130 <d of County Commissioners By: ZZ - (Contractor) ATTEST: 'f 7 ' 0 C ark of 0hoard� til Approved as to form: Philip C. Hunsucker Chief Civil Deputy Prosecuting Attorney Jefferson County Prosecuting Attorney's Office EXHIBIT A Scope of Work RESPONSIBILITIES: The Jumping Mouse Children's Center Services agency as a contracted provider, agrees to: l) 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 hcalth/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. 1 1) 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, 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) 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 EXHIBIT B Jefferson County 1/10th of 1% for Mental Health & Substance Abuse 2017 Quarterly Evaluation Reporting Template For clinical and care management services for up to 45 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. iPareotl are liver Ern to 0nt:Status Not in the work force Employed work full time 7to9 Employed work part time 0 Unknown Total Total 0 Parent/careghoer requesting 0 employment support Deferral to DVR Homeless at any time during the quarter " ski P"I CIO es not ";,77: rI Live in car/tent/ry Transitional onclucinelftnptel j Child -served by Private insurance Medicaid Medicare--- Uninsured edicare_Uninsured Other Unknown Total 0 Child -billable intern Caregiver n _ 0 Clients by Age and Gender: Age Range Male Female Total 0to6 0 7to9 0 10 to 12* may be >12 @ close 0 Total 0 0 0 Adverse Childhood Experlences- historical known Parent/Household Mental Illness Parent/Household Alcoholism or Drug Addiction Drug/Alcohol Exposure in Utero Loss: Ditorce or Separation Boss: Death single parent toss: Abandonmerit _ __ _ faster care Loss: Foster Care of Adoption adoptive care Lass: Other kinship care Abuse: Emotional Abuse: Physical Abuse: Sexual `.---- ----__`_---- .`_`---- due to paperwork status (different Neglect: Physical Neglect: Emotional Domestic Violence Incarceration of Parent/Household Member Homelessness . .P than reporting # due to 0 count reporters) Any (unduplicated) Count/Reporting Experience Count Yes %of Reporting %of Total Non -Reporting #D1 V/01 0 Experiences 0 #DIV/01 #DIV/01 1 Experiences 0 #DIV/01 #DIV/Ot 2 Experiences Q #DIV/01 #DIV/01 3 Experiences 0 #DIViol #DIV/01 4 Ex edences 0 #DIV/01 #DIV/01 5 Experiences 0 #DIVlol #DIV/01 6 or more Experiences 0 #DIV/01 #DIV/01 THIS SECTION IS FOR All CLIENTS WHO CLOSED DURING CURRENT QUARTER Client Discharge Outcome: Successful completion Other (please specs # and t pe) Disappeared/Left serVees Not yet reported Dropped out/Quit Hospitalized Deceased What did client die from? � Mohd out of County ANNUAL OUTCOMES i" "Al MART Ob ective a 46 Is re� e ►ivmfiitato 90% of children served will #children #children successfully participate in medium/long successfully #VALUEI thera py term outcome participating participating 80% of parents served will #parents successfully #parents #VALUEI successfully develop intended medium/long participating skills/behaviors of proram term outcome developing # pa rti c i pa nts #participants X% of participants report reporting program completing program has helped them has helped parenting skills #VALUEI improve parentingskills (4 or satisfaction improve parent 5) outcome serve skills question # participants reporting program #participants X%of participants report has helped reach completing #VALUEI program has helped them goals for family family and self reach goals for family and self satisfaction and self goals question 4 or S� outcome curve EXHIBIT C Fee Schedule January — December 2017: 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. In addition: May — December 2017: 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 $70,125.00 in completion of services for the duration of this contract without express written amendment. ATTACHMENT A J131"FERSON 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 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 I/ I Oth of 1 % sales tax initiative) to augment state funding for mental health 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.