solicitation - family services planning team - circuit 7 - 20017-001€¦ · 07/07/2017 ·...

Fiscal Year 2017‐2018

SOLICITATIONFamilyServicesPlanningTeam–Circuit7

2017‐001

SECTION 1: BACKGROUND, NEED AND PURPOSE, STATEMENT OF WORK, AND REQUIRED PROPOSAL CONTENT I. Background LSF Health Systems is the Managing Entity for the Department of Children and Families Behavioral Health programs responsible for the administration of mental health and substance abuse treatment programs for children and adults. LSF Health Systems covers the Northeast and North Central region of Florida, encompassing the following Counties: St. Johns, Putnam, Flagler, and Volusia. Each program serves the most vulnerable and neediest individuals and provides for a comprehensive array of outpatient, inpatient and residential services including, but not limited to; therapy, case management, medication management, residential, room and board, crisis and emergency support, prevention, intervention, outreach, supported housing, and supported employment. Clients served must meet the eligibility requirements outlined in the Managing Entity contract and 65E‐14, F.A.C. The anticipated effective date of the proposed contract is September 1, 2017. The award recipient

will be expected to work with the existing Family Service Planning Team Network Service Provider in

circuit 7 to transition the program by mid‐September 2017. LSF Health Systems will accept proposals

with budgets between $103,315 ‐ $105,017 total; funding is subject to availability of funds from the

Department.

II. Need and Purpose The Children’s Mental Health Care Coordination Program is a network of community‐based services and

supports that is youth‐guided and family‐driven to produce individualized, evidence‐based, culturally

and linguistically competent outcomes that improve the lives of children and their families. Section

394.491, Florida Statute, outlines guiding principles for child and adolescent mental health treatment

and support systems. Consistent with these principles, children and adolescents receive services within

the least restrictive and most normal environment appropriate to meet their individual clinical and

behavioral needs. In addition to offering traditional Case Management and therapies, LSFHS implements

the Family Service Planning Team (FSPT) and Child and Family Staffing (CFS) program models to offer

care coordination and non‐traditional supports to children and families in need of more intensive

mental health treatment. These services are offered by contracted Network Service Providers

throughout the Region.

The FSPT process is designed to be a child‐centered, family‐focused and a community‐based program

that funds less traditional therapeutic services for children living in the community to divert them from

residential placement. Through participation in the FSPT process, families are able to access services

such as therapeutic camps, behavior analyst services, therapeutic friends or mentors, and specialized

therapies that would not be covered under the child’s insurance plan. The FSPT team is a

multidisciplinary group of professionals that engages the child and parents or other caregivers to

consider the strengths and needs of the child and family. These teams work together with the family to

strategize ways for a youth to remain at home or to return home from a residential treatment setting as

soon as possible.

The CFS process facilitates the placement of youth into residential treatment when a child is

recommended for this level of care by a physician. The CFS team is comprised of all individuals involved

with the child and family (i.e. AHCA, legal guardian, treating provider, Department of Juvenile Justice,

school representative(s), family advocate, Managed Care Organizations or other persons invited by the

youth and family). The CFS team provides information and support to facilitate the child’s admission into

residential treatment. The CFS team monitors the child’s progress while in residential treatment and

ensures recommended services are in place when a youth is discharged.

LSFHS seeks to contract with a Network Service Providers in Circuit 7 to coordinate both of the

processes described above. To ensure the implementation and administration of these programs, the

Network Service Provider shall adhere to the staffing, service delivery and reporting requirements

described in Appendix A – Incorporated Document 30 – Children’s Mental Health Care Coordination

Program.

III. Statement of Work The terms and conditions of the LSF Health Systems standard contract and its supplemental documentation will be in effect for this award. All services rendered under this potential contract are subject to the rules, regulations and governance of the LSF‐DCF contract, the State of Florida and the Federal Government. Information specific to this project is contained in Appendix A. This document, subject to revision by LSF Health Systems, will be incorporated into any contract entered into by recipients of this award. Preference will be given to agencies with an established relationship with children and family programming, including relationships with school representatives, family advocates, Department of Juvenile Justice, Behavioral Health providers, and Circuit 7 Community Based Care organizations (St. Johns County Board of County Commissioners and Community Partnership for Children, Inc.). The award recipient will be expected to leverage existing resources where available.

IV. Required Proposal Content

This section describes the format and organization of the agency's response. Failure to conform to these specifications may result in the disqualification of the submission.

A. Number of Responses Agencies shall submit only one proposal per agency; however, LSF Health Systems may select multiple subcontractors to provide services. Each contract shall be entered into by only one agency; any collaborative submissions shall designate a lead agency to which the award would be granted contractually with appropriate subcontracts to support any collaboration.

B. Preparation Proposals should be prepared simply and economically, providing a straightforward, concise description of agency’s ability to meet the requirements of the proposed project. C. Trade Secrets Should any materials contained within a submission contain information subject to the protections of a trade secret, agencies submitting said material shall enclose the portions which are subject to this protection in a separate envelope clearly labeled, “Trade Secret” with a watermark indicated any pages contained trade secrets printed clearly across the document. Failure to submit protected information in this manner waives the agency’s right to assert a trade secret privilege in later public records requests, should they arise.

D. Response Content and Organization The response to this solicitation must be organized in the following format and must contain, as a minimum, all listed items in the sequence indicated: Title Page; Table of Contents; Narrative Program Description; Proposed Budget with Narrative Description; References.

Forms for some of the above requirements are contained within the appendices. If no form is provided, agencies may utilize the format of their preference. Agencies selected for negotiation or award will be subject to providing evidence of eligibility to subcontract for state or federal funding. Several additional forms, certifications and documents will be required upon notification of an award. Failure to provide the requested materials will disqualify the recipient from funding and the agency with the next highest score will be contacted for negotiations. Any response that does not adhere to the requirements outlined in this solicitation may be deemed non‐responsive and rejected on that basis. The following is a list of required content:

A. Title Page Agency’s response must include a coversheet or title page detailing the agency name, Procurement Manager Name and contact information along with a title page addressed to the contact indicated in Section 2.

B. Table of Contents The table of contents must contain a list of all sections of the response and the corresponding page numbers. Alternatively, submissions may contain tabs as an index to the contents contained therein. C. Narrative Program Description

The response to the solicitation should address the need and purposed outlined herein with an overview of how the agency intends to meet same. The agency must provide a thorough description of objectives and services to be provided under the project. Agencies must provide a detailed description of staffing in their responses. The minimum requirements for this section are: A description of the staff that will be employed or contracted by the provider and their qualifications such as education, years of work experience, role and management responsibilities, licenses, certificates, and any relevant technical courses or training. Identify the number of unduplicated consumers that the team anticipates serving under the project. Describe any community partnerships in place to support the project. If any matching funds or collaborative funding sources are available for this project, provide details on said availability. D. Budget and Budget Narrative Agencies will include a proposed budget, accompanied by a detailed budget narrative. The budget narrative must explain and demonstrate that each entry on the line item budget sheet is allowable, reasonable and necessary. E. References Each proposal should contain three references who can be contacted to obtain a recommendation concerning the provider’s performance in providing services similar to those required by this project. Agencies may submit letters of support in lieu of simply listing a reference.

SECTION 2: SUBMISSION INSTRUCTIONS

I. Process The process involved in soliciting proposals, evaluation proposals, and selecting the agency for contract negotiation leading to the award of a contract is a multi‐step process:

a. Solicitation release by LSF Health Systems; b. Written questions submitted in accordance with the Schedule of Events and Deadlines; c. Response to written questions in accordance with the Schedule of Events and Deadlines; d. Agency’s responses submitted in accordance with Schedule of Events and Deadlines; e. Evaluation of Proposals; f. Proposal scoring; g. Notification of award recipients; and h. Contract negotiations.

II. Contact Person This solicitation is issued by LSF Health Systems, the DCF SAMH Managing Entity for the Northeast Region. The single point of contact is:

Shelley Katz

Vice President of Operations [email protected]

904‐900‐1075

III. Proposer Questions or Inquiries Questions related to this solicitation must be received in writing by the contact person listed in Section 2, II, and in accordance with the Schedule of Events and Deadlines. Questions must be sent via e‐mail. Responses to questions will also be published in accordance with the Schedule of Events and Deadlines. Inquiries shall not be made via telephone. No inquiry shall be made to any other personnel from either LSF Health Systems or the Department of Children and Families with regard to this solicitation.

IV. How to Submit a Proposal

This section describes how to correctly submit a proposal for this solicitation. Failure to submit all information requested or failure to follow instructions may result in the proposal being considered non‐responsive and therefore rejected. Please follow the instructions carefully.

1. Proposals must be delivered, sealed, clearly marked “Solicitation, Family Services Planning Team

– Circuit 7,” and delivered by the deadline indicated in the Schedule of Events and Deadlines.

2. Pages should be numbered, have 1 inch margins, using size 11.5 font, 1.15 spaced, on 8 ½ by 11 paper and printed on one side only. Double‐sided proposals will not be accepted. Applicants are encouraged to use economy in preparing submissions and present information in the most succinct manner possible.

3. Do not include spiral or bound materials or pamphlets. All attachments or exhibits must be letter sized, and if reduced to letter sized, must be readable. Ink and paper colors must not prevent the entire proposal from being photocopied.

4. Each proposal should be unbound, collated, and include a table of contents with each section

clearly labeled with the appropriate heading. 5. An original and two copies of the proposal and supporting materials are required. An electronic

version of the proposal should be submitted on a USB Thumb Drive. The original must be marked “original” and must contain an original signature of an official of the agency who is authorized to bind the agency to its proposal.

V. Limitations on Contacting LSF Health Systems Personnel

Prospective agencies are prohibited from contacting LSF Health Systems personnel, DCF personnel or any person other than the person named in Section 2, II regarding this solicitation. Violation of this limitation may result in disqualification of the prospective agency.

VI. Acceptance of Proposals

Proposals must be received by LSF Health Systems by 5pm on the assigned date in accordance with the Schedule of Events and Deadlines at 9428 Baymeadows Rd, Ste 320; Jacksonville, FL 32256. No changes, modifications or additions to the proposals submitted after this deadline will be accepted by or be binding on LSF Health Systems. Any proposal submitted shall remain a valid offer for at least 90 days after the proposal submission date. Proposals not received at either the specified place or by the specified date and time, or both, will be rejected. Proposals may be sent via U. S. Mail, commercial carrier or hand delivered. Proposals submitted by facsimile or electronically will be rejected. LSF Health Systems reserves the right to reject any and all proposals or to waive minor irregularities when to do so would be in the best interest of LSF Health Systems. Minor irregularities are defined as a variation from the terms and conditions which does not affect the process of the proposal, or give the prospective agency an advantage or benefit not enjoyed by other prospective agencies, or does not adversely impact the interest of the agency. At its opinion, LSF may correct minor irregularities, but is under no obligation to do so.

VII. Withdrawal of Proposal

A written request for withdrawal, signed by the agency, may be considered if received by LSF Health Systems within 72 hours after the proposal opening time and date indicated in the Schedule of Events and Deadlines. A request received in accordance with this provision may be granted upon proof of the impossibility to perform based upon obvious error on the part of the agency.

VIII. Special Accommodations

A person with a qualified disability shall not be denied equal access and effective communication regarding any proposal documents or the attendance at any related meeting or proposal opening. If accommodations are needed because of a disability, please contact:

Shelley Katz Vice President of Operations 9428 Baymeadows Rd, Ste 320

Jacksonville, FL 32256 [email protected]

904‐900‐1075

IX. Cost of Developing and Submitting a Proposal LSF Health Systems is not liable for any costs incurred by any agency in responding to this solicitation. All proposals become the property of LSF Health Systems and will not be returned to the agency once opened. LSF Health Systems shall have the right to use any and all ideas or adaptations of ideas contained in any proposal received in response to this solicitation unless protected by trade secret and submitted in the manner outlined in the document herein required to assert such privilege. Selection or rejection of a proposal will not affect this right.

SECTION 3: EVALUATION AND AWARD

I. Selection Committee Each submission meeting the minimum requirements will be reviewed and scored by at least three people comprised of LSF Health Systems and Department of Children and Families staff members, and a community member. The submissions will be ranked based on the scores assigned by the reviewers during their evaluations. LSF Health Systems will be the final decision making authority.

II. Selection Committee EvaluationThe maximum possible score for any proposal is 100 points. Proposals that score less than 70 areineligible for award under this RFP. While developing the response, please refer to the scoringcriteria below for assuring completion.

Each member from the selection committee will read and score each proposal independently,discuss each proposal jointly and then submit final results for tabulation. The score from eachmember will be summed and a final score will be assigned to the proposal. Scores will be ranked innumerical order and be submitted to the CEO for final approval.

The proposal(s) most responsive to community needs will be funded through the solicitation.Negotiations will be conducted with selected contractor(s) until contract terms are mutually agreedupon. All proposals will remain with LSF Health Systems and will not be returned to the agency.

Scored criteria are grouped into the following categories and weighting: Response to Need and Purpose (15 maximum points): The proposal contains sufficient

information to determine that the agency understands the need for and purpose of theproject.

Description of Objectives/Services to be Provided (25 maximum points): The proposalcontains a narrative description of the activities to be performed, including a detailed workplan and sustainability plan that is adequate and sufficient to accomplish the requirementsof the project as described in the Statement of Work and referenced Guidance Document.The proposal contains a description of the system used to monitor and evaluate projectimplementation and effectiveness. The description should include an explanation of: howthe provider will monitor the progress of the work and accomplishments of the outcomes;how the provider will identify and address any project issues, problems, or concerns as theyarise; and how the provider will evaluate the effectiveness of the project.

Ability of Agency to Develop and Implement Project (25 maximum points): The agencyshall be sufficiently established with appropriate community connections and resources toinstitute the project. The submission shall clearly outline factors contributing to the abilityto be successful in developing, implementing and maintaining the team as well asdocumenting and reporting on the team’s successes following implementation.

Description of Staffing (15 maximum points): Person(s) engaged to complete the activitiesof this project are qualified to perform the required duties, including relevant experience inthe areas of assessment of individuals experiencing mental health and substance use andare organized to meet the time frames established. Describe how the staffing will addresscommunication with individuals who have limited English proficiency, who are deaf or whoare hard of hearing.

Response to Mandatory Specifications (Pass/Fail): The proposal addressed all items listed in the solicitation. Agencies who fail this portion of the proposal will not be considered.

Budget and Budget Narrative (15 maximum points): The proposal includes a proposed line item budget, accompanied by a detailed budget narrative, on a separate sheet of paper. The budget narrative must explain and demonstrate that each entry on the line item budget sheet is allowable, reasonable and necessary. The budget and narrative must present a cost effective funding level for achieving the purpose of the project.

References (5 maximum points): The proposal includes at least three references. Letters of support shall carry additional weight over references which may be validated.

TOTAL MAXIMUM POINTS 100

III. Identical Tie If there is identical scoring, preference shall be given to the proposal with the lowest cost. If there is identical scoring and identical pricing, LSF Health Systems shall invite the proposers with tied scores to make an oral presentation. Following the presentation and a question and answer period, the selection committee will select the proposal deemed in the best interest of LSF Health Systems.

IV. Post Award & Contract Development LSF Health Systems will contact the agency selected for award to begin contract negotiation. As part of the contract negotiation process, conditions identified by either LSF Health Systems staff of the selection team will be addressed. If the agency has had their financial statements audited, a copy of the most recent audit statement, along with any management letter, will be requested. Additional materials evidencing the ability to contract with LSF Health Systems will be requested and failure to provide any requested materials will disqualify the agency from receipt of an award.

SECTION 5: PROPOSAL SCHEDULE OF EVENTS AND DEADLINES ACTIVITY/EVENT

DATE METHOD

Solicitation published 7/7/2017 LSF Health Systems Website

Written questions due

7/19/2017 Submit to: Shelley Katz VP of Operations [email protected]

Responses to written questions

7/24/2017 Posted on LSF Health Systems Website

Sealed solicitation responses due

8/3/2017 Submit to: Shelley Katz VP of Operations 9428 Baymeadows Rd Ste 320 Jacksonville, FL 32256

Mandatory criteria evaluation and proposal scoring begins

8/4/2017 LSF Health Systems

Posting of top ranked agency(ies)

8/11/2017 LSF Health Systems Website

Start contractual negotiations

Week of 8/14/2017

Anticipated Contract start date

9/01/2017

APPENDIX A: Guidance 30

The Children’s Mental Health Care Coordination Program

Program Guidance for Contract Deliverables Incorporated Document 30

Updated 03/15/2017 Incorporated Document 30, Page 1


Requirement: 65E‐9.008(4), F.A.C. and 394.4781, F.S.

Frequency: Reports Due Monthly and Quarterly

Due Date: 10th of each month and quarter

Description:

The Children’s Mental Health Care Coordination Program is a network of community‐based services and

supports that is youth‐guided and family‐driven to produce individualized, evidence‐based, culturally

and linguistically competent outcomes that improve the lives of children and their families. Section

394.491, Florida Statute, outlines guiding principles for child and adolescent mental health treatment

and support systems. Consistent with these principles, children and adolescents receive services within

the least restrictive and most normal environment appropriate to meet their individual clinical and

behavioral needs. In addition to offering traditional Case Management and therapies, LSFHS implements

the Family Service Planning Team (FSPT) and Child and Family Staffing (CFS) program models to offer

care coordination and non‐traditional supports to children and families in need of more intensive

mental health treatment. These services are offered by contracted Network Service Providers

throughout the Region.

The FSPT process is designed to be a child‐centered, family‐focused and a community‐based program

that funds less traditional therapeutic services for children living in the community to divert them from

residential placement. Through participation in the FSPT process, families are able to access services

such as therapeutic camps, behavior analyst services, therapeutic friends or mentors, and specialized

therapies that would not be covered under the child’s insurance plan. The FSPT team is a

multidisciplinary group of professionals that engages the child and parents or other caregivers to

consider the strengths and needs of the child and family. These teams work together with the family to

strategize ways for a youth to remain at home or to return home from a residential treatment setting as

soon as possible.

The CFS process facilitates the placement of youth into residential treatment when a child is

recommended for this level of care by a physician. The CFS team is comprised of all individuals involved

with the child and family (i.e. AHCA, legal guardian, treating provider, Department of Juvenile Justice,

school representative(s), family advocate, Managed Care Organizations or other persons invited by the

youth and family). The CFS team provides information and support to facilitate the child’s admission into

residential treatment. The CFS team monitors the child’s progress while in residential treatment and

ensures recommended services are in place when a youth is discharged.

LSFHS has contracted with Network Service Providers in each Circuit to coordinate both of the processes

described above. To ensure the implementation and administration of these programs, the Network

Service Providers shall adhere to the staffing, service delivery and reporting requirements described in

this Incorporated Document.



Eligibility:

In order to be eligible for FSPT services, the Network Service Provider shall ensure that the child meets

the following eligibility criteria:

1. Are eligible for publicly funded substance abuse and mental health services pursuant to s.

394.674, F.S.; For Children’s mental health services:

a. Children who are at risk of an emotional disturbance;

b. Children who have an emotional disturbance;

c. Children who have a serious emotional disturbance; and

d. Children diagnosed as having a co‐occurring substance abuse and emotional disturbance

or serious emotional disturbance;

2. Has an IQ of 70 or higher; individuals with an IQ below 70 will be considered on a case‐by‐case

basis.

3. Does not meet criteria for Autism, Intellectual Disability, or Pervasive Developmental Delay as a

primary diagnosis or area of concern;

4. Are not in foster care and does not have an open case with DCF/CBC oversight;

5. Are participating with a community mental health provider but the provider has determined

that outpatient services covered by insurance are not effective in resolving the child’s behaviors;

6. Are willing to participate in a family‐driven process that ensures all least restrictive measures

have been exhausted before pursuing residential treatment; and

7. Are willing to participate in non‐traditional therapeutic services.

In order to be eligible for CFS services, the Network Service Provider shall ensure that the youth meet

the following eligibility criteria:

1. Has documented exhaustion of all least restrictive community services;

2. Has been recommended for residential treatment by a physician;

3. Has been assessed and diagnosed as being emotionally disturbed by a psychiatrist or clinical

psychologist who has specialty training and experience with children, per s. 394.4781, F.S., and

who meet the following criteria, per Chapters 65E‐9 and 65E‐10, F.A.C.:

a. Be under the age of 18;

b. Currently assessed (within 90 days prior to placement) by a psychologist or a psychiatrist

licensed to practice in the State of Florida, with experience or training in children’s

disorders; who attests, in writing, that:

i. The child has an emotional disturbance as defined in Section 394.492(5),

F.S., or a serious emotional disturbance as defined in Section 394.492(6),

F.S.;

ii. The emotional disturbance or serious emotional disturbance requires

treatment in a residential treatment setting;

iii. A less restrictive setting than residential treatment is not available or

clinically recommended;



iv. The treatment provided in the residential treatment setting is reasonably

likely to resolve the child’s presenting problems as identified by the

psychiatrist or psychologist; and

v. The nature, purpose, and expected length of treatment have been

explained to the child and the child’s parent or guardian.

Program Requirements:

FSPT Program Requirements

The Network Service Provider serves as a vehicle for youth and families to purchase non‐traditional

therapeutic services to prevent the need for residential placement. FSPT team providers shall:

1. Identify specific dates and times no more than twice a month per County to schedule FSPT

staffings with youth and families. These dates and times should be at fixed intervals (i.e.

second and fourth Wednesday of the month etc.) FSPT staffings are approximately 15

minutes for each youth and family;

2. Ensure youth and families referred to FSPT meet the eligibility criteria;

3. Notify the referral source within 48 hours of the receipt of the referral, advise the referral

source of acceptance or denial due to FSPT eligibility criteria and the date and time of the

next FSPT staffing;

4. Collect and file a completed referral packet for each youth which includes a completed FSPT

application and exchange of information forms (See Appendix D), and any supportive

documentation validating the need for non‐traditional therapeutic services being requested;

5. Schedule FSPT meetings to staff cases referred to FSPT and submit the CFS/FSPT agenda to

LSFHS at [email protected] one week prior to the staffing date;

6. Coordinate FSPT staffings which includes ensuring that all parties involved with the child

have been invited (i.e. legal guardians, school system representatives, insurance

representatives, Department of Juvenile Justice representatives, agency providers, etc.);

7. Develop relationships and work collaboratively with agency providers which includes

fostering communication between case managers, care coordinators and school personnel;

8. Facilitate the FSPT staffing with the goal of identifying non‐traditional therapeutic services in

accordance to youth and family preferences;

9. Assess appropriateness for youth and families to benefit from non‐traditional therapeutic

services during FSPT meetings.

10. Communicate the POS review and approval process to youth and families;

11. If it is determined that the youth would benefit from services within the community and the

service is not covered by a Third Party Liability (TPL) or reimbursable by another payor source,

the FSPT Chairperson from each circuit will submit both the FSPT application and the POS

request form (See Appendix E) to the Clinical Care Support Specialist at LSFHS. The information

must be emailed to the LSFHS encrypted email: [email protected];

12. The POS form must be completed in its entirety and provide a clinical justification for the

requested POS service;



13. Services that may be requested include but are not limited to: therapeutic friend/life coach,

parent education, outpatient counseling, psychiatric services, behavioral analysts,

psychological assessments (for mental health purposes only), psychosexual assessments,

tutoring, therapeutic camps, respite and extracurricular activities;

14. LSFHS will monitor the email daily for any POS requests. LSFHS will review and either approve

or deny the request. If the POS is denied LSFHS will complete the section with justification for

the denial and forward the POS in an encrypted email and send back to the FSPT Chairperson

requesting the services;

15. Any POS request in excess of $1,000 will require dual signatures, (of both the clinical care

support specialist and the Director of Program Operations or above) for authorization. All

requests under $1,000 will only require the signature of the clinical care support specialist

for authorization.

16. Reasons to deny a POS include but are not limited to: incomplete FSPT application, incomplete

POS request, TPL covers the service being requested, lack of therapeutic justification for how

the service will benefit the client, a non‐community child such as a foster care child or under

DCF supervision with CBC oversight, a non‐behavioral primary health diagnosis such as autism,

pervasive developmental delay, non‐emotional or non‐behavioral based developmental

disability or an IQ below 70 (consumers with an IQ less than 70 will be considered on a case by

case basis);

17. It is the Network Service Providers’ responsibility to ensure adequate resources to fund

approved POS requests;

18. Original invoices are to be maintained in the Network Service Providers’ records for audit

purposes;

19. The Network Service Provider shall keep a current list of proposed vendors and rates for

services to be utilized during the POS process that can be provided at any time upon

request. The Network Service Provider will exhaust all other funding sources for treatment

first before requesting funds from the Managing Entity;

20. The Network Service Provider shall staff youth and families receiving non‐traditional services

funded through the POS process bimonthly to assess progress and appropriateness of

services; and

21. Complete the FSPT/CFS Staffing Form (See Appendix B) by indicating individuals that

participated in the FSPT, staffing notes and recommended services.

CFS Program Requirements

The Network Service Provider shall schedule and facilitate CFS as appropriate. The Network Service

Provider shall:

1. Refer youth to CFS who have documented exhaustion of all least restrictive community

services and have a recommendation for residential treatment by a physician;

2. Request and review clinical documentation from community service providers (i.e.

psychological, psychiatric evaluations, treatment plans, treatment plan reviews, discharge



summaries etc.). This is in an effort to ensure that the SIPP packet (See Appendix G) is

complete utilizing the SIPP Packet Checklist (See Appendix F);

3. Has been assessed and diagnosed as being emotionally disturbed by a psychiatrist or clinical

psychologist who has specialty training and experience with children, per s. 394.4781, F.S.,

and who meet the following criteria, per Chapters 65E‐9 and 65E‐10, F.A.C.:

a. Be under the age of 18;

b. Currently assessed (within 90 days prior to placement) by a psychologist or a psychiatrist

licensed to practice in the State of Florida, with experience or training in children’s

disorders; who attests, in writing, that:

i. The child has an emotional disturbance as defined in Section 394.492(5), F.S., or

a serious emotional disturbance as defined in Section 394.492(6), F.S.;

ii. The emotional disturbance or serious emotional disturbance requires treatment

in a residential treatment setting;

iii. A less restrictive setting than residential treatment is not available or clinically

recommended;

iv. The treatment provided in the residential treatment setting is reasonably likely

to resolve the child’s presenting problems as identified by the psychiatrist or

psychologist; and

v. The nature, purpose, and expected length of treatment have been explained to

the child and the child’s parent or guardian.

c. Have been reviewed a minimum by the CFS team and been presented with all available

options for treatment.

4. Schedule a CFS staffing, submit agenda at least one week prior to the scheduled CFS and

submit clinical documentation (See Appendix A) to LSFHS at [email protected]

prior to the staffing date;

5. Ensure a copy of the completed SIPP packet is forwarded to the appropriate AHCA or

Managed Care Organization representative with notification of the scheduled staffing;

6. Coordinate CFS staffing which includes ensuring that all parties involved with the child have

been invited (i.e. legal guardians, school system representatives, insurance representatives,

Department of Juvenile Justice representatives, agency providers, etc.);

7. During the CFS staffing, the Network Service Provider shall inform the parent, guardian, or

family member(s) of the availability of SIPP treatment programs, provide information

regarding how to request a tour of the available facilities and the Managed Care

Organization shall update the guardian of the medical necessity determination;

8. Complete the FSPT/CFS Staffing Form (Appendix B) by indicating individuals that

participated in the CFS and staffing notes. FSPT/CFS Staffing Forms are to be maintained in

the Network Service Providers’ records for audit purposes;

9. Forward the completed SIPP packet to the identified SIPP provider for determination of

appropriateness. Upon approval, the SIPP provider will contact the referring provider, the

managing entity, Network Service Provider, or legal guardian to advise, schedule and

coordinate the residential treatment admission;



10. In the event a legal guardian chooses to waive a CFS, the Network Service Provider shall

submit the completed SIPP packet to LSFHS at [email protected] along with the

CFS waiver form (Appendix J.) This should be done prior to sending the packet to SIPP

providers;

11. While youth is in residential placement, staff youth 11 or older at least every 90 days and

youth 10 or under at least every 30 days;

12. Ensure case managers complete the CFS Review Report (See Appendix H) to be presented at

the CFS staffing. This information should be kept in the consumer file; and

13. Ensure recommended services are in place when a youth is discharged from residential

treatment.

Funding and Allocations

In order to appropriately serve children in accordance with the provisions contained herein, the

following allocations must be made to the contract award for this program:

Incidental Expenditures for Purchase of Services for Enrolled Clients: 35%

Intervention Services for Specific, Identified Clients: 35%

Information and Referral Services: 30%

Providers may elect to designate up to 10% of total contract award to Recovery Support services by

reducing the allocation to Incidental Expenditures for Purchase of Services for Enrolled Clients with prior

approval from LSF Health Systems.

Reports and Performance Measures

The Network Service Provider shall submit the Monthly FSPT Tracking Report by the 10th of each month

using Appendix C, detailing the services provided for the previous month. The Network Service Provider

shall submit the Quarterly FSPT Tracking Report by the 10th of each quarter using Appendix I, detailing

the outcomes for the quarter. Submit the required reports to LSF at [email protected]. The

Network Service Provider shall attain a minimum of 100 percent of the performance measures identified

below.

1. 65% of youth and families participating in FSPT are diverted from CFS.

a. The numerator is the total number of youth and families diverted from CFS.

b. The denominator is the total number of youth and families participating in FSPT

services.

c. The percentage of youth and families diverted from CFS will be equal to or greater

than 65%.

2. 100% of youth and families that request to have a CFS without participating in the FSPT

process will be successfully diverted back to complete the FSPT process:



a. The numerator is the total number of youth and families requesting a CFS without

participating in the FSPT process that are diverted back to the FSPT process.

b. The denominator is the total number of youth and families requesting a CFS without

having participated in the FSPT process.

c. The percentage of youth and families requesting a CFS without participating in the

FSPT process successfully diverted back to the FSPT process will be equal to 100%.



APPENDIX A

FSPT/CFS AGENDA

Date: Location:

TIME NAME STATUS SCHOOL/PLACEMENT REVIEW/NEW DOB MH CASE MGT. PARENT OTHER

9:00

9:15

9:30

10:00

10:15

10:30

11:00

11:15

11:30

12:00

12:15

12:30

*If you are the Case Manager for a child on this agenda, it is your responsibility to notify the parent, school, and any other parties

involved. Any problems or changes, please call _______



APPENDIX B

Community Service Plan/Notes

FAMILY SERVICE PLANNING TEAM (FSPT)/CHILD AND FAMILY STAFFING (CFS) FORM

STATEMENT OF CONFIDENTIALITY

Date: _________________________________

Client: ________________________________ Client ID:________________________

My signature below indicates that I understand and affirm that all information being release to me under Florida Statue 394.459 is confidential

and will be used for the sole purpose of treatment, education and/or case management for the child identified.

NAME RELATIONSHIP TO CHILD PHONE # SIGNATURE



Client: ________________________________ Client ID: ___________________ Date of Service: __________________

Mental Health Services/TCM/Therapy/Medication Management:

Substance Abuse:

Health:

Educational:

Family/Social Supports:

Activity:

Duration: Staff Signature:



APPENDIX C

FSPT Monthly Tracking Report

Month: _________________________

Circuit: _________________________

Please identify the number of Consumer staffed through the Family Services Planning Team this month:

_________

Of those staffed, how many Purchase of Service (POS) requests were completed?

_________

How many consumers were referred to other non‐LSFHS funded community services or resources?

_________

How many consumers were referred to CFS this month that were redirected to FSPT?

_________

Please identify the number of consumers staffed through Child and Family Staffings this month. Please

specify new referrals versus youth currently placed in SIPP:

_________

Please identify below any consumers by name that were staffed through FSPT that will require a referral

to CFS:

Submitted by: ___________________________________Agency:_____________________________



APPENDIX D

Family Services Planning Team‐FSPT Application

Date Application Completed By

Child’s Name DOB Age County

SS # Insurance Financial Information

Parent/Guardian Relationship to Client

Address City Zip

Phone – Home Work Cell

Email Address Emergency Contact Phone

Strengths

Challenges

Diagnosis

Medications

History of Abuse/Neglect

Yes No Comments:

Current Agencies Involved

Child Welfare Department of Juvenile Justice Involvement Child Medical Services

Agency For Persons With Disability Other______________________________________

Child was adopted through the state of Florida (not private) Yes No Comments:

Mental Health Assessment(s) Completed Yes No (If yes, please include with application)

Psychological Evaluation Completed Yes No (If yes, please include with application)

Medication Evaluation Completed Yes No (If yes, please include with application)

School

Student ID IQ Grade

Previous and Current Mental Health and Substance Abuse Treatment Providers

Individual Therapy Provider Name: Dates:

Medication Management

Provider Name: Dates:

Family Therapy Provider Name: Dates:

Baker Acts Provider Name: Dates:

Mentoring Services Provider Name: Dates:

Behavioral Therapy Provider Name: Dates:

Day Treatment Provider Name: Dates:

Substance Abuse Treatment

Provider Name: Dates:

Reason for FSPT Referral:



BEHAVIORAL CHECKLIST

Victim of physical abuse Noncompliant behavior

Victim of sexual abuse Runaway

Perpetrator of sexual abuse Damaged property

Socially inappropriate sexual behavior Fire setting

Emotional abuse/neglect Stole property

Verbally threatens suicide Suicidal gesture

Avoids social contact Actual suicidal attempt

Frequently anxious Hurt someone

Frequent nightmares Poor peer relationships

Threatened to hurt someone Bizarre behaviors

Thought disorder/hallucinations Chronic eating disorder

Cruelty to animals Self‐injurious behavior

Frequent bedwetting (in child over five) Pregnancy

Used drugs or alcohol Chronic eating disorder

School suspensions Parental abandonment

Frequently unmanageable behavior Truancy

Significant school behavior/problems

Notes:________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

____________________________________________________________________________________

Within last 6

months

More than

6

months ago

Within last 6

months

More than

6

months ago



INFORMATION RELEASE AUTHORIZATION

BY PARENT/LEGAL GUARDIAN

I hereby authorize the release of all available substance abuse, alcohol abuse, medical, social,

psychological, psychiatric and/or educational information from the records of:

Child

Social Security number

to the Department of Children and Families, Family Service Planning Team (FSPT) and/or Child

and Family Staffing Committee (CFS).

I authorize the Department of Children & Families/Substance Abuse and Mental Health

Program Office, Lutheran Services of Florida Health Systems to release this information to

providers of medical, mental health and substance abuse treatment, the FSPT, the FSPT

Coordinator, the CFS and the CFS Coordinator.

I understand that all of the information transferred in these instances will be considered

confidential and will be made available or used only for professional purposes for one (1)

year. Therefore, I release all agencies involved from any legal liability that may arise from the

transfers of information.

I certify that I am the parent or legal guardian of the above named child, or that I am a

student of majority age, and have the authority to sign this release.

Signature Date

PRINT Name

_______

Witness Date



APPENDIX E REQUEST FOR PURCHASE OF SERVICES

Client Data SSN: County of Residence: Last Name: Primary Insurance: First Name: Legal Custodian’s Name:

Middle Initial: Legal Custodian’s Phone Number:

Gender: Male Female Legal Custodian’s Address:

Date of Birth: Current Mental Health Provider:

Other Services already in place? If yes, which ones? (e.g. outpatient counseling, med mgmt., etc.)

Other funding streams already explored? If yes, which ones?

Part I – Initial Screening – Clinical Eligibility The child meets the following criteria: 1) A current mental health diagnosis. 2) An IQ of 70 or higher. 3) The child is a community child (not in foster care or have DCF/CBC oversight). 4) The child does not meet criteria for Autism/Mental Retardation/Pervasive Developmental Delay. 5) The child would benefit from services not covered by Third Party Liability or reimbursable by another payor source.

Yes

No

Part II – Service Requested Type of Service:

Therapeutic Friend/Life Coach Parent Education

Outpatient Counseling Psychiatric Services

Behavior Analyst Psychosexual

Tutoring Camp Gas Cards Respite

Psychological (mental health purposes only)

Sexual Victim’s Counseling Extracurricular Activities

Other:

Clinical justification on how the requested service will

benefit the client therapeutically:

Estimated Cost of Service: Vendor to Provide Service:

Frequency of Service: Vendor Credentials:

Length of Service: Vendor Telephone No.:

Duration of Service: Vendor Address:

Requestor Data

Form completed by: Date:

FSPT Agency: FSPT Chairperson Name:

FSPT Address: FSPT Telephone No.:

FSPT Fax Number: FSPT Email:

This section to be completed by LSF: (Director signature required ONLY for those purchases in excess of $1000)

The requested services has been: Approved: Denied

Comments:



Client Data SSN: County of Residence: _____________________________________________

Clinical Care Support Specialist ______________________________________________

Date

_____________________________________________

Director of Program Operations ______________________________________________

Date



APPENDIX F SIPP PACKET COMPONENT CHECKLIST

_____ Child and Family Staffing Summary

_____ Admissions Checklist

_____ Magellan Release Form

_____ LSF Paperwork

_____ SIPP recommendation by clinical psychologist/psychiatrist (within the last 3 months)

_____ Current FSPT Application (check that consent is within 1 year

_____ School Psychological (if available) most useful

_____ Passing FCAT scores

_____ Proof that youth has passing school grades (on grade level)

_____ IQ is required.

Clinical Records – purpose is to show that outside services have been exhausted _____ Baker Act discharge reports

_____ Therapy notes/history of attending individual, family counseling

_____ Medication management reports (psychiatrist notes etc.)

_____ Family Preservation Team notes

_____ Behavioral Analyst notes

_____ ANY proof of therapy which has occurred

_____ CFAR(s)

School Records _____ IEP (if ESE student)

_____ Report card

_____ School Social history (if available)

Medical _____ Immunization records

_____Birth Certificate

_____ Medical Stability within 3 months

_____ Physical within three months

_____ Copy of Medicaid card

_____ Dental within the last year



APPENDIX G

SIPP PACKET DOCUMENTS

Family Commitment Involvement Form

A Residential Application has been submitted LSF Health Systems for _____________________for

consideration for a mental health residential treatment. Please check each box to indicate your

agreement with the following:

I have been given information on Residential Treatment and the Child and Family Staffing (CFS) and

understand the process. I may contact the Lutheran Services Florida Managing Entity 904‐900‐1075, for

concerns and additional questions that may arise.

I understand, if and when my child is found eligible for Residential Treatment, my child may not be

placed until LSF Health Systems authorizes an appropriate level of treatment and funding is secured.

While my child is awaiting treatment, I agree to continue working with the Community Mental Health

and Substance Providers to ensure that my child remains as stable as possible until admission to the

treatment facility.

I have completed the financial information form and agree to financially participate in the support of

residential treatment services to the extent of my ability. Services will not be denied based solely on the

inability to pay for services.

I am committed to actively participate in my child’s treatment including family therapy weekly and to

assist my child in achieving his/her treatment goals. I will participate in family therapy in person at least

once a month while my child is receiving treatment at the Residential Treatment Facility. I will also

participate in treatment planning and discharge planning, which includes follow up services (i.e.

medication, mental health and social support services) as recommended. In addition, I will schedule an

appointment with the Children’s Targeted Case Manager for continued services to ensure that my child

remains stable in the community.

I may invite additional people to attend the Child and Family Staffing that have knowledge of my

child, including my child. (My child can attend, but will be asked to participate after the clinical

information has been presented).

This form is to be completed and submitted to the Children’s Targeted Case Manager and LSF Health

Systems or their designee with the Residential Application.

_________________________________________

Name (Please Print)

_________________________________________

Signature Date



Consent to Release Protected Health Information (PHI)

LSF Health Systems

[9428 Baymeadows Rd, Ste 320]

[Jacksonville, FL 32256]

Managing Entity for

Florida Medicaid Statewide Inpatient Psychiatric Programs

Protected Health Information (PHI) means information about your health. Federal and state laws

protect the privacy of your PHI. The laws say we cannot give anyone your child’s PHI unless you say it is

OK. By signing this paper, you give us your OK. We will only give out the PHI that you say we can share.

And, we will only give it to the people or agencies that you list. Do you have questions? We can help.

Call LSF Health Systems at 904‐900‐1075.

Part 1 Who is the patient?

Last Name

First Name

Middle Initial

ID Number (SSN)

Date of Birth (MM/DD/YYYY)

Phone Number (with area code)

Address

City

State

Zip Code

Check One

I am the patient OR

I have the legal right to act for this person. (Check one below; if “other” fill in blank)

I’m his or her: Parent OR Guardian, OR Other

Part 2 Who can give out the PHI?

LSF Health Systems or the designated Network Service Provider may give out your child’s PHI. LSF Health

Systems provides oversight for Florida’s Statewide Inpatient Psychiatric Programs (SIPP).

Part 3 Who can the PHI be given to?

Part 4 What PHI can we share?

LSF Health Systems or the designated Network Service Provider makes a reasonable effort to limit the

use and disclosure of PHI to the minimum necessary to accomplish the intended purpose of the use,

request, or disclosure. We will only share the PHI that you OK. This OK includes facts about your child’s

treatment while receiving services in Florida’s Statewide Inpatient Psychiatric Program (SIPP).

Part 5 When does my OK end?

Your OK will end when you tell us it does. Tell us when you want your OK to end:

My OK ends on this date (It cannot be more than one year from your OK)

OR

My OK ends when this happens:



(It can be something like “you can share my child’s medical records this one time.”) If you do not tell us when your

OK ends then we will end your OK in one year from when you sign. After one year, we will need a new OK.

Part 6 Your Rights and Important Facts

Giving your OK is up to you. You do not have to share your child’s information.

You do not have to OK this paper. You will still get benefits and treatment.

You can take back your OK. You must tell us in writing. Mail it to [9428 Baymeadows Rd, Ste.

320]; [Jacksonville, Florida 32256].

What if you take back your OK? This will not take back the PHI that we have already shared.

But, we will not share any more of your child’s PHI.

If we share your child’s PHI with the people or agencies that you named, they may share it with

others. Not everyone has to follow privacy rules.

You have a right to get a copy of this signed OK. If you need a copy, call LSF at [904‐900‐1075].

If you do not understand, or have questions, we can help. Call LSF at [904‐900‐1075].

Part 7 Signature of Patient

I give my OK to share the information listed in this paper.

Signature or Mark of Patient Date

Part 8 Signature of Authorized Representative (if any)

Authorized Representative means you have legal proof that you can act for this person. A

representative signs for a person who cannot legally sign on his or her own. If the patient is less than 18

years old, a parent or guardian should sign for the minor.

Signature of Person signing on behalf of patient Date

Printed Name:

Address:

Phone:

You should get a copy of this signed paper. Remember, Protected Health Information (PHI) means any

information about your health in the past, present, or future. It includes facts like your child’s address

and date of birth. A full definition of PHI is at 45 CFR §160.103.

NOTICE TO ANYONE OTHER THAN THE PATIENT

This information has been disclosed to you from records the confidentiality of which may be

protected by federal and/or state law. If the records are protected under the federal

regulations on the confidentiality of alcohol and drug abuse patient records (42 CFR Part 2), you

are prohibited from making any further disclosure of this information unless further disclosure

is expressly permitted by the written consent of the person to whom it pertains, or as

otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or



other information is NOT sufficient for this purpose. The federal rules restrict any use of the

information to criminally investigate or prosecute any alcohol or drug abuse patient.



Residential Treatment Application

Today’s Date Date of CFS Request

CFS Denied Yes No Reason Denied

CFS Date(s) FSPT Date(s)

Requested

Program

Statewide Inpatient Psychiatric Program

Residential Treatment Program

Specialized Therapeutic Group Care

Other________________________

Client Name DOB Age County

SS # Medicaid # Private

Insurance


Address City Zip


Email Address Emergency

Contact Phone

Family Service

Counselor Agency

Phone – Office Cell Fax

Email Address

Juvenile Probation

Officer


Email Address

Targeted Case Manager Agency

Phone‐Office Cell Fax

Email Address

Other Provider: Agency


FSPT Documents

Attached Yes No

Brief History of

Presenting Problems

DSM V Diagnosis



Current

Medications

1.

2.

3.

4.

5.

Past Medications

1.

2.

3.

4.

5.

Allergies

Additional

Information about

Medications

History of

Baker Acts

1. Location____________________ Dates____________________________

2. Location____________________ Dates____________________________

3. Location____________________ Dates____________________________

4. Location____________________ Dates____________________________

5. Location____________________ Dates____________________________

Department

of Juvenile

Justice

Involvement

Yes No (If yes, attach DJJ Face Sheet)

Previous and Current Mental Health and Substance Abuse Treatment Providers

Individual Therapy Provider Name: Dates:

Medication

Management Provider Name: Dates:

Family Therapy Provider Name: Dates:

Mentoring Services Provider Name: Dates:

Behavioral Therapy Provider Name: Dates:

Day Treatment Provider Name: Dates:

Substance Abuse

Treatment Provider Name: Dates:

Substances Used By Client:

Other Treatment

Provider Provider Name: Dates:

Treatment That Has Been Successful:

Barriers To Treatment (i.e. transportation, compliance, etc…):



Describe the Child’s Emotional and Behavioral Patterns Where Appropriate

Self‐Destructive

Behaviors

Aggressive

Behaviors

Social and

Emotional

Maladjustment

Arson

Suicidal Attempts,

Gestures, Plan or

Intention

Neglect of Self

Withdrawal or

Isolating Behaviors

Impaired Self

Control or Risk

Taking Behaviors

Sexual Acting Out

Behaviors

Hallucinations or

Delusions

Disruptive Behaviors

Running Away or

Truancy Behaviors

Substance Abuse



Residential Treatment Application Checklist Use this three‐step checklist to guide you in completing the residential treatment application. Once you

have checked all the boxes and attached the necessary documents the application is complete. Please

return the checklist with your application and supporting documentation.

The Substance Abuse and Mental Health Program Office (LSF Health Systems or designee) will review all

applications for completeness within 72 hours of receipt (provided staff availability). Every family will be

offered a Child and Family Staffing when Residential Treatment is being considered for their child. In

some instances this staffing may be optional. It is the Program Offices goal to access residential

treatment for eligible children in the most timely and efficient manner.

STEP 1

An assessment completed by a licensed psychologist or psychiatrist that must include:

The child has an emotional disturbance as defined in Section 394.492(5), F.S., or a

serious emotional disturbance as defined in Section 394.492(6), F.S.;

The emotional disturbance or serious emotional disturbance requires treatment in a

residential treatment center; please specify Statewide Inpatient Psychiatric Program for

Medicaid funded/eligible children or Residential Treatment Center for Non‐Medicaid

funded children or Specialized Therapeutic Group Care,

All available treatment that is less restrictive than residential treatment has been

considered or is unavailable;

The treatment provided in the residential treatment center is reasonably likely to

resolve the child’s presenting problems as identified by the licensed psychologist or

psychiatrist;

The treatment facility is qualified by staff, program and equipment to give the care and

treatment required by the child’s condition, age, and cognitive ability;

The child is under the age of 18; and

The nature, purpose and expected length of the treatment has been explained to the

child and the child’s parent or guardian.

STEP 2

FSPT/CFS Packet and Initial CFS Report

Clinical Records (Psychiatric and/or Psychological evaluations will be required)

Psychiatric Evaluation with recommendation completed within the last year (must include

information listed in Step 1)

Psychological Evaluation (including full scale IQ) with recommendation completed in the last year or

most recent School Psychological Evaluation, if child is under ESE Classification other performance

factors may help identify a child’s intellectual capacity.

Psychosocial Evaluation, if applicable



Previous Clinical Information (i.e., admission reports, evaluations, discharge summaries) from Baker

Acts, Residential & Inpatient Admissions, Partial Hospitalizations, Outpatient Treatment, etc.

Psychiatric Notes/Medication Log

Baker Act Reports (Admission, Discharge, History and Physical)

Previous Residential Information

Foster Care Only for SIPP (plus above documents, if applicable):

Suitability Assessment

Comprehensive Assessment

Court Order for residential care

Court Order for medications

Medical & School Records

Birth Certificate

Immunization Records

Medical Stability or Medical Clearance ‐ Physical within last 90 days

IEP, if in Special Education (ESE Classification) or last Report Card, if Regular Education

Dental Records

Court Ordered Custody/Adoption

Financial Worksheet (NON Medicaid Children & Medicaid Children recommended for RTC or STGH)

Family Involvement Commitment Letter and the Lutheran Services Consent Form

STEP 3

Complete Part 1, Part 2 and Gather & Include All the Clinical, Medical, Educational & Financial

Information listed in the Checklist Section of this application.

PACKET/DOCUMENTS CONFIDENTIAL SUBMISSION OPTIONS

Deliver or mail two (2) copies of the completed packet to Children’s Services at LSF Health Systems:

9428 Baymeadows Rd., Ste. 320; Jacksonville, FL 32256 (preferred method). You may also contact LSF

Health Systems at [email protected] to send the scanned application to a secure, encrypted

e‐mail account. Please note, often times large packets faxed to the office are not faxed in their entirety

due to pages sticking together, or the fax running out of paper, faxed copies also tend to be harder to

read. (Confidential ‐ Please call the Program Office at 904‐900‐1075 when documents are faxed so staff

may insure receipt)

Forwarded to__________________________________________

Packet reviewed by: _______________________________

Provider: ________________________________________

Date: ___________________________________________



DO NOT FORWARD PACKETS TO THE RESIDENTIAL TREAMENT PROVIDER. THEY WILL ONLY ACCEPT

PACKETS FROM THE SAMH MANAGING ENTITY CONTRACTED PROVIDER

If your child has been ACCEPTED, you will be NOTIFIED of the admission date or in some cases, that your child

has been placed on the Northeast Region (Circuits 4,7, 3,8, and 5) waitlist for admission.

If your child has been DENIED by the SIPP or Magellan, you will be NOTIFIED and informed how to appeal the

decision and/or the Grievance Procedures, which ever applies to your situation.

For questions, contact LSF Health Systems and ask for the Children’s Mental Health Specialist at (904)900‐1075.



Sliding Fee Scale Assessment For Placement In Residential Treatment Facilities

Florida Administrative Code 65E‐14.018 requires all state contracted agencies “develop a sliding scale fee that

applies to persons for services that are paid for by state, federal, or local matching funds who have an annual

gross family income at or above 150 percent of the Federal Poverty Income Guidelines.”

Date: __________ Client’s Name: _________________________________DOB:____________

Client’s SS#:_____________________ LSFHS/CFS Approval Date: __________________________

Parent/Guardian Name: _______________________________________________________

Case Manager’s Name: ________________Case Management Agency: __________________

Name of person completing this form: ____________________________________________

Current Family Income: Please include all adult family members’ income, consisting of part‐time and/or full‐

time employment, unemployment compensation, SSI benefits, etc. Income from sources such as seasonal type

work or other work of less than 12 months duration, commissions, overtime, bonuses and unemployment

compensation shall be computed as the estimated annual amount of such income for the ensuing 12 months.

Historical data based on the past 12 months may be used if a determination of expected income cannot logically

be made.

Worksheet for each adult family member (Use additional sheets if necessary)

Total Annual Family Income $_________________________

Number of Adult Persons in the Household__________________

Number of Children in the Household______________________

Monthly Contribution: Guardian Signature: _ Date: _

A. HOURLY WAGE $ A. HOURLY WAGE $

B. WEEKLY WAGE $ B. WEEKLY WAGE $

C. BI‐WEEKLY $ C. BI‐WEEKLY $

D. MONTHLY WAGE $ D. MONTHLY WAGE $

E. ANNUAL WAGE $ E. ANNUAL WAGE $

F. SSI BENEFITS $ F. SSI BENEFITS $

G. UNEMPLOYMENT $ G. UNEMPLOYMENT $

H. OTHER $ H. OTHER



Table 1

The 2016 Poverty Guidelines for the 48 Contiguous States and the District of Columbia

Table 2

Persons in the family Poverty guideline

1 $11,880

2 $16,020

3 $20,160

4 $24,300

5 $28,440

6 $32,580

7 $36,730

8 $40,890

For families with more than 8 persons, add $4,160 for

each additional person.

Federal

Poverty Guideline

Discount Co‐Pay Amount Federal

Poverty Guideline

Discount Co‐Pay Amount

0%‐150% Co‐pay $ 2.00 per day 225%‐240% 56% $______ per day

150%‐165% 96% $____ per day 240%‐255% 39% $______ per day

165%‐180% 94% $____ per day 255%‐270% 19% $______ per day

180%‐195% 89% $____ per day 270%‐285% 10% $______ per day

195%‐210% 81% $____ per day 285%‐300% 5% $______ per day

210%‐225% 70% $____ per day 300% and above 0% $______ per day

*The total negotiated charges to a client shall not exceed 5% gross household income



Sample:

Step 1) Take the amount of your family’s gross yearly earnings.

2) Use the number of persons in the family (household Ex: 1, 2, 3, 4 etc.), move to the right of

Table 2 and get the poverty guideline amount.

3) Divide the gross income by the poverty guideline amount.

4) When you get the answer, move the decimal over two places. This will be a percentage

5) Look up the percentage from step 4, on table 1. Move to the right on table 1 to see the

discounted amount. (ex: 0% thru 96%)

6) The discounted amount is adjusted off of the per day fee of residential treatment.

*Gross income: 40,000.00

*Persons in household 3, look at Table 2 and find the number of persons in household. Scan to

the right and find the amount in the poverty guidelines.

*Table 2, Poverty Guidelines amount. 20,160.00

*Divide, the gross income by Table 2 1.984

by the Poverty guidelines amount.

*Move decimal two places to the right. 198.4%

*Look up the % on Table1 (discount). 81%

*The Residential Daily rate maybe. $430.00

*Apply the 81% discount. $81.70

The family co‐pay amount is: $81.70 per day or $2532.70 per 31 day

month. Place this number in the monthly contribution space on page 1.

Please note: Prior to placement in a residential treatment you may be asked to show proof of earnings.



MEDICAL STABILITY STATEMENT FOR RESIDENTIAL TREATMENT

SERVICES Date:

PATIENT (PRINT): COUNTY: LAST FIRST

Date of Birth: ‐ ‐ Social Security #: ‐ ‐

I, , have examined the

above patient on (Date) and have determined

that he or she is currently in good physical health. At this time, this patient has no

acute or chronic conditions that will require extensive medical treatment and the

need for medical care other than routine.

Physician Signature Date

ATTACHACOPYOFTHEPHYSICALEXAMINATIONTHATHASBEENDONEWITHINTHELAST90DAYS………………..……………………………...

INTERNAL USE ONLY Residential Facility:

The attending Psychiatrist reviewed the above statement and the supporting documents.

Physician Signature Date



APPENDIX H

CFS Review Report

Today’s Date Report Completed By

Date of Last CFS

(either initial/review)

Previous CFS

Recommendations/

Status

Current Placement

(include date of

admission)

Client Name DOB Age County

SS # Medicaid # Private

Insurance


Address City Zip


Email Address Emergency

Contact Phone

Family Service

Counselor Agency


Email Address

Juvenile Probation

Officer


Email Address

Case Manager Agency


Email Address

Other Provider: Agency


Presenting Issues

Current DSM V

Diagnosis

Medication (response,

side effects, change in

medications)

Discharge Plan

Anticipated

Discharge Date



Mental Health Treatment Goal Update

(Complete the following or attach an updated treatment plan review)

Status Rate Key: 1‐Goal Reached 2‐Progression 3‐No Change 4‐Regression

Goal 1

Status Rate # Comments:

Goal 2


Goal 3


Brief Summary of

Client’s Progress in

Treatment Since the

Last CFS



APPENDIX I


QUARTERLY PROGRESS REPORT

Provider Name

Circuit

Reporting Period From To

Reporting Requirement Annual Target This Quarter Year to Date

The percentage of

youth/families in FSPT that are

diverted from CFS.

65%

The percentage of

youth/families that request to

have a CFS without participating

in the FSPT process that are

successfully diverted to

complete the FSPT process.

100%

ATTESTATION

I hereby attest the information provided herein is accurate, reflects services provided in

accordance with the terms and conditions of this contract, and is supported by client

documentation records maintained by this agency.

Authorized Name, Title,

and Agency Name

(please print)



APPENDIX J

Child Family Staffing Waiver

I, _____________________________, (parent/legal guardian) of child _______________________,

DOB____________________, am requesting to waive the child and family staffing for my child. I

understand that waiving the Child and Family Staffing means my child’s case will not be reviewed by an

interdisciplinary team of mental health professionals for the purpose of care coordination. I understand

that waiving the Child and Family Staffing has no bearing on whether or not my insurance will cover my

child’s treatment.

I understand that this waiver is applicable only to inpatient residential treatment and those applicants for

therapeutic group homes, must complete a child and family staffing prior to placement.

_________________________________________ ___________________ Signature of Parent/Legal Guardian Date: _________________________________________ ___________________ Signature of FSPT/CFS Coordinator Date: _________________________________________ ___________________ Signature of LSFHS Representative Date:



FSPT/CFS Process Flow Chart

Consumer/family seeks FSPT services: FSPT application and consents signed.

Consumer is staffed at FSPT for non‐traditional therapeutic services. FSPT staffing notes are completed.

FSPT provider notifies the referral source within 48 hours of the receipt of the referral, notify the referral source of

acceptance/denial due to FSPT eligibility criteria and the date/time of the next FSPT staffing.

Request for Purchase of Services Form is submitted to LSFHS for approval.

Y N

Consumer/family referred to community based

services that may be covered by another funder.

Once LSFHS approves POS request; the FSPT provider funds

the approved services

Is consumer responding positively to community‐based treatment programs?

Y N

Consumer is staffed in FSPT bimonthly to

assess progress.

Consumer is staffed in FSPT bimonthly to assess additional

therapeutic services that may benefit the consumer.

Consumer progresses and is stabilized

through community based services.

Y

Case Closed

A SIPP packet is compiled by the case manager/legal

guardian as appropriate.

Consumer is staffed at CFS and the SIPP packet is reviewed utilizing the SIPP packet checklist

by the FSPT provider. Forward the completed SIPP packet to the identified SIPP provider for

determination of appropriateness. Upon approval, the residential treatment admission is

scheduled and conducted.

Staff youth 11 or older at least every 90 days while in residential placement and for

youth 10 or under, youth will be staffed monthly through the CFS process.

N

FSPT providers ensure recommended services are in place when a youth is discharged from residential treatment.

APPENDIX B: FORMS

Exhibit C ‐ Projected Operating and Capital Budget Exhibit D ‐ Personnel Detail Report

Exhibit C

AGENCY Date

CONTRACT # Fiscal Year

PART I: PROJECTED FUNDING SOURCES & REVENUES

FUNDING SOURCES & REVENUES DCFOther Funding

SourceOther Funding

SourceOther Funding

SourceOther Funding

SourceOther Funding

SourceOther Funding

SourceOther Funding

SourceTotal Revenue

IA. STATE SAMH FUNDING (1) Management, Oversight and Administration $ $0 (2) Services Revenue $ $0IB. OTHER GOVT. FUNDING (1) Other State Agency Funding $ $ $ $ $ $ $ $0 (2) Medicaid $ $ $ $ $ $ $ $0 (3) Local Government $ $ $ $ $ $ $ $0 (4) Federal Grants and Contracts $ $ $ $ $ $ $ $0 (5) In-kind from local govt. only $ $ $ $ $ $ $ $0

TOTAL GOVERNMENT FUNDING = $0 $0 $0 $0 $0 $0 $0 $0 $0 ========== ========== ========== ========== ========== ========== ========== ========== ==========

IC. ALL OTHER REVENUES (1) 1st & 2nd Party Payments -$ -$ -$ -$ -$ -$ -$ $0 (2) 3rd Party Payments (except Medicare) -$ -$ -$ -$ -$ -$ -$ $0 (3) Medicare -$ -$ -$ -$ -$ -$ -$ $0 (4) Contributions and Donations -$ -$ -$ -$ -$ -$ -$ $0 (5) Other Grants and Contracts -$ -$ -$ -$ -$ -$ -$ $0 (6) In-kind -$ -$ -$ -$ -$ -$ -$ $0

TOTAL ALL OTHER REVENUES = $0 $0 $0 $0 $0 $0 $0 $0 $0TOTAL PROJECTED FUNDING = $0 $0 $0 $0 $0 $0 $0 $0 $0

`

SAMH PROJECTED OPERATING AND CAPITAL BUDGET

Page 1 Revised 07.01.2016

Exhibit C

EXPENSE CATEGORIES DCFOther Funding

SourceOther Funding

SourceOther Funding

SourceOther Funding

SourceOther Funding

SourceOther Funding

SourceOther Funding

SourceTotal Expenses

IIA. PERSONNEL EXPENSES (1) Salaries -$ -$ -$ -$ -$ -$ -$ -$ $0

(2) Fringe Benefits -$ -$ -$ -$ -$ -$ -$ -$ $0

TOTAL PERSONNEL EXPENSES = $0 $0 $0 $0 $ $0 $0 $0 $0========== ========== ========== ========== ========== ========== ========== ========== ==========

IIB. OTHER EXPENSES (1) Building Occupancy $0

(2) Professional Services $0

(3) Travel $0

(4) Equipment $0

(5) Food Services $0

(6) Medical and Pharmacy $0

(7) Subcontracted Services $0

(8) Insurance $0

(9) Interest Paid $0

(10) Operating Supplies & Expenses $0

(11) Donated Items $0

(12) Other Expense $0

TOTAL OTHER EXPENSES = $0 $0 $0 $0 $0 $0 $0 $0 $0========== ========== ========== ========== ========== ========== ========== ========== ==========

TOTAL PERSONNEL & OTHER EXPENSES = $0 $0 $0 $0 #VALUE! $0 $0 $0 $0========== ========== ========== ========== ========== ========== ========== ========== ==========

IIC. DISTRIBUTED INDIRECT COSTS (a) Other Support Costs (Optional) $ $ $ $ $ $ $ $ $0

(b) Administration $ $ $ $ $ $ $ $ $0TOTAL DISTRIBUTED INDIRECT COSTS = $0 $0 $0 $0 $0 $0 $0 $0 $0

========== ========== ========== ========== ========== ========== ========== ========== ==========TOTAL ALLOWABLE OPERATING EXPENSES = $0 $0 $0 $0 #VALUE! $0 $0 $0 $0

========== ========== ========== ========== ========== ========== ========== ========== ==========IID. UNALLOWABLE COSTS $ $ $ $ $ $ $ $ $0

========== ========== ========== ========== ========== ========== ========== ========== ==========IIE. CAPITAL EXPENDITURES $ $ $ $ $ $ $ $ $0

========== ========== ========== ========== ========== ========== ========== ========== ==========

TOTAL PROJECTED OPERATING EXPENSES = $0 $0 $0 $0 #VALUE! $0 $0 $0 $0

IIG. BUDGET NARRATIVE (attach separate set of workpapers)

PART III: CERTIFICATIONI certify the above to be an accurate projection and in agreement with this agency's records and with the terms of this agency's contract.

Signature Title Date


Exhibit D

AGENCY DATE

# of Annual % of # ofFTE Salary Cost Time FTE Salary

1 0.00 $0

2 0.00 $0

3 0.00 $0

4 0.00 $0

5 0.00 $0

6 0.00 $0

7 0.00 $0

8 0.00 $0

9 0.00 $0

10 0.00 $0

11 0.00 $0

12 0.00 $0

13 0.00 $0

14 0.00 $0

15 0.00 $0

16 0.00 $0

17 0.00 $0

18 0.00 $0

19 0.00 $0

20 0.00 $0

21 0.00 $0

22 0.00 $0

23 0.00 $0

24 0.00 $0

25 0.00 $0

26 0.00 $0

27 0.00 $0

28 0.00 $0

29 0.00 $0

30 0.00 $0

Totals 0.0 $0 0.00 $0

Total Agency DCF ME Contract

POSITION TITLE / NUMBER

SAMH PROJECTED OPERATING AND CAPITAL BUDGET PERSONNEL DETAIL
