Encumbrance CT 10A 20160613*4140
DHHS Agreement CFS-17-8601
Vendor/Customer VC1000017773

STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Agreement to Purchase Services

THIS AGREEMENT, made this if day of July, 2016 is by and between the State of Maine, Department of
Health and Human Services, hereinafter called ?Department,? and Community Concepts, Inc. located at 240
Bates Street, Lewiston, ME 04240, hereinafter called ?Provider,? for the period of July 1, 2016 to June 30,
2018.

 

WITNESSETH, that for and in consideration of the payments and agreements hereinafter mentioned, to be
made and performed by the Department, the Provider hereby agrees with the Department to furnish all
qualified personnel, facilities, materials and services and in consultation with the Department, to perform the
services, study or projects described in Rider A, and under the terms of this Agreement.

The following Riders and Attachments are hereby incorporated into this Agreement and made part of it by
reference:

Rider A - Specifications of Work to be Performed
Rider - Payment and Other Provisions
Rider - Additional Requirements
Rider - F-1 Agreement Settlement Form, F-2 Agreement Compliance Form
Rider - Identification of Country In Which Contracted Work Will Be Performed
Rider - Assurance of Compliance
Rider - Exceptions
Appendix A - UNCOPE Tool
Appendix - Activities for Continued Assessment and Developing the Family Plan

IN WITNESS WHEREOF, the Department and the Provider, by their representatives duly authorized, have
executed this agreement in gas original copy.

DEPARTMENT OF HUMAN SERVICES
sf?

 
 

By: .,

Alexander Porteous, Deputy CommISSIoner of Finance
And
COMMUNITY CONCEPTS, INC.

By:

 

Walter Riseman, Executive Director

Total Agreement Amount: $1,220,600.00

Approved:

 

Chair, State Purchases Review Committee

DCM Agreement Administrator: Robert Burman
Provider Contact i e-mail: Colleen 

RIDER A
SPECIFICATIONS OF WORK TO BE PERFORMED

TABLE OF CONTENTS

DEFINITIONS 1

3

IV. DELIVERABLES 4

V. PERFORMANCE MEASURES 8

VI. REPORTS 9

DEFINITIONS

A. Advanced Practice Registered Nurse?PMH-Clinical Nurse Specialist (APRN-PMH-CNS): As
defined in 32 M.R.S.A. 

B. Advanced Practice Registered Nurse-PMH --Nurse Practitioner (APRN-PMH-NP): As defined in
32 M.R.S.A. 

C. Alternate Response Program (ARP): Provides community-based intervention services or
coordinate these services to families who are considered to be at a low?moderate level of risk for
child abuse/neglect. The services are designed to reduce the risk of child abuse or neglect utilizing
case management, counseling, Substance Abuse treatment and parenting education.

D. Certified Social Worker Independent Practice (CSQ-IP): As defined in 32 M.R.S.A. 7001-A


E. Child Protective Services (CPS) Report: A report made regarding suspected child abuse/neglect
to either a child protective worker or their Intake Department.

F. Domestic Violence: As defined in WA M.R.S.A. 207-A, 209-A, 21 0-8, 210-C, 211-A.

G. Eligible Families:

1. Families who have been reported to the Department with allegations of Low/Moderate Severity
child abuse or neglect by the parent/caregiver;

2. Families who received and completed the Department child protective assessment, in which
Low/Moderate Severity of child abuse or neglect by the parent/caregiver has been found. in
addition, the parents have the capacity and willingness to make changes that will enable them to
care for and protect their children;

3. Families who received and completed the Department child protective assessment and no

maltreatment was found; however, the Department is concerned for the Safety and well-being of
the children due to significant risk factors being present;

4. Child protective service cases for which the Department has facilitated a Family Plan, the risk to
the children in the household has been reduced and the family is cooperating with adherence to
the Family Plan;

5. Families with a recently born baby that is reported by medical providers because of a suspicion
that the baby has been affected by prenatal drug exposure.

Rider A, Page 1 Version DHHS 2017.FFS.1

H. Family Plan: Developed during the Family Team Meeting (FTM) to determine what steps are
necessary to meet the needs for child Safety, who is responsible for completing the steps, and
timeframes for meeting goals. This is created based on the needs and of the family and
includes Safety goals. See Appendix B.

I. Family Team Meeting (FTM): When the service providerjoins with families, their Informal Supports
and the community to develop plans and make decisions for the Safety, permanency and well-being
of children. The FTM process should focus on building a unique Safety network for the involved
children that consists of committed lasting supports for the family that continue long after service
provider involvement and closure. The FTM will help to determine how to help the family meet their
needs, as well as how their progress will be measured.

J. Flex Funds: A component of the Alternative Response Program (ARP) that involves the Provider
being able to readily access Department funds, up to $10,000 for the Agreement period, to meet
needs of each participating, Eligible Family. Flex Funds are made immediately accessible to the
Provider to support participating, Eligible Families in meeting needs such as bedding, transportation,
food, housing, safety items, etc. for the family.

K. Formal Supports: Service providers and other professionals who are able to help identify family
and needs, and who are able to help sustain efforts to provide and maintain child Safety.

L. Indian Child Welfare Act of 1978 (IOWA): The federal law that outlines how cases with family
members identified with Native American heritage must be handled. In meeting the intent of this law
the State of Maine?s Child Welfare Services extends these principles throughout all phases of a
case involving family members with Native American heritage. Refer to 25 U.S.C. 1901-1963.

M. Indicated Finding: When facts and evidence gathered during an assessment/investigation support
a decision that a person responsible for a child has, by preponderance, subjected that child to
Low/Moderate Severity of Child Abuse/Neglect.

N. Informal Supports: Family friends, neighbors, extended family members and community members
who are able to help identify family and needs and who are able to help sustain efforts to
provide and maintain child Safety.

0. Intake Department: The section of Child Protective Services that accepts and processes child
abuse/neglect reports.

P. Licensed Clinical Professional Counselor (LCPC): As defined in 32 M.R.S.A. 1385(2).

Q. Licensed Clinical Professional Counselor-Conditional (LCPC-C): As defined in 32 M.R.S.A. 
1385(2) (4).

R. Licensed Clinical Social Worker (LCSW): As defined in 32 M.R.S.A. 7001-A (6).
8. Licensed Marriage and Family Therapist (LMFT): As defined in 32 M.R.S.A. 1385(7).

T. Licensed Marriage and Family Therapist-Conditional (LMFT-C): As defined in 32 M.R.S.A. 
1385(4) (8).

U. Licensed Master Social Worker? Conditional Clinical (LMSW-CC): As defined in 32 M.R.S.A. 
7001-A (7).

Rider A, Page 2 Version DHHS 2017.FFS.1

V.

Licensed Social Worker (LSW): As defined in 32 M.R.S.A. (8).

W. Licensed Social Worker-Conditional (LSW-C): As defined in 32 M.R.S.A. 

X.

Y.

BB.

CC.

DD.

EE.

FF.

GG.

Mandated Reporting: As defined in 22 M.R.S.A. 4012.

Maine Automated Child Welfare Informational System (MACWIS): A system used by the Office
of Child and Family Services (OCFS) to maintain child welfare electronic client case records.

Maine Automated Child Welfare Information System (MACWIS) Recordings: Child Protective
Services (CPS) Reports referred to agencies, prior CPS Reports and assessments, and narrative
logs on specific cases.

Mental Illness: that significantly impair a parent/caregiver?s ability to meet the essential

needs of a child in their care. Examples include:

1. Depression and/or that results in caregiving impairment;

2. Misperception of a child?s abilities due to mental illness that impact the child?s Safety; and/or

3. Misperception of a child?s intentions/behavior in a way that the parent/caregiver has harmed, or
is at risk of harming the child.

Medical Doctor: An individual who met, and continues to meet, the requirements of
32 M.R.S.A. 3271 and thereafter received, and maintains, a license under the seal of the board of
licensure signed by the chair and the secretary of the board of licensure to practice medicine.

As defined in 32 M.R.S.A. 3811(2).

Safe/Safety: A child is Safe when there is no evidence of child abuse and neglect or child abuse
and neglect has occurred, but is unlikely to reoccur, and there are no signs of danger present.
Signs of risk may be present.

Safety Planning: A timely process which involves family members and their Informal Supports and
Formal Supports when possible, that is designed to create, increase or support signs of Safety in
order to control and manage present Signs of Danger and threats of serious harm.

Services Substantially Completed: Families have successfully completed services to
reduce/eliminate the risk of child abuse/neglect.

Severity of Child Abuse/Neglect [LowlModerate or High]: The degree to which a child has been
impacted by maltreatment. The degrees are Low/Moderate or High. Low/Moderate Severity of
Child Abuse/Neglect would include aspects such as a minor physical injury to that child that did not
or would not require medical attention, failure to provide essential food, clothing, shelter, care,
supervision, medical and/or mental health treatment, failure to protect the child from experiencing
low to moderate severity physicai, sexual, emotional abuse and/or neglect caused by another
person that could have been prevented. High Severity of Child Abuse Neglect would include
aspects such as a serious inflicted physical injury to that child that required medical attention
(whether or not medical attention was actually received), failed to provide essential food, clothing,
shelter, care, supervision, medical and/or mental health treatment when that failure caused or was
very likely to cause (threat of) a serious injury, serious illness or serious impairment in the near
future that required or would require treatment, had physical contact with either a child?s breasts,
genitals, buttocks, or other body parts in a sexualized manner or for sexual gratification; or had that
child touch himiherself or anyone else in a sexualized manner; or forces or encourages a child to
view either adult or child pornography. A high severity physical abuse, neglect, sexual abuse or

Rider A, Page 3 Version DHHS 2017.FFS.1

emotional abuse findings are based on the identification of a Sign of Danger supported by an
analysis of available information and/or a lack of parental protective capacity.

HH. Significant Risk: When a family in which a child is five (5) years old or younger presents at least
one (1) of the following risk factors and the risk has an impact on child Safety: Domestic Violence,
parental Substance Abuse, unmanaged parental Mental illness, maternal depression or multiple
unrelated caregivers.

ll. Signs of Danger: Very serious parental behaviors, conditions and child or family circumstances
that either have caused or very soon could cause High Severity Child Abuse/Neglect. When they
are present, Signs of Danger require prompt consultation with the Department staff and/or referral to
the Intake Department.

JJ. Signs of Risk: Negative factors and/or the lack of resources within the family and family
environment that, because they exist, may be or become challenges to achieving and maintaining
child Safety. These factors aiso increase the likelihood of a child experiencing child maltreatment.

KK. Signs of Safety: Positive factors andlor resources within the family and family environment that are
capable of promoting and maintaining child Safety.

LL. Substance Abuse: Substance use that significantly impairs a parent/caregiver?s ability to meet
essential needs, including residential stability and constancy of a caregiving figure for the child in
their care.

MM. Substantiated Finding: When facts and evidence gathered during an assessment/investigation
support a decision that a person responsible for a child has, by preponderance, subjected that chiid
to specific High Severity of Child Abuse/Neglect thus causing the child to be in danger.

NN. Tickler: Internal messages sent through the Maine Automated Child Welfare information System
(MACWIS).

00. Transfer Meeting: Meetings facilitated by a Department Caseworker to discuss a plan, Safety
concerns, expectations, etc. The list of Transfer Meeting attendants should consist of a
minimum of the Department Caseworker, Alternate Response Program (ARP) caseworker, and
client(s).

PP. Unsafe: A child is unsafe when there is evidence of child abuse and neglect and Signs of Danger
(threats of serious harm) are present that cannot be controlled or managed by a family plan.

QQ. UNCOPE Substance Abuse Tool: Consists of six questions found in existing instruments and
assorted research reports. See Appendix A.

INTRODUCTIONIOVERVIEW

This Agreement is for the purpose of providing the Alternate Response Program (ARP), which provides
community-based intervention services to reach the target population of Eligible Families (as described
in the Definitions Section above). ARP supports the Department?s Office of Child and Family Services?
(OCFS) practice model, which focuses on the family?s and needs.

The Provider shall partner with Eiigible Families to provide case management services and to plan for
the Safety, permanency, and well-being of their child(ren).

Rider A, Page 4 Version DHHS 2017.FFS.1

DELIVERABLES

The Provider shall perform all services and maintain all standards and requirements for services
provided under this Agreement in accordance with the below:

A. MaineCare, Private Health Insurance, and Billing

1. Before being provided with services under this Agreement, it shall be determined whether or not
each individual possesses either private health insurance or is a MaineCare Member. If it is
determined that the individual:

a. Is a MaineCare Member, then MaineCare shall be billed for all services provided which
MaineCare will reimburse for.;

b. Is a MaineCare Member with a Medically Needy Deductible, then the Department shall be
billed for all services provided until the Medically Needy Deductible is met. Once the
Medically Needy Deductible has been met then MaineCare shall be billed for all services
provided which MaineCare will reimburse for;

c. Has private health insurance then the individual? 5 health insurance carrier shall be billed for
all portions of ali services provided which the carrier will reimburse for, with the remaining
portions being billed to the Department; or

d. Is neither a MaineCare Member nor has private health insurance, then the Department shall
be 

2. Assistance shall be provided to each individual receiving services in applying for MaineCare
benefits within fourteen (14) days of the date such services are initiated. Retroactive MaineCare
coverage and reimbursement for these services shall be sought and any such retroactive
reimbursements shail be credited to the Agreement funds, according to 10444 C.M.R. ch. 332,
Part 2, 13.4. Agreement funds shall be managed such that individuals receiving services are
not prematurely discharged when the clinical need for the service is still present.

B. Staffing Qualifications/Reduirements

1. Maintain an ARP Supervisor that has:
a. A degree in the human services area (a master?s degree in social work is preferred);
b. One (1) of the following iicenses:
i. Licensed Clinical Professional Counseior 
ii. Licensed Clinical Professional Counselor- Conditional 
Licensed Clinical Social Worker 
iv. Certified Social Worker-Independent Practice 
v. Licensed Master Social Worker? Conditional Clinical 
vi. Licensed Marriage and Family Therapist 
vii. Licensed Marriage and Family Therapist-Conditional 
Advanced Practice Registered Nurse?PMH~Ciinica  Nurse Specialist 
ix. Advanced Practice Registered Nurse-PMH ?Nurse Practitioner 
x. Medical Doctor; or
xi. 
c. Field experience working with multi?problem families; and
d. Demonstrated experience in, or potential for, providing supervision to workers who provide
in-home services as well as knowledge of child welfare policies and programs, family

Rider A, Page 5 Version DHHS 2017.FFS.1

therapy theories, treatment philosophies and strategies of home-based services and
knowledge and availability of local resources.

2. Maintain ARP Case Managers that have:

a.
b.

A bachelor degree in the human services area (BSW preferred); and
One (1) of the following licenses:

i. Licensed Social Worker or

ii. Licensed Social Worker-Conditional (LSW-C).

C. Eligibility to Receive Services and Provider Process for Determination to Receive Services

1. Accept all Eligible Family referrals from the Department and from Native American tribal
partners, in cooperation with the Department.

2. Provide an initial assessment for each Department-referred Eligible Family. The assessment
shall include the following:

a.
b.

Review of any available Department and APR history for the referred Eligible Family;
Contacting the Eligible Family to arrange a mutually-convenient time to initiate the
assessment. If the assessment cannot be completed within three (3) calendar days of
receipt of the referral, then the Provider shall determine which resources are likely to have

current information on the location of the family. The Provider shall then consult with

Department staff to search for additional information on current locations where the family is
likely to be found, and when a family cannot be located within thirty-five (35) days of receipt
of the report, the assessment shall be closed as unable to locate. The Provider shall then
notify the Department that they were unable to locate the family and document such in the
Maine Automated Child Welfare Information System (MACWIS) narrative window;

Conduct initial face-to-face contact or make a home visit with the parent/caregiver and
alleged victim within seventy-two (72) hours of receipt of referral to observe the environment.
The date of receipt of the referral is the date of the decision ?Assign to Contract Agency? in
MACWIS. The Provider shall meet individually with all family members. Exceptions must be
documented in MACWIS that demonstrate reasonable diligence, to include correspondence
of attempts to schedule, contact, cancelations, no shows, etc.

Make a decision whether or not a Sign of Danger is present following the initial
parent/caregiver and child interviews. If any Sign of Danger is present, the assessment shall
be immediately returned to the Department. If not, then the Provider?s work with the family
shall be focused on assessing the risk of maltreatment, planning and providing services to
lower the risks and increasing the Eligible Family?s Informal Supports and Formal Supports.
A level of risk for each chiid to experience maltreatment in the future is reached by
considering the Eligible Family?s Signs of Safety, Signs of Risk, and analyzing the
interactions between those Signs of Risk and Signs of Safety to determine the likelihood of
future child maltreatment (low, moderate, or high);

Use the UNCOPE Substance Abuse Tool in all assessments and with all parents and
caregivers in the home. When concerns are raised about the parents and caregivers who
live outside the home, but who have regular contact with or for chiidren who
are the subject of the assessment, the Provider shall also use the UNCOPE Substance
Abuse Tool. A copy of the UNCOPE Substance Abuse Tool resuits shall be in kept in the
Providers client paper files;

Close the assessment if there are no child maltreatment concerns, and/or it has been
determined that there is a low level of risk for each child;

Make additional face-to-face contacts and home visits as necessary to complete the
assessment, engage and partner with the family, help motivate the family to participate in a

Rider A, Page 6 Version DHHS 2017.FFS.1

Family Team Meeting (FTM) for the purpose of developing a Family Plan where they
acknowledge and work together to reduce the risk of child maltreatment;

h. Complete assessments within thirty-five (35) days of the receipt of referral and document all
contacts in MACWIS within ten (10) days after each contact with the family;

i. Engage in Transfer Meetings on post-assessment cases, unless the Provider and the
Department mutually agree that a Transfer Meeting is not necessary;

j. Address the areas to explore and assess, based-on the referral allegations or post-
assessment needs identified; and

k. Abide by the lndian Child Welfare Act of 1978 (IOWA). The Provider shall include the tribe
or band associated with the Eligible Family in their work as equal partners. The tribe or band
must be included in all decisions, such as court recommendations and FTMs. The Provider
must assist tribal partners, as requested by the Department and the tribe. Please see
for more information.

D. Services to be Provided

1. Alternate Response Program (ARP) Supervisor Duties
a. Ensure that an ARP Supervisor is:

i. Supervising all ARP Case Managers and meeting with them at a minimum of every other
week to review and document progress being made by all of the Eligible Families
assigned to the ARP Case Manager;

ii. Assisting all ARP Case Managers in determining the next steps of action for each of the
participating, Eligible Families; and

Supervising all ARP Case Managers to ensure that they are performing ali oftheir
required services (as stated in Section of this Rider).

2. Alternate Response Program (ARP) Case Manager Duties
3. Ensure that all ARP Case Managers perform all services listed within Section 
8: of this Rider.

3. Family Team Meetings (FTMs)

a. Plan and facilitate Family Team Meetings (FTM) and assist Eligible Families in identifying
Formal Supports and Informal Supports, and encouraging their participation, and identifying
individual/family and needs in regards to Signs of Safety, Risk, and Danger. Must
be complete and documented within 35 days of the receipt of the referral.

b. Involve all Eligible Family members in all stages of the case, through the use of
encouragement to participate in meetings and services, motivational interviewing,
identification of barriers to participation and services to remediate barriers.

0. Inform Eligible Families, through the use of verbal and written material, about the
community-based services and resources available that can help meet their needs, to
ensure that parents/caregivers are aware and able to access services when needed as well
as increase use of community resources by families.

d. Refer Eligible Families (as group or individually) to appropriate services such as mental
health services, behavioral services, Substance Abuse services, family preservation
services, etc. based on their risk level.

4. Family Plans
a. Partner with the Eligible Family to continue assessment activities, prepare for a FTM, and to
develop a Family Plan during the FTM once it is determined that the Eligible Family will
participate in in the program.
b. Ensure that the Family Plan follows the format designated in Appendix and is signed by
the child (when appropriate), and Provider staff. The Provider shall

Rider A, Page 7 Version DHHS 2017.FFS.1

$1.0

make copies of the plan available to the family participants either during the FTM or shall
mail them on the day following the FTM. The Provider shall also provide copies to other
participants, no later than seven (7) days after the meeting.

Complete each Family Plan within thirty-five (35) days of receipt of the referral.

Ensure that provision of and/or arrangements for services outlined in the Family Plan occur
within thirty-five (35) days of completion of the Family Plan.

Review the Family Plan every thirty-five (35) days (or sooner if necessary) to assess and
review whether the family is making progress toward the agreed upon goals of the Family
Plan, and modify the Family Plan (if needed) during a FTM to identify additional needs and


Facilitate the coordination of services and activities identified in the Family Plan to ensure
compliance with the Family Plan.

5. Ongoing Services and Assessments

3.

Make individual, face-to-face contact with critical case members, including the child(ren) and
the in-home caregivers, at least throughout the life of the case and make individual,
face-to-face contact with critical case members twice for at least three (3) months in
cases referred where there is Significant Risk of child maltreatment. Exceptions must be
documented that show diligence and/or reasonable explanations for this not occurring, to
include correspondence of attempts to schedule, contact, cancelations, no shows, etc.
Contact service providers as needed for collateral information to include status in services,

- medical appointments, behavioral services, Substance Abuse services, etc.
Demonstrate efforts to engage the family in APR services and document how those efforts
directly relate to the identified needs of the family in terms of child Safety and well-being.
Explore questions as part of the review process as outlined in the Alternative Response
training provided by Department staff.
Report any new allegations of abuse/neglect as a mandated reporter is required to,
according to 22 M.R.S.A. 4012, and also notify the Department via the MACWIS Tickler.
Refer families to additional services such as parent educations, Substance Abuse
counseling, individual counseling, etc, as needed.

6. Case Closing

a.

b.

C.

Notify the Department by the next business day, when a family refuses services. The

preferred method of notification is by telephone or voice mail message

Close all cases no later than four (4) months from receipt of referral, unless an exception is

granted by the Department?s supervisory staff.

Generate a closing summary for each client served by the Provider under this Agreement.

The closing summary shall be entered into MACWIS under the case?s MACWIS number

within seven (7) days of termination of services and shall include the following:

i. Date of closure;

ii. Brief summary of what prompted the Provider?s involvement, what was assessed related
to Safety and risk of child maltreatment, and what risk reduction services/supports were
provided/put in place;

Brief summary of changes that occurred to improve and/or maintain child Safety/well-
being and lower the level of risk;

iv. Family functioning at closing, including Signs of Safety and Signs of Risk;

v. Informal Supports and Formal Supports and how they will continue to help the family;

vi. Resulting level of Safety and risk for each child;
vii. How likely it is for the child to experience maltreatment within the next six (6) months; and
Names, addresses and telephone numbers of all providers of services such as parent
educations, Substance Abuse counseling, individual counseling, etc., to the client (when
known by the Provider) during the term of this Agreement.

Rider A, Page 8 Version DHHS 2017.FFS.1

7. Flex Funds
a. Ensure the proper use of Flex Funds. Flex Funds may be used according to the following:

i. When use of the Flex Funds' Is to purchase concrete goods and services that are vital to
carrying out the Family Plan to reduce risk to children involved in services;

ii. When use of the Flex Funds is reasonable (for example, mental health and medical
needs that cannot be funded in another way, food, household goods, basic living needs,
and respite care); and

When the Flex Funds are used in a way that promotes the Safety, permanency and well-u
being needs of the child and family.

iv. Purchase/incur the itemslexpenses directly and pass the benefits on to the client.

8. Maine Automated Child Welfare Information System (MACWIS)
a. Enter narrative logs in MACWIS regarding all Eligible Family contacts, case openings and
case closings (including a closing summary as described in Section of this Rider).
b. Report any new allegations of abuse/neglect as a mandated reporter is required to,
according to 22 M.R.S.A. 4012, via the MACWIS Tickler and to the District?s Department
Supervisor.
0. Enter a family?s refusal to participate in services into the MACWIS.

Note: Provider staff shall be limited to access of only current client report and history. Abuse
of MA CWIS privileges, including the breaking of con?dentiality by Provider staff, will result in
a review by the Department and may result in the termination of this Agreement; as
determined by the Department. The Department will issue a Secure ID Card and access to
MAC WIS to each of the Provider?s staff for the sole purpose of entering case information into
MACWIS. The Secure ID Card used to access the MACWIS system is to be used only by
the worker whom it was issued to and cannot be shared or used by other employees,
regardless of status. Inappropriate use of the Secure ID Card and the system may
result in disciplinary action against the Provider and/or the offender. Agency/offender-
specific discipline will be executed against users who violate this Policy and will depend on
circumstances and severity of offense. When an employee with a Secure ID Card used to
access the system is terminated, the Provider must notify the Program
Administrator in Rider 8 section 6 no later than two (2) business days after the termination.

9. Cooperation with the Department

a. Provide otherwise confidential mental health record information pursuant to 34-8 M.R.S.A. 


b. Participate in scheduled meetings with the Program Administrator and/or other
Department personnel. The primary purpose of such meetings is to identify and resolve
barriers to in-person contact with all families where reports of child abuse and neglect are
reported to the Department.

V. PERFORMANCE MEASURES

The Provider shall maintain all standards and requirements for services provided under this Agreement
in accordance with the table below:

 

 

COLUMN I: COLUMN ll: COLUMN Ill:

Required Standards Source of Information Exact Data Points from
Name of report, Column ll, Source of
on-site visit, or Information
database)

 

 

 

 

Rider A, Page 9 Version DHHS 2017.FFS.1

 

At least 94.6% of participating
families identified at case closure as
?Services Substantially Completed?
will not have subsequent findings
(Indicated or Substantiated) of child
maltreatment within six (6) months of
closing.

Performance-

Based Report and
Referrals Summary
Repon

Information from the
Performance-
Based Report and
Referrals Summary
Report

 

90% of families with identified
needs, as a result of a completed
assessment, will develop a Family
Plan to meet those needs.

Performance-
Based Report and
Referrals Summary
Repon

Information from the
Performance-
Based Report and
Referrals Summary
Repon

 

80% of families with identified
needs, which have developed a
Family Plan to meet those needs,
will successfully complete services
and be identified at case closure as
?Services Substantially Completed.?

Performance-
Based Report and
Referrals Summary
Repon

Information from the
Performance?
Based Report and
Referrals Summary
Report

 

80% of families referred to the APR

Performance-

lnformation from the
Performance-

assessment).

 

 

D. will accept APR services (open to

Based Report and
Referrals Summary
Repon

Based Report and
Referrals Summary
Report

 

 

 

VI. REPORTS

A. Reguired Reports

The Provider shall track and record
the table below:

all data/information necessary to complete the reports listed in

 

Name of Report or 0n~Site
Visit:

 

Description or Appendix 

 

Performance-Based
Report

Documents the Performance Measure data (as listed in
Section (V) of this Rider) for all cases during this Agreement
pedod

 

2. Referrals Summary Report

Documents the number of referrals received, timeframes,
family contacts and number closed and closure reason

 

3. Flex Funds Expense Report

Documents the status of Flex Funds expenses in relation to
Agreement budget. This report should indicate the family
name, case number, itemized list of purchases, and a brief
summary of why the procurement was made.

 

4. Agreement Closeout Report

 

 

 

Located at: 
2017lindex.html

 

The original copy of the Final Agreement Closeout Report along with a check payable to
Treasurer, State of Maine for any surplus balance must be sent to: DHHS Service Center, 221
State Street 3rd Floor SSC-ACR, Augusta, ME 04333-0011.

B. Reporting Schedule

Rider A, Page 10

Version DHHS 2017.FFS.1

 

 

The Provider shall submit all of the reports listed in the table below to the Department in accordance
with the deadlines established within the table:

 

Name of Report or

 

 

Reporting Period Captured in

 

Due Dates andlor

 

 

 

 

 

 

 

 

0n~Site Visit: Report: Frequency:
.
Forty-five (45) days after the
1. Performance-Based report month
Report
Referrals Summary Forty~five (45) days after the
2' Report report month
Flex Funds Expense Fifteen (15) days after the
3' Report report month
Due sixty (60) days following
4. Agreement Closeout Entire Agreement period the close of the Agreement
Report period

 

 

 

The Provider understands that the reports are due within the timeframes established and that the 
Department will not make subsequent payment installments under this Agreement until such reports
are received, reviewed and accepted.

The Provider further agrees to submit such other data and reports as may be requested by the
Agreement Administrator. The Provider shall submit all data and reports to the Department in
accordance with Section 6 of Rider of this Agreement.

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RIDER 
METHOD OF PAYMENT AND OTHER PROVISIONS

1. AGREEMENT AMOUNT: $1,220,600.00
The sources of funds and compliance requirements for this Agreement follow:

A. State Funds
SFY2017 $610,300.00
SFY2018 $610,300.00

2. INVOICES AND PAYMENT. The Department will pay the Provider twenty-four (24) payments for
the period ending June 30, 2018, upon receipt of approved invoices. These payments will be based
upon actual services delivered at the DHHS approved rate stated in chart below which includes both targeted
case management service and non?targeted case management client expenses (flex per district
served) up to a total of $1,220,600.00. Flex Funds should be expended in a way that maximizes caregivers'
ability to safely provide for their children. The determination of the actual payment will be based on invoices
submitted, which are due on the 15th day of each month. The Provider must submit each invoice,
including the final invoice, no later than forty five (45) days after the test day of the month for which the service
being billed for was performed.

Payments are subject to the Provider's compliance with all items set forth in this Agreement and subject to the
availability of funds. No payment will be made if the Provider does not comply with these terms.

 

 

 

District Rate Units Subtotal Flex Funds Total

3 $435.00 2760 $1,200,600.00 $20,000 $1,220,600.00
(1380 each ($10,000 each 
year) each year) year) each year)

 

 

 

 

 

 

 

3. BENEFITS AND DEDUCTIONS If the Provider is an individual, the Provider understands and agrees
that he/she is an independent contractor for whom no Federal or State Income Tax wili be deducted by the
Department, and for whom no retirement benefits, survivor benefit insurance, group life insurance, vacation
and sick leave, and similar benefits available toState employees will accrue. The Provider further understands
that annual information returns, as required by the Internal Revenue Code or State of Maine Income Tax Law,
will be filed by the State Controller with the Internal Revenue Service and the State of Maine Bureau of
Revenue Services, copies of which will be furnished to the Provider for his/her Income Tax records.

4. INDEPENDENT CAPACITY In the performance of this Agreement, the parties hereto agree that the
Provider, and any agents and employees of the Provider shall act in the capacity of an independent contractor
and not as officers or employees or agents of the State.

5. REPRESENTATIVE The Agreement Administrator shall be the Department's
representative during the period of this Agreement. He/she has authority to curtail services if necessary to
ensure proper execution. He/she shall certify to the Department when payments under the Agreement are due
and the amounts to be paid. He/she shall make decisions on all claims of the Provider, subject to the approval
of the Commissioner of the Department.

6. AGREEMENT ADMINISTRATOR All progress reports, correspondence and related submissions
from the Provider shalt be submitted to:

Name and Title: Robert Burman, Contract Administrator
Address: 221 State Street, 11 SHS

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Augusta ,Maine 04333-0011
Telephone: 207-287-6886
Email Address: Robert.burman@maine.gov

who is designated as the Agreement Administrator on behalf of the Department for this Agreement, except
where specified otherwise in this Agreement.

The following is designated as the Program Administrator for this Agreement and shall be responsible for
oversight of the programmatic aspects of this Agreement.

Name and Title: Lisa Salger
151 Jetport Blvd.

Address; South Portland, Maine 04106
Telephone: (207) 795-4535
E-mail Address: Lisa.Salger@Maine.gov
7. CHANGES IN THE WORK The Department may order changes in the work, the Agreement

 

Amount being adjusted accordingly. Any monetary adjustment or any substantive change in the work shall be
in the form of an amendment, signed by both parties and approved by the State Purchases Review Committee.
Said amendment must be effective prior to execution of the work.

8. SUB-AGREEMENTS Unless provided for in this Agreement, no arrangement shall be made by the
Provider with any other party for furnishing any of the services herein contracted for without the consent and
approval of the Agreement Administrator. Any sub-agreement hereunder entered into subsequent to the
execution of this Agreement must be annotated "approved" by the Agreement Administrator before it is
reimbursable hereunder. This provision will not be taken as requiring the approval of contracts of employment
between the Provider and its employees assigned for services thereunder.

9. SUBLETTING, ASSIGNMENT OR TRANSFER The Provider shall not sublet, sell, transfer, assign
or otherwise dispose of this Agreement or any portion thereof, or of its right, title or interest therein, without
written request to and written consent of the Agreement Administrator. No subcontracts or transfer of
agreement shall in any case release the Provider of its liability under this Agreement.

10. EQUAL EMPLOYMENT OPPORTUNITY During the performance of this Agreement, the Provider
agrees as follows:

a. The Provider shall not discriminate against any employee or applicant for employment
relating to this Agreement because of race, color, religious creed, sex, national origin, ancestry,
age, physical or mental disability, or sexual orientation, unless related to a bona fide
occupational qualification. The Provider shall take affirmative action to ensure that applicants
are employed and employees are treated during employment, without regard to their race, color,
religion, sex, age, national origin, physical or mental disability, or sexual orientation.

Such action shall include but not be limited to the following: employment, upgrading,
demotions, or transfers; recruitment or recruitment advertising; iayoffs or terminations; rates of
pay or other forms of compensation; and selection for training including apprenticeship. The
Provider agrees to post in conspicuous places available to employees and applicants for
employment notices setting forth the provisions of this nondiscrimination clause.

b. The Provider shall, in all solicitations or advertising for employees placed by or on behalf
of the Provider relating to this Agreement, state that all qualified applicants shall receive

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consideration for employment without regard to race, color, religious creed, sex, national origin,
ancestry, age, physical or mental disability, or sexual orientation.

0. The Provider shall send to each labor union or representative of the workers with which
it has a collective bargaining agreement, or other agreement or understanding, whereby it is
furnished with iabor for the performance of this Agreement a notice to be provided by the
contracting agency, advising the said labor union or workers' representative of the Provider?s
commitment under this section and shall post copies of the notice in conspicuous places
available to employees and applicants for employment.

d. The Provider shall inform the contracting Department?s Equal Employment Opportunity
Coordinator of any discrimination complaints brought to an external regulatory body (Maine
Human Rights Commission, EEOC, Office of Civil Rights) against their agency by any individual
as well as any lawsuit regarding alleged discriminatory practice.

e. The Provider shall comply with all aspects of the Americans with Disabilities Act (ADA) in
employment and in the provision of service to include accessibility and reasonable
accommodations for employees and clients.

f. Contractors and subcontractors with contracts in excess of $50,000 shall also pursue in
good faith affirmative action programs.

g. The Provider shall cause the foregoing provisions to be inserted in any subcontract for
any work covered by this Agreement so that such provisions shall be binding upon each
subcontractor, provided that the foregoing provisions shall not apply to contracts or subcontracts
for standard commercial supplies or raw materials.

11. EMPLOYMENT AND PERSONNEL The Provider shall not engage any person in the employ of any
State Department or Agency in a position that would constitute a violation of 5 18 or 17 MRSA 3104.
The Contractor shall not engage on a fuli?time, part~time or other basis during the period of this Agreement,
any other personnel who are or have been at any time during the period of this Agreement in the employ of any
State Department or Agency, except regularly retired employees, without the written consent of the State
Purchases Review Committee. Further, the Provider shall not engage on this project on a full-time, part?time
or other basis during the period of this Agreement any retired employee of the Department who has not been
retired for at least one year, without the written consent of the State Purchases Review Committee. The
Provider shall cause the foregoing provisions to be inserted in any subcontract for any work covered by this
Agreement so that such provisions shail be binding upon each subcontractor, provided that the foregoing
provisions shall not apply to contracts or subcontracts for standard commercial supplies or raw materials.

12. STATE EMPLOYEES NOT TO BENEFIT No individual employed by the State at the time this
Agreement is executed or any time thereafter shall be admitted to any share or part of this Agreement or to any
benefit that might arise therefrom directly or indirectly that would constitute a violation of 5 MRSA 18 or 17
MRSA 3104. No other individual employed by the State at the time this Agreement is executed or any time
thereafter shall be admitted to any share or part of this Agreement or to any benefit that might arise therefrom
directly or indirectly due to his employment by or financial interest in the Provider or any affiliate of the
Provider, without the written consent of the State Purchases Review Committee. The Provider shall cause the
foregoing provisions to be inserted in any subcontract for any work covered by this Agreement so that such
provisions shalt be binding upon each subcontractor, provided that the foregoing provisions shall not apply to
contracts or subcontracts for standard commercial supplies or raw materials.

13. WARRANTY The Provider warrants that it has not employed or contracted with any company or

person, other than for assistance with the normal study and preparation of a proposal, to solicit or secure this
Agreement and that it has not paid, or agreed to pay, any company or person, other than a bona fide employee

Rider B, Page 3 Version DHHS 2017.FFS.1

working solely for the Provider, any fee, commission, percentage, brokerage fee, gifts, or any other
consideration, contingent upon, or resulting from the award for making this Agreement. For breach or violation
of this warranty, the Department shall have the right to annul this Agreement without liability or, in its discretion
to otherwise recover the full amount of such fee, commission, percentage, brokerage fee, gift, or contingent
fee.

14. ACCESS TO RECORDS. As a condition of accepting an Agreement for services under this section, a
Provider must agree to treat all records, other than prOprietary information, relating to personal services work
performed under the Agreement as public records under the freedom of access laws to the same extent as if
the work were performed directly by the Department or agency. For the purposes of this subsection,
"proprietary information" means information that is a. trade secret or commercial or financial information, the
disclosure of which would impair the competitive position of the Provider and would make available information
not othenrvise publicly available. Information relating to wages and benefits of the employees performing the
personal services work under the Agreement and information concerning employee and Agreement oversight
and accountability procedures and systems are not proprietary information. The Provider shall maintain all
books, documents, payrolls, papers, accounting records and other evidence pertaining to this Agreement and
make such materials available at its offices at all reasonable times during the period of this Agreement and for
such subsequent period as specified under Maine Uniform Accounting and Auditing Practices for Community
Agencies (MAAP) rules. The Provider shall allow inspection of pertinent documents by the Department or any
authorized representative of the State of Maine or Federal Government, and shall furnish c0pies thereof, if
requested. This subsection applies to contracts, contract extensions and contract amendments executed on or
after October 1 2009.

15. TERMINATION The performance of work under the Agreement may be terminated by the
Department in whole, or in part, whenever for any reason the Agreement Administrator shall determine that
such termination is in the best interest of the Department. Any such termination shalt be effected by delivery to
the Provider of a Notice of Termination specifying the extent to which performance of the work under the
Agreement is terminated and the date on which such termination becomes effective. The Agreement shall be
equitably adjusted to compensate for such termination, and modified accordingly.

16. GOVERNMENTAL REQUIREMENTS The Provider warrants and represents that it will comply
with all governmental ordinances, laws and reguiations.

17. GOVERNING LAW This Agreement shall be governed in all respects by the laws, statutes,
and regulations of the United States of America and of the State of Maine. Any legal proceeding against the
State regarding this Agreement shall be brought in State of Maine administrative or judicial forums. The
Provider consents to personal jurisdiction in the State of Maine.

18. STATE HELD HARMLESS The Provider agrees to indemnify, defend and save harmless the State,
its officers, agents and employees from any and all claims, costs, expenses, injuries, liabilities, losses and
damages of every kind and description (hereinafter in this paragraph referred to as ?claims?) resulting from or
arising out of the performance of this Agreement by the Provider, its employees, agents, or subcontractors.
Claims to which this indemnification applies include, but without limitation, the following: ciaims suffered or
incurred by any contractor, subcontractor, materialman, laborer and any other person, firm, corporation or
other legal entity (hereinafter in this paragraph referred to as ?person?) providing work, services, materials,
equipment or supplies in connection with the performance of this Agreement; (ii) claims arising out of a
violation or infringement of any proprietary right, copyright, trademark, right of privacy or other right arising out
of publication, translation, development, reproduction, delivery, use, or disposition of any data, information or
other matter furnished or used in connection with this Agreement; Claims arising out of a libeious or other
unlawful matter used or developed in connection with this Agreement; (iv) claims suffered or incurred by any
person who may be otherwise injured or damaged in the performance of this Agreement; and all legal costs
and other expenses of defense against any asserted claims to which this indemnification applies. This
indemnification does not extend to a claim that results solely and directly from the Department?s negligence

Rider B, Page 4 Version DHHS 2017.FFS.1

or unlawful act, or (ii) action by the Provider taken in reasonable reliance upon an instruction or direction given
by an authorized person acting on behalf of the Department in accordance with this Agreement.

19. NOTICE OF CLAIMS The Provider shall give the Contract Administrator immediate notice in
writing of any legal action or suit filed related in any way to the Agreement or which may affect the performance
of duties under the Agreement, and prompt notice of any claim made against the Provider by any
subcontractor which may result in litigation related in any way to the Agreement or which may affect the
performance of duties under the Agreement.

20. APPROVAL This Agreement must have the approval of the State Controller and the State Purchases
Review Committee before it can be considered a valid, enforceable document.

21. LIABILITY INSURANCE The Provider shall keep in force a liability policy issued by a company
fully licensed or designated as an eligible surplus line insurer to do business in this State by the Maine
Department of Professional 8: Financial Regulation, Bureau of Insurance, which policy includes the activity to
be covered by this Agreement with adequate liability coverage to protect itself and the Department from suits.
Providers insured through a ?risk retention group? insurer prior to July 1, 1991 may continue under that
arrangement. Prior to or upon execution of this Agreement, the Provider shall furnish the Department with
written or photocopied verification of the existence of such liability insurance poiicy.

22. NON-APPROPRIATION Notwithstanding any other provision of this Agreement, if the State does
not receive sufficient funds to fund this Agreement and other obligations of the State, if funds are de-
appropriated, or if the State does not receive legal authority to expend funds from the Maine State Legislature
or Maine courts, then the State is not obligated to make payment under this Agreement.

23. SEVERABILITY The invalidity or unenforceability of any particular provision or part thereof of this
Agreement shall not affect the remainder of said provision or any other provisions, and this Agreement shall be
construed in all respects as if such invalid or unenforceable provision or part thereof had been omitted.

24. INTEGRATION All terms of this Agreement are to be interpreted in such a way as to be
consistent at all times with the terms of Rider 8 (except for expressed exceptions to Rider 8 included in Rider
C), followed in precedence by Rider A, and any remaining Riders in alphabeticai order.

25. FORCE MAJEURE The Department may, at its discretion, excuse the performance of an obligation
by a partyunder this Agreement in the event that performance of that obligation by that party is prevented by
an act of God, act of war, riot, fire, explosion, flood or other catastrophe, sabotage, severe shortage of fuel,
power or raw materials, change in law, court order, national defense requirement, or strike or labor dispute,
provided that any such event and the delay caused thereby is beyond the control of, and could not reasonably
be avoided by, that party. The Department may, at its discretion, extend the time period for performance of the
obligation excused under this section by the period of the excused delay together with a reasonable period to
reinstate compliance with the terms of this Agreement.

26. RIGHTS The State shall have all of its common law, equitable and statutory rights of set-
off. These rights shall include, but not be limited to, the State?s option to withhold for the purposes of set-off
any monies due to the Provider under this Agreement up to any amounts due and owing to the State with
regard to this Agreement, any other Agreement, any other Agreement with any State department or agency,
including any Agreement for a term commencing prior to the term of this Agreement, plus any amounts due
and owing to the State for any other reason including, without limitation, tax delinquencies, fee delinquencies
or monetary penaities relative thereto. The State shall exercise its set-off rights in accordance with normal
State practices including, in cases of set-off pursuant to an audit, the finalization of such audit by the State
agency, its representatives, or the State Controller.

Rider B, Page 5 Version DHHS 2017.FFS.1

27. ENTIRE AGREEMENT This document contains the entire Agreement of the parties, and neither
party shall be bound by any statement or representation not contained herein. No waiver shall be deemed to
have been made by any of the parties unless expressed in writing and signed by the waiving party. The
parties expressly agree that they shall not assert in any action relating to the Agreement that any implied
waiver occurred between the parties which is not expressed in writing. The failure of any party to insist in any
one or more instances upon strict performance of any of the terms or provisions of the Agreement, or to
exercise an option or election under the Agreement, shall not be construed as a waiver or relinquishment for
the future of such terms, provisions, option or election, but the same shall continue in full force and effect, and
no waiver by any party of any one or more of its rights or remedies under the Agreement shall be deemed to
be a waiver of any prior or subsequent rights or remedy under the Agreement or at law.

Rider B, Page 6 Version DHHS 2017.FFS.1

1)

2)

Rider 
Additional Requirements

Confidentiality. To the extent that the services carried out under this Agreement involve the use,
disclosure, access to, acquisition or maintenance of information that actually or reasonably could identify
an individual or consumer receiving benefits or services from or through the Department (?Protected
Information?), the Provider agrees to a) maintain the confidentiality and security of such Protected
Information as required by applicable state and federal laws, rules, regulations and Department policy, b)
contact the Department within 24 hours of a privacy or security incident that actually or potentially could be
a breach of Protected Information and c) cooperate with the Department in its investigation and any
required reporting and notification of individuals regarding such incident involving Protected Information. To
the extent that a breach of Protected information is caused by the Provider or one of its subcontractors or
agents, the Provider agrees to pay the cost of notification, as well as any financial costs and/or penalties
incurred by the Department as a result of such breach."

To the extent the Provider under this Agreement is considered a Business Associate under the Health
insurance Portability and Accountability Act of 1996, Public Law 104-191 (HIPAA) and its updates and
associated regulatory requirements, rules and standards, including those issued under the Health
information Technology for Economic and Clinical Care Act the Provider shall execute the
Department?s Business Associate Agreement template (BA Agreement). The terms of the BA Agreement
shall be incorporated into this Agreement by reference. Provider agrees that failure of Provider to execute
and deliver such BA Agreement to the Department or to adhere to the terms of the BA Agreement shall
result in breach of the underlying Agreement, and that remedies available to the Department for breach of
the Agreement apply hereto.

Lobbying. No Federal or State appropriated funds shall be expended by the Provider for influencing or
attempting to influence, as prohibited by state or federal law, an officer or employee of any Federal or State
agency, a member of Congress or a State Legislature, or an officer or employee of Congress or a State
Legislature in connection with any of the following covered actions: the awarding of any Agreement; the
making of any grant; the entering into of any cooperative agreement; or the extension, continuation,
renewal, amendment, or modification of any Agreement, grant, or cooperative agreement. The signing of
this Agreement fulfills the requirement that providers receiving over $100,000 in Federal or State funds file
with the Department with respect to this provision.

If any other funds have been or will be paid to any person in connection with any of the covered actions
specified in this provision, the Provider shall complete and submit a ?Disclosure of Lobbying Activities" form
available at: 

Drug-Free Workplace. By signing this Agreement, the Provider certifies that it shall provide a drug-free
workplace by: publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the Provider?s workplace and
specifying the actions that will be taken against employees for violation of such prohibition; establishing a
drug-free awareness program to inform employees about the dangers of drug abuse in the workplace, the
Provider?s policy of maintaining a drug~free workplace, available drug counseling and rehabilitation
programs, employee assistance programs, and the penalties that may be imposed upon employees for
drug abuse violations occurring in the workplace; providing a copy of the drug-free workplace statement to
each employee to be engaged in the performance of this Agreement; notifying the employees that as a
condition of employment under the Agreement the employee will abide by the terms of the statement and
notify the employer of any criminal drug conviction for a violation occurring in the workplace no later than
five days after such conviction.

The Provider shall notify the state agency within ten days after receiving notice of criminal drug convictions
occurring in the workplace from an employee, or otherwise receiving actual notice of such conviction, and
will take one of the following actions within 30 days of receiving such notice with respect to any employee

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5)

7)

9)

who is so convicted: take appropriate personnel action against the employee, up to and including
termination, or requiring the employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or
other appropriate agency.

Debarment and Suspension. By signing this Agreement, the Provider certifies to the best of its
knowledge and belief that it and all persons associated with the Agreement, including persons or
corporations who have critical influence on or control over the Agreement, are not presently debarred,
suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation by any
federal department or agency.

The Provider further agrees that the Debarment and Suspension Provision shall be included, without
modification, in all sub-agreements

Environment Tobacco Smoke. By signing this Agreement, the Provider certifies that it shall comply with
the Pro-Children Act of 1994, PL. 103-227, Part C, which requires that smoking not be permitted in any
portion of any indoor facility owned, leased, or contracted for by an entity and used routinely or regularly for
the provision of health, day care, education, or library services to children under the age of 18, if the
services are funded by Federal programs either directly or through State or local governments by Federal
grant, Agreement, loan, or loan guarantee. The law does not apply to children?s services provided in
private residences, facilities funded solely by Medicare or MaineCare funds, and portions of facilities used
for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may result in the
imposition of a civil monetary penalty of up to $1,000 per day and/or the imposition of an administrative
compliance order on the responsible entity.

Also, the Provider of foster care services agrees that it will comply with Resolve 2003, c. 134, which
prohibits smoking in the homes and vehicles Operated by foster parents.

Medicare and MaineCare Anti-Kickback. By signing this Agreement, the Provider agrees that it shall
comply with the dictates of 42 U.S.C. which prohibits the solicitation or receipt of any direct or
indirect remuneration in return for referring or arranging for the referral of an individual to a Provider of
goods or services that may be paid for with Medicare, MaineCare, or state health program funds.


Publications. When issuing reports, brochures, or other documents describing programs funded in whole
or in part with funds provided through this Agreement, the Provider agrees to clearly acknowledge the
participation of the Department of Health and Human Services in the program. In addition, when issuing
press releases and requests for proposals, the Provider shall clearly state the percentage of the total cost
of the project or program to be financed with Agreement funds and the dollar amount of Agreement funds
for the project or program.

Ownership. All notebooks, plans, working papers, data, or other work produced in the performance of this
Agreement, which are related to specific deliverables under this Agreement, are the property of the
Department and upon request shall be turned over to the Department.

Software Ownership. Upon request, the State and all appropriate federal agencies shall receive a royalty?
free, nonexclusive, and irrevocable license to reproduce, publish, or otherwise use, and to authorize others
to do so, all application software produced in the performance of this Agreement, including, but not limited
to, all source, object, and executable code, data files, and job control language, or other system
instructions. This requirement applies only to software that is a specific deliverable under this Agreement,
or is integral to the program or service funded under this Agreement, and is primarily financed with funding
provided under this Agreement.

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10) Provider Responsibilities 1 Sub Agreements. The Provider is soiely responsible for fulfillment of this
Agreement with the Department. The Provider assumes responsibility for all services offered and products
to be delivered whether or not the Provider is the manufacturer or producer of said services.



Sub-agreements.
i) All sub-agreements must contain the'assurances of Rider and Rider of this Agreement;

ii) All sub-agreements must be signed and delivered to the Department?s Agreement Administrator
within five (5) business days following the execution date of the sub-agreement.

See Rider Section 8.

Relationship between Provider, Subcontractor and Department. The Provider shall be wholly
responsible for performance of the entire Agreement whether or not subcontractors are used. Any sub?
agreement into which the Provider enters with respect to performance under this Agreement shall not
relieve the Provider in any way of responsibility for performance of its duties. Further, the Department
will consider the Provider to be the sole point of contact with regard to any matters related to this
Agreement, including payment of any and all charges resulting from this Agreement. The Department
shall bear no liability for paying the claims of any subcontractors, whether or not those claims are valid.
The Provider is responsible for ensuring that all staff, employees, subcontractors, or other individuals or
entities providing any services on behalf of the Provider clearly explain, verbally and in writing, to clients
and families their relationship to the Provider and the Provider?s relationship to the Department.

Liability to Subcontractor. The requirement of prior approval of any sub-agreement under this
Agreement shall not make the Department a party to any sub~agreement or create any right, claim or
interest in the subcontractor or proposed subcontractor against the Department. The Provider agrees
to defend (subject to the approval of the Attorney General) and indemnify and hold harmiess the
Department against any claim, loss, damage, or liability against the Department based upon the
requirements of Rider B, Section 18.

11) Renewals. This Agreement may be renewed at the discretion of the Department.

12) No Rule of Construction. The parties acknowledge that this Agreement was initially prepared by the
Department solely as a convenience'and that ail parties hereto, and their counsel, have read and fully
negotiated all the language used in the Agreement. The parties acknowledge that, because all parties and
their counsel participated in negotiating and drafting this Agreement, no rule of construction shall apply to
this Agreement that construes ambiguous or unclear language in favor of or against any party because
such party drafted this Agreement.

13) Conflict of Interest. The Provider covenants that it presently has no interest and shall not acquire any

 

interest, direct or indirect, which would conflict in any manner or degree with the performance of its
services hereunder. The Provider further covenants that in the performance of this Agreement, no person
having any such known interests shall be employed. [See also Rider B, #11 and #12]

14) Whistleblower Protection.
3) This Agreement and employees working on this Agreement will be subject to the Whistleblower rights

and remedies in the pilot program on employee Whistleblower protections established at 41 U80.
4712 by section 828 of the National Defense Authorization Act for Fiscal Year 2013 (Pub. L. 112-239)
and FAR 3.908.

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b) The Provider shall inform its employees in writing, in the predominant language of the workforce, of
employee whistleblower rights and protections under 41 U.S.C. 4712, as described in section 3.908 of
the Federal Acquisition Regulation.

c) The Provider shall insert the substance of this clause, including this paragraph in all subcontracts
over the simplified acquisition threshold.

15) Funding Sources Reduced. Notwithstanding any other provision of this Agreement, if the United States
Government or any department of the United States Government, has de?appropriated or suspended funds
for this Agreement, or where the Governor of the State of Maine has curtailed funds for this Agreement -
then the Department is not obligated to make payment under this Agreement to the extent of such de-
appropriation, suspension or curtailment of funds. In the event of such suspension or
curtailment of funds, the Agreement shall be modified accordingly.

16) Change of Operations
The Provider shall report to the Agreement Administrator and Program Administrator any anticipated
changes of the Provider?s operations, including but not limited to mergers, acquisitions, or closings, at the
earliest possible date and no later than sixty (60) days prior to the anticipated closure date, with the
exception of reasonably unforeseen circumstance.

17) Termination or Change of Work Performance.
In addition to the requirements of Rider D, Section 16, the written communication shall be specific and also
include, and not be limited to, the date of expected closure, description of any and all programs affected,
number of clients projected to be impacted, plans for addressing needs of the clients affected, and the
name and contact information of the person(s) responsible for the care of clients affected and their
records. The Provider shall assist the client and the client's case manager or other supports in obtaining
services from another provider.

a) The Provider shall report to the Program Administrator all major programming and structural changes in
programs funded, seeded, or licensed by the Department within the timeframe noted above. Any
changes that add, alter, or eliminate existing services must be negotiated and approved by the Program
Administrator prior to implementation. Major program changes include, but are not limited to, the
following: (1) The addition of new services or deletion of existing services; (2) Serving a population not
served by the agency previously; (3) Significant increases or decreases in service capacity as defined
by the governing body; (4) Significant changes in the organizational structure as defined by the
governing body; (5) Changes in the executive director or name or ownership of the agency; or 6)
Relocation of services. For MaineCare funded services, the Provider shall give due process notification
as required by MaineCare regulations, Chapter I, ?1.03-4 of the MaineCare Benefits Manual. In
addition to MaineCare Benefits Manual Chapter I, ?1.03-4, the following shall apply:

i) If a provider provides services under this Agreement and chooses to voluntarily terminate
participation in MaineCare or voluntarily terminates State funded services funded in whole or part
by this agreement, the provider must inform the Program Administrator of the intent. This notice
should be concurrent with the notice to MaineCare as required in Chapter I. The provider is
expected to work cooperatively with the Department on the planning the transition to replacement
services for the affected members. In order to facilitate continuity of services for the member(s), the
Department reserves the right to require that the provider continue to provide necessary services
until appropriate replacement services are secured for the member(s).

ii) If a provider chooses to terminate services to a specific member or group of members, the provider
must request permission to do so from the Program Administrator. Such a request must be in
writing and with a minimum of 30 days advance notice. The written request must state that the
provider will agree to work with the member, the Department and any potential replacement

Rider D, Page 4 Version DHHS 2017.GR.1

provider on the transition of services. In order to facilitate continuity of services for the member(s),
the Department reserves the right to request that the provider continue to provide necessary
services until appropriate replacement services are secured for the member(s).

18)Audit. Funds provided under this Agreement to community agencies for social services are subject to the
audit requirements contained in the Maine Uniform Accounting and Auditing Practices for Community
Agencies (MAAP), Federal OMB Circular A-110, and may further be subject to audit by authorized
representatives of the Federal Government, according to the Agreement Settlement Form (proforma)
contained in Rider F, if applicable. Agencies that expend $500,000 or more in a year in Federal Awards
shall have a single or program?specific audit conducted for that year in accordance with Federal Circular
OMB Audits of States, Local Governments, and Non?Profit Organizations.

Please see for details on this requirement.

The Department?s Agreement Administrator may approve Provider submissions, but has no authority to
relieve the Provider from being audited according to MAAP and Federal regulations in cases where this
approval may be counter to the MAAP and Federal regulations.

19) Motor Vehicle Check. The Provider shall complete a check with the Bureau of Motor Vehicles on all of
Provider?s staff and volunteers who transport clients or who may transport clients. This check must be
completed before the Provider allows the staff person or volunteer to transport clients, and at least every
two years thereafter. if the record of a staff member or volunteer contains an arrest or conviction for
Operating under the influence or any other violations which, in the judgment of the Provider, indicate an
unsafe driving history within the previous three (3) years, the Provider shall not permit the staff member or
volunteer to transport clients. The Provider shall implement appropriate procedures to ensure compliance
with the requirements of this section.

20) Exceptions to OMB Circulars for Non-Federallv-Funded Activities.

a) Travel. The reimbursement rate for mileage charged to Department funded programs cannot exceed
the reimbursement rate allowed for state employees. (5 M.R.S.A. 

b) Any other exceptions to OMB Circular A-122 are allowable only with prior written approval from the
Department and must be offset against identified unrestricted now-Federal revenue.

21) MaineCare Regulations. Providers who receive MaineCare funds will assure that their programmatic and
financial management policies and procedures are in accordance with applicable MaineCare regulations
and that their staff members are familiar with the requirements of the applicable MaineCare service they
are providing. Providers will ensure that they are in compliance with the applicable MaineCare regulation
prior to billing for the service.

22) Revenue Maximization. The Provider shall conduct its services in such a way as to maximize revenues
from MaineCare and other third-party sources such as private insurance as may be available to reduce the
need for funds from the Department. Agreement funds may not be used to pay for services that are
reimbursable by other third party sources, such as private health insurance and MaineCare, under any
circumstances. It is the Provider?s obligation to seek and obtain reimbursement from other third party
sources for any reimbursable services provided to covered individuals.

23) Illegal Aliens Ineligible for State and Local Public Benefits. Notwithstanding any other provision of this
Agreement, if this Agreement is for the provision of any State or local public benefit, the Provider certifies
that it shall comply with the requirements of 8 U.S.C. 1621 regarding the ineligibility of illegal aliens for
any State or local public benefits.

Rider D, Page 5 Version DHHS 2017.GR.1

24) Background Checks. The Provider agrees to conduct background checks on all employees, temporary
staff persons, persons contracted or hired, consultants, volunteers, students, and other persons who may
provide services under this Agreement. The results of each background check shall be made available to
the Program Administrator within five (5) days of completion and prior to the person providing services
under this agreement. The cost of performing each background check shall be the responsibility of the
Provider. The methods of performing the background checks must first be approved by the Department in
writing and will include information from the Bureau of Motor Vehicles, the Sex Offender Registry, and the
Maine State Bureau of Investigation. it services to be provided under this agreement include services to
minor children then the background check will include information from the Department?s Office of Child
and Family Services regarding allegations of abuse or neglect of a child. if services to be provided under
this agreement are to be performed by a person who is professionally licensed then the background check
wili include information from the appropriate licensing board or entity regarding the status of the person?s
license. The Provider must receive written permission from the Department before making any changes to
such methods.

The Provider shall not hire or retain in any capacity any person who may directly provide services to a
client under this Agreement if that person has a record of: -

a) any criminal conviction that involves ciient abuse, neglect or exploitation;

b) any criminal conviction, classified as Class A, or or the equivalent of any of these, or any reckless
conduct that caused, threatened, solicited or created the substantial risk of bodily injury to another
person within the preceding two years; or

c) any criminal conviction resulting from a sexual act, contact, touching or solicitation in connection to any
victim.

The Provider shall not hire or retain in any capacity any person who may directly provide services to a
client who is minor child under this Agreement if that person has a record of substantiated abuse or neglect
of a child.

The Provider shall not hire or retain a person to perform any service under this agreement that is required
to be performed by a person with an appropriate license unless it has confirmation from the appropriate
licensing board or entity that the person has a license in good standing.

25) Notification and Reporting. The Provider shall follow all policies, procedures, and protocols developed
by the Department, including procedures and protocols for tracking and reporting to the Program
Administrator reportable events; (ii) critical incidents; including all incidents of abuse and neglect or
children and adults. The Provider shall develop the capacity to transmit identified uniform data elements in
accordance with specifications established by the office of the Program Administrator.

insofar as the Provider serves members of the class outlined in the ?Community Consent Decree",
Consumer Advisory Board v. DHHS Commissioner, No. (D. Ct. Me), all terms and conditions
of the Community Consent Decree are applicable to this Agreement. All Providers must pay particular
attention to the Grievance process available to persons with developmental disabilities served by the
Provider, and ensure that notice of the process is regularly provided to persons served by the Provider.
Providing notice includes ensuring that written notice of the grievance process is provided to the person
and/or their guardian at any planning meeting; posting notice of the grievance process in an appropriate
common area of all facilities operated by the Provider; and posting notice of the grievance process on any
website maintained by the Provider. In addition, the Provider must ensure that all new staff is trained in the
grievance process and that it is available to all persons served by the Department. The Provider is also
responsible for ensuring that all staff, employees, subcontractors, or other individuals or entities providing
any services on behaif of the Provider clearly explain verbally and in writing to clients and families their

Rider D, Page 6 Version DHHS 

relationship to the Provider and their roles and responsibilities and include, in writing, contact information
for the individual(s) responsible for responding to complaints or grievances on behalf of the Provider.

Rider D, Page 7 Version DHHS 2017.GR.1

 

 
 
 
    
 
     

RIDER F-1
PROFORMA

(see instructions and MAAP iV)

 

 

 

 

 

AGENCY NAME:
FISCAL YEAR END:
FUNDING DEPARTMENT:
DHHS 
AGREEMENT START DATE:
AGREEMENT END DATE:
AGREEMENT AMOUNT:
PROGRAM NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service Service Code Flex Funds of Units (A) Rate (B) Units Rate( 
District 3 FY17 10,000.00 1,380 435.00 600,300.00
District 3 FY18 10,000.00 1,380 435.00 600,300.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL PAYMENTS 1,220,600.00

 

 

 

 

 

 

8..

Last Updated: 5/28/15
Vs. 2016?1 FFS Rider F??i ASF

RIDER F-2
AGREEMENT COMPLIANCE FORM

AGENCY NAME:
PROGRAM NAME:
AGREEMENT START DATE:

AGREEMENT END DATE:
DHHS 

 

This section identifies compliance requirements that must be considered in audits of agreements between the
Department and a Community Agency. Below is a summary of required compliance tests as well as sections within the
agreement award relevant to such testing. Failure to comply with any of these areas could lead to material deficiencies.

Review the Federal compliance requirements specific to the following CFDA identifiers:

CFDA CFDA 
CFDA 

and review all the State compliance requirements listed below that apply to Federal Funds.
Review the State compliance requirements in applicable areas specified below:
1 CONTROL
2 STANDARD ADMINISTRATIVE PRACTICES
I a. 2 CFR 200 Subpart 

b. Department Additions
Program Budget

3 ACTIVITIES ALLOWED OR UNALLOWED - Rider A

 



4 ALLOWABLE COSTSICOST PRINCIPLES
2 CFR 200 Subparl 

5 CASH MANAGEMENT

 

6 ELIGIBILITY Rider A

 

7 EQUIPMENT AND REAL PROPERTY MANAGEMENT

 

8 MATCHING, LEVEL OF EFFORT, EARMARKING

 

9 PERIOD OF AVAILABILITY OF FUNDS

 

10 PROCUREMENT AND SUSPENSION AND DEBARMENT

 

?11 PROGRAM INCOME

 

?12 REPORTING Rider A

 

13 SUB-RECIPIENT MONITORING

 

14 SPECIAL TESTS AND PROVISIONS

 

IDDHHEHDDHE

15 AGREEMENT SETTLEMENT METHOD
{Check allI that are applicable)

DCOST SETTLED .FEE FOR SERVICE
DLINE ITEM EXPENSE

Last Updated: 5/28/15 Vs. 2016-1 Rider F-2

RIDER 
IDENTIFICATION OF COUNTRY
IN WHICH CONTRACTED WORK WILL BE PERFORMED

 

 

Please identify the country in which the services purchased through this Agreement will be performed:

United States. Please identify state:' Maine
Other. Please identify country:

 

Notification of Changes to the Information

The Provider agrees to notify the Division of Purchases of any changes to the information provided above.

Rider G, Page 1 Version DHHS 2016.1

RIDER I
MAINE STATE DEPARTMENT OF HEALTH AND HUMAN SERVICES
ASSURANCE OF COMPLIANCE

ASSURANCE OF COMPLIANCE WITH TITLES OF THE CIVIL RIGHTS ACT OF 1964, SECTION 504 OF
THE REHABILITATION ACT OF 1973, TITLE IX OF THE EDUCATION AMENDMENTS OF 1972, THE AGE
DISCRIMINATION ACT OF 1975, THE CODE OF FAIR PRACTICES AND AFFIRMATIVE ACTION AND
STATE OF MAINE EXECUTIVE ORDER 17IFY 04/05.

The Provider/Contractor provides this assurance in consideration of and for the purpose of obtaining
Federal/State grants, loans, contracts, agreements, property, discounts or other Federal/State financial
assistance from the U.S./State Departments of Health and Human Services.

By signing this Agreement, Rider Assurance of Compliance is by agreement fully incorporated into the
Agreement.

THE HEREBY AGREES THAT IT WILL COMPLY WITH:

1. Titles Vi of the Civil Rights Act of 1964 (Pub. L. 88-352), as amended, and all requirements imposed by or
pursuant to the Regulation of the Department of Health and Human Service (45 C.F.R. Part 80), to the end
that, in accordance with Title VI of that Act and the Regulation, no person in the United States, shall on the
grounds of race, color or national origin be excluded from participation in, be denied the benefits of, or be
subjected to discrimination under any program or activity for which the Provider/Contractor receives
Federal/State financial assistance from the Department. Specifically, providers of client services shall develop
clear, written communication plans, provide and document training in order to ensure that staff can
communicate meaningfuily with applicants/clients and/or family members who are limited English proficient
determine the primary language of applicants/clients and/or family members, and ensure that bi-lingual
workers or qualified interpreters will be provided at no cost to the appiicant/client.

2. Section 504 of the Rehabilitation Act of 1973 (Pub. L. 93?112), as amended, and all requirements imposed
by or pursuant to the Regulation ofthe Department of Health and Human Services (45 C.F.R. Part 84), to the
end that, in accordance with Section 504 of that Act and the Regulation, no othennrise qualified handicapped
individual in the United States shall, solely by reason of his handicap be excluded from participation in, be
denied the benefits of, or subjected to discrimination under any program or activity for which the
Provider/Contractor receives Federal/State financial assistance from the Department. Specifically, providers
shall develop clear, written communication plans, provide and document training in order to ensure that staff
can communicate meaningfully with applicants/clients and/or family members who are deaf, hard or hearing,
late deafened, speech impaired and/or nonverbal. The Provider will provide visible or tactile alarms for safety
and privacy, telecommunications device for the deaf (TTY), amplified phone or fax machine, and train staff in
the use of adaptive equipment. The Provider shall obtain the services of a qualified, licensed sign language
interpreter or other adaptive service such as CART or C-Print at no expense to the applicant/client or family
member.

3. Title IX of the Educational Amendments of 1972 (Pub. L. 92-318), as amended, and all requirements
imposed by for pursuant to the Regulation ofthe Department of Health and Human Services (45 C.F.R. Part
86), to the end that, in accordance with Title IX and the Regulation, no person in the United States shall, on the
basis of sex, be excluded from participation in, be denied the benefits of [or be otherwise subjected to
discrimination under any education program or activity for which the Provider/Contractor receives
Federal/State financial assistance from the Department.

4. The Age Discrimination Act of 1975 (Pub. L. 94-135), as amended, and all requirements imposed by or

pursuant to the Regulation of the Department of Heaith and Human Services (45 C.F.R. Part 91), to the end
that, in accordance with the Act and the Regulation, no person in the United States shall, on the basis of age,

Rider l, Page 1 Version DHHS 2016.1

be denied the benefits of, be excluded from participation in or be subjected to discrimination under any
program or activity for which the Provider/Contractor receives Federal/State financial assistance from the
Department.

5. The Code of Fair Practices and Affirmative Action, 5 M.R.S.A. 781 et. seq, to the end that, in accordance
with the Code of Fair Practices and Affirmative Action, no state or state related agency contractor,
subcontractor, or labor union or representative of the workers with which the contractor has an agreement will
discriminate because of race, color, religious creed, sex, national origin, ancestry, age, physical or mental
disability while providing any function or service to the public, in enforcing any regulation, or in any education,
counseling, vocational guidance, apprenticeship and on the job training programs, unless based upon a bona
fide occupational qualification. During the performance of this contract, the Provider/Contractor agrees as
follows:

A. That it will not discriminate against any employee or applicant for employment because
of race, color, religiouscreed, sex, national origin, ancestry, age physical or mental
disability. Such action shall include, but not be limited to the foilowing: Employment,
upgrading, demotions, transfers, recruitment or recruitment advertising; layoffs or
terminations; rates of pay or other forms of compensation; and selection for training,
including apprenticeship.

B. The Provider/Contractor will, in all solicitations or advertisements for employees place by
or on behalf of the Provider/Contractor, state that all qualified applicants will receive
consideration for employment without regard to race, color, religious creed, sex, national
origin, ancestry, age, physical or mental disability.

C. The Provider/Contractor will send to each labor union or representative of the workers
with which it has a coliective or bargaining agreement, or other contract or
understanding, whereby he is furnished with labor for the performances of his contract, a
notice, to be provided by the contracting department or agency, advising the said labor
union or workers? representative of the contractor?s commitment under this section and
shall post copies of the notice in conspicuous places available to employees and
applicants for employment.

D. The Provider/Contractor will cause the foregoing provisions to be inserted in all contracts
for any work covered by this agreement so that such provisions will be binding upon
each subcontractor.

E. Provider/Contractors and subcontractors with contracts in excess of $50,000 will also
pursue in good faith affirmative action programs.

6. State of Maine Executive Order 17 FY 04/05 which provides that all contractors entering into contracts for
services to be provided to or on behalf of the State of Maine not discriminate against any employee or
applicant for employment because of that employee?s or applicant?s sexual orientation. Solicitations or
advertisements for employment by the contractor or subcontractor shall state that all qualified applicants will
receive consideration for employment without regard to sexual orientation. Contractor will notify each labor
union or workers? representative of the contractor?s obligations under State of Maine Executive Order 17 FY
04/05 and post such notice in conspicuous places available to employees and applicants for employment. The
contractor will cause the requirement of State of Maine Executive Order ?17 FY 04/05 to be inserted in all
contracts for work covered by a State contract for services such that the requirements will be binding on any
and all subcontractors. The Provider further stipulates that services will be provided in a culturally sensitive and
age appropriate manner.

The Provider/Contractor agrees that compliance with this assurance constitutes a condition of continued
receipt of Federal/State financial assistance, and that it is binding upon the Provider/Contractor, its successors,
transferees and assignees for the period during which such assistance is provided. The Provider/Contractor
also agrees that the Department may withhold financial assistance to any recipient found to be in violation of
the Maine Human Rights Act, 5 M.R.S.A. 4551 et. seq. or the Federal Civil Rights Act, 42 USC. 1981 et.

Rider t, Page 2 Version DHHS 2016.1

seq. in accordance with 5 M.R.S.A. 783. If any real property or structure thereon is provided or improved
with the aid of Federal/State financial assistance extended to the Provider/Contractor by the Department, this
assurance shall obligate the Provider/Contractor, or in the case of any transfer of such property, any
transferee, for the period during which the real property or structure is used for a purpose for which the
Federal/State financial assistance is extended or for another purpose involving the provision of similar service
or benefits. If any personal property is so provided, this assurance shall obligate the Provider/Contractor for
the period during which it retains ownership or possession of the property. The Provider/Contractor further
recognizes and agrees that the United States shalt have the right to seek judicial enforcement of the
assurance.

Technical assistance and information relating to the requirements associated with sections 1 through 5 can
be found at U.S. Health and Human Services Website: Technical assistance and
information regarding section ?1 can also be found at the US. Equal Employment Opportunity Commission
website: Technical assistance and information relating to the requirements associated with
section 6 can be found at Information relating to section 6 can be found
at 

 

Rider l, Page 3 Version DHHS 2016.1

EXCEPTIONS T0 AGREEMENT

There are no exceptions to State Riders in this agreement. 

Exceptions Rider, Page 1 Version DHHS 2016.1

Appendix A Tool

Caseworkers will use the UNCOPE tool in all assessments. UNCOPE will be used with all parents and caregivers in
the home. When concerns are raised for parents and caregivers who live outside the home--but have regular contact
with or responsibility for children who are the subject of the assessment?caseworkers should consider using the
UNCOPE.

Responses to the UNCOPE are to be documented on this form. When the UNCOPE is not used, the caseworker
must document the reason in the record.

The UNCOPE is to be used as a guide. The questions need not be asked verbatim, but should be incorporated into
the interview in a natural way. In looking at the UNCOPE form, caseworkers should use the bolded and underlined
words to form the question in a way that is relevant to the caregiver?s real life experiences. Follow-up questions
should be used to determine the quantity and pattern of the behavior.

Collateral information must be used as part of the UNCOPE and in scoring.
UNCOPE

Used I 0
Question: ?In the past year, have you drank or used drugs more than you meant to??
Or Have you spent more time drinking or using than you intended to??

Neglected 
Question: ?Have you ever negIected some of your usual responsibilities because of using alcohol or drugs??

Cut Down I 
Question: ?Have you felt you wanted or needed to cut down on your drinking or drug use in the last year??

0 Objected I 
Question: ?Has anyone objected to your drinking or drug use??
Or ?Has your family, a friend or anyone else ever told you they objected to your alcohol or drug use??

Preoccupied I 
Question: ?Have you ever found yourself preoccupied with wanting to use alcohol or drugs??
Or ?Have you found yourself thinking a lot about drinking or using??

Emotional Discomfort 
Question: ?Have you ever used alcohol or drugs to relieve emotionaI discomfort, such as sadness, anger or
boredom??

of positive responses by individual being screened (I):
of positive responses indicated by Collateral information (C):
Total Score (Total of positive reSponses by Individual and/or CoIIaterai per question max. total 6

Appendix 
ACTIVITIES FOR CONTINUED ASSESSMENT AND DEVELOPING THE FAMILY PLAN:

1) When sufficient factual information has been gathered that determines this is a family in need of ARP services,
the caseworker will partner with the family to continue assessment activities, prepare for a Family Team Meeting, and
to develop a Family Plan. Generally, children age 6 or older are to be included in service planning unless there are
clinical justifications for not doing so.

2) Caseworkers will prep the family and supports, schedule, and facilitate a Family Team Meeting for further
assessment and identification of individual/family and needs. The team will develop a plan to meet those
needs. These activities must be completed, documented, and have supervisory approval within 35 days of the report.

3) The purpose of the Family Team Meeting is to identify, share, and review the current family and
needs related to child safety. This team will help to determine how to help the family meet those needs, as well as how
progress will be measured.

4) A Family Plan will be developed during this meeting to determine what steps are necessary to meet the needs
for child safety, who is responsible, and timeframes for meeting the goal.

5) The following Family Plan will be used and entered into MACWIS following the Team Meeting. The plan
should be signed by the and ARP staff. Copies of the Family Plan will be made available for all

team participants at the Family Team Meeting. Family Plan for meeting the needs of the family:
1. The current of the family related to child safety are:

2. The current needs with respect to child safety, permanency, and well~being are:

3. The services/supports needed to assist the family with regard to child safety and weliwbeing:

The Caseworker is responsible for:

4. Who will do what/when to carry out the plan:

5. Progress and change will be measured by:

6. Possible outcomes in relation to child safety are:
7. Relatives:

8. Visitation Plan (if the child is placed outside the home):
The Family Plan will be reviewed/amended at least every six months or sooner as needed.

I accept the (insert provider name) offerto assist me in obtaining needed services and will receive Case Management
services from (insert provider name) in order to gain access to and manage needed medical, nutritional, social,
educational, transportation, housing, and other services identified in this plan.

Signature of ParentICaregiver Date:
Signature of Parent/Caregiver Date:

Signature of Child (Age 6 and older) Date:

Signature of Caseworker Date:

Name of Supervisor