Eastpointe Managed Care Organization REQUEST FOR …...Jun 21, 2019 · Residential Treatment Level...

Residential Treatment Level III- 1

Eastpointe

Managed Care Organization

REQUEST FOR PROPOSAL

(RFP)

For

Residential Treatment - Level III for Dually Diagnosed Members

RFP RELEASE DATE: June 21, 2019

NOTE:

Eastpointe Reserves the right to modify this RFP to correct any errors

or to clarify requirements. Any changes will be posted on our website

www.eastpointe.net.

All questions related to this RFP need to be sent to

[email protected]. Only questions submitted by

email to this address will be responded to.

http://www.eastpointe.net/

mailto:[email protected]


Table of Contents

KEY EVENTS AND DATES .................................................................................. 3

DEFINITIONS ......................................................................................................... 3

PROJECT DESCRIPTION .................................................................................... 4

A. Introduction ........................................................................................................ 4

B. Services provided by the Contractor for Residential Treatment-Level III 5

C. Other Requirement for Residential Treatment Level III 7

D. Other Staff Requirements .................................................................................. 8

E. Eligible Bidders .................................................................................................. 9

II. THE PROPOSAL ............................................................................................... 9

IV. SELECTION OF AWARD .............................................................................10

A. Proposal Review Criteria .................................................................................10

B. Final Selection of Contractor ...........................................................................11

V. PROJECT FUNDING AND CONTRACTS ..................................................11

A. Contract Content and Payment Process ...........................................................11

B. Accounting Records .........................................................................................11

C. Monitoring .......................................................................................................12

VI. TERMS AND CONDITIONS GOVERNING THIS REQUEST FOR ......12

PROPOSALS PROCESS ......................................................................................12

VII. REQUEST FOR PROPOSAL PROTEST ..................................................14

A. Reason for Automatic Rejection of an Application ......................................14

B. Notification of Deficiencies .............................................................................14

C. Public Information ...........................................................................................14

APPLICATION PACKAGE .................................................................................15

INSTRUCTIONS & FORMS ............................................................................................... 15 Outline Order for Submission ............................................................................................... 15

A. Cover Letter .....................................................................................................15

B. Executive Summary .........................................................................................15

C. Relevant Experience of the Applicant .............................................................15

D. Project Narrative ..............................................................................................16

E. Staffing Plan .....................................................................................................16

G. Fiscal Year Audit/Annual Report ....................................................................17

H. Results of Investigations/Legal Information ...................................................17


Eastpointe Request for Proposal for Residential Treatment – Level III ............................... 19

Proposal Cover Letter ........................................................................................19

Residential Treatment – Level III PROPOSAL AGREEMENT: ......................................... 22 Reference Form ..................................................................................................................... 23 Additional Funding Form ..................................................................................................... 25

Attachment A: Residential Treatment – Level III Definition 26

KEY EVENTS AND DATES

Date Event

June 21, 2019 Release of RFP

June 28, 2019 Questions to RFP due no later than

5:00pm

July 8, 2019 Responses to questions posted at

www.eastpointe.net

July 22, 2019 Proposal due by 5:00pm

By September 23, 2019 Start up day for selected vendor(s)

Proposals must be submitted to: [email protected] to the attention

of, Linda Hawley Isbell in the format and means of delivery described in this RFP.

Questions received in formats of delivery modes outside of that detailed in this

proposal will not be responded to.

DEFINITIONS

Dually Diagnosed Members: The members that would be admitted to the Level III facilities as

part of this RFI would have both a Mental Health Diagnosis and an Intellectual Developmental

Disability (IDD) that they are receiving treatment for.

LME: Local Management Entity

MCO: Managed Care Organization

RFP: Request for Proposal

http://www.eastpointe.net/



PIHP: Prepaid Inpatient Health Plan through which all mental health, substance abuse and

developmental disabilities services are authorized for Medicaid enrollees. MCO/LMEs are area

authorities in the State of NC which are responsible for certain management and oversight

activities with respect to publically funded DMH/DD/SAS services and are PIHP’s for the

waiver.

Contractor: A company or individual with a formal contract to do a specific job, supplying

labor and materials and providing and overseeing staff and consumers.

Good Standing- MCO: means the provider has a history of compliance with DMA Clinical

Policy specific to service delivery and does not have an open Plan of Correction (POC) with the

LME. A POC must be timely submitted, approved and implemented before the POC action can

be closed. A POC is fully implemented when the POC is being followed and all out of

compliance findings have been minimized or eliminated as determined by the LME in a

maximum of two follow-up reviews. The POC action is closed when the provider receives the

official notification from the LME stating the action is closed

And

The provider must be in compliance with the requirements of the contract.

PROJECT DESCRIPTION

A. Introduction

Eastpointe needs qualified providers to provide Residential Treatment - Level III to our members

with sites in the Eastpointe catchment area. This RFP is for:

• One Residential Treatment Level III group home for Males who are dually diagnosed

(with a Mental Health Diagnosis and an IDD Diagnosis) and

• One Residential Treatment Level III group home for Females who are dually diagnosed

(with a Mental Health Diagnosis and an IDD Diagnosis).

Both homes must be located in one of the following counties: Bladen, Duplin,

Edgecombe, Greene, Lenoir, Sampson, Robeson, Scotland, Wayne and Wilson Counties.

A contractor can submit a request to provide only one of the two homes listed above.


Eastpointe is a Managed Care Organization (MCO) and is responsible for managing both state

and Medicaid funded mental health, intellectual/developmental disability, and substance abuse

services for residents of twelve (10) counties in the eastern and southeastern areas of North

Carolina. The catchment area consists of the following counties, Bladen, Duplin, Edgecombe,

Greene, Lenoir, Sampson, Robeson, Scotland, Wayne and Wilson Counties.

Eastpointe manages financial resources and links members in need of mental health,

developmental disability and substance abuse treatment to appropriate, medically necessary

services. These services are provided by our contracted network of hospitals, provider agencies

and licensed independent practitioners located both in and outside of our catchment area.

Eastpointe seeks to forge a partnership or partnerships with a provider(s) to provide services in

our catchment area for this service. Eastpointe seeks a contractor(s) who will provide this

service as described in this Request for Proposal. Submitted proposals must contain budgets for

the remainder of the current fiscal year and as well as for the following fiscal year.

This service must be provided in accordance with all elements of the Request for Proposal

document requirements, Clinical Coverage Policy No: 8-D-2 and all aspects of the Service

Record Manual must also be followed.

B. Service to be provided by the Contractor under this RFP

Residential Treatment - Level III

• One Residential Treatment Level III group home for Males who are dually diagnosed

(with a Mental Health Diagnosis and an IDD Diagnosis) and/or

• One Residential Treatment Level III group home for Females who are dually diagnosed

(with a Mental Health Diagnosis and an IDD Diagnosis).

The Contractor must be willing to accept members stepping down from Psychiatric Residential

Facilities (PRTF’s) as deemed medically necessary and appropriate with the other members

placed in that facility.

The Contractor will need to participate in Training(s) with Eastpointe Staff on the Six Core

Strategies.

The Contractor will need to work with the Division of Health Service Regulation (DHSR) to

determine the appropriate license type to be utilized for this facility.


Residential Treatment – Level III Services as outlined in Clinical Coverage Policy No: 8-D-

2.

Residential Treatment Level III service is responsive to the need for intensive, active therapeutic

intervention, which requires a staff secure treatment setting in order to be successfully

implemented. This setting has a higher level of consultative and direct service from

psychologists, psychiatrists, medical professionals, etc.

Staff are awake during sleep hours and supervision is continuous.

This service includes all Family/Program Residential Treatment elements and the following

activities:

a. Individualized, intensive, and constant supervision and structure of daily living designed to

minimize the occurrence of behavior related to functional deficits, to ensure safety and contain

out of-control behaviors including intensive and frequent crisis management with or without

physical restraint or to maintain optimum level of functioning.

b. Includes active efforts to contain and actively confront inappropriate behaviors and assist

beneficiaries in unlearning maladaptive behaviors. Includes relationship support to assist the

beneficiary in managing the stress and discomfort associated with the process of change and

maintenance of gains achieved earlier and specifically planned and implemented therapeutically

focused interactions designed to assist the beneficiary in correcting various patterns of grossly

inappropriate interpersonal behavior, as needed. Additionally, providers require significant skill

in maintaining positive relationship in interpersonal dynamics, which typically provoke rejection,

hostility, anger and avoidance.

Treatment is provided in a structured program setting and staff is present and available at all

times of the day, including overnight awake. A minimum of one staff is required per four

beneficiaries at all times. Additionally, consultative and treatment services at a qualified

professional level shall be provided four hours per child per week. This staff time may be

contributed by a variety of individuals. For example, a social worker may conduct group

treatment or activity; a psychologist may consult on behavioral management; or, a psychiatrist

may provide evaluation and treatment services. These services must be provided at the facility


site. Group therapy or activity time may be included as total time per beneficiary (i.e., if there are

six members in a group for 90 minutes, this may be counted as 90 minutes per beneficiary).

*Note: Periodic services may not be used to augment residential services.

A. Therapeutic Relationship This service provides all Family/Program Residential Treatment

Level II elements plus the relationship, which is structured to remain therapeutically positive in

response to grossly inappropriate and provocative interpersonal behaviors including verbal and

some physical aggression.

B. Structure of Daily Living Daily living is structured to provide all elements of Family/Program

Residential Treatment Level II plus intensified structure, supervision, and containment of

frequent and highly inappropriate behavior. This setting is typically defined as being "staff

secure."

C. Cognitive/Behavioral Skill Acquisition Treatment provides all Family/Program Residential

Treatment Level II elements plus active "unlearning" of grossly inappropriate behaviors with

intensive skill acquisition. Includes specialized, on site interventions from qualified

professionals.

Service Type Residential Treatment Level III is a 24-hour service. Licensed under 122-C.

Resiliency/Environmental Intervention This service is to support the youth in gaining the skills

necessary to step down to a lower level of care.

Service Delivery Setting Program/Group Home type.

C. Other Requirements for: Residential Treatment – Level III requirements

Contractors who provide these services must conform to certain standards, including:

• Be community based and culturally competent in service delivery.

• Adhere to all applicable State Statutes, Licensure Rules, and Federal laws in the performance

of this agreement. Accreditation Standards if relevant to the services provided. This

includes maintenance of a Quality Assurance Plan that complies with Accreditation


Standards of the Division of Mental Health, Developmental Disabilities, and Substance

Abuse Services if relevant to the type of services provided.

• Comply with APSM 95-2 Client Rights in Community Mental Health, Developmental

Disabilities, Substance Abuse Services.

• Develop consent for release of information in accordance with 42 CFR Part2: Confidentiality

of Alcohol and Drug Patients Records and HIPAA.

• Comply with rules and regulations as promulgated by the Division of Mental

Health/Developmental Disabilities/Substance Abuse Services, APSM 30-1.

• Adhere to Public Law 103-227 also known as the Pro Children Act of 1994 (ACT).

• Comply with APSM 75-1 (Budgeting and Procedures manual).

• Comply with Title VI and VII of the Civil Rights Act of 1964.

• Comply with the Rehabilitation Acts of 1973, section 504.

• Assure that facilities are accessible to those with physical disabilities.

• Remain in compliance with OSHA regulations concerning exposure risks and controls to

reduce risks of exposure to blood borne pathogens.

• Provide the MCO’s Client Rights Committee an annual report from the Provider’s client

grievance committee. This report will summarize the actions of the committee related to

client grievances, alleged violations of rights including cases of abuse, neglect or

exploitation, or failure to provide services.

• Follow all aspects of the Eastpointe’s Provider Manual.

• Maintain documentation as required by the Service Records Management and

Documentation Manual and the applicable service definition.

D. Other Staff Requirements

All staff responsible for the provision of services to consumers under the terms of the MCO

contract must have:

a. Verification of employment history of personnel.

b. Criminal record check and if they have not been in the State of North Carolina for

the last five years a national criminal records check must be done. Individuals

with convictions for felony crimes class D or higher per NC ratings should be

considered eligible for these staffing positions unless approved by the Eastpointe

Credentialing Committee.

c. Department of Motor Vehicles driving record check for personnel transporting


recipients.

d. Ensure staff providing transportation maintains emergency information on

consumers in the event of an accident. Information should include but not be

limited to: client name, address, emergency contact, Doctor’s name, address and

phone number, preferred hospital, and information regarding allergies.

e. Ensure all staff providing transportation via private vehicle maintains annual

inspections as required by North Carolina law.

f. Minimum of two positive work related references on personnel.

g. Employers may access the Health Care Personnel Registry voice response system

by calling (919) 715-0562 for information regarding individuals with

substantiated findings of abuse, neglect, misappropriation of property, diversion

of drugs or fraud.

h. Comply with all staffing requirements as specified in the applicable service

definition.

The Contractor will insure all staff are supervised and credentialed/privileged to deliver all

services. Record of such supervision and credentialing are maintained by the Provider readily

available for Local, State or Federal review.

E. Eligible Bidders

Proposals may be submitted by any private for-profit, not-for-profit or public agency that

currently has a Medicaid contract with Eastpointe demonstrating the ability to complete the

desired project and approved by the MCO and eligible to receive funding. Proposals will only be

accepted from in network status providers.

II. THE PROPOSAL

The proposal must include the following items and be submitted in the order identified in

the Outline Order for Submission section of this announcement:


• Cover letter

• Agreement Form

• Executive Summary

• Relevant Experience of Applicant

• Project Narrative

• Staffing Plan

• Budget Request

• Fiscal Year Audit/Annual Report Information

• Results of Investigations/Legal Information

• Reference List Form

• Additional Funding Form

The proposal must be emailed to [email protected] to the attention of

Linda Hawley Isbell on or before 5:00 P.M. on July 22, 2019.

It is solely the proposer’s responsibility to ensure that all required and necessary information,

documents and attachments are included prior to submitting a response and to ensure that the

response is received at the correct location and time.

When responding to this RFP be sure to follow all instructions carefully. Submit proposal

contents according to the outline specified and submit documents according to the instructions.

Failure to follow these instructions will be considered a non-responsive proposal and may result

in immediate elimination from further consideration. Bidders are responsible for reviewing the

Eastpointe website for additional information that is posted after the initial release of the RFP.

IV. SELECTION OF AWARD

A. Proposal Review Criteria

The proposal will be reviewed by a panel convened by Eastpointe and composed of persons with

expertise in applicable areas and related fields. Scoring will be based on the rating of the written

proposal as well as other evaluation criteria. Such activities may include reference checks and

discussions with other funding/contractual organizations or members. The panel will evaluate

the bidder’s strengths, capabilities, and experience including corporate background, past and

current projects, financial soundness, and performance history. Submission of the proposal

establishes the bidder’s agreement for Eastpointe to make any contacts it deems necessary to

confirm the organization’s experience and performance.



The weighting of scoring is based on the following:

Section Point Assignment

Cover Letter/Executive Summary 5%

Relevant Experience of the Applicant 25%

Project Narrative 25%

Staffing Plan 20%

Budget Request/ Fiscal Year Audit/Annual

Report

15%

Results of Investigations/Legal Information 10%

Total 100%

B. Final Selection of Contractor

The final selection of a contractor will be made by Eastpointe based on the recommendations of

the panel described above. Each bidder will be notified in writing as to the outcome of the

proposal submission.

V. PROJECT FUNDING AND CONTRACTS

A. Contract Content and Payment Process

When the award is announced for the successful proposal(s), the contract process will be

initiated between Eastpointe and the successful bidder. Negotiations will be conducted and based

on the bidder’s proposed budget in combination with the project narrative and startup

timeframes.

B. Accounting Records

The contractor will be required to maintain current and accurate fiscal and accounting controls to

show the status of costs incurred under this contract. Accounting records must be supported by

documentation and show a clear “audit trail” for all funds received and disbursed. The contractor

will maintain for a period of five years from the date of service (unless another timeframe is

mandated), accounting records in accordance with generally acceptable accounting principles


and Medicaid record keeping requirements and other records as necessary to disclose fully the

extent of services provided and billed to the Medicaid/IPRS Programs as applicable. For

providers who are required to submit annual cost reports, records including invoices, checks,

ledgers, contracts, personnel records, work sheets, schedules, etc. such records are subject to

review and audit and reviewed by Federal and State Representatives.

C. Monitoring

The service will be monitored by Eastpointe on a regular basis throughout the term of the

contract. Monitoring may include oral reports, site visits, and telephone contact and/or

discussions of reports. The goal of this monitoring will be to ensure that the terms of the contract

are being met and to provide technical assistance, where necessary, to help the contractor meet

these obligations. As a contract provider of services for Eastpointe members, the contractor may

be reviewed by any agency reviewing Eastpointe.

VI. TERMS AND CONDITIONS GOVERNING THIS REQUEST FOR

PROPOSALS PROCESS

The term of the contract shall be on the same timeline as the Medicaid Contract and will be

included in that contract. No services may be subcontracted without written approval of

Eastpointe.

1. The contract will be subject to Eastpointe processing procedures for contracts of this type,

including approval as to form by the Area Director and Finance Director. The successful bidder

shall commence contract activities only after receipt of a fully approved copy of the contract.

2. The RFP does not commit Eastpointe to award any contracts, to pay the costs incurred in the

preparation of a response to the RFP, or to procure or contract for services.

3. Eastpointe reserves the right to amend, modify or withdraw this RFP and to reject any

proposals submitted, and may exercise such right at any time, without prior notice and without

liability to any applicant or other parties for expenses incurred in the preparation of a proposal or

otherwise. Proposals will be prepared at the sole cost and expense of the bidder.


4. Eastpointe reserves the right to accept or reject any or all proposals which do not completely

conform to the instructions given in the RFP.

5. The proposal of the successful bidder will serve as the basis for the contract, the terms of

which may be modified within the context of this RFP.

6. Submission of a proposal will be deemed to be the consent of the bidder to any inquiry made

by Eastpointe or third parties with regard to bidder’s experience or other matters relevant to the

proposal.

7. Eastpointe reserves the right to request and consider additional information from any bidder

beyond that presented in the initial proposal. The award of the contract, if any, may be made in

reliance on additional information requested. Such information may include budget justification,

program information, operation details, personnel information, or other funding source

information.

8. All products, deliverable items, and working papers resulting from this contract will be the

sole property of Eastpointe and the bidder is prohibited from releasing these documents to any

persons other than Eastpointe or Eastpointe’s designee, unless authorized by Eastpointe to do so.

9. Eastpointe reserves the right to investigate the bidder’s qualification, financial standing and

ability to perform the proposed work. Should Eastpointe determine that the bidder’s

qualifications, financial standing or ability to perform the work are inadequate, Eastpointe may

reject the proposal.

10. By submitting a proposal, the bidder agrees that it will not make any claims for or have any

right to damages because of any misinterpretation or misunderstanding of the specifications or

because of any misinformation or lack of information.

11. In order to enable Eastpointe to acquire goods and services that represent the “best value”,

Eastpointe reserves rights to:

a. Establish evaluation criteria relating to quality, quantity, performance and cost; establish the

relative importance of each criterion; and evaluate proposals as well as award contracts on the

basis of these criteria;

b. Provide that every offer shall be firm and not revocable for a period of up to sixty (60) days

unless withdrawn in writing or unless otherwise specified in the solicitation; and


c. Award a contract for any or all parts of a proposal and negotiate contract terms and conditions

to meet agency program requirements consistent with the solicitation.

VII. REQUEST FOR PROPOSAL PROTEST

A. Reason for Automatic Rejection of an Application

The following reasons shall be grounds for automatic rejection of an application due to failure to

conform to the requirements of the RFP:

1. Applicant did not meet the required application deadline;

2. The Proposal Agreement form is not signed in the appropriate places. Signature(s) on

attachments or other documents do not count as signature(s) on the Proposal Agreement

form;

3. Application is incomplete in critical areas as determined by a review team convened by

the Area Director;

4. Non-compliance with the administrative requirements, including but not limited to the

absence of attachments, price verifications, and letters of intent to provide service;

5. Proof of eligibility, if applicable;

6. Application submitted in an unacceptable manner, e.g., telephone, fax.

7. Applicant does not meet the standards for receipt of State and Federal block grant or

other funding source requirements if applicable.

B. Notification of Deficiencies

Nothing in this process shall preclude Eastpointe from notifying the applicant of any deficiencies

in the application. However, all corrections must be completed and received by Eastpointe by the

application deadline as set forth in the RFP. The notification of discrepancies shall be uniformly

made to all applicants in a timely manner.

C. Public Information

The RFP shall become public information at the completion of the RFP process including the

protest process, despite any other disclaimers submitted by the applicant to the contrary.


APPLICATION PACKAGE

INSTRUCTIONS & FORMS Proposal Instructions

The proposal must adhere to the outline described below. Proposals should be clear and well

defined in describing the proposed deliverables and activities to achieve them. All required

documents must be submitted in the following outline order for proposal submission to be

considered. Elaborate proposals in the form of brochures or other presentations beyond the

necessary to present a complete and effective proposal are not desired. All submissions are to be

printed double sided and use a font of at least 11 point.

Outline Order for Submission

(Items under each section can be responded to in narrative format versus question and answer)

A. Cover Letter

Complete all questions in the Proposal Cover Letter form.

B. Executive Summary

This section should outline the required deliverables and provide an overview of the proposal.

Describe why you believe your organization, from a professional and technical perspective is the

best fit.

Describe the distinguishing features the panel should know about your services and company as

well as an overview of your proposal.

Describe which of the Eastpointe catchment counties you will and will not be willing to serve for

this service.

C. Relevant Experience of the Applicant

Evidence of bidder’s organizational ability to implement the program(s) described.

Description of bidder’s experience, if any, providing Residential Treatment – Level III.

Quality improvement experience and procedures to be used by bidder to assure the quality and

completeness of the services in accordance with this RFP.


Description of bidder’s experience, if any, working with various community organizations

(hospitals, health centers, group practices, schools, juvenile justice and DSS etc.) which will

support timely access to services for members.

Reference checks will be done based on the completion of the required Reference forms. Three

references must also be submitted for any bidder and subcontractor.

D. Project Narrative

Describe why your organization is interested providing Residential Treatment – Level III as an

agency.

Describe your strategies and abilities to provide the required service(s) and begin services in the

required timeframe.

Describe all the methods that your agency will use for completing all aspects of the project(s).

This includes the projects mentioned in this proposal and any other innovative proposals.

Describe what has worked and has not worked in providing Residential Services – Level III.

Describe how you will ensure that the service follows person centered principles.

Describe how your organization renders services that are culturally and gender responsive.

Describe your relationship with the community stake holders in the region your organization

serves.

If a subcontract(s) will be used, identify the subcontractor(s) and their specific role in achieving

the components.

A letter and references from the subcontractor(s) must accompany the application specifying the

qualifications of the subcontractor to provide the services to be supplied and the availability of

the subcontractor(s) to perform the work during the contract period.

Describe how you plan to track performance data use outcomes to guide services.

E. Staffing Plan

Applicants must include a staffing proposal that includes a copy of staff job descriptions needed

to complete the project(s) components.


Provide the proposed staffing level with the number of FTEs by position.

Identify any staff that have licensure, certification, etc. that is specific to the staffing

requirements in the applicable service definition.

Submit a proposed organizational chart; identify vacancies.

Provide information about your strategies for recruitment, retention and support of qualified

staffing.

Describe any subcontractors you will anticipate using to carry out this service.

Describe the type of trainings and timeframes for each training by FTE.

Describe your organization’s philosophy and policy on hiring individuals with criminal records.

G. Fiscal Year Audit/Annual Report

Include an electronic copy of your most recent audited financial statement; include a

management letter if received. If an audit has not been conducted an electronic copy of the

compilation report by an independent auditor is acceptable.

Include an electronic copy of your organization’s most recent annual report.

Indicate if your organization is complaint with all reporting requirements from all funding

sources.

Indicate if your organization is current on all tax filings and payments, including all payroll tax

returns and annual tax returns.

H. Results of Investigations/Legal Information

A statement indicating any investigative actions by any Local, State or Federal entity indicating

the dates of the investigation, the entity conducting the investigation and the outcome since July

1, 2013.

Identify any litigation or governmental or regulatory action pending against your organization.

Describe the organization’s corrective actions to address these issues.


Provide information about whether or not your organization ever defaulted on a contract to

provide MH/DD/SAS services or had a contract terminated.

Document if your organization has been involved in litigation involving such contracts.

Describe any pending agreements to merge or sell you organization.

Provide details of any office closures that resulted in the termination of services in the last three

years.


Eastpointe Request for Proposal for Residential Treatment – Level III

Proposal Cover Letter

1a. Name and Address of Bidder (Include name and title of official authorized to sign)

Click or tap here to enter text.

Name/Title of Official: Click or tap here to enter text.

1b. Type of Organization ☐ Not-for-Profit ☐ For-Profit ☐ Public

2. Contact Person

Name: Click or tap here to enter text.

Title: Click or tap here to enter text.

Telephone Number Click or tap here to enter text.

Fax Number: Click or tap here to enter text.

Email address: Click or tap here to enter text.

Will this individual be directly in charge of the program ☐Yes ☐No If no, who will be in

direct charge?

Name/Title: Click or tap here to enter text.

Telephone and Fax Number: Click or tap here to enter text.

3. Do you have a corporate seal? ☐Yes ☐ No

4. Federal Payee Identification Number: Click or tap here to enter text.


5. Payment address (if different from#1) :Click or tap here to enter text.

Has your organization, under the name listed here, currently a provider in the Eastpointe

provider network? ☐Yes ☐ No If yes, please indicate for what services: Click or tap here to

enter text.

Does your agency currently have a contract with any MCO’s other than Eastpointe?

☐Yes ☐No If yes, please describe: Click or tap here to enter text.

Has your agency had any adverse fiscal, clinical or administrative actions from any regulatory

agency in the past 12 months? ☐Yes ☐No If yes, please explain: Click or tap here to enter text.

Is your agency in Good Standing with all entities that your agency has a Memorandum of

Agreement/Contract with? ☐ Yes ☐No If No, please explain: Click or tap here to enter text.

Is your agency in Good Standing with other contractual and regulatory agencies?

☐ Yes ☐No If No, please explain: Click or tap here to enter text.

Which of the following county(s) do you propose to provide the RFP service in? (Check all that

apply) ☐Bladen ☐Duplin ☐Edgecombe ☐Greene ☐Lenoir ☐Sampson ☐Robeson

☐Scotland ☐Wayne ☐Wilson


Residential Treatment – Level III PROPOSAL AGREEMENT:

It is understood and agreed to by the bidder that (1) The project(s) may be terminated in whole,

or in part, immediately upon notice by Eastpointe. Such termination shall not affect obligations

incurred under the contract prior to the effective date of such terminations. (2) Any significant

revision of the approved project proposal must be requested in writing by the contractor and

approved by Eastpointe prior to enactment of the change. (3) Progress reports must be submitted

as required by Eastpointe. (4) Necessary records and accounts, including financial and property

controls, must be established and maintained by the Contractor for five years and made available

to Eastpointe for audit purposes. (5) All reports of investigations, studies, publication, etc. made

as a result of this proposal must acknowledge the support provided by Eastpointe (6) All

personal information concerning individuals served or studied under the project is confidential

and such information must not be disclosed to unauthorized persons. (7) Eastpointe reserves a

royalty-free, non-exclusive license to use and authorize others to use all copyrighted material

resulting from this project.

The bidder certifies that to the best of his/her knowledge and belief the data in this application is

true and correct, and that he/she will comply with the above agreement if the contract is received.

______________________________________________________________________

Signature of Official Authorized to Sign for Bidder Date


Reference Form

Complete one form for the agency

Names and telephone numbers of 3 references that can speak to your agency’s qualifications to

operate the project which you are applying for funding must be provided. Please include the

description of work done, including the value of the contract, and the applicable contract

manager(s) as references(s).

A) _____________________________________________________________________

Name


Telephone Number


Agency Name and Address


Description of Work Done


Value of Contract:


B) _______________________________________________________________________

Name


Telephone Number







Value of Contract:


C) _____________________________________________________________________

Name


Telephone Number






Value of Contract:



Additional Funding Form

Name of Organization Click or tap here to enter text.

List all funding received from any North Carolina State/Local Government Agency during the

past three (3) years. Complete the following information including the name and telephone

number of a representative of the state/local agency who can be contacted by Eastpointe. Use

additional pages if necessary.


COPY OF CLINICAL COVERAGE POLICY

NC Medicaid Medicaid and Health Choice

Residential Treatment Services Clinical Coverage Policy No.: 8-D-2

Amended Date: March 15, 2019

19C5

Attachment D: Residential Treatment—Level III

Residential Treatment Level III service is responsive to the need for intensive, active therapeutic

intervention, which requires a staff secure treatment setting in order to be successfully

implemented. This setting has a higher level of consultative and direct service from

psychologists, psychiatrists, medical professionals, etc.

Staff are awake during sleep hours and supervision is continuous.

This service includes all Family/Program Residential Treatment elements and the following

activities:

a. Individualized, intensive, and constant supervision and structure of daily living designed to

minimize the occurrence of behavior related to functional deficits, to ensure safety and contain

out of-control behaviors including intensive and frequent crisis management with or without

physical restraint or to maintain optimum level of functioning.

b. Includes active efforts to contain and actively confront inappropriate behaviors and assist

beneficiaries in unlearning maladaptive behaviors. Includes relationship support to assist the

beneficiary in managing the stress and discomfort associated with the process of change and

maintenance of gains achieved earlier and specifically planned and implemented therapeutically

focused interactions designed to assist the beneficiary in correcting various patterns of grossly

inappropriate interpersonal behavior, as needed. Additionally, providers require significant skill

in maintaining positive relationship in interpersonal dynamics, which typically provoke rejection,

hostility, anger and avoidance.

Treatment is provided in a structured program setting and staff is present and available at all

times of the day, including overnight awake. A minimum of one staff is required per four

beneficiaries at all times. Additionally, consultative and treatment services at a qualified

professional level shall be provided four hours per child per week. This staff time may be

contributed by a variety of individuals. For example, a social worker may conduct group

treatment or activity; a psychologist may consult on behavioral management; or, a psychiatrist

may provide evaluation and treatment services. These services must be provided at the facility


site. Group therapy or activity time may be included as total time per beneficiary (i.e., if there are

six members in a group for 90 minutes, this may be counted as 90 minutes per

beneficiary).

*Note: Periodic services may not be used to augment residential services.

A.Therapeutic Relationship

This service provides all Family/Program Residential Treatment Level II elements plus the

relationship, which is structured to remain therapeutically positive in response to grossly

inappropriate and provocative interpersonal behaviors including verbal and some physical

aggression.

B. Structure of Daily Living

Daily living is structured to provide all elements of Family/Program Residential Treatment Level

II plus intensified structure, supervision, and containment of frequent and highly inappropriate

behavior. This setting is typically defined as being "staff secure."

C. Cognitive/Behavioral Skill Acquisition

Treatment provides all Family/Program Residential Treatment Level II elements plus active

"unlearning" of grossly inappropriate behaviors with intensive skill acquisition. Includes

specialized, on site interventions from qualified professionals.

Service Type

Residential Treatment Level III is a 24-hour service. Licensed under 122-C.

Resiliency/Environmental Intervention

This service is to support the youth in gaining the skills necessary to step down to a lower level

of care.

Service Delivery Setting

Program/Group Home type.

D. Medical Necessity

The beneficiary is eligible for this service when:

Medically stable but may need significant intervention to comply with medical treatment.


AND

The beneficiary’s identified needs cannot be met with Family/Program Residential Treatment

service.

AND

The beneficiary is experiencing any one of the following (may be related to the presence of

severe affective, cognitive or behavioral problems or intellectual/developmental

delays/disabilities):

a. Severe difficulty maintaining in the naturally available family setting or lower level treatment

setting as evidenced by, but not limited to:

1. frequent and severe conflict in the setting, OR

2. frequently and severely limited acceptance of behavioral expectations and other

structure,

OR

3. frequently and severely limited involvement in support or impaired ability to form

trusting relationships with caretakers, OR

4. a pervasive and severe inability to form trusting relationships with caretakers or family

members, OR

5. an inability to consider the effect of inappropriate personal conduct on others.

b. Frequent physical aggression including severe property damage or moderate to severe

aggression toward self or others.

c. Severe functional problems in school or vocational setting or other community setting as

evidenced by:

1. failure in school or vocational setting because of frequent and severely disruptive

behavioral problems, OR

2. frequent and severely disruptive difficulty in maintaining appropriate conduct in

community settings, OR

3. severe and pervasive inability to accept age appropriate direction and supervision from

caretakers or family members, coupled with involvement in potentially life-threatening,

high-risk behaviors.

d. Medication administration and monitoring have alleviated some symptoms but other treatment

interventions are needed to control severe symptoms.

e. Significant limitations in ability to independently access or participate in other human services

and requires intensive, active support and supervision to stay involved in other services.

f. Significant deficits in ability to manage personal health, welfare, and safety without intense

support and supervision.

g. For beneficiaries identified with or at risk for inappropriate sexual behavior:

1. The parent/caregiver is unable to provide the supervision of the sex offender required

for community safety.


2. Moderate to high-risk for re-offending.

3. Moderate to high-risk for sexually victimizing others.

4. Deficits that put the community at risk for victimization unless specifically treated for

sexual aggression problems.

5. A Sex Offender Specific Evaluation (SOSE) shall be provided by a trained

professional and a level of risk shall be established (low, moderate, high) using the Risk

Checklist for Sexual Offenders, the Juvenile Sexual Offender Decision Criteria, and a

Checklist for Risk Assessment of Adolescent Sex Offenders.

E. Service Order Requirement

Service must be ordered by a primary care physician, psychiatrist or a licensed psychologist. All

service orders must be made prior to or on the day service is initiated.

F. Continuation/Utilization Service Review

The desired outcome or level of functioning has not been restored, improved or sustained over

the time frame outlined in the beneficiary’s service plan or the beneficiary continues to be at risk

for relapse based on history or the tenuous nature of the functional gains or any one of the

following apply:

a. Beneficiary has achieved initial service plan goals and additional goals are indicated.

b. Beneficiary is making satisfactory progress toward meeting goals.

c. Beneficiary is making some progress, but the service plan (specific interventions)

needs to be modified so that greater gains, which are consistent with the beneficiary’s

pre-morbid level of functioning, are possible or can be achieved.

d. Beneficiary is not making progress; the service plan must be modified to identify more

effective interventions.

e. Beneficiary is regressing; the service plan must be modified to identify more effective

interventions.

AND

The statewide vendor authorizes admission and conducts concurrent utilization reviews.

Utilization review must be documented in the service record.

G. Discharge Criteria

The beneficiary shall be discharged from this level of care if any one of the following is true:

a. The level of functioning has improved with respect to the goals outlined in the service plan

and the beneficiary can reasonably be expected to maintain these gains at a lower level of

treatment.


OR

b. The beneficiary no longer benefits from service as evidenced by absence of progress toward

service plan goals and more appropriate service(s) is available.

OR

c. Discharge or step-down services can be considered when in a less restrictive environment, the

safety of the beneficiary around sexual behavior and the safety of the community can

reasonably be assured.

*Note: Any denial, reduction, suspension or termination of services requires notification to the

beneficiary or legal guardian about their appeal rights.

H. Service Maintenance Criteria

If beneficiary is functioning effectively at this level of treatment and discharge would otherwise

be indicated, this level of service shall be maintained when it can be reasonably anticipated that

regression is likely to occur if the service were to be withdrawn. This decision should be based

on at least one of the following:

a. There is a past history of regression in the absence of residential treatment or a lower level of

residential treatment.

b. There are current indications that beneficiary requires this residential service to maintain level

of functioning as evidenced by difficulties experienced on therapeutic visits or stays in a

nontreatment residential setting or in a lower level of residential treatment.

c. In the event there are epidemiologically sound expectations that symptoms will persist and that

ongoing treatment interventions are needed to sustain functional gains, the presence of a DSM-

5, or any subsequent editions of this reference material, diagnosis would necessitate a

disability management approach.

*Note: Any denial, reduction, suspension or termination of services requires notification to the

beneficiary or legal guardian about their appeal rights.

I. Provider Requirement and Supervision

The minimum requirements are:

a. a high school diploma or GED, associate degree with one (1) year of experience, OR


b. a four-year degree in a human service field; OR

c. a combination of experience, skills, and competencies that is equivalent; PLUS

d. Skills and competencies of this service provider must be at a level that offers

psychoeducational and relational support, behavioral modeling of interventions, and

supervision. These preplanned, therapeutically structured interventions occur as required and

outlined in the beneficiary’s service plan.

e. Must meet requirements established by state personnel system or equivalent for job

classifications. Supervision provided by a qualified professional as stated in 10A NCAC

27G.0104 rules regarding professionals and paraprofessionals.

AND

f. Sex Offender Specific Service Provision: In addition to the above, when the beneficiary

requires sex offender specific treatment as outlined in their treatment plan, special training of

the caregiver is required in all aspects of sex offender specific treatment. Implementation of

therapeutic gains is to be the goal of the placement setting.

AND

g. Supervision provided by a qualified professional with sex offender-specific treatment

expertise is available per shift.

J. Documentation Requirements

The minimum documentation standard is a full service note per shift on the standardized form.

The documentation of interventions and activities is directly related to the beneficiaries:

a. identified needs,

b. preferences or choices,

c. specific goals, services, and interventions, and

d. frequency of the service which assists in restoring, improving or maintaining the

beneficiary’s level of functioning.

e. Documentation of critical events, significant events or changes in status in the course

of treatment shall be evidenced in the beneficiary’s medical record as appropriate.

f. Documentation includes the specific goals of sex offender treatment as supported and

carried out through the therapeutic milieu and interventions outlined in the service plan.

K. Residential Treatment—Level III

For Medicaid, the Residential Treatment—High is a service targeted to children under age 21

which offers a highly structured and supervised environment in a program setting only,

excluding room and board.

For NCHC, the Residential Treatment—High is a service targeted to children 6 through 18 years


of age which offers a highly structured and supervised environment in a program setting only,

excluding room and board.

This service provides the following activities under its core program:

YES NO

Staff secure and structured therapeutic

environment designed to maximize the

opportunity to improve the beneficiary’s

level of functioning.

Activities provided by Medicaid or NCHC

funded residential programs: acute

hospitalization, ICF-MR, rehabilitation

facilities, and nursing facilities for medically

fragile children, etc.

Immediate staff support/supervision for

person directed and managed activities in all

identified need areas.

Child care facilities which cannot meet

mental

health licensure and standards.

Foster care.

Run-away shelters

Respite providers.

Summer recreation camps.

Periodic services may not be used to augment

residential services.

Mentoring.

Direct assistance with adaptive skills

training.

Direct assistance with adaptive skills

training.

Directed/supervised community integration

activities.


Modeling, positive reinforcement,

redirection, de-escalation, guidance, etc.

through staff/individual/peer interactions.

Supervised recreational activities when used

as a strategy to meet clinical goals.

Directed/supervised psychoeducational

activities including the development and

maintenance of daily living, anger

management, social, family living,

communication, and stress management

skills, etc.

Consultation from psychiatrist/psychologist

on a monthly basis.

Eastpointe Managed Care Organization REQUEST FOR …...Jun 21, 2019 · Residential Treatment Level...

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