VACSB Quality Leadership Committee

Performance Contract Monitoring FY 17

Requirements Matrix

Development Team: Sally Berger, Cheryl Collier, Melissa Constantine, Nancy Curry, Robert Horne, Michelle Lakins, Heather Rupe, Laura Schmitt
6/24/2016
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Section I – Performance Contract Document

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I. FY 2017/2018 COMMUNITY SERVICES PERFORMANCE CONTRACT

4. Scope of 4.a Services 3 CSB shall DBHDS Notification & As required, prior to
Services  Notify DBHDS and obtain approval before License Modification approval and change
o Providing a new category of core services, and receive approval
before starting new or ending existing
o Modifying a licensed service (at least 45 days in advance)
o Closing a Residential Crisis Stabilization program or increasing or
decreasing licensed number of beds
o Annual utilization of CSU of 75% Monitor Annually CCS Reporting of
 Establish appropriate criteria for TDOs and accept any appropriate CSU utilization
referrals; criteria to be submitted with contract
4.b Expenses for 3 CSB shall provide services funded within the funds and for expenses set forth Monitor & Audit Ongoing
Services in Exhibit A
 Documented in CSB’s financial management system in an auditable way
that satisfies Generally Accepted Accounting Principles
 Distribute reasonable administrative & management expenses across DD,
MH, SA
4c Continuity of 3 CSB shall follow Continuity of Care Procedures; refer to Section A – CSB Orient, Monitor & Ongoing
Care Administrative Requirements, Discharge Protocols for CSBs & State Hospitals Report
and Admission & Discharge Protocols for Individuals with Intellectual
Disabilities
 Coordinate ID Waiver services and provide case management services to
all who receive ID Waiver services
 Collaborate with hospitals, inpatient psych facilities, and emergency room
staff to promote Continuity of Care
 Provide information about substance abuse services for minors to all
hospitals licensed in service area (Article 1, Chapter 5, Title 32)
 Follow Medical Screening and Assessment Guidelines and collaborate with
other treatment providers to ensure timely and effective medical services.
 Coordinate with local psychiatric hospitals to assure appropriate
treatment & discharge planning

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 Provide rehabilitative mental health and targeted ID case management in

accordance with applicable DMAS manuals
 Establish procedure to ensure individuals have choice of case managers
 Provide a procedure to DBHDS upon request
 Ensure individuals are not required to receive case management services
in order to receive other services
 PACT programs shall
o Prioritize services for individuals with SMI who are homeless or
frequent recipients of inpatient services
o Maintain a caseload of 80 individuals
o Participate in TA recommended by DBHDS

 Participate in and utilize the VA Psychiatric Bed Registry and maintain up- Update whenever
to-date information about Crisis Stabilization bed availability in the there is a change in
registry bed availability, or at
least daily
 Preadmission screening
o For any person in need of involuntary admission for psychiatric
treatment
o Ensure screening services are provided by qualified evaluators
that have received DBHDS training
 Discharge planning
o Provide in accordance with state policies, procedures and
protocols, and
o Monitor extraordinary barriers to discharge and strive to achieve
community placement for individuals
 Provide reliable, timely and accurate Developmental Disabilities
Information and Referral for individuals seeking services and supports

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4d Population 6 Prioritize services for a) adults with SMI, b) children at risk of SED, and c)
Served individuals with ID, DD or SUD as defined in the current Core Service Taxonomy
4e DOJ 6 Comply with requirements 1-24 in DOJ settlement Agreement as applied to Monitor, Report, As required in PC
Settlement individuals with developmental disabilities who reside in training centers, meet Participate Section 4e
Agreement criteria for ID or DD Waiver waiting list, reside in a nursing home or ICF, or
Requirement receive Medicaid Home & Community-based ID or DD Waiver
s
4f Emergency 10 Emergency Services shall Establish procedure; Upon DBHDS request
Services  Operate at least one local and where appropriate, one toll-free number Support & Monitor 9/30/2015
Availability for ES calls available 24 hours per day sufficient to provide immediate
access to a qualified ES staff member. Phone number shall be displayed on
the main page of the CSB web site
 Document and Implement procedures for handling ES calls that ensure
adequate coverage by qualified staff.
 Ensure calls are not answered electronically or immediately transferred to
other ES staff, 911 or the local sheriff or police department phone number
 Ensures protocol for coordination and referral to REACH for individuals
with developmental disabilities
4g Emergency 10 CSBs shall ensure all Emergency Evaluations include required elements and are Monitor
Evaluations performed by certified preadmission screening evaluators
4h Emergency 11 CSB shall Monitor
Evaluation  Prioritize having emergency custody and preadmission screening
Staff evaluations conducted by the most qualified, knowledgeable and
experience CSB staff
 CSB will comply with the Certification of Preadmission Screening Clinicians
document

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4i Development 11 Case managers shall Monitor for DBHDS

al Case  meet KSA qualifications in licensing regulations – to be verified during inspections
Management licensure inspections by review of personnel records
Services  ISP reviews to include modifications when individuals’ needs/desires
change are to be conducted quarterly or every 90 days.
 Ensure all information is up-to-date in the waiver electronic system
 Request from DBHDS a Supports Intensity Scale (SIS) assessment when a
newly enrolled individual requests or if the individual’s status or needs
change after six months support
 CMs will cooperate with designated SIS contractor in scheduling and
participating in assessments
 CMs will notify the designated DBHDS staff when an individual is
terminated from all waiver services within 10 Days Notify DBHDS Within 10 Days
 CMs shall submit Request to Retain a Slot form and Slot Assignment
Results spreadsheet to appropriate DHBDS staff
 CM’s will complete level of care tool for DD waiver services within 60 days
of application
 CM’s will comply with DD waitlist process and slot assignment process and
implement any changes in the process within 30 calendar days of written
notice
5. Resources 5a Allocation of 12 Provide accurate CCS or CARS reporting to substantiate the funds allocated CARS Report Monthly
State and CCS Report
Federal
Funds
5b Disbursemen 12 Provide accurate CCS or CARS reporting substantiate semi-monthly payments CARS Report Monthly
t of State or of restricted or earmarked state and federal funds CCS Report
Federal
Funds
5c Conditions on 12 Meet and monitor any conditions set forth by the department as a part of fund Monitor As Required
the Use of allocation
Resources

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6. CSB 6a State Hospital 12  Work with DBHDS and private providers in collaboration w/ public
Responsibilities Bed MH/SA/DD to manage utilization (bed days)
Utilization  Implement procedures to manage each admission by TDO
6b Quality of 13  Work with DBHDS and private providers in collaboration w/ public CSB Preadmission Upon DBHDS request
Care MH/SA/DD to manage utilization (bed days) screening
 Implement procedures to manage each admission by TDO.
1. Performance Measures Monitor and report Quarterly to CSB BoD
 CSB to monitor outcome and performance measures in Exhibit B measures
 CSB to identify and implement procedures for measures below
benchmarks
13 2. QIP Monitor, Review, and At least every 4 years
 Develop QIP for continuity of care and to address risk and perceived update as appropriate
risk
 Maintain Risk Management Plan-to address quality improvement
activities with DBHDS
 Collaborate regionally, state hospitals, Training Centers, & private
providers on Regional Utilization Management by using the guidance
document which can be found at the following link:
www.dbhds.virginia.gov/OCC-default.htm
13 3. Incident Reporting CHRIS Upon DBHDS request
 CSB to inform ED’s of deaths, serious injury, allegations of neglect
when reported to DBHDS
 Provide DBHDS with procedures upon request
13-14 4. Individual Outcomes and CSB Performance Measures
a. Report outcomes & measures in Exhibit B Report Upon DBHDS request
b. Ind. CSB measures may be negotiated by DBHDS due to Monitor
performance concerns and included in Exhibit D
c. Satisfaction surveys for individuals receiving services Participate Individual’s annual
planning meeting

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d. Strategic Prevention Framework: evidence-based model to Monitor

develop logic models and prevention plan in partnership with
community collaborators
e. Logic Model & Comprehensive Prevention Services Delivery Plan Monitor and
to outline CSB grant-funded prevention services and CSB implement
partnership coalition logic model
f. CSB to work with DBHDS’s OMNI Institute to evaluate SAPT Block Monitor
Grant Funded Services
Note: 75% SAPT Block grant prevention must be programs
included in the federal list of evidence-based interventions of
which a minimum 25% will be environmental strategies
g. SYNAR Amendment to decrease youth tobacco access. Provide Marketing &
merchant education to sustain merchant Retail Violation Rate education activities
(RVR) under 20%.
h. Administer ROSI Implement and Biennially last
Monitor business day of
March on odd year
15 5. CM Training: CSB to ensure all new CM complete DBHDS CM Curriculum Staff compliance within 30 days of
employment
CSB shall ensure developmental CM’s complete ISP training modules within 60
days of their availability within 60 days of
availability
6. Developmental CM Services Organization: CSB to ensure developmental CM Monitor Annually
is distinct & separate from services
15 7. Program & Service Review: DBHDS will conduct reviews of Monitor and Review At any time (DBHDS
programs/services provided by CSB. CSB to provide access to records and discretion)
critical incidents.
15 8. Response to Complaints Implement, Monitor With every complaint
 CSB to implement procedures for local dispute resolution for and Report from individuals
individuals receiving services. CSB to respond to complaints to seek receiving services

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satisfactory resolution.
 CSB shall inform DBHDS of complaints within 5 business days;
provided follow-up within 10 business days
 CSB to post complaint procedures in public areas and on CSB website
9. Access to Opioid Treatment Implement and Ongoing
 CSB will provide rapid access to appropriate treatment within 14 days Monitor
of request; 120 days if no capacity is available; 48 hours for interim
services
6c Reporting 16 1. CSB Responsibilities
Requirements a. Community Consumer Submission (CCS): individual service data to Implement, Review, Monthly
DBHDS. Monitor, Report
b. Core Services Taxonomy and CCS Extract Specifications and Design
Specifications
c. Complete National Survey of SA Treatment Services (N-SSATS) to Annually
update National Directory of Drug and ETOH abuse treatment
Programs.

d. Follow user acceptance testing under Appendix D of CSB Upon request from
Administrative Requirements DBHDS.
e. ETO Prevention Data System for Service Data June 15
CARS for Funding, expenditure and cost data
f. Supply info of NGRI to Department’s Forensic Information
Management System
g. Report data required by Appropriation Act
h. (if CSB is fiscal agent) report thru VACSB DMC on regional REACH
17 2. Routine Reporting Requirements
a. Types of services provided, costs for services provided, and funds Implement, Review, Semi-Annually
received for emergency and ancillary services Monitor, Report

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17 b. Demographics Monthly via CCS

c. Community Waiting List for Comprehensive State Plan
d. State Facility Discharge Waiting List Data Base

e. Federal Balance Report October 15

f. PATH reports Mid/end of fiscal year

g. Report amounts of funds used to pay for services End of fiscal year
17 3. Subsequent Reporting Requirements: Monitor, Review, and
a. CSB to work with Data Management Committee (DMC) of VACSB to Report
ensure all reporting is consistent with Core Services Taxonomy, CCS,
and Treatment Episode Data Set (TEDS).
b. CSB to work with DMC in planning and developing any additional
reporting.
17 4. Data Elements: a. CSB to work with DMC to evaluate and update data Review and Report
elements
17 5. Streamlining Reporting Requirements: Review, Monitor, and
a. CSB to work with DMC to review, streamline, reporting requirements Report
b. b. to ensure reporting requirements are consistent with current CCS
Extract Specifications and Core Services Taxonomy
6d Providing 18 CSB to provide DBHDS any information related to services, funds, or Report Upon request of
Information expenditures. DBHDS

6e Compliance 18 a. CSB to comply with all applicable federal, state, and local laws. Review, Monitor, and Ongoing
Requirements b. CSB will comply with HIPAA. Report
c. CSB will ensure sensitive data (PHI) exchanged electronically with DBHDS,
state hospitals, and training centers meet requirements of FIPS 140-2
(encryption).

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6f Regional 18 a. CSB will report on regional programs Implement Ongoing

Programs b. CSB agrees to participate in any utilization review conducted by DBHDS
c. PHI may be disclosed as permitted by 45 CFR

6g Intensive 19 1. CSB is considered the most appropriate provider for intensive care Develop a plan, Ongoing
Care coordination (ICC) services thru the Comprehensive Services Act for At Risk Monitor, Implement
Coordination Youth and Families.
2. If CSB is identified as ICC, it shall work with Community Policy and
Management Team (CPMT(s)) and Family Assessment and Planning
Team(s) to implement services, to assure adequate support, and to assure
all children receive appropriate assessment and care planning services.
6h Electronic 19 CSB to implement and maintain EHR that is fully certified. Implement and Ongoing
Health Monitor
Record
6i Reviews 19 a. CSB to participate in periodic, comprehensive administrative and Monitor Periodic
programmatic reviews by DBHDS.
b. CSB shall address recommendations by the date specified.
6j Consideration 19 ED and BoD are to consider issues/concerns raised by Commissioner of DBHDS Respond to DBHDS Ongoing
of regarding operations or performance.
Department
Comments
7. Department Responsibilities Not included in analysis as this section outlines Department’s responsibilities. can be referenced at www.dbhds.virginia.gov/OCC-default.htm
8. Sub- 8a Subcontracts 25 Review subcontracts for the following elements: Review Subcontracts As needed
contracting  Activities to be performed
 Time schedule and duration
 Policies and Requirements
 Data reporting applicable to the subcontractor
 Max amount of money for which the CSB may be obligated
 Manner of compensation
 Payment Timeframes

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8b Subcontractor 25 Monitor Compliance of subcontractor in following areas: Monitor Compliance As Needed

Compliance - Compliance with applicable laws
- Submission of CCS 3 data on all persons served
- Maintain that the individual meets all relevant qualifications
- Compliance to Human Rights Regulations
8c Dispute 25 Contracts should include contract dispute procedures Monitor As Needed
Resolution
8d Quality 25 Incorporate subcontracts into quality improvement activities Monitor Annually
Improvement
9. Terms and 9a Availability of 26 The Department and the CSB shall be bound by the provisions of this contract Information
Conditions Funds only to the extent of the funds available or that may hereafter become
available for the purposes of the contract.
9b Compliance 26 CSB must satisfy reporting requirements in the contract. DBHDS may utilize Monitor
various remedies to assure CSB Compliance
9c Disputes 26 The dispute resolution process outlined in 9f will be used to appeal disputes. Information

9d Termination 26 Conditions under which DBHDS or CSB can terminate this contract Information/process
immediately.
9e Remediation 27 The remediation process is an informal procedure that shall be used by DBHDS Information/process
Process and the CSB to address a particular situation or condition identified DBHDS or
the CSB that may, if unresolved, result in termination of the contract, in whole
or in part.
9f Dispute 27 Outline of steps in the dispute resolution process. Information/process
Resolution
9g Contract 28 The performance contract constitutes the entire agreement between CSB and Information
Amendment DBHDS. Exhibit E outlines process for amending the contract.
9h Liability 28 CSB shall obtain and maintain sufficient liability insurance to cover claims of Monitor
bodily injury and property damage and suitable administrative or directors and
officers liability insurance.
The CSB shall provide a copy of any such policy or program to the Department
upon request.

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9i Constitution 28 The resolutions or ordinances currently in effect that were enacted by the Monitor
of the CSB governing body or bodies of the local government or governments to establish
the CSB are consistent with applicable statutory requirements in §§ 37.2-500,
37.2-501, and 37.2-502 or §§ 37.2-601, 37.2-602, and 37.2-603 of the Code of
Virginia.
9j Severability 29 Each paragraph and provision of the contract is severable from the entire Information
contract.
10. Signatures 10 Signatures 29 Contract will be signed by CSB Chairperson and the CSB Executive Director Signatures

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A Resources 30 Exhibit A is submitted to the department by the CSB electronically using Report via CARS Semi- Annual
and Services the CARS software application. Information includes but is not limited to:
1. Consolidated Budget Information
2. Funds for specific MH & SA Services
3. Local Government Tax Appropriations
4. Reconciliation of Projected Resources and Core Services Costs by
Program Area
5. Projected service capacity, program specific for Emergency and
Ancillary Services, ID, MH &SA
6. Projected numbers of individuals receiving services, program
specific for Emergency and Ancillary Services ID, MH &SA
7. Projected total service costs, , program specific for Emergency
and Ancillary Services ID, MH &SA
8. Numbers of individuals receiving Pharmacy Medication Supports
B Continuous 44 I. The CSB agrees to monitor and report on the following Exhibit B Report via CCS 3 and Quarterly
Quality performance measures, using the Exhibit B Quarterly Performance Avatar
Improvement Measures Report:
Process and A. Those who keep a face-to-face (non-emergency) service visit
CSB within seven business days after having been discharged from a
Performance private psychiatric hospital or psychiatric unit in a public or
Measures private hospital following involvement in the civil involuntary
admission process.
B. Monitor the % of adults (18 or older) in the DOJ Settlement
Agreement population receiving CM services whose case
managers discussed employment with them during their annual
CM ISP meeting or updates.
C. Monitor the % of adults (18 or older) in the DOJ Settlement
Agreement population receiving CM services whose ISPs included
employment related or employment readiness goals.
D. Percentage of Individuals in the DOJ settlement agreement
population who receive CM whose CM discussed community

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engagement opportunities with them during their most recent

annual case management ISP meeting,
E. Percentage of individuals in DOJ settlement agreement
population receiving Cm whose ISP contained community
engagement goals.

II. Data Quality Feedback – When requested by DBHDS, the CSB Ex Report When requested by
Director shall develop and submit a plan of correction to remedy DBHDS
persistent deficiencies in the CSB’s CCS 3 submissions
III. CSB Performance Measures – Use the CSB Performance Measures to Monitor Ongoing
monitor outcome and performance – improve when CSB falls below
benchmark.
IV. Residential Crisis Stabilization Program Utilization – CSB’s operating Ensure 75% utilization Ongoing
these programs shall ensure that the program achieves an annual
average utilization rate of at least 75% of available bed days as
measured by data from CCS 3 and CARS service capacity data.
V. Ensure Access within 48 hours to SA Services for Pregnant Women Report via CARS Ongoing
per SAPT block grant
C Discharge 48 DAP Requirements
Assistance 1. DBHDS will work with VACSB, CSB and Regional Managers to develop Monitor Monthly
Programs clear and consistent criteria for identification of individuals who would
be eligible for IDAPP and standard terminology

2. CSB will comply with the Discharge Assistance Program Manual Monitor Monthly

3. CSB will participate on the regional management group (RMG) and Monthly
regional utilization management and consultation team (RUMCT)
4. CSB though RMG and RUMCT will ensure that other funds are used to Monthly
offset the cost of approved IDAPP
5. Regional Manager will submit mid-year and end of year fiscal repot to Monitor Monthly
DBHDS is designated format

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6. The CSB and state hospital representative on the RMG shall have the Monthly
authority to reallocate regional state DAP funds among CSB’s that
cannot use them in a reasonable time to CSB’s that need additional
regional state DAP funds to implement more IDAPP to reduce EBL.
7. If CSB’s in the region cannot expend at least 90% and obligate at least Monitor Monthly
95% of the total annual regional state DAP fund allocations on a
regional basis by the end of the fiscal year, DBHDS may work with
RMG to transfer funds to other regions.
8. Regional Manager will submit quarterly summary of IDAPP to DBHDS Monthly
in a designate format that displays year to date information about
ongoing and one-time IDAPP including date about each individual
receiving DAP services, the amounts, total number of IDAPP that have
been implemented and projected total net regional DAP funds
obligated for these IDAPPs.
9. DBHDS may conduct utilization reviews of the CSB or region at any Monthly
time to confirm the effective utilization of regional state DAP funds
and the implementation of all approved ongoing and one-time
IDAPPs.
D Individual 49 Individual CSB Performance Measures Quality Management Quarterly
CSB & Programs
Performance Monitor
Measures
E Performance 50 This section lists out the specific dates in which elements of the PC must Meet Established Monthly, Quarterly,
Contract be met by the CSB (5-08-15 to 09-01-2016). Deadlines in the and Semi Monthly as
Process Note: Also includes Performance Contract Revision Instructions for contract Required
revisions to Exhibit A.
F Federal 56 Assure compliance with the applicable provision of the federal MH Monitor Ongoing
Compliance Services Block Grant and the federal SA Prevention and Treatment Block
Grant.

See Exhibit F for exclusions on the use of these funds.

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G Local Contact 58 Form – Exhibit G: Provide the Local Contact for Disbursement of Funds to Report Annually
for DBHDS via the form.
Disbursement
of Funds

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I Administrative 59 CSB shall meet these administrative performance standards in submitting CARS
Performance its performance contract, contract revisions, quarterly performance
Standards contract reports in CARS and CCS extracts to the Department:

1. a-d: The performance contract and any revisions submitted by CCS

the CSB shall be complete, consistent, prepared in accordance to
instruction, received by the due date.
2. a-e: Quarterly performance contract reports submitted by the CSB shall CARS or CCS Monthly as required
be: complete, consistent, prepared in accordance to instruction,
received by the due date, understand the financial penalty associated
with not meeting the standards along with delayed payments
3. Monthly consumer type of care and service extract files shall be CARS or CCS Monthly as required
submitted by the end of the monthly following the extract in
accordance with the CCS extract and Design specification including the
currently business rules.
4. If the Department negotiates an Exhibit D with a CSB because of CCS Monthly
unacceptable data quality, and the CSB fails to satisfy the requirement
in Exhibit D by the end of the contract term, the Department may
impose a one-time one percent reduction not to exceed a total of
$15,000 of state funds apportioned for CSB administrative expenses on
the CSB
59 Process for obtaining an extension of the End of the Fiscal Year CARS Meet time required Monthly or as
Report Due Date Deadlines required by contract
Numbers 1-4: CSB Must contract the department four days prior
to the due date. A written notice must be submitted to the
contract by close of business at 5:00 PM. This can be done by fax.
J Other CSB 61 I. Compliance with State Requirements: General State Requirements –
Accountability The CSB shall comply with all applicable state statutes and regulations and
Requirements policies and Department procedures including the following requirements

A1. 2.2-3100.1 Code of Virginia CSB shall ensure the new board members Provide copy of Conflict One time for new
are furnished with a copy of the State and Local Government Conflicts of of Interest policy and board members, two

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Interest Acts by the Executive Director within two weeks of appointment document weeks of
appointment

61 A2. 2.2-3702 Code of Virginia CSB shall ensure all new board member are Provide a copy of FOIA One time for new
furnished a copy of the Freedom of Information Act by the executive board member, two
director or designee within two weeks of appointment, and new member weeks of
shall read and become familiar with provisions of the act. appointment

B1 Human Rights – The CSB shall comply with the current Rules and Monitor Daily Operation
Regulation to Assure the Rights of Individuals Receiving Services from
Providers Licensed, Funded or Operated by the Department of Behavioral
Health and Developmental Services

B2 – Disputes – The filing of a complaint or use of the informal dispute Policy Daily Operations
resolution mechanism in the human rights regulation by an individual or
his or her family member or authorized representative shall not adversely
affect the quantity, quality or effect is based on clinical or safety
considerations and is documented in the individual’s service plan
B3 Licensing – The CSB shall comply with the Rules and Regulations for QM Plan, Policies, Daily Operations
Licensing Providers by the Department of Behavioral Health and Monitor
Developmental Services. The CSB shall establish a system to ensure
ongoing compliance with applicable licensing regulations

C - CSB and Board of Directors Organization and Operations: The CSB Organizational Chart Daily Operations
Organization chart shall be consistent with current board of directors and and Policy, Board
staff organization. The organization shall include the local governing body position descriptions
or bodies that established the CSB

61 D. Reporting Fraud – Upon discovery of circumstances suggesting a Monitor Policy Daily Operations
reasonable possibility that a fraudulent transaction occurred, the CSB
executive director shall report this information immediately to any
applicable local law enforcement authorities and the Department Internal

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Audit Director. CSB shall refund any state or federal funds disbursed by
the Department to it that were involved in those financial transactions.
The CSB shall ensure new board members receive training on their
fiduciary responsibilities

63 Financial Management – The CSB shall comply with the following Monitor Daily Operations
requirements as applicable, 1-11
63 Employment of a CSB Executive Director or BHA Chief Executive Officer Hiring Policy, Monitor, Daily Operations
Notify DBHDS
65 Compliance with Federal Requirements Monitor Policies At least quarterly
A. General Federal Compliance Regulations – The CSB shall comply with all
applicable federal statutes regulations, policies and other requirements
including applicable provisions of the federal Project for Assistance in
Transition from Homelessness, Mental health services block grant,
Substance abuse prevention and treatment block grant, Federal
Immigration Reform and Control Act of 1986, Confidentiality of Alcohol
and Substance Abuse Records 42 CFR Part 2

66 B. Disaster Response and Emergency Services Preparedness Requirement Monitor Procedures Daily Operations
– The CSB agrees to comply with section 416 of Public Law 93-288 and 44-
146.13 through 44-146.28 Code of Virginia regarding disaster response and
emergency service preparedness. Section 416 of Public Law 93-288
authorizes the State Office of Emergency Services to require the
Department to comply with the Commonwealth of Virginia Emergency
Operations Plan, Volume 2, Emergency Support Function No 8: Health and
Medical Services, Section 4: Emergency mental health services – requires
the CSB to comply with the Department directive coordinating disaster
planning, preparedness, and response to emergencies and to development
procedures for responding to major disasters. These procedures shall
address: 1) conducting preparedness training activities 2) designating staff
to provide counseling 3) coordinating with state facilities and local health
departments or other responsible local agencies, department, or units in

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preparing CSB all hazards disaster plans, 4) providing crisis counseling and
support to local agencies including volunteer agencies 5) negotiating
disaster response agreement with local government and state facilities and
6) identify community resources.

67 C. Federal Certification Regarding Lobbying for the mental health and Monitor Daily Operations
substance abuse prevention and treatment block grants: The CSB certifies
to the best of its knowledge and belief that 1) no federal appropriated
funds have been paid or will be paid on behalf of the CSB to any person
influencing or attempting to influence an officer or employee of any
agency, member of congress, office employee of congress 2) CSB shall
complete and submit Standard Form – LLL, Disclosure Form to Report
Lobbying 3) CSB shall require the language of this certification be included
in the award documents for all sub awards at all tiers.

III Compliance with State and Federal Requirements Human Resources Daily Operations and
Monitor review of policies at
Employment Anti- Discriminations – The CSB shall conform to the Policy least every two year
applicable provisions of Title VII of the Civil Rights Act of 1964, Equal Pay Posting or as required by
Act of 1963, Sections 503 and 504 of the Rehabilitation Act of 1973, the other accrediting
Vietnam Era Veterans Readjustment Act of 1974, the Age Discrimination in organizations
Employment Act of 1990, The Virginians with Disability Act, the Virginia
Fair Employment Contracting Act, the Civil Rights Act of 1991, regulations
issued by Federal Granting Agencies and other applicable statutes and
regulations, including 2.2-4310 of the Code of Virginia. The CSB shall agree
not to discriminate, in all solicitations and advertisement state that it is an
equal opportunity employer

Service Delivery Anti-Discrimination – The CSB shall conform to

applicable provisions of Title VI of the Civil Rights Act of 1964, Sections 504
of the Rehabilitation Act of 1973, The American with Disabilities Act of

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1990, the Virginians with Disabilities Act, the Civil Rights Act of 1991,
regulations issued by the US Department of Health and Human Services.

1) CSB have been and will continue to operate in such a manner that no
person will be excluded from participating in, denied in the benefits of or
otherwise subjected to discrimination under such services on the grounds
of race, religion, color, national origin, age, gender or disability 2) The CSB
and it direct and contractual services will include these assurances in their
policy and practices and will post suitable notices of these assurances at
each facilities 3) CSB will periodically review it operating procedures and
practices to insure continued conformance with applicable statutes,
regulations and orders related to non-discrimination in service delivery.

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II. PC FY 2016 CSB ADMINISTRATIVE REQUIREMENTS

A. CSB A.1 State 1 The CSB shall comply with applicable state statutes and regulations, State Publish Meeting place
REQUIREMENTS Requirements Board of Behavioral Health and Developmental Services (State Board) notice & public meeting
regulations and policies, and Department procedures including: provisions
a. § 37.2-500 through § 37.2-512 & § 37.2-600 through § 37.2-615 Code
of VA
b. State and Local Government Conflict of Interests Act, § 2.2-3100
through § 2.2-3131
c. VA Freedom of Information Act, § 2.2-3700 through § 2.2 -3714
d. Government Data Collection and Dissemination Practices Act, § 2.2-
3800 through § 2.2-3809
e. Virginia Public Procurement Act, § 2.2-4300 through § 2.2-4377
f. Chapter 8 (Admissions and Dispositions); Title 37.2 provisions
g. Current Appropriation Act.
A.2 Financial 2 a. Use Generally Accepted Accounting Principles a. Submit timely
Management reports
Requirements,
Policies and
Procedures
b. Accounting: account for all service and administrative expenses b. Submit audit reports
to DBHDS Office of
Budget & local
government.

c. Independent Audit follow-up local government audit policies and Annually

procedures
d. Federal Audit Requirements: Satisfy federal audit requirements

e. Subcontractor Audits. e. Obtain, review &

Notes: Resolve audit deficiencies & exceptions & report w/in reasonable take actions on

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negotiated time with DBHDS, subcontractors; submit

copies to OBFR
f. f. Bonding (non-city or county department CSB/BHS) – CSB finance Submit PC
staff shall be bonded with local financial policies
g. g. Fiscal Policies and procedures – for non-city or county department
CSB/BHS’s P&P must conform to applicable State Board P &
Departmental P&P
h. h. Financial Management Manual

i. Local Government Approval – Submit Performance Contracts to local Approved by

governments for review & approval. 9.30.each year
according to local
authorities schedule
or 15 days before
meeting.

May submit PC to
DBHDS before
approved unless
prohibited.

j. Department Review: Allow DBHDS reviews for noted Submit formal plans of W/in 45 days of
deficiencies/problems or complaints. correction to OBFR receipt of
notification.
As audited by DBHDS
Minor compliance
issues to be
corrected w/in 45
days of Plan of
Correction.
Major compliance
issues correction

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initiated in 45 days
and completed in
180 after plan
submission.

k. Balances of unspent funds: CSB shall adhere to the Unspent Balances

Principles in Appendix C

A.3 Procurement 5 a. Procurement Policies and Procedures:

Requirements,  Non-City or County boards/authorities must have written
Policies and procurement P &Ps. .
Procedures  City/County CSBs follow local government Procurement P & P.

Written P &Ps must address internal procurement responsibilities,

small purchases, $$ thresholds, ethics, surplus property
disposal. Must conform to VA Public Procurement Act.

May conduct review of CSBs procurement activities – including

subcontracts.
b. Department Review W/in 45 days of receipt
 Allow Department Review in response to significant of reviews.
deficiencies/problems identified in audits or complaints. Minor compliance
 Non-City/County boards/authorities allow DBHDS to review corrected in 45 days of
sampling of contract. plan submission. Major
compliance issues
initiated in 45 days &
resolved in 180 days of
response submitted.
May be granted
extension

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A.4 Reim- 6 a. Reimbursement System – Each CSB’s reimbursement system shall Reimbursement
bursement comply with Code of VA and State Board Policy. Operations shall be
Requirements, described in
Policies and organizational charts
Procedures (staff names & job
descriptions).
b. Policies and Procedures : Have written fee collection P &Ps –
maximizing fees (individual and 3rd party payers)
c. Schedule of Charges: F/ PC Services, have a reasonable schedule of
charges which is applied to all service recipients.
d. Ability to Pay: Have a BOD approved method to evaluate recipient’s
ability to pay for services.

e. Department Review: Allow DBHDS to conduct reimbursement reviews Submit formal Plan of Minor compliance
(per problems, irregularities, etc.). Correction (POC) to corrections due in 45
OCAR in 45 days of days of plan
review notice. submission. Upon
formal DBHDS notice.
Major compliance
corrections initiated
in 45 days and
completed in 180
days. *May be
granted an
extension.
f. Medicaid & Medicare Regulations: CSBS shall comply with applicable
federal & state M & M regulations, policies & procedures and Provider
Agreements.
a. Notes: DBHDS identified Medicaid non-compliance will be
communicated to DMAS.

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A.5 Human 6 a. Statutory Requirements:

Resource  For non-city/county CSBs, operate a Human Resource
Management Department that complies with state & federal statutes,
Requirements, regulations and policies.
Policies and  For city/county CSBs adhere to local HRs government P & P, in
Procedures addition to above.
7 b. Policies and Procedures:
 For Non-city/county CSBs, have a written HRs management P &P
1.) nature of employment;
2.) equal employment opportunity;
3.) recruitment and selection;
4.) criminal background and reference check requirements;
5.) classification and compensation, including a uniform
employee pay plan;
6.) employment medical examinations (e.g., TB);
7.) nepotism (employment of relatives);
8.) probationary period;
9.) initial employee orientation;
10.) transfer and promotion;
11.) termination, layoff, and resignation;
12.) benefits, including types and amounts of leave, holidays, and
health, disability, and other insurances;
13.) hours of work;
14.) outside employment;
15.) professional conduct;
16.) employee ethics;
17.) compliance with state Human Rights Regulations and the
CSB’s local human rights policies and procedures;
18.) HIPAA compliance and privacy protection;
19.) compliance with the Americans with Disabilities Act;
20.) compliance with Immigration Reform and Control Act of
1986;

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21.) conflicts of interests and compliance with the Conflict of

Interests Act;
22.) compliance with Fair Labor Standards Act, including exempt
status, overtime, and compensatory leave;
23.) drug-free workplace and drug testing;
24.) maintenance of a positive and respectful workplace
environment;
25.) prevention of sexual harassment;
26.) prevention of workplace violence;
27.) whistleblower protections;
28.) smoking;
29.) computer, internet, email, and other electronic equipment
usage;
30.) progressive discipline (standards of conduct);
31.) employee performance evaluation;
32.) employee grievances;
33.) travel reimbursement and on-the-job expenses;
34.) employee to executive director and board of directors
contact protocol; and
35.) Communication with stakeholders, media, and government
officials.
 For City/County Department CSBs adhere to local government
requirements Human Resources P & Ps.
c. Job Descriptions: Have written job descriptions for all positions –
including essential functions, explicit responsibilities, qualification
statements, expressed knowledge, skills and abilities, bona fide
occupational requirements.
d. Grievance Procedure: Have a grievance procedure that satisfies Code
of VA (§15.2-15-6 or §15.2-1507).
e. Uniform Pay Plan: CSB shall adopt a uniform pay plan in accordance
with Code of VA (§15.2-1506 & §15.2-1507)

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f. Department Review: CSB submit formal plan Conduct PRN

 For Non-City/County CSBs, shall allow DBHDS to conduct a human of correction for reviews, based on
resource management review to determine compliance with PC deficiencies complaints. Minor
issues – 45 days of
requirements, based on complaints about HR management
receipt of report.
practices. Major compliance
 For City/County CSBs, employee complaints will be forwarded to issues, plan of
local government for appropriate local remedies. HR City/County correction shall be
Departments will allow DBHDS to conduct a review of local initiated within 45
government’s human resource management practices. days & resolved in
180 days, unless
granted extension.
A.6 Information 9 a. Maintain that all IT Hardware and Software purchases for compliance Monitor Ongoing
Technology to department standards.
Capabilities b. Maintain that all IT systems can communicate with the Departments
and network- including CCS3 and CARS
Requirements c. Maintain that all IT systems are compliant with HIPAA in
communications with the Department
d. Data access- CSB will:
 Provide the Department with names of staff for whom
permission to the SFTP service has been rescinded
 Shale provide the Department with the name, email address,
telephone number and applications that addition staff have
been given permission to access
 Keep the list of its staff with permission to access the SFTP
server
A.7 Planning 9 a - b: CSB will work with local, regional and state facilities as appropriate Community Prevention Annually - June 15
including prevention planning bodies Plan and Logic Model
A.8 Forensic 10 CSB will provide restoration services that include: Monitor Ongoing
Services  treatment and restoration
 ES
 Assessment

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 Provisions of medications and med management

 Prevention admission to state hospital for these services
Once restoration has been determined CSB will provide the following to
maintain competency to stand trial:
 Treatment and restoration
 ES
 Assessment
 Provisions of medications and med management
 Prevention readmission to state hospital for these services
Upon court order CSB will provide juvenile competency evaluation as well
as service to restore competency.
CSB will provide forensic evaluations per court order
Forensic services should be provided on an OPT basis unless
hospitalization if indicated in the evaluation. In that case the following will
occur:
 CSB will consult with courts regarding placement decisions
 Assessment of risk will be completed and provided to the
Commissioner
 CSB coordinates with Forensic Coordinator of State facility
 CSB will follow Continuity of Care Procedures
CSB shall designated the following positions:
 Forensic Admissions Coordinator
 Forensic Evaluation Coordinator
 NGRI Coordinator
DBHDS will be kept updated with the individuals in this positions. The
individuals in these positions will completed training designated by the
Commissioner
CSB shall provide discharge planning for individuals in NGRI status.
Including written monthly reports on progress for first 12 months of
individual’s release.
If individual in forensic status does not meet hospitalization criteria
individual will be served in local jail, prison, detention center or other

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correctional facility.

A.9 Access to 11 CSB will develop working relationship with Region Deaf Services Program Monitor Ongoing
Services for and Regional Deaf Services Coordinator
Individuals
who are Deaf,
Hard of
Hearing, Late
Deafened, or
Deaf blind
A.10 Interagency 11 a. Due to needs of CM- CSB will develop working linkages with Monitor Ongoing
Relationships community and state agencies assuring access to those services for
clients services and if necessary pursuing interagency agreements.
b. CSB will develop linkages and working relationships with courts and Monitor Ongoing
other required to meet Code of Virginia related to involuntary
admission process
c. CSB will develop necessary linkages, protocols and interagency CSA protocols and Annually
agreements to meet the provisions for the Comprehensive Services interagency
Act for At – Risk Youth and Families. agreements
III. FY 2015 CSB ADMINISTRATIVE REQUIREMENTS - DEPARTMENT REQUIREMENTS
Not included in this analysis as this section outlines Department’s responsibilities.

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II.I PERFORMANCE CONTRACT ADMINISTRATIVE REQUIREMENTS APPENDICES

A. Continuity of 13 Assure that individuals receive: Monitor Ongoing
Care 1. Preadmission screening that confirms the appropriateness of As needed
Procedures admission to a state hospital or training center
2. Discharge planning services, beginning at the time of admission
to the state facility.
Follow the Continuity of Care Procedures for State Facility Admission
Criteria as outlined in Appendix A in conjunction with the Discharge
Protocols for Community Services Boards and State Hospitals. In the event
of a conflict between any of the Continuity of Care Procedures and
protocols, the provisions in the protocols shall apply. Procedures include:
I. State Facility Admission Criteria
II. Preadmission Screening Services and Assessments Required Prior
to State Facility Admission
III. CSB Participation on Interdisciplinary Treatment Teams and
Coordination with State Facility in Service Planning
IV. CSB Discharge Planning Responsibilities
V. Discharge Criteria and Resolution of Disagreements about an
Individual’s Readiness for Discharge.
VI. CSB Post-discharge Services
B. Substance 24 Certification Regarding Environmental Tobacco Smoke: Substance Abuse Policy on Smoking Ongoing
Abuse Prevention and Treatment (SAPT) Block Grant and Community Mental
Treatment Health Services Block Grant
and
Prevention
Block Grant
Requirements

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Special Federal Substance Abuse Prevention and Treatment Block Grant Monitor Ongoing 2nd quarter
(CFDA 93.959) Compliance Requirements and 4th quarter

1. Meet Set-Aside Requirements – Federal law requires that the state

expend its allocations to address minimum set asides. In order to
address these set – asides the Department shall designate its awards
to the CSB in specified categories which may include:
a. Primary prevention
b. Treatment services for substances use disorders and
c. Services to pregnancy women and women with dependent
children
2. Primary Prevention Services Monitor Ongoing
a. Information Dissemination Program Plans
b. Education
c. Alternatives
d. Problems Identification and Referral
e. Community Based Process
f. Environmental
3. Services to Pregnant Women and Women with Dependent Children, Admission Protocol Ongoing
Including Women who are attempting to regain custody of their Program Plan
children, except in cases where parental rights have been terminated. Monitor
Federal law requires that funds allocated to the CSB under this set-
aside must support at a minimum the following services, either
directly or by a written memorandum of understanding.
4. Preference in Admission: The CSB must give preference in admission Admission Protocol Ongoing
to pregnant women who seek or are referred for and would benefit Program Plan
from SAPT Block Grant funded treatment services. The CSB must give Monitor
admission preference to individuals in the following order:
a. Pregnant injecting drug users
b. Other pregnant substance abusers
c. Other injecting drug users and
d. All other individuals

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5. Services for persons at risk of HIV/AIDS: If a CSB has a HIV rate of 10% Monitor Ongoing
or higher and wish to continue it HIV EIS during the contract term, it Assessment
may use state general funds. CSB should determine if individuals are
engaging in high risk behaviors for HIV infection and encourage them
to contact the local health department for HIV testing and
preventative supplies
6. Interim Services: Make available services for persons who have sought Program Plan Ongoing
admission for SU but due to capacity are not admitted to the Admission Procedures
program. While waiting the person are provided counseling and Monitor
education about HIV and TB.
7. Services for Individuals with Intravenous Drug Use: provide notice to Program Plan 7 days
department within 7 days if program reaches 90% of capacity, admit Monitor 14 days
person who request and in need of IV drug treatment; establish at Service Delivery policy 120 days
waitlist if appropriate; maintain contact with persons awaiting
services; manage waitlist; encourage individuals in need of IV use to
seek treatment. Review Administrative requirements for details
8. Tuberculosis (TB) Services – make available counseling with respect to Program Plan Ongoing
TB, testing or providing for or referring the individuals infected with Documentation
TC for appropriate medical evaluation and treatment. Service Delivery Policy
9. Others Requirements Training Ongoing
Human Rights
Confidentiality
Licensure
Monitor
Oversight
10. Faith-Based Service Providers: CSB shall consider faith-based Monitor Ongoing
organization when awarding contracts for SU treatment. CSB shall be
responsible for assuring that the faith-based organization complies
with the provision described in these sections.

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11. Prevention Services Addressing Youth Tobacco Use and Underage Prevention Program Ongoing
Drinking: CSB shall select and implement evidence based programs, Plan and Service
practices and strategies that target youth tobacco use, access and Delivery Policy
underage drinking
12. Theoretical Frameworks for Evidence Based Programs, Practices and Program Plan Ongoing
Strategies: CSB shall utilize Institute of Medicine model to identify Assessments
target populations based on level of risks Documentation
C. Unspent 31 1. Applicability: The principles and procedures apply equally to all CSB’s. Monitor and Report Based on fiscal year
Balances They applies to unspent balances of state funds present in a CSB’s balances
Principles and accounts and reflected in its financial management.
Procedures 2. CSB Allocation of Funds not affected by Amounts of Unspent
Balances: DBHDS to allocate funds in Grants to localities of the
Appropriation Act.
3. Calculation of Balances: DBHDS will calculate unspent balances for all
types of funds (except federal grants). Balances will be determined by
CARS reports
4. Reserve Funds: CSB will place all unspent balances in a separate
reserve fund. CSB will only use this reserve fun for MH/SA/ID
services. Reserve of contingency funds must not be established by
using current fiscal year funds.
5. Maintenance of Effort: There is to be no reduction of local matching
funds as a result of a CSB’s retention of any balances of unspent state
funds.
6. Size of Reserve Funds: The maximum amount of unspent state funds
balances is equal to the amount of all state funds received from
DBHDS during the current fiscal year.
7. Unspent Balances for Regional Programs: Unspent balances for
regional program may be handled by the participating CSB’s. All
participating CSB’s must review and approve how the balances are to
be handled.
8. Effective Period of Restrictions on State General Funds: Allowable
uses of state funds appropriated in the Grants to Localities item of

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Appropriation Act remain in effect for each fiscal year thru the end of
the biennium.
9. Uses of Unexpected Restricted State Funds During the Current Fiscal
Year: Restricted funds must be used for the purposes for which they
were appropriated in the biennium.
10. Allowable Uses of Unspent State Fund Balances: CSB’s may use
unspent balances of state funds only for MH/ID/SA services.
11. Preferred Acceptable Uses of Accumulated Unspent State Fund
Balances From Previous Fiscal Years: land/buildings used for services;
vehicles to transport individuals receiving services; start-up expenses;
capital equipment; initiation of discharge assistance plans; IT system
or software; land/buildings for management/administrative
operations.
12. Other Acceptable Uses of Accumulated Unspent State Fund Balances
From Previous Fiscal Years: in exceptional circumstances, unspent
balances may be used to temporarily absorb short term effects of
budget reduction or unanticipated fund shortfalls.
13. Collective Uses of Unspent Balances: a group of CSB’s may pool
unspent balances on one-time issues that address collective needs.
14. Performance Contract Documentation: All uses of unspent balances
of state funds are to be documented in the CSB Performance
Contract for the year in which the unspent balances are expended.
Review of Unspent Balances: DBHDS may review available unspent
balances of state funds with a CSB that exhibits a persistent patter of
providing lower levels of services while generating significant
balances of unspent state funds.
D. User 35 The following process will be used by the CSBs and DBHDS for major new DMC and select CSB’s As Needed
Acceptance releases of CCS3 or other applications that involve the addition of new to test.
Testing data elements, reporting requirements, or functions that require
Process significant work by CSB IT staff and venders.

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E. Continuous 36 CSB will have protocol for access to ES staff as well as ES staff to have ES Protocol Policy
Quality access to CM staff and information 24/7 for screenings
Improvement
(CQI) Process
CSB will have protocol for engaging individuals post hospital discharge and Client engagement
increasing engagement and compliance with discharge appointments protocol policy
CSB’s will respond to requests for face to face emergency preadmission Monitoring
screening within specified timelines (1 hour for Urban CSB; 2 hours for
Rural CSB)
Preadmission screening evaluators hired after July 1, 2008 will meet Monitoring
DBHDS qualifications.
Preadmission screening evaluators employed by CSB will complete Affirmation of
certification program certification in
personnel record
Preadmission screening evaluators with have knowledge, skills and Monitor
abilities to establish welcoming and engaging environment
CSB prescreening evaluator participate or makes arrangements to have a ES Protocol
someone participate in commitment or recommitment hearings
Preadmission screening evaluation reports will consider and contain the Monitor
following information:
 Review of clinical records
 Wellness recovery plans
 Advance directives
 Information or recommendations provided by other current
service providers or significant other persons
Report will reference the relevant clinical information.
If emergency services intervention occurs at hospital or emergency room ES Protocol
the CSB preadmission screening evaluators informs the charge nurse and
leaves clinical documentation of disposition as well as documents in
preadmission report this coordination.

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Case managers will be welcoming, recovery oriented and co-occurring Monitor

competent.
ISP reviews are completed with the individual, quarterly or every 90 days Policy and Procedure
and include the following:
 Changes to the individuals status
 Engagement
 Participation in recovery planning
 Preferences for services
The ISP will be revised accordingly and includes:
 Individual- directed wellness plan
 Crisis self-management strategies
 Advanced directives
For individuals discontinuing services due to dissatisfaction, a review of ISP
will be completed to determine a reasonable solution.
CSB will have available during normal business hours case managers to Policy and procedure
respond to ES preadmission screeners to provide clinical information
CSB will assure that individuals discharged from psychiatric facility who Assessment Protocol
has been referred will receive a CM assessment within 14 or no more than
30 days from referral as well as initiate ISP within 24 hours of assessment.

CSB will routinely review individuals whose CM services are discontinued Policy and Procedure
due to failure to engage in services. CSB will document outreach
attempts. CSB will review rates and reasons for CM discontinuation and
make efforts to reduce those rates.
CSB will screen adolescent and adult for co-occurring MH/SA with Validated Brief
validated brief screening instrument. Screening for MH/SA
Every three years CSB’s will complete organizational self-assessment of COMPASS, COMPASS- Every Three Years
service integration and utilize results as part of quality improvement EZ OR
DDCAT/DDMHT

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CSB’s will maintain the clinical record/ information system with Monitor
appropriate dx and program enrollment to identify individuals as co-
occurring

CSB’s submit 100% CCS extracts by the end of the month following the CCS Report Monthly
month they are due. End of the Month

CSB monitors the total number of records rejected for fatal errors divided Monitor Monthly
by the total number of consumer records. The failure rate for any one
month will be 5% or less. If it is 5% or above a QI plan will developed with
DBHDS.
CSB ensures data is collected and submitted to CCS when a client is Monitor Quarterly
opened, individual is enrolled in a program area, updated at least annually
and at discharge. CSB monitors for missing or inaccurate data. CSB
monitors total number of individuals without service records submitted
showing receipt of SA services within the prior 90 days by the total
number of individuals with typeofcare records showing a SA discharge in
those 90 days. If more than 10% CSB develops plan to reduce.
CSB reviews and revises joint agreement with Department of Aging and Joint Agreement with As necessary
Rehabilitation (DARS) and agrees to work with DARS and ESOs regarding DARS
employment of individuals served. Where ESOs do not exist, CSB will work
with other entities to develop employment services.
CSB ensures that case managers discuss integrated, community based Monitor Annually
employment services at least annually with adults receiving services and
when appropriate integrates into the services plan for the individual.
CSB reviews and revises joint agreements with public housing agencies to Joint agreements with As necessary
support affordable housing for individuals who receive services. Public Housing
Agencies
CSB works with DBHDS through Data Management Committee (DMC) to DMC participation Monthly
develop, collect and monitor housing and employment outcomes.

June 24, 2016 Section II.I – Administrative Requirements Appendices Page 37 of 37