HomeMy WebLinkAboutResolution - 2023-R0438 - Amendment No. 3, HHS Contract No. HHS000779500004 - 09/12/2023Resolution No. 2023-R0438
Item No. 5.33
September 12, 2023
I��I.YI]�iY�(IJ►1
BE IT RESOLVED BY TIIE CITY COUNCIL OF TIIL CITY OF LUBBOCK:
THAT the acts of the Mayor of the City of Lubbock in executing, on behalf of the City of
Lubbock, Amendment No. 3 to the Health and Human Services Commission Conlract No.
HHS000779500004, under the Substance Use Prevention, Treatmcnt and Recovery Services
Block Grant, to provide funding for Treatment for I�emales (TRF), by and between the City of
Lubbock and the State of 1'exas' Health and Human Services Commission, and related
documents are hereby ratified in full. Said Amendment is attached hereto and incorporated in
this resolution as if fully set forih hcrein and shall be included in the minutes of the City Council.
Passed by the City Council on September 12, 2023 _
TT�ST:
Paz,
PROVLD AS TO CON1'�N"1':
Bill Ho rton, Deputy City � ger
APPROVCD AS TO PORM:
Rachael Foster, Ass�stant City Attorney
RES.HHSC Contract No. I-IHS000779500004 Amendment No.3 Ratification
8.25.23
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Resolution No. 2023-RO438
HEALTH AND HUMAN SERVICES COMMISSION
CONTRACT No. IIHS000779500004
AMENDMENT No. 3
The HEALTH AND HUMAN SERVICES COMMISSION ("HHSC" or "System Agency") and CITY
OF LUBBOCK ("Grantee"), collectively referred to as the "Parties" to that certain Treatment for
Females (TRF) Contract effective August 1, 2020, and denominated HHSC Contract No.
HHS000779500004 ("Contract"), as amended, now desire to further amend the Contract.
WHEREAS, HHSC desires to revise Attachment A, Statement of Work, and Attachment B,
Program Services and Unit Rates;
Whereas, HHSC desires to update certain Contract terms and conditions.
Now, THEREFORE, the Parties amend and modify the Contract as follows:
1. ATTACHMENT A: STATEMENT OF WORK APRIL 2021 is deleted in its entirety and
replaced with ATTACHMENT A: REVISED STATEMENT OF WORK (AUGUST 2023).
2. ATTACHMENT B: PROGRAM SERVICES AND UNIT RATES OCTOBER 2022 is deleted in its
entirety and replaced with ATTACHMENT B: REVISED PROGRAM SERVICES AND UNIT
RATES (AUGUST 2023).
3. ATTACHMENT H-1, FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT
(FFATA) FORM is incorporated as part of the Amendment and requires Grantee to
complete the Certification to meet the federal requirement.
4. The U.S. Health and Services Commission, Substance Abuse and Mental Health Services
Administration (SAMHSA) revised the name of the "Substance Abuse Prevention and
Treatment Block Grant (SABG/SAPT)" (assistance listing number 93.959) to the
"Substance Use Prevention, Treatment and Recovery Services (SUPTRS) Block Grant."
Therefore, all references in the executed agreement that reference "SABG" or "SAPT"
are replaced with "Substance Use Prevention, Treatment and Recovery Services
(SUPTRS) Block Grant."
5. This Amendment shall be effective on August 31, 2023, provided both Parties have signed
below on or before said date.
6. Except as modified by this Amendment, all terms and conditions of the Contract, as
amended, shall remain in effect.
7. Any further revisions to the Contract shall be by written agreement of the Parties.
HHSC Solicitation No: HHS0007795
HHSC Contract No. HES000779500004
Amendment No. 3
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SIGNATURE PAGE IMMEDIATELY FOLLOWS.
HHSC Solicitation No: HHS0007795
HHSC Contract No. HHS000779500004
Amendment No. 3
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SIGNATURE PAGE FOR AMENDMENT NO. 3
HHSC CONTRACT No. HHS000779500004
HEALTH AND HUMAN SERVICES
COMMISSION
By: FDoeuSigned by:
S o a Gailn.t s
Sonja Gaines
NoSG
August 28, 2023
Date of Signature:
CITY OF LUBBOCK
DoeuSigned by:
By: "rV payVJ-
Tray Payne
Mayor
August 28, 2023
Date of Signature:
The following attachments are attached and incorporated as part of the Contract:
D ATTACHMENT A: REVISED STATEMENT OF WORK (AUGUST 2023);
❑ ATTACHMENT B: REVISED PROGRAM SERVICES AND UNIT RATES (AUGUST
2023); and
O ATTACHMENT H-1: FEDERAL FUNDING ACCOUNTABILITY AND
TRANSPARENCY ACT (FFATA) FORM.
HHSC Solicitation No: HHS0007795
HHSC Contract No. HHS000779500004
Amendment No. 3
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ATTACHMENT A
REVISED STATEMENT OF WORK
(AUGUST 2023)
Grantee shall provide Substance Use Disorder Treatment Services for one (1) or more of the
following service types/levels of care listed in Section II. The service types/levels of care, listed
in Section II, are based on Texas Administrative Code (TAC) requirements, as referenced in the
Substance Use Disorder (SUD) Program Guide, located at the following link:
https:Hhhs.texas. gov/doing-business-hhs/provider-portals/behavioral-health-services-
providers/substance-use-disorder-service-providers, and American Society of Addiction
Medicine (ASAM) criteria located at the following link:
https://www.asam.org/asam-criteria/about, which is a collection of objective guidelines that
give clinicians a standardized approach to admission and treatment planning.
A. TREATMENT FOR FEMALES (TRF)
Adult pregnant women and women with Dependent Children (including women whose
children are in custody of the State) who meet Client Eligibility for System Agency -
funded substance use disorder services as stated in the System Agency Substance Use
Disorder (SUD) Program Guide.
1. Outpatient Treatment Services
(ASAM Level 1 Outpatient Services)
2. Supportive Residential Treatment Services
(ASAM Level 3.1 Clinically Managed Low -Intensity Residential Services)
3. Intensive Residential Treatment Services
(ASAM Level 3.5 Clinically Managed High -Intensity Residential Services)
4. Residential Withdrawal Management Services
(ASAM Level 3.7 :Medically Monitored Withdrawal Services)
5. Ambulatory Withdrawal Management Services
(ASAM Level 2 Withdrawal Management)
B. TREATMENT FOR WOMEN AND CHLDREN
Adult pregnant women and women with Dependent Children (including women whose
children are in custody of the State) who meet Client Eligibility for System Agency -
funded substance use disorder services as stated in the System Agency Substance Use
Disorder (SUD) Program Guide
Clients being admitted into Women and Children's treatment facilities must meet at least
one (1) of the following criteria:
1. Be in the third trimester of her pregnancy; and/or
2. Have at least one (1) child physically residing overnight with her in the facility; and/or
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3. Have a referral by Department of Family and Protective Services (DFPS).
4. Note: DFPS will not allow at least one (1) child to initially reside overnight butDFPS
plans to place the child in the facility within the first thirty (30) ServiceDays of
treatment.
i. Women and Children's Intensive Residential Services
(ASAM Level 3.5 Clinically Managed High -Intensity Residential Services)
ii. Women and Children's Supportive Residential Services
(ASAM Level 3.1 Clinically Managed Low -Intensity Residential Services)
Grantee shall:
A. Administrative Requirements
1. Adhere to the most current SUD Program Guide.
2. Provide age -appropriate medical and psychological therapeutic services designedto treat an
individual's SUD and restore functions while promoting Recovery.
3. Adhere to Level of Care/Service Type licensure requirements.
4. Comply with all applicable TAC rules adopted by System Agency related to SUD treatment.
5. Document all specified required activities and services in the Clinical Management of
Behavioral Health Services (CMBHS) system. Documents that require Client or staff signature
shall be maintained according to TAC requirements and made available to System Agency for
review upon request.
6. In addition to TAC and SUD Program Guide required Policies and Procedures, Grantee shall
develop and implement organizational policies and procedures for:
i. A marketing plan to engage local referral sources and provide informationto these sources
regarding the availability of SUD treatment and the Client Eligibility criteria for
admissions;
ii. All marketing materials published shall include Priority Populations for Treatment
Programs admissions;
iii. Client Retention in services, including protocols for addressing Clients absent from
treatment and policies defining treatment non-compliance; and
iv. All policies and procedures shall be provided to System Agency upon request.
7. Ensure that Program Directors participate in their specific Program and service type conference
calls as scheduled by System Agency. Program Directors shall participate unless otherwise
agreed to by System Agency in writing. Grantee executive management may participate in the
conference calls.
8. Actively attend and share representative knowledge about Grantee's system and services at the
Outreach, Screening, Assessment, and Referrals (OSAR) quarterly regional collaborative
meetings.
9. Ensure compliance with Client Eligibility requirements to include Texas residence eligibility,
Financial Eligibility and clinical eligibility as specified in SUD Program Guide.
IO.Document a Life Event Note in CMBHS upon active Client's delivery of newborn.
11.Grantee will develop a local agreement with DFPS local offices to address referral process,
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coordination of services, and sharing of information as allowed per the consent and agreement
form.
12.Adhere to Memorandum of Understanding requirements as stated in the SUD Program Guide.
13.Maintain a list of community resources and document referrals when appropriate to
14. ensure that children of the client have access to services to address their needs and support
healthy development including primary pediatric care, early childhood intervention services,
and other therapeutic interventions that address the children's development needs and any
issues of abuse and neglect.
B. Service Delivery
1. Adhere to the Priority Populations for Treatment Programs as stated in the SUD Program
Guide.
2. Maintain Daily Capacity Management Report in CMBHS as required in the SUD Program
Guide.
3. Maintain a Waiting List to track all eligible individuals who have been screened but cannot be
admitted to SUD treatment immediately.
i. Grantee that has an individual identified as a federal and State priority population on the
waiting list shall confirm this in the Daily Capacity Management Report.
ii. Grantee shall arrange for appropriate services in another treatment facility or provide
access to interim services as indicated within forty-eight (48) hours when efforts to refer
to other appropriate services are exhausted.
iii. Grantee shall offer directly or through referral interim services towaitlisted individuals.
iv. Establish a wait list that includes priority populations and interim serviceswhile awaiting
admission to treatment services.
v. Develop a mechanism for maintaining contact with individuals awaiting admission.
4. If unable to provide admissions to individuals within Priority Populations for Treatment
Programs according to SUD Program Guide:
i. Implement written procedures that address maintaining weekly contact with individuals
waiting for admissions as well as what referrals are made when a Client cannot be admitted
for services immediately.
ii. When Grantee cannot admit a Client, who is at risk for dangerous withdrawal, Grantee
shall ensure that an emergency medical care provider isnotified.
iii. Coordinate with an alternate provider for immediate admission.
iv. Notify System Agency programs (Substance_ Use_ Disorder@hhs.texas.gov) so that
assistance can be provided that ensures immediate admission to other appropriate services
and proper coordination when appropriate.
v. Provide pre -admission service coordination to reduce barriers to treatment, enhance
motivation, stabilize life situations, and facilitate engagement in treatment.
vi. Adhere to Informed Consent Document for Opioid Use Disorder applicable to individual
as stated in the SUD Program Guide.
vii. When an individual is placed on the Wait List, Grantee shall document interim services
as referrals that provides applicable testing, counseling, and treatment for Human
Immunodeficiency Virus (HIV), Tuberculosis (TB) and sexually transmitted infections
(STIs).
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C. Screening and Assessment
1. Comply with all applicable rules in the TAC for SUD programs as stated in the SUD Program
Guide Information, Rules, and Regulations regarding Screening andAssessment.
2. When documenting a CMBHS Substance Use Disorder screening, Grantee shall conduct the
screening in a confidential, face-to-face interview unless there is documented justification for
any other method used.
3. Document Financial Eligibility in CMBHS as required in the SUD Program Guide.
4. Conduct and document a CMBHS SUD Initial Assessment with the Client to determine the
appropriate levels of care for SUD treatment. The CMBHS assessment will identify the impact
of substances on the physical, mental health, and other identified issues including TB, Hepatitis
B and C, STI, HIV.
i. If Client indicates risk for these communicable diseases, Grantee shallrefer the Client to the
appropriate community resources for further testing and counseling.
ii. If the Client is at risk for HIV, Grantee shall refer the Client to pre and post-test counseling
on HIV.
5. If the Client is living with HIV, Grantee shall refer the Client to the appropriate community
resources to complete the necessary referrals and health related paperwork.
D. Treatment Planning, Implementation, and Review
Comply with all applicable rules in the TAC for SUD Programs as stated in theSUD Program
Guide Information, Rules, and Regulations regarding Treatment Planning, Implementation, and
Review.
Collaborate actively with Clients and family, when appropriate, to develop and implement an
individualized, written treatment plan that identifies services and support needed to address
problems and needs identified in the assessment. The treatment plan shall document the
expected length of stay and treatment intensity. Grantee shall use clinical judgment to assign a
Projected length of stay for each individual Client.
Document referral and referral follow-up in CMBHS to the appropriate community resources
based on the individual need of the Client.
E. Discharge
1. Comply with all applicable rules in the TAC for SUD Programs as stated in the SUD Program
Guide Information, Rules, and Regulations regarding Discharge.
2. Develop and implement an individualized discharge plan with the Client to assist in sustaining
Recovery.
3. Document in CMBHS the Client -specific information that supports the reason for discharge
listed on the discharge report. A QCC shall sign the discharge summary. Appropriate referrals
shall be made and documented in the Client record. A Client's treatment is considered
successfully completed if the following criteria are met:
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i. Client has completed the clinically recommended number of treatment units (either initially
Projected or modified with clinical justification) as indicated in CMBHS; and
ii. All problems on the treatment plan have been addressed. Grantee shall use the treatment plan
component of CMBHS to create a final and completed treatment plan version.
4. Problems designated as "treat" or "case manage" status shall have all objectivesresolved prior
to discharge:
i. Problems that have been "referred" shall have associated documented referrals in CMBHS;
ii. Problems with "deferred" status shall be re -assessed. Upon successful discharge, all
deferred problems shall be resolved, either through referral, withdrawal, treatment, or case
management with clinical justification reflected in CMBHS through the Progress Note and
Treatment Plan Review Components; and
iii."Withdrawn" problems shall have clinical justification reflected in CMBHS, through the
Progress Note and Treatment Plan Review Components.
F. Additional Service Requirements
1. Comply with all applicable rules in the TAC for SUD Programs as stated in the SUD Program
Guide Information, Rules, and Regulations.
2. Deliver and provide.access to services at times and locations that meet the needs of the target
population. Provide or arrange for transportation to all required services not provided at
Grantee's facility.
3. Accept referrals from the OSAR.
4. Provide evidenced -based education at minimum on the following topics: (i) TB; (ii) HIV;
(iii) Hepatitis B and C; (iv) STIs/Diseases; and (v) health risks of tobacco and nicotine product
use.
5. Provide Case Management as needed with documentation in CMBHS, as Case Management is
essential to the ultimate success of the Client.
6. Ensure Client access to the full continuum of treatment services and shall provide sufficient
treatment intensity to achieve treatment plan goals.
7. Provide all services in a culturally, linguistically, non -threatening, respectful and
developmentally appropriate manner for Clients, families, and/or significant others.
8. Provide trauma -informed services that address the multiple and complex issues related to
violence, trauma, and substance use disorders.
9. Provide overdose prevention education to all Clients. Document overdose prevention education
in CMBHS.
10. Specific overdose prevention activities shall be conducted with Clients with opioid use
disorders and those Clients that use drugs intravenously. Grantee will directly provide or refer
to community support services for overdose prevention and reversal education to all identified
at risk Clients prior to discharge. Grantee will document all overdose prevention and reversal
education in CMBHS.
11. Ensure access to adequate and appropriate medical and psychosocial tobacco cessation
treatment as follow:
i. Assess all Clients for tobacco use and Clients seeking to cut back or quit.
ii. If the Client indicates wanting assistance with cutting back or quitting, the Clientwill
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be referred to appropriate tobacco cessation treatment.
12. Provide and document in CMBHS case management activities as indicated by
assessment and treatment plan.
13. Provide and document in CMBHS research -based education on the effects ofAlcohol,
Tobacco, and Other Drugs (ATOD) on the fetus.
14. Utilize an evidenced -based, trauma -informed curriculum in the treatment of womenwith
substance use disorders.
15. Utilize System Agency as the payer of last resort if the Client hasother: outside funding
available (i.e., wages, insurance, etc.).
SECTION IV : STAFF COMPETENCIES AND ,UQUIR,EMNIS
A. All personnel shall receive the training and supervision necessary to ensurecompliance with
System Agency rules, provision of appropriate and individualized treatment, and protection of
Client health, safety, and welfare.
B. Ensure that all direct care staff receive a copy of this Statement of Work and SUD Program
Guide.
C. Ensure that all direct care staff review all policies and procedures related to theProgram or
organization on an annual basis.
D. Ensure compliance for Personnel Practices and Development with TAC and System Agency
SUD Program Guide requirements.
E. Within ninety (90) business days of hire and prior to service delivery, direct care staff shall have
specific documented training in the following:
1. Motivational Interviewing Techniques or Motivational Enhancement Therapy;
2. Trauma -informed care;
3. Cultural competency;
4. Harm reduction trainings;
5. Health Insurance Portability and Accountability Act (HIPAA) and 42 Code of Federal
Regulations (CFR) Part 2 training;
6. Alcohol, Tobacco and Other Drugs on the Developing Fetus;
7. Child welfare education, and
8. State of Texas co-occurring psychiatric and substance use disorder (COPSD) training
located at the following website: www.centralizedtraining.com.
F. Ensure all direct care staff complete annual education on HIPAA and 42 CFR Part2
training.
G. Ensure all direct care staff complete a minimum often (10) hours of training each State
Fiscal Year in any of the following areas:
1. Motivational Interviewing Techniques;
2. Cultural competencies;
3. Reproductive health education;
4. Risk and harm reduction strategies;
5. Trauma Informed Care;
6. Substance exposed pregnancy (such as Fetal Alcohol Spectrum Disorder or
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7. Neonatal Abstinence Syndrome);
8. Child welfare education; or
9. Suicide prevention and intervention.
H. Individuals responsible for planning, directing, or supervising treatment services shall be
QCCS.
I. Contractor shall have a clinical Program Director known as a "Program Director" with at least
two (2) years of post-QCC licensure experience providing substance use disorder treatment.
J. Substance Use Disorder counseling shall be provided by a QCC, or Chemical Dependency
Counselor Intern. Substance use disorder education and life skills training shall be provided by
counselors or individuals who have appropriate specialized education and expertise. All
counselor interns shall work under the direct Supervision of a QCC.
K. Licensed Chemical Dependency Counselors shall recognize the limitations of their license and
shall not provide services outside the scope of practice of licensure or use techniques that exceed
the license authorization orprofessional competence.
L. Contractor shall train staff and develop a policy to ensure that information gatheredfrom
Clients is conducted in a respectful, non -threatening, and culturally competent manner.
M. Grantee shall adapt services and accommodate persons as appropriate to meet theneeds of
special populations.
N. Grantee shall develop and implement a mechanism to ensure that all direct care staff have
the knowledge, skills, and abilities to provide services to women and children, as they
relate to the individual's job duties.
O. Grantee shall be able to demonstrate through documented training, credentials and/or
experience that all direct care staff are proficient in areas pertaining to the needs of and
provision of services to women and children.
.i '
A. OUTPATIENT TREATMENT SERVICES
(ASAM Level 1 Outpatient Services)
Grantee shall:
1. Adhere to TAC requirements and SUD Program Guide for outpatient treatment
Programs / services.
2. Provide and document in CMBHS one (1) hour of group or individual counseling services for
every six (6) hours of educational activities.
3. Document in CMBHS a discharge follow-up no sooner than sixty (60) calendar days and no
later than ninety (90) calendar days afterdischarge from the outpatient treatment services.
4. When the assessment indicates placement in System Agency funded Women and Children
Intensive or Supportive Residential services but there are no available beds, Grantee shall
provide coordinated interim care until a Women and Children Intensive or Supportive
Residential bed becomes available. A pregnant Client, if she choosesand is appropriate for this
service type, shall be transferred to Women and Children Intensive and Supportive Residential
services no later than the eighth month of
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pregnancy in order to provide sufficient time to adjust to the changes prior to delivery of her
child.
5. As part of the education hours, Grantee will provide and document in CMBHS:
i. A minimum of one (1) hour per week (or one (1) hour per month for Clients who have been
transferred to outpatient after successfully completing a residential level of care) of
evidence -based parenting education and document these services; and
ii. A minimum of six (6) hours (or two (2) hours for Clients who have been transferred to
outpatient after successfully completing a residential level of care) of reproductive health
education prior to discharge and document these services.
6. Provide and document in CMBHS research -based education on the effects of ATOD on the
fetus.
B. SUPPORTIVE RESIDENTIAL TREATMENT SERVICES
(ASAM Level 3.1 Clinically Managed Low -Intensity Residential Services)
Grantee shall:
1. Adhere to TAC and SUD Program Guide applicable to supportive services requirements.
2. When the assessment indicates placement in System Agency -funded Women and Children
Intensive or Supportive Residential services but there are no available beds, Contractor shall
provide coordinated interim care until a Women and Children Intensive or Supportive
Residential bed becomes available. A pregnant Client, if she chooses and is appropriate for
this service type, shall be transferred to Women and Children Intensive and Supportive
Residential services no later than the eighth month of pregnancy in order to provide sufficient
time to adjust to the changes prior to delivery of her child.
3. As part of education hours, Grantee will provide:
i. A minimum of one (1) hour per week of evidenced -based parenting education; and
ii. A minimum of two (2) hours of reproductive health education within thirty
(30) Service Days of admission.
4. Document in CMBHS a discharge follow-up no sooner than sixty (60) calendar days and no
later than ninety (90) calendar days after discharge from the supportive residential treatment
services.
C. SUPPORTIVE RESIDENTIAL FOR WOMEN AND CHLDREN
(ASAM Level 3.1 Clinically Managed Low -Intensity Residential Services)
Grantee shall:
1. Adhere to TAC and SUD Program Guide applicable to supportive services requirements.
2. In addition, adhere to TAC requirements applicable to Treatment Services for Women
and Children.
As part of education hours, Grantee will provide and document in CMBHS:
i. A minimum of two (2) hours per week of evidence -based parenting education
and document these services;
ii. A minimum of six (6) hours of reproductive health education withinthirty
(30) service days of admission and document these services; and
iii. At minimum, evidenced -based education on the effects of ATOD during pregnancy.
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4. Document in CMBHS a discharge follow-up no sooner than sixty (60) calendar days and no
later than ninety (90) calendar days after discharge from the supportive residential treatment
services.
D. INTENSIVE RESIDENTIAL TREATMENT SERVICES
(ASAM Level 3.5 Clinically Managed High -Intensity Residential Services)
Grantee shall:
l . Adhere to TAC and SUD Program Guide applicable to intensive services requirements.
2. When the assessment indicates placement in System Agency -funded Women and
Children Intensive or Supportive Residential services but there are no available beds,
Grantee shall provide coordinated interim care until a Women and Children Intensive or
Supportive Residential bed becomes available. A pregnant Client, if she chooses and is
appropriate for this service type, shall be transferred to Women and Children Intensive
and Supportive Residential services no later than the eighth month of pregnancy in order
to provide sufficient time to adjust to the changes prior to delivery of herchild.
3. As part of education hours, Grantee will provide and document in CMBHS:
i. A minimum of two (2) hours per week of evidenced -based parenting education; and
ii. A minimum of six (6) hours of reproductive health education within thirty (30)
Service Days of admission.
4. Document in CMBHS a discharge follow-up no sooner than sixty (60) calendar days
and no later than ninety (90) calendar days after discharge from the intensive residential
treatment services.
E. INTENSIVE RESIDENTIAL FOR WOMEN AND CHLDREN
(ASAM Level 3.5 Clinically Managed High -Intensity Residential Services)
Grantee shall:
1. Adhere to TAC and SUD Program Guide applicable to intensive residential services for
women and children requirements.
2. Adhere to TAC requirements applicable to Treatment Services for Women and Children.
3. As part of education hours, Grantee will provide and document in CMBHS:
i. A minimum of two (2) hours per week of evidence -based parentingeducation;
and
ii. A minimum of six (6) hours of reproductive health education within thirty (30)
Service Days of admission.
F. RESIDENTIAL DETOXIFICATION / WITHDRAWALMANAGEMENT
(ASAM LEVEL 3.7 MEDICALLY MONITORED WITHDRAWAL MANAGEMENT)
Grantee shall:
1. Adhere to TAC requirements for detoxification services.
2. Adhere to the SUD Program Guide for detoxification services.
3. Adhere to the following additional service delivery requirements:
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i. Document in CMBHS a Withdrawal Management Intake Form.
ii. Document in CMBHS a discharge plan prior to discharge or transfer.
iii. Document in CMBHS a discharge follow-up no more than ten (10) calendar days
after discharge from withdrawal management services.
iv. Develop and Implement Policies, Procedures, and Medical Protocols to ensure
Client placement into the appropriate level of withdrawal management services
in accordance with national guidelines, peer -reviewed literature, and best
practices and have available for System Agency review.
G. AMBULATORY WITHDRAWAL MANAGEMENT
(ASAM LEVEL 2 WITHC)RAWALMANAGEMENT)
Grantee shall:
1. Adhere to TAC requirements for detoxification services.
2. Adhere to the SUD Program Guide for detoxification services.
3. Adhere to the following additional service delivery requirements:
i. Document in CMBHS a Withdrawal Management Intake Form.
ii. Document in CMBHS a discharge plan prior to discharge or transfer.
iii. Document in CMBHS a discharge follow-up no more than ten (10) calendar days after
discharge from withdrawal management services.
iv. Develop and Implement Policies, Procedures, and Medical Protocols to ensure Client
placement into the appropriate level of withdrawal management
services in accordance with national guidelines, peer -reviewed literature, and best
practices and have available for System Agency review.
4. Ambulatory detoxification shall not be a stand-alone service. Grantees shall ensure
the Client is simultaneously admitted to a substance use disorder treatment service
while admitted to ambulatory detoxification services.
A. Grantee shall submit required reports of monitoring activities to System Agency by the applicable
due date outlined below. The following reports must be submitted to System Agency through
CMBHS, an alternate HHSC submission system, or by email to the SUD Mailbox,
SUD.Contracts6�hhs.texas.gov., by the required due date and report name described in Table 1:
Submission Requirements.
B. Deliverable reports submitted to the SUD Mailbox require the email subject line to utilize the
following naming convention:
[FY for Deliverable] Deliverable [Name of Deliverable] TRF [contract no.]
C. Grantee is required to maintain access to CMBHS for the term of this contract.
D. Grantee shall submit all documents listed in Table 1 by the Due Date stated.
E. Grantee will note that if the due date is on a weekend or holiday, the due date is the following
business day.
IHISC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500004
Amendment No. 3
10
DocuSign Envelope ID: 0587B1C7-D688-4EF6-931A-1478FBF3FA15
F. Grantee shall submit monthly clams in Clinical Management for Behavioral Health Services
(CMBHS), in accordance with Attachment B.
G. Grantee shall submit a quarterly match report on the System Agency approved template, which
documents Grantee's compliance to contribute five percent match. The report is due on the 15'h
day of the month, following the closure of the state quarter.
H. Grantee shall submit annual Contract Closeout documentation each fiscal year witha final contract
closeout due 45 days after contract end date.
I. Grantee shall submit a CMBHS Security Attestation Form electronically on or before September
15`h and March 15", each fiscal year.
I Grantee's duty to submit documents will survive the termination or expiration ofthis Contract.
K. System Agency will monitor Grantee's performance of the requirements in Attachment A
and compliance with the Contract's terms and conditions.
Table 1: Submission Requirements
Submission System
Requirement
Deliverable
Due Date
(Report
Name
Section VI
Quarterly
Each FY_ Ouarter1 j:
SUD Mailbox:
Match Report
Q1: December 15th
SUD.Contracts@hhs.texas.gov
Q2: March 15th
Q3: June 15th
Q4: September 15th
Section VI
FY Closeout
Each FY;
SUD Mailbox:
October 15`h
SUD.Contracts@hhs.texas.gov
Section VI
Final Closeout
By 45 days after
SUD Mailbox:
contract end date
SUD.Contracts@hhs.texas.gov
Section VI
CMBHS
Each FY;
SUD Mailbox:
Security
September 15`h &
SUD.Contracts@hhs.texas.gov
Attestation
March 15`h
Form and list
of authorized
users
HHSC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500004
Amendment No. 3
11
DocuSign Envelope ID: 0587B1C7-0688-4EF6-931A-1478FBF3FA15
5LL1ION VIL CLINICAL MANAGEMENT FUR BEHAVIORAL HEALTH SERVLLS
A. All CMBHS requirements for the TRF program are detailed in Section V, System of Record
of the Program Guide, which includes the following references:
1. Designation of Security Administrator and backup Security Administrator
2. Establishment of Security Policy
3. Notifications to CMBHS Help -desk within 10 business days of any changes to Security
Administrator
4. CMBHS user access, including removal of user access within 24 hours for those who
are no longer authorized to have access to secure data.
B. In addition to CMBHS Helpdesk notification, Grantee shall submit a signed CMBHS
Security Attestation Form and a list of Grantee's employees and contracted laborers
authorized to have access to secure data. The CMBHS Security Attestation Form shall be
submitted electronically on or before the 15th day of September and March 15th, each
fiscal year.
C. Attend System Agency training on CMBHS documentation.
HHSC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500004
Amendment No. 3
12
DocuSign Envelope ID: 0587B1C7-D688-4EF6-931A-1478FBF3FA15
ATTACHMENT B
REVISED PROGRAM SERVICES AND UNIT RATES
(AUGUST 2023)
A. Contract is funded with the United States Health and Human Services (HHS), the Substance
Abuse and Mental Health Services Administration (SAMSHA), Substance Use Prevention
Treatment Recovery Services (SUPTRS) Block Grant, Assistance Listing Number (ALN)
93.959, and System Agency General Revenue.
B. Compliance with the following Code of Federal Regulation (CFR):
1. SUPTRS Block Grant: 45 CFR Part 96, Subpart C, link: 45 CFR Part 96.
2. Federal Uniform Grant Guidance for Title 2, Grants and Agreements, Subtitle A. Office
of Management and Budget Guidance for Grant and Agreements, Chapter II Office of
Management and Budget Guidance, Part 200 Uniform Administrative Requirements, Cost
Principles, and Audit Requirements for Federal Awards for, link:_
https://www.hhs.texas.gov/business/grants/federal-uniform- rg ant -guidance
C. Compliance with Texas Grant Management Standards, located at Texas Comptroller of Public
Accounts, link: https:HcomptroIler.texas.gov/purchasing/grant-management
D. Funding
1. System Agency's share of total reimbursements is not to exceed $3,208,258.00 for the
period of 8/l/2020 through August 31, 2025, as further specified and allocated by fiscal
year (FY) in Article IV, Budget of the Contract Signature Document.
2. The required Grantee match for the same period is $145,880.00. Grantee is required to
contribute five (5%) matching of funds. All funding from the SUPTRS Supplemental
funding (HR133 and/or COVID-19) do not require the matching of funds and is excluded
from the match calculations.
E. Claims and Payment Requirements:
1. Grantee shall submit claims in CMBHS after services are rendered; no later than monthly.
2. After the closure of each fiscal year, System Agency shall conduct contract close-out
activities. Grantee shall ensure all claims for each state fiscal year (September — August)
are submitted in CMBHS by October 15". Claims submitted after October 15' may be
denied.
HHSC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500004
I
DocuSign Envelope ID: 0587B1C7-D688-4EF6-931A-1478FBF3FA15
3. All claims for September service period of the current fiscal year must be submitted by
October 15th. Claims submitted after this date may be denied due to the grant budget
period being closed.
4. System Agency may request additional supportive documentation to support the claims.
All requests for additional information shall be provided by the deadline requested
F. Except as indicated by the CMBHS financial eligibility assessment, Grantee shall accept
reimbursement or payment from System Agency as payment in full for services or goods
provided to clients or participants; and Grantee shall not seek additional reimbursement or
payment for services or goods, to include benefits received from federal, state, or local sources,
from clients or participants.
G. Budget Program Adjustment (BPA) Requirements
Grantee may request revisions to the approved service group distribution of funds budgeted
in the Service Type/Numbers Served/Capacity: Funding Amounts Chart, by completing a
Budget Program Adjustment (BPA) Form and submitting to the System Agency Contract
Manager and the SUD Mailbox at SUD.Contracts@hhs.texas.gov.
2. System Agency will review the request to determine if the request is allowable under the
RFA, if applicable, and if the request is approved or denied. The estimated timeline for
System Agency to review and provide written communication on the results of the BPA
request is 30 days from receiving an accepted form. Any revisions to the distribution of
funds will result in revised numbers served and/or capacity requirements.
3. Each Fiscal Year (FY), the deadline to submit a BPA is March 1st.
H. Any unexpended balance associated with any other System Agency Contract may not be
applied to this System Agency Contract.
I. System Agency funded capacity is defined as the stated number of clients who will be
concurrently served as determined by this Contract.
J. Service Unit Rates
1. The unit rates for the service charts referenced in Section N of this Attachment are located
at the HHSC Substance Use Disorder Service Provider's webpage, under Forms,
document name: Treatment Rate Sheet, the link to the webpage is below. All unit rates
are subject to change and contingent on available funding.
https:Hhhs.texas. gov/doing-business-hhs/provider-portals/behavioral-health-services-
providers/substance-use-disorder-service-providers
If the link to the webpage and/or location of the applicable unit rate document changes,
System Agency will provide Grantee notice through a broadcast message via email.
HHSC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500004
2
DocuSign Envelope ID: 0587B1C7-D688-4EF6-931A-1478FBF3FA15
If unit rates are adjusted in accordance with Section J.1. of this Attachment., System
Agency will provide Grantee notice through a broadcast message via email. All broadcast
messages will be maintained in Grantee Contract file, and document the following:
a. Treatment Program/Service Type unit rate adjustments;
b. Treatment Program/Service Type unit rate adjustments effective date;
c. Treatment Program/Service Type method for receiving payments for the unit rate
adjustment, in accordance with Section J.3. of this Attachment.
There may be a delay between the effective date of the rate adjustment and those updated
rates being reflected in CMBHS. In the event of a difference in the posted adjusted rate and
the rate in CMBHS, the posted rate controls and payment will be adjusted as described in
Section J.4. of this Attachment.
4. The System Agency effective date of the rate adjustment will determine the method(s) to
implement the unit rate adjustment, as follows:
a. During the fiscal year close-out, System Agency may conduct reconciliation to extract
paid claims data for services provided by Grantee during the unit rate adjustment
approval period. System Agency may calculate the difference between Grantee's
payment utilizing the unit rate in CMBHS versus the revised unit rate. System Agency
will thereafter issue Grantee a final reconciliation payment for the difference between
the two service unit rates. Grantee's fiscal year payment may not exceed the total fiscal
year allocation set forth in Contract Signature document, Section IV, and/or
amendments documenting FY revisions.
b. System Agency may revise the service unit rates in CMBHS to ensure all service claims
during the approved service period may be reimbursed at the revised rate.
c. System Agency reserves the right to utilize different method(s) to process unit rate
adjustments.
d. Method(s) used to process unit rate adjustments will be described in the broadcast
message in Section J.1. of this Attachment.
K. Clinic numbers must be approved by the System Agency Contract Manager before billing can
occur. The Clinic Change Request Form is located at the HHSC Substance Use Disorder
Service Provider's webpage, under Forms, document name: Clinic Request Form, the link to
the webpage is below:
https:Hhhs.texas.gov/doing-business-hhs/provider-portals/behavioral-health-services-
providers/substance-use-disorder-service-providers.
L. Service Types with no associated amount will be paid from the preceding Service Type with
an associated amount.
M. Reimbursement of Allowable Costs for State Fiscal Year 2022 and State Fiscal Year 2023
HHSC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500004
3
DocuSign Envelope ID: 0587B1C7-D688-4EF6-931A-1478FBF3FA15
Grantees may be eligible to receive additional payments for fiscal years 2022 and 2023 for
COVID 19-related costs incurred for covered services that were not included under the fee -for
service payment reimbursement mechanism.
Additional payments will only be made upon written approval from System Agency. The
agency does not guarantee the additional payments will cover all COVID 19-related costs. In
no event will the total amount paid to any Grantee exceed the contract values as specified in
Article IV, Budget, for the associated fiscal year.
At its sole discretion, System Agency will determine additional payment amounts by applying
inflationary and/or market adjustment factors, such as the Consumer Price Index. Additional
payments will be based on Grantee's actual claim services provided and submitted to System
Agency for reimbursement through CMBHS no later than October 15th of each fiscal year.
Additional payments shall comply with applicable provisions within Title 2 of the Code of
Federal Regulations, Part 200 (Uniform Administrative Requirements, Cost Principles, and
Audit Requirements for Federal Awards), and Title 45 of the Code of Federal Regulations Part
96 (Block Grants), and the Texas Grant Management Standards (TxGMS).
Additional payments will be made at the sole discretion of System Agency and are subject to
availability
N. The Service Types, Numbers Served, Capacity, and Funding Amounts in the table below are
approved by System Agency. Grantee shall perform the required services set forth in
Attachment A of this Contract in accordance with the following cost categories:
SERVICE TYPE/NUMBERS SERVED/CAPACITY/FUNDING AMOUNTS
FY 24 SERVICE CHART
Service Type
Number
Served
Capacity
Amount
Adult Specialized Female Residential Intensive
164
13
$555,405.00
Adult Specialized Female Residential Supportive
20
2
$50,000.00
Adult Specialized Female Residential Detox
0
0
$0.00
Adult Specialized Female Ambulatory Detox
0
0
$0.00
Adult Specialized Female W/C Residential
Intensive
0
0
$0.00
Adult Spec Fern W/C Residential Wraparound
Services -LESS THAN 21
Adult Spec Fern W/C Residential Wraparound
Services- 21 and OVER
Adult Specialized Female W/C Residential
Supportive
0
0
$0.00
Adult Specialized Female Outpatient Services
311
4
$50,000.00
HHSC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500004
4
DocuSign Envelope ID: 0587B1C7-D688-4EF6-931A-1478FBF3FA15
Adult Spec Female Outpatient Group Counseling
Adult Spec Female Outpatient Group Education
Adult Spec Female Outpatient Individual
Total
215
$655,405.00
FY 25 SERVICE CHART
Service Type
Number
Served
Capacity
Amount
Adult Specialized Female Residential Intensive
164
13
$555,405.00
Adult Specialized Female Residential Supportive
20
2
$50,000.00
Adult Specialized Female Residential Detox
0
0
$0.00
Adult Specialized Female Ambulatory Detox
0
0
$0.00
Adult Specialized Female W/C Residential
Intensive
0
0
$0.00
Adult Spec Fern W/C Residential Wraparound
Services -LESS THAN 21
Adult Spec Fem W/C Residential Wraparound
Services- 21 and OVER
Adult Specialized Female W/C Residential
Supportive
0
0
$0.00
Adult Specialized Female Outpatient Services
31
4
$50,000.00
Adult Spec Female Outpatient Group Counseling
Adult Spec Female Outpatient Group Education
Adult Spec Female Outpatient Individual
Total
215
$655,405.00
HHSC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500004
DocuSign Envelope ID: 0587B1C7-D688-4EF6-931A-1478FBF3FA15
., Form 8040-A
TEXAS August 2022-E
Health and Human Federal Funding Accountability and Transparency Act FFATA
Services 9 tY p Y ( )
Certification Form
The certifications enumerated below represent material facts upon which HHSC relies when reporting information to the federal government
required under federal law. If HHSC later determines that the contractor knowingly rendered an erroneous certification, HHSC may pursue all
available remedies in accordance with Texas and U.S. laws. The signer further agrees that they will provide immediate written notice to HHSC
if at any time they learn that any of the certifications provided for below were erroneous when submitted or have since become erroneous by
reason of changed circumstances. Note: If the signer cannot certify all of the statements contained in this section, they must provide written
notice to HHSC detailing which of the below statements they cannot certify and why.
Did your organization have a gross income, from all sources, of less than $300,000 in your previous tax year?
Q Yes — Skip questions A, B and C and continue to section D. ® No — Answer questions A and B.
A. Certification Regarding Percent of Annual Gross from Federal Awards
Did your organization receive 80% or more of its annual gross revenue from federal awards during the preceding fiscal year?
Q Yes ® No — Skip question C.
B. Certification Regarding Amount of Annual Gross from Federal Awards
Did your organization receive $25 million or more in annual gross revenues from federal awards in the preceding fiscal year?
® Yes p No — Skip question C.
If your answer is Yes to both questions A and B, you must answer question C.
If your answer is No to either question A or B, skip question C and continue to section D.
C. Certification Regarding Public Access to Compensation Information
Does the public have access to information about the highly compensated officers/senior executives in your business or organization (including
parent organization, all branches and all affiliates worldwide) through periodic reports filed under Section 13(a) or 15(d) of the Securities
Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or Section 6104 of the Internal Revenue Code of 1986?
i) Yes Q No — Provide the names and total compensation of the top five highly compensated officers/senior executives.
Name of Officer or Senior Executive
Total Compensation
1.
2.
3.
4.
5.
D. Signatures
As the duly authorized representative (signer) of the contractor, I hereby certify that the statements made by me in this certification form are
true, complete and correct to the best of my knowledge.
CDoauSigned by: F z , - August 28, 2023
Signature of Authorized Representative Date
Printed Name of Authorized Representative
Tray Payne
Title of Authorized Representative
Mayor
Legal Name of Contractor
Unique Entity Identifier
City of Lubbock
Applicable HHSC Contract No.(s):
DocuSign Envelope ID: 0587B1C7-D688-4EF6-931A-1478FBF3FA15
TEXAS
o PCS 515 CONTRACT ROUTING AND APPROVAL REQUEST Health and Human
Services
Section
U.
• • -
New Contract Number Amendment Number
❑ HHS000779500004 ❑X 3
New Work Order Number Amendment Number
Contractor Legal Business Name:
CITY OF LUBBOCK
Total Contract Value (Including Renewals) Note: Contract value is defined as the estimated dollar amount that the agency may be obligated to pay
$3,354,138.00 pursuant to the contract and oil executed and proposed amendments, extensions and renewals of the contract.
Requesting Agency/Program
HHSC MSS-SUDCMU
Contract Manager Name Contract Manager Email Contract Manager Phone
Cristina Bunyard cristina.bunyard@hhs.texas.gov N/A
Purchaser/Buyer Name Purchaser/Buyer Email Purchaser/Buyer Phone
Approvals
This section contains all contract-sp• Program. These individuals will be inserted into the CAPPS Financials approval process. The minimurn
approvalsrequired approvers listed in Section 2 must include the contract manager, program staff, and legal approval; legal approval may be provided by email for boileriplate template
contracts. All contract -specific approvers, exceptforthe contract signatory who will review and approve in DocuSign, must be listed in this section to approve the contract in
order
Is this a legal approved boilerplate template? ® Yes ❑ No If "Yes" attach Proof of Approval
Approver Title Approver Name Approver E-mail Address
1. Contract Analyst Cristina Bunyard cristina.bunyard@hhs.texas.gov
2• Contract Administration M [James Driscoll Fjames.driscoll@hhs.texas.gov
3• Legal Fonzalez,Steven I I Steven.Gonzalez10@hhs.texas.gov
4. 1 F I F
5.
6. F__
7. 1 F
8. 1 F
E:_ I E_
9.
10.
11.
Effective 10/23/2017 - 1 - Revised 01/13/2022
Effective 10/23/2017 - 1 - Revised 01/13/2022
DocuSign Envelope ID: 0587B1C7-D688-4EF6-931A-1478FBF3FA15
TEXAS
oPCS 515 CONTRACT ROUTING AND APPROVAL REQUEST Health and Human
0 Services
DocuSign Routing Path Begins
Section 3: Internal d DocuSign Review and Approvals
In addition to the approvals in Section 2 the following approvers are needed consistent with the chart below.
HHSC ntracts
t rr�•��r
Approver
Name
E-mail Address
Chief Financial Officer
Trey Wood
Trey.Wood@hhs.texas.gov
System Contracting Director
Andy Marker
Edward. Marker@hhs.texas.gov
Chief Financial Officer
Trey Wood
Trey.Wood@hhs.texas.gov
System Contracting Director
Andy Marker
Edward.Marker@hhs.texas.gov
Office of Chief Counsel
Karen Ray
Karen.Ray@hhs.texas.gov
OIG Contracts
000 000 up to $19,999,999
Approver
Name
E-mail Address
Chief Financial Officer
Trey Wood
Trey.Wood@hhs.texas.gov
Chief Financial Officer
Trey Wood
Trey.Wood@hhs.texas.gov
System Contracting Director
Andy Marker
Edward. Marker@hhs.texas.gov
Office of Chief Counsel
Karen Ray
Karen. Ray@hhs.texas.gov
DSHS Contracts
Approver
Name
E-mail Address
System Contracting Director
Andy Marker
Edward.Marker@hhs.texas.gov
DSHS General Counsel
Cynthia Hernandez
Cynthia.Hernandez3@hhs.texas.gov
off lot .
System Contracting Director
Andy Marker
Edward. Marker@hhs.texas.gov
Office of Chief Counsel
Karen Ray
Karen. Ray@hhs.texas.gov
Effective 10/23/2017 - 2 - Revised 01/13/2022
DocuSign Envelope ID: 0587B1C7-D688-4EF6-931A-1478FBF3FA15
TEXAS
o PCS 515 CONTRACT ROUTING AND APPROVAL REQUEST Health and Human
U.Services
SectionDocuSign Signatories
Signatory
Name
E-mail Address
Contractor Signature Authority
Tray Payne
TrayPayne@mylubbock.us
Additional Contractor Signature
Authority*
Contractor Signature cc
Gloria Diaz
Fgdlaz@mylubbock.us
HHS Signature Authority
Sonja Gaines
sonja.gaines@hhs.texas.gov
HHS Signature Authority cc
SA Mailbox
SUD.Contracts@hhs.texas.gov
General Inbox cc
Cristina Bunyard
Fcristina.bunyard@hhs.texas.gov
* If adding an additional contractor signature authority, please provide instructions on which documents need to be completed by this individual.
Please cc: Katherine Wells at: kwells@mylubbock.us
Effective 10/23/2017 - 3 - Revised O1/13/2022
DocuSign Envelope ID: 0587B1C7-D688-4EF6-931A-1478FBF3FA15
TEXAS
o PCS 515 CONTRACT ROUTING AND APPROVAL REQUEST Health and Human
rL Services
go
INSTRUCTIONS
PURPOSE
To direct HHS contracts, work orders, amendments, renewals, and extensions through the routing and approval process.
WHEN TO PREPARE THIS FORM
This form shall be completed for any document requiring CAPPS Financials approval routing and for DocuSign contract signature routing.
Program area shall adhere to any HHS Circular-046 requirements to complete the form prior to submission to Procurement and
Contracting Services Quality Assurance ("PCS QA").
PROCEDURE TO COMPLETE SS 515
Section 1: To be completed by Program.
This section contains necessary contract information.
Section 2: To be completed by Program.
This section contains all contract -specific approvers as designated by Program. These individuals will be inserted into the CAPPS
Financials approval process. The minimum required approvers listed in Section 2 must include the contract manager, program staff, and
legal approval. All contract -specific approvers, except for the contract signatory who will review and approve in DocuSign, must
be listed in this section to approve the contract in CAPPS Financials. CAPPS approvals must occur in the order listed in Section 2.
DocuSign Routing Path Begins
Section 3: Required Approvals.
This section contains all required Office of Chief Counsel and Chief Financial Officer approvals based on contract value.
Section 4: To be completed by Program.
This section shall contain all required contract signatory information. These individuals will be inserted into the DocuSign routing path.
Effective10/23/2017 -4- Revised 01/13/2022
Certificate Of Completion
Envelope Id: 0587BlC7D6884EF693lAl478FBF3FA15
Subject: Amending $3,354,138.00; HHS000779500004; CITY OF LUBBOCK A-3; HHSC MSS-SUDCMU
Procurement Number:
Source Envelope:
Document Pages: 48 Signatures: 3
Certificate Pages: 2 Initials: 0
AutoNav: Enabled
Envelopeld Stamping. Enabled
Time Zone: (UTC•06:00) Central Time (US & Canada)
Record Tracking
Status: Original
8/9/2023 11.21:33 PM
Security Appliance Status: Connected
Storage Appliance Status. Connected
Signer Events
Tray Payne
TrayPayne@mylubbock.us
Mayor
City of Lubbock
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Sonja Gaines
Sonja.Gaines@hhs.texas.gov
NoSG
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
In Person Signer Events
Editor Delivery Events
Agent Delivery Events
Intermediary Delivery Events
Certified Delivery Events
Holder. Texas Health and Human Services
Commission
PCS DocuSign@hhsc.state.tx.us
Pool: FedRamp
Pool: Texas Health and Human Services
Commission
Signature
OoeuS'g—d by
C76FE32CI148 D
Signature Adoption: Pre -selected Style
Using IP Address: 208.84.91.41
[D*,uSl,n*d by:
btq& Gatln _s
147 CA41340941B
Signature Adoption: Pre -selected Style
Using IP Address: 151.124.105.51
Signed using mobile
Signature
Status
Status
Status
Status
Carbon Copy Events Status
SA Mailbox COPIED
SUD.Contracts@hhs.texas.gov
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
DocuSign
Status: Completed
Envelope Originator:
Texas Health and Human Services Commission
1100 W. 49th St.
Austin, TX 78756
PCS—DocuSign@hhsc.state.tx.us
IP Address: 168.60.133.247
Location: DocuSign
Location: DocuSign
Timestamp
Sent: 8/9/2023 11:45:01 PM
Viewed: 8/25/2023 2:26:13 PM
Signed: 8/28/2023 8:53:21 AM
Sent: 8/28/2023 8:53:24 AM
Viewed: 8/28/2023 10:05:29 AM
Signed: 8/28/2023 10:05:38 AM
Timestamp
Timestamp
Timestamp
Timestamp
Timestamp
Timestamp
Sent: 8/9/2023 11:45:00 PM
Viewed: 8/21/2023 8:59:14 PM
Carbon Copy Events Status Timestamp
Not Offered via DocuSign
Cristina Bunyard
cristina.bunyard@hhs.texas.gov
Contract Specialist IV
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
COPIED
Gloria Diaz COPIED
gdiaz@mylubbock.us
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Katherine Wells COPIED
kwells@mylubbock.us
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Sent: 8/9/2023 11:44:59 PM
Viewed: 8/28/2023 11:20:42 AM
Sent: 8/24/2023 11:19:42 PM
Viewed: 8/25/2023 8:17:05 AM
Sent: 8/24/2023 11:19:42 PM
Viewed: 8/28/2023 10:37:00 AM
Witness Events
Signature
Timestamp
Notary Events
Signature
Timestamp
Envelope Summary Events
Status
Timestamps
Envelope Sent
Hashed/Encrypted
8/9/2023 11:45:00 PM
Envelope Updated
Security Checked
8/24/2023 11:19:41 PM
Envelope Updated
Security Checked
8/24/2023 11:19:41 PM
Envelope Updated
Security Checked
8/24/2023 11:19:41 PM
Certified Delivered
Security Checked
8/28/2023 10:05:29 AM
Signing Complete
Security Checked
8/28/2023 10:05:38 AM
Completed
Security Checked
8/28/2023 10:05:38 AM
Payment Events
Status
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No Text