ADDENDUM # The Contractor and its staff shall not become the legal guardian of any Person receiving services under this contract.

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1 DEPARTMENT OF HUMAN SERVICES PALMER DePAULIS Executive Director State of Utah GARY R. HERBERT Governor GREG BELL Lieutenant Governor OFFICE OF FISCAL OPERATIONS JENNIFER C. EVANS Director BUREAU OF CONTRACT MANAGEMENT STEPHANIE M. CASTRO Director ADDENDUM # 3 REQUEST #: DHS90539 Agency: Division of Services for People with Disabilities DESCRIPTION: Eligibility and Forensic Psychological Evaluations 1. Part III, Scope of Work: Replace with the following to correct numbering, incorporate changes made in addendum #1 and replace the payment rate table rates effective July 1, A. GENERAL REQUIREMENTS 1. In accordance with Utah Code 62A through 62A-2-122, the Contractor shall ensure all individuals working in an employment or volunteer capacity who have direct access to Persons (people receiving services pursuant to this Contract) annually pass a background check conducted by the Department of Human Services/Office of Licensing (DHS/OL). Any staff member who has lived outside the State of Utah for a period greater than 28 days during the preceding five (5) years, shall also pass a Federal Bureau of Investigation Nationwide Criminal Background check consistent with current DHS/OL. 2. The Contractor and its staff shall not become the legal guardian of any Person receiving services under this contract. 3. Contractor s Staff Qualifications: The staff member providing services shall have the following: a. a Doctorate in Psychology from an American or Canadian accredited college or university, and be licensed as a Psychologist within the State of Utah pursuant to Utah Code Title 58 Chapter 61, Psychologist Licensing Act. b. to perform eligibility evaluations, the staff member must have at least three (3) years experience working directly with people with ID.RC, and one-year experience in conducting psychological evaluations for determining eligibility. 195 North 1950 West, Salt Lake City, Utah telephone (801) facsimile (801) Page 1 of 9

2 c. to perform forensic evaluations, the staff must have at least a minimum of three (3) years experience performing forensic evaluations, and one-year of experience diagnosing intellectual disabilities. 4. Population Served a. Eligibility Determination: (1) Persons who may have Intellectual Disabilities and Related Conditions (ID.RC) who must submit to a psychological evaluation to assist DHS/DSPD in determining eligibility for services offered by DHS/DSPD. (2) those initially applying for services with DHS/DSPD, Persons on the Waiting List referred by DHS/DSPD for an eligibility evaluation, and Persons receiving services who may be referred to the Contractor by DHS/DSPD for an evaluation to determine continued eligibility, as per Administrative Rule R b. Forensic Evaluation: The population requiring evaluation includes juvenile offenders or criminal defendants who have been referred to DHS/DSPD for evaluation pursuant to an order of State of Utah District or Juvenile Courts, for the purpose of determining the exception to the death penalty, competency to proceed, psychological restoration evaluation of competency to stand trial or for special needs such as neuropsychological or psychosexual evaluations. Defendants may be housed in community jails, regional correctional facilities, the Utah State Hospital, the Utah State Developmental Center, or in the community (having been released on their own recognizance). Evaluations shall be performed in any of the above locations. For those individuals in the community, evaluations shall be conducted in a Stateowned or State-leased building, with the exclusion of public schools. 5. Staff-To-Person Ratio Psychological evaluations shall be provided as a one-to-one (1:1) service. 6. Referral Requirements All services provided pursuant to this Contract shall only be provided after the Contractor receives a referral/request (Form 1056) from DHS/DSPD. 7. Consultation and Court Appearance Requirements. The Contractor shall: a. consult with DHS/DSPD staff to assist DHS/DSPD staff with interpreting evaluations. b. appear and provide testimony in related court proceedings. 8. Record Keeping a. Personnel Records Page 2 of 9

3 The Contractor shall maintain the following information in its staff's personnel files: (1) results of the annual background screenings conducted in accordance with Utah Code 62A through 122, or Utah Administrative Code, Rule R501-14, for all staff working in an employment or volunteer capacity. (2) DHS Provider Code of Conduct and DHS/DSPD Provider Code of Conduct. (3) copies of educational transcripts and degrees (if transcripts and degrees are used by the Contractor to prove competency). (4) a copy of the W-4 and/or I-9 as applicable. b. Persons' Clinical Records The Contractor shall maintain separate clinical records for each Person served and protect the documentation by maintaining it in a secure (locked) area. Each Person s record shall include the following information: (1) the name, address, phone number, and birth date of the Person receiving services; and (2) the name and phone number of the DHS/DSPD staff (such as the intake worker), or the Person s support coordinator external. (3) the name of the individual who provided the service; (4) the specific service provided; and, (5) the date the service was provided. c. Reporting and Billing Requirements The Contractor shall submit the reports listed below to the applicable DHS/DSPD office where the referral originated, by the specified due date. If required reports and billings are not submitted within 15 days of their due date, payment may be denied. DOCUMENT Person s Psychological Eligibility or Forensic Evaluations DHS 295S Billing Form for each evaluation DUE DATE 20 days from the DHS/DSPD referral date, or the date specified in the referral (Form 1056). The DHS295S Billing Form (for each evaluation) will be due to DHS/DSPD within 15 days of the date that DSPD Page 3 of 9

4 DOCUMENT DUE DATE received the Person s completed Psychological Eligibility or Forensic Evaluation. B. PSYCHOLOGICAL EVALUATIONS FOR DHS/DSPD ELIGIBILITY DETERMINATION (APL) Specific Service Requirements for Eligibility Evaluations: At a minimum, an eligibility evaluation shall include the following: 1. Reason for referral; 2. Background information including the following: a. social history; b. developmental history; and, c. service/ support/ treatment history. 3. Observations from testing and interview; 4. Testing instruments administered; 5. Scores and interpretations of individualized standardized assessment of intellectual functioning such as Wechsler Adult Intelligence Scale (WAIS), Stanford Binet, Test of Non-Verbal Intelligence, etc; 6. Scores and interpretations of assessment of adaptive behaviors such as Vineland, Scales of Independent Behavior, etc; 7. Other psychological testing as indicated or requested such as assessment of autism, depression, etc. Test results, interpretation of results, clinical observations, and discussion of previous evaluations if conflicting or supporting; 8. Summary and Conclusions; 9. Diagnostics & Statistical Manual for Mental Disorders (DSM) (current edition) Diagnosis; 10. Assessment of the Person s level of functioning in the seven major life areas as defined in R , (2): a. self-care; b. expressive/receptive language; c. learning; Page 4 of 9

5 d. mobility; e. capacity for independent living; f. self-direction; and g. economic self-sufficiency (age 18 or older); and l1. Recommendations for services, supports, treatments, or supervision needs. C. FORENSIC EVALUATIONS 1. General Description of Forensic Evaluations: The Contractor may be required to perform an exception to death penalty, competency-to-proceed, or a progress towards competency restoration evaluation. Any or all of the following services may be required of the Contractor depending on the particular order of the Court and whether or not the Contractor has requested an exemption from performing exception from the death penalty evaluations. 2. General Service Requirements: The Contractor shall: a. complete all required evaluations within the time frames established by law or order of the Court and the results shall be made available to the Court, prosecuting attorney, defense attorney, and DHS/DSPD in writing as required by law, statute, regulation, procedure, or order of the Court. b. be familiar with, understand, and focus on the relevant legal issues pertaining to the particular type of evaluation ordered by the Court. c. conduct the following types of forensic evaluations: (1) Determination of Intellectual Disability and Competency-to-Proceed (DHS/DSPD Service Code APC) (Utah Code ); (2) Progress towards Competency Restoration (DHS/DSPD Service Code APC) (Utah Code ); (3) Exception from the Death Penalty (DHS/DSPD Service Code APD) (Utah Code 77-15a-101); and d. provide the following for items (1) through (3) above: (1) written reports and evaluations with copies for the juvenile's or criminal defendant's medical record for the Court and attorneys as needed or required; and (2) court appearances as required by the Court (DHS/DSPD Service Code (APQ). 3. Specific Service Requirements for Forensic Evaluations: Page 5 of 9

6 a. the Contractor shall comply with the requirements of Title 77 of the Utah Code, including any amendments to the code. b. at a minimum, the Contractor s forensic evaluations shall be in writing and include the following information: (1) reason for referral; (2) background information including the following; (a) (b) (c) social history; developmental history; and, service/support /treatment history. (3) observations from testing and interview; (4) testing instruments administered; (5) scores and interpretations of individualized standardized assessment of intellectual functioning such as Wechsler Adult Intelligence Scale (WAIS), Stanford Binet, Test of Non-Verbal Intelligence, etc. (6) scores and interpretations of assessment of adaptive behaviors such as Vineland, Scales of Independent Behavior, etc.; (7) other psychological testing as indicated or requested such as assessment of autism, depression etc. Test results, interpretation of results, clinical observations, and discussion of previous evaluations if conflicting or supporting; (8) summary and conclusions; (9) Diagnostics & Statistical Manual for Mental Disorders (DSM) (current edition) Diagnosis; (10) in conducting its evaluation, the Contractor shall consider and address, the following: (a) the defendant s present capacity to: (i) (ii) (iii) comprehend and appreciate the charges or allegations against him; disclose to counsel pertinent facts, events, and states of mind; comprehend and appreciate the range and nature of possible penalties, if applicable, that may be imposed in the proceedings against him; Page 6 of 9

7 (iv) (v) (vi) (vii) engage in reasoned choice of legal strategies and options; understand the adversary nature of the proceedings against him; manifest appropriate courtroom behavior; and, testify relevantly, if applicable; (b) (c) the impact of the mental disorder, or intellectual disability, if any, on the nature and quality of the defendant's relationship with counsel; if psychoactive medication is currently being administered: (i) (ii) whether the medication is necessary to maintain the defendant's competency; and, the effect of the medication, if any, on the defendant's demeanor and affect and ability to participate in the proceedings. (11) if the Contractor s opinion is that the defendant is incompetent to proceed, the Contractor shall indicate in the evaluation: (a) (b) (c) (d) which of the above factors in subparagraph (10) contributes to the defendant's incompetency; the nature of the defendant's mental disorder or intellectual disability and its relationship to the factors contributing to the defendant's incompetency; the treatment(s) appropriate and available; and the defendant's capacity to give informed consent to treatment to restore competency. (12) the Contractor s evaluation shall: (a) (b) identify the specific matters referred for evaluation; describe the procedures, techniques, and tests used in the examination and the purpose or purposes for each; (c ) state the Contractor s clinical observations, findings, and opinions on each issue referred for examination by the Court, and indicate specifically those issues, if any, on which the expert could not give an opinion; and Page 7 of 9

8 (d) identify the sources of information used by the Contractor and present the basis for the Contractor s clinical findings and opinions. D. NON-ROUTINE TRAVEL Non-routine (exceeding a 75 mile round trip) travel expenses are not included in the rates for evaluation services and court appearances. The Contractor shall separately bill for non-routine travel using its own reimbursement request form which shall include the following: 1. Driver s name; 2. Date and time of travel; 3. Purpose of the trip; 4. Beginning and ending physical locations including addresses; and 5. The number of miles traveled (beginning and ending mileage from odometer). The travel reimbursement request shall be submitted at the same time the billing for the service (AP codes) is submitted to DHS/DSPD. E. RATES The table below contains the rates for each service code. The session is the total time needed to complete the evaluation and other related duties associated with the evaluation, with the exception of travel and Court appearance or testimony. Payment Rate Table Description of Services Psychological Evaluations for DHS/DSPD Eligibility Determination Basic competency evaluation to stand trial or restoration evaluation of competency to stand trial. (each service shall be billed separately) Exception to Death Penalty Evaluation Unit Service Code Rate Limitations Population Served Session APL $ Requires a Persons who may have IDRC and/or written referral Juveniles or Criminal Defendants from referred to DHS/DSPD for evaluation DHS/DSPD pursuant to order of the District Court or have been referred by others to DHS/DSPD to determine eligibility Session APC $ Requires a written Juveniles or Criminal Defendants referral from referred to DHS/DSPD for DHS/DSPD. evaluation pursuant to order of the District Court or have been referred by others to DHS/DSPD to determine psychological competency evaluation to stand trial or psychological restoration Session APD $ Requires a written referral from DHS/DSPD. Page 8 of 9 evaluation of competency to stand trail Persons with ID.RC and/or Juveniles or Criminal Defendants who have been referred to DHS/DSPD for evaluation pursuant to order of the District Court or have been referred by others to DHS/DSPD to determine exception to death penalty

9 Description of Services Appear and provide testimony in related court proceedings or conduct a consultation Non-Routine Travel. For use when providing all psychological evaluation services and Court Appearances. Unit Quarter Hour Each Mile Service Code Rate Limitations Population Served APQ $16.50 Requires a written Persons with IDRC and/or Juveniles or referral from Criminal Defendants referred to DHS/DSPD. DHS/DSPD for evaluation pursuant to order of the District Court or have been referred by others to DHS/DSPD n/a $0.38 Requires a Travel Reimbursement form. Persons with IDRC and/or Juveniles or Criminal Defendants referred to DHS/DSPD for evaluation pursuant to order of the District Court or have been referred by others to DHS/DSPD **********End of Addendum********** To acknowledge receipt of addendum, include a copy of this addendum with the Response or give written acknowledgement with the Response. It shall be the responsibility of the Offeror to appropriately disseminate this information to all concerned. Name Company Signature Date Page 9 of 9