SECTION 6200
COORDINATING OFFICE FOR DRUG AND ALCOHOL ABUSE PROGRAMS
Section 6201 - General Information
.01 The Coordinating Office for Drug and Alcohol Abuse Programs (CODAAP) is a component of the Philadelphia Department of Health, and also serves as the single county authority for the County of Philadelphia reporting to the State Office of Drug/Alcohol Abuse Programs. Acting in these dual capacities, CODAAP has a broad range of responsibilities which fall into the general categories of planning, funding, monitoring and coordination. Under the category of planning, CODAAP's efforts result in the preparation of a three year plan which is updated annually. This plan details local efforts to address all aspects of the citywide campaign against substance abuse. Based upon the priorities established in the plan, CODAAP allocates federal, state and local resources to service providers within the City. It also monitors these service providers against service projections and budgets established at the beginning of each fiscal year, and federal, state, and local standards/regulations. The provision of program and fiscal management technical assistance, as well as the dissemination of information concerning additional available funding sources for the expansion of treatment/prevention programs, are also responsibilities of the office. Another responsibility of CODAAP, is the liaison function it provides between contract programs and federal/state funding and regulatory agencies.
.02 In addition to its overall management responsibilities, CODAAP is engaged in a number of more direct activities. CODAAP provides and/or arranges training for provider agency staff and medical and human services professionals, as well as educational activities for the general public. It arranges for speakers and educational materials for community meetings, health fairs, special programs, and other educational activities. It provides and distributes educational materials to agencies, organizations, and the general public, and publishes a Resource Guide to D&A services available in the Philadelphia area. It also publishes the CODAAP REPORT, a newsletter for drug/alcohol treatment and prevention professionals.
Section 6210 - Program Descriptions and Operations
.01 CODAAP provides the following types of program services.
.02 Treatment Services:
Treatment services supported by CODAAP include outpatient counseling and therapy, methadone maintenance, residential treatment programs, and detoxification. More than 50 facilities located throughout the city deliver these services to almost 18,000 clients a year, nearly 7,500 at any given time.
.03 Prevention Services:
CODAAP supported prevention services reach more than 120,000 students and citizens in Philadelphia each year. These prevention services are both school and community-based.
Section 6210 (Cont.)
School-based programs include the presentation of a drug and alcohol prevention curriculum in the lower grades, a small group problem-solving approach in the middle grades, and more intensive peer counseling at the high school level. These services are provided in more than 80 public and parochial schools in all areas of the city.
.04 Community-based services include presentations and workshops for parents, residents of housing projects, church groups, and recreation centers, etc.
.05 The above noted CODAAP operations are funded through potential providers via a contract award which may be either program funded or fee-for-service funded. The following briefly describes those funding mechanisms:
… Program funded projects are privately administered and staffed and are reimbursed for their total personnel, operating and fixed asset expenses as predetermined by the City of Philadelphia - CODAAP less all interest or other incomes derived by the Agency from the use of agreement funds.
… Fee-for-service are service providers which are privately administered, staffed and partially funded by a contracted per diem or fee rate by the City of Philadelphia - CODAAP.
Section 6220 - Federal CFDA Numbers/Other Regulations
.01 The following federal CFDA numbers are applicable to CODAAP programs:
Reference CFDA Number Formal Reference
PENN DOT 20.600 State and Community Highway Safety Program
ADAMH 93.959 Alcohol & Drug Abuse Mental
Health Block Grant
OSAP 93.194 Office of Substance Abuse
Prevention
Family Preservation 93.667 Social Services Block Grant
Governor's Discretionary Fund 84.186 Governor's Discretionary Fund
Drug Abuse Improvement 93.196 Targeted Cities
.02 In addition to the above the auditor should be familiar with the following document:
… Fiscal Management Guidelines for County Drug and Alcohol Programs.
… Fiscal Federal Block Grant Regulations.
Section 6230 - Program Compliance Procedures
.01 As discussed in Sections 300 and 500 of this Audit Guide, each City of Philadelphia Department program has specific auditing requirements. These requirements are in addition to those areas of audit specified in Sections 300 and 500 of this Guide. The audit requirements listed on the following pages are not all inclusive and do not represent an audit program for conducting a financial and compliance audit of the program(s). The audit requirements listed are presented as highlights of areas of special interest to the Department. Any deficiencies noted as a result of the procedures are to be disclosed in
Section 6230 (Cont.)
the Schedule of Findings and Questioned Costs
.02 Service objective projection and implementation are integral parts of the CODAAP contracting process. Each year prior to the allocation of funds, CODAAP contract programs must submit a set of service projections estimating the number of services they will provide to clients during the year. Some of the data an agency may report to CODAAP could be, for example, the number of residential days, number of counseling hours, methadone visits, and school presentations. CODAAP program staff review this information as to its propriety, and programs are instructed to change projections in cases where over or under projecting is identified.
.03 During the year, approximately 10 working days following the end of each quarter, programs are required to submit reports to CODAAP indicating their progress in meeting their projections. In cases where a ten percent (10%) deviation from what was projected is evident, programs must submit a written narrative explaining the deviation.
.04 As service objective reporting constitutes such an important aspect in CODAAP's efforts to test the viability of the service system, it is expected that the auditor solicit from each contract agency answers to the following questions, and include any deficiencies noted as a compliance finding in any final audit report:
… How does the program collect its quarterly service objective implementation information? Indicate which staff are involved, the data used in this process, and describe.
… Determine the process used by the program to check the accuracy/validity of the quarterly service objective reports to CODAAP. If no validation process is used, determine why not and report upon.
… What steps does the program take to address consistent patterns of under implementation/over implementation of projected service objectives? What staff are involved in this process? How are they involved?
.05 Copies of the service objective forms used by CODAAP and their instructions for completion are included as Exhibits 1 to 6.
Section 6240 - Financial Compliance Procedures
.01 As discussed in Sections 300 and 500 of this Audit Guide, each City of Philadelphia Department program has specific auditing requirements. These requirements are in addition to those areas of audit specified in Sections 300 and 500 of this Guide. The audit requirements listed on the following pages are not all inclusive and do not represent an audit program for conducting a financial and compliance audit of the program(s). The audit requirements listed are presented as highlights of areas of special interest to the Department. Any deficiencies noted as a result of the procedures are to be disclosed in the Schedule of Findings and Questioned Costs.
Section 6240 (Cont.)
.02 The financial and compliance procedures for CODAAP are provided on the following pages based upon two types of program services:
a. Program Funded Projects (Section 6240.03 to 6240.07)
b. Fee-for-Service Projects (Section 6240.08 and 6240.09)
Program Funded Projects
Revenues:
.03 Program-funding is the most common method employed by CODAAP to fund its provider agencies. This method allows CODAAP to fund a provider agency's actual eligible expenditures for a provider agency's service(s), offsetting these expenses by anticipated revenues to be received directly by the provider, and establishing the remaining deficit as its authorized level of funding (allocation). Reimbursement is affected on a "last-dollar-in" basis and is based upon actual eligible expenses incurred less actual revenue generated, up to the maximum contract funding.
.04 Audit procedures should include the following:
… Does the Agency have a system in place to adequately account for all applicable income received or earned by the agency and that such income was properly reported to CODAAP.
… That medical assistance billings for the program are fully recorded and that re-billings are submitted on claims which have been denied for payment.
… That medical assistance payments are recorded on the accrual basis recognizing any applicable reserves for uncollectible amounts (after pursuing all means of collecting on payments as discussed above).
Expenditures:
.05 The Agency reports expenses to CODAAP in Section III of Form 311 "Year-To-Date Fiscal Report and Cash Request" (Exhibit 7). This report breaks down the expenses into personnel services, operating expenses, and fixed assets. The auditor should utilize this report as the basis of determining the appropriateness of amounts reported to CODAAP and to develop audit procedures to test these expenses. The audit procedures developed are to include, at a minimum, appropriate procedures from Section 300 of the Guide, required compliance matters from the Fiscal Management Guidelines for CODAAP, and consider the following items:
Section 6240 (Cont.)
… Personnel costs charged to the program as reported to CODAAP on the Personnel Roster Report are appropriate, properly supported and allocations of time are documented.
… Administrative overhead costs appear reasonable and are based upon a documented allocation plan. The auditor should consider appropriate procedures from Section 300 - Indirect Costs.
… Capital expenditures or depreciation expense are not eligible for reimbursement.
… Items charged to rent expense are in fact only for building rent expense and do not include any use charges in lieu of rent. Additionally, that rent expense charged by a related party be examined for reasonableness based upon comparable space at current market prices. The related party transaction must be disclosed in the notes to the financial statements in accordance with Financial Accounting Standards Board requirements (SFAS No. 57).
… Interest expense charged to the program is only due to temporary loans the Agency had to obtain to cover cash flow deficiencies due to lack of timely payments from CODAAP.
Budget Modifications:
.06 The contract between CODAAP and the Agency contains a clause, labeled Budget and Service Modifications, which states the following:
"Changes in AGENCY's program budget and Service Objectives may be authorized by CITY where such changes are the result of a written request, with supporting documentation, submitted to and approved by the Director of CODAAP. AGENCY shall make no such changes prior to its receipt of written approval by said Director. Said budgets and Service Objectives will be maintained in an AGENCY file kept by CITY. All final requests for budget and/or Service Objective modifications, with supporting justification, shall be submitted to CITY by April 1st for approval. Budget and/or Service Objectives revisions will not be reviewed unless supporting justification is provided. Failure to comply with the provisions of this paragraph may result in non-reimbursement of expenses resulting from such modifications."
.07 Based upon the above the auditor should determine that:
… The budgetary amounts reported in Section III of the Year-To-Date Fiscal Report and Cash Request are the final amounts approved, including any modifications.
… If applicable, the Agency has followed the modification process as detailed above.
Fee-for-Service Projects
Revenues:
.08 Revenues for a fee-for-service funded program are based upon a set fee or rate of reimbursement for each authorized unit of service rendered by the provider agency to eligible clients. The agency invoices CODAAP on a monthly basis, by client, for such services on Form 310 - Fee-for-Service Invoice/Report (Exhibit 8a).
Section 6240 (Cont.)
The fee-for-service type of funding requires special types of audit tests, since there are no expenses reported to CODAAP. The auditor is to determine the appropriateness of the units billed, the units of service actually provided and any offsetting revenue earned.
.09 Audit procedures should include the following:
… Does the agency have a system in place which accumulates the units of service by client and by type. In addition, are third party revenues maximized prior to billing those units to CODAAP.
… Obtain from the Agency a Summary of Services Billed by Type (this will be utilized in the audit report - see Supplemental Financial Statements Section 6250) for the audit period.
… Determine appropriateness of units of service billings to CODAAP by testing that:
- Service units reported on Form 310 are supported by agency and client records and that the units agree in amount, type of service, date service was rendered, and were adjusted appropriately for any third party (non-CODAAP) revenue.
- Rate per unit billed to CODAAP is appropriate after all deductions have been made for first and/or third party revenues.
Section 6250 - Supplemental Financial Schedules and Reports
.01 The organization's audit report must include the following supplemental financial schedules, for each City of Philadelphia contract with $300,000 or more of expenditures in addition to the financial statements as specified in Sections 400 and 500 of this Audit Guide. A designation has been made for those supplemental schedules required for a "single audit" report (Section 400) or a "program audit" report (Section 500). The auditor will be required to issue an opinion on the Supplemental Schedules listed below as specified in Section 400 of this Audit Guide.
.02 The supplemental financial schedules for a program funded and a fee-for-service project, are as follows:
Program Funded Project
Section
Ref. to Single Program
Supplemental Sample Audit Audit
Financial Schedule Format Report Report
… Statement of Functional Expenditures
by Contract/Program and Revenues
by Funding Source (1) 6250.03 Yes No (3)
… Reconciliation of Agency Reported
Expenditures/Revenues to Audited
Expenditures/Revenues (2) 6250.04 Yes Yes
Section 6250 (Cont.)
Explanatory Notes:
(1) Statement will present expenditures by cost center and revenues by category type as reported and utilized in Form 311 - Year-to-Date Fiscal Report and Cash Request. A separate financial reporting for each CODAAP award must be presented. In addition, the supplemental financial statement must detail the costs by budget cost category and type of revenue. Combining multiple CODAAP awards in one financial statement is not acceptable.
(2) The statement must present expenditures and revenues as reported to CODAAP, report any additional accruals and other adjustments to reconcile the amount reported on the Statement of Functional Expenditures by Contract/Program and Revenues by Funding Source. The reconciliation schedule is required only for those contracts where the amounts reported by the agency to CODAAP differ from the final audited amounts. An explanation of any "other adjustment" must be provided. The accrual explanation, at a minimum, should indicate the type of expense accrued.
The explanation(s) to "other adjustments", however, must be detailed by the type of expense category, and then totaled by cost center.
(3) The statement of revenues and expenditures should contain the captions provided in the sample report format.
Fee-for-Service Projects
Section
Ref. to Single Program
Supplemental Sample Audit Audit
Financial Schedule Format Report Report
… Statement of Units of Service and
Program Revenue 6250.05 Yes Yes
Explanatory Note:
(4) The statement is to present the following information for each individual type of CODAAP Fee-for-Service Award.
ď The total units of service per the audit would represent the units reported by the subrecipient to CODAAP, net of any adjustments the auditor determines appropriate based upon his/her audit of the units of service billed. Where the audited units of service reflected on this statement differ from the total reported by the subrecipient, the auditor must provide on this schedule or on a following page the explanation of the difference with the amount adjusted.
ď The approved unit rate is that unit rate by type of service reflected in the contract between the subrecipient and CODAAP.
Section 6250 (Cont.)
ď The gross cost is the result of multiplying the total units of service per audit by the approved unit rate.
ď The program income is that income applicable to the particular program service. The details of the program revenue by type of service must be provided in the "Detail of Program Revenue" section of the statement.
ď The net billing per audit is the result of subtracting the program revenue from the gross cost.
The above statement format is required for each unit of service award the subrecipient has entered into with CODAAP. A separate statement for each CODAAP award is to be presented, therefore, combining more than one CODAAP contract on a statement is not acceptable.
Section 6250.03
ABC NOT-FOR-PROFIT CORPORATION
COORDINATING OFFICE FOR DRUG AND ALCOHOL ABUSE PROGRAMS
CITY OF PHILADELPHIA CONTRACT NUMBERS XX-XXXX AND XX-XXXX
STATEMENT OF FUNCTIONAL EXPENDITURES BY CONTRACT/PROGRAM
AND REVENUES BY FUNDING SOURCE (1)
JULY 1, 19XX to JUNE 30, 19XX
(1) (1)
Outpatient Women's
Services Program
XX-XXX XX-XXXX
Expenditures by cost center:
Total Personnel Services $ xxxxx $ xxxxx
Total Operating expenses xxxxx xxxxx
Total Fixed assets xxxxx
Total expenditures by cost center xxxxx xxxx
Funding sources:
Client fees xxxxx
City of Philadelphia, Coordinating Office for
Drug and Alcohol Abuse xxxxx xxxx
Medical assistance fees, Commonwealth
of Pennsylvania xxxxx
Total funding xxxxxx xxxx
Excess of expenditures over funding sources $ xxxxx $ xxx
(1) A separate statement of expenditures and revenues must be provided separately for each CODAAP contract. Therefore, if an agency has five contracts the above schedule will have five separate financial amount columns, or five separate financial statements, one for each CODAAP contract.
Section 6250.04
ABC NOT-FOR-PROFIT CORPORATION
COORDINATING OFFICE FOR DRUG AND ALCOHOL ABUSE PROGRAMS
CITY OF PHILADELPHIA CONTRACT NUMBER XX-XXXX
RECONCILIATION OF AGENCY REPORTED EXPENDITURES/REVENUES
TO AUDITED EXPENDITURES/REVENUES
JULY 1, 19XX to JUNE 30, 19XX
Amount (B)
Reported (A) Amount
on Fiscal Other per
Outpatient Services Report Adjustments Audit
Expenditures by cost center:
Total personnel services $ xxxxx $ (xx) $ xxxxx
Total operating expenses xxxx (xx) xxxxx
Total fixed assets xxxx xxxx
Total expenditures by
cost center xxxxx (xx) xxxxx
Funding sources:
Client fees xxxxx xxxxx
City of Philadelphia, Coordinating
Office for Drug and Alcohol Abuse xxxxx xxxxx
Medical assistance fees,
Commonwealth of Pennsylvania xxxxx xxx xxxxx
Total funding xxxxxx xxx xxxxxx
Excess of expenditures over
funding sources $ xxxxx $ xx $ xxxxxx
(A) See following page for explanation of adjustments.
(B) Amount funded under contract in accordance with CODAAP fiscal guidelines.
Section 6250.04 (Cont.)
ABC NOT-FOR-PROFIT CORPORATION
COORDINATING OFFICE FOR DRUG AND ALCOHOL ABUSE PROGRAMS
CITY OF PHILADELPHIA CONTRACT NUMBER XX-XXXX
RECONCILIATION OF AGENCY REPORTED EXPENDITURES/REVENUES
TO AUDITED EXPENDITURES/REVENUES (CONT.)
July 1, 19XX to June 30, 19XX
Explanation of Other Adjustments:
Budget Category Adjustment Explanation Adjustments
Expenditures adjustments:
Personnel Services:
Administrative salaries To correct wages $
incorrectly allocated to
administrative salaries,
should be chargeable to
another program. (xxx)
Client oriented service To correct erroneous
salaries posting of payroll for
pay period ending
May 10, 19XX. xx
Total personnel service
cost adjustments (xx)
Operational expenses:
Utilities To adjust for expenses
charged to this contract
which pertain to another
program. (xx)
Total operating expense
adjustments (xx)
Total expenditure
adjustments $ (xx)
Section 6250.04 (Cont.)
ABC NOT-FOR-PROFIT CORPORATION
COORDINATING OFFICE FOR DRUG AND ALCOHOL ABUSE PROGRAMS
CITY OF PHILADELPHIA CONTRACT NUMBER XX-XXXX
RECONCILIATION OF AGENCY REPORTED EXPENDITURES/REVENUES
TO AUDITED EXPENDITURES/REVENUES (CONT.)
July 1, 19XX to June 30, 19XX
Budget Category Adjustment Explanation Adjustments
Funding source adjustments:
Medical assistance fees To record previously
denied billings which
were collected by agency
and not reported. $ xxx
To adjust reserve for
uncollectible billings
on current year billings. (x)
Total medical assistant
fees adjustments $ xxx
Section 6250.05
ABC NOT-FOR-PROFIT CORPORATION
COORDINATING OFFICE FOR DRUG AND ALCOHOL ABUSE PROGRAMS
CITY OF PHILADELPHIA CONTRACT NUMBER XX-XXXX
STATEMENT OF UNITS OF SERVICE AND PROGRAM REVENUE
JULY 1, 19XX to JUNE 30, 19XX
Total
Units of Approved Less: Net
Service Unit Program Billing
Type of Service Per Audit Rate Gross Cost Revenue Per Audit
Residential xxx $ xx.xx $ xxxxx $ (xxx) $ xxxx
Detail of Program Revenue:
Program Revenues Related To
Private Total
Client Health Food Other Third Other Program
Type of Service Fees Ins. Stamps Party Fees Income Revenue
CODAAP - EXHIBITS
TABLE OF CONTENTS
EXHIBIT DESCRIPTION
1. Outpatient Instructions
1A. Service Objectives Projections - Outpatient Form
2. Inpatient Service Objectives Instructions
2A. Service Objectives Projections - Inpatient Form
2B Service Objectives Projections ń Step-Down or Recovery Housing
3. Shelter Service Objectives Instructions
3A. Shelter Service Objectives
4. Prevention Instructions
4A. Prevention Services Objectives Form
5. Intervention Instructions
5A. Intervention Service Objectives Form
6. Non-Hospital Experimental Service Objectives Form
7. Instructions Year-to-Date Fiscal Report and Cash Request with Sample Forms
8. Instructions for Fee-for-Services Invoice/Report and Form
8A. Fee-for Service Invoice/Report
8B. Guidelines for Billing for Fee-for-Service Residential Days
Exhibit 1
FY'97 CODAAP SERVICE OBJECTIVES INSTRUCTIONS FOR OUTPATIENT
AGENCY NAME: Enter the Corporate name shown at the top of the Allocation Sheet.
FACILITY #: Enter the six digit identification number assigned to the facility by ODAPís licensing division.
FACILITY ADDRESS: Enter the facility(ies) street addresses).
FACILITY NAME: Enter the name(s) used to identify the facility(ies). This should be the same as the Facility Name on the Allocation Sheet across from the funding amount.
1. TOTAL AGENCY SLOTS Enter the total number of slots (static capacity) funded at this facility regardless of funding source.
2. CODAAP FUNDED SLOTS: Enter the number of slots (static capacity) funded by the CODAAP allocation at this facility.
3. ADMISSIONS: Enter the projected number of persons to be admitted to the facility during the funding period.
4. NUMBER OF CLIENTS TO BE SERVED: Enter the projected number of clients to be served during FY'97. This equals the projected census on July 1, 1996 plus projected admissions (line 3).
5. CLIENT VISITS, METHADONE DISPENSING: Enter the projected number of methadone dispensing visits to be made by clients at the facility during the funding period.
6. INDIVIDUAL COUNSELING HOURS: Enter the projected number of individual counseling hours to be provided by the facility during the funding period.
7. GROUP COUNSELING:
a) STAFF HOURS: Enter the projected number of hours to be spent by counseling staff members in the provision of group counseling services to active clients.
b) CLIENT HOURS: Enter the projected total number of group counseling client hours to be provided during the funding period. This equals line 7a multiplied by the projected average group size.
8. TOTAL STAFF HOURS, COUNSELING: Enter the sum of the entries on lines 6 and 7a to obtain the projected total direct service staff hours to be provided during the funding period.
(continued)
Exhibit 1 (Cont.)
NOTE: THIS NUMBER SHOULD REFLECT A MINIMUM OF 924 HOURS PER FULL TIME COUNSELOR EOUIVALENT AS ENTERED ON LINE 15.
REMEMBER, WHAT IS BEING ASKED FOR HERE ARE SPECIFIC
HOURS RELATIVE ONLY TO COUNSELING. ADDITIONAL SERVICE HOURS PROVIDED BY STAFF MAY BE PROJECTED ON LINE 10, ENTITLED "SUPPORT SERVICE INTERVENTIONS."
9. TOTAL CLIENT HOURS, COUNSELING: Enter the sum of the entries on lines 6 and 7b to obtain the projected total number of client hours to be provided during the funding period.
10. SUPPORT SERVICE INTERVENTIONS: Indicate the projected number of staff hours in support service interventions to be provided to clients by counseling staff during their program enrollment. These interventions should not be confused with counseling service hours and not include service hours provided by agency case managers. They should include but not be limited to the following areas:
a) legal b) medical c) vocational
d) educational e) recreational f) family
g) housing h) mental health i) welfare
11. NUMBER OF DIRECT SERVICE HOURS PROVIDED BY CASE MANAGERS: Indicate the projected number of face to face service hours between Case Mangers and clients to be provided during FY97.
Only information effecting Case Managers hired by the agency need be included in these sections.
12. NUMBER OF INDIRECT SERVICE HOURS PROVIDED BY CASE MANAGERS: Indicate the projected number of non direct service hours (i.e., phone calls to welfare,, CJS, meetings with housing providers, etc.) to be provided by case managers during FY'97.
13. NUMBER OF SERVICE HOURS PROVIDED TO CHILDREN: Indicate the number of direct and indirect staff service hours to be provided to children of clients enrolled in your program during the funding period.
14. PHYSICAL/PSYCHIATRIC EXAMS: Enter the number of projected physical/psychiatric exams to be provided to clients at your. facility during the funding period.
Exhibit 1 (Cont.)
15. NUMBER OF FULL TIME COUNSELOR EOUIVALENTS: Enter the number of full time counselor equivalents projected for the funding period. A full time counselor equivalent (FTE) is an employee working a minimum of 35 hours per week providing individual and/or group counseling at the facility. This number should be obtained by adding the appropriate number of counselor equivalents reflected on the Personnel Roster of the program funded budget form. If a supervisor or administrative staff member is also providing direct counseling to clients, that portion of such staff personís time spent in counseling should also be included in the total projection. The calculation of FTEís is best done by adding the total weekly hours to be provided by counselors to the number of counseling hours to be provided by administrative supervisory, or other staff, and dividing this sum by the number of hours in the normal work week of full time staff of the facility.
16. NUMBER OF FULL TIME CASE MANAGER EOUIVALENTS: Enter the number of full time case manager equivalents projected for the funding period. A full time case manager equivalent (FTE) is an employee working a minimum of 35 hours per week providing case management services at the facility. This number should be obtained by adding the appropriate number of case manager equivalents reflected on the Personnel Roster of the program funded budget form. If a supervisor or administrative staff member also provides case management to clients, that portion of such staff person's time should also be included in the total projection. The calculation of FTE's is best done by adding the total weekly hours to be provided by case manager to the number of case management hours to be provided by administrative supervisory, or other staff, and dividing this sum by the number of hours in the normal work week of full time staff of the facility.
DATE SUBMITTED: Enter the actual date the form is submitted to CODAAP.
SUBMITTED BY: The person responsible for preparing the facility information included on this form (i.e. the facility Director) should sign here.
NAME AND TITLE: Type the name and title of the person who signs this form for the facility.
EFFECTIVE DATE OF CHANGE: Use this line only for a Service
objectives revision during the fiscal year.
APPROVED BY: Leave this blank. Final accepted Service objectives Forms will be signed by the Assistant Health Commissioner for CODAAP and appended to your contract. You will be required to achieve the levels of services indicated on the approved Service Objectives Form.
Exhibit 1A
FY'97 CODAAP SERVICE OBJECTIVES PROJECTIONS OUTPATIENT
(SEE INSTRUCTIONS BEFORE ATTEMPTING TO COMPLETE THIS FORM)
AGENCY
FACILITY # FACILITY ADDRESS
FACILITY NAME
INDICATE THE APPROPRIATE SERVICE OBJECTIVES TO BE ACHIEVED UNDER THE CONTRACT DURING FY'97.
1. TOTAL AGENCY SLOTS
2. CODAAP FUNDED SLOTS 3. ADMISSIONS
4. NUMBER OF CLIENTS TO BE SERVED (equals projected census on
July 1, 1996 plus admissions on Line 3)
5. CLIENT VISITS, METHADONE DISPENSING
6. INDIVIDUAL COUNSELING HOURS
7. GROUP COUNSELING a) staff hours
8. TOTAL STAFF HOURS, COUNSELING (equals #6 plus #7a)
9. TOTAL CLIENT HOURS, COUNSELING (equals #6 plus #7b)
10. SUPPORT SERVICE INTERVENTIONS: staff hours
MANAGERS
12. NUMBER OF INDIRECT SERVICE HOURS TO BE PROVIDED BY CASE MANAGERS
13. NUMBER OF SERVICE HOURS TO BE PROVIDED TO CHILDREN
14. NUMBER OF PHYSICAL/PSYCHIATRIC EXAMS
15. NUMBER OF FULL TIME COUNSELOR EQUIVALENTS
16. NUMBER OF FULL TIME CASE MANAGER EQUIVALENTS
DATE SUBMITTED SUBMITTED BY
(signature)
NAME AND TITLE
(name and title typed)
EFFECTIVE DATE OF CHANGE
(use only for the date of a revision during the Fiscal Year)
APPROVED BY
(Assistant Health Commissioner for CODAAP)
Exhibit 2
FY'97 CODAAP SERVICE OBJECTIVES INSTRUCTIONS FOR INPATIENT
AGENCY NAME: Enter the Corporate name shown at the top of the Allocation Sheet.
FACILITY: Enter the six digit identification number assigned to the facility by ODAPís licensing division.
FACILITY ADDRESS: Enter the facility(ies) street address(es).
FACILITY NAME: Enter the name used to identify the facility. This should be the same as the Facility Name on the Allocation Sheet across from the funding amount.
1. TOTAL AGENCY SLOTS: Enter the total number of slots (static capacity) funded at this facility regardless of funding source.
2. CODAAP FUNDED SLOTS: Enter the number of slots (static capacity) funded by the CODAAP allocation at this facility.
3. ADMISSIONS., Enter the projected number of persons to be admitted to the facility during the funding period.
4. NUMBER OF CLIENTS TO BE SERVED: Enter the projected number of clients to be served during the funding period. This equals the projected census on July 1, 1996, plus projected admissions (line 3).
5. TOTAL CLIENT DAYS IN ACTUAL ATTENDANCE: Enter the projected total number client days during the funding period. This should equal 85-100% of the number of slots multiplied by the number of days the facility operates during the year.
6. AVERAGE LENGTH OF STAY (calendar days): Enter the projected average length of stay per client for the funding period. This number equals the total client days on line 5 divided by the total clients to be served on line 4.
7. COST PER DAY: This is the FYí97 total cost of the facility (from the budget) divided by Total Client Days on line 5.
8. INDIVIDUAL COUNSELING HOURS: Enter the projected number of individual counseling hours to be provided by the facility during the funding period.
9. GROUP COUNSELING:
a) Staff Hours: Enter the projected number of hours to be spent by counseling staff members in the provision of group counseling services to active clients enrolled in the facility during the funding period.
Exhibit 2 (Cont.)
10. TOTAL STAFF HOURS, COUNSELING: Enter the sum of the entries on lines 8 and 9a to obtain the projected total direct service staff hours to be provided during the funding period.
NOTE: THIS NUMBER SHOULD REFLECT A TOTAL OF 924 HOURS PER FULL TIME COUNSELOR EQUIVALENT AS ENTERED ON LINE 17. REMEMBER, WHAT IS BEING ASKED FOR HERE ARE SPECIFIC HOURS RELATIVE ONLY TO COUNSELING. ADDITIONAL SERVICE HOURS PROVIDED BY STAFF MAY BE PROJECTED ON LINE 12, ENTITLED "SUPPORT SERVICE INTERVENTIONS."
11. TOTAL CLIENT HOURS, COUNSELING: Enter the sum of the entries on lines 8 and 9b to obtain the projected total number of client hours to be provided during the funding period.
12. SUPPORT SERVICE INTERVIENTIONS: Indicate the projected number of staff hours n support service interventions to be provided to clients by counseling staff during their length of stay. These interventions should not be confused with counseling service hours. They should include but not be limited to the following areas and not include service hours provided by agency case managers:
a) legal b) medical c) vocational
d) educational e) recreational f) family
g) housing h) mental health i) welfare
13. NUMBER OF DIRECT SERVICE HOURS PROVIDED BY CASE MANAGERS: Indicate the projected number of face to face service hours between case manager and clients to be provided during the funding period.
Only information effecting Case Managers directly hired by the agency should be included in these sections.
14. NUMBER OF INDIRECT SERVICE HOURS PROVIDED BY CASE MANAGERS: Indicate the projected number of non-direct service hours (i.e. phone calls to Welfare, CJS, meetings with housing providers, etc.) to be provided by Case Managers during the funding period.
Exhibit 2 (Cont.)
17. NUMBER OF FULL TIME COUNSELOR EOUIVALENTS: Enter the number of full time counselor equivalents projected for the funding period. A full time counselor equivalent (FTE) is an employee working a minimum of 35 hours per week providing individual and/or group counseling at the facility. This number is determined by indicating the appropriate number of counselor equivalents reflected on the Personnel Roster of the program funded budget form. If a supervisor or administrative staff member is also providing direct counseling to clients, that portion of such staff person's time spent in counseling should also be included in the total weekly hours to be provided by counselors to the number of counseling hours to be provided by administrative, supervisory, or other staff. Divide this sum by the number of hours in the normal work week of full time staff.
18. NUMBER OF FULL TIME CASE MANAGER EOUIVALENTS: Enter the number of full time case managers equivalents projected for the funding period. A full time case manager equivalent (FTE) is an employee working a minimum of 35 hours per week providing case management services at the facility. This number should be obtained by adding the appropriate number of case manager equivalents reflected on the Personnel Roster of the programís budget forms. If a supervisor or administrative staff is also providing case management to clients, that portion of such staff personís time should also be included in the total projection. The calculation of FTE's is also best done by adding the total weekly hours to be provided by case managers to the number of case management hours to be provided by administrative, supervisory, or other staff, and dividing this sum by the number of hours in the normal work week of full time staff of the facility.
DATE SUBMITTED: Enter the actual date the form is submitted to CODAAP.
SUBMITTED BY: The person responsible for preparing the facility information included on this form (i.e., the facility Director) should sign here.
NAME AND TITLE: Type the name and title of the person who signs this form for the facility.
EFFECTIVE DATE OF CHANGE: Use this line.only for a service objective revision during the fiscal year.
APPROVED BY: Leave this blank. Final accepted Service Objectives Forms will be signed by the Assistant Health Commissioner required to achieve the levels of services indicated on the approved Service Objectives Form.
Exhibit 2A
FY'97 CODAAP SERVICE OBJECTIVES PROJECTION FORM INPATIENT
(SEE INSTRUCTIONS BEFORE ATTEMPTING TO COMPLETE THIS FORM)
AGENCY:
FACILITY #: FACILITY ADDRESS:
FACILITY NAME:
INDICATE THE APPROPRIATE SERVICE OBJECTIVES TO BE ACHIEVED UNDER THE CONTRACT DURING FY'97.
1. TOTAL AGENCY SLOTS
2. CODAAP FUNDED SLOTS
3. ADMISSIONS
4. NUMBER OF CLIENTS TO BE SERVED
(equals projected census on 7/l/96 plus admissions on line 3)
5. TOTAL CLIENT DAYS IN ACTUAL ATTENDANCE
(should be 85-100% of the # of slots times the # of days the facility operates from 7/l/96 - 6/30/97)
6. AVERAGE LENGTH OF STAY (calendar days)
(equals line 5 divided by line 4)
7. COST PER DAY (total cost divided by line 5)
8. INDIVIDUAL COUNSELING HOURS
9. GROUP COUNSELING a) STAFF HOURS
b) CLIENT HOURS
10. TOTAL STAFF HOURS, COUNSELING (equals line 8 + line 9a)
11. TOTAL CLIENT HOURS, COUNSELING (equals line 8 + line 9b)
12. SUPPORT SERVICE INTERVENTIONS: staff hours
13. NUMBER OF DIRECT SERVICE HOURS TO BE PROVIDED BY CASE MANAGERS
14. NUMBER OF INDIRECT SERVICE HOURS TO BE PROVIDED BY CASE MANAGERS
15. NUMBER OF SERVICE HOURS TO BE PROVIDED TO CHILDREN
16. NUMBER OF PHYSICAL/PSYCHIATRIC EXAMS
17. NUMBER OF FULL TIME COUNSELOR EQUIVALENTS
18. NUMBER OF FULL TIME CASE MANAGER EQUIVALENTS
DATE SUBMITTED SUBMITTED BY:
(Signature)
Effective Date of Change Name and Title (typed)
Approved by:
Assistant Health Commissioner for CODAAP
Exhibit 2B
FY'97 CODAAP SERVICE OBJECTIVES PROJECTIONS
STEP-DOWN OR RECOVERY HOUSING
AGENCY:
ADDRESS OF HOUSING SITE:
1. NUMBER OF SLOTS:
2. PROJECTED CENSUS AS OF JUNE 30, 1996:
3. PROJECTED NUMBER OF NEW ADMISSIONS FROM 7/l/96 TO 6/30/97:
4. NUMBER OF DIFFERENT CLIENTS TO BE SERVED (LINE 2 PLUS LINE 3):
5. NUMBER OF CLIENT DAYS IN RESIDENCE: (SHOULD BE A MINIMUM OF .85 MULTIPLIED BY THE NUMBER OF SLOTS MULTIPLIED BY 365 DAYS. THIS FIGURE MUST BE THE SAME AS THE CLIENT DAYS ON THE BUDGET)
6. NUMBER OF ON SITE MEETINGS DEVOTED TO RECOVERY ISSUES PER WEEK:
7. NUMBER OF OFF-SITE RECOVERY MEETINGS PER CLIENT PER WEEK:
(Do not include treatment appointments.)
DATE SUBMITTED:
SIGNATURE OF EXECUTIVE DIRECTOR:
NAME AND TITLE:
(name and title typed)
EFFECTIVE DATE OF CHANGE:
(use only for the date of a revision during the Fiscal Year)
APPROVED BY:
(Assistant Health Commissioner for CODAAP)
Exhibit 3
FYí97 CODAAP SERVICE OBJECTIVES INSTRUCTIONS FOR SHELTERS
AND TRANSITIONAL LIVING FACILITIES
AGENCY NAME: Enter the Corporate name shown at the top of the Allocation Sheet.
FACILITY NAME: Enter the name used to identify the facility. This should be the same as the Facility Name on the Allocation Sheet across from the funding amount.
FACILITY ADDRESS: Enter the facility street address.
FACILITY: If your facility is licensed, enter the six digit identification number assigned to the facility by the State Health Department's licensing division.
1. CODAAP FUNDED BLOTS: Enter the number of slots (static capacity) funded by this allocation.
2. TOTAL FACILITY SLOTS: Enter the total number of funded slots in this facility by all sources.
3. ADMISSIONS: Enter the total projected number of persons to be admitted to the facility during FY'97.
4. NUMBER OF CLIENTS TO BE SERVED: Enter the total projected number of clients to be served during FY'97. This equals the admissions (line #3) plus the projected census on July 1,1996.
5. NUMBER OF CLIENTS RECEIVING D/A TREATMENT SERVICES OFF SITE: Enter the projected number of persons living in your facility who will be enrolled in an off-site licensed drug and alcohol treatment program during the funding period.
6. TOTAL HOURS DAYS IN D/A TREATMENT: Enter the projected number of hours that clients from your facility will attend treatment off-site during the funding period.
DATE SUBMITTED: Enter the actual date the form is submitted to CODAAP.
SUBMITTED BY: The person responsible for preparing the facility information included on this form (i.e. the facility Director) should sign here.
NAME AND TITLE: Type the name and title of the person who signs this form for the facility.
EFFECTIVE DATE OF CHANGE: Use this line only for a Service objectives revisions during the fiscal year.
APPROVED BY: Leave this blank. Final accepted Service Objectives Forms will be signed by the Assistant Health commissioner for CODAAP and appended to your contract. You will be required to achieve the levels of services indicated on the approved Service Objectives Form.
Exhibit 3A
SERVICE OBJECTIVES FOR CODAAP FUNDED SHELTERS FISCAL YEAR F97
Agency:
Facility Name:
Facility Address:
Facility Number:
Activity Code:
INDICATE APPROPRIATE SERVICE OBJECTIVES TO BE ACHIEVED UNDER
THE CONTRACT DURING FY'97.
1. CODAAP Funded Slots
2. Total Facility Slots
3. Admissions
4. Number of Clients To Be Served
5. Number of Clients Receiving D/A Treatment Services Off Site
6. Total Client Hours in treatment off-site.
Date Submitted Submitted By
(Signature)
Name and title of signer (typed)
Effective Date of Change
(use only for amendment of a contract in place)
Approved By:
Assistant Health Commissioner for CODAAP Date
Exhibit 4
FY'97 CODAAP SERVICE OBJECTIVES INSTRUCTIONS FOR PREVENTION
AGENCY NAME: Enter the Corporate name shown at the top of the Allocation Sheet.
FACILITY # Enter the six digit identification number assigned to the facility by ODAP's licensing division.
FACILITY/ACTIVITY NAME: Enter the name used to identify the program component (e.g. High School Program). This should be the same as the Facility Name on the Allocation Sheet across from the funding amount.
SCHOOL SETTING: Prevention services provided in the school setting to students, parents, and/or school staff. Presentation numbers must be reported by grade level as indicated on the form.
LARGE GROUP PRESENTATIONS (20 PERSONS OR MORE): Enter the appropriate number in each column for presentations to be provided to groups of 20 persons or more during the funding period.
SMALL GROUP PRESENTATIONS (2 TO 19 PERSONS): Enter the appropriate numbers in each column for presentations to be provided to groups of 2 to 19 persons during the funding period.
INDIVIDUAL CONTACTS: Enter the appropriate numbers in each column for individual prevention services contacts or consultations with school staff, students, or parents to be provided during the funding period.
PROM/GRADUATION/YTSC PRESENTATIONS (20 PERSONS OR MORE): Enter the appropriate numbers in each column for prom/graduation presentations to be made in high schools during the funding period.
FAMILY CONSULTATIONS: Enter the appropriate numbers in each column for conferences with parents or other family members regarding students served by prevention specialists.
TOTAL: SCHOOL SETTING: Enter the sums of the columns for School Setting.
(continued)
Exhibit 4 (Cont.)
COMMUNITY SETTING: Prevention services are provided in the community to adults or children. Services may be provided to, and/or in conjunction with, community organizations or individuals in order to increase the communityís knowledge and awareness of substance use issues, encourage community initiatives, or promote community change or control directed toward reducing substance abuse. Presentation numbers must be reported by age groups as indicated on the form.
LARGE GROUP PRESENTATIONS (20 PERSONS OR MORE): Enter the appropriate numbers in each column for presentations to be provided in community settings to groups of 20 persons or more during the funding period.
SMALL GROUP PRESENTATIONS (2 TO 19 PERSONS): Enter the appropriate numbers in each column for presentations to be provided to groups of 2 to 19 persons during the funding period.
INDIVIDUAL CONTACTS: Enter the appropriate numbers in each column for individual community members to be provided during the funding period.
COMMUNITY OUTREACH PRESENTATION: Enter the appropriate number of presentation made to established community groups (as distinct from ad hoc community groups) for the purpose of coordinating efforts to address common issues.
TOTAL: COMMUNITY SETTING: Enter the sums of the columns in the Community Setting section.
GRAND TOTAL: For each column add the amount on the TOTAL: SCHOOL SETTING line to the amount on the TOTAL: COMMUNITY SETTING line.
COLUMN DEFINITIONS
NUMBER OF PRESENTATIONS/SESSIONS: Enter the total number of presentations or sessions to be made by the Program's staff during the funding period.
STAFF HOURS IN DIRECT PRESENTATION SESSIONS: Enter the total number of staff hours in direct presentations/sessions during the funding period. This should NOT include preparation time.
NOTE: The GRAND TOTAL of this column should reflect a minimum of 770 hours per Full Time Prevention Specialist Equivalent in 10 month program or 924 hours in 12 month program.
(continued)
Exhibit 4 (Cont.)
UNDUPLICATED INDIVIDUALS: Enter the total number of unduplicated (unique) individuals to be provided services during the funding period.
TOTAL ATTENDANCE: Enter the cumulative attendance of individuals to be served during the funding period.
NOTE:The GRAND TOTAL for each column consists of the sum of the School Setting and the Community Setting Totals. The service numbers for prom/graduation programs and YTSC activities are to be INCLUDED in the respective School Setting Total, Community Setting Total, and Grand Total.
Number of Referrals to be Made: Enter the total number of students to be referred to other human services providers during the funding period. D//A treatment and on the appropriate line.
NUMBER OF FULL TIME PREVENTION SPECIALIST EQUIVALENTS: Enter the number of full time Prevention specialist equivalents projected for the funding period. A full time Prevention specialist equivalent (FTE) is an employee working a minimum of 35 hours per week providing prevention/early intervention services. This number should be obtained by adding the appropriate number of counselor equivalents reflected on the Personnel Roster of the program funded budget form. If a supervisor or administrative staff member is also providing prevention/intervention services, that portion of such staff person's time spent in providing direct prevention/intervention services should also be included in the total projection. The calculation of FTE's is best done by adding the total weekly hours to be provided by Prevention Specialists to the number of prevention service hours to be provided by administrative, supervisory, or other staff, and dividing this sum by the number of hours in the normal work week of full time service staff.
DATE SUBMITTED: Enter the actual date the form is submitted to CODAAP.
SUBMITTED BY: The person responsible for preparing the facility information included on this form (i.e. the facility Director) should sign here.
NAME AND TITLE OF SIGNER: Type the name and title of the person who signs this form for the facility.
EFFECTIVE DATE OF CHANGE: Use this line only for a Service objectives revision during the fiscal year.
APPROVED BY: Leave this blank. Final accepted Service Objectives Forms will be signed by the Assistant Health Commissioner for CODAAP and appended to your contract. You will be required to achieve the levels of services indicated on the approved Service Objectives Form.
Exhibit 4A
CODAAP SERVICE OBJECTIVES FORM FOR PREVENTION - FY/97
AGENCY/FACILITY FACILITY#
|
School Setting |
Number of Presentations/Sessions |
Staff Hours in Direct Service |
Unduplicated Individuals |
Total Attendance |
|||
|
K-5 |
6-8 |
9-12 |
Adults |
||||
|
Large group presentations (20 persons or more) |
|||||||
|
Small group presentations (2 to 19 persons) |
|||||||
|
Individual Contacts
|
|||||||
|
Prom/graduation/YTSC presentations (20 persons or more) |
|||||||
|
Family Consultants |
|||||||
|
Total: School Setting |
|||||||
|
Community Setting
Large group presentations (20 persons or more) |
<10 |
11-13 |
14-17 |
Adults |
|||
|
Small group presentations (2 to 19 persons) |
|||||||
|
Individual Contacts |
|||||||
|
Community Outreach Presentations |
|||||||
|
Total: Community Setting |
|||||||
|
Grand Total |
|||||||
Number of referrals made: D/A Treatment Other services
Number of full-time prevention specialist equivalents
Submitted by: Date submitted
(Signature)
Name and title of signer:
(Typed)
Effective date of change:
Approved by: Assistant Health Commissioner for CODAAP
Exhibit 5
FY 97 CODAAP SERVICE OBJECTIVES INSTRUCTIONS FOR INTERVENTION
AGENCY NAME: Enter the Corporate name shown at the top of the Allocation Sheet.
FACILITY: Enter the six digit identification number assigned to the facility by ODAP's licensing division.
FACILITY NAME: Enter the name used to identify the facility. This should be the same as the Facility Name on the Allocation Sheet across from the funding amount.
FACILITY ADDRESS: Enter the facility street address.
ACTIVITY CODE: Enter the appropriate activity code, i.e. 71 or 73.
1. INDIVIDUAL COUNSELING HOURS: Enter the projected number of individual counseling hours to be provided by the facility during the funding period.
2. GROUP COUNSELING:
a) STAFF HOURS - Enter the projected number of hours to be spent by counseling staff members in the provision of group counseling services to active clients enrolled in the facility during the funding period.
b) CLIENT HOURS - Enter the projected total number of group counseling client hours to be provided during the funding period. This equals line 2a multiplied by the projected average group size.
3. INFORMATIONIEDUCATIONAL GROUP
a) STAFF HOURS - Enter the projected number of hours to be spent by the clinical staff in the provision of information or education to clients during the funding period. These services include substance abuse information regarding other services needed by the clients and education on topics pertinent to the needs of the program's target population.
b) CLIENT HOURS - Enter the projected number of hours of substance abuse educational and information services to be provided to clients during the funding period. This line equals line 3a multiplied by the average group size.
4. TOTAL STAFF HOURS: Enter the sum of the entries on lines 1 and 2a and 3a to obtain the projected total direct service staff hours to be provided during the funding period.
NOTE: THIS NUMBER SHOULD REFLECT A MINIMUM OF 924 HOURS PER FULL TIME COUNSELOR EOUIVALENT AS ENTERED ON LINE 8.
Exhibit 5 (Cont.)
5. TOTAL CLIENT HOURS: Enter the sum of the entries on lines 1, 2b, and 3b to obtain the projected total number of client hours to be provided during the funding period.
6. CLIENTS SCREENED:
a) IN PERSON - Enter the projected number of in person client screenings for the funding period.
7 CLIENTS REFERRED:
b) TELEPHONE ONLY - Enter the projected number of clients to be referred by telephone only during the funding period.
c) TOTAL CLIENTS REFERRED: Sum of lines 7a and 7b.
8. NUMBER OF FULL TIME DIRECT CLIENT SERVICE STAFF EOUIVALENTS:
Enter the number of full time direct client service staff equivalents projected for the funding period. A full time direct client service staff equivalent is an employee working a minimum of 35 hours per week providing direct client services at the facility. This includes but is not limited to, individual and group counseling. and information and educational services. This number of such staff equivalents to be entered on line 8 should be obtained by adding the appropriate number of direct client service staff equivalents ref leeched on the Personnel Roster of the program funded budget form. If a supervisor or administrative staff member is also providing direct client services, that portion of such staff person's time spent in direct client services should also be included in the total projection. The calculation is best done by adding the total weekly hours to be provided by the appropriate staff to the number of appropriate hours to be provided by administrative, supervisory, or other staff, and dividing this sum by the number of hours in the normal work week of full time staff of the facility.
DATE SUBMITTED: Enter the actual date the form is submitted to CODAAP.
SUBMITTED BY: The person responsible for preparing the facility information included on this form (i.e. the facility Director) should sign here.
NAME AND TITLE: Type the name and title of the person who signs this form for the facility.
EFFECTIVE DATE OF CHANGE: Use this line only for a Service objectives revision during the fiscal Year.
Exhibit 5 (Cont.)
APPROVED BY: Leave this blank. Final accepted Service Objectives Forms will be signed by the Assistant Health Commissioner for CODAAP and appended to your contract. You will be required to achieve the levels of services indicated on the approved Service Objectives Form.
Exhibit 5A
FY'97 CODAAP SERVICE OBJECTIVES PROJECTIONS INTERVENTION (SEE INSTRUCTIONS BEFORE ATTEMPTING TO COMPLETE THIS FORM)
AGENCY
FACILITY # FACILITY ADDRESS
FACILITY NAME
ACTIVITY CODE
INDICATE THE APPROPRIATE SERVICE OBJECTIVES TO BE ACHIEVED UNDER THE CONTRACT DURING FY'97.
NOTE: Agencies providing intervention services under code 71 or 73 should fill in all sections of this form. Where service information does not apply to a program, enter a zero on those lines.
1. INDIVIDUAL COUNSELING HOURS
2. GROUP COUNSELING a) staff hours
b) client hours
3. INFORMATION/EDUCATIONAL GROUPS a) staff hours
b) client hours
4. TOTAL STAFF HOURS, (equals line 1 plus 2a plus 3a)
5. TOTAL CLIENT HOURS, (equals line 1 plus 2b plus 3b)
6. CLIENTS SCREENED
a) In person
b) Telephone only
c) Total Clients Screened (6a + 6b)
7 CLIENTS REFERRED
8. NUMBER OF FULL TIME DIRECT CLIENT SERVICE
STAFF EQUIVALENTS
DATE SUBMITTED SUBMITTED BY
(signature)
NAME AND TITLE
(name and title typed)
EFFECTIVE DATE OF CHANGE
(use only for the date of a revision during the Fiscal Year)
APPROVED BY
(Assistant Health commissioner for CODAAP)
Exhibit 6
FY' 97 CODAAP SERVICE OBJECTIVES PROJECTIONS
NON-HOSPITAL EXPERIMENTAL
AGENCY: IMPACT SERVICES CORPORATION
FACILITY #: 860087 FACILITY ADDRESS: 124 E. INDIANA AVENUE
FACILITY NAME: IMPACT SERVICES
ACTIVITY: CLIENT TRAINING ACTIVITY CODE: 53
INDICATE THE APPROPRIATE SERVICE OBJECTIVES TO BE ACHIEVED UNDER THE CONTRACT DURING FY' 97.
DATE SUBMITTED SUBMITTED BY
(signature)
NAME AND TITLE
(name and title typed)
EFFECTIVE DATE OF CHANGE
(use only for the date of a revision during the Fiscal Year)
APPROVED BY
(Assistant Health Commissioner for CODAAP)
Exhibit 7
This Exhibit should be obtained from either the subrecipient or the Department of Health.
Exhibits 8, 8A, 8B
This Exhibit should be obtained from either the subrecipient or the Department of Health.