HomeMy WebLinkAbout326581
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Agreement No. 18-111
AGREEMENT
THIS AGREEMENT is made and entered into this 20th day of March, 2018, by and between the
COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter referred to as
"COUNTY", and each PROVIDER listed in Exhibit A, "List of Providers", attached hereto and by
this reference incorporated herein, collectively hereinafter referred to as
PROVIDER(s)", and such additional PROVIDER(s) as may, from tjme to time during the term of this
Agreement, be added by COUNTY with the Department of Behavioral Health (DBH) Director, or
designee, approval. References in this Agreement to "party" or "parties" shall be understood to refer to
COUNTY and each PROVIDER, unless otherwise specified.
WI T NE S S E T H:
WHEREAS, COUNTY, through its Department of Behavioral Health, is a Mental Health Plan as
defined in Title 9 of the California Code of Regulations (C.C.R.), section 1810.226; and
WHEREAS, COUNTY, through its Mental Health Plan is in need of PROVIDER(s) to provide
specialty mental health services to certain COUNTY's Medi-Cal beneficiaries, as specified in this
Agreement and as part of the Mental Health Plan, submitted to the California Department of Health
Care Services, pursuant to Article 5, section 14680-14685, Chapter 8.8, Division 9, Welfare and
Institutions Code, and originally approved by the COUNTY Board of Supervisors on March 17, 1998,
and again on May 16, 2006, and updated year-to-year; and
WHEREAS, PROVIDER(s) are qualified and willing to provide said services pursuant to the
terms and conditions of this Agreement; and
WHEREAS, it is to the mutual benefit of the parties hereto that an effective and economical
mental health managed care program be provided through a locally-administered program.
NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties
hereto agree as follows:
1. SERVICES
A. PROVIDER(s) shall provide specialty mental health services as a "Provider",
specifically identified as either a "Group Provider" or "Individual Provider":
- 1 -COUNTY OF FRESNO
Fresno, CA
COUNTY OF FRESNO
Fresno, CA
- 2 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
“Provider” shall mean any mental health professional licensed in the State of
California as a psychiatrist, psychologist, clinical social worker, professional clinical counselor,
marriage and family therapist, or a registered nurse with a Master’s Degree, hereinafter referred to as
“Provider”, and contracting with County to render certain covered services to Clients, pursuant to the
terms and conditions of this Agreement and as addressed in the “Fresno County Mental Health Plan
Individual/Group Provider Manual” (http://www.co.fresno.ca.us/departments/behavioral-
health/managed-care/contract-providers/provider-manual).
“Group Provider” is an organization that provides specialty mental health services
through two or more individual providers. Group Providers include entities such as independent
practice associations, hospital outpatient departments, health care service plans and clinics.
“Individual Provider” is a licensed mental health professional whose scope of
practice permits the practice of psychotherapy without supervision who provides specialty mental
health services directly to beneficiaries. Individual Provider includes licensed physicians, licensed
psychologists, licensed clinical social workers, licensed marriage, family and child counselors,
licensed professional clinical counselors, and registered nurses with a master’s degree within their
scope of practice. Individual Provider does not include licensed mental health professionals when they
are acting as employees of an organizational provider or PROVIDER(s) of organizational providers
other than the Mental Health Plan.
B. PROVIDER(s) shall provide specialty mental health services as listed in the
identified “Covered Services” listed below:
1. “Covered Services” with requirements as identified in the current Fresno
County Mental Health Plan Individual/Group Provider Manual (hereinafter “Provider Manual”),
together with any amendments or changes to the manual, and only when rendered by professionals
who meet the appropriate requirements to render Covered Services as described herein:
a. Rehabilitative services, including mental health services, and
medication services.
b. Psychiatric inpatient hospital professional services.
c. Targeted case management.
COUNTY OF FRESNO
Fresno, CA
- 3 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
d. Psychiatric services.
e. Psychologist services.
f. Early and Periodic Screening Diagnosis and Treatment (EPSDT)
supplemental specialty mental health services.
g. Psychiatric nursing facility professional services.
2. These Covered Services are subject to the limitations set forth in the
statewide Medi-Cal Program, which is in accordance with Title 9, California Code of Regulations,
Chapter 11, Medi-Cal Specialty Mental Health Services, unless specifically exempted by the
COUNTY.
3. Exempted services shall be only those services identified as excepted,
authorized in advance as exempted, and shall only apply to a specific and discreet time period and
number of authorized exempted services. Any one authorization to a PROVIDER(s) for exempted
services to a client shall not infer nor constitute subsequent or combined authorization for additional
exempted services to that client, nor to any other client, nor to the PROVIDER(s), nor to any other
PROVIDER(s).
4. Covered Services provided shall be subject to the limitations and
procedures listed in the Provider Manual, unless PROVIDER(s) is notified by COUNTY of a
modification to that policy.
C. PROVIDER(s) shall provide specialty mental health services as a Provider, and
recognize the “Imposition of Additional Controls” as listed and identified below:
“Imposition of Additional Controls” – PROVIDER(s) recognizes that the
COUNTY, through the utilization management and quality improvement process, may be required to
take action necessitating consultation with its Medical Director or with other physicians prior to
authorization of Covered Services or to terminate this Agreement. In the interest of program integrity
or the welfare of clients, COUNTY may introduce additional utilization controls as may be necessary
at any time and without advance notice to PROVIDER(s). In the event of such change, COUNTY
shall notify PROVIDER(s) in writing, and the change shall take effect upon the tenth (10th) calendar
day following the deposit of said notice, by COUNTY, in the United States mail, postage prepaid.
COUNTY OF FRESNO
Fresno, CA
- 4 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
2. TERM
This Agreement shall become effective on the 20th day of March 2018, and shall
terminate on the 30th day of June 2018. This Agreement may be extended for two (2) additional
consecutive twelve (12) month periods upon approval of COUNTY no later than thirty (30) days prior
to the first day of the next twelve (12) month extension period. The Director, Department of
Behavioral Health, or his or her designee is authorized to execute such written approval on behalf of
COUNTY based on PROVIDER’s satisfactory performance of this Agreement.
3. TERMINATION
A. Non-Allocation of Funds - The terms of this Agreement, and the services to be
provided thereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated at any time by giving PROVIDER(s) sixty (60) days advance written notice.
B. Breach of Contract - COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of COUNTY there is:
1) An illegal or improper use of funds;
2) A failure to comply with any term of this Agreement;
3) A substantially incorrect or incomplete report submitted to COUNTY;
4) Improperly performed service.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of
any breach of this Agreement or any default which may then exist on the part of PROVIDER(s).
Neither shall such payment impair or prejudice any remedy available to COUNTY with respect to the
breach or default. COUNTY shall have the right to demand of PROVIDER(s) the repayment to
COUNTY of any funds disbursed to PROVIDER(s) under this Agreement, which in the judgment of
COUNTY were not expended in accordance with the terms of this Agreement. PROVIDER(s) shall
promptly refund any such funds upon demand or at COUNTY’s option, such repayment shall be
deducted from future payments owing to PROVIDER(s) under this Agreement.
C. Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by PROVIDER(s) or COUNTY or COUNTY’s DBH Director, or
COUNTY OF FRESNO
Fresno, CA
- 5 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
designee, upon the giving of sixty (60) days advance written notice of an intention to terminate. The
date of termination shall be set by consideration for the welfare of clients and necessary allowance for
notification to PROVIDER(s) and clients.
PROVIDER(s) may terminate with appropriate sixty (60) days advance written
notice of intent to terminate (with allowance for appropriate clinical transition of clients prior to
termination of services) by PROVIDER(s) to COUNTY by Certified U.S. Mail, Return Receipt
Requested, addressed to the office of COUNTY as follows:
Director
County of Fresno
Department of Behavioral Health
3133 N. Millbrook Ave.
Fresno, CA 93703
4. COMPENSATION
A. COUNTY agrees to pay PROVIDER(s) and PROVIDER(s) agrees to receive
compensation at the reimbursement rates identified in Exhibit B, “Individual and Group Provider Fee
Schedule”, attached hereto and incorporated herein by this reference.
For the period effective from March 20, 2018 through June 30, 2018, the
maximum compensation amount under this Agreement shall not exceed One Million, Forty-Three
Thousand, Nineteen and 20/100 Dollars ($1,043,019.20) for all PROVIDER(s) combined.
For the period effective from July 1, 2018 through June 30, 2019, the maximum
compensation amount under this Agreement shall not exceed Three Million, Seven Hundred Thirteen
Thousand, One Hundred Fifty and No/100 Dollars ($3,713,150.00) for all PROVIDER(s) combined.
For the period effective from July 1, 2019 through June 30, 2020, the maximum
compensation amount under this Agreement shall not exceed Three Million, Eight Hundred Twenty-
Four Thousand, Five Hundred Forty-Five and No/100 Dollars ($3,824,545.00) for all PROVIDER(s)
combined.
For the entire term of this Agreement, the total maximum compensation amount
under this Agreement shall not exceed Eight Million, Five Hundred Eighty Thousand, Seven Hundred
Fourteen and 20/100 Dollars ($8,580,714.20) for all PROVIDER(s) combined.
B. Payments shall be made upon certification or other proof satisfactory to
COUNTY OF FRESNO
Fresno, CA
- 6 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
COUNTY’s DBH that services have actually been performed by PROVIDER(s) as specified in this
Agreement.
It is understood that all expenses incidental to PROVIDER(s) performance of
services under this Agreement shall be borne by PROVIDER(s). If PROVIDER(s) fails to comply
with any provision of this Agreement, COUNTY shall be relieved of its obligation for further
compensation.
C. Payments shall be made by COUNTY to PROVIDER(s) in arrears, for services
provided during the preceding month, within forty-five (45) days after the date of receipt and approval
by COUNTY of the monthly invoicing as described in Section 5 herein. The parties acknowledge that
the PROVIDER(s) will be performing hiring, training, and submitting credentialing applications of
staff to COUNTY, configuring the facility and office space, and obtaining site certification from the
COUNTY’s DBH Mental Health Plan.
D. COUNTY shall not be obligated to make any payments under this
Agreement if the request for payment is received by COUNTY more than sixty (60) days after this
Agreement has terminated or expired.
All final claims shall be submitted by PROVIDER(s) within sixty (60) days
following the final month of service for which payment is claimed. No action shall be taken by
COUNTY on claims submitted beyond the sixty (60) day closeout period. Any compensation which is
not expended by PROVIDER(s) pursuant to the terms and conditions of this Agreement shall
automatically revert to COUNTY.
E. The services provided by PROVIDER(s) under this Agreement are funded in
whole or in part by the State of California. In the event that funding for these services is delayed by
the State Controller, COUNTY may defer payments to PROVIDER(s). The amount of the deferred
payment shall not exceed the amount of funding delayed by the State Controller to COUNTY. The
period of time of the deferral by COUNTY shall not exceed the period of time of the State Controller’s
delay of payment to COUNTY plus forty-five (45) days.
F. PROVIDER(s) shall be held financially liable for any and all future
disallowances/audit exceptions due to PROVIDER(s) deficiency discovered through the State audit
COUNTY OF FRESNO
Fresno, CA
- 7 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
process and COUNTY utilization review during the course of this Agreement. At COUNTY’s
election, the disallowed amount will be remitted within forty-five (45) days to COUNTY upon
notification or shall be withheld from subsequent payments to PROVIDER(s). PROVIDER(s) shall
not receive reimbursement for any units of services rendered that are disallowed or denied by the
Mental Health Plan utilization review process or through the California Department of Health Care
Services (DHCS) cost report audit settlement process as described in Section 15 of this Agreement for
Medi-Cal eligible clients.
5. PAYMENT AND CLAIMS PROCESSING
A. Condition for Payment – COUNTY will reimburse PROVIDER(s) for Covered
Services rendered to clients only when all of the following conditions are met:
1. The client is eligible for Medi-Cal Program benefits at the time the Covered
Service is rendered by PROVIDER(s);
2. The service is Covered/Billable under the Mental Health Plan according to the
terms and conditions set forth in the Fresno County Mental Health Plan Individual/Group Provider
Manual in effect at the time said services are rendered by PROVIDER(s); and
3. Claims for payment are submitted within thirty (30) days after the month in
which services were rendered.
B. Claims – PROVIDER(s) shall obtain and complete claim forms as adopted by the
COUNTY, as may be amended from time to time for use in the Mental Health Plan, for Covered
Services rendered to clients, and shall submit completed claims to COUNTY within thirty (30) days
after the month in which services were rendered. For claims submitted for the payment of inpatient
care, fees shall be submitted within sixty (60) days after the month in which services were rendered.
Payment by COUNTY for PROVIDER(s)’ services shall be in arrears within forty-five (45) days after
receipt and verification of PROVIDER(s)’ claims by the COUNTY. Provider(s) certifies that with
each claim submitted that the Covered Services were provided solely by a Mental Health Services
PROVIDER. PROVIDER(s) further certifies with each claim submitted, that no active employee of
COUNTY has provided any service to any clients on said claim, (Government Code § 1090 and
Fresno County Charter § 41). Should PROVIDER(s) fail to comply with any provision of this
COUNTY OF FRESNO
Fresno, CA
- 8 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Agreement, C OUNTY shall be relieved of any obligation to compensate for services provided.
It is understood by all parties that all expenses incidental to PROVIDER(s)’ performance of
services under this Agreement shall be borne by PROVIDER(s).
It is understood that each claim is subject to audit for compliance with
Federal and State regulations and the Provider Manual, and that COUNTY may be making
payments on billings in advance of said review. In the event that a claim is disapproved,
COUNTY may, at its sole discretion, withhold compensation or set off from other payments due
in the amount of said disapproved billings. This remedy is not exclusive and COUNTY may
seek requital from any other means, including but not limited to, a separate contract or
agreement with PROVIDER(s).
PROVIDER(s) shall submit claims at least monthly to: County of Fresno,
Department of Behavioral Health, Managed Care, P.O. Box 45003, Fresno, CA 93718-9886,
Attention: Provider Relations Specialist. Claims shall be submitted on the CMS 1500 insurance
form as outlined in the Provider Manual on a calendar month basis for all services provided to
clients during the preceding month. Each claim shall be for one client only and shall include the
name of individual client, type of service, time and date of service, COUNTY billing code, and
duration of service. COUNTY shall have the right to deny payment for invoices not submitted
within thirty (30) days after the month in which services were rendered, with the exception of
claims submitted by PROVIDER(s) which received a prior authorization from COUNTY.
COUNTY shall not make payment for services rendered to clients which are,
in the opinion of COUNTY, determined to be not medically necessary or which have not been
authorized for reimbursement by C OUNTY.
C. Claim Submission
Individual Providers shall submit hard copy claims to COUNTY as identified in
Section 5, herein. Group Providers may have the option of submitting hard copy claims as identified
herein, or to submit electronic billing for services directly through the COUNTY’s billing module,
AVATAR. For Group Providers that decide to enter electronic claiming data, PROVIDER(s) must
attend COUNTY’s Business Office training on the AVATAR claiming module.
COUNTY OF FRESNO
Fresno, CA
- 9 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
PROVIDER(s) must provide all necessary data to allow the COUNTY to bill
Medi-Cal and any other third-party source, for services and meet State and Federal reporting
requirements. For any Group Providers entering data directly into AVATAR, the necessary data can
be provided by a variety of means, including, but not limited to: 1) direct data entry into COUNTY’s
information system; 2) providing an electronic file compatible with COUNTY’s information system;
or 3) integration between COUNTY’s information system and the Group Provider’s information
system.
Data entry shall be the responsibility of the Group Providers. The data for billing
must be reconciled by the Group Providers to the monthly claims submitted for payment. COUNTY
shall monitor the number and dollar amount of services entered into AVATAR. Group Providers shall
comply with all applicable policies, procedures, directives, and guidelines regarding the use of
COUNTY’s billing system.
D. Medi-Cal Certification and Mental Health Plan Compliance
1. Individual and Group Providers:
All PROVIDER(s) will establish and maintain Medi-Cal certification or
become certified within ninety (90) days of the effective date of this Agreement through the COUNTY
to provide reimbursable services to Medi-Cal eligible clients. In addition, PROVIDER(s) shall work
with the COUNTY’s DBH Managed Care Division for credentialing of staff. PROVIDER(s) will be
required to become Medi-Cal certified prior to providing services to Medi-Cal eligible clients and
seeking reimbursement in COUNTY’s billing system. Group Providers will not be reimbursed by
COUNTY for any Medi-Cal services rendered prior to certification.
2. Utilization of Associates:
Medi-Cal billing shall be in accordance with the Mental Health Plan.
Medi-Cal can be billed for direct specialty mental health services of
unlicensed staff as long as the individual is employed under the direct supervision of a licensed mental
professional in accordance with 9 CCR 1840.314 (e)(1)(F) and who is credentialed by the Mental
Health Plan. Eligible unlicensed staff are any mental health professional with a Master’s Degree or
higher and registered with the State of California as a Registered Waivered Psychologist, Registered
COUNTY OF FRESNO
Fresno, CA
- 10 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Associate Social Worker, Registered Associate Professional Clinical Counselor, or Registered
Associate Marriage and Family Therapist.
A licensed professional in private practice who has satisfied the
requirements of subdivision (g) of BPC Chapter 13, Section 4980.03 may supervise or employ, at any
one time, no more than a total of three individuals registered as an associate marriage and family
therapist, associate professional clinical counselor, associate clinical social worker, or registered
psychologist in that private practice.
The individual directing a service is not required to be physically present
at the service site to exercise direction. The licensed professional directing a service assumes ultimate
responsibility for the Rehabilitative Mental Health Service provided. Services are provided under the
direction of: a physician; a licensed or waivered psychologist; a licensed, waivered or registered social
worker; a licensed, waivered or registered marriage and family therapist; a licensed, waivered or
registered professional clinical counselor, or a registered nurse (including a certified nurse specialist,
or a nurse practitioner).
Pursuant to BPC Chapter 13, Sections 4980.43, 4996.23, and 4999.47, all
Mental Health Plan unlicensed staff shall be at all times under the supervision of a supervisor who
shall be responsible for ensuring that the extent, kind, and quality of counseling performed is
consistent with the training and experience of the person being supervised, and who shall be
responsible to the Board of Behavioral Sciences for compliance with all laws, rules, and regulations.
Unlicensed staff shall not be employed as independent contractors, and shall not gain experience for
work performed as an independent contractor, reported on an IRS Form 1099, or both.
An associate who is employed in an Individual or Group Provider setting
shall be under the direct supervision of a licensee at all times to satisfy Sections 4980.03(g), 4996.23,
4999.47, and the supervising licensee must be credentialed with the COUNTY through the
PROVIDER’s practice. In addition, direct supervision must be arranged for and provided to the
associate when a supervising licensee’s vacation or sick leave exceeds one week. The supervising
licensee shall either be employed by and practice at the same site as the associate’s employer, or shall
COUNTY OF FRESNO
Fresno, CA
- 11 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
be an owner or shareholder of the private practice. All supervising licensees must be credentialed with
the COUNTY through the PROVIDER’s practice.
It is understood that each claim is subject to audit for compliance with
Federal and State regulations, and that COUNTY may be making payments in advance of said review.
In the event that a Medi-Cal billable service is disapproved, COUNTY may, at its sole discretion,
withhold compensation or set off from other payments due the amount of said disapproved services.
PROVIDER(s) shall be responsible for audit exceptions to ineligible dates of services or incorrect
application of utilization review requirements.
6. INDEPENDENT CONTRACTORS
In performance of the work, duties, and obligations assumed by PROVIDER(s) under this
Agreement, it is mutually understood and agreed that PROVIDER(s), including any and all of
PROVIDER’(s) officers, agents, and employees will at all times be acting and performing as
independent contractor(s), and shall act in an independent capacity and not as an officer, agent,
servant, employee, joint venturer, partner, or associate of COUNTY. Furthermore, COUNTY shall
have no right to control or supervise or direct the manner or method by which PROVIDER(s) shall
perform its work and function. However, COUNTY shall retain the right to administer this Agreement
so as to verify that PROVIDER(s) is performing their obligations in accordance with the terms and
conditions thereof. PROVIDER(s) and COUNTY shall comply with all applicable provisions of law
and the rules and regulations, if any, of governmental authorities having jurisdiction over matters
which are directly or indirectly the subject of this Agreement.
Because of its status as an independent contractor(s), PROVIDER(s) shall have
absolutely no right to employment rights and benefits available to COUNTY employees.
PROVIDER(s) shall be solely liable and responsible for providing to, or on behalf of, its employees all
legally-required employee benefits. In addition, PROVIDER(s) shall be solely responsible and save
COUNTY harmless from all matters relating to payment of PROVIDER’(s) employees, including
compliance with Social Security, withholding, and all other regulations governing such matters. It is
acknowledged that during the term of this Agreement, PROVIDER(s) may be providing services to
others unrelated to COUNTY or to this Agreement.
COUNTY OF FRESNO
Fresno, CA
- 12 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
7. MODIFICATION
Any matters of this Agreement may be modified from time to time by the written consent
of all the parties without, in any way, affecting the remainder.
Additions to Exhibit A, “List of Providers”, may be made with written approval of
COUNTY’s DBH Director, or designee, as defined further in Section 8 of this Agreement. Changes to
the rates/types of service identified in Exhibit B, “Individual and Group Provider Fee Schedule”, as
established by the Mental Health Plan, may be made with written approval of COUNTY’s DBH
Director, or designee. Said rate/types of service changes shall not result in any change to the
maximum compensation amount payable to PROVIDER(s), as stated herein. PROVIDER(s) will be
notified of any rate changes thirty (30) days prior to the effective date of the rate change.
8. ADDITIONS/DELETIONS OF PROVIDER(s)
COUNTY’s DBH Director, or designee, reserves the right at any time during the term of
this Agreement to add PROVIDER(s) to Exhibit A, “List of Providers”. It is understood any such
additions will not affect compensation paid to the other PROVIDER(s) under this Agreement.
9. ADDITIONS/DELETIONS OF INDIVIDUAL PROVIDERS BY GROUP
PROVIDER
As it relates to Group PROVIDER(s) who hire or subcontract the performance of services
under this Agreement, Group PROVIDER(s) shall notify COUNTY within ten (10) days of any
change in staff or subcontractors providing services to COUNTY clients, on behalf of the Group
PROVIDER. Individual PROVIDER(s), new to a Group, must be credentialed and approved by
COUNTY before being permitted to provide services to COUNTY clients.
10. NON-ASSIGNMENT
No party shall assign, transfer or subcontract this Agreement nor their rights or duties
under this Agreement without the prior written consent of COUNTY and PROVIDER(s).
11. HOLD-HARMLESS
PROVIDER(s) agrees to indemnify, save, hold harmless, and at COUNTY's request,
defend COUNTY, its officers, agents and employees from any and all costs and expenses, including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
COUNTY OF FRESNO
Fresno, CA
- 13 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
COUNTY in connection with the performance, or failure to perform, by PROVIDER(s), its officers,
agents or employees under this Agreement, and from any and all costs and expenses, including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to any
person, firm or corporation who may be injured or damaged by the performance, or failure to perform,
of PROVIDER(s), their officers, agents or employees under this Agreement.
PROVIDER(s) agrees to indemnify COUNTY for Federal and/or State of California
audit exceptions resulting from noncompliance herein on the part of PROVIDER(s).
12. INSURANCE
Without limiting COUNTY's right to obtain indemnification from PROVIDER(s) or any
third parties, PROVIDER(s), at its sole expense, shall maintain in full force and effect the following
insurance policies throughout the term of this Agreement:
A. Commercial General Liability
Commercial General Liability Insurance with limits of not less than One Million
Dollars ($1,000,000) per occurrence and an annual aggregate of Two Million
Dollars ($2,000,000). This policy shall be issued on a per occurrence basis.
COUNTY may require specific coverage including completed operations, product
liability, contractual liability, Explosion, Collapse, and Underground (XCU), fire
legal liability or any other liability insurance deemed necessary because of the
nature of the Agreement.
B. Automobile Liability
Comprehensive Automobile Liability Insurance with limits for bodily injury of
not less than Two Hundred Fifty Thousand Dollars ($250,000) per person, Five
Hundred Thousand Dollars ($500,000) per accident and for property damages of
not less than Fifty Thousand Dollars ($50,000), or such coverage with a combined
single limit of One Million Dollars ($1,000,000). Coverage should include owned
and non-owned vehicles used in connection with this Agreement.
C. Professional Liability
If PROVIDER(s) employs licensed/registered/waivered professional staff (e.g.
Ph.D., R.N., L.C.S.W., L.M.F.T., L.P.C.C., A.S.W., A.M.F.T., A.P.C.C.) in
providing services, Professional Liability Insurance with limits of not less than
One Million Dollars ($1,000,000) per occurrence, Three Million Dollars
($3,000,000) annual aggregate. PROVIDER(s) agrees that it shall maintain, at its
sole expense, in full force and effect for a period of three (3) years following the
termination of this Agreement, one or more policies of professional liability
COUNTY OF FRESNO
Fresno, CA
- 14 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
insurance with limits of coverage as specified herein.
D. Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
E. Child Abuse/Molestation and Social Services Coverage
PROVIDER(s) shall have either separate policies or umbrella policy with
endorsements covering Child Abuse/Molestation and Social Services Liability
coverage or have a specific endorsement on their General Commercial liability
policy covering Child Abuse/Molestation and Social Services Liability. The
policy limits for these policies shall be $1,000,000 per occurrence with
$2,000,000 annual aggregate. The policies are to be on a per occurrence basis.
PROVIDER(s) shall obtain endorsements to the Commercial General Liability insurance
naming the County of Fresno, its officers, agents, and employees, individually and collectively, as
additional insured, but only insofar as the operations under this Agreement are concerned. Such
coverage for additional insured shall apply as primary insurance and any other insurance, or self-
insurance, maintained by COUNTY, its officers, agents and employees shall be excess only and not
contributing with insurance provided under PROVIDER’(s) policies herein. This insurance shall not
be cancelled or changed without a minimum of thirty (30) days advance written notice given to
COUNTY.
Within thirty (30) days from the date PROVIDER(s) signs this Agreement,
PROVIDER(s) shall provide certificates of insurance and endorsements as stated above for all of the
foregoing policies, as required herein, to the County of Fresno, Department of Behavioral Health,
3133 N. Millbrook Ave, Fresno, CA 93703, Attention: Mental Health Contracted Services, stating
that such insurance coverages have been obtained and are in full force; that the County of Fresno, its
officers, agents and employees will not be responsible for any premiums on the policies; that such
Commercial General Liability insurance names the County of Fresno, its officers, agents and
employees, individually and collectively, as additional insured, but only insofar as the operations
under this Agreement are concerned; that such coverage for additional insured shall apply as primary
insurance and any other insurance, or self-insurance, maintained by COUNTY, its officers, agents and
COUNTY OF FRESNO
Fresno, CA
- 15 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
employees, shall be excess only and not contributing with insurance provided under PROVIDER’(s)
policies herein; and that this insurance shall not be cancelled or changed without a minimum of thirty
(30) days advance, written notice given to COUNTY.
In the event PROVIDER(s) fails to keep in effect at all times insurance coverage as herein
provided, COUNTY may, in addition to other remedies it may have, suspend or terminate this
Agreement upon the occurrence of such event.
All policies shall be with admitted insurers licensed to do business in the State of
California. Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating
of A FSC VII or better.
13. LICENSES/CERTIFICATES
Throughout each term of this Agreement, PROVIDER(s) and PROVIDER’(s) staff shall
maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions necessary for
the provision of the services hereunder and required by the laws and regulations of the United States of
America, State of California, the County of Fresno, and any other applicable governmental agencies.
PROVIDER(s) shall notify COUNTY immediately in writing of its inability to obtain or maintain such
licenses, permits, approvals, certificates, waivers and exemptions irrespective of the pendency of any
appeal related thereto. Additionally, PROVIDER(s) and PROVIDER’(s) staff shall comply with all
applicable laws, rules or regulations, as may now exist or be hereafter changed.
14. RECORDS
PROVIDER(s) shall maintain records in accordance with Exhibit D, “Documentation
Standards for Client Records”, attached hereto and by this reference incorporated herein and made part
of this Agreement. During site visits, COUNTY shall be allowed to review records of services
provided, including the goals and objectives of the treatment plan, and how the therapy provided is
achieving the goals and objectives. All medical records shall be maintained for a minimum of 10
years from the date of the end of the Agreement.
15. REPORTS
A. Outcome Reports – PROVIDER(s) shall submit to COUNTY’s DBH service
outcome reports as requested by DBH. Outcome reports and outcome requirements are subject to
COUNTY OF FRESNO
Fresno, CA
- 16 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
change at COUNTY DBH’s discretion.
B. Additional Reports – PROVIDER(s) shall also furnish to COUNTY such
statements, records, reports, data, and other information as COUNTY’s DBH may request pertaining
to matters covered by this Agreement. In the event that PROVIDER(s) fails to provide such reports or
other information required hereunder, it shall be deemed sufficient cause for COUNTY to withhold
monthly payments until there is compliance. In addition, PROVIDER(s) shall provide written
notification and explanation to COUNTY within five (5) days of any funds received from another
source to conduct the same services covered by this Agreement.
16. MONITORING
PROVIDER(s) agrees to extend to COUNTY’s staff, COUNTY’s DBH Director and
DHCS, or their designees, the right to review and monitor records, programs or procedures, at any
time, in regard to clients, as well as the overall operation of PROVIDER’(s) programs, in order to
ensure compliance with the terms and conditions of this Agreement.
17. REFERENCES TO LAWS AND RULES
In the event any law, regulation, or policy referred to in this Agreement is amended
during the term thereof, the parties hereto agree to comply with the amended provision as of the
effective date of such amendment.
18. COMPLIANCE WITH STATE REQUIREMENTS
PROVIDER(s) recognizes that COUNTY operates its mental health programs under an
agreement with DHCS, and that under said agreement the State imposes certain requirements on
COUNTY and its PROVIDER(s) and its subcontractors. PROVIDER(s) shall adhere to all State
requirements, including those identified in Exhibit E “State Mental Health Requirements”, attached
hereto and by this reference incorporated herein and made part of this Agreement.
19. COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
PROVIDER(s) shall be required to maintain Medi-Cal provider certification by Fresno
County. PROVIDER(s) must meet Medi-Cal provider standards as listed in Exhibit F, “Medi-Cal
Provider Standards”, attached hereto and by this reference incorporated herein and made part of this
Agreement. It is acknowledged that all references to Provider and/or Medi-Cal Provider in Exhibit F
COUNTY OF FRESNO
Fresno, CA
- 17 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
shall refer to PROVIDER(s). In addition, PROVIDER(s) shall inform every client of their rights
under the COUNTY’s Mental Health Plan as described in “Fresno County Mental Health Plan
Grievances and Appeals Process” Exhibit G , attached hereto and by this reference incorporated herein
and made part of this Agreement. PROVIDER(s) shall also file an incident report for all incidents
involving clients, following the Protocol for Completion of Incident Report and using the Worksheet
identified in the “Fresno County Mental Health Plan Incident Reporting”, Exhibit H, attached hereto
and by this reference incorporated herein and made part of this Agreement, or a protocol and
worksheet presented by PROVIDER(s) that is accepted by COUNTY’S DBH Director, or designee.
20. CONFIDENTIALITY
All services performed by PROVIDER(s) under this Agreement shall be in strict
conformance with all applicable Federal, State of California and/or local laws and regulations relating
to confidentiality.
21. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and PROVIDER(s) each consider and represent themselves as covered entities
as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law 104-
191(HIPAA) and agree to use and disclose Protected Health Information (PHI) as required by law.
COUNTY and PROVIDER(s) acknowledge that the exchange of PHI between them is only
for treatment, payment, and health care operations.
COUNTY and PROVIDER(s) intend to protect the privacy and provide for the
security of PHI pursuant to the Agreement in compliance with HIPAA, the Health Information
Technology for Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations
promulgated thereunder by the U.S. Department of Health and Human Services (HIPAA Regulations)
and other applicable laws.
As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
PROVIDER(s) to enter into a contract containing specific requirements prior to the disclosure of PHI,
as set forth in, but not limited to, Title 45, sections 164.314(a), 164.502(e) and 164.504(e) of the Code
of Federal Regulations (CFR).
///
COUNTY OF FRESNO
Fresno, CA
- 18 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
22. DATA SECURITY
For the purpose of preventing the potential loss, misappropriation or inadvertent access,
viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse
of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that
enter into a contractual relationship with the COUNTY for the purpose of providing services under
this Agreement must employ adequate data security measures to protect the confidential information
provided to PROVIDER(s) by the COUNTY, including but not limited to the following:
A. PROVIDER(s)-Owned Mobile, Wireless, or Handheld Devices
PROVIDER(s) may not connect to COUNTY networks via personally-owned
mobile, wireless or handheld devices, unless the following conditions are met:
1) PROVIDER(s) has received authorization by COUNTY for
telecommuting purposes;
2) Current virus protection software is in place;
3) Mobile device has the remote wipe feature enabled; and
4) A secure connection is used.
B. PROVIDER(s)-Owned Computers or Computer Peripherals
PROVIDER(s) may not bring PROVIDER(s)-owned computers or computer
peripherals into the COUNTY for use without prior authorization from the COUNTY’s Chief
Information Officer, and/or designee(s), including but not limited to mobile storage devices. If data is
approved to be transferred, data must be stored on a secure server approved by the COUNTY and
transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
connection. Said data must be encrypted.
C. COUNTY-Owned Computer Equipment
PROVIDER(s) may not use COUNTY computers or computer peripherals on
non-COUNTY premises without prior authorization from the COUNTY’s Chief Information Officer,
and/or designee(s).
D. PROVIDER(s) may not store COUNTY’s private, confidential or sensitive data
on any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
COUNTY OF FRESNO
Fresno, CA
- 19 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
E. PROVIDER(s) shall be responsible to employ strict controls to ensure the
integrity and security of COUNTY’s confidential information and to prevent unauthorized access,
viewing, use or disclosure of data maintained in computer files, program documentation, data
processing systems, data files and data processing equipment which stores or processes COUNTY data
internally and externally.
F. Confidential client information transmitted to one party by the other by means of
electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of
128 BIT or higher. Additionally, a password or pass phrase must be utilized.
G. PROVIDER(s) is responsible to immediately notify COUNTY of any violations,
breaches or potential breaches of security related to COUNTY’s confidential information, data
maintained in computer files, program documentation, data processing systems, data files and data
processing equipment which stores or processes COUNTY data internally or externally.
H. COUNTY shall provide oversight to PROVIDER(s) response to all incidents
arising from a possible breach of security related to COUNTY’s confidential client information
provided to PROVIDER(s). PROVIDER(s) will be responsible to issue any notification to affected
individuals as required by law or as deemed necessary by COUNTY in its sole discretion.
PROVIDER(s) will be responsible for all costs incurred as a result of providing the required
notification.
23. NON-DISCRIMINATION
During the performance of this Agreement, PROVIDER(s) and its subcontractors shall
not deny the contract’s benefits to any person on the basis of race, religious creed, color, national
origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital
status, sex, gender, gender identity, gender expression, age, sexual orientation, or military and veteran
status, nor shall they discriminate unlawfully against any employee or applicant for employment
because of race, religious creed, color, national origin, ancestry, physical disability, mental disability,
medical condition, genetic information, marital status, sex, gender, gender identity, gender expression,
age, sexual orientation, or military and veteran status. PROVIDER shall insure that the evaluation and
treatment of employees and applicants for employment are free of such discrimination. PROVIDER
COUNTY OF FRESNO
Fresno, CA
- 20 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
and subcontractors shall comply with the provisions of the Fair Employment and Housing Act (Gov.
Code §12900 et seq.), the regulations promulgated thereunder (Cal. Code Regs., tit. 2, §11000 et seq.),
the provisions of Article 9.5, Chapter 1, Part 1, Division 3, Title 2 of the Government Code (Gov.
Code §§11135-11139.5), and the regulations or standards adopted by the awarding state agency to
implement such article. Contractor shall permit access by representatives of the Department of Fair
Employment and Housing and the awarding state agency upon reasonable notice at any time during
the normal business hours, but in no case less than 24 hours’ notice, to such of its books, records,
accounts, and all other sources of information and its facilities as said Department or Agency shall
require to ascertain compliance with this clause. PROVIDER(s) and its subcontractors shall give
written notice of their obligations under this clause to labor organizations with which they have a
collective bargaining or other agreement. (See Cal. Code Regs., tit. 2, §11105.) PROVIDER(s) shall
include the Non-Discrimination and compliance provisions of this clause in all subcontracts to perform
work under the Agreement.
24. CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, PROVIDER(s) shall comply with:
A. Title 6 of the Civil Rights Act of 1964 (42 U.S.C. section 2000d, and 45 C.F.R.
Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance
from discriminating against persons based on race, color, national origin, sex, disability or religion.
This is interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access
and participation in federally funded programs through the provision of comprehensive and quality
bilingual services.
B. Policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP clients, including, but not limited to, assessing
the cultural and linguistic needs of its clients, training of staff on the policies and procedures, and
monitoring its language assistance program. The PROVIDER(s) procedures must include ensuring
compliance of any sub-contracted providers with these requirements.
C. PROVIDER(s) shall not use minors as interpreters.
D. PROVIDER(s) shall provide and pay for interpreting and translation services to
COUNTY OF FRESNO
Fresno, CA
- 21 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
persons participating in PROVIDER(s) services who have limited or no English language proficiency,
including services to persons who are deaf or blind. Interpreter and translation services shall be
provided as necessary to allow such participants meaningful access to the programs, services and
benefits provided by PROVIDER(s). Interpreter and translation services, including translation of
PROVIDER(s) “vital documents” (those documents that contain information that is critical for
accessing PROVIDER(s) services or are required by law) shall be provided to participants at no cost to
the participant. PROVIDER(s) shall ensure that any employees, agents, subcontractors, or partners
who interpret or translate for a program participant, or who directly communicate with a program
participant in a language other than English, demonstrate proficiency in the participant's language and
can effectively communicate any specialized terms and concepts peculiar to PROVIDER(s) services.
E. In compliance with the State mandated Culturally and Linguistically Appropriate
standards as published by the Office of Minority Health, PROVIDER(s) must submit to COUNTY for
approval, within sixty (60) days from date of contract execution, PROVIDER(s) plan to address all
fifteen (15) national cultural competency standards as set forth in the “National Standards on
Culturally and Linguistically Appropriate Services (CLAS)”. COUNTY’s annual on-site review of
PROVIDER(s) shall include collection of documentation to ensure all national standards are
implemented. As the national competency standards are updated, PROVIDER (s) plan must be
updated accordingly. Cultural competency training for PROVIDER(s) staff should be substantively
integrated into health professions education and training at all levels, both academic and functional,
including core curriculum, professional licensure, and continuing professional development programs.
PROVIDER(s) on a monthly basis shall provide COUNTY DBH a monthly monitoring tool/report
that shows all PROVIDER(s) staff cultural competency trainings completed.
25. AMERICANS WITH DISABILITIES ACT
PROVIDER(s) agrees to ensure that deliverables developed and produced, pursuant to
this Agreement shall comply with the accessibility requirements of Section 508 of the Rehabilitation
Act and the Americans with Disabilities Act of 1973 as amended (29 U.S.C. § 794 (d)), and
regulations implementing that Act as set forth in Part 1194 of Title 36 of the Code of Federal
Regulations. In 1998, Congress amended the Rehabilitation Act of 1973 to require Federal agencies to
COUNTY OF FRESNO
Fresno, CA
- 22 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
make their electronic and information technology (EIT) accessible to people with disabilities.
California Government Code section 11135 codifies section 508 of the Act requiring accessibility of
electronic and information technology.
26. TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section 1861(v)
(1) (I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four (4)
years after the furnishing of services under this Agreement, PROVIDER(s) shall make available, upon
written request of the Secretary of the United States Department of Health and Human Services, or
upon request of the Comptroller General of the United States General Accounting Office, or any of
their duly authorized representatives, a copy of this Agreement and such books, documents, and
records as are necessary to certify the nature and extent of the costs of these services provided by
PROVIDER(s) under this Agreement. PROVIDER(s) further agrees that in the event PROVIDER(s)
carries out any of its duties under this Agreement through a subcontract, with a value or cost of Ten
Thousand and No/100 Dollars ($10,000.00) or more over a twelve (12) month period, with a related
organization, such Agreement shall contain a clause to the effect that until the expiration of four (4)
years after the furnishing of such services pursuant to such subcontract, the related organizations shall
make available, upon written request of the Secretary of the United States Department of Health and
Human Services, or upon request of the Comptroller General of the United States General Accounting
Office, or any of their duly authorized representatives, a copy of such subcontract and such books,
documents, and records of such organization as are necessary to verify the nature and extent of such
costs.
27. SINGLE AUDIT CLAUSE
A. If PROVIDER(s) expends Seven Hundred Fifty Thousand Dollars ($750,000) or
more in Federal and Federal flow-through monies, PROVIDER(s) agrees to conduct an annual audit in
accordance with the requirements of the Single Audit Standards as set forth in Office of Management
and Budget (OMB) 2 CFR 200. PROVIDER(s) shall submit said audit and management letter to
COUNTY. The audit must include a statement of findings or a statement that there were no findings.
If there are negative findings, PROVIDER(s) must include a corrective action plan signed by an
COUNTY OF FRESNO
Fresno, CA
- 23 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
authorized individual. PROVIDER(s) agrees to take action to correct any material non-compliance or
weakness found as a result of such audit. Such audit shall be delivered to COUNTY’s DBH Business
Office for review within nine (9) months of the end of any fiscal year in which funds were expended
and/or received for the program. Failure to perform the requisite audit functions as required by this
Agreement may result in COUNTY performing the necessary audit tasks, or at COUNTY’s option,
contracting with a public accountant to perform said audit, or may result in the inability of COUNTY
to enter into future agreements with PROVIDER(s). All audit costs related to this Agreement are the
sole responsibility of PROVIDER(s).
B. PROVIDER(s) shall make available all records and accounts for inspection by
COUNTY, the State of California, if applicable, the Comptroller General of the United States, the
Federal Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a
period of at least three (3) years following final payment under this Agreement or the closure of all
other pending matters, whichever is later.
28. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST
INFORMATION
This provision is only applicable if PROVIDER(s) is a disclosing entity, fiscal agent, or
managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101 455.104,
and 455.106(a)(1),(2).
In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2),
the following information must be disclosed by PROVIDER(s) by completing Exhibit I, “Disclosure
of Ownership and Control Interest Statement”, attached hereto and by this reference incorporated
herein and made part of this Agreement. PROVIDER(s) shall submit this form to COUNTY’s DBH
within thirty (30) days of the effective date of this Agreement. Additionally, PROVIDER(s) shall
report any changes to this information within thirty-five (35) days of occurrence by completing
Exhibit I, “Disclosure of Ownership and Control Interest Statement.” PROVIDER(s) is required to
submit a set of fingerprints for any person with a 5 percent or greater direct or indirect ownership
interest in PROVIDER. COUNTY may terminate this Agreement where any person with a 5 percent
or greater direct or indirect ownership interest in the PROVIDER and did not submit timely and
COUNTY OF FRESNO
Fresno, CA
- 24 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
accurate information and cooperate with any screening method required in CFR, title 42, section
455.416. Submissions shall be scanned pdf copies and are to be sent via email to
DBHAdministration@co.fresno.ca.us, Attention: Contracts Administration. COUNTY may deny
enrollment or terminate this Agreement where any person with a 5 percent or greater direct or indirect
ownership interest in PROVIDER has been convicted of a criminal offense related to that person’s
involvement with the Medicare, Medicaid, or title XXI program in the last 10 years.
29. DISCLOSURE – CRIMINAL HISTORY AND CIVIL ACTIONS
PROVIDER(s) is required to disclose if any of the following conditions apply to them,
their owners, officers, corporate managers and partners (hereinafter collectively referred to as
“PROVIDER(s)”):
A. Within the three-year period preceding the Agreement award, they have been
convicted of, or had a civil judgment rendered against them for:
1. Fraud or a criminal offense in connection with obtaining, attempting to
obtain, or performing a public (federal, state, or local) transaction or contract under a public
transaction;
2. Violation of a federal or state antitrust statute;
3. Embezzlement, theft, forgery, bribery, falsification, or destruction of
records; or
4. False statements or receipt of stolen property.
B. Within a three-year period preceding their Agreement award, they have had a
public transaction (federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate
PROVIDER(s) from further business consideration. The information will be considered as part of
the determination of whether to continue and/or renew the Contract and any additional information
or explanation that a PROVIDER(s) elects to submit with the disclosed information will be
considered. If it is later determined that the PROVIDER(s) failed to disclose required information,
any contract awarded to such PROVIDER(s) may be immediately voided and terminated for
material failure to comply with the terms and conditions of the award.
COUNTY OF FRESNO
Fresno, CA
- 25 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
PROVIDER(s) must sign a “Certification Regarding Debarment, Suspension, and
Other Responsibility Matters- Primary Covered Transactions” in the form set forth in Exhibit J,
attached hereto and by this reference incorporated herein. Additionally, PROVIDER(s) must
immediately advise the County in writing if, during the term of this Agreement: (1) PROVIDER(s)
becomes suspended, debarred, excluded or ineligible for participation in federal or state funded
programs or from receiving federal funds as listed in the excluded parties’ list system
(http://www.sam.gov); or (2) any of the above listed conditions become applicable to PROVIDER(s).
PROVIDER(s) shall indemnify, defend and hold the COUNTY harmless for any loss or damage
resulting from a conviction, debarment, exclusion, ineligibility or other matter listed in the signed
Certification Regarding Debarment, Suspension, and Other Responsibility Matters.
30. DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the PROVIDER(s) is operating as a corporation (a
for-profit or non-profit corporation) or if during the term of this agreement, the PROVIDER(s)
changes its status to operate as a corporation.
Clients of the PROVIDER(s) Board of Directors shall disclose any self-dealing
transactions that they are a party to while PROVIDER(s) is providing goods or performing services
under this agreement. A self-dealing transaction shall mean a transaction to which the PROVIDER(s)
is a party and in which one or more of its directors has a material financial interest. Clients of the
Board of Directors shall disclose any self-dealing transactions that they are a party to by completing
and signing a Self-Dealing Transaction Disclosure Form (Exhibit K attached hereto and by this
reference incorporated herein and made part of this Agreement) and submitting it to the COUNTY
prior to commencing with the self-dealing transaction or immediately thereafter.
31. COMPLIANCE
PROVIDER(s) shall comply with all requirements of the “Fresno County Mental Health
Compliance Program and PROVIDER(s) Code of Conduct and Ethics” as set forth in Exhibit C.
Within thirty (30) days of entering into this Agreement with the COUNTY, PROVIDER(s) shall have
all of PROVIDER(s) employees, agents and subcontractors providing services under this Agreement
certify in writing, that they have received, read, understood, and shall abide by the requirements set
COUNTY OF FRESNO
Fresno, CA
- 26 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
forth in Exhibit C. PROVIDER(s) shall ensure that within thirty (30) days of hire, all new employees,
agents and subcontractors providing services under this Agreement certify in writing that they have
received, read, understood, and shall abide by the requirements set forth in Exhibit C. PROVIDER(s)
understands that the promotion of and adherence to such requirements is an element in evaluating the
performance of PROVIDER(s) and its employees, agents and subcontractors.
Within thirty (30) days of entering into this Agreement, and annually thereafter, all
employees, agents and subcontractors providing services under this Agreement shall complete general
compliance training and appropriate employees, agents and subcontractors shall complete
documentation and billing or billing/reimbursement training. All new employees, agents and
subcontractors shall attend the appropriate training within thirty (30) days of hire. Each individual
who is required to attend training shall certify in writing that he or she has received the required
training. The certification shall specify the type of training received and the date received. The
certification shall be provided to the COUNTY’s Compliance Officer at 3133 N. Millbrook, Room
171, Fresno, CA 93703. PROVIDER(s) agrees to reimburse COUNTY for the entire cost of any
penalty imposed upon COUNTY by the Federal Government as a result of PROVIDER(s) violation of
the terms of this Agreement.
32. ASSURANCES
In entering into this Agreement, PROVIDER(s) certifies that it nor any of its officers are
not currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal
Health Care Programs: that it or any of its officers have not been convicted of a criminal offense
related to the provision of health care items or services; nor has it or its officers been reinstated to
participation in the Federal Health Care Programs after a period of exclusion, suspension, debarment,
or ineligibility. If COUNTY learns, subsequent to entering into a contract, that PROVIDER(s) is
ineligible on these grounds, COUNTY will remove PROVIDER(s) from responsibility for, or
involvement with, COUNTY’s business operations related to the Federal Health Care Programs and
shall remove such PROVIDER(s) from any position in which PROVIDER(s) compensation, or the
items or services rendered, ordered or prescribed by PROVIDER(s) may be paid in whole or part,
directly or indirectly, by Federal Health Care Programs or otherwise with Federal Funds at least until
COUNTY OF FRESNO
Fresno, CA
- 27 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
such time as PROVIDER(s) is reinstated into participation in the Federal Health Care Programs.
A. If COUNTY has notice that PROVIDER(s) or its officers has been charged with
a criminal offense related to any Federal Health Care Program, or is proposed for exclusion during the
term on any contract, PROVIDER(s) and COUNTY shall take all appropriate actions to ensure the
accuracy of any claims submitted to any Federal Health Care Program. At its discretion given such
circumstances, COUNTY may request that PROVIDER(s) cease providing services until resolution
of the charges or the proposed exclusion.
B. PROVIDER(s) agrees that all potential new employees of PROVIDER(s) or
subcontractors of PROVIDER(s) who, in each case, are expected to perform professional services
under this Agreement, will be queried as to whether (1) they are now or ever have been excluded,
suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2)
they have been convicted of a criminal offense related to the provision of health care items or services;
and or (3) they have been reinstated to participation in the Federal Health Care Programs after a period
of exclusion, suspension, debarment, or ineligibility.
1. In the event the potential employee or subcontractor informs
PROVIDER(s) that he or she is excluded, suspended, debarred or
otherwise ineligible, or has been convicted of a criminal offense relating to
the provision of health care services, and PROVIDER(s) hires or engages
such potential employee or subcontractor, PROVIDER(s) will ensure that
said employee or subcontractor does no work, either directly or indirectly
relating to services provided to COUNTY.
2. Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section 3 of this Agreement, or require
adequate assurance (as defined by COUNTY) that no excluded, suspended
or otherwise ineligible employee or subcontractor of PROVIDER(s) will
perform work, either directly or indirectly, relating to services provided to
COUNTY. Such demand for adequate assurance shall be effective upon a
time frame to be determined by COUNTY to protect the interests of
COUNTY OF FRESNO
Fresno, CA
- 28 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
COUNTY clients.
C. PROVIDER(s) shall verify (by asking the applicable employees and
subcontractors) that all current employees and existing subcontractors who, in each case, are expected
to perform professional services under this Agreement: (1) are not currently excluded, suspended,
debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been
convicted of a criminal offense related to the provision of health care items or services; and (3) have
not been reinstated to participation in the Federal Health Care Program after a period of exclusion,
suspension, debarment, or ineligibility. In the event any existing employee or subcontractor informs
PROVIDER(s) that he or she is excluded, suspended, debarred or otherwise ineligible to participate
in the Federal Health Care Programs, or has been convicted of a criminal offense relating to the
provision of health care services, PROVIDER(s) will ensure that said employee or subcontractor does
no work, either direct or indirect, relating to services provided to COUNTY.
1. PROVIDER(s) agrees to notify COUNTY immediately during the term
of this Agreement whenever PROVIDER(s) learns that an employee or
subcontractor who, in each case, is providing professional services under
Section 1 this Agreement is excluded, suspended, debarred or otherwise
ineligible to participate in the Federal Health Care Programs, or is
convicted of a criminal offense relating to the provision of health care
services.
2. Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section 3 of this Agreement, or require
adequate assurance (as defined by COUNTY) that no excluded, suspended
or otherwise ineligible employee or subcontractor of PROVIDER(s) will
perform work, either directly or indirectly, relating to services provided to
COUNTY. Such demand for adequate assurance shall be effective upon a
time frame to be determined by COUNTY to protect the interests of
COUNTY clients.
D. PROVIDER(s) agrees to cooperate fully with any reasonable requests for
COUNTY OF FRESNO
Fresno, CA
- 29 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
information from COUNTY which may be necessary to complete any internal or external audits
relating to PROVIDER(s) compliance with the provisions of this Section 32.
E. PROVIDER(s) agrees to reimburse COUNTY for the entire cost of any penalty
imposed upon COUNTY by the Federal Government as a result of PROVIDER(s) violation of
PROVIDER(s) obligations as described in this Section 32.
33. COMPLAINTS
PROVIDER(s) shall log complaints and the disposition of all complaints from a client or
a client's family. PROVIDER(s) shall provide a copy of the detailed complaint log entries concerning
COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (10th) day of the following
month, in a format that is mutually agreed upon. Besides the detailed complaint log, PROVIDER(s)
shall provide details and attach documentation of each complaint with the log. PROVIDER(s) shall
post signs informing clients of their right to file a complaint or grievance. PROVIDER(s) shall notify
COUNTY of all incidents reportable to state licensing bodies that affect COUNTY clients within
twenty-four (24) hours of receipt of a complaint.
Within ten (10) days after each incident or complaint affecting COUNTY-sponsored
clients, PROVIDER(s) shall provide COUNTY with information relevant to the complaint,
investigative details of the complaint, the complaint and PROVIDER(s) disposition of, or corrective
action taken to resolve the complaint. In addition, PROVIDER(s) shall inform every client of their
rights as set forth in Exhibit G. PROVIDER(s) shall file an incident report for all incidents involving
clients, following the Protocol and using the Worksheet identified in Exhibit H.
34. PROHIBITION ON PUBLICITY
None of the funds, materials, property or services provided directly or indirectly under
this Agreement shall be used for PROVIDER(s) advertising, fundraising, or publicity (i.e., purchasing
of tickets/tables, silent auction donations, etc.) for the purpose of self-promotion. Notwithstanding the
above, publicity of the services described in Section 1 of this Agreement shall be allowed as necessary
to raise public awareness about the availability of such specific services when approved in advance by
COUNTY’s DBH Director or designee and at a cost to be provided in Section 4 of this Agreement for
COUNTY OF FRESNO
Fresno, CA
- 30 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
such items as written/printed materials, the use of media (i.e., radio, television, newspapers) and any
other related expense(s).
35. SEPARATE AGREEMENT
It is mutually understood by the parties that this Agreement does not, in any way, create a
joint venture among PROVIDER(s). By execution of this Agreement, PROVIDER(s) understand that a
separate Agreement is formed between each individual PROVIDER and COUNTY.
36. AUDITS AND INSPECTIONS
PROVIDER(s) shall at any time during business hours, and as often as the COUNTY
may deem necessary, make available to the COUNTY for examination all of its records and data with
respect to the matters covered by this Agreement. PROVIDER(s) shall, upon request by the
COUNTY, permit the COUNTY to audit and inspect all such records and data necessary to ensure
PROVIDER(s) compliance with the terms of this Agreement.
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
PROVIDER(s) shall be subject to the examination and audit of the State Auditor General for a period
of three (3) years after final payment under contract (Government Code section 8546.7).
37. NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY PROVIDER(s)
Director, Fresno County (See Exhibit A)
Department of Behavioral Health
3133 N. Millbrook Ave.
Fresno, CA 93703
Any and all notices between the COUNTY and the PROVIDER(s) provided for or
permitted under this Agreement or by law shall be in writing and shall be deemed duly served when
personally delivered to one of the parties, or in lieu of such personal service, when deposited in the
United States Mail, postage prepaid, addressed to such party.
38. GOVERNING LAW
The parties agree that for the purpose of venue, performance under this Agreement is in
COUNTY OF FRESNO
Fresno, CA
- 31 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Fresno County, California.
The rights and obligations of the parties and all interpretation and performance of this
Agreement shall be governed in all respects by the laws of the State of California.
39. SUPERSEDE
This Agreement shall supersede in its entirety and render null and void the Agreement
between the parties for these same services identified as County Agreement No. 15-247, effective
upon execution of this Agreement.
40. ENTIRE AGREEMENT
This Agreement, including all Exhibits, constitutes the entire agreement between
PROVIDER(s) and COUNTY with respect to the subject matter hereof and supersedes all previous
agreement negotiations, proposals, commitments, writings, advertisements, publications, and
understandings of any nature whatsoever unless expressly included in this Agreement.
///
///
///
///
///
///
///
///
///
///
///
///
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
IN WI TNES S WHEREOF, th e pa rti es he reto have executed thi s Agreeme nt as of th e day a nd
yea r fir st herein abo ve written .
PROVIDER(s)
SE E A TT ACHED EXHIBIT A
Fund /S ub c las s : 000 I /10000
Accoun t/Progra m : 7223/0
Organi zatio n/Cost Cente r : 56302666
COUNTY OF FRESNO
By:_~"""--~-...-~~---
S
s
Date:
ATTEST :
Bernic e E. Sei del,
h a irpe rson of th e Board of
he Coun ty of F res no
C le rk of the Boa rd of Supervi so rs
Co unt y of Fre s no, St ate of Cali fo rn ia
By : ~SA.tn ~sbOf)
De pu ty
Date : -~3~--aQ~_-_1~'.6~-
PLEASE SEE ADDITIONAL
SIGNATURE PAGES ATTAC HED
-32 -COUNTY OF FRESNO
Fresno, CA
33
34
35
36
37
1
2
3
4
5
6
'1
8
9
1_0
l- l_
I2
IJ
t4
r-5
L6
I7
l-8
19
zv
2L
22
23
24
25
zo
21
z6
PRoVIDER (INDIVIDUAL): tU\,' t".-( 1-nn I
Flr,
PrintName:
Title:
Li{tr++*
Date: *(- Z 'r/
COUNTY OF FRESNO
Fresnor CA
38
Exhibit A
Individual Providers
Name Address
Gabriele Case 4420 N. First #121 Fresno, CA 93726
Jeanette Tamberi Lopez 2008 N. Fine #103 Fresno, CA 93727
Judith A Dickey 5707 N. Palm #103 Fresno, CA 93704
Justin Armer 614 N. St Sanger, CA 93657
Michael Tucibat 5150 N 6th St Suite 162 Fresno, CA 93710
Group Providers
Name Address
Marjaree Mason Center 1600 M Street Fresno, CA 93721
Exhibit B
Page 1 of 1
Avatar
Service
Codes Rate/min Flat Rate
Psychiatrist
MD Meds Eval Mngt Assessment (up to 120 min)170 $4.23 N/A
MD Reauthorization including plan development only (up to 60 min)170 $4.23 N/A
MD Med Eval Mngt Brief 172 $4.23 N/A
MD Meds Eval Mngt Follow-Up 173 $4.23 N/A
Individual Medical Psychotherapy 126 $1.20 N/A
Hospital Care - Inpatient - New/Established (flat rate)839 N/A $100.00
Hospital Care - Subsequent - Bedside (flat rate)840 N/A $55.00
Inpatient Consultation - Initial - New/Established 822 $1.27 N/A
Emergency Department 823 $1.17 N/A
Nursing Facility Assessment 825 $1.42 N/A
Subsequent Nursing Facility 828 $1.67 N/A
Individual Assessment 103 $1.20 N/A
Group Therapy 82 $1.53 N/A
Individual or Family Psychotherapy 83 $1.27 N/A
Family Therapy 156 $0.95 N/A
Collateral 150 $1.00 N/A
Case Management / Linkage & Consult 205 $0.67 N/A
Psychologist (Licensed/Registered/Waivered)
Individual Assessment 103 $0.95 N/A
Individual or Family Psychotherapy 83 $1.53 N/A
Group Therapy 82 $1.53 N/A
Test Administration Including Pre-Interview 891 $0.87 N/A
Collateral 150 $1.00 N/A
Case Management / Linkage & Consult 205 $0.67 N/A
Plan Development 159 $0.95 N/A
Rehabilitation 158 $0.95 N/A
LCSW/ASW, LMFT/AMFT, LPCC/APCC, RN - MS
Individual Assessment 103 $0.95 N/A
Individual or Family Psychotherapy 83 $0.95 N/A
Group Therapy 82 $1.53 N/A
Collateral 150 $1.00 N/A
Case Management / Linkage & Consult 205 $0.67 N/A
Plan Development 159 $0.95 N/A
Rehabilitation 158 $0.95 N/A
Service Description
Fresno County Mental Health Plan
Individual and Group Provider Fee Schedule
Effective 3/2018
Exhibit C
Page 1 of 3
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws,
regulations, rules and guidelines that apply to the provision and payment of mental health services.
Mental health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with which
contractor and its employees, associates, and subcontractors shall comply. Contractor shall require
its employees, associates, and subcontractors to attend a compliance training that will be provided by
Fresno County. After completion of this training, each contractor, contractor’s employee, associate,
and subcontractor must sign the Contractor Acknowledgment and Agreement form and return this
form to the Compliance officer or designee.
Contractor and its employees and subcontractor shall:
1. Comply with all applicable laws, regulations, rules or guidelines when providing and billing
for mental health services.
2. Conduct themselves honestly, fairly, courteously and with a high degree of integrity in their
professional dealing related to their contract with the County and avoid any conduct that could
reasonably be expected to reflect adversely upon the integrity of the County.
3. Treat County employees, consumers, and other mental health contractors fairly and with
respect.
4. NOT engage in any activity in violation of the County’s Compliance Program, nor engage in
any other conduct which violates any applicable law, regulation, rule or guideline
5. Take precautions to ensure that claims are prepared and submitted accurately, timely and are
consistent with all applicable laws, regulations, rules or guidelines.
6. Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement
of any kind are submitted.
7. Bill only for eligible services actually rendered and fully documented. Use billing codes that
accurately describe the services provided.
Exhibit C
Page 2 of 3
8. Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9. Promptly report to the Compliance Officer any suspected violation(s) of this Code of Conduct
and Ethics by County employees or other mental health contractors, or report any activity that
they believe may violate the standards of the Compliance Program, or any other applicable
law, regulation, rule or guideline. Fresno County prohibits retaliation against any person
making a report. Any person engaging in any form of retaliation will be subject to disciplinary
or other appropriate action by the County. Contractor may report anonymously.
10. Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
11. Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
Exhibit C
Page 3 of 3
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and
Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof. I further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement. I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County. I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print): _____________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Other:___________________________________________
Signature :________________________________ Date : ___/____/___
For Group or Organizational Providers
Group/Org. Name (print): _______________________________________
Employee Name (print): ________________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Other:___________________________________________
Job Title (if different from Discipline): ___________________________
Signature: _________________________________ Date: ____/___/____
Exhibit D
Page 1 of 3
Documentation Standards For Client Records
The documentation standards are described below under key topics related to client care. All
standards must be addressed in the client record; however, there is no requirement that the record
have a specific document or section addressing these topics. All medical records shall be
maintained for a minimum of 10 years from the date of the end of the Agreement.
A. Assessments
1. The following areas will be included as appropriate as a part of a comprehensive client record.
• Relevant physical health conditions reported by the client will be prominently identified
and updated as appropriate.
• Presenting problems and relevant conditions affecting the client’s physical health and
mental health status will be documented, for example: living situation, daily activities,
and social support.
• Documentation will describe client’s strengths in achieving client plan goals.
• Special status situations that present a risk to clients or others will be prominently
documented and updated as appropriate.
• Documentations will include medications that have been described by mental health plan
physicians, dosage of each medication, dates of initial prescriptions and refills, and
documentations of informed consent for medications.
• Client self report of allergies and adverse reactions to medications, or lack of known
allergies/sensitivities will be clearly documented.
• A mental health history will be documented, including: previous treatment dates,
providers, therapeutic interventions and responses, sources of clinical data, relevant
family information and relevant results of relevant lab tests and consultations reports.
• For children and adolescents, pre-natal and perinatal events and complete developmental
history will be documented.
• Documentations will include past and present use of tobacco, alcohol, and caffeine, as
well as illicit, prescribed and over-the-counter drugs.
• A relevant mental status examination will be documented.
• A DSM-5 diagnosis, or a diagnosis from the most current ICD, will be documented,
consistent with the presenting problems, history mental status evaluation and/or other
assessment data.
2. Timeliness/Frequency Standard for Assessment
• An assessment will be completed at intake and updated as needed to document changes in
the client’s condition.
• Client conditions will be assessed at least annually and, in most cases, at more frequent
intervals.
Exhibit D
Page 2 of 3
B. Client Plans
1. Client plans will:
• have specific observable and/or specific quantifiable goals
• identify the proposed type(s) of intervention
• have a proposed duration of intervention(s)
• be signed (or electronic equivalent) by:
the person providing the service(s), or
a person representing a team or program providing services, or
a person representing the MHP providing services
when the client plan is used to establish that the services are provided under the
direction of an approved category of staff, and if the below staff are not the approved
category,
a physician
a licensed/ “waivered” psychologist
a licensed/ “associate” social worker
a licensed/ registered/marriage and family therapist or
a registered nurse
• In addition,
client plans will be consistent with the diagnosis, and the focus of intervention will be
consistent with the client plan goals, and there will be documentation of the client’s
participation in and agreement with the plan. Examples of the documentation include,
but are not limited to, reference to the client’s participation and agreement in the body
of the plan, client signature on the plan, or a description of the client’s participation
and agreement in progress notes.
client signature on the plan will be used as the means by which the
CONTRACTOR(S) documents the participation of the client
when the client’s signature is required on the client plan and the client refuses or is
unavailable for signature, the client plan will include a written explanation of the
refusal or unavailability.
The CONTRACTOR(S) will give a copy of the client plan to the client on request.
2. Timeliness/Frequency of Client Plan:
• Will be updated at least annually
• The CONTRACTOR(S) will establish standards for timeliness and frequency for the
individual elements of the client plan described in item 1.
C. Progress Notes
1. Items that must be contained in the client record related to the client’s progress in treatment
include:
• The client record will provide timely documentation of relevant aspects of client care
Exhibit D
Page 3 of 3
• Mental health staff/practitioners will use client records to document client encounters,
including relevant clinical decisions and interventions
• All entries in the client record will include the signature of the person providing the
service (or electronic equivalent); the person’s professional degree, licensure or job title;
and the relevant identification number, if applicable
• All entries will include the date services were provided
• The record will be legible
• The client record will document follow-up care, or as appropriate, a discharge summary
2. Timeliness/Frequency of Progress Notes:
Progress notes shall be documented at the frequency by type of service indicated below:
A. Every Service Contact
Mental Health Services
Medication Support Services
Crisis Intervention
Exhibit E
Page 1 of 6
STATE MENTAL HEALTH REQUIREMENTS
1. CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2. PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business and
Professions and Welfare and Institutions Codes.
3. CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with
all State of California and Federal statutes and regulations regarding
confidentiality, including but not limited to confidentiality of information
requirements at 42, Code of Federal Regulations sections 2.1 et seq; California
Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division
10.5 and 10.6 of the California Health and Safety Code; Title 22, California Code
of Regulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 of the
California Civil Code.
4. NON-DISCRIMINATION
A. Eligibility for Services
CONTRACTOR shall prepare and make available to COUNTY and to the
public all eligibility requirements to participate in the program plan set
forth in the Agreement. No person shall, because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance.
B. Employment Opportunity
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer,
Exhibit E
Page 2 of 6
rates of pay or other forms of compensation, use of facilities, and other
terms and conditions of employment.
C. Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all
further funds, until CONTRACTOR can show clear and convincing
evidence to the satisfaction of COUNTY that funds provided under this
Agreement were not used in connection with the alleged discrimination.
D. Nepotism
Except by consent of COUNTY’s Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR.
5. PATIENTS' RIGHTS
CONTRACTOR shall comply with applicable laws and regulations, including but
not limited to, laws, regulations, and State policies relating to patients' rights.
STATE CONTRACTOR CERTIFICATION CLAUSES
1. STATEMENT OF COMPLIANCE: Contractor has, unless exempted, complied with
the non-discrimination program requirements. (Gov. Code§ 12990 (a-f) and CCR, Title 2,
Section 111 02) (Not applicable to public entities.)
2. DRUG-FREE WORKPLACE REQUIREMENTS: Contractor will comply with the
requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-free
workplace by taking the following actions:
a. Publish a statement notifying employees that unlawful manufacture, distribution,
dispensation, possession or use of a controlled substance is prohibited and specifying
actions to be taken against employees for violations.
b. Establish a Drug-Free Awareness Program to inform employees about:
1) the dangers of drug abuse in the workplace;
2) the person's or organization's policy of maintaining a drug-free workplace;
3) any available counseling, rehabilitation and employee assistance programs; and,
4) penalties that may be imposed upon employees for drug abuse violations.
c. Every employee who works on the proposed Agreement will:
1) receive a copy of the company's drug-free workplace policy statement; and,
Exhibit E
Page 3 of 6
2) agree to abide by the terms of the company's statement as a condition of employment
on the Agreement.
Failure to comply with these requirements may result in suspension of payments under
the Agreement or termination of the Agreement or both and Contractor may be ineligible
for award of any future State agreements if the department determines that any of the
following has occurred: the Contractor has made false certification, or violated the
certification by failing to carry out the requirements as noted above. (Gov. Code §8350 et
seq.)
3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION: Contractor certifies
that no more than one (1) final unappealable finding of contempt of court by a Federal
court has been issued against Contractor within the immediately preceding two-year
period because of Contractor's failure to comply with an order of a Federal court, which
orders Contractor to comply with an order of the National Labor Relations Board. (Pub.
Contract Code §10296) (Not applicable to public entities.)
4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO
REQUIREMENT: Contractor hereby certifies that Contractor will comply with the
requirements of Section 6072 of the Business and Professions Code, effective January 1,
2003.
Contractor agrees to make a good faith effort to provide a minimum number of hours of
pro bono legal services during each year of the contract equal to the lessor of 30
multiplied by the number of full time attorneys in the firm’s offices in the State, with the
number of hours prorated on an actual day basis for any contract period of less than a full
year or 10% of its contract with the State.
Failure to make a good faith effort may be cause for non-renewal of a state contract for
legal services, and may be taken into account when determining the award of future
contracts with the State for legal services.
5. EXPATRIATE CORPORATIONS: Contractor hereby declares that it is not an
expatriate corporation or subsidiary of an expatriate corporation within the meaning of
Public Contract Code Section 10286 and 10286.1, and is eligible to contract with the
State of California.
6. SWEATFREE CODE OF CONDUCT:
a. All Contractors contracting for the procurement or laundering of apparel, garments or
corresponding accessories, or the procurement of equipment, materials, or supplies, other
than procurement related to a public works contract, declare under penalty of perjury that
no apparel, garments or corresponding accessories, equipment, materials, or supplies
furnished to the state pursuant to the contract have been laundered or produced in whole
or in part by sweatshop labor, forced labor, convict labor, indentured labor under penal
sanction, abusive forms of child labor or exploitation of children in sweatshop labor, or
with the benefit of sweatshop labor, forced labor, convict labor, indentured labor under
Exhibit E
Page 4 of 6
penal sanction, abusive forms of child labor or exploitation of children in sweatshop
labor. The contractor further declares under penalty of perjury that they adhere to the
Sweatfree Code of Conduct as set forth on the California Department of Industrial
Relations website located at www.dir.ca.gov, and Public Contract Code Section 6108.
b. The contractor agrees to cooperate fully in providing reasonable access to the
contractor’s records, documents, agents or employees, or premises if reasonably required
by authorized officials of the contracting agency, the Department of Industrial Relations,
or the Department of Justice to determine the contractor’s compliance with the
requirements under paragraph (a).
7. DOMESTIC PARTNERS: For contracts of $100,000 or more, Contractor certifies that
Contractor is in compliance with Public Contract Code section 10295.3.
8. GENDER IDENTITY: For contracts of $100,000 or more, Contractor certifies that
Contractor is in compliance with Public Contract Code section 10295.35.
DOING BUSINESS WITH THE STATE OF CALIFORNIA
The following laws apply to persons or entities doing business with the State of
California.
1. CONFLICT OF INTEREST: Contractor needs to be aware of the following provisions
regarding current or former state employees. If Contractor has any questions on the
status of any person rendering services or involved with the Agreement, the awarding
agency must be contacted immediately for clarification.
Current State Employees (Pub. Contract Code §10410):
1). No officer or employee shall engage in any employment, activity or enterprise from
which the officer or employee receives compensation or has a financial interest and
which is sponsored or funded by any state agency, unless the employment, activity or
enterprise is required as a condition of regular state employment.
2). No officer or employee shall contract on his or her own behalf as an independent
contractor with any state agency to provide goods or services.
Former State Employees (Pub. Contract Code §10411):
1). For the two-year period from the date he or she left state employment, no former state
officer or employee may enter into a contract in which he or she engaged in any of the
negotiations, transactions, planning, arrangements or any part of the decision-making
process relevant to the contract while employed in any capacity by any state agency.
2). For the twelve-month period from the date he or she left state employment, no former
state officer or employee may enter into a contract with any state agency if he or she was
Exhibit E
Page 5 of 6
employed by that state agency in a policy-making position in the same general subject
area as the proposed contract within the 12-month period prior to his or her leaving state
service.
If Contractor violates any provisions of above paragraphs, such action by Contractor shall
render this Agreement void. (Pub. Contract Code §10420)
Members of boards and commissions are exempt from this section if they do not receive
payment other than payment of each meeting of the board or commission, payment for
preparatory time and payment for per diem. (Pub. Contract Code §10430 (e))
2. LABOR CODE/WORKERS' COMPENSATION: Contractor needs to be aware of the
provisions which require every employer to be insured against liability for Worker's
Compensation or to undertake self-insurance in accordance with the provisions, and
Contractor affirms to comply with such provisions before commencing the performance
of the work of this Agreement. (Labor Code Section 3700)
3. AMERICANS WITH DISABILITIES ACT: Contractor assures the State that it
complies with the Americans with Disabilities Act (ADA) of 1990, which prohibits
discrimination on the basis of disability, as well as all applicable regulations and
guidelines issued pursuant to the ADA. (42 U.S.C. 12101 et seq.)
4. CONTRACTOR NAME CHANGE: An amendment is required to change the
Contractor's name as listed on this Agreement. Upon receipt of legal documentation of
the name change the State will process the amendment. Payment of invoices presented
with a new name cannot be paid prior to approval of said amendment.
5. CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:
a. When agreements are to be performed in the state by corporations, the contracting
agencies will be verifying that the contractor is currently qualified to do business in
California in order to ensure that all obligations due to the state are fulfilled.
b. "Doing business" is defined in R&TC Section 23101 as actively engaging in any
transaction for the purpose of financial or pecuniary gain or profit. Although there are
some statutory exceptions to taxation, rarely will a corporate contractor performing
within the state not be subject to the franchise tax.
c. Both domestic and foreign corporations (those incorporated outside of California) must
be in good standing in order to be qualified to do business in California. Agencies will
determine whether a corporation is in good standing by calling the Office of the Secretary
of State.
6. RESOLUTION: A county, city, district, or other local public body must provide the
State with a copy of a resolution, order, motion, or ordinance of the local governing body
Exhibit E
Page 6 of 6
which by law has authority to enter into an agreement, authorizing execution of the
agreement.
7. AIR OR WATER POLLUTION VIOLATION: Under the State laws, the Contractor
shall not be: (1) in violation of any order or resolution not subject to review promulgated
by the State Air Resources Board or an air pollution control district; (2) subject to cease
and desist order not subject to review issued pursuant to Section 13301 of the Water
Code for violation of waste discharge requirements or discharge prohibitions; or (3)
finally determined to be in violation of provisions of federal law relating to air or water
pollution.
8. PAYEE DATA RECORD FORM STD. 204: This form must be completed by all
contractors that are not another state agency or other governmental entity.
9. INSPECTION and Audit of Records and access to Facilities.
The State, CMS, the Office of the Inspector General, the Comptroller General, and their
designees may, at any time, inspect and audit any records or documents of
CONTRACTOR or its subcontractors, and may, at any time, inspect the premises,
physical facilities, and equipment where Medicaid-related activities or work is conducted.
The right to audit under this section exists for 10 years from the final date of the contract
period or from the date of completion of any audit, whichever is later.
Federal database checks. Consistent with the requirements at § 455.436 of this chapter,
the State must confirm the identity and determine the exclusion status of
CONTRACTOR, any subcontractor, as well as any person with an ownership or control
interest, or who is an agent or managing employee of CONTRACTOR through routine
checks of Federal databases. This includes the Social Security Administration's Death
Master File, the National Plan and Provider Enumeration System (NPPES), the List of
Excluded Individuals/Entities (LEIE), the System for Award Management (SAM), and
any other databases as the State or Secretary may prescribe. These databases must be
consulted upon contracting and no less frequently than monthly thereafter. If the State
finds a party that is excluded, it must promptly notify the CONTRACTOR and take
action consistent with § 438.610(c).
The State must ensure that CONTRACTOR with which the State contracts under this part
is not located outside of the United States and that no claims paid by a CONTRACTOR
to a network provider, out-of-network provider, subcontractor or financial institution
located outside of the U.S. are considered in the development of actuarially sound
capitation rates.
Exhibit F
Page 1 of 2
Medi-Cal Provider Standards
1. The Medi-Cal Provider possesses the necessary license to operate, if applicable, and any
required certification.
2. The space owned, leased or operated by the Provider and used for services or staff meets
local fire codes.
3. The physical plant of any site owned, leased, or operated by the Provider and used for
services or staff is clean, sanitary and in good repair.
4. The Medi-Cal Provider maintains client records in a manner that meets applicable state
and federal standards.
5. The Medi-Cal Provider has staffing adequate to allow the County to claim federal
financial participation for the services the Provider delivers to beneficiaries, as described
in Division 1, Chapter 11, Subchapter 4 of Title 9, CCR, when applicable.
6. The Medi-Cal Provider that provides or stores medications, the Provider stores and
dispenses medications in compliance with all pertinent state and federal standards. In
particular:
A. All drugs obtained by prescription are labeled in compliance with federal and
state laws. Prescription labels are altered only by persons legally authorized to do
so.
B. Drugs intended for external use only or food stuffs are stored separately from
drugs for internal use.
C. All drugs are stored at proper temperatures, room temperature drugs at 59-86
degrees F and refrigerated drugs at 36-46 degrees F.
D. Drugs are stored in a locked area with access limited to those medical personnel
authorized to prescribe, dispense or administer medication.
E. Drugs are not retained after the expiration date. IM multi-dose vials are dated and
initialed when opened.
F. A drug log is maintained to ensure the Provider disposes of expired,
contaminated, deteriorated and abandoned drugs in a manner consistent with state
and federal laws.
G. Policies and procedures are in place for dispensing, administering and storing
medications.
Exhibit F
Page 2 of 2
7. The Medi-Cal Provider that provides day treatment intensive or day rehabilitation, the
Provider must have a written description of the day treatment intensive and/or day
treatment rehabilitation program that complies with State Department of Health Care
Services’ day treatment requirements. The COUNTY shall review the Provider’s written
program description for compliance with the State Department of Health Care Services’
day treatment requirements.
8. The COUNTY may accept the host county’s site certification and reserves the right to
conduct an on-site certification review at least every three (3) years. The COUNTY may
also conduct additional certification reviews when:
A. The Provider makes major staffing changes.
B. The Provider makes organizational and/or corporate structure changes (example:
conversion from a non-profit status).
C. The Provider adds day treatment or medication support services when
medications shall be administered or dispensed from the Provider site.
D. There are significant changes in the physical plant of the Provider site (some
physical plant changes could require a new fire clearance).
E. There is change of ownership or location.
F. There are complaints against the Provider.
G. There are unusual events, accidents, or injuries requiring medical treatment for
clients, staff or members of the community.
Exhibit G
Page 1 of 2
Fresno County Mental Health Plan Grievances and Appeals Process
The Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance
and appeal process and an expedited appeal process to resolve grievances and
disputes at the earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-for-
service providers to give verbal and written information to Medi-Cal beneficiaries
regarding the following:
• How to access specialty mental health services
• How to file a grievance about services
• How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a grievance
form, an appeal form, and Request for Change of Provider Form. All of these
beneficiary materials must be posted in prominent locations where Medi-Cal
beneficiaries receive outpatient specialty mental health services, including the waiting
rooms of providers’ offices of service.
Beneficiaries have the right to use the grievance and/or appeal process without any
penalty, change in mental health services, or any form of retaliation. All Medi-Cal
beneficiaries can file an appeal or state hearing.
Grievances and appeals forms and self-addressed envelopes must be available for
beneficiaries to pick up at all provider sites without having to make a verbal or written
request. Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
(800) 654-3937 (for more information)
(TTY) Dial 771 to reach the California Relay Service
Provider Problem Resolution and Appeals Process
The MHP uses a simple, informal procedure in identifying and resolving provider
concerns and problems regarding payment authorization issues, other complaints and
concerns.
Informal provider problem resolution process – the provider may first speak to a
Provider Relations Specialist (PRS) regarding his or her complaint or concern.
Exhibit G
Page 2 of 2
The PRS will attempt to settle the complaint or concern with the provider. If the attempt
is unsuccessful and the provider chooses to forego the informal grievance process, the
provider will be advised to file a written complaint to the MHP address (listed above).
Formal provider appeal process – the provider has the right to access the provider
appeal process at any time before, during, or after the provider problem resolution
process has begun, when the complaint concerns a denied or modified request for MHP
payment authorization, or the process or payment of a provider’s claim to the MHP.
Payment authorization issues – the provider may appeal a denied or modified request
for payment authorization or a dispute with the MHP regarding the processing or
payment of a provider’s claim to the MHP. The written appeal must be submitted to the
MHP within ninety (90) calendar days of the date of the receipt of the non-approval of
payment.
The MHP shall have sixty (60) calendar days from its receipt of the appeal to inform the
provider in writing of the decision, including a statement of the reasons for the decision
that addresses each issue raised by the provider, and any action required by the
provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request, the
MHP utilizes Managed Care staff who were not involved in the initial denial or
modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be asked to
submit a revised request for payment within thirty (30) calendar days of receipt of the
decision
Other complaints – if there are other issues or complaints, which are not related to
payment authorization issues, providers are encouraged to send a letter of complaint to
the MHP. The provider will receive a written response from the MHP within sixty (60)
calendar days of receipt of the complaint. The decision rendered by the MHP is final.
Exhibit H
Page 1 of 2
FFRREESSNNOO CCOOUUNNTTYY MMEENNTTAALL HHEEAALLTTHH PPLLAANN
IINNCCIIDDEENNTT RREEPPOORRTTIINNGG
PPRROOTTOOCCOOLL FFOORR CCOOMMPPLLEETTIIOONN OOFF IINNCCIIDDEENNTT RREEPPOORRTT
• The Incident Report must be completed for all incidents involving clients. The staff person
who becomes aware of the incident completes this form, and the supervisor co-signs it.
• When more than one client is involved in an incident, a separate form must be completed
for each client.
Where the forms should be sent - within 24 hours from the time of the incident
• Incident Report should be sent to:
Managed Care Division Manager
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
Exhibit H
Page 2 of 2
INCIDENT REPORT WORKSHEET
When did this happen? (date/time) Where did this happen?
Name/DMH #
1. Background information of the incident:
2. Method of investigation: (chart review, face-to-face interview, etc.)
Who was affected? (If other than consumer)
List key people involved. (witnesses, visitors, physicians, employees)
3. Preliminary findings: How did it happen? Sequence of events. Be specific. If attachments are needed write
comments on an 8 1/2 sheet of paper and attach to worksheet.
Outcome severity: Nonexistent inconsequential consequential death not applicable unknown
4. Response: a) corrective action, b) Plan of Action, c) other
Completed by (print name)
Completed by (signature) Date completed
Reviewed by Supervisor (print name)
Supervisor Signature Date
Exhibit I
Page 1 of 2
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of entity D/B/A
Address (number, street) City State ZIP code
CLIA number Taxpayer ID number (EIN) Telephone number
( )
II. Answer the following questions by checking “Yes” or “No.” If any of the questions are answered “Yes,” list names and
addresses of individuals or corporations under “Remarks” on page 2. Identify each item number to be continued.
A. Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percent or more in the institution, organizations, or agency that have been convicted of a criminal
offense related to the involvement of such persons or organizations in any of the programs established
YES NO
by Titles XVIII, XIX, or XX? ......................................................................................................................... ❒ ❒
B. Are there any directors, officers, agents, or managing employees of the institution, agency, or
organization who have ever been convicted of a criminal offense related to their involvement in such
programs established by Titles XVIII, XIX, or XX? ...................................................................................... ❒ ❒
C. Are there any individuals currently employed by the institution, agency, or organization in a managerial,
accounting, auditing, or similar capacity who were employed by the institution’s, organization’s, or
agency’s fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) ........... ❒ ❒
III. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling
interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names
and addresses under “Remarks” on page 2. If more than one individual is reported and any of these persons are
related to each other, this must be reported under “Remarks.”
NAME ADDRESS EIN
B. Type of entity: ❒ Sole proprietorship ❒ Partnership ❒ Corporation
❒ Unincorporated Associations ❒ Other (specify)
C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations
under “Remarks.”
D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses
of individuals, and provider numbers. ..........................................................................................................
❒ ❒
NAME ADDRESS PROVIDER NUMBER
Exhibit I
Page 2 of 2
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... ❒ ❒
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... ❒ ❒
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ ❒ ❒
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... ❒ ❒
If yes, give date of change in operations.
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... ❒ ❒
VII. A. Is this facility chain affiliated? ...................................................................................................................... ❒ ❒
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
B. If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed) Title
Signature Date Remarks
Exhibit J
1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2. The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The prospective
participant shall submit an explanation of why it cannot provide the certification set out
below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation
shall disqualify such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which
reliance was placed when the department or agency determined to enter into this
transaction. If it is later determined that the prospective primary participant knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause or default.
4. The prospective primary participant shall provide immediate written notice to
the department or agency to which this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as
used in this clause, have the meanings set out in the Definitions and Coverage
sections of the rules implementing Executive Order 12549. You may contact the
department or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
Exhibit J
2 of 2
CERTIFICATION
(1) The prospective primary participant certifies to the best of its knowledge and belief,
that it, its owners, officers, corporate managers and partners:
(a) Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of
or had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c) (d) Have not within a three-year period preceding this application/proposal
had one or more public transactions (Federal, State or local) terminated for cause or
default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or
Company)
Exhibit K
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “County”), members
of a contractor’s board of directors (hereinafter referred to as “County Contractor”), must disclose any
self-dealing transactions that they are a party to while providing goods, performing services, or both
for the County. A self-dealing transaction is defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in which one
or more of its directors has a material financial interest”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member’s name, job title (if applicable), and date this disclosure is being made.
(2) Enter the board member’s company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the transaction; and
b. The nature of the material financial interest in the Corporation’s transaction that the
board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections (3) and (4).
Exhibit K
Page 2 of 2
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to)
(4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a)
(5) Authorized Signature
Signature: Date: