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AGREEMENT
THIS AGREEMENT is made and entered into this day of May, 2018, by and
between the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter
referred to as "COUNTY", and CENTRAL STAR BEHAVIORAL HEALTH INC., a California
Corporation, whose address is 1501 Hughes Way, Suite 150, Long Beach, California 90810,
hereinafter referred to as "CONTRACTOR".
W I T N E S S E T H:
W HEREAS, Senate Bill 163 (SB 163), Chapter 795, Statutes of 1997 (Welfare and Institutions
Code Sections 18250, et seq.) authorizes California counties to provide children with service alternatives to
congregate care through the development of expanded family-based service programs, including
“wraparound” services, where services are wrapped around a child living with his or her birthparent(s),
relative(s), adoptive parent(s), licensed or certified resource parent(s), or guardian(s), and are built on the
strengths of each eligible child and family and tailored to address their unique and changing needs; and
WHEREAS, COUNTY, through its Department of Social Services (DSS), is in need of a qualified
agency to provide SB163 wraparound services to eligible children and their families involved in the Child
Welfare Services (CWS) and Probation systems and the Adoption Assistance Program (AAP); and
WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), is a Mental Health Plan
(MHP) as defined in Title 9 of the California Code of Regulations (CCR), Section 1810.226; and
WHEREAS, CONTRACTOR represents that it is qualified and willing to provide said services
pursuant to the terms and conditions of this Agreement.
NOW, THEREFORE, in consideration of the mutual covenants, terms and conditions herein
contained, the parties hereto agree as follows:
1.SERVICES
A.CONTRACTOR shall perform all services and fulfill all responsibilities as identified
in Exhibit A, “Summary of Services”, attached hereto and by this reference incorporated herein.
B.CONTRACTOR shall also perform all services and fulfill all responsibilities as
specified in COUNTY’s Request for Proposal (RFP) No. 18-015 dated November 9, 2017 and Addendum
No. One (1) to COUNTY’s RFP No. 18-015 dated December 13, 2017, herein collectively referred to as
Agreement No. 18-233
1st
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COUNTY’s Revised RFP, and CONTRACTOR’s Response to said Revised RFP dated January 9, 2018;
all incorporated herein by reference and made part of this Agreement. In the event of any inconsistency
among these documents, the inconsistency shall be resolved by giving precedence in the following order
of priority: (1) to this Agreement, including all Exhibits; (2) to the Revised RFP; and (3) to CONTRACTOR’s
Response to the Revised RFP. A copy of COUNTY’s Revised RFP No. 18-015 and CONTRACTOR’s
Response thereto shall be retained and made available during the term of this Agreement by COUNTY’s
DSS Administration.
C.CONTRACTOR shall provide all behavioral health services, programs, and
practices with the vision, mission, and guiding principles of COUNTY’s DBH as further described in Exhibit
B, “Fresno County Department of Behavioral Health Guiding Principles of Care Delivery,” attached hereto
and incorporated herein by reference.
D.It is acknowledged by all parties hereto that COUNTY’s DSS and DBH
Administrative Units shall monitor the services provided by the CONTRACTOR.
E.CONTRACTOR shall participate in periodic workgroup meetings including staff from
COUNTY’s DSS and DBH Administrative Units. The meetings shall be held monthly, or as needed, to
discuss program requirements, data reporting, outcomes measurement, training, policies and procedures,
and overall program operations.
F.During the term of this Agreement, CONTRACTOR’s service site shall be at 2930
N. Fresno Street, Fresno, California 93703. Any change to CONTRACTOR’s location of the service site
may be made only upon thirty (30) days advance written notification to COUNTY’s DSS and DBH Directors
and upon written approval from the COUNTY’s DSS and DBH Directors, or designees.
G.CONTRACTOR shall maintain requirements as an organizational provider
throughout the term of this Agreement, as further defined herein. If for any reason, this status is not
maintained, COUNTY may terminate this Agreement pursuant to Section 3 of this Agreement.
H.CONTRACTOR agrees that prior to providing services under the terms and
conditions of this Agreement, it shall have appropriate staff hired and in place for program services and
operations or COUNTY may, in addition to other remedies it may have, suspend referrals or terminate this
Agreement in accordance with Section 3 of this Agreement.
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Upon execution of this Agreement, CONTRACTOR shall send to County’s DSS and DBH,
a detailed plan ensuring clinically appropriate leadership and supervision of their clinical program. Plans
for recruitment and retention of clinical leadership with the clinical competencies to oversee services based
on the level of care and program design presented herein shall be included in this plan.
I.CONTRACTOR shall provide timely access to services that meet the State of
California standards for care. CONTRACTOR shall provide non-urgent services within ten (10)
business days from request/referral to first appointment. CONTRACTOR shall provide psychiatry
services within fifteen (15) business days from request/referral to first appointment. CONTRACTOR
shall provide urgent services as soon as needed based on each client’s needs. CONTRACTOR shall
track timeliness of services to clients and provide a monthly report showing the monitoring or tracking
tool that captures this data. COUNTY and CONTRACTOR shall meet to go over this monitoring tool on
a monthly basis, as needed. COUNTY shall take corrective action if there is a failure to comply by
CONTRACTOR with the above timely access standards. CONTRACTOR shall also provide tracking
tools and measurements for effectiveness, efficiency, access, and client satisfaction indicators as
required by the Commission on Accreditation of Rehabilitation Facilities (CARF) standards and as
further detailed in Exhibit A, Summary of Services. Documentation for these four indicators shall include
the following data: to whom the indicator applies, who is responsible for collecting the data, time of
measure, data source, and target goal expectancy.
J.CONTRACTOR shall utilize the California Child and Adolescents Needs and
Strengths (CANS-50) or CANS Core 50, and Pediatric Symptom Checklist – parent/caregiver version
(PSC-35) tools to measure child and youth functioning, as intended by WIC Section 14707.5.
CONTRACTOR shall complete the CANS-50 for children and youth aged six (6) to seventeen (17) or the
CANS Core 50 for children and youth aged birth to five (5). Parent/caregivers will complete the PSC-35 for
children and youth aged four (4) to eighteen (18). These tools shall be completed at the beginning of
treatment, every six months following the original completion of the tools, and at the end of treatment.
Facilitators of these tools shall be trained by a CANS-certified trainer approved by the State. Training for
the PSC-35 is not required.
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2.TERM
The term of this Agreement shall be for a period of three (3) years and one (1) month,
commencing on 1st day of June 2018 through and including June 30, 2021. This Agreement may be
extended for two (2) additional consecutive twelve (12) month periods upon written approval of both parties
no later than sixty (60) days prior to the first day of the next twelve (12) month extension period. The DSS
and DBH Directors, or designees, are authorized to execute such written approval on behalf of COUNTY
based on CONTRACTOR’S satisfactory performance. TERMINATION
A.Non-Allocation of Funds - The terms of this Agreement, and the services to be
provided hereunder, 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 the CONTRACTOR thirty (30) days advance written notice.
B.Breach of Contract - The COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of the 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 the COUNTY;
4)Improperly performed service.
In no event shall any payment by the COUNTY constitute a waiver by the COUNTY
of any breach of this Agreement or any default which may then exist on the part of the CONTRACTOR.
Neither shall such payment impair or prejudice any remedy available to the COUNTY with respect to the
breach or default. The COUNTY shall have the right to demand of the CONTRACTOR the repayment to
the COUNTY of any funds disbursed to the CONTRACTOR under this Agreement, which in the judgment
of the COUNTY were not expended in accordance with the terms of this Agreement. The CONTRACTOR
shall promptly refund any such funds upon demand.
C.Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by COUNTY or COUNTY’s DSS and DBH Directors or designees, upon the
giving of sixty (60) days advance written notice of an intention to terminate to CONTRACTOR.
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3.COMPENSATION
In no event shall the administrative costs exceed the total amounts identified in Exhibit C.
Payment shall be made upon certification or other proof satisfactory to COUNTY’s DSS and DBH that
services have actually been performed by CONTRACTOR as specified in this Agreement.
A.MHP Specialty Mental Health Services
Subject to the Claims and Payment Processing requirements set forth in Section 5
herein, COUNTY’s DBH agrees to reimburse CONTRACTOR for rendering MHP Specialty Mental Health
Services to clients in the manner detailed in this Section 4B. During the entire term of this Agreement,
payment for CONTRACTOR’s services will be reimbursed at the rates set forth in Exhibit C, listed under
“Medi-Cal Revenue”.
Said reimbursement rates shall be payment in full, subject to the cost settlement
process identified in Section 13, herein, third party liability, and client share of costs for the Specialty
Mental Health Services CONTRACTOR provides to a client. CONTRACTOR shall be knowledgeable of all
possible Medi-Cal billable services, in order to maximize the Federal Financial Participation (FFP)
reimbursement for Medi-Cal eligible services. If clients have other health insurance coverage,
CONTRACTOR must bill any such third-party payers, before requesting payment from the COUNTY. In
the event there is such third party coverage for the covered services provided, COUNTY shall have no
obligation to make any payment to CONTRACTOR. Where applicable, CONTRACTOR shall submit
claims to the COUNTY along with a copy of the Medi-Cal denial letter or explanation of benefits or other
third-party payer denial letter or explanation of benefits within thirty (30) days of the date of such denial.
CONTRACTOR understands that COUNTY makes no guarantee to CONTRACTOR that any MHP
Specialty Mental Health Services shall be provided to any client under this Agreement.
COUNTY shall not make payment for services rendered to MHP clients which are,
in the opinion of COUNTY, determined to be not medically necessary or which have not been authorized
for reimbursement by COUNTY MHP. CONTRACTOR understands and agrees that services are not MHP
Specialty Mental Health Services subject to compensation under this Agreement unless authorized in
advance for reimbursement by the COUNTY MHP.
Unless the client has other health insurance coverage, CONTRACTOR shall look
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only to COUNTY for compensation for MHP Specialty Mental Health Services and, with the exception of
authorized share of cost payments and/or non-covered services, shall at no time seek compensation from
clients.
B.Non-MHP Mental Health Services and Other Wraparound Services
Subject to the Claims and Payment Processing requirements set forth in Section 5
herein, COUNTY’s DSS agrees to reimburse CONTRACTOR for rendering Non-MHP Mental Health
Services and Other Wraparound Services as follows:
1.Reimbursement for Non-MHP Mental Health Services shall be made at the
rates set forth in Exhibit C, under “OTHER REVENUE: Non Medi-cal Revenue”; and
2.Reimbursement for Other Wraparound Services shall be made at the rates
set forth in Exhibit C, under “OTHER REVENUE: Non Medi-cal Revenue”.
For the first thirteen (13) month period (June 1, 2018 through June 30, 2019) of this
Agreement, and for each twelve (12) month period thereafter, in no event shall services performed by
CONTRACTOR for Non-MHP Mental Health Services and Other Wraparound Services be in excess of
One Million One Hundred Twenty-Five Thousand and No/100 Dollars ($1,125,000.00)
C.For the first thirteen (13) month period (June 1, 2018 through June 30, 2019) of this
Agreement, and each twelve (12) month period thereafter, in no event shall all actual services performed
under this Agreement, including MHP Specialty Mental Health Services, Non-MHP Mental Health Services
and Other Wraparound Services, be in excess of Four Million Five Hundred Thousand and No/100 Dollars
($4,500,000.00). The cumulative total of this Agreement for the entire five (5) year and one (1) month term
for both Specialty Mental Health, Medi-Cal and Non-Medi-Cal billable services shall not be in excess of
Twenty-Two Million Five Hundred Thousand and No/100 Dollars ($22,500,000.00). It is understood that all
expenses incidental to CONTRACTOR’s performance of services under this Agreement shall be borne by
CONTRACTOR.
Except as provided below regarding State payment delays, payments by COUNTY
shall be in arrears, for services provided during the preceding month, within forty-five (45) days after
receipt, verification and approval of CONTRACTOR’s invoices by COUNTY’s DSS and/or DBH, as
applicable. If CONTRACTOR should fail to comply with any provision of this Agreement, COUNTY shall be
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relieved of its obligation for further compensation. All final claims and/or any final budget modification
requests shall be submitted by CONTRACTOR 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 CONTRACTOR pursuant to the
terms and conditions of this Agreement shall automatically revert to COUNTY.
The services provided by CONTRACTOR 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 payment to CONTRACTOR. 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.
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, including actual costs per unit, and/or any final budget modification
requests shall be submitted by CONTRACTOR 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 CONTRACTOR pursuant to the
terms and conditions of this Agreement shall automatically revert to COUNTY.
E.CONTRACTOR shall be held financially liable for any and all future
disallowances/audit exceptions due to CONTRACTOR’s deficiency discovered through the State audit
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 CONTRACTOR. CONTRACTOR shall not receive reimbursement
for any units of services rendered that are disallowed or denied by the Fresno County MHP utilization
review process or through State Department of Health Care Services (DHCS) Cost Report audit settlement
process for Medi-Cal eligible clients.
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4.INVOICING
A.CONTRACTOR shall invoice COUNTY in arrears by the twentieth (20th) day of
each month for actual expenses incurred and services rendered in the previous month to the distribution
list of COUNTY’s DSS and DBH Staff as provided in Exhibit A, under “Contractor Responsibilities”.
Complete invoices shall include Exhibit D, “Invoice Summary”, attached hereto and by this reference
incorporated herein, including the following tabs: 1) Invoice Summary, 2) Invoice Detail of Medi-Cal Billable
Items, 3) Invoice Detail of Non-Medi-Cal Billable Items, and 4) Invoice Detail of Flex Fund Billable Items; as
well as Exhibit E, “Cost Allocation Detail Tracking”, attached hereto and by this reference incorporated
herein, including the following tabs: 1) Cost Allocation Summary, 2) Combined Medi-Cal and Non-Medi-
Cal, 3) Medi-Cal, and 4) Non-Medi-Cal. If any document is missing, invoicing will be considered
incomplete. The formatting of Exhibits D and E are subject to change, as necessary.
B.At the discretion of COUNTY’s DSS and DBH Directors, or designees, if an invoice
is incorrect or is otherwise not in proper form or substance, COUNTY’s DSS and DBH Directors, or
designees, shall have the right to withhold payment as to only that portion of the invoice that is incorrect or
improper after five (5) days prior notice to CONTRACTOR. CONTRACTOR agrees to continue to provide
services for a period of ninety (90) days after notification of an incorrect or improper invoice. If after the
ninety (90) day period, the invoice(s) is still not corrected to COUNTY’s satisfaction, COUNTY’s DSS and
DBH Directors, or designees, may elect to terminate this Agreement, pursuant to the termination
provisions stated in Section 3 of this Agreement. In addition, for invoices received sixty (60) days after the
expiration of each term of this Agreement or termination of this Agreement, at the discretion of COUNTY’s
DSS and DBH Directors, or designees, COUNTY’s DSS and DBH shall have the right to deny payment of
any additional invoices received.
C.After CONTRACTOR renders services to referred clients, CONTRACTOR will
submit electronic billing for services directly into COUNTY’s electronic information system for all clients,
including contracted cost per unit and actual cost per unit, within thirty (30) calendar days from the date
services were rendered for all clients, including those eligible for Medi-Cal as well as those that are not
eligible for Medi-Cal. COUNTY’s DBH must pay CONTRACTOR before submitting claims to DHCS for
Federal and State reimbursement for Medi-Cal eligible clients. DHCS FFP reimbursement for Medi-Cal
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services is based on public expenditures certified by the CONTRACTOR. CONTRACTOR must submit a
signed certified public expenditure report with the monthly invoice. DHCS expects the claim for
reimbursement to equal the amount the COUNTY paid to CONTRACTOR for the services rendered less
any funding sources not eligible for Federal reimbursement.
D.Exhibit E, “Cost Allocation Detail Tracking”, will also serve for the COUNTY to
certify the public funds expended for purposes of claiming Federal reimbursement for the cost of Medi-Cal
services and activities. With each Cost Allocation Detail Tracking report, CONTRACTOR shall submit a
detailed general ledger (GL) itemizing costs incurred in the previous month. Failure to submit GL reports
and supporting documentation shall be deemed sufficient cause for COUNTY to withhold payments until
there is compliance, as further detailed in this Section 5.
E.CONTRACTOR must report all third party collections from other funding sources for
private insurance, client private pay, or any other third party along with each monthly invoice.
F.CONTRACTOR will remit annually within ninety (90) days from June 30, a schedule
to provide the required information on published charges (PC) for all authorized services. The PC listing
will serve as a source document to determine their usual and customary charge prevalent in the public
mental health sector that is used to bill the general public, insurers, or other Non-Medi-Cal third party
payers during the course of business operations.
G.CONTRACTOR shall submit a monthly staffing report that identifies all direct
service and support staff, applicable licensure/certifications, trainings in-progress, and full-time hours
worked to be used as a tracking tool to determine if CONTRACTOR’s program is staffed according to the
Agreement requirements.
H.CONTRACTOR must maintain such financial records for a period of seven (7)
years or until the dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be
responsible for any disallowances related to inadequate documentation.
I.CONTRACTOR shall be responsible for collecting and managing data in a manner
to be determined by DHCS and the County MHP in accordance with applicable rules and regulations. The
COUNTY electronic billing system is a critical source of information for purposes of monitoring service
volume and obtaining reimbursement. CONTRACTOR must attend COUNTY DBH’s Business Office
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training on equipment reporting for assets, intangible and sensitive minor assets, COUNTY DBH’s
electronic information system, and related cost reporting.
J.CONTRACTOR 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. The
necessary data can be provided by a variety of means, including but not limited to: 1) direct data entry into
COUNTY’s electronic information system 2) providing an electronic file compatible with COUNTY’s
electronic information system, or 3) integration between COUNTY’s electronic information system and
CONTRACTOR’s information system(s).
K.If a Medi-Cal client has dual coverage, such as Other Health Coverage (OHC), the
CONTRACTOR will be responsible for billing the carrier and obtaining a payment/denial or have validation
of claiming with no response within ninety (90) days after the claim was mailed before the services can be
entered into COUNTY’s electronic information system. CONTRACTOR must report all third party
collections or client pay, in the monthly invoice and in the Cost Report that is required to be submitted. A
copy of explanation of benefits of CWM 1500 is required as documentation.
L.Data entry shall be the responsibility of the CONTRACTOR. The data for billing
must be reconciled by the CONTRACTOR to the monthly invoice submitted for payment. COUNTY shall
monitor the volume and cost of services entered into COUNTY’s electronic information system. Any and all
audit exceptions resulting from the provision and reporting of specialty mental health services by
CONTRACTOR shall be the sole responsibility of the CONTRACTOR. CONTRACTOR will comply with all
applicable policies, procedures, directives and guidelines regarding the use of COUNTY’s electronic
information system. If CONTRACTOR elects to use their own Electronic Health Record (EHR) system, the
EHR must have CCHIT certification for Security Access Control, Audit and Authentication.
CONTRACTOR’s billers entering data in the EHR system will need to sign an Electronic Signature
Certification (ESR).
M.Medi-Cal Certification and Mental Health Plan Compliance
CONTRACTOR will establish and maintain Medi-Cal certification or become
certified within ninety (90) days of the start of this Agreement through the COUNTY and DHCS to provide
reimbursable services to Medi-Cal eligible clients. In addition, CONTRACTOR shall work with the
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COUNTY’s DBH Managed Care to execute the process, if not currently certified by COUNTY, for
credentialing of staff. Service location must be approved by the COUNTY’s DSS and DBH. During this
process the CONTRACTOR will obtain a legal entity number established by DHCS, a requirement for
maintaining organizational provider status throughout the term of this Agreement. CONTRACTOR 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. CONTRACTOR will not be reimbursed by COUNTY for any
Medi-Cal services rendered prior to certification.
CONTRACTOR shall provide Specialty Mental Health Services in accordance with
the COUNTY’s MHP. CONTRACTOR must comply with Exhibit F, “Fresno County Mental Health Plan
Compliance Program and Contractor Code of Conduct and Ethics”, attached hereto and by this reference
incorporated herein.
CONTRACTOR may provide direct Specialty Mental Health Services using
unlicensed staff as long as the individual is approved as a provider by the COUNTY’s MHP, is supervised
by licensed staff, works within his/her scope and only delivers allowable direct Specialty Mental Health
Services.
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 service(s). CONTRACTOR shall be
responsible for audit exceptions to ineligible dates of service(s) or incorrect application of utilization review
requirements.
5.INDEPENDENT CONTRACTOR
In performance of the work, duties and obligations assumed by CONTRACTOR under this
Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of the
CONTRACTOR'S officers, agents, and employees will at all times be acting and performing as an
independent contractor, and shall act in an independent capacity and not as an officer, agent, servant,
employee, joint venturer, partner, or associate of the COUNTY. Furthermore, COUNTY shall have no right
to control or supervise or direct the manner or method by which CONTRACTOR shall perform its work and
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function. However, COUNTY shall retain the right to administer this Agreement so as to verify that
CONTRACTOR is performing its obligations in accordance with the terms and conditions thereof.
CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the
rules and regulations, if any, of governmental authorities having jurisdiction over matters the subject
thereof. Because of its status as an independent contractor, CONTRACTOR shall have absolutely no right
to employment rights and benefits available to COUNTY employees. CONTRACTOR shall be solely liable
and responsible for providing to, or on behalf of, its employees all legally-required employee benefits. In
addition, CONTRACTOR shall be solely responsible and save COUNTY harmless from all matters relating
to payment of CONTRACTOR'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,
CONTRACTOR may be providing services to others unrelated to the COUNTY or to this Agreement.
6.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.
Notwithstanding the above, changes to services and responsibilities of the CONTRACTOR
and changes to staffing, as needed, to accommodate changes in the law relating to SB163 services and/or
mental health treatment, as set forth in Exhibit A, may be made with the signed written approval of
COUNTY’s DSS and DBH Directors, or designees, and CONTRACTOR through an amendment approved
by County Counsel and the COUNTY’s Auditor’s Office.
In addition, changes to line items identified in Exhibit C, as appropriate, that do not exceed
ten percent (10%) of the total maximum compensation, changes to the volume of units of services/types of
service units, and changes to the service rate to be provided, as set forth in Exhibit C, may be made with
the written approval of COUNTY’s DSS and DBH Directors, or designees, and CONTRACTOR.
Said modifications to budget line items, service volume/types of service units, and
summary of services, shall not result in any change to the maximum compensation amount payable to
CONTRACTOR, as stated herein.
CONTRACTOR hereby agrees that changes to the compensation under this Agreement
may be necessitated by a reduction in funding from State and/or Federal sources. COUNTY’s DSS and
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DBH Directors, or designees, may modify the maximum compensation depending on State and/or Federal
funding availability, as stated in Section 4 of this Agreement. CONTRACTOR further understands that this
Agreement is subject to any restrictions, limitations or enactments of all legislative bodies which affect the
provisions, term or funding of this Agreement in any manner.
7.NON-ASSIGNMENT
Neither party shall assign, transfer or sub-contract this Agreement nor their rights or duties
under this Agreement without the prior written consent of the other party.
8.HOLD HARMLESS
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY'S request,
defend the COUNTY, its officers, agents, and employees from any and all costs and expenses, damages,
liabilities, claims, and losses occurring or resulting to COUNTY in connection with the performance, or
failure to perform, by CONTRACTOR, its officers, agents, or employees under this Agreement, and from
any and all costs and expenses, 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 CONTRACTOR, its officers, agents, or employees under this Agreement. In addition, CONTRACTOR
agrees to indemnify COUNTY for Federal, State, and/or local audit exceptions resulting from
noncompliance herein on the part of the CONTRACTOR.
9.INSURANCE
Without limiting the COUNTY's right to obtain indemnification from CONTRACTOR or any
third parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect, the following
insurance policies or a program of self-insurance, including but not limited to, an insurance pooling
arrangement or Joint Powers Agreement (JPA) throughout the term of the 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 coverages including
completed operations, products liability, contractual liability, Explosion-Collapse-Underground, fire legal
liability or any other liability insurance deemed necessary because of the nature of this contract.
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B.Automobile Liability
Comprehensive Automobile Liability Insurance with limits for bodily injury of not less
than Two Hundred Fifty Thousand Dollars ($250,000.00) per person, Five Hundred Thousand Dollars
($500,000.00) per accident and for property damages of not less than Fifty Thousand Dollars
($50,000.00), or such coverage with a combined single limit of Five Hundred Thousand Dollars
($500,000.00). Coverage should include owned and non-owned vehicles used in connection with this
Agreement.
C.Professional Liability
If CONTRACTOR employs licensed professional staff, (e.g., Ph.D., R.N., L.C.S.W.,
M.F.C.C.) in providing services, Professional Liability Insurance with limits of not less than One Million
Dollars ($1,000,000.00) per occurrence, Three Million Dollars ($3,000,000.00) annual aggregate.
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
CONTRACTOR shall have either separate policies or an 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 One Million Dollars ($1,000,000) per
occurrence with a Two Million Dollar ($2,000,000) annual aggregate. Policies are to be on a per
occurrence basis.
CONTRACTOR 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 CONTRACTOR's policies herein. This insurance shall not be
cancelled or changed without a minimum of thirty (30) days advance written notice given to COUNTY.
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Within thirty (30) days from the date CONTRACTOR signs and executes this
Agreement, CONTRACTOR shall provide certificates of insurance and endorsement as stated above for
all of the foregoing policies, as required herein, to the County of Fresno, (DSS, P.O. Box 1912, Fresno,
California, 93718), stating that such insurance coverage 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 employees,
shall be excess only and not contributing with insurance provided under CONTRACTOR'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 CONTRACTOR fails to keep in effect at all times insurance coverage
as herein provided, the 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 issued by admitted insurers licensed to do business in the State
of California, and such insurance shall be purchased from companies possessing a current A.M. Best, Inc.
rating of A FSC VII or better.
10.LICENSES/CERTIFICATES
Throughout the term of this Agreement, CONTRACTOR and CONTRACTOR’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.
CONTRACTOR 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, CONTRACTOR and CONTRACTOR’s staff shall comply with all
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applicable laws, rules and regulations, as may now exist or hereafter changed.
11. RECORDS
CONTRACTOR shall maintain records in accordance with COUNTY’s Exhibit G,
“Documentation Standards for Client Records”, attached hereto and by this reference incorporated herein.
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 ten (10) years from the date of the end of the
Agreement.
12. REPORTS
A. Cost Report
CONTRACTOR agrees to submit a complete and accurate detailed Cost Report on
an annual basis for each fiscal year ending June 30th in the format prescribed by DHCS for the purposes of
Short Doyle Medi-Cal reimbursements and total costs for programs. The Cost Report will be the source
document for several phases of settlement with the DHCS for the purposes of Short Doyle Medi-Cal
reimbursement. CONTRACTOR shall report costs under their approved legal entity number established
during the Medi-Cal certification process. The information provided applies to CONTRACTOR for program
related costs for services rendered to Medi-Cal and Non-Medi-Cal eligible clients. CONTRACTOR will
remit a schedule to provide the required information on PC for all authorized services. The report will serve
as a source document to determine their usual and customary charge prevalent in the public mental health
sector that is used to bill the general public, insurers, or other Non-Medi-Cal third party payers during the
course of business operations. CONTRACTOR must report all collections for Medi-Cal services.
CONTRACTOR shall also submit with the Cost Report a copy of CONTRACTOR’s general ledger that
supports revenues and expenditures and reconciled detailed report of reported total units of services
rendered under this Agreement to the units of services reported by CONTRACTOR to COUNTY’s
electronic information system.
Cost Reports must be submitted to the COUNTY in hard copy with a signed cover
letter and electronic copy of the completed DHCS Cost Report form along with requested support
documents following each fiscal year ending June 30th. During the month of September of each year this
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Agreement is effective, COUNTY will issue instructions of the annual Cost Report which indicates the
training session, DHCS Cost Report template worksheets, and deadlines to submit, as determined by the
State annually. CONTRACTOR shall remit the hard copy of the Cost Report to County of Fresno,
Department of Behavioral Health, Attention: Cost Report Team, P.O. Box 45003, Fresno, California,
97318. CONTRACTOR shall remit electronic copies and/or any inquiries to
DBHcostreportteam@co.fresno.ca.us and carbon copy (cc) bivend@co.fresno.ca.us.
All Cost Reports must be prepared in accordance with Generally Accepted
Accounting Principles (GAAP) and Welfare and Institutions Code 5651(a)(4), 5664(a), 5705(b)(3), and
5718(c). Unallowable costs such as lobby or political donations must be deducted on the Cost Report and
invoice reimbursements.
If CONTRACTOR does not submit the Cost Report by the deadline, including any
extension period granted by the COUNTY, the COUNTY may withhold payments of pending invoicing
under compensation until the Cost Report has been submitted and clears COUNTY desk audit for
completeness.
B. Settlements with DHCS
During the term of this Agreement and thereafter, COUNTY and CONTRACTOR
agree to settle dollar amounts disallowed or settled in accordance with DHCS and COUNTY audit
settlement findings related to Medi-Cal and realignment reimbursements. CONTRACTOR will participate in
several phases of settlements between COUNTY/CONTRACTOR and DHCS. The phases are initial cost
reporting for settlement, settlement according to State reconciliation of records for paid Medi-Cal services
and audit settlement-DHCS audit: 1) Initial cost reporting – after an internal review by COUNTY, COUNTY
files Cost Report with DHCS on behalf of CONTRACTOR’s legal entity for the fiscal year; 2) Settlement –
State reconciliation of records for paid Medi-Cal Services, approximately eighteen (18) to thirty-six (36)
months following the State close of the fiscal year, DHCS will send notice for any settlement under this
provision to COUNTY; 3) Audit Settlement – DHCS audit. After final reconciliation and settlement,
COUNTY and/or DHCS may conduct a review of medical records and Cost Reports along with support
documents submitted to COUNTY in initial submission to determine accuracy and may disallow cost
and/or unit of service reported on the CONTRACTOR’s legal entity Cost Report. COUNTY may choose to
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appeal and therefore reserves the right to defer payback settlement with CONTRACTOR until resolution of
the appeal. DHCS audits will follow Federal MediCaid procedures for managing overpayments.
If at the end of the Audit Settlement process, the COUNTY determines that it
overpaid the CONTRACTOR, it will require the CONTRACTOR to repay the Medi-Cal related
overpayment back to the COUNTY. If at the end of the Audit Settlement process, the COUNTY determines
that it underpaid the CONTRACTOR, COUNTY will make a payment for the Medi-Cal related
underpayment to the CONTRACTOR based on Federal/State funds received.
Funds owed to COUNTY will be due within forty-five (45) days of notification by the
COUNTY, or COUNTY shall withhold future payments until all excess funds have been recouped by
means of an offset against any payments then or thereafter owing to CONTRACTOR under this or any
other Agreement.
C.Outcome Reports
CONTRACTOR shall submit to COUNTY’s DSS and DBH, service outcome reports
as requested, at a minimum of every six (6) months, as defined in Exhibit A. Outcome reports and
outcome requirements are subject to change at COUNTY’s DSS or DBH discretion. As of the execution of
this Agreement, COUNTY’s DSS and DBH identified outcome measurements are outlined in Exhibit H,
“Outcome Measurements”, attached hereto and by this reference incorporated herein.
D.Additional Reports
CONTRACTOR shall submit to COUNTY’s DSS and DBH by the 20th of each
month all monthly activity and budget reports (requirements are subject to change at the COUNTY’s DSS
or DBH discretion) for the preceding month. COUNTY’s DSS and DBH Exhibit I, “Monthly Activity Report”,
is attached hereto and by this reference incorporated herein.
In addition, CONTRACTOR shall also furnish to COUNTY such statements,
records, reports, data, and other information as COUNTY may request pertaining to matters covered by
this Agreement. In the event that CONTRACTOR 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, CONTRACTOR 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
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this Agreement.
13.MONITORING
CONTRACTOR agrees to extend to COUNTY’s staff, COUNTY’s DSS and DBH Directors,
or their designees, the California Department of Social Services (CDSS), and DHCS the right to review
and monitor records, programs and/or procedures, at any time, in regard to clients, as well as the overall
operation of CONTRACTOR’s program, in order to ensure compliance with the terms and conditions of
this Agreement.
14.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.
15.COMPLIANCE WITH STATE REQUIREMENTS
CONTRACTOR recognizes that COUNTY operates its mental health programs under an
agreement with the DHCS, and that under said agreement the State imposes certain requirements on
COUNTY and its subcontractors. CONTRACTOR shall adhere and be responsible for compliance as of
the effective date of each Federal, State, or local law or regulation specified, including those identified in
Exhibit J, “State Mental Health Requirements”, attached hereto and by this reference incorporated herein.
16.COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
CONTRACTOR shall be required to maintain organizational provider certification by the
County of Fresno. CONTRACTOR must meet Medi-Cal organizational provider standards as listed in
Exhibit K, “Medi-Cal Organizational Provider Standards”, attached hereto and by this reference
incorporated herein. It is acknowledged that all references to Organizational Provider and/or Provider in
Exhibit K shall refer to CONTRACTOR. In addition, CONTRACTOR shall inform every client of their rights
under the COUNTY’s MHP as set forth in Exhibit L, “Fresno County Mental Health Plan Grievances”,
attached hereto and by this reference incorporated herein. CONTRACTOR shall also file an “Incident
Report” for all incidents involving clients, following the protocol and using the worksheet identified in Exhibit
M, “Fresno County Mental Health Plan Incident Report”, attached hereto and by this reference
incorporated herein, or a protocol and worksheet presented by CONTRACTOR that is accepted by
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COUNTY’s DBH and DSS Director, or designees.
17.CONFIDENTIALITY
All services performed by CONTRACTOR under this Agreement shall be in strict
conformance with all applicable Federal, State of California and/or local laws and regulations relating to
confidentiality.
18.HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and CONTRACTOR 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 CONTRACTOR acknowledge that the exchange of PHI between them is
only for treatment, payment, and health care operations.
COUNTY and CONTRACTOR 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
CONTRACTOR 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.
19.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
CONTRACTOR by the COUNTY, including but not limited to the following:
A.CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
CONTRACTOR may not connect to COUNTY networks via personally-owned
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mobile, wireless or handheld devices, unless the following conditions are met:
1.CONTRACTOR 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.CONTRACTOR-Owned Computers or Computer Peripherals
CONTRACTOR may not bring CONTRACTOR-owned computers or computer
peripherals into the COUNTY for use without prior authorization from the COUNTY's Chief Information
Officer, or designee, 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 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
CONTRACTOR, including its subcontractors and employees, may not use
COUNTY computers of computer peripherals on non-COUNTY premises without prior authorization from
the COUNTY's Chief Information Officer, or designee.
D.CONTRACTOR may not store COUNTY's private, confidential or sensitive data on
any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
E.CONTRACTOR 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.CONTRACTOR is responsible to immediately notify COUNTY of any violations,
breaches or potential breaches of security related to COUNTY's confidential information, data maintained
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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 CONTRACTOR's responses to all incidents
arising from a possible breach of security related to COUNTY's confidential client information provided to
CONTRACTOR. CONTRACTOR will be responsible to issue any notification to affected individuals as
required by law or as deemed necessary by COUNTY in its sole discretion. CONTRACTOR will be
responsible for all costs incurred as a result of providing the required notification.
20.PROPERTY OF COUNTY
A.COUNTY and CONTRACTOR recognize that fixed assets are tangible and
intangible property obtained or controlled under COUNTY's MHP for use in operational capacity and will
benefit COUNTY for a period more than one (1) year. Depreciation of the qualified items will be on a
straight-line basis.
For COUNTY purposes, fixed assets must fulfill three (3) qualifications:
A.Asset must have life span of over one (1) year;
B.The asset is not a repair part;
C.The asset must be valued at or greater than the capitalization
thresholds for the asset type:
Asset Type Threshold
•Land $0
•Buildings and improvements $100,000
•Infrastructure $100,000
•Be tangible $5,000
o Equipment
o Vehicles
•Or intangible asset $100,000
o Internally generated software
o Purchased software
o Easements
o Patents
• And capital lease $5,000
Qualified fixed asset equipment is to be reported and approved by COUNTY. If it is
approved and identified as an asset it will be tagged with a COUNTY program number. A Fixed Asset Log
will be maintained by COUNTY’s Asset Management System and annually inventoried until the asset is
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fully depreciated. During the term of this Agreement, CONTRACTOR’s fixed assets may be inventoried in
comparison to COUNTY’s DSS and/or DBH Asset Inventory System.
B.Certain purchases less than Five Thousand and No/100 Dollars ($5,000) but more
than One Thousand and No/100 Dollars ($1,000), with over one (1) year life span, and are mobile and high
risk of theft or loss are sensitive assets. Such sensitive items are not limited to computers, copiers,
televisions, cameras and other sensitive items as determined by COUNTY's DSS and DBH Directors, or
designees. CONTRACTOR maintains a tracking system on the items and are not required to be
capitalized or depreciated. The items are subject to annual inventory for compliance.
C.Assets shall be retained by COUNTY, as COUNTY property, in the event this
Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate in an
annual inventory of all COUNTY fixed and inventoried assets. Upon termination or expiration of this
Agreement CONTRACTOR shall be physically present when fixed and inventoried assets are returned to
COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all COUNTY-owned
undepreciated fixed and inventoried assets, or the monetary value of said assets if unable to produce the
assets at the expiration or termination of this Agreement.
CONTRACTOR further agrees to the following:
l.To maintain all items of equipment in good working order and
condition, normal wear and tear is expected;
2.To label all items of equipment with COUNTY assigned program
number, to perform periodic inventories as required by COUNTY and to maintain an inventory list showing
where and how the equipment is being used, in accordance with procedures developed by COUNTY. All
such lists shall be submitted to COUNTY within ten (10) days of any request therefore; and
3.To report in writing to COUNTY immediately after discovery, the loss
or theft of any items of equipment. For stolen items, the local law enforcement agency must be contacted
and a copy of the police report submitted to COUNTY.
D.The purchase of any equipment by CONTRACTOR with funds provided hereunder
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shall require the prior written approval of COUNTY's DSS and/or DBH, shall fulfill the provisions of this
Agreement as appropriate, and must be directly related to CONTRACTOR's services or activity under the
terms of this Agreement. COUNTY's DSS and/or DBH may refuse reimbursement for any costs resulting
from equipment purchased, which are incurred by CONTRACTOR, if prior written approval has not been
obtained from COUNTY.
E.CONTRACTOR must obtain prior written approval from COUNTY's DBH whenever
there is any modification or change in the use of any property acquired or improved, in whole or in part,
using funds under this agreement. If any real or personal property acquired or improved with said funds
identified herein is sold and/or is utilized by CONTRACTOR for a use which does not qualify under this
program, CONTRACTOR shall reimburse COUNTY in an amount equal to the current fair market value of
the property, less any portion thereof attributable to expenditures of non-program funds. These
requirements shall continue in effect for the life of the property. In the event the program is closed out, the
requirements for this Section 21 shall remain in effect for activities or property funded with said funds,
unless action is taken by the State government to relieve COUNTY of these obligations.
21.NON-DISCRIMINATION
During the performance of this Agreement, CONTRACTOR and its subcontractors shall not
deny the contract’s benefits to any person 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
unlawfully discriminate 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, sexual orientation, or military
and veteran status.
CONTRACTOR shall insure that the evaluation and treatment of employees and applicants
for employment are free of such discrimination. CONTRACTOR 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,
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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. CONTRACTOR 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.)
CONTRACTOR shall include the Non-Discrimination and compliance provisions of this clause in all
subcontracts to perform work under the Agreement
22. CONFLICT OF INTEREST
No officer, agent, or employee of COUNTY who exercises any function or responsibility for
planning and carrying out the services provided under this Agreement shall have any direct or indirect
personal financial interest in this Agreement. No officer, agent, or employee of COUNTY who exercises
any function or responsibility for planning and carrying out the services provided under this Agreement
shall have any direct or indirect personal financial interest in this Agreement. In addition, no employee of
COUNTY shall be employed by CONTRACTOR to fulfill any contractual obligations with COUNTY.
CONTRACTOR shall also comply with all Federal, State of California, and local conflict of interest laws,
statutes, and regulations, which shall be applicable to all parties and beneficiaries under this Agreement
and any officer, agent, or employee of COUNTY.
23. CHARITABLE CHOICE
CONTRACTOR may not discriminate in its program delivery against a client or potential
client on the basis of religion or religious belief, a refusal to hold a religious belief, or a refusal to actively
participate in a religious practice. Any specifically religious activity or service made available to individuals
by CONTRACTOR must be voluntary as well as separate in time and location from COUNTY-funded
activities and services. CONTRACTOR shall inform COUNTY as to whether it is faith-based. If
CONTRACTOR identifies as faith-based it must submit to COUNTY's DSS and DBH a copy of its policy on
referring individuals to an alternate treatment provider, and include a copy of this policy in its client
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admission forms. The policy must inform individuals that they may be referred to an alternative provider if
they object to the religious nature of the program, and include a notice to COUNTY's DSS and DBH.
Adherence to this will be monitored during annual site reviews, and a review of client files. If
CONTRACTOR identifies as faith-based, by July 1st of each year CONTRACTOR will be required to
report to COUNTY's DSS and DBH the number of individual who requested referrals to alternate providers
based on religious objection.
24. CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, CONTRACTOR shall comply with:
A. Title 6 of the Civil Rights Act of 1964 (42 USC Section 2000d, and 45 CFR 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 CONTRACTOR's procedures must include ensuring compliance of any
sub-contracted providers with these requirements.
C. CONTRACTOR shall not use minors as interpreters.
D. CONTRACTOR shall provide and pay for interpreting and translation services to
persons participating in CONTRACTOR'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 CONTRACTOR. Interpreter and translation services, including translation of CONTRACTOR's "vital
documents" (those documents that contain information that is critical for accessing CONTRACTOR's
services or are required by law) shall be provided to participants at no cost to the participant.
CONTRACTOR shall ensure that any employees, agents, subcontractors, or partners who interpret or
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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 CONTRACTOR's services.
E.In compliance with the State mandated Culturally and Linguistically Appropriate
Services standards as published by the Office of Minority Health, CONTRACTOR must submit to
COUNTY for approval, within sixty (60) days from date of contract execution, CONTRACTOR's plan to
address all fifteen national cultural competency standards as set forth in the "National Standards on
Culturally and Linguistically Appropriate Services (CLAS)"
http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf. COUNTY's annual on-site review of
CONTRACTOR shall include collection of documentation to ensure all national standards are
implemented. As the national competency standards are updated, CONTRACTOR's plan must be updated
accordingly. Cultural competency training for CONTRACTOR 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. CONTRACTOR
on a monthly basis shall provide COUNTY DBH a monthly monitoring tool/report that shows all
CONTRACTOR staff cultural competency trainings completed.
25.AMERICANS WITH DISABILITIES ACT
CONTRACTOR 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 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 disallowances of reimbursement under Section
1861(v)(l)(I) of the Social Security Act, (42 USC§ 1395x, subd. (v)(l)[I]), until the expiration of four (4) years
after the furnishing of services under this Agreement, CONTRACTOR shall make available, upon written
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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 CONTRACTOR under this
Agreement. CONTRACTOR further agrees that in the event CONTRACTOR 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) 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 CONTRACTOR expends Five Hundred Thousand and No/100 Dollars ($500,000)
or more in Federal and Federal flow-through monies, CONTRACTOR agrees to conduct an annual audit in
accordance with the requirements of the Single Audit requirements as set forth in the Office of
Management and Budget (OMB) 2 CFR 200. CONTRACTOR 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 were negative findings, CONTRACTOR must include a corrective action plan signed by
an authorized individual. CONTRACTOR 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 DSS and/or 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 CONTRACTOR. All audit costs related to this Agreement are the sole
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responsibility of CONTRACTOR.
B.A single audit report is not applicable if CONTRACTOR's Federal contracts do not
exceed the Five Hundred Thousand and No/l00 Dollars ($500,000) requirement or CONTRACTOR's only
funding is through drug-related Medi-Cal. If a single audit is not applicable, a program audit must be
performed and a program audit report with management letter shall be submitted by CONTRACTOR to
COUNTY as a minimum requirement to attest to CONTRACTOR's solvency. Said audit report shall be
delivered to COUNTY's DSS and/or DBH for review, no later than nine (9) months after the close of the
fiscal year in which the funds supplied through this Agreement are expended. Failure to comply with this
Act may result in COUNTY performing the necessary audit tasks or contracting with a qualified accountant
to perform said audit. All audit costs related to this Agreement are the sole responsibility of
CONTRACTOR who agrees to take corrective action to eliminate any material noncompliance or
weakness found as a result of such audit. Audit work performed by COUNTY under this Section 27 shall
be billed to the CONTRACTOR at COUNTY's cost, as determined by COUNTY's Auditor-
Controller/Treasurer-Tax Collector.
C.CONTRACTOR 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.COMPLIANCE
CONTRACTOR shall comply with COUNTY's "Fresno County Mental Health Compliance -
Contractor Code of Conduct and Ethics", attached as Exhibit F. Within thirty (30) days of entering into the
Agreement with the COUNTY, CONTRACTOR shall have all of its employees, agents and subcontractors
providing services under this Agreement certify in writing, that he or she has received, read, understood,
and shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR shall additionally ensure
that within thirty (30) days of hire, all new employees, agents and subcontractors providing services under
this Agreement certify in writing that he or she has received, read, understood, and shall abide by the
Contractor Code of Conduct and Ethics. CONTRACTOR understands that the promotion of and
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adherence to the Code of Conduct and Ethics is an element in evaluating the performance of
CONTRACTOR 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, Fresno, CA 93703. CONTRACTOR agrees to reimburse
COUNTY for the entire cost of any penalty imposed upon COUNTY by the Federal Government as a result
of CONTRACTOR's violation of the terms of this Agreement.
29.ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that neither it nor any of its officers
are currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal Health
Care Programs: that it has not been convicted of a criminal offense related to the provision of health care
items or services; nor has it 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
this Agreement, that CONTRACTOR is ineligible on these grounds, COUNTY will remove CONTRACTOR
from responsibility for, or involvement with, COUNTY' s business operations related to the Federal Health
Care Programs and shall remove such CONTRACTOR from any position in which CONTRACTOR's
compensation, or the items or services rendered, ordered or prescribed by CONTRACTOR may be paid in
whole or part, directly or indirectly, by Federal Health Care Programs or otherwise with Federal Funds at
least until such time as CONTRACTOR is reinstated into participation in the Federal Health Care
Programs.
A.If COUNTY has notice that CONTRACTOR has been charged with a criminal
offense related to any Federal Health Care Program, or is proposed for exclusion during the term of this
Agreement, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the accuracy of any
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claims submitted to any Federal Health Care Program. At its discretion given such circumstances,
COUNTY may request that CONTRACTOR cease providing services until resolution of the charges or the
proposed exclusion.
B.CONTRACTOR agrees that all potential new employees of CONTRACTOR or
subcontractors of CONTRACTOR 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
CONTRACTOR 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 CONTRACTOR hires
or engages such potential employee or subcontractor, CONTRACTOR 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
CONTRACTOR 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.
C.CONTRACTOR 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 CONTRACTOR that he or she is
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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,
CONTRACTOR will ensure that said employee or subcontractor does no work, either direct or indirect,
relating to services provided to COUNTY.
1.CONTRACTOR agrees to notify COUNTY immediately during the term of
this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each case, is
providing professional services under 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
CONTRACTOR 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.CONTRACTOR agrees to cooperate fully with any reasonable requests for
information from COUNTY which may be necessary to complete any internal or external audits relating to
CONTRACTOR's compliance with the provisions of this Section 29.
E.CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty
imposed upon COUNTY by the Federal Government as a result of CONTRACTOR's violation of
CONTRACTOR's obligations as described in this Section 29.
30.AUDITS AND INSPECTIONS
The CONTRACTOR 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. The CONTRACTOR shall, upon request by the
COUNTY, permit the COUNTY to audit and inspect all of such records and data necessary to ensure
CONTRACTOR'S compliance with the terms of this Agreement.
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000), CONTRACTOR
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shall be subject to the examination and audit of the Auditor General for a period of three (3) years after
final payment under contract (Government Code Section 8546.7).
31.PROHIBITION ON PUBLICITY
None of the funds, materials, property or services provided directly or indirectly under this
Agreement shall be used for CONTRACTOR'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 l 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
DSS and DBH Directors, or designees, and at a cost to be provided identified in Exhibit C for such items
as written/printed materials, the use of media (i.e., radio, television, newspapers) and any other related
expense(s).
32.COMPLAINTS
CONTRACTOR shall log complaints and the disposition of all complaints from a client or
client's family. CONTRACTOR 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. In addition to the detailed complaint log, CONTRACTOR
shall provide details and attach documentation of each complaint with the log. CONTRACTOR shall post
signs informing consumer of their right to file a complaint or grievance. CONTRACTOR shall notify
COUNTY of all incidents reportable to state licensing bodies that affect COUNTY consumers within
twenty-four (24) hours of receipt of a complaint.
Within ten (10) days after each incident or complaint affecting COUNTY-sponsored clients,
CONTRACTOR shall provide COUNTY with information relevant to the complaint, investigative details of
the complaint, the complaint and CONTRACTOR's disposition of, or corrective action taken to resolve the
complaint.
33.NOTICES
The persons and their addresses having authority to give and receive notices under this
Agreement include the following:
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COUNTY CONTRACTOR
COUNTY OF FRESNO Chief Executive Officer Director, Department of Social Services Central Star Behavioral Health, Inc. P.O. Box 1912 1501 Hughes Way, Suite 150 Fresno, CA 93718 Long Beach, CA 90810
All notices between the COUNTY and CONTRACTOR provided for or permitted under this
Agreement must be in writing and delivered either by personal service, by first-class United States mail, by
an overnight commercial courier service, or by telephonic facsimile transmission. A notice delivered by
personal service is effective upon service to the recipient. A notice delivered by first-class United States
mail is effective three (3) COUNTY business days after deposit in the United States mail, postage prepaid,
addressed to the recipient. A notice delivered by an overnight commercial courier service is effective one
(1)COUNTY business day after deposit with the overnight commercial courier service, delivery fees
prepaid, with delivery instructions given for next day delivery, addressed to the recipient. A notice
delivered by telephonic facsimile is effective when transmission to the recipient is completed (but, if such
transmission is completed outside of COUNTY business hours, then such delivery shall be deemed to be
effective at the next beginning of a COUNTY business day), provided that the sender maintains a machine
record of the completed transmission. For all claims arising out of or related to this Agreement, nothing in
this section establishes, waives, or modifies any claims presentation requirements or procedures provided
by law, including but not limited to the Government Claims Act (Division 3.6 of Title 1 of the Government
Code, beginning with section 810).
34.DISCLOSURE – CRIMINAL HISTORY & CIVIL ACTIONS
CONTRACTOR 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
“CONTRACTOR”):
A.Within the three (3) year period preceding this Agreement award, they have been
convicted of, or had a civil judgement rendered against them for:
A.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;
B.Violation of a Federal or State antitrust statute;
C.Embezzlement, theft, forgery, falsification, or destruction of records; or
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D.False statements or receipt of stolen property.
B.Within the three (3) year period preceding the 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 CONTRACTOR
from further business consideration. The information will be considered as part of the determination of
whether to continue and/or renew this Agreement and any additional information or explanation that a
CONTRACTOR elects to submit with the disclosed information will be considered. If it is later determined
that the CONTRACTOR failed to disclose required information, any Agreement awarded to such
CONTRACTOR may be immediately voided and terminated for material failure to comply with the terms
and conditions of the award.
CONTRACTOR must sign Exhibit N, "Certification Regarding Debarment,
Suspension, and Other Responsibility Matters- Primary Covered Transactions," attached hereto and by
this reference incorporated herein. Additionally, CONTRACTOR must immediately advise the COUNTY in
writing if, during the term of the Agreement: (1) CONTRACTOR 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 CONTRACTOR. CONTRACTOR 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.
35.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR is operating as a corporation (a
for-profit or non-profit corporation) or if during the term of the agreement, the CONTRACTOR changes
its status to operate as a corporation.
Members of the CONTRACTOR’s Board of Directors shall disclose any self-dealing
transactions that they are a party to while CONTRACTOR is providing goods or performing services
under this agreement. A self-dealing transaction shall mean a transaction to which the CONTRACTOR
is a party and in which one or more of its directors has a material financial interest. Members of the
Board of Directors shall disclose any self-dealing transactions that they are a party to by completing
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and signing a Self-Dealing Transaction Disclosure Form, attached hereto as Exhibit O and incorporated
herein by reference, and submitting it to the COUNTY prior to commencing with the self-dealing
transaction or immediately thereafter.
36.DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
This provision is only applicable if CONTRACTOR 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.l06(a)(1)(2), the
following information must be disclosed by CONTRACTOR by completing Exhibit P, "Disclosure of
Ownership and Control Interest Statement", attached hereto and by this reference incorporated herein.
CONTRACTOR shall submit this form to the COUNTY's DBH within thirty (30) days of the effective date of
this Agreement. Additionally, CONTRACTOR shall report any changes to this information within thirty-five
(35)days of occurrence by completing Exhibit P. CONTRACTOR is required to submit a set of fingerprints
for any person with a 5 percent or greater direct or indirect ownership interest in CONTRACTOR.
COUNTY may terminate this Agreement where any person with a 5 percent or greater direct or indirect
ownership interest in the CONTRACTOR and did not submit timely and 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 CONTRACTOR has been convicted of a
criminal offense related to that person’s involvement with the Medi-care, Medicaid, or title XXI program in
the last ten (10) years.
37.GOVERNING LAW
Venue for any action arising out of or related to this Agreement shall only be in 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.
38.ENTIRE AGREEMENT
This Agreement constitutes the entire agreement between the CONTRACTOR and
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COUNTY with respect to the subject matter hereof and supersedes all previous Agreement negotiations,
proposals, commitments, writings, advertisements, publications, and understanding of any nature
whatsoever unless expressly included in this Agreement.
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1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year
2 first hereinabove written.
3
4 CONTRACTOR
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Centra ,Star .. Behavioral Health
Kent Dunlap
Print Name
President and Chief Executive Officer
Title
Iara Morgan
15 Print Name
16
Secretary
17 Title (Secretary of Corporation, or
Chief Financial Officerrrreasurer, or
18 any Assistant Secretary or Treasurer)
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Mailing Address
22 1501 Hughes Way, Suite 150
LonA Beach, CA 90810
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25 FOR ACCOUNTING USE ONLY:
26 Fund/Subclass: 0001/10000
ORG No.: 56107870
27 Account No.: 7223
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COUNTY OF FRESNO
ATTEST:
irperson of the Board of
__,....,..,. .... County of Fresno
rb~ ~ ~e,.a; l• • • "-
Bernice E. Sei~' J
Clerk of the Board of Supervisors
County of Fresno, State of California
Exhibit A
Page 1 of 6
SUMMARY OF SERVICES
ORGANIZATION: Central Star Behavioral Health, Inc.
PROJECT TITLE: TEAMMATES
ADDRESS: 1501 Hughes Way, Suite 150, Long Beach, CA 90810
SERVICES: Senate Bill 163 Wraparound Services
TELEPHONE: (310)221-6336
CONTACT: Kent Dunlap, President & CEO
EMAIL: kdunlap@starsinc.com
CONTRACT PERIOD: June 1, 2018 – June 30, 2023
AMOUNT: $4,500,000 (June 1, 2018 – June 30, 2019)
$4,500,000 (July 1, 2019 – June 30, 2020)
$4,500,000 (July 1, 2020 – June 30, 2021)
$4,500,000 (July 1, 2021 – June 30, 2022)
$4,500,000 (July 1, 2022 – June 30, 2023)
Central Star Behavioral Health, Inc., (CONTRACTOR) shall provide Specialty Mental Health
Services and Wraparound Services to no more than 150 children at any given time. Services
shall emphasize the strengths of the child and family. Services shall be highly coordinated,
individualized, unconditional, and assist children and families in addressing identified needs as
indicated in their Plan of Care (POC). Services may include, but are not limited to: mental health
services, Intensive Care Coordination (ICC), Intensive Home-Based Services (IHBS), case
management, crisis intervention, and mental health assessments, when applicable.
CONTRACTOR recognizes that the COUNTY operates its mental health programs under an
agreement with the State Department of Health Care Services (DHCS), and that under said
agreement the State imposes certain requirements on COUNTY and its subcontractors. As a
subcontractor of COUNTY, CONTRACTOR agrees to provide Specialty Mental Health Services
in compliance with COUNTY’s Agreement with DHCS.
CONTRACTOR shall adhere to, and be responsible for compliance with, all applicable Federal,
State and local laws and regulations. In the event any law, regulation or policy referred to in the
Agreement, RFP or this Exhibit A, is amended during the term of this Agreement, the parties
agree to comply with the amended provision as of the effective date of such amendment.
Exhibit A
Page 2 of 6
SCHEDULE OF SERVICES
CONTRACTOR’s office(s) shall be open Monday through Friday, 8:00 a.m. to 7:00 p.m.,
Saturday 10:00am to 6:00pm, with Sunday and later evening availability as needed. The
majority of services will be provided in the community and shall be scheduled on days and times
that are convenient for the families, including evenings and weekends. Youth/families also have
access to on-call crisis support twenty-four (24) hours/day, seven (7) days/week. The on-call
worker, in consultation with a supervisor, will determine the level of support needed to address
the crisis, which ranges from telephone support and coaching to an immediate in person
response by staff.
TARGET POPULATION
Children considered eligible for Wraparound will meet the following criteria:
1.Must be California Welfare and Institutions Code (WIC) 300, 601, 602, and/or Adoption
Assistance Program (AAP) eligible; and
2.Currently placed, or at risk of being placed in a group home licensed at a Rate
Classification Level (RCL) of 10-14 or a licensed STRTP; and
3.Must be receiving services through Fresno County or be eligible to receive services in
Fresno County through presumptive transfer in accordance with Assembly Bill No.1299;
and
4.There must be a family member/relative, legal guardian or potential provider(s) who is
open to strength-based, family-centered planning.
CONTRACTOR RESPONSIBILITIES
CONTRACTOR shall perform all services and fulfill all requirements identified in COUNTY's
Revised RFP. The following are highlights and/or further defined/updated responsibilities.
CONTRACTOR SHALL:
1.Work collaboratively in an integrated service delivery model within the community, region
and state to obtain the outcomes, goals and strategies of the Integrated Core Practice
Model and SB163 Service Models.
2.Comply with applicable Federal and State of California laws and regulations, including
but not limited to the Health Insurance Portability and Accountability Act (HIPAA), 45
CFR parts 160, 162 and 164, the Health Information Technology for Economic and
Clinical Health (HITECH) Act regarding the confidentiality and security of patient
information; and the Genetic Information Nondiscrimination Act (GINA) of 2008
regarding the confidentiality of genetic information.
3.Maintain responsibility to provide and appropriately bill for Katie A. Subclass members or
any child/youth receiving mental health services, if medically necessary and provided
within the Core Practice Model and in accordance with the “Medi-Cal Manual for
Intensive Care Coordination (ICC), Intensive Home Based Services (IHBS), and
Therapeutic Foster Care (TFC) Services for Medi-Cal Beneficiaries”, incorporated herein
by reference.
Exhibit A
Page 3 of 6
4.Address demographic make-up and population trends of the target population to identify
their cultural and linguistic needs in designing and planning for appropriate services.
5.Recruit qualified subcontractors, as needed, to provide authorized Wraparound services.
6.Work cooperatively and collaboratively with Child Welfare Service (CWS) staff, Child
Welfare Mental Health Program staff and all treatment providers, caregivers, Foster
Family Agencies (FFA) to achieve the individual and collective treatment goals and
support the CWS case plan, communicate/resolve barriers to care, provide continuity
and warm-handoffs whenever possible when clients transition from higher-to-lower or
lower-to-higher levels of care whether within or outside of Fresno County.
7.Ensure clinical supervision of registered/waivered mental health clinicians, including co-
signing or reviewing documentation and claiming in Electronic Health Records as
required by the Board of Behavioral Sciences (BBS) or COUNTY requirements. All
supervision shall be provided by licensed Clinical Supervisors. The Clinical Supervisor(s)
shall be two (2) years post-licensure and have completed the required training in
accordance with the BBS.
8.Arrange for and complete a mental health assessment, if needed, including clinical
analysis of the history and current status of a beneficiary's mental, emotional, or
behavioral disorder; relevant cultural issues and history; diagnosis; and use of testing
procedures within sixty (60) days of referral.
9.Ensure community-based intervention, including the delivery of highly coordinated and
individualized services to address the needs of the child and his/her family. Teams
developed to serve youth under this model shall maintain a maximum capacity of 25
children per team.
10.Ensure employees attend Cultural Competency, Compliance, and Billing and
Documentation trainings provided by the COUNTY upon hire and annually thereafter or
as needed.
11.Assist with training COUNTY staff and the community in SB163 Wraparound Service
processes and service options.
12.Develop training curriculum as COUNTY identifies a need.
13. Meet and maintain all requirements to become a Short-Doyle Medi-Cal organizational
provider for Specialty Mental Health Services in the Fresno County Mental Health Plan
(MHP).
14.Maintain ongoing responsibility for data and reporting, including the following:
a.Send applicable information and reports to the following distribution list for COUNTY
staff: DSS Financial Analyst, DSS Contract Analyst, DSS Program Manager, DSS
Social Work Supervisor and DBH Contract Analyst (actual names and email
addresses to be provided at a later date).
Exhibit A
Page 4 of 6
b.Possess the administrative and fiscal capability to provide and manage the proposed
services and ensure a cost-effective service delivery and operational structure with
an audit trail that adheres to Generally Accepted Accounting Principles.
c.Report on performance measures (utilizing the Monthly Activity Report, identified in
Exhibit I), outcomes, units of service for Medi-Cal and Non Medi-Cal billable
services, cost allocation reports, or other reports as established by COUNTY. This
Agreement will be closely monitored for performance and CONTRACTOR will be
required to report monthly outcomes and expenses.
d.All reports will be due to the County by the 20th of each month, and will be reviewed
for accuracy. (If the 20th lands on a weekend or Holiday, reports will be due the next
business day). Reimbursement for monthly expenses may be delayed in the event
inaccurate reports are submitted.
e.Provide COUNTY with Outcome Reports every six (6) months. Outcome Report
formats will be established through COUNTY/CONTRACTOR collaboration.
Outcome Report measures may change, based on information or measures needed.
Current outcome measures are listed as follows:
1)Cost Effectiveness
2)Family Functioning
3)Prevention of Placement in More Restrictive Environments
4)Improvement of Emotional and Behavioral Adjustment
5)School Attendance
6)Academic Performance
7)Parent or Caregiver Satisfaction
8)Improvement in Family Involvement, Family & Child Goal Attainment
f.Provide COUNTY with various reports throughout the length of the child's enrollment
in the program; a few of which are standardized and included herein; Exhibit Q
"Monthly Progress Report", Exhibit R "Discharge Presentation", Exhibit S "Individual
Child and Family Plan Presentation Outline", and Exhibit T "Individual Child and
Family Plan (ICFP)"
g.Maintain electronic health records and supply their own personal computers, Internet
access, printers, signature pads and other network devices to meet statistical
reporting requirements, report client and program outcomes and any State or County
data requirements of the Katie A. Implementation Plan. CONTRACTOR shall also
maintain capability to enter electronic billing data into COUNTY's Avatar system. A
computer with Internet access is required for office and field-based staff.
15.Cooperate and participate with the COUNTY MHP in Quality Assurance/Improvement
and Utilization Review Programs and grievance procedures, and comply with all final
determinations rendered by COUNTY's Quality Assurance/Improvement and Utilization
Review Programs, unless the decision is reversed on appeal as set forth in the COUNTY
MHP Provider Manual, incorporated herein by this reference. COUNTY's adverse
decisions regarding CONTRACTOR’s services to clients may result in the disallowance
of payment for services rendered; or may result in additional controls to the delivery of
services; or may result in the termination of this Agreement. COUNTY shall have sole
discretion in the determination of Quality Assurance/Improvement and Utilization Review
outcomes, decisions and actions.
Exhibit A
Page 5 of 6
16.Establish criteria and protocols to insure referral to services are therapeutically
appropriate, benefits the client and caregiver, achieves the client's treatment goals and
supports the success of the CWS case plan and avoids any potential for perceived or
actual conflict of interest or self-referral.
17.Maintain responsibility for any court reports and/or necessary testimony:
a.Court Reports - Documented reports of assessment and evaluation findings,
progress in treatment, recommendations for treatment and service plans regarding
reunification, maintenance and termination of parental rights, and justification for
recommendations.
b.Court Testimony - On-site court testimony of assessment and evaluation findings,
treatment and service plan recommendations regarding reunification, maintenance
and termination of parental rights, and justification for recommendations.
18.Obtain signatures, as required, regarding consent:
a.Care provider can sign for day trips and other minor miscellaneous items.
b.Court Order should suffice for most other items.
19.Upon notification of a pending court hearing, CONTRACTOR agrees to complete and
submit to the COUNTY a "Periodic Review Report" twenty-one (21) calendar days prior
to the court date or seven (7) calendar days after notification.
COUNTY RESPONSIBILITIES:
1.Designate a contact person for CONTRACTOR to communicate with, when necessary.
2.Meet with CONTRACTOR monthly, or as often as needed, to exchange pertinent
information, resolve problems, and work collaboratively to coordinate services.
3.Include necessary items in initial referral packets, as agreed upon by both
CONTRACTOR and COUNTY. Referral Packets shall include the following:
a.A completed referral
b.Placement History
c.Current court orders - detention minute order (CHDP Medical/Dental)
d.Health and Education Passport (HEP)
e.Mental Health Assessment (including most recent, if available)
f.Team Decision Meeting (TDM)/Staffing notes (if available)
g. Individualized Education Program (IEP) (if available/applicable)
h.JV220 (if applicable)
i.FFA/Group Home Quarterly Report
4.Facilitate Intensive Care Coordination (ICC) meetings initially, and no less than every
ninety (90) days thereafter, for a child/youth identified as requiring ICC services.
5.Organize teaming meetings in alignment with the Core Practice Model and SB 163 for
which CONTRACTOR will be required to participate, when appropriate.
Exhibit A
Page 6 of 6
6.Provide education and training on CWS, practice models and Medi-Cal licensing,
documentation and billing requirements, as needed.
7.Expedite court processes required to change placements.
8.Screen children and their families for enrollment in Wraparound program. Ongoing
monitoring and compliance with State and County regulations related to the JV220
process or other court requirements and coordinating client care with the therapist and
treatment team.
9.Act as liaison between staff and/or representatives of the California Department of Social
Services (CDSS) and CONTRACTOR.
10.Manage the Wraparound Program trust funds.
11.Monitor this Agreement for achievement of agreed upon outcomes and for compliance
with the specified terms and conditions herein.
12.Through the MHP 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 MHP Covered Services, or to terminate this
Agreement. In the interest of program integrity and/or the welfare of clients, COUNTY
may introduce additional utilization controls as may be necessary at any time and
without advance notice to CONTRACTOR. In the event of such change, COUNTY shall
notify CONTRACTOR in writing, and the change shall take effect upon the tenth (10th)
calendar day following the deposit of said notice, by COUNTY, into the United States
mail, postage prepaid, to the address set forth in Section 33 of this Agreement.
13.Notify the CONTRACTOR when court hearings are scheduled.
PERFORMANCE MEASURES:
Under the Katie A. Settlement Agreement and Implementation Plan, the DHCS and CDSS are
working to adopt statewide use of a data-informed system of performance oversight,
accountability, and communication that efficiently monitors, measures, and evaluates access,
quality, satisfaction, effectiveness, costs, and outcomes at the individual, program, and system
levels.
Performance measurements developed by COUNTY will reflect the information required by
DHCS and CDSS. Outcome indicators for this Agreement will continue to be developed in
conjunction with CONTRACTOR and State departments. County may adjust the performance
and outcome measures periodically throughout the duration of the Agreement, as needed, to
best measure the program as determined by COUNTY. The Contractor must utilize a
computerized tracking system with which performance and outcome measures and other
relevant data, such as demographics, will be maintained. At a minimum, CONTRACTOR must
track information and data for the outcome measurements identified in Exhibit H.
Exhibit B
1
rev 01-02-2018
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
DBH VISION:
Health and well-being for our community.
DBH MISSION:
The Department of Behavioral Health is dedicated to supporting the wellness of
individuals, families and communities in Fresno County who are affected by, or are at risk
of, mental illness and/or substance use disorders through cultivation of strengths toward
promoting recovery in the least restrictive environment.
DBH GOALS:
Quadruple Aim
•Deliver quality care
•Maximize resources while focusing on efficiency
•Provide an excellent care experience
•Promote workforce well-being
GUIDING PRINCIPLES OF CARE DELIVERY:
The DBH 11 principles of care delivery define and guide a system that strives for
excellence in the provision of behavioral health services where the values of wellness,
resiliency, and recovery are central to the development of programs, services, and
workforce. The principles provide the clinical framework that influences decision-making
on all aspects of care delivery including program design and implementation, service
delivery, training of the workforce, allocation of resources, and measurement of
outcomes.
1.Principle One - Timely Access & Integrated Services
o Individuals and families are connected with services in a manner that is
streamlined, effective, and seamless
o Collaborative care coordination occurs across agencies, plans for care are
integrated, and whole person care considers all life domains such as health,
education, employment, housing, and spirituality
o Barriers to access and treatment are identified and addressed
o Excellent customer service ensures individuals and families are transitioned
from one point of care to another without disruption of care
Exhibit B
2
rev 01-02-2018
2. Principle Two - Strengths-based
o Positive change occurs within the context of genuine trusting relationships
o Individuals, families, and communities are resourceful and resilient in the way
they solve problems
o Hope and optimism is created through identification of, and focus on, the
unique abilities of individuals and families
3. Principle Three - Person-driven and Family-driven
o Self-determination and self-direction are the foundations for recovery
o Individuals and families optimize their autonomy and independence by leading
the process, including the identification of strengths, needs, and preferences
o Providers contribute clinical expertise, provide options, and support individuals
and families in informed decision making, developing goals and objectives, and
identifying pathways to recovery
o Individuals and families partner with their provider in determining the services
and supports that would be most effective and helpful and they exercise choice
in the services and supports they receive
4. Principle Four - Inclusive of Natural Supports
o The person served identifies and defines family and other natural supports to
be included in care
o Individuals and families speak for themselves
o Natural support systems are vital to successful recovery and the maintaining of
ongoing wellness; these supports include personal associations and
relationships typically developed in the community that enhance a person’s
quality of life
o Providers assist individuals and families in developing and utilizing natural
supports.
5. Principle Five - Clinical Significance and Evidence Based Practices (EBP)
o Services are effective, resulting in a noticeable change in daily life that is
measurable.
o Clinical practice is informed by best available research evidence, best clinical
expertise, and client values and preferences
o Other clinically significant interventions such as innovative, promising, and
emerging practices are embraced
6. Principle Six - Culturally Responsive
Exhibit B
3
rev 01-02-2018
o Values, traditions, and beliefs specific to an individual’s or family’s culture(s)
are valued and referenced in the path of wellness, resilience, and recovery
o Services are culturally grounded, congruent, and personalized to reflect the
unique cultural experience of each individual and family
o Providers exhibit the highest level of cultural humility and sensitivity to the self-
identified culture(s) of the person or family served in striving to achieve the
greatest competency in care delivery
7. Principle Seven - Trauma-informed and Trauma-responsive
o The widespread impacts of all types of trauma are recognized and the various
potential paths for recovery from trauma are understood
o Signs and symptoms of trauma in individuals, families, staff, and others are
recognized and persons receive trauma-informed responses
o Physical, psychological and emotional safety for individuals, families, and
providers is emphasized
8. Principle Eight - Co-occurring Capable
o Services are reflective of whole-person care; providers understand the
influence of bio-psycho-social factors and the interactions between physical
health, mental health, and substance use disorders
o Treatment of substance use disorders and mental health disorders are
integrated; a provider or team may deliver treatment for mental health and
substance use disorders at the same time
9. Principle Nine - Stages of Change, Motivation, and Harm Reduction
o Interventions are motivation-based and adapted to the client’s stage of change
o Progression though stages of change are supported through positive working
relationships and alliances that are motivating
o Providers support individuals and families to develop strategies aimed at
reducing negative outcomes of substance misuse though a harm reduction
approach
o Each individual defines their own recovery and recovers at their own pace
when provided with sufficient time and support
10. Principle Ten - Continuous Quality Improvement and Outcomes-Driven
o Individual and program outcomes are collected and evaluated for quality and
efficacy
Exhibit B
4
rev 01-02-2018
o Strategies are implemented to achieve a system of continuous quality
improvement and improved performance outcomes
o Providers participate in ongoing professional development activities needed for
proficiency in practice and implementation of treatment models
11. Principle Eleven - Health and Wellness Promotion, Illness and Harm Prevention, and
Stigma Reduction
o The rights of all people are respected
o Behavioral health is recognized as integral to individual and community well-
being
o Promotion of health and wellness is interwoven throughout all aspects of DBH
services
o Specific strategies to prevent illness and harm are implemented at the
individual, family, program, and community levels
o Stigma is actively reduced by promoting awareness, accountability, and
positive change in attitudes, beliefs, practices, and policies within all systems
o The vision of health and well-being for our community is continually addressed
through collaborations between providers, individuals, families, and community
members
Exhibit C
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Director of Community Services 0.25 $32,870 $32,870
0002 Program Manager 1.00 $82,138 $82,138
0003 TM Wraparound supervisor 3.00 $221,815 $221,815
0004 Clinical Supervisor 1.00 $77,815 $77,815
0005 Clinicians - Mental Health Specialist 6.00 $321,940 $321,940
0006 Facilitator 15.00 $838,327 $838,327
0007 Child and Family Specialist 10.00 $337,996 $337,996
0008 Parent Partner 15.00 $518,238 $518,238
0009 Resource Specialist 1.00 $40,464 $40,464
0010 Family Search & Engagement Specialist 1.00 $38,216 $38,216
0011 Intake Coordinator 1.00 $33,292 $33,292
0012 Billing Specialist 0.50 $31,212 $31,212
0013 Human Resource Manager 0.25 $13,645 $13,645
0014 Regional Training Manager 0.25 $14,050 $14,050
0015 Quality Assurance Manager 0.25 $17,563 $17,563
SALARY TOTAL 55.50 $142,632 $2,476,949 $2,619,581
PAYROLL TAXES:
0030 OASDI $8,843 $153,571 $162,414
0031 FICA/MEDICARE $2,068 $35,916 $37,984
0032 SUI $3,352 $58,208 $61,560
PAYROLL TAX TOTAL $14,263 $247,695 $261,958
EMPLOYEE BENEFITS:
0040 Retirement $3,209 $55,731 $58,941
0041 Workers Compensation $4,279 $74,308 $78,587
0042 Health Insurance (medical, vision, life, dental)$12,706 $228,524 $241,230
EMPLOYEE BENEFITS TOTAL $20,194 $358,564 $378,758
SALARY & BENEFITS GRAND TOTAL $3,260,297
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $34,650
1011 Rent/Lease Equipment $7,200
1012 Utilities $8,250
1013 Building Maintenance $5,000
1014 Equipment purchase $20,084
FACILITY/EQUIPMENT TOTAL $75,184
OPERATING EXPENSES:
1060 Telephone $55,375
1061 Answering Service $0
1062 Postage $650
1063 Printing/Reproduction $0
1064 Publications $0
Line Item Description (Must be itemized)
BUDGET
SB 163 WRAPAROUND PROGRAM
13 Months (June 1, 2018 - June 30, 2019)
Budget Categories - Total Proposed Budget
Page 1 of 32
Exhibit C
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $12,840
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies - Therapeutic $8,250
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $138,184
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $5,460
1075 Lodging $0
1076 Other - Purchased services $11,435
1077 Other - Centralized services - program $99,327
1078 Other - Life Domains $45,000
1079 Other - Start-up $230,243
OPERATING EXPENSES TOTAL $606,764
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $3,000
1082 Liability Insurance $26,250
1083 Administrative Overhead $191,303
1084 Payroll Services $14,674
1085 Professional Liability Insurance $0
1086 Centralized fiscal services $191,303
FINANCIAL SERVICES TOTAL $426,530
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)
1091 Translation Services $1,625
1092 Medication Supports $129,600
SPECIAL EXPENSES TOTAL $131,225
FIXED ASSETS:
Page 2 of 32
Exhibit C
1190 Computers & Software
1191 Furniture & Fixtures
1192 Other - (Identify)
1193 Other - (Identify)
FIXED ASSETS TOTAL
TOTAL PROGRAM EXPENSES $4,500,000
MEDI-CAL REVENUE:Units of Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)24,624 2.87$ $70,671
3100 Case Management
3200 Crisis Services 25,650 4.17$ $106,961
3300 Medication Support 34,200 5.18$ $177,156
3400 Collateral 102,600 2.87$ $294,462
3500 Plan Development 2,280 2.87$ $6,544
3600 Assessment 3,420 2.87$ $9,815
3700 Rehabilitation 2.87$ $0
3800 Intensive Case Coordination - Wraparound Services 580,797 2.21$ $1,283,561
3700 Intensive Home-Based Services 637,920 2.87$ $1,830,830
DIRECT SERVICE REVENUE TOTAL 1,411,491 $3,780,000
OTHER REVENUE: Non Medical Revenue
4000 Mental Health Services 39,309 2.87$ $112,817
4100 Case Management 41,908 2.21$ $92,617
4200 Medication Support 1,766 5.28$ $9,324
4300 Crisis Intervention 1,351 4.17$ $5,634
4300 Wrap services N/A $252.56/client/mo $454,608
4400 Life Domain N/A Avg $25/family/mo $45,000
Page 3 of 32
Exhibit C
OTHER REVENUE TOTAL 84,334 $720,000
TOTAL PROGRAM REVENUE $720,000
$4,500,000
Medi-Cal Revenue 50% FFP $1,890,000
Medi-Cal Revenue 40% EPSDT $1,512,000
County SB163 Trust Fund 10%$378,000
Total Medi-Cal Revenue 3,780,000$
Total Medi-Cal Units 1,411,491
Medi-Cal cost per unit $2.68
Non Medi-Cal Billable Service Cost 220,392$
Total Non Medi-Cal Billable Units 84,334
Non Medi-Cal cost per unit $2.61
499,608.00$
Wrap Services 454,608.00$
Life Domain 45,000.00$
Other Non Medi-Cal Billable Services Cost
Page 4 of 32
Exhibit C
PROGRAM EXPENSES
Personnel Salaries, Payroll Taxes & Employee Benefits - Line Items 0001- 0042
2619581
Program Manager: $82,138 for 1 FTE Will oversee all staff and operations, assuring compliance with Federal, State, County and
local laws and regulations. He/she oversees Supervisors who directly manage these programs or provides direct management in
their absence.
13 Months (June 1, 2018 - June 30, 2019)
BUDGET NARRATIVE - EXPENSES
Director of Community Services: $32,870 for 0.25 FTE oversee program management and maintain in compliance with contract
and legal requirements
Regional Training Manager: $14,050 for 0.25 FTE Responsible for development coordination, and supervision of training
programs for the CRP. Develops and coordinates the provision of new employees orientations, required in-service trainings, and
clinical training.
TM Wraparound Supervisor: $221,815 for 3 FTE's Under general direction, supervises operations, Family Specialists, and is
responsible for other operations of support staff and planning and coordination of clinic staff.
Clinical Supervisor: $77,815 for 1 FTE Under general direction, supervises Specialty Mental Health Services, and the work of
license-eligible therapists in accordance with BBS requirements. May also provide individual mental health services.
Mental Health Specialist II: $321,940 for 6 FTE's Provides initial and ongoing assessment; develops EPSDT plan. Provides
individual and family trauma-informed mental health services and therapy. Provides clinical support and information to CFTs, as
CFT and ICC team member. Documents and bills for services, and completes outcomes information.
Facilitators: $838,327 for 15 FTE's Primary contact for family; assessment, development, implementation and evaluation of IFPs;
responsibility for configuring and facilitating CFTs; case management/ICC to secure formal resources; ensures integration of
plans from system partners; oversees rehabilitative services; completes required documentation, day-to-day supervision for Child
& Family Specialists. Participates in 24-hour on-call system. (Shall not serve as assigned Therapist/Clinician for any child/youth
for whom they are assigned to serve as the Facilitator).
Child & Family Specialist: $337,996 for 10 FTE's Work directly with the child(ren) and family in their respective environments to
help them achieve permanency. Provides direct intervention services in homes and communities, which may include: role-
modeling, role-play, behavior modification, interventions/structures, socialization skills training, development of parenting skills;
under direction of Facilitator, accesses community-based resources; participates in CFTs and 24 hour on-call system.
Parent Partners: $518,238 for 15 FTE's Works closely with the Wraparound child’s parent/caregiver to represent their best
interests and participate as a member of the CFT. For a Wraparound child/youth in out-of-home placement, work with both the
out-of-home caregiver and parent/current caregiver. Shares the story of their own journey, mentors and coaches parents,
caregivers and kin in achieving POC goals; demonstrates creativity and resourcefulness in navigating systems of care; assists in
the development/facilitation of support groups; provides peer support; links family members with appropriate services, advocating
for them when necessary. Participates in 24-hour on-call system, and CFTs.
Resource Specialist: $40,464 for 1 FTE Helps coordinate and develop community resources for all participants, including
housing, vocational, educational services, transportation and other social support services. Aid in ensuring coordination of
services. Assist CFT's track delivery of service referrals.
Family Search and Engagement Specialist: $38,216 for 1 FTE Responsible for the family search & engagement process and
services. The development of a systemic program that identifies, plans, and executes plans to assist specific teams in helping
clients in the program with family searching and engagement. Conducting trainings, monitoring and tracking of progress, and
maintaining the technology to assist teams. Represents TEAMMATES to county agencies and in the community, and assist in
direct services as necessary in facilitating permanency planning.
Intake Coordinator: $33,292 for 1 FTE processes referrals, consent packets, and paperwork, etc.
Billing Specialist: $31,212 for 0.5 FTE for billing AR, AP and general ledger accounting
Human Resources Manager: $13,645 for 0.25 FTE Human Resources Recruiting, hiring, training, HR Policies and procedures
and the administration of employee's benefits.
Quality Assurance Manager: $17,563 for 0.25 FTE Oversees Quality Assurance processes, including audits, utilization Review
tracking reports and forms, creating reports and general QA tasks.
Page 5 of 32
Exhibit C
261958
378758
Facilities/Equipment Expenses – Line Items 1010-1014
75184
Operating Expenses - Line Items 1060-1077
606764
Financial Services Expenses – Line Items 1080-1085
Utilities: $8,250 Electricity, Water, Gas, Trash for Start-up; for 13 months
Payroll Taxes.
OASDI Payroll Taxes: $162,414 6.2% of annual salaries
FICA Payroll Taxes: $37,984 1.45% of annual salaries
SUI Payroll Taxes: $61,560 2.35% of annual salaries
Employee Benefits:
Retirement $58,941 2.25% This includes ESOP and 401k employer match
Worker Compensation: $78,587 3% of total salaries.
Health insurance $241,230 12%
Rent/Lease Building: $34,650 based on $1.05 per square foot per month for 3,000 square feet for 10 months and allocated rent
from use of current Central Star - facility for three monhts.
Rent/Lease Equipment: $7,200 for copier lease, toner and maintenance for 13 months
Other: $230,243 Start up costs - One time start up costs are $183,930 for office equipment, office furniture, IT hardware,
software, cabling and install in office, $18,300 recruitment of 55.5 FTE's, $9,863 for office supplies, equipment, reference
materials, dues and subscriptions, $9,000 for training costs and materials for new staff, $2,500 for travel for administrative
planning, hiring and training new staff. Ongoing costs that will also occur during one month start up period are one month rent
$3,150, leased equipment (copier) $600, utilities $750, maintenance for readying new site $1,000, phone $1,150.
Building Maintenance: $5,000 for janitorial services, repairs and maintenance for 13 months
Equipment purchases: $204,013 for minor office equipment, furniture, IT equipment, software and support of $20,084 for minor
office equipment
Telephone and communications $55,375; includes staff cell phone reimbursement ($60 per month for 53 staff and one at $100
per month), internet & phones cost is $41,000 which also includes Wi-Fi for staff tablets; and for $14,375 for landline.
Postage $650 for postage and delivery.
Office supplies and equipment $12,840; $9,990 for office supplies for 55.5 FTE's, $650 for professional dues and subscriptions,
$1,300 property taxes, $900 for business licenses and Joint Commission fees
Program Supplies $8,250 for client supplies and incentives based on $5 per client per month - this will cover food for family
meetings and graduation celebrations.
Staff Travel: $138,184 for mileage reimbursement based on 54.5 cents a mile for 48 FTE's for 100 miles per week plus 4 staff for
approximately 80 miles per month.
Staff Training: $5,460 which includes on-going program required education, training and materials for staff calculated at $420 per
month
Other: Purchased service $11,435 includes document shredding, water and coffee service, postage meter rental.
Other: Centralized Program Services totaling $99,327 is comprised of the SBHG corporate and regional support in the numerous
areas including support from the Senior Administrator as well as services provided for Program Development and Evaluation,
Quality & Compliance, and Training. There is a significant cost advantage to all the SBHG company programs in sharing these
costs rather than building them into each program. SBHG support provides oversight of all of our programs to ensure
consistency with our standards and policies and procedures. The cost of this support is shared by all programs and is budgeted
between 2.5% and 3% of total expenses less flex and start up expenses.
Other: $45,000 Life domain funds for clients, transportation, lodging, utilities, clothing and food.
External Audit $3,000 for annual audit fees.
Liability Insurance: $26,250 for general liability, property and professional liability based on $473 per FTE.
Administrative overhead: $191,303 This is an allocation from Stars Behavioral Health Group of operations administration,
information technology, human resources, communications, finance, and associated fringe benefits and expenses. Costs are
budgeted between 4.5% and 5% of total costs based on our current allocation mode.
Payroll services: $14,674 for payroll processing fees based on $21.50 per month for 56 employees.
Professional Insurances: cost included above in Liability insurance.
Page 6 of 32
Exhibit C
426530
Centralized fiscal services (5%) - $191,303- This line item represents operating income for Central Star. As a profit provider,
Central Star has no ability to do fund raising to offset overhead costs such as income taxes, interest expense, and other
unreimbursed expenses. This line item provides a cushion to mitigate this exposure. Calculated at 5% of total program expenses
less Client support expenses and Centralized services - Administrative
Page 7 of 32
Exhibit C
Special Expenses – Line Items 1090-1092
131225
Fixed Assets – Line Items 1190-1193
($xxx,xxx.xx)
Translation Services $1,625 for annual translation service.
Medication Supports - Psychiatrist: $129,600 for 45 hours per month at $240 per hour.
Include all purchases over Five Thousand Dollars ($5,000) including sales tax, and certain
purchases under said amount such as camera, televisions, VCRs/DVDs and other sensitive
items, made during the life of the Agreement resulting from this Request for Proposal, with funds
paid pursuant to this Agreement and that will outlive the life of this Agreement.
TOTAL PROGRAM EXPENSE:4,500,000$
Page 8 of 32
Exhibit C
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Director of Community Services 0.25 $31,326 $31,326
0002 Program Manager 1.00 $78,280 $78,280
0003 TM Wraparound supervisor 3.00 $222,480 $222,480
0004 Clinical Supervisor 1.00 $74,160 $74,160
0005 Clinicians - Mental Health Specialist 6.00 $322,905 $322,905
0006 Facilitator 15.00 $849,750 $849,750
0007 Child and Family Specialist 10.00 $525,300 $525,300
0008 Parent Partner 15.00 $339,900 $339,900
0009 Resource Specialist 1.00 $38,563 $38,563
0010 Family Search & Engagement Specialist 1.00 $36,421 $36,421
0011 Intake Coordinator 1.00 $32,960 $32,960
0012 Billing Specialist 0.50 $30,900 $30,900
0013 Human Resource Manager 0.25 $13,004 $13,004
0014 Regional Training Manager 0.25 $13,390 $13,390
0015 Quality Assurance Manager 0.25 $16,738 $16,738
SALARY TOTAL 55.50 $138,318 $2,487,759 $2,626,077
PAYROLL TAXES:
0030 OASDI $8,576 $154,241 $162,817
0031 FICA/MEDICARE $2,006 $36,073 $38,078
0032 SUI $3,250 $58,462 $61,713
PAYROLL TAX TOTAL $13,832 $248,776 $262,608
EMPLOYEE BENEFITS:
0040 Retirement $3,112 $55,975 $59,087
0041 Workers Compensation $4,150 $74,633 $78,782
0042 Health Insurance (medical, vision, life, dental)$16,598 $298,531 $315,129
EMPLOYEE BENEFITS TOTAL $23,860 $429,138 $452,998
SALARY & BENEFITS GRAND TOTAL $3,341,683
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $38,556
1011 Rent/Lease Equipment $7,344
1012 Utilities $9,180
1013 Building Maintenance $6,120
1014 Equipment purchase $88,503
FACILITY/EQUIPMENT TOTAL $149,703
OPERATING EXPENSES:
1060 Telephone $53,436
1061 Answering Service $0
1062 Postage $612
Line Item Description (Must be itemized)
BUDGET
SB 163 WRAPAROUND PROGRAM
FISCAL YEAR 2019-20
Budget Categories -Total Proposed Budget
Page 9 of 32
Exhibit C
1063 Printing/Reproduction $0
1064 Publications $0
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $22,650
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies - Therapeutic $9,000
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $138,184
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $5,141
1075 Lodging $0
1076 Other - Purchased services $45,374
1077 Other - Centralized services - program $118,274
1078 Other - Life Domains $45,000
1079 Other - Start-up $0
OPERATING EXPENSES TOTAL $437,671
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $3,000
1082 Liability Insurance $26,775
1083 Administrative Overhead $197,124
1084 Payroll Services $15,790
1085 Professional Liability Insurance $0
1086 Centralized fiscal services $197,124
FINANCIAL SERVICES TOTAL $439,813
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)
1091 Translation Services $1,530
1092 Medication Supports $129,600
SPECIAL EXPENSES TOTAL $131,130
FIXED ASSETS:
1190 Computers & Software
1191 Furniture & Fixtures
1192 Other - (Identify)
1193 Other - (Identify)
FIXED ASSETS TOTAL
TOTAL PROGRAM EXPENSES $4,500,000
MEDI-CAL REVENUE:Units of Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)24,624 2.87$ $70,671
3100 Case Management
3200 Crisis Services 25,650 4.17$ $106,961
3300 Medication Support 34,200 5.18$ $177,156
Page 10 of 32
Exhibit C
3400 Collateral 102,600 2.87$ $294,462
3500 Plan Development 2,280 2.87$ $6,544
3600 Assessment 3,420 2.87$ $9,815
3700 Rehabilitation 2.87$ $0
3800 Intensive Case Coordination - Wraparound Services 580,797 2.21$ $1,283,561
3700 Intensive Home-Based Services 637,920 2.87$ $1,830,830
DIRECT SERVICE REVENUE TOTAL 1,411,491 $3,780,000
OTHER REVENUE: Non Medical Revenue
4000 Mental Health Services 39,309 2.87$ $112,817
4100 Case Management 41,908 2.21$ $92,617
4200 Medication Support 1,766 5.28$ $9,324
4300 Crisis Intervention 1,351 4.17$ $5,634
4300 Wrap services N/A $252.56/client/mo $454,608
4400 Life Domain N/A Avg $25/family/mo $45,000
OTHER REVENUE TOTAL 84,334 $720,000
TOTAL PROGRAM REVENUE $720,000
$4,500,000
Medi-Cal Revenue 50% FFP $1,890,000
Medi-Cal Revenue 40% EPSDT $1,512,000
County SB163 Trust Fund 10%$378,000
Total Medi-Cal Revenue 3,780,000$
Total Medi-Cal Units 1,411,491
Medi-Cal cost per unit $2.68
Non Medi-Cal Billable Service Cost 220,392$
Total Non Medi-Cal Billable Units 84,334
Non Medi-Cal cost per unit $2.61
Page 11 of 32
Exhibit C
SB 163 WRAPAROUND PROGRAM
FY 2019-20
BUDGET NARRATIVE - EXPENSES
PROGRAM EXPENSES
Personnel Salaries, Payroll Taxes & Employee Benefits - Line Items 0001- 0042
Director of Community Services: $31,326 for 0.25 FTE oversee program management and maintain in compliance with contract
and legal requirements
Program Manager: $78,280 for 1 FTE Will oversee all staff and operations, assuring compliance with Federal, State, County and
TM Wraparound Supervisor: $222,480 for 3 FTE's Under general direction, supervises operations, Family Specialists, and is
responsible for other operations of support staff and planning and coordination of clinic staff.
Clinical Supervisor: $74,160 for 1 FTE Under general direction, supervises Specialty Mental Health Services, and the work of
license-eligible therapists in accordance with BBS requirements. May also provide individual mental health services.
Mental Health Specialist II: $322,905 for 6 FTE's Provides initial and ongoing assessment; develops EPSDT plan. Provides
individual and family trauma-informed mental health services and therapy. Provides clinical support and information to CFTs, as
CFT and ICC team member. Documents and bills for services, and completes outcomes information.
Facilitators: $849,750 for 15 FTE's Primary contact for family; assessment, development, implementation and evaluation of IFPs;
responsibility for configuring and facilitating CFTs; case management/ICC to secure formal resources; ensures integration of
plans from system partners; oversees rehabilitative services; completes required documentation, day-to-day supervision for Child
& Family Specialists. Participates in 24-hour on-call system. (Shall not serve as assigned Therapist/Clinician for any child/youth
for whom they are assigned to serve as the Facilitator).
Child & Family Specialist: $525,300 for 10 FTE's Work directly with the child(ren) and family in their respective environments to
help them achieve permanency. Provides direct intervention services in homes and communities, which may include: role-
modeling, role-play, behavior modification, interventions/structures, socialization skills training, development of parenting skills;
under direction of Facilitator, accesses community-based resources; participates in CFTs and 24 hour on-call system.
Parent Partners: $339,900 for 15 FTE's Works closely with the Wraparound child’s parent/caregiver to represent their best
interests and participate as a member of the CFT. For a Wraparound child/youth in out-of-home placement, work with both the
out-of-home caregiver and parent/current caregiver. Shares the story of their own journey, mentors and coaches parents,
caregivers and kin in achieving POC goals; demonstrates creativity and resourcefulness in navigating systems of care; assists in
the development/facilitation of support groups; provides peer support; links family members with appropriate services, advocating
for them when necessary. Participates in 24-hour on-call system, and CFTs.
Resource Specialist: $38,563 for 1 FTE Helps coordinate and develop community resources for all participants, including
housing, vocational, educational services, transportation and other social support services. Aid in ensuring coordination of
services. Assist CFT's track delivery of service referrals.
Family Search and Engagement Specialist: $36,421 for 1 FTE Responsible for the family search & engagement process and
services. The development of a systemic program that identifies, plans, and executes plans to assist specific teams in helping
clients in the program with family searching and engagement. Conducting trainings, monitoring and tracking of progress, and
maintaining the technology to assist teams. Represents TEAMMATES to county agencies and in the community, and assist in
direct services as necessary in facilitating permanency planning.
Intake Coordinator: $32,960 for 1 FTE processes referrals, consent packets, and paperwork, etc.
Billing Specialist: $30,900 for .5 FTE for billing, AR, AP and general ledger accounting.
Human Resources Manager: $13,004 for 0.25 FTE Human Resources Recruiting, hiring, training, HR Policies and procedures
and the administration of employee's benefits.
Regional Training Manager: $13,390 for 0.25 FTE Responsible for development coordination, and supervision of training
programs for the CRP. Develops and coordinates the provision of new employees orientations, required in-service trainings, and
clinical training.
Quality Assurance Manager: $16,738 for 0.25 FTE Oversees Quality Assurance processes, including audits, utilization Review
tracking reports and forms, creating reports and general QA tasks.
2626077
Payroll Taxes.
OASDI Payroll Taxes: $162,817 6.2% of annual salaries
Page12 of 32
Exhibit C
262608
452998
Facilities/Equipment Expenses – Line Items 1010-1014
149703
Operating Expenses - Line Items 1060-1077
437671
Financial Services Expenses – Line Items 1080-1085
439813
Special Expenses – Line Items 1090-1092
131130
Other: Purchased service $45,374 which includes consulting, on-going staff recruitment, document shredding, water and
coffee service.
Other: Centralized Program Services totaling $118,274 is comprised of the SBHG corporate and regional support in the
numerous areas including support from the Senior Administrator as well as services provided for Program Development and
Evaluation, Quality & Compliance, and Training. There is a significant cost advantage to all the SBHG company programs in
sharing these costs rather than building them into each program. SBHG support provides oversight of all of our programs to
ensure consistency with our standards and policies and procedures. The cost of this support is shared by all programs and is
budgeted at approximately 2.5% to 3% of total expenses less life domain funds.
Other: $45,000 Life domain funds for clients, transportation, lodging, utilities, clothing and food
External Audit $3,000 for annual audit fees.
Medication Supports - Psychiatrist: $129,600 for 45 hours per month at $240 per hour.
Centralized fiscal services (5%) - $197,124- This line item represents operating income for Central Star. As a profit provider,
Central Star has no ability to do fund raising to offset overhead costs such as income taxes, interest expense, and other
unreimbursed expenses. This line item provides a cushion to mitigate this exposure. Calculated at 5% of total program expenses
less Client support expenses and Centralized services - Administrative.
Liability Insurance: $26,775 for general liability, property and professional liability based on $482.43 per FTE.
Administrative overhead: $197,124 This is an allocation from Stars Behavioral Health Group of operations administration,
information technology, human resources, communications, finance, and associated fringe benefits and expenses.Costs are
budgeted between 4.5% and 5% of total costs based on our current allocation mode.
Payroll services: $15,790 for payroll processing fees based on $21.93 per month for 60 employees.
Professional Insurances: cost included above in Liability insurance.
Translation Services $1,530 for annual translation service.
Office supplies and equipment $22,650 based on approximately $30 per month for 55.5 FTE's, $624 for professional dues and
subscriptions, $1,249 property taxes, $936 for business licenses and Joint Commission fees.
Program Supplies $9,000 for client supplies and incentives based on $5 per client per month - this will cover food for family
meetings and graduation celebrations.
Staff Travel: $138,184 for mileage reimbursement based on 54.5 cents a mile for 48 FTE's for 100 miles per week plus 4 staff for
approximately 80 miles per month.
Staff Training: $5,141 which includes on-going program required education, training and materials for staff calculated at
approximately $428 per month.
Rent/Lease Equipment: $7,344 for copier lease, toner and maintenance
Utilities: $9,180 Electricity, Water, Gas, Trash; $765 per month
Building Maintenance: $6,120 for janitorial services, repairs and maintenance $510 per month
Equipment purchases: $88,503 for minor office equipment, furniture IT equipment, software and support
Telephone and communications $53,436; includes staff cell phone reimbursement ($60 per month for 53 staff and one at $100
per month), internet & phones cost is $39,360 which also includes Wi-Fi for staff tablets; and for $14,076 for landline.
Postage $612 for postage and delivery.
Employee Benefits:
Retirement $59,087 2.25% This includes ESOP and 401k employer match
Worker Compensation: $78,782 3% of total salaries.
Health insurance $315,129 12%
Rent/Lease Building: $38,556 based on approximately $1.07 per square foot per month for 3,000 square feet
FICA Payroll Taxes: $38,078 1.45% of annual salaries
SUI Payroll Taxes: $61,713 2.35% of annual salaries
Page 13 of 32
Exhibit C
Fixed Assets – Line Items 1190-1193
($xxx,xxx.xx)
Include all purchases over Five Thousand Dollars ($5,000) including sales tax, and certain
purchases under said amount such as camera, televisions, VCRs/DVDs and other sensitive
items, made during the life of the Agreement resulting from this Request for Proposal, with funds
paid pursuant to this Agreement and that will outlive the life of this Agreement.
TOTAL PROGRAM EXPENSE:4,500,000.00$
Page 14 of 32
Exhibit C
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Director of Community Services 0.25 $31,952 $31,952
0002 Program Manager 1.00 $79,846 $79,846
0003 TM Wraparound supervisor 3.00 $226,930 $226,930
0004 Clinical Supervisor 1.00 $75,643 $75,643
0005 Clinicians - Mental Health Specialist 6.00 $329,363 $329,363
0006 Facilitator 15.00 $866,745 $866,745
0007 Child and Family Specialist 10.00 $535,806 $535,806
0008 Parent Partner 15.00 $346,698 $346,698
0009 Resource Specialist 1.00 $39,334 $39,334
0010 Family Search & Engagement Specialist 1.00 $37,149 $37,149
0011 Intake Coordinator 1.00 $33,619 $33,619
0012 Billing Specialist 0.50 $31,518 $31,518
0013 Human Resource Manager 0.25 $13,264 $13,264
0014 Regional Training Manager 0.25 $13,658 $13,658
0015 Quality Assurance Manager 0.25 $17,072 $17,072
SALARY TOTAL 55.50 $141,083 $2,537,514 $2,678,597
PAYROLL TAXES:
0030 OASDI $8,747 $157,326 $166,073
0031 FICA/MEDICARE $2,046 $36,794 $38,840
0032 SUI $3,315 $59,632 $62,947
PAYROLL TAX TOTAL $14,108 $253,751 $267,860
EMPLOYEE BENEFITS:
0040 Retirement $3,174 $57,094 $60,268
0041 Workers Compensation $4,232 $76,125 $80,358
0042 Health Insurance (medical, vision, life, dental)$16,930 $304,502 $321,432
EMPLOYEE BENEFITS TOTAL $24,337 $437,721 $462,058
SALARY & BENEFITS GRAND TOTAL $3,408,515
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $39,327
1011 Rent/Lease Equipment $7,491
1012 Utilities $9,364
1013 Building Maintenance $6,242
1014 Equipment purchase $69,355
FACILITY/EQUIPMENT TOTAL $131,779
OPERATING EXPENSES:
1060 Telephone $53,718
1061 Answering Service $0
1062 Postage $624
1063 Printing/Reproduction $0
Line Item Description (Must be itemized)
BUDGET
SB 163 WRAPAROUND PROGRAM
FISCAL YEAR 2020-21
Budget Categories -Total Proposed Budget
Page 15 of 32
Exhibit C
1064 Publications $0
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $15,126
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies - Therapeutic $9,000
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $140,948
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $5,244
1075 Lodging $0
1076 Other - Purchased services $11,551
1077 Other - Centralized services - program $118,274
1078 Other - Life Domains $45,000
1079 Other - Start-up $0
OPERATING EXPENSES TOTAL $399,485
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $3,000
1082 Liability Insurance $27,312
1083 Administrative Overhead $197,124
1084 Payroll Services $4,500
1085 Professional Liability Insurance $0
1086 Centralized fiscal services $197,124
FINANCIAL SERVICES TOTAL $429,060
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)
1091 Translation Services $1,561
1092 Medication Supports $129,600
SPECIAL EXPENSES TOTAL $131,161
FIXED ASSETS:
1190 Computers & Software
1191 Furniture & Fixtures
1192 Other - (Identify)
1193 Other - (Identify)
FIXED ASSETS TOTAL
TOTAL PROGRAM EXPENSES $4,500,000
MEDI-CAL REVENUE:Units of Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)24,624 2.87$ $70,671
3100 Case Management
3200 Crisis Services 25,650 4.17$ $106,961
3300 Medication Support 34,200 5.18$ $177,156
3400 Collateral 102,600 2.87$ $294,462
3500 Plan Development 2,280 2.87$ $6,544
Page 16 of 32
Exhibit C
3600 Assessment 3,420 2.87$ $9,815
3700 Rehabilitation 2.87$ $0
3800 Intensive Case Coordination - Wraparound Services 580,797 2.21$ $1,283,561
3700 Intensive Home-Based Services 637,920 2.87$ $1,830,830
DIRECT SERVICE REVENUE TOTAL 1,411,491 $3,780,000
OTHER REVENUE: Non Medical Revenue
4000 Mental Health Services 39,309 2.87$ $112,817
4100 Case Management 41,908 2.21$ $92,617
4200 Medication Support 1,766 5.28$ $9,324
4300 Crisis Intervention 1,351 4.17$ $5,634
4300 Wrap services N/A $252.56/client/mo $454,608
4400 Life Domain N/A Avg $25/family/mo $45,000
OTHER REVENUE TOTAL 84,334 $720,000
TOTAL PROGRAM REVENUE $720,000
$4,500,000
Medi-Cal Revenue 50% FFP $1,890,000
Medi-Cal Revenue 40% EPSDT $1,512,000
County SB163 Trust Fund 10%$378,000
Total Medi-Cal Revenue 3,780,000$
Total Medi-Cal Units 1,411,491
Medi-Cal cost per unit $2.68
Non Medi-Cal Billable Service Cost 220,392$
Total Non Medi-Cal Billable Units 84,334
Non Medi-Cal cost per unit $2.61
499,608.00$
Wrap Services 454,608.00$
Life Domain 45,000.00$
Other Non Medi-Cal Billable Services Cost
Page 17 of 32
Exhibit C
PROGRAM EXPENSES
Personnel Salaries, Payroll Taxes & Employee Benefits - Line Items 0001- 0042
2678597
Billing Specialist: $31,518 for 0.5 FTE for billing, AR, AP and general ledger accounting,
Human Resources Manager: $13,264 for 0.25 FTE Human Resources Recruiting, hiring, training, HR Policies and procedures
and the administration of employee's benefits.
Quality Assurance Manager: $17,072 for 0.25 FTE Oversees Quality Assurance processes, including audits, utilization Review
tracking reports and forms, creating reports and general QA tasks.
Regional Training Manager: $13,658 for 0.25 FTE Responsible for development coordination, and supervision of training
programs for the CRP. Develops and coordinates the provision of new employees orientations, required in-service trainings, and
clinical training.
Program Manager: $79,846 for 1 FTE Will oversee all staff and operations, assuring compliance with Federal, State, County and
local laws and regulations. He/she oversees Supervisors who directly manage these programs or provides direct management in
their absence.
TM Wraparound Supervisor: $226,930 for 3 FTE's Under general direction, supervises operations, Family Specialists, and is
responsible for other operations of support staff and planning and coordination of clinic staff.
Clinical Supervisor: $75,643 for 1 FTE Under general direction, supervises Specialty Mental Health Services, and the work of
license-eligible therapists in accordance with BBS requirements. May also provide individual mental health services.
Family Search and Engagement Specialist: $37,149 for 1 FTE Responsible for the family search & engagement process and
services. The development of a systemic program that identifies, plans, and executes plans to assist specific teams in helping
clients in the program with family searching and engagement. Conducting trainings, monitoring and tracking of progress, and
maintaining the technology to assist teams. Represents TEAMMATES to county agencies and in the community, and assist in
direct services as necessary in facilitating permanency planning.
Intake Coordinator: $33,619 for 1 FTE processes referrals, consent packets, and paperwork, etc.
Mental Health Specialist II: $329,363 for 6 FTE's Provides initial and ongoing assessment; develops EPSDT plan. Provides
individual and family trauma-informed mental health services and therapy. Provides clinical support and information to CFTs, as
CFT and ICC team member. Documents and bills for services, and completes outcomes information.
Facilitators: $866,745 for 15 FTE's Primary contact for family; assessment, development, implementation and evaluation of IFPs;
responsibility for configuring and facilitating CFTs; case management/ICC to secure formal resources; ensures integration of
plans from system partners; oversees rehabilitative services; completes required documentation, day-to-day supervision for Child
& Family Specialists. Participates in 24-hour on-call system. (Shall not serve as assigned Therapist/Clinician for any child/youth for
whom they are assigned to serve as the Facilitator).
Child & Family Specialist: $535,806 for 10 FTE's Work directly with the child(ren) and family in their respective environments to
help them achieve permanency. Provides direct intervention services in homes and communities, which may include: role-
modeling, role-play, behavior modification, interventions/structures, socialization skills training, development of parenting skills;
under direction of Facilitator, accesses community-based resources; participates in CFTs and 24 hour on-call system.
Parent Partners: $346,698 for 15 FTE's Works closely with the Wraparound child’s parent/caregiver to represent their best
interests and participate as a member of the CFT. For a Wraparound child/youth in out-of-home placement, work with both the out-
of-home caregiver and parent/current caregiver. Shares the story of their own journey, mentors and coaches parents, caregivers
and kin in achieving POC goals; demonstrates creativity and resourcefulness in navigating systems of care; assists in the
development/facilitation of support groups; provides peer support; links family members with appropriate services, advocating for
them when necessary. Participates in 24-hour on-call system, and CFTs.
Resource Specialist: $39,334 for 1 FTE Helps coordinate and develop community resources for all participants, including housing,
vocational, educational services, transportation and other social support services. Aid in ensuring coordination of services. Assist
CFT's track delivery of service referrals.
SB 163 WRAPAROUND PROGRAM
BUDGET NARRATIVE - EXPENSES
FY 2020-21
Director of Community Services: $31,952 for 0.25 FTE oversee program management and maintain in compliance with contract
and legal requirements
Page 18 of 32
Exhibit C
Payroll Taxes.
OASDI Payroll Taxes: $166,073 6.2% of annual salaries
FICA Payroll Taxes: $38,840 1.45% of annual salaries
SUI Payroll Taxes: $62,947 2.35% of annual salaries
267860
Employee Benefits:
Retirement $60,268 2.25% This includes ESOP and 401k employer match
Worker Compensation: $80,358 3% of total salaries.
Health insurance $321,432 12%
462058
Facilities/Equipment Expenses – Line Items 1010-1014
Rent/Lease Building: $39,327 based on approximately $1.09 per square foot per month for 3,000 square feet
Rent/Lease Equipment: $7,491 for copier lease, toner and maintenance
Utilities: $9,364 Electricity, W ater, Gas, Trash; $780.33 per month
Building Maintenance: $6,242 for janitorial services, repairs and maintenance $520.17 per month
Equipment purchases: $69,355 for minor office equipment, furniture IT equipment, software and support
131779
Operating Expenses - Line Items 1060-1077
Telephone and communications $53,718; includes staff cell phone reimbursement ($60 per month for 53 staff and one at $100
per month), internet & phones cost is $39,360 which also includes Wi-Fi for staff tablets; and for $14,358 for landline.
Postage $624 for postage and delivery.
Office supplies and equipment $15,126 based on approximately $18.50 per month for 55.5 FTE's, $624 for professional dues and
subscriptions, $1,249 property taxes, $936 for business licenses and Joint Commission fees.
Program Supplies $9,000 for client supplies and incentives based on $5 per client per month - this will cover food for family
meetings and graduation celebrations.
Staff Travel: $140,948 for mileage reimbursement based on 55.5 cents a mile for 48 FTE's for 100 miles per week plus 4 staff for
approximately 80 miles per month.
Staff Training: $5,244 which includes on-going program required education, training and materials for staff calculated at
approximately $437 per month.
Other: Purchased service $11,551 which includes consulting, on-going staff recruitment, document shredding, water and coffee
service.
Other: Centralized Program Services totaling $118,274 is comprised of the SBHG corporate and regional support in the numerous
areas including support from the Senior Administrator as well as services provided for Program Development and Evaluation,
Quality & Compliance, and Training. There is a significant cost advantage to all the SBHG company programs in sharing these
costs rather than building them into each program. SBHG support provides oversight of all of our programs to ensure consistency
with our standards and policies and procedures. The cost of this support is shared by all programs and is budgeted at
approximately 2.5% to 3% of total expenses less life domain funds
Other: $45,000 Life domain funds for clients, transportation, lodging, utilities, clothing and food.
399485
Financial Services Expenses – Line Items 1080-1085
External Audit $3,000 for annual audit fees.
Liability Insurance: $27,312 for general liability, property and professional liability based on $492.11 per FTE.
Administrative overhead: $197,124 This is an allocation from Stars Behavioral Health Group of operations administration,
information technology, human resources, communications, finance, and associated fringe benefits and expenses. Costs are
budgeted between 4.5% and 5% of total costs based on our current allocation mode.
Payroll services: $4,500 for payroll processing fees based on $6.25 per month for 60 employees - changing payroll processing
vendor.
Professional Insurances: cost included above in Liability insurance.
Centralized fiscal services (5%) - $197,124- This line item represents operating income for Central Star. As a profit provider,
Central Star has no ability to do fund raising to offset overhead costs such as income taxes, interest expense, and other
unreimbursed expenses. This line item provides a cushion to mitigate this exposure. Calculated at 5% of total program expenses
less Client support expenses and Centralized services - Administrative.
Page 19 of 32
Exhibit C
429060
Special Expenses – Line Items 1090-1092
131161
Fixed Assets – Line Items 1190-1193
($xxx,xxx.xx)
Medication Supports - Psychiatrist: $129,600 for 45 hours per month at $240 per hour.
Include all purchases over Five Thousand Dollars ($5,000) including sales tax, and certain
purchases under said amount such as camera, televisions, VCRs/DVDs and other sensitive items,
made during the life of the Agreement resulting from this Request for Proposal, with funds paid
pursuant to this Agreement and that will outlive the life of this Agreement.
TOTAL PROGRAM EXPENSE:4,500,000.00$
Translation Services $1,561 for annual translation service.
Page 20 of 32
Exhibit C
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Director of Community Services 0.25 $32,432 $32,432
0002 Program Manager 1.00 $81,043 $81,043
0003 TM Wraparound supervisor 3.00 $230,334 $230,334
0004 Clinical Supervisor 1.00 $76,778 $76,778
0005 Clinicians - Mental Health Specialist 6.00 $334,304 $334,304
0006 Facilitator 15.00 $879,746 $879,746
0007 Child and Family Specialist 10.00 $543,843 $543,843
0008 Parent Partner 15.00 $351,898 $351,898
0009 Resource Specialist 1.00 $39,924 $39,924
0010 Family Search & Engagement Specialist 1.00 $37,706 $37,706
0011 Intake Coordinator 1.00 $34,123 $34,123
0012 Billing Specialist 0.50 $31,991 $31,991
0013 Human Resource Manager 0.25 $13,463 $13,463
0014 Regional Training Manager 0.25 $13,863 $13,863
0015 Quality Assurance Manager 0.25 $17,329 $17,329
SALARY TOTAL 55.50 $143,200 $2,575,577 $2,718,777
PAYROLL TAXES:
0030 OASDI $8,878 $159,686 $168,564
0031 FICA/MEDICARE $2,076 $37,346 $39,422
0032 SUI $3,365 $60,526 $63,891
PAYROLL TAX TOTAL $14,320 $257,557 $271,877
EMPLOYEE BENEFITS:
0040 Retirement $3,222 $57,950 $61,172
0041 Workers Compensation $4,296 $77,267 $81,563
0042 Health Insurance (medical, vision, life, dental)$16,826 $302,630 $319,457
EMPLOYEE BENEFITS TOTAL $24,344 $437,848 $462,192
SALARY & BENEFITS GRAND TOTAL $3,452,846
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $40,114
1011 Rent/Lease Equipment $7,641
1012 Utilities $9,551
1013 Building Maintenance $6,242
1014 Equipment purchase $27,960
FACILITY/EQUIPMENT TOTAL $91,508
OPERATING EXPENSES:
1060 Telephone $54,005
1061 Answering Service $0
1062 Postage $637
1063 Printing/Reproduction $0
Line Item Description (Must be itemized)
BUDGET
SB 163 WRAPAROUND PROGRAM
FISCAL YEAR 2021-22
Budget Categories -Total Proposed Budget
Page 21 of 32
Exhibit C
1064 Publications $0
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $15,428
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies - Therapeutic $9,000
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $140,948
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $5,348
1075 Lodging $0
1076 Other - Purchased services $9,233
1077 Other - Centralized services - program $114,849
1078 Other - Life Domains $45,000
1079 Other - Start-up $0
OPERATING EXPENSES TOTAL $394,448
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $3,000
1082 Liability Insurance $27,857
1083 Administrative Overhead $197,280
1084 Payroll Services $4,590
1085 Professional Liability Insurance $0
1086 Centralized fiscal services $197,280
FINANCIAL SERVICES TOTAL $430,006
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)
1091 Translation Services $1,592
1092 Medication Supports $129,600
SPECIAL EXPENSES TOTAL $131,192
FIXED ASSETS:
1190 Computers & Software
1191 Furniture & Fixtures
1192 Other - (Identify)
1193 Other - (Identify)
FIXED ASSETS TOTAL
TOTAL PROGRAM EXPENSES $4,500,000
MEDI-CAL REVENUE:Units of Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)24,624 2.87$ $70,671
3100 Case Management
3200 Crisis Services 25,650 4.17$ $106,961
3300 Medication Support 34,200 5.18$ $177,156
3400 Collateral 102,600 2.87$ $294,462
3500 Plan Development 2,280 2.87$ $6,544
Page 22 of 32
Exhibit C
3600 Assessment 3,420 2.87$ $9,815
3700 Rehabilitation 2.87$ $0
3800 Intensive Case Coordination - Wraparound Services 580,797 2.21$ $1,283,561
3700 Intensive Home-Based Services 637,920 2.87$ $1,830,830
DIRECT SERVICE REVENUE TOTAL 1,411,491 $3,780,000
OTHER REVENUE: Non Medical Revenue
4000 Mental Health Services 39,309 2.87$ $112,817
4100 Case Management 41,908 2.21$ $92,617
4200 Medication Support 1,766 5.28$ $9,324
4300 Crisis Intervention 1,351 4.17$ $5,634
4300 Wrap services N/A $252.56/client/mo $454,608
4400 Life Domain N/A Avg $25/family/mo $45,000
OTHER REVENUE TOTAL 84,334 $720,000
TOTAL PROGRAM REVENUE $720,000
$4,500,000
Medi-Cal Revenue 50% FFP $1,890,000
Medi-Cal Revenue 40% EPSDT $1,512,000
County SB163 Trust Fund 10%$378,000
Total Medi-Cal Revenue 3,780,000$
Total Medi-Cal Units 1,411,491
Medi-Cal cost per unit $2.68
Non Medi-Cal Billable Service Cost 220,392$
Total Non Medi-Cal Billable Units 84,334
Non Medi-Cal cost per unit $2.61
499,608.00$
Wrap Services 454,608.00$
Life Domain 45,000.00$
Other Non Medi-Cal Billable Services Cost
Page 23 of 32
Exhibit C
PROGRAM EXPENSES
Personnel Salaries, Payroll Taxes & Employee Benefits - Line Items 0001- 0042
2718777
Billing Specialist: $31,991 for 0.5 FTE for billing, AR, AP and general ledger accounting.
Human Resources Manager: $13,463 for 0.25 FTE Human Resources Recruiting, hiring, training, HR Policies and procedures
and the administration of employee's benefits.
Quality Assurance Manager: $17,329 for 0.25 FTE Oversees Quality Assurance processes, including audits, utilization Review
tracking reports and forms, creating reports and general QA tasks.
Regional Training Manager: $13,863 for 0.25 FTE Responsible for development coordination, and supervision of training
programs for the CRP. Develops and coordinates the provision of new employees orientations, required in-service trainings, and
clinical training.
SUI Payroll Taxes: $63,891 2.35% of annual salaries
Payroll Taxes.
OASDI Payroll Taxes: $168,564 6.2% of annual salaries
FICA Payroll Taxes: $39,422 1.45% of annual salaries
Program Manager: $81,043 for 1 FTE Will oversee all staff and operations, assuring compliance with Federal, State, County and
local laws and regulations. He/she oversees Supervisors who directly manage these programs or provides direct management in
their absence.
TM Wraparound Supervisor: $230,334 for 3 FTE's Under general direction, supervises operations, Family Specialists, and is
responsible for other operations of support staff and planning and coordination of clinic staff.
Clinical Supervisor: $76,778 for 1 FTE Under general direction, supervises Specialty Mental Health Services, and the work of
license-eligible therapists in accordance with BBS requirements. May also provide individual mental health services.
Family Search and Engagement Specialist: $37,706 for 1 FTE Responsible for the family search & engagement process and
services. The development of a systemic program that identifies, plans, and executes plans to assist specific teams in helping
clients in the program with family searching and engagement. Conducting trainings, monitoring and tracking of progress, and
maintaining the technology to assist teams. Represents TEAMMATES to county agencies and in the community, and assist in
direct services as necessary in facilitating permanency planning.
Intake Coordinator: $34,123 for 1 FTE processes referrals, consent packets, and paperwork, etc.
Mental Health Specialist II: $334,304 for 6 FTE's Provides initial and ongoing assessment; develops EPSDT plan. Provides
individual and family trauma-informed mental health services and therapy. Provides clinical support and information to CFTs, as
CFT and ICC team member. Documents and bills for services, and completes outcomes information.
Facilitators: $879,746 for 15 FTE's Primary contact for family; assessment, development, implementation and evaluation of IFPs;
responsibility for configuring and facilitating CFTs; case management/ICC to secure formal resources; ensures integration of
plans from system partners; oversees rehabilitative services; completes required documentation, day-to-day supervision for Child
& Family Specialists. Participates in 24-hour on-call system. (Shall not serve as assigned Therapist/Clinician for any child/youth
for whom they are assigned to serve as the Facilitator).
Child & Family Specialist: $543,843 for 10 FTE's Work directly with the child(ren) and family in their respective environments to
help them achieve permanency. Provides direct intervention services in homes and communities, which may include: role-
modeling, role-play, behavior modification, interventions/structures, socialization skills training, development of parenting skills;
under direction of Facilitator, accesses community-based resources; participates in CFTs and 24 hour on-call system.
Parent Partners: $351,898 for 15 FTE's Works closely with the Wraparound child’s parent/caregiver to represent their best
interests and participate as a member of the CFT. For a Wraparound child/youth in out-of-home placement, work with both the
out-of-home caregiver and parent/current caregiver. Shares the story of their own journey, mentors and coaches parents,
caregivers and kin in achieving POC goals; demonstrates creativity and resourcefulness in navigating systems of care; assists in
the development/facilitation of support groups; provides peer support; links family members with appropriate services, advocating
for them when necessary. Participates in 24-hour on-call system, and CFTs.
Resource Specialist: $39,924 for 1 FTE Helps coordinate and develop community resources for all participants, including
housing, vocational, educational services, transportation and other social support services. Aid in ensuring coordination of
services. Assist CFT's track delivery of service referrals.
SB 163 WRAPAROUND PROGRAM
BUDGET NARRATIVE - EXPENSES
FY 2021-22
Director of Community Services: $32,432 for 0.25 FTE oversee program management and maintain in compliance with contract
and legal requirements.
Page 24 of 32
Exhibit C
271877
462192
Facilities/Equipment Expenses – Line Items 1010-1014
91508
Operating Expenses - Line Items 1060-1077
Telephone and communications $54,005; includes staff cell phone reimbursement ($60 per month for 53 staff and one at $100
per month), internet & phones cost is $39,360 which also includes Wi-Fi for staff tablets; and for $14,645 for landline.
Postage $637 for postage and delivery.
Office supplies and equipment $15,428 based on approximately $18.95 per month for 55.5 FTE's, $624 for professional dues
and subscriptions, $1,249 property taxes, $936 for business licenses and Joint Commission fees.
Program Supplies $9,000 for client supplies and incentives based on $5 per client per month - this will cover food for family
meetings and graduation celebrations.
Staff Travel: $140,948 for mileage reimbursement based on 55.5 cents a mile for 48 FTE's for 100 miles per week plus 4 staff for
approximately 80 miles per month.
Staff Training: $5,348 which includes on-going program required education, training and materials for staff calculated at
approximately $437 per month.
Other: Purchased service $9,233 which includes consulting, on-going staff recruitment, document shredding, water and coffee
service.
Other: Centralized Program Services totaling $114,849 is comprised of the SBHG corporate and regional support in the
numerous areas including support from the Senior Administrator as well as services provided for Program Development and
Evaluation, Quality & Compliance, and Training. There is a significant cost advantage to all the SBHG company programs in
sharing these costs rather than building them into each program. SBHG support provides oversight of all of our programs to
ensure consistency with our standards and policies and procedures. The cost of this support is shared by all programs and is
budgeted at approximately 2.5% to 3% of total expenses less life domain funds.
Other: $45,000 Life domain funds for clients, transportation, lodging, utilities, clothing and food.
394448
Financial Services Expenses – Line Items 1080-1085
External Audit $3,000 for annual audit fees.
Liability Insurance: $27,857 for general liability, property and professional liability based on $501.93 per FTE.
Administrative overhead: $194,280 This is an allocation from Stars Behavioral Health Group of operations administration,
information technology, human resources, communications, finance, and associated fringe benefits and expenses. Costs are
budgeted between 4.5% and 5% of total costs based on our current allocation mode.
Payroll services: $4,590 for payroll processing fees based on $6.375 per month for 60 employees - changing payroll processing
vendor.
Professional Insurances: cost included above in Liability insurance.
Centralized fiscal services (5%) - $197,280- This line item represents operating income for Central Star. As a profit provider,
Central Star has no ability to do fund raising to offset overhead costs such as income taxes, interest expense, and other
unreimbursed expenses. This line item provides a cushion to mitigate this exposure. Calculated at 5% of total program expenses
less Client support expenses and Centralized services - Administrative.
430006
Special Expenses – Line Items 1090-1092
Translation Services $1,592 for annual translation service.
Medication Supports - Psychiatrist: $129,600 for 45 hours per month at $240 per hour.
131192
Fixed Assets – Line Items 1190-1193
Health insurance $319,457 11.75%
Equipment purchases: $27,960 for minor office equipment, furniture IT equipment, software and support
Employee Benefits:
Retirement $61,172 2.25% This includes ESOP and 401k employer match
Worker Compensation: $81,563 3% of total salaries.
Rent/Lease Building: $40,114 based on approximately $1.11 per square foot per month for 3,000 square feet
Rent/Lease Equipment: $7,641 for copier lease, toner and maintenance
Utilities: $9,551 Electricity, Water, Gas, Trash; $796 per month
Building Maintenance: $6,242 for janitorial services, repairs and maintenance $520.17 per month
Page 25 of 32
Exhibit C
($xxx,xxx.xx)
Include all purchases over Five Thousand Dollars ($5,000) including sales tax, and certain
purchases under said amount such as camera, televisions, VCRs/DVDs and other sensitive items,
made during the life of the Agreement resulting from this Request for Proposal, with funds paid
pursuant to this Agreement and that will outlive the life of this Agreement.
TOTAL PROGRAM EXPENSE:4,500,000.00$
Page 26 of 32
Exhibit C
FTE %Admin.Direct Total
PERSONNEL SALARIES:
0001 Director of Community Services 0.25 $32,918 $32,918
0002 Program Manager 1.00 $82,259 $82,258
0003 TM Wraparound supervisor 3.00 $233,789 $233,789
0004 Clinical Supervisor 1.00 $77,930 $77,930
0005 Clinicians - Mental Health Specialist 6.00 $339,318 $339,318
0006 Facilitator 15.00 $892,942 $892,942
0007 Child and Family Specialist 10.00 $552,001 $552,001
0008 Parent Partner 15.00 $357,177 $357,177
0009 Resource Specialist 1.00 $40,523 $40,523
0010 Family Search & Engagement Specialist 1.00 $38,272 $38,272
0011 Intake Coordinator 1.00 $34,635 $34,635
0012 Billing Specialist 0.50 $32,471 $32,471
0013 Human Resource Manager 0.25 $13,665 $13,665
0014 Regional Training Manager 0.25 $14,071 $14,071
0015 Quality Assurance Manager 0.25 $17,588 $17,588
SALARY TOTAL 55.50 $145,348 $2,614,211 $2,759,558
PAYROLL TAXES:
0030 OASDI $9,012 $162,081 $171,093
0031 FICA/MEDICARE $2,108 $37,906 $40,014
0032 SUI $3,416 $61,434 $64,849
PAYROLL TAX TOTAL $14,535 $261,421 $275,956
EMPLOYEE BENEFITS:
0040 Retirement $3,270 $58,820 $62,090
0041 Workers Compensation $4,360 $78,426 $82,787
0042 Health Insurance (medical, vision, life, dental)$16,352 $294,099 $310,450
EMPLOYEE BENEFITS TOTAL $23,982 $431,345 $455,327
SALARY & BENEFITS GRAND TOTAL $3,490,840
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $40,114
1011 Rent/Lease Equipment $7,641
1012 Utilities $9,551
1013 Building Maintenance $6,242
1014 Equipment purchase $24,760
FACILITY/EQUIPMENT TOTAL $88,308
OPERATING EXPENSES:
1060 Telephone $54,005
1061 Answering Service $0
1062 Postage $637
Line Item Description (Must be itemized)
BUDGET
SB 163 WRAPAROUND PROGRAM
FISCAL YEAR 2022-23
Budget Categories -Total Proposed Budget
Page 27 of 32
Exhibit C
1063 Printing/Reproduction $0
1064 Publications $0
1065 Legal Notices/Advertising $0
1066 Office Supplies & Equipment $10,048
1067 Household Supplies $0
1068 Food $0
1069 Program Supplies - Therapeutic $9,000
1070 Program Supplies - Medical $0
1071 Transportation of Clients $0
1072 Staff Mileage/vehicle maintenance $143,062
1073 Staff Travel (Out of County)$0
1074 Staff Training/Registration $5,348
1075 Lodging $0
1076 Other - Purchased services $9,233
1077 Other - Centralized services - program $99,442
1078 Other - Life Domains $45,000
1079 Other - Start-up $0
OPERATING EXPENSES TOTAL $375,775
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $3,000
1082 Liability Insurance $28,415
1083 Administrative Overhead $178,995
1084 Payroll Services $4,590
1085 Professional Liability Insurance $0
1086 Centralized fiscal services $198,885
FINANCIAL SERVICES TOTAL $413,885
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management)
1091 Translation Services $1,592
1092 Medication Supports $129,600
SPECIAL EXPENSES TOTAL $131,192
FIXED ASSETS:
1190 Computers & Software
1191 Furniture & Fixtures
1192 Other - (Identify)
1193 Other - (Identify)
FIXED ASSETS TOTAL
TOTAL PROGRAM EXPENSES $4,500,000
MEDI-CAL REVENUE:Units of Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)24,624 2.87$ $70,671
3100 Case Management
3200 Crisis Services 25,650 4.17$ $106,961
3300 Medication Support 34,200 5.18$ $177,156
Page 28 of 32
Exhibit C
3400 Collateral 102,600 2.87$ $294,462
3500 Plan Development 2,280 2.87$ $6,544
3600 Assessment 3,420 2.87$ $9,815
3700 Rehabilitation 2.87$ $0
3800 Intensive Case Coordination - Wraparound Services 580,797 2.21$ $1,283,561
3700 Intensive Home-Based Services 637,920 2.87$ $1,830,830
DIRECT SERVICE REVENUE TOTAL 1,411,491 $3,780,000
OTHER REVENUE: Non Medical Revenue
4000 Mental Health Services 39,309 2.87$ $112,817
4100 Case Management 41,908 2.21$ $92,617
4200 Medication Support 1,766 5.28$ $9,324
4300 Crisis Intervention 1,351 4.17$ $5,634
4300 Wrap services N/A $252.56/client/mo $454,608
4400 Life Domain N/A vg $25/family/mo $45,000
OTHER REVENUE TOTAL 84,334 $720,000
TOTAL PROGRAM REVENUE $720,000
$4,500,000
Medi-Cal Revenue 50% FFP $1,890,000
Medi-Cal Revenue 40% EPSDT $1,512,000
County SB163 Trust Fund 10%$378,000
Total Medi-Cal Revenue 3,780,000$
Total Medi-Cal Units 1,411,491
Medi-Cal cost per unit $2.68
Non Medi-Cal Billable Service Cost 220,392$
Total Non Medi-Cal Billable Units 84,334
Non Medi-Cal cost per unit $2.61
499,608.00$
Wrap Services 454,608.00$
Life Domain 45,000.00$
Other Non Medi-Cal Billable Services Cost
Page 29 of 32
Exhibit C
PROGRAM EXPENSES
Personnel Salaries, Payroll Taxes & Employee Benefits - Line Items 0001- 0042
2759558
Billing Specialist: $32,471 for .5 FTE for billing, AR, AP and general ledger accounting.
Human Resources Manager: $13,665 for 0.25 FTE Human Resources Recruiting, hiring, training, HR Policies and procedures and
the administration of employee's benefits.
Quality Assurance Manager: $17,588 for 0.25 FTE Oversees Quality Assurance processes, including audits, utilization Review
tracking reports and forms, creating reports and general QA tasks.
Regional Training Manager: $14,071 for 0.25 FTE Responsible for development coordination, and supervision of training
programs for the CRP. Develops and coordinates the provision of new employees orientations, required in-service trainings, and
clinical training.
Program Manager: $82,258 for 1 FTE Will oversee all staff and operations, assuring compliance with Federal, State, County and
local laws and regulations. He/she oversees Supervisors who directly manage these programs or provides direct management in
their absence.
TM Wraparound Supervisor: $233,789 for 3 FTE's Under general direction, supervises operations, Family Specialists, and is
responsible for other operations of support staff and planning and coordination of clinic staff.
Clinical Supervisor: $77,930 for 1 FTE Under general direction, supervises Specialty Mental Health Services, and the work of
license-eligible therapists in accordance with BBS requirements. May also provide individual mental health services.
Family Search and Engagement Specialist: $38,272 for 1 FTE Responsible for the family search & engagement process and
services. The development of a systemic program that identifies, plans, and executes plans to assist specific teams in helping
clients in the program with family searching and engagement. Conducting trainings, monitoring and tracking of progress, and
maintaining the technology to assist teams. Represents TEAMMATES to county agencies and in the community, and assist in
direct services as necessary in facilitating permanency planning.
Intake Coordinator: $34,635 for 1 FTE processes referrals, consent packets, and paperwork, etc.
Mental Health Specialist II: $339,318 for 6 FTE's Provides initial and ongoing assessment; develops EPSDT plan. Provides
individual and family trauma-informed mental health services and therapy. Provides clinical support and information to CFTs, as
CFT and ICC team member. Documents and bills for services, and completes outcomes information.
Facilitators: $892,942 for 15 FTE's Primary contact for family; assessment, development, implementation and evaluation of IFPs;
responsibility for configuring and facilitating CFTs; case management/ICC to secure formal resources; ensures integration of plans
from system partners; oversees rehabilitative services; completes required documentation, day-to-day supervision for Child &
Family Specialists. Participates in 24-hour on-call system. (Shall not serve as assigned Therapist/Clinician for any child/youth for
whom they are assigned to serve as the Facilitator).
Child & Family Specialist: $552,001 for 10 FTE's Work directly with the child(ren) and family in their respective environments to
help them achieve permanency. Provides direct intervention services in homes and communities, which may include: role-
modeling, role-play, behavior modification, interventions/structures, socialization skills training, development of parenting skills;
under direction of Facilitator, accesses community-based resources; participates in CFTs and 24 hour on-call system.
Parent Partners: $357,177 for 15 FTE's Works closely with the Wraparound child’s parent/caregiver to represent their best
interests and participate as a member of the CFT. For a Wraparound child/youth in out-of-home placement, work with both the out-
of-home caregiver and parent/current caregiver. Shares the story of their own journey, mentors and coaches parents, caregivers
and kin in achieving POC goals; demonstrates creativity and resourcefulness in navigating systems of care; assists in the
development/facilitation of support groups; provides peer support; links family members with appropriate services, advocating for
them when necessary. Participates in 24-hour on-call system, and CFTs.
Resource Specialist: $40,523 for 1 FTE Helps coordinate and develop community resources for all participants, including housing,
vocational, educational services, transportation and other social support services. Aid in ensuring coordination of services. Assist
CFT's track delivery of service referrals.
SB 163 WRAPAROUND PROGRAM
BUDGET NARRATIVE - EXPENSES
FY 2021-22
Director of Community Services: $32,918 for 0.25 FTE oversee program management and maintain in compliance with contract
and legal requirements
Page 30 of 32
Exhibit C
275956
455327
Facilities/Equipment Expenses – Line Items 1010-1014
88308
Operating Expenses - Line Items 1060-1077
375775
Financial Services Expenses – Line Items 1080-1085
413884
Telephone and communications $54,005; includes staff cell phone reimbursement ($60 per month for 53 staff and one at $100 per
month), internet & phones cost is $39,360 which also includes Wi-Fi for staff tablets; and for $14,645 for landline.
Liability Insurance: $28,415 for general liability, property and professional liability based on $511.98 per FTE.
Administrative overhead: $179,995 This is an allocation from Stars Behavioral Health Group of operations administration,
information technology, human resources, communications, finance, and associated fringe benefits and expenses. Costs are
budgeted between 4.5% and 5% of total costs based on our current allocation mode.
Payroll services: $4,590 for payroll processing fees based on $6.375 per month for 60 employees.
Professional Insurances: cost included above in Liability insurance.
Centralized fiscal services (5%) - $198,885- This line item represents operating income for Central Star. As a profit provider,
Central Star has no ability to do fund raising to offset overhead costs such as income taxes, interest expense, and other
unreimbursed expenses. This line item provides a cushion to mitigate this exposure. Calculated at 5% of total program expenses
less Client support expenses and Centralized services - Administrative.
Staff Training: $5,348 which includes on-going program required education, training and materials for staff calculated at
approximately $437 per month Other: Purchased service $9,233 which includes consulting, on-going staff recruitment, document shredding, water and coffee
service.
Other: Centralized Program Services totaling $99,442 is comprised of the SBHG corporate and regional support in the numerous
areas including support from the Senior Administrator as well as services provided for Program Development and Evaluation,
Quality & Compliance, and Training. There is a significant cost advantage to all the SBHG company programs in sharing these
costs rather than building them into each program. SBHG support provides oversight of all of our programs to ensure consistency
with our standards and policies and procedures. The cost of this support is shared by all programs and is budgeted at
approximately 2.5% to 3% of total expenses less life domain funds.
Other: $45,000 Life domain funds for clients, transportation, lodging, utilities, clothing and food.
External Audit $3,000 for annual audit fees.
Postage $637 for postage and delivery.
Office supplies and equipment $10,048 based on approximately $11 per month for 56.5 FTE's, $624 for professional dues and
subscriptions, $1,249 property taxes, $936 for business licenses and Joint Commission fees.
Program Supplies $9,000 for client supplies and incentives based on $5 per client per month - this will cover food for family
meetings and graduation celebrations.
Staff Travel: $143,062 for mileage reimbursement based on 56.5 cents a mile for 48 FTE's for 100 miles per week plus 4 staff for
approximately 80 miles per month.
SUI Payroll Taxes: $64,849 2.35% of annual salaries
Health insurance $310,450 11.25%
Equipment purchases: $24,760 for minor office equipment, furniture IT equipment, software and support
Payroll Taxes.
OASDI Payroll Taxes: $171,093 6.2% of annual salaries
FICA Payroll Taxes: $40,014 1.45% of annual salaries
Employee Benefits:
Retirement $62,090 2.25% This includes ESOP and 401k employer match
Worker Compensation: $82,787 3% of total salaries.
Rent/Lease Building: $40,114 based on approximately $1.11 per square foot per month for 3,000 square feet
Rent/Lease Equipment: $7,641 for copier lease, toner and maintenance
Utilities: $9,551 Electricity, Water, Gas, Trash; $796 per month
Building Maintenance: $6,242 for janitorial services, repairs and maintenance $520.17 per month
Page 31 of 32
Exhibit C
Special Expenses – Line Items 1090-1092
131192
Fixed Assets – Line Items 1190-1193
($xxx,xxx.xx)
Medication Supports - Psychiatrist: $129,600 for 45 hours per month at $240 per hour.
Include all purchases over Five Thousand Dollars ($5,000) including sales tax, and certain
purchases under said amount such as camera, televisions, VCRs/DVDs and other sensitive items,
made during the life of the Agreement resulting from this Request for Proposal, with funds paid
pursuant to this Agreement and that will outlive the life of this Agreement.
TOTAL PROGRAM EXPENSE:4,500,000.00$
Translation Services $1,592 for annual translation service.
Page 32 of 32
RFP 18-015 Page 1 of 4 Exhibit D
Contract #Contractor Name
Contract Term Address
Annual Contract Max Invoice End Date
Maximum Contract sum Reporting Month
Total Billed to date
% Billed
Aid Flex
DSS Case#Case Name DOB Date #Mo.Start Current Code AAP PRO TFC Units Amount Units Amount Funds Units Amount
AAP Non-MC Dollars
Non-AAP Non-MC Dollars
AAP Count 0 Total Non-MC Dollars
PRO Count 0 Total Non-MC Units Total Medi-Cal Dollars
TFC Count 0 Total Medi-Cal Units Total Flex Fund Dollars
Total Child Count 0 Grand total Units Grand Total Dollars
Average Cost/Child:
Prepared by: Approved by:
Date:Date:
(DSS)
0
0
0
-$
-$
-$
-$
Program Non-Medi-Cal Medi-Cal TotalEnrolledRCL
-$
-$
Invoice Summary
DSS Client Identification
RFP 18-015 Page 2 of 4 Exhibit D
Contract #Contractor Name
Contract Term Report Begin Date
Annual Contract Max Report End Date
Annual Medi-Cal Total Units
Total Billed to date Total Dollars
% Billed
Service Date DSS Case ID DSS WA ID Program PATID Patient Name Service #Service Description Units Provider Cost Status
Total Child Count
Medi-Cal Unit Detail
RFP 18-015 Page 3 of 4 Exhibit D
Contract #Contractor Name
Contract Term Report Begin Date
Annual Contract Max Report End Date
Annual NonMedi-Cal Total Units
Total Billed to date Total Dollars
% Billed
Service Date DSS Case ID DSS WA ID Program PATID Patient Name Service #Service Description Units Provider Cost Status
Total Child Count
Non Medi-Cal Unit Detail
RFP 18-015 Page 4 of 4 Exhibit D
Contract #Contractor Name
Contract Term Report Begin Date
Annual Contract Max Report End Date
Annual Flex Fund Total Units
Total Billed to date Total Dollars
% Billed
Service Date DSS Case ID
Total Child Count
CMTor Management Description/Reason Flex Fund ID Code
Flex Fund Detail
Flex Fund Definition Amount
RFP 18-015 Page: 1 of 4 Exhibit E
June 2018 - June 2019 Contract Year
Combined Program Cost Budget %Q1 (Jul-Sept)Q2 (Oct-Dec)Q3 (Jan-Mar)Q4 (Apr-Jun)YTD FY2015-16 % of Total
Salaries -$ -$ -$ -$ -$
Payroll taxes -$ -$ -$ -$ -$
Employee Benefits -$ -$ -$ -$ -$
Rents/Lease Building -$ -$ -$ -$ -$
Rents/Lease Equipment -$ -$ -$ -$ -$
Maintenance (Facility)-$ -$ -$ -$ -$
Other - Depreciation -$ -$ -$ -$ -$
Telephone -$ -$ -$ -$ -$
Postage/shipping/Printing -$ -$ -$ -$ -$
Office Supplies and Equipment -$ -$ -$ -$ -$
Program Supplies - Therapeutic -$ -$ -$ -$ -$
Staff MileageVehicle maintenance -$ -$ -$ -$ -$
Staff Trainin Registration -$ -$ -$ -$ -$
Other - Emergency Flex Funds -$ -$ -$ -$ -$
External Audit -$ -$ -$ -$ -$
Liability insurance -$ -$ -$ -$ -$
Other - Administrative Overhead -$ -$ -$ -$ -$
Medication Supports -$ -$ -$ -$ -$
Total Expenses -$ -$ -$ -$ -$
Budget Total Q1 Q2 Q3 Q4 Total YTD No. of Consumers
Medical -$ -$ -$ -$ -$ 0 < Medi-Cal
NonMedical -$ -$ -$ -$ -$ 0 < non-Medi-Cal
Total -$ -$ -$ -$ -$ 0
Budget Total %Q1 %Q2 %Q3 %Q4 %Total YTD %
Medical
NonMedical
PROGRAM EXPENSES (150 Clients)
Budget Categories -
Line Item Description (Must be itemized)FTE %Total MediCal Non Medi-Cal Non-AAP AAP Non-AAP AAP
PERSONNEL SALARIES:
SALARY TOTAL
PAYROLL TAXES:
PAYROLL TAX TOTAL
EMPLOYEE BENEFITS:
EMPLOYEE BENEFITS TOTAL
SALARY & BENEFITS GRAND TOTAL
FACILITIES/EQUIPMENT EXPENSES:
Rent/Lease Building
Rent/Lease Equipment
Maintenance (facility)
Other - Depreciation
FACILITY/EQUIPMENT TOTAL
OPERATING EXPENSES:
Telephone
Postage/Shipping/Printing
Office Supplies & Equipment
Program Supplies - Therapeutic
Staff Mileage/vehicle maintenance
Staff Training/Registration
Other - Emergency Flex Funds
OPERATING EXPENSES TOTAL
FINANCIAL SERVICES EXPENSES:
External Audit
Liability Insurance
Other - Administrative Overhead
FINANCIAL SERVICES TOTAL
SPECIAL EXPENSES (Consultant/Etc.):
Medication Supports
SPECIAL EXPENSES TOTAL
TOTAL PROGRAM EXPENSE
Medi-Cal Billable Cost Non Medi-Cal Billable CostTotal
Cost Allocation and Contract Budget Comparison
~-I I I I I I I
I I I I
I
I
I
I
I
I
RFP 18-015 Page: 2 of 4 Exhibit E
June 2018 - June 2019 Contract Year
Combined ALL Budget Q1 Q2 Q3 Q4 YTD % of Total
Salaries - - - - -
Payroll taxes - - - - -
Employee Benefits - - - - -
Rents/Lease Building - - - - -
Rents/Lease Equipment - - - - -
Maintenance (Facility)- - - - -
Other - Depreciation - - - - -
Telephone - - - - -
Postage/shipping/Printing - - - - -
Office Supplies and Equipment - - - - -
Program Supplies - Therapeutic - - - - -
Staff MileageVehicle maintenance - - - - -
Staff Trainin Registration - - - - -
Other - Emergency Flex Funds - - - - -
External Audit - - - - -
Liability insurance - - - - -
Other - Administrative Overhead - - - - -
Medication Supports - - - - -
- - - - - -
Total Expenses - - - - -
Combined Non AAP Budget Jul-15 Aug-15 Sep-15 Q1 Oct-15 Nov-15 Dec-15 Q2 Jan-16 Feb-16 Mar-16 Q3 Apr-16 May-16 Jun-16 Q4 YTD % of Total
Salaries - - - - - - - - - - - - - - - - -
Payroll taxes - - - - - - - - - - - - - - - - -
Employee Benefits - - - - - - - - - - - - - - - - -
Rents/Lease Building - - - - - - - - - - - - - - - - -
Rents/Lease Equipment - - - - - - - - - - - - - - - - -
Maintenance (Facility)- - - - - - - - - - - - - - - - -
Other - Depreciation - - - - - - - - - - - - - - - - -
Telephone - - - - - - - - - - - - - - - - -
Postage/shipping/Printing - - - - - - - - - - - - - - - - -
Office Supplies and Equipment - - - - - - - - - - - - - - - - -
Program Supplies - Therapeutic - - - - - - - - - - - - - - - - -
Staff MileageVehicle maintenance - - - - - - - - - - - - - - - - -
Staff Trainin Registration - - - - - - - - - - - - - - - - -
Other - Emergency Flex Funds - - - - - - - - - - - - - - - - -
External Audit - - - - - - - - - - - - - - - - -
Liability insurance - - - - - - - - - - - - - - - - -
Other - Administrative Overhead - - - - - - - - - - - - - - - - -
Medication Supports - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - -
Total Expenses 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -
Combined AAP Budget Jul-15 Aug-15 Sep-15 Q1 Oct-15 Nov-15 Dec-15 Q1 Jan-16 Feb-16 Mar-16 Q3 Apr-16 May-16 Jun-16 Q4 YTD % of Total
Salaries - - - - - - - - - - - - - - - - -
Payroll taxes - - - - - - - - - - - - - - - - -
Employee Benefits - - - - - - - - - - - - - - - - -
Rents/Lease Building - - - - - - - - - - - - - - - - -
Rents/Lease Equipment - - - - - - - - - - - - - - - - -
Maintenance (Facility)- - - - - - - - - - - - - - - - -
Other - Depreciation - - - - - - - - - - - - - - - - -
Telephone - - - - - - - - - - - - - - - - -
Postage/shipping/Printing - - - - - - - - - - - - - - - - -
Office Supplies and Equipment - - - - - - - - - - - - - - - - -
Program Supplies - Therapeutic - - - - - - - - - - - - - - - - -
Staff MileageVehicle maintenance - - - - - - - - - - - - - - - - -
Staff Trainin Registration - - - - - - - - - - - - - - - - -
Other - Emergency Flex Funds - - - - - - - - - - - - - - - - -
External Audit - - - - - - - - - - - - - - - - -
Liability insurance - - - - - - - - - - - - - - - - -
Other - Administrative Overhead - - - - - - - - - - - - - - - - -
Medication Supports - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - -
Total Expenses 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -
RFP 18-015 Page: 3 of 4 Exhibit E
June 2018 - June 2019 Contract Year
MediCal Non AAP Budget Jul-15 Aug-15 Sep-15 Q1 Oct-15 Nov-15 Dec-15 Q2 Jan-16 Feb-16 Mar-16 Q3 Apr-16 May-16 Jun-16 Q4 YTD % of Total
Salaries - - - - -
Payroll taxes - - - - -
Employee Benefits - - - - -
Rents/Lease Building - - - - -
Rents/Lease Equipment - - - - -
Maintenance (Facility)- - - - -
Other - Depreciation - - - - -
Telephone - - - - -
Postage/shipping/Printing - - - - -
Office Supplies and Equipment - - - - -
Program Supplies - Therapeutic - - - - -
Staff MileageVehicle maintenance - - - - -
Staff Trainin Registration - - - - -
Other - Emergency Flex Funds - - - - -
External Audit - - - - -
Liability insurance - - - - -
Other - Administrative Overhead - - - - -
Medication Supports - - - - -
- - - - -
Total Expenses 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
MediCal - AAP Budget Jul-15 Aug-15 Sep-15 Q1 Oct-15 Nov-15 Dec-15 Q2 Jan-16 Feb-16 Mar-16 Q3 Apr-16 May-16 Jun-16 Q4 YTD % of Total
Salaries - - - - -
Payroll taxes - - - - -
Employee Benefits - - - - -
Rents/Lease Building - - - - -
Rents/Lease Equipment - - - - -
Maintenance (Facility)- - - - -
Other - Depreciation - - - - -
Telephone - - - - -
Postage/shipping/Printing - - - - -
Office Supplies and Equipment - - - - -
Program Supplies - Therapeutic - - - - -
Staff MileageVehicle maintenance - - - - -
Staff Trainin Registration - - - - -
Other - Emergency Flex Funds - - - - -
External Audit - - - - -
Liability insurance - - - - -
Other - Administrative Overhead - - - - -
Medication Supports - - - - -
- - - - - Total Expenses 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -
-
Cost Allocation and Contract Budget Comparison
RFP 18-015 Page: 4 of 4 Exhibit E
June 2018 - June 2019 Contract Year
SB 163 Program Cost Budget Jul-15 Aug-15 Sep-15 Q1 Oct-15 Nov-15 Dec-15 Q2 Jan-16 Feb-16 Mar-16 Q3 Apr-16 May-16 Jun-16 Q4 YTD % of Total
Salaries - - - - -
Payroll taxes - - - - -
Employee Benefits - - - - -
Rents/Lease Building - - - - -
Rents/Lease Equipment - - - - -
Maintenance (Facility)- - - - -
Other - Depreciation - - - - -
Telephone - - - - -
Postage/shipping/Printing - - - - -
Office Supplies and Equipment - - - - -
Program Supplies - Therapeutic - - - - -
Staff MileageVehicle maintenance - - - - -
Staff Trainin Registration - - - - -
Other - Emergency Flex Funds - - - - -
External Audit - - - - -
Liability insurance - - - - -
Other - Administrative Overhead - - - - -
Medication Supports - - - - -
- - - - -
Total Expenses 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
AAP Program Cost Budget Jul-15 Aug-15 Sep-15 Q1 Oct-15 Nov-15 Dec-15 Q2 Jan-16 Feb-16 Mar-16 Q3 Apr-16 May-16 Jun-16 Q4 YTD % of Total
Salaries - - - - -
Payroll taxes - - - - -
Employee Benefits - - - - -
Rents/Lease Building - - - - -
Rents/Lease Equipment - - - - -
Maintenance (Facility)- - - - -
Other - Depreciation - - - - -
Telephone - - - - -
Postage/shipping/Printing - - - - -
Office Supplies and Equipment - - - - -
Program Supplies - Therapeutic - - - - -
Staff MileageVehicle maintenance - - - - -
Staff Trainin Registration - - - - -
Other - Emergency Flex Funds - - - - -
External Audit - - - - -
Liability insurance - - - - -
Other - Administrative Overhead - - - - -
Medication Supports - - - - -
- - - - -
Total Expenses 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Cost Allocation and Contract Budget Comparison
Exhibit F
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 and subcontractors shall comply. Contractor shall require its
employees and subcontractors to attend a compliance training that will be provided by Fresno
County. After completion of this training, each contractor, contractor’s employee 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 F
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 F
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
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 G
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 ten (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.
B. Client Plans
1. Client plans will:
• have specific observable and/or specific quantifiable goals
Exhibit G
Page 2 of 3
• 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
• 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
Exhibit G
Page 3 of 3
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 H
Page 1 of 2
FRESNO COUNTY DSS OUTCOME MEASUREMENTS
Evaluation Element Outcomes Indicators Data Sources/
Measuring Tool
Cost Effectiveness Cost Neutrality
NO additional funding requested/required
Family Functioning Measurable improvement in
individual and family
functioning status
Improved scores on clinical assessment tools
Prevention of Placements in More
Restrictive
Environments
Maintain target pop. children
with complex needs (RCL 10 -
14) in family like settings
WRAP Participants:
- Reduce incidence of Placement in RCL
10-14 group homes for those in Program
- Placement in a stable, family-like setting
- Move to lower level family-like setting
Improvement of
Emotional and
Behavioral Adjustment
Measurable improvement in
functioning status
Improved scores on clinical assessment tools
School Attendance Increased school attendance
of children in the target
population Enrollment in the
least restrictive environment
Increase in # of days child attends school.
Decrease in the level of restrictiveness in the
school environment.
Academic Performance Increased student
performance, particularly in
reading, math and spelling
- Improvement on standardized tests
- Improvement on daily class assignments
- Class Level Advancement
Parent/Caregiver Satisfaction High level of satisfaction with
the services provided through
the Wraparound Process
High satisfaction scores on the following
instruments:
- CSQ-8
- CSQ-18/EMQ
- YSQ
Improvement in Family Involvement Increased level of
parent/child/sibling
involvement
Observing increased involvement
Narratives re: increased involvement
Scores on clinical scales
Family & Child Goal
Attainment
High level of goal attainment High level of goal attainment reported on
Self-Report Questionnaire
Exhibit H
Page 2 of 2
FRESNO COUNTY DBH OUTCOME MEASUREMENTS
CONTRACTOR shall provide tracking tools and measurements for effectiveness,
efficiency, access, and client satisfaction indicators as required by the Commission on
Accreditation of Rehabilitation Facilities (CARF) standards. Documentation for these
four indicators shall include the following data: to whom the indicator applied, who is
responsible for collecting the data, time of measure, data source, and target goal
expectancy.
1. Access to care: The ability of clients to receive the right service at the right time.
a. Timeliness of referral to contact
b. Timeliness between referral to assessment and completion of
assessment; assessment to first treatment service; and first treatment
service to subsequent follow-up visit(s)
c. Timeliness between referral to medication evaluation and subsequent
follow-up visit(s)
2. Effectiveness: Objective results achieved through services.
a. Effectiveness of treatment interventions
b. Effectiveness of providing care providers with training
c. Effectiveness of discharge planning (e.g. percentage of clients
successfully linked to lower levels of care
3. Efficiency: Demonstration of the relationship between results and the resources
used to achieve them.
a. Length of client stay in program
b. Number of units of service per client
c. Cost per client
4. Satisfaction and Compliance: The degree to which clients, County, and other
stakeholders are satisfied with the services.
a. Audits and other performance and utilization reviews of health care
services and compliance with agreement terms and conditions
b. Surveys of persons serviced, family members, other health care
providers, and other stakeholders
RFP 18-015 Page: 1 of 2 Exhibit I
ACTIVITY REPORT
ORGANIZATION:Central Star Behavioral Health
SERVICES:Senate Bill 163 (SB163) Wraparound Services
CONTRACT PERIOD:June 1 2018 to June 30, 2019
GENERAL OUTCOME GOAL:
Jul Aug Sep Q1 Oct Nov Dec Q2
SB163 SERVICES CLIENT INFORMATION:
1.Existing number of clients at the beginning of the month 0 0 0 0 0 0 0 0
a. AAP 0 0 0 0 0 0 0 0
b. Probation 0 0 0 0 0 0 0 0
c. Child Welfare 0 0 0 0 0 0 0 0
2.Total number of new clients enrolled after IRPC approval referred by:0 0 0 0 0 0 0 0
a. AAP 0 0 0 0 0 0 0 0
b. Probation 0 0 0 0 0 0 0 0
c. Child Welfare 0 0 0 0 0 0 0 0
3.0 0 0 0 0 0 0 0
a. In custody the 1st of the month 0 0 0 0 0 0 0 0
b. In custody the last day of the month 0 0 0 0 0 0 0 0
c. Ended the program during the month (for any reason)0 0 0 0 0 0 0 0
4.Total Number of clients who received face to face initial contact 0 0 0 0 0 0 0 0
a. Clients receiving face-to-face contact 72 hours or less after enrollment 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
5.Total number of clients actively receiving services 0 0 0 0 0 0 0 0
a. Number of clients billed to Medi-Cal and SB163 Trust 0 0 0 0 0 0 0 0
b. Number of clients billed only to the SB163 Trust 0 0 0 0 0 0 0 0
6.Enrolled/Active in Program
Clients enrolled for 0 - 3 months 0 0 0 0 0 0 0 0
Clients enrolled for 3 - 6 months 0 0 0 0 0 0 0 0
Clients enrolled for 6 - 12 months 0 0 0 0 0 0 0 0
Clients enrolled for over 12 months 0 0 0 0 0 0 0 0
Clients enrolled for 18+ months (All of these need to be tracked in the Notes Tab)0 0 0 0 0 0 0 0
7.Number of clients participating in ongoing counseling/therapy (6a+6b+6c)0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
Exiting from Program
1.0 0 0 0 0 0 0 0
a.0 0 0 0 0 0 0 0
b.0 0 0 0 0 0 0 0
c.0 0 0 0 0 0 0 0
d.Returned to out of home care (higher level of care)0 0 0 0 0 0 0 0
e.Subsequent removal due to abuse 0 0 0 0 0 0 0 0
f.In JJC custody/youth rearrested 0 0 0 0 0 0 0 0
g.0 0 0 0 0 0 0 0
h.0 0 0 0 0 0 0 0
i.0 0 0 0 0 0 0 0
j.0 0 0 0 0 0 0 0
k.AWOL/Ran away 0 0 0 0 0 0 0 0
2.0 0 0 0 0 0 0 0
a.Clients enrolled for 0 - 3 months 0 0 0 0 0 0 0 0
b.Clients enrolled for 3 - 6 months 0 0 0 0 0 0 0 0
c.Clients enrolled for 6 - 12 months 0 0 0 0 0 0 0 0
d.Clients enrolled for 12-18 months 0 0 0 0 0 0 0 0
e.Clients enrolled for 18+ months 0 0 0 0 0 0 0 0
Katie A Mandates
a.Number of Clients who received an ICC Meeting 0 0 0 0 0 0 0 0
b.Number of Clients who received an IHBS Service 0 0 0 0 0 0 0 0
c.Number of Teaming Meetings attended with CWS 0 0 0 0 0 0 0 0
CLIENT DEMOGRAPHICS (For current month)
a.0 0 0 0 0 0 0 0
b.0 0 0 0 0 0 0 0
c.0 0 0 0 0 0 0 0
d.0 0 0 0 0 0 0 0
e.0 0 0 0 0 0 0 0
f.0 0 0 0 0 0 0 0
g.0 0 0 0 0 0 0 0
h.0 0 0 0 0 0 0 0
i.0 0 0 0 0 0 0 0
COMMENTS: PLEASE PLACE ANY COMMENTS OR NOTES IN THE NOTES TAB. THANK YOU
Total number of Hispanic or Latino clients
Total number of White clients
Total number of Black or African American
Total number of Asian clients
Length of Stay when exited program
Total number clients of an ethnicity not defined by the above categories
Total number female clients
Total number male clients
Total number of clients residing with parent/ relative
Total number of clients residing with foster care provider
Services no longer needed to meet educational needs (IEP)
Moved out of area
a. Counseling/Therapy provided by SB163 Provider staff
Probation Minors in custody the 1st of the month and received services while in custody during the reporting
a. Clients receiving face-to-face contact 72 hours or more after enrollment
Children and their long-term supports will receive services to help them
build on their strengths, to prevent group home placement, step down
from group home level of care 10 or higher, and/or maintain current living
arrangements.
Family declined intensive service
b. Counseling/Therapy provided by Star, Uplift or CPI
c. Counseling/Therapy provided by County Mental Health Staff
Primary reason for discharge (total monthly discharges: one count per child)
Goal Achievement
Dependency dismissed at youth's request (of age)
Reunification was successful and dependency was dismissed
Dissatisfied with services/voluntarily disenrolled
RFP 18-015 Page: 2 of 2 Exhibit I
ACTIVITY REPORT
ORGANIZATION:Central Star Behavioral Health
SERVICES:Senate Bill 163 (SB163) Wraparound Services
CONTRACT PERIOD:June 1 2018 to June 30, 2019
GENERAL OUTCOME GOAL:
SB163 SERVICES CLIENT INFORMATION:
1.Existing number of clients at the beginning of the month
a. AAP
b. Probation
c. Child Welfare
2.Total number of new clients enrolled after IRPC approval referred by:
a. AAP
b. Probation
c. Child Welfare
3.
a. In custody the 1st of the month
b. In custody the last day of the month
c. Ended the program during the month (for any reason)
4.Total Number of clients who received face to face initial contact
a. Clients receiving face-to-face contact 72 hours or less after enrollment
5.Total number of clients actively receiving services
a. Number of clients billed to Medi-Cal and SB163 Trust
b. Number of clients billed only to the SB163 Trust
6.Enrolled/Active in Program
Clients enrolled for 0 - 3 months
Clients enrolled for 3 - 6 months
Clients enrolled for 6 - 12 months
Clients enrolled for over 12 months
Clients enrolled for 18+ months (All of these need to be tracked in the Notes Tab)
7.Number of clients participating in ongoing counseling/therapy (6a+6b+6c)
Exiting from Program
1.a.
b.
c.
d.Returned to out of home care (higher level of care)
e.Subsequent removal due to abuse
f.In JJC custody/youth rearrested
g.
h.
i.
j.
k.AWOL/Ran away
2.
a.Clients enrolled for 0 - 3 months
b.Clients enrolled for 3 - 6 months
c.Clients enrolled for 6 - 12 months
d.Clients enrolled for 12-18 months
e.Clients enrolled for 18+ months
Katie A Mandates
a.Number of Clients who received an ICC Meeting
b.Number of Clients who received an IHBS Service
c.Number of Teaming Meetings attended with CWS
CLIENT DEMOGRAPHICS (For current month)
a.
b.
c.
d.
e.
f.
g.
h.
i.
COMMENTS: PLEASE PLACE ANY COMMENTS OR NOTES IN THE NOTES TAB. THANK YOU
Total number of Hispanic or Latino clients
Total number of White clients
Total number of Black or African American
Total number of Asian clients
Length of Stay when exited program
Total number clients of an ethnicity not defined by the above categories
Total number female clients
Total number male clients
Total number of clients residing with parent/ relative
Total number of clients residing with foster care provider
Services no longer needed to meet educational needs (IEP)
Moved out of area
a. Counseling/Therapy provided by SB163 Provider staff
Probation Minors in custody the 1st of the month and received services while in custody during the reporting
a. Clients receiving face-to-face contact 72 hours or more after enrollment
Children and their long-term supports will receive services to help them
build on their strengths, to prevent group home placement, step down
from group home level of care 10 or higher, and/or maintain current living
arrangements.
Family declined intensive service
b. Counseling/Therapy provided by Star, Uplift or CPI
c. Counseling/Therapy provided by County Mental Health Staff
Primary reason for discharge (total monthly discharges: one count per child)
Goal Achievement
Dependency dismissed at youth's request (of age)
Reunification was successful and dependency was dismissed
Dissatisfied with services/voluntarily disenrolled
Jan Feb Mar Q3 Apr May Jun Q4
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
Exhibit J
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, rates
of pay or other forms of compensation, use of facilities, and other terms
and conditions of employment.
Exhibit J
Page 2 of 6
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 this Agreement will:
1) Receive a copy of the company's drug-free workplace policy
statement; and,
2) Agree to abide by the terms of the company's statement as a
condition of employment on this Agreement.
Exhibit J
Page 3 of 6
Failure to comply with these requirements may result in suspension of payments under
this Agreement or termination of this 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 (2) 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 penal sanction, abusive forms of child labor or
exploitation of children in sweatshop labor. 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.
Exhibit J
Page 4 of 6
b. 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 this
Agreement, the awarding agency must be contacted immediately for clarification.
Current State Employees (Pub. Contract Code §10410):
a). 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.
b). 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):
a). For the two (2) 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.
b). For the twelve (12) 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 employed by that state agency in a policy-making position in the
same general subject area as the proposed contract within the twelve (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)
Exhibit J
Page 5 of 6
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, 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.
Exhibit J
Page 6 of 6
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 ten (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 K
Page 1 of 2
Medi-Cal Organizational Provider Standards
1. The organizational 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 organizational provider establishes and implements maintenance policies for any site
owned, leased, or operated by the provider and used for services or staff to ensure the safety
and well being of beneficiaries and staff.
5. The organizational provider has a current administrative manual which includes: personnel
policies and procedures, general operating procedures, service delivery policies, and
procedures for reporting unusual occurrences relating to health and safety issues.
6. The organizational provider maintains client records in a manner that meets applicable state
and federal standards.
7. The organization 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.
8. The organizational provider has written procedures for referring individuals to a psychiatrist
when necessary, or to a physician, if a psychiatrist is not available.
9. The organizational provider has as head of service a licensed mental health professional of
other appropriate individual as described in Title 9, CCR, Sections 622 through 630.
10. For organizational providers that provide or store 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.
EXHIBIT K
Page 2 of 2
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.
11. For organizational providers that provide 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
Service’s day treatment requirements. The COUNTY shall review the provider’s written
program description for compliance with the State Department of Health Care Service’s
day treatment requirements.
12. 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 years. The COUNTY may also
conduct additional certification reviews when:
• The provider makes major staffing changes.
• The provider makes organizational and/or corporate structure changes (example: conversion
from a non-profit status).
• The provider adds day treatment or medication support services when medications shall be
administered or dispensed from the provider site.
• There are significant changes in the physical plant of the provider site (some physical plant
changes could require a new fire clearance).
• There is change of ownership or location.
• There are complaints against the provider.
• There are unusual events, accidents, or injuries requiring medical treatment for clients, staff or
members of the community.
Exhibit L
Page 1 of 2
Fresno County Mental Health Plan
Grievances and Appeals Process
Grievances
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.
Please note that all fee-for-service providers and contract agencies are required to give their
clients copies of all current beneficiary information annually at the time their treatment plans are
updated and at intake.
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)
(559) 488-3055 (TTY)
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.
Exhibit L
Page 2 of 2
Informal provider problem resolution process – the provider may first speak to a Provider
Relations Specialist (PRS) regarding his or her complaint or concern.
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 buy the MHP is final.
Exhibit M
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:
DBH Program Supervisor
Exhibit M
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 N
Page 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 N
Page 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) 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 O
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 O
Page 1 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:
I I
Exhibit P
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 P
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
Monthly Progress Report
Children's Wraparound Program
SW Name/Phone No:
DPO Name/Phone No:
Facilitator/Phone No:
Therapist/Phone No:
Parent/Guardian:
Updated Phone No:
Updated Home Address:
I Family's Big Goal:
ISP: D In Progress D Approved On: __
CFT MEMBERS IN A TIEN DANCE:
1.VVhat's Working?2.Immediate Needs & Concerns:3.Family updates & progress since last CFT mtg:4.School/Work Updates:5.Compliance with court mandates:6.Facilitator updates:7.Counselor updates:8.Parent Partner updates:9.Youth Partner updates:10.0ther Team Supports & Misc updates:11.Next CFT meeting date/time/location:
Exhibit Q Page 1 of 1
YOUTH:
CFT DATE:
WRAP Team:
•Facilitator:
•Parent Partner:
•Counselor:
•Youth Partner:
•MSW Intern:
Discharge Presentation
(Enter Case Name)
DIC: (Date)
Section One: Demographics
•Child's Name: :
•Date of Birth:
• Enrollment Date:
•Discharge Date:
Section Two: Referral to Wraparound
A.Reason for referral to the WRAP Program:
B.Youth and Family Strengths:
C.Youth and Family Challenges
Section Three: Participation in Wraparound Services
Section Four: Current Stability of Youth/Family and Linkages
A.Current stability of Youth and Family
B.Linkages, Resources and Natural Supports
Exhibit R
Page 1 of 1
ICFP Presentation Outline
Exhibit S
Page 1 of 1
1.Provide Demographic Information (child's age, gender, grade, school attending,
IEP, Mental health services).
•Name:
•Date of Birth:
•School:
•IEP:
•Last Annual IEP:
•Mental Health Services:
•Diagnosis:
•Mediations:
2.Provide relevant family information, including brief description of caregiver(s)
(Foster Family, Birth Family, Mentor, etc.).
•Foster Parent/s:
•Foster Home:
•Biological Mother:
•Presumed Biological Father:
3.Provide Reason for referral to Wraparound:
• Enrollment Date:
•History of Placements:
•Reason for Re ferral:
Individual Child and Family Plan (ICFP)
Youth's Name: I Referred Bv (CW, Probation, DBH, AAP):
Life Domains: check all domains that will be addressed in ICFP
D Safety D Legal D Family D Relationship D School D Emotional
Housing
D Finances D Medical/Health D Work D Cultural D Spiritual D Social/Fun
Family's Bia Goal:
NEEDS &
Exhibit T
Page 1 of 2
D
D Other
LIFE DOMAIN CONCERNS STRENGTHS STRATEGY RESOURCES
School
Spiritual
Emotional
Other
I
Signatures Required for Approval:
ParenUGuardian Signature Date Youth's Signature
Facilitator Date System Partner (SW, DPO, DMH)
Counselor Date Parent Partner, if available
Youth's Partner, if available Date Therapist, if available
Other Team Members Date Other Team Members
Plan has been reviewed and approved by (Supervisor's Signature):
Date
Date
Date
Date
Date
Exhibit T
Page 2 of 2