HomeMy WebLinkAbout32785COUNTY OF FRESNO
Fresno, CA
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MASTER AGREEMENT
THIS AGREEMENT is made and entered into this ___________day of _____________, 2017,
by and between the COUNTY OF FRESNO, a Political Subdivision of the State of California,
hereinafter referred to as “COUNTY”, and each CONTRACTOR listed in Exhibit A, attached hereto
and by this reference incorporated herein, hereinafter referred to as “CONTRACTOR(S),” and such
additional CONTRACTOR(S) as may, from time to time during the term of this Agreement, be added or
deleted by COUNTY, or Department of Behavioral Health (DBH) Director or designee. Reference to
party or parties shall be understood to refer to COUNTY and each individual CONTRACTOR unless
otherwise specified.
W I T N E S S E T H:
WHEREAS, COUNTY, through its DBH, is in need of qualified primary health care centers to
provide three service components of integrated mental health: prevention and early intervention (PEI);
severely and mentally ill (SMI) and severely emotionally disturbed (SED); and substance use disorder
(SUD) treatment services for children, families, and adults at community primary care clinics as
specified in this Agreement and as part of the County of Fresno’s development of a broad continuum of
services at various levels of care; and
WHEREAS, COUNTY, through its DBH, is a Mental Health Plan (MHP) as defined in Title 9 of
the California Code of Regulations (C.C.R.), section 1810.226; and
WHEREAS, CONTRACTOR(S) are qualified and willing to provide PEI, SMI, SED, and SUD
services pursuant to the terms and conditions of this Agreement.
NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties
hereto agree as follows:
1.SERVICES
A. CONTRACTOR(S) shall perform all services and fulfill all responsibilities as set
forth in Exhibits B-1 through B-3, “Summary of Services,” attached hereto and by this reference
incorporated herein and made part of this Agreement.
B.CONRACTOR(S) shall also perform all services and fulfill all responsibilities as
specified in COUNTY’s Request for Proposal (RFP) No. 952-5481, dated July 22, 2016 and
Agreement No. 17-579
14th November
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Addendum No. One (1) to COUNTY’s RFP No. 952-5481 dated August 10, 2016, hereinafter
collectively referred to as COUNTY’s Revised RFP, and CONTRACTOR(S)’ responses to said
Revised RFP. In the event of any inconsistency among these documents, the inconsistency shall be
resolved by giving precedence in the following order of priority: 1) this Agreement, including all
Exhibits, 2) the Revised RFP, and 3) the Responses to the Revised RFP. A copy of COUNTY’s RFP
No. 952-5481 and CONTRACTOR(S)’ responses thereto shall be retained and made available during
the term of this Agreement by COUNTY’s DBH Contracts Division.
C.It is acknowledged by all parties hereto that COUNTY's DBH Contracts Division
shall monitor the integrated mental health and primary care services program operated by
CONTRACTOR(S), in accordance with Section Fifteen (15) of this Agreement.
D.CONTRACTOR(S) shall participate in monthly, or as needed, workgroup
meetings consisting of staff from COUNTY's DBH to discuss program requirements, data reporting,
training, policies and procedures, overall program operations, and any problems or foreseeable
problems that may arise.
E.CONTRACTOR(S) shall maintain requirements as Fresno County Mental Health
Plan Organizational Providers(s) throughout the term of this Agreement, as described in Section
Eighteen (18) of this Agreement. If, for any reason, this status is not maintained, COUNTY may
terminate this Agreement pursuant to Section Three (3) of this Agreement.
F.CONTRACTOR(S) agree that prior to providing services under the terms and
conditions of this Agreement, CONTRACTOR(S) shall have staff hired and in place for program
services and operations or COUNTY may, in addition to other remedies, suspend referrals or terminate
this Agreement, in accordance with Section Three (3) of this Agreement.
2.TERM
This Agreement shall become effective upon execution and shall terminate on the 30th
day of June 2018.
Effective July 1, 2018, this Agreement, subject to satisfactory outcomes performance and
State funding each year, shall continue for an additional three (3) year term, with an option for two (2)
additional twelve (12) month periods, upon the same terms and conditions herein set forth, unless
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written notice of non-renewal is given by COUNTY, CONTRACTOR(S), or COUNTY’s DBH
Director or designee, not later than sixty (60) days prior to the close of the current Agreement term.
3.TERMINATION
A.Non-Allocation of Funds
The terms of this Agreement and the services to be provided thereunder are
contingent on the approval of funds by the appropriating government agency. Should sufficient funds
not be allocated, the services provided may be modified, or this Agreement terminated at any time by
giving CONTRACTOR(S) thirty (30) days advance written notice.
B.Breach of Contract
COUNTY may immediately suspend or terminate this Agreement in whole or in
part, where in the determination of COUNTY there is:
1. An illegal or improper use of funds;
2.A failure to comply with any term of this Agreement;
3.A substantially incorrect or incomplete report submitted to COUNTY;
4.Improperly performed service.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of
any breach of this Agreement or any default which may then exist on the part of CONTRACTOR(S).
Neither shall such payment impair or prejudice any remedy available to COUNTY with respect to the
breach or default. COUNTY shall have the right to demand of CONTRACTOR(S) the repayment to
COUNTY of any funds disbursed to CONTRACTOR(S) under this Agreement, which in the judgment
of COUNTY were not expended in accordance with the terms of this Agreement. CONTRACTOR(S)
shall promptly refund any such funds upon demand or at COUNTY’s option such repayment shall be
deducted from future payments owing to CONTRACTOR(S) under this Agreement.
C.Without Cause
Under circumstances other than those set forth above, this Agreement may be
terminated by COUNTY upon the giving of sixty (60) days advance written notice of an intention to
terminate to CONTRACTOR(S).
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4.COMPENSATION
A.Contingent upon confirmation of funding by the California Department of Health
Care Services, COUNTY agrees to pay CONTRACTOR(S) and CONTRACTOR(S) agree to receive
compensation for actual expenditures incurred in accordance with the budget projections specified
Exhibit C, “Budget,” attached hereto and incorporated herein by this reference and made part of this
Agreement.
The maximum compensation amount under this Agreement for the initial term
through June 30, 2018 shall not exceed Three Million One Hundred Thousand and No/100 Dollars
($3,100,000.00) for all CONTRACTOR(S) for PEI, SMI, SED, and SUD services. It is understood by
CONTRACTOR(S) and COUNTY that the cumulative amount of Mental Health Services Act (MHSA)
Prevention and Early Intervention (PEI) funds payable under this Agreement to CONTRACTOR(S) for
PEI services shall not exceed Two Hundred Forty-Eight Thousand and No/100 Dollars ($248,000.00);
the cumulative amount of MHSA Community Services and Supports (CSS) funding for SMI services
shall not exceed Two Hundred Thousand and No/100 Dollars ($200,000.00); and the cumulative
MHSA CSS funding for SED services shall not exceed Six Hundred Thousand and No/100 Dollars
($600,000.00). It is also understood by CONTRACTOR(S) and COUNTY that CONTRACTOR(S)
estimate to generate a cumulative total of One Million Seven Hundred Eleven Thousand and No/100
Dollars ($1,711,000.00) in Medi-Cal Federal Financial Participation (FFP) for SMI and SED services
under this Agreement to offset CONTRACTOR(S) program costs as set forth in Exhibit C. The
cumulative funding for SUD services shall not exceed Three Hundred Forty-One Thousand and No/100
Dollars ($341,000.00).
The maximum compensation amount under this Agreement for the term July 1,
2018 through June 30, 2019 shall not exceed Twenty Million Two Hundred Thousand and No/100
Dollars ($20,200,000.00) for all CONTRACTOR(S) for PEI, SMI, SED, and SUD services. It is
understood by CONTRACTOR(S) and COUNTY that the cumulative amount of MHSA PEI funds
payable under this Agreement to CONTRACTOR(S) for PEI services shall not exceed One Million Six
Hundred Sixteen Thousand and No/100 Dollars ($1,616,000.00); the cumulative amount of MHSA
CSS funding for SMI services shall not exceed One Million Four Hundred Thousand and No/100
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Dollars ($1,400,000.00); and the cumulative amount of MSHA CSS funding for SED services shall not
exceed Eight Hundred Thousand and No/100 Dollars ($800,000.00). It is also understood by
CONTRACTOR(S) and COUNTY that CONTRACTOR(S) estimate to generate a cumulative total of
Fourteen Million One Hundred Sixty-Two Thousand and No/100 Dollars ($14,162,000.00) in Medi-
Cal FFP for SMI and SED services under this Agreement to offset CONTRACTOR(S) program costs
as set forth in Exhibit C. The cumulative funding for SUD services shall not exceed Two Million Two
Hundred Twenty-Two Thousand and No/100 Dollars ($2,222,000.00).
The maximum compensation under this Agreement for the term July 1, 2019
through June 30, 2020 shall not exceed Twenty-Six Million Six Hundred Thousand and No/100 Dollars
($26,600,000.00) for all CONTRACTOR(S) for PEI, SMI, SED, and SUD services. It is understood by
CONTRACTOR(S) and COUNTY that the cumulative amount of MHSA PEI funds payable under this
Agreement to CONTRACTOR(S) for PEI services shall not exceed Two Million One Hundred
Twenty-Eight Thousand and No/100 Dollars ($2,128,000.00); the cumulative amount of MHSA CSS
funding for SMI services shall not exceed One Million Nine Hundred Thousand and No/100 Dollars
($1,900,000.00); and the cumulative amount of MHSA CSS funding for SED services shall not exceed
One Million and No/100 Dollars ($1,000,000.00). It is also understood by CONTRACTOR(S) and
COUNTY that CONTRACTOR(S) estimate to generate a cumulative total of Eighteen Million Six
Hundred Forty-Six Thousand and No/100 Dollars ($18,646,000.00) in Medi-Cal FFP for SMI and SED
services under this Agreement to offset CONTRACTOR(S) program costs as set forth in Exhibit C.
The cumulative funding for SUD services shall not exceed Two Million Nine Hundred Twenty-Six
Thousand and No/100 Dollars ($2,926,000.00).
The maximum compensation under this Agreement for each subsequent twelve
(12) month period beginning with term July 1, 2020 through June 30, 2021 shall not exceed Twenty-
Six Million and No/100 Dollars ($26,000,000.00) for all CONTRACTOR(S) for PEI, SMI, SED, and
SUD services. It is understood by CONTRACTOR(S) and COUNTY that the cumulative amount of
MHSA PEI funds payable under this Agreement to CONTRACTOR(S) for PEI services shall not
exceed Two Million Eighty Thousand and No/100 Dollars ($2,080,000.00); the cumulative amount of
MHSA CSS funding for SMI services shall not exceed One Million Nine Hundred Thousand and
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No/100 Dollars ($1,900,000.00); and the cumulative amount of MHSA CSS funding for SED services
shall not exceed One Million and No/100 Dollars ($1,000,000.00). It is also understood by
CONTRACTOR(S) and COUNTY that CONTRACTOR(S) estimate to generate a cumulative total of
Eighteen Million One Hundred Sixty Thousand and No/100 Dollars ($18,160,000.00) in Medi-Cal FFP
for SMI and SED services under this Agreement to offset CONTRACTOR(S) program costs as set
forth in Exhibit C. The cumulative funding for SUD services shall not exceed Two Million Eight
Hundred Sixty Thousand and No/100 Dollars ($2,860,000.00).
The total contract maximum shall not exceed One Hundred Twenty-Seven
Million Nine Hundred Thousand and No/100 Dollars ($127,900,000.00). The maximum amounts paid
to each CONTRACTOR shall be in accordance to budget maximums stated in Exhibit C.
Drug Medi-Cal revenue generated as a result of SUD services provided under this
Agreement will be used to directly offset COUNTY’s contribution of funds as identified in Exhibit C.
The offset of funds will also be clearly identified in monthly invoices received from
CONTRACTOR(S) as further described in Section Five (5) of this Agreement.
It is understood that all expenses incidental to CONTRACTOR(S)’ performance
of services under this Agreement shall be borne by CONTRACTOR(S).
B.If CONTRACTOR(S) fail to generate the Medi-Cal and Drug Medi-Cal revenue
amounts set forth in Exhibit C, COUNTY shall not be obligated to pay the difference between the
estimated revenue and the actual revenue generated.
It is further understood by COUNTY and CONTRACTOR(S) that any Medi-Cal
revenue above the amounts stated herein will be used to directly offset COUNTY’s contribution of
funds identified in Exhibit C. The offset of funds will also be clearly identified in monthly invoices
received from CONTRACTOR(S) as further described in Section Five (5) of this Agreement.
C.Travel shall be reimbursed based on actual expenditures and mileage
reimbursement shall be at CONTRACTOR(S)’ adopted rate per mile, not to exceed the Internal
Revenue Service published rate. Payment shall be made upon certification or other proof satisfactory
to COUNTY’s DBH that services have actually been performed by CONTRACTOR(S) as specified in
this Agreement.
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D. It is understood that all expenses incidental to CONTRACTOR(S)’ performances
of services under this Agreement shall be borne by CONTRACTOR(S). If CONTRACTOR(S) fail to
comply with any provision of this Agreement, COUNTY shall be relieved of its obligation for further
compensation.
E.Payments shall be made by COUNTY to CONTRACTOR(S) in arrears, for
services provided in the preceding month, within forty-five (45) days after the date of receipt and
approval by COUNTY of the monthly invoicing as described in Section Five (5) herein. Payments
shall be made after receipt and verification of actual expenditures incurred by CONTRACTOR(S) for
monthly program costs, as identified in Exhibit C, in the performance of this Agreement and shall be
documented to COUNTY on a monthly basis by the tenth (10th) day of the month following the month
of said expenditures.
CONTRACTOR(S) shall submit to COUNTY by the tenth (10th) of each month 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 described in Section Five (5) herein.
F.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 invoices, including actual cost 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 invoices
submitted beyond the sixty (60) day closeout period. Any compensation which is not expended by
CONTRACTOR(S) pursuant to the terms and conditions of this Agreement shall automatically revert
to COUNTY.
G.The services provided by CONTRACTOR(S) under this Agreement are funded in
whole or in part by the State of California. In the event that funding for these services is delayed by the
State Controller, COUNTY may defer payments to CONTRACTOR(S). The amount of the deferred
payment shall not exceed the amount of funding delayed by the State Controller to COUNTY. The
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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.
H.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(S).
CONTRACTOR(S) shall not receive reimbursement for any units of services rendered that are
disallowed or denied by the Mental Health Plan utilization review process or through the State
Department of Health Care Services (DHCS) cost report audit settlement process for Medi-Cal eligible
clients.
I.It is understood by CONTRACTOR(S) and COUNTY that this Agreement is
funded with Mental Health Services Act funds to serve individuals for PEI and individuals with SMI or
SED diagnoses; and SUD Realignment for individuals with Substance Use Disorders. It is further
understood by CONTRACTOR(S) and COUNTY that funds shall be used to support appropriately
integrated services for co-occurring substance use disorders in the target population, and that integrated
services can be documented in crisis assessments, interventions, and progress notes documenting
linkages.
J.CONTRACTOR(S) shall submit proposed annual budget(s) for review for each
subsequent term of the Agreement to COUNTY’s DBH Director or designee for approval no later than
the first (1st) day of March of the current contract year. If said budget is not received by the March 1st
due date, the current budget will remain for the following contract period. The collective amount of
annual approved budget(s) shall not exceed the maximum compensation of the current Agreement
term.
5.INVOICING
A. CONTRACTOR(S) shall provide invoices as described below to COUNTY in
arrears by the fifteenth (15th) day of each month for the prior month’s actual services rendered.
Invoices for PEI, SMI, and SED shall be submitted via e-mail to the assigned staff analyst and to
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DBHInvoices@co.fresno.ca.us. Invoices for SUD shall be submitted via e-mail to the assigned staff
analyst and to SAS@co.fresno.ca.us. CONTRACTOR(S) shall include certification of expenditures
with the invoice, and submit electronic claiming data into COUNTY’s electronic information system
for all clients (Medi-Cal eligible and ineligible clients), including contracted cost per unit and actual
cost per unit. COUNTY must pay CONTRACTOR(S) before submitting claims to DHCS for Federal
and State reimbursement for Medi-Cal eligible clients.
B.COUNTY’s DBH shall invoice CONTRACTOR(S) in arrears by the fifth (5th)
day of the month for the prior month’s hosting fee for access to COUNTY’s electronic information
system in accordance with the fee schedule set forth in Exhibit D, “Electronic Health Records Software
Charges,” attached hereto and incorporated herein by this reference and made part of this Agreement.
COUNTY shall invoice CONTRACTOR(S) annually for the annual maintenance and licensing fee for
access to COUNTY’s electronic information system in accordance with the fee schedule as set forth in
Exhibit D. CONTRACTOR(S) shall provide payment for these expenditures to COUNTY’s
Department of Behavioral Health, Accounts Receivable, P.O. Box 712, Fresno, CA 93717-0712,
Attention: Business Office, within forty-five (45) days after the date of receipt by CONTRACTOR(S)
of the invoicing provided by COUNTY.
C.At the discretion of COUNTY’s DBH Director or designee, if an invoice is
incorrect or is otherwise not in proper form or substance, COUNTY’s DBH Director or designee shall
have the right to withhold payment as to only that portion of the invoice that is incorrect or improper,
with five (5) days prior notice of intent to withhold funds to CONTRACTOR(S). CONTRACTOR(S)
agree 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 the
satisfaction of COUNTY DBH, COUNTY’s DBH Director, or designee, may elect to terminate this
Agreement, pursuant to the termination provisions stated in Section Three (3) of this Agreement.
COUNTY’s DBH, at the discretion of COUNTY’s DBH Director or designee, shall have the right to
deny payment of any additional invoices received ninety (90) days after the expiration of each term of
this Agreement or termination of this Agreement.
D.Monthly invoices shall include a client roster, identifying volume reported by
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payer group for clients served (including third party payer of services) by month and year-to-date,
including percentages. Each roster shall include the name, date of service, type of mental health
service received, duration of service, and Diagnostic and Statistical Manual (DSM) V, or currently
implemented manual, diagnosis of each client.
E.CONTRACTOR(S) shall submit monthly invoices and general ledgers with
itemized line item charges for monthly program costs (per applicable budget, as identified in Exhibit
C), including the cost per unit calculation based on clients served within the invoice month, and
excluding unallowable costs. Unallowable costs such as lobbying or political donations must be
deducted from the monthly invoice reimbursements.
F.CONTRACTOR(S) will remit annually, within ninety (90) days following June
30th, a schedule to provide the required information on published charges for all authorized direct
specialty mental health services. The published charge listing will serve as a source document to
determine CONTRACTOR(S)’ 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(S) shall submit monthly staffing reports that identify all direct
service and support staff, applicable licensure/certifications, and full time hours worked to be used as a
tracking tool to determine if CONTRACTOR(S)’ program is staffed in accordance with the services
provided under this Agreement.
H. CONTRACTOR(S) shall maintain financial records for a period of seven (7)
years or until any dispute, audit or inspection is resolved, whichever is later. CONTRACTOR(S) are
responsible for any disallowances related to inadequate documentation.
I.CONTRACTOR(S) are responsible for collection and managing data in a manner
to be determined by DHCS and the Fresno County Mental Health Plan in accordance with applicable
rules and regulations. CONTRACTOR(S) must attend COUNTY DBH’s Business Office training on
equipment reporting for assets, intangible and sensitive minor assets; COUNTY’s electronic
information system; and related cost reporting.
J.CONTRACTOR(S) shall submit service data into COUNTY’s electronic
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information system within ten (10) calendar days from the date services were rendered. Federal and
State reimbursement for Medi-Cal specialty mental health services is based on public expenditures
certified by CONTRACTOR(S).
K.CONTRACTOR(S) shall provide all necessary data to allow COUNTY to bill
Medi-Cal and any other third-party source, for services and to 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) 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).
L.If a client has other health coverage (OHC) such as private insurance, or Federal
Medicare, CONTRACTOR(S) shall be responsible for billing the private insurance carrier and
obtaining a payment/denial, or show validation of claiming with no response ninety (90) days after
the claim was mailed, before the service can be entered into COUNTY’s electronic information
system. CONTRACTOR(S) must report all third party collections for Medicare, third party or client
pay, or private pay in each monthly invoice and in the cost report that is required to be submitted. A
copy of explanation of benefits or CMS 1500 is required as documentation. CONTRACTOR(S)
must report all revenue collected from OHC, third-party, client-pay or private-pay in each monthly
invoice and in the cost report that is required to be submitted. CONTRACTOR(S) shall submit
monthly invoices for reimbursement that equal the amount due CONTRACTOR(S) less any funding
sources not eligible for Federal and State reimbursement. CONTRACTOR(S) must comply with all
laws and regulations governing the Federal Medicare program, including, but not limited to: 1)
requirement of the Medicare Act, 42 U.S.C. section 1395 et seq; and 2) regulations and rules
promulgated by the Federal Centers for Medicare and Medicaid Services as they relate to
participation, coverage, and claiming reimbursement. CONTRACTOR(S) will be responsible for
maintaining compliance with Federal, State, or local laws or regulations pursuant to the respective
effective dates of each piece of legislation.
M.CONTRACTOR(S) shall compile and reconcile data for direct specialty mental
health services, to be submitted with monthly invoices. Data entry shall be the responsibility of
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CONTRACTOR(S). COUNTY shall monitor the volume of services and cost of services entered into
COUNTY’s electronic information system. Any and all audit exceptions resulting from the provision
and reporting of Medi-Cal specialty mental health services by CONTRACTOR(S) shall be the sole
responsibility of CONTRACTOR(S). CONTRACTOR(S) shall comply with all applicable policies,
procedures, directives and guidelines regarding the use of COUNTY’s electronic information system.
N.Medi-Cal Certification and Mental Health Plan Compliance
CONTRACTOR(S) shall establish and maintain Medi-Cal certification or become
certified within ninety (90) days of the effective date of this Agreement through COUNTY to provide
reimbursable services to Medi-Cal eligible clients. CONTRACTOR(S) shall work with COUNTY’s
DBH to execute the process, if not currently certified by COUNTY, for credentialing of staff. During
this process, CONTRACTOR(S) will obtain a legal entity number established by the DHCS to maintain
Mental Health Plan Organizational Provider status throughout the term of this Agreement.
CONTRACTOR(S) will be required to become Medi-Cal certified prior to providing services to Medi-
Cal eligible clients and seeking reimbursement from COUNTY. CONTRACTOR(S) will not be
reimbursed by COUNTY for any services rendered prior to certification.
CONTRACTOR(S) shall provide specialty mental health services in accordance
with COUNTY’s Mental Health Plan and must comply with the “Fresno County Mental Health Plan
Compliance Program and Code of Conduct and Ethics” set forth in Exhibit E, attached hereto and
incorporated herein by reference and made part of this Agreement.
CONTRACTOR(S) may provide direct specialty mental health services using
unlicensed staff as long as the individual is approved as a CONTRACTOR by the Mental Health Plan,
is supervised by licensed staff, works within his/her scope, and only delivers allowable direct specialty
mental health services. It is understood that each service is subject to audit for compliance with
Federal and State regulations, and that COUNTY may make payments in advance of said audit. In the
event that a service is disapproved, COUNTY, at its sole discretion, may withhold compensation or set
off from other payments due the amount of disapproved services. CONTRACTOR(S) shall be
responsible for audit exceptions to ineligible dates of services or incorrect application of utilization
review requirements.
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6.INDEPENDENT CONTRACTOR
In performance of the work, duties, and obligations assumed by CONTRACTOR(S)
under this Agreement, it is mutually understood and agreed that CONTRACTOR(S), including any and
all of CONTRACTOR(S)’ officers, agents, and employees will at all times be acting and performing as
independent contractor, and shall act in an independent capacity and not as an officer, agent, servant,
employee, joint venturer, partner, or associate of COUNTY. Furthermore, COUNTY shall have no
right to control or supervise or direct the manner or method by which CONTRACTOR(S) shall perform
its work and function. However, COUNTY shall retain the right to administer this Agreement so as to
verify that CONTRACTOR(S) are performing their obligations in accordance with the terms and
conditions thereof. CONTRACTOR(S) and COUNTY shall comply with all applicable provisions of
law and the rules and regulations, if any, of governmental authorities having jurisdiction over matters
which are directly or indirectly the subject of this Agreement.
Because of its status as an independent contractor, CONTRACTOR(S) shall have
absolutely no right to employment rights and benefits available to COUNTY employees.
CONTRACTOR(S) shall be solely liable and responsible for providing to, or on behalf of, its
employees all legally-required employee benefits. In addition, CONTRACTOR(S) 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(S) may be providing services to others unrelated to COUNTY or to this Agreement.
7.MODIFICATION
Any matters of this Agreement may be modified from time to time by the written consent
of all the parties without, in any way, affecting the remainder.
Notwithstanding the above, changes to services, staffing, and responsibilities of
CONTRACTOR(S), as needed, to accommodate changes in the laws relating to mental health and
substance use disorder treatment, as set forth in Exhibits B-1 through B-3, may be made with the signed
written approval of COUNTY’s DBH Director or designee and CONTRACTOR(S) through an
amendment approved by COUNTY’s Counsel and COUNTY’s Auditor-Controller’s Office.
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Changes to line items in the budget, as set forth in Exhibit C, that do not exceed 10% of
the maximum compensation payable to CONTRACTOR(S), and changes to the volume of
services/types of service units, and changes to the service rates to be provided, as set forth in Exhibit C,
may be made with the written approval of COUNTY’s Department of Behavioral Health Director, or
designee. Changes to the line items in the budget that exceed 10% of the maximum compensation
payable to CONTRACTOR(S), may be made with the signed written approval of COUNTY’s
Department of Behavioral Health Director, or designee, through an amendment approved by
COUNTY’s Counsel and COUNTY’s Auditor-Controller’s Office.
Said modifications shall not result in any change to the annual maximum compensation
amount payable to CONTRACTOR(S), as stated in this Agreement.
8.NON-ASSIGNMENT
No party shall assign, transfer or subcontract this Agreement nor their rights or duties
under this Agreement without the prior written consent of COUNTY.
9.HOLD-HARMLESS
CONTRACTOR(S) agree to indemnify, save, hold harmless, and at COUNTY's request,
defend COUNTY, its officers, agents and employees from any and all costs and expenses including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to COUNTY
in connection with the performance, or failure to perform, by CONTRACTOR(S), its officers, agents or
employees under this Agreement, and from any and all costs and expenses, including attorney fees and
court costs, damages, liabilities, claims and losses occurring or resulting to any person, firm or
corporation who may be injured or damaged by the performance, or failure to perform, of
CONTRACTOR(S), their officers, agents or employees under this Agreement.
CONTRACTOR(S) agree to indemnify COUNTY for Federal and/or State of California
audit exceptions resulting from noncompliance herein on the part of CONTRACTOR(S).
10.INSURANCE
Without limiting COUNTY's right to obtain indemnification from CONTRACTOR(S) or
any third parties, CONTRACTOR(S), at its sole expense, shall maintain in full force and affect the
following insurance policies throughout the term of this Agreement:
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A.Commercial General Liability
Commercial General Liability Insurance with limits of not less than Two Million
Dollars ($2,000,000) per occurrence and an annual aggregate of Five Million
Dollars ($5,000,000). This policy shall be issued on a per occurrence basis.
COUNTY may require specific coverage including completed operations, product
liability, contractual liability, Explosion-Collapse-Underground (XCU) liability,
fire legal liability, or any other liability insurance deemed necessary because of
the nature of the Agreement.
B.Automobile Liability
Comprehensive Automobile Liability Insurance with limits for bodily injury of
not less than Five Hundred Thousand Dollars ($500,000) per person, One Million
Dollars ($1,000,000) per accident and for property damages of not less than One
Hundred Thousand Dollars ($100,000), or such coverage with a combined single
limit of One Million Dollars ($1,000,000). Coverage should include owned and
non-owned vehicles used in connection with this Agreement.
C. Real and Property Insurance
CONTRACTOR(S) shall maintain a policy of insurance for all risk personal
property coverage which shall be endorsed naming the County of Fresno as an
additional loss payee. The personal property coverage shall be in an amount that
will cover the total of COUNTY purchase and owned property, at a minimum, as
discussed in Section Twenty-Four (24) of this Agreement.
D.All Risk Property Insurance
CONTRACTOR(S) will provide property coverage for the full replacement value
of COUNTY’s personal property in possession of CONTRACTOR(S) and/or
used in the execution of this Agreement. COUNTY will be identified on an
appropriate certificate of insurance as the certificate holder and will be named as
an Additional Loss Payee on the Property Insurance Policy.
E.Professional/Medical Malpractice Liability
If CONTRACTOR(S) employ licensed professional staff (e.g. Ph.D., R.N.,
L.C.S.W., M.F.T.) in providing services, Professional Liability Insurance with
limits of not less than One Million Dollars ($1,000,000) per occurrence, Three
Million Dollars ($3,000,000) annual aggregate. CONTRACTOR(S) agree that it
shall maintain, at its sole expense, in full force and effect for a period of three (3)
years following the termination of this Agreement, one or more policies of
professional liability insurance with limits of coverage as specified herein.
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F.Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
G.Child Abuse/Molestation and Social Services Coverage
CONTRACTOR(S) shall have either separate policies or umbrella policy with
endorsements covering Child Abuse/Molestation and Social Services Liability
coverage or have a specific endorsement on their General Commercial Liability
policy covering Child Abuse/Molestation and Social Service Liability. The
policy limits for these policies shall be $1,000,000 per occurrence with a
$2,000,000 annual aggregate.
CONTRACTOR(S) shall obtain endorsements to the Commercial General Liability
insurance naming the County of Fresno, its officers, agents, and employees, individually and
collectively, as additional insured, but only insofar as the operations under this Agreement are
concerned. Such coverage for additional insured shall apply as primary insurance and any other
insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees shall be
excess only and not contributing with insurance provided under 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.
Within thirty (30) days from the date CONTRACTOR(S) sign this Agreement,
CONTRACTOR(S) shall provide certificates of insurance and endorsements as stated above for all of
the foregoing policies, as required herein, to the County of Fresno, Department of Behavioral Health,
Contracts Division, 3133 N. Millbrook Ave, Fresno, California, 93703, Attention: Mental Health and
SUD Staff Analysts, stating that such insurance coverages have been obtained and are in full force; that
the County of Fresno, its officers, agents and employees will not be responsible for any premiums on
the policies; that such Commercial General Liability insurance names the County of Fresno, its
officers, agents and employees, individually and collectively, as additional insured, but only insofar as
the operations under this Agreement are concerned; that such coverage for additional insured shall
apply as primary insurance and any other insurance, or self-insurance, maintained by COUNTY, its
officers, agents and employees, shall be excess only and not contributing with insurance provided
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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(S) fail to keep in effect at all times insurance coverage as
herein provided, COUNTY may, in addition to other remedies it may have, suspend or terminate this
Agreement with CONTRACTOR(S) upon the occurrence of such event.
All policies shall be with admitted insurers licensed to do business in the State of
California. Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating of
A FSC VII or better.
11.LICENSES/CERTIFICATES
Throughout each term of this Agreement, CONTRACTOR(S) 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(S) shall notify COUNTY immediately in writing of its
inability to obtain or maintain such licenses, permits, approvals, certificates, waivers and exemptions
irrespective of the pendency of any appeal related thereto. Additionally, CONTRACTOR(S) and
CONTRACTOR(S)’ staff shall comply with all applicable laws, rules or regulations, as may now exist
or be hereafter changed.
12.RECORDS
CONTRACTOR(S) shall maintain records in accordance with Exhibit F, "Documentation
Standards for Client Records", attached hereto and by this reference incorporated herein and made part
of this Agreement. During site visits, COUNTY shall be allowed to review records of services
provided, including the goals and objectives of the treatment plan, and how the therapy provided is
achieving the goals and objectives.
A.Record Establishment and Maintenance
CONTRACTOR(S) shall establish and maintain records in accordance with State
and Federal rules and regulations in addition to those requirements prescribed by COUNTY with respect
to all matters covered by this Agreement. Except as otherwise authorized by COUNTY,
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CONTRACTOR(S) shall retain all other records for a period of five (5) years after receiving the final
payment under this Agreement or the earlier termination of this Agreement, or until State and/or Federal
audit findings applicable to such services are resolved, whichever is later.
B.Documentation
CONTRACTOR(S) shall maintain adequate records in sufficient detail to make
possible an evaluation of services, and contain all the data necessary in reporting to the State of
California and/or Federal agency. All client records shall be maintained pursuant to applicable State of
California and Federal requirements concerning confidentiality.
C.Reports
CONTRACTOR(S) shall submit to COUNTY monthly fiscal and all program
reports as further described in Sections Thirteen (13) and Fourteen (14) of this Agreement.
CONTRACTOR(S) shall submit a complete and accurate year-end cost report for each fiscal year
affected by this Agreement, following the end of each fiscal year affected by this Agreement.
CONTRACTOR(S) shall also furnish to COUNTY such statements, records, reports, data, and
information as COUNTY may request pertaining to matters covered by this Agreement. All reports
submitted by CONTRACTOR(S) to COUNTY must be typewritten.
D.Suspension of Compensation
In the event that CONTRACTOR(S) fail to provide reports specified in this
Agreement, it shall be deemed sufficient cause for COUNTY to withhold payments until there is
compliance.
E.Disallowances
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 DBH-SUD Services. If payment for services are denied
or disallowed by State; and subsequently resubmitted to COUNTY by CONTRACTOR(S), the
disallowed portion will be withheld from the next reimbursement to the CONTRACTOR(S) until
COUNTY has received reimbursement from State for said services.
///
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F.Client Confidentiality
CONTRACTOR(S) shall conform to and COUNTY shall monitor compliance with
all State and Federal statutes and regulations regarding confidentiality, including but not limited to
confidentiality of information requirements of 42 Code of Federal Regulations § 2.1 et seq., Welfare and
Institutions Code §§ 5328, 10850 and 14100.2, Health and Safety Code §§ 11977 and 11812, Civil Code,
Division 1, Part 2.6, and 22 California Code of Regulations § 51009.
13.REPORTS – MENTAL HEALTH SERVICES
A. A.Outcome Reports
CONTRACTOR(S) shall submit to COUNTY’s DBH service outcome reports as
requested by COUNTY’s DBH. Outcome reports and outcome requirements are subject to change at
COUNTY’s DBH discretion.
. B.Additional Reports
CONTRACTOR(S) shall also furnish to COUNTY such statements, records,
reports, data, and other information as COUNTY’s DBH may request pertaining to matters covered by
this Agreement. In the event that CONTRACTOR(S) fail 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(S) shall provide written notification and
explanation to COUNTY within five (5) days of any funds received from another source to conduct the
same services covered by this Agreement.
. E.Cost Report
CONTRACTOR(S) agree to submit a complete and accurate detailed cost report
to COUNTY’s DBH on an annual basis for each fiscal year ending June 30th in the format prescribed
by the State 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(S) shall report costs under
their approved legal entity number established during the Medi-Cal certification process. The
information provided applies to CONTRACTOR(S) for program related costs for services rendered to
Medi-Cal and non Medi-Cal clients. The CONTRACTOR(S) will remit a schedule to provide the
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required information on published charges for all authorized services. The report will serve as a source
document to determine the CONTRACTOR(S)’ 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
payors during the course of business operations. CONTRACTOR(S) must report all collections for
Medi-Cal/Medicare services and collections. CONTRACTOR(S) shall also submit with the cost report
a copy of the 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(S) to COUNTY’S electronic information system.
Each fiscal year ending June 30, CONTRACTOR(S) shall remit a hard copy of
their annual cost report with a signed cover letter and requested support documents to County of
Fresno, Attention: DBH Cost Report Team, PO BOX 45003, Fresno CA 93718. In addition,
CONTRACTOR(S) shall remit an electronic copy or any inquiries to
DBHCostReportTeam@co.fresno.ca.us. COUNTY shall provide instructions of the cost report, cost
report training, State DHCS cost report template worksheets, and deadlines to submit the cost reports as
determined by the State each fiscal year.
All cost reports must be prepared in accordance with General Accepted
Accounting Principles (GAAP) and Welfare and Institutions Code §§ 5651(a)(4), 5664(a), 5705(b)(3)
and 5718(c). Unallowable costs such as lobbying or political donations must be deducted on the cost
report and monthly invoice reimbursements.
If CONTRACTOR(S) do not submit the cost report by the deadline, including any
extension period granted by COUNTY, COUNTY may withhold payments of pending invoicing under
compensation until the cost report has been submitted and clears COUNTY desk audit for
completeness.
. F.Settlements with State Department of Health Care Services (DHCS)
During the term of this Agreement and thereafter, COUNTY and
CONTRACTOR(S) agree to settle dollar amounts disallowed or settled in accordance with DHCS audit
settlement findings related to the reimbursement provided under this Agreement. CONTRACTOR(S)
will participate in the several phases of settlements between COUNTY/CONTRACTOR(S) and DHCS.
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The phases of initial cost reporting for settlement according to State reconciliation of records for paid
Medi-Cal services and audit settlement are: 1) Initial cost reporting – after an internal review by
COUNTY, COUNTY files the cost report with State DHCS on behalf of CONTRACTOR(S)’ legal
entity for the fiscal year; 2) Settlement – State reconciliation of records for paid Medi-Cal services,
approximately 18 to 36 months following the State close of the fiscal year, DHCS will send notice for
any settlement under this provision to COUNTY; and 3) Audit Settlement – State DHCS audit. After
final reconciliation and settlement DHCS may conduct a review of medical records, cost report along
with support documents submitted to COUNTY in initial submission to determine accuracy and may
disallow costs and/or units of services reported on the CONTRACTOR(S)’ legal entity cost report.
COUNTY may choose to appeal and therefore reserves the right to defer payback settlement with
CONTRACTOR(S) until resolution of the appeal is determined. DHCS Audits will follow Federal
Medicaid procedures for managing overpayments. If at the end of the Audit Settlement, COUNTY
determines that it overpaid CONTRACTOR(S), CONTRACTOR(S) will be required to repay the
Medi-Cal related overpayment back to COUNTY.
Funds owed to COUNTY will be due within forty-five (45) days of notification
by 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(S) under this
or any other Agreement between COUNTY and CONTRACTOR(S).
14.REPORTS – SUBSTANCE USE DISORDER SERVICES
CONTRACTOR(S) shall submit all information and data required by State, including,
but not limited to the following:
A.CONTRACTOR(S) shall complete and submit Drug and Alcohol Treatment
Access Report (DATAR) and Provider Waiting List Record (WLR) in an electronic format, as provided
by the State, no later than five (5) days after the preceding month.
B.CalOMS Treatment
CONTRACTOR(S) shall submit CalOMS treatment admission, discharge, annual
update, and “provider activity report” record in an electronic format through COUNTY’s SAIS system,
and on a schedule as determined by COUNTY which complies with State requirements for data
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content, data quality, reporting frequency, reporting deadlines, and report method and due no later than
five (5) days after the preceding month. All CalOMS admissions, discharges, and annual updates must
be entered into COUNTY’s CalOMS system within twenty-four (24) hours of occurrence.
C.CONTRACTOR(S) shall submit to COUNTY monthly fiscal and all program
reports, including Provider Waiting List Record (WLR), within twenty (20) days of the end of each
month.
D.Americans with Disabilities (ADA)
Annually, upon request by COUNTY, CONTRACTOR(S) shall complete a
system-wide accessibility survey in a format determined by COUNTY for each service location and
modality and shall submit an ADA Accessibility Certification and Self-Assessment, including an
Implementation Plan, for each service location.
E. Cost Reports
On an annual basis for each fiscal year ending June 30th CONTRACTOR(S) shall
submit a complete, accurate, and detailed cost report(s). Cost reports must be submitted to COUNTY
as a hard copy with a signed cover letter and an electronic copy by the due date. Submittal must also
include any requested support documents such as general ledgers. All reports submitted by
CONTRACTOR(S) to COUNTY must be typewritten. COUNTY will issue instructions for
completion and submittal of the annual cost report, including the relevant cost report template(s) and
due dates within forty-five (45) days of each fiscal year end. All cost reports must be prepared in
accordance with Generally Accepted Accounting Principles (GAAP). Unallowable costs such as
lobbying or political donations must be deducted from the cost report and all invoices. If
CONTRACTOR(S) do not submit the cost report by the due date, including any extension period
granted by COUNTY, COUNTY may withhold payment of pending invoices until the cost report(s)
has been submitted and clears COUNTY desk audit for completeness and accuracy.
1.Drug Medi-Cal - A DMC cost report must be submitted in a format
prescribed by the DHCS for the purposes of Short Doyle Medi-Cal reimbursement of total costs for all
programs. CONTRACTOR(S) shall report costs under their approved legal entity number established
during the DMC certification process. Total units of service reported on the cost report will be
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compared to the units of services entered by CONTRACTOR(S) into COUNTY’s data system.
CONTRACTOR(S) will be required to correct discrepancies and resubmit to COUNTY prior to
COUNTY’s final acceptance of the cost report.
2. Other Funding Sources – CONTRACTOR(S) will be required to submit a
cost report on a form(s) approved and provided by COUNTY to reflect actual costs and reimbursement
for services provided through funding sources other than DMC. Contracts that include a negotiated
rate per unit of service will be reimbursed only for the costs of approved units of service up to the
negotiated unit of service rate approved in the Agreement, regardless of the contract maximum. If the
cost report indicates an amount due to COUNTY, CONTRACTOR(S) shall submit payment with the
report. If an amount is due to CONTRACTOR(S), COUNTY shall reimburse CONTRACTOR(S)
within forty-five (45) days of receiving and accepting the year-end cost report.
3.Multiple Funding Sources – CONTRACTOR(S) who have multiple
agreements for the same services provided at the same location where at least one of the Agreements is
funded through DMC and the other funding is other federal or county realignment funding will be
required to complete DMC cost reports and COUNTY approved cost reports. Such Agreements will be
settled for actual costs in accordance with Medicaid reimbursement requirements as specified in Title
XIX or Title XXI of the Social Security Act; Title 22, and the State’s Medicaid Plan.
During the term of this Agreement and thereafter, COUNTY and CONTRACTOR(S)
agree to settle dollar amounts disallowed or settled in accordance with DHCS and COUNTY audit
settlement findings. The DHCS audit process is approximately eighteen (18) to thirty-six (36) months
following the close of the State fiscal year. COUNTY may choose to appeal DHCS settlement results
and therefore reserves the right to defer payback settlement with CONTRACTOR(S) until resolution of
the appeal.
In the event that CONTRACTOR(S) fails to provide such reports or other information
required hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly payments
until there is compliance. In addition, CONTRACTOR(S) shall provide written notification and
explanation to COUNTY within fifteen (15) days of any funds received from another source to conduct
the same services covered by this Agreement.
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15.MONITORING
CONTRACTOR(S) agree to extend to COUNTY’s staff, COUNTY’s DBH Director and
the State DHCS, or their designees, the right to review and monitor records, programs or procedures, at
any time, in regard to clients, as well as the overall operation of CONTRACTOR(S)’ programs, in
order to ensure compliance with the terms and conditions of this Agreement.
COUNTY’s DBH Director, or designee, and DHCS or their designees shall monitor and
evaluate the performance of CONTRACTOR(S) under this Agreement to determine to the best possible
degree the success or failure of the services provided under this Agreement. At the discretion of
COUNTY, a subcontractor may be obtained by COUNTY to independently evaluate and monitor the
performance of CONTRACTOR(S). CONTRACTOR(S) shall participate in the evaluation of the
program as needed, at the discretion of COUNTY.
COUNTY shall recapture from CONTRACTOR(S) the value of any services or other
expenditures determined to be ineligible based on COUNTY or State monitoring results. At the
discretion of COUNTY, recoupment can be made through a future invoice reduction or reimbursement
by CONTRACTOR(S).
CONTRACTOR(S) shall participate in a program review of the program at least yearly
or more frequently, or as needed, at the discretion of COUNTY. CONTRACTOR(S) agree to supply
all information requested by COUNTY, DHCS, and/or the subcontractor during program evaluation,
monitoring, and/or review.
16.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.
17.COMPLIANCE WITH STATE REQUIREMENTS
CONTRACTOR(S) recognize that COUNTY operates its mental health programs under
an agreement with the State DHCS, and that under said agreement the State imposes certain
requirements on COUNTY and its subcontractors. CONTRACTOR(S) shall adhere to all State
requirements, including those identified in Exhibit G, “State Mental Health Requirements,” attached
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hereto and by this reference incorporated herein and made part of this Agreement.
18.COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
CONTRACTOR(S) shall be required to maintain Mental Health Plan organizational
CONTRACTOR certification by COUNTY. CONTRACTOR(S) must meet Medi-Cal organizational
provider standards as listed in Exhibit H, “Medi-Cal Organizational Provider Standards,” attached
hereto and incorporated herein and made part of this Agreement. It is acknowledged that all references
to Organizational CONTRACTOR and/or CONTRACTOR in Exhibit H shall refer to
CONTRACTOR(S). In addition, CONTRACTOR(S) shall inform every client of their rights as
described in Exhibit I, under COUNTY's “Fresno County Mental Health Plan – Grievance and
Appeals” protocol, attached hereto and by this reference incorporated herein and made part of this
Agreement. CONTRACTOR(S) shall also file an incident report for all incidents involving clients,
following the protocol and using the worksheet identified in Exhibit J, “Incident Reporting,” attached
hereto and by this reference incorporated herein and made part of this Agreement, or a protocol and
worksheet presented by CONTRACTOR(S) that is acceptable by COUNTY’s DBH Director or
designee.
19.FIDELITY TO EVIDENCE-BASED PRACTICES
A. CONTRACTOR(S) offering perinatal residential or youth treatment services shall
submit to COUNTY for approval, within 60 days from date of contract execution, a plan to address
Program Fidelity to describe adherence to the evidence-based practices as reviewed by the Substance
Abuse and Mental Health Services Administration (SAMHSA). For more information, refer to
http://nrepp.samhsa.gov/landing.aspx.
B.CONTRACTOR(S) shall modify and update the plan in response to deficiencies
found in self-audits, COUNTY site reports, or in the case of implementing other evidence-based
practices.
20.UNLAWFUL USE OF DRUGS AND ALCOHOL
CONTRACTOR(S) shall ensure that information provided to clients contains a clearly
written statement that there shall be no unlawful use of drugs or alcohol associated with
CONTRACTOR(S). Additionally, CONTRACTOR(S) shall ensure that no aspect of the program
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includes any message in materials, curricula, teachings, or promotion of the responsible use, if the use
is unlawful, of drugs or alcohol pursuant to Health and Safety Code (HSC) 11999-11999.3.
CONTRACTOR(S) shall maintain that any unlawful use of drugs and alcohol is illegal and dangerous.
CONTRACTOR(S) must sign the “Unlawful Use of Drugs and Alcohol Certification”,
attached hereto as Exhibit K, incorporated herein by reference and made part of this Agreement
agreeing to uphold the obligations of HSC 11999 – 11999.3.
CONTRACTOR(S) shall enforce the requirement of “No Unlawful Use” set forth by
DHCS and requires CONTRACTOR(S) to enforce the requirement as well.
This Agreement may be unilaterally terminated, without penalty, if CONTRACTOR(S)
or a subcontractor that is a private entity is determined to have violated a prohibition of the Unlawful
Use of Drugs and Alcohol message or has an employee who is determined by the DBH Director or her
designee to have violated a prohibition of the Unlawful Use of Drugs and Alcohol message.
21.STATE ALCOHOL AND DRUG REQUIREMENTS
A.INDEMNIFICATION
CONTRACTOR(S) agree to indemnify, defend, and hold harmless the State, its
officers, agents and employees from any and all claims and losses accruing or resulting to any and all
contractors, subcontractors, material men, laborers and any other person, firm or corporation furnishing
or supplying work, services, materials or supplies in connection with the performance of this
Agreement and from any and all claims and losses accruing or resulting to any person, firm or
corporation who may be injured or damaged by the CONTRACTOR(S) in the performance of this
Agreement.
B.CONTROL REQUIREMENTS
This Agreement is subject to all applicable Federal and State laws, regulations,
and standards. CONTRACTOR(S) shall establish written procedures consistent with the State NNA
requirements. The provisions of this Agreement are not intended to abrogate any provisions of law or
regulation existing or enacted during the term of this Agreement.
///
///
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C.NON - DISCRIMINATION PROVISION
1)Eligibility for Services
CONTRACTOR(S) shall prepare and make available to COUNTY and to
the public all eligibility requirements to participate in the program plan set forth in
CONTRACTOR(S)’ response to the RFP. No person shall, because of ethnic group identification, age,
sex, 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.
2)EMPLOYMENT OPPORTUNITY
CONTRACTOR(S) 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.
3)SUSPENSION OF COMPETITION
If an allegation of discrimination occurs, COUNTY may withhold all
further funds, until CONTRACTOR (S) 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.
4)NEPOTISM
Except by consent of COUNTY’s DBH Director or designee, no person
shall be employed by CONTRACTOR(S) who is related by blood or marriage to, or who is a member
of the Board of Directors or an officer of CONTRACTOR(S).
D.CONFIDENTIALITY
CONTRACTOR(S) shall conform to and COUNTY shall monitor compliance
with all State of California and Federal statutes and regulations regarding confidentiality, including but
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not limited to confidentiality of information requirements at Part 2, Title 42, Code of Federal
Regulations; 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.
E. REVENUE COLLECTION POLICY
CONTRACTOR(S) shall conform to all policies and procedures regarding
revenue collection issued by the State under the provisions of the Health and Safety Code, Division
10.5.
F. EXPENDITURE OF STATE GENERAL AND FEDERAL FUNDS
CONTRACTOR(S) agree that all funds paid out by the State shall be used
exclusively for providing alcohol and/or drug program services, administrative costs, and allowable
overhead.
G. ACCESS TO SERVICES
CONTRACTOR(S) shall provide accessible and appropriate services in
accordance with Federal and State statutes and regulations to all eligible persons.
H. REPORTS
CONTRACTOR(S) agree to participate in surveys related to the performance of
this Agreement and expenditure of funds and agrees to provide any such information in a mutually
agreed upon format.
I. AUDITS
All State and Federal funds furnished to CONTRACTOR(S) pursuant to this
Agreement along with required COUNTY match, related patient and participant fees, third-party
payments, or other related revenues and funds commingled with the foregoing funds are subject to
audit by the State. The State may audit all alcohol and drug program revenue and expenditures
contained in this Agreement for the purpose of establishing the basis for the subsequent year's
negotiation.
J. RECORDS MAINTENANCE
1) CONTRACTOR(S) shall maintain books, records, documents, and other
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evidence necessary to monitor and audit this Agreement.
2)CONTRACTOR(S) shall maintain adequate program and fiscal records
relating to individuals served under the terms of this Agreement, as required, to meet the needs of the
State in monitoring quality, quantity, fiscal accountability, and accessibility of services. Information on
each individual shall include, but not be limited to, admission records, patient and participant
interviews and progress notes, and records of service provided by various service locations, in
sufficient detail to make possible an evaluation of services provided and compliance with this
Agreement.
22.RESTRICTION ON DISTRIBUTION OF STERILE NEEDLES
CONTRACTOR(S) shall adhere to the State-County Contract requirement that no funds
shall be used to carry out any program of distributing sterile needles or syringes for the hypodermic
injection of any illegal drug unless the DHCS chooses to implement a demonstration syringe services
program for intravenous drug users with Substance Abuse Prevention and Treatment (SAPT) Block
Grant funds.
23.CONFIDENTIALITY
All services performed by CONTRACTOR(S) under this Agreement shall be in strict
conformance with all applicable Federal, State of California and/or local laws and regulations relating
to confidentiality.
CONTRACTOR(S) shall ensure that all of its employees sign the “Oath of
Confidentiality,” attached hereto as Exhibit L, incorporated herein by reference and made part of this
Agreement, before they begin employment with CONTRACTOR(S) and shall renew said document
annually thereafter. CONTRACTOR(S) shall retain each employee’s written confidentiality oath for
COUNTY and DHCS inspection for a period of six (6) years following the termination of this
Agreement.
24.TRAFFICKING IN PERSONS PROVISIONS – PRIVATE ENTITY
CONTRACTOR(S) shall conform to all Federal statutes and regulations prohibiting
trafficking of persons, as well as trafficking-related activities, including, but not limited to the
trafficking of persons provisions in Section 106(g) of the Trafficking Victims Protection Act of 2000
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(TVPA) as amended by Section 1702.
CONTRACTOR(S), CONTRACTOR(S)’ employees, subrecipients, and subrecipients’
employees may not:
A)Engage in severe forms of trafficking in persons during the period of time that the
award is in effect;
B)Procure a commercial sex act during the period of time that the award is in effect;
or
C)Use forced labor in the performance of the award or subawards under the award.
This Agreement may be unilaterally terminated, without penalty, if CONTRACTOR(S)
or a subrecipient that is a private entity is determined to have violated a prohibition of the TVPA or has
an employee who is determined by the COUNTY’s DBH Director or designee to have violated a
prohibition of the TVPA through conduct that is either associated with performance under the award or
imputed to CONTRACTOR(S) or their subrecipient using the standards and due process for imputing
the conduct of an individual to an organization that are provided in 2 C.F.R. Part 180, “OMB
Guidelines to Agencies on Government-wide Debarment and Suspension (Nonprocurement).”
CONTRACTOR(S) must inform the COUNTY’s DBH Director or designee immediately
of any information received from any source alleging a violation of a prohibition of the TVPA.
CONTRACTOR(S) must sign the “Trafficking Victims Protection Act of 2000
Certification” (TVPA Certification), attached hereto as Exhibit M, incorporated herein by reference and
made part of this Agreement, and must require all employees to complete annual TVPA training.
25.HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and CONTRACTOR(S) each consider and represent themselves as covered
entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law
104-191 (HIPAA) and agree to use and disclose Protected Health Information (PHI) as required by law.
COUNTY and CONTRACTOR(S) acknowledge that the exchange of PHI between them
is only for treatment, payment, and health care operations.
COUNTY and CONTRACTOR(S) intend to protect the privacy and provide for the
security of PHI pursuant to the Agreement in compliance with HIPAA, the Health Information
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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(S) to enter into a contract containing specific requirements prior to the disclosure of
PHI, as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e) of the
Code of Federal Regulations.
26.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 COUNTY for the purpose of providing services under this
Agreement must employ adequate data security measures to protect the confidential information
provided to CONTRACTOR(S) by COUNTY, including but not limited to the following:
A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
CONTRACTOR(S) may not connect to COUNTY networks via personally-
owned mobile, wireless or handheld devices, unless the following conditions are met:
1.CONTRACTOR(S) have 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(S) may not bring CONTRACTOR-owned computers or
computer peripherals into COUNTY facilities for use without prior authorization from COUNTY’s
Chief Information Officer, and/or designee(s), including but not limited to mobile storage devices. If
data is approved to be transferred, data must be stored on a secure server approved by COUNTY and
transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
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connection. Said data must be encrypted.
C. COUNTY-Owned Computer Equipment
CONTRACTOR(S) may not use COUNTY computers or computer peripherals on
non-COUNTY premises without prior authorization from COUNTY’s Chief Information Officer,
and/or designee(s).
D. CONTRACTOR(S) may not store COUNTY’s private, confidential or sensitive
data on any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
E. CONTRACTOR(S) shall be responsible to employ strict controls to ensure the
integrity and security of COUNTY’s confidential information and to prevent unauthorized access,
viewing, use or disclosure of data maintained in computer files, program documentation, data
processing systems, data files and data processing equipment which stores or processes COUNTY data
internally and externally.
F. Confidential client information transmitted to one party by the other by means of
electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of 128
BIT or higher. Additionally, a password or pass phrase must be utilized.
G. CONTRACTOR(S) are responsible to immediately notify COUNTY of any
violations, breaches or potential breaches of security related to COUNTY’s confidential information,
data maintained in computer files, program documentation, data processing systems, data files and data
processing equipment which stores or processes COUNTY data internally or externally.
H. COUNTY shall provide oversight to CONTRACTOR(S)’ response to all
incidents arising from a possible breach of security related to COUNTY’s confidential client
information provided to CONTRACTOR(S). CONTRACTOR(S) will be responsible to issue any
notification to affected individuals as required by law or as deemed necessary by COUNTY in its sole
discretion. CONTRACTOR(S) will be responsible for all costs incurred as a result of providing the
required notification.
27. PROPERTY OF COUNTY
A. COUNTY and CONTRACTOR(S) recognize that fixed assets include tangible
and intangible property obtained or controlled under COUNTY’s Mental Health Plan for use in
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operational capacity and will benefit COUNTY for a period more than one year. Depreciation of
qualified items will be on a straight-line basis.
For COUNTY purposes, fixed assets must fulfill three qualifications:
1.Asset must have life span of over one year;
2.The asset is not a repair part; and
3.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
•Tangible $5,000
o equipment
o vehicles
•Intangible $100,000
o Internally generated software
o Purchased software
o Easements
o Patents
•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 fully depreciated. During the terms of this Agreement, CONTRACTOR(S)’ fixed assets
may be inventoried in comparison to COUNTY’s DBH Asset Inventory S ystem.
B.Certain purchases less than Five Thousand and No/100 Dollars ($5,000.00) but
more than One Thousand and No/100 Dollars ($1,000.00), with over one year life span, and are mobile
and high risk of theft or loss are sensitive assets. Sensitive assets are not limited to computers, copiers,
televisions, cameras and other sensitive items as determined by COUNTY’s DBH Director or designee.
CONTRACTOR(S) shall maintain 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
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Agreement is terminated or upon expiration of this Agreement. CONTRACTOR(S) agree to
participate in an annual inventory of all COUNTY fixed and inventoried assets. Upon termination or
expiration of this Agreement CONTRACTOR(S) shall be physically present when fixed and
inventoried assets are returned to COUNTY possession. CONTRACTOR(S) are 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(S) further agree to the following:
1. Maintain all items of equipment in good working order and condition;
normal wear and tear is expected;
2. 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. 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 must be submitted to COUNTY.
D. The purchase of any equipment by CONTRACTOR(S) with funds provided
hereunder shall require the prior written approval of COUNTY’s 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 DBH may refuse reimbursement for any costs
resulting from equipment purchased, which are incurred by CONTRACTOR(S), if prior written
approval has not been obtained from COUNTY.
E. CONTRACTOR(S) 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(S) for a use
which does not qualify under this Agreement, CONTRACTOR(S) shall reimburse COUNTY in an
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amount equal to the current fair market value of the property, less any portion thereof attributable to
expenditures of funds not provided under this Agreement. These requirements shall continue in effect
for the life of the property. In the event this Agreement expires or terminates, the requirements for this
Section 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
28.NON-DISCRIMINATION
During the performance of this Agreement, CONTRACTOR(S) shall not unlawfully
discriminate against any employee or applicant for employment, or recipient of services, because of
race, religion, color, national origin, ancestry, physical handicap, medical condition, marital status, age
or gender, pursuant to all applicable State and Federal statutes and regulations.
29.CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, CONTRACTOR(S) shall comply
with:
A.Title 6 of the Civil Rights Act of 1964 (42 U.S.C. Section 2000d, and 45 C.F.R.
Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance
from discriminating against persons based on race, color, national origin, sex, disability or religion.
This is interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access
and participation in federally funded programs through the provision of comprehensive and quality
bilingual services.
B.Policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP consumers, including, but not limited to,
assessing the cultural and linguistic needs of its consumers, training of staff on the policies and
procedures, and monitoring its language assistance program. CONTRACTOR(S)’ procedures must
include ensuring compliance of any sub-contracted CONTRACTORs with these requirements.
C.CONTRACTOR(S) shall not use minors as interpreters.
D. CONTRACTOR(S) 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
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shall be provided as necessary to allow such participants meaningful access to the programs, services
and benefits provided by CONTRACTOR(S). 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(S) shall ensure that any employees, agents, subcontractors, or
partners who interpret or translate for a program participant, or who directly communicate with a
program participant in a language other than English, demonstrate proficiency in the participant's
language and can effectively communicate any specialized terms and concepts peculiar to
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(S) must submit to
COUNTY for approval, within 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(S) 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.
30. SEPARATE AGREEMENT
It is mutually understood by the parties that this Agreement does not, in any way, create a
joint venture among CONTRACTOR(S). By execution of this Agreement, CONTRACTOR(S)
understand that a separate agreement is formed between each individual CONTRACTOR(S) and
COUNTY.
31. TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section 1861(v)
(1) (I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four (4)
years after the furnishing of services under this Agreement, CONTRACTOR(S) shall make available,
upon written request to the Secretary of the United States Department of Health and Human Services,
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or upon request to 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(S) under this Agreement. CONTRACTOR(S) further agrees that in the event
CONTRACTOR(S) carries out any of its duties under this Agreement through a subcontract, with a
value or cost of Ten Thousand and No/100 Dollars ($10,000.00) or more over a twelve (12) month
period, with a related organization, such Agreement shall contain a clause to the effect that until the
expiration of four (4) years after the furnishing of such services pursuant to such subcontract, the
related organizations shall make available, upon written request to the Secretary of the United States
Department of Health and Human Services, or upon request to 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.
32.SINGLE AUDIT CLAUSE
A. If CONTRACTOR(S) expends Seven Hundred Fifty Thousand and No/100
Dollars ($750,000.00) or more in Federal and Federal flow-through monies, CONTRACTOR(S) agrees
to conduct an annual audit in accordance with the requirements of the Single Audit Standards as set
forth in Office of Management and Budget (OMB) Circular A-133. CONTRACTOR(S) shall submit
said audit report and management letter to COUNTY. The audit report must include a statement of
findings or a statement that there were no findings. If there were negative findings,
CONTRACTOR(S) must include a corrective action plan signed by an authorized individual.
CONTRACTOR(S) agree to take action to correct any material non-compliance or weakness found as a
result of such audit. Such audit report shall be delivered to COUNTY’s DBH Business Office, for
review within nine (9) months of the end of any fiscal year in which funds were expended and/or
received for the program. Failure to perform the requisite audit functions as required by this
Agreement may result in COUNTY performing the necessary audit tasks, or at COUNTY’s option,
contracting with a public accountant to perform said audit, or, may result in the inability of COUNTY
to enter into future agreements with CONTRACTOR(S). All audit costs related to this Agreement are
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the sole responsibility of CONTRACTOR(S).
B.A single audit report is not applicable if CONTRACTOR(S)’ Federal contracts do
not exceed the Seven Hundred Fifty Thousand and No/100 Dollars ($750,000.00) 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(S) to COUNTY as a minimum requirement to attest to
CONTRACTOR(S)’ solvency. Said audit report shall be delivered to COUNTY’s DBH Business
Office, 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(S) who agree 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 paragraph shall be billed to CONTRACTOR(S)
at COUNTY cost, as determined by COUNTY’s Auditor-Controller/Treasurer-Tax Collector.
C.CONTRACTOR(S) shall make available all records and accounts for
inspection by COUNTY, the State of California, if applicable, the Comptroller General of the United
States, the Federal Grantor Agency, or any of their duly authorized representatives, at all reasonable
times for a period of at least three (3) years following final payment under this Agreement or the
closure of all other pending matters, whichever is later.
33.COMPLIANCE
CONTRACTOR(S) agree to comply with COUNTY’s Contractor Code of Conduct and
Ethics and COUNTY’s Compliance Program in accordance with Exhibit E. Within thirty (30) days of
entering into this Agreement with COUNTY, CONTRACTOR(S) shall have all of
CONTRACTOR(S)’ 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(S) shall ensure that within thirty (30) days of hire, all new
employees, agents and subcontractors providing services under this Agreement shall certify in writing
that he or she has received, read, understood, and shall abide by the Contractor Code of Conduct and
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Ethics. CONTRACTOR(S) understand that the promotion of and adherence to the Code of Conduct
and Ethics is an element in evaluating the performance of CONTRACTOR(S) and its employees,
agents and subcontractors.
Within thirty (30) days of entering into this Agreement, and annually thereafter, all
employees, agents and subcontractors providing services under this Agreement shall complete general
compliance training and appropriate employees, agents and subcontractors shall complete
documentation and billing or billing/reimbursement training. All new employees, agents and
subcontractors shall attend the appropriate training within 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 COUNTY’s Compliance Officer at 3133 N. Millbrook, Fresno, California 93703.
CONTRACTOR(S) agree 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.
34.ASSURANCES
In entering into this Agreement, CONTRACTOR(S) certifies that it, nor any of its
officers, are not currently excluded, suspended, debarred, or otherwise ineligible to participate in the
Federal Health Care Programs: that it, nor any of its officers, have not been convicted of a criminal
offense related to the provision of health care items or services; nor has it, or any of its officers, been
reinstated to participate in the Federal Health Care Programs after a period of exclusion, suspension,
debarment, or ineligibility. If COUNTY learns, subsequent to entering into a contract, that
CONTRACTOR(S) is ineligible on these grounds, COUNTY will remove CONTRACTOR(S) from
responsibility for, or involvement with, COUNTY’s business operations related to the Federal Health
Care Programs and shall remove such CONTRACTOR(S) from any position in which
CONTRACTOR(S)’ compensation, or the items or services rendered, ordered or prescribed by
CONTRACTOR(S) 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(S) are reinstated
into participation in the Federal Health Care Programs.
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A. If COUNTY has notice that CONTRACTOR(S), or its officers, has been charged
with a criminal offense related to any Federal Health Care Program, or is proposed for exclusion during
the term of any contract, CONTRACTOR(S) and COUNTY shall take all appropriate actions to ensure
the accuracy of any claims submitted to any Federal Health Care Program. At its discretion given such
circumstances, COUNTY may request that CONTRACTOR(S) cease providing services until
resolution of the charges or the proposed exclusion.
B. CONTRACTOR(S) agree that all potential new employees of CONTRACTOR(S)
or subcontractors of CONTRACTOR(S) who, in each case, are expected to perform professional
services under this Agreement, will be queried as to whether (1) they are now or ever have been
excluded, suspended, debarred, or otherwise ineligible to participate in the Federal Health Care
Programs; (2) they have been convicted of a criminal offense related to the provision of health care
items or services; and or (3) they have been reinstated to participate 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(S) that he or she is excluded, suspended, debarred or otherwise ineligible, or has been
convicted of a criminal offense relating to the provision of health care services, and
CONTRACTOR(S) hires or engages such potential employee or subcontractor, CONTRACTOR(S)
will ensure that said employee or subcontractor does no work, either directly or indirectly relating to
services provided to COUNTY.
2. Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance (as
defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor
of CONTRACTOR(S) will perform work, either directly or indirectly, relating to services provided to
COUNTY. Such demand for adequate assurance shall be effective upon a time frame to be determined
by COUNTY to protect the interests of COUNTY consumers.
C. CONTRACTOR(S) shall verify (by asking the applicable employees and
subcontractors) that all current employees and existing subcontractors who, in each case, are expected
to perform professional services under this Agreement (1) are not currently excluded, suspended,
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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(S) that he or she is excluded, suspended, debarred or otherwise ineligible to
participate in the Federal Health Care Programs, or has been convicted of a criminal offense relating to
the provision of health care services, CONTRACTOR(S) will ensure that said employee or
subcontractor does no work, either direct or indirect, relating to services provided to COUNTY.
1.CONTRACTOR(S) agree to notify COUNTY immediately during the
term of this Agreement whenever CONTRACTOR(S) 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 Three (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 consumers.
D. CONTRACTOR(S) agree 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.
E.CONTRACTOR(S) agree 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.
35.PUBLICITY PROHIBITION
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.,
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purchasing of tickets/tables, silent auction donations, etc.) for the purpose of self-promotion.
Notwithstanding the above, publicity of the services described in Section One (1) of this Agreement
shall be allowed as necessary to raise public awareness about the availability of such specific services
when approved in advance by COUNTY’s DBH Director or designee and at a cost to be provided in
Exhibit C for such items as written/printed materials, the use of media (i.e., radio, television,
newspapers) and any other related expense(s).
36. COMPLAINTS
CONTRACTOR(S) shall log complaints and the disposition of all complaints from a
client or a client’s family. CONTRACTOR(S) shall provide a copy of the detailed complaint log
entries concerning COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (l0th)
day of the following month, in a format that is mutually agreed upon. In addition, CONTRACTOR(S)
shall provide details and attach documentation of each complaint with the log. CONTRACTOR(S)
shall post signs informing clients of their right to file a complaint or grievance. CONTRACTOR(S)
shall notify COUNTY of all incidents reportable to State licensing bodies that affect COUNTY clients
within twenty-four (24) hours of receipt of a complaint.
Within ten (10) days after each incident or complaint affecting COUNTY-sponsored
clients, CONTRACTOR(S) shall provide COUNTY with information relevant to the complaint;
investigative details of the complaint; and the complaint and CONTRACTOR(S)' disposition of or
corrective action taken to resolve the complaint. In addition, CONTRACTOR(S) shall inform every
client of their rights as set forth in Exhibit I.
37. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST
INFORMATION
This provision is only applicable if CONTRACTOR(S) are disclosing entities, fiscal
agents, or managed care entities as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101
455.104, and 455.106(a)(1),(2).
In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2),
the following information must be disclosed by CONTRACTOR(S) by completing Exhibit N,
“Disclosure of Ownership and Control Interest Statement,” attached hereto and by this reference
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incorporated herein and made part of this Agreement. CONTRACTOR(S) shall submit this form to the
Department of Behavioral Health within thirty (30) days of the effective date of this Agreement.
Additionally, CONTRACTOR(S) shall report any changes to this information within thirty five (35)
days of occurrence by completing Exhibit N. Submissions shall be scanned PDF copies and are to be
sent via email to DBHAdministration@co.fresno.ca.us Attention: Contracts Administration.
38.DISCLOSURE – CRIMINAL HISTORY AND CIVIL ACTIONS
CONTRACTOR(S) are 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(S)”]:
A.Within the three-year period preceding the Agreement award, they have been
convicted of, or had a civil judgment rendered against them for:
1.Fraud or a criminal offense in connection with obtaining, attempting to
obtain, or performing a public (federal, state, or local) transaction or contract under a public
transaction;
2.Violation of a federal or state antitrust statute;
3.Embezzlement, theft, forgery, bribery, falsification, or destruction of
records; or
4.False statements or receipt of stolen property.
B.Within a three-year period preceding their Agreement award, they have had a
public transaction (federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate
CONTRACTOR(S) from further business consideration. The information will be considered as part
of the determination of whether to continue and/or renew the Agreement and any additional
information or explanation that a CONTRACTOR(S) elects to submit with the disclosed information
will be considered. If it is later determined that the CONTRACTOR(S) failed to disclose required
information, any contract awarded to such CONTRACTOR(S) may be immediately voided and
terminated for material failure to comply with the terms and conditions of the award.
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CONTRACTOR(S) must sign a “Certification Regarding Debarment, Suspension,
and Other Responsibility Matters–Primary Covered Transactions” in the form set forth in Exhibit O,
attached hereto and by this reference incorporated herein and made part of this Agreement.
Additionally, CONTRACTOR(S) must immediately advise COUNTY in writing if, during the term of
this Agreement: (1) CONTRACTOR(S) become 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.epls.gov); or (2) any of the above listed conditions become
applicable to CONTRACTOR(S). CONTRACTOR(S) shall indemnify, defend and hold 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.
39. FEDERAL CERTIFICATIONS
A. CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
INELIGIBILITY AND VOLUNTARY EXCLUSION - LOWER TIER
COVERED TRANSACTIONS
1. DBH-Substance Abuse Specialist (SAS) and CONTRACTOR(S)
recognize that Federal assistance funds will be used under the terms of this Agreement. For purposes
of this paragraph, CONTRACTOR(S) will be referred to as the "prospective recipient".
2. This certification is required by the regulations implementing Executive
Order 12549, Debarment and Suspension, 29 CFR Part 98, Section 98.510, Participants'
responsibilities. The regulations were published as Part VII of the May 26, 1988 Federal Register
(pages19160-19211).
a) The prospective recipient of Federal assistance funds certifies by
entering this Agreement, that neither it nor its principals are presently debarred, suspended, proposed
for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any
Federal department or agency.
b) The prospective recipient of funds agrees by entering into this
Agreement, that it shall not knowingly enter into any lower tier covered transaction with a person who
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is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered
transaction, unless authorized by the Federal department or agency with which this transaction
originated.
c)Where the prospective recipient of Federal assistance funds is
unable to certify to any of the statements in this certification, such prospective participant shall attach
an explanation to this Agreement.
d)The prospective recipient shall provide immediate written notice
to DBH-SAS if at any time prospective recipient learns that its certification in this clause of this
Agreement was erroneous when submitted or has become erroneous by reason of changed
circumstances.
e) The prospective recipient further agrees that by entering this
Agreement, it will include a clause identical to this clause of this Agreement, and titled "Certification
Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered
Transactions", in all lower tier covered transactions and in all Solicitations for lower tier covered
transactions.
f)The certification in this clause of this Agreement is a material
representation of fact upon which reliance was placed by COUNTY when this transaction was entered
into.
B.AUDIT
CONTRACTOR(S) shall grant DBH-SUD Services, State of California (if
applicable), the Federal grantor agency, the Comptroller General of the United States, or any of their
duly authorized representatives access to any books, documents, papers, and records of the
CONTRACTOR(S) which are directly pertinent to this Agreement for the purpose of audits,
examinations, excerpts and transactions. The CONTRACTOR(S) must retain all such required records
for three (3) years after CONTRACTOR(S) makes final payment and all other pending matters are
closed.
C.CLEAN AIR AND WATER
In the event funding under this Agreement exceeds one hundred thousand dollars
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($100,000.00), the CONTRACTOR(S) must comply with all applicable standards, orders, or
requirements issued under Section 306 of the Clean Air Act (42 U.S.C. 1857 (h)), Section 506 of the
Clean Water Act (33 U.S.C. 1368), Executive Order 11738, and Environmental Protection Agency
Regulations (40 CFR part 32).
D. ENERGY EFFICIENCY
The CONTRACTOR(S) must comply with the mandatory standards and policies
relating to energy efficiency which are contained in the state energy conservation plan issued in
compliance with Energy Policy and Conservation Act (Pub. L. 94-163).
E. REPORTING REQUIREMENTS, COPYRIGHT AND PATENTS
The awarding agency's reporting requirements are stated in this Agreement. The
awarding agency's requirements and regulations pertaining to copyright and rights in data, and patent
rights with respect to any discovery or invention which arise or is developed in the course of or under
this Agreement (if any), are likewise stated in this Agreement.
40. DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if CONTRACTOR(S) are operating as a corporation (a
for-profit or non-profit corporation) or if during the term of this Agreement, CONTRACTOR(S)
change 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(S) is providing goods or performing
services under this Agreement. A self-dealing transaction shall mean a transaction to which
CONTRACTOR(S) are 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 and signing a “Self-Dealing Transaction Disclosure Form,” attached hereto as
Exhibit P, incorporated herein by reference and made part of this Agreement, and submitting it to
COUNTY prior to commencing with the self-dealing transaction or immediately thereafter.
41. ADDITION/DELETION OF CONTRACTOR(S)
COUNTY’s DBH Director or designee reserves the right at any time during the term of
this Agreement to add new CONTRACTOR(S) to those listed in Exhibit A. It is understood any such
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additions will not affect compensation paid to the other CONTRACTOR(S), and therefore such
additions may be made by COUNTY without notice to or approval from other CONTRACTOR(S)
under this Agreement. These same provisions shall apply to the deletion of any CONTRACTOR(S)
listed in Exhibit A, except that deletions shall be made by written mutual agreement between the
COUNTY, COUNTY’S DBH Director or designee, and the particular CONTRACTOR(S) to be
deleted, or shall be in accordance with the provisions of Section Three (3) of this Agreement.
42.AUDITS AND INSPECTIONS
CONTRACTOR(S) shall, at any time during business hours, and as often as COUNTY
may deem necessary, make available to COUNTY for examination all of its records and data with
respect to the matters covered by this Agreement. CONTRACTOR(S) shall, upon request by
COUNTY, permit COUNTY to audit and inspect all 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 ($10,000.00),
CONTRACTOR(S) shall be subject to the examination and audit of the State Auditor General for a
period of three (3) years after final payment under contract (California Government Code section
8546.7).
43.NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR
Director, County of Fresno See Exhibit A
Department of Behavioral Health
3133 N. Millbrook Avenue
Fresno, CA 93702
Any and all notices between COUNTY and CONTRACTOR(S) provided for or
permitted under this Agreement or by law shall be in writing and shall be deemed duly served when
personally delivered to one of the parties, or in lieu of such personal service, when deposited in the
United States Mail, postage prepaid, addressed to such party.
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44.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.
45.ENTIRE AGREEMENT
This Agreement, including all Exhibits, COUNTY’s Revised RFP No. 952-5481 and
CONTRACTOR(S)’ Responses constitutes the entire agreement between CONTRACTOR(S) and
COUNTY with respect to the subject matter hereof and supersedes all previous agreement negotiations,
proposals, commitments, writings, advertisements, publications, and understandings of any nature
whatsoever unless expressly included in this Agreement.
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1 fN WITNESS WHEREOF, the parties hereto have executed this Agreement a s of the day and
2 year fir st hereinabove written .
3
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CONTRACTOR(S):
PLEASE SEE ATTACHED SIGNATURES
COUNTY OF FRESNO
By:_IL_· fa1_ __ _
Brian Pacheco, C hairman of the Board of
Supervisors o f the County of F res no
Date: __ } f_-_1_4_-_l -'-! ___ _
ATTEST:
Bernice E. Se idel
Clerk to the Board of Supervi so rs
County of Fresno , State of Ca li fornia
By : ~SA,y\ ~~P'p
Deputy
Date : JJ-1tJ-11 ------------
PLEASE SEE ADDITIONAL
SIGNATURE PAGES ATTACHED
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Master Agreement for Primary Care Integration
Fund/Subclass: 0001/10000
Organization: 56304325
56304532
56302081
Account/Program: 7295/0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 CLINICA SIERRA VISTA By:~fU~ Print Name: 3'k()\\rD \j\\ · ~('.,Vv\ ~l( ~~ Title: ~Vu cJ' ge~u,11 \JG Orn~uV-Chairman of Board, or President Or any Vice President Print Name: Oo"1Sue/o €". {}.t:th.J-u Title: -------------Secretary of Corporation, or Any Assistant Secretary, or Chief Financial Officer, or Any Assistant Treasurer Mailing Address: 1430 Truxtun Avenue, Suite #400 Bakersfield, CA 93301 Phone No.: (661) 635-3050 Contact Name: Christopher Reilly -51 -COUNTY OF FRESNO Fresno, CA
Exhibit A
Page 1 of 1
Contractor List
Clinica Sierra Vista, Inc.
1430 Truxtun Avenue, Suite #400
Bakersfield, CA 93301
Phone No.: (661) 635-3050
Contact: Stephen W. Schilling, Chief Executive Officer
E-Mail: schilling@clinicasierravista.org
SITE
LOCATION
PRIMARY CARE &
PREVENTION & EARLY INTERVENTION
SPECIALTY MENTAL HEALTH &
SUBSTANCE USE DISORDERS
Airport
1945 N. Fine Avenue, Suite 100
Fresno, CA 93727
Monday – Friday
8:30AM – 5:30PM
Services estimated to begin: March 1, 2018
2002 N. Fine Street, Suite 101
Fresno, CA 93727
Monday – Friday
8:30AM – 5:30PM
Services estimated to begin: March 1, 2018
West Fresno
302 W. Fresno Street, Suite 101
Fresno, CA 93706
Monday – Friday
8:30AM – 5:30PM
Services estimated to begin: March 1, 2018
302 W. Fresno Street, Suite 106
Fresno, CA 93706
Monday – Friday
8:30AM – 5:30PM
Services estimated to begin: July 1, 2018
Regional
Medical
Center
2505 Divisadero Street
Fresno, CA 93721
Monday – Saturday
8:30AM – 5:30PM
Services estimated to begin: March 1, 2018
2900 Fresno Street, Suite 106-107
Fresno, CA 93721
Monday – Saturday
8:30AM – 5:30PM
Services estimated to begin: March 1, 2018
Exhibit B-1
Page 1 of 5
Primary Care Integration
Prevention and Early Intervention (PEI)
Summary of Service
SERVICE:
Integrated Mental Health Prevention and Early Intervention (PEI) services at Primary Care Clinics
SCHEDULE OF SERVICES:
CONTRACTOR(S) shall operate the integrated primary care clinics on a consistent schedule to allow ease of
access to individuals seeking services. CONTRACTOR(S) shall provide an answering service to take
incoming calls after hours and on non-operational days to route calls to a medical provider, thereby ensuring
that all clients have access to a medical provider seven (7) days a week and twenty-four (24) hours a day. The
answering service shall make available interpretation services in the threshold languages of Fresno County, at
a minimum, which include Spanish and Hmong. The answering service shall not be used in lieu of calls to 9-1-
1 for emergency situations.
TARGET POPULATION:
The target population will include residents of Fresno County including children, youth, adolescents, adults,
perinatal women, and older adults. Additionally, target populations include indigent, uninsured, underserved,
special needs underserved, cultural populations, migrant and seasonal farmworkers, and other person of
limited access. Specific target areas include the eastern foothills, south central, other rural regions, and
metropolitan areas of Fresno County, as well as underserved cultural, ethnic, racial, and linguistic
populations. These areas typically experience disproportionately higher rates of untreated mental health
concerns and illnesses due to a number of factors, including stigma, cultural and linguistic barriers to
services, poverty, distrust, geographic isolation, and transportation needs.
SERVICE:
The PEI service component aims to fully integrate medical primary care with mild to moderate mental health
concerns and illnesses, above and beyond the primary care clinic’s regulatory responsibilities for mental
health. Individuals experiencing early manifestations of a mental health concern or illness shall receive early
intervention services to prevent the illness or concern from worsening.
This portion of the Primary Care Integration Master Agreement is funded by the PEI component of the
Mental Health Services Act (MHSA) and is intended to provide short-term services to persons experiencing
symptoms less than one year prior to the date of seeking service. PEI services should not exceed one year.
Individuals who require more than one year of service must be referred to mental health services not funded
through the PEI component of the MHSA, or to the corresponding Severely Mentally Ill or Serious Emotional
Disturbance (SMI/SED) component of the Primary Care Integration program, as appropriate.
CONTRACTOR(S) will provide screening, assessment, diagnosis, development of individual treatment plans,
short-term therapeutic treatment, case management, care coordination, and referrals to appropriate community
resources, as needed.
Additional services may include, but are not limited to, the following:
• Outreach
• Education for increasing recognition of early signs of mental illness programs
• Access and linkage to treatment and other resources in efforts to improve timely access and outcomes
for unserved and underserved populations
• Suicide prevention programs and approaches
Exhibit B-1
Page 2 of 5
CONTRACTOR(S) REQUIREMENTS:
CONTRACTOR(S) shall:
1. Provide integrated PEI services, in compliance with all State and Federal PEI rules and
regulations, at primary care clinic sites certified in accordance with Medi-Cal regulations and the
Americans with Disabilities Act.
2. Apply to and be approved by the Fresno County Mental Health Plan Credentialing Committee for
Medi-Cal billing and payment.
3. Ensure the following is provided in regard to cultural competence:
A. Demonstrate flexibility in meeting the unique needs of clients by including equal access to
those with disabilities, gender-specific services, and culturally sensitive services that adhere
to the National Standards on Culturally and Linguistically Appropriate Services (CLAS).
CONTRACTOR(S) shall submit a CLAS plan within 30 days of execution of this Agreement,
stating how the 15 National CLAS standards will be addressed via
http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53.
B. Recruit and hire staff who have demonstrated experience working with Latino, African
American, Southeast Asian, Native American, and other minority populations and have
knowledge about the respective cultures as well as other diverse communities.
C. Attend annual trainings regarding cultural competency, awareness, and diversity as
provided by CONTRACTOR(S), or online via COUNTY’s eLearning system.
CONTRACTOR(S)’ staff shall be appropriately trained in providing services in a culturally
sensitive manner.
D. Conduct an annual cultural competency self-assessment and provide the results to
COUNTY. COUNTY shall review and revise the self-assessment tool as necessary to meet
COUNTY’s approval.
E. Attend civil rights training as provided by CONTRACTOR(S) or online via COUNTY’s
eLearning system.
F. Recruit and hire bilingual staff. At a minimum, CONTRACTOR(S) shall hire staff who are
competent in Spanish and Hmong, the threshold languages of Fresno County.
G. Secure trained translation and interpretation services in the threshold languages as well as
Cambodian, Russian, Arabic, Armenian, Punjabi, and other languages commonly used in
Fresno County. Translators and interpreters shall be appropriately trained to provide
services in a culturally sensitive manner.
H. Distribute literature or informational brochures in threshold languages to clients and request
feedback in regard to engaging and improving access to care for culturally diverse
communities within the service area.
I. Provide services by seeking to understand and placing importance on the traditional values,
beliefs, and family histories of clients, as cultural values and traditions offer special
strengths in treating and helping to guide clients toward wellness and recovery.
J. Provide services within the most relevant and meaningful cultural, gender-sensitive, and
age-appropriate context for the target population.
K. Collaborate with agencies recognized and accepted by the target populations.
Exhibit B-1
Page 3 of 5
L. Provide and integrate family support and the creation of family partnerships and peer
support for families to strengthen family-driven services.
M. Seek to hire and train staff and community stakeholders that provide services to the target
populations in the development of age specific and gender appropriate program services
and service delivery methods.
4. Demonstrate staff proficiency (training and certification) in suicide and crisis intervention
procedures and other training subjects that would benefit the client in their wellness goals.
5. Ensure Live Scan criminal background checks for all staff and counselors who have contact with
children.
6. Ensure primary care practitioners, other medical staff, and office staff are trained on mental health
issues, mental illness warning signs and precursors, as well as sensitivity and privacy issues,
medications, mental health resources, and HIPAA/mental health record keeping, as appropriate,
in order to facilitate capacity building and communication with on-site mental health providers.
7. Utilize recognized screening tools (e.g., Screening Brief Intervention Referral and Treatment
[SBIRT], PHQ-9, and GAD) to make mental health diagnoses.
8. Consult with the primary care provider as well as mental health staff (e.g., psychiatrist,
psychologist) on complex cases in the development of treatment plans and other care
considerations.
9. Use current and effective evidence-based practices to treat PEI diagnoses.
10. As it relates to Timeliness of Service, CONTRACTOR(S) shall not exceed 10 business days from
date of Initial request to first face to face Assessment for PEI services.
11. Collaborate and coordinate with other agencies to provide referrals and linkages to appropriate
agencies and family supportive services.
12. Ensure appropriately credentialed and licensed staff are available and utilized to assess, develop,
facilitate, and manage service provision, and provide treatment services.
13. Work with COUNTY to capture and enter all Client Service Information (CSI), admission data, and
billing information into COUNTY’s data system for the purposes of effective care coordination and
State reporting. Selected CONTRACTOR(S) shall provide all necessary data to allow COUNTY
to capture all CSI data for services provided and to meet all State and Federal reporting
requirements. Methods of providing such information include, but are not limited to, the following
A. Direct data entry in COUNTY’s electronic information system;
B. Provide an electronic file compatible with COUNTY’s electronic information system; or
C. Interface CONTRACTOR(S)’ information system(s) with COUNTY’s information system.
COUNTY REQUIREMENTS:
COUNTY shall:
1. Provider oversight, through its MHSA Coordinator or designee, and collaborate with
CONTRACTOR(S), other County departments, and community agencies to help achieve program
goals and outcomes. Oversight includes, but is not limited to contract monitoring, annual
utilization reviews, and coordination with the Department of Health Care Services in regard to
program administration and outcomes.
Exhibit B-1
Page 4 of 5
2. Assist CONTRACTOR(S) in making linkages with the total mental health system of care. This will
be accomplished through regularly scheduled meetings as well as formal and informal
consultation.
3. Participate in evaluating overall program progress and efficiency, and be available for ongoing
consultation for program improvement.
4. Gather outcome information from target client groups and CONTRACTOR(S) through each term
of this Agreement. COUNTY shall notify CONTRACTOR(S) when its participation is required.
The performance outcome measurement process will not be limited to survey instruments but will
also include, as appropriate, client and staff interviews, chart review and other methods of
obtaining required information.
5. Assist CONTRACTOR(S) toward cultural and linguistic competency by providing the following to
CONTRACTOR(S):
A. Technical assistance and training regarding cultural competency requirements at no cost to
CONTRACTOR(S).
B. Mandatory cultural competency training for CONTRACTOR(S) personnel, on an annual
basis, at minimum.
C. Technical assistance for translating written information into Fresno County threshold
languages (Spanish and Hmong). Translation services and associated costs will be the
responsibility of CONTRACTOR(S).
PROGRAM OUTCOMES AND PERFORMANCE MEASURES:
1. CONTRACTOR(S) shall collect client data using the following methods:
A. Interviews with staff, participants, and family members; and case file reviews.
B. Consumer satisfaction surveys to identify service efficacy and opportunities for program
development, as well as gaps in meeting cultural needs of the clients and/or families.
2. CONTRACTOR(S) shall collect data regarding the ethnic and language demographics of clients
and/or families receiving services, as well as survey clients and families in regard to
improvements to programs to ensure cultural relevance in service provision.
3. CONTRACTOR(S) shall maintain all client data in permanent electronic case records, and have
established policies and procedures for data collection and client confidentiality.
4. In regard to the four domains below, CONTRACTOR(S) agree to work with COUNTY to develop
outcomes that are measurable, obtainable, clear, accurately reflect the expected result, and include
specific time frames, and CONTRACTOR(S) agree to collect data to monitor and report progress:
A. Effectiveness of Services – A measurement of how well the program performed and the
results achieved, and measures the quality of care through a client’s change over time.
Examples include, but are not limited to, reduction of hospitalization time, reduction of
symptoms, employment and housing status, and reduction of recidivism rate and incidence of
relapse.
B. Efficiency of Services – A measurement of the relationship between outcomes and the
resources used. Examples include, but are not limited to, service delivery cost per service
unit, length of stay, and direct service hours of clinical and medical staff.
Exhibit B-1
Page 5 of 5
C. Access to Service – A measurement of changes or improvements in the program’s capacity
and timeliness to provide services to those who request or require them. Examples include,
but are not limited to, wait/length of time from first request/referral to first service, assessment,
or subsequent appointment; convenience of service hours and locations; number of clients
served by program capacity; and no-show and cancellation rates.
D. Satisfaction and Feedback from Clients and Stakeholders – A measurement of changes or
increased positive/negative feedback regarding the experiences of the persons served and
others (families, referral sources, payors/guarantors, etc.). Satisfaction measures are usually
oriented toward clients, family members, personnel, the community, and funding sources.
Examples include, but are not limited to, whether or not the program focused on the client’s
recovery, grievances or concerns were addressed, there were overall feelings of satisfaction,
and there was satisfaction with physical facilities, fees, access, service effectiveness, and
efficiency.
5. COUNTY may request additional data collection by CONTRACTOR(S) at a later date, as needed.
6. Performance outcomes shall be mutually determined by COUNTY and CONTRACTOR(S).
7. CONTRACTOR(S) shall prepare an evaluation report annually, which will be submitted to
COUNTY’s DBH and made available to partnering and interested local agencies and
organizations (e.g., project collaborators, other community agencies, and mental health treatment
providers). Each annual evaluation report shall include demographics of the target population
served, services provided to each participant, number of hospitalizations, enrollment in school,
results of data analysis compared to planned process, output and outcome measures, barriers to
program implementation and measures taken to overcome those barriers, accomplishments of
program participants, lessons learned, and the final results of any and all satisfactory surveys.
8. Additional reports and outcome information may be requested by COUNTY at a later date, as
needed.
Exhibit B-2
Page 1 of 5
Primary Care Integration
Severely Mentally Ill and Seriously Emotionally Disturbed (SMI & SED)
Summary of Service
SERVICE:
Integrated Mental Health services for Severely Mentally Ill (SMI) and Seriously Emotionally Disturbed (SED)
clients at Primary Care Clinic locations. SMI and SED services will be provided at site(s) in close proximity to,
but not within, the Primary Care Clinic.
SCHEDULE OF SERVICES:
CONTRACTOR(S) shall operate the integrated primary care clinics consistent schedule to allow ease of
access to individuals referred for services. CONTRACTOR(S) shall provide an answering service to take
incoming calls after hours and on non-operational days to route calls to a medical provider, thereby ensuring
that all clients have access to a medical provider seven (7) days a week and twenty-four (24) hours a day. The
answering service shall make available interpretation services in the threshold languages of Fresno County, at
a minimum, which include Spanish and Hmong. The answering service shall not be used in lieu of calls to 9-1-
1 for emergency situations.
TARGET POPULATION:
The target population will include residents of Fresno County including children, youth, adolescents, adults,
perinatal women, and older adults who are experiencing mental health symptoms at a more extensive level
and duration than those receiving services for Prevention and Early Intervention. Services provided through
this contract are intended to develop, enhance, and integrate mental health services for the SMI/SED
population in addition to services currently provided at local primary care facilities. Specific target areas
include the eastern foothills, south central, other rural regions, and metropolitan areas of Fresno County, as
well as underserved cultural, ethnic, racial, and linguistic populations. These areas typically experience
disproportionately higher rates of untreated mental health concerns and illnesses due to a number of factors,
including stigma, cultural and linguistic barriers to services, poverty, distrust, geographic isolation, and
transportation needs.
Individuals referred for SMI services are adults ages 18 and over who have at least one mental health
disorder as identified in the current edition of the Diagnostic and Statistical Manual (DSM) of Mental
Disorders excluding a substance use or developmental disorder; have substantial functional impairments or
symptoms, or a history of such symptoms; and is likely to require public assistance, services, or entitlements
as a result of such disorders.
Individuals referred for SED services are children and youth under the age of 18 and must have at least one
mental health disorder as identified in the current edition of the DSM of Mental Disorders excluding a
substance use or developmental disorder; have substantial impairment in self-care, school, and
relationships; be at risk of or have already experienced removal from the home; have a mental disorder or
impairment present for at least six months or is likely to persist for more than one year without treatment;
displays psychotic features, risk of suicide, or risk of violence due to a mental disorder; or has been
assessed and determined to have an emotional disturbance.
PROJECT DESCRIPTION:
The SMI/SED service component aims to provide services to clients with SMI/SED diagnoses recognized
evidence-based practices and outcome-informed short-term therapy targeted to address and treat mental
health concerns and diagnoses on a case by case basis. CONTRACTOR(S) shall fully integrate primary care
provision with specialty mental health services for the SMI/SED population, in accordance to individualized
treatment plans.
Exhibit B-2
Page 2 of 5
CONTRACTOR(S) will provide screening, assessments, specialty mental health therapeutic treatment, case
management, care coordination, and referrals and linkages to other appropriate providers, as necessary.
Additional services may include, but are not limited to, the following:
• Individual, family, and/or group therapy
• Case management
• Medication services
• Rehabilitation services
• Collateral sessions
• Integrated care coordination
• Office and/or home based services
CONTRACTOR(S) RESPONSIBILITIES:
CONTRACTOR(S) shall:
1. Provide integrated specialty mental health services in compliance with all State and Federal
specialty mental health rules and regulations, at primary care clinic sites certified in accordance
with Medi-Cal regulations and the Americans with Disabilities Act.
2. Apply and be approved by the Fresno County Mental Health Plan Credentialing Committee for
Medi-Cal billing and payment.
3. Ensure the following occurs in regard to cultural competence:
A. Demonstrate flexibility in meeting the unique needs of clients by including equal access to
those with disabilities, gender-specific services, and culturally sensitive services that adhere
to the National Standards on Culturally and Linguistically Appropriate Services (CLAS).
CONTRACTOR(S) shall submit a CLAS plan within 30 days of execution of this Agreement,
stating how the 15 National CLAS standards will be addressed via
http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53.
B. Recruit and hire staff who have demonstrated experience working with Latino, African
American, Southeast Asian, Native American, and other minority populations and have
knowledge about the respective cultures as well as other diverse communities.
C. Attend annual trainings regarding cultural competency, awareness, and diversity as
provided by CONTRACTOR(S), or online via COUNTY’s eLearning system.
CONTRACTOR(S)’ staff shall be appropriately trained in providing services in a culturally
sensitive manner.
D. Conduct an annual cultural competency self-assessment and provide the results to
COUNTY. COUNTY shall review and revise the self-assessment tool as necessary to meet
COUNTY’s approval.
E. Attend civil rights training as provided by CONTRACTOR(S) or online via COUNTY’s
eLearning system.
F. Recruit and hire bilingual staff. At a minimum, CONTRACTOR(S) shall hire staff who are
competent in Spanish and Hmong, the threshold languages of Fresno County.
G. Secure trained translation and interpretation services in the threshold languages as well as
Cambodian, Russian, Arabic, Armenian, Punjabi, among others. Translators and
interpreters shall be appropriately trained to provide services in a culturally sensitive
manner.
Exhibit B-2
Page 3 of 5
H. Distribute literature or informational brochures in threshold languages to clients and request
feedback in regard to engaging and improving access to care for culturally diverse
communities within the service area.
I. Provide services by seeking to understand and placing importance on the traditional values,
beliefs, and family histories of clients, as cultural values and traditions offer special
strengths in treating and helping to guide clients toward wellness and recovery.
J. Provide services within the most relevant and meaningful cultural, gender-sensitive, and
age-appropriate context for the target population.
K. Collaborate with agencies recognized and accepted by the target populations.
L. Provide and integrate family support and the creation of family partnerships and peer
support for families to strengthen family-driven services.
M. Seek to hire and train staff and community stakeholders that provide services to the target
populations in the development of age specific and gender appropriate program services
and service delivery methods.
4. Demonstrate staff proficiency (training and certification) in suicide and crisis intervention
procedures and other training subjects that would benefit the client in their wellness goals.
5. Ensure Live Scan criminal background checks for all staff and counselors who have contact with
children.
6. Ensure primary care practitioners, other medical staff, and office staff are trained on mental health
issues, mental illness warning signs and precursors, as well as sensitivity and privacy issues,
medications, mental health resources, and HIPAA/mental health record keeping, as appropriate,
in order to facilitate capacity building and communication with on-site mental health providers.
7. Utilize recognized screening tools (e.g., Screening Brief Intervention Referral and Treatment
[SBIRT], PHQ-9, and GAD) to make mental health diagnoses.
8. Consult with the primary care provider as well as mental health staff (e.g., psychiatrist,
psychologist) on complex cases in the development of treatment plans and other care
considerations.
9. Utilize current and effective evidence-based practices to treat SMI/SED diagnoses including, but
not limited to, SBIRT, MATRIX, Motivational Interviewing, Trauma-Focused Cognitive Behavioral
Therapy, Therapeutic Behavioral Services, Solution Focused Brief Therapy, and EMDR.
10. Link clients with dual diagnoses of mental health and substance use disorders to appropriate
agencies or corresponding in-house substance use programs.
11. As it relates to Timeliness of Service, CONTRACTOR(S) shall not exceed 10 business days from
date of Initial request to first face to face Assessment for non-urgent SMI and SED services. For
psychiatry requests/referrals, CONTRACTOR(S) shall not exceed 15 business days from the date
of request/referral to the first psychiatric appointment.
12. Make accommodations for urgent cases to be seen within 24 hours of diagnosis or crisis, if not
immediately, whether by CONTRACTOR(S)’ psychiatric/clinical staff or by an appropriate outside
agency that is properly equipped to receive, stabilize, and treat such cases.
13. Collaborate and coordinate with other agencies to provide referrals and linkages to appropriate
agencies and family supportive services.
Exhibit B-2
Page 4 of 5
14. Ensure appropriately credentialed and licensed staff are available and utilized to assess, develop,
facilitate, and manage service provision, and provide treatment services.
15. Work with COUNTY to capture and enter all Client Service Information (CSI), admission data, and
billing information into COUNTY’s data system for the purposes of effective care coordination and
State reporting. Selected CONTRACTOR(S) shall provide all necessary data to allow COUNTY
to capture all CSI data for services provided and to meet all State and Federal reporting
requirements. Methods of providing such information include, but are not limited to, the following
A. Direct data entry in COUNTY’s electronic information system;
B. Provide an electronic file compatible with COUNTY’s electronic information system; or
C. Interface CONTRACTOR(S)’ information system(s) with COUNTY’s information system.
COUNTY RESPONSIBILITIES:
COUNTY shall:
1. Provider oversight, through its MHSA Coordinator or designee, and collaborate with
CONTRACTOR(S), other County departments, and community agencies to help achieve program
goals and outcomes. Oversight includes, but is not limited to contract monitoring, annual
utilization reviews, and coordination with the Department of Health Care Services in regard to
program administration and outcomes.
2. Assist CONTRACTOR(S) in making linkages with the total mental health system of care. This will
be accomplished through regularly scheduled meetings as well as formal and informal
consultation.
3. Participate in evaluating overall program progress and efficiency, and be available for ongoing
consultation for program improvement.
4. Gather outcome information from target client groups and CONTRACTOR(S) through each term
of this Agreement. COUNTY shall notify CONTRACTOR(S) when its participation is required.
The performance outcome measurement process will not be limited to survey instruments but will
also include, as appropriate, client and staff interviews, chart review and other methods of
obtaining required information.
5. Assist CONTRACTOR(S) toward cultural and linguistic competency by providing the following to
CONTRACTOR(S):
A. Technical assistance and training regarding cultural competency requirements at no cost to
CONTRACTOR(S).
B. Mandatory cultural competency training for CONTRACTOR(S) personnel, on an annual
basis, at minimum.
C. Technical assistance for translating written information into Fresno County threshold
languages (Spanish and Hmong). Translation services and associated costs will be the
responsibility of CONTRACTOR(S).
PROGRAM OUTCOMES AND PERFORMANCE MEASURES:
1. CONTRACTOR(S) shall collect client data using the following methods:
A. Interviews with staff, participants, and family members; and case file reviews.
Exhibit B-2
Page 5 of 5
B. Consumer satisfaction surveys to identify service efficacy and opportunities for program
development, as well as gaps in meeting cultural needs of the clients and/or families.
2. CONTRACTOR(S) shall collect data regarding the ethnic and language demographics of clients
and/or families receiving services, as well as survey clients and families in regard to
improvements to programs to ensure cultural relevance in service provision.
3. CONTRACTOR(S) shall maintain all client data in permanent electronic case records, and have
established policies and procedures for data collection and client confidentiality.
4. In regard to the four domains below, CONTRACTOR(S) agree to work with COUNTY to develop
outcomes that are measurable, obtainable, clear, accurately reflect the expected result, and include
specific time frames, and CONTRACTOR(S) agree to collect data to monitor and report progress:
A. Effectiveness of Services – A measurement of how well the program performed and the
results achieved, and measures the quality of care through a client’s change over time.
Examples include, but are not limited to, reduction of hospitalization time, reduction of
symptoms, employment and housing status, and reduction of recidivism rate and incidence of
relapse.
B. Efficiency of Services – A measurement of the relationship between outcomes and the
resources used. Examples include, but are not limited to, service delivery cost per service
unit, length of stay, and direct service hours of clinical and medical staff.
C. Access to Service – A measurement of changes or improvements in the program’s capacity
and timeliness to provide services to those who request or require them. Examples include,
but are not limited to, wait/length of time from first request/referral to first service or
subsequent appointment, convenience of service hours and locations, number of clients
served by program capacity, and no-show and cancellation rates.
D. Satisfaction and Feedback from Clients and Stakeholders – A measurement of changes or
increased positive/negative feedback regarding the experiences of the persons served and
others (families, referral sources, payors/guarantors, etc.). Satisfaction measures are usually
oriented toward clients, family members, personnel, the community, and funding sources.
Examples include, but are not limited to, whether or not the program focused on the client’s
recovery, grievances or concerns were addressed, there were overall feelings of satisfaction,
and there was satisfaction with physical facilities, fees, access, service effectiveness, and
efficiency.
5. COUNTY may request additional data collection by CONTRACTOR(S) at a later date, as needed.
6. Performance outcomes shall be mutually determined by COUNTY and CONTRACTOR(S).
7. CONTRACTOR(S) shall prepare an evaluation report annually, which will be submitted to
COUNTY’s DBH and made available to partnering and interested local agencies and
organizations (e.g., project collaborators, other community agencies, and mental health treatment
providers). Each annual evaluation report shall include demographics of the target population
served, services provided to each participant, number of hospitalizations, enrollment in school,
results of data analysis compared to planned process, output and outcome measures, barriers to
program implementation and measures taken to overcome those barriers, accomplishments of
program participants, lessons learned, and the final results of any and all satisfactory surveys.
8. Additional reports and outcome information may be requested by COUNTY at a later date, as
needed.
Exhibit B-3
Page 1 of 7
Primary Care Integration
Substance Use Disorder Services (SUD)
Summary of Service
SERVICE:
Integrated Substance Use Disorder (SUD) services at Primary Care Clinic locations. SUD services will be
provided at site(s) in close proximity to, but not within, the Primary Care Clinic.
OVERVIEW:
CONTRACTOR(S) shall fully integrate outpatient substance use disorder services with mental health and
primary care services at the primary care setting. SUD services are designed to assist individuals to identify
and accept their substance abuse or dependence; understand the dynamics of the addictive process;
understand the consequences of the process on themselves, their families and support system, as well as their
ability to function in society; and lead a productive, self-sufficient, and alcohol and drug-free lifestyle.
The Integrated SUD services will be located at CONTRACTOR(S)’ Primary Care Clinic locations throughout
Fresno County. CONTRACTOR(S) shall operate the integrated primary care clinics on a consistent schedule
to allow ease of access to individuals referred for services. CONTRACTOR(S) shall provide an answering
service to take incoming calls after hours and on non-operational days to route calls to a medical provider,
thereby ensuring that all clients have access to medical care seven (7) days a week and twenty-four (24) hours
a day. The answering service shall make available interpretation services in the threshold languages of
Fresno County, at a minimum, which include Spanish and Hmong. The answering service shall not be used in
lieu of calls to 9-1-1 for emergency situations.
CONTRACTOR(S) shall provide quick access to SUD services, linkages to prevention and early intervention
activities in the community that are culturally and linguistically appropriate, and make referrals to more
intensive SUD services within Fresno, as needed.
CONTRACTOR(S) shall provide at a minimum, the following:
• Individual, group, and/or family counseling
• Treatment, recovery, and discharge planning
• Resource assistance for the purpose of recovery
TARGET POPULATION
The target population will include residents of Fresno County including adolescents, adults, perinatal women,
and older adults. Services provided through this contract are intended to develop or enhance services for
clients diagnosed with substance use disorders in addition to services currently provided at local primary
care facilities. Specific target areas include the eastern foothills, south central, other rural regions, and
metropolitan areas of Fresno County, as well as underserved cultural, ethnic, racial, and linguistic
populations. These areas typically experience disproportionately higher rates of untreated substance use
disorders due to a number of factors, including stigma, cultural and linguistic barriers to services, poverty,
distrust, geographic isolation, and transportation needs.
Persons served through this program must meet medical necessity based on the American Society of
Addiction Medicine (ASAM) criteria; youth must meet the ASAM adolescent treatment criteria. Additionally,
service recipients must have at least one diagnosis from the most recent edition of the Diagnostic and
Statistical Manual (DSM) of Mental Disorders for Substance-Related and Addictive Disorders, with the
exception of Tobacco-Related and Non-Substance-Related Disorders.
Exhibit B-3
Page 2 of 7
SERVICE REQUIREMENTS:
CONTRACTOR(S) shall meet or exceed the following requirements:
1. Ensure all services are performed within the applicable regulations and standards, including but
not limited to California Code of Regulations (CCR) Title 22, Alcohol and Other Drug (AOD)
Certification Standards, CCR Title 9, Department of Health Care Services (DHCS) - Mental Health
Substance Use Disorder Services (MHSUDS), and County of Fresno SUD Bulletins.
2. Provide proof of application for State of California AOD Program certification within thirty (30)
days of execution of this Agreement.
3. Possess or apply to have Drug Medi-Cal certification within sixty (60) days of execution of this
Agreement.
4. Ensure staff providing counseling services in AOD recovery and treatment programs meet all
requirements for certification in accordance with CCR Title 9, Division 4, Chapter 8; also
referenced in SUD Bulletin #15-02—Counselor Certification and Program Requirements, located
at http://www.co.fresno.ca.us/DepartmentPage.aspx?id=63345.
A. COUNSELOR
Program staff who conducts individual or group counseling sessions, intake interviews, client
exit conferences, and/or assessments of clients' alcohol and/or other drug problems shall
demonstrate sufficient knowledge in the field of substance abuse treatment, principles of
recovery, and counseling.
Minimum requirements for staff are as follows:
i. Two (2) years of experience in providing direct counseling services to persons with
alcohol and/or other drug problems;
ii. Two (2) years of college-level education;
iii. Two (2) years of alcohol and other drug counseling experience may be substituted for
one (1) year of college-level education. No more than one (1) year of college-level
education may be substituted with alcohol and other drug counseling experience; and
iv. Per CA Assembly Bill No. 2374 (“Monsoor Bill”), SEC 2. Section 11833(b)(1), “The
department shall require that a counselor working within a program described in
subdivision (a) be certified by a nationally accredited certifying organization that has
consulted with all other nationally accredited certifying organizations and the National
Practitioner Data Bank to determine whether the person has ever had his or her
license or certification as a counselor revoked.”
Additional Requirements and Definitions:
i. As used for these standards, "one (1) year of college-level education" is defined as the
satisfactory completion of at least twenty-four (24) semester units, or the equivalent, of
classroom instruction provided by an accredited or state-approved, public or private,
post-secondary institution of higher learning;
ii. At minimum, twelve (12) of the twenty-four (24) semester units required shall be in
alcohol and drug studies, psychology, counseling, social work or a closely related field;
iii. As used in these standards, "one (1) year of experience" means 1,776 total hours of full
or part-time, compensated or uncompensated, work experience;
Exhibit B-3
Page 3 of 7
iv. The provider agency shall require all employees to have written evidence of their
qualifications;
v. Resumes, applications, reference checks and/or transcripts documenting work
experience and education may be used to meet the requirements of this section;
vi. The provider agency shall have written guidelines specifying the requirements to be
employed by the provider agency;
vii. Volunteers and/or interns may assist in conducting educational sessions, group
counseling sessions, intake interviews, exit interviews or assessments of alcohol and/or
other drug problems;
viii. Volunteers and/or interns shall be under the direct supervision of program staff;
ix. Volunteers and/or interns shall not provide services unless the supervising staff member
is present in the room during the provision of services; and
x. Providers that cannot meet the minimum experience, educational and/or certification
requirements as described above shall submit for County approval a plan that describes
how the agency plans to adequately train and supervise these staff. This plan shall be
approved prior to these staff conducting individual or group counseling sessions, intake
interviews, client exit conferences, or assessments of clients' alcohol and/or other drug
problems, and/or clinical supervision.
B. Psychiatrist and/or Psychologist – Provide leadership, guidance, and consultation in
provision and management of mental health and care coordination services including but not
limited to assessment, diagnosis, treatment planning, rehabilitation, evaluation, medication
and other supportive services. Works closely with primary care medical providers and SUD
staff
C. Licensed Mental Health Professional – Provide nonjudgmental and direct mental health
services to clients in accordance with the treatment plan and toward wellness and recovery
(e.g., LCSW, LMFT).
D. Substance Abuse Counselor – Provide support and treatment to persons suffering from
addiction to drugs and/or alcohol through counseling and instruction on how to modify
harmful behaviors to reach recovery. (A minimum of thirty (30) percent or program staff
providing counseling services in all AOD programs shall be licensed or certified pursuant to
the requirements of CCR, Title 9, Division 4, Chapter 8, Subchapter 1, Section 13010).
E. Case Manager – Ensure client’s needs are met, coordinate transportation, encourage and
ensure client complies with treatment plan, and assist clients in accessing resources to help
clients follow treatment plans and reach treatment goals.
5. Ensure the following occurs in regard to cultural competence:
A. Demonstrate flexibility in meeting the unique needs of clients by including equal access to
those with disabilities, gender-specific services, and culturally sensitive services that adhere
to the National Standards on Culturally and Linguistically Appropriate Services (CLAS).
CONTRACTOR(S) shall submit a CLAS plan within 30 days of execution of this Agreement,
stating how the 15 National CLAS standards will be addressed via
http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53.
B. Seek to recruit and hire staff who have demonstrated cultural competency and have
knowledge of diverse communities within Fresno County.
C. Attend annual trainings regarding cultural competency, awareness, and diversity as
provided by CONTRACTOR(S), or online via COUNTY’s eLearning system.
CONTRACTOR(S)’ staff shall be appropriately trained in providing services in a culturally
sensitive manner.
Exhibit B-3
Page 4 of 7
D. Conduct an annual cultural competency self-assessment and provide the results to
COUNTY. COUNTY shall review and revise the self-assessment tool as necessary to meet
COUNTY’s approval.
E. Collaborate with agencies recognized and accepted by the target populations.
F. Seek to recruit and hire bilingual staff.
G. Secure trained translation and interpretation services in the threshold languages as well as
Cambodian, Russian, Arabic, Armenian, Punjabi, among others. Translators and
interpreters shall be appropriately trained to provide services in a culturally sensitive
manner.
H. Distribute literature or informational brochures in the threshold languages to clients and
request feedback in regard to engaging and improving access to care for culturally diverse
communities within the service area.
I. Provide services by seeking to understand and placing importance on the traditional values,
beliefs, and family histories of clients, as cultural values and traditions offer special
strengths in treating and helping to guide clients toward wellness and recovery.
J. Provide services within the most relevant and meaningful cultural, gender-sensitive, and
age-appropriate context for the target population.
K. Collaborate with agencies recognized and accepted by the target populations.
L. Provide and integrate family support and the creation of family partnerships and peer
support for families to strengthen family-driven services.
M. Seek to hire and train staff and community stakeholders that provide services to the target
populations in the development of age specific and gender appropriate program services
and service delivery methods.
6. Demonstrate staff proficiency (training and certification) in suicide and crisis intervention
procedures, Mental Health First Aid, Stigma Reduction, and other subject matters that would
benefit the client’s safety and recovery.
7. Ensure Live Scan criminal background checks for all staff and counselors who have contact with
children.
8. Utilize current and recognized screening tools to determine if a client has a substance use
disorder and its severity (e.g., CRAFFT, AUDIT-C, DAST, PHQ-2). Screening tools should be
age appropriate and should encompass screening for both alcohol and drugs. Standardized
screening tools can be found at the following site: https://www.drugabuse.gov/nidamed-medical-
health-professionals/tool-resources-your-practice/screening -assessment-drug-testing-
resources/chart-evidence-based-screening-tools-adults.
9. Utilize current and effective outcome-informed treatments and evidence-based practices for
persons with SUD diagnoses. Motivational Interviewing (mandatory), Cognitive Behavioral
Therapy, Trauma Informed Care, Psychoeducation and Relapse Prevention are the five
evidenced based practices that providers must utilize under the ODS – Waiver. For providers
contracted with Fresno County, Motivational Interviewing will be a mandatory requirement. The
provider must implement at least two of the other evidenced based practices listed.
10. As it relates to Timeliness of Service, CONTRACTOR(S) shall not exceed 10 business days from
date of Initial request to first Substance Use Disorder (SUD) Service, or in accordance with
timeframes established in Fresno County’s Drug Medi-Cal Organized Delivery System (DMC-ODS)
Exhibit B-3
Page 5 of 7
Implementation Plan. CONTRACTOR(S) shall collect data regarding the average interval between
referral and participation in services to which a client was referred.
11. Ensure all waitlisted clients are engaged with interim SUD services until they are admitted into a
treatment program. Interim services shall be documented, and this documented information shall
be available upon request.
12. Collaborate and coordinate with other agencies to provide referrals and linkages to appropriate
agencies and family supportive services.
13. Work with COUNTY to capture and enter all Client Service Information (CSI), admission data, and
billing information into COUNTY’s data system for the purposes of effective care coordination and
State reporting. Selected CONTRACTOR(S) shall provide all necessary data to allow COUNTY
to capture all CSI data for services provided and to meet all State and Federal reporting
requirements. Methods of providing such information include, but are not limited to, the following:
A. Direct data entry in COUNTY’s electronic information system;
B. Provide an electronic file compatible with COUNTY’s electronic information system; or
C. Interface CONTRACTOR(S)’ information system(s) with COUNTY’s information system.
COUNTY RESPONSIBILITIES:
The County of Fresno will be responsible for the following:
Will provide oversight, which includes, but is not limited to contract monitoring, annual utilization reviews,
and coordination with the Department of Health Care Services in regard to program administration and
outcomes.
1. Provide site and contract monitoring to ensure that local agencies maintain quality services and in
in compliance with State and Federal regulations and contract requirements.
2. Participate in evaluating overall program progress and efficiency, and be available for ongoing
consultation for program improvement.
3. Gather outcome information from target client groups and CONTRACTOR(S) through each term
of this Agreement. COUNTY shall notify CONTRACTOR(S) when its participation is required.
The performance outcome measurement process will not be limited to survey instruments but will
also include, as appropriate, client and staff interviews, chart review and other methods of
obtaining required information.
4. Assist CONTRACTOR(S) toward cultural and linguistic competency by providing the following to
CONTRACTOR(S):
A. Technical assistance and training regarding cultural competency requirements at no cost to
CONTRACTOR(S).
B. Mandatory cultural competency training for CONTRACTOR(S) personnel, on an annual
basis, at minimum.
C. Technical assistance for translating written information into Fresno County threshold
languages (Spanish and Hmong). Translation services and associated costs will be the
responsibility of CONTRACTOR(S).
Exhibit B-3
Page 6 of 7
OUTCOMES AND PERFORMANCE MEASURES:
Data shall be collected in the following methods:
1. Interviews with staff, participants, and family members; and case file reviews.
2. CONTRACTOR(S) shall conduct consumer satisfaction surveys to identify service efficacy and
opportunities for program development, as well as gaps in meeting cultural needs of the clients
and/or families.
3. CONTRACTOR(S) shall collect data regarding the ethnic and language demographics of clients
and/or families receiving services, as well as survey clients and families in regard to
improvements to programs to ensure cultural relevance in service provision.
4. CONTRACTOR(S) shall maintain a daily census of all participants served and statistical data as
requested by COUNTY, including but not limited to treatment entry date, discharge date, and the
monthly waitlist.
5. CONTRACTOR(S) shall submit all information and data required by the State, including but not
limited to CalOMS Treatment submissions, DATAR, and annual cost reports.
6. CONTRACTOR(S) shall maintain all client data in permanent electronic case records, and have
established policies and procedures for data collection and client confidentiality.
7. In regard to the four domains below, CONTRACTOR(S) agree to work with COUNTY to develop
outcomes that are measurable, obtainable, clear, accurately reflect the expected result, and include
specific time frames, and CONTRACTOR(S) agree to collect data to monitor and report progress:
A. Effectiveness of Services – A measurement of how well the program performed and the
results achieved, and measures the quality of care through a client’s change over time.
Examples include, but are not limited to, reduction of hospitalization time, reduction of
symptoms, employment and housing status, and reduction of recidivism rate and incidence of
relapse.
B. Efficiency of Services – A measurement of the relationship between outcomes and the
resources used. Examples include, but are not limited to, service delivery cost per service
unit, length of stay, and direct service hours of clinical and medical staff.
C. Access to Service – A measurement of changes or improvements in the program’s capacity
and timeliness to provide services to those who request or require them. Examples include,
but are not limited to, wait/length of time from first request/referral to first service or
subsequent appointment, convenience of service hours and locations, number of clients
served by program capacity, and no-show and cancellation rates.
D. Satisfaction and Feedback from Clients and Stakeholders – A measurement of changes or
increased positive/negative feedback regarding the experiences of the persons served and
others (families, referral sources, payors/guarantors, etc.). Satisfaction measures are usually
oriented toward clients, family members, personnel, the community, and funding sources.
Examples include, but are not limited to, whether or not the program focused on the client’s
recovery, grievances or concerns were addressed, there were overall feelings of satisfaction,
and there was satisfaction with physical facilities, fees, access, service effectiveness, and
efficiency.
8. COUNTY may request additional data collection by CONTRACTOR(S) at a later date, as needed.
9. Performance outcomes shall be mutually determined by COUNTY and CONTRACTOR(S) and
Exhibit B-3
Page 7 of 7
demonstrate an effective increase in penetration rates in traditionally unserved and underserved
populations.
10. CONTRACTOR(S) shall prepare an evaluation report annually, which will be submitted to
COUNTY’s DBH and made available to partnering and interested local agencies and
organizations (e.g., project collaborators, other community agencies, and mental health treatment
providers). Each annual evaluation report shall include demographics of the target population
served, services provided to each participant, number of hospitalizations, enrollment in school,
results of data analysis compared to planned process, output and outcome measures, barriers to
program implementation and measures taken to overcome those barriers, accomplishments of
program participants, lessons learned, and the final results of any and all satisfactory surveys.
11. Additional reports and outcome information may be requested by COUNTY at a later date, as
needed.
Exhibit C
Page 1 of 28
START-UP EXPENSES
Computers and Software 10,600.00$
Furniture and Fixtures 3,000.00$
Telephone System -$
Tenant Improvements -$
Other - Identify -$
Other - Identify -$
TOTAL START-UP EXPENSES 13,600.00$
PRIMARY CARE INTEGRATION
Clinica Sierra Vista
Prevention and Early Intervention (PEI)
Projected Start-Up Budget - Fiscal Year 2017-18
Budget Categories -Proposed
BudgetLine Item Description (Must be itemized)
Exhibit C
Page 2 of 28
FTE %Admin Direct Total
PERSONNEL SALARIES:
0001 Associate Therapist (MH Intern)1.00 -$ 37,679$ 37,679$
0002 Medical Assistant 3.00 53,155$ -$ 53,155$
0003
0004
0005
0006
0007
0008
0009
0010
0011
0012
SALARY TOTAL 4.00 53,155$ 37,679$ 90,835$
PAYROLL TAXES:
0030 OASDI -$ -$ -$
0031 FICA/MEDICARE 4,066$ 2,882$ 6,948$
0032 SUI 30$ 1,201$ 1,231$
PAYROLL TAX TOTAL 4,096$ 4,083$ 8,179$
EMPLOYEE BENEFITS:
0040 Retirement 1,063$ 754$ 1,817$
0041 Workers Compensation 797$ 565$ 1,362$
0042 Health Insurance (medical, vision, life, dental)7,973$ 23,511$ 31,484$
EMPLOYEE BENEFITS TOTAL 9,833$ 24,830$ 34,663$
SALARY & BENEFITS GRAND TOTAL 133,677$
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building -$
1011 Rent/Lease Equipment -$
1012 Utilities 4,320$
1013 Building Maintenance 648$
1014 Equipment purchase -$
FACILITY/EQUIPMENT TOTAL 4,968$
OPERATING EXPENSES:
1060 Telephone 1,377$
1061 Answering Service 180$
1062 Postage 180$
1063 Printing/Reproduction 1,200$
1064 Publications -$
1065 Legal Notices/Advertising -$
1066 Office Supplies & Equipment 8,100$
1067 Household Supplies -$
1068 Food -$
Line Item Description (Must be itemized)
PRIMARY CARE INTEGRATION
Clinica Sierra Vista
Prevention and Early Intervention (PEI)
Projected Budget - Fiscal Year 2017-18
Budget Categories -Total Proposed Budget
Exhibit C
Page 3 of 28
1069 Program Supplies - Therapeutic -$
1070 Program Supplies - Medical -$
1071 Transportation of Clients 1,125$
1072 Staff Mileage/Vehicle Maintenance -$
1073 Staff Travel (Out of County)-$
1074 Staff Training/Registration 2,250$
1075 Lodging -$
1076 Other - Recruitment 2,500$
OPERATING EXPENSES TOTAL 16,912$
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping -$
1081 External Audit 250$
1082 Liability Insurance 750$
1083 Administrative Overhead (includes payroll services)29,810$
1084 Payroll Services -$
1085 Professional Liability Insurance -$
FINANCIAL SERVICES TOTAL 30,810$
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management) / IT Support 375$
1091 Translation Services 600$
1092 Contract Psychiatrist 12,784$
SPECIAL EXPENSES TOTAL 13,759$
FIXED ASSETS:
1190 Computers & Software -$
1191 Furniture & Fixtures -$
1192 Other - (Identify)-$
1193 Other - (Identify)-$
FIXED ASSETS TOTAL -$
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)-$
2001 Client Housing Operating Expenditures (SFC 71)-$
2002.1 Clothing, Food & Hygiene (SFC 72)-$
2002.2 Client Transportation & Support (SFC 72)-$
2002.3 Education Support (SFC 72)-$
2002.4 Employment Support (SFC 72)-$
2002.5 Respite Care (SFC 72)-$
2002.6 Household Items -$
2002.7 Utility Vouchers (SFC 72)-$
2002.8 Child Care (SFC 72)-$
NON MEDI-CAL CLIENT SUPPORT TOTAL -$
TOTAL PROGRAM EXPENSES 200,126$
MEDI-CAL REVENUE:
Units of
Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)0 -$ -$
3100 Case Management 0 -$ -$
3200 Crisis Services 0 -$ -$
3300 Medication Support 0 -$ -$
3400 Collateral 0 -$ -$
Exhibit C
Page 4 of 28
3500 Plan Development 0 -$ -$
3600 Assessment 0 -$ -$
3700 Rehabilitation 0 -$ -$
Estimated Medi-Cal Billing Totals 0 -$
Estimated % of Federal Financial Participation Reimbursement 0.00%$0
Estimated % of Early and Periodic Screening, Diagnostic, and Treatment Reimbursement 0.00%$0
MEDI-CAL REVENUE TOTAL -$
OTHER REVENUE:
4000 Other - (Identify)-$
4100 Other - (Identify)-$
4200 Other - (Identify)-$
4300 Other - (Identify)-$
OTHER REVENUE TOTAL -$
MHSA FUNDS:
5000 Prevention & Early Intervention Funds 200,126$
5100 Community Services & Supports Funds -$
5200 Innovation Funds -$
5300 Workforce Education & Training Funds -$
MHSA FUNDS TOTAL 200,126$
TOTAL PROGRAM REVENUE 200,126$
Exhibit C
Page 5 of 28
FTE %Admin Direct Total
PERSONNEL SALARIES:
0001 Associate Therapist (MH Intern)1.00 -$ $64,369 64,369$
0002 Medical Assistant 3.00 $90,807 90,807$
0003
0004
0005
0006
0007
0008
0009
0010
0011
0012
SALARY TOTAL 4.00 $90,807 $64,369 $155,176
PAYROLL TAXES:
0030 OASDI -$ -$ -$
0031 FICA/MEDICARE 6,947$ 4,924$ 11,871$
0032 SUI 30$ 1,201$ 1,231$
PAYROLL TAX TOTAL $6,977 $6,125 $13,102
EMPLOYEE BENEFITS:
0040 Retirement 1,816$ 1,287$ 3,103$
0041 Workers Compensation 1,362$ 966$ 2,328$
0042 Health Insurance (medical, vision, life, dental)13,621$ 24,130$ 37,751$
EMPLOYEE BENEFITS TOTAL 16,799$ 26,383$ 43,182$
SALARY & BENEFITS GRAND TOTAL 211,460$
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building -$
1011 Rent/Lease Equipment -$
1012 Utilities 7,200$
1013 Building Maintenance 1,080$
1014 Equipment purchase -$
FACILITY/EQUIPMENT TOTAL 8,280$
OPERATING EXPENSES:
1060 Telephone 2,295$
1061 Answering Service 300$
1062 Postage 300$
1063 Printing/Reproduction 2,000$
1064 Publications -$
1065 Legal Notices/Advertising -$
1066 Office Supplies & Equipment 13,500$
1067 Household Supplies -$
1068 Food -$
Line Item Description (Must be itemized)
PRIMARY CARE INTEGRATION
Clinica Sierra Vista
Prevention and Early Intervention (PEI)
Projected Budget - Fiscal Year 2018-19
Budget Categories -Total Proposed Budget
Exhibit C
Page 6 of 28
1069 Program Supplies - Therapeutic -$
1070 Program Supplies - Medical -$
1071 Transportation of Clients 1,875$
1072 Staff Mileage/Vehicle Maintenance -$
1073 Staff Travel (Out of County)-$
1074 Staff Training/Registration 3,750$
1075 Lodging -$
1076 Other - Recruitment 1,000$
OPERATING EXPENSES TOTAL 25,020$
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping -$
1081 External Audit 250$
1082 Liability Insurance 750$
1083 Administrative Overhead (includes payroll services)47,156$
1084 Payroll Services -$
1085 Professional Liability Insurance -$
FINANCIAL SERVICES TOTAL 48,156$
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management) / IT Support 375$
1091 Translation Services 600$
1092 Contract Psychiatrist 21,840$
SPECIAL EXPENSES TOTAL 22,815$
FIXED ASSETS:
1190 Computers & Software -$
1191 Furniture & Fixtures -$
1192 Other - (Identify)-$
1193 Other - (Identify)-$
FIXED ASSETS TOTAL -$
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)-$
2001 Client Housing Operating Expenditures (SFC 71)-$
2002.1 Clothing, Food & Hygiene (SFC 72)-$
2002.2 Client Transportation & Support (SFC 72)-$
2002.3 Education Support (SFC 72)-$
2002.4 Employment Support (SFC 72)-$
2002.5 Respite Care (SFC 72)-$
2002.6 Household Items -$
2002.7 Utility Vouchers (SFC 72)-$
2002.8 Child Care (SFC 72)-$
NON MEDI-CAL CLIENT SUPPORT TOTAL -$
TOTAL PROGRAM EXPENSES 315,731$
MEDI-CAL REVENUE:
Units of
Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)0 -$ -$
3100 Case Management 0 -$ -$
3200 Crisis Services 0 -$ -$
3300 Medication Support 0 -$ -$
3400 Collateral 0 -$ -$
Exhibit C
Page 7 of 28
3500 Plan Development 0 -$ -$
3600 Assessment 0 -$ -$
3700 Rehabilitation 0 -$ -$
Estimated Medi-Cal Billing Totals 0 -$
Estimated % of Federal Financial Participation Reimbursement 0.00%$0
Estimated % of Early and Periodic Screening, Diagnostic, and Treatment Reimbursement 0.00%$0
MEDI-CAL REVENUE TOTAL $0
OTHER REVENUE:
4000 Other - (Identify)-$
4100 Other - (Identify)-$
4200 Other - (Identify)-$
4300 Other - (Identify)-$
OTHER REVENUE TOTAL -$
MHSA FUNDS:
5000 Prevention & Early Intervention Funds 315,731$
5100 Community Services & Supports Funds -$
5200 Innovation Funds -$
5300 Workforce Education & Training Funds -$
MHSA FUNDS TOTAL 315,731$
TOTAL PROGRAM REVENUE 315,731$
Exhibit C
Page 8 of 28
START-UP EXPENSES
Computers and Software 86,350.00$
Furniture and Fixtures 38,170.00$
Telephone System 36,800.00$
Tenant Improvements 63,140.00$
Other - Identify -$
Other - Identify -$
TOTAL START-UP EXPENSES 224,460.00$
PRIMARY CARE INTEGRATION
Clinica Sierra Vista
Severely Mentally Ill (SMI)
Projected Start-Up Budget - Fiscal Year 2017-18
Budget Categories -
Proposed BudgetLine Item Description (Must be itemized)
Exhibit C
Page 9 of 28
FTE %Admin Direct Total
PERSONNEL SALARIES:
0001 Behavioral Health Director 0.35 $19,250 19,250$
0002 Quality Improvement Supervisor 0.50 $11,662 11,662$
0003 Quality Improvement Staff 0.50 $6,489 6,489$
0004 Clinic Manager 1.00 $30,342 $3,371 33,714$
0005 Licensed Therapist 2.00 $59,620 59,620$
0006 Case Manager .6.00 $92,376 92,376$
0007 Receptionist 3.00 $9,599 $22,398 31,997$
0008 MH Associate Therapist 3.00 $46,188 46,188$
0009 Medical Assistant 1.00 $10,666 10,666$
0010
0011
0012
SALARY TOTAL 17.35 77,342$ 234,619$ 311,961$
PAYROLL TAXES:
0030 OASDI -$ -$ -$
0031 FICA/MEDICARE 6,690$ 20,295$ 26,985$
0032 SUI 2,707$ 8,212$ 10,919$
PAYROLL TAX TOTAL 9,397$ 28,507$ 37,904$
EMPLOYEE BENEFITS:
0040 Retirement 2,707$ 8,212$ 10,919$
0041 Workers Compensation 2,166$ 6,569$ 8,735$
0042 Health Insurance (medical, vision, life, dental)9,668$ 29,327$ 38,995$
EMPLOYEE BENEFITS TOTAL 14,541$ 44,108$ 58,649$
SALARY & BENEFITS GRAND TOTAL 408,514$
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building (3 sites)34,450$
1011 Rent/Lease Equipment -$
1012 Utilities (3 sites)8,880$
1013 Building Maintenance 2,120$
1014 Equipment purchase -$
FACILITY/EQUIPMENT TOTAL 45,450$
OPERATING EXPENSES:
1060 Telephone (3 sites)15,600$
1061 Answering Service 150$
1062 Postage 150$
1063 Printing/Reproduction 1,440$
1064 Publications -$
1065 Legal Notices/Advertising -$
1066 Office Supplies & Equipment (3 sites)10,584$
1067 Household Supplies -$
1068 Food -$
Line Item Description (Must be itemized)
PRIMARY CARE INTEGRATION
Clinica Sierra Vista
Severely Mentally Ill (SMI)
Projected Budget - Fiscal Year 2017-18
Budget Categories -Total Proposed Budget
Exhibit C
Page 10 of 28
1069 Program Supplies - Therapeutic 1,200$
1070 Program Supplies - Medical 1,200$
1071 Transportation of Clients 1,470$
1072 Staff Mileage/Vehicle Maintenance 4,800$
1073 Staff Travel (Out of County)-$
1074 Staff Training/Registration 4,380$
1075 Lodging -$
1076 Other - Recruitment 6,390$
OPERATING EXPENSES TOTAL 47,364$
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping -$
1081 External Audit 1,000$
1082 Liability Insurance 2,296$
1083 Administrative Overhead (includes payroll services)91,098.62$
1084 Payroll Services -$
1085 Professional Liability Insurance -$
FINANCIAL SERVICES TOTAL 94,395$
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management) / IT Support / Avatar 25,796$
1091 Translation Services 1,200$
1092 Contract Psychiatrist 150,340$
SPECIAL EXPENSES TOTAL 177,336$
FIXED ASSETS:
1190 Computers & Software + 3 sets Telehealth Equipment -$
1191 Furniture & Fixtures -$
1192 Other - Tenant Improvements -$
1193 Other - VOIP Phone System Installation/Setup -$
FIXED ASSETS TOTAL -$
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)-$
2001 Client Housing Operating Expenditures (SFC 71)-$
2002.1 Clothing, Food & Hygiene (SFC 72)-$
2002.2 Client Transportation & Support (SFC 72)-$
2002.3 Education Support (SFC 72)-$
2002.4 Employment Support (SFC 72)-$
2002.5 Respite Care (SFC 72)-$
2002.6 Household Items -$
2002.7 Utility Vouchers (SFC 72)-$
2002.8 Child Care (SFC 72)-$
NON MEDI-CAL CLIENT SUPPORT TOTAL -$
TOTAL PROGRAM EXPENSES 773,059$
MEDI-CAL REVENUE:
Units of
Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)59,383 2.45$ 145,487$
3100 Case Management 15,226 2.45$ 37,304$
3200 Crisis Services 1,668 2.75$ 4,586$
3300 Medication Support 17,281 4.00$ 69,123$
3400 Collateral 3,021 2.45$ 7,402$
Exhibit C
Page 11 of 28
3500 Plan Development 1,825 1.60$ 2,919$
3600 Assessment 1,825 1.60$ 2,919$
3700 Rehabilitation 2,755 2.45$ 6,750$
Estimated Medi-Cal Billing Totals 102,983 276,492$
Estimated % of Federal Financial Participation Reimbursement 0.00%-$
Estimated % of Early and Periodic Screening, Diagnostic, and Treatment Reimbursement 0.00%-$
MEDI-CAL REVENUE TOTAL 276,492$
OTHER REVENUE:
4000 Other - (Identify)-$
4100 Other - (Identify)-$
4200 Other - (Identify)-$
4300 Other - (Identify)-$
OTHER REVENUE TOTAL -$
MHSA FUNDS:
5000 Prevention & Early Intervention Funds -$
5100 Community Services & Supports Funds 496,567$
5200 Innovation Funds -$
5300 Workforce Education & Training Funds -$
MHSA FUNDS TOTAL 496,567$
TOTAL PROGRAM REVENUE 773,059$
Exhibit C
Page 12 of 28
FTE %Admin Direct Total
PERSONNEL SALARIES:
0001 Behavioral Health Director 0.35 41,388$ -$ 41,388$
0002 Quality Improvement Supervisor 0.50 31,342$ -$ 31,342$
0003 Quality Improvement Staff 0.50 17,439$ -$ 17,439$
0004 Clinic Manager 1.00 81,545$ 9,061$ 90,606$
0005 Licensed Therapist 2.00 -$ 160,229$ 160,229$
0006 Case Manager .6.00 -$ 248,261$ 248,261$
0007 Receptionist 3.00 25,797$ 60,194$ 85,991$
0008 MH Associate Therapist 3.00 -$ 124,130$ 124,130$
0009 Medical Assistant 1.00 -$ 28,664$ 28,664$
0010
0011
0012
SALARY TOTAL 17.35 197,511$ 630,539$ 828,050$
PAYROLL TAXES:
0030 OASDI -$ -$ -$
0031 FICA/MEDICARE 17,085$ 54,542$ 71,627$
0032 SUI 6,913$ 22,069$ 28,982$
PAYROLL TAX TOTAL 23,998$ 76,611$ 100,609$
EMPLOYEE BENEFITS:
0040 Retirement 6,913$ 22,069$ 28,982$
0041 Workers Compensation 5,530$ 17,655$ 23,185$
0042 Health Insurance (medical, vision, life, dental)24,689$ 78,817$ 103,506$
EMPLOYEE BENEFITS TOTAL 37,132$ 118,541$ 155,673$
SALARY & BENEFITS GRAND TOTAL 1,084,332$
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building (3 sites)92,190$
1011 Rent/Lease Equipment -$
1012 Utilities (3 sites)14,800$
1013 Building Maintenance 2,120$
1014 Equipment purchase -$
FACILITY/EQUIPMENT TOTAL 109,110$
OPERATING EXPENSES:
1060 Telephone (3 sites)26,000$
1061 Answering Service 300$
1062 Postage 300$
1063 Printing/Reproduction 3,600$
1064 Publications -$
1065 Legal Notices/Advertising -$
1066 Office Supplies & Equipment (3 sites)26,460$
1067 Household Supplies -$
1068 Food -$
Line Item Description (Must be itemized)
PRIMARY CARE INTEGRATION
Clinica Sierra Vista
Severely Mentally Ill (SMI)
Projected Budget - Fiscal Year 2018-19
Budget Categories -Total Proposed Budget
Exhibit C
Page 13 of 28
1069 Program Supplies - Therapeutic 1,200$
1070 Program Supplies - Medical 1,200$
1071 Transportation of Clients 3,675$
1072 Staff Mileage/Vehicle Maintenance 12,000$
1073 Staff Travel (Out of County)-$
1074 Staff Training/Registration 10,950$
1075 Lodging -$
1076 Other - Recruitment 6,390$
OPERATING EXPENSES TOTAL 92,075$
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping -$
1081 External Audit 1,000$
1082 Liability Insurance 1,435$
1083 Administrative Overhead (includes payroll services)210,598$
1084 Payroll Services -$
1085 Professional Liability Insurance -$
FINANCIAL SERVICES TOTAL 213,033$
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management) / IT Support / Avatar 27,897$
1091 Translation Services 1,200$
1092 Contract Psychiatrist 436,800$
SPECIAL EXPENSES TOTAL 465,897$
FIXED ASSETS:
1190 Computers & Software -$
1191 Furniture & Fixtures -$
1192 Other - Tenant Improvements -$
1193 Other - (Identify)-$
FIXED ASSETS TOTAL -$
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)-$
2001 Client Housing Operating Expenditures (SFC 71)-$
2002.1 Clothing, Food & Hygiene (SFC 72)-$
2002.2 Client Transportation & Support (SFC 72)-$
2002.3 Education Support (SFC 72)-$
2002.4 Employment Support (SFC 72)-$
2002.5 Respite Care (SFC 72)-$
2002.6 Household Items -$
2002.7 Utility Vouchers (SFC 72)-$
2002.8 Child Care (SFC 72)-$
NON MEDI-CAL CLIENT SUPPORT TOTAL -$
TOTAL PROGRAM EXPENSES 1,964,447$
MEDI-CAL REVENUE:
Units of
Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)324,577 2.45$ 795,213$
3100 Case Management 83,224 2.45$ 203,899$
3200 Crisis Services 9,115 2.75$ 25,067$
3300 Medication Support 94,455 4.00$ 377,818$
3400 Collateral 16,513 2.45$ 40,458$
Exhibit C
Page 14 of 28
3500 Plan Development 9,973 1.60$ 15,956$
3600 Assessment 9,973 1.60$ 15,956$
3700 Rehabilitation 15,060 2.45$ 36,896$
Estimated Medi-Cal Billing Totals 562,889 1,511,264$
Estimated % of Federal Financial Participation Reimbursement 0.00%-$
Estimated % of Early and Periodic Screening, Diagnostic, and Treatment Reimbursement 0.00%-$
MEDI-CAL REVENUE TOTAL 1,511,264$
OTHER REVENUE:
4000 Other - (Identify)-$
4100 Other - (Identify)-$
4200 Other - (Identify)-$
4300 Other - (Identify)-$
OTHER REVENUE TOTAL -$
MHSA FUNDS:
5000 Prevention & Early Intervention Funds -$
5100 Community Services & Supports Funds 453,183$
5200 Innovation Funds -$
5300 Workforce Education & Training Funds -$
MHSA FUNDS TOTAL 453,183$
TOTAL PROGRAM REVENUE 1,964,447$
Exhibit C
Page 15 of 28
START-UP EXPENSES
Computers and Software 90,150.00$
Furniture and Fixtures 38,170.00$
Telephone System 36,800.00$
Tenant Improvements 63,140.00$
Other - Identify -$
Other - Identify -$
TOTAL START-UP EXPENSES 228,260.00$
PRIMARY CARE INTEGRATION
Clinica Sierra Vista
Seriously Emotionally Disturbed (SED)
Projected Start-Up Budget - Fiscal Year 2017-18
Budget Categories -
Proposed BudgetLine Item Description (Must be itemized)
Exhibit C
Page 16 of 28
FTE %Admin Direct Total
PERSONNEL SALARIES:
0001 Behavioral Health Director 0.35 19,250$ -$ 19,250$
0002 Quality Improvement Supervisor 0.50 11,662$ -$ 11,662$
0003 Quality Improvement Staff 0.50 6,489$ -$ 6,489$
0004 Clinic Manager 1.00 10,114$ 23,600$ 33,714$
0005 Case Manager 6.00 -$ 92,376$ 92,376$
0006 Mental Health Associate 3.00 -$ 69,928$ 69,928$
0007 Medical Assistant 1.00 -$ 10,666$ 10,666$
0008 Receptionist 3.00 12,799$ 12,799$ 25,597$
0009 LicensedTherapist 2.00 -$ 59,285$ 59,285$
0010
0011
0012
SALARY TOTAL 17.35 60,314$ 268,652$ 328,966$
PAYROLL TAXES:
0030 OASDI -$ -$ -$
0031 FICA/MEDICARE 5,217$ 23,238$ 28,455$
0032 SUI 2,111$ 9,403$ 11,514$
PAYROLL TAX TOTAL 7,328$ 32,641$ 39,969$
EMPLOYEE BENEFITS:
0040 Retirement 2,111$ 9,403$ 11,514$
0041 Workers Compensation 1,689$ 7,522$ 9,211$
0042 Health Insurance (medical, vision, life, dental)7,539$ 33,582$ 41,121$
EMPLOYEE BENEFITS TOTAL 11,339$ 50,507$ 61,846$
SALARY & BENEFITS GRAND TOTAL 430,781$
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building (3 sites)30,801$
1011 Rent/Lease Equipment -$
1012 Utilities (3 sites)8,880$
1013 Building Maintenance 750$
1014 Equipment purchase -$
FACILITY/EQUIPMENT TOTAL 40,431$
OPERATING EXPENSES:
1060 Telephone (3 sites)15,600$
1061 Answering Service 180$
1062 Postage 270$
1063 Printing/Reproduction 3,600$
1064 Publications -$
1065 Legal Notices/Advertising -$
1066 Office Supplies & Equipment 14,254$
1067 Household Supplies -$
1068 Food -$
Line Item Description (Must be itemized)
PRIMARY CARE INTEGRATION
Clinica Sierra Vista
Seriously Emotionally Disturbed (SED)
Projected Budget - Fiscal Year 2017-18
Budget Categories - Total Proposed Budget
Exhibit C
Page 17 of 28
1069 Program Supplies - Therapeutic 1,200$
1070 Program Supplies - Medical 1,200$
1071 Transportation of Clients 1,470$
1072 Staff Mileage/Vehicle Maintenance 4,800$
1073 Staff Travel (Out of County)-$
1074 Staff Training/Registration 4,380$
1075 Lodging -$
1076 Other - Recruitment 6,390$
OPERATING EXPENSES TOTAL 53,344$
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping -$
1081 External Audit 1,000$
1082 Liability Insurance 2,870$
1083 Administrative Overhead (includes payroll services)96,064$
1084 Payroll Services -$
1085 Professional Liability Insurance -$
FINANCIAL SERVICES TOTAL 99,934$
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management) / IT Support / Avatar 15,184$
1091 Translation Services 1,200$
1092 Contract Psychiatrist 163,564$
SPECIAL EXPENSES TOTAL 179,948$
FIXED ASSETS:
1190 Computers & Software + 3 sets Telehealth Equipment -$
1191 Furniture & Fixtures -$
1192 Other - Tenant Improvements -$
1193 Other - VOIP Phone System Installation/Setup -$
FIXED ASSETS TOTAL -$
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)-$
2001 Client Housing Operating Expenditures (SFC 71)-$
2002.1 Clothing, Food & Hygiene (SFC 72)-$
2002.2 Client Transportation & Support (SFC 72)-$
2002.3 Education Support (SFC 72)-$
2002.4 Employment Support (SFC 72)-$
2002.5 Respite Care (SFC 72)-$
2002.6 Household Items -$
2002.7 Utility Vouchers (SFC 72)-$
2002.8 Child Care (SFC 72)-$
NON MEDI-CAL CLIENT SUPPORT TOTAL -$
TOTAL PROGRAM EXPENSES 804,438$
MEDI-CAL REVENUE:
Units of
Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)76,844 2.45$ 188,269$
3100 Case Management 14,353 2.45$ 35,165$
3200 Crisis Services 578 2.75$ 1,589$
3300 Medication Support 7,177 4.00$ 28,707$
3400 Collateral 6,990 2.45$ 17,126$
Exhibit C
Page 18 of 28
3500 Plan Development 2,296 1.60$ 3,673$
3600 Assessment 2,296 1.60$ 3,673$
3700 Rehabilitation 3,467 2.45$ 8,495$
Estimated Medi-Cal Billing Totals 114,001 286,697$
Estimated % of Federal Financial Participation Reimbursement 0.00%-$
Estimated % of Early and Periodic Screening, Diagnostic, and Treatment Reimbursement 0.00%-$
MEDI-CAL REVENUE TOTAL 286,697$
OTHER REVENUE:
4000 Other - (Identify)-$
4100 Other - (Identify)-$
4200 Other - (Identify)-$
4300 Other - (Identify)-$
OTHER REVENUE TOTAL -$
MHSA FUNDS:
5000 Prevention & Early Intervention Funds -$
5100 Community Services & Supports Funds 517,741$
5200 Innovation Funds -$
5300 Workforce Education & Training Funds -$
MHSA FUNDS TOTAL 517,741$
TOTAL PROGRAM REVENUE 804,438$
Exhibit C
Page 19 of 28
FTE %Admin Direct Total
PERSONNEL SALARIES:
0001 Behavioral Health Director 0.35 41,388$ -$ 41,388$
0002 Quality Improvement Supervisor 0.50 31,342$ -$ 31,342$
0003 Quality Improvement Staff 0.50 17,439$ -$ 17,439$
0004 Clinic Manager 1.00 27,182$ 63,424$ 90,606$
0005 Case Manager 6.00 -$ 248,261$ 248,261$
0006 Mental Health Associate 3.00 -$ 187,930$ 187,930$
0007 Medical Assistant 1.00 -$ 28,664$ 28,664$
0008 Receptionist 3.00 42,996$ 42,996$ 85,992$
0009 LicensedTherapist 2.00 -$ 159,328$ 159,328$
0010
0011
0012
SALARY TOTAL 17.35 160,347$ 730,603$ 890,950$
PAYROLL TAXES:
0030 OASDI -$ -$ -$
0031 FICA/MEDICARE 13,870$ 63,197$ 77,067$
0032 SUI 5,612$ 25,571$ 31,183$
PAYROLL TAX TOTAL 19,482$ 88,768$ 108,250$
EMPLOYEE BENEFITS:
0040 Retirement 5,612$ 25,571$ 31,183$
0041 Workers Compensation 4,490$ 20,457$ 24,947$
0042 Health Insurance (medical, vision, life, dental)20,043$ 91,325$ 111,368$
EMPLOYEE BENEFITS TOTAL 30,145$ 137,353$ 167,498$
SALARY & BENEFITS GRAND TOTAL 1,166,698$
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building (3 sites)72,834$
1011 Rent/Lease Equipment -$
1012 Utilities (3 sites)14,800$
1013 Building Maintenance 750$
1014 Equipment purchase -$
FACILITY/EQUIPMENT TOTAL 88,384$
OPERATING EXPENSES:
1060 Telephone (3 sites)26,000$
1061 Answering Service 300$
1062 Postage 450$
1063 Printing/Reproduction 4,410$
1064 Publications -$
1065 Legal Notices/Advertising -$
1066 Office Supplies & Equipment 35,600$
1067 Household Supplies -$
1068 Food -$
Line Item Description (Must be itemized)
PRIMARY CARE INTEGRATION
Clinica Sierra Vista
Seriously Emotionally Disturbed (SED)
Projected Budget - Fiscal Year 2018-19
Budget Categories - Total Proposed Budget
Exhibit C
Page 20 of 28
1069 Program Supplies - Therapeutic 1,200$
1070 Program Supplies - Medical 1,200$
1071 Transportation of Clients 3,675$
1072 Staff Mileage/Vehicle Maintenance 12,000$
1073 Staff Travel (Out of County)-$
1074 Staff Training/Registration 10,950$
1075 Lodging -$
1076 Other - Recruitment 6,390$
OPERATING EXPENSES TOTAL 102,175$
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping -$
1081 External Audit 1,000$
1082 Liability Insurance 1,435$
1083 Administrative Overhead (includes payroll services)260,174$
1084 Payroll Services -$
1085 Professional Liability Insurance -$
FINANCIAL SERVICES TOTAL 262,609$
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant (network & data management) / IT Support / Avatar 15,897$
1091 Translation Services 600$
1092 Contract Psychiatrist 308,400$
SPECIAL EXPENSES TOTAL 324,897$
FIXED ASSETS:
1190 Computers & Software -$
1191 Furniture & Fixtures -$
1192 Other - Tenant Improvements -$
1193 Other - (Identify)-$
FIXED ASSETS TOTAL -$
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures (SFC 70)-$
2001 Client Housing Operating Expenditures (SFC 71)-$
2002.1 Clothing, Food & Hygiene (SFC 72)-$
2002.2 Client Transportation & Support (SFC 72)-$
2002.3 Education Support (SFC 72)-$
2002.4 Employment Support (SFC 72)-$
2002.5 Respite Care (SFC 72)-$
2002.6 Household Items -$
2002.7 Utility Vouchers (SFC 72)-$
2002.8 Child Care (SFC 72)-$
NON MEDI-CAL CLIENT SUPPORT TOTAL -$
TOTAL PROGRAM EXPENSES 1,944,763$
MEDI-CAL REVENUE:
Units of
Service Rate $ Amount
3000 Mental Health Services (Individual/Family/Group Therapy)446,853 2.45$ 1,094,791$
3100 Case Management 89,534 2.45$ 219,358$
3200 Crisis Services 3,605 2.75$ 9,913$
3300 Medication Support 44,768 4.00$ 179,071$
3400 Collateral 43,605 2.45$ 106,833$
Exhibit C
Page 21 of 28
3500 Plan Development 14,321 1.60$ 22,914$
3600 Assessment 14,321 1.60$ 22,914$
3700 Rehabilitation 21,629 2.45$ 52,990$
Estimated Medi-Cal Billing Totals 678,636 1,708,784$
Estimated % of Federal Financial Participation Reimbursement 0.00%-$
Estimated % of Early and Periodic Screening, Diagnostic, and Treatment Reimbursement 0.00%-$
MEDI-CAL REVENUE TOTAL 1,708,784$
OTHER REVENUE:
4000 Other - (Identify)-$
4100 Other - (Identify)-$
4200 Other - (Identify)-$
4300 Other - (Identify)-$
OTHER REVENUE TOTAL -$
MHSA FUNDS:
5000 Prevention & Early Intervention Funds -$
5100 Community Services & Supports Funds 235,979$
5200 Innovation Funds -$
5300 Workforce Education & Training Funds -$
MHSA FUNDS TOTAL 235,979$
TOTAL PROGRAM REVENUE 1,944,763$
Exhibit C
Page 22 of 28
START-UP EXPENSES
Computers and Software 23,850.00$
Furniture and Fixtures 18,072.00$
Telephone System 1,800.00$
Other - Identify
Other - Identify
Other - Identify
TOTAL START-UP EXPENSES 43,722.00$
PRIMARY CARE INTEGRATION
Clinica Sierra Vista
Substance Use Disorder (SUD)
Projected Start-Up Budget - Fiscal Year 2017-18
Budget Categories -
Proposed BudgetLine Item Description (Must be itemized)
Exhibit C
Page 23 of 28
Mailing Address:
Street Address:
1.90 Phone Number:
6.10 Fax Number:
E-mail Address:
% of FTE
Annual dedicated to
Salary this program Admin.Direct Admin.Direct
0101 Psychiatric Team 170,453$ 3%100%-$ 5,114$ 5,114$
0102 Substance Use Counselor (x3)16,355$ 300%100%-$ 49,066$ 49,066$
0103 Receptionist (x3)10,666$ 300%100%0%31,997$ -$ 31,997$
0104 BH Director 44,000$ 20%100%0%8,800$ -$ 8,800$
0105 Clinic Manager 33,714$ 30%100%0%10,114$ -$ 10,114$
0106 -$ -$ -$
0107 -$ -$ -$
0108 -$ -$
0109 -$ -$
0110 -$ -$
0111 -$ -$
0112 -$ -$
SALARIES TOTAL 50,911$ 54,180$ 105,091$
Rate 48.44%51.56%100.00%
0151 F.I.C.A. Social Security and Medicare SS 6.2 % rate applied to $127.2k of gross earnings per employee 8.650%4,404$ 4,687$ 9,090$
0152 Federal Unemployment (FUTA)Rate applied to only first $7k of gross earnings per employee 0.000%-$ -$
0153 State Employment Training Tax (ETT)Rate applied to only first $7k of gross earnings per employee 0.000%-$ -$ -$
0154 State Unemployment Insurance (UI)Rate applied to only first $7k of gross earnings per employee 3.500%1,782$ 1,896$ 3,678$
0155 2.800%1,426$ 1,517$ 2,943$
PAYROLL TAXES TOTAL 7,612$ 8,100$ 15,711$
EMPLOYEE BENEFITS Rate 48.44%51.56%100.00%
0201 Health Insurance 12.50%6,364$ 6,773$ 13,136$
PRIMARY CARE INTEGRATION
Clinica Sierra Vista
Substance Use Disorder (SUD)
Projected Budget - Fiscal Year 2017-18
Provider Name:Clinica Sierra Vista PO Box 1559
Program Name:SUD Portion Only Bakersfield, CA 93302
Approved by:1430 Truxtun Ave, Ste 400
Bakersfield, CA 93301
No. of Budgeted FTEs - Admin:661-397-8775 x4790
No. of Budgeted FTEs - Direct:
Line Item Description to services Total Proposed
Budget(Must be Itemized)
reillyc@clinicasierravista.org
powert@clinicasierravista.org
Budget Categories-% Time dedicated Proposed Program Budget
PERSONNEL/SALARIES
PAYROLL TAXES
Workers' Compensation Insurance
I I
Exhibit C
Page 24 of 28
0202 Life Insurance -$ -$
0203 Retirement 3.50%1,782$ 1,896$ 3,678$
0204 Benefits Other - Specify -$ -$
EMPLOYEE BENEFITS TOTAL 8,146$ 8,669$ 16,815$
TAXES & BENEFITS TOTAL 0.000%32,526$
TOTAL DIRECT (ADMIN) SALARIES, PAYROLL TAXES, AND EMPLOYEE BENEFITS 137,617$
TOTAL PERCENT OF BENEFITS TO SALARIES 31.0%
Services and Supplies
0252 780$
0253 -$
780$
0301 7,800$
0302 90$
7,890$
0351 4,306$
0352 -$
0353 600$
0354 -$
0355 -$
4,906$
0401 -$
0402 150$
0403 -$
150$
FACILITIES
0451 13,278$
0452 1,124$
0453 756$
15,158$
0501 1,050$
0502 -$
0503 1,170$
0504 585$
INSURANCE TOTAL
INSURANCE
Liability Insurance
Insurance Other-Specify
EQUIPMENT
COMMUNICATIONS
Telecommunications/data lines
Answering Service
COMMUNICATIONS TOTAL
OFFICE EXPENSE
Office Supplies
Soc Rec., Workbooks
Printing/Reproduction
Publications
Legal Notices/Advertising
OFFICE EXPENSE TOTAL
Staff Training/Registration
Purchase of Equipment (Computers/Furniture/VOIP Phone)
Equipment Rent/Lease (Copy Machines)
Equipment Maintenance
EQUIPMENT TOTAL
Rent/Lease Building
Facilities Maintenance
Utilities
FACILITIES TOTAL
TRAVEL COSTS
Staff Mileage
Staff Travel (Out of County)
Transportation
Exhibit C
Page 25 of 28
2,805$
0551 780$
0552 -$
0553 -$
780$
0601 600$
0602 3,156$
3,756$
0651 312$
0652 260$
572$
0701 Indirect Costs @ 22.3% Federally approved indirec rate based on direct labor including fringe benefits and payroll taxes 30,689$
0702 Licenses/Taxes -$
0703 -$
0749 -$
30,689$
205,103$
3120
3130
3140 Private Donations
3150
3160
-$
205,103$
FISCAL AND AUDITS
TRAVEL COSTS TOTAL
PROGRAM SUPPLIES
Program Supplies-Client Incentives
Program Supplies-Curriculum
Program Supplies-Food
PROGRAM SUPPLIES TOTAL
CONSULTANCY
Consultant Services (Interpretive Services)
Contracted Services (Recruitment)
CONSULTANCY TOTAL
Drug Medi-Cal
Accounting/Bookkeeping (IT Support)
External Audit
FISCAL AND AUDITS TOTAL
OTHER COSTS
County Administration Fee
Other Business Services
OTHER COSTS TOTAL
ONE TIME ADVANCE - Start Up Costs
TOTAL PROGRAM EXPENDITURES
REVENUE/MATCH
State Grant
Client Fees
Insurance
REVENUE/MATCH TOTAL
NET PROGRAM BUDGET
Exhibit C
Page 26 of 28
Mailing Address:
Street Address:
2.90 Phone Number:
10.10 Fax Number:
E-mail Address:
% of FTE
Annual dedicated to Indirect Indirect
Salary this program Admin.Direct Admin.Direct
0101 Psychiatric Team 436,800$ 3%100%-$ 13,104$ 13,104$
0102 Substance Use Counselor (x3)41,911$ 300%100%-$ 125,732$ 125,732$
0103 Receptionist (x3)27,330$ 300%100%0%81,990$ -$ 81,990$
0104 BH Director 112,750$ 20%100%0%22,550$ -$ 22,550$
0105 Clinic Manager 86,390$ 30%100%0%25,917$ -$ 25,917$
0106 LMFT/LCSW (Waiver Requirement)78,257$ 100%100%-$ 78,257$ 78,257$
0107 Case Manager (Waiver Requirement)41,638$ 100%100%-$ 41,638$ 41,638$
0108
0109
0110
0111
0112
SALARIES TOTAL 130,457$ 258,730$ 389,187$
Rate 33.52%66.48%100.00%
0151 F.I.C.A. Social Security and Medicare SS 6.2 % rate applied to $127.2k of gross earnings per employee 7.650%9,980$ 19,793$ 29,773$
0152 Federal Unemployment (FUTA)Rate applied to only first $7k of gross earnings per employee 0.000%-$ -$ -$
0153 State Employment Training Tax (ETT)Rate applied to only first $7k of gross earnings per employee 0.000%-$ -$ -$
0154 State Unemployment Insurance (UI)Rate applied to only first $7k of gross earnings per employee 1.930%2,518$ 4,994$ 7,512$
0155 1.544%2,015$ 3,995$ 6,010$
PRIMARY CARE INTEGRATION
Clinica Sierra Vista
Substance Use Disorder (SUD)
Projected Budget - Fiscal Year 2018-19
Provider Name:Clinica Sierra Vista PO Box 1559
Program Name:SUD Portion Only Bakersfield, CA 93302
Approved by:1430 Truxtun Ave, Ste 400
Bakersfield, CA 93301
No. of Budgeted FTEs - Admin:661-397-8775 x4790
No. of Budgeted FTEs - Direct:
Line Item Description Total Proposed
Budget(Must be Itemized)
reillyc@clinicasierravista.org
powert@clinicasierravista.org
Budget Categories-
Note: Billable services provided
to clients classified as Direct,
while admin services are
Indirect Proposed Program Budget
PERSONNEL/SALARIES
PAYROLL TAXES
Workers' Compensation Insurance
Exhibit C
Page 27 of 28
PAYROLL TAXES TOTAL 14,513$ 28,782$ 43,295$
EMPLOYEE BENEFITS Rate 33.52%66.48%100.00%
0201 Health Insurance 12.50%16,307$ 32,341$ 48,648$
0202 Life Insurance -$ -$ -$
0203 Retirement 3.50%4,566$ 9,056$ 13,622$
0204 Benefits Other - Specify -$ -$ -$
EMPLOYEE BENEFITS TOTAL 20,873$ 41,397$ 62,270$
TOTAL INDIRECT (ADMIN) SALARIES, PAYROLL TAXES, AND EMPLOYEE BENEFITS 165,843$
TOTAL DIRECT (ADMIN) SALARIES, PAYROLL TAXES, AND EMPLOYEE BENEFITS 494,752$
TAXES & BENEFITS (BOTH INDIRECT (ADMIN) AND DIRECT TOTAL 105,565$
TOTAL PERCENT OF BENEFITS TO SALARIES 27.1%
Services and Supplies
0252 780$
0253 -$
780$
0301 26,000$
0302 300$
26,300$
0351 14,352$
0352 -$
0353 2,000$
0354 -$
0355 -$
16,352$
0401 -$
0402 150$
0403 -$
150$
FACILITIES
0451 23,048$
0452 1,124$
0453 2,520$
26,692$
Utilities
FACILITIES TOTAL
TRAVEL COSTS
Office Supplies
Soc Rec., Workbooks
Printing/Reproduction
EQUIPMENT TOTAL
Facilities Maintenance
INSURANCE
Liability Insurance
Insurance Other-Specify
INSURANCE TOTAL
COMMUNICATIONS
Telecommunications/data lines
Purchase of Equipment (Computers/Furniture)
Rent/Lease Building
OFFICE EXPENSE TOTAL
EQUIPMENT
Equipment Rent/Lease (Copy Machines)
Equipment Maintenance
Answering Service
COMMUNICATIONS TOTAL
OFFICE EXPENSE
Publications
Legal Notices/Advertising
Exhibit C
Page 28 of 28
0501 3,501$
0502 -$
0503 3,900$
0504 1,950$
9,351$
0551 3,000$
0552 -$
0553 -$
3,000$
0601 200$
0602 500$
700$
0651 225$
0652 260$
485$
0701 Indirect Costs @ HHS approved 22.3% of Direct Salaries and wages including all fringe benefits (which includes payroll taxes)110,330$
0702 Licenses/Taxes -$
0703
0749 -$
110,330$
688,892$
3120
3130
3140 Private Donations
3150
3160
Contracted Services (Recruitment)
CONSULTANCY TOTAL
FISCAL AND AUDITS
Accounting/Bookkeeping (IT Support)
External Audit
OTHER COSTS TOTAL
ONE TIME ADVANCE - Start Up Costs
FISCAL AND AUDITS TOTAL
OTHER COSTS
County Administration Fee
Other Business Services
TOTAL PROGRAM EXPENDITURES
State Grant
REVENUE/MATCH
Program Supplies-Curriculum
Program Supplies-Food
Staff Mileage
Drug Medi-Cal
Client Fees
Insurance
Staff Travel (Out of County)
Program Supplies-Client Incentives
Staff Training/Registration
Transportation
TRAVEL COSTS TOTAL
PROGRAM SUPPLIES
PROGRAM SUPPLIES TOTAL
CONSULTANCY
Consultant Services (Interpretive Services)
Exhibit D
Page 1 of 1
Electronic Health Records Software Charges
CONTRACTOR(S) understand that COUNTY utilizes NetSmart’s Avatar for its Electronic Health Records
management. CONTRACTOR(S) agree to reimburse COUNTY for all user license fees for accessing NetSmart’s
Avatar, as set forth below:
Description Fee Per User/License FY 2017-18 FY 2018-19 FY 2019-20 FY 2020-21 FY 2021-22
NetSmart Avatar Monthly
Hosting Service
(per named user per month)
$ 37.00 $ 37.00 $ 37.00 $ 37.00 $ 37.00
NetSmart Avatar Annual
Maintenance/License*
(per named license per year)
$ 168.00 $ 173.04 $ 178.23 $ 183.58 $ 189.09
OrderConnect License1
(per named license per year)
$ 1,278.00 $ 1,278.00 $ 1,278.00 $ 1,278.00 $ 1,278.00
Reaching Recovery
(per named user per year)
$ 10.00 $ 10.00 $ 10.00 $ 10.00 $ 10.00
Should CONTRACTOR(S) choose not to utilize NetSmart’s Avatar for its Electronic Health Records
management, CONTRACTOR(S) will be responsible for obtaining its own system for Electronic Health Records
management.
__________________________________________________________________________________________
*Annual maintenance fee increases by 3% each FY on July 1st.
1Includes 100 faxed pages per month. An additional fee of $0.20 per faxed page will apply thereafter.
Exhibit E
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
Exhibit E
Page 2 of 3
accurately describe the services provided.
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 E
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: ____/___/____
D D D D
D D D D
D
Exhibit F
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.
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 five axis diagnosis from the most current DSM, or a diagnosis from the most current
ICD, will be documented, consistent with the presenting problems, history mental status
evaluation and/or other assessment data.
2. Timeliness/Frequency Standard for Assessment
• An assessment will be completed at intake and updated as needed to document changes in
the client’s condition.
• Client conditions will be assessed at least annually and, in most cases, at more frequent
intervals.
Exhibit F
Page 2 of 3
B. Client Plans
1. Client plans will:
• have specific observable and/or specific quantifiable goals
• identify the proposed type(s) of intervention
• have a proposed duration of intervention(s)
• be signed (or electronic equivalent) by:
the person providing the service(s), or
a person representing a team or program providing services, or
a person representing the MHP providing services
when the client plan is used to establish that the services are provided under the
direction of an approved category of staff, and if the below staff are not the approved
category,
o a physician
o a licensed/ “waivered” psychologist
o a licensed/ “associate” social worker
o a licensed/ registered/marriage and family therapist or
o 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
Exhibit F
Page 3 of 3
• All entries in the client record will include the signature of the person providing the
service (or electronic equivalent); the person’s professional degree, licensure or job title;
and the relevant identification number, if applicable
• All entries will include the date services were provided
• The record will be legible
• The client record will document follow-up care, or as appropriate, a discharge summary
2. Timeliness/Frequency of Progress Notes:
Progress notes shall be documented at the frequency by type of service indicated below:
A. Every Service Contact
Mental Health Services
Medication Support Services
Crisis Intervention
Exhibit G
Page 1 of 2
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(S) 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(S) 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(S) shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer,
Exhibit G
Page 2 of 2
rates of pay or other forms of compensation, use of facilities, and other
terms and conditions of employment.
C.Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all
further funds, until CONTRACTOR(S) 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(S)
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR(S).
5.PATIENTS' RIGHTS
CONTRACTOR(S) shall comply with applicable laws and regulations, including
but not limited to, laws, regulations, and State policies relating to patients' rights.
Exhibit H
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 H
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 (3) 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 I
Page 1 of 2
Fresno County Mental Health Plan
Grievances
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 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 I
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 90 calendar days of the date of the receipt
of the non-approval of payment.
The MHP shall have 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 a Managed Care staff who was 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 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 60 calendar days of receipt of the complaint. The decision rendered
buy the MHP is final.
Exhibit J
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 J
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 x 11 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
D D D D D D
Exhibit K
Page 1 of 1
UNLAWFUL USE OF DRUGS AND ALCOHOL
CERTIFICATION
I, ______________________________________, as an authorized agent of
(Print Name)
________________________________________, acknowledge the requirement to
(Organization Name)
comply with California HSC 11999-11999.3, which authorizes the County of Fresno to
terminate a contract, without penalty, if this organization or its employees, or a
subcontractor or its employees fail to ensure that:
• The program contains a component that clearly explains in written materials
that there shall be no unlawful use of drugs or alcohol. No aspect of a drug- or
alcohol-related program shall include any message on the responsible use, if
the use is unlawful, of drugs or alcohol;
• All aspects of a drug- or alcohol-related program are consistent with the “no
unlawful use” message, including, but not limited to, program standards,
curricula, materials, and teachings; and
• The “no unlawful use” of drugs and alcohol message contained in drug- or
alcohol-related programs applies to the use of drugs and alcohol prohibited by
law.
I understand that the State of California enforces an Unlawful Use policy in
which there is zero tolerance for promoting the unlawful use of and drugs or alcohol in
an AOD treatment facility. If this organization fails to satisfy the guidelines adopted by
the State of California, the drug or alcohol program shall not receive state funds and
their contract with Fresno County will be terminated.
I understand that this organization is obligated to ensure any subcontractors are
informed of the requirements of HSC 11999-11999.3 and, if found in violation, will be
immediately terminated.
Signature:_____________________________ Date:______________________
Title:_________________________________
3133 N Millbrook, Fresno, California 93703
FAX (559) 600-7673 www.co.fresno.ca.us
The County of Fresno is an Equal Employment Opportunity Employer
County of Fresno
DEPARTMENT OF BEHAVIORAL HEALTH
DAWAN UTECHT
DIRECTOR
PRIVACY AND SECURITY AGREEMENT REGARDING AUTHORIZED ACCESS TO
CONFIDENTIAL PROTECTED HEALTH INFORMATION FOR FRESNO COUNTY DEPARTMENT
OF BEHAVIORAL HEALTH (DBH) EMPLOYEES AND/OR NON-DBH SUD SERVICES
WORKFORCE MEMBERS
OATH OF CONFIDENTIALITY
As a condition of obtaining access to any Protected Health Information (PHI) that is necessary to carry
out my function with DBH, I ___________________________, agree to not divulge any PHI to
unauthorized persons. Furthermore, I maintain that I will not publish or otherwise make public any
information regarding persons who receive Substance Use Disorder Services such that the persons who
receive or have received such services are identifiable.
Access to such data shall be limited to Fresno County DBH personnel, subcontractors, and
subcontractors’ personnel who require this information in the performance of their duties and have signed
an Oath of Confidentiality with DBH.
By signing this oath, I agree to uphold the security and confidentiality requirements outlined by the Medi-
Cal Privacy and Security Agreement signed by DBH, surveillance and safeguarding announcements
issued by DHCS, and other applicable terms and stipulations provided by the HIPAA doctrine as well as
other relevant state and federal regulations.
I hereby certify my understanding of the need to:
1.Exercise due care to preserve data integrity and confidentiality.
2.Treat passwords and user accounts as confidential information.
3.Take reasonable precautions to ensure the protection of PHI from unauthorized access.
4.Notify DHCS when there is a possible security violation including unauthorized access to PHI by
completing a “Privacy Incident Report” at:
http://www.dhcs.ca.gov/formsandpubs/laws/priv/Pages/DHCSBusinessAssociatesOnly.aspx and
return the completed form to: privacyofficer@dhcs.ca.gov.
I recognize that unauthorized release of confidential information may make me subject to civil and
criminal sanctions pursuant to the provisions of the Welfare and Institutions Code Section 14100.2,
Welfare and Institutions Code Section 5328 et seq. and the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). I further acknowledge that the unauthorized release of confidential
information as described in this document may result in disciplinary action up to and including
termination of any office of employment or contract.
Agency Name:
Signature:
____________________________________
Date:
____________________________________
Exhibit L
Page 1 of 1
Exhibit M
Page 1 of 1
TRAFFICKING VICTIMS PROTECTION ACT OF 2000
CERTIFICATION
I, ______________________________________, as an authorized agent of (Print Name)
________________________________________, acknowledge the requirement to (Organization Name)
comply with the Trafficking Victims Protection Act of 2000 (TVPA), specifically Section
106(g), which authorizes the County of Fresno to terminate a contract, without penalty,
if this organization or its employees, or a subcontractor or its employees:
• Engages in severe forms of trafficking in persons during the period of time that
the award is in effect;
• Procures a commercial sex act during the period of time that the award in in
effect; or
• Uses forced labor in the performance of the award or subawards under the
award.
I understand that the TVPA establishes human trafficking and related offenses
as federal crimes and attaches severe penalties to them. I will immediately inform the
County of Fresno, Department of Behavioral Health, Contracts Division – Substance
Use Disorder (SUD) Services immediately of any information received from any
source alleging a violation of the TVPA by either this organization or its employees, or
a subcontractor or its employees during the term of this contract.
I understand that this organization is obligated to ensure any subcontractors are
informed of the requirements of the TVPA and, if found in violation, will be immediately
terminated. I agree to submit this signed certification annually on behalf of the
organization acknowledging requirements under the TVPA and attesting that all
employees will receive annual TVPA training, and that documentation of training will
be placed in personnel files.
Signature:_____________________________ Date:______________________
Title:_________________________________
Exhibit N
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 N
Page 2 of 2
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... ❒ ❒
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... ❒ ❒
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ ❒ ❒
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... ❒ ❒
If yes, give date of change in operations.
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... ❒ ❒
VII. A. Is this facility chain affiliated? ...................................................................................................................... ❒ ❒
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
B. If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed) Title
Signature Date Remarks
Exhibit O
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 O
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 P
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 P
Page 2 of 2
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to)
(4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a)
(5) Authorized Signature
Signature: Date:
I I