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HomeMy WebLinkAboutCombined BAI 37 and A-22-308 with Kings View.pdf COtj��� Board Agenda Item 37 O 1856 O FRE`'� DATE: July 12, 2022 TO: Board of Supervisors SUBMITTED BY: Susan Holt, Director, Department of Behavioral Health Sanja Bugay, Director, Department of Social Services Kirk Haynes, Chief Probation Officer, Department of Probation SUBJECT: Retroactive Agreement with Kings View for Mobile Response Services RECOMMENDED ACTION(S): Approve and authorize the Chairman to execute a retroactive Agreement with Kings View for ramp-up and implementation of mobile response services for current and former foster youth, including foster youth with prior or current Probation involvement, and their caregivers, effective June 1, 2022, not to exceed 30 days and five consecutive years,which includes a 30 day and three-year base contract and two optional one-year extensions, total not to exceed $2,254,812. Approval of the recommended action will allow for the provision of urgent and non-urgent mobile response services to current and former foster youth and their caregivers involved with the Departments of Behavioral Health (DBH), Social Services (DSS), and Probation, with no increase in Net County Cost. The agreement will be funded with a combination of Mental Health Realignment Funds the State Family Urgent Response System (FURS)allocation. This item is countywide. ALTERNATIVE ACTION(S): If the recommended action is not approved, the County will be out of compliance with Section 107 of Senate Bill 80 (Chapter 27, Statutes of 2019)and Assembly Bill 79 (Chapter 11, Statutes of 2020), which impact the provision of mobile/urgent services to high needs current and former foster youth. RETROACTIVE AGREEMENT: This recommended agreement is retroactive to June 1, 2022, to allow the program time to ramp up services. FISCAL IMPACT: There is no increase in Net County Cost associated with the recommended action. The maximum compensation ($2,254,812)will be offset with Mental Health Realignment funds, reimbursed by the State's FURS allocation. Sufficient appropriations and estimated revenues are available in DBH's Org 5630 FY 2021-22 Adopted Budget, were included in the FY 2022-23 Recommended Budget and will be included in future budget requests for the duration of the contract. DISCUSSION: The Family Urgent Response System (FURS)for Caregivers and Children or Youth, originally enacted County of Fresno Page 1 File Number.22-0724 File Number:22-0724 through Section 107 of SB 80 and amended by AB 79, is a coordinated statewide, regional, and county-level system designed to provide a collaborative and timely state-level phone-based response, as well as a county-level in-home/community, in-person mobile response during situations of instability for the purpose of preserving the relationship of the caregiver and the child/youth. FURS is intended to provide support to current and former foster youth, including foster youth involved (or formerly involved) in the probation system, as well as their caregivers. On March 1, 2021, California DSS (CDSS)established the statewide, toll-free 24/7 hotline, in order to effectively engage caregivers and children/youth currently or previously in the foster care system who are experiencing tension or conflict in their relationships, emotional distress, behavioral difficulties, or other difficulties that may threaten their placements. Operators of the statewide hotline provide immediate assistance over the phone to help defuse conflict and provide focused engagement and assessment to make a referral to the applicable county's mobile response system for further support. On February 1, 2022, Request for Proposals (RFP)22-038 was released with assistance from the Internal Service Department- Purchasing Division, through Fresno County Public Purchase requesting proposals from qualified vendors to operate a FURS program to provide a mobile response- system 24/7 for current and former foster youth, including foster youth with prior or current probation involvement. The RFP closed on March 1, 2022, and the evaluation panel, consisting of staff from DBH Fiscal, DBH Managed Care, DBH Contracts, DSS Contracts, and Probation Contracts, found the proposal submitted by Kings View best satisfied the County's intent of this project. In coordination with DSS and Probation, Kings View will provide the behavioral health services for in-person mobile response within prescribed timeframes. Upon approval by your Board, the recommended agreement will become effective retroactive to June 1, 2022, and may be terminated by the County, DBH Director, or designees, or Kings View, upon providing a 60-day advanced written notice. Additionally, the recommended agreement allows the DBH Director to approve Kings View's term extension for each additional 12-month period, based on satisfactory performance. The recommended agreement allows changes to services, staffing, and responsibilities of Kings View, as needed, to accommodate changes in the laws relating to FURS requirements and specialty mental health treatment and may be made with the signed written approval of County's DBH Director, or designee, and Kings View through an amendment approved by County Counsel and the Auditor-Controller/Treasurer-Tax Collector's Office. Additionally, changes to expense category (i.e., Salary& Benefits, Facilities/Equipment, Operating, Financial Services, Special Expenses, Fixed Assets, etc.) subtotals as set forth in the recommended agreement, that do not exceed 10% of the total annual maximum compensation, changes to the volume of units of services/types of service units to be provided, and changes to service rates as set forth in the recommended agreement, may be made with the written approval of County's DBH Director or designee. Modifications approved by the DBH Director shall not result in any change to the maximum compensation payable under the recommended agreement, without returning to your Board for approval. OTHER REVIEWING AGENCIES: The Behavioral Health Board was informed of the recommended Agreement on June 15, 2022. REFERENCE MATERIAL: BAI #29, June 8, 2021 ATTACHMENTS INCLUDED AND/OR ON FILE: On file with Clerk-Agreement with Kings View CAO ANALYST: Sonia M. De La Rosa County of Fresno Page 2 File Number.22-0724 Agreement No. 22-308 1 SERVICE AGREEMENT 2 This Service Agreement ("Agreement") is dated July 12th, 2022 and is between 3 Kings View, a California public benefit nonprofit corporation ("Contractor"), and the County of 4 Fresno, a political subdivision of the State of California ("County"). 5 Recitals 6 A. The Family Urgent Response System (FURS) for Caregivers and Children or Youth, 7 originally enacted through Section 107 of Senate Bill 80 (Statutes of 2019) and amended by 8 Assembly Bill 79 (Statutes of 2020), is a coordinated statewide, regional, and county-level 9 system designed to provide a collaborative and timely state-level phone-based response, as 10 well as a county-level in-home/community, in-person mobile response during situations of 11 instability for the purpose of preserving the relationship of the caregiver and the child/youth. 12 FURS is intended to provide support to current and former foster youth, including foster youth 13 with prior or current Probation involvement, as well as their caregivers. 14 On March 1, 2021, the California Department of Social Services (CDSS) established the 15 statewide, toll-free 24/7 hotline, in order to effectively engage caregivers and children and youth 16 currently or previously in the foster care system who are experiencing tension or conflict in their 17 relationships, emotional distress, behavioral difficulties, or other difficulties that may threaten 18 their relationships. Operators of the statewide hotline provide immediate assistance over the 19 phone to help defuse conflict and provide focused engagement and assessment to make a 20 referral to the applicable county's mobile response system for further support. 21 B. The County of Fresno on behalf of the Department of Behavioral Health (DBH), the 22 Department of Social Services (DSS), and the Probation Department (Probation) requires a 23 qualified vendor to operate a Family Urgent Response System (FURS) to provide a mobile 24 response system twenty-four (24) hours a day, seven (7) days per week (24/7) for current and 25 former foster youth, including foster youth with prior or current Probation involvement. Vendors 26 are expected to receive a warm handoff from the FURS statewide hotline and provide face-to- 27 face, in-home or in-community supportive services for both urgent and non-urgent calls. The 28 mobile response team shall be a mobilized coordinated response by the vendor with County's 1 1 DSS and Probation staff and on behalf of DBH. 2 C. On February 1, 2022 RFP 22-038 was released through Fresno County Public Purchase 3 requesting proposals from qualified vendors to operate a FURS program to provide a mobile 4 response system twenty-four (24) hours a day, seven (7) days per week (24/7) for current and 5 former foster youth, including foster youth with prior or current Probation involvement. This RFP 6 closed on March 1, 2022 and the proposal submitted by Kings View best satisfied the County's 7 intent of this project. 8 The parties therefore agree as follows: 9 Article 1 10 Contractor's Services 11 1.1 Scope of Services. The Contractor shall perform all of the services provided in 12 Exhibit A to this Agreement, titled "Scope of Services." 13 Contractor shall also perform all services and fulfill all responsibilities as specified in 14 County's Request for Proposal (RFP) No. 22-038 dated February 1, 2022, and Addendum No. 15 One (1) to County's RFP No. 22-038 dated February 15, 2022, herein collectively referred to as 16 County's Revised RFP, and Contractor's response to said Revised RFP dated February 28, 17 2022, all incorporated herein by reference and made part of this Agreement. In the event of any 18 inconsistency among these documents, the inconsistency shall be resolved by giving 19 precedence in the following order of priority: 1) to this Agreement, including all Exhibits; 2) to the 20 Revised RFP, and 3) to the Contractor's Response to the Revised RFP. A copy of County's 21 Revised RFP No. 22-038 and Contractor's response to the RFP shall be retained and made 22 available during the term of this Agreement by County's DBH Contracts Division. 23 1.2 Representation. The Contractor represents that it is qualified, ready, willing, and 24 able to perform all of the services provided in this Agreement. 25 1.3 Compliance with Laws. The Contractor shall, at its own cost, comply with all 26 applicable federal, state, and local laws and regulations in the performance of its obligations 27 under this Agreement, including but not limited to workers compensation, labor, and 28 confidentiality laws and regulations. 2 1 1.4 Monitoring. Contractor agrees to extend to County's staff, County's DBH and the 2 DHCS, or their designees, the right to review and monitor records, programs, or procedures, at 3 any time, in regard to clients, as well as the overall operation of Contractor's programs, in order 4 to ensure compliance with the terms and conditions of this Agreement. 5 1.5 Meetings. Contractor shall participate in monthly, or as needed, workgroup meetings 6 consisting of staff from County's DBH, DSS, and Probation to discuss FURS requirements, data 7 reporting, outcomes, training, policies and procedures, overall program operations, and any 8 problems or foreseeable problems that may arise. Contractor shall also attend bi-monthly 9 County DBH meetings for mental health providers, as required by the County. Schedule for 10 these meetings may change based on the needs of the County. 11 1.6 Reports. The Contractor shall submit the following reports: 12 (A) Cost Report: 13 Contractor agrees to submit a complete and accurate detailed cost report on an 14 annual basis for each fiscal year ending June 30th in the format prescribed by the DHCS 15 for the purposes of Short Doyle Medi-Cal reimbursements and total costs for programs. 16 Each cost report will be the source document for several phases of settlement with the 17 DHCS for the purposes of Short Doyle Medi-Cal reimbursement. Contractor shall report 18 costs under their approved legal entity number established during the Medi-Cal 19 certification process. The information provided applies to Contractor for program related 20 costs for services rendered to Medi-Cal and non-Medi-Cal. The Contractor will remit a 21 schedule to provide the required information on published charges for all authorized 22 services. The report will serve as a source document to determine the Contractor's 23 usual and customary charge prevalent in the public mental health sector that is used to 24 bill the general public, insurers, or other non-Medi-Cal third party payers during the 25 course of business operations. Contractor must report all collections for Medi- 26 Cal/Medicare services and collections. Contractor shall also submit with each cost 27 report a copy of the Contractor's general ledger that supports revenues and 28 expenditures for the FURS program. Contractor must also include a reconciled detailed 3 1 report of the total units of services rendered under this Agreement compared to the units 2 of services entered by Contractor to County's electronic information system. 3 Cost reports must be submitted to the County as a hard copy with a signed cover 4 letter and electronic copy of the completed DHCS cost report form along with requested 5 support documents following each fiscal year ending June 30th. During the month of 6 September of each year this Agreement is effective, County will issue instructions of the 7 annual cost report which indicates the training session, DHCS cost report template 8 worksheets, and deadlines to submit as determined by the State annually. Remit the 9 hard copies of the cost reports to County of Fresno, Attention: Cost Report Team, P.O. 10 Box 45003, Fresno, CA 93718. Remit the electronic copy or any inquiries to 11 DBHcostreportteam@co.fresno.ca.us. 12 All Cost Reports must be prepared in accordance with General Accepted 13 Accounting Principles (GAAP) and Welfare and Institutions Code §§ 5651(a)(4), 5664(a), 14 5705(b)(3) and 5718(c). Unallowable costs such as lobby or political donations must be 15 deducted on the cost report and invoice reimbursements. 16 If the Contractor does not submit the cost report(s) by the deadline, including any 17 extension period granted by the County, the County may withhold payments of pending 18 invoicing under compensation until the cost report(s) has been submitted and clears 19 County desk audit for completeness. 20 (B) Settlements with State Department of Health Care Services (DHCS) 21 During the term of this Agreement and thereafter, County and Contractor agree 22 to settle dollar amounts disallowed or settled in accordance with DHCS and County audit 23 settlement findings related to the reimbursements provided under this Agreement. 24 Contractor will participate in the several phases of settlements between 25 County/Contractor and DHCS. The phases of initial cost reporting for settlement 26 according to State reconciliation of records for paid Medi-Cal services and audit 27 settlement-State DHCS audit: 1) initial cost reporting - after an internal review by 28 County, the County files cost report with DHCS on behalf of the Contractor's legal entity 4 1 for the fiscal year; 2) Settlement—State reconciliation of records for paid Medi-Cal 2 services, approximately eighteen (18) to thirty-six (36) months following the State close 3 of the fiscal year, DHCS will send notice for any settlement under this provision to the 4 County; and 3) Audit Settlement-DHCS audit. After final reconciliation and settlement, 5 County and/or DHCS may conduct a review of medical records, cost report along with 6 support documents submitted to County in initial submission to determine accuracy and 7 may disallow cost and/or unit of service reported on the Contractor's legal entity cost 8 report. County may choose to appeal and therefore reserves the right to defer payback 9 settlement with Contractor until resolution of the appeal. DHCS Audits will follow federal 10 Medicaid procedures for managing overpayments. 11 If at the end of the Audit Settlement, the County determines that it overpaid the 12 Contractor, it will require the Contractor to repay the Medi-Cal related overpayment back 13 to the County. 14 Funds owed to County will be due within forty-five (45) days of notification by the 15 County, or County shall withhold future payments until all excess funds have been 16 recouped by means of an offset against any payments then or thereafter owing to 17 Contractor under this or any other Agreement. 18 (C) Outcome Reports 19 Contractor shall submit to County's DBH service outcome reports, as requested. 20 Outcome reports and outcome requirements are subject to change at County DBH's 21 discretion. Contractor shall provide outcomes as stated in Exhibit A. 22 (D)Additional Reports 23 Contractor shall also furnish to County such statements, records, reports, data, 24 and other information as County's DBH may request pertaining to matters covered by 25 this Agreement. In the event that Contractor fails to provide such reports or other 26 information required hereunder, it shall be deemed sufficient cause for County to 27 withhold monthly payments until there is compliance. In addition, Contractor shall 28 5 1 provide written notification and explanation to County within five (5) days of any funds 2 received from another source to conduct the same services covered by this Agreement. 3 1.7 Organizational Provider. Contractor shall maintain requirements as an MHP 4 organizational provider throughout the term of this Agreement, as described in section 13.1 of 5 this Agreement. If for any reason, this status is not maintained, County may terminate this 6 Agreement pursuant to Article 5 of this Agreement. 7 1.8 Staffing. Contractor agrees that prior to providing services under the terms and 8 conditions of this Agreement, Contractor shall have staff hired and in place for program services 9 and operations or County may, in addition to other remedies it may have, suspend referrals or 10 terminate this Agreement, in accordance with Article 5 of this Agreement. Contractor shall 11 submit monthly staffing reports due by the 10th of each month that identify all direct service and 12 support staff by first and last name, applicable Iicensure/certifications, and full-time hours 13 worked to be used as a tracking tool to determine if Contractor's program is staffed according to 14 the requirements of this Agreement. 15 1.9 Guiding Principles. Contractor shall align programs, services, and practices with 16 the vision, mission, and guiding principles of the DBH, as further described in Exhibit E, "Fresno 17 County Department of Behavioral Health Guiding Principles of Care Delivery", attached hereto 18 and by this reference incorporated herein and made part of this Agreement. 19 1.10 Clinical Leadership. Contractor shall send to County's DBH upon execution of this 20 Agreement, a detailed plan ensuring clinically appropriate leadership and supervision of their 21 clinical program. Recruitment and retaining clinical leadership with the clinical competencies to 22 oversee services based on the level of care and program design presented herein shall be 23 included in this plan. A description and monitoring of this plan shall be provided. 24 1.11 Timely Access. It is the expectation of the County that Contractor provide timely 25 access to services that meet the State of California standards for care. Contractor shall track 26 timeliness of services to clients and provide a monthly report showing the monitoring or tracking 27 tool that captures this data. County and Contractor shall meet to go over this monitoring tool, as 28 needed but at least on a monthly basis. County shall take corrective action if there is a failure to 6 1 comply by Contractor with timely access standards. Contractor shall also provide tracking tools 2 and measurements for effectiveness, efficiency, and client satisfaction indicators as required by 3 Commission on Accreditation of Rehabilitation Facilities (CARF) standards and as further 4 detailed in Exhibit A. 5 1.12 Electronic Health Record. Contractor may maintain its records in County's 6 electronic health record (EHR) system (currently Avatar) in accordance with Exhibit F, 7 "Documentation Standards for Client Records", as licenses become available. The client record 8 shall begin with registration and intake, and include client authorizations, assessments, plans of 9 care, and progress notes, as well as other documents as approved by County's DBH. County 10 shall be allowed to review records of services provided, including the goals and objectives of the 11 treatment plan, and how the therapy provided is achieving the goals and objectives. If 12 Contractor determines to maintain its records in Avatar, it shall provide County's DBH Director, 13 or his or her designee, with a thirty (30) day notice. If at any time Contractor chooses not to 14 maintain its records in Avatar, it shall provide County's DBH Director, or his or her designee, 15 with thirty (30) days advance written notice and Contractor will be responsible for obtaining its 16 own system, at its own cost, for electronic health records management. 17 Disclaimer 18 County makes no warranty or representation that information entered into the County's 19 DBH EHR system by Contractor will be accurate, adequate, or satisfactory for Contractor's own 20 purposes or that any information in Contractor's possession or control, or transmitted or 21 received by Contractor, is or will be secure from unauthorized access, viewing, use, disclosure, 22 or breach. Contractor is solely responsible for client information entered by Contractor into the 23 County's DBH EHR system. Contractor agrees that all Private Health Information (PHI) 24 maintained by Contractor in County's DBH EHR system will be maintained in conformance with 25 all HIPAA laws, as stated in section 14.1, "Health Insurance Portability and Accountability Act." 26 27 28 7 1 Article 2 2 Compensation, Invoices, and Payments 3 2.1 The County agrees to pay, and the Contractor agrees to receive, compensation for 4 the performance of its services under this Agreement as described in this section in accordance 5 with the budget set forth in Exhibit B. 6 2.2 Maximum Compensation. The maximum compensation payable to the Contractor 7 under this Agreement is Two Million Two Hundred Fifty-Four Thousand Eight Hundred Twelve 8 and No/100 Dollars ($2,254,812.00). 9 The maximum compensation payable to the Contractor under this Agreement for the 10 ramp-up period June 1, 2022 through June 30, 2022 shall not exceed Thirty-Five Thousand 11 Three Hundred Eighteen and No/100 Dollars ($35,318.00). 12 The maximum compensation payable to the Contractor under this Agreement for the 13 period July 1, 2022 through June 30, 2023 shall not exceed Four Hundred Twenty-Nine 14 Thousand Nine Hundred Eight and No/100 Dollars ($429,908.00). 15 The maximum compensation payable to the Contractor under this Agreement for the 16 period July 1, 2023 through June 30, 2024 shall not exceed Four Hundred Thirty-Two Thousand 17 Twenty-One and No/100 Dollars ($432,021.00). 18 The maximum compensation payable to the Contractor under this Agreement for the 19 period July 1, 2024 through June 30, 2025 shall not exceed Four Hundred Forty-Eight 20 Thousand Five Hundred Nineteen and No/100 Dollars ($448,519.00). 21 The maximum compensation payable to the Contractor under this Agreement for the 22 period June 1, 2022 through June 30, 2025 shall not exceed One Million Three Hundred Forty- 23 Five Thousand Seven Hundred Sixty-Six and No/100 Dollars ($1,345,766.00). 24 If performance standards are met and this Agreement is extended for an additional 25 twelve (12) month term pursuant to Article 3 of this Agreement, then in no event shall the 26 maximum compensation payable to the Contractor under this Agreement for the period July 1, 27 2025 through June 30, 2026 exceed Four Hundred Forty-Nine Thousand Two Hundred Thirty- 28 One and No/100 Dollars ($449,231.00). 8 1 The maximum compensation payable to the Contractor under this Agreement for the 2 period June 1, 2022 through June 30, 2026 shall not exceed One Million Seven Hundred 3 Ninety-Four Thousand Nine Hundred Ninety-Seven and No/100 Dollars ($1,794,997.00). 4 If performance standards are met and this Agreement is extended for an additional 5 twelve (12) month term pursuant to Article 3 of this Agreement, then in no event shall the 6 maximum compensation payable to the Contractor under this Agreement for the period July 1, 7 2026 through June 30, 2027 exceed Four Hundred Fifty-Nine Thousand Eight Hundred Fifteen 8 and No/100 Dollars ($459,815.00). 9 The maximum compensation payable to the Contractor under this Agreement for the 10 period June 1, 2022 through June 30, 2027 shall not exceed Two Million Two Hundred Fifty- 11 Four Thousand Eight Hundred Twelve and No/100 Dollars ($2,254,812.00). 12 The Contractor acknowledges that the County is a local government entity and does 13 so with notice that the County's powers are limited by the California Constitution and by State 14 law, and with notice that the Contractor may receive compensation under this Agreement only 15 for services performed according to the terms of this Agreement and while this Agreement is in 16 effect, and subject to the maximum amount payable under this section. The Contractor further 17 acknowledges that County employees have no authority to pay the Contractor except as 18 expressly provided in this Agreement. 19 2.3 Invoices. The Contractor shall submit monthly invoices to 1) 20 dbhinvoicereview@fresnocountyca.gov, 2) DBH-invoices@fresnocountyca.gov; and 3) 21 dbhcontractedservicesdivision@fresnocountyca.gov with a copy to the assigned DBH Mental 22 Health Contracts Staff Analyst. The Contractor shall submit each invoice by the tenth (10'") day 23 of each month for actual expenses incurred during the prior month. After Contractor renders 24 service to referred clients, Contractor shall invoice County for payment, certify the expenditure, 25 and submit electronic claiming data into County's electronic information system for all clients, 26 including those eligible for Medi-Cal as well as those that are not eligible for Medi-Cal, including 27 contracted cost per unit and actual cost per unit. No reimbursement for costs incurred by 28 Contractor for services delivered under this Agreement shall be made until the invoice and 9 1 supporting documentation is received, verified, and approved by County's DBH. County must 2 pay Contractor before submitting claims to DHCS for Federal and State reimbursement for 3 Medi-Cal eligible clients. 4 At the discretion of County's DBH Director, or designee, if an invoice is incorrect or is 5 otherwise not in proper form or substance, County's DBH Director, or designee, shall have the 6 right to withhold payment as to only that portion of the invoice that is incorrect or improper after 7 five (5) days prior notice to Contractor. Contractor agrees to continue to provide services for a 8 period of ninety (90) days after notification of an incorrect or improper invoice. If after the ninety 9 (90) day period, the invoice(s) is still not corrected to County DBH's satisfaction, County's DBH 10 Director, or designee, may elect to terminate this Agreement, pursuant to the termination 11 provisions stated in Article 5 of this Agreement. In addition, for invoices received ninety (90) 12 days after the expiration of each term of this Agreement or termination of this Agreement, at the 13 discretion of County's DBH Director, or designee, County's DBH shall have the right to deny 14 payment of any additional invoices received. 15 Contractor shall submit monthly invoices and general ledgers that itemize the line 16 item charges for monthly program costs. Unallowable costs such as lobbying or political 17 donations must be deducted from the monthly invoice reimbursements. The invoices and 18 general ledgers will serve as tracking tools to determine if Contractor's program costs are in 19 accordance with its budgeted cost. Failure to submit reports and other supporting 20 documentation shall be deemed sufficient cause for County to withhold payments until there is 21 compliance, as further described in this Article. 22 Contractor will remit annually within ninety (90) days from June 30, a schedule to 23 provide the required information on published charges (PC) for all authorized direct specialty 24 mental health services. The published charge listing will serve as a source document to 25 determine the Contractor's usual and customary charge prevalent in the public mental health 26 sector that is used to bill the general public, insurers or other non-Medi-Cal third party payers 27 during the course of business operations. 28 10 1 Contractor must maintain financial records for a period of seven (7) years or until any 2 dispute, audit or inspection is resolved, whichever is later. Contractor will be responsible for any 3 disallowances related to inadequate documentation. 4 Contractor is responsible for collection and managing data in a manner to be 5 determined by DHCS and the Mental Health Plan in accordance with applicable rules and 6 regulations. County's electronic information system is a critical source of information for 7 purposes of monitoring service volume and obtaining reimbursement. Contractor must attend 8 County DBH's Business Office training on equipment reporting for assets, intangible and 9 sensitive minor assets, County's electronic information system, and related cost reporting. 10 Contractor shall submit service data into County's electronic information system 11 within thirty (30) calendar days from the date services were rendered. Federal and State 12 reimbursement for Medi-Cal specialty mental health services is based on public expenditures 13 certified by the Contractor. Contractor must submit a signed certified public expenditure report, 14 with each monthly invoice. DHCS expects the claims for Federal and State reimbursement to 15 equal the amount the County paid the Contractor for the service rendered less any funding 16 sources not eligible for Federal and State reimbursement. 17 Contractor must provide all necessary data to allow the County to bill Medi-Cal, and 18 any other third-party source, for services and meet State and Federal reporting requirements. 19 The necessary data can be provided by a variety of means, including but not limited to: 1) direct 20 data entry into County's information system; 2) providing an electronic file compatible with 21 County's electronic information system; or 3) integration between County's electronic 22 information system and Contractor's information system(s). 23 If a client has other health coverage (OHC) such as private insurance or Federal 24 Medicare, the Contractor will be responsible for billing the carrier and obtaining a 25 payment/denial or have validation of claiming with no response ninety (90) days after the claim 26 was mailed before the service can be entered into the County's electronic information system. 27 A copy of explanation of benefits or CSM 1500 is required as documentation. Contractor must 28 report all revenue collected from OHC, third-party, client-pay or private-pay in each monthly 11 1 invoice and in the cost report that is required to be submitted. Contractor shall submit monthly 2 invoices for reimbursement that equal the amount due Contractor less any funding sources not 3 eligible for Federal and State reimbursement. Contractor must comply with all laws and 4 regulations governing the Federal Medicare program, including, but not limited to: 1) the 5 requirement of the Medicare Act, 42 U.S.C. section 1395 et seq; and 2) the regulations and 6 rules promulgated by the Federal Centers for Medicare and Medicaid Services as they relate to 7 participation, coverage and claiming reimbursement. Contractor will be responsible for 8 compliance as of the effective date of each Federal, State, or local law or regulation specified. 9 Data entry shall be the responsibility of the Contractor. The direct specialty mental 10 health services data for billing must be reconciled by the Contractor to the monthly invoices 11 submitted for payment. County shall monitor the volume of services and cost of services 12 entered into the County's electronic information system. Any and all audit exceptions resulting 13 from the provision and reporting of Medi-Cal services by Contractor shall be the sole 14 responsibility of the Contractor. Contractor will comply with all applicable policies, procedures, 15 directives, and guidelines regarding the use of County's electronic information system. 16 All final invoices and/or any final budget modification requests shall be submitted by 17 Contractor within sixty (60) days following the final month of service for which payment is 18 claimed. No action shall be taken by County on invoices submitted beyond the sixty (60) day 19 closeout period. Any compensation which is not expended by Contractor pursuant to the terms 20 and conditions of this Agreement shall automatically revert to County. 21 2.4 Medi-Cal Certification and Mental Health Plan Compliance. Contractor will 22 establish and maintain Medi-Cal certification or become certified within ninety (90) days of the 23 effective date of this Agreement through County to provide reimbursable services to Medi-Cal 24 eligible clients. In addition, Contractor shall work with the County's DBH to execute the process 25 if not currently certified by County for credentialing of staff. During this process, the Contractor 26 will obtain a legal entity number established by the DHCS, a requirement for maintaining Mental 27 Health Plan organizational provider status throughout the term of this Agreement. Contractor 28 will be required to become Medi-Cal certified prior to providing services to Medi-Cal eligible 12 1 clients and seeking reimbursement from the County. Contractor will not be reimbursed by 2 County for any services rendered prior to certification. 3 Contractor shall provide direct specialty mental health services in accordance with 4 the Mental Health Plan. Contractor must comply with the "Fresno County Mental Health Plan 5 Compliance Program and Code of Conduct" set forth in Exhibit G, attached hereto and 6 incorporated herein by reference and made part of this Agreement. 7 Contractor may provide direct specialty mental health services using unlicensed staff 8 as long as the individual is approved as a provider by the Mental Health Plan, is supervised by 9 licensed staff, works within his/her scope and only delivers allowable direct specialty mental 10 health services. It is understood that each service is subject to audit for compliance with 11 Federal and State regulations, and that County may be making payments in advance of said 12 review. In the event that a service is disapproved, County may, at its sole discretion, withhold 13 compensation or set off from other payments due the amount of said disapproved services. 14 Contractor shall be responsible for audit exceptions to ineligible dates of services or incorrect 15 application of utilization review requirements. 16 2.5 Payment. The County shall pay each correctly completed and timely submitted 17 invoice within 45 days after receipt. The County shall remit any payment to the Contractor's 18 address specified in the invoice. 19 Payments shall be made by County to Contractor in arrears, for services provided 20 during the preceding month, within forty-five (45) days after the date of receipt and approval by 21 County of the monthly invoicing as described in this Article. Payments shall be made after 22 receipt and verification of actual expenditures incurred by Contractor for monthly program costs, 23 as identified in Exhibit G, "Fresno County Mental Health Plan Compliance Program and Code of 24 Conduct", in the performance of this Agreement in accordance with Exhibit A and shall be 25 submitted to the County on a monthly basis by the tenth (10th) of the month following the month 26 of said expenditures. 27 Contractor shall submit to County by the tenth (10th) of each month a detailed 28 general ledger (GL) itemizing costs incurred in the previous month. Failure to submit GL reports 13 1 and supporting documentation shall be deemed sufficient cause for County to withhold 2 payments until there is compliance, as further described in this Article. 3 County shall not be obligated to make any payments under this Agreement if the 4 request for payment is received by County more than sixty (60) days after this Agreement as 5 terminated or expired. 6 The services provided by Contractor under this Agreement are funded in whole or in 7 part by the State of California. In the event that funding for these services is delayed by the 8 State Controller, County may defer payments to Contractor. The amount of the deferred 9 payment shall not exceed the amount of funding delayed by the State Controller to the County. 10 The period of time of the deferral by County shall not exceed the period of time of the State 11 Controller's delay of payment to County plus forty-five (45) days. 12 Contractor shall be held financially liable for any and all future disallowances/audit 13 exceptions due to Contractor's deficiency discovered through the State's audit process and 14 County's utilization review process during the course of this Agreement. At County's election, 15 the disallowed amount will be remitted within forty-five (45) days to County upon notification or 16 shall be withheld from subsequent payments to Contractor. Contractors shall not receive 17 reimbursement for any units of services rendered that are disallowed or denied by the County's 18 Mental Health Plan utilization review process or through the State Department of Health Care 19 Services (DHCS) cost report audit settlement process for Medi-Cal eligible clients. 20 2.6 Incidental Expenses. The Contractor is solely responsible for all of its costs and 21 expenses that are not specified as payable by the County under this Agreement. 22 Article 3 23 Term of Agreement 24 3.1 Term. This Agreement is effective on June 1, 2022 and terminates on June 30, 25 2025, except as provided in section 4.2, "Extension," or Article 5, "Termination and Suspension," 26 below. 27 3.2 Extension. The term of this Agreement may be extended for no more than two (2), 28 one-year periods only upon written approval of both parties at least thirty (30) days before the 14 1 first day of the next one-year extension period. The County's DBH Director or his or her 2 designee is authorized to sign the written approval on behalf of the County based on the 3 Contractor's satisfactory performance. The extension of this Agreement by the County is not a 4 waiver or compromise of any default or breach of this Agreement by the Contractor existing at 5 the time of the extension whether or not known to the County. 6 Article 4 7 Notices 8 4.1 Contact Information. The persons and their addresses having authority to give and 9 receive notices provided for or permitted under this Agreement include the following: 10 For the County: 11 Director of Behavioral Health County of Fresno 12 1925 E. Dakota Ave. Fresno, CA 93726 13 For the Contractor: 14 Chief Executive Officer Kings View 15 7170 N. Financial Dr. Ste. 110 Fresno, CA 93720 16 17 4.2 Change of Contact Information. Either party may change the information in section 18 5.1 by giving notice as provided in section 5.3. 19 4.3 Method of Delivery. Each notice between the County and the Contractor provided 20 for or permitted under this Agreement must be in writing, state that it is a notice provided under 21 this Agreement, and be delivered either by personal service, by first-class United States mail, by 22 an overnight commercial courier service, by telephonic facsimile transmission, or by Portable 23 Document Format (PDF) document attached to an email. 24 (A) A notice delivered by personal service is effective upon service to the recipient. 25 (B) A notice delivered by first-class United States mail is effective three County 26 business days after deposit in the United States mail, postage prepaid, addressed to the 27 recipient. 28 15 1 (C)A notice delivered by an overnight commercial courier service is effective one 2 County business day after deposit with the overnight commercial courier service, 3 delivery fees prepaid, with delivery instructions given for next day delivery, addressed to 4 the recipient. 5 (D)A notice delivered by telephonic facsimile transmission or by PDF document 6 attached to an email is effective when transmission to the recipient is completed (but, if 7 such transmission is completed outside of County business hours, then such delivery is 8 deemed to be effective at the next beginning of a County business day), provided that 9 the sender maintains a machine record of the completed transmission. 10 4.4 Claims Presentation. For all claims arising from or related to this Agreement, 11 nothing in this Agreement establishes, waives, or modifies any claims presentation 12 requirements or procedures provided by law, including the Government Claims Act (Division 3.6 13 of Title 1 of the Government Code, beginning with section 810). 14 Article 5 15 Termination and Suspension 16 5.1 Termination for Non-Allocation of Funds. The terms of this Agreement are 17 contingent on the approval of funds by the appropriating government agency. If sufficient funds 18 are not allocated, then the County, upon at least 30 days' advance written notice to the 19 Contractor, may: 20 (A) Modify the services provided by the Contractor under this Agreement; or 21 (B) Terminate this Agreement. 22 5.2 Termination for Breach. 23 (A) Upon determining that a breach (as defined in paragraph (C) below) has 24 occurred, the County may give written notice of the breach to the Contractor. The written 25 notice may suspend performance under this Agreement, and must provide at least 30 26 days for the Contractor to cure the breach. 27 (B) If the Contractor fails to cure the breach to the County's satisfaction within the 28 time stated in the written notice, the County may terminate this Agreement immediately. 16 1 (C) For purposes of this section, a breach occurs when, in the determination of the 2 County, the Contractor has: 3 (1) Obtained or used funds illegally or improperly; 4 (2) Failed to comply with any part of this Agreement; 5 (3) Submitted a substantially incorrect or incomplete report to the County; or 6 (4) Improperly performed any of its obligations under this Agreement. 7 5.3 Termination without Cause. In circumstances other than those set forth above, the 8 County or Contractor may terminate this Agreement by giving at least 60 days advance written 9 notice of intention to terminate. 10 5.4 No Penalty or Further Obligation. Any termination of this Agreement by the County 11 under this Article 5 is without penalty to or further obligation of the County. 12 5.5 County's Rights upon Termination. Upon termination for breach under this Article 13 5, the County may demand repayment by the Contractor of any monies disbursed to the 14 Contractor under this Agreement that, in the County's sole judgment, were not expended in 15 compliance with this Agreement. The Contractor shall promptly refund all such monies upon 16 demand. This section survives the termination of this Agreement. 17 Article 6 18 Independent Contractor 19 6.1 Status. In performing under this Agreement, the Contractor, including its officers, 20 agents, employees, and volunteers, is at all times acting and performing as an independent 21 contractor, in an independent capacity, and not as an officer, agent, servant, employee,joint 22 venturer, partner, or associate of the County. 23 6.2 Verifying Performance. The County has no right to control, supervise, or direct the 24 manner or method of the Contractor's performance under this Agreement, but the County may 25 verify that the Contractor is performing according to the terms of this Agreement. 26 6.3 Benefits. Because of its status as an independent Contractor, the Contractor has no 27 right to employment rights or benefits available to County employees. The Contractor is solely 28 responsible for providing to its own employees all employee benefits required by law. The 17 1 Contractor shall save the County harmless from all matters relating to the payment of 2 Contractor's employees, including compliance with Social Security withholding and all related 3 regulations. 4 6.4 Services to Others. The parties acknowledge that, during the term of this 5 Agreement, the Contractor may provide services to others unrelated to the County. 6 Article 7 7 Indemnity and Defense 8 7.1 Indemnity. The Contractor shall indemnify and hold harmless and defend the 9 County (including its officers, agents, employees, and volunteers) against all claims, demands, 10 injuries, damages, costs, expenses (including attorney fees and costs), fines, penalties, and 11 liabilities of any kind to the County, the Contractor, or any third party that arise from or relate to 12 the performance or failure to perform by the Contractor (or any of its officers, agents, 13 subcontractors, or employees) under this Agreement. The County may conduct or participate in 14 its own defense without affecting the Contractor's obligation to indemnify and hold harmless or 15 defend the County. Contractor agrees to indemnify County for Federal and/or State of California 16 audit exceptions resulting from noncompliance herein on the part of the Contractor. 17 7.2 Survival. This Article 7 survives the termination of this Agreement. 18 Article 8 19 Insurance, Assurances, and Licenses/Certificates 20 8.1 Insurance. The Contractor shall comply with all the insurance requirements in 21 Exhibit D to this Agreement. 22 8.2 Assurances. In entering into this Agreement, Contractor certifies that neither they, 23 nor any of their officers, are currently excluded, suspended, debarred, or otherwise ineligible to 24 participate in the Federal Health Care Programs; that neither they, nor any of their officers, have 25 been convicted of a criminal offense related to the provision of health care items or services; nor 26 have they, nor any of their officers, been reinstated to participate in the Federal Health Care 27 Programs after a period of exclusion, suspension, debarment, or ineligibility. If County learns, 28 subsequent to entering into a contract, that Contractor is ineligible on these grounds, County will 18 1 remove Contractor from responsibility for, or involvement with, County's business operations 2 related to the Federal Health Care Programs and shall remove such Contractor from any 3 position in which Contractor's compensation, or the items or services rendered, ordered or 4 prescribed by Contractor may be paid in whole or part, directly or indirectly, by Federal Health 5 Care Programs or otherwise with Federal Funds at least until such time as Contractor is 6 reinstated into participation in the Federal Health Care Programs. 7 (A) If County has notice that Contractor, or its officers, has been charged with a 8 criminal offense related to any Federal Health Care Program, or is proposed for 9 exclusion during the term on any contract, Contractor and County shall take all 10 appropriate actions to ensure the accuracy of any claims submitted to any Federal 11 Health Care Program. At its discretion given such circumstances, County may request 12 that Contractor cease providing services until resolution of the charges or the proposed 13 exclusion. 14 (B) Contractor agrees that all potential new employees of Contractor or 15 subcontractors of Contractor who, in each case, are expected to perform professional 16 services under this Agreement, will be queried as to whether: (1) they are now or ever 17 have been excluded, suspended, debarred, or otherwise ineligible to participate in the 18 Federal Health Care Programs; (2) they have been convicted of a criminal offense 19 related to the provision of health care items or services; and (3) they have been 20 reinstated to participate in the Federal Health Care Programs after a period of exclusion, 21 suspension, debarment, or ineligibility. 22 (1) In the event the potential employee or subcontractor informs Contractor that 23 he or she is excluded, suspended, debarred, or otherwise ineligible, or has been 24 convicted of a criminal offense relating to the provision of health care services, and 25 Contractor hires or engages such potential employee or subcontractor, Contractor 26 will ensure that said employee or subcontractor does not work, either directly or 27 indirectly relating to services provided to County. 28 19 1 (2) Notwithstanding the above, County, at its discretion, may terminate this 2 Agreement in accordance with Article 5 of this Agreement, or require adequate 3 assurance (as defined by County) that no excluded, suspended, or otherwise 4 ineligible employee or subcontractor of Contractor will perform work, either directly or 5 indirectly, relating to services provided to County. Such demand for adequate 6 assurance shall be effective upon a time frame to be determined by County to 7 protect the interests of County consumers. 8 (C) Contractor shall verify (by asking the applicable employees and subcontractors) 9 that all current employees and existing subcontractors who, in each case, are expected 10 to perform professional services under this Agreement: (1) are not currently excluded, 11 suspended, debarred, or otherwise ineligible to participate in the Federal Health Care 12 Programs; (2) have not been convicted of a criminal offense related to the provision of 13 health care items or services; and (3) have not been reinstated to participate in the 14 Federal Health Care Program after a period of exclusion, suspension, debarment, or 15 ineligibility. In the event any existing employee or subcontractor informs Contractor that 16 he or she is excluded, suspended, debarred, or otherwise ineligible to participate in the 17 Federal Health Care Programs, or has been convicted of a criminal offense relating to 18 the provision of health care services, Contractor will ensure that said employee or 19 subcontractor does not work, either direct or indirect, relating to services provided to 20 County. 21 (1) Contractor agrees to notify County immediately during the term of this 22 Agreement whenever Contractor learns that an employee or subcontractor who, in 23 each case, is providing professional services under this Agreement is excluded, 24 suspended, debarred or otherwise ineligible to participate in the Federal Health Care 25 Programs, or is convicted of a criminal offense relating to the provision of health care 26 services. 27 (2) Notwithstanding the above, County, at its discretion, may terminate this 28 Agreement in accordance with Article 5 of this Agreement, or require adequate 20 1 assurance (as defined by County) that no excluded, suspended or otherwise 2 ineligible employee or subcontractor of Contractor will perform work, either directly or 3 indirectly, relating to services provided to County. Such demand for adequate 4 assurance shall be effective upon a time frame to be determined by County to 5 protect the interests of County clients. 6 (D) Contractor agrees to cooperate fully with any reasonable requests for information 7 from County which may be necessary to complete any internal or external audits relating 8 to Contractor's compliance with the provisions of this section. 9 (E) Contractor agrees to reimburse County for the entire cost of any penalty imposed 10 upon County by the Federal Government as a result of Contractor's violation of 11 Contractor's obligations as described in this section. 12 8.3 Licenses/Certificates. Throughout each term of this Agreement, Contractor and 13 Contractor's staff shall maintain all necessary licenses, permits, approvals, certificates, waivers, 14 and exemptions necessary for the provision of the services hereunder and required by the laws 15 and regulations of the United States of America, State of California, the County of Fresno, and 16 any other applicable governmental agencies. Contractor shall notify County immediately in 17 writing of its inability to obtain or maintain such licenses, permits, approvals, certificates, 18 waivers, and exemptions irrespective of the pendency of any appeal related thereto. 19 Additionally, Contractor and Contractor's staff shall comply with all applicable laws, rules, or 20 regulations, as may now exist or be hereafter changed. 21 Article 9 22 Inspections, Audits, and Public Records 23 9.1 Inspection of Documents. The Contractor shall make available to the County, and 24 the County may examine at any time during business hours and as often as the County deems 25 necessary, all of the Contractor's records and data with respect to the matters covered by this 26 Agreement, excluding attorney-client privileged communications. The Contractor shall, upon 27 request by the County, permit the County to audit and inspect all of such records and data to 28 ensure the Contractor's compliance with the terms of this Agreement. 21 1 9.2 State Audit Requirements. If the compensation to be paid by the County under this 2 Agreement exceeds $10,000, the Contractor is subject to the examination and audit of the 3 California State Auditor, as provided in Government Code section 8546.7, for a period of three 4 years after final payment under this Agreement. This section survives the termination of this 5 Agreement. 6 9.3 Public Records. The County is not limited in any manner with respect to its public 7 disclosure of this Agreement or any record or data that the Contractor may provide to the 8 County. The County's public disclosure of this Agreement or any record or data that the 9 Contractor may provide to the County may include but is not limited to the following: 10 (A) The County may voluntarily, or upon request by any member of the public or 11 governmental agency, disclose this Agreement to the public or such governmental 12 agency. 13 (B) The County may voluntarily, or upon request by any member of the public or 14 governmental agency, disclose to the public or such governmental agency any record or 15 data that the Contractor may provide to the County, unless such disclosure is prohibited 16 by court order. 17 (C)This Agreement, and any record or data that the Contractor may provide to the 18 County, is subject to public disclosure under the Ralph M. Brown Act (California 19 Government Code, Title 5, Division 2, Part 1, Chapter 9, beginning with section 54950). 20 (D)This Agreement, and any record or data that the Contractor may provide to the 21 County, is subject to public disclosure as a public record under the California Public 22 Records Act (California Government Code, Title 1, Division 7, Chapter 3.5, beginning 23 with section 6250) ("CPRA"). 24 (E) This Agreement, and any record or data that the Contractor may provide to the 25 County, is subject to public disclosure as information concerning the conduct of the 26 people's business of the State of California under California Constitution, Article 1, 27 section 3, subdivision (b). 28 22 1 (F) Any marking of confidentiality or restricted access upon or otherwise made with 2 respect to any record or data that the Contractor may provide to the County shall be 3 disregarded and have no effect on the County's right or duty to disclose to the public or 4 governmental agency any such record or data. 5 9.4 Public Records Act Requests. If the County receives a written or oral request 6 under the CPRA to publicly disclose any record that is in the Contractor's possession or control, 7 and which the County has a right, under any provision of this Agreement or applicable law, to 8 possess or control, then the County may demand, in writing, that the Contractor deliver to the 9 County, for purposes of public disclosure, the requested records that may be in the possession 10 or control of the Contractor. Within five business days after the County's demand, the 11 Contractor shall (a) deliver to the County all of the requested records that are in the Contractor's 12 possession or control, together with a written statement that the Contractor, after conducting a 13 diligent search, has produced all requested records that are in the Contractor's possession or 14 control, or (b) provide to the County a written statement that the Contractor, after conducting a 15 diligent search, does not possess or control any of the requested records. The Contractor shall 16 cooperate with the County with respect to any County demand for such records. If the 17 Contractor wishes to assert that any specific record or data is exempt from disclosure under the 18 CPRA or other applicable law, it must deliver the record or data to the County and assert the 19 exemption by citation to specific legal authority within the written statement that it provides to 20 the County under this section. The Contractor's assertion of any exemption from disclosure is 21 not binding on the County, but the County will give at least 10 days' advance written notice to 22 the Contractor before disclosing any record subject to the Contractor's assertion of exemption 23 from disclosure. The Contractor shall indemnify the County for any court-ordered award of costs 24 or attorney's fees under the CPRA that results from the Contractor's delay, claim of exemption, 25 failure to produce any such records, or failure to cooperate with the County with respect to any 26 County demand for any such records. 27 9.5 Single Audit Clause. If Contractor expends Seven Hundred Fifty Thousand and 28 No/100 Dollars ($750,000.00) or more in Federal and Federal flow-through monies, Contractor 23 1 agrees to conduct an annual audit in accordance with the requirements of the Single Audit 2 Standards as set forth in Office of Management and Budget (OMB) 2 CFR 200. Contractor shall 3 submit said audit and management letter to County. The audit must include a statement of 4 findings or a statement that there were no findings. If there were negative findings, Contractor 5 must include a corrective action plan signed by an authorized individual. Contractor agrees to 6 take action to correct any material non-compliance or weakness found as a result of such audit. 7 Such audit shall be delivered to County's DBH Finance Division for review within nine (9) 8 months of the end of any fiscal year in which funds were expended and/or received for the 9 program. Failure to perform the requisite audit functions as required by this Agreement may 10 result in County performing the necessary audit tasks, or at County's option, contracting with a 11 public accountant to perform said audit, or may result in the inability of County to enter into 12 future agreements with Contractor. All audit costs related to this Agreement are the sole 13 responsibility of Contractor. 14 A single audit report is not applicable if Contractor's Federal contracts do not exceed 15 the Seven Hundred Fifty Thousand and No/100 Dollars ($750,000.00) requirement or 16 Contractor's only funding is through Drug-related Medi-Cal. If a single audit is not applicable, a 17 program audit must be performed and a program audit report with management letter shall be 18 submitted by Contractor to County as a minimum requirement to attest to Contractor solvency. 19 Said audit report shall be delivered to County's DBH Finance Division for review no later than 20 nine (9) months after the close of the fiscal year in which the funds supplied through this 21 Agreement are expended. Failure to comply with this Act may result in County performing the 22 necessary audit tasks or contracting with a qualified accountant to perform said audit. All audit 23 costs related to this Agreement are the sole responsibility of Contractor who agrees to take 24 corrective action to eliminate any material noncompliance or weakness found as a result of such 25 audit. Audit work performed by County under this paragraph shall be billed to Contractor at 26 County cost, as determined by County's Auditor-Controller/Treasurer-Tax Collector. 27 Contractor shall make available all records and accounts for inspection by County, 28 the State of California, if applicable, the Comptroller General of the United States, the Federal 24 1 Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a 2 period of at least three (3) years following final payment under this Agreement or the closure of 3 all other pending matters, whichever is later. 4 9.6 Client Records. Contractor shall maintain records in accordance with Exhibit F, 5 "Documentation Standards for Client Records", attached hereto and by this reference 6 incorporated herein and made part of this Agreement. During site visits, County shall be 7 allowed to review records of services provided. All medical records shall be maintained for a 8 minimum of ten (10) years from the date of the end of the Agreement. 9 Article 10 10 Complaints 11 10.1 Documentation. Contractor shall log complaints and the disposition of all complaints 12 from a client or a client's family. Contractor shall provide a copy of the detailed complaint log 13 entries concerning County-sponsored clients to County at monthly intervals by the tenth (10th) 14 day of the following month, in a format that is mutually agreed upon. Besides the detailed 15 complaint log, Contractor shall provide details and attach documentation of each complaint with 16 the log. Contractor shall notify County of all incidents reportable to state licensing bodies that 17 affect County clients within twenty-four (24) hours of receipt of a complaint. Within ten (10) days 18 after each incident or complaint affecting County clients, Contractor shall provide County with 19 information relevant to the complaint, investigative details of the complaint, the complaint and 20 Contractor's disposition of, or corrective action taken to resolve the complaint. 21 10.2 Client Rights. Contractor shall post signs informing clients of their right to file a 22 complaint or grievance. In addition, Contractor shall inform every client of their rights as set 23 forth in Exhibit H. 24 10.3 Incident Reporting. Contractor shall file an incident report for all incidents involving 25 clients, following the protocol identified in Exhibit I. 26 Article 11 27 Property of County 28 25 1 11.1 Fixed Assets. County and Contractor recognize that fixed assets are tangible and 2 intangible property obtained or controlled under County for use in operational capacity and will 3 benefit County for a period more than one (1) year. Depreciation of the qualified items will be 4 on a straight-line basis. For County purposes, fixed assets must fulfill three (3) qualifications: 5 (A) Have life span of over one (1) year; 6 (B) Is not a repair part; and 7 (C) Must be valued at or greater than the capitalization thresholds for the asset type: 8 Asset type Threshold ■ Land $0 9 ■ Buildings and Improvements $100,000 ■ Infrastructure $100,000 10 ■ Tangible $5,000 • Equipment 11 . Vehicles ■ Intangible $100,000 12 • Internally Generated Software • Purchased Software 13 • Easements • Patents 14 ■ And Capital Lease $5,000 15 Qualified fixed asset equipment is to be reported and approved by County. If it is 16 approved and identified as an asset it will be tagged with a County program number. A Fixed 17 Asset Log will be maintained by County's Asset Management System and inventoried annually 18 until the asset is fully depreciated. During the terms of this Agreement, Contractor's fixed 19 assets may be inventoried in comparison to County's DBH Asset Inventory System. 20 11.2 Sensitive Assets. Certain purchases less than Five Thousand and No/100 Dollars 21 ($5,000.00) but more than One Thousand and No/100 Dollars ($1,000.00)with over a one (1) 22 year life span, and/or are mobile and high risk of theft or loss are sensitive assets. Such 23 sensitive items are not limited to computers, copiers, televisions, cameras, and other sensitive 24 items as determined by County's DBH Director or designee. Contractor shall maintain a 25 tracking system on the items that are not required to be capitalized or depreciated. The items 26 are subject to annual inventory review by the County's DBH for compliance. 27 11.3 Retention and Maintenance. Assets shall be retained by County, as County 28 property, in the event this Agreement is terminated or upon expiration of this Agreement. 26 1 Contractor agrees to participate in an annual inventory of all County fixed and inventoried 2 assets. Upon termination or expiration of this Agreement, Contractor shall be physically present 3 when fixed and inventoried assets are returned to County possession. Contractor is responsible 4 for returning to County all County owned undepreciated fixed and inventoried assets, or the 5 monetary value of said assets if unable to produce the assets at the expiration or termination of 6 this Agreement. Contractor further agrees to the following: 7 (A) Maintain all items of equipment in good working order and condition, normal wear 8 and tear excepted; 9 (B) Label all items of equipment with County assigned program number, to perform 10 periodic inventories as required by County and to maintain an inventory list showing 11 where and how the equipment is being used in accordance with procedures developed 12 by County. All such lists shall be submitted to County within ten (10) days of any 13 request therefore; and 14 (C) Report in writing to County immediately after discovery, the loss or theft of any 15 items of equipment. For stolen items, the local law enforcement agency must be 16 contacted, and a copy of the police report submitted to County. 17 11.4 Equipment Purchase. The purchase of any equipment by Contractor with funds 18 provided hereunder shall require the prior written approval of County's DBH Director or 19 designee, shall fulfill the provisions of this Agreement as appropriate, and must be directly 20 related to Contractor's services or activity under the terms of this Agreement. County's DBH 21 may refuse reimbursement for any costs resulting from equipment purchased, which are 22 incurred by Contractor, if prior written approval has not been obtained from County. 23 11.5 Modification. Contractor must obtain prior written approval from County's DBH 24 whenever there is any modification or change in the use of any property acquired or improved, 25 in whole or in part, using funds under this Agreement. If any real or personal property acquired 26 or improved with said funds identified herein is sold and/or is utilized by Contractor for a use 27 which does not qualify under this Agreement, Contractor shall reimburse County in an amount 28 equal to the current fair market value of the property, less any portion thereof attributable to 27 1 expenditures of funds not provided under this Agreement. These requirements shall continue in 2 effect for the life of the property. In the event this Agreement expires, the requirements for this 3 Article shall remain in effect for activities or property funded with said funds, unless action is 4 taken by the State government to relieve County of these obligations. 5 Article 12 6 Compliance 7 12.1 Compliance. Contractor agrees to comply with County's Contractor Code of 8 Conduct and Ethics and the County's Compliance Program in accordance with Exhibit H. 9 Within thirty (30) days of entering into this Agreement with County, Contractor shall have all of 10 Contractor's employees, agents, and subcontractors providing services under this Agreement 11 certify in writing, that he or she has received, read, understood, and shall abide by the 12 Contractor Code of Conduct and Ethics. Contractor shall ensure that within thirty (30) days of 13 hire, all new employees, agents, and subcontractors providing services under this Agreement 14 shall certify in writing that he or she has received, read, understood, and shall abide by the 15 Contractor Code of Conduct and Ethics. Contractor understands that the promotion of and 16 adherence to the Contractor Code of Conduct is an element in evaluating the performance of 17 Contractor and its employees, agents, and subcontractors. 18 Within thirty (30) days of entering into this Agreement, and annually thereafter, all 19 employees, agents, and subcontractors providing services under this Agreement shall complete 20 general compliance training, and appropriate employees, agents, and subcontractors shall 21 complete documentation and billing or billing/reimbursement training. All new employees, 22 agents, and subcontractors shall attend the appropriate training within thirty (30) days of hire. 23 Each individual who is required to attend training shall certify in writing that he or she has 24 received the required training. The certification shall specify the type of training received and 25 the date received. The certification shall be provided to County's DBH Compliance Officer at 26 1925 E. Dakota Ave, Fresno, California 93726. Contractor agrees to reimburse County for the 27 entire cost of any penalty imposed upon County by the Federal Government as a result of 28 Contractor's violation of the terms of this Agreement. 28 1 12.2 Compliance with State Requirements. Contractor recognizes that County operates 2 its mental health programs under an agreement with DHCS, and that under said agreement the 3 State imposes certain requirements on County and its subcontractors. Contractor shall adhere 4 to all State requirements, including those identified in Exhibit J, "State Mental Health 5 Requirements", attached hereto and by this reference incorporated herein and made part of this 6 Agreement. 7 12.3 Compliance with State Medi-Cal Requirements. Contractor shall be required to 8 maintain Mental Health Plan organizational provider certification by Fresno County. Contractor 9 must meet Medi-Cal organization provider standards as listed in Exhibit K, "Medi-Cal 10 Organizational Provider Standards", attached hereto and by this reference incorporated herein 11 and made part of this Agreement. It is acknowledged that all references to Organizational 12 Provider and/or Provider in Exhibit K shall refer to Contractor. In addition, Contractor shall 13 inform every client of their rights under the County's Mental Health Plan as described in Exhibit 14 H, "Fresno County Mental Health Plan Grievances and Incident Reporting", attached hereto and 15 by this reference incorporated herein. Contractor shall also file an incident report for all 16 incidents involving clients, following the "Protocol for Completion of Incident Report" identified in 17 Exhibit I, attached hereto and by this reference incorporated herein and made part of this 18 Agreement, or a protocol presented by Contractor that is accepted by County's DBH Director, or 19 designee. 20 Article 13 21 Federal and State Laws 22 13.1 Health Insurance Portability and Accountability Act. County and Contractor each 23 consider and represent themselves as covered entities as defined by the U.S. Health Insurance 24 Portability and Accountability Act of 1996, Public Law 104-191(HIPAA) and agree to use and 25 disclose Protected Health Information (PHI) as required by law. 26 County and Contractor acknowledge that the exchange of PHI between them is only 27 for treatment, payment, and health care operations. 28 29 1 County and Contractor intend to protect the privacy and provide for the security of 2 PHI pursuant to the Agreement in compliance with HIPAA, the Health Information Technology 3 for Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations 4 promulgated thereunder by the U.S. Department of Health and Human Services (HIPAA 5 Regulations) and other applicable laws. 6 As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require 7 Contractor to enter into a contract containing specific requirements prior to the disclosure of 8 PHI, as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e) 9 of the Code of Federal Regulations. 10 13.2 Americans with Disabilities Act. Contractor agrees to ensure that deliverables 11 developed and produced, pursuant to this Agreement, shall comply with the accessibility 12 requirements of Section 508 of the Rehabilitation Act and the Americans with Disabilities Act of 13 1973 as amended (29 U.S.C. § 794 (d)), and regulations implementing that Act as set forth in 14 Part 1194 of Title 36 of the Code of Federal Regulations. In 1998, Congress amended the 15 Rehabilitation Act of 1973 to require Federal agencies to make their electronic and information 16 technology (EIT) accessible to people with disabilities. California Government Code section 17 11135 codifies section 508 of the Act requiring accessibility of electronic and information 18 technology. 19 No officer, agent, or employee of County who exercises any function or responsibility 20 for planning and carrying out the services provided under this Agreement shall have any direct 21 or indirect personal financial interest in this Agreement. In addition, no employee of County 22 shall be employed by Contractor to fulfill any contractual obligations with County. Contractor 23 shall also comply with all Federal, State of California, and local conflict of interest laws, statutes, 24 and regulations, which shall be applicable to all parties and beneficiaries under this Agreement 25 and any officer, agent, or employee of County. 26 13.3 Tax Equity and Fiscal Responsibility Act. To the extent necessary to prevent 27 disallowance of reimbursement under section 1861(v)(1) (I) of the Social Security Act, (42 28 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four (4) years after the furnishing of 30 1 services under this Agreement, Contractor shall make available, upon written request to the 2 Secretary of the United States Department of Health and Human Services, or upon request to 3 the Comptroller General of the United States General Accounting Office, or any of their duly 4 authorized representatives, a copy of this Agreement and such books, documents, and records 5 as are necessary to certify the nature and extent of the costs of these services provided by 6 Contractor under this Agreement. Contractor further agrees that in the event Contractor carries 7 out any of its duties under this Agreement through a subcontract, with a value or cost of Ten 8 Thousand and No/100 Dollars ($10,000.00) or more over a twelve (12) month period, with a 9 related organization, such Agreement shall contain a clause to the effect that until the expiration 10 of four (4) years after the furnishing of such services pursuant to such subcontract, the related 11 organizations shall make available, upon written request to the Secretary of the United States 12 Department of Health and Human Services, or upon request to the Comptroller General of the 13 United States General Accounting Office, or any of their duly authorized representatives, a copy 14 of such subcontract and such books, documents, and records of such organization as are 15 necessary to verify the nature and extent of such costs. 16 13.4 Child Abuse Reporting Act. Contractor shall establish a procedure acceptable to 17 the County's DBH Director, or his or her designee, to ensure that all of the Contractor's 18 employees, consultants, subcontractors, or agents described in the Child Abuse Reporting Act, 19 section 1116 et seq. of the Penal Code, and performing services under this Agreement shall 20 report all known or suspected child abuse or neglect to a child protective agency as defined in 21 Penal Code section 11165.9. This procedure shall include: 22 (A) A requirement that all Contractor's employees, consultants, subcontractors, or 23 agents performing services shall sign a statement that he or she knows of and will 24 comply with the reporting requirements as defined in Penal Code section 11166(a). 25 (B) Establishing procedures to ensure reporting even when employees, consultants, 26 subcontractors, or agents who are not required to report child abuse under Penal Code 27 section 11166(a), gain knowledge of or reasonably suspect that a child has been a 28 victim of abuse or neglect. 31 1 Article 14 2 Cultural and Linguistic Competency 3 14.1 Equal Access. Contractor shall not discriminate against beneficiaries based on race, 4 color, national origin, sex, disability, or religion. Contractor shall ensure that a limited and/or no 5 English beneficiary is entitled to equal access and participation in federally funded programs 6 through the provision of comprehensive and quality bilingual services pursuant to Title 6 of the 7 Civil Rights Act of 1964 (42 U.S.C. Section 2000d, and 45 C.F.R. Part 80) and Executive Order 8 12250 of 1979. 9 14.2 Policies and Procedures. Contractor shall comply with requirements of policies and 10 procedures for ensuring access and appropriate use of trained interpreters and material 11 translation services for all limited and/or no English proficient beneficiaries, including, but not 12 limited to, assessing the cultural and linguistic needs of the beneficiaries, training of staff on the 13 policies and procedures, and monitoring its language assistance program. Contractor's policies 14 and procedures shall ensure compliance of any subcontracted providers with these 15 requirements. 16 14.3 Interpreter Services. Contractor shall notify its beneficiaries that oral interpretation 17 is available for any language and written translation is available in prevalent languages and that 18 auxiliary aids and services are available upon request, at no cost and in a timely manner for 19 limited and/or no English proficient beneficiaries and/or beneficiaries with disabilities. 20 Contractor shall avoid relying on an adult or minor child accompanying the beneficiary to 21 interpret or facilitate communication; however, if the beneficiary refuses language assistance 22 services, the Contractor must document the offer, refusal, and justification in the beneficiary's 23 file. 24 14.4 Interpreter Qualifications. Contractor shall ensure that employees, agents, 25 subcontractors, and/or partners who interpret or translate for a beneficiary or who directly 26 communicate with a beneficiary in a language other than English (1) have completed annual 27 training provided by County at no cost to Contractor; (2) have demonstrated proficiency in the 28 beneficiary's language; (3) can effectively communicate any specialized terms and concepts 32 1 specific to Contractor's services; and (4) adheres to generally accepted interpreter ethic 2 principles. As requested by County, Contractor shall identify all who interpret for or provide 3 direct communication to any program beneficiary in a language other than English and identify 4 when the Contractor last monitored the interpreter for language competence. 5 14.5 CLAS Standards. Contractor shall submit to County for approval, within ninety (90) 6 days from date of contract execution, Contractor's plan to address all fifteen (15) National 7 Standards for Culturally and Linguistically Appropriate Service (CLAS), as published by the 8 Office of Minority Health and as set forth in Exhibit L "National Standards on Culturally and 9 Linguistically Appropriate Services", attached hereto and incorporated herein by reference and 10 made part of this Agreement. As the CLAS standards are updated, Contractor's plan must be 11 updated accordingly. As requested by County, Contractor shall be responsible for conducting 12 an annual CLAS self-assessment and providing the results of the self-assessment to the 13 County. The annual CLAS self-assessment instruments shall be reviewed by the County and 14 revised as necessary to meet the approval of the County. 15 14.6 Training Requirements. Cultural competency training for Contractor staff should be 16 substantively integrated into health professions education and training at all levels, both 17 academically and functionally, including core curriculum, professional licensure, and continuing 18 professional development programs. As requested by County, Contractor shall report on the 19 completion of cultural competency trainings to ensure direct service providers are completing a 20 minimum of eight (8) hours of cultural competency training annually. 21 14.7 Continuing Cultural Competence. Contractor shall create and sustain a forum that 22 includes staff at all agency levels to discuss cultural competence. County encourages a 23 representative from Contractor's forum to attend County's Cultural Humility Committee. 24 Article 15 25 Data Security 26 15.1 Security Requirements. For the purpose of preventing the potential loss, 27 misappropriation or inadvertent access, viewing, use or disclosure of County data including 28 sensitive or personal client information; abuse of County resources; and/or disruption to County 33 1 operations, individuals and/or agencies that enter into a contractual relationship with the County 2 for the purpose of providing services under this Agreement must employ adequate data security 3 measures to protect the confidential information provided to Contractor by the County, including 4 but not limited to the following: 5 (A) Contractor-Owned Mobile, Wireless, or Handheld Devices 6 Contractor may not connect to County networks via personally-owned mobile, 7 wireless, or handheld devices, unless the following conditions are met: 8 (1) Contractor has received authorization by County for telecommuting purposes; 9 (2) Current virus protection software is in place; 10 (3) Mobile device has the remote wipe feature enabled; and 11 (4) A secure connection is used. 12 (B) Contractor-Owned Computers or Computer Peripherals 13 Contractor may not bring Contractor-owned computers or computer peripherals 14 into County for use without prior authorization from the County's Chief Information Officer, 15 and/or designee(s), including but not limited to mobile storage devices. If data is approved to be 16 transferred, data must be stored on a secure server approved by the County and transferred by 17 means of a Virtual Private Network (VPN) connection, or another type of secure connection. 18 Said data must be encrypted. 19 (C) County-Owned Computer Equipment 20 Contractor may not use County computers or computer peripherals on non- 21 County premises without prior authorization from the County's Chief Information Officer, and/or 22 designee(s). 23 (D) Contractor may not store County's private, confidential, or sensitive data on any 24 hard-disk drive, portable storage device, or remote storage installation unless encrypted. 25 (E) Contractor shall be responsible to employ strict controls to ensure the integrity 26 and security of County's confidential information and to prevent unauthorized access, viewing, 27 use or disclosure of data maintained in computer files, program documentation, data processing 28 34 1 systems, data files and data processing equipment which stores or processes County data 2 internally and externally. 3 (F) Confidential client information transmitted to one party by the other by means of 4 electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) 5 of 128 BIT or higher. Additionally, a password or pass phrase must be utilized. 6 (G)Contractor is responsible to immediately notify County of any violations, 7 breaches or potential breaches of security related to County's confidential information, data 8 maintained in computer files, program documentation, data processing systems, data files and 9 data processing equipment which stores or processes County data internally or externally. 10 (H) County shall provide oversight to Contractor's response to all incidents arising 11 from a possible breach of security related to County's confidential client information provided to 12 Contractor. Contractor will be responsible to issue any notification to affected individuals as 13 required by law or as deemed necessary by County in its sole discretion. Contractor will be 14 responsible for all costs incurred as a result of providing the required notification. 15 Article 16 16 Publicity Prohibition 17 16.1 Self-Promotion. None of the funds, materials, property, or services provided directly 18 or indirectly under this Agreement shall be used for Contractor's advertising, fundraising, or 19 publicity (i.e., purchasing of tickets/tables, silent auction donations, etc.) for the purpose of self- 20 promotion. 21 16.2 Public Awareness. Notwithstanding the above, publicity of the services described in 22 Article 1 of this Agreement shall be allowed as necessary to raise public awareness about the 23 availability of such specific services when approved in advance by County's DBH Director or 24 designee and at a cost to be provided in Exhibit B for such items as written/printed materials, 25 the use of media (i.e., radio, television, newspapers), and any other related expense(s). 26 27 28 35 1 Article 17 2 Disclosure of Self-Dealing Transactions 3 17.1 Applicability. This Article 17 applies if the Contractor is operating as a corporation 4 or changes its status to operate as a corporation. 5 17.2 Duty to Disclose. If any member of the Contractor's board of directors is party to a 6 self-dealing transaction, he or she shall disclose the transaction by completing and signing a 7 "Self-Dealing Transaction Disclosure Form" (Exhibit C to this Agreement) and submitting it to 8 the County before commencing the transaction or immediately after. 9 17.3 Definition. "Self-dealing transaction" means a transaction to which the Contractor is 10 a party and in which one or more of its directors, as an individual, has a material financial 11 interest. 12 Article 18 13 Disclosure of Ownership and/or Control Interest Information 14 18.1 Applicability. This provision is only applicable if Contractor is disclosing entities, 15 fiscal agents, or managed care entities, as defined in Code of Federal Regulations (C.F.R.), 16 Title 42 §§ 455.101, 455.104 and 455.106(a)(1),(2). 17 18.2 Duty to Disclose. In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 18 and 455.106(a)(1), (2), the following information must be disclosed by Contractor by completing 19 Exhibit M, "Disclosure of Ownership and Control Interest Statement", attached hereto and by 20 this reference incorporated herein and made part of this Agreement. Contractor shall submit 21 this form to the County's DBH within thirty (30) days of the effective date of this Agreement. 22 Additionally, Contractor shall report any changes to this information within thirty-five (35) days of 23 occurrence by completing Exhibit M. Submissions shall be scanned portable document format 24 (pdf) copies and are to be sent via email to County's DBH assigned Staff Analyst. 25 Contractor is required to submit a set of fingerprints for any person with five (5) percent 26 or greater direct or indirect ownership interest in Contractor. County may terminate this 27 Agreement where any person with five (5) percent or greater direct or indirect ownership interest 28 in the Contractor did not submit timely and accurate information and cooperate with any 36 1 screening method required in CFR, Title 42, Section 455.416. Submissions shall be scanned 2 pdf copies and are to be sent via email to DBHContractedServices@fresnocountyca.gov. 3 County may deny enrollment or terminate this Agreement where any person with five (5) 4 percent or greater direct or indirect ownership interest in Contractor has been convicted of a 5 criminal offense related to that person's involvement with the Medicare, Medicaid, or Title XXI 6 program in the last ten (10) years. 7 Article 19 8 Disclosure of Criminal History and Civil Actions 9 19.1 Applicability. Contractor is required to disclose if any of the following conditions 10 apply to them, their owners, officers, corporate managers, or partners (hereinafter collectively 11 referred to as "Contractor"): 12 (A) Within the three (3) year period preceding the Agreement award, they have been 13 convicted of, or had a civil judgment tendered against them for: 14 (1) Fraud or criminal offense in connection with obtaining, attempting to obtain, 15 or performing a public (federal, state, or local) transaction or contract under a public 16 transaction; 17 (2) Violation of a federal or state antitrust statute; 18 (3) Embezzlement, theft, forgery, bribery, falsification, or destruction of records; 19 or 20 (4) False statements or receipt of stolen property. 21 (B) Within a three (3) year period preceding their Agreement award, they have had a 22 public transaction (federal, state, or local) terminated for cause or default. 23 19.2 Duty to Disclose. Disclosure of the above information will not automatically 24 eliminate Contractor from further business consideration. The information will be considered as 25 part of the determination of whether to continue and/or renew this Agreement and any additional 26 information or explanation that Contractor elects to submit with the disclosed information will be 27 considered. If it is later determined that the Contractor failed to disclose required information, 28 37 1 any contract awarded to such Contractor may be immediately voided and terminated for 2 material failure to comply with the terms and conditions of the award. 3 Contractor must sign a "Certification Regarding Debarment, Suspension, and Other 4 Responsible Matters— Primary Covered Transactions" in the form set forth in Exhibit N attached 5 hereto and by this reference incorporated herein. Additionally, Contractor must immediately 6 advise the County's DBH in writing if, during the term of the Agreement: (1) Contractor becomes 7 suspended, debarred, excluded or ineligible for participation in Federal or State funded 8 programs or from receiving federal funds as listed in the excluded parties list system 9 (http://www.epls.gov); or (2) any of the above listed conditions become applicable to Contractor. 10 Contractor shall indemnify, defend, and hold County harmless for any loss or damage resulting 11 from a conviction, debarment, exclusion, ineligibility, or other matter listed in the signed 12 Certification Regarding Debarment, Suspension, and Other Responsibility Matters. 13 Article 20 14 General Terms 15 20.1 Modification. Any matters of this Agreement may be modified from time to time by 16 the written consent of all the parties without, in any way, affecting the remainder. 17 Notwithstanding the above, changes to services, staffing, and responsibilities of the 18 Contractor, as needed, to accommodate changes in the laws relating to FURS requirements 19 and specialty mental health treatment, may be made with the signed written approval of 20 County's DBH Director, or designee, and Contractor through an amendment approved by 21 County's County Counsel and the County's Auditor-Controller/Treasurer-Tax Collector's Office. 22 In addition, changes to expense category (i.e., Salary & Benefits, 23 Facilities/Equipment, Operating, Financial Services, Special Expenses, Fixed Assets, etc.) 24 subtotals as set forth in Exhibit B, that do not exceed ten percent (10%) of the total annual 25 maximum compensation, changes to the volume of units of services/types of service units to be 26 provided, and changes to service rates as set forth in Exhibit B, may be made with the written 27 approval of County's DBH Director or designee. 28 38 1 Changes to expense category subtotals that exceed ten percent (10%) of the 2 Contractor's total annual maximum compensation may be made with the signed written 3 approval of County's DBH Director, or designee, through an amendment approved by County's 4 County Counsel and County's Auditor-Controller/Treasurer-Tax Collector's Office. 5 Said modifications to budget expense categories, service volume/types of service 6 units, and summary of services shall not result in any change to the maximum compensation 7 amount payable to Contractor, as stated herein. 8 20.2 Non-Assignment. Neither party may assign its rights or delegate its obligations 9 under this Agreement without the prior written consent of the other party. 10 20.3 Governing Law. The laws of the State of California govern all matters arising from 11 or related to this Agreement. 12 20.4 Jurisdiction and Venue. This Agreement is signed and performed in Fresno 13 County, California. Contractor consents to California jurisdiction for actions arising from or 14 related to this Agreement, and, subject to the Government Claims Act, all such actions must be 15 brought and maintained in Fresno County. 16 20.5 Construction. The final form of this Agreement is the result of the parties' combined 17 efforts. If anything in this Agreement is found by a court of competent jurisdiction to be 18 ambiguous, that ambiguity shall not be resolved by construing the terms of this Agreement 19 against either party. 20 20.6 Days. Unless otherwise specified, "days" means calendar days. 21 20.7 Headings. The headings and section titles in this Agreement are for convenience 22 only and are not part of this Agreement. 23 20.8 References to Laws and Rules. In the event any law, regulation, or policy referred 24 to in this Agreement is amended during the term thereof, the parties hereto agree to comply with 25 the amended provision as of the effective date of such amendment. 26 20.9 Severability. If anything in this Agreement is found by a court of competent 27 jurisdiction to be unlawful or otherwise unenforceable, the balance of this Agreement remains in 28 effect, and the parties shall make best efforts to replace the unlawful or unenforceable part of 39 1 this Agreement with lawful and enforceable terms intended to accomplish the parties' original 2 intent. 3 20.10 Nondiscrimination. During the performance of this Agreement, the Contractor shall 4 not unlawfully discriminate against any employee or applicant for employment, or recipient of 5 services, because of race, religious creed, color, national origin, ancestry, physical disability, 6 mental disability, medical condition, genetic information, marital status, sex, gender, gender 7 identity, gender expression, age, sexual orientation, military status or veteran status pursuant to 8 all applicable State of California and federal statutes and regulation. 9 20.11 No Waiver. Payment, waiver, or discharge by the County of any liability or obligation 10 of the Contractor under this Agreement on any one or more occasions is not a waiver of 11 performance of any continuing or other obligation of the Contractor and does not prohibit 12 enforcement by the County of any obligation on any other occasion. 13 20.12 Entire Agreement. This Agreement, including its exhibits, Revised RFP No. 22-038, 14 and Contractor's Response to the RFP, is the entire agreement between the Contractor and the 15 County with respect to the subject matter of this Agreement, and it supersedes all previous 16 negotiations, proposals, commitments, writings, advertisements, publications, and 17 understandings of any nature unless those things are expressly included in this Agreement. If 18 there is any inconsistency between the terms of this Agreement without its exhibits and the 19 terms of the exhibits, then the inconsistency will be resolved by giving precedence first to the 20 terms of this Agreement without its exhibits, and then to the terms of the exhibits. 21 20.13 No Third-Party Beneficiaries. This Agreement does not and is not intended to 22 create any rights or obligations for any person or entity except for the parties. 23 20.14 Authorized Signature. The Contractor represents and warrants to the County that: 24 (A) The Contractor is duly authorized and empowered to sign and perform its 25 obligations under this Agreement. 26 (B) The individual signing this Agreement on behalf of the Contractor is duly 27 authorized to do so and his or her signature on this Agreement legally binds the 28 Contractor to the terms of this Agreement. 40 1 20.15 Electronic Signatures. The parties agree that this Agreement may be executed by 2 electronic signature as provided in this section. 3 (A) An "electronic signature" means any symbol or process intended by an individual 4 signing this Agreement to represent their signature, including but not limited to (1) a 5 digital signature; (2) a faxed version of an original handwritten signature; or (3) an 6 electronically scanned and transmitted (for example by PDF document) version of an 7 original handwritten signature. 8 (B) Each electronic signature affixed or attached to this Agreement (1) is deemed 9 equivalent to a valid original handwritten signature of the person signing this Agreement 10 for all purposes, including but not limited to evidentiary proof in any administrative or 11 judicial proceeding, and (2) has the same force and effect as the valid original 12 handwritten signature of that person. 13 (C)The provisions of this section satisfy the requirements of Civil Code section 14 1633.5, subdivision (b), in the Uniform Electronic Transaction Act (Civil Code, Division 3, 15 Part 2, Title 2.5, beginning with section 1633.1). 16 (D) Each party using a digital signature represents that it has undertaken and 17 satisfied the requirements of Government Code section 16.5, subdivision (a), 18 paragraphs (1) through (5), and agrees that each other party may rely upon that 19 representation. 20 (E) This Agreement is not conditioned upon the parties conducting the transactions 21 under it by electronic means and either party may sign this Agreement with an original 22 handwritten signature. 23 20.16 Counterparts. This Agreement may be signed in counterparts, each of which is an 24 original, and all of which together constitute this Agreement. 25 [SIGNATURE PAGE FOLLOWS] 26 27 28 41 ii DocuSign Envelope ID:A2018629-44D94A74-6961-9AB1E99OE269 1 The parties are signing this Agreement on the date stated in the introductory clause. 2 KINGS VIEW COUNTY OF FRESNO 3 4 rD..S19r%.dt01: ,a"Na&a.x D44-c ■/MI'1� 5 Aman a ivine, Chief Executive Officer Brian Pacheco, Chairman of the Board of Supervisors of the County of Fresno 6 7170 N. Financial Dr. Ste. 110 Fresno, CA 93720 Attest: 7 Bernice E. Seidel Clerk of the Board of Supervisors 8 County of Fresno, State of California 9 By: 10 Deputy 11 For accounting use only: 12 Org No.: 5630 Account No.: 7295 13 Fund No.: 0001 Subclass No.: 10000 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 42 Exhibit A 1 Scope of Services 2 3 ORGANIZATION: Kings View 4 ADDRESS: 7170 N. Financial Dr. Ste. 110 Fresno, CA 93720 5 SITE ADDRESS: 4910 E Ashlan Ave Unit 118, Fresno, CA 93726 6 SERVICES: Family Urgent Response System 7 PROJECT DIRECTOR: Amanda Nugent-Divine, Chief Executive Officer 8 CONTRACT PERIOD: June 1, 2022 — June 30, 2025, with two (2) twelve (12) 9 month renewal options 10 CONTRACT AMOUNT: Fiscal Year Contract Maximum 11 June 2022 $35,318.00 12 FY 2022-23 $429,908.00 13 FY 2023-24 $432,021.00 14 FY 2024-25 $448,519.00 15 FY 2025-26 $449,231.00 16 FY 2026-27 $459,815.00 17 I. Project Description 18 Kings View shall operate a Family Urgent Response System (FURS) to provide mobile 19 responses twenty-four (24) hours a day, seven (7) days per week (24/7) for current and former 20 foster youth, including foster youth currently or formerly involved with the Probation Department. 21 Kings View shall expect to receive a warm handoff from the FURS statewide hotline and provide 22 face-to-face, in-home or in-community supportive services for both urgent and nonurgent calls. 23 Kings View's mobile response team shall be a mobilized coordinated response by the vendor 24 with County's DSS and Probation staff and on behalf of DBH. 25 Kings View's FURS program will operate a culturally competent, person-centered 26 delivery model that will meet the multiple systemic needs of this population in the least 27 restrictive environment. These needs include in-home coaching for individuals, families, and 28 caregivers, as well as coordination between multiple agencies, including mental health A-1 Exhibit A 1 providers, schools, hospitals, courts, probation, and a host of other systems that become 2 involved in the lives of these youth and their families. The services provided by FURS are 3 intended to support the youth and families and foster a trusting and healing environment. 4 II. Target Population 5 Kings View shall provide services to current or former foster children or youth and their 6 caregivers. Referrals from the statewide hotline are based on the location where the face-to- 7 face mobile response is needed, and not based on the county of jurisdiction. 8 "Current or former foster children or youth" is defined to include "a child or youth 9 adjudicated under Section 300, 601, 602, or 727(a) and who is served by a county child welfare 10 agency or probation department, and a child or youth who has exited foster care to reunification, 11 guardianship, or adoption. A current or former foster child or youth shall be eligible for services 12 under this chapter until they attain 21 years of age." There is no time restriction on when an exit 13 must have occurred for a former foster youth. The former foster youth may have been adopted, 14 re unified, or appointed a legal guardian at an early age and can still access FURS. 15 A "caregiver" is defined as "a person responsible for meeting the daily care needs of a 16 current or former foster child or youth, and who is entrusted to provide a loving and supportive 17 environment for the child or youth to promote their healing from trauma." Caregiver is defined 18 broadly and includes individuals beyond a parent who are acting in a caregiving role. 19 III. Location of Services and Hours of Operation 20 FURS is a mobile response system, and Kings View shall provide face-to-face services 21 wherever the current or former foster youth is currently located, within the County of Fresno, 22 including both metro and rural areas. 23 Kings View will provide immediate, in-person support 24 hours per day, 7 days per 24 week. 25 Kings View's required response times are as follows: 26 Urgent Response: Within one (1) hour, but not to exceed three (3) 27 hours (in extenuating circumstances) to calls deemed "Urgent" by the 28 statewide hotline. A-2 Exhibit A 1 Non-Urgent Response: Same-day (or within 24 hours) response. 2 IV. Description of Services 3 The California Department of Social Services (CDSS) operates Cal-FURS, the statewide 4 hotline established to receive the initial call from the caregiver or foster care youth (current or 5 former) in order to effectively engage caregivers and youth who are experiencing instability, 6 including tension or conflict, emotional distress, behavioral difficulties, or other difficulties that 7 may threaten their relationships. Cal-FURS triages all calls received to determine the most 8 appropriate response for the family and situation. Operators are trained to provide immediate 9 assistance over the phone to help defuse conflict and to provide focused engagement and 10 assessment. When it is determined that an immediate, in-person response is required, hotline 11 staff immediately routes the call to the relevant County, based on the location where the face-to- 12 face mobile response services are needed. Kings View will receive said calls on behalf of the 13 County. 14 If in-person support is warranted, the Cal-FURS hotline worker will seek to engage each 15 caller to establish a direct and live connection through a three-way call that includes the hotline 16 worker, caregiver and/or youth, and Kings View in order to conduct a "warm handoff" to the 17 County's FURS Mobile Response Team. The warm handoff allows for the transfer of information 18 between the CDSS statewide hotline and the County's Mobile Response Team without requiring 19 the family to repeat information or undergo a second triage process. 20 Kings View will incorporate DSS into the call for additional information required from the 21 Child Welfare System/Case Management System (CWS/CMS), as appropriate. If the foster 22 youth is currently or was involved with Probation, then Kings View will incorporate County's 23 Probation Department into the phone call. Once all necessary information is obtained, Kings 24 View will deploy their FURS Mobile Response Team to provide the youth, caregiver, and family 25 with immediate support in an effort to stabilize the situation and prevent placement disruption. 26 This support will ultimately improve overall placement stability and help reduce some of the 27 negative short- and long-term effects from placement disruptions in foster care. 28 A-3 Exhibit A 1 During the warm handoff, Cal-FURS hotline staff will remain on the line with Kings View 2 until it is clinically appropriate to complete the process of transferring the call. During the warm 3 handoff, the Cal-FURS hotline staff will ensure that there is a supportive handoff that supports 4 the youth and/or caregiver throughout the entire process. Youth and family voice and choice 5 shall be honored and respected throughout this process to provide individualized support. 6 Additionally, the Cal-FURS hotline staff will confirm that there is a clear plan to provide in- 7 person support, including arrangements for location and expected timeline. 8 If a direct three-way communication cannot be established, the Cal-FURS hotline worker 9 will make a referral directly to the County-based service and a follow-up call to ensure that a 10 connection to the caregiver or youth occurs. 11 When the call involves a child or youth who is a member of an Indian Tribe, a Tribal 12 Agency or other identified service provider may be an appropriate support. Additionally, an 13 involved Foster Family Agency (FFA) may be an appropriate support if it provides case 14 management, conflict resolution and support to their resource parents. 15 Kings View should utilize the information provided by the Cal-FURS statewide hotline 16 during the warm handoff to determine how to respond, which County Department(s) will need to 17 be involved, and the timeframe required for the response (i.e., urgent or non-urgent response). 18 Kings View's FURS Mobile Response Team may provide services such as de- 19 escalation, crisis stabilization, and/or reconnection to social services or mental health services. 20 In addition to providing trauma-informed, in-person support, Kings View's FURS Mobile 21 Response Team will be expected to provide the family with a plan of action to address identified 22 additional support or ongoing stabilization needs and connect them to needed ongoing services 23 through the existing local network of care service systems. 24 A. Kings View's responsibilities include the following: 25 i. Receive live phone responses from the Cal-FURS statewide hotline that 26 facilitates entry of the caregivers and current or former foster youth into 27 mobile response services; 28 A-4 Exhibit A 1 ii. Establish a process for determining which County Department(s), if any, will 2 respond with Kings View's FURS Mobile Response Team, as appropriate; 3 iii. Kings View's FURS Mobile Response Team shall be available 24/7 and able 4 to provide an immediate, in-person, face-to-face response preferably within 5 one (1) hour, but not to exceed three (3) hours in extenuating circumstances 6 for urgent needs, or same-day response within twenty-four (24) hours for 7 non-urgent situations; 8 iv. Utilization of Mobile Response Team staff with specialized training in trauma 9 of children or youth and the foster care system; 10 V. Provision of in-home/community de-escalation, stabilization, and support 11 services, including all of the following: 12 1. Establishing in-person, face-to-face contact with the child or youth and 13 caregiver; 14 2. Identifying the underlying causes of, and precursors to, the situation that 15 led to the instability; 16 3. Identifying the caregiver interventions attempted; 17 4. Observing the child or youth and caregiver interaction; 18 5. Diffusing the immediate situation; 19 6. Coaching and working with the caregiver and the child or youth in order to 20 preserve the family unit and maintain the current living situation or create 21 a healthy transition plan, if necessary; 22 7. Establishing connections to other counties, or community-based supports 23 and services, to ensure continuity of care, including, but not limited to, 24 linkage to additional trauma-informed and culturally and linguistically 25 responsive family supportive services and youth and family wellness 26 resources; 27 28 A-5 Exhibit A 1 8. Following up within twenty-four (24) hours after the initial face-to-face 2 mobile response to determine if additional supports or services are 3 needed; and 4 9. Identifying any additional support or ongoing stabilization needs for the 5 family and developing a plan for, or referral to, appropriate youth and 6 family supportive services within the County. Supportive services may 7 also be available through community-based organizations, foster family 8 agencies, or tribal agencies. 9 B. The scope of the Fresno County FURS program does not currently include delegated 10 authority for clinical staff to write an involuntary hold and the DBH reserves the right 11 to reevaluate that element during the course of the contract term as the Department 12 continuously evaluates the crisis care continuum across our network, emerging 13 statewide FURS best practices, and other elements impacting this program. 14 C. Twenty-four (24) hours after the initial call and referral, the Cal-FURS hotline worker 15 will contact the caregiver and the child or youth to offer additional support, if needed. 16 After this follow-up call to the youth and/or caregiver, if there is an open case at the 17 time of the FURS call, Kings View will initiate a warm handoff of the case back to the 18 appropriate County department. 19 D. On-Going Services: 20 Ongoing supportive face-to-face services provided by Kings View include, but are 21 not limited to: 22 i. Motivational Interviewing and Positive Psychology; 23 ii. Harm Reduction; 24 iii. Development of healthy conflict resolution skills; 25 iv. Relationships/social skills; 26 V. Stabilization of a crisis situation; 27 vi. Trauma-informed care; 28 vii. Development of a plan of action with family input; A-6 Exhibit A 1 viii. Identification of additional services needed and assistance with linkage and 2 overcoming barriers; and 3 ix. Assessment of safety, potential for a psychiatric hold, and coordination with 4 related providers (e.g. County's Crisis Stabilization Center). 5 V. Staffing 6 Kings View shall staff its FURS Mobile Response Team with individuals with specialized 7 training in trauma-informed care of children or youth in the foster care system. 8 Due to the acuity level of a crisis response, clinical staff should be comprised of licensed 9 clinicians or associate mental health clinicians with targeted training for the program design. 10 Kings View shall ensure staff are qualified in education, experience, and clinical competencies. 11 Kings View shall make efforts to include peer partners and those with lived experience in 12 its FURS program, whenever possible. 13 It is also highly encouraged that Kings View seeks to hire bilingual staff who are fluent or 14 proficient in the threshold languages of Fresno County: Spanish and Hmong. 15 VI. Training 16 Once qualified staff members are hired, Kings View shall provide extensive training in 17 the population being served, the multi-systemic collaboration that is expected, and in the 18 specific psychoeducational modality that is employed. All staff are expected to participate in all 19 of the training provided in the FURS model. Training will include information on crisis 20 prevention, calming children in crisis, trauma-informed practices, in-home coaching, and 21 provider support. 22 A. Kings View's staff must receive the typical County-required training for Medi-Cal site 23 certified/credentialed staff. 24 B. Kings View must also provide trauma informed care and conflict resolution training to 25 all staff on its FURS Mobile Response Team. 26 C. Kings View will be required to develop and submit a training plan for all FURS Mobile 27 Response Team staff. The training plan should include hours of training for new staff 28 A-7 Exhibit A 1 as well as ongoing training for existing staff. The detailed training plan for FURS staff 2 should include topics important to the program scope such as: 3 i. Child Welfare/Probation Overview (including a review of Foster Youth 4 Rights). 5 ii. De-escalation, crisis intervention and conflict resolution. 6 iii. Trauma-Informed Care and the impact of trauma on child and youth 7 development and behavior. 8 iv. Short-term intervention strategies. 9 v. Principles of behavior management/modification. 10 vi. Sexual Orientation and Gender Identity and Expression (SOGIE). 11 vii. Healthy Parenting Skills and Positive Discipline Coaching. 12 viii. Healthy Coping Skills. 13 ix. Mandated Reporter Training. 14 x. Suicide Prevention. 15 xi. Secondary Trauma. 16 VII. Data Collection and Data Elements 17 A. Data Collection 18 Kings View must establish protocols for data collection including, but not limited to: 19 i. Data collection efforts to track all incoming calls (including all Data Elements 20 listed below) as well as the number of individuals with follow up case 21 management needs (including length of time that Kings View provides service 22 to each individual); 23 ii. Transitions from mobile response and stabilization services to ongoing 24 services; 25 iii. A process for identifying if the child or youth has an existing child and family 26 team so that efforts can be coordinated to address the instability, and a plan 27 can be made for ongoing care to support that relationship in a trusting and 28 healing environment; A-8 Exhibit A 1 iv. A process and criteria for determining mobile response; 2 v. The composition of the staff on the FURS Mobile Response Team, including 3 efforts to include peer partners and those with lived experience in the 4 response team, whenever possible; 5 vi. Both existing and new services that will be used to support the mobile 6 response and stabilization services; 7 vii. Response protocols for the child or youth in family-based and congregate 8 care settings based on guidelines developed by California Department of 9 Social Services (CDSS), in consultation with stakeholders. The response 10 protocols shall ensure protections for children and youth to minimize use of 11 congregate care settings, psychiatric institutions, and hospital settings; 12 viii.A process for identifying whether the child or youth has an existing mental 13 health treatment plan and a placement preservation strategy through Child 14 Welfare or Probation, and for coordinating response and services consistent 15 with the plan and strategy; and 16 ix. A plan for the mobile response and stabilization team to provide supportive 17 services in the least intrusive and most child, youth, and family friendly 18 manner, such that Mobile Response and Stabilization Teams do not trigger 19 further trauma to the child or youth. 20 B. Data Elements 21 Kings View must track the following data elements, as required by CDSS, and 22 submitted to DBH, on a monthly basis (or a frequency as established by DBH). 23 Kings View must abide by all then-enacted requirements. 24 i. CWS/CMS client identifier 25 ii. FURS youth identifier (for all children/youth, including those with no 26 CWS/CMS client identifier) 27 iii. Status of youth as current or former foster youth, including foster youth 28 currently or formerly involved with the Probation Department A-9 Exhibit A 1 iv. First name of youth 2 v. Last name of youth 3 vi. Date of birth of youth 4 vii. Gender of youth (values as defined by CDSS) 5 viii. Race/Ethnicity of youth (values as defined by CDSS) 6 ix. Date of call/response 7 x. Call initiated by caregiver or youth 8 xi. Incident type 9 Vill. Medical Records 10 Kings View shall maintain records in accordance with Exhibit F, "Documentation 11 Standards for Client Records." During site visits, County shall be allowed to review records of 12 services provided. 13 Kings View will be responsible for "release of information" requests and shall adhere to 14 applicable federal and state regulations. 15 IX. Utilization Review, Billing and Cost Report 16 Kings View shall enter all mental health data and billing information into the County's 17 electronic information system and will be responsible for any and all audit exceptions pertaining 18 to the delivery of services. 19 Kings View shall ensure that cost reports are prepared in accordance with General 20 Accepted Accounting Principles (GAAP) and the standards set forth by the DHCS and the 21 County. 22 X. Grievances and Incident Reports 23 Kings View shall follow the process of submitting all grievance and incident reports to the 24 DBH, per Exhibit H, "Fresno County Mental Health Plan Grievances and Incident Reporting." 25 Kings View shall have all grievance forms readily available for clients and their families. 26 Kings View shall log all grievances and the disposition of all grievances received from a client or 27 a client's family in accordance with the Fresno County Mental Health Plan (FCMHP) policies 28 and procedures as indicated within Exhibit G. Kings View shall provide a summary of the A-10 Exhibit A 1 grievance log entries concerning County-sponsored clients to the DBH Director, or designee, at 2 monthly intervals, by the fifteenth (15th) day of the following month, in a format that is mutually 3 agreed upon. Kings View shall post signs, provided by the County, informing clients of their right 4 to file a grievance and appeal. 5 Kings View shall submit all incident reports to the DBH within 24 hours of incident 6 occurrence. If not all of the information regarding the incident has been obtained, Kings View 7 shall complete the report as thoroughly as possible and update the DBH, once all information 8 has been obtained. The DBH shall follow-up with Kings View regarding outstanding questions 9 or issues, if Kings View has not provided an update in a timely manner. 10 Within fifteen (15) days after each grievance or incident affecting County-sponsored 11 clients, Kings View shall provide County with the complaint and Kings View's disposition of, or 12 corrective action taken, to resolve the complaint or incident. 13 XI. Administrative Meetings 14 Kings View shall participate in administrative meetings with the County, including but not 15 limited to: 16 A. Periodic workgroup meetings scheduled by staff from County's DBH Mental Health 17 Contracted Services Division and including the currently assigned DSS Staff 18 Analyst(s). The meetings shall be held monthly, or as needed, to discuss contract 19 requirements, data reporting, outcomes measurement, training, policies and 20 procedures, and overall program operations. 21 B. Regularly scheduled monthly Behavioral Health Board meetings. An administrative 22 level representative who is duly authorized to act on behalf of Kings View, shall 23 attend this meeting. 24 C. Quarterly or periodic DBH Contractor/Provider Meetings, as scheduled by staff from 25 County's Mental Health Contracted Services Division. 26 Kings View may also be asked to make presentations in the community about the 27 program and services that are available. 28 XII. Cultural Competency A-11 Exhibit A 1 In alignment with the County's Mental Health Plan and Cultural Competency Plan, Kings 2 View shall provide culturally competent and culturally responsive services. Kings View's 3 responsibilities include: 4 A. Ensure compliance with Title 6 of the Civil Rights Act of 1964 (42 U.S.C. Section 5 2000d, and 45 C.F.R. Part 80) and Executive Order 12250 of 1979 which prohibits 6 recipients of federal financial assistance from discriminating against persons based 7 on race, color, national origin, sex, disability or religion. This is interpreted to mean 8 that a limited English proficient (LEP) individual is entitled to equal access and 9 participation in federally funded programs through the provision of comprehensive 10 and quality bilingual services. 11 B. Create and maintain policies and procedures for ensuring access and appropriate 12 use of trained interpreters and material translation services for all LEP clients, 13 including, but not limited to, assessing the cultural and linguistic needs of its clients, 14 training of staff on the policies and procedures, and monitoring its language 15 assistance program. Kings View's procedures must include ensuring compliance of 16 any subcontracted providers with these requirements. 17 C. Ensure that minors shall not be used as interpreters. 18 D. Conduct and submit to County an annual cultural and linguistic needs assessment to 19 promote the provision and utilization of appropriate services for its diverse client 20 population. The needs assessment report shall include findings and a plan outlining 21 the proposed services to be improved or implemented as a result of the assessment 22 findings, with special attention to addressing cultural and linguistic barriers and 23 reducing racial, ethnic, language, abilities, gender, and age disparities. 24 E. Develop internal systems to meet the cultural and linguistic needs of Kings View's 25 client census including the incorporation of cultural competency in Kings View's 26 mission; establishing and maintaining a process to evaluate and determine the need 27 for special -- administrative, clinical, welcoming, billing, etc. -- initiatives related to 28 cultural competency. A-12 Exhibit A 1 F. Develop recruitment and retention initiatives to establish contracted program staffing 2 that is reflective and responsive to the needs of the program and target population. 3 G. Establish designated staff person to coordinate and facilitate the integration of 4 cultural competency guidelines and attend County's DBH Cultural Diversity 5 Committee scheduled meetings. The designated person will provide an array of 6 communication tools to distribute information to staff relating to cultural competency 7 issues. 8 H. Keep abreast of evidence-based and best practices in cultural competency in mental 9 health care and treatment to ensure that Kings View maintains current information 10 and an external perspective in its policies. Kings View shall evaluate the 11 effectiveness of strategies and programs in improving the health status of cultural- 12 defined populations. 13 I. Ensure that an assessment of a client's sexual orientation is included in the 14 biopsychosocial intake process. Kings View's staff shall assume that the population 15 served may not be in heterosexual relationships. Sensitivity to gender and sexual 16 orientation must be covered in annual training. 17 J. Utilize existing community supports, referrals to transgender support groups, etc., 18 when appropriate. 19 K. Attend annual Cultural Competence, Compliance, Health Insurance Portability and 20 Accountability Act (HIPAA), and Billing and Documentation training provided by 21 County's DBH. 22 L. Report its efforts to evaluate cultural and linguistic activities as part of Kings View's 23 ongoing quality improvement efforts in the monthly activities report. Reported 24 information may include clients' complaints and grievances, any resulting actions 25 regarding complaints and grievances, results from client satisfaction surveys, and 26 utilization and other clinical data that may reveal health disparities that are a result of 27 cultural and linguistic barriers. 28 XIII. Performance Measures A-13 Exhibit A 1 Kings View will adhere to the outcome measures identified by SB 80, any additional 2 measures developed by County, and any requirements established by the CDSS and the 3 DHCS. County may adjust these outcome measurements, periodically, so as to best measure 4 the success of the program. These outcome measurements and indicators will continue to be 5 developed in conjunction with Kings View, County, and the State Departments. 6 Kings View will be required to submit measurable outcomes on a semi-annual basis, as 7 identified in the DBH Policy and Procedure Guide (PPG) 1.2.7 "Performance Outcomes 8 Measures", attached at the end of this Exhibit A. Performance outcome measures must be 9 approved by DBH and satisfy all State and local mandates. DBH will provide technical 10 assistance and support in defining measurable outcomes. All performance indicators will reflect 11 the four (4) domains identified by the Commission Accreditation of Rehabilitation Facilities 12 (CARF). The domains, Effectiveness, Efficiency, Access, and Satisfaction, as well as Kings 13 View's selected outcome measurements and indicators are listed below. 14 Effectiveness 15 A. Emergency Services Involvement 16 i. Objective: Prevent the need for a 911 call or law enforcement 17 involvement to avoid criminalization of traumatized youth 18 ii. Goal: 30% or less of calls will result in the need to contact 911 19 iii. Methodology: Total number of calls resulting in Family Urgent Responder 20 contacting 911 or law enforcement divided by the total number of calls 21 iv. Timeline: Each fiscal year 22 v. Tool: Medical record report from FURS team 23 B. Preventing Psychiatric Hospitalization and Placement into Congregate Care 24 i. Objective: Prevent the need to request 5150 evaluation and subsequent 25 admittance to psychiatric hospital and/or placement change to congregate 26 care setting with the proposed protocols 27 ii. Goal: 30% or less of calls will result in 5150 evaluation or placement 28 change into congregate care setting A-14 Exhibit A 1 iii. Methodology: Total number of calls resulting in Family Urgent Responder 2 contacting emergency services for 5150 evaluation or placement changes 3 to congregate care settings divided by the total number of calls 4 iv. Timeline: Each fiscal year 5 v. Tool: Medical record report from FURS team 6 C. Prevent Placement Disruptions 7 i. Objective: Preserve relationships between child/youth and their caregiver 8 ii. Goal: 30% or less of calls will result in the need to disrupt placement 9 iii. Methodology: Total number of calls resulting in placement changes of any 10 kind divided by the number of total calls 11 iv. Timeline: Each fiscal year 12 v. Tool: Medical record report from FURS team 13 D. Process for Determining Mobile Response Criteria 14 i. Objective: Kings View FURS will institute an evidence-based practice, 15 once agreed upon by the respective Fresno County Departments, that will 16 include the Columbia Suicide Severity Rating Scale (C-SSRS) 17 ii. Goal: 100% of calls will include utilization of the C-SSRS, or another 18 evidence-based process and criteria that is approved by Fresno County 19 iii. Methodology: Track each number of calls using this tool and including a 20 copy of this in coordination efforts with treatment providers 21 iv. Timeline: Tracked in aggregate each fiscal year 22 v. Tool: Columbia Suicide Severity Scale 23 E. A process for identifying whether the child or youth has an existing mental health 24 treatment plan and a placement preservation strategy through Child Welfare or 25 Probation, and for coordinating response and services consistent with the plan 26 and strategy 27 i. Objective: Kings View FURS will make concerted efforts to contact 28 existing behavioral health, child welfare, probation, and/or other child- A-15 Exhibit A 1 serving system professionals and request a copy of any plan and 2 coordinate care with the child-serving system(s) 3 ii. Goal: Kings View FURS staff will confirm child welfare or probation 4 services involvement for 100% of callers 5 iii. Methodology: Kings View will collaborate with co-responder to confirm 6 current status and identity appropriate personnel from whom to request 7 case files 8 iv. Timeline: Tracked in aggregate each fiscal year 9 v. Tool: Kings View will create a tracking log to support this 10 Efficiency 11 A. Transitions from mobile response and stabilization services to ongoing services 12 i. Objective: Assuring closed-loop referral occurs and individuals are 13 connected or reconnected to behavioral health services, including length 14 of time that Kings View provides services to each individual and the total 15 number receiving postcrisis coordination 16 ii. Goal: 100% of post crisis coordination will result in confirmation that a 17 treating provider will deliver ongoing services with a caller 18 iii. Methodology: Total number of successful post crisis coordination efforts 19 divided by the number of callers 20 iv. Timeline: Each fiscal year 21 v. Tool: The FURS team contacts receiving provider and confirms both 22 scheduling and attendance of first appointments. 23 B. Cost per caller 24 i. Objective: To efficiency utilize financial resources to assure services are 25 available to as many beneficiaries as possible 26 ii. Goal: First fiscal year will establish baseline and subsequent fiscal years 27 will demonstrate no less than a 10% improvement due to limited historical 28 data A-16 Exhibit A 1 iii. Methodology: Total numbers of dollars expended divided by the total 2 number of callers served 3 iv. Timeline: Each fiscal year 4 v. Tool: Financial reporting and auditing track by Kings View 5 C. FURS Team Composition 6 i. Objective: Include Family Partner staff in mobile responses as often as 7 practicably possible 8 ii. Goal: 70% of mobile responses will include the community-based of the 9 Family Partner 10 iii. Methodology: Total number of mobile responses that include the Family 11 Partner divided by the total number of mobile responses 12 iv. Timeline: Each fiscal year with the first fiscal year of operation serving as 13 a baseline for subsequent fiscal years 14 v. Tool: Tracking service activities to which the Family Partner responds 15 D. Service Types for Mobile Responses 16 i. Objective: Make available reimbursable Medi-Cal specialty mental health 17 services to each child or youth accessing FURS services 18 ii. Goal: 95% or more of mobile responses will include a claimable specialty 19 mental health service 20 iii. Methodology: Total number of claims for unique beneficiaries divided by 21 the number of unique beneficiaries 22 iv. Timeline: Each fiscal year 23 v. Tool: Leverage claim data for unique individuals in electronic medical 24 record 25 Access 26 A. Timely Responses (Urgent) 27 i. Objective: Assure that each caller receives care as soon as possible to 28 prevent escalation in the least intrusive manner possible that is child, A-17 Exhibit A 1 youth, and family friendly such that mobile responses do not trigger 2 further trauma 3 ii. Goal: 100% of urgent mobile responses will be achieved in under one (1) 4 but no less than three (3) hours 5 iii. Methodology: FURS staff will track the call time, end time, and length of 6 travel time to arrive on scene. Total number of minutes will be compared 7 to goal.100% of responses will meet the target goal 8 iv. Timeline: Each fiscal year 9 v. Tool: Cross referencing cellular telephone tracking data, and co-response 10 time as recorded by Kings View FURS team 11 B. Timely Responses (Non-Urgent) 12 i. Objective: Assure that each caller receives care as soon as possible to 13 prevent escalation in the least intrusive manner possible that is child, 14 youth, and family friendly such that mobile responses do not trigger 15 further trauma 16 ii. Goal: 100% of non-urgent mobile response will be achieved the same day 17 or within 24 hours 18 iii. Methodology: FURS staff will track the call time, end time, and length of 19 time to arrive on scene. Total number of minutes will be compared to 20 goal. 100% of responses will meet the target goal 21 iv. Timeline: Each fiscal year 22 v. Tool: Cross referencing cellular telephone tracking data and co-response 23 day &time as recorded by Kings View 24 C. Identifying if the child or youth has an existing child and family team so that 25 efforts can be coordinated to address the instability, and a plan can be made for 26 ongoing care to support that relationship in a trusting, healing environment 27 i. Objective: To provide comprehensive care coordination and collaboration 28 with system partners A-18 Exhibit A 1 ii. Goal: FURS team members will attend 100% of Child and Family 2 Teaming meetings and exchange pertinent information 3 iii. Methodology: The total number of attendances to Child and Family Team 4 meetings divided by the number of invitations 5 iv. Timeline: Each fiscal year 6 v. Tool: FURS team members will track the number of care coordination 7 attempts county departments, foster family agencies, or other child- 8 serving systems/programs request FURS team presence, or FURS team 9 shall initiate calls. These will be tracked and reported 10 D. Service Availability Independent of Payor Status 11 i. Objective: Ensure FURS services are available and provided regardless 12 of ability to pay 13 ii. Goal: 100% of individuals requesting services will receive them 14 iii. Methodology: Kings View will respond to all calls response status and 15 divided the number of responded by the total number of callers 16 iv. Timeline: Each fiscal year, or monthly as necessary 17 v. Tool: Kings View FURS will track calls and call type 18 Satisfaction 19 A. Stakeholder Satisfaction — Services Provided 20 i. Objective: Assure that behavioral health, child welfare, and probation staff 21 are satisfied with the quality of care delivered by the Kings View FURS 22 program 23 ii. Goal: 80% of stakeholders will report either strongly agree or agree that 24 services provided were useful, reliable, and of high quality 25 iii. Methodology: Kings View will issue satisfaction surveys 26 iv. Timeline: Each fiscal year, or quarterly if declining 27 v. Tool: Quantitative measurement tool developed by Kings View quality 28 improvement team A-19 Exhibit A 1 B. Stakeholder Satisfaction — Recommend Family Urgent Responder 2 i. Objective: Assure that behavioral health, social workers, and probation 3 staff are satisfied with the effectiveness of FURS team staff 4 ii. Goal: 80% of stakeholders will report either strongly agree or agree that 5 they would recommend Kings View FURS staff 6 iii. Methodology: Kings View will issue satisfaction surveys 7 iv. Timeline: Each fiscal year, or quarterly if declining 8 v. Tool: Quantitative measurement tool developed by Kings View quality 9 improvement team 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 A-20 coU,y,.� Department of 0� 185 Behavioral Health FRE`' PPG 1.2.7 V#: 1 Section: Administration, DBH Policies & Procedures Effective Date: 05/31/2017 Policy Title: Performance Outcome Measures Approved by: Dawan Utecht (Director of Behavioral Health), Francisco Escobedo (Managed Care Coordinator), Kannika Toonnachat (Division Manager) POLICY: It is the policy of Fresno County Department of Behavioral Health and the Fresno County Mental Health Plan (FCMHP) to ensure procedures for developing performance measures which accurately reflect vital areas of performance and provide for systematic, ongoing collection and analysis of valid and reliable data. Data collection is not intended to be an additional task for FCMHP programs/providers but rather embedded within the various non-treatment, treatment and clinical documentation. PURPOSE: To determine the effectiveness and efficiency of services provided by measuring performance outcomes/results achieved by the persons served during service delivery or following service completion, delivery of service, and of the individuals' satisfaction. This is a vital management tool used to clarify goals, document the efforts toward achieving those goals, and thus measure the benefit the service delivery to the persons served. Performance measurement selection is part of the planning and developing process design of the program. Performance measurement is the ongoing monitoring and reporting of progress towards pre-established objectives/goals. REFERENCE: California Code of Regulations, Title 9, Chapter 11, Section 1810.380(a)(1): State Oversight DHCS Service, Administrative and Operational Requirements Mental Health Services Act (MHSA), California Code of Regulations, Title 9, Section 3320, 3200.050, and 3200.120 Commission on Accreditation of Rehabilitation Facilities (CARF) DEFINITIONS: 1. Indicator: Qualitative or quantitative measure(s) that tell if the outcomes have been accomplished. Indicators evaluate key performance in relation to objectives. It indicates what the program is accomplishing and if the anticipated results are being achieved. 2. Intervention: A systematic plan of action consciously adapted in an attempt to address and reduce the causes of failure or need to improve upon system. MISSION STATEMENT The Department of Behavioral Health is dedicated to supporting the wellness of individuals,families and communities in Fresno County who are affected by,or are at risk of,mental illness and/or substance use disorders through cultivation of strengths toward promoting recovery in the least restrictive environment. Template Review Date 3128116 11 Section:Administration, DBH Policies& Procedures ' Co CoU Revised Date:05/31/2017 Department of o� 18560 Behavioral Health FR�S� PPG 1.2.7 V#: 1 Policy Title: Performance Outcome Measures 3. Fresno County Mental Health Plan (FCMHP): Fresno County's contract with the State Department of Health and Human Services that allows for the provision of specialty mental health services. Services may be delivered by county-operated programs, contracted organizational, or group providers. 4. Objective (Goal): Intended results or the impact of learning, programs, or activities. 5. Outcomes: Specific results or changes achieved as a consequence of the program or intervention. Outcomes are connected to the objectives/goals identified by the program or intervention. PROCEDURE: I. Each FCMHP program/provider shall engage in measurement of outcomes in order to generate reliable and valid data on the effectiveness and efficiency of programs or interventions. Programs/providers will establish/select objectives (goals), decide on a methodology and timeline for the collection of data, and use an appropriate data collection tool. This occurs during the program planning and development process. Outcomes should be in alignment with the program/provider goals. II. Outcomes should be measureable, obtainable, clear, accurately reflect the expected result, and include specific time frames. Once the measures have been selected, it is necessary to design a way to gather the information. For each service delivery performance indicator, FCMHP program/provider shall determine: to whom the indicator will be applied; who is responsible for collecting the data; the tool from which data will be collected; and a performance target based on an industry benchmark, or a benchmark set by the program/provider. III. Performance measures are subject to review and approval by FCMHP Administration. IV. Performance measurement is the ongoing monitoring and reporting of progress towards pre-established objectives/goals. Annually, each FCMHP program/provider must measure service delivery performance in each of the areas/domains listed below. Dependent on the program/provider service deliverables, exceptions must be approved by the FCMHP Administration. a. Effectiveness of services — How well programs performed and the results achieved. Effectiveness measures address the quality of care through measuring change over time. Examples include but are not limited to: reduction 2 1 P a g e Section:Administration, DBH Policies& Procedures cot Revised Date:05/31/2017 , Department of o� 1856 Behavioral Health PPG 1.2.7 V#: 1 Policy Title: Performance Outcome Measures of hospitalization, reduction of symptoms, employment and housing status, and reduction of recidivism rate and incidence of relapse. b. Efficiency of services — The relationship between the 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. Services access — Changes or improvements in the program/provider's capacity and timeliness to provide services to those who request 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 persons served and stakeholders— 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: did the organization/program focus on the recovery of the person served, were grievances or concerns addressed, overall feelings of satisfaction, and satisfaction with physical facilities, fees, access, service effectiveness, and efficiency. V. Each FCMHP program/provider shall use the following templates to document the defined goals, intervention(s), specific indicators, and outcomes. 1. FCMHP Outcome Report template (see Attachment A) 2. FCMHP Outcome Analysis template (see Attachment C) 3 1 P a g e FRESNO COUNTY MENTAL HEALTH PLAN OUTCOMES REPORT- Attachment A PROGRAM INFORMATION: I Program Title: Click here to enter text. Provider: Click here to enter text. Program Description: Click here to enter text. MHP Work Plan: Choose an item. Choose an item. Choose an item. Age Group Served 1: ADULT Dates Of Operation: Click here to enter text. Age Group Served 2: Choose an item. Reporting Period: Choose an item. Funding Source 1: Choose an item. Funding Source 3: Choose an item. Funding Source 2: Choose an item. Other Funding: Click here to enter text. FISCAL INFORMATION: Program Budget Amount: Click here to enter text. Program Actual Amount: 0 Number of Unique Clients Served During Time Period: 0 Number of Services Rendered During Time Period: Click here to enter text. Actual Cost Per Client: CONTRACT INFORMATION: A&M Program Type: Type of Program: Contract Term: Click here to enter text. For Other: Click here to enter text. Renewal Date: Click here to enter text. Level of Care Information Age 18&Over: Choose an item. Level of Care Information Age 0- 17: Choose an item. TARGET POPULATION INFORMATION: Target Population: Click here to enter text. Revised March 2017 FRESNO COUNTY MENTAL HEALTH PLAN OUTCOMES REPORT- Attachment A CORE CONCEPTS: • Community collaboration: individuals,families, agencies, and businesses work together to accomplish a shared vision. • Cultural competence: adopting behaviors, attitudes and policies that enable providers to work effectively in cross-cultural situations. • Individual/Family-Driven,Wellness/Recovery/Resiliency-Focused Services: adult clients and families of children and youth identify needs and preferences that result in the most effective services and supports. •Access to underserved communities: Historically unserved and underserved communities are those groups that either have documented low levels of access and/or use of mental health services,face barriers to participation in the policy making process in public mental health, have low rates of insurance coverage for mental health care, and/or have been identified as priorities for mental health services. •Integrated service experiences: services for clients and families are seamless. Clients and families do not have to negotiate with multiple agencies and funding sources to meet their needs. Please select core concepts embedded in services/program: p, y'."",,,,,,< <. Please describe how the selected concept (s) embedded Choose an item. Click here to enter text. Choose an item. Choose an item. Choose an item. PROGRAM OUTCOME&GOALS - Must include each of these areas/domains: (1) Effectiveness, (2) Efficiency, (3)Access, (4)Satisfaction&Feedback Of Persons Served &Stakeholder - Include the following components for documenting each goal: (1) Indicator, (2)Who Applied, (3)Time of Measure, (4) Data Source, (5)Target Goal Expectancy Click here to enter tPut. DEPARTMENT RECOMMENDATION(S): Click here to enter text Revised March 2017 FRESNO COUNTY MENTAL HEALTH PLAN Outcomes Analysis Attachment C Name of Program: Click here to enter text. What is the Program/Contract Goals? Click here to enter text. Program Type: Type of Program: Other, please specify below Other: Click here to enter text. CLINICAL INFORMATION: Does the Program Utilize Any of the Following? (May select more than one) Evidence Informed Practice Best Practice Evidence Based Practice Other: Click here to enter text. Please Describe: Click here to enter text. OUTCOMES What Outcome Measures Are Being Used? Click here to enter text. What Outcome Measures/Functional Variables Could Be Added to Better Explain the Program's Effectiveness? Click here to enter text. Describe the Program's analysis(i.e. have the program/contract goals been met? Number served, waiting list, wait times, budget to volume, etc.): Click here to enter text. What Barriers Prevent the Program from Achieving Better Outcomes? Click here to enter text. What Changes to the Program Would You Recommend to Improve the outcomes? Click here to enter text. For Committee Use Only: Recommendations: do include a conclusion and a to-do list with action items Click here to enter text. Exhibit B Kings View Family Urgent Response System(FURS) Kings View Fiscal Year(FY)Ramp-up 6/1/22-6/30/22 PROGRAM EXPENSES 1000:DIRECT SALARIES&BENEFITS Direct Employee Salaries Acct# Administrative Position FTE Admin Program Total 1101 Executive Director 0.03 $ 453 $ 453 1102 Regional Director 0.03 324 324 1103 Staff Accountant 0.03 147 147 1104 Administrative Specialist 0.03 129 129 1105 Quality Assurance Specialist 0.03 208 208 1106 - 1107 - 1108 1109 1110 1111 1112 1113 1114 1115 Direct Personnel Admin Salaries Subtotal 0.15 $ 1,261 $ 1,261 Acct# Program Position FTE Admin Program Total 1116 Program Manager 0.10 $ 901 $ 901 1117 Licensed Clinician 1.00 3,813 3,813 1118 Unlicensed Clinician 1.00 2,947 2,947 1119 Peer Support 1.00 1,603 1,603 1120 On-Call 1,917 1,917 1121 - - 1122 1123 1124 1125 1126 1127 1128 1129 1130 1131 1132 1133 1134 - Direct Personnel Program Salaries Subtotal 3.10 $ 11,181 $ 11,181 Admin Program Total Direct Personnel Salaries Subtotal 3.25 $ 1,261 $ 11,181 $ 12,442 Direct Employee Benefits Acct# Description Total 1201 Retirement $ 24 $ 212 $ 236 1202 Worker's Compensation 44 391 435 1203 Insurance 156 1,384 1,540 1204 - 1205 1206 Direct Employee Benefits Subtotal: $ 224 $ 1,987 $ 2,211 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Direct Payroll Taxes&Expenses: Acct# Description Admin Program Total 1301 OASDI $ - 1302 FICA/MEDICARE 97 855 952 1303 SUI 8 67 75 1304 Other(specify) 1305 Other(specify) - - 1306 Other(specify) Direct Payroll Taxes&Expenses Subtotal: $ 105 $ 922 $ 1,027 DIRECT EMPLOYEE SALARIES&BENEFITS TOTAL: Admin Program Total $ 1,590 $ 14,090 $ 15,680 DIRECT EMPLOYEE SALARIES&BENEFITS PERCENTAGE: Admin Program 10% 90% 2000:DIRECT CLIENT SUPPORT Acct# Line Item Description Amount 2001 Child Care $ 2002 Client Housing Support 2003 Client Transportation&Support 2004 Clothing, Food,&Hygiene 2005 jEclucation Support 2006 Employment Support 2007 Household Items for Clients 2008 Medication Supports 2009 Program Supplies-Medical 2010 Utility Vouchers 2011 Other(specify) 2012 Other(specify) 2013 Other(specify) 2014 Other(specify) 2015 Other(specify) 2016 Other(specify) DIRECT CLIENT CARE TOTAL $ 3000:DIRECT OPERATING EXPENSES Acct# Line Item Description Amount 3001 Telecommunications $ 408 3002 Printing/Postage 3003 Office,Household&Program Supplies 500 3004 Advertising 3005 Staff Development&Training 5,000 3006 Staff Mileage 150 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance 3009 Other(specify) 3010 Other(specify) 3011 Other(specify) 3012 Other(specify) - DIRECT OPERATING EXPENSES TOTAL: $ 6,058 4000:DIRECT FACILITIES&EQUIPMENT Acct# Line Item Description Amount 4001 Building Maintenance $ 200 4002 Rent/Lease Building 417 4003 Rent/Lease Equipment 42 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B 4004 Rent/Lease Vehicles 4005 Security 4006 Utilities 100 4007 Other(Staff Recruitment) 750 4008 Other(Insurance) 148 4009 Other(specify) 4010 10ther(specify) DIRECT FACILITIES/EQUIPMENT TOTAL:j $ 1,657 5000:DIRECT SPECIAL EXPENSES Acct# Line Item Description Amount 5001 Consultant(Network&Data Management) $ 722 5002 HMIS(Health Management Information System) 5003 Contractual/Consulting Services (Specify) 5004 Translation Services 5005 Other(specify) 5006 Other(specify) 5007 Other(specify) 5008 Other(specify) - DIRECT SPECIAL EXPENSES TOTAL: $ 722 6000:INDIRECT EXPENSES Acct# Line Item Description Amount Administrative Overhead 6001 Use this line and only this line for approved indirect cost rate Administrative Overhead 6002 Professional Liability Insurance 6003 Accounting/Bookkeeping 6004 External Audit 6005 Insurance(Specify):Property 6006 Payroll Services 6007 Depreciation(Provider-Owned Equipment to be UsedforProgram Purposes) - 6008 Personnel(Indirect Salaries&Benefits) 2,732 6009 10ther(Operating) 911 6010 Other(specify) 6011 Other(specify) 6012 Other(specify) 6013 Other(specify) INDIRECT EXPENSES TOTAL $ 3,643 INDIRECT COST RATE 11.50% 7000:DIRECT FIXED ASSETS Acct# Line Item Description Amount 7001 Computer Equipment&Software $ 7,058 7002 Copiers,Cell Phones,Tablets, Devices to Contain HIPAA Data - 7003 Furniture&Fixtures 500 7004 Leasehold/Tenant/Building Improvements 7005 Other Assets over$500 with Lifespan of 2 Years+ 7006 Assets over$5,000/unit(Specify) 7007 Other(specify) 7008 Other(specify) - FIXED ASSETS EXPENSES TOTAL $ 7,558 TOTAL PROGRAM EXPENSES $ 35,318 PROGRAM FUNDING SOURCES Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) Acct# Line Item Description Service Units Rate Amount 8001 Mental Health Services $ 8002 Case Management 8003 Crisis Services 8004 Medication Support 8005 Collateral 8006 Plan Development 8007 Assessment 8008 Rehabilitation 8009 Other(Specify) 8010 10ther(Specify) Estimated Specialty Mental Health Services Billing Totals: 0 $ - Estimated%of Clients who are Medi-Cal Beneficiaries 85% Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries - Federal Financial Participation(FFP)% 1 65% MEDI-CAL FFP TOTAL $ 8100-SUBSTANCE USE DISORDER FUNDS Acct# Line Item Description Amount 8101 Drug Medi-Cal $ 8102 SABG $ SUBSTANCE USE DISORDER FUNDS TOTAL $ 8200-REALIGNMENT Acct# Line Item Description Amount 8201 lRealignment $ 35,318 REALIGNMENT TOTAL $ 35,318 8300-MENTAL HEALTH SERVICE ACT(MHSA) Acct# MHSA Component MHSA Program Name Amount 8301 CSS-Community Services&Supports $ - 8302 PEI-Prevention&Early Intervention 8303 INN-Innovations 8304 WET-Workforce Education&Training 8305 CFTN-Capital Facilities&Technology MHSA TOTAL $ 8400-OTHER REVENUE Acct# Line Item Description Amount 8401 Client Fees $ 8402 Client Insurance 8403 Family Urgent Response General Fund 8404 Other(Specify) 8405 10ther(Specify) OTHER REVENUE TOTAL $ TOTAL PROGRAM FUNDING SOURCES: $ 35,318 NET PROGRAM COST: $ - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System (FURS) Kings View Fiscal Year(FY) Ramp-up 6/1/22-6/30/22 Budget Narrative PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1000:DIRECT SALARIES&BENEFITS 15,680 Administrative Positions 1,261 1101 Executive Director 453 Position will provide agency specific staff oversight and represent and maintain the collaborative relationship between agencies.(1 month) 1102 Regional Director 324 Provide program management and direction.Ensures operations are running smoothly and in compliance with contract requirements.(1 month) 1103 Staff Accountant 147 Provides budget guidance,monthly invoicing and other fiscal services.(1 month) 1104 Administrative Specialist 129 Provides administrative support for the program and assist with medical billing and records.(1 month) 1105 Quality Assurance Specialist 208 Ensures compliance and reports on contract deliverables.(1 month) 1106 0 - 1107 0 1108 0 1109 0 1110 0 1111 0 1112 0 1113 0 1114 0 1115 0 Program Positions 11,181 1116 Program Manager 901 Provides supervision of all staff and direct oversight of program.(1 month) 1117 Licensed Clinician 3,813 Assist with managing the client's illness and reduce its impact on the client's life,and referrals to appropriate linkages.(2 weeks) 1118 Unlicensed Clinician 2,947 Assist with managing the client's illness and reduce its impact on the client's life,and referrals to appropriate linkages.(2 weeks) 1119 Peer Support 1,603 Provides outreach and engagement services,provides linkage to needed services.(2 weeks) 1120 On-Call 1,917 Cost for afterhours phone response.(2 weeks) 1121 0 1122 0 1123 0 1124 0 1125 0 1126 0 1127 0 1128 0 1129 0 1130 0 1131 0 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1132 0 1133 0 1134 0 Direct Employee Benefits 2,211 1201 Retirement 214 Cost of 401K 1202 Worker's Compensation 397 Workers Comp Insurance 1203 Insurance 1,406 Cost of Medical,Vision,Dental,Life and Long Term Disability Insurance 1204 0 1205 0 1206 0 Direct Payroll Taxes&Expenses: 1,027 1301 OASDI 1302 FICA/MEDICARE 869 Cost of FICA/Medicare 1303 SUI 68 Cost of SUI 1304 1305 1306 Other(specify) 2000:DIRECT CLIENT SUPPORT 2001 Child Care 2002 Client Housing Support 2003 Client Transportation&Support 2004 Clothing,Food,&Hygiene 2005 Long Term Disability 2006 Employment Support 2007 Household Items for Clients 2008 Medication Supports 2009 Program Supplies-Medical 2010 Utility Vouchers 2011 Other(specify) 2012 Other(specify) 2013 Other(specify) 2014 Other(specify) 2015 Other(specify) 2016 1 Other(specify) 3000:DIRECT OPERATING EXPENSES 6,058 3001 Telecommunications 408 Cost of telephone services,cell phones service,data connectivity. 3002 Printing/Postage - 3003 Office,Household&Program Supplies 500 Includes all supplies used by staff. 3004 Advertising - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 3005 Staff Development&Training 5,000 Cost of staff development and training package from PESI and internal matter experts for new hires during this time.Includes expenses such as travel transportation,hotel stays,and meals. 3006 Staff Mileage 150 Reimbursements to staff for personal vehicle use to provide services or other program needs,paid at IRS rate.Any travel transportation fees,such as parking fees. 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance 3009 Other(specify) 3010 Other(specify) 3011 Other(specify) 3012 1 Other(specify) 4000:DIRECT FACILITIES&EQUIPMENT 1,657 4001 Building Maintenance 200 Shared cost for copier maintenance,inspection services,pest control,alarm services, janitorial services and minor building repairs and maintenance,and necessary expenses to maintain building maintenance. 4002 Rent/Lease Building 417 Estimated share building space lease. 4003 Rent/Lease Equipment 42 Shared cost for copier lease and water dispenser rental. 4004 Rent/Lease Vehicles - 4005 Security - 4006 Utilities 100 Estimated share cost of gas and electric. 4007 Other(Staff Recruitment) 750 Thorough background checks and drug testing. 4008 Other(Insurance) 148 Direct expense to program for general,professional liability,personal property, accidental,and auto insurance. 4009 Other(specify) - 4010 Other(specify) 5000:DIRECT SPECIAL EXPENSES 722 5001 Consultant(Network&Data Management) 722 Kings View Information Technology Department(KVIT)will provide hardware and software support successful data collection.Information services and management consisting of managed internet service provider,network and desktop management, project management,technology procurement,telecommunication management, strategic technology planning,system documentation,application/data hosting,access to data/documents/application 24/7. After hours support via email and phone 24/7. 5002 HMIS(Health Management Information System) 5003 Contractual/Consulting Services (Specify) 5004 Translation Services 5005 Other(specify) 5006 Other(specify) 5007 Other(specify) 5008 Other(specify) Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 6000:INDIRECT EXPENSES 3,643 6001 Administrative Overhead - 6002 Professional Liability Insurance 6003 Accounting/Bookkeeping 6004 External Audit 6005 Insurance(Specify):Property Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 6006 Payroll Services 6007 Depreciation(Provider-Owned Equipment to be Used 6008 Personnel(Indirect Salaries&Benefits) 2,732 Expenses provides corporate management,fiscal services,payroll,human resources, accounts payable and other administrative functions. 6009 Other(Operating) 911 Expenses provides corporate management,fiscal services,payroll,human resources, accounts payable and other administrative functions. 6010 Other(specify) - 6011 Other(specify) 6012 Other(specify) - 6013 1 Other(specify) 7000:DIRECT FIXED ASSETS 7,558 7001 Computer Equipment&Software 7,058 3 computer set ups for direct staff.Estimated software needs to support staff. 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA 7003 Furniture&Fixtures 500 Furnishing costs for new staff. 7004 Leasehold/Tenant/Building Improvements 7005 Other Assets over$500 with Lifespan of 2 Years+ 7006 Assets over$5,000/unit(Specify) 7007 Other(specify) 7008 1 Other(specify) PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) PROVIDE DETAILS OF METHODOLOGY(IES)USED IN DETERMINING MEDI-CAL ACCT# LINE ITEM SERVICE RATES AND/OR SERVICE UNITS,IF APPLICABLE AND/OR AS REQUIRED BY THE RFP 8001 Mental Health Services 8002 Case Management 8003 Crisis Services E 8004 Medication Services 8005 Collateral 8006 Plan Development 8007 Assessment 8008 Rehabilitation 8009 Other(Specify) 8010 1 Other(Specify) TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 35,318 TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 35,318 0 BUDGET CHECK: - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System(FURS) Kings View Fiscal Year(FY)2022-23 PROGRAM EXPENSES 1000:DIRECT SALARIES&BENEFITS Direct Employee Salaries Acct# Administrative Position FTE Admin Program Total 1101 Executive Director 0.03 $ 5,433 $ 5,433 1102 Regional Director 0.03 3,890 3,890 1103 Staff Accountant 0.03 1,769 1,769 1104 Administrative Specialist 0.03 1,546 1,546 1105 Quality Assurance Specialist 0.03 2,496 2,496 1106 1107 - - 1108 - - 1109 - - 1110 - - 1111 - 1112 - 1113 - - 1114 - 1115 - - Direct Personnel Admin Salaries Subtotal 0.15 $ 15,134 $ 15,134 Acct# Program Position FTE Admin Program Total 1116 Program Manager 0.10 $ 10,816 $ 10,816 1117 Licensed Clinician 1.00 91,520 91,520 1118 Unlicensed Clinician 1.00 70,720 70,720 1119 Peer Support 1.00 38,480 38,480 1120 On-Call 46,000 46,000 1121 - - 1122 - 1123 - - 1124 - 1125 - 1126 - 1127 - - 1128 - 1129 - - 1130 - 1131 - - 1132 - 1133 - - 1134 - - Direct Personnel Program Salaries Subtotall 3.10 1 $ 257,536 1 $ 257,536 Admin Program Total Direct Personnel Salaries Subtotall 3.25 1 $ 15,134 1 $ 257,536 1 $ 272,670 Direct Employee Benefits Acct# Description Admin Program Total 1201 Retirement $ 286 $ 4,867 $ 5,153 1202 Worker's Compensation 528 8,989 9,517 1203 Insurance 1,872 31,857 33,729 1204 - 1205 - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B 1206 - Direct Employee Benefits Subtotal: $ 2,686 $ 45,713 $ 48,399 Direct Payroll Taxes&Expenses: Acct# Description Admin Program Total 1301 OASDI $ - $ - $ - 1302 FICA/MEDICARE 1,158 19,701 20,859 1303 SUI 91 1,545 1,636 1304 Other(specify) - 1305 10ther(specify) - - - 1306 10ther(specify) - - - Direct Payroll Taxes&Expenses Subtotal: $ 1,249 $ 21,246 $ 22,495 DIRECT EMPLOYEE SALARIES&BENEFITS TOTAL: Admin Program Total $ 19,069 $ 324,495 $ 343,564 DIRECT EMPLOYEE SALARIES&BENEFITS PERCENTAGE: Admin Program 6%1 94% 2000: DIRECT CLIENT SUPPORT Acct# Line Item Description Amount 2001 Child Care $ - 2002 Client Housing Support - 2003 Client Transportation&Support - 2004 Clothing, Food,&Hygiene - 2005 Education Support - 2006 Employment Support - 2007 Household Items for Clients - 2008 Medication Supports - 2009 Program Supplies-Medical - 2010 Utility Vouchers - 2011 Other(specify) - 2012 Other(specify) - 2013 Other(specify) - 2014 Other(specify) - 2015 Other(specify) - 2016 Other(specify) - DIRECT CLIENT CARE TOTAL $ - 3000: DIRECT OPERATING EXPENSES Acct# Line Item Description Amount 3001 Telecommunications $ 4,895 3002 Printing/Postage 500 3003 Office, Household&Program Supplies 3,750 3004 Advertising - 3005 Staff Development&Training 5,000 3006 Staff Mileage 5,000 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance - 3009 Other(specify) - 3010 Other(specify) - 3011 10ther(specify) - 3012 10ther(specify) - DIRECT OPERATING EXPENSES TOTAL: $ 19,145 4000: DIRECT FACILITIES&EQUIPMENT Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Acct# Line Item Description Amount 4001 Building Maintenance $ 2,295 4002 Rent/Lease Building 5,000 4003 Rent/Lease Equipment 500 4004 Rent/Lease Vehicles - 4005 Security 1,350 4006 jUtilities 1,000 4007 Other(Staff Recruitment) 750 4008 Other(insurance) 1,750 4009 Other(specify) - 4010 Other(specify) - DIRECT FACILITIES/EQUIPMENT TOTAL: $ 12,645 5000: DIRECT SPECIAL EXPENSES Acct# Line Item Description Amount 5001 Consultant(Network&Data Management) $ 8,668 5002 HMIS(Health Management Information System) - 5003 Contractual/Consulting Services (Specify) - 5004 Translation Services 350 5005 Other(specify) - 5006 Other(specify) - 5007 Other(specify) - 5008 Other(specify) - DIRECT SPECIAL EXPENSES TOTAL: $ 9,018 6000: INDIRECT EXPENSES Acct# Line Item Description Amount Administrative Overhead 6001 Use this line and only this line for approved indirect cost rate $ - Administrative Overhead 6002 Professional Liability Insurance - 6003 Accounting/Bookkeeping - 6004 External Audit - 6005 Insurance(Specify): Property - 6006 Payroll Services - 6007 Depreciation(Provider-Owned Equipment to be Used for Program Purposes) - 6008 Personnel(Indirect Salaries&Benefits) 33,255 6009 Other(Operating) 11,085 6010 Other(specify) - 6011 Other(specify) - 6012 Other(specify) - 6013 Other(specify) - INDIRECT EXPENSES TOTAL $ 44,340 INDIRECT COST RATE 11.50% 7000: DIRECT FIXED ASSETS Acct# Line Item Description Amount 7001 Computer Equipment&Software $ 696 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA Data - 7003 Furniture&Fixtures 500 7004 Leasehold/Tenant/Building Improvements - 7005 Other Assets over$500 with Lifespan of 2 Years+ d- Fresno 7006 Assets over$5,000/unit(Specify)7007 Other(specify)County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B 7008 Other(specify) - FIXED ASSETS EXPENSES TOTAL $ 1,196 TOTAL PROGRAM EXPENSES $ 429,908 PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) Acct# Line Item Description Service Units Rate Amount 8001 Mental Health Services 216 4.00 $ 864 8002 Case Management 108 3.85 416 8003 Crisis Services 540 5.85 3,159 8004 Medication Support 0 - - 8005 Collateral 216 4.00 864 8006 Plan Development 0 - - 8007 Assessment 0 - - 8008 Rehabilitation 0 - 8009 Other(Specify) 0 - 8010 Other(Specify) 0 - Estimated Specialty Mental Health Services Billing Totals: 1 1,0801 $ 5,303 Estimated%of Clients who are Medi-Cal Beneficiaries 85% Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 4,507 Federal Financial Participation(FFP)% 65% 2,930 MEDI-CAL FFP TOTAL $ 2,930 8100-SUBSTANCE USE DISORDER FUNDS Acct# Line Item Description Amount 8101 Drug Medi-Cal $ - 8102 SABG $ - SUBSTANCE USE DISORDER FUNDS TOTAL $ - 8200-REALIGNMENT Acct# Line Item Description Amount 8201 Realignment $ 426,978 REALIGNMENT TOTAL $ 426,978 8300-MENTAL HEALTH SERVICE ACT(MHSA) Acct# MHSA Component MHSA Program Name Amount 8301 CSS-Community Services&Supports $ - 8302 PEI-Prevention&Early Intervention - 8303 INN-Innovations - 8304 WET-Workforce Education&Training - 8305 JCFTN-Capital Facilities&Technology - MHSA TOTAL $ - 8400-OTHER REVENUE Acct# Line Item Description Amount 8401 Client Fees $ - 8402 Client Insurance - 8403 Other(Specify) - 8404 Other(Specify) - 8405 Other(Specify) - OTHER REVENUE TOTAL $ - TOTAL PROGRAM FUNDING SOURCES: $ 429,908 NET PROGRAM COST: $ 0 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System (FURS) Kings View Fiscal Year(FY)2022-23 PARTIAL FTE DETAIL For all positions with FTE's split among multiple programs/contracts the below must be filled out Position Contract#/Name/Department/County FTE Executive Director PATH SMHS/Fresno 0.01 PATH OEL/Fresno 0.01 PATH MOP/Fresno 0.03 Blue Sky/Fresno 0.05 Rural Crisis Intervention/Fresno 0.03 Metro CIT/Fresno 0.02 Map Point/Fresno 0.01 FURS/Fresno 0.03 Suicide Prevention Follow-up Call/Fresno 0.01 CVSPH/California State,Tulare,Calaveras,Tuolumne&Kings 0.14 Shasta 0.09 Tulare 0.26 Madera 0.06 Kings 1 0.23 Administrative Department 1 0.02 Tota 1 1.00 Position Contract#/Name/Department/County FTE Regional Director PATH SMHS/Fresno 0.02 PATH OEL/Fresno 0.02 PATH MOP/Fresno 0.06 Blue Sky/Fresno 0.11 Rural Crisis Intervention/Fresno 0.16 Metro CIT/Fresno 0.25 Map Point/Fresno 0.05 FURS/Fresno 0.03 Suicide Prevention Follow-up Call/Fresno 0.01 CVSPH/California State,Tulare,Calaveras,Tuolumne&Kings 0.15 Madera 0.14 Tota 1 1.00 Position Contract#/Name/Department/County FTE Staff Accountant PATH SMHS/Fresno 0.06 PATH OEL/Fresno 0.07 PATH MOP/Fresno 0.06 Blue Sky/Fresno 0.10 Rural Crisis Intervention/Fresno 0.12 Metro CIT/Fresno 0.10 FURS/Fresno 0.03 Suicide Prevention Follow-up Call/Fresno 0.01 CVSPH/California State,Tulare,Calaveras,Tuolumne&Kings 0.05 Shasta 0.07 Finance Department 0.34 Tota 1 1.00 Position Contract#/Name/Department/County FTE Administrative Specialist PATH SMHS/Fresno 0.17 PATH OEL/Fresno 0.05 Rural Crisis Intervention/Fresno 0.75 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B FURS/Fresno 0.03 Tota 1 1.00 Position Contract#/Name/Department/County FTE Quality Assurance Specialist FURS/Fresno 0.03 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Tota 1 0.03 Position Contract#/Name/Department/County FTE Program Manager FURS/Fresno 0.10 Total 0.10 Position Contract#/Name/Department/County FTE Tota 1 0.00 Position Contract#/Name/Department/County FTE Tota 1 0.00 Position Contract#/Name/Department/County FTE Tota 1 0.00 Position Contract#/Name/Department/County FTE Tota 1 0.00 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System (FURS) Kings View Fiscal Year (FY) 2022-23 Budget Narrative PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1000:DIRECT SALARIES&BENEFITS 343,564 Administrative Positions 15,134 1101 Executive Director 5,433 Position will provide agency specific staff oversight and represent and maintain the collaborative relationship between agencies. 1102 Regional Director 3,890 Provide program management and direction.Ensures operations are running smoothly and in compliance with contract requirements. 1103 Staff Accountant 1,769 Provides budget guidance,monthly invoicing and other fiscal services. 1104 Administrative Specialist 1,546 Provides administrative support for the program and assist with medical billing and records. 1105 Quality Assurance Specialist 2,496 Ensures compliance and reports on contract deliverables. 1106 0 - 1107 0 - 1108 0 - 1109 0 - 1110 0 - 1111 0 - 1112 0 - 1113 0 - 1114 0 - 1115 0 - Program Positions 1116 Program Manager 10,816 Provides supervision of all staff and direct oversight of program. 1117 Licensed Clinician 91,520 Assist with managing the client's illness and reduce its impact on the client's life,and referrals to appropriate linkages. 1118 Unlicensed Clinician 70,720 Assist with managing the client's illness and reduce its impact on the client's life,and referrals to appropriate linkages. 1119 Peer Support 38,480 Provides outreach and engagement services,provides linkage to needed services. 1120 On Call 46,000 Cost for afterhours phone response. 1121 0 - 1122 0 - 1123 0 - 1124 0 - 1125 0 - 1126 0 - 1127 0 - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1128 0 1129 0 1130 0 - 1131 0 - 1132 0 - 1133 0 - 1134 0 - Direct Employee Benefits 48,399 1201 Retirement 5,153 Cost of 401K 1202 Worker's Compensation 9,517 Workers Comp Insurance 1203 Insurance 33,729 Cost of Medical,Vision,Dental,Life and Long Term Disability Insurance 1204 0 - 1205 0 - 1206 0 - Direct Payroll Taxes&Expenses: 22,495 1301 OASDI - 1302 FICA/MEDICARE 20,859 Cost of FICA/Medicare 1303 SUI 1,636 Cost of SUI 1304 - 1305 - 1306 Other(specify) - 2000:DIRECT CLIENT SUPPORT - 2001 Child Care - 2002 Client Housing Support - 2003 Client Transportation&Support - 2004 Clothing,Food,&Hygiene - 2005 Long Term Disability - 2006 Employment Support - 2007 Household Items for Clients - 2008 Medication Supports - 2009 Program Supplies-Medical - 2010 Utility Vouchers - 2011 Other(specify) - 2012 Other(specify) - 2013 Other(specify) - 2014 Other(specify) - 2015 Other(specify) - 2016 Other(specify) - Fresno County Departmentof benavioralea on rac budget emp a e Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 3000:DIRECT OPERATING EXPENSES 19,145 3001 Telecommunications 4,895 Cost of telephone services,cell phones service,data connectivity. 3002 Printing/Postage 500 Anticipating courier services and postage necessary for program.Business cards and other special printing in bulk that is less cost effective to outsource rather than utilization of a copier. 3003 Office,Household&Program Supplies 3,750 Includes all supplies used by staff in the course of providing services. 3004 Advertising - 3005 Staff Development&Training 5,000 Cost of staff development and training package from PESI and internal matter experts. Includes expenses such as travel transportation,hotel stays,and meals. 3006 Staff Mileage 5,000 Reimbursements to staff for personal vehicle use to provide services or other program needs,paid at IRS rate.Any travel transportation fees,such as parking fees. 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance - 3009 Other(specify) - 3010 Other(specify) - 3011 Other(specify) - 3012 1 Other(specify) 4000:DIRECT FACILITIES&EQUIPMENT 12,645 4001 Building Maintenance 2,295 Shared cost for copier maintenance,inspection services,pest control,alarm services, janitorial services and minor building repairs and maintenance,and necessary expenses to maintain building maintenance. 4002 Rent/Lease Building 5,000 Estimated shared building space lease. 4003 Rent/Lease Equipment 500 Shared cost for copier lease and water dispenser rental. 4004 Rent/Lease Vehicles - 4005 Security 1,350 Shared expense of afterhours security. 4006 Utilities 1,000 Estimated share cost of gas and electric. 4007 Other(Staff Recruitment) 750 Thorough background checks and drug testing. 4008 Other(Insurance) 1,750 Direct expense to program for general,professional liability, personal property,accidental,and auto insurance. 4009 Other(specify) - 4010 Other(specify) - 5000:DIRECT SPECIAL EXPENSES 9,018 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 5001 Consultant(Network&Data Management) 8,668 Kings View Information Technology Department(KVIT)will provide hardware and software support successful data collection.Information services and management consisting of managed internet service provider,network and desktop management, project management,technology procurement,telecommunication management, strategic technology planning,system documentation,application/data hosting,access to data/documents/application 24/7. After hours support via email and phone 24/7. 5002 HMIS(Health Management Information System) - 5003 Contractual/Consulting Services (Specify) - 5004 Translation Services 350 Anticipating translation services to assist clients. 5005 Other(specify) - 5006 Other(specify) - 5007 Other(specify) - 5008 Other(specify) - 6000:INDIRECT EXPENSES 44,340 6001 Administrative Overhead - 6002 Professional Liability Insurance - 6003 Accounting/Bookkeeping - 6004 External Audit - 6005 Insurance(Specify):Property - 6006 Payroll Services - 6007 Depreciation(Provider-Owned Equipment to be Used - 6008 Personnel(Indirect Salaries&Benefits) 33,255 Expense provides corporate management,fiscal services,payroll,human resources, accounts payable and other administrative functions. 6009 Other(Operating) 11,085 Expense provides corporate management,fiscal services,payroll,human resources, accounts payable and other administrative functions. 6010 Other(specify) - 6011 Other(specify) - 6012 Other(specify) - 6013 Other(specify) - 7000:DIRECT FIXED ASSETS 1,196 7001 Computer Equipment&Software 696 Estimated software needs to support staff. 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA - 7003 Furniture&Fixtures 500 Furnishing costs for new staff 7004 Leasehold/Tenant/Building Improvements - 7005 Other Assets over$500 with Lifespan of 2 Years+ - 7006 Assets over$5,000/unit(Specify) - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACC T# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 7007 Other(specify) - 7008 Other(specify) - PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) PROVIDE DETAILS OF METHODOLOGY(IES)USED IN DETERMINING MEDI-CAL ACCT# LINE ITEM SERVICE RATES AND/OR SERVICE UNITS,IF APPLICABLE AND/OR AS REQUIRED BY THE RFP 8001 Mental Health Services Estimated billable services based on reported approximately 1 call per month.Made assumptions on type of service:50%crisis,20%each counseling and collateral,10% linkage. 8002 Case Management Used rates from current outpatient programs. 8003 Crisis Services Estimated that majority of consumers would have MediCal,collaterals might not.-85% eligibility E 8004 Medication Services Estimated a blended reimbursement rate of 65%assuming some would have ACA or enhanced aid codes,while others would be regular FFP at 50%. 8005 Collateral 8006 Plan Development 8007 Assessment 8008 Rehabilitation 8009 Other(Specify) 8010 Other(Specify) TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 429,908 TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 429,908 BUDGET CHECK: - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System(FURS) Kings View Fiscal Year(FY)2023-24 PROGRAM EXPENSES 1000:DIRECT SALARIES&BENEFITS Direct Employee Salaries Acct# Administrative Position FTE Admin Program Total 1101 Executive Director 0.03 $ 5,596 $ 5,596 1102 Regional Director 0.03 4,007 4,007 1103 Staff Accountant 0.03 1,822 1,822 1104 Administrative Specialist 0.03 1,592 1,592 1105 Quality Assurance Specialist 0.03 2,571 2,571 1106 1107 - - 1108 - - 1109 - - 1110 - - 1111 - 1112 - 1113 - - 1114 - 1115 - - Direct Personnel Admin Salaries Subtotal 0.15 $ 15,588 $ 15,588 Acct# Program Position FTE Admin Program Total 1116 Program Manager 0.03 $ 3,342 $ 3,342 1117 Licensed Clinician 1.00 94,266 94,266 1118 Unlicensed Clinician 1.00 72,842 72,842 1119 Peer Support 1.00 39,634 39,634 1120 On-Call 46,000 46,000 1121 - - 1122 - 1123 - - 1124 - 1125 - 1126 - 1127 - - 1128 - 1129 - - 1130 - 1131 - - 1132 - 1133 - - 1134 - Direct Personnel Program Salaries Subtotall 3.03 1 $ 256,084 1 $ 256,084 Admin Program Total Direct Personnel Salaries Subtotall 3.18 1 $ 15,588 1 $ 256,084 1 $ 271,672 Direct Employee Benefits Acct# Description Admin Program Total 1201 Retirement $ 295 $ 4,840 $ 5,135 1202 Worker's Compensation 544 8,938 9,482 1203 Insurance 1,928 31,677 33,605 1204 - 1205 - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B 1206 - Direct Employee Benefits Subtotal: $ 2,767 $ 45,455 $ 48,222 Direct Payroll Taxes&Expenses: Acct# Description Admin Program Total 1301 OASDI $ - $ - $ - 1302 FICA/MEDICARE 1,192 19,591 20,783 1303 SUI 94 1,536 1,630 1304 - 1305 10ther(specify) - - - 1306 10ther(specify) - I - - Direct Payroll Taxes&Expenses Subtotal: $ 1,286 $ 21,127 $ 22,413 DIRECT EMPLOYEE SALARIES&BENEFITS TOTAL: Admin Program Total $ 19,641 $ 322,666 $ 342,307 DIRECT EMPLOYEE SALARIES&BENEFITS PERCENTAGE: Admin Program 6%1 94% 2000: DIRECT CLIENT SUPPORT Acct# Line Item Description Amount 2001 Child Care $ - 2002 Client Housing Support - 2003 Client Transportation&Support - 2004 Clothing, Food,&Hygiene - 2005 Education Support - 2006 Employment Support - 2007 Household Items for Clients - 2008 Medication Supports - 2009 Program Supplies-Medical - 2010 Utility Vouchers - 2011 Other(specify) - 2012 Other(specify) - 2013 Other(specify) - 2014 Other(specify) - 2015 Other(specify) - 2016 Other(specify) - DIRECT CLIENT CARE TOTAL $ - 3000: DIRECT OPERATING EXPENSES Acct# Line Item Description Amount 3001 Telecommunications $ 5,140 3002 Printing/Postage 500 3003 Office, Household&Program Supplies 3,764 3004 Advertising - 3005 Staff Development&Training 7,425 3006 Staff Mileage 5,250 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance - 3009 Other(specify) - 3010 Other(specify) - 3011 10ther(specify) - 3012 10ther(specify) - DIRECT OPERATING EXPENSES TOTAL: $ 22,079 4000: DIRECT FACILITIES&EQUIPMENT Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Acct# Line Item Description Amount 4001 Building Maintenance $ 2,397 4002 Rent/Lease Building 5,150 4003 Rent/Lease Equipment 500 4004 Rent/Lease Vehicles - 4005 Security 1,418 4006 jUtilities 1,050 4007 Other(Staff Recruitment) 750 4008 Other(insurance) 1,838 4009 Other(specify) - 4010 Other(specify) - DIRECT FACILITIES/EQUIPMENT TOTAL: $ 13,103 5000: DIRECT SPECIAL EXPENSES Acct# Line Item Description Amount 5001 Consultant(Network&Data Management) $ 8,928 5002 HMIS(Health Management Information System) - 5003 Contractual/Consulting Services (Specify) - 5004 Translation Services 350 5005 Other(specify) - 5006 Other(specify) - 5007 Other(specify) - 5008 Other(specify) - DIRECT SPECIAL EXPENSES TOTAL: $ 9,278 6000: INDIRECT EXPENSES Acct# Line Item Description Amount Administrative Overhead 6001 Use this line and only this line for approved indirect cost rate $ - Administrative Overhead 6002 Professional Liability Insurance 6003 Accounting/Bookkeeping 6004 External Audit 6005 Insurance(Specify): Property 6006 Payroll Services - 6007 Depreciation(Provider-Owned Equipment to be Used for Program Purposes) - 6008 Personnel(Indirect Salaries&Benefits) 33,418 6009 Other(Operating) 11,140 6010 Other(specify) - 6011 Other(specify) - 6012 Other(specify) - 6013 Other(specify) - INDIRECT EXPENSES TOTAL $ 44,558 INDIRECT COST RATE 11.50% 7000: DIRECT FIXED ASSETS Acct# Line Item Description Amount 7001 Computer Equipment&Software $ 696 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA Data - 7003 Furniture&Fixtures - 7004 Leasehold/Tenant/Building Improvements - 7005 Other Assets over$500 with Lifespan of 2 Years+ d- Fresno 7006 Assets over$5,000/unit(Specify) 7007 Other(specify)County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B 7008 Other(specify) - FIXED ASSETS EXPENSES TOTAL $ 696 TOTAL PROGRAM EXPENSES $ 432,021 PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) Acct# Line Item Description Service Units Rate Amount 8001 Mental Health Services 432 4.00 $ 1,728 8002 Case Management 216 3.85 832 8003 Crisis Services 1,080 5.85 6,318 8004 Medication Support 0 - - 8005 Collateral 432 4.00 1,728 8006 Plan Development 0 - - 8007 Assessment 0 - - 8008 Rehabilitation 0 - - 8009 Other(Specify) 0 - - 8010 Other(Specify) 0 - Estimated Specialty Mental Health Services Billing Totals: 1 2,1601 $ 10,606 Estimated%of Clients who are Medi-Cal Beneficiaries 85% Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 9,015 Federal Financial Participation(FFP)% 65% 5,860 MEDI-CAL FFP TOTAL $ 5,860 8100-SUBSTANCE USE DISORDER FUNDS Acct# Line Item Description Amount 8101 Drug Medi-Cal $ - 8102 SABG $ - SUBSTANCE USE DISORDER FUNDS TOTAL $ - 8200-REALIGNMENT Acct# Line Item Description Amount 8201 Realignment $ 426,161 REALIGNMENT TOTAL $ 426,161 8300-MENTAL HEALTH SERVICE ACT(MHSA) Acct# MHSA Component MHSA Program Name Amount 8301 CSS-Community Services&Supports $ - 8302 PEI-Prevention&Early Intervention - 8303 INN-Innovations - 8304 WET-Workforce Education&Training - 8305 JCFTN-Capital Facilities&Technology - MHSA TOTAL $ - 8400-OTHER REVENUE Acct# Line Item Description Amount 8401 Client Fees $ - 8402 Client Insurance - 8403 Other(Specify) 8404 Other(Specify) - 8405 Other(Specify) - OTHER REVENUE TOTAL $ - TOTAL PROGRAM FUNDING SOURCES: $ 432,021 NET PROGRAM COST: $ 0 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System(FURS) Kings View Fiscal Year(FY)2023-24 PARTIAL FTE DETAIL For all positions with FTE's split among multiple programs/contracts the below must be filled out Position Contract#/Name/Department/County FTE Executive Director PATH SMHS/Fresno 0.01 PATH OEL/Fresno 0.01 PATH MOP/Fresno 0.03 Blue Sky/Fresno 0.05 Rural Crisis Intervention/Fresno 0.03 Metro CIT/Fresno 0.02 Map Point/Fresno 0.01 Suicide Prevention Follow-up Call/Fresno 0.01 FURS/Fresno 0.03 CVSPH/California State,Tulare,Calaveras,Tuolum 0.14 Shasta 0.09 Tulare 0.26 Madera 0.06 Kings 0.23 Administrative Department 0.02 Total 1.00 Position Contract#/Name/Department/County FTE Regional Director PATH SMHS/Fresno 0.02 PATH OEL/Fresno 0.02 PATH MOP/Fresno 0.06 Blue Sky/Fresno 0.11 Rural Crisis Intervention/Fresno 0.16 Metro CIT/Fresno 0.25 Map Point/Fresno 0.05 FURS/Fresno 0.03 Suicide Prevention Follow-up Call/Fresno 0.01 CVSPH/California State,Tulare,Calaveras,Tuolum 0.15 Madera 0.14 1.00 Position Contract#/Name/Department/County FTE Staff Accountant PATH SMHS/Fresno 0.06 PATH OEL/Fresno 0.07 PATH MOP/Fresno 0.06 Blue Sky/Fresno 0.10 Rural Crisis Intervention/Fresno 0.12 Metro CIT/Fresno 0.10 FURS/Fresno 0.03 Suicide Prevention Follow-up Call/Fresno 0.01 CVSPH/California State,Tulare,Calaveras,Tuolumi 0.05 Shasta 0.07 Finance Department 0.34 Total 1.00 Position Contract#/Name/Department/County FTE Quality Assurance Specialist FURS/Fresno 0.03 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Total 0.03 Position Contract#/Name/Department/County FTE Administrative Specialist PATH SMHS/Fresno 0.17 PATH OEL/Fresno 0.05 Rural Crisis Intervention/Fresno 0.75 FURS/Fresno 0.03 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Total 1.00 Position Contract#/Name/Department/County FTE Program Manager FURS/Fresno 0.03 Total 0.03 Position Contract#/Name/Department/County FTE Total 0.11 Position Contract#/Name/Department/County FTE Total 0.10 Position Contract#/Name/Department/County FTE Total 0.78 Position Contract#/Name/Department/County FTE Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System (FURS) Kings View Fiscal Year (FY) 2023-24 Budget Narrative PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1000:DIRECT SALARIES&BENEFITS 342,307 Administrative Positions 15,588 1101 Executive Director 5,596 Position will provide agency specific staff oversight and represent and maintain the collaborative relationship between agencies. 1102 Regional Director 4,007 Provide program management and direction.Ensures operations are running smoothly and in compliance with contract requirements. 1103 Staff Accountant 1,822 Provides budget guidance,monthly invoicing and other fiscal services. 1104 Administrative Specialist 1,592 Provides administrative support for the program and assist with medical billing and records. 1105 Quality Assurance Specialist 2,571 Ensures compliance and reports on contract deliverables. 1106 0 - 1107 0 - 1108 0 - 1109 0 - 1110 0 - 1111 0 - 1112 0 - 1113 0 - 1114 0 - 1115 0 - Program Positions 256,084 1116 Program Manager 3,342 Provides supervision of all staff and direct oversight of program. 1117 Licensed Clinician 94,266 Assist with managing the client's illness and reduce its impact on the client's life,and referrals to appropriate linkages. 1118 Unlicensed Clinician 72,842 Assist with managing the client's illness and reduce its impact on the client's life,and 1119 Peer Support 39,634 Provides outreach and engagement services,provides linkage to needed services. 1120 On-Call 46,000 Cost for afterhours phone response. 1121 0 1122 0 - 1123 0 - 1124 0 - 1125 0 - 1126 0 - 1127 0 - 1128 0 - 1129 0 - 1130 0 - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1131 0 1132 0 1133 0 - 1134 0 - Direct Employee Benefits 48,222 1201 Retirement 5,135 Cost of 401K 1202 Worker's Compensation 9,482 Workers Comp Insurance 1203 Insurance 33,605 Cost of Medical,Vision,Dental,Life and Long Term Disability Insurance 1204 0 - 1205 0 - 1206 0 - Direct Payroll Taxes&Expenses: 22,413 1301 OASDI - 1302 FICA/MEDICARE 20,783 Cost of FICA/Medicare 1303 Dental Insurance 1,630 Cost of SUI 1304 Vision Insurance - 1305 Life Insurance - 1306 Other(specify) - 2000:DIRECT CLIENT SUPPORT - 2001 Child Care - 2002 Client Housing Support - 2003 Client Transportation&Support - 2004 Clothing,Food,&Hygiene - 2005 Long Term Disability - 2006 Employment Support - 2007 Household Items for Clients - 2008 Medication Supports - 2009 Program Supplies-Medical - 2010 Utility Vouchers - 2011 Other(specify) - 2012 Other(specify) - 2013 Other(specify) - 2014 Other(specify) - 2015 Other(specify) - 2016 Other(specify) - 3000:DIRECT OPERATING EXPENSES 22,079 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 3001 Telecommunications 5,140 Cost of telephone services,cell phones service,data connectivity. 3002 Printing/Postage 500 Anticipating courier services and postage necessary for program. Business cards and other special printing in bulk that is less cost effective to outsource rather than utilization of a copier. 3003 Office,Household&Program Supplies 3,764 Includes all supplies used by staff in the course of providing services. 3004 Advertising - 3005 Staff Development&Training 7,425 Cost of staff development and training package from PESI and internal matter experts. Includes expenses such as travel transportation,hotel stays,and meals. 3006 Staff Mileage 5,250 Reimbursements to staff for personal vehicle use to provide services or other program needs,paid at IRS rate.Any travel transportation fees,such as parking fees. 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance - 3009 Other(specify) - 3010 Other(specify) - 3011 Other(specify) - 3012 Other(specify) 4000:DIRECT FACILITIES&EQUIPMENT 13,103 4001 Building Maintenance 2,397 Shared cost for copier maintenance,inspection services,pest control,alarm services, janitorial services and minor building repairs and maintenance,and necessary expenses to maintain building maintenance. 4002 Rent/Lease Building 5,150 Estimated shared building space lease. 4003 Rent/Lease Equipment 500 Shared cost for copier lease and water dispenser rental. 4004 Rent/Lease Vehicles - 4005 Security 1,418 Shared expense of afterhours security. 4006 Utilities 1,050 Estimated share cost of gas and electric. 4007 Other(Staff Recruitment) 750 Thorough background checks and drug testing. 4008 Other(Insurance) 1,838 Direct expense to program for general,professional liability, personal property,accidental,and auto insurance. 4009 Other(specify) - 4010 Other(specify) - 5000:DIRECT SPECIAL EXPENSES 9,278 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 5001 Consultant(Network&Data Management) 8,928 Kings View Information Technology Department(KVIT)will provide hardware and software support successful data collection.Information services and management consisting of managed internet service provider,network and desktop management, project management,technology procurement,telecommunication management, strategic technology planning,system documentation,application/data hosting,access to data/documents/application 24/7. After hours support via email and phone 24/7. 5002 HMIS(Health Management Information System) - 5003 Contractual/Consulting Services (Specify) - 5004 Translation Services 350 Anticipating translation services to assist clients. 5005 Other(specify) - 5006 Other(specify) - 5007 Other(specify) - 5008 Other(specify) - 6000:INDIRECT EXPENSES 44,558 6001 Administrative Overhead - 6002 Professional Liability Insurance - 6003 Accounting/Bookkeeping 6004 External Audit - 6005 Insurance(Specify):Property - 6006 Payroll Services 6007 Depreciation(Provider-Owned Equipment to be Used - 6008 Personnel(Indirect Salaries&Benefits) 33,418 Expenses provides corporate management,fiscal services,payroll,human resources, accounts payable and other administrative functions. 6009 Other(Operating) 11,140 Expenses provides corporate management,fiscal services,payroll,human resources, accounts payable and other administrative functions. 6010 Other(specify) - 6011 Other(specify) - 6012 Other(specify) - 6013 Other(specify) - 7000:DIRECT FIXED ASSETS 696 7001 Computer Equipment&Software 696 Estimated software needs to support staff. 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA - 7003 Furniture&Fixtures - 7004 Leasehold/Tenant/Building Improvements - 7005 Other Assets over$500 with Lifespan of 2 Years+ - 7006 Assets over$5,000/unit(Specify) - 7007 Other(specify) - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 7008 Other(specify) PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) PROVIDE DETAILS OF METHODOLOGY(IES)USED IN DETERMINING MEDI-CAL ACCT# LINE ITEM SERVICE RATES AND/OR SERVICE UNITS,IF APPLICABLE AND/OR AS REQUIRED BY THE RFP 8001 Mental Health Services Estimated billable services based on reported approximately 2 calls per month.Made assumptions on type of service:50%crisis,20%each counseling and collateral,10% linkage. 8002 Case Management Used rates from current outpatient programs. 8003 Crisis Services Estimated that majority of consumers would have Medical,collaterals might not.-85% eligibility 8004 Insurance(Specify): Property Estimated a blended reimbursement rate of 65%assuming some would have ACA or enhanced aid codes,while others would be regular FFP at 50%. 8005 Collateral 8006 Plan Development 8007 Assessment 8008 Staff Recruitment 8009 Other(Specify) 8010 Other(Specify) TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 432,021 TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 432,021 0 BUDGET CHECK: - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System(FURS) Kings View Fiscal Year(FY)2024-25 PROGRAM EXPENSES 1000:DIRECT SALARIES&BENEFITS Direct Employee Salaries Acct# Administrative Position FTE Admin Program Total 1101 Executive Director 0.03 $ 5,764 $ 5,764 1102 Regional Director 0.03 4,127 4,127 1103 Staff Accountant 0.03 1,877 1,877 1104 Administrative Specialist 0.03 1,640 1,640 1105 Quality Assurance Specialist 0.03 2,648 2,648 1106 1107 - 1108 - 1109 - - 1110 - 1111 - 1112 - 1113 - - 1114 - 1115 - - Direct Personnel Admin Salaries Subtotal 0.15 $ 16,056 $ 16,056 Acct# Program Position FTE Admin Program Total 1116 Program Manager 0.03 $ 3,442 $ 3,442 1117 Licensed Clinician 1.00 97,094 97,094 1118 Unlicensed Clinician 1.00 75,027 75,027 1119 Peer Support 1.00 40,823 40,823 1120 On-Call 46,000 46,000 1121 - - 1122 - - 1123 - - 1124 - 1125 - 1126 - 1127 - - 1128 - 1129 - - 1130 - 1131 - - 1132 - 1133 - - 1134 - - Direct Personnel Program Salaries Subtotall 3.03 1 $ 262,386 1 $ 262,386 Admin Program Total Direct Personnel Salaries Subtotall 3.18 1 $ 16,056 1 $ 262,386 1 $ 278,442 Direct Employee Benefits Acct# Description Admin Program Total 1201 Retirement $ 303 $ 4,960 $ 5,263 1202 Worker's Compensation 560 9,157 9,717 1203 Insurance 1,986 32,456 34,442 1204 - 1205 - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B 1206 - Direct Employee Benefits Subtotal: $ 2,850 $ 46,572 $ 49,422 Direct Payroll Taxes&Expenses: Acct# Description Admin Program Total 1301 OASDI $ - $ - $ - 1302 FICA/MEDICARE 1,228 20,073 21,301 1303 SUI 96 1,575 1,671 1304 Other(specify) - 1305 10ther(specify) - - - 1306 10ther(specify) - - - Direct Payroll Taxes&Expenses Subtotal: $ 1,325 $ 21,647 $ 22,972 DIRECT EMPLOYEE SALARIES&BENEFITS TOTAL: Admin Program Total $ 20,231 $ 330,605 $ 350,836 DIRECT EMPLOYEE SALARIES&BENEFITS PERCENTAGE: Admin Program 6%1 94% 2000: DIRECT CLIENT SUPPORT Acct# Line Item Description Amount 2001 Child Care $ - 2002 Client Housing Support - 2003 Client Transportation&Support - 2004 Clothing, Food,&Hygiene - 2005 Education Support - 2006 Employment Support - 2007 Household Items for Clients - 2008 Medication Supports - 2009 Program Supplies-Medical - 2010 Utility Vouchers - 2011 Other(specify) - 2012 Other(specify) - 2013 Other(specify) - 2014 Other(specify) - 2015 Other(specify) - 2016 Other(specify) - DIRECT CLIENT CARE TOTAL $ - 3000: DIRECT OPERATING EXPENSES Acct# Line Item Description Amount 3001 Telecommunications $ 5,345 3002 Printing/Postage 500 3003 Office, Household&Program Supplies 4,095 3004 Advertising - 3005 Staff Development&Training 7,123 3006 Staff Mileage 5,460 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance - 3009 Other(specify) - 3010 Other(specify) - 3011 10ther(specify) - 3012 10ther(specify) - DIRECT OPERATING EXPENSES TOTAL: $ 22,523 4000: DIRECT FACILITIES&EQUIPMENT Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Acct# Line Item Description Amount 4001 Building Maintenance $ 2,483 4002 Rent/Lease Building 5,305 4003 Rent/Lease Equipment 500 4004 Rent/Lease Vehicles - 4005 Security 1,474 4006 Utilities 1,092 4007 Other(Staff Recruitment) 750 4008 Other(insurance) 1,911 4009 Other(specify) - 4010 Other(specify) - DIRECT FACILITIES/EQUIPMENT TOTAL: $ 13,515 5000: DIRECT SPECIAL EXPENSES Acct# Line Item Description Amount 5001 Consultant(Network&Data Management) $ 9,285 5002 HMIS(Health Management Information System) - 5003 Contractual/Consulting Services (Specify) - 5004 Translation Services 350 5005 Other(specify) - 5006 Other(specify) - 5007 Other(specify) - 5008 Other(specify) - DIRECT SPECIAL EXPENSES TOTAL: $ 9,635 6000: INDIRECT EXPENSES Acct# Line Item Description Amount Administrative Overhead 6001 Use this line and only this line for approved indirect cost rate $ - Administrative Overhead 6002 Professional Liability Insurance 6003 Accounting/Bookkeeping 6004 External Audit 6005 Insurance(Specify): Property 6006 Payroll Services - 6007 Depreciation(Provider-Owned Equipment to be Used for Program Purposes) - 6008 Personnel(Indirect Salaries&Benefits) 34,695 6009 Other(Operating) 11,565 6010 Other(specify) - 6011 Other(specify) - 6012 Other(specify) - 6013 Other(specify) - INDIRECT EXPENSES TOTAL $ 46,260 INDIRECT COST RATE 11.50% 7000: DIRECT FIXED ASSETS Acct# Line Item Description Amount 7001 Computer Equipment&Software $ 5,750 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA Data - 7003 Furniture&Fixtures - 7004 Leasehold/Tenant/Building Improvements - 7005 Other Assets over$500 with Lifespan of 2 Years+ d- Fresno 7006 Assets over$5,000/unit(Specify) 7007 Other(specify)County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B 7008 Other(specify) - FIXED ASSETS EXPENSES TOTAL $ 5,750 TOTAL PROGRAM EXPENSES $ 448,519 PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) Acct# Line Item Description Service Units Rate Amount 8001 Mental Health Services 864 4.00 $ 3,456 8002 Case Management 432 3.85 1,663 8003 Crisis Services 2,160 5.85 12,636 8004 Medication Support 0 - 8005 Collateral 864 4.00 3,456 8006 Plan Development 0 - - 8007 Assessment 0 - - 8008 Rehabilitation 0 - - 8009 Other(Specify) 0 - - 8010 Other(Specify) 0 - Estimated Specialty Mental Health Services Billing Totals: 1 4,3201 $ 21,211 Estimated%of Clients who are Medi-Cal Beneficiaries 85% Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 18,030 Federal Financial Participation(FFP)% 65% 11,719 MEDI-CAL FFP TOTAL $ 11,719 8100-SUBSTANCE USE DISORDER FUNDS Acct# Line Item Description Amount 8101 Drug Medi-Cal $ - 8102 SABG $ - SUBSTANCE USE DISORDER FUNDS TOTAL $ - 8200-REALIGNMENT Acct# Line Item Description Amount 8201 lRealignment $ 436,800 REALIGNMENT TOTAL $ 436,800 8300-MENTAL HEALTH SERVICE ACT(MHSA) Acct# MHSA Component MHSA Program Name Amount 8301 CSS-Community Services&Supports $ - 8302 PEI-Prevention&Early Intervention - 8303 INN-Innovations - 8304 WET-Workforce Education&Training - 8305 JCFTN-Capital Facilities&Technology - MHSA TOTAL $ - 8400-OTHER REVENUE Acct# Line Item Description Amount 8401 Client Fees $ - 8402 Client Insurance - 8403 Other(Specify) 8404 Other(Specify) - 8405 Other(Specify) - OTHER REVENUE TOTAL $ - TOTAL PROGRAM FUNDING SOURCES: $ 448,519 NET PROGRAM COST: $ (0) Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System (FURS) Kings View Fiscal Year(FY)2024-25 PARTIAL FTE DETAIL For all positions with FTE's split among multiple programs/contracts the below must be filled out Position Contract#/Name/Department/County FTE Executive Director PATH SMHS/Fresno 0.01 PATH OEL/Fresno 0.01 PATH MOP/Fresno 0.03 Blue Sky/Fresno 0.05 Rural Crisis Intervention/Fresno 0.03 Metro CIT/Fresno 0.02 Map Point/Fresno 0.01 Suicide Prevention Follow-up Call/Fresno 0.01 FURS/Fresno 0.03 CVSPH/California State,Tulare,Calaveras,Tuolum 0.14 Shasta 0.09 Tulare 0.26 Madera 0.06 Kings 0.23 Administrative Department 0.02 Tota 1 1.00 Position Contract#/Name/Department/County FTE Regional Director PATH SMHS/Fresno 0.02 PATH OEL/Fresno 0.02 PATH MOP/Fresno 0.06 Blue Sky/Fresno 0.11 Rural Crisis Intervention/Fresno 0.16 Metro CIT/Fresno 0.25 Map Point/Fresno 0.05 FURS/Fresno 0.03 Suicide Prevention Follow-up Call/Fresno 0.01 CVSPH/California State,Tulare,Calaveras,Tuolum 0.15 Madera I0.14 1.00 Position Contract#/Name/Department/County FTE Staff Accountant PATHSMHS/Fresno 0.06 PATH OEL/Fresno 0.07 PATH MOP/Fresno 0.06 Blue Sky/Fresno 0.10 Rural Crisis Intervention/Fresno 0.12 Metro CIT/Fresno 0.10 FURS/Fresno 0.03 Suicide Prevention Follow-up Call/Fresno 0.01 CVSPH/California State,Tulare,Calaveras,Tuolumi 0.05 Shasta 0.07 Finance Department 0.34 Tota 1 1.00 Position Contract#/Name/Department/County FTE Quality Assurance Specialist FURS/Fresno 0.03 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Tota 1 0.03 Position Contract#/Name/Department/County FTE Administrative Specialist PATH SMHS/Fresno 0.17 PATH OEL/Fresno 0.05 Rural Crisis Intervention/Fresno 0.75 FURS/Fresno 0.03 Tota 1 1.00 Position Contract#/Name/Department/County FTE% Program Manager FURS/Fresno 0.03 Tota 1 0.03 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System (FURS) Kings View Fiscal Year (FY) 2024-25 Budget Narrative PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1000:DIRECT SALARIES&BENEFITS 350,836 Administrative Positions 16,056 1101 Executive Director 5,764 Position will provide agency specific staff oversight and represent and maintain the collaborative relationship between agencies. 1102 Regional Director 4,127 Provide program management and direction.Ensures operations are running smoothly and in compliance with contract requirements. 1103 Staff Accountant 1,877 Provides budget guidance,monthly invoicing and other fiscal services. 1104 Administrative Specialist 1,640 Provides administrative support for the program and assist with medical billing and records. 1105 Quality Assurance Specialist 2,648 Ensures compliance and reports on contract deliverables. 1106 0 - 1107 0 - 1108 0 - 1109 0 - 1110 0 - 1111 0 - 1112 0 - 1113 0 - 1114 0 - 1115 0 - Program Positions 262,386 1116 Program Manager 3,442 Provides supervision of all staff and direct oversight of program. 1117 Licensed Clinician 97,094 Assist with managing the client's illness and reduce its impact on the client's life,and referrals to appropriate linkages. 1118 Unlicensed Clinician 75,027 Assist with managing the client's illness and reduce its impact on the client's life,and referrals to appropriate linkages. 1119 Peer Support 40,823 Provides outreach and engagement services,provides linkage to needed services. 1120 On-Call 46,000 Cost for afterhours phone response. 1121 0 1122 0 - 1123 0 - 1124 0 - 1125 0 - 1126 0 - 1127 0 - 1128 0 - 1129 0 - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1130 0 1131 0 1132 0 - 1133 0 - 1134 0 - Direct Employee Benefits 49,422 1201 Retirement 5,263 Cost of 401K 1202 Worker's Compensation 9,717 Workers Comp Insurance 1203 Insurance 34,442 Cost of Medical,Vision,Dental,Life and Long Term Disability Insurance 1204 0 - 1205 0 - 1206 0 - Direct Payroll Taxes&Expenses: 22,972 1301 OASDI - 1302 FICA/MEDICARE 21,301 Cost of FICA/Medicare 1303 Dental Insurance 1,671 Cost of SUI 1304 Vision Insurance - 1305 Life Insurance - 1306 Other(specify) - 2000:DIRECT CLIENT SUPPORT - 2001 Child Care - 2002 Client Housing Support - 2003 Client Transportation&Support - 2004 Clothing,Food,&Hygiene - 2005 Long Term Disability - 2006 Employment Support - 2007 Household Items for Clients - 2008 Medication Supports - 2009 Program Supplies-Medical - 2010 Utility Vouchers - 2011 Other(specify) - 2012 Other(specify) - 2013 Other(specify) - 2014 Other(specify) - 2015 Other(specify) - 2016 Other(specify) - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 3000:DIRECT OPERATING EXPENSES 22,523 3001 Telecommunications 5,345 Cost of telephone services,cell phones service,data connectivity. 3002 Printing/Postage 500 Anticipating courier services and postage necessary for program.Business cards and other special printing in bulk that is less cost effective to outsource rather than utilization of a copier. 3003 Office,Household&Program Supplies 4,095 Includes all supplies used by staff in the course of providing services. 3004 Advertising - 3005 Staff Development&Training 7,123 Cost of staff development and training package from PESI and internal matter experts. Includes expenses such as travel transportation,hotel stays,and meals. 3006 Staff Mileage 5,460 Reimbursements to staff for personal vehicle use to provide services or other program needs,paid at IRS rate.Any travel transportation fees,such as parking fees. 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance - 3009 Other(specify) - 3010 Other(specify) - 3011 Other(specify) - 3012 Other(specify) - 4000:DIRECT FACILITIES&EQUIPMENT 13,515 4001 Building Maintenance 2,483 Shared cost for copier maintenance,inspection services,pest control,alarm services, janitorial services and minor building repairs and maintenance,and necessary expenses to maintain building maintenance. 4002 Rent/Lease Building 5,305 Estimated shared building space lease. 4003 Rent/Lease Equipment 500 Shared cost for copier lease and water dispenser rental. 4004 Rent/Lease Vehicles - 4005 Security 1,474 Shared expense of afterhours security. 4006 Utilities 1,092 Estimated share cost of gas and electric. 4007 Other(Staff Recruitment) 750 Thorough background checks and drug testing. 4008 Other(Insurance) 1,911 Direct expense to program for general,professional liability, personal property,accidental,and auto insurance. 4009 Other(specify) - 4010 Other(specify) - 5000:DIRECT SPECIAL EXPENSES 9,635 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 5001 Consultant(Network&Data Management) 9,285 Kings View Information Technology Department(KVIT)will provide hardware and software support successful data collection.Information services and management consisting of managed internet service provider,network and desktop management, project management,technology procurement,telecommunication management, strategic technology planning,system documentation,application/data hosting,access to data/documents/application 24/7. After hours support via email and phone 24/7. 5002 HMIS(Health Management Information System) - 5003 Contractual/Consulting Services (Specify) - 5004 Translation Services 350 Anticipating translation services to assist clients. 5005 Other(specify) - 5006 Other(specify) - 5007 Other(specify) - 5008 Other(specify) - 6000:INDIRECT EXPENSES 46,260 6001 Administrative Overhead - 6002 Professional Liability Insurance - 6003 Accounting/Bookkeeping 6004 External Audit - 6005 Insurance(Specify):Property - 6006 Payroll Services 6007 Depreciation(Provider-Owned Equipment to be Used - 6008 Personnel(Indirect Salaries&Benefits) 34,695 Expenses provides corporate management,fiscal services,payroll,human resources, accounts payable and other administrative functions. 6009 Other(Operating) 11,565 Expenses provides corporate management,fiscal services,payroll,human resources, accounts payable and other administrative functions. 6010 Other(specify) - 6011 Other(specify) - 6012 Other(specify) - 6013 Other(specify) - 7000:DIRECT FIXED ASSETS 5,750 7001 Computer Equipment&Software 5,750 Anticipating computer equipment replacement. Estimated software needs to support staff. 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA - 7003 Furniture&Fixtures - 7004 Leasehold/Tenant/Building Improvements - 7005 Other Assets over$500 with Lifespan of 2 Years+ - 7006 Assets over$5,000/unit(Specify) - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACC T# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 7007 Other(specify) - 7008 Other(specify) - PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) PROVIDE DETAILS OF METHODOLOGY(IES)USED IN DETERMINING MEDI-CAL ACCT# LINE ITEM SERVICE RATES AND/OR SERVICE UNITS,IF APPLICABLE AND/OR AS REQUIRED BY THE RFP 8001 Mental Health Services Estimated billable services based on reported approximately 4 calls per month.Made assumptions on type of service:50%crisis,20%each counseling and collateral,10% linkage. 8002 Case Management Used rates from current outpatient programs. 8003 Crisis Services Estimated that majority of consumers would have MediCal,collaterals might not.-85% eligibility 8004 Insurance(Specify):Property Estimated a blended reimbursement rate of 65%assuming some would have ACA or enhanced aid codes,while others would be regular FFP at 50%. 8005 Collateral 8006 Plan Development 8007 Assessment 8008 Staff Recruitment 8009 Other(Specify) 8010 Other(Specify) TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 448,519 TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 448,519 0 BUDGET CHECK: - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System(FURS) Kings View Fiscal Year(FY)2025-26 PROGRAM EXPENSES 1000:DIRECT SALARIES&BENEFITS Direct Employee Salaries Acct# Administrative Position FTE Admin Program Total 1101 Executive Director 0.03 $ 5,937 $ 5,937 1102 Regional Director 0.03 4,251 4,251 1103 Staff Accountant 0.03 1,933 1,933 1104 Administrative Specialist 0.03 1,689 1,689 1105 Quality Assurance Specialist 0.03 2,727 2,727 1106 1107 - - 1108 - - 1109 - - 1110 - - 1111 - 1112 - 1113 - - 1114 - 1115 - - Direct Personnel Admin Salaries Subtotal 0.15 $ 16,537 $ 16,537 Acct# Program Position FTE Admin Program Total 1116 Program Manager 0.03 $ 3,545 $ 3,545 1117 Licensed Clinician 1.00 100,007 100,007 1118 Unlicensed Clinician 1.00 77,278 77,278 1119 Peer Support 1.00 42,048 42,048 1120 On-Call 46,000 46,000 1121 - - 1122 - 1123 - - 1124 - 1125 - 1126 - 1127 - - 1128 - 1129 - - 1130 - 1131 - - 1132 - 1133 - - 1134 - Direct Personnel Program Salaries Subtotall 3.03 1 $ 268,878 1 $ 268,878 Admin Program Total Direct Personnel Salaries Subtotall 3.18 1 $ 16,537 1 $ 268,878 1 $ 285,415 Direct Employee Benefits Acct# Description Admin Program Total 1201 Retirement $ 313 $ 5,082 $ 5,395 1202 Worker's Compensation 577 9,384 9,961 1203 Insurance 2,046 33,260 35,306 1204 - 1205 - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B 1206 - Direct Employee Benefits Subtotal: $ 2,935 $ 47,727 $ 50,662 Direct Payroll Taxes&Expenses: Acct# Description Admin Program Total 1301 OASDI $ - $ - $ - 1302 FICA/MEDICARE 1,265 20,569 21,834 1303 SUI 99 1,613 1,712 1304 Other(specify) - 1305 10ther(specify) - - - 1306 10ther(specify) - - - Direct Payroll Taxes&Expenses Subtotal: $ 1,364 $ 22,182 $ 23,546 DIRECT EMPLOYEE SALARIES&BENEFITS TOTAL: Admin Program Total $ 20,837 $ 338,786 $ 359,623 DIRECT EMPLOYEE SALARIES&BENEFITS PERCENTAGE: Admin Program 6%1 94% 2000: DIRECT CLIENT SUPPORT Acct# Line Item Description Amount 2001 Child Care $ - 2002 Client Housing Support - 2003 Client Transportation&Support - 2004 Clothing, Food,&Hygiene - 2005 Education Support - 2006 Employment Support - 2007 Household Items for Clients - 2008 Medication Supports - 2009 Program Supplies-Medical - 2010 Utility Vouchers - 2011 Other(specify) - 2012 Other(specify) - 2013 Other(specify) - 2014 Other(specify) - 2015 Other(specify) - 2016 Other(specify) - DIRECT CLIENT CARE TOTAL $ - 3000: DIRECT OPERATING EXPENSES Acct# Line Item Description Amount 3001 Telecommunications $ 5,559 3002 Printing/Postage 400 3003 Office, Household&Program Supplies 3,484 3004 Advertising - 3005 Staff Development&Training 4,000 3006 Staff Mileage 5,569 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance - 3009 Other(specify) - 3010 Other(specify) - 3011 10ther(specify) - 3012 10ther(specify) - DIRECT OPERATING EXPENSES TOTAL: $ 19,012 4000: DIRECT FACILITIES&EQUIPMENT Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Acct# Line Item Description Amount 4001 Building Maintenance $ 2,572 4002 Rent/Lease Building 5,464 4003 Rent/Lease Equipment 500 4004 Rent/Lease Vehicles - 4005 Security 1,533 4006 jUtilities 1,136 4007 Other(Staff Recruitment) 500 4008 Other(insurance) 1,988 4009 Other(specify) - 4010 Other(specify) - DIRECT FACILITIES/EQUIPMENT TOTAL: $ 13,693 5000: DIRECT SPECIAL EXPENSES Acct# Line Item Description Amount 5001 Consultant(Network&Data Management) $ 9,470 5002 HMIS(Health Management Information System) - 5003 Contractual/Consulting Services (Specify) - 5004 Translation Services 350 5005 Other(specify) - 5006 Other(specify) - 5007 Other(specify) - 5008 Other(specify) - DIRECT SPECIAL EXPENSES TOTAL: $ 9,820 6000: INDIRECT EXPENSES Acct# Line Item Description Amount Administrative Overhead 6001 Use this line and only this line for approved indirect cost rate $ - Administrative Overhead 6002 Professional Liability Insurance 6003 Accounting/Bookkeeping 6004 External Audit 6005 Insurance(Specify): Property 6006 Payroll Services - 6007 Depreciation(Provider-Owned Equipment to be Used for Program Purposes) - 6008 Personnel(Indirect Salaries&Benefits) 34,750 6009 Other(Operating) 11,583 6010 Other(specify) - 6011 Other(specify) - 6012 Other(specify) - 6013 Other(specify) - INDIRECT EXPENSES TOTAL $ 46,333 INDIRECT COST RATE 11.50% 7000: DIRECT FIXED ASSETS Acct# Line Item Description Amount 7001 Computer Equipment&Software $ 750 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA Data - 7003 Furniture&Fixtures - 7004 Leasehold/Tenant/Building Improvements - 7005 Other Assets over$500 with Lifespan of 2 Years+ d- Fresno 7006 Assets over$5,000/unit(Specify) 7007 Other(specify)County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B 7008 Other(specify) j FIXED ASSETS EXPENSES TOTAL $ 75 TOTAL PROGRAM EXPENSES $ 449,231 PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) Acct# Line Item Description Service Units Rate Amount 8001 Mental Health Services 1,080 4.00 $ 4,320 8002 Case Management 540 3.85 2,079 8003 Crisis Services 2,700 5.85 15,795 8004 Medication Support - - 8005 Collateral 1,080 4.00 4,320 8006 Plan Development 0 - - 8007 Assessment 0 - - 8008 Rehabilitation 0 - 8009 Other(Specify) 0 - 8010 Other(Specify) 0 - Estimated Specialty Mental Health Services Billing Totals: 1 5,4001 $ 26,514 Estimated%of Clients who are Medi-Cal Beneficiaries 85% Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 22,537 Federal Financial Participation(FFP)% 65% 14,649 MEDI-CAL FFP TOTAL $ 14,649 8100-SUBSTANCE USE DISORDER FUNDS Acct# Line Item Description Amount 8101 Drug Medi-Cal $ - 8102 SABG $ - SUBSTANCE USE DISORDER FUNDS TOTAL $ - 8200-REALIGNMENT Acct# Line Item Description Amount 8201 Realignment $ 434,582 REALIGNMENT TOTAL $ 434,582 8300-MENTAL HEALTH SERVICE ACT(MHSA) Acct# MHSA Component MHSA Program Name Amount 8301 CSS-Community Services&Supports $ - 8302 PEI-Prevention&Early Intervention - 8303 INN-Innovations - 8304 WET-Workforce Education&Training - 8305 JCFTN-Capital Facilities&Technology - MHSA TOTAL $ - 8400-OTHER REVENUE Acct# Line Item Description Amount 8401 Client Fees $ - 8402 Client Insurance - 8403 Other(Specify) 8404 Other(Specify) - 8405 Other(Specify) - OTHER REVENUE TOTAL $ - TOTAL PROGRAM FUNDING SOURCES: $ 449,231 NET PROGRAM COST: $ 0 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System(FURS) Kings View Fiscal Year(FY)2025-26 PARTIAL FTE DETAIL For all positions with FTE's split among multiple programs/contracts the below must be filled out Position Contract#/Name/Department/County FTE Executive Director PATH SMHS/Fresno 0.01 PATH OEL/Fresno 0.01 PATH MOP/Fresno 0.03 Blue Sky/Fresno 0.05 Rural Crisis Intervention/Fresno 0.03 Metro CIT/Fresno 0.02 Map Point/Fresno 0.01 Suicide Prevention Follow-up Call/Fresno 0.01 FURS/Fresno 0.03 CVSPH/California State,Tulare,Calaveras,Tuolumi 0.14 Shasta 0.09 Tulare 0.26 Madera 0.06 Kings 0.23 Administrative Department 0.02 Tota 1 1.00 Position Contract#/Name/Department/County FTE Regional Director PATH SMHS/Fresno 0.02 PATH OEL/Fresno 0.02 PATH MOP/Fresno 0.06 Blue Sky/Fresno 0.11 Rural Crisis Intervention/Fresno 0.16 Metro CIT/Fresno 0.25 Map Point/Fresno 0.05 FURS/Fresno 0.03 Suicide Prevention Follow-up Call/Fresno 0.01 CVSPH/California State,Tulare,Calaveras,Tuolum 0.15 Madera 0.14 1.00 Position Contract#/Name/Department/County FTE Staff Accountant PATH SMHS/Fresno 0.06 PATH OEL/Fresno 0.07 PATH MOP/Fresno 0.06 Blue Sky/Fresno 0.10 Rural Crisis Intervention/Fresno 0.12 Metro CIT/Fresno 0.10 FURS/Fresno 0.03 Suicide Prevention Follow-up Call/Fresno 0.01 CVSPH/California State,Tulare,Calaveras,Tuolumi 0.05 Shasta 0.07 Finance Department 0.34 Tota 1 1.00 Position Contract#/Name/Department/County FTE Quality Assurance Specialist FURS/Fresno 0.03 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Total 0.03 Position Contract#/Name/Department/County FTE Administrative Specialist PATH SMHS/Fresno 0.17 PATH OEL/Fresno 0.05 Rural Crisis Intervention/Fresno 0.75 FURS/Fresno 0.03 Total 1.00 Position Contract#/Name/Department/County FTE Program Manager FURS/Fresno 0.03 Total 0.03 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System (FURS) Kings View Fiscal Year (FY) 2025-26 Budget Narrative PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1000:DIRECT SALARIES&BENEFITS 359,623 Administrative Positions 16,537 1101 Executive Director 5,937 Position will provide agency specific staff oversight and represent and maintain the collaborative relationship between agencies. 1102 Regional Director 4,251 Provide program management and direction.Ensures operations are running smoothly and in compliance with contract requirements. 1103 Staff Accountant 1,933 Provides budget guidance,monthly invoicing and other fiscal services. 1104 Administrative Specialist 1,689 Provides administrative support for the program and assist with medical billing and records. 1105 Quality Assurance Specialist 2,727 Ensures compliance and reports on contract deliverables. 1106 0 - 1107 0 1108 0 - 1109 0 - 1110 0 - 1111 0 - 1112 0 - 1113 0 - 1114 0 - 1115 0 - Program Positions 268,878 1116 Program Manager 3,545 Provides supervision of all staff and direct oversight of program. 1117 Licensed Clinician 100,007 Assist with managing the client's illness and reduce its impact on the client's life,and referrals to appropriate linkages. 1118 Unlicensed Clinician 77,278 Assist with managing the client's illness and reduce its impact on the client's life,and referrals to appropriate linkages. 1119 Peer Support 42,048 Provides outreach and engagement services,provides linkage to needed services. 1120 On-Call 46,000 Cost for afterhours phone response. 1121 0 - 1122 0 - 1123 0 - 1124 0 - 1125 0 - 1126 0 - 1127 0 - 1128 0 - 1129 0 - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1130 0 1131 0 1132 0 - 1133 0 - 1134 0 - Direct Employee Benefits 50,662 1201 Retirement 5,395 Cost of 401K 1202 Worker's Compensation 9,961 Workers Comp Insurance 1203 Insurance 35,306 Cost of Medical,Vision,Dental,Life and Long Term Disability Insurance 1204 0 - 1205 0 - 1206 0 - Direct Payroll Taxes&Expenses: 23,546 1301 OASDI - 1302 FICA/MEDICARE 21,834 Cost of FICA/Medicare 1303 Dental Insurance 1,712 Cost of SUI 1304 Vision Insurance - 1305 Life Insurance - 1306 Other(specify) - 2000:DIRECT CLIENT SUPPORT - 2001 Child Care - 2002 Client Housing Support - 2003 Client Transportation&Support - 2004 Clothing,Food,&Hygiene - 2005 Long Term Disability - 2006 Employment Support - 2007 Household Items for Clients - 2008 Medication Supports - 2009 Program Supplies-Medical - 2010 Utility Vouchers - 2011 Other(specify) - 2012 Other(specify) - 2013 Other(specify) - 2014 Other(specify) - 2015 Other(specify) - 2016 Other(specify) - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 3000:DIRECT OPERATING EXPENSES 19,012 3001 Telecommunications 5,559 Cost of telephone services,cell phones service,data connectivity. 3002 Printing/Postage 400 Anticipating courier services and postage necessary for program.Business cards and other special printing in bulk that is less cost effective to outsource rather than utilization of a copier. 3003 Office,Household&Program Supplies 3,484 Includes all supplies used by staff in the course of providing services. 3004 Advertising - 3005 Staff Development&Training 4,000 Cost of staff development and training package from PESI and internal matter experts. Includes expenses such as travel transportation,hotel stays,and meals. 3006 Staff Mileage 5,569 Reimbursements to staff for personal vehicle use to provide services or other program needs,paid at IRS rate.Any travel transportation fees,such as parking fees. 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance - 3009 Other(specify) - 3010 Other(specify) - 3011 Other(specify) - 3012 Other(specify) - 4000:DIRECT FACILITIES&EQUIPMENT 13,693 4001 Building Maintenance 2,572 Shared cost for copier maintenance,inspection services,pest control,alarm services, janitorial services and minor building repairs and maintenance,and necessary expenses to maintain building maintenance. 4002 Rent/Lease Building 5,464 Estimated shared building space lease. 4003 Rent/Lease Equipment 500 Shared cost for copier lease and water dispenser rental. 4004 Rent/Lease Vehicles - 4005 Security 1,533 Shared expense of afterhours security. 4006 Utilities 1,136 Estimated share cost of gas and electric. 4007 Other(Staff Recruitment) 500 Thorough background checks and drug testing. 4008 Other(Insurance) 1,988 Direct expense to program for general,professional liability, personal property,accidental,and auto insurance. 4009 Other(specify) - 4010 Other(specify) - 5000:DIRECT SPECIAL EXPENSES 9,820 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 5001 Consultant(Network&Data Management) 9,470 Kings View Information Technology Department(KVIT)will provide hardware and software support successful data collection.Information services and management consisting of managed internet service provider,network and desktop management, project management,technology procurement,telecommunication management, strategic technology planning,system documentation,application/data hosting,access to data/documents/application 24/7. After hours support via email and phone 24/7. 5002 HMIS(Health Management Information System) - 5003 Contractual/Consulting Services (Specify) - 5004 Translation Services 350 Anticipating translation services to assist clients. 5005 Other(specify) - 5006 Other(specify) - 5007 Other(specify) - 5008 Other(specify) - 6000:INDIRECT EXPENSES 46,333 6001 Administrative Overhead - 6002 Professional Liability Insurance - 6003 Accounting/Bookkeeping 6004 External Audit - 6005 Insurance(Specify):Property - 6006 Payroll Services 6007 Depreciation(Provider-Owned Equipment to be Used - 6008 Personnel(Indirect Salaries&Benefits) 34,750 Expenses provides corporate management,fiscal services,payroll,human resources, accounts payable and other administrative functions. 6009 Other(Operating) 11,583 Expenses provides corporate management,fiscal services,payroll,human resources, accounts payable and other administrative functions. 6010 Other(specify) - 6011 Other(specify) - 6012 Other(specify) - 6013 Other(specify) - 7000:DIRECT FIXED ASSETS 750 7001 Computer Equipment&Software 750 Estimated software needs to support staff. 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA - 7003 Furniture&Fixtures 7004 Leasehold/Tenant/Building Improvements - 7005 Other Assets over$500 with Lifespan of 2 Years+ - 7006 Assets over$5,000/unit(Specify) - 7007 Other(specify) - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 7008 Other(specify) PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) PROVIDE DETAILS OF METHODOLOGY(IES)USED IN DETERMINING MEDI-CAL ACCT# LINE ITEM SERVICE RATES AND/OR SERVICE UNITS,IF APPLICABLE AND/OR AS REQUIRED BY THE RFP 8001 Mental Health Services Estimated billable services based on reported approximately 5 calls per month.Made assumptions on type of service:50%crisis,20%each counseling and collateral,10% linkage. 8002 Case Management Used rates from current outpatient programs. 8003 Crisis Services Estimated that majority of consumers would have Medical,collaterals might not.-85% eligibility 8004 Insurance(Specify): Property Estimated a blended reimbursement rate of 65%assuming some would have ACA or enhanced aid codes,while others would be regular FFP at 50%. 8005 Collateral 8006 Plan Development 8007 Assessment 8008 Staff Recruitment 8009 Other(Specify) 8010 Other(Specify) TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 449,231 TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 449,231 0 BUDGET CHECK: - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System(FURS) Kings View Fiscal Year(FY)2026-27 PROGRAM EXPENSES 1000:DIRECT SALARIES&BENEFITS Direct Employee Salaries Acct# Administrative Position FTE Admin Program Total 1101 Executive Director 0.03 $ 6,115 $ 6,115 1102 Regional Director 0.03 4,379 4,379 1103 Staff Accountant 0.03 1,991 1,991 1104 Administrative Specialist 0.03 1,740 1,740 1105 Quality Assurance Specialist 0.03 2,809 2,809 1106 1107 - - 1108 - - 1109 - - 1110 - - 1111 - 1112 - 1113 - - 1114 - 1115 - - Direct Personnel Admin Salaries Subtotal 0.15 $ 17,034 $ 17,034 Acct# Program Position FTE Admin Program Total 1116 Program Manager 0.05 $ 3,651 $ 3,651 1117 Licensed Clinician 1.00 103,007 103,007 1118 Unlicensed Clinician 1.00 79,596 79,596 1119 Peer Support 1.00 43,309 43,309 1120 On-Call 46,000 46,000 1121 - - 1122 - 1123 - - 1124 - 1125 - 1126 - 1127 - - 1128 - 1129 - - 1130 - 1131 - - 1132 - 1133 - - 1134 - - Direct Personnel Program Salaries Subtotall 3.05 1 $ 275,563 1 $ 275,563 Admin Program Total Direct Personnel Salaries Subtotall 3.20 1 $ 17,034 1 $ 275,563 1 $ 292,597 Direct Employee Benefits Acct# Description Admin Program Total 1201 Retirement $ 322 $ 5,208 $ 5,530 1202 Worker's Compensation 595 9,617 10,212 1203 Insurance 2,106 34,069 36,175 1204 - 1205 - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B 1206 - Direct Employee Benefits Subtotal: $ 3,022 $ 48,895 $ 51,917 Direct Payroll Taxes&Expenses: Acct# Description Admin Program Total 1301 OASDI $ - $ - $ - 1302 FICA/MEDICARE 1,303 21,080 22,383 1303 SUI 102 1,653 1,755 1304 - 1305 10ther(specify) - - - 1306 10ther(specify) - - - Direct Payroll Taxes&Expenses Subtotal: $ 1,405 $ 22,733 $ 24,138 DIRECT EMPLOYEE SALARIES&BENEFITS TOTAL: Admin Program Total $ 21,462 $ 347,190 $ 368,652 DIRECT EMPLOYEE SALARIES&BENEFITS PERCENTAGE: Admin Program 6%1 94% 2000: DIRECT CLIENT SUPPORT Acct# Line Item Description Amount 2001 Child Care $ - 2002 Client Housing Support - 2003 Client Transportation&Support - 2004 Clothing, Food,&Hygiene - 2005 Education Support - 2006 Employment Support - 2007 Household Items for Clients - 2008 Medication Supports - 2009 Program Supplies-Medical - 2010 Utility Vouchers - 2011 Other(specify) - 2012 Other(specify) - 2013 Other(specify) - 2014 Other(specify) - 2015 Other(specify) - 2016 Other(specify) - DIRECT CLIENT CARE TOTAL $ - 3000: DIRECT OPERATING EXPENSES Acct# Line Item Description Amount 3001 Telecommunications $ 5,782 3002 Printing/Postage 400 3003 Office, Household&Program Supplies 3,215 3004 Advertising - 3005 Staff Development&Training 4,000 3006 Staff Mileage 5,792 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance - 3009 Other(specify) - 3010 Other(specify) - 3011 10ther(specify) - 3012 10ther(specify) - DIRECT OPERATING EXPENSES TOTAL: $ 19,189 4000: DIRECT FACILITIES&EQUIPMENT Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Acct# Line Item Description Amount 4001 Building Maintenance $ 2,665 4002 Rent/Lease Building 5,683 4003 Rent/Lease Equipment 500 4004 Rent/Lease Vehicles - 4005 Security 1,594 4006 Utilities 1,181 4007 Other(Staff Recruitment) - 4008 Other(insurance) 2,067 4009 Other(specify) - 4010 Other(specify) j DIRECT FACILITIES/EQUIPMENT TOTAL: $ 13,69 5000: DIRECT SPECIAL EXPENSES Acct# Line Item Description Amount 5001 Consultant(Network&Data Management) $ 9,754 5002 HMIS(Health Management Information System) - 5003 Contractual/Consulting Services (Specify) - 5004 Translation Services 350 5005 Other(specify) - 5006 Other(specify) - 5007 Other(specify) - 5008 Other(specify) - DIRECT SPECIAL EXPENSES TOTAL: $ 10,104 6000: INDIRECT EXPENSES Acct# Line Item Description Amount Administrative Overhead 6001 Use this line and only this line for approved indirect cost rate $ - Administrative Overhead 6002 Professional Liability Insurance 6003 Accounting/Bookkeeping 6004 External Audit 6005 Insurance(Specify): Property 6006 Payroll Services - 6007 Depreciation(Provider-Owned Equipment to be Used for Program Purposes) - 6008 Personnel(Indirect Salaries&Benefits) 35,572 6009 Other(Operating) 11,858 6010 Other(specify) - 6011 Other(specify) - 6012 Other(specify) - 6013 Other(specify) - INDIRECT EXPENSES TOTAL $ 47,430 INDIRECT COST RATE 11.50% 7000: DIRECT FIXED ASSETS Acct# Line Item Description Amount 7001 Computer Equipment&Software $ 750 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA Data - 7003 Furniture&Fixtures - 7004 Leasehold/Tenant/Building Improvements - 7005 Other Assets over$500 with Lifespan of 2 Years+ d- Fresno 7006 Assets over$5,000/unit(Specify) 7007 Other(specify)County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B 7008 Other(specify) - FIXED ASSETS EXPENSES TOTAL $ 750 TOTAL PROGRAM EXPENSES $ 459,815 PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) Acct# Line Item Description Service Units Rate Amount 8001 Mental Health Services 1,512 4.00 $ 6,048 8002 Case Management 756 3.85 2,911 8003 Crisis Services 3,780 5.50 20,790 8004 Medication Support 0 - 8005 Collateral 1,512 4.00 6,048 8006 Plan Development 0 - - 8007 Assessment 0 - - 8008 Rehabilitation 0 - - 8009 Other(Specify) 0 - - 8010 Other(Specify) 0 - Estimated Specialty Mental Health Services Billing Totals: 1 7,5601 $ 35,797 Estimated%of Clients who are Medi-Cal Beneficiaries 85% Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 30,427 Federal Financial Participation(FFP)% 65% 19,778 MEDI-CAL FFP TOTAL $ 19,778 8100-SUBSTANCE USE DISORDER FUNDS Acct# Line Item Description Amount 8101 Drug Medi-Cal $ - 8102 SABG $ - SUBSTANCE USE DISORDER FUNDS TOTAL $ - 8200-REALIGNMENT Acct# Line Item Description Amount 8201 Realignment $ 440,037 REALIGNMENT TOTAL $ 440,037 8300-MENTAL HEALTH SERVICE ACT(MHSA) Acct# MHSA Component MHSA Program Name Amount 8301 CSS-Community Services&Supports $ - 8302 PEI-Prevention&Early Intervention - 8303 INN-Innovations - 8304 WET-Workforce Education&Training - 8305 JCFTN-Capital Facilities&Technology - MHSA TOTAL $ - 8400-OTHER REVENUE Acct# Line Item Description Amount 8401 Client Fees $ - 8402 Client Insurance - 8403 Other(Specify) - 8404 Other(Specify) - 8405 Other(Specify) - OTHER REVENUE TOTAL $ - TOTAL PROGRAM FUNDING SOURCES: $ 459,815 NET PROGRAM COST: $ 0 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System(FURS) Kings View Fiscal Year(FY)2026-27 PARTIAL FTE DETAIL For all positions with FTE's split among multiple programs/contracts the below must be filled out Position Contract#/Name/Department/County FTE Executive Director PATH SMHS/Fresno 0.01 PATH OEL/Fresno 0.01 PATH MOP/Fresno 0.03 Blue Sky/Fresno 0.05 Rural Crisis Intervention/Fresno 0.03 Metro CIT/Fresno 0.02 Map Point/Fresno 0.01 Suicide Prevention Follow-up Call/Fresno 0.01 FURS/Fresno 0.03 CVSPH/California State,Tulare,Calaveras,Tuolumi 0.14 Shasta 0.09 Tulare 0.26 Madera 0.06 Kings 0.23 Administrative Department 0.02 Tota 1 1.00 Position Contract#/Name/Department/County FTE Regional Director PATH SMHS/Fresno 0.02 PATH OEL/Fresno 0.02 PATH MOP/Fresno 0.06 Blue Sky/Fresno 0.11 Rural Crisis Intervention/Fresno 0.16 Metro CIT/Fresno 0.25 Map Point/Fresno 0.05 FURS/Fresno 0.03 Suicide Prevention Follow-up Call/Fresno 0.01 CVSPH/California State,Tulare,Calaveras,Tuolum 0.15 Madera 0.14 1.00 Position Contract#/Name/Department/County FTE Staff Accountant PATH SMHS/Fresno 0.06 PATH OEL/Fresno 0.07 PATH MOP/Fresno 0.06 Blue Sky/Fresno 0.10 Rural Crisis Intervention/Fresno 0.12 Metro CIT/Fresno 0.10 FURS/Fresno 0.03 Suicide Prevention Follow-up Call/Fresno 0.01 CVSPH/California State,Tulare,Calaveras,Tuolumi 0.05 Shasta 0.07 Finance Department 0.34 Tota 1 1.00 Position Contract#/Name/Department/County FTE Quality Assurance Specialist FURS/Fresno 0.03 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Total 0.03 Position Contract#/Name/Department/County FTE Administrative Specialist PATH SMHS/Fresno 0.17 PATH OEL/Fresno 0.05 Rural Crisis Intervention/Fresno 0.75 FURS/Fresno 0.03 Total 1.00 Position Contract#/Name/Department/County FTE Program Manager FURS/Fresno 0.05 Total 0.05 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B Kings View Family Urgent Response System (FURS) Kings View Fiscal Year (FY) 2026-27 Budget Narrative PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1000:DIRECT SALARIES&BENEFITS 368,652 Administrative Positions 17,034 1101 Executive Director 6,115 Position will provide agency specific staff oversight and represent and maintain the collaborative relationship between agencies. 1102 Regional Director 4,379 Provide program management and direction.Ensures operations are running smoothly and in compliance with contract requirements. 1103 Staff Accountant 1,991 Provides budget guidance,monthly invoicing and other fiscal services. 1104 Administrative Specialist 1,740 Provides administrative support for the program and assist with medical billing and records. 1105 Quality Assurance Specialist 2,809 Ensures compliance and reports on contract deliverables. 1106 0 - 1107 0 1108 0 - 1109 0 - 1110 0 - 1111 0 - 1112 0 - 1113 0 - 1114 0 - 1115 0 - Program Positions 275,563 1116 Program Manager 3,651 Provides supervision of all staff and direct oversight of program. 1117 Licensed Clinician 103,007 Assist with managing the client's illness and reduce its impact on the client's life,and referrals to appropriate linkages. 1118 Unlicensed Clinician 79,596 Assist with managing the client's illness and reduce its impact on the client's life,and referrals to appropriate linkages. 1119 Peer Support 43,309 Provides outreach and engagement services,provides linkage to needed services. 1120 On-Call 46,000 Cost for afterhours phone response. 1121 0 - 1122 0 - 1123 0 - 1124 0 - 1125 0 - 1126 0 - 1127 0 - 1128 0 - 1129 0 - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1130 0 1131 0 1132 0 - 1133 0 - 1134 0 - Direct Employee Benefits 51,917 1201 Retirement 5,530 Cost of 401K 1202 Worker's Compensation 10,212 Workers Comp Insurance 1203 Insurance 36,175 Cost of Medical,Vision,Dental,Life and Long Term Disability Insurance 1204 0 - 1205 0 - 1206 0 - Direct Payroll Taxes&Expenses: 24,138 1301 OASDI - 1302 FICA/MEDICARE 22,383 Cost of FICA/Medicare 1303 Dental Insurance 1,755 Cost of SUI 1304 Vision Insurance - 1305 Life Insurance - 1306 Other(specify) - 2000:DIRECT CLIENT SUPPORT - 2001 Child Care - 2002 Client Housing Support - 2003 Client Transportation&Support - 2004 Clothing,Food,&Hygiene - 2005 Long Term Disability - 2006 Employment Support - 2007 Household Items for Clients - 2008 Medication Supports - 2009 Program Supplies-Medical - 2010 Utility Vouchers - 2011 Other(specify) - 2012 Other(specify) - 2013 Other(specify) - 2014 Other(specify) - 2015 Other(specify) - 2016 Other(specify) - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 3000:DIRECT OPERATING EXPENSES 19,189 3001 Telecommunications 5,782 Cost of telephone services,cell phones service,data connectivity. 3002 Printing/Postage 400 Anticipating courier services and postage necessary for program.Business cards and other special printing in bulk that is less cost effective to outsource rather than utilization of a copier. 3003 Office,Household&Program Supplies 3,215 Includes all supplies used by staff in the course of providing services. 3004 Advertising - 3005 Staff Development&Training 4,000 Cost of staff development and training package from PESI and internal matter experts. Includes expenses such as travel transportation,hotel stays,and meals. 3006 Staff Mileage 5,792 Reimbursements to staff for personal vehicle use to provide services or other program needs,paid at IRS rate.Any travel transportation fees,such as parking fees. 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance - 3009 Other(specify) - 3010 Other(specify) - 3011 Other(specify) - 3012 Other(specify) - 4000:DIRECT FACILITIES&EQUIPMENT 13,690 4001 Building Maintenance 2,665 Shared cost for copier maintenance,inspection services,pest control,alarm services, janitorial services and minor building repairs and maintenance,and necessary expenses to maintain building maintenance. 4002 Rent/Lease Building 5,683 Estimated shared building space lease. 4003 Rent/Lease Equipment 500 Shared cost for copier lease and water dispenser rental. 4004 Rent/Lease Vehicles - 4005 Security 1,594 Shared expense of afterhours security. 4006 Utilities 1,181 Estimated share cost of gas and electric. 4007 Other(Staff Recruitment) - 4008 Other(Insurance) 2,067 Direct expense to program for general,professional liability, personal property,accidental,and auto insurance. 4009 Other(specify) - 4010 Other(specify) - 5000:DIRECT SPECIAL EXPENSES 10,104 Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 5001 Consultant(Network&Data Management) 9,754 Kings View Information Technology Department(KVIT)will provide hardware and software support successful data collection.Information services and management consisting of managed internet service provider,network and desktop management, project management,technology procurement,telecommunication management, strategic technology planning,system documentation,application/data hosting,access to data/documents/application 24/7. After hours support via email and phone 24/7. 5002 HMIS(Health Management Information System) - 5003 Contractual/Consulting Services (Specify) - 5004 Translation Services 350 Anticipating translation services to assist clients. 5005 Other(specify) - 5006 Other(specify) - 5007 Other(specify) - 5008 Other(specify) - 6000:INDIRECT EXPENSES 47,430 6001 Administrative Overhead - 6002 Professional Liability Insurance - 6003 Accounting/Bookkeeping - 6004 External Audit - 6005 Insurance(Specify):Property - 6006 Payroll Services - 6007 Depreciation(Provider-Owned Equipment to be Used - 6008 Personnel(Indirect Salaries&Benefits) 35,572 Expenses provides corporate management,fiscal services,payroll,human resources, accounts payable and other administrative functions. 6009 Other(Operating) 11,858 Expenses provides corporate management,fiscal services,payroll,human resources, accounts payable and other administrative functions. 6010 Other(specify) - 6011 Other(specify) - 6012 Other(specify) - 6013 Other(specify) - 7000:DIRECT FIXED ASSETS 750 7001 Computer Equipment&Software 750 Estimated software needs to support staff. 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA - 7003 Furniture&Fixtures 7004 Leasehold/Tenant/Building Improvements - 7005 Other Assets over$500 with Lifespan of 2 Years+ - 7006 Assets over$5,000/unit(Specify) - 7007 Other(specify) - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit B PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 7008 Other(specify) PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) PROVIDE DETAILS OF METHODOLOGY(IES)USED IN DETERMINING MEDI-CAL ACCT# LINE ITEM SERVICE RATES AND/OR SERVICE UNITS,IF APPLICABLE AND/OR AS REQUIRED BY THE RFP 8001 Mental Health Services Estimated billable services based on reported approximately 7 calls per month.Made assumptions on type of service:50%crisis,20%each counseling and collateral,10% linkage. 8002 Case Management Used rates from current outpatient programs. 8003 Crisis Services Estimated that majority of consumers would have Medical,collaterals might not.-85% eligibility 8004 Insurance(Specify): Property Estimated a blended reimbursement rate of 65%assuming some would have ACA or enhanced aid codes,while others would be regular FFP at 50%. 8005 Collateral 8006 Plan Development 8007 Assessment 8008 Staff Recruitment 8009 Other(Specify) 8010 Other(Specify) TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 459,815 TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 459,815 0 BUDGET CHECK: - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Exhibit C Self-Dealing Transaction Disclosure Form In order to conduct business with the County of Fresno ("County"), members of a Contractor's board of directors ("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 used 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. The form must be signed by the board member that is involved in the self-dealing transaction described in Sections (3) and (4). C-1 Exhibit C (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: C-2 Exhibit D Insurance Requirements 1. Required Policies Without limiting the County's right to obtain indemnification from the Contractor or any third parties, Contractor, at its sole expense, shall maintain in full force and effect the following insurance policies throughout the term of this Agreement. (A) Commercial General Liability. Commercial general liability insurance with limits of not less than Two Million Dollars ($2,000,000) per occurrence and an annual aggregate of Four Million Dollars ($4,000,000). This policy must be issued on a per occurrence basis. Coverage must include products, completed operations, property damage, bodily injury, personal injury, and advertising injury. The Contractor shall obtain an endorsement to this policy naming the County of Fresno, its officers, agents, employees, and volunteers, individually and collectively, as additional insureds, but only insofar as the operations under this Agreement are concerned. Such coverage for additional insureds will apply as primary insurance and any other insurance, or self-insurance, maintained by the County is excess only and not contributing with insurance provided under the Contractor's policy. (B) Automobile Liability. Automobile liability insurance with limits of not less than One Million Dollars ($1,000,000) per occurrence for bodily injury and for property damages. Coverage must include any auto used in connection with this Agreement. (C) Property Liability. All risk personal property insurance 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 Article 11 of this Agreement. As applicable, Contractor will provide property coverage for the full replacement value of County's personal property in possession of Contractor 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. (D)Workers Compensation. Workers compensation insurance as required by the laws of the State of California with statutory limits. (E) Employer's Liability. Employer's liability insurance with limits of not less than One Million Dollars ($1,000,000) per occurrence for bodily injury and for disease. (F) Professional Liability. Professional liability insurance with limits of not less than One Million Dollars ($1,000,000) per occurrence and an annual aggregate of Three Million Dollars ($3,000,000). If this is a claims-made policy, then (1)the retroactive date must be prior to the date on which services began under this Agreement; (2)the Contractor shall maintain the policy and provide to the County annual evidence of insurance for not less than five years after completion of services under this Agreement; and (3) if the policy is canceled or not renewed, and not replaced with another claims-made policy with a retroactive date prior to the date on which services begin under this Agreement, then the Contractor shall purchase extended reporting coverage on its claims-made policy for a minimum of five years after completion of services under this Agreement. D-1 Exhibit D (G)Molestation Liability. Sexual abuse/ molestation liability insurance with limits of not less than Two Million Dollars ($2,000,000) per occurrence, with an annual aggregate of Four Million Dollars ($4,000,000). This policy must be issued on a per occurrence basis. (H)Technology Professional Liability (Errors and Omissions). Technology professional liability (errors and omissions) insurance with limits of not less than Two Million Dollars ($2,000,000) per occurrence and in the aggregate. Coverage must encompass all of the Contractor's obligations under this Agreement, including but not limited to claims involving Cyber Risks. (1) Cyber Liability. Cyber liability insurance with limits of not less than Two Million Dollars ($2,000,000) per occurrence. Coverage must include claims involving Cyber Risks. The cyber liability policy must be endorsed to cover the full replacement value of damage to, alteration of, loss of, or destruction of intangible property (including but not limited to information or data) that is in the care, custody, or control of the Contractor. Definition of Cyber Risks. "Cyber Risks" include but are not limited to (i) Security Breach, which may include Disclosure of Personal Information to an Unauthorized Third Party; (ii) data breach; (iii) breach of any of the Contractor's obligations under Article 15 of this Agreement; (iv) system failure; (v) data recovery; (vi) failure to timely disclose data breach or Security Breach; (vii) failure to comply with privacy policy; (viii) payment card liabilities and costs; (ix) infringement of intellectual property, including but not limited to infringement of copyright, trademark, and trade dress; (x) invasion of privacy, including release of private information; (xi) information theft; (xii) damage to or destruction or alteration of electronic information; (xiii) cyber extortion; (xiv) extortion related to the Contractor's obligations under this Agreement regarding electronic information, including Personal Information; (xv)fraudulent instruction; (xvi) funds transfer fraud; (xvii) telephone fraud; (xviii) network security; (xix) data breach response costs, including Security Breach response costs; (xx) regulatory fines and penalties related to the Contractor's obligations under this Agreement regarding electronic information, including Personal Information; and (xxi) credit monitoring expenses. 2. Additional Requirements (A) Verification of Coverage. Within 30 days after the Contractor signs this Agreement, and at any time during the term of this Agreement as requested by the County's Risk Manager or the County Administrative Office, the Contractor shall deliver, or cause its broker or producer to deliver, to the County of Fresno, Department of Behavioral Health, 3133 N. Millbrook Ave, Fresno, California, 93703, Attention: Contracted Services Division or electronically to dbhcontractedservicesdivision@fresnocountyca.gov with a copy to the assigned County's DBH Staff Analyst. (i) Each insurance certificate must state that: (1) the insurance coverage has been obtained and is in full force; (2) the County, its officers, agents, employees, and volunteers are not responsible for any premiums on the policy; and (3) the Contractor has waived its right to recover from the County, its officers, agents, employees, and volunteers any amounts paid under any insurance policy required by this Agreement and that waiver does not invalidate the insurance policy. D-2 Exhibit D (ii) The commercial general liability insurance certificate must also state, and include an endorsement, that the County of Fresno, its officers, agents, employees, and volunteers, individually and collectively, are additional insureds insofar as the operations under this Agreement are concerned. The commercial general liability insurance certificate must also state that the coverage shall apply as primary insurance and any other insurance, or self-insurance, maintained by the County shall be excess only and not contributing with insurance provided under the Contractor's policy. (iii) The automobile liability insurance certificate must state that the policy covers any auto used in connection with this Agreement. (iv) The professional liability insurance certificate, if it is a claims-made policy, must also state the retroactive date of the policy, which must be prior to the date on which services began under this Agreement. (v) The technology professional liability insurance certificate must also state that coverage encompasses all of the Contractor's obligations under this Agreement, including but not limited to claims involving Cyber Risks, as that term is defined in this Agreement. (vi) The cyber liability insurance certificate must also state that it is endorsed, and include an endorsement, to cover the full replacement value of damage to, alteration of, loss of, or destruction of intangible property (including but not limited to information or data) that is in the care, custody, or control of the Contractor. (B) Acceptability of Insurers. All insurance policies required under this Agreement must be issued by admitted insurers licensed to do business in the State of California and possessing at all times during the term of this Agreement an A.M. Best, Inc. rating of no less than A: VI I. (C) Notice of Cancellation or Change. For each insurance policy required under this Agreement, the Contractor shall provide to the County, or ensure that the policy requires the insurer to provide to the County, written notice of any cancellation or change in the policy as required in this paragraph. For cancellation of the policy for nonpayment of premium, the Contractor shall, or shall cause the insurer to, provide written notice to the County not less than 10 days in advance of cancellation. For cancellation of the policy for any other reason, and for any other change to the policy, the Contractor shall, or shall cause the insurer to, provide written notice to the County not less than 30 days in advance of cancellation or change. The County in its sole discretion may determine that the failure of the Contractor or its insurer to timely provide a written notice required by this paragraph is a breach of this Agreement. (D) County's Entitlement to Greater Coverage. If the Contractor has or obtains insurance with broader coverage, higher limits, or both, than what is required under this Agreement, then the County requires and is entitled to the broader coverage, higher limits, or both. To that end, the Contractor shall deliver, or cause its broker or producer to deliver, to the County's Risk Manager certificates of insurance and endorsements for all of the coverages that have such broader coverage, higher limits, or both, as required under this Agreement. D-3 Exhibit D (E) Waiver of Subrogation. The Contractor waives any right to recover from the County, its officers, agents, employees, and volunteers any amounts paid under the policy of worker's compensation insurance required by this Agreement. The Contractor is solely responsible to obtain any policy endorsement that may be necessary to accomplish that waiver, but the Contractor's waiver of subrogation under this paragraph is effective whether or not the Contractor obtains such an endorsement. (F) County's Remedy for Contractor's Failure to Maintain. If the Contractor fails to keep in effect at all times any insurance coverage required under this Agreement, the County may, in addition to any other remedies it may have, suspend or terminate this Agreement upon the occurrence of that failure, or purchase such insurance coverage, and charge the cost of that coverage to the Contractor. The County may offset such charges against any amounts owed by the County to the Contractor under this Agreement. (G)SubContractors. The Contractor shall require and verify that all subcontractors used by the Contractor to provide services under this Agreement maintain insurance meeting all insurance requirements provided in this Agreement. This paragraph does not authorize the Contractor to provide services under this Agreement using subcontractors. D-4 Exhibit E Page 1 of 4 Fresno County Department of Behavioral Health Guiding Principles of Care Delivery DBH VISION: Health and well-being for our community. DBH MISSION: DBH, in partnership with our diverse community, is dedicated to providing quality, culturally responsive, behavioral health services to promote wellness, recovery, and resiliency for individuals and families in our community. DBH GOALS: Quadruple Aim • Deliver quality care • Maximize resources while focusing on efficiency • Provide an excellent care experience • Promote workforce well-being GUIDING PRINCIPLES OF CARE DELIVERY: The DBH 11 principles of care delivery define and guide a system that strives for excellence in the provision of behavioral health services where the values of wellness, resiliency, and recovery are central to the development of programs, services, and workforce. The principles provide the clinical framework that influences decision-making on all aspects of care delivery including program design and implementation, service delivery, training of the workforce, allocation of resources, and measurement of outcomes. 1. Principle One -Timely Access & Integrated Services o Individuals and families are connected with services in a manner that is streamlined, effective, and seamless o Collaborative care coordination occurs across agencies, plans for care are integrated, and whole person care considers all life domains such as health, education, employment, housing, and spirituality o Barriers to access and treatment are identified and addressed o Excellent customer service ensures individuals and families are transitioned from one point of care to another without disruption of care 1 rev 01-02-2020 Exhibit E Page 2 of 4 Fresno County Department of Behavioral Health Guiding Principles of Care Delivery 2. Principle Two - Strengths-based o Positive change occurs within the context of genuine trusting relationships o Individuals, families, and communities are resourceful and resilient in the way they solve problems o Hope and optimism is created through identification of, and focus on, the unique abilities of individuals and families 3. Principle Three - Person-driven and Family-driven o Self-determination and self-direction are the foundations for recovery o Individuals and families optimize their autonomy and independence by leading the process, including the identification of strengths, needs, and preferences o Providers contribute clinical expertise, provide options, and support individuals and families in informed decision making, developing goals and objectives, and identifying pathways to recovery o Individuals and families partner with their provider in determining the services and supports that would be most effective and helpful and they exercise choice in the services and supports they receive 4. Principle Four- Inclusive of Natural Supports o The person served identifies and defines family and other natural supports to be included in care o Individuals and families speak for themselves o Natural support systems are vital to successful recovery and the maintaining of ongoing wellness; these supports include personal associations and relationships typically developed in the community that enhance a person's quality of life o Providers assist individuals and families in developing and utilizing natural supports. 5. Principle Five - Clinical Significance and Evidence Based Practices (EBP) o Services are effective, resulting in a noticeable change in daily life that is measurable. o Clinical practice is informed by best available research evidence, best clinical expertise, and values and preferences of those we serve o Other clinically significant interventions such as innovative, promising, and emerging practices are embraced 2 rev 01-02-2020 Exhibit E Page 3 of 4 Fresno County Department of Behavioral Health Guiding Principles of Care Delivery 6. Principle Six- Culturally Responsive o Values, traditions, and beliefs specific to an individual's or family's culture(s) are valued and referenced in the path of wellness, resilience, and recovery o Services are culturally grounded, congruent, and personalized to reflect the unique cultural experience of each individual and family o Providers exhibit the highest level of cultural humility and sensitivity to the self- identified culture(s) of the person or family served in striving to achieve the greatest competency in care delivery 7. Principle Seven -Trauma-informed and Trauma-responsive o The widespread impacts of all types of trauma are recognized and the various potential paths for recovery from trauma are understood o Signs and symptoms of trauma in individuals, families, staff, and others are recognized and persons receive trauma-informed responses o Physical, psychological and emotional safety for individuals, families, and providers is emphasized 8. Principle Eight - Co-occurring Capable o Services are reflective of whole-person care; providers understand the influence of bio-psycho-social factors and the interactions between physical health, mental health, and substance use disorders o Treatment of substance use disorders and mental health disorders are integrated; a provider or team may deliver treatment for mental health and substance use disorders at the same time 9. Principle Nine - Stages of Change, Motivation, and Harm Reduction o Interventions are motivation-based and adapted to the person's stage of change o Progression though stages of change are supported through positive working relationships and alliances that are motivating o Providers support individuals and families to develop strategies aimed at reducing negative outcomes of substance misuse though a harm reduction approach o Each individual defines their own recovery and recovers at their own pace when provided with sufficient time and support 3 rev 01-02-2020 Exhibit E Page 4 of 4 Fresno County Department of Behavioral Health Guiding Principles of Care Delivery 10. Principle Ten - Continuous Quality Improvement and Outcomes-Driven o Individual and program outcomes are collected and evaluated for quality and efficacy o Strategies are implemented to achieve a system of continuous quality improvement and improved performance outcomes o Providers participate in ongoing professional development activities needed for proficiency in practice and implementation of treatment models 11. Principle Eleven - Health and Wellness Promotion, Illness and Harm Prevention, and Stigma Reduction o The rights of all people are respected o Behavioral health is recognized as integral to individual and community well-being o Promotion of health and wellness is interwoven throughout all aspects of DBH services o Specific strategies to prevent illness and harm are implemented at the individual, family, program, and community levels o Stigma is actively reduced by promoting awareness, accountability, and positive change in attitudes, beliefs, practices, and policies within all systems o The vision of health and well-being for our community is continually addressed through collaborations between providers, individuals, families, and community members 4 rev 01-02-2020 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. All medical records shall be maintained for a minimum of 10 years from the date of the end of the Agreement. A. Assessments 1. The following areas will be included as appropriate as a part of a comprehensive client record. • Relevant physical health conditions reported by the client will be prominently identified and updated as appropriate. • Presenting problems and relevant conditions affecting the client's physical health and mental health status will be documented, for example: living situation, daily activities, and social support. • Documentation will describe client's strengths in achieving client plan goals. • Special status situations that present a risk to clients or others will be prominently documented and updated as appropriate. • Documentations will include medications that have been described by mental health plan physicians, dosage of each medication, dates of initial prescriptions and refills, and documentations of informed consent for medications. • Client self report of allergies and adverse reactions to medications, or lack of known allergies/sensitivities will be clearly documented. • A mental health history will be documented, including: previous treatment dates, providers, therapeutic interventions and responses, sources of clinical data, relevant family information and relevant results of relevant lab tests and consultations reports. • For children and adolescents, pre-natal and perinatal events and complete developmental history will be documented. • Documentations will include past and present use of tobacco, alcohol, and caffeine, as well as illicit, prescribed and over-the-counter drugs. • A relevant mental status examination will be documented. • A DSM-5 diagnosis, or a diagnosis from the most current ICD, will be documented, consistent with the presenting problems, history mental status evaluation and/or other assessment data. Exhibit F Page 2of3 2. Timeliness/Frequency Standard for Assessment • An assessment will be completed at intake and updated as needed to document changes in the client's condition. • Client conditions will be assessed at least annually and, in most cases, at more frequent intervals. B. Client Plans 1. Client plans will: • have specific observable and/or specific quantifiable goals • identify the proposed type(s) of intervention • have a proposed duration of intervention(s) • be signed (or electronic equivalent) by: ➢ the person providing the service(s), or ➢ a person representing a team or program providing services, or ➢ a person representing the MHP providing services ➢ when the client plan is used to establish that the services are provided under the direction of an approved category of staff, and if the below staff are not the approved category, ➢ a physician ➢ a licensed/"waivered" psychologist ➢ a licensed/"associate" social worker ➢ a licensed/ registered/marriage and family therapist or ➢ a registered nurse • In addition, ➢ Client plans will be consistent with the diagnosis, and the focus of intervention will be consistent with the client plan goals, and there will be documentation of the client's participation in and agreement with the plan. Examples of the documentation include, but are not limited to, reference to the client's participation and agreement in the body of the plan, client signature on the plan, or a description of the client's participation and agreement in progress notes. Exhibit F Page 3 of 3 ➢ Client signature on the plan will be used as the means by which the CONTRACTOR 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 will give a copy of the client plan to the client on request. 2. Timeliness/Frequency of Client Plan: • Will be updated at least annually. • The CONTRACTOR(S) will establish standards for timeliness and frequency for the individual elements of the client plan described in item 1. C. Progress Notes 1. Items that must be contained in the client record related to the client's progress in treatment include: • The client record will provide timely documentation of relevant aspects of client care. • Mental health staff/practitioners will use client records to document client encounters, including relevant clinical decisions and interventions. • All entries in the client record will include the signature of the person providing the service (or electronic equivalent); the person's professional degree, licensure or job title; and the relevant identification number, if applicable. • All entries will include the date services were provided. • The record will be legible. • The client record will document follow-up care, or as appropriate, a discharge summary. 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 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(S) shall require its employees and subcontractors to attend a compliance training that will be provided by Fresno County. After completion of this training, CONTRACTOR(S), CONTRACTOR(S)' employees and subcontractors 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. Exhibit G Page 2of3 7. Bill only for eligible services actually rendered and fully documented. Use billing codes that 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(S) 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 G Page 3 of 3 Fresno County Mental Health Compliance Program Contractor Acknowledgment and Agreement I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental Health Compliance Program and understand the contents thereof. I further agree to abide by the Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my responsibilities as a mental health contractor for Fresno County. I understand and accept my responsibilities under this Agreement. I further understand that any violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program may result in termination of my agreement with Fresno County. I further understand that Fresno County will report me to the appropriate Federal or State agency. For Individual Providers Name (print): Discipline: ❑ Psychiatrist ❑ Psychologist ❑ LCSW ❑ LMFT Signature: Date: For Group or Organizational Providers Group/Org. Name (print): Employee Name (print): Discipline: ❑ Psychiatrist ❑ Psychologist ❑ LCSW ❑ LMFT ❑ Other: Job Title (if different from Discipline): Signature: Date: / / Exhibit H 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 the individuals served 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. Informal provider problem resolution process—the provider may first speak to a Provider Relations Specialist (PRS) regarding his or her complaint or concern. Exhibit H Page 2 of 2 The PRS will attempt to settle the complaint or concern with the provider. If the attempt is unsuccessful and the provider chooses to forego the informal grievance process, the provider will be advised to file a written complaint to the MHP address (listed above). Formal provider appeal process—the provider has the right to access the provider appeal process at any time before, during, or after the provider problem resolution process has begun, when the complaint concerns a denied or modified request for MHP payment authorization, or the process or payment of a provider's claim to the MHP. Payment authorization issues—the provider may appeal a denied or modified request for payment authorization or a dispute with the MHP regarding the processing or payment of a provider's claim to the MHP. The written appeal must be submitted to the MHP within 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 I Page 1 of 9 INCIDENT REPORTING PROTOCOL FOR COMPLETION OF INCIDENT REPORT The Incident Report must be completed for all incidents involving individuals served through DBH's current incident reporting portal, Logic Manager, at https:Hfresnodbh.logicmanager.com/incidents/?t=9&p=1&k=182beOc5cdcd5072bb1864cdee 4d3d6e • The reporting portal is available 24 hours a day, every day. • Any employee of the CONTRACTOR can submit an incident using the reporting portal at any time. No login is required. • The designated administrator of the CONTRACTOR can add information to the follow up section of the report after submission. • When an employee submits an incident within 24 hours from the time of the incident or first knowledge of the incident, the CONTRACTOR's designated administrator, the assigned contract analyst and the Incident Reporting email inbox will be notified immediately via email from the Logic Manager system that there is a new incident to review. • Meeting the 24 hour incident reporting requirements will be easier as there are no signatures to collect. • The user guide attached identifies the reporting process and the reviewer process, and is subject to updates based on DBH's selected incident reporting portal system. Questions about incident reporting, how to use the incident reporting portal, or designating/changing the name of the administrator who will review incidents for the CONTRACTOR should be emailed to DBHlncidentReporting@fresnocountyca.gov and the assigned contract analyst. Mental Health Plan (MHP) and Substance Use Disorder(SUD) services Exhibit Page 2 of 9 Co�,� Incident Reporting System 19 INCIDENT REVIEWER ROLE — User Guide Fresno County Department of Behavioral Health (DBH) requires all of its county-operated and contracted providers (through the Mental Health Plan (MHP) and Substance Use Disorder (SUD) services) to complete a written report of any incidents compromising the health and safety of persons served, employees, or community members. Yes! Incident reports will now be made through an on online reporting portal hosted by Logic Manager. It's an easier way for any employee to report an incident at any time. A few highlights: • No supervisor signature is immediately required. • Additional information can be added to the report by the program supervisor/manager without having to resubmit the incident. • When an incident is submitted, the assigned contract analyst, program supervisor/manager, clinical supervisor and the DBHlncidentReporting mailbox automatically receives an email notification of a new incident and can log in any time to review the incident. Everything that was on the original paper/electronic form matches the online form. • Do away with submitting a paper version with a signature. • This online submission allows for timely action for the health and safety of the persons-served, as well as compliance with state reporting timelines when necessary. As an Incident Reviewer,the responsibility is to: • Log in to Logic Manager and review incident submitted within 48 hours of notification of incident. • Review incident for clarity, missing information and add in additional information deemed appropriate. • Notify DBHlncidentReporting@fresnocountyca.gov if there is additional information to be report after initial submission • Contact.DBHlncidentReporting@fresnocountVca.gov if there are any concerns, questions or comments with Logic Manager or incident reporting. Below is the link to report incidents https://fresnodbh.logicmanager.com/incidents/?t=9&p=1&k=182be0c5cdcdSO72bbl864cdee4d3d6e The link will take employees to the reporting screen to begin incident submission: Exhibit I Page 3 of 9 E C O Y Iresrtotfohlragicnunagcr.com, _ - - ... - - . LogicManager Incident Report Please complete this form • client information Nam.of facility' Name of Reporting Party Faclllty Address' Facility Phone Numher- M-1 Hwlth or Subztanc.Us.Disorder Program?' Client First Name' Cllont last Nam. F C O r client Data.181rth [Gent Address cLmuD tsender county of origin' • Summary Subject u Incident icheck all that apply) If olh.-p-fy ll...fire,poisomng.epidemic outbreaks,other catastropin—ents that jeopardise the walfam and safety of chants,staff and for members of the commumtyj: D—Opllon of the Incident' Exhibit I Page 4 of 9 Similar to the paper version, multiple incident categories can be selected incident)check MIIhaI apply Medr,MEmmgency , D.AA.Client Homicide/Homicide Attempt AWOL;Elopement from locked facility Vlol....lAbuselAssault Doward lb—,client and'or prop.ny Attempted Sulcule(resulting In serious injury) injury(seV-lnflkted w by accident) Medlcau—Error E C d a besnodbbJopkmenagercaNrk4Mnts(11-qft:t&k-182DedScdcd$072bb7064cdeeAd]d6e Dal.of Incldonl' Time of Iricident- Location of Inciderit- Bay Poopl.Dlr.cfly Indeed in Incident Iwltresses.st.M Did the Injured Parry seek Medical Attention? Allach any additional details ®P�tl Eilc or Drop Rio H.- Reported by Name' Reported By Email' Reported On 10/30120/9 Exhibit I Page 5 of 9 As another bonus feature, either drag files (such as a copy of a UOR, additional statements/document) or click on Add File to r ur ptre sdmlie.ig. . 4 rr,rom Reported By Name' Reported By Email Ruponod On 10/30/2019 • follow Up kini.Taken(check all that apply) Please sp—fy it other Dvw 1ptlon of Action Takon- Outcome' Similar to the paper version, multiple Action Taken categories can be selected. . T•ttnw U, action Taken(check all that apply, Law E.Iorcement Contacted• Called9ll/EMS Conwlted with Physician fir:)Aid;C PR Ad--stered Chant nmev.M hem bund�ng Parentr'Legal Goardlan Contacted Other When done entering all the information, simply click submit. Any fields that have a red asterisk, require information an will prevent submission of the form if left blank. A "Thank you for your submission" statement will pop up if an incident is successfully submitted. Click"Reload the Form"to submit another incident. LogicManager Thank you for your submission) RELOAD THE FORM Exhibit I Page 6 of 9 A Notification email will be received when a new incident is reported, or a new comment has been made regarding an incident. Click on "Open this incident in Logic Manager" and the Logic Manager login screen will show. Wed 10/30/2019 10:40 AM SL SYSTEM LogicManager via custom r.support@logicmanager.com <customer.support@logicmanager.com> Notification- To DBH Incident Reporting ©f there are problems with haw this message is displayed,click here to view it in a web Click here to download pictures.To help protect your privacy,Outlook prevented autom ocdownload of some pictures in this message. CAUTION!!I-EXTERNAL EMAIL-THINK BEFORE YOU CLICK 0"hlchhd W re hdd hve m dwnkm pn,res.TP h*W,,te car Wtlmk Prrmdd wmnvEc dwmbd dMu PCWre Fontlx lv,rNan9r,IM. Ri Mila Arevalo, You have received a notficafion through LogicManager.Please see the details below. Type:Incident Report Subject:102 Notification To:Mila Arevalo 01xn this incident in LogicManager If using Internet Explorer,click here to open the notification. This email was generated by LogicManager If you have any technical issues. please email supportC@Iogicmanager.com. Enter in email address and password. First time users will be prompted to set up a password. C Q Q fresnodbh.my.logicmanager.com/login LogicManager F61 dI FuasI,"ICJ Exhibit I Page 7 of 9 Once logged in,the main screen will show reviewer task (incidents to review). Click on analyst/supervisor follow up to view the incident. Your Task List TASK NAM[ SV�((l! ,1:.1�iY .�,.,.1�., �..,,I. P• _i_..t. This screen below will then pop up. There are 5 tabs to navigate through. Client information will show the client and facility information. No edits can be made to this section. Analyst Follow Up -.uMarm. The next tab is Sum ary: No edits can be made to this section. Analyst Follow Up wr�.�ra.r r .an u+.�r..nn.w��..w�i..a.....e�.�«w...a..r.«u.w.+.-�e.wi«va.m.r•....e..rreo..�.,ue,.•e m.....b...erw.<.mW��nr B I V S 11 bmwrma«n• w,nrw. I r Exhibit I Page 8 of 9 The next tab is Follow up: This section can be edited. Add to th areas below or make corrections to these fields. Be E w en edits are made.Then Cancel to Exi ut of the incident. Analyst Follow Up Actwn r,ken to«a.0 tM+OMri' uw Fdwe.m.nt[wr.,ne r - D�,.phond,ncr:»en ,ed,n M«m.ao. gut.ordwm.,nt«p«toton«ta nab r.fkia nx lnwnr tot nm • ., O The next tab is Documents: View and add attachments to the incident. Be sure to click SAVE when adding documents.Then Cancel to Exit out of the incident. Analyst Follow Up in;k Uctal: fli,M iMnrmttlnn ;ur^.r•nv tol•,w t'c bocumrnr• ® Add Darament v !lame Tree Source tlp1..d D,t, upt.—d Dv �i !b OocumrnF yel Drop fi z here or tuck—he Add livcum«A drop.— « < ! [AN[rl - ra.k tD:n3 sou.<r:tox Holt IrD If all tasks are followed up with and the incident no longer needs further review/information, click SUBMIT. Once submitted,the incident will be removed from the task list and no further edits can be made. Notice the SUBMIT button is on every tab. If further information needs to be included, email DBHlncidentReportine@fresnocountyca.gov Exhibit I Page 9 of 9 To get back to the home view, cli�thheis Manager icon at any time. Any incidents that still need review will show on this screen, click o and start the review process again. Your Task List TASK NAMf SOU— fi:l�.s .��li�ti r.Ci�.� ,..S�I'._`:r:b'• _�_;>. Exhibit J Page 1 of 6 STATE MENTAL HEALTH REQUIREMENTS 1. CONTROL REQUIREMENTS The COUNTY and its subcontractors shall provide services in accordance with all applicable Federal and State statutes and regulations. 2. PROFESSIONAL LICENSURE All (professional level) persons employed by the COUNTY Mental Health Program (directly or through contract) providing Short-Doyle/Medi-Cal services have met applicable professional licensure requirements pursuant to Business and Professions and Welfare and Institutions Codes. 3. CONFIDENTIALITY CONTRACTOR shall conform to and COUNTY shall monitor compliance with all State of California and Federal statutes and regulations regarding confidentiality, including but not limited to confidentiality of information requirements at 42, Code of Federal Regulations sections 2.1 of seq; California Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division 10.5 and 10.6 of the California Health and Safety Code; Title 22, California Code of Regulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 of the California Civil Code. 4. NON-DISCRIMINATION A. Eligibility for Services CONTRACTOR shall prepare and make available to COUNTY and to the public all eligibility requirements to participate in the program plan set forth in the Agreement. No person shall, because of ethnic group identification, age, gender, color, disability, medical condition, national origin, race, ancestry, marital status, religion, religious creed, political belief or sexual preference be excluded from participation, be denied benefits of, or be subject to discrimination under any program or activity receiving Federal or State of California assistance. B. Employment Opportunity CONTRACTOR shall comply with COUNTY policy, and the Equal Employment Opportunity Commission guidelines, which forbids discrimination against any person on the grounds of race, color, national origin, sex, religion, age, disability status, or sexual preference in employment practices. Such practices include retirement, recruitment advertising, hiring, layoff, termination, upgrading, demotion, transfer, rates of pay or other forms of compensation, use of facilities, and other terms and conditions of employment. Exhibit J Page 2 of 6 C. Suspension of Compensation If an allegation of discrimination occurs, COUNTY may withhold all further funds, until CONTRACTOR can show clear and convincing evidence to the satisfaction of COUNTY that funds provided under this Agreement were not used in connection with the alleged discrimination. D. Nepotism Except by consent of COUNTY's Department of Behavioral Health Director, or designee, no person shall be employed by CONTRACTOR who is related by blood or marriage to, or who is a member of the Board of Directors or an officer of CONTRACTOR. 5. PATIENTS' RIGHTS CONTRACTOR shall comply with applicable laws and regulations, including but not limited to, laws, regulations, and State policies relating to patients' rights. STATE CONTRACTOR CERTIFICATION CLAUSES 1. STATEMENT OF COMPLIANCE: CONTRACTOR has, unless exempted, complied with the non-discrimination program requirements. (Gov. Code§ 12990 (a-f) and CCR, Title 2, Section 111 02) (Not applicable to public entities.) 2. DRUG-FREE WORKPLACE REQUIREMENTS: CONTRACTOR will comply with the requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-free workplace by taking the following actions: a. Publish a statement notifying employees that unlawful manufacture, distribution, dispensation, possession or use of a controlled substance is prohibited and specifying actions to be taken against employees for violations. b. Establish a Drug-Free Awareness Program to inform employees about: 1) the dangers of drug abuse in the workplace; 2) the person's or organization's policy of maintaining a drug-free workplace; 3) any available counseling, rehabilitation and employee assistance programs; and, 4) penalties that may be imposed upon employees for drug abuse violations. C. Every employee who works on this Agreement will: 1) receive a copy of the company's drug-free workplace policy statement; and, 2) agree to abide by the terms of the company's statement as a condition of employment on this Agreement. Failure to comply with these requirements may result in suspension of payments under this Agreement or termination of this Agreement or both and Exhibit J Page 3 of 6 CONTRACTOR may be ineligible for award of any future State agreements if the department determines that any of the following has occurred: the CONTRACTOR has made false certification, or violated the certification by failing to carry out the requirements as noted above. (Gov. Code §8350 et seq.) 3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION: CONTRACTOR certifies that no more than one (1) final unappealable finding of contempt of court by a Federal court has been issued against CONTRACTOR within the immediately preceding two (2) year period because of CONTRACTOR's failure to comply with an order of a Federal court, which orders CONTRACTOR to comply with an order of the National Labor Relations Board. (Pub. Contract Code §10296) (Not applicable to public entities.) 4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO REQUIREMENT: CONTRACTOR hereby certifies that CONTRACTOR will comply with the requirements of Section 6072 of the Business and Professions Code, effective January 1, 2003. CONTRACTOR agrees to make a good faith effort to provide a minimum number of hours of pro bono legal services during each year of the contract equal to the lessor of 30 multiplied by the number of full time attorneys in the firm's offices in the State, with the number of hours prorated on an actual day basis for any contract period of less than a full year or 10% of its contract with the State. Failure to make a good faith effort may be cause for non-renewal of a state contract for legal services, and may be taken into account when determining the award of future contracts with the State for legal services. 5. EXPATRIATE CORPORATIONS: CONTRACTOR hereby declares that it is not an expatriate corporation or subsidiary of an expatriate corporation within the meaning of Public Contract Code Section 10286 and 10286.1, and is eligible to contract with the State of California. 6. SWEATFREE CODE OF CONDUCT: a. All CONTRACTORS contracting for the procurement or laundering of apparel, garments or corresponding accessories, or the procurement of equipment, materials, or supplies, other than procurement related to a public works contract, declare under penalty of perjury that no apparel, garments or corresponding accessories, equipment, materials, or supplies furnished to the state pursuant to the contract have been laundered or produced in whole or in part by sweatshop labor, forced labor, convict labor, indentured labor under penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor, or with the benefit of sweatshop labor, forced labor, convict labor, indentured labor under penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor. CONTRACTOR further declares under penalty of perjury that they adhere to the Sweatfree Code of Conduct as set forth on the California Department of Industrial Relations website located at www.dir.ca.gov, and Public Contract Code Section 6108. Exhibit J Page 4 of 6 b. CONTRACTOR agrees to cooperate fully in providing reasonable access to the CONTRACTOR's records, documents, agents or employees, or premises if reasonably required by authorized officials of the contracting agency, the Department of Industrial Relations, or the Department of Justice to determine the contractor's compliance with the requirements under paragraph (a). 7. DOMESTIC PARTNERS: For contracts of$100,000 or more, CONTRACTOR certifies that CONTRACTOR is in compliance with Public Contract Code Section 10295.3. 8. GENDER IDENTITY: For contracts of$100,000 or more, CONTRACTOR certifies that CONTRACTOR is in compliance with Public Contract Code Section 10295.35. DOING BUSINESS WITH THE STATE OF CALIFORNIA The following laws apply to persons or entities doing business with the State of California. 1. CONFLICT OF INTEREST: CONTRACTOR needs to be aware of the following provisions regarding current or former state employees. If CONTRACTOR has any questions on the status of any person rendering services or involved with this Agreement, the awarding agency must be contacted immediately for clarification. Current State Employees (Pub. Contract Code §10410): a). No officer or employee shall engage in any employment, activity or enterprise from which the officer or employee receives compensation or has a financial interest and which is sponsored or funded by any state agency, unless the employment, activity or enterprise is required as a condition of regular state employment. b). No officer or employee shall contract on his or her own behalf as an independent contractor with any state agency to provide goods or services. Former State Employees (Pub. Contract Code §10411): a). For the two (2) year period from the date he or she left state employment, no former state officer or employee may enter into a contract in which he or she engaged in any of the negotiations, transactions, planning, arrangements or any part of the decision-making process relevant to the contract while employed in any capacity by any state agency. b). For the twelve (12) month period from the date he or she left state employment, no former state officer or employee may enter into a contract with any state agency if he or she was employed by that state agency in a policy-making position in the same general subject area as Exhibit J Page 5 of 6 the proposed contract within the twelve (12) month period prior to his or her leaving state service. If CONTRACTOR violates any provisions of above paragraphs, such action by CONTRACTOR shall render this Agreement void. (Pub. Contract Code §10420) Members of boards and commissions are exempt from this section if they do not receive payment other than payment of each meeting of the board or commission, payment for preparatory time and payment for per diem. (Pub. Contract Code §10430 (e)) 2. LABOR CODE/WORKERS' COMPENSATION: CONTRACTOR needs to be aware of the provisions which require every employer to be insured against liability for Worker's Compensation or to undertake self-insurance in accordance with the provisions, and CONTRACTOR affirms to comply with such provisions before commencing the performance of the work of this Agreement. (Labor Code Section 3700) 3. AMERICANS WITH DISABILITIES ACT: CONTRACTOR assures the State that it complies with the Americans with Disabilities Act (ADA) of 1990, which prohibits discrimination on the basis of disability, as well as all applicable regulations and guidelines issued pursuant to the ADA. (42 U.S.C. 12101 et seq.) 4. CONTRACTOR NAME CHANGE: An amendment is required to change the CONTRACTOR's name as listed on this Agreement. Upon receipt of legal documentation of the name change the State will process the amendment. Payment of invoices presented with a new name cannot be paid prior to approval of said amendment. 5. CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA: a. When agreements are to be performed in the state by corporations, the contracting agencies will be verifying that the CONTRACTOR is currently qualified to do business in California in order to ensure that all obligations due to the state are fulfilled. b. "Doing business" is defined in R&TC Section 23101 as actively engaging in any transaction for the purpose of financial or pecuniary gain or profit. Although there are some statutory exceptions to taxation, rarely will a corporate contractor performing within the state not be subject to the franchise tax. C. Both domestic and foreign corporations (those incorporated outside of California) must be in good standing in order to be qualified to do business in California. Agencies will determine whether a corporation is in good standing by calling the Office of the Secretary of State. 6. RESOLUTION: A county, city, district, or other local public body must provide the State with a copy of a resolution, order, motion, or ordinance of the local governing body, which by law has authority to enter into an agreement, authorizing execution of the agreement. Exhibit J Page 6 of 6 7. AIR OR WATER POLLUTION VIOLATION: Under the State laws, the CONTRACTOR shall not be: (1) in violation of any order or resolution not subject to review promulgated by the State Air Resources Board or an air pollution control district; (2) subject to cease and desist order not subject to review issued pursuant to Section 13301 of the Water Code for violation of waste discharge requirements or discharge prohibitions; or (3) finally determined to be in violation of provisions of federal law relating to air or water pollution. 8. PAYEE DATA RECORD FORM STD. 204: This form must be completed by all contractors that are not another state agency or other governmental entity. 9. INSPECTION and Audit of Records and access to Facilities. The State, CMS, the Office of the Inspector General, the Comptroller General, and their designees may, at any time, inspect and audit any records or documents of CONTRACTOR or its subcontractors, and may, at any time, inspect the premises, physical facilities, and equipment where Medicaid-related activities or work is conducted. The right to audit under this section exists for ten (10) years from the final date of the contract period or from the date of completion of any audit, whichever is later. Federal database checks. Consistent with the requirements at § 455.436 of this chapter, the State must confirm the identity and determine the exclusion status of CONTRACTOR, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of CONTRACTOR through routine checks of Federal databases. This includes the Social Security Administration's Death Master File, the National Plan and Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE), the System for Award Management (SAM), and any other databases as the State or Secretary may prescribe. These databases must be consulted upon contracting and no less frequently than monthly thereafter. If the State finds a party that is excluded, it must promptly notify the CONTRACTOR and take action consistent with § 438.610(c). The State must ensure that CONTRACTOR with which the State contracts under this part is not located outside of the United States and that no claims paid by a CONTRACTOR to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. Exhibit K Page 1 of 2 COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS CONTRACTOR shall be required to maintain organizational provider certification by the host county. A copy of this renewal certificate must be furnished to COUNTY within thirty (30) days of receipt of certificate from host county. The CONTRACTOR must meet Medi-Cal organization provider standards as stated below. It is acknowledged that all references to Organizational Provider and/or Provider below shall refer to the CONTRACTOR. 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 as head of service a licensed mental health professional or other appropriate individual as described in Title 9, CCR, Sections 622 through 630. 9. For organizational providers that provide or store medications, the provider stores and dispenses medications in compliance with all pertinent state and federal standards. In particular: A. All drugs obtained by prescription are labeled in compliance with federal and state laws. Prescription labels are altered only by persons legally authorized to do so. B. Drugs intended for external use only or food stuffs are stored separately from drugs for internal use. C. All drugs are stored at proper temperatures, room temperature drugs at 59-86 degrees F and refrigerated drugs at 36-46 degrees F. Exhibit K Page 2 of 2 D. Drugs are stored in a locked area with access limited to those medical personnel authorized to prescribe, dispense or administer medication. E. Drugs are not retained after the expiration date. IM multi-dose vials are dated and initialed when opened. F. A drug log is maintained to ensure the provider disposes of expired, contaminated, deteriorated and abandoned drugs in a manner consistent with state and federal laws. G. Policies and procedures are in place for dispensing, administering and storing medications. 10. The COUNTY may accept the host county's site certification and reserves the right to conduct an on-site certification review at least every three years. The COUNTY may also conduct additional certification reviews when: • The provider makes major staffing changes. • The provider makes organizational and/or corporate structure changes (example: conversion from a non-profit status). • The provider adds day treatment or medication support services when medications shall be administered or dispensed from the provider site. • There are significant changes in the physical plant of the provider site (some physical plant changes could require a new fire clearance). • There is change of ownership or location. • There are complaints against the provider. • There are unusual events, accidents, or injuries requiring medical treatment for clients, staff or members of the community. Exhibit L Page 1 of 2 1 National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations to: Principal Standard: 1. Provide effective,equitable,understandable,and respectful quality care and services that are responsive to diverse cultural health beliefs and practices,preferred languages,health literacy,and other communication needs. Governance,Leadership,and Workforce: 2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy,practices,and allocated resources. 3. Recruit,promote,and support a culturally and linguistically diverse governance,leadership,and workforce that are responsive to the population in the service area. 4. Educate and train governance,leadership,and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis. Communication and Language Assistance: 5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs,at no cost to them,to facilitate timely access to all health care and services. 6. Inform all individuals of the availability of language assistance services clearly and in their preferred language,verbally and in writing. 7. Ensure the competence of individuals providing language assistance,recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. Engagement,Continuous Improvement,and Accountability: 9. Establish culturally and linguistically appropriate goals,policies,and management accountability,and infuse them throughout the organization's planning and operations. 10. Conduct ongoing assessments of the organization's CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities. 11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. 12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. 13. Partner with the community to design,implement,and evaluate policies,practices,and services to ensure cultural and linguistic appropriateness. 14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify,prevent,and resolve conflicts or complaints. 15. Communicate the organization's progress in implementing and sustaining CLAS to all stakeholders,constituents,and the general public. ��� 1 Think Cultural Health F S(_ U.S.Deporfinentof https://www.thinkculturalhealth.hhs.gov/ �O M H Health and Human Services Office of Minority Health contact@thinkculturalhealth.hhs.gov o�� Exhibit L Page 2 of 2 2 The Case for the National CLAS Standards Health equity is the attainment of the highest level of health for all people.'Currently,individuals across the United States from various cultural backgrounds are unable to attain their highest level of health for several reasons,including the social determinants of health,or those conditions in which individuals are born,grow,live,work,and age,2 such as socioeconomic status,education level,and the availability of health services.3 Though health inequities are directly related to the existence of historical and current discrimination and social injustice,one of the most modifiable factors is the lack of culturally and linguistically appropriate services,broadly defined as care and services that are respectful of and responsive to the cultural and linguistic needs of all individuals. Of all the forms of Health inequities result in disparities that directly affect the quality of life for all individuals. Health disparities adversely affect neighborhoods,communities,and the broader society,thus making inequality, injustice in the issue not only an individual concern but also a public health concern. In the United States,it health care is the most has been estimated that the combined cost of health disparities and subsequent deaths due to shocking and inhumane. inadequate and/or inequitable care is$1.24 trillion.4 Culturally and linguistically appropriate services are increasingly recognized as effective in improving —Dr. Martin Luther King,Jr. the quality of care and services.5,6 By providing a structure to implement culturally and linguistically appropriate services,the National CLAS Standards will improve an organization's ability to address health care disparities. The National CLAS Standards align with the HHS Action Plan to Reduce Racial and Ethnic Health Disparities'and the National Stakeholder Strategy for Achieving Health Equity,8 which aim to promote health equity through providing clear plans and strategies to guide collaborative efforts that address racial and ethnic health disparities across the country. Similar to these initiatives,the National CLAS Standards are intended to advance health equity,improve quality,and help eliminate health care disparities by providing a blueprint for individuals and health and health care organizations to implement culturally and linguistically appropriate services.Adoption of these Standards will help advance better health and health care in the United States. Bibliography 1. U.S.Department of Health and Human Services,Office of Minority Health(2011).National Partnership for Action to End Health Disparities.Retrieved from http://minorityhealth.hhs.gov/npa 2.World Health Organization.(2012).Social determinants of health.Retrieved from http://www.who.int/social_determinants/en/ 3. U.S.Department of Health and Human Services,Office of Disease Prevention and Health Promotion.(2010).Healthy people 2020:Social determinants of health.Retrieved from http://www. hea lthypeopl e.gov/2020/to picsobjectives2O20/overvi ew.as px?topicid=39 4. LaVeist,T A.,Gaskin,D.J.,&Richard,P(2009).The economic burden of health inequalities in the United States.Retrieved from the Joint Center for Political and Economic Studies website:http://www. jointeenter.org/sites/default/files/upload/research/files/The%20Economic%2 OBurden%20of%2OHealth%201nequalities%20in%20the%2OUnited%2OStates.pdf 5. Beach,M.C.,Cooper,L.A.,Robinson,K.A.,Price,E.G.,Gary,T.L.,Jenckes,M.W.,Powe,N.R.(2004).Strategies for improving minority healthcare quality.(AHRQ Publication No.04-EO08-02).Retrieved from the Agency of Healthcare Research and Quality website:http://www.ahrq.gov/downloads/pub/evidence/pdf/minqual/minquai.pdf 6.Goode,T.D.,Dunne,M.C.,&Bronheim,S.M.(2006).The evidence base for cultural and linguistic competency in health care.(Commonwealth Fund Publication No.962).Retrieved from The Commonwealth Fund website:http://www.commonwealthfund.org/usr_doc/Goode_evidencebasecultiinguisticcomp_962.pdf 7. U.S.Department of Health and Human Services.(2011).HHS action plan to reduce racial and ethnic health disparities:A nation free of disparities in health and health care.Retrieved from http:// minorityhealth.hhs.gov/npa/f les/Plans/HHS/H HS_Plan_complete.pdf 8. National Partnership for Action to End Health Disparities.(2011).National stakeholder strategy for achieving health equity.Retrieved from U.S.Department of Health and Human Services,Office of Minority Health website:http://www.minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286 ��� 1 Think Cultural Health F S(_ U.S.Deporfinentof https://www.thinkculturalhealth.hhs.gov/ 1O M H Health and Human Services Office of Minority Health contact@thinkculturalhealth.hhs.gov o�� Exhibit M 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. YES NO 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 by Titles XVIII, XIX, or XX? ......................................................................................................................... o 0 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 XVI Il, XIX, or XX?...................................................................................... o 71 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)........... o 71 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: o Sole proprietorship o Partnership o Corporation n Unincorporated Associations o 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 ofindividuals, and provider numbers........................................................................................................... 71 o NAME ADDRESS PROVIDER NUMBER Exhibit M Page 2 of 2 YES NO IV. A. Has there been a change in ownership or control within the last year? ....................................................... o 0 If yes, give date. B. Do you anticipate any change of ownership or control within the year?....................................................... o 0 If yes, when? C. Do you anticipate filing for bankruptcy within the year?................................................................................ o 0 If yes, when? V. Is the facility operated by a management company or leased in whole or part by another organization?.......... n n 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?......... n n VII. A. Is this facility chain affiliated? ...................................................................................................................... n n 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 N Page 1 of 2 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS INSTRUCTIONS FOR CERTIFICATION 1. By signing and submitting this proposal, the prospective primary participant is providing the certification set out below. 2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction. 3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. 4. The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 5. The terms covered transaction, debarred, suspended, ineligible, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations. 6. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 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; Exhibit N Page 2 of 2 (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)