HomeMy WebLinkAboutAgreement A-22-254.pdf ii
DocuSign Envelope ID:6FB146A4-41C0-4C41-9E59-39331742019E
Agreement No. 22-254
1 AGREEMENT
2 THIS AGREEMENT is made and entered into this 21S' day of June , 2022, by and between
3 the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter referred to as
4 "COUNTY", and KINGS VIEW, a private Non-profit, 501 (c) (3), Organization, whose address is 7170
5 N Financial Dr., Ste 110, Fresno, CA 93720, hereinafter referred to as "CONTRACTOR" (collectively
6 the "parties"). W I T N E S S E T H:
7 WHEREAS, COUNTY, through its Department of Behavioral Health (DBH) is in need of a
8 qualified agency to provide Senate Bill (SB) 82 Rural Mental Health Triage services in East and West
9 cities in Fresno County as specified in this Agreement, to help reduce stigma and discrimination
10 against mental illness and provide mental health triage services in a working partnership with rural
11 first responders; and
12 WHEREAS, COUNTY, through its DBH, is a Mental Health Plan (MHP) as defined in Title 9 of
13 the California Code of Regulations (C.C.R.), Section 1810.226; and
14 WHEREAS, CONTRACTOR is qualified and willing to provide said services pursuant to the
15 terms and conditions of this Agreement; and
16 WHEREAS, CONTRACTOR has requested greater access to the COUNTY's DBH electronic
17 health record system (Avatar); and
18 WHEREAS, COUNTY, through DBH, is willing to provide CONTRACTOR with greater access
19 to its electronic health record system; and
20 WHEREAS, COUNTY entered into Agreements No. A-15-317, No. A-15-317-1, No. A-15-317-
21 2, and No. A-15-317-3 with CONTRACTOR, whose legal entity name was incorrectly referred to as
22 "KINGS VIEW BEHAVIORAL HEALTH"; and
23 WHEREAS, this Agreement shall be retroactive to July 15, 2015, and shall replace, restate,
24 and supersede Agreements No. A-15-317, No. A-15-317-1, No. A-15-317-2, and No. A-15-317-3 in
25 their entirety.
26 NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties
27 hereto agree as follows:
28 1. SERVICES
1 - COUNTY OF FRESNO
Fresno,CA
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DocuSign Envelope ID:6FB146A4-41C0-4C41-9E59-39331742019E
1 A. CONTRACTOR(S) shall perform all services and fulfill all responsibilities as
2 identified in Exhibit A "SB 82 Rural Mental Health Triage Scope of Work", attached hereto and by this
3 reference incorporated herein and made part of this Agreement.
4 B. This Agreement provides for Rural Triage services to East Fresno County and
5 West Fresno County. CONTRACTOR shall collect, maintain and report all data for East and West
6 Fresno County Rural Triage services independent of one another, including but not limited to: Medi-
7 Cal billing, other insurance billing, and reports; staff schedules and reports; performance measures;
8 monthly invoices and general ledgers; and other data as requested.
9 C. It is acknowledged by all parties hereto that COUNTY's DBH Contracts Division
10 unit shall monitor the SB 82 Rural Triage Program operated by CONTRACTOR, in accordance with
11 Section Fourteen (14) of this Agreement.
12 D. CONTRACTOR shall participate in monthly, or as needed, workgroup meetings
13 consisting of staff from COUNTY's DBH to discuss MHSA requirements, data reporting, training,
14 policies and procedures, overall program operations and any problems or foreseeable problems that
15 may arise.
16 E. It is acknowledged that upon execution of this Agreement, or as indicated under
17 Section Two (2) of this Agreement, CONTRACTOR shall provide SB 82 Rural Mental Health Triage
18 Services, as identified and incorporated herein, in the rural East Fresno County cities of Selma,
19 Sanger, Kingsburg, Fowler, Reedley, Orange Cove and Parlier; and in the rural West Fresno County
20 cities of Firebaugh, Mendota, Kerman, San Joaquin, Huron, and Coalinga. It is further acknowledged
21 that the service site for client records, Medi-Cal billing, and other billing requirements for both East
22 and West County Rural Triage services is to be determined at a later date and approved by
23 COUNTY's DBH Director or designee. Any change to CONTRACTOR's location of the service site
24 must be made with thirty (30) days advance written notice to COUNTY's DBH Director or designee
25 and only upon written approval from COUNTY's DBH Director or designee.
26 F. CONTRACTOR shall maintain requirements as an organizational provider
27 throughout the term of this Agreement, as described in Section Seventeen (17) of this Agreement. If
28 for any reason this status is not maintained COUNTY may terminate this Agreement pursuant to
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1 Section Three (3) of this Agreement.
2 G. CONTRACTOR agrees that prior to and while providing services under the
3 terms and conditions of this Agreement, CONTRACTOR shall have staff hired and in place for
4 program services and operations or COUNTY may, in addition to other remedies it may have,
5 suspend or terminate this Agreement, in accordance with Section Three (3) of this Agreement.
6 H. CONTRACTOR may maintain its records in COUNTY's Electronic Health
7 Record (EHR) system, Avatar, in accordance with Exhibit E, "Documentation Standards for Client
8 Records," as licenses become available. The client record shall begin with registration and intake
9 and include client authorizations, assessments, plans of care, and progress notes, as well as other
10 documents as approved by the COUNTY's DBH. COUNTY shall be allowed to review records of
11 services provided, including the goals and objectives of the treatment plan, and how the therapy
12 provided is achieving the goals and objectives. If CONTRACTOR determines to maintain its records
13 in Avatar, it shall provide COUNTY's DBH Director, or designee, with a thirty (30) day notice. If at any
14 time CONTRACTOR chooses not to maintain its records in Avatar, it shall provide COUNTY'S DBH
15 Director, or designee, with thirty (30) days advance written notice and CONTRACTOR will be
16 responsible for obtaining its 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
19 COUNTY's EHR system by CONTRACTOR will be accurate, adequate or satisfactory for
20 CONTRACTOR's own purposes or that any information in CONTRACTOR's possession or control, or
21 transmitted or received by CONTRACTOR, is or will be secure from unauthorized access, viewing,
22 use, disclosure, or breach. CONTRACTOR is solely responsible for client information entered by
23 CONTRACTOR into the COUNTY's EHR system. CONTRACTOR agrees that all Private Health
24 Information (PHI) maintained by CONTRACTOR in COUNTY's EHR system will be maintained in
25 conformance with all HIPAA laws, as stated in Section Nineteen (19), Health Insurance Portability
26 and Accountability Act.
27 2. TERM
28 This Agreement shall become effective retroactively to July 14, 2015 for East Fresno
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1 County and shall terminate on the 30th day of June, 2022.
2 This Agreement shall become effective retroactively to October 1, 2015, for West
3 Fresno County and shall terminate on the 30th day of June, 2022.
4 3. TERMINATION
5 A. Non-Allocation of Funds - The terms of this Agreement, and the services to be
6 provided thereunder, are contingent on the approval of funds by the appropriating government
7 agency. Should sufficient funds not be allocated, the services provided may be modified, or this
8 Agreement terminated at any time by giving the CONTRACTOR thirty (30) days advance written
9 notice.
10 B. Breach of Contract - The COUNTY may immediately suspend or terminate this
11 Agreement in whole or in part, where in the determination of the COUNTY there is:
12 1) An illegal or improper use of funds;
13 2) A failure to comply with any term of this Agreement;
14 3) A substantially incorrect or incomplete report submitted to the COUNTY;
15 4) Improperly performed service.
16 In no event shall any payment by COUNTY constitute a waiver by COUNTY of
17 any breach of this Agreement or any default which may then exist on the part of CONTRACTOR.
18 Neither shall such payment impair or prejudice any remedy available to COUNTY with respect to the
19 breach or default. COUNTY shall have the right to demand of CONTRACTOR repayment to
20 COUNTY of any funds disbursed to CONTRACTOR under this Agreement, which in the judgment of
21 COUNTY were not expended in accordance with the terms of this Agreement. CONTRACTOR shall
22 promptly refund any such funds upon demand or, at COUNTY's option; such repayment shall be
23 deducted from future payments owing to CONTRACTOR under this Agreement.
24 C. Without Cause - Under circumstances other than those set forth above, this
25 Agreement may be terminated by COUNTY, or CONTRACTOR, or COUNTY's DBH Director or
26 designee, upon the giving of thirty (30) days advance written notice of intent to terminate.
27 CONTRACTOR may terminate with appropriate thirty (30) days advance written
28 notice of intent to terminate transmitted by CONTRACTOR to COUNTY by Certified U.S. Mail, Return
4 - COUNTY OF FRESNO
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DocuSign Envelope ID:6FB146A4-41C0-4C41-9E59-39331742019E
1 Receipt Requested, addressed to the office of COUNTY as follows:
2 Director (or designee)
County of Fresno
3 Department of Behavioral Health
4 P.O. Box 45003
Fresno, CA 93718-9886
5
6 4. COMPENSATION
The maximum compensation amount under this Agreement for Rural Triage Services in
8 East Fresno County and West Fresno County combined for the period July 14, 2015 through June 30,
9 2022, shall not exceed Seventeen Million, Five Hundred Forty-Five Thousand, Three Hundred Ninety-
10 One and No/100 Dollars ($17,545,391.00).
11 East Fresno County
12 The maximum compensation amount under this Agreement for East Fresno County
13 Rural Triage Services for the period July 14, 2015 through June 30, 2022, for all funding and revenue
14 streams collectively shall not exceed Nine Million, Six Hundred Seven Thousand, Five Hundred
15 Seventy-Six and No/100 Dollars ($9,607,576.00).
16 The maximum compensation amount under this Agreement for East Fresno County
17 Rural Triage Services for the period of July 14, 2015 through June 30, 2016, shall not exceed One
18 Million, Three Hundred Thousand, Four Hundred Thirty-One and No/100 Dollars ($1,300,431.00).
19 The maximum amount of SB 82 funding under this Agreement during said time period shall not
20 exceed Eight Hundred, Forty-Nine Thousand, Six Hundred Fifty-Three and No/100 Dollars
21 ($849,653.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR
22 estimates to generate Four Hundred Fifty Thousand, Seven Hundred Seventy-Eight and No/100
23 Dollars ($450,778.00) in Medi-Cal Federal Financial Participation (FFP) to offset CONTRACTOR's
24 program costs.
25 The maximum compensation amount under this Agreement for East Fresno County
26 Rural Triage Services for the period of July 1, 2016 through June 30, 2017, shall not exceed One
27 Million, Two Hundred Eighty-Eight Thousand, One Hundred Twenty-Four and No/100 Dollars
28 ($1,288,124.00). The maximum amount of SB 82 funding under this Agreement during said time
period shall not exceed Eight Hundred Forty-Two Thousand, One Hundred Twenty-Two and No/100
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1 Dollars ($842,122.00). In addition, it is understood by CONTRACTOR and COUNTY that
2 CONTRACTOR estimates to generate Four Hundred Forty-Six Thousand, Two and No/100 Dollars
3 ($446,002.00) in Medi-Cal FFP to offset CONTRACTOR's program costs.
4 The maximum compensation amount under this Agreement for East Fresno County
5 Rural Triage Services for the period of July 1, 2017 through June 30, 2018, shall not exceed One
6 Million, Three Hundred Twenty-Seven Thousand, Three Hundred Twenty-Two and No/100 Dollars
7 ($1,327,322.00). The maximum amount of SB 82 funding under this Agreement for said time period
8 shall not exceed Eight Hundred Sixty-Seven Thousand, One Hundred Sixty-Eight and No/100 Dollars
9 ($867,168.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR
10 estimates to generate Four Hundred Sixty Thousand, One Hundred Fifty-Four and No/100 Dollars
11 ($460,154.00) in Medi-Cal FFP to offset CONTRACTOR's program costs.
12 The maximum compensation amount under this Agreement for East Fresno County
13 Rural Triage Services for the period of July 1, 2018 through June 30, 2019, shall not exceed One
14 Million, Three Hundred Seventy-Five Thousand, Nine Hundred Fifty-Two and No/100 Dollars
15 ($1,375,952.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR
16 estimates to generate Three Hundred Thousand, Three Hundred Sixty and No/100 Dollars
17 ($300,360.00) in Medi-Cal FFP to offset CONTRACTOR's program costs.
18 The maximum compensation amount under this Agreement for East Fresno County
19 Rural Triage Services for the period of July 1, 2019 through June 30, 2020, shall not exceed One
20 Million, Four Hundred Ten Thousand, Three Hundred Seventy-Five and No/100 Dollars
21 ($1,410,375.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR
22 estimates to generate Three Hundred Thousand, Three Hundred Sixty and No/100 Dollars
23 ($300,360.00) in Medi-Cal FFP to offset CONTRACTOR's program costs.
24 The maximum compensation amount under this Agreement for East Fresno County
25 Rural Triage Services for the period of July 1, 2020 through June 30, 2021, shall not exceed One
26 Million Four Hundred Fifty-Two Thousand, Six Hundred Eighty-Six and No/100 Dollars
27 ($1,452,686.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR
28 estimates to generate Four Hundred Eighty-Two Thousand, Eight Hundred Eighty-One and No/100
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1 Dollars ($482,881.00) in Medi-Cal FFP to offset CONTRACTOR's program costs.
2 The maximum compensation amount under this Agreement for East Fresno County
3 Rural Triage Services for the period of July 1, 2021 through June 30, 2022, shall not exceed One
4 Million Four Hundred Fifty-Two Thousand, Six Hundred Eighty-Six and No/100 Dollars
5 ($1,452,686.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR
6 estimates to generate Four Hundred Eighty-Two Thousand, Eight Hundred Eighty-One and No/100
7 Dollars ($482,881.00) in Medi-Cal FFP to offset CONTRACTOR's program costs.
8 West Fresno County
9 The maximum compensation amount under this Agreement for West Fresno County
10 Rural Triage Services for the period October 1, 2015 through June 30, 2022, shall not exceed Seven
11 Million, Nine Hundred Thirty-Seven Thousand, Eight Hundred Fifteen and No/100 Dollars
12 ($7,937,815.00).
13 The maximum compensation amount under this Agreement for West Fresno County
14 Rural Triage Services for the period of October 1, 2015 through June 30, 2016, shall not exceed Nine
15 Hundred Eight Thousand, Four Hundred Twenty and No/100 Dollars ($908,420.00). The maximum
16 amount of Public Safety Realignment funding under this Agreement for said time period shall not
17 exceed Thirty-Three Thousand, Seven Hundred Thirty-Two and No/100 Dollars ($33,732.00). The
18 maximum amount of Mental Health Services Act (MHSA) funding under this Agreement for said time
19 period shall not exceed Five Hundred Fourteen Thousand, Seven Hundred Twenty-One and No/100
20 Dollars ($514,721.00). In addition, it is understood by CONTRACTOR and COUNTY that
21 CONTRACTOR estimates to generate Three Hundred Fifty-Nine Thousand, Nine Hundred Sixty-
22 Seven and No/100 Dollars ($359,967.00) in Medi-Cal FFP in this term to offset CONTRACTOR's
23 program costs.
24 The maximum compensation amount under this Agreement for West Fresno County
25 Rural Triage Services for the period of July 1, 2016 through June 30, 2017, shall not exceed One
26 Million, Eighty-Nine Thousand, Five Hundred Fifty and No/100 Dollars ($1,089,550.00). The
27 maximum amount of MHSA funding under this Agreement for said time period shall not exceed Six
28 Hundred Forty-Three Thousand, Five Hundred Forty-Eight and No/100 Dollars ($643,548.00). In
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1 addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR estimates to
2 generate Four Hundred Forty-Six Thousand, Two and No/100 Dollars ($446,002.00) in Medi-Cal FFP
3 in this term to offset CONTRACTOR's program costs.
4 The maximum compensation amount under this Agreement for West Fresno County
5 Rural Triage Services for the period of July 1, 2017 through June 30, 2018, shall not exceed One
6 Million, One Hundred Twenty-Two Thousand, Seven Hundred Ninety-One and No/100 Dollars
7 ($1,122,791.00). The maximum amount of MHSA funding under this Agreement in this term shall not
8 exceed Six Hundred Sixty-Two Thousand, Six Hundred Thirty-Seven and No/100 Dollars
9 ($662,637.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR
10 estimates to generate Four Hundred Sixty Thousand, One Hundred Fifty-Four and No/100 Dollars
11 ($460,154.00) in Medi-Cal FFP for said time period to offset CONTRACTOR's program costs.
12 The maximum compensation amount under this Agreement for West Fresno County
13 Rural Triage Services for the period of July 1, 2018 through June 30, 2019, shall not exceed One
14 Million, One Hundred Sixty-Five Thousand, Two Hundred Eighty-Six and No/100 Dollars
15 ($1,165,286.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR
16 estimates to generate One Hundred Nine Thousand, Eight Hundred Ninety-Five and No/100 Dollars
17 ($109,895.00) in Medi-Cal FFP to offset CONTRACTOR's program costs.
18 The maximum compensation amount under this Agreement for West Fresno County
19 Rural Triage Services for the period of July 1, 2019 through June 30, 2020, shall not exceed One
20 Million, One Hundred Ninety-Three Thousand, Three Hundred Eighty-Eight and No/100 Dollars
21 ($1,193,388.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR
22 estimates to generate One Hundred Nine Thousand, Eight Hundred Ninety-Five and No/100 Dollars
23 ($109,895.00) in Medi-Cal FFP to offset CONTRACTOR's program costs.
24 The maximum compensation amount under this Agreement for West Fresno County
25 Rural Triage Services for the period of July 1, 2020 through June 30, 2021, shall not exceed One
26 Million, Two Hundred Twenty-Nine Thousand, One Hundred Ninety and No/100 Dollars
27 ($1,229,190.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR
28 estimates to generate One Hundred Eighty-Three Thousand, Five Hundred Sixty-Seven and No/100
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1 Dollars ($183,567.00) in Medi-Cal FFP to offset CONTRACTOR's program costs.
2 The maximum compensation amount under this Agreement for West Fresno County
3 Rural Triage Services for the period of July 1, 2021 through June 30, 2022, shall not exceed One
4 Million, Two Hundred Twenty-Nine Thousand, One Hundred Ninety and No/100 Dollars
5 ($1,229,190.00). In addition, it is understood by CONTRACTOR and COUNTY that CONTRACTOR
6 estimates to generate One Hundred Eighty-Three Thousand, Five Hundred Sixty-Seven and No/100
7 Dollars ($183,567.00) in Medi-Cal FFP to offset CONTRACTOR's program costs.
8 The maximum amounts paid to the CONTRACTOR for East and West Fresno County
9 Rural Mental Health Triage services identified in the Agreement are stated in Exhibit C, C-1 and C-2
10 "East Budget" and "West Budget", attached hereto and by this reference incorporated herein.
11 A. COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
12 compensation based upon actual expenditures incurred by CONTRACTOR for monthly program
13 costs, in accordance with the budgets identified in Exhibit C, C-1 and C-2.
14 B. If CONTRACTOR fails to generate the Medi-Cal FFP set forth hereinabove, the
15 COUNTY shall not be obligated to pay the difference between these estimated amounts and the
16 actual amounts generated.
17 It is further understood by COUNTY and CONTRACTOR that any Medi-Cal FFP
18 generated above the amounts stated herein will be used to directly offset the COUNTY's contribution
19 of SB 82 funds identified in Exhibit C, C-1 and C-2. The offset of funds will also be clearly identified in
20 monthly invoices received from CONTRACTOR as further described in Section Five (5) of this
21 Agreement.
22 Travel shall be reimbursed based on actual expenditures and mileage
23 reimbursement shall be at CONTRACTOR's adopted rate per mile, no to exceed the Internal
24 Revenue Service (IRS) published rate.
25 Payment shall be made upon certification or other proof satisfactory to
26 COUNTY's DBH that services have actually been performed by CONTRACTOR as specified in this
27 Agreement.
28 C. It is understood that all expenses incidental to CONTRACTOR performance of
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1 services under this Agreement shall be borne by CONTRACTOR. If CONTRACTOR fails to comply
2 with any provision of this Agreement, COUNTY shall be relieved of its obligation for further
3 compensation.
4 D. Except as provided below regarding State payment delays, payments shall be
5 made by COUNTY to CONTRACTOR in arrears, for services provided during the preceding month,
6 within forty-five (45) days after the date of receipt and approval by COUNTY of the monthly invoicing
7 as described in Section Five (5) herein. Payments shall be made after receipt and verification of
8 actual expenditures incurred by CONTRACTOR for monthly program costs, as identified in Exhibit C,
9 C-1 and C-2 in the performance of this Agreement and shall be documented to COUNTY on a
10 monthly basis by the fifteenth (15th) of the month following the month of said expenditures. The
11 parties acknowledge that the CONTRACTOR will be performing hiring, training, and credentialing of
12 staff, configuring the facility and office space, and obtaining site certification from the COUNTY
13 Mental Health Plan.
14 CONTRACTOR shall submit to the COUNTY by the fifteenth (15th) of each
15 month a detailed general ledger (GL) itemizing costs incurred in the previous month. Failure to
16 submit GL reports and supporting documentation shall be deemed sufficient cause for COUNTY to
17 withhold payments until there is compliance, as further described in Section Five (5) herein.
18 E. COUNTY shall not be obligated to make any payments under this Agreement if
19 the request for payment is received by COUNTY more than sixty (60) days after this Agreement has
20 terminated or expired.
21 All final claims, including actual cost per unit, and/or any final budget modification
22 requests shall be submitted by CONTRACTOR within sixty (60) days following the final month of
23 service for which payment is claimed. No action shall be taken by COUNTY on claims submitted
24 beyond the sixty (60) day closeout period. Any compensation which is not expended by
25 CONTRACTOR pursuant to the terms and conditions of this Agreement shall automatically revert to
26 COUNTY.
27 F. The services provided by CONTRACTOR under this Agreement are funded in
28 whole or in part by the State of California. In the event that funding for these services is delayed by
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1 the State Controller, COUNTY may defer payment to CONTRACTOR. The amount of the deferred
2 payment shall not exceed the amount of funding delayed by the State Controller to the COUNTY.
3 The period of time of the deferral by COUNTY shall not exceed the period of time of the State
4 Controller's delay of payment to COUNTY plus forty-five (45) days.
5 G. CONTRACTOR shall be held financially liable for any and all future
6 disallowances/audit exceptions due to CONTRACTOR's deficiency discovered through the State
7 audit process and COUNTY utilization review during the course of this Agreement. At COUNTY's
8 election, the disallowed amount will be remitted within forty-five (45) days to COUNTY upon
9 notification or shall be withheld from subsequent payments to CONTRACTOR. CONTRACTOR shall
10 not receive reimbursement for any units of services rendered that are disallowed or denied by the
11 Fresno County Mental Health Plan utilization review process or through the Department of Health
12 Care Services (DHCS) cost report audit settlement process for Medi-Cal eligible clients.
13 H. Any compensation which is not expended by CONTRACTOR pursuant to the
14 terms and conditions of this Agreement shall be remitted to COUNTY within sixty (60) days of receipt
15 and verification of inappropriate expenditures by COUNTY's DBH Director, or designee.
16 I. Any compensation which is not consumed by expenditures of CONTRACTOR
17 by the expiration or termination of this Agreement shall automatically revert to COUNTY.
18 5. INVOICING
19 A. COUNTY's DBH shall invoice CONTRACTOR in arrears by the fifth (5th) day of
20 each month for the prior months hosting, maintenance, and hosting perceptive fees for access to
21 Avatar in accordance with the fee schedule as set forth in Exhibit N, "Electronic Health Records
22 Software Charges", attached hereto and incorporated herein by reference. COUNTY shall invoice
23 CONTRACTOR annually for the annual maintenance and licensing fee for access to Avatar in
24 accordance with the fee schedule as set forth in Exhibit N. CONTRACTOR shall provide payment for
25 these expenditures to COUNTY's Fresno County Department of Behavioral Health, Accounts
26 Receivable, P.O. Box 712, Fresno, CA 93717-0712, Attention: Business Office, within forty-five (45)
27 days after the date of receipt by CONTRACTOR of the invoicing provided by COUNTY.
28 B. CONTRACTOR shall invoice COUNTY in arrears by the fifteenth (15t") day of
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1 each month for the prior month's actual services rendered to DBHlnvoices(a),co.fresno.ca.us. After
2 CONTRACTOR renders service to referred clients, CONTRACTOR will invoice COUNTY for
3 payment, certify the expenditure, and submit electronic claiming billing directly into COUNTY's billing
4 system (AVATAR) for the DHCS reimbursements for all clients, including those eligible for Medi-Cal
5 as well as those that are not eligible for Medi-Cal, including contracted cost per unit and actual cost
6 per unit. COUNTY must pay CONTRACTOR before submitting a claim to DHCS for Federal
7 reimbursement for Medi-Cal eligible clients.
8 C. At the discretion of COUNTY's DBH Director, or designee, if an invoice is
9 incorrect or is otherwise not in proper form or substance, COUNTY's DBH Director, or designee, shall
10 have the right to withhold payment as to only that portion of the invoice that is incorrect or improper
11 after five (5) days prior notice to CONTRACTOR. CONTRACTOR agrees to continue to provide
12 services for a period of ninety (90) days after notification of an incorrect or improper invoice. If after
13 the ninety (90) day period, the invoice(s) is still not corrected to COUNTY DBH's satisfaction,
14 COUNTY's DBH Director, or designee, may elect to terminate this Agreement, pursuant to the
15 termination provisions stated in Section Three (3) of this Agreement. In addition, for invoices
16 received ninety (90) days after the expiration of each term of this Agreement or termination of this
17 Agreement, at the discretion of COUNTY's DBH Director, or designee, COUNTY's DBH shall have
18 the right to deny payment of any additional invoices received.
19 D. Monthly invoices shall include a client roster, identifying volume reported by
20 payer group clients served (including third party payer of services) by month and year-to-date,
21 including percentages.
22 E. CONTRACTOR shall submit monthly invoices and general ledgers that itemize
23 the line item charges for monthly program costs (per applicable budget, as identified in Exhibit C, C-1
24 and C-2), including the cost per unit calculation based on clients served within that month, and
25 excluding lobbying costs. The invoices and general ledgers will serve as tracking tools to determine if
26 CONTRACTOR's program costs are in accordance with its budgeted cost, and cost per unit
27 negotiated by service modes compared to actual cost per unit, as set forth in Exhibit C, C-1 and C-2.
28 The actual cost per unit will be based upon total costs and total units of service. It will also serve for
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1 the COUNTY to certify the public funds expended for purposes of claiming federal reimbursement for
2 the cost of Medicaid services and activities. CONTRACTOR shall remit to COUNTY on a quarterly
3 basis, a summary report of total operational costs and volume of service unit to report the actual costs
4 per unit compared to the negotiated rate, as identified in Exhibit C, C-1 and C-2, to report interim cost
5 per unit. The quarterly reports will be used by COUNTY to ensure compliance with federal
6 reimbursements certified public expenditures.
7 F. CONTRACTOR must report all third party collections from other funding
8 sources such as Medicare, private insurance, client private pay or any other third party. COUNTY
9 expects the invoice for reimbursement to equal the amount due CONTRACTOR less any funding
10 sources not eligible for federal reimbursement.
11 G. CONTRACTOR will remit annually within ninety (90) days from June 30, a
12 schedule to provide the required information on published charges (PC) for all authorized services.
13 The published charge listing will serve as a source document to determine the CONTRACTOR's
14 usual and customary charge prevalent in the public mental health sector that is used to bill the
15 general public, insurers or other non-Medi-Cal third party payers during the course of business
16 operations.
17 H. CONTRACTOR shall submit monthly staffing reports that identify all direct
18 service and support staff, applicable licensure/certifications, and full time hours worked to be used as
19 a tracking tool to determine if CONTRACTOR's program is staffed according to the Agreement
20 requirements.
21 I. CONTRACTOR must maintain such financial records for a period of seven (7)
22 years or until any dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be
23 responsible for any disallowances related to inadequate documentation.
24 J. CONTRACTOR is responsible for collection and managing data in a manner to
25 be determined by DHCS and the Mental Health Plan in accordance with applicable rules and
26 regulations. COUNTY electronic billing system is a critical source of information for purposes of
27 monitoring and obtaining reimbursement. CONTRACTOR must attend COUNTY's Business Office
28 training on equipment reporting for assets, intangible and sensitive minor assets, Avatar claiming
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1 module and related cost reporting.
2 K. CONTRACTOR shall submit electronic billing for services directly into
3 COUNTY's billing module (AVATAR) within ten (10) calendar days from the date services were
4 rendered. DHCS' FFP reimbursement for Medi-Cal specialty mental health services is based on
5 public expenditures certified by the CONTRACTOR. CONTRACTOR must submit a signed certified
6 public expenditure report, with each respective monthly invoice. DHCS expects the claim for
7 reimbursement to equal the amount the COUNTY paid the CONTRACTOR for the service rendered
8 less any funding sources not eligible for Federal reimbursement.
9 L. CONTRACTOR must provide all necessary data to allow the COUNTY to bill
10 Medi-Cal, and any other third-party source, for services and meet State and Federal reporting
11 requirements. The necessary data can be provided by a variety of means, including but not limited
12 to: 1) direct data entry into COUNTY's information system; 2) providing an electronic file compatible
13 with COUNTY's information system; or 3) integration between COUNTY's information system and
14 CONTRACTOR's information system(s).
15 M. If a Medi-Cal client has dual coverage, such as other health coverage (OHC)
16 or Medicare, the CONTRACTOR will be responsible for billing the carrier and obtaining a
17 payment/denial or have validation of claiming with no response ninety (90) days after the claim was
18 mailed before the service can be entered into AVATAR. CONTRACTOR must report all third party
19 collections for Medicare, third party or client pay or private pay in each monthly invoice and in the
20 cost report that is required to be submitted. A copy of explanation of benefits or CSM 1500 is
21 required as documentation. CONTRACTOR must comply with all laws and regulations governing
22 Medicare program, including, but not limited to: 1) the requirement of the Medicare Act, 42 U.S.C.
23 section 1395 et seq; and 2) the regulation and rules promulgated by the Centers for Medicare and
24 Medicaid Services as they relate to participation, coverage and claiming reimbursement.
25 CONTRACTOR will be responsible for compliance as of the effective date of each federal, state or
26 local law or regulation specified.
27 N. Data entry shall be the responsibility of the CONTRACTOR. The data for billing
28 must be reconciled by the CONTRACTOR to the monthly invoices submitted for payment. COUNTY
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1 shall monitor the number and dollar amount of services entered into AVATAR. Any and all audit
2 exceptions resulting from the provision and billing of Medi-Cal services by CONTRACTOR shall be
3 the sole responsibility of the CONTRACTOR. CONTRACTOR will comply with all applicable policies,
4 procedures, directives and guidelines regarding the use of COUNTY's billing system.
5 O. Medi-Cal Certification and Mental Health Plan Compliance
6 CONTRACTOR will establish and maintain Medi-Cal certification or become
7 certified within ninety (90) days of the effective date of this Agreement through COUNTY to provide
8 reimbursable services to Medi-Cal eligible adult clients. In addition, CONTRACTOR shall work with
9 the COUNTY's DBH Managed Care and Business Office to execute the process if not currently
10 certified by COUNTY for credentialing of staff. During this process, the CONTRACTOR will obtain a
11 legal entity number established by the DHCS, a requirement for maintaining organizational provider
12 status throughout the term of this Agreement. CONTRACTOR will be required to become Medi-Cal
13 certified prior to providing services to Medi-Cal eligible clients and seeking reimbursement in
14 COUNTY's billing system. CONTRACTOR will not be reimbursed by COUNTY for any Medi-Cal
15 services rendered prior to certification.
16 Medi-Cal billing shall be in accordance with the Mental Health Plan.
17 CONTRACTOR must comply with the "Fresno County Mental Health Plan Compliance Program and
18 Code of Conduct" set forth in Exhibit D, attached hereto and incorporated herein by reference and
19 made part of this Agreement.
20 Medi-Cal can be billed for direct specialty mental health services of unlicensed
21 staff as long as the individual is approved as an organizational provider by the Mental Health Plan, is
22 supervised by licensed staff, works within his/her scope and only bills Medi-Cal for allowable specialty
23 mental health services. It is understood that each claim is subject to audit for compliance with Federal
24 and State regulations, and that COUNTY may be making payments in advance of said review. In the
25 event that a Medi-Cal billable service is disapproved, COUNTY may, at its sole discretion, withhold
26 compensation or set off from other payments due the amount of said disapproved services.
27 CONTRACTOR shall be responsible for audit exceptions to ineligible dates of services or incorrect
28 application of utilization review requirements.
15 — COUNTY OF FRESNO
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1 6. INDEPENDENT CONTRACTOR
2 In performance of the work, duties, and obligations assumed by CONTRACTOR under
3 this Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of
4 CONTRACTOR's officers, agents, and employees will at all times be acting and performing as an
5 independent contractor, and shall act in an independent capacity and not as an officer, agent,
6 servant, employee, joint venturer, partner, or associate of the COUNTY. Furthermore, COUNTY shall
7 have no right to control or supervise or direct the manner or method by which CONTRACTOR shall
8 perform its work and function. However, COUNTY shall retain the right to administer this Agreement
9 so as to verify that CONTRACTOR is performing its obligations in accordance with the terms and
10 conditions thereof. CONTRACTOR and COUNTY shall comply with all applicable
11 provisions of law and the rules and regulations, if any, of governmental authorities having jurisdiction
12 over matters which are directly or indirectly the subject of this Agreement.
13 Because of its status as an independent contractor, CONTRACTOR shall have
14 absolutely no right to employment rights and benefits available to COUNTY employees.
15 CONTRACTOR shall be solely liable and responsible for providing to, or on behalf of, its employees
16 all legally-required employee benefits. In addition, CONTRACTOR shall be solely responsible and
17 save COUNTY harmless from all matters relating to payment of CONTRACTOR's employees,
18 including compliance with Social Security, withholding, and all other regulations governing such
19 matters. It is acknowledged that during the term of this Agreement, CONTRACTOR may be providing
20 services to others unrelated to the COUNTY or to this Agreement.
21 7. MODIFICATION
22 Notwithstanding the above, changes to services, staffing and responsibilities of the
23 CONTRACTOR, as needed, to accommodate changes in the laws relating to mental health and
24 substance use disorder treatment, as set forth in Exhibit A, may be made with the signed written
25 approval of COUNTY's DBH Director, or designee, and CONTRACTOR through an amendment
26 approved by COUNTY's County Counsel and the COUNTY's Auditor-Controller/Treasurer-Tax
27 Collector's Office.
28 In addition, changes to expense category (i.e., Salary & Benefits, Facilities/Equipment,
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1 Operating, Financial Services, Special Expenses, Fixed Assets, etc.) subtotals in the budgets, and
2 changes to the volume of units of services/types of service units to be provided, as set forth in Exhibit
3 C, C-1 and C-2, that do not exceed ten percent (10%) of the maximum compensation payable to the
4 CONTRACTOR may be made with the written approval of COUNTY's DBH Director, or designee.
5 Changes to the expense categories in the budgets that exceed ten percent (10%) of the maximum
6 compensation payable to the CONTRACTOR may be made with the signed written approval of
7 COUNTY's DBH Director, or designee, through an amendment approved by COUNTY's Counsel and
8 COUNTY's Auditor-Controller/Treasurer-Tax Collector's Office.
9 Said modifications shall not result in any change to the maximum compensation
10 amounts payable to CONTRACTOR, as stated in this Agreement.
11 8. NON-ASSIGNMENT
12 Neither party shall assign, transfer or subcontract this Agreement nor their rights or
13 duties under this Agreement without the prior written consent of the other party.
14 9. HOLD-HARMLESS
15 CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
16 defend the COUNTY, its officers, agents and employees from any and all costs and expenses,
17 including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting
18 to COUNTY in connection with the performance, or failure to perform, by CONTRACTOR, its officers,
19 agents or employees under this Agreement, and from any and all costs and expenses, including
20 attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to any
21 person, firm or corporation who may be injured or damaged by the performance, or failure to perform,
22 of CONTRACTOR, its officers, agents or employees under this Agreement.
23 CONTRACTOR agrees to indemnify COUNTY for Federal, State of California and/or
24 local audit exceptions resulting from noncompliance herein on the part of the CONTRACTOR.
25 10. INSURANCE
26 Without limiting the COUNTY's right to obtain indemnification from CONTRACTOR or
27 any third parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect, the
28 following insurance policies or a program of self-insurance, including but not limited to, an insurance
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1 pooling arrangement or Joint Powers Agreement (JPA) throughout the term of the Agreement:
2 A. Commercial General Liability
3 Effective July 14, 2015 through June 30, 2021, CONTRACTOR is required to
4 have Commercial General Liability Insurance with limits of not less than One
5 Million Dollars ($1,000,000) per occurrence and an annual aggregate of Two
6 Million Dollars ($2,000,000). Effective July 1, 2021 through June 30, 2022,
7 CONTRACTOR is required to have Commercial General Liability Insurance with
8 limits of not less than Two Million Dollars ($2,000,000.00) per occurrence and
9 an annual aggregate of Four Million Dollars ($4,000,000.00). This policy shall be
10 issued on a per occurrence basis. COUNTY may require specific coverages
11 including completed operations, products liability, contractual liability, Explosion-
12 Collapse-Underground, fire legal liability or any other liability insurance deemed
13 necessary because of the nature of this contract.
14 B. Automobile Liability
15 Effective July 14, 2015 through June 30, 2021, CONTRACTOR is required to
16 have Comprehensive Automobile Liability Insurance with limits for bodily injury
17 of not less than Two Hundred Fifty Thousand Dollars ($250,000) per person,
18 Five Hundred Thousand Dollars ($500,000) per accident and for property
19 damages of not less than Fifty Thousand Dollars ($50,000), or such coverage
20 with a combined single limit of One Million Dollars ($1,000,000). Effective July 1,
21 2021 through June 30, 2022, CONTRACTOR is required to have
22 Comprehensive Automobile Liability Insurance with limits of not less than One
23 Million Dollars ($1,000,000.00) per accident for bodily injury and for property
24 damages. Coverage should include any auto used in connection with this
25 Agreement.
26 C. Real And Personal Property
27 Effective July 14, 2015 through June 30, 2021, CONTRACTOR shall maintain a
28 policy of insurance for all risk personal property coverage which shall be
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1 endorsed naming the County of Fresno as an additional loss payee. The
2 personal property coverage shall be in an amount that will cover the total of the
3 COUNTY purchased and owned property, at a minimum, as discussed in
4 Section Twenty-Seven (27) of this Agreement.
5 All Risk Property Insurance
6 CONTRACTOR will provide property coverage for the full replacement value of
7 the COUNTY'S personal property in possession of CONTRACTOR and/or used
8 in the execution of this Agreement. COUNTY will be identified on an appropriate
9 certificate of insurance as the certificate holder and will be named as an
10 Additional Loss Payee on the Property Insurance Policy.
11 D. Fire Insurance and Extended Coverage
12 Effective July 14, 2015 through June 30, 2021, CONTRACTOR shall add
13 COUNTY as an additional Loss Payee thereon.
14 E. Professional Liability
15 If CONTRACTOR employs licensed professional staff, (e.g., Ph.D., R.N.,
16 L.C.S.W., M.F.C.C.) in providing services, Professional Liability Insurance with
17 limits of not less than One Million Dollars ($1,000,000.00) per occurrence, Three
18 Million Dollars ($3,000,000.00) annual aggregate. CONTRACTOR agrees that it
19 shall maintain, at its sole expense, in full force and effect for a period of three (3)
20 years following the termination of this Agreement, one or more policies of
21 professional liability insurance with limits of coverage as specified herein.
22 F. Worker's Compensation
23 A policy of Worker's Compensation insurance as may be required by the
24 California Labor Code.
25 G. Molestation
26 Effective July 1, 2021 through June 30, 2022, CONTRACTOR is required to
27 have Sexual abuse / molestation liability insurance with limits of not less than
28 One Million Dollars ($1,000,000.00) per occurrence, Two Million Dollars
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1 ($2,000,000.00) annual aggregate. This policy shall be issued on a per
2 occurrence basis.
3 H. Cyber Liability
4 Effective July 1, 2021 through June 30, 2022, CONTRACTOR is required to
5 have Cyber liability Insurance with limits not less than $2,000,000 per
6 occurrence or claim, $2,000,000 aggregate. Coverage shall be sufficiently broad
7 to respond to the duties and obligations as is undertaken by Vendor in this
8 agreement and shall include, but not be limited to, claims involving infringement
9 of intellectual property, including but not limited to infringement of copyright,
10 trademark, trade dress, invasion of privacy violations, information theft, damage
11 to or destruction of electronic information, release of private information,
12 alteration of electronic information, extortion and network security. The policy
13 shall provide coverage for breach response costs as well as regulatory fines and
14 penalties as well as credit monitoring expenses with limits sufficient to respond
15 to these obligations.
16 CONTRACTOR shall obtain endorsements to the Commercial General Liability
17 insurance naming the County of Fresno, its officers, agents, and employees, individually and
18 collectively, as additional insured, but only insofar as the operations under this Agreement are
19 concerned. Such coverage for additional insured shall apply as primary insurance and any other
20 insurance, or self insurance, maintained by COUNTY, its officers, agents and employees shall be
21 excess only and not contributing with insurance provided under CONTRACTOR's policies herein.
22 This insurance shall not be cancelled or changed without a minimum of thirty (30) days advance
23 written notice given to COUNTY.
24 Effective July 1, 2021 through June 30, 2022, CONTRACTOR hereby waives its right to
25 recover from COUNTY, its officers, agents, and employees any amounts paid by the policy of
26 worker's compensation insurance required by this Agreement. CONTRACTOR is solely responsible
27 to obtain any endorsement to such policy that may be necessary to accomplish such waiver of
28 subrogation, but CONTRACTOR's waiver of subrogation under this paragraph is effective whether or
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1 not CONTRACTOR obtains such an endorsement.
2 Within Thirty (30) days from the date CONTRACTOR signs and executes this
3 Agreement, CONTRACTOR shall provide certificates of insurance and endorsement as stated above
4 for all of the foregoing policies, as required herein, to the County of Fresno, (Name and Address of
5 the official who will administer this contract), stating that such insurance coverage have been
6 obtained and are in full force; that the County of Fresno, its officers, agents and employees will not be
7 responsible for any premiums on the policies; that for such worker's compensation insurance the
8 CONTRACTOR has waived its right to recover from the COUNTY, its officers, agents, and employees
9 any amounts paid under the insurance policy and that waiver does not invalidate the insurance policy;
10 that such Commercial General Liability insurance names the County of Fresno, its officers, agents
11 and employees, individually and collectively, as additional insured, but only insofar as the operations
12 under this Agreement are concerned; that such coverage for additional insured shall apply as primary
13 insurance and any other insurance, or self insurance, maintained by COUNTY, its officers, agents
14 and employees, shall be excess only and not contributing with insurance provided under
15 CONTRACTOR's policies herein; and that this insurance shall not be cancelled or changed without a
16 minimum of thirty (30) days advance, written notice given to COUNTY.
17 In the event CONTRACTOR fails to keep in effect at all times insurance coverage as
18 herein provided, the COUNTY may, in addition to other remedies it may have, suspend or terminate
19 this Agreement upon the occurrence of such event.
20 All policies shall be issued by admitted insurers licensed to do business in the State of
21 California, and such insurance shall be purchased from companies possessing a current A.M. Best,
22 Inc. rating of A FSC VII or better.
23 11. LICENSES/CERTIFICATES
24 Throughout each term of this Agreement, CONTRACTOR and CONTRACTOR's staff
25 shall maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions
26 necessary for the provision of the services hereunder and required by the laws and regulations of the
27 United States of America, State of California, the County of Fresno, and any other applicable
28 governmental agencies. CONTRACTOR shall notify COUNTY immediately in writing of its inability to
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1 obtain or maintain such licenses, permits, approvals, certificates, waivers and exemptions irrespective
2 of the pendency of any appeal related thereto. Additionally, CONTRACTOR and CONTRACTOR's
3 staff shall comply with all applicable laws, rules or regulations, as may now exist or be hereafter
4 changed.
5 12. RECORDS
6 CONTRACTOR shall maintain records in accordance with Exhibit E, "Documentation
7 Standards for Client Records", attached hereto and by this reference incorporated herein and made
8 part of this Agreement. During site visits, COUNTY shall be allowed to review records of services
9 provided, including the goals and objectives of the treatment plan, and how the therapy provided is
10 achieving the goals and objectives.
11 13. REPORTS
12 A. Cost Report— CONTRACTOR agrees to submit a complete and accurate
13 detailed cost report on an annual basis for each fiscal year ending June 30`h in the format prescribed
14 by the DHCS for the purposes of Short Doyle Medi-Cal reimbursements and total costs for programs.
15 Each cost report will be the source document for several phases of settlement with the DHCS for the
16 purposes of Short Doyle Medi-Cal reimbursement. CONTRACTOR shall report costs under their
17 approved legal entity number established during the Medi-Cal certification process. The information
18 provided applies to CONTRACTOR for program related costs for services rendered to Medi-Cal and
19 non Medi-Cal. The CONTRACTOR will remit a schedule to provide the required information on
20 published charges (PC) for all authorized services. The report will serve as a source document to
21 determine their usual and customary charge prevalent in the public mental health sector that is used
22 to bill the general public, insurers or other non-Medi-Cal third party payers during the course of
23 business operations. CONTRACTOR must report all collections for Medi-Cal/Medicare services and
24 collections. CONTRACTOR shall also submit with each cost report a copy of the CONTRACTOR's
25 general ledger that supports revenues and expenditures. CONTRACTOR must also include a
26 reconciled detailed report of the total units of services rendered under this Agreement compared to
27 the units of services entered by CONTRACTOR into COUNTY's data system.
28 Cost reports must be submitted to the COUNTY as a hard copy with a signed
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DocuSign Envelope ID:6FB146A4-41C0-4C41-9E59-39331742019E
1 cover letter and electronic copy of the completed DHCS cost report form along with requested
2 support documents following each fiscal year ending June 301". During the month of September of
3 each year this Agreement is effective, COUNTY will issue instructions of the annual cost report which
4 indicates the training session, DHCS cost report template worksheets, and deadlines to submit as
5 determined by the State annually. Remit the hard copies of the cost reports to County of Fresno,
6 Attention: Cost Report Team, P.O. Box 45003, Fresno, CA 93718. Remit the electronic copy or any
7 inquiries to DBHcostreportteam@co.fresno.ca.us.
8 All cost reports must be prepared in accordance with Generally Accepted
9 Accounting Principles (GAAP) and Welfare and Institutions Code §§ 5651(a)(4), 5664(a), 5705(b)(3)
10 and 5718(c). Unallowable costs such as lobby or political donations must be deducted on the cost
11 report and invoice reimbursements.
12 If the CONTRACTOR does not submit the cost report by the deadline, including
13 any extension period granted by the COUNTY, the COUNTY may withhold payments of pending
14 invoicing under compensation until the cost report has been submitted and clears COUNTY desk
15 audit for completeness.
16 B. Settlements with State Department of Health Care Services (DHCS)
17 During the term of this Agreement and thereafter, COUNTY and CONTRACTOR
18 agree to settle dollar amounts disallowed or settled in accordance with DHCS and COUNTY audit
19 settlement findings related to the Medi-Cal and realignment reimbursements. CONTRACTOR will
20 participate in the several phases of settlements between COUNTY, CONTRACTOR and DHCS. The
21 phases of initial cost reporting for settlement according to State reconciliation of records for paid
22 Medi-Cal services and audit settlement are: DHCS audit: 1) initial cost reporting - after an internal
23 review by COUNTY, the COUNTY files cost report with DHCS on behalf of the CONTRACTOR's legal
24 entity for the fiscal year; 2) Settlement—State reconciliation of records for paid Medi-Cal services,
25 approximately eighteen (18) to thirty-six (36) months following the State close of the fiscal year,
26 DHCS will send notice for any settlement under this provision will be sent to the COUNTY; and 3)
27 Audit Settlement-DHCS audit. After final reconciliation and settlement, COUNTY and/or DHCS may
28 conduct a review of medical records, cost report along with support documents submitted to
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1 COUNTY in initial submission to determine accuracy and may disallow cost and/or unit of service
2 reported on the CONTRACTOR's legal entity cost report. COUNTY may choose to appeal and
3 therefore reserves the right to defer payback settlement with CONTRACTOR until resolution of the
4 appeal. DHCS Audits will follow federal Medicaid procedures for managing overpayments.
5 If at the end of the Audit Settlement, the COUNTY determines that it overpaid
6 the CONTRACTOR, it will require the CONTRACTOR to repay the Medi-Cal related overpayment
7 back to the COUNTY.
8 Funds owed to COUNTY will be due within forty-five (45) days of notification
9 by the COUNTY, or COUNTY shall withhold future payments until all excess funds have been
10 recouped by means of an offset against any payments then or thereafter owing to CONTRACTOR
11 under this or any other Agreement.
12 C. Monthly Reports — CONTRACTOR shall submit a monthly report to the County
13 that will include, but not be limited to dollars billed for Medi-Cal and MHSA (non Medi-Cal) clients;
14 actual expenses; the number of clients served/anticipated to be served; utilization of services by
15 clients; and staff composition. This report will be due within thirty (30) days after the last day of the
16 previous month or payments may be delayed. CONTRACTOR will utilize a computerized tracking
17 system with which outcome measures and other relevant client data, such as demographics, will be
18 maintained.
19 D. Outcome Reports — CONTRACTOR shall submit to COUNTY's DBH service
20 outcome reports as requested by DBH. Outcome reports and outcome requirements are subject to
21 change at COUNTY DBH's discretion.
22 E. Additional Reports — CONTRACTOR shall also furnish to COUNTY such
23 statements, records, reports, data, and other information as COUNTY's DBH may request pertaining
24 to matters covered by this Agreement. In the event that CONTRACTOR fails to provide such reports
25 or other information required hereunder, it shall be deemed sufficient cause for COUNTY to withhold
26 monthly payments until there is compliance. In addition, CONTRACTOR shall provide written
27 notification and explanation to COUNTY within five (5) days of any funds received from another
28 source to conduct the same services covered by this Agreement.
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1 F. Progress Report Updates — CONTRACTOR shall complete Progress Report
2 updates according to DHCS regulations, in the form set forth in Exhibit F and Exhibit Fa, attached
3 hereto and by this reference incorporated herein and made part of this Agreement. CONTRACTOR
4 shall submit the required progress updates, as shown in Exhibit F and Exhibit Fa, to COUNTY's DBH
5 Mental Health Contracts Division for review.
6 CONTRACTOR shall submit to COUNTY's DBH by the Fifteenth (151") of each month
7 all monthly activity, outcome and budget reports for the preceding month. CONTRACTOR shall also
8 provide records of rents collected from each client and include the client's name, date of birth and
9 social security number. All data transmitted must be in strict conformance with Section Nineteen (19)
10 and Section Twenty (20) of this Agreement.
11 14. MONITORING
12 CONTRACTOR(S) agrees to extend to COUNTY's staff, COUNTY's DBH Director and
13 the DHCS, or their designees, the right to review and monitor records, program or procedures, at any
14 time, in regard to clients, as well as the overall operation of CONTRACTOR's program, in order to
15 ensure compliance with the terms and conditions of this Agreement.
16 15. REFERENCES TO LAWS AND RULES
17 In the event any law, regulation, or policy referred to in this Agreement is amended
18 during the term thereof, the parties hereto agree to comply with the amended provision as of the
19 effective date of such amendment.
20 16. COMPLIANCE WITH STATE REQUIREMENTS
21 CONTRACTOR recognizes that COUNTY operates its mental health programs under
22 an agreement with DHCS, and that under said agreement the State imposes certain requirements on
23 COUNTY and its subcontractors. CONTRACTOR shall adhere to all State requirements, including
24 those identified in Exhibit G, "State Mental Health Requirements", attached hereto and by this
25 reference incorporated herein and made part of this Agreement.
26 17. COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
27 CONTRACTOR shall be required to maintain organizational provider certification by
28 Fresno County. CONTRACTOR must meet Medi-Cal organization provider standards as listed in
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1 Exhibit H, "Medi-Cal Organizational Provider Standards", attached hereto and by this reference
2 incorporated herein and made part of this Agreement. It is acknowledged that all references to
3 Organizational Provider and/or Provider in Exhibit H shall refer to CONTRACTOR. In addition,
4 CONTRACTOR shall inform every client of their rights under the COUNTY's Mental Health Plan as
5 described in Exhibit I, "Fresno County Mental Health Plan Grievances and Incident Reporting",
6 attached hereto and by this reference incorporated herein. CONTRACTOR shall also file an incident
7 report for all incidents involving clients, following the Protocol for Completion of Incident Report and
8 using the "Incident Report Worksheet" both identified in Exhibit I, attached hereto and by this
9 reference incorporated herein and made part of this Agreement, or a protocol and worksheet
10 presented by CONTRACTOR that is accepted by County's DBH Director, or designee.
11 18. CONFIDENTIALITY
12 All services performed by CONTRACTOR under this Agreement and any information
13 CONTRACTOR creates, receives, or maintains pertaining to protected health information shall be in
14 strict conformance with all applicable Federal, State of California and/or local laws and regulations
15 relating to confidentiality.
16 19. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
17 COUNTY and CONTRACTOR each consider and represent themselves as covered
18 entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law
19 104-191(HIPAA) and agree to use and disclose Protected Health Information (PHI) as required by
20 law.
21 COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is
22 only for treatment, payment, and health care operations.
23 COUNTY and CONTRACTOR intend to protect the privacy and provide for the
24 security of PHI pursuant to the Agreement in compliance with HIPAA, the Health Information
25 Technology for Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations
26 promulgated thereunder by the U.S. Department of Health and Human Services (HIPAA Regulations)
27 and other applicable laws.
28
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1 As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
2 CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of
3 PHI, as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e) of the
4 Code of Federal Regulations (CFR).
5 20. DATA SECURITY
6 For the purpose of preventing the potential loss, misappropriation or inadvertent
7 access, viewing, use or disclosure of COUNTY data including sensitive or personal client information;
8 abuse of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies
9 that enter into a contractual relationship with the COUNTY for the purpose of providing services under
10 this Agreement must employ adequate data security measures to protect the confidential information
11 provided to CONTRACTOR by the COUNTY, including but not limited to the following:
12 A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
13 CONTRACTOR may not connect to COUNTY networks via personally-owned
14 mobile, wireless or handheld devices, unless the following conditions are met:
15 1) CONTRACTOR has received authorization by COUNTY for
16 telecommuting purposes;
17 2) Current virus protection software is in place;
18 3) Mobile device has the remote wipe feature enabled; and
19 4) A secure connection is used.
20 B. CONTRACTOR-Owned Computers or Computer Peripherals
21 CONTRACTOR may not bring CONTRACTOR-owned computers or computer
22 peripherals into the COUNTY for use without prior authorization from the COUNTY's Chief
23 Information Officer, and/or designee(s), including but not limited to mobile storage devices. If data is
24 approved to be transferred, data must be stored on a secure server approved by the COUNTY and
25 transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
26 connection. Said data must be encrypted.
27 C. COUNTY-Owned Computer Equipment
28
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1 CONTRACTOR, including its subcontractors and employees, may not use
2 COUNTY computers or computer peripherals on non-COUNTY premises without prior authorization
3 from the COUNTY's Chief Information Officer, and/or designee(s).
4 D. CONTRACTOR may not store COUNTY's private, confidential or sensitive data
5 on any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
6 E. CONTRACTOR shall be responsible to employ strict controls to ensure the
7 integrity and security of COUNTY's confidential information and to prevent unauthorized access,
8 viewing, use or disclosure of data maintained in computer files, program documentation, data
9 processing systems, data files and data processing equipment which stores or processes COUNTY
10 data internally and externally.
11 F. Confidential client information transmitted to one party by the other by means of
12 electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of
13 128 BIT or higher. Additionally, a password or pass phrase must be utilized.
14 G. CONTRACTOR is responsible to immediately notify COUNTY of any violations,
15 breaches or potential breaches of security related to COUNTY's confidential information, data
16 maintained in computer files, program documentation, data processing systems, data files and data
17 processing equipment which stores or processes COUNTY data internally or externally.
18 H. COUNTY shall provide oversight to CONTRACTOR's response to all incidents
19 arising from a possible breach of security related to COUNTY's confidential client information
20 provided to CONTRACTOR. CONTRACTOR will be responsible to issue any notification to affected
21 individuals as required by law or as deemed necessary by COUNTY in its sole discretion.
22 CONTRACTOR will be responsible for all costs incurred as a result of providing the required
23 notification.
24 21. NON-DISCRIMINATION
25 During the performance of this Agreement CONTRACTOR shall not unlawfully
26 discriminate against any employee or applicant for employment, or recipient of services, because of
27 race, religion, color, national origin, ancestry, physical disability, medical condition, marital status, age
28 or gender, pursuant to all applicable State of California and Federal statutes and regulations.
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1 22. TAX EQUITY AND FISCALRESPONSIBILITY ACT
2 To the extent necessary to prevent disallowance of reimbursement under section
3 1861(v)(1)(1) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[1]), until the expiration of four
4 (4) years after the furnishing of services under this Agreement, CONTRACTOR shall make available,
5 upon written request of the Secretary of the United States Department of Health and Human
6 Services, or upon request of the Comptroller General of the United States General Accounting Office,
7 or any of their duly authorized representatives, a copy of this Agreement and such books, documents,
8 and records as are necessary to certify the nature and extent of the costs of these services provided
9 by CONTRACTOR under this Agreement. CONTRACTOR further agrees that in the event
10 CONTRACTOR carries out any of its duties under this Agreement through a subcontract, with a value
11 or cost of Ten Thousand and No/100 Dollars ($10,000.00) or more over a twelve (12) month period,
12 with a related organization, such Agreement shall contain a clause to the effect that until the
13 expiration of four (4) years after the furnishing of such services pursuant to such subcontract, the
14 related organizations shall make available, upon written request of the Secretary of the United States
15 Department of Health and Human Services, or upon request of the Comptroller General of the United
16 States General Accounting Office, or any of their duly authorized representatives, a copy of such
17 subcontract and such books, documents, and records of such organization as are necessary to verify
18 the nature and extent of such costs.
19 23. SINGLE AUDIT CLAUSE
20 If any CONTRACTOR expends Seven Hundred FiftyThousand Dollars ($750,000.00) or
21 more in Federal and Federal flow-through monies, CONTRACTOR agrees to conduct an annual audit
22 in accordance with the requirements of the Single Audit Standards as set forth in Office of
23 Management and Budget (OMB) Circular A-133. CONTRACTOR shall submit said audit and
24 management letter to COUNTY. The audit must include a statement of findings or a statement that
25 there were no findings. If there were negative findings, CONTRACTOR shall include a corrective
26 action plan signed by an authorized individual. CONTRACTOR agrees to take action to correct any
27 material non-compliance or weakness found as a result of such audit. Such audits shall be delivered
28 to COUNTY's DBH Business Office for review within nine (9) months of the end of any fiscal year in
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1 which funds were expended and/or received for the program. Failure to perform the requisite audit
2 functions as required by this Agreement may result in COUNTY performing the necessary audit tasks,
3 or at COUNTY's option, contracting with a public accountant to perform said audit, or may result in
4 the inability of COUNTY to enter into future agreements with CONTRACTOR. All audit costs related
5 to this Agreement are the sole responsibility of CONTRACTOR.
6 A. A single audit report is not applicable if CONTRACTOR's Federal contracts do
7 not exceed the Seven Hundred Fifty Thousand Dollars ($750,000.00) requirement or
8 CONTRACTOR's only funding is through Medi-Cal. If a single audit is not applicable, a program audit
9 must be performed and a program audit report with management letter shall be submitted by
10 CONTRACTOR to COUNTY as a minimum requirement to attest to CONTRACTOR's solvency. Said
11 audit reports shall be delivered to COUNTY's DBH Business Office for review no later than nine (9)
12 months after the close of the fiscal year in which the funds supplied through this Agreement are
13 expended. Failure to comply with this Act may result in COUNTY performing the necessary audit
14 tasks or contracting with a qualified accountant to perform said audit. All audit costs related to this
15 Agreement are the sole responsibility of CONTRACTOR who agrees to take corrective action to
16 eliminate any material noncompliance or weakness found as a result of such audit. Audit work
17 performed by COUNTY under this Section shall be billed to the CONTRACTOR at COUNTY's cost,
18 as determined by COUNTY's Auditor-Controller/ Treasurer-Tax Collector.
19 B. CONTRACTOR shall make available all records and accounts for inspection by
20 COUNTY, the State of California, if applicable, the Comptroller General of the United States, the
21 Federal Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a
22 period of at least three (3) years following final payment under this Agreement or the closure of all
23 other pending matters, whichever is later.
24 24. COMPLIANCE
25 CONTRACTOR agrees to comply with COUNTY's Contractor Code of Conduct and
26 Ethics and the COUNTY's Compliance Program in accordance with Exhibit D. Within thirty (30) days
27 of entering into this Agreement with the COUNTY, CONTRACTOR shall have all of CONTRACTOR's
28 employees, agents and subcontractors providing services under this Agreement certify in writing, that
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1 he or she has received, read, understood, and shall abide by the Contractor Code of Conduct and
2 Ethics. CONTRACTOR shall ensure that within thirty (30) days of hire, all new employees, agents
3 and subcontractors providing services under this Agreement shall certify in writing that he or she has
4 received, read, understood, and shall abide by the Contractor Code of Conduct and Ethics.
5 CONTRACTOR understand that the promotion of and adherence to the code of Conduct and Ethics
6 is an element in evaluating the performance of CONTRACTOR and its employees, agents and
7 subcontractors.
8 Within thirty (30) days of entering into this Agreement, and annually thereafter, all
9 employees, agent and subcontractors providing services under this Agreement shall complete
10 general compliance training and appropriate employees, agents and subcontractors shall complete
11 documentation and billing or billing/reimbursement training. All new employees, agents and
12 subcontractors shall attend the appropriate training within thirty (30) days of hire. Each individual
13 required to attend training shall certify in writing that he or she has received the required training. The
14 certification shall specify the type of training received and the date received. The certification shall be
15 provided to the COUNTY's Compliance Officer at 3133 N. Millbrook, Fresno, California 93703.
16 CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty imposed upon
17 COUNTY by the Federal Government as a result of CONTRACTOR's violation of the terms of this
18 Agreement.
19 25. ASSURANCES
20 In entering into this Agreement, CONTRATOR certifies that it nor any of its officers are
21 not currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal
22 Health Care Programs: that it or any of its officers have not been convicted of a criminal offense
23 related to the provision of health care items or services; nor have they been reinstated to participate
24 in the Federal Health Care Programs after a period of exclusion, suspension, debarment, or
25 ineligibility. If COUNTY learns, subsequent to entering into this Agreement, that CONTRACTOR is
26 ineligible on these grounds, COUNTY will remove CONTRACTOR from responsibility for, or
27 involvement with, COUNTY's business operations related to the Federal Health Care Programs and
28 shall remove such CONTRACTOR from any position in which CONTRACTOR's compensation, or the
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1 items or services rendered, ordered or prescribed by CONTRACTOR may be paid in whole or part,
2 directly or indirectly, by Federal Health Care Programs or otherwise with Federal Funds at least until
3 such time as CONTRACTOR is reinstated into participation in the Federal Health Care Programs.
4 A. If COUNTY has notice that CONTRACTOR has been charged with a criminal
5 offense related to any Federal Health Care Programs, or proposed for exclusion during the term on
6 any contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the accuracy
7 of any claims submitted to any Federal Health Care Program. At its discretion given such
8 circumstances,
9 COUNTY may request that CONTRACTOR cease providing services until resolution of the charges or
10 the proposed exclusion.
11 B. CONTRACTOR agrees that all potential new employees of CONTRACTOR or
12 subcontractors of CONTRACTOR who, in each case, are expected to perform professional services
13 under this Agreement, will be queried as to whether (1) they are now or ever have been excluded,
14 suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2)
15 they have been convicted of criminal offense related to the provision of health care items or services;
16 and or (3) they have been reinstated to participate in the Federal Health Care Programs after a period
17 of exclusion, suspension, debarment, or ineligibility.
18 1. In the event the potential employee or subcontractor informs
19 CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible, or has been
20 convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR
21 hires or engages such potential employee or subcontractor, the CONTRACTOR will ensure that said
22 employee or subcontractor does no work, either directly or indirectly relating to services provided to
23 COUNTY.
24 2. Notwithstanding the above, COUNTY at its discretion may terminate this
25 Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance
26 (as defined by COUNTY) that no excluded, suspended or otherwise ineligible employee of
27 CONTRACTOR will perform work, either directly or indirectly, relating to services provided to
28 COUNTY. Such demand for adequate assurance shall be effective upon a time frame to be
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1 determined by COUNTY to protect the interests of COUNTY clients.
2 C. CONTRACTOR shall verify (by asking the applicable employees and
3 subcontractors) that all current employees and existing subcontractors who, in each case, are
4 expected to perform professional services under this Agreement: (1) are not currently excluded,
5 suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2)
6 have not been convicted of a criminal offense related to the provision of health care items or services;
7 and (3) have not been reinstated to participate in the Federal Health Care Programs after a period of
8 exclusion, suspension, debarment, or ineligibility. In the event any existing employee or
9 subcontractor informs a CONTRACTOR that he or she is excluded, suspended, debarred or
10 otherwise ineligible to participate in the Federal Health Care Programs, or has been convicted of a
11 criminal offense relating to the provision of heath care services, CONTRACTOR will ensure that said
12 employee or subcontractor does no work, either direct or indirect, relating to services provided to
13 COUNTY.
14 1. CONTRACTOR agrees to notify COUNTY immediately during the term
15 of this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each
16 case, is providing professional services under Section One (1) of this Agreement is excluded,
17 suspended, debarred or otherwise ineligible to participate in the Federal Health Care Programs, or is
18 convicted of a criminal offense relating to the provision of health care services.
19 2. Notwithstanding the above, COUNTY at its discretion may terminate this
20 Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance
21 (as defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or
22 subcontractor of CONTRACTOR will perform work, either directly or indirectly, relating to services
23 provided to COUNTY. Such demand for adequate assurance shall be effective upon a time frame to
24 be determined by COUNTY to protect the interests of COUNTY clients.
25 D. CONTRACTOR agrees to cooperate fully with any reasonable requests for
26 information from COUNTY which may be necessary to complete any internal or external audits
27 relating to CONTRACTOR's compliance with the provisions of this Section.
28 E. CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty
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1 imposed upon COUNTY by the Federal Government as a result of CONTRACTOR's violation of
2 CONTRACTOR's obligations as described in this Section.
3 26. PROHIBITION ON PUBLICITY
4 None of the funds, materials, property or services provided directly or indirectly under
5 this Agreement shall be used for CONTRACTOR's advertising, fundraising, or publicity (i.e.,
6 purchasing of tickets/tables, silent auction donations, etc.) for the purpose of self-promotion.
7 Notwithstanding the above, publicity of the services described in Section One (1) of this Agreement
8 shall be allowed as necessary to raise public awareness about the availability of such specific
9 services when approved in advance by COUNTY's DBH Director or designee and at a cost to be
10 provided in Section Four (4) of this Agreement for such items as written/printed materials, the use of
11 media (i.e., radio, television, newspapers) and any other related expense(s).
12 27. PROPERTY OF COUNTY
13 A. COUNTY and CONTRACTOR recognize that fixed assets are tangible and
14 intangible property obtained or controlled under COUNTY's Mental Health Plan for use in operational
15 capacity and will benefit COUNTY for a period more than one (1) year. Depreciation of the qualified
16 items will be on a straight-lien basis.
17 For COUNTY purposes, fixed assets must fulfill three qualifications:
18 1. Asset must have life span of over one year.
19 2. The asset is not a repair part.
20 3. The asset must be valued at or greater than the capitalization thresholds
21 for the asset type:
22 Asset type Threshold
23 • land $0
• buildings and improvements $100,000
24 • infrastructure $100,000
25 • be tangible $5,000
o equipment
26 o vehicles
• or intangible asset $100,000
27 o Internally generated software
2 8 o Purchased software
o Easements
o Patents
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1 . and capital lease $5,000
2 Qualified fixed asset equipment is to be reported and approved by COUNTY. If
3 it is approved and identified as an asset it will be tagged with a COUNTY program number. A Fixed
4 Asset Log, (Exhibit J and Ja — Fixed Asset Log Instructions) will be maintained by COUNTY's Asset
5 Management System and inventoried annually until the asset is fully depreciated. During the terms of
6 this Agreement, CONTRACTOR's fixed assets may be inventoried in comparison to COUNTY's DBH
Asset Inventory System.
8 B. Certain purchases under Five Thousand and No/100 Dollars ($5,000.00) but
9 more than One Thousand and No/100 Dollars ($1,000.00) with over one (1) year life span, and are
10 mobile and high risk of theft or loss are sensitive assets. Such sensitive items are not limited to
11 computers, copiers, televisions, cameras and other sensitive items as determined by COUNTY's DBH
12 Director or designee. CONTRACTOR maintains a tracking system on the items and are not required
13 to be capitalized or depreciated. The items are subject to annual inventory for compliance.
14 C. Assets shall be retained by COUNTY, as COUNTY property, in the event this
15 Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate
16 in an annual inventory of all COUNTY fixed and inventoried assets. Upon termination of this
17 Agreement, CONTRACTOR shall be physically present when fixed and inventoried assets are
18 returned to COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all
19 COUNTY owned undepreciated fixed and inventoried assets, or the monetary value of said assets if
20 unable to produce the assets at the expiration or termination of this Agreement.
21 CONTRACTOR further agrees to the following:
22 1. To maintain all items of equipment in good working order and condition,
23 normal wear and tear excepted;
24 2. To label all items of equipment with COUNTY assigned program number,
25 to perform periodic inventories as required by COUNTY and to maintain an inventory list showing
26 where and how the equipment is being used in accordance with procedures developed by COUNTY.
27 All such lists shall be submitted to COUNTY within ten (10) days of any request therefore;
28 3. To report in writing to COUNTY immediately after discovery, the loss or
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1 theft of any items of equipment. For stolen items, the local law enforcement agency must be contacted
2 and a copy of the police report submitted to COUNTY
3 D. The purchase of any equipment by CONTRACTOR with funds provided
4 hereunder shall require the prior written approval of COUNTY's DBH Director or designee, shall fulfill
5 the provisions of this Agreement as appropriate, and must be directly related to CONTRACTOR's
6 services or activity under the terms of this Agreement. COUNTY's DBH may refuse reimbursement for
7 any costs resulting from equipment purchased, which are incurred by CONTRACTOR, if prior written
8 approval has not been obtained from COUNTY's DBH Director or designee.
9 E. CONTRACTOR must obtain prior written approval form COUNTY's DBH
10 whenever there is any modification or change in the use of any property acquired or improved, in whole
11 or in part, using funds under this Agreement. If any real or personal property acquired or improved with
12 said funds identified herein is sold and/or is utilized by CONTRACTOR for a use which does not qualify
13 under this program, CONTRACTOR shall reimburse COUNTY in an amount equal to the current fair
14 market value of the property, less any portion thereof attributable to expenditures of non-program funds.
15 These requirements shall continue in effect for the life of the property. In the event the program is
16 closed out, the requirements for this Section shall remain in effect for activities or property funded with
17 said funds, unless action is taken by the State government to relieve COUNTY of these obligations.
18 28. CULTURAL COMPETENCY
19 As related to Cultural and Linguistic Competence, CONTRACTOR shall comply with:
20 A. Title 6 of the Civil Rights Act of 1964 (42 U.S.C. Section 2000d, and 45 C.F.R.
21 Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance
22 from discriminating against persons based on race, color, national origin, sex, disability or religion.
23 This is interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access
24 and participation in federally funded programs through the provision of comprehensive and quality
25 bilingual services.
26 B. Policies and procedures for ensuring access and appropriate use of trained
27 interpreters and material translation services for all LEP clients, including, but not limited to,
28 assessing the cultural and linguistic needs of its clients, training of staff on the policies and
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1 procedures, and monitoring its language assistance program. The CONTRACTOR's procedures must
2 include ensuring compliance of any sub-contracted providers with these requirements.
3 C. CONTRACTOR shall not use minors as interpreters.
4 D. CONTRACTOR shall provide and pay for interpreting and translation services to
5 persons participating in CONTRACTOR's services who have limited or no English language
6 proficiency, including services to persons who are deaf or blind. Interpreter and translation services
7 shall be provided as necessary to allow such participants meaningful access to the programs,
8 services
9 and benefits provided by CONTRACTOR. Interpreter and translation services, including translation
10 of CONTRACTOR's "vital documents" (those documents that contain information that is critical for
11 accessing CONTRACTOR's services or are required by law) shall be provided to participants at no
12 cost to the participant. CONTRACTOR shall ensure that any employees, agents, subcontractors, or
13 partners who interpret or translate for a program participant, or who directly communicate with a
14 program participant in a language other than English, demonstrate proficiency in the participant's
15 language and can effectively communicate any specialized terms and concepts peculiar to
16 CONTRACTOR's services.
17 E. In compliance with the State mandated Culturally and Linguistically Appropriate
18 Services standards as published by the Office of Minority Health, CONTRACTOR must submit to
19 COUNTY for approval, within 60 days from date of contract execution, CONTRACTOR's plan to
20 address all fifteen national cultural competency standards as set forth in the "National Standards on
21 Culturally and Linguistically Appropriate Services (CLAS)"
22 http://minoritVhealth.hhs.gov/assets/pdf/checked/finalreport.pdf). COUNTY's annual
23 on-site review of CONTRACTOR shall include collection of documentation to ensure all national
24 standards are implemented. As the national competency standards are updated, CONTRACTOR's
25 plan must be updated accordingly.
26 29. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
27 This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or
28 managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101, 455.104,
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1 and 455.106(a)(1),(2).
2 In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and
3 455.106(a)(1),(2), the following information must be disclosed by CONTRACTOR by completing
4 Exhibit K, "Disclosure of Ownership and Control Interest Statement", attached hereto and by this
5 reference incorporated herein and made part of this Agreement. CONTRACTOR shall submit this
6 form to the Department of Behavioral Health within thirty (30) days of the effective date of this
7 Agreement. Additionally, CONTRACTOR shall report any changes to this information within thirty five
8 (35) days of occurrence by completing Exhibit K. Submissions shall be scanned PDF copies and are
9 to be sent via email to DBHAdministrationCa)co.fresno.ca.us attention: Contracts Administration.
10 30. DISCLOSURE — CRIMINAL HISTORY AND CIVIL ACTIONS
11 CONTRACTOR is required to disclose if any of the following conditions apply to them,
12 their owners, officers, corporate managers and partners (hereinafter collectively referred to as
13 "CONTRACTOR"):
14 A. Within the three-year period preceding the Agreement award, they have been
15 convicted of, or had a civil judgment rendered against them for:
16 1. Fraud or a criminal offense in connection with obtaining, attempting to
17 obtain, or performing a public (federal, state, or local) transaction or contract under a public
18 transaction;
19 2. Violation of a federal or state antitrust statute;
20 3. Embezzlement, theft, forgery, bribery, falsification, or destruction of
21 records; or
22 4. False statements or receipt of stolen property.
23 B. Within a three-year period preceding their Agreement award, they have had a
24 public transaction (federal, state, or local) terminated for cause or default.
25 Disclosure of the above information will not automatically eliminate CONTRACTOR
26 from further business consideration. The information will be considered as part of the determination
27 of whether to continue and/or renew the Agreement and any additional information or explanation
28 that a CONTRACTOR elects to submit with the disclosed information will be considered. If it is later
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1 determined that the CONTRACTOR failed to disclose required
2 information, any Agreement awarded to such CONTRACTOR may be immediately voided and
3 terminated for material failure to comply with the terms and conditions of the award.
4 CONTRACTOR must sign an appropriate "Certification Regarding Debarment,
5 Suspension, and Other Responsibility Matters-Primary Covered Transactions", Exhibit L, attached
6 hereto and by this reference incorporated herein. Additionally, CONTRACTOR must immediately
7 advise COUNTY in writing if, during the term of this Agreement: (1) CONTRACTOR becomes
8 suspended, debarred, excluded or ineligible for participation in federal or state funded programs or
9 from receiving federal funds as listed in the excluded parties list system (http://www.sam.gov); or (2)
10 any of the above listed conditions become applicable to CONTRACTOR. CONTRACTOR shall
11 indemnify, defend and hold COUNTY harmless for any loss or damage resulting from a conviction,
12 debarment, exclusion, ineligibility or other matter listed in the signed "Certification Regarding
13 Debarment, Suspension, and Other Responsibility Matters."
14 31. AUDITS AND INSPECTIONS
15 The CONTRACTOR shall at any time during business hours, and as often as the
16 COUNTY may deem necessary, make available to COUNTY for examination all of its records and
17 data with respect to the matters covered by this Agreement. CONTRACTOR shall, upon request by
18 COUNTY, permit COUNTY to audit and inspect all such records and data necessary to ensure
19 CONTRACTOR's compliance with the terms of this Agreement.
20 If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
21 CONTRACTOR shall be subject to the examination and audit of the State Auditor General for a
22 period of three (3) years after final payment under contract (Government Code section 8546.7).
23 32. COMPLAINTS
24 CONTRACTOR shall log complaints and the disposition of all complaints from a client
25 or a client's family. CONTRACTOR shall provide a copy of the detailed complaint log entries
26 concerning COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (101") day of the
27 following month, in a format that is mutually agreed upon. Besides the detailed complaint log,
28 CONTRACTOR shall provide details and attach documentation of each complaint with the log.
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1 CONTRACTOR shall post signs informing clients of their right to file a complaint or grievance.
2 CONTRACTOR shall notify COUNTY of all incidents reportable to state licensing bodies that affect
3 COUNTY clients within twenty-four (24) hours of receipt of a complaint.
4 Within ten (10) days after each incident or complaint affecting COUNTY-sponsored
5 clients, CONTRACTOR shall provide COUNTY with information relevant to the complaint,
6 investigative details of the complaint, the complaint and CONTRACTOR's disposition of, or corrective
7 action taken to resolve the complaint. In addition, CONTRACTOR shall inform every client of their
8 rights as set forth in Exhibit I. CONTRACTOR shall file an incident report for all incidents involving
9 clients, following the Protocol and using the Worksheet identified in Exhibit I.
10 33. DISCLOSURE OF SELF-DEALING TRANSACTIONS
11 This provision is only applicable if the CONTRACTOR is operating as a corporation (a
12 for-profit or non-profit corporation) or if during the term of this agreement, the CONTRACTOR
13 changes its status to operate as a corporation.
14 Members of the CONTRACTOR's Board of Directors shall disclose any self-dealing
15 transactions that they are a party to while CONTRACTOR is providing goods or performing services
16 under this agreement. A self-dealing transaction shall mean a transaction to which the
17 CONTRACTOR is a party and in which one or more of its directors has a material financial interest.
18 Members of the Board of Directors shall disclose any self-dealing transactions that they are a party to
19 by completing and signing a Self-Dealing Transaction Disclosure Form (Exhibit M, attached hereto
20 and by this reference incorporated herein and made part of this Agreement) and submitting it to the
21 COUNTY prior to commencing with the self-dealing transaction or immediately thereafter.
22 34. NOTICES
23 The persons having authority to give and receive notices under this Agreement and
24 their addresses include the following:
25 COUNTY CONTRACTOR
26 Director, Fresno County Chief Executive Officer
Department of Behavioral Health Kings View
27 1925 E. Dakota Ave. 7170 North Financial Drive, Suite 110
28 Fresno, CA 93726 Fresno, CA 93720
Any and all notices between the COUNTY and the CONTRACTOR provided for or
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1 permitted under this Agreement or by law shall be in writing and shall be deemed duly served when
2 personally delivered to one of the parties, or in lieu of such personal service, when deposited in the
3 United States Mail, postage prepaid, addressed to such party.
4 35. GOVERNING LAW
5 The parties agree, that for the purposes of venue, performance under this Agreement is
6 to be in Fresno County, California.
7 The rights and obligations of the parties and all interpretation and performance of this
8 Agreement shall be governed in all respects by the laws of the State of California.
9 36. ELECTRONIC SIGNATURE: The parties agree that this Agreement may be executed
10 by electronic signature as provided in this section. An "electronic signature" means any symbol or
11 process intended by an individual signing this Agreement to represent their signature, including but
12 not limited to (1) a digital signature; (2) a faxed version of an original handwritten signature; or (3) an
13 electronically scanned and transmitted (for example by PDF document) of a handwritten signature.
14 Each electronic signature affixed or attached to this Agreement (1) is deemed equivalent to a valid
15 original handwritten signature of the person signing this Agreement for all purposes, including but not
16 limited to evidentiary proof in any administrative or judicial proceeding, and (2) has the same force
17 and effect as the valid original handwritten signature of that person. The provisions of this section
18 satisfy the requirements of Civil Code section 1633.5, subdivision (b), in the Uniform Electronic
19 Transaction Act (Civil Code, Division 3, Part 2, Title 2.5, beginning with section 1633.1). Each party
20 using a digital signature represents that it has undertaken and satisfied the requirements of
21 Government Code section 16.5, subdivision (a), paragraphs (1) through (5), and agrees that each
22 other party may rely upon that representation. This Agreement is not conditioned upon the parties
23 conducting the transactions under it by electronic means and either party may sign this Agreement
24 with an original handwritten signature.
25 37. ENTIRE AGREEMENT
26 This Agreement, including all Exhibits between the CONTRACTOR and COUNTY with
27 respect to the subject matter hereof and supersedes all previous agreement negotiations,
28 proposals, commitments, writings, advertisements, publications, and understandings of any nature
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1 whatsoever unless expressly included in this Agreement.
2
3
5
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9
10
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12
13
14
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18
19
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1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and
2 year first hereinabove written.
3
CONTRACTOR COUNTY OF FRESNO
4 KINGS VIEW
5 o«usfonan by: ^ 1
E."'Ou N'j" (al'IL �111r
6 A04F8177391405...
Authorized Signature Brian Pacheco, Chairman of the Board of
7 Supervisors of the County of Fresno
8 Amanda Nugent Divine CEO
Print Name and Title
9 Date: � "a 02 �--
10
11 ATTEST:
Bernice E. Seidel
12 Clerk of the Board of Supervisors
County of Fresno, State of California
13
14 By: _
15
Deputy
16 Mailing Address:
17 Kings View
7170 North Financial Avenue, Suite 110
18 Fresno, CA 93720
19 FOR ACCOUNTING PURPOSES ONLY:
20 Fund/Subclass: 0001/10000
21 Account/Program: 7295/0
Organization: 56304766 East
22 56304767 West
23 EAST WEST
FY 2015-16: $2,208,851 $1,300,431 $ 908,420(9 months)
24 FY 2016-17: $2,377,674 $1,288,124 $1,089,550
FY 2017-18: $2,450,113 $1,327,322 $1,122,791
25 FY 2018-19: $2,541,238 $1,375,952 $1,165,286
FY 2019-20: $2,603,763 $1,410,375 $1,193,388
26 FY 2020-21: $2,681,876 $1,452,686 $1,229,190
FY 2021-22: $2,681,876 $1,452,686 $1,229,190
27 TOTAL: $17,645,391 $9,607,576 $7,937,815
28
- 43 - COUNTY OF FRESNO
Fresno,CA
Exhibit A
Page 1 of 8
MENTAL HEALTH SERVICES ACT
PREVENTION AND EARLY INTERVENTION
SB 82 RURAL MENTAL HEALTH TRIAGE SERVICES
SCOPE OF WORK
CONTRACTOR: Kings View
7170 N. Financial Drive, Suite 110
Fresno, CA 93720
CONTRACT SERVICES: SB 82 Rural Triage Services
East and West Fresno County Cities
CONTRACT TERM: July 14, 2015 —June 30, 2022 (East)
October 1, 2015 — June 30, 2022 (West)
CONTRACT MEDI-CAL 4910 E. Ashlan Avenue, Suite 118
BILLING ADDRESS: Fresno, CA 93726
CONTRACT MAXIMUM: $17,545,391 (East &West Combined)
Contract Max Contract Max
Fiscal Year East Cities West Cities
2015 - 16 1,300,431 908,422
2016 - 17 1,288,124 1,089,550
2017 - 18 1,327,322 1,122,792
2018 - 19 1,375,952 1,165,286
2019 - 20 1,410,375 1,193,388
2020 — 21 1,452,686 1,229,190
2021 —22 1,452,686 1,229,190
$ 9,607,576 $ 7,937,815
PROJECT DESCRIPTION
The County of Fresno, on behalf of the Department of Behavioral Health (DBH), Mental
Health Services Act (MHSA), is providing for Rural Mental Health Triage Services (Rural
Triage Services) in East and West rural Fresno County cities. Rural Mental Health
Triage Services are fully funded by Senate Bill (SB) 82, Public Safety Realignment,
Mental Health Services Act Prevention and Early Intervention, and Medi-Cal Federal
Financial Participation (FFP). Rural Triage Services will be provided in the East Fresno
County cities of: Selma, Sanger, Kingsburg, Fowler, Reedley, Orange Cove and Parlier;
and in the rural West Fresno County cities of Firebaugh, Mendota, Kerman, San
Joaquin, Huron, and Coalinga. Services should be flexible to the needs of rural Fresno
County and may include other rural cities and areas between and around the indicated
cities.
Exhibit A
Page 2 of 8
Rural Triage Services may include, but is not limited to: assessment, crisis intervention,
community referrals and linkages, and short-term/brief case management. In addition,
time permitting, services shall also include community outreach, engagement,
education, and prevention to those potentially in need of services for mental illness
and/or co-occurring substance use disorders, the general public, emergency first
responders, and other community agencies. Rural Triage Services shall be provided in
collaboration with first responders and out in the field where client interaction with law
enforcement and emergency services personnel (first responders) typically occurs, and
where triage services are most beneficial.
PROGRAM GOALS AND OBJECTIVES
The goal of this project is to provide triage staff and peer/family consultation service to
the East Fresno County Cities' of Selma, Sanger, Parlier, Orange Cove, Fowler,
Reedley and Kingsburg, and the West Fresno County Cities' of Firebaugh, Mendota,
Kerman, San Joaquin, Huron, and Coalinga in a means that has never been provided.
These services shall be provided by interagency coordination between mental health
and law enforcement to identify, triage, assess, and connect or reconnect clients to
treatment and support, and mitigate unnecessary expenditures of law enforcement.
Program Methods:
1) With the placement of triage staff in rural law enforcement agencies, staff will be
able to establish data that denotes mental health clients, crisis and interventions
for each of the identified communities;
a. Data will identify those that have repeated use of 911/crisis resources,
triage staff will be available to engage and work with clients/families on a
local prevention plan using Wellness Recovery Action Plan tools.
2) Triage staff placement and participation with local law enforcement agencies will
increase justice system resources for response to safety and criminal behavior
calls/needs.
a. Triage staff will be on-site for rapid response and mental health triage and
assessment as a subject matter expert and provide appropriate
interventions and or linkages with follow up.
3) Individuals with mental illness who engage with law enforcement will have more
efficient access to crisis services, receive treatment more sensitive to their
mental condition, experience fewer legal concerns and costs related to the
encounter with law enforcement, have improved safety and experience less
discrimination.
4) Provision of mental health sensitivity and crisis education to assist paramedics to
triage clients in an appropriate means if medical criteria do not indicate an
Emergency Department admission.
Exhibit A
Page 3 of 8
To achieve these objectives, refer to Exhibit B and Exhibit Be for indicators of what
will be tracked.
CONTRACTOR RESPONSIBILITIES:
CONTRACTOR SHALL:
1) Establish and maintain co-location space with emergency first responders in rural
Fresno County cities. Rural East Fresno County cities served include: Selma,
Sanger, Kingsburg, Fowler, Reedley, Orange cove and Parlier; Rural West
Fresno County cities served include: Firebaugh, Mendota, Kerman, San
Joaquin, Huron, and Coalinga. Not all cities will have co-location facilities
available at all times. Co-location arrangements should be flexible and adaptable
to meet the evolving needs of the community, in particular the volume of mental
health related calls received and services required.
2) Co-respond to potential mental health related calls with emergency first
responders and provide rural triage services as indicated herein;
3) In East Fresno County, serve a minimum of 2,100 unique individuals in the first
12 months of operation, and 700 unique individuals each 12 month period
following.
4) In West Fresno County, serve a minimum of 1,600 unique individuals in the first
12 months of operation, and 500 unique individuals each 12 month period
following.
5) Provide culturally, ethnically, and linguistically relevant rural triage services;
6) Meet equipment and technology needs to support the required software. It is
anticipated electronic billing will occur though use of a Cisco VPN connection
directly into the County's billing module (AVATAR).
7) Ensure billable Mental Health Specialty Services meet any/all County, State,
Federal regulations including any utilization review and quality assurance
standards. Provide all pertinent and appropriate information in a timely manner
to County to bill Medi-Cal for services rendered. The Vendor is responsible for
billing private insurance and Medicare, if applicable, prior to billing Medi-Cal.
Notice of denial/approval of private insurance and/or Medicare must be
received prior to billing Medi-Cal.
8) Refer clients who meet the criteria and are eligible for entitlement programs for
benefits/ services. All clients currently in the program and any new clients to be
enrolled will go through Social Services to qualify for financial resources.
Exhibit A
Page 4 of 8
9) Utilize the County Peer Support and Family Advocate as informational
resources to aid in serving the rural communities, including the provision of
training, materials creation and ongoing support.
10)Ensure Triage staff captures 60% of their time as documentable productive
direct services. It is expected that Medi-Cal will be billed when and wherever
appropriate, however the 60% productivity rate shall also include services such
as one-on-one consultations, outreach and education, targeted short-term/brief
case management and follow up. When not conducting direct Mental Health
Triage services, staff should conduct and document training, outreach,
education and engagement in the East 7 cities, West 6 cities, and outlying
areas.
STAFFING REQUIREMENTS:
Staffing shall include:
1. A Supervisory/float Licensed Clinician to provide oversight to all clinicians, work
with agencies to build and expand services, and provide crisis response as
needed;
2. Staff Clinicians adequate to cover shifts 7 days a week to provide response 18
hours a day;
3. On call/extra help part time clinical staff to cover shifts and back up as needed;
4. One part-time designated administrative support for the purpose of data
collection, tracking and reporting;
5. Triage staff skilled at engaging persons in crisis in stabilizing, therapeutic,
recovery/wellbeing focused manner;
6. Triage staff with established rotation schedules to meet the needs of the various
rural area cities. This should include staff availability for individual/direct calls for
services on regularly scheduled days and hours per city.
PERFORMANCE MEASURES AND REPORTIING REQUIREMENTS:
SIB 82 Rural Mental Health Triage Services will be monitored and evaluated based on
established performance measures. The attached Exhibit B, Exhibit Ba, and Bb will
be used for evaluating and reporting to the COUNTY, the effectiveness of program
strategies and efforts in the provision of SB 82 Rural Triage Services. Exhibit B
represents the established minimum performance measures which SIB 82 Rural Triage
Services will be evaluated. Exhibit Ba and Exhibit Bb are used by the CONTRACTOR
when requested by COUNTY (typically annually), to report accumulative annual
performance outcomes to COUNTY.
Exhibit A
Page 5 of 8
Proposed and recommended performance measures may be reviewed for input and
approval by a designated Department of Behavioral Health work group upon contract
execution. The purpose of this input process is to ensure a comprehensive system
wide approach to the evaluation of programs through an effective performance
reporting process. Evaluation tools (such as Exhibit B, Ba, and Bb) are subject to
modification, replacement, and/or deletion by COUNTY based on the effectiveness of
the tools and changes in Federal, State and/or COUNTY reporting requirements.
In addition to the above mentioned reports, the following is required by the Department
of Behavioral Health and must be reported to the Department Analyst each month by
the loth of the month following the report period, unless otherwise indicated. The report
period is the prior month of services. As there will be two distinct budgets, one for
Eastern and one for Western Fresno County triage services, the following reports must
be provided independently for each of the Eastern and Western rural triage services.
Funding, billing, staffing, and related data must be collected, maintained and reported
separately for Eastern and Western rural triage services.
• Monthly Invoicing: Invoices must be submitted by the 10th of each month to the DBH
Analyst and shall include expenses and revenues of the prior month report period.
• Staffing Report: Staffing report (Exhibit Bc) shall be submitted by the loth of each
month to the DBH Program Technician and DBH Analyst and must include each
program staffing, their FTE and their salary.
Contract Reporting and Evaluation as Required by the SB 82 Triage Services Grant
(Exhibit Bd and Exhibit Be)
• Process Information Report, due quarterly (one for Eastern and one for Western)
and to include the following:
i. Number, FTE and type/classification of new triage personnel hired by contractor
in each report period, including date of hire and Full-Time-Equivalent (FTE), and
total number of triage personnel on staff at the end of each report period.
ii. Triage service locations/points of access used in each report period (e.g.,
hospital emergency rooms, psychiatric hospitals, crisis stabilization programs,
homeless shelters, jails, clinics, other community-based service points).
iii. Number of clients served at each triage service location/point of access in each
report period.
• Encounter Based Information Report, due quarterly (one for Eastern and one for
Western) and to include the following:
i. Total unduplicated persons served in each report period.
ii. Total number of service contacts in each report period.
Exhibit A
Page 6 of 8
iii. Basic demographic information for each individual client served in each report
period. Demographic information shall include information on age, race,
ethnicity, gender. If available, the Contractor shall also provide information on
language spoken, cultural heritage, LGBTQ, and military status.
iv. Description of specific services that each client was referred to by triage
personnel in each report period.
v. For each client served in a report period, at the time the triage service was
provided, was the person served enrolled in any mental health service? If yes,
what service?
• Evaluation of Program Effectiveness is due every six (6) months (one for Eastern
and one for Western) and to include the following:
i. Contractor's goals and objectives for increased triage personnel and/or the
improved crisis response system.
ii. The system indicators, measures, and outcomes that Contractor used to track to
document the effectiveness of services.
iii. Evaluation analysis and findings about whether specific system and individual
outcomes have been attained.
• Success Reporting (Exhibit Bd) is due quarterly (one for Eastern and one for
Western) as part of documentation assignments. Included in the report is a fiscal
worksheet to identify how an intervention has saved the community/system of care
dollars.
STAFF TRAINING AND RESOURCE/COMMUNITY DEVELOPMENT
• Time spent completing training and resource/community development shall be
captured (not billed as revenue) and reported each month (one for Eastern and one
for Western) to the DBH Analyst, by the 10t" of the month following the report period.
• Compliance, Billing and Documentation Training are required and will be provided by
DBH to Contractor staff annually and with new hires upon hire.
FUNDING
East and West Rural Triage Services are funded by different revenue streams and
shall be budgeted independent of one another. East Rural Triage Services are funded
by SB 82 and Medi-Cal FFP revenue generated by the provider; and West Rural
Triage Services are funded by Public Safety Realignment, Mental Health Services Act
Prevention and Early Intervention, and Medi-Cal FFP revenue generated by the
provider.
Exhibit A
Page 7 of 8
All revenues and expenses shall be managed and reported separately for East and
West. Provider shall submit an invoice and associated general ledger each month;
one for East and one for West. Refer to Exhibit C "East" and Exhibit C "West" for
further breakdown of allocations for each term of the Agreement. The sum of direct
costs (staff for data collection, analysis and reporting) and indirect costs (e.g.: support
staff, billing) may not exceed fifteen percent (15%) of the total awarded budget.
COUNTY RESPONSIBILITIES:
COUNTY SHALL:
1) Provide oversight, support, coordination, and ongoing monitoring of SB 82 Rural
Triage Services.
2) Notify CONTRACTOR staff of their responsibilities through DBH letters and other
written communications, conferences, formal and informal trainings and individual
consultation.
3) Provide individual consultation on a regular basis and facilitate monthly meetings to
include DBH assigned Analyst and CONTRACTOR's staff.
4) Provide oversight (through the County Department of Behavioral Health (DBH),
Contracts Division of the SB 82 Rural Triage Services program. In addition to
contract monitoring, oversight includes, but is not limited to, coordination with the
State Department of Mental Health as it may pertain to program administration and
outcomes.
5) Assist the CONTRACTOR in making linkages with the total mental health system.
This will be accomplished through regularly scheduled meetings as well as formal
and informal consultation.
6) Participate in evaluating the performance outcomes and progress of the SB 82 Rural
Triage Services program.
7) Receive and analyze statistical performance data information from vendor
throughout the term of contract on a monthly basis. DBH will notify the vendor when
additional participation is required. The performance measurement process will not
be limited to survey instruments but will also include, as appropriate, client and staff
interviews, chart reviews, and other methods of obtaining required information.
8) Recognize that cultural competence is a goal toward which professionals, agencies,
and systems should strive. Becoming culturally competent is a developmental
process and incorporates at all levels the importance of culture, the assessment of
cross-cultural relations, vigilance towards the dynamics that result from cultural
differences, the expansion of cultural knowledge, and the adaptation of services to
meet culturally-unique needs. Offering those services in a manner that fails to
achieve its intended result due to cultural and linguistic barriers is not cost effective.
Exhibit A
Page 8 of 8
To assist the vendor efforts towards cultural and linguistic competency, DBH shall
provide the following at no cost to vendor(s):
A. Technical assistance to vendor regarding cultural competency requirements
and sexual orientation training; and
B. Mandatory cultural competency training including sexual orientation and
sensitivity training for DBH and vendor personnel, at minimum once per year.
COUNTY will provide mandatory training regarding the special needs of this
diverse population and will be included in the cultural competence training(s).
Sexual orientation and sensitivity to gender differences is a basic cultural
competence principle and shall be included in the cultural competency
training. Literature suggests that the mental health needs of lesbian, gay,
bisexual, transgender (LGBT) individuals may be at increased risk for mental
disorders and mental health problems due to exposure to societal stressors
such as stigmatization, prejudice and anti-gay violence. Social support may
be critical for this population. Access to care may be limited due to concerns
about providers' sensitivity to differences in sexual orientation.
9) Assist CONTRACTOR in establishing and maintaining working relationships with
rural first responders, including co-location and co-response needs that may arise.
Performance Measures Exhibit
SIB 82 Rural Mental Health Triage Services
Objective Indicators Collection Method Timeline
1 a. Co-location to increase ability to la. Data collection of calls
identify those with mental illness via a responded to and frequency of 1a. From clinician hire and start
diagnosis that have law enforcement mental health diagnosis to be date and ongoing.
encounters captured on crisis assessment
1 b. Frequency and nature of calls
to be compiled into each 1 b. Ongoing after clinician hired
1 b. Ability for triage staff to engage community having a `top 5 callers' and at least 40 hours spent
the officers and clients within the designated
list and interventions that can be
1. Establishment of data to better communicated by anv responder community.
define problem statement and 1 c. Name of person, demographic
volume of mental health crisis info, triage outcome, and referrals
calls. documented and tracked for linkage
success
1 e. Crosswalk client information (in a
protected means) with law
enforcement contacts will identify
`frequent contact
clients' and provide a local,
sustainable prevention intervention
Ian
2. Increase time for law a. Program bupervisor and/or 2a. Tracked through Avatar (DBH 2a. From clinician hire/start
enforcement agencies to respond designated staff will track calls in electronic health record) and date and ongoing.
to safety and criminal behavior conjunction with law enforcement to community dispatch loqs.
calls/needs. identify decrease in mental health 2b. Tracked through Avatar and 2b Monthly reporting and data
crisis calls. reports available via that s stem evaluation
5/26/2022
3a. Triage staff will have referral 3a. Referrals made and Exhibit B
resources and relationships built documented via crisis and 3a. From clinician hire and start
3. Triage staff will be able to comprehensive assessment or date and ongoing.
make appropriate referrals to within each local community. plan of care.
local treatment, prevention and 3b. Triage staff will make referrals 3b. Triage staff will be making
support services. upon each (100%) contact in the follow up contact for 30 days to 3b. Monthly data sharing.
community ensure and assist with all linkages.
4a. Supervisory Paramedics will 4a. Training will be designed
4. Quarterly crisis mental health receive training and refreshers on 4a. Training outlines and sign in and initiated within 4 months of
and sensitivity training for regular basis, pre/post tests will be sheets, analysis of pre/post tests grant award
Supervisory Paramedics will utilized to track training obiectives
decrease use of Emergency 4b. QI and EMS documentation 4b. Department review of run 4b. Monthly data sharing will
review on a monthly basis to denote use of interventions that
Departments. determine implementation of sheets and use of Quality did not result in emergency
information Improvement system De artment access.
The program's effectiveness will be evaluated not only by the above indicators, but also through additional means:
1) Shared communication already established with Fresno Police Department and Emergency Medical Services to identify those
individuals that are homeless with mental illness that are transient between communities to create a county-wide system of care and
intervention plan.
2) Each of the receiving agencies will track `rural triage' as a referring party to their programs, this will capture referral information for
the various prevention and innovation programs that exist outside of traditional mental health facilities in the communities (speakers
bureau, cultural based navigation specialists, community gardens, holistic wellness center, etc).
3) Designated staff will check electronic record system at 3, 6 and 9 month intervals to ensure that additional services were not
provided outside of the plan of care and referrals as outlined by the clinician. This data will provide an overview of effective and less
effective interventions based client needs and each community's resources. Data collection and analysis will be used in community
stakeholder processes, client and family forums and other means to solicit enhanced resources as needed based on actual data.
4) Fresno County Department of Behavioral Health will monitor for program effectiveness, via annual reporting to the community,
outcomes are vetted through client/family advisory committee and Department outcomes review
5/26/2022
[Type text] Performance Measures Exhibit Ba
PROGRAM TITLE: PROVIDER:
PROGRAM DESCRIPTION:
AGES SERVED:
❑ Children ❑ TAY
❑ Adult ❑ Older Adult
DATES OF OPERATION: DATES OF DATA REPORTING PERIOD:
OUTCOME GOAL OUTCOME DATA
DEPARTMENT RECOMMENDATION(S):
See page 2 for tables
[Type text] Performance Measures Exhibit Ba
Comparison of Consumers'Outcomes Prior to
and Since Enrollment in AB 2034
90
80
70
60
50
March 2001-February 2003 40
❑Prior to 30%
Enrollment 20%
10%
❑Since 0%
Enrollment Days H.pitahz Days H—d.. Days In nl
[Type text] [Type text] Exhibit Bb
Performance Effectiveness Form—Attachment C
Name of Program: Click here to enter text.
What is the Program/Contract Goal? lick here to Pnter text.
Funding Source:
❑ Prevention ❑ Community Services and Supports
❑ Early Intervention ❑ EPSDT
❑ Realignment ❑ Innovations
❑ Other: Click hereto enter text.
Fiscal Information:
Budget Amount: $Click here to enter text.
Source(s)of Funding: Click here to enter text.
Number of Unique Clients Served During Time Period: Click here to enter text.
Number of Services Rendered During Time Period: Click here to enter text.
Cost Per Client: lick here to enter text.
Type of Program:
❑ Outpatient ❑ Inpatient ❑ Other
❑ DBH-Operated ❑ Contract-Operated
Level of Care Information:
Level of Care: ❑ 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5
Please Describe: lick here to enter text.
Target Population Information:
Target Population: Click here to enter text.
[Type text] [Type text] Exhibit Bb
Clinical Information:
Does the Program Utilize Any of the Following?
❑ Evidence Based Practice ❑ Evidence Informed Practice ❑ Best Practice
Please Describe: lick hereto enter text.
Outcomes and Effectiveness:
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? (ACK nere to enter tex,
Describe the Program's Effectiveness(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 Effectiveness? Click here to
enter text.
For Committee Use Only:
Recommendations: Click here to enter text.
Staffing Report Exhibit Be
Program:
Contract Start Date:
Submitted By: Date
Staffing FTE Date of Schedule Tentative Identified Bi-Lingual Direct Consumer Other
Name/Classification/ If not FTE, id % Hire (days, hours) Hire Date (if as Hard to If yes, note Service Staff Staff
Academic Degree of position for offer/start Fill? If yes, tang (Mark X, if (Mark X,
(per contract) MHSA Program date note why spoken applies) if
Onlypending) applies)
inn= Mark One Box Only
Staffing to be updated monthly in this format and submitted to dtijerinakco.fresno.ca.us (by the IOth of every month).
Exhibit Bd
COUNTY OF FRESNO
Success Report
Department of Behavioral Health
Complete the document to report client/family 'successes' with multi-agency/systems involvement
REPORT OF SUCCESS MAY BE UTILIZED (DE IDENTIFIED AS NEEDED) IN KUDOS AND NEWLETTERS (NOT A PART
OF MEDICAL RECORDS)
Name of Person Reporting:
Staff Names and Programs Involved in the Success:
Client Name: Patient ID:
Gender: El Male
Male C Female
Date of Birth: Age:
Primary Language: Marital Status:
Living Situation: Other Living Situation:
Date of Success Being Reported:
Date Range of Success(in days approximately) :
Account of the success (please include milestones of client, support system and supporting
agencies) :
Date of Success Meeting:
Attendees to Success Meeting:
Factors that Achieved the Success:
Signature of Person Reporting Supervisor Signature
Exhibit Bd
COUNTY OF FRESNO
Success Report Worksheet
Department of Behavioral Health
This worksheet is to be utilized with the Success Report Form.
Client Name: Patient ID:
Date of Success Being Reported:
Interval Prior to Success Being Reported:
❑1 month ❑3 months ❑6 months ❑9 months ❑12 months
Please complete to the best of your knowledge
Number of days homeless
Number of days in jail
5150 incidents
ER visits
Number of FPD contacts
Number of EMS contacts
Law enforcement contacts (not
including FPD contacts)
Minutes of Mental Health
services provided
Number of admissions to crisis
unit (CSU)
Other significant events prior to reported success:
Exhibit Be
County: Fresno
Triage Program Name: Triage Program 123
Program Type(s) Mobile Crisis Select One Select One Select One
State Fiscal Year 2014/15 State Fiscal Year 2015/16
Persons Served (Duplicated,
Warmline, Outreach, etc.) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Total Number of Persons Served
Community Events (Optional) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Total Number of Events
Total Persons Served
(Unduplicated) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
New
Carryover
Total Persons Served 0 0 0 0 0 0 0 0 0 0
Service Contacts (Duplicated) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Total Service Contacts I I I I I I
Age Group (Unduplicated) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Children (0-15)
Transition Age Youth (16-25)
Adult(26-59)
Older Adult (60+)
Unknown/ Not Reported
Total 0 I 0 I 0 I 0 I 0 I 1 0 1 0 0 0 0
Gender (Unduplicated) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Male
Female
Other
Unknown/Not Reported
Total 0 0 0 0 0 I 0 I 0 I 0 I 0 I 0
Page 1 of 8
Triage Exhibit Be
Total Duplicated/Unduplicated Persons Served
State Fiscal Year 2014/15 State Fiscal Year 2015/16
Ethnicity (Unduplicated) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Hispanic or Latino
Not Hispanic or Latino
Unknown/Not Reported
Total 0 1 0 1 0 1 0 1 0 0 1 0 1 0 _ 0 0
Race (Unduplicated) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
American Native
Asian Indian
Black
Cambodian
Chinese
Filipino
Guamanian
Hawaiian Native
Hmong
Japanese
Korean
Laotian
Mien
Multiple
Other
Other Asian or Pacific Islander
Samoan
Unknown/ Not Reported
Vietnamese
White
Total 0 0 0 0 0 0 0 0 0 0
Page 2 of 8
Triage Demographics Reporting (Optional) Exhibit Be
Unduplicated
County: Fresno
Triage Program Name: Triage Program 123
State Fiscal Year 2014/15 State Fiscal Year 2015/16
Language (Unduplicated) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
American Sign Language (ASL)
Arabic
Armenian
Cambodian
Cantonese
English
Farsi
French
Hebrew
Hmong
Ilocano
Italian
Japanese
Korean
Lao
Mandarin
Mien
Other Chinese Dialects
Other Non-English
Other Sign Language
Polish
Portuguese
Russian
Samoan
Spanish
Tagalog
Thai
Turkish
Vietnamese
Unknown/ Not Reported
Optional
Page 3 of 8
Triage Demographics Reporting (Optional) Exhibit Be
Unduplicated
(Total F5-7 0 I 0 0 0 0 0 0 0 I 0
State Fiscal Year 2014/15 State Fiscal Year 2015/16
LGBQ (Unduplicated) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Gay or Lesbian
Heterosexual or Straight
Bisexual
Questioning
Queer
Aother Sexual Orientation
Unknown/ Not Reported
Total 0 0 0 0 0 0 0 0 0 0
Military Status (Unduplicated) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Veteran
Active
Unknown/ Not Reported
Total 0 0 0 0 0 0 0 0 0 0
Cultural Heritage (Unduplicated) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Total 0 0 0 0 0 0 0 0 0 0
Optional
Page 4 of 8
Triage Referrals Reporting Exhibit Be
Duplicated
County: Fresno
Triage Program Name: Triage Program 123
State Fiscal Year 2014/15 State Fiscal Year 2015/16
Service Referrals Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Mental Health Services
AB109 Programs
Crisis Residential(Children)
Crisis Residential (Adult)
Crisis Stabilization Unit
Full Service Partnership
HMO/Managed Care Plan _
IMD/State Hospital
MH/BH Practitioner
Outpatient Clinic/Services
Outreach (Mobile)
Partial Hospitalization/ Intensive
Outpatient
Peer Services
Private Services
Psychiatric Inpatient
Wellness Center
Other
Housing Services Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Board And Care
Emergency Housing
Homeless Shelter
Motel/Hotel
Permenant Supported Hoursing
Residential Rehabilitation
Room and Board
Skilled Nursing Facility
Other
Page 5 of 8
Triage Referrals Reporting Exhibit Be
Duplicated
FY 2014/15 FY 2015/16
Other Services Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Adult Protective Services
Alcohol/Narcotics Anonymous
Child Protective Services
Department of Social Services
Detox(Alcohol or Drug)
Domestic Violence/Sexual Assault
Services
Family
Foster Care
General Assistance
Hospital Medical Unit
Law Enforcement
Office on Aging
Outpatient Substance Abuse
Parole
Primary Care Physician
Probation
Regional Center
Residential Substance Abuse
School/University
Spiritual Support Centers
Transitional Age Youth Services
Veteran Services
Victim/Witness Services
Warm Line
Other
Total 0 0 0 0 0 0 0 0 0 0
Page 6 of 8
Triage Enrolled Reporting Exhibit Be
Unduplicated and Duplicated
County: Fresno
Triage Program Name: Triage Program 123
State Fiscal Year 2014/15 State Fiscal Year 2015/16
Enrolled In Mental Health Services
(Unduplicated) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Yes
No
Unknown
Total 0 0 0 0 0 0 0 0 0 0
State Fiscal Year 2014/15 State Fiscal Year 2015/16
Type of Mental Health Services
(Duplicated) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Full Service Partnership
Prevention Program
Early Intervention Program
Outpatient Clinic/Services
Wellness Center
Employment Program
MH/BH Practitioner
Workforce Education and Training
Medication Management
Peer Services
Other
Page 7 of 8
Errors Exhibit Be
County: Fresno
Triage Program Name: Triage Program 123
State Fiscal Year 2014/15 State Fiscal Year 2015/16
Unduplicated Totals Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Full Year
Total Persons Served 0 0 0 0 0 0 0 0 0 0
Age Group 0 0 0 0 0 0 0 0 0 0
Gender 0 0 0 0 0 0 0 0 0 0
Ethnicity 0 0 0 0 0 0 0 0 0 0
Race 0 0 0 1 0 0 0 0 0 0 0
Language 0 0 0 0 0 0 0 T 0 0 0
LGBQ 0 0 0 0 0 0 0 0 0 0
Military Status 0 0 0 0 0 0 0 0 0 0
Enrolled In Mental Health Services 0 0 0 0 0 0 0 0 0 0
Mandatory Fields Error
Optional Fields Error
Page 8 of 8
Errors Exhibit Be
Page 9
RURAL MENTAL HEALTH TRIAGE-East Exhibit C
Page 1 of 10
Kings View
FYS 2015-2016 THROUGH 2O19-2020
Line Item Description FY 2015-2016 FY 2016-2017 FY 2017-2018 FY 2018-2019 FY 2019-2020
PERSONNEL SALARIES:
0001 Executive Director(Licensed)0.02 FTE $3,066 $3,158 $3,253 $3,601 $3,709
0002 Program Director(Licensed)0.08 FTE $7,488 $7,713 $7,944 $10,052 $10,354
0009 Clinical Director(Licensed)0.33 FTE $40,000 $41,200
0003 Program Manager (Licensed).50 FTE $46,800 $48,204 $49,650 $57,363 $59,084
0004 UR Specialist(Licensed).40 FTE $20,800 $21,424 $22,067 $37,133 $38,247
0005 Licensed Clinician 7 FTE $553,280 $569,878 $586,975 $596,960 $614,869
0006 Program Support 0.83 FTE $19,760 $20,353 $20,963 $46,005 $47,385
0007 Medical Director(on-call) $6,240 $6,427 $6,620 $0 $0
Per Diem Team responders (Licensed) 1,000
0008 hours/year $40,000 $41,200 $42,436 $28,709 $29,570
SALARY TOTAL $697,434 $718,357 $739,908 $819,823 $844,418
PAYROLL TAXES:
0031 FICA/MEDICARE $53,354 $54,954 $56,603 $62,716 $64,598
0032 U.1. $6,974 $7,184 $7,399 $8,198 $8,444
0033 Workers Compensation $27,897 $28,734 $29,596 $22,793 $23,777
PAYROLL TAX TOTAL $88,225 $90,872 $93,598 $93,708 $96,819
EMPLOYEE BENEFITS:
0040 Retirement $14,367 $14,798 $8,198 $8,444
0041 Health Insurance(medical vision, life,dental) $118,564 $122,121 $125,784 $122,9731 $126,663
EMPLOYEE BENEFITS TOTAL $118,564 $136,488 $140,582 $131,172 $135,107
SALARY&BENEFITS GRAND TOTAL $904,223 $945,717 $974,089 $1,044,702 $1,076,343
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $12,000 $12,360 $12,731 $19,113 $19,686
1011 Rent/Lease Equipment(copier) $1,800 $1,854 $1,910 $1,967 $2,026
1012 Utilities $3,000 $3,090 $3,183 $3,278 $3,377
1013 Janitorial/Building $1,500 $1,545 $1,591 $7,639 $7,868
1015 Other-Vehicle Leasing(4 vehicles) $22,000 $17,600 $17,6001 $17,600 $17,600
FACILITY/EQUIPMENT TOTAL $40,300 $36,449 $37,0141 $49,597 $50,557
RURAL MENTAL HEALTH TRIAGE-East Exhibit C
Page 2 of 10
Kings View
FYS 2015-2016 THROUGH 2O19-2020
OPERATING EXPENSES:
1060 Telephone $14,640 $15,079 $15,532 $3,998 $4,117
1062 Postage $125 $125 $125 $125 $125
1063 Printing/Reproduction $2,500 $1,500 $1,500 $2,059 $1,422
1066 Office Supplies&Equipment $7,500 $4,000 $4,120 $4,244 $4,371
1069 Program Supplies $5,000 $5,150 $5,305 $2,964 $3,053
1072 Staff Mileage/vehicle maintenance $5,000 $5,150 $5,305 $5,464 $5,628
1074 Staff Training/Registration $10,000 $10,000 $10,000 $5,000 $8,000
1077 Other-Miscellaneous $1,800 $800 $800 $800 $800
1078 Staff Recruitment/backgound checks $7,550 $2,250 $2,250 $2,250 $2,250
1079 Communications(cell phone&mobile internet) 1 $14,550 $12,600 $12,600 $16,000 $15,100
OPERATING EXPENSES TOTAL $68,665 $56,654 $57,536 $42,902 $44,865
FINANCIAL SERVICES EXPENSES:
1082 Liability Insurance(Auto, Property,General) $8,200 $8,446 $8,699 $10,960 $11,289
1083 Other-Professional Liability $3,600 $3,708 $3,819 $3,934 $4,052
1084 Other-Administrative Overhead(11%) $111,148 $110,096 $113,446 $135,530 $138,942
FINANCIAL SERVICES TOTAL $122,948 $122,250 $125,965 $150,424 $154,283
SPECIAL EXPENSES(Consultant/Etc.):
1090 Consultant(network&data management) $77,804 $77,067 $79,412 $70,000 $70,000
1091 Translation Services $2,000 $2,000 $2,000 $2,000 $2,000
1092 CVSPH Dispatcher services 6,570 hrs.(50%) $53,381 $43,986 $45,306 $0 $0
1093 Avatar License Fee $8,3271 $8,327
SPECIAL EXPENSES TOTAL i $133,185 $123,053 $126,718 $80,3271 $80,327
FIXED ASSETS:
2000 Computers&Software $23,610 $4,000 $6,000 $8,000 $4,000
2001 Furniture&Fixtures $7,500 $0 $0 $0 $0
2002 Other $0 $0 $0 $0 $0
2003 Other 1 $0 $0 $0 $0 $0
FIXED ASSETS TOTAL 1 $31,110 1 $4,000 $6,000 $8,000 $4,000
$1,300,431 $1,288,124 $1,327,3221 $1,375,9521 $1,410,375
RURAL MENTAL HEALTH TRIAGE-East Exhibit C
Page 3 of 10
Kings View
FYS 2015-2016 THROUGH 2O19-2020
Units o
FY 2015-16 MEDI-CAL REVENUE: Service Rate $Amount
3000 Mental Health Services(Individual/Family/Group Therapy) $2.40 $0
3100 Case Management 72,800 $1.86 $135,408
3200 Crisis Services 218,400 $3.58 $781,872
3300 Medication Support $0.00 $0
3400 Collateral $0.00 $0
3500 Plan Development $2.40 $0
3600 Assessment 87,360 $2.40 $209,664
3700 Rehabilitation $0.00 $0
Estimated Medi-Cal Billing Totalsi 378,560 $1,126,944
Estimated %of Federal Financial Participation Reimbursement 50.00% $563,472
Estimated%of Clients Served that will be Medi-Cal Eligible 80.00%
MEDI-CAL REVENUE TOTAL $450,778
OTHER REVENUE:
4000 Other-SB 82 Grant $849,653
4100 Other-
OTHER REVENUE TOTAL $849,653
MHSA FUNDS:
5100 Prevention and Early Intervention 0
MHSA FUNDS TOTAL $0
TOTAL PROGRAM REVENUEJ $1,300,431
Units o
FY 2016-2017 MEDI-CAL REVENUE: Service Rate $Amount
3000 Mental Health Services(Individual/Family/Group Therapy) $2.38 $0
3100 Case Management 72,800 $1.84 $133,952
3200 Crisis Services 218,400 $3.54 $773,136
3300 Medication Support $0.00 $0
3400 Collateral $0.00 $0
3500 Plan Development $2.38 $0
3600 Assessment 87,360 $2.38 $207,917
3700 Rehabilitation $0.00 $0
Estimated Medi-Cal Billing Totalsi 378,560 $1,115,005
Estimated %of Federal Financial Participation Reimbursement 50.00% $557,502
Estimated %of Clients Served that will be Medi-Cal Eligible 80.00%
MEDI-CAL REVENUE TOTAL $446,002
OTHER REVENUE:
4000 Other-SB 82 Grant $842,122
4100 Other-
OTHER REVENUE TOTAL $842,122
MHSA FUNDS:
5100 Prevention and Early Intervention 0
MHSA FUNDS TOTAL 0
TOTAL PROGRAM REVENUE $1,288,124
Units o
FY 2017-2018 MEDI-CAL REVENUE: Service Rate $Amount
3000 Mental Health Services(Individual/Family/Group Therapy) $2.46 $0
3100 Case Management 72,800 $1.90 $138,320
3200 Crisis Services 218,400 $3.65 $797,160
3300 Medication Support $0.00 $0
RURAL MENTAL HEALTH TRIAGE-East Exhibit C
Page 4 of 10
Kings View
FYS 2015-2016 THROUGH 2O19-2020
3400 Collateral $0.00 $0
3500 Plan Development $2.46 $0
3600 Assessment 87,360 $2.46 $214,906
3700 Rehabilitation $0.00 $0
Estimated Medi-Cal Billing Totals 378,560 $1,150,386
Estimated%of Federal Financial Participation Reimbursement 50.00% $575,193
Estimated%of Clients Served that will be Medi-Cal Eligiblel 80.00%
MEDI-CAL REVENUE TOTAL $460,154
OTHER REVENUE:
4000 Other-SB 82 Grant $867,168
4100 Other-
OTHER REVENUE TOTAL $867,168
MHSA FUNDS:
5100 Prevention and Early Intervention 0
MHSA FUNDS TOTAL 0
TOTAL PROGRAM REVENUE $1,327,322
Units o
FY 2018-2019 MEDI-CAL REVENUE: Service Rate $Amount
3000 Mental Health Services(Individual/Family/Group Therapy) $3.26 $0
3100 Case Management 15,000 $2.76 $41,400
3200 Crisis Services 125,000 $5.35 $668,750
3300 Medication Support $0.00 $0
3400 Collateral $0.00 $0
3500 Plan Development $3.26 $0
3600 Assessment 12,500 $3.26 $40,750
3700 Rehabilitation $0.00 $0
Estimated Medi-Cal Billing Totalsi 152,500 $750,900
Estimated%of Federal Financial Participation Reimbursement 50.00% $375,450
Estimated%of Clients Served that will be Medi-Cal Eligible 80.00%
MEDI-CAL REVENUE TOTAL $300,360
OTHER REVENUE:
4000 Other-
4100 Other-
OTHER REVENUE TOTAL 0
MHSA FUNDS:
5100 Prevention and Early Intervention $1,075,592
MHSA FUNDS TOTAL $1,075,592
TOTAL PROGRAM REVENUEJ $1,375,952
Units o
FY 2019-2020 MEDI-CAL REVENUE: Service Rate $Amount
3000 Mental Health Services(Individual/Family/Group Therapy) $3.26 $0
3100 Case Management 15,000 $2.76 $41,400
3200 Crisis Services 125,000 $5.35 $668,750
3300 Medication Support $0.00 $0
3400 Collateral $0.00 $0
3500 Plan Development $3.26 $0
3600 Assessment 12,500 $3.26 $40,750
3700 Rehabilitation 1 1 $0.00 1 $0
Estimated Medi-Cal Billing Totalsi 152,500 750,900
RURAL MENTAL HEALTH TRIAGE-East Exhibit C
Page 5 of 10
Kings View
FYS 2015-2016 THROUGH 2O19-2020
Estimated %of Federal Financial Participation Reimbursementl 50.00% $375,450
Estimated %of Clients Served that will be Medi-Cal Eligiblel 80.00%
MEDI-CAL REVENUE TOTAL $300,360
OTHER REVENUE:
4000 Other-
4100 Other-
OTHER REVENUE TOTAL $0
MHSA FUNDS:
5100 Prevention and Early Intervention $1,110,015
MHSA FUNDS TOTAL $1,110,015
TOTAL PROGRAM REVENUE $1,410,375
Exhibit C
Page 6 of 10
RURAL MENTAL HEALTH TRIAGE-West
Kings View
FYS 2015-2016 THROUGH 2O19-2020
FY 2015-2016
Line Item Description (9 Months) FY 2016-2017 FY 2017-2018 FY 2018-2019 FY 2019-2020
PERSONNEL SALARIES:
0001 Executive Director(Licensed)0.02 FTE $2,300 $3,158 $3,253 $3,601 $3,709
0002 Program Director(Licensed)0.08 FTE $5,616 $7,713 $7,944 $10,052 $10,354
0009 Clinical Director(Licensed)0.33 FTE $40,000 $41,200
0003 Program Manager (Licensed).50 FTE $46,800 $48,204 $49,650 $57,363 $59,084
0004 UR Specialist(Licensed).40 FTE $15,600 $21,424 $22,067 $37,133 $38,247
0005 Clinician(2 Licensed,5 Unlicensed)7 FTE $330,720 $440,960 $454,189 $433,680 $446,691
0006 Program Support 0.5 FTE $19,760 $20,353 $20,963 $46,005 $47,385
0007 Medical Director(on-call) $4,680 $6,427 $6,620 $0 $0
Per Diem Team responders (Licensed)1,000
0008 hours/year $30,000 $41,200 $42,436 $39,709 $38,400
SALARY TOTAL $455,476 $589,439 $607,122 $667,543 $685,070
PAYROLL TAXES:
0031 FICA/MEDICARE $34,844 $45,092 $46,445 $51,067 $52,408
0032 U.1. $4,555 $5,894 $6,071 $6,675 $6,851
0033 Workers Compensation $18,219 $23,578 $24,285 $16,702 $17,403
PAYROLL TAX TOTAL $57,618 $74,564 $76,801 $74,444 $76,661
EMPLOYEE BENEFITS:
0040 Retirement $11,789 $12,142 $6,675 $6,851
0041 Health Insurance(medical vision,life,dental) $77,431 $100,205 $103,211 $100,131 $102,760
EMPLOYEE BENEFITS TOTAL $77,431 $111,993 $115,353 $106,807 $109,611
SALARY&BENEFITS GRAND TOTAL $590,524 $775,996 $799,276 $848,794 $871,342
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $12,000 $12,360 $12,731 $17,113 $19,626
1011 Rent/Lease Equipment(copier) $1,800 $1,854 $1,910 $1,967 $2,026
1012 Utilities $3,000 $3,090 $3,183 $3,278 $3,377
1013 Janitorial/Building $1,500 $1,545 $1,591 $9,639 $10,787
1015 Other-Vehicle Leasing(4 vehicles) $22,0001 $17,6001 $17,6001 $17,6001 $17,600
FACILITY/EQUIPMENT TOTAL $40,3001 $36,4491 $37,0141 $49,5971 $53,416
OPERATING EXPENSES:
1060 Telephone $14,640 $15,079 $15,532 $3,998 $4,117
1062 Postage $125 $125 $125 $125 $125
1063 Printing/Reproduction $2,500 $1,500 $1,500 $1,356 $1,500
1066 Office Supplies&Equipment $7,500 $4,000 $4,120 $4,244 $4,371
1069 Program Supplies $5,000 $5,150 $5,305 $2,964 $3,053
1072 Staff Mileage/vehicle maintenance $5,000 $5,150 $5,305 $13,464 $13,868
1074 Staff Training/Registration $10,000 $10,000 $10,000 $5,000 $5,000
1077 Other-Miscellaneous $1,800 $800 $800 $800 $800
1078 Staff Recruitment/backgound checks $7,550 $2,250 $2,250 $2,250 $2,250
1079 Communications(cell phone&mobile internet) $14,550 $12,600 $12,600 $12,600 $12,600
OPERATING EXPENSES TOTAL $68,665 $56,654 $57,536 $46,799 $47,683
FINANCIAL SERVICES EXPENSES:
1082 Liability Insurance(Auto,Property,General) $8,200 $8,446 $8,699 $8,960 $9,229
1083 Other-Professional Liability 1 $3,600 $3,708 $3,819 $3,934 $4,052
Exhibit C
Page 7 of 10
RURAL MENTAL HEALTH TRIAGE-West
Kings View
FYS 2015-2016 THROUGH 2O19-2020
1084 Other-Administrative Overhead(11%) $77,643 $93,124 $95,965 $114,654 $117,438
FINANCIAL SERVICES TOTAL $89,4431 $105,2781 $108,4841 $127,5481 $130,719
SPECIAL EXPENSES(Consultant/Etc.):
1090 Consultant(network&data management) $54,350 $65,187 $67,176 $75,220 $76,901
1091 Translation Services $2,000 $2,000 $2,000 $1,000 $1,000
1092 CVSPH Dispatcher services 6,570 hrs.(50%) $32,029 $43,986 $45,306 $0 $0
1093 Avatar License Fee $8,3271 $8,327
SPECIAL EXPENSES TOTAL 1 $88,3791 $111,1731 $114,4811 $84,5471 $86,228
FIXED ASSETS:
2000 Computers&Software $23,610 $4,000 $6,000 $8,000 $4,000
2001 Furniture&Fixtures $7,500 $0 $0 $0 $0
2002 Other $0 $0 $0 $0 $0
2003 Other $0 $0 $0 $0 $0
FIXED ASSETS TOTAL $31,1101 $4,0001 $6,0001 $8,0001 $4,000
$908,4201 $1,089,5501 $1,122,7911 $1,165,2861 $1,193,388
Units or
FY 2015-2016 MEDI-CAL REVENUE: Service Rate $Amount
Exhibit C
Page 8 of 10
RURAL MENTAL HEALTH TRIAGE-West
Kings View
FYS 2015-2016 THROUGH 2O19-2020
3000 Mental Health Services(Individual/Family/Group Therapy) $2.56 $0
3100 Case Management 54,600 $1.98 $108,108
3200 Crisis Services 163,800 $3.81 $624,078
3300 Medication Support $0.00 $0
3400 Collateral $0.00 $0
3500 Plan Development $2.56 $0
3600 Assessment 65,520 $2.56 $167,731
3700 Rehabilitation $0.00 $0
Estimated Medi-Cal Billing Totalsi 283,920 $80,917
Estimated%of Federal Financial Participation Reimbursement 50.00% $449,959
Estimated%of Clients Served that will be Medi-Cal Eligible 80.00%
MEDI-CAL REVENUE TOTAL 359,967
OTHER REVENUE:
4000 Other-Public Safety Realignment Funds $350,000
4100 Other-
OTHER REVENUE TOTAL $350,0001
MHSA FUNDS:
5100 Prevention and Early Intervention �$908,422
MHSA FUNDS TOTAL
TOTAL PROGRAM REVENUE
Units o
FY 2016-2017 MEDI-CAL REVENUE: Service Rate $Amount
3000 Mental Health Services(Individual/Family/Group Therapy) $2.38 $0
3100 Case Management 72,800 $1.84 $133,952
3200 Crisis Services 218,400 $3.54 $773,136
3300 Medication Support $0.00 $0
3400 Collateral $0.00 $0
3500 Plan Development $2.38 $0
3600 Assessment 87,360 $2.38 $207,917
3700 Rehabilitation $0.00 $0
Estimated Medi-Cal Billing Totalsi 378,560 $1,115,005
Estimated%of Federal Financial Participation Reimbursement 50.00% $557,503
Estimated%of Clients Served that will be Medi-Cal Eligible 80.00%
MEDI-CAL REVENUE TOTAL 446,002
OTHER REVENUE:
4000 Other-Public Safety Realignment(if allocated)or PEI $350,000
4100 Other-
OTHER REVENUE TOTAL 350,000
MHSA FUNDS:
5100 Prevention and Early Intervention 293,548
MHSA FUNDS TOTAL 293,548
TOTAL PROGRAM REVENUE $1,089,550
units of
FY 2017-2018 MEDI-CAL REVENUE: Service Rate $Amount
3000 Mental Health Services(Individual/Family/Group Therapy) $2.46 $0
3100 Case Management 72,800 $1.90 $138,320
3200 Crisis Services 218,400 $3.65 $797,160
Exhibit C
Page 9 of 10
RURAL MENTAL HEALTH TRIAGE-West
Kings View
FYS 2015-2016 THROUGH 2O19-2020
3300 Medication Support $0.00 $0
3400 Collateral $0.00 $0
3500 Plan Development $2.46 $0
3600 Assessment 87,360 $2.46 $214,906
3700 Rehabilitation $0.00 $0
Estimated Medi-Cal Billing Totals 378,560 1,150,386
Estimated%of Federal Financial Participation Reimbursementj 50.00% $575,193
Estimated%of Clients Served that will be Medi-Cal Eligiblel 80.00%
MEDI-CAL REVENUE TOTAL $460,154
OTHER REVENUE:
4000 Other- Public Safety Realignment(if allocated)or PEI $350,000
4100 Other-
OTHER REVENUE TOTAL 350,000
MHSA FUNDS:
5100 Prevention and Early Intervention 312,638
MHSA FUNDS TOTAL 312,638
TOTAL PROGRAM REVENUE $1,122,792
units of
FY 2018-2019 MEDI-CAL REVENUE: Service Rate $Amount
3000 Mental Health Services(Individual/Family/Group Therapy) $3.59 $0
3100 Case Management 6,000 $3.03 $18,202
3200 Crisis Services 40,000 $5.83 $233,200
3300 Medication Support $0.00 $0
3400 Collateral $0.00 $0
3500 Plan Development $3.59 $0
3600 Assessment 6,500 $3.59 $23,335
3700 Rehabilitation $0.00 $0
Estimated Medi-Cal Billing Totalsi 52,500 274,737
Estimated%of Federal Financial Participation Reimbursement 50.00% $137,369
Estimated%of Clients Served that will be Medi-Cal Eligible 80.00%
MEDI-CAL REVENUE TOTAL 109,895
OTHER REVENUE:
4000 Other
4100 Other-
OTHER REVENUE TOTAL I ::J0
MHSA FUNDS:
5100 Prevention and Early Intervention $1,055,391
MHSA FUNDS TOTAL $1,055,391
TOTAL PROGRAM REVENUEJ $1,165,286
Units o
FY 2019-2020 MEDI-CAL REVENUE: Service Rate $Amount
3000 Mental Health Services(Individual/Family/Group Therapy) $3.59 $0
3100 Case Management 6,000 $3.03 $18,202
3200 Crisis Services 40,000 $5.83 $233,200
3300 Medication Support $0.00 $0
3400 Collateral $0.00 $0
3500 Plan Development $3.59 $0
Exhibit C
Page 10 of 10
RURAL MENTAL HEALTH TRIAGE-West
Kings View
FYS 2015-2016 THROUGH 2O19-2020
3600 Assessment 6,500 $3.59 $23,335
3700 Rehabilitation 1 $0.00 $0
Estimated Medi-Cal Billing Totalsi 52,500 274,737
Estimated%of Federal Financial Participation Reimbursement 50.00% $137,369
Estimated%of Clients Served that will be Medi-Cal Eligible 80.00%
MEDI-CAL REVENUE TOTAL 109,895
OTHER REVENUE:
4000 Other
4100 Other-
OTHER REVENUE TOTAL I ::J0
MHSA FUNDS:
5100 Prevention and Early Intervention $1,083,493
MHSA FUNDS TOTAL $1,083,493
TOTAL PROGRAM REVENUEJ $1,193,388
Exhibit C-1
Page 1 of 14
Rural Mental Health Triage- East
Kings View Corporation
Fiscal Year(FY 2020-21)
PROGRAM EXPENSES
1000:SALARIES&BENEFITS
Employee Salaries
Acct# Position FTE Admin Direct Total
1101 Program Oversight 0.27 $ - $ 33,553 $ 33,553
1102 Clinical Supervisor 0.55 58,779 58,779
1103 Program Manager 0.55 - 71,523 71,523
1104 lClinician (2 unlicensed,5 Licensed) 7.00 - 641,516 641,516
1105 Per Diem Team Responders(Licensed) 0.45 - 37,137 37,137
1106 Program Staff Accountant 0.11 - 5,967 5,967
1107 Administrative Support 0.40 - 19,427 19,427
1108 - -
1109 - - -
1110 - - -
1111 - - -
1112 - - -
1113 - - -
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
Personnel Salaries Subtotal 9.33 $ - $ 867,902 $ 867,902
Employee Benefits
Acct# Description Admin Direct Total
1201 Retirement $ - $ 15,364 $ 15,364
1202 Worker's Compensation - 25,883 25,883
1203 Health Insurance - 111,259 111,259
1204 1 Other(Specify) - - -
1205 10ther(Specify) - - -
1206 1 Other(Specify) - - -
Employee Benefits Subtotal: $ - $ 152,506 $ 152,506
Payroll Taxes&Expenses:
Acct# Description Admin Direct Total
1301 OASDI $ - $ - $ -
1302 FICA/MEDICARE - 66,395 66,395
1303 SUI - 6,509 6,509
1304 1 Other(Specify) - - -
1305 10ther(Specify) - - -
1306 1 Other(Specify) - - -
Payroll Taxes&Expenses Subtotal: $ - $ 72,904 $ 72,904
EMPLOYEE SALARIES&BENEFITS TOTAL: $ - $ 1,093,312 $ 1,093,312
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit C-1
Page 2 of 14
2000:CLIENT SUPPORT
Acct# Line Item Description Amount
2001 Child Care $ -
2002 Client Housing Support -
2003 Client Transportation &Support -
2004 IClothing, 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:OPERATING EXPENSES
Acct# Line Item Description Amount
3001 Telecommunications $ 10,200
3002 Printing/Postage 1,847
3003 Office, Household& Program Supplies 10,350
3004 lAdvertising -
3005 Staff Development&Training 6,500
3006 Staff Mileage 3,500
3007 Subscriptions& Memberships -
3008 Vehicle Maintenance 27,200
3009 10ther(Miscellaneous) 150
3010 Other(Staff Recuitment/Background Checks) 650
3011 Other(Specify) -
3012 Other(Specify) -
OPERATING EXPENSES TOTAL: $ 60,397
4000: FACILITIES&EQUIPMENT
Acct# Line Item Description Amount
4001 Building Maintenance $ 9,500
4002 Rent/Lease Building 26,500
4003 Rent/Lease Equipment 3,526
4004 Rent/Lease Vehicles 25,400
4005 Security -
4006 Utilities 6,650
4007 Other(Specify) -
4008 Other(Specify) -
4009 Other(Specify) -
4010 Other(Specify) -
FACILITIES/EQUIPMENT TOTAL: $ 71,576
5000:SPECIAL EXPENSES
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit C-1
Page 3 of 14
Acct# Line Item Description Amount
5001 Consultant(Network& Data Management) $ 38,118
5002 HMIS(Health Management Information System) -
5003 Contractual/Consulting Services (Specify) -
5004 ITranslation Services 100
5005 Other(Avatar License Fee) 8,577
5006 Other(Specify) -
5007 Other(Specify) -
5008 Other(Specify) -
SPECIAL EXPENSES T0TAL:1 $ 46,795
6000:ADMINISTRATIVE EXPENSES
Acct# Line Item Description Amount
6001 Administrative Overhead $ 143,960
6002 Professional Liability Insurance 6,940
6003 Accounting/Bookkeeping -
6004 External Audit -
6005 Insurance(Liability): 18,500
6006 Payroll Services -
6007 Depreciation(Provider-Owned Equipment to be Used for Program Purposes) -
6008 Other(Specify) -
6009 Other(Specify) -
6010 Other(Specify) -
6011 Other(Specify) -
6012 Other(Specify) -
ADMINISTRATIVE EXPENSES TOTAL $ 169,400
7000: FIXED ASSETS
Acct# Line Item Description Amount
7001 Computer Equipment&Software $ 7,706
7002 Copiers,Cell Phones,Tablets, Devices to Contain HIPAA Data 500
7003 Furniture& Fixtures 3,000
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 $ 11,206
TOTAL PROGRAM EXPENSES 1 $ 1,452,686
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit C-1
Page 4 of 14
PROGRAM FUNDING SOURCES
8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION)
Acct# Line Item Description Service Units Rate Amount
8001 Mental Health Services 25,000 3.26 $ 81,498
8002 Case Management 32,474 2.50 81,184
8003 Crisis Services 225,000 5.00 1,125,000
8004 Medication Support 0 - -
8005 Collateral 0 -
8006 Plan Development 0 -
8007 Assessment 0 -
8008 lRehabilitation 1 0 -
Estimated Specialty Mental Health Services Billing Totals: 1 282,4731 $ 1,287,682
Estimated %of Clients who are Medi-Cal Beneficiaries 75%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 965,762
Federal Financial Participation (FFP)% 1 50% 482,881
MEDI-CAL FFP TOTAL $ 482,881
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 $REALIGNMENT TOTAL $
8300-MENTAL HEALTH SERVICE ACT(MHSA)
Acct# MHSA Component MHSA Program Name Amount
8301 CSS-Community Services&Supports
8302 PEI -Prevention & Early Intervention 969,805
8303 INN -Innovations -
8304 WET-Workforce Education &Training -
8305 CFTN -Capital Facilities&Technology -
MHSA TOTAL $ 969,805
8400-OTHER REVENUE
Acct# Line Item Description Amount
8401 Client Fees $ -
8402 Client Insurance -
8403 Grants(Specify) -
8404 Other(Specify) -
8405 1 Other(Specify) -
OTHER REVENUE TOTAL $
TOTAL PROGRAM FUNDING SOURCES: 1 $ 1,452,686
NET PROGRAM COST: 1 $ 0
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Revised Exhibit C-1
Page 5 of 14
Rural Mental Health Triage-East
Kings View Corporation
Fiscal Year(FY 2020-21) Budget Narrative
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000:SALARIES&BENEFITS 1,093,312
Employee Salaries 867,902
1101 Program Oversight 33,553 Positions will provide agency specific staff oversight and represent and maintain the
collaborative relationship between agencies.Provide program management and
direction.Ensures operations are running smoothly and in compliance with contract
requirements.
1102 Clinical Supervisor 58,779 Provides supervision of all licenced and unlicensed clinical staff.
1103 Program Manager 71,523 Provides supervision of all staff and direct oversight of program management.
1104 Clinician(2 unlicensed,5 Licensed) 641,516 Assist with managing the client's illness and reduce its impact on the client's life,and
referrals to appropriate linkages.
1105 Per Diem Team Responders(Licensed) 37,137 Per Diem-Assist with managing the client's illness and reduce its impact on the
client's life,and referrals to appropriate linkages.
1106 Program Staff Accountant 5,967 Provides budget guidance,monthly invoicing and other fiscal services.
1107 Administrative Support 19,427 Provides administrative support for the program and assist with medical billing and
records.
1108 0
1109 0
1110 0
1111 0
1112 0
1113 0
1114 0
1115 0
1116 0
1117 0
1118 0
1119 0
1120 10
Employee Benefits 152,506
1201 Retirement 15,364 Cost of 401K
1202 Worker's Compensation 25,883 Workers Comp Insurance
1203 Health Insurance 111,259 Cost of Medical,Vision,Dental,Life and Long Term Disability Insurance
1204 Other(Specify) -
1205 Other(Specify)
1206 Other(Specify)
Payroll Taxes&Expenses: 72,904
1301 OASDI -
1302 FICA/MEDICARE 66,395 Cost of FICA/Medicare
1303 SUI 6,509 Cost of SUI
1304 Other(Specify) -
1305 Other(Specify)
1306 Other(Specify)
2000:CLIENT SUPPORT
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)
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2/7/2020
Revised Exhibit C-1
Page 6 of 14
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
2016 Other(Specify)
3000:OPERATING EXPENSES 60,397
3001 Telecommunications 10,200 Cost of telephone services,cell phones service,data connectivity.
3002 Printing/Postage 1,847 Aniticapting courier services and postage nesessary 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 10,350 Includes all supplies used by staff in the course of providing services.
3004 Advertising -
3005 Staff Development&Training 6,500 Cost of continuation of staff development and training.
3006 Staff Mileage 3,500 Reimbusements to staff for personal vehicle use when lease vehicle not available
and require to provide services or other program needs,paid at IRS rate.Any travel
transporation fees,such as parking fees.
3007 Subscriptions&Memberships -
3008 Vehicle Maintenance 27,200 Auto repairs&maintenance required to maintain leased vehicles for client
transporation and program needs,such as oil changes and car washes.Yearly cost of
GPS,vehicle tracking service.
3009 Other(Miscellaneous) 150 Anticipating minor expense that would not fall under any other category.
3010 Other(Staff Recuitment/Background Checks) 650 Thorough background checks and drug testing.
3011 Other(Specify) -
3012 Other(Specify) -
4000:FACILITIES&EQUIPMENT 71,576
4001 Building Maintenance 9,500 Copier maintenance,inspection services,pest control,alarm services,janitorial
services and minor building repairs and maintenance.
4002 Rent/Lease Building 26,500 Building space lease.
4003 Rent/Lease Equipment 3,526 Copier lease and water dispenser rental.
4004 Rent/Lease Vehicles 25,400 The cost of lease vehicles to assist with program and client needs.
4005 Security -
4006 Utilities 6,650 The cost of gas and electric.
4007 Other(Specify) -
4008 Other(Specify)
4009 Other(Specify)
4010 Other(Specify) -
5000:SPECIAL EXPENSES 46,795
5001 Consultant(Network&Data Management) 38,118 Kings View Information Technology Department(KVIT)will provide hardware and
software support for successful data collection.A database will be designed for this
program.WIT will procure equipment,software&other services from approved&
authorized vendors. Provide online,onsite,or phone-based emergency support-
24/7 from the WIT Help Desk.
5002 HMIS(Health Management Information
System)
5003 Contractual/Consulting Services (Specify)
5004 Translation Services 100 Anticipating need of outsource transaltion services.
5005 Other(Avatar License Fee) 8,577 Estimated cost of Avatar fees.
5006 Other(Specify) -
5007 Other(Specify)
5008 Other(Specify)
6000:ADMINISTRATIVE EXPENSES 169,400
6001 Administrative Overhead 143,960 Expenses provides program management,fiscal services,payroll,human resources,
accounts payable and other administrative functions.
6002 Professional Liability Insurance 6,940 Cost general and professional liablity insurance.
6003 Accounting/Bookkeeping -
6004 External Audit
6005 Insurance(Liability): 18,500 Cost of personal property,accidental and auto insurance.
6006 Payroll Services -
6007 Depreciation(Provider-Owned Equipment to
be Used for Program Purposes)
6008 Other(Specify)
6009 Other(Specify)
6010 Other(Specify)
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2/7/2020
Revised Exhibit C-1
Page 7 of 14
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
6011 Other(Specify)
6012 Other(Specify)
7000:FIXED ASSETS 11,206
7001 Computer Equipment&Software 7,706 �Anitipating additional computer equipment needed for new staff and or
replacement.Duo factor licensing and other computer software.
7002 Copiers,Cell Phones,Tablets,Devices to 500 Anticipating additional equipment cost for new staff and or replacement.
Contain HIPAA Data
7003 Furniture&Fixtures 3,000 Anticipating additional furniture cost for new staff and or replacement.
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)
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 1,452,686
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 1,452,686
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2/7/2020
Exhibit C-1
Page 8 of 14
Rural Mental Health Triage-West
Kings View
Fiscal Year(FY 2020-21)
PROGRAM EXPENSES
1000:SALARIES&BENEFITS
Employee Salaries
Acct# Position FTE Admin Direct Total
1101 Program Oversight 0.23 $ - $ 27,387 $ 27,387
1102 Clinical Supervisor 0.45 48,092 48,092
1103 Program Manager 0.45 - 58,519 58,519
1104 lClinician (2 Licensed,5 Unlicensed) 7.00 - 555,944 555,944
1105 Per Diem Team Responders(Licensed) 0.38 - 32,919 32,919
1106 Program Staff Accountant 0.09 - 4,842 4,842
1107 Administrative Support 0.26 - 12,628 12,628
1108 - -
1109 - - -
1110 - - -
1111 - - -
1112 - - -
1113 - - -
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - - -
Personnel Salaries Subtotal 8.86 $ - $ 740,331 $ 740,331
Employee Benefits
Acct# Description Admin Direct Total
1201 Retirement $ - $ 13,083 $ 13,083
1202 Worker's Compensation - 22,078 22,078
1203 Health Insurance - 94,739 94,739
1204 1 Other(Specify) - - -
1205 10ther(Specify) - - -
1206 1 Other(Specify) - - -
Employee Benefits Subtotal: $ - $ 129,900 $ 129,900
Payroll Taxes&Expenses:
Acct# Description Admin Direct Total
1301 OASDI $ - $ - $ -
1302 FICA/MEDICARE - 56,635 56,635
1303 SUI - 5,553 5,553
1304 1 Other(Specify) - - -
1305 10ther(Specify) - - -
1306 1 Other(Specify) - - -
Payroll Taxes&Expenses Subtotal: $ - $ 62,188 $ 62,188
EMPLOYEE SALARIES&BENEFITS TOTAL: $ - $ 932,419 $ 932,419
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit C-1
Page 9 of 14
2000:CLIENT SUPPORT
Acct# Line Item Description Amount
2001 Child Care $ -
2002 Client Housing Support -
2003 Client Transportation &Support -
2004 IClothing, 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:OPERATING EXPENSES
Acct# Line Item Description Amount
3001 Telecommunications $ 9,591
3002 Printing/Postage 1,500
3003 Office, Household& Program Supplies 6,500
3004 lAdvertising -
3005 Staff Development&Training 5,000
3006 Staff Mileage 1,600
3007 Subscriptions& Memberships -
3008 Vehicle Maintenance 20,218
3009 10ther(Miscellaneous) 150
3010 Other(Staff Recuitment/Background Checks) 450
3011 Other(Specify) -
3012 Other(Specify) -
OPERATING EXPENSES TOTAL: $ 45,009
4000: FACILITIES&EQUIPMENT
Acct# Line Item Description Amount
4001 Building Maintenance $ 8,000
4002 Rent/Lease Building 23,000
4003 Rent/Lease Equipment 2,200
4004 Rent/Lease Vehicles 23,176
4005 Security -
4006 Utilities 4,800
4007 Other(Specify) -
4008 Other(Specify) -
4009 Other(Specify) -
4010 Other(Specify) -
FACILITIES/EQUIPMENT TOTAL: $ 61,176
5000:SPECIAL EXPENSES
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit C-1
Page 10 of 14
Acct# Line Item Description Amount
5001 Consultant(Network& Data Management) $ 32,400
5002 HMIS(Health Management Information System) -
5003 Contractual/Consulting Services (Specify) -
5004 ITranslation Services 100
5005 Other(Avatar License Fee) 8,577
5006 Other(Specify) -
5007 Other(Specify) -
5008 Other(Specify) -
SPECIAL EXPENSES T0TAL:1 $ 41,077
6000:ADMINISTRATIVE EXPENSES
Acct# Line Item Description Amount
6001 Administrative Overhead $ 116,801
6002 Professional Liability Insurance 5,940
6003 Accounting/Bookkeeping -
6004 External Audit -
6005 Insurance(Liability): 17,500
6006 Payroll Services -
6007 Depreciation(Provider-Owned Equipment to be Used for Program Purposes) -
6008 Other(Specify) -
6009 Other(Specify) -
6010 Other(Specify) -
6011 Other(Specify) -
6012 Other(Specify) -
ADMINISTRATIVE EXPENSES TOTAL $ 140,241
7000: FIXED ASSETS
Acct# Line Item Description Amount
7001 Computer Equipment&Software $ 7,768
7002 Copiers,Cell Phones,Tablets, Devices to Contain HIPAA Data 500
7003 Furniture& Fixtures 1,000
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 $ 9,268
TOTAL PROGRAM EXPENSES $ 1,229,190
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit C-1
Page 11 of 14
PROGRAM FUNDING SOURCES
8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION)
Acct# Line Item Description Service Units Rate Amount
8001 Mental Health Services 15,955 3.26 $ 52,013
8002 Case Management 15,000 2.50 37,500
8003 Crisis Services 80,000 5.00 400,000
8004 Medication Support 0 - -
8005 Collateral 0 -
8006 Plan Development 0 -
8007 Assessment 0 -
8008 lRehabilitation 1 0 -
Estimated Specialty Mental Health Services Billing Totals: 1 110,9551 $ 489,513
Estimated %of Clients who are Medi-Cal Beneficiaries 75%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 367,135
Federal Financial Participation (FFP)% 1 50% 183,567
MEDI-CAL FFP TOTAL $ 183,567
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 $REALIGNMENT TOTAL $
8300-MENTAL HEALTH SERVICE ACT(MHSA)
Acct# MHSA Component MHSA Program Name Amount
8301 CSS-Community Services&Supports $ -
8302 PEI -Prevention & Early Intervention 1,045,623
8303 INN -Innovations -
8304 WET-Workforce Education &Training -
8305 CFTN -Capital Facilities&Technology -
MHSA TOTAL $ 1,045,623
8400-OTHER REVENUE
Acct# Line Item Description Amount
8401 Client Fees $ -
8402 Client Insurance -
8403 Grants(Specify) -
8404 Other(Specify) -
8405 1 Other(Specify) -
OTHER REVENUE TOTAL $
TOTAL PROGRAM FUNDING SOURCES: 1 $ 1,229,190
NET PROGRAM COST: 1 $ (0)
Fresno County Department of Behavioral Health Contract Budget Template Revised 2/7/2020
Exhibit C-1
Page 12 of 14
Rural Mental Health Triage-West
Kings View
Fiscal Year(FY 2020-21) Budget Narrative
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000:SALARIES&BENEFITS 932,419
Employee Salaries 740,331
1101 Program Oversight 27,387 Positions will provide agency specific staff oversight and represent and maintain the
collaborative relationship between agencies.Provide program management and
direction.Ensures operations are running smoothly and in compliance with contract
requirements.
1102 Clinical Supervisor 48,092 Provides supervision of all licenced and unlicensed clinical staff.
1103 Program Manager 58,519 Provides supervision of all staff and direct oversight of program management.
1104 Clinician(2 Licensed,5 Unlicensed) 555,944 Assist with managing the client's illness and reduce its impact on the client's life,and
referrals to appropriate linkages.
1105 Per Diem Team Responders(Licensed) 32,919 Per Diem-Assist with managing the client's illness and reduce its impact on the
client's life,and referrals to appropriate linkages.
1106 Program Staff Accountant 4,842 Provides budget guidance,monthly invoicing and other fiscal services.
1107 Administrative Support 12,628 Provides administrative support for the program and assist with medical billing and
records.
1108 0
1109 0
1110 0
1111 0
1112 0
1113 0
1114 0
1115 0
1116 0
1117 0
1118 0
1119 0
1120 10
Employee Benefits 129,900
1201 Retirement 13,083 Cost of 401K
1202 Worker's Compensation 22,078 Workers Comp Insurance
1203 Health Insurance 94,739 Cost of Medical,Vision,Dental,Life and Long Term Disability Insurance
1204 Other(Specify) -
1205 Other(Specify)
1206 Other(Specify) -
Payroll Taxes&Expenses: 62,188
1301 OASDI -
1302 FICA/MEDICARE 56,635 Cost of FICA/Medicare
1303 SUI 5,553 Cost of SUI
1304 Other(Specify) -
1305 Other(Specify)
1306 Other(Specify)
2000:CLIENT SUPPORT
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)
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2/7/2020
Exhibit C-1
Page 13 of 14
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
2016 Other(Specify)
3000:OPERATING EXPENSES 45,009
3001 Telecommunications 9,591 Cost of telephone services,cell phones service,data connectivity.
3002 Printing/Postage 1,500 Aniticapting courier services and postage nesessary 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 6,500 Includes all supplies used by staff in the course of providing services.
3004 Advertising -
3005 Staff Development&Training 5,000 Cost of continuation of staff development and training.
3006 Staff Mileage 1,600 Reimbusements to staff for personal vehicle use when lease vehicle not available
and require to provide services or other program needs,paid at IRS rate.Any travel
transporation fees,such as parking fees.
3007 Subscriptions&Memberships -
3008 Vehicle Maintenance 20,218 Auto repairs&maintenance required to maintain leased vehicles for client
transporation and program needs,such as oil changes and car washes.Yearly cost of
GPS,vehicle tracking service.
3009 Other(Miscellaneous) 150 Anticipating minor expense that would not fall under any other category.
3010 Other(Staff Recuitment/Background Checks) 450 Thorough background checks and drug testing.
3011 Other(Specify) -
3012 Other(Specify) -
4000:FACILITIES&EQUIPMENT 61,176
4001 Building Maintenance 8,000 Copier maintenance,inspection services,pest control,alarm services,janitorial
services and minor building repairs and maintenance.
4002 Rent/Lease Building 23,000 Building space lease.
4003 Rent/Lease Equipment 2,200 Copier lease and water dispenser rental.
4004 Rent/Lease Vehicles 23,176 The cost of lease vehicles to assist with program and client needs.
4005 Security -
4006 Utilities 4,800 The cost of gas and electric.
4007 Other(Specify) -
4008 Other(Specify)
4009 Other(Specify)
4010 Other(Specify) -
5000:SPECIAL EXPENSES 41,077
5001 Consultant(Network&Data Management) 32,400 Kings View Information Technology Department(KVIT)will provide hardware and
software support for successful data collection.A database will be designed for this
program.WIT will procure equipment,software&other services from approved&
authorized vendors. Provide online,onsite,or phone-based emergency support-
24/7 from the WIT Help Desk.
5002 HMIS(Health Management Information
System)
5003 Contractual/Consulting Services (Specify)
5004 Translation Services 100 Anticipating need of outsource transaltion services.
5005 Other(Avatar License Fee) 8,577 Estimated cost of Avatar fees.
5006 Other(Specify) -
5007 Other(Specify)
5008 Other(Specify)
6000:ADMINISTRATIVE EXPENSES 140,241
6001 Administrative Overhead 116,801 Expenses provides program management,fiscal services,payroll,human resources,
accounts payable and other administrative functions.
6002 Professional Liability Insurance 5,940 Cost general and professional liablity insurance.
6003 Accounting/Bookkeeping -
6004 External Audit
6005 Insurance(Liability): 17,500 Cost of personal property,accidental and auto insurance.
6006 Payroll Services -
6007 Depreciation(Provider-Owned Equipment to
be Used for Program Purposes)
6008 Other(Specify)
6009 Other(Specify)
6010 Other(Specify)
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2/7/2020
Exhibit C-1
Page 14 of 14
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
6011 Other(Specify)
6012 Other(Specify)
7000:FIXED ASSETS 9,268
7001 Computer Equipment&Software 7,768 �Anitipating additional computer equipment needed for new staff and or
replacement.Duo factor licensing and other computer software.
7002 Copiers,Cell Phones,Tablets,Devices to 500 Anticipating additional equipment cost for new staff and or replacement.
Contain HIPAA Data
7003 Furniture&Fixtures 1,000 Anticipating additional furniture cost for new staff and or replacement.
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)
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 1,229,190
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 1,229,190
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2/7/2020
Exhibit C-2
Page 1 of 14
Rural Mental Health Triage- East
Kings View
Fiscal Year(FY 2021-22)
PROGRAM EXPENSES
1000:SALARIES&BENEFITS
Employee Salaries
Acct# Position FTE Admin Direct Total
1101 Program Oversight 0.27 $ - $ 33,553 $ 33,553
1102 Clinical Supervisor 0.55 58,779 58,779
1103 Program Manager 0.55 - 71,523 71,523
1104 Clinician (2 unlicensed,5 Licensed) 7.00 - 641,516 641,516
1105 Per Diem Team Responders(Licensed) 0.45 - 37,137 37,137
1106 Program Staff Accountant 0.11 - 5,967 5,967
1107 Administrative Support 0.40 - 19,427 19,427
1108 - - -
1109 - - -
1110 - - -
1111 - - -
1112 - - -
1113 - - -
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - -
Personnel Salaries Subtotall 9.33 1 $ - $ 867,902 $ 867,902
Employee Benefits
Acct# Description Admin Direct Total
1101 Retirement $ - $ 15,364 $ 15,364
1102 Worker's Compensation - 25,883 25,883
1103 Health Insurance - 111,259 111,259
1104 1 Other(Specify) - - -
1105 10ther(Specify) - - -
1106 1 Other(Specify) - - -
Employee Benefits Subtotal: $ - $ 152,506 $ 152,506
Employee Benefits%:1 0.162101432
Payroll Taxes&Expenses:
Acct# Description Admin Direct Total
1201 OASDI $ - $ - $ -
1202 FICA/MEDICARE - 66,395 66,395
1203 SUI - 6,509 6,509
1204 Other(Specify) - - -
1205 1 Other(Specify) I -
1206 1 Other(Specify) I -
Payroll Taxes&Expenses Subtotal: $ - $ 72,904 $ 72,904
EMPLOYEE SALARIES&BENEFITS TOTAL: $ - $ 940,806 $ 1,093,312
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Exhibit C-2
Page 2 of 14
2000:CLIENT SUPPORT
Acct# Line Item Description Amount
2001 Child Care $ -
2002 Client Housing Support -
2003 Client Transportation &Support -
2004 lClothing, 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(Program Supplies)
2012 Other(Specify) -
2013 Other(Specify) -
2014 1 Other(Specify) -
2015 10ther(Specify) -
2016 1 Other(Specify) I -
DIRECT CLIENT CARE TOTAL $ -
3000:OPERATING EXPENSES
Acct# Line Item Description Amount
3001 Telecommunications $ 10,200
3002 Printing/Postage 1,847
3003 Office, Household& Program Supplies 10,350
3004 lAdvertising -
3005 Staff Development&Training 6,500
3006 Staff Mileage 3,500
3007 Subscriptions& Memberships -
3008 Vehicle Maintenance 27,200
3009 Other(Miscellaneous) 150
3010 Other(Staff Recuitment/Background Checks) 650
3011 Other(Specify) -
3012 Other(Specify) -
OPERATING EXPENSES TOTAL: $ 60,397
4000: FACILITIES&EQUIPMENT
Acct# Line Item Description Amount
4001 Building Maintenance $ 9,500
4002 Rent/Lease Building 26,500
4003 Rent/Lease Equipment 3,526
4004 1 Rent/Lease Vehicles 25,400
4005 Security -
4006 Utilities 6,650
4007 Other(Specify) -
4008 Other(Specify) -
4009 1 Other(Specify) -
4010 1 Other(Specify) -
FACILITIES/EQUIPMENT TOTAL: $ 71,576
5000:SPECIAL EXPENSES
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Exhibit C-2
Page 3 of 14
Acct# Line Item Description Amount
5001 Consultant(Network& Data Management) $ 38,118
5002 HMIS(Homeless Management Information System) -
5003 Contractual/Consulting Services (Specify) -
5004 ITranslation Services 100
5005 Other(Avatar License Fee) 8,577
5006 Other(Specify) -
5007 Other(Specify) -
5008 Other(Specify) -
SPECIAL EXPENSES TOTAL: $ 46,795
6000:ADMINISTRATIVE EXPENSES
Acct# Line Item Description Amount
6001 Administrative Overhead $ 143,960
6002 Professional Liability Insurance 6,940
6003 Accounting/Bookkeeping -
6004 External Audit -
6005 Insurance(Liability): 18,500
6006 Payroll Services -
6007 Depreciation(Provider-Owned Equipment to be Used for Program Purposes) -
6008 Other(Specify) -
6009 Other(Specify) -
6010 Other(Specify) -
6011 Other(Specify) -
6012 Other(Specify) -
ADMINISTRATIVE EXPENSES TOTAL $ 169,400
7000: FIXED ASSETS
Acct# Line Item Description Amount
7001 Computer Equipment&Software $ 7,706
7002 Copiers,Cell Phones,Tablets, Devices to Contain HIPAA Data 500
7003 Furniture& Fixtures 3,000
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 $ 11,206
TOTAL PROGRAM EXPENSES $ 1,452,686
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Exhibit C-2
Page 4 of 14
PROGRAM FUNDING SOURCES
8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION)
Acct# Line Item Description Service Units Rate Amount
8001 Mental Health Services 25,000 3.26 $ 81,500
8002 Case Management 32,473 2.50 81,183
8003 Crisis Services 225,000 5.00 1,125,000
8004 Medication Support 0 - -
8005 Collateral 0 -
8006 Plan Development 0 -
8007 Assessment 0 -
8008 lRehabilitation 1 0 -
Estimated Specialty Mental Health Services Billing Totals: 1 282,4731 $ 1,287,683
Estimated %of Clients who are Medi-Cal Beneficiaries 75%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 965,762
Federal Financial Participation (FFP)% 1 50% 482,881
MEDI-CAL FFP TOTAL $ 482,881
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 $ 0
REALIGNMENT TOTAL $ 0
8300-MENTAL HEALTH SERVICE ACT(MHSA)
Acct# MHSA Component MHSA Program Name Amount
8301 CSS-Community Services&Supports $ 969,805
8302 PEI -Prevention & Early Intervention -
8303 INN -Innovations -
8304 WET-Workforce Education &Training -
8305 CFTN -Capital Facilities&Technology -
MHSA TOTAL $ 969,805
8400-OTHER REVENUE
Acct# Line Item Description Amount
8401 Client Fees $ -
8402 Client Insurance -
8403 Grants(Specify) -
8404 Other(Specify) -
8405 1 Other(Specify) -
OTHER REVENUE TOTAL $ -
TOTAL PROGRAM FUNDING SOURCES: 1 $ 1,452,686
NET PROGRAM COST: $ -
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Exhibit C-2
Page 5 of 14
Rural Mental Health Triage-East
Kings View
Fiscal Year(FY 2021-22) Budget Narrative
ACCT#j LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000:SALARIES&BENEFITS 1,093,312
Employee Salaries 867,902
1101 Program Oversight 33,553 Positions will provide agency specific staff oversight and represent and maintain the
collaborative relationship between agencies.Provide program management and
direction.Ensures operations are running smoothly and in compliance with contract
requirements.
1102 Clinical Supervisor 58,779 Provides supervision of all licensed and unlicensed clinical staff.
1103 Program Manager 71,523 Provides supervision of all staff and direct oversight of program management.
1104 Clinician(2 unlicensed,5 Licensed) 641,516 Assist with managing the client's illness and reduce its impact on the client's life,and
referrals to appropriate linkages.
1105 Per Diem Team Responders(Licensed) 37,137 Per Diem-Assist with managing the client's illness and reduce its impact on the
client's life,and referrals to appropriate linkages.
1106 Program Staff Accountant 5,967 Provides budget guidance,monthly invoicing and other fiscal services.
1107 Administrative Support 19,427 Provides administrative support for the program and assist with medical billing and
records.
1108 0
1109 0
1110 0
1111 0
1112 0
1113 0
1114 0
1115 0
1116 0
1117 0
1118 0
1119 0
1120 10
Employee Benefits 152,506
1101 Retirement 15,364 Cost of 401K
1102 Worker's Compensation 25,883 Workers Comp Insurance
1103 Health Insurance 111,259 Cost of Medical,Vision,Dental,Life and Long Term Disability Insurance
1104 Other(Specify) -
1105 Other(Specify)
1106 Other(Specify)
Payroll Taxes&Expenses: 72,904
1201 OASDI -
1202 FICA/MEDICARE 66,395 Cost of FICA/Medicare
1203 SUI 6,509 Cost of SUI
1204 Other(Specify) -
1205 Other(Specify)
1206 Other(Specify)
2000:CLIENT SUPPORT
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(Program Supplies)
2012 Other(Specify)
2013 Other(Specify)
2014 Other(Specify)
2015 Other(Specify)
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
Exhibit C-2
Page 6 of 14
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
2016 Other(Specify)
3000:OPERATING EXPENSES 60,397
3001 Telecommunications 10,200 Cost of telephone services,cell phones service,data connectivity.
3002 Printing/Postage 1,847 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 10,350 Includes all supplies used by staff in the course of providing services.
3004 Advertising -
3005 Staff Development&Training 6,500 Cost of continuation of staff development and training.
3006 Staff Mileage 3,500 Reimbursements to staff for personal vehicle use when lease vehicle not available
and require 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 27,200 Auto repairs&maintenance required to maintain leased vehicles for client
transportation and program needs,such as oil changes and car washes.Yearly cost
of GPS,vehicle tracking service.
3009 Other(Miscellaneous) 150 Anticipating minor expense that would not fall under any other category.
3010 Other(Staff Recuitment/Background Checks) 650 Thorough background checks and drug testing.
3011 Other(Specify) -
3012 Other(Specify) -
4000:FACILITIES&EQUIPMENT 71,576
4001 Building Maintenance 9,500 Copier maintenance,inspection services,pest control,alarm services,janitorial
services and minor building repairs and maintenance.
4002 Rent/Lease Building 26,500 Building space lease.
4003 Rent/Lease Equipment 3,526 Copier lease and water dispenser rental.
4004 Rent/Lease Vehicles 25,400 The cost of lease vehicles to assist with program and client needs.
4005 Security -
4006 Utilities 6,650 The cost of gas and electric.
4007 Other(Specify) -
4008 Other(Specify)
4009 Other(Specify)
4010 Other(Specify) -
5000:SPECIAL EXPENSES 46,795
5001 Consultant(Network&Data Management) 38,118 Kings View Information Technology Department(KVIT)will provide hardware and
software support for successful data collection.A database will be designed for this
program.WIT will procure equipment,software&other services from approved&
authorized vendors. Provide online,onsite,or phone-based emergency support-
24/7 from the WIT Help Desk.
5002 HMIS(Homeless Management Information
System)
5003 Contractual/Consulting Services (Specify)
5004 Translation Services 100 Anticipating need of outsource translation services.
5005 Other(Avatar License Fee) 8,577 Estimated cost of Avatar fees.
5006 Other(Specify) -
5007 Other(Specify)
5008 Other(Specify)
6000:ADMINISTRATIVE EXPENSES 169,400
6001 Administrative Overhead 143,960 Expenses provides program management,fiscal services,payroll,human resources,
accounts payable and other administrative functions.
6002 Professional Liability Insurance 6,940 Cost general and professional liability insurance.
6003 Accounting/Bookkeeping -
6004 External Audit
6005 Insurance(Liability): 18,500 Cost of personal property,accidental and auto insurance.
6006 Payroll Services -
6007 Depreciation(Provider-Owned Equipment to
be Used for Program Purposes)
6008 Other(Specify)
6009 Other(Specify)
6010 Other(Specify)
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
Exhibit C-2
Page 7 of 14
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
6011 Other(Specify)
6012 Other(Specify)
7000:FIXED ASSETS 11,206
7001 Computer Equipment&Software 7,706 Anticipating additional computer equipment needed for new staff and or
replacement.Duo factor licensing and other computer software.
7002 Copiers,Cell Phones,Tablets,Devices to 500 Anticipating additional equipment cost for new staff and or replacement.
Contain HIPAA Data
7003 Furniture&Fixtures 3,000 Anticipating additional furniture cost for new staff and or replacement.
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)
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 1,452,686
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 1,452,686
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
Exhibit C-2
Page 8 of 14
Rural Mental Health Triage-West
Kings View
Fiscal Year(FY 2021-22)
PROGRAM EXPENSES
1000:SALARIES&BENEFITS
Employee Salaries
Acct# Position FTE Admin Direct Total
1101 Program Oversight 0.23 $ - $ 27,387 $ 27,387
1102 Clinical Supervisor 0.45 48,092 48,092
1103 Program Manager 0.45 - 58,519 58,519
1104 Clinician (2 Licensed, 5 Unlicensed) 7.00 - 555,944 555,944
1105 Per Diem Team Responders(Licensed) 0.38 - 32,919 32,919
1106 Program Staff Accountant 0.09 - 4,842 4,842
1107 Administrative Support 0.26 - 12,628 12,628
1108 - - -
1109 - - -
1110 - - -
1111 - - -
1112 - - -
1113 - - -
1114 - - -
1115 - - -
1116 - - -
1117 - - -
1118 - - -
1119 - - -
1120 - -
Personnel Salaries Subtotall 8.86 1 $ - $ 740,331 $ 740,331
Employee Benefits
Acct# Description Admin Direct Total
1101 Retirement $ - $ 13,083 $ 13,083
1102 Worker's Compensation - 22,078 22,078
1103 Health Insurance - 94,739 94,739
1104 1 Other(Specify) - - -
1105 10ther(Specify) - - -
1106 1 Other(Specify) - - -
Employee Benefits Subtotal: $ - $ 129,900 $ 129,900
Employee Benefits%:1 0.161865327
Payroll Taxes&Expenses:
Acct# Description Admin Direct Total
1201 OASDI $ - $ - $ -
1202 FICA/MEDICARE - 56,635 56,635
1203 SUI - 5,553 5,553
1204 Other(Specify) - - -
1205 1 Other(Specify) I -
1206 1 Other(Specify) - -
Payroll Taxes&Expenses Subtotal: $ - $ 62,188 $ 62,188
EMPLOYEE SALARIES&BENEFITS TOTAL: $ - $ 802,519 $ 932,419
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Exhibit C-2
Page 9 of 14
2000:CLIENT SUPPORT
Acct# Line Item Description Amount
2001 Child Care $ -
2002 Client Housing Support -
2003 Client Transportation &Support -
2004 lClothing, 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(Program Supplies)
2012 Other(Specify) -
2013 Other(Specify) -
2014 1 Other(Specify) -
2015 10ther(Specify) -
2016 1 Other(Specify) I -
DIRECT CLIENT CARE TOTAL $ -
3000:OPERATING EXPENSES
Acct# Line Item Description Amount
3001 Telecommunications $ 9,591
3002 Printing/Postage 1,500
3003 Office, Household& Program Supplies 6,500
3004 lAdvertising -
3005 Staff Development&Training 5,000
3006 Staff Mileage 1,600
3007 Subscriptions& Memberships -
3008 Vehicle Maintenance 20,218
3009 Other(Miscellaneous) 150
3010 Other(Staff Recuitment/Background Checks) 450
3011 Other(Specify) -
3012 Other(Specify) I -
OPERATING EXPENSES TOTAL: $ 45,009
4000: FACILITIES&EQUIPMENT
Acct# Line Item Description Amount
4001 Building Maintenance $ 8,000
4002 Rent/Lease Building 23,000
4003 Rent/Lease Equipment 2,200
4004 1 Rent/Lease Vehicles 23,176
4005 Security -
4006 Utilities 4,800
4007 Other(Specify) -
4008 Other(Specify) -
4009 1 Other(Specify) -
4010 1 Other(Specify) -
FACILITIES/EQUIPMENT TOTAL: $ 61,176
5000:SPECIAL EXPENSES
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Exhibit C-2
Page 10 of 14
Acct# Line Item Description Amount
5001 Consultant(Network& Data Management) $ 32,400
5002 HMIS(Homeless Management Information System) -
5003 Contractual/Consulting Services (Specify) -
5004 ITranslation Services 100
5005 Other(Avatar License Fee) 8,577
5006 Other(Specify) -
5007 Other(Specify) -
5008 Other(Specify) -
SPECIAL EXPENSES TOTAL: $ 41,077
6000:ADMINISTRATIVE EXPENSES
Acct# Line Item Description Amount
6001 Administrative Overhead $ 116,801
6002 Professional Liability Insurance 5,940
6003 Accounting/Bookkeeping -
6004 External Audit -
6005 Insurance(Liability): 17,500
6006 Payroll Services -
6007 Depreciation(Provider-Owned Equipment to be Used for Program Purposes) -
6008 Other(Specify) -
6009 Other(Specify) -
6010 Other(Specify) -
6011 Other(Specify) -
6012 Other(Specify) -
ADMINISTRATIVE EXPENSES TOTAL $ 140,241
7000: FIXED ASSETS
Acct# Line Item Description Amount
7001 Computer Equipment&Software $ 7,768
7002 Copiers,Cell Phones,Tablets, Devices to Contain HIPAA Data 500
7003 Furniture& Fixtures 1,000
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 $ 9,268
TOTAL PROGRAM EXPENSES $ 1,229,190
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Exhibit C-2
Page 11 of 14
PROGRAM FUNDING SOURCES
8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION)
Acct# Line Item Description Service Units Rate Amount
8001 Mental Health Services 15,955 3.26 $ 52,013
8002 Case Management 15,000 2.50 37,500
8003 Crisis Services 80,000 5.00 400,000
8004 Medication Support 0 - -
8005 Collateral 0 -
8006 Plan Development 0 -
8007 Assessment 0 -
8008 lRehabilitation 1 0 -
Estimated Specialty Mental Health Services Billing Totals: 1 110,9551 $ 489,513
Estimated %of Clients who are Medi-Cal Beneficiaries 75%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 367,135
Federal Financial Participation (FFP)% 1 50% 183,567
MEDI-CAL FFP TOTAL $ 183,567
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 $ 0
REALIGNMENT TOTAL $ 0
8300-MENTAL HEALTH SERVICE ACT(MHSA)
Acct# MHSA Component MHSA Program Name Amount
8301 CSS-Community Services&Supports $ 1,045,622
8302 PEI -Prevention & Early Intervention -
8303 INN -Innovations -
8304 WET-Workforce Education &Training -
8305 CFTN -Capital Facilities&Technology -
MHSA TOTAL $ 1,045,622
8400-OTHER REVENUE
Acct# Line Item Description Amount
8401 Client Fees $ -
8402 Client Insurance -
8403 Grants(Specify) -
8404 Other(Specify) -
8405 1 Other(Specify) -
OTHER REVENUE TOTAL $ -
TOTAL PROGRAM FUNDING SOURCES: 1 $ 1,229,190
NET PROGRAM COST: $ -
Fresno County Department of Behavioral Health Contract Budget Template Revised 9/12/2019
Exhibit C-2
Page 12 of 14
Rural Mental Health Triage-West
Kings View
Fiscal Year(FY 2021-22) Budget Narrative
ACCT#j LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000:SALARIES&BENEFITS 932,419
Employee Salaries 740,331
1101 Program Oversight 27,387 Positions will provide agency specific staff oversight and represent and maintain the
collaborative relationship between agencies.Provide program management and
direction.Ensures operations are running smoothly and in compliance with contract
requirements.
1102 Clinical Supervisor 48,092 Provides supervision of all lisenced and unlicensed clinical staff.
1103 Program Manager 58,519 Provides supervision of all staff and direct oversight of program management.
1104 Clinician(2 Licensed,5 Unlicensed) 555,944 Assist with managing the client's illness and reduce its impact on the client's life,and
referrals to appropriate linkages.
1105 Per Diem Team Responders(Licensed) 32,919 Per Diem-Assist with managing the client's illness and reduce its impact on the
client's life,and referrals to appropriate linkages.
1106 Program Staff Accountant 4,842 Provides budget guidance,monthly invoicing and other fiscal services.
1107 Administrative Support 12,628 Provides administrative support for the program and assist with medical billing and
records.
1108 0
1109 0
1110 0
1111 0
1112 0
1113 0
1114 0
1115 0
1116 0
1117 0
1118 0
1119 0
1120 10
Employee Benefits 129,900
1101 Retirement 13,083 Cost of 401K
1102 Worker's Compensation 22,078 Workers Comp Insurance
1103 Health Insurance 94,739 Cost of Medical,Vision,Dental,Life and Long Term Disability Insurance
1104 Other(Specify) -
1105 Other(Specify)
1106 Other(Specify) -
Payroll Taxes&Expenses: 62,188
1201 OASDI -
1202 FICA/MEDICARE 56,635 Cost of FICA/Medicare
1203 SUI 5,553 Cost of SUI
1204 Other(Specify) -
1205 Other(Specify)
1206 Other(Specify)
2000:CLIENT SUPPORT
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(Program Supplies)
2012 Other(Specify)
2013 Other(Specify)
2014 Other(Specify)
2015 Other(Specify)
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
Exhibit C-2
Page 13 of 14
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
2016 Other(Specify)
3000:OPERATING EXPENSES 45,009
3001 Telecommunications 9,591 Cost of telephone services,cell phones service,data connectivity.
3002 Printing/Postage 1,500 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 6,500 Includes all supplies used by staff in the course of providing services.
3004 Advertising -
3005 Staff Development&Training 5,000 Cost of continuation of staff development and training.
3006 Staff Mileage 1,600 Reimbursements to staff for personal vehicle use when lease vehicle not available
and require 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 20,218 Auto repairs&maintenance required to maintain leased vehicles for client
transportation and program needs,such as oil changes and car washes.Yearly cost
of GPS,vehicle tracking service.
3009 Other(Miscellaneous) 150 Anticipating minor expense that would not fall under any other category.
3010 Other(Staff Recuitment/Background Checks) 450 Thorough background checks and drug testing.
3011 Other(Specify) -
3012 Other(Specify) -
4000:FACILITIES&EQUIPMENT 61,176
4001 Building Maintenance 8,000 Copier maintenance,inspection services,pest control,alarm services,janitorial
services and minor building repairs and maintenance.
4002 Rent/Lease Building 23,000 Building space lease.
4003 Rent/Lease Equipment 2,200 Copier lease and water dispenser rental.
4004 Rent/Lease Vehicles 23,176 The cost of lease vehicles to assist with program and client needs.
4005 Security -
4006 Utilities 4,800 The cost of gas and electric.
4007 Other(Specify) -
4008 Other(Specify)
4009 Other(Specify)
4010 Other(Specify) -
5000:SPECIAL EXPENSES 41,077
5001 Consultant(Network&Data Management) 32,400 Kings View Information Technology Department(KVIT)will provide hardware and
software support for successful data collection.A database will be designed for this
program.WIT will procure equipment,software&other services from approved&
authorized vendors. Provide online,onsite,or phone-based emergency support-
24/7 from the WIT Help Desk.
5002 HMIS(Homeless Management Information
System)
5003 Contractual/Consulting Services (Specify)
5004 Translation Services 100 Anticipating need of outsource translation services.
5005 Other(Avatar License Fee) 8,577 Estimated cost of Avatar fees.
5006 Other(Specify) -
5007 Other(Specify)
5008 Other(Specify)
6000:ADMINISTRATIVE EXPENSES 140,241
6001 Administrative Overhead 116,801 Expenses provides program management,fiscal services,payroll,human resources,
accounts payable and other administrative functions.
6002 Professional Liability Insurance 5,940 Cost general and professional liability insurance.
6003 Accounting/Bookkeeping -
6004 External Audit
6005 Insurance(Liability): 17,500 Cost of personal property,accidental and auto insurance.
6006 Payroll Services -
6007 Depreciation(Provider-Owned Equipment to
be Used for Program Purposes)
6008 Other(Specify)
6009 Other(Specify)
6010 Other(Specify)
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
Exhibit C-2
Page 14 of 14
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
6011 Other(Specify)
6012 Other(Specify)
7000:FIXED ASSETS 9,268
7001 Computer Equipment&Software 7,768 Anticipating additional computer equipment needed for new staff and or
replacement.Duo factor licensing and other computer software.
7002 Copiers,Cell Phones,Tablets,Devices to 500 Anticipating additional equipment cost for new staff and or replacement.
Contain HIPAA Data
7003 Furniture&Fixtures 1,000 Anticipating additional furniture cost for new staff and or replacement.
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)
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 1,229,190
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 1,229,190
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 9/12/2019
Exhibit D
Page 1 of 3
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws,
regulations, rules and guidelines that apply to the provision and payment of mental health services.
Mental health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with which
contractor and its employees and subcontractors shall comply. Contractor shall require its employees
and subcontractors to attend a compliance training that will be provided by Fresno County. After
completion of this training, each contractor, contractor's employee and subcontractor must sign the
Contractor Acknowledgment and Agreement form and return this form to the Compliance officer or
designee.
Contractor and its employees and subcontractor shall:
1. Comply with all applicable laws, regulations, rules or guidelines when providing and billing
for mental health services.
2. Conduct themselves honestly, fairly, courteously and with a high degree of integrity in their
professional dealing related to their contract with the County and avoid any conduct that could
reasonably be expected to reflect adversely upon the integrity of the County.
3. Treat County employees, consumers, and other mental health contractors fairly and with
respect.
4. NOT engage in any activity in violation of the County's Compliance Program, nor engage in
any other conduct which violates any applicable law, regulation, rule or guideline
5. Take precautions to ensure that claims are prepared and submitted accurately, timely and are
consistent with all applicable laws, regulations, rules or guidelines.
6. Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement
of any kind are submitted.
7. Bill only for eligible services actually rendered and fully documented. Use billing codes that
accurately describe the services provided.
Exhibit D
Page 2 of 3
8. Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9. Promptly report to the Compliance Officer any suspected violation(s) of this Code of Conduct
and Ethics by County employees or other mental health contractors, or report any activity that
they believe may violate the standards of the Compliance Program, or any other applicable
law, regulation, rule or guideline. Fresno County prohibits retaliation against any person
making a report. Any person engaging in any form of retaliation will be subject to disciplinary
or other appropriate action by the County. Contractor may report anonymously.
10. Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
11. Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
Exhibit D
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 E
Page 1 of 3
Documentation Standards For Client Records
The documentation standards are described below under key topics related to client care. All
standards must be addressed in the client record; however, there is no requirement that the record
have a specific document or section addressing these topics.
A. Assessments
1. The following areas will be included as appropriate as a part of a comprehensive client record.
• Relevant physical health conditions reported by the client will be prominently identified and
updated as appropriate.
• Presenting problems and relevant conditions affecting the client's physical health and mental
health status will be documented, for example: living situation, daily activities, and social
support.
• Documentation will describe client's strengths in achieving client plan goals.
• Special status situations that present a risk to clients or others will be prominently documented
and updated as appropriate.
• Documentations will include medications that have been described by mental health plan
physicians, dosage of each medication, dates of initial prescriptions and refills, and
documentations of informed consent for medications.
• Client self report of allergies and adverse reactions to medications, or lack of known
allergies/sensitivities will be clearly documented.
•A mental health history will be documented, including: previous treatment dates,providers,
therapeutic interventions and responses, sources of clinical data, relevant family information and
relevant results of relevant lab tests and consultations reports.
• For children and adolescents, pre-natal and perinatal events and complete developmental
history will be documented.
• Documentations will include past and present use of tobacco, alcohol, and caffeine, as well as
illicit,prescribed and over-the-counter drugs.
•A relevant mental status examination will be documented.
•A five axis diagnosis from the most current DSM, or a diagnosis from the most current ICD,
will be documented, consistent with the presenting problems, history mental status evaluation
and/or other assessment data.
2. Timeliness/Frequency Standard for Assessment
•An assessment will be completed at intake and updated as needed to document changes in the
client's condition.
• Client conditions will be assessed at least annually and, in most cases, at more frequent
intervals.
B. Client Plans
1.Client plans will:
0302 f dbh
Exhibit E
Page 2 of 3
•have specific observable and/or specific quantifiable goals
• identify the proposed type(s) of intervention
•have a proposed duration of intervention(s)
•be signed(or electronic equivalent)by:
* the person providing the service(s), or
* a person representing a team or program providing services, or
* a person representing the MHP providing services
* when the client plan is used to establish that the services are provided under the direction of an
approved category of staff, and if the below staff are not the approved category,
* a physician
* a licensed/"waivered"psychologist
* a licensed/"associate" social worker
* a licensed/registered/marriage and family therapist or
* a registered nurse
• In addition,
* client plans will be consistent with the diagnosis, and the focus of intervention will be
consistent with the client plan goals, and there will be documentation of the client's participation
in and agreement with the plan. Examples of the documentation include, but are not limited to,
reference to the client's participation and agreement in the body of the plan, client signature on
the plan, or a description of the client's participation and agreement in progress notes.
* client signature on the plan will be used as the means by which the CONTRACTOR(S)
documents the participation of the client
* when the client's signature is required on the client plan and the client refuses or is unavailable
for signature, the client plan will include a written explanation of the refusal or unavailability.
• The CONTRACTOR(S) will give a copy of the client plan to the client on request.
2.Timeliness/Frequency of Client Plan:
•Will be updated at least annually
• The CONTRACTOR(S) will establish standards for timeliness and frequency for the individual
elements of the client plan described in item 1.
C. Progress Notes
1.Items that must be contained in the client record related to the client's progress in treatment
include:
• The client record will provide timely documentation of relevant aspects of client care
• 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
0302 f dbh
Exhibit E
Page 3 of 3
2.Timeliness/Frequency of Progress Notes:
Progress notes shall be documented at the frequency by type of service indicated below:
A.Every Service Contact
■Mental Health Services
■Medication Support Services
■ Crisis Intervention
0302 f dbh
Exhibit F
State Exhibit 6 - Quarterly Report
Page 1 of 3
Current Quarterly Progress Report Process Overview
Current Regulations
Title 9, Division 1, Chapter 14, Article 5: Quarterly Progress Reports must be submitted
to the State Department of Mental Health no later than 60 days following the end of
each reporting quarter and are compiled by service category for each approved
program and/or service. The following information must be included in the Quarterly
Progress Report:
• The targeted number of individuals or families to be served in each reporting
quarter by each program/service during the quarter
• The total number of individuals or families actually served in each reporting
quarter by each program/service during the quarter
• The final Quarterly Progress Report must include the total number of
unduplicated individuals or families served by each program/service during the
fiscal year
Following is a review of how to calculate individuals served within each service category
(Full Service Partnerships, System Development and Outreach and Engagement).
Quarterly Counts:
The quarterly count is unduplicative within quarters but is duplicative between quarters.
The number of actual individuals served equals: the total number of individuals or
families enrolled in the program on the first day of each quarter plus any individuals or
families newly enrolled throughout the quarter.
Example:
Program Q1 Q2 Q3 Q4
Currently enrolled on first day of quarter 10 20 20 26
Newly Enrolled 10 5 7 5
Actually Served 20 25 27 31
Disenrolled 0 (5) (1) 0
Explanation:
Q1: At the beginning of Quarter 1, 10 people were enrolled and 10 people were newly
enrolled throughout the quarter, so the total actual served for Quarter 1 would
equal 20 (10 + 10 = 20).
Q2: At the beginning of Quarter 2, 20 people were currently enrolled and 5 more
people were newly enrolled, so the total actual served would equal 25 (20 + 5 =
25).
Exhibit F
State Exhibit 6 - Quarterly Report
Page 2 of 3
Q3: At the beginning of Quarter 3, 20 people were currently enrolled and 7 more
people were newly enrolled throughout the quarter, so the total actual served
would equal 27 (20 + 7 = 27). (Five people disenrolled the previous quarter, so on
the first day of Quarter 3, 20 people were currently enrolled.)
Q4: At the beginning of Quarter 4, 26 people were currently enrolled because one had
disenrolled during Quarter 3, but 5 had been newly enrolled so the total actual
served of 31 (26 + 5 = 27)
Quarterly targets: The quarterly target is an estimate of the total number of individuals
you expect to serve for that quarter. Targeted counts should follow the same strategy as
for actual counts described above.
Unduplicated Annual Counts:
The unduplicated annual count: Equals the total number of people served for the entire
year.
Example:
Total
Program Q1 Q2 Q3 Q4 Annual
Currently enrolled on first day of
quarter 10 20 20 26
NewlyEnrolled 10 5 7 5
Total Unduplicated Actual Served 20 5 7 5 37
Disenrolled 0 (5) (1) 0
Q1: At the beginning of Quarter 1, 10 people were enrolled and 10 people were newly
enrolled throughout the quarter, so the total unduplicated for Quarter 1 would
equal 20 (10 + 10 = 20).
Q2: At the beginning of Quarter 2, 20 people were currently enrolled and 5 more
people were newly enrolled, so the total unduplicated for quarter 2 would be 5.
Q3: At the beginning of Quarter 3, 20 people were currently enrolled and 7 more
people were newly enrolled throughout the quarter, so the total unduplicated for
quarter 3 would be 7.
Q4: At the beginning of Quarter 4, 26 people were currently enrolled and 5 had been
newly enrolled so the total unduplicated for quarter 4 would be 5.
Total Unduplicated Annual Actual Served: 20 + 5 + 7 + 5 = 37
Total Unduplicated Annual Targets: The unduplicated annual target is an estimate of
the total number of unduplicated individuals you expect to serve annually,
Exhibit F
State Exhibit 6 - Quarterly Report
Page 3 of 3
Options for Improving the
MHSA Quarterly Progress Reporting Process
Outreach and Engagement:
There are many different methods of providing outreach and engagement services.
Some services are offered in a group or community wide forum and sometimes services
are offered individually. Ideally, it would be helpful to have a combination of service
based and individual level data collection that is submitted on a quarterly basis.
Potential Methods for reporting counts in these service categories:
Categories could be created based on the nature of the services provided. There are
two very broad categories of services and they could be reported differently based on
these categories: For instance:
Community Forum Outreach and Engagement Activities:
When conducting a community forum activity such as a county-wide presentation to
a group of people about a mental health issue, a count of the number of
presentations and the number of individuals that attended could be submitted.
Some indication of the purpose of each event would also be helpful. For instance,
broad categories such as education, workforce development, stigma reduction or
outreach to engage in services could be indicated.
Individual Outreach and Engagement Services:
When conducting outreach and engagement services to individuals, you may have
multiple contacts with an individual prior to engaging them into services. Counting
the number of contacts rather than the number of individuals would provide more
accurate information regarding individual services.
In addition, some demographic information regarding the individuals receiving
services within these categories would be helpful including gender, age and
race/ethnicity. In addition, information regarding the number of face-to-face
contacts vs. phone contacts would also be useful.
System Development:
There are many types of services provided through this category. Some services maybe
offered in a group or community wide forum and some services may be offered to
individuals and families. In addition, some services center around linkage with other
community based organizations. Should the services be categorized similar to what
has been proposed for Outreach and Engagement or should there be different
categories for System Development services?
Exhibit Fa
EXHIBIT 6: THREE-YEAR PLAN — QUARTERLY PROGRESS GOALS AND REPORT
Estimated/Actual Population Served
County: Fresno
Program Work Plan:
Program Work Plan Name:
Fiscal Year:
Qtr 1 Qtr 2 Qtr 3 Qtr 4
HTCC Program 07/O1/09—09/30/09 10/O1/09—12/31/09 01/01/10—03/31/10 04/O1/10—06/30/10 Total
Total
Number to Description of Initial
be served Population Target Actual Target Actual Target ; Actual Target Actual Target Actual
Exhibit G
STATE MENTAL HEALTH REQUIREMENTS
1. CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all applicable
Federal and State statutes and regulations.
2. PROFESSIONAL LICENSURE
All (professional level)persons employed by the COUNTY Mental Health Program(directly
or through contract)providing Short-Doyle/Medi-Cal services have met applicable
professional licensure requirements pursuant to Business and Professions and Welfare and
Institutions Codes.
3. CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with all State of
California and Federal statutes and regulations regarding confidentiality, including but not
limited to confidentiality of information requirements at 42, Code of Federal Regulations
sections 2.1 et seq; California Welfare and Institutions Code, sections 14100.2, 11977, 11812,
5328; Division 10.5 and 10.6 of the California Health and Safety Code; Title 22, California
Code of Regulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 of the California
Civil Code.
4. NON-DISCRIMINATION
A. Eli ig bility 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, sex, color, disability,
medical condition, national origin, race, ancestry, marital status, religion, religious
creed, political belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity receiving
Federal or State of California assistance.
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.
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
Exhibit G
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.
EXHIBIT H
Page 1 of 2
Medi-Cal Organizational Provider Standards
1. The organizational provider possesses the necessary license to operate, if applicable, and any
required certification.
2. The space owned, leased or operated by the provider and used for services or staff meets
local fire codes.
3. The physical plant of any site owned, leased, or operated by the provider and used for
services or staff is clean, sanitary and in good repair.
4. The organizational provider establishes and implements maintenance policies for any site
owned, leased, or operated by the provider and used for services or staff to ensure the safety
and well being of beneficiaries and staff.
5. The organizational provider has a current administrative manual which includes: personnel
policies and procedures, general operating procedures, service delivery policies, and
procedures for reporting unusual occurrences relating to health and safety issues.
6. The organizational provider maintains client records in a manner that meets applicable state
and federal standards.
7. The organization provider has staffing adequate to allow the County to claim federal
financial participation for the services the Provider delivers to beneficiaries, as described in
Division 1, Chapter 11, Subchapter 4 of Title 9, CCR, when applicable.
8. The organizational provider has written procedures for referring individuals to a psychiatrist
when necessary, or to a physician, if a psychiatrist is not available.
9. The organizational provider has as head of service a licensed mental health professional of
other appropriate individual as described in Title 9, CCR, Sections 622 through 630.
10. For organizational providers that provide or store medications, the provider stores and
dispenses medications in compliance with all pertinent state and federal standards. In
particular:
A. All drugs obtained by prescription are labeled in compliance with federal and state laws.
Prescription labels are altered only by persons legally authorized to do so.
B. Drugs intended for external use only or food stuffs are stored separately from drugs for
internal use.
C. All drugs are stored at proper temperatures, room temperature drugs at 59-86 degrees F
and refrigerated drugs at 36-46 degrees F.
EXHIBIT H
Page 2 of 2
D. Drugs are stored in a locked area with access limited to those medical personnel
authorized to prescribe, dispense or administer medication.
E. Drugs are not retained after the expiration date. IM multi-dose vials are dated and
initialed when opened.
F. A drug log is maintained to ensure the provider disposes of expired, contaminated,
deteriorated and abandoned drugs in a manner consistent with state and federal laws.
G. Policies and procedures are in place for dispensing, administering and storing
medications.
11. For organizational providers that provide day treatment intensive or day rehabilitation,
the provider must have a written description of the day treatment intensive and/or day
treatment rehabilitation program that complies with State Department of Mental Health's
day treatment requirements. The COUNTY shall review the provider's written program
description for compliance with the State Department of Mental Health's day treatment
requirements.
12. The COUNTY may accept the host county's site certification and reserves the right to
conduct an on-site certification review at least every three years. The COUNTY may also
conduct additional certification reviews when:
• The provider makes major staffing changes.
• The provider makes organizational and/or corporate structure changes (example: conversion
from a non-profit status).
• The provider adds day treatment or medication support services when medications shall be
administered or dispensed from the provider site.
• There are significant changes in the physical plant of the provider site (some physical plant
changes could require a new fire clearance).
• There is change of ownership or location.
• There are complaints against the provider.
• There are unusual events, accidents, or injuries requiring medical treatment for clients, staff or
members of the community.
Proposal No. Exhibit I
Page 1 of 4
FRESNO COUNTY MENTAL HEALTH PLAN
GRIEVANCES AND INCIDENT REPORTING
Grievances
Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance and appeal
process and an expedited appeal process to resolve grievances and disputes at the earliest
and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-for-service
providers give verbal and written information to Medi-Cal beneficiaries regarding the following:
• How to access specialty mental health services
• How to file a grievance about services
• How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a grievance form, an
appeal form, and Request for Change of Provider Form. All of these beneficiary materials
must be posted in prominent locations where Medi-Cal beneficiaries receive outpatient
specialty mental health services, including the waiting rooms of providers' offices of service.
Please note that all fee-for-service providers and contract agencies are required to give their
clients copies of all current beneficiary information annually at the time their treatment plans
are updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without any penalty,
change in mental health services, or any form of retaliation. All Medi-Cal beneficiaries can file
an appeal or state hearing.
Grievances and appeals forms and self addressed envelopes must be available for
beneficiaries to pick up at all provider sites without having to make a verbal or written request.
Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 712
Fresno, CA 93712
(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.
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
Proposal No. Exhibit I
Page 2 of 4
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.
Proposal No. Exhibit I
Page 3 of 4
PROTOCOL FOR COMPLETION OF INCIDENT REPORT
• The Incident Report must be completed for all incidents involving clients. The staff person
who becomes aware of the incident completes this form, and the supervisor co-signs it.
• When more than one client is involved in an incident, a separate form must be completed
for each client.
Where the forms should be sent - within 24 hours from the time of the incident
• Incident Report should be sent to:
• DBH Program Supervisor
Proposal No. Exhibit I
Page 4 of 4
INCIDENT REPORT WORKSHEET
When did this happen? (date/time) Where did this happen?
Name/DMH#
1. Background information of the incident:
2. Method of investigation: (chart review,face-to-face interview, etc.)
Who was affected? (If other than consumer)
List key people involved. (witnesses,visitors, physicians,employees)
3. Preliminary findings: How did it happen?Sequence of events. Be specific. If attachments are needed write
comments on an 8 1/2 sheet of paper and attach to worksheet.
Outcome severity: Nonexistent inconsequential �❑ consequential death not applicable �❑ unknown �❑
4. Response: a)corrective action, b)Plan of Action, c)other
Completed by(print name)
Completed by(signature) Date completed
Reviewed by Supervisor(print name)
Supervisor Signature Date
Exhibit J
Vendor: Contract# Contact Person Contact#
> Date Date Fresno
y
a E Requested Approved( Purchase County
Make/Brand Model Serial# «' (If Fixed If Fixed Date Location Condition Inventory Cost
5 Asset) I Assset) I Number
U.
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DVD Player DV2230 PXC4356A 4/1/2008 $450.00
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Date Prepared:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Exhibit J
22
23
24
25
Date Received:
Exhibit Ja
FI XED ASSET AND SENSI TI VE I TEM TRACM NG
Fi el d Number Fi el d I nst r uct i on or Conrrent s Requi red or Condi t i onal
Descr i pt i on
Header Vendor I ndi cat e t he I egal name of t he agency cont r act ed t o Required
pr ovi de ser vi ces.
Header Pr ogr am I ndi cat a the title of the project as described in the Required
cont r act wi t h t he Count y.
Header Cont r act # I ndi cat e t he assi gned Count y cont r act nurrber.. I f not Requi red
known, County st of f can pr ovi de.
Header Contact Person I ndi cat a the first and last name of the pr i mar y agency Required
contact for the contract .
Header Cont act # I ndi cat a the rrost appropriate telephone nurrber of the Requi red
pr i mar y agency cont act f or t he cont r act .
Header Dat a Pr epar ed I ndi cat e t he most cur r ent dat e t hat t he t r acki ng form Required
was corrpl et ed by the vendor .
a Item I dent i f y t he i t em by pr ovi di ng a comTonl y recognized Requi red
descr i pt i on of the item
b IVbke/ Brand I dent i f y t he company t hat manuf act ur ed t he i t em Requi red
c IVbdel I dent i f y t he model nurrber f or t he i t errs i f appl i cable. Condi t i onal
d Ser i al # I dent i f y t he ser i al number f or t he i t ern i f appl i cabl e. Condi t i onal
IVbr k t he box wi t h an "X' i f t he cost of t he i t em i s
e Fi xed Asset $5, 000 or rror e to i ndi cat e that the i t em i s a fixed Condi t i onal
asset .
Nbr k the box with an "X' if the item meets the cr i t er i a
f Sensitive Item of a sensi t i ve i t em as def i ned by t he Count y. Conditional
g Dat a Request ed I ndi cat e t he dat e t hat t he agency subrri t t ed a request Required
to the County to purchase the item
h Date Approved I ndi cat e t he dat e t hat t he Count y approved t he request Required
to purchase t he i t em
i Purchase Date I ndi cat a the dat e t he agency purchased t he i t em Requi red
j Locat i on I ndi cat e the physi cal I ocat i on of t he i t em Required
k Condi t i on I ndi cat e the general condi t i on of t he i t em ( New, Good, Requi red
Mr n, Bad) .
Fresno County
I I nvent or y I ndi cat e t he FIR # provided by the County for the item Condi t i onal
Number
m Cost I ndi cat e t he t of al pur chase pr i ce of t he i t em i ncl udi ng Requi red
sales tax and other costs, such as shi ppi ng.
Exhibit K
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
)
Il. 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 ll, XIX, or XX?...................................................................................... o 0
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 0
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 n Partnership o Corporation
o Unincorporated Associations n Other(specify)
C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations
under"Remarks."
D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses
of individuals, and provider numbers........................................................................................................... —1 n
NAME ADDRESS PROVIDER NUMBER
Exhibit K
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?.......... o 0
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?......... o 0
VII. A. Is this facility chain affiliated? ...................................................................................................................... o 0
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 L
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.
11SANTACRUZ156301STAFF FOLDERSIARYALSIMENTAL HEALTHIKV SUPERSEDING AGREEMENTSIA-15-317 RURAL TRIAGEIEXHIBIT L-
CERTIFICATION REGARDING DEBARMENT.DOC
Exhibit L
CERTIFICATION
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it,
its owners, officers, corporate managers and partners:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of or had a
civil judgment rendered against them for commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State
or local) transaction or contract under a public transaction; violation of Federal or State
antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
(c) Have not within a three-year period preceding this application/proposal had one or
more public transactions (Federal, State or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or Company)"
11SANTACRUZ156301STAFF FOLDERSIARYALSIMENTAL HEALTHIKV SUPERSEDING AGREEMENTSIA-15-317 RURAL TRIAGEIEXHIBIT L-
CERTIFICATION REGARDING DEBARMENT.DOC
Exhibit M
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as "County'),
members of a contractor's board of directors (hereinafter referred to as "County Contractor"), must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self-dealing transaction is defined below:
"A self-dealing transaction means a transaction to which the corporation is a party and in which one
or more of its directors has a material financial interest"
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member's name,job title (if applicable), and date this disclosure is being made.
(2) Enter the board member's company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the transaction; and
b. The nature of the material financial interest in the Corporation's transaction that the
board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections (3) and (4).
Exhibit M
Page 2 of 2
(1)Company Board Member Information:
Name: Date:
Job Title:
(2)Company/Agency Name and Address:
(3) Disclosure(Please describe the nature of the self-dealing transaction you are a party to)
(4)Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233(a)
(5)Authorized Signature
Signature: Date:
Exhibit N
Page 1 of 1
Electronic Health Records Software Charges
CONTRACTOR understands that COUNTY utilizes Netsmart's Avatar for its Electronic Health Records management.
CONTRACTOR agrees to reimburse COUNTY for all user license fees for accessing Netsmart's Avatar, as set forth below:
Estimated Fee Per Estimated Fee Per
Fiscal Year Fiscal Year
Description Effective Fee Per User Est. Quantity FY 18-19
of Users FY 19-20
NetSmart Avatar Monthly
Hosting Service 07/01/2017 $37.00 22-25 $9,768 - $11,100 $9,768 - $11,100
(per named user per month)
NetSmart Avatar Monthly
Maintenance/License 07/01/2017 $14.00* 22-25 $3,696 - $4,200 $3,696 - $4,200
(per named user per month)
NetSmart Avatar Monthly
Hosting Perceptive 07/01/2017 $4.66 22-25 $1,231 - $1,398 $1,231 - $1,398
(per named user per month)
Estimated Total Per Fiscal Year $14,695 - $16,698 $14,695 - $16,698
*Monthly maintenance increases each FY on July I"based upon the CPI rate.
Should CONTRACTOR choose not to utilize Netsmart's Avatar for its Electronic Health Records management, CONTRACTOR will
be responsible for obtaining its own system for Electronic Health Records management.