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HomeMy WebLinkAboutAgreement A-22-421 with Kings View Metro CIT.pdf ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Agreement No. 22-421 1 AGREEMENT 2 THIS AGREEMENT("Agreement") is made and entered into this 20t" day of September, 2022, 3 by and between the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter 4 referred to as "COUNTY', and Kings View, a California non-profit corporation, whose address is 7170 North 5 Financial Drive, Suite 110, Fresno, California, 93720, hereinafter referred to as "CONTRACTOR," 6 collectively, "the parties." 7 WITNESSETH: 8 WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), is in need of a 9 qualified agency to operate Mental Health Crisis Intervention Services within the Fresno Metropolitan 10 (Metro) area as specified in this Agreement, to help reduce stigma and discrimination against mental 11 illness and provide mental health crisis intervention services in a working partnership with Fresno 12 metro first responders; and 13 WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), is a Mental 14 Health Plan (MHP) as defined in Title 9 of the California Code of Regulations (C.C.R.), section 15 1810.226; 16 WHEREAS, CONTRACTOR is qualified and willing to provide said services pursuant to the 17 terms and conditions of this Agreement; 18 WHEREAS, the COUNTY, through its DBH, has received additional grant funds for, and wishes 19 CONTRACTOR to employ additional case management staff to provide post-crisis follow-up services in 20 conjunction with other services provided pursuant to this Agreement; 21 WHEREAS, COUNTY entered into Agreement No. A-18-688 with CONTRACTOR, whose legal 22 entity name was incorrectly referred to as"KINGS VIEW BEHAVIORAL HEALTH"; and 23 WHEREAS, this Agreement shall be retroactive to December 11, 2018, and shall supersede 24 Agreement No. A-18-688 in its entirety. 25 NOW, THEREFORE, in consideration of the mutual covenants, terms and conditions herein 26 contained, the parties hereto agree as follows: 27 1. SERVICES 28 A. CONTRACTOR shall perform all services and fulfill all responsibilities as set forth -1- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 in Exhibit A, "Scope of Work" and Exhibit A-2 "Crisis Care Mobile Units Grant Scope of Work", attached 2 hereto and by this reference incorporated herein and made part of this Agreement. 3 B. CONTRACTOR shall also perform all services and fulfill all responsibilities as 4 specified in COUNTY's Request for Proposal (RFP) No. 18-059 dated July 3, 2018, and Addendum II 5 No. One (1) to COUNTY'S RFP No. 18-059 dated July 30, 2018, herein collectively referred to as 6 COUNTY's Revised RFP, and CONTRACTOR's Response to said Revised RFP dated August 8, 2018, 7 all incorporated herein by reference and made part of this Agreement. In the event of any inconsistency 8 among these documents, the inconsistency shall be resolved by giving precedence in the following 9 order of priority: 1) to this Agreement, including all Exhibits, 2) to the Revised RFP No. 18-059, and 3) to 10 the Response to the Revised RFP No. 18-059. A copy of COUNTY's Revised RFP No. 18-059 and 11 CONTRACTOR's response thereto shall be retained and made available during the term of this 12 Agreement by COUNTY's DBH MHSA Administration. 13 C. It is acknowledged by all parties hereto that COUNTY's DBH's Mental Health 14 Services Act (MHSA) Administrative unit shall monitor said MHSA Fresno Metro Mental Health Crisis 15 Intervention Services in accordance with Section Fourteen (14) of this Agreement. 16 D. CONTRACTOR shall participate in monthly, or as needed, workgroup meetings 17 consisting of staff from COUNTY's DBH's MHSA Administrative unit to discuss the MHSA Fresno Metro 18 Mental Health Crisis Intervention program, requirements, data reporting, training, policies and 19 procedures, overall program operations, outcomes, and any problems or foreseeable problems that may 20 arise. 21 E. It is acknowledged that upon execution of this Agreement, CONTRACTOR's 22 service site is to be determined. Any changes to the CONTRACTOR's location of the service site may 23 be made only upon ninety (90) days advanced written notification to COUNTY's DBH Director and upon 24 written approval from COUNTY's DBH Director, or designee. 25 F. CONTRACTOR shall maintain requirements as an organizational provider 26 throughout the term of this Agreement, as described in Section Seventeen (17) of this Agreement and 27 within Exhibit B, "Medi-Cal Organizational Provider Standards", attached hereto and incorporated herein 28 by reference and made part of this Agreement. If for any reason, this status is not maintained, COUNTY -2- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 may terminate this Agreement pursuant to Section Three (3) of this Agreement. 2 G. CONTRACTOR agrees that prior to providing services under the terms and 3 conditions of this Agreement, CONTRACTOR shall have appropriate staff hired and in place for program 4 services and operations or COUNTY may, in addition to other remedies it may have, suspend referrals 5 or terminate this Agreement, in accordance with Section Three (3) of this Agreement. 6 H. CONTRACTOR shall provide all behavioral health services, programs, and 7 practices with the vision, mission and guiding principles of COUNTY's DBH as further described in 8 Exhibit C, "Fresno County Department of Behavioral Health Guiding Principles of Care Delivery," 9 attached hereto and incorporated herein by reference. 10 I. CONTRACTOR may maintain its records in COUNTY's Electronic Health Record 11 (EHR) system (Avatar) in accordance with Exhibit D, "Documentation Standards for Client Records," 12 attached hereto and incorporated herein by reference and made part of this Agreement. The client 13 record shall begin with registration and intake and include client authorizations, assessments, plans of 14 care, and progress notes, as well as other documents as approved by the COUNTY's DBH. COUNTY 15 shall be allowed to review records of services provided, including the goals and objectives of the 16 treatment plan, and how the therapy provided is achieving the goals and objectives. If CONTRACTOR 17 determines to maintain its records in COUNTY's EHR system, it shall provide COUNTY's DBH Director, 18 or designee, with a 30-day notice. If at any time CONTRACTOR chooses not to maintain its records in 19 COUNTY's EHR system, it shall provide COUNTY'S DBH Director, or designee, with a 30-day notice 20 and CONTRACTOR will be responsible for obtaining its own system, at its own cost, for Electronic 21 Health Records management. Disclaimer - COUNTY makes no warranty or representation that 22 information entered into the COUNTY's EHR system by CONTRACTOR will be accurate, adequate or 23 satisfactory for CONTRACTOR's own purposes or that any information in CONTRACTOR's possession 24 or control, or transmitted or received by CONTRACTOR, is or will be secure from unauthorized access, 25 viewing, use, disclosure, or breach. CONTRACTOR is solely responsible for client information entered 26 by CONTRACTOR into the COUNTY's EHR system. CONTRACTOR agrees that all Protected Health 27 Information (PHI) maintained by CONTRACTOR in COUNTY's EHR system will be maintained in 28 conformance with all HIPAA laws, as stated in Section Nineteen (19), "Health Insurance Portability and -3- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 Accountability Act". 2 J. It is mutually agreed by all parties to this Agreement, that the program funded 3 under this Agreement shall be identified and subsequently named/branded through the review and 4 approval of the Director, COUNTY DBH or designee. All print or media materials, including program 5 branding and program references shall be reviewed and approved by the Director, Department of 6 Behavioral Health or designee. The program funded under this Agreement shall be identified as a 7 County of Fresno, Department of Behavioral Health funded program, and operated by the 8 CONTRACTOR under the terms and conditions of this Agreement. 9 2. TERM 10 The term of this Agreement shall be for a period of three (3)years, commencing on 11 December 11, 2018 through and including June 30, 2021. This Agreement may be extended for two (2) 12 additional consecutive twelve (12) month periods upon written approval of both parties no later than sixty 13 (60) days prior to the first day of the next twelve (12) month extension period. The COUNTY's DBH 14 Director, or his or her designee is authorized to execute such written approval on behalf of COUNTY based 15 on CONTRACTOR'S satisfactory performance. 16 3. TERMINATION 17 A. Non-Allocation of Funds - The terms of this Agreement, and the services-to be 18 provided hereunder, are contingent on the approval of funds by the appropriating government agency. 19 Should sufficient funds not be allocated, the services provided may be modified, or this Agreement 20 terminated, at any time by giving the CONTRACTOR thirty (30) days advance written notice. 21 B. Breach of Contract-The COUNTY may immediately suspend or terminate this 22 Agreement in whole or in part, where in the determination of the COUNTY there is: 23 1) An illegal or improper use of funds; 24 2) A failure to comply with any term of this Agreement; 25 3) A substantially incorrect or incomplete report submitted to the COUNTY; 26 4) Improperly performed service. 27 In no event shall any payment by the COUNTY constitute a waiver by the COUNTY of any breach 28 of this Agreement or any default which may then exist on the part of the CONTRACTOR. Neither shall such -4- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 payment impair or prejudice any remedy available to the COUNTY with respect to the breach or default. 2 The COUNTY shall have the right to demand of the CONTRACTOR the repayment to the COUNTY of any 3 funds disbursed to the CONTRACTOR under this Agreement, which in the judgment of the COUNTY were 4 not expended in accordance with the terms of this Agreement. The CONTRACTOR shall promptly refund 5 any such funds upon demand. 6 C. Without Cause - Under circumstances other than those set forth above, this 7 Agreement may be terminated by COUNTY upon the giving of thirty (30) days advance written notice of an 8 intention to terminate to CONTRACTOR. 9 4. COMPENSATION 10 COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive compensation in 11 accordance with the budgets set forth in Exhibit E and Exhibit E-2, attached hereto and by this reference 12 incorporated herein and made part of this Agreement. 13 A. Maximum Contract Amount- The maximum amount payable to CONTRACTOR for 14 the period of effective upon execution through June 30, 2019 shall not exceed One Million, Three Hundred 15 Seventy-Nine Thousand, Six-Hundred Ninety-Four and No/100 Dollars ($1,379,694.00). 16 The maximum amount payable to CONTRACTOR for the period of July 1, 2019 17 through June 30, 2020 shall not exceed Two Million, Three Hundred Fifty-Nine Thousand, Six Hundred 18 Nine and No/100 Dollars ($2,359,609.00). 19 The maximum amount payable to CONTRACTOR for the period of July 1, 2020 20 through June 30, 2021 shall not exceed Two Million, Four Hundred Twenty-Five Thousand, Eight 21 Hundred Twenty-Six and No/100 Dollars ($2,425,826.00). 22 If this Agreement is extended for an additional twelve (12) month renewal period 23 beginning July 1, 2021 through June 30, 2022, the maximum amount payable to CONTRACTOR for 24 said period shall not exceed Two Million, Four Hundred Ninety-Three Thousand, Eight Hundred Ninety- 25 Seven and No/100 Dollars ($2,493,897.00). 26 If this Agreement is extended for an additional twelve (12) month renewal period 27 beginning July 1, 2022 through June 30, 2023, the maximum amount payable to CONTRACTOR for 28 said period shall not exceed Two Million, Seven Hundred Sixteen Thousand, One Hundred Seventy- -5- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 Five and No/100 Dollars ($2,716,175.00). 2 In no event shall compensation paid for services performed under this Agreement be 3 in excess of exceed Eleven Million, Three Hundred Seventy-Five Thousand, Two Hundred One and 4 No/100 Dollars ($11,375,201.00) during the term of this Agreement. It is understood that all expenses 5 incidental to CONTRACTOR'S performance of services under this Agreement shall be borne by 6 CONTRACTOR. 7 Payment shall be made upon certification or other proof satisfactory to COUNTY's 8 DBH that services have actually been performed by CONTRACTOR as specified in this Agreement. 9 B. If CONTRACTOR fails to generate the Medi-Cal revenue and/or client fee 10 reimbursement amounts set forth in Exhibit E, the COUNTY shall not be obligated to pay the 11 difference between these estimated amounts and the actual amounts generated. 12 It is further understood by COUNTY and CONTRACTOR that any Medi-Cal revenue 13 and/or client fee reimbursements above the amounts stated herein will be used to directly offset the 14 COUNTY's contribution of COUNTY funds identified in Exhibit E. The offset of funds will also be clearly 15 identified in monthly invoices received from CONTRACTOR as further described in Section Five (5) of 16 this Agreement. 17 Travel shall be reimbursed based on actual expenditures and mileage reimbursement 18 shall be at CONTRACTOR's adopted rate per mile, not to exceed the Federal Internal Revenue 19 Services (IRS) published rate for the then current year. 20 C. It is understood that all expenses incidental to CONTRACTOR's performance of 21 services under this Agreement shall be borne by CONTRACTOR. If CONTRACTOR fails to comply with 22 any provision of this Agreement, COUNTY shall be relieved of its obligation for further compensation. 23 D. Payments shall be made by COUNTY to CONTRACTOR in arrears, for services 24 provided during the preceding month, within forty-five (45) days after the date of receipt and approval by 25 COUNTY of the monthly invoicing as described in Section Five (5) herein. Payments shall be made after 26 receipt and verification of actual expenditures incurred by CONTRACTOR for monthly program costs, as 27 identified in Exhibit E, in the performance of this Agreement and shall be documented to COUNTY on a 28 monthly basis by the tenth (10th) of the month following the month of said expenditures. The parties -6- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 acknowledge that the CONTRACTOR will be performing hiring, training, and credentialing of staff, and the 2 COUNTY will be performing additional staff credentialing to ensure compliance with State and Federal 3 regulations. 4 E. COUNTY shall not be obligated to make any payments under this Agreement if the 5 request for payment is received by COUNTY more than sixty (60) days after this Agreement has terminated 6 or expired. 7 All final invoices shall be submitted by CONTRACTOR within sixty (60) days 8 following the final month of service for which payment is claimed. No action shall be taken by COUNTY on 9 invoices submitted beyond the sixty (60) day closeout period. Any compensation which is not expended by 10 CONTRACTOR pursuant to the terms and conditions of this Agreement shall automatically revert to 11 COUNTY. 12 F. The services provided by CONTRACTOR under this Agreement are funded in 13 whole or in part by the State of California. In the event that funding for these services is delayed by 14 the State Controller, COUNTY may defer payments to CONTRACTOR. The amount of the deferred 15 payment shall not exceed the amount of funding delayed by the State Controller to the COUNTY. The 16 period of time of the deferral by COUNTY shall not exceed the period of time of the State Controller's delay 17 of payment to COUNTY plus forty-five (45) days. 18 G. CONTRACTOR shall be held financially liable for any and all future 19 disallowances/audit exceptions due to CONTRACTOR's deficiency discovered through the State audit 20 process and COUNTY utilization review during the course of this Agreement. At COUNTY's election, the 21 disallowed amount will be remitted within forty-five (45) days to COUNTY upon notification or shall be 22 withheld from subsequent payments to CONTRACTOR. CONTRACTOR shall not receive reimbursement 23 for any units of services rendered that are disallowed or denied by the Fresno County Mental Health Plan 24 (Mental Health Plan) utilization review process or through the State Department of Health Care Services 25 (DHCS) cost report audit settlement process for Medi-Cal eligible clients. Notwithstanding the above, 26 COUNTY must notify CONTRACTOR prior to any State audit process and/or COUNTY utilization review. 27 To the extent allowable by law, CONTRACTOR shall have the right to be present during each phase of any 28 State audit process and/or COUNTY utilization review and shall be provided all documentation related to -7- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 each phase of any State audit process and/or COUNTY utilization review. Additionally, prior to any 2 disallowances/audit exceptions becoming final, CONTRACTOR shall be given at least ten (10) business 3 days to respond to such proposed disallowances/audit exceptions. 4 H. Any compensation which is not expended by CONTRACTOR pursuant to the terms 5 and conditions of this Agreement shall be remitted to COUNTY within sixty (60) days of receipt and 6 verification sof inappropriate expenditures by COUNTY's DBH Director, or designee. 7 5. INVOICING 8 CONTRACTOR shall invoice COUNTY in arrears by the tenth (10th) day of each 9 month for the prior month's actual services rendered to DBH-Invoices a( fresnocountyca.gov, 10 DBHlnvoiceReview(a)fresnocountyca.gov and DBH Contracted ServicesDivision(a)fresnocountyca.gov. 11 After CONTRACTOR renders service to referred clients, CONTRACTOR will invoice COUNTY for 12 payment, certify the expenditure, and submit electronic claiming data into COUNTY's electronic 13 information system for all clients, including those eligible for Medi-Cal as well as those that are not 14 eligible for Medi-Cal, including contracted cost per unit and actual cost per unit. COUNTY must pay 15 CONTRACTOR before submitting a claim to DHCS for Federal reimbursement for Medi-Cal eligible 16 clients. 17 If CONTRACTOR chooses to utilize the COUNTY's electronic health record 18 system (currently AVATAR, the preferred EHR system by DBH) method as their own full electronic 19 health records system, COUNTY's DBH shall invoice CONTRACTOR in arrears by the fifth (5th) day of 20 each month for the prior month's hosting fee for access to the COUNTY's electronic information system 21 in accordance with the fee schedule as set forth in Exhibit E-3, "Electronic Health Records Software 22 Charges" attached hereto and incorporated herein by this reference and made part of this Agreement. 23 COUNTY shall invoice CONTRACTOR annually for the annual maintenance and licensing fee for 24 access to the COUNTY's electronic information system in accordance with the fee schedule as set forth 25 in Exhibit E. COUNTY shall invoice CONTRACTOR annually for the Reaching Recovery fee, as 26 applicable, for access to the COUNTY's electronic information system in accordance with the fee 27 schedule as set forth in Exhibit E. CONTRACTOR shall provide payment for these expenditures to 28 COUNTY's Fresno County Department of Behavioral Health, Accounts Receivable, P.O. Box 712, -8- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 Fresno, CA 93717-0712, Attention: Business Office, within forty-five (45) days after the date of receipt 2 by CONTRACTOR of the invoicing provided by COUNTY. 3 A. At the discretion of COUNTY's DBH Director, or his or her designee, if an invoice is 4 incorrect or is otherwise not in proper form or substance, COUNTY's DBH Director, or his or her designee, 5 shall have the right to withhold payment as to only that portion of the invoice that is incorrect or improper 6 after five (5) days prior notice to CONTRACTOR. CONTRACTOR agrees to continue to provide services 7 for a period of ninety (90)days after notification of an incorrect or improper invoice. If after the ninety (90) 8 day period, the invoice(s) is still not corrected to COUNTY DBH's satisfaction, COUNTY's DBH Director, or 9 his or her designee, may elect to terminate this Agreement, pursuant to the termination provisions stated in 10 Section Three (3) of this Agreement. In addition, for invoices received ninety (90) days after the expiration 11 of each term of this Agreement or termination of this Agreement, at the discretion of COUNTY's DBH 12 Director, or his or her designee, COUNTY's DBH shall have the right to deny payment of any additional 13 invoices received. 14 B. Monthly invoices shall include a client roster, identifying volume reported by payer 15 group clients served (including third-party payer of services) by month and year-to-date, including 16 percentages. 17 C. CONTRACTOR shall submit to the COUNTY by the tenth (10th) of each month a 18 detailed general ledger(GL), itemizing costs incurred in the previous month. Failure to submit GL reports 19 and supporting documentation shall be deemed sufficient cause for COUNTY to withhold payments until 20 there is compliance, as further described in Section Five (5) herein. 21 D. CONTRACTOR will remit annually within ninety (90) days from June 30, a schedule to 22 provide the required information on published charges for all authorized direct specialty mental health 23 services. The published charge listing will serve as a source document to determine the CONTRACTOR's 24 usual and customary charge prevalent in the public mental health sector that is used to bill the general 25 public, insurers or other non-Medi-Cal third party payers during the course of business operations. 26 E. CONTRACTOR shall submit monthly staffing reports that identify all direct service 27 and support staff, applicable licensure/certifications, and full time hours worked to be used as a tracking tool 28 to determine if CONTRACTOR's program is staffed according to the services provided under this -9- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 Agreement. 2 F. CONTRACTOR must maintain financial records for a period of ten (10) years or until 3 any dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be responsible for any 4 disallowances related to inadequate documentation. 5 G. CONTRACTOR is responsible for collection and managing of data in a manner to be 6 determined by DHCS and the COUNTY's Mental Health Plan in accordance with applicable rules and 7 regulations. COUNTY's electronic information system is a critical source of information for purposes of 8 monitoring service volume and obtaining reimbursement. 9 H. CONTRACTOR shall submit service data into COUNTY's electronic information 10 system according to COUNTY's DBH documentation standards to allow the COUNTY to bill Medi-Cal, and 11 any other third-party source, for services and meet State and Federal reporting requirements. 12 I. CONTRACTOR must comply with all laws and regulations governing the Federal 13 Medicare program, including, but not limited to: 1)the requirement of the Medicare Act, 42 U.S.C. section 14 111395 et seq; and 2)the regulations and rules promulgated by the Federal Centers for Medicare and 15 Medicaid Services as they relate to participation, coverage and claiming reimbursement. CONTRACTOR 16 will be responsible for compliance as of the effective date of each Federal, State or local law or regulation 17 specified. 18 J. If a client has dual coverage, such as other health coverage (OHC) or Federal 19 Medicare, the CONTRACTOR will be responsible for billing the carrier and obtaining a payment/denial or 20 have validation of claiming with no response ninety (90) days after the claim was mailed before the service 21 can be entered into the COUNTY's electronic information system. CONTRACTOR must report all third- 22 party collections for Medicare, third party or client pay or private pay in each monthly invoice and in the 23 annual cost report that is required to be submitted. A copy of explanation of benefits or CMS 1500 form is 24 required as documentation. CONTRACTOR must report all revenue collected from OHC, third-party, client- 25 pay or private-pay in each monthly invoice and in the cost report that is required to be submitted. 26 CONTRACTOR shall submit monthly invoices for reimbursement that equal the amount due 27 CONTRACTOR less any funding sources not eligible for Federal and State reimbursement. 28 CONTRACTOR must comply with all laws and regulations governing the Federal Medicare program, -10- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 including, but not limited to: 1)the requirement of the Medicare Act, 42 U.S.C. section 1395 et seq; and 2) 2 the regulation and rules promulgated by the Federal Centers for Medicare and Medicaid Services as they 3 relate to participation, coverage and claiming reimbursement. CONTRACTOR will be responsible for 4 compliance as of the effective date of each Federal, State or local law or regulation specified. 5 K. Data entry shall be the responsibility of the CONTRACTOR. COUNTY shall monitor 6 the volume of services and cost of services entered into the COUNTY's electronic information system. Any 7 and all audit exceptions resulting from the provision and reporting of specialty mental health services by 8 CONTRACTOR shall be the sole responsibility of the CONTRACTOR. CONTRACTOR will comply with all 9 applicable policies, procedures, directives and guidelines regarding the use of COUNTY's electronic 10 information system. 11 L. Medi-Cal Certification and Mental Health Plan Compliance - CONTRACTOR shall 12 comply with any and all requests and directives associated with COUNTY maintaining State Medi-Cal site 13 certification. CONTRACTOR shall provide specialty mental health services in accordance with the 14 COUNTY's Mental Health Plan Compliance Program and Code of Conduct and Ethics ("Code of Conduct"). 15 CONTRACTOR must comply with the Code of Conduct as set forth in Exhibit F, "Fresno County Mental 16 Health Plan Compliance Program - Code of Conduct Policy and Procedure", attached hereto and 17 incorporated herein by reference and made part of this Agreement. CONTRACTOR shall comply with any 18 and all requests associated with any State/Federal reviews or audits. 19 CONTRACTOR may provide direct specialty mental health services using unlicensed 20 staff as long as the individual is approved as a provider by the COUNTY's Mental Health Plan, is 21 supervised by licensed staff, works within his/her scope and only delivers allowable direct specialty mental 22 health services. It is understood that each service is subject to audit for compliance with Federal and State 23 regulations, and that COUNTY may be making payments in advance of said review. In the event that a 24 service is disapproved, COUNTY may, at its sole discretion, withhold compensation or set off from other 25 payments due the amount of said disapproved services CONTRACTOR shall be responsible for audit 26 exceptions to ineligible dates of services or incorrect application of utilization review requirements. 27 6. INDEPENDENT CONTRACTOR 28 In performance of the work, duties and obligations assumed by CONTRACTOR under this -11- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of the 2 CONTRACTOR'S officers, agents, and employees will at all times be acting and performing as an 3 independent contractor, and shall act in an independent capacity and not as an officer, agent, servant, 4 employee,joint venturer, partner, or associate of the COUNTY. Furthermore, COUNTY shall have no right 5 to control or supervise or direct the manner or method by which CONTRACTOR shall perform its work and 6 function. However, COUNTY shall retain the right to administer this Agreement so as to verify that 7 CONTRACTOR is performing its obligations in accordance with the terms and conditions thereof. 8 CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the 9 rules and regulations, if any, of governmental authorities having jurisdiction over matters the subject 10 thereof. 11 Because of its status as an independent contractor, CONTRACTOR shall have absolutely 12 no right to employment rights and benefits available to COUNTY employees. CONTRACTOR shall be 13 solely liable and responsible for providing to, or on behalf of, its employees all legally-required employee 14 benefits. In addition, CONTRACTOR shall be solely responsible and save COUNTY harmless from all 15 matters relating to payment of CONTRACTOR'S employees, including compliance with Social Security 16 withholding and all other regulations governing such matters. It is acknowledged that during the term of this 17 Agreement, CONTRACTOR may be providing services to others unrelated to the COUNTY or to this 18 Agreement. 19 7. MODIFICATION 20 Any matters of this Agreement may be modified from time to time by the written consent of 21 all the parties without, in any way, affecting the remainder. 22 In addition, changes to expense category (i.e., Salary & Benefits, Facilities/Equipment, 23 Operating, Financial Services, Special Expenses, Fixed Assets, etc.) subtotals in the budgets, and 24 changes to the volume of units of services/types of service units to be provided as set forth in Exhibit E and 25 Exhibit E-2, that do not exceed ten percent(10%) of the maximum compensation payable to the 26 CONTRACTOR may be made with the written approval of COUNTY's DBH Director, or his or her designee. 27 Said modifications shall not result in any change to the annual maximum compensation 28 amount payable to CONTRACTOR, as stated in this Agreement. -12- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 8. NON-ASSIGNMENT 2 Neither party shall assign, transfer or sub-contract this Agreement nor their rights or duties 3 under this Agreement without the prior written consent of the other party. 4 9. HOLD HARMLESS 5 CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY'S request, 6 defend the COUNTY, its officers, agents, and employees from any and all costs and expenses (including 7 attorney's fees and costs), damages, liabilities, claims, and losses occurring or resulting to COUNTY in 8 connection with the performance, or failure to perform, by CONTRACTOR, its officers, agents, or 9 employees under this Agreement, and from any and all costs and expenses (including attorney's fees and 10 costs), damages, liabilities, claims, and losses occurring or resulting to any person, firm, or corporation who 11 may be injured or damaged by the performance, or failure to perform, of CONTRACTOR, its officers, 12 agents, or employees under this Agreement. 13 The provisions of this Section 9 shall survive termination of this Agreement. 14 10. INSURANCE 15 Without limiting the COUNTY's right to obtain indemnification from CONTRACTOR or any 16 third parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect, the following 17 insurance policies or a program of self-insurance, including but not limited to, an insurance pooling 18 arrangement or Joint Powers Agreement (JPA)throughout the term of the Agreement: 19 A. Commercial General Liabilitv 20 Effective December 11, 2018 through September 19, 2022, Commercial General Liability 21 Insurance with limits of not less than Two Million Dollars ($2,000,000.00) per occurrence and an annual 22 aggregate of Five Million Dollars ($5,000,000.00). Effective September 20, 2022 through June 30, 2023, 23 Commercial General Liability Insurance with limits of not less than Two Million Dollars ($2,000,000.00) per 24 occurrence and an annual aggregate of Four Million Dollars ($4,000,000.00). This policy shall be issued on 25 a per occurrence basis. COUNTY may require specific coverages including completed operations, 26 products liability, contractual liability, Explosion-Collapse-Underground, fire legal liability or any other liability 27 insurance deemed necessary because of the nature of this contract. 28 B. Automobile Liabilitv -13- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 Comprehensive Automobile Liability Insurance with limits of not less than One Million Dollars 2 ($1,000,000.00) per accident for bodily injury and for property damages. Coverage should include any auto 3 used in connection with this Agreement. 4 C. Real and Property Insurance 5 CONTRACTOR shall maintain a policy of insurance for all risk personal property coverage 6 which shall be endorsed naming the County of Fresno as an additional loss payee. The personal property 7 coverage shall be in an amount that will cover the total of the COUNTY purchase and owned property, at a 8 minimum, as discussed in Section Twenty (21) of this Agreement. 9 D. All Risk Property Insurance 10 CONTRACTOR will provide property coverage for the full replacement value of the 11 COUNTY'S personal property in possession of CONTRACTOR and/or used in the execution of this 12 Agreement. COUNTY will be identified on an appropriate certificate of insurance as the certificate holder 13 and will be named as an Additional Loss Payee on the Property Insurance Policy. 14 E. Professional Liability 15 If CONTRACTOR employs licensed professional staff, (e.g., Ph.D., R.N., L.C.S.W., 16 M.F.C.C.) in providing services, Professional Liability Insurance with limits of not less than One Million 17 Dollars ($1,000,000.00) per occurrence, Three Million Dollars ($3,000,000.00) annual aggregate. 18 CONTRACTOR agrees that it shall maintain, at its sole expense, in full force and effect for a period of three 19 (3) years following the termination of this Agreement, one or more policies of professional liability insurance 20 with limits of coverage as specified herein. 21 F. Child Abuse/Molestation and Social Services Coverage 22 CONTRACTOR shall have either separate policies or an umbrella policy with endorsements 23 covering Child Abuse/Molestation and Social Services Liability coverage or have a specific endorsement on 24 their General Commercial liability policy covering Child Abuse/Molestation and Social Services Liability. The 25 policy limits for these policies shall be One Million Dollars ($1,000,000) per occurrence with a Two Million 26 Dollars ($2,000,000) annual aggregate. The policies are to be on a per occurrence basis. 27 G. Worker's Compensation 28 A policy of Worker's Compensation insurance as may be required by the California Labor -14- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 Code. 2 H. Cyber Liability 3 Cyber Liability Insurance, with limits not less than $2,000,000 per occurrence or claim, 4 $2,000,000 aggregate. Coverage shall be sufficiently broad to respond to duties and obligations 5 undertaken by CONTRACTOR in this agreement and shall include, but not be limited to, claims 6 involving infringement of intellectual property, including but not limited to infringement of copyright, 7 trademark, trade dress, invasion of privacy violations, information theft, damage to or destruction of 8 electronic information, release of private information, alteration of electronic information, extortion and 9 network security. The policy shall provide coverage for breach response costs as well as regulatory 10 fines and penalties as well as credit monitoring expenses with limits sufficient to respond to these 11 obligations. 12 I. Molestation 13 Effective September 20, 2022 through June 30, 2023, sexual abuse/molestation liability 14 insurance with limits of not less than One Million Dollars ($1,000,000.00) per occurrence, Two Million 15 Dollars ($2,000,000.00) annual aggregate. This policy shall be issued on a per occurrence basis. 16 J. Waiver of Subrogation 17 CONTRACTOR hereby grants to COUNTY a waiver of any right to subrogation which 18 any insurer of said CONTRACTOR may acquire against the COUNTY by 'virtue of the payment of any 19 loss under insurance. CONTRACTOR agrees to obtain any endorsement that may be necessary to 20 affect this waiver of subrogation, but this provision applies regardless of whether or not the COUNTY 21 has received a waiver of subrogation endorsement from the insurer. 22 K. Additional Requirements Relating to Insurance 23 CONTRACTOR shall obtain endorsements to the Commercial General Liability insurance 24 naming the County of Fresno, its officers, agents, and employees, individually and collectively, as additional 25 insured, but only insofar as the operations under this Agreement are concerned. Such coverage for 26 additional insured shall apply as primary insurance and any other insurance, or self-insurance, maintained 27 by COUNTY, its officers, agents and employees shall be excess only and not contributing with insurance 28 provided under CONTRACTOR's policies herein. This insurance shall not be cancelled or changed without -15- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 a minimum of thirty (30) days advance written notice given to COUNTY. 2 CONTRACTOR hereby waives its right to recover from COUNTY, its officers, agents, and 3 employees any amounts paid by the policy of worker's compensation insurance required by this 4 Agreement. CONTRACTOR is solely responsible to obtain any endorsement to such policy that may be 5 necessary to accomplish such waiver of subrogation, but CONTRACTOR's waiver of subrogation under 6 this paragraph is effective whether or not CONTRACTOR obtains such an endorsement. 7 Within Thirty (30) days from the date CONTRACTOR signs and executes this Agreement, 8 CONTRACTOR shall provide certificates of insurance and endorsement as stated above for all of the 9 foregoing policies, as required herein, to the County of Fresno, (Name and Address of the official who will 10 administer this contract), stating that such insurance coverage have been obtained and are in full force; that 11 the County of Fresno, its officers, agents and employees will not be responsible for any premiums on the 12 policies; that for such worker's compensation insurance the CONTRACTOR has waived its right to recover 13 from the COUNTY, its officers, agents, and employees any amounts paid under the insurance policy and 14 that waiver does not invalidate the insurance policy; that such Commercial General Liability insurance 15 names the County of Fresno, its officers, agents and employees, individually and collectively, as additional 16 insured, but only insofar as the operations under this Agreement are concerned; that such coverage for 17 additional insured shall apply as primary insurance and any other insurance, or self-insurance, maintained 18 by COUNTY, its officers, agents and employees, shall be excess only and not contributing with insurance 19 provided under CONTRACTOR's policies herein; and that this insurance shall not be cancelled or changed 20 without a minimum of thirty (30) days advance, written notice given to COUNTY. 21 In the event CONTRACTOR fails to keep in effect at all times insurance coverage as herein 22 provided, the COUNTY may, in addition to other remedies it may have, suspend or terminate this 23 Agreement upon the occurrence of such event. 24 All policies shall be issued by admitted insurers licensed to do business in the State of 25 California, and such insurance shall be purchased from companies possessing a current A.M. Best, Inc. 26 rating of A FSC VII or better. 27 11. LICENSES/CERTIFICATES 28 Throughout each term of this Agreement, CONTRACTOR and CONTRACTOR's staff shall -16- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions necessary for 2 the provision of the services hereunder and required by the laws and regulations of the United States of 3 America, State of California, the County of Fresno, and any other applicable governmental agencies. 4 CONTRACTOR shall notify COUNTY immediately in writing of its inability to obtain or maintain such 5 licenses, permits, approvals, certificates, waivers and exemptions irrespective of the pendency of any 6 appeal related thereto. Additionally, CONTRACTOR and CONTRACTOR's staff shall comply with all 7 applicable laws, rules or regulations, as may now exist or be hereafter changed. 8 12. RECORDS 9 CONTRACTOR shall maintain records in accordance with Exhibit D, "Documentation Standards for 10 Client Records", attached hereto and by this reference incorporated herein and made part of this 11 Agreement. COUNTY shall be allowed to review all records of services provided, including the goals and 12 objectives of the treatment plan, and how the therapy provided is achieving the goals and objectives. All 13 medical records shall be maintained for a minimum of ten (10) years from the date of the end of the 14 Agreement. 15 13. REPORTS 16 A. Outcome Reports - CONTRACTOR shall submit to COUNTY's DBH service 17 outcome reports as reasonably requested by COUNTY's DBH. Outcome reports and performance 18 outcome measures requirements are subject to change at COUNTY's DBH discretion. All 19 performance outcome measures shall adhere to the Commission on Accreditation of 20 Rehabilitation Facilities (CARF) standards as identified in Exhibit G, attached hereto and 21 incorporated herein by reference and made part of this Agreement. 22 B. Additional Reports- CONTRACTOR shall also furnish to COUNTY such statements, 23 records, reports, data, and other information as COUNTY's DBH may reasonably request pertaining to 24 matters covered by this Agreement. In the event that CONTRACTOR fails to provide such reports or other 25 information required hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly 26 payments until there is compliance. In addition, CONTRACTOR shall provide written notification and 27 explanation to COUNTY within five (5) days of any funds received from another source to conduct the 28 same services covered by this Agreement. -17- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 C. Cost Reports - CONTRACTOR agrees to submit a complete and accurate detailed 2 cost report on an annual basis for each fiscal year ending June 30th in the format prescribed by the DHCS 3 for the purposes of Short Doyle Medi-Cal reimbursements and total costs for programs. The cost report will 4 be the source document for several phases of settlement with the DHCS for the purposes of Short Doyle 5 Medi-Cal reimbursement. CONTRACTOR shall report costs under their approved legal entity number 6 established during the Medi-Cal certification process. The information provided applies to CONTRACTOR 7 for program related costs for services rendered to Medi-Cal and non-Medi-Cal. CONTRACTOR will remit a 8 schedule to provide the required information on published charges (PC)for all authorized services. The 9 report will serve as a source document to determine their usual and customary charge prevalent in the 10 public mental health sector that is used to bill the general public, insurers, or other non-Medi-Cal third party 11 payers during the course of business operations. CONTRACTOR must report all collections for Medi- 12 Cal/Medicare services and collections. The CONTRACTOR shall also submit with the cost report a copy of 13 the CONTRACTOR's general ledger that supports revenues and expenditures and reconciled detailed 14 report of reported total units of services rendered under this Agreement to the units of services reported by 15 CONTRACTOR to COUNTY'S data system. 16 Cost Reports must be submitted to the COUNTY as a hard copy with a signed cover 17 letter and electronic copy of completed DHCS cost report form along with requested support documents 18 following each fiscal year ending June 30th. During the month of September of each year this 19 Agreement is effective, COUNTY will issue instructions of the annual cost report which indicates the 20 training session, DHCS cost report template worksheets, and deadlines to submit, as determined by 21 State annually. CONTRACTOR(S) shall remit a hard copy of cost report to County of Fresno, Attention: 22 Cost Report Team, PO BOX 45003, Fresno CA 93718. CONTRACTOR(S) shall remit the electronic 23 copy or any inquiries to DBHcostreportteam@FresnoCountyCA.gov. 24 All Cost Reports must be prepared in accordance with General Accepted Accounting 25 Principles (GAAP) and Welfare and Institutions Code§§ 5651 (a)(4), 5664(a), 5705(b)(3) and 5718(c). 26 Unallowable costs such as lobby or political donations must be deducted on the cost report and invoice 27 reimbursement. 28 If the CONTRACTOR does not submit the cost report by the deadline, including any -18- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 extension period granted by the COUNTY, the COUNTY may withhold payments of pending invoicing 2 under compensation until the cost report has been submitted and clears COUNTY desk audit for 3 completeness. 4 D. Settlements with State Department of Health Care Services (DHCS) - During the term 5 of this Agreement and thereafter, COUNTY and CONTRACTOR agree to settle dollar amounts disallowed 6 or settled in accordance with DHCS audit settlement findings related to the reimbursement provided under 7 this Agreement. CONTRACTOR will participate in the several phases of settlements between 8 COUNTY/CONTRACTOR and DHCS. The phases of initial cost reporting for settlement according to State 9 reconciliation of records for paid Medi-Cal services and audit settlement are: State DHCS audit 1) initial 10 cost reporting - after an internal review by COUNTY, the COUNTY files the cost report with State DHCS on 11 behalf of the CONTRACTOR's legal entity for the fiscal year; 2) Settlement-State reconciliation of records 12 for paid Medi-Cal services, approximately 18 to 36 months following the State close of the fiscal year, 13 DHCS will send notice for any settlement under this provision to the COUNTY; 3) Audit Settlement-State 14 DHCS audit. After final reconciliation and settlement DHCS may conduct a review of medical records, cost 15 report along with support documents submitted to COUNTY in initial submission to determine accuracy and 16 may disallow costs and/or units of services. COUNTY may choose to appeal and therefore reserves the 17 right to defer payback settlement with CONTRACTOR until resolution of the appeal. DHCS Audits will 18 follow Federal Medicaid procedures for managing overpayments. If at the end of the Audit Settlement, the 19 COUNTY determines that it overpaid the CONTRACTOR, it will require the CONTRACTOR to repay the 20 Medi-Cal related overpayment back to the COUNTY. 21 Funds owed to COUNTY will be due within forty-five (45) days of notification by the 22 COUNTY, or COUNTY shall withhold future payments until all excess funds have been recouped by means 23 of an offset against any payments then or thereafter owing to COUNTY under this or any other Agreement 24 between the COUNTY and CONTRACTOR. 25 14. MONITORING 26 CONTRACTOR agrees to extend to COUNTY's staff, COUNTY's DBH Director and the 27 State DHCS or their designees, the right to review and monitor records, services or procedures, at any 28 time, in regard to clients, as well as the overall operation of CONTRACTOR's performance, in order to -19- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 ensure compliance with the terms and conditions of this Agreement. 2 15. REFERENCES TO LAWS AND RULES 3 In the event any law, regulation, or policy referred to in this Agreement is amended during 4 the term thereof, the parties hereto agree to comply with the amended provision as of the effective date of 5 such amendment. 6 16. COMPLIANCE WITH STATE REQUIREMENTS 7 CONTRACTOR recognizes that COUNTY operates its mental health programs under an 8 agreement with the State DHCS, and that under said agreement the State imposes certain requirements on 9 COUNTY and its subcontractors. CONTRACTOR shall adhere to all State requirements, including those 10 identified in Exhibit H, "State Mental Health Requirements", attached hereto and by this reference 11 incorporated herein and made part of this Agreement. CONTRACTOR shall also file an incident report for 12 all incidents involving clients, following the COUNTY's DBH's "Incident Reporting and Intensive Analysis" 13 policy and procedure guide and using the "Incident Report"Worksheet identified in Exhibit I, "Fresno 14 County Mental Health Plan Incident Reporting", attached hereto and by this reference incorporated herein 15 and made part of this Agreement, or a protocol and worksheet presented by CONTRACTOR that is 16 accepted by COUNTY's DBH Director, or his or her designee. 17 17. COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS 18 CONTRACTOR shall be required to maintain organizational provider certification by 19 Fresno County. CONTRACTOR must meet Medi-Cal organization provider standards as listed in Exhibit 20 B, "Medi-Cal Organizational Provider Standards", attached hereto and by this reference incorporated 21 herein and made part of this Agreement. It is acknowledged that all references to Organizational 22 Provider and/or Provider in Exhibit B shall refer to CONTRACTOR. In addition, CONTRACTOR shall 23 inform every client of their rights under the COUNTY's Mental Health Plan Grievances and Appeals 24 Process, as described in Exhibit J, "Fresno County Mental Health Plan - Grievances", attached hereto 25 and by this reference incorporated herein and made part of this Agreement. 26 18. CONFIDENTIALITY 27 All services performed by CONTRACTOR under this Agreement shall be in strict 28 conformance with all applicable Federal, State of California and/or local laws and regulations relating to -20- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 confidentiality. 2 19. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT 3 COUNTY and CONTRACTOR each consider and represent themselves as covered entities 4 as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 5 (HIPAA) and agree to use and disclose Protected Health Information (PHI) as required by law. 6 COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is only 7 for treatment, payment, and health care operations. 8 COUNTY and CONTRACTOR intend to protect the privacy and provide for the security of 9 PHI pursuant to the Agreement in compliance with HIPAA, the Health Information Technology for Economic 10 and Clinical Health Act, Public Law 111-005 (HITECH), and regulations promulgated thereunder by the 11 U.S. Department of Health and Human Services (HIPAA Regulations) and other applicable laws. 12 As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require 13 CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of PHI, as 14 set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504€ of the Code of 15 Federal Regulations. 16 20. DATA SECURITY 17 For the purpose of preventing the potential loss, misappropriation or inadvertent access, 18 viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse of 19 COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that enter into a 20 contractual relationship with the COUNTY for the purpose of providing services under this Agreement must 21 employ adequate data security measures to protect the confidential information provided to 22 CONTRACTOR by the COUNTY, including but not limited to the following: 23 A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices- CONTRACTOR 24 may not connect to COUNTY networks via personally-owned mobile, wireless or handheld devices, unless 25 the following conditions are met: 26 1) CONTRACTOR has received authorization by COUNTY for telecommuting 27 purposes; 28 2) Current virus protection software is in place; -21- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 3) Mobile device has the remote wipe feature enabled; and 2 4) A secure connection is used. 3 B. CONTRACTOR-Owned Computers or Computer Peripherals - CONTRACTOR may 4 not bring CONTRACTOR-owned computers or computer peripherals into the COUNTY for use without prior 5 authorization from the COUNTY's Chief Information Officer, and/or his or her designee(s), including but not 6 limited to mobile storage devices. If data is approved to be transferred, data must be stored on a secure 7 server approved by the COUNTY and transferred by means of a Virtual Private Network (VPN) connection, 8 or another type of secure connection. Said data must be encrypted. 9 C. COUNTY-Owned Computer Equipment - CONTRACTOR may not use COUNTY 10 computers or computer peripherals on non-COUNTY premises without prior authorization from the 11 COUNTY's Chief Information Officer, and/or his or her designee(s). 12 D. CONTRACTOR may not store COUNTY's private, confidential or sensitive data 13 on any hard-disk drive, portable storage device, or remote storage installation unless encrypted. 14 E. CONTRACTOR shall be responsible to employ strict controls to ensure the integrity 15 and security of COUNTY's confidential information and to prevent unauthorized access, viewing, use or 16 disclosure of data maintained in computer files, program documentation, data processing systems, data 17 files and data processing equipment which stores or processes COUNTY data internally and externally. 18 F. Confidential client information transmitted to one party by the other by means of 19 electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of 128 BIT 20 or higher. Additionally, a password or pass phrase must be utilized. 21 G. CONTRACTOR is responsible to immediately notify COUNTY of any violations, 22 breaches or potential breaches of security related to COUNTY's confidential information, data maintained in 23 computer files, program documentation, data processing systems, data files and data processing 24 equipment which stores or processes COUNTY data internally or externally. 25 H. COUNTY shall provide oversight to CONTRACTOR's response to all incidents 26 arising from a possible breach of security related to COUNTY's confidential client information provided to 27 CONTRACTOR. CONTRACTOR will be responsible to issue any notification to affected individuals as 28 required by law or as deemed necessary by COUNTY in its sole discretion. CONTRACTOR will be -22- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 responsible for all costs incurred as a result of providing the required notification. 2 21. PROPERTY OF COUNTY 3 A. COUNTY and CONTRACTOR recognize that fixed assets are tangible and intangible 4 property obtained or controlled under COUNTY's Mental Health Plan for use in 5 operational capacity and will benefit COUNTY for a period more than one year. 6 Depreciation of the qualified items will be on a straight-line basis. 7 For COUNTY purposes, fixed assets must fulfill three qualifications: 8 1. Asset must have life span of over one year. 9 2. The asset is not a repair part. 10 3. The asset must be valued at or greater than the capitalization thresholds 11 for the asset type: 12 Asset type Threshold 13 • land $0 • buildings and improvements $100,000 14 infrastructure $100,000 15 • be tangible $5,000 o equipment 16 o vehicles • or intangible asset $100,000 17 o Internally generated software 18 o Purchased software o Easements 19 o Patents • and capital lease $5,000 20 21 Qualified fixed asset equipment is to be reported and approved by COUNTY. If it is 22 approved and identified as an asset it will be tagged with a COUNTY program number. A Fixed Asset 23 Log, (Exhibit K)will be maintained by COUNTY's Asset Management System and inventoried annually 24 until the asset is fully depreciated. During the terms of this Agreement, CONTRACTOR's fixed assets 25 may be inventoried in comparison to COUNTY's DBH Asset Inventory System. 26 B. Certain purchases under Five Thousand and No/100 Dollars ($5,000.00) but more than One 27 Thousand and No/100 Dollars ($1,000.00) with over one (1) year life span, and are mobile and high 28 risk of theft or loss are sensitive assets. Such sensitive items are not limited to computers, copiers, -23- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 televisions, cameras and other sensitive items as determined by COUNTY's DBH Director or designee. 2 CONTRACTOR maintains a tracking system on the items and are not required to be capitalized or 3 depreciated. The items are subject to annual inventory for compliance. 4 C. Assets shall be retained by COUNTY, as COUNTY property, in the event this 5 Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate in 6 an annual inventory of all COUNTY fixed and inventoried assets. Upon termination of this Agreement, 7 CONTRACTOR shall be physically present when fixed and inventoried assets are returned to COUNTY 8 possession. CONTRACTOR is responsible for returning to COUNTY all COUNTY owned 9 undepreciated fixed and inventoried assets, or the monetary value of said assets if unable to produce 10 the assets at the expiration or termination of this Agreement. 11 CONTRACTOR further agrees to the following: 12 1. To maintain all items of equipment in good working order and condition, 13 normal wear and tear excepted; 14 2. To label all items of equipment with COUNTY assigned program number, t 15 perform periodic inventories as required by COUNTY and to maintain an inventory list showing where 16 and how the equipment is being used in accordance with procedures developed by COUNTY. All such 17 lists shall be submitted to COUNTY within ten (10) days of any request therefore; 18 3. To report in writing to COUNTY immediately after discovery, the loss or the 19 of any items of equipment. For stolen items, the local law enforcement agency must be contacted and a 20 copy of the police report submitted to COUNTY 21 D. The purchase of any equipment by CONTRACTOR with funds provided hereunder 22 shall require the prior written approval of COUNTY's DBH Director or designee, shall fulfill the provisions 23 of this Agreement as appropriate, and must be directly related to CONTRACTOR's services or activity 24 under the terms of this Agreement. COUNTY's DBH may refuse reimbursement for any costs resulting 25 from equipment purchased, which are incurred by CONTRACTOR, if prior written approval has not been 26 obtained from COUNTY's DBH Director or designee. 27 E. CONTRACTOR must obtain prior written approval form COUNTY's DBH whenever 28 there is any modification or change in the use of any property acquired or improved, in whole or in part, -24- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 using funds under this Agreement. If any real or personal property acquired or improved with said funds 2 identified herein is sold and/or is utilized by CONTRACTOR for a use which does not qualify under this 3 program, CONTRACTOR shall reimburse COUNTY in an amount equal to the current fair market value 4 of the property, less any portion thereof attributable to expenditures of non-program funds. These 5 requirements shall continue in effect for the life of the property. In the event the program is closed out, 6 the requirements for this Section shall remain in effect for activities or property funded with said funds, 7 unless action is taken by the State government to relieve COUNTY of these obligations. 8 22. NON-DISCRIMINATION 9 During the performance of this Agreement CONTRACTOR shall not unlawfully discriminate 10 against any employee or applicant for employment, or recipient of services, because of race, religion, 11 color, national origin, ancestry, physical disability, medical condition, marital status, age or gender, 12 pursuant to all applicable State of California and Federal statutes and regulations. 13 23. CULTURAL COMPETENCY 14 As related to Cultural and Linguistic Competence: 15 A. CONTRACTOR shall not discriminate against beneficiaries based on race, 16 color, national origin, sex, disability, or religion. CONTRACTOR shall ensure that a limited and/or no 17 English proficient beneficiary is entitled to equal access and participation in federally funded programs 18 through the provision of comprehensive and quality bilingual services pursuant to Title 6 of the Civil 19 Rights Act of 1964 (42 U.S.C. Section 2000d, and 45 C.F.R. Part 80) and Executive Order 12250 of 20 1979. 21 B. CONTRACTOR shall comply with requirements of policies and procedures 22 for ensuring access and appropriate use of trained interpreters and material translation services for all 23 limited and/or no English proficient beneficiaries, including, but not limited to, assessing the cultural and 24 linguistic needs of the beneficiaries, training of staff on the policies and procedures, and monitoring its 25 language assistance program. CONTRACTOR's policies and procedures shall ensure compliance of any 26 subcontracted providers with these requirements. 27 C. CONTRACTOR shall notify its beneficiaries that oral interpretation is 28 available for any language and written translation is available in prevalent languages and that auxiliary aids -25- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 and services are available upon request, at no cost and in a timely manner for limited and/or no English 2 proficient beneficiaries and/or beneficiaries with disabilities. CONTRACTOR shall avoid relying on an adult 3 or minor child accompanying the beneficiary to interpret or facilitate communication; however, if the 4 beneficiary refuses language assistance services, the CONTRACTOR must document the offer, refusal 5 and justification in the beneficiary's file. 6 D. CONTRACTOR shall ensure that employees, agents, subcontractors, and/or 7 partners who interpret or translate for a beneficiary or who directly communicate with a beneficiary in a 8 language other than English (1) have completed annual training provided by COUNTY at no cost to 9 CONTRACTOR; (2) have demonstrated proficiency in the beneficiary's language; (3) can effectively 10 communicate any specialized terms and concepts specific to CONTRACTOR's services; and (4) adheres 11 to generally accepted interpreter ethic principles. As requested by COUNTY, CONTRACTOR shall identify 12 all who interpret for or provide direct communication to any program beneficiary in a language other than 13 English, and identify when the CONTRACTOR last monitored the interpreter for language competence. 14 E. CONTRACTOR shall submit to COUNTY for approval, within ninety (90) 15 days from date of contract execution, CONTRACTOR's plan to address all fifteen (15) National Standards 16 for Culturally and Linguistically Appropriate Service (CLAS), as published by the Office of Minority Health 17 and as set forth in Exhibit L "National Standards on Culturally and Linguistically Appropriate Services," and 18 any future amendments to these standards, attached hereto and incorporated herein by reference and 19 made part of this Agreement. As the CLAS standards are updated, CONTRACTOR's plan must be 20 updated accordingly. As requested by COUNTY, CONTRACTOR shall be responsible for conducting an 21 annual CLAS self-assessment and providing the results of the self-assessment to the COUNTY. The 22 annual CLAS self-assessment instruments shall be reviewed by the COUNTY and revised as necessary to 23 meet the approval of the COUNTY. 24 F. Cultural competency training for CONTRACTOR staff should be 25 substantively integrated into health professions education and training at all levels, both academically and 26 functionally, including core curriculum, professional licensure, and continuing professional development 27 programs. As requested by COUNTY, CONTRACTOR shall report on the completion of cultural 28 competency trainings to ensure direct service providers are completing a minimum of one (1) cultural -26- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 competency training annually. 2 G. CONTRACTOR shall create and sustain a forum that includes staff at all 3 agency levels to discuss cultural competence. COUNTY encourages a representative from 4 CONTRACTOR's forum to attend COUNTY's Diversity, Equity and Inclusion (DEI) Committee, formerly 5 known as Cultural Humility Committee. 6 24. AMERICANS WITH DISABILITIES ACT 7 CONTRACTOR agrees to ensure that deliverables developed and produced, pursuant to 8 this Agreement shall comply with the accessibility requirements of Section 508 of the Rehabilitation Act 9 and the Americans with Disabilities Act of 1973 as amended (29 U.S.C. § 794 (d)), and regulations 10 implementing that Act as set forth in Part 1194 of Title 36 of the Code of Federal Regulations. In 1998, 11 Congress amended the Rehabilitation Act of 1973 to require Federal agencies to make their electronic and 12 information technology (EIT) accessible to people with disabilities. California Government Code section 13 11135 codifies section 508 of the Act requiring accessibility of electronic and information technology. 14 25. TAX EQUITY AND FISCAL RESPONSIBILITY ACT 15 To the extent necessary to prevent disallowance of reimbursement under section 16 1861(v)(1)(I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four 17 (4) years after the furnishing of services under this Agreement, CONTRACTOR shall make available, 18 upon written request of the Secretary of the United States Department of Health and Human Services, 19 or upon request of the Comptroller General of the United States General Accounting Office, or any of 20 their duly authorized representatives, a copy of this Agreement and such books, documents, and 21 records as are necessary to certify the nature and extent of the costs of these services provided by 22 CONTRACTOR under this Agreement. CONTRACTOR further agrees that in the event 23 CONTRACTOR carries out any of its duties under this Agreement through a subcontract, with a value 24 or cost of Ten Thousand and No/100 Dollars ($10,000.00) or more over a twelve (12) month period, 25 with a related organization, such Agreement shall contain a clause to the effect that until the expiration 26 of four (4) years after the furnishing of such services pursuant to such subcontract, the related 27 organizations shall make available, upon written request of the Secretary of the United States 28 Department of Health and Human Services, or upon request of the Comptroller General of the United -27- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 States General Accounting Office, or any of their duly authorized representatives, a copy of such 2 subcontract and such books, documents, and records of such organization as are necessary to verify 3 the nature and extent of such costs. 4 26. SINGLE AUDIT CLAUSE 5 If any CONTRACTOR expends Seven Hundred Fifty-Thousand Dollars ($750,000.00) or 6 more in Federal and Federal flow-through monies, CONTRACTOR agrees to conduct an annual audit in 7 accordance with the requirements of the Single Audit Standards as set forth in Office of Management and 8 Budget (OMB) Circular A-133. CONTRACTOR shall submit said audit and management letter to 9 COUNTY. The audit must include a statement of findings or a statement that there were no findings. If 10 there were negative findings, CONTRACTOR shall include a corrective action plan signed by an 11 authorized individual. CONTRACTOR agrees to take action to correct any material non-compliance or 12 weakness found as a result of such audit. Such audits shall be delivered to COUNTY's DBH Business 13 Office for review within nine (9) months of the end of any fiscal year in which funds were expended and/or 14 received for the program. Failure to perform the requisite audit functions as required by this Agreement 15 may result in COUNTY performing the necessary audit tasks, or at COUNTY's option, contracting with a 16 public accountant to perform said audit, or may result in the inability of COUNTY to enter into future 17 agreements with CONTRACTOR. All audit costs related to this Agreement are the sole responsibility of 18 CONTRACTOR. 19 A. A single audit report is not applicable if CONTRACTOR's Federal contracts do not 20 exceed the Seven Hundred Fifty Thousand Dollars ($750,000.00) requirement or CONTRACTOR's only 21 funding is through Medi-Cal. If a single audit is not applicable, a program audit must be performed and a 22 program audit report with management letter shall be submitted by CONTRACTOR to COUNTY as a 23 minimum requirement to attest to CONTRACTOR's solvency. Said audit reports shall be delivered to 24 COUNTY's DBH Business Office for review no later than nine (9) months after the close of the fiscal year 25 in which the funds supplied through this Agreement are expended. Failure to comply with this Act may 26 result in COUNTY performing the necessary audit tasks or contracting with a qualified accountant to 27 perform said audit. All audit costs related to this Agreement are the sole responsibility of CONTRACTOR 28 who agrees to take corrective action to eliminate any material noncompliance or weakness found as a -28- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 result of such audit. Audit work performed by COUNTY under this Section shall be billed to the 2 CONTRACTOR at COUNTY's cost, as determined by COUNTY's Auditor-Controller/Treasurer-Tax 3 Collector. 4 B. CONTRACTOR shall make available all records and accounts for inspection by 5 COUNTY, the State of California, if applicable, the Comptroller General of the United States, the 6 Federal Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a 7 period of at least three (3) years following final payment under this Agreement or the closure of all 8 other pending matters, whichever is later. 9 27. COMPLIANCE 10 CONTRACTOR agrees to comply with COUNTY's Contractor Code of Conduct and 11 Ethics and the COUNTY's Compliance Program in accordance with Exhibit F. Within thirty (30) days of 12 entering into this Agreement with the COUNTY, CONTRACTOR shall have all of CONTRACTOR's 13 employees, agents and subcontractors providing services under this Agreement certify in writing, that 14 he or she has received, read, understood, and shall abide by the Contractor Code of Conduct and 15 Ethics. CONTRACTOR shall ensure that within thirty (30) days of hire, all new employees, agents and 16 subcontractors providing services under this Agreement shall certify in writing that he or she has 17 received, read, understood, and shall abide by the Contractor Code of Conduct and Ethics. 18 CONTRACTOR understand that the promotion of and adherence to the code of Conduct and Ethics is 19 an element in evaluating the performance of CONTRACTOR and its employees, agents and 20 subcontractors. 21 Within thirty (30) days of entering into this Agreement, and annually thereafter, all 22 employees, agent and subcontractors providing services under this Agreement shall complete general 23 compliance training and appropriate employees, agents and subcontractors shall complete 24 documentation and billing or billing/reimbursement training. All new employees, agents and 25 subcontractors shall attend the appropriate training within thirty (30) days of hire. Each individual 26 required to attend training shall certify in writing that he or she has received the required training. The 27 certification shall specify the type of training received and the date received. The certification shall be 28 provided to the COUNTY's Compliance Officer at 3133 N. Millbrook, Fresno, California 93703. -29- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty imposed upon 2 COUNTY by the Federal Government as a result of CONTRACTOR's violation of the terms of this 3 Agreement. 4 28. ASSURANCES 5 In entering into this Agreement, CONTRATOR certifies that it nor any of its officers are 6 not currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal Health 7 Care Programs: that it or any of its officers have not been convicted of a criminal offense related to the 8 provision of health care items or services; nor have they been reinstated to participate in the Federal 9 Health Care Programs after a period of exclusion, suspension, debarment, or ineligibility. If COUNTY 10 learns, subsequent to entering into this Agreement, that CONTRACTOR is ineligible on these grounds, 11 COUNTY will remove CONTRACTOR from responsibility for, or involvement with, COUNTY's business 12 operations related to the Federal Health Care Programs and shall remove such CONTRACTOR from 13 any position in which CONTRACTOR's compensation, or the items or services rendered, ordered or 14 prescribed by CONTRACTOR may be paid in whole or part, directly or indirectly, by Federal Health 15 Care Programs or otherwise with Federal Funds at least until such time as CONTRACTOR is 16 reinstated into participation in the Federal Health Care Programs. 17 A. If COUNTY has notice that CONTRACTOR has been charged with a criminal 18 offense related to any Federal Health Care Programs, or proposed for exclusion during the term on any 19 contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the accuracy of any 20 claims submitted to any Federal Health Care Program. At its discretion given such circumstances, 21 COUNTY may request that CONTRACTOR cease providing services until resolution of the charges or 22 the proposed exclusion. 23 B. CONTRACTOR agrees that all potential new employees of CONTRACTOR or 24 subcontractors of CONTRACTOR who, in each case, are expected to perform professional services 25 under this Agreement, will be queried as to whether (1) they are now or ever have been excluded, 26 suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) 27 they have been convicted of criminal offense related to the provision of health care items or services; 28 and or (3) they have been reinstated to participate in the Federal Health Care Programs after a period -30- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 of exclusion, suspension, debarment, or ineligibility. 2 1. In the event the potential employee or subcontractor informs 3 CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible, or has been 4 convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR 5 hires or engages such potential employee or subcontractor, the CONTRACTOR will ensure that said 6 employee or subcontractor does no work, either directly or indirectly relating to services provided to 7 COUNTY. 8 2. Notwithstanding the above, COUNTY at its discretion may terminate this 9 Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance (as 10 defined by COUNTY) that no excluded, suspended or otherwise ineligible employee of CONTRACTOR 11 will perform work, either directly or indirectly, relating to services provided to 12 COUNTY. Such demand for adequate assurance shall be effective upon a time frame to be 13 determined by COUNTY to protect the interests of COUNTY clients. 14 C. CONTRACTOR shall verify (by asking the applicable employees and 15 subcontractors) that all current employees and existing subcontractors who, in each case, are 16 expected to perform professional services under this Agreement: (1) are not currently excluded, 17 suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) 18 have not been convicted of a criminal offense related to the provision of health care items or services; 19 and (3) have not been reinstated to participate in the Federal Health Care Programs after a period of 20 exclusion, suspension, debarment, or ineligibility. In the event any existing employee or subcontractor 21 informs a CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible to 22 participate in the Federal Health Care Programs, or has been convicted of a criminal offense relating to 23 the provision of heath care services, CONTRACTOR will ensure that said employee or subcontractor 24 does no work, either direct or indirect, relating to services provided to COUNTY. 25 1. CONTRACTOR agrees to notify COUNTY immediately during the term of 26 this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each 27 case, is providing professional services under Section One (1) of this Agreement is excluded, 28 suspended, debarred or otherwise ineligible to participate in the Federal Health Care Programs, or is -31- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 convicted of a criminal offense relating to the provision of health care services. 2 2. Notwithstanding the above, COUNTY at its discretion may terminate this 3 Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance (as 4 defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor of 5 CONTRACTOR will perform work, either directly or indirectly, relating to services provided to COUNTY. 6 Such demand for adequate assurance shall be effective upon a time frame to be determined by 7 COUNTY to protect the interests of COUNTY clients. 8 D. CONTRACTOR agrees to cooperate fully with any reasonable requests for 9 information from COUNTY which may be necessary to complete any internal or external audits relating 10 to CONTRACTOR's compliance with the provisions of this Section. 11 E. CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty 12 imposed upon COUNTY by the Federal Government as a result of CONTRACTOR's violation of 13 CONTRACTOR's obligations as described in this Section. 14 29. PUBLICITY PROHIBITION 15 None of the funds, materials, property or services provided directly or indirectly under this 16 Agreement shall be used for CONTRACTOR's advertising, fundraising, or publicity (i.e., purchasing of 17 tickets/tables, silent auction donations, etc.) for the purpose of self-promotion. Notwithstanding the 18 above, publicity of the services described in Section One (1) of this Agreement shall be allowed as 19 necessary to raise public awareness about the availability of such specific services when approved in 20 advance by COUNTY's DBH Director or designee and at a cost to be provided in Section Four (4) of 21 this Agreement for such items as written/printed materials, the use of media (i.e., radio, television, 22 newspapers) and any other related expense(s). 23 30. COMPLAINTS 24 CONTRACTOR shall log complaints and the disposition of all complaints from a client or 25 a client's family. CONTRACTOR shall provide a copy of the detailed complaint log entries concerning 26 COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (10th) day of the following 27 month, in a format that is mutually agreed upon. Besides the detailed complaint log, CONTRACTOR 28 shall provide details and attach documentation of each complaint with the log. CONTRACTOR shall -32- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 post signs informing clients of their right to file a complaint or grievance. CONTRACTOR shall notify 2 COUNTY of all incidents reportable to state licensing bodies that affect COUNTY clients within twenty- 3 four (24) hours of receipt of a complaint. 4 Within ten (10) days after each incident or complaint affecting COUNTY- 5 sponsored 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 J. CONTRACTOR shall file an incident report for all incidents involving 9 clients, following the Protocol and using the Worksheet identified in Exhibit I. 10 31. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION 11 This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or 12 managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101, 455.104, 13 and 455.106(a)(1),(2). 14 In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2), 15 the following information must be disclosed by CONTRACTOR by completing Exhibit M, "Disclosure of 16 Ownership and Control Interest Statement", attached hereto and by this reference incorporated herein 17 and made part of this Agreement. CONTRACTOR shall submit this form to the Department of 18 Behavioral Health within thirty (30) days of the effective date of this Agreement. Additionally, 19 CONTRACTOR shall report any changes to this information within thirty-five (35) days of occurrence by 20 completing Exhibit M. Submissions shall be scanned PDF copies and are to be sent via email to 21 DBHContractedServicesDivision(a)fresnocountyca.us attention: Contracts Administration. 22 32. DISCLOSURE—CRIMINAL HISTORY AND CIVIL ACTIONS 23 CONTRACTOR is required to disclose if any of the following conditions apply to them, 24 their owners, officers, corporate managers and partners (hereinafter collectively referred to as 25 "CONTRACTOR"): 26 A. Within the three-year period preceding the Agreement award, they have been 27 convicted of, or had a civil judgment rendered against them for: 28 1. Fraud or a criminal offense in connection with obtaining, attempting to -33- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 obtain, or performing a public (federal, state, or local) transaction or contract under a public 2 transaction; 3 2. Violation of a federal or state antitrust statute; 4 3. Embezzlement, theft, forgery, bribery, falsification, or destruction of 5 records; or 6 4. False statements or receipt of stolen property. 7 B. Within a three-year period preceding their Agreement award, they have had a 8 public transaction (federal, state, or local) terminated for cause or default. 9 Disclosure of the above information will not automatically eliminate CONTRACTOR 10 from further business consideration. The information will be considered as part of the determination 11 of whether to continue and/or renew the Agreement and any additional information or explanation 12 that a CONTRACTOR elects to submit with the disclosed information will be considered. If it is later 13 determined that the CONTRACTOR failed to disclose required 14 information, any Agreement awarded to such CONTRACTOR may be immediately voided and 15 terminated for material failure to comply with the terms and conditions of the award. 16 CONTRACTOR must sign an appropriate "Certification Regarding Debarment, 17 Suspension, and Other Responsibility Matters-Primary Covered Transactions", Exhibit N, attached 18 hereto and by this reference incorporated herein. Additionally, CONTRACTOR must immediately 19 advise COUNTY in writing if, during the term of this Agreement: (1) CONTRACTOR becomes 20 suspended, debarred, excluded or ineligible for participation in federal or state funded programs or 21 from receiving federal funds as listed in the excluded parties list system (http://www.sam.gov); or (2) 22 any of the above listed conditions become applicable to CONTRACTOR. CONTRACTOR shall 23 indemnify, defend and hold COUNTY harmless for any loss or damage resulting from a conviction, 24 debarment, exclusion, ineligibility or other matter listed in the signed "Certification Regarding 25 Debarment, Suspension, and Other Responsibility Matters." 26 33. AUDITS AND INSPECTIONS: 27 The CONTRACTOR shall at any time during business hours, and as often as the COUNTY 28 may deem necessary, make available to the COUNTY for examination all of its records and data with -34- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 respect to the matters covered by this Agreement. The CONTRACTOR shall, upon request by the 2 COUNTY, permit the COUNTY to audit and inspect all of such records and data necessary to ensure 3 CONTRACTOR'S compliance with the terms of this Agreement. 4 If this Agreement exceeds ten thousand dollars ($10,000.00), CONTRACTOR shall be subject to 5 the examination and audit of the California State Auditor for a period of three (3)years after final payment 6 under contract (Government Code Section 8546.7). 7 34. NOTICES 8 The persons and their addresses having authority to give and receive notices under this 9 Agreement include the following: 10 COUNTY CONTRACTOR Director, Fresno County Chief Executive Officer 11 Department of Behavioral Health Kings View 1925 E. Dakota Ave. 7170 N. Financial Dr., Suite 110 12 Fresno, CA 93726 Fresno, CA 93720 13 All notices between the COUNTY and CONTRACTOR provided for or permitted under this 14 Agreement must be in writing and delivered either by personal service, by first-class United States mail, by 15 an overnight commercial courier service, or by telephonic facsimile transmission. A notice delivered by 16 personal service is effective upon service to the recipient. A notice delivered by first-class United States 17 mail is effective three COUNTY business days after deposit in the United States mail, postage prepaid, 18 addressed to the recipient. A notice delivered by an overnight commercial courier service is effective one 19 COUNTY business day after deposit with the overnight commercial courier service, delivery fees prepaid, 20 with delivery instructions given for next day delivery, addressed to the recipient. A notice delivered by 21 telephonic facsimile is effective when transmission to the recipient is completed (but, if such transmission is 22 completed outside of COUNTY business hours, then such delivery shall be deemed to be effective at the 23 next beginning of a COUNTY business day), provided that the sender maintains a machine record of the 24 completed transmission. For all claims arising out of or related to this Agreement, nothing in this section 25 establishes, waives, or modifies any claims presentation requirements or procedures provided by law, 26 including but not limited to the Government Claims Act(Division 3.6 of Title 1 of the Government Code, 27 beginning with section 810). 28 35. SEVERABILITY -35- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 If any non-material term, provision, covenant, or condition of this Agreement is held by a 2 court of competent jurisdiction to be invalid, void or unenforceable, the reminder of the provisions shall 3 remain in full force and effective, and shall in no way be affected, impaired or invalidated. 4 36. GOVERNING LAW 5 Venue for any action arising out of or related to this Agreement shall only be in Fresno 6 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 37. DISCLOSURE OF SELF-DEALING TRANSACTIONS 10 This provision is only applicable if the CONTRACTOR is operating as a corporation (a for-profit 11 or non-profit corporation) or if during the term of the agreement, the CONTRACTOR changes its status 12 to operate as a corporation. 13 Members of the CONTRACTOR's Board of Directors shall disclose any self-dealing transactions 14 that they are a party to while CONTRACTOR is providing goods or performing services under this 15 agreement. A self-dealing transaction shall mean a transaction to which the CONTRACTOR is a party 16 and in which one or more of its directors has a material financial interest. Members of the Board of 17 Directors shall disclose any self-dealing transactions that they are a party to by completing and signing a 18 Self-Dealing Transaction Disclosure Form, attached hereto as Exhibit O and incorporated herein by 19 reference, and submitting it to the COUNTY prior to commencing with the self-dealing transaction or 20 immediately thereafter. 21 38. ELECTRONIC SIGNATURE 22 The parties agree that this Agreement may be executed by electronic signature as provided 23 in this section. An "electronic signature" means any symbol or process intended by an individual signing this 24 Agreement to represent their signature, including but not limited to (1)a digital signature; (2) a faxed 25 version of an original handwritten signature; or(3) an electronically scanned and transmitted (for example 26 by PDF document) of a handwritten signature. Each electronic signature affixed or attached to this 27 Agreement (1) is deemed equivalent to a valid original handwritten signature of the person signing this 28 Agreement for all purposes, including but not limited to evidentiary proof in any administrative or judicial -36- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 proceeding, and (2) has the same force and effect as the valid original handwritten signature of that person. 2 The provisions of this section satisfy the requirements of Civil Code section 1633.5, subdivision (b), in the 3 Uniform Electronic Transaction Act (Civil Code, Division 3, Part 2, Title 2.5, beginning with section 1633.1). 4 Each party using a digital signature represents that it has undertaken and satisfied the requirements of 5 Government Code section 16.5, subdivision (a), paragraphs (1)through (5), and agrees that each other 6 party may rely upon that representation. This Agreement is not conditioned upon the parties conducting the 7 transactions under it by electronic means and either party may sign this Agreement with an original 8 handwritten signature. 9 39. ENTIRE AGREEMENT 10 This Agreement constitutes the entire agreement between the CONTRACTOR and 11 COUNTY with respect to the subject matter hereof and supersedes all previous Agreement negotiations, 12 proposals, commitments, writings, advertisements, publications, and understanding of any nature 13 whatsoever unless expressly included in this Agreement. 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 -37- ii DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year 2 first hereinabove written. 3 CONTRACTOR COUNTY OF FRESNO 4 rA.,�Mjt4 .� 5 ( u honze Signature) Brian Pacheco, Chairman of the Board of Supervisors of the County of Fresno 6 Amanda Nugent Divine CEO 7 Print Name &Title 8 7170 N. Financial Drive, Suite 110 9 Fresno, CA 93720 Mailing Address ATTEST: 10 Bernice E. Seidel 11 Clerk of the Board of Supervisors County of Fresno, State of California 12 13 14 By: _ 15 Deputy 16 FOR ACCOUNTING USE ONLY: Fund: 0001 17 Subclass: 10000 ORG: 56304763 18 Account: 7295 19 Program Budget CCMU Grant Budget Total 20 FY 2018-19: $1,379,694 FY 2018-19: $0 $1,379,694 FY 2019-20: $2,359,609 FY 2019-20: $0 $2,359,609 21 FY 2020-21: $2,425,826 FY 2020-21: $0 $2,425,826 FY 2021-22: $2,493,897 FY 2021-22: $0 $2,493,897 22 FY 2022-23: $2,564,280 FY 2022-23: $151,895 $2,716,175 Total: $11,223,306 Total: $151,895 $11,375,201 23 24 25 26 27 28 -38- DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit A Page 1 of 7 Fresno Metropolitan (Metro) Crisis Intervention Team (CIT) Services SCOPE OF WORK ORGANIZATION/CONTRACTOR: Kings View ADDRESS: 7170 North Financial Drive, Suite 110, Fresno, California 93720 SITE ADDRESS: TBD SERVICES: Mental Health, Crisis Intervention Services CONTRACT PERIOD: Effective upon execution — June 30, 2021 With two possible 12-month extensions CONTRACT AMOUNT: FY 2018-19: $1,379,694 FY 2019-20: $2,359,609 FY 2020-21: $2,425,826 FY 2021-22: $2,493,897 FY 2022-23: $2,564,280 CONTRACTOR shall provide the following mental health crisis intervention services to individuals within the Fresno Metropolitan (Metro) area. Crisis intervention services shall be provided in collaboration with Law Enforcement Agencies (which includes City of Fresno Police Department, City of Clovis Police Department, and the COUNTY's Sheriff's Office) and other first responders. These services shall be provided 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. Crisis intervention services that are community based, incorporate stigma reduction and prevention as a product of the placement of staff in first responder scenarios. I. Background The Crisis Intervention Team (CIT) Field Clinicians shall serve as active liaisons with law enforcement to provide training, outreach, and direct field response to clients actively engaged in a mental health crisis in the community, specifically in the Fresno Metro area. Evaluations for 5150's and recurrent calls from law enforcement are a primary focus. A pilot project began in September of 2017 with a small group of COUNTY DBH field clinicians co-located and providing co-response with the Fresno Police Department (PD). Through evaluation of that initial phase of the pilot, it was determined that the need for this type of crisis intervention team (CIT) is far greater. With this Agreement, COUNTY's DBH will be entering into Phase 2 of the Fresno CIT program, which will include services provided by the CONTRACTOR. This CIT program growth will allow for expansion to include COUNTY's Sheriff's Office (FSO) and the City of Clovis Police Department (PD). DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit A Page 2 of 7 II. Services Start Date This Agreement shall become effective upon execution. CONTRACTOR will be reimbursed for ramp-up expenditures during the initial ramp-up period, up to ninety (90) days from the effective date of this Agreement, such as hiring staff, procuring office equipment and/or office space, and establishing business/clinical operations. CONTRACTOR shall become an organizational provider, subject to the Medi-Cal site certification approval process by COUNTY DBH's Managed Care Division, which shall be completed by the first date of service delivery. Services shall begin no later than March 15, 2019, but may begin earlier upon mutual agreement between CONTRACTOR and COUNTY's DBH. III. Target Population The target population to be served by the Metro CIT shall be individuals within the Fresno Metro area currently experiencing an acute mental health crisis, including any behavioral health signs and symptoms, requiring immediate crisis intervention, de-escalation, and triage services. There is no stipulation regarding age or severity of mental illness. IV. Location of Services Services shall be provided to individuals throughout the greater Fresno Metro area and within the community, as opposed to services being performed at traditional mental health department offices or clinics. Crisis intervention services are intended to be provided in the field where client interaction with law enforcement and emergency services personnel (first responders) typically occurs and where crisis intervention services are most beneficial. V. Description of Services CONTRACTOR shall have the willingness and ability to provide Fresno CIT services throughout the Fresno Metro area. Crisis intervention services will be provided within the city limits of Fresno and Clovis, and within the area under Sheriff Jurisdiction (known as "County Islands"). The types of crisis intervention services provided should be consistent; however, the location and hours of operation should be flexible to the needs of each the jurisdictions and Law Enforcement Agencies identified. Mental health crisis intervention services may include, but are 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. CIT services shall be provided out in the field and in collaboration with assigned Law Enforcement Agencies as well as the first responders and the CONTRACTOR will be expected to coordinate and build relationships with community agencies, such as schools, hospitals, and churches. The CIT will be a unit consisting of field clinicians and law enforcement officers, providing a dual- response to crisis calls. This collaboration will allow the CIT to respond to calls in which there is a behavioral health need to provide compassionate, client/family centered crisis interventions to persons and support systems that are experiencing behavioral health signs and symptoms. The Metro CIT will assist in 911 calls from the public and will be dispatched jointly to the scene, which will allow law enforcement patrol officers to continue on to new incoming 911 calls. The Metro CIT will jointly provide the behavioral health interventions within a secure scene. The Metro CIT will be able to respond to and handle the initial crisis, but shall also provide post-crisis DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit A Page 3 of 7 contacts, referrals, and linkages to appropriate services. The Metro CIT program shall be a partnership between CONTRACTOR and COUNTY DBH. DBH staff shall oversee program expenditures, outcomes reporting, and contract monitoring. CIT services will be fully funded by Mental Health Services Act (MHSA) Prevention and Early Intervention (PEI), and Medi-Cal Federal Financial Participation (FFP), which also mandate specific reporting requirements of CONTRACTOR. As this Agreement will initiate Phase 2 of the Fresno CIT pilot program, the CONTRACTOR will be expected to demonstrate a capability to evolve the program along its intended course and re- direct, as needed, upon coordination with COUNTY DBH's Director, or designee, and input from each of the Law Enforcement Agencies. The CONTRACTOR shall agree to cooperate with COUNTY DBH and all Law Enforcement Agencies involved in discussing and evaluating the program and be open to testing/experimenting with appropriate and effective co-response design(s). Existing COUNTY DBH field clinicians teamed up with Fresno PD are currently experimenting with a "full co-response" model, which includes allowing clinicians to ride along to the crisis calls in the PD vehicles. If this model works effectively, DBH may decide to include said model with these contracted services. If this occurs, DBH will negotiate with CONTRACTOR to amend the existing contract terms. With regard to crisis intervention services, the CONTRACTOR shall demonstrate the capability to meet the following service provisions: 1. Crisis intervention services shall be provided in the field during client interaction with law enforcement and first responders. Given the nature of crisis intervention services, CONTRACTOR shall include all of the following: A. Crisis prevention and intervention services, including 5150 holds, as necessary. B. Determination if the client who is in need of crisis services, has other health coverage, no health coverage, or Medi-Cal. Ensure crisis intervention services are provided regardless of ability to pay. C. Provide post-crisis follow-up if applicable. D. Address and minimize recidivism with regards to use of local emergency services. E. Ensure the crisis response system is monitored and rapidly responsive to changing needs within the Fresno Metro area. 2. The Metro CIT Program is designed to be a co-response model and therefore staffing will be co-located with each participating Law Enforcement Agency. The CONTRACTOR shall collaborate with participating Law Enforcement Agencies with regard to site location selections. The COUNTY will work with the CONTRACTOR and the participating Law Enforcement Agencies to identify appropriate sites where Metro CIT staff and law enforcement officers shall be co-located in order to provide co-response for the purpose of providing rapid, effective, recovery/well-being oriented crisis services. Available co-location sites may vary by agency and may be modified during the term of this Agreement. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit A Page 4 of 7 3. CONTRACTOR shall provide data collection and reporting, including but not limited to. A. Staffing Report: Staffing report shall be submitted, by the 10th of each month, for the preceding month, to the DBH Contracted Services Program Technician and the assigned DBH Staff Analyst and must include each employee, FTE, and salary. B. Training and resource/community development hours shall be captured and reported by the 10th of the month, for the preceding reporting period, to the DBH Staff Analyst. This data will not be billed as revenue. C. The CONTRACTOR shall ensure billable specialty mental health services meet all County, State, Federal regulations including any utilization review, credentialing, site certifications, and other quality assurance standards. All pertinent and appropriate information shall be provided in a timely manner to COUNTY in order to bill Medi-Cal for services rendered. The CONTRACTOR should also ensure that private insurance and/or Medi-Care is properly billed prior to submitting Medi-Cal claims to the COUNTY. The necessary data can be provided by a variety of means, including but not limited to: 1) direct data entry into COUNTY's information system; 2) providing an electronic file compatible with COUNTY's information system; or 3) integration between COUNTY's information system and CONTRACTOR's information system(s). D. The CONTRACTOR shall maintain ongoing crisis tracking data per individual Law Enforcement Agency as requested by COUNTY's DBH and/or Law Enforcement. 4. The CONTRACTOR must also use any standardized tools, such as the "Columbia Suicide Severity Risk," as directed by COUNTY's DBH. 5. The CONTRACTOR must adhere to any and all applicable statutes as stated in MHSUDS Notice 18-011, "Federal Network Adequacy Standards for Mental Health Plans (MHPs) and Drug Medi-Cal Organized Delivery System (DMC-ODS) Pilot Counties." 6. CONTRACTOR may be asked, at the request of specific law enforcement agencies, to have clinical personnel participate in hostage negotiation training and make that personnel available to co-respond with the law enforcement agencies in matters which require that unique expertise. Each law enforcement agency will determine whether CIT clinicians will be utilized in this fashion. VI. Staffing 1. CONTRACTOR shall recruit and maintain the identified number of skilled, licensed, culturally competent and appropriately trained staff dedicated to the Fresno Metro CIT program throughout the term of this Agreement. 2. All Metro CIT clinicians shall be skilled at engaging persons in crisis in a stabilizing, therapeutic, recovery/well-being focused manner and be well versed in crisis de-escalation techniques. All CIT clinicians shall be 5150 trained and certified by COUNTY's Managed Care Division. 3. Every Metro CIT clinician will need to be credentialed via DBH's Managed Care Division. Training in Compliance, and Documentation and Billing are required and will be provided by DBH to CONTRACTOR staff for all new hires within their first thirty (30) days of being credentialed, and then annually thereafter. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit A Page 5 of 7 4. As this Agreement initiates Phase 2 of the pilot program, staffing levels may need to be modified, as appropriate, based upon need, as agreed upon between COUNTY and CONTRACTOR. 5. Specific geographic boundaries will be established for each Law Enforcement Agency; however, cooperation among the Metro CITs will allow for crossover in jurisdiction to assist in immediate crisis need. 6. Clinicians are to be directly assigned to each Law Enforcement Agency permanently, not to be on a rotational basis between agencies. This shall be conducted to encourage rapport-building between law enforcement staff and clinical staff. Although clinicians will be assigned to one specific agency on a permanent basis, it will be expected that all CIT clinicians be cross-trained in the event there is a urgent need for CIT clinician(s) within another Law Enforcement Agency jurisdiction. 7. On call/extra help part-time clinical staff to cover shifts and back up, as needed. 8. A Supervisory Clinician shall provide oversight to all clinicians, work collaboratively with the Law Enforcement Agencies to build and expand services, and provide additional crisis response as needed. 9. Designated administrative support shall collect data for tracking and reporting purposes. VII. Hours of Operation CONTRACTOR will be required to be available to provide services eighteen (18) hours per day, seven (7) days per week throughout the year, including telephone and face-to-face contact as needed. Staff work schedules shall be responsive to client needs and shall permit staff to work evenings and weekends. During off-hour periods (5:00 pm — 8:00 am), CONTRACTOR shall have identified staff that are regularly scheduled to work after regular business hours and/or on the weekends, if deemed necessary, in order to reduce over-time costs and in order to provide a more flexible treatment schedule for clients. VIII. Program Outcomes COUNTY's DBH is dedicated to supporting the wellness of individuals, families and communities in Fresno County who are affected by, or at the risk of, mental illness and/or substance use disorders through the cultivation of strengths toward promoting recovery in the least restrictive environment. CONTRACTOR will be required to submit measureable outcomes on an annual basis, as identified in the Departments Policy and Procedure Guide (PPG) 1.2.7 Performance Outcomes Measures, attached as Exhibit G. Performance outcomes measures must be approved by COUNTY's DBH and satisfy all State and local mandates. COUNTY's DBH will provide technical assistance and support in defining measureable outcomes. All performance indicators will reflect the four (4) domains identified by the Commission Accreditation of Rehabilitation Facilities (CARF). The domains are Effectiveness, Efficiency, Access, and Satisfaction. These are defined and listed below. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit A Page 6 of 7 COUNTY's DBH collects data about the characteristics of the persons served and measures service delivery performance indicators in each of the following CARF domains: At minimum, one (1) performance indicator will be identified for each of the four (4) CARF domains listed below. 1. Effectiveness: A performance dimension that assesses the degree to which an intervention or services have achieved the desired outcome/result/quality of care through measuring change over time. The results achieved and outcomes observed are for persons served. Examples of indicators include: Persons get a job with benefits, or receive supports needed to live in the community, increased function, activities, or participation, and improvement of health, employment/earnings, or plan of care goal attainment. 2. Efficiency: Relationship between results and resources used, such as time, money, and staff. The demonstration of the relationship between results and the resources used to achieve them. A performance dimension addressing the relationship between the outputs/results and the resources used to deliver the service. Examples of indicators include: Direct staff cost per person served, amount of time it takes to achieve an outcome, gain in scores per days of service, service hours per person achieving some positive outcome, total budget (actual cost) per person served, length of stay and direct service hours of clinical and medical staff. 3. Access: Organizations' capacity to provide services of those who desire or need services. Barriers or lack thereof for persons obtaining services. The ability of clients to receive the right service at the right time. A performance dimension addressing the degree to which a person needing services is able to access those services. Examples of indicators include: Timeliness of program entry (From 1 st request for service to 1st service), ongoing wait times/wait lists, minimizing barriers to getting services, and no- show/cancellation rates. 4. Satisfaction: Satisfaction Measures are usually orientated towards clients, family, staff, and stakeholders. The degree to which clients, the COUNTY and other stakeholders are satisfied with services. A performance dimension that describes reports or ratings from persons served about services received from an organization. Examples of indicators include: opinion of persons served or other key stakeholders in regards to access, process, or outcome of services received, client and/or Treatment Perception Survey. CONTRACTOR must address each of the categories referenced above and any additional performance and outcome measures that are deemed best to evaluate the services provided to clients and/or to evaluate overall program performance. DBH may adjust the performance and outcome measures periodically throughout the duration of this Agreement, as needed, to best measure the program as determined by the COUNTY. CONTRACTOR will be required to utilize and integrate clinical tools as directed by DBH. CONTRACTOR must utilize a computerized tracking system with which performance and outcome measures and other relevant data, such as demographics, will be maintained. The data tracking system may be incorporated into the selected CONTRACTOR's Electronic DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit A Page 7 of 7 Health Record (EHR) or be a stand-alone database. COUNTY's DBH must be afforded read- only access to the data tracking system, if applicable. In addition to the requirements set above, the following items listed below represent program goals to be achieved by CONTRACTOR. The program's success will be based on the number of goals it can achieve, resulting from performance outcomes. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit A-2 Page 1 of 5 Crisis Care Mobile Units (CCMU) Grant SCOPE OF WORK CONTRACTOR: Kings View PROGRAMS: Metro Crisis Intervention Team (Metro CIT) SITE ADDRESS: 1925 E. Dakota Ave., Ste. Q, Fresno, CA 93726 PROJECT TERM: September 20, 2022 — June 30, 2023 I. PROJECT DESCRIPTION DHCS utilized $150 million in funding received from the Behavioral Health Continuum Infrastructure Program and $55 million in funding received from the Substance Abuse and Mental Health Services Administration through the Coronavirus Response and Relief Appropriations Act to solicit applications from county or city behavioral health agencies to support and expand behavioral health mobile crisis and non-crisis services. The County of Fresno Department of Behavioral Health (DBH) included $161,663 in grant funding to add case management staff to the Metro CIT program. The goal of the CCMU grant project is to expand crisis intervention team (CIT) services to youth twenty-five (25) years of age and younger by adding dedicated case management staff to follow up on every CIT encounter with this population. Services are provided by interagency coordination between behavioral health clinicians, case managers and community-based organizations to link these individuals to behavioral health services and other supports identified by the behavioral health clinician during the CIT encounter(s). II. SERVICES START DATE Contractor shall begin recruiting for case management staff effective September 20, 2022. III. TARGET POPULATION The target population to be served by the case managers funded through the CCMU grant project shall be every youth twenty-five (25) years of age or younger after a CIT encounter with contractor's CIT clinician. Although this population must be prioritized, the case management staff may conduct post-crisis follow-up with other individuals if time permits. Based on CIT services provided in FY 2021-22, the added case management staff will provide an estimated 1,650 services per fiscal year to 1,550 youth. Youth twenty-five (25) years old and younger make up approximately 23% of individuals served by the CIT programs and accounts for about 17% of CIT services provided. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit A-2 Page 2 of 5 Contractor shall provide culturally and linguistically appropriate services that will meet the needs of the youth population of Fresno County. IV. LOCATION OF SERVICES Post-crisis follow-up services are to be provided face-to-face, over the phone, using video or via United States mail as appropriate and in accordance with DBH's Guiding Principles of Care Delivery. V. DESCRIPTION OF SERVICES Services are provided by interagency coordination between behavioral health clinicians, case managers and community-based organizations to link these individuals to behavioral health services and other supports identified by the behavioral health clinician during the CIT encounter(s). A case manager must be assigned to each individual within twenty-four (24) hours of the crisis encounter. Case management services will be culturally responsive, strengths-based, trauma-informed and recovery-oriented. These services will be continuously evaluated by the County and Contractor. The Contractor must adapt to meet the geographically dispersed needs of those living in rural and metropolitan Fresno County, the communities' needs as crisis services and demands fluctuate, and as Fresno County identifies more appropriate CIT models that improve service delivery. Case management services must be community-based; incorporate stigma reduction and suicide prevention; and comprehensive of recovery practices and community engagement during the course of service delivery. A. Documentation and Billing 1 . Contractor will use Fresno County DBH's electronic health record (EHR) and billing system (currently Avatar), and business management platform (currently Domo) to conduct data analysis. 2. Contractor must complete all documentation within 24 hours of service delivery, including but not limited to: access forms, client referral forms and progress notes. In addition, all related documents need to be uploaded within the same timeframe. 3. Contractor must adhere to the documentation standards established in DBH's Clinical Documentation and Billing Manual for Specialty Mental Health Services, DBH Policy and Procedure Guides (PPG) 2.1.9 "Assessments" and DBH PPG 4.4.6 "Documentation Standards for Progress Notes" as well as any future amendments to these documents. 4. Contractor shall utilize collaborative documentation with the person served whenever it is clinically indicated. Staff must adhere to DBH's collaborative documentation standards, which may include training courses offered by DBH. B. Care Coordination and Community Collaboration 1 . Contractor shall participate in care coordination activities with DBH, law enforcement and other community agencies. 2. Contractor agrees to coordinate with the Family Urgent Response System in Fresno County and utilize this program as a resource for qualified individuals. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit A-2 Page 3 of 5 3. Comprehensive knowledge of community resources is essential for case management staff to refer persons served to appropriate services. Contractor must make all attempts to ensure program staff are aware of applicable community resources and how to refer to these programs. 4. If the person served is linked to a DBH program, Contractor will notify the service provider as soon as practicable. This Scope of Work provides an outline of desired services and should not be considered all- inclusive. VI. STAFFING LEVELS The Kings View Metro CIT program will employ two (2) case managers. DBH is working to establish a standard productivity rate for contracted providers. Once determined, the awarded vendor must be prepared to capture, evaluate, report staff productivity, and make necessary program adjustments to meet the requirements. VII. HOURS OF OPERATION Case management services shall be provided from 8:OOam - 5:OOpm, Monday through Friday. VIIII. PERFORMANCE AND OUTCOME MEASUREMENTS Contractor shall comply with all project monitoring and compliance protocols, procedures, data collection methods, and reporting requirements requested by the County. Additionally, the Contractor is required to complete CCMU grant reports as requested (see Attachment 1 for data metrics). County and Contractor shall use performance outcome measures for evaluating program and system effectiveness to ensure services and service delivery strategies are positively impacting the service population. In addition, these measures shall be used to ensure the program is in alignment with MHSA guiding principles which are inclusive of: an integrated service experience; community collaboration; cultural competence; individual/family driven service; and wellness, resilience, and recovery-focused services. Performance outcome measures shall be tracked on an ongoing basis and used to update the County as requested. In addition, performance outcome measures are reported to the County annually in accumulative reports for overall program and contract evaluation. Forms and tools used to gather, and report data reflecting services provided, populations served, and impact of those services are to be developed by the County and Contractor. Contractor will work closely with the County to analyze the data and make necessary adjustments to service delivery and reporting requirements before the start of each new fiscal year and at appropriate intervals during the fiscal year. Measurable outcomes may be reviewed for input and approval by a designated DBH work group upon contract execution and adjusted as needed each new fiscal year. The purpose of DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit A-2 Page 4 of 5 this review process is to ensure a comprehensive system-wide approach to the evaluation of programs through an effective outcome reporting process. The following items listed below represent program goals to be achieved by Contractor. The program's success will be based on the number of goals it can achieve, resulting from performance outcomes. Contractor will utilize a computerized tracking system with which outcome measures and other relevant individual data, such as demographics, will be maintained. Contractor will collect data about the characteristics of the individuals served and measure service delivery performance indicators in the four Commission on Accreditation of Rehabilitation Facilities (CARF) domains listed below, with at least one performance indicator for each of the four domains. Contractor shall submit annual outcomes on a report template to be provided by the County for each level of care provided. 1. Effectiveness 2. Efficiency 3. Access 4. Satisfaction & Feedback of Persons Served & Stakeholders Additional Reporting Requirements Contractor will be responsible for meeting with DBH on a monthly basis, or more often as agreed upon between DBH and Contractor, for contract and performance monitoring. Contractor will be required to submit monthly reports to the County that will include, but not be limited to: dollars billed for Medi-Cal, DSH, CCMU and MHSA (non-Medi-Cal or non-Medi-Cal services) persons served; actual expenses; the number of persons served/anticipated to be served; wait lists; utilization of services by persons served; and staff composition. These reports will be due within 30 days after the last day of the previous month or payments may be delayed. DBH requires the following data reporting, which must be submitted to the Department by the loth of each month, unless otherwise indicated. The reporting period is typically the prior month in which services were provided. The following funding, staffing, services and data must be collected, maintained and reported by the established deadlines. Reporting templates and requirements are subject to change based on State and Federal regulations, funding guidelines and efforts to improve service delivery. A. Invoices must be submitted each month and shall include expenses and revenues from the prior month. B. The Monthly Staffing Report shall be submitted each month and must include each program staff member, their title, full-time equivalent, salary and other information as deemed appropriate by DBH. C. CCMU grant reports must be submitted at least quarterly, but more frequently as needed. D. Annual Performance Outcome Measures reports shall be completed at least annually and submitted to DBH as requested. County staff will notify the awarded vendor when its agency's participation is required. The performance outcome measurement report process will include survey instruments, person served and staff interviews, chart reviews, and other methods of obtaining necessary information as appropriate. E. The awarded vendor will be required to provide culturally and linguistically appropriate services DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit A-2 Page 5 of 5 that align with the National Standards for Culturally and Linguistically Appropriate Services and DBH PPG 1.5.1 Culturally and Linguistically Appropriate Services as well as any updates to these standards. The program will be required to report staff training related to cultural competency as requested by DBH. VIII. County RESPONSIBILITIES: A. The County will make available the expertise of County identified Peer Support and Family Advocate(s) as informational resources for the awarded vendor. These resources may have designated hours of contact for each rural community or clinician for the purpose of training, material development and ongoing support. B. Provide oversight, support, technical assistance and ongoing monitoring of the CCMU grant project through an assigned Contract Analyst and Utilization Review Specialist. C. Provide consultation on a regular basis by facilitating monthly provider meetings between DBH and the awarded vendor. D. Assist the Contractor in analyzing program-generated data to identify system barriers, memorialize program strengths and improve outcomes. E. Provide support in establishing and maintaining working relationships between the Contractor and community-based organizations. F. Offer training opportunities as funding allows. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 DHCS CRISIS CARE MOBILE UNITS PROGRAM CCMU Implementation Grantees Quarterly Report Narrative Summary QUARTER BEGIN DATE: QUARTER END DATE: GRANTEE ID: PROGRAM NAME: NAME OF PERSON SUBMITTING FORM: EMAIL OF PERSON SUBMITTING FORM: DATE SUBMITTED: Narrative Questions: 1. Provide a brief(up to 50 words) executive summary of your project and accomplishments this quarter. 2. For each area of activity in your statement of work for this quarter, provide a description of major activities or accomplishments that occurred during the reporting period. a. Activities/Deliverables i. Equipment/Property ii. Activities/Deliverables That Build the CCMU Infrastructure 1. Vehicle-related Costs for the CCMU 2. Field Communications for CCMU 3. Dispatch of CCMU Teams 4. Trainings 5. Coordination and Planning Activities with Local and Regional Organizations and/or to Manage Multiple CCMUs 6. Developing Peer Supports within Crisis Services 7. Marketing for CCMU Services 8. Data Collection, Analysis, and Quarterly Reporting for CCMU DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 iii. Direct Services 3. What challenges or barriers are you encountering and, if applicable, possible resolutions in implementing your plan? 4. Are there any staffing or program changes this quarter? ❑Yes ❑ No—If yes, please explain your answer. 5. Have you purchased any equipment/property this quarter? ❑Yes ❑ No—If yes, what is status? 6. Do you have any pending or new TA requests? (Check one) ❑ Yes, request in process ❑Yes, new request❑ No—If a new request, please describe here: Quarterly Report Data Questions CCMU PROGRAM STATUS: 1. How many total CCMU teams do you currently have? 1a. Have new teams started this quarter? ❑Yes ❑ No 1b. If yes, how many new teams started this quarter? 2. Do CCMU teams serve all zip codes in your jurisdiction? ❑Yes ❑ No 2a. If no, what zip codes are served? 2b. If no, what zip codes are not served? 2c. Are there zip codes where new services began this quarter? ❑ Yes ❑ No 3. Are CCMU services available 24/7? ❑ Yes ❑ No 3a. If no, what are the hours of operation? 3b. If no, how many hours a week are CCMU services available? 4. How many total hours of CCMU services were available this quarter? (all hours for all teams) 5. What is the makeup of your CCMU teams? Please indicate how many of each type of team in the table below. Staffing Number of teams One clinician and one peer One clinician and one para-professional (e.g., bachelor level) Two clinicians DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 One clinician and one case manager One clinician and one EMT or other health provider Other: If other, please describe: ABOUT CCMU INQUIRIES RESULTING IN DISPATCH 1. For each zip code in your jurisdiction, provide,for the reporting quarter,the number of calls/requests received, resulting in dispatch, and resulting in CCMU services. Zip Code Number of calls/ Number of calls/ Number of dispatches requests to CCMU requests resulting in resulting in CCMU dispatch services Zip code not known TOTAL 2. For each referral source, indicate how many calls were received, resulted in dispatch, and resulted in CCMU services,for the reporting quarter. Referral source initiating Number of calls/ Number of calls/ Number of call/request to CCMU requests to CCMU requests resulting dispatches resulting in dispatch in CCMU services Crisis line/suicide hotline/988 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 911 211 FURS Law enforcement Medical/health provider Criminal justice referral Business Homeless service provider Community member Family/friend Self-referral Other Source not available Total 3. Reasons for dispatch and behavioral health conditions. 3.a. For each listed primary reason for dispatch, indicate how many calls were received, resulted in dispatch, and resulted in CCMU services,for the reporting quarter. Primary reason for dispatch Number of calls/ Number of calls/ Number of requests to CCMU requests resulting in dispatches resulting dispatch in CCMU services Possible risk of harm to self or suicide risk Possible risk of harm to others Significant decompensation or inability to care for self Possible substance use, intoxication, or overdose risk DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 Welfare check(individual receiving BH Services) Welfare check-other Significant agitation or bizarre behavior Otherreason Unknown reason Total 3.b. For each listed behavioral health condition, indicate how many calls were received, resulted in dispatch, and resulted in CCMU services, for the reporting quarter. 3b. Which best describes Number of calls/ Number of calls/ Number of the behavioral health requests to CCMU requests resulting in dispatches resulting condition? dispatch in CCMU services Substance misuse/SUD MH/SMI or SED COD Unknown Total 4.Please indicate the number of calls, by response time, that did not result in dispatch, that resulted in dispatch but no CCMU services,that resulted in dispatch and CCMU services, and that resulted in dispatch,total, for the reporting quarter. Response Time Mean Response Time in Minutes (all calls over quarter) Median Response Time in Minutes (all calls over quarter) Dispatch status Number of Calls and Response Time Windows DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 < 1 > 1 hours >2 hours >4 hours > 24 hours unknown hour < 2 hours <4 hours < 24 hours Dispatch, no CCMU services Dispatch, CCMU services Total calls resulting in dispatch 5. For the dispatches that did not result in CCMU services, how many were due to each of the following reasons,for the specified quarter? Reason Number of Calls Individual not found Individual refused services Situation resolved in community prior to CCMU arrival Law enforcement responded first and declined CCMU participation Emergency health responded first and declined CCMU participation Another reason (please describe and provide number) Unknown If another reason, please describe and provide number(s): NON-DISPATCHED CCMU CALLS 6a. Does your CCMU team provide crisis services in the community without a dispatch (e.g., through mobile outreach or walk-in)? ❑Yes ❑ No If yes, complete the following tables. 6b. If yes, please indicate the number of unduplicated individuals seen, for the specified quarter, without a dispatch (include services with CCMU metrics). DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 6b. Reason for CCMU services Number of unduplicated individuals seen without dispatch Possible risk of harm to self or suicide risk Possible risk of harm to others Significant decompensation or inability to care for self Significant agitation or bizarre behavior Substance use: intoxication or overdose risk School referral Welfare check(individual receiving BH services) Welfare check(other) Otherreason Unknown Total (may not add up exactly) 6c. Which of the following best describes the Number of unduplicated individuals behavioral health reason for crisis services seen without dispatch Substance misuse/Substance Use Disorder(SUD) Mental health (MH)/Serious Mental Illness (SMI) or Serious Emotional Disturbance (SED) Co-occurring (COD) Unknown Total DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 CCMU SERVICES AND RESOLUTION 1. What CCMU services were delivered during the reporting quarter? Type of CCMU service Number of individuals Percent of individuals receiving this service receiving this service this quarter. Total number of CCMU service 100% recipients Triage/screening onsite Clinical assessment by MH professional De-escalation Support for family/friends Coordination with medical services Coordination with behavioral health services Crisis and safety planning 5150/5185 Administered Naloxone Other(please describe and indicate number and percent) If other, please describe and list the number and percentage of each other service: 2. How were CCMU services resolved during the reporting quarter? Resolution of CCMU services Number of individuals with Percentage of individuals CCMU resolved in this way resolved in this way DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 Total number of CCMU service N/A recipients De-escalated onsite (no resources/referrals) De-escalated onsite with referrals/ warm handoff Transported to community behavioral health Transported to medical care Detained 5150 or 5185 hold (involuntarily taken to hospital) Detained by law enforcement Unresolved Other(please describe) If other, please describe and list the number and percentage of each other service: 3. Complete tables below for more information on the types of agencies referred or transported to as described in question 2 above. 3a. Referrals and Warm Handoffs Name of agency Type of agency Zip Code Number of warm handoffs/referrals 3b. When individuals are transported to agencies (medical or behavioral health) Name of agency Type of agency Zip Code Number of warm handoffs/referrals DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 4. Follow Up Services Services received Number of individuals Percent of individuals receiving CCMU services who received each of the following: Any CCMU services Any follow-up care Follow-up care within 48 hours Engaged in at least one service at the time of follow-up Other(please describe and indicate number and percent) If other, please describe and list the number and percentage of each other service: CCMU SERVICES— DIAGNOSES AND DEMOGRAPHICS 1. Please indicate the primary diagnosis of individuals receiving CCMU services,for the specified quarter, by count and as a percentage of individuals receiving CCMU services. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 Primary diagnosis Total number of individuals Percentage of individuals receiving CCMU services who served receiving CCMU have this diagnosis services who have this diagnosis Psychosis Substance use disorder Adjustment disorder Bipolar disorder Depressive disorder (including MDD) Anxiety disorder (including PTSD) Schizoaffective disorder Schizophrenia Neurodevelopmental disorder Severely Emotionally Disturbed (SED) Unspecified mental disorder No diagnosis Other Unknown Total 2. Enter the number and percentage of individuals served,for the reporting quarter, by race/ethnicity. Race/Ethnicity Number receiving services As a percent of individuals receiving services American Indian/Alaska Native Asian or Asian American DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 Black/African American Native Hawaiian/Pacific Islander Latinx/Chicanx/Hispanic More than one race White Other (please describe) Unknown Tota I If"something else (not listed here)," please describe and list number: 3. Enter the number and percentage of individuals served,for the reporting quarter, by primary language. Primary language Number receiving services Percent of individuals served who speak: English Spanish Mandarin Cantonese Tagalog(including Filipino) Vietnamese Korean Armenian Farsi Arabic Other(please identify and provide numbers) Unknown DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 Tota I If"something else (not listed here)," please describe and list number: 4. Enter the number and percentage of individuals receiving CCMU services,for the reporting quarter, by gender. Gender Number As a percentage of receiving individuals receiving services services Male Female Non-binary/other Unknown Total 5. How many individuals served during the reporting quarter were pregnant? 6. Enter the number and percent of all individuals receiving CCMU services, for the reporting quarter, by age group. Age Number receiving services As a percentage of individuals receiving services < 12 12-17 18-24 25-44 45-64 65+ Unknown DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 Total 6a. Provide the living arrangements for individuals under 18 receiving CCMU services,for the reporting quarter, by number and as a percentage of individuals under 18 receiving services. Living situation Number receiving services Percent of individuals aged <18 served who: Lives with a parent/guardian Does not live with a parent/guardian Unknown Total 7. Enter the number and percentage of individuals receiving CCMU services, for the reporting quarter, by sexual orientation. Sexual orientation Number receiving Percent of individuals served services who are: Asexual Bisexual/pansexual Gay Heterosexual/straight Lesbian Queer Two-Spirit Something else (not listed here; please describe and provide number and percentage) Unknown Total DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 If"Something else (not listed here)," please describe and list number: 8. Enter the number and percentage of individuals receiving CCMU services, for the reporting quarter, by military status. Military status Number receiving Percent of individuals served who are: services Active military Military family Non-military Veteran Unknown Total 9. Enter the number and percentage of individuals receiving CCMU services, by insurance status. Insurance status Number receiving Percent of individual services served who have: Medi-Cal enrolled Medi-Cal expired or in- process Medicare Other health insurance No health insurance Unknown Total 10. Enter the number and percentage of individuals receiving CCMU services, for the reporting quarter, by housing status: DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 Housing status Number receiving "Percent of individuals services served who are: Unhoused, unsheltered Unhoused, sheltered At risk of homeless Stably housed Other Unknown Total 11. Enter the number and percentage of individuals receiving CCMU services,for the reporting quarter, by previous experience with behavioral health care. Previous behavioral health experience Number Percent of receiving individuals services served who: Never received behavioral health services before Receive or have received SMI/SED services (Full-Service Partnerships or other SMI services) Receive or have received SUD services Have received some counseling or health/community based mental health services in the past Other(please describe) Unknown Total If"Other" please describe and list number: DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 OTHER ORGANIZATIONAL AND INFRASTRUCTURE RELATED ITEMS 1. Staffing Please provide the following information about the staffing of your CCMU program. Position FTEs working on FTEs currently Unduplicated count of Vacant positions CCMU paid by CCMU staff working on CCMU in CCMU (regardless of program (regardless of hours or program (by funding source) funding source) FTE) Clinicians Peer staff Other direct service staff Management and administrative staff Other If"Other" please describe: 2. Outreach Enter the total number of outreach materials developed and distributed by your organization during the reporting quarter. Outreach materials are any materials developed to reach providers,the community or other project stakeholders.This could include flyers, newsletters, social media posts, billboard, email blasts, podcasts, PSAs, advertisements etc. 3a. Number of outreach materials developed this quarter: 3b. Number of outreach materials distributed this quarter: 3c. Enter the number of unique outreach materials developed, during the reporting quarter, in each of the languages below. If a material is in more than one language, include it under each relevant language. Language Number of products developed English Spanish DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 Mandarin Cantonese Tagalog(including Filipino) Vietnamese Korean Armenian Farsi Arabic Other(please list) If"Other" please list: 3d. Enter the number of visitors to the CCMU website (if applicable) during the reporting quarter: 3e. Enter the total number of in-person or virtual community events held by or attended by your organization for purpose of awareness/outreach, during the reporting quarter, and the total number of attendees across all events of each type: Outreach Event Type Number of events Total number of attendees Community events held Community events attended 3f. Who was the audience for your outreach activities during the reporting quarter? (Check all that apply.) ❑ People who use drugs ❑ People with mental health conditions DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 ❑ People who have never accessed behavioral health care before ❑ Family members of individuals with SUD/SMI ❑ Native American/Tribal/Urban Indian populations ❑ Black/African American populations ❑ Latino/a/x specific populations ❑ Southeast Asian populations ❑ LGBTQ2SIA+ ❑ Individuals experiencing homelessness ❑ Youth (under 18) ❑ TAY(18-24) ❑ Veterans ❑ Immigrants without documentation ❑ People involved with the justice system ❑ Pregnant and post-partum persons ❑ Other(please list) 3. Collaboration 3a. Enter the total number of each of the following types of agencies with whom your CCMU program currently collaborates with: Organization type Total number of current Total number of current referral relationships MOUs Peer-run organizations SUD treatment centers Mental health treatment centers Hospitals Law enforcement agencies Schools/educational institutions Homeless service providers DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 Other (please list and indicate numbers) If"Other" please describe and list number of relationships: 3b. How are you collaborating with each of the stakeholder groups in the development and implementation of CCMU? Stakeholder group Brief description of involvement in planning and implementation of CCMU this quarter Individuals with lived experience of MH/SUD Family members Crisis and suicide hotlines 911 dispatch First responders Law enforcement Tribal representatives DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 College/university Schools (k-12) Housing/homeless services Health care SUD services MH services Business community Other city/county govt Other community agencies DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 Other 4. Trainings 4a. Enter the total number of trainings made available to staff of the CCMU and community partners,for the reporting quarter, by training type. Training type/topic Number of in- Total number Number of Total number person attended virtual attended trainings trainings POST-approved Crisis Intervention Training Other crisis intervention training De-escalation techniques (e.g., management of agitation and verbal de- escalation) Understanding SMI and MH crisis response Understanding SUD and crisis response (including Naloxone training) Suicide risk assessment and intervention (and MH First Aid) Cultural humility and culturally responsive services Trauma-informed care Working with youth/TAY and SED DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Attachment 1 Safety and self-care for field workers Other evidence-based practices(e.g., harm reduction, structured brief interventions) Collaboration or administrative excellence Accessing mobile crisis services Other(please list) 4b. Enter the total number of individuals trained (in 5a), by job category, during the reporting quarter: Job category Total number of individuals trained Clinician Peer Other behavioral health provider Administrator/manager Administrative support Law enforcement Other system partner Other(please list) Unknown Total DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT B 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. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT B 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. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit C Page 1 of 4 Fresno County Department of Behavioral Health Guiding Principles of Care Delivery DBH VISION: Health and well-being for our community. DBH MISSION: DBH, in partnership with our diverse community, is dedicated to providing quality, culturally responsive, behavioral health services to promote wellness, recovery, and resiliency for individuals and families in our community. DBH GOALS: Quadruple Aim • Deliver quality care • Maximize resources while focusing on efficiency • Provide an excellent care experience • Promote workforce well-being GUIDING PRINCIPLES OF CARE DELIVERY: The DBH 11 principles of care delivery define and guide a system that strives for excellence in the provision of behavioral health services where the values of wellness, resiliency, and recovery are central to the development of programs, services, and workforce. The principles provide the clinical framework that influences decision-making on all aspects of care delivery including program design and implementation, service delivery, training of the workforce, allocation of resources, and measurement of outcomes. 1. Principle One -Timely Access & Integrated Services o Individuals and families are connected with services in a manner that is streamlined, effective, and seamless o Collaborative care coordination occurs across agencies, plans for care are integrated, and whole person care considers all life domains such as health, education, employment, housing, and spirituality o Barriers to access and treatment are identified and addressed o Excellent customer service ensures individuals and families are transitioned from one point of care to another without disruption of care 1 rev 01-02-2020 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit C Page 2 of 4 Fresno County Department of Behavioral Health Guiding Principles of Care Delivery 2. Principle Two - Strengths-based o Positive change occurs within the context of genuine trusting relationships o Individuals, families, and communities are resourceful and resilient in the way they solve problems o Hope and optimism is created through identification of, and focus on, the unique abilities of individuals and families 3. Principle Three - Person-driven and Family-driven o Self-determination and self-direction are the foundations for recovery o Individuals and families optimize their autonomy and independence by leading the process, including the identification of strengths, needs, and preferences o Providers contribute clinical expertise, provide options, and support individuals and families in informed decision making, developing goals and objectives, and identifying pathways to recovery o Individuals and families partner with their provider in determining the services and supports that would be most effective and helpful and they exercise choice in the services and supports they receive 4. Principle Four- Inclusive of Natural Supports o The person served identifies and defines family and other natural supports to be included in care o Individuals and families speak for themselves o Natural support systems are vital to successful recovery and the maintaining of ongoing wellness; these supports include personal associations and relationships typically developed in the community that enhance a person's quality of life o Providers assist individuals and families in developing and utilizing natural supports. 5. Principle Five - Clinical Significance and Evidence Based Practices (EBP) o Services are effective, resulting in a noticeable change in daily life that is measurable. o Clinical practice is informed by best available research evidence, best clinical expertise, and values and preferences of those we serve o Other clinically significant interventions such as innovative, promising, and emerging practices are embraced 2 rev 01-02-2020 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit C Page 3 of 4 Fresno County Department of Behavioral Health Guiding Principles of Care Delivery 6. Principle Six- Culturally Responsive o Values, traditions, and beliefs specific to an individual's or family's culture(s) are valued and referenced in the path of wellness, resilience, and recovery o Services are culturally grounded, congruent, and personalized to reflect the unique cultural experience of each individual and family o Providers exhibit the highest level of cultural humility and sensitivity to the self- identified culture(s) of the person or family served in striving to achieve the greatest competency in care delivery 7. Principle Seven -Trauma-informed and Trauma-responsive o The widespread impacts of all types of trauma are recognized and the various potential paths for recovery from trauma are understood o Signs and symptoms of trauma in individuals, families, staff, and others are recognized and persons receive trauma-informed responses o Physical, psychological and emotional safety for individuals, families, and providers is emphasized 8. Principle Eight - Co-occurring Capable o Services are reflective of whole-person care; providers understand the influence of bio-psycho-social factors and the interactions between physical health, mental health, and substance use disorders o Treatment of substance use disorders and mental health disorders are integrated; a provider or team may deliver treatment for mental health and substance use disorders at the same time 9. Principle Nine - Stages of Change, Motivation, and Harm Reduction o Interventions are motivation-based and adapted to the person's stage of change o Progression though stages of change are supported through positive working relationships and alliances that are motivating o Providers support individuals and families to develop strategies aimed at reducing negative outcomes of substance misuse though a harm reduction approach o Each individual defines their own recovery and recovers at their own pace when provided with sufficient time and support 3 rev 01-02-2020 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit C Page 4 of 4 Fresno County Department of Behavioral Health Guiding Principles of Care Delivery 10. Principle Ten - Continuous Quality Improvement and Outcomes-Driven o Individual and program outcomes are collected and evaluated for quality and efficacy o Strategies are implemented to achieve a system of continuous quality improvement and improved performance outcomes o Providers participate in ongoing professional development activities needed for proficiency in practice and implementation of treatment models 11. Principle Eleven - Health and Wellness Promotion, Illness and Harm Prevention, and Stigma Reduction o The rights of all people are respected o Behavioral health is recognized as integral to individual and community well-being o Promotion of health and wellness is interwoven throughout all aspects of DBH services o Specific strategies to prevent illness and harm are implemented at the individual, family, program, and community levels o Stigma is actively reduced by promoting awareness, accountability, and positive change in attitudes, beliefs, practices, and policies within all systems o The vision of health and well-being for our community is continually addressed through collaborations between providers, individuals, families, and community members 4 rev 01-02-2020 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit D Page 1 of 3 DOCUMENTATION STANDARDS FOR CLIENT RECORDS The documentation standards are described below under key topics related to client care. All standards must be addressed in the client record; however, there is no requirement that the record have a specific document or section addressing these topics. All medical records shall be maintained for a minimum of 10 years from the date of the end of the Agreement. A. Assessments 1. The following areas will be included as appropriate as a part of a comprehensive client record. • Relevant physical health conditions reported by the client will be prominently identified and updated as appropriate. • Presenting problems and relevant conditions affecting the client's physical health and mental health status will be documented, for example: living situation, daily activities, and social support. • Documentation will describe client's strengths in achieving client plan goals. • Special status situations that present a risk to clients or others will be prominently documented and updated as appropriate. • Documentations will include medications that have been described by mental health plan physicians, dosage of each medication, dates of initial prescriptions and refills, and documentations of informed consent for medications. • Client self report of allergies and adverse reactions to medications, or lack of known allergies/sensitivities will be clearly documented. • A mental health history will be documented, including: previous treatment dates, providers, therapeutic interventions and responses, sources of clinical data, relevant family information and relevant results of relevant lab tests and consultations reports. • For children and adolescents, pre-natal and perinatal events and complete developmental history will be documented. • Documentations will include past and present use of tobacco, alcohol, and caffeine, as well as illicit, prescribed and over-the-counter drugs. • A relevant mental status examination will be documented. • A DSM-5 diagnosis, or a diagnosis from the most current ICD, will be documented, consistent with the presenting problems, history mental status evaluation and/or other assessment data. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit D Page 2of3 2. Timeliness/Frequency Standard for Assessment • An assessment will be completed at intake and updated as needed to document changes in the client's condition. • Client conditions will be assessed at least annually and, in most cases, at more frequent intervals. B. Client Plans 1. Client plans will: • have specific observable and/or specific quantifiable goals • identify the proposed type(s) of intervention • have a proposed duration of intervention(s) • be signed (or electronic equivalent) by: ➢ the person providing the service(s), or ➢ a person representing a team or program providing services, or ➢ a person representing the MHP providing services ➢ when the client plan is used to establish that the services are provided under the direction of an approved category of staff, and if the below staff are not the approved category, ➢ a physician a licensed/"waivered" psychologist ➢ a licensed/"associate" social worker ➢ a licensed/ registered/marriage and family therapist or ➢ a registered nurse • In addition, Client plans will be consistent with the diagnosis, and the focus of intervention will be consistent with the client plan goals, and there will be documentation of the client's participation in and agreement with the plan. Examples of the documentation include, but are not limited to, reference to the client's participation and agreement in the body of the plan, client signature on the plan, or a description of the client's participation and agreement in progress notes. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit D Page 3 of 3 ➢ Client signature on the plan will be used as the means by which the CONTRACTOR documents the participation of the client. ➢ When the client's signature is required on the client plan and the client refuses or is unavailable for signature, the client plan will include a written explanation of the refusal or unavailability. • The CONTRACTOR will give a copy of the client plan to the client on request. 2. Timeliness/Frequency of Client Plan: • Will be updated at least annually. • The CONTRACTOR(S) will establish standards for timeliness and frequency for the individual elements of the client plan described in item 1. C. Progress Notes 1. Items that must be contained in the client record related to the client's progress in treatment include: • The client record will provide timely documentation of relevant aspects of client care. • Mental health staff/practitioners will use client records to document client encounters, including relevant clinical decisions and interventions. • All entries in the client record will include the signature of the person providing the service (or electronic equivalent); the person's professional degree, licensure or job title; and the relevant identification number, if applicable. • All entries will include the date services were provided. • The record will be legible. • The client record will document follow-up care, or as appropriate, a discharge summary. 2. Timeliness/Frequency of Progress Notes: • Progress notes shall be documented at the frequency by type of service indicated below: a. Every Service Contact • Mental Health Services • Medication Support Services • Crisis Intervention DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 1 of 15 County of Fresno - Fresno Metro Crisis Intervention (CIT) Services Kings View Corporation FY 2018-2019 (Nov. 1, 2018 -Jun. 30, 2019) Budget Categories- Total Proposed Budget Line Item Description (Must be itemized) FTE % Admin. Direct Total PERSONNEL SALARIES: 0001 Executive Director(Licensed) 0.02 $1,789 $1,789 0002 Director of Program Development (Licensed) 0.08 $4,368 $4,368 0003 Director of Clinical Operations 0.25 $17,593 $17,593 0004 CIT Program Manager 1.00 $59,453 $59,453 0005 UR Specialist 1.00 $52,173 $52,173 0006 Licensed Field Clinician 2.00 $101,920 $101,920 0007 Unlicensed Field Clinician 8.00 $368,853 $368,853 0008 Administrative Specialist 1.00 $26,693 $26,693 0009 Licensed Lead Field Clinician 2.00 $104,347 $104,347 0010 Fiscal Analyst 0.10 $3,640 $3,640 0011 CVSPH - Call Responder 1.00 $18,830 $18,830 0012 Per Diem Field Clinician Licensed 1,000 hours/year 0.00 $24,500 $24,500 SALARY TOTAL 16.45 $88,663 $695,496 $784,159 PAYROLL TAXES: 0031 FICA/MEDICARE $6,783 $53,205 $59,988 0032 SUI $887 $6,955 $7,842 PAYROLL TAX TOTAL $7,670 $60,160 $67,830 EMPLOYEE BENEFITS (22.45%): 0040 Retirement $401 $3,146 $3,547 0041 Workers Compensation $3,547 $27,820 $31,367 0042 Health Insurance (medical, vision, life, dental) 1 $15,959 $125,189 $141,148 EMPLOYEE BENEFITS TOTAL $19,907 $156,155 $176,062 SALARY& BENEFITS GRAND TOTAL $1,028,051 FACILITIES/EQUIPMENT EXPENSES: 1010 Rent/Lease Building (Ashlan Avenue Building) $12,250 1010 Rent/Lease Building (F Street Building) $5,250 1011 Rent/Lease Equipment (Copier, Hub-Printer) $2,188 1012 Utilities $3,442 1013 Janitorial/Building $1,283 1015 Other-Vehicle Leasing 11 Vehicles $38,500 FACILITY/EQUIPMENT TOTAL $62,913 OPERATING EXPENSES: 1060 Telephone $8,546 1062 Postage $292 1063 Printing/Reproduction $1,342 1066 Office Supplies & Equipment $4,667 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 2 of 15 1069 Program Supplies $4,083 1072 Staff Mileage/vehicle maintenance $4,667 1074 Staff Training/Registration $8,750 1076 Data Lines (data drops, hub hookups, landline, Avatar) $11,900 1077 Other- Staff Uniforms/Miscellaneous $10,325 1078 Staff Recruitment/background checks $4,113 1079 Communications (cell phone & mobile internet) $11,375 OPERATING EXPENSES TOTAL $70,060 FINANCIAL SERVICES EXPENSES: 1082 Liability Insurance (Auto, Property, General) $5,192 1083 Other- Professional Liability $2,450 1084 Other-Administrative Overhead 11.5% $137,871 FINANCIAL SERVICES TOTAL $145,513 SPECIAL EXPENSES Consultant/Etc. : 1090 Consultant (network&data management) $42,942 1091 Translation Services $1,050 1092 Medication Supports $0 SPECIAL EXPENSES TOTAL $43,992 FIXED ASSETS: 2000 Computers & Software $23,333 2001 Furniture & Fixtures $5,832 2002 Other- (Identify) $0 2003 Other- (identify) $0 FIXED ASSETS TOTAL $29,165 TOTAL PROGRAM EXPENSES $1,379,694 MEDI-CAL REVENUE: Units of Service Rate $Amount 3000 Mental Health Services (Individual/Family/Group Therapy) 0 $0.00 $0 3100 Case Management 4,375 $2.67 $11,681 3200 Crisis Services 96,250 $5.15 $495,688 3300 Medication Support 0 $0.00 $0 3400 Collateral 0 $0.00 $0 3500 Plan Development 0 $0.00 $0 3600 Assessment 8,750 $3.20 $28,000 3700 Rehabilitation 0 $0.00 $0 3800 ICC 0 $0.00 $0 3900 IHBS 0 $0.00 $0 Estimated Specialty Mental Health Services Billing Totals 109,375 1 $535 369 Estimated % of Clients that are Medi-Cal Beneficiaries 20.0% Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $107,074 Federal M/Cal Share of Cost % (Federal Financial Participation-FFP) 85.00% $91,013 State M/Cal Share of Cost % BH Reali nment/EPSDT 0.00% $0 MEDI-CAL REVENUE TOTAL $91,013 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 3 of 15 OTHER REVENUE: 4000 Non Medi-Cal eligible/Private Insurance $0 4100 Other- (Identify) $0 OTHER REVENUE TOTAL: MHSA Funds $0 MENTAL HEALTH SERVICES ACT (MHSA) REVENUE: 5000 Prevention & Early Intervention (PEI) Funds $1,288,681 5100 Community Services & Supports (CSS) Funds $0 5200 Innovation (INN) Funds $0 5300 Workforce Education &Training (WET) Funds $0 MHSA FUNDS TOTAL $1,288,681 TOTAL PROGRAM REVENUE $1,379,694 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 4 of 15 County of Fresno - Fresno Metro Crisis Intervention (CIT) Services Kings View Corporation FY 2019-2020 Budget Categories - Total Proposed Budget Line Item Description (Must be itemized) FTE % Admin. Direct Total PERSONNEL SALARIES: 0001 Executive Director(Licensed) 0.02 $3,158 $3,158 0002 Director of Program Development (Licensed) 0.08 $7,713 $7,713 0003 Director of Clinical Operations 0.25 $31,065 $31,065 0004 CIT Program Manager 1.00 $104,978 $104,978 0005 UR Specialist 1.00 $92,123 $92,123 0006 Licensed Field Clinician 2.00 $179,962 $179,962 0007 Unlicensed Field Clinician 8.00 $651,290 $651,290 0008 Administrative Specialist 1.00 $47,133 $47,133 0009 Licensed Lead Field Clinician 2.00 $184,246 $184,246 0010 Fiscal Analyst 0.10 $6,427 $6,427 0011 CVSPH - Call Responder 1.00 $33,248 $33,248 0012 Per Diem Field Clinician Licensed 1,000 hours/year 0.00 $43,260 $43,260 SALARY TOTAL 16.45 $156,554 $1,228,049 $1,384,603 PAYROLL TAXES: 0031 FICA/MEDICARE $11,976 $93,946 $105,922 0032 SUI $1,566 $12,280 $13,846 PAYROLL TAX TOTAL $13,542 $106,226 $119,768 EMPLOYEE BENEFITS (22.45%): 0040 Retirement $3,131 $24,561 $27,692 0041 Workers Compensation $6,262 $49,122 $55,384 0042 Health Insurance (medical, vision, life, dental) 1 $28,180 $221,049 $249,229 EMPLOYEE BENEFITS TOTAL $37,573 $294,732 $332,305 SALARY& BENEFITS GRAND TOTAL $1,836,676 FACILITIES/EQUIPMENT EXPENSES: 1010 Rent/Lease Building (Ashlan Avenue Building) $21,630 1010 Rent/Lease Building (F Street Building) $9,270 1011 Rent/Lease Equipment (Copier, Hub-Printer) $3,863 1012 Utilities $6,077 1013 Janitorial/Building $2,266 1015 Other-Vehicle Leasing (11 Vehicles) $44,220 FACILITY/EQUIPMENT TOTAL $87,326 OPERATING EXPENSES: 1060 Telephone $15,090 1062 Postage $450 1063 Printing/Reproduction $1,800 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 5 of 15 1066 Office Supplies & Equipment $8,240 1069 Program Supplies $7,210 1072 Staff Mileage/vehicle maintenance $8,240 1074 Staff Training/Registration $10,000 1076 Data Lines (data drops, hub hookups, landline, Avatar) $21,012 1077 Other- Staff Uniforms/Miscellaneous $10,000 1078 Staff Recruitment/background checks $2,050 1079 Communications (cell phone & mobile internet) $16,000 OPERATING EXPENSES TOTAL $100,092 FINANCIAL SERVICES EXPENSES: 1082 Liability Insurance (Auto, Property, General) $9,167 1083 Other- Professional Liability $4,326 1084 Other-Administrative Overhaead (11.5%) $235,794 FINANCIAL SERVICES TOTAL 1 $249,287 SPECIAL EXPENSES (Consultant/Etc.): 1090 Consultant(network &data management) $73,428 1091 Translation Services $1,800 1092 Medication Supports $0 SPECIAL EXPENSES TOTAL 1 $75,228 FIXED ASSETS: 2000 Computers &Software $8,000 2001 Furniture & Fixtures $3,000 2002 Other- (Identify) $0 2003 Other- (Identify) $0 FIXED ASSETS TOTAL $11,000 TOTAL PROGRAM EXPENSES $2,359,609 MEDI-CAL REVENUE: Units of Service Rate $Amount 3000 Mental Health Services (Individual/Family/Group Therapy) 0 $0.00 $0 3100 Case Management 7,800 $2.78 $21,684 3200 Crisis Services 171,600 $5.36 $919,776 3300 Medication Support 0 $0.00 $0 3400 Collateral 0 $0.00 $0 3500 Plan Development 0 $0.00 $0 3600 Assessment 15,600 $3.33 $51,948 3700 Rehabilitation 0 $0.00 $0 3800 ICC 0 $0.00 $0 3900 IHBS 0 $0.00 $0 Estimated Specialty Mental Health Services Billing Totals 195,000 $993,408 Estimated % of Clients that are Medi-Cal Beneficiaries 20.0% Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $198,682 Federal M/Cal Share of Cost% (Federal Financial Participation-FFP) 1 85.00% $168,879 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 6 of 15 State M/Cal Share of Cost% (BH Realignment/EPSDT) 0.00% $0 MEDI-CAL REVENUE TOTAL $168,879 OTHER REVENUE: 4100 Other- (Identify) $0 4200 Other- (Identify) $0 4300 Other- (Identify) $0 OTHER REVENUE TOTAL: MHSA Funds 1 $0 MENTAL HEALTH SERVICES ACT MHSA REVENUE: 5000 Prevention & Early Intervention (PEI) Funds $2,190,730 5100 Community Services &Supports (CSS) Funds $0 5200 Innovation (INN) Funds $0 5300 Workforce Education &Training (WET) Funds $0 MHSA FUNDS TOTAL $2,190,730 TOTAL PROGRAM REVENUE $2,359,609 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 7 of 15 County of Fresno - Fresno Metro Crisis Intervention (CIT) Services Kings View Corporation FY 2020-2021 Budget Categories - Total Proposed Budget Line Item Description (Must be itemized) FTE % Admin. Direct Total PERSONNEL SALARIES: 0001 Executive Director(Licensed) 0.02 $3,253 $3,253 0002 Director of Program Development (Licensed) 0.08 $7,944 $7,944 0003 Director of Clinical Operations 0.25 $31,997 $31,997 0004 CIT Program Manager 1.00 $108,127 $108,127 0005 UR Specialist 1.00 $94,887 $94,887 0006 Licensed Field Clinician 2.00 $185,360 $185,360 0007 Unlicensed Field Clinician 8.00 $670,828 $670,828 0008 Administrative Specialist 1.00 $48,547 $48,547 0009 Licensed Lead Field Clinician 2.00 $189,774 $189,774 0010 Fiscal Analyst 0.10 $6,620 $6,620 0011 CVSPH - Call Responder 1.00 $34,246 $34,246 0012 Per Diem Field Clinician (Licensed) 1,000 hours/year 0.00 $44,558 $44,558 SALARY TOTAL 16.45 $161,251 $1,264,890 $1,426,141 PAYROLL TAXES: 0031 FICA/MEDICARE $12,336 $96,764 $109,100 0032 SUI $1,613 $12,648 $14,261 PAYROLL TAX TOTAL $13,949 $109,412 $123,361 EMPLOYEE BENEFITS (22.45%): 0040 Retirement $3,225 $25,298 $28,523 0041 Workers Compensation $6,450 $50,596 $57,046 0042 Health Insurance (medical, vision, life, dental) 1 $29,025 $227,680 $256,705 EMPLOYEE BENEFITS TOTAL $38,700 $303,574 $342,274 SALARY& BENEFITS GRAND TOTAL $1,891,776 FACILITIES/EQUIPMENT EXPENSES: 1010 Rent/Lease Building (Ashlan Avenue Building) $22,279 1010 Rent/Lease Building (F Street Building) $9,548 1011 Rent/Lease Equipment(Copier, Hub-Printer) $3,978 1012 Utilities $6,259 1013 Janitorial/Building $2,334 1015 Other-Vehicle Leasing (11 Vehicles) $44,220 FACILITY/EQUIPMENT TOTAL $88,618 OPERATING EXPENSES: 1060 Telephone $15,542 1062 Postage $400 1063 Printing/Reproduction $1,800 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 8 of 15 1066 Office Supplies & Equipment $8,487 1069 Program Supplies $7,426 1072 Staff Mileage/vehicle maintenance $8,487 1074 Staff Training/Registration $10,000 1076 Data Lines (data drops, hub hookups, landline, Avatar) $21,642 1077 Other- Staff Uniforms/Miscellaneous $10,000 1078 Staff Recruitment/background checks $2,050 1079 Communications cell phone & mobile internet $16,000 OPERATING EXPENSES TOTAL $101,834 FINANCIAL SERVICES EXPENSES: 1082 Liability Insurance (Auto, Property, General) $9,442 1083 Other- Professional Liability $4,456 1084 Other-Administrative Overhead 11.5% $242,412 FINANCIAL SERVICES TOTAL $256,310 SPECIAL EXPENSES (Consultant/Etc.): 1090 Consultant(network &data management) $75,488 1091 Translation Services $1,800 1092 Medication Supports $0 SPECIAL EXPENSES TOTAL $77,288 FIXED ASSETS: 2000 Computers &Software $7,000 2001 Furniture & Fixtures $3,000 2002 Other- (Identify) $0 2003 Other- (Identify) $0 FIXED ASSETS TOTAL $10,000 TOTAL PROGRAM EXPENSES $2,425,826 MEDI-CAL REVENUE: Units of Service Rate $Amount 3000 Mental Health Services (Individual/Family/Group Therapy) 0 $0.00 $0 3100 Case Management 7,800 $2.89 $22,542 3200 Crisis Services 171,600 $5.57 $955,812 3300 Medication Support 0 $0.00 $0 3400 Collateral 0 $0.00 $0 3500 Plan Development 0 $0.00 $0 3600 Assessment 15,600 $3.46 $53,976 3700 Rehabilitation 0 $0.00 $0 3800 ICC 0 $0.00 $0 3900 IHBS 0 $0.00 $0 Estimated Specialty Mental Health Services Billing Totals 195,000 $1,032,330 Estimated % of Clients that are Medi-Cal Beneficiaries 20.0% Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $206,466 Federal M/Cal Share of Cost% (Federal Financial Participation-FFP) 1 85.00% 1 $175,496 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 9 of 15 State M/Cal Share of Cost% (BH Realignment/EPSDT) 0.00% $0 MEDI-CAL REVENUE TOTAL $175,496 OTHER REVENUE: 4100 Other- (Identify) $0 4200 Other- (Identify) $0 4300 Other- (Identify) $0 OTHER REVENUE TOTAL: MHSA Funds 1 $0 MENTAL HEALTH SERVICES ACT MHSA REVENUE: 5000 Prevention & Early Intervention (PEI) Funds $2,250,330 5100 Community Services &Supports (CSS) Funds $0 5200 Innovation (INN) Funds $0 5300 Workforce Education &Training (WET) Funds $0 MHSA FUNDS TOTAL $2,250,330 TOTAL PROGRAM REVENUE $2,425,826 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 10 of 15 County of Fresno - Fresno Metro Crisis Intervention (CIT) Services Kings View Corporation FY 2021-2022 Budget Categories - Total Proposed Budget Line Item Description (Must be itemized) FTE % Admin. Direct Total PERSONNEL SALARIES: 0001 Executive Director(Licensed) 0.02 $3,350 $3,350 0002 Director of Program Development (Licensed) 0.08 $8,182 $8,182 0003 Director of Clinical Operations 0.25 $32,957 $32,957 0004 CIT Program Manager 1.00 $111,371 $111,371 0005 UR Specialist 1.00 $97,734 $97,734 0006 Licensed Field Clinician 2.00 $190,921 $190,921 0007 Unlicensed Field Clinician 8.00 $690,953 $690,953 0008 Administrative Specialist 1.00 $50,003 $50,003 0009 Licensed Lead Field Clinician 2.00 $195,467 $195,467 0010 Fiscal Analyst 0.10 $6,819 $6,819 0011 CVSPH - Call Responder 1.00 $35,273 $35,273 0012 Per Diem Field Clinician Licensed 1,000 hours/year 0.00 $45,895 $45,895 SALARY TOTAL 16.45 $166,088 $1,302,837 $1,468,925 PAYROLL TAXES: 0031 FICA/MEDICARE $12,706 $99,667 $112,373 0032 SUI $1,661 $13,028 $14,689 PAYROLL TAX TOTAL $14,367 $112,695 $127,062 EMPLOYEE BENEFITS (22.45%): 0040 Retirement $3,322 $26,057 $29,379 0041 Workers Compensation $6,644 $52,113 $58,757 0042 Health Insurance (medical, vision, life, dental) 1 $29,895 $234,511 $264,406 EMPLOYEE BENEFITS TOTAL $39,861 $312,681 $352,542 SALARY& BENEFITS GRAND TOTAL $1,948,529 FACILITIES/EQUIPMENT EXPENSES: 1010 Rent/Lease Building (Ashlan Avenue Building) $22,947 1010 Rent/Lease Building (F Street Building) $9,835 1011 Rent/Lease Equipment (Copier, Hub-Printer) $4,098 1012 Utilities $6,447 1013 Janitorial/Building $2,404 1015 Other-Vehicle Leasing (11 Vehicles) $44,220 FACILITY/EQUIPMENT TOTAL $89,951 OPERATING EXPENSES: 1060 Telephone $16,008 1062 Postage $400 1063 Printing/Reproduction $1,600 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 11 of 15 1066 Office Supplies & Equipment $8,742 1069 Program Supplies $7,649 1072 Staff Mileage/vehicle maintenance $8,742 1074 Staff Training/Registration $10,000 1076 Data Lines (data drops, hub hookups, landline, Avatar) $22,292 1077 Other- Staff Uniforms/Miscellaneous $10,000 1078 Staff Recruitment/background checks $2,050 1079 Communications (cell phone & mobile internet) $16,000 OPERATING EXPENSES TOTAL $103,483 FINANCIAL SERVICES EXPENSES: 1082 Liability Insurance (Auto, Property, General) $9,725 1083 Other- Professional Liability $4,589 1084 Other-Administrative Overhead (11.5%) $249,214 FINANCIAL SERVICES TOTAL 1 $263,528 SPECIAL EXPENSES (Consultant/Etc.): 1090 Consultant(network &data management) $77,606 1091 Translation Services $1,800 1092 Medication Supports $0 SPECIAL EXPENSES TOTAL 1 $79,406 FIXED ASSETS: 2000 Computers &Software $6,000 2001 Furniture & Fixtures $3,000 2002 Other- (Identify) $0 2003 Other- (Identify) $0 FIXED ASSETS TOTAL $9,000 TOTAL PROGRAM EXPENSES $2,493,897 MEDI-CAL REVENUE: Units of Service Rate $Amount 3000 Mental Health Services (Individual/Family/Group Therapy) 0 $0.00 $0 3100 Case Management 8,150 $3.00 $24,450 3200 Crisis Services 178,500 $5.80 $1,035,300 3300 Medication Support 0 $0.00 $0 3400 Collateral 0 $0.00 $0 3500 Plan Development 0 $0.00 $0 3600 Assessment 16,200 $3.60 $58,320 3700 Rehabilitation 0 $0.00 $0 3800 ICC 0 $0.00 $0 3900 IHBS 0 $0.00 $0 Estimated Specialty Mental Health Services Billing Totalsl 202,850 $1,118,070 Estimated % of Clients that are Medi-Cal Beneficiaries 20.0% Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $223,614 Federal M/Cal Share of Cost% (Federal Financial Participation-FFP) 1 85.00% $190,072 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 12 of 15 State M/Cal Share of Cost% (BH Realignment/EPSDT) 0.00% $0 MEDI-CAL REVENUE TOTAL $190,072 OTHER REVENUE: 4100 Other- (Identify) $0 4200 Other- (Identify) $0 4300 Other- (Identify) $0 OTHER REVENUE TOTAL: MHSA Funds 1 $0 MENTAL HEALTH SERVICES ACT MHSA REVENUE: 5000 Prevention & Early Intervention (PEI) Funds $2,303,825 5100 Community Services &Supports (CSS) Funds $0 5200 Innovation (INN) Funds $0 5300 Workforce Education &Training (WET) Funds $0 MHSA FUNDS TOTAL $2,303,825 TOTAL PROGRAM REVENUE $2,493,897 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 13 of 15 County of Fresno - Fresno Metro Crisis Intervention (CIT) Services Kings View Corporation FY 2022-2023 Budget Categories - Total Proposed Budget Line Item Description (Must be itemized) FTE % Admin. Direct Total PERSONNEL SALARIES: 0001 Executive Director(Licensed) 0.02 $3,451 $3,451 0002 Director of Program Development (Licensed) 0.08 $8,428 $8,428 0003 Director of Clinical Operations 0.25 $33,945 $33,945 0004 CIT Program Manager 1.00 $114,712 $114,712 0005 UR Specialist 1.00 $100,666 $100,666 0006 Licensed Field Clinician 2.00 $196,649 $196,649 0007 Unlicensed Field Clinician 8.00 $711,682 $711,682 0008 Administrative Specialist 1.00 $51,503 $51,503 0009 Licensed Lead Field Clinician 2.00 $201,331 $201,331 0010 Fiscal Analyst 0.10 $7,023 $7,023 0011 CVSPH - Call Responder 1.00 $36,331 $36,331 0012 Per Diem Field Clinician (Licensed) 1,000 hours/year 0.00 $47,271 $47,271 SALARY TOTAL 16.45 $171,071 $1,341,921 $1,512,992 PAYROLL TAXES: 0031 FICA/MEDICARE $13,087 $102,657 $115,744 0032 SUI $1,711 $13,419 $15,130 PAYROLL TAX TOTAL $14,798 $116,076 $130,874 EMPLOYEE BENEFITS (22.45%): 0040 Retirement $3,421 $26,838 $30,259 0041 Workers Compensation $6,843 $53,677 $60,520 0042 Health Insurance (medical, vision, life, dental) 1 $30,793 $241,546 $272,339 EMPLOYEE BENEFITS TOTAL $41,057 $322,061 $363,118 SALARY& BENEFITS GRAND TOTAL $2,006,984 FACILITIES/EQUIPMENT EXPENSES: 1010 Rent/Lease Building (Ashlan Avenue Building) $23,636 1010 Rent/Lease Building (F Street Building) $10,130 1011 Rent/Lease Equipment(Copier, Hub-Printer) $4,221 1012 Utilities $6,641 1013 Janitorial/Building $2,476 1015 Other-Vehicle Leasing (11 Vehicles) $44,220 FACILITY/EQUIPMENT TOTAL $91,324 OPERATING EXPENSES: 1060 Telephone $16,489 1062 Postage $400 1063 Printing/Reproduction $1,600 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 14 of 15 1066 Office Supplies & Equipment $9,004 1069 Program Supplies $7,879 1072 Staff Mileage/vehicle maintenance $9,004 1074 Staff Training/Registration $10,000 1076 Data Lines (data drops, hub hookups, landline, Avatar) $22,960 1077 Other- Staff Uniforms/Miscellaneous $10,000 1078 Staff Recruitment/background checks $2,050 1079 Communications cell phone & mobile internet $16,000 OPERATING EXPENSES TOTAL $105,386 FINANCIAL SERVICES EXPENSES: 1082 Liability Insurance (Auto, Property, General) $10,017 1083 Other- Professional Liability $4,727 1084 Other-Administrative Overhead 11.5% $256,247 FINANCIAL SERVICES TOTAL $270,991 SPECIAL EXPENSES (Consultant/Etc.): 1090 Consultant(network &data management) $79,795 1091 Translation Services $1,800 1092 Medication Supports $0 SPECIAL EXPENSES TOTAL $81,595 FIXED ASSETS: 2000 Computers &Software $5,000 2001 Furniture & Fixtures $3,000 2002 Other- (Identify) $0 2003 Other- (Identify) $0 FIXED ASSETS TOTAL $8,000 TOTAL PROGRAM EXPENSES $2,564,280 MEDI-CAL REVENUE: Units of Service Rate $Amount 3000 Mental Health Services (Individual/Family/Group Therapy) 0 $0.00 $0 3100 Case Management 8,500 $3.12 $26,520 3200 Crisis Services 186,000 $6.03 $1,121,580 3300 Medication Support 0 $0.00 $0 3400 Collateral 0 $0.00 $0 3500 Plan Development 0 $0.00 $0 3600 Assessment 17,000 $3.75 $63,750 3700 Rehabilitation 0 $0.00 $0 3800 ICC 0 $0.00 $0 3900 IHBS 0 $0.00 $0 Estimated Specialty Mental Health Services Billing Totals 211,500 $1,211,850 Estimated % of Clients that are Medi-Cal Beneficiaries 20.0% Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $242,370 Federal M/Cal Share of Cost% (Federal Financial Participation-FFP) 1 85.00% $206,015 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit E Page 15 of 15 State M/Cal Share of Cost% (BH Real ignment/EPSDT) 0.00% $0 MEDI-CAL REVENUE TOTAL $206,015 OTHER REVENUE: 4100 Other- (Identify) $0 4200 Other- (Identify) $0 4300 Other- (Identify) $0 OTHER REVENUE TOTAL: MHSA Funds 1 $0 MENTAL HEALTH SERVICES ACT (MHSA) REVENUE: 5000 Prevention & Early Intervention (PEI) Funds $2,358,265 5100 Community Services &Supports (CSS) Funds $0 5200 Innovation (INN) Funds $0 5300 Workforce Education &Training (WET) Funds $0 MHSA FUNDS TOTAL $2,358,265 TOTAL PROGRAM REVENUE $2,564,280 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Crisis Care Mobile Units(CCMU)Grant Funds Kings View Metro CIT Fiscal Year(FY)2022-23 PROGRAM EXPENSES 1000:DIRECT SALARIES&BENEFITS Direct Employee Salaries Acct# Administrative Position FTE Admin Program Total 1101 QI Data Analyst 0.11 $ 7,550 $ 7,550 1102 - - 1103 1104 1105 1106 1107 1108 1109 1110 1111 1112 1113 1114 1115 Direct Personnel Admin Salaries Subtotal 0.11 $ 7,550 $ 7,550 Acct# Program Position FTE Admin Program Total 1116 Case Manager 2.00 $ 85,090 $ 85,090 1117 - - 1118 1119 1120 1121 1122 1123 1124 1125 1126 1127 1128 1129 1130 1131 1132 1133 1134 Direct Personnel Program Salaries Subtotall 2.00 1 1 $ 85,0901 $ 85,090 Admin I Program Total Direct Personnel Salaries Subtotall 2.11 1 $ 7,550 1 $ 85,090 1 $ 92,640 Direct Employee Benefits Acct# Description Admin Program Total 1201 Retirement $ 93 $ 1,046 $ 1,139 1202 Worker's Compensation 140 1,582 1,722 1203 Health Insurance 896 10,094 10,990 1204 Other(specify) - - 1205 10ther(specify) - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 1206 10ther(specify) - Direct Employee Benefits Subtotal:l $ 1,129 $ 12,722 $ 13,851 Direct Payroll Taxes&Expenses: Acct# Description Admin Program Total 1301 OASDI $ - $ - $ - 1302 FICA/MEDICARE 578 6,510 7,088 1303 SUI 30 340 370 1304 Other(specify) - - 1305 10ther(specify) 1306 10ther(specify) - - Direct Payroll Taxes&Expenses Subtotal: $ 608 $ 6,850 $ 7,458 DIRECT EMPLOYEE SALARIES&BENEFITS TOTAL: Admin Program Total $ 9,287 $ 104,662 $ 113,949 DIRECT EMPLOYEE SALARIES&BENEFITS PERCENTAGE: Admin Program 8%1 92% 2000: DIRECT CLIENT SUPPORT Acct# Line Item Description Amount 2001 Child Care $ - 2002 Client Housing Support 2003 Client Transportation&Support - 2004 Clothing,Food,&Hygiene 1,500 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) 500 2012 Other(specify) - 2013 Other(specify) - 2014 Other(specify) 2015 10ther(specify) - 2016 10ther(specify) DIRECT CLIENT CARE TOTAL $ 2,030 3000: DIRECT OPERATING EXPENSES Acct# Line Item Description Amount 3001 Telecommunications $ 1,560 3002 Printing/Postage - 3003 Office,Household&Program Supplies 3004 Advertising - 3005 Staff Development&Training 3006 Staff Mileage 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance 10,099 3009 Other(specify) - 3010 Other(specify) - 3011 Other(specify) 3012 Other(specify) - DIRECT OPERATING EXPENSES TOTAL: $ 11,659 4000: DIRECT FACILITIES&EQUIPMENT Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Acct# Line Item Description Amount 4001 Building Maintenance $ 4002 Rent/Lease Building 4003 Rent/Lease Equipment 4004 Rent/Lease Vehicles 6,855 4005 Security - 4006 Utilities 4007 Other(specify) 4008 Other(specify) 4009 Other(specify) 4010 10ther(specify) DIRECT FACILITIES/EQUIPMENT TOTAL: $ 6,855 5000:DIRECT SPECIAL EXPENSES Acct# Line Item Description Amount 5001 Consultant(Network&Data Management) $ 5002 HMIS(Health Management Information System) 5003 Contractual/Consulting Services (Specify) 5004 Translation Services 5005 Other(specify) 5006 Other(specify) 5007 Other(specify) 5008 Other(specify) DIRECT SPECIAL EXPENSES TOTAL: $ 6000: INDIRECT EXPENSES Acct# Line Item Description Amount Administrative Overhead 6001 Use this line and only this line for approved indirect cost rate $ Administrative Overhead 6002 Professional Liability Insurance 6003 Accounting/Bookkeeping 6004 External Audit 6005 Insurance(Specify): 6006 Payroll Services 6007 Depreciation(Provider-Owned Equipment to be Used for Program Purposes) 6008 Personnel(Indirect Salaries&Benefits) - 6009 Other(Administrative Overhead) 13,232 6010 Other(specify) - 6011 Other(specify) 6012 Other(specify) 6013 10ther(specify) INDIRECT EXPENSES TOTAL 1 $ 13 232 INDIRECT COST RATE 9.54% 7000: DIRECT FIXED ASSETS Acct# Line Item Description Amount 7001 Computer Equipment&Software $ 4,200 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA Data - 7003 Furniture&Fixtures 7004 Leasehold/Tenant/Building Improvements 7005 Other Assets over$500 with Lifespan of 2 Years+ 7006 Assets over$5,000/unit(Specify) 7007 Other(specify) I Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 7008 Other(specify) FIXED ASSETS EXPENSES TOTAL $ 4,200 TOTAL PROGRAM EXPENSES $ 151,895 PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) Acct# Line Item Description Service Units Rate Amount 8001 Mental Health Services 0 - $ 8002 Case Management 0 - 8003 Crisis Services 0 - 8004 Medication Support 0 - 8005 Collateral 0 - 8006 Plan Development 0 - 8007 Assessment 0 - 8008 Rehabilitation p - 8009 Other(Specify) 0 - 8010 10ther(Specify) 0 - Estimated Specialty Mental Health Services Billing Totals: 0 $ Estimated%of Clients who are Medi-Cal Beneficiaries 0% Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries - Federal Financial Participation(FFP)% 1 0% MEDI-CAL FFP TOTAL $ 8100-SUBSTANCE USE DISORDER FUNDS Acct# Line Item Description Amount 8101 Drug Medi-Cal $ 8102 SABG $ SUBSTANCE USE DISORDER FUNDS TOTAL $ 8200-REALIGNMENT Acct# Line Item Description Amount 8201 lRealignment $ 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 8303 INN-Innovations 8304 WET-Workforce Education&Training 8305 JCFTN-Capital Facilities&Technology MHSA TOTAL $ 8400-OTHER REVENUE Acct# Line Item Description Amount 8401 Client Fees $ 8402 Client Insurance 8403 Grants(Crisis Care Mobile Units) 151,895 8404 Other(Specify) 8405 10ther(Specify) OTHER REVENUE TOTAL $ 151,895 TOTAL PROGRAM FUNDING SOURCES: $ 151,895 NET PROGRAM COST: $ - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Crisis Care Mobile Units (CCMU) Grant Funds Kings View Metro CIT Fiscal Year (FY) 2022-23 PARTIAL FTE DETAIL For all positions with FTE's split among multiple programs/contracts the below must be filled out Position Contract#/Name/Department/County FTE QI Data Analyst PATH SMHS/Fresno 0.02 PATH/OEL Fresno 0.05 PATH MOP/Fresno 0.05 Blue Sky/Fresno 0.12 Rural CIT/Fresno 0.14 Rural CIT-CCMU/Fresno 0.11 Metro CIT/Fresno 0.01 Metro CIT-CCMU/Fresno 0.11 Map Point/Fresno 0.07 FURS/Fresno 0.03 Shasta 0.04 Kings 0.24 Quality& Performance Improvement Depart. 0.01 Total 1.00 Position Contract#/Name/Department/County FTE Total 0.00 Position Contract#/Name/Department/County FTE Total 0.00 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Position Contract#/Name/Department/County FTE Total 0.00 Position Contract#/Name/Department/County FTE Total 0.00 Position Contract#/Name/Department/County FTE Total 0.00 Position Contract#/Name/Department/County FTE Total 0.00 Position Contract#/Name/Department/County FTE DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Total 0.00 Position Contract#/Name/Department/County FTE Total 0.00 Position Contract#/Name/Department/County FTE Total 0.00 Position Contract#/Name/Department/County FTE Total 0.00 Position Contract#/Name/Department/County FTE DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Total 0.00 Position Contract#/Name/Department/County FTE Total 0.00 Position Contract#/Name/Department/County FTE Total 0.00 Position Contract#/Name/Department/County FTE Total 0.00 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Crisis Care Mobile Units(CCMU)Grant Funds Kings View Metro CIT Fiscal Year(FY)2022-23 Budget Narrative PROGRAM EXPENSE ACCT#1 LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1000:DIRECT SALARIES&BENEFITS 113,949 Administrative Positions 7,550 1101 QI Data Analyst 7,550 This position will perform a wide range of duties to support data collection, management,and reporting needs required for CCMU grant. 1102 0 - 1103 0 1104 0 1105 0 1106 0 1107 0 1108 0 1109 0 1110 0 1111 0 1112 0 1113 0 1114 0 1115 0 Program Positions 85,090 1116 Case Manager 85,090 Provides post-crisis case management and care coordination activites. 1117 0 - 1118 0 1119 0 1120 0 1121 0 1122 0 1123 0 1124 0 1125 0 1126 0 1127 0 1128 0 1129 0 1130 0 1131 0 1132 0 1133 0 1134 10 Direct Employee Benefits 13,851 1201 Retirement 1,139 Cost of 401K 1202 Worker's Compensation 1,722 Workers'compensation insurance 1203 Health Insurance 10,990 Cost of medical,vision,dental,life and long-term disability insurance. 1204 Other(specify) - 1205 Other(specify) 1206 Other(specify) - Direct Payroll Taxes&Expenses: 7,458 1301 OASDI _ 1302 FICA/MEDICARE 7,088 Cost of FICA/Medicare 1303 SUI 370 Cost of SUI 1304 Other(specify) - 1305 Other(specify) 1306 Other(specify) 2000:DIRECT CLIENT SUPPORT 2,000 2001 Child Care - 2002 Client Housing Support _ 2003 Client Transportation&Support _ 2004 Clothing,Food,&Hygiene 1,500 Includes program supplies that support clients with items such as,clothing,snacks, drinks,blankets,and hygiene supplies.Clothing items consist of the following:Shirts, pants,shorts,shoes,underwear,outerwear(jackets,beanies,gloves,socks,etc.)and any other wearable items to protect clients from the weather elements. 2005 Education Support 2006 Employment Support 2007 Household Items for Clients 2008 Medication Supports 2009 Program Supplies-Medical 2010 Utility Vouchers Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2I7I2020 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 PROGRAM EXPENSE ACCT p LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 2011 Other(Program Supplies) 500 Includes therapeutic supplies that can be used to assist in focus enhancement and emotional regulation.Additional benefits include distraction,anxiety reduction, soothing of sensitive sensory nerves,reducing agitation,and restoring an individual's sense of control.These items include stress relief sensory items such as pop-its,stress balls,fidget spinners,coloring books/crayons,etc. 2012 Other(specify) 2013 Other(specify) 2014 Other(specify) 2015 Other(specify) 2016 1 Other(specify) 3000:DIRECT OPERATING EXPENSES 11,659 3001 Telecommunications 1,560 Cost of cell phones,cell phones service,data connectivity. 3002 Printing/Postage - 3003 Office,Household&Program Supplies 3004 Advertising 3005 Staff Development&Training 3006 Staff Mileage 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance 10,099 Minor auto repairs&maintenance required to maintain 2 leased vehicles for client transportation and program needs.Includes expenses such as oil changes,car washes, vehicle tracking service,auto fuel,and DMV fees. 3009 Other(specify) 3010 Other(specify) 3011 Other(specify) 3012 Other(specify) 4000:DIRECT FACILITIES&EQUIPMENT 6,855 4001 Building Maintenance - 4002 Rent/Lease Building 4003 Rent/Lease Equipment - 4004 Rent/Lease Vehicles 6,855 Cost of 2 leased vehicles to allow case management staff to conduct post-crisis follow- up services in person and transport persons served,as appropriate. 4005 Security - 4006 Utilities 4007 Other(specify) 4008 Other(specify) 4009 Other(specify) 4010 other(specify) 5000:DIRECT SPECIAL EXPENSES 5001 Consultant(Network&Data Management) 5002 HMIS(Health Management Information System) 5003 Contractual/Consulting Services (Specify) 5004 Translation Services 5005 Other(specify) 5006 Other(specify) 5007 Other(specify) 5008 Other(specify) 6000:INDIRECT EXPENSES 13,232 6001 Administrative Overhead - 6002 Professional Liability Insurance 6003 Accounting/Bookkeeping 6004 External Audit 6005 Insurance(Specify): 6006 Payroll Services 6007 Depreciation(Provider-Owned Equipment to be Used 6008 Personnel(Indirect Salaries&Benefits) - 6009 Other(Administrative Overhead) 13,232 Expense provides corporate management,fiscal services,payroll,human resources, accounts payable and other administrative functions. 6010 Other(specify) - 6011 Other(specify) 6012 Other(specify) 6013 1 Other(specify) 7000:DIRECT FIXED ASSETS 4,200 7001 Computer Equipment&Software 4,200 Purchase of 2 computers for case management staff and estimated software needs to support staff. 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA - 7003 Furniture&Fixtures 7004 Leasehold/Tenant/Building Improvements Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2I7I2020 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 PROGRAM EXPENSE ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 7005 Other Assets over$500 with Lifespan of 2 Years+ - 7006 Assets over$5,000/unit(Specify) - 7007 Other(specify) - 7008 Other(specify) - PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) PROVIDE DETAILS OF METHODOLOGY(IES)USED IN DETERMINING MEDI-CAL ACCT# LINE ITEM SERVICE RATES AND/OR SERVICE UNITS,IF APPLICABLE AND/OR AS REQUIRED BY THE RFP 8001 Mental Health Services 8002 Case Management 8003 Crisis Services 8004 Medication Support 8005 Collateral 8006 Plan Development 8007 Assessment 8008 Rehabilitation 8009 Other(Specify) 8010 1 Other(Specify) TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 151,895 TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 151,895 BUDGET CHECK: - Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2/7/2020 00 rn N Cd N M Cd w O 00 " N —c'I �vj O Cd � W W 9 00 V N 00 M ~ ) 00 M M w u �. x o N o E C) ,c 00 M Cd Uan o Q °O s '� W w o Cd 'd Cd Cd r01 o 00 M m �" cn r N 00 M rs acd x x N a o � .� Cd Zcn al ° N v N W � � z O a� > LU a� OU o 0 o y Cd V N N N W N p U O O O rA U 6 '� W 'C v N a '!S -00 LO O o o o U LU v d ( O i v U �" LO a O O oA m oA U U � •- = vs c � N O S N •� � N p N zx � z � zx � U) 0 ') DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit F Page 1 of 3 FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM CONTRACTOR CODE OF CONDUCT AND ETHICS Fresno County is firmly committed to full compliance with all applicable laws, regulations, rules and guidelines that apply to the provision and payment of mental health services. Mental health contractors and the manner in which they conduct themselves are a vital part of this commitment. Fresno County has established this Contractor Code of Conduct and Ethics with which contractor and its employees and subcontractors shall comply. CONTRACTOR(S) shall require its employees and subcontractors to attend a compliance training that will be provided by Fresno County. After completion of this training, CONTRACTOR(S), CONTRACTOR(S)' employees and subcontractors must sign the Contractor Acknowledgment and Agreement form and return this form to the Compliance Officer or designee. Contractor and its employees and subcontractor shall: 1. Comply with all applicable laws, regulations, rules or guidelines when providing and billing for mental health services. 2. Conduct themselves honestly, fairly, courteously and with a high degree of integrity in their professional dealing related to their contract with the COUNTY and avoid any conduct that could reasonably be expected to reflect adversely upon the integrity of the COUNTY. 3. Treat COUNTY employees, consumers, and other mental health contractors fairly and with respect. 4. NOT engage in any activity in violation of the COUNTY's Compliance Program, nor engage in any other conduct which violates any applicable law, regulation, rule or guideline 5. Take precautions to ensure that claims are prepared and submitted accurately, timely and are consistent with all applicable laws, regulations, rules or guidelines. 6. Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement of any kind are submitted. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit F Page 2of3 7. Bill only for eligible services actually rendered and fully documented. Use billing codes that accurately describe the services provided. 8. Act promptly to investigate and correct problems if errors in claims or billing are discovered. 9. Promptly report to the Compliance Officer any suspected violation(s) of this Code of Conduct and Ethics by COUNTY employees or other mental health contractors, or report any activity that they believe may violate the standards of the Compliance Program, or any other applicable law, regulation, rule or guideline. Fresno County prohibits retaliation against any person making a report. Any person engaging in any form of retaliation will be subject to disciplinary or other appropriate action by the COUNTY. CONTRACTOR(S) may report anonymously. 10. Consult with the Compliance Officer if you have any questions or are uncertain of any Compliance Program standard or any other applicable law, regulation, rule or guideline. 11. Immediately notify the Compliance Officer if they become or may become an Ineligible person and therefore excluded from participation in the Federal Health Care Programs. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit F Page 3 of 3 Fresno County Mental Health Compliance Program Contractor Acknowledgment and Agreement I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental Health Compliance Program and understand the contents thereof. I further agree to abide by the Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my responsibilities as a mental health contractor for Fresno County. I understand and accept my responsibilities under this Agreement. I further understand that any violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program may result in termination of my agreement with Fresno County. I further understand that Fresno County will report me to the appropriate Federal or State agency. For Individual Providers Name (print): Discipline: ❑ Psychiatrist ❑ Psychologist ❑ LCSW ❑ LMFT Signature: Date: For Group or Organizational Providers Group/Org. Name (print): Kings view Employee Name (print): Amanda Nugent Divine Discipline: ❑ Psychiatrist ❑ Psychologist ❑ LCSW ❑ LMFT ❑ Other: Job Title (if diffewntifrdapa Discipline): CEO A+h N D-V / Signature: �'z Date:8�30 zoZz DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT H Ur, ""INEIrw Department of o� 1$560 Behavioral Health FRV`, PPG 1.2.7 V#: 1 Section: Administration, DBH Policies & Procedures Effective Date: 05/31/2017 Policy Title: Performance Outcome Measures Approved by: Dawan Utecht (Director of Behavioral Health), Francisco Escobedo (Managed Care Coordinator), Kannika Toonnachat (Division Manager) POLICY: It is the policy of Fresno County Department of Behavioral Health and the Fresno County Mental Health Plan (FCMHP) to ensure procedures for developing performance measures which accurately reflect vital areas of performance and provide for systematic, ongoing collection and analysis of valid and reliable data. Data collection is not intended to be an additional task for FCMHP programs/providers but rather embedded within the various non-treatment, treatment and clinical documentation. PURPOSE: To determine the effectiveness and efficiency of services provided by measuring performance outcomes/results achieved by the persons served during service delivery or following service completion, delivery of service, and of the individuals' satisfaction. This is a vital management tool used to clarify goals, document the efforts toward achieving those goals, and thus measure the benefit the service delivery to the persons served. Performance measurement selection is part of the planning and developing process design of the program. Performance measurement is the ongoing monitoring and reporting of progress towards pre-established objectives/goals. REFERENCE: California Code of Regulations, Title 9, Chapter 11 , Section 1810.380(a)(1): State Oversight DHCS Service, Administrative and Operational Requirements Mental Health Services Act (MHSA), California Code of Regulations, Title 9, Section 3320, 3200.050, and 3200.120 Commission on Accreditation of Rehabilitation Facilities (CARF) DEFINITIONS: 1. Indicator: Qualitative or quantitative measure(s) that tell if the outcomes have been accomplished. Indicators evaluate key performance in relation to objectives. It indicates what the program is accomplishing and if the anticipated results are being achieved. 2. Intervention: A systematic plan of action consciously adapted in an attempt to address and reduce the causes of failure or need to improve upon system. MISSION STATEMENT The Department of Behavioral Health is dedicated to supporting the wellness of individuals,families and communities in Fresno County who are affected by,or are at risk of,mental illness and/or substance use disorders through cultivation of strengths toward promoting recovery in the least restrictive environment. Temp Review Date 3128116 11Page EXHIBIT H DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Section:Administration, DBH Policies& Procedures cot,- Revised Date:05/31/2017 Department of o� 1856 o Behavioral Health FRESH PPG 1.2.7 V#: 1 Policy Title: Performance Outcome Measures 3. Fresno County Mental Health Plan (FCMHP): Fresno County's contract with the State Department of Health and Human Services that allows for the provision of specialty mental health services. Services may be delivered by county-operated programs, contracted organizational, or group providers. 4. Objective (Goal): Intended results or the impact of learning, programs, or activities. 5. Outcomes: Specific results or changes achieved as a consequence of the program or intervention. Outcomes are connected to the objectives/goals identified by the program or intervention. PROCEDURE: I. Each FCMHP program/provider shall engage in measurement of outcomes in order to generate reliable and valid data on the effectiveness and efficiency of programs or interventions. Programs/providers will establish/select objectives (goals), decide on a methodology and timeline for the collection of data, and use an appropriate data collection tool. This occurs during the program planning and development process. Outcomes should be in alignment with the program/provider goals. II. Outcomes should be measureable, obtainable, clear, accurately reflect the expected result, and include specific time frames. Once the measures have been selected, it is necessary to design a way to gather the information. For each service delivery performance indicator, FCMHP program/provider shall determine: to whom the indicator will be applied; who is responsible for collecting the data; the tool from which data will be collected; and a performance target based on an industry benchmark, or a benchmark set by the program/provider. III. Performance measures are subject to review and approval by FCMHP Administration. IV. Performance measurement is the ongoing monitoring and reporting of progress towards pre-established objectives/goals. Annually, each FCMHP program/provider must measure service delivery performance in each of the areas/domains listed below. Dependent on the program/provider service deliverables, exceptions must be approved by the FCMHP Administration. a. Effectiveness of services — How well programs performed and the results achieved. Effectiveness measures address the quality of care through measuring change over time. Examples include but are not limited to: reduction 2 1 P a g e EXHIBIT H DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Section:Administration, DBH Policies& Procedures coU��� Department of Revised Date: 05/31/2017 � o� 1896 Behavioral Health FRES PPG 1.2.7 V#: 1 Policy Title: Performance Outcome Measures of hospitalization, reduction of symptoms, employment and housing status, and reduction of recidivism rate and incidence of relapse. b. Efficiency of services — The relationship between the outcomes and the resources used. Examples include but are not limited to: service delivery cost per service unit, length of stay, and direct service hours of clinical and medical staff. c. Services access — Changes or improvements in the program/provider's capacity and timeliness to provide services to those who request them. Examples include but are not limited to: wait/length of time from first request/referral to first service or subsequent appointment, convenience of service hours and locations, number of clients served by program capacity, and no-show and cancellation rates. d. Satisfaction and feedback from persons served and stakeholders— Changes or increased positive/negative feedback regarding the experiences of the persons served and others (families, referral sources, payors/guarantors, etc.). Satisfaction measures are usually oriented toward clients, family members, personnel, the community, and funding sources. Examples include but are not limited to: did the organization/program focus on the recovery of the person served, were grievances or concerns addressed, overall feelings of satisfaction, and satisfaction with physical facilities, fees, access, service effectiveness, and efficiency. V. Each FCMHP program/provider shall use the following templates to document the defined goals, intervention(s), specific indicators, and outcomes. 1. FCMHP Outcome Report template (see Attachment A) 2. FCMHP Outcome Analysis template (see Attachment C) 3 1 P a g e 2 H CO LLXI o Y O Q �ti y N A� W E N N O X X X X w aO+ v OM aO+ aO+ L a,,, +O+ L O 4U 4U 4O Q c —C C C C i 4J 4J 41 N 0 p .� O O O Y 1 O v o v v v N N N v N U N N N t t O t t d 0 0 0 O N u U U U U U u = U U LLI 3 o M O Y0 Q V astw H a +r D Y O W N Q L D O a 'a N i O L L X O ++ > d W O "C d qp 4J N O v 0 2 ++ C. c s O +' C. C L a` o cc Li O a` c LL oC c v 0 v L v U . 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U c U f 0 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT H FRESNO COUNTY MENTAL HEALTH PLAN Outcomes Analysis Template Attachment B Name of Program: Click here to enter text. What is the Program/Contract Goals? Click here to enter text. Program Type: Type of Program: Other, please specify below Other: Click here to enter text. CLINICAL INFORMATION: Does the Program Utilize Any of the Following? (May select more than one) Evidence Informed Practice Best Practice Evidence Based Practice Other: Click here to enter text. Please Describe: Click here to enter text. OUTCOMES What Outcome Measures Are Being Used? Click here to enter text. What Outcome Measures/Functional Variables Could Be Added to Better Explain the Program's Effectiveness? Click here to enter text. Describe the Program's analysis (i.e. have the program/contract goals been met? Number served, waiting list,wait times, budget to volume, etc.): Click here to enter text. What Barriers Prevent the Program from Achieving Better Outcomes? Click here to enter text. What Changes to the Program Would You Recommend to Improve the outcomes ? Click here to enter text. For Committee Use Only: Recommendations: do include a conclusion and a to-do list with action items Click here to enter text. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT H Page 1 of 6 STATE MENTAL HEALTH REQUIREMENTS 1. CONTROL REQUIREMENTS The COUNTY and its subcontractors shall provide services in accordance with all applicable Federal and State statutes and regulations. 2. PROFESSIONAL LICENSURE All (professional level) persons employed by the COUNTY Mental Health Program (directly or through contract) providing Short-Doyle/Medi-Cal services have met applicable professional licensure requirements pursuant to Business and Professions and Welfare and Institutions Codes. 3. CONFIDENTIALITY CONTRACTOR shall conform to and COUNTY shall monitor compliance with all State of California and Federal statutes and regulations regarding confidentiality, including but not limited to confidentiality of information requirements at 42, Code of Federal Regulations sections 2.1 et seq; California Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division 10.5 and 10.6 of the California Health and Safety Code; Title 22, California Code of Regulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 of the California Civil Code. 4. NON-DISCRIMINATION A. Eligibility for Services CONTRACTOR shall prepare and make available to COUNTY and to the public all eligibility requirements to participate in the program plan set forth in the Agreement. No person shall, because of ethnic group identification, age, gender, color, disability, medical condition, national origin, race, ancestry, marital status, religion, religious creed, political belief or sexual preference be excluded from participation, be denied benefits of, or be subject to discrimination under any program or activity receiving Federal or State of California assistance. B. Employment Opportunity CONTRACTOR shall comply with COUNTY policy, and the Equal Employment Opportunity Commission guidelines, which forbids discrimination against any person on the grounds of race, color, national origin, sex, religion, age, disability status, or sexual preference in employment practices. Such practices include retirement, recruitment advertising, hiring, layoff, termination, upgrading, demotion, transfer, rates of pay or other forms of compensation, use of facilities, and other terms and conditions of employment. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT H Page 2 of 6 C. Suspension of Compensation If an allegation of discrimination occurs, COUNTY may withhold all further funds, until CONTRACTOR can show clear and convincing evidence to the satisfaction of COUNTY that funds provided under this Agreement were not used in connection with the alleged discrimination. D. Nepotism Except by consent of COUNTY's Department of Behavioral Health Director, or designee, no person shall be employed by CONTRACTOR who is related by blood or marriage to, or who is a member of the Board of Directors or an officer of CONTRACTOR. 5. PATIENTS' RIGHTS CONTRACTOR shall comply with applicable laws and regulations, including but not limited to, laws, regulations, and State policies relating to patients' rights. STATE CONTRACTOR CERTIFICATION CLAUSES 1. STATEMENT OF COMPLIANCE: CONTRACTOR has, unless exempted, complied with the non-discrimination program requirements. (Gov. Code§ 12990 (a-f) and CCR, Title 2, Section 111 02) (Not applicable to public entities.) 2. DRUG-FREE WORKPLACE REQUIREMENTS: CONTRACTOR will comply with the requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-free workplace by taking the following actions: a. Publish a statement notifying employees that unlawful manufacture, distribution, dispensation, possession or use of a controlled substance is prohibited and specifying actions to be taken against employees for violations. b. Establish a Drug-Free Awareness Program to inform employees about: 1) the dangers of drug abuse in the workplace; 2) the person's or organization's policy of maintaining a drug-free workplace; 3) any available counseling, rehabilitation and employee assistance programs; and, 4) penalties that may be imposed upon employees for drug abuse violations. C. Every employee who works on this Agreement will: 1) receive a copy of the company's drug-free workplace policy statement; and, 2) agree to abide by the terms of the company's statement as a condition of employment on this Agreement. Failure to comply with these requirements may result in suspension of payments under this Agreement or termination of this Agreement or both and DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT H Page 3of6 CONTRACTOR may be ineligible for award of any future State agreements if the department determines that any of the following has occurred: the CONTRACTOR has made false certification, or violated the certification by failing to carry out the requirements as noted above. (Gov. Code §8350 et seq.) 3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION: CONTRACTOR certifies that no more than one (1) final unappealable finding of contempt of court by a Federal court has been issued against CONTRACTOR within the immediately preceding two (2) year period because of CONTRACTOR's failure to comply with an order of a Federal court, which orders CONTRACTOR to comply with an order of the National Labor Relations Board. (Pub. Contract Code §10296) (Not applicable to public entities.) 4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO REQUIREMENT: CONTRACTOR hereby certifies that CONTRACTOR will comply with the requirements of Section 6072 of the Business and Professions Code, effective January 1, 2003. CONTRACTOR agrees to make a good faith effort to provide a minimum number of hours of pro bono legal services during each year of the contract equal to the lessor of 30 multiplied by the number of full time attorneys in the firm's offices in the State, with the number of hours prorated on an actual day basis for any contract period of less than a full year or 10% of its contract with the State. Failure to make a good faith effort may be cause for non-renewal of a state contract for legal services, and may be taken into account when determining the award of future contracts with the State for legal services. 5. EXPATRIATE CORPORATIONS: CONTRACTOR hereby declares that it is not an expatriate corporation or subsidiary of an expatriate corporation within the meaning of Public Contract Code Section 10286 and 10286.1, and is eligible to contract with the State of California. 6. SWEATFREE CODE OF CONDUCT: a. All CONTRACTORS contracting for the procurement or laundering of apparel, garments or corresponding accessories, or the procurement of equipment, materials, or supplies, other than procurement related to a public works contract, declare under penalty of perjury that no apparel, garments or corresponding accessories, equipment, materials, or supplies furnished to the state pursuant to the contract have been laundered or produced in whole or in part by sweatshop labor, forced labor, convict labor, indentured labor under penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor, or with the benefit of sweatshop labor, forced labor, convict labor, indentured labor under penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor. CONTRACTOR further declares under penalty of perjury that they adhere to the Sweatfree Code of Conduct as set forth on the California Department of Industrial Relations website located at www.dir.ca.gov, and Public Contract Code Section 6108. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT H Page 4 of 6 b. CONTRACTOR agrees to cooperate fully in providing reasonable access to the CONTRACTOR's records, documents, agents or employees, or premises if reasonably required by authorized officials of the contracting agency, the Department of Industrial Relations, or the Department of Justice to determine the contractor's compliance with the requirements under paragraph (a). 7. DOMESTIC PARTNERS: For contracts of$100,000 or more, CONTRACTOR certifies that CONTRACTOR is in compliance with Public Contract Code Section 10295.3. 8. GENDER IDENTITY: For contracts of$100,000 or more, CONTRACTOR certifies that CONTRACTOR is in compliance with Public Contract Code Section 10295.35. DOING BUSINESS WITH THE STATE OF CALIFORNIA The following laws apply to persons or entities doing business with the State of California. 1. CONFLICT OF INTEREST: CONTRACTOR needs to be aware of the following provisions regarding current or former state employees. If CONTRACTOR has any questions on the status of any person rendering services or involved with this Agreement, the awarding agency must be contacted immediately for clarification. Current State Employees (Pub. Contract Code �10410): a). No officer or employee shall engage in any employment, activity or enterprise from which the officer or employee receives compensation or has a financial interest and which is sponsored or funded by any state agency, unless the employment, activity or enterprise is required as a condition of regular state employment. b). No officer or employee shall contract on his or her own behalf as an independent contractor with any state agency to provide goods or services. Former State Employees (Pub. Contract Code M0411): a). For the two (2) year period from the date he or she left state employment, no former state officer or employee may enter into a contract in which he or she engaged in any of the negotiations, transactions, planning, arrangements or any part of the decision-making process relevant to the contract while employed in any capacity by any state agency. b). For the twelve (12) month period from the date he or she left state employment, no former state officer or employee may enter into a contract with any state agency if he or she was employed by that state agency in a policy-making position in the same general subject area as DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT H Page 5 of 6 the proposed contract within the twelve (12) month period prior to his or her leaving state service. If CONTRACTOR violates any provisions of above paragraphs, such action by CONTRACTOR shall render this Agreement void. (Pub. Contract Code §10420) Members of boards and commissions are exempt from this section if they do not receive payment other than payment of each meeting of the board or commission, payment for preparatory time and payment for per diem. (Pub. Contract Code §10430 (e)) 2. LABOR CODE/WORKERS' COMPENSATION: CONTRACTOR needs to be aware of the provisions which require every employer to be insured against liability for Worker's Compensation or to undertake self-insurance in accordance with the provisions, and CONTRACTOR affirms to comply with such provisions before commencing the performance of the work of this Agreement. (Labor Code Section 3700) 3. AMERICANS WITH DISABILITIES ACT: CONTRACTOR assures the State that it complies with the Americans with Disabilities Act (ADA) of 1990, which prohibits discrimination on the basis of disability, as well as all applicable regulations and guidelines issued pursuant to the ADA. (42 U.S.C. 12101 et seq.) 4. CONTRACTOR NAME CHANGE: An amendment is required to change the CONTRACTOR's name as listed on this Agreement. Upon receipt of legal documentation of the name change the State will process the amendment. Payment of invoices presented with a new name cannot be paid prior to approval of said amendment. 5. CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA: a. When agreements are to be performed in the state by corporations, the contracting agencies will be verifying that the CONTRACTOR is currently qualified to do business in California in order to ensure that all obligations due to the state are fulfilled. b. "Doing business" is defined in R&TC Section 23101 as actively engaging in any transaction for the purpose of financial or pecuniary gain or profit. Although there are some statutory exceptions to taxation, rarely will a corporate contractor performing within the state not be subject to the franchise tax. C. Both domestic and foreign corporations (those incorporated outside of California) must be in good standing in order to be qualified to do business in California. Agencies will determine whether a corporation is in good standing by calling the Office of the Secretary of State. 6. RESOLUTION: A county, city, district, or other local public body must provide the State with a copy of a resolution, order, motion, or ordinance of the local governing body, which by law has authority to enter into an agreement, authorizing execution of the agreement. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT H Page 6 of 6 7. AIR OR WATER POLLUTION VIOLATION: Under the State laws, the CONTRACTOR shall not be: (1) in violation of any order or resolution not subject to review promulgated by the State Air Resources Board or an air pollution control district; (2) subject to cease and desist order not subject to review issued pursuant to Section 13301 of the Water Code for violation of waste discharge requirements or discharge prohibitions; or (3) finally determined to be in violation of provisions of federal law relating to air or water pollution. 8. PAYEE DATA RECORD FORM STD. 204: This form must be completed by all contractors that are not another state agency or other governmental entity. 9. INSPECTION and Audit of Records and access to Facilities. The State, CMS, the Office of the Inspector General, the Comptroller General, and their designees may, at any time, inspect and audit any records or documents of CONTRACTOR or its subcontractors, and may, at any time, inspect the premises, physical facilities, and equipment where Medicaid-related activities or work is conducted. The right to audit under this section exists for ten (10) years from the final date of the contract period or from the date of completion of any audit, whichever is later. Federal database checks. Consistent with the requirements at § 455.436 of this chapter, the State must confirm the identity and determine the exclusion status of CONTRACTOR, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of CONTRACTOR through routine checks of Federal databases. This includes the Social Security Administration's Death Master File, the National Plan and Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE), the System for Award Management (SAM), and any other databases as the State or Secretary may prescribe. These databases must be consulted upon contracting and no less frequently than monthly thereafter. If the State finds a party that is excluded, it must promptly notify the CONTRACTOR and take action consistent with § 438.610(c). The State must ensure that CONTRACTOR with which the State contracts under this part is not located outside of the United States and that no claims paid by a CONTRACTOR to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT I Page 1 of 9 INCIDENT REPORTING PROTOCOL FOR COMPLETION OF INCIDENT REPORT The Incident Report must be completed for all incidents involving individuals served through DBH's current incident reporting portal, Logic Manager, at https://fresnodbh.logicmanager.com/incidents/?t=9&p=1&k=182beOc5cdcd5072bb1864cdee 4d3d6e • The reporting portal is available 24 hours a day, every day. • Any employee of the CONTRACTOR can submit an incident using the reporting portal at any time. No login is required. • The designated administrator of the CONTRACTOR can add information to the follow up section of the report after submission. • When an employee submits an incident within 24 hours from the time of the incident or first knowledge of the incident, the CONTRACTOR's designated administrator, the assigned contract analyst and the Incident Reporting email inbox will be notified immediately via email from the Logic Manager system that there is a new incident to review. • Meeting the 24 hour incident reporting requirements will be easier as there are no signatures to collect. • The user guide attached identifies the reporting process and the reviewer process, and is subject to updates based on DBH's selected incident reporting portal system. Questions about incident reporting, how to use the incident reporting portal, or designating/changing the name of the administrator who will review incidents for the CONTRACTOR should be emailed to DBHlncidentReporting@fresnocountyca.gov and the assigned contract analyst. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Mental Health Plan (MHP) and Substance Use Disorder (SUD) services EXHIBIT I co Incident Reporting System Page 2 of 9 INCIDENT REVIEWER ROLE — User Guide Fresno County Department of Behavioral Health (DBH) requires all of its county-operated and contracted providers (through the Mental Health Plan (MHP) and Substance Use Disorder (SUD) services) to complete a written report of any incidents compromising the health and safety of persons served, employees, or community members. Yes! Incident reports will now be made through an on online reporting portal hosted by Logic Manager. It's an easier way for any employee to report an incident at any time. A few highlights: • No supervisor signature is immediately required. • Additional information can be added to the report by the program supervisor/manager without having to resubmit the incident. • When an incident is submitted, the assigned contract analyst, program supervisor/manager, clinical supervisor and the DBHlncidentReporting mailbox automatically receives an email notification of a new incident and can log in any time to review the incident. Everything that was on the original paper/electronic form matches the online form. • Do away with submitting a paper version with a signature. • This online submission allows for timely action for the health and safety of the persons-served, as well as compliance with state reporting timelines when necessary. As an Incident Reviewer,the responsibility is to: • Log in to Logic Manager and review incident submitted within 48 hours of notification of incident. • Review incident for clarity, missing information and add in additional information deemed appropriate. • Notify DBHlncidentReporting@fresnocountyca.gov if there is additional information to be report after initial submission • Contact.DBHlncidentReporting@fresnocountVca.gov if there are any concerns, questions or comments with Logic Manager or incident reporting. Below is the link to report incidents https://fresnodbh.logicmanager.com/incidents/?t=9&p=1&k=182be0c5cdcd5072bbl864cdee4d3d6e The link will take employees to the reporting screen to begin incident submission: DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT I Page 3 of 9 F �, p 0 hc.nudul>_logi<ntaregc:.mrn LogicManager Incident Report Please complete this form Client lnlormatian Namo of Fazlllty' Nance of Reporting Party' Fadllty Address Facility Phone Number" Mortal Hoalth or Substance Uw Disorder Program?' Client First!tame' Client Last Name E C 6 r + Client Date of Binh Client Address Client ID C,ender County of Origm' Summary Subject a Incident itheck all that apply) if Other-specify 11.0.fire,poisoning,epide—outbreaks.other catastroplwsr'ev cats mat jeopardise the erelfare and safety of cbents,staff and for memb..of the commumry): Descnptlonuf Iheinddent' DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT I Similar to the paper version, multiple incident categories can be selected Page 4 of 9 Incident(check all that apply: Medical Emergency. Death of Client - Homicide/Homicide Attempt AWOL;Elopement from lockod facility Vlolence,Wbuse;Assault(toward other,client anther property Attempted Suicide(resulting In serious Injury) Injury(sell-In0kted or by accident) Medication Error E C O Y besnalWilDgk menageccwn(ncklentsJ+t 9&V 1&k-182be0c5cdcd50726b1961cdeeM1dldUe Date of Incident' Time of I.Went' Location of Inudent' Key people Directly Involved In Incident Iwdnesses,staff)' Did the Injured party seek Medical Attention? Attach any additional details ®A04 fll. or Drop pile Hero Reported by Name' Reported 0y Email' Reported On 10130l2019 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT I Page 5 of 9 As another bonus feature, either drag files (such as a copy of a UOR, additional statements/document) or click on Add File to uplG file. trecnxihh.la�i<marwge,,<um�u,;u. I k IF Reported BY Namo' Reported By Email' Roportod On 10!30;2019 • Follow up Action Taken(check all that apply) Pime speclly d other Da:ci 1ptlon of Action Taken' Outcome' Similar to the paper version, multiple Action Taken categories can be selected. - Fulbw Up Action Taken icheck all that applyl' Law Entdreement Contacted if Called 913jEMS x Consulted with Phyvclan First Aid;CPR Admin,ste,ed Chent removed Irom building parentil."al Guardian Contacted Other When done entering all the information, simply click submit. Any fields that have a red asterisk, require information an will prevent submission of the form if left blank. A"Thank you for your submission" statement will pop up if an incident is successfully submitted. Click"Reload the Form"to submit another incident. LogicManager Thank you for your submission) RELOAD THE FORM DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT Page 6 of 9 A Notification email will be received when a new incident is reported, or a new comment has been made regarding an incident. Click on "Open this incident in Logic Manager" and the Logic Manager login screen will show. Wed 10/30/2019 10:40 AM SL SYSTEM LogicManager via custom r.support@logicmanager.com <customer.support@ log icmanager.com> Notification- -Er,—dent Reporting 0 If there are problems with how this message is displayed,click here to view it in a web Click here to download pictures.To help protect your privacy,Outlook prevented autom Ic download of some pictures in this message. CAUTION!!!-EXTERNAL EMAIL-THINK BEFORE YOU CLICK z�FyM1l ka YV ardldltrebdunhd pkhrw.To h*yraxtyar— v.ortl�P..arEneEc dwnYvd dtlas pkwe fran qe lnpfcMan x,GK. Hi Mila Arevalo, You have received a notification through LogicManager Please see the details below Type:Incident Report Subject:102_ Not cation To:Mila Arevalo Open this incident in LogicManager If using Intemet Explorer,click here to open the notification. This email was generated by LogicManager.If you have any technical issues, please email suo0ortltblom manacter.com. Enter in email address and password. First time users will be prompted to set up a password. Q O fresnodbh.my.logicmanager.com/login Log icManager Forgot your password? DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT I Page 7 of 9 Once logged in,the main screen will show reviewer task(incidents to review). Click on analyst/supervisor follow up to view the incident. .. Your Task List TASKM"F This screen below will then pop up. There are 5 tabs to navigate through. Client information will show the client and facility information. No edits can be made to this section. Analyst Follow Up cure iKw.�rr. war«w r..rta.rrturviu w«.rm.:pa�r• «rM+r«r wnra x..ena•mm�<..v uv.e.r nap.n. uranw.».. a».aar.xnw •W iD nl wr.�if..d �� The next tab is Sum ary: No edits can be made to this section. Analyst Follow Up tx N.a taxw W n«aptri' aw.auwx Y - •oa.,w«i�v..��.o..«x•rs.mN.�xwpm......ar.n<«.n.na+o«.�e.wr»wrr.a.v.v«.wuryara.�«.ra..w ro.«..e...w.n..a..n.n�yi m�n ex xnN.nr r o.uau.n.�r ra,ono» r r««xn a acNmr EXHIBIT I DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Page 8 of 9 The next tab is Follow up: This section can be edited. Add to the areas below or make corrections to these fields. Be sure to click SAVE when edits are made.Then Cancel to Exit out of the incident. Analyst Follow Up n<uoa rawm cur<w au:na apv,n l.w[nlore.mw,t ConbcNd f1 rlrav perny:r cur, oeu.mr,on at Anw,.rnen r aeoea,,,re.m„roa o:e waexn-.r,n e.n.<wo..io ii iq issk,P_11.t 5omtt-30k null rr r " CANC The next tab is Documents: View and add attachments to the incident. Be sure to click SAVE when adding documents.Then Cancel to Exit out of the incident. Analyst Follow Up Onee oeeumant .. Nam. Type Seurce Ilplead pare Uploaded p_r a 1 ko do[umenta Yet. omp foes here or click on the Add Decunxnt dropdo— « l S r rANCrtCIWI r..4 rD:IIJ Sourer Ipa.null If all tasks are followed up with and the incident no longer needs further review/information, click SUBMIT. Once submitted,the incident will be removed from the task list and no further edits can be made. Notice the SUBMIT button is on every tab. If further information needs to be included, email DBHlncidentReporting@fresnocountyca.eov DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT I Page 9 of 9 To get back to the home view, click on the Lo is Manager icon at any time. Any incidents that still need review will show on this screen, click o c Incident and start the review process again. Your Task List DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT J FRESNO COUNTY MENTAL HEALTH PLAN Page 1 of 2 Grievances Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance and appeal process and an expedited appeal process to resolve grievances and disputes at the earliest and the lowest possible level. Title 9 of the California Code of Regulations requires that the MHP and its fee-for-service providers give verbal and written information to Medi-Cal beneficiaries regarding the following: • How to access specialty mental health services • How to file a grievance about services • How to file for a State Fair Hearing The MHP has developed a Consumer Guide, a beneficiary rights poster, a grievance form, an appeal form, and Request for Change of Provider Form. All of these beneficiary materials must be posted in prominent locations where Medi-Cal beneficiaries receive outpatient specialty mental health services, including the waiting rooms of providers' offices of service. Please note that all fee-for-service providers and contract agencies are required to give the individuals served copies of all current beneficiary information annually at the time their treatment plans are updated and at intake. Beneficiaries have the right to use the grievance and/or appeal process without any penalty, change in mental health services, or any form of retaliation. All Medi-Cal beneficiaries can file an appeal or state hearing. Grievances and appeals forms and self addressed envelopes must be available for beneficiaries to pick up at all provider sites without having to make a verbal or written request. Forms can be sent to the following address: Fresno County Mental Health Plan P.O. Box 45003 Fresno, CA 93718-9886 (800) 654-3937 (for more information) (559) 488-3055 (TTY) Provider Problem Resolution and Appeals Process The MHP uses a simple, informal procedure in identifying and resolving provider concerns and problems regarding payment authorization issues, other complaints and concerns. Informal provider problem resolution process—the provider may first speak to a Provider Relations Specialist (PRS) regarding his or her complaint or concern. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT J Page 2 of 2 The PRS will attempt to settle the complaint or concern with the provider. If the attempt is unsuccessful and the provider chooses to forego the informal grievance process, the provider will be advised to file a written complaint to the MHP address (listed above). Formal provider appeal process—the provider has the right to access the provider appeal process at any time before, during, or after the provider problem resolution process has begun, when the complaint concerns a denied or modified request for MHP payment authorization, or the process or payment of a provider's claim to the MHP. Payment authorization issues—the provider may appeal a denied or modified request for payment authorization or a dispute with the MHP regarding the processing or payment of a provider's claim to the MHP. The written appeal must be submitted to the MHP within 90 calendar days of the date of the receipt of the non-approval of payment. The MHP shall have 60 calendar days from its receipt of the appeal to inform the provider in writing of the decision, including a statement of the reasons for the decision that addresses each issue raised by the provider, and any action required by the provider to implement the decision. If the appeal concerns a denial or modification of payment authorization request, the MHP utilizes a Managed Care staff who was not involved in the initial denial or modification decision to determine the appeal decision. If the Managed Care staff reverses the appealed decision, the provider will be asked to submit a revised request for payment within 30 calendar days of receipt of the decision Other complaints— if there are other issues or complaints, which are not related to payment authorization issues, providers are encouraged to send a letter of complaint to the MHP. The provider will receive a written response from the MHP within 60 calendar days of receipt of the complaint. The decision rendered buy the MHP is final. L�I / ( -F »k E� 1 T k $0 CD CD m w0- 2 § [ u) { L § j k 7 } 2 u � u § & & 2 g ° ® § \ k k U � 00 \ \ � 6 \ � • & ■ K f � � � �= � § m . k ) \ # ; � 0 � - M well a gaS s x a=l k \ / Lr) e C) L. 2 \ } @ o § U \ j / e ° / / \ ® 2 \ � f L 2 [ 3 / .hecu / � \ ¥ / D k / CL / 3 2 / \ \ @ ƒ » k 3 B �_gawn\ � NM � mo ¥ MMC) M � mo1- MMC) mtm 2 - - - - - - - - - - q a q a q a DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT K Page 2 of 3 FI XED ASSET AND SENSI TI VE I TEM TRACF4 NG Fi el d Fi el d I nst r uct i on or Comrent s Required or Number Descr i pt i on Condi t i onal I ndi cat e t he I egal name of t he Header Vendor agency contracted to provide Requi red services. I ndi cat a the title of the project as Header Pr ogr am described in the contract with the Requi red Count y. I ndi cat e t he assi gned Count y Header Cont r act # cont r act number . I f not known, Requi red Count y st of f can pr ovi de. Header Contact Person n 1 cate e 1 r s an as name of Required I ndi cat a the most appropriate Header Cont act # t el ephone nurrber of t he pr i rrar y Required agency contact for the contract . I ndi cat e t he most cur r ent dat e t hat Header Date Prepared the tracking form was corrpl et ed by Required the vendor . Identify the item by providing a a Item comTDnl y recognized description of Required t he i t em b IVbke/ Br and I dent i f y the company t hat Required rranuf act ur ed t he i t em c IVbdel I dent i f y t he model nurrber f or t he Condi t i onal item if appl i cabl e. d Seri al # I dent i f y t he ser i al number f or t he Condi t i onal item if appl i cabl e. IVbr k t he box wi t h an "X' i f t he cost e Fi xed Asset of t he i t em i s $5, 000 or mor e t o Condi t i onal i ndi cat e t hat t he i t em i s a fixed asset . IVbr k t he box wi t h an "X' if the item f Sensi t i ve Item meets the criteria of a sensi t i ve Condi t i onal item as defined by t he Count y. I ndi cat e t he date t hat the agency g Dat a Request ed subrri t t ed a r equest t o t he Count y t o Required purchase t he i t em I ndi cat e t he date t hat t he County h Dat e Approved approved t he request to purchase t he Required item i Purchase Date I ndi cat e t he date the agency Required purchased the i t em j Locat i on I ndi cat e t he physi cal I ocat i on of Required t he i t em k Condi t i on I ndi cat e t he general condi t i on of Required t he i t em ( New, Good, V\6r n, Bad) . DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT K Page 3 of 3 Fresno County I ndi cat e the FR # provided by the I I nvent or y County for the item Condi t i onal Nu rrb e r I ndi cat e t he t of al pur chase pr i ce of m Cost the i t em i ncl udi ng sales tax and Requi red of her cost s, such as shi ppi ng. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT L National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations to: Principal Standard: 1. Provide effective,equitable,understandable,and respectful quality care and services that are responsive to diverse cultural health beliefs and practices,preferred languages,health literacy,and other communication needs. Governance,Leadership,and Workforce: 2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy,practices,and allocated resources. 3. Recruit,promote,and support a culturally and linguistically diverse governance,leadership,and workforce that are responsive to the population in the service area. 4. Educate and train governance,leadership,and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis. Communication and Language Assistance: 5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs,at no cost to them,to facilitate timely access to all health care and services. 6. Inform all individuals of the availability of language assistance services clearly and in their preferred language,verbally and in writing. 7. Ensure the competence of individuals providing language assistance,recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. Engagement,Continuous Improvement,and Accountability: 9. Establish culturally and linguistically appropriate goals,policies,and management accountability,and infuse them throughout the organization's planning and operations. 10. Conduct ongoing assessments of the organization's CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities. 11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. 12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. 13. Partner with the community to design,implement,and evaluate policies,practices,and services to ensure cultural and linguistic appropriateness. 14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify,prevent,and resolve conflicts or complaints. 15. Communicate the organization's progress in implementing and sustaining CLAS to all stakeholders,constituents,and the general public. m L Think Cultural Health U.S.Department of https://W Ww.thinkcu ltural health.hhs.gov/ HecRh and Human Services W° Z -��M H Office of MinorityHeclth contactC�thlnkculturalhealth.hhs.gov DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 EXHIBIT L 2 The Case for the National CLAS Standards Health equity is the attainment of the highest level of health for all people.'Currently,individuals across the United States from various cultural backgrounds are unable to attain their highest level of health for several reasons,including the social determinants of health,or those conditions in which individuals are born,grow,live,work,and age,2 such as socioeconomic status,education level,and the availability of health services.3 Though health inequities are directly related to the existence of historical and current discrimination and social injustice,one of the most modifiable factors is the lack of culturally and linguistically appropriate services,broadly defined as care and services that are respectful of and responsive to the cultural and linguistic needs of all individuals. Of all the forms of Health inequities result in disparities that directly affect the quality of life for all individuals. Health disparities adversely affect neighborhoods,communities,and the broader society,thus making inequality, injustice in the issue not only an individual concern but also a public health concern. In the United States,it health care is the most has been estimated that the combined cost of health disparities and subsequent deaths due to shocking and inhumane. inadequate and/or inequitable care is$1.24 trillion.° Culturally and linguistically appropriate services are increasingly recognized as effective in improving —Dr. Martin Luther King,Jr. the quality of care and services.5.6 By providing a structure to implement culturally and linguistically appropriate services,the National CLAS Standards will improve an organization's ability to address health care disparities. The National CLAS Standards align with the HHS Action Plan to Reduce Racial and Ethnic Health Disparities'and the National Stakeholder Strategy for Achieving Health Equity,$which aim to promote health equity through providing clear plans and strategies to guide collaborative efforts that address racial and ethnic health disparities across the country. Similar to these initiatives,the National CLAS Standards are intended to advance health equity,improve quality,and help eliminate health care disparities by providing a blueprint for individuals and health and health care organizations to implement culturally and linguistically appropriate services.Adoption of these Standards will help advance better health and health care in the United States. Bibliography 1.U.S.Department of Health and Human Services,Office of Minority Health(2011).National Partnership for Action to End Health Disparities.Retrieved from http://minorityhealth.hhs.gov/npa 2.World Health Organization.(2012).Social determinants of health.Retrieved from http://www.who.int/social_determinants/en/ 3.U.S.Department of Health and Human Services,Office of Disease Prevention and Health Promotion.(2010).Healthy people 2020:Social determinants of health.Retrieved from http://www. hea lthypeopl e.gov/2020/to piesobj ectives2O20/overvi ew.as px?topi c i d=39 4.LaVeist,T.A.,Gaskin,D.J.,&Richard,P.(2009).The economic burden of health inequalities in the United States.Retrieved from the Joint Center for Political and Economic Studies website:http://www. jointcenter.org/sites/default/files/upload/research/files/The%20Economic%2 OBurden%20ofk2OHealth%201nequalities%20in%20the%2OUnited%20States.pdf 5.Beach,M.C.,Cooper,L.A.,Robinson,K.A.,Price,E.G.,Gary,T.L.,Jenckes,M.W.,Powe,N.R.(2004).Strategies for improving minority healthcare quality.(AHRQ Publication No.04-EO08-02).Retrieved from the Agency of Healthcare Research and Quality website:http://www.ahrq.gov/downloads/pub/evidence/pdf/minqual/minquai.pdf 6.Goode,T.D.,Dunne,M.C.,&Bronheim,S.M.(2006).The evidence base for cultural and linguistic competency in health care.(Commonwealth Fund Publication No.962).Retrieved from The Commonwealth Fund website:http://www.commonwealthfund.org/usr_doc/Goode_evidencebasecultlinguisticcomp_962.pdf 7.U.S.Department of Health and Human Services.(2011).HHS action plan to reduce racial and ethnic health disparities:A nation free of disparities in health and health care.Retrieved from http:// minorityhealth.hhs.gov/npa/files/Plans/HHS/H HS_Plan_com plete.pdf 8.National Partnership for Action to End Health Disparities.(2011).National stakeholder strategy for achieving health equity.Retrieved from U.S.Department of Health and Human Services,Office of Minority Health website:http://www.minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286 m L Think Cultural Health U. W S.Department of https://W w.thinkcu ltural health.hhs.gov/ Health and Human Services W° Z 1,0MH Office of Minority Health contact@thlnkculturalhealth.hhs.gov 4 DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit M Page 1 of 2 DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT I. Identifying Information Name of entity D/B/A Address(number,street) City State ZIP code CLIA number Taxpayer ID number(EIN) /Telephone number ) II. Answer the following questions by checking "Yes" or "No." If any of the questions are answered "Yes," list names and addresses of individuals or corporations under"Remarks"on page 2. Identify each item number to be continued. YES NO A. Are there any individuals or organizations having a direct or indirect ownership or control interest of five percent or more in the institution, organizations, or agency that have been convicted of a criminal offense related to the involvement of such persons or organizations in any of the programs established byTitles XVI 11, 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 II, XIX, or XX?...................................................................................... > C. Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar capacity who were employed by the institution's, organization's, or agency's fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only)........... > III. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names and addresses under "Remarks" on page 2. If more than one individual is reported and any of these persons are related to each other, this must be reported under"Remarks." NAME ADDRESS EIN B. Type of entity: o Sole proprietorship o Partnership o Corporation o Unincorporated Associations o Other(specify) C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations under"Remarks." D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities? (Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses of individuals, and provider numbers........................................................................................................... o 0 NAME ADDRESS PROVIDER NUMBER DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit M Page 2 of 2 YES NO IV. A. Has there been a change in ownership or control within the last year? ....................................................... 0 0 If yes, give date. B. Do you anticipate any change of ownership or control within the year?....................................................... 0 0 If yes, when? C. Do you anticipate filing for bankruptcy within the year?................................................................................ 0 0 If yes, when? V. Is the facility operated by a management company or leased in whole or part by another organization?.......... 0 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?......... 0 0 VII. A. Is this facility chain affiliated? ...................................................................................................................... 71 71 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 Amanda Nugent Divine CEO Sf�cuSigned by: Date �.r•lrs.r N4.&tyxvs+t 8/30/2022 Remarks DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit N Page 1 of 2 Certification Regarding Debarment, Suspension, and Other Responsibility Matters - Primary Covered Transactions INSTRUCTIONS FOR CERTIFICATION 1. By signing and submitting this proposal, the prospective primary participant is providing the certification set out below. 2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction. 3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. 4. The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 5. The terms covered transaction, debarred, suspended, ineligible, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations. 6. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit N Page 2 of 2 CERTIFICATION (1) The prospective primary participant certifies to the best of its knowledge and belief, that it, its owners, officers, corporate managers and partners: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency; (b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) (d) Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default. (2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. DocuSigned by: Signature: p, N4.p#4 NvZ4, t Date: 8/30/2022 Amanda Nugent Divine Kings view (Printed Name & Title) (Name of Agency or Company) DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit O Page 1 of 2 SELF-DEALING TRANSACTION DISCLOSURE FORM In order to conduct business with the County of Fresno (hereinafter referred to as "County'), members of a contractor's board of directors (hereinafter referred to as "County Contractor"), must disclose any self-dealing transactions that they are a party to while providing goods, performing services, or both for the County. A self-dealing transaction is defined below: "A self-dealing transaction means a transaction to which the corporation is a party and in which one or more of its directors has a material financial interest" The definition above will be utilized for purposes of completing this disclosure form. INSTRUCTIONS (1) Enter board member's name,job title (if applicable), and date this disclosure is being made. (2) Enter the board member's company/agency name and address. (3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the County. At a minimum, include a description of the following: a. The name of the agency/company with which the corporation has the transaction; and b. The nature of the material financial interest in the Corporation's transaction that the board member has. (4) Describe in detail why the self-dealing transaction is appropriate based on applicable provisions of the Corporations Code. (5) Form must be signed by the board member that is involved in the self-dealing transaction described in Sections (3) and (4). DocuSign Envelope ID:245ECE7F-B586-4422-842C-65CF9442DE69 Exhibit O 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 ' Ug ed by: Signature: Ate" N'S" Date: 8/30/2022 FSa. i aaaa