HomeMy WebLinkAboutAgt 19-277-1 Pacific Clinics CWMH Name Change Docs.pdf CO
ti County of Fresno
DEPARTMENT OF BEHAVIORAL HEALTH
Q 56 O SUSAN L. HOLT
DIRECTOR OF BEHAVIORAL HEALTH
July 12, 2022
Marilyn Bamford
Uplift Family Services
251 Llewellyn Avenue
Campbell, CA 95008
Re: Master Agreement#19-277-1 Child Welfare Mental Health
Dear Ms. Bamford:
Enclosed is the executed Fresno County Agreement #19-277-1 between Pacific Clinics
and the County of Fresno on behalf of the Department of Behavioral Health, effective
June 9, 2022. This Agreement is for the provision of specialty mental health services
for individuals involved in the Child Welfare system.
Please retain this copy for your records.
If you have any questions, please contact Staff Analyst, Huong Chung or Senior Staff
Analyst, Emma Mejia.
Sincerely,
Am%**�
Susan Holt, LMFT
Director of the Department of Behavioral Health
cc: Sanja Bugay, Director of the Department of Social Services
1925 E.Dakota Ave.,Fresno,CA 93726
FAX(559)600-7905 www.hopefresnocount,
The County of Fresno is an Equal Employment Opportunity Employer
Agreement A-19-277-1
1 AMENDMENT I TO MASTER AGREEMENT
2 THIS AMENDMENT, hereinafter referred to as "Amendment I", is made and entered into this
3 13th day of April , 2021, by and between the COUNTY OF FRESNO, a Political
4 Subdivision of the State of California, hereinafter referred to as "COUNTY", and each CONTRACTOR
5 listed in Exhibit A"List of Contractors", attached hereto and by this reference incorporated herein, and
6 collectively hereinafter referred to as "CONTRACTORS", and such additional CONTRACTOR(S) as
7 may, from time to time during the term of this Agreement, be added by County. Reference in this
8 Amendment to "parties" shall be understood to refer to COUNTY and each individual
9 CONTRACTOR, unless otherwise specified.
10 WHEREAS the parties entered into that certain Agreement, identified as COUNTY Agreement
11 No. A-19-277, effective the 1s' day of July 2019, hereinafter referred to as "Agreement", whereby
12 CONTRACTOR(S) agreed to provide outpatient specialty mental health, court-specific, and
13 community-based support services for children and youth involved in the Child Welfare (CWS)
14 system to COUNTY's Department of Behavioral Health (DBH) and COUNTY's Department of Social
15 Services (DSS); and
16 WHEREAS the number of referrals for the services provided under this Agreement have
17 increased beyond the capacity of the original three CONTRACTORS and it is necessary to add a
18 fourth CONTRACTOR—Turning Point of Central California and, therefore it was determined that this
19 Agreement would need to be amended to provide for the addition of this CONTRACTOR and
20 increase the maximum compensation payable; and
21 WHEREAS the parties now desire to amend the Agreement regarding changes as stated
22 below and restate the Agreement in its entirety.
23 NOW, THEREFORE, in consideration of their mutual promises, covenants and conditions,
24 hereinafter set forth, the sufficiency of which is hereby acknowledged, the parties agree as follows:
25 1. That the existing COUNTY Agreement No. A-19-277, Page Five (5), beginning with
26 Section Four (4) "COMPENSATION", Line Seven (7), with the word "COUNTY" and ending on Page
27 Six (6), Line Seventeen (17), with the word "combined" be deleted and the following inserted in its
28 place:
1 - COUNTY OF FRESNO
Fresno, CA
I "COUNTY agrees to pay CONTRACTOR(S) and CONTRACTOR(S) agree to receive
2 compensation in accordance with the budget(s) set forth in Revised Exhibit D-1, et seq., attached
3 hereto and by this reference incorporated herein and made part of this Agreement.
4 A. Maximum Contract Amount
5 For fiscal year (FY) July 1, 2019 through June 30, 2020, in no event shall the
6 maximum compensation amount under this Agreement exceed Sixteen Million and No/100 Dollars
7 ($16,000,000.00) for all CONTRACTOR(S) combined.
8 For FY July 1, 2020 through June 30, 2021, in no event shall the maximum
9 compensation amount under this Agreement exceed Nineteen Million and No/100 Dollars
10 ($19,000,000.00) for all CONTRACTOR(S) combined.
11 For FY July 1, 2021 through June 30, 2022, in no event shall the maximum
12 compensation amount under this Agreement exceed Twenty-Three Million Five Hundred Thousand
13 and No/100 Dollars ($23,500,000.00) for all CONTRACTOR(S) combined.
14 If this Agreement has been extended for an additional twelve (12) month
15 renewal period for FY July 1, 2022 through June 30, 2023, in no event shall the maximum
16 compensation amount under this Agreement exceed Twenty-Four Million and No/100 Dollars
17 ($24,000,000.00) for all CONTRACTOR(S) combined.
18 If this Agreement has been extended for an additional twelve (12) month
19 renewal period for FY July 1, 2023 through June 30, 2024, in no event shall the maximum
20 compensation amount under this Agreement exceed Twenty-Four Million Five Hundred Thousand
21 and No/100 Dollars ($24,500,000.00) for all CONTRACTOR(S) combined.
22 The maximum amounts paid to each CONTRACTOR(S) identified in this
23 Agreement shall be as stated in the individual CONTRACTOR(S)'s "Revised Budget" documents
24 approved by the COUNTY's DBH and DSS Directors, or their designees, and attached hereto as
25 Revised Exhibits D-1 et seq. and incorporated herein by this reference.
26 B. Maximum Compensation Amounts
27 In no event shall the total maximum compensation amount under this
28 Agreement for FY 2019-20, FY 2020-21, and FY 2021-22 combined exceed Fifty-Eight Million Five
- 2 - COUNTY OF FRESNO
Fresno, CA
I Hundred Thousand and No/100 Dollars ($58,500,000.00)for all CONTRACTOR(S) combined.
2 If performance standards are met and this Agreement is extended for an
3 additional twelve (12) month term pursuant to Section Three (3) of this Agreement, then in no event
4 shall the total maximum compensation amount under this Agreement for FY 2019-20, FY 2020-21,
5 FY 2021-22, and FY 2022-23 combined exceed Eighty-Two Million Five Hundred Thousand and
6 No/100 Dollars ($82,500,000.00) for all CONTRACTOR(S) combined.
7 If performance standards are met and this Agreement is extended for an
8 additional twelve (12) month term pursuant to Section Three (3) of this Agreement, then in no event
9 shall the total maximum compensation amount under this Agreement for FY 2019-20, FY 2020-21,
10 FY 2021-22, FY 2022-23, and FY 2023-24 combined exceed One Hundred Seven Million and No/100
11 Dollars ($107,000,000.00) for all CONTRACTOR(S) combined."
12
13 2. That the existing COUNTY Agreement No. A-19-277, Page Thirteen (13), beginning
14 with Line Seventeen (17) with the word "Notwithstanding" and ending on Page Thirteen (13), Line
15 Twenty-One (21), with the word "Office" be deleted and the following inserted in its place:
16 "Notwithstanding the above, changes to services, staffing, and responsibilities of the
17 CONTRACTOR(S), as needed, to accommodate changes in the laws relating to specialty mental
18 health treatment may be made with the signed written approval of COUNTY's DBH Director, or his or
19 her designee, and CONTRACTOR(S) through an amendment approved by COUNTY's County
20 Counsel and the COUNTY's Auditor-Controller/Treasurer-Tax Collector's Office.
21 It is acknowledged by all parties hereto that the dates of the ramp-up period(s) and of
22 the initial operating period(s), as well as necessary staffing identified within the Revised Exhibits D-1,
23 et. seq. may be adjusted due to unforeseen circumstances (e.g. delays in the location and
24 procurement of a facility, delays in staffing, fluctuations in referrals from DSS and caseloads,
25 pandemics, state declaration of a state of emergency, etc.)."
26 3. That all references in existing COUNTY Agreement No. A-19-277 to Exhibit A shall be
27 changed to read "Revised Exhibit A," which is attached hereto and incorporated herein by this
28 reference.
- 3 - COUNTY OF FRESNO
Fresno, CA
1 4. That Exhibit B-4, which is attached hereto, is incorporated herein by this reference.
2 5. That all references in existing COUNTY Agreement No. A-19-277 to Exhibit D-1 et seq.
3 shall be changed to read "Revised Exhibit D-1 et seq."
4 COUNTY and CONTRACTOR(S) agree that this Amendment is sufficient to amend the
5 Agreement and, that upon execution of this Amendment, the Agreement and this Amendment
6 together shall be considered the Agreement. The Agreement, as hereby amended, is ratified and
7 continued. Except as otherwise provided in this Amendment I, all other provisions of the Agreement
8 remain unchanged and in full force and effect. This Amendment I shall become effective upon
9 execution.
10
11
12 ///
13 ///
14 ///
15
16
17 ///
18 ///
19 ///
20
21
22 ///
23 ///
24 ///
25 ///
26 ///
27
28
4 - COUNTY OF FRESNO
Fresno, CA
1 IN WITNESS WHEREOF, the parties hereto have executed this Amendment I to Agreement as
2 of the day and year first hereinabove written.
3
COUNTY OF FRESNO:
4
5
By
k-
6 Steven Brandau,
7 Chairman of the Board of Supervisors
of the County of Fresno
8
9
ATTEST:
10 Bernice E. Seidel,
11 Clerk of the Board of Supervisors
County of Fresno, State of California
12
13
By_
14 Deputy
15
16
17
18
19
20 Fund/Subclass: 0001/10000
21 Organization: 5630 PLEASE SEE ADDITIONAL
Account#: 7295 SIGNATURE PAGES ATTACHED
22
23 EM
24
25
26
27
28
- 5 - COUNTY OF FRESNO
Fresno, CA
1
CONTRACTOR:
2 PACIFIC CLINICS
3
4
y
5
6 Print Name:Qathy McCarthy
7
Title: President/CEO
8 Chairman of the Board, or
9 President, or any Vice President
10
Date; _l
11
12
13
By
14 Print Name: thy McCarthy
15
16 Title: President/CEO
Secretary (of Corporation), or
17 any Assistant Secretary, or
18 Chief Financial Officer, or
any Assistant Treasurer
19
20 Date:
21
22
23
24
Mailing Address:
25 251 Llewellyn Avenue
Campbell, CA 95008
26 Phone No.: (408) 379-3790
Contact: Executive Director
27
28
7 - COUNTY OF FRESNO
Fresno, CA
Revised Exhibit A
CHILD WELFARE MENTAL HEALTH
MASTER AGREEMENT
LIST OF CONTRACTORS
1. CALIFORNIA PSYCHOLOGICAL INSTITUTE (Exhibit B-1; Revised Exhibit D-1)
1470 W. Herndon Avenue, Suite 300
Fresno, CA 93711
Phone #: (559) 256-2000
Contact for Notices: Administrative Director
2. CENTRAL STAR BEHAVIORAL HEALTH, INC. (Exhibit B-2; Revised Exhibit D-2)
1501 Hughes Way, Suite 150
Long Beach, CA 90810
Phone #: (310) 221-6336 ext, 125
Contact for Notices: Senior Vice President
3. TURNING POINT OF CENTRAL CALIFORNIA (Exhibit B-4; Revised Exhibit D-4)
615 South Atwood Street
Visalia, CA 93277
Phone #: (559) 732-8086
Contact for Notices: Regional Director
4. PACIFIC CLINICS (Revised Exhibit B-5; Revised Exhibit D-5)
251 Llewellyn Avenue
Campbell, CA 95008
Phone #: (408) 379-3790
Contact for Notices: Executive Director
Revised Exhibit B-5
Page 1 of 17
CHILD WELFARE MENTAL HEALTH (CWMH)
SUMMARY OF SERVICES
ORGANIZATION: Pacific Clinics
ADDRESS: 251 Llewellyn Avenue
Campbell, CA 95008
TELEPHONE: (408) 379-3790
CONTACT PERSON: Marilyn Bamford, Executive Director, Central Region
CONTRACT PERIOD: July 1, 2022 — June 30, 2023
with one (1) optional twelve (12) month renewal
CONTRACT AMOUNT: $5,130,216 (July 1, 2022 — June 30, 2023)
$5,263,602 (July 1 , 2023 — June 30, 2024)
SUMMARY OF SERVICES:
Pacific Clinics, henceforth referred to as CONTRACTOR, will be responsible for
providing medically necessary outpatient specialty mental health services for
children, youth, and their parents who meet medical necessity, as well as court-
specific services to children and families involved in Fresno County's Child Welfare
Services (CWS) system. The majority of outpatient specialty mental health
services, such as assessments, plan development, therapy, rehabilitation services,
crisis intervention, case management, intensive home-based services and intensive
care coordination are expected to be community-based and provided in the family's
home or in the community, whenever possible.
SCHEDULE OF SERVICES:
The CONTRACTOR's office(s) shall be open Monday through Friday, 8:OOam to 5:OOpm.
Clinicians will be available to see clients and families for in-home and community-based
appointments during the day, weekend, and evening hours, up to 8:00 pm. Group
services will be provided during the day and evening hours, up to 8:00 pm, on a scheduled
basis, at CONTRACTOR's offices. The CONTRACTOR's office will be located at a site
in the metropolitan and/or rural community that offers public transportation in close
proximity, adequate parking, and a secure setting. In addition to the Fresno metropolitan
area, CONTRACTOR shall serve the rural areas of Fresno County as needed. Any
addition or change to the location of office-based services must be approved by the
COUNTY in advance of such a change.
Revised Exhibit B-5
Page 2 of 17
TARGET POPULATION:
CONTRACTOR shall provide specialty mental health services to all referred children,
youth, parents, guardians, and foster parents involved with a child's CWS case. The
target population includes children and youth as referred to in the Katie A. Settlement
Agreement as members of the "class" and "subclass."
1. Katie A. "Class" is defined as children in California who:
A. Are in foster care or are at imminent risk of foster care placement, and
B. Have a mental illness or condition that has been documented or had an
assessment already conducted, and
C. Need individualized mental health services, including but not limited to,
mental health assessments, outpatient specialty mental health services,
case management services, family support, crisis intervention, and other
medically necessary services in the home or in a home-like setting, to treat
mental illness or condition.
Imminent Risk of foster care placement means that within the last 180 days a child has
been participating in voluntary family maintenance or family reunification services and/or
has been the subject of either a telephone call to the Child Protective Services hotline or
some other documented communication made to a local Child Protective Services agency
regarding suspicions of abuse, neglect or abandonment.
Members of this class include children living with their parents, relatives, or in any variety
of placements, such as group homes, short-term residential therapeutic programs
(STRTPs), or foster homes.
2. "Katie A. Subclass" is identified as children in California who:
A. Have an open CWS case; and
B. Are full-scope Medi-Cal (Title XIX) eligible; and
C. Meet the medical necessity criteria for Medi-Cal Outpatient Specialty Mental
Health Services (SMHS) as set forth in CCR, Title 9, Section 1830.205 or
Section 1830.210; and
D. Are currently in or being considered for a Wraparound program, Therapeutic
Foster Care, or specialized care rate due to behavioral health needs or
other intensive Early and Periodic Screening Diagnostic and Treatment
(EPSDT) services, including but not limited to Therapeutic Behavioral
Services or crisis stabilization/intervention; or
E. Are currently in or being considered for placement in a group home (Rate
Classification 10 or above) or STRTP, psychiatric hospital, 24-hour mental
health treatment facility (e.g., psychiatric inpatient hospital, community
Revised Exhibit B-5
Page 3 of 17
residential treatment facility); or has experienced three (3) or more
placements within 24 months due to behavioral health needs.
I. CONTRACTOR SHALL BE RESPONSIBLE FOR THE FOLLOWING SERVICES:
A. Referrals and Engagement
1. CONTRACTOR will provide an array of outpatient specialty mental
health services to all referrals received from the Department of
Behavioral Health's (DBH) CWMH Team. CONTRACTOR shall accept
the adequate number of referrals to meet CWMH demand and to cover
program costs. Referral priority is determined by the CWMH Team and
assessments should be completed within the following designated
timeframes:
a. Crisis Referrals — Three (3) days
b. Standard Referrals — Ten (10) days
c. Psychiatric Referrals — Fifteen (15) days
2. CONTRACTOR shall make every attempt to engage clients in service.
CONTRACTOR is expected to make at least four (4) contact attempts
(in-person or via phone), at minimum one (1) attempt each week, over
the course of thirty (30) days and then send a letter to the client if
CONTRACTOR is still unable to engage them in services.
CONTRACTOR must also maintain regular contact with DSS Social
Workers, Supervisors, and Program Managers if they are unable to
contact or engage a client. If still unable to reach client, CONTRACTOR
must submit a Notice of Action to Managed Care and the CWMH Team.
A Notice of Action is not required if the referral packet received by
CONTRACTOR is incomplete.
B. Outpatient Specialty Mental Health Services
1. CONTRACTOR shall provide the following specialty mental health
services for the appropriate duration, frequency, and intensity based
upon the needs of the individual receiving services, as determined to be
clinically appropriate by a licensed/waivered mental health clinician and
the fidelity of the therapeutic intervention provided. It is understood that
a child who meets the definition of "Katie A. Subclass" does not, in and
of itself, require a higher level or intensity of mental health treatment
absent a clinical determination by the treating mental health clinician:
a. Mental Health Assessments
Clinical analysis of the history and current status of a
beneficiary's mental, emotional, or behavioral disorder;
relevant cultural issues and history; diagnosis; and use of
testing procedures. A comprehensive assessment shall be
completed by a designated licensed or registered/waivered
Revised Exhibit B-5
Page 4 of 17
staff within thirty (30) days from the initial contact date. When
a person remains in continuous services, an update/re-
assessment shall be completed at least every two (2) years.
The clinician may complete a comprehensive assessment
instead of an update/re-assessment if it is determined to be
the more appropriate clinical decision for the person served.
Additionally, current State mandates require that the CANS-
50 and PSC-35 are part of the assessment at the beginning
of treatment and are administered every six (6) months and at
the end of treatment. These will be shared with the Child and
Family Team (CFT). If a current assessment has been
completed by another CFT team member, it will be accepted
in lieu of an assessment completed by the clinician.
b. Therapy
A therapeutic intervention that focuses primarily on symptom
reduction as a means to improve functional impairments.
Therapy may be delivered to an individual or group of
beneficiaries (see below) and may include family therapy at
which the beneficiary is present.
1) Individual
2) Collateral
3) Conjoint
4) Family therapy
5) Group therapy
i. Groups will be led by clinicians and
supervised by a licensed clinician. Larger
groups may be co-facilitated by two (2)
unlicensed clinicians. Licensed Clinical
Supervisors will provide in-vivo training, co-
facilitation and supervision to ensure group
facilitation is high quality, clinically effective,
and appropriate.
c. Crisis Intervention
A service lasting less than 24 hours, to or on behalf of a
beneficiary, for a condition which requires more timely
response than a regularly scheduled visit. Activities may
include, but are not limited to, assessment, therapy and
service access to any significant support person in the
beneficiary's life with the intent of improving or maintaining the
mental health status of the beneficiary.
d. Case Management
Any service that assists a beneficiary to access needed
medical, educational, social, prevocational, vocational,
rehabilitative, or other community service. Services may
Revised Exhibit B-5
Page 5 of 17
include, but are not limited to, communication, coordination,
and referral to available resources. CONTRACTOR will be
responsible for monitoring service delivery to beneficiary by
third parties, beneficiary progress, and plan development.
e. Rehabilitation
Any activity that seeks to improve, maintain, or restore a
beneficiary's functional, daily living, social, leisure, grooming,
personal hygiene, and meal preparation skills while also
providing access to support resources and medication
education.
f. Plan Development
The development of individual treatment plans, approval of
said treatment plans, and/or monitoring of a beneficiary's
progress.
g. Medication Support
Any service that includes prescribing, administering,
dispensing, and monitoring psychiatric medications or
biologicals, which are necessary to alleviate the symptoms of
mental illness. Services may also include evaluation for the
need of medication, evaluation of clinical effectiveness and
side effects, obtaining informed consent, medication
education and plan development related to the delivery of the
service, and/or assessment of the beneficiary.
CONTRACTOR shall have a plan in place to ensure
medication support coverage, in the event that the
Psychiatrist is unavailable to provide services for an extended
period of time.
2. CONTRACTOR shall be responsible to provide and appropriately bill for
the following services for referred clients, including Katie A. Subclass
members, if medically necessary and provided within the California
Integrated Core Practice Model and Pathways to Mental Health Core
Practice Model, and in accordance with the "Medi-Cal Manual for
Intensive Care Coordination (ICC), Intensive Home-Based Services
(IHBS) & Therapeutic Foster Care (TFC) for Medi-Cal Beneficiaries":
a. IHBS may include, but are not limited to:
1) Skill-based interventions for the remediation of behaviors
or improvement of symptoms;
2) Development of functional skills to improve self-care, self-
regulation, or other functional impairments by intervening
to decrease or replace non-functional behavior that
interferes with daily living tasks or the avoidance of
exploitation by others;
Revised Exhibit B-5
Page 6 of 17
3) Development of skills or replacement behaviors that allow
the child/youth to fully participate in the teaming process
and service plans including but not limited to the treatment
plan and/or child welfare case plan;
4) Improvement in self-management of symptoms, including
self-administration of medications, as appropriate;
5) Education of the child/youth and/or their family or
caregiver(s) about how to manage the child/youth's mental
health disorder or symptoms;
6) Support of the development, maintenance and use of
social networks, including the use of natural and
community resources;
7) Support to address behaviors that interfere with the
achievement of a stable and permanent family life;
8) Support to address behaviors that interfere with seeking
and maintaining a job, if applicable;
9) Support to address behaviors that interfere with a
child/youth's success in achieving educational objectives.
b. IHBS can be provided by more than one (1) agency when
multiple agencies are serving a client. A minimum of 15% of
all services provided by CONTRACTOR must be IHBS. It is
expected that CONTRACTOR will provide IHBS, unless
clinical justification is provided. Clinical justification must be
documented in the client's mental health record (this will be
reviewed and audited by the COUNTY).
c. CONTRACTOR is required to attend ICC meetings and any
teaming processes scheduled by other agencies, CWS, or by
the DBH CWMH Team to ensure coordination of all mental
health treatment services that may involve one (1) or more
provider agencies, no less than every ninety (90) days for the
child/youth.
d. ICC service components/activities include comprehensive
assessment and periodic reassessment, development and
periodic revision of the plan, referral, monitoring, follow-up
activities, and transition.
3. CONTRACTOR will be responsible for providing services in either an
office-based or community-based setting. The location of service
delivery will be determined based on the needs of the client, preference
of the client, and clinical appropriateness. Based on current data, clients
prefer or require that their services are provided in a community-based
setting. The expectation is that, at minimum, 70% of all
CONTRACTOR's client services will be provided in the home or a
Revised Exhibit B-5
Page 7 of 17
community-based setting. Location of service delivery should be
clinically justified and documented in the client record.
4. CONTRACTOR will be responsible to work cooperatively and
collaboratively with CWS staff, DBH staff, CWMH Team staff, and all
treatment providers, caregivers, and Foster Family Agencies to achieve
the individual and collective treatment goals. Providers are to support
the CWS case plan, communicate/resolve barriers to care, and provide
continuity and warm hand-offs whenever possible as individuals
transition from higher to lower or lower to higher levels of care within or
outside of Fresno County.
CONTRACTOR will be able to refer to other Fresno County Mental
Health Plan (MHP) providers, Managed Care Medi-Cal Health Plans,
and other community providers as may be appropriate and in
concurrence with the DBH CWMH Team. CONTRACTOR shall provide
case management services until client is properly linked with another
provider.
5. CONTRACTOR must use evidence-based practices (EBPs) found
effective in serving this target population. This includes the provision of
training, ongoing sustainability and fidelity to a core competency for
CONTRACTOR's mental health clinicians. To date, CONTRACTOR
and COUNTY have agreed upon the provision of the following evidence-
based practices:
a. Managing and Adapting Practices (MAP)
b. Motivational Interviewing (MI)
c. Dialectical Behavioral Therapy (DBT)
d. Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT)
e. Child Parent Psychotherapy (CPP)
f. Infant Mental Health
Any additional evidence-based practices CONTRACTOR would like to
utilize will require review and consultation with COUNTY.
COUNTY requires CONTRACTOR to ensure their staff pursue
certification/accreditation in the agreed upon evidence-based practices,
as appropriate, during the first year term, and demonstrate to COUNTY
that they are moving toward successful completion. CONTRACTOR is
required to explain in writing their plan to require/support staff in this
regard, and their expected timeframe for completion of the
certification/accreditation process within the first year term.
C. Court-Specific Mental Health Services
1. CONTRACTOR will provide the following court-ordered mental health
services to children and families in CWS:
Revised Exhibit B-5
Page 8 of 17
a. Court-Ordered Mental Health Assessments
Clinical analysis of the history and current status of an
individual's mental, emotional, or behavioral disorder; relevant
cultural issues and history; diagnosis; and use of testing
procedures.
b. Psychological and Neuropsychological Evaluations
A structured, analytical interview with the individual (i.e.,
minor, parent, or guardian) which consists of a clinical
assessment, the use of testing instruments, a mental status
examination, and a clinical diagnosis (as defined/ruled out
using the ICD-10) that is performed only by a Licensed
Psychologist with at least five (5) years of postgraduate
experience. Services also include a review of CPS and
mental health services received to date and contact with
relevant others, as necessary. A second psychological or
neuropsychological evaluation may be ordered and must be
performed by a different Licensed Psychologist and
independent of the first evaluation.
c. Bonding Studies
A structured, forensic, analytic interview that includes a
mental health assessment (in order to define or rule out
clinical diagnosis using the ICD-10) for either parent(s) or
whomever has been identified by the court to participate in the
study, and the child(ren). The study includes assessment of
the interaction between the parent(s) and the child(ren) and
may include the use of testing instruments (as needed) to
more accurately gauge the strength of the bond between
parent and child. It may also include the current care
provider(s) or prospective adoptive parent(s)when ordered by
the court. These studies are to be performed only by a
Licensed Mental Health Clinician with appropriate experience
or a Waivered Psychologist working under a qualified
Licensed Psychologist. A qualified clinician will have
completed twenty (20) hours of training in Child Custody as
required by the California Board of Psychology (if the child is
0-36 months), training in the Marshak Interaction Method, and
training or experience in providing forensic evaluations for the
court.
d. Court Reports And Court Testimony
CONTRACTOR is responsible for any court reports and/or
necessary testimony.
Revised Exhibit B-5
Page 9 of 17
1) Court Reports
Documented report of assessment and evaluation
findings, progress in treatment, recommendations for
treatment, and service plan regarding reunification,
maintenance and termination of parental rights, and
justification for recommendations. CONTRACTOR
shall provide the DBH CWMH Team with a copy of the
reports, for tracking purposes.
2) Court Testimony
On-site court testimony of assessment and evaluation
findings, treatment and service plan
recommendations regarding reunification,
maintenance and termination of parental rights, and
justification for recommendations.
D. Staffing
1. CONTRACTOR shall ensure staff are qualified in education, experience,
and clinical competencies.
2. CONTRACTOR shall maintain adequate staffing levels in relation to the
number of open client cases at any given point to ensure quality service.
CONTRACTOR shall not go over a 1:20 staffing ratio.
3. CONTRACTOR will ensure that Clinical Supervisors oversee the work
of the Clinicians, including oversight of documentation and claiming in
the electronic medical record. Clinical Supervisors who provide
mentorship to Clinicians shall be two (2) years post licensure and able
to provide Board of Behavioral Sciences (BBS) supervision.
4. CONTRACTOR's Clinicians must be post-graduate and registered with
their local licensing board.
5. Assessments must be conducted by Licensed Practitioners of the
Healing Arts (LPHA), which includes licensed mental health
professionals and registered associates.
6. Interns, including graduate student interns, may be utilized by
CONTRACTOR to provide case management-type services, including
ICC and IHBS.
7. CONTRACTOR's clinical staff are required to go through the
credentialing process through DBH's Managed Care Division. Interns
are required to go through the non-credentialing application process
through DBH's Managed Care Division.
Revised Exhibit B-5
Page 10 of 17
8. If CONTRACTOR has other agreements with COUNTY to provide
specialty mental health treatment services, it will establish criteria and
protocols via a Child and Family Team (CFT) meeting, to ensure referral
to services are therapeutically appropriate, benefits the client and
caregiver, achieves the client's treatment goals, supports the success of
the CWS case plan, and avoids any potential for perceived or actual
conflict of interest or self-referral.
9. CONTRACTOR shall have established clinical competency standards
when hiring direct service staff and a staff development and training
program. CONTRACTOR will provide appropriate training for all staff to
include but not limited to trauma-informed practice, EBPs utilized,
working with specialized populations such as Infant Mental Health (IMH)
and Commercially Sexually Exploited Children (CSEC), and co-
occurring competence to serve individuals with mental health and
substance use/abuse disorders.
E. Affordable Care Act and Medi-Cal Managed Care Plan requirements
1. CONTRACTOR understands that effective January 1, 2014, Medi-Cal
managed care health plans (MCHPs) are required to serve Medi-Cal
beneficiaries with mild to moderate impairment of mental, emotional,
or behavioral functioning resulting from a mental health condition
defined by the current Diagnostic and Statistical Manual. Outpatient
benefits available through MCHPs include:
a. Individual and group mental health evaluation and treatment
(psychotherapy)
b. Psychological testing, when clinically indicated to evaluate a
mental health condition;
c. Outpatient services for the purposes of monitoring drug
therapy;
d. Psychiatric consultation; and
e. Outpatient laboratory, drugs, supplies and supplements
(excluding medications as described in the forthcoming "Medi-
Cal Managed Care Plan Responsibilities for Outpatient
Mental Health Services and Coordination with County Mental
Health Plans").
2. CONTRACTOR will comply with all requirements established by the
California Department of Health Care Services (DHCS), Fresno County
MHP, and Medi-Cal MCHPs for screening, referral, and coordination of
care for mild to moderate cases, when clinically appropriate.
Revised Exhibit B-5
Page 11 of 17
F. Administrative Requirements
1. CONTRACTOR shall meet with COUNTY staff monthly, or as often as
needed, for monitoring of program services, client capacity, staffing
levels and to exchange pertinent operational information, resolve
problems, and coordinate services.
2. CONTRACTOR shall participate in a joint meeting with COUNTY staff
and other vendors for CWMH services on a quarterly basis, or as often
as needed, to discuss program trends and resolution of concerns and
problems across all vendors.
3. CONTRACTOR shall attend bi-monthly Mental Health Contracted
Provider Meetings held by DBH.
4. CONTRACTOR will complete and submit monthly activity reports in a
manner determined by DBH and DSS.
5. CONTRACTOR will provide annual Civil Rights training to their staff in
the first quarter of every calendar year and will provide relevant proof to
DBH and DSS by April 1, for each year of the contract.
G. Data and Reporting
1. CONTRACTOR shall maintain and provide the COUNTY with monthly
statistics on the number of individuals/families to include, but not limited
to:
a. Number of clients referred for mental health assessments;
average time between referral and contact with caregiver;
average time between referral and assessment; number of
assessments completed, number of missed/no- show
appointments, number that did not meet Medi-Cal medical
necessity criteria;
b. Number of clients referred for court-ordered services
including type of service, average time between referral
and contact with the caregiver to schedule the
appointment, average number of days between the
referral and the court-ordered service, number of
missed/no-show appointments;
C. Average wait time between assessment and first visit with
assigned therapist;
d. Average wait time between referral and provision of
medication evaluation;
Revised Exhibit B-5
Page 12 of 17
e. Unique clients served; units and dollars of services billed,
average cost per client;
f. Number and reasons for discharge from care;
g. Number of active clients in ongoing treatment
This information, in addition to the outcome measures to be developed,
will be provided to COUNTY on a monthly basis via an activity report
template developed by the COUNTY and due no later than the loth of
each month.
2. Maintain case files on each individual/family, including, but not limited to
the following information:
a. Documentation of referrals to/from COUNTY, self-referrals,
and others;
b. Chronological record of individual and family services
provided including relevant contact dates, incidents, actions
taken, and results; and,
c. Case closure summary, indicating the reasons for closure and
the results of the services provided.
3. CONTRACTOR shall maintain secure case files with limited access only
to designated staff to ensure confidentiality.
4. CONTRACTOR shall submit a monthly staffing report, due no later than
the loth of each month, detailing the total number of positions by
classification in the approved budget, number of staff hired (including
licensure, ethnicity, bilingual language capability, clinical
training/certification in EBPs), and number of vacancies.
II. COUNTY SHALL BE RESPONSIBLE FOR THE FOLLOWING:
A. Provide mental health service referrals to CONTRACTOR for children and
families involved in the CWS system.
B. Designate a contact person from DSS and DBH for CONTRACTOR to
communicate with, when necessary.
C. Meet with CONTRACTOR monthly, or as often as needed, to exchange pertinent
information, resolve problems, and work together to coordinate referrals and
services.
Revised Exhibit B-5
Page 13 of 17
D. Support coordination of ICC meetings initially and no less than every ninety (90)
days for a child/youth.
E. Convene team meetings in alignment withthe Continuum of Care Reform (CCR),
Child and Family Teaming, Senate Bill 163 Wraparound, and the Integrated Core
Practice models for which CONTRACTOR will be required to participate when
appropriate.
F. Provide education and training on CWS, practice models and Medi-Cal licensing,
documentation and billing requirements, as needed.
III. PERFORMANCE MEASUREMENTS
Overall Service Objective:
CONTRACTOR will adhere to the outcome measures developed by COUNTY and any
requirements established by the California Department of Social Services (CDSS) and
DHCS. County may adjust these outcome measurements, periodically, so as to best
measure the success of the program. These outcome measurements and indicators will
continue to be developed in conjunction with the CONTRACTOR, COUNTY, and the
State Departments.
Services provided by the CONTRACTOR will align and support the principles of Fresno
County's child welfare practice model, the Katie A Settlement Agreement, as well as other
relevant laws, regulations, statutes, and effective operating principles required to provide
the services. Specialty mental health services will be integrated, timely, ongoing, and
uninterrupted in a family-focused, trauma-informed delivery model that supports the goals
of the client plan developed by COUNTY. Intensive home-based mental health services
are expected to provide children and families in the CWS system with effective treatment,
improve outcomes, promote wellness, aid in resiliency, and maintain family relationships
conducive to healthy emotional development.
Performance Outcomes and Measures:
Under the Katie A. Settlement Agreement and Implementation Plan, DHCS and CDSS
are collectively working to adopt statewide use of a data-informed system of
performance oversight, accountability, and communication that efficiently monitors,
measures, and evaluates access, quality, satisfaction, effectiveness, costs, and
outcomes at the individual, program, and system levels.
CONTRACTOR is required to submit measureable outcomes on a semi-annual basis,
as identified in the DBH's Policy and Procedure Guide (PPG) 1.2.7 Performance
Outcomes Measures. Performance outcome measures must be approved by DBH and
satisfy all State and local mandates. 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).
Revised Exhibit B-5
Page 14 of 17
DBH collects data about the characteristics of the persons served and measures service
delivery performance indicators in each of the following CARF domains.
A. Effectiveness - A performance dimension that assesses the degree to which
an intervention or series have achieved the desired outcome/result/quality of
care through measuring change overtime. The results achieved and outcomes
observed are for persons served.
B. 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 of the resources used to deliver the
service.
C. Access - Organizations' capacity to provide services to 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.
D. Satisfaction - Satisfaction Measures are usually oriented towards clients,
family, staff, and stakeholders. The degree to which the 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.
DBH may adjust the performance and outcome measures periodically throughout the
duration of the Agreement, as needed, to best measure the program as determined by
COUNTY. CONTRACTOR must utilize a computerized tracking system with which
performance and outcome measures and other relevant client data, such as
demographics, will be maintained.
The outcome measures and indicators provided below represent COUNTY DBH and DSS
program goals to be achieved by the CONTRACTOR in addition to CONTRACTOR's
developed outcomes.
A. Timeliness of Service — CONTRACTOR will respond to referrals within the
timeframes required by the Final Rule, in order to engage with the clients as
soon as possible.
1. Timely access to services from referral to assessment.
a. Crisis referrals: within three (3) days
b. Standard referrals: within ten (10) days
C. Psychiatric referrals: within fifteen (15) days
2. 100% of all assessments will be signed/completed within thirty (30)
days.
Revised Exhibit B-5
Page 15 of 17
3. Timely access to service from assessment to ongoing treatment
4. Timely access to services from referral to medication evaluation, when
appropriate
B. Access and Engagement—CONTRACTOR will ensure that clients have access
to treatment, that the client is actively involved in treatment, and that every
effort is made to aid the client in successfully completing treatment.
1. CONTRACTOR will provide services in a location determined by the
needs/preference of the client and clinical appropriateness. The
expectation is that 70% of client services will be provided in the home or
a community-based setting.
2. CONTRACTOR will track the number, type, and location of services per
client.
3. CONTRACTOR will actively provide ICC and IHBS services. The
expectation is that a minimum of fifteen percent (15%) of
CONTRACTOR's services will be IHBS.
4. Clinician attendance at 100% of teaming meetings.
5. CONTRACTOR will track the "no-show" and cancellation (by client or
provider) rates for treatment. The expectation is that the "no-show" and
cancellation rates will be ten percent (10%) or less.
6. CONTRACTOR will track the number and reasons for discharge. The
expectation is that there will be a low number of discharges due to "no-
shows" and a low number of discharges in which the client has not
successfully completed treatment.
7. Seventy percent (70%)of individuals with an open child welfare case will
successfully complete treatment.
C. Wellness, Recovery, and Resiliency Supports — a collaborative approach to
treatment strategies to aid in the successful completion of treatment,
reunification, and reduction in recidivism.
1. Improved Child Functioning -
Improvement in relationships, behavior, and academic achievements,
as demonstrated through the tracking tools, CANS 50 and PSC-35,
implemented by the CONTRACTOR and caregivers, respectively.
2. Improved Family Functioning
Improvement in ability to provide for and maintain a safe and stable
environment for the child, as demonstrated through tracking tool, CANS
50, implemented by the CONTRACTOR.
Revised Exhibit B-5
Page 16 of 17
3. Improved Parent Functioning
Improvement in relationships, behavior, and sustaining basic needs, as
demonstrated through tracking tool, CANS 50, implemented by the
CONTRACTOR.
4. Effectiveness of discharge planning as demonstrated by referral and
linkage to other COUNTY programs, community providers, and
community resources.
5. Placement, Stability, & Permanency
a. Number of placement changes while in treatment
b. Permanency status of clients
IV. Cultural Competency
In alignment with the County's DBH Mental Health Services Act Three-Year Plan, Mental
Health Plan, and Cultural Competency Plan, CONTRACTOR shall provide culturally
competent and culturally responsive services. CONTRACTOR's responsibilities shall
include:
A. Mental Health and Substance Use Disorder direct service providers must
complete eight (8) hours of annual cultural competency training. Training hours
may include completing culturally competent courses through DBH Learning
Management System or attending cultural awareness events. DBH will provide
opportunities and track completion of training hours through its Learning
Management System.
B. When providing interpretation services for DBH clients, CONTRACTOR must
utilize interpreters who have received annual training and have been monitored
for language competence. By July 1st of each year, CONTRACTOR shall
provide DBH with its current list of interpreters, which includes training dates
and monitoring results. CONTRACTOR shall not utilize any interpreter who
has not received annual training and/or has not demonstrated language
competence. CONTRACTOR shall have access to DBH approved translators
via DBH's established protocol.
C. In order for DBH to ensure a cultural, racial/ethnic, and linguistic group of direct
service providers representative of the population needing services and being
served, CONTRACTOR shall complete and email the Monthly Staffing Report,
which includes gender, ethnicity, and bilingual language capacity by the tenth
(10th) of every month.
D. CONTRACTOR shall provide a plan to address cultural competency standards
as set forth in the National Standards on Culturally and Linguistically
Appropriate Services (CLAS).
Revised Exhibit B-5
Page 17 of 17
E. CONTRACTOR shall provide services within the most relevant and meaningful
cultural, gender-sensitive, and age-appropriate context for the target
population.
F. CONTRACTOR shall distribute literature/information brochures in appropriate
languages and request feedback as to how access to care could be improved
for culturally diverse communities. Distributed information will be approved by
DBH and/or DSS designee and translated as needed via DBH protocols.
Exhibit C
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
DBH VISION:
Health and well-being for our community.
DBH MISSION:
The Department of Behavioral Health is dedicated to supporting the wellness of individuals,
families and communities in Fresno County who are affected by, or are at risk of, mental illness
and/or substance use disorders through cultivation of strengths toward promoting recovery in
the least restrictive environment.
DBH GOALS:
Quadruple Aim
• Deliver quality care
• Maximize resources while focusing on efficiency
• Provide an excellent care experience
• Promote workforce well-being
GUIDING PRINCIPLES OF CARE DELIVERY:
The DBH 11 principles of care delivery define and guide a system that strives for excellence in the
provision of behavioral health services where the values of wellness, resiliency, and recovery are
central to the development of programs, services, and workforce. The principles provide the
clinical framework that influences decision-making on all aspects of care delivery including
program design and implementation, service delivery, training of the workforce, allocation of
resources, and measurement of outcomes.
1. Principle One -Timely Access & Integrated Services
o Individuals and families are connected with services in a manner that is streamlined,
effective, and seamless
o Collaborative care coordination occurs across agencies, plans for care are integrated,
and whole person care considers all life domains such as health, education,
employment, housing, and spirituality
o Barriers to access and treatment are identified and addressed
o Excellent customer service ensures individuals and families are transitioned from one
point of care to another without disruption of care
1
rev 01-02-2018
Exhibit C
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 client values and preferences
o Other clinically significant interventions such as innovative, promising, and emerging
practices are embraced
2
rev 01-02-2018
Exhibit C
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 client's stage of change
o Progression though stages of change are supported through positive working
relationships and alliances that are motivating
o Providers support individuals and families to develop strategies aimed at reducing
negative outcomes of substance misuse though a harm reduction approach
o Each individual defines their own recovery and recovers at their own pace when
provided with sufficient time and support
3
rev 01-02-2018
Exhibit C
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 01-02-2018
Revised Exhibit D-5
Child Welfare Mental Health Services
Pacific Clinics
Fiscal Year (FY) 2022-23
PROGRAM EXPENSES
1000:SALARIES& BENEFITS
Employee Salaries
Acct# Position FTE Admin Direct Total
1101 Clinician 1 18.00 $ - $ 1,511,292 $ 1,511,292
1102 Clinician II 5.00 - 466,451 466,451
1103 Family Specialist 4.00 - 145,408 145,408
1104 lClinical Program Manager 5.31 - 585,849 585,849
1105 Clinical Director 1.00 - 138,978 138,978
1106 Support Services Coordinator 1.00 - 47,052 47,052
1107 Doctors Assistant 0.40 - 16,212 16,212
1108 Customer Support Spec 1.00 - 58,152 58,152
1109 jAdministrative Assistant 0.89 46,442 - 46,442
1110 Regional Director 0.45 78,327 - 78,327
1111 Supervisor of Administrative Operations 0.45 28,270 - 28,270
1112 Customer Services 1.34 75,145 - 75,145
1113 lAssociate Director of Quality Support 0.45 51,535 - 51,535
1114 Health Information Manager 0.11 13,320 - 13,320
1115 Supervisor Physical Plant Operations 0.09 7,646 - 7,646
1116 Outcome- Research Specialist 0.55 51,070 - 51,070
1117 Training- Learning Partner 0.27 20,224 - 20,224
1118 - - -
1119 - - -
1120 - -
Personnel Salaries Subtotall 40.31 1 $ 371,979 1 $ 2,969,394 1 3,341,373
Employee Benefits
Acct# Description Admin Direct Total
1201 Retirement $ 14,880 $ 118,776 $ 133,656
1202 Worker's Compensation $ 7,440 $ 59,388 66,828
1203 Health Insurance $ 83,695 $ 668,114 751,809
1204 Other (specify) - - -
1205 Other (specify) - - -
1206 Other (specify) - - -
Employee Benefits Subtotal: $ 106,015 $ 846,278 $ 952,293
Payroll Taxes& Expenses:
Acct# Description Admin Direct Total
1301 OASDI $ 23,063 $ 184,102 $ 207,165
1302 FICA/MEDICARE $ 5,394 $ 43,056 48,450
1303 SUI $ 2,790 $ 22,271 25,061
1304 Other (specify) - - -
1305 Other (specify) - - -
1306 Other (specify) - - -
Payroll Taxes& Expenses Subtotal: $ 31,247 $ 249,429 $ 280,676
EMPLOYEE SALARIES& BENEFITS TOTAL: $ 509,241 $ 4,065,101 $ 4,574,342
Revised Exhibit D-5
2000: CLIENT SUPPORT
Acct# Line Item Description Amount
2001 Child Care $ -
2002 Client Housing Support -
2003 Client Transportation &Support -
2004 IClothing, Food, & Hygiene -
2005 Education Support -
2006 Employment Support -
2007 Household Items for Clients -
2008 Medication Supports -
2009 113rogram Supplies- Medical -
2010 Utility Vouchers -
2011 Other (specify) -
2012 Other (specify) -
2013 Other (specify) -
2014 Other (specify) -
2015 Other (specify) -
2016 10ther (specify) -
DIRECT CLIENT CARE TOTAL $ -
3000: OPERATING EXPENSES
Acct# I Line Item Description Amount
3001 Telecommunications $ 66,741
3002 Printing/Postage 1,946
3003 Office Supplies & Equipment 6,000
3004 Advertising -
3005 Staff Development &Training 102,648
3006 Staff Travel and Mileage/Vehicle Maintenance 106,090
3007 ISubscriptions & Memberships 4,829
3008 Program Supplies -Therapeutic 6,000
3009 Depreciation 5,799
3010 Other (Specify) -
3011 Other (Specify) -
3012 10ther (Specify) -
OPERATING EXPENSES TOTAL:j $ 300,053
4000: FACILITIES& EQUIPMENT
Acct# Line Item Description Amount
4001 Building Maintenance $ 2,345
4002 Rent/Lease Building 228,545
4003 Rent/Lease Equipment 5,072
4004 Rent/Lease Vehicles -
4005 ISecurity -
4006 Utilities -
4007 Equipment Purchase 36,710
4008 Other (Specify) -
4009 Other (Specify) -
4010 10ther (Specify) -
FACILITIES/EQUIPMENT TOTAL:j $ 272,672
5000: SPECIAL EXPENSES
Acct# I Line Item Description Amount
Revised Exhibit D-5
5001 Consultant (Network& Data Management) $ 16,000
5002 HMIS (Health Management Information System) -
5003 Contract Psychiatrist 145,310
5004 Translation Services 25,000
5005 Other (Specify) -
5006 10ther (Specify) -
5007 Other (Specify) -
5008 10ther (Specify) -
SPECIAL EXPENSES TOTAL:1 $ 186,310
6000:ADMINISTRATIVE EXPENSES
Acct# Line Item Description Amount
6001 Administrative Overhead $ 813,336
6002 Professional Liability Insurance 83,534
6003 Accounting/Bookkeeping -
6004 External Audit 5,330
6005 Insurance (Specify): -
6006 Payroll Services -
6007 Depreciation (Provider-Owned Equipment to be Used for Program Purposes) -
6008 Other (Specify) -
6009 Other (Specify) -
6010 Other (Specify) -
6011 Other (Specify) -
6012 10ther (Specify) -
ADMINISTRATIVE EXPENSES TOTAL $ 902,200
7000: FIXED ASSETS
Acct# Line Item Description Amount
7001 Computer Equipment &Software $ -
7002 Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data -
7003 Furniture & Fixtures -
7004 Leasehold/Tenant/Building Improvements -
7005 Other Assets over$S00 with Lifespan of 2 Years+ -
7006 Assets over$5,000/unit (Specify) -
7007 Other (Specify) -
7008 Other (Specify) -
FIXED ASSETS EXPENSES TOTAL $ -
TOTAL PROGRAM EXPENSES $ 6,235,577
Revised Exhibit D-5
PROGRAM FUNDING SOURCES
8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION)
Acct# Line Item Description Service Units Rate Amount
8001 Mental Health Services 876,320 3.70 $ 3,238,772
8002 Case Management 84,228 2.88 242,302
8003 Crisis Services 16,855 5.42 91,386
8004 Medication Support 16,855 6.74 113,576
8005 Collateral 101,131 3.70 373,768
8006 Plan Development 33,710 2.88 96,975
8007 Assessment 134,841 3.70 498,356
8008 Rehabilitation 84,276 3.70 311,474
8009 1 Intensive Care Coordination 84,3241 2.88 1 242,578
8010 jIntensive Home-Based Services 252,9731 3.70 1 934,957
Estimated Specialty Mental Health Services Billing Totals: 1 1,685,5131 $ 6,144,144
Estimated %of Clients who are Medi-Cal Beneficiaries 93%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 5,722,556
Federal Financial Participation (FFP) % 1 50% 2,861,278
MEDI-CAL FFP TOTAL $ 2,861,278
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 $ 2,861,278
REALIGNMENT TOTAL $ 2,861,278
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 (DSS)
Acct# Line Item Description Amount
8401 Court Documentation -- 1,380 units; $74.00 per report $ 102,120
8402 Psychological Evaluations- 24,480 units; $2.89 per unit $ 70,747
8403 Mental Health Services (Individual/Family/Group Therapy) - 58,363 units; $3.70 per unit $ 215,702
8404 Case Management-7,207 units; $2.88 per unit $ 20,732
8405 Crisis Services-765 units; $5.42 per unit $ 4,149
8406 Medication Support- 616 units; $6.74 per unit $ 4,149
8407 Collateral - 6,735 units; $3.70 per unit $ 24,893
8408 Plan Development- 2,884 units; $2.88 per unit $ 8,298
8409 lAssessment-8,980 units; $3.70 per unit $ 33,191
8410 1 Rehabilitation -5,613 units; $3.70 per unit $ 20,744
Revised Exhibit D-5
8411 Intensive Care Coordination - 1,442 units; $2.88 per unit $ 4,149
8412 lIntensive Home-Based Services - 1,123 units; $3.70 per unit $ 4,149
OTHER REVENUE TOTAL $ 513,021
TOTAL PROGRAM FUNDING SOURCES: $ 6,235,577
NET PROGRAM COST: $ -
Revised Exhibit D-5
Child Welfare Mental Health Services
Pacific Clinics
Fiscal Year (FY) 2022-23 Budget Narrative
PROGRAM EXPENSE
ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES & BENEFITS 4,574,342
Employee Salaries 3,341,373
1101 Clinician 1 1,511,292 Master's Degree (MA/MS) and at least two years of experience working with youth,
young adults and families in a therapeutic environment is required. If unlicensed must
be a registered intern with the Board of Behavioral Sciences and receiving appropriate
clinical supervision. Provides psychotherapy and psychotherapeutic support to children
and families.
1102 Clinician 11 466,451 Master's Degree (MA/MS) and at least two years of experience working with youth,
young adults and families in a therapeutic environment is required. If unlicensed must
be a registered intern with the Board of Behavioral Sciences and receiving appropriate
clinical supervision. Provides psychotherapy and psychotherapeutic support to children
and families. Applies advanced use of assessment information in development of the
treatment plan and applies information and resources to ensure quality care.Applies
advanced skill in acquisition and application of clinically related information to
effectively intervene with children and families. Understands and applies multi-modal
approaches and perspectives to therapeutic direction. Provides coaching and mentoring
of others in the implementation of Evidence Based Practices (EBPs). Leads problem
solving interaction and work with external customers. Maintains audit ready charts and
audits charts independently. Provides observations and feedback to supervisor in order
to monitor and/or modify programs or approaches.Actively participates in the
identification of team opportunities for improvement or identification of deficiencies
and in the development of strategies to address or bridge gaps. Leads Continuous
Quality Improvement (CQI) activities and project implementation. Required to meet
applicable productivity and documentation requirements.
1103 Family Specialist 145,408 Provides direct services to youth and families. Provides direct billable mental health
services, documents in alignment with MediCal regulations, and achieves set
productivity expectations. Engages and builds alignment and relationships with parents,
youth, and others in the normal course of working with the families. Utilizes strengths of
youth,families, and others to assist in the implementation and achievement of goals and
outcomes. Works with youth and family teams to support family driven, strength based
planning and interventions. Understands and takes advantage of therapeutic
opportunities in crisis situations. Conducts observations regarding specific target
behavior,track progress and modify plans with the family to support their intended
identified outcome. Assists teams in developing a hypothesis of function and underlying
unmet need in an effort to develop individualized, strength based strategies and
interventions that will result in positive behavior change. Engages caregiver,family
members, and other natural supports in building youth specific parenting responses that
support positive behavior change and overall family relationships. Works in the
community directly with youth and families to develop and implement safety and skill
refinement plans. Supports families in bridging to and or building on natural resources
and accessing community based program supports that will continue support over time.
Develops resources within the community to serve children and families. Assists youth
and family teams to meet specific service needs (ie: help develop strategy or resource
specific to an identified need) and monitor outcomes. Participates in family finding team
activities by identifying family finding need, obtaining authorizations, creating teams,
conducting searches and setting deadlines. Completes Connectedness Maps as needed.
Documents interactions and practices and maintain administrative expectations in a
timely manner. Meets and or exceeds all direct service expectations and documentation
requirements. Assists in developing program responses to needs identified across a
number of youth and families where natural community resources are not available or
appropriate. Builds on individual strengths, concerns, and needs with balanced focus on
Revised Exhibit D-5
PROGRAM EXPENSE
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1104 Clinical Program Manager 585,849 Ensures effective coordination of services for youth and families with other providers,
both internal and external, by supporting the development of constructive relationships
and problem-solving barriers. Develops, interprets and ensures consistent
implementation of clinical program philosophy, objectives, standards, policies,
procedures and practices. Analyzes and integrates the use of outcome data to improve
clinical service delivery within assigned team. Ensures and monitors defined outcome
achievement for youth and families, as well as satisfaction levels for youth, families, and
referring workers and agencies. Initiates and participates in organizational quality
improvement efforts. Lead and/or delegate work groups to respond to program
development needs. Ensures compliance with all policy and procedures including
adherence to all licensing, quality, Information Technology(IT), Human Resources (HR),
compliance and regulatory standards. Leads and manages change. Proactively identifies
potential conflicts; leads parties to consensus and develops same skills in direct reports.
Manages to ensure fiscally viable programming. Ensures staff billable productivity and
other revenue related activities meet or exceed revenue forecasts. Ensures effective
quality clinical services delivery for assigned youth and families. Provides effective crisis
and risk prevention and management. Partners with county referring departments,
agencies and the community to ensure comprehensive care. Participates in staff
development; hires, coaches, mentors, supervises, conducts direct field observations,
trains, disciplines, and terminates. Ensures clinical documentation and quality assurance
meets both agency and payor standards, ensuring audit ready charts and continuous
quality improvement. Provides 24/7 availability as needed. Culturally responsive to
internal and external customers, and ensures family voice. Provides direct services to
families and children, as support to the direct service staff,to ensure smooth delivery of
service to assigned families and youth. Provides outreach to the community including
education about agency, program and general mental health and foster care topics.
Advocates for system change in relationship to agency service delivery philosophy.
1105 Clinical Director 138,978 Master's degree (MA/MS). Must have appropriate license to practice as a Licensed
Clinical Social Worker or Marriage Family Therapist in the State of California. Must meet
the BBS requirements to provide clinical oversight and supervision with three to ten
years of experience in healthcare/psychology/behavioral/mental health.The Clinical
Director implements strategies to accomplish the agency annual priorities at the
program level. Directs and develops managers, ensures CPMS are competent and have
all tools necessary to lead teams.
1106 Support Services Coordinator 47,052 Bachelor's degree required. (with emphasis in Psychology, social Work, Sociology or
related course work)Two years of experience in Mental Health field required.Four years
of experience in Mental Health field preferred. Knowledge of excel spreadsheets;
moderate computer literacy. Clinical skills relevant to intake services including: client
triage, understanding of legal/ethical issues, and risk management. Works within the
vision, mission, and philosophy of the agency, provides customerfriendly services to
internal and external customers. With limited supervision, sets up, coordinates and runs
parenting groups, trains new staff and coaches and supports existing staff in effectively
using therapeutic interventions with children and families and in meeting
documentation quality and timeliness expectations.Analyzes outcome data in
partnership with Outcomes and Evaluation to identify quality improvement activities.
Leads quality improvement activities from start to finish, including evaluation of the
effectiveness of the activities.
1107 Doctors Assistant 16,212 The Doctor's assistant position directly supports the Psychiatrist and Nurse Practitioner
in all the administrative tasks related to medical support for clients. This position was
previously held by an Administrative Assistant; however requires a higher level of
education and expertise given the specialized nature of the medication support tasks.
1108 Customer Support Spec 58,152 The CSS II is the lead position for our intake coordinators. This position was added to
manage the newly added requirements of tracking all of the access data. This position
also handles additional billing tasks and requirements, as well as supports and trains the
other intake coordinators. This position also assists with data collection for the Monthly
Activity Report specific to the Hope contract.
1109 Administrative Assistant 46,442 These positions are shared direct program costs that provide direct clinical, operational
support, quality, compliance and outcomes support and management and supervision
support,to produce required program outcomes to all programs in this region.
Approximately 45%of cost is allocated to this program using the basis of direct wages by
program for this region's programs.
Revised Exhibit D-5
PROGRAM EXPENSE
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1110 Regional Director 78,327 These positions are shared direct program costs that provide direct clinical, operational
support, quality, compliance and outcomes support and management and supervision
support, to produce required program outcomes to all programs in this region.
Approximately 45% of cost is allocated to this program using the basis of direct wages by
program for this region's programs.
1111 Supervisor of Administrative Operations 28,270 These positions are shared direct program costs that provide direct clinical, operational
support, quality, compliance and outcomes support and management and supervision
support, to produce required program outcomes to all programs in this region.
Approximately 45% of cost is allocated to this program using the basis of direct wages by
program for this region's programs.
1112 Customer Services 75,145 These positions are shared direct program costs that provide direct clinical, operational
support, quality, compliance and outcomes support and management and supervision
support, to produce required program outcomes to all programs in this region.
Approximately 45% of cost is allocated to this program using the basis of direct wages by
program for this region's programs.
1113 Associate Director of Quality Support 51,535 These positions are shared direct program costs that provide direct clinical, operational
support, quality, compliance and outcomes support and management and supervision
support, to produce required program outcomes to all programs in this region.
Approximately 45% of cost is allocated to this program using the basis of direct wages by
program for this region's programs.
1114 Health Information Manager 13,320 These positions are shared direct program costs that provide direct clinical, operational
support, quality, compliance and outcomes support and management and supervision
support, to produce required program outcomes to all programs in this region.
Approximately 45% of cost is allocated to this program using the basis of direct wages by
program for this region's programs.
1115 Supervisor Physical Plant Operations 7,646 These positions are shared direct program costs that provide direct clinical, operational
support, quality, compliance and outcomes support and management and supervision
support, to produce required program outcomes to all programs in this region.
Approximately 45% of cost is allocated to this program using the basis of direct wages by
program for this region's programs.
1116 Outcome - Research Specialist 51,070 These positions are shared direct program costs that provide direct clinical, operational
support, quality, compliance and outcomes support and management and supervision
support, to produce required program outcomes to all programs in this region.
Approximately 45% of cost is allocated to this program using the basis of direct wages by
program for this region's programs.
1117 Training- Learning Partner 20,224 These positions are shared direct program costs that provide direct clinical, operational
support, quality, compliance and outcomes support and management and supervision
support, to produce required program outcomes to all programs in this region.
Approximately 45% of cost is allocated to this program using the basis of direct wages by
program for this region's programs.
1118 0 -
1119 0 -
1120 0 -
Employee Benefits 952,293
1201 Retirement 133,656 Calculated at 4%of salaries.
1202 Worker's Compensation 66,828 Calculated at 2%of salaries.
1203 Health Insurance 751,809 Calculated at 22.5%of salaries.
1204 Other (specify) -
1205 Other (specify) -
1206 Other (specify) -
Payroll Taxes & Expenses: 280,676
1301 OASDI 207,165 Calculated at 6.2%of salaries.
1302 FICA/MEDICARE 48,450 Calculated at 1.45%of salaries.
1303 SUI 25,061 Calculated at 0.75%of salaries.
1304 Other (specify) -
1305 Other(specify) -
1306 Other (specify) -
Revised Exhibit D-5
PROGRAM EXPENSE
ACCT#j LINE ITEM I AMT I DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
2000: CLIENT SUPPORT -
2001 Child Care -
2002 Client Housing Support -
2003 Client Transportation &Support -
2004 Clothing, Food, & Hygiene -
2005 Education Support -
2006 Employment Support -
2007 Household Items for Clients -
2008 Medication Supports -
2009 Program Supplies- Medical -
2010 Utility Vouchers -
2011 Other (specify) -
2012 Other(specify) -
2013 Other (specify) -
2014 Other (specify) -
2015 Other (specify) -
2016 Other (specify) -
3000: OPERATING EXPENSES 300,053
3001 Telecommunications 66,741 Cell phones, Land Lines, DSL, fax charges, phone system; wireless cards for laptop
computers enabling UFS to maintain a fully functional mobile work force to deliver in-
home/in the community services. Costs are allocated between programs on the basis of
payroll dollars and have been estimated based on historical trends.
3002 Printing/Postage 1,946 Postage, printing, US mail, GSO, Federal Express, UPS, postage machine refills, outside
reproduction costs, program specific brochures and flyers when reimbursable by the
program. Costs are allocated between programs on the basis of payroll dollars and have
been estimated based on historical trends.
3003 Office Supplies & Equipment 6,000 Office supplies and equipment include, but are not limited to: paper, pens, files,
staplers, break rooms supplies (e.g., coffee, paper cups, plastic utensils); subscriptions to
periodicals or newspapers, annual Agency dues and fees paid to accrediting agencies and
laptop replacement. Costs are allocated between programs on the basis of direct labor
dollars and have been estimated based on historical trends.
3004 Advertising -
3005 Staff Development &Training 102,648 Includes training in the Evidence-Based Practices of Trauma-Focused Cognitive
Behavioral Therapy (TFCBT), Motivational Interviewing (MI), Cognitive Behavioral
Therapy (CBT), Child Parent Psychotherapy(CPP), and Dialectical Behavior Therapy
(DBT), organizational tools, team/organizational psychology, philosophy of client based
services, integration of roles/team dynamics, assessment and individualized treatment
planning, general services, organizing admissions and individualized treatment planning
associated with the EBPs.This includes train-the-trainer and any other program
development training needs. Trainings are inclusive of internal and external trainings,
and all costs, except mileage associated with training, including transportation, parking
room and board, meals, refreshments cost of the program, instructor fees and
materials/manuals are included. Also includes other mandatory trainings such as first aid
and CPR.
3006 Staff Travel and Mileage/Vehicle 106,090 Includes travel costs such as air fare, lodging, and mileage reimbursement,which is paid
Maintenance at the prevailing federal rate (currently$0.575 per mile) to program service staff and
program administrative staff.This also includes upkeep costs for vehicles.
3007 Subscriptions & Memberships 4,829 Includes subscriptions to periodicals, databases, software, and other subscription
services, as well as annual agency dues and fees. Costs are allocated between programs
on the basis of payroll dollars and have been estimated based on historical trends.
3008 Program Supplies-Therapeutic 6,000 Includes those supplies utilized in the direct delivery of therapeutic services to clients.
Cost is estimated to be approximately$18.50 per direct care staff per month. Materials,
cash payments, outing costs, etc. used to motivate or reinforce desired behavior, as well
as materials required for use in Evidenced Based Practices
3009 Depreciation 5,799 Depreciation includes deprecation on leasehold improvements, office furniture/fixtures
and equipment meeting amortization thresholds. Costs are allocated between programs
on the basis of payroll dollars and have been estimated based on historical trends.
Revised Exhibit D-5
PROGRAM EXPENSE
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
3010 Other (Specify) -
3011 Other (Specify) -
3012 Other (Specify) -
4000: FACILITIES& EQUIPMENT 272,672
4001 Building Maintenance 2,345 This includes common area maintenance on leased building charges,
maintenance/building repair charges, HVAC maintenance and repair, landscaping,
janitorial services, confidential paper shredding services, in-house or outside equipment
repair and labor. Costs are allocated between programs on the basis of payroll dollars
and have been estimated based on historical trends and the utilization of the Agency's
office in Fresno.
4002 Rent/Lease Building 228,545 This includes building rent or depreciation, storage and file storage unit rental payments
and all the costs associated with storing and retrieving of client, personnel or other files
or records. Costs are allocated between programs on the basis of payroll dollars and
have been estimated based on historical trends and the utilization of the Agency's new
office in Fresno.
4003 Rent/Lease Equipment 5,072 This includes rental payments for equipment including leased copiers, postage machines,
phone systems, laptops or other communication, office or facility equipment. Costs are
allocated between programs on the basis of payroll dollars and have been estimated
based on historical trends and the utilization of the Agency's office in Fresno.
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities -
4007 Equipment Purchase 36,710 Equipment, parts and materials includes the purchase of non-capital assets. Sample
items include, but are not limited to, laptops, desktops, printers, calculators and fax
machines, as well as system user licenses. Costs are allocated between programs on the
basis of payroll dollars and estimated.
4008 Other (Specify) -
4009 Other (Specify) -
4010 Other (Specify) -
5000: SPECIAL EXPENSES 186,310
5001 Consultant (Network& Data Management) 16,000 The consultant will provide additional clinical supervision support for program staff. This
will also be used to hire a contract psychologist to provide court ordered psychological
testing and reports to the Court. Contract Psychologist estimated to cost $212 per hour.
The psychologist will be required to provide at least 25 hours per month on average.
This will also cover the cost of the psychological testing and scoring materials.
5002 HMIS (Health Management Information -
System)
5003 Contract Psychiatrist 145,310 This includes a contract Psychiatrist position estimated to cost$212 per hour.The
psychiatrist will be required to provide at least 35 hours per month, and will provide
psychiatric evaluations and medication support services.This also includes a Nurse
Practitioner, estimated to cost$125 per hour. The nurse practitioner will be required to
provide 6 hours per week and will provide additional psychiatric evaluations and
medication support services.
5004 Translation Services 25,000 To ensure the provision of culturally sensitive services including assurance of language
access, when there is not availability of bilingual staff interpreter/translation services are
used to support a culturally appropriate evaluation, diagnosis,treatment and referral
services.
5005 Other (Specify) -
5006 Other (Specify) -
5007 Other (Specify) -
5008 Other (Specify) -
6000:ADMINISTRATIVE EXPENSES 902,200
6001 Administrative Overhead 813,336 Represents the overhead of the Agency's general and administrative shared support
services such as finance, accounting, billing, human resources, clinical administration,
information technology, professional fees, HIPPA compliance and clinical record audits,
risk management and program fidelity, recruiting and human resources support, MIS
infrastructure &QI/UM department support and oversight as well as executive
management. Costs that cannot be specifically charged to a program are allocated to
programs on the basis of direct program salary costs prior to the addition of taxes and
benefits.Administrative Overhead has been budgeted at 15%of total program expenses.
Revised Exhibit D-5
PROGRAM EXPENSE
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
6002 Professional Liability Insurance 83,534 Includes general business liability and property coverage along with professional liability
insurance. Costs are allocated between programs on the basis of direct labor dollars and
estimated based on historical trends.
6003 Accounting/Bookkeeping -
6004 External Audit 5,330 Includes annual audit ensuring all financial records are relevant and accurate and in
compliance with state and federal laws and regulations. Audit costs are allocated
between programs on the basis of payroll dollars and have been estimated based on
historical costs.
6005 Insurance(Specify): -
6006 Payroll Services -
6007 Depreciation (Provider-Owned Equipment to be Used for Program Purposes)
6008 Other(Specify) -
6009 Other(Specify) -
6010 Other(Specify) -
6011 Other(Specify) -
6012 Other (Specify) -
7000: FIXED ASSETS -
7001 Computer Equipment&Software -
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) -
7008 Other (Specify) -
PROGRAM FUNDING SOURCES
8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION)
PROVIDE DETAILS OF METHOD LOGY IES USED IN DETERMINING MEDI-CAL SERVICE RATES
ACCT# LINE ITEM AND/OR SERVICE UNITS, IF APPLICABLE AND/OR AS REQUIRED BY THE RFP.
8001 Mental Health Services Estimated 876,320 units at$3.79 per unit
8002 Case Management Estimated 84,228 units at$2.95 per unit
8003 Crisis Services Estimated 16,855 units at$5.56 per unit
8004 Medication Support Estimated 16,855 units at$6.91 per unit
8005 Collateral Estimated 101,131 units at$3.79 per unit
8006 Plan Development Estimated 33,710 units at$2.95 per unit
8007 Assessment Estimated 134,841 units at$3.79 per unit
8008 Rehabilitation Estimated 84,276 units at$3.79 per unit
8009 Intensive Care Coordination Estimated 84,324 units at$2.95 per unit
8010 Intensive Home-Based Services Estimated 252,973 units at$3.79 per unit
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 6,235,577
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 6,235,577
BUDGET CHECK: -
Revised Exhibit D-5
Child Welfare Mental Health Services
Pacific Clinics
Fiscal Year (FY) 2023-24
PROGRAM EXPENSES
1000: SALARIES& BENEFITS
Employee Salaries
Acct# Position FTE Admin Direct Total
1101 Clinician 1 18.00 $ - $ 1,556,631 $ 1,556,631
1102 Clinician II 5.00 - 480,445 480,445
1103 Family Specialist 4.00 - 149,770 149,770
1104 lClinical Program Manager 5.31 - 603,424 603,424
1105 Clinical Director 1.00 - 143,147 143,147
1106 Support Services Coordinator 1.00 - 48,464 48,464
1107 Doctors Assistant 0.40 - 16,698 16,698
1108 Customer Support Spec 1.00 - 59,897 59,897
1109 jAdministrative Assistant 0.89 47,835 - 47,835
1110 Regional Director 0.45 80,677 - 80,677
1111 Supervisor of Administrative Operations 0.45 29,118 - 29,118
1112 Customer Services 1.34 77,399 - 77,399
1113 lAssociate Director of Quality Support 0.45 53,081 - 53,081
1114 Health Information Manager 0.11 13,720 - 13,720
1115 Supervisor Physical Plant Operations 0.09 7,875 - 7,875
1116 Outcome- Research Specialist 0.55 52,602 - 52,602
1117 Training- Learning Partner 0.27 20,831 - 20,831
1118 - - -
1119 - - -
1120 - - -
Personnel Salaries Subtotall 40.31 1 $ 383,138 1 $ 3,058,476 1 3,441,614
Employee Benefits
Acct# Description Admin Direct Total
1201 Retirement $ 15,326 $ 122,339 $ 137,665
1202 Worker's Compensation $ 7,663 $ 61,170 68,833
1203 Health Insurance $ 86,206 $ 688,157 774,363
1204 Other (specify) - - -
1205 Other (specify) - - -
1206 Other (specify) - - -
Employee Benefits Subtotal: $ 109,195 $ 871,666 $ 980,861
Payroll Taxes& Expenses:
Acct# Description Admin Direct Total
1301 OASDI $ 23,755 $ 189,625 $ 213,380
1302 FICA/MEDICARE $ 5,556 $ 44,348 49,904
1303 SUI $ 2,874 $ 22,939 25,813
1304 Other (specify) - - -
1305 Other (specify) - - -
1306 Other (specify) - - -
Payroll Taxes& Expenses Subtotal: $ 32,185 $ 256,912 $ 289,097
EMPLOYEE SALARIES& BENEFITS TOTAL: $ 524,518 1 $ 4,187,0541 $ 4,711,572
Revised Exhibit D-5
2000: CLIENT SUPPORT
Acct# Line Item Description Amount
2001 Child Care $ -
2002 Client Housing Support -
2003 Client Transportation &Support -
2004 IClothing, Food, & Hygiene -
2005 Education Support -
2006 Employment Support -
2007 Household Items for Clients -
2008 Medication Supports -
2009 113rogram Supplies- Medical -
2010 Utility Vouchers -
2011 Other (specify) -
2012 Other (specify) -
2013 Other (specify) -
2014 Other (specify) -
2015 Other (specify) -
2016 10ther (specify) -
DIRECT CLIENT CARE TOTAL $ -
3000: OPERATING EXPENSES
Acct# I Line Item Description Amount
3001 Telecommunications $ 68,743
3002 Printing/Postage 1,946
3003 Office Supplies & Equipment 6,000
3004 Advertising -
3005 Staff Development &Training 102,648
3006 Staff Travel and Mileage/Vehicle Maintenance 109,273
3007 ISubscriptions & Memberships 4,829
3008 Program Supplies -Therapeutic 6,000
3009 Depreciation 5,799
3010 Other (Specify) -
3011 Other (Specify) -
3012 10ther (Specify) -
OPERATING EXPENSES TOTAL:j $ 305,238
4000: FACILITIES& EQUIPMENT
Acct# Line Item Description Amount
4001 Building Maintenance $ 2,462
4002 Rent/Lease Building 228,545
4003 Rent/Lease Equipment 5,326
4004 Rent/Lease Vehicles -
4005 ISecurity -
4006 Utilities -
4007 Equipment Purchase 36,710
4008 Other (Specify) -
4009 Other (Specify) -
4010 10ther (Specify) -
FACILITIES/EQUIPMENT TOTAL:j $ 273,043
5000: SPECIAL EXPENSES
Acct# I Line Item Description Amount
Revised Exhibit D-5
5001 Consultant (Network& Data Management) $ 16,000
5002 HMIS (Health Management Information System) -
5003 Contract Psychiatrist 149,669
5004 Translation Services 25,000
5005 Other (Specify) -
5006 10ther (Specify) -
5007 Other (Specify) -
5008 10ther (Specify) -
SPECIAL EXPENSES TOTAL:1 $ 190,669
6000:ADMINISTRATIVE EXPENSES
Acct# Line Item Description Amount
6001 Administrative Overhead $ 835,864
6002 Professional Liability Insurance 86,040
6003 Accounting/Bookkeeping -
6004 External Audit 5,863
6005 Insurance (Specify): -
6006 Payroll Services -
6007 Depreciation (Provider-Owned Equipment to be Used for Program Purposes) -
6008 Other (Specify) -
6009 Other (Specify) -
6010 Other (Specify) -
6011 Other (Specify) -
6012 10ther (Specify) -
ADMINISTRATIVE EXPENSES TOTAL $ 927,767
7000: FIXED ASSETS
Acct# Line Item Description Amount
7001 Computer Equipment &Software $ -
7002 Copiers, Cell Phones, Tablets, Devices to Contain HIPAA Data -
7003 Furniture & Fixtures -
7004 Leasehold/Tenant/Building Improvements -
7005 Other Assets over$S00 with Lifespan of 2 Years+ -
7006 Assets over$5,000/unit (Specify) -
7007 Other (Specify) -
7008 Other (Specify) -
FIXED ASSETS EXPENSES TOTAL $ -
TOTAL PROGRAM EXPENSES $ 6,408,290
Revised Exhibit D-5
PROGRAM FUNDING SOURCES
8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION)
Acct# Line Item Description Service Units Rate Amount
8001 Mental Health Services 899,904 3.70 $ 3,332,880
8002 Case Management 86,495 2.88 248,687
8003 Crisis Services 17,309 5.43 93,965
8004 Medication Support 17,309 6.74 116,740
8005 Collateral 103,852 3.70 384,626
8006 Plan Development 34,617 2.88 99,529
8007 Assessment 138,469 3.70 512,833
8008 Rehabilitation 86,543 3.70 320,520
8009 1 Intensive Care Coordination 86,5911 2.88 1 248,963
8010 jIntensive Home-Based Services 259,7741 3.70 1 962,098
Estimated Specialty Mental Health Services Billing Totals: 1 1,730,8631 $ 6,320,841
Estimated %of Clients who are Medi-Cal Beneficiaries 93%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries 5,881,930
Federal Financial Participation (FFP) % 1 50% 2,940,965
MEDI-CAL FFP TOTAL $ 2,940,965
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 $ 2,940,965
REALIGNMENT TOTAL $ 2,940,965
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 (DSS)
Acct# Line Item Description Amount
8401 Court Documentation -- 1,380 units; $74.00 per report $ 102,120
8402 Psychological Evaluations- 24,480 units; $2.89 per unit $ 70,747
8403 Mental Health Services (Individual/Family/Group Therapy) - 60,525 units; $3.70 per unit $ 224,161
8404 Case Management-7,494 units; $2.88 per unit $ 21,545
8405 Crisis Services-794 units; $5.43 per unit $ 4,312
8406 Medication Support- 639 units; $6.74 per unit $ 4,312
8407 Collateral - 6,985 units; $3.70 per unit $ 25,869
8408 Plan Development- 2,999 units; $2.88 per unit $ 8,623
8409 lAssessment-9,313 units; $3.70 per unit $ 34,492
8410 1 Rehabilitation -5,821 units; $3.70 per unit $ 21,557
Revised Exhibit D-5
8411 Intensive Care Coordination - 1,500 units; $2.88 per unit $ 4,312
8412 Intensive Home-Based Services - 1,164 units; $3.70 per unit $ 4,312
OTHER REVENUE TOTAL $ 526,360
TOTAL PROGRAM FUNDING SOURCES: $ 6,408,290
NET PROGRAM COST: $ -
Revised Exhibit D-5
Child Welfare Mental Health Services
Pacific Clinics
Fiscal Year (FY) 2023-24 Budget Narrative
PROGRAM EXPENSE
ACCT#1 LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1000: SALARIES& BENEFITS 4,711,572
Employee Salaries 3,441,614
1101 Clinician 1 1,556,631 Master's Degree (MA/MS) and at least two years of experience working with youth,
young adults and families in a therapeutic environment is required. If unlicensed
must be a registered intern with the Board of Behavioral Sciences and receiving
appropriate clinical supervision. Provides psychotherapy and psychotherapeutic
support to children and families.
1102 Clinician II 480,445 Master's Degree (MA/MS) and at least two years of experience working with youth,
young adults and families in a therapeutic environment is required. If unlicensed
must be a registered intern with the Board of Behavioral Sciences and receiving
appropriate clinical supervision. Provides psychotherapy and psychotherapeutic
support to children and families. Applies advanced use of assessment information in
development of the treatment plan and applies information and resources to ensure
quality care. Applies advanced skill in acquisition and application of clinically related
information to effectively intervene with children and families. Understands and
applies multi-modal approaches and perspectives to therapeutic direction. Provides
coaching and mentoring of others in the implementation of Evidence Based Practices
(EBPs). Leads problem solving interaction and work with external customers.
Maintains audit ready charts and audits charts independently. Provides observations
and feedback to supervisor in order to monitor and/or modify programs or
approaches. Actively participates in the identification of team opportunities for
improvement or identification of deficiencies and in the development of strategies
to address or bridge gaps. Leads Continuous Quality Improvement (CQI) activities
and project implementation. Required to meet applicable productivity and
documentation requirements.
1103 Family Specialist 149,770 Provides direct services to youth and families. Provides direct billable mental health
services, documents in alignment with MediCal regulations, and achieves set
productivity expectations. Engages and builds alignment and relationships with
parents,youth, and others in the normal course of working with the families. Utilizes
strengths of youth,families, and others to assist in the implementation and
achievement of goals and outcomes. Works with youth and family teams to support
family driven, strength based planning and interventions. Understands and takes
advantage of therapeutic opportunities in crisis situations. Conducts observations
regarding specific target behavior,track progress and modify plans with the family to
support their intended identified outcome. Assists teams in developing a hypothesis
of function and underlying unmet need in an effort to develop individualized,
strength based strategies and interventions that will result in positive behavior
change. Engages caregiver,family members, and other natural supports in building
youth specific parenting responses that support positive behavior change and overall
family relationships. Works in the community directly with youth and families to
develop and implement safety and skill refinement plans. Supports families in
bridging to and or building on natural resources and accessing community based
program supports that will continue support over time. Develops resources within
the community to serve children and families. Assists youth and family teams to
meet specific service needs (ie: help develop strategy or resource specific to an
identified need) and monitor outcomes. Participates in family finding team activities
by identifying family finding need, obtaining authorizations, creating teams,
conducting searches and setting deadlines. Completes Connectedness Maps as
needed. Documents interactions and practices and maintain administrative
expectations in a timely manner. Meets and or exceeds all direct service
expectations and documentation requirements. Assists in developing program
responses to needs identified across a number of youth and families where natural
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2/7/2020
Revised Exhibit D-5
PROGRAM EXPENSE
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1104 Clinical Program Manager 603,424 Ensures effective coordination of services for youth and families with other
providers, both internal and external, by supporting the development of constructive
relationships and problem-solving barriers. Develops, interprets and ensures
consistent implementation of clinical program philosophy, objectives, standards,
policies, procedures and practices. Analyzes and integrates the use of outcome data
to improve clinical service delivery within assigned team. Ensures and monitors
defined outcome achievement for youth and families, as well as satisfaction levels
for youth, families, and referring workers and agencies. Initiates and participates in
organizational quality improvement efforts. Lead and/or delegate work groups to
respond to program development needs. Ensures compliance with all policy and
procedures including adherence to all licensing, quality, Information Technology(IT),
Human Resources (HR), compliance and regulatory standards. Leads and manages
change. Proactively identifies potential conflicts; leads parties to consensus and
develops same skills in direct reports. Manages to ensure fiscally viable
programming. Ensures staff billable productivity and other revenue related activities
meet or exceed revenue forecasts. Ensures effective quality clinical services delivery
for assigned youth and families. Provides effective crisis and risk prevention and
management. Partners with county referring departments, agencies and the
community to ensure comprehensive care. Participates in staff development; hires,
coaches, mentors, supervises, conducts direct field observations,trains, disciplines,
and terminates. Ensures clinical documentation and quality assurance meets both
agency and payor standards, ensuring audit ready charts and continuous quality
improvement. Provides 24/7 availability as needed. Culturally responsive to internal
and external customers, and ensures family voice. Provides direct services to families
and children, as support to the direct service staff,to ensure smooth delivery of
service to assigned families and youth. Provides outreach to the community
including education about agency, program and general mental health and foster
1105 Clinical Director 143,147 Master's degree (MA/MS). Must have appropriate license to practice as a Licensed
Clinical Social Worker or Marriage Family Therapist in the State of California. Must
meet the BBS requirements to provide clinical oversight and supervision with three
to ten years of experience in healthcare/psychology/behavioral/mental health.The
Clinical Director implements strategies to accomplish the agency annual priorities at
the program level. Directs and develops managers, ensures CPMS are competent
and have all tools necessary to lead teams.
1106 Support Services Coordinator 48,464 Bachelor's degree required. (with emphasis in Psychology, social Work, Sociology or
related course work)Two years of experience in Mental Health field required.Four
years of experience in Mental Health field preferred. Knowledge of excel
spreadsheets; moderate computer literacy. Clinical skills relevant to intake services
including: client triage, understanding of legal/ethical issues, and risk management.
Works within the vision, mission, and philosophy of the agency, provides
customerfriendly services to internal and external customers. With limited
supervision, sets up, coordinates and runs parenting groups,trains new staff and
coaches and supports existing staff in effectively using therapeutic interventions
with children and families and in meeting documentation quality and timeliness
expectations.Analyzes outcome data in partnership with Outcomes and Evaluation
to identify quality improvement activities.
Leads quality improvement activities from start to finish, including evaluation of the
effectiveness of the activities.
1107 Doctors Assistant 16,698 The Doctor's assistant position directly supports the Psychiatrist and Nurse
Practitioner in all the administrative tasks related to medical support for clients. This
position was previously held by an Administrative Assistant; however requires a
higher level of education and expertise given the specialized nature of the
medication support tasks.
1108 Customer Support Spec 59,897 The CSS II is the lead position for our intake coordinators. This position was added to
manage the newly added requirements of tracking all of the access data. This
position also handles additional billing tasks and requirements, as well as supports
and trains the other intake coordinators. This position also assists with data
collection for the Monthly Activity Report specific to the Hope contract.
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2/7/2020
Revised Exhibit D-5
PROGRAM EXPENSE
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
1109 Administrative Assistant 47,835 These positions are shared direct program costs that provide direct clinical,
operational support, quality, compliance and outcomes support and management
and supervision support,to produce required program outcomes to all programs in
this region.Approximately 45%of cost is allocated to this program using the basis of
direct wages by program for this region's programs.
1110 Regional Director 80,677 These positions are shared direct program costs that provide direct clinical,
operational support, quality, compliance and outcomes support and management
and supervision support,to produce required program outcomes to all programs in
this region. Approximately 45%of cost is allocated to this program using the basis of
direct wages by program for this region's programs.
1111 Supervisor of Administrative Operations 29,118 These positions are shared direct program costs that provide direct clinical,
operational support, quality, compliance and outcomes support and management
and supervision support,to produce required program outcomes to all programs in
this region.Approximately 45%of cost is allocated to this program using the basis of
direct wages by program for this region's programs.
1112 Customer Services 77,399 These positions are shared direct program costs that provide direct clinical,
operational support, quality, compliance and outcomes support and management
and supervision support,to produce required program outcomes to all programs in
this region. Approximately 45%of cost is allocated to this program using the basis of
direct wages by program for this region's programs.
1113 Associate Director of Quality Support 53,081 These positions are shared direct program costs that provide direct clinical,
operational support, quality, compliance and outcomes support and management
and supervision support,to produce required program outcomes to all programs in
this region.Approximately 45%of cost is allocated to this program using the basis of
direct wages by program for this region's programs.
1114 Health Information Manager 13,720 These positions are shared direct program costs that provide direct clinical,
operational support, quality, compliance and outcomes support and management
and supervision support,to produce required program outcomes to all programs in
this region. Approximately 45%of cost is allocated to this program using the basis of
direct wages by program for this region's programs.
1115 Supervisor Physical Plant Operations 7,875 These positions are shared direct program costs that provide direct clinical,
operational support, quality, compliance and outcomes support and management
and supervision support,to produce required program outcomes to all programs in
this region.Approximately 45%of cost is allocated to this program using the basis of
direct wages by program for this region's programs.
1116 Outcome- Research Specialist 52,602 These positions are shared direct program costs that provide direct clinical,
operational support, quality, compliance and outcomes support and management
and supervision support,to produce required program outcomes to all programs in
this region. Approximately 45%of cost is allocated to this program using the basis of
direct wages by program for this region's programs.
1117 Training- Learning Partner 20,831 These positions are shared direct program costs that provide direct clinical,
operational support, quality, compliance and outcomes support and management
and supervision support,to produce required program outcomes to all programs in
this region.Approximately 45%of cost is allocated to this program using the basis of
direct wages by program for this region's programs.
1118 0 -
1119 0 -
1120 0 -
Employee Benefits 980,861
1201 Retirement 137,665 Calculated at 4%of salaries.
1202 Worker's Compensation 68,833 Calculated at 2%of salaries.
1203 Health Insurance 774,363 Calculated at 22.5%of salaries.
1204 Other(specify) -
1205 Other(specify) -
1206 Other(specify) -
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 21712020
Revised Exhibit D-5
PROGRAM EXPENSE
ACCT#1 LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
Payroll Taxes& Expenses: 289,097
1301 OASDI 213,380 Calculated at 6.2%of salaries.
1302 FICA/MEDICARE 49,904 Calculated at 1.45%of salaries.
1303 SUI 25,813 Calculated at 0.75%of salaries.
1304 Other(specify) -
1305 Other(specify) -
1306 Other(specify) -
2000: CLIENT SUPPORT -
2001 Child Care -
2002 Client Housing Support -
2003 Client Transportation &Support -
2004 Clothing, Food,& Hygiene -
2005 Education Support -
2006 Employment Support -
2007 Household Items for Clients -
2008 Medication Supports -
2009 Program Supplies- Medical -
2010 Utility Vouchers -
2011 Other(specify) -
2012 Other(specify) -
2013 Other(specify) -
2014 Other(specify) -
2015 Other(specify) -
2016 Other(specify) -
3000: OPERATING EXPENSES 305,238
3001 Telecommunications 68,743 Cell phones, Land Lines, DSL, fax charges, phone system; wireless cards for laptop
computers enabling UFS to maintain a fully functional mobile work force to deliver
in-home/in the community services. Costs are allocated between programs on the
basis of payroll dollars and have been estimated based on historical trends.
3002 Printing/Postage 1,946 Postage, printing, US mail,GSO, Federal Express, UPS, postage machine refills,
outside reproduction costs, program specific brochures and flyers when
reimbursable by the program. Costs are allocated between programs on the basis of
payroll dollars and have been estimated based on historical trends.
3003 Office Supplies & Equipment 6,000 Office supplies and equipment include, but are not limited to: paper, pens, files,
staplers, break rooms supplies (e.g., coffee, paper cups, plastic utensils);
subscriptions to periodicals or newspapers, annual Agency dues and fees paid to
accrediting agencies and laptop replacement. Costs are allocated between programs
on the basis of direct labor dollars and have been estimated based on historical
trends.
3004 Advertising -
3005 Staff Development &Training 102,648 Includes training in the Evidence-Based Practices of Trauma-Focused Cognitive
Behavioral Therapy (TFCBT), Motivational Interviewing (MI), Cognitive Behavioral
Therapy (CBT), Child Parent Psychotherapy (CPP), and Dialectical Behavior Therapy
(DBT), organizational tools, team/organizational psychology, philosophy of client
based services, integration of roles/team dynamics, assessment and individualized
treatment planning, general services, organizing admissions and individualized
treatment planning associated with the EBPs. This includes train-the-trainer and any
other program development training needs.Trainings are inclusive of internal and
external trainings, and all costs, except mileage associated with training, including
transportation, parking room and board, meals, refreshments cost of the program,
instructor fees and materials/manuals are included. Also includes other mandatory
trainings such as first aid and CPR.
3006 Staff Travel and Mileage/Vehicle 109,273 Includes travel costs such as air fare, lodging, and mileage reimbursement, which is
Maintenance paid at the prevailing federal rate (currently$0.575 per mile) to program service staff
and program administrative staff. This also includes upkeep costs for vehicles.
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2/7/2020
Revised Exhibit D-5
PROGRAM EXPENSE
ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
3007 Subscriptions & Memberships 4,829 Includes subscriptions to periodicals, databases, software, and other subscription
services, as well as annual agency dues and fees. Costs are allocated between
programs on the basis of payroll dollars and have been estimated based on historical
trends.
3008 Program Supplies-Therapeutic 6,000 Includes those supplies utilized in the direct delivery of therapeutic services to
clients. Cost is estimated to be approximately$18.50 per direct care staff per month.
Materials, cash payments, outing costs, etc. used to motivate or reinforce desired
behavior, as well as materials required for use in Evidenced Based Practices
3009 Depreciation 5,799 Depreciation includes deprecation on leasehold improvements, office
furniture/fixtures and equipment meeting amortization thresholds. Costs are
allocated between programs on the basis of payroll dollars and have been estimated
based on historical trends.
3010 Other(Specify) -
3011 Other(Specify) -
3012 Other(Specify) -
4000: FACILITIES& EQUIPMENT 273,043
4001 Building Maintenance 2,462 This includes common area maintenance on leased building charges,
maintenance/building repair charges, HVAC maintenance and repair, landscaping,
janitorial services, confidential paper shredding services, in-house or outside
equipment repair and labor. Costs are allocated between programs on the basis of
payroll dollars and have been estimated based on historical trends and the
utilization of the Agency's office in Fresno.
4002 Rent/Lease Building 228,545 This includes building rent or depreciation, storage and file storage unit rental
payments and all the costs associated with storing and retrieving of client, personnel
or other files or records. Costs are allocated between programs on the basis of
payroll dollars and have been estimated based on historical trends and the
utilization of the Agency's new office in Fresno.
4003 Rent/Lease Equipment 5,326 This includes rental payments for equipment including leased copiers, postage
machines, phone systems, laptops or other communication, office or facility
equipment. Costs are allocated between programs on the basis of payroll dollars and
have been estimated based on historical trends and the utilization of the Agency's
office in Fresno.
4004 Rent/Lease Vehicles -
4005 Security -
4006 Utilities -
4007 Equipment Purchase 36,710 Equipment, parts and materials includes the purchase of non-capital assets. Sample
items include, but are not limited to, laptops, desktops, printers, calculators and fax
machines, as well as system user licenses. Costs are allocated between programs on
the basis of payroll dollars and estimated.
4008 Other(Specify) -
4009 Other(Specify) -
4010 Other(Specify) -
5000: SPECIAL EXPENSES 190,669
5001 Consultant (Network& Data Management) 16,000 The consultant will provide additional clinical supervision support for program staff.
This will also be used to hire a contract psychologist to provide court ordered
psychological testing and reports to the Court. Contract Psychologist estimated to
cost $219 per hour. The psychologist will be required to provide at least 25 hours
per month on average. This will also cover the cost of the psychological testing and
scoring materials.
5002 HMIS(Health Management Information -
System)
5003 Contract Psychiatrist 149,669 This includes a contract Psychiatrist position estimated to cost$219 per hour.The
psychiatrist will be required to provide at least 35 hours per month, and will provide
psychiatric evaluations and medication support services. This also includes a Nurse
Practitioner, estimated to cost$125 per hour. The nurse practitioner will be
required to provide 6 hours per week and will provide additional psychiatric
evaluations and medication support services.
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2/7/2020
Revised Exhibit D-5
PROGRAM EXPENSE
ACCT# LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
5004 Translation Services 25,000 To ensure the provision of culturally sensitive services including assurance of
language access,when there is not availability of bilingual staff
interpreter/translation services are used to support a culturally appropriate
evaluation, diagnosis,treatment and referral services.
5005 Other(Specify) -
5006 Other(Specify) -
5007 Other(Specify) -
5008 Other(Specify) -
6000:ADMINISTRATIVE EXPENSES 927,767
6001 Administrative Overhead 835,864 Represents the overhead of the Agency's general and administrative shared support
services such as finance, accounting, billing, human resources, clinical
administration, information technology, professional fees, HIPPA compliance and
clinical record audits, risk management and program fidelity, recruiting and human
resources support, MIS infrastructure & QI/UM department support and oversight as
well as executive management. Costs that cannot be specifically charged to a
program are allocated to programs on the basis of direct program salary costs prior
to the addition of taxes and benefits. Administrative Overhead has been budgeted at
15% of total program expenses.
6002 Professional Liability Insurance 86,040 Includes general business liability and property coverage along with professional
liability insurance. Costs are allocated between programs on the basis of direct labor
dollars and estimated based on historical trends.
6003 Accounting/Bookkeeping -
6004 External Audit 5,863 Includes annual audit ensuring all financial records are relevant and accurate and in
compliance with state and federal laws and regulations.Audit costs are allocated
between programs on the basis of payroll dollars and have been estimated based on
historical costs.
6005 Insurance (Specify): -
6006 Payroll Services -
6007 Depreciation (Provider-Owned Equipment to -
be Used for Program Purposes)
6008 Other(Specify) -
6009 Other(Specify) -
6010 Other(Specify) -
6011 Other(Specify) -
6012 Other(Specify) -
7000: FIXED ASSETS -
7001 Computer Equipment&Software -
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) -
7008 1 Other(Specify) -
PROGRAM FUNDING SOURCES
8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION)
PROVIDE DETAILS OF METH D L Y IE USED IN DETERMINING MEDI-CAL SERVICE
ACCT# LINE ITEM RATES AND/OR SERVICE UNITS, IF APPLICABLE AND/OR AS REQUIRED BY THE RFP.
8001 Mental Health Services Estimated 899,904 units at$3.80 per unit
8002 Case Management Estimated 86,495 units at$2.95 per unit
8003 Crisis Services Estimated 17,309 units at$5.57 per unit
8004 Medication Support Estimated 17,309 units at$6.92 per unit
8005 Collateral Estimated 103,852 units at$3.80 per unit
8006 Plan Development Estimated 34,617 units at$2.95 per unit
8007 Assessment Estimated 138,469 units at$3.80 per unit
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2/7/2020
Revised Exhibit D-5
PROGRAM EXPENSE
ACCT# LINE ITEM AMT I DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE
8008 Rehabilitation Estimated 86,543 units at$3.89 per unit
8009 Intensive Care Coordination Estimated 86,591 units at$2.95 per unit
8010 Intensive Home-Based Services Estimated 259,774 units at$3.80 per unit
TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 6,408,290
TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 6,408,290
BUDGET CHECK: -
Fresno County Department of Behavioral Health Contract Budget Narrative Revised 2/7/2020
Exhibit E
Page 1 of 3
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws,
regulations, rules and guidelines that apply to the provision and payment of mental health services.
Mental health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this "Contractor Code of Conduct and Ethics" with which
CONTRACTOR and its employees and subcontractor(s) shall comply. CONTRACTOR shall require
its employees and subcontractor(s) to attend a compliance training that will be provided by Fresno
County. After completion of this training, CONTRACTOR, its employee and subcontractor(s), 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, clients, and other mental health contractors fairly and with
respect.
4. NOT engage in any activity in violation of the COUNTY's Compliance Program, nor engage in
any other conduct which violates any applicable law, regulation, rule or guideline
5. Take precautions to ensure that claims are prepared and submitted accurately, timely and are
consistent with all applicable laws, regulations, rules or guidelines.
6. Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement
of any kind are submitted.
7. Bill only for eligible services actually rendered and fully documented. Use billing codes that
accurately describe the services provided.
Exhibit E
Page 2of3
8. Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9. Promptly report to the Compliance Officer any suspected violation(s) of this "Code of Conduct
and Ethics" by COUNTY employees or other mental health contractors, or report any activity
that they believe may violate the standards of the Compliance Program, or any other
applicable law, regulation, rule or guideline. Fresno County prohibits retaliation against any
person making a report. Any person engaging in any form of retaliation will be subject to
disciplinary or other appropriate action by the COUNTY. CONTRACTOR may report
anonymously.
10. Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
11. Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
Exhibit E
Page 3of3
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and
Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof. I further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement. I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County. I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print):
Discipline: ❑ Psychiatrist ❑ Psychologist ❑ LCSW ❑ LMFT
Signature : Date
For Group or Organizational Providers
Group/Org. Name (print):
Employee Name (print):
Discipline: ❑ Psychiatrist ❑ Psychologist ❑ LCSW ❑ LMFT
❑ Other:
Job Title (if different from Discipline):
Signature: Date: / /
Exhibit F
Page 1 of 3
Documentation Standards For Client Records
The documentation standards are described below under key topics related to client care. All
standards must be addressed in the client record; however, there is no requirement that the
record have a specific document or section addressing these topics. All medical records shall be
maintained for a minimum of 10 years from the date of the end of the Agreement.
A. Assessments
1. The following areas will be included as appropriate as a part of a comprehensive client
record.
• Relevant physical health conditions reported by the client will be prominently identified
and updated as appropriate.
• Presenting problems and relevant conditions affecting the client's physical health and
mental health status will be documented, for example: living situation, daily activities,
and social support.
• Documentation will describe client's strengths in achieving client plan goals.
• Special status situations that present a risk to clients or others will be prominently
documented and updated as appropriate.
• Documentations will include medications that have been described by mental health plan
physicians, dosage of each medication, dates of initial prescriptions and refills, and
documentations of informed consent for medications.
• Client self report of allergies and adverse reactions to medications, or lack of known
allergies/sensitivities will be clearly documented.
• A mental health history will be documented, including: previous treatment dates,
providers, therapeutic interventions and responses, sources of clinical data, relevant
family information and relevant results of relevant lab tests and consultations reports.
• For children and adolescents, pre-natal and perinatal events and complete
developmental history will be documented.
• Documentations will include past and present use of tobacco, alcohol, and caffeine, as
well as illicit, prescribed and over-the-counter drugs.
• A relevant mental status examination will be documented.
• A DSM-5 diagnosis, or a diagnosis from the most current ICD, will be documented,
consistent with the presenting problems, history mental status evaluation and/or other
assessment data.
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
Exhibit F
Page 2 of 3
• have a proposed duration of intervention(s)
• be signed (or electronic equivalent) by:
➢ the person providing the service(s), or
➢ a person representing a team or program providing services, or
➢ a person representing the MHP providing services
➢ when the client plan is used to establish that the services are provided under the
direction of an approved category of staff, and if the below staff are not the approved
category,
➢ a physician
➢ a licensed/"waivered" psychologist
➢ a licensed/"associate" social worker
➢ a licensed/ registered/marriage and family therapist or
➢ a registered nurse
• In addition,
➢ client plans will be consistent with the diagnosis, and the focus of intervention will be
consistent with the client plan goals, and there will be documentation of the client's
participation in and agreement with the plan. Examples of the documentation include,
but are not limited to, reference to the client's participation and agreement in the
body of the plan, client signature on the plan, or a description of the client's
participation and agreement in progress notes.
➢ client signature on the plan will be used as the means by which the
CONTRACTOR(S) documents the participation of the client
➢ when the client's signature is required on the client plan and the client refuses or is
unavailable for signature, the client plan will include a written explanation of the
refusal or unavailability.
• The CONTRACTOR(S) will give a copy of the client plan to the client on request.
2. Timeliness/Frequency of Client Plan:
• Will be updated at least annually
• The CONTRACTOR(S) will establish standards for timeliness and frequency for the
individual elements of the client plan described in item 1.
C. Progress Notes
1. Items that must be contained in the client record related to the client's progress in treatment
include:
• The client record will provide timely documentation of relevant aspects of client care
• Mental health staff/practitioners will use client records to document client encounters,
including relevant clinical decisions and interventions
• All entries in the client record will include the signature of the person providing the
service (or electronic equivalent); the person's professional degree, licensure or job title;
and the relevant identification number, if applicable
• All entries will include the date services were provided
• The record will be legible
• The client record will document follow-up care, or as appropriate, a discharge summary
2. Timeliness/Frequency of Progress Notes:
Exhibit F
Page 3 of 3
Progress notes shall be documented at the frequency by type of service indicated below:
A. Every Service Contact
• Mental Health Services
• Medication Support Services
• Crisis Intervention
Exhibit G
Page 1 of 7
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,
Exhibit G
Page 2 of 7
upgrading, demotion, transfer, rates of pay or other forms of
compensation, use of facilities, and other terms and conditions of
employment.
C. Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all
further funds, until CONTRACTOR can show clear and convincing
evidence to the satisfaction of 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,
Exhibit G
Page 3 of 7
4) penalties that may be imposed upon employees for drug abuse
violations.
c. Every employee who works on the proposed 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 the Agreement.
Failure to comply with these requirements may result in suspension of payments
under the Agreement or termination of the Agreement or both and Contractor
may be ineligible for award of any future State agreements if the department
determines that any of the following has occurred: the Contractor has made false
certification, or violated the certification by failing to carry out the requirements as
noted above. (Gov. Code §8350 et seq.)
3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION: Contractor
certifies that no more than one (1) final unappealable finding of contempt of court
by a Federal court has been issued against Contractor within the immediately
preceding two-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.
Exhibit G
Page 4 of 7
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. The 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.
b. The 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 the
Agreement, the awarding agency must be contacted immediately for clarification.
Current State Employees (Pub. Contract Code §10410):
Exhibit G
Page 5 of 7
1) 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.
2) No officer or employee shall contract on his or her own behalf as an
independent contractor with any state agency to provide goods or
services.
Former State Employees (Pub. Contract Code §10411):
1) For the two-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.
2) For the twelve-month period from the date he or she left state
employment, no former state officer or employee may enter into a contract
with any state agency if he or she was employed by that state agency in a
policy-making position in the same general subject area as the proposed
contract within the 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.)
Exhibit G
Page 6 of 7
4. CONTRACTOR NAME CHANGE: An amendment is required to change the
Contractor's name as listed on this Agreement. Upon receipt of legal
documentation of the name change the State will process the amendment.
Payment of invoices presented with a new name cannot be paid prior to approval
of said amendment.
5. CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:
a. When agreements are to be performed in the state by corporations, the
contracting agencies will be verifying that the contractor is currently
qualified to do business in California in order to ensure that all obligations
due to the state are fulfilled.
b. "Doing business" is defined in R&TC Section 23101 as actively engaging
in any transaction for the purpose of financial or pecuniary gain or profit.
Although there are some statutory exceptions to taxation, rarely will a
corporate contractor performing within the state not be subject to the
franchise tax.
c. Both domestic and foreign corporations (those incorporated outside of
California) must be in good standing in order to be qualified to do business
in California. Agencies will determine whether a corporation is in good
standing by calling the Office of the Secretary of State.
6. RESOLUTION: A county, city, district, or other local public body must provide
the State with a copy of a resolution, order, motion, or ordinance of the local
governing body which by law has authority to enter into an agreement,
authorizing execution of the agreement.
7. AIR OR WATER POLLUTION VIOLATION: Under the State laws, the
Contractor shall not be: (1) in violation of any order or resolution not subject to
review promulgated by the State Air Resources Board or an air pollution control
district; (2) subject to cease and desist order not subject to review issued
pursuant to Section 13301 of the Water Code for violation of waste discharge
requirements or discharge prohibitions; or (3) finally determined to be in violation
of provisions of federal law relating to air or water pollution.
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
Exhibit G
Page 7 of 7
activities or work is conducted. The right to audit under this section exists for 10
years from the final date of the contract period or from the date of completion of
any audit, whichever is later.
Federal database checks. Consistent with the requirements at § 455.436 of this
chapter, the State must confirm the identity and determine the exclusion status of
CONTRACTOR, any subcontractor, as well as any person with an ownership or
control interest, or who is an agent or managing employee of CONTRACTOR
through routine checks of Federal databases. This includes the Social Security
Administration's Death Master File, the National Plan and Provider Enumeration
System (NPPES), the List of Excluded Individuals/Entities (LEIE), the System for
Award Management (SAM), and any other databases as the State or Secretary
may prescribe. These databases must be consulted upon contracting and no less
frequently than monthly thereafter. If the State finds a party that is excluded, it
must promptly notify the CONTRACTOR and take action consistent with §
438.610(c).
The State must ensure that CONTRACTOR with which the State contracts under
this part is not located outside of the United States and that no claims paid by a
CONTRACTOR to a network provider, out-of-network provider, subcontractor or
financial institution located outside of the U.S. are considered in the development
of actuarially sound capitation rates.
EXHIBIT H
Page 1 of 2
Medi-Cal Organizational Provider Standards
1. The organizational provider possesses the necessary license to operate, if applicable, and
any required certification.
2. The space owned, leased or operated by the provider and used for services or staff meets
local fire codes.
3. The physical plant of any site owned, leased, or operated by the provider and used for
services or staff is clean, sanitary and in good repair.
4. The organizational provider establishes and implements maintenance policies for any site
owned, leased, or operated by the provider and used for services or staff to ensure the
safety and well being of beneficiaries and staff.
5. The organizational provider has a current administrative manual which includes: personnel
policies and procedures, general operating procedures, service delivery policies, and
procedures for reporting unusual occurrences relating to health and safety issues.
6. The organizational provider maintains client records in a manner that meets applicable state
and federal standards.
7. The organization provider has staffing adequate to allow the County to claim federal
financial participation for the services the Provider delivers to beneficiaries, as described in
Division 1, Chapter 11, Subchapter 4 of Title 9, CCR, when applicable.
8. The organizational provider has written procedures for referring individuals to a psychiatrist
when necessary, or to a physician, if a psychiatrist is not available.
9. The organizational provider has as head of service a licensed mental health professional of
other appropriate individual as described in Title 9, CCR, Sections 622 through 630.
10. For organizational providers that provide or store medications, the provider stores and
dispenses medications in compliance with all pertinent state and federal standards. In
particular:
A. All drugs obtained by prescription are labeled in compliance with federal and state laws.
Prescription labels are altered only by persons legally authorized to do so.
B. Drugs intended for external use only or food stuffs are stored separately from drugs for
internal use.
C. All drugs are stored at proper temperatures, room temperature drugs at 59-86 degrees
F and refrigerated drugs at 36-46 degrees F.
D. Drugs are stored in a locked area with access limited to those medical personnel
authorized to prescribe, dispense or administer medication.
EXHIBIT H
Page 2 of 2
E. Drugs are not retained after the expiration date. IM multi-dose vials are dated and
initialed when opened.
F. A drug log is maintained to ensure the provider disposes of expired, contaminated,
deteriorated and abandoned drugs in a manner consistent with state and federal laws.
G. Policies and procedures are in place for dispensing, administering and storing
medications.
11. For organizational providers that provide day treatment intensive or day rehabilitation,
the provider must have a written description of the day treatment intensive and/or day
treatment rehabilitation program that complies with State Department of Health Care
Service's day treatment requirements. The COUNTY shall review the provider's written
program description for compliance with the State Department of Health Care Service's
day treatment requirements.
12. The COUNTY may accept the host county's site certification and reserves the right to
conduct an on-site certification review at least every three years. The COUNTY may also
conduct additional certification reviews when:
• The provider makes major staffing changes.
• The provider makes organizational and/or corporate structure changes (example:
conversion from a non-profit status).
• The provider adds day treatment or medication support services when
medications shall be administered or dispensed from the provider site.
• There are significant changes in the physical plant of the provider site (some
physical plant changes could require a new fire clearance).
• There is change of ownership or location.
• There are complaints against the provider.
• There are unusual events, accidents, or injuries requiring medical treatment for
clients, staff or members of the community.
Exhibit I
Page 1 of 2
Fresno County Mental Health Plan
Grievances and Appeals Process
Grievances
The Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance and
appeal process and an expedited appeal process to resolve grievances and disputes at the
earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-for-service
providers to give verbal and written information to Medi-Cal beneficiaries regarding the
following:
• How to access specialty mental health services
• How to file a grievance about services
• How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a grievance form, an
appeal form, and Request for Change of Provider Form. All of these beneficiary materials must
be posted in prominent locations where Medi-Cal beneficiaries receive outpatient specialty
mental health services, including the waiting rooms of providers' offices of service.
Please note that all fee-for-service providers and contract agencies are required to give their
clients copies of all current beneficiary information annually at the time their treatment plans are
updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without any penalty,
change in mental health services, or any form of retaliation. All Medi-Cal beneficiaries can file
an appeal or state hearing.
Grievances and appeals forms and self-addressed envelopes must be available for
beneficiaries to pick up at all provider sites without having to make a verbal or written request.
Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
(800) 654-3937 (for more information)
(559) 488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple, informal procedure in identifying and resolving provider concerns and
problems regarding payment authorization issues, other complaints and concerns.
Exhibit I
Page 2of2
Informal provider problem resolution process—the provider may first speak to a Provider
Relations Specialist (PRS) regarding his or her complaint or concern.
The PRS will attempt to settle the complaint or concern with the provider. If the attempt is
unsuccessful and the provider chooses to forego the informal grievance process, the provider
will be advised to file a written complaint to the MHP address (listed above).
Formal provider appeal process—the provider has the right to access the provider appeal
process at any time before, during, or after the provider problem resolution process has begun,
when the complaint concerns a denied or modified request for MHP payment authorization, or
the process or payment of a provider's claim to the MHP.
Payment authorization issues—the provider may appeal a denied or modified request for
payment authorization or a dispute with the MHP regarding the processing or payment of a
provider's claim to the MHP. The written appeal must be submitted to the MHP within ninety
(90) calendar days of the date of the receipt of the non-approval of payment.
The MHP shall have sixty (60) calendar days from its receipt of the appeal to inform the provider
in writing of the decision, including a statement of the reasons for the decision that addresses
each issue raised by the provider, and any action required by the provider to implement the
decision.
If the appeal concerns a denial or modification of payment authorization request, the MHP
utilizes Managed Care staff who were not involved in the initial denial or modification decision to
determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be asked to submit a
revised request for payment within thirty (30) calendar days of receipt of the decision
Other complaints— if there are other issues or complaints, which are not related to payment
authorization issues, providers are encouraged to send a letter of complaint to the MHP. The
provider will receive a written response from the MHP within sixty (60) calendar days of receipt
of the complaint. The decision rendered buy the MHP is final.
Exhibit J
coU Department of Behavioral Health
Policy and Procedure Guide
O� 1$50
FRES PPG 1.2.4
Section: Administration
Effective Date: 11/01/2010 Revised Date: 03/07/2018
Policy Title: Incident Reporting and Intensive Analysis
Approved by: Dawan Utecht (Director of Behavioral Health), Elizabeth Vasquez (Compliance Officer), Kannika
Toonnachat (Division Manager-Technology and Quality Management)
POLICY: The 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
clients, employees, or community members. The incident report must
include a thorough description of: the incident itself, client information,
type of event, location, people directly involved, action taken, and outcome
(if known). The written report must be signed and submitted to the
Department of Behavioral Health Incident Reporting email address
DBHlncidentReporting(o)_co.fresno.ca.us within 24 hours of the incident or
knowledge of the incident. An amendment to the original incident report
may be submitted if all the required information is not readily available
within the 24 hour reporting requirement. The Intensive Analysis
Committee (IAC) will review selected incidents. Incidents that occur within
the six months following discharge must also be reported.
PURPOSE: To ensure employees identify, document and report incidents consistently
and promptly. To review incidents and recommend system, policy, and
protocol changes. To increase best practice and safety in the provision of
behavioral health care and substance use disorder services.
REFERENCE: California Evidence Code 1157, 1157.5, 1157.6 and 1157.7., Welfare and
Institutions Code on Privileged Information", DMH Letter 1995-04, page
7-12. Fresno County Management Directive, Chapter 1700, Subject 1750,
Mental Health Plan, Policy No. RSK 100.0. MHP Contract boilerplate,
Exhibit H. Fresno County DBH Incident Report, MHRC 24-Hour Unusual
Occurrence Report-DHCS form, PSD-RM 301 Report, PHF 24-Hour
Unusual Occurrence Report-DHCS form, Unusual Occurrence Report.
"Note: California Evidence Code 1157 does not _guarantee that all committee
discussions, reports and records are protected from discovery and disclosure in all
cases.
MISSION STATEMENT
The Department of Behavioral Health is dedicated to supporting the wellness of individuals,families and communities in Fresno County who are affected by,or are at risk
of,mental illness and/or substance use disorders through cultivation of strengths toward promoting recovery in the least restrictive environment.
Template Review Date 3128116
Page 1 of 6
Exhibit J
coU Department of Behavioral Health
ti �c
Policy and Procedure Guide
O 1856 O
FRESH Section:Administration Effective Date: 11/01/2010 PPG 1.2.4
Policy Title: Reporting Incidents and Unusual Occurrences
DEFINITIONS:
24 Hours — 24 clock hours
Department of Behavioral Health Incident Reporting email address (DBH Incident Reporting)-
DBHlncidentReporting(o)_co.fresno.ca.us
Department of Health Care Services- DHCS
Fresno County Department of Behavioral Health- DBH
Intensive Analysis Committee — IAC
Mental Health Plan- MHP
Mental Health Rehabilitation Center- MHRC
Psychiatric Health Facility- PHF
Quality Improvement Committee- QIC
Substance Use Disorder - SUD
Unusual Occurrence Report- UOR
An Incident is any event which jeopardizes the health and/or safety of clients, employees, or
members of the community.
Incidents include, but are not limited to:
• All client deaths
• Attempted suicide (resulting in serious injury)
• Homicide or attempts at homicide
• Injury connected to services or at a service site (self-inflicted or by accident)
• Medical Emergency connected to services or at a service site
• Other (i.e. Clients escaping from a locked facility, medication errors)
• Violence, Abuse or Assault connected to services or at a service site (toward
client, others or property; resulting in serious injury)
The Fresno County DBH Incident Report, MHRC/PHF 24-hour Unusual Occurrence Report,
PSD-RM 301 and/or Unusual Occurrence Report are all confidential reports and are not to be
part of the client's medical record.
• DO NOT file a copy of or transcribe the Fresno County DBH Incident Report,
MHRC/PHF 24-hour Unusual Occurrence Report, PSD-RM 301 and/or Unusual
Occurrence Report in to the client's medical record.
• DO NOT document in the medical record that a Fresno County DBH Incident
Report, MHRC/PHF 24-hour Unusual Occurrence Report, PSD-RM 301 and/or
Unusual Occurrence Report was filed.
• Details of the incident that are relevant to clinical treatment may be documented
in the client's medical record by the appropriate practitioner.
Page 2 of 6
Exhibit J
coU Department of Behavioral Health
ti �c
Policy and Procedure Guide
O 1856 O
FRESH Section:Administration Effective Date: 11/01/2010 PPG 1.2.4
1—policy Title: Reporting Incidents and Unusual Occurrences
PROCEDURE:
I. Employees having knowledge of an incident will follow the appropriate process listed in
sections II or III below:
II. DBH County Operated Programs
A. Employees involved in or first aware of an incident shall complete and submit
encrypted Form PSD-RM 301-Incident Report: Non-Employee to a supervisor
and/or Division Manager.
1. Supervisor and/or Division Manager shall review the report for
completeness and gather any further information needed. Supervisor,
Division Manager, or designee sends the encrypted report to the DBH
Incident Reporting email address, Division Manager and DBH Human
Resources email address within 24 hours of an incident or knowledge
of an incident.
2. Intensive Analysis Chair or designated committee member will review
the PSD-RM 301-Incident Report and request further information if
needed.
III. Contracted Providers
A. All contracted providers shall complete the Fresno County DBH Incident Report.
1. The report shall be completed and signed by the employee involved in or
first aware of an incident, reviewed and signed by a supervisor and/or
Program Director and the encrypted Incident Report will be sent to the
DBH Incident Reporting email address and designated Contract Staff
Analyst within 24 hours of an incident or knowledge of an incident.
2. Intensive Analysis Chair or designated committee member will review the
DBH Incident Report. If further information is needed, designated
Contract Staff Analyst shall assist in gathering requested information and
provide the information to Intensive Analysis Chair or designated
committee member.
B. In addition to completing the Fresno County DBH Incident Report under item III-
A, Mental Health Rehabilitation Centers (MHRC) and Psychiatric Health Facilities
(PHF) must also complete the respective below report.
1. MHRC shall complete the DHCS MHRC 24-Hour Unusual Occurrence
Report.
a. Report shall be completed and signed by staff involved in or first
aware of an incident, reviewed and signed by a supervisor and/or
Page 3 of 6
Exhibit J
coU Department of Behavioral Health
ti �c
Policy and Procedure Guide
O 1856 O
FRESH Section:Administration Effective Date: 11/01/2010 PPG 1.2.4
Policy Title: Reporting Incidents and Unusual Occurrences
Program Director and submitted to DHCS via fax: (916) 440-5600
or encrypted email to the DHCS designated reporting contact (per
form instructions), Contract Staff Analyst and the DBH Incident
Reporting email address within 24 hours of an incident or
knowledge of an incident.
2. PHF shall complete the DHCS PHF 24-Hour Unusual Occurrence Report.
a. Report shall be completed and signed by staff involved in or first
aware of an incident, reviewed and signed by a supervisor and/or
Program Director and submitted to DHCS via fax: (916) 440-5600
or encrypted email to the DHCS designated reporting contact (per
form instructions), Contract Staff Analyst and the DBH Incident
Reporting email address within 24 hours of an incident or
knowledge of an incident.
IV. Unusual Occurrence Reporting to DHCS
A. Unusual Occurrences may include but are not limited to physical injury and
death. The MHP will report Unusual Occurrences to DHCS as determined
necessary. The Unusual Occurrence Report (UOR) shall include:
1. A written description of the incident and outcome of the incident
2. List of persons directly involved/having direct knowledge of the incident
3. Report of providers investigation and conclusion.
B. If a reported incident is determined to be an Unusual Occurrence, the UOR shall
be completed and signed by a Division Manager or a designated IAC member.
Contracted Providers (not licensed directly by the state) who have determined an
incident to be an Unusual Occurrence may elect to submit their own UORs in lieu
of a DBH Division Manager or IAC member. The UOR shall be emailed
encrypted to the DHCS designated reporting contact (per DHCS instructions),
Contract Staff Analyst (if applicable) and the DBH Incident Reporting email
address within five (5) calendar days of an incident or knowledge of an incident.
MHRC's and PHF's will continue to follow reporting guidelines detailed above in
Section III, 131 and B2.
C. UORs sent to DHCS may be subject to further investigation and/or information
requested by DHCS, such as: Site Reviews and Plan(s) of Correction. All
correspondence between contracted provider and DHCS regarding UORs shall
also be sent to the Contract Staff Analyst and the DBH Incident Reporting email
address for informational purposes.
D. Site visits by DBH may be conducted as needed.
Page 4 of 6
Exhibit J
coU Department of Behavioral Health
ti �c
Policy and Procedure Guide
O 1856 O
FRESH Section:Administration Effective Date: 11/01/2010 PPG 1.2.4
Policy Title: Reporting Incidents and Unusual Occurrences
E. DBH may request contracted providers attest that an Intensive Analysis or similar
(i.e. incident review, possible cause) has occurred. DBH may request additional
analysis or information when necessary.
V. The IAC will review incidents and recommend system, policy, and protocol changes, as
needed, based on its findings. The IAC can conduct a case review with the employees
involved to determine possible cause. The IAC shall track and trend incidents and report
to the Quality Improvement Committee (QIC). The DBH Incident Reporting email
address shall be monitored by the Intensive Analysis Chair, with supportive monitoring
by the Quality Improvement Coordinator, Division Managers and Compliance Officer.
A. The IAC will be comprised of the following:
1. Intensive Analysis Chair— Chair shall be a Licensed Marriage and Family
Therapist, Licensed Clinical Social Worker, Psychologist, or Psychiatrist
2. Deputy Director
3. Quality Improvement Coordinator
4. Division Manager from Clinical Operations
5. Compliance Officer
6. Quality Improvement Licensed Mental Health Clinician(s)
7. Medical Director
8. Other subject matter experts as deemed necessary
9. +Case specific staff
B. The IAC shall review incidents and identify those that require further review to
determine possible cause.
C. The IAC shall meet at least quarterly unless there are no incidents during the
quarter. The IAC may meet more frequently as needed.
D. The IAC shall make recommendations for changes in policy, procedure and
practice.
E. When necessary, the IAC may report personnel concerns to the appropriate HR
department; the IAC does not make or take disciplinary actions but may be
obligated to share employee concerns.
F. Copies of Incident Reporting forms received and committee notes related to
action items will be maintained by the IAC for 10 years.
G. The IAC will report aggregate data and system recommendations at QIC.
Page 5 of 6
Exhibit J
Page 6 of 6
Fresno County Department of Behavioral Health-Incident Report
Send completed forms to dbhincidentreporting@co.fresno.ca.us and designated contract analyst within 24 hours of an
incident or knowledge of an incident. DO NOT COPY OR REPRODUCE/NOT part of the medical record.
Client Information
Last Name: Click or tap here to enter text. First Name: Click or tap here to enter text. Middle Initial:Click or tap here to enter text.
Date of Birth:Click or tap here to enter text.Client ID#:Click or tap here to enter text. Gender: ❑ Male ❑ Female
County of Origin:Click or tap here to enter text.
Name of Reporting Party:Click or tap here to enter text. Name of Facility:Click or tap here to enter text.
Facility Address:Click or tap here to enter text. Facility Phone Number:Click or tap here to enter text.
Incident(check all that apply)
❑ Homicide/Homicide Attempt ❑ Attempted Suicide(resulting in serious injury) ❑ Death of Client ❑ Medical Emergency
❑ Injury(self-inflicted or by accident) ❑ Violence/Abuse/Attempts to Assault(toward others,client and/or property)
❑ Other-Specify(i.e. medication errors, client escaping from locked facility,fire, poisoning,epidemic outbreaks,other
catastrophes/events that jeopardize the welfare and safety of clients,staff and/or members of the community):Click or tap here to
enter text.
Date of Incident: Click or tap here to enter text. Time of Incident: Click or tap here to enter text.❑am ❑pm
Location of Incident:Click or tap here to enter text.
Description of the Incident(Attach additional sheet if needed):Click or tap here to enter text.
Key People Directly Involved in Incident(witnesses,staff): Click or tap here to enter text.
Action Taken (check all that apply)
❑ Consulted with Physician ❑ Called 911/EMS ❑ First Aid/CPR Administered ❑ Law Enforcement Contacted
❑ Client removed from building ❑ Parent/Legal Guardian Contacted ❑Other(Specify): Click or tap here to enter text.
Description of Action Taken: Click or tap here to enter text.
Outcome of Incident(If Known): Click or tap here to enter text.
Form Completed by:
Printed Name Signature Date
Reviewed by Supervisor/Program Manager:
Printed Name Signature Date
For Internal Use only:
❑ Report to Administration ❑ Report to Intensive Analysis Committee for additional review ❑Request Additional Information
❑ No Action ❑ Unusual Occurrence ❑ Other: Click or tap here to enter text.
Revised 12/2017
Exhibit K
Page 1 of 2
Vendor: Contract# Contact Person Contact#
;_
* w m Date Date Fresno
a m Requested Approved( Purchase County
Item Model Serial# >_ Location Condition Cost
(If Fixed If Fixed Date Inventory
x N
iiN Asset) Assset) Number
m
a
m Copier Canon 27CRT 9YHJY65R x 3/27/2008 4/1/2008 4/10/2008 Heritage New $6,500.00
x
w
m
a
m DVD Player Sony DV2230 PXC4356A n/a 4/1/2008 Heritage New $450.00
x
w
Date Prepared:
1
2
3ME
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23 MM
24
25 72
Date Received:
EXHIBIT-K
Page 2 of 2
FI XED ASSET AND SENSI TI VE I TEM TRACM NG
Fi el d Number Fi el d I nst r uct i on or Comment s Required or
Descr i pt i on Condi t i onal
Header Vendor I ndi cat e t he I egal name of t he agency cont r act ed t o Requi red
provide services.
Header Pr ogr am I ndi cat e t he title of the project as described in the Required
cont r act wi t h t he Count y.
Header Cont r act # I ndi cat e t he assi gned Count y cont r act number. I f not Required
known, Count y st of f can pr ovi de.
Header Cont act Person I ndi cat e the first and last nacre of the pr i mar y agency Required
cont act f or t he cont r act.
Header Cont act # I ndi cat e t he rrost appr opr i at e t el ephone number of t he Requi red
pr i rrar y agency cont act f or t he cont r act.
Header Date Prepared I ndi cat e t he rrost cur rent dat e t hat t he t r acki ng form Requi red
was corrpl et ed by the vendor.
a I t em I dent i f y t he i t em by pr ovi di ng a comrronl y recognized Requi red
descr i pt i on of t he i t em
b Nbke/Brand I dent i f y t he corrpany t hat manuf act ur ed t he i t em Requi red
c IVbdel I dent i f y t he model number for t he i t ern i f appl i cabl e. Condit i onal
d Ser i al # I dent i f y t he ser i al number f or t he i t ems if Condit i onal
appl i cabl e.
IVbr k t he box with an "X" i f the cost oft he i t em i s
e Fi xed Asset $5,000 or more to i ndi cat e that the item i s a f i xed Condit i onal
asset.
f Sensi t i ve I t em fvbr k t he box with an "X" if the item meets t he Condit i onal
cr i t er i a of a sensitive item as defined by t he Count y.
g Dat a Request ed I ndi cat e t he dat e t hat t he agency submi t t ed a request Requi red
t o the County to purchase the item
h Date Approved I ndi cat e t he dat e t hat t he Count y approved t he request Requi red
to purchase t he i t em
i Purchase Date I ndi cat e t he date t he agency purchased t he i tern Requi red
j Locat i on I ndi cat e t he physi cal I ocat i on of t he i t em Requi red
k Condi t i on I ndi cat e t he general condition of t he i t em (New, Good, Requi red
V)br n, Bad).
Fresno County
I I nvent or y I ndi cat e t he FIR # pr ovi ded by t he County for the item Condit i onal
Nurrber
m Cost I ndi cat e t he t of al purchase pr i ce of t he i t em Requi red
i ncl udi ng sal es t ax and of her cost s, such as shi ppi ng.
Exhibit L
Page 1 of 2
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of entity D/B/A
Address(number,street) City State ZIP code
CLIA number Taxpayer ID number(EIN) /Telephone number
)
II. Answer the following questions by checking "Yes" or "No." If any of the questions are answered "Yes," list names and
addresses of individuals or corporations under"Remarks"on page 2. Identify each item number to be continued.
YES NO
A. Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percent or more in the institution, organizations, or agency that have been convicted of a criminal
offense related to the involvement of such persons or organizations in any of the programs established
by Titles XVIII, XIX, or XX?......................................................................................................................... o 0
B. Are there any directors, officers, agents, or managing employees of the institution, agency, or
organization who have ever been convicted of a criminal offense related to their involvement in such
programs established by Titles XVIII, XIX, or XX?...................................................................................... O o
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 XVI I I providers only)........... o 0
III. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling
interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names
and addresses under "Remarks" on page 2. If more than one individual is reported and any of these persons are
related to each other, this must be reported under"Remarks."
NAME ADDRESS EIN
B. Type of entity: o Sole proprietorship 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
Exhibit L
Page 2 of 2
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... o 0
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... o 0
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ o 0
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... o 0
If yes, give date of change in operations.
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... a o
VII. A. Is this facility chain affiliated? ...................................................................................................................... o 0
If yes, list name, address of corporation, and EIN.
Name EIN
Address(number,name) City State ZIP code
B. If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address(number,name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative(typed) Title
Signature Date
Remarks
Exhibit M
Page 1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2. The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The prospective
participant shall submit an explanation of why it cannot provide the certification set out
below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation
shall disqualify such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which
reliance was placed when the department or agency determined to enter into this
transaction. If it is later determined that the prospective primary participant knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause or default.
4. The prospective primary participant shall provide immediate written notice to
the department or agency to which this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as
used in this clause, have the meanings set out in the Definitions and Coverage
sections of the rules implementing Executive Order 12549. You may contact the
department or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
Exhibit M
Page 2of2
CERTIFICATION
(1) The prospective primary participant certifies to the best of its knowledge and belief,
that it, its owners, officers, corporate managers and partners:
(a) Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of
or had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c) Have not within a three-year period preceding this application/proposal had one
or more public transactions (Federal, State or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or
Company)
Exhibit N
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as "County"),
members of a contractor's board of directors (hereinafter referred to as "County Contractor"),
must disclose any self-dealing transactions that they are a party to while providing goods,
performing services, or both for the County. A self-dealing transaction is defined below:
"A self-dealing transaction means a transaction to which the corporation is a party and in
which one or more of its directors has a material financial interest"
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member's name, job title (if applicable), and date this disclosure is being
made.
(2) Enter the board member's company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to
the County. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the
transaction; and
b. The nature of the material financial interest in the Corporation's transaction that
the board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing
transaction described in Sections (3) and (4).
Exhibit N
Page 2of2
(1)Company Board Member Information:
Name: Date:
Job Title:
(2)Company/Agency Name and Address:
(3)Disclosure(Please describe the nature of the self-dealing transaction you are a party to)
(4)Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233(a)
(5)Authorized Signature
Signature: Date: