HomeMy WebLinkAboutAgreement A-13-574-2 with Mental Health Systems Inc..pdf Agreement No. 13-574-2
1 AMENDMENT II TO AGREEMENT
2 THIS AMENDMENT is made and entered into this 20th day of June , 2017,
3 by and between the COUNTY OF FRESNO, a political subdivision of the State of California,
4 hereinafter referred to as "COUNTY', and MENTAL HEALTH SYSTEMS, INC., a California
5 corporation, whose address is 9465 Farnham Street, San Diego, California, 92123, hereinafter referred
6 to as "CONTRACTOR" (collectively the "parties").
7 WHEREAS, the parties entered into that certain Agreement, identified as COUNTY Agreement
8 No. 13-574, effective September 17, 2013, as amended by Amendment I, identified as County
9 Agreement No. 13-574-1 effective May 24, 2016, hereafter referred to collectively as the Agreement;
10 and
11 WHEREAS, CONTRACTOR has agreed to provide outpatient alcohol and substance use disorder
12 treatment services to Fresno County minors between the ages of 12 and 17 years old; and
13 WHEREAS the parties desire to amend the Agreement, regarding changes as stated below and
14 restate the Agreement in its entirety.
15 NOW, THEREFORE, in consideration of their mutual promises, covenants and conditions,
16 hereinafter set forth, the sufficiency of which is acknowledged, the parties agree as follows:
17 1. That Paragraph Four(4)—Compensation, in the Agreement, on Page Three (3),beginning
18 with Line Thirteen(13) and ending on Page Five (5), Line Twenty-One (21)be deleted in in its entirety
19 and the following inserted in its place:
20 114. COMPENSATION
21 A. COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to
22 receive compensation for provision of Outpatient Substance Use Disorder treatment services performed
23 by CONTRACTOR in accordance with the published State Maximum Allowable Drug Medi-Cal rates
24 for Fiscal Year 2017-18, or when applicable, the rate(s) subsequently approved by California
25 Department of Health Care Services for the then current twelve-month period during which the
26 Agreement is in effect. For each twelve (12) month period of July 1, 2013 through June 30, 2017, in no
27 event shall the total compensation for actual services performed under this Agreement be in excess of
28 Eighty Thousand and No/100 Dollars ($80,000). For the twelve month period of July 1, 2017 through
1 - COUNTY OF FRESNO
Fresno, CA
1 June 30, 2018, in no event shall the total compensation for actual services performed under this
2 Agreement be in excess of Twenty-Five Thousand and No/100 Dollars ($25,000.00).
3 It is understood that all expenses incidental to CONTRACTOR's performance of
4 services under this agreement shall be borne by CONTRACTOR.
5 B. The contract maximum amount as identified in this Agreement may be
6 reduced based upon State, Federal, and local funding availability. In the event of such action,
7 COUNTY's DBH Director or her designee, shall notify the CONTRACTOR in writing of the reduction
8 in the maximum amount within 30 days of notification of same from the funding source.
9 In the event funding for these services is delayed by the State Controller,
10 COUNTY may defer payment to CONTRACTOR. The amount of the deferred payment shall not
11 exceed the amount of funding delayed by the State Controller to the COUNTY. The period of time of
12 the deferral by COUNTY shall not exceed the period of time of the State Controller's delay of payment
13 to the COUNTY plus forty-five days.
14 C. Payments—CONTRACTOR(S) shall complete the year end cost report in
15 accordance to Section 16 of this Agreement at the end of each fiscal year to reflect actual cost and
16 reimbursement for services provided. Within forty-five (45) days of the reconciliation by COUNTY,
17 CONTRACTOR(S) shall make payment to COUNTY or COUNTY shall reimburse CONTRACTOR(S)
18 as appropriate.
19 Payment by COUNTY shall be in arrears, based on CONTRACTOR(S)' monthly
20 invoices submitted for services provided during the preceding month, within forty-five (45) days after
21 receipt and verification of CONTRACTOR(S)' monthly invoices by COUNTY's DBH Substance Use
22 Disorder Services.
23 For services rendered herein, CONTRACTOR(S) shall assure that an on-going
24 quality assurance component is in place and is occurring. CONTRACTOR(S) shall assure that clinical
25 records for each participant are of such detail and length that a review of said record will verify that
26 appropriate services were provided. If the record is unclear, incomplete, and/or indicates that
27 appropriate services were not provided, COUNTY reserves the right to withhold payment for the
28 applicable unit(s) of service. If CONTRACTOR(S) should fail to comply with any provision of this
- 2 - COUNTY OF FRESNO
Fresno, CA
1 Agreement, COUNTY shall be relieved of its obligation for further compensation. CONTRACTOR(S)'
2 and COUNTY's obligations under this section shall survive the termination or expiration of this
3 Agreement with respect to services provided during the Term of this Agreement without regard to the
4 cause of termination of this Agreement.
5 D. Public Information- CONTRACTOR(S) shall disclose its funding source
6 in all public information, however, this requirement of disclosure of funding source shall not be required
7 in spot radio or television advertising.
8 E. Lobby Ag ctivitX- CONTRACTOR(S) shall not directly or indirectly use
9 any of the funds provided under this Agreement for publicity, lobbying, or propaganda purposes
10 designed to support or defeat legislation pending before the Congress of the United States or the
11 Legislature of the State of California.
12 F. Political Activity- CONTRACTOR(S) shall not directly or indirectly use
13 any of the funds under this Agreement for any political activity or to further the election or defeat of any
14 candidate for public office.
15 G. Funding Sources—Any direct or indirect service provided by
16 CONTRACTOR as part of its overall alcohol and SUD program may be partially supported by revenues
17 or in-kind contributions generated by CONTRACTOR. Said direct and indirect services provided under
18 this Agreement may be partially supported by private or agency contributions. It shall be the obligation
19 of CONTRACTOR(S)to determine and claim all revenue possible from private pay sources and third
20 party payers. CONTRACTOR(S) shall not use any funds under this Agreement for services covered by
21 Drug Medi-Cal or other health insurance for eligible beneficiaries. CONTRACTOR(S) shall claim all
22 Drug Medi-Cal covered services for eligible beneficiaries through the Drug Medi-Cal claiming process.
23 COUNTY will only reimburse CONTRACTOR(S) for services rendered that are not covered by Drug
24 Medi-Cal, other insurance or other revenue sources.
25 Any revenues generated by CONTRACTOR(S) in excess of the amounts budgeted
26 in this Agreement, may be utilized to expand/enhance the services during COUNTY's fiscal years in
27 which revenues are collected or in the following COUNTY fiscal year. Additional revenues will be
28 considered separate and distinct from COUNTY's payment to CONTRACTOR(S). The manner and
- 3 - COUNTY OF FRESNO
Fresno, CA
1 means of service expansion/enhancement shall be subject to the prior written approval of COUNTY's
2 DBH Director or her designee. CONTRACTOR(S) shall disclose all sources of revenue to COUNTY.
3 Under no circumstances will COUNTY funded staff time be used for fund-raising purposes.
4 H. Cost of Living Adjustment—CONTRACTOR(S) shall not utilize any
5 funds provided under this Agreement for cost of living adjustments to CONTRACTOR(S)' employee
6 compensation in excess of what is approved in the budget submitted with the RFP response."
7 2. That Paragraph Forty-Three (43)—Trafficking In Persons Provisions—Private Entity-,
8 which was added to the Agreement by Amendment I at Page Forty(40), Line Twenty-One (21) be
9 deleted in its entirety and the following inserted in its place, and insert Paragraphs Forty-Four(44),
10 Forty-Five (45) and Forty-Six (46) to read as follows:
11 1143. TRAFFICKING IN PERSONS PROVISIONS—PRIVATE ENTITY
12 CONTRACTOR shall conform to all Federal statutes and regulations prohibiting
13 trafficking in persons, as well as trafficking-related activities, including, but not limited to the trafficking
14 of persons provisions in Section 106(g) of the Trafficking Victims Protection Act of 2000 (TVPA) as
15 amended by Section 1702.
16 CONTRACTOR, CONTRACTOR's employees, subrecipients, and subrecipients'
17 employees may not:
18 A. Engage in severe forms of trafficking in persons during the period of time
19 that the award is in effect;
20 B. Procure a commercial sex act during the period of time that the award is in
21 effect; or
22 C. Use forced labor in the performance of the award or subawards under the
23 award.
24 This agreement may be unilaterally terminated, without penalty, if
25 CONTRACTOR or a subrecipient that is a private entity is determined to have violated a prohibition of
26 the TVPA or has an employee who is determined by the DBH Director or designee to have violated a
27 prohibition of the TVPA through conduct that is either associated with performance under the award or
28 imputed to the CONTRACTOR or their subrecipient using the standards and due process for imputing
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Fresno, CA
1 the conduct of an individual to an organization that are provided in 2 C.F.R. Part 180, "OMB Guidelines
2 to Agencies on Government-wide Debarment and Suspension(Nonprocurement).
3 CONTRACTOR must inform the DBH Director or her designee immediately of
4 any information received from any source alleging a violation of a prohibition of the TVPA.
5 CONTRACTOR must sign a certification annually acknowledging the Trafficking
6 Victims Protection Act of 2000 requirements, attached hereto as Exhibit G: TVPA 2000 Certification,
7 incorporated herein by reference and made part of this Agreement and must require all employees to
8 complete annual TVPA training.
9 44. RESTRICTION ON DISTRIBUTION OF STERILE NEEDLES
10 CONTRACTOR shall adhere to the State-County Contract requirement that no
11 funds shall be used to carry out any program of distributing sterile needles or syringes for the
12 hypodermic injection of any illegal drug unless the DHCS chooses to implement a demonstration
13 syringe services program for intravenous drug users.
14 45. UNLAWFUL USE OF DRUGS AND ALCOHOL
15 CONTRACTOR shall ensure that information provided to clients contains a
16 clearly written statement that there shall be no unlawful use of drugs or alcohol associated with
17 CONTRACTOR. Additionally CONTRACTOR shall ensure that no aspect of the program includes any
18 message in materials, curricula, teachings, or promotion of the responsible use, if the use is unlawful, of
19 drugs or alcohol pursuant to Health and Safety Code (HSC) 11999-11999.3. CONTRACTOR shall
20 maintain that any unlawful use of drugs and alcohol is illegal and dangerous.
21 CONTRACTOR must sign the certification attached hereto as Exhibit H: Unlawful
22 Use of Drugs and Alcohol Certification, incorporated herein by reference and made part of this
23 Agreement agreeing to uphold the obligations of HSC 11999— 11999.3.
24 COUNTY shall enforce the requirement of"No Unlawful Use" set forth by DHCS
25 and requires CONTRACTOR to enforce the requirement as well.
26 46. CONFIDENTIALITY OATH
27 CONTRACTOR shall ensure that all of its employees sign a written confidentiality
28 oath, attached hereto as Exhibit I: Oath of Confidentiality, before they begin employment with
- 5 - COUNTY OF FRESNO
Fresno, CA
1 CONTRACTOR and shall renew said document annually thereafter. CONTRACTOR shall retain each
2 employee's written confidentiality oath for COUNTY and DHCS inspection for a period of six (6) years
3 following the termination of this agreement."
4 3. That Paragraph Forty-Four(44)—Governing Law—shall be renumbered to read as
5 Paragraph Forty-Seven(47) "GOVERNING LAW" and Paragraph Forty-Five (45)—Entire
6 Agreement—shall be renumbered to read as Paragraph Forty-Eight(48) "ENTIRE AGREEMENT":
7 4. That Exhibit A, Scope of Work,be deleted and replaced with Revised Exhibit A, attached
8 hereto and incorporated herein by this reference. All references in the Agreement to "Exhibit A" shall
9 be deleted and replaced with"Revised Exhibit A".
10 5. That Exhibit C be deleted in its entirety. All references in the Agreement to "Exhibit C"
11 shall be deleted.
12 6. COUNTY and CONTRACTOR agree that this Amendment II is sufficient to amend the
13 Agreement; and that upon execution of this Amendment II, the Agreement, Amendment I and
14 Amendment II together shall be considered the Agreement.
15 7. The Agreement, as hereby amended, is ratified and continued. All provisions, terms,
16 covenants, conditions, and promises contained in the Agreement and not amended herein shall remain in
17 full force and effect. This Amendment II shall be effective July 1, 2017.
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6 - COUNTY OF FRESNO
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1 IN WITNESS WHEREOF,the parties hereto have executed this Amendment II to Agreement No.
2 13-574 as of the day and year first hereinabove written.
3
4 ATTEST:
5
6 PROVIDER:
7 MENTAL HEALTH SYSTEMS,INC. COUNTY OF FRESNO
8 f
9 By !Q BY L
10 Brian Pacheco,Chairman
Board of Supervisors
11 print Name: 1ruMp� (�_, ('a �aa1n (1 fir.
i
12 �Q —� � �1
Title: �-�y�c�n-t- � CEO Date:
13 Chairman of the Board, or
14 President, or any Vice President
15
16 BERNICE E. SEIDEL, Clerk
17
Board of Supervisors
nn
18 By ByS0.ry�
19
20
Print Name: aXC"- Date:21 Title: QYO
Secretary of Corporation,
22 any Assistant Secretary, or
23 Chief Financial Officer,or
Assistant Treasurer
24
Mailing Address:
25 Mental Health Systems, Inc.
26 9465 Farnham Street
San Diego,CA 92123
27 Contact: President
28
- 7 - COUNTY OF FRESNO
Fresno, CA
APPROVED AS TO LEGAL FORM:
DANIEL CEDERBORG, COUNTY COUNSEL
2
3
4 By
ro Date:
7
APPROVED AS TO ACCOUNTING FORM:
OSCAR J. GARCIA, C.P.A., AUDITOR-CONTROLLER/
9 TREASURER-TAX COLLECTOR
10 By I
11 V J�x
12 Date:
13
14 REVIEWED AND RECOMMENDED FOR
15 APPROVAL:
16
17 By
18 Dawan Utecht, Director
Department of Behavioral Health
19
20 Date: t--I
21
22
23 Fund/Subclass: 0001/10000
24
25 Account/Program: 7295/0
26
27
28 yl
COUNTY OF FRESNO
Fresno, CA
REVISED EXHIBIT A—SCOPE
OF WORK
Page 1 of 5
SCOPE OF WORK
Youth Treatment Services
ORGANIZATION: Mental Health Systems
MAILING ADDRESS: 9465 Farnham Street, San Diego, CA 92123
SERVICES: Youth (ages 12 to 17) Outpatient Substance Use Disorders Treatment
Services
Director: Kimberly R. Bond, L.M.F.T., CEO (858) 573-0982
Vice President: Susan Murdock
Program Manager: Mark Jackson, M.S.W., A.C.S.W., R.A.Si.
County Division: Department of Behavioral Health, Substance Abuse Services
County Contact: Kathy Anderson, Staff Analyst
CONTRACT PERIOD: September 17, 2013 through June 30, 2016
AUTO-RENEWAL 1: July 1, 2016 through June 30, 2017
AUTO-RENEWAL 2: July 1, 2017 through June 30, 2018
CONTRACT AMOUNT: $345,000
Term Total Budget
FYI 3-14 $80,000
FY14-15 $80,000
FYI 5-16 $80,000
FYI 6-17 $80,000
FYI 7-18 $25,000
REVISED EXHIBIT A—SCOPE
OF WORK
Page 2 of 5
Youth Treatment Services
PROGRAM DESCRIPTION
The Mental Health Systems Youth Treatment program is a minimum 90-day Outpatient Substance
Use Disorder treatment program that implements a variety of evidence-based treatment strategies
that are culturally and linguistically sensitive, and gender specific. Services are delivered in individual
and group therapy sessions located at 3122 N Millbrook Ave., Suites A & B, Fresno, CA 93703.
SCHEDULE OF SERVICES
CONTRACTOR staff shall be available to provide Outpatient Substance Use Disorder and Co-
occurring treatment services Mondays through Fridays. CONTRACTOR shall enroll clients into an
appropriate level of treatment within 72 hours of initial assessment.
TARGET POPULATION
The target population that will participate in or more of the programs is:
1) Between the ages of 12 to 17 years old,
2) residents of Fresno County;
3) meeting the DSM IV-TR criteria for placement in the appropriate program.
STAFFING REQUIREMENTS
1. CONTRACTOR shall implement each program through guidance and oversight of the
project, including operations, strategic planning/development, and direct services, provided
by the Program Manager, and a Medical Director.
2. Clinical Treatment Staff: The AOD Counselor and Family Support Partner work as part of a
Multi-disciplinary Casework team that is under the direction of the Program Manager. Direct
services are delivered by the AOD Counselor. According to CCR Title 9, by October 1, 2005
or within six months of the date of hire, whichever is later, all non-licensed or non-certified
individuals providing counseling services in an AOD program are required to register to
obtain certification as an AOD counselor by one of the certifying organizations specified in
the regulation. Further, registrants shall complete certification as an AOD counselor within
five years of the date of registration. In addition, according to CCR Title 9, by April 2010, at
least 30% of staff providing counseling services in AOD programs shall be licensed or
certified.
3. The Outpatient treatment staff will be available on-site X hours a day, X days a week.
Participants may access crisis intervention through the main facility telephone number (559)
225-9117.
REVISED EXHIBIT A—SCOPE
OF WORK
Page 3 of 5
CONTRACTOR'S RESPONSIBILITIES
CONTRACTOR shall provide-
(1) a comprehensive assessment, including drug use, psychological, social, vocational, and
legal problems, and a health screening;
(2) a gender-specific, culturally and linguistically sensitive, substance use disorder and co-
occurring treatment program for Fresno County youth ages 12 to 17 who are non-Medi-Cal
eligible;
(3) a minimum 90-day outpatient treatment program incorporating a variety of innovative, and
evidence-based treatment methods;
(4) linkages to ancillary services (e.g., medical, vocational, psychological, legal);
(5) development of individual treatment plans within 30 days from admission, and shall update
each treatment plan every 90 calendar days or more often if necessary.
(7) management of a waitlist, including documented referrals to other treatment providers and
ancillary services;
(8) age-appropriate, evidence-based treatment that is outcome informed;
(9) adherence to the Youth Treatment Guidelines (Revised 2002);
(10) a cultural and linguistic competency plan to address the 15 Cultural and Linguistically
Appropriate Sensitivity Standards (CLASS); and
(11) a Program Fidelity plan to ensure proper integration and adherence to the Evidence-Based
practices adopted by the program.
PROGRAM REPORTS AND OUTCOMES
1. Certification and Licensing Standards:.
a. CONTRACTOR shall maintain at all times current and applicable licensure and
certifications for Alcohol and Other Drug Treatment Programs.
b. CONTRACTOR shall ensure at all times that staff maintain at all times all applicable
requirements as dictated by applicable regulations, this agreement, and County
Policies.
2. Indemnity
a. CONTRACTOR shall maintain valid and current insurance coverage at or above the
minimum requirements of Paragraph 14 of this agreement.
b. CONTRACTOR shall provide a Certificate of Commercial General Liability naming
the County of Fresno as additional insured.
c. CONTRACTOR shall provide a Certificate of Automobile Liability naming the County
of Fresno as additional insured.
REVISED EXHIBIT A—SCOPE
OF WORK
Page 4 of 5
d. CONTRACTOR shall provide a Certificate of Professional Liability naming the County
of Fresno as additional insured.
e. CONTRACTOR shall provide a Certificate of Worker's Compensation insurance.
3. Culturally and Linguistically Appropriate Services
a. CONTRACTOR shall submit to COUNTY for approval, within 60 days from date of
contract execution, a plan to address all fourteen national cultural competency
standards, as identified in Exhibit D of this agreement.
b. CONTRACTOR shall review and document adherence to the plan.
c. CONTRACTOR shall modify and update the plan in response to deficiencies sited in
COUNTY site reports, or in response to updates to the national competency
standards.
4. Program Fidelity
a. CONTRACTOR shall submit to COUNTY for approval, within 60 days from date of
contract execution, a plan to address Program Fidelity to address adherence to the
evidence-based practices as approved by the Substance Abuse and Mental Health
Services Administration (SAMSHA). For more information refer to
http://www.nrepp.samhsa.gov/.
b. CONTRACTOR shall modify and update the plan in response to deficiencies found in
self-audits, COUNTY site reports, or in the case of implementing other evidence-
based practices.
5. Report Delivery and Content Requirements
CONTRACTOR shall deliver all Department of Behavioral Health, Substance Abuse
Services Division required reporting in approved data collection format in a timely and
accurate manner.
6. Billable Services
CONTRACTOR shall ensure billable Substance Use Disorder treatment services meet
any/all County, State, Federal regulations including any utilization review and quality
assurance standards, and provide all pertinent and appropriate information in a timely
manner to County for services rendered.
7. Outcome Measurements and Reporting
Outcomes to be measured are:
1. 70% of clients admitted for Outpatient Treatment services will be engaged in
treatment for 60 days or more.
2. 60% of clients receiving treatment will have satisfactory progress at discharge.
REVISED EXHIBIT A—SCOPE
OF WORK Page 5 of 5
COUNTY'S RESPONSIBILITIES
COUNTY shall:
1. Provide oversight through the County Department of Behavioral Health (DBH), Substance
Abuse Services Division
2. Assist CONTRACTOR in making linkages with Mental Health Services.
3. Participate in evaluating the progress of the overall program and the efficiency of
collaboration with the CONTRACTOR staff and will be available to the CONTRACTOR for
ongoing consultation.
4. Receive and analyze statistical data outcome information from CONTRACTOR throughout
the term of contract on a monthly basis. DBH will notify the CONTRACTOR when additional
participation is required. The performance outcome measurement process will not be limited
to survey instruments but will also include, as appropriate, client and staff interviews, chart
reviews, and other methods of obtaining required information.
5. Recognize that program competency is a goal toward which professionals, agencies, and
systems should strive. To assist the CONTRACTOR's efforts towards program
competency, DBH shall provide the following at no cost to CONTRACTOR:
a. Technical assistance to CONTRACTOR regarding County, State, and Federal
requirements for Substance Use Disorder treatment services.
b. Technical assistance for CONTRACTOR in translating behavioral health and
substance abuse services information into DBH's threshold languages (Spanish,
Laotian, Cambodian and Hmong). Translation services and costs associated will be
the responsibility of CONTRACTOR.
Exhibit G
Page I of I
TRAFFICKING VICTIMS PROTECTION ACT OF 2000
CERTIFICATION
I, as an authorized agent of
(Print Name)
acknowledge the requirement to
(Organization Name)
comply with the Trafficking Victims Protection Act of 2000 (TVPA), specifically Section
106(g), which authorizes the County of Fresno to terminate a contract, without penalty,
if this organization or its employees, or a subcontractor or its employees:
• Engages in severe forms of trafficking in persons during the period of time that
the award is in effect;
• Procures a commercial sex act during the period of time that the award in in
effect; or
• Uses forced labor in the performance of the award or subawards under the
award.
I understand that the TVPA establishes human trafficking and related offenses
as federal crimes and attaches severe penalties to them. I will immediately inform the
County of Fresno, Department of Behavioral Health, Contracts Division — Substance
Use Disorder (SUD) Services immediately of any information received from any
source alleging a violation of the TVPA by either this organization or its employees, or
a subcontractor or its employees during the term of this contract.
I understand that this organization is obligated to ensure any subcontractors are
informed of the requirements of the TVPA and, if found in violation, will be immediately
terminated. I agree to submit this signed certification annually on behalf of the
organization acknowledging requirements under the TVPA and attesting that all
employees will receive annual TVPA training, and that documentation of training will
be placed in personnel files.
Signature: Date.-
Title:
Exhibit H
Page I of 1
UNLAWFUL USE OF DRUGS AND ALCOHOL
CERTIFICATION
as an authorized agent of
(Print Name)
acknowledge the requirement to
(Organization Name)
comply with California HSC 11999-11999.3, which authorizes the County of Fresno to
terminate a contract, without penalty, if this organization or its employees, or a
subcontractor or its employees fail to ensure that:
• The program contains a component that clearly explains in written materials
that there shall be no unlawful use of drugs or alcohol. No aspect of a drug- or
alcohol-related program shall include any message on the responsible use, if
the use is unlawful, of drugs or alcohol;
• All aspects of a drug- or alcohol-related program are consistent with the "no
unlawful use" message, including, but not limited to, program standards,
curricula, materials, and teachings; and
• The "no unlawful use" of drugs and alcohol message contained in drug- or
alcohol-related programs applies to the use of drugs and alcohol prohibited by
law.
I understand that the State of California enforces an Unlawful Use policy in
which there is zero tolerance for promoting the unlawful use of and drugs or alcohol in
an AOD treatment facility. If this organization fails to satisfy the guidelines adopted by
the State of California, the drug or alcohol program shall not receive state funds and
their contract with Fresno County will be terminated.
I understand that this organization is obligated to ensure any subcontractors are
informed of the requirements of HSC 11999-11999.3 and, if found in violation, will be
immediately terminated.
Signature: — Date:
Title:
Co
' County of Fresno
DEPARTMENT OF BEHAVIORAL HEALTH
DAWAN UTECHT
y .w' DIRECTOR
Exhibit I
Page 1 of I
PRIVACY AND SECURITY AGREEMENT REGARDING AUTHORIZED ACCESS TO
CONFIDENTIAL PROTECTED HEALTH INFORMATION FOR FRESNO COUNTY DEPARTMENT
OF BEHAVIORAL HEALTH(DBH)EMPLOYEES AND/OR NON-DBH SUD SERVICES
WORKFORCE MEMBERS
OATH OF CONFIDENTIALITY
As a condition of obtaining access to any Protected Health Information(PHI)that is necessary to carry
out my function with DBH, I ,agree to not divulge any PHI to
unauthorized persons. Furthermore, I maintain that I will not publish or otherwise make public any
information regarding persons who receive Substance Use Disorder Services such that the persons who
receive or have received such services are identifiable.
Access to such data shall be limited to Fresno County DBH personnel, subcontractors, and
subcontractors' personnel who require this information in the performance of their duties and have signed
an Oath of Confidentiality with DBH.
By signing this oath, I agree to uphold the security and confidentiality requirements outlined by the Medi-
Cal Privacy and Security Agreement signed by DBH, surveillance and safeguarding announcements
issued by DHCS, and other applicable terms and stipulations provided by the HIPAA doctrine as well as
other relevant state and federal regulations.
I hereby certify my understanding of the need to:
1. Exercise due care to preserve data integrity and confidentiality.
2. Treat passwords and user accounts as confidential information.
3. Take reasonable precautions to ensure the protection of PHI from unauthorized access.
4. Notify CMHDMEDS@dhcs.ca.gov and iso@dhcs.ca.gov of a possible security violation
including unauthorized access to PHI.
I recognize that unauthorized release of confidential information may make me subject to civil and
criminal sanctions pursuant to the provisions of the Welfare and Institutions Code Section 14100.2,
Welfare and Institutions Code Section 5328 et seq. and the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). I further acknowledge that the unauthorized release of confidential
information as described in this document may result in disciplinary action up to and including
termination of any office of employment or contract.
Agency Name
Signature: Date:
3133 N Millbrook,Fresno,California 93703
FAX(559)600-7673 www.co.fresno.ca.us
The County of Fresno is an Equal Employment Opportunity Employer