HomeMy WebLinkAboutAgreement A-18-686 with WestCare California Inc..pdf Agreement No. 18-686
1 AGREEMENT
2 THIS AGREEMENT is made and entered into this 11th day of December 2018, by
3 and between the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter
4 referred to as"COUNTY', and WESTCARE CALIFORNIA, INC., a California Non-profit Corporation,
5 whose business address is PO Box 12107, Fresno, CA 93776, hereinafter referred to as
6 "CONTRACTOR" (collectively the"parties").
7 WIT NE SSETH:
8 WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), is in need of a qualified
9 agency to provide supervised after hourslovemight stay services, linkage,targeted case management,
10 assessments, and other specialty mental health services,for adults referred from local hospital emergency
11 departments and California Welfare and Institutions Code 5150 facilities; and
12 WHEREAS,COUNTY,through its Department of Behavioral Health(DBH), is a Mental Health Plan
13 (MHP)as defined in Title 9 of the California Code of Regulations(C.C.R.), section 1810.226;and
14 WHEREAS,CONTRACTOR is qualified and willing to operate said supervised overnight stay and
15 mental health services pursuant to the terms and conditions of this Agreement.
16 NOW,THEREFORE, in consideration of their mutual covenants and conditions, the parties hereto
17 agree as follows-
18 1. SEVERABILITY
19 The Provisions of this Agreement are severable. The invalidity or unenforceability of any
20 one provision in the Agreement shall not affect the other provisions.
21 2. SERVICES
22 A. CONTRACTOR shall perform all services and fulfill all responsibilities as set forth in
23 Exhibit A"Overnight Stay Facility Scope of Work", attached hereto and by this reference incorporated
24 herein and made part of this Agreement.
25 B. CONTRACTOR shall also perform all services and fulfill all responsibilities as
26 specified in COUNTY's Request for Proposal(RFP)No. 18-040 dated April 9, 2018, Addendum No.One
27 (1)to COUNTY's RFP No. 18-040 dated April 17,2018,Addendum No.Two(2)to COUNTY's RFP No.
28 18-040 dated May 3,2018,Addendum No,Three(3)to COUNTY's RFP No. 18-040 dated May 16, 2018
1
I and Addendum No. Four(4)to COUNTY's RFP No. 18-040 dated May 23, 2018, collectively referred to
2 herein as COUNTY's Revised RFP, and CONTRACTOR's response to said Revised RFP dated June 4,
3 2018 all incorporated herein by reference and made part of this Agreement. In the event of any
inconsistency among these documents,the inconsistency shall be resolved by giving precedence in the
4b d RFP '
O Contractor's Response to Revised RFP; 2)to the Revised RFP; and 3)to CONTRACTOR's Response to
7 the Revised RFP. A copy of COUNTY's Revised RFP No. 18-040 and CONTRACTOR's response thereto
8 shall be retained and made available during the term of this Agreement by COUNTY's DBH Contracts
9
10 C. CONTRACTOR shall perform all services defined in Exhibit A in accordance with
11 Exhibit C'Guiding Principles of Care Delivery", attached hereto and by this reference incorporated herein
12 and made part of this Agreement.
13 D. It is acknowledged by all parties hereto that COUNTY's DBH shall monitor the
14 services provided by CONTRACTOR, in accordance with Section Fourteen(14) of this Agreement.
15 E. CONTRACTOR shall participate in periodic workgroup meetings consisting of staff
10 from COUNTYs DBH to discuss service requirements, data reporting, outcomes measurement,training,
17 policies and procedures, overall program operations, and any problems or foreseeable problems that may
18 arise.
19 F. Changes to any CONTRACTOR corporate information orservice sites shall be
20 made upon 30 days advance written notification to COUNTY's DBH Director and upon written approval
21 from C[JUNlY'oDBH Director ordesignee.
22 G. CONTRACTOR shall maintain requirements as CC)UNTYMHP organizational
23 provider throughout the hann of this Agreement, if,for any naason,this status is not maintained,COUNTY
24 may terminate this Agreement pursuant to Section 3of this Agreement.
25 H. CONTRACTOR agrees that, prior to providing services under the terms and
28 conditions nf this Agreement, it shall have appropriate otoffhiredwndinp|mceforpnoQrannaamicaoand
27 operations, or COUNTY may, in addition to other remedies it may have, suspend referrals or terminate this
28 Agreement amto Section Three(3)of this Agreement,
2
1 CONTRACTOR may maintain its records in COUNTY's Electronic Health Record
2 (EHR) system (Avatar) in accordance with Exhibit E, "Documentation Standards for Client Records,"
3 attached hereto and incorporated herein by reference and made part of this Agreement, beginning
4 January 1, 2019. The client record shall begin with registration and intake and include client
5 authorizations, assessments, plans of care, and progress notes, as well as other documents as
6 approved by the COUNTY's DBH, COUNTY shall be allowed to review records of services provided,
7 including the goals and objectives of the treatment plan, and how the therapy provided is achieving the
8 goals and objectives, If CONTRACTOR determines to maintain its records in COUNTY's EHR system,
9 it shall provide COUNTY's DBH Director, or designee, with a 30-day notice. If at any time
10 CONTRACTOR chooses not to maintain its records in COUNTY's EHR system, it shall provide
11 COUNTY'S DBH Director, or designee, with a 30-day notice and CONTRACTOR will be responsible for
12 obtaining its own system, at its own cost, for Electronic Health Records management. Disclaimer-
13 COUNTY makes no warranty or representation that information entered into the COUNTY's EHR
14 system by CONTRACTOR will be accurate, adequate or satisfactory for CONTRACTOR's own
15 purposes or that any information in CONTRACTOR's possession or control, or transmitted or received
16 by CONTRACTOR, is or will be secure from unauthorized access, viewing, use, disclosure, or breach.
17 CONTRACTOR is solely responsible for client information entered by CONTRACTOR into the
18 COUNTY's EHR system. CONTRACTOR agrees that all Private Health Information (PHI)maintained
19 by CONTRACTOR in COUNTY's EHR system will be maintained in conformance with all HIPAA laws,
20 as stated in Section Nineteen (19), "Health Insurance Portability and Accountability Act".
21 J. It is mutually agreed by all parties to this Agreement, that the program funded
22 under this Agreement shall be identified and subsequently namedibranded through the review and
23 approval of the Director, COUNTY DBH or designee.All print or media materials, including program
24 branding and program references shall be reviewed and approved by the Director, Department of
25 Behavioral Health or designee. The program funded under this Agreement shall be identified as a
26 County of Fresno, Department of Behavioral Health funded program, and operated by the
27 CONTRACTOR under the terms and conditions of this Agreement.
28 3. TERM
3
I This Agreement shall become effective on the 1 st day of January,2019 and shall terminate
2 oD the 3Om day of June, 2021.
3 This Agreement may be extended for two (2)additional twelve(12) month periods upon the
4 written approval of both parties not later than sixty(8{)days priorhzthmOrstdayofthanexthwevg (12)
5 month extension period. The COUNTY's DBH Director or designee is authorized to execute such written
8 approval on behalf of COUNTY based on CONTRACTOR's satisfactory performance.
7 3. TERMINATION
8 A. —The terms of this Agreement, and the services b/ bo
9 provided thereunder, are contingent on the approval of funds by the appropriating government agency.
10 Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
11 terminated at any time by giving CONTRACTOR thirty(30)days advance written notice.
12 B. Breach of Contract—COUNTY may immediately suspend or terminate this
13 Agreement in whole or in part, where in the determination of COUNTY there is:
14 1) /\n illegal o[improper use offunds;
15 2) A failure tu comply with any term of this Agreement;
18 8) A substantially incorrect or incomplete report submitted toCOUNTY;
17 4\ Improperly performed service.
18 In no event shall any payment by COUNTY constitute a waiver by the COUNTY of any
19 breach of this Agreement or any default which may then exist on the part of the CONTRACTOR. Neither
20 shall such payment impair orprejudice any remedy available to the COUNTY with respect*/the breach or
21 default. The COUNTY shall have the right to demand of the CONTRACTOR the repayment to the
22 COUNTY of any funds disbursed to CONTRACTOR under this Agreement,which in the judgment ofthe
23 COUNTY were not expended|n accordance with the terms of this Agreement. CONTRACTOR shall
34 promptly refund any such funds upon demand or, at COUNTY's option, such repayment shall be deducted
25 from future payments owing ho CONTRACTOR under this Agreement,
26 C. Without Cause-Undarcircurnstmnceaotharthenthoeeaetfodhabove, th|s
27 Agreement may be terminated by CONTRACTOR or COUNTY or COUNTY's DBH Director,or designee,
28 upon the giving of sixty(60)days advance written notice of an intention to terminate.
4
1 [i CONTRACTOR may terminate this Agreement. If terminated by
3 termination shall require sixty(60)days advance written notice of intent to terminate(with allowance for
3 appropriate clinical transition of clients priorto termination of ,transmitted byCONTRACTOR to
4 COUNTY by Certified or Registered U.8. Mail, Return Receipt Requested, addressed to the office of .
5 COUNTY a8follows:
6 Director(or designee)
Department of Behavioral Health
7 3133N. K8iUbrook �
Fresno, CA@37O3
O
S 4. COMPENSATION
10 COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees toreceive �
11 compensation |n accordance with the budget set forth in Exhibit B"Budget', attached hereto and by this
12 reference incorporated herein and made part of this Agreement. !
13 A. Maximum Contract Amount �
14 The maximum amount payable to CONTRACTOR for the period of January 1, 2019
15 through June 30, 2019 shall not exceed Eight Hundred Sixty-Six Thousand Seven Hundred Twenty-Nine
18 and No/10D Dollars($8O6.739.00). |tio understood bv CONTRACTOR and COUNTY that the cumulative
17 total mf Mental Health Services Act(MHSA)funds payable under this Agreement to CONTRACTOR shall
18 not exceed Six Hundred Thirty-Nine Thousand Nine Hundred Sixty-Seven and No/I 00 Dollars
19 ($839'987.0[). It is also understood by CONTRACTOR and COUNTY that CONTRACTOR is estimated
20 to generate a cumulative total of Two Hundred Twenty-Six Thousand Seven Hundred Sixty-Two and
21 No/1 00 Dollars($226,762.00)in Medi-Cal Federal Financial Participation (FFP)for services under this
22 Agreement to offset CONTRACTOR'S program costs as set forth|n Exhibit B.
23 The maximum amount payable to CONTRACTOR for each subsequent twelve(12)
24 month period of this Agreement shall not exceed One Million One Hundred Forty-One Thousand Four
25 Hundred Forty and No/1OO Dollars ($1.141.44O.0O). |tin understood bv CONTRACTOR and COUNTY
28 that the total Mental Health Services Act(MHSA)funds payable under this Agreement to CONTRACTOR
27 for each subsequent twelve(12)month period of this Agreement shall not exceed Eight Hundred Thirty-
28 NineThPusond. Ninety and No/1OD Dollars(G83B.O8D). |t|s also understood bv CONTRACTOR and
5
1 COUNTY that CONTRACTOR estimates to generate a total of Three Hundred Two Thousand Three
2 Hundred Fifty and Noll 00 Dollars($302,350.00) in Medl-Cal Federal Financial Participation(FFP)funds3 for each subsequent twelve (12)month period of this Agreement to offset CONTRACTOR's program costs
4 as set forth in Exhibit B.
5 In no event shall the maximum contract amount,for the full contract term of January
6 1, 2019 through June 30, 2023,for all the services provided by CONTRACTOR to COUNTY under the
7 terms and conditions of this Agreement be in excess of Five Million Four Hundred Thirty-Two Thousand
8 Four Hundred Eighty-Nine and No/1100 Dollars ($5,432,489)during the total term of this Agreement. The
G maximum amount of MHSA funds payable to CONTRACTOR for all services provided under this
10
Agreement shall not exceed Three Million Nine Hundred Ninety-Six Thousand Three Hundred Twenty-
11 Seven and Noll 00 Dollars($3,996,327). The total FFP funds estimated to be generated by
12 CONTRACTOR under this Agreement is One Million Four Hundred Thirty-Six Thousand One Hundred
13 Sixty Two and Noll 00 Dollars($1,436,162).
14 Payment shall be made upon certification or other proof satisfactory mCwum/ , ^
15 DBH that services have actually been performed bv CONTRACTOR mo specified in this
18 B. if CONTRACTOR fails ho generate the ModACo|revenue and/or client fee
17 reimbursement amounts set forth in Exhibit B, COUNTY shall not be obligated to pay the difference
18 between these estimated amounts and the actual amounts generated.
19, |t|m further understood bv COUNTY and CONTRACTOR that any K8edi-Co|
20 revenue and/or client fee reimbursements above the amounts stated herein will be used to directly offset
21 the C)OUNTY'e contribution of COUNTY funds identified!n Exhibit 8. The offset of funds will also be
22 clearly identified in monthly invoices received from CONTRACTOR as further described in Section Five(5)
23 nf this AoneemnenL
24 Travel shall be reimbursed based on actual expenditures and mileage
25 reimbursement shall be at CONTRACTOR's adopted rate per mile, not to exceed the Federal Internal
20 Revenue Services UR8\published nate.
27 O. It is understood that all expenses incidental to CONTRACTOR's performance of
28 services under this Agreement shall be borne bvCONTRACTOR. |f CONTRACTOR fails ho comply with
6
1 any provisionofthis Agreement, COUNTY shall be relieved ofits obligation for further .
2 D. Payments shall bamade by COUNTY to CONTRACTOR in arrears for services
3 provided during the preceding month, within (45)days after the date of receipt and approval by
4 COUNTY of the monthly invoicing aa described in Section Five(g) herein. Payments shall be made after
5 receipt and verification of actual expenditures incurred by CONTRACTOR for monthly program costs, as
O identified in Exhibit B, in the performance of this Agreement and shall be documented to COUNTY on a
7 monthly basis by the tenth (1 Oth)of the month following the month of said expenditures. The parties
8 acknowledge that CONTRACTOR will be performing hiring,training, and credentialing of staff, and
8 COUNTY will be performing additional staff credentialing to ensure compliance with State and Federal
10 regulations.
11 E. COUNTY shall not be obligated to make any payments under this Agreement ifthe
12 request for payment is received by COUNTY more than sixty(60)days after this Agreement has
13 terminated orexpired.
14 All final invoices shall be submitted by CONTRACTOR within sixty 0[8days
15 following the final month of service for which payment|nclaimed. No action shall ba taken bv COUNTY on
16 invoices submitted beyond the sixty(GC)day closeout period. Any compensation which is not expended
17 by CONTRACTOR pursuant to the terms and conditions of this Agreement shall automatically revert to
18 COUNTY.
19 F. The services provided by CONTRACTOR under this Agreement are funded in
20 whole or/n part bv the State ofCalifornia. |n the event that funding for these services io delayed bvthe
21 State Controller, COUNTY may defer payments to CONTRACTOR. The amount mf the deferred payment
22 shall not exceed the amount of funding delayed bv the State Controller 10 the COUNTY. The period nf
23 time of the deferral bvCC)UNTYahaUncdaxcaedthmpehodofdrneofUleStateContnQUmr'eda|aycf
24 payment ho COUNTY plus fort^five (45)days.
25 G. CONTRACTOR shall be held financially liable for any and all future
26 disallowances/audit exceptions due to CONTRACTOR deficiency discovered through the State audit
27 process and COUNTY utilization review dudnQ the course of this Agreement. /#CC)UNTY's election,the
20 disallowed amount will be remitted within forty-five(45)days to COUNTY upon notification or shall be
7
I withheld from subsequent payments to CONTRACTOR. CONTRACTOR shall not receive reimbursement
2 for any units of services rendered that are disallowed or denied by the Fresno County Mental Health Plan
3 (Mental Health Plan) utilization review process or through the State Department of Health Care Services
4 (DHCS)cost report audit settlement process for Medi-Cal eligible clients. Notwithstanding the above,
5 COUNTY must notify CONTRACTOR prior to any State audit process and/or COUNTY utilization review.
6 To the extent allowable by law, CONTRACTOR shall have the right to be present during each phase of
7 any State audit process and/or COUNTY utilization review and shall be provided all documentation related
8 to each phase of any State audit process and/or COUNTY utilization review. Additionally, prior to any
9 disallowances/audit exceptions becoming final, CONTRACTOR shall be given at least 10 business days to
10 respond to such proposed disallowanceslaudit exceptions.
11 H. It is understood by CONTRACTOR and COUNTY that this Agreement is funded
12 with mental health funds to serve adults, many of whom have mental health and co-occurring substance
13 use disorders. It is further understood by CONTRACTOR and COUNTY that funds shall be used to
14 support appropriately integrated and documented treatment services for co-occurring mental health and
15 substance use disorders.
16 5. INVOICING
17 A. CONTRACTOR shall invoice COUNTY in arrears by the tenth (10'")day of each
18 month for the prior month's actual services rendered to DBH—lnvoices(a7fresnocount .cy a.gOy. After
19 CONTRACTOR renders service to referred clients, CONTRACTOR will invoice COUNTY for payment,
20 certify the expenditure, and submit electronic claiming data into COUNTY's electronic information system
21 for all clients, including those eligible for Medi-Cal as well as those that are not eligible for Medi-Cal,
22 including contracted cost per unit and actual cost per unit. COUNTY must pay CONTRACTOR before
23 submitting a claim to DHCS for Federal reimbursement for Medi-Cal eligible clients.
24 B. If CONTRACTOR chooses to utilize the COUNTY's electronic health record system
25 (currently AVATAR,the preferred EHR system by DBH) method as their own full electronic health records
26 system, COUNTY's DBH shall invoice CONTRACTOR in arrears by the fifth (5th)day of each month for
27 the prior month's hosting fee for access to the COUNTY's electronic information system in accordance with
28 the fee schedule as set forth in Exhibit B-2, "Electronic Health Records Software Charges"attached hereto
8
I and incorporated herein by this reference and made part of this Agreement. COUNTY shall invoice
2 CONTRACTOR annually for the annual maintenance and licensing fee for access to the COUNTY's
3 electronic information system in accordance with the fee schedule as set forth in Exhibit B. COUNTY shall
4 invoice CONTRACTOR annually for the Reaching Recovefy fee, as applicable,for access to the
5 COUNTY's electronic information system in accordance with the fee schedule as set forth in Exhibit B.
O CONTRACTOR shall provide payment for these expenditures to COUNTY's Fresno County Department of
7 Behavioral Health,Accounts Receivable, P.O. Box 712, Fresno, CA 93717-0712, Attention:Business
8 Office,within forty-five(45)days after the date of receipt by CONTRACTOR of the invoicing provided by
H
10 C. At the discretion of COUNTY's DBH Director or designee, if an invoice is incorrect
11 or is otherwise not in proper form or substance, COUNTY's DBH Director or designee, shall have the right
12 to withhold payment as to only that portion of the invoice that is incorrect or improper after five(5)days
13 prior notice V)CONTRACTOR. CONTRACTOR agrees no continue oo provide services for w period v/
14 ninety(QO)days after notification ofon incorrect nr improper invoice. If after the ninety/QO\day period,the
15 invoice(s)is still not corrected to COUNTY DBH's satisfaction, COUNTY's DBH Director or designee, may
16 elect to terminate this Agreement, pursuant to the termination provisionsstated in Section Three C}\ofthis
17 Agreement. In addition,for invoices received ninety(90)days after the expiration of each term of this
18 Agreement or termination of this Agreement, mt the discretion of{}OUNT/'a[)BM Director mrdesignee,
18 CC)UNTY'eDBH shall have the rightbodenypmynoerdofonyodd0ona| invoioesremaived.
30 D. Monthly invoices shall include a client roster, identifying volume reported by
21 guarantor group clients served (including third party payer of services) by month and year-to-clate,
22 including percentages,
23 E. CONTRACTOR shall submit to the COUNTY by the tenth (1O{h)of each month a
24 detailed general ledger(GL), itemizing costs incurred in the pnav|Oum month. Failure to aubmitQL reports
25 and supporting documentation shall be deemed sufficient cause for COUNTY to withhold payments until
26 there|g compliance, oa further described in Section Five (E)herein.
27 F. CONTRACTOR will remit annually within ninety(90)days from June 30,a schedule
28 to provide the required information on published charges for all authorized direct specialty mental health
9
I services, The published charge listing will serve as a source document to determine the.CONTRACTOR's
3 usual and customary charge prevalent in the public mental health sector that is used to bill the general
3 public, insurers or other non-Medi-Cal third party payers during the course of business operations.
4 G. CONTRACTOR shall submit monthly staffing reports that identify all direct service
5 and support staff, applicable licensure/certifications, and full time hours worked to be used as a tracking
O tool to determine if CONTRACTOR's program is staffed according to the services provided under this
7
8 H. CONTRACTOR must maintain financial records for a period of ten(10)years or
g until any dispute,audit or inspection is resolved,whichever is later. CONTRACTOR will be responsible for
10 any disallowances related to inadequate documentation.
11 1, CONTRACTOR is responsible for collecting and managing of data in a manner to
12 be determined by DHCS and COUNTY's Mental Health Plan in accordance with applicable rules and
13 regulafions. COUNTY's electronic information system is a critical source of information for purposes of
14 monitoring service volume and obtaining reimbursement.
15 J. CONTRACTOR shall submit service data into COUNTY's electronic information
16 system, in accordance with COUNTY's DBH documentation standards,to allow COUNTY to bill Medi-Cal,
17 and any other third-party source,for services and meet State and Federal reporting requirements.
18 K. CONTRACTOR must comply With all laws and regulations governing the Federal
19 Medicare program, including, but not limited to: 1\the requirement of the Medicare Act,42U.8.C. section
20 1395 et seq; and 2)the regulations and rules promulgated by the Federal Centers for Medicare and
21 Medicaid Services as they relate to participation, coverage and claiming reimbursement. CONTRACTOR
22 will be responsible for compliance as of the effective date of each Federal, State or local law or regulation
28 specified.
24 L. If a client has dual coverage, such om other health coverage/OHC\orFederal
25 Medicare, CONTRACTOR will be responsible for billing the carrier and obtaining a payment/denial or have
26 validation of claiming with no response ninety(90)days after the claim was mailed before the service can
27 be entered into COUNTY's electronic information system. CONTRACTOR must report all third party
38 collections for Medicare,third party, client pay, or private pay in each monthly invoice and in the annual
10
1 cost report that is required to be submitted. A copy of explanation of benefits or CIVIS 1500 form is
2 required as documentation. CONTRACTOR must report all revenue collected from OHC, third-party,
3 client-pay, or private-pay in each monthly invoice and in the cost report that is required to be submitted.
4 CONTRACTOR shall submit monthly invoices for reimbursement that equal the amount due
5 CONTRACTOR less any funding sources not eligible for Federal and State reimbursement.
8 CONTRACTOR must comply with all laws and regulations governing the Federal Medicare program,
7 including, but not limited to: 1)the requirement of the Medicare Act, 42 U.S.C. section 1395 et seq; and 2)
8 the regulation and rules promulgated by the Federal Centers for Medicare and Medicaid Services as they
9 relate to participation, coverage and claiming reimbursement. CONTRACTOR will be responsible for
10 compliance as of the effective date of each Federal, State or local law or regulation specified.
11 M. Data entry shall be the responsibility of CONTRACTOR. COUNTY shall monitor
12 the volume of services and cost of services entered into COUNTY's electronic inforrnation system. Any
13 and.all audit exceptions resulting from the provision and reporting of specialty mental health services by
14 CONTRACTORshall be the sole responsibility of CONTRACTOR. CONTRACTOR will comply with all
15 applicable policies, procedures,directives and guidelines regarding the use of COUNTY's electronic
16 information system.
17 N. Medi-Cal Certification and Mental Health Plan Compliance
18 CONTRACTOR shall comply with any and all requests and directives associated
18 with COUNTY maintaining State K8mdi-Co|site certification. CONTRACTOR shall provide specialty mental
20 health services in accordance with COUNTY's Mental Health Plan. CONTRACTOR must comply with the
21 "Fresno County Mental Health Plan Compliance Program and Code of Conduct"set forth in Exhibit D,
22 attached hereto and incorporated herein by reference and made part of this Agreement. CONTRACTOR
23 shall comply with any and all requests associated with any State and/or Federal reviews or audits.
24 CONTRACTOR may provide direct specialty menta(beo)thsonvioeouwingp;e-
25 licensed staff as long as the individual is approved as a provider by the Mental Health Plan, is supervised
20 by licensed staff,works within his/her scope,and only delivers allowable direct specialty mental health
27 services. It is understood that each service is subject to audit for compliance with Federal and State
28 regulations, and that COUNTY may be making payments in advance of said review. (n the event that m
11
I service is disapproved, COUNTY may, at its sole discretion,withhold compensation or set off from other
2 payments due the amount of said disapproved services. CONTRACTOR shall be responsible for audit
3 exceptions to ineligible dates of services or incorrect application of utilization review requirements.
4 6. INDEPENDENT CONTRACTOR
5 In performance of the work, duties, and obligations assumed by CONTRACTOR under this
6 Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of
7 CONTRACTOR's officers, agents, and employees will at all times be acting and performing as an
8 independent contractor, and shall act in an independent capacity and not as an officer, agent,servant,
9 employee,joint venturer, partner, or associate of COUNTY. Furthermore, COUNTY shall have no right to
10 control or supervise or direct the manner or method by which CONTRACTOR shall perform its work and
11 function. However, COUNTY shall retain the right to administer this Agreement so as to verify that
12 CONTRACTOR is 'performing its obligations in accordance with the terms and conditions thereof.
13 CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the rules and
14 regulations, if any, of governmental authorities having jurisdiction over matters,which are directly or
15 indirectly the subject of this Agreement.
16 Because of its status as an independent contractor, CONTRACTOR shall have absolutely
17 no right to employment rights and benefits available to COUNTY employees. CONTRACTOR shall be
18 solely liable and responsible for providing to, or on behalf of, its employees all legally-required employee
19 benefits. In addition, CONTRACTOR shall be solely responsible and save COUNTY harmless from all
20 matters relating to payment of CONTRACTOR's employees, including compliance with Social Security,
21 withholding, and all other regulations governing such matters. It Is acknowledged that during the term of
22 this Agreement, CONTRACTOR may be providing services to others unrelated to COUNTY or to this
23 Agreement.
24 7. MODIFICATION
25 Any matters of this Agreement may be modified from time to time by the written consent of
26 all the parties without, in any way, affecting the remainder.
27 Notwithstanding the above, changes to services, staffing, and responsibilities of
28 CONTRACTOR,as needed,to accommodate changes in the laws relating to mental health treatment, as
12
I set forth in Exhibit A, may be made with the signed written approval of COUNTY's DBH Director or
2 designee and CONTRACTOR through an amendment approved by COUNTY's County Counsel and the
3 COUNTY's Auditor-Controller's Office.
4 in addition, changes to expense category(i.e., Salary&Benefits, Facilities/Equipment,
5 Operating, Financial Services, Special Expenses, Fixed Assets, etc.) subtotals in the budgets, as set forth
6 in Exhibit B, that do not exceed 10%of the maximum compensation payable to CONTRACTOR may be
7 made with the written approval of COUNTY's DBH Director or designee. Changes to the expense
8 categories in the budget that exceed ten percent(10%)of the maximum compensation payable to
9 CONTRACTOR, may be made with the signed written approval of COUNTY's DBH Director or designee
10 through an amendment approved by COUNTY's Counsel and COUNTY's Auditor-Controllers Office.
11 Modifications shall not result in any change to the annual maximum compensation amount
12 payable to CONTRACTOR, as stated in this Agreement.
13 8. NON-ASSIGNMENT
14 No party shall assign,transfer or subcontract this Agreement nor their rights or duties under
15 this Agreement without the prior written consent of COUNTY.
16 9. HOLD-HARMLESS
17 CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
18 defend COUNTY, its officers, agents, and employees from any and all costs and expenses, including
19 attorney fees and court costs, damages, liabilities, claims, and losses occurring or resulting to COUNTY
20 in connection with the negligent performance, or failure to perform, by CONTRACTOR, its officers,
21 agents, or employees under this Agreement, and from any and all costs and expenses, including
22 attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to any
23 person,firm or corporation who may be injured or damaged by the negligent performance, or failure to
24 perform, of CONTRACTOR, its officers, agents, or employees under this Agreement.
25 CONTRACTOR agrees to indemnify COUNTY for Federal, State of California and/or local
26 audit exceptions resulting from noncompliance herein on the part of CONTRACTOR.
27 10. INSURANCE
28 Without limiting COUNTY's right to obtain indemnification from CONTRACTOR or any third
13
I parties, CONTRACTOR, at its sole expense shall maintain in full force and affect the following insurance
2 policies throughout the term of this Agreement:
3 A. Commercial General Liability
4 Commercial General Liability Insurance with limits of not less than Two Million
Dollars ($2,000,000) per occurrence and an annual aggregate of Four Million
5 Dollars ($4,000,000). This policy shall be issued on a per occurrence basis.
COUNTY may require specific coverages including completed operations,
6 product liability, contractual liability, Explosion-Collapse-Underground (XCU), fire
legal liability, or any other liability insurance deemed necessary because of the
7 nature of the Agreement.
8
B. Automobile Liability
9
Insurance Services Office Form Number CA 0001 covering, Code 1 (any auto),
10 or if Consultant has no owned autos, Code 8 (hired) and 9 (non-owned).with
limits for bodily injury of not less than Five Hundred Thousand Dollars($500,000)
11 per person and with limits no less than One Million Dollars ($1,000,000)per
accident for bodily injury and property damage. Coverage should include any
12 vehicle used in connection with this Agreement.
13 C. Real and Property Insurance
14 CONTRACTOR shall maintain a policy of insurance for all risk personal property
coverage which shall be endorsed naming the County of Fresno as an additional
15 loss payee.The personal property coverage shall be in an amount that will cover
the total of COUNTY purchase and owned property, at a minimum, as discussed
16 in Section Twenty One(21) of this Agreement.
17
D. All Risk Property Insurance
18
CONTRACTOR will provide property coverage for the full replacement value of
19 COUNTY'S personal property in possession of CONTRACTOR and/or used in
the execution of this Agreement. COUNTY will be identified on an appropriate
20 certificate of insurance as the certificate holder and will be named as an
Additional Loss Payee on the Property Insurance Policy.
21
22 E. Professional Liability
23 Professional Liability Insurance with limits of not less than One Million Dollars
($1,000,000) per occurrence,Three Million Dollars ($3,000,000) annual
24 aggregate. CONTRACTOR agrees that it shall maintain, at its sole expense, in
full force and effect for a period of three (3)years following the termination of this
25 Agreement, one or more policies of professional liability insurance with limits of
coverage as specified herein.
26
27 F. Child Abuse/Molestation and Social Services Coverage
28
14
l CONTRACTOR shall have either separate policies or an umbrella policy withendorsements covering Child Abuse/Molestation and Social Services Liability
2 coverage or have a specific endorsement on their General Commercial liability
policy covering Child Abuse/Molestation and Social Services Liability, The policy
3 limits for these policies shall be One Million Dollars ($1,000,000) per occurrence
with a Two Million Dollars ($2,000,000) annual aggregate. The policies are to be
'
on a per occurrence basis.
~
G. Workers Compensation
A policy of Worker's Compensation Insurance as may be required by the
7 California Labor Code.
9 H. Cyber Liability
Cyber Liability Insurance, with limits not less than$2,000,000 per occurrence or
10 claim, $2,000,000 aggregate. Coverage shall be sufficiently broad to respond to
duties and obligations undertaken by CONTRACTOR in this agreement and shall
11 include, but not be limited to, claims involving infringement of intellectual
property, including but not limited to infringement of copyright, trademark, trade
12 dress, invasion of privacy violations, information theft, damage to or destruction
of electronic information, release of private information, alteration of electronic
13 information, extortion and network security. The policy shall provide coverage for
breach response costs as well as regulatory fines and penalties as well as credit
14 monitoring expenses With limits sufficient to respond to these obligations.
15
18 1. Waiver of Subrogation
CONTRACTOR hereby grant to COUNTY a waiver of any right to subrogation
17 which any insurer of said CONTRACTOR may acquire against COUNTY by
virtue of the 18 obtain ' ' ' CONTRACTOR agrees to
endorsement any that may be necessary to affect this ' —
subrogation, but this vxketharorno COUNTY has
19 nanak�d awaiverof 'uhuooabo` 'endorsement~ fhzn7U1einnune:
20
21
CONTRACTOR shall obtain endorsements to the Commercial General Liability insurance
~
22 naming the County of Fresno, its officers, agents, and employees, individually and collectively, me
23 additional ineured, but only insofar as the operations under this Agreement are concerned. Such opVmnmQe
24
for additional insured shall apply as primary insurance and any other insurance, ormeU-}Dnuronoe
'
25 maintained by COUNTY, its officers, agents, and employees shall be excess only and not contributing with
26
insurance provided under CONTRACTORS poU 'ckaohanain This insurance shall not bo cancelled or
changed vWUloutenoinimnUnn of1hi�y(3D)doyn�dmanmawdt�/nno�negiv�nto<�[)UNTT
27 ` ' .
VVdhnthht/(3O\�eyo�oV�\he�oba�{JNTF&�{�TI�/�aiQnathiaAoreenner8
2O � ` `' ' Agreement,
15
U
I CONTRACTOR shall provide certificates of insurance and endorsements as stated above for all of the
2 foregoing policies, as required herein,to the County of Fresno, Department of Behavioral Health,3133 N.
3 Miilbrook Ave, Fresno, California, 93703,Attention: Contracts Division, stating that such insurance
4 coverages have been obtained and are in full force;that the County of Fresno, its officers, agents, and
5 employees will not be responsible for any premiums on the policies;that such Commercial General
6 Liability insurance names the County of Fresno, its officers, agents, and employees, individually and
7 collectively, as additional insured, but only insofar as the operations under this Agreement are concerned;
8 that such coverage for additional insured shall apply as primary insurance and any other insurance, or self-
9 insurance, maintained by COUNTY, its officers, agents,and employees, shall be excess only and not
10 contributing with insurance provided under CONTRACTOR's policies herein; and that this insurance shall
11 not be cancelled or changed without a minimum of thirty(30)days advance,written notice given to
12 COUNTY.
13 In the event CONTRACTOR fails to keep in effect at all times insurance coverage as herein
14 provided, COUNTY may, in addition to other remedies it may have, suspend or terminate this Agreement
15 upon the occurrence of such event.
16 All policies shall be with admitted insurers licensed to do business in the State of California.
17 Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating of A FSC VII or
18 better.
19 11. LICENSESICERTIFICATES
20 Throughout each term of this Agreement, CONTRACTOR and CONTRACTOR's staff shall
21 maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions necessary for the
22 provision of the services hereunder and required by the laws and regulations of the United States of
23 America,State of California, the County of Fresno, and any other applicable governmental agencies.
24 CONTRACTOR shall notify COUNTY immediately in writing of its inability to obtain or maintain such
25 licenses, permits, approvals, certificates,waivers and exemptions irrespective of the pendency of any
26 appeal related thereto. Additionally,CONTRACTOR and CONTRACTOR's staff shall comply with all
27 applicable laws, rules or regulations, as may now exist or be hereafter changed.
28 12. RECORDS
16
I CONTRACTOR shall maintain records in accordance with Exhibit E, "Documentation
2 Standards for Client Records", attached hereto and by this reference incorporated herein and made part of
3 this Agreement. COUNTY shall be allowed to review all records of services provided, including the goals
4 and objectives of the treatment plan, and how the therapy provided is achieving the goals and objectives.
5 All mental health records shall be considered the property of the COUNTY and shall be retained by the
6 COUNTY upon termination or expiration of this Agreement.
7 13. REPORTS
8 A. Outcome Reports
9 CONTRACTOR shall submit to COUNTY's DBH service outcome reports as
10 reasonably requested by COUNTY's DBH. Outcome reports and outcome requirements are subject to
11 change at COUNTY's DBH discretion.
12 B. Additional Reports
13 CONTRACTOR shall also furnish to COUNTY such statements, records,reports,
14 data, and other information as COUNTY's DBH may reasonably request pertaining to matters covered by
15 this Agreement. in the event that CONTRACTOR fails to provide such reports or other information
16 required hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly payments until
17 there is compliance. In addition, CONTRACTOR shall provide written notification and explanation to
18 COUNTY within five(5)days of any funds received from another source to conduct the same services
19 covered by this Agreement.
20 C. Cost Report
21 CONTRACTOR shall provide financial data to identify all direct and indirect costs
22 incurred by CONTRACTOR for all services delivered under this Agreement. All Cost Reports must be
23 prepared in accordance with Generally Accepted Accounting Principles(GAAP) and Welfare and
24 Institutions Code§§5651(a)(4), 5664(a), 5705(b)(3)and 5718(c). Unallowable costs such as lobbying or
25 political donations must be deducted on the cost report and monthly invoice reimbursements,
26 D. Settlements with State Department of Health Care Services(DHCS)
27 During the term of this Agreement and thereafter, COUNTY and CONTRACTOR
28 agree to settle dollar amounts disallowed or settled in accordance with DHCS audit settlement findings
17
I related to the reimbursement provided under this Agreement. CONTRACTOR will participate in the
2 several phases of settlements between COUNTYICONTRACTOR and DHCS. The phases of initial cost
3 reporting for settlement according to State reconciliation of records for paid Medi-Cal services and audit
4 settlement are: State DHCS audit 1)initial cost reporting—after an internal review by COUNTY,the
5 COUNTY files the cost report with State DHCS on behalf of CONTRACTOR's legal entity for the fiscal
8 year,2)Settlement—State reconciliation of records for paid Medi-Cal services, approximately 18 to 36
7 months following the State close of the fiscal year,DHCS will send notice for any settlement under this
B provision to COUNTY; and 3)Audit Seftlement-State DHCS audit. After final reconciliation and settlement
S DHCS may conduct a review of medical records, cost report along with support documents submitted to
10 COUNTY in initial submission to determine accuracy and may disallow costs and/or units of services.
11 COUNTY may choose to appeal and therefore reserves the right to defer payback settlement with
12 CONTRACTOR until resolution of the appeal. DHCS Audits will follow Federal Medicaid procedures for
13 managing overpayments. If at the end of the Audit Settlement, COUNTY determines that it overpaid
14 CONTRACTOR, it will require CONTRACTOR to repay the Medi-Cal related overpayment back to
15
18 Funds owed to C OUNTY will be due within forty-five(45)days of notification by COUNTY,
17 or COUNTY shall withhold future payments until all excess funds have been recouped by means of an
10 offset against any payments then or thereafter owing to COUNTY under this or any other Agreement
19 between the COUNTY and CONTRACTOR.
20 14. MONITORING
21 CONTRACTOR agrees to extend toCOUNTY's staff, COUWTY's DBH Director,and the
22 State Department of Health Care Services or their designees,the right to review and monitor records,
23 oamioee, or procedures, m1 any time, in regard to o||enta` as well as the overall operation of
24 CONTRACTOR's performance, in order to ensure compliance with the terms and conditions of this
25 Agreement.
26 15, REFERENCES TO LAWS AND RULES
27 In the event any law, regulation, or policy referred to in this Agreement is amendedduring
28 the term thereof,the parties hereto agree to comply with the amended provision aanf the effective date of
18
1 such amendment.
2 16. COMPLIANCE WITH STATE REQUIREMENTS
3 CONTRACTOR recognizes that COUNTY operates its mental health programs under an
4 agreement with the State of California Department Health Care Services, and that under said agreement
5 the State imposes certain requirements on COUNTY and its subcontractors. CONTRACTOR shall adhere
6 to all State requirements, including those identified in Exhibit F, "State Mental Health Requirements",
7 attached hereto and by this reference incorporated herein and made part of this Agreement,
8 CONTRACTOR shall also file an incident report for all incidents involving clients, following the Protocol and
9 using the Worksheet identified in Exhibit G, "Incident Reporting", attached hereto and by this reference
10 incorporated herein and made part of this Agreement, or a protocol and worksheet presented by
11 CONTRACTOR that is accepted by COUNTY's DBH Director or designee.
12 17. COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
13 CONTRACTOR shall perform all services as set forth in Exhibit A in accordance with the
14 Assertive Community Treatment Model and in alignment with"Medl-Cal Organizational Provider
15 Standards", as set forth in Exhibit H, attached hereto and by this reference incorporated herein and made
16 part of this Agreement.
17 CONTRACTOR shall inform every client of their rights under the COUNTY's Mental Health
18 Plan as described in Exhibit 1,"Mental Health Plan", attached hereto and by this reference incorporated
19 herein and made part of this Agreement.
20 18, CONFIDENTIALITY
21 All services performed by CONTRACTOR under this Agreement shall be in strict
22 conformance with all applicable Federal, State of California and/or local laws and regulations relating to
23 confidentiality.
24 19. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
25 COUNTY and CONTRACTOR each consider and represent themselves as covered
26 entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law 104-
27 191 (HIPAA)and agree to use and disclose Protected Health Information (PHI)as required by law.
28 COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is
19
I only for treatment, payment, and health care operations.
2 COUNTY and CONTRACTOR intend to protect the privacy and provide for the security of
3 PHI pursuant to the Agreement in compliance with HIPAA,the Health Information Technology for
4 Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations promulgated thereunder
5 by the U.S. Department of Health and Human Services(HIPAA Regulations)and other applicable laws,
6 As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
7 CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of PHI, as
8 set forth in, but not limited to,Title 45, Sections 164.314(a), 164.502(e)and 164.504(e) of the Code of
9 Federal Regulations,
10 20. DATA SECURITY
11 For the purpose of preventing the potential loss, misappropriation or inadvertent access
12 viewing, use or disclosure of COUNTY data including sensitive or personal client information,abuse of
13 COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that enter into
14 a contractual relationship with COUNTY for the purpose of providing services under this Agreement must
15 employ adequate data security measures to protect the confidential information provided to
16 CONTRACTOR by COUNTY, including but not limited to the following:
17 A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
18 CONTRACTOR may not connect to COUNTY networks via personally-owned
19 mobile, wireless or handheld devices, unless the following conditions are met:
20 1) CONTRACTOR has received authorization by COUNTY for telecommuting
21 purposes;
22 2) Current virus protection software is in place;
23 3) Mobile device has the remote wipe feature enabled;and
24 4) A secure connection is used.
25 B. CONTRACTOR-Owned Computers or Computer Peripherals
26 CONTRACTOR may not bring contractor-owned computers or computer
27 peripherals into COUNTY for use without prior authorization from COUNTY's Chief Information Officer
28 and/or designee(s), including but not limited to mobile storage devices. If data is approved to be
20
1 transferred, data must be encrypted and stored on a secure server approved by COUNTY and transferred
2 by means of a Virtual Private Network(VPN) connection, or another type of secure connection.
3 C. COUNTY-Owned Computer Equipment
4 CONTRACTOR may not use COUNTY computers or computer peripherals on non-
5 County premises without prior authorization from COUNTY's Chief Information Officer and/or designee(s).
6 D. CONTRACTOR may not store COUNTY's private, confidential or sensitive data on
7 any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
8 E. CONTRACTOR shall be responsible to employ strict controls to ensure the integrity
9 and security of COUNTY's confidential information and prevent unauthorized access, viewing, use, or
10 disclosure of data maintained in computer files, program documentation, data processing systems, data
11 fifes, and data processing equipment which stores or processes COUNTY data internally and externally.
12 F. Confidential client information transmitted to one party by the other by means of
13 electronic transmissions must be encrypted according to Advanced Encryption Standards(AES)of 128
14 SIT or higher. Additionally, a password or pass phrase must be utilized.
15 G. CONTRACTOR is responsible to immediately notify COUNTY of any violations,
16 breaches or potential breaches of security related to COUNTY's confidential information, data maintained
17 in computer files, program documentation, data processing systems, data files and data processing
18 equipment which stores or processes COUNTY data internally or externally.
19 H. COUNTY shall provide oversight to CONTRACTOR's response to all incidents
20 arising from a possible breach of security related to COUNTY's confidential client information provided to
21 CONTRACTOR. CONTRACTOR will be responsible to issue any notification to affected individuals as
22 required by law or as deemed necessary by COUNTY in its sole discretion. CONTRACTOR will be
23 responsible for all costs incurred as a result of providing the required notification.
24 21. PROPERTY OF COUNTY
25 A. COUNTY and CONTRACTOR recognize that fixed assets are tangible and
26 intangible property obtained or controlled under COUNTY's Mental Health Plan for use in operational
27 capacity and will benefit COUNTY for a period more than one year. Depreciation of the qualified items will
28 be on a straight-line basis.
21
I For COUNTY purposes,fixed assets must fulfill three qualifications:
2 1. Have life span of over one year;
3 2. Is not a repair part; and
4 3. Must be valued at or greater than the capitalization thresholds for the asset
5 type.
6
7 Asset Type Threshold
8 a Land $0
Buildings and improvements $100,000
9 • Infrastructure $100,000
• Tangible $5,000
10 o Equipment
o Vehicles
11 . Intangible $100,000
o Internally generated software
12 o Purchased software
o Easements
13 o Patents
• Capital lease $5,000
14
15
Qualified fixed asset equipment is to be reported and approved by COUNTY. If it is
16
approved and identified as an asset, it will be tagged with a COUNTY program number. A Fixed Asset
17
Log will be maintained by COUNTY's Asset Management System and annually inventoried until the asset
18
is fully depreciated. During the terms of this Agreement, CONTRACTOR's fixed assets may be
19
inventoried in comparison to COUNTY's DBH Asset Inventory System.
20
B. Certain purchases less than Five Thousand and Noll00 Dollars($5,000,00) but
21
more than$1,000,with over one year life span, and are mobile and high risk of theft or loss are sensitive
22
assets. Such sensitive items are not limited to computers,copiers,televisions, cameras and other
23
sensitive items as determined by COUNTY's DBH Director or designee. CONTRACTOR will maintain a
24
tracking system on the items and are not required to be capitalize or depreciated. The items are subject to
25
annual inventory for compliance.
26
C. Assets shall be retained by COUNTY, as COUNTY property, in the event this
27
Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate in an
28
22
I annual inventory of all COUNTY fixed and inventoried,assets. Upon termination or expiration of this
2 Agreement, CONTRACTOR shall be physically present when fixed and inventoried assets are retumed to
3 COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all COUNTY-owned
4 undepreciated fixed and inventoried assets, or the monetary value of said assets if unable to produce the
5 assets at the expiration or termination of this Agreement.
6 CONTRACTOR further agrees to the following:
7 1. Maintain all items of equipment in good working order and condition, normal
8 wear and tear is expected;
9 2. Label all items of equipment with COUNTY assigned program number,
10 perform periodic inventories as required by COUNTY, and maintain an inventory list showing where and
11 how the equipment is being used, in accordance with procedures developed by COUNTY. All such lists
12 shall be submitted to COUNTY within ten(10)days of any request therefore; and
13 3. Report in writing to COUNTY immediately after discovery,the loss or theft of
14 any Items of equipment. For stolen items,the local law enforcement agency must be contacted and a
15 copy of the police report submitted to COUNTY.
16 D. The purchase of any equipment by CONTRACTOR with funds provided hereunder
17 shall require the prior written approval of COUNTY's DBH, shall fulfill the provisions of this Agreement as
18 appropriate, and must be directly related to CONTRACTORS services or activities under the terms of this
19 Agreement, COUNTY's DBH may refuse reimbursement for any costs resulting from equipment
20 purchased,which are incurred by CONTRACTOR, if prior written approval has not been obtained from
21 COUNTY.
22 E. CONTRACTOR must obtain prior written approval from COUNTY's DBH whenever
23 there is any modification or change in the use of any property acquired or improved, in whole or in part,
24 using funds under this Agreement. If any real or personal property acquired or improved with said funds
25 identified herein is sold and/or is utilized by CONTRACTOR for a use which does not qualify under this
26 Agreement, CONTRACTOR shall reimburse COUNTY in an amount equal to the current fair market value
27 of the property, less any portion thereof attributable to expenditures of funds not provided under this
28 Agreement. These requirements shall continue in effect for the life of the property. In the event this
23
/ Agreement expires, or terminates,the requirements for this Section shall remain in effect for activities or2 property funded with said funds, unless action is taken by the State government to relieve COUNTY of
3 these obligations.
5 During the performance of this Agreement, CONTRACTOR shall not unlawfully
O discriminate against any employee or applicant for employment, or recipient of services because of race,
7 religion, color, national origin, ancestry, physical handicap,medical condition, marital status,age,or sex,
8 pursuant to all applicable State and Federal statutes and regulations.
S 23. CULTURAL COMPETENCY
10 As related to Cultural and Linguistic Competence,CONTRACTOR shall comply with:
11 A. Title 6 of the Civil Rights Act of 1964(42 U.S.C. section 2000d, and 45 C.F.R, Part
12 86)and Executive Order 12250 of 1979,which prohibits recipients of federal financial assistance from
13 discriminating against persons based on race, color, national origin, sex, disability, or religion. This is
14 interpreted to mean that a limited English proficient(LEP)individual is entitled to equal access and
15 participation in federally funded programs through the provision of comprehensive and quality bilingual
16
17 B. Policies and procedures for ensuring access and appropriate use of trained
18 interpreters and material translation services for all LEPclients, including, but not limited to,assessing the
19 cultural and linguistic needs of its clients, of staff onthe policies and procedures, and monitoring its
20 language assistance program. CONTFACTOFYe procedures must include ensuring compliance ofany
21 sub-contracted providers with these requirements.
22 C. CONTRACTOR shall not use minors oa interpreters.
23 D. CONTRACTOR shall provide and pay for interpreting and translation services to
24 persons participating in CONTFACTDR'a eem'ioea who have Unndod or no English language proficiency,
25 including services to persons who are deaf orblind, Interpreter and translation services shall beprovided
26 as necessary to allow such participants meaningful mccmyn to the pooQrmnnm, aen/icmw and benefits provided
27 by CONTRACTOR. Interpreter and translation services, including translation of CONTRACTOR's"vital
28 documents"(those documents that contain information that is critical for accessing CONTRACTOR's
24
I services or are required by law)shall be provided to participants at no cost to the participant.
2 CONTRACTOR shall ensure that any employees, agents, subcontractors, or partners who interpret or
3 translate for a program participant, or who directly communicate with a program participant in a language
4 other than English, demonstrate proficiency in the participant's preferred language and can effectively
5 communicate any specialized terms and concepts peculiar to CONTRACTOR's services.
6 E. In compliance with the State mandated Culturally and Linguistically Appropriate
7 standards as published by the Office of Minority Health, CONTRACTOR must submit to COUNTY for
8 approval,within sixty (60) days from date of execution of this Agreement, CONTRACTOR's plan to
9 address all national cultural competency standards as set forth in Exhibit J°National Standards on
10 Culturally and Linguistically Appropriate Services(CLAS)", attached hereto and incorporated herein by
11 reference and made part of this Agreement. COUNTY's annual on-site review of CONTRACTOR shall
12 include collection of documentation to ensure all national standards are implemented. As the national
13 competency standards are updated, CONTRACTOR's cultural competency plan must be updated
14 accordingly. Cultural competency training for CONTRACTOR's staff should be substantively integrated
15 into health professions education and training at all levels, both academic and functional, including core
16 curriculum, professional licensure, and continuing professional development programs. CONTRACTOR,
17 on a monthly basis, shall provide COUNTY's DBH a monthly monitoring tool/report that shows all
18 CONTRACTOR's staff completed cultural competency trainings.
19 24. AMERICANS WITH DISABILITIES ACT
20 CONTRACTOR agrees to ensure that deliverables developed and produced, pursuant to
21 this Agreement, shall comply with the accessibility requirements of Section 508 of the Rehabilitation Act
22 and the Americans with Disabilities Act of 1973 as amended(29 U.S.C. §794 (d)), and regulations
23 implementing that Act asset forth in Part 1194 of Title 36 of the Code of Federal Regulations. In 1998,
24 Congress amended the Rehabilitation Act of 1973 to require Federal agencies to make their electronic and
25 information technology(EIT)accessible to people with disabilities. California Government Code section
26 11135 codifies section 508 of the Act requiring accessibility of electronic and information technology.
27 25. TAX EQUITY AND FISCAL RESPONSIBILITY ACT
28 To the extent necessary to prevent disallowance of reimbursement under section
25
1 1861(v)(1) (1)of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[1]), until the expiration of four(4)
2 years after the furnishing of services under this Agreement, CONTRACTOR shall make available,upon
3 written request to the Secretary of the United States Department of Health and Human Services,or upon
4 request to the Comptroller General of the United States General Accounting Office, or any of their duly
5 authorized representatives, a copy of this Agreement and such books,documents, and records as are
6 necessary to certify the nature and extent of the costs of these services provided by CONTRACTOR under
7 this Agreement. CONTRACTOR further agrees that in the event CONTRACTOR carries out any of its
8 duties under this Agreement through a subcontract,with a value or cost of Ten Thousand and Noll 00
9 Dollars($10,000.00)or more over a twelve(12)month period,with a related organization,such Agreement
10 shall contain a clause to the effect that until the expiration of four(4)years after the furnishing of such
11 services pursuant to such subcontract,the related organizations shall make available, upon written request
12 to the Secretary of the United States Department of Health and Human Services, or upon request to the
13 Comptroller General of the United States General Accounting Office, or any of their duly authorized
14 representatives, a copy of such subcontract and such books, documents, and records of such organization
15 as are necessary to verify the nature and extent of such costs.
16 26. SINGLE AUDIT CLAUSE
17 A. If CONTRACTOR expends Seven Hundred Fifty Thousand Dollars($750,000.00)
18 or more in Federal and Federal flow-through monies, CONTRACTOR agrees to conduct an annual audit in
19 accordance with the requirements of the Single Audit Standards as set forth in Office of Management and
20 Budget(OMB)Circular A 133. CONTRACTOR shall submit said audit and management letter to
21 COUNTY. The audit must include a statement of findings or a statement that there were no findings. If
22 there were negative findings, CONTRACTOR must include a corrective action plan signed by an
23 authorized individual. CONTRACTOR agrees to take action to correct any material non-compliance or
24 weakness found as a result of such audit. Such audit shall be delivered to COUNTY's DBH Business
25 Office for review within nine(9)months of the end of any fiscal year in which funds were expended and/or
26 received for the program. Failure to perform the requisite audit functions as required by this Agreement
27 may result in COUNTY performing the necessary audit tasks, or at COUNTY's option,contracting with a
28 public accountant to perform said audit, or may result in the inability of COUNTY to enter into future
26
I agreements with CONTRACTOR. All audit costs related to this Agreement are the sole responsibility of
2
3 B. A single audit report is not applicable if CONTRACTOR's Federal contracts do not
4 exceed the Seven Hundred Fifty Thousand Dollars($750,000.00) requirement or CONTRACTOR's only
5 funding is through Drug related Medl-Cal. If a single audit is not applicable, a program audit must be
O performed and a program audit report with management letter shall be submitted by CONTRACTOR to
7 COUNTY as a minimum requirement to attest to CONTRACTOR solvency. Said audit report shall be
8 delivered to COUNTY's DBH Business Office for review no later than nine(9)months after the close of the
S fiscal year in which the funds supplied through this Agreement are expended. Failure to comply with this
10 Act may result in COUNTY performing the necessary audit tasks or contracting with a qualified accountant
11 to perform said audit. All audit costs related to this Agreement are the sole responsibility of
12 CONTRACTOR who agrees to take corrective action to eliminate any material noncompliance or
13 weakness found as a result of such audit. Audit work performed by COUNTY under this paragraph shall
14
be billed to CONTRACTOR at COUNTY cost,as determined by COUNTY's Auditor-Controller/Treasurer-
15 Tax Collector.
16 C. CONTRACTOR shall make available all records and accounts ,m oinspection vy
17 COUNTY,the State of California, if applicable,the Comptroller General of the United States,the Federal
18 Grantor Agency, or any cf their duly authorized representatives, at all reasonable times for m period nfat
19 least three (3)years following final payment under this Agreement or the closure of all other pending
20 matters,whichever imlater.
21 27. COMPLIANCE
22 CONTRACTOR agrees 1ocomply withQOUNTY's Contractor Code of Conduct and Ethics
23 and the COUNTY's Compliance Program in accordance with Exhibit D. Within thirty(30)days of entering
24 into this Agreement with COUNTY. CONTRACTOR shall have ail of C(]NTF0\CT[>R'n ornplovaem. agents,
25 and subcontractors providing services under this Agreement certify in writing,that he or she has received,
26 read, understood, and shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR shall
27 ensure that within thirty(30)days of hire, all new employees, agents, and subcontractors providing
28 services under this Agreement shall certify in writing that he or she has received, read, understood, and
27
1 shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR understands that the
2 promotion of and adherence to the Contractor Code of Conduct is an element in evaluating the
3 performance of CONTRACTOR and its employees, agents and subcontractors.
4 Within thirty(30)days of entering into this Agreement, and annually thereafter,all
5 employees, agents, and subcontractors providing services under this Agreement shall complete general
6 compliance training and appropriate employees, agents, and subcontractors shall complete documentation
7 and billing or billing/reimbursement training. All new employees, agents, and subcontractors shall attend
8 the appropriate training within thirty(30)days of hire. Each individual who is required to attend training
9 shall certify in writing that he or she has received the required training. The certification shall specify the
10 type of training received and the date received. The certification shalt be provided to COUNTY's
11 Compliance Officer at 3133 N. Millbrook, Fresno, California 93703. CONTRACTOR agrees to reimburse
12 COUNTY for the entire cost of any penalty imposed upon COUNTY by the Federal Government as a result
13 of CONTRACTOR's violation of the terms of this Agreement.
14 28. ASSURANCES
15 In entering into this Agreement, CONTRACTOR certifies that neither they, nor any of their
16 officers, are currently excluded, suspended,debarred, or otherwise ineligible to participate in the Federal
17 Health Care Programs; that neither they, nor any of their officers, have been convicted of a criminal
18 offense related to the provision of health care items or services; nor have they, nor any of their officers,
19 been reinstated to participate in the Federal Health Care Programs after a period of exclusion, suspension,
20 debarment, or ineligibility. If COUNTY learns, subsequent to entering into a contract, that CONTRACTOR
21 is ineligible on these grounds, COUNTY will remove CONTRACTOR from responsibility for,or involvement
22 with, COUNTY's business operations related to the Federal Health Care Programs and shall remove such
23 CONTRACTOR from any position in which CONTRACTOR's compensation, or the items or services
24 rendered, ordered or prescribed by CONTRACTOR may be paid in whole or part, directly or indirectly, by
25 Federal Health Care Programs or otherwise with Federal Funds at least until such time as CONTRACTOR
26 is reinstated into participation in the Federal Health Care Programs.
27 A. If COUNTY has notice that either CONTRACTOR, or its officers, have been
28 charged with a criminal offense related to any Federal Health Care Program, or are proposed for exclusion
28
�
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|
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'
1 during the term of any contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure
2 the accuracy of any claims submitted to any Federal Health Care Program. At its discretion,given such !
/
3 circumstances, COUNTY may request that CONTRACTOR cease providing services until resolution of the
4 charges or the proposed exclusion,
5 B. CONTRACTOR agrees that all potential new employees of CONTRACTOR or
U subcontractors of CONTRACTOR who, in each case, are expected to perform professional services under
7 this Agreement, will be queried as to whether(1)they are now or ever have been excluded,suspended,
8 debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2)they have been
g convicted of a criminal offense related to the provision of health care items or services; and(3)they have
10 been reinstated to participate in the Federal Health Care Programs after a period of exclusion, suspension,
11 debarment, or ineligibility.
12 1. In the event the potential employee or subcontractor informs
13 CONTRACTOR that he or she is excluded, suspended, debarred, or otherwise ineligible,or has been
14 convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR hires
15 or engages such potential employee or subcontractor, CONTRACTOR will ensure that said employee or
18 subcontractor does no work, either directly or indirectly relating to services provided to COUNTY.
17 2. Notwithstanding the above, COUNTY, ao its discretion, may terminate this
18 Agreement in accordance with Section Three(3)of this Agreement, orrequire adequate assurance(am
19 defined by COUNTY)that no excluded, suspended, or otherwise ineligible employee or subcontractor of
20 CONTRACTOR will perform work,either directly or indirectly, relating to services provided to COUNTY.
21 Such demand for adequate assurance shall be effective upon a time frame to be determined by COUNTY
22 to protect the interests of COUNTY consumers.
23 C. CONTRACTOR shall verify(by asking the applicable employees and
24 subcontractors)that all current employees and existing subcontractors who, in each case, are expected to
35 perform professional services under this Agreement(1)are not currently excluded, suspended,debarred,
26 or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been convicted of a
27 criminal offense related to the provision of health care items or services; and(3) have not been reinstated
28 to participate in the Federal Health Care Program after a period of exclusion, suspension,debarment, or
29
I ineligibility. In the event any existing employee or subcontractor informs CONTRACTOR that he or she is
2 excluded, suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs,
3 or has been convicted of a criminal offense relating to the provision of health care services,
4 CONTRACTOR will ensure that said employee or subcontractor does no work, either direct or indirect,
5 relating to services provided to COUNTY.
O 1. CONTRACTOR agrees to notify COUNTY immediately during the term of
7 this Agreement whenever CONTRACTOR leams that an employee or subcontractor who, in each case, is
8 providing professional services under this Agreement is excluded, suspended, debarred, or otherwise
9 ineligible to participate in the Federal Health Care Programs, or is convicted of a criminal offense relating
10 to the provision of health care services.
11 2. Notwithstanding the above, COUNTY, at its discretion, may terminate this
12 Agreement in accordance with Section Three(3) of this Agreement, or require adequate assurance(as
13 defined by COUNTY)that no excluded, suspended, or otherwise ineligible employee or subcontractor of
14 CONTRACTOR will perform work, either directly or indirectly, relating to services provided to COUNTY.
15 Such demand for ade'quate assurance shall be effective upon a time frame to be determined by COUNTY
16 to protect the interests of COUNTY consumers.
17 D. CONTRACTOR agrees zo cooperate fully with any reasonable requests for
18 information from COUNTY which may be necessary to complete any internal or external audits relating to
18 C(]NTRACTOR's compliance with the provisions uf this Section.
20 E. CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty
21 imposed upon COUNTY by the Federal Government as a result of CONTRACTOR's violation of
22 C|ONTRA[Tl]R'e obligations modosnhbndinU1iaSeciion.
23 29. PUBLICITY PROHIBITION
24 None of the funds, materials, property orservices provideddirectly or indirectly under this
25 Agreement shall be used fVrC{}NTRACTOR'g advertiaing,fundraising, or publicity (la, purchasing of
26 t|ohato8ab|pm. oi|nrt auction donations, etc.)for the purpose ofoe|f-pronlotion. Notwithstanding the above,
27 publicity of the services described in Section One (1)of this Agreement shall be allowed as necessary to
28 raise public awareness about the availability of such specific services when approved in advance by
30
1 COUNTY's DBH Director or designee and at a cost to be provided in Exhibit B for such items as
2 written/printed materials, the use of media(i.e.,radio,television, newspapers), and any other related
3 expense(s).
4 30. COMPLAINTS
5 CONTRACTOR shall log complaints and the disposition of all complaints from a client or a
6 client's family. CONTRACTOR shall provide a copy of the detailed complaint log entries concerning
7 COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (1011)day of the following month,
8 in a format that is mutually agreed upon. In addition, CONTRACTOR shall provide details and attach
9 documentation of each complaint with the log. CONTRACTOR shall post signs informing clients of their
10 right to file a complaint or grievance. CONTRACTOR shall notify COUNTY of all incidents reportable to
11 State licensing bodies that affect COUNTY clients within twenty-four(24) hours of receipt of a complaint.
12 Within ten (10)days after each incident or complaint affecting COUNTY clients,
13 CONTRACTOR shall provide COUNTY with information relevant to the complaint, investigative details of
14 the complaint, the complaint and CONTRACTORS disposition of, or corrective action taken to resolve the
15 complaint. In addition, CONTRACTOR shall inform every client of their rights as set forth in Exhibit 1.
16 CONTRACTOR shall file an incident report for all incidents involving clients,following the protocol and
17 using the worksheet identified in Exhibit G.
18 31. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
19 This provision is only applicable if CONTRACTOR is disclosing entities,fiscal agents, or
20 managed care entities, as defined in Code of Federal Regulations (C.F.R),Title 42§455,101 455,104,
21 and 455.106(a)(1),(2).
22 In accordance with G.F.R.,Title 42§§455.101,455.104,455.105 and 455.106(a)(1),(2),
23 the following information must be disclosed by CONTRACTOR by completing Exhibit K, "Disclosure of
24 Ownership and Control Interest Statement", attached hereto and by this reference incorporated herein and
25 made part of this Agreement. CONTRACTOR shall submit this form to the COUNTY's DBH within thirty
26 (30)days of the effective date of this Agreement. Additionally,CONTRACTOR shall report any changes to
27 this information within thirty-five(35)days of occurrence by completing Exhibit K. Submissions shall be
28 scanned pdf copies and are to be sent via email to COUNTY's assigned Staff Analyst with the DBH
31
i
�
1 Contracts Division.
2 �
3 CONTRACTOR is required to disclose if any of the following conditions apply to them,their
4 owners, officers, corporate managers, and partners(hereinafter collectively referred to in this Section as
5
G A. Within the three-year period preceding the Agreement award,they have been
7 convicted of, or had a civil judgment rendered against them for
8 1. Fraud or a criminal offense in connection with obtaining, attempting to
9 obtain,or performing a public(federal, state, or local)transaction or contract under a public transaction;
10 2. Violation of a federal or state antitrust statute;
11 3. Embezzlement,theft,forgery, bribery,falsification, or destruction of records;
12 or
13 4. False statements or receipt of stolen property.
14 B. Within a three-year period preceding their Agreement award,they have had a
15 public transaction (federal, state, or local)terminated for cause or default.
16 Disclosure of the above information will not automatically eliminate CONTRACTOR from
17 further business consideration. The information will be considered as part of the determination of whether
18 to continue and/or renew this Agreement and any additional information or explanation that
10 CONTRACTOR elects to submit with the disclosed information will be considered. If it is later determined
20 that CONTRACTOR failed to disclose required information, any contract awarded to such CONTRACTOR
21 may be immediately voided and terminated for material failure to comply with the terms and conditions of
22 the award.
23 CONTRACTOR must sign a"Certification Regarding Debarment, Suspension, and Other
24 ResponsibUitvMotters- FMmary Covered Transactions"in the form set forth in Exhibit L, attached hereto
25 and by this reference incorporated herein and made part of this Agreement. Additionally, CONTRACTOR
28 must immediately advise[|OUNTY'mDBH in writing if, during the term of this Agreement: (1)
27 CONTRACTOR becomes auoponded, de6aned,axduded, or ineligible for participation in Federal or State
28 funded programs or from receiving federal funds as listed in the excluded parties'list system
32
1 (bttp://www.epls.gov); or(2) any of the above listed conditions become applicable to CONTRACTOR.
2 CONTRACTOR shall indemnify, defend, and hold COUNTY harmless for any loss or damage resulting
3 from a conviction, debarment, exclusion, ineligibility, or other matter listed in the signed Certification
4 Regarding Debarment, Suspension, and Other Responsibility Matters.
5 33. DISCLOSURE OF SELF-DEALING TRANSACTIONS
G
This provision is only applicable if a CONTRACTOR is operating as a corporation(a for-
7 profit or non-profit corporation) or if during the term of this Agreement, CONTRACTOR changes its status
8 to operate as a corporation.
S Members of a CONTRACTORS Board of Directors shall disclose any self-dealing
10 transactions that they are a party to while CONTRACTOR is providing goods or performing services under
11 this Agreement. A self-dealing transaction shall mean a transaction to which CONTRACTOR is a party
12 and in which one or more of its directors has m material financial interest. Members of the Board m
13 Directors shall disclose any self-dealing transactions that they are a party to by completing and signinge
14 "Self-Dealing Transaction Disclosure Fonn", attached hereto as Exhibit N1 and incorporated herein by
15 reference and made part of this Agreement, and submitting it to COUNTY prior to commencing with the
18 self-dealing transaction or immediately thereafter.
17 34. AUDITS AND INSPECTIONS
18 CONTRACTOR shall, at any time during business hours and as often as COUNTY may
19 deem necessary, make available to COUNTY for examination all of its ecmndo and data with respect to the
20 matters oomanad by this Agreement. CONTRACTOR shoU, upon request by COUNTY, permit COUNTY to
21 audit and inspect all such records and data necessary to ensure CONTRACTOR's compliance with the
22 terms of this Agreement.
23 |f this Agreement exceeds Ten Thousand and No/10O Dollars($1O`0OOOU).
24 CONTRACTOR shall be subject to the examination and audit ofthe State Auditor General for m period of
25 three(3)years after final payment under contract(Ca|ifornim Government Code section 854O.7).
26 36' NOTICES
27 The persons having authority to give and receive notices under this Agreement and their
28 addresses include the following:
33
I COUNTY CONTRACTO
2 Director, Fresno County Senior Vice President
Department of Behavioral Health Westcare California, Inc.3133 N. Millbrook Ave 4944 E. Clinton Way, Ste. 101
Fresno, CA 93702 Fresno, CA 93776
4 '
5 All notices between COUNTY and CONTRACTOR provided for or permitted under this �
8 Agreement must be in writing and delivered either by personal service, by first-class United States mail, by
7 an overnight commercial courier service, or by telephonic facsimile transmission. A notice delivered by
8 personal service is effective upon service to the recipient. A notice delivered by first-class United States
3 mail is effective three (3)COUNTY business days after deposit in the United States mail, postage prepaid,
10 addressed to the recipient. A notice delivered by an overnight commercial courier service is effective one
11 (1) COUNTY business day after deposit iMth the overnight commercial courier service, delivery fees
12 prepaid,with delivery instructions given for next day delivery, addressed to the recipient, A notice
13 delivered by telephonic facsimile is effective when transmission to the recipient is completed(but, K such
14 transmission is completed outside of COUNTY business hours,then such delivery shall be deemed to be
15 effective at the next beginning of a COUNTY business day), provided that the sender maintains a machine
16 record of the completed transmission. For all claims arising out of or related to this Agreement, nothing in
17 this section establishes,waives,or modifies any claims presentation requirements or procedures provided
18 by law, including but not limited bn the Government Claims Act(Division 3.oco Title of the Government
19 Code, beginning with section G10).
20 36. GOVERNING LAW
21 Venue for any action arising out ofor related bz the Agreement shall only be in Fresno
22 County, California,
28 The rightsandobU mUonmof1hmporUenondoU |nheqpretoUunandpedbnnaDueofthia
24 Agreement shall bo governed ina|| reopoctsbvthe|owanfthe8tateofCa|iforn|o.
25 37^ ENTIRE AGREEMENT 28 This Agreement, including all Exhibits, Reu/eadRFp No, 18-O38 and C(]NTRACTOR's
27 Response thereto, constitutes the entire agreement between CONTRACTOR and COUNTY with respect
28 tm the subject matter hereof and supersedes all previous agreement negotiations, proposals,
34
I commitments, writings, advertisements, publications, and understandings of any nature whatsoever unless
2 expressly included in this Agreement.
3 N
4 111
5 111
6 ill
7 111
8 111
9 N
10 /1l
11 Ill
12 N
13 111
14 Ill
15 111
16 111
17 111
18 Ill
19 llt
20 111
21 111
22 Ill
23 N
24 /ll
25 //l
26 111
27 ll1
28 N
35
1 IN WITNESS WHEREOF,the parties hereto have executed this Agreement as of the day
2 and year first hereinabove written.
3
4 CONTRACTOR: COUNTY OF FRESNO
WESTCARE CALIFORNIA, INC.
5
6
7 _
(Authorize Signatu S Qu t o,
8 (.,ft&iF0rS0rrM the Board of Supervisors
9 �, n S�,,y�, �i't� . r` i�is� of the County of Fresno
Print Name &Title
10
11 190� ✓1.h� a-, t31u�, svr�c /o t
12
13 FVcJhD , jjj6nprl 1a 93 7Z 7
Mailing Address ATTEST:
14 Bernice E. Seidel
15 Clerk of the Board of Supervisors
County of Fresno, State of California
16
17 By: SO.v�
Deputy
18 FOR ACCOUNTING USE ONLY:
19 ORG No.: 56304782
20 Account No.: 7295
Requisition No.:
21
22
23
24
25
26
27
28
36
Exhibit
Page I of 5
Overnight Stay
Facility
Scope mfWork
ORGANIZATION: \NestConaCo|ihurnia. Inc.
SITE ADDRESS: 37T2G. Martin Luther King Blvd, Fresno, CA937O0(Overnight Gtay
Facility)
3O3ON. First Street Suite#123` Fresno, CA8372O(Outpatient
Facility)
SERVICES: Overnight stay services,clinical response services,peer support
services, crisis intervention and assessments, discharge
services, transportation and linkage to appropriate mental team
programs.
CONTRACT PERIOD: January 1' 2O19 through June 3O. 2U23
SCHEDULE OF '
CON TRACTOR'S staff shall beavailable to provide Overnight Stay Paci|hvaen/|oeoto
individuals seven days o week,24hourseday.
Contractor shall provide services on eleven (11)County observed holidays ineach calendar
yeoroefoUnms:
New Year's Day
Martin Luther King, Jr. Holiday
President's Day
Cesar Chavez Day
Memorial Day
Independence Day
Labor Day
Veterans Day
Thanksgiving Day
Day after Thanksgiving Day
Christmas Day
TARGET,POPULATI ON-
Adults and older adults receiving services from emergency departments/5150 facilities who are in
crisis but do not require o 5150 hold. The pnzgnann will provide nenvioao client referred from local
emergency departments and 5150 facilities including but not limited to: Fresno Community
Regional Medical Center(CRMC), St.Agnes, Clovis Community Regional Medical Center and
Exodus Crisis Stabilization Center.
Exhibit A
Page 2 of 5
PROJECT DESCRIPTION:
The overnight stay program will provide individuals who present at the ED in crisis, but do not
require a 5150 hold the opportunity to be voluntarily discharged to the care of SOS where they
may spend the night, receive a meal, a shower, a place to sleep, and be assessed and linked
the following day to an appropriate mental health or co-occurring treatment service. The
program will also provide mental health assessment,crisis intervention, targeted case
management, bridge medication support and other short-term, specialty mental health
services delivered by qualified staff with the goal to increase engagement, address symptoms
and bridge the gap while the consumer awaits admission to other services in the community.
This will reduce ED recidivism and lengths of stay in the emergency department or crisis
stabilization unit. Individuals may stay at the SOS facility for up to four nights consecutively
when necessary to enhance the probability that a successful linkage will occur. Because at
least 80%of individuals of the population to be served are homeless, this opportunity for a
longer stay may enable housing to be secured as well as mental health service linkage.When
individuals are housed first,the likelihood of initiating and staying with treatment services is
enhanced,they are less likely to be lost to follow-up and the opportunity to build a helpful
therapeutic alliance is strengthened. The SOS program is an established bridge and
permanent supportive housing provider in Fresno County and has long-term and ongoing
partnerships with housing providers including Fresno Housing Authority and Turning Point.
CONTRACTOR'S RgSPONSIBILITIES:_
CONTRACTOR shall:
1. Provide services to individuals discharged from local hospital Emergency Department's
(ED)/designated 5150 facilities as requested by the County. The CONTRACTOR may
expand to provide services to other agencies in the County of Fresno as needed or if
requested to do so by COUNTY, Department of Behavioral Health(DB-l).
2. Transport individuals referred by local ED/5150 facilities to the overnight stay facility.
Response time to the ED is expected to be less than 30 minutes from referral call from ED.
Individuals are transported as necessary 24 hours per day, 7 days per week, including
holidays. Individuals will additionally be transported by staff to the Outpatient Center every
morning for assessment and other services.SOS case managers are expected to facilitate
linkage services of all kinds by accompanying the consumer in a program vehicle to various
necessary appointments, including navigation of the mental health system in order to
support engagement and followthrough.
3. Provide overnight stay and linkage to appropriate levels of care the following business
day. Services can be anywhere from 24 hours up to four nights if a client arrives at the
facility on a Friday of a holiday weekend and linkage cannot be provided until regular
business hours are resumed. The overnight stay shall be between the hours of 8pm-
8am; however, the hours of Barn to 8pm will be used for linkage, targeted case
management, assessments and other mental health services as needed.
4. Engage individuals at the EDs where they have been admitted.
Exhibit A
Page 3 of 5
5. Be notified by ED staff or County's CPRS staff assigned at the ED of the pending discharge of a
consumer.
6. Encourage individual to accept the offer to stay overnight and be provided
transportation and assistance to outpatient services the following day, or the following
business day when applicable.
7. Provide supervision of individuals who are being discharged from the emergency
department/designated 5150 facility. Provide for the basic care of individuals i.e.:food,
bedding, shower/bath,medication supervision,etc.
8. Maintain staffing including, but not be limited to: program supervisor, clinician, case
manager, peer support specialist, personal service coordinator, data/program assistant
and medical director.
9. Ensure that the safety of the community, consumer and staff are a priority.
10. Have a process in place for each individual who utilizes the overnight-stay facility to
ensure the individual is actively participating in services. CONTRACTOR will make
telephone contacts with each participant's service provider once a week for up to 45
days. Individuals who are not keeping appointments or following through on referrals
will be contacted directly, twice weekly at a minimum. Individuals who drop out will be
located and motivational interviewing techniques will be used to encourage their return
to their treatment program. CONTRACTOR will contact participants at least once a
month until the individual has consistently participated in an outpatient program for 3
months and is functioning at a lower level of care
11. Ensure service delivery is culturally sensitive and appropriate for individuals and their
families
12. Provide family support services through Peer Support Specialists and Linkage
Specialists to aid in the recovery of the individual as well as to educate and engage the
whole family.
COUNTY RESPONSIBILITIES:
COUNTY shall:
1. Provide program and budget oversight through the County Department of Behavioral Health
(DBH), Contracted Services Division to the CONTRACTOR'S Overnight Stay Facility. In
addition to contract monitoring of the program, oversight includes, but not limited to,
coordination with the State Department of Mental Health, Mental Health Services Act in
regard to program administration and outcomes.
2. Participate in evaluating the progress of the overall program and the efficiency of
collaboration with the CONTRACTOR staff and be available to the CONTRACTOR for
ongoing consultation.
Exhibit A
Page 4 of 5
3. Receive and analyze statistical data outcome information from vendor throughout the term
of contract on a monthly basis. DBH will notify the vendor when additional participation is
required.The performance outcome measurement process will not be limited to survey
instruments but may also include, as appropriate, consumer and staff interviews, chart
reviews, and other methods of obtaining required information.
4. Recognize that cultural competency is a goal toward which professionals, agencies, and
systems should strive. Becoming culturally competent is a developmental process and
incorporates at all levels the importance of culture, the assessment of cross-cultural
relations, vigilance towards the dynamics that result from cultural differences,the
expansion of cultural knowledge, and the adaptation of services to meet culturally-unique
needs. Offering those services in a manner that fails to achieve its intended result due to
cultural and linguistic barriers is not cost effective.To assist the vendor efforts towards
cultural and linguistic competency, DBH shall provide the following at no cost to
CONTRACTOR):
A. Technical assistance and mandatory cultural competency training including sexual
orientation and sensitivity training for vendor personnel, at minimum once per year.
County will provide mandatory training regarding the special needs of this diverse
population. Sexual orientation and sensitivity to gender differences is a basic cultural
competence principle and shall be included in the cultural competency training.
Literature suggests that the mental health needs of lesbian, gay, bisexual, transgender
(LGBT) individuals may be at increased risk for mental disorders and mental health
problems due to exposure to societal stressors such as stigmatization,prejudice, and
anti-gay violence. Social support may be critical for this population. Access to care
may be limited due to concerns about providers' sensitivity to differences in sexual
orientation.
B. Technical assistance for vendor 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 the
vendor.
PROGRAM OUTCOMES
At minimum, one performance indicator will be identified for each of the four CARF domains
listed below.
a. Access to care:The ability of clients to receive the right service at the right time. Examples
include:
1. Timeliness of bridging prescriptions
2. Timeliness of identifying clients with a serious mental illness
3. Timeliness between client referral for assessment and completion of assessment;
assessment to first treatment service; and,first treatment service to nextfollow-up
4. Timeliness of subsequent follow-up visits
5. Timeliness of response to sick call/health service requests
Exhibit
Page 6of5
b. Objective results achieved through healthcare services. Examples include:
i. Effectiveness of crisis interventions
2. Effectiveness of treatment interventions(medical and behavioral health indicators)
3. Effectiveness of discharge planning(such as percentage of clients successfully linked to
County programs,community providers,and/or other community resources after
release)
4. Timely continuity of verified community prescriptions for medication(s), upon client's
release
B. Effectiveness of transportation coordination, upon release
o. Efficiency: The demonstration of the relationship between results and the resources used to
achieve them.
Examples include:
1. Cost per client
2 Number of units ofservices per FTEbvdiscipline
3. Number of clients served per general population
4. Comparison of numbers served against industry standards
d. The degree to which clients, County, and other stakeholders
are satisfied with theservimye..
Examples include:
1 Audits and other performance and utilization reviews of health care services and
compliance with agreement terms and conditions
2. Surveys of persons served,family members,other health care providers,and other
stakeholders
ExhlUn B
Page 1 of 16
SUPERVISED OVERNIGHT STAY SERVICES
WESTCARE CALIFORNIA,INC.
FY 2018-19(January 1,2019 through June 30,2019)
Budget Categories- Total Proposed Budget
Line Item Description Must be itemized) FTE% Admin. Direct Total
PERSONNEL SALARIES:
0001 Program Supervisor 1.00 $42,525 $42,525
0002 Case Manager 3.00 $92,700 $92,700
0003 Peer Support Specialists/Driver 5.00 $105,300 $105,300
0004 Personal Service Coordinators 4.00 $96,720 $96,720
0005 Data/Program Assistant 1.50 $33,930 $33,930
0006 Medical Director 0.17 $24,953 $24,953
0007 LCSW(Mental Health Clinician) 2.00 $87,000 $87,000
0008 Temp Help/Overtime 0.00 $1,875 $1,875
0009 Title 0.00 $0
0010 Title 0.00 $0
0011 Title 0,00 $0
0012 Title 0.00 $0
SALARY TOTAL 16.67 $0 $485,003 $485,003
PAYROLL TAXES:
0030 OASDI $0
0031 FICA/MEDICARE $31,719 $31,719
0032 SUI $8,245 $8,245
PAYROLL TAX TOTAL $0 $39,964 $39,964
EMPLOYEE BENEFITS:
0040 Retirement $14,550 $14,550
0041 Workers Compensation $33,756 $33,756
0042 dental) $32,495 $32,495
EMPLOYEE BENEFITS TOTAL $0 $80,801 $80,801
SALARY&BENEFITS GRAND TOTAL $605,768
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $45,200
1011 Rent/Lease Equipment $21,600
1012 Utilities $15,000
1013 Building Maintenance $1,800
1014 Equipment purchase $0
FACILITY/EQUIPMENT TOTAL $83,600
Exhibit B
Page 2 of 16
OPERATING EXPENSES:
1060 Telephone $10,600
1061 Answering Service $0
1062 Postage $75
1063 Printing/Reproduction $75
1064 Publications ' $0
1065 Legal Notices/Advertising $0
1066 Office Supplies&Equipment $7,352
1067 Household Supplies $4,500
1068 Food $188
1069 Program Supplies-Therapeutic $0
1070 Program Supplies-Medical $1,125
1071 Transportation of Clients $188
1072 Staff Mileage/vehicle maintenance $6,000
1073 Staff Travel(Out of County) $0
1074 Staff Training/Registration $1,125
1075 Lodging $0
1076 Other-(identify) $0
1077 Other-(identify) $0
OPERATING EXPENSES TOTAL $31,227
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability insurance $0
1083 Administrative Overhead $108,584
1084 Payroll Services $0
1085 Professional Liability Insurance $3,600
FINANCIAL SERVICES TOTAL $112,184
SPECIAL EXPENSES Consultant/Etc.):
1090 Consultant(network&data management) $0
1091 Translation Services $750
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $750
FIXED ASSETS:
1190 Computers&Software $6,000
1191 Furniture&Fixtures $12,950
1192 Other-(Identify) $0
1193 Other-(Identify) $0
FIXED ASSETS TOTAL $18,950
Exhibit B
Page 3 of 16
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures(SFC 70) $0
2001 Client Housing Operating Expenditures(SFC 71) $0
2002.1 Clothing, Food&Hygiene(SFC 72) $11,250
2002.2 Client Transportation&Support(SFC 72) $2,250
2002.3 Education Support(SFC 72) $0
2002.4 Employment Support(SFC 72) $0
2002.5 Respite Care(SFC 72) $0
2002.6 Household Items $750
2002.7 Utility Vouchers(SFC 72) $0
12002,8 Child Care(SFC 72) 1 $0
_NON MEDI-CAL CLIENT SUPPORT TOTAL 1 $14,250
TOTAL PROGRAM EXPENSES 1 $866,729
MEDI-CAL REVENUE: Units of Service Rate $Amount
3000 Mental Health Services(individual/Family/Group Th 67,500 $2.12 $143,100
3100 Case Management 120,000 $1.45 $174,000
3200 Crisis Services 8,250 $2.81 $23,183
3300 Medication Support 9,750 $3.90 $38,025
3400 Collateral 9,750 $2.12 $20,670
3500 Plan Development 4,500 $2.12 $9,540
3600 Assessment 22,500 $2.12 $47,700
3700 Rehabilitation 22,600 $2.12 $47,700
Estimated Specialty Mental Health Services Billing Totalsi 264,7150 $503,918
Estimated%of Clients that are Medi-Cal Beneficiaries 90%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $463,526
Federal M/Cal Share of Cost% (Federal Financial Participation-FFP) 50.00% $226,762
State M/Cal Share of Cost%(BH Realign t/EPSDT 0.00% $0
MEDI-CAL REVENUE TOTAL $226,762
OTHER REVENUE:
4100 Other-(identify) $0
4200 Other-(identify) $0
4300 Other-(Identify) $0
OTHER REVENUE TOTAL $0
MENTAL HEALTH SERVICES ACT(MHSA)REVENUE:
5000 Prevention &Early Intervention(PEI) Funds $639,967
6100 Community Services&Supports(CSS)Funds $0
5200 Innovation(INN)Funds $0
.5300 Workforce Education&Training (WET)Funds $01;
MHSA FUNDS TOTAL $639,9671
TOTAL PROGRAM REVENUEJ $866,7291
Exhibit B
Page 4 of 16
SUPERVISED OVERNIGHT STAY SERVICES
WESTCARE CALIFORNIA,INC.
FY 2019-2020
Budget Categories- Total Proposed Budget
Line Item Description(Must be itemized) FTE% Admin. Direct Total
PERSONNEL SALARIES:
0001 Program Supervisor 1.00 $56,700 $56,700
0002 Case Manager 3.00 $123,600 $123,600
0003 Peer Support SpecialistslDriver 5.00 $150,800 $150,800
0004 Personal Service Coordinators 4.00 $133,120 $133,120
0005 Data/Program Assistant 1.50 $48,360 $48,360
0006 Medical Director 0.17 $33,270 $33,270
0007 LCSW(Mental Health Clinician) 2.00 $116,000 $116,000
0008 Tamp Help/Overtime 0,00 $2,500 $2,500
0009 Title 0.00 $0
0010 Title 0.00 $0
0011 Title 0.00 $0
0012 Title 0.00 $0
SALARY TOTAL 16.67 $0 $664,350 $664,350
PAYROLL TAXES:
0030 OASDI $0
0031 FICA/MEDICARE $43,448 $43,448
0032 SUI $11,294 $11,294
PAYROLL TAX TOTAL $0 $54,742 $54,742
EMPLOYEE BENEFITS:
0040 Retirement $19,931 $19,931
0041 Workers Compensation $46,239 $46,239
0042 dental) $44,511 $44,511
EMPLOYEE BENEFITS TOTAL $0 $110,681 $110,681
SALARY&BENEFITS GRAND TOTAL $829,773
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $53,600
1011 Rent/Lease Equipment $28,800
1012 Utilities $20,000
1013 Building Maintenance $2,400
1014 Equipment purchase $0
FACILITY/EQUIPMENT TOTAL $104,800
Exhibit 8
Page 5 of 16
OPERATING EXPENSES:
1060 Telephone $13,200
1061 Answering Service $0
1062 Postage $100
1063 Printing/Reproduction $100
1064 Publications $0
1065 Legal Notices/Advertising $0
1066 Office Supplies&Equipment $7,370
1067 Household Supplies $6,000
1068 Food $250
1069 Program Supplies-Therapeutic $0
1070 Program Supplies-Medical $1,500
1071 Transportation of Clients $250
1072 Staff Mileage/vehicle maintenance $8,000
1073 Staff Travel(Out of County) $0
1074 Staff Training/Registration $1,500
1075 Lodging $0
1076 Other-(Identify) $0
1077 Other-(identify) $0
OPERATING EXPENSES TOTAL $38,270
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $0
1083 Administrative Overhead $143,797
1084 Payroll Services $0
1085 Professional Liability Insurance $4,800
FINANCIAL SERVICES TOTAL $148,597
SPECIAL EXPENSES ConsultantlEtc. :
1090 Consultant(network&data management) $0
1091 Translation Services $1,000
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $1,000
FIXED ASSETS:
1190 Computers&Software $0
1191 Furniture&Fixtures $0
1192 Other-(Identify) $0
1193 Other-(identify) $0
$0
FIXED ASSETS TOTAL
Exhibit B
Page 6 of 16
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures(SFC 70) $0
2001 Client Housing Operating Expenditures(SFC 71) $0
2002.1 Clothing, Food&Hygiene(SFC 72) $15,000
2002.2 Client Transportation&Support(SFC 72) $3,000
20023 Education Support(SFC 72) $0
2002.4 Employment Support(SFC 72) $0
2002,5 Respite Care(SFC 72) $0
2002.6 Household Items $1,000
2002.7 Utility Vouchers(SFC 72) $0
12002.8 Child Care(SFC 72) 1 $0
NON MEDI-CAL CLIENT SUPPORT TOTAL 1 $19,000
TOTAL PROGRAM EXPENSES I $1,141,4401
MEDI-CAL REVENUE: Units of Service Rate $Amount
3000 Mental Health Services(individual/Family/Group Thi 90,000 $2.12 $190,800
3100 Case Management 160,000 $1.45 $232,000
3200 Crisis Services 11,000 $2.81 $30,910
3300 Medication Support 13,000 $3.90 $60,700
3400 Collateral 13,000 $2.12 $27,560
3500 Plan Development 6,000 $2.12 $12,720
3600 Assessment 30,000 $2,12 $63,600
3700 Rehabilitation 1 30,000 1 $2.12 $63,600
Estimated Special!y Mental Health Services Billing Totals l 353,000 $671,890
Estimated%of Clients that are Medl-Cal Beneficiaries 90%
Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries $604,701
Federal M/Cal Share of Cost% (Federal Financial Participation-FFP) 50.00% $302,350
State M/Cal Share of Cost%(BH RealignmentUIEPSDT) 0.00% $0
MEDI-CAL REVENUE TOTAL $302,350
OTHER REVENUE:
4100 Other-(identify) $0
4200 Other-(identify) $0
4300 Other-(identify) $0
OTHER REVENUE TOTAL $0,
MENTAL HEALTH SERVICES ACT(MHSA)REVENUE:
5000 Prevention&Early Intervention(PEI) Funds $839,090
5100 Community Services&Supports(CSS)Funds $0
5200 Innovation(INN) Funds $0
5300 Workforce Education&Training (WET)Funds $01
MHSA FUNDS TOTAL $839,0901
TOTAL PROGRAM REVENUE $11,10,4401
Exhibit B
Page 7 of 16
SUPERVISED OVERNIGHT STAY SERVICES
WESTCARE CALIFORNIA,INC.
FY 2020-2021
Budget Categories- Total Proposed Budget
Line Item Descli tlon(Must be Itemized) FTE% Admin. Direct Total
PERSONNEL SALARIES:
0001 Program Supervisor 1.00 $56,700 $56,700
0002 Case Manager 3.00 $123,600 $123,600
0003 Peer Support Specialists/Driver 5.00 $150,800 $150,800
0004 Personal Service Coordinators 4.00 $133,120
0005 Data/Program Assistant 1.50 $48,360 $48,360
0006 Medical Director 0.17 $33,270 $33,270
0007 LCSW(Mental Health Clinician) 2.00 $116,000 $116,000
0008 Temp Help/Overtime 0.00 $2,500 $2,600
0009 Title 0.00 $0
0010 Title 0.00 $0
0011 Title 0.00 $0
0012 Title 01.00 $0
SALARY TOTAL 16.67 $0 $664,350 $664,350
PAYROLL TAXES:
0030 OASDI $0
0031 FICA/MEDICARE $43,448 $43,448
0032 SUI $11,294 $11,294
PAYROLL TAX TOTAL $0 $54,742 $54,742
EMPLOYEE BENEFITS:
0040 Retirement $19,931 $19,931
0041 Workers Compensation $46,239 $46,239
0042 Health Insurance(medical,vision,life, dental) $44,511 $44,5111
EMPLOYEE BENEFITS TOTAL $01, $110,681 $110, 1 681 SALARY&BENEFITS GRAND TOTAL
77829,7731
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $53.600
1011 Rent/Lease Equipment $28,800
1012 Utilities $20,000
1013 Building Maintenance $2,400
11014 Equipment purchase $01
FACILITY/EQUIPMENT TOTAL $104,800
Exhibit B
Page 6 of Is
OPERATING EXPENSES:
1060 Telephone $13,200
1061 Answering Service $0
1062 Postage $100
1063 Printing/Reproduction $100
1064 Publications $0
1065 Legal Notices/Advertising $0
1066 Office Supplies&Equipment $7,370
1067 Household Supplies $6,000
1068 Food $250
1069 Program Supplies-Therapeutic $0
1070 Program Supplies-Medical $1,500
1071 Transportation of Clients $250
1072 Staff Mileage/vehicle maintenance $8,000
1073 Staff Travel(Out of County) $0
1074 Staff Training/Registration $1,500
1075 Lodging $0
1076 Other-(Identify) $0
11077 Other-(Identify) $0
OPERATING EXPENSES TOTAL $38,270
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $0
1083 Administrative Overhead $143,797
1084 Payroll Services $0
11085 Professional Liability Insurance $4,800
FINANCIAL SERVICES TOTAL $148,597
SPECIAL EXPENSES Consu►tant/Etc.):
1090 Consultant(network&data management) $
1091 Translation Services $1,000
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $1,0001
FIXED AS-SETS:
1190 Computers&Software $0
1191 Furniture&Fixtures $0
1192 Other-(identify) $0
,1193 Other-(identify) $0
1 FIXED ASSETS TOTAL $0
Exhibit B
Page 9 of 16
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures(SFC 70) $0
2001 Client Housing Operating Expenditures(SFC 71) $0
2002.1 Clothing, Food&Hygiene(SFC 72) $15,000
2002.2 Client Transportation&Support(SFC 72) $3,000
2002.3 Education Support(SFC 72) $0
2002.4 Employment Support(SFC 72) $0
2002.5 Respite Care(SFC 72) $0
2002.6 Household Items $1,000
2002.7 Utility Vouchers(SFC 72) $0
2002.8 Child Care(SFC 72) 1 $0
NON MEDI-CAL CLIENT SUPPORT TOTAL 1 $19,000
TOTAL PROGRAM EXPENSES1 $1,141,440
MEDI-CAL REVENUE: Units of Service Rate $Amount
3000 Mental Health Services(individuaVFamily/Group Therapy) 90,000 $2.12 $190,800
3100 Case Management 160,000 $1.45 $232,000
3200 Crisis Services 11,000 $2.81 $30,910
3300 Medication Support 13,000 $3.90 $60,700
3400 Collateral 13,000 $2.12 $27,560
3500 Plan Development 6,000 $2.12 $12,720
3600 Assessment 30,000 $2.12 $63,600
3700 Rehabilitation 30,000 1 $2.12 $63,600
Estimated Specialty Mental Health Services Billing Totalsi 353,000 fl $671,890
Estimated%of Clients that are Medi-Cal Beneficiaries 90%
Estimated Total Cost of S ecialty Mental Health Services Provided to Medi-Cal Beneficiaries $604,701
Federal M/Cal Share of Cost%(Federal Financial Participation-FFP) 50.00% $302,350
State M/Cal Share of Cost% BH Reali nment/EPSDT_l 0.00% $0
MEDI-CAL REVENUE TOTAL $302,350
OTHER REVENUE:
4100 Other-(identify) $0
4200 Other-(identify) $0
4300 Other-(Identify) $0
OTHER REVENUE TOTAL $0
MENTAL HEALTH SERVICES ACT MHSA)REVENUE:
5000 Prevention&Early Intervention(PEI)Funds $839,090
5100 Community Services&Supports(CSS)Funds $0
5200 Innovation(INN)Funds $0
5300 Workforce Education&Training(WET)Funds $0
MHSA FUNDS TOTAL $839,090
TOTAL PROGRAM REVENUEJ $1,141,440
Exhibit B
Page 10 of 16
SUPERVISED OVERNIGHT STAY SERVICES
WESTCARE CALIFORNIA,INC.
FY 2021-2022
Budget Categories- Total Proposed Budget
Line Item Description(Must be itemized) FTE% Admin. Direct Total
PERSONNEL SALARIES:
0001 Program Supervisor 1.00 $56,700 $56,700
0002 Case Manager 3.00 $123,600 $123,600
0003 Peer Support Specialists/Driver 5.00 $166,000 $156,000
0004 Personal Service Coordinators 4.00 $133,120 $133,120
0005 Data/Program Assistant 1.50 $48,360 $48,360
0006 Medical Director 0.17 $33,270 $33,270
0007 LCSW(Mental Health Clinician) 2.00 $116,000 $116,000
0008 Temp HelplOvertime 0.00 $850 $860
0009 Title 0.00 $0
0010 Title 0.00 $0
0011 Title 0.00 $0
0012 Title 0.00 $0
SALARY TOTAL 16.67 $0 $667,900 $667,900
PAYROLL TAXES:
0030 OASDI $0
0031 FICA/MED(CARE $43,681 $43,681
0032 SUI $11,354 $11,354
PAYROLL TAX TOTAL $0 $55,035 $55,035
EMPLOYEE BENEFITS:
0040 Retirement $20,037 $20,037
0041 Workers Compensation $46,486 $46,486
0042 Health Insurance(medical,vision, life,dental) $44,749 $44,749
EMPLOYEE BENEFITS TOTAL $01 $111,272 $111,272
SALARY&BENEFITS GRAND TOTAL $834,207
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $53,600
1011 Rent/Lease Equipment $28,800
1012 Utilities $20,000
1013 Building Maintenance $2,400
1014 Equipment purchase $0
FACILITY/EQUIPMENT TOTAL L $104,800
Exhibit 8
Page 11 of 16
OPERATING EXPENSES:
1060 Telephone $13,200
1061 Answering Service $0
1062 Postage $68
1063 Printing/Reproduction $68
1064 Publications $0
1065 Legal Notices/Advertising $0
1066 Office Supplies&Equipment $6,000
1067 Household Supplies $5,000
1068 Food $250
1069 Program Supplies-Therapeutic $0
1070 Program Supplies-Medical $1,000
1071 Transportation of Clients $250
1072 Staff Mileage/vehicle maintenance $8,000
1073 Staff Travel(Out of County) $0
1074 Staff Training/Registration $500
1075 Lodging $0
1076 Other-(identify) $0
1077 Other-(Identify) $0
OPERATING EXPENSES TOTAL $34,336
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability Insurance $0
1083 Administrative Overhead $143,797
1084 Payroll Services $0
1085 Professional Liability Insurance $4,800
FINANCIAL SERVICES TOTAL $148,597
SPECIAL EXPENSES(Consultant/Etc.):
1090 Consultant(network&data management) $0
1091 Translation Services $500
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $500
FIXED ASSETS:
1190 Computers&Software $0
1191 Furniture&Fixtures $0
1192 Other-(Identify) $0
1193 Other-(identify) $0
FIXED ASSETS TOTAL $0
Page 12 of 16
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures(SFC 70) $0
2001 Client Housing Operating Expenditures(SFC 71) $0
2002.1 Clothing, Food&Hygiene(SFC 72) $15,000
2002.2 Client Transportation&Support(SFC 72) $3,000
2002.3 Education Support(SFC 72) $0
2002.4 Employment Support(SFC 72) $0
2002.5 Respite Care(SFC 72) $0
2002.6 Household Items $1,000
2002.7 Utility Vouchers(SFC 72) $0
2002.8 Child Care(SFC 72).. $0
NON MEDI-CAL CLIENT SUPPORT TOTAL $19,000
TOTAL PROGRAM EXPENSES 1 $1,141,440
MEDI-CAL REVENUE: Units of Service Rate $Amount
3000 Mental Health Services(Individual/Family/Group Therapy) 90,000 $2.12 $190,600
3100 Case Management 160,000 $1,45 $232,000
3200 Crisis Services 11,000 $2.81 $30,910
3300 Medication Support 13,000 $3.90 $50,700
3400 Collateral 13,000 $2.12 $27,560
3500 Plan Development 6,000 $2.12 $12,720
3600 Assessment 30,000 .$2.12 $63,600
3700 Rehabilitation 30,000 $2.12 $63,600
Estimated Specialty Mental Health Services BillingTotalsl 353,000 $671,890
Estimated%of Clients that are Medi-Cal Beneficiaries 90%
Estimated Total Cost of Specialty Mental Health Services Provided to Medl-Cal Beneficiaries $604,701
Federal M/Cal Share of Cost%(Federal Financial Participation-FFP) 50,00% $302,350
State M/Cal Share of Cost%(SH Realignment/EPSOT) 0.00% $0
MEDI-CAL REVENUE TOTAL $302,350
OTHER REVENUE:
4100 Other-(identify) $0
4200 Other-(Identify) $0
4300 Other- Identify) $0
OTHER REVENUE TOTAL $0,
MENTAL HEALTH SERVICES ACT(MHSA)REVENUE:
5000 Prevention&Early Intervention(PEI)Funds $839,090
5100 Community Services&Supports(CSS)Funds $0
5200 Innovation(INN)Funds $0
15300 Workforce Education&Training(WET)Funds $0
MHSA FUNDS TOTAL $839,090
TOTAL PROGRAM REVENUE J $1,141,440
Exhibit B
Page 13 of 16
SUPERVISED OVERNIGHT STAY SERVICES
WESTCARE CALIFORNIA,INC.
FY 2022-2023
Budget Categories- Total Proposed Budget
Line Item Description(Must be itemized) FTE% Admin. Direct Total
PERSONNEL SALARIES:
0001 Program Supervisor 1.00 $56,700 $56,700
0002 Case Manager 3.00 $123,600 $123,600
0003 Peer Support Specialists/Driver 5.00 $156,000 $156,000
0004 Personal Service Coordinators 4.00 $133,120 $133,120
0005 Data/Program Assistant 1.50 $48,360 $48,360
0006 Medical Director 0.17 $33,270 $33,270
0007 LCSW(Mental Health Clinician) 2.00 $116,000 $118,000
0008 Tamp Help/Overtime 0.00 $850 $850
0009 Title 0.00 $0
0010 Title 0.00 $0
0011 Title 0.00 $0
D012 Title 0.00 $0
SALARY TOTAL 16.67 $0 $667,900 $667,900
PAYROLL TAXES:
0030 OASDI $0
0031 FICAIMEDICARE $43,681 $43,681
0032 SUI $11,354 $11,354
PAYROLL TAX TOTAL $0 $55,035 $55,035
EMPLOYEE BENEFITS:
0040 Retirement $20,037 $20,037
0041 Workers Compensation $46,486 $46,486
0042 Health Insurance(medical,vision,life,dental) $44,749 $44,749
1 EMPLOYEE BENEFITS TOTAL $01 $111,272 $111,272 EMPLOYEE
&BENEFITS GRAND TOTAL $834,2071
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $53,600
1011 Rent/Lease Equipment $28,800
1012 Utilities $20,000
1013 Building Maintenance $2,400
1014 Equipment purchase $0
FACILITY/EQUIPMENT TOTAL $104,800 .
Exhibit B
Page 14 of 16
OPERATING EXPENSES:
1060 Telephone $13,200
1061 Answering Service $0
1062 Postage $68
1063 Printing/Reproduction $68
1064 Publications $0
1065 Legal Notices/Advertising $0
1066 Office Supplies&Equipment $6,000
1067 Household Supplies $5,000
1068 Food $250
1069 Program Supplies-Therapeutic $0
1070 Program Supplies-Medical $1,000
1071 Transportation of Clients $250
1072 Staff Mileage/vehicle maintenance $8,000
1073 Staff Travel(Out of County) $0
1074 Staff Training/Registration $500
1075 Lodging $0
1076 Other-(Identify) $0
1077 Other-(Identify) $0
OPERATING EXPENSES TOTAL $34,336
FINANCIAL SERVICES EXPENSES:
1080 Accounting/Bookkeeping $0
1081 External Audit $0
1082 Liability insurance $0
1083 Administrative Overhead $143,797
1084 Payroll Services $0
1085 Professional Liability Insurance $4,800
FINANCIAL SERVICES TOTAL $148,597
SPECIAL EXPENSES(Consultant/Etc.):
1090 Consultant(network&data management) $0
1091 Translation Services $500
1092 Medication Supports $0
SPECIAL EXPENSES TOTAL $500
FIXER ASSETS:
1190 Computers&Software $0
1191 Furniture&Fixtures $0
1192 Other-(Identify) $0
1193 Other-(Identify) $0
FIXED ASSETS TOTAL $0
Exhibit B
Page 15 of 16
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
2000 Client Housing Support Expenditures(SFC 70) $0
2001 Client Housing Operating Expenditures(SFC 71) $0
2002.1 Clothing, Food&Hygiene(SFC 72) $15,000
2002.2 Client Transportation&Support(SFC 72) $3,000
2002.3 Education Support(SFC 72) $0
2.002.4 Employment Support(SFC 72) $0
2002.5 Respite Care(SFC 72) $0
2002.6 Household Items $1,000
2002.7 Utility Vouchers(SFC 72) $0
12002.8 Child Care(SFC 72) 1 $0
r-NON MEDI-CAL CLIENT SUPPORT TOTAL 1 $19,000
TOTAL PROGRAM EXPENSES I $1,141,440
MEDI-CAL REVENUE: Units of Service Rate $Amount
�3000 Mental Health Services(Individual/Family/Group Thera 90,000 $2.12 $190,800
3100 Case Management 160,000 $1.45 $232,000
3200 Crisis Services 11,000 $2.81 $30,910
3300 Medication Support 13,000 $3.90 $50,700
3400 Collateral 13,000 $2.12 $27,560
3500 Plan Development 6,000 $2.12 $12,720
3600 Assessment 30,000 $2.12 $63,600
3700 Rehabilitation 30,000 $2.12 $63,600
Estimated Specialty Mental Health Services Billing Totals l 353,000 .1 $671,890
Estimated%of Clients that are Medl-Cal Beneficiaries 90%
Estimated Total Cost of Specialty Mental Health Services Provided to Medl-Cal Beneficiaries $604,701
Federal M/Cal Share of Cost%(Federal Financial Participation-FFP) 50,00% $302,360
State M/Cal Share of Cost%(BH Realignmenm 0.00% $0
MEDI-CAL REVENUE TOTAL $302,350
OTHER REVENUE:
4100 Other-(identify) $0
4200 Other-(Identify) $0
4300 Other-(Identi $0
OTHER REVENUE TOTAL $0,
MENTAL HEALTH SERVICES ACT(MHSA)REVENUE:
5000 Prevention&Early Intervention(PEI)Funds $839,090
5100 Community Services&Supports(CSS)Funds $0
5200 Innovation(INN)Funds $0
5300 Workforce Education&Training(WET)Funds $0
MHSA FUNDS TOTAL $839,0901
TOTAL PROGRAM REVENUE[_ _$1,141,44()l
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Exhibit C
Page 4 of 4
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.
DSH GOALS:
Quadruple Alm
• 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
rev 01-02-2018
Exhibit C
Fresno County Department of Behavioral Health Page 2 of 4
Guiding Principles of Care Deliver
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 leadingthe
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 fife
o Providers assist individuals and families in developing and utilizing natural supports.
5. Principle Five-Clinical Significance and Evidence Based Practices ON
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
rev 01-02-2018
Exhibit C
Fresno County Department of Behavioral Health Page 3 of 4
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
a Each individual defines their own recovery and recovers at their own pace when
provided with sufficient time and support
rev 01-02-2018
Exhibit C
Fresno County Department of Behavioral Health Page 4 of 4
Guiding Principles of Care Delivery
mRbt4RRi4i
10. Principle Ten-Continuous Quality Improvement and Outcomes-Driven
a 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-Wealth 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
a 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
rev01-02-2018
Exhibit D
Page 1 of 3
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF COND UCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable Iaws,
regulations,rules and guidelines that apply to the provision and payment of mental health services.
Mental health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with which
contractor and its employees and subcontractors shall comply. Contractor shall require its employees
and subcontractors to attend a compliance training that will be provided by Fresno County. After
completion of this training, each contractor, contractor's employee and subcontractor must sign the
Contractor Acknowledgment and Agreement form and return this form to the Compliance officer or
designee.
Contractor and its employees and subcontractor shall:
1. Comply with all applicable laws, regulations,rules or guidelines when providing and billing
for mental health services.
Z. Conduct themselves honestly,fairly, courteously and with a high degree of integrity in their
professional dealing related to their contract with the County and avoid any conduct that could
reasonably be expected to reflect adversely upon the integrity of the County.
3. Treat County employees, consumers, and other mental health contractors fairly and with
respect.
4. NOT engage in any activity in violation of the County's Compliance Program, nor engage in
any other conduct which violates any applicable law,regulation, rule or guideline
S. Take precautions to ensure that claims are prepared and submitted accurately,timely and are
consistent with all applicable laws, regulations, rules or guidelines.
b. 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
Exhibit D
Page 2 of 3
accurately describe the services provided.
8. Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9. Promptly report to the Compliance Officer any suspected violation(s) of this Code of Conduct
and Ethics by County employees or other mental health contractors,or report any activity that
they believe may violate the standards of the Compliance Program, or any other applicable
law,regulation, rule or guideline. Fresno County prohibits retaliation against any person
making a report. Any person engaging in any form of retaliation will be subject to disciplinary
or other appropriate action by the County. Contractor may report anonymously.
10. Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
11. Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
Exhibit D
Page 3 of 3
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and
Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof. i further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement. I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County. I further understand that Fresno
County will report me to the appropriate Federal or State agency.
� rrrr�rrlr I I rrl
For Individual Providers
Name(print):
Discipline: ❑ Psychiatrist ❑ Psychologist ❑ LCSW ❑ LMFT
Signature : Date
� 1■ I I��rr�rlrrrYrrlrrrr�rr
For Group or Oraanizationai Providers
p g (print): Y _'��i. "tZr ' rGrou /Or .Name rant : �`" �tk .�..n C .
Employee Name(print):
Discipline: ❑ Psychiatrist ❑ Psychologist ❑ LCSW ❑ LMFT
Other:
Job Title(if different from Discipline): Q d. _
Signature: Date: t / 7
Exhibit E
Pagel of 3
Documentation Standards For Client Records
The documentation standards are described below under key topics related to client care.All
standards must be addressed in the client record;however,there is no requirement that the record
have a specific document or section addressing these topics.
A. Assessments
1. The following areas will be included as appropriate as a part of a comprehensive client record.
• Relevant physical health conditions reported by the client will be prominently identified
and updated as appropriate.
• Presenting problems and relevant conditions affecting the client's physical health and
mental health status will be documented,for example: living situation,daily activities,
and social support.
• Documentation will describe client's strengths in achieving client plan goals.
• Special status situations that present a risk to clients or others will be prominently
documented and updated as appropriate,
• Documentations will include medications that have been described by mental health plan
physicians, dosage of each medication,dates of initial prescriptions and refills,and
documentations of informed consent for medications.
• Client self report of allergies and adverse reactions to medications,or lack of known
allergies/sensitivities will be clearly documented.
• A mental health history will be documented,including:previous treatment dates,
providers,therapeutic interventions and responses, sources of clinical data,relevant
family information and relevant results of relevant lab tests and consultations reports.
• For children and adolescents,pre-natal and perinatal events and complete developmental
history will be documented.
• Documentations will include past and present use of tobacco,alcohol,and caffeine,as
well as illicit,prescribed and over-the-counter drugs.
• A relevant mental status examination will be documented.
• A five axis diagnosis from the most current DSM,or a diagnosis from the most current
ICD,will be documented, consistent with the presenting problems, history mental status
evaluation and/or other assessment data.
2. Timeliness/Frequency Standard for Assessment
• An assessment will be completed at intake and updated as needed to document changes in
the client's condition.
• Client conditions will be assessed at least annually and, inmost cases,at more frequent
intervals.
B. Client Plans
1.Client plans will:
Exhibit E
Page 2 of 3
• have specific observable and/or specific quantifiable goals
• identify the proposed type(s)of intervention
• have a proposed duration of intervention(s)
: be signed(or electronic equivalent)by:
➢ the person providing the service(s),or
➢ a person representing a team or program providing services,or
➢ a person representing the MHP providing services
➢ when the client plan is used to establish that the services are provided under the
direction of an approved category of staff, and if the below staff are not the approved
category,
➢ a physician
➢ a licensed/"waivered"psychologist
➢ a licensed/"associate"social worker
➢ a licensed/registered/marriage and family therapist or
➢ a registered nurse
• In addition,
➢ client plans will be consistent with the diagnosis,and the focus of intervention will be
consistent with the client plan goals,and there will be documentation of the client's
participation in and agreement with the plan. Examples of the documentation include,
but are not limited to,reference to the client's participation and agreement in the body
of the plan,client signature on the plan,or a description of the client's participation
and agreement in progress notes.
➢ client signature on the plan will be used as the means by which the
CONTRACTOR(S)documents the participation of the client
➢ when the client's signature is required on the client plan and the client refuses or is
unavailable for signature,the client plan will include a written explanation of the
refusal or unavailability.
• The CONTRACTOR(S)will give a copy of the client plan to the client on request.
2.Timeliness/Frequency of Client Plan:
• Will be updated at least annually
• The CONTRACTOR(S)will establish standards for timeliness and frequency for the
individual elements of the client plan described in item 1.
C. Progress Notes
1.Items that must be contained in the client record related to the client's progress in treatment
include:
• The client record will provide timely documentation of relevant aspects of client care
• Mental health staff/practitioners will use client records to document client encounters,
including relevant clinical decisions and interventions
• All entries in the client record will include the signature of the person providing the
service (or electronic equivalent);the person's professional degree, Iicensure or job title;
and the relevant identification number, if applicable
Exhibit E
Page 3 of 3
All entries will include the date services were provided
• The record will be legible
e The client record will document follow-up care,or as appropriate,a discharge summary
2.Timeliness/Frequency of Progress Notes:
Progress notes shall be documented at the frequency by type of service indicated below:
A.Every Service Contact
a Mental Health Services
• Medication Support Services
• Crisis Intervention
Exhibit F
Page 1 of 2
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-DoylelMedi-Cal services
have met applicable professional licensure requirements pursuant to Business and
Professions and Welfare and Institutions Codes,
3. CONFIDENTIALITY
CONTRACTOR(S)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-DISCRBUNATION
A. Eligibility for Services
CONTRACTOR(S)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(S) shall comply with COUNTY policy,and the Equal
Employment Opportunity Commission guidelines,which forbids
discrimination against any person on the grounds of race,color,national
origin,sex,religion,age, disability status, or sexual preference in
employment practices. Such practices include retirement,recruitment
advertising,hiring, layoff,termination,upgrading,demotion,transfer,
Exhibit F
Page 2 of 2
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(S)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(S)
who is related by blood or marriage to,or who is a member of the Board
of Directors or an officer of CONTRACTOR(S),
5. PATIENTS' RIGHTS
CONTRACTOR(S)shall comply with applicable laws and regulations, including
but not limited to, laws,regulations,and State policies relating to patients'rights.
Exhibit G
C-
Page I of 3
Department of Behavioral Health
Dawan Utecht,Mental Health Director/Public Guardian
Providing Quality Mental Health and Substance Abuse Se?-vicesjbr the People ofFresno County
Information Notice
Date: May 29, 2018
To: Fresno County Mental Health Plan and Substance Use Services Contracted Providers
Subject: New Policy and Procedure Guide Regarding Incident Reporting and Intensive Analysis
PPG 1.2.4,
Effective June 11t,2018,all contracted providers working within the Fresno County Mental Health
Plan and Substance Use Disorder Services Providers will need to follow the new instructions for
reporting incidents,
An"Incident" is any event that compromises the health and safety of clients,employees,or community
members. Any employee having knowledge of an incident will need to follow the appropriate reporting
process. Incident reports help to increase safety in the provision of behavioral health care and substance use
disorder services as well as recommend possible system,policy and/or protocol changes.
The list below includes types of incidents to report:
• All client deaths(natural causes or unexplained/unknown reasons)
• 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)
Example-a client trips and falls but doesn't require medical attention
• Medical Emergency connected to services or at a service site
Example: Client has a seizure/heart attack during appointment
• Other(i.e. Clients escaping from a locked facility, medication erroneously given during
appointment or mistakenly prescribed)
• Violence,Abuse or Assault connected to services or at a service site(toward client,others or
property;resulting in serious injury)
Example: Client hits a staff member/another client,sets fire to a trash can in the building
Reporting Process
1.) The encrypted report shall be completed and signed by the employee involved in or first aware of
an incident.
2.) Reviewed and signed by a supervisor and/or Program Director and sent encrypted to the
designated Contract Staff Analyst and DBHlncidentReporting@co.ftesno.ca.us
3.) ***MHRC1s and PHF's must ALSO send the encrypted 24-Hour Unusual
Occurrence Report(UOR)to the designated reporting contact at DHCS,your Contract Staff
Analyst and DBHlnoidentReportinjz&co.fresno.ca.us within 24 hours of an incident or first
knowledge of an incident.
Steps 1,2 and 3 must be completed within 24 hours of an incident or first knowledge of an incident
4441 E.Kings Canyon Road/Fresno,California 93702-3604
(559)600-9180+FAX(559)600-7674
Equal Employment Opportunity i Affirmative Action+Disabled Employer
-.y%vw.co.frpM.ca,us♦%v%vw.ftesno.net-tvorkofeare.oTp,
Exhibit G
Page 2 of 3
All reported incidents are reviewed by the DBH Intensive Analysis Committee(IAC). If further information
is needed,your analyst will contact you as soon as possible. If a reported incident is determined to be an
Unusual Occurrence(which the Department of Health Care Services defines as.any event which jeopardizes
the health andlor safety of clients, staff, and/or members of the community including but not limited to
physical injury and death),Contracted Providers not Iicensed directly by the state,may elect to submit their
own Unusual Occurrence Report(UOR) in lieu of a DBH Manager or Intensive Analysis Committee
member. UOR's shall be ernailed encrypted to the DHCS designated reporting contact(per DHCS
instructions),your Contract Staff Analyst and DBHlncidentReporting(aco.fresno.ca.us within Irve 5
calendar days of an incident or first knowledge of an incident.
UOR's sent to DHCS may be subject to further investigation and/or information requested by DHCS,such
as: Site Reviews and Plan(s)of Correction.A courtesy copy of correspondence between contracted providers
and DHCS regarding UOR's shall also be sent to your Contract Staff Analyst and
DBIEIIncidentRenortina,co.fresno.ca.us for informational purposes. DBH may also conduct site visits,
request contracted providers attest that an Intensive Analysis or similar(incident review,root cause analysis)
has occurred, and/or may request additional analysis or information when necessary.
If you are not sure if something is considered a reportable incident,need clarification on the reporting
process and/or need a copy of the reporting forcn(s),contact your Contract Staff Analyst for
assistance.
Exhibit G
Page 3 of 3
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 knowledee 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 entertext. 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;] volved,.n lncident(witnesses,.staff):.glick,pl tap her #o,enter.text.:..
Action Taken(check all that ao,&
❑Consulted with Physician ❑.'Coifed 911'EMS;`%"fl First Ail}'CPR dmiAisfered C7,Law En#arce
1 A,. ;' merit Contacted
El Client removed from6uifding C Patren't/Legal Guardian.Gontacfed = ❑Other(Sp'ei:{y}:Clie;C or tip her'e'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 hereto enter text.
Revised 2212027
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 Iabels are altered only by persons legally authorized to do so.
B. Drugs intended for external use only or food stuffs are stored separately from drugs for
internal use.
C. All drugs are stored at proper temperatures,room temperature drugs at 59-86 degrees F
and refrigerated drugs at 36-46 degrees F.
Exhibit H
Page 2 of 2
D. Drugs are stored in a locked area with access limited to those medical personnel
authorized to prescribe, dispense or administer medication,
E. Drugs are not retained after the expiration date. IM multi-dose vials are dated and
initialed when opened,
F. A drug log is maintained to ensure the provider disposes of expired,contaminated,
deteriorated and abandoned drugs in a manner consistent with state and federal laws.
G. Policies and procedures are in place for dispensing, administering and storing
medications.
11, For organizational providers that provide day treatment intensive or day rehabilitation,the
provider must have a written description of the day treatment intensive and/or day treatment
rehabilitation program that complies with State Department of 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(3)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 1
Page 1 of 2
Fresno County Mental Health Plan
Grievances
Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance
and appeal process and an expedited appeal process to resolve grievances and
disputes at the earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-
for-service providers give verbal and written information to Medi-Cal beneficiaries
regarding the following:
• How to access specialty mental health services
• How to file a grievance about services
• How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a
grievance form, an appeal form, and Request for Change of Provider Form. All
of these beneficiary materials must be posted in prominent locations where Medi-
cal beneficiaries receive outpatient specialty mental health services, including
the waiting rooms of providers' offices of service.
Please note that all fee-far-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 2 of 2
Informal orovider,aroblem 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 rovider anDeal process--the provider has the right to access the
provider appeal process at any time before, during, or after the provider problem
resolution process has begun,when the complaint concerns a denied or modified
request for MHP payment authorization, or the process or payment of a
provider's claim to the MHP.
Payment authorization issues—the provider may appeal a denied or modified
request for payment authorization or a dispute with the MHP regarding the
processing or payment of a provider's claim to the MHP. The written appeal
must be submitted to the MHP within 90 calendar days of the date of the receipt
of the non-approval of payment,
The MHP shall have 60 calendar days from its receipt of the appeal to inform the
provider in writing of the decision, including a statement of the reasons for the
decision that addresses each issue raised by the provider, and any action
required by the provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request,
the MHP utilizes a Managed Care staff who was not involved in the initial denial
or modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be
asked to submit a revised request for payment within 30 calendar days of receipt
of the decision
Other complaints— if there are other issues or complaints, which are not related
to payment authorization issues, providers are encouraged to send a letter of
complaint to the MHP. The provider will receive a written response from the
MHP within 60 calendar days of receipt of the complaint. The decision rendered
buy the MHP is final.
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Exhibit �
National Standards for Culturally and Linguistically Page 1of2 �
Appropriate Services (CU AS) in
Health and Health Care (
|
MeAativxal[Z/S Standards are Intended to advance health e4mYby,Improve 4msI14|and help e0hnta&e health care �
oXspaxidesby establishing ablueprint for health and health care mrganbnDonsto:
�
Principal Standard: i
1. Provide effective,equitable, understandable,and respectful quality care and services that are responsive bsdiverse �
co/tma|haa/thbdiefsandpnodjces preferred languages,health literacy,and other onmmun>o*donneeds.
Governance,Leadership,and Workforce:
2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy,
practices,and allocated resources.
3. Recruit,promote,and support a culturally and linguistically diverse governance, leadership,and workforce thatare
responsive ho the population |n the service area.
4. Educate and train governance,leadership,and workforce In culturally and linguistically appropriate policies and
practices unan ongoing basis.
Communication and Language Assistance:
5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs,at
no cost hn them,tu facilitate timely access Uo all health care and services,
6. Inform all Individuals of the availability of language assistance services dearly and in their preferred language,
verbally and Inwriting.
7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals
and/or minors as Interpreters should beavoided,
8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the
populations in the service area.
Engagement,Continuous Improvement,and Accountability;
9. EotabUshodhuraUyand||nguisbcaUyappnopdategna|o/pdkje\nndmanagomemtaocountabi|ihy, and|ofusadhem
throughout the organizaUont planning and operations.
10. Conduct ongoing assessments of the organization's CLAS-related activities and integrate CLAS-related measures Into
measurement and continuous quality Improvement adUvibes.
11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health
equity and outcomes and tn inform service delivery.
12. Conduct regular assessments of community health assets and needs and use the results to plan and implement
services that respond to the cultural and linguistic diversity of populations In the service area,
13, Partner with the community to design, Implement,and evaluate policies, practices,and services to ensure cultural
and linguistic appropriateness.
14. Create conflict and grievance resoludon processes that are culturally and linguistically appropriate to identify,prevent,
and resolve conflicts nrcomplaints.
15. Communicate the organization's progress In implementing and sustaining CLAS to all stakeholders, constituents, and
the general public.
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Exhibit J
The Case for the Enhanced National CLAS Standards Page 2 of 2
Of all the forms of inequality,injustice in health care is the most shocking and inhumane.
--Dr. Martln Luther King,Jr.
Health equity is the attainment of the highest level of health for all people (U.S. Department of Health and Human
Services [HHS] Office of Minority Health, 2011). Currently, individuals across the United States from various cultural
backgrounds are unable to attain their highest level of health for several reasons, including the social determinants of
health, or those conditions in which individuals are born, grow, live, work, and age (World Health Organization, 2012),
such as socioeconomic status, education level, and the availability of health services (HHS Office of Disease Prevention
and Health Promotion, 2010). Though health inequities are directly related to the existence of historical and current
discrimination and social injustice,one of the most modifiable factors Is the lack of culturally and linguistically appropriate
services, broadly defined as care and services that are respectful of and responsive to the cultural and linguistic needs of
all individuals.
Health inequities result in disparities that directly affect the quality of life for all individuals. Health disparities adversely
affect neighborhoods, communities, and the broader society, thus making the issue not only an individual concern but
also a public health concern. In the United States, it has been estimated that the combined cost of health disparities and
subsequent deaths due to inadequate and/or inequitable care is $1.24 trillion (LaVeist, Gaskin, & Richard, 2009).
Culturally and linguistically appropriate services are increasingly recognized as effective in improving the quality of care
and services(Beach et al., 2004; Goode,Dunne;&Bronheim,2006). By providing a structure to implement culturally and
linguistically appropriate services,the enhanced National CLAS Standards will Improve an organization's ability to address
health care disparities.
The enhanced National CLAS Standards align with the HHS Action Plan to Reduce Racial and Ethnic Health Disparities
(HHS, 2011) and the National Stakeholder Strategy for Achieving Health Equity (HHS National Partnership for Action to
End Health Disparities, 2011), which aim to promote health equity through providing clear plans and strategies to guide
collaborative efforts that address racial and ethnic health disparities across the country. Similar to these initiatives, the
enhanced National CLAS Standards are intended to advance health equity,Improve quality,and help eliminate health care
disparities by providing a blueprint for individuals and health and health care organizations to Implement culturally and
linguistically appropriate services. Adoption of these Standards will help advance better health and health care in the
United States.
Bibliography:
Beach,M.C.,Cooper,L.A.,Robinson,K.A.,Price,E.G.,Gary,T.L.,Jenckes,M.W.,Powe,N.R.(2004).Strategies for improving minority healthcare quality.(AHRQ
Publication No.04-E008-02).Retrieved from the Agency of Healthcare Research and Quality website:
http://www.ahrq.gov/downfoads/pub/evidence/pdf/minqual/minquaLpdf
Goode,T.D.,Dunne,M.C.,&Bronheim,S.M.(2006).The evidence base for cultural and linguistic competency in health care.(Commonwealth Fund Publication No.962).
Retrieved from The commonwealth Fund website:http://www.commonwealthfund.org/usr doc/Goode_evidencebaseculdingulst[ccomp 962.pdf
LaVeist,T.A.,Gaskin,D.I.,&Richard,P.(2009).The economic burden of health inequalities in the United States.Retrieved from the)oint Center for Political and Economic
Studies website:http://www.jointcenter.orgisites/default/files/upload/research/fiks[The%2OEconomlc%2
OBurden%20of%20Health%20Inequalides°h20in%20the°/u20United%20States.pdf
National Partnership for Action to End Health Disparities.(2011).National stakeholder strategy for achieving health equity.Retrieved from U,S.Department of Health and
Human services,office of Minority Health website:http://www.minorityhealth,hhs.goy/npa/tempiates/content.aspx?M=1&Mid-33&ID=286
U.S.Department of Health and Human Services.(2011).HHS action plan to reduce racial and ethnic health disparities:A nation free of disparities in health and health care.
Retrieved from http://minodtyhealth.hhs.gov/npa/fles/PlansiHHS/IiHS Plan compiete.pdf
U.S.Department of Health and Human Services,office of Disease Prevention and Health Promotion.(2010).Healthy people 2020:Social determinants of health.Retrieved
from http://www.healthypeople.gov/2020/tnpicsobjecHves2020/0vemew.aspx?topicid=39
U.S.Department of Health and Human Services,Office of Minority Health(2011).National Partnership for Action to End Health Disparities.Retrieved from
http://minofthealth,hbs.gov/npa
World Health Organization.(2012).Social determinants of health.Retrieved from http://www.who.int/soc!aLdeterminants/en/
THINK
�p www.ThinkCulturalHealth.hhs.gov CULTURAL
IViH «o _ HEALTH
Exhibit K
Page 1 of 2
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of entity Dl81A
t is f
Address(number.street) aty Stole Z0 coda
1 qoa a �vcshd c �3-�z
CUA er VayerIDnumber(@7N) Telephone number
a- ITO
2 j -7 cl 57D (55q ) x.5 t-u 00
il. Answer the following questions by checking "Yes"or"No." if any of the questions are answered "Yes,"list names and
addresses of individuals or corporations under"Remarks"on page 2. Identify each item number to be continued.
YES NO
A. Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percent or more In the institution, organizations,or agency that have been convicted of a criminal
offense related to the involvement of such persons or organizations in any of the programs established
byTitles XVIII,XIX,or XX?.........................................................................................................................
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
C. Are there any individuals currently employed by the institution, agency,or organization in a managerial,
accounting, auditing, or similar capacity who were employed by the institution's, organization's, or
agency's fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only)...........
ill. 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 M Corporation
d 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...........................................................................................................
NAME ADDRESS PROVIDER NUMBER
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1
Exhibit
Page 2Of2
YES NO
|\( A. Has there been o change In ownership or control within the last year?........................... ...................— 0
If yes,give date.
.
B. Du you anticipate any change of ownership or control within the ...................................................... M/ |
If yes,when? �
C. Do you anticipate filing for bankruptcy within the year?.--...—.---.—...'~----_—................. o �
If yes,when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... o M/
If yes,give date of change inoperations.
V|. Has there been a change in Administrator, Director of Nursing,or Medical Director within the last year?...... o el
/,
o uo
V1i A� |o this�cUhyoh�na�|�bad? --.-----..-------.------------.--------^—'—
(if yes, list name,address of corporation,and EIN.)
Name EIN
City State ZIP Code
Address(number,name)
B. If the answer ho question VU.A.is NO,was the facility ever affi|iatedwith echain?
(If yes,list name, address of corporation,and EIN.)
'
Exhibit �
Page 1of2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS-PRIMARY COVERED TRANSACTIONS
INSTRUGTIONS FOR CERTIFICATION
1. By signing and submitting this proposal,the prospective primary participant im
providing the certification set out below.
2. The inability ofa person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction.The prospective
participant shall submit mn explanation of why\t cannot provide the certification set out
below. The certification or explanation will be considered \n 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 iae 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 ordefault.
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 o copy ofthose regulations.
8. 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 L
Page 2 of 2
CERTIFICATION
(1)The prospective primary participant certifies to the best of its knowledge and belief,
that it, its owners, officers, corporate managers and partners:
(a) Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of
or had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local)transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery,falsification or destruction of records, making false statements, or receiving
stolen property;
(c) 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: — —
`5�lq A n r• U 19 �, lcsf C�+. CahfOVs'Ii'g
(Prin ed Name&TI e (Name of Agency or Company)
Exhibit M
Page 9 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 white 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 materiai 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 an applicable
provisions of the Corporations Code.
(S) Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections(3)and (4).
Exhibit M
Page 2 of 2
:,(-T}rEir�papy B:gard Membel Etiformation s
Name: Date:
Job Title:
3£DI$closure Please d`escrlbe;theai hire of the self dealingXtral�s�etion;yoU are�party+tci},
„�4)Explai3.
n yrjr thise[f dea}ing trar�saction�ls conslst�nt,w3th the reguirements,9f Corporatiot�srCode 523 (a}
.{5}Mitt.jzWlAinati
Signature: Date: