HomeMy WebLinkAboutAgreement A-23-359 with FCHMC.pdf Agreement No. 23-359
1 SERVICE AGREEMENT
2 This Service Agreement ("Agreement") is dated July 18, 2023 and is between
3 Fresno Community Hospital and Medical Center d.b.a. Community Behavioral Health Center
4 (CBHC), California nonprofit corporation ("Contractor"), and the County of Fresno, a political
5 subdivision of the State of California ("County").
6 Recitals
7 A. Through an agreement with the California Department of Health Care Services (DHCS),
8 the Fresno County Department of Behavioral Health (DBH) operates a Managed Care Mental
9 Health Plan (MHP). This MHP oversees the provision of mandated mental health services to
10 Medi-Cal beneficiaries, the medically indigent and uninsured persons served of all ages.
11 Pursuant to California Welfare and Institutions Code (W&IC) 14712, the County must ensure the
12 availability of accessibility of an adequate number of beds at inpatient facilities to provide
13 medically necessary acute inpatient psychiatric services. The County is also mandated by W&IC
14 5600 to provide mental health crisis and psychiatric inpatient services to indigent and uninsured
15 persons served. As DBH's contracted Psychiatric Health Facility (PHF) is frequently full, space
16 for adult persons served with acute psychiatric needs is needed so that services to this
17 population are not delayed.
18 B. On June 4, 2019, the Board of Supervisors executed agreement No. 19-235 with
19 Community Behavioral Health Center via a Suspension of Competition to provide acute
20 inpatient psychiatric services on an overflow basis. This agreement was a three-year term
21 retroactive to July 1, 2018, ending June 30, 2021, and eligible for two optional one-year
22 extensions, concluding June 30, 2023.
23 C. The County, on behalf of the DBH, requires qualified vendors to provide inpatient
24 psychiatric health services to persons served on an overflow basis. There are only three local
25 certified and State licensed facilities within a 100-mile radius and two of those facilities are
26 willing to accept the County's medically indigent, Medi-Cal beneficiaries and recipient referrals
27 on an overflow basis. The other hospital, Kaweah Delta Mental Health Hospital, has an existing
28 contract for these services with the County.
1
1 The parties therefore agree as follows:
2 Article 1
3 Contractor's Services
4 1.1 Scope of Services. The Contractor shall perform all of the services provided in
5 Exhibit A to this Agreement, titled "Scope of Services."
6 1.2 Representation. The Contractor represents that it is qualified, ready, willing, and
7 able to perform all of the services provided in this Agreement.
8 1.3 Compliance with Laws. The Contractor shall, at its own cost, comply with all
9 applicable federal, state, and local laws and regulations in the performance of its obligations
10 under this Agreement, including but not limited to workers compensation, labor, and
11 confidentiality laws and regulations.
12 Contractor shall provide services in conformance with all applicable State and Federal
13 statutes, regulations and subregulatory guidance, as from time to time amended, including but
14 not limited to:
15 (A) California Code of Regulations, Title 9;
16 (B) California Code of Regulations, Title 22;
17 (C) California Welfare and Institutions Code, Division 5;
18 (D) United States Code of Federal Regulations, Title 42, including but not limited to
19 Parts 438 and 455;
20 (E) United States Code of Federal Regulations, Title 45;
21 (F) United States Code, Title 42 (The Public Health and Welfare), as applicable;
22 (G)Balanced Budget Act of 1997;
23 (H) Health Insurance Portability and Accountability Act (HIPAA); and
24 (1) Applicable Medi-Cal laws and regulations, including applicable sub-regulatory
25 guidance, such as Behavioral Health Information Notices (BHINs), Mental Health and
26 Substance Use Disorder Services Information Notices (MHSUDS INs), and provisions of
27 County's, state or federal contracts governing services for persons served.
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2
1 In the event any law, regulation, or guidance referred to in this section 1.3 is amended
2 during the term of this Agreement, the parties agree to comply with the amended authority as of
3 the effective date of such amendment without amending this Agreement.
4 Contractor recognizes that County operates its mental health programs under an
5 agreement with DHCS, and that under said agreement the State imposes certain requirements
6 on County and its subcontractors. Contractor shall adhere to all State requirements, including
7 those identified in Exhibit B, "Behavioral Health Requirements."
8 1.4 Meetings. Contractor shall participate in monthly, or as needed, workgroup meetings
9 consisting of staff from County's DBH to discuss service requirements, data reporting, training,
10 policies and procedures, overall program operations and any problems or foreseeable problems
11 that may arise. Contractor shall also participate in other County meetings, such as but not
12 limited to quality improvement meetings, provider meetings, Behavioral Health Board meetings,
13 bi-monthly contractor meetings, etc. Schedule for these meetings may change based on the
14 needs of the County.
15 1.5 Organizational Provider. Contractor shall maintain requirements as a Mental Health
16 Plan (MHP) organizational provider throughout the term of this Agreement, as described in
17 Article 16 of this Agreement. If for any reason, this status is not maintained, County may
18 terminate this Agreement pursuant to Article 7 of this Agreement.
19 1.6 Staffing. Contractor agrees that prior to providing services under the terms and
20 conditions of this Agreement, Contractor shall have staff hired and in place for program services
21 and operations or County may, in addition to other remedies it may have, suspend referrals or
22 terminate this Agreement, in accordance with Article 7 of this Agreement.
23 1.7 Credentialing and Recredentialing. Contractor and their respective staff must
24 follow the uniform process for credentialing and recredentialing of service providers established
25 by County, including disciplinary actions such as reducing, suspending, or terminating provider's
26 privileges. Failure to comply with specified requirements can result in suspension or termination
27 of an individual or provider.
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3
1 Upon request, the Contractor must demonstrate to the County that each of its providers
2 are qualified in accordance with current legal, professional, and technical standards, and that
3 they are appropriately licensed, registered, waivered, and/or certified.
4 Contractor must not employ or subcontract with providers debarred, suspended or
5 otherwise excluded (individually, and collectively referred to as "Excluded") from participation in
6 Federal Health Care Programs, including Medi-Cal/Medicaid or procurement activities, as set
7 forth in 42 C.F.R. §438.610. See Article 12 below.
8 Contractor is required to verify and document at a minimum every three years that each
9 network provider that delivers covered services continues to possess valid credentials, including
10 verification of each of the credentialing requirements as per the County's uniform process for
11 credentialing and recredentialing. If any of the requirements are not up-to-date, updated
12 information should be obtained from network providers to complete the re-credentialing process.
13 1.8 Criminal Background Check. Contractor shall ensure that all providers and/or
14 subcontracted providers consent to a criminal background check, including fingerprinting to the
15 extent required under state law and 42 C.F.R. § 455.434(a). Contractor shall provide evidence
16 of completed consents when requested by the County, DHCS or the US Department of Health &
17 Human Services (US DHHS).
18 1.9 Guiding Principles. Contractor shall align programs, services, and practices with
19 the vision, mission, and guiding principles of DBH, as further described in Exhibit C, "Fresno
20 County Department of Behavioral Health Guiding Principles of Care Delivery.
21 1.10 Clinical Leadership. Contractor shall send to County upon execution of this
22 Agreement, a detailed plan ensuring clinically appropriate leadership and supervision of their
23 clinical program. Recruitment and retaining clinical leadership with the clinical competencies to
24 oversee services based on the level of care and program design presented herein shall be
25 included in this plan. A description and monitoring of this plan shall be provided.
26 1.11 Timely Access. It is the expectation of the County that Contractor provide timely
27 access to services that meet the State of California standards for care. Contractor shall track
28 timeliness of services to persons served and provide a monthly report showing the monitoring or
4
1 tracking tool that captures this data. County and Contractor shall meet to go over this monitoring
2 tool, as needed but at least on a monthly basis. County shall take corrective action if there is a
3 failure to comply by Contractor with timely access standards. Contractor shall also provide
4 tracking tools and measurements for effectiveness, efficiency, and persons served satisfaction
5 as further detailed in Exhibit A.
6 1.12 Electronic Health Record. Contractor may maintain its records in County's
7 electronic health record (EHR) system in accordance with Exhibit D, "Documentation Standards
8 for Persons Served Records", as licenses become available. The person served record shall
9 begin with registration and intake, and include person served authorizations, assessments,
10 plans of care, and progress notes, as well as other documents as approved by County. County
11 shall be allowed to review records of all and any services provided. If Contractor determines to
12 maintain its records in the County's EHR, it shall provide County's DBH Director, or his or her
13 designee, with a thirty (30) day notice. If at any time Contractor chooses not to maintain its
14 records in the County's EHR, it shall provide County's DBH Director, or designee, with thirty (30)
15 days advance written notice and Contractor will be responsible for obtaining its own system, at
16 its own cost, for electronic health records management.
17 Disclaimer
18 County makes no warranty or representation that information entered into the County's
19 DBH EHR system by Contractor will be accurate, adequate, or satisfactory for Contractor's own
20 purposes or that any information in Contractor's possession or control, or transmitted or
21 received by Contractor, is or will be secure from unauthorized access, viewing, use, disclosure,
22 or breach. Contractor is solely responsible for person served information entered by Contractor
23 into the County's DBH EHR system. Contractor agrees that all Private Health Information (PHI)
24 maintained by Contractor in County's DBH EHR system will be maintained in conformance with
25 all HIPAA laws, as stated in section 17.1, "Health Insurance Portability and Accountability Act."
26 1.13 Records. Contractor shall maintain records in accordance with Exhibit D,
27 "Documentation Standards for Client Records". All persons served's records shall be
28 maintained for a minimum of 10 years from the date of the end of this Agreement.
5
1 1.14 Access to Records. Contractor shall provide County with access to all
2 documentation of services provided under this Agreement for County's use in administering this
3 Agreement. Contractor shall allow County, CMS, the Office of the Inspector General, the
4 Controller General of the United States, and any other authorized Federal and State agencies to
5 evaluate performance under this Agreement, and to inspect, evaluate, and audit any and all
6 records, documents, and the premises, equipment and facilities maintained by the Contractor
7 pertaining to such services at any time and as otherwise required under this Agreement.
8 1.15 Quality Improvement Activities and Participation. Contractor shall comply with
9 the County's ongoing comprehensive Quality Assessment and Performance Improvement
10 (QAPI) Program (42 C.F.R. § 438.330(a)) and work with the County to improve established
11 outcomes by following structural and operational processes and activities that are consistent
12 with current practice standards.
13 Contractor shall participate in quality improvement (QI) activities, including clinical and
14 non-clinical performance improvement projects (PIPs), as requested by the County in relation to
15 State and Federal requirements and responsibilities, to improve health outcomes and
16 individuals' satisfaction over time. Other QI activities include quality assurance, collection and
17 submission of performance measures specified by the County, mechanisms to detect both
18 underutilization and overutilization of services, individual and system outcomes, utilization
19 management, utilization review, provider appeals, provider credentialing and re-credentialing,
20 and person served grievances. Contractor shall measure, monitor, and annually report to the
21 County its performance.
22 1.16 Rights of Persons Served. Contractor shall comply with applicable laws and
23 regulations relating to patients' rights, including but not limited to Wel. & Inst. Code 5325, Cal.
24 Code Regs., tit. 9, sections 862 through 868, and 42 C. F. R. § 438.100. The Contractor shall
25 ensure that its subcontractors comply with all applicable patients' rights laws and regulations.
26 Article 2
27 Reporting
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6
1 2.1 Reports. The Contractor shall furnish to County such statements, records, reports,
2 data, and other information as County may request pertaining to matters covered by this
3 Agreement. In the event that Contractor fails to provide such reports or other information
4 required hereunder, it shall be deemed sufficient cause for County to withhold monthly
5 payments until there is compliance. In addition, Contractor shall provide written notification and
6 explanation to County within five (5) days of any funds received from another source to conduct
7 the same services covered by this Agreement.
8 2.2 Monitoring. Contractor agrees to extend to County's staff, County's DBH and the
9 DHCS, or their designees, the right to review and monitor records, programs, or procedures, at
10 any time, in regard to persons served, as well as the overall operation of Contractor's programs,
11 in order to ensure compliance with the terms and conditions of this Agreement.
12 Article 3
13 County's Responsibilities
14 3.1 The County shall provide oversight and collaborate with Contractor, other County
15 Departments and community agencies to help achieve program goals and outcomes. In addition
16 to contractor monitoring of program, oversight includes, but not limited to, coordination with
17 Department of Health Care Services (DHCS) in regard to program administration and outcomes.
18 County shall receive and analyze statistical outcome data from Contractor throughout
19 the term of contract, on a monthly basis. County shall notify the Contractor when additional
20 participation is required. The performance outcome measurement process will not be limited to
21 survey instruments but will also include, as appropriate, persons served and staff surveys, chart
22 reviews, and other methods of obtaining required information.
23 Article 4
24 Compensation, Invoices, and Payments
25 4.1 The County agrees to pay, and the Contractor agrees to receive, compensation for
26 the performance of its services under this Agreement as described in Exhibit F to this
27 Agreement, titled "Compensation."
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7
1 4.2 Maximum Compensation. The maximum compensation payable to the Contractor
2 under this Agreement for the period of July 1, 2023 through June 30, 2024 is Four Million Five
3 Hundred Fifty Thousand and No/100 Dollars ($4,550,000.00), which is not a guaranteed sum
4 but shall be paid only for services rendered and received. The maximum compensation payable
5 to the Contractor under this Agreement for the period of July 1, 2024 through June 30, 2025 is
6 Four Million Five Hundred Fifty Thousand and No/100 Dollars ($4,550,000.00),which is not a
7 guaranteed sum but shall be paid only for services rendered and received. The maximum
8 compensation payable to the Contractor under this Agreement for the period of July 1, 2025
9 through June 30, 2026 is Four Million Five Hundred Fifty Thousand and No/100 Dollars
10 ($4,550,000.00),which is not a guaranteed sum but shall be paid only for services rendered and
11 received. The maximum compensation payable to the Contractor under this Agreement for the
12 period of July 1, 2026 through June 30, 2027 is Four Million Five Hundred Fifty Thousand and
13 No/100 Dollars ($4,550,000.00), which is not a guaranteed sum but shall be paid only for
14 services rendered and received. The maximum compensation payable to the Contractor under
15 this Agreement for the period of July 1, 2027 through June 30, 2028 is Four Million Five
16 Hundred Fifty Thousand and No/100 Dollars ($4,550,000.00), which is not a guaranteed sum
17 but shall be paid only for services rendered and received.
18 4.3 Total Maximum Compensation. In no event shall the maximum contract amount for
19 all the services provided by the Contractor to County under the terms and conditions of this
20 Agreement be in excess of Twenty-Two Million Seven Hundred Fifty Thousand and No/100
21 Dollars ($22,750,00.00) during the entire term of this Agreement.
22 The Contractor acknowledges that the County is a local government entity and does so
23 with notice that the County's powers are limited by the California Constitution and by State law,
24 and with notice that the Contractor may receive compensation under this Agreement only for
25 services performed according to the terms of this Agreement and while this Agreement is in
26 effect, and subject to the maximum amount payable under this section. The Contractor further
27 acknowledges that County employees have no authority to pay the Contractor except as
28 expressly provided in this Agreement.
8
1 4.4 Claiming. Contractor shall enter claims data into the County's billing and
2 transactional database system by the fifteenth (1511) of every month for actual services rendered
3 in the previous month. Contractor shall use Current Procedural Terminology (CPT) or
4 Healthcare Common Procedure Coding System (HCPCS) codes, as provided in the DHCS
5 Billing Manual available at https://www.dhcs.ca.gov/services/MH/Pages/MedCCC-LibrarV.aspx,
6 as from time to time amended.
7 Claims shall be complete and accurate and must include all required information
8 regarding the claimed services. Claims data entry into the County's electronic health record
9 system shall be the responsibility of Contractor. County shall monitor the volume of services,
10 billing amounts and service types entered into County's electronic health record/information
11 system. Any and all audit exceptions resulting from the provision and reporting of specialty
12 mental health services by Contractor shall be the sole responsibility of Contractor. Contractor
13 will comply with all applicable policies, procedures, directives, and guidelines regarding the use
14 of County's electronic health record/information system.
15 Contractor must provide all necessary data to allow County to bill Medi-Cal, and any
16 other third-party source, for services and meet State and Federal reporting requirements. The
17 necessary data can be provided by a variety of means, including but not limited to: 1) direct data
18 entry into County's electronic health record/information system; 2) providing an electronic file
19 compatible with County's electronic health record/information system; or 3) integration between
20 County's electronic health record/information system and Contractor's information system(s).
21 Contractor shall maximize the Federal Financial Participation (FFP) reimbursement by claiming
22 all possible Medi-Cal services and correcting denied services for resubmission as needed.
23 4.5 Applicable Fees. Contractor shall not charge any persons served or third-party
24 payers any fee for service unless directed to do so by the County's DBH Director or designee at
25 the time the individual is referred for services. When directed to charge for services, Contractor
26 shall use the uniform billing and collection guidelines prescribed by DHCS.
27
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9
1 Contractor will perform eligibility and financial determinations, in accordance with DHCS'
2 Uniform Method of Determining Ability to Pay (UMDAP), for all individuals unless directed
3 otherwise by the County's DBH Director or designee.
4 Contractor shall not submit a claim to, or demand or otherwise collect reimbursement
5 from, the person served or persons acting on behalf of the person served for any specialty
6 mental health or related administrative services provided under this Contract, except to collect
7 other health insurance coverage, share of cost, and co-payments (Cal. Code Regs., tit. 9,
8 §1810.365(c)).
9 The Contractor must not bill persons served, for covered services, any amount greater
10 than would be owed if the County provided the services directly as per and otherwise not bill
11 persons served as set forth in 42 C.F.R. § 438.106.
12 If a person served has dual coverage, such as other health coverage (OHC) or Federal
13 Medicare, Contractor will be responsible for billing the carrier and obtaining a payment/denial or
14 have validation of claiming with no response for ninety (90) days after the claim was mailed
15 before the service can be entered into the County's electronic health record/information system.
16 Contractor must report all third-party collections for Medicare, third-party or client-pay or private-
17 pay in each month. A copy of explanation of benefits or CMS 1500 form is required as
18 documentation. 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, 42
20 U.S.C. section 1395 et seq; and 2) the regulation and rules promulgated by the Federal Centers
21 for Medicare and Medicaid Services as they relate to participation, coverage and claiming
22 reimbursement. Contractor will be responsible for compliance as of the effective date of each
23 Federal, State or local law or regulation specified.
24 4.6 Invoices. The Contractor shall submit monthly invoices, in arrears by the fifteenth
25 (15th) day of each month, in the format directed by the County. The Contractor shall submit
26 invoices electronically to: 1) dbhinvoicereview@fresnocountyca.gov, 2) dbh-
27 invoices@fresnocountyca.gov; and 3) dbhcontractedservicesdivision@fresnocountyca.gov with
28 a copy to the assigned County's DBH Staff Analyst..
10
1 At the discretion of County's DBH Director or designee, if an invoice is incorrect or is
2 otherwise not in proper form or substance, County's DBH Director, or designee, shall have the
3 right to withhold payment as to only the portion of the invoice that is incorrect or improper after
4 five (5) days prior notice to Contractor. Contractor agrees to continue to provide services for a
5 period of ninety (90) days after notification of an incorrect or improper invoice. If after the ninety
6 (90) day period, the invoice is still not corrected to County satisfaction, County's DBH Director,
7 or designee, may elect to terminate this Agreement, pursuant to the termination provisions
8 stated in Article 7 of this Agreement.
9 4.7 Specialty Mental Health Services Claimable Services. For claimable services,
10 invoices shall be based on claims entered into the County's billing and transactional database
11 system for the prior month.
12 Monthly payments for claimed services shall only be based on the units of time assigned
13 to each CPT or HCPCS code entered in the County's billing and transactional database
14 multiplied by the practitioner service rates in Exhibit F.
15 County's payments to Contractor for performance of claimed services are provisional
16 and subject to adjustment until the completion of all settlement activities. County's adjustments
17 to provisional payments for claimed services shall be based on the terms, conditions, and
18 limitations of this Agreement or the reasons for recoupment set forth in Article 4 and 13.
19 Any claimable services submitted beyond six (6) months from the month of service may
20 be ineligible for payment.
21 4.8 Corrective Action Plans. Contractors shall enter services into the County's billing
22 and transactional database and submit invoices in accordance with the deadlines listed above
23 and information shall be accurate. Failure to meet the requirements set forth above will result in
24 a corrective action plan at the discretion of the County's DBH Director, or designee, and may
25 result in financial penalties or termination of agreement per Article 7.
26 4.9 Payments. Payments shall be made by County to Contractor in arrears, for services
27 provided during the preceding month, within forty-five (45) days after the date of receipt,
28 verification, and approval by County. All final invoices and/or any final budget modification
11
1 requests shall be submitted by Contractor within sixty (60) days following the final month of
2 service for which payment is claimed. No action shall be taken by County on claims submitted
3 beyond the sixty (60) day closeout period. Any compensation which is not expended by
4 Contractor pursuant to the terms and conditions of this Agreement shall automatically revert to
5 County.
6 4.10 Recoupments and Audits. County shall recapture from Contractor the value of any
7 services or other expenditures determined to be ineligible based on the County or State
8 monitoring results. The County reserves the right to enter into a repayment agreement with
9 Contractor, with total monthly payments not to exceed twelve (12) months from the date of the
10 repayment agreement, to recover the amount of funds to be recouped. The County has the
11 discretion to extend the repayment plan up to a total of twenty-four (24) months from the date of
12 the repayment agreement. The repayment agreement may be made with the signed written
13 approval of County's DBH Director, or designee, and respective Contractor through a
14 repayment agreement. The monthly repayment amounts may be netted against the Contractor's
15 monthly billing for services rendered during the month, or the County may, in its sole discretion,
16 forego a repayment agreement and recoup all funds immediately. This remedy is not exclusive,
17 and County may seek requital from any other means, including, but not limited to, a separate
18 contract or agreement with Contractor.
19 Contractor shall be held financially liable for any and all future disallowances/audit
20 exceptions due to Contractor's deficiency discovered through the State audit process and
21 County utilization review for services provided during the course of this Agreement. At County's
22 election, the disallowed amount will be remitted within forty-five (45) days to County upon
23 notification or shall be withheld from subsequent payments to Contractor. Contractor shall not
24 receive reimbursement for any units of services rendered that are disallowed or denied by the
25 Fresno County Mental Health Plan (Mental Health Plan) utilization review process or through
26 the State of California DHCS audit and review process, cost report audit settlement if applicable,
27 for Medi-Cal eligible beneficiaries.
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1 4.11 Incidental Expenses. The Contractor is solely responsible for all of its costs and
2 expenses that are not specified as payable by the County under this Agreement. If Contractor
3 fails to comply with any provision of this Agreement, County shall be relieved of its obligation for
4 further compensation.
5 4.12 Restrictions and Limitations. This Agreement shall be subject to any restrictions,
6 limitations, and/or conditions imposed by County or state or federal funding sources that may in
7 any way affect the fiscal provisions of, or funding for this Agreement. This Agreement is also
8 contingent upon sufficient funds being made available by County, state, or federal funding
9 sources for the term of the Agreement. If the federal or state governments reduce financial
10 participation in the Medi-Cal program, County agrees to meet with Contractor to discuss
11 renegotiating the services required by this Agreement.
12 Funding is provided by fiscal year. Any unspent fiscal year appropriation does not roll
13 over and is not available for services provided in subsequent years.
14 In the event that funding for these services is delayed by the State Controller, County
15 may defer payments to Contractor. The amount of the deferred payment shall not exceed the
16 amount of funding delayed by the State Controller to the County. The period of time of the
17 deferral by County shall not exceed the period of time of the State Controller's delay of payment
18 to County plus forty-five (45) days.
19 4.13 Additional Financial Requirements. County has the right to monitor the
20 performance of this Agreement to ensure the accuracy of claims for reimbursement and
21 compliance with all applicable laws and regulations.
22 Contractor must comply with the False Claims Act employee training and policy
23 requirements set forth in 42 U.S.C. 1396a(a)(68) and as the Secretary of the United States
24 Department of Health and Human Services may specify.
25 Contractor agrees that no part of any federal funds provided under this Agreement shall
26 be used to pay the salary of an individual per fiscal year at a rate in excess of Level 1 of the
27 Executive Schedule at https://www.opm.gov/ (U.S. Office of Personnel Management), as from
28 time to time amended.
13
1 Federal Financial Participation is not available for any amount furnished to an Excluded
2 individual or entity, or at the direction of a physician during the period of exclusion when the
3 person providing the service knew or had reason to know of the exclusion, or to an individual or
4 entity when the County failed to suspend payments during an investigation of a credible
5 allegation of fraud [42 U.S.C. section 1396b(i)(2)].
6 Contractor must maintain financial records for a minimum period of ten (10) years or until
7 any dispute, audit or inspection is resolved, whichever is later. Contractor will be responsible for
8 any disallowances related to inadequate documentation.
9 4.14 Contractor Prohibited from Redirection of Contracted Funds. Contractor may
10 not redirect or transfer funds from one funded program to another funded program under which
11 Contractor provides services pursuant to this Agreement except through a duly executed
12 amendment to this Agreement.
13 Contractor may not charge services delivered to an eligible person served under one
14 funded program to another funded program unless the person served is also eligible for services
15 under the second funded program.
16 4.15 Financial Audit Report Requirements for Pass-Through Entities. If County
17 determines that Contractor is a "subrecipient" (also known as a "pass-through entity") as defined
18 in 2 C.F.R. § 200 et seq., Contractor represents that it will comply with the applicable cost
19 principles and administrative requirements including claims for payment or reimbursement by
20 County as set forth in 2 C.F.R. § 200 et seq., as may be amended from time to time. Contractor
21 shall observe and comply with all applicable financial audit report requirements and standards.
22 Financial audit reports must contain a separate schedule that identifies all funds included
23 in the audit that are received from or passed through the County. County programs must be
24 identified by Agreement number, Agreement amount, Agreement period, and the amount
25 expended during the fiscal year by funding source.
26 Contractor will provide a financial audit report including all attachments to the report and
27 the management letter and corresponding response within six months of the end of the audit
28
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1 year to the County's DBH Director or designee. The County's Director or designee is
2 responsible for providing the audit report to the County Auditor.
3 Contractor must submit any required corrective action plan to the County simultaneously
4 with the audit report or as soon thereafter as it is available. The County shall monitor
5 implementation of the corrective action plan as it pertains to services provided pursuant to this
6 Agreement.
7 4.16 Physician Services. Non-psychiatric Physician services and medically necessary
8 physical health services provided post admittance of a County Beneficiary or Recipient covered
9 under this Agreement, are not covered under this Agreement and shall not be paid by the
10 County.
11 4.17 Transportation Services. The rate structure in Exhibit F is for Hospital Services and
12 shall not include Transportation Services required in providing Psychiatric Inpatient Hospital
13 Services. However, in the event that Transportation Services are Medi-Cal eligible services,
14 they shall be billed separately from the per diem rate for Psychiatric Inpatient Hospital Services
15 to the State's Fiscal Intermediary.
16 4.18 Utilization Controls. As express conditions precedent to any authorization by
17 County for payment obligation under the terms of this Agreement:
18 (A) Contractor shall adhere to all utilization controls and obtain authorization for
19 services in accordance with Sections 14712 and 14718 of the California Welfare and
20 Institutions Code and regulations adopted pursuant thereto; and
21 (B) Contractor shall notify County within ten (10) calendar days of the emergency
22 admission of a Beneficiary or Recipient.
23 4.19 Assumption of Payment Risk. Whether rendered directly or through the
24 instrumentality of a Delegate as permitted under this Agreement, Contractor shall bear total risk
25 for the cost of all Adult Psychiatric Inpatient Hospital Services rendered under this Agreement.
26 As used in this section, "risk" means that Contractor covenants to accept as payment in full for
27 the Adult Psychiatric Inpatient Hospital Services described herein, those payments received
28 pursuant to this article. Such acceptance of the risk shall be made irrespective of whether the
15
1 cost of such services and related administrative expenses shall have exceeded the authorized
2 payment by County as set forth in this Agreement.
3 Article 5
4 Term of Agreement
5 5.1 Term. This Agreement is effective on July 1, 2023 and terminates on June 30, 2026
6 except as provided in section 5.2, "Extension," or Article 7, "Termination and Suspension,"
7 below.
8 5.2 Extension. The term of this Agreement may be extended for no more than two (2)
9 are one-year periods only upon written approval of both parties at least 30 days before the first
10 day of the one-year extension period. The County's DBH Director, or designee, is authorized to
11 sign the written approval on behalf of the County based on the Contractor's satisfactory
12 performance. The extension of this Agreement by the County is not a waiver or compromise of
13 any default or breach of this Agreement by the Contractor existing at the time of the extension
14 whether or not known to the County.
15 Article 6
16 Notices
17 6.1 Contact Information. The persons and their addresses having authority to give and
18 receive notices provided for or permitted under this Agreement include the following:
19
For the County:
20 Director
County of Fresno
21 1925 E. Dakota Avenue
Fresno, CA 93726
22
For the Contractor:
23 Director, Behavioral Health Services
Fresno Community Hospital and Medical Center
24 7171 N. Cedar Avenue
Fresno, CA 93720
25
6.2 Change of Contact Information. Either party may change the information in section
26
6.1 by giving notice as provided in section 6.3.
27
6.3 Method of Delivery. Each notice between the County and the Contractor provided
28
for or permitted under this Agreement must be in writing, state that it is a notice provided under
16
1 this Agreement, and be delivered either by personal service, by first-class United States mail, by
2 an overnight commercial courier service, by telephonic facsimile transmission, or by Portable
3 Document Format (PDF) document attached to an email.
4 (A) A notice delivered by personal service is effective upon service to the recipient.
5 (B) A notice delivered by first-class United States mail is effective three (3) County
6 business days after deposit in the United States mail, postage prepaid, addressed to the
7 recipient.
8 (C)A notice delivered by an overnight commercial courier service is effective one (1)
9 County business day after deposit with the overnight commercial courier service,
10 delivery fees prepaid, with delivery instructions given for next day delivery, addressed to
11 the recipient.
12 6.4 Claims Presentation. For all claims arising from or related to this Agreement,
13 nothing in this Agreement establishes, waives, or modifies any claims presentation
14 requirements or procedures provided by law, including the Government Claims Act (Division 3.6
15 of Title 1 of the Government Code, beginning with section 810).
16 6.5 Notification of Changes. Contractor shall notify County in writing of any change in
17 organizational name, Head of Service or principal business at least fifteen (15) business days in
18 advance of the change. Contractor shall notify County of a change of service location at least
19 six (6) months in advance to allow County sufficient time to comply with site certification
20 requirements. Said notice shall become part of this Agreement upon acknowledgment in writing
21 by the County, and no further amendment of the Agreement shall be necessary provided that
22 such change of address does not conflict with any other provisions of this Agreement.
23 Contractor must immediately notify County of a change in ownership, organizational
24 status, licensure, or ability of Contractor to provide the quantity or quality of the contracted
25 services in a and in no event more than 15 days of the change.
26
27
28
17
1 Article 7
2 Termination and Suspension
3 7.1 Termination for Non-Allocation of Funds. The terms of this Agreement are
4 contingent on the approval of funds by the appropriating government agency. If sufficient funds
5 are not allocated, then the County, upon at least thirty (30) days' advance written notice to the
6 Contractor, may:
7 (A) Modify the services provided by the Contractor under this Agreement; or
8 (B) Terminate this Agreement.
9 7.2 Termination for Breach.
10 (A) Upon determining that a breach (as defined in paragraph (C) below) has
11 occurred, the County may give written notice of the breach to the Contractor. The written
12 notice may suspend performance under this Agreement and must provide at least thirty
13 (30) days for the Contractor to cure the breach.
14 (B) If the Contractor fails to cure the breach to the County's satisfaction within the
15 time stated in the written notice, the County may terminate this Agreement immediately.
16 (C) For purposes of this section, a breach occurs when, in the determination of the
17 County, the Contractor has:
18 (1) Obtained or used funds illegally or improperly;
19 (2) Failed to comply with any part of this Agreement;
20 (3) Submitted a substantially incorrect or incomplete report to the County; or
21 (4) Improperly performed any of its obligations under this Agreement.
22 7.3 Termination without Cause. In circumstances other than those set forth above, the
23 County may terminate this Agreement by giving at least thirty (30) days advance written notice
24 to the Contractor.
25 7.4 No Penalty or Further Obligation. Any termination of this Agreement by the County
26 under this Article 7 is without penalty to or further obligation of the County.
27 7.5 County's Rights upon Termination. Upon termination for breach under this Article
28 7, the County may demand repayment by the Contractor of any monies disbursed to the
18
1 Contractor under this Agreement that, in the County's sole judgment, were not expended in
2 compliance with this Agreement. The Contractor shall promptly refund all such monies upon
3 demand. This section survives the termination of this Agreement.
4 In the event this Agreement is terminated, Contractor shall be entitled to compensation
5 for all Specialty Mental Health Services (SMHS) satisfactorily provided pursuant to the terms
6 and conditions of this Agreement through and including the effective date of termination. This
7 provision shall not limit or reduce any damages owed to the County due to a breach of this
8 Agreement by Contractor.
9 Article 8
10 Informing Materials for Persons Served
11 8.1 Basic Information Requirements. Contractor shall provide information in a manner
12 and format that is easily understood and readily accessible to the persons served (42 C.F.R. §
13 438.10(c)(1)). Contractor shall provide all written materials for persons served in easily
14 understood language, format, and alternative formats that take into consideration the special
15 needs of individuals in compliance with 42 C.F.R. § 438.10(d)(6). Contractor shall inform the
16 persons served that information is available in alternate formats and how to access those
17 formats in compliance with 42 C.F.R. § 438.10.
18 Contractor shall provide the required information in this section to each individual
19 receiving SMHS under this Agreement and upon request (1915(b) Medi-Cal Specialty Mental
20 Health Services Waiver, § (2), subd. (d), at p. 26., attachments 3, 4; Cal. Code Regs., tit. 9, §
21 1810.360(e)).
22 Contractor shall utilize the County's website that provides the content required in this
23 section and 42 C.F.R. § 438.10 and complies with all requirements regarding the same set forth
24 in 42 C.F.R. § 438.10.
25 Contractor shall use the DHCS/County-developed beneficiary handbook and persons
26 served notices.(42 C.F.R. §§ 438.10(c)(4)(ii), 438.62(b)(3)).
27 8.2 Electronic Submission. Persons served information required in this section may
28 only be provided electronically by the Contractor if all of the following conditions are met:
19
1 (A) The format is readily accessible;
2 (B) The information is placed in a location on the Contractor's website that is
3 prominent and readily accessible;
4 (C)The information is provided in an electronic form which can be electronically
5 retained and printed;
6 (D)The information is consistent with the content and language requirements of this
7 Agreement;
8 (E) The individual is informed that the information is available in paper form without
9 charge upon request and the Contractor shall provide it upon request within five (5)
10 business days (42 C.F.R. § 438.10(c)(6)).
11 8.3 Language and Format. Contractor shall provide all written materials, including
12 taglines, for persons served or potential persons served in a font size no smaller than twelve
13 (12) point (42 C.F.R. 438.10(d)(6)(ii)).
14 Contractor shall ensure its written materials that are critical to obtaining services are
15 available in alternative formats, upon request of the person served or potential person served at
16 no cost.
17 Contractor shall make its written materials that are critical to obtaining services,
18 including, at a minimum, provider directories, beneficiary handbook, appeal and grievance
19 notices, denial and termination notices, and the Contractor's mental health education materials,
20 available in the prevalent non-English languages in the County (42 C.F.R. § 438.10(d)(3)).
21 (A) Contractor shall notify persons served, prospective persons served, and
22 members of the public that written translation is available in prevalent languages free of
23 cost and how to access those materials (42 C.F.R. § 438.10(d)(5)(i), (iii); Welfare & Inst.
24 Code § 14727(a)(1); Cal. Code Regs. tit. 9 § 1810.410, subd. (e), para. (4)).
25 Contractor shall make auxiliary aids and services available upon request and free of
26 charge to each person served (42 C.F.R. § 438.10(d)(3)-(4)).
27
28
20
1 Contractor shall make oral interpretation and auxiliary aids, such as Teletypewriter
2 Telephone/Text Telephone (TTY/TDY) and American Sign Language (ASL), available and free
3 of charge for any language in compliance with 42 C.F.R. § 438.10(d)(2), (4)-(5).
4 Taglines for written materials critical to obtaining services must be printed in a conspicuously
5 visible font size, no smaller than twelve (12) point font.
6 8.4 Beneficiary Informing Materials. Each person served must receive and have
7 access to the beneficiary informing materials upon request by the individual and when first
8 receiving SMHS from Contractor. Beneficiary informing materials include but are not limited to:
9 (A) Consumer Handbook
10 (B) Provider Directory
11 (C) Grievance form
12 (D)Appeal/Expedited Appeal form
13 (E) Advance Directives brochure
14 (F) Change of Provider form
15 (G)Suggestions brochure
16 (H) Notice of Privacy Practices
17 (1) Notices of Adverse Benefit Determination (NOABDs — Including Denial and
18 Termination notices)
19 (J) Early & Periodic Screening, Diagnostic and Treatment (EPSDT) poster (if serving
20 individuals under the age of 21)
21 (K) Contractor shall ensure beneficiary informing material are displayed in the
22 threshold languages of Fresno County at all service sites, including but not limited to the
23 following:
24 (1) Consumer Handbook
25 (2) Provider Directory
26 (3) Grievance form
27 (4) Appeal/Expedited Appeal form
28 (5) Advance Directives brochure
21
1 (6) Change of Provider form
2 (7) Suggestions brochure
3 All beneficiary informing written materials will use easily understood language and
4 format (i.e. material written and formatted at a 6th grade reading level), and will use a font size
5 no smaller than 12 point. All beneficiary informing written materials shall inform beneficiaries of
6 the availability of information in alternative formats and how to make a request for an alternative
7 format. Inventory and maintenance of all beneficiary informing materials will be maintained by
8 the County's DBH Managed Care Division. Contractor will ensure that its written materials
9 include taglines or that an additional taglines document is available.
10 8.5 Beneficiary Handbook. Contractor shall provide each persons served with a
11 beneficiary handbook at the time the individual first accesses services and thereafter upon
12 request. The beneficiary handbook shall be provided to beneficiaries within fourteen (14)
13 business days after receiving notice of enrollment.
14 Contractor shall give each individual notice of any significant change to the information
15 contained in the beneficiary handbook at least thirty (30) days before the intended effective date
16 of change as per BHIN 22-060.
17 8.6 Accessibility. Required informing materials must be electronically available on
18 Contractor's website and must be physically available at the Contractor's facility lobby for
19 individuals' access.
20 Informing materials must be made available upon request, at no cost, in alternate
21 formats (i.e., Braille or audio) and auxiliary aids (i.e., California Relay Service (CRS) 711 and
22 American Sign Language) and must be provided to persons served within five (5) business
23 days. Large print materials shall be in a minimum of eighteen (18) point font size.
24 Informing materials will be considered provided to the individual if Contractor does one
25 or more of the following:
26 (A) Mails a printed copy of the information to the persons served's mailing address
27 before the individual receives their first specialty mental health service;
28
22
1 (B) Mails a printed copy of the information upon the individual's request to their
2 mailing address;
3 (C) Provides the information by email after obtaining the persons served's agreement
4 to receive the information by email;
5 (D) Posts the information on the Contractor's website and advises the person served
6 in paper or electronic form that the information is available on the internet and includes
7 applicable internet addresses, provided that individuals with disabilities who cannot
8 access this information online are provided auxiliary aids and services upon request and
9 at no cost; or,
10 (E) Provides the information by any other method that can reasonably be expected
11 to result in the person served receiving that information. If Contractor provides informing
12 materials in person, when the individual first receives specialty mental health services,
13 the date and method of delivery shall be documented in the persons served's file.
14 8.7 Provider Directory. Contractor must follow the County's provider directory policy, in
15 compliance with MHSUDS IN 18-020.
16 Contractor must make available to persons served, in paper form upon request and
17 electronic form, specified information about the County provider network as per 42 C.F.R. §
18 438.10(h). The most current provider directory is electronically available on the County website
19 and is updated by the County no later than thirty (30) calendar days after information is received
20 to update provider information. A paper provider directory must be updated at least monthly as
21 set forth in 42 C.F.R. § 438.10(h)(3)(i).
22 Any changes to information published in the provider directory must be reported to the
23 County within two (2) weeks of the change.
24 Contractor will only need to report changes/updates to the provider directory for
25 licensed, waivered, or registered mental health providers.
26
27
28
23
1 Article 9
2 Independent Contractor
3 9.1 Status. In performing under this Agreement, the Contractor, including its officers,
4 agents, employees, and volunteers, is at all times acting and performing as an independent
5 contractor, in an independent capacity, and not as an officer, agent, servant, employee,joint
6 venturer, partner, or associate of the County.
7 9.2 Verifying Performance. The County has no right to control, supervise, or direct the
8 manner or method of the Contractor's performance under this Agreement, but the County may
9 verify that the Contractor is performing according to the terms of this Agreement.
10 9.3 Benefits. Because of its status as an independent contractor, the Contractor has no
11 right to employment rights or benefits available to County employees. The Contractor is solely
12 responsible for providing to its own employees all employee benefits required by law. The
13 Contractor shall save the County harmless from all matters relating to the payment of
14 Contractor's employees, including compliance with Social Security withholding and all related
15 regulations.
16 9.4 Services to Others. The parties acknowledge that, during the term of this
17 Agreement, the Contractor may provide services to others unrelated to the County.
18 9.5 Operating Costs. Contractor shall provide all personnel, supplies, and operating
19 expenses of any kind required for the performance of this Agreement.
20 9.6 Additional Responsibilities. The parties acknowledge that, during the term of this
21 Agreement, the Contractor will be performing hiring, training, and credentialing of staff, and
22 County will be performing additional staff credentialing to ensure compliance with State and
23 Federal regulations.
24 9.7 Subcontracts. Contractor shall obtain written approval from County's Department of
25 Behavioral Health Director, or designee, before subcontracting any of the services delivered
26 under this Agreement. County's Department of Behavioral Health Director, or designee retains
27 the right to approve or reject any request for subcontracting services. Any transferee, assignee,
28 or subcontractor will be subject to all applicable provisions of this Agreement, and all applicable
24
1 State and Federal regulations. Contractor shall be held primarily responsible by County for the
2 performance of any transferee, assignee, or subcontractor unless otherwise expressly agreed to
3 in writing by County's Department of Behavioral Health Director, or designee. The use of
4 subcontractors by Contractor shall not entitle Contractor to any additional compensation that is
5 provided for under this Agreement.
6 Contractor shall remain legally responsible for the performance of all terms and
7 conditions of this Agreement, including, without limitation, all SMHS provided by third parties
8 under subcontracts, whether approved by the County or not.
9 Article 10
10 Indemnity and Defense
11 10.1 Indemnity. The Contractor shall indemnify and hold harmless and defend the
12 County (including its officers, agents, employees, and volunteers) against all claims, demands,
13 injuries, damages, costs, expenses (including attorney fees and costs), fines, penalties, and
14 liabilities of any kind to the County, the Contractor, or any third party that arise from or relate to
15 the performance or failure to perform by the Contractor (or any of its officers, agents,
16 subcontractors, or employees) under this Agreement. The County may conduct or participate in
17 its own defense without affecting the Contractor's obligation to indemnify and hold harmless or
18 defend the County.
19 10.2 Survival. This Article 10 survives the termination of this Agreement.
20 Article 11
21 Insurance
22 11.1 The Contractor shall comply with all the insurance requirements in Exhibit G to this
23 Agreement.
24 Article 12
25 Assurances
26 12.1 Certification of Non-exclusion or Suspension from Participation in a Federal
27 Health Care Program.
28
25
1 (A) In entering into this Agreement, Contractor certifies that it is not excluded from
2 participation in Federal Health Care Programs under either Section 1128 or 1128A of the
3 Social Security Act. Failure to so certify will render all provisions of this Agreement null
4 and void and may result in the immediate termination of this Agreement.
5 (B) In entering into this Agreement, Contractor certifies, that the Contractor does not
6 employ or subcontract with providers or have other relationships with providers excluded
7 from participation in Federal Health Care Programs, including Medi-Cal/Medicaid or
8 procurement activities, as set forth in 42 C.F.R. §438.610. Contractor shall conduct initial
9 and monthly exclusion and suspension searches of the following databases and provide
10 evidence of these completed searches when requested by County, DHCS or the US
11 Department of Health and Human Services (DHHS):
12 (1) www.oig.hhs.gov/exclusions - Office of Inspector General's List of Excluded
13 Individuals/Entities (LEIE) Federal Exclusions
14 (2) www.sam.gov/content/exclusions - General Service Administration (GSA)
15 Exclusions Extractwww.Medi-Cal.ca.gov- Suspended & Ineligible Provider List
16 (3) https:Hnppes.cros.hhs.gov/#/- National Plan and Provider Enumeration
17 System (NPPES)
18 (4) any other database required by DHCS or US DHHS.
19 (C) In entering into this Agreement, Contractor certifies, that Contractor does not
20 employ staff or individual contractors/vendors that are on the Social Security
21 Administration's Death Master File. Contractor shall check the database prior to
22 employing staff or individual contractors/vendors and provide evidence of these
23 completed searches when requested by the County, DHCS or the US DHHS.
24 (D) Contractor is required to notify County immediately if Contractor becomes aware
25 of any information that may indicate their (including employees/staff and individual
26 contractors/vendors) potential placement on an exclusions list.
27 (E) Contractor shall screen and periodically revalidate all network providers in
28 accordance with the requirements of 42 C.F.R., Part 455, Subparts B and E.
26
1 (F) Contractor must confirm the identity and determine the exclusion status of all its
2 providers, as well as any person with an ownership or control interest, or who is an
3 agent or managing employee of the contracted agency through routine checks of federal
4 and state databases. This includes the Social Security Administration's Death Master
5 File, NPPES, the Office of Inspector General's LEIE, the Medi-Cal Suspended and
6 Ineligible Provider List (S&I List) as consistent with the requirements of 42 C.F.R. §
7 455.436.
8 (G) If Contractor finds a provider that is excluded, it must promptly notify the County
9 as per 42 C.F.R. § 438.608(a)(2), (4). The Contractor shall not certify or pay any
10 Excluded provider with Medi-Cal funds, must treat any payments made to an excluded
11 provider as an overpayment, and any such inappropriate payments may be subject to
12 recovery.
13 Article 13
14 Inspections, Audits, and Public Records
15 13.1 Inspection of Documents. The Contractor shall make available to the County, and
16 the County may examine at any time during business hours and as often as the County deems
17 necessary, all of the Contractor's records and data with respect to the matters covered by this
18 Agreement, excluding attorney-client privileged communications. The Contractor shall, upon
19 request by the County, permit the County to audit and inspect all of such records and data to
20 ensure the Contractor's compliance with the terms of this Agreement.
21 13.2 State Audit Requirements. If the compensation to be paid by the County under this
22 Agreement exceeds $10,000, the Contractor is subject to the examination and audit of the
23 California State Auditor, as provided in Government Code section 8546.7, for a period of three
24 years after final payment under this Agreement. This section survives the termination of this
25 Agreement.
26 13.3 Internal Auditing. Contractors of sufficient size as determined by County shall
27 institute and conduct a Quality Assurance Process for all services provided hereunder. Said
28
27
1 process shall include at a minimum a system for verifying that all services provided and claimed
2 for reimbursement shall meet SMHS definitions and be documented accurately.
3 In addition, Contractors with medication prescribing authority shall adhere to County's
4 medication monitoring review practices. Contractor shall provide County with notification and a
5 summary of any internal audit exceptions and the specific corrective actions taken to sufficiently
6 reduce the errors that are discovered through Contractor's internal audit process. Contractor
7 shall provide this notification and summary to County as requested by the County.
8 13.4 Confidentiality in Audit Process. Contractor and County mutually agree to
9 maintain the confidentiality of Contractor's records and information of persons served, in
10 compliance with all applicable State and Federal statutes and regulations, including but not
11 limited to HIPAA and California Welfare and Institutions Code, Section 5328. Contractor shall
12 inform all of its officers, employees, and agents of the confidentiality provisions of all applicable
13 statutes.
14 Contractor's fiscal records shall contain sufficient data to enable auditors to perform a
15 complete audit and shall be maintained in conformance with standard procedures and
16 accounting principles.
17 Contractor's records shall be maintained as required by DBH and DHCS on forms
18 furnished by DHCS or the County. All statistical data or information requested by the County's
19 DBH Director or designee shall be provided by the Contractor in a complete and timely manner.
20 13.5 Reasons for Recoupment. County will conduct periodic audits of Contractor files to
21 ensure appropriate clinical documentation, high quality service provision and compliance with
22 applicable federal, state and county regulations.
23 Such audits may result in requirements for Contractor to reimburse County for services
24 previously paid in the following circumstances:
25 (A) Identification of Fraud, Waste or Abuse as defined in federal regulation
26 (1) Fraud and abuse are defined in C.F.R. Title 42, § 455.2 and W&I Code,
27 section 14107.11, subdivision (d).
28
28
1 (2) Definitions for"fraud," "waste," and "abuse" can also be found in the Medicare
2 Managed Care Manual available at https://www.cros.gov/Regulations-and-
3 Guidance/Guidance/Manuals
4 (B) Overpayment of Contractor by County due to errors in claiming or
5 documentation.
6 (C) Other reasons specified in the SMHS Reasons for Recoupment document
7 released annually by DHCS and posted on the DHCS BHIN website.
8 Contractor shall reimburse County for all overpayments identified by Contractor, County,
9 and/or state or federal oversight agencies as an audit exception within the timeframes required
10 by law or Country or state or federal agency. Funds owed to County will be due within forty-five
11 (45) days of notification by County, or County shall withhold future payments until all excess
12 funds have been recouped by means of an offset against any payments then or thereafter owing
13 to County under this or any other Agreement between the County and Contractor.
14 13.6 Cooperation with Audits. Contractor shall cooperate with County in any review
15 and/or audit initiated by County, DHCS, or any other applicable regulatory body. This
16 cooperation may include such activities as onsite program, fiscal, or chart reviews and/or audits.
17 In addition, Contractor shall comply with all requests for any documentation or files
18 including, but not limited to, files for persons served.
19 Contractor shall notify the County of any scheduled or unscheduled external evaluation
20 or site visits when it becomes aware of such visit. County shall reserve the right to attend any or
21 all parts of external review processes.
22 Contractor shall allow inspection, evaluation and audit of its records, documents and
23 facilities for ten (10) years from the term end date of this Agreement or in the event Contractor
24 has been notified that an audit or investigation of this Agreement has been commenced, until
25 such time as the matter under audit or investigation has been resolved, including the exhaustion
26 of all legal remedies, whichever is later pursuant to 42 C.F.R.§§ 438.3(h) and 438.2301(3)(i-iii).
27 13.7 Single Audit Clause. If Contractor expends Seven Hundred Fifty Thousand and
28 No/100 Dollars ($750,000.00) or more in Federal and Federal flow-through monies, Contractor
29
1 agrees to conduct an annual audit in accordance with the requirements of the Single Audit
2 Standards as set forth in Office of Management and Budget (OMB) 2 CFR 200. Contractor shall
3 submit said audit and management letter to County. The audit must include a statement of
4 findings or a statement that there were no findings. If there were negative findings, Contractor
5 must include a corrective action plan signed by an authorized individual. Contractor agrees to
6 take action to correct any material non-compliance or weakness found as a result of such audit.
7 Such audit shall be delivered to County's DBH Finance Division for review within nine (9)
8 months of the end of any fiscal year in which funds were expended and/or received for the
9 program. Failure to perform the requisite audit functions as required by this Agreement may
10 result in County performing the necessary audit tasks, or at County's option, contracting with a
11 public accountant to perform said audit, or may result in the inability of County to enter into
12 future agreements with Contractor. All audit costs related to this Agreement are the sole
13 responsibility of Contractor.
14 A single audit report is not applicable if Contractor's Federal contracts do not exceed the
15 Seven Hundred Fifty Thousand and No/100 Dollars ($750,000.00) requirement or Contractor's
16 only funding is through Drug-related Medi-Cal. If a single audit is not applicable, a program audit
17 must be performed and a program audit report with management letter shall be submitted by
18 Contractor to County as a minimum requirement to attest to Contractor solvency. Said audit
19 report shall be delivered to County's DBH Finance Division for review no later than nine (9)
20 months after the close of the fiscal year in which the funds supplied through this Agreement are
21 expended. Failure to comply with this Act may result in County performing the necessary audit
22 tasks or contracting with a qualified accountant to perform said audit. All audit costs related to
23 this Agreement are the sole responsibility of Contractor who agrees to take corrective action to
24 eliminate any material noncompliance or weakness found as a result of such audit. Audit work
25 performed by County under this paragraph shall be billed to Contractor at County cost, as
26 determined by County's Auditor-Controller/Treasurer-Tax Collector.
27 Contractor shall make available all records and accounts for inspection by County, the
28 State of California, if applicable, the Controller General of the United States, the Federal Grantor
30
1 Agency, or any of their duly authorized representatives, at all reasonable times for a period of at
2 least three (3) years following final payment under this Agreement or the closure of all other
3 pending matters, whichever is later.
4 13.8 Mental Health Certification Review Hearings. County will be responsible to
5 provide for and compensate the Mental Health Certification Review Hearing Officer for all
6 hearings performed at Contractor's facility in accordance with Division 5, Part 1, Chapter 2 of
7 the Welfare and Institutions Code. Contractor will provide a location that allows for
8 confidentiality and is compatible with and is least disruptive to the treatment being provided to
9 the Beneficiary or Recipient.
10 13.9 Public Records. The County is not limited in any manner with respect to its public
11 disclosure of this Agreement or any record or data that the Contractor may provide to the
12 County. The County's public disclosure of this Agreement or any record or data that the
13 Contractor may provide to the County may include but is not limited to the following:
14 (A) The County may voluntarily, or upon request by any member of the public or
15 governmental agency, disclose this Agreement to the public or such governmental
16 agency.
17 (B) The County may voluntarily, or upon request by any member of the public or
18 governmental agency, disclose to the public or such governmental agency any record or
19 data that the Contractor may provide to the County, unless such disclosure is prohibited
20 by court order.
21 (C)This Agreement, and any record or data that the Contractor may provide to the
22 County, is subject to public disclosure under the Ralph M. Brown Act (California
23 Government Code, Title 5, Division 2, Part 1, Chapter 9, beginning with section 54950).
24 (D)This Agreement, and any record or data that the Contractor may provide to the
25 County, is subject to public disclosure as a public record under the California Public
26 Records Act (California Government Code, Title 1, Division 7, Chapter 3.5, beginning
27 with section 6250) ("CPRA").
28
31
1 (E) This Agreement, and any record or data that the Contractor may provide to the
2 County, is subject to public disclosure as information concerning the conduct of the
3 people's business of the State of California under California Constitution, Article 1,
4 section 3, subdivision (b).
5 (F) Any marking of confidentiality or restricted access upon or otherwise made with
6 respect to any record or data that the Contractor may provide to the County shall be
7 disregarded and have no effect on the County's right or duty to disclose to the public or
8 governmental agency any such record or data.
9 13.10 Public Records Act Requests. If the County receives a written or oral request
10 under the CPRA to publicly disclose any record that is in the Contractor's possession or control,
11 and which the County has a right, under any provision of this Agreement or applicable law, to
12 possess or control, then the County may demand, in writing, that the Contractor deliver to the
13 County, for purposes of public disclosure, the requested records that may be in the possession
14 or control of the Contractor. Within five business days after the County's demand, the
15 Contractor shall (a) deliver to the County all of the requested records that are in the Contractor's
16 possession or control, together with a written statement that the Contractor, after conducting a
17 diligent search, has produced all requested records that are in the Contractor's possession or
18 control, or (b) provide to the County a written statement that the Contractor, after conducting a
19 diligent search, does not possess or control any of the requested records. The Contractor shall
20 cooperate with the County with respect to any County demand for such records. If the
21 Contractor wishes to assert that any specific record or data is exempt from disclosure under the
22 CPRA or other applicable law, it must deliver the record or data to the County and assert the
23 exemption by citation to specific legal authority within the written statement that it provides to
24 the County under this section. The Contractor's assertion of any exemption from disclosure is
25 not binding on the County, but the County will give at least 10 days' advance written notice to
26 the Contractor before disclosing any record subject to the Contractor's assertion of exemption
27 from disclosure. The Contractor shall indemnify the County for any court-ordered award of costs
28 or attorney's fees under the CPRA that results from the Contractor's delay, claim of exemption,
32
1 failure to produce any such records, or failure to cooperate with the County with respect to any
2 County demand for any such records.
3 Article 14
4 Right to Monitor
5 14.1 Right to Monitor. County or any subdivision or appointee thereof, and the State of
6 California or any subdivision or appointee thereof, including the Auditor General, shall have
7 absolute right to review and audit all records, books, papers, documents, corporate minutes,
8 financial records, staff information, records of persons served, other pertinent items as
9 requested, and shall have absolute right to monitor the performance of Contractor in the delivery
10 of services provided under this Agreement. Full cooperation shall be given by the Contractor in
11 any auditing or monitoring conducted, according to this agreement.
12 14.2 Accessibility. Contractor shall make all of its premises, physical facilities,
13 equipment, books, records, documents, agreements, computers, or other electronic systems
14 pertaining to Medi-Cal enrollees, Medi-Cal-related activities, services, and activities furnished
15 under the terms of this Agreement, or determinations of amounts payable available at any time
16 for inspection, examination, or copying by County, the State of California or any subdivision or
17 appointee thereof, CMS, U.S. Department of Health and Human Services (HHS) Office of
18 Inspector General, the United States Controller General or their designees, and other
19 authorized federal and state agencies. This audit right will exist for at least ten years from the
20 final date of the Agreement period or in the event the Contractor has been notified that an audit
21 or investigation of this Agreement has commenced, until such time as the matter under audit or
22 investigation has been resolved, including the exhaustion of all legal remedies, whichever is
23 later (42 CFR §438.230(c)(3)(I)-(ii)).
24 The County, DHCS, CMS, or the HHS Office of Inspector General may inspect,
25 evaluate, and audit the Contractor at any time if there is a reasonable possibility of fraud or
26 similar risk. The Department's inspection shall occur at the Contractor's place of business,
27 premises, or physical facilities (42 CFR §438.230(c)(3)(iv)).
28
33
1 14.3 Cooperation. Contractor shall cooperate with County in the implementation,
2 monitoring and evaluation of this Agreement and comply with any and all reporting requirements
3 established by County. Should County identify an issue or receive notification of a complaint or
4 potential/actual/suspected violation of requirements, County may audit, monitor, and/or request
5 information from Contractor to ensure compliance with laws, regulations, and requirements, as
6 applicable.
7 14.4 Probationary Status. County reserves the right to place Contractor on probationary
8 status, as referenced in the Probationary Status Article, should Contractor fail to meet
9 performance requirements; including, but not limited to violations such as high disallowance
10 rates, failure to report incidents and changes as contractually required, failure to correct issues,
11 inappropriate invoicing, untimely and inaccurate data entry, not meeting performance outcomes
12 expectations, and violations issued directly from the State. Additionally, Contractor may be
13 subject to Probationary Status or termination if agreement monitoring and auditing corrective
14 actions are not resolved within specified timeframes.
15 14.5 Record Retention. Contractor shall retain all records and documents originated or
16 prepared pursuant to Contractor's performance under this Agreement, including grievance and
17 appeal records, and the data, information and documentation specified in 42 C.F.R. parts
18 438.604, 438.606, 438.608, and 438.610 for a period of no less than ten years from the term
19 end date of this Agreement or until such time as the matter under audit or investigation has
20 been resolved. Records and documents include but are not limited to all physical and electronic
21 records and documents originated or prepared pursuant to Contractor's or subcontractor's
22 performance under this Agreement including working papers, reports, financial records and
23 documents of account, records of persons served, prescription files, subcontracts, and any
24 other documentation pertaining to covered services and other related services for persons
25 served.
26 14.6 Record Maintenance. Contractor shall maintain all records and management books
27 pertaining to service delivery and demonstrate accountability for agreement performance and
28 maintain all fiscal, statistical, and management books and records pertaining to the program.
34
1 Records should include, but not be limited to, monthly summary sheets, sign-in sheets, and
2 other primary source documents. Fiscal records shall be kept in accordance with Generally
3 Accepted Accounting Principles and must account for all funds, tangible assets, revenue and
4 expenditures. Fiscal records must also comply with the Code of Federal Regulations (CFR),
5 Title II, Subtitle A, Chapter 11, Part 200, Uniform Administrative Requirements, Cost Principles,
6 and Audit Requirements for Federal Awards.
7 All records shall be complete and current and comply with all Agreement requirements.
8 Failure to maintain acceptable records per the preceding requirements shall be considered
9 grounds for withholding of payments for billings submitted and for termination of Agreement.
10 Contractor shall maintain records of persons served and community service in
11 compliance with all regulations set forth by local, state, and federal requirements, laws, and
12 regulations, and provide access to clinical records by County staff.
13 Contractor shall comply with the Article 18 and Article 1 regarding relinquishing or
14 maintaining medical records.
15 Contractor shall agree to maintain and retain all appropriate service and financial
16 records for a period of at least ten (10) years from the date of final payment, the final date of the
17 contract period, final settlement, or until audit findings are resolved, whichever is later.
18 14.7 Financial Reports. Contractor shall submit audited financial reports on an annual
19 basis to the County. The audit shall be conducted in accordance with Generally Accepted
20 Accounting Principles and generally accepted auditing standards.
21 14.8 Agreement Termination. In the event the Agreement is terminated, ends its
22 designated term or Contractor ceases operation of its business, Contractor shall deliver or make
23 available to County all financial records that may have been accumulated by Contractor or
24 subcontractor under this Agreement, whether completed, partially completed or in progress
25 within seven (7) calendar days of said termination/end date.
26 14.9 Facilities and Assistance. Contractor shall provide all reasonable facilities and
27 assistance for the safety and convenience of the County's representatives in the performance of
28
35
1 their duties. All inspections and evaluations shall be performed in such a manner that will not
2 unduly delay the work of Contractor.
3 14.10 County Discretion to Revoke. County has the discretion to revoke full or partial
4 provisions of the Agreement, delegated activities or obligations, or application of other remedies
5 permitted by state or federal law when the County or DHCS determines Contractor has not
6 performed satisfactorily.
7 14.11 Site Inspection. Without limiting any other provision related to inspections or audits
8 otherwise set forth in this Agreement, Contractor shall permit authorized County, state, and/or
9 federal agency(ies), through any authorized representative, the right to inspect or otherwise
10 evaluate the work performed or being performed hereunder including subcontract support
11 activities and the premises which it is being performed. Contractor shall provide all reasonable
12 assistance for the safety and convenience of the authorized representative in the performance
13 of their duties. All inspections and evaluations shall be made in a manner that will not unduly
14 delay the work of the Contractor.
15 Article 15
16 Complaint Logs and Grievances
17 15.1 Documentation. Contractor shall log complaints and the disposition of all complaints
18 from a person served or their family. Contractor shall provide a copy of the detailed complaint
19 log entries concerning County-sponsored persons served to County at monthly intervals by the
20 tenth (10th) day of the following month, in a format that is mutually agreed upon. Contractor
21 shall allow beneficiaries or their representative to file a grievance either orally, or in writing at
22 any time with the Mental health Plan. In the event Contractor is notified by a beneficiary or their
23 representative of a discrimination grievance, subcontractor shall report discrimination
24 grievances to the Mental Health Plan within 24 hours. The Contractor shall not require a
25 beneficiary or their representative to file a Discrimination Grievance with the Mental Health Plan
26 before filing the complaint directly with the DHCS Office of Civil Rights and the U.S. Health and
27 Human Services Office for Civil Rights.
28
36
1 15.2 Rights of Persons Served. Contractor shall post signs informing persons served of
2 their right to file a complaint or grievance, appeals, and expedited appeals. In addition,
3 Contractor shall inform every person served of their rights as set forth in Exhibit H.
4 Article 16
5 Compliance
6 16.1 Compliance. Contractor agrees to comply with County's Contractor Code of
7 Conduct and Ethics and the County's Compliance Program in accordance with Exhibit I. Within
8 thirty (30) days of entering into this Agreement with County, Contractor shall ensure all of
9 Contractor's employees, agents, and subcontractors providing services under this Agreement
10 certify in writing, that he or she has received, read, understood, and shall abide by the
11 Contractor Code of Conduct and Ethics. Contractor shall ensure that within thirty (30) days of
12 hire, all new employees, agents, and subcontractors providing services under this Agreement
13 shall certify in writing that he or she has received, read, understood, and shall abide by the
14 Contractor Code of Conduct and Ethics. Contractor understands that the promotion of and
15 adherence to the Contractor Code of Conduct is an element in evaluating the performance of
16 Contractor and its employees, agents, and subcontractors.
17 Within thirty (30) days of entering into this Agreement, and annually thereafter, all
18 employees, agents, and subcontractors providing services under this Agreement shall complete
19 general compliance training, and appropriate employees, agents, and subcontractors shall
20 complete documentation and billing or billing/reimbursement training. All new employees,
21 agents, and subcontractors shall attend the appropriate training within thirty (30) days of hire.
22 Each individual who is required to attend training shall certify in writing that he or she has
23 received the required training. The certification shall specify the type of training received and
24 the date received. The certification shall be provided to County's DBH Compliance Officer at
25 1925 E. Dakota Ave, Fresno, California 93726. Contractor agrees to reimburse County for the
26 entire cost of any penalty imposed upon County by the Federal Government as a result of
27 Contractor's violation of the terms of this Agreement.
28
37
1 16.2 Compliance with State Medi-Cal Requirements. Contractor shall be required to
2 maintain Mental Health Plan organizational provider certification by Fresno County. Contractor
3 must meet Medi-Cal organization provider standards as listed in Exhibit J, "Medi-Cal
4 Organizational Provider Standards". It is acknowledged that all references to Organizational
5 Provider and/or Provider in Exhibit J shall refer to Contractor.
6 16.3 Medi-Cal Certification and Mental Health Plan Compliance. Contractor will
7 establish and maintain Medi-Cal certification or become certified within ninety (90) days of the
8 effective date of this Agreement through County to provide reimbursable services to Medi-Cal
9 eligible persons served. In addition, Contractor shall work with the County's DBH to execute the
10 process if not currently certified by County for credentialing of staff. During this process, the
11 Contractor will obtain a legal entity number established by the DHCS, a requirement for
12 maintaining Mental Health Plan organizational provider status throughout the term of this
13 Agreement. Contractor will be required to become Medi-Cal certified prior to providing services
14 to Medi-Cal eligible persons served and seeking reimbursement from the County. Contractor
15 will not be reimbursed by County for any services rendered prior to certification.
16 Contractor shall provide direct specialty mental health services in accordance with the
17 Mental Health Plan. Contractor must comply with the "Fresno County Mental Health Plan
18 Compliance Program and Code of Conduct" set forth in Exhibit I.
19 Contractor may provide direct specialty mental health services using unlicensed staff as
20 long as the individual is approved as a provider by the Mental Health Plan, is supervised by
21 licensed staff, works within his/her scope and only delivers allowable direct specialty mental
22 health services. It is understood that each service is subject to audit for compliance with
23 Federal and State regulations, and that County may be making payments in advance of said
24 review. In the event that a service is disapproved, County may, at its sole discretion, withhold
25 compensation or set off from other payments due the amount of said disapproved services.
26 Contractor shall be responsible for audit exceptions to ineligible dates of services or incorrect
27 application of utilization review requirements.
28
38
1 16.4 Network Adequacy. The Contractor shall ensure that all services covered under this
2 Agreement are available and accessible to persons served in a timely manner and in
3 accordance with the network adequacy standards required by regulation. (42 C.F.R. §438.206
4 (a), (c)).
5 Contractor shall submit, when requested by County and in a manner and format
6 determined by the County, network adequacy certification information to the County, utilizing a
7 provided template or other designated format.
8 Contractor shall submit updated network adequacy information to the County any time
9 there has been a significant change that would affect the adequacy and capacity of services.
10 To the extent possible and appropriately consistent with CCR, Title 9, §1830.225 and 42
11 C.F.R. §438.3 (1), the Contractor shall provide a person served the ability to choose the person
12 providing services to them.
13 16.5 Compliance Program, Including Fraud Prevention and Overpayments.
14 Contractor shall have in place a compliance program designed to detect and prevent fraud,
15 waste and abuse, as per 42 C.F.R. § 438.608(a)(1), that must include:
16 (A) Written policies, procedures, and standards of conduct that articulate the
17 organization's commitment to comply with all applicable requirements and standards
18 under the Agreement, and all applicable federal and state requirements.
19 (B) A Compliance Office (CO) who is responsible for developing and implementing
20 policies, procedures, and practices designed to ensure compliance with the
21 requirements of this Agreement and who reports directly to the CEO and/or the Board of
22 Directors.
23 (C)A Regulatory Compliance Committee on the Board of Directors and at the senior
24 management level charged with overseeing the organization's compliance program and
25 its compliance with the requirements under the Agreement.
26 (D)A system for training and education for the Compliance Officer, the organization's
27 senior management, and the organization's employees for the federal and state
28 standards and requirements under the Agreement.
39
1 (E) Effective lines of communication between the Compliance Officer and the
2 organization's employees.
3 (F) Enforcement of standards through well-publicized disciplinary guidelines.
4 (G)The establishment and implementation of procedures and a system with
5 dedicated staff for routine internal monitoring and auditing of compliance risks, prompt
6 response to compliance issues as they are raised, investigation of potential compliance
7 problems as identified in the course of self-evaluation and audits, corrections of such
8 problems promptly and thoroughly to reduce the potential for recurrence and ongoing
9 compliance with the requirements under the Agreement.
10 (H)The requirement for prompt reporting and repayment of any overpayments
11 identified.
12 16.6 Reporting. Contractor must have administrative and management arrangements or
13 procedures designed to detect and prevent fraud, waste and abuse of federal or state health
14 care funding. Contractor must report fraud and abuse information to the County including but
15 not limited to:
16 (A) Any potential fraud, waste, or abuse as per 42 C.F.R. § 438.608(a), (a)(7),
17 (B) All overpayments identified or recovered, specifying the overpayment due to
18 potential fraud as per 42 C.F.R. § 438.608(a), (a)(2),
19 (C) Information about changes in a persons served's circumstances that may affect
20 the person served's eligibility including changes in the their residence or the death of the
21 person served as per 42 C.F.R. § 438.608(a)(3).
22 (D) Information about a change in the Contractor's circumstances that may affect the
23 network provider's eligibility to participate in the managed care program, including the
24 termination of this Agreement with the Contractor as per 42 C.F.R. § 438.608(a)(6).
25 Contractor shall implement written policies that provide detailed information about the
26 False Claims Act ("Act") and other federal and state laws described in section 1902(a)(68) of the
27 Act, including information about rights of employees to be protected as whistleblowers.
28
40
1 Contractor shall make prompt referral of any potential fraud, waste or abuse to County or
2 potential fraud directly to the State Medicaid Fraud Control Unit.
3 16.7 Overpayments. County may suspend payments to Contractor if DHCS or County
4 determine that there is a credible allegation of fraud in accordance with 42 C.F.R. §455.23. (42
5 C.F.R. §438.608 (a)(8)).
6 Contractor shall report to County all identified overpayments and reason for the
7 overpayment, including overpayments due to potential fraud. Contractor shall return any
8 overpayments to the County within 60 calendar days after the date on which the overpayment
9 was identified. (42 C.F.R. § 438.608 (a)(2), (c)(3)).
10 Article 17
11 Federal and State Laws
12 17.1 Health Insurance Portability and Accountability Act. County and Contractor each
13 consider and represent themselves as covered entities as defined by the U.S. Health Insurance
14 Portability and Accountability Act of 1996, Public Law 104-191(HIPAA) and agree to use and
15 disclose Protected Health Information (PHI) as required by law.
16 County and Contractor acknowledge that the exchange of PHI between them is only for
17 treatment, payment, and health care operations.
18 County and Contractor intend to protect the privacy and provide for the security of PHI
19 pursuant to the Agreement in compliance with HIPAA, the Health Information Technology for
20 Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations promulgated
21 thereunder by the U.S. Department of Health and Human Services (HIPAA Regulations) and
22 other applicable laws.
23 As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
24 Contractor to enter into a agreement containing specific requirements prior to the disclosure of
25 PHI, as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e)
26 of the Code of Federal Regulations.
27 17.2 Physical Accessibility. In accordance with the accessibility requirements of section
28 508 of the Rehabilitation Act and the Americans with Disabilities Act of 1973, Contractor must
41
1 provide physical access, reasonable accommodations, and accessible equipment for Medi-Cal
2 beneficiaries with physical or mental disabilities.
3 Article 18
4 Data Security
5 18.1 Data Security Requirements. Contractor shall comply with data security
6 requirements in Exhibit K to this Agreement.
7 Article 19
8 Publicity Prohibition
9 19.1 Self-Promotion. None of the funds, materials, property, or services provided directly
10 or indirectly under this Agreement shall be used for Contractor's advertising, fundraising, or
11 publicity (i.e., purchasing of tickets/tables, silent auction donations, etc.)for the purpose of self-
12 promotion.
13 19.2 Public Awareness. Notwithstanding the above, publicity of the services described in
14 Article 1 of this Agreement shall be allowed as necessary to raise public awareness about the
15 availability of such specific services when approved in advance by County's DBH Director or
16 designee. Communication products must follow DBH graphic standards, including typefaces
17 and colors, to communicate our authority and project a unified brand. This includes all media
18 types and channels and all materials on and offline that are created as part of DBH's efforts to
19 provide information to the public.
20 Article 20
21 Disclosure of Self-Dealing Transactions
22 20.1 Applicability. This Article 20 applies if the Contractor is operating as a corporation,
23 or changes its status to operate as a corporation.
24 20.2 Duty to Disclose. If any member of the Contractor's board of directors is party to a
25 self-dealing transaction, he or she shall disclose the transaction by completing and signing a
26 "Self-Dealing Transaction Disclosure Form" (Exhibit L to this Agreement) and submitting it to the
27 County before commencing the transaction or immediately after.
28
42
1 20.3 Definition. "Self-dealing transaction" means a transaction to which the Contractor is
2 a party and in which one or more of its directors, as an individual, has a material financial
3 interest, and which does not meet the requirements of paragraph (1), (2), or (3) of subdivision
4 (d) of Cal. Corp. Code § 5233.
5 Article 21
6 Disclosure of Ownership and/or Control Interest Information
7 21.1 Applicability. This provision is only applicable if Contractor is disclosing entities,
8 fiscal agents, or managed care entities, as defined in Code of Federal Regulations (C.F.R.),
9 Title 42 §§ 455.101, 455.104 and 455.106(a)(1),(2).
10 21.2 Duty to Disclose. Contractor must disclose the following information as requested in
11 the Provider Disclosure Statement, Disclosure of Ownership and Control Interest Statement,
12 Exhibit M:
13 (A) Disclosure of 5% or More Ownership Interest:
14 (1) In the case of corporate entities with an ownership or control interest in the
15 disclosing entity, the primary business address as well as every business location
16 and P.O. Box address must be disclosed. In the case of an individual, the date of
17 birth and Social Security number must be disclosed.
18 (2) In the case of a corporation with ownership or control interest in the
19 disclosing entity or in any subcontractor in which the disclosing entity has a five
20 percent (5%) or more interest, the corporation tax identification number must be
21 disclosed.
22 (3) For individuals or corporations with ownership or control interest in any
23 subcontractor in which the disclosing entity has a five percent (5%) or more interest,
24 the disclosure of familial relationship is required.
25 (4) For individuals with five percent (5%) or more direct or indirect ownership
26 interest of a disclosing entity, the individual shall provide evidence of completion of a
27 criminal background check, including fingerprinting, if required by law, prior to
28 execution of Contract. (42 C.F.R. § 455.434)
43
1 (B) Disclosures Related to Business Transactions:
2 (1) The ownership of any subcontractor with whom Contractor has had business
3 transactions totaling more than $25,000 during the 12-month period ending on the
4 date of the request.
5 (2) Any significant business transactions between Contractor and any wholly
6 owned supplier, or between Contractor and any subcontractor, during the 5-year
7 period ending on the date of the request. (42 C.F.R. § 455.105(b).)
8 (C) Disclosures Related to Persons Convicted of Crimes:
9 (1) The identity of any person who has an ownership or control interest in the
10 provider or is an agent or managing employee of the provider who has been
11 convicted of a criminal offense related to that person's involvement in any program
12 under the Medicare, Medicaid, or the Title XXI services program since the inception
13 of those programs. (42 C.F.R. § 455.106.)
14 (2) County shall terminate the enrollment of Contractor if any person with five
15 percent (5%) or greater direct or indirect ownership interest in the disclosing entity
16 has been convicted of a criminal offense related to the person's involvement with
17 Medicare, Medicaid, or Title XXI program in the last 10 years.
18 21.3 Contractor must provide disclosure upon execution of Contract, extension for
19 renewal, and within 35 days after any change in Contractor ownership or upon request of
20 County. County may refuse to enter into an agreement or terminate an existing agreement with
21 Contractor if Contractor fails to disclose ownership and control interest information, information
22 related to business transactions and information on persons convicted of crimes, or if Contractor
23 did not fully and accurately make the disclosure as required.
24 21.4 Contractor must provide the County with written disclosure of any prohibited
25 affiliations under 42 C.F.R. § 438.610. Contractor must not employ or subcontract with providers
26 or have other relationships with providers Excluded from participation in Federal Health Care
27 Programs, including Medi-Cal/Medicaid or procurement activities, as set forth in 42 C.F.R.
28 §438.610.
44
1 21.5 Reporting. Submissions shall be scanned pdf copies and are to be sent via email to
2 DBHContractedServices@fresnocountyca.gov. County may deny enrollment or terminate this
3 Agreement where any person with five (5) percent or greater direct or indirect ownership interest
4 in Contractor has been convicted of a criminal offense related to that person's involvement with
5 the Medicare, Medicaid, or Title XXI program in the last ten (10) years. County may terminate
6 this Agreement where any person with five (5) percent or greater direct or indirect ownership
7 interest in the Contractor did not submit timely and accurate information and cooperate with any
8 screening method required in CFR, Title 42, Section 455.416.
9 Article 22
10 Disclosure of Criminal History and Civil Actions
11 22.1 Applicability. Contractor is required to disclose if any of the following conditions
12 apply to them, their owners, officers, corporate managers, or partners (hereinafter collectively
13 referred to as "Contractor"):
14 (A) Within the three (3) year period preceding the Agreement award, they have been
15 convicted of, or had a civil judgment tendered against them for:
16 (1) Fraud or criminal offense in connection with obtaining, attempting to obtain,
17 or performing a public (federal, state, or local) transaction or contract under a public
18 transaction;
19 (2) Violation of a federal or state antitrust statute;
20 (3) Embezzlement, theft, forgery, bribery, falsification, or destruction of records;
21 or
22 (4) False statements or receipt of stolen property.
23 (B) Within a three (3) year period preceding their Agreement award, they have had a
24 public transaction (federal, state, or local) terminated for cause or default.
25 22.2 Duty to Disclose. Disclosure of the above information will not automatically
26 eliminate Contractor from further business consideration. The information will be considered as
27 part of the determination of whether to continue and/or renew this Agreement and any additional
28 information or explanation that Contractor elects to submit with the disclosed information will be
45
1 considered. If it is later determined that the Contractor failed to disclose required information,
2 any contract awarded to such Contractor may be immediately voided and terminated for
3 material failure to comply with the terms and conditions of the award.
4 Contractor must sign a "Certification Regarding Debarment, Suspension, and Other
5 Responsible Matters— Primary Covered Transactions" in the form set forth in Exhibit N.
6 Additionally, Contractor must immediately advise the County in writing if, during the term of the
7 Agreement: (1) Contractor becomes suspended, debarred, excluded or ineligible for
8 participation in Federal or State funded programs or from receiving federal funds as listed in the
9 excluded parties list system (http://www.epis.gov); or (2) any of the above listed conditions
10 become applicable to Contractor. Contractor shall indemnify, defend, and hold County
11 harmless for any loss or damage resulting from a conviction, debarment, exclusion, ineligibility,
12 or other matter listed in the signed Certification Regarding Debarment, Suspension, and Other
13 Responsibility Matters.
14 Article 23
15 Cultural and Linguistic Competency
16 23.1 General.All services, policies and procedures must be culturally and linguistically
17 appropriate. Contractor must participate in the implementation of the most recent Cultural
18 Competency Plan for the County and shall adhere to all cultural competency standards and
19 requirements. Contractor shall participate in the County's efforts to promote the delivery of
20 services in a culturally competent and equitable manner to all individuals, including those with
21 limited English proficiency and diverse cultural and ethnic backgrounds, disabilities, and
22 regardless of gender, sexual orientation, or gender identity including active participation in the
23 County's Diversity, Equity and Inclusion Committee.
24 23.2 Policies and Procedures. Contractor shall comply with requirements of policies and
25 procedures for ensuring access and appropriate use of trained interpreters and material
26 translation services for all limited and/or no English proficient beneficiaries, including, but not
27 limited to, assessing the cultural and linguistic needs of the beneficiaries, training of staff on the
28 policies and procedures, and monitoring its language assistance program. Contractor's policies
46
1 and procedures shall ensure compliance of any subcontracted providers with these
2 requirements.
3 23.3 Interpreter Services. Contractor shall notify its beneficiaries that oral interpretation
4 is available for any language and written translation is available in prevalent languages and that
5 auxiliary aids and services are available upon request, at no cost and in a timely manner for
6 limited and/or no English proficient beneficiaries and/or beneficiaries with disabilities.
7 Contractor shall avoid relying on an adult or minor child accompanying the beneficiary to
8 interpret or facilitate communication; however, if the beneficiary refuses language assistance
9 services, the Contractor must document the offer, refusal, and justification in the beneficiary's
10 file.
11 23.4 Interpreter Qualifications. Contractor shall ensure that employees, agents,
12 subcontractors, and/or partners who interpret or translate for a beneficiary or who directly
13 communicate with a beneficiary in a language other than English (1) have completed annual
14 training provided by County at no cost to Contractor; (2) have demonstrated proficiency in the
15 beneficiary's language; (3) can effectively communicate any specialized terms and concepts
16 specific to Contractor's services; and (4) adheres to generally accepted interpreter ethic
17 principles. As requested by County, Contractor shall identify all who interpret for or provide
18 direct communication to any program beneficiary in a language other than English and identify
19 when the Contractor last monitored the interpreter for language competence.
20 23.5 CLAS Standards. Contractor shall submit to County for approval, within ninety (90)
21 days from date of contract execution, Contractor's plan to address all fifteen (15) National
22 Standards for Culturally and Linguistically Appropriate Service (CLAS), as published by the
23 Office of Minority Health and as set forth in Exhibit O "National Standards on Culturally and
24 Linguistically Appropriate Services". As the CLAS standards are updated, Contractor's plan
25 must be updated accordingly. As requested by County, Contractor shall be responsible for
26 conducting an annual CLAS self-assessment and providing the results of the self-assessment to
27 the County. The annual CLAS self-assessment instruments shall be reviewed by the County
28 and revised as necessary to meet the approval of the County.
47
1 23.6 Training Requirements. Cultural competency training for Contractor staff should be
2 substantively integrated into health professions education and training at all levels, both
3 academically and functionally, including core curriculum, professional licensure, and continuing
4 professional development programs. As requested by County, Contractor shall report on the
5 completion of cultural competency trainings to ensure direct service providers are completing a
6 minimum of eight (8) hours of cultural competency training annually.
7 23.7 Continuing Cultural Competence. Contractor shall create and sustain a forum that
8 includes staff at all agency levels to discuss cultural competence. Contractor shall designate a
9 representative from Contractor's team to attend County's Diversity, Equity and Inclusion
10 Committee.
11 Article 24
12 General Terms
13 24.1 Modification. Except as provided in Article 7, "Termination and Suspension," this
14 Agreement may not be modified, and no waiver is effective, except by written agreement signed
15 by both parties. The Contractor acknowledges that County employees have no authority to
16 modify this Agreement except as expressly provided in this Agreement.
17 (A) Notwithstanding the above, non-material changes to services, staffing, and
18 responsibilities of the Contractor, as needed, to accommodate changes in the laws
19 relating to service requirements and specialty mental health treatment, may be made
20 with the signed written approval of County's DBH Director, or designee, and Contractor
21 through an amendment approved by County's County Counsel and the County's Auditor-
22 Controller/Treasurer-Tax Collector's Office. Said modifications shall not result in any
23 change to the maximum compensation amount payable to Contractor, as stated herein.
24 (B) In addition, changes to service rates on Exhibit F that do not exceed 4% of the
25 approved rate, or that are needed to accommodate state-mandated rate increases, may
26 be made with the written approval of the DBH Director or designee. These rate changes
27 may not add or alter any other terms or conditions of the Agreement. Said modifications
28
48
1 shall not result in any change to the maximum compensation amount payable to
2 Contractor, as stated herein.
3 24.2 Non-Assignment. Neither party may assign its rights or delegate its obligations
4 under this Agreement without the prior written consent of the other party.
5 24.3 Governing Law. The laws of the State of California govern all matters arising from
6 or related to this Agreement.
7 24.4 Jurisdiction and Venue. This Agreement is signed and performed in Fresno
8 County, California. Contractor consents to California jurisdiction for actions arising from or
9 related to this Agreement, and, subject to the Government Claims Act, all such actions must be
10 brought and maintained in Fresno County.
11 24.5 Construction. The final form of this Agreement is the result of the parties' combined
12 efforts. If anything in this Agreement is found by a court of competent jurisdiction to be
13 ambiguous, that ambiguity shall not be resolved by construing the terms of this Agreement
14 against either party.
15 24.6 Days. Unless otherwise specified, "days" means calendar days.
16 24.7 Headings. The headings and section titles in this Agreement are for convenience
17 only and are not part of this Agreement.
18 24.8 Severability. If anything in this Agreement is found by a court of competent
19 jurisdiction to be unlawful or otherwise unenforceable, the balance of this Agreement remains in
20 effect, and the parties shall make best efforts to replace the unlawful or unenforceable part of
21 this Agreement with lawful and enforceable terms intended to accomplish the parties' original
22 intent.
23 24.9 Nondiscrimination. During the performance of this Agreement, the Contractor shall
24 not unlawfully discriminate against any employee or applicant for employment, or recipient of
25 services, because of race, religious creed, color, national origin, ancestry, physical disability,
26 mental disability, medical condition, genetic information, marital status, sex, gender, gender
27 identity, gender expression, age, sexual orientation, military status or veteran status pursuant to
28 all applicable State of California and federal statutes and regulation.
49
1 Contractor shall take affirmative action to ensure that services to intended Medi-Cal
2 beneficiaries are provided without use of any policy or practice that has the effect of
3 discriminating on the basis of race, color, religion, ancestry, marital status, national origin, ethnic
4 group identification, sex, sexual orientation, gender, gender identity, age, medical condition,
5 genetic information, health status or need for health care services, or mental or physical
6 disability.
7 24.10 No Waiver. Payment, waiver, or discharge by the County of any liability or obligation
8 of the Contractor under this Agreement on any one or more occasions is not a waiver of
9 performance of any continuing or other obligation of the Contractor and does not prohibit
10 enforcement by the County of any obligation on any other occasion.
11 24.11 Entire Agreement. This Agreement, including its exhibits, is the entire agreement
12 between the Contractor and the County with respect to the subject matter of this Agreement,
13 and it supersedes all previous negotiations, proposals, commitments, writings, advertisements,
14 publications, and understandings of any nature unless those things are expressly included in
15 this Agreement. If there is any inconsistency between the terms of this Agreement without its
16 exhibits and the terms of the exhibits, then the inconsistency will be resolved by giving
17 precedence first to the terms of this Agreement without its exhibits, and then to the terms of the
18 exhibits.
19 24.12 No Third-Party Beneficiaries. This Agreement does not and is not intended to
20 create any rights or obligations for any person or entity except for the parties.
21 24.13 Authorized Signature. The Contractor represents and warrants to the County that:
22 (A) The Contractor is duly authorized and empowered to sign and perform its
23 obligations under this Agreement.
24 (B) The individual signing this Agreement on behalf of the Contractor is duly
25 authorized to do so and his or her signature on this Agreement legally binds the
26 Contractor to the terms of this Agreement.
27 24.14 Electronic Signatures. The parties agree that this Agreement may be executed by
28 electronic signature as provided in this section.
50
1 (A) An "electronic signature" means any symbol or process intended by an individual
2 signing this Agreement to represent their signature, including but not limited to (1) a
3 digital signature; (2) a faxed version of an original handwritten signature; or (3) an
4 electronically scanned and transmitted (for example by PDF document) version of an
5 original handwritten signature.
6 (B) Each electronic signature affixed or attached to this Agreement (1) is deemed
7 equivalent to a valid original handwritten signature of the person signing this Agreement
8 for all purposes, including but not limited to evidentiary proof in any administrative or
9 judicial proceeding, and (2) has the same force and effect as the valid original
10 handwritten signature of that person.
11 (C)The provisions of this section satisfy the requirements of Civil Code section
12 1633.5, subdivision (b), in the Uniform Electronic Transaction Act (Civil Code, Division 3,
13 Part 2, Title 2.5, beginning with section 1633.1).
14 (D) Each party using a digital signature represents that it has undertaken and
15 satisfied the requirements of Government Code section 16.5, subdivision (a),
16 paragraphs (1) through (5), and agrees that each other party may rely upon that
17 representation.
18 (E) This Agreement is not conditioned upon the parties conducting the transactions
19 under it by electronic means and either party may sign this Agreement with an original
20 handwritten signature.
21 24.15 Counterparts. This Agreement may be signed in counterparts, each of which is an
22 original, and all of which together constitute this Agreement.
23 [SIGNATURE PAGE FOLLOWS]
24
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26
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51
ii
DocuSign Envelope ID:EA80258A-97D4-4CE6-8F7B-35978187351C
1 The parties are signing this Agreement on the date stated in the introductory clause.
2 FRESNO COMMUNITY HOSPITAL AND
MEDICAL CENTER d.b.a. COMMUNITY COUNTY OF FRESNO
3 BEHAVIORAL HEALTH CENTER (CBHC)
4 DocuSigned by:
5 � � Sal in r , Ch .rman of the Board of
Craig Castro, President/CEO Supe rs County of Fresno
6
7 �DocuSigned by: Attest:
� Bernice E. Seidel
M AdnAFRO'1741 Clerk of the Board of Supervisors
8 Christopher Neuman, Senior VP/ CFO County of Fresno, State of California
9
By: _
10 7171 N. Cedar Avenue Deputy
Fresno, CA 93720
11
12
13 For accounting use only:
14 Org No.: 56302666
Account No.: 7295
15 Fund No.: 0001
Subclass No.: 1000
16
17
18
19
20
21
22
23
24
25
26
27
28
52
Exhibit A
1 Scope of Services
2 I. Definitions
3 The words and terms used in this Agreement are intended to have their usual
4 meanings unless a particular or more limited meaning is associated with their
5 usage in Sections 14700 et seq. and 14712 et seq. of the California Welfare and
6 Institutions Code, or the Medi-Cal Psychiatric Inpatient Hospital Services
7 Consolidation Regulations pertaining to the rendition of health care or unless
8 specifically defined in this section or otherwise in this Agreement.
9 a. Administrative Day: "Administrative Day" means those days authorized by
10 the County in an acute inpatient facility when, due to the lack of an
11 available nursing facility, the Beneficiary's or Recipient's stay at an acute
12 inpatient facility must be continued beyond the Beneficiary's or
13 Recipient's need for acute care.
14 b. Beneficiary: "Beneficiary" means a person certified as eligible for services
15 under the Medi-Cal program according to Section 41001, Title 22,
16 California Code of Regulations, who is a Fresno County Beneficiary and
17 who is designated by "County Code 10."
18 c. Delegate: "Delegate" means any natural or corporate person to whom the
19 Contractor transfers, pursuant to the terms of this Agreement, the primary
20 responsibility to perform any covenant assumed by Contractor in this
21 Agreement.
22 d. Fiscal Intermediary: "Fiscal Intermediary" means that person or entity that
23 has contracted, as specified in Section 14104.3 of the California Welfare
24 and Institutions Code, with the Department to perform fiscal intermediary
25 services related to this Agreement.
26 e. Recipients: "Recipients" refers to all persons including, without limitation,
27 low income, uninsured and under-insured persons who qualify for
28 mandated health services under the Uniform Method for Determining
Exhibit A
1 Ability to Pay (UMDAP) under California Welfare and Institutions Code
2 Sections 5709 and 5710 as determined by County.
3 f. Psychiatric Inpatient Hospital Services: "Psychiatric Inpatient Hospital
4 Services" means services, to include but not limited to, facilities,
5 professional, allied and supportive medical and paramedical personnel as
6 provided either in an acute care hospital or a free-standing psychiatric
7 hospital to Beneficiaries and Recipients referred by County, for the care
8 and treatment of an acute episode of mental illness.
9 g. Medically Necessary Services: "Medically Necessary Services" are as
10 defined by California Code of Regulations, Title 9, Chapter 11, Section
11 1820.205.
12 h. Physician and Transportation Services: "Physician Services" are those
13 services provided by physician(s) or Psychologist(s) during an acute
14 inpatient stay. "Transportation Services" means those services provided
15 for transport to or from an acute inpatient facility or to or from an
16 appropriate facility.
17 i. Day of Discharge: "Day of Discharge" means the day from 12:00 midnight
18 to 11:59 P.M. where the Beneficiary or Recipient is discharged from
19 Contractor's facility.
20 II. Psychiatric Services
21 a. Contractor agrees to render adult Inpatient Psychiatric Hospital services
22 to any Beneficiary in need of such services in accordance with regulations
23 adopted pursuant to Sections 14700 et seq., 14712 et seq., and 14680 et
24 seq. of the California Welfare and Institutions Code, and to Recipients
25 referred by County or by an acute inpatient facility following medical
26 clearance of a beneficiary or recipient placed on an involuntary
27 psychiatric hold pursuant to California Welfare and Institutions Code 5150
28 when Contractor has the facilities available.
Exhibit A
1 b. Contractor shall also triage any Beneficiary who directly seeks Adult
2 Psychiatric Inpatient Hospital Services. Contractor shall also accept any
3 Beneficiary who directly seeks Adult Psychiatric Inpatient Hospital
4 Services when Contractor has facilities available. Subject to third party
5 liability and patient share of costs, if applicable, Contractor agrees to
6 accept as payment in full for Adult Psychiatric Inpatient Hospital Services
7 payment, as provided in Article 4.
8 c. County and Contractor mutually recognize that services under this
9 Agreement will be rendered by Contractor to persons who meet medical
10 necessity criteria for inpatient psychiatric hospitalization and it is not the
11 intention of either County or Contractor that such individuals occupy the
12 position of third-party beneficiaries of the obligations assumed by either
13 party to this Agreement.
14 d. Contractor shall provide or arrange for the provision and compensation of
15 Physician services for Beneficiaries and Recipients as it relates to
16 physical health issues, with the exception of the initial physical and health
17 (P&H) examination at admission which is included in the day rate as
18 provided in Exhibit F.
19 e. Contractor shall, at its own expense, provide and maintain facilities and
20 professional, allied and supportive medical and paramedical personnel to
21 provide all necessary and appropriate Adult Psychiatric Inpatient Hospital
22 Services and shall ensure that family members are involved in treatment
23 when appropriate and family is willing to participate.
24 f. Contractor shall, at its own expense, provide and maintain the
25 organizational and administrative capabilities to carry out its duties and
26 responsibilities under this Agreement and all applicable statutes and
27 regulations pertaining to Medi-Cal contractors.
28
Exhibit A
1 g. Contractor shall receive reimbursement for an Administrative Day(s) from
2 the California State Department of Health Care Services, upon the
3 condition that Contractor agrees to be responsible for contacting less
4 restrictive facilities (i.e., board and care facilities, room and board
5 facilities, licensed adult residential care facilities, etc.) within a sixty (60)
6 mile radius of Contractor's facility at least once every five (5) days to
7 place Beneficiary when Beneficiary no longer requires Contractor's acute
8 care. These contacts must be documented by a brief description of
9 status and the signature of the person making the contacts.
10 Beneficiary's chart shall be reviewed on a weekly basis if the
11 Beneficiary's status has changed.
12 h. Adult Psychiatric Inpatient Hospital Services rendered pursuant to this
13 Agreement shall be rendered at the following facility: Community
14 Behavioral Health Center, 7171 N. Cedar Avenue, Fresno, CA 93720,
15 except as permitted Section V of this exhibit.
16 i. Quality of Care: As express conditions precedent to any authorization by
17 County for payment under the terms of this Agreement, whether services
18 are performed directly or through the instrumentality of a Delegate as
19 permitted under this Agreement, Contractor shall:
20 i. Assure that any and all eligible Beneficiaries receive care as
21 required by Sections 14700 et seq. and 14712 et seq. of the
22 California Welfare and Institutions Code (WIC) and assure that
23 the same quality of care is rendered to all Recipients referred by
24 County. Payment may be denied by County when requirements
25 of cited WIC sections are not met.
26 ii. Take such action as required by Contractor's Medical Staff
27 bylaws against medical staff members who violate those bylaws,
28 as the same may be from time to time amended.
Exhibit A
1 iii. Provide Psychiatric Inpatient Hospital Services in the same
2 manner to persons covered by this Agreement as it provides to
3 all persons to whom it renders Psychiatric Inpatient Hospital
4 Services.
5 iv. Not discriminate in any manner, including admission practices
6 and placement in special or separate wings or rooms, nor make
7 any provision of special or separate meals.
8 III. Contractor's Professional and Administrative Responsibilities
9 To the extent required by Title 22, Division 5, Chapter 1, Section 70713 of the
10 California Code of Regulations, Contractor retains professional and
11 administrative responsibility for the services rendered pursuant to this
12 Agreement. Contractor's retention of these responsibilities shall not alter or
13 modify, in any way, the hold harmless, indemnification, insurance or independent
14 contractor provisions set forth in this Agreement.
15 IV. Licensure and Certification Conditions:
16 a. Contractor hereby represents and warrants that it is currently, and for the
17 duration of this Agreement shall remain, certified by the Joint Commission
18 and licensed as a general acute care hospital or acute psychiatric hospital
19 in accordance with Sections 1250 et seq. of the Health and Safety Code
20 and the licensing regulations contained in Title 22 and Title 17 of the
21 California Code of Regulations.
22 b. Contractor hereby represents and warrants that it is currently, and for the
23 duration of this Agreement shall remain, certified under Title XVIII of the
24 Federal Social Security Act (42 U.S.C. Sections 1395 et seq.).
25 V. Delegation of Contractor's Duties.
26 a. When Permitted:
27 i. Contractor and County recognize that the Adult Psychiatric
28 Inpatient Hospital Services to be rendered under this Agreement
Exhibit A
1 are personal and non-delegable, except as provided in this
2 Agreement. Any attempt by Contractor to delegate or otherwise
3 vest responsibility for performance of its duties in any manner
4 other than those expressly permitted in this article shall
5 constitute a present material breach of this Agreement.
6 ii. Except as limited by section V(a)(v), delegation of duties by
7 Contractor shall not constitute a present material breach only if
8 such delegation is in conformity with one of the following:
9 1. The Delegate renders the Adult Psychiatric Inpatient
10 Hospital Services at Contractor's facility or location.
11 2. For services to Medi-Cal Beneficiaries only, if the total of
12 all payments by Contractor for all delegated services not
13 covered under this section by V(a)(ii)(1) nor specially
14 authorized under V(a)(ii)(3) will not exceed five percent
15 (5%) of the total Medi-Cal inpatient psychiatric billing by
16 Contractor in any consecutive three (3) month period,
17 Contractor may delegate duties to any qualified delegate
18 section V(a)(iii) without written approval of County.
19 3. Any delegation not authorized under this V(a)(ii) by (1) or
20 by (2) shall require the prior written approval of County.
21 Such prior written approval must be requested in a written
22 application which identifies the proposed Delegate or
23 Delegates, warrants their qualification to render services
24 required by and in conformity with the terms of this
25 Agreement, and identifies the categories of services to be
26 delegated along with an estimate of the percentage of
27 services in those categories which Contractor anticipates
28 will be rendered by the Delegate or Delegates.
Exhibit A
1 iii. When authorization is given pursuant to section V(a)(ii)(3),
2 Contractor shall be responsible for all aspects of performance by
3 its Delegate or Delegates. Contractor hereby agrees that any
4 default, refusal to perform or defective performance of any
5 delegated duty or service shall constitute a breach of this
6 Agreement on the part of Contractor to the same extent as if
7 such default, refusal to perform or defective performance had
8 been directly committed or incurred by Contractor.
9 iv. All costs for services rendered by a Delegate or Delegates are
10 included in the all—inclusive rates paid to Contractor pursuant to
11 Exhibit F.
12 V. As a limitation upon the authorizations set forth in this section
13 V(a), no delegation shall be attempted or entered if:
14 1. The Delegate is not licensed and certified to the same
15 extent as that required of Contractor under section 12.1 of
16 the agreement; or
17 2. The location at which the Delegate is to perform the
18 delegated services is at such a distance from Contractor's
19 location that it is beyond the range considered acceptable
20 in the opinion of County for provision of the delegated
21 services as it could unnecessarily or unduly burden
22 affected Beneficiaries or Recipients; or
23 3. The services are available at Contractor's location.
24 Contractor shall not discriminate against Beneficiaries in
25 making a determination of availability of facilities at its own
26 location.
27 b. How Accomplished:
28
Exhibit A
1 In any delegation pursuant to authorization contained in Exhibit F,
2 Contractor shall contract in writing with a Delegate or Delegates for the
3 assumption of the primary duty of performance of the duties assumed by
4 Contractor under the terms of this Agreement. Any written contract of
5 delegation shall include the following:
6 i. Covenants on the part of Contractor and the Delegate that the
7 contract of delegation shall be governed by and construed in
8 accordance with all applicable laws and regulations and this
9 Agreement.
10 ii. Specification of the services to be provided by the Delegate.
11 iii. Specification of the term of the contract of delegation including
12 the beginning and ending dates, as well as methods of
13 extension, renegotiation and termination.
14 iv. A warranty by the Delegate that it presently conforms, and
15 during the life of the delegation shall continue to conform, to the
16 Iicensure and certification requirements exacted from Contractor
17 under section 12.1 and that its failure to abide by the terms of
18 this warranty shall be an express condition subsequently
19 discharging Contractor from all obligations under the terms of
20 the contract of delegation.
21 V. A covenant running to County as an intended third-party
22 beneficiary of the contract of delegation where by the Delegate
23 promises:
24 1. To maintain, for at least six (6) years after the close of the
25 fiscal year (FY) in which the contract of delegation was in
26 effect, full books and records pertaining to the goods and
27 services furnished under the terms of the delegation in
28
Exhibit A
1 accordance with general standards applicable to such
2 book and record keeping.
3 2. To make the books and records maintained per subsection
4 V(B)(v)(1), above, available for inspection, examination or
5 copying by agents of County, DHCS, and the United States
6 Department of Health and Human Services at all
7 reasonable times at the Delegate's place of business, or at
8 such other location in California approved in writing by
9 County.
10 3. To make full disclosure of the method and amount of
11 compensation or other direct or indirect consideration
12 received by the Delegate from Contractor.
13 4. That no services rendered on behalf of Contractor by the
14 Delegate pursuant to the contract of delegation will be
15 billed to County or the fiscal intermediary by the Delegate;
16 the Delegate will look exclusively to Contractor for
17 compensation under the terms of the contract of
18 delegation.
19 5. To hold harmless County, the California State Department
20 of Health Care Services, the State of California and
21 Beneficiaries in the event that Contractor cannot or will not
22 pay for services performed by the Delegate pursuant to the
23 terms of the contract of delegation.
24 VI. Notification of Admission
25 Contractor shall notify County within 24 hours, or next business day, of all
26 Beneficiaries and or Recipients admitted for services if those admitted are not
27 direct referrals of County.
28 VII. Discharge Planning and Care Coordination
Exhibit A
1 All parties, pursuant to the Mental Health Plan, shall participate as needed in
2 discharge planning and care coordination to ensure that each person
3 hospitalized is supported through the transition process with necessary
4 outpatient mental health and other necessary services once the person served is
5 discharged. DBH case managers will provide input on planning to Contractor and
6 will assist seriously mentally ill persons served with necessary outpatient mental
7 health and other necessary services once the person served is discharged.
8 County staff will not be responsible for the outcome of the discharge planning or
9 the bed utilization of the persons served.
10 VIII. UMDAP Application
11 Contractor shall inform low income, uninsured and under-insured persons
12 admitted to facility of the County's UMDAP program. County authorizes
13 Contractor to initiate the UMDAP application process using a County-approved
14 form (Exhibit E of this Agreement) and may transcribe information as stated by
15 person or family onto said form. The application form must have the original
16 signature of the person admitted to facility or his/her authorized representative.
17 The completed application shall be submitted to County within one (1) business
18 day of admission for inpatient psychiatric services. County reserves the right to
19 determine UMDAP eligibility and will notify Contractor of the person's eligibility
20 within five (5) working days.
21
22
23
24
25
26
27
28
Exhibit B
BEHAVIORAL 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 Plan
(directly or through contract) providing Short-Doyle/Medi-Cal services have met
applicable professional licensure requirements pursuant to Business and
Professions and Welfare and Institutions Codes.
3. CONFIDENTIALITY
Contractor shall conform to and County shall monitor compliance with all State of
California and Federal statutes and regulations regarding confidentiality,
including but not limited to confidentiality of information requirements at 42, Code
of Federal Regulations sections 2.1 et seq; California Welfare and Institutions
Code, sections 14100.2, 11977, 11812, 5328; Division 10.5 and 10.6 of the
California Health and Safety Code; Title 22, California Code of Regulations,
section 51009; and Division 1, Part 2.6, Chapters 1-7 of the California Civil Code.
4. NON-DISCRIMINATION
A. Eligibility for Services
Contractor shall prepare and make available to County and to the public
all eligibility requirements to participate in the program plan set forth in the
Agreement. No person shall, because of ethnic group identification, age,
gender, color, disability, medical condition, national origin, race, ancestry,
marital status, religion, religious creed, political belief or sexual
preference be excluded from participation, be denied benefits of, or be
subject to discrimination under any program or activity receiving Federal
or State of California assistance.
B. Employment Opportunity
Contractor shall comply with County policy, and the Equal Employment
Opportunity Commission guidelines, which forbids discrimination against
any person on the grounds of race, color, national origin, sex, religion,
age, disability status, or sexual preference in employment practices.
Such practices include retirement, recruitment advertising, hiring, layoff,
termination, upgrading, demotion, transfer, rates of pay or other forms of
compensation, use of facilities, and other terms and conditions of
employment.
B-1
Exhibit B
C. Suspension of Compensation
If an allegation of discrimination occurs, County may withhold all further
funds, until Contractor can show clear and convincing evidence to the
satisfaction of County that funds provided under this Agreement were not
used in connection with the alleged discrimination.
D. Nepotism
Except by consent of County's Department of Behavioral Health Director,
or designee, no person shall be employed by Contractor who is related by
blood or marriage to, or who is a member of the Board of Directors or an
officer of Contractor.
5. PATIENTS' RIGHTS
Contractor shall comply with applicable laws and regulations, including but not
limited to, laws, regulations, and State policies relating to patients' rights.
STATE CONTRACTOR CERTIFICATION CLAUSES
1. STATEMENT OF COMPLIANCE: Contractor has, unless exempted, complied
with the non-discrimination program requirements. (Gov. Code§ 12990 (a-f) and
CCR, Title 2, Section 111 02) (Not applicable to public entities.)
2. DRUG-FREE WORKPLACE REQUIREMENTS: Contractor will comply with the
requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-
free workplace by taking the following actions:
A. Publish a statement notifying employees that unlawful manufacture,
distribution, dispensation, possession or use of a controlled substance is
prohibited and specifying actions to be taken against employees for
violations.
b. Establish a Drug-Free Awareness Program to inform employees about:
1) the dangers of drug abuse in the workplace;
2) the person's or organization's policy of maintaining a drug-free
workplace;
3) any available counseling, rehabilitation and employee assistance
programs; and,
4) penalties that may be imposed upon employees for drug abuse
violations.
C. Every employee who works on this Agreement will:
1) receive a copy of the company's drug-free workplace policy
statement; and,
2) agree to abide by the terms of the company's statement as a
condition of employment on this Agreement.
B-2
Exhibit B
Failure to comply with these requirements may result in suspension of payments
under this Agreement or termination of this Agreement or both and Contractor
may be ineligible for award of any future State agreements if the department
determines that any of the following has occurred: the Contractor has made
false certification, or violated the certification by failing to carry out the
requirements as noted above. (Gov. Code §8350 et seq.)
3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION: Contractor
certifies that no more than one (1) final unappealable finding of contempt of court
by a Federal court has been issued against Contractor within the immediately
preceding two (2) year period because of Contractor's failure to comply with an
order of a Federal court, which orders Contractor to comply with an order of the
National Labor Relations Board. (Pub. Contract Code §10296) (Not applicable to
public entities.)
4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO
REQUIREMENT: Contractor hereby certifies that Contractor will comply with the
requirements of Section 6072 of the Business and Professions Code, effective
January 1, 2003.
Contractor agrees to make a good faith effort to provide a minimum number of
hours of pro bono legal services during each year of the contract equal to the
lessor of 30 multiplied by the number of full time attorneys in the firm's offices in
the State, with the number of hours prorated on an actual day basis for any
contract period of less than a full year or 10% of its contract with the State.
Failure to make a good faith effort may be cause for non-renewal of a state
contract for legal services, and may be taken into account when determining the
award of future contracts with the State for legal services.
5. EXPATRIATE CORPORATIONS: Contractor hereby declares that it is not an
expatriate corporation or subsidiary of an expatriate corporation within the
meaning of Public Contract Code Section 10286 and 10286.1, and is eligible to
contract with the State of California.
6. SWEATFREE CODE OF CONDUCT:
a. All Contractors contracting for the procurement or laundering of apparel,
garments or corresponding accessories, or the procurement of
equipment, materials, or supplies, other than procurement related to a
public works contract, declare under penalty of perjury that no apparel,
garments or corresponding accessories, equipment, materials, or
supplies furnished to the state pursuant to the contract have been
laundered or produced in whole or in part by sweatshop labor, forced
labor, convict labor, indentured labor under penal sanction, abusive forms
of child labor or exploitation of children in sweatshop labor, or with the
benefit of sweatshop labor, forced labor, convict labor, indentured labor
under penal sanction, abusive forms of child labor or exploitation of
children in sweatshop labor. Contractor further declares under penalty of
perjury that they adhere to the Sweatfree Code of Conduct as set forth on
B-3
Exhibit B
the California Department of Industrial Relations website located at
www.dir.ca.gov, and Public Contract Code Section 6108.
b. Contractor agrees to cooperate fully in providing reasonable access to the
Contractor's records, documents, agents or employees, or premises if
reasonably required by authorized officials of the contracting agency, the
Department of Industrial Relations, or the Department of Justice to
determine the Contractor's compliance with the requirements under
paragraph (a).
7. DOMESTIC PARTNERS: For contracts of$100,000 or more, Contractor
certifies that Contractor is in compliance with Public Contract Code Section
10295.3.
8. GENDER IDENTITY: For contracts of$100,000 or more, Contractor certifies
that CONTRACTOR is in compliance with Public Contract Code Section
10295.35.
DOING BUSINESS WITH THE STATE OF CALIFORNIA
The following laws apply to persons or entities doing business with the State of
California.
1. CONFLICT OF INTEREST: Contractor needs to be aware of the following
provisions regarding current or former state employees. If Contractor has any
questions on the status of any person rendering services or involved with this
Agreement, the awarding agency must be contacted immediately for clarification.
Current State Employees (Pub. Contract Code M 0410):
a). No officer or employee shall engage in any employment, activity or
enterprise from which the officer or employee receives compensation or
has a financial interest and which is sponsored or funded by any state
agency, unless the employment, activity or enterprise is required as a
condition of regular state employment.
b). No officer or employee shall contract on his or her own behalf as an
independent Contractor with any state agency to provide goods or
services.
Former State Employees (Pub. Contract Code §10411):
a). For the two (2) year period from the date he or she left state employment,
no former state officer or employee may enter into a contract in which he
or she engaged in any of the negotiations, transactions, planning,
arrangements or any part of the decision-making process relevant to the
contract while employed in any capacity by any state agency.
B-4
Exhibit B
b). For the twelve (12) month period from the date he or she left state
employment, no former state officer or employee may enter into a
contract with any state agency if he or she was employed by that state
agency in a policy-making position in the same general subject area as
the proposed contract within the twelve (12) month period prior to his or
her leaving state service.
If Contractor violates any provisions of above paragraphs, such action by
Contractor shall render this Agreement void. (Pub. Contract Code §10420)
Members of boards and commissions are exempt from this section if they do not
receive payment other than payment of each meeting of the board or
commission, payment for preparatory time and payment for per diem. (Pub.
Contract Code §10430 (e))
2. LABOR CODE/WORKERS' COMPENSATION: Contractor needs to be aware
of the provisions which require every employer to be insured against liability for
Worker's Compensation or to undertake self-insurance in accordance with the
provisions, and CONTRACTOR affirms to comply with such provisions before
commencing the performance of the work of this Agreement. (Labor Code
Section 3700)
3. AMERICANS WITH DISABILITIES ACT: Contractor assures the State that it
complies with the Americans with Disabilities Act (ADA) of 1990, which prohibits
discrimination on the basis of disability, as well as all applicable regulations and
guidelines issued pursuant to the ADA. (42 U.S.C. 12101 et seq.)
4. CONTRACTOR NAME CHANGE: An amendment is required to change the
Contractor's name as listed on this Agreement. Upon receipt of legal
documentation of the name change the State will process the amendment.
Payment of invoices presented with a new name cannot be paid prior to approval
of said amendment.
5. CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:
a. When agreements are to be performed in the state by corporations, the
contracting agencies will be verifying that the CONTRACTOR is currently
qualified to do business in California in order to ensure that all obligations
due to the state are fulfilled.
b. "Doing business" is defined in R&TC Section 23101 as actively engaging
in any transaction for the purpose of financial or pecuniary gain or profit.
Although there are some statutory exceptions to taxation, rarely will a
corporate Contractor performing within the state not be subject to the
franchise tax.
C. Both domestic and foreign corporations (those incorporated outside of
California) must be in good standing in order to be qualified to do
business in California. Agencies will determine whether a corporation is
in good standing by calling the Office of the Secretary of State.
B-5
Exhibit B
6. RESOLUTION: A County, city, district, or other local public body must provide
the State with a copy of a resolution, order, motion, or ordinance of the local
governing body, which by law has authority to enter into an agreement,
authorizing execution of the agreement.
7. AIR OR WATER POLLUTION VIOLATION: Under the State laws, the
Contractor shall not be: (1) in violation of any order or resolution not subject to
review promulgated by the State Air Resources Board or an air pollution control
district; (2) subject to cease and desist order not subject to review issued
pursuant to Section 13301 of the Water Code for violation of waste discharge
requirements or discharge prohibitions; or (3)finally determined to be in violation
of provisions of federal law relating to air or water pollution.
8. PAYEE DATA RECORD FORM STD. 204: This form must be completed by all
Contractors that are not another state agency or other governmental entity.
9. INSPECTION AND AUDIT OF RECORDS AND ACCESS TO FACILITIES:
The State, CMS, the Office of the Inspector General, the Comptroller General,
and their designees may, at any time, inspect and audit any records or
documents of Contractor or its subcontractors, and may, at any time, inspect the
premises, physical facilities, and equipment where Medicaid-related activities or
work is conducted. The right to audit under this section exists for ten (10) years
from the final date of the contract period or from the date of completion of any
audit, whichever is later.
Federal database checks.
Consistent with the requirements at § 455.436 of this chapter, the State must
confirm the identity and determine the exclusion status of Contractor, any
subcontractor, as well as any person with an ownership or control interest, or
who is an agent or managing employee of Contractor through routine checks of
Federal databases. This includes the Social Security Administration's Death
Master File, the National Plan and Provider Enumeration System (NPPES), the
List of Excluded Individuals/Entities (LEIE), the System for Award Management
(SAM), and any other databases as the State or Secretary may prescribe. These
databases must be consulted upon contracting and no less frequently than
monthly thereafter. If the State finds a party that is excluded, it must promptly
notify the Contractor and take action consistent with § 438.610(c).
The State must ensure that Contractor with which the State contracts under this
part is not located outside of the United States and that no claims paid by a
Contractor to a network provider, out-of-network provider, subcontractor or
financial institution located outside of the U.S. are considered in the development
of actuarially sound capitation rates.
B-6
Exhibit B
CALIFORNIA ADVANCING AND INNOVATING MEDI-CAL (CAL-AIM)
REQUIREMENTS
1. SERVICES AND ACCESS PROVISIONS
a. CERTIFICATION OF ELIGIBILITY
i. Contractor will, in cooperation with County, comply with Section
14705.5 of California Welfare and Institutions Code to obtain a
certification of an individual's eligibility for Specialty Mental Health
Services (SMHS) under Medi-Cal.
b. ACCESS TO SPECIALTY MENTAL HEALTH SERVICES
i. In collaboration with the County, Contractor will work to ensure
that individuals to whom the Contractor provides SMHS meet
access criteria, as per Department of Health Care Services
(DHCS) guidance specified in BHIN 21-073. Specifically, the
Contractor will ensure that the clinical record for each individual
includes information as a whole indicating that individual's
presentation and needs are aligned with the criteria applicable to
their age at the time of service provision as specified below.
ii. For enrolled individuals under 21 years of age, Contractor shall
provide all medically necessary SMHS required pursuant to
Section 1396d(r) of Title 42 of the United States Code. Covered
SMHS shall be provided to enrolled individuals who meet either of
the following criteria, (1) or (11) below. If an individual under age 21
meets the criteria as described in (1) below, the beneficiary meets
criteria to access SMHS; it is not necessary to establish that the
beneficiary also meets the criteria in (b) below.
1. The individual has a condition placing them at high risk for
a mental health disorder due to experience of trauma
evidenced by any of the following: scoring in the high-risk
range under a trauma screening tool approved by DHCS,
involvement in the child welfare system, juvenile justice
involvement, or experiencing homelessness.
OR
2. The individual has at least one of the following:
a. A significant impairment
b. A reasonable probability of significant deterioration
in an important area of life functioning
c. A reasonable probability of not progressing
developmentally as appropriate.
d. A need for SMHS, regardless of presence of
impairment, that are not included within the mental
health benefits that a Medi-Cal Managed Care Plan
(MCP) is required to provide.
AND the individual's condition as described in subparagraph
(11 a-d) above is due to one of the following:
B-7
Exhibit B
a. A diagnosed mental health disorder, according to
the criteria in the current editions of the Diagnostic
and Statistical Manual of Mental Disorders (DSM)
and the International Classification of Diseases and
Related Health Problems (ICD).
b. A suspected mental health disorder that has not yet
been diagnosed.
c. Significant trauma placing the individual at risk of a
future mental health condition, based on the
assessment of a licensed mental health
professional.
iii. For individuals 21 years of age or older, Contractor shall provide
covered SMHS for clients who meet both of the following criteria,
(a) and (b) below:
1. The individual has one or both of the following:
a. Significant impairment, where impairment is defined
as distress, disability, or dysfunction in social,
occupational, or other important activities.
b. A reasonable probability of significant deterioration
in an important area of life functioning.
2. The individual's condition as described in paragraph (a) is
due to either of the following:
a. A diagnosed mental health disorder, according to
the criteria in the current editions of the DSM and
ICD.
b. A suspected mental disorder that has not yet been
diagnosed.
c. ADDITIONAL CLARIFICATIONS
i. Criteria
1. A clinically appropriate and covered mental health
prevention, screening, assessment, treatment, or recovery
service listed within Exhibit A of this Agreement can be
provided and submitted to the County for reimbursement
under any of the following circumstances:
a. The services were provided prior to determining a
diagnosis, including clinically appropriate and
covered services provided during the assessment
process;
b. The service was not included in an individual
treatment plan; or
c. The individual had a co-occurring substance use
disorder.
ii. Diagnosis Not a Prerequisite
1. Per BHIN 21-073, a mental health diagnosis is not a
prerequisite for access to covered SMHS. This does not
eliminate the requirement that all Medi-Cal claims,
including SMHS claims, include a current Centers for
B-8
Exhibit B
Medicare & Medicaid Services (CMS) approved ICD
diagnosis code
d. MEDICAL NECESSITY
i. Contractor will ensure that services provided are medically
necessary in compliance with BHIN 21-073 and pursuant to
Welfare and Institutions Code section 14184.402(a). Services
provided to a client must be medically necessary and clinically
appropriate to address the individual's presenting condition.
Documentation in each individual's chart as a whole will
demonstrate medical necessity as defined below, based on the
client's age at the time of service provision.
ii. For individuals 21 years of age or older, a service is "medically
necessary" or a "medical necessity" when it is reasonable and
necessary to protect life, to prevent significant illness or significant
disability, or to alleviate severe pain as set forth in Welfare and
Institutions Code section 14059.5.
iii. For individuals under 21 years of age, a service is "medically
necessary" or a "medical necessity" if the service meets the
standards set forth in Section 1396d(r)(5) of Title 42 of the United
States Code.
e. COORDINATION OF CARE
i. Contractor shall ensure that all care, treatment and services
provided pursuant to this Agreement are coordinated among all
providers who are serving the individual, including all other SMHS
providers, as well as providers of Non-Specialty Mental Health
Services (NSMHS), substance use disorder treatment services,
physical health services, dental services, regional center services
and all other services as applicable to ensure a client-centered
and whole-person approach to services.
ii. Contractor shall ensure that care coordination activities support
the monitoring and treatment of comorbid substance use disorder
and/or health conditions.
iii. Contractor shall include in care coordination activities efforts to
connect, refer and link individual s to community-based services
and supports, including but not limited to educational, social,
prevocational, vocational, housing, nutritional, criminal justice,
transportation, childcare, child development, family/marriage
education, cultural sources, and mutual aid support groups.
iv. Contractor shall engage in care coordination activities beginning
at intake and throughout the treatment and discharge planning
processes.
v. To facilitate care coordination, Contractor will request a HIPAA
and California law compliant client authorization to share the
individual's information with and among all other providers
involved in the individual's care, in satisfaction of state and federal
privacy laws and regulations.
f. CO-OCCURRING TREATMENT AND NO WRONG DOOR
B-9
Exhibit B
i. Per BHIN 22-011, Specialty and Non-Specialty Mental Health
Services can be provided concurrently, if those services are
clinically appropriate, coordinated, and not duplicative. When a
client meets criteria for both NSMHS and SMHS, the individual
should receive services based on individual clinical need and
established therapeutic relationships. Clinically appropriate and
covered SMHS can also be provided when the individual has a co-
occurring mental health condition and substance use disorder.
ii. Under this Agreement, Contractor will ensure that individual s
receive timely mental health services without delay. Services are
reimbursable to Contractor by County even when:
1. Services are provided prior to determination of a diagnosis,
during the assessment or prior to determination of whether
SMHS access criteria are met, even if the assessment
ultimately indicates the individual does not meet criteria for
SMHS.
2. If Contractor is serving a individual receiving both SMHS
and NSMHS, Contractor holds responsibility for
documenting coordination of care and ensuring that
services are non-duplicative.
2. AUTHORIZATION AND DOCUMENTATION PROVISIONS
a. SERVICE AUTHORIZATION
i. Contractor will collaborate with County to complete authorization
requests in line with County and DHCS policy.
ii. Contractor shall have in place, and follow, written policies and
procedures for completing requests for initial and continuing
authorizations of services, as required by County guidance.
iii. Contractor shall respond to County in a timely manner when
consultation is necessary for County to make appropriate
authorization determinations.
iv. County shall provide Contractor with written notice of authorization
determinations within the timeframes set forth in BHINs 22-016
and 22-017, or any subsequent DHCS notices.
v. Contractor shall alert County when an expedited authorization
decision (no later than 72 hours) is necessary due to an
individual's specific needs and circumstances that could seriously
jeopardize the individual s life or health, or ability to attain,
maintain, or regain maximum function.
b. DOCUMENTATION REQUIREMENTS
i. Contractor will follow all documentation requirements as specified
in Article 4.2-4.8 inclusive in compliance with federal, state and
County requirements.
ii. All Contractor documentation shall be accurate, complete, and
legible, shall list each date of service, and include the face-to-face
time for each service. Contractor shall document travel and
documentation time for each service separately from face-to-face
time and provide this information to County upon request.
B-10
Exhibit B
Services must be identified as provided in-person, by telephone,
or by telehealth.
iii. All services shall be documented utilizing County-approved
templates and contain all required elements. Contractor agrees to
satisfy the chart documentation requirements set forth in BHIN 22-
019 and the contract between County and DHCS. Failure to
comply with documentation standards specified in this Article
require corrective action plans.
c. ASSESSMENT
i. Contractor shall ensure that all individuals' medical records
include an assessment of each individual's need for mental health
services.
ii. Contractor will utilize the seven uniform assessment domains and
include other required elements as identified in BHIN 22-019 and
document the assessment in the individual's medical record.
iii. For individuals aged 6 through 21, the Child and Adolescent
Needs and Strengths (CANS), and for individual s aged 3 through
18, the Pediatric Symptom Checklist-35 (PSC-35) tools are
required at intake, every six months during treatment, and at
discharge, as specified in DHCS MHSUDS INs 17-052 and 18-
048.
iv. The time period for providers to complete an initial assessment
and subsequent assessments for SMHS are up to clinical
discretion of County; however, Contractor's providers shall
complete assessments within a reasonable time and in
accordance with generally accepted standards of practice.
d. ICD-10
i. Contractor shall use the criteria set forth in the current edition of
the DSM as the clinical tool to make diagnostic determinations.
ii. Once a DSM diagnosis is determined, the Contractor shall
determine the corresponding mental health diagnosis in the
current edition of ICD. Contractor shall use the ICD diagnosis
code(s) to submit a claim for SMHS to receive reimbursement
from County.
iii. The ICD Tabular List of Diseases and Injuries is maintained by
CMS and may be updated during the term of this Agreement.
Changes to the lists of ICD diagnoses do not require an
amendment to this Agreement, and County may implement these
changes as provided by CMS
e. PROBLEM LIST
i. Contractor will create and maintain a Problem List for each
individual served under this Agreement. The problem list is a list of
symptoms, conditions, diagnoses, and/or risk factors identified
through assessment, psychiatric diagnostic evaluation, crisis
encounters, or other types of service encounters.
ii. Contractor must document a problem list that adheres to industry
standards utilizing at minimum current SNOMED International,
B-11
Exhibit B
Systematized Nomenclature of Medicine Clinical Terms
(SNOMED CTO) U.S. Edition, September 2022 Release, and ICD-
10-CM 2023.
iii. A problem identified during a service encounter may be addressed
by the service provider during that service encounter and
subsequently added to the problem list.
iv. The problem list shall include, but is not limited to, all elements
specified in BHIN 22-019.
v. County does not require the problem list to be updated within a
specific timeframe or have a requirement about how frequently the
problem list should be updated after a problem has initially been
added. However, Contractor shall update the problem list within a
reasonable time such that the problem list reflects the current
issues facing the client, in accordance with generally accepted
standards of practice and in specific circumstances specified in
BHIN 22-019.
f. TREATMENT AND CARE PLANS
i. Contractor is not required to complete treatment or care plans for
clients under this Agreement, except in the circumstances
specified in BHIN 22-019 and additional guidance from DHCS that
may follow after execution of this Agreement.
g. PROGRESS NOTES
i. Contractor shall create progress notes for the provision of all
SMHS services provided under this Agreement.
ii. Each progress note shall provide sufficient detail to support the
service code selected for the service type as indicated by the
service code description.
iii. Progress notes shall include all elements specified in BHIN 22-
019, whether the note be for an individual or a group service.
iv. Contractor shall complete progress notes within three business
days of providing a service, with the exception of notes for crisis
services, which shall be completed within 24 hours.
v. Providers shall complete a daily progress note for services that
are billed on a daily basis, such as residential and day treatment
services, if applicable.
h. TRANSITION OF CARE TOOL
i. Contractor shall use a Transition of Care Tool for any individual
whose existing services will be transferred from Contractor to an
Medi-Cal Managed Care Plan (MCP) provider or when NSMHS
will be added to the existing mental health treatment provided by
Contractor, as specified in BHIN 22-065, in order to ensure
continuity of care.
ii. Determinations to transition care or add services from an MCP
shall be made in alignment with County policies and via a person-
centered, shared decision-making process.
iii. Contractor may directly use the DHCS-provided Transition of Care
Tool, found at https://www.dhcs.ca.gov/Pages/Screening-and-
B-12
Exhibit B
Transition-of-Care-Tools-for-Medi-Cal-Mental-Health-
Services.aspx, or obtain a copy of that tool provided by the
County. Contractor may create the Transition of Care Tool in its
Electronic Health Record (EHR). However, the contents of the
Transition of Care Tool, including the specific wording and order of
fields, shall remain identical to the DHCS provided form. The only
exception to this requirement is when the tool is translated into
languages other than English.
i. TELEHEALTH
i. Contractor may use telehealth, when it deems clinically
appropriate, as a mode of delivering behavioral health services in
accordance with all applicable County, state, and federal
requirements, including those related to privacy/security,
efficiency, and standards of care. Such services will conform to
the definitions and meet the requirements included in the Medi-Cal
Provider Manual: Telehealth, available in the DHCS Telehealth
Resources page at:
https://www.dhcs.ca.gov/provqovpart/Pages/TelehealthResources
.aspx.
ii. All telehealth equipment and service locations must ensure that
client confidentiality is maintained.
iii. Licensed providers and staff may provide services via telephone
and telehealth as long as the service is within their scope of
practice.
iv. Medical records for individuals served by Contractor under this
Agreement must include documentation of written or verbal
consent for telehealth or telephone services if such services are
provided by Contractor. Such consent must be obtained at least
once prior to initiating applicable health care services and consent
must include all elements as specified in BHIN 22-019.
v. County may at any time audit Contractor's telehealth practices,
and Contractor must allow access to all materials needed to
adequately monitor Contractor's adherence to telehealth
standards and requirements.
3. CLIENT PROTECTIONS
a. GRIEVANCES, APPEALS AND NOTICES OF ADVERSE BENEFIT
DETERMINATION
i. All grievances (as defined by 42 C.F.R. § 438.400) and complaints
received by Contractor must be immediately forwarded to the
County's Managed Care Department or other designated persons
via a secure method (e.g., encrypted email or by fax) to allow
ample time for the Managed Care staff to acknowledge receipt of
the grievance and complaints and issue appropriate responses.
ii. Contractor shall not discourage the filing of grievances and
individual s do not need to use the term "grievance" for a
complaint to be captured as an expression of dissatisfaction and,
therefore, a grievance.
B-13
Exhibit B
iii. Aligned with MHSUDS IN 18-010E and 42 C.F.R. §438.404, the
appropriate and delegated Notice of Adverse Benefit
Determination (NOABD) must be issued by Contractor within the
specified timeframes using the template provided by the County.
iv. NOABDs must be issued to individuals anytime the Contractor has
made or intends to make an adverse benefit determination that
includes the reduction, suspension, or termination of a previously
authorized service and/or the failure to provide services in a timely
manner. The notice must have a clear and concise explanation of
the reason(s) for the decision as established by DHCS and the
County. The Contractor must inform the County immediately after
issuing a NOABD.
v. Procedures and timeframes for responding to grievances, issuing
and responding to adverse benefit determinations, appeals, and
state hearings must be followed as per 42 C.F.R., Part 438,
Subpart F (42 C.F.R. §§ 438.400 —438.424).
vi. Contractor must provide individuals any reasonable assistance in
completing forms and taking other procedural steps related to a
grievance or appeal such as auxiliary aids and interpreter
services.
vii. Contractor must maintain records of grievances and appeals and
must review the information as part of its ongoing monitoring
procedures. The record must be accurately maintained in a
manner accessible to the County and available upon request to
DHCS.
b. Advanced Directives
i. Contractor must comply with all County policies and procedures
regarding Advanced Directives in compliance with the
requirements of 42 C.F.R. §§ 422.128 and 438.6(i) (1), (3) and (4).
c. Continuity of Care
i. Contractor shall follow the County's continuity of care policy that is
in accordance with applicable state and federal regulations,
MHSUDS IN 18-059 and any BHINs issued by DHCS for parity in
mental health and substance use disorder benefits subsequent to
the effective date of this Agreement (42 C.F.R. § 438.62(b)(1)-(2).)
4. QUALITY IMPROVEMENT PROGRAM
a. QUALITY IMPROVEMENT ACTIVITIES AND PARTICIPATION
i. Contractor shall implement mechanisms to assess person
served/family satisfaction based on County's guidance. The
Contractor shall assess individual/family satisfaction by:
1. Surveying person served/family satisfaction with the
Contractor's services at least annually.
2. Evaluating person served's grievances, appeals and State
Hearings at least annually.
3. Evaluating requests to change persons providing services
at least annually.
B-14
Exhibit B
4. Informing the County and individuals of the results of
client/family satisfaction activities.
ii. Contractor, if applicable, shall implement mechanisms to monitor
the safety and effectiveness of medication practices. This
mechanism shall be under the supervision of a person licensed to
prescribe or dispense prescription drugs, at least annually and as
required by DBH.
iii. Contractor shall implement mechanisms to monitor appropriate
and timely intervention of occurrences that raise quality of care
concerns. The Contractor shall take appropriate follow-up action
when such an occurrence is identified. The results of the
intervention shall be evaluated by the Contractor at least annually
and shared with the County.
iv. Contractor shall assist County, as needed, with the development
and implementation of Corrective Action Plans.
v. Contractor shall collaborate with County to create a County's QI
Work Plan with documented annual evaluations and documented
revisions as needed. The QI Work Plan shall evaluate the impact
and effectiveness of its quality assessment and performance
improvement program.
vi. Contractor shall attend and participate in the County's Quality
Improvement Committee (QIC) to recommend policy decisions,
review and evaluate results of QI activities, including PIPs,
institute needed Ql actions, and ensure follow-up of Ql processes.
Contractor shall ensure that there is active participation by the
Contractor's practitioners and providers in the QIC.
vii. Contractor shall participate, as required, in annual, independent
external quality reviews (EQR) of the quality, timeliness, and
access to the services covered under this Contract, which are
conducted pursuant to Subpart E of Part 438 of the Code of
Federal Regulations. (42 C.F.R. §§ 438.350(a) and 438.320)
b. TIMELY ACCESS
i. Timely access standards include:
1. Contractor must have hours of operation during which
services are provided to Medi-Cal individuals that are no
less than the hours of operation during which the provider
offers services to non-Medi-Cal individual s. If the
Contractor's provider only serves Medi-Cal clients, the
provider must provide hours of operation comparable to
the hours the provider makes available for Medi-Cal
services that are not covered by the Agreement or another
County.
2. Appointments data, including wait times for requested
services, must be recorded and tracked by Contractor, and
submitted to the County on a monthly basis in a format
specified by the County. Appointments' data should be
submitted to the County's Quality Management
Department or other designated persons.
B-15
Exhibit B
3. Urgent care appointments for services that do not require
prior authorization must be provided to individual s within
48 hours of a request. Urgent appointments for services
that do require prior authorization must be provided to
clients within 96 hours of request.
4. Non-urgent non-psychiatry mental health services,
including, but not limited to Assessment, Targeted Case
Management, and Individual and Group Therapy
appointments (for both adult and children/youth) must be
made available to Medi-Cal individuals within 10 business
days from the date the individual or a provider acting on
behalf of the individual, requests an appointment for a
medically necessary service. Non-urgent psychiatry
appointments (for both adult and children/youth) must be
made available to Medi-Cal individual s within 15 business
days from the date the client or a provider acting on behalf
of the individual, requests an appointment for a medically
necessary service.
5. Applicable appointment time standards may be extended if
the referring or treating provider has determined and noted
in the individual's record that a longer waiting period will
not have a detrimental impact on the health of the
individual.
6. Periodic office visits to monitor and treat mental health
conditions may be scheduled in advance consistent with
professionally recognized standards of practice as
determined by the treating licensed mental health provider
acting within the scope of their practice.
c. PROVIDER APPLICATION AND VALIDATION FOR ENROLLMENT
(PAVE)
i. Contractor shall ensure that all of its required clinical staff, who
are rendering SMHS to Medi-Cal individuals on behalf of
Contractor, are registered through DHCS' Provider Application
and Validation for Enrollment (PAVE) portal, pursuant to BHIN 20-
071 requirements, the 21st Century Cures Act and the CMS
Medicaid and Children's Health Insurance Program (CHIP)
Managed Care Final Rule.
ii. SMHS licensed individuals required to enroll via the "Ordering,
Referring and Prescribing" (ORP) PAVE enrollment pathway (i.e.
PAVE application package) available through the DHCS PED
Pave Portal, include: Licensed Clinical Social Worker (LCSW),
Licensed Marriage and Family Therapist (LMFT), Licensed
Professional Clinical Counselor (LPCC), Psychologist, Licensed
Educational Psychologist, Physician (MD and DO), Physician
Assistant, Registered Pharmacist/Pharmacist, Certified
Pediatric/Family Nurse Practitioner, Nurse Practitioner,
Occupational Therapist, and Speech-Language Pathologist.
Interns, trainees, and associates are not eligible for enrollment.
B-16
Exhibit B
d. PHYSICIAN INCENTIVE PLAN
i. If Contractor wants to institute a Physician Incentive Plan,
Contractor shall submit the proposed plan to the County which will
in turn submit the Plan to the State for approval, in accordance
with the provisions of 42 C.F.R. § 438.6(c).
5. DATA, PRIVACY AND SECURITY REQUIREMENTS
a. ELECTRONIC PRIVACY AND SECURITY
i. Contractor shall have a secure email system and send any email
containing PII or PHI in a secure and encrypted manner.
Contractor's email transmissions shall display a warning banner
stating that data is confidential, systems activities are monitored
and logged for administrative and security purposes, systems use
is for authorized users only, and that users are directed to log off
the system if they do not agree with these requirements.
ii. Contractor shall institute compliant password management
policies and procedures, which shall include but not be limited to
procedures for creating, changing, and safeguarding passwords.
Contractor shall establish guidelines for creating passwords and
ensuring that passwords expire and are changed at least once
every 90 days.
iii. Any Electronic Health Records (EHRs) maintained by Contractor
that contain PHI or PII for individuals served through this
Agreement shall contain a warning banner regarding the PHI or
PII contained within the EHR. Contractors that utilize an EHR shall
maintain all parts of the clinical record that are not stored in the
EHR, including but not limited to the following examples of client
signed documents: discharge plans, informing materials, and
health questionnaire.
iv. Contractor entering data into any County electronic systems shall
ensure that staff are trained to enter and maintain data within this
system.
6. PROGRAM INTEGRITY
a. Credentialing and Re-credentialing of Providers
i. Contractor shall ensure that all of their network providers
delivering covered services, sign and date an attestation
statement on a form provided by County, in which each provider
attests to the following:
1. Any limitations or inabilities that affect the provider's ability
to perform any of the position's essential functions, with or
without accommodation;
2. A history of loss of license or felony convictions;
3. A history of loss or limitation of privileges or disciplinary
activity;
4. A lack of present illegal drug use; and
5. The application's accuracy and completeness
B-17
Exhibit B
ii. Contractor must file and keep track of attestation statements,
credentialing applications and credentialing status for all of their
providers and must make those available to the County upon
request at any time.
iii. Contractor is required to sign an annual attestation statement at
the time of Agreement renewal in which they will attest that they
will follow County's Credentialing Policy and MHSUDS IN 18-019
and ensure that all of their rendering providers are credentialed as
per established guidelines.
B-18
Exhibit C
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
DBH VISION:
Health and well-being for our community.
DBH MISSION:
DBH, in partnership with our diverse community, is dedicated to providing quality, culturally
responsive, behavioral health services to promote wellness, recovery, and resiliency for
individuals and families in our community.
DBH GOALS:
Quadruple Aim
• Deliver quality care
• Maximize resources while focusing on efficiency
• Provide an excellent care experience
• Promote workforce well-being
GUIDING PRINCIPLES OF CARE DELIVERY:
The DBH 11 principles of care delivery define and guide a system that strives for excellence in the
provision of behavioral health services where the values of wellness, resiliency, and recovery are
central to the development of programs, services, and workforce. The principles provide the
clinical framework that influences decision-making on all aspects of care delivery including
program design and implementation, service delivery, training of the workforce, allocation of
resources, and measurement of outcomes.
1. Principle One -Timely Access & Integrated Services
o Individuals and families are connected with services in a manner that is streamlined,
effective, and seamless
o Collaborative care coordination occurs across agencies, plans for care are integrated,
and whole person care considers all life domains such as health, education,
employment, housing, and spirituality
o Barriers to access and treatment are identified and addressed
o Excellent customer service ensures individuals and families are transitioned from one
point of care to another without disruption of care
1
rev 01-02-2020
C-1
Exhibit C
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
2. Principle Two - Strengths-based
o Positive change occurs within the context of genuine trusting relationships
o Individuals, families, and communities are resourceful and resilient in the way they
solve problems
o Hope and optimism is created through identification of, and focus on, the unique
abilities of individuals and families
3. Principle Three - Person-driven and Family-driven
o Self-determination and self-direction are the foundations for recovery
o Individuals and families optimize their autonomy and independence by leading the
process, including the identification of strengths, needs, and preferences
o Providers contribute clinical expertise, provide options, and support individuals and
families in informed decision making, developing goals and objectives, and identifying
pathways to recovery
o Individuals and families partner with their provider in determining the services and
supports that would be most effective and helpful and they exercise choice in the
services and supports they receive
4. Principle Four- Inclusive of Natural Supports
o The person served identifies and defines family and other natural supports to be
included in care
o Individuals and families speak for themselves
o Natural support systems are vital to successful recovery and the maintaining of
ongoing wellness; these supports include personal associations and relationships
typically developed in the community that enhance a person's quality of life
o Providers assist individuals and families in developing and utilizing natural supports.
5. Principle Five - Clinical Significance and Evidence Based Practices (EBP)
o Services are effective, resulting in a noticeable change in daily life that is measurable.
o Clinical practice is informed by best available research evidence, best clinical
expertise, and values and preferences of those we serve
o Other clinically significant interventions such as innovative, promising, and emerging
practices are embraced
2
rev 01-02-2020
C-2
Exhibit C
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
6. Principle Six- Culturally Responsive
o Values, traditions, and beliefs specific to an individual's or family's culture(s) are
valued and referenced in the path of wellness, resilience, and recovery
o Services are culturally grounded, congruent, and personalized to reflect the unique
cultural experience of each individual and family
o Providers exhibit the highest level of cultural humility and sensitivity to the self-
identified culture(s) of the person or family served in striving to achieve the greatest
competency in care delivery
7. Principle Seven -Trauma-informed and Trauma-responsive
o The widespread impacts of all types of trauma are recognized and the various
potential paths for recovery from trauma are understood
o Signs and symptoms of trauma in individuals, families, staff, and others are recognized
and persons receive trauma-informed responses
o Physical, psychological and emotional safety for individuals, families, and providers is
emphasized
8. Principle Eight - Co-occurring Capable
o Services are reflective of whole-person care; providers understand the influence of
bio-psycho-social factors and the interactions between physical health, mental health,
and substance use disorders
o Treatment of substance use disorders and mental health disorders are integrated; a
provider or team may deliver treatment for mental health and substance use
disorders at the same time
9. Principle Nine - Stages of Change, Motivation, and Harm Reduction
o Interventions are motivation-based and adapted to the person's stage of change
o Progression though stages of change are supported through positive working
relationships and alliances that are motivating
o Providers support individuals and families to develop strategies aimed at reducing
negative outcomes of substance misuse though a harm reduction approach
o Each individual defines their own recovery and recovers at their own pace when
provided with sufficient time and support
3
rev 01-02-2020
C-3
Exhibit C
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
10. Principle Ten - Continuous Quality Improvement and Outcomes-Driven
o Individual and program outcomes are collected and evaluated for quality and efficacy
o Strategies are implemented to achieve a system of continuous quality improvement
and improved performance outcomes
o Providers participate in ongoing professional development activities needed for
proficiency in practice and implementation of treatment models
11. Principle Eleven - Health and Wellness Promotion, Illness and Harm Prevention, and Stigma
Reduction
o The rights of all people are respected
o Behavioral health is recognized as integral to individual and community well-being
o Promotion of health and wellness is interwoven throughout all aspects of DBH services
o Specific strategies to prevent illness and harm are implemented at the individual,
family, program, and community levels
o Stigma is actively reduced by promoting awareness, accountability, and positive
change in attitudes, beliefs, practices, and policies within all systems
o The vision of health and well-being for our community is continually addressed
through collaborations between providers, individuals, families, and community
members
4
rev 01-02-2020
C-4
Exhibit D
DOCUMENTATION STANDARDS FOR PERSON SERVED RECORDS
The documentation standards are described below under key topics related to care for persons
served. All standards must be addressed in the person served's record; however, there is no
requirement that the record have a specific document or section addressing these topics. All
medical records shall be maintained for a minimum of 10 years from the date of the end of the
Agreement.
A. Assessments
1. The following areas will be included as a part of a comprehensive person served's
record:
• Presenting problems, including impairments in function, and current mental
status exam.
• Traumatic incidents which include trauma exposures, trauma reactions, trauma
screenings, and systems involvement if relevant
• Behavioral health history including mental health history, substance use/abuse,
and previous services
• Medical history including physical health conditions, medications, and
developmental history
• Psychosocial factors including family, social and life circumstances, cultural
considerations
• Strengths, risks, and protective factors, including safety planning
• Clinical summary, treatment recommendations, and level of care determination
including diagnostic and clinical impression with a diagnosis
• The assessment shall include a typed or legibly printed name, signature of the
service provider and date of signature.
2. Timeliness/Frequency Standard for Assessment
• The time period to complete an initial assessment and subsequent assessments
for SMHS is up to clinical discretion.
• Assessments shall be completed within a reasonable time and in accordance
with generally accepted standards of practice.
B. Problem list
The use of a Problem List has largely replaced the use of treatment plans and is
therefore required to be part of the person served's record. The problem list shall be
updated on an ongoing basis to reflect the current presentation of the person in care.
The problem list shall include, but is not limited to, the following:
• Diagnoses identified by a provider acting within their scope of practice
• Problems identified by a provider acting within their scope of practice
• Problems or illnesses identified by the person in care and/or significant support
person if any
• The name and title of the provider that identified, added, or removed the problem,
and the date the problem was identified, added, or removed
Rev 04/2023 D-1
Exhibit D
C. Treatment and Care Plan Requirements
1. Targeted Case Management
• Specifies the goals, treatment, service activities, and assistance to address the
negotiated objectives of the plan and the medical, social, educational, and other
services needed by the person in care
• Identifies a course of action to respond to the assessed needs of the person in
care
• Includes development of a transition plan when the person in care has achieved
the goals of the care plan
• Peer support services must be based on an approved care plan
• Must be provided in a narrative format in the person's progress notes
• Updated at least annually
2. Services requiring Treatments Plans
• Intensive Home-Based Services (IHBS)
• Intensive Care Coordination (ICC)
• Therapeutic Behavioral Services (TBS)
• Must have specific observable and/or specific quantifiable goals
• Must identify the proposed type(s) of intervention
• Must 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 person served's 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,
➢ Person served's plans will be consistent with the diagnosis, and the focus of
intervention will be consistent with the person served's plan goals, and there will
be documentation of the person served's participation in and agreement with
the plan. Examples of the documentation include, but are not limited to,
reference to the person served's participation and agreement in the body of the
plan, person served's signature on the plan, or a description of the person
served's participation and agreement in progress notes.
➢ Person served's signature on the plan will be used as the means by which the
Contractor documents the participation of the person served. When the person
served's signature is required on the person served's plan and the person
Rev 04/2023 D-2
Exhibit D
served refuses or is unavailable for signature, the person served's plan will
include a written explanation of the refusal or unavailability.
➢ The Contractor will give a copy of the person served's plan to the person served
on request.
D. Progress Notes
1. Providers shall create progress notes for the provision of all SMHS. Each progress
note shall provide sufficient detail to support the service code selected for the service
type as indicated by the service code description. Progress notes shall include:
• The type of service rendered.
• A narrative describing the service, including how the service addressed the
beneficiary's behavioral health need (e.g., symptom, condition, diagnosis, and/or
risk factors).
• The date that the service was provided to the beneficiary.
• Duration of the service, including travel and documentation time.
• Location of the beneficiary at the time of receiving the service.
• A typed or legibly printed name, signature of the service provider and date of
signature.
• ICD 10 code
• Current Procedural Terminology (CPT) or Healthcare Common Procedure
Coding System (HCPCS) code.
• Next steps including, but not limited to, planned action steps by the provider or by
the beneficiary, collaboration with the beneficiary, collaboration with other
provider(s) and any update to the problem list as appropriate.
2. Timeliness/Frequency of Progress Notes
• Progress notes shall be completed within 3 business days of providing a service,
except for notes for crisis services, which shall be completed within 24 hours.
• A note must be completed for every service contact
Rev 04/2023 D-3
Exhibit E
Page 1 of 2
UMDAP Application
CLIENT INFORMATION
1. Name Date of Birth File Number
RESPONSIBLE PARTY INFORMATION
2. Name PRelationship to Client Date of Birth Marital Status
3.Address Telephone Number
4. Veteran Social Security Number
5. Employer Position If not employed,date last
worked
6. Employer's Address Telephone Number
7. Spouse Address
8. Spouse's Employer Position If not employed, date last worked
9. Spouse's Employer's Address Telephone Number
10. Nearest Relative Telephone/Address
THIRD PARTY INFORMATION
11. Insurance Company Address
12. Policy/Group/ID Number Assignment/Release of Information obtained
13. V.A. Claim Number Medicare Claim Number
14. Medi-Cal Claim Number Date referred for Eligibility Determination
FINANCIAL LIABILITY Schedule of Asset Allowances
Persons
15. Gross monthly family income:
Responsible person 1 $1500 6 $2600
Spouse 2 $2250 7 $2700
Other 3 $2300 8 $2800
16. TOTAL 4 $2400 9 $2900
17. Number of dependent on income 5 $2500 10 or more $3000
ASSET DETERMINATION
18. List all liquid assets(savings, bank balances, market value of stocks, bonds and
Mutual savings):
Source Amount $
19. Total of liquid assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
20. Insert amount from schedule of Asset Allowances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $
21. Total net liquid assets (Deduct line 20 from line 19) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
22. Divide line 21 by 12 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
23. Add lines 16 and 22 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
0017aamhd
Exhibit E
Page 2of2
UMDAP Application
ALLOWABLE EXPENSES
24. Court ordered obligations paid monthly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
25. Monthly child care(necessary for employment) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
26. Monthly dependent support payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
27. Monthly medical expense payments in excess of 3%of gross income . . . . . . . . . . . . . . . . . . . . . . . . $
28. Monthly mandated deductions from gross income for retirement plans(not Social
Security—Allowance made in payment schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
29. Total allowable expense (add lines 24 through 28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
30. Deduct line 29 from line 23 (adjusted gross income) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
31. Use line 17 and line 30 to determine the annual liability from Fee Schedule . . . . . . . . . . . . . . . . . . . . $
32. Agreed upon payment plan to satisfy the above liability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
33. Annual liability and service period: From To
34. Provider of Financial Information (if other than patient or responsible person)
Name Address
35. Adjusted by Reason
36. Approved by Date
37. 1 affirm that the statements made herein are true and correct to the best of my knowledge and 1 agree
to the payment plan as stated on line 34.
Signature of Patient or Responsible Person Date
38. An explanation of the UMDAP liability was provided.
Signature of Interviewer Date
0017aamhd
Exhibit F
1 Compensation
2 The Contractor will be compensated for performance of its services under this
3 Agreement as provided in this Exhibit F. The Contractor is not entitled to any compensation
4 except as expressly provided in this Exhibit F.
5 Rate Structure
6 (A) Beneficiaries:
7 For Beneficiaries, provided that there shall first have been a submission of claims in
8 accordance with this section, and payment authorization from County, Contractor shall be paid
9 by the State Department of Health Care Services at the following all-inclusive rate per patient
10 per day for acute Adult Psychiatric Inpatient Hospital Services, excluding professional fees,
11 based on the following accommodation codes:
12 Description Accommodation Code Rate
13 Administrative Day 169 $883.71 (effective 8/1/22)
14 Room & Board, Semi-Private 124 $1,423.02 (FY 2023-24)
15 2-Bed, Psychiatric
16 (B) Recipients
17 For Recipients specifically referred by County to Contractor, provided that there shall
18 first have been a submission of claims in accordance with this section, Contractor shall be paid
19 by County at the following all-inclusive rate per patient per day for acute Adult Psychiatric
20 Inpatient Hospital Services excluding professional fees based on the following accommodation
21 codes:
22 Description Accommodation Code Rate
23 Administrative Day 169 $883.71 (effective 8/1/22)
24 Room & Board, Semi-Private 124 $1,423.02 (FY 2023-24)
25 2-Bed, Psychiatric
26 For those Beneficiaries and Recipients determined by County staff to meet medical
27 necessity criteria for acute inpatient hospitalization and referred by County and admitted to the
28 facility; and should the retrospective review of the client record fail to meet Medi-Cal medical
F-1
Exhibit F
1 necessity criteria, County will compensate Contractor at the rate of$1,423.02 per day of
2 admission in these instances. If the person served is a Beneficiary, County will adjust the
3 Treatment Authorization Request (TAR) in accordance with Medi-Cal medical necessity criteria
4 to prevent an incorrect claim to the State. If Medi-Cal funding is subsequently secured,
5 Contractor will credit County the appropriate amount.
6 An authorized day of service shall be billed for each adult person who occupies an
7 inpatient psychiatric bed at 12:00 midnight in the facilities of either Contractor or an authorized
8 Delegate. Day of discharge shall not be billed. However, a day of service may be billed if the
9 adult person is admitted and discharged during the same day provided that such admission and
10 discharge is not within twenty-four (24) hours of a prior discharge. For billing purposes,
11 Beneficiaries and Recipients receiving Adult Psychiatric Inpatient Hospital Services, as
12 described herein, must meet emergency admission criteria, documentation requirements,
13 treatment and discharge planning requirements and have received an approved TAR for the
14 days being billed. Said TAR and supporting documentation must be submitted by Contractor or
15 County within fourteen (14) days of said Beneficiaries and Recipients being discharged from
16 said facility(ies).
17 As an express condition precedent to County's authorization for payment under this
18 exhibit, Contractor shall determine that Adult Psychiatric Inpatient Hospital Services rendered
19 are not covered, in whole or in part, under any State of California or Federal medical care
20 program other than Medi-Cal, Medicare, UMDAP, or under any other contractual or legal
21 entitlement, including, but not limited to, a private group indemnification or insurance program or
22 worker's compensation. To the extent that such coverage is available, the payment received by
23 Contractor from such coverage will reduce County's payment obligation for a combined amount
24 not to exceed the all-inclusive rate pursuant to this section. The Beneficiary's or individual's
25 share of cost, i.e., payments required to be made by Beneficiary or individuals under applicable
26 insurance policies, etc., will also reduce the State's Medi-Cal payment obligation or County's
27 payment obligation, by the amount of the share of cost.
28
F-2
Exhibit F
1 Rate Establishment
2 It is understood by County and Contractor that the annual fiscal year rate increases will
3 reflect the Consumer Price Index (CPI) rate for inpatient hospital services that is released during
4 the last month of the current fiscal year not to exceed a maximum increase of four (4) percent
5 from the previous fiscal year's rate for each subsequent fiscal year throughout the contract
6 period. It is understood by County and Contractor that the California Department of Health Care
7 Services Rate Development Branch is responsible for establishing the administrative day rate
8 during each State fiscal year, which may supersede the rate stated above. It is further
9 understood by County and Contractor that the Department of Behavioral Health Director or
10 designee and the Director or designee of Fresno Community Medical Center dba Community
11 Behavioral Health Center (Contractor) are responsible for negotiating and establishing the
12 Psychiatric Inpatient Day Rate (Room & Board, Semi-Private, 2-bed, Psychiatric) during each
13 fiscal year, which may supersede the rate stated above. Said rate adjustment(s) shall be
14 approved by County's DBH Director, or designee and Contractor and become part of this
15 Agreement. Any rate adjustment shall not result in an increase to the maximum compensation
16 of the Agreement as stated herein.
17
18
19
20
21
22
23
24
25
26
27
28
F-3
Exhibit G
Insurance Requirements
1. Required Policies
Without limiting the County's right to obtain indemnification from the Contractor or any third
parties, Contractor, at its sole expense, shall maintain in full force and effect the following
insurance policies throughout the term of this Agreement.
(A) Commercial General Liability. 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 Dollars ($4,000,000). This policy must be issued on a per occurrence basis.
Coverage must include products, completed operations, property damage, bodily injury,
personal injury, and advertising injury. The Contractor shall obtain an endorsement to
this policy naming the County of Fresno, its officers, agents, employees, and volunteers,
individually and collectively, as additional insureds, but only insofar as the operations
under this Agreement are concerned. Such coverage for additional insureds will apply as
primary insurance and any other insurance, or self-insurance, maintained by the County
is excess only and not contributing with insurance provided under the Contractor's
policy.
(B) Automobile Liability. Automobile liability insurance with limits of not less than One
Million Dollars ($1,000,000) per occurrence for bodily injury and for property damages.
Coverage must include any auto used in connection with this Agreement.
(C)Workers Compensation. Workers compensation insurance as required by the laws of
the State of California with statutory limits.
(D) Employer's Liability. Employer's liability insurance with limits of not less than One
Million Dollars ($1,000,000) per occurrence for bodily injury and for disease.
(E) Professional Liability. Professional liability insurance with limits of not less than One
Million Dollars ($1,000,000) per occurrence and an annual aggregate of Three Million
Dollars ($3,000,000). If this is a claims-made policy, then (1)the retroactive date must
be prior to the date on which services began under this Agreement; (2)the Contractor
shall maintain the policy and provide to the County annual evidence of insurance for not
less than five years after completion of services under this Agreement; and (3) if the
policy is canceled or not renewed, and not replaced with another claims-made policy
with a retroactive date prior to the date on which services begin under this Agreement,
then the Contractor shall purchase extended reporting coverage on its claims-made
policy for a minimum of five years after completion of services under this Agreement.
(F) Molestation Liability. Sexual abuse/ molestation liability insurance with limits of not
less than Two Million Dollars ($2,000,000) per occurrence, with an annual aggregate of
Four Million Dollars ($4,000,000). This policy must be issued on a per occurrence basis.
(G)Cyber Liability. Cyber liability insurance with limits of not less than Two Million Dollars
($2,000,000) per occurrence. Coverage must include claims involving Cyber Risks. The
cyber liability policy must be endorsed to cover the full replacement value of damage to,
alteration of, loss of, or destruction of intangible property (including but not limited to
information or data) that is in the care, custody, or control of the Contractor.
G-1
Exhibit G
Definition of Cyber Risks. "Cyber Risks" include but are not limited to (i) Security
Breach, which may include Disclosure of Personal Information to an Unauthorized Third
Party; (ii) data breach; (iii) breach of any of the Contractor's obligations under Article 18
of this Agreement; (iv) system failure; (v) data recovery; (vi) failure to timely disclose
data breach or Security Breach; (vii) failure to comply with privacy policy; (viii) payment
card liabilities and costs; (ix) infringement of intellectual property, including but not
limited to infringement of copyright, trademark, and trade dress; (x) invasion of privacy,
including release of private information; (xi) information theft; (xii) damage to or
destruction or alteration of electronic information; (xiii) cyber extortion; (xiv) extortion
related to the Contractor's obligations under this Agreement regarding electronic
information, including Personal Information; (xv)fraudulent instruction; (xvi) funds
transfer fraud; (xvii) telephone fraud; (xviii) network security; (xix) data breach response
costs, including Security Breach response costs; (xx) regulatory fines and penalties
related to the Contractor's obligations under this Agreement regarding electronic
information, including Personal Information; and (xxi) credit monitoring expenses.
2. Additional Requirements
(A) Verification of Coverage. Within 30 days after the Contractor signs this Agreement,
and at any time during the term of this Agreement as requested by the County's Risk
Manager or the County Administrative Office, the Contractor shall deliver, or cause its
broker or producer to deliver, to the County Risk Manager, at 2220 Tulare Street, 16th
Floor, Fresno, California 93721, or HRRiskManagement@fresnocountyca.gov, and by
mail or email to the person identified to receive notices under this Agreement,
certificates of insurance and endorsements for all of the coverages required under this
Agreement.
(i) Each insurance certificate must state that: (1) the insurance coverage has been
obtained and is in full force; (2) the County, its officers, agents, employees, and
volunteers are not responsible for any premiums on the policy; and (3) the
Contractor has waived its right to recover from the County, its officers, agents,
employees, and volunteers any amounts paid under any insurance policy
required by this Agreement and that waiver does not invalidate the insurance
policy.
(ii) The commercial general liability insurance certificate must also state, and include
an endorsement, that the County of Fresno, its officers, agents, employees, and
volunteers, individually and collectively, are additional insureds insofar as the
operations under this Agreement are concerned. The commercial general liability
insurance certificate must also state that the coverage shall apply as primary
insurance and any other insurance, or self-insurance, maintained by the County
shall be excess only and not contributing with insurance provided under the
Contractor's policy.
(iii) The automobile liability insurance certificate must state that the policy covers any
auto used in connection with this Agreement.
G-2
Exhibit G
(iv) The professional liability insurance certificate, if it is a claims-made policy, must
also state the retroactive date of the policy, which must be prior to the date on
which services began under this Agreement.
(v) The cyber liability insurance certificate must also state that it is endorsed, and
include an endorsement, to cover the full replacement value of damage to,
alteration of, loss of, or destruction of intangible property (including but not limited
to information or data) that is in the care, custody, or control of the Contractor.
(B) Acceptability of Insurers. All insurance policies required under this Agreement must be
issued by admitted insurers licensed to do business in the State of California and
possessing at all times during the term of this Agreement an A.M. Best, Inc. rating of no
less than A: VI I.
(C) Notice of Cancellation or Change. For each insurance policy required under this
Agreement, the Contractor shall provide to the County, or ensure that the policy requires
the insurer to provide to the County, written notice of any cancellation or change in the
policy as required in this paragraph. For cancellation of the policy for nonpayment of
premium, the Contractor shall, or shall cause the insurer to, provide written notice to the
County not less than 10 days in advance of cancellation. For cancellation of the policy
for any other reason, and for any other change to the policy, the Contractor shall, or shall
cause the insurer to, provide written notice to the County not less than 30 days in
advance of cancellation or change. The County in its sole discretion may determine that
the failure of the Contractor or its insurer to timely provide a written notice required by
this paragraph is a breach of this Agreement.
(D) County's Entitlement to Greater Coverage. If the Contractor has or obtains insurance
with broader coverage, higher limits, or both, than what is required under this
Agreement, then the County requires and is entitled to the broader coverage, higher
limits, or both. To that end, the Contractor shall deliver, or cause its broker or producer
to deliver, to the County's Risk Manager certificates of insurance and endorsements for
all of the coverages that have such broader coverage, higher limits, or both, as required
under this Agreement.
(E) Waiver of Subrogation. The Contractor waives any right to recover from the County, its
officers, agents, employees, and volunteers any amounts paid under the policy of
worker's compensation insurance required by this Agreement. The Contractor is solely
responsible to obtain any policy endorsement that may be necessary to accomplish that
waiver, but the Contractor's waiver of subrogation under this paragraph is effective
whether or not the Contractor obtains such an endorsement.
(F) County's Remedy for Contractor's Failure to Maintain. If the Contractor fails to keep
in effect at all times any insurance coverage required under this Agreement, the County
may, in addition to any other remedies it may have, suspend or terminate this
Agreement upon the occurrence of that failure, or purchase such insurance coverage,
and charge the cost of that coverage to the Contractor. The County may offset such
charges against any amounts owed by the County to the Contractor under this
Agreement.
G-3
Exhibit G
(G)Subcontractors. The Contractor shall require and verify that all subcontractors used by
the Contractor to provide services under this Agreement maintain insurance meeting all
insurance requirements provided in this Agreement. This paragraph does not authorize
the Contractor to provide services under this Agreement using subcontractors.
G-4
Exhibit H
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-for-service providers and contract agencies are required to give
the individuals served copies of all current beneficiary information at intake and annually
thereafter.
Beneficiaries have the right to use the grievance and/or appeal process without any
penalty, change in mental health services, or any form of retaliation. All Medi-Cal
beneficiaries can file an appeal or state hearing.
Grievances and appeals forms and self addressed envelopes must be available for
beneficiaries to pick up at all provider sites without having to make a verbal or written
request. Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
(800) 654-3937 (for more information)
(559)488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple, informal procedure in identifying and resolving provider
concerns and problems regarding payment authorization issues, other complaints and
concerns.
Informal provider problem resolution process—the provider may first speak to a Provider
Relations Specialist (PRS) regarding his or her complaint or concern.
H-1
Exhibit H
The PRS will attempt to settle the complaint or concern with the provider. If the attempt
is unsuccessful and the provider chooses to forego the informal grievance process, the
provider will be advised to file a written complaint to the MHP address (listed above).
Formal provider appeal process—the provider has the right to access the provider
appeal process at any time before, during, or after the provider problem resolution
process has begun, when the complaint concerns a denied or modified request for MHP
payment authorization, or the process or payment of a provider's claim to the MHP.
Payment authorization issues—the provider may appeal a denied or modified request
for payment authorization or a dispute with the MHP regarding the processing or
payment of a provider's claim to the MHP. The written appeal must be submitted to the
MHP within 90 calendar days of the date of the receipt of the non-approval of payment.
The MHP shall have 60 calendar days from its receipt of the appeal to inform the
provider in writing of the decision, including a statement of the reasons for the decision
that addresses each issue raised by the provider, and any action required by the
provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request, the
MHP utilizes a Managed Care staff who was not involved in the initial denial or
modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be asked to
submit a revised request for payment within 30 calendar days of receipt of the decision
Other complaints— if there are other issues or complaints, which are not related to
payment authorization issues, providers are encouraged to send a letter of complaint to
the MHP. The provider will receive a written response from the MHP within 60 calendar
days of receipt of the complaint. The decision rendered buy the MHP is final.
H-2
Exhibit I
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws, regulations,
rules and guidelines that apply to the provision and payment of mental health services. Mental
health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with which
contractor and its employees and subcontractors shall comply. Contractor shall require its
employees and subcontractors to attend a compliance training that will be provided by Fresno
County. After completion of this training, Contractor, Contractor' employees and subcontractors must
sign the Contractor Acknowledgment and Agreement form and return this form to the Compliance
Officer or designee.
Contractor and its employees and subcontractor shall:
1. Comply with all applicable laws, regulations, rules or guidelines when providing and
billing for mental health services.
2. Conduct themselves honestly, fairly, courteously and with a high degree of integrity in
their professional dealing related to their contract with the County and avoid any
conduct that could reasonably be expected to reflect adversely upon the integrity of the
County.
3. Treat County employees, persons served, and other mental health contractors fairly
and with respect.
4. NOT engage in any activity in violation of the County's Compliance Program, nor
engage in any other conduct which violates any applicable law, regulation, rule or
guideline
5. Take precautions to ensure that claims are prepared and submitted accurately, timely
and are consistent with all applicable laws, regulations, rules or guidelines.
6. Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or
reimbursement of any kind are submitted.
1-1
Exhibit 1
7. Bill only for eligible services actually rendered and fully documented. Use billing codes
that accurately describe the services provided.
8. Act promptly to investigate and correct problems if errors in claims or billing are
discovered.
9. Promptly report to the Compliance Officer any suspected violation(s) of this Code of
Conduct and Ethics by County employees or other mental health contractors, or report
any activity that they believe may violate the standards of the Compliance Program, or
any other applicable law, regulation, rule or guideline. Fresno County prohibits
retaliation against any person making a report. Any person engaging in any form of
retaliation will be subject to disciplinary or other appropriate action by the County.
Contractor 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.
1-2
Exhibit I
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and
Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof. I further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement. I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County. I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print):
Discipline: ❑ Psychiatrist ❑ Psychologist ❑ LCSW ❑ LMFT
Signature: Date:
For Group or Organizational Providers
Group/Org. Name (print):
Employee Name (print):
Discipline: ❑ Psychiatrist ❑ Psychologist ❑ LCSW ❑ LMFT
❑ Other:
Job Title (if different from Discipline):
Signature: Date:
1-3
Exhibit J
COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
Contractor shall be required to maintain organizational provider certification by the host county.
A copy of this renewal certificate must be furnished to County within thirty (30) days of receipt of
certificate from host county. The Contractor must meet Medi-Cal organization provider
standards as stated below. It is acknowledged that all references to Organizational Provider
and/or Provider below shall refer to the Contractor.
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 as head of service a licensed mental health
professional or other appropriate individual as described in Title 9, CCR, Sections 622
through 630.
9. For organizational providers that provide or store medications, the provider stores and
dispenses medications in compliance with all pertinent state and federal standards. In
particular:
A. All drugs obtained by prescription are labeled in compliance with federal and state
laws. Prescription labels are altered only by persons legally authorized to do so.
B. Drugs intended for external use only or food stuffs are stored separately from drugs
for internal use.
C. All drugs are stored at proper temperatures, room temperature drugs at 59-86
degrees F and refrigerated drugs at 36-46 degrees F.
J-1
Exhibit J
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.
10. The County may accept the host county's site certification and reserves the right to
conduct an on-site certification review at least every three years. The County may also
conduct additional certification reviews when:
• The provider makes major staffing changes.
• The provider makes organizational and/or corporate structure changes
(example: conversion from a non-profit status).
• The provider adds day treatment or medication support services when
medications shall be administered or dispensed from the provider site.
• There are significant changes in the physical plant of the provider site (some
physical plant changes could require a new fire clearance).
• There is change of ownership or location.
• There are complaints against the provider.
• There are unusual events, accidents, or injuries requiring medical treatment for
clients, staff or members of the community.
J-2
Exhibit K
Data Security
1. Definitions
Capitalized terms used in this Exhibit have the meanings set forth in this section 1.
(A) "Authorized Employees" means the Contractor's employees who have access to
Personal Information.
(B) "Authorized Persons" means: (i) any and all Authorized Employees; and (ii) any and all
of the Contractor's subcontractors, representatives, agents, outsourcers, and
consultants, and providers of professional services to the Contractor, who have access
to Personal Information and are bound by law or in writing by confidentiality obligations
sufficient to protect Personal Information in accordance with the terms of this Exhibit L.
(C)"Director" means the County's Director of the Department of Behavioral Health or his or
her designee.
(D) "Disclose" or any derivative of that word means to disclose, release, transfer,
disseminate, or otherwise provide access to or communicate all or any part of any
Personal Information orally, in writing, or by electronic or any other means to any person.
(E) "Person" means any natural person, corporation, partnership, limited liability company,
firm, or association.
(F) "Personal Information" means any and all information, including any data, provided, or
to which access is provided, to the Contractor by or upon the authorization of the
County, under this Agreement, including but not limited to vital records, that: (i) identifies,
describes, or relates to, or is associated with, or is capable of being used to identify,
describe, or relate to, or associate with, a person (including, without limitation, names,
physical descriptions, signatures, addresses, telephone numbers, e-mail addresses,
education, financial matters, employment history, and other unique identifiers, as well as
statements made by or attributable to the person); (ii) is used or is capable of being used
to authenticate a person (including, without limitation, employee identification numbers,
government-issued identification numbers, passwords or personal identification numbers
(PINs), financial account numbers, credit report information, answers to security
questions, and other personal identifiers); or (iii) is personal information within the
meaning of California Civil Code section 1798.3, subdivision (a), or 1798.80, subdivision
(e). Personal Information does not include publicly available information that is lawfully
made available to the general public from federal, state, or local government records.
(G)"Privacy Practices Complaint" means a complaint received by the County relating to
the Contractor's (or any Authorized Person's) privacy practices, or alleging a Security
Breach. Such complaint shall have sufficient detail to enable the Contractor to promptly
investigate and take remedial action under this Exhibit L.
(H) "Security Safeguards" means physical, technical, administrative or organizational
security procedures and practices put in place by the Contractor (or any Authorized
Persons) that relate to the protection of the security, confidentiality, value, or integrity of
Personal Information. Security Safeguards shall satisfy the minimal requirements set
forth in section 3(C) of this Exhibit L.
K-1
Exhibit K
(1) "Security Breach" means (i) any act or omission that compromises either the security,
confidentiality, value, or integrity of any Personal Information or the Security Safeguards,
or (ii) any unauthorized Use, Disclosure, or modification of, or any loss or destruction of,
or any corruption of or damage to, any Personal Information.
(J) "Use" or any derivative of that word means to receive, acquire, collect, apply,
manipulate, employ, process, transmit, disseminate, access, store, disclose, or dispose
of Personal Information.
2. Standard of Care
(A) The Contractor acknowledges that, in the course of its engagement by the County under
this Agreement, the Contractor, or any Authorized Persons, may Use Personal
Information only as permitted in this Agreement.
(B) The Contractor acknowledges that Personal Information is deemed to be confidential
information of, or owned by, the County (or persons from whom the County receives or
has received Personal Information) and is not confidential information of, or owned or by,
the Contractor, or any Authorized Persons. The Contractor further acknowledges that all
right, title, and interest in or to the Personal Information remains in the County (or
persons from whom the County receives or has received Personal Information)
regardless of the Contractor's, or any Authorized Person's, Use of that Personal
Information.
(C)The Contractor agrees and covenants in favor of the Country that the Contractor shall:
(i) keep and maintain all Personal Information in strict confidence, using such
degree of care under this section 2 as is reasonable and appropriate to avoid a
Security Breach;
(ii) Use Personal Information exclusively for the purposes for which the Personal
Information is made accessible to the Contractor pursuant to the terms of this
Exhibit L;
(iii) not Use, Disclose, sell, rent, license, or otherwise make available Personal
Information for the Contractor's own purposes or for the benefit of anyone other
than the County, without the County's express prior written consent, which the
County may give or withhold in its sole and absolute discretion; and
(iv) not, directly or indirectly, Disclose Personal Information to any person (an
"Unauthorized Third Party") other than Authorized Persons pursuant to this
Agreement, without the Director's express prior written consent.
(D) Notwithstanding the foregoing paragraph, in any case in which the Contractor believes it,
or any Authorized Person, is required to disclose Personal Information to government
regulatory authorities, or pursuant to a legal proceeding, or otherwise as may be
required by applicable law, Contractor shall (i) immediately notify the County of the
specific demand for, and legal authority for the disclosure, including providing County
with a copy of any notice, discovery demand, subpoena, or order, as applicable,
received by the Contractor, or any Authorized Person, from any government regulatory
authorities, or in relation to any legal proceeding, and (ii) promptly notify the County
K-2
Exhibit K
before such Personal Information is offered by the Contractor for such disclosure so that
the County may have sufficient time to obtain a court order or take any other action the
County may deem necessary to protect the Personal Information from such disclosure,
and the Contractor shall cooperate with the County to minimize the scope of such
disclosure of such Personal Information.
(E) The Contractor shall remain liable to the County for the actions and omissions of any
Unauthorized Third Party concerning its Use of such Personal Information as if they
were the Contractor's own actions and omissions.
3. Information Security
(A) The Contractor covenants, represents and warrants to the County that the Contractor's
Use of Personal Information under this Agreement does and will at all times comply with
all applicable federal, state, and local, privacy and data protection laws, as well as all
other applicable regulations and directives, including but not limited to California Civil
Code, Division 3, Part 4, Title 1.81 (beginning with section 1798.80), and the Song-
Beverly Credit Card Act of 1971 (California Civil Code, Division 3, Part 4, Title 1.3,
beginning with section 1747). If the Contractor Uses credit, debit or other payment
cardholder information, the Contractor shall at all times remain in compliance with the
Payment Card Industry Data Security Standard ("PCI DSS") requirements, including
remaining aware at all times of changes to the PCI DSS and promptly implementing and
maintaining all procedures and practices as may be necessary to remain in compliance
with the PCI DSS, in each case, at the Contractor's sole cost and expense.
(B) The Contractor covenants, represents and warrants to the County that, as of the
effective date of this Agreement, the Contractor has not received notice of any violation
of any privacy or data protection laws, as well as any other applicable regulations or
directives, and is not the subject of any pending legal action or investigation by, any
government regulatory authority regarding same.
(C)Without limiting the Contractor's obligations under section 3(A) of this Exhibit L, the
Contractor's (or Authorized Person's) Security Safeguards shall be no less rigorous than
accepted industry practices and, at a minimum, include the following:
(i) limiting Use of Personal Information strictly to the Contractor's and Authorized
Persons' technical and administrative personnel who are necessary for the
Contractor's, or Authorized Persons', Use of the Personal Information pursuant to
this Agreement;
(ii) ensuring that all of the Contractor's connectivity to County computing systems
will only be through the County's security gateways and firewalls, and only
through security procedures approved upon the express prior written consent of
the Director;
(iii) to the extent that they contain or provide access to Personal Information, (a)
securing business facilities, data centers, paper files, servers, back-up systems
and computing equipment, operating systems, and software applications,
including, but not limited to, all mobile devices and other equipment, operating
systems, and software applications with information storage capability; (b)
K-3
Exhibit K
employing adequate controls and data security measures, both internally and
externally, to protect (1) the Personal Information from potential loss or
misappropriation, or unauthorized Use, and (2) the County's operations from
disruption and abuse; (c) having and maintaining network, device application,
database and platform security; (d) maintaining authentication and access
controls within media, computing equipment, operating systems, and software
applications; and (e) installing and maintaining in all mobile, wireless, or
handheld devices a secure internet connection, having continuously updated
anti-virus software protection and a remote wipe feature always enabled, all of
which is subject to express prior written consent of the Director;
(iv) encrypting all Personal Information at advance encryption standards of Advanced
Encryption Standards (AES) of 128 bit or higher (a) stored on any mobile
devices, including but not limited to hard disks, portable storage devices, or
remote installation, or (b) transmitted over public or wireless networks (the
encrypted Personal Information must be subject to password or pass phrase, and
be stored on a secure server and transferred by means of a Virtual Private
Network (VPN) connection, or another type of secure connection, all of which is
subject to express prior written consent of the Director);
(v) strictly segregating Personal Information from all other information of the
Contractor, including any Authorized Person, or anyone with whom the
Contractor or any Authorized Person deals so that Personal Information is not
commingled with any other types of information;
(vi) having a patch management process including installation of all operating system
and software vendor security patches;
(vii) maintaining appropriate personnel security and integrity procedures and
practices, including, but not limited to, conducting background checks of
Authorized Employees consistent with applicable law; and
(viii) providing appropriate privacy and information security training to Authorized
Employees.
(D) During the term of each Authorized Employee's employment by the Contractor, the
Contractor shall cause such Authorized Employees to abide strictly by the Contractor's
obligations under this Exhibit L. The Contractor shall maintain a disciplinary process to
address any unauthorized Use of Personal Information by any Authorized Employees.
(E) The Contractor shall, in a secure manner, backup daily, or more frequently if it is the
Contractor's practice to do so more frequently, Personal Information received from the
County, and the County shall have immediate, real time access, at all times, to such
backups via a secure, remote access connection provided by the Contractor, through the
Internet.
(F) The Contractor shall provide the County with the name and contact information for each
Authorized Employee (including such Authorized Employee's work shift, and at least one
alternate Authorized Employee for each Authorized Employee during such work shift)
who shall serve as the County's primary security contact with the Contractor and shall be
K-4
Exhibit K
available to assist the County twenty-four (24) hours per day, seven (7) days per week
as a contact in resolving the Contractor's and any Authorized Persons' obligations
associated with a Security Breach or a Privacy Practices Complaint.
(G)The Contractor shall not knowingly include or authorize any Trojan Horse, back door,
time bomb, drop dead device, worm, virus, or other code of any kind that may disable,
erase, display any unauthorized message within, or otherwise impair any County
computing system, with or without the intent to cause harm.
4. Security Breach Procedures
(A) Immediately upon the Contractor's awareness or reasonable belief of a Security Breach,
the Contractor shall (i) notify the Director of the Security Breach, such notice to be given
first by telephone at the following telephone number, followed promptly by email at the
following email addresses: incidents(aNresnocountyca.gov, 559-600-5900, (559) 600-
4645, dbhcontractedservices(a-)-fresnocountyca.gov,
dbhforensicservices(a-)-fresnocountyca.gov (which telephone number and email address
the County may update by providing notice to the Contractor), and (ii) preserve all
relevant evidence (and cause any affected Authorized Person to preserve all relevant
evidence) relating to the Security Breach. The notification shall include, to the extent
reasonably possible, the identification of each type and the extent of Personal
Information that has been, or is reasonably believed to have been, breached, including
but not limited to, compromised, or subjected to unauthorized Use, Disclosure, or
modification, or any loss or destruction, corruption, or damage.
(B) Immediately following the Contractor's notification to the County of a Security Breach, as
provided pursuant to section 4(A) of this Exhibit L, the Parties shall coordinate with each
other to investigate the Security Breach. The Contractor agrees to fully cooperate with
the County, including, without limitation:
(i) assisting the County in conducting any investigation;
(ii) providing the County with physical access to the facilities and operations
affected;
(iii) facilitating interviews with Authorized Persons and any of the Contractor's other
employees knowledgeable of the matter; and
(iv) making available all relevant records, logs, files, data reporting and other
materials required to comply with applicable law, regulation, industry standards,
or as otherwise reasonably required by the County.
To that end, the Contractor shall, with respect to a Security Breach, be solely
responsible, at its cost, for all notifications required by law and regulation, or deemed
reasonably necessary by the County, and the Contractor shall provide a written report of
the investigation and reporting required to the Director within 30 days after the
Contractor's discovery of the Security Breach.
(C) County shall promptly notify the Contractor of the Director's knowledge, or reasonable
belief, of any Privacy Practices Complaint, and upon the Contractor's receipt of that
notification, the Contractor shall promptly address such Privacy Practices Complaint,
K-5
Exhibit K
including taking any corrective action under this Exhibit L, all at the Contractor's sole
expense, in accordance with applicable privacy rights, laws, regulations and standards.
In the event the Contractor discovers a Security Breach, the Contractor shall treat the
Privacy Practices Complaint as a Security Breach. Within 24 hours of the Contractor's
receipt of notification of such Privacy Practices Complaint, the Contractor shall notify the
County whether the matter is a Security Breach, or otherwise has been corrected and
the manner of correction, or determined not to require corrective action and the reason
for that determination.
(D)The Contractor shall take prompt corrective action to respond to and remedy any
Security Breach and take mitigating actions, including but not limiting to, preventing any
reoccurrence of the Security Breach and correcting any deficiency in Security
Safeguards as a result of such incident, all at the Contractor's sole expense, in
accordance with applicable privacy rights, laws, regulations and standards. The
Contractor shall reimburse the County for all reasonable costs incurred by the County in
responding to, and mitigating damages caused by, any Security Breach, including all
costs of the County incurred relation to any litigation or other action described section
4(E) of this Exhibit L.
(E) The Contractor agrees to cooperate, at its sole expense, with the County in any litigation
or other action to protect the County's rights relating to Personal Information, including
the rights of persons from whom the County receives Personal Information.
5. Oversight of Security Compliance
(A) The Contractor shall have and maintain a written information security policy that
specifies Security Safeguards appropriate to the size and complexity of the Contractor's
operations and the nature and scope of its activities.
(B) Upon the County's written request, to confirm the Contractor's compliance with this
Exhibit L, as well as any applicable laws, regulations and industry standards, the
Contractor grants the County or, upon the County's election, a third party on the
County's behalf, permission to perform an assessment, audit, examination or review of
all controls in the Contractor's physical and technical environment in relation to all
Personal Information that is Used by the Contractor pursuant to this Agreement. The
Contractor shall fully cooperate with such assessment, audit or examination, as
applicable, by providing the County or the third party on the County's behalf, access to
all Authorized Employees and other knowledgeable personnel, physical premises,
documentation, infrastructure and application software that is Used by the Contractor for
Personal Information pursuant to this Agreement. In addition, the Contractor shall
provide the County with the results of any audit by or on behalf of the Contractor that
assesses the effectiveness of the Contractor's information security program as relevant
to the security and confidentiality of Personal Information Used by the Contractor or
Authorized Persons during the course of this Agreement under this Exhibit L.
(C)The Contractor shall ensure that all Authorized Persons who Use Personal Information
agree to the same restrictions and conditions in this Exhibit L. that apply to the
Contractor with respect to such Personal Information by incorporating the relevant
provisions of these provisions into a valid and binding written agreement between the
K-6
Exhibit K
Contractor and such Authorized Persons, or amending any written agreements to
provide same.
6. Return or Destruction of Personal Information. Upon the termination of this Agreement,
the Contractor shall, and shall instruct all Authorized Persons to, promptly return to the County
all Personal Information, whether in written, electronic or other form or media, in its possession
or the possession of such Authorized Persons, in a machine readable form used by the County
at the time of such return, or upon the express prior written consent of the Director, securely
destroy all such Personal Information, and certify in writing to the County that such Personal
Information have been returned to the County or disposed of securely, as applicable. If the
Contractor is authorized to dispose of any such Personal Information, as provided in this Exhibit
L, such certification shall state the date, time, and manner (including standard) of disposal and
by whom, specifying the title of the individual. The Contractor shall comply with all reasonable
directions provided by the Director with respect to the return or disposal of Personal Information
and copies of Personal Information. If return or disposal of such Personal Information or copies
of Personal Information is not feasible, the Contractor shall notify the County according,
specifying the reason, and continue to extend the protections of this Exhibit L to all such
Personal Information and copies of Personal Information. The Contractor shall not retain any
copy of any Personal Information after returning or disposing of Personal Information as
required by this section 6. The Contractor's obligations under this section 6 survive the
termination of this Agreement and apply to all Personal Information that the Contractor retains if
return or disposal is not feasible and to all Personal Information that the Contractor may later
discover.
7. Equitable Relief. The Contractor acknowledges that any breach of its covenants or
obligations set forth in this Exhibit L may cause the County irreparable harm for which monetary
damages would not be adequate compensation and agrees that, in the event of such breach or
threatened breach, the County is entitled to seek equitable relief, including a restraining order,
injunctive relief, specific performance and any other relief that may be available from any court,
in addition to any other remedy to which the County may be entitled at law or in equity. Such
remedies shall not be deemed to be exclusive but shall be in addition to all other remedies
available to the County at law or in equity or under this Agreement.
8. Indemnity. The Contractor shall defend, indemnify and hold harmless the County, its
officers, employees, and agents, (each, a "County Indemnitee") from and against any and all
infringement of intellectual property including, but not limited to infringement of copyright,
trademark, and trade dress, invasion of privacy, information theft, and extortion, unauthorized
Use, Disclosure, or modification of, or any loss or destruction of, or any corruption of or damage
to, Personal Information, Security Breach response and remedy costs, credit monitoring
expenses, forfeitures, losses, damages, liabilities, deficiencies, actions,judgments, interest,
awards, fines and penalties (including regulatory fines and penalties), costs or expenses of
whatever kind, including attorneys' fees and costs, the cost of enforcing any right to
indemnification or defense under this Exhibit L and the cost of pursuing any insurance
providers, arising out of or resulting from any third party claim or action against any County
Indemnitee in relation to the Contractor's, its officers, employees, or agents, or any Authorized
Employee's or Authorized Person's, performance or failure to perform under this Exhibit L or
arising out of or resulting from the Contractor's failure to comply with any of its obligations under
this section 8. The provisions of this section 8 do not apply to the acts or omissions of the
K-7
Exhibit K
County. The provisions of this section 8 are cumulative to any other obligation of the Contractor
to, defend, indemnify, or hold harmless any County Indemnitee under this Agreement. The
provisions of this section 8 shall survive the termination of this Agreement.
9. Survival. The respective rights and obligations of the Contractor and the County as stated
in this Exhibit L shall survive the termination of this Agreement.
10. No Third Party Beneficiary. Nothing express or implied in the provisions of in this Exhibit L
is intended to confer, nor shall anything in this Exhibit L confer, upon any person other than the
County or the Contractor and their respective successors or assignees, any rights, remedies,
obligations or liabilities whatsoever.
11. No County Warranty. The County does not make any warranty or representation whether
any Personal Information in the Contractor's (or any Authorized Person's) possession or control,
or Use by the Contractor (or any Authorized Person), pursuant to the terms of this Agreement is
or will be secure from unauthorized Use, or a Security Breach or Privacy Practices Complaint.
K-8
Exhibit L
Self-Dealing Transaction Disclosure Form
In order to conduct business with the County of Fresno ("County"), members of a
contractor's board of directors ("County Contractor"), must disclose any self-dealing transactions
that they are a party to while providing goods, performing services, or both for the County. A
self-dealing transaction is defined below:
"A self-dealing transaction means a transaction to which the corporation is a party and in
which one or more of its directors has a material financial interest."
The definition above will be used for purposes of completing this disclosure form.
Instructions
(1) Enter board member's name, job title (if applicable), and date this disclosure is being
made.
(2) Enter the board member's company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the transaction;
and
b. The nature of the material financial interest in the Corporation's transaction that
the board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
The form must be signed by the board member that is involved in the self-dealing
transaction described in Sections (3) and (4).
L-1
Exhibit L
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a
party to)
(4) Explain why this self-dealing transaction is consistent with the requirements of
Corporations Code § 5233 (a)
(5) Authorized Signature
Signature: Date:
L-2
Exhibit M
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of entity D/B/A
Address(number,street) City State ZIP code
CLIA number Taxpayer ID number(EIN) /Telephone number
l )
Il. Answer the following questions by checking "Yes" or "No." If any of the questions are answered "Yes," list names and
addresses of individuals or corporations under"Remarks"on page 2. Identify each item number to be continued.
YES NO
A. Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percent or more in the institution, organizations, or agency that have been convicted of a criminal
offense related to the involvement of such persons or organizations in any of the programs established
by Titles XVIII, XIX, or XX? ......................................................................................................................... o 71
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 0
C. Are there any individuals currently employed by the institution, agency, or organization in a managerial,
accounting, auditing, or similar capacity who were employed by the institution's, organization's, or
agency's fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only)........... o 0
III. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling
interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names
and addresses under "Remarks" on page 2. If more than one individual is reported and any of these persons are
related to each other, this must be reported under"Remarks."
NAME ADDRESS EIN
B. Type of entity: o Sole proprietorship o Partnership o Corporation
o Unincorporated Associations o Other(specify)
C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations
under"Remarks."
D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses
of individuals, and provider numbers........................................................................................................... o 0
NAME ADDRESS PROVIDER NUMBER
M-1
Exhibit M
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... o n
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... n n
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ o 0
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... o 0
If yes, give date of change in operations.
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... o 0
VII. A. Is this facility chain affiliated? ...................................................................................................................... o 0
If yes, list name, address of corporation, and EIN.
Name FIN
Address(number,name) City State ZIP code
B. If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name FIN
Address(number,name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative(typed) Title
Signature Date
Remarks
M-2
Exhibit N
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is providing
the certification set out below.
2. The inability of a person to provide the certification required below will not necessarily
result in denial of participation in this covered transaction. The prospective participant shall
submit an explanation of why it cannot provide the certification set out below. The
certification or explanation will be considered in connection with the department or
agency's determination whether to enter into this transaction. However, failure of the
prospective primary participant to furnish a certification or an explanation shall disqualify
such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which reliance was
placed when the department or agency determined to enter into this transaction. If it is
later determined that the prospective primary participant knowingly rendered an erroneous
certification, in addition to other remedies available to the Federal Government, the
department or agency may terminate this transaction for cause or default.
4. The prospective primary participant shall provide immediate written notice to the
department or agency to which this proposal is submitted if at any time the prospective
primary participant learns that its certification was erroneous when submitted or has
become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant, person,
primary covered transaction, principal, proposal, and voluntarily excluded, as used in this
clause, have the meanings set out in the Definitions and Coverage sections of the rules
implementing Executive Order 12549. You may contact the department or agency to which
this proposal is being submitted for assistance in obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment of a system
of records in order to render in good faith the certification required by this clause. The
knowledge and information of a participant is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.
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;
N-1
Exhibit N
(c) Have not within a three-year period preceding this application/proposal had one or
more public transactions (Federal, State or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or Company)
N-2
Exhibit O
1
National Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health and Health Care
The National CLAS Standards are intended to advance health equity, improve quality, and help
eliminate health care disparities by establishing a blueprint for health and health care organizations to:
Principal Standard:
1. Provide effective,equitable,understandable,and respectful quality care and services that are responsive to diverse cultural health beliefs and
practices,preferred languages,health literacy,and other communication needs.
Governance,Leadership,and Workforce:
2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy,practices,and
allocated resources.
3. Recruit,promote,and support a culturally and linguistically diverse governance,leadership,and workforce that are responsive to the population in
the service area.
4. Educate and train governance,leadership,and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.
Communication and Language Assistance:
5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs,at no cost to them,to facilitate
timely access to all health care and services.
6. Inform all individuals of the availability of language assistance services clearly and in their preferred language,verbally and in writing.
7. Ensure the competence of individuals providing language assistance,recognizing that the use of untrained individuals and/or minors as interpreters
should be avoided.
8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.
Engagement,Continuous Improvement,and Accountability:
9. Establish culturally and linguistically appropriate goals,policies,and management accountability,and infuse them throughout the organization's
planning and operations.
10. Conduct ongoing assessments of the organization's CLAS-related activities and integrate CLAS-related measures into measurement and continuous
quality improvement activities.
11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to
inform service delivery.
12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the
cultural and linguistic diversity of populations in the service area.
13. Partner with the community to design,implement,and evaluate policies,practices,and services to ensure cultural and linguistic appropriateness.
14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify,prevent,and resolve conflicts
or complaints.
15. Communicate the organization's progress in implementing and sustaining CLAS to all stakeholders,constituents,and the general public.
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O-1
Exhibit O
2
The Case for the National CLAS Standards
Health equity is the attainment of the highest level of health for all people.'Currently,individuals across the United States from various cultural
backgrounds are unable to attain their highest level of health for several reasons,including the social determinants of health,or those conditions in which
individuals are born,grow,live,work,and age,2 such as socioeconomic status,education level,and the availability of health services.3
Though health inequities are directly related to the existence of historical and current discrimination
and social injustice,one of the most modifiable factors is the lack of culturally and linguistically
appropriate services,broadly defined as care and services that are respectful of and responsive to
the cultural and linguistic needs of all individuals.
Of all the forms of
Health inequities result in disparities that directly affect the quality of life for all individuals. Health
disparities adversely affect neighborhoods,communities,and the broader society,thus making inequality, injustice in
the issue not only an individual concern but also a public health concern. In the United States,it health care is the most
has been estimated that the combined cost of health disparities and subsequent deaths due to shocking and inhumane.
inadequate and/or inequitable care is$1.24 trillion.4
Culturally and linguistically appropriate services are increasingly recognized as effective in improving —Dr. Martin Luther King,Jr.
the quality of care and services.5,6 By providing a structure to implement culturally and linguistically
appropriate services,the National CLAS Standards will improve an organization's ability to address
health care disparities.
The National CLAS Standards align with the HHS Action Plan to Reduce Racial and Ethnic Health Disparities'and the National Stakeholder Strategy for
Achieving Health Equity,8 which aim to promote health equity through providing clear plans and strategies to guide collaborative efforts that address racial
and ethnic health disparities across the country.
Similar to these initiatives,the National CLAS Standards are intended to advance health equity,improve quality,and help eliminate health care disparities
by providing a blueprint for individuals and health and health care organizations to implement culturally and linguistically appropriate services.Adoption of
these Standards will help advance better health and health care in the United States.
Bibliography
1. U.S.Department of Health and Human Services,Office of Minority Health(2011).National Partnership for Action to End Health Disparities.Retrieved from http://minorityhealth.hhs.gov/npa
2.World Health Organization.(2012).Social determinants of health.Retrieved from http://www.who.int/social_determinants/en/
3. U.S.Department of Health and Human Services,Office of Disease Prevention and Health Promotion.(2010).Healthy people 2020:Social determinants of health.Retrieved from http://www.
hea lthypeopl e.gov/2020/to picsobjectives2O20/overvi ew.as px?topicid=39
4. LaVeist,T A.,Gaskin,D.J.,&Richard,P(2009).The economic burden of health inequalities in the United States.Retrieved from the Joint Center for Political and Economic Studies website:http://www.
jointeenter.org/sites/default/files/upload/research/files/The%20Economic%2 OBurden%20of%2OHealth%201nequalities%20in%20the%2OUnited%2OStates.pdf
5. Beach,M.C.,Cooper,L.A.,Robinson,K.A.,Price,E.G.,Gary,T.L.,Jenckes,M.W.,Powe,N.R.(2004).Strategies for improving minority healthcare quality.(AHRQ Publication No.04-EO08-02).Retrieved
from the Agency of Healthcare Research and Quality website:http://www.ahrq.gov/downloads/pub/evidence/pdf/minqual/minquai.pdf
6.Goode,T.D.,Dunne,M.C.,&Bronheim,S.M.(2006).The evidence base for cultural and linguistic competency in health care.(Commonwealth Fund Publication No.962).Retrieved from The
Commonwealth Fund website:http://www.commonwealthfund.org/usr_doc/Goode_evidencebasecultiinguisticcomp_962.pdf
7. U.S.Department of Health and Human Services.(2011).HHS action plan to reduce racial and ethnic health disparities:A nation free of disparities in health and health care.Retrieved from http://
minorityhealth.hhs.gov/npa/f les/Plans/HHS/H HS_Plan_complete.pdf
8. National Partnership for Action to End Health Disparities.(2011).National stakeholder strategy for achieving health equity.Retrieved from U.S.Department of Health and Human Services,Office of
Minority Health website:http://www.minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286
��� 1 Think Cultural Health
F
S(_ U.S.Deportment of https://www.thinkculturalhealth.hhs.gov/
1O M H Health and Human Services
Office of Minority Health contact@thinkculturalhealth.hhs.gov
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0-2