HomeMy WebLinkAboutAgreement A-19-586 with MHPRAP.pdf1
2
3
Agreement No. 19-586
AGREEMENT
THIS AGREEMENT is made and entered into this 19th day of November , 2019,
by and between the COUNTY OF FRESNO, a Political Subdivision of the State of California,
4 hereinafter referred to as "COUNTY", and Mental Health Patient's Rights Advocate Program, a
5 Sole Proprietorship, whose address is 1357 W . Shaw Ave . Suite 101 , Fresno , CA 93711, hereinafter
6 referred to as "CONTRACTOR".
7 W I T N E S S E T H:
8 WHEREAS , COUNTY , through its Department of Behavioral Health (DBH), is in need of a
9 qualified agency to operate mental health patient's rights advocacy services in accordance with
1 O Welfare and Institutions Code Division 5 , Part 1, Chapter 6 .2; Article 3 , sections 5520 through 5523 of
11 the Lanterman-Petris-Short Act ; and
12 WHEREAS , COUNTY, through its Managed Care program , is a Mental Health Plan (MHP) as
13 defined in Title 9 of the California Code of Regulations (C .C .R.), section 1810 .226; and
14 WHEREAS , CONTRACTOR is qualified to operate a patient's rights advocacy program , and has
15 the facility, equipment and personnel skilled in the provision of such services pursuant to the terms
16 and conditions of this Agreement.
1 7 NOW, THEREFORE, in cons ideration of their mutual covenants and conditions , the parties
18 hereto agree as follows :
19
20
21
22
23
24
25
26
27
28
1. SERVICES
A. CONTRACTOR and COUNTY shall perform all services and fulfill all
responsibilities as specified in Exhibit A, "Scope of Work ," attached hereto and incorporated herein by
reference .
B. CONTRACTOR shall also perform all services and fulfill all responsibilities as
specified in COUNTY 's Request for Proposal (RFP) issued under the name of "Mental Health
Patients ' Rights Advocate Program " RFP No . 20-002 dated July 26th , 2019 and Addendum No . One
(1) to COUNTY 's RFP No . 20-002 dated September 12 , 2019 (collectively referred to herein as
COUNTY 's Revised RFP) and CONTRACTOR 's response to COUNTY 's Revised RFP dated
September 19 , 2019 , all incorporated herein by reference and made part of this Agreement. In the
-1 -COUNTY OF FRESNO
Fresno , CA
COUNTY OF FRESNO
Fresno, CA
-2 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
event of any inconsistency among these documents, the inconsistency shall be resolved by giving
precedence in the following order of priority: (1) to the Agreement, including all Exhibits; (2) to the
Revised RFP; and (3) to the Response to the Revised RFP. A copy of COUNTY’s Revised RFP and
CONTRACTOR’s response thereto shall be retained and made available during the term of this
Agreement by COUNTY’s DBH Contracted Services Division.
C.It is acknowledged by all parties hereto that COUNTY’s DBH’s Contracted
Services Division shall monitor said patient’s rights advocacy program in accordance with Section 13
of this Agreement.
D.CONTRACTOR shall participate in monthly, or as needed, workgroup meetings
consisting of staff from COUNTY’s DBH Contracted Services Division to discuss the patient’s rights
advocacy program, requirements, data reporting, training, policies and procedures, overall program
operations, outcomes, and any problems or foreseeable problems that may arise.
E.It is acknowledged that upon execution of this Agreement, CONTRACTOR’s
service site for the patient’s rights advocacy program will located at 1357 W. Shaw Ave Suite 101,
Fresno CA 93711. Any change to CONTRACTOR’s location of the service site may be made only
upon thirty (30) days advance written notification to COUNTY's DBH Director or his/her designee and
written approval from COUNTY’s DBH Director or his/her designee.
F.CONTRACTOR agrees that prior to providing services under the terms and
conditions of this Agreement, CONTRACTOR shall have appropriate staff hired and in place for
program services and operations or COUNTY may, in addition to other remedies, suspend referrals
or terminate this Agreement, in accordance with Section 3 of this Agreement.
G.It is acknowledged that CONTRACTOR shall:
1.Perform all services working effectively and respectfully with service
recipients and providers, public administrators, community groups, and the judicial system.
2.Verbally notify the Director of the Department of Behavioral Health
twenty-four hours prior to commencing monitoring or formal investigative services involving
COUNTY’s Department of Behavioral Health sites.
3.Not request access to review or copy confidential service recipient
COUNTY OF FRESNO
Fresno, CA
-3 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
information without a valid voluntary written authorization from the service recipient or in the case of
an incompetent, the guardian, conservator, guardian ad litem or other legal representative. All record
requests shall be submitted directly to the custodian of records of the department where the records
are kept, or COUNTY’s Division Manager responsible for the facility, program, or service provided to
the recipient whose records are requested.
4.Coordinate all services with designated facilities, services program, and
COUNTY representatives.
5.Perform all monitoring services during the normal work and visitation
hours.
6.Conduct specific incident investigations in good faith and only when there
is probable cause to believe that a violation has occurred (more evidence tending to establish a
violation occurred than evidence of no violation).
7.Focus specific incident investigation services to a non-hostile resolution.
8.Submit copies of the draft monitoring and investigative reports to the
Local Mental Health Director for review and comment prior to finalization and release.
9.Attend Fresno County Behavioral Health Advisory Board meetings and
only those Fresno County Department of Behavioral Health meetings for which prior expressed
permission has been given by the Director or designee of the Department of Behavioral Health.
10.Limit participation at meetings to those issues that pertain to patient rights
specific to a complaint(s) received, a program or policy issue that may have an adverse impact to
clients or to provide education and training.
11.Coordinate the provision of services identified in this Agreement with
COUNTY Department of Behavioral Health’s Directoror her designee.
12.At minimum, quarterly attend Quality Improvement Committee meetings.
2.TERM
This Agreement shall be effective January 1, 2020 and shall terminate on the 30th day of
June, 2023.
This Agreement may be extended for two (2) additional consecutive twelve (12) month
COUNTY OF FRESNO
Fresno, CA
-4 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
periods upon written approval of both parties no later than thirty (30) days prior to the first day of the
next twelve (12) month extension period. The DBH Director or designee is authorized to execute
such written approval on behalf of COUNTY based on (vendor) satisfactory performance.
3.TERMINATION
A.Non-Allocation of Funds - The terms of this Agreement, and the services to be
provided thereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated at any time by giving CONTRACTOR sixty (60) days advance written notice.
B.Breach of Contract - COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of COUNTY there is:
1)An illegal or improper use of funds;
2)A failure to comply with any term of this Agreement;
3)A substantially incorrect or incomplete report submitted to COUNTY;
4)Improperly performed service.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of
any breach of this Agreement or any default, which may then exist on the part of CONTRACTOR.
Neither shall such payment impair or prejudice any remedy available to COUNTY with respect to the
breach or default. The COUNTY shall have the right to demand of the CONTRACTOR the repayment
to the COUNTY of any funds disbursed to CONTRACTOR under this Agreement, which in the
judgment of COUNTY were not expended in accordance with the terms of this Agreement. The
CONTRACTOR shall promptly refund any such funds upon demand, or at COUNTY’s option, such
repayment shall be deducted from future payments owing to CONTRACTOR under this Agreement.
C.Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by COUNTY, CONTRACTOR, or COUNTY’s DBH Director or designee
upon the giving of sixty (60) days advance written notice of an intention to terminate.
4.COMPENSATION AND PAYMENTS
COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation for actual expenditures incurred by CONTRACTOR in accordance with Exhibit B,
COUNTY OF FRESNO
Fresno, CA
-5 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
“Budget”, attached hereto and by this reference incorporated herein.
A.Maximum Contract Amount
The maximum amount payable to CONTRACTOR for the period of January 1,
2020 through June 30, 2020 shall not exceed One Hundred Twenty-Seven Thousand Three Hundred
Ninety-Six and No/100 Dollars ($127,196.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2020
through June 30, 2021 shall not exceed Two Hundred Fifty-Eight Thousand One Hundred Eighty-
Three and No/100 Dollars ($258,183.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2021
through June 30, 2022 shall not exceed Two Hundred Sixty-Three Thousand Seven Hundred Forty-
Seven and No/100 Dollars ($263,747.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2022
through June 30, 2023 shall not exceed Two Hundred Sixty-Eight Thousand Two Hundred Thirty-
Seven and No/100 Dollars ($268,237.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2023
through June 30, 2024 shall not exceed Two Hunrdred Seventy-Seven Thousand Thirty-Four and
No/100 Dollars ($277,034.00).
The maximum amount payable to CONTRACTOR for the period of July 1, 2024
through June 30, 2025 shall not exceed Two Hunrdred Eighty-One Thousand Nine Hundred Forty and
No/100 Dollars ($281,940.00).
In no event shall the maximum contract amount for the services provided by the
CONTRACTOR to COUNTY under the terms and conditions of this Agreement be in excess of One
Million Four Hundred Seventy-Six Thousand Three Hundred Thirty-Seven and No/100 Dollars
($1,476,337.00) during the total term of the Agreement.
B.It is understood that all expenses incidental to CONTRACTOR’s performance of
services under this Agreement shall be borne by CONTRACTOR. If CONTRACTOR should fail to
comply with any provision of this Agreement, COUNTY shall be relieved of its obligation for further
compensation.
COUNTY OF FRESNO
Fresno, CA
-6 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
C.Payments shall be made by COUNTY to CONTRACTOR in arrears, for services
provided during the preceding month, within forty-five (45) days after the date of receipt and approval
by COUNTY of the monthly invoicing as described in Section Five (5) herein. Payments shall be made
after receipt and verification of actual expenditures incurred by CONTRACTOR for monthly program
costs, as identified in Exhibit B, in the performance of this Agreement and shall be documented to
COUNTY on a monthly basis by the tenth (10th) of the month following the month of said expenditures.
CONTRACTOR shall submit to the COUNTY by the tenth (10th) of each month a
detailed general ledger (GL), itemizing costs incurred in the previous month. Failure to submit GL
reports and supporting documentation shall be deemed sufficient cause for COUNTY to withhold
payments until there is compliance, as further described in Section Five (5) herein.
D.COUNTY shall not be obligated to make any payments under this Agreement if
the request for payment is received by COUNTY more than sixty (60) days after this Agreement has
terminated or expired.
E.All final invoices and/or any final budget modification requests shall be submitted
by CONTRACTOR within sixty (60) days following the final month of service for which payment is
claimed. No action shall be taken by COUNTY on invoices submitted beyond the sixty (60) day
closeout period. Any compensation which is not expended by CONTRACTOR pursuant to the terms
and conditions of this Agreement shall automatically revert to COUNTY.
F.The services provided by CONTRACTOR under this Agreement are funded in
whole or in part by the State of California. In the event that funding for these services is delayed by the
State Controller, COUNTY may defer payments to CONTRACTOR. The amount of the deferred
payment shall not exceed the amount of funding delayed by the State Controller to the COUNTY. The
period of time of the deferral by COUNTY shall not exceed the period of time of the State Controller’s
delay of payment to COUNTY plus forty-five (45) days.
5.INVOICING
A.CONTRACTOR shall provide invoices as described below to COUNTY by the
tenth (10th) day of each month for the prior month’s expenditures, to DBH-
Invoices@fresnocountyca.gov, dbhinvoicereview@fresnocountyca.gov,
COUNTY OF FRESNO
Fresno, CA
-7 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
dbhcontractedservicesdivision@fresnocountyca.gov, and to the currently assigned contract analyst.
Invoices and reports shall be in such detail as acceptable to COUNTY’s DBH, as described in Section
Five (5) and Twelve (12) of this Agreement. Additionally, invoicing supporting documentation may be
mailed to 3133 N. Millbrook, Fresno, CA 93703, Attention: Contracts Division. No reimbursement for
services shall be made until the invoice and report is received, verified and approved by COUNTY’s
DBH.
B.At the discretion of COUNTY’s DBH Director, or designee, if an invoice is
incorrect or is otherwise not in proper form or substance, COUNTY’s DBH Director, or designee, shall
have the right to withhold payment as to only that portion of the invoice that is incorrect or improper
af ter five (5) days prior notice to CONTRACTOR. CONTRACTOR agrees to continue to provide
services for a period of ninety (90) days after notification of an incorrect or improper invoice. If after
the ninety (90) day period, the invoice(s) is still not corrected to COUNTY DBH’s satisfaction,
COUNTY’s DBH Director, or designee, may elect to terminate this Agreement, pursuant to the
termination provisions stated in Section Three (3) of this Agreement. In addition, for invoices
received ninety (90) days after the expiration of each term of this Agreement or termination of this
Agreement, at the discretion of COUNTY’s DBH Director, or designee, COUNTY’s DBH shall have
the right to deny payment of any additional invoices received.
C.CONTRACTOR shall provide a monthly activity report with each invoice, further
described in Section Twelve (12). In addition, each monthly invoice will be in the format as identified in
Exhibit B, showing each budget line item, expenses incurred, and the balance remaining for each
budget line item for all services and items as identified in Exhibit B.
D.CONTRACTOR shall submit monthly staffing reports that identify all direct
service and support staff, applicable licensure/certifications, and full time hours worked to be used as
a tracking tool to determine if CONTRACTOR’s program is staffed according to the services provided
under this Agreement.
E.CONTRACTOR must attend COUNTY DBH’s Business Office training on
equipment reporting for assets, intangible and sensitive minor assets.
6.INDEPENDENT CONTRACTOR
COUNTY OF FRESNO
Fresno, CA
-8 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
In performance of the work, duties, and obligations assumed by CONTRACTOR under
this Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of
CONTRACTOR’s officers, agents, and employees will at all times be acting and performing as
independent CONTRACTOR, and shall act in an independent capacity and not as an officer, agent,
servant, employee, joint venturer, partner, or associate of COUNTY. Furthermore, COUNTY shall
have no right to control or supervise or direct the manner or method by which CONTRACTOR shall
perform its work and function. However, COUNTY shall retain the right to administer this Agreement
so as to verify that CONTRACTOR is performing their obligations in accordance with the terms and
conditions thereof. CONTRACTOR and COUNTY shall comply with all applicable provisions of law
and the rules and regulations, if any, of governmental authorities having jurisdiction over matters,
which are directly, or indirectly, the subject of this Agreement.
Because of its status as an independent contractor, CONTRACTOR shall have
absolutely no right to employment rights and benefits available to COUNTY employees.
CONTRACTOR shall be solely liable and responsible for providing to, or on behalf of, its employees all
legally-required employee benef its. In addition, CONTRACTOR shall be solely responsible and save
COUNTY harmless from all matters relating to payment of CONTRACTOR’s employees, including
compliance with Social Security, withholding, and all other regulations governing such matters. It is
acknowledged that during the term of this Agreement, CONTRACTOR may be providing services to
others unrelated to COUNTY or to this Agreement.
7.MODIFICATION
Any matters of this Agreement may be modified from time to time by the written consent
of all the parties without, in any way, affecting the remainder.
Notwithstanding the above, changes to services, staffing, and responsibilities of the
CONTRACTOR, as needed, to accommodate changes in the laws relating to mental health
treatment, as set forth in Exhibit A, may be made with the signed written approval of COUNTY’s DBH
Director, or his or her designee, and CONTRACTOR through an amendment approved by COUNTY’s
County Counsel and the COUNTY’s Auditor-Controller’s Office.
In addition, changes to expense category (i.e., Salary & Benefits, Facilities/Equipment,
COUNTY OF FRESNO
Fresno, CA
-9 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Operating, Financial Services, Special Expenses, Fixed Assets, etc.) subtotals in the budgets, and
changes to the volume of units of services/types of service units to be provided as set forth in Exhibit
B, that do not exceed ten percent (10%) of the maximum compensation payable to the
CONTRACTOR may be made with the written approval of COUNTY’s DBH Director, or his or her
designee. Changes to the expense categories in the budget that exceed ten percent (10%) of the
maximum compensation payable to the CONTRACTOR, may be made with the signed written
approval of COUNTY’s DBH Director, or his or her designee through an amendment approved by
COUNTY’s Counsel and COUNTY’s Auditor-Controller’s Office.
Said modifications shall not result in any change to the annual maximum compensation
amount payable to CONTRACTOR, as stated in this Agreement.
8.NON-ASSIGNMENT
No party shall assign, transfer or subcontract this Agreement nor their rights or duties
under this Agreement without the prior written consent of COUNY.
9.HOLD-HARMLESS
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
defend COUNTY, its officers, agents and employees from any and all costs and expenses including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
COUNTY in connection with the performance, or failure to perform, by CONTRACTOR, its officers,
agents or employees under this Agreement, and from any and all costs and expenses, including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to any
person, firm or corporation who may be injured or damaged by the performance, or failure to perform,
of CONTRACTOR, their officers, agents or employees under this Agreement.
CONTRACTOR agrees to indemnify COUNTY for Federal and/or State of California
audit exceptions resulting from noncompliance herein on the part of CONTRACTOR.
10.INSURANCE
Without limiting COUNTY's right to obtain indemnification from CONTRACTOR or any
third parties, each CONTRACTOR, at its sole expense, shall maintain in full force and effect the
following insurance policies throughout the term of this Agreement:
COUNTY OF FRESNO
Fresno, CA
-10 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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 shall be issued on a per occurrence basis.
COUNTY may require specific coverages including completed operations,
product liability, contractual liability, Explosion-Collapse-Underground, fire legal
liability or any other liability insurance deemed necessary because of the nature
of the Agreement.
B.Automobile Liability
Comprehensive Automobile Liability Insurance with limits no less than One
Million Dollars ($1,000,000) per accident for bodily injury and property damage.
Coverage should include any automobile used in connection with this
Agreement. If CONTRACTOR employees are not covered by CONTRACTOR
automobile liability insurance policy, CONTRACTOR shall ensure that each
employee as part of this Agreement procures and maintains their own private
automobile coverage in force during the term of this Agreement, at the
employee’s sole cost and expense.
C.Professional Liability
If CONTRACTOR employs licensed professional staff (e.g. Ph.D., R.N.,
L.C.S.W., L.M.F.T., etc.) in providing services, Professional Liability Insurance
with limits of not less than One Million Dollars ($1,000,000) per occurrence,
Three Million Dollars ($3,000,000) annual aggregate. CONTRACTOR agrees
that it shall maintain, at its sole expense, in full force and effect for a period of
five (5) years following the termination of this Agreement, one or more policies of
professional liability insurance with limits of coverage as specified herein.
D.Real and Property Insurance
CONTRACTOR shall maintain a policy of insurance for all risk personal property
coverage which shall be endorsed naming the County of Fresno as an additional
loss payee. The personal property coverage shall be in an amount that will cover
the total of the COUNTY purchase and owned property, at a minimum, as
discussed in Section Twenty One (21) of this Agreement.
All Risk Property Insurance
As applicable, CONTRACTOR will provide property coverage for the full
replacement value of the COUNTY’S personal property in possession of
CONTRACTOR and/or used in the execution of this Agreement. COUNTY will
be identified on an appropriate certificate of insurance as the certificate holder
and will be named as an Additional Loss Payee on the Property Insurance Policy.
E.W orker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
COUNTY OF FRESNO
Fresno, CA
-11 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
F.Child Abuse/Molestation and Social Services Coverage
Each CONTRACTOR shall have either separate policies or an umbrella policy
with endorsements covering Child Abuse/Molestation and Social Services
Liability coverage or have a specific endorsement on their General Commercial
liability policy covering Child Abuse/Molestation and Social Services Liability.
The policy limits for these policies shall be One Million Dollars ($1,000,000) per
occurrence with a Two Million Dollars ($2,000,000) annual aggregate. The
policies are to be on a per occurrence basis.
G.Cyber Liability
Cyber Liability Insurance, with limits not less than Two Million Dollars
($2,000,000) per occurrence or claim, Two Million Dollars ($2,000,000)
aggregate. Coverage shall be sufficiently broad to respond to the duties and
obligations as is undertaken by CONTRACTOR in this Agreement and shall
include, but not be limited to, claims involving infringement of intellectual
property, including but not limited to infringement of copyright, trademark, trade
dress, invasion of privacy violations, information theft, damage to or destruction
of electronic information, release of private information, alteration of electronic
information, extortion and network security. The policy shall provide coverage for
breach response costs as well as regulatory fines and penalties as well as credit
monitoring expenses with limits sufficient to respond to these obligations.
H.Waiver of Subrogation
CONTRACTOR hereby grants to COUNTY a waiver of any right to subrogation
which any insurer of said CONTRACTOR may acquire against the COUNTY by
virtue of the payment of any loss under such insurance. CONTRACTOR agrees
to obtain any endorsement that may be necessary to affect this waiver of
subrogation, but this provision applies regardless of whether or not the COUNTY
has received a waiver of subrogation endorsement from the insurer.
CONTRACTOR shall obtain endorsements to the Commercial General Liability
insurance naming the County of Fresno, its officers, agents, and employees, individually and
collectively, as additional insured, but only insofar as the operations under this Agreement are
concerned. Such coverage for additional insured shall apply as primary insurance and any other
insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees shall be
excess only and not contributing with insurance provided under CONTRACTOR’s policies herein. This
insurance shall not be cancelled or changed without a minimum of thirty (30) days advance written
notice given to COUNTY.
Within thirty (30) days from the date CONTRACTOR signs this Agreement,
COUNTY OF FRESNO
Fresno, CA
-12 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
CONTRACTOR shall provide certificates of insurance and endorsements as stated above for all of the
foregoing policies, as required herein, to the County of Fresno, Department of Behavioral Health, 3133
N Millbrook Ave, Fresno, California, 93703, Attention: Contracts Division, stating that such insurance
coverages have been obtained and are in full force; that the County of Fresno, its officers, agents and
employees will not be responsible for any premiums on the policies; that such Commercial General
Liability insurance names the County of Fresno, its officers, agents and employees, individually and
collectively, as additional insured, but only insofar as the operations under this Agreement are
concerned; that such coverage for additional insured shall apply as primary insurance and any other
insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees, shall be
excess only and not contributing with insurance provided under CONTRACTOR’s policies herein; and
that this insurance shall not be cancelled or changed without a minimum of thirty (30) days advance,
written notice given to COUNTY.
In the event CONTRACTOR fails to keep in effect at all times insurance coverage as
herein provided, COUNTY may, in addition to other remedies it may have, suspend or terminate this
Agreement upon the occurrence of such event.
All policies shall be with admitted insurers licensed to do business in the State of
California. Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating
of A FSC VII or better.
11.LICENSES/CERTIFICATES
Throughout the term of this Agreement, CONTRACTOR and CONT RACTOR’s staff
shall maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions
necessary for the provision of the services hereunder and required by the laws and regulations of the
United States of America, State of California, the County of Fresno, and any other applicable
governmental agencies. CONTRACTOR shall notify COUNTY immediately in writing of its inability to
obtain or maintain such licenses, permits, approvals, certificates, waivers and exemptions irrespective
of the pendency of any appeal related thereto. Additionally, CONTRACTOR and CONTRACTOR’s
staff shall comply with all applicable laws, rules or regulations, as may now exist or be hereafter
changed.
COUNTY OF FRESNO
Fresno, CA
-13 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
12.REPORTS
A.Activity Reports
CONTRACTOR shall submit to COUNTY’s DBH by the 10th of each month all
monthly activity and budget reports for the preceding month.
B.Additional Reports
In addition, CONTRACTOR shall also furnish to COUNTY such statements,
records, reports, data, and other information as COUNTY may request pertaining to matters covered
by this Agreement. In the event that CONTRACTOR fails to provide such reports or other information
required hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly payments
until there is compliance. In addition, CONTRACTOR shall provide written notification and explanation
to COUNTY within five (5) days of any funds received from another source to conduct the same
services covered by this Agreement.
C.Quarterly Progress Reports
CONTRACTOR shall complete Quarterly Progress Reports in the form
set forth in Exhibit D, attached hereto and by this reference incorporated herein and made part of this
Agreement. Quarterly reports shall be submitted to COUNTY’s DBH Contracts Division for review
within thirty (30) days of the end of each quarter.
13.MONITORING
CONTRACTOR agrees to extend to COUNTY’s staff, COUNTY’s DBH Director and the
State Department of Health Care Services, or their designees, the right to review and monitor records,
programs or procedures, at any time, in regard to clients, as well as the overall operation of
CONTRACTOR’s programs, in order to ensure compliance with the terms and conditions of this
Agreement.
14. REFERENCES TO LAWS AND RULES
In the event any law, regulation, or policy referred to in this Agreement is amended
during the term thereof, the parties hereto agree to comply with the amended provision as of the
effective date of such amendment.
15.COMPLIANCE WITH STATE REQUIREMENTS
COUNTY OF FRESNO
Fresno, CA
-14 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
CONTRACTOR recognizes that COUNTY operates its mental health programs under an
agreement with the State of California Department of Health Care Services, and that under said
agreement the State imposes certain requirements on COUNTY and its subcontractors.
CONTRACTOR shall adhere to all State requirements, including those identified in Exhibit E “State
Mental Health Requirements”, attached hereto and by this reference incorporated herein.
CONTRACTOR shall also file an incident report for all incidents involving consumers, following the
Protocol and using the Worksheet identified in Exhibit G, attached hereto and by this reference
incorporated herein.
16.CONFIDENTIALITY
All services performed by CONTRACTOR under this Agreement shall be in strict
conformance with all applicable Federal, State of California and/or local laws and regulations relating to
confidentiality.
17.HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
A.The parties to this Agreement shall be in strict conformance with all applicable
Federal and State of California laws and regulations, including but not limited to Sections 5328, 10850,
and 14100.2 et seq. of the Welfare and Institutions Code, Sections 2.1 and 431.300 et seq. of Title 42,
Code of Federal Regulations (CFR), Section 56 et seq. of the California Civil Code, and the Health
Insurance Portability and Accountability Act (HIPAA), including but not limited to Section 1320 D et
seq. of Title 42, United States Code (USC) and its implementing regulations, including, but not limited
to Title 45, CFR, Sections 142, 160, 162, and 164, The Health Information Technology for Economic
and Clinical Health Act (HITECH) regarding the confidentiality and security of patient information, and
the Genetic Information Nondiscrimination Act (GINA) of 2008 regarding the confidentiality of genetic
information.
Except as otherwise provided in this Agreement, CONTRACTOR, as a Business
Associate of COUNTY, may use or disclose Protected Health Information (PHI) to perform functions,
activities or services for or on behalf of COUNTY, as specified in this Agreement, provided that such
use or disclosure shall not violate the Health Insurance Portability and Accountability Act (HIPAA),
USC 1320d et seq. The uses and disclosures of PHI may not be more expansive than those
COUNTY OF FRESNO
Fresno, CA
-15 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
applicable to COUNTY, as the “Covered Entity” under the HIPAA Privacy Rule (45 CFR 164.500 et
seq.), except as authorized for management, administrative or legal responsibilities of the Business
Associate.
B.CONTRACTOR, including its subcontractors and employees, shall protect, from
unauthorized access, use, or disclosure of names and other identifying information, including genetic
information, concerning persons receiving services pursuant to this Agreement, except where
permitted in order to carry out data aggregation purposes for health care operations [45 CFR Sections
164.504 (e)(2)(i), 164.504 (3)(2)(ii)(A), and 164.504 (e)(4)(i)] This pertains to any and all persons
receiving services pursuant to a COUNTY funded program. This requirement applies to electronic
PHI. CONTRACTOR shall not use such identifying information or genetic information for any purpose
other than carrying out CONTRACTOR’s obligations under this Agreement.
C. CONTRACTOR, including its subcontractors and employees, shall not disclose
any such identifying information or genetic information to any person or entity, except as otherwise
specifically permitted by this Agreement, authorized by Subpart E of 45 CFR Part 164 or other law,
required by the Secretary, or authorized by the client/patient in writing. In using or disclosing PHI that
is permitted by this Agreement or authorized by law, CONTRACTOR shall make reasonable efforts to
limit PHI to the minimum necessary to accomplish intended purpose of use, disclosure or request.
D.For purposes of the above sections, identifying information shall include, but not
be limited to name, identifying number, symbol, or other identifying particular assigned to the
individual, such as finger or voice print, or photograph.
E.For purposes of the above sections, genetic information shall include genetic
tests of family members of an individual or individual, manifestation of disease or disorder of family
members of an individual, or any request for or receipt of, genetic services by individual or family
members. Family member means a dependent or any person who is first, second, third, or fourth
degree relative.
F.CONTRACTOR shall provide access, at the request of COUNTY, and in the time
and manner designated by COUNTY, to PHI in a designated record set (as def ined in 45 CFR Section
164.501), to an individual or to COUNTY in order to meet the requirements of 45 CFR Section 164.524
COUNTY OF FRESNO
Fresno, CA
-16 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
regarding access by individuals to their PHI. With respect to individual requests, access shall be
provided within thirty (30) days from request. Access may be extended if CONTRACTOR cannot
provide access and provides individual with the reasons for the delay and the date when access may
be granted. PHI shall be provided in the form and format requested by the individual or COUNTY.
CONTRACTOR shall make any amendment(s) to PHI in a designated record set
at the request of COUNTY or individual, and in the time and manner designated by COUNTY in
accordance with 45 CFR Section 164.526.
CONTRACTOR shall provide to COUNTY or to an individual, in a time and
manner designated by COUNTY, information collected in accordance with 45 CFR Section 164.528, to
permit COUNTY to respond to a request by the individual for an accounting of disclosures of PHI in
accordance with 45 CFR Section 164.528.
G.CONTRACTOR shall report to COUNTY, in writing, any knowledge or
reasonable belief that there has been unauthorized access, viewing, use, disclosure, security incident,
or breach of unsecured PHI not permitted by this Agreement of which it becomes aware, immediately
and without reasonable delay and in no case later than two (2) business days of discovery. Immediate
notification shall be made to COUNTY’s Information Security Officer and Privacy Officer and
COUNTY’s DPH HIPAA Representative, within two (2) business days of discovery. The notification
shall include, to the extent possible, the identification of each individual whose unsecured PHI has
been, or is reasonably believed to have been, accessed, acquired, used, disclosed, or breached.
CONTRACTOR shall take prompt corrective action to cure any deficiencies and any action pertaining
to such unauthorized disclosure required by applicable Federal and State Laws and regulations.
CONTRACTOR shall investigate such breach and is responsible for all notifications required by law
and regulation or deemed necessary by COUNTY and shall provide a written report of the
investigation and reporting required to COUNTY’s Information Security Officer and Privacy Officer and
COUNTY’s DPH HIPAA Representative. This written investigation and description of any reporting
necessary shall be postmarked within the thirty (30) working days of the discovery of the breach to the
addresses below:
County of Fresno County of Fresno County of Fresno
COUNTY OF FRESNO
Fresno, CA
-17 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Dept. of Behavioral Health Dept. of Public Health Information Technology Services
HIPAA Representative Privacy Officer Information Security Officer
(559)600-9180 (559) 600-6405 (559) 600-5800
1925 E Dakota Ave P.O. Box 11867 333 W . Pontiac Way
Fresno, CA 93726 Fresno, CA 93775 Clovis, CA 93612
H.CONTRACTOR shall make its internal practices, books, and records relating to
the use and disclosure of PHI received from COUNTY, or created or received by the CONTRACTOR
on behalf of COUNTY, in compliance with HIPAA’s Privacy Rule, including, but not limited to the
requirements set forth in Title 45, CFR, Sections 160 and 164. CONTRACTOR shall make its internal
practices, books, and records relating to the use and disclosure of PHI received from COUNTY, or
created or received by the CONTRACTOR on behalf of COUNTY, available to the United States
Department of Health and Human Services (Secretary) upon demand.
CONTRACTOR shall cooperate with the compliance and investigation reviews
conducted by the Secretary. PHI access to the Secretary must be provided during the
CONTRACTOR’s normal business hours, however, upon exigent circumstances access at any time
must be granted. Upon the Secretary’s compliance or investigation review, if PHI is unavailable to
CONTRACTOR and in possession of a Subcontractor, it must certify efforts to obtain the information
to the Secretary.
I.Safeguards
CONTRACTOR shall implement administrative, physical, and technical
safeguards as required by the HIPAA Security Rule, Subpart C of 45 CFR 164, that reasonably and
appropriately protect the confidentiality, integrity, and availability of PHI, including electronic PHI, that it
creates, receives, maintains or transmits on behalf of COUNTY and to prevent unauthorized access,
viewing, use, disclosure, or breach of PHI other than as provided for by this Agreement.
CONTRACTOR shall conduct an accurate and thorough assessment of the potential risks and
vulnerabilities to the confidential, integrity and availaibility of electronic PHI. CONTRACTOR shall
develop and maintain a written information privacy and security program that includes administrative,
technical and physical safeguards appropriate to the size and complexity of CONTRACTOR’s
operations and the nature and scope of its activities. Upon COUNTY’s request, CONTRACTOR shall
provide COUNTY with information concerning such safeguards.
COUNTY OF FRESNO
Fresno, CA
-18 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
CONTRACTOR shall implement strong access controls and other security
safeguards and precautions in order to restrict logical and physical access to confidential, personal
(e.g., PHI) or sensitive data to authorized users only. Said safeguards and precautions shall include
the following administrative and technical password controls for all systems used to process or store
confidential, personal, or sensitive data:
1.Passwords must not be:
a.Shared or written down where they are accessible or recognizable
by anyone else; such as taped to computer screens, stored under keyboards, or visible in a work area;
b.A dictionary word; or
c. Stored in clear text
2.Passwords must be:
a.Eight (8) characters or more in length;
b.Changed every ninety (90) days;
c. Changed immediately if revealed or compromised; and
d.Composed of characters from at least three (3) of the following
four (4) groups from the standard keyboard:
1)Upper case letters (A-Z);
2)Lowercase letters (a-z);
3)Arabic numerals (0 through 9); and
4)Non-alphanumeric characters (punctuation symbols).
CONTRACTOR shall implement the following security controls on each
workstation or portable computing device (e.g., laptop computer) containing confidential,
personal, or sensitive data:
1.Network-based firewall and/or personal firewall;
2.Continuously updated anti-virus software; and
3.Patch management process including installation of all operating
system/software vendor security patches.
CONTRACTOR shall utilize a commercial encryption solution that has received
COUNTY OF FRESNO
Fresno, CA
-19 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
FIPS 140-2 validation to encrypt all confidential, personal, or sensitive data stored on portable
electronic media (including, but not limited to, compact disks and thumb drives) and on portable
computing devices (including, but not limited to, laptop and notebook computers).
CONTRACTOR shall not transmit conf idential, personal, or sensitive data via e-
mail or other internet transport protocol unless the data is encrypted by a solution that has been
validated by the National Institute of Standards and Technology (NIST) as conforming to the
Advanced Encryption Standard (AES) Algorithm. CONTRACTOR must apply appropriate sanctions
against its employees who fail to comply with these safeguards. CONTRACTOR must adopt
procedures for terminating access to PHI when employment of employee ends.
J.Mitigation of Harmful Effects
CONTRACTOR shall mitigate, to the extent practicable, any harmful effect that is
suspected or known to CONTRACTOR of an unauthorized access, viewing, use, disclosure, or breach
of PHI by CONTRACTOR or its subcontractors in violation of the requirements of these provisions.
CONTRACTOR must document suspected or known harmful effects and the outcome.
K.CONTRACTOR’s Subcontractors
CONTRACTOR shall ensure that any of its contractors, including subcontractors,
if applicable, to whom CONTRACTOR provides PHI received from or created or received by
CONTRACTOR on behalf of COUNTY, agree to the same restrictions, safeguards, and conditions that
apply to CONTRACTOR with respect to such PHI and to incorporate, when applicable, the relevant
provisions of these provisions into each subcontract or sub-award to such agents or subcontractors..
L.Employee Training and Discipline
CONTRACTOR shall train and use reasonable measures to ensure compliance
with the requirements of these provisions by employees who assist in the performance of functions or
activities on behalf of COUNTY under this Agreement and use or disclose PHI and discipline such
employees who intentionally violate any provisions of these provisions, including termination of
employment.
M.Termination for Cause
Upon COUNTY’s knowledge of a material breach of these provisions by
COUNTY OF FRESNO
Fresno, CA
-20 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
CONTRACTOR, COUNTY shall either:
1.Provide an opportunity for CONTRACTOR to cure the breach or end the
violation and terminate this Agreement if CONTRACTOR does not cure the breach or end the violation
within the time specified by COUNTY; or
2.Immediately terminate this Agreement if CONTRACTOR has breached a
material term of these provisions and cure is not possible.
3.If neither cure nor termination is feasible, the COUNTY’s Privacy Officer
shall report the violation to the Secretary of the U.S. Department of Health and Human Services.
N.Judicial or Administrative Proceedings
COUNTY may terminate this Agreement in accordance with the terms and
conditions of this Agreement as written hereinabove, if: (1) CONTRACTOR is found guilty in a
criminal proceeding for a violation of the HIPAA Privacy or Security Laws or the HITECH Act; or (2) a
finding or stipulation that the CONTRACTOR has violated a privacy or security standard or
requirement of the HITECH Act, HIPAA or other security or privacy laws in an administrative or civil
proceeding in which the CONTRACTOR is a party.
O.Effect of Termination
Upon termination or expiration of this Agreement for any reason, CONTRACTOR
shall return or destroy all PHI received from COUNTY (or created or received by CONTRACTOR on
behalf of COUNTY) that CONTRACTOR still maintains in any form, and shall retain no copies of such
PHI. If return or destruction of PHI is not feasible, it shall continue to extend the protections of these
provisions to such information, and limit further use of such PHI to those purposes that make the
return or destruction of such PHI infeasible. This provision shall apply to PHI that is in the possession
of subcontractors or agents, if applicable, of CONTRACTOR. If CONTRACTOR destroys the PHI
data, a certification of date and time of destruction shall be provided to the COUNTY by
CONTRACTOR.
P.Disclaimer
COUNTY makes no warranty or representation that compliance by
CONTRACTOR with these provisions, the HITECH Act, HIPAA or the HIPAA regulations will be
COUNTY OF FRESNO
Fresno, CA
-21 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
adequate or satisfactory for CONTRACTOR’s own purposes or that any information in
CONTRACTOR’s possession or control, or transmitted or received by CONTRACTOR, is or will be
secure from unauthorized access, viewing, use, disclosure, or breach. CONTRACTOR is solely
responsible for all decisions made by CONTRACTOR regarding the safeguarding of PHI.
Q.Amendment
The parties acknowledge that Federal and State laws relating to electronic data
security and privacy are rapidly evolving and that amendment of these provisions may be required to
provide for procedures to ensure compliance with such developments. The parties specifically agree
to take such action as is necessary to amend this agreement in order to implement the standards and
requirements of HIPAA, the HIPAA regulations, the HITECH Act and other applicable laws relating to
the security or privacy of PHI. COUNTY may terminate this Agreement upon thirty (30) days written
notice in the event that CONTRACTOR does not enter into an amendment providing assurances
regarding the safeguarding of PHI that COUNTY in its sole discretion, deems sufficient to satisfy the
standards and req uirements of HIPAA, the HIPAA regulations and the HITECH Act.
R.No Third-Party Beneficiaries
Nothing express or implied in the terms and conditions of these provisions is
intended to confer, nor shall anything herein confer, upon any person other than COUNTY or
CONTRACTOR and their respective successors or assignees, any rights, remedies, obligations or
liabilities whatsoever.
S.Interpretation
The terms and conditions in these provisions shall be interpreted as broadly as
necessary to implement and comply with HIPAA, the HIPAA regulations and applicable State laws.
The parties agree that any ambiguity in the terms and conditions of these provisions shall be resolved
in favor of a meaning that complies and is consistent with HlPAA and the HIPAA regulations.
T.Regulatory References
A reference in the terms and conditions of these provisions to a section in the
HIPAA regulations means the section as in effect or as amended.
U.Survival
COUNTY OF FRESNO
Fresno, CA
-22 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
The respective rights and obligations of CONTRACTOR as stated in this Section
shall survive the termination or expiration of this Agreement.
V.No Waiver of Obligations
No change, waiver or discharge of any liability or obligation hereunder on any
one or more occasions shall be deemed a waiver of performance of any continuing or other obligation,
or shall prohibit enforcement of any obligation on any other occasion.
18.DATA SECURITY
For the purpose of preventing the potential loss, misappropriation or inadvertent access,
viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse of
COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that enter
into a contractual relationship with the COUNTY for the purpose of providing services under this
Agreement must employ adequate data security measures to protect the confidential information
provided to CONTRACTOR by the COUNTY, including but not limited to the following:
A.CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
CONTRACTOR may not connect to COUNTY networks via personally-owned
mobile, wireless or handheld devices, unless the following conditions are met:
1)CONTRACTOR has received authorization by COUNTY for
telecommuting purposes;
2)Current virus protection software is in place;
3)Mobile device has the remote wipe feature enabled; and
4)A secure connection is used.
B.CONTRACTOR-Owned Computers or Computer Peripherals
CONTRACTOR may not bring CONTRACTOR-owned computers or computer
peripherals into the COUNTY for use without prior authorization from the COUNTY’s Chief Information
Officer, and/or his or her designee(s), including but not limited to mobile storage devices. If data is
approved to be transferred, data must be stored on a secure server approved by the COUNTY and
transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
connection. Said data must be encrypted.
COUNTY OF FRESNO
Fresno, CA
-23 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
C. COUNTY-Owned Computer Equipment
CONTRACTOR may not use COUNTY computers or computer peripherals on
non-COUNTY premises without prior authorization from the COUNTY’s Chief Information Officer,
and/or his or her designee(s).
D. CONTRACTOR may not store COUNTY’s private, confidential or sensitive data
on any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
E.CONTRACTOR shall be responsible to employ strict controls to ensure the
integrity and security of COUNTY’s confidential information and to prevent unauthorized access,
viewing, use or disclosure of data maintained in computer files, program documentation, data
processing systems, data files and data processing equipment which stores or processes COUNTY
data internally and externally.
F. Confidential client information transmitted to one party by the other by means of
electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of 128
BIT or higher. Additionally, a password or pass phrase must be utilized.
G.CONTRACTOR is responsible to immediately notify COUNTY of any violations,
breaches or potential breaches of security related to COUNTY’s confidential information, data
maintained in computer files, program documentation, data processing systems, data files and data
processing equipment which stores or processes COUNTY data internally or externally.
H.COUNTY shall provide oversight to CONTRACTOR’s response to all incidents arising
from a possible breach of security related to COUNTY’s confidential client information provided to
CONTRACTOR. CONTRACTOR will be responsible to issue any notification to affected individuals
as required by law or as deemed necessary by COUNTY in its sole discretion. CONTRACTOR will
be responsible for all costs incurred as a result of providing the required notification.
19.PROPERTY OF COUNTY
A.COUNTY and CONTRACTOR recognize that fixed assets are tangible and
intangible property obtained or controlled under COUNTY’s Mental Health Plan for use in operational
capacity and will benefit COUNTY for a period more than one year. Depreciation of the qualified items
will be on a straight-line basis.
COUNTY OF FRESNO
Fresno, CA
-24 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
For COUNTY purposes, fixed assets must fulfill three qualifications:
1.Asset must have life span of over one year.
2.The asset is not a repair part
3.The asset must be valued at or greater than the capitalization thresholds for the asset
type
Asset type Threshold
•land $0
•buildings and improvements $100,000
•infrastructure $100,000
•be tangible $5,000
o equipment
o vehicles
•or intangible asset $100,000
o Internally generated software
o Purchased software
o Easements
o Patents
•and capital lease $5,000
Qualified fixed asset equipment is to be reported and approved by COUNTY. If it
is approved and identified as an asset it will be tagged with a COUNTY program number. A Fixed
asset log will be maintained by COUNTY’s Asset Management System and annual inventoried until
the asset is fully depreciated. During the terms of this Agreement, CONTRACTOR’s fixed assets
may be inventoried in comparison to COUNTY’s DBH Asset Inventory System.
B.Certain purchases less than Five Thousand and No/100 Dollars ($5,000.00) but
more than $1,000, with over one year life span, and are mobile and high risk of theft or loss are
sensitive assets. Such sensitive items are not limited to computers, copiers, televisions, cameras and
other sensitive items as determined by COUNTY’s DBH Director or designee. CONTRACTOR
maintains a tracking system on the items and are not required to be capitalized or depreciated. The
items are subject to annual inventory for compliance.
C.Assets shall be retained by COUNTY, as COUNTY property, in the event this
Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate
in an annual inventory of all COUNTY fixed and inventoried assets. Upon termination or expiration of
this Agreement CONTRACTOR shall be physically present when fixed and inventoried assets are
COUNTY OF FRESNO
Fresno, CA
-25 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
returned to COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all
COUNTY owned undepreciated fixed and inventoried assets, or the monetary value of said assets if
unable to produce the assets at the expiration or termination of this Agreement.
CONTRACTOR further agrees to the following:
1.To maintain all items of equipment in good working order and condition,
normal wear and tear is expected;
2.To label all items of equipment with COUNTY assigned program number,
to perform periodic inventories as required by COUNTY and to maintain an inventory list showing
where and how the equipment is being used, in accordance with procedures developed by COUNTY.
All such lists shall be submitted to COUNTY within ten (10) days of any request therefore; and
3.To report in writing to COUNTY immediately after discovery, the lost or
theft of any items of equipment. For stolen items, the local law enforcement agency must be
contacted and a copy of the police report submitted to COUNTY.
D.The purchase of any equipment by CONTRACTOR with funds provided
hereunder shall require the prior written approval of COUNTY’s DBH, shall fulfill the provisions of this
Agreement as appropriate, and must be directly related to CONTRACTOR’s services or activity under
the terms of this Agreement. COUNTY’s DBH may refuse reimbursement for any costs resulting from
equipment purchased, which are incurred by CONTRACTOR, if prior written approval has not been
obtained from COUNTY.
E.CONTRACTOR must obtain prior written approval from COUNTY’s DBH
whenever there is any modification or change in the use of any property acquired or improved, in
whole or in part, using funds under this Agreement. If any real or personal property acquired or
improved with said funds identified herein is sold and/or is utilized by CONTRACTOR for a use which
does not qualify under this Agreement, CONTRACTOR shall reimburse COUNTY in an amount equal
to the current fair market value of the property, less any portion thereof attributable to expenditures of
funds not provided under this Agreement. These requirements shall continue in effect for the life of
the property. In the event this Agreement expires, or terminates, the requirements for this Section
shall remain in effect for activities or property funded with said funds, unless action is taken by the
COUNTY OF FRESNO
Fresno, CA
-26 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
State government to relieve COUNTY of these obligations
20.NON-DISCRIMINATION
During the performance of this Agreement, CONTRACTOR shall not unlawfully
discriminate against any employee or applicant for employment, or recipient of services, because of
race, religion, color, national origin, ancestry, physical handicap, medical condition, marital status,
age or sex, pursuant to all applicable State and Federal statutes and regulations.
21.CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, CONTRACTOR shall comply with:
A.Title 6 of the Civil Rights Act of 1964 (42 U.S.C. Section 2000d, and 45 C.F.R
Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance
from discriminating against persons based on race, color, national origin, sex, disability or religion.
This is interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access
and participation in federally funded programs through the provision of comprehensive and quality
bilingual services.
B.Policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP consumers, including, but not limited to,
assessing the cultural and linguistic needs of its consumers, training of staff on the policies and
procedures, and monitoring its language assistance program. The CONTRACTOR’s procedures must
include ensuring compliance of any sub-contracted providers with these requirements.
C. CONTRACTOR shall not use minors as interpreters.
D. CONTRACTOR shall provide and pay for interpreting and translation services to
persons participating in CONTRACTOR’ services who have limited or no English language proficiency,
including services to persons who are deaf or blind. Interpreter and translation services shall be
provided as necessary to allow such participants meaningful access to the programs, services and
benefits provided by CONTRACTOR. Interpreter and translation services, including translation of
CONTRACTOR’ “vital documents” (those documents that contain information that is critical for
accessing CONTRACTOR’ services or are required by law) shall be provided to participants at no cost
to the participant. CONTRACTOR shall ensure that any employees, agents, subcontractors, or
COUNTY OF FRESNO
Fresno, CA
-27 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
partners who interpret or translate for a program participant, or who directly communicate with a
program participant in a language other than English, demonstrate prof iciency in the participant’s
language and can effectively communicate any specialized terms and concepts peculiar to
CONTRACTOR services.
E.In compliance with the State mandated Culturally and Linguistically Appropriate
Services standards as published by the Office of Minority Health, CONTRACTOR must submit to
COUNTY for approval, within sixty (60) days from date of contract execution, CONTRACTOR’ plan to
address all fifteen (15) national cultural competency standards as set forth in the “National Standards
on Culturally and Linguistically Appropriate Services (CLAS)”
(http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf) and Exhibit K, “Cultural Competence
Form”, attached hereto and by this reference incorporated herein and made a part of this Agreement.
COUNTY’s annual on-site review of CONTRACTOR shall include collection of documentation to ensure
all national standards are implemented. As the national competency standards are updated,
CONTRACTOR’ plan must be updated accordingly.
F.CONTRACTOR shall be responsible for conducting an annual cultural
competency self-assessment and provide the results of said self-assessment to the COUNTY”S DBH.
The annual cultural competency self-assessment instruments shall be reviewed by the COUNTY and
revised as necessary to meet the approval of the COUNTY.
G.Cultural competency training for CONTRACTOR staff should be substantively
integrated into health professions education and training at all levels, both academic and
functional, including core curriculum, professional licensure, and continuing professional development
programs. On an annual basis, CONTRACTOR’s direct service providers shall complete eight (8)
hours of cultural competency training. CONTRACTOR on a monthly basis shall provide COUNTY DBH
a monthly monitoring tool/report that shows cultural competency trainings completed as per Exhibit L.
CONTRACTOR shall attend the COUNTY’s Cultural Competency Committee monthly
meetings, maintain its own cultural competence oversight committee, and develop a cultural
competency plan to address and evaluate cultural competency issues.
22.AMERICANS WITH DISABILITIES ACT
COUNTY OF FRESNO
Fresno, CA
-28 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
CONTRACTOR agrees to ensure that deliverables developed and produced, pursuant to
this Agreement shall comply with the accessibility requirements of Section 508 of the Rehabilitation Act
and the Americans with Disabilities Act of 1973 as amended (29 U.S.C. §794 (d)), and regulations
implementing that Act as set forth in Part 1194 of Title 36 of the Code of Federal Regulations. In 1998,
Congress amended the Rehabilitation Act of 1973 to require Federal agencies to make their electronic
and information technology (EIT) accessible to people with disabilities. California Government Code
Section 11135 codifies section 508 of the Act requiring accessibility of electronic and information
technology.
23.CONFLICT OF INTEREST
No officer, agent, or employee of COUNTY who exercises any function or responsibility
for planning and carrying out the services provided under this Agreement shall have any direct or
indirect personal financial interest in this Agreement. In addition, no employee of COUNTY shall be
employed by CONTRACTOR to fulfill any contractual obligations with COUNTY.
CONTRACTOR shall also comply with all Federal, State of California, and local conflict
of interest laws, statutes, and regulations, which shall be applicable to all parties and beneficiaries
under this Agreement and any officer, agent, or employee of COUNTY.
24.CHARITABLE CHOICE
CONTRACTOR may not discriminate in its program delivery against a client or potential
client on the basis of religion or religious belief, a refusal to hold a religious belief, or a refusal to
actively participate in a religious practice. Any specifically religious activity or service made available
to individuals by CONTRACTOR must be voluntary as well as separate in time and location from
COUNTY-funded activities and services. CONTRACTOR shall inform COUNTY as to whether it is
faith-based. If CONTRACTOR identifies as faith-based, it must submit to COUNTY’s DBH a copy of
its policy on referring individuals to an alternate treatment provider, and include a copy of this policy in
its client admission forms. The policy must inform individuals that they may be referred to an
alternative provider if they object to the religious nature of the program, and include a notice to
COUNTY’s DBH. Adherence to this policy will be monitored during annual site reviews and reviews of
client files. If CONTRACTOR identifies as faith-based, by July 1st of each year CONTRACTOR will be
COUNTY OF FRESNO
Fresno, CA
-29 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
required to report to COUNTY’s DBH the number of individuals who requested referrals to alternate
providers based on religious objection.
25.TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section
1861(v) (1) (I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four
(4)years after the furnishing of services under this Agreement, CONTRACTOR shall make available,
upon written request to the Secretary of the United States Department of Health and Human Services,
or upon request to the Comptroller General of the United States General Accounting Office, or any of
their duly authorized representatives, a copy of this Agreement and such books, documents, and
records as are necessary to certify the nature and extent of the costs of these services provided by
CONTRACTOR under this Agreement. CONTRACTOR further agrees that in the event
CONTRACTOR carries out any of its duties under this Agreement through a subcontract, with a value
or cost of Ten Thousand and No/100 Dollars ($10,000.00) or more over a twelve (12) month period,
with a related organization, such Agreement shall contain a clause to the effect that until the expiration
of four (4) years after the furnishing of such services pursuant to such subcontract, the related
organizations shall make available, upon written request to the Secretary of the United States
Department of Health and Human Services, or upon request to the Comptroller General of the United
States General Accounting Office, or any of their duly authorized representatives, a copy of such
subcontract and such books, documents, and records of such organization as are necessary to verify
the nature and extent of such costs.
26.SINGLE AUDIT CLAUSE
A.If CONTRACTOR expends Seven Hundred Fifty Thousand Dollars
($750,000.00) or more in Federal and Federal flow-through monies, CONTRACTOR agrees to
conduct an annual audit in accordance with the requirements of the Single Audit Standards as set
forth in Office of Management and Budget (OMB) Circular A-133. CONTRACTOR shall submit said
audit and management letter to COUNTY. The audit must include a statement of findings or a
statement that there were no findings. If there were negative findings, CONTRACTOR must include a
corrective action plan signed by an authorized individual. CONTRACTOR agrees to take action to
COUNTY OF FRESNO
Fresno, CA
-30 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
correct any material non-compliance or weakness found as a result of such audit. Such audit shall be
delivered to COUNTY’s DBH Business Office for review within nine (9) months of the end of any fiscal
year in which funds were expended and/or received for the program. Failure to perf orm the requisite
audit functions as required by this Agreement may result in COUNTY performing the necessary audit
tasks, or at COUNTY’s option, contracting with a public accountant to perform said audit, or, may
result in the inability of COUNTY to enter into future agreements with CONTRACTOR. All audit costs
related to this Agreement are the sole responsibility of CONTRACTOR.
B.A single audit report is not applicable if CONTRACTOR’s Federal
contracts do not exceed the Seven Hundred Fifty Thousand Dollars ($750,000.00) requirement or
CONTRACTOR’s only funding is through Drug related Medi-Cal. If a single audit is not applicable, a
program audit must be performed and a program audit report with management letter shall be
submitted by CONTRACTOR to COUNTY as a minimum requirement to attest to CONTRACTOR’s
solvency. Said audit report shall be delivered to COUNTY’s DBH Finance Division, for review no later
than nine (9) months after the close of the fiscal year in which the funds supplied through this
Agreement are expended. Failure to comply with this Act may result in COUNTY performing the
necessary audit tasks or contracting with a qualified accountant to perform said audit. All audit costs
related to this Agreement are the sole responsibility of CONTRACTOR who agrees to take corrective
action to eliminate any material noncompliance or weakness found as a result of such audit. Audit
work performed by COUNTY under this paragraph shall be billed to the CONTRACTOR at COUNTY
cost, as determined by COUNTY’s Auditor-Controller/Treasurer-Tax Collector.
C. CONTRACTOR shall make available all records and accounts for
inspection by COUNTY, the State of California, if applicable, the Comptroller General of the United
States, the Federal Grantor Agency, or any of their duly authorized representatives, at all reasonable
times for a period of at least three (3) years following final payment under this Agreement or the
closure of all other pending matters, whichever is later.
27.COMPLIANCE
CONTRACTOR agrees to comply with the COUNTY’s Contractor Code of
Conduct and Ethics and the COUNTY’s Compliance Program in accordance with Exhibit C, attached
COUNTY OF FRESNO
Fresno, CA
-31 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
hereto and incorporated herein by reference. Within thirty (30) days of entering into this Agreement
with the COUNTY, CONTRACTOR shall have all of CONTRACTOR’s employees, agents and
subcontractors providing services under this Agreement certify in writing, that he or she has received,
read, understood, and shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR
shall ensure that within thirty (30) days of hire, all new employees, agents and subcontractors
providing services under this Agreement shall certify in writing that he or she has received, read,
understood, and shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR
understands that the promotion of and adherence to the Code of Conduct is an element in evaluating
the performance of CONTRACTOR and its employees, agents and subcontractors.
Within thirty (30) days of entering into this Agreement, and annually thereafter, all employees,
agents and subcontractors providing services under this Agreement shall complete general
compliance training and appropriate employees, agents and subcontractors shall complete
documentation and billing or billing/reimbursement training. All new employees, agents and
subcontractors shall attend the appropriate training within 30 days of hire. Each individual who is
required to attend training shall certify in writing that he or she has received the required training. The
certification shall specify the type of training received and the date received. The certification shall be
provided to the COUNTY’s Compliance Officer at 3133 N. Millbrook Ave, Fresno, California 93703.
CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty imposed upon
COUNTY by the Federal Government as a result of CONTRACTOR’s violation of the terms of this
Agreement.
28.ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that it is not currently excluded,
suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs: that it
has not been convicted of a criminal offense related to the provision of health care items or services;
nor has it been reinstated to participation in the Federal Health Care Programs after a period of
exclusion, suspension, debarment, or ineligibility. If COUNTY learns, subsequent to entering into a
contract, that CONTRACTOR is ineligible on these grounds, COUNTY will remove CONTRACTOR
from responsibility for, or involvement with, COUNTY’s business operations related to the Federal
COUNTY OF FRESNO
Fresno, CA
-32 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Health Care Programs and shall remove such CONTRACTOR from any position in which
CONTRACTOR’s compensation, or the items or services rendered, ordered or prescribed by
CONTRACTOR may be paid in whole or part, directly or indirectly, by Federal Health Care Programs
or otherwise with Federal Funds at least until such time as CONTRACTOR is reinstated into
participation in the Federal Health Care Programs.
A.If COUNTY has notice that CONTRACTOR has been charged with a criminal
offense related to any Federal Health Care Program, or is proposed for exclusion during the term of
any contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the accuracy
of any claims submitted to any Federal Health Care Program. At its discretion given such
circumstances, COUNTY may request that CONTRACTOR cease providing services until resolution of
the charges or the proposed exclusion.
B.CONTRACTOR agrees that all potential new employees of CONTRACTOR or
subcontractors of CONTRACTOR who, in each case, are expected to perform professional services
under this Agreement, will be queried as to whether (1) they are now or ever have been excluded,
suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2)
they have been convicted of a criminal offense related to the provision of health care items or services;
and or (3) they have been reinstated to participation in the Federal Health Care Programs after a
period of exclusion, suspension, debarment, or ineligibility.
1.In the event the potential employee or subcontractor informs
CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible, or has been
convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR
hires or engages such potential employee or subcontractor, CONTRACTOR will ensure that said
employee or subcontractor does no work, either directly or indirectly relating to services provided to
COUNTY.
2.Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance
(as defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or
subcontractor of CONTRACTOR will perform work, either directly or indirectly, relating to services
COUNTY OF FRESNO
Fresno, CA
-33 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
provided to COUNTY. Such demand for adequate assurance shall be effective upon a time frame to
be determined by COUNTY to protect the interests of COUNTY consumers.
C. CONTRACTOR shall verify (by asking the applicable employees and
subcontractors) that all current employees and existing subcontractors who, in each case, are expected
to perform professional services under this Agreement (1) are not currently excluded, suspended,
debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been
convicted of a criminal offense related to the provision of health care items or services; and (3) have not
been reinstated to participation in the Federal Health Care Program after a period of exclusion,
suspension, debarment, or ineligibility. In the event any existing employee or subcontractor informs
CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible to participate in
the Federal Health Care Programs, or has been convicted of a criminal offense relating to the provision
of health care services, CONTRACTOR will ensure that said employee or subcontractor does no work,
either direct or indirect, relating to services provided to COUNTY.
1.CONTRACTOR agrees to notify COUNTY immediately during the term of
this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each
case, is providing professional services under this Agreement is excluded, suspended, debarred or
otherwise ineligible to participate in the Federal Health Care Programs, or is convicted of a criminal
offense relating to the provision of health care services.
2.Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section 3 of this Agreement, or require adequate assurance (as
defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor
of CONTRACTOR will perform work, either directly or indirectly, relating to services provided to
COUNTY. Such demand for adequate assurance shall be effective upon a time frame to be
determined by COUNTY to protect the interests of COUNTY consumers.
D.CONTRACTOR agrees to cooperate fully with any reasonable requests for
information from COUNTY which may be necessary to complete any internal or external audits relating
to CONTRACTOR’s compliance with the provisions of this Section.
E.CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty
COUNTY OF FRESNO
Fresno, CA
-34 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
imposed upon COUNTY by the Federal Government as a result of CONTRACTOR’S violation of
CONTRACTOR’S obligations as described in this Section.
29.PROHIBITION ON PUBLICITY
None of the funds, materials, property or services provided directly or indirectly under
this Agreement shall be used for CONTRACTOR’s advertising, fundraising, or publicity (i.e.,
purchasing of tickets/tables, silent auction donations, etc.) for the purpose of self-promotion.
Notwithstanding the above, publicity of the services described in Section 1 of this Agreement shall be
allowed as necessary to raise public awareness about the availability of such specific services when
approved in advance by COUNTY’s DBH Director or designee and at a cost to be provided in Section
4 for such items as written/printed materials, the use of media (i.e., radio, television, newspapers) and
any other related expense(s).
30.COMPLAINTS
CONTRACTOR shall log complaints and the disposition of all complaints from a client or
a client’s family. CONTRACTOR shall provide a copy of the detailed complaint log entries concerning
COUNTY -sponsored clients to COUNTY at monthly intervals by the tenth (l0th) day of the following
month, in a format that is mutually agreed upon. In addition, CONTRACTOR shall provide details and
attach documentation of each complaint with the log. CONTRACTO R shall post signs informing
clients of their right to file a complaint or grievance. CONTRACTOR shall notify COUNTY of all
incidents reportable to State licensing bodies that affect COUNTY clients within twenty-four (24)
hours of receipt of a complaint.
Within ten (10) days after each incident or complaint affecting COUNTY-sponsored
clients, CONTRACTOR shall provide COUNTY with information relevant to the complaint,
investigative details of the complaint, the complaint and CONTRACTOR's disposition of, or corrective
action taken to resolve the complaint. In addition, CONTRACTOR shall inform every client of their
rights as set forth in Exhibit G.
31.CHILD ABUSE REPORTING ACT
CONTRACTOR shall establish a procedure acceptable to the COUNTY’s DBH Director,
or his or her designee, to ensure that all of the CONTRACTOR’s employees, consultants,
COUNTY OF FRESNO
Fresno, CA
-35 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
subcontractors or agents described in the Child Abuse Reporting Act, section 1116 et seq. of the Penal
Code, and performing services under this Agreement shall report all known or suspected child abuse or
neglect to a child protective agency as defined in Penal Code section 11165.9. This procedure shall
include:
A.A requirement that all CONTRACTOR’s employees, consultants, subcontractors
or agents performing services shall sign a statement that he or she knows of and will comply with the
reporting requirements as defined in Penal Code section 11166(a), identified in Exhibit F, attached
hereto and incorporated herein by reference and made part of this Agreement.
B.Establishing procedures to ensure reporting even when employees, consultants,
subcontractors, or agents who are not required to report child abuse under Penal Code section
11166(a), gain knowledge of or reasonably suspect that a child has been a victim of abuse or neglect.
32.DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or
managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101 455.104,
and 455.106(a)(1),(2).
A)In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and
455.106(a)(1),(2), the following information must be disclosed by CONTRACTOR by completing
Exhibit H, “Disclosure of Ownership and Control Interest Statement”, attached hereto and by this
reference incorporated herein and made part of this Agreement. CONTRACTOR shall submit this
form to COUNTY’s DBH within thirty (30) days of the effective date of this Agreement. Additionally,
CONTRACTOR shall report any changes to this information within thirty-five (35) days of occurrence
by completing Exhibit H. CONTRACTOR is required to submit a set of fingerprints for any person
with a five (5) percent or greater direct or indirect ownership interest in CONTRACTOR. COUNTY
may terminate this Agreement where any person with a five (5) percent or greater direct or indirect
ownership interest in the CONTRACTOR did not submit timely and accurate information and
cooperate with any screening method required in CFR, Title 42, Section 455.416. Submissions shall
be scanned portable document format (pdf) copies and are to be sent via email to
DBHAdministration@fresnocountyca.gov, Attention: Contracts Administration. COUNTY may deny
COUNTY OF FRESNO
Fresno, CA
-36 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
enrollment or terminate this Agreement where any person with a five (5) percent or greater direct or
indirect ownership interest in CONTRACTOR has been convicted of a criminal offense related to that
person’s involvement with the Medicare, Medicaid, or Title XXI program in the last ten (10) years.
33.DISCLOSURE – CRIMINAL HISTORY AND CIVIL ACTIONS
CONTRACTOR is required to disclose if any of the following conditions apply to them, their
owners, officers, corporate managers and partners (hereinafter collectively referred to as
“CONTRACTOR”):
A.Within the three-year period preceding the Agreement award, they have been
convicted of, or had a civil judgment rendered against them for:
1.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;
2.Violation of a federal or state antitrust statute;
3.Embezzlement, theft, forgery, bribery, falsification, or destruction of
records; or
4.False statements or receipt of stolen property.
B.Within a three-year period preceding their Agreement award, they have had a
public transaction (federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate CONTRACTOR
from further business consideration. The information will be considered as part of the determination
of whether to continue and/or renew the Contract and any additional information or explanation that
a CONTRACTOR elects to submit with the disclosed information will be considered. If it is later
determined that the CONTRACTOR failed to disclose required information, any contract awarded to
such CONTRACTOR may be immediately voided and terminated for material failure to comply with
the terms and conditions of the award.
CONTRACTOR must sign a “Certification Regarding Debarment, Suspension,
and Other Responsibility Matters- Primary Covered Transactions” in the form set forth in Exhibit I,
COUNTY OF FRESNO
Fresno, CA
-37 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
attached hereto and by this reference incorporated herein and made part of this Ag reement.
Additionally, CONTRACTOR must immediately advise the COUNTY in writing if, during the term of
this Agreement: (1) CONTRACTOR becomes suspended, debarred, excluded or ineligible for
participation in federal or state funded programs or from receiving Federal funds as listed in the
excluded parties’ list system (Error! Hyperlink reference not valid.); or (2) any of the above listed
conditions become applicable to CONTRACTOR. CONTRACTOR shall indemnify, defend and hold
the COUNTY harmless for any loss or damage resulting from a conviction, debarment, exclusion,
ineligibility or other matter listed in the signed Certification Regarding Debarment, Suspension, and
Other Responsibility Matters.
34.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR is operating as a corporation (a
for-profit or non-profit corporation) or if during the term of this Agreement, the CONTRACTOR
changes its status to operate as a corporation.
Members of the CONTRACTOR’s Board of Directors shall disclose any self-dealing
transactions that they are a party to while CONTRACTOR is providing goods or performing services
under this Agreement. A self-dealing transaction shall mean a transaction to which the
CONTRACTOR is a party and in which one or more of its directors has a material financial interest.
Members of the Board of Directors shall disclose any self-dealing transactions that they are a party to
by completing and signing a Self-Dealing Transaction Disclosure Form, attached hereto as Exhibit J
and incorporated herein by reference and made part of this Agreement, and submitting it to the
COUNTY prior to commencing with the self-dealing transaction or immediately thereafter.
35.AUDITS AND INSPECTIONS
The CONTRACTOR shall at any time during business hours, and as often as the
COUNTY may deem necessary, make available to the COUNTY for examination all of its records and
data with respect to the matters covered by this Agreement. The CONTRACTOR shall, upon request
by the COUNTY, permit the COUNTY to audit and inspect all such records and data necessary to
ensure CONTRACTOR’s compliance with the terms of this Agreement.
COUNTY OF FRESNO
Fresno, CA
-38 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
CONTRACTOR shall be subject to the examination and audit of the State Auditor General for a period
of three (3) years after final payment under contract (California Government Code section 8546.7).
36.NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR
Director, Fresno County Stan Lum, Sole Proprietor
Department of Behavioral Health Mental Health Patient’s Rights Advocate Program
1925 E Dakota Ave 1357 W. Shaw Ave, Suite 101
Fresno, CA 93726 Fresno, CA 93711
Any and all notices between COUNTY and CONTRACTOR provided for or permitted
under this Agreement or by law shall be in writing and shall be deemed duly served when personally
delivered to one of the parties, or in lieu of such personal service, when deposited in the United
States Mail, postage prepaid, addressed to such party.
37.SEVERABILITY
If any non-material term, provision, covenant, or condition of this Agreement is held by a
court of competent jurisdiction to be invalid, void or unenforceable, the remainder of the provisions shall
remain in full force and effect, and shall in no way be affected, impaired or invalidated.
38.GOVERNING LAW
The parties agree that for the purpose of venue, performance under this Agreement is in
Fresno County, California.
The rights and obligations of the parties and all interpretation and performance of this
Agreement shall be governed in all respects by the laws of the State of California.
39.ENTIRE AGREEMENT
This Agreement, including all Exhibits, County’s Revised RFP #20-002, Contractor’s
Response to RFP, constitutes the entire agreement between CONTRACTOR and COUNTY with
respect to the subject matter hereof and supersedes all previous agreement negotiations, proposals,
commitments, writings, advertisements, publications, and understandings of any nature whatsoever
COUNTY OF FRESNO
Fresno, CA
- 39 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
unless expressly included in this Agreement.
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
///
1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the
2 day and year first hereinabove written .
3 ATTEST:
CONTRACTOR COUNTY OF FRESNO 4
5
6
7
8
Mental Health Patient's Rights Advocate
Programw ·
By : A!!!J. By ~ 2 .--i<i ;::> -
9
10
Print Name : ad-12 t1 Lunq
Nathan Magsig, Cha irman of the Board of Supervisors
of the County of Fresno
11 Title : _____________ _
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Chairman of Board , or President
Or any Vice President
By _____________ _
Print Name : ------------
Title:. _____________ _
ATTEST:
BERNICE E . SEIDEL ,
Clerk of the Board of Supervisors
County of Fresno , State of California
Secretary of Corporation, or Any Assistant Secretary,
Or Chief Financial Officer, or Chief Operating Officer,
Or Any Assistant Treasurer
Mailing Address:
1357 W . Shaw Ave, Suite 101
Fresno, CA 93711
Phone : (559) 470-7087
Contact: Stan Lum, Sole Proprietor
Fund/Subclass: 0001/10000
Organizations/Cost Centers :
Account/Program : 7295/0
56304710
56302003
56302230
-40 -COU NTY OF FRESN O
Fresno, CA
Exhibit A
Page 1 of 7
SCOPE OF WORK
Patients’ Rights Advocate
The Local Mental Health Director is responsible for the provision of Patients’ Rights Advocate
(PRA) services in Fresno County, as indicated in the Welfare and Institutions (W&I) Code
Division 5, Part 1, Chapter 6.2, Article 3, § 5000 et seq.
The County’s goals and objectives for the patients’ rights advocacy program include:
A. Develop/maintain a comprehensive, high quality Patients’ Rights Advocate
program which assures the rights and dignity of individuals receiving mental health
services.
B. Provide sound policy consultation to the Department of Behavioral Health
administration.
C. Report to and work with the Director of the Department of Behavioral Health or
designee to ensure local compliance with state law regarding rights of individuals
receiving psychiatric services (monthly or as requested).
D. It is important that vendor advocates recognize that the rights and desires of the
client are being represented and not those of the advocates.
I. GENERAL REQUIREMENTS
A. Patients’ Rights Advocacy (PRA) program will encompass two components; receiving
and investigating grievances and other duties and the Patients’ Rights Advocate shall
have the PRA function as the individual’s representative in all AB 3454 certification
review hearings. The PRA shall provide the notification of rights to the individual and
shall represent the individual at the certification review hearings.
Component 1: Advisements and Hearings;
Component 2: Receive and Investigate Grievances/Complaints and Coordinate
County-approved Advocacy Activities
B. Provide relief/backup coverage for advocate staff in the event of illness and vacation.
All potential advocate staff identified by position and/or name must be stated in the
proposal response or the bid may be rejected.
C. Provide training and education about mental health law and patients’ rights to mental
health providers. PRA must provide mental health law trainings, to licensed health and
community care facilities staff, at minimum 13 per year, or requested by County.
Trainings will be conducted at health and community care facilities.
D. Ensure that recipients of mental health services in all licensed health and community
care facilities are notified of their rights.
Exhibit A
Page 2 of 7
E. Exchange information and cooperate with the State Patients’ Rights Office.
F. Provide monthly and quarterly reports detailing accomplished work, or as requested,
written documentation of activities in all the above areas, and prepare such written
reports relating to the responsibilities and activities of the Patients’ Rights Advocate as
may be necessary or required by the County Plan, the Department of Behavioral
Health, the Behavioral Health Board, the State Patients’ Rights Office, or State
directive or mandate.
G. Ensure flexible or adjustable hours of operation to meet accessibility needs of
individuals and/or family members.
H. Have a working knowledge of the Lanterman Petris Short (LPS) Act.
I. Strictly adhere with all applicable Federal (including HIPAA laws), State of California
and/or local laws and regulations relating to confidentiality and protected health
information.
J. Submit monthly invoices to include the time period services were provided and the
programs, departments/agencies and exact facilities services were provided. Invoice
must also be accompanied by all required reports requested by the Local Mental
Health Director, or designee (see Estimates of Service Section, IV of this RFP).
K. Report to and work with the Director of the Department of Behavioral Health or their
designee to ensure local compliance with state law regarding rights of individuals
receiving psychiatric services, including but not limited to services outlined in this
Scope of Work.
L. Be in full compliance with Title VI of the Civil Rights Act of 1964. PRA must guarantee
that services provided will be performed in compliance with all applicable State and
Federal laws and regulations pertinent to this Agreement and shall execute the
agreement in full compliance with Title VI of the Civil Rights Act of 1964.
M. Provide/demonstrate ability to access competent and appropriate linguistic services in
the identified individual’s language of choice and have a working knowledge of
accessing and utilizing qualified staff /third-party interpreters or language lines during
advisement and hearing certification processes, complaints/grievances and
investigations or other related services. Interpretation services will be at the cost of the
PRA.
N. Assist with the review and revision of policies and procedures which are critical
components of effective advocacy. Establishing good policies and procedures sets the
ground work for improving facility operations: good policy and procedures promote
good practice.
O. Provide advocates who are aware of the cultural differences in the treatment of mental
health. It is essential that the advocate, in doing their job, is aware of the dynamic that
culture plays in competent service representation. In representing and promoting the
rights and interests of an individual, the advocate must be aware that it is the
Exhibit A
Page 3 of 7
individual’s voice that is being heard and represented and that sensitivity to the cultural
context of the individual is recognized. This will require an ongoing commitment by
patients’ right advocates being knowledgeable of and promoting cultural understanding
and self-awareness. Patients’ Rights Advocate shall be required to adhere to the
Department’s Cultural Competency requirement (Exhibit K).
P. Collaborate with County Mental Health Services Act (MHSA) program providers
promoting and educating awareness of the PRA and available services.
Q. Comply with the County’s Contractor Code of Conduct and Ethics, and the County’s
Compliance Program in accordance with Exhibit C.
R. Comply with all state and federal regulations pertaining to Health Insurance Portability
and Accountability Act (HIPAA).
II. SPECIFIC REQUIREMENTS
The County would like to delineate the two components of the Patients’ Rights Advocate
program as follows:
1. Advisements and Hearings
2. Receive/Investigate Grievances and Coordinate County-approved Advocacy
Activities
A. COMPONENT 1: ADVISEMENTS AND HEARINGS
The duties of the contracted Patients’ Rights Advocate shall include, but not be limited
to the following:
1. The Patients’ Rights Advocate (PRA) shall f unction as the individual’s
representative in all AB 3454 certification review hearings. The PRA shall
provide the notification and advisement of rights to those individuals admitted to
County-operated and County-contracted acute inpatient psychiatric facilities, as
required by Welfare and Institutions Code Sections 5250, 5260 and 5270, prior to
the certification review hearing. The contracted PRA may be directed by the
Local Mental Health Director to provide similar services at other mental health
facilities in the County of Fresno based on requirements of the W&I Code.
2. Function as the individual’s representative in all certification review hearings held
in Fresno County. Hearing activity and outcome shall be logged and provided in a
secure electronic format to the Department Director and/or designee on a
monthly basis by the 10th of each month. Report of notification and hearing
activity must include, but not be limited to:
a) Documentation of notification of rights for each individual served.
b) Date, start/end time of hearing, location, outcome of hearing for each
Exhibit A
Page 4 of 7
individual served.
c) Identification of family/support system present at hearing.
3. Patients’ Rights Advocate(s) must be knowledgeable of the LPS Act. The LPS
Act, in shifting the emphasis of mental health treatment away from involuntary
treatment to a commitment to community-based voluntary treatment narrowed
the criteria under which a person can be detained involuntarily.
B. COMPONENT 2: RECEIVE/ INVESTIGATE GRIEVANCES/COMPLAINTS AND
COORDINATE COUNTY-APPROVED ADVOCACY ACTIVITIES
The duties of the contracted Patients’ Rights Advocate shall include, but not be limited
to the following:
1. Under contract supervision, plans, directs, and coordinates advocacy services on
behalf of individuals receiving mental health services and their families and performs
related tasks as required that will promote and support the transformative
components of Mental Health Services Act (Vision and Values).
2. Deliver advocate services to provide both information/referral and grievance
resolution services to clients and family members. Information and referral may
involve a brief explanation of legal rights and available services. Grievance
resolution activities are the services provided when an individual or family
member alleges a violation of her/his rights. Grievance resolution can range from
a simple phone call to a provider to multiple interviews, record reviews and
written correspondence. Every effort should be made to resolve complaints at the
lowest level.
Receive and investigate complaints from or concerning recipients of mental
health services residing in licensed health or community care facilities regarding
abuse, unreasonable denial, or punitive withholding of rights guaranteed under
the provisions of Division 5 (commencing with Section 5000) of the Welfare and
Institutions Code. Contractor shall respond to each grievance within forty-eight
(48) hours.
Under the provision of the Mental Health Services Act (MHSA), also known as
Proposition 63, the provision of these client advocacy services will assist in
transforming the mental health system to ensure that services are client focused
and family centered and that it addresses the issue of underutilization and under
representation on the part of populations of cultural/ethnic decent.
3. To receive and investigate grievances from or concerning recipients of mental health
services residing in licensed health or community care facilities regarding abuse,
unreasonable denials or punitive withholding of rights guaranteed under the
provisions of the Welfare and Institutions Code:
A. Develop and implement a format for the recording of patients’ rights
grievances and the disposition of each grievance. Such a format shall
indicate both the level of care provided to the individual, conservatorship
Exhibit A
Page 5 of 7
status, voluntary or involuntary treatment status, facility, nature of the
grievance, validity of the grievance, disposition of the grievance, and any
other information deemed necessary by the Local Mental Health Director.
Written documentation of the investigation of each grievance, including the
disposition of each grievance, shall be prepared and forwarded to Local
Mental Health Director at the office of the Director of Behavioral Health.
B. Report significant patients’ rights grievances to the Local Mental Health
Director, or designee, as soon as possible, verbally and in writing no later
than five (5) days after receipt of grievance in the event of facility violation,
harm/death to client or other significant event requiring immediate
notification and action. Monthly reports of patients’ rights complaints shall
be prepared for the Director or designee, including verbal and written
response when required. Monthly and quarterly reports detailing the work
accomplished during the reporting period and problems, existing or
anticipated, shall be brought to the attention of respective Director of the
Department of Behavioral Health or designee.
C. Make available the files maintained by the Patients’ Rights Advocate to
authorized representative from the Department of Behavioral Health (DBH)
upon request. Contractor shall meet with DBH officials to determine
authorized representative.
D. All reports related to complaints and investigations should be sent to the
Local Mental Health Director/designee. .
4. To monitor mental health facilities, services and programs for compliance with
statutory and regulatory patient’s rights provisions.
Monitor mental health facilities services and programs for compliance with
statutory and regulatory patients’ rights provisions. Each mental health facility
shall be visited at least once every three (3) months.
Monitoring is the systemic observation of a mental health facility, its staff, its clients
and/or its records. Monitoring is important because it provides information about the
ways an institution functions, and why. An Advocate identifies institutional policies
and practices, reviews how they affect clients, and identifies if goals toward wellness
and recovery, client-focused, and culturally/linguistically accessible services are
being provided. Monitoring usually focuses on finding patterns as opposed to one-
time occurrence, looking at patients' problems in the aggregate rather than
individually. Although the process may be initiated by an individual grievance or
informal observation, monitoring focuses on the institution and institutional change.
Monitoring should have a high degree of organization, formality and objectivity in the
investigation, documentation and use of information and specifically gauge policy
and practice to the Mental Health Services Act guiding principles as outline under
definitions.
5. To provide training and education about mental health law and patients’ rights to
mental health providers as requested and scheduled through County designee.
Training is to be arranged to take place at least quarterly.
Exhibit A
Page 6 of 7
6. To ensure that recipients of mental health services in all licensed health and
community care facilities are notified of their rights.
7. To act as a liaison, to exchange information and cooperate with the State
Department of Health Care Services Mental Health Patients’ Rights Office.
8. Ensure that patients’ rights are posted in all facilities where posting is required
pursuant to Section 860 the Title 9 of the California Code of Regulations.
9. To act as advocate on behalf of individuals who are unable to register a grievance
because of their mental or physical condition.
10. To act as the local consultant in the area of clients’ rights.
11. To confer and meet with DBH administration regarding programs, policies,
procedures, and operational issues regarding the advocacy program.
12. Act as a liaison between the DBH and individual or family members, the community,
county and state agencies and the Behavioral Health Advisory Board.
13. Act as the Departmental liaison in providing leadership, technical assistance and
program guidance on individual and family driven services.
14. Participate in the orientation activities for new DBH staff to ensure they have an
appropriate perspective in the delivery of services.
15. Assist in developing, monitoring and evaluating mental health projects and
programs.
16. Develop various techniques and tools to systematically analyze and report on
specific client focused performance outcome measures.
17. Assist in the oversight of culturally efficient, co-occurring capable services to
ethnically diverse individuals receiving mental health services.
18. Develop means of direct communication with individuals such as the development
of a newsletter, client specific focus groups, and the administration of client
satisfaction survey.
IV. ESTIMATE OF SERVICES EXPECTED TO BE PROVIDED:
I. The following is an estimate of the volume of the various activities the Advocate will be
involved as defined in Component 1:
• 14-day Certification: average 80 per quarter
• Advisement to Clients average 80 per quarter
• Hearings Attendance: average 289 per quarter
Exhibit A
Page 7 of 7
• 14-Day Post Certification (5260); average 1 per quarter
• 30-Day Post Certification (5270): average 16 per quarter
II. The following is an estimate of the volume of the various activities the Advocate will be
involved as defined in Component 2:
• Telephone Contacts: average 315 per quarter
• Number of Complaints/Grievances average 49 per quarter
• Number of Visits to County–designated facilities*: average 52 per quarter
• Participation on committees: average 6 meetings per quarter
• Monitoring of Records: average 270 records per quarter
*County-designated facilities include, but are not limited to: Community Behavioral Health
Center (CBHC), Fresno County Adult Psychiatric Health Facility (PHF), Veterans Affairs
Central California Health Care Systems, Exodus Recovery Fresno Crisis Stabilization
Center, Community Regional Medical Center (CRMC), Fresno County Adolescent
Psychiatric Health Facility (PHF), and the Fresno County Adolescent Crisis Stabilization
Unit (CSU). These designated facilities are subject to change and will be communicated
to selected vendor for service provision.
MENTAL HEALTH PATIENT’S RIGHTS ADVOCACY PROGRAM BUDGET
Term 01/01/2020-06/30/2020
Budget Categories Line Item Description BUDGET AMOUNT
Administrative Direct Total
PERSONNEL WAGES:
Supervisor Patients' Rights Advocate 3,260 29,340 32,600
Patients' Rights Advocate 1 25,000 25,000
Patients' Rights Advocate 2 20,800 20,800
-
-
-
-
-
-
-
-
-
-
-
-
Salary Total 3,260 75,140 78,400
PAYROLL TAX & BENEFITS:
F.I.C.A./O.A.S.D.I.249 5,748 5,997
S.U.I./ETT/FUTA 27 819 846
Workers Comp. Insurance 39 902 941
Retirement 261 6,011 6,272
Health & Dental Insurance 390 9,540 9,930
Life Insurance
Payroll Tax & Benefit Total 966 23,020 23,986
Total Salary, Payroll Tax & Employee Benefits 4,226 98,160 102,386
OPERATIONAL EXPENSE:
Employee Travel & Per Diem 1,500 1,500
Office Rent 8,100 8,100
Budget Categories Line Item Description BUDGET
Administrative Direct Total
Office Maintenance 80 80
Utilities 1,050 1,050
Exhibit B
1 of 12
Insurance 470 470
Furniture & Equipment Maintenance 200 200
Postage 180 180
Photocopy/Printing 300 300
Communications/Internet/Computers 5,760 5,760
Translation Services -
Advertising/Public Outreach 600 600
Vehicle Maintenance/Gas -
-
-
-
Miscellaneous (specify) -
Operational Expense Total - 18,240 18,240
FINANCIAL SERVICE EXPENSES:
Accounting/Bookkeeping 6,000 6,000
External Audit -
Worker's Compensation Insurance -
Liability Insurance -
Insurance – Other -
Payroll Processing 570 570
Financial Service Expense Total 6,570 6,570
TOTAL EXPENSES 10,796 116,400 127,196
TOTAL ANNUAL BUDGET 10,796 116,400 127,196
Exhibit B
2 of 12
MENTAL HEALTH PATIENT’S RIGHTS ADVOCACY PROGRAM BUDGET
Term 7/1/2020 – 06/30/2021
Budget Categories Line Item Description BUDGET AMOUNT
Administrative Direct Total
PERSONNEL WAGES:
Supervisor Patients' Rights Advocate 6,450 58,050 64,500
Patients' Rights Advocate 1 50,000 50,000
Patients' Rights Advocate 2 47,500 47,500
-
-
-
-
-
-
-
-
-
-
-
-
Salary Total 6,450 155,550 162,000
PAYROLL TAX & BENEFITS:
F.I.C.A./O.A.S.D.I. 493 11,900 12,393
S.U.I./ETT/FUTA 27 819 846
Workers Comp. Insurance 77 1,867 1,944
Retirement 516 12,444 12,960
Health & Dental Insurance 780 19,080 19,860
Life Insurance
Payroll Tax & Benefit Total 1,893 46,110 48,003
Total Salary, Payroll Tax & Employee Benefits 8,343 201,660 210,003
OPERATIONAL EXPENSE:
Employee Travel & Per Diem 3,000 3,000
Office Rent 16,200 16,200
Budget Categories Line Item Description BUDGET
Administrative Direct Total
Office Maintenance 120 120
Utilities 2,160 2,160
Exhibit B
3 of 12
Insurance 940 940
Furniture & Equipment Maintenance 400 400
Postage 360 360
Photocopy/Printing 600 600
Communications/Internet/Computers 8,560 8,560
Translation Services -
Advertising/Public Outreach 1,200 1,200
Vehicle Maintenance/Gas -
-
-
-
Miscellaneous (specify) -
Operational Expense Total - 332,540 33,540
FINANCIAL SERVICE EXPENSES:
Accounting/Bookkeeping 13,500 13,500
External Audit -
Worker's Compensation Insurance -
Liability Insurance -
Insurance – Other -
Payroll Processing 1,140 1,140
Financial Service Expense Total 14,640 14,640
TOTAL EXPENSES 22,983 235,200 258,183
TOTAL ANNUAL BUDGET 22,983 235,200 258,183
Exhibit B
4 of 12
MENTAL HEALTH PATIENT’S RIGHTS ADVOCACY PROGRAM BUDGET
Term 7/1/2021 – 06/30/2022
Budget Categories Line Item Description BUDGET AMOUNT
Administrative Direct Total
PERSONNEL WAGES:
Supervisor Patients' Rights Advocate 6,579 59,211 65,790
Patients' Rights Advocate 1 - 51,000 51,000
Patients' Rights Advocate 2 - 48,450 48,450
- - -
- - -
- - -
- - -
- - -
Salary Total 6,579 158,661 165,240
PAYROLL TAX & BENEFITS:
F.I.C.A./O.A.S.D.I. 503 12,138 12,641
S.U.I./ETT/FUTA 27 819 846
Workers Comp. Insurance 79 1,904 1,983
Retirement 526 12,693 13,219
Health & Dental Insurance 819 20,034 20,853
Life Insurance
Payroll Tax & Benefit Total 1,954 47,588 49,542
Total Salary, Payroll Tax & Employee Benefits 8,533 206,249 214,782
OPERATIONAL EXPENSE:
Employee Travel & Per Diem 3,000 3,000
Office Rent 16,200 16,200
Budget Categories Line Item Description BUDGET
Administrative Direct Total
Office Maintenance 132 132
Utilities 2,225 2,225
Exhibit B
5 of 12
Insurance 960 960
Furniture & Equipment Maintenance 400 400
Postage 360 360
Photocopy/Printing 600 600
Communications/Internet/Computers 9,180 9,180
Translation Services -
Advertising/Public Outreach 1,200 1,200
Vehicle Maintenance/Gas -
-
-
Miscellaneous (specify)
Operational Expense Total - 34,257 34,257
FINANCIAL SERVICE EXPENSES:
Accounting/Bookkeeping 13,500 13,500
External Audit -
Worker's Compensation Insurance -
Liability Insurance -
Insurance – Other -
Payroll Processing 1,208 1,208
Financial Service Expense Total 14,708 14,708
TOTAL EXPENSES 23,241 240,506 263,747
TOTAL ANNUAL BUDGET 23,241 240,506 263,747
Exhibit B
6 of 12
MENTAL HEALTH PATIENT’S RIGHTS ADVOCACY PROGRAM BUDGET
Term 7/1/2022 – 06/30/2023
Budget Categories Line Item Description BUDGET AMOUNT
Administrative Direct Total
PERSONNEL WAGES:
Supervisor Patients' Rights Advocate 6,711 60,395 67,106
Patients' Rights Advocate 1 - 52,020 52,020
Patients' Rights Advocate 2 - 49,419 49,419
- - -
- - -
- - -
- - -
- -
- -
- -
- -
Salary Total 6,711 161,834 168,545
PAYROLL TAX & BENEFITS:
F.I.C.A./O.A.S.D.I. 513 12,380 12,893
S.U.I./ETT/FUTA 27 819 846
Workers Comp. Insurance 81 1,942 2,023
Retirement 537 12,947 13,484
Health & Dental Insurance 860 21,036 21,896
Life Insurance
Payroll Tax & Benefit Total 2,018 49,124 51,142
Total Salary, Payroll Tax & Employee Benefits 8,729 210,958 219,687
OPERATIONAL EXPENSE:
Employee Travel & Per Diem 3,000 3,000
Office Rent 16,200 16,200
Budget Categories Line Item Description BUDGET
Administrative Direct Total
Office Maintenance 150 150
Utilities 2,292 2,292
Exhibit B
7 of 12
Insurance 990 990
Furniture & Equipment Maintenance 400 400
Postage 360 360
Photocopy/Printing 600 600
Communications/Internet/Computers 8,616 8,616
Translation Services -
Advertising/Public Outreach 1,200 1,200
Vehicle Maintenance/Gas -
-
-
Miscellaneous (specify)
Operational Expense Total 33,808 33,808
FINANCIAL SERVICE EXPENSES:
Accounting/Bookkeeping 13,500 13,500
External Audit -
Worker's Compensation Insurance -
Liability Insurance -
Insurance – Other -
Payroll Processing 1,242 1,242
Financial Service Expense Total 14,742 14,742
TOTAL EXPENSES 23,471 244,766 268,237
TOTAL ANNUAL BUDGET 23,471 244,766 268,237
Exhibit B
8 of 12
MENTAL HEALTH PATIENT’S RIGHTS ADVOCACY PROGRAM BUDGET
Term 7/1/2023 – 06/30/2024
Budget Categories Line Item Description BUDGET
AMOUNT
Administrative Direct Total
PERSONNEL WAGES:
Supervisor Patients' Rights Advocate 6,845 61,603 68,448
Patients' Rights Advocate 1 53,060 53,060
Patients' Rights Advocate 2 50,407 50,407
-
-
-
-
Salary Total 6,845 165,070 171,915
PAYROLL TAX & BENEFITS:
F.I.C.A./O.A.S.D.I. 524 12,628 13,152
S.U.I./ETT/FUTA 27 819 846
Workers Comp. Insurance 82 1,981 2,063
Retirement 548 13,206 13,754
Health & Dental Insurance 903 22,087 22,990
Life Insurance
Payroll Tax & Benefit Total 2,084 50,721 52,805
Total Salary, Payroll Tax & Employee Benefits 8,929 215,791 224,720
OPERATIONAL EXPENSE:
Employee Travel & Per Diem 3,150 3,150
Office Rent 17,010 17,010
Budget Categories Line Item Description BUDGET
Administrative Direct Total
Office Maintenance 175 175
Utilities 2,375 2,375
Exhibit B
9 of 12
Insurance 1,020 1,020
Furniture & Equipment Maintenance 400 400
Postage 360 360
Photocopy/Printing 600 600
Communications/Internet/Computers 9,744 9,744
Translation Services -
Advertising/Public Outreach 1,200 1,200
Vehicle Maintenance/Gas
Miscellaneous (specify)
Operational Expense Total 36,034 36,034
FINANCIAL SERVICE EXPENSES:
Accounting/Bookkeeping 15,000 15,000
External Audit -
Worker's Compensation Insurance -
Liability Insurance -
Insurance – Other -
Payroll Processing 1,280 1,280
Financial Service Expense Total 16,280 16,280
TOTAL EXPENSES 25,209 251,825 277,034
TOTAL ANNUAL BUDGET 25,209 251,825 277,034
Exhibit B
10 of 12
MENTAL HEALTH PATIENT’S RIGHTS ADVOCACY PROGRAM BUDGET
Term 7/1/2024 – 06/30/2025
Budget Categories Line Item Description BUDGET
AMOUNT
Administrative Direct Total
PERSONNEL WAGES:
Supervisor Patients' Rights Advocate 6,982 62,835 69,817
Patients' Rights Advocate 1 54,122 54,122
Patients' Rights Advocate 2 51,416 51,416
Salary Total 6,982 168,373 175,355
PAYROLL TAX & BENEFITS:
F.I.C.A./O.A.S.D.I. 534 12,880 13,414
S.U.I./ETT/FUTA 27 819 846
Workers Comp. Insurance 84 2,020 2,104
Retirement 559 13,470 14,029
Health & Dental Insurance 948 23,192 24,140
Life Insurance
Payroll Tax & Benefit Total 2,152 52,381 54,533
Total Salary, Payroll Tax & Employee Benefits 9,134 220,754 229,888
OPERATIONAL EXPENSE:
Employee Travel & Per Diem 3,300 3,300
Office Rent 17,010 17,010
Budget Categories Line Item Description BUDGET
Administrative Direct Total
Office Maintenance 175 175
Utilities 2,445 2,445
Exhibit B
11 of 12
Insurance 1,050 1,050
Furniture & Equipment Maintenance 400 400
Postage 360 360
Photocopy/Printing 600 600
Communications/Internet/Computers 9,192 9,192
Translation Services -
Advertising/Public Outreach 1,200 1,200
Vehicle Maintenance/Gas
Miscellaneous (specify)
Operational Expense Total 35,732 35,732
FINANCIAL SERVICE EXPENSES:
Accounting/Bookkeeping 15,000 15,000
External Audit -
Worker's Compensation Insurance -
Liability Insurance -
Insurance – Other -
Payroll Processing 1,320 1,320
Financial Service Expense Total 16,320 16,320
TOTAL EXPENSES 25,454 256,486 281,940
TOTAL ANNUAL BUDGET 25,454 256,486 281,940
Exhibit B
12 of 12
Section: Administration
Effective Date: 08/01/2004 Revised Date: 11/28/2018
Policy Title: Code of Conduct
Approved by: Dawan Utecht (Director of Behavioral Health), Elizabeth Vasquez (Compliance Officer)
1 | P a g e
MISSION STATEMENT
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.
Template Review Date 11/29/18
Department of Behavioral Health
Policy and Procedure Guide
PPG 1.3.4 V#: 3
POLICY:Fresno County is firmly committed to full compliance with all applicable
laws, regulations, rules, and guidelines that apply to its behavioral health
operations and services. At the core of this commitment are Fresno
County’s employees, contractors (including contractor’s
employees/subcontractors), volunteers and students, also referred to as
“Covered Persons”, and the manner in which they conduct themselves.
To assure that Fresno County’s commitment is shared by all Covered
Persons, this Code of Conduct (the “Code”) has been established. All
Covered Persons will be required to acknowledge and certify their
compliance with this Code.
PURPOSE: To provide specific conduct standards prescribed by the Fresno County
Mental Health Plan/Drug Medi-Cal Organized Delivery System (DMC-
ODS) Compliance Program designed to detect and prevent fraud, waste,
and abuse. This Code of Conduct is maintained in addition to the County’s
Code of Ethics already in effect.
REFERENCE:Fresno County Department of Behavioral Health Compliance Plan; 42
CFR 438.608.
DEFINITIONS:Covered Persons – All employees, contractors (including contractor’s
employees and subcontractors), volunteers, interns, and students working
in behavioral health programs.
Excluded/Ineligible Person – Any Covered Person who is or may become
suspended, excluded, or ineligible from participation in any Federal
healthcare program.
PROCEDURE:
I. A copy of the Code of Conduct (Attachment I) will be provided to all Covered
Persons at the time of their initial compliance training which must be provided
within 30 business days of hire or contract effective date. This Code will also be
provided during the annual General Compliance training or within 30 business
days after any revision is finalized.
II. Upon initial receipt and review of the Code, Covered Persons shall certify their
intention to abide with it by signing the Acknowledgement and Agreement form,
Exhibit C - Code of Conduct, Ethics and Compliance
2 | P a g e
Department of Behavioral Health
Policy and Procedure Guide
PPG 1.3.4 V#: 3
Policy Title: Code of Conduct
Section: Administration Revised Date: 11/28/2018
which is provided by the Compliance Office at the time of training. The
Compliance Office will retain these signed forms. Covered Persons shall certify
within 30 business days after distribution of a revised Code.
III. The Compliance Office will track these certifications and regularly report to the
Compliance Committee and the Director of the Department of Behavioral Health
regarding progress towards 100% certification by all Covered Persons.
IV. The Code will be prominently posted in all Fresno County facilities and Behavioral
Health Contractor sites.
V.This Code is not intended to be an exhaustive list of all standards by which
Covered Persons are to be governed. Rather, it is intended to convey the
County’s commitment to the high standards set forth by the County.
Exhibit C - Code of Conduct, Ethics and Compliance
CODE OF CONDUCT:
Fresno County Mental Health Plan - (Attachment I)
Compliance Program
All Fresno County Behavioral/Mental Health Employees, Contractors (including Contractor's
Employees/Subcontractors), Volunteers and Students will:
1.Read, acknowledge, and abide by this Code of Conduct.
2.Be responsible for reviewing and understanding Compliance Program policies and
procedures including the possible consequences for failure to comply or failure to report
such non-compliance.
3.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. Conduct
yourself honestly, fairly, courteously, and with a high degree of integrity in your professional
dealings related to their employment/contract with the County and avoid any conduct that
could reasonably be expected to reflect adversely upon the integrity of the County and the
services it provides.
4.Practice good faith in transactions occurring during the course of business and never use
or exploit professional relationships or confidential information for personal purposes.
5.Promptly report any activity or suspected violation of this Code of Conduct, the policies and
procedures of the County, the Compliance Program, or any other applicable law,
regulation, rule or guideline. All reports may be made anonymously. 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.
6.Comply with not only the letter of Compliance Program and mental health policies and
procedures, but also with the spirit of those policies and procedures as well as other rules
or guidelines adopted by the County. Consult with your supervisor or the Compliance
Office regarding any Compliance Program standard or other applicable law, regulation, rule
or guideline.
7.Comply with all laws governing the confidentiality and privacy of information. Protect and
retain records and documents as required by County contract/standards, professional
standards, governmental regulations, or organizational policies.
8.Comply with all applicable laws, regulations, rules, guidelines, and County policies and
procedures when providing and billing mental health services. Bill only for eligible services
actually rendered and fully documented. Use billing codes that accurately describe the
services provided. Ensure that no false, fraudulent, inaccurate, or fictitious claims for
payment or reimbursement of any kind are prepared or submitted. Ensure that claims are
prepared and submitted accurately and timely and are consistent with all applicable laws,
regulations, rules and guidelines. Act promptly to investigate and correct problems if errors
in claims or billings are discovered.
9.Immediately notify your supervisor, Department Head, Administrator, or the Compliance
Office if you become or may become an Ineligible/Excluded Person and therefore excluded
from participation in the Federal health care programs.
Page 3 of 3
Revised 12/2012
Exhibit C - Code of Conduct, Ethics and Compliance
Exhibit D
PROGRAM OUTCOMES
Quarterly Progress Report
The following items listed below represent program goals to be achieved by contractor
in addition to contractor-developed outcomes. The selected contractor will utilize a
tracking system with which outcome measures and other relevant client data, such as
demographics, will be maintained.
Performance Measurements/Outcomes Reports shall be completed and submitted to the
designated DBH staff member as requested. The performance measurement/ outcome
process will not be limited to survey instruments but will also include, as appropriate,
client and staff interviews, and other methods of obtaining needed information. Monthly
outcomes to be tracked for annual report include but are not limited to:
1. Effectiveness of program
2. Efficiency
3. Access and timeliness
4. Clients/persons served satisfaction
Reporting Documents:
Annual, Quarterly, and monthly reports requested by the County, and utilized by the
Contractor to measure program goals/success are to be developed by the Contractor
and approved by the Department of Behavioral Health (DBH) Director and/or designee.
Additional program outcomes developed by Contractor will be established and approved
by DBH prior to commencement of program operation.
Outcomes are pending review and approval by the Department.
Exhibit E
Page 1 of 2
0374 f dbh
STATE MENTAL HEALTH REQUIREMENTS
1. CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2. PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business and
Professions and Welfare and Institutions Codes.
3. CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with
all State of California and Federal statutes and regulations regarding
confidentiality, including but not limited to confidentiality of information
requirements at 42, Code of Federal Regulations sections 2.1 et seq; California
Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division
10.5 and 10.6 of the California Health and Safety Code; Title 22, California Code
of Regulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 of the
California Civil Code.
4. NON-DISCRIMINATION
A. Eligibility for Services
CONTRACTOR shall prepare and make available to COUNTY and to the
public all eligibility requirements to participate in the program plan set
forth in the Agreement. No person shall, because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance.
B. Employment Opportunity
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer,
Exhibit E
Page 2 of 2
0374 f dbh
rates of pay or other forms of compensation, use of facilities, and other
terms and conditions of employment.
C. Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all
further funds, until CONTRACTOR can show clear and convincing
evidence to the satisfaction of COUNTY that funds provided under this
Agreement were not used in connection with the alleged discrimination.
D. Nepotism
Except by consent of COUNTY’s Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR.
5. PATIENTS' RIGHTS
CONTRACTOR shall comply with applicable laws and regulations, including but
not limited to, laws, regulations, and State policies relating to patients' rights.
Exhibit F
NOTICE OF CHILD ABUSE REPORTING LAW
The undersigned hereby acknowledges that Penal Code section 11166 and the
contractual obligations between County of Fresno (COUNTY) and CONTRACTOR
related to the provision of Family Advocacy Services, require that the undersigned report
all known or suspected child abuse or neglect to one or more of the agencies set forth in
Penal Code (PC) section (§) 11165.9.
For purposes of the undersigned’s child abuse reporting requirements, “child
abuse or neglect” includes physical injury inflicted by other than accidental means upon
a child by another person, sexual abuse as defined in PC §11165.1, neglect as defined
in PC §11165.2, willful cruelty or unjustifiable punishment as defined in PC §11165.3,
and unlawful corporal punishment or injury as defined in PC §11165.4.
A child abuse report shall be made whenever the undersigned, in his or her
professional capacity or within the scope of his or her employment, has knowledge of or
observes a child whom the undersigned knows or reasonably suspects has been the
victim of child abuse or neglect. (PC §11166.) The child abuse report shall be made to
any police department or sheriff’s department (not including a school district police or
security department), or to any county welfare department, including Fresno County
Department of Social Services’ 24 Hour CARELINE. (See PC §11165.9.)
For purposes of child abuse reporting, a “reasonable suspicion” means that it is
objectively reasonable for a person to entertain a suspicion, based upon facts that could
cause a reasonable person in a like position, drawing, when appropriate, on his or her
training and experience, to suspect child abuse or neglect. The pregnancy of a child
does not, in and of itself, constitute a basis for reasonable suspicion of sexual abuse.
(PC §11166(a)(1).)
Substantial penalties may be imposed for failure to comply with these child abuse
reporting requirements.
Further information and a copy of the law may be obtained from the department
head or designee.
I have read and understand the above statement and agree to comply with the
child abuse reporting requirements.
SIGNATURE _____________________________ DATE ______________________
Exhibit G
Page 1 of 4
FFRREESSNNOO CCOOUUNNTTYY MMEENNTTAALL HHEEAALLTTHH PPLLAANN
GGRRIIEEVVAANNCCEESS AANNDD IINNCCIIDDEENNTT RREEPPOORRTTIINNGG
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 their
clients copies of all current beneficiary information annually at the time their treatment plans
are updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without any penalty,
change in mental health services, or any form of retaliation. All Medi-Cal beneficiaries can file
an appeal or state hearing.
Grievances and appeals forms and self addressed envelopes must be available for
beneficiaries to pick up at all provider sites without having to make a verbal or written request.
Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 712
Fresno, CA 93712
(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.
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
Exhibit G
Page 2 of 4
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.
Exhibit G
Page 3 of 4
PPRROOTTOOCCOOLL FFOORR CCOOMMPPLLEETTIIOONN OOFF IINNCCIIDDEENNTT RREEPPOORRTT
• The Incident Report must be completed for all incidents involving clients. The staff person
who becomes aware of the incident completes this form, and the supervisor co-signs it.
• When more than one client is involved in an incident, a separate form must be completed
for each client.
Where the forms should be sent - within 24 hours from the time of the incident
• Incident Report should be sent to:
DBH Program Supervisor
Exhibit G
Page 4 of 4
INCIDENT REPORT WORKSHEET
When did this happen? (date/time) Where did this happen?
Name/DMH #
1. Background information of the incident:
2. Method of investigation: (chart review, face-to-face interview, etc.)
Who was affected? (If other than consumer)
List key people involved. (witnesses, visitors, physicians, employees)
3. Preliminary findings: How did it happen? Sequence of events. Be specific. If attachments are needed write
comments on an 8 1/2 sheet of paper and attach to worksheet.
Outcome severity: Nonexistent inconsequential consequential death not applicable unknown
4. Response: a) corrective action, b) Plan of Action, c) other
Completed by (print name)
Completed by (signature) Date completed
Reviewed by Supervisor (print name)
Supervisor Signature Date
Exhibit H
Page 1 of 2
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of entity D/B/A
Address (number, street) City State ZIP code
CLIA number Taxpayer ID number (EIN) Telephone number
( )
II. Answer the following questions by checking “Yes” or “No.” If any of the questions are answered “Yes,” list names and
addresses of individuals or corporations under “Remarks” on page 2. Identify each item number to be continued.
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
YES NO
by Titles XVIII, XIX, or XX? ......................................................................................................................... ❒ ❒
B. Are there any directors, officers, agents, or managing employees of the institution, agency, or
organization who have ever been convicted of a criminal offense related to their involvement in such
programs established by Titles XVIII, XIX, or XX? ...................................................................................... ❒ ❒
C. Are there any individuals currently employed by the institution, agency, or organization in a managerial,
accounting, auditing, or similar capacity who were employed by the institution’s, organization’s, or
agency’s fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) ........... ❒ ❒
III. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling
interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names
and addresses under “Remarks” on page 2. If more than one individual is reported and any of these persons are
related to each other, this must be reported under “Remarks.”
NAME ADDRESS EIN
B. Type of entity: ❒ Sole proprietorship ❒ Partnership ❒ Corporation ❒ Unincorporated Associations ❒ Other (specify)
C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations
under “Remarks.”
D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses
of individuals, and provider numbers. ..........................................................................................................
❒ ❒
NAME ADDRESS PROVIDER NUMBER
Exhibit H
Page 2 of 2
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... ❒ ❒
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... ❒ ❒
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ ❒ ❒
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... ❒ ❒
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?......... ❒ ❒
VII. A. Is this facility chain affiliated? ...................................................................................................................... ❒ ❒
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
B. If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed) Title
Signature Date Remarks
Exhibit I
1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2. The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The prospective
participant shall submit an explanation of why it cannot provide the certification set out
below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation
shall disqualify such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which
reliance was placed when the department or agency determined to enter into this
transaction. If it is later determined that the prospective primary participant knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause or default.
4. The prospective primary participant shall provide immediate written notice to
the department or agency to which this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as
used in this clause, have the meanings set out in the Definitions and Coverage
sections of the rules implementing Executive Order 12549. You may contact the
department or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
Exhibit I
2 of 2
CERTIFICATION
(1) The prospective primary participant certifies to the best of its knowledge and belief,
that it, its owners, officers, corporate managers and partners:
(a) Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of
or had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c) (d) Have not within a three-year period preceding this application/proposal
had one or more public transactions (Federal, State or local) terminated for cause or
default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or
Company)
Exhibit J
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “County”),
members of a contractor’s board of directors (hereinafter referred to as “County Contractor”), must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self-dealing transaction is defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in which one
or more of its directors has a material financial interest”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member’s name, job title (if applicable), and date this disclosure is being made.
(2) Enter the board member’s company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the transaction; and
b. The nature of the material financial interest in the Corporation’s transaction that the
board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections (3) and (4).
Exhibit J
Page 2 of 2
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to)
(4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a)
(5) Authorized Signature
Signature: Date:
Page 1 of 1
CULTURAL COMPETENCE FORM
Agency Name:
Program Category:
Identify the Agency’s ability to apply language, gender, and culturally specific competencies to the RFP services provided by
checking all that apply and/or provide the name of Agency that you have an arrangement with to respond to these referrals.
A B C
Language, Gender, and/or Cultural
Competence Have staff 1 2 Name of Agency that you have an arrangement with to respond to these referrals Included in staffing work
plan
Not included in staffing work
plan. Explain below
Spanish (Language)
Vietnamese (Language)
Other Language:
LGBT Staff
African American Staff
Latino Staff
Native American Staff
Asian American Staff
Pacific Islander Staff
Others:
Exhibit L 1 of 11
Exhibit L 2 of 11
Exhibit L 3 of 11
Exhibit L 4 of 11
Exhibit L 5 of 11
Exhibit L 6 of 11
Exhibit L 7 of 11
Exhibit L 8 of 11
Exhibit L 9 of 11
To assist the Department of Behavioral Health in (1) Tracking annual cultural competency training and (2) Ensuring bilingual staff and/or interpreters are being
assessed for language proficiency; please complete this Biannual Cultural Competency Report, identifying all current staff and interpreters, and email the form to
DBHStaffDevelopment@FresnoCountyCa.gov by December 31, 2019 and June 30, 2020.
Program Name: _______________________________________________________________
STAFFING NAME
(LAST, FIRST)
CLASSIFICATION
(PER CONTRACT)
HAS STAFF COMPLETED
CULTURAL COMPETENCY
TRAINING BETWEEN
07/01/19 – 06/30/20?
(YES/NO)
If yes, enter date of training
NAME OF CULTURAL
COMPETENCY TRAINING
IS STAFF AND/OR THE
INTERPRETER BEING
UTILIZED IN A BILINGUAL
CAPACITY?
(YES/NO)
If yes, enter language
DATE
LANGUAGE
PROFICIENCY
WAS LAST
ASSESSED
Exhibit L
10 of 11
STAFFING NAME
(LAST, FIRST)
CLASSIFICATION
(PER CONTRACT)
HAS STAFF COMPLETED
CULTURAL COMPETENCY
TRAINING BETWEEN
07/01/19 – 06/30/20?
(YES/NO)
If yes, enter date of training
NAME OF CULTURAL
COMPETENCY TRAINING
IS STAFF AND/OR THE
INTERPRETER BEING
UTILIZED IN A BILINGUAL
CAPACITY?
(YES/NO)
If yes, enter language
DATE
LANGUAGE
PROFICIENCY
WAS LAST
ASSESSED
Exhibit L
11 of 11