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Agreement A-15-193 Master Agreement with Dept. of Behavioral Health Clients.pdf
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Agreement No. 15-193 MASTER AGREEMENT This Agreement is made and entered into this 19th day of May , 2015, by and between the COUNTY OF FRESNO, a Political Subdivision ofthe State of California, hereinafter referred to as "COUNTY", and each CONTRACTOR listed in Exhibit A "CONTRACTORS" ' attached hereto and by this reference incorporated herein, and collectively hereinafter referred to as "CONTRACTORS", and ~uch additional CONTRACTOR(S) as may, from time to time during the term ofthis Agreement, be added by COUNTY, with the Department of Behavioral Health (DBH) Director or designee approval. Reference in this Agreement to "parties" shall be understood to refer to COUNTY and each individual CONTRACTOR, unless otherwise specified. W IT N E S S E T H: WHEREAS, COUNTY, through its DBH, Mental Health Services Act (MHSA), Prevention and Early Intervention (PEl) component, and through input from the community stakeholder process, recognizes the need to provide Horticultural Therapeutic Community Centers (HTCC), as specified in this Agreement and as part of Fresno County's PEl Plan, to help reduce stigma and discrimination against mental illness and provide services related to mental well being and mental health services; and WHEREAS, CONTRACTOR(S) are qualified and willing to provide said services pursuant to the terms and conditions of this Agreement. NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties hereto agree as follows: l. COVERED SERVICES 22 CONTRACTOR(S) shall perform all services and fulfill all responsibilities as identified 23 in Exhibit B "Scope of Work", incorporated by reference and made part of this Agreement. 2. TERM 24 25 This Agreement shall become effective on the 1st day of July, 2015 and shall terminate 26 on the 30111 day of June, 2018. 27 Effective July 1, 2015, this Agreement, subject to available funding each year, and 28 subject to satisfactory performance measures as identified in Exhibit B, shall be extended for two (2) - 1 - COUN'IY OF F!UlSNO Fresno, C:\ 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 additional twelve (12) month periods upon the same terms and conditions herein set forth, unless written notice of non-renewal is given by COUNTY, CONTRACTOR(S), or COUNTY's DBH Director or designee, not later than thirty (30) days prior to the renewal period. 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 the CONTRACTOR(S) thirty (30) days advance written notice. B. Breach of Contract -The COUNTY may immediately suspend or terminate this Agreement in whole or in part, where in the determination of the 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 the COUNTY; 4) Improperly performed service. In no event shall any payment by COUNTY constitute a waiver by COUNTY of any breach ofthis Agreement or any default which may then exist on the part ofCONTRACTOR(S). Neither shall such payment impair or prejudice any remedy available to COUNTY with respect to the breach or default. COUNTY shall have the right to demand of CONTRACTOR(S) repayment to COUNTY of any funds disbursed to CONTRACTOR(S) under this Agreement, which in the judgment of COUNTY were not expended in accordance with the terms ofthis Agreement. CONTRACTOR(S) shall promptly refund any such funds upon demand or, at COUNTY's option; such repayment shall be deducted from future payments owing to CONTRACTOR(S) under this Agreement. C. Without Cause -Under circumstances other than those set forth above, this Agreement may be terminated by COUNTY, or CONTRACTOR(S), or COUNTY's DBH Director or designee, upon the giving of thirty (30) days advance written notice of intent to terminate. CONTRACTOR(S) may terminate with appropriate thirty (30) days advance written notice of intent to terminate transmitted by CONTRACTOR(S) to COUNTY by Certified U.S. Mail, Return Receipt Requested, addressed to the office of COUNTY as follows: - 2 - COUNTY OF FRESNO Fresno, CA Director (or designee) County of Fresno Department of Behavioral Health P.O. Box 45003 Fresno, CA 93718-9886 1 2 3 4 5 4. COMPENSATION 6 The maximum collective compensation amount under this Agreement for the period July 7 1, 2015 through June 30, 2020 shall not exceed One Million Six Hundred Twenty-Five Thousand and 8 No/100 Dollars ($1,625,000.00) for all CONTRACTORS and HTCC sites. 9 The maximum collective compensation amount under this Agreement for each twelve- 10 month term shall not exceed Three Hundred Twenty-Five Thousand and No/100 Dollars 11 ($325,000.00) for all CONTRACTORS and HTCC sites. 12 A. The maximum amounts paid to each CONTRACTOR identified in the 13 Agreement are stated in Exhibit C "Budgets", attached hereto and by this reference incorporated 14 herein. 15 B. COUNTY agrees to pay CONTRACTOR(S) and CONTRACTOR(S) agrees to 16 receive compensation based upon actual expenditures incurred by CONTRACTOR(S) for monthly 17 program costs, in accordance with the budgets identified in Exhibit C. 18 C. It is understood that all expenses incidental to CONTRACTOR(S) performance 19 of services under this Agreement shall be borne by CONTRACTOR(S). If CONTRACTOR(S) fails to 20 comply with any provision of this Agreement, COUNTY shall be relieved ofits obligation for further 21 compensation. 22 D. Any compensation which is not expended by CONTRACTOR pursuant to the 23 terms and conditions of this Agreement shall be remitted to COUNTY within sixty (60) days of receipt 24 and verification of inappropriate expenditures by COUNTY's DBH Director, or designee. 25 E. Any compensation which is not consumed by expenditures of 26 CONTRACTOR(S) by the expiration or termination of this Agreement shall automatically revert to 27 COUNTY. 28 /// - 3 - COUNTY OF FRESNO Fresno,CA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 F. All final claims and/or any final budget modification requests shall be submitted by CONTRACTOR within sixty (60) days following the end ofthe fiscal year of service for which payment is claimed. No action shall be taken by COUNTY on claims submitted beyond the sixty (60) day closeout period. G. 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. H. Except as provided below regarding State payment delays, payments shall be made by COUNTY to CONTRACTOR(S) in arrears for services provided during the preceding month, within forty-five (45) days of receipt, verification and approval of CONTRACTOR's monthly invoices by COUNTY's DBH Director, or designee. Payments shall be made after receipt and verification of actual expenditures incurred by CONTRACTOR(S) in the performance of this Agreement and shall be documented to COUNTY on a monthly basis by the tenth (1oth) of the month following the month of said expenditures. I. CONTRACTOR(S) shall be held financially liable for any and all future 16 disallowances/audit exceptions due to CONTRACTOR(S) deficiency discovered through the State 17 audit process. At COUNTY's election, the disallowed amount will be remitted within forty-five (45) 18 days to COUNTY upon notification or shall be withheld from subsequent payments to 19 CONTRACTOR(S). 20 J. The services provided by CONTRACTOR(S) under this Agreement are funded 21 in whole or in part by the State of California. In the event that funding for these services is delayed by 22 the State Controller, COUNTY may defer payment to CONTRACTOR(S). The amount of the 23 deferred payment shall not exceed the amount of funding delayed by the State Controller to the 24 COUNTY. The period of time ofthe deferral by COUNTY shall not exceed the period oftime ofthe 25 State Controller's delay of payment to COUNTY plus forty-five (45) days. 26 Ill 27 Ill 28 Ill - 4 - COUNTY OF FRESNO Fresno,CA 1 2 5. INVOICING A. CONTRACTOR(S) shall invoice COUNTY in arrears by the tenth (lOth) day of 3 the month following the month of said expenditure. Invoices shall be submitted each month to 4 DBHinvoices@co.fresno.ca.us. 5 B. CONTRACTOR(S) shall submit monthly staffing report that identifies all direct 6 service and support staff, and full time hours worked to be used as a tracking tool to determine if 7 CONTRACTOR's program is staffed according to the Agreement requirements. 8 c. CONTRACTOR(S) must maintain financial records for a period of seven (7) 9 years or until any dispute, audit or inspection is resolved, whichever is later. CONTRACTOR will be 10 responsible for any disallowances related to inadequate documentation. 11 6. INDEPENDENT CONTRACTOR 12 In performance of the work, duties, and obligations assumed by CONTRACTOR(S) 13 under this Agreement, it is mutually understood and agreed that CONTRACTOR(S), including any 14 and all of CONTRACTOR(S)'s officers, agents, and employees will at all times be acting and 15 performing as an independent contractor, and shall act in an independent capacity and not as an 16 officer, agent, servant, employee, joint venturer, partner, or associate of the COUNTY. Furthermore, 17 COUNTY shall have no right to control or supervise or direct the manner or method by which 18 CONTRACTOR(S) shall perform its work and function. However, COUNTY shall retain the right to 19 administer this Agreement so as to verify that CONTRACTOR(S) is performing its obligations in 20 accordance with the terms and conditions thereof. CONTRACTOR(S) and COUNTY shall comply 21 with all applicable provisions of law and the rules and regulations, if any, of governmental authorities 22 having jurisdiction over matters which are directly or indirectly the subject of this Agreement. 23 Because of its status as an independent contractor, CONTRACTOR(S) shall have 24 absolutely no right to employment rights and benefits available to COUNTY employees. 25 CONTRACTOR(S) shall be solely liable and responsible for providing to, or on behalf of, its 26 employees all legally-required employee benefits. In addition, CONTRACTOR(S) shall be solely 27 responsible and save COUNTY harmless from all matters relating to payment of CONTRACTOR(S)'s 28 employees, including compliance with Social Security, withholding, and all other regulations - 5 - COUNTY OF FRESNO Fresno, CA 1 governing such matters. It is acknowledged that during the term of this Agreement, 2 CONTRACTOR(S) may be providing services to others unrelated to the COUNTY or to this 3 Agreement. 4 7. MODIFICATION 5 Any matters of this Agreement may be modified from time to time by the written 6 consent of all the parties without, in any way, affecting the remainder. 7 Notwithstanding the above, changes to line items in the budgets, attached hereto as 8 Exhibit C, that do not exceed 10% ofthe individual CONTRACTOR(S)'s program total maximum 9 compensation payable to CONTRACTOR(S), may be made with the written approval of COUNTY's 10 DBH Director or designee and CONTRACTOR(S). Said budget line item changes shall not result in 11 any change to the individual CONTRACTOR(S)'s program maximum compensation amount payable 12 to CONTRACTOR(S), as stated herein. 13 Additions and or deletions of Contractors may be made to Exhibit A "Contractors" and 14 Exhibit C "Budgets" with written approval of COUNTY's DBH Director or designee, upon 15 COUNTY's DBH Director or designee having received and approved submitted proposals for 16 additional HTCC CONTRACTOR(S) and/or HTCC sites. Proposals for the inclusion ofHTCC 17 CONTRACTOR(S) and/or HTCC sites must be prepared and submitted to: County of Fresno, 18 Department of Behavioral Health, Mental Health Services Act, 3133 N. Millbrook Avenue, Fresno, 19 CA 93703, Attention: HTCC Contract Analyst. 20 8. NON-ASSIGNMENT 21 Neither party shall assign, transfer or subcontract this Agreement nor their rights or 22 duties under this Agreement without the prior written consent of the other party. 23 9. HOLD-HARMLESS 24 CONTRACTOR(S) agrees to indemnify, save, hold harmless, and at COUNTY's 25 request, defend the COUNTY, its officers, agents and employees from any and all costs and expenses, 26 including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to 27 COUNTY in connection with the performance, or failure to perform, by CONTRACTOR(S), its 28 officers, agents or employees under this Agreement, and from any and all costs and expenses, -6 -COUN1Y OF FRESNO Fresno,CA 1 including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to 2 any person, firm or corporation who may be injured or damaged by the performance, or failure to 3 perform, of CONTRACTOR(S), its officers, agents or employees under this Agreement. 4 CONTRACTOR(S) agrees to indemnify COUNTY for Federal, State of California and/or 5 local audit exceptions resulting from noncompliance herein on the part of the CONTRACTOR(S). 6 10. INSURANCE 7 Without limiting the COUNTY's right to obtain indemnification from 8 CONTRACTOR(S) or any third parties, CONTRACTOR(S), at its sole expense, shall maintain in full 9 force and effect the following insurance policies throughout the term of this Agreement: 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 A. B. c. D. Commercial General Liability Commercial General Liability Insurance with limits of not less than One Million Dollars ($1 ,000,000) per occurrence and an annual aggregate of Two Million Dollars ($2,000,000). This policy shall be issued on a per occurrence basis. COUNTY may require specific coverage including completed operations, product liability, contractual liability, Explosion, Collapse, and Underground (XCU), fire legal liability or any other liability insurance deemed necessary because of the nature of the Agreement. Automobile Liability Comprehensive Automobile Liability Insurance with limits for bodily injury of not less than Two Hundred Fifty Thousand Dollars ($250,000) per person, Five Hundred Thousand Dollars ($500,000) per accident and for property damages of not less than Fifty Thousand Dollars ($50,000), or such coverage with a combined single limit of One Million Dollars ($1 ,000,000). Coverage should include owned and non-owned vehicles used in connection with this Agreement. Real And Personal Property CONTRACTOR(S) 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 purchased and owned property, at a minimum, as discussed in Section Nineteen (19) of this Agreement. All Risk Property Insurance CONTRACTOR will provide property coverage for the full replacement value of COUNTY's Personal Property in the possession of CONTRACTOR and/or used in the execution of this Agreement. COUNTY will be identified on an - 7 - COUNTY OF FRESNO Fresno, CA 1 2 3 4 5 6 7 8 9 10 11 12 13 E. F. G. appropriate certificate of insurance as the certificate holder and will be named as an Additional Loss Payee on the Property Insurance Policy. Fire Insurance and Extended Coverage CONTRACTOR(S) shall add COUNTY as an additional Loss Payee thereon. Professional Liability IfCONTRACTOR(S) employs licensed professional staff(e.g. Ph.D., R.N., L.C.S.W., L.M.F.T.) 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 three (3) years following the termination of this Agreement, one or more policies of professional liability insurance with limits of coverage as specified herein. Worker's Compensation A policy of Worker's Compensation Insurance as may be required by the California Labor Code. 14 CONTRACTOR(S) shall obtain endorsements to the Commercial General Liability 15 insurance naming the County of Fresno, its officers, agents, and employees, individually and 16 collectively, as additional insured, but only insofar as the operations under this Agreement are 17 concerned. Such coverage for additional insured shall apply as primary insurance and any other 18 insurance, or self-insurance, maintained by the COUNTY, its officers, agents and employees shall be 19 excess only and not contributing with insurance provided under the CONTRACTOR(S) 's policies 20 herein. This insurance shall not be cancelled or changed without a minimum of thirty (30) days 21 advance written notice given to COUNTY. 22 Within thirty (30) days from the date CONTRACTOR(S) signs this Agreement, 23 CONTRACTOR shall provide certificates of insurance and endorsements as stated above for all ofthe 24 foregoing policies, as required herein, to the County of Fresno, Department of Behavioral Health, 25 Mental Health Services Act, 3133 N. Millbrook Ave., Fresno, California, 93703, Attention: HTCC 26 Contract Analyst, stating that such insurance coverage's have been obtained and are in full force; that 27 the County of Fresno, its officers, agents and employees will not be responsible for any premiums on 28 the policies; that such Commercial General Liability insurance names the County of Fresno, its - 8 - COUNTY OF FRESNO Fresno, CA 1 officers, agents and employees, individually and collectively, as additional insured, but only insofar as 2 the operations under this Agreement are concerned; that such coverage for additional insured shall 3 apply as primary insurance and any other insurance, or self-insurance, maintained by the COUNTY, 4 its officers, agents and employees, shall be excess only and not contributing with insurance provided 5 under the CONTRACTOR(S)'s policies herein; and that this insurance shall not be cancelled or 6 changed without a minimum of thirty (30) days advance, written notice given to COUNTY. 7 In the event CONTRACTOR(S) fails to keep in effect at all times insurance coverage as 8 herein provided, the COUNTY may, in addition to other remedies it may have, suspend or terminate 9 this Agreement upon the occurrence of such event. 10 All policies shall be with admitted insurers licensed to do business in the State of 11 California. Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating 12 of A FSC VII or better. 13 11. CONFIDENTIALITY 14 All services performed by CONTRACTOR(S) under this Agreement and any 15 information CONTRACTOR(S) creates, receives, or maintains pertaining to protected health 16 information shall be in strict conformance with all applicable Federal, State of California and/or local 17 laws and regulations relating to confidentiality. 18 12. LICENSES/CERTIFICATES 19 Throughout each term of this Agreement, CONTRACTOR(S) and CONTRACTOR(S)'s 20 staff shall maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions 21 necessary for the provision of the services hereunder and required by the laws and regulations ofthe 22 United States of America, State of California, the County of Fresno, and any other applicable 23 governmental agencies. CONTRACTOR(S) shall notify COUNTY immediately in writing of its 24 inability to obtain or maintain such licenses, permits, approvals, certificates, waivers and exemptions 25 irrespective of the pendency of any appeal related thereto. Additionally, CONTRACTOR(S) and 26 CONTRACTOR(S)'s staff shall comply with all applicable laws, rules or regulations, as may now 27 exist or be hereafter changed. 28 Ill - 9 - COUN1Y OF FRESNO Fresno, CA 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 13. REPORTS A. Reports-CONTRACTOR(S) shall submit to COUNTY's DBH reports as identified in Exhibit B "Scope of Work" as requested by COUNTY. Monthly reports shall be submitted by the tenth (1Oth) of each month a report of all monthly events, activities and budget reports for the preceding month. In addition, CONTRACTOR(S) 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(S) 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(S) 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. B. Performance Measurement Reports-CONTRACTOR(S) shall complete and submit Performance Measurement Reports, and any other information as COUNTY may request pertaining to matters covered by this Agreement. In the event that CONTRACTOR(S) 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. C. Quarterly Report Progress Updates-CONTRACTOR(S) shall complete all Quarterlr Report Progress updates according to the State Department of Mental Health regulations in accordance with Exhibit D "Quarterly Progress Goals and Report", attached hereto and incorporated herein by reference. CONTRACTOR(S) shall utilize the "Current Quarterly Progress Report Overview" instruction sheet as shown in Exhibit E, attached hereto and incorporated herein by reference, to submit the Quarterly Report Progress updates referenced in Exhibit D. All quarterly reporting is to be submitted to the DBH's MHSA Administrative unit within thirty (30) days of quarter ending for review by COUNTY'S MHSA Administrative unit. 14. MONITORING 27 CONTRACTOR(S) agrees to extend to COUNTY's staff, COUNTY's DBH Director 28 and the State Department of Mental Health, or their designees, the right to review and monitor records, -10 -COUNTY OF FRESNO Fresno, CA 1 program or procedures, at any time, in regard to clients, as well as the overall operation of 2 CO~TRACTOR(S)'s program, in order to ensure compliance with the terms and conditions of this 3 Agreement. 4 15. REFERENCES TO LAWS AND RULES 5 In the event any law, regulation, or policy referred to in this Agreement is amended 6 during the term thereof, the parties hereto agree to comply with the amended provision as of the 7 effective date of such amendment. 8 16. COMPLIANCE WITH STATE REQIDREMENTS 9 CONTRACTOR(S) recognizes that COUNTY operates its mental health programs 10 under an agreement with the State of California Department of Mental Health, and that under said 11 agreement the State imposes certain requirements on COUNTY and its subcontractors. · 12 CONTRACTOR(S) shall adhere to all State Requirements, including those identified in Exhibit F 13 "State Mental Health Requirements", attached hereto and by this reference incorporated herein. 14 17. DATA SECURITY 15 For the purpose of preventing the potential loss, misappropriation or inadvertent access, 16 viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse 17 of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that 18 enter into a contractual relationship with the COUNTY for the purpose of providing services under 19 this Agreement must employ adequate data security measures to protect the confidential information 20 provided to CONTRACTOR(S) by the COUNTY, including but not limited to the following: 21 A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices 22 CONTRACTOR(S) may not connect to COUNTY networks via personally- 23 owned mobile, wireless or handheld devices, unless the following conditions are met: 24 1) 25 telecommuting purposes; 26 27 28 2) 3) 4) CONTRACTOR(S) has received authorization by COUNTY for Current virus protection software is in place; Mobile device has the remote wipe feature enabled; and A secure connection is used. -11 -COUN1Y OF FRESNO Fresno, CA 1 2 B. CONTRACTOR-Owned Computers or Computer Peripherals CONTRACTOR(S) may not bring CONTRACTOR(S)-owned computers or 3 computer peripherals into the COUNTY for use without prior authorization from the COUNTY's 4 Chieflnformation Officer, and/or designee(s), including but not limited to mobile storage devices. If 5 data is approved to be transferred, data must be stored on a secure server approved by the COUNTY 6 and transferred by means of a Virtual Private Network (VPN) connection, or another type of secure 7 connection. Said data must be encrypted. 8 C. COUNTY -Owned Computer Equipment 9 CONTRACTOR(S) may not use COUNTY computers or computer peripherals 10 on non-COUNTY premises without prior authorization from the COUNTY's Chief Information 11 Officer, and/or designee(s). 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 D. CONTRACTOR(S) 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(S) 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(S) 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)'s response to all incidents arising from a possible breach of security related to COUNTY's confidential client information provided to CONTRACTOR(S). CONTRACTOR(S) will be responsible to issue any -12 -COUNTY OF FRESNO Fresno, CA 1 notification to affected individuals as required by law or as deemed necessary by COUNTY in its sole 2 discretion. CONTRACTOR(S) will be responsible for all costs incurred as a result of providing the 3 required notification. 4 18. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT 5 COUNTY and CONTRACTOR(S) each consider and represent themselves as covered 6 entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1969, Public 7 Law 104-191 (HIPAA) and agrees to use and disclose Protected health Information (PHI) as required 8 by law. 9 COUNTY and CONTRACTOR(S) acknowledg~ that the exchange of PHI between 10 them is only for treatment, payment, and health care options. 11 COUNTY and CONTRACTOR(S) intend to protect the privacy and provide for the 12 security ofPHI pursuant to the Agreement in compliance with HIPAA, the Health Information 13 Technology for Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations 14 promulgated thereunder by the U.S. Department ofHealth and Human Services (HIPAA Regulations) 15 and other applicable laws. 16 As part ofthe HIPAA Regulations, the Privacy Rule and the Security Rule require 17 CONTRACTOR(S) to enter into a contract containing specific requirements prior to the disclosure of 18 PHI, as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e) ofthe 19 Code of Federal Regulations (CFR). 19. EQUIPMENT 20 21 A. All purchases over Five Thousand and No/100 Dollars ($5,000.00) including 22 .sales tax, and certain purchases under said amount such as cameras, televisions, VCRs/DVDs and 23 other sensitive items, made during the life of this Agreement with funds paid pursuant to this 24 Agreement and that will outlive the life of this Agreement, shall be identified as fixed assets with an 25 assigned Fresno County Inventory Numbers. All fixed assets shall be reported to COUNTY utilizing 26 Exhibit G "Fixed Assets and Sensitive Items Tracking Form" and Exhibit Ga "Fixed Assets and 27 Sensitive Items Tracking Form Instructions", attached hereto and by this reference incorporated 28 herein. These fixed assets shall be retained by COUNTY, as COUNTY property, in the event this -13 -COUN1Y OF FRESNO Fresno, CA 1 Agreement is terminated or upon expiration of this Agreement. CONTRACTOR(S) agrees to 2 participate in an annual inventory of all COUNTY fixed assets and shall be physically present when 3 fixed assets are returned to COUNTY possession at the termination or expiration of this Agreement. 4 CONTRACTOR(s) is responsible for returning to COUNTY all COUNTY owned fixed assets at the 5 expiration or termination of this Agreement. 6 CONTRACTOR(S) further agrees to the following: 7 1. To maintain all items of capital equipment in good working order and 8 condition, normal wear and tear excepted; and 9 2. To label all items of capital equipment, to perform periodic inventories as 10 required by COUNTY and to maintain an inventory list showing where and how the capital equipment is 11 being used in accordance with procedures developed by COUNTY. All such lists shall be submitted to 12 COUNTY within ten (1 0) days of any request therefore. 13 3. To report in writing to COUNTY immediately after discovery, the loss or 14 theft of any items of capital equipment. For stolen items, the local law enforcement agency must be 15 contacted and a copy of the police report submitted to COUNTY. 16 4. CONTRACTOR(S) shall maintain a policy of insurance for all risk 17 personal property coyerage which shall be endorsed naming the County of Fresno as an additional loss 18 payee. 19 B. The purchase of any capital equipment over Five Thousand and No/Dollars 20 ($5,000.00) by CONTRACTOR(S) with funds provided hereunder shall require the prior written 21 approval of COUNTY's DBH Director or designee, shall fulfill the provisions ofthis Agreement as 22 appropriate and must be directly related to CONTRACTOR(S)'s services or activity under the terms and 23 conditions of this Agreement. COUNTY's DBH may refuse reimbursement for any costs resulting from 24 capital equipment purchased, which are incurred by CONTRACTOR(S), if prior written approval has 25 not been obtained from COUNTY's DBH Director or designee. 26 C. CONTRACTOR(S) must obtain prior written approval form COUNTY's DBH 27 whenever there is any modification or change in the use of any property acquired or improved, in whole 28 or in part, using MHSA funds. If any real or personal property acquired or improved with MHSA funds -14 -COUNTY OF FRESNO Fresno, CA 1 is sold and/or is utilized by CONTRACTOR(S) for a use which does not qualify under the MHSA 2 program, CONTRACTOR(S) shall reimburse COUNTY in an amount equal to the current fair market 3 value of the property, less any portion thereof attributable to expenditures ofnon-MHSA funds. These 4 requirements shall continue in effect for the life of the property. In the event the MHSA program is 5 closed out, the requirements for this Section shall remain in effect for activities or property funded with 6 MHSA funds, unless action is taken by the State government to relieve COUNTY of these obligations. 7 D. The terms and conditions described in this Section are not applicable to the leasing 8 of vehicles by CONTRACTORS with the funds provided under this Agreement. 9 20. NON-DISCRIMINATION 10 During the performance of this Agreement CONTRACTOR(S) shall not unlawfully 11 discriminate against any employee or applicant for employment, or recipient of services, because of 12 · race, religion, color, national origin, ancestry, physical disability, medical condition, marital status, 13 age or gender, pursuant to all applicable State of California and Federal statutes and regulations. 14 15 16 17 18 19 20 21 22 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 I 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 23 interpreters and material translation services for all LEP clients, including, but not limited to, 2 4 assessing the cultural and linguistic needs of its clients, training of staff on the policies and 25 procedures, and monitoring its language assistance program. The CONTRACTOR's procedures must 26 include ensuring compliance of any sub-contracted providers with these requirements. 27 C. 28 /// CONTRACTOR shall not use minors as interpreters. -15 -COUNTY OF FRESNO Fresno, CA 1 D. CONTRACTOR shall provide and pay for interpreting and translation services to 2 persons participating in CONTRACTOR's services who have limited or no English language 3 proficiency, including services to persons who are deaf or blind. Interpreter and translation services 4 shall be provided as necessary to allow such participants meaningful access to the programs, services 5 and benefits provided by CONTRACTOR. Interpreter and translation services, including translation 6 of CONTRACTOR's "vital documents" (those documents that contain information that is critical for 7 accessing CONTRACTOR's services or are required by law) shall be provided to participants at no 8 cost to the participant. CONTRACTOR shall ensure that any employees, agents, subcontractors, or 9 partners who interpret or translate for a program participant, or who directly communicate with a 10 program participant in a language other than English, demonstrate proficiency in the participant's 11 language and can effectively communicate any specialized terms and concepts peculiar to 12 CONTRACTOR(S)'s services. 13 E. In compliance with the State mandated Culturally and Linguistically Appropriate 14 Services standards as published by the Office of Minority Health, CONTRACTOR must submit to 15 COUNTY for approval, within 60 days from date of contract execution, CONTRACTOR's plan to 16 address all fifteen national cultural competency standards as set forth in the "National Standards on 17 Culturally and Linguistically Appropriate Services 18 (CLAS)"http :1/minorityhealth. hhs.gov/assets/pdf/checked/finalreport. pdf). COUNTY's annual 19 on-site review of CONTRACTOR shall include collection of documentation to ensure all national 20 standards are implemented. As the national competency standards are updated, CONTRACTOR's 21 plan must be updated accordingly. 22 22. TAX EQUITY AND FISCAL RESPONSIBILITY ACT 23 To the extent necessary to prevent disallowance of reimbursement under Section 24 1861(v) (1) (1) of the Social Security Act, (42 U.S.C. § 139x, subd. (v)(l){l} ), until the expiration of 25 four ( 4) years after the furnishing of services under this Agreement, CONTRACTOR(S) shall make 26 available upon written request of the Secretary of the United States Department of Health and Human 27 Services, or upon request of the Comptroller General of the United States General Accounting Office, 28 or any of their duly authorized representatives, a copy ofthis Agreement and such books, documents, -16 -COUNTY OF FRESNO Fresno, CA 1 and records as are necessary to certify the nature and extent of the costs of these services provided by 2 CONTRACTOR(S) under this Agreement. CONTRACTOR(S) further agrees that in the event 3 CONTRACTOR(S) carries out any of its duties under this Agreement through a subcontract, with a 4 value or cost ofTen Thousand and No/100 Dollars ($10,000.00) or more over a twelve (12) month 5 period, with a related organization, such Agreement shall contain a clause to the effect that until the 6 expiration of four ( 4) years after the furnishing of such services pursuant to such subcontract, the 7 related organizations shall make available, upon written request of the Secretary of the United States 8 Department of Health and Human Services, or upon request of the Comptroller General of the United 9 States General Accounting Office, or any of their duly authorized representatives, a copy of such 1 0 subcontract and such books, documents, and records of such organization as are necessary to verify the 11 nature and extent of such costs. 23. SINGLE AUDIT CLAUSE 12 13 A. If CONTRACTOR(S) expends Five Hundred Thousand Dollars ($500,000.00) or 14 more in Federal and Federal flow-through monies, CONTRACTOR(S) agrees to conduct an annual 15 audit in accordance with the requirements of the Single Audit Standards as set forth in Office of 16 Management and Budget (OMB) Circular A-133. CONTRACTOR(S) shall submit said audit and 17 management letter to COUNTY. The audit must include a statement of findings or a statement that 18 there were no findings. If there were negative findings, CONTRACTOR(S) must include a corrective 19 action plan signed by an authorized individual. CONTRACTOR(S) agrees to take action to correct 20 any material non-compliance or weakness found as a result of such audit. Such audit shall be 21 delivered to COUNTY's Human Services Finance for review within nine (9) months of the end of any 22 fiscal year in which funds were expended and/or received for the program. :Failure to perform the 23 requisite audit functions as required by this Agreement may result in COUNTY performing the 24 necessary audit tasks, or at COUNTY's option, contracting with a public accountant to perform said 25 audit, or, may result in the inability of COUNTY to enter into future agreements with 26 CONTRACTOR(S). All audit costs related to this Agreement are the sole responsibility of 27 CONTRACTOR(S). 28 B. A single audit report is not applicable if CONTRACTOR(S)'s Federal contracts -17 -COUNTY OF FRESNO Fresno, CA 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 do not exceed the Five Hundred Thousand Dollars ($500,000.00) requirement or CONTRACTOR(S)'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(S) to COUNTY as a minimum requirement to attest to CONTRACTOR's solvency. Said audit report shall be delivered to COUNTY's DBH Business Officer 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(S) 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 section shall be billed to the CONTRACTOR at COUNTY's cost, as determined by COUNTY's Auditor-Controller/Treasurer-Tax Collector . C. CONTRACTOR(S) 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. 24. COMPLIANCE-"CONTRACTOR CODE OF CONDUCT AND ETHICS" CONTRACTOR(S) agrees to comply with COUNTY's "Contractor Code of Conduct and Ethics", and COUNTY's "Fresno County Mental Health Compliance Program Contractor Acknowledgement and Agreement," both attached hereto as Exhibit H, and by this reference incorporated herein. Within thirty (30) days of entering into this Agreement with COUNTY, CONTRACTOR(S) shall have all ofCONTRACTOR(S)'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(S) 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, -18 -COUN1Y OF FRESNO Fresno,CA 1 understood, and shall abide by the "Contactor Code of Conduct and Ethics." CONTRACTOR(S) 2 understands that the promotion of and adherence to the "Contractor Code of Conduct and Ethics" is an 3 element in evaluating the performance of CONTRACTOR(S) and its employees, agents and 4 subcontractors. 5 Within thirty (3 0) days of entering into this Agreement, and annually thereafter, all 6 employees, agents and subcontractors providing services under this Agreement shall complete general 7 compliance training; and appropriate employees, agents and subcontractors shall complete 8 documentation and billing or billing/reimbursement training. All new employees, agents and 9 subcontractor shall attend the appropriate training within thirty (30) days of hire. Each individual who 10 is required to attend training shall certify, in writing, that he or she has received the required training. 11 The certification shall specify the type oftraining received and the date received. The certification 12 shall be provided to COUNTY's Compliance Officer at 313 3 N. Millbrook A venue, Fresno, California 13. 93703. CONTRACTOR(S) agrees to reimburse COUNTY for the entire cost of any penalty imposed 14 upon COUNTY by the Federal Government as a result ofCONTRACTOR(S)'s violation of the terms 15 .. of this Agreement. 16 17 25. ASSURANCES A. In entering into this Agreement, CONTRACTOR(S) certifies that it nor any of its 18 officers are not currently excluded, suspended, debarred, or otherwise ineligible to participate in the 19 Federal Health Care Programs; that it has not been convinced of a criminal offense related to the 20 provision of health care items or services; nor has it or its officers been reinstated to participation in the 21 Federal Health Care Programs after a period of exclusion, suspension, debarment, or ineligibility. If 22 COUNTY learns, subsequent to entering into contract, that CONTRACTOR(S) is ineligible on these 23 grounds, COUNTY will remove CONTRACTOR(S) from responsibility for, or involvement with 24 COUNTY's business operations related to the Federal Health Care Programs and shall remove such 25 CONTRACTOR(S) from any position in which CONTRACTOR may be paid in whole or part, directly 26 or indirectly, by Federal Health Care Programs or otherwise with Federal Funds at least until such time 27 as CONTRACTOR(S) is reinstated into participation in the Federal Health Care Programs. 28 Ill -19 -COUNTY OF FRESNO Fresno, CA 1 B. If COUNTY has notice that CONTRACTOR(S) has been charged with a criminal 2 offense related to any Federal Health Care Program, or is proposed for exclusion during the term on 3 any contract, CONTRACTOR(S) and COUNTY shall take all appropriate actions to ensure the 4 accuracy of any claims submitted to any Federal Health Care Program. At its discretion given such 5 circumstances, COUNTY may request that CONTRACTOR(S) cease providing services until 6 resolution of the charges or the proposed exclusion. 7 c. CONTRACTOR(S) agrees that all potential new employees of 8 CONTRACTOR(S) or subcontractors ofCONTRACTOR(S) who, in each case, are expected to 9 perform professional services under this Agreement, will be queried as to whether (1) they are now or 10 ever have been excluded, suspended, debarred, or otherwise ineligible to participate in the Federal 11 health Care Programs; (2) they have been convicted of criminal offense related to the provision of 12 health care items or services; and/or (3) they have been reinstated to participation in the Federal Health 13 Care Programs after a period of exclusion, suspension, debarment, or ineligibility. 14 1. In the event the potential employee or subcontractor informs 15 .. CONTRACTOR(S) that he or she is excluded, suspended, debarred or otherwise ineligible, or has 16 been convicted of a criminal offense relating to the provision of health care services, and 17 CONTRACTOR(S) hires or engages such potential employee or subcontractor, CONTRACTOR(S) 18 will ensure that said employee or subcontractor does not work, either directly or indirectly, relating to 19 services provided to COUNTY. 20 2. Notwithstanding any other provision of this Agreement, COUNTY at its 21 discretion may terminate this Agreement in accordance with Paragraph 3 hereof, or require adequate 22 assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible individual 23 will perform work, either directly or indirectly, relating to services provided to COUNTY. Such 24 demand for adequate assurance shall be effective upon a time frame to be determined by COUNTY to 25 protect the interests of COUNTY consumers. 26 D. CONTRACTOR(S) shall verify (by asking the applicable employees and 27 subcontractors) that all current employees and existing subcontractors who, in each case, are expected 28 to perform professional services under this Agreement; (a) are not currently excluded, suspended, -20 -COUNTY OF FRESNO Fresno, CA 1 debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (b) have not been 2 convicted of a criminal offense related to the provision of health care items or services; and (c) have not 3 been reinstated to participation in the Federal Health Care Program after a period of exclusion, 4 suspension, debarment, or ineligibility. In the event any existing employee or subcontractor informs 5 CONTRACTOR(S) that he or she is excluded, suspended, debarred or otherwise ineligible to 6 participate in the Federal Health Care Programs, or has been convicted of a criminal offense relating to 7 the provision of health care services, CONTRACTOR(S) will ensure that said employee or 8 subcontractor does not work, either directly or indirectly, relating to services provided to COUNTY. 9 1. CONTRACTOR(S) agrees to notify COUNTY immediately during the 10 term of this Agreement whenever CONTRACTOR(S)'s engagement partner under this Agreement 11 learns that an employee or subcontractor who, in each case, is providing professional services under 12 this Agreement is excluded, suspended, debarred or otherwise ineligible to participate in the Federal 13 Health Care Programs, or is convicted of a criminal offense relating to the provision of health care 14 services. 15 2. Notwithstanding the above, COUNTY at its discretion may terminate this 16 Agreement in accordance with the Termination Section of this Agreement, or require adequate 17 assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or 18 subcontractor of CONTRACTOR(S) will perform work, either directly or indirectly, relating to 19 services provided to COUNTY. Such demand for adequate assurance shall be effective upon a time 20 frame to be determined by COUNTY to protect the interests of COUNTY consumers. 21 E. CONTRACTOR(S) agrees to cooperate fully with any reasonable requests for 22 information from COUNTY which may be necessary to complete any internal or external audits 23 relating to CONTRACTOR(S)'s compliance with the provisions of this Section. 24 F. CONTRACTOR(S) agrees to reimburse COUNTY for the entire cost of any 25 penalty imposed upon COUNTY by the Federal Government as a result of CONTRACTOR(S)' s 26 violation ofCONTRACTOR(S)'s obligations as described in the Section. 27 Ill 28 Ill -21 -COUNTY OF FRESNO Fresno, CA 1 2 26. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION 3 This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, 4 or managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101 5 455.104, and 455.106(a)(1),(2). 6 In accordance with C.F.R., Title 42 §§ 455.101, 455.104,455.105 and 455.106(a)(1),(2), 7 the following information must be disclosed by CONTRACTOR by completing Exhibit I, 8 "Disclosure of Ownership and Control Interest Statement", attached hereto and by this reference 9 incorporated herein and made part of this Agreement. CONTRACTOR shall submit this form to the 10 Department of Behavioral Health within thirty (30) days ofthe effective date ofthis Agreement. 11 Additionally, CONTRACTOR shall report any changes to this information within thirty five (35) 12 days of occurrence by completing Exhibit I. Submissions shall be scanned PDF copies and are to be 13 · sent via email to DBHAdministration@co.fresno.ca.us attention: HTCC Analyst. 14 15 27. DISCLOSURE-CRIMINAL HISTORY AND CIVIL ACTIONS CONTRACTOR(S) is required to disclose if any of the following conditions apply to 16 them, their owners, officers, corporate managers and partners (hereinafter collectively referred to as 17 .. "CONTRACTOR(S)"): 18 A. Within the three-year period preceding the Agreement award, they have been 19 convicted of, or ,had a civil judgment rendered against them for: 20 1. Fraud or a criminal offense in connection with obtaining, attempting to 21 obtain, or performing a public (federal, state, or local) transaction or contract under a public 22 transaction; 23 24 25 26 27 28 records; or 2. 3. Violation of a federal or state antitrust statute; Embezzlement, theft, forgery, bribery, falsification, or destruction of 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. -22 -COUNTY OF FRESNO Fresno, CA 1 Disclosure of the above information will not automatically eliminate 2 CONTRACTOR(S) from further business consideration. The information will be considered as part 3 of the determination of whether to continue and/or renew the Agreement and any additional 4 information or explanation that a CONTRACTOR(S) elects to submit with the disclosed information 5 will be considered. If it is later determined that the CONTRACTOR(S) failed to disclose required 6 information, any Agreement awarded to such CONTRACTOR(S) may be immediately voided and 7 terminated for material failure to comply with the terms and conditions of the award. 8 CONTRACTOR(S) must sign an appropriate "Certification Regarding Debarment, 9 Suspension, and Other Responsibility Matters-Primary Covered Transactions", Exhibit J, attached 10 hereto and by this reference incorporated herein. Additionally, CONTRACTOR(S) must immediately 11 advise COUNTY in writing if, during the term of this Agreement: (1) CONTRACTOR(S) becomes 12 suspended, debarred, excluded or ineligible for participation in federal or state funded programs or 13 from receiving federal funds as listed in the excluded parties list system (http://www/epls/gov); or (2) 14 any of the above llsted conditions become applicable to CONTRACTOR(S). CONTRACTOR(S) 15 shall indemnify, defend and hold COUNTY harmless for any loss or damage resulting from a 16 conviction, debarment, exclusion, ineligibility or other matter listed in the signed Certification 17 Regarding Debarment, Suspension, and Other Responsibility Matters. 28. AUDITS AND INSPECTIONS 18 19 The CONTRACTOR(S) shall with seventy-two (72) hours advance notice provided by 20 the COUNTY, during business hours, and as often as the COUNTY may deem necessary, make 21 available to COUNTY for examination all of its records and data with respect to the matters covered 22 by this Agreement. CONTRACTOR(S) shall, upon request by COUNTY, permit COUNTY to audit 23 and inspect all such records and data necessary to ensure CONTRACTOR(S)'s compliance with the 2 4 terms of this Agreement. 25 If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00), 26 CONTRACTOR(S) shall be subject to the examination and audit of the State Auditor General for a 27 period ofthree (3) years after final payment under contract (Government Code section 8546.7). 28 /// -23 -COUNTY OF FRESNO Fresno, CA 1 2 3 4 5 6 7 8 9 10 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)'s advertising, fundraising, or publicity (i.e., purchasing tickets/tables, silent auction donations, etc.) for the purpose of self-promotion. Notwithstanding the above, publicity of the services described in Section One (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 Exhibit C, attached hereto, for such items as written/printed materials, the use of media (i.e., radio, television, newspapers) and any other related expense(s). 30. COMPLAINTS 11 CONTRACTOR(S) shall log complaints and the disposition of all complaints from a 12 consumer or a consumer's family. CONTRACTOR(S) shall provide a copy of the detailed complaint 13 log entries concerning COUNTY-sponsored consumers to COUNTY at monthly intervals by the tenth 14 (10 1 h) day of the following month, in a format that is mutually agreed upon. Besides the detailed 15 complaint log, CONTRACTOR(S) shall provide details and attach documentation of each complaint 16 with the log. CONTRACTOR(S) shall post signs informing consumer of their right to file a complaint 17 or grievance. CONTRACTOR(S) shall notify COUNTY of all incidents reportable to state licensing 18 bodies that affect COUNTY consumers within twenty-four (24) hours of receipt of a complaint as 19 indicated in Exhibit K "Grievances and Incident Reporting", attached hereto and by this reference 20 incorporated herein. 21 31. DISCLOSURE OF SELF-DEALING TRANSACTIONS 22 This provision is only applicable if the CONTRACTOR is operating as a corporation (a 23 for-profit or non-profit corporation) or if during the term of this agreement, the CONTRACTOR 24 changes its status to operate as a corporation. 25 Members ofthe CONTRACTOR's Board ofDirectors shall disclose any self-dealing 26 transactions that they are a party to while CONTRACTOR is providing goods or performing services 27 under this agreement. A self-dealing transaction shall mean a transaction to which the 28 CONTRACTOR is a party and in which one or more of its directors has a material financial interest. -24 -COUN1Y OF FRESNO Fresno, CA 1 Members of the Board of Directors shall disclose any self-dealing transactions that they are a party to 2 by completing and signing a Self-Dealing Transaction Disclosure Form (Exhibit L attached hereto 3 and by this reference incorporated herein and made part of this Agreement) and submitting it to the 4 COUNTY prior to commencing with the self-dealing transaction or immediately thereafter. 5 32. NOTICES 6 The persons having authority to give and receive notices under this Agreement and their 7 addresses include the following: 8 9 10 11 COUNTY Director, Fresno County Department of Behavioral Health 3133 N. Millbrook Avenue Fresno, CA 93 703 CONTRACTOR(S) (See Exhibit A) 12 Any and all notices between the COUNTY and the CONTRACTOR(S) provided for or 13 permitted under this Agreement or by law shall be in writing and shall be deemed duly served when 14 personally delivered to one of the parties, or in lieu of such personal service, when deposited in the 15 United States Mail, postage prepaid, addressed to such party. 16 33. GOVERNING LAW 17 The parties agree, that for the purposes of venue, performance under this Agreement is 18 to be in Fresno County, California. 19 The rights and obligations of the parties and all interpretation and performance of this 20 Agreement shall be governed in all respects by the laws ofthe State of California. 21 34. ENTIRE AGREEMENT 22 This Agreement, including all Exhibits between the CONTRACTOR(S) and COUNTY 23 with respect to the subject matter hereof and supersedes all previous agreement negotiations, 24 proposals, commitments, writings, advertisements, publications, and understandings of any nature 25 whatsoever unless expressly included in this Agreement. 26 Ill 27 Ill 28 Ill -25 -COUN1Y OF FRESNO Fresno, CA 1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as ofthe day and 2 year first hereinabove written. 3 ATTEST: 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(S) PLEASE SEE EXHIBIT A, Attached hereto COUNTY OF FRESNO By~~~~~~~ruu~~~~ C airman, Board of Superviso BERNICE E. SEIDEL, Clerk Board of Supervisors Date: '('(\CCJ \ q ) aD fo PLEASE SEE ADDITIONAL SIGNATURE PAGES ATTACHED -26 - ' COUNTY OF FRESNO Fresno, CA APPROVED AS TO LEGAL FORM: DANIEL CEDERBORG, COUNTY COUNSEL By D<% APPROVED AS TO ACCOUNTING FORM: VICKI CROW, C.P.A., AUDITOR-CONTROLLER/ TREASURER-TAX COLLECTOR 1 2 3 4 5 6 7 8 9 By ------\;;::a~/?1--'----=-'~=----~----~--+.=--- 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 REVIEWED AND RECOMMENDED FOR APPROVAL: By ~l--~cft:J:- Dawan Utecht, Director Department of Behavioral Health Fund/Subclass: 0001/10000 Organization: 56304765 Account/Program: 7295/0 FY 2015-16 $325,000 FY 2016-17 $325,000 FY 2017-18 $325,000 FY 2018-19 $325,000 FY 2019-20 $325,000 -27 - PLEASE SEE ADDITIONAL SIGNATURE PAGES ATTACHED COUN'IY OF FRESNO Fresno,CA 1 2 3 4 FRESNO INTERDENOMINATIONAL REFUGEE MINISTRIES (FIRM) (c ----; ~ (.~ ______ ........... / By~~.., J 5 Print Name: ----z-;;;;;;;,S j:r..., s//l:JS 6 7 Title: Ciczt ~ ----~~~-------------- 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Chairman of the Board, or President, or any Vice President ,I -JJ iJ By {1!~- PrintName: Lr"'A<fa, a~ ..., r' Title: /1~ lJJ·.~fur Secretary (of Corporation), or any Assistant Secretary, or ChiefFinancial Officer, or any Assistant Treasurer Mailing Address: 1940 N. Fresno Street Fresno, CA 93703 Phone No.: (559) 487-1500 Contact: Zachary Darrah, Executive Director -28 - PLEASE SEE ADDITIONAL SIGNATURE PAGES COUNTY OF FRESNO Fresno, CA 1 FRESNO CENTER FOR NEW AMERICANS (FCNA) 2 3 4 6 7 8 9 10 11 12 13 14 By Title: JZ;ocYJ~ 41-es L J ~J- Chairman of the Board, or President, or any Vice President By _______:_=:_!Wtv--------'~-=---f--~-. -- 15 Print N~e: /{I r /f /8 V /?. V frl. 16 17 18 19 20 21 22 23 24 25 26 27 28 Title: ~tJ fJ'n b Tfl.. 1s n ~ o r< 1!:. /!. Secretary (of Corporation), or any Assistant Secretary, or Chief Financial Officer, or any Assistant Treasurer Mailing Address: , 4879 E. Kings Canyon Road Fresno, CA 93727 Phone No.: (559) 255-8395 Contact: Jeff Xiong, Program Director -29 - PLEASE SEE ADDITIONAL SIGNATURE PAGES ATTACHED COUNTY OF FRESNO Fresno, CA 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 2-8 ', SARBAT BHALA, INC Print Name: lti1?lf/t'fi:t#lf ~~ .. j}r/q L1~#L Title:&..r/~ Chairman of the Board, or President, or any Vice President By~Cu'L) Print Name: Aroand j p S 6 i 1 I Title: 'Ifeo5 \1«?,'( Secretary (of Corporation), or any Assistant Secretary, or ChiefFinancial Officer, or any Assistant Treasurer Mailing Address: 7 460 E. Floral A venue Selma, CA 93662 Phone No.: (559) 466-0013 Contact: Amandip S. Gill, Chief Financial Officer -30 - PLEASE SEE ADDITIONAL SIGNATURE PAGES ATTACHED COUNTY OF FRESNO Fresno, CA 1 WEST FRESNO FAMILY RESOURCE CENTER (WFFRC) 2 3 4 5 6 7 8 9 10 11 12 By YJuur Jd£ Print Name: JJ~ ~f- Title: Cklcnw4Lrl2~~£, Chairman of the Board, or President, or any Vice President 13 By~ 7J1j(_J 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Print Name: me!{s;so, /JJi ke"' I Title: ____:~..:::::.!__~~..::::±::---- Secretary (of Co oration), or any Assistant Secretary, or ChiefFinancial Officer, or any Assistant Treasurer Mailing Address: 1802 East California A venue Fresno, CA 93706 Phone No.: (559) 621-2962 Contact: Yolanda Randles, Program Director -31 -COUN1Y OF FRESNO Fresno,CA HORTICULTURAL THERAPEUTIC COMMUNITY CENTERS CONTRACTORS AND SITES I. Fresno Interdenominational Refugee Ministries (FIRM) 1940 N. Fresno Street, Fresno CA 93703 Site 1: Central Fresno, FIRM 1940 N. Fresno Street, Fresno, CA 93 703 Property Owner: FIRM No Lease Expense; 14 Acre Target Population: Hmong/Southeast Asian Site 2: Clovis, Memorial United Methodist Church 1726 Pollasky Avenue, Clovis CA, 93612 Property Owner: Memorial United Methodist Church Lease: $3 per year; % Acre; Operational Garden at Contract Signing Target Population: Hmong Site 3: Central Fresno, Mennonite Community Church 5015 E. Olive Avenue, Fresno, CA Property Owner: Mennonite Community Church Lease: $3 per year; % Acre; Operational Garden at Contract Sigding Target Population: Southeast Asian Site 4: East Fresno, 4005 E. Mono Avenue, Fresno, CA 93702 Property Owner: House of The Gospel Church Lease: No Cost; 500 sq ft Target Population: Slavic/Russian Immigrants Site 5: East Fresno, 4141 N. Fresno Street, Fresno CA 93 702 Property Owner: 4141 Ministries, a local 501©3 Lease: No Cost; 4,000 sq ft Target Population: African Refugees II. Fresno Center for New Americans (FCNA) 48779 E. Kings Canyon Road, Fresno, CA93727 Site 1: South-East Fresno, 11451 East Shields Avenue, Sanger, CA 93657 Property Owner: Mr. Pao Lee Lease: $2,000 per year; 5 Acres; existing farm land Target Population: Hmong III. Sarbat Bhala, Inc. 7460 E. Floral Avenue, Selma, CA 93662 Site 1: Southern Fresno County, 4250 Lincoln Avenue, Fresno CA 93725 Property Owner: The Sikh Temple-Gurudwara Nanak Prachar Lease: $300 per month; approximately 3 Acres Exhibit A Target Population: Punjabi-Sikh Communities of Selma, Fowler, Sanger and Parlier IV. West Fresno Family Resource Center 1802 E. California A venue, Fresno, CA 93 706 Site 1: 1802 E. California A venue, Fresno, CA 93 706 Property Owner: City of Fresno Lease: $1 per year; %Acre Target Population: African American, Hispanic, Veteran's and Homeless Exhibit A MENTAL HEALTH SERVICES ACT PREVENTION AND EARLY INTERVENTION HORTICULTURAL THERAPEUTIC COMMUNITY CENTERS SCOPE OF WORK CONTRACT SERVICES: Horticultural Therapeutic Community Centers CONTRACT TERM: July 1, 2015-June 30, 2020 CONTRACT SITES: See Exhibit A CONTRACTORS: See Exhibit A CONTRACTOR AWARDS: See Exhibit C CONTRACT MAXIMUM: PROJECT DESCRIPTION Fiscal Year 2015-16 2016-17 2017-18 2018-19 2019-20 Contract Maximum $325,000 $325,000 $325,000 $325,000 $325,000 ExhibitB Page 1 of9 The County of Fresno, on behalf of the Department of Behavioral Health (DBH), Mental Health Services Act (MHSA), Prevention and Early Intervention (PEl) component, is providing funding for the development of Horticultural Therapeutic Community Centers (HTCC) (community gardens) or to enhance existing community gardens as a platform for peer support, mental health delivery and engagement on matters that relate to mental well being and mental health services, and to deliver mental health PEl activities in traditionally and culturally relevant environments to un-served and underserved suburban and rural communities. Under this Master Agreement, DBH anticipates awarding additional contracts to ensure that the horticulture-based PEl community centers are developed in geographically dispersed locations of the County; thereby facilitating the universal outreach and delivery of mental health information to a variety of unserved and underserved communities. In addition, COUNTY encourages the ongoing collaboration of various community members and service providers to further facilitate the delivery of PEl and other mental health services and activities to those unserved and underserved throughout the County. This HTCC project includes: 1) The development of geographically dispersed community gardens, or enhance existing community gardens with a focus on universal mental health support/prevention and early intervention. Gardens shall be planned, developed and maintained to reflect the interests, cultural character and values of the targeted community members. Gardens may include ExhibitB Page 2 of9 customary fruits and vegetables, and/or may be ornamental or park-like in nature, such as a flower garden with walking paths, water and rock features, and sitting areas. 2) The provision of covered shelters at community garden sites: • As an informal meeting place and neighborhood resour¢e center for the delivery of mental health peer support services; . [ i • As a place for interaction and communication with Community Health Workers (CHW) and other formal/informal trusted individuals from the community· and I I • As a place for outreach and engagement of mental health related issues and other human service needs, as required of each community. [ i 3) The provision of a designated liaison(s) to fulfill the role of 'poordinator' for community garden sites and related mental health support activities to ;ensure integration of the garden, community members, and mental health peer suppprt services as identified by the California State approved Fresno County PEl plan, which i~ available at: 1 http://www.co.fresno.ca.us/uploadedFiles/Departments/Be~aviorai_Health/MHSA. TARGET POPULATION: Traditionally un-served, underserved and inappropriately serve,d communities targeted in this HTCC project include but are not limited to: 1 • American Indians in the eastern foothills and metropolitan areas of Fresno; • Southeast Asians in the central and southwest Fresno metropolitan area; • African American communities in the west Fresno metropolitan area; • Underserved Latino communities in west Fresno County; • Lesbian/Gay/Bisexuai/Transgender/Questioning (LGBTQ); and • Homeless, Veterans and destitute communities. Each CONTRACTOR shall: 1. Serve the target population and community as indicated by their respective proposals, and as identified on Exhibit A; and 2. Engage community members who remain unserved or underserved, and are thereby included in the designated target population. CONTRACTOR(S) RESPONSIBILITIES: The following guidelines are not all inclusive, and the order of implementation may not be as indicated herein. Each project will vary depending upon the development stage and resources available for each site from the beginning of, and throughout development. Final performance measures will be evaluated according to the progress made and completion of each component relative to each site. CONTRACTOR(S) SHALL: 1) Plan, develop and maintain a site, or sites, (identified on Exhibit A) as Horticultural Therapeutic Community Centers. Site planning, development and maintenance shall include, but may not be limited to the following: ExhibitB Page 3 of9 A. Secured rent/lease Agreement that includes pertinent information such as property ?Wner, rent/lease amount, lot size and location, and any limitations or expectations Imposed by the property owner. Copies of all related rent/lease agreements must be provided to the County of Fresno; B. Security measures, such as lighting, fencing, neighborhood watch, security patrol, etc.; C. Health and safety measures, such as parking, restroom facilities, potable water for drinking and washing/cleaning, janitorial/maintenance, garden waste/garbage, etc; D. Developing a map of the lot(s) layout, including area reserved for shelter. This should be done to scale showing the resulting size of the shelter and garden areas; E. Securing required resources, tools and equipment such as tractors, shovels, hoes, pruners, culturally traditional tools, and other equipment as necessary; F. Securing and documenting the use of consultants, their areas of expertise, and their contribution to the project; and G. Accessibility and transportation plans for the target community to be served. 2) Plan, develop and/or maintain a selected site(s) (as indicated in #1 above) for cultivating, planting and harvesting activities. This shall include, but may not be limited to the following: A. Clearing, leveling, adding or removing soil, tilling, fertilizing, etc.; B. Irrigation plans, including the purchase of necessary pipes, fittings, pumps, etc, and installation; C. Planning for and utilizing of environmentally sensitive features, i.e. green land use, drought tolerant plantings, composting, natural pest controls, water conservation, etc.; D. Crop selection (culturally relevant), seed/plant acquisitions, and planting; E. Ongoing maintenance of the garden, crop harvesting, and crop distribution; and F. Planning for and utilizing water resources in an environmentally responsible and conservative manner for long term garden sustainability. Planning should include water storage, drip irrigation, and other methods of irrigating with minimal loss to evaporation or run off. 3) Plan, develop and/or maintain selected site(s) (as indicated in #1 above) for the construction of a structurally sound covered shelter. The shelter shall be used for community gatherings where mental health information will be distributed and shared in a culturally sensitive and receptive environment. Shelters shall be developed and maintained to reflect the interests, cultural character and values of the targeted community members covered shelters shall include, but may not be limited to the following: A. Secured covering/roof-The shelter and covering must be secure and built in compliance with any/all relative government codes/regulations. The shelter/covering may include designs and/or variety of materials that are culturally relevant to the target community. The shelter may be enclosed, or partially enclosed, but this is not required; B. Solid/firm ground/flooring-May be dirt, brick, wood, tile, etc., but should be suitable for exposure to outdoor conditions; C. Seating for community group gatherings -May be folding chairs, portable benches, secured benches, etc. Tables are not required, but may be included; ExhibitB Page 4 of9 D. Kiosk or bulletin board for the placement, viewing, and distribution of mental health and other community information; and E. Shelters may be further developed and enhanced annually as funding and resources permit. 4) Ensure all services are provided in a culturally sensitive and competent manner. 5) Track costs and verify hours worked and billed to COUNTY for monthly invoicing. 6) Serve the target population and community as indicated by their respective proposals, and as identified on Exhibit A. 7) Obtain and report program statistics and outcome data as follows: A. Obtain data as identified in Exhibit M "Performance Measures", attached hereto and by this reference incorporated herein; B. Report data to Fresno County annually on Exhibit N "Performance Measures", attached hereto and by this reference incorporated herein; C. Report data on Quarterly Reports -State Exhibit 6 (Exhibits D and E), attached hereto and by this reference incorporated herein; D. Report data monthly to County on Exhibit 0 "Event Log and Performance Comparison", attached hereto and by this reference incorporated herein. Data collected shall be relevant to HTCC monthly activities and events, and relevant to client reported mental health and physical wellbeing status. These reports will be provided to COUNTY on a regular and reoccurring basis so as to determine program effectiveness over period of client's program participation. The tool currently in test phase to gather data is the Event Log and Performance Comparison spreadsheet (Exhibit 0). This tool and its effectiveness will be evaluated on an ongoing basis and enhanced based on user feedback and the needs of the County and communities served. The goal of this reporting tool is to provide outcome measures that more closely indicate HTCC program effectiveness; E. Other required reporting as requested to applicable local and State governing and oversight boards; and F. Data and performance reporting and documentation methods and tools are flexible working documents that may be adjusted or revised during the contract term to meet the changing needs of all parties concerned. 8) CONTRACTOR will develop a satisfaction survey, approved by DBH Division Manager or designee, which will comply with mandated State performance outcomes and quality improvement reports/outcomes (www.dmh.ca.gov/POQID. At a minimum, seventy-five percent (75%) of consumers will report, via the Consumer Oriented Report qard, their satisfaction with program services. A summary of of all consumer reports shall be provided to the COUNTY semi-annually. ' 9) Provide a designated liaison(s) to fulfill the role of 'coordinator' for community garden sites and related mental health support activities to ensure integration of the garden, community ExhibitB Page 5 of9 members, and mental health peer support services. The designated liaison/coordinator shall be knowledgeable about the cultures and communities in which they work and sensitive to and aware of multicultural issues. Liaison/Coordinator duties and responsibilities may include, but may not be limited to the following: A. Development and maintenance of positive communication and working relationships with HTCC site participants and other HTCCs; B. Posting, in the community's primary language(s), at each community site: 1. Schedule of Coordinator work hours and locations as applicable; 2. Schedule of Garden hours of operation; 3. Safety Rules and Regulations for Garden and Shelter operations; 4. Site Participant Conduct Rules, including smoking, drinking, discrimination, etc; 5. Rules and policies to encourage and maintain community participation in the actual gardening. Any and all rules and policies must be non-discriminatory; 6. A statement that ensures community access to any and all prevention and early intervention activities and/or services for which these community gardens are receiving MHSA support or enhancement resources; and 7. Emergency contact information for police, fire, ambulance, poison control, etc. C. Maintaining the kiosk and/or bulletin board with: 1. Current and relevant mental health informational materials in the community's primary language(s); 2. Current community Mental Health Resource Directory; 3. Planned and/or scheduled community activities, including traditional celebrations, guest speakers, etc to be hosted at the shelter site; and 4. All postings shall be in the primary language(s) of the community designated to serve. D. Coordinating mental health activities and informal gatherings at the shelter site to discuss and share mental health related issues specific to the community. Informational meetings/gatherings shall be with COUNTY staff, Community Mental Health Workers, community leaders and partners, Peer Support Specialists, faith- based organizations, and advocacy groups. E. Coordinating gardening activities and schedules among community members/families, including opening/closing the garden/shelter sites as scheduled. F. Outreach to, and engage community members who remain unserved or underserved, and are thereby included in the designated target population. PEl PERFORMANCE MEASURES: The following minimum performance measures (See Exhibit M) will be used for evaluating and reporting to the COUNTY, the effectiveness of its strategies and efforts to provide prevention and early intervention services. Individual Performance Measurements: • Decrease in suicide ideation; • Improved well being and hopefulness; • Increased community connectedness; • Increased social supports and reduced isolation; • Improved access to care and knowledge of care options; and • Increased skills in problem solving and help-seeking. Program/System Performance Measurements: Exhibit B Page 6 of9 • Increase in number of prevention and early intervention activities that are directed at culture-specific communities who are un-served and underserved; and • Increase in number of individuals/families who receive prevention and early intervention services and who are from un-served and underserved cultural, ethnic, racial, and linguistic communities, including rural areas of Fresno County. Long Term Community Performance Measurements: • Increase in cultural competency and in the understanding that there is no one-size- fits-all model for delivery of prevention and early intervention strategies for mental health illness; • Reduction in stigmatizing attitudes towards mental health illness and suicide; and • Earlier access to mental health treatment and services for un-served and underserved cultural, ethnic, racial, and linguistic communities. HTCC PERFORMANCE REPORTING REQUIREMENTS: Measuring performance may change considerably in the first years of operation, depending on the initial resources available and progress made on each component or phase of site development, including: shelter development, land preparation and planting, and Coordinator/Liaison duties and responsibilities. For example, a proposal may include an existing operational garden but lacks a covered structure; another may have a shelter, but no garden; and another proposed project may be starting from vacant unused land. Each of these would develop at different rates; therefore, the measureable performances in the first years would measure differently. Performance status reports shall be provided by the designated site coordinator/liaison to the MHSA Analyst on the 1oth of each month for the prior report month, unless otherwise stated. Performance reports, in addition to the PEl minimum performance measures identified above, shall include, but not be limited to the following: • Community garden/land development progress, maintenance and plans for future development; • Covered shelter development progress, including maintenance and repairs and plans for future shelter enhancements; • General site development, maintenance and security, including parking and lighting; • Activities held and planned that address mental health concerns of the community; • Target population/community involvement and issues addressed/to be addressed; ExhibitB Page 7 of9 • <?ollaborations with community mental health service providers, including activities, linkage for mental health services, etc; • • Funding and other resources sought and/or obtained for program development and sustainability; and Liaison/coordinator scheduled and hours worked . Documentation shall include, but may not be limited to the following: • Receipts and other verification (site audit, pictures, produce) that materials purchased and used are resulting in community garden and covered shelter as contracted; • Reports and/or surveys from community members; • Numbers and types of activities promoting mental health outreach and engagement; • Number of participants, including the target populations represented; • Names and contact information for partnering community agencies that have provided services on site or via referrals/linkages, including a description of the on- site outreach/engagement service provided; • Issues and barriers to mental health wellness and recovery that are identified and/or resolved; • Numbers and types of support services provided to promote community involvement, such as translation, transportation, incentives, etc.; and • Numbers and types of linkages/referrals to mental health services, etc. Proposed and recommended performance measures may be reviewed for input and approval by a designated Department of Behavioral Health work group upon contract execution. The purpose of this input process is to ensure a comprehensive system wide approach to the evaluation of programs through an effective performance reporting process. Funding Awarded funds must be used for the specific property(s) as indicated on Exhibit A. Funding will vary based on each CONTRACTORS cost proposals, project design, and resources available at each site (existing operational garden; existing shelter, existing irrigation, etc). It is expected that the percentage of funding designated for the shelter and the garden will vary from year to year as the project progresses from the initial development stage into ongoing maintenance. For example, to build a new shelter it is expected that a higher percentage of funds may be used in the first term of the contract, but may be considerably reduced in subsequent years to provide maintenance of the shelter. Or, if there is an existing shelter, it may be that a larger percentage of funds would be allocated to developing the land in the first term. Funding shall not be used for land acquisition/purchase. COUNTY RESPONSIBILITIES: COUNTY SHALL: Exhibit B Page 8 of9 1) Provide oversight, support, coordination, authorization and ongoing monitoring of HTCCs. 2) Provide evaluation and response to HTCC proposals for additional sites and/or CONTRACTORS within thirty (30) calendar days of receipt. 3) Notify CONTRACTORS of their responsibilities through DBH letters and other written communications, conferences, formal and informal trainings and individual consultation. 4) Provide individual consultation on a regular basis and facilitate monthly meetings of all HTCC CONTRACTORS. 5) Provide oversight (through the County Department of Behavioral Health (DBH), Adult System of Care, and the MHSA, Division Manager or designee) of the CONTRACTOR's program. In addition to contract monitoring of program, oversight includes, but not limited to, coordination with the State Department of Mental Health, MHSA PEl in regard to program administration and outcomes. 6) Assist the CONTRACTOR in making linkages with the total mental health system. This will be accomplished through regularly scheduled meetings as well as formal and informal consultation. 7) Participate in evaluating the performance and progress of the overall program and the efficiency of collaboration with the CONTRACTOR staff and will be available to the contractor for ongoing consultation. 8) Receive and analyze statistical performance data information from vendor throughout the term of contract on a monthly basis. DBH will notify the vendor when additional participation is required. The performance measurement process will not be limited to survey instruments but will also include, as appropriate, client and staff interviews, chart reviews, and other methods of obtaining required information. 9) Recognize that cultural competence is a goal toward which professionals, agencies, and systems should strive. Becoming culturally competent is a developmental process and incorporates at all levels the importance of culture, the assessment of cross-cultural relations, vigilance towards the dynamics that result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to meet culturally-unique needs. Offering those services in a manner that fails to achieve its intended result due to cultural and linguistic barriers is not cost effective. To assist the vendor efforts towards cultural and linguistic competency, DBH shall provide the following at no cost to vendor(s): A. Technical assistance to vendor regarding cultural competency requirements and sexual orientation training; and B. Mandatory cultural competency training including sexual orientation and sensitivity training for DBH and vendor personnel, at minimum once per year. COUNTY will provide mandatory training regarding the special needs of this diverse population and will be included in the cultural competence training(s). Sexual orientation and sensitivity to gender differences is a basic cultural competence principle and shall be included in the cultural competency training. Literature suggests that the mental Exhibit B Page 9 of9 health needs of lesbian, gay, bisexual, transgender (LGBT) individuals may be at increased risk for mental disorders and mental health problems due to exposure to societal stressors such as stigmatization, prejudice and anti-gay violence. Social support may be critical for this population. Access to care may be limited due to concerns about providers' sensitivity to differences in sexual orientation. Exhibit C · MHSA PEl Horticultural Therapeutic Community Centers FRESNO INTERDENOMINATIONAL REFUGEE SERVCIES (FIRM) PREVENTION AND EARLY INTERVENTION BUDGET (PEl) FY 2015-16 Page 1 of6 Budget Categories -Total Proposed Budget Line Item Description (Must be itemized) FTE% Admin. Direct Total PERSONNEL SALARIES: 0001 Therapeutic Centers Coordinator (5 gardens) 35% 0 12,558 12,558 0002 Project Director 60% 0 21,840 21,840 0003 Project Director-African Refugee Garden 25% 0 8,320 8,320 0003 Executive Director 7% 4,340 0 4,340 0012 Title 0.00 0 0 0 SALARY TOTAL 1.27 $4,340 $42,718 $47,058 PAYROLL TAXES: 0030 OASDI 0 0 0 0031 FICA/MEDICARE 332 3,268 3,600 0032 SUI 30 521 551 PAYROLL TAX TOTAL $362 $3,789 $4,151 EMPLOYEE BENEFITS: 0040 Retirement 0 0 0 0041 Workers Compensation 41 402 443 0042 Health Insurance (medical, vision, life, dental) 294 5,334 5,628 EMPLOYEE BENEFITS TOTAL $335 $5,736 $6,071 SALARY &BENEFITS GRAND TOTAL $57,280 FACILITIES/EQUIPMENT EXPENSES· 1010 Office Space Rent 1,060 1011 Irrigation Water 6,000 1012 Rent/Lease Equipment (@$300 ea/5 gardens) 1,500 1013 Utilities ($360 yr/garden x 5) 1,800 1014 Equipment purchase (@$1 DO/garden x 4) 500 1015 FACILITY/EQUIPMENT TOTAL $10,860 OPERATING EXPENSES: 1060 Phone ($80/mo; incl Yz for cell/land line) 1,184 1061 Sub-Contract 0 1062 Postage 0 1063 Printing/Reproduction ($20/mo) 240 1064 Publications 0 1065 Legal Not/Advertising ($150 x 4 Hmng Rad/TV) 600 1066 Office Supplies & Equipment ($100 mo) 600 1067 Household Supplies 0 Exhibit C . - 1068 Security ($50/garden x 5) 1069 Program Supplies-Therapeutic (MH Training) 1070 Grading, Leveling, Trenching, etc 1071 Transport of Clients (.51/mile x 40 x 12 mos) 1072 Staff Mileage (.51/mile x 150 x 50 wks) 1073 Equipment/Supplies-tools, stakes, etc 1 07 4 Ground Materials -soil, fertilizers, pesticides etc 1075 Shelter Maintenance ($200/ x5 gardens) 1076 Irrigation Supplies 1 077 Plant Materials -seeds, starter plants, etc OPERATING EXPENSES TOTAL FINANCIAL SERVICES EXPENSES· 1080 Accounting/Bookkeeping 1081 External Audit 1082 Liability Insurance 1083 Administrative Overhead 1084 Payroll Services 1085 Professional Liability Insurance FINANCIAL SERVICES TOTAL SPECIAL EXPENSES (Consultant/Etc.): 1090 Consultant 1091 Translation Services 1092 Community Incentives 1093 SPECIAL EXPENSES TOTAL FIXED ASSETS· 1190 Shelter Development (African Refugee Garden) 1191 Security Fencing 1192 1193 FIXED ASSETS TOTAL FIRM FY 2015-16 TOTAL PROGRAM EXPENSES PER FY PROGRAM REVENUE· 5000 PEl Funds 5100 CSS Funds MHSA FUNDS TOTAL FIRM FY 2015-16 TOTAL PROGRAM REVENUE PER FY Page 2 of6 250 500 500 414 4,312 750 1,500 1,000 2,000 800 $14,650 6,000 1,000 600 10,816 0 0 $18,416 0 0 4,000 $4,000. 10,000 20,000 0 $30,000 $135,206 135,206 $0 $0 $135,206 Exhibit C __ __ Page 3 of6 MHSA PEl Horticultural Therapeutic Community Centers FRESNO INTERDENOMINATIONAL REFUGEE SERVCIES (FIRM) PREVENTION AND EARLY INTERVENTION BUDGET (PEl) FY 2016-17 Budget Categories -Total Proposed Budget Line Item Description (Must be itemized) FTE% Admin. Direct Total PERSONNEL SALARIES: 0001 Therapeutic Centers Coordinator (5 gardens) 35% 0 12,558 12,558 0002 Project Director 60% 0 21,840 21,840 0003 Project Director-African Refugee Garden 25% 0 8,320 8,320 0003 Executive Director 7% 4,340 0 4,340 0012 Title 0.00 0 0 0 SALARY TOTAL 1.27 $4,340 $42,718 $47,058 PAYROLL TAXES: 0030 OASDI 0 0 0 0031 FICNMEDICARE 332 3,268 3,600 0032 SUI 30 521 551 PAYROLL TAX TOTAL $362 $3,789 $4,151 EMPLOYEE BENEFITS: 0040 Retirement 0 0 0 0041 Workers Compensation 41 402 443 0042 Health Insurance (medical, vision, life, dental) 294 5,334 5,628 EMPLOYEE BENEFITS TOTAL $335 $5,736 $6,071 SALARY & BENEFITS GRAND TOTAL $57,280 FACILITIES/EQUIPMENT EXPENSES· 1010 Office Space Rent 1,060 1011 Irrigation Water 12,000 1012 Rent/Lease Equipment (@$300 ea/5 gardens) 1,500 1013 Utilities ($360 yr/garden x 5) 1,800 1014 Equipment purchase (@$100/garden x 4) 500 1015 FACILITY/EQUIPMENT TOTAL $16,860 OPERATING EXPENSES: 1060 Phone ($80/mo; incl% for cell/land line) 1,200 1061 Sub-Contract 0 1062 Postage 0 1063 Printing/Reproduction ($20/mo) 240 1064 Publications 0 1065 Legal Not/Advertising ($150 x 4 Hmng Rad/TV) 600 1066 Office Supplies & Equipment ($100 mo) 1,200 1067 Household Supplies 0 Exhibit C 1068 Security ($50/garden x 5) 1069 Program Supplies-Therapeutic (MH Training) 1070 Grading, Leveling, Trenching, etc 1071 Transport of Clients (.51/mile x 40 x 12 mas) 1072 Staff Mileage (.51/mile x 150 x 50 wks) 1073 Equipment/Supplies-tools, stakes, etc 1074 Ground Materials -soil, fertilizers, pesticides etc 1075 Shelter Maintenance ($200/ x5 gardens) 1076 Irrigation Supplies 1077 Plant Materials-seeds, starter plants, etc OPERATING EXPENSES TOTAL FINANCIAL SERVICES EXPENSES· 1080 Accounting/Bookkeeping 1081 External Audit 1082 Liability Insurance 1083 Administrative Overhead 1084 Payroll Services 1085 Professional Liability Insurance FINANCIAL SERVICES TOTAL SPECIAL EXPENSES (Consultant/Etc.): 1090 Consultant 1091 Translation Services 1092 Community Incentives 1093 Quarterly Events/Outreach 1094 Lead Gardener Stipends SPECIAL EXPENSES TOTAL FIXED ASSETS· 1190 Shelter Development 1191 Security Fencing 1192 Shelter Signage 1193 FIXED ASSETS TOTAL FIRM FY 2016-17 TOTAL PROGRAM EXPENSES PER FY PROGRAM REVENUE· 5000 PEl Funds 5100 CSS Funds MHSA FUNDS TOTAL FIRM FY 2016-17 TOTAL PROGRAM REVENUE PER FY Page 4 of6 250 1,000 1,000 414 4,312 1,500 1,500 1,000 2,000 1,000 $17,216 6,000 1,000 600 15,941 0 0 $23,541 0 0 5,000 5,509 4,800 $15,309 0 0 5,000 0 $5,000 $135,206 135,206 $0 $0 $135,206 Exhibit C ... MHSA PEl Horticultural Therapeutic Community Centers FRESNO INTERDENOMINATIONAL REFUGEE SERVCIES (FIRM) PREVENTION AND EARLY INTERVENTION BUDGET (PEl) FY 2017-18 Through FY 2019-20 Page 5 of6 Budget Categories -Total Proposed Budget Line Item Description (Must be itemized) FTE% Admin. Direct Total PERSONNEL SALARIES: 0001 Therapeutic Centers Coordinator (5 gardens) 35% 0 12,558 12,558 0002 Project Director 60% 0 21,840 21,840 0003 Project Director-African Refugee Garden 25% 0 8,320 8,320 0003 Executive Director 7% 4,340 0 4,340 0012 Title 0.00 0 0 0 SALARY TOTAL 1.27 $4,340 $42,718 $47,058 PAYROLL TAXES: 0030 OASDI 0 0 0 0031 FICA/MEDICARE 332 3,268 3,600 0032 SUI 30 521 551 PAYROLL TAX TOTAL $362 $3,789 $4,151 EMPLOYEE BENEFITS: 0040 Retirement 0 0 0 0041 Workers Compensation 41 402 443 0042 Health Insurance (medical, vision, life, dental) 294 5,334 5,628 EMPLOYEE BENEFITS TOTAL $335 $5,736 $6,071 SALARY & BENEFITS GRAND TOTAL $57,280 FACILITIES/EQUIPMENT EXPENSES· 1010 Office Space Rent 1,060 1011 Irrigation Water 12,000 1012 Rent/Lease Equipment (@$300 ea/5 gardens) 1,500 1013 Utilities ($360 yr/garden x 5) 1,800 1014 Equipment purchase (@$1 DO/garden x 4) 1,500 1015 FACILITY/EQUIPMENT TOTAL $17,860 OPERATING EXPENSES: 1060 Phone ($80/mo; inc! %for cell/land line) 1,200 1061 Sub-Contract 0 1062 Postage 0 1063 Printing/Reproduction ($20/mo) 240 1064 Publications 0 1065 Legal Not/Advertising ($150 x 4 Hmng Rad/TV) 600 1066 Office Supplies & Equipment ($100 mo) 1,200 1067 Household Supplies 0 Exhibit C ·-. ~--,~; 1068 Security ($50/garden x 5) 1069 Program Supplies-Therapeutic (MH Training) 1070 Grading, Leveling, Trenching, etc 1071 Transport of Clients (.51/mile x 40 x 12 mos) 1072 Staff Mileage (.51/mile x 150 x 50 wks) 1073 Equipment/Supplies-tools, stakes, etc 107 4 Ground Materials -soil, fertilizers, pesticides etc 1075 Shelter Maintenance ($200/ x5 gardens) 1076 Irrigation Supplies 1 077 Plant Materials -seeds, starter plants, etc OPERATING EXPENSES TOTAL FINANCIAL SERVICES EXPENSES· 1080 Accounting/Bookkeeping 1081 External Audit 1082 Liability Insurance 1083 Administrative Overhead 1084 Payroll Services 1085 Professional Liability lns~.:~rance FINANCIAL SERVICES TOTAL SPECIAL EXPENSES (Consultant/Etc.): 1090 Consultant 1091 Translation Services 1092 Community Incentives 1093 Quarterly Events/Outreach 1094 Lead Gardener Stipends SPECIAL EXPENSES TOTAL FIXED ASSETS· 1190 Shelter Development 1191 Security Fencing 1192 Shelter Signage 1193 Furniture & Fixtures FIXED ASSETS TOTAL FIRM FY 2017-18 Through FY 2019-20 TOTAL PROGRAM EXPENSES PER FY PROGRAM REVENUE· 5000 PEl Funds 5100 CSS Funds MHSA FUNDS TOTAL FIRM FY 2017-18 Through FY 2019-20 TOTAL PROGRAM REVENUE PER FY Page 6 of6 250 1,000 1,500 414 4,312 1,500 1,500 2,500 2,000 1,000 $19,216 6,000 1,000 600 15,941 0 0 $23,541 0 0 5,000 6,840 4,800 $16,640 0 0 0 669 $669 $135,206 135,206 $0 $0 $135,206 Exhibit C MHSA PEl Horticultural Therapeutic Community Centers FRESNO CENTER FOR NEW AMERICANS PREVENTION AND EARLY INTERVENTION BUDGET FY 2015-16 through FY 2019-20 Page 1 of2 Budget Categories -Total Proposed Budget Line Item Description (Must be itemized) FTE% Admin. Direct Total PERSONNEL SALARIES: 0001 Project Director ($45k @ 1 0% FTE) .10 4,500 4,500 . 0002 Site Coordinator/Liaison ($35k @ 20% FTE) .20 7,000 7,000 0003 Gardener/Support Staff ($22k @ 50% FTE) '.50 11,439 11,439 SALARY TOTAL .80 $0 $22,939 $22,939 PAYROLL TAXES: 0030 OASDI 0 0 0 0031 FICA/MEDICARE (@7.65%) 0 1,755 1,755 0032 SUI 0 405 405 PAYROLL TAX TOTAL $0 $2,160 $2,160 EMPLOYEE BENEFITS: 0040 Retirement(@ 3%) 0 345 345 0041 Workers Compensation (@1.20%) 0 229 229 0042 Health Insurance (medical, vision, life, dental) 0 1,980 1,980 EMPLOYEE BENEFITS TOTAL $0 $2,554 $2,554 SALARY & BENEFITS GRAND TOTAL $27,653 FACILITIES/EQUIPMENT EXPENSES· 1010 Rent/Lease Land 2,000 1011 Rent/Lease Equipment (2 Restroom Facilities) 840 1012 Utilities 1,800 1013 Shelter Development/Maintenance 200 1014 lrriqation Water 0 FACILITY/EQUIPMENT TOTAL $4,840 OPERATING EXPENSES: 1060 Telephone 0 1061 Answering Service 0 1062 Postage 0 1063 Printing/Reproduction 0 1064 Publications 0 1065 Legal Notices/Advertising 0 1066 Office Supplies & Equipment 0 1067 Household Supplies 0 1068 Food 0 1069 Program Supplies -Therapeutic 0 Exhibit C. 1070 Program Supplies -Medical 1071 Transportation of Clients 1 072 Staff Mileage/vehicle maintenance 1073 Staff Travel (Out of County) 1074 Equipment/Supplies-tools, stakes, wire, etc 1075 Ground Material 1076 Irrigation Supplies 1077 Grading I Leveling I Trenching OPERATING EXPENSES TOTAL FINANCIAL SERVICES EXPENSES· 1080 Accounting/Bookkeeping 1081 External Audit 1082 Liability Insurance 1083 Administrative Overhead 1084 Payroll Services 1085 Professional Liability Insurance FINANCIAL SERVICES TOTAL SPECIAL EXPENSES (Consultant/Etc.): 1090 Consultant 1091 Translation Services 1092 Medication Supports SPECIAL EXPENSES TOTAL FIXED ASSETS· 1190 Computers & Software 1191 Furniture & Fixtures 1192 Other-(Identify) 1193 Other-(Identify) FIXED ASSETS TOTAL FY 2015-16 through FY 2019-20 TOTAL PROGRAM EXPENSES PER FY MHSA FUNDS· 5000 PEl Funds 5100 CSS Funds MHSA FUNDS TOTAL FY 2015-16 through FY 2019-20 TOTAL PROGRAM REVENUE PER FY Page 2 of2 0 4,500 1,680 0 2,765 500 0 500 $9,945 0 750 500 5,000 0 0 . 6,250 0 0 0 0 0 0 0 0 $0 $48,688 48,688 0 $48,688 $48,688 / Exhibit C .. MHSA PEl Horticultural Therapeutic Community Centers SARBAT BHALA, INC. PREVENTION AND EARLY INTERVENTION BUDGET FY 2015-16 through FY 2019-20 Page 1 of2 Budget Categories -Total Proposed Budget Line Item Description (Must be itemized) FTE% Admin. Direct Total PERSONNEL SALARIES: 0001 Project Director 0 0 0002 Site Coordinator 13,000 16,500 0003 Liaison (Peer Support) 11,000 12,500 0012 SALARY TOTAL 0.00 $0 24,000 29,000 PAYROLL TAXES: 0030 OASDI 0 0 0 0031 FICA/MEDICARE 0 1,836 2,136 0032 SUI 0 1,488 1,688 PAYROLL TAX TOTAL $0 3,324 3,824 EMPLOYEE BENEFITS: 0040 Retirement 0 0 0 0041 Workers Compensation 0 480 480 0042 Health Insurance (medical, vision, life, dental) 0 0 0 EMPLOYEE BENEFITS TOTAL $0 480 480 SALARY & BENEFITS GRAND TOTAL $33,304 FACILITIES/EQUIPMENT EXPENSES· 1010 Rent/Lease Land 800 1011 Utilities 400 1012 Shelter Development/Maintenance 250 1013 Rent/Lease Equipment 250 1014 Equipment Purchase 0 1015 Water (Irrigation) 350 1016 Other-Bathroom/Washing Station 450 FACILITY/EQUIPMENT TOTAL $2,500 OPERATING EXPENSES: 1030 Phone 550 1031 Printing/Reproduction/Postage/Publications 384 1032 Office Supplies 315 1033 Legal Notices/Advertising 0 1034. Transportation of Clients 2,000 1035 Staff MileageNehicle Maintenance 0 1036 Ground Material-top soil, fertilizers, pesticides 400 Exhibit C 1037 Mise EquipmenUSupplies-tools, stakes, etc 1038 Grading/Leveling/Trenching 1039 Security-fencing, patrol, lighting, etc 1040 Irrigation Supplies 1 041 Plant Materials -seed starter plants, etc 1042 1043 OPERATING EXPENSES TOTAL FINANCIAL SERVICES EXPENSES· 1060 Accounting/Bookkeeping 1061 External Audit 1062 Liability Insurance 1063 Administrative Overhead 1064 Payroll Services 1065 Professional Liability Insurance FINANCIAL SERVICES TOTAL SPECIAL EXPENSES (ConsultanUEtc.): 1070 Consultant 1071 Translation Services 1072 Community Incentives SPECIAL EXPENSES TOTAL FIXED ASSETS· - 1080 Shelter Development 1081 Furniture & Fixtures 1082 Security Fencing 1083 Other-(Identify) FIXED ASSETS TOTAL SARBAT FY 2015-16 through FY 2019-20 TOTAL PROGRAM EXPENSES PER FY PROGRAM REVENUE· 2000 PEl Funds 2001 CSS Funds MHSA FUNDS TOTAL SARBAT FY 2015-16 through FY 2019-20 TOTAL PROGRAM REVENUE PER FY Page 2 of2 400 0 0 450 0 0 0 $4,499 700 0 550 345 0 0 $1,595 0 0 0 $0 0 0 0 0 $0 $41,898 41,898 $0 41,898 $41,898 Exhibit C - . . . , " :: MHSA PEl Horticultural Therapeutic Community Centers West Fresno Family Resource Center PREVENTION AND EARLY INTERVENTION BUDGET (PEl) FY 2015-16 Through FY 2019-20 Page 1 of2 Budget Categories -Total Proposed Budget Line Item Description (Must be itemized) FTE% Admin. Direct Total PERSONNEL SALARIES: 0001 Therapeutic Centers Coordinator 45% 12,600 12,600 0002 Therapeutic Center Helper 15% 0 1,500 1,500 0003 Co-Interim Director 0% 0 0 0 0012 Title 0.00 0 0 0 SALARY TOTAL 0.00 $0 $14,100 $14,100 PAYROLL TAXES: 0030 OASDI 0 0 874 0031 FICNMEDICARE 0 0 204 0032 SUI 0 0 874 0033 CA Employment Training 0 0 14 PAYROLL TAX TOTAL $0 $0 $1,966 EMPLOYEE BENEFITS: 0040 Retirement 0 0 0 0041 Workers Compensation 0 0 141 0042 Health Insurance (medical, vision, life, dental) 0 0 0 EMPLOYEE BENEFITS TOTAL $0 $0 $141 SALARY & BENEFITS GRAND TOTAL $16,207 FACILITIES/EQUIPMENT EXPENSES· 1010 Office Space Rent 0 1011 Irrigation Water ($144mo/1 ,728yr x 4 gardens) 0 1012 RenULease Equipment (@$400 ea/4 gardens) 0 1013 Utilities ($360 yr/garden x 4) 0 1014 Equipment purchase (@$100/garden x 4) 0 1015 FACILITY/EQUIPMENT TOTAL $0 OPERATING EXPENSES: 1060 Phone ($80/mo; incl% for cell/land line) 0 1061 Sub-Contract 0 1062 Postage 0 1063 Printing/Reproduction ($20/mo) 200 1064 Publications 0 1065 Legal NoUAdvertising ($150 x 4 Hmng Rad/TV) 0 1066 Office Supplies & Equipment ($100 mo) 150 1067 Household Supplies 0 1068 1069 1070 1071 1072 1073 1074 1075 1076 1077 Security ($50/garden x 5) Program Supplies-Therapeutic (MH Training) Grading, Leveling, Trenching, etc Transport of Clients (.51/mile x 40 x 12 mos) Staff Mileage (.51/mile x 150 x 50 wks) EquipmenUSupplies-tools, stakes, etc Ground Materials -soil, fertilizers, pesticides etc Shelter Maintenance ($300/ x4 gardens) Irrigation Supplies Plant Materials -seeds, starter plants, etc OPERATING EXPENSES TOTAL FINANCIAL SERVICES EXPENSES· 1080 Accounting/Bookkeeping 1081 External Audit 1082 Liability Insurance 1083 Administrative Overhead 1084 Payroll Services 1085 Professional Liability Insurance FINANCIAL SERVICES TOTAL SPECIAL EXPENSES (ConsultanUEtc.): 1090 CSUF Interns 1091 Educational Workshops 1092 Community Incentives SPECIAL EXPENSES TOTAL FIXED ASSETS· 1190 Shelter Development 1191 Furniture & Fixtures 1192 Security Fencing 1193 Computers & Software FIXED ASSETS TOTAL Exhibit C : _ _ ':!_ Page 2 of2 0 0 0 0 0 0 0 0 0 200 $550 1,200 0 0 0 0 0 $1,200 2,250 637 0 $2,887 2,500 0 0 0 $2,500 WFFRC FY 2015-16 Through FY 2019-20 TOTAL PROGRAM EXPENSES PER FY $23,344 PROGRAM REVENUE· 5000 PEl Funds 23,344 5100 CSS Funds $0 MHSA FUNDS TOTAL $0 WFFRC FY 2015-16 Through FY 2019-20 TOTAL PROGRAM REVENUE PER FY $23,344 Exhibit D Estimated/Actual Population Served Exhibit E State Exhibit 6 -Quarterly Report Page 1 of 3 Current Quarterly Progress Report Process Overview Current Regulations (Note: HTCCs are not FSPs; however, this reporting structure will be utilized to track consumers served): Title 9, Division 1, Chapter 14, Article 5: Quarterly Progress Reports must be submitted to the State Department of Mental Health no later than 60 days following the end of each reporting quarter and are compiled by service category for each approved program and/or service. The following information must be included in the Quarterly Progress Report: • The targeted number of individuals or families to be served in each reporting quarter by each program/service during the quarter • The total number of individuals or families actually served in each reporting quarter by each program/service during the quarter • The final Quarterly Progress Report must include the total number of unduplicated individuals or families served by each program/service during the fiscal year Following is a review of how to calculate individuals served within each service category (Full Service Partnerships, System Development and Outreach and Engagement). Quarterly Counts: The quarterly count is unduplicative within quarters but is duplicative between quarters. The number of actual individuals served equals: the total number of individuals or families enrolled in the program on the first day of each quarter plus any individuals or families newly enrolled throughout the quarter. Example: Explanation: Q1: At the beginning of Quarter 1, 10 people were enrolled and 10 people were newly enrolled throughout the quarter, so the total actual served for Quarter 1 would equal 20 (1 0 + 10 = 20). Q2: At the beginning of Quarter 2, 20 people were currently enrolled and 5 more people were newly enrolled, so the total actual served would equal 25 (20 + 5 = 25). Exhibit E State Exhibit 6 -Quarterly Report Page 2 of 3 Q3: At the beginning of Quarter 3, 20 people were currently enrolled and 7 more people were newly enrolled throughout the quarter, so the total actual served would equal 27 (20 + 7 = 27). (Five people disenrolled the previous quarter, so on the first day of Quarter 3, 20 people were currently enrolled.) Q4: At the beginning of Quarter 4, 26 people were currently enrolled because one had disenrolled during Quarter 3, but 5 had been newly enrolled so the total actual served of 31 (26 + 5 = 27) Quarterly targets: The quarterly target is an estimate of the total number of individuals you expect to serve for that quarter. Targeted counts should follow the same strategy as for actual counts described above. Unduplicated Annual Counts: The unduplicated annual count: Equals the total number of people served for the entire year. Example: 10 10 cated Actual Served 20 0 Q1: At the beginning of Quarter 1, 10 people were enrolled and 1 0 people were newly enrolled throughout the quarter, so the total unduplicated for Quarter 1 would · equal20 (10 + 10 = 20). Q2: At the beginning of Quarter 2, 20 people were currently enrolled and 5 more people were newly enrolled, so the total unduplicated for quarter 2 would be 5. Q3: At the beginning of Quarter 3, 20 people were currently enrolled and 7 more people were newly enrolled throughout the quarter, so the total unduplicated for quarter 3 would be 7. Q4: At the beginning of Quarter 4, 26 people were currently enrolled and 5 had been newly enrolled so the total unduplicated for quarter 4 would be 5. Total Unduplicated Annual Actual Served: 20 + 5 + 7 + 5 = 37 Total Unduplicated Annual Targets: The unduplicated annual target is an estimate of the total number _of unduplicated individuals you expect to serve annually, Exhibit E State Exhibit 6 -Quarterly Report Page 3 of 3 Options for Improving the MHSA Quarterly Progress Reporting Process Outreach and Engagement: There are many different methods of providing outreach and engagement services. Some services are offered in a group or community wide forum and sometimes services are offered individually. Ideally, it would be helpful to have a combination of service based and individual level data collection that is submitted on a quarterly basis. Potential Methods for reporting counts in these service categories: Categories could be created based on the nature of the services provided. There are two very broad categories of services and they could be reported differently based on these categories: For instance: Community Forum Outreach and Engagement Activities: When conducting a community forum activity such as a county-wide presentation to a group of people about a mental health issue, a count of the number of presentations and the number of individuals that attended could be submitted. Some indication of the purpose of each event would also be helpful. For instance, broad categories such as education, workforce development, stigma reduction or outreach to engage in services could be indicated. Individual Outreach and Engagement Services: When conducting outreach and engagement services to individuals, you may have multiple contacts with an individual prior to engaging them into services. Counting the number of contacts rather than the number of individuals would provide more accurate information regarding individual services. In addition, some demographic information regarding the individuals receiving ser\iices within these categories would be helpful including gender, age and race/ethnicity. In addition, information regarding the number of face-to-face contacts vs. phone contacts would also be useful. System Development: There are many types of services provided through this category. Some services maybe offered in .a group or community wide forum and some services may be offered to individuals and families. In addition, some services center around linkage with other community based organizations. Should the services be categorized similar to what has been proposed for Outreach and Engagement or should there be different categories for System Development services? Exhibit F 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 ofFederal Regulations sections 2.1 et seq; California Welfare and Institutions Code, sections 14-100.2, 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 ofthe 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, sex, color, disability, medical condition, national origin, race, ancestry, marital status, religion, religious creed, political belief or sexual preference be excluded from participation, be denied benefits of, or be subject to discrimination under any program or activity receiving Federal or State of California assistance. B. Employment Opportunity CONTRACTOR shall comply with COUNTY policy, and the Equal Employment Opportunity Commission guidelines, which forbids discrimination against any_ person on the grounds of race, color, national origin, sex, religion, age, disability status, or sexual preference in employment practices. Such practices include retirement, recruitment advertising, hiring, layoff, termination, upgrading, demotion, transfer, rates of pay or other forms of compensation, use of facilities, and other terms and conditions of employment. 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 Exhibit F 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. 5 6 7 8 9 10 11 12 13 . 14 Vendor: Exhibit G Contract# Contact Person Contact# Header Header Header Header Header Header a b c d e f g h i j k l m FIXED ASSET AND SENSITIVE ITEM TRACKING Vendor Program Contract # Contact Person Contact # Date Prepared Item Make/Brand Model Serial # Fixed Asset name provide services. Indicate the title of the project as described in the contract with the County. Indicate the assigned County contract number. If not known, County staff can provide. Indicate the first and last name of the primary agency contact for the contract. Indicate the most appropriate telephone number of the primary agency contact for the contract. Indicate the most current date that the tracking form was completed by the vendor. Identify the item by providing a commonly recognized description of the item. Identify the company that manufactured the item. Identify the model number for the item, if applicable. Identify the serial number for the item, if applicable. Mark the box with an "X" if the cost of the item is $5,000 or more to indicate that the item is a fixed asset. Mark the box with an "X" if the item meets the criteria Sensitive Item of a sensitive item as defined by the County. Indicate the date that the agency submitted a request Date Requested to the County to purchase the item. Date Approved Purchase Date Location Condition Fresno County Inventory Number Cost Indicate the date that the County approved the request to purchase the item. Indicate the date the agency purchased the item. Indicate· the. physical: location of the .item Indicate the general condition of the item (New, Good, Worn, Bad). Indicate the FR # provided by the County for the item. Indicate the total purchase price of the item including sales tax and other costs, such as shipping. Exhibit Ga Required Required Required Required Required Required Required Required Conditional Conditional Conditional Conditional Required Required Required Required Required Conditional Required Fresno County Mental Health Plan Compliance Program Subject: Code ofConduct Effective [)ate: August 1, 2()04 ReVision Date: July 9, 2010 POLICYi Policy and Procedure Exhibit H Fre·snoCounty is firmly committed to full compliancewith all applicable laws, reg~;~latioi'JS, rules, and guidelines that apply to its mental health operations arid services. At the c_cire oOhis_ - 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 to this Code. PURPOSE: To provide specific conduct standards prescribed by the Fresno County Mental Health Plan Compliance Program. This Code of Conduct is maintained in addition to the County's Code of Ethics already in effect. DEFINITIONS: Covered Persons-All employees, contractors (including contractor's employees and subcontractors), volunteers and students working in behavioral/mental health programs. Excluded Person-Any Covered Person who is or may become suspended, excluded, or ineligible from participation in any Federal healthcare program. PROCEDURE: 1. A copy of the Code of Conduct (Attachment A) will be provided to all Covered Persons at the time of their initial compliance training which must be provided within 30 busihe_ss 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 revi$ion ·is finalized. 2. Upon initial receipt and review of the Code , Covered Persons shall certify their intention to abide by it by signing the Acknowledgement and Agreement form (Attachment BJcirsample form). These signed forms will be retained by the Compliance Office, Covered Persons shall certify within 30 business days after distribution of a revised Code •. 3. The Compliance Office will track these certifications and regularly report to th.e Compliance Committee C'lnd the Directors of the Departments of Behavioral Health and Public Health. regarding progress towards 1 00% certification by all Covered Persons. 4. The Code will be prominently posted in all Fresno County and contractor mental health facilities and sites. 5. This Code is not intended to be an exhaustive list of all standards b,y which Covered Persons are to be governed. Rather, i.t is intended to convey the County's committnenUo the high standards set forth by the County. Page 1 of3 Attachment A Fresno County Mental Health Pla:n Compliance Program CODE OF CONDUCT: All Fresno County Behavioral/Mental Health Employees, Contractors Contractor's Employees/Subcontractors), Volunteers and Students will: 1. Read, acknowledge, and abide by this Code of Conduct. (including 2. Be r~sponsible 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 a\/oid 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 procedl)res of the County, . the Cornpliance Program, o·r 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 oth.er appropriate action by the County. 6. Comply with riot only the letter of Compliance Program and mental health policies and procedures, but aJso with the spirit of those· policies and procedures as well as Qther 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.· · ·1. 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 ~II 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 d.ocumented. Use billing codes that accurately clescribe the service.s provided. Ensure that no false, fraudulent, inacc(Jrate, or fictitious. claims for payment or reimbursement of any kind are prepared or st.lbrifitted. Ensure that claims are prepared an·d submitted accurately and timely ,and are consistent with all ap'plicable laws, regulations, rules and guidelines. Act promptly to investigate and correct-problemS' if errors-in claims or billings are discovered'. g, Immediately notify your supervisor, Department Head, Admi.nistra.tor, 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. Revised: 7/9/10 Page 2 of 3 FRESNO CoUNTY MENTAL HEALTH PlAN COMPLIANCE PROGRAM Acknowledgment and Agreement Attachment B I hereby acknowledge that I have received, read and understand Fresno County's Code of Conduct, Code of Ethics (County employees only), and have received training and information oh the Compliance Program and l]nderstand the contents thereof. I further acknowledge that I have received, read and understand the Compliance Program policy titled "Prevention, Detection, and Correction of Fraud, V\.laste and Abuse.". I agree to abide by the Code of Conduct, Code of Ethics (County employees only) and all Compliallce Program requirements as they apply to my responsibilities as a County employee, contractor/subcontractor, volunteer or student. I understand and accept my responsibilities under this Acknowledgment and Agreementand understand that any violation of the Code of Conduct, Code of Ethics (County employees only), or the PompliC:lnce Program is a violation of County policy and may also be a violation of applicable lavvs, · re_g(JiaUons,. niles or .guidelines. I further understand that violation .of these policies .can result in disCiplinary action, up to. arid including termination of my employment or contractual agreement with the County. Coun.ty Employees Only-Complete this S'ec.tion Full Name (printed):. ____ -'-----------------'- Job Title: ________ ___,-------------~-- Disciplihe (for ficenseq staff only): [ ]Psychiatrist [ ]Psychologist [ ]LCSW [ ]LMFT [ ]NP [ ]RN [ ]LVN [ ] LPT Department: DBH: [ ] Adult MH [ ] Children MH [ ] Business Office/ISD [ ] Managed Care [ ] MHSA [ ) PL!blic Health [ ] Other:.~.-'-------,-----..,...----------- Cost Center# Program Name: ______________ _ Supe~isorName:. _____________________________________ _ Employee Signature: Date:_. _/_. _/_ .. _. Phone: ·----------------- Contractors/Contractor Staff, Volunteers, Students otlly-Complete this Section Agency Name (If applicable):----~--~-------'--"~--~----~------'--'- Full Name (Printed):, ____________ ~---~------------ Discipline (Indicate below if applicable): Licensed: [ ] Psychiatrist [ ] Psychologist [ ] LCSW [ ] LMFT Unlicensed: [ ] Psycbelogist [ ] ASW [ ] IMF Other __ ~---------------------- Job Title (If different from Discipline):--------------------~------- Signature:, ______________________ Date: __ / __ / __ Phone: _____________ _ New Emp/Contr Ack Rev: 7/9/10 Page 3 of3 DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT I. ldenti in Information Name of entity D/B/A Address (number, street) City CLIAnumber Taxpayer ID number (EIN) Telephone number ZIP code Exhibit I Page 1 of2 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 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 fisc~l intermediary or carrier within the previous 12 months? (Title XVIII providers only) ......... .. YES NO Cl Cl Cl Cl Cl Cl Ill. A List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names and addresses under "Remarks" on page 2. If more than one individual is reported and any of these persons are related to each other, this must be reported under "Remarks." NAME ADDRESS EIN B. Type of entity: Cl Sole proprietorship Cl Partnership CJ Corporation Cl Unincorporated Associations Cl 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 .......................................................................................................... . Cl Cl NAME ADDRESS PROVIDER NUMBER 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? .............................................................................. .. lfyes,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 es, list name, address of cor oration, and EIN. Name EIN Address (number, name) City State 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 ZIP code Exhibit I Page 2 of 2 YES NO (j (j (j (j (j (j (j (j (j (j (j (j 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 J 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. M:IMHSA\CONTRACTS AND PROGRAMSIHTCC-COMMUNITY GARDENS-A-14-XXX\HISTORIAL RECORDS\CONTRACTIEXHIBIT J-CERTIFICATION REGARDING DEBARMENT.DOC Exhibit J CERTIFICATION (1) The prospective primary participant certifies to the best of its knowledge and belief, that it, its owners, officers, corporate managers and partners: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency; (b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default. (2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. Signature: Date: (Printed Name & Title) (Name of Agency or Company)" M:IMHSA\CONTRACTS AND PROGRAMS\HTCC-COMMUNITY GARDENS -A-14-XXXIHISTORIAL RECORDSICONTRACTIEXHIBIT J-CERTIFICATION REGARDING DEBARMENT.DOC Proposal No. Exhibit K Page 1 of 4 FRESNO COUNTY MENTAL HEALTH PLAN GRIEVANCES AND INCIDENT REPORTING 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 Proposal No. Exhibit K Page 2 of4 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. Proposal No. Exhibit K Page 3 of4 PROTOCOL FOR COMPLETION OF INCIDENT REPORT • 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 . I L Proposal No. 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) Exhibit K Page 4 of4 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. inc;om;e,quential IDI conseque ath IDI not applicable 101 unknown IDI 4. Response: a) corrective action, b) Plan of Action, c) other Comp~~d~(p~tnam~ -------------------------~ Completed by (signature) _____________ Date completed Reviewed by Supervisor (print name) Supervisor Signature Date SELF-DEALING TRANSACTION DISCLOSURE FORM Exhibit L Page 1 of2 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 L Page 2 of2 Performance Measures Exhibit M Horticultural Thera eutic Communi Covered Shelter Development, including Completed and operational culturally seati and Bulletin Board relevant covered shelter Land Preparation & Farming/Gardening of traditional crops; generational/family · nated Liaison/Coordinator Secured and prepared land; Planted crops; harvested crops; increased community connectedness; Improved fam functioni resources for anti-stigma and MH information; maximum community participation, including consumers, oomm MH e~ Completed shelter; Scheduled and Ongoing Activities; Displays of Mental Health related Materials Schedule of community participation and hours of operation; Increase in numbers of families/individuals participating; Number and type of cultural farmi Schedule of ours and Community Participation, including programs, activities, and Satisfaction Surveys; Visual confirmation; Records of activities, including types and numbers in attendance. Schedule of operation, documentation of participation; visual confirmation· Consumer Feedback from Satisfaction Surveys; Records of activities and ::~rrl=-nrl~=>~=>·<:ur•::~ Reduced stigma; increased MH education Increase community participation in in community; Reduced stress and anxiety gardening and Shelter Activities; Consumer an community Feedback from Satisfaction Surveys; Records of activities and attendees/participants; Client reports documented on Event Log Community Engagement & Linkage; tours; Social Supports for underserved families of participants; Participating families feel increase cultural pride and increased social support and reduced acceptance; ability to access services, isolation PEl programs targeted at underserved/unserved cultural communities; Reduced stigma; increased Community Outreach; knowledge of and MH education in community; increased access to care ns and access to care supports, resources and rehab services; Community Activities (e.g.: Informal peer-Increased awareness of types of to-peer discussions re stigmatization; stigmatization and tolerance of others; informal support/rehab groups; cultural Improved well-being and hopefulness members Commun Reduced need for level of services r ------------------ and Outcome Co n tools Community members will demonstrate County demographic enrollment increased comfort level to participate rates; Consumer Feedback from in programs; Increase community Satisfaction Surveys; Records of participation in gardening and Shelter activities and Activities; Decrease in SMI episodes attendees/participants; Client for culturally unserved/underserved reports documented on Event Log communities and Outcome Com rison tools Beck Depression Inventory, Beck Hopelessness Scale, Increase in community participation in gardening and shelter activities; #s in attenda rtici Documentation of attendance, types of group activities, types of cultural events/practices; Client documented on Event Log Outcome Com tools ule of speakers/activities and documentation of those in attendance 4/17/2015 [Type text] . PROGRAM TITLE: PROGRAM DESCRIPTION: AGES SERVED: D Children D Adult DATES OF OPERATION: OUTCOME GOAL Performance Measures PROVIDER: D TAY D Older Adult DATES OF DATA REPORTING PERIOD: OUTCOME DATA DEPARTMENT RECOMMENDATION(S): See page 2 for tables Exhibit N [Type text] 90 so• M.il'chal01-febn.ory2J03 400 DPrior to 3o Enrollment 20 OSince Enrollment Comparisoo of COns...ners' Outcomes Prior to and Since ErTollment il AB 2034 Day• Hospilalized Days Homeless O<l'fs lnJaU Performance Measures Exhibit N [Type text] [Type text] Exhibit Na Performance Effectiveness Form~Attachment C Name of Program: Click here to enter text. What is the Program/Contract Goal? Click here to enter text. Funding Source: D Prevention D Early Intervention D Realignment D Other: Click here to enter text. D Community Services and Supports 0 EPSDT D Innovations Fiscal Information: Budget Amount: $ Click here to enter text. Source(s) of Funding: Click here to enter text. Number of Unique Clients Served During Time Period: Click here to enter text. Number of Services Rendered During Time Period: Click here to enter text. Cost Per Client: Click here to enter text. Type of Program: D Outpatient D Inpatient D Other 0 DBH-Operated D Contract-Operated level of Care Information: level of Care: D 1 D 2 D 3 D 4 D 5 Please Describe: Click here to enter text. Target Population Information: Target Population: Click here to enter text. [Type text] [Type text] Exhibit Na Clinical Information: Does the Program Utilize Any of the Following? D Evidence Based Practice D Evidence Informed Practice D Best Practice Please Describe: Click here to enter text. Outcomes and Effectiveness: What Outcome Measures Are Being Used? Click here to enter text What Outcome Measures/Functional Variables Could Be Added to Better Explain the Program's Effectiveness? Click here to enter text. Describe the Program's Effectiveness (i.e. have the program/contract goals been met? Number served, waiting list, wait times, budget to volume, etc): Click here to enter text. What Barriers Prevent the Program from Achieving Better Outcomes? Click here to enter text. What Changes to the Program Would You Recommend to Improve the Effectiveness? Click here to enter text. For Committee Use Only: Recommendations: Click here to enter text. PERFORMANCE COMPARISON Exhibit 0 Date >Event Type Occurance NOTES M:\MHSA\Contracts and Programs\HTCC-Community Gardens-A-14-XXX\Historial Records\Contract\Exhibit 0 Event log & Periodic Performance Comp.xlsm 1 of 12 PERFORMANCE COMPARISON ... _,... '· Exhibit 0 M:\MHSA\Contracts and Programs\HTCC-Community Gardens-A-14-XXX\Historial Records\Contract\Exhibit 0 Event Log & Periodic Performance Comp.xlsm 2 of12 PERFORMANCE COMPARISON Exhibit 0 M:\MHSA\Contracts and Programs\HTCC-Community Gardens-A-14-XXX\Historial Records\Contract\Exhibit 0 Event Log & Periodic Performance Comp.xlsm 3 of 12 PERFORMANCE COMPARISON Exhibit 0 Date Client Unique Identifier M:\MHSA\Contracts and Programs\HTCC-Community Gardens-A-14-XXX\Historial Records\Contract\Exhibit 0 Event Log & Periodic Performance Comp.xlsm 4 of 12 EVENT LOG 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Exhibit 0 M:\MHSA\Contracts and Programs\HTCC-Community Gardens-A-14-XXX\Historial Records\Contract\Exhibit 0 Event Log & Periodic Performance Comp.xlsm Page 1 EVENT LOG Exhibit 0 M:\MHSA\Contracts and Programs\HTCC-Community Gardens-A-14-XXX\Historial Records\Contract\Exhibit 0 Event Log & Periodic Performance Comp.xlsm Page 2 EVENT LOG Exhibit 0 M:\MHSA\Contracts and Programs\HTCC-Community Gardens-A-14-XXX\Historial Records\Contract\Exhibit 0 Event Log & Periodic Performance Comp.xlsm Page 3 interactive; less than 1 hour. Training and Education: Typically interactive; 1+ days Workshop: Typically interactive; less than 1 day. Community Development: Staff interaction with other community agencies for program development, monitoring and enhancement. Drop Down Lists for Events Log Exhibit 0 1 of8 Drop Down Lists for Events Log ~------------~----------4 Fam -Return New Service Rot·or•·::~l RP~P,ivPdl Fam-Return Repeat Service ~~------~----------~~~ Fam -Services Declined · ~----------~~--------~ Hmlss-Services Declined Hnilss-lnkg 1st Time Hmlss-Lnkg Return New Service . . . Hmlss-Lnkg Return Repeat Service lnd -Lnkg 1st Time lnc:l-Services Declined lnd -Lrikg Return New Service lnd -Lnkg Return 2 of8 FB = Faith Based Fam =Family Hmlss=Homeless Lnkg = Linkage . lnd = Individual Exhibit 0 Drop Down Lists for Events Log Exhibit 0 Fac = Facilitated WET= Workforce Education & Training 3 of8 Drop Down lists for Events Log w~~~~~~~~~~~~~ CBANS -CLFAS CBANS-FAIHP CBANS-FIRM CBANS-Kings View CBANS -Sarbat CBANS-WFFRC Advocacy-CLFAS Advocacy-FIRM Advocacy-K. Williams HTCC-FCNA HTCC-FIRM HTCC-Sarbat HTCC-WFFRC Other "Enter Here" ;'7&I[7;;~t~~·.·syH}l~£:ji~ Anger Management Anxiety/Stress Citizenship Community Resources Depression Domestic Violence Health in General Human Trafficking Interpersonal Relationships Job Readiness Nutrition Other "Enter Here" Parenting/Child Care Physical Health Physical Safety PTSD Question, Persuade, Refer (QPR) Self-Advocating Stigma Suicide ID/Prev 4 of8 Exhibit 0 Drop Down Lists for Events Log Hisp LGBTQ Not ID'd Not Specific "Enter Here" Punj Russ/51 SEACamb SEAHm SEA Lao SEA Viet White Unk .-E«,;~~{;~~'~'ityjft:~1Ws}fl:t{fl~ij Advocate CHW/CMHW Coordinator Lead ""-="'"""'"'~ PSS "Enter Here" Farsi Hmong Khmer Lao Not ID'd "Enter Here" Punjabi Spanish Slavic Unknown 5 of8 African American American/Alaskan Native Hispanic LGBTQ Not Identified Not Culture Specific "Enter Here" Punjabi Russian/Slavic SEA Cambodian SEA Hmong SEA Lao SEA Vietnamese Anglo Saxon Unknown Peer Support Specialist Exhibit 0 Drop Down Lists for Events Log Caruthers Clovis Coalinga Firebaugh Fresno Fowler Huron Kerman Kingsburg Mendota Orange Cove Other "Enter Here" Parlier Reedley Riverdale San Joaquin Sanger Selma Squaw Valley ~i~:E~r.#e..~!1!i!t~~fli~s£~r~~ff~~J2;;;5~ .. ;r:.~~~ill Initial/Intake 1 Month Follow Up 2 Month Follow Up Quarterly Follow Up "Enter Here" Oto 15 16 to 25 26 to 59 60+ 6 of8 Exhibit 0 Please use: first name, last initial, birth date-two digits each of month, date, year (example: janeiiS112759) Drop Down Lists for Events Log Married Divorced Separated Widowed "Enter Here" Yes No Unknown "Enter Here" Alcoholism Behav/Emotion Bullying Chronic Illness/Pain Clothing Dental Health Disability Domestic Violence Drug Addiction Education Employment Family Conflict Financial Food Hearing Loss Health Insurance Hospitalization Immigration Incarceration Language/Cultural Legal 7 of8 Exhibit 0 Behavioral/Emotional '·!:' ~ I 7 l Drop Down Lists for Events Log Loss of Loved One Mental Health Personal Safety Physical Health School Shelter Transportation Trauma Vision Loss "Enter Here" (not specified) No One Question 1 1 Person Question 1 2-3 People Question 1 4-5 People Question 1 6 + People Question 1 A Lot Question 2 Some Question 2 A Little Question 2 Not at All Question 2 Exhibit 0 1 Questions 3 through 8: Range is from 1 to 6, from 1 being "not at all" and 6 being "Extremely" 2 3 4 5 6 1to4 5 to 9 10 to 14 20-27 8 of8 PHQ-9 Score Key Minimal Mild Moderate Severe