The URL can be used to link to this page

Home My WebLink AboutAgreement A-17-121 with Promesa Behavioral Health.pdfAgreement No. 17-121 AGREEMENT 2 3 THIS AGREEMENT is made and entered into this 4th day of April 2017, by and between the 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 COUNTY OF FRESNO, a political subdivision of the State of California, hereinafter referred to as "COUNTY", and Promesa Behavioral Health, a California Corporation, whose service addresses are identified on Exhibit A, "Service Addresses", attached hereto and incorporated herein by this reference, and remittance address is 7120 N Marks, Suite110, Fresno, CA 93711 , herein referred to as "PROVIDER". WI TN E S S E T H: WHEREAS, COUNTY, through its Department of Behavioral Health (DBH), Contracts Division- Substance Use Disorder (SUD) Services, has determined there is a need for outpatient services in rural communities such as Firebaugh/Mendota and Coalinga/Huron; and WHEREAS, COUNTY is authorized to contract with privately operated agencies for the provision of alcohol and other drug treatment services, pursuant to Title 9 , Division 4 of the California Code of Regulations and Divis ion 10 .5 (commencing with Section 11750) of the California Health and Safety Code; and WHEREAS, PROVIDER is willing and able to provide services required by COUNTY, pursuant to the terms and conditions ofthis Agreement. NOW, THEREFORE, in consideration of their mutual covenants and conditions, the party hereto agree as follows : 1. SERVICES A. PROVIDER shall perform all services and fulfill all responsibilities for the provision of Rural Outpatient SUD treatment services, as identified in COUNTY's Request for Proposal (RFP) # 17- 030 dated November 1, 2016; Addendum No. One (1) dated November 17,2016, hereinafter collectively referred to as COUNTY Revised RFP #17-030, and PROVIDER's re s ponse to said RFP#17-030, dated December 7, 2016 identified as Exhibit B, "Scope of Work", all incorporated herein by reference and made pa1t of this Agreement. B. In the event of any inconsistency among these documents, the inconsistency shall be resolved by giving precedence in the following order of priority: 1) to this Agreement, including any -I - 12345678910111213141516171819202122232425262728Exhibitsattachedhereto;2)totheRevisedRFPNo.17-030,and;3)totheResponsetotheRevisedRFPidentifiedasExhibitB,“ScopeofWork”.AcopyofCOUNTY’SRevisedRFP#17-030,andPROVIDER’SresponseshallberetainedandmadeavailableduringthetermofthisAgreementbyCOUNTY’SPurchasingDivision.C.PROVIDER(S)servingclientsreferredbyDrugCourtorProbationshallcarryoutthefollowing:1.ComplywithreportingrequirementsofCourtorProbationrelatingtoclientstatuschangeandtreatmentprogress;and2.Conductclientintakewithinforty-eight(48)hoursofreferralorcontact.D.PROVIDERshallmaintain,atPROVIDER’Scost,acomputersystemcompatiblewithCOUNTY’SSubstanceAbuseInformationSystem(SAIS)fortheprovisionofsubmittinginformationrequiredunderthetennsandconditionsofthisAgreement.PROVIDERshallcompleterequiredSAISdataentiyasfollows:Registrationsandadmissionsmustbecompletewithinfive(5)businessdaysofprogramcompletionordismissal.E.PROVIDER’Sadministrativelevelagencyrepresentative,whoisdulyauthorizedtoactonbehalfofthePROVIDER,mustattendregularlyscheduledmonthlyBehavioralHealthBoardSubstanceUseDisorderCommitteemeetingsandregularlyscheduledPROVIDERmeetingsF.PROVIDER’Sstaffmayalsoberequiredtoattendmeetingsandtrainingsonanas-neededbasis,whichmayincludebutarenotlimitedtoSUDtreatmentandfiscaltrainingsprovidedbytheStateofCalifornia.2.TERMThisAgreementshallbecomeeffectiveuponexecution,andshallterminateonthe30thdayofJune,2019.Thisagreementmaybeextendedfortwo(2)additionalconsecutivetwelve(12)monthperiodsuponwrittenapprovalofbothpartiesnolaterthanthirty(30)dayspriortothefirstdayofthenexttwelve(12)monthextensionperiod.TheDBHDirectororherdesigneeisauthorizedtoexecutesuchwrittenapprovalonbehalfofCOUNTYbasedonPROVIDER’Ssatisfactoryperformance.3-TERMINATIONA.NON-ALLOCATIONOFFUNDS-ThetennsofthisAgreement,andtheservices-2- 12345678910111213141516171819202122232425262728tobeprovidedthereunder,arecontingentontheapprovaloffundsbytheappropriatinggovernmentagency.Shouldsufficientfundsnotbeallocated,theservicesprovidedmaybemodified,orthisAgreementterminated,atanytimebygivingthePROVIDERthirty(30)daysadvancewrittennotice.B.BREACHOFCONTRACT-COUNTYmayimmediatelysuspendorterminatethisAgreementinwholeorinpart,whereinthedeterminationofCOUNTYthereis:1)Anillegalorimproperuseoffunds;2)AfailuretocomplywithanytermofthisAgreement;3)AsubstantiallyincorrectorincompletereportsubmittedtoCOUNTY;4)Improperlyperformedservice.InnoeventshallanypaymentbyCOUNTYconstituteawaiverbyCOUNTYofanybreachofthisAgreementoranydefaultwhichmaythenexistonthepartofthePROVIDER.NeithershallsuchpaymentimpairorprejudiceanyremedyavailabletoCOUNTYwithrespecttothebreachordefault.COUNTYshallhavetherighttodemandofthePROVIDERtherepaymenttoCOUNTYofanyfundsdisbursedtothePROVIDERunderthisAgreement,whichinthejudgmentofCOUNTYwerenotexpendedinaccordancewiththetermsofthisAgreement.ThePROVIDERshallpromptlyrefundanysuchfundsupondemand.C.WITHOUTCAUSE-Undercircumstancesotherthanthosesetforthabove,thisAgreementmaybeterminatedbyCOUNTYoranyone(1)PROVIDERupongivingthirty(30)daysadvancewrittennotice.4.COMPENSATIONA.COMPENSATION-ForclaimssubmittedforservicesrenderedunderthisAgreement,COUNTYagreestopayPROVIDERandPROVIDERagreestoreceivecompensationinequalmonthlyinstallments,lessDrugMedi-Cal(DMC)reimbursements,uptotheannualcontractmaximum,inaccordancewithExhibitC,“Budget,”attachedheretoandbythisreferenceincorporatedherein,foreachtermoftheAgreement.PROVIDERshallnotbepaidanyamountinexcessoftheactualannualcostsofprovidingservices.MonthlyinvoicesshallbesubmittedinaccordancewithSectionFive(5),INVOICING,ofthisAgreement.ItisunderstoodthatallexpensesincidentaltoPROVIDER’SperformanceofservicesunderthisAgreementshallbebornebyPROVIDER.Forthe-3- 12345678910111213141516171819202122232425262728periodcommencinguponexecutionandendingJune30,2017,innoeventshallactualservicesperformedbeinexcessofEightyOneThousandTwoHundredFiftyandNo/100Dollars($81,250.00).FortheperiodsofJuly1,2017throughJune30,2018,andJuly1,2018throughJune30,2019,innoeventshallactualservicesperformedbeinexcessofThreeHundredTwenty-FiveThousandandNo/100($325,000.00)foreachtwelve(12)monthperiod.ShouldtheAgreementbeextendedasstatedinSection2,fortheextensionperiodsofJuly1,2019throughJune30,2020,andJuly1,2020throughJune30,2021,innoeventshallactualservicesperformedbeinexcessofThreeHundredTwenty-FiveThousandandNo/100($325,000.00)foreachtwelve(12)monthperiod.B.ThecontractmaximumamountasidentifiedinthisAgreementmaybereducedbaseduponState,Federal,andlocalfundingavailability.Intheeventofsuchaction,theCOUNTY’SDBHDirectororherdesigneeshallnotifythePROVIDERinwritingofthereductioninthemaximumamountwithinthirty(30)days.IntheeventthatfundingfortheseservicesisdelayedbytheStateController,COUNTYmaydeferpaymenttoPROVIDER.TheamountofthedeferredpaymentshallnotexceedtheamountoffundingdelayedbytheStateControllertotheCOUNTY.ThedeferralbyCOUNTYshallnotexceedtheperiodoftimeoftheStateController’sdelayofpaymenttoCOUNTYplusforty-five(45)days.Inaddition,iftheStateofCaliforniadoesnotallocatefundingforservicesdescribedinthetermsandconditionsofthisAgreement,DBH-SUDServicesshallnotbeobligatedtoreimbursePROVIDERforservicesperformed.C.PAYMENTS-Regardlessofthecontractmaximum,PROVIDERwillbereimbursedonlyforactualcostsforeachfiscalyear.PROVIDERshallsubmitadetailedexpenditurereportuponrequestbyCOUNTY,forreconciliationtomonthlyinstallmentpayments.Withinforty-five(45)daysofthereconciliationbyCOUNTY,PROVIDERshallmakepaymenttoCOUNTYorCOUNTYshallreimbursePROVIDERasappropriate.PaymentbyCOUNTYshallbeinarrears,basedonPROVIDER’Smonthlyinvoicessubmittedforservicesprovidedduringtheprecedingmonth,withinforty-five(45)daysafterreceiptandverificationofPROVIDER’SmonthlyinvoicesbyCOUNTY’SDBH,ContractsDivision-SUDServices.-4- 12345678910111213141516171819202122232425262728D.QUALITYASSURANCE-Forservicesrenderedherein,PROVIDERshallassurethatanon-goingqualityassurancecomponentisinplaceandisoccurring.PROVIDERshallassurethatclinicalrecordsforeachparticipantareofsuchdetailandlengththatareviewofsaidrecordwillverifythatappropriateserviceswereprovided.Iftherecordisunclear,incomplete,and/orindicatesthatappropriateserviceswerenotprovided,COUNTYreservestherighttowithholdpaymentfortheapplicableunit(s)ofservice.E.COMPLIANCE-IfPROVIDERshouldfailtocomplywithanyprovisionofthisAgreement,COUNTYshallberelievedofitsobligationforfurthercompensation.PROVIDER’SandCOUNTY’SobligationsunderthissectionshallsurvivetheterminationofthisAgreementwithrespecttoservicesprovidedduringthetermofthisAgreementwithoutregardtothecauseoftenninationofthisAgreement.F.PUBLICINFORMATION-PROVIDERshalldiscloseitsfundingsourceinallpublicinformation;however,thisrequirementofdisclosureoffundingsourceshallnotberequiredinspotradioortelevisionadvertising.G.LOBBYINGACTIVITY-PROVIDERshallnotdirectlyorindirectlyuseanyofthefundsprovidedunderthisAgreementforpublicity,lobbying,orpropagandapurposesdesignedtosupportordefeatlegislationpendingbeforetheCongressoftheUnitedStatesortheLegislatureoftheStateofCalifornia.H.POLITICALACTIVITY-PROVIDERshallnotdirectlyorindirectlyuseanyofthefundsunderthisAgreementforanypoliticalactivityortofurthertheelectionordefeatofanycandidateforpublicoffice.I.FUNDINGSOURCES-ItshallbetheobligationofPROVIDERtodetermineandclaimallrevenuepossiblefromprivatepaysourcesandthirdpartypayers.PROVIDERshallnotuseanyfundsunderthisAgreementforservicescoveredbyDrugMedi-Calorotherhealthinsuranceforeligiblebeneficiaries.PROVIDERshallclaimallDrugMedi-CalcoveredservicesforeligiblebeneficiariesthroughtheDrugMedi-Calclaimingprocess.PROVIDERshallnotuseanyfundsunderthisAgreementtotheextentthataparticipantiseligibleforMedi-Cal,insuranceorotherrevenuereimbursementforservicesrendered.-5- 12345678910111213141516171819202122232425262728AnyrevenuesgeneratedbyPROVIDERinexcessoftheamountsbudgetedinthisAgreementmaybeutilizedtoexpand/enhancetheservicesduringCOUNTY’SfiscalyearsinwhichrevenuesarecollectedorinthefollowingCOUNTYfiscalyear.AdditionalrevenueswillbeconsideredseparateanddistinctfromCOUNTY’SpaymenttoPROVIDER.Themannerandmeansofserviceexpansion/enhancementshallbesubjecttothepriorwrittenapprovalofCOUNTY’SDBHDirectororherdesignee.PROVIDERshalldiscloseallsourcesofrevenuetoCOUNTY.UndernocircumstanceswillCOUNTYfundedstafftimebeusedforfund-raisingpurposes.5.INVOICINGPROVIDERshallinvoiceCOUNTYbythetwentieth(20th)ofeachmonth.COUNTYwillmakepaymenttoPROVIDERinanamountequaltoone-twelfth(1/12)oftheannualcontractmaximum,lessanyamountclaimedforDragMedi-Calreimbursement.Totalreimbursement,includingDMC,cannotexceedthemaximumannualcontractamount.FinalinvoiceforeachfiscalperiodwillbereconciledtoPROVIDER’Sprofitandlossstatementandadjustedtonotexceedactualcosts.Invoicesshallbesubmittedviae-mailtotheassignedstaffanalystandtoSAS@co.fresno.ca.us.PROVIDERshallincludesupportingdocumentationforallexpendituresincludedinthemonthlyinvoice.Supportingdocumentationincludes,butisnotlimitedto,invoices,receipts,payrollrecordsandgeneralledgers.Costallocationmethodologiesshouldbeclearlyshown.Ifaninvoiceisincorrectorisotherwisenotinproperformorsubstance,COUNTY'SDBHDirectororherdesigneeshallhavetherighttowithholdpaymentastoonlythatportionoftheinvoicethatisincorrectorimproperafterfive(5)dayspriornoticetoPROVIDER.PROVIDERagreestocontinuetoprovideservicesforaperiodofninety(90)daysafternotificationofanincorrectorimproperinvoice.Ifaftersaidninety(90)dayperiodsaidinvoice(s)isstillnotcorrectedtoCOUNTY'SDBHDirector'sorherdesignee'ssatisfaction,COUNTY'SDBHDirectororherdesigneemayelecttoterminatethisAgreement,pursuanttotheterminationprovisionsstatedinSectionThree(3),TERMINATIONofthisAgreement.Inaddition,PROVIDERshallsubmitallinvoicestoCOUNTY'SDBHDirectororherdesigneeforservicesprovidedwithinninety(90)daysaftereachtwelve(12)monthperiodexpiresorthisAgreementisterminated.Ifinvoicesarenotsubmittedwithinninety(90)daysaftereachtwelve(12)monthperiod-6- 12345678910111213141516171819202122232425262728expiresorthisAgreementisterminated,COUNTY'SDBHDirectororherdesigneeshallhavetherighttodenypaymentonsuchinvoices.6-PROHIBITIONONPUBLICITYNoneofthefunds,materials,propertyorservicesprovideddirectlyorindirectlyunderthisAgreementshallbeusedforPROVIDER’Sadvertising,fundraising,orpublicity(i.e.,purchasingoftickets/tables,silentauctiondonations,etc.)forthepurposeofself-promotion.Notwithstandingtheabove,publicityoftheservicesdescribedinSectionOne(1),SERVICES,ofthisAgreementshallbeallowedasnecessarytoraisepublicawarenessabouttheavailabilityofsuchspecificserviceswhenapprovedinadvancebytheDBHDirectororherdesignee,andatacosttobeprovidedforsuchitemsaswritten/printedmaterials,theuseofmedia(i.e.,radio,television,newspapers)andanyotherrelatedexpense(s).7.INDEPENDENTCONTRACTORInperformanceofthework,dutiesandobligationsassumedbyPROVIDERunderthisAgreement,itismutuallyunderstoodandagreedthatPROVIDER,includinganyandallofthePROVIDER'Sofficers,agents,andemployeeswillatalltimesbeactingandperformingasanindependentcontractor,andshallactinanindependentcapacityandnotasanofficer,agent,servant,employee,jointventurer,partner,orassociateoftheCOUNTY.Furthermore,COUNTYshallhavenorighttocontrolorsuperviseordirectthemannerormethodbywhichPROVIDERshallperformitsworkandfunction.However,COUNTYshallretaintherighttoadministerthisAgreementsoastoverifythatPROVIDERisperformingitsobligationsinaccordancewiththetermsandconditionsthereof.PROVIDERandCOUNTYshallcomplywithallapplicableprovisionsoflawandtherulesandregulations,ifany,ofgovernmentalauthoritieshavingjurisdictionovermattersthesubjectthereof.Becauseofitsstatusasanindependentcontractor,PROVIDERshallhaveabsolutelynorighttoemploymentrightsandbenefitsavailabletoCOUNTYemployees.PROVIDERshallbesolelyliableandresponsibleforprovidingto,oronbehalfof,itsemployeesalllegally-requiredemployeebenefits.Inaddition,PROVIDERshallbesolelyresponsibleandsaveCOUNTYharmlessfromallmattersrelatingtopaymentofPROVIDER'Semployees,includingcompliancewithSocialSecuritywithholdingandallotherregulationsgoverningsuchmatters.ItisacknowledgedthatduringthetermofthisAgreement,PROVIDERmaybeprovidingservicestoothersunrelatedtotheCOUNTYortothisAgreement.-7- 12456789101112131415161718192021222324252627288.CONFLICTOFINTERESTNoofficer,agent,oremployeeofCOUNTYwhoexercisesanyfunctionorresponsibilityforplanningandcarryingouttheservicesprovidedunderthisAgreementshallhaveanydirectorindirectpersonalfinancialinterestinthisAgreement.PROVIDERshallcomplywithallFederal,StateofCalifornia,andlocalconflictofinterestlaws,statutes,andregulations,whichshallbeapplicabletoallpartiesandbeneficiariesunderthisAgreementandanyofficer,agent,oremployeeofCOUNTY.9.DISCLOSUREOFSELF-DEALINGTRANSACTIONSThisprovisionisonlyapplicableifthePROVIDERisoperatingasacorporation(afor-profitornon-profitcorporation)orifduringthetennofthisagreement,thePROVIDERchangesitsstatustooperateasacorporation.MembersofthePROVIDER’SBoardofDirectorsshalldiscloseanyself-dealingtransactionsthattheyareapartytowhilePROVIDERisprovidinggoodsorperformingservicesunderthisAgreement.Aself-dealingtransactionshallmeanatransactiontowhichthePROVIDERisapartyandinwhichoneormoreofitsdirectorshasamaterialfinancialinterest.MembersoftheBoardofDirectorsshalldiscloseanyself-dealingtransactionsthattheyareapartytobycompletingandsigninga“Self-DealingTransactionDisclosureForm’’(ExhibitD)andsubmittingittotheCOUNTYpriortocommencingwiththeself-dealingtransactionorimmediatelythereafter.10.PROPERTYOFCOUNTYA.PROVIDERshallsubmitpurchaseinvoicesforthepurchaseofanyfixedassetswiththeirmonthlyinvoices.AllpurchasesoverFiveThousandandNo/100Dollars($5,000.00),andcertainpurchasesunderFiveThousandandNo/100Dollars($5,000.00)suchasfans,calculators,cameras,VCRs,DVDsandothersensitiveitemsasdeterminedbyCOUNTY’SDBHDirector,orherdesignee,madeduringthelifeofthisAgreementshallbeidentifiedasassetsthatcanbeinventoriedandmaintainedinCOUNTY’SDBHAssetInventorySystem.TheseassetsshallberetainedbyCOUNTY,asCOUNTYproperty,intheeventthisAgreementisterminatedoruponexpirationofthisAgreement.PROVIDERagreestoparticipateinanannualinventoryofallCOUNTYfixedassetsandshallbephysicallypresentwhenfixedassetsarereturnedtoCOUNTY’SpossessionattheterminationorexpirationofthisAgreement.PROVIDERisresponsibleforreturningtoCOUNTYallCOUNTYownedfixedassets,orthemonetary-8- 12345678910111213141516171819202122232425262728valueofsaidfixedassetsifunabletoproducethefixedassetsattheexpirationorterminationofthisAgreement.B.ThepurchaseofanyequipmentbyPROVIDERwithfundsprovidedhereundershallrequirethepriorwrittenapprovalofCOUNTY’SDBHDirectororherdesignee,shallfulfilltheprovisionsofthisAgreementasappropriate,andmustbedirectlyrelatedtoPROVIDER’SservicesoractivityunderthetermsofthisAgreement.COUNTY’SDBHDirectororherdesigneemayrefusereimbursementforanycostsresultingfromequipmentpurchased,whichareincurredbyPROVIDER,ifpriorwrittenapprovalhasnotbeenobtainedfromCOUNTY.C.ThetermsandconditionsdescribedinthisSectionarenotapplicabletotheleasingofvehiclesbyPROVIDERwiththefundsprovidedunderthisAgreement.11.MODIFICATIONAnymattersofthisAgreementmaybemodifiedfromtimetotimebythewrittenconsentofallthepartieswithout,inanyway,affectingtheremainder.Notwithstandingtheabove,changestoservicesasneededtoaccommodatechangesinthelawrelatingtosubstanceusedisordertreatment,assetforthinExhibitC,“Budget,”maybemadewiththesignedwrittenapprovalofCOUNTY’SDBHDirector,orherdesignee,andPROVIDERthroughanamendmentapprovedbyCountyCounselandAuditor.Changestolineitemsinthebudgets,attachedheretoasExhibitC,“Budget,”asappropriate,thatdonotexceedtenpercent(10%)ofthePROVIDER’SprogramtotalmaximumcompensationpayabletoPROVIDER,maybemadewiththewrittenapprovalofCOUNTY’SDBHDirector,orherdesignee,andPROVIDER.Changestothelineitemsinthebudgetthatexceedtenpercent(10%)ofthemaximumcompensationpayabletothePROVIDERmaybemadewiththesignedwrittenapprovalofCOUNTY’SDBHDirector,orherdesignee,throughanamendmentapprovedbyCountyCounselandAuditor.SaidbudgetlineitemchangesshallnotresultinanychangetothePROVIDER’SprogrammaximumcompensationamountpayabletoPROVIDER,asstatedherein.12.NON-ASSIGNMENTNeitherpartyshallassign,transferorsub-contractthisAgreementnortheirrightsordutiesunderthisAgreementwithoutthepriorwrittenconsentoftheotherparty.Ill-9- 124567891011121314151617181920212223242526272813.HOLDHARMLESSPROVIDERagreestoindemnify,save,holdharmless,andatCOUNTY'Srequest,defendtheCOUNTY,itsofficers,agents,andemployeesfromanyandallcostsandexpenses,damages,liabilities,claims,andlossesoccurringorresultingtoCOUNTYinconnectionwiththeperformance,orfailuretoperform,byPROVIDER,itsofficers,agents,oremployeesunderthisAgreement,andfromanyandallcostsandexpenses,damages,liabilities,claims,andlossesoccurringorresultingtoanyperson,firm,orcorporationwhomaybeinjuredordamagedbytheperformance,orfailuretoperform,ofPROVIDER,itsofficers,agents,oremployeesunderthisAgreement.PROVIDERagreestoindemnifyCOUNTYforFederal,StateofCaliforniaauditexceptionsresultingfromnoncompliancehereinonthepartofthePROVIDER.14.INSURANCEWithoutlimitingtheCOUNTY'SrighttoobtainindemnificationfromPROVIDERoranythirdparties,PROVIDER,atitssoleexpense,shallmaintaininfullforceandeffect,thefollowinginsurancepoliciesoraprogramofself-insurance,includingbutnotlimitedto,aninsurancepoolingarrangementorJointPowersAgreement(JPA)throughoutthetermoftheAgreement:A.COMMERCIALGENERALLIABILITYCommercialGeneralLiabilityInsurancewithlimitsofnotlessthanOneMillionDollars($1,000,000.00)peroccurrenceandanannualaggregateofTwoMillionDollars($2,000,000.00).Thispolicyshallbeissuedonaperoccurrencebasis.COUNTYmayrequirespecificcoveragesincludingcompletedoperations,productsliability,contractualliability,Explosion-Collapse-Underground,firelegalliabilityoranyotherliabilityinsurancedeemednecessarybecauseofthenatureofthiscontract.InadditiontotheCommercialGeneralLiabilitycoverage,PROVIDERshallprovideaninsurancepolicyforsexualabuseandmolestationliabilitywiththesesamelimits.B.AUTOMOBILELIABILITYComprehensiveAutomobileLiabilityInsurancewithlimitsforbodilyinjuiyofnotlessthanFiveHundredThousandDollars($500,000.00)perperson,OneMillionDollars($1,000,000.00)peraccidentandforpropertydamagesofnotlessthanOneHundredThousandDollars($100,000.00),orsuchcoveragewithacombinedsinglelimitofOneMillionDollars($1,000,000.00).Coverageshould-10- 12345678910111213141516171819202122232425262728includeownedandnon-ownedvehiclesusedinconnectionwiththisAgreement.C.PROFESSIONALLIABILITYIfPROVIDERemployslicensedprofessionalstaff,(e.g.,Ph.D.,R.N.,L.C.S.W.,LM.F.T.)inprovidingservices,ProfessionalLiabilityInsurancewithlimitsofnotlessthanOneMillionDollars($1,000,000.00)peroccurrence,ThreeMillionDollars($3,000,000.00)annualaggregate.PROVIDERagreesthatitshallmaintain,atitssoleexpense,infoilforceandeffectforaperiodofthree(3)yearsfollowingtheterminationofthisAgreement,oneormorepoliciesofprofessionalliabilityinsurancewithlimitsofcoverageasspecifiedherein.D.WORKER'SCOMPENSATIONApolicyofWorker'sCompensationinsuranceasmayberequiredbytheCaliforniaLaborCode.PROVIDERshallobtainendorsementstotheCommercialGeneralLiabilityinsurancenamingtheCountyofFresno,itsofficers,agents,andemployees,individuallyandcollectively,asadditionalinsured,butonlyinsofarastheoperationsunderthisAgreementareconcerned.Suchcoverageforadditionalinsuredshallapplyasprimaryinsuranceandanyotherinsurance,orself-insurance,maintainedbyCOUNTY,itsofficers,agentsandemployeesshallbeexcessonlyandnotcontributingwithinsuranceprovidedunderPROVIDER'Spoliciesherein.Thisinsuranceshallnotbecancelledorchangedwithoutaminimumofthirty(30)daysadvancewrittennoticegiventoCOUNTY.Withinthirty(30)daysfromthedatePROVIDERsignsthisAgreement,PROVIDERshallprovidecertificatesofinsuranceandendorsementsasstatedaboveforalloftheforegoingpolicies,asrequiredherein,totheCountyofFresno,DepartmentofBehavioralHealth,ContractsDivision-SubstanceUseDisorderServicesat3133N.MillbrookAve.,Fresno,California,93703,Attention:SUDServicesStaffAnalyst,statingthatsuchinsurancecoverageshavebeenobtainedandareinfullforce;thattheCountyofFresno,itsofficers,agentsandemployeeswillnotberesponsibleforanypremiumsonthepolicies;thatsuchCommercialGeneralLiabilityinsurancenamestheCountyofFresno,itsofficers,agentsandemployees,individuallyandcollectively,asadditionalinsured,butonlyinsofarastheoperationsunderthisAgreementareconcerned;thatsuchcoverageforadditionalinsuredshallapplyasprimaryinsuranceandanyotherinsurance,orself-insurance,maintainedbyCOUNTY,itsofficers,agentsandemployees,-i i- 12345678910111213141516171819202122232425262728shallbeexcessonlyandnotcontributingwithinsuranceprovidedunderPROVIDER’Spoliciesherein;andthatthisinsuranceshallnotbecancelledorchangedwithoutaminimumofthirty(30)daysadvance,writtennoticegiventoCOUNTY.IntheeventanyPROVIDERfailstokeepineffectatalltimesinsurancecoverageashereinprovided,COUNTYmay,inadditiontootherremediesitmayhave,suspendorterminatethisAgreementwithPROVIDERupontheoccurrenceofsuchevent.AllpoliciesshallbewithadmittedinsurerslicensedtodobusinessintheStateofCalifornia.InsurancepurchasedshallbefromcompaniespossessingacurrentA.M.Best,Inc.ratingofAFSCVIIorbetter.15.SUBCONTRACTSPROVIDERshallberequiredtoassumefullresponsibilityforallservicesandactivitiescoveredbythisAgreement,whetherornotPROVIDERisprovidingservicesdirectly.Further,PROVIDERshallbethesolepointofcontactwithregardtocontractualmatters,includingpaymentofanyandallchargesresultingfromthisAgreement.IfPROVIDERshouldproposetosubcontractwithoneormorethirdpartiestocarryoutaportionofservicescoveredbythisAgreement,anysuchsubcontractshallbeinwritingandapprovedastoformandcontentbyCOUNTY’SDBHDirectororherdesigneepriortoexecutionandimplementation.COUNTY’SDBHDirectororherdesigneeshallhavetherighttorejectanysuchproposedsubcontract.AnysuchsubcontracttogetherwithallactivitiesbyorcausedbyPROVIDERshallnotrequirecompensationgreaterthanthetotalbudgetcontainedherein.AnexecutedcopyofanysuchsubcontractshallbereceivedbyCOUNTYbeforeanyimplementationandshallberetainedbyCOUNTY.PROVIDERshallberesponsibletoCOUNTYfortheproperperformanceofanysubcontract.AnysubcontractorshallbesubjecttothesametermsandconditionsthatPROVIDERissubjecttounderthisAgreement.ItisexpresslyrecognizedthatPROVIDERcannotengageinthepracticeofmedicine.IfanymedicalservicesaretobeprovidedinconnectionwiththeservicesunderthisAgreement,suchmedicalservicesshallbeperformedbyanindependentcontractphysician.Inthisinstance,therequirementsoftheConfidentialMedicalInformationAct(CivilCode56etseq.)shallbemet.-12- 12345678910111213141516171819202122232425262728IfPROVIDERhiresanindependentcontractphysician,PROVIDERshallrequireandensurethatsuchindependentcontractphysiciancarriesProfessionalLiability(MedicalMalpractice)Insurance,withlimitsofnotlessthanOneMillionDollars($1,000,000.00)peroccurrence,ThreeMillionDollars($3,000,000.00)annualaggregate.16.NOTHIRDPARTYBENEFICIARIESItisunderstoodandagreedbyandbetweenthepartiesthattheservicesprovidedbyPROVIDERforCOUNTYhereinaresolelyforthebenefitoftheCOUNTY,andthatnothinginthisAgreementisintendedtoconferonanypersonotherthanthepartiesheretoanyrightunderorbyreasonofthisAgreement.17.REPORTS—SUBSTANCEUSEDISORDERSERVICESPROVIDER(S)shallsubmitallinformationanddatarequiredbyState,including,butnotlimitedtothefollowing:1.DrugandAlcoholTreatmentAccessReport(DATAR)andProviderWaitingListRecord(WLR)inanelectronicformatprovidedbytheStateandduenolaterthanfive(5)daysaftertheprecedingmonth;and2.CalOMSTreatment-SubmitCalOMStreatmentadmission,discharge,annualupdate,and“provideractivityreport”recordinanelectronicformatthroughCOUNTY’SSAISsystem,andonascheduleasdeterminedbytheCOUNTYwhichcomplieswithStaterequirementsfordatacontent,dataquality,reportingfrequency,reportingdeadlines,andreportmethodandduenolaterthanfive(5)daysaftertheprecedingmonth.AllCalOMSadmissions,discharges,andannualupdatesmustbeenteredintotheCOUNTY’SCalOMSsystemwithintwenty-four(24)hoursofoccurrence;and3.PROVIDER(S)shallsubmittoCOUNTYmonthlyfiscalandallprogramreports,includingProviderWaitingListRecord(WLR),withintwenty(20)daysoftheendofeachmonth.4.AmericanswithDisabilities(ADA)-Annually,uponrequestbyDBH,PROVIDER(S)shallcompleteasystem-wideaccessibilitysurveyinaformatdeterminedbyDBHforeachservicelocationandmodalityandshallsubmitanADAAccessibilityCertificationandSelf-Assessment,includinganImplementationPlan,foreachservicelocation.-13- 12456789101 112131415161718192021222324252627285.CostReports-OnanannualbasisforeachfiscalyearendingJune30thPROVIDER(S)shallsubmitacompleteandaccuratedetailedcostreport(s).CostreportsmustbesubmittedtotheCOUNTYasahardcopywithasignedcoverletterandanelectroniccopybytheduedate.Submittalmustalsoincludeanyrequestedsupportdocumentssuchasgeneralledgers.AllreportssubmittedbyPROVIDER(S)toCOUNTYmustbetypewritten.COUNTYwillissueinstructionsforcompletionandsubmittaloftheannualcostreport,includingtherelevantcostreporttemplate(s)andduedateswithinforty-five(45)daysofeachfiscalyearend.AllcostreportsmustbepreparedinaccordancewithGenerallyAcceptedAccountingPrinciples.Unallowablecostssuchaslobbyingorpoliticaldonationsmustbedeductedfromthecostreportandallinvoices.IfthePROVIDER(S)doesnotsubmitthecostreportbytheduedate,includinganyextensionperiodgrantedbytheCOUNTY,theCOUNTYmaywithholdpaymentofpendinginvoicesuntilthecostreport(s)hasbeensubmittedandclearsCOUNTYdeskauditforcompletenessandaccuracy.A.DMC-ADMCcostreportmustbesubmittedinaformatprescribedbytheDHCSforthepurposesofShortDoyleMedi-Calreimbursementoftotalcostsforallprograms.PROVIDER(S)shallreportcostsundertheirapprovedlegalentitynumberestablishedduringtheDMCcertificationprocess.TotalunitsofservicereportedonthecostreportwillbecomparedtotheunitsofservicesenteredbyPROVIDER(S)intoCOUNTY’Sdatasystem.PROVIDER(S)willberequiredtocorrectdiscrepanciesandresubmittoCOUNTYpriortoCOUNTY’Sfinalacceptanceofthecostreport.B.OTHERFUNDINGSOURCES-PROVIDER(S)willberequiredtosubmitacostreportonaform(s)approvedandprovidedbytheCOUNTYtoreflectactualcostsandreimbursementforservicesprovidedthroughfundingsourcesotherthanDMC.ContractsthatincludeanegotiatedrateperunitofservicewillbereimbursedonlyforthecostsofapprovedunitsofserviceuptothenegotiatedunitofservicerateapprovedintheAgreement,regardlessofthecontractmaximum.Ifthecostreportindicates-14- 1245678910111213141516171819202122232425262728anamountduetoCOUNTY,PROVIDER(S)shallsubmitpaymentwiththereport.IfanamountisduetoPROVIDER(S)COUNTYshallreimbursePROVIDERwithinforty-five(45)daysofreceivingandacceptingtheyear-endcostreport.C.MULTIPLEFUNDINGSOURCES-PROVIDER(S)whohasmultipleagreementsforthesameservicesprovidedatthesamelocationwhereatleastoneoftheAgreementsisfundedthroughDMCandtheotherfundingisotherfederalorcountyrealignmentfundingwillberequiredtocompleteDMCcostreportsandCOUNTYapprovedcostreports.SuchAgreementswillbesettledforactualcostsinaccordancewithMedicaidreimbursementrequirementsasspecifiedinTitleXIXorTitleXXIoftheSocialSecurityAct;Title22,andtheState’sMedicaidPlan.DuringthetennofthisAgreementandthereafter,COUNTYandPROVIDER(S)agreetosettledollaramountsdisallowedorsettledinaccordancewithDHCSandCOUNTYauditsettlementfindings.DHCSauditprocessisapproximatelyeighteen(18)tothirty-six(36)monthsfollowingthecloseoftheStatefiscalyear.COUNTYmaychoosetoappealDHCSsettlementresultsandthereforereservestherighttodeferpaybacksettlementwithPROVIDER(S)untilresolutionoftheappeal.IntheeventthatPROVIDER(S)failstoprovidesuchreportsorotherinformationrequiredhereunder,itshallbedeemedsufficientcausefortheCOUNTYtowithholdmonthlypaymentsuntilthereiscompliance.Inaddition,thePROVIDERshallprovidewrittennotificationandexplanationtotheCOUNTYwithinfifteen(15)daysofanyfundsreceivedfromanothersourcetoconductthesameservicescoveredbythisAgreement.18.EVALUATION-MONITORINGOUTCOMES-COUNTY’SDBHDirector,orherdesignee,andDHCSortheirdesigneesshallmonitorandevaluatetheperformanceofPROVIDERunderthisAgreementtodeterminetothebestpossibledegreethesuccessorfailureoftheservicesprovidedunderthisAgreement.AtthediscretionoftheCOUNTY,asubcontractormaybeobtainedbytheCOUNTYtoindependentlyevaluateandmonitortheperformanceofthePROVIDER.PROVIDERshallparticipateintheevaluationoftheprogramas-15- 12345678910111213141516171819202122232425262728needed,atthediscretionofCOUNTY.COUNTYshallrecapturefromPROVIDERthevalueofanyservicesorotherexpendituresdeterminedtobeineligiblebasedontheCOUNTYorStatemonitoringresults.AtthediscretionoftheCOUNTY,recoupmentcanbemadethroughafutureinvoicereductionorreimbursementbythePROVIDER.PROVIDERshallparticipateinaprogramreviewoftheprogramatleastyearlyormorefrequently,orasneeded,atthediscretionofCOUNTY.ThePROVIDERagreestosupplyallinformationrequestedbytheCOUNTY,DHCS,and/orthesubcontractorduringtheprogramevaluation,monitoring,and/orreview.19.DATASECURITYForthepurposeofpreventingthepotentialloss,misappropriationorinadvertentaccess,viewing,useordisclosureofCOUNTYdataincludingsensitiveorpersonalclientinformation;abuseofCOUNTYresources;and/ordisruptiontoCOUNTYoperations,individualsand/oragenciesthatenterintoacontractualrelationshipwiththeCOUNTYforthepurposeofprovidingservicesunderthisAgreementmustemployadequatedatasecuritymeasurestoprotecttheconfidentialinformationprovidedtoPROVIDERbytheCOUNTY,includingbutnotlimitedtothefollowing:A.PROVIDER-OWNEDMOBILE.WIRELESS.ORHANDHELDDEVICESPROVIDERmaynotconnecttoCOUNTYnetworksviapersonally-ownedmobile,wirelessorhandhelddevices,unlessthefollowingconditionsaremet:1)PROVIDERhasreceivedauthorizationbyCOUNTYfortelecommutingpurposes;2)Currentvirusprotectionsoftwareisinplace;3)Mobiledevicehastheremotewipefeatureenabled;and4)Asecureconnectionisused.B.PROVIDER-OWNEDCOMPUTERSORCOMPUTERPERIPHERALSPROVIDERmaynotbringPROVIDER-ownedcomputersorcomputerperipheralsintotheCOUNTYforusewithoutpriorauthorizationfromtheCOUNTY’SChiefInformationOfficer,and/ordesignee(s),includingbutnotlimitedtomobilestoragedevices.Ifdataisapprovedtobe-16- 12345678910111213141516171819202122232425262728transferred,datamustbestoredonasecureserverapprovedbytheCOUNTYandtransferredbymeansofaVirtualPrivateNetwork(VPN)connection,oranothertypeofsecureconnection.Saiddatamustbeencrypted.C.COUNTY-OWNEDCOMPUTEREQUIPMENTPROVIDERoranyonehavinganemploymentrelationshipwiththeCOUNTYmaynotuseCOUNTYcomputersorcomputerperipheralsonnon-COUNTYpremiseswithoutpriorauthorizationfromtheCOUNTY’SChiefInformationOfficer,and/ordesignee(s).D.PROVIDERmaynotstoreCOUNTY’Sprivate,confidentialorsensitivedataonanyhard-diskdrive,portablestoragedevice,orremotestorageinstallationunlessencrypted.E.PROVIDERshallberesponsibletoemploystrictcontrolstoensuretheintegrityandsecurityofCOUNTY’Sconfidentialinformationandtopreventunauthorizedaccess,viewing,useordisclosureofdatamaintainedincomputerfiles,programdocumentation,dataprocessingsystems,datafilesanddataprocessingequipmentwhichstoresorprocessesCOUNTYdatainternallyandexternally.F.ConfidentialclientinformationtransmittedtoonepartybytheotherbymeansofelectronictransmissionsmustbeencryptedaccordingtoAdvancedEncryptionStandards(AES)of128BITorhigher.Additionally,apasswordorpassphrasemustbeutilized.G.PROVIDERisresponsibletoimmediatelynotifyCOUNTYofanyviolations,breachesorpotentialbreachesofsecurityrelatedtoCOUNTY’Sconfidentialinformation,datamaintainedincomputerfiles,programdocumentation,dataprocessingsystems,datafilesanddataprocessingequipmentwhichstoresorprocessesCOUNTYdatainternallyorexternally.H.COUNTYshallprovideoversighttoPROVIDER’SresponsetoallincidentsarisingfromapossiblebreachofsecurityrelatedtoCOUNTY’SconfidentialclientinformationprovidedtoPROVIDER.PROVIDERwillberesponsibletoissueanynotificationtoaffectedindividualsasrequiredbylaworasdeemednecessarybyCOUNTYinitssolediscretion.PROVIDERwillberesponsibleforallcostsincurredasaresultofprovidingtherequirednotification.20-PERINATALSERVICESPROVIDERshallcomplywiththerequirementsfor"PerinatalServicesNetworkGuidelines2016,"availableattheDHCSwebaddressbelowandbythisreferenceincorporatedherein,-17- 1245678910111213141516171819202122232425262728andtheState-CountyContractbetweenDHCSandtheCOUNTYuntilsuchtimenewPerinatalServicesNetworkGuidelinesandtheState-CountyContractareupdatedandadopted.Noformalamendmentofthiscontractisrequiredfornewguidelinestoapply.http://www.dhcs.ca.gov/individuals/Pages/InformationNotices2016.aspxPROVIDERshallcomplywithfederalandstatemandatestoprovidealcoholandotherdrugtreatmentservicesdeemedmedicallynecessaryforMedi-Caleligible:(1)pregnantandpostpartumwomen,and(2)youthunderage21whoareeligibleundertheEarlyandPeriodicScreening,Diagnostic,andTreatment(EPSDT)Program.PROVIDERshallrequirethatprovidersofperinatalDMCservicesareproperlycertifiedtoprovidetheseservicesandcomplywiththerequirementscontainedinTitle22,Section51341.1,ServicesforPregnantandPostpartumWomenandTitle9commencingwithsection10360.21.INTERIMSERVICESPROVIDERmustadheretotheState-CountyContractrequirementtoprovideInterimServicesintheeventthatanindividualmustwaittobeplacedintreatment.InterimSubstanceAbuseServicesmeansservicesthatareprovideduntilanindividualisadmittedtoasubstanceabusetreatmentprogram.Thepurposesoftheservicesaretoreducetheadversehealtheffectsofsuchabuse,promotethehealthoftheindividual,andreducetheriskoftransmissionofdisease.Ataminimum,interimservicesincludecounselingandeducationaboutHIVandtuberculosis(TB),abouttherisksofneedle-sharing,therisksoftransmissiontosexualpartnersandinfants,andaboutstepsthatcanbetakentoensuretheHIVandTBtransmissiondoesnotoccur,aswellasreferralforHIVorTBtreatmentservicesifnecessary.Forpregnantwomen,interimservicesalsoincludecounselingontheeffectsofalcoholanddruguseonthefetus,aswellasreferralforprenatalcare.RecordsmustindicateevidencethatInterimServiceshavebeenprovidedanddocumentationwillbereviewedforcompliance.22.REFERENCESTOLAWSANDRULESIntheeventanylaw,regulation,orpolicyreferredtointhisAgreementisamendedduringthetermthereof,thepartiesheretoagreetocomplywiththeamendedprovisionasoftheeffectivedateofsuchamendment.-18- 1234567891011121314151617181920212223242526272823.STATEALCOHOLANDDRUGREQUIREMENTSA.INDEMNIFICATIONThePROVIDERagreestoindemnify,defendandsaveharmlesstheState,itsofficers,agentsandemployeesfromanyandallclaimsandlossesaccruingorresultingtoanyandallcontractors,subcontractors,materialmen,laborersandanyotherperson,firmorcorporationfurnishingorsupplyingwork,services,materialsorsuppliesinconnectionwiththeperfomianceofthisAgreementandfromanyandallclaimsandlossesaccruingorresultingtoanyperson,fimiorcorporationwhomaybeinjuredordamagedbythePROVIDERintheperformanceofthisAgreement.B.INDEPENDENTCONTRACTORThePROVIDERandtheagentsandemployeesofPROVIDER,intheperfomianceofthisAgreement,shallactinanindependentcapacityandnotasofficersoremployeesoragentsofStateofCalifornia.C.CONTROLREQUIREMENTSThisAgreementissubjecttoallapplicableFederalandStatelaws,regulationsandstandards.PROVIDER(S)shallestablishwrittenproceduresconsistentwithState-CountyContractrequirements.TheprovisionsofthisAgreementarenotintendedtoabrogateanyprovisionsoflaworregulationexistingorenactedduringthetermofthisAgreement.D.CONFIDENTIALITYPROVIDERshallconformtoandCOUNTYshallmonitorcompliancewithallStateofCaliforniaandFederalstatutesandregulationsregardingconfidentiality,includingbutnotlimitedtoconfidentialityofinformationrequirementsatPart2,Title42,CodeofFederalRegulations;CaliforniaWelfareandInstitutionsCode,sections14100.2,11977,11812,5328;Division10.5and10.6oftheCaliforniaHealthandSafetyCode;Title22,CaliforniaCodeofRegulations,section51009;andDivision1,Part2.6,Chapters1-7oftheCaliforniaCivilCode.E.REVENUECOLLECTIONPOLICYPROVIDERshallconformtoallpoliciesandproceduresregardingrevenuecollectionissuedbytheStateundertheprovisionsoftheHealthandSafetyCode,Division10.5.F.EXPENDITUREOFSTATEGENERALANDFEDERALFUNDS-19- 12345678910111213141516171819202122232425262728PROVIDERagreesthatallfundspaidoutbytheStateshallbeusedexclusivelyforprovidingalcoholand/ordrugprogramservices,administrativecosts,andallowableoverhead.G.ACCESSTOSERVICESPROVIDERshallprovideaccessibleandappropriateservicesinaccordancewithFederalandStatestatutesandregulationstoalleligiblepersons.IllH.REPORTSPROVIDERagreestoparticipateinsurveysrelatedtotheperformanceofthisAgreementandexpenditureoffundsandagreestoprovideanysuchinformationinamutuallyagreeduponformat.I.AUDITSAllStateandFederalfundsfurnishedtothePROVIDER(S)pursuanttothisAgreementalongwithrelatedpatientfees,thirdpartypayments,orotherrelatedrevenuesandfundscommingledwiththeforegoingfundsaresubjecttoauditbytheState.TheStatemayauditallalcoholanddrugprogramrevenueandexpenditurescontainedinthisAgreementforthepurposeofestablishingthebasisforthesubsequentyear'snegotiation.J.RECORDSMAINTENANCE1)PROVIDERshallmaintainbooks,records,documents,andotherevidencenecessarytomonitorandauditthisAgreement.2)PROVIDERshallmaintainadequateprogramandfiscalrecordsrelatingtoindividualsservedunderthetermsofthisAgreement,asrequired,tomeettheneedsoftheStateinmonitoringquality,quantity,fiscalaccountability,andaccessibilityofservices.Informationoneachindividualshallinclude,butnotbelimitedto,admissionrecords,patientandparticipantinterviewsandprogressnotes,andrecordsofserviceprovidedbyvariousservicelocations,insufficientdetailtomakepossibleanevaluationofservicesprovidedandcompliancewiththisAgreement.IllIIIIII-20- 1234567891011121314151617181920212223242526272824.HEALTHINSURANCEPORTABILITYANDACCOUNTABILITYACTCOUNTYandPROVIDEReachconsiderandrepresentthemselvesascoveredentitiesasdefinedbytheU.S.HealthInsurancePortabilityandAccountabilityActof1996,PublicLaw104-191(HIPAA)andagreetouseanddiscloseprotectedhealthinformationasrequiredbylaw.COUNTYandPROVIDERacknowledgethattheexchangeofprotectedhealthinformationbetweenthemisonlyfortreatment,payment,andhealthcareoperations.COUNTYandPROVIDERintendtoprotecttheprivacyandprovideforthesecurityofProtectedHealthInformation(PHI)pursuanttotheAgreementincompliancewithHIPAA,theHealthInformationTechnologyforEconomicandClinicalHealthAct,PublicLaw111-005(HITECH),andregulationspromulgatedthereunderbytheU.S.DepartmentofHealthandHumanServices(HIPAARegulations)andotherapplicablelaws.AspartoftheHIPAARegulations,thePrivacyRuleandtheSecurityRulerequirePROVIDERtoenterintoacontractcontainingspecificrequirementspriortothedisclosureofPHI,assetforthin,butnotlimitedto,Title45,Sections164.314(a),164.502(e)and164.504(e)oftheCodeofFederalRegulations(CFR).25.CULTURALCOMPETENCYAsrelatedtoCulturalandLinguisticCompetence,PROVIDERshallcomplywiththefollowing:A.Title6oftheCivilRightsActof1964(42U.S.C.Section2000d,and45C.F.R.Part80)andExecutiveOrder12250of1979whichprohibitsrecipientsoffederalfinancialassistancefromdiscriminatingagainstpersonsbasedonrace,color,nationalorigin,sex,disabilityorreligion.ThisisinterpretedtomeanthatalimitedEnglishproficient(LEP)individualisentitledtoequalaccessandparticipationinfederallyfundedprogramsthroughtheprovisionofcomprehensiveandqualitybilingualservices.B.PoliciesandproceduresforensuringaccessandappropriateuseoftrainedinterpretersandmaterialtranslationservicesforallLEPconsumers,including,butnotlimitedto,assessingtheculturalandlinguisticneedsofitsconsumers,trainingofstaffonthepoliciesandprocedures,andmonitoringitslanguageassistanceprogram.ThePROVIDER’Sproceduresmustincludeensuring-21- 12345678910111213141516171819202122232425262728complianceofanysub-contractedproviderswiththeserequirements.C.PROVIDERassurancesthatminorsshallnotbeusedasinterpreters.D.PROVIDERshallprovideandpayforinterpretingandtranslationservicestopersonsparticipatinginPROVIDER’SserviceswhohavelimitedornoEnglishlanguageproficiency,includingservicestopersonswhoaredeaforblind.Interpreterandtranslationservicesshallbeprovidedasnecessarytoallowsuchparticipantsmeaningfulaccesstotheprograms,servicesandbenefitsprovidedbyPROVIDER.Interpreterandtranslationservices,includingtranslationofPROVIDER’S“vitaldocuments”(thosedocumentsthatcontaininformationthatiscriticalforaccessingPROVIDER’Sservicesorarerequiredbylaw)shallbeprovidedtoparticipantsatnocosttotheparticipant.PROVIDERshallensurethatanyemployees,agents,subcontractors,orpartnerswhointerpretortranslateforaprogramparticipant,orwhodirectlycommunicatewithaprogramparticipantinalanguageotherthanEnglish,demonstrateproficiencyintheparticipant'slanguageandcaneffectivelycommunicateanyspecializedtermsandconceptspeculiartoPROVIDER’Sservices.E.IncompliancewiththeStatemandatedCulturallyandLinguisticallyAppropriateServicesstandardsaspublishedbytheOfficeofMinorityHealth,PROVIDERmustsubmittoCOUNTYforapproval,within60daysfromdateofcontractexecution,PROVIDER’Splantoaddressallfifteennationalculturalcompetencystandardsassetforthinthe“NationalStandardsonCulturallyandLinguisticallyAppropriateServices”(CLAS),attachedheretoasExhibitE,andincorporatedhereinbythisreference.County’sannualon-sitereviewofPROVIDERshallincludecollectionofdocumentationtoensureallnationalstandardsareimplemented.Asthenationalcompetencystandardsareupdated,PROVIDER’Splanmustbeupdatedaccordingly.F.PROVIDERshallcompleteandsubmitcounty-issuedCLASself-assessmentannually.PROVIDERshallupdateCLASplanasnecessary.26.SINGLEAUDITCLAUSEA.IfPROVIDERexpendsSevenHundredFiftyThousandandNo/100Dollars($750,000.00)ormoreinFederalandFederalflow-throughmonies,PROVIDERagreestoconductanannualauditinaccordancewiththerequirementsoftheSingleAuditStandardsassetforthinOfficeofManagementandBudget(OMB)CircularA-133.PROVIDERshallsubmitsaidauditandmanagement-22- 12345678910111213141516171819202122232425262728lettertoCOUNTY.Theauditmustincludeastatementoffindingsorastatementthattherewerenofindings.Iftherewerenegativefindings,PROVIDERmustincludeacorrectiveactionplansignedbyanauthorizedindividual.PROVIDERagreestotakeactiontocorrectanymaterialnon-complianceorweaknessfoundasaresultofsuchaudit.SuchauditshallbedeliveredtoCOUNTY’SDepartmentofBehavioralHealth,BusinessOfficeforreviewwithinnine(9)monthsoftheendofanyfiscalyearinwhichfundswereexpendedand/orreceivedfortheprogram.FailuretoperformtherequisiteauditfunctionsasrequiredbythisAgreementmayresultinCOUNTYperformingthenecessaryaudittasks,oratCOUNTY’Soption,contractingwithapublicaccountanttoperformsaidaudit,or,mayresultintheinabilityofCOUNTYtoenterintofutureagreementswithPROVIDER.AllauditcostsrelatedtothisAgreementarethesoleresponsibilityofPROVIDER.B.AsingleauditreportisnotapplicableifPROVIDER’SFederalcontractsdonotexceedtheSevenHundredFiftyThousandandNo/100Dollars($750,000.00)requirementorPROVIDER’SonlyfundingisthroughDrugrelatedMedi-Cal.Ifasingleauditisnotapplicable,aprogramauditmustbeperformedandaprogramauditreportwithmanagementlettershallbesubmittedbyPROVIDERtoCOUNTYasaminimumrequirementtoattesttoPROVIDER’Ssolvency.SaidauditreportshallbedeliveredtoCOUNTY’SDepartmentofBehavioralHealth,BusinessOfficeforreview,nolaterthannine(9)monthsafterthecloseofthefiscalyearinwhichthefundssuppliedthroughthisAgreementareexpended.FailuretocomplywiththisActmayresultinCOUNTYperformingthenecessaryaudittasksorcontractingwithaqualifiedaccountanttoperformsaidaudit.AllauditcostsrelatedtothisAgreementarethesoleresponsibilityofPROVIDERwhoagreestotakecorrectiveactiontoeliminateanymaterialnoncomplianceorweaknessfoundasaresultofsuchaudit.AuditworkperformedbyCOUNTYunderthissectionshallbebilledtothePROVIDERatCOUNTY’Scost,asdeterminedbyCOUNTY’SAuditor-Controller/Treasurer-TaxCollector.Tomaintaintheintegrityoftheaudits,PROVIDERisrequiredtochangeitsauditor(CertifiedPublicAccountant)atleasteverythree(3)years.C.PROVIDERshallmakeavailableallrecordsandaccountsforinspectionbyCOUNTY,theStateofCalifornia,ifapplicable,theComptrollerGeneraloftheUnitedStates,theFederalGrantorAgency,oranyoftheirdulyauthorizedrepresentatives,atallreasonabletimesforaperiodofat-23- 12345678910111213141516171819202122232425262728leastthree(3)yearsfollowingfinalpaymentunderthisAgreementortheclosureofallotherpendingmatters,whicheverislater.27.TAXEQUITYANDFISCALRESPONSIBILITYACTTotheextentnecessarytopreventdisallowanceofreimbursementundersection1861(v)(1)(I)oftheSocialSecurityAct,(42U.S.C.§1395x,subd.(v)(l)[I]),untiltheexpirationoffive(5)yearsafterthefurnishingofservicesunderthisAgreement,PROVIDERshallmakeavailable,uponwrittenrequestoftheSecretaryoftheUnitedStatesDepartmentofHealthandHumanServices,oruponrequestoftheComptrollerGeneraloftheUnitedStatesGeneralAccountingOffice,oranyoftheirdulyauthorizedrepresentatives,acopyofthisAgreementandsuchbooks,documents,andrecordsasarenecessarytocertifythenatureandextentofthecostsoftheseservicesprovidedbyPROVIDERunderthisAgreement.PROVIDERfurtheragreesthatintheeventPROVIDERcarriesoutanyofitsdutiesunderthisAgreementthroughasubcontract,withavalueorcostofTenThousandandNo/100Dollars($10,000.00)ormoreoveratwelve(12)monthperiod,witharelatedorganization,suchAgreementshallcontainaclausetotheeffectthatuntiltheexpirationoffive(5)yearsafterthefurnishingofsuchservicespursuanttosuchsubcontract,therelatedorganizationsshallmakeavailable,uponwrittenrequestoftheSecretaryoftheUnitedStatesDepartmentofHealthandHumanServices,oruponrequestoftheComptrollerGeneraloftheUnitedStatesGeneralAccountingOffice,oranyoftheirdulyauthorizedrepresentatives,acopyofsuchsubcontractandsuchbooks,documents,andrecordsofsuchorganizationassirenecessarytoverifythenatureandextentofsuchcosts.28.COMPLIANCEWITHLAWSANDPOLICIESPROVIDERshallcomplywithallapplicablerulesandregulationssetforthinTitles9and22oftheCaliforniaCodeofRegulations,andCaliforniaHealthandSafetyCodesection11750etseq.PROVIDERshallcomplywithanyotherFederalandStatelawsorguidelinesapplicabletoPROVIDER’SperformanceunderthisAgreementoranylocalordinances,regulations,orpoliciesapplicable.Suchprovisionsinclude,butarenotrestrictedto:A.PROVIDERshallprovidethateachclient'sabilitytopayforservicesisdetenninedbytheuseofthemethodapprovedbyCOUNTY.B.PROVIDERshallestablishanduseCOUNTY’Sapprovedmethodofdetermining-24- 1245678910111213141516171819202122232425262728andcollectingfeesfromclients.C.PROVIDERshallfurnishclientrecordsinaccordancewiththeapplicableFederalandStateregulations,andwiththeStandardsforAlcoholandDrugTreatmentProgramssetforthbytheStateDepartmentofAlcoholandDrugPrograms,includinginsuchrecordsatreatmentplanforeachclient,andevidenceofeachservicerendered.D.PROVIDERshallsubmitaccurate,completeandtimelyclaimsandcostreports,reportingonlyallowablecosts.E.PROVIDERshallcomplywithstatisticalreportingandprogramevaluationsystemsasprovidedinStateofCaliforniaregulationsandinthisAgreement.F.PROVIDERshallcomplywithrequirementscontainedintheState-CountyContractwithDHCSbythisreferenceincorporatedherein,untilsuchtimethatanewState-CountyContractisestablished.UponamendmentoftheState-CountyContract,thetermsoftheamendedContractshallautomaticallybeincorporatedintothisAgreement.29.FEDERALCERTIFICATIONSCERTIFICATIONREGARDINGDEBARMENT.SUSPENSION.INELIGIBILITYANDVOLUNTARYEXCLUSIONLOWERTIERCOVEREDTRANSACTIONSA.DBHandPROVIDERrecognizethatFederalassistancefundswillbeusedunderthetermsofthisAgreement.Forpurposesofthissection,DBHwillbereferredtoasthe"prospectiverecipient".B.ThiscertificationisrequiredbytheregulationsimplementingExecutiveOrder12549,DebarmentandSuspension,29CFRPart98,section98.510,Participants'responsibilities.TheregulationswerepublishedasPartVIIoftheMay26,1988FederalRegister(pages19160-19211).1)TheprospectiverecipientofFederalassistancefundscertifiesbyenteringthisAgreement,thatneitheritnoritsprincipalsarepresentlydebarred,suspended,proposedfordebamient,declaredineligible,orvoluntarilyexcludedfromparticipationinthistransactionbyanyFederaldepartmentoragency.2)TheprospectiverecipientoffundsagreesbyenteringintothisAgreement,thatitshallnotknowinglyenterintoanylowertiercoveredtransactionwithapersonwhoisdebarred,-25- 12345678910111213141516171819202122232425262728suspended,declaredineligible,orvoluntarilyexcludedfromparticipationinthiscoveredtransaction,unlessauthorizedbytheFederaldepartmentoragencywithwhichthistransactionoriginated.3)WheretheprospectiverecipientofFederalassistancefundsisunabletocertifytoanyofthestatementsinthiscertification,suchprospectiveparticipantshallattachanexplanationtothisAgreement.4)TheprospectiverecipientshallprovideimmediatewrittennoticetoDBHifatanytimeprospectiverecipientlearnsthatitscertificationinthisclauseofthisAgreementwaserroneouswhensubmittedorhasbecomeerroneousbyreasonofchangedcircumstances.5)TheprospectiverecipientfurtheragreesthatbyenteringintothisAgreement,itwillincludeaclauseidenticaltothisclauseofthisAgreement,andtitled"CertificationRegardingDebarment,Suspension,IneligibilityandVoluntaryExclusionLowerTierCoveredTransactions",inalllowertiercoveredtransactionsandinallsolicitationsforlowertiercoveredtransactions.6)ThecertificationinthisclauseofthisAgreementisamaterialrepresentationoffactuponwhichreliancewasplacedbyCOUNTYwhenthistransactionwasenteredinto.30.CLEANAIRANDWATERIntheeventfundingunderthisAgreementexceedsOneHundredThousandandNo/100Dollars($100,000.00),thePROVIDERmustcomplywithallapplicablestandards,orders,orrequirementsissuedundersection306oftheCleanAirAct(42U.S.C.1857(h)),section506oftheCleanWaterAct(33U.S.C.1368),ExecutiveOrder11738,andEnvironmentalProtectionAgencyRegulations(40CFRpart32).31.SMOKINGPROHIBITIONREQUIREMENTSPROVIDERshallcomplywithPublicLaw103-227,alsoknownasthePro-ChildrenActof1994(20USCSection6081,etseq.),andwithCaliforniaLaborCodeSection6404.5,theCaliforniaSmoke-FreeWorkplaceLaw.32.ENERGYEFFICIENCYThePROVIDERmustcomplywiththemandatorystandardsandpoliciesrelatingtoenergyefficiencywhicharecontainedinthestateenergyconservationplanissuedincompliancewithEnergyPolicyandConservationAct(Pub.L.94163).-26- 1234567891011121314151617181920212223242526272833.NON-DISCRIMINATIONPROVISIONA.ELIGIBILITYFORSERVICES-PROVIDERshallprepare,prominentlypostinitsfacility,andmakeavailabletotheDBHDirectororherdesigneeandtothepublicalleligibilityrequirementstoparticipateintheprogramfundedunderthisAgreement.PROVIDERshallnotunlawfullydiscriminateintheprovisionofservicesbecauseofrace,color,creed,nationalorigin,gender,age,orphysicalormentaldisabilityasprovidedbyStateofCaliforniaandFederallawinaccordancewithTitleVIoftheCivilRightsActof1964(42USCsection2000(d));AgeDiscriminationActof1975(42USCsection1681);RehabilitationActof1973(29USCsection794);EducationAmendmentsof1972(20USCsection1681);AmericanswithDisabilitiesActof1990(42USCsection12132);Title45,CodeofFederalRegulations,Part84;provisionsoftheFairEmploymentandHousingAct(CaliforniaGovernmentCodesection12900);andregulationspromulgatedthereunder(Title2,CCR,section7285.0);Title2,Division3,Article9.5oftheCaliforniaGovernmentCodecommencingwithsection11135;andTitle9,Division4,Chapter6oftheCaliforniaCodeofRegulationscommencingwithsection10800.B.EQUALOPPORTUNITY-PROVIDERshallcomplywithCaliforniaGovernmentCode,section12990andCaliforniaCodeofRegulations,TitleII,Division4,Chapter5,inmattersrelatedtothedevelopment,implementation,andmaintenanceofanondiscriminationprogram.PROVIDERshallnotdiscriminateagainstanyemployeeorapplicantforemploymentbecauseofrace,religion,color,nationalorigin,physicalormentaldisability,maritalstatus,gender,orage.Suchpracticesincluderetirement,recruitment,advertising,hiring,layoff,termination,upgrading,demotion,transfer,ratesofpayorotherformsofcompensation,useoffacilities,andothertennsandconditionsofemployment.PROVIDERagreestopostinconspicuousplaces,noticesavailabletoallemployeesandapplicantsforemploymentsettingforththeprovisionsoftheEqualOpportunityAct(42USCsection2000(e))inconformancewithFederalExecutiveOrderNo.11246.PROVIDERagreestocomplywiththeprovisionsoftheRehabilitationActof1973(29USCSection794).C.SUSPENSIONOFCOMPENSATION-Ifanallegationofdiscriminationoccurs,DBHmaywithholdallfurtherfunds,untilPROVIDERcanshowbyclearandconvincingevidencetothesatisfactionofDBHthatfundsprovidedunderthisAgreementwerenotusedinconnectionwiththeallegeddiscrimination.-27- 12345678910111213141516171819202122232425262728D.NEPOTISM-ExceptbyconsentoftheDBHDirectororherdesignee,nopersonshallbeemployedbyPROVIDERwhoisrelatedbybloodormarriagetoorwhoisamemberoftheBoardofDirectorsoranofficerofPROVIDER.E.NEWFACILITIESANDDISABILITYACCESS-Newfacilitiesshallbewheelchairaccessibleandprovideaccesstothedisabled,consistentwithTitle9,CaliforniaCodeofRegulations,section10820.Ifanewfacilitywillbeutilized,aplanensuringaccessibilitytothedisabledmustbedeveloped.DBHshallassess,monitor,anddocumentPROVIDER’ScompliancewiththeRehabilitationActof1973andAmericanswithDisabilitiesActof1990toensurethatrecipients/beneficiariesandintendedrecipients/beneficiariesofservicesareprovidedserviceswithoutregal'dtophysicalormentaldisabilityandthatPROVIDERhasprovidedafacilityaccessibletothephysicallydisabled.34.ASSURANCESInenteringintothisAgreement,PROVIDERcertifiesthatitisnotcurrentlyexcluded,suspended,debarred,orotherwiseineligibletoparticipateintheFederalHealthCarePrograms;thatithasnotbeenconvictedofacriminaloffenserelatedtotheprovisionofhealthcareitemsorservices;norhasitbeenreinstatedtoparticipationintheFederalHealthCareProgramsafteraperiodofexclusion,suspension,debarment,orineligibility.IfCOUNTYlearns,subsequenttoenteringintoacontract,thatPROVIDERisineligibleonthesegrounds,COUNTYwillremovePROVIDERfromresponsibilityfor,orinvolvementwith,COUNTY’SbusinessoperationsrelatedtotheFederalHealthCareProgramsandshallremovesuchPROVIDERfromanypositioninwhichPROVIDER’Scompensation,ortheitemsorservicesrendered,orderedorprescribedbyPROVIDERmaybepaidinwholeorpart,directlyorindirectly,byFederalHealthCareProgramsorotherwisewithFederalFundsatleastuntilsuchtimeasPROVIDERisreinstatedintoparticipationintheFederalHealthCarePrograms.FurtherthePROVIDERagreestotheDisclosureofCriminalHistoryandCivilActionsandCertificationregardingdebarmentsuspensionandotherresponsibilitymattersprimarycoveredtransactions;PROVIDERmustsignanappropriateCertificationregardingdebarment,suspension,andotherresponsibilitymatters,attachedheretoasExhibitF,“DisclosureofCriminalHistory”,incorporatedhereinbyreferenceandmadepartofthisAgreement.A.IfCOUNTYhasnoticethatPROVIDERhasbeenchargedwithacriminaloffense-28- 12345678910111213141516171819202122232425262728relatedtoanyFederalHealthCareProgram,orisproposedforexclusionduringthetermonanycontract,PROVIDERandCOUNTYshalltakeallappropriateactionstoensuretheaccuracyofanyclaimssubmittedtoanyFederalHealthCareProgram.Atitsdiscretiongivensuchcircumstances,COUNTYmayrequestthatPROVIDERceaseprovidingservicesuntilresolutionofthechargesortheproposedexclusion.B.PROVIDERagreesthatallpotentialnewemployeesofPROVIDERorsubcontractorsofPROVIDERwho,ineachcase,areexpectedtoperformprofessionalservicesunderthisAgreement,willbequeriedastowhether(1)theyarenoworeverhavebeenexcluded,suspended,debarred,orotherwiseineligibletoparticipateintheFederalHealthCarePrograms;(2)theyhavebeenconvictedofacriminaloffenserelatedtotheprovisionofhealthcareitemsorservices;andor(3)theyhavebeenreinstatedtoparticipationintheFederalHealthCareProgramsafteraperiodofexclusion,suspension,debarment,orineligibility.1)IntheeventthepotentialemployeeorsubcontractorinformsPROVIDERthatheorsheisexcluded,suspended,debarredorotherwiseineligible,orhasbeenconvictedofacriminaloffenserelatingtotheprovisionofhealthcareservices,andPROVIDERhiresorengagessuchpotentialemployeeorsubcontractor,PROVIDERwillensurethatsaidemployeeorsubcontractordoesnowork,eitherdirectlyorindirectlyrelatingtoservicesprovidedtoCOUNTY.2)Notwithstandingtheabove,COUNTYatitsdiscretionmayterminatethisAgreementinaccordancewithSectionThree(3)TERMINATIONofthisAgreement,orrequireadequateassurance(asdefinedbyCOUNTY)thatnoexcluded,suspendedorotherwiseineligibleemployeeorsubcontractorofPROVIDERwillperformwork,eitherdirectlyorindirectly,relatingtoservicesprovidedtoCOUNTY.SuchdemandforadequateassuranceshallbeeffectiveuponatimeframetobedetemiinedbyCOUNTYtoprotecttheinterestsofCOUNTYconsumers.C.PROVIDERshallverify(byaskingtheapplicableemployeesandsubcontractors)thatallcurrentemployeesandexistingsubcontractorswho,ineachcase,areexpectedtoperformprofessionalservicesunderthisAgreement(1)arenotcurrentlyexcluded,suspended,debarred,orotherwiseineligibletoparticipateintheFederalHealthCarePrograms;(2)havenotbeenconvictedofacriminaloffenserelatedtotheprovisionofhealthcareitemsorservices;and(3)havenotbeenreinstatedtoparticipationintheFederalHealthCareProgramafteraperiodofexclusion,suspension,debarment,or-29- 12345678910111213141516171819202122232425262728ineligibility.IntheeventanyexistingemployeeorsubcontractorinformsPROVIDERthatheorsheisexcluded,suspended,debarredorotherwiseineligibletoparticipateintheFederalHealthCarePrograms,orhasbeenconvictedofacriminaloffenserelatingtotheprovisionofhealthcareservices,PROVIDERwillensurethatsaidemployeeorsubcontractordoesnowork,eitherdirectorindirect,relatingtoservicesprovidedtoCOUNTY.1)PROVIDERagreestonotifyCOUNTYimmediatelyduringthetennofthisAgreementwheneverPROVIDERlearnsthatanemployeeorsubcontractorwho,ineachcase,isprovidingprofessionalservicesunderthisAgreementisexcluded,suspended,debarredorotherwiseineligibletoparticipateintheFederalHealthCarePrograms,orisconvictedofacriminaloffenserelatingtotheprovisionofhealthcareservices.2)Notwithstandingtheabove,COUNTYatitsdiscretionmayterminatethisAgreementinaccordancewithSectionThree(3)TERMINATIONofthisAgreement,orrequireadequateassurance(asdefinedbyCOUNTY)thatnoexcluded,suspendedorotherwiseineligibleemployeeorsubcontractorofPROVIDERwillperformwork,eitherdirectlyorindirectly,relatingtoservicesprovidedtoCOUNTY.SuchdemandforadequateassuranceshallbeeffectiveuponatimeframetobedeterminedbyCOUNTYtoprotecttheinterestsofCOUNTYconsumers.D.PROVIDERagreestocooperatefullywithanyreasonablerequestsforinformationfromCOUNTYwhichmaybenecessarytocompleteanyinternalorexternalauditsrelatingtothisAgreement.E.PROVIDERagreestoreimburseCOUNTYfortheentirecostofanypenaltyimposeduponCOUNTYbytheFederalGovernmentasaresultofPROVIDER’SviolationofPROVIDER’SviolationofthetemrsofthisAgreement.35.AUDITSANDINSPECTIONSThePROVIDERshallatanytimeduringbusinesshours,andasoftenastheCOUNTYmaydeemnecessary,makeavailabletotheCOUNTYforexaminationallofitsrecordsanddatawithrespecttothematterscoveredbythisAgreement.ThePROVIDERshall,uponrequestbytheCOUNTY,permittheCOUNTYtoauditandinspectallofsuchrecordsanddatanecessarytoensurePROVIDER’ScompliancewiththetermsofthisAgreement.-30- 1245678910111213141516171819202122232425262728IfthisAgreementexceedsTenThousandandNo/100Dollars($10,000.00),PROVIDERshallbesubjecttotheexaminationandauditoftheAuditorGeneralforaperiodofthree(3)yearsafterfinalpaymentundercontract(GovernmentCodeSection8546.7).NotwithstandingtheprovisionsstatedinSectionTwo(2)TERMofthisAgreement,itisacknowledgedbythepartiesheretothatthisAgreementshallcontinueinfullforceandeffectuntilallauditproceduresandrequirementsasstatedinthisAgreementhavebeencompletedtothereviewandsatisfactionofCOUNTY.PROVIDERshallbearallcostsinconnectionwithorresultingfromanyauditand/orinspectionsincluding,butnotlimitedto,actualcostsincurredandthepaymentofanyexpendituresdisallowedbyeitherCOUNTY,State,orFederalgovernmentalentities,includinganyassessedinterestandpenalties.36.RECORDSA.RECORDESTABLISHMENTANDMAINTENANCE-PROVIDERshallestablishandmaintainrecordsinaccordancewithStateandFederalrulesandregulationsinadditiontothoserequirementsprescribedbyCOUNTYwithrespecttoallmatterscoveredbythisAgreement.ExceptasotherwiseauthorizedbyCOUNTY,PROVIDERshallretainallotherrecordsforaperiodoffive(5)yearsafterreceivingthefinalpaymentunderthisAgreementortheearlierterminationofthisAgreement,oruntilStateand/orFederalauditfindingsapplicabletosuchservicesareresolved,whicheverislater.B.DOCUMENTATION-PROVIDERshallmaintainadequaterecordsinsufficientdetailtomakepossibleanevaluationofservices,andcontainallthedatanecessaryinreportingtotheStateofCaliforniaand/orFederalagency.AllclientrecordsshallbemaintainedpursuanttoapplicableStateofCaliforniaandFederalrequirementsconcerningconfidentiality.C.REPORTS-PROVIDERshallsubmittoCOUNTYmonthlyfiscalandallprogramreportsasfurtherdescribedinSectionSeventeen(17)REPORTS-SubstanceUseDisorderServices.PROVIDERshallsubmitacompleteandaccurateyear-endcostreportforeachfiscalyearaffectedbythisAgreement,followingtheendofeachfiscalyearaffectedbythisAgreement.PROVIDERshallalsofurnishtoCOUNTYsuchstatements,records,reports,data,andinformationasCOUNTYmayrequestpertainingtomatterscoveredbythisAgreement.AllreportssubmittedbyPROVIDERtoCOUNTYmustbetypewritten.-31- 1245678910111213141516171819202122232425262728D.SUSPENSIONOFCOMPENSATION-IntheeventthatPROVIDERfailtoprovidereportsspecifiedinthisAgreement,itshallbedeemedsufficientcauseforCOUNTYtowithholdpaymentsuntilthereiscompliance.E.DISALLOWANCES-PaymentsbyCOUNTYshallbeinarrears,forservicesprovidedduringtheprecedingmonth,withinforty-five(45)daysafterreceipt,verificationandapprovalofPROVIDERinvoicesbyCOUNTY’SDBH-SUDServices.IfpaymentforservicesaredeniedordisallowedbyState;andsubsequentlyresubmittedtoCOUNTYbyPROVIDER,thedisallowedportionwillbewithheldfromthenextreimbursementtothePROVIDERuntilCOUNTYhasreceivedreimbursementfromStateforsaidservices.F.CLIENTCONFIDENTIALITY-PROVIDERshallconformtoandCOUNTYshallmonitorcompliancewithallStateandFederalstatutesandregulationsregardingconfidentiality,includingbutnotlimitedtoconfidentialityofinformationrequirementsof42CodeofFederalRegulations§2.1etseq.,WelfareandInstitutionsCode§§5328,10850and14100.2,HealthandSafetyCode§§11977and11812,CivilCode,Division1,Part2.6,and22CaliforniaCodeofRegulations§51009.37.NOTICESThepersonsandtheiraddresseshavingauthoritytogiveandreceivenoticesunderthisAgreementincludethefollowing:COUNTYPROVIDERDirector,FresnoCountyDepartmentofBehavioralHealth4441EastKingsCanyonAveFresno,CA93702PromesaBehavioralHealth7120N.MarksAve,Ste110Fresno,Ca93711AnyandallnoticesbetweentheCOUNTYandthePROVIDERprovidedfororpermittedunderthisAgreementorbylawshallbeinwritingandshallbedeemeddulyservedwhenpersonallydeliveredtooneoftheparties,orinlieuofsuchpersonalservices,whendepositedintheUnitedStatesMail,postageprepaid,addressedtosuchparty.38.CHANGEOFLEADERSHIP/MANAGEMENTAnyandallnoticesbetweenCOUNTYandPROVIDERprovidedfororpermittedunderthisAgreementorbylaw,shallbeinwritingandshallbedeemeddulyservedwhenpersonallydeliveredtoone-32- 1245678910111213141516171819202122232425262728oftheparties,orinlieuofsuchpersonalservice,whendepositedintheUnitedStatesMail,postageprepaid,addressedtosuchparty.IntheeventofanychangeinthestatusofPROVIDER’Sleadershipormanagement,PROVIDERshallprovidewrittennoticetoCOUNTYwithinthirty(30)daysfromthedateofchange.Suchnotificationshallincludeanynewleaderormanager’sname,addressandqualifications.“Leadershipormanagement”shallincludeanyemployee,member,orownerofPROVIDERwhoeithera)directsindividualsprovidingservicespursuanttothisAgreement;b)exercisescontroloverthemannerinwhichservicesareprovided;orc)hasauthorityoverPROVIDER’Sfinances.39.CHARITABLECHOICEPROVIDERmaynotdiscriminateinitsprogramdeliveryagainstaclientorpotentialclientonthebasisofreligionorreligiousbelief,arefusaltoholdareligiousbelief,orarefusaltoactivelyparticipateinareligiouspractice.AnyspecificallyreligiousactivityorservicemadeavailabletoindividualsbythePROVIDERmustbevoluntaryaswellasseparateintimeandlocationfromCountyfundedactivitiesandservices.PROVIDERshallinformCountyastowhetheritisfaith-based.IfPROVIDERidentifiesasfaith-baseditmustsubmittoSubstanceUseDisorderServicesacopyofitspolicyonreferringindividualstoalternatetreatmentPROVIDER,andincludeacopyofthispolicyinitsclientadmissionforms.Thepolicymustinformindividualsthattheymaybereferredtoanalternativeprovideriftheyobjecttothereligiousnatureoftheprogram,andincludeanoticetoSUDServices.Adherencetothispolicywillbemonitoredduringannualsitereviews,andareviewofclientfiles.IfPROVIDERidentifiesasfaith-based,byJuly1ofeachyearPROVIDERwillberequiredtoreporttoSUDServicesthenumberofindividualswhorequestedreferralstoalternateprovidersbasedonreligiousobjection.40.LICENSING-CERTIFICATESThroughouteachtermofthisAgreement,PROVIDERandPROVIDER’Sstaffshallmaintainallnecessarylicenses,permits,approvals,certificates,waiversandexemptionsnecessaryfortheprovisionoftheserviceshereunderandrequiredbythelawsandregulationsoftheUnitedStatesofAmerica,StateofCalifornia,theCountyofFresno,andanyotherapplicablegovernmentalagencies.PROVIDERshallnotifyCOUNTYimmediatelyinwritingofitsinabilitytoobtainormaintainsuch-33- 12345678910111213141516171819202122232425262728licenses,permits,approvals,certificates,waiversandexemptionsirrespectiveofthependencyofanyappealrelatedthereto.Additionally,PROVIDERandPROVIDER’Sstaffshallcomplywithallapplicablelaws,rulesorregulations,asmaynowexistorbehereafterchanged.41.AODCERTIFICATIONA.TheCOUNTYrequiresallCOUNTYcontractedprovidersofAlcoholandOtherSubstanceUseDisordertreatmentservicestoobtaintheCaliforniaDepartmentofHealthCareServices(DHCS)AlcoholandOtherDrugProgram(AOD)Certification.TheAODCertificationStandardswillapplytoallresidentialandoutpatienttreatmentmodalities.ThepurposeoftheAODCertificationStandardsistoensureanacceptablelevelofservicequalityisprovidedtoprogramparticipants.B.PROVIDERshallprovideproofofacompletedapplicationforAODCertificationtotheCountywithinThirty(30)daysfromtheexecutiondateofthisAgreementwiththeCOUNTY.AcopyoftheAODCertificationshallbesubmittedtotheCOUNTYwhenapprovedbytheCaliforniaDepartmentofAlcoholDrugPrograms.C.ThisAODCertificationrequirementappliestoeveiytreatmentfacilityoperatedbythePROVIDER.PROVIDERSwhoseagenciesarenationallyaccreditedwiththeJointCommissiononAccreditationofHealthCareOrganizations(JCAHO)ortheCommissiononAccreditationofRehabilitativeFacilities(CARF)areexemptfromthisrequirementofAODCertification.PROVIDERshallsubmitacopyoftheirJCAHOorCARFaccreditationtotheCOUNTYwithinthirty(30)daysfromthedatethisAgreementisexecuted.PROVIDERshallnotifyCOUNTYifatanytimetheirJCAHOorCARFaccreditationlapsesorbecomesinvalidduetoanyreasonduringthetermofthisAgreement.PROVIDERshallapplywithDHCSforAODCertificationiftheirJCAHOorCARFaccreditationlapsesorbecomesinvalidandshallsubmitacopyofthecompletedapplicationforAODCertificationtotheCOUNTYwithinthirty(30)daysfromthedatetheJCAHOorCARFaccreditationlapsesorbecomesinvalid.D.COUNTYshallterminatethisAgreementimmediatelyintheeventanyofthefollowingoccurs:1)PROVIDERfailstosubmitacopyofthecompletedapplicationforAODCertification,oracopyofeithertheirJCAHOorCARFaccreditationwithinthirty(30)daysfromthe-34- 12345678910111213141516171819202122232425262728executiondateofthisAgreementwiththeCOUNTY.2)PROVIDER’SapplicationforAODCertificationisdeniedbyDHCS.3)PROVIDERfailstosubmittotheCOUNTYacopyoftheAODCertificationwithinthirty(30)daysafterbeingapprovedbytheDHCS,orcertificationisnotmaintainedthroughoutthecontractperiod.4)PROVIDERfailstoapplyforAODCertificationwithDHCSorfailstosubmittotheCOUNTYacopyofthecompletedapplicationforAODCertificationwithinthirty(30)daysaftertheJCAHOorCARFaccreditationlapsesorbecomesinvalid.42.COMPLAINTSPROVIDERshalllogcomplaintsandthedispositionofallcomplaintsfromaconsumeroraconsumer'sfamily.PROVIDERshallprovideasummaryofthecomplaintlogentriesconcerningCOUNTY-sponsoredconsumerstoCOUNTYatmonthlyintervalsbythefifteenth(15th)dayofthefollowingmonth,inaformatthatismutuallyagreedupon.PROVIDERshallpostsignsinformingconsumeroftheirrighttofileacomplaintorgrievance.PROVIDERshallnotifyCOUNTYofallincidentsreportabletostatelicensingbodiesthataffectCOUNTYconsumerswithintwenty-four(24)hoursofreceiptofacomplaint.Withinfifteen(15)daysaftereachincidentorcomplaintaffectingCOUNTY-sponsoredconsumers,PROVIDERshallprovideCOUNTYwithinformationrelevanttothecomplaint,investigativedetailsofthecomplaint,thecomplaintandPROVIDER'Sdispositionof,orcorrectiveactiontakentoresolvethecomplaint.43-DRUGFREEWORKPLACEPROVIDERshallcomplywiththerequirementsoftheDrug-FreeWorkPlaceActof1990(CaliforniaGovernmentCodesection8350).44.UNLAWFULUSEOFDRUGSANDALCOHOLPROVIDERshallensurethatinformationprovidedtoclientscontainsaclearlywrittenstatementthatthereshallbenounlawfuluseofdrugsoralcoholassociatedwithPROVIDER.AdditionallyPROVIDERshallensurethatnoaspectoftheprogramincludesanymessageinmaterials,curricula,teachings,orpromotionoftheresponsibleuse,iftheuseisunlawful,ofdrugsoralcoholpursuanttoHealth-35- 1245678910111213141516171819202122232425262728andSafetyCode(HSC)11999-11999.3.PROVIDERshallmaintainthatanyunlawfuluseofdrugsandalcoholisillegalanddangerous.PROVIDERmustsignthe“UnlawfulUseofDrugsandAlcoholCertification”,attachedheretoasExhibitG,incorporatedhereinbyreferenceandmadepartofthisAgreementagreeingtoupholdtheobligationsofHSC11999-11999.3.COUNTYshallenforcetherequirementof“NoUnlawfulUse”setforthbyDHCSandrequiresPROVIDERtoenforcetherequirementaswell.Thisagreementmaybeunilaterallyterminated,withoutpenalty,ifPROVIDERorasubcontractorthatisaprivateentityisdeterminedtohaveviolatedaprohibitionoftheUnlawfulUseofDrugsandAlcoholmessageorhasanemployeewhoisdeterminedbytheDBHDirectororherdesigneetohaveviolatedaprohibitionoftheUnlawfulUseofDrugsandAlcoholmessage.45.RESTRICTIONONDISTRIBUTIONOFSTERILENEEDLESPROVIDERshalladheretotheState-CountyContractrequirementthatnofundsshallbeusedtocarryoutanyprogramofdistributingsterileneedlesorsyringesforthehypodermicinjectionofanyillegaldrugunlesstheDHCSchoosestoimplementademonstrationsyringeservicesprogramforintravenousdruguserswithSubstanceAbusePreventionandTreatment(SAPT)BlockGrantfunds.46.CHILDABUSEREPORTINGPROVIDERshallutilizeaprocedureacceptabletotheCOUNTYtoensurethatallofPROVIDER’Semployees,volunteers,consultants,subcontractorsoragentsperformingseivicesunderthisAgreementshallreportallknownorsuspectedchildabuseorneglecttooneormoreoftheagenciessetforthinPenalCodesection11165.9.ThisprocedureshallincludehavingallofPROVIDER’Semployees,volunteers,consultants,subcontractorsoragentsperformingservicesunderthisAgreementsignastatementthatheorsheknowsofandwillcomplywiththereportingrequirementssetforthinPenalCodesection11166.ThestatementtobeutilizedbyPROVIDERforreportingissetforthinExhibitH,“NoticeofChildAbuseReporting”attachedheretoandbythisreferenceincorporatedherein.47.TRAFFICKINGOFPERSONSPROVISIONSPROVIDERshallconfonntoallFederalstatutesandregulationsprohibitingtraffickingofpersons,aswellastrafficking-relatedactivities,including,butnotlimitedtothetraffickingofpersons-36- 12345678910111213141516171819202122232425262728provisionsinSection106(g)oftheTraffickingVictimsProtectionActof2000(TVPA).not:PROVIDER,PROVIDER’Semployees,subrecipients,andsubrecipients’employeesmayA.Engageinsevereformsoftraffickingofpersonsduringtheperiodoftimethattheawardisineffect;B.Procureacommercialsexactduringtheperiodoftimethattheawardisineffect;orC.Useforcedlaborintheperformanceoftheawardorsubawardsundertheaward.Thisagreementmaybeunilaterallyterminated,withoutpenalty,ifPROVIDERorasubrecipientthatisaprivateentityisdeterminedtohaveviolatedaprohibitionoftheTVPAorhasanemployeewhoisdeterminedbytheDBHDirectororherdesigneetohaveviolatedaprohibitionoftheTVPAthroughconductthatiseitherassociatedwithperformanceundertheawardorimputedtothePROVIDERortheirsubrecipientusingthestandardsanddueprocessforimputingtheconductofanindividualtoanorganizationthatareprovidedin2C.F.R.Part180,“OMBGuidelinestoAgenciesonGovernment-wideDebarmentandSuspension(Nonprocurement).PROVIDERmustinformtheDBHDirectororherdesigneeimmediatelyofanyinformationreceivedfromanysourceallegingaviolationofaprohibitionoftheTVPA.PROVIDERmustsignacertificationannuallyacknowledgingtheTraffickingVictimsProtectionActof2000requirements(TVPACertification),attachedheretoasExhibitI,incorporatedhereinbyreferenceandmadepartofthisAgreementandmustrequireallemployeestocompleteannualTVPAtraining.48.DISCLOSUREOFOWNERSHIPAND/ORCONTROLINTERESTINFORMATIONThisprovisionisonlyapplicableifPROVIDERisadisclosingentity,fiscalagent,ormanagedcareentityasdefinedinCodeofFederalRegulations(C.F.R),Title42§455.101455.104,and455.106(a)(1),(2).InaccordancewithC.F.R.,Title42§§455.101,455.104,455.105and455.106(a)(1),(2),thefollowinginformationmustbedisclosedbyPROVIDERbycompletingExhibitJ“Disclosureof-37- 12345678910111213141516171819202122232425262728OwnershipandControlInterestStatement,”attachedheretoandbythisreferenceincorporatedherein.PROVIDERshallsubmitthisformtotheDepartmentofBehavioralHealthwithinthirty(30)daysoftheeffectivedateofthisAgreement.SubmissionsshallbescannedpdfcopiesandaretobesentviaemailtoDBHAdministration@co.fresno.ca.usattention:ContractsAdministration.A.Nameandaddressofanyperson(s)whetheritbeanindividualorcorporationwithanownershiporcontrollinginterestinthedisclosingentityormanagedcareentity.1)Addressmustincludetheprimarybusinessaddress,everybusinesslocationandP.O.Boxaddress(es).2)DateofbirthandSocialSecurityNumberforindividuals.3)Taxidentificationnumberforothercorporationsorentitieswithownershiporcontrollinginterestinthedisclosingentity.B.Anysubcontractor(s)inwhichthedisclosingentityhasfive(5)percentormoreinterest.C.Whethertheperson(s)withanownershiporcontrollinginterestofthedisclosingentityisrelatedtoanotherpersonhavingownershiporcontrollinginterestasaparent,spouse,siblingorchild.Includingwhethertheperson(s)withownershiporcontrollinginterestofthedisclosingentityisrelatedtoaperson(parent,spouse,siblingorchild)withownershiporhasfive(5)percentormoreinterestinanyofitssubcontractors.D.Nameofanyotherdisclosingentityinwhichanownerofthedisclosingentityhasanownershiporcontrolinterest.E.Theownershipofanysubcontractorwithwhomtheproviderhashadbusinesstransactionstotalingmorethan$25,000duringthe12-monthperiodendingonthedateoftherequest;andF.Anysignificantbusinesstransactionsbetweentheproviderandanywhollyownedsupplier,orbetweentheproviderandanysubcontractor,duringthe5-yearperiodendingonthedateoftherequest.G.Anyperson(s)withanownershiporcontrolinterestintheprovider,oragentormanagingemployeeoftheprovider;and-38- 123456789101112131415161718192021222324252627281)Hasbeenconvictedofacriminaloffenserelatedtothatperson'sinvolvementinanyprogramunderMedicare,Medicaid,orthetitleXXservicesprogramsincetheinceptionofthoseprograms.H.Theownershipofanysubcontractorwithwhomtheproviderhashadbusinesstransactionstotalingmorethan$25,000duringthe12-monthperiodendingonthedateoftherequest;andI.Anysignificantbusinesstransactionsbetweentheproviderandanywhollyownedsupplier,orbetweentheproviderandanysubcontractor,duringthe5-yearperiodendingonthedateoftherequest.49.CONTROLREQUIREMENTSPerformanceunderthisAgreementissubjecttoallapplicableFederalandStatelaws,regulationsandstandards.InacceptingtheStatedrugandalcoholcombinedprogramallocationpursuanttoCaliforniaHealthandSafetyCodesection11757,PROVIDERshallestablishwrittenaccountingproceduresconsistentwithapplicableFederalandStatelaws,regulationsandstandards,andshallbeheldaccountableforauditexceptionstakenbytheStateorCOUNTYforfailuretocomplywiththeserequirements.Theserequirementsinclude,butmaynotbelimitedto,thosesetforthinthisAgreement,and:A.Division10.5oftheCaliforniaHealthandSafetyCode;B.CaliforniaGovernmentCodesections16366.1through16367.9and53130through53138;C.Title9,Division4oftheCaliforniaCodeofRegulations;D.42UnitedStatesCode(U.S.C.)section300x-5;E.31U.S.C.sections7501-7507(SingleAuditActof1984;SingleAuditActAmendmentsof1996);F.OfficeofManagementandBudget(OMB)CircularA-133(AuditsofStates,LocalGovernmentsandNon-ProfitOrganizations):andG.Title45,Part96,SubpartsB,CandLoftheCodeofFederalRegulations(BlockGrants).-39- 124567891011121314151617181920212223242526272850.SEPARATEAGREEMENTItismutuallyunderstoodbythepartiesthatthisAgreementdoesnot,inanyway,createajointventureamongPROVIDER(S).ByexecutionofthisAgreement,PROVIDER(S)understandsthataseparateAgreementisformedbetweeneachindividualPROVIDERandCOUNTY.51.GOVERNINGLAWVenueforanyactionarisingoutoforrelatedtothisAgreementshallonlybeinFresnoCounty,California.TherightsandobligationsofthepartiesandallinterpretationandperformanceofthisAgreementshallbegovernedinallrespectsbythelawsoftheStateofCalifornia.52.ENTIREAGREEMENTThisAgreement,includingallExhibits,COUNTY’SRevisedRFPNo.17-030andPROVIDER’Sresponsethereto,constitutestheentireAgreementbetweenPROVIDERandCOUNTYwithrespecttothesubjectmatterhereofandsupersedesallpreviousagreementnegotiations,proposals,commitments,writings,advertisements,publications,andunderstandingsofanynaturewhatsoeverunlessexpresslyincludedinthisAgreement.IllIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII-40- IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year first 2 hereinabove written. 3 4 ATIEST: 5 6 7 8 9 10 ll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 CONTRACTOR: PROMESA BEHAVIORAL HEALTH By~Jl~ Print Name/!bctfllel. a/? 11}11 NCtti!:c., Title: 4csl DG 1./ C Chairman of Board, or President or and Vice President Print Name: si!Aa (\ "-A • PC?N-.tt Title: ~~\\Q{L Secretary (of Corporation), or any Assistant Secretary, or Chief Financial Officer, or any Assistant Treasurer COUNTY OF FRESNO By: --,---'-'{L~-~~L--- Brian Pacheco, Chairman Board of Supervisors Date: L.J -4 -I J BERNICE E. SEIDEL, Clerk Board of Supervisors By: SuSO&. ~sh o-p,~ Date: Y -~ -I) PLEASE SEE ADDITIONAL SIGNATURE PAGES ATTACHED Contact: Chief Executive Officer Promesa Behavioral Health 7120 N Marks Ave, Ste 110 Fresno, Ca 93711 -41- 12345678910111213141516171819202122232425262728APPROVEDASTOLEGALFORM:DANIELC.CEDERBORG,COUNTYCOUNSELBy:APPROVEDASTOACCOUNTINGFORM:OSCARJ.GARCIA,CPA,AUDITOR-CONTROLLER/TREASURER-TAXCOLLECTORBy:fkJUREVIEWEDANDRECOMMENDEDFORAPPROVAL:By:DAWANUTECHT,DirectorDepartmentofBehavioralHealthThefollowingisforCOUNTY’Suse:Fund/Subclass:0001/10000Organization:56302081Account/Program:7295/0lw-42- Exhibit A 3/10/2017 1 of 1 VENUE SITE LOCATION First Presbyterian Church of Coalinga 475 Sunset St Coalinga, Ca 93210 Westside Family Preservation Service Network 16846 4th St Huron, Ca 93234 Firebaugh Police Department 1575 11th St Firebaugh, Ca 93622 Firebaugh Office V.S Kaleka MD 992 O Street Firebaugh, Ca 93622 Mendota Office V.S Kaleka MD 507 Oller St Mendota, Ca 93640 United Health Centers of the San Joaquin Valley 16928 11th St Huron, Ca 93234 United Health Centers of the San Joaquin Valley 121 Barboza St Mendota, Ca 93640 Promesa Behavioral Health Service Addresses Exhibit B Page1 Promesa Behavioral Rural Outpatient Services SCOPE OF WORK Promesa will provide evidence-based, quality outpatient treatment services to rural adult residents in Fresno County. Promesa further understands that the purpose is to increase participation in Drug Court recommended assessments, treatment planning and treatment services. In order to meet this objective, Promesa proposes to provide Promesa’s TOADS program, a telecare driven service in rural Fresno, supported by on-site sessions. Promesa will implement as follows: 1. SUD services to rural Fresno County residents (male/female) when it is determined that services are medically necessary. i. Enrolled clients will be assessed to determine medical necessity for treatment determined by board certified physicians. ii. Once medical necessity is established, clients are placed into a treatment program (preferably telecare). iii. Medical necessity is determined by medical review and through assessments using the DSM-V for diagnosis as well as ASAM levels to determine level of care. iv. If medical necessity is not established, clinical staff refer clients to a lower level of care; staff actively assists clients to make these linkages. v. Telecare treatment is supported by a minimum of 3 onsite, individual meetings. The on- site in-person meetings are the intake/assessment/placement in treatment, continuous treatment plan reviews and a treatment completion/ discharge planning interview. Clients will remain active as long as medical necessity for treatment is determined and signed off by the Medical Director (the Justification To Continue Treatment Services). TOADS follows both ASAM protocols and MediCal procedures for treatment continuation. ASAM calls for continuous review of dimensions of level of care while MediCal requires review every 90 days for treatment planning updates. vi. Through telecare treatment, SUD clients will identify and accept their use and dependence. vii. Through telecare treatment, SUD clients will come to understand the dynamics of the addictive process and the outcomes/results of addiction on self, family and employability. viii. Through successful completion of telecare based treatment, SUD clients will emerge to lead productive, self-sufficient and substance free lifestyles. 2. SUD services meet all applicable regulations and standards. 3. SUD services are delivered in line with CLAS standards. 4. SUD services are delivered under DMC certification. 5. SUD clients will have at least 1 diagnosis from the ASAM and/or DSM for Substance Related and Addictive Disorders. 6. SUD services will begin between 30-60 days of notice of award and contract execution. 7. SUD services will be provided primarily in the communities of Firebaugh/Mendota and Coalinga/Huron, with satellite sites in other rural communities, as need arises. 8. SUD services are provided in the threshold languages prevalent in the County. In the identified services areas (Firebaugh/Mendota, Coalinga/Huron) the threshold language is Spanish. For clients who are in need of another language, Promesa draws from local resources to assist. Additionally, services are provided in compliance with the Americans Exhibit B Page2 with Disabilities Act provisions. All of Promesa’s facilities are accessible. In the event that a client is deaf or hard of hearing, the agency contracts with the Deaf and Hard of Hearing Services for sign language services. In providing telecare, if a deaf/hard of hearing client is referred, ongoing sign interpretation is arranged for that client. 9. Promesa has existing, County-approved CLAS policies. Further, all services are provided with cultural competency/humility as a standard, using members of the diverse staff and/or contracting with ethnically and linguistically skilled professionals in the community. 10. SUD clients are provided with a copy of the agency’s grievance policies and process as part of their intake and admission to treatment. The grievance policy is included in the client’s copies of their treatment agreement. All grievance procedures are posted in agency offices, in threshold languages. 11. SUD services will be delivered at community locations identified in the RFP and through negotiated collation agreements with community based organizations. Experience and knowledge of adult outpatient drug free services, using evidence based practices and outcome informed treatments. Promesa’s Telecare Outpatient Alcohol and Drug Services (TOADS) will serve rural Fresno County residents needing SUD treatment. All treatment services are outpatient. To ensure success in treatment outcomes for clients, Promesa utilizes several evidenced based approaches to treatment for substance use, use or addiction, detailed below: A. Treatment Modalities are behavioral approaches. Promesa meets clients were they are and are in the “here and now”. Behavioral interventions help adults actively participate in their recovery from use and addiction, enhancing abilities to resist drug use. One main behavioral approach is Cognitive-Behavioral Therapy (CBT). CBT strategies are based on the theory that learning processes play a critical role in the development of problem behaviors like drug use. Thus, Psycho-education continuously educates about substances and the harm they cause to the body. Clients learn how to anticipate problems and develop effective coping strategies. They may be assisted in this by the Peer Support Specialist. B. In CBT, adults explore the positive and negative consequences of using drugs. They learn to recognize distorted thinking patterns and triggers of use; identify and anticipate high-risk situations; and apply self-disciplined skills. Skills including practical problem solving, anger management, emotional regulation and refusal. C. Another behavioral approach modality is Motivational Enhancement Therapy (MET), that supports adolescents and adults to resolve their uncertainty about engaging in treatment and abandoning their drug use. MET includes an initial assessment of motivation to participate in treatment, where counselor supports the client to develop a desire to participate by providing non-confrontational feedback and is to strengthen motivation and build a plan for change. Both of these Evidence-Based approaches yield successful outcomes when conjoined. D. Promesa also utilizes the MATRIX Model, a proven effective, evidence based protocol, particularly for cocaine and methamphetamine addicts. Its design is intensive outpatient program services, using telecare-based treatment that covers 6 key clinical areas (individual/conjoint therapy, early recovery, relapse prevention, family education, social support and urine testing). MATRIX runs from 16-52 weeks of treatment, depending upon client success. MATRIX is a directive, behavior-focused treatment approach, applied to adult clients. Exhibit B Page3 Services will be delivered by a multidisciplinary, culturally competent staff and will include a broad array of medical, mental health and recovery-centered supports based on the cognitive behavioral model of treatment applied to telecare services: o Risk-focused assessments, covering mental health and substance use; o Psychiatric assessment, recovery plan through telecare treatment; o Medication administration and management, when deemed necessary, is under supervision of aboard certified psychiatrist, Herbert A Cruz, MD (this is done through in person consultations); o Family and support system engagement via individualized telecare; o Individualized treatment plans, which also focuses on the process of awakening hope and enlivening the recovery journey which will be covered in the initial intake and assessment, then delivered through telecare. The goal of TOADS is to provide a recovery-oriented, trauma-informed learning environment that promotes independence, self-responsibility and self-determination through participating in a telecare treatment program; o Noncompliant Clients -- Staff addresses non-compliant participants in several ways. If non- compliance is determined to be the result of resistance to electronically based treatment, counselors will add a schedule of direct individual and/or group sessions. If non-compliance is determined to be a lack of commitment to treatment, counselors will discuss the ‘stages of commitment or readiness’ (URICA) with clients, assisting clients to understand where they are on a ‘readiness’ scale. Staff may guide clients toward treatment while maintaining them on a caseload. Non-compliant clients will continue to receive messaging from both the assigned counselor and the Peer Support Specialist (PSS) on a weekly basis. Staff will contact clients who change phone numbers through mail and/or alternative contact identified during the admissions interview; o Transitions of care -- are handled by securing client agreements to amend their treatment plan, along with an accompanying diagnosis supported by the DSM and/or ASAM. Staff will guide clients needing higher levels of care, generally residential treatment to choose an appropriate placement. Staff initiates a referral to a local facility, with the client present. Staff will track the referral until client is admitted to residential treatment or a program providing intensive outpatient treatment. o Staff will transition clients needing lower levels of care, yet still meeting medical necessity, into aftercare services. These clients still need contact with the treatment team to ensure commitment to recovery goals, while meeting less often. Lower levels of care may include additional contacts by the PSS. o Timeframes, revised: Staff shall maintain clients in active status in telecare services as long as they meet medical necessity for SUD treatment. During the admissions interview, clients and counselors determine the frequency of sessions. o Staff will schedule discharge planning sessions when either clients or counselors determine that treatment goals were met and recovery is progressing to the client’s satisfaction and can realistically be sustained by the client. o Additional notes on the telecare resources integrated into TOADS. Promesa will utilize the resources and curricula available through Hazelden, which offers a plethora of addiction treatment and recovery materials and resources to agencies (and clients). For example, Hazelden offers tremendous amount of digital resources: o THE DAILY PLEDGE: PEOPLE HELPING PEOPLE 24/7 o Interact with others who are establishing lives and families free from addiction. Clients may Access chats, online meetings, discussions and healthy check-in activities any day, any time, from anywhere. Clients may participate as anonymously, if they prefer. This Exhibit B Page4 resource is similar to Facebook. Clients may post pictures and videos, post blogs and comment on discussions. It’s free. o Hazelden's Social Community (SC) o Similar to the Daily Pledge, the SC is a free online resource for anyone with a genuine interest in recovery from addiction, including those seeking recovery, maintaining recovery, working professionally in the field (or supporting friends or loved ones) in recovery. This unique community is home to daily recovery meetings, a lively discussion board, blogs by industry professionals, a book club with special offers and, most notably, a collection of supportive peers o Mobile Apps o With Hazelden’s mobile applications, clients will find the instant motivation needed to strengthen recovery and inspire personal growth no matter where they are (both geographically and stage of recovery). Promesa’s telecare staff utilizes Hazelden’s mobile apps to support their counseling with clients. o eBooks o Clients are invited to explore Hazelden’s vast library of tablet and mobile-friendly reading resources available to help people recognize, understand and overcome addiction and closely related issues. o Online Meetings o Hazelden - Clients, who desire more online meetings than are available through Promesa, are advised that 1. if they participate in Hazelden’s online meetings to supplement their recovery goals, AND 2. Want their online meeting attendance to count toward a court- ordered requirement, 3. Hazelden will provide confirmation of participation. Clients will be asked to provide a release of information to permit Promesa to obtain a record of these supplemental meetings.  Oher AA websites offer online AA/NA meetings, with information on these resources provided to clients. o Podcasts o Podcasts of recovery related discussions, ideas and resources are routinely posted. o After care – Staff transitions clients to aftercare when it is determined that recovery is progressing and clients seem to need fewer contacts. Thus, aftercare is a step down in counseling sessions, instead of weekly or bi-monthly, sessions are monthly. Check-ins with clients before and after ‘troublesome’ anniversary dates or cultural celebrations would also occur in aftercare. For many clients, anniversaries (weddings, deaths, divorces are triggers, along with cultural events that are often celebrated with alcohol – Cinco de Mayo, Sept. 16th, Dia de los Muertos). o Additionally, clients will be encouraged to participate in locally available 12-step activities (AA/NA, Celebrate Recovery or other groups; staff will research available activities/schedules and provide information to clients). These recovery programs are very effective in helping clients maintain their sobriety goals. o Clients would also receive support from the Peer Support Specialist, who would send texts, inspirational messages and other electronic encouragements. o After care will continue as long as medical necessity is present, as determined by ASAM level of care reviews and DSM assessments. o Further, counseling staff and the peer support specialist will connect clients to these additional resources to sustain the progress they have made in recovery. o In serving clients through electronic resources, Promesa has found that providing clients with access to vetted, high quality online resources aids in recovery, one key resource is: Exhibit B Page5 http://drugabuse.com/?s=after+care. Staff also conducts random drug testing for client accountability. o Alumni of the telecare program are encouraged to participate in:  Alumni meetings as a component of the aftercare plan  Attend alumni contact/events/activities, such as  Recovery Book club  Dinners  Picnics  Recovery workshops  Volunteer –Tell your story of recovery to current clients in treatment  Sign up to receive informative emails from Hazelden, from staff and from the Peer Support Specialist. By providing online real-time, interactive audio and video-based alcohol and drug use treatment, TOADS brings electronic, web based, mobile treatment to its clients. TOADS is designed to be ideal for anyone who is seeking an alternative to traditional treatment programs, who is unable to access traditional treatment programs (due to transportation difficulties, lack of locally available services or inability to pay for treatment). TOADS uses a proven treatment approach that is based on cognitive behavioral therapy, supported by strong connections to other successful treatment strategies, such as the 12-Step philosophy. Online sessions present information on relapse prevention, medical aspects of addiction, anger management and other topics. The evidenced based treatment modality utilized by Promesa in addiction treatment is Cognitive-Behavioral Therapy (CBT), which is an empirically supported treatment that focuses on patterns of thinking that are maladaptive and the beliefs that underlie such thinking. For example, a person who is depressed may have the belief, "I’m worthless," and a person with a phobia may have the belief, "I am in danger." While the person in distress likely holds such beliefs with great conviction, with a therapist’s help, the individual is encouraged to view such beliefs as hypotheses rather than facts and to test out such beliefs by running experiments. Telecare aids in changing these thought patterns by giving patients more frequent access to a counselor (than the typical once a week or once a month appointment). Continuous contact through texting and voice messaging enables the client to perhaps more quickly establish new behavioral patterns. As an added benefit, telecare has the potential to greatly decrease the cost of traditional face- to-face therapy while still maintaining effectiveness. The combination of low cost, ease of use, and accessibility in a society that values the use of instant communication make telecare therapy plausible for rural patients. Telecare has proved an effective tool in reaching patients of all age groups – even seniors who respond well to technological additions to treatment and access to their treatment team. In Promesa’s experience in implementing in telecare, Promesa found that the benefits of ‘mobile’ therapy lie in its ability to help patients receive more individual attention from addiction counselors. Because, as a means not only of communication but also of getting, exchanging information, being entertained irrespective of social class or literacy level, smart phone usage is a ubiquitous presence in life -- these benefits combine effortlessly considering society’s increasing tendency to communicate via text messaging as opposed to voice conversations. The combination of instant communication, availability, and user friendliness contribute to the effectiveness of telecare. The addiction counselors at Promesa have observed client responses to cognitive-behavioral therapies (CBTs) to be positive and produce successful treatment outcomes. CBT is among the most frequently evaluated approaches used to treat substance use disorders, has been shown to be effective with all types of substance users, especially those 18-30 who have more affinity for electronic Exhibit B Page6 communication and are comfortable with instant messaging, texting, e-mailing, tweeting, Facebook® and other forms of electronic connecting. Promesa’s clients respond well to telecare based CBT, because: o It is based on social learning and behavioral theories of drug use o The basic approach is "recognize, avoid, and cope" these learning strategies are o Easily communicated via telecommunications o Treatment is organized around a functional analysis of substance use; i.e., o Understanding substance use with respect to its antecedents and consequences, o Insights are amenable to text messaging, for example. o Skills training -- that is easily reinforced through web-enabled mobile phones -- is o Focused on strategies for coping with craving, fostering motivation to change, o Managing thoughts about drugs, developing problem solving skills, planning for and managing high-risk situations, identifying apparently irrelevant decisions, and o Cultivating drug refusal skills. o Underlying principles of CBT are that: (a) Basic skills should be mastered before more complex ones are given, (b) Material presented by the addiction counselor is matched to patient needs, (c) Repetition fosters the development of skills which are easy to deliver by web based methods, (d) Since practice is needed for mastery of skills, patients get more reinforcement from addiction counselors, (e) The patient is an active client in treatment, and (f) Skills taught are generalizable to a variety of problem areas. Researchers have noted that there is nothing inherent in CBT that would make it inappropriate for use with diverse clients. Promesa’s bilingual/bicultural substance use counselors have successfully utilized CBT with many of the Latino, Asian, Native and African American clients. In fact, the specific ways in which CBT may be particularly useful for multicultural clients: • CBT emphasizes the uniqueness of the individual: At its core, CBT argues that the treatment should be adapted to meet the needs of the individual. • CBT focuses on client empowerment: The inherent belief that clients are in control and, therefore, capable of bringing about change themselves helps create a collaborative relationship which appreciates individual and cultural differences. • CBT focuses on conscious processes and specific behaviors (instead of unconscious processes and abstract ideas): Hays notes that this may be especially important when therapy is conducted in a client's second (or third, etc.) language or with an interpreter. Research indicates that fluency in a 2nd language is negatively affected by emotional distress. A therapy that emphasizes theoretical and abstract ideas may result in a greater potential for misunderstanding between the therapist and a distressed client. • CBT integrates assessment throughout the course of therapy: This cognitive-behavioral assessment maps progress from the client's perspective. In fact, assessment measures could easily be added to the battery that addresses concepts important to the client (e.g., the family's views of the client's progress). Additionally, this emphasis on continuing assessment demonstrates therapist commitment and respect for the client's opinion, which is important for all clients, but perhaps more so for the client and therapist whose backgrounds differ. CBT is rendered more effective when supported through Mindfulness and Motivational Interviewing techniques. These strategies lend themselves well to electronically delivered treatment and the telecare clients have responded well to these techniques. Promesa’s retention in telecare treatment is nearly 80%. Exhibit B Page7 Experience and/or knowledge of working with relevant statewide, municipal and community based organizations that interface with target population. 1. Most of Promesa’s clientele are referred from municipal departments (Department of Social Services, Department of Behavioral Health, Probation and/or Drug Courts), thus the agency have deep experience in working closely with agencies which interface with the target population. 2. Promesa has provided substance use services throughout Fresno County, often in collaboration with local school districts. 3. Promesa’s TOADS program was aimed specifically at rural clients faced with obstacles to treatment (transportation difficulties, lack of local services or inability to meet the cost of treatment, lack of childcare). When treatment is electronically available through telecare, rural clients respond favorably and generally tend to ‘stick it out’ to meet treatment goals. Promesa’s telecare program experienced self-referrals for treatment, largely due to convenience along with quality of care. Promesa’s ability to work in cooperation with other agencies to provide linkages to supportive and ancillary services (AA/NA) a) The power of 12 Step Programs lies in the self-help philosophy which enables clients to exercise some of the skills they will learn – such as reaching out for social support when the temptation to drink/use comes up. Studies have shown that people who attend 12 step groups and work the program by getting involved, finding a sponsor, working the steps and giving back (making speeches, commitments to help out at meetings, sponsoring others or in other ways) tend to do well in recovery in the long term. b) How these will be brought to rural areas -- That said, 12 step programs are not available in every rural community. Promesa will work with clients and the AA Central Office in Fresno for their assistance to organize groups in the targeted rural communities of Firebaugh/Mendota and Coalinga/Huron. c) Promesa offers outpatient substance use programs that serve clients across the age spectrum (12-17 years, adults (18+). Promesa’s services are available at school based sites (for juveniles) and Promesa’s clinical sites in Fresno and Mendota (for adults). d) Promesa’s outpatient services adhere to Medi-Cal standards. Generally, a referral is made by a counselor, teacher, parent, probation officer, social worker, self-referral or a friend. The referral is given to the substance use counselor who makes an appointment for a complete assessment. The counselor assesses the client by taking a complete history to determine if client qualifies according to the criteria found in the DSM-V and the levels noted in the ASAM diagnostic tools. Typically, a client who has been using drugs or alcohol in the last 12 months which severely impacts their life, such as their health, school work, work, relationships, and truancy screen positively for admission. e) Other services provided are crisis management for substance use and collateral counseling. Counselors do crisis counseling when a client is in danger of relapse. Counselors also do a family, close relative or friend session in relation to the client’s sobriety or safety. Counselors coordinate with probation officers, Child Protective Services, Department of Behavioral Health, Superior Court officials and other agencies in order to coordinate services. Exhibit B Page8 Promesa’s principals, who will be responsible for project, background, credentials, training, experience Lisa Weigant Chief Executive Officer Education Masters of Arts in Counseling Psychology from National University Qualification in Mental Health Administration Appointed CEO of Promesa Behavioral Health in June 2009; Previously Program Manager for TAY program in Fresno County. Experience 25+ years’ experience in the Social Services field in different administrative capacities Expertise in Mental Health Administration Mental Health Clinician with Outpatient Mental Health Department since April 2007; TAY program coordinator from 2007 – 2009. Roles and Responsibilities: Provide agency oversite to all Division Managers, meet with funders and program analysts of funded projects. Supervise all Division Managers. Report to Board of Directors. Mandi Reed Director, Substance Use Division, Licensed MFT (License # 51916), Principal Rural Outpatient Program Lead Education Masters of Science, Counseling, Marriage & Family Therapy, CSUF 2008 Licenses Marriage and Family Therapist; clearance: California Board of Marriage & Family Therapists approved supervisor Expertise Program Manager for the Telecare Outpatient alcohol and Drug Services (TOADS) program, supervising the dialing administration and treatment staff, including direct client care. Roles and Responsibilities: Oversee the rural communities drug treatment services including direct and telecare, along with overall daily oversight of staff to ensure program outcomes; accurate recordkeeping and documentation of program activities; regular communication with designated County staff. Reports to C.E.O. Susanne Pruett Controller Education CSU – Fresno and Reedley College majors in accounting Expertise in Accounting and Fiscal Management Professional background in accounting and fiscal management; Promesa’s Controller since 2010, oversees all fiscal aspects of annual budget of $8.4 million Roles and Responsibilities: Prepares all fiscal reports for governmental agencies, Board of Directors, funding entities. Prepares all documentation essential for annual audit of Promesa. Completes all month-end and year end procedures and fiscal reporting. Reports to the C.E.O. Herbert A Cruz, MD Consulting Psychiatrist Education MD Michigan State University College of Human Medicine; UCSF Fresno General Psychiatry Medical Education Program Expertise Specialty in culturally competent, board certified in psychiatric services and mental health education; consulting psychiatric work for the agency. Roles and Responsibilities: Provide psychiatric recommendations for best practices for treatment, education and general medical direction regarding rural services, engage staff in case overview and in reflective practice, conduct in service training to staff, particularly in regards to rendering culturally appropriate telecare. Reports to the CEO and Program Manager. Jessica Taylor Telecare Treatment Specialist Exhibit B Page9 Education Masters of Science in Rehabilitation Counseling, CSU Fresno Experience Bilingual/bicultural Spanish speaking Expertise Provided telecare based treatment for clients enrolled in TOADS program Roles and Responsibilities: Provide telecare substance use treatment to rural and urban residents. Reports to Program Director. Jessica Uriarte Telecare Treatment Specialist/SUD Counselor Education Substance Abuse Counselor RADT, CAAR Institute, Fresno Experience Bilingual/bicultural Spanish speaking service to substance use clients Expertise Treatment substance use direct and telecare counseling services. Roles and Responsibilities: Provide treatment, telecare based counseling and referral services to rural clients dealing with substance use/misuse. Reports to Program Director. Michael Molina Substance Use Counselor Experience Bilingual/bicultural Spanish speaking Expertise Direct counseling in substance use, adults Roles and Responsibilities: Provide telecare based counseling and referral services to rural clients dealing with substance use/misuse. Reports to Program Director. Ruby Fabela Program Office Assistant, Bilingual Spanish/English Education AA in Criminal Justice, 2009, Kaplan College Experience Broad experience in providing bilingual program services and educational training in life skills, independent living and similar activities. Roles and Responsibilities: Knowledge of helping client complete Hazelden supplemental treatment materials, as well as knowledge and adaptability in a non-static environment. Assists treatment team in data collection, compilation and reporting. Acted as a bilingual liaison between different agencies and programs to coordinate projects. Reports to the Program Director. John Kasdorf Consulting Telecare Technologist Education Masters in Information Technology, AI University, Chicago Experience Broad experience in developing telecare based networks for institutions and County governments Roles and Responsibilities: Knowledge of telecare based technologies, networks and interfaces, keeps equipment and encryption software functioning, services distal sites. Reports to CEO and Program Director. Ryan Rinard Peer Support Specialist, Contracted Experience Ryan attributes his recovery and maintenance of recovery to the treatment he received as a telecare client. Ryan has developed websites and other electronic tools to offer support and encouragement to others in recovery and serve as a telecare coach. Roles and Responsibilities: Knowledge of telecare based recovery and available online resources to support recovery, attends training for Support Specialists, adheres to confidentiality guidelines and processes. Provides progress notes to counselors on his interactions with clients, types of messages/contacts he has made with clients (texts, emails, podcasts, online resources), services as a member of the treatment team, collaborates with counseling staff, reports to Program Manager. Exhibit B Page10 Key personnel, including sub-contractors: a) Key personnel are identified immediately above. Resumes for each staff are included in the Attachments portion of the application. b) One key consultant for the TOADS program is Herbert A Cruz, M.D., who serves in a clinical capacity, reviewing cases as requested by treatment staff, suggesting treatment recommendations, prescribing and monitoring psychotropic medications and providing in service training to staff. Dr. Cruz is well versed in the requirements for implementing telecare SUD treatment services. c) The telecare technology expert who will provide services to ensure equipment and encryption software functions is John Kasdorf. He will set up distal sites and provide troubleshooting if issues arise. d) A Peer Support Specialist, Ryan Rinard, will provide peer support services to clients and serve as a paraprofessional member of the treatment team. i. Promesa’s Peer Support Specialist (PSS) offers recovery support to clients in TOADS. Counselors will provide the PSS with contact information for active clients. ii. The PSS will receive training in the role of a PSS in the recovery support of clients, both active, in aftercare and non-compliant. This training will follow the recommendations of NAADAC. iii. The interaction with Promesa’s PSS can be a tremendous resource and adjunct to the foundation of recovery and aftercare. With inspirational words, motivational text messages and supportive emails, the PSS will be the extra support assisting with not only the direct duration of a treatment program but extending into the aftercare planning as well. Promesa’s PSS is committed to offering personalized coaching and support. Recovery is a lifelong journey and the PSS is a testament that clients are not alone in the journey. iv. The PSS’s only contact with clients will be electronic. v. The PSS will conduct engagement activities electronically through agency- approved means (YouTube, texting, inspirational messages). The PSS will document all contacts with clients and share his field notes with the counseling staff. vi. The PSS promotes and models the concept of recovery to program participants; Serves as a member of the multidisciplinary team and shares practical insight related to illness management, life skills, and the lifelong recovery process; May act as an advocate for the client when appropriate. vii. The PSS will adhere to confidential codes of conduct regarding clients. The PSS will have demonstrated an ability to remain clean/sober resulting from his own journey to recovery. viii. The PSS will also be an essential partner to clients in the aftercare portion of the program, sharing connections to resources, such as Hazelden, SAMHSA and other online resources. The PSS may also -- at his discretion -- discuss his recovery journey. Exhibit B Page11 e) There are no subcontractors involved in this program. Intake and assessment process for clients referred  Diagnostic assessments for adults are conducted in a manner that identifies the historical and current information of the potential client as well as his or her needs, abilities, and strengths. Information is gathered in a face-to-face interview, written documentation, and contact with referring agencies and family.  Clients must meet medical necessity, as determined by a physician, AND must have at least one diagnosis from the DSM III/IV for substance related and addictive disorders as well as a positive placement in an ASAM level.  Clients must be 18 years of age (or over) to qualify for adult rural outpatient services.  Clients must have a history of substance use. The substances involved are identified as part of the intake/assessment/diagnostic interview, along with the social, psychological, and physical and/or behavioral problems related to alcohol and other drug use as determined by ASAM level, and medically determined.  Admission to treatment is not denied on the basis of ethnic group identification, religion, age, sex, color, or disability. Promesa does not restrict admission to those persons who can be expected, physically and mentally, to benefit from the services and settings available.  Clients will not be admitted who have major physical or emotional disabilities or illness which represent an immediate danger to staff, self, or others; or who require an immediate medical evaluation or medical/nursing care.  Clients must have some motivation to address their drug/alcohol issues; clients will also be assessed for their willingness to receive counseling through telecare services. Clients will be advised of the role and support resources being offered in telecare treatment and permission to connect them with the Peer Support Specialist will occur during intake.  The staff will review the personal technology available to the client (personal smartphone, laptop computer with webcam, or ability to get to a local distal site to access technology). This technology review is essential to enroll a client in telecare based services.  At the time of the intake interview, the Counselor will determine whether the client qualifies for services, should be referred to a medical facility, in-patient facility or other facility for detoxification, based upon clinical assessment of client.  When a prospective client is incarcerated or hospitalized, the counselor will make arrangements for a face-to-face interview at the client’s location, as appropriate and permitted by the institution.  When a client does not meet the medical necessity determination, staff provides referral to a lower level of care. As noted above, clients recommended for treatment must meet the definition of medical necessity for services based on the ASAM Criteria A. In order for Promesa to admit to treatment, the client must meet the definition of medical necessity, based on ASAM criteria. o Promesa regularly reviews each case, with the contracted psychiatrist, to ensure that clients meet the definition of medical necessity for services, based on ASAM criteria; in each case review, staff measures each client’s progress against the criteria for a Level 1 or Level 2 outpatient program recommended by the American Society for Addiction Medicine. The Exhibit B Page12 program expects those clients who engaged in treatment meet the ASAM criteria for admission to treatment. Firm organizational structure 1. Promesa Behavioral Health is structured in accordance with the regulations governing nonprofits. The agency is steered by a Board of Directors, who provide governance and administrative oversight to the Chief Executive Officer (CEO). 2. The CEO manages the organization with the assistance of 4 Division Managers, along with a Human Resources Director, a Controller and IT Technical Resource Specialist. 3. The 4 Agency Divisions are: Substance Use/Mental Health, Residential Services, Foster Family Agency and Adoptions. The Division Managers provide daily oversight to technicians, social workers, interns, counselors, and professional staff. 4. The agency’s administrative and management teams are highly qualified with specific experience, licensing or certifications in the programs they guide. These programs encompass a variety of services -- 24 hour groups homes, foster families in multiple California counties whose referrals represent many different language and ethnic groups, outpatient mental health, and outpatient alcohol and drug use, adoption home studies conducted in several California counties. 5. Each Division and client component brings unique legal, reporting, billing, accounting, and human resource requirements. The broad range and evolving composition of the programs requires a management team that is responsive to the needs of the clientele, referring partners and to the Counties who contract for Promesa’s services. To meet this need, the Human Resources Department seeks candidates who are well prepared in terms of education, licensing and experience. B. To assist in ensuring the highest quality of services, Promesa secures the services of consultants, experts in their fields, to guide staff. Substance use/mental health services are assisted through the services of Diane Kesckes, M.D., Substance Use Division Chief Medical Director, with addiction and culturally relevant specialty consulting provided by psychiatrist Herbert A. Cruz, M.D. C. With a budget of $8.5 million annually the agency has fully staffed finance, human resources and maintenance departments. The directors of finance and human resources have an average of 20 years of experience in their respective fields. D. Continuous quality assurance is carried out by each Division Manager and designated staff. Organizational plan and management structure Telecare is an innovative approach to reach communities that are unserved and disenfranchised. Promesa’s TOADS program brings treatment and care even closer through the means of smart devices and/or remote, secure technology. In order to be admitted into the telecare portion of treatment, clients must be willing to use technology to receive counseling. During the intake interview, clients are evaluated on their personal technology resources. Since smart devices are essential to receive counseling through telecare, clients must have such a device that can send and receive text messages, be video enabled and have internet access. Staff prefers clients to use their own technology for counseling sessions, as it enables treatment to occur without travel or other worries about accessibility and reduces costs to the agency and its funder. Those who do not have personal smart devices with sufficient data plans are scheduled to receive treatment through a secure Exhibit B Page13 web-based terminal set up in a health care clinic, pharmacy or private office in a centrally located community setting. During the admissions interview, clients are advised they will be contacted by the Peer Support Specialist, informed of his role in supporting their recovery and to expect electronic contact from this paraprofessional member of the treatment team. Permission for this member of the treatment team to contact them will be obtained during the admissions interview. For clients are provided confidentiality training during their assessment, intake and treatment planning appointment (which is done in person). Confidentiality training emphasizes that clients need to find a secure space within their home while their session is occurring. Clients are advised that a session will NOT occur if they are in a public, non-secure setting (ex: restaurant, coffeehouse, waiting room, library). Clients are provided with a personal access code that connects them to their counselor using encryption software which ensures their privacy during treatment sessions, texting correspondence and other electronic communications. • Clinicians and addiction counselors schedule sessions with rural adult clients using video Smartphone and laptop technology that can securely access clients, to ensure they are receiving in-the-moment information or scheduled consultation/ treatment session; • Existing EHR platform built to scale for expanding electronic record keeping (Promesa uses FAMCare, Promesa’s federally certified EHR); • Security around the EHR Promesa utilizes continues to match and/or exceed HIPAA regulations; • Emergency tracking services are employed within the TOADS program. Electronic devices owned by Promesa which are used in treatment (like Smartphones and laptops (laptops enabled video or IM (instant messaging) have GPS built in to enable 911 responses to track emergency event locations (for example, a psychiatric crisis, evidence of immediate violence, an expressed threat of homicide or suicide or possible overdosing). Further, GPS enables staff to track devices owned by the agency, in the event of theft. • Client’s personal technology may or may not have GPS enabled tracking. Promesa does not request GPS information embedded in client devices. • Additionally, Promesa seeks to expand Telecare services to un-served and/or under-served populations in rural communities. Promesa expects to demonstrate the cost effectiveness of telecare for rural substance use treatment as the most efficient model of care for rural residents who are hampered in seeking treatment by geography, accessibility/ availability or other limiting variable. One measure of cost effectiveness is to provide telecare through smart devices owned by clients. In providing telecare with clients using their own technology, Promesa has never experienced a confidentiality or security breach. When clients use their own technology for treatment, it seems to strengthen their commitment to treatment. Clients respect the integrity of the mobile therapy process and engage in the collaborative aspect of treatment. Become DMC certified  Promesa is currently DMC certified  Promesa is currently AOD certified Proof of these facts are contained in the Attachments portion of the binder. SUD Certification (CARF)  Promesa is currently CARF accredited. Proof of this certification is contained in the Attachments portion of the binder. Exhibit B Page14 CQI process Clinical records are continually monitored by program staff, managers and consultants to assure that record keeping and services comply with applicable laws and regulations, standards of quality care, HIPAA requirements, meaningful use and the policies of Promesa Behavioral Health. The Program Director is responsible for assuring that reviews take place. The file and the treatment plan reviews occur under the direction of the Program Director who involves the Medical Director, as appropriate. CQM review is to assure: Continuity of Activities A recovery treatment plan is developed within 30 days of the client’s admission. • Services required are provided and documented in the client’s file. • Failure of the client to keep scheduled appointments is discussed by the treatment team and action documented in the client’s file. Every reasonable effort is made to sustain non-compliant clients in treatment. • Progress in achieving the objectives identified in the treatment plan is assessed and documented, along with periodic review and updates to the treatment plan. • The treatment plan is reviewed by the client and updated as needed, at least every 90 days, in accordance with MediCal procedures for justification to continue treatment services. • The client’s file contains all required documents according to all regulatory guidelines, including clinical notes. • The client’s interactions with the Peer Support Specialist are fully documented and included in the CQI review. • If feasible, the client is followed-up after completion of program services as scheduled in the discharge summary. File Review – at minimum shall occur at intake, when treatment plan revision is appropriate and at discharge. This review will assure that: • The treatment plan/plan updates was relevant to the stated problem(s); • The services delivered were relevant to the treatment plan; and • Record keeping was in accordance with these standards Treatment Plan Review – shall occur when a change in problem or in the focus if treatment occurs (as per ASAM levels of care reviews), or updates/changes to the treatment plan, or no later than 90 days after signing the initial treatment plan and no later than every 90 days thereafter as per MediCal regulations. • Assess progress to date; • Reassess needs and services; and • Identify additional problem areas and formulate new goals, when appropriate. Eligibility Review Frequent review of client’s third party payment eligibility, particularly for clients who are non-Drug MediCal eligible at intake. Assess that clients who became Drug MediCal eligible were guided through that qualification’s process. Exhibit B Page15 Focus on Results The TOADS program aims to provide substance use/addiction counseling services in areas without direct SUD services, such as rural communities from which travel represents a significant commitment in time and an impediment to traditional, site-based services. 1) TOADS will provide innovative and secure videoconferencing for SUD treatment, enabling rural residents to meet sobriety goals, complete Drug Court recommendations and otherwise live healthier lifestyles. 2) Since Promesa currently uses telecare in substance use counseling, the agency is ready to implement the project upon award. Promesa has established workflow patterns in place for telecare staff, who schedule clients upon referral, guide them through the intake, assessment and orientation to telecare, who are skilled at scheduling the teleconferences, routinely send out appointment reminders to clients, answer questions promptly and serve as ambassadors of the program to clinicians, practitioners and others in the health care field. 3) The existing telecare staff, under the supervision of Promesa’s consulting psychiatrist, Dr. Cruz, would be able to oversee a caseload of 60+ clients. In Promesa’s substance use treatment program, there are 4 addiction counselors who are providing location based treatment, as well as telecare to support the treatment goals of clients. Counselors provide treatment at the urban Fresno location and in rural Mendota. 4) The Peer Support Specialist will only meet clients electronically. All contacts and types of messages will be documented. Tracking and Reporting on Performance 1) From its inception Promesa has made performing to contract measures a priority. The measurement of contract performance is included in several of the quality management activities that Promesa conducts – with particular emphasis upon contract compliance agreements detailed by each County. 2) Promesa provides data reports on contract measures to its providers, based upon the frequency detailed by each County. The data captured in the reports is primarily from internal data sources. Data on contract measures is also available to providers and Promesa’s Division management on a daily basis through an internal on-line database – FAMCare. 3) In addition to the continual review of data on performance measures, Promesa’s Managers also conducts monthly Continuous Quality Improvement meetings with staff to review and discuss contractual indicators. Continuous Quality Improvement meetings are also used as a platform for staff to report on strategies utilized to increase any identified substandard performance. Processes and techniques that are used by those achieving performance are also discussed so that practice changes can occur. 4) Consistent with CARF standards, Division Managers are responsible for ensuring that clear, accurate, and timely information regarding all aspects of the quality management process are provided to its service recipients, Board, staff, and community stakeholders. Promesa attends and participates in monthly meetings with California Community Alliance. 5) At least annually, Promesa provides a report of findings of key quality assurance activities in the Annual Report. Exhibit B Page16 o Certificates of insurance are included in Attachments in the RFP binders.  Commercial liability  Automobile liability  Professional liability  Workers compensation coverage o Fire clearance to be provided upon request. Flexibility in meeting unique client needs … With Telecare, this cost of treatment represents a vast savings over residential and/or traditional office-based outpatient care. Moreover, with telecare not only is money saved over time, but also time invested in recovery. The value of telecare for rural clients is it relieves the anxiety concerning transportation, especially if the client has no personal vehicle or no license to drive. Clients are also relieved of the stress of locating a treatment facility within urban Fresno, if one is unfamiliar with urban traffic. Because Promesa can more easily serve clients using their own smart technology, staff conducts a technology review with each client, to determine the feasibility of the personal device for counseling sessions. In assessing the type of technology personally available to clients, Promesa staff conduct a thorough technology review and training with each client. This results in individualized ‘connection’ plans for each client, thus the counselors are electronically meeting with each client using a wide span of smart devices (laptops, iPhones, iPads, Blackberry, and so forth). Clients are schooled in issues of confidentiality when using their smart device for counseling. They are advised to NOT be in a public place when a session is scheduled, but rather a private place in their home or by conducting their session at a distal location arranged for the program. Clients with limited data plans, older equipment or reluctance to use their own devices receive orientation for their scheduled sessions at a distal site (a clinic, community center or other spot that Promesa has secured for telecare services). Dr. Cruz, the consulting psychiatrist for the TOADS program, prefers to meet clients using video- enabled smart technology. In concert with staff, he will review client treatment plans, particularly if the addiction counseling staff requests a medication review for the client. At intake, clients receive orientation and instruction using the chosen internet platform (most likely WebEx) for their sessions with Dr. Cruz or the counseling staff. Length of Treatment The majority of treatment plans call for a minimum of 2 counseling sessions per month. Clients are typically provided a status interview at the end of 90 days (3 months) in treatment (as required by MediCal regulations). Clients will remain active in treatment as long as medical necessity exists. Clients who have met treatment goals will be transitioned into aftercare for a period of time, if medical necessity for “stepped down” frequency in treatment is determined. Discharge planning begins as clients progress through the ASAM levels of care and it is determined by the medical director that they can sustain recovery on their own. The added value of TOADS is that clients can be scheduled for more frequent clinical sessions, since telecare is more cost effective to the agency and to the clients. Clients are send text reminders for sessions and provided electronic inspirational messages. Clients are provided with a wide variety of additional online resources, primarily from Hazelden, to supplement their recovery. Client utilization of these expanded resources will be noted in their case files. Further, counselors are more immediately available to clients, should need arise. Exhibit B Page17 To review, treatment planning follows the following protocols: A. The goal of the treatment is abstinence. However, since most clients experience a myriad of social problems including involvement in the criminal justice system, lack of employment, family, and other mental health issues, the agency recognizes the value of harm reduction strategies and utilizes them to achieve the ultimate goal of complete abstinence. Through networking and through other services provided by other divisions within the agency, the alcohol and drug treatment program is able to broaden its approach in addressing the range of these problems the client’s experience. B. Promesa emphasizes services provided by caring, professional staff and makes every effort to hire licensed or certified staff as well as contract with board certified medical personnel when that is appropriate or required. C. On-site SUD counseling services are provided at Promesa’s headquarters location from 8-5:30 Monday – Friday; Promesa offers evening sessions twice a week, from 6:00-8:00 pm. For rural clients, assessment/intake services are on-site at a distal location (a community center or health clinic) and through telecare for ongoing treatment. D. Promesa has a 24/7 emergency contact for those clients who may need immediate crisis management. i. Bio-Psycho-social assessment (ASI), a mental health assessment and evaluation will occur in person/on site upon intake and upon program completion. ii. Individual counseling for crisis, prevention of immediate relapse, or if relapse has occurred, recovery therapy, individual sessions primarily through telecare based sessions. iii. Collaborative treatment planning occurs with client, counselor, and/or physician in an in- person, local context. Assessment, intake and treatment planning occurs in a location convenient to the client, on-site in a setting that can sustain confidentiality. iv. Outpatient group therapy is offered in the telecare program, on-site for monthly group sessions; the majority of treatment is individual telecare sessions. v. Collateral sessions with close family or friends who may be impacted by the treatment may be provided, through telecare, as well. Family members are also offered an orientation to telecare, a technology review and a confidentiality training. vi. Collaboration with other agencies to create a comprehensive treatment program including entering into distal location agreements with local agencies or health clinics. vii. Promesa’s programs continue this focus of providing local services. The agency has (or is willing to) establish collocated services with local organizations. viii. Promesa recognizes that the San Joaquin Valley encompasses a culturally, socially and ethnically diverse population. The people who seek treatment here are doing their best to create meaningful, satisfying lives for themselves, usually under very difficult circumstances. Therefore, the services provided at Promesa enables clients to build successful and responsible lives for themselves. ix. Promesa introduces and encourages use of 12 step programs. x. Referrals are made by the Department of Behavioral Health, Fresno County Probation Department and Drug Court, Department of Social Services, Welfare to Work as well as Superior Court of Fresno County, parents, schools and self. xi. Additionally, Promesa uses a holistic community framework to ensure that programs and services are using evidence based treatment services. xii. As previously noted, the determination of treatment services emerges from a variety of assessment instruments. Promesa administers the complete ASAM, as well as the Addiction Exhibit B Page18 Severity Index, a drug use screening along with a general health questionnaire. These assessment instruments frame the treatment recommendations of the staff. xiii. The California Outcomes Measurement System (CALOMS) is a data collection and reporting system for substance use disorders (SUD) treatment services utilized by staff. Staff enters information monthly, which builds a comprehensive picture of client behavior with alcohol/drug use, employment and education, legal/criminal justice, medical/physical health, mental health and social/family life. Summary reports which emerge from this treatment outcome data, contribute to understanding of treatment and the improvement of SUD treatment in the continuum of prevention, treatment and recovery services. xiv. Provide a safe and confidential environment for growth and health, with culturally specific and family centered approaches, while building community support for at-risk populations. E. The treatment strategies integrate culturally competent electronically based therapy with traditional drug treatment/relapse prevention modalities, such as 12 step AA/NA models, relapse prevention, cognitive behavioral and cultural interventions. The physical health problems associated with drug use will be addressed through linking clients with needed medical services. F. Staff also continually review client eligibility for drug MediCal services, if they are not eligible upon intake. G. One insight that Promesa feels contributes to treatment retention and extension rates is the sensitivity of the staff — the Addiction Counselors, the Peer Support Specialist and/or interns electronically contact each client every Monday to check-in (for many clients, weekends are fraught with temptations to relapse, so the check-in is an important connection for the clients). Counselors also conduct check-ins after holidays and any major life event revealed by clients (for example, anniversaries for weddings, divorces, deaths -- often sources of difficulty for clients in recovery). This attentiveness helps clients to maintain equilibrium and practice the harm reduction strategies they work so hard to embrace. H. Many of Promesa’s telecare clients often report that they are not ‘sober’ yet in the sense of complete abstinence from their substance/s of choice; yet, they simultaneously note a decrease in symptoms (drinking/using less, drinking/using less often, and/or using fewer illegal substances) while reporting increased refusal abilities. In assessing the type of technology personally available to clients, Promesa staff conducts a thorough technology review and electronic device training with each client. Resulting in individualized ‘connection’ plans for each client, enabling the counselors efficiently electronically meet with each client no matter the span of smart devices (laptops, android-enabled, iPhones, iPads, Blackberry, and so forth). One tantalizing insight that has emerged from utilizing the personal devices of clients is that they seem more committed to treatment, Promesa concludes that providing their own equipment likely contributes to a stronger ‘buy-in’ to treatment, where clients strive to meet their sobriety goals. Exhibit B Page19 Goal: Increase treatment engagement for rural residents with substance use or addictions Objective: Offer assessment, treatment and follow up care for rural residents using collocated distal locations in the delivery of telecare treatment services Risk Factors Strategies Short Term Intermediate Long Term Indicator i/ rural adults who meet medical necessity based on ASAM and DSM assessment are not following through with treatment ii/ Adults cited for alcohol and/or drug related offenses are failing to appear in Drug Court iii/ Rural adults lack either the transportation to treatment or means to otherwise access treatment i/ Intake interviews conducted in person and on-site in a safe setting in rural communities; clients assessed for enrollment in telecare treatment for rural residents who meet medical necessity for substance use treatment ii/ On-site, in person assessment/intake interviews, where they receive telecare orientation and virtual counseling session scheduling; appointment reminders sent via text or instant messaging, or email iii/For clients without personal smartphones, sessions will be virtually conducted through equipment installed at a local community location iv/On-site, in person mid- point status interviews v/On-site, in person exit interviews if client has met treatment goals or commitment to extended treatment vi/Clients will be connected to a Peer Support Specialist for additional assistance in recovery ‘work’ vii/Clients will be connected to online resources to supplement the information received from TOADS i/by 6/30/17, increase participation in substance use/use/ addiction treatment using telecare by rural residents who meet medical necessity ii/increase in court appearances for rural adults cited for Drug Court iii/decrease in hardship to access treatment for rural residents through locally available on site and/or telecare treatment v/increase commitment to recovery through a Peer Support Specialist and an enriched array of online supports i/by 1/1/18, increase in treatment success for rural residents using telecare supported by regular electronic checkins ii/ decrease in relapse behavior by rural residents who completed telecare based treatment iii/ increase in self referral for treatment for substance use iv/increase in client sobriety rates and successful completion of treatment i/ by 1/1/19 increase in sobriety maintenance by clients using telecare ii/ decrease in relapse behavior by rural residents iii/decrease in unmet treatment needs by rural residents Data tracking will be: i/Reporting instruments required by DBH, ii/data tracking tool of Promesa iii/Annual focus group field notes, Interviews with clients, law enforcement, community leaders iv/ASAM & DSM along with ASI post assessments v/CalOHMS data tracking vi/client self reports of experiences with telecare vii/client self reports of sobriety and drug/alcohol free lifestyle changes 17-030 EXHIBIT C, Page 1 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx % of FTE 3 MONTH dedicated to Salary this program Admin.Direct Admin.Direct Admin.Direct Admin.Direct Admin.Direct 0101 Executive Director Lisa Weigant (In-Kind)-$ -$ 0102 Program Manager Mandi Reed $15,250 50%100%$7,625 -$ 7,625$ 0103 AOD Counselor I Jessica Taylor $11,271 100%100%$11,271 -$ 11,271$ 0104 AOD Counselor I Cecilia Rubalcaba $11,271 100%100%$11,271 -$ 11,271$ 0105 Administrative Assistant Ruby Fabela $6,630 100%100%$6,630 6,630$ -$ 0106 -$ -$ 0107 -$ -$ 0108 -$ -$ 0109 -$ -$ 0110 -$ -$ 0111 -$ -$ 0112 -$ -$ 0113 -$ -$ 0114 -$ -$ 0115 -$ -$ 0116 -$ -$ 0117 -$ -$ 0118 -$ -$ 0119 -$ -$ 0120 -$ -$ 0121 -$ -$ 0122 -$ -$ 0123 -$ -$ 0124 -$ -$ 0125 -$ -$ 0126 -$ -$ 0127 -$ -$ 0128 -$ -$ 0129 -$ -$ 0130 -$ -$ SALARIES TOTAL $6,630 $30,167 6,630$ 30,167$ 0151 $38 $175 38$ 175$ 0152 $411 $1,870 411$ 1,870$ 0153 $96 $437 96$ 437$ 0154 $51 $510 51$ 510$ PAYROLL TAXES TOTAL $597 $2,993 597$ 2,993$ EMPLOYEE BENEFITS 0201 Health Insurance $741 $2,140 741$ 2,140$ 0202 Life Insurance $27 $135 27$ 135$ 0203 Retirement $199 $905 199$ 905$ 0204 Benefits Other - Specify -$ -$ EMPLOYEE BENEFITS TOTAL $967 $3,180 967$ 3,180$ TAXES & BENEFITS TOTAL 1,564$ 6,173$ TOTAL PERCENT OF BENEFITS TO SALARIES 24%20% 7120 N. Marks Avenue, Suite #110 E-mail Address: TOADS - Telecare Outpatient Alcohol and Drug Services Promesa Behavioral Heath Fresno, CA 93711 559-439-5437 559-436-6119 Program Name: Approved by:Street Address: Budget Categories- FISCAL YEAR 2016-17 Total Proposed BudgetLine Item Description to services SAPT Funding Other Funding Other Funding Provider Name:Mailing Address: FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUBSTANCE USE DISORDER SERVICES RURAL OUTPATIENT TREATMENT SERVICES % Time dedicated No. of Budgeted FTEs - Admin:Phone Number: No. of Budgeted FTEs - Direct:Fax Number: Medicare Workers' Compensation Insurance PAYROLL TAXES State Unemployment Insurance F.I.C.A. (Must be Itemized) PERSONNEL/SALARIES Proposed Program Budget 17-030 EXHIBIT C, Page 2 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx TOADS - Telecare Outpatient Alcohol and Drug Services SAPT Funding Other Funding Other Funding Proposed Program Budget Budget Budget Budget SALARY, PAYROLL TAX, AND EMPLOYEE BENEFITS TOTAL $44,533 $0 $0 $44,533 0252 $1,204 $1,204 0253 $0 $1,204 $0 $0 $1,204 0301 $624 $624 0302 $0 $624 $0 $0 $624 0351 $300 $300 0352 $0 0353 $900 $900 0354 $0 0355 $0 $1,200 $0 $0 $1,200 0401 $4,000 $4,000 0402 $1,710 $1,710 0403 $0 $5,710 $0 $0 $5,710 FACILITIES 0451 $1,050 $1,050 0452 $0 0453 $0 $1,050 $0 $0 $1,050 0501 $5,454 $5,454 0502 $0 0503 $0 0504 $0 $5,454 $0 $0 $5,454 0551 $0 0552 $750 $750 0553 $0 $750 $0 $0 $750 0601 $8,100 $8,100 0602 $4,500 $4,500 $12,600 $0 $0 $12,600 0651 $0 0652 $0 $0 $0 $0 $0 0701 $8,125 $8,125 0702 Licenses/Taxes $0 0703 $0 0749 $0 $8,125 $0 $0 $8,125 $0 $81,250 $0 $0 $81,250 3120 $0 3130 $0 3140 $0 3150 $0 $0 $0 $0 $0 $81,250 $0 $0 $81,250 REVENUE/MATCH TOTAL NET PROGRAM BUDGET TOTAL PROGRAM EXPENDITURES REVENUE/MATCH Medi-Cal State Grant Private Donations FISCAL AND AUDITS Accounting/Bookkeeping External Audit Client Fees ONE TIME ADVANCE - Start Up Costs FISCAL AND AUDITS TOTAL OTHER COSTS Indirect Costs County Administration Fee Other Business Services OTHER COSTS TOTAL CONSULTANCY PROGRAM SUPPLIES Consultant Services Contracted Services CONSULTANCY TOTAL TRAVEL COSTS TOTAL Program Supplies-Client Incentives Program Supplies-Curriculum Program Supplies-Food PROGRAM SUPPLIES TOTAL Telecommunications/data lines COMMUNICATIONS TOTAL Office Supplies Transportation FACILITIES TOTAL Staff Mileage Equipment Rent/Lease Equipment Maintenance Facilities Maintenance Utilities EQUIPMENT TOTAL Rent/Lease Building TRAVEL COSTS Staff Travel (Out of County) Staff Training/Registration Printing/Reproduction OFFICE EXPENSE TOTAL Purchase of Equipment Answering Service OFFICE EXPENSE Soc Rec., Workbooks Publications Legal Notices/Advertising EQUIPMENT COMMUNICATIONS INSURANCE TOTAL Provider Name: (Must Be Itemized) Program: INSURANCE Date: Promesa Behavioral Heath Budget Categories-Line Item Description FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUBSTANCE USE DISORDER SERVICES RURAL OUTPATIENT TREATMENT SERVICES Liability Insurance Insurance Other-Specify FISCAL YEAR 2016-17 17-030 EXHIBIT C, Page 3 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx Provider Name: Budget Categories-Line Item Description Executive Director In-Kind Program Manager $30,500 50% AOD Counselor I $22,541 100% AOD Counselor I $22,541 100% Administrative Assistant $13,260 100% PAYROLL TAXES TOTAL EMPLOYEE BENEFITS TOTAL EQUIPMENT List the following equipment categories and provide a brief description for each  0401 - Purchase of Equipment - Laptops for distal sites for client use  0402 - Equipment Rent/Lease - Leased laptops for staff use  0403-Equipment Maintenance: minor equipment repair for copier and COMMUNICATIONS  0301 - Telecommunications/data lines - Cell ph, Webex, Wifi, email encryp.  0302 - Answering Service - N/a OFFICE EXPENSE  0351-Office Supplies: Includes Items necessary to carry out the daily activities to accomplish the program goals and objectives including paper, filing supplies, pens, pencils, scissors, and other supplies.  0352 - Social/Rec, Workbooks.- N/a  0353-Printing/Reproduction includes items such as the printing of business cards, program pamphlets, position vacancy advertising and other materials related to the program.  0354 - Publications - N/a  0355 - Legal Notices/Advertising - N/a INSURANCE List the following insurance categories:  0251 - Workers Compensation Insurance - N/a (Incl. in employee benefits)  0252 - Liability Insurance - General Liability  0253 - Insurance Other - N/a FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUD SERVICES RURAL OUTPATIENT TREATMENT SERVICES PERSONNEL/ SALARIES Annual Salary and FTE equivalence as in budget. 6 Month Salary for this Program % of FTE dedicated to this program Position descriptions submitted with proposal. FISCAL YEAR 2016-17 Promesa Behavioral Heath 17-030 EXHIBIT C, Page 4 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx Provider Name: FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUD SERVICES RURAL OUTPATIENT TREATMENT SERVICES FISCAL YEAR 2016-17 Promesa Behavioral Heath FACILITIES List the following facilities categories and provide a brief description for each  0451 - Rent/Lease Building - Monthly rent for distal sites  0452 - Facilities Maintenance - N/a  0453 - Utilities - N/a CONSULTANCY List the following consulting categories and provide a brief description for each  0601 - Consultant Services - Consult Psych., Peer Support Specialist  0602 - Contracted Services - Telecare I.T. technician TRAVEL List the following travel categories and provide a brief description for each  0501 - Staff Mileage - Staff travel to distal sites weekly for first intake  0502 - Staff Travel (Out of County) - Travel expenses for required training  0503 - Staff Training/Registration - ASAM annual conf, 2 staff beg. Apr2018  0504 - Transportation - N/a PROGRAM SUPPLIES List the following program supplies categories and provide a brief description  0551 - Program Supplies - Client Incentives  0552 - Program Supplies - Curriculum  0553 - Program Supplies - Food FISCAL AND AUDITS List the following fiscal and audits categories and provide a brief description for  0651 - Accounting/Bookkeeping - N/a  0652 - External Audit - N/a OTHER COSTS List the following categories and provide a brief description for each category:  0701 - Indirect Costs - 10% program costs  0702 - Licenses/Taxes - N/a  0703 - County Administration Fee - N/a  0749-Other Costs - Other business services such as applicant TB tests, drug screens, and other program-related items that don't necessarily fit into another line item. ONE TIME ADVANCE Used for startup costs and is available upon request with a detailed The amount cannot exceed 1/12th of the total cost proposal for this section. REVENUE/MATCH Please identify all anticipated funding sources and distinguish whether the  3120 - Drug Medi-Cal - Mental Health Medi-Cal -  3130 - State Grant -  3140 - Private Donations -  3150 - Client Fees - 17-030 EXHIBIT C, Page 5 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx Annual % of FTE (12-Month)dedicated to Salary this program Admin.Direct Admin.Direct Admin.Direct Admin.Direct Admin.Direct 0101 Executive Director Lisa Weigant (In-Kind)-$ -$ 0102 Program Manager Mandi Reed $61,000 50%100%$0 $30,500 -$ 30,500$ 0103 AOD Counselor I Jessica Taylor $45,082 100%100%$0 $45,082 -$ 45,082$ 0104 AOD Counselor I Cecilia Rubalcaba $45,082 100%100%$0 $45,082 -$ 45,082$ 0105 Administrative Assistant Ruby Fabela $26,520 100%100%$26,520 26,520$ -$ 0106 -$ -$ 0107 -$ -$ 0108 -$ -$ 0109 -$ -$ 0110 -$ -$ 0111 -$ -$ 0112 -$ -$ 0113 -$ -$ 0114 -$ -$ 0115 -$ -$ 0116 -$ -$ 0117 -$ -$ 0118 -$ -$ 0119 -$ -$ 0120 -$ -$ 0121 -$ -$ 0122 -$ -$ 0123 -$ -$ 0124 -$ -$ 0125 -$ -$ 0126 -$ -$ 0127 -$ -$ 0128 -$ -$ 0129 -$ -$ 0130 -$ -$ SALARIES TOTAL $26,520 $120,664 $0 $0 $0 $0 26,520$ 120,664$ 0151 $154 $700 154$ 700$ 0152 $1,644 $7,481 1,644$ 7,481$ 0153 $385 $1,750 385$ 1,750$ 0154 $204 $2,039 204$ 2,039$ PAYROLL TAXES TOTAL $2,387 $11,970 $0 $0 $0 $0 2,387$ 11,970$ EMPLOYEE BENEFITS 0201 Health Insurance $2,964 $8,561 2,964$ 8,561$ 0202 Life Insurance $109 $539 109$ 539$ 0203 Retirement $796 $3,620 796$ 3,620$ 0204 Benefits Other - Specify -$ -$ EMPLOYEE BENEFITS TOTAL $3,868 $12,720 $0 $0 $0 $0 3,868$ 12,720$ TAXES & BENEFITS TOTAL 6,255$ 24,690$ TOTAL PERCENT OF BENEFITS TO SALARIES 24%20% E-mail Address: 0 7120 N. Marks Avenue, Suite #110 Fresno, CA 93711 0 559-439-5437 559-436-6119 0 No. of Budgeted FTEs - Admin:Phone Number: No. of Budgeted FTEs - Direct:Fax Number: TOADS - Telecare Outpatient Alcohol and Drug Services Approved by:0 Street Address: Workers' Compensation Insurance PAYROLL TAXES State Unemployment Insurance F.I.C.A. Medicare (Must be Itemized) PERSONNEL/SALARIES Line Item Description to services FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUBSTANCE USE DISORDER SERVICES RURAL OUTPATIENT TREATMENT SERVICES FISCAL YEAR 2017-18 Other Funding Other Funding Total Proposed Budget Budget Categories-% Time dedicated Proposed Program Budget SAPT Funding Provider Name:Promesa Behavioral Heath Mailing Address: Program Name: 17-030 EXHIBIT C, Page 6 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx TOADS - Telecare Outpatient Alcohol and Drug Services SAPT Funding Other Funding Other Funding Proposed Program Budget Budget Budget Budget SALARY, PAYROLL TAX, AND EMPLOYEE BENEFITS TOTAL $178,128 $0 $0 $178,128 0252 $4,814 $4,814 0253 $0 $4,814 $0 $0 $4,814 0301 $3,576 $3,576 0302 $0 $3,576 $0 $0 $3,576 0351 $1,200 $1,200 0352 $0 0353 $3,600 $3,600 0354 $0 0355 $0 $4,800 $0 $0 $4,800 0401 $0 0402 $6,840 $6,840 0403 $0 $6,840 $0 $0 $6,840 FACILITIES 0451 $7,200 $7,200 0452 $0 0453 $0 $7,200 $0 $0 $7,200 0501 $24,942 $24,942 0502 $2,200 $2,200 0503 $3,130 $3,130 0504 $0 $30,272 $0 $0 $30,272 0551 $0 0552 $6,470 $6,470 0553 $0 $6,470 $0 $0 $6,470 0601 $32,400 $32,400 0602 $18,000 $18,000 $50,400 $0 $0 $50,400 0651 $0 0652 $0 $0 $0 $0 $0 0701 $32,500 $32,500 0702 Licenses/Taxes $0 0703 $0 0749 $0 $32,500 $0 $0 $32,500 $325,000 $0 $0 $325,000 3120 $0 3130 $0 3140 $0 3150 $0 $0 $0 $0 $0 $325,000 $0 $0 $325,000 Other Business Services OTHER COSTS TOTAL REVENUE/MATCH TOTAL NET PROGRAM BUDGET TOTAL PROGRAM EXPENDITURES REVENUE/MATCH Medi-Cal State Grant Private Donations Client Fees External Audit FISCAL AND AUDITS TOTAL OTHER COSTS Indirect Costs County Administration Fee Consultant Services Contracted Services CONSULTANCY TOTAL FISCAL AND AUDITS Accounting/Bookkeeping Program Supplies-Client Incentives Program Supplies-Curriculum Program Supplies-Food PROGRAM SUPPLIES TOTAL CONSULTANCY Staff Travel (Out of County) Staff Training/Registration Transportation TRAVEL COSTS TOTAL PROGRAM SUPPLIES Facilities Maintenance Utilities FACILITIES TOTAL TRAVEL COSTS Staff Mileage Purchase of Equipment Equipment Rent/Lease Equipment Maintenance EQUIPMENT TOTAL Rent/Lease Building Printing/Reproduction Publications Legal Notices/Advertising OFFICE EXPENSE TOTAL EQUIPMENT Answering Service COMMUNICATIONS TOTAL OFFICE EXPENSE Office Supplies Soc Rec., Workbooks Liability Insurance Insurance Other-Specify INSURANCE TOTAL COMMUNICATIONS Telecommunications/data lines Provider Name: Budget Categories-Line Item Description (Must Be Itemized) INSURANCE FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUBSTANCE USE DISORDER SERVICES RURAL OUTPATIENT TREATMENT SERVICES FISCAL YEAR 2017-18 Program: Date: Promesa Behavioral Heath 17-030 EXHIBIT C, Page 7 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx Provider Name: Budget Categories-Line Item Description Executive Director In-Kind Program Manager $61,000 50% AOD Counselor I $45,082 100% AOD Counselor I $45,082 100% Administrative Assistant $26,520 100% PAYROLL TAXES TOTAL EMPLOYEE BENEFITS TOTAL EQUIPMENT List the following equipment categories and provide a brief description for each category:  0401 - Purchase of Equipment - N/a  0402 - Equipment Rent/Lease - Leased laptops for staff use  0403-Equipment Maintenance: minor equipment repair for copier and vehicle maintenance. COMMUNICATIONS  0301 - Telecommunications/data lines - Cell ph, Webex, Wifi, email encryp.  0302 - Answering Service - N/a OFFICE EXPENSE  0351-Office Supplies: Includes Items necessary to carry out the daily activities to accomplish the program goals and objectives including paper, filing supplies, pens, pencils, scissors, and other supplies.  0352 - Social/Rec, Workbooks.- N/a  0353-Printing/Reproduction includes items such as the printing of business cards, program pamphlets, position vacancy advertising and other materials related to the program.  0354 - Publications - N/a  0355 - Legal Notices/Advertising - N/a INSURANCE List the following insurance categories:  0251 - Workers Compensation Insurance - N/a (Incl. in employee benefits)  0252 - Liability Insurance - General Liability  0253 - Insurance Other - N/a FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUD SERVICES RURAL OUTPATIENT TREATMENT SERVICES PERSONNEL/ SALARIES Annual Salary and FTE equivalence as in budget. Annual (12 Month) Salary for this % of FTE dedicated to this program Position descriptions submitted with proposal. FISCAL YEAR 2017-18 Promesa Behavioral Heath 17-030 EXHIBIT C, Page 8 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx Provider Name: FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUD SERVICES RURAL OUTPATIENT TREATMENT SERVICES FISCAL YEAR 2017-18 Promesa Behavioral Heath REVENUE/MATCH Please identify all anticipated funding sources and distinguish whether the  3120 - Drug Medi-Cal - Mental Health Medi-Cal -  3130 - State Grant -  3140 - Private Donations -  3150 - Client Fees -  0652 - External Audit - N/a OTHER COSTS List the following categories and provide a brief description for each category:  0701 - Indirect Costs - 10% program costs  0702 - Licenses/Taxes - N/a  0703 - County Administration Fee - N/a  0749-Other Costs - Other business services such as applicant TB tests, drug screens, and other program-related items that don't necessarily fit into another line item. FISCAL AND AUDITS List the following fiscal and audits categories and provide a brief description for CONSULTANCY List the following consulting categories and provide a brief description for each  0601 - Consultant Services - Consult Psych., Peer Support Specialist  0602 - Contracted Services - Telecare I.T. technician  0651 - Accounting/Bookkeeping - N/a PROGRAM SUPPLIES List the following program supplies categories and provide a brief description  0551 - Program Supplies - Client Incentives  0552 - Program Supplies - Curriculum  0553 - Program Supplies - Food TRAVEL List the following travel categories and provide a brief description for each  0501 - Staff Mileage - Staff travel to distal sites weekly for first intake  0502 - Staff Travel (Out of County) - Travel expenses for required training  0503 - Staff Training/Registration - ASAM annual conf., and local trainings  0504 - Transportation - N/a FACILITIES List the following facilities categories and provide a brief description for each category:  0451 - Rent/Lease Building - Monthly rent for distal sites  0452 - Facilities Maintenance - N/a  0453 - Utilities - N/a 17-030 EXHIBIT C, Page 9 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx Annual % of FTE (12-Month)dedicated to Salary this program Admin.Direct Admin.Direct Admin.Direct Admin.Direct Admin.Direct 0101 Executive Director Lisa Weigant (In-Kind)-$ -$ 0102 Program Manager Mandi Reed $61,000 50%100%$0 $30,500 -$ 30,500$ 0103 AOD Counselor I Jessica Taylor $45,082 100%100%$0 $45,082 -$ 45,082$ 0104 AOD Counselor I Cecilia Rubalcaba $45,082 100%100%$0 $45,082 -$ 45,082$ 0105 Administrative Assistant Ruby Fabela $26,520 100%100%$26,520 26,520$ -$ 0106 -$ -$ 0107 -$ -$ 0108 -$ -$ 0109 -$ -$ 0110 -$ -$ 0111 -$ -$ 0112 -$ -$ 0113 -$ -$ 0114 -$ -$ 0115 -$ -$ 0116 -$ -$ 0117 -$ -$ 0118 -$ -$ 0119 -$ -$ 0120 -$ -$ 0121 -$ -$ 0122 -$ -$ 0123 -$ -$ 0124 -$ -$ 0125 -$ -$ 0126 -$ -$ 0127 -$ -$ 0128 -$ -$ 0129 -$ -$ 0130 -$ -$ SALARIES TOTAL $26,520 $120,664 $0 $0 $0 $0 26,520$ 120,664$ 0151 $154 $700 154$ 700$ 0152 $1,644 $7,481 1,644$ 7,481$ 0153 $385 $1,750 385$ 1,750$ 0154 $204 $2,039 204$ 2,039$ PAYROLL TAXES TOTAL $2,387 $11,970 $0 $0 $0 $0 2,387$ 11,970$ EMPLOYEE BENEFITS 0201 Health Insurance $2,964 $8,561 2,964$ 8,561$ 0202 Life Insurance $109 $539 109$ 539$ 0203 Retirement $796 $3,620 796$ 3,620$ 0204 Benefits Other - Specify -$ -$ EMPLOYEE BENEFITS TOTAL $3,868 $12,720 $0 $0 $0 $0 3,868$ 12,720$ TAXES & BENEFITS TOTAL 6,255$ 24,690$ TOTAL PERCENT OF BENEFITS TO SALARIES 24%20% E-mail Address: 0 7120 N. Marks Avenue, Suite #110 Fresno, CA 93711 0 559-439-5437 559-436-6119 0 No. of Budgeted FTEs - Admin:Phone Number: No. of Budgeted FTEs - Direct:Fax Number: TOADS - Telecare Outpatient Alcohol and Drug Services Approved by:0 Street Address: Workers' Compensation Insurance PAYROLL TAXES State Unemployment Insurance F.I.C.A. Medicare (Must be Itemized) PERSONNEL/SALARIES Line Item Description to services FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUBSTANCE USE DISORDER SERVICES RURAL OUTPATIENT TREATMENT SERVICES FISCAL YEAR 2018-19 Other Funding Other Funding Total Proposed Budget Budget Categories-% Time dedicated Proposed Program Budget SAPT Funding Provider Name:Promesa Behavioral Heath Mailing Address: Program Name: 17-030 EXHIBIT C, Page 10 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx TOADS - Telecare Outpatient Alcohol and Drug Services SAPT Funding Other Funding Other Funding Proposed Program Budget Budget Budget Budget SALARY, PAYROLL TAX, AND EMPLOYEE BENEFITS TOTAL $178,128 $0 $0 $178,128 0252 $4,814 $4,814 0253 $0 $4,814 $0 $0 $4,814 0301 $3,576 $3,576 0302 $0 $3,576 $0 $0 $3,576 0351 $1,200 $1,200 0352 $0 0353 $3,600 $3,600 0354 $0 0355 $0 $4,800 $0 $0 $4,800 0401 $0 0402 $6,840 $6,840 0403 $0 $6,840 $0 $0 $6,840 FACILITIES 0451 $7,200 $7,200 0452 $0 0453 $0 $7,200 $0 $0 $7,200 0501 $24,942 $24,942 0502 $2,200 $2,200 0503 $3,130 $3,130 0504 $0 $30,272 $0 $0 $30,272 0551 $0 0552 $6,470 $6,470 0553 $0 $6,470 $0 $0 $6,470 0601 $32,400 $32,400 0602 $18,000 $18,000 $50,400 $0 $0 $50,400 0651 $0 0652 $0 $0 $0 $0 $0 0701 $32,500 $32,500 0702 Licenses/Taxes $0 0703 $0 0749 $0 $32,500 $0 $0 $32,500 $325,000 $0 $0 $325,000 3120 $0 3130 $0 3140 $0 3150 $0 $0 $0 $0 $0 $325,000 $0 $0 $325,000 Other Business Services OTHER COSTS TOTAL REVENUE/MATCH TOTAL NET PROGRAM BUDGET TOTAL PROGRAM EXPENDITURES REVENUE/MATCH Medi-Cal State Grant Private Donations Client Fees External Audit FISCAL AND AUDITS TOTAL OTHER COSTS Indirect Costs County Administration Fee Consultant Services Contracted Services CONSULTANCY TOTAL FISCAL AND AUDITS Accounting/Bookkeeping Program Supplies-Client Incentives Program Supplies-Curriculum Program Supplies-Food PROGRAM SUPPLIES TOTAL CONSULTANCY Staff Travel (Out of County) Staff Training/Registration Transportation TRAVEL COSTS TOTAL PROGRAM SUPPLIES Facilities Maintenance Utilities FACILITIES TOTAL TRAVEL COSTS Staff Mileage Purchase of Equipment Equipment Rent/Lease Equipment Maintenance EQUIPMENT TOTAL Rent/Lease Building Printing/Reproduction Publications Legal Notices/Advertising OFFICE EXPENSE TOTAL EQUIPMENT Answering Service COMMUNICATIONS TOTAL OFFICE EXPENSE Office Supplies Soc Rec., Workbooks INSURANCE TOTAL COMMUNICATIONS Telecommunications/data lines FISCAL YEAR 2018-19 Program: Date: Promesa Behavioral Heath FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUBSTANCE USE DISORDER SERVICES RURAL OUTPATIENT TREATMENT SERVICES Liability Insurance Insurance Other-Specify Provider Name: Budget Categories-Line Item Description (Must Be Itemized) INSURANCE 17-030 EXHIBIT C, Page 11 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx Provider Name: Budget Categories-Line Item Description Executive Director In-Kind Program Manager $61,000 50% AOD Counselor I $45,082 100% AOD Counselor I $45,082 100% Administrative Assistant $26,520 100% PAYROLL TAXES TOTAL EMPLOYEE BENEFITS TOTAL EQUIPMENT List the following equipment categories and provide a brief description for each category:  0401 - Purchase of Equipment - N/a  0402 - Equipment Rent/Lease - Leased laptops for staff use  0403-Equipment Maintenance: minor equipment repair for copier and vehicle maintenance. COMMUNICATIONS  0301 - Telecommunications/data lines - Cell ph, Webex, Wifi, email encryp.  0302 - Answering Service - N/a OFFICE EXPENSE  0351-Office Supplies: Includes Items necessary to carry out the daily activities to accomplish the program goals and objectives including paper, filing supplies, pens, pencils, scissors, and other supplies.  0352 - Social/Rec, Workbooks.- N/a  0353-Printing/Reproduction includes items such as the printing of business cards, program pamphlets, position vacancy advertising and other materials related to the program.  0354 - Publications - N/a  0355 - Legal Notices/Advertising - N/a INSURANCE List the following insurance categories:  0251 - Workers Compensation Insurance - N/a (Incl. in employee benefits)  0252 - Liability Insurance - General Liability  0253 - Insurance Other - N/a FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUD SERVICES RURAL OUTPATIENT TREATMENT SERVICES PERSONNEL/ SALARIES Annual Salary and FTE equivalence as in budget. Annual (12 Month) Salary for this % of FTE dedicated to this program Position descriptions submitted with proposal. FISCAL YEAR 2018-19 Promesa Behavioral Heath 17-030 EXHIBIT C, Page 12 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx Provider Name: FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUD SERVICES RURAL OUTPATIENT TREATMENT SERVICES FISCAL YEAR 2018-19 Promesa Behavioral Heath REVENUE/MATCH Please identify all anticipated funding sources and distinguish whether the  3120 - Drug Medi-Cal - Mental Health Medi-Cal -  3130 - State Grant -  3140 - Private Donations -  3150 - Client Fees -  0652 - External Audit - N/a OTHER COSTS List the following categories and provide a brief description for each category:  0701 - Indirect Costs - 10% program costs  0702 - Licenses/Taxes - N/a  0703 - County Administration Fee - N/a  0749-Other Costs - Other business services such as applicant TB tests, drug screens, and other program-related items that don't necessarily fit into another line item. FISCAL AND AUDITS List the following fiscal and audits categories and provide a brief description for CONSULTANCY List the following consulting categories and provide a brief description for each  0601 - Consultant Services - Consult Psych., Peer Support Specialist  0602 - Contracted Services - Telecare I.T. technician  0651 - Accounting/Bookkeeping - N/a PROGRAM SUPPLIES List the following program supplies categories and provide a brief description  0551 - Program Supplies - Client Incentives  0552 - Program Supplies - Curriculum  0553 - Program Supplies - Food TRAVEL List the following travel categories and provide a brief description for each  0501 - Staff Mileage - Staff travel to distal sites weekly for first intake  0502 - Staff Travel (Out of County) - Travel expenses for required training  0503 - Staff Training/Registration - ASAM annual conf., and local trainings  0504 - Transportation - N/a FACILITIES List the following facilities categories and provide a brief description for each category:  0451 - Rent/Lease Building - Monthly rent for distal sites  0452 - Facilities Maintenance - N/a  0453 - Utilities - N/a 17-030 EXHIBIT C, Page 13 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx Annual % of FTE (12-Month)dedicated to Salary this program Admin.Direct Admin.Direct Admin.Direct Admin.Direct Admin.Direct 0101 Executive Director Lisa Weigant (In-Kind)-$ -$ 0102 Program Manager Mandi Reed $61,000 50%100%$0 $30,500 -$ 30,500$ 0103 AOD Counselor I Jessica Taylor $45,082 100%100%$0 $45,082 -$ 45,082$ 0104 AOD Counselor I Cecilia Rubalcaba $45,082 100%100%$0 $45,082 -$ 45,082$ 0105 Administrative Assistant Ruby Fabela $26,520 100%100%$26,520 26,520$ -$ 0106 -$ -$ 0107 -$ -$ 0108 -$ -$ 0109 -$ -$ 0110 -$ -$ 0111 -$ -$ 0112 -$ -$ 0113 -$ -$ 0114 -$ -$ 0115 -$ -$ 0116 -$ -$ 0117 -$ -$ 0118 -$ -$ 0119 -$ -$ 0120 -$ -$ 0121 -$ -$ 0122 -$ -$ 0123 -$ -$ 0124 -$ -$ 0125 -$ -$ 0126 -$ -$ 0127 -$ -$ 0128 -$ -$ 0129 -$ -$ 0130 -$ -$ SALARIES TOTAL $26,520 $120,664 $0 $0 $0 $0 26,520$ 120,664$ 0151 $154 $700 154$ 700$ 0152 $1,644 $7,481 1,644$ 7,481$ 0153 $385 $1,750 385$ 1,750$ 0154 $204 $2,039 204$ 2,039$ PAYROLL TAXES TOTAL $2,387 $11,970 $0 $0 $0 $0 2,387$ 11,970$ EMPLOYEE BENEFITS 0201 Health Insurance $2,964 $8,561 2,964$ 8,561$ 0202 Life Insurance $109 $539 109$ 539$ 0203 Retirement $796 $3,620 796$ 3,620$ 0204 Benefits Other - Specify -$ -$ EMPLOYEE BENEFITS TOTAL $3,868 $12,720 $0 $0 $0 $0 3,868$ 12,720$ TAXES & BENEFITS TOTAL 6,255$ 24,690$ TOTAL PERCENT OF BENEFITS TO SALARIES 24%20% E-mail Address: 0 7120 N. Marks Avenue, Suite #110 Fresno, CA 93711 0 559-439-5437 559-436-6119 0 No. of Budgeted FTEs - Admin:Phone Number: No. of Budgeted FTEs - Direct:Fax Number: TOADS - Telecare Outpatient Alcohol and Drug Services Approved by:0 Street Address: Workers' Compensation Insurance PAYROLL TAXES State Unemployment Insurance F.I.C.A. Medicare (Must be Itemized) PERSONNEL/SALARIES Line Item Description to services FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUBSTANCE USE DISORDER SERVICES RURAL OUTPATIENT TREATMENT SERVICES FISCAL YEAR 2019-20 Other Funding Other Funding Total Proposed Budget Budget Categories-% Time dedicated Proposed Program Budget SAPT Funding Provider Name:Promesa Behavioral Heath Mailing Address: Program Name: 17-030 EXHIBIT C, Page 14 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx TOADS - Telecare Outpatient Alcohol and Drug Services SAPT Funding Other Funding Other Funding Proposed Program Budget Budget Budget Budget SALARY, PAYROLL TAX, AND EMPLOYEE BENEFITS TOTAL $178,128 $0 $0 $178,128 0252 $4,814 $4,814 0253 $0 $4,814 $0 $0 $4,814 0301 $3,576 $3,576 0302 $0 $3,576 $0 $0 $3,576 0351 $1,200 $1,200 0352 $0 0353 $3,600 $3,600 0354 $0 0355 $0 $4,800 $0 $0 $4,800 0401 $0 0402 $6,840 $6,840 0403 $0 $6,840 $0 $0 $6,840 FACILITIES 0451 $7,200 $7,200 0452 $0 0453 $0 $7,200 $0 $0 $7,200 0501 $24,942 $24,942 0502 $2,200 $2,200 0503 $3,130 $3,130 0504 $0 $30,272 $0 $0 $30,272 0551 $0 0552 $6,470 $6,470 0553 $0 $6,470 $0 $0 $6,470 0601 $32,400 $32,400 0602 $18,000 $18,000 $50,400 $0 $0 $50,400 0651 $0 0652 $0 $0 $0 $0 $0 0701 $32,500 $32,500 0702 Licenses/Taxes $0 0703 $0 0749 $0 $32,500 $0 $0 $32,500 $325,000 $0 $0 $325,000 3120 $0 3130 $0 3140 $0 3150 $0 $0 $0 $0 $0 $325,000 $0 $0 $325,000 Other Business Services OTHER COSTS TOTAL REVENUE/MATCH TOTAL NET PROGRAM BUDGET TOTAL PROGRAM EXPENDITURES REVENUE/MATCH Medi-Cal State Grant Private Donations Client Fees External Audit FISCAL AND AUDITS TOTAL OTHER COSTS Indirect Costs County Administration Fee Consultant Services Contracted Services CONSULTANCY TOTAL FISCAL AND AUDITS Accounting/Bookkeeping Program Supplies-Client Incentives Program Supplies-Curriculum Program Supplies-Food PROGRAM SUPPLIES TOTAL CONSULTANCY Staff Travel (Out of County) Staff Training/Registration Transportation TRAVEL COSTS TOTAL PROGRAM SUPPLIES Facilities Maintenance Utilities FACILITIES TOTAL TRAVEL COSTS Staff Mileage Purchase of Equipment Equipment Rent/Lease Equipment Maintenance EQUIPMENT TOTAL Rent/Lease Building Printing/Reproduction Publications Legal Notices/Advertising OFFICE EXPENSE TOTAL EQUIPMENT Answering Service COMMUNICATIONS TOTAL OFFICE EXPENSE Office Supplies Soc Rec., Workbooks INSURANCE TOTAL COMMUNICATIONS Telecommunications/data lines FISCAL YEAR 2019-20 Program: Date: Promesa Behavioral Heath FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUBSTANCE USE DISORDER SERVICES RURAL OUTPATIENT TREATMENT SERVICES Liability Insurance Insurance Other-Specify Provider Name: Budget Categories-Line Item Description (Must Be Itemized) INSURANCE 17-030 EXHIBIT C, Page 15 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx Provider Name: Budget Categories-Line Item Description Executive Director In-Kind Program Manager $61,000 50% AOD Counselor I $45,082 100% AOD Counselor I $45,082 100% Administrative Assistant $26,520 100% PAYROLL TAXES TOTAL EMPLOYEE BENEFITS TOTAL EQUIPMENT List the following equipment categories and provide a brief description for each category:  0401 - Purchase of Equipment - N/a  0402 - Equipment Rent/Lease - Leased laptops for staff use  0403-Equipment Maintenance: minor equipment repair for copier and vehicle maintenance. COMMUNICATIONS  0301 - Telecommunications/data lines - Cell ph, Webex, Wifi, email encryp.  0302 - Answering Service - N/a OFFICE EXPENSE  0351-Office Supplies: Includes Items necessary to carry out the daily activities to accomplish the program goals and objectives including paper, filing supplies, pens, pencils, scissors, and other supplies.  0352 - Social/Rec, Workbooks.- N/a  0353-Printing/Reproduction includes items such as the printing of business cards, program pamphlets, position vacancy advertising and other materials related to the program.  0354 - Publications - N/a  0355 - Legal Notices/Advertising - N/a INSURANCE List the following insurance categories:  0251 - Workers Compensation Insurance - N/a (Incl. in employee benefits)  0252 - Liability Insurance - General Liability  0253 - Insurance Other - N/a FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUD SERVICES RURAL OUTPATIENT TREATMENT SERVICES PERSONNEL/ SALARIES Annual Salary and FTE equivalence as in budget. Annual (12 Month) Salary for this % of FTE dedicated to this program Position descriptions submitted with proposal. FISCAL YEAR 2019-20 Promesa Behavioral Heath 17-030 EXHIBIT C, Page 16 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx Provider Name: FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUD SERVICES RURAL OUTPATIENT TREATMENT SERVICES FISCAL YEAR 2019-20 Promesa Behavioral Heath REVENUE/MATCH Please identify all anticipated funding sources and distinguish whether the  3120 - Drug Medi-Cal - Mental Health Medi-Cal -  3130 - State Grant -  3140 - Private Donations -  3150 - Client Fees -  0652 - External Audit - N/a OTHER COSTS List the following categories and provide a brief description for each category:  0701 - Indirect Costs - 10% program costs  0702 - Licenses/Taxes - N/a  0703 - County Administration Fee - N/a  0749-Other Costs - Other business services such as applicant TB tests, drug screens, and other program-related items that don't necessarily fit into another line item. FISCAL AND AUDITS List the following fiscal and audits categories and provide a brief description for CONSULTANCY List the following consulting categories and provide a brief description for each  0601 - Consultant Services - Consult Psych., Peer Support Specialist  0602 - Contracted Services - Telecare I.T. technician  0651 - Accounting/Bookkeeping - N/a PROGRAM SUPPLIES List the following program supplies categories and provide a brief description  0551 - Program Supplies - Client Incentives  0552 - Program Supplies - Curriculum  0553 - Program Supplies - Food TRAVEL List the following travel categories and provide a brief description for each  0501 - Staff Mileage - Staff travel to distal sites weekly for first intake  0502 - Staff Travel (Out of County) - Travel expenses for required training  0503 - Staff Training/Registration - ASAM annual conf., and local trainings  0504 - Transportation - N/a FACILITIES List the following facilities categories and provide a brief description for each category:  0451 - Rent/Lease Building - Monthly rent for distal sites  0452 - Facilities Maintenance - N/a  0453 - Utilities - N/a 17-030 EXHIBIT C, Page 17 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx Annual % of FTE (12-Month)dedicated to Salary this program Admin.Direct Admin.Direct Admin.Direct Admin.Direct Admin.Direct 0101 Executive Director Lisa Weigant (In-Kind)-$ -$ 0102 Program Manager Mandi Reed $61,000 50%100%$0 $30,500 -$ 30,500$ 0103 AOD Counselor I Jessica Taylor $45,082 100%100%$0 $45,082 -$ 45,082$ 0104 AOD Counselor I Cecilia Rubalcaba $45,082 100%100%$0 $45,082 -$ 45,082$ 0105 Administrative Assistant Ruby Fabela $26,520 100%100%$26,520 26,520$ -$ 0106 -$ -$ 0107 -$ -$ 0108 -$ -$ 0109 -$ -$ 0110 -$ -$ 0111 -$ -$ 0112 -$ -$ 0113 -$ -$ 0114 -$ -$ 0115 -$ -$ 0116 -$ -$ 0117 -$ -$ 0118 -$ -$ 0119 -$ -$ 0120 -$ -$ 0121 -$ -$ 0122 -$ -$ 0123 -$ -$ 0124 -$ -$ 0125 -$ -$ 0126 -$ -$ 0127 -$ -$ 0128 -$ -$ 0129 -$ -$ 0130 -$ -$ SALARIES TOTAL $26,520 $120,664 $0 $0 $0 $0 26,520$ 120,664$ 0151 $154 $700 154$ 700$ 0152 $1,644 $7,481 1,644$ 7,481$ 0153 $385 $1,750 385$ 1,750$ 0154 $204 $2,039 204$ 2,039$ PAYROLL TAXES TOTAL $2,387 $11,970 $0 $0 $0 $0 2,387$ 11,970$ EMPLOYEE BENEFITS 0201 Health Insurance $2,964 $8,561 2,964$ 8,561$ 0202 Life Insurance $109 $539 109$ 539$ 0203 Retirement $796 $3,620 796$ 3,620$ 0204 Benefits Other - Specify -$ -$ EMPLOYEE BENEFITS TOTAL $3,868 $12,720 $0 $0 $0 $0 3,868$ 12,720$ TAXES & BENEFITS TOTAL 6,255$ 24,690$ TOTAL PERCENT OF BENEFITS TO SALARIES 24%20% State Unemployment Insurance F.I.C.A. Medicare Workers' Compensation Insurance FISCAL YEAR 2020-21 Provider Name:Promesa Behavioral Heath Mailing Address: Program Name: 0 0 0 No. of Budgeted FTEs - Admin:Phone Number: No. of Budgeted FTEs - Direct: PAYROLL TAXES Total Proposed Budget (Must be Itemized) PERSONNEL/SALARIES Line Item Description to services SAPT Funding Other Funding Other Funding Budget Categories-% Time dedicated Proposed Program Budget E-mail Address: TOADS - Telecare Outpatient Alcohol and Drug Services Fax Number: 559-439-5437 559-436-6119 Approved by:0 Street Address: 7120 N. Marks Avenue, Suite #110 Fresno, CA 93711 FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUBSTANCE USE DISORDER SERVICES RURAL OUTPATIENT TREATMENT SERVICES 17-030 EXHIBIT C, Page 18 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx TOADS - Telecare Outpatient Alcohol and Drug Services SAPT Funding Other Funding Other Funding Proposed Program Budget Budget Budget Budget SALARY, PAYROLL TAX, AND EMPLOYEE BENEFITS TOTAL $178,128 $0 $0 $178,128 0252 $4,814 $4,814 0253 $0 $4,814 $0 $0 $4,814 0301 $3,576 $3,576 0302 $0 $3,576 $0 $0 $3,576 0351 $1,200 $1,200 0352 $0 0353 $3,600 $3,600 0354 $0 0355 $0 $4,800 $0 $0 $4,800 0401 $0 0402 $6,840 $6,840 0403 $0 $6,840 $0 $0 $6,840 FACILITIES 0451 $7,200 $7,200 0452 $0 0453 $0 $7,200 $0 $0 $7,200 0501 $24,942 $24,942 0502 $2,200 $2,200 0503 $3,130 $3,130 0504 $0 $30,272 $0 $0 $30,272 0551 $0 0552 $6,470 $6,470 0553 $0 $6,470 $0 $0 $6,470 0601 $32,400 $32,400 0602 $18,000 $18,000 $50,400 $0 $0 $50,400 0651 $0 0652 $0 $0 $0 $0 $0 0701 $32,500 $32,500 0702 Licenses/Taxes $0 0703 $0 0749 $0 $32,500 $0 $0 $32,500 $325,000 $0 $0 $325,000 3120 $0 3130 $0 3140 $0 3150 $0 $0 $0 $0 $0 $325,000 $0 $0 $325,000NET PROGRAM BUDGET FISCAL YEAR 2020-21 Program: Date: Promesa Behavioral Heath REVENUE/MATCH Medi-Cal State Grant Private Donations Client Fees REVENUE/MATCH TOTAL OTHER COSTS Indirect Costs County Administration Fee Other Business Services OTHER COSTS TOTAL TOTAL PROGRAM EXPENDITURES CONSULTANCY TOTAL FISCAL AND AUDITS Accounting/Bookkeeping External Audit FISCAL AND AUDITS TOTAL Program Supplies-Food PROGRAM SUPPLIES TOTAL CONSULTANCY Consultant Services Contracted Services Transportation TRAVEL COSTS TOTAL PROGRAM SUPPLIES Program Supplies-Client Incentives Program Supplies-Curriculum FACILITIES TOTAL TRAVEL COSTS Staff Mileage Staff Travel (Out of County) Staff Training/Registration Equipment Maintenance EQUIPMENT TOTAL Rent/Lease Building Facilities Maintenance Utilities Legal Notices/Advertising OFFICE EXPENSE TOTAL EQUIPMENT Purchase of Equipment Equipment Rent/Lease OFFICE EXPENSE Office Supplies Soc Rec., Workbooks Printing/Reproduction Publications INSURANCE TOTAL COMMUNICATIONS Telecommunications/data lines Answering Service COMMUNICATIONS TOTAL FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUBSTANCE USE DISORDER SERVICES RURAL OUTPATIENT TREATMENT SERVICES Liability Insurance Insurance Other-Specify Provider Name: Budget Categories-Line Item Description (Must Be Itemized) INSURANCE 17-030 EXHIBIT C, Page 19 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx Page 19 Provider Name: Budget Categories-Line Item Description Executive Director In-Kind Program Manager $61,000 50% AOD Counselor I $45,082 100% AOD Counselor I $45,082 100% Administrative Assistant $26,520 100% PAYROLL TAXES TOTAL EMPLOYEE BENEFITS TOTAL EQUIPMENT List the following equipment categories and provide a brief description for each category:  0401 - Purchase of Equipment - N/a  0402 - Equipment Rent/Lease - Leased laptops for staff use  0403-Equipment Maintenance: minor equipment repair for copier and vehicle maintenance. COMMUNICATIONS  0301 - Telecommunications/data lines - Cell ph, Webex, Wifi, email encryp.  0302 - Answering Service - N/a OFFICE EXPENSE  0351-Office Supplies: Includes Items necessary to carry out the daily activities to accomplish the program goals and objectives including paper, filing supplies, pens, pencils, scissors, and other supplies.  0352 - Social/Rec, Workbooks.- N/a  0353-Printing/Reproduction includes items such as the printing of business cards, program pamphlets, position vacancy advertising and other materials related to the program.  0354 - Publications - N/a  0355 - Legal Notices/Advertising - N/a INSURANCE List the following insurance categories:  0251 - Workers Compensation Insurance - N/a (Incl. in employee benefits)  0252 - Liability Insurance - General Liability  0253 - Insurance Other - N/a FRESNO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH - SUD SERVICES RURAL OUTPATIENT TREATMENT SERVICES PERSONNEL/ SALARIES Annual Salary and FTE equivalence as in budget. Annual (12 Month) Salary for this % of FTE dedicated to this program Position descriptions submitted with proposal. FISCAL YEAR 2020-21 Promesa Behavioral Heath 17-030 EXHIBIT C, Page 20 of 20 G:\Substance Abuse Services\RFPs\FY 16-17\Rural OPT RFP\RFP FINAL Documents\Exhibit C - Budget FINAL.xlsx Page 20 REVENUE/MATCH Please identify all anticipated funding sources and distinguish whether the  3120 - Drug Medi-Cal - Mental Health Medi-Cal -  3130 - State Grant -  3140 - Private Donations -  3150 - Client Fees -  0652 - External Audit - N/a OTHER COSTS List the following categories and provide a brief description for each category:  0701 - Indirect Costs - 10% program costs  0702 - Licenses/Taxes - N/a  0703 - County Administration Fee - N/a  0749-Other Costs - Other business services such as applicant TB tests, drug screens, and other program-related items that don't necessarily fit into another line item. FISCAL AND AUDITS List the following fiscal and audits categories and provide a brief description for CONSULTANCY List the following consulting categories and provide a brief description for each  0601 - Consultant Services - Consult Psych., Peer Support Specialist  0602 - Contracted Services - Telecare I.T. technician  0651 - Accounting/Bookkeeping - N/a PROGRAM SUPPLIES List the following program supplies categories and provide a brief description  0551 - Program Supplies - Client Incentives  0552 - Program Supplies - Curriculum  0553 - Program Supplies - Food TRAVEL List the following travel categories and provide a brief description for each  0501 - Staff Mileage - Staff travel to distal sites weekly for first intake  0502 - Staff Travel (Out of County) - Travel expenses for required training  0503 - Staff Training/Registration - ASAM annual conf., and local trainings  0504 - Transportation - N/a FACILITIES List the following facilities categories and provide a brief description for each category:  0451 - Rent/Lease Building - Monthly rent for distal sites  0452 - Facilities Maintenance - N/a  0453 - Utilities - N/a Exhibit D Page 1 of 2 SELF-DEALING TRANSACTION DISCLOSURE FORM In order to conduct business with the County of Fresno (hereinafter referred to as “County”), members of a contractor’s board of directors (hereinafter referred to as “County Contractor”), must disclose any self-dealing transactions that they are a party to while providing goods, performing services, or both for the County. A self-dealing transaction is defined below: “A self-dealing transaction means a transaction to which the corporation is a party and in which one or more of its directors has a material financial interest” The definition above will be utilized for purposes of completing this disclosure form. INSTRUCTIONS (1) Enter board member’s name, job title (if applicable), and date this disclosure is being made. (2) Enter the board member’s company/agency name and address. (3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the County. At a minimum, include a description of the following: a. The name of the agency/company with which the corporation has the transaction; and b. The nature of the material financial interest in the Corporation’s transaction that the board member has. (4) Describe in detail why the self-dealing transaction is appropriate based on applicable provisions of the Corporations Code. (5) Form must be signed by the board member that is involved in the self-dealing transaction described in Sections (3) and (4). Exhibit D Page 2 of 2 (1) Company Board Member Information: Name: Date: Job Title: (2) Company/Agency Name and Address: (3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to): (4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a): (5) Authorized Signature Signature: Date: National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations to: Principal Standard: 1.Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Governance, Leadership, and Workforce: 2.Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources. 3.Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area. 4.Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis. Communication and Language Assistance: 5.Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. 6.Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 7.Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 8.Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. Engagement, Continuous Improvement, and Accountability: 9.Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations. 10.Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities. 11.Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. 12.Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. 13.Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness. 14.Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints. 15.Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public. Exhibit E QMH U-S.Department of Health and Human Services Office of Minority Heolth www.ThinkCulturalHeaIth.hhs.gov THINK *CULTURALHEALTHIt * l The Case for the Enhanced National CLAS Standards Of all the forms of inequality, injustice in health care is the most shocking and inhumane. — Dr. Martin Luther King, Jr. Health equity is the attainment of the highest level of health for all people (U.S. Department of Health and Human Services [HHS] Office of Minority Health, 2011). Currently, individuals across the United States from various cultural backgrounds are unable to attain their highest level of health for several reasons, including the social determinants of health, or those conditions in which individuals are born, grow, live, work, and age (World Health Organization, 2012), such as socioeconomic status, education level, and the availability of health services (HHS Office of Disease Prevention and Health Promotion, 2010). Though health inequities are directly related to the existence of historical and current discrimination and social injustice, one of the most modifiable factors is the lack of culturally and linguistically appropriate services, broadly defined as care and services that are respectful of and responsive to the cultural and linguistic needs of all individuals. Health inequities result in disparities that directly affect the quality of life for all individuals. Health disparities adversely affect neighborhoods, communities, and the broader society, thus making the issue not only an individual concern but also a public health concern. In the United States, it has been estimated that the combined cost of health disparities and subsequent deaths due to inadequate and/or inequitable care is $1.24 trillion (LaVeist, Gaskin, & Richard, 2009). Culturally and linguistically appropriate services are increasingly recognized as effective in improving the quality of care and services (Beach et al., 2004; Goode, Dunne, & Bronheim, 2006). By providing a structure to implement culturally and linguistically appropriate services, the enhanced National CLAS Standards will improve an organization’s ability to address health care disparities. The enhanced National CLAS Standards align with the HHS Action Plan to Reduce Racial and Ethnic Health Disparities (HHS, 2011) and the National Stakeholder Strategy for Achieving Health Equity (HHS National Partnership for Action to End Health Disparities, 2011), which aim to promote health equity through providing clear plans and strategies to guide collaborative efforts that address racial and ethnic health disparities across the country. Similar to these initiatives, the enhanced National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint for individuals and health and health care organizations to implement culturally and linguistically appropriate services. Adoption of these Standards will help advance better health and health care in the United States. Bibliography: Beach, M. C., Cooper, L. A., Robinson, K. A., Price, E. G., Gary, T. L., Jenckes, M. W., Powe, N.R. (2004). Strategies for improving minority healthcare quality. (AHRQ Publication No. 04-E008-02). Retrieved from the Agency of Healthcare Research and Quality website: http://www.ahrq.gov/downloads/pub/evidence/pdf/minqual/minqual.pdf Goode, T. D., Dunne, M. C., & Bronheim, S. M. (2006). The evidence base for cultural and linguistic competency in health care. (Commonwealth Fund Publication No. 962). Retrieved from The Commonwealth Fund website: http://www.commonwealthfund.org/usr_doc/Goode_evidencebasecultlinguisticcomp_962.pdf LaVeist, T. A., Gaskin, D. J., & Richard, P. (2009). The economic burden of health inequalities in the United States. Retrieved from the Joint Center for Political and Economic Studies website: http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic%2 0Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf National Partnership for Action to End Health Disparities. (2011). National stakeholder strategy for achieving health equity. Retrieved from U.S. Department of Health and Human Services, Office of Minority Health website: http://www.minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286 U.S. Department of Health and Human Services. (2011). HHS action plan to reduce racial and ethnic health disparities: A nation free of disparities in health and health care. Retrieved from http://minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). Healthy people 2020: Social determinants of health. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=39 U.S. Department of Health and Human Services, Office of Minority Health (2011). National Partnership for Action to End Health Disparities. Retrieved from http://minorityhealth.hhs.gov/npa World Health Organization. (2012). Social determinants of health. Retrieved from http://www.who.int/social_determinants/en/ Exhibit E QMH U-S.Department of Health and Human Services Office of Minority Heolth www.ThinkCulturalHeaIth.hhs.gov THINK *CULTURALHEALTHIt * l Exhibit F Page 1 of 3 G:\SUBSTANCE ABUSE SERVICES\RFPS\FY 16-17\RURAL OPT RFP\RFP FINAL DOCUMENTS\EXHIBIT F - DISCLOSURE CRIMINAL HISTORY & CIVIL ACTIONS.DOC DISCLOSURE – CRIMINAL HISTORY & CIVIL ACTIONS: In their proposal, the bidder is required to disclose if any of the following conditions apply to them, their owners, officers, corporate managers and partners (hereinafter collectively referred to as “Bidder”): • Within the three-year period preceding the proposal, they have been convicted of, or had a civil judgment rendered against them for: o 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; o violation of a federal or state antitrust statute; o embezzlement, theft, forgery, bribery, falsification, or destruction of records; or o false statements or receipt of stolen property • Within a three-year period preceding their proposal, they have had a public transaction (federal, state, or local) terminated for cause or default. Disclosure of the above information will not automatically eliminate a Bidder from consideration. The information will be considered as part of the determination of whether to award the contract and any additional information or explanation that a Bidder elects to submit with the disclosed information will be considered. If it is later determined that the Bidder failed to disclose required information, any contract awarded to such Bidder may be immediately voided and terminated for material failure to comply with the terms and conditions of the award. Any Bidder who is awarded a contract must sign an appropriate Certification Regarding Debarment, Suspension, and Other Responsibility Matters, pages 2 and 3 of this Exhibit, Additionally, the Bidder awarded the contract must immediately advise the County in writing if, during the term of the agreement: (1) Bidder becomes suspended, debarred, excluded or ineligible for participation in federal or state funded programs or from receiving federal funds as listed in the excluded parties list system (http://www/epls/gov); or (2) any of the above listed conditions become applicable to Bidder. The Bidder will indemnify, defend and hold the County harmless for any loss or damage resulting from a conviction, debarment, exclusion, ineligibility or other matter listed in the signed Certification Regarding Debarment, Suspension, and Other Responsibility Matters. Exhibit F Page 2 of 3 G:\SUBSTANCE ABUSE SERVICES\RFPS\FY 16-17\RURAL OPT RFP\RFP FINAL DOCUMENTS\EXHIBIT F - DISCLOSURE CRIMINAL HISTORY & CIVIL ACTIONS.DOC CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS INSTRUCTIONS FOR CERTIFICATION 1. By signing and submitting this proposal, the prospective primary participant is providing the certification set out below. 2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction. 3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. 4. The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 5. The terms covered transaction, debarred, suspended, ineligible, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations. 6. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. Exhibit F Page 3 of 3 G:\SUBSTANCE ABUSE SERVICES\RFPS\FY 16-17\RURAL OPT RFP\RFP FINAL DOCUMENTS\EXHIBIT F - DISCLOSURE CRIMINAL HISTORY & CIVIL ACTIONS.DOC 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) Exhibit G Page 1 of 1 UNLAWFUL USE OF DRUGS AND ALCOHOL CERTIFICATION I, ______________________________________, as an authorized agent of (Print Name) ________________________________________, acknowledge the requirement to (Organization Name) comply with California HSC 11999-11999.3, which authorizes the County of Fresno to terminate a contract, without penalty, if this organization or its employees, or a subcontractor or its employees fail to ensure that: • The program contains a component that clearly explains in written materials that there shall be no unlawful use of drugs or alcohol. No aspect of a drug- or alcohol-related program shall include any message on the responsible use, if the use is unlawful, of drugs or alcohol; • All aspects of a drug- or alcohol-related program are consistent with the “no unlawful use” message, including, but not limited to, program standards, curricula, materials, and teachings; and • The “no unlawful use” of drugs and alcohol message contained in drug- or alcohol-related programs applies to the use of drugs and alcohol prohibited by law. I understand that the State of California enforces an Unlawful Use policy in which there is zero tolerance for promoting the unlawful use of and drugs or alcohol in an AOD treatment facility. If this organization fails to satisfy the guidelines adopted by the State of California, the drug or alcohol program shall not receive state funds and their contract with Fresno County will be terminated. I understand that this organization is obligated to ensure any subcontractors are informed of the requirements of HSC 11999-11999.3 and, if found in violation, will be immediately terminated. Signature:_____________________________ Date:______________________ Title:_________________________________ Exhibit H NOTICE OF CHILD ABUSE REPORTING LAW The undersigned hereby acknowledges that Penal Code section 11166 and the contractual obligations between County of Fresno (COUNTY) and PROVIDER(S) related to provision of alcohol and drug abuse treatment services for Fresno County residents, require that the undersigned report all known or suspected child abuse or neglect to one or more of the agencies set forth in Penal Code (P.C.) section (§) 11165.9. For purposes of the undersigned’s child abuse reporting requirements, “child abuse or neglect” includes physical injury inflicted by other than accidental means upon a child by another person, sexual abuse as defined in P.C. §11165.1, neglect as defined in P.C. §11165.2, willful cruelty or unjustifiable punishment as defined in P.C. §11165.3, and unlawful corporal punishment or injury as defined in P.C. §11165.4. A child abuse report shall be made whenever the undersigned, in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a child whom the undersigned knows or reasonably suspects has been the victim of child abuse or neglect. (P.C §11166.) The child abuse report shall be made to any police department or sheriff’s department (not including a school district police or security department), or to any county welfare department, including Fresno County Department of Children and Family Services’ 24 Hour CARELINE. (See PC §11165.9.) For purposes of child abuse reporting, a “reasonable suspicion” means that it is objectively reasonable for a person to entertain a suspicion, based upon facts that could cause a reasonable person in a like position, drawing, when appropriate, on his or her training and experience, to suspect child abuse or neglect. The pregnancy of a child does not, in and of itself, constitute a basis for reasonable suspicion of sexual abuse. (P.C. §11166(a)(1).) Substantial penalties may be imposed for failure to comply with these child abuse reporting requirements. Further information and a copy of the law may be obtained from the department head or designee. I have read and understand the above statement and agree to comply with the child abuse reporting requirements. __________________________________ ________________________ SIGNATURE DATE 0980fadx Exhibit I Page 1 of 1 TRAFFICKING VICTIMS PROTECTION ACT OF 2000 CERTIFICATION I, ______________________________________, as an authorized agent of (Print Name) ________________________________________, acknowledge the requirement to (Organization Name) comply with the Trafficking Victims Protection Act of 2000 (TVPA), specifically Section 106(g), which authorizes the County of Fresno to terminate a contract, without penalty, if this organization or its employees, or a subcontractor or its employees: • Engages in severe forms of trafficking in persons during the period of time that the award is in effect; • Procures a commercial sex act during the period of time that the award in in effect; or • Uses forced labor in the performance of the award or subawards under the award. I understand that the TVPA establishes human trafficking and related offenses as federal crimes and attaches severe penalties to them. I will immediately inform the County of Fresno, Department of Behavioral Health, Contracts Division – Substance Use Disorder (SUD) Services immediately of any information received from any source alleging a violation of the TVPA by either this organization or its employees, or a subcontractor or its employees during the term of this contract. I understand that this organization is obligated to ensure any subcontractors are informed of the requirements of the TVPA and, if found in violation, will be immediately terminated. I agree to submit this signed certification annually on behalf of the organization acknowledging requirements under the TVPA and attesting that all employees will receive annual TVPA training, and that documentation of training will be placed in personnel files. Signature:_____________________________ Date:______________________ Title:_________________________________ Exhibit J Page 1 of 3 DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT I. Identifying Information Name of entity D/B/A Address (number, street) City State ZIP code CLIA number Taxpayer ID number (EIN) Telephone number ( ) II. Answer the following questions by checking “Yes” or “No.” If any of the questions are answered “Yes,” list names and addresses of individuals or corporations under “Remarks” on page 2. Identify each item number to be continued. A. Are there any individuals or organizations having a direct or indirect ownership or control interest of five percent or more in the institution, organizations, or agency that have been convicted of a criminal offense related to the involvement of such persons or organizations in any of the programs established YES NO by Titles XVIII, XIX, or XX? ......................................................................................................................... ❒ ❒ B. Are there any directors, officers, agents, or managing employees of the institution, agency, or organization who have ever been convicted of a criminal offense related to their involvement in such programs established by Titles XVIII, XIX, or XX? ...................................................................................... ❒ ❒ C. Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar capacity who were employed by the institution’s, organization’s, or agency’s fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) ........... ❒ ❒ III. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names and addresses under “Remarks” on page 2. If more than one individual is reported and any of these persons are related to each other, this must be reported under “Remarks.” NAME ADDRESS EIN B. Type of entity: ❒ Sole proprietorship ❒ Partnership ❒ Corporation ❒ Unincorporated Associations ❒ Other (specify) C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations under “Remarks.” D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities? (Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses of individuals, and provider numbers. .......................................................................................................... ❒ ❒ NAME ADDRESS PROVIDER NUMBER Exhibit J Page 2 of 3 YES NO IV. A. Has there been a change in ownership or control within the last year? ....................................................... ❒ ❒ If yes, give date. B. Do you anticipate any change of ownership or control within the year?....................................................... ❒ ❒ If yes, when? C. Do you anticipate filing for bankruptcy within the year?................................................................................ ❒ ❒ If yes, when? V. Is the facility operated by a management company or leased in whole or part by another organization?.......... ❒ ❒ If yes, give date of change in operations. VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... ❒ ❒ VII. A. Is this facility chain affiliated? ...................................................................................................................... ❒ ❒ (If yes, list name, address of corporation, and EIN.) Name EIN Address (number, name) City State ZIP code B. If the answer to question VII.A. is NO, was the facility ever affiliated with a chain? (If yes, list name, address of corporation, and EIN.) Name EIN Address (number, name) City State ZIP code Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of a request to participate or where the entity already participates, a termination of its agreement or contract with the agency, as appropriate. Name of authorized representative (typed) Title Signature Date Remarks Exhibit J Page 3 of 3 INSTRUCTIONS FOR COMPLETING DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT A full and accurate disclosure of ownership and financial interest is required. Failure to submit requested information may result in a refusal by the Secretary or appropriate State agency to enter into an agreement or contract with any such institution or in termination of existing agreements. General Instructions Please answer all questions as of the current date. If the yes block for any item is checked, list requested additional information under the Remarks section on page 2, referencing the item number to be continued. If additional space is needed use an attached sheet. Return the original and second and third copies to the State agency; retain the first copy for your files. This form is to be completed annually. Any substantial delay in completing the form should be reported to the State survey agency. DETAIL ED INSTRUCTIONS These instructions are designed to clarify certain questions on the form. Instructions are listed in question order for easy reference. No instructions have been given for questions considered self-explanatory. IT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE ANSWERED ACCURATELY AND THAT ALL INFORMATION BE CURRENT. Item I - Under identifying information specify in what capacity the entity is doing business as (DBA), example, name of trade or corporation. Item II - Self-explanatory. Item III - List the names of all individuals and organizations having direct or indirect ownership interests, or controlling interest separately or in combination amounting to an ownership interest of 5 percent or more in the disclosing entity. Direct ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of the disclosing entity. A disclosing entity is defined as a Medicare provider or supplier, or other entity that furnishes services or arranges for furnishing services under Medicaid or the Maternal and Child Health program, or health related services under the social services program. Indirect ownership interest is defined as ownership interest in an entity that has direct or indirect ownership interest in the disclosing entity. The amount of indirect ownership in the disclosing entity that is held by any other entity is determined by multiplying the percentage of ownership interest at each level. An indirect ownership interest must be reported if it equates to an ownership interest of 5 percent or more in the disclosing entity. Example: if A owns 10 percent of the stock in a corporation that owns 80 percent of the stock of the disclosing entity, A's interest equates to an 8 percent indirect ownership and must be reported. Controlling interest is defined as the operational direction or management of a disclosing entity which may be maintained by any or all of the following devices: the ability or authority, expressed or reserved, to amend or change the corporate identity (i.e., joint venture agreement, unincorporated business status) of the disclosing entity; the ability or authority to nominate or name members of the Board of Directors or Trustees of the disclosing entity; the ability or authority, expressed or reserved, to amend or change the by-laws, constitution, or other operating or management direction of the disclosing entity; the right to control any or all of the assets or other property of the disclosing entity upon the sale or dissolution of that entity; the ability or authority, expressed or reserved, to control the sale of any or all of the assets, to encumber such assets by way of mortgage or other indebtedness, to dissolve the entity, or to arrange for the sale or transfer of the disclosing entity to new ownership or control. Items IV – VII - Changes in Provider Status Change in provider status is defined as any change in management control. Examples of such changes would include: a change in Medical or Nursing Director, a new Administrator, contracting the operation of the facility to a management corporation, a change in the composition of the owning partnership which under applicable State law is not considered a change in ownership, or the hiring or dismissing of any employees with 5 percent or more financial interest in the facility or in an owning corporation, or any change of ownership. For Items IV – VII, if the yes box is checked, list additional information requested under Remarks. Clearly identify which item is being continued. Item IV - (a & b) If there has been a change in ownership within the last year or if you anticipate a change, indicate the date in the appropriate space. Item V - If the answer is yes, list name of the management firm and employer identification number (EIN), or the name of the leasing organization. A management company is defined as any organization that operates and manages a business on behalf of the owner of that business, with the owner retaining ultimate legal responsibility for operation of the facility. Item VI - If the answer is yes, identify which has changed (Administrator, Medical Director, or Director of Nursing) and the date the change was made. Be sure to include name of the new Administrator, Director of Nursing or Medical Director, as appropriate. Item VII - A chain affiliate is any free-standing health care facility that is either owned, controlled, or operated under lease or contract by an organization consisting of two or more free-standing health care facilities organized within or across State lines which is under the ownership or through any other device, control and direction of a common party. Chain affiliates include such facilities whether public, private, charitable or proprietary. They also include subsidiary organizations and holding corporations. Provider-based facilities, such as hospital-based home health agencies, are not considered to be chain affiliates