HomeMy WebLinkAboutAgreement A-19-283 with Kaweah Delta Health Care District.pdf1
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Agreement No. 19-283
AGREEMENT
This AGREEMENT is made and entered into this 18th day of _ __.._,Ju...,_n,.,,.e ___ , 2019 by and
between the COUNTY OF FRESNO , a Political Subdivision of the State of California , hereinafter
referred to as "COUNTY", and KAWEAH DELTA HEALTHCARE DISTRICT (DISTRICT), a local
health care district organized and existing pursuant to California Health and Safety Code Sections
32000 et seq., d.b.a KAWEAH DELTA MENTAL HEALTH HOSPITAL, whose address is 100 South
Akers Street , Visalia , CA 93277 , hereinafter referred to as "CONTRACTOR."
W I TN E S S ET H:
WHEREAS , COUNTY has an Agreement with the California State Department of Health Care
Services (DHCS) to operate the Fresno County Mental1 Health Managed Care Plan in accordance with
Welfare and Institutions Code Section 5000 et seq . which sets forth COUNTY's requirements to
provide , to the extent available , public mental health services ; and
WHEREAS , COUNTY is authorized to contract for the provision of Adult Psych iatric Inpatient
Hospital Services to Fresno County Beneficiaries eligible for such services under the Med i-Cal program ,
pursuant to Sections 14700 et seq . and 14712 et seq . of the California Welfare and Institutions Code ,
and COUNTY may also determine the need to refer persons not eligible for Medi-Cal ; and
WHEREAS , CONTRACTOR is w illing and able to provide such services to eligible Fresno
County Beneficiaries and Recipients , pursuant to the terms and cond itions of this Agreement ; and
WHEREAS, COUNTY and CONTRACTOR mutually recognize that services under this
Agreement will be rendered by CONTRACTOR to persons referred by COUNTY and it is not the
intention of either COUNTY or CONTRACTOR that such individuals occupy the position of third-party
beneficiaries of the obligations assumed by either party to this Agreement; and
WHEREAS , the words and terms used in th is Agreement are intended to have their usual
meanings unless a particular or more limited meaning is associated with their usage in Sections 14712
et seq. and 14680 et seq. of the Californ ia Welfare and Institutions Code , or the Medi-Cal Psychiatric
Inpatient Hospital Services Consolidation Regulations pertaining to the rendition of health care or
unless specifically defined in Exhibit A "Definitions", which is attached hereto and incorporated herein
by reference .
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NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties
hereto agree as follows:
1.SCOPE OF WORK
A.Psychiatric Services
1)CONTRACTOR agrees to render adult Inpatient Psychiatric Hospital
services to any Beneficiary in need of such services in accordance with regulations adopted pursuant
to Sections 14700 et seq., 14712 et seq., and 14680 et seq. of the California Welfare and Institutions
Code, and to Recipients referred by COUNTY or by an acute inpatient facility following medical
clearance of a beneficiary or recipient placed on an involuntary psychiatric hold pursuant to California
Welfare and Institutions Code 5150 when CONTRACTOR has the facilities available.
2)CONTRACTOR shall also triage any Beneficiary who directly seeks Adult
Psychiatric Inpatient Hospital Services. CONTRACTOR shall also accept any Beneficiary who directly
seeks Adult Psychiatric Inpatient Hospital Services when CONTRACTOR has facilities available.
Subject to third party liability and patient share of costs, if applicable, CONTRACTOR agrees to accept
as payment in full for Adult Psychiatric Inpatient Hospital Services payment, as provided in PAYMENT
PROVISIONS, Section 12 of this Agreement.
3)COUNTY and CONTRACTOR mutually recognize that services under this
Agreement will be rendered by CONTRACTOR to persons who meet medically necessity criteria for
inpatient psychiatric hospitalization and it is not the intention of either COUNTY or CONTRACTOR that
such individuals occupy the position of third-party beneficiaries of the obligations assumed by either
party to this Agreement.
4)CONTRACTOR shall provide or arrange for the provision and
compensation of Physician services for Beneficiaries and Recipients as it relates to physical health
issues, with the exception of the initial physical and health (p&h) examination at admission which is
included in the day rate as provided in PAYMENT PROVISIONS, Section 12 of this Agreement.
5)CONTRACTOR shall, at its own expense, provide and maintain facilities
and professional, allied and supportive medical and paramedical personnel to provide all necessary
and appropriate Adult Psychiatric Inpatient Hospital Services and shall ensure that family members
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are involved in treatment when appropriate and family is willing to participate.
6)CONTRACTOR shall, at its own expense, provide and maintain the
organizational and administrative capabilities to carry out its duties and responsibilities under this
Agreement and all applicable statutes and regulations pertaining to Medi-Cal contractors.
7)CONTRACTOR shall receive reimbursement for an Administrative Day(s)
from the California State Department of Health Care Services, upon the condition that CONTRACTOR
agrees to be responsible for contacting less restrictive facilities (i.e., board and care facilities, room
and board facilities, licensed adult residential care facilities, etc.) within a sixty (60) mile radius of
CONTRACTOR’s facility at least once every five (5) days to place Beneficiary when Beneficiary no
longer requires CONTRACTOR’s acute care. These contacts must be documented by a brief
description of status and the signature of the person making the contacts. Beneficiary’s chart shall be
reviewed on a weekly basis if the Beneficiary’s status has changed.
8)Adult Psychiatric Inpatient Hospital Services rendered pursuant to this
Agreement shall be rendered at the following facility: Kaweah Delta Mental Health Hospital, 1100
South Akers Street, Visalia, CA 93277, except as permitted by Section 2, DELEGATION OF
CONTRACTOR’S DUTIES: WHEN PERMITTED.
9)CONTRACTOR shall provide Adult Psychiatric Inpatient Hospital
Services in the same manner to persons referred by COUNTY as it provides to all patients to whom it
renders Adult Psychiatric Inpatient Hospital Services.
10)CONTRACTOR shall not discriminate in any manner, including admission
practices, placement in special or separate wings or rooms, nor make any provision for special or
separate means.
11)CONTRACTOR shall take such action as required by CONTRACTOR’s
Medical Staff Bylaws against medical staff members who violate those bylaws, as the same may be
amended from time to time.
12)CONTRACTOR shall align programs, services, and practices with the
vision, mission, and guiding principles of the DBH, as further described in Exhibit B, “Fresno County
Department of Behavioral Health Guiding Principles of Care Delivery”, attached hereto and by this
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reference incorporated herein and made part of this Agreement.
13)Quality of Care
As express conditions precedent to any authorization by COUNTY for
payment under the terms of this Agreement, whether services are performed directly or through the
instrumentality of a Delegate as permitted under this Agreement, CONTRACTOR shall:
a)Assure that any and all eligible Beneficiaries receive care as
required by Sections 14700 et seq. and 14712 et seq. of the California Welfare and Institutions Code
(WIC) and assure that the same quality of care is rendered to all Recipients referred by COUNTY.
Payment may be denied by COUNTY when requirements of cited WIC sections are not met.
b)Take such action as required by CONTRACTOR’s Medical Staff
bylaws against medical staff members who violate those bylaws, as the same may be from time to
time amended.
c)Provide Psychiatric Inpatient Hospital Services in the same
manner to persons covered by this Agreement as it provides to all patients to whom it renders
Psychiatric Inpatient Hospital Services.
B.Contractor’s Professional And Administrative Responsibilities
To the extent required by Title 22, Division 5, Chapter 1, Section 70713 of the
California Code of Regulations, CONTRACTOR retains professional and administrative responsibility
for the services rendered pursuant to this Agreement. CONTRACTOR’s retention of these
responsibilities shall not alter or modify, in any way, the hold harmless, indemnification, insurance or
independent contractor provisions set forth in this Agreement.
C.Licensure and Certification Conditions:
1)CONTRACTOR hereby represents and warrants that it is currently, and
for the duration of this Agreement shall remain, certified by the Joint Commission and licensed as a
general acute care hospital or acute psychiatric hospital in accordance with Sections 1250 et seq. of
the Health and Safety Code and the licensing regulations contained in Title 22 and Title 17 of the
California Code of Regulations.
2)CONTRACTOR hereby represents and warrants that it is currently, and
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for the duration of this Agreement shall remain, certified under Title XVIII of the Federal Social Security
Act (42 U.S.C. Sections 1395 et seq.).
2. DELEGATION OF CONTRACTOR’S DUTIES: WHEN PERMITTED
A. CONTRACTOR and COUNTY recognize that the Adult Psychiatric Inpatient
Hospital Services to be rendered under this Agreement are personal and non-delegable, except as
provided in this Agreement. Any attempt by CONTRACTOR to delegate or otherwise vest
responsibility for performance of its duties in any manner other than those expressly permitted in this
Section 2 shall constitute a present material breach of this Agreement.
B. Except as limited by (E) of this Section 2, delegation of duties by CONTRACTOR
shall not constitute a present material breach only if such delegation is in conformity with one of the
following:
1) The Delegate renders the Adult Psychiatric Inpatient Hospital Services at
CONTRACTOR’s facility or location.
2) For services to Medi-Cal Beneficiaries only, if the total of all payments by
CONTRACTOR for all delegated services not covered under this Section 2 (B) by (1) nor specially
authorized under (3) will not exceed five percent (5%) of the total Medi-Cal inpatient psychiatric billing
by CONTRACTOR in any consecutive three (3) month period, CONTRACTOR may delegate duties to
any qualified delegate under (C) of this Section 2 without written approval of COUNTY.
3) Any delegation not authorized under this Section 2(B) by (1) or by (2)
shall require the prior written approval of COUNTY. Such prior written approval must be requested in
a written application which identifies the proposed Delegate or Delegates, warrants their qualification
to render services required by and in conformity with the terms of this Agreement, and identifies the
categories of services to be delegated along with an estimate of the percentage of services in those
categories which CONTRACTOR anticipates will be rendered by the Delegate or Delegates.
COUNTY’s prior approval of a proposed delegation shall not be required
if CONTRACTOR can demonstrate to COUNTY that any such proposed delegation does not offend
the express provisions of this Section 2. Such consent is contingent upon COUNTY’s good faith
assessment of the burdens and benefits to the Medi-Cal or COUNTY programs and potentially
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affected Beneficiaries or Recipients of those programs.
C.When authorization is given pursuant to Section 2(B)(3), CONTRACTOR shall be
responsible for all aspects of performance by its Delegate or Delegates. CONTRACTOR hereby
agrees that any default, refusal to perform or defective performance of any delegated duty or service
shall constitute a breach of this Agreement on the part of CONTRACTOR to the same extent as if
such default, refusal to perform or defective performance had been directly committed or incurred by
CONTRACTOR.
D.All costs for services rendered by a Delegate or Delegates are included in the
all–inclusive rates paid to CONTRACTOR pursuant to PAYMENT PROVISIONS, Section 12 of this
Agreement.
E.As a limitation upon the authorizations set forth in this Section 2(B), no
delegation shall be attempted or entered if:
1)The Delegate is not licensed and certified to the same extent as that
required of CONTRACTOR under Section 6, LICENSURE AND CERTIFICATION CONDITIONS
of this Agreement; or
2)The location at which the Delegate is to perform the delegated services is
at such a distance from CONTRACTOR’s location that it is beyond the range considered acceptable in
the opinion of COUNTY for provision of the delegated services as it could unnecessarily or unduly
burden affected Beneficiaries or Recipients; or
3)The services are available at CONTRACTOR’s location. CONTRACTOR
shall not discriminate against Beneficiaries in making a determination of availability of facilities at its
own location.
3.DELEGATION OF CONTRACTOR’s DUTIES: HOW ACCOMPLISHED
In any delegation pursuant to authorization contained in Section 2(B)(3), DELEGATION
OF CONTRACTOR’S DUTIES: WHEN PERMITTED, CONTRACTOR shall contract in writing with a
Delegate or Delegates for the assumption of the primary duty of performance of the duties assumed
by CONTRACTOR under the terms of this Agreement. Any written contract of delegation shall include
the following:
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A. Covenants on the part of CONTRACTOR and the Delegate that the contract of
delegation shall be governed by and construed in accordance with all applicable laws and regulations
and this Agreement.
B. Specification of the services to be provided by the Delegate.
C. Specification of the term of the contract of delegation including the beginning and
ending dates, as well as methods of extension, renegotiation and termination.
D. A warranty by the Delegate that it presently conforms, and during the life of the
delegation shall continue to conform, to the licensure and certification requirements exacted from
CONTRACTOR under Section 6, LICENSURE AND CERTIFICATION CONDITIONS, of this
Agreement and that its failure to abide by the terms of this warranty shall be an express condition
subsequently discharging CONTRACTOR from all obligations under the terms of the contract of
delegation.
E. A covenant running to COUNTY as an intended third party beneficiary of the
contract of delegation where by the Delegate promises:
1) To maintain, for at least six (6) years after the close of the fiscal year in
which the contract of delegation was in effect, full books and records pertaining to the goods and
services furnished under the terms of the delegation in accordance with general standards applicable
to such book and record keeping.
2) To make the books and records maintained under (E)(1) of this Section 3
available for inspection, examination or copying by agents of COUNTY, the California State
Department of Health Care Services and the United States Department of Health and Human Services
at all reasonable times at the Delegate’s place of business, or at such other location in California
approved in writing by COUNTY.
3) To make full disclosure of the method and amount of compensation or
other direct or indirect consideration received by the Delegate from CONTRACTOR.
4) That no services rendered on behalf of CONTRACTOR by the Delegate
pursuant to the contract of delegation will be billed to COUNTY or the fiscal intermediary by the
Delegate; the Delegate will look exclusively to CONTRACTOR for compensation under the terms of
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the contract of delegation.
5)To hold harmless COUNTY, the California State Department of Health
Care Services, the State of California and Beneficiaries in the event that CONTRACTOR cannot or will
not pay for services performed by the Delegate pursuant to the terms of the contract of delegation.
4.ASSUMPTION OF RISK BY CONTRACTOR
W hether rendered directly or through the instrumentality of a Delegate as permitted
under this Agreement, CONTRACTOR shall bear total risk for the cost of all Adult Psychiatric Inpatient
Hospital Services rendered under this Agreement. As used in this section, “risk” means that
CONTRACTOR covenants to accept as payment in full for the Adult Psychiatric Inpatient Hospital
Services described herein, those payments received pursuant to Section 12, PAYMENT
PROVISIONS, of this Agreement. Such acceptance of the risk shall be made irrespective of whether
the cost of such services and related administrative expenses shall have exceeded the authorized
payment by COUNTY as set forth in this Agreement.
5.COMPLAINTS
CONTRACTOR shall log all complaints and the disposition of all complaints from a
Beneficiary or Recipient (collectively referred to as “consumers”) or a Beneficiary’s or Recipient’s
family. CONTRACTOR shall provide a summary of the complaint log entries concerning COUNTY-
sponsored Beneficiaries or Recipients to COUNTY at monthly intervals, by the fifteenth (15th) day of
the following month, in a format that is mutually agreed upon. CONTRACTOR shall post signs
informing consumers of their right to file a complaint or grievance. CONTRACTOR shall notify
COUNTY of all incidents reportable to state licensing bodies that affect COUNTY consumers within
twenty-four (24) hours of receipt of a complaint. Consistent with consumer privacy rights;
CONTRACTOR shall allow Patient’s Rights Advocates access to the acute psychiatric inpatient unit to
investigate all complaints concerning conditions in that unit.
Within fifteen (15) days after each incident or complaint affecting COUNTY-sponsored
consumers, CONTRACTOR shall provide COUNTY with information relevant to the complaint,
investigative details of the complaint, and the disposition of, or corrective action taken to resolve the
complaint. W ithin fifteen (15) days after CONTRACTOR submits a corrective action plan to a
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California State licensing and/or accrediting body concerning any sentinel event, as that term is
defined by the licensing or accrediting agency, and within fifteen (15) days after CONTRACTOR
receives a corrective action order from a California State licensing and/or accrediting body to address
a sentinel event, CONTRACTOR shall provide a summary of such plans and orders to COUNTY.
6.LICENSURE AND CERTIFICATION CONDITIONS
CONTRACTOR hereby represents and warrants that it is currently, and for the duration
of this Agreement shall remain, certified by the JCAHO and licensed as a general acute care hospital
or acute psychiatric hospital in accordance with Section 1250 et seq. of the California Health and
Safety Code and the licensing regulations contained in Title 22 and Title 17 of the California Code of
Regulations.
7.UTILIZATION CONTROLS
As express conditions precedent to any authorization by COUNTY for payment
obligation under the terms of this Agreement: (1) CONTRACTOR shall adhere to all utilization controls
and obtain authorization for services in accordance with Sections 14712 and 14718 of the California
Welfare and Institutions Code and regulations adopted pursuant thereto; and (2) CONTRACTOR shall
notify COUNTY within ten (10) calendar days of the emergency admission of a Beneficiary or
Recipient.
8.TERM
The term of this Agreement shall be for a period of three (3) years, commencing on July
1, 2018 through and including June 30, 2021. This Agreement may be extended for two (2) additional
consecutive twelve (12) month periods upon written approval of both parties no later than thirty (30)
days prior to the first day of the next twelve (12) month extension period. The Director, Department of
Behavioral Health, or his or her designee is authorized to execute such written approval on behalf of
COUNTY based on CONTRACTOR’s satisfactory performance.
The terms of this Agreement shall continue to apply to any Beneficiary(ies) and
Recipient(s) receiving Adult Psychiatric Inpatient Hospital Services at the date of termination.
9.TERMINATION
A.Non-Allocation of Funds - terms of this Agreement, and the services to be
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provided hereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated at any time by giving CONTRACTOR thirty (30) days advance written notice.
B.Breach of Contract - COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of COUNTY there is:
1)An illegal or improper use of funds;
2)A failure to comply with any term of this Agreement;
3)A substantially incorrect or incomplete report submitted to COUNTY;
4)Improperly performed service.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of any
breach of this Agreement or any default which may then exist on the part of CONTRACTOR. Neither
shall such payment impair or prejudice any remedy available to COUNTY with respect to the breach or
default. COUNTY shall have the right to demand of CONTRACTOR the repayment to the COUNTY of
any funds disbursed to CONTRACTOR under this Agreement, which in the judgment of COUNTY
were not expended in accordance with the terms of this Agreement. CONTRACTOR shall promptly
refund any such funds upon demand or, at COUNTY’s option, such repayment shall be deducted from
future payments owing to CONTRACTOR under this Agreement.
C.Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by CONTRACTOR or COUNTY or COUNTY’s Department of
Behavioral Health Director, or designee, upon the giving of ninety (90) days advance written notice of
an intention to terminate.
10.APPOINTMENT OF LIAISONS AND AGENCY STATUS OF CONTRACTOR’S LIAISON
A.CONTRACTOR shall designate in writing a person to act as liaison to COUNTY.
Such person shall coordinate all communications between the parties. The written designation of such
person shall constitute the conferral of full agency powers to bind CONTRACTOR as principal in all
dealings with COUNTY/Department(s).
B.COUNTY shall designate a liaison in conformity with the procedures and with
such authority as specified in Section 40, ONSITE REVIEWS & LIAISON SERVICES BY DBH, of this
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Agreement. In addition, a COUNTY Admitting Interviewer shall certify Universal Method of
Determining Ability to Pay (UMDAP) qualification for Recipients referred by COUNTY. COUNTY shall
also designate a Case Manager to coordinate discharges of Medi-Cal and UMDAP clients.
Communications to COUNTY shall be submitted to its liaison at the following:
Director or Designee Department of Behavioral Health 1925 E. Dakota Ave
Fresno, CA 93726
11.UMDAP APPLICATION
CONTRACTOR shall inform low income, uninsured and under-insured persons admitted
to facility of the COUNTY’s UMDAP program. COUNTY authorizes CONTRACTOR to initiate the
UMDAP application process using a COUNTY-approved form (Exhibit C of this Agreement, attached
hereto and incorporated herein by reference) and may transcribe information as stated by person or
family onto said form. The application form must have the original signature of the person admitted to
facility or his/her authorized representative. The completed application shall be submitted to COUNTY
within one (1) business day of admission for inpatient psychiatric services. COUNTY reserves the
right to determine UMDAP eligibility and will notify CONTRACTOR of the person’s eligibility within five
(5)working days.
12.PAYMENT PROVISIONS
A.Rate Structure:
1)Beneficiaries:
For Beneficiaries, provided that there shall first have been a submission
of claims in accordance with Section 12(D) of this Agreement, and payment authorization from
COUNTY, CONTRACTOR shall be paid by the State Department of Health Care Services at the
following all-inclusive rate per patient per day for acute Adult Psychiatric Inpatient Hospital Services,
excluding professional fees, based on the following accommodation codes:
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Description Accommodation Code Rate
Administrative Day 169 $597.34 (effective 8/1/18)
Room & Board, Semi-Private 124 $1,273.00 (Fiscal Year 2018-19)
2-Bed, Psychiatric
2)Recipients:
For Recipients specifically referred by COUNTY to CONTRACTOR,
provided that there shall first have been a submission of claims in accordance with Section 12(D) of
this Agreement, CONTRACTOR shall be paid by COUNTY at the following all-inclusive rate per
patient per day for acute Adult Psychiatric Inpatient Hospital Services excluding professional fees
based on the following accommodation codes:
Description Accommodation Code Rate
Administrative Day 169 $597.34 (effective 8/1/18)
Room & Board, Semi-Private 124 $1,273.00 (Fiscal Year 2018-19)
2-Bed, Psychiatric
The maximum amount payable to CONTRACTOR by COUNTY for Adult Psychiatric
Inpatient Hospital Services provided by CONTRACTOR to Recipients, under the terms and conditions of
this Agreement, is Two Million Two Hundred Fifty Thousand and No/100 Dollars ($2,250,000.00) for each
twelve (12)-month period of this Agreement. The maximum amount payable under this Agreement
throughout the term of this Agreement, which includes a three-year base contract and two optional one-
year extensions, is Eleven Million Two Hundred Fifty Thousand and No/100 Dollars ($11,250,000.00).
COUNTY shall pay CONTRACTOR, in arrears for services provided during the previous month, within
forty-five (45) days after receipt and verification of CONTRACTOR’s invoices by COUNTY.
For those Beneficiaries and Recipients determined by COUNTY staff to meet
medical necessity criteria for acute inpatient hospitalization and referred by COUNTY and admitted to
the facility; and should the retrospective review of the client record fail to meet Medi-Cal medical
necessity criteria, COUNTY will compensate CONTRACTOR at the rate of One Thousand Two
Hundred Seventy-Three and No/100 Dollars ($1,273.00) per day of admission in these instances. If
client is a Beneficiary, COUNTY will adjust the Treatment Authorization Request (TAR) in accordance
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with Medi-Cal medical necessity criteria to prevent an incorrect claim to the State. If Medi-Cal funding
is subsequently secured, CONTRACTOR will credit COUNTY the appropriate amount. It is
understood by COUNTY and CONTRACTOR that the California Department of Health Care Services
Rate Development Branch is responsible for establishing the administrative day rate during each State
fiscal year, which may supersede the rate stated herein. It is further understood by COUNTY and
CONTRACTOR that Kaweah Delta Mental Health Hospital’s Psychiatric Inpatient Day Rate (Room &
Board, Semi-Private, 2-bed, Psychiatric) is established based on negotiations with Tulare County
during each fiscal year, which may supersede the rate stated herein. Said rate adjustment(s) shall be
approved by COUNTY’s DBH Director, or designee and CONTRACTOR and become part of this
Agreement. Any rate adjustment shall not result in an increase to the maximum compensation of the
Agreement as stated herein.
B.Physician Services:
Non-psychiatric Physician services and medically necessary physical health
services provided post admittance of a COUNTY Beneficiary or Recipient covered under this
Agreement, are not covered under this Agreement and shall not be paid by the COUNTY.
C.Transportation Services:
In the event transportation services are required by those patients receiving Adult
Psychiatric Inpatient Hospital Services, such transportation services and the cost and expense thereof
shall be the sole responsibility of the COUNTY.
D.Billing Procedures as Express Conditions Precedent to COUNTY’s Authorization
for Payment:
1)As an express condition precedent to COUNTY’s authorization for
payment under this Section 12 of this Agreement, CONTRACTOR shall determine that Adult
Psychiatric Inpatient Hospital Services rendered are not covered, in whole or in part, under any State
of California or Federal medical care program other than Medi-Cal, Medicare, or under any other
contractual or legal entitlement, including, but not limited to, a private group indemnification or
insurance program or worker’s compensation. To the extent that such coverage is available, the
payment received by CONTRACTOR from such coverage will reduce COUNTY’s payment obligation
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for a combined amount not to exceed the all-inclusive rate pursuant to Section 12(A). The
Beneficiary’s or individual’s share of cost, i.e., payments required to be made by Beneficiary or
individuals under applicable insurance policies, etc., will also reduce the State’s Medi-Cal payment
obligation or COUNTY’s payment obligation, by the amount of the share of cost.
2) As a further express condition precedent to any COUNTY authorization
for payment under Section 12(A) of this Agreement, CONTRACTOR shall submit claims addressed to
Fresno County Mental Health Plan, 1925 E. Dakota Ave, Fresno, CA 93726: Attention Division
Manager, for all services rendered to adult person covered under the terms of this Agreement, in
accordance with the applicable billing requirements contained in Section 5778 of the California
Welfare and Institutions Code and the regulations adopted thereto.
3) An authorized day of service shall be billed for each adult person who
occupies an inpatient psychiatric bed at 12:00 midnight in the facilities of either CONTRACTOR or an
authorized Delegate. Day of discharge shall not be billed. However, a day of service may be billed if
the adult person is admitted and discharged during the same day provided that such admission and
discharge is not within twenty-four (24) hours of a prior discharge. For billing purposes, Beneficiaries
and Recipients receiving Adult Psychiatric Inpatient Hospital Services, as described herein, must meet
emergency admission criteria, documentation requirements, treatment and discharge planning
requirements and have received an approved TAR for the days being billed. Said TAR and supporting
documentation must be submitted by CONTRACTOR or COUNTY within fourteen (14) days of said
Beneficiaries and Recipients being discharged from said facility(ies).
E. Recovery of Overpayments to CONTRACTOR, Liability for Interest:
1) When an audit performed by COUNTY, the California State Department
of Health Care Services, the California State Controller’s Office, or any other authorized agency
discloses that CONTRACTOR has been overpaid under this Agreement, pursuant to Section 12(A),
CONTRACTOR covenants that any such overpayment may be recouped by COUNTY by reducing
future payment or invoicing the CONTRACTOR for such overpayment.
2) Overpayments determined as a result of audits of periods prior to the
effective date of this Agreement may be recouped by COUNTY withholding authorization of the
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amount due from what would otherwise be COUNTY liability under this Agreement, seeking recovery
by payment from CONTRACTOR, or a combination of these two methods.
3) When recoupment or recovery is sought under Section 12(E) of this
Agreement, CONTRACTOR may appeal according to applicable procedural requirements of Sections
14700 et seq. and 14712 et seq. of the California Welfare and Institutions Code, with the following
exceptions:
a) The recovery or recoupment shall commence sixty (60) days after
issuance of account status or demand resulting from an audit or review and shall not be deferred by
the filing of a request for an appeal according to the applicable regulations.
b) CONTRACTOR’s liability to COUNTY for any amount recovered
under this section shall be as provided in Section 14718 of the California Welfare and Institutions
Code and regulations adopted pursuant thereto.
F. Customary Charges Limitation:
1) Notwithstanding any other provision in this Agreement, COUNTY’s
authorization for payment to CONTRACTOR shall not exceed CONTRACTOR’s total customary
charges for like services during each hospital fiscal year, or part thereof, in which this Agreement is in
effect. COUNTY may recoup any excess of total payments above such total customary charges under
Section 12(E).
2) As used in Section 12(F)(1), “customary charges” is defined as those
uniform charges listed in a CONTRACTOR’s established fee schedule, which is in effect and applied
consistently to most patients and recognized for program reimbursement. Where a CONTRACTOR
does not have an established fee schedule in effect and applied to most patients, the determined
“customary charges” are the most frequent or typical charges imposed uniformly for given items or
services. However, in either case, in order to be considered customary charges, they must actually be
imposed uniformly on most patients and actually be collected from a substantial percentage of patients
liable for payment on a charge basis. Such charges must also be recognized for program
reimbursement (see Department of Health and Human Services, Health Care Financing
Administration, Medicare Provider Reimbursement Manual, Part 1 (“HCFA 15-1”), Chapter 26 Section
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2604.3), and are defined in conformity with 42 USC Section 1395f, 42 CFR Part 413 and the
regulations promulgated pursuant thereto.
13.FUNDING
In the event that funding for these services is delayed by the State Controller, COUNTY
my defer payment to CONTRACTOR. The amount of the deferred payment shall not exceed the
amount of funding delayed by the State Controller to COUNTY. The period of time of the deferral by
COUNTY shall not exceed the period of time of the State Controller’s delay of payment to COUNTY
plus forty-five (45) days.
14.INDEPENDENT CONTRACTOR
In performance of the work, duties, and obligations assumed by CONTRACTOR under
this Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of
CONTRACTOR’s officers, agents, and employees will at all times be acting and performing as an
independent contractor, and shall act in an independent capacity and not as an officer, agent, servant,
employee, joint venturer, partner, or associate of COUNTY. Furthermore, COUNTY shall have no
right to control or supervise or direct the manner or method by which CONTRACTOR shall perform its
work and function. However, COUNTY shall retain the right to administer this Agreement so as to
verify that CONTRACTOR is performing its obligations in accordance with the terms and conditions
thereof. CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the rules
and regulations, if any, of governmental authorities having jurisdiction over matters which are directly
or indirectly the subject of this Agreement.
Because of its status as an independent contractor, CONTRACTOR shall have absolutely
no right to employment rights and benefits available to COUNTY employees. CONTRACTOR shall be
solely liable and responsible for providing to, or on behalf of, its employees all legally-required
employee benefits. In addition, CONTRACTOR shall be solely responsible and save COUNTY
harmless from all matters relating to payment of CONTRACTOR’s employees, including compliance
with Social Security, withholding, and all other regulations governing such matters. It is acknowledged
that during the term of this Agreement, CONTRACTOR may be providing services to others unrelated
to the COUNTY or this Agreement.
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15.MODIFICATION
Any matters of this Agreement may be modified from time to time by the written consent
of all the parties without, in any way, affecting the remainder. Rate changes as a result of the action
by the California Department of Health Care Services Rate Development Branch, as provided in
PAYMENT PROVISIONS, Section 12(A) of this Agreement, may be approved by COUNTY’s DBH
Director, or designee and CONTRACTOR. In addition, rate changes may be approved by the written
approval of the COUNTY’s Department of Behavioral Health Director or designee; said rate changes
shall not result in any change to the maximum compensation amount payable to CONTRACTOR, as
stated herein.
16.BENEFICIARY ELIGIBILITY
This Agreement is not intended to change the determination of Medi-Cal eligibility for
Beneficiaries in any way. However, in the event the California State Legislature or Congress of the
United States enacts a statute which redefines Medi-Cal eligibility so as to affect the provision of
Psychiatric Inpatient Hospital Services under this Agreement, this new definition shall apply to the
terms of this Agreement. The parties agree to negotiate in good faith regarding an amendment to the
contract if any such statute changes substantially alters the terms of the existing agreement.
17.LIMITED ENGLISH PROFICIENCY (LEP)
CONTRACTOR shall provide interpreting and translation services to consumers
participating in CONTRACTOR’s services who have limited or no English language proficiency,
including services to persons who are deaf or blind. Interpreter and translation services shall be
provided as necessary to allow such consumers meaningful access to the programs, services and
benefits provided by CONTRACTOR. Interpreter and translation services, including translation of
CONTRACTOR’s “vital documents”: (those documents that contain information that is critical for
accessing CONTRACTOR’s services or are required by law) shall be provided to consumers at no
cost to the consumer. CONTRACTOR shall ensure that any employees, agents, subcontractors, or
partners who interpret or translate for a program participant, or who directly communicate with a
program consumer in a language other than English, demonstrate proficiency in the consumer’s
language and can effectively communicate any specialized terms and concepts peculiar to
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CONTRACTOR’s services.
18.CULTURAL COMPETENCE
As related to Cultural and Linguistic Competence:
A.CONTRACTOR shall not discriminate against beneficiaries based on race, color,
national origin, sex, disability or religion. CONTRACTOR shall ensure that a limited and/or no English
proficient beneficiary is entitled to equal access and participation in federally funded programs through
the provision of comprehensive and quality bilingual services pursuant to Title 6 of the Civil Rights Act
of 1964 (42 U.S.C. Section 2000d, and 45 C.F.R. Part 80) and Executive Order 12250 of 1979.
B.CONTRACTOR shall comply with requirements of policies and procedures for
ensuring access and appropriate use of trained interpreters and material translation services for all
limited and/or no English proficient beneficiaries, including, but not limited to, assessing the cultural
and linguistic needs of the beneficiaries, training of staff on the policies and procedures, and
monitoring its language assistance program. CONTRACTOR’s policies and procedures shall ensure
compliance of any subcontracted providers with these requirements.
C.CONTRACTOR shall notify its beneficiaries that oral interpretation is available for
any language and written translation is available in prevalent languages and that auxiliary aids and
services are available upon request, at no cost and in a timely manner for limited and/or no English
proficient beneficiaries and/or beneficiaries with disabilities. CONTRACTOR shall avoid relying on an
adult or minor child accompanying the beneficiary to interpret or facilitate communication; however, if
the beneficiary refuses language assistance services, the CONTRACTOR must document the offer,
refusal and justification in the beneficiary’s file.
D.CONTRACTOR shall ensure that employees, agents, subcontractors, and/or
partners who interpret or translate for a beneficiary or who directly communicate with a beneficiary in a
language other than English: (1) have demonstrated proficiency in the beneficiary’s language; (2) can
effectively communicate any specialized terms and concepts specific to CONTRACTOR’s services;
and (3) adheres to generally accepted interpreter ethic principles.
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E.CONTRACTOR’s accreditation under Joint Commission will address all fifteen
(15)National Standards for Culturally and Linguistically Appropriate Services (CLAS), as published by
the Office of Minority Health.
F.As requested by COUNTY, CONTRACTOR shall report on the completion of
cultural competency trainings as governed by the Joint Commission and California Department of
Managed Health Care.
19.NON-ASSIGNMENT
Neither party shall assign, transfer or subcontract this Agreement nor their rights or
duties under this Agreement without the prior written consent of the other party, except as provided
under Section 2, DELEGATION OF CONTRACTOR’S DUTIES: WHEN PERMITTED, of this
Agreement.
20.HOLD-HARMLESS
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
defend the COUNTY, its officers, agents and employees from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
COUNTY in connection with the performance, or failure to perform, by CONTRACTOR, its officers,
agents or employees under this Agreement, and from any and all costs and expenses, including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to any
person, firm or corporation who may be injured or damaged by the performance, or failure to perform,
of CONTRACTOR, its officers, agents or employees under this Agreement. The party requesting
indemnification must provide prompt notification of the claim to the indemnifying party. In addition,
CONTRACTOR agrees to indemnify COUNTY for Federal, State of California and/or local audit
exceptions resulting from noncompliance herein on the part of CONTRACTOR.
21.INSURANCE
Without limiting the COUNTY's right to obtain indemnification from CONTRACTOR or any
third parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect, the following
insurance policies or a program of self-insurance, including but not limited to, an insurance pooling
arrangement or Joint Powers Agreement (JPA) throughout the term of the Agreement:
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A.Commercial General Liability
Commercial General Liability Insurance with limits of not less than Two Million
Dollars ($2,000,000.00) per occurrence and an annual aggregate of Four Million Dollars ($4,000,000.00).
This policy shall be issued on a per occurrence basis. COUNTY may require specific coverages
including completed operations, products liability, contractual liability, Explosion-Collapse-Underground,
fire legal liability or any other liability insurance deemed necessary because of the nature of this contract.
B.Automobile Liability
Comprehensive Automobile Liability Insurance with limits of not less than One
Million Dollars ($1,000,000.00) per accident for bodily injury and for property damages. Coverage should
include any auto used in connection with this Agreement.
C.Professional Liability
CONTRACTOR agrees that it shall maintain, at its sole expense, in full force and
effect for a period of five (5) years following the termination of this Agreement, one or more policies of
professional liability insurance with limits of coverage as specified herein.
If CONTRACTOR employs licensed professional staff, (e.g., Ph.D., R.N.,
L.C.S.W., M.F.C.C.) in providing services, Professional Liability Insurance with limits of not less than
One Million Dollars ($1,000,000.00) per occurrence, Three Million Dollars ($3,000,000.00) annual
aggregate.
D.Worker's Compensation
A policy of Worker's Compensation insurance as may be required by the
California Labor Code.
E.Sexual Abuse/Molestation Liability
CONTRACTOR serving vulnerable classes of persons (e.g., children, elderly)
shall maintain Sexual Abuse / Molestation Liability Insurance with limits of not less than One Million
Dollars ($1,000,000.00) per occurrence, Two Million Dollars ($2,000,000.00) annual aggregate. This
policy shall be issued on a per occurrence basis.
F.Cyber Liability
Cyber Liability Insurance, with limits not less than Two Million Dollars
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($2,000,000.00) per occurrence or claim, Two Million Dollars ($2,000,000.00) aggregate. Coverage
shall be sufficiently broad to respond to the duties and obligations as is undertaken by CONTRACTOR
in this agreement and shall include, but not be limited to, claims involving infringement of intellectual
property, including but not limited to infringement of copyright, trademark, trade dress, invasion of
privacy violations, information theft, damage to or destruction of electronic information, release of
private information, alteration of electronic information, extortion and network security. The policy shall
provide coverage for breach response costs as well as regulatory fines and penalties as well as credit
monitoring expenses with limits sufficient to respond to these obligations.
Additional Insurance Obligations
CONTRACTOR hereby waives its right to recover from COUNTY, its officers, agents, and
employees any amounts paid by the policy of worker’s compensation insurance required by this
Agreement. CONTRACTOR is solely responsible to obtain any endorsement to such policy that may be
necessary to accomplish such waiver of subrogation, but CONTRACTOR’s waiver of subrogation under
this paragraph is effective whether or not CONTRACTOR obtains such an endorsement.
In the event CONTRACTOR fails to keep in effect at all times insurance coverage as
herein provided, the COUNTY may, in addition to other remedies it may have, suspend or terminate this
Agreement upon the occurrence of such event. All policies shall be issued by admitted insurers
licensed to do business in the State of California, and such insurance shall be purchased from
companies possessing a current A.M. Best, Inc. rating of A FSC VII or better, or through a program of
self-insurance that is acceptable to the COUNTY’s Risk Management Division. Within thirty (30) days
from the date CONTRACTOR signs and executes this Agreement, CONTRACTOR shall provide a
certificate of insurance or other documentation identifying the types and level of coverage to the County
of Fresno, 1925 E. Dakota Ave, Fresno, CA 93726, Attention: Mental Health Plan, stating that such
insurance coverage have been obtained and are in full force; that the County of Fresno, it’s officers,
agents and employees will not be responsible for any premiums on the policies; and that for such
worker’s compensation insurance the CONTRACTOR has waived its right to recover from the
COUNTY, its officers, agents, and employees any amounts paid under the insurance policy.
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22.REFERENCES TO LAWS AND RULES
In the event any law, regulation, or policy referred to in this Agreement is amended
during the term thereof, the parties hereto agree to comply with the amended provision as of the
effective date of such amendment. The parties agree to negotiate in good faith regarding an
amendment to the contract if any such statute changes substantially alters the terms of the existing
agreement.
23.CONFIDENTIALITY OF INFORMATION
Notwithstanding any other provision of this Agreement, names of persons receiving
public social services are confidential and are to be protected from unauthorized disclosure in
accordance with Title 45, Code of Federal Regulations Section 205.50; Sections 5328, 10850 and
14100.2 of the California Welfare and Institutions Code; and, regulations adopted pursuant thereto.
For the purpose of this Agreement, all information, records, and data elements pertaining to
Beneficiaries shall be protected by CONTRACTOR from unauthorized disclosure.
All services performed by CONTRACTOR under this Agreement shall be in strict
conformance with all applicable Federal, State of California and/or local laws and regulations relating to
confidentiality.
24.HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and CONTRACTOR each consider and represent themselves as covered
entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law
104-191(HIPAA) and agree to use and disclose Protected Health Information (PHI) as required by law.
COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is
only for treatment, payment, and health care operations.
COUNTY and CONTRACTOR intend to protect the privacy and provide for the security
of PHI pursuant to the Agreement in compliance with HIPAA, the Health Information Technology for
Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations promulgated
thereunder by the U.S. Department of Health and Human Services (HIPAA Regulations) and other
applicable laws.
As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
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CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of PHI,
as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e) of the Code
of Federal Regulations (CFR).
25.ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that it or any of its officers are
not currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal
Health Care Programs: that it or any of its officers have not been convicted of a criminal offense
related to the provision of health care items or services; nor has it, or any of its officers, been
reinstated to participate in the Federal Health Care Programs after a period of exclusion, suspension,
debarment, or ineligibility. If COUNTY learns, subsequent to entering into this Agreement, that
CONTRACTOR is ineligible on these grounds, COUNTY will remove CONTRACTOR from
responsibility for, or involvement with, COUNTY’s business operations related to the Federal Health
Care Programs and shall remove such CONTRACTOR from any position in which CONTRACTOR’s
compensation, or the items or services rendered, ordered or prescribed by CONTRACTOR may be
paid in whole or part, directly or indirectly, by Federal Health Care Programs or otherwise with Federal
Funds at least until such time as CONTRACTOR is reinstated into participation in the Federal Health
Care Programs.
A.If COUNTY has notice that CONTRACTOR has been charged with a criminal
offense related to any Federal Health Care Program, or is proposed for exclusion during the term on
any contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the accuracy
of any claims submitted to any Federal Health Care Program. At its discretion given such
circumstances, COUNTY may request that CONTRACTOR cease providing services until resolution of
the charges or the proposed exclusion.
B.CONTRACTOR agrees that all potential new employees of CONTRACTOR or
subcontractors of CONTRACTOR who, in each case, are expected to perform professional services
under this Agreement, will be queried as to whether (1) they are now or ever have been excluded,
suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2)
they have been convicted of a criminal offense related to the provision of health care items or services;
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and or (3) they have been reinstated to participate in the Federal Health Care Programs after a period
of exclusion, suspension, debarment, or ineligibility.
1) In the event the potential employee or subcontractor informs
CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible, or has been
convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR
hires or engages such potential employee or subcontractor, the CONTRACTOR will ensure that said
employee or subcontractor does no work, either directly or indirectly relating to services provided to
COUNTY.
2) Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section 9, TERMINATION, of this Agreement, or require adequate
assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or
subcontractor of CONTRACTOR will perform work, either directly or indirectly, relating to services
provided to COUNTY. Such demand for adequate assurance shall be effective upon a time frame to
be determined by COUNTY to protect the interests of COUNTY clients.
C. CONTRACTOR shall verify (by asking the applicable employees and
subcontractors) that all current employees and existing subcontractors who, in each case, are
expected to perform professional services under this Agreement: (1) are not currently excluded,
suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2)
have not been convicted of a criminal offense related to the provision of health care items or services;
and (3) have not been reinstated to participate in the Federal Health Care Programs after a period of
exclusion, suspension, debarment, or ineligibility. In the event any existing employee or subcontractor
informs a CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible to
participate in the Federal Health Care Programs, or has been convicted of a criminal offense relating
to the provision of heath care services, CONTRACTOR will ensure that said employee or
subcontractor does no work, either direct or indirect, relating to services provided to COUNTY.
1) CONTRACTOR agrees to notify COUNTY immediately during the term of
this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each
case, is providing professional services under Section 1, SCOPE OF WORK, of this Agreement is
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excluded, suspended, debarred or otherwise ineligible to participate in the Federal Health Care
Programs, or is convicted of a criminal offense relating to the provision of health care services.
2)Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section 9 of this Agreement, or require adequate assurance (as
defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor
of CONTRACTOR will perform work, either directly or indirectly, relating to services provided to
COUNTY. Such demand for adequate assurance shall be effective upon a time frame to be
determined by COUNTY to protect the interests of COUNTY clients.
D.CONTRACTOR agrees to cooperate fully with any reasonable requests for
information from COUNTY which may be necessary to complete any internal or external audits relating
to CONTRACTOR’s compliance with the provisions of this section.
26.NON-DISCRIMINATION
During the performance of this Agreement, CONTRACTOR(S) and its subcontractors
shall not deny the contract’s benefits to any person on the basis of race, religious creed, color, national
origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital
status, sex, gender, gender identity, gender expression, age, sexual orientation, or military and
veteran status, nor shall they discriminate unlawfully against any employee or applicant for
employment because of race, religious creed, color, national origin, ancestry, physical disability,
mental disability, medical condition, genetic information, marital status, sex, gender, gender identity,
gender expression, age, sexual orientation, or military and veteran status. CONTRACTOR shall
insure that the evaluation and treatment of employees and applicants for employment are free of such
discrimination. CONTRACTOR and subcontractors shall comply with the provisions of the Fair
Employment and Housing Act (Gov. Code §12900 et seq.), the regulations promulgated thereunder
(Cal. Code Regs., tit. 2, §11000 et seq.), the provisions of Article 9.5, Chapter 1, Part 1, Division 3,
Title 2 of the Government Code (Gov. Code §§11135-11139), and the regulations or standards
adopted by the awarding state agency to implement such article. Contractor shall permit access by
representatives of the Department of Fair Employment and Housing and the awarding state agency
upon reasonable notice at any time during the normal business hours, but in no case less than 24
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hours’ notice, to such of its books, records, accounts, and all other sources of information and its
facilities as said Department or Agency shall require to ascertain compliance with this clause.
CONTRACTOR and its subcontractors shall give written notice of their obligations under this clause to
labor organizations with which they have a collective bargaining or other agreement. (See Cal. Code
Regs., tit. 2, §11105.) CONTRACTOR shall include the Non-Discrimination and compliance provisions
of this clause in all subcontracts to perform work under the Agreement.
27. GOVERNING AUTHORITIES
A. This Agreement shall be governed and constructed in accordance with:
1) Part 2.5, Division 5 of the California Welfare and Institutions Code and
regulations adopted pursuant thereto and all other applicable State of California laws and regulations
according to their content on the effective date stipulated in Section 8, TERM, of this Agreement;
2) Titles 42 and 45 of the Code of Federal Regulations and all other
applicable Federal laws and regulations according to their content on and after the Agreement’s;
effective date stipulated in Section 8, except those provisions or applications of those provisions
waived by the Secretary of the Department of Health and Human Services; and
3) The laws of the State of California.
B. Any provision of this Agreement in conflict with the laws and regulations
stipulated in SCOPE OF WORK Section 1(A) and/or this Section 28(A) is hereby amended to conform
to any restrictions, limitations, or enactments of all legislative bodies which affect the provisions, term,
or funding of this Agreement. Such amendment of the Agreement shall be effective on the effective
date of the statute or regulation necessitating it, and shall be binding on the parties even though such
amendment may not have been reduced to writing and formally agreed upon and executed by the
parties as provided in Section 14, INDEPENDENT CONTRACTOR, of this Agreement.
28. CONFORMANCE WITH FEDERAL REGULATIONS AND STATE STATUTES
A. CONTRACTOR stipulates that this Agreement, in part, implements Title XIX of
the Federal Social Security Act (42 U.S.C. §§1396 et seq.) and, accordingly, covenants that it will
conform to such requirements and regulations as the United States Department of Health and Human
Services may issue from time to time, pursuant to Title XIX of the Federal Social Security Act, except
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for those provisions waived by the Secretary of the United States Department of Health and Human
Services.
B.CONTRACTOR shall comply with the provisions of Title 42,CFR, Section
438.610 and Executive Orders 12549 and 12689, "Debarment and Suspension," which excludes
parties listed on the General Services Administration's list of parties excluded from federal
procurement or non-procurement programs from having a relationship with the Contractor.
C. CONTRACTOR shall not employ or contract with provider or other individuals
and entities excluded from participation in Federal health care programs under either Section 1128 or
1128A of the Social Security Act. Federal financial participation is not available for amounts expended
for providers excluded by Medicare, Medicaid, or the State Children's Insurance Program, except for
emergency services.
29.CONFLICT OF INTEREST
A.This Agreement shall be terminated immediately if COUNTY determines that a
COUNTY or State of California employee responsible for development, negotiation, contract
management or supervision of this Agreement has a financial interest in the Agreement as that term is
defined in Section 87013 of the California Government Code and the regulations adopted pursuant
thereto.
B.No officer, agent, or employee of COUNTY who exercises any function or
responsibility for planning and carrying out the services provided under this Agreement shall have any
direct or indirect personal financial interest in this Agreement.
C.In addition, no employee of COUNTY shall be employed by CONTRACTOR to
fulfill any contractual obligations with COUNTY. CONTRACTOR shall also comply with all Federal,
State of California, and local conflict of interest laws, statutes, and regulations, which shall be
applicable to all parties and beneficiaries under this Agreement and any officer, agent, or employee of
COUNTY.
30.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if CONTRACTOR is operating as a corporation (a for-
profit or non-profit corporation) or if during the term of this Agreement, CONTRACTOR changes its
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status to operate as a corporation.
Members of CONTRACTOR’s Board of Directors shall disclose any self-dealing
transactions that they are a party to while CONTRACTOR is providing goods or performing services
under this Agreement. A self-dealing transaction shall mean a transaction to which CONTRACTOR is
a party and in which one or more of its directors has a material financial interest. Members of the
Board of Directors shall disclose any self-dealing transactions that they are a party to by completing
and signing a Self-Dealing Transaction Disclosure Form (Exhibit D), attached hereto and incorporated
herein by reference, and submitting it to the COUNTY prior to commencing with the self-dealing
transaction or immediately thereafter.
31. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or
managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101 455.104,
and 455.106(a)(1),(2). In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and
455.106(a)(1),(2), the following information must be disclosed by CONTRACTOR by completing
Exhibit E, “Disclosure of Ownership and Control Interest Statement”, attached hereto and by this
reference incorporated herein. CONTRACTOR shall submit this form to the Department of Behavioral
Health within thirty (30) days of the effective date of this Agreement. Additionally, CONTRACTOR
shall report any changes to this information within thirty-five (35) days of occurrence by completing
Exhibit E. Submissions shall be scanned pdf copies and are to be sent via email to
dbhcontractedservicesdivision@fresnocountyca.gov, Attention: Contracts Administration.
32. DISCLOSURE OF CRIMINAL HISTORY & CIVIL ACTIONS
CONTRACTOR is required to disclose if any of the following conditions apply to them,
their owners, officers, corporate managers or partners (hereinafter collectively referred to as
“CONTRACTOR”):
A. Within the three-year period preceding the Agreement award, CONTRACTOR
has been convicted of, or had a civil judgment tendered against it for:
1) Fraud or criminal offense in connection with obtaining, attempting to
obtain, or performing a public (federal, state, or local) transaction or contract under a public
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transaction;
2)Violation of a federal or state antitrust statute;
3)Embezzlement, theft, forgery, bribery, falsification, or destruction of
records; or
4)False statements or receipt of stolen property.
B.Within a three-year period preceding their Agreement award, CONTRACTOR
has had a public transaction (federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate CONTRACTOR from
further business consideration. The information will be considered as part of the determination of
whether to continue and/or renew the Contract and any additional information or explanation that a
CONTRACTOR elects to submit with the disclosed information will be considered. If it is later
determined that the CONTRACTOR failed to disclose required information, any contract awarded to
such CONTRACTOR may be immediately voided and terminated for material failure to comply with the
terms and conditions of the award.
CONTRACTOR may sign a “Certification Regarding Debarment, Suspension, and Other
Responsible Matters – Primary Covered Transactions” in the form set forth in Exhibit F attached
hereto and by this reference incorporated herein, or complete Exhibit E every twelve-month period in
response to COUNTY’s request for documentation. Additionally CONTRACTOR must immediately
advise the COUNTY in writing if, during the term of the Agreement: (1) CONTRACTOR becomes
suspended, debarred, excluded or ineligible for participation in federal or state funded programs or
from receiving federal funds as listed in the excluded parties list system (http://www.sam.gov); or (2)
any of the above listed conditions become applicable to CONTRACTOR. CONTRACTOR shall
indemnify, defend and hold the COUNTY harmless for any loss or damage resulting from a conviction,
debarment, exclusion, ineligibility or other matter listed in the signed “Certification Regarding
Debarment, Suspension, and Other Responsible Matters”.
33.WAIVER
Notwithstanding any provision herein to the contrary, any delay or failure to require
performance, or failure to insist upon strict compliance with any of the terms, covenants, conditions or
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provisions of this Agreement shall not constitute or be deemed a waiver of such term, covenant,
condition or provision, nor shall any waiver or relinquishment of any right or power hereunder at any
one time or more times be deemed a waiver or relinquishment of such right or power at any other time
or times. Any waiver granted by a party must be in writing to be effective and shall apply solely to the
specific instance expressly stated.
34. FORCE MAJEURE
Neither party shall be liable or deemed to be in default for any delay or failure in
performance under this Agreement or other interruption of service deemed to result, directly or
indirectly, from acts of God, civil or military authority, acts of public enemy, war, accidents, fires,
explosions, earthquakes, floods, failure of transportation, strikes or other work interruptions by either
party’s employees, or any other similar cause beyond the reasonable control of either party unless
such delay or failure in performance is expressly addressed elsewhere in this Agreement.
35. UTILIZATION CONTROLS
As express conditions precedent to any authorization by COUNTY for payment
obligations under the terms of this Agreement: (1) CONTRACTOR shall adhere to all utilizations
controls and obtain authorization for services in accordance with Sections 5777 and 5778 of the
California Welfare and Institutions Code and regulations adopted pursuant thereto; and (2)
CONTRACTOR shall notify COUNTY within ten (10) calendar days of the emergency admission of a
Beneficiary or Recipient.
36. AGREEMENT ADMINISTRATOR-DELEGATION OF AUTHORITY
COUNTY will administer this Agreement through a single administrator, the Director or
designee, Fresno County Department of Behavioral Health. Until such time as COUNTY gives
CONTRACTOR written notice of a successor appointment, the person designated above shall make
all determinations and take all actions necessary to administer this Agreement, subject to the
limitations of California laws and California State administrative regulations. No person other than the
Director or designee shall be considered to have the delegated authority of, or to be acting on
behalf of, the Director or designee unless the Director or designee has expressly stated in writing that
the person is acting as his/her authorized agent.
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37.NOTIFICATION OF ADMISSION
CONTRACTOR shall notify COUNTY within 24 hours, or next business day, of all
Beneficiaries and or Recipients admitted for services, if those admitted are not direct referrals of
COUNTY.
38.MENTAL HEALTH CERTIFICATION REVIEW HEARINGS
COUNTY will be responsible to provide for and compensate the Mental Health
Certification Review Hearing Officer for all hearings performed at CONTRACTOR’s facility in
accordance with Welfare and Institutions Code Sections 5250 through 5270.35. CONTRACTOR will
provide a location that allows for confidentiality and is compatible with and is least disruptive to the
treatment being provided to the Beneficiary or Recipient.
39.DISCHARGE PLANNING AND CARE COORDINATION
All parties, pursuant to the Mental Health Plan, shall participate as needed in discharge
planning and care coordination to ensure that each person hospitalized is supported through the
transition process with necessary outpatient mental health and other necessary services once the
client is discharged. COUNTY staff will not be responsible for the outcome of the discharge planning
or the bed utilization of the clients.
40.HEADINGS
The headings contained in this Agreement are for reference purposes only and shall not
affect in any way its meaning or interpretation.
41.PATIENTS RIGHTS
CONTRACTOR, or any Delegate performing the covenants of CONTRACTOR pursuant
to the terms of this Agreement, shall adopt and post in a conspicuous place a written policy on patient
rights in accordance with Section 70707 of Title 22 of the California Code of Regulations and Section
5325.1 of the California Welfare and Institutions Code and Title 42 Code of Federal Regulations
Section 438.100. Complaints by Beneficiaries or Recipients with regard to substandard conditions
may be investigated by COUNTY’s Patient’s Rights Advocate, COUNTY, the State Department of
Health Care Services, the JCAHO, or such other agency, as required by law or regulation.
42.REPORTING
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CONTRACTOR, or any Delegate performing the covenants of CONTRACTOR pursuant
to the terms of this Agreement, shall provide at COUNTY’s request, any required reports to COUNTY
which may include performance outcome reports.
43. IMPLEMENTATION PLAN
CONTRACTOR’s services and processes for implementation as identified in this
Agreement, shall incorporate COUNTY’s “Implementation Plan for Psychiatric Inpatient Hospital
Services Consolidation” incorporated herein by reference. COUNTY promptly shall furnish a copy of
such plan to CONTRACTOR upon request. Upon the giving of thirty (30) days advance written notice
to CONTRACTOR, any and all changes to such plan shall be incorporated herein and become part of
this Agreement.
44. RECORDS AND AUDIT PROVISIONS
A. On-Site Reviews:
1) Agents of COUNTY and the California State Department of Health Care
Services shall conduct audits or reviews, including on-site audits or reviews, of performance under this
Agreement. These audits or reviews may evaluate the following:
a) Level and quality of care and the necessity and appropriateness of
the services provided;
b) Internal procedures for assuring efficiency, economy and quality of
care;
c) Compliance with COUNTY Client Grievance Procedures;
d) Monitoring of Beneficiary complaints; and
e) Financial records for fiscal audits when determined necessary to
protect public funds.
2) CONTRACTOR shall make adequate office space available for the review
team or auditors to meet and confer. Such space must be capable of being locked and secured to
protect the work of the review team or auditors during the period of their investigation.
3) On-site reviews and audits shall occur during normal working hours with
at least a seventy-two (72) hour notice, except that unannounced on-site reviews and requests for
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information may be made in those exceptional situations where arrangement of an appointment
beforehand is clearly not possible or clearly inappropriate to the nature of the intended visit.
B.Records to be Kept, Audit or Review, Availability, Period of Retention:
CONTRACTOR covenants that the following shall occur:
1)It shall maintain books, records, documents and other evidence,
accounting procedures and practices sufficient to properly reflect all direct and indirect costs of
whatever nature claimed to have incurred in the performance of this Agreement.
2)The above information shall be maintained in accordance with Medicare
principles of reimbursement and generally accepted accounting principles and shall be consistent with
the requirement of the California Office of Statewide Health Planning and Development.
3)It shall also maintain medical records required by Sections 70747 - 70751
of Title 22 of the California Code of Regulations, and other records related to a Beneficiary’s or
Recipient's eligibility for services, the service rendered, the Beneficiary to whom the service was
rendered, the date of the service, the medical necessity of the service and the quality of the care
provided. Records shall be maintained in accordance with Section 51476 of Title 22 of the California
Code of Regulations.
4)The facility or office, or such part thereof as may be engaged in the
performance of this Agreement, and the information specified in this section of this Agreement shall be
subject at all reasonable times to inspection, audits and reproduction by any duly authorized agents of
COUNTY, California State Department of Health Care Services, the Federal Department of Health and
Human Services and Comptroller General of the United States.
5)It shall preserve and make available its records relating to payments
made under this Agreement for a period of six (6) years from the close of CONTRACTOR’s fiscal year,
or for such longer period as may be required by Subsections (a) and (b) herein below.
a)If this Agreement is terminated, the records relating to the work
terminated shall be preserved and made available for a period of six (6) years from the date of the last
payment made under the Agreement.
b)If any litigation, claim, negotiation, audit or other action involving
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the records has been started before the expiration of the six (6) year period, the related records shall
be retained until completion and resolution of all issues arising there from or until the end of the six (6)
year period, whichever is later.
45. AUDITS AND INSPECTIONS
CONTRACTOR shall at any time during business hours, once every twelve-month
period, and with at least a seventy-two (72) hour notice,make available to COUNTY for examination all
of its records and data with respect to the matters covered by this Agreement. CONTRACTOR shall,
upon request by COUNTY, permit COUNTY to audit and inspect all such records and data necessary
to ensure CONTRACTOR’s compliance with the terms of this Agreement.
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
CONTRACTOR shall be subject to the examination and audit of the State Auditor General for a period
of three (3) years after final payment under contract (California Government Code Section 8546.7).
46. NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR
Director, Fresno County Kaweah Delta Health Care District
Department of Behavioral Health d.b.a Kaweah Delta Mental Health Hospital
1925 E. Dakota Ave Attention: COO
Fresno, CA 93726 400 W. Mineral King Avenue
Visalia, CA 93291
Any and all notices between COUNTY and CONTRACTOR provided for or permitted
under this Agreement or by law shall be in writing and shall be deemed duly served when personally
delivered to one of the parties, or in lieu of such personal service, when delivered by certified United
States Mail, postage prepaid, address to such party.
47. GOVERNING LAW
The parties agree, that for the purposes of venue, performance under this Agreement is
to be in Fresno County, California. The rights and obligations of the parties and all interpretation and
performance of this Agreement shall be governed in all respects by the laws of the State of California.
48. ENTIRE AGREEMENT
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This Agreement constitutes the entire agreement between the CONTRACTOR and
COUNTY with respect to the subject matter hereof and supersedes all previous agreement
negotiations, proposals, commitments, writings, advertisements, publications, and understandings of
any nature whatsoever unless expressly included in this Agreement.
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1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and
2 year first hereinabove written.
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CONTRACTOR
Title {Chairma of Board, or President,
~GEO) ,• A ~ ,=~
(Authorized Signature) -
~ttlJwlo Tu.r;;,,:c
Print Name
Title ~LY.War Corporation, or Chief
Financial Officer/Treasurer, or any
Assistant Secretary or Treasurer
21 Mailing Address :
400 W . Mineral King Avenue
22 Visalia , CA 93291
Phone No .: (559) 624-3723
23 Contact: Administrator, Kaweah Delta
Mental Health Hospital
COUNTY OF FRESNO
Nathan Magsig , Chairman of the Board of
Supervisors of the County of Fresno
ATTEST:
Bernice E. Seidel
Clerk of the Board of Supervisors
County of Fresno, State of California
By: £\ostk:\ ~shOf
Deputy
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FOR FRESNO COUNTY ACCOUNTING USE ONLY :
Fund/Subclass : 0001/10000
Organization: 56302666 ($2 ,250 ,000 per 12-month per iod ; $11 ,250,000 contract maximum)
AccounUProgram : 7295/0
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Exhibit A
0348adbh
DEFINITIONS
1.Administrative Day: “Administrative Day” means those days authorized by COUNTY in
an acute inpatient facility when, due to lack of an available nursing facility, the
Beneficiary’s or Recipient’s stay at an acute inpatient facility must be continued beyond
the Beneficiary’s or Recipient’s need for acute care.
2.Beneficiary: “Beneficiary” means an adult person certified as eligible for services under
the Medi-Cal program according to section 41001, Title 22, California Code of
Regulations who is a Fresno County Beneficiary and is designated by “County Code 10”.
3.Delegate: “Delegate” means any natural or corporate person to whom PROVIDER
transfers, pursuant to the terms of this Agreement, the primary responsibility to perform
any covenant assumed by PROVIDER in this Agreement.
4.Department: “Department” means the California State Department of Health Care
Services.
5.Fiscal Intermediary: “Fiscal Intermediary” means the entity which has contracted with the
Department of Health Care Services to perform services for the Medi-Cal program
pursuant to section 14104.3 of the Welfare and Institutions Code.
6.Recipients: “Recipients” refers to all adult persons, including without limitation low
income, uninsured and under-insured persons, who qualify for mandated health services
under the Uniform Method for Determining Ability to Pay (UMDAP) under sections 5709
and 5710 of the California Welfare and Institutions Code as determined by COUNTY.
7.Psychiatric Inpatient Hospital Services: “Psychiatric Inpatient Hospital Services” means
services, to include but not limited to, facilities, professional, allied and supportive medical
and paramedical personnel as provided either in an acute care hospital or a free-standing
psychiatric hospital to Beneficiaries and Recipients referred by COUNTY, for the care and
treatment of an acute episode of mental illness.
8.Medically Necessary Services: as defined by California Code of Regulations, Title 9,
Chapter 11, Section 1820.205 identified in Exhibit B which is attached hereto and
incorporated herein.
9.Physician and Transportation Services: “Physician Services” are those services provided
by a physician(s) during an acute inpatient stay. “Transportation Services” means those
services provided for transport to or from an acute inpatient facility or to or from an
appropriate facility.
10.Physician Services: “Physician Services” means those services provided by a
physician(s) or Psychologist(s) during an acute inpatient stay.
11.May: “May” is used to indicate a permissive or discretionary term or function.
12.Shall: “Shall” is used to indicate a mandatory term of function when used in a covenant
of either COUNTY or PROVIDER.
13.Or: “Or” is not exclusive
14.Will: “Will” is used to indicate a mandatory term or function when used in a covenant or
either COUNTY or PROVIDER.
15.Day of Discharge: “Day of Discharge” means the day from 12:00 midnight to 11:59 P.M.
where the Beneficiary or Recipient is discharged from PROVIDER’s facility.
16.Includes and Including: “Includes” and “Including” are not limiting (e.g., “including” means
“including without limitation”).
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
1
rev 01-02-2018
DBH VISION:
Health and well-being for our community.
DBH MISSION:
The Department of Behavioral Health is dedicated to supporting the wellness of individuals,
families and communities in Fresno County who are affected by, or are at risk of, mental illness
and/or substance use disorders through cultivation of strengths toward promoting recovery in
the least restrictive environment.
DBH GOALS:
Quadruple Aim
Deliver quality care
Maximize resources while focusing on efficiency
Provide an excellent care experience
Promote workforce well-being
GUIDING PRINCIPLES OF CARE DELIVERY:
The DBH 11 principles of care delivery define and guide a system that strives for excellence in the
provision of behavioral health services where the values of wellness, resiliency, and recovery are
central to the development of programs, services, and workforce. The principles provide the
clinical framework that influences decision-making on all aspects of care delivery including
program design and implementation, service delivery, training of the workforce, allocation of
resources, and measurement of outcomes.
1.Principle One - Timely Access & Integrated Services
o Individuals and families are connected with services in a manner that is streamlined,
effective, and seamless
o Collaborative care coordination occurs across agencies, plans for care are integrated,
and whole person care considers all life domains such as health, education,
employment, housing, and spirituality
o Barriers to access and treatment are identified and addressed
o Excellent customer service ensures individuals and families are transitioned from one
point of care to another without disruption of care
Exhibit B
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
2
rev 01-02-2018
2.Principle Two - Strengths-based
o Positive change occurs within the context of genuine trusting relationships
o Individuals, families, and communities are resourceful and resilient in the way they
solve problems
o Hope and optimism is created through identification of, and focus on, the unique
abilities of individuals and families
3.Principle Three - Person-driven and Family-driven
o Self-determination and self-direction are the foundations for recovery
o Individuals and families optimize their autonomy and independence by leading the
process, including the identification of strengths, needs, and preferences
o Providers contribute clinical expertise, provide options, and support individuals and
families in informed decision making, developing goals and objectives, and identifying
pathways to recovery
o Individuals and families partner with their provider in determining the services and
supports that would be most effective and helpful and they exercise choice in the
services and supports they receive
4.Principle Four - Inclusive of Natural Supports
o The person served identifies and defines family and other natural supports to be
included in care
o Individuals and families speak for themselves
o Natural support systems are vital to successful recovery and the maintaining of
ongoing wellness; these supports include personal associations and relationships
typically developed in the community that enhance a person’s quality of life
o Providers assist individuals and families in developing and utilizing natural supports.
5.Principle Five - Clinical Significance and Evidence Based Practices (EBP)
o Services are effective, resulting in a noticeable change in daily life that is measurable.
o Clinical practice is informed by best available research evidence, best clinical
expertise, and client values and preferences
o Other clinically significant interventions such as innovative, promising, and emerging
practices are embraced
Exhibit B
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
3
rev 01-02-2018
6.Principle Six - Culturally Responsive
o Values, traditions, and beliefs specific to an individual’s or family’s culture(s) are
valued and referenced in the path of wellness, resilience, and recovery
o Services are culturally grounded, congruent, and personalized to reflect the unique
cultural experience of each individual and family
o Providers exhibit the highest level of cultural humility and sensitivity to the self-
identified culture(s) of the person or family served in striving to achieve the greatest
competency in care delivery
7.Principle Seven - Trauma-informed and Trauma-responsive
o The widespread impacts of all types of trauma are recognized and the various
potential paths for recovery from trauma are understood
o Signs and symptoms of trauma in individuals, families, staff, and others are recognized
and persons receive trauma-informed responses
o Physical, psychological and emotional safety for individuals, families, and providers is
emphasized
8.Principle Eight - Co-occurring Capable
o Services are reflective of whole-person care; providers understand the influence of
bio-psycho-social factors and the interactions between physical health, mental health,
and substance use disorders
o Treatment of substance use disorders and mental health disorders are integrated; a
provider or team may deliver treatment for mental health and substance use
disorders at the same time
9.Principle Nine - Stages of Change, Motivation, and Harm Reduction
o Interventions are motivation-based and adapted to the client’s stage of change
o Progression though stages of change are supported through positive working
relationships and alliances that are motivating
o Providers support individuals and families to develop strategies aimed at reducing
negative outcomes of substance misuse though a harm reduction approach
o Each individual defines their own recovery and recovers at their own pace when
provided with sufficient time and support
Exhibit B
Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
4
rev 01-02-2018
10.Principle Ten - Continuous Quality Improvement and Outcomes-Driven
o Individual and program outcomes are collected and evaluated for quality and efficacy
o Strategies are implemented to achieve a system of continuous quality improvement
and improved performance outcomes
o Providers participate in ongoing professional development activities needed for
proficiency in practice and implementation of treatment models
11.Principle Eleven - Health and Wellness Promotion, Illness and Harm Prevention, and Stigma
Reduction
o The rights of all people are respected
o Behavioral health is recognized as integral to individual and community well-being
o Promotion of health and wellness is interwoven throughout all aspects of DBH
services
o Specific strategies to prevent illness and harm are implemented at the individual,
family, program, and community levels
o Stigma is actively reduced by promoting awareness, accountability, and positive
change in attitudes, beliefs, practices, and policies within all systems
o The vision of health and well-being for our community is continually addressed
through collaborations between providers, individuals, families, and community
members
Exhibit B
Exhibit C
Page 1 of 2
UMDAP Application
0017aamhd
CLIENT INFORMATION
1. Name
Date of Birth
File Number
RESPONSIBLE PARTY INFORMATION
2. Name
Relationship to Client
Date of Birth
Marital Status
3. Address
Telephone Number
4. Veteran
Social Security Number
5. Employer
Position
If not employed, date last
worked
6. Employer’s Address
Telephone Number
7. Spouse
Address
8. Spouse’s Employer
Position
If not employed, date last worked
9. Spouse’s Employer’s Address
Telephone Number
10. Nearest Relative
Telephone/Address
THIRD PARTY INFORMATION
11. Insurance Company
Address
12. Policy/Group/ID Number
Assignment/Release of Information obtained
13. V.A. Claim Number
Medicare Claim Number
14. Medi-Cal Claim Number
Date referred for Eligibility Determination
FINANCIAL LIABILITY Schedule of Asset Allowances Persons
15. Gross monthly family income:
Responsible person 1 $1500 6 $2600
Spouse 2 $2250 7 $2700
Other 3 $2300 8 $2800
16. TOTAL 4 $2400 9 $2900
17. Number of dependent on income 5 $2500 10 or more $3000
ASSET DETERMINATION
18. List all liquid assets (savings, bank balances, market value of stocks, bonds and
Mutual savings):
Source Amount $
$
$
19. Total of liquid assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
20. Insert amount from schedule of Asset Allowances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $
21. Total net liquid assets (Deduct line 20 from line 19) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
22. Divide line 21 by 12 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
23. Add lines 16 and 22 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Exhibit C
Page 2 of 2
UMDAP Application
0017aamhd
ALLOWABLE EXPENSES
24. Court ordered obligations paid monthly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
25. Monthly child care (necessary for employment) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
26. Monthly dependent support payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
27. Monthly medical expense payments in excess of 3% of gross income . . . . . . . . . . . . . . . . . . . . . . . . $
28. Monthly mandated deductions from gross income for retirement plans (not Social
Security – Allowance made in payment schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
29. Total allowable expense (add lines 24 through 28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
30. Deduct line 29 from line 23 (adjusted gross income) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
31. Use line 17 and line 30 to determine the annual liability from Fee Schedule . . . . . . . . . . . . . . . . . . . . $
32. Agreed upon payment plan to satisfy the above liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
33. Annual liability and service period: From To
34. Provider of Financial Information (if other than patient or responsible person)
Name Address
35. Adjusted by Reason
36. Approved by Date
37. I affirm that the statements made herein are true and correct to the best of my knowledge and I agree
to the payment plan as stated on line 34.
Signature of Patient or Responsible Person Date
38. An explanation of the UMDAP liability was provided.
Signature of Interviewer Date
Exhibit D
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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
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(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:
Exhibit E
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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 E
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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 F
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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
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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)