HomeMy WebLinkAboutAgreement A-18-250 with Each Contractors listed in Exhibit A.pdfAgreement No. 18-250
1 AGREEMENT
2 THIS MASTER AGREEMENT is made and entered into this 8th day of May , 2018,
3 by and between the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter
4 referred to as "COUNTY'', and each CONTRACTOR to be listed in Exhibit A "List of Contractors" attached
5 hereto and incorporated herein by reference, and collectively hereinafter referred to as
6 "CONTRACTOR(S)", and such additional CONTRACTOR(S) as may, from time to time during the term of ·
7 this Agreement, be added or deleted by COUNTY. Reference in this Agreement to party or "parties" shall
8 be understood to refer to COUNTY and each individual CONTRACTOR(S), unless otherwise specified.
9 W I T N E S S ET H:
1 O WHEREAS, COUNTY has an Agreement with the California State Department of Health Care
11 Services (DHCS) to operate the Fresno County Mental Health Managed Care Plan in accordance with
12 Welfare and Institutions Code Section 5000 et seq. which sets forth COUNTY's requirements to
13 provide, to the extent available, public mental health services; and
14 WHEREAS, COUNTY is authorized to contract for the provision of inpatient psychiatric
15 hospital services to Fresno County Beneficiaries eligible for such services under the Medi-Cal program,
16 pursuant to Sections 14700 et seq. and 14712 et seq. of the California Welfare and Institutions Code
17 and COUNTY may also determine the need to refer persons not eligible for Medi-Cal; and
18 WHEREAS, CONTRACTOR(S) is willing and able to provide such services to eligible
19 Fresno County Beneficiaries and Recipients, pursuant to the terms and conditions of this Agreement;
20 and
21 WHEREAS, COUNTY and CONTRACTOR(S) mutually recognize that services under
22 this Agreement will be rendered by CONTRACTOR(S) to persons referred by COUNTY and it is not the
23 intention of either COUNTY or CONTRACTOR(S) that such individuals occupy the position of third-
24 party beneficiaries of the obligations assumed by either party to this Agreement; and
25 WHEREAS, the words and terms used in this Agreement are intended to have their usual
26 meanings unless a particular or more limited meaning is associated with their usage in Sections 14712 et
27 seq. and 14680, et seq. of the California Welfare and Institutions Code, or the Medi-Cal Inpatient
28 Ill
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Psychiatric Hospital Services Consolidation Regulations pertaining to the rendition of health care or unless
specifically defined in Exhibit B “Definitions”, attached hereto and incorporated herein by reference.
NOW, THEREFORE, in consideration of the mutual covenants, terms and conditions
herein contained, the parties hereto agree as follows:
1. OBLIGATIONS OF THE CONTRACTOR(S)
A. CONTRACTOR(S) agrees to render adolescent and/or 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(S) has the facilities available.
B. COUNTY and CONTRACTOR(S) mutually recognize that services
under this Agreement will be rendered by CONTRACTOR(S) to persons who meet medically
necessity criteria for inpatient psychiatric hospitalization and it is not the intention of either
COUNTY or CONTRACTOR(S) that such individuals occupy the position of third-party
beneficiaries of the obligations assumed by either party to this Agreement.
C. CONTRACTOR shall align programs, services, and practices with the
vision, mission, and guiding principles of the DBH, as further described in Exhibit C, “Fresno County
Department of Behavioral Health Guiding Principles of Care Delivery”, attached hereto and by this
reference incorporated herein and made part of this Agreement.
D. CONTRACTOR shall send to County’s DBH upon execution of this
Agreement, a detailed plan ensuring clinically appropriate leadership and supervision of their clinical
program. Recruitment and retaining clinical leadership with the clinical competencies to oversee services
based on the level of care and program design presented herein shall be included in this plan. A
description and monitoring of this plan shall be provided.
E. CONTRACTOR shall participate in utilizing and integrating the Reaching
Recovery and other clinical tools and measures as directed by the DBH.
F. CONTRACTOR(S) agrees to accept payment in full for Inpatient Psychiatric
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Hospital Services, as provided in Section 14 PAYMENT PROVISIONS and as identified in
CONTRACTOR(S)’S respective Exhibit D, et seq. of this Agreement, subject to third party liability and
patient share of costs, if applicable.
G. CONTRACTOR(S) 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.
H. CONTRACTOR(S) shall, at its own expense, provide and maintain
facilities and professional, allied and supportive medical and paramedical personnel to provide all
necessary and appropriate Inpatient Psychiatric Hospital Services and shall ensure that family
members are involved in treatment when appropriate and family is willing to participate.
I. CONTRACTOR(S) 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.
J. CONTRACTOR(S) shall receive reimbursement for an Administrative
Day(s) from the California State Department of Health Care Services, upon the condition that
CONTRACTOR(S) agrees to be responsible for contacting less restrictive facilities (i.e., board and care
facilities, room and board facilities, licensed residential care facilities, etc.) within a sixty (60) mile radius
of CONTRACTOR(S)’S facility at least once every five (5) days to place Beneficiary when Beneficiary
no longer requires CONTRACTOR(S)’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.
K. Inpatient Psychiatric Hospital Services rendered pursuant to this
Agreement shall be rendered at the facility location identified on Exhibit A, except as permitted by
Section 4. DELEGATION OF CONTRACTOR(S)’S DUTIES: WHEN PERMITTED
L. CONTRACTOR(S) shall provide Inpatient Psychiatric Hospital Services
in the same manner to persons referred by COUNTY as it provides to all patients to whom it renders
Inpatient Psychiatric Hospital Services.
M. CONTRACTOR(S) shall not discriminate in any manner, including
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admission practices, placement in special or separate wings or rooms, nor make any provision for
special or separate means.
N.CONTRACTOR(S) shall take such action as required by
CONTRACTOR(S)’S Medical Staff Bylaws against medical staff members who violate those bylaws, as
the same may be amended from time to time.
O.CONTRACTOR(S) shall 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 and assure that the same quality of care is rendered to all Recipients referred by
COUNTY. Payment may be denied by COUNTY when requirements are not met.
2.CONTRACTOR(S)’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(S) retains professional and administrative
responsibility for the services rendered pursuant to this Agreement. CONTRACTOR(S)’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.
3.PROTECTION OF LICENSURE AND ACCREDITATION
Notwithstanding any provision herein to the contrary, in the event performance by
any of the parties hereto of any term, covenant, condition or provision of this Agreement shall
jeopardize the licensure of any of CONTRACTOR(S)’S facilities, or the full accreditation of any of
CONTRACTOR(S)’S facilities by the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) or any other regulatory or accrediting agency, or for any other reason said performance
should be in violation of applicable statutes, ordinances or regulations, or be deemed unethical by any
recognized body, agency or association in the health care filed, it is the duty of the party acquiring such
knowledge to notify the other party within five (5) working days, and such term, covenant, condition or
provision shall be renegotiated by the parties. In the event the parties are unable to renegotiate said
term or terms within a reasonable time, either party may terminate this Agreement upon thirty (30) days
advance written notice to the other party.
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4. DELEGATION OF CONTRACTOR(S)’S DUTIES: WHEN PERMITTED
A. CONTRACTOR(S) and COUNTY recognize that the 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(S) to delegate or otherwise vest
responsibility for performance of its duties in any manner other than those expressly permitted in this
Section 4 shall constitute a present material breach of this Agreement.
B. Except as limited by (E) of this Section 4, delegation of duties by
CONTRACTOR(S) shall not constitute a present material breach only if such delegation is in conformity
with one of the following:
1) The Delegate renders the Inpatient Psychiatric Hospital Services
at CONTRACTOR(S)’S facility or location.
2) For services to Medi-Cal Beneficiaries only, if the total of all
payments by CONTRACTOR(S) for all delegated services not covered under this Section 4(B)(1), nor
specially authorized under 4(B)(3), will not exceed five percent (5%) of the total Medi-Cal inpatient
psychiatric billing by CONTRACTOR(S) in any consecutive three (3) month period,
CONTRACTOR(S) may delegate duties to any qualified Delegate under (C) of this Section 4 without
written approval of COUNTY.
3) Any delegation not authorized under Section 4(B)(1) or 4(B)(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(S) anticipates will be rendered by the Delegate or Delegates.
C. When authorization is given pursuant to Section 4(B)(3),
CONTRACTOR(S) shall be responsible for all aspects of performance by its Delegate or Delegates.
CONTRACTOR(S) 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(S)
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to the same extent as if such default, refusal to perform or defective performance had been directly
committed or incurred by CONTRACTOR(S).
D. All costs for services rendered by a Delegate or Delegates are included
in the all–inclusive rates paid to CONTRACTOR(S) pursuant to Section 14 of this Agreement.
E. As a limitation upon the authorizations set forth in this Section 4(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(S) under Section 8. 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)’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)’S location.
CONTRACTOR(S) shall not discriminate against Beneficiaries in making a determination of availability
of facilities at its own location.
5. DELEGATION OF CONTRACTOR(S)’S DUTIES: HOW ACCOMPLISHED
In any delegation pursuant to authorization contained in Section 4(B)(3),
CONTRACTOR(S) shall contract in writing with a Delegate or Delegates for the assumption of the
primary duty of performance of the duties assumed by CONTRACTOR(S) under the terms of this
Agreement. Any written contract of delegation shall include the following:
A. Covenants on the part of CONTRACTOR(S) 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
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of the delegation shall continue to conform, to the licensure and certification requirements exacted from
CONTRACTOR(S) under Section 8 of this Agreement and that its failure to abide by the terms of this
warranty shall be an express condition subsequently discharging CONTRACTOR(S) 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 Section 5(E)(1)
of this Agreement 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(S).
4)That no services rendered on behalf of CONTRACTOR(S) 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(S) for compensation under the
terms of 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(S)
cannot or will not pay for services performed by the Delegate pursuant to the terms of the contract of
delegation.
6.ASSUMPTION OF RISK BY CONTRACTOR(S)
Whether rendered directly or through the instrumentality of a Delegate as
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permitted under this Agreement, CONTRACTOR(S) shall bear total risk for the cost of all Inpatient
Psychiatric Hospital Services rendered under this Agreement. As used in this Section, “risk” means
that CONTRACTOR(S) covenants to accept as payment in full for the Inpatient Psychiatric Hospital
Services described herein, those payments received pursuant to Section 14 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.
7.COMPLAINTS
CONTRACTOR(S) 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(S) 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(S) shall post signs informing
consumers of their right to file a complaint or grievance. CONTRACTOR(S) 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(S) 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(S) 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.
Within fifteen (15) days after CONTRACTOR(S) submits a corrective action plan
to a 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(S)
receives a corrective action order from a California State licensing and/or accrediting body to address a
sentinel event, CONTRACTOR(S) shall provide a summary of such plans and orders to COUNTY.
COUNTY agrees to assist with the discharge planning of all COUNTY Beneficiaries and Recipients. In
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addition, COUNTY agrees to meet with CONTRACTOR(S) periodically to identify means to more
effectively transition Beneficiaries and Recipients from the hospital.
8. LICENSURE AND CERTIFICATION CONDITIONS
CONTRACTOR(S) 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.
9. UTILIZATION CONTROLS
As express conditions precedent to any authorization by COUNTY for payment
obligation under the terms of this Agreement: (1) CONTRACTOR(S) 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(S) shall notify COUNTY within ten (10) calendar days of the emergency admission of a
Beneficiary or Recipient.
10. APPOINTMENT OF LIAISONS
A. CONTRACTOR(S) 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(S) 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 10 of this 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
3133 N. Millbrook Avenue
Fresno, CA 93703
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11. UMDAP APPLICATION
CONTRACTOR(S) shall inform low income, uninsured and under-insured persons
admitted to facility of the COUNTY’s UMDAP program. COUNTY authorizes CONTRACTOR(S) to
initiate the UMDAP application process using a COUNTY-approved form (Exhibit E 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(S) of the person’s eligibility within
five (5) working days.
12. TERM
The term of this Agreement shall be effective upon execution through and including
June 30, 2023. The term includes a base term of approximately three years two months, and may be
extended for two (2) additional consecutive twelve (12) month periods upon written approval of parties
concerned 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)’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. Individual
CONTRACTOR(S) terms may vary and are identified in each CONTRACTOR(S)’S respective Exhibit D, et
seq.
13. TERMINATION
A. Non-Allocation of Funds - The terms of this Agreement, and the services to
be 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 the CONTRACTOR(S) thirty (30) days advance written notice.
B. Breach of Contract - The COUNTY may immediately suspend or
terminate this Agreement in whole or in part, where in the determination of the COUNTY there is:
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1)An illegal or improper use of funds;
2)A failure to comply with any term of this Agreement;
3)A substantially incorrect or incomplete report submitted to the
COUNTY;
4)Improperly performed service.
In no event shall any payment by the COUNTY constitute a waiver by the
COUNTY of any breach of this Agreement or any default which may then exist on the part of the
CONTRACTOR(S). Neither shall such payment impair or prejudice any remedy available to the COUNTY
with respect to the breach or default. The COUNTY shall have the right to demand of the
CONTRACTOR(S) the repayment to the COUNTY of any funds disbursed to the CONTRACTOR(S) under
this Agreement, which in the judgment of the COUNTY were not expended in accordance with the terms of
this Agreement. The CONTRACTOR(S) shall promptly refund any such funds upon demand.
C.Without Cause - Under circumstances other than those set forth above,
this Agreement may be terminated by COUNTY upon the giving of thirty (30) days advance written
notice of an intention to terminate to CONTRACTOR(S).
14.PAYMENT PROVISIONS
A.COUNTY agrees to pay CONTRACTOR(S) and CONTRACTOR(S)
agrees to receive compensation for inpatient mental health services as stated in this Agreement at
service rates to be determined by COUNTY and CONTRACTOR(S). Said service rates shall be
referenced within CONTRACTOR(S)’S respective Exhibit D, et seq., which shall also contain the
service location and any specific contractual responsibilities relative to each individual
CONTRACTOR.
B.Negotiated inpatient mental health service rates referenced in Section
14(A) shall not, whenever possible, exceed the California Department of Health Care Services annual
published rate for Medi-Cal Psychiatric inpatient Hospital Services Regional Average Non-Negotiated
Rates, excluding professional (Physician and Psychiatrist) fees. Fiscal Year 2017-18 published rates
are included in Exhibit F of this Agreement, attached hereto and incorporated herein by reference.
Negotiated service rates that are greater than the published rate must be clearly validated and, at the
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sole discretion of the Director or her designee, approved prior to implementation by the Director or her
designee.
C.Rate Structure:
1)Beneficiaries: Provided that there shall first have been a
submission of claims in accordance with Section 14(G) of this Agreement, and payment authorization
from COUNTY, CONTRACTOR(S) shall be paid by the State Department of Health Care Services at
the all-inclusive rate(s) as identified in CONTRACTOR(S)’S respective Exhibit D, et seq. per patient per
day for acute Inpatient Psychiatric Hospital Services, excluding Physician and Psychiatrist fees, based
on the following accommodation codes:
Description Accommodation Code Rate
Administrative Day 169 See Exhibit D, et seq.
Room & Board, Semi-Private 124 See Exhibit D, et seq.
2-Bed, Psychiatric
2)Recipients: Only for those Recipients with UMDAP eligibility or
retroactive eligibility for the period of hospitalization and where COUNTY received notification within
twenty-four (24) hours of admission specifically referred by COUNTY to CONTRACTOR(S), and for
which there shall first have been a submission of claims in accordance with Section 14(I) of this
Agreement and for each approved day as determined by utilization review performed by COUNTY,
CONTRACTOR(S) shall be paid by COUNTY at the all-inclusive rate(s) as identified in
CONTRACTOR(S)’S respective Exhibit D, et seq., per patient per day for acute Psychiatric Inpatient
Hospital Services, excluding Physician and Psychiatrist fees, based on the following accommodation
codes:
Description Accommodation Code Rate
Administrative Day 169 See Exhibit D, et seq.
Room & Board, Semi-Private 124 See Exhibit D, et seq.
2-Bed, Psychiatric
D.The maximum combined amount payable to CONTRACTOR(S) by
COUNTY for Inpatient Psychiatric Hospital Services provided by CONTRACTOR(S) to Recipients, under
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the terms and conditions of this Agreement for each fiscal year is: (FY) 2017-18 ending on June 30, 2018,
is Five Hundred Thousand and No/100 Dollars ($500,000); FY 2018-19 is Six Hundred Twenty-Four
Thousand and No/100 Dollars ($624,000); FY 2019-20 is Six Hundred Forty-Nine Thousand and No/100
Dollars ($649,000); FY 2020-21 is Six Hundred Seventy-Five Thousand and No/100 Dollars ($675,000);
FY 2021-22 is Seven Hundred Two Thousand and No/100 Dollars ($702,000); and FY 2022-23 is Seven
Hundred Thirty Thousand and No/100 Dollars ($730,000). The maximum amount payable under this
Agreement to all CONTRACTORS combined throughout the term of this Agreement, which includes a
three-year two month base contract and two optional one-year extensions, is Three Million Eight Hundred
Eighty Thousand and No/100 Dollars ($3,880,000).
E. It is understood by COUNTY and CONTRACTOR(S) that the California
Department of Health Care Services Rate Development Branch is responsible for establishing the
administrative day rate during each State fiscal year. The rate established by the California Department of
Health Care Services Rate Development Branch may supersede the rate identified in CONTRACTOR(S)’S
respective Exhibit D, et seq., if the rate stated in CONTRACTOR(S)’S respective Exhibit D, et seq.
exceeds the rate established by the California Department of Health Care Services Rate Development
Branch. Any rate adjustment(s) shall not result in an increase to the maximum compensation of the
Agreement as stated herein.
F. It is understood by COUNTY and CONTRACTOR(S) that the Department
of Behavioral Health Director or designee and the CONTRACTOR(S)’S Director or designee are
responsible for negotiating and establishing the Inpatient Psychiatric Day Rate (Room & Board, Semi-
Private, 2-bed, Psychiatric) during each fiscal year, which may supersede the rate identified in
CONTRACTOR(S)’S respective Exhibit D, et seq. Said rate adjustments(s) shall be approved by
COUNTY’s Department of Behavioral Health Director, or designee and CONTRACTOR(S) and become
part of this Agreement. Any rate adjustment(s) shall not result in an increase to the maximum
compensation of the Agreement as stated herein.
G. COUNTY shall pay CONTRACTOR(S), in arrears for services provided
during the previous month, within forty-five (45) days after receipt and verification of
CONTRACTOR(S)’S invoices by COUNTY.
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1) 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(S) at the rate as identified
on CONTRACTOR(S)’S respective Exhibit D, et seq., per day of admission in these instances.
2) If client is a Beneficiary, COUNTY will adjust the Treatment
Authorization Request (TAR) in accordance with Medi-Cal medical necessity criteria to prevent an
incorrect claim to the State. If Medi-Cal funding is subsequently secured, CONTRACTOR(S) will credit
COUNTY the appropriate amount.
H. 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.
I. Psychiatrist Services: Psychiatrist/professional fees, as negotiated by
COUNTY and CONTRACTOR(S) shall be identified in CONTRACTOR(S)’S respective Exhibit D, et
seq. and may or may not be included in the Inpatient Day Rate.
J. Adolescent Eating Disorders Program (AEDP) service fees, if applicable,
are determined by COUNTY and CONTRACTOR(S) and shall be identified in CONTRACTOR(S)’S
respective Exhibit D, et seq.
K. Transportation Services: In the event transportation services are required
by those patients receiving Inpatient Psychiatric Hospital Services, such transportation services and the
cost and expense thereof shall be in accordance with CONTRACTOR(S)’S respective Exhibit D, et seq.
L. 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 14 of this Agreement, CONTRACTOR(S) shall determine that Inpatient
Psychiatric 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
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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(S) from such coverage will reduce COUNTY’s payment
obligation for a combined amount not to exceed the rate pursuant to Section 14(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 14 of this Agreement, CONTRACTOR(S) shall submit claims
addressed to Fresno County Mental Health Plan, 4409 E. Inyo, Mod A, Fresno, CA 93702: Attention
Division Manager, for all services rendered to persons covered under the terms of this Agreement, in
accordance with the applicable billing requirements contained in Section 14778 of the California
Welfare and Institutions Code and the regulations adopted thereto.
3)An authorized day of service shall be billed for each person who
occupies an inpatient psychiatric bed at 12:00 midnight in the facilities of either CONTRACTOR(S) or
an authorized Delegate. Day of discharge shall not be billed. However, a day of service may be billed
if the 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 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(S) or COUNTY within fourteen (14) days of said
Beneficiaries and Recipients being discharged from said facility(ies).
M.Recovery of Overpayments to CONTRACTOR(S), 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(S) has been overpaid under this Agreement, pursuant to
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Section 14(A), CONTRACTOR(S) covenants that any such overpayment may be recouped by
COUNTY by reducing future payment or invoicing the CONTRACTOR(S) 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
amount due from what would otherwise be COUNTY liability under this Agreement, seeking recovery
by payment from CONTRACTOR(S), or a combination of these two methods.
3)When recoupment or recovery is sought under Section 14(M) of
this Agreement, CONTRACTOR(S) 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)’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.
N.Customary Charges Limitation
1)Notwithstanding any other provision in this Agreement,
COUNTY’s authorization for payment to CONTRACTOR(S) shall not exceed CONTRACTOR(S)’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 14(M).
2)As used in Section 14(N), “customary charges” is defined as
those uniform charges listed in a CONTRACTOR(S)’S established fee schedule, which is in effect
and applied consistently to most patients and recognized for program reimbursement. Where a
CONTRACTOR(S) 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
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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 CONTRACTOR(S) Reimbursement Manual, Part 1 (“HCFA 15-1”), Chapter
26 Section 2604.3), and are defined in conformity with 42 USC Section 1395f, 42 CFR Part 413 and
the regulations promulgated pursuant thereto.
15. FUNDING
In the event that funding for these services is delayed by the State Controller,
COUNTY may defer payment to CONTRACTOR(S). 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.
16. GOVERNING AUTHORITIES
A. This Agreement shall be governed and construed 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 12; and
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 Six (6) A, except those provisions or applications of those provisions waived by
the Secretary of the United States 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 or regulations
stipulated in “A” of this Section is hereby amended to conform to the provisions of those laws and
regulations. 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 Six (6) Sub-section J.
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C. Conformance with Federal Regulations:
1) CONTRACTOR(S) 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 for those provisions waived by the Secretary of the United States
Department of Health and Human Services.
2) CONTRACTOR(S) shall conform with the provisions of the
Copeland Anti-Kickback Act (18 U.S.C. 874 and 40 U.S.C. §3145) which required that all contracts and
subcontracts in excess of Two Thousand and No/100 Dollars ($2,000.00) for construction or repair
awarded by the CONTRACTOR(S) and its subcontractors shall include a provision for compliance with
the Copeland Anti-Kickback Act (18 U.SC. 874), as supplemented by Department of Labor regulations
(Title 29, CFR, Part 3, "Contractors and Subcontractors on Public Building or Public Work Financed in
Whole or in part by Loans or Grants from the United States").
3) CONTRACTOR(S) shall comply with the provisions of Davis-
Bacon Act, as amended (40 U.S.C. 3142 to 3148), which requires that, when required by Federal
Medicaid program legislation, all construction contracts awarded by the CONTRACTOR(S) and its
Subcontractors of more than Two Thousand and No/100 Dollars ($2,000.00) shall include a provision
for compliance with the Davis-Bacon Act (40 U.S.C. 3142 to 3148) as supplemented by Department of
Labor regulations (Title 29, CFR, Part 5, "Labor Standards Provisions Applicable to Contracts
Governing Federally Financed and Assisted Construction").
4) CONTRACTOR(S) shall comply with the provisions of the
Contract Work Hours and Safety Standards Act (40 USCS 3701 to 3708), as applicable, which
requires that all subcontracts awarded by the CONTRACTOR(S) in excess of Two Thousand and
No/100 Dollars ($2,000.00) for construction and in excess of Two Thousand Five Hundred and
No/100 Dollars ($2,500.00) for other subcontracts that involve the employment of mechanics or
laborers shall involve a provision for compliance with sections 102 and 107 of the Contract Work
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Hours and Safety Standards Act (40 USCS 3701 to 3708), as supplemented by Department of Labor
regulations (Title 29, CFR, Part 5).
5)CONTRACTOR(S) 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(S).
6)CONTRACTOR(S) 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.
17.AGREEMENT ADMINISTRATOR - DELEGATION OF AUTHORITY
COUNTY will administer this Agreement through a single administrator, the
Director or designee of Department of Behavioral Health. Until such time as COUNTY gives
CONTRACTOR(S) 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.
18.AMERICANS WITH DISABILITIES ACT
CONTRACTOR agrees to ensure that deliverables developed and produced,
pursuant to this Agreement shall comply with the accessibility requirements of Section 508 of the
Rehabilitation Act (29 USCS § 794d) and the Americans with Disabilities Act of 1973 as amended (29
U.S.C. § 794 (d)), and regulations implementing that Act as set forth in Part 1194 of Title 36 of the
Code of Federal Regulations. In 1998, Congress amended the Rehabilitation Act of 1973 to require
Federal agencies to make their electronic and information technology (EIT) accessible to people with
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disabilities. California Government Code section 11135 codifies section 508 of the Act requiring
accessibility of electronic and information technology.
19.TAX EQUITY AND FISCAL RESPONSIBILITY ACT
To the extent necessary to prevent disallowance of reimbursement under section
1861(v)(1) (I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four
(4) years after the furnishing of services under this Agreement, CONTRACTOR shall make available,
upon written request to the Secretary of the United States Department of Health and Human Services,
or upon request to the Comptroller General of the United States General Accounting Office, or any of
their duly authorized representatives, a copy of this Agreement and such books, documents, and
records as are necessary to certify the nature and extent of the costs of these services provided by
CONTRACTOR under this Agreement. CONTRACTOR further agrees that in the event
CONTRACTOR carries out any of its duties under this Agreement through a subcontract, with a value
or cost of Ten Thousand and No/100 Dollars ($10,000.00) or more over a twelve (12) month period,
with a related organization, such Agreement shall contain a clause to the effect that until the expiration
of four (4) years after the furnishing of such services pursuant to such subcontract, the related
organizations shall make available, upon written request to the Secretary of the United States
Department of Health and Human Services, or upon request to the Comptroller General of the United
States General Accounting Office, or any of their duly authorized representatives, a copy of such
subcontract and such books, documents, and records of such organization as are necessary to verify
the nature and extent of such costs.
20.SINGLE AUDIT CLAUSE
A.If CONTRACTOR(S) expends Seven Hundred Fifty Thousand and
No/100 Dollars ($750,000.00) or more in Federal and Federal flow through monies, CONTRACTOR(S)
agrees to conduct an annual audit in accordance with the requirements of the Single Audit Standards
as set forth in Office of Management and Budget (OMB) 2 CFR 200. CONTRACTOR(S) shall submit
said audit and management letter to COUNTY. The audit must include a statement of findings or a
statement that there were no findings. If there were negative findings, CONTRACTOR(S) must include
a corrective action plan signed by an authorized individual. CONTRACTOR(S) agrees to take action
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correct any material non-compliance or weakness found as a result of such audit. Such audit shall be
delivered to COUNTY’s Department of Behavioral Health Business Office for review within nine (9)
months of the end of any fiscal year in which funds were expended and/or received for the program.
Failure to perform the requisite audit functions as required by this Agreement may result in COUNTY
performing the necessary audit tasks, or at COUNTY’s option, contracting with a public accountant to
perform said audit, or, may result in the inability of COUNTY to enter into future agreements with
CONTRACTOR(S). All audit costs related to this Agreement are the sole responsibility of
CONTRACTOR(S).
B. A single audit report is not applicable if all CONTRACTOR(S)’S Federal
contracts do not exceed the Seven Hundred Fifty Thousand Dollars ($750,000.00) requirement or
CONTRACTOR(S)’S only funding is through Drug related Medi-Cal. If a single audit is not applicable, a
program audit must be performed and a program audit report with management letter shall be submitted
by CONTRACTOR(S) to COUNTY as a minimum requirement to attest to CONTRACTOR(S)’S solvency.
Said audit report shall be delivered to COUNTY’S Department of Behavioral Health Business Office for
review no later than nine (9) months after the close of the fiscal year in which the funds supplied through
this Agreement are expended. Failure to comply with this Act may result in COUNTY performing the
necessary audit tasks or contracting with a qualified accountant to perform said audit. All audit costs
related to this Agreement are the sole responsibility of CONTRACTOR(S) who agrees to take corrective
action to eliminate any material noncompliance or weakness found as a result of such audit. Audit work
performed by COUNTY under this Section shall be billed to the CONTRACTOR(S) at COUNTY cost, as
determined by COUNTY’S Auditor-Controller/Treasurer-Tax Collector.
C. CONTRACTOR(S) shall make available all records and accounts for
inspection by COUNTY, the State of California, if applicable, the Comptroller General of the United
States, the Federal Grantor Agency, or any of their duly authorized representatives, at all reasonable
times for a period of at least three (3) years following final payment under this Agreement or the
closure of all other pending matters, whichever is later.
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21. INDEPENDENT CONTRACTOR(S)
In performance of the work, duties and obligations assumed by CONTRACTOR(S)
under this Agreement, it is mutually understood and agreed that CONTRACTOR(S), including any and all
of the CONTRACTOR(S)'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 the COUNTY. Furthermore, COUNTY shall have no right
to control or supervise or direct the manner or method by which CONTRACTOR(S) shall perform its work
and function. However, COUNTY shall retain the right to administer this Agreement so as to verify that
CONTRACTOR(S) is performing its obligations in accordance with the terms and conditions thereof.
CONTRACTOR(S) and COUNTY shall comply with all applicable provisions of law and the rules and
regulations, if any, of governmental authorities having jurisdiction over matters the subject thereof.
Because of its status as an independent contractor, CONTRACTOR(S) shall have
absolutely no right to employment rights and benefits available to COUNTY employees. CONTRACTOR(S)
shall be solely liable and responsible for providing to, or on behalf of, its employees all legally-required
employee benefits. In addition, CONTRACTOR(S) shall be solely responsible and save COUNTY harmless
from all matters relating to payment of CONTRACTOR(S)'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(S) may be providing services to others unrelated to the COUNTY
or to this Agreement.
22. 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.
23. 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.
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24.ADDITIONS OF CONTRACTOR(S)
COUNTY’s DBH Director or her designee reserves the right at any time during the
term of this Agreement to add or delete CONTRACTOR(S) to Exhibit A. It is understood any such
additions or deletions will not affect compensation paid to the other CONTRACTOR(S) and therefore
such additions or deletions may be made by COUNTY without notice or approval of other
CONTRACTOR(S) under this Agreement.
25.MONITORING
CONTRACTOR(S) agrees to extend to COUNTY’s DBH Director and the State
Department Health Care Services, Mental Health Services Division (MHSD), or their designees, the right
to review and monitor records, programs or procedures, at any time, in regard to clients, as well as the
overall operation on CONTRACTOR(S) programs, in order to ensure compliance with the terms and
conditions of this Agreement.
26.NON-ASSIGNMENT
Neither party shall assign, transfer or sub-contract this Agreement nor their rights
or duties under this Agreement without the prior written consent of the other party.
27.HOLD HARMLESS
CONTRACTOR(S) agrees to indemnify, save, hold harmless, and at COUNTY’s
request, defend COUNTY, its officers, agents and employees from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
COUNTY in connection with the performance, or failure to perform, by CONTRACTOR(S), 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(S), its officers, agents or employees under this Agreement. In addition,
CONTRACTOR(S) agrees to indemnify COUNTY for Federal, State of California and/or local audit
exceptions resulting from noncompliance herein on the part of the CONTRACTOR(S).
28.INSURANCE
Without limiting the COUNTY's right to obtain indemnification from
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CONTRACTOR(S) or any third parties, CONTRACTOR(S), 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:
A.Commercial General Liability
Commercial General Liability Insurance with limits of not less than One
Million Dollars ($1,000,000) per occurrence and an annual aggregate of Two Million Dollars ($2,000,000).
This policy shall be issued on a per occurrence basis. COUNTY may require specific 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 for bodily injury of
not less than Two Hundred Fifty Thousand Dollars ($250,000.00) per person, Five Hundred Thousand
Dollars ($500,000.00) per accident and for property damages of not less than Fifty Thousand Dollars
($50,000.00), or such coverage with a combined single limit of Five Hundred Thousand Dollars
($500,000.00). Coverage should include owned and non-owned vehicles used in connection with this
Agreement.
C.Professional Liability
If CONTRACTOR(S) 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(S) serving adolescents shall maintain Sexual Abuse/
Molestation Liability Insurance (including but not limited to corporal punishment liability, sexual abuse
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and molestation liability, and child abduction liability) 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.
CONTRACTOR(S) shall obtain endorsements to the Commercial General Liability
insurance naming the County of Fresno, its officers, agents, and employees, individually and collectively,
as additional insured, but only insofar as the operations under this Agreement are concerned. Such
coverage for additional insured shall apply as primary insurance and any other insurance, or
self-insurance, maintained by COUNTY, its officers, agents and employees shall be excess only and not
contributing with insurance provided under CONTRACTOR(S)'S policies herein. This insurance shall not
be cancelled or changed without a minimum of thirty (30) days advance written notice given to COUNTY.
Within Thirty (30) days from the date CONTRACTOR(S) signs and executes this
Agreement, CONTRACTOR(S) shall provide certificates of insurance and endorsement as stated above
for all of the foregoing policies, as required herein, to the County of Fresno, 4409 E. Inyo Street, Fresno,
California, 93727, Attention: Mental Health Plan, stating that such insurance coverage have been
obtained and are in full force; that the County of Fresno, its officers, agents and employees will not be
responsible for any premiums on the policies; that such Commercial General Liability insurance names
the County of Fresno, its officers, agents and employees, individually and collectively, as additional
insured, but only insofar as the operations under this Agreement are concerned; that such coverage for
additional insured shall apply as primary insurance and any other insurance, or self-insurance,
maintained by COUNTY, its officers, agents and employees, shall be excess only and not contributing
with insurance provided under CONTRACTOR(S)'S policies herein; and that this insurance shall not be
cancelled or changed without a minimum of thirty (30) days advance, written notice given to COUNTY.
In the event CONTRACTOR(S) 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.
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29. AUDITS AND INSPECTIONS
The CONTRACTOR(S) shall at any time during business hours, and as often as the
COUNTY may deem necessary, make available to the COUNTY for examination all of its records and data
with respect to the matters covered by this Agreement. The CONTRACTOR(S) shall, upon request by the
COUNTY, permit the COUNTY to audit and inspect all of such records and data necessary to ensure
CONTRACTOR(S)'S compliance with the terms of this Agreement.
If this Agreement exceeds ten thousand dollars ($10,000.00), CONTRACTOR(S)
shall be subject to the examination and audit of the Auditor General for a period of three (3) years after
final payment under contract (Government Code Section 8546.7).
30. LICENSES/CERTIFICATES
Throughout each term of this Agreement, CONTRACTOR(S) and
CONTRACTOR(S)’S staff shall maintain all necessary licenses, permits, approvals, certificates,
waivers and exemptions necessary for the provision of the services hereunder and required by the laws
and regulations of the United States of America, State of California, the County of Fresno, and any
other applicable governmental agencies. CONTRACTOR(S) shall notify COUNTY immediately in
writing of its inability to obtain or maintain such licenses, permits, approvals, certificates, waivers and
exemptions irrespective of the pendency of any appeal related thereto. Additionally, CONTRACTOR(S)
and CONTRACTOR(S)’S staff shall comply with all applicable laws, rules or regulations, as may now
exist or be hereafter changed.
31. RECORDS
CONTRACTOR(S) shall maintain records in accordance with Exhibit G,
“Documentation Standards for Client Records”, attached hereto and incorporated herein by reference.
During site visits, COUNTY shall be allowed to review records of services provided, including the goals
and objectives of the treatment plan, and how the therapy provided is achieving the goals and objectives.
All medical records shall be maintained for a minimum of 10 years from the date of the end of the
Agreement.
32. REPORTS
A. Cost Report – CONTRACTOR(S) agrees to submit a complete and
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accurate detailed cost report on an annual basis for each fiscal year ending June 30th in the format
prescribed by the DHCS for the purposes of Short Doyle Medi-Cal reimbursements and total costs for
programs. Each cost report will be the source document for several phases of settlement with the
DHCS for the purposes of Short Doyle Medi-Cal reimbursement. CONTRACTOR(S) shall report costs
under their approved legal entity number established during the Medi-Cal certification process. The
information provided applies to CONTRACTOR(S) for program related costs for services rendered to
Medi-Cal and non Medi-Cal. The CONTRACTOR(S) will remit a schedule to provide the required
information on published charges (PC) for all authorized services. The report will serve as a source
document to determine their usual and customary charge prevalent in the public mental health sector
that is used to bill the general public, insurers or other non-Medi-Cal third party payers during the
course of business operations. CONTRACTOR(S) must report all collections for Medi-Cal/Medicare
services and collections. CONTRACTOR(S) shall also submit with each cost report a copy of the
CONTRACTOR(S) general ledger that supports revenues and expenditures for the said services.
CONTRACTOR(S) must also include a reconciled detailed report of the total units of services rendered
under this Agreement compared to the units of services entered by CONTRACTOR(S) into COUNTY’s
data system.
Cost reports must be submitted to the COUNTY as a hard copy with a
signed cover letter and electronic copy of the completed DHCS cost report form along with requested
support documents following each fiscal year ending June 30th. During the month of September of
each year this Agreement is effective, COUNTY will issue instructions of the annual cost report which
indicates the training session, DHCS cost report template worksheets, and deadlines to submit as
determined by the State annually. Remit the hard copies of the cost reports to County of Fresno,
Attention: Cost Report Team, P.O. Box 45003, Fresno, CA 93718. Remit the electronic copy or any
inquiries to DBHcostreportteam@fresnocountyca.gov.
All cost reports must be prepared in accordance with Generally
Accepted Accounting Principles (GAAP) and Welfare and Institutions Code §§ 5651(a)(4), 5664(a),
5705(b)(3) and 5718(c). Unallowable costs such as lobby or political donations must be deducted on
the cost report and invoice reimbursements.
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If the CONTRACTOR(S) does not submit the cost report by the deadline,
including any extension period granted by the COUNTY, the COUNTY may withhold payments of
pending invoicing under compensation until the cost report has been submitted and clears COUNTY
desk audit for completeness.
B. Settlements with State Department of Health Care Services (DHCS)
During the term of this Agreement and thereafter, COUNTY and
CONTRACTOR(S) agree to settle dollar amounts disallowed or settled in accordance with DHCS and
COUNTY audit settlement findings related to the Medi-Cal and realignment reimbursements.
CONTRACTOR(S) will participate in the several phases of settlements between COUNTY,
CONTRACTOR(S) and DHCS. The phases of initial cost reporting for settlement according to State
reconciliation of records for paid Medi-Cal services and audit settlement-DHCS audit: 1) initial cost
reporting - after an internal review by COUNTY, the COUNTY files cost report with DHCS on behalf of
the CONTRACTOR(S) legal entity for the fiscal year; 2) Settlement –State reconciliation of records for
paid Medi-Cal services, approximately eighteen (18) to thirty-six (36) months following the State close
of the fiscal year, DHCS will send notice for any settlement under this provision will be sent to the
COUNTY; and 3) Audit Settlement-DHCS audit. After final reconciliation and settlement, COUNTY
and/or DHCS may conduct a review of medical records, cost report along with support documents
submitted to COUNTY in initial submission to determine accuracy and may disallow cost and/or unit of
service reported on the CONTRACTOR(S) legal entity cost report. COUNTY may choose to appeal
and therefore reserves the right to defer payback settlement with CONTRACTOR(S) until resolution of
the appeal. DHCS Audits will follow federal Medicaid procedures for managing overpayments.
If at the end of the Audit Settlement, the COUNTY determines that it
overpaid the CONTRACTOR(S), it will require the CONTRACTOR(S) to repay the Medi-Cal related
overpayment back to the COUNTY.
Funds owed to COUNTY will be due within forty -five (45) days of
notification by the COUNTY, or COUNTY shall withhold future payments until all excess fund s have
been recouped by means of an offset against any payments then or thereafter owing to
CONTRACTOR(S) under this or any other Agreement.
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C. Outcome Reports – CONTRACTOR(S) shall submit to COUNTY’s DBH
service outcome reports as requested by DBH. Outcome reports and outcome requirements are
subject to change at COUNTY DBH’s discretion.
D. Additional Reports – CONTRACTOR(S) shall also furnish to COUNTY
such statements, records, reports, data, and other information as COUNTY’s DBH may request
pertaining to matters covered by this Agreement. In the event that CONTRACTOR(S) fails to provide
such reports or other information required hereunder, it shall be deemed sufficient cause for COUNTY to
withhold monthly payments until there is compliance. In addition, CONTRACTOR(S) shall provide
written notification and explanation to COUNTY within five (5) days of any funds received from another
source to conduct the same services covered by this Agreement.
33. CONFLICT OF INTEREST
No officer, agent, or employee of the 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. No officer, agent, or employee of the
COUNTY who exercises any function or responsibility for planning and carrying out the services
provided under this Agreement shall have any direct or indirect personal financial interest in this
Agreement. In addition, no employee of the COUNTY shall be employed by CONTRACTOR(S) to
fulfill any contractual obligations with COUNTY. The CONTRACTOR(S) 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
the COUNTY.
34. 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.
35. COMPLIANCE WITH STATE REQUIREMENTS
CONTRACTOR(S) recognizes that COUNTY operates its mental health
programs under an agreement with DHCS, and that under said agreement the State imposes certain
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requirements on COUNTY and its CONTRACTOR(S) and its subcontractors. CONTRACTOR(S)
shall adhere to all State requirements, including those identified in Exhibit H “State Mental Health
Requirements”, attached hereto and incorporated herein by reference. Compliance shall include
completion of Exhibit H1 “Certification” (attached hereto and incorporated herein by reference) and
Exhibit H2 “Payee-Data-Record” (attached hereto and incorporated herein by reference) as required
by and identified in Exhibit H.
36.COMPLIANCE WITH STATE MEDI-CAL REQUIREMENTS
CONTRACTOR(S) shall be required to maintain organizational provider
certification by Fresno County. CONTRACTOR(S) must meet Medi-Cal organization provider
standards as listed in Exhibit I, “Medi-Cal Organizational Provider Standards”, attached hereto and
incorporated herein by reference. It is acknowledged that all references to Organizational Provider
and/or Provider in Exhibit I shall refer to CONTRACTOR(S) as identified in Exhibit A. In addition,
CONTRACTOR(S) shall inform every client of their rights under the COUNTY’s Mental Health Plan as
described in “Fresno County Mental Health Plan Grievances and Appeals Process” Exhibit J, attached
hereto and incorporated herein by reference. CONTRACTOR(S) shall also file an incident report for all
incidents involving clients, following the Protocol for Completion of Incident Report and using the
Worksheet identified in the “Fresno County Mental Health Plan Incident Reporting”, Exhibit K, attached
hereto and incorporated herein by reference, or a protocol and worksheet presented by
CONTRACTOR(S) that is accepted by COUNTY’S DBH Director, or designee.
37.CONFIDENTIALITY OF INFORMATION
A.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(S) from unauthorized disclosure.
B.With respect to any identifiable information concerning Beneficiaries
under this Agreement that is obtained by CONTRACTOR(S) or its Delegates, CONTRACTOR(S);
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1)Shall not use any such information for any purpose other than
carrying out the express terms of this Agreement; and
2)Shall promptly transmit to COUNTY all requests for disclosure of
such information; and
3)Shall not disclose, except as otherwise specifically permitted by
this Agreement, any such information to any party other than COUNTY without COUNTY’s prior
written authorization specifying that the information may be released under Title 45, Code of Federal
Regulations Section 205.50; sections 10850 and 14100.2 of the California Welfare and Institutions
Code; and, regulations adopted pursuant thereto; and,
4)Shall, at the termination of this Agreement, return all such
information to COUNTY or maintain such information according to written procedures sent to
CONTRACTOR(S) by COUNTY for this purpose.
5)All services performed by CONTRACTOR(S) under this
Agreement shall be in strict conformance with all applicable Federal, State of California and/or local
laws and regulations relating to confidentiality.
38.HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and CONTRACTOR(S) 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(S) acknowledge that the exchange of PHI
between them is only for treatment, payment, and health care operations.
COUNTY and CONTRACTOR(S) 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
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require CONTRACTOR(S) 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).
39. DATA SECURITY
For the purpose of preventing the potential loss, misappropriation or inadvertent
access, viewing, use or disclosure of COUNTY data including sensitive or personal client information;
abuse of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies
that enter into a contractual relationship with the COUNTY for the purpose of providing services under
this Agreement must employ adequate data security measures to protect the confidential information
provided to CONTRACTOR(S) by the COUNTY, including but not limited to the following:
A. CONTRACTOR(S)-Owned Mobile, Wireless, or Handheld Devices:
CONTRACTOR(S) may not connect to COUNTY networks via
personally-owned mobile, wireless or handheld devices, unless the following conditions are met:
1) CONTRACTOR(S) has received authorization by COUNTY for
telecommuting purposes;
2) Current virus protection software is in place;
3) Mobile device has the remote wipe feature enabled; and
4) A secure connection is used.
B. CONTRACTOR(S)-Owned Computers or Computer Peripherals:
CONTRACTOR(S) may not bring CONTRACTOR(S)-owned computers
or computer peripherals into the COUNTY for use without prior authorization from the COUNTY’s
Chief Information Officer, and/or designee(s), including but not limited to mobile storage devices. If
data is approved to be transferred, data must be stored on a secure server approved by the COUNTY
and transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
connection. Said data must be encrypted.
C. COUNTY-Owned Computer Equipment:
CONTRACTOR(S) may not use COUNTY computers or computer
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peripherals on non-COUNTY premises without prior authorization from the COUNTY’s Chief
Information Officer, and/or designee(s).
D. CONTRACTOR(S) may not store COUNTY’s private, confidential or
sensitive data on any hard-disk drive, portable storage device, or remote storage installation unless
encrypted.
E. CONTRACTOR(S) shall be responsible to employ strict controls to
ensure the integrity and security of COUNTY’s confidential information and to prevent unauthorized
access, viewing, use or disclosure of data maintained in computer files, program documentation, data
processing systems, data files and data processing equipment which stores or processes COUNTY
data internally and externally.
F. Confidential client information transmitted to one party by the other by
means of electronic transmissions must be encrypted according to Advanced Encryption Standards
(AES) of 128 BIT or higher. Additionally, a password or pass phrase must be utilized.
G. CONTRACTOR(S) is responsible to immediately notify COUNTY of any
violations, breaches or potential breaches of security related to COUNTY’s confidential information,
data maintained in computer files, program documentation, data processing systems, data files and
data processing equipment which stores or processes COUNTY data internally or externally.
H. COUNTY shall provide oversight to CONTRACTOR(S) response to all
incidents arising from a possible breach of security related to COUNTY’s confidential client
information provided to CONTRACTOR(S). CONTRACTOR(S) will be responsible to issue any
notification to affected individuals as required by law or as deemed necessary by COUNTY in its sole
discretion. CONTRACTOR(S) will be responsible for all costs incurred as a result of providing the
required notification.
40. NOTICES
The persons and their addresses having authority to give and receive notices
under this Agreement include the following:
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COUNTY OF FRESNO CONTRACTOR(S)
Department of Behavioral Health See Exhibit D, et seq.
3133 N. Millbrook Avenue
Fresno CA 93703
All notices between the COUNTY and CONTRACTOR(S) provided for or permitted
under this Agreement must be in writing and delivered either by personal service, by first-class United
States mail, by an overnight commercial courier service, or by telephonic facsimile transmission. A notice
delivered by personal service is effective upon service to the recipient. A notice delivered by first-class
United States mail is effective three COUNTY business days after deposit in the United States mail,
postage prepaid, addressed to the recipient. A notice delivered by an overnight commercial courier
service is effective one COUNTY business day after deposit with the overnight commercial courier service,
delivery fees prepaid, with delivery instructions given for next day delivery, addressed to the recipient. A
notice delivered by telephonic facsimile is effective when transmission to the recipient is completed (but, if
such transmission is completed outside of COUNTY business hours, then such delivery shall be deemed
to be effective at the next beginning of a COUNTY business day), provided that the sender maintains a
machine record of the completed transmission. For all claims arising out of or related to this Agreement,
nothing in this Section establishes, waives, or modifies any claims presentation requirements or
procedures provided by law, including but not limited to the Government Claims Act (Division 3.6 of Title 1
of the Government Code, beginning with Section 810).
41. GOVERNING LAW
Venue for any action arising out of or related to this Agreement shall only 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.
42. ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that neither it nor any of its
officers are currently excluded, suspended, debarred, or otherwise ineligible to participate in the Federal
Health Care Programs; that neither it nor any of its officers have been convicted of a criminal offense
related to the provision of health care items or services; and that neither it, nor any of its officers, have
been reinstated to participate in the Federal Health Care Programs after a period of exclusion, suspension,
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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(S) has been charged with a
criminal offense related to any Federal Health Care Program, or is proposed for exclusion during the
term of any contract, CONTRACTOR(S) 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(S) cease providing services until
resolution of the charges or the proposed exclusion.
B.CONTRACTOR(S) agrees that all potential new employees of
CONTRACTOR(S) or subcontractors of CONTRACTOR(S) who, in each case, are expected to perform
professional services under this Agreement, will be queried as to whether (1) they are now or ever have
been excluded, suspended, debarred, or otherwise ineligible to participate in the Federal Health Care
Programs; (2) they have been convicted of a criminal offense related to the provision of health care
items or services; and whether (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(S) 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(S)
hires or engages such potential employee or subcontractor, the CONTRACTOR(S) 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
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terminate this Agreement in accordance with Section Three (3) of this Agreement, or require adequate
assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or
subcontractor of CONTRACTOR(S) 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(S) 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 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(S) 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(S) will ensure that said employee or
subcontractor does no work, either direct or indirect, relating to services provided to COUNTY.
1) CONTRACTOR(S) agrees to notify COUNTY immediately
during the term of this Agreement whenever CONTRACTOR(S) learns that an employee or
subcontractor who, in each case, is providing professional services under Section One (1) of this
Agreement is excluded, suspended, debarred or otherwise ineligible to participate in the Federal
Health Care Programs, or is convicted of a criminal offense relating to the provision of health care
services.
2) Notwithstanding the above, COUNTY at its discretion may
terminate this Agreement in accordance with Section Three (3) of this Agreement, or require
adequate assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible
employee or subcontractor of CONTRACTOR(S) 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.
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D. CONTRACTOR(S) 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)’S compliance with the provisions of this Section.
E. CONTRACTOR(S) agrees to reimburse COUNTY for the entire cost of
any penalty imposed upon COUNTY by the State or Federal Government as a result of
CONTRACTOR(S)’S violation of CONTRACTOR(S)’S obligations as described in this Section.
43. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST INFORMATION
This provision is only applicable if CONTRACTOR(S) 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(S) by completing
Exhibit L “Disclosure of Ownership and Control Interest Statement”, attached hereto and incorporated
herein by reference. CONTRACTOR(S) shall submit this form to COUNTY’s DBH within thirty (30) days
of the effective date of this Agreement. Additionally, CONTRACTOR(S) shall report any changes to this
information within thirty-five (35) days of occurrence by completing Exhibit L. Submissions shall be
scanned pdf copies and are to be sent via email to DBHAdministration@fresnocountyca.gov, Attention:
Contracts Administration. CONTRACTOR is required to submit a set of fingerprints for any person with
a 5 percent or greater direct or indirect ownership interest in CONTRACTOR. COUNTY may terminate
this Agreement where any person with a 5 percent or greater direct or indirect ownership interest in the
CONTRACTOR and did not submit timely and accurate information and cooperate with any screening
method required in CFR, title 42, section 455.416. Submissions shall be scanned pdf copies and are to
be sent via email to DBHAdministration@fresnocountyca.gov, Attention: Contracts Administration.
COUNTY may deny enrollment or terminate this Agreement where any person with a 5 percent or
greater direct or indirect ownership interest in CONTRACTOR has been convicted of a criminal offense
related to that person’s involvement with the Medicare, Medicaid, or title XXI program in the last 10
years.
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44. DISCLOSURE OF CRIMINAL HISTORY & CIVIL ACTIONS
CONTRACTOR(S) 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(S)”):
A. Within the three-year period preceding the Agreement award,
CONTRACTOR(S) 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
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(S) has had a public transaction (federal, state, or local) terminated for cause or
default.
Disclosure of the above information will not automatically eliminate
CONTRACTOR(S) 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(S) elects to submit with the disclosed information will be considered.
If it is later determined that the CONTRACTOR(S) failed to disclose required information, any contract
awarded to such CONTRACTOR(S) may be immediately voided and terminated for material failure to
comply with the terms and conditions of the award.
CONTRACTOR(S) must sign a “Certification Regarding Debarment, Suspension,
and Other Responsible Matters – Primary Covered Transactions” in the form set forth in Exhibit M,
attached hereto and incorporated herein by reference. Additionally CONTRACTOR(S) must
immediately advise the COUNTY in writing if, during the term of the Agreement: (1) CONTRACTOR(S)
becomes suspended, debarred, excluded or ineligible for participation in federal or state funded
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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(S).
CONTRACTOR(S) 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.
45.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR(S) is operating as a
corporation (a for-profit or non-profit corporation) or if during the term of the agreement, the
CONTRACTOR(S) changes its status to operate as a corporation.
Members of the CONTRACTOR(S)’S Board of Directors shall disclose any self-
dealing transactions that they are a party to while CONTRACTOR(S) is providing goods or performing
services under this agreement. A self-dealing transaction shall mean a transaction to which the
CONTRACTOR(S) 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 Exhibit N “Self-Dealing Transaction Disclosure Form”, attached hereto and
incorporated herein by reference, and submitting it to the COUNTY prior to commencing with the self-
dealing transaction or immediately thereafter.
46.CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, CONTRACTOR(S) shall
comply with:
A.Title 6 of the Civil Rights Act of 1964 (42 U.S.C. section 2000d, and 45
C.F.R. Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial
assistance from discriminating against persons based on race, color, national origin, sex, disability or
religion. This is interpreted to mean that a limited English proficient (LEP) individual is entitled to equal
access and participation in federally funded programs through the provision of comprehensive and
quality bilingual services.
B.Policies and procedures for ensuring access and appropriate use of
trained interpreters and material translation services for all LEP clients, including, but not limited to,
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assessing the cultural and linguistic needs of its clients, training of staff on the policies and procedures,
and monitoring its language assistance program. The CONTRACTOR(S) procedures must include
ensuring compliance of any sub-contracted providers with these requirements.
C. CONTRACTOR(S) shall not use minors as interpreters.
D. CONTRACTOR(S) shall provide and pay for interpreting and translation
services to persons 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 participants meaningful access to the programs,
services and benefits provided by CONTRACTOR(S). 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
participants at no cost to the participant. CONTRACTOR(S) shall ensure that any employees, agents,
subcontractors, or partners who interpret or translate for a program participant, or who directly
communicate with a program participant in a language other than English, demonstrate proficiency in
the participant's language and can effectively communicate any specialized terms and concepts
peculiar to CONTRACTOR(S) services.
E. In compliance with the State mandated Culturally and Linguistically
Appropriate Services standards as published by the Office of Minority Health, CONTRACTOR(S) must
submit to COUNTY for approval, within sixty (60) days from date of contract execution,
CONTRACTOR(S) plan to address all fifteen national cultural competency standards as set forth in the
“National Standards on Culturally and Linguistically Appropriate Services (CLAS)”
http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf. COUNTY’s annual on-site review of
CONTRACTOR(S) shall include collection of documentation to ensure all national standards are
implemented. As the national competency standards are updated, CONTRACTOR(S) plan must be
updated accordingly. Cultural competency training for CONTRACTOR staff should be substantively
integrated into health professions education and training at all levels, both academic and functional,
including core curriculum, professional licensure, and continuing professional development programs.
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CONTRACTOR on a monthly basis shall provide COUNTY DBH a monthly monitoring tool/report that
shows all CONTRACTOR staff cultural competency trainings completed.
47. 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 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.
48. PROHIBITION ON PUBLICITY
None of the funds, materials, property or services provided directly or indirectly
under this Agreement shall be used for CONTRACTOR(S) advertising, fundraising, or publicity (i.e.,
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purchasing of tickets/tables, silent auction donations, etc.) for the purpose of self-promotion.
Notwithstanding the above, publicity of the services described in Section 1 of this Agreement shall be
allowed as necessary to raise public awareness about the availability of such specific services when
approved in advance by COUNTY’s DBH Director or designee and at a cost to be provided in Section 4
of this Agreement for such items as written/printed materials, the use of media (i.e., radio, television,
newspapers) and any other related expense(s).
49.SEPARATE AGREEMENT
It is mutually understood by the parties that this Agreement does not, in any way,
create a joint venture among CONTRACTOR(S). By execution of this Agreement, CONTRACTOR(S)
understand that a separate Agreement is formed between each individual CONTRACTOR(S) and
COUNTY.
50.ENTIRE AGREEMENT
This Agreement constitutes the entire agreement between the CONTRACTOR(S)
and COUNTY with respect to the subject matter hereof and supersedes all previous Agreement
negotiations, proposals, commitments, writings, advertisements, publications, and understanding of any
nature whatsoever unless expressly included in this Agreement.
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IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year
first hereinabove written .
FOR A CCOUNTING USE ONLY :
ORG No .: 56302666
Account No.: 7223/0
Revenue : §3,880,000
$500,000
$624,000
$649,000
$675,000
$702,000
$730,000
COUNTY OF FRESNO
ATTEST :
Bernice E. Seidel
Clerk of the Board of Supervisors
County of Fresno , State of California
Maximum for Contract Term
FY 2017-18 Prorated
FY 2018-19
FY 2019-20
FY 2020-21
FY 2021-22
FY 2022-23
4 3
MASTER AGREEMENT
INPATIENT PSYCHIATRIC MENTAL HEALTH SERVICES
LIST OF CONTRACTORS
Exhibit A
PROVIDER
SERVES
ADULTS
SERVES
YOUTH AEDP*
MEDI-
CAL
CA
REGION
MILES
(1-WAY)CITY ZIP INTAKE PHONE INTAKE FAX NOTES
Behavioral Health Care
Freemont Hospital Yes Yes Yes Yes Bay Area 171.3 Fremont 94538 (888) 796-1101 (510) 574-4885 24/7; See Exhibit D-1
Bakersfield Behavioral
Health Hospital Yes Yes No Yes Central 110.8 Bakersfield 93309 (661) 241-5507 (661) 241-5587 See Exhibit D-3
AEDP* = Adolescent Eating Disorders Program
Exhibit B
MASTER AGREEMENT
INPATIENT PSYCHIATRIC MENTAL HEALTH SERVICES
DEFINITIONS
1. General Meaning of Words and Terms: The words and terms used in this Agreement are
intended to have their usual meanings unless a particular or more limited meaning is
associated with their usage in sections 5775, et seq. and 14680, et seq. of the California
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 this Section or otherwise in this Agreement.
2. Administrative Day: “Administrative Day” means those days authorized by the
COUNTY in an acute inpatient facility when, due to the 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.
3. Beneficiary: “Beneficiary” means a person certified as eligible for services under the
Medi-Cal program according to 22, California Code of Regulations section 5100.2, who
is a Fresno County Beneficiary and who is designated by “County Code 10.”
4. Delegate: “Delegate” means any natural or corporate person to whom the PROVIDER
transfers, pursuant to the terms of this Agreement, the primary responsibility to perform
any covenant assumed by PROVIDER in this Agreement.
5. Department: “Department” means the State Department of Health Care Services.
6. Fiscal Intermediary: “Fiscal Intermediary” means that person or entity that has
contracted, as specified in section 14104.3 of the California Welfare and Institutions
Code, with the Department to perform fiscal intermediary services related to this
Agreement.
7. Recipients: Refers to all 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 California Welfare and
Institutions Code sections 5709 and 5710 as determined by COUNTY.
8. 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.
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. May: “May” is used to indicate a permissive or discretionary term or function.
11. Shall: “Shall” is used to introduce a covenant of either COUNTY or PROVIDER, and is
mandatory.
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 C
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
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
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 E
Page 1 of 2
Community Behavioral Health Center
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 E
Page 2 of 2
Community Behavioral Health Center
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 2 4 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
Inpatient Psychiatric Services
Exhibit F
MEDI-CAL PSYCHIATRIC INPATIENT HOSPITAL SERVICES
REGIONAL AVERAGE NON-NEGOTIATED RATES1
JULY 1, 2017
REGION2 ACCOMMODATION CODES
114 124 134 154 204
BAY AREA $ 735 $ 1,271 $ 1,226 $ 523 $ 1,550
LOS ANGELES $ 736 $ 676 $ 691 $ 523 $ 724
CENTRAL $ 735 $ 1,102 $ 731 $ 523 $ 804
SOUTHERN $ 721 $ 780 $ 765 $ 523 $ 763
SUPERIOR $ 735 $ 853 $ 731 $ 523 $ 804
STATEWIDE $ 735 $ 853 $ 731 $ 523 $ 804
114 Room and Board-Private Psychiatric
124 Room and Board-Semi-Private 2 Bed, Psychiatric
134 Room and Board-Semi-Private 3 or 4 Bed, Psychiatric
154 Room and Board, Ward (Medical or General), Psychiatric
204 Intensive Care, Psychiatric
Rate Regions
1. Superior - Butte, Colusa, Del Norte, Glenn, Humboldt, Inyo, Lake, Lassen, Mendocino, Modoc,
Nevada, Plumas, Shasta, Sierra, Siskiyou, Tehama, and Trinity counties. Border communities
(Oregon cities) are Ashland, Brookings, Cave Junction, Grants Pass, Jacksonville, Klamath Falls,
Lakeview, Medford, and Merrill.
2. Central - Alpine, Amador, Calaveras, El Dorado, Fresno, Kings, Madera, Mariposa, Merced,
Mono, Placer, Sacramento, San Joaquin, Stanislaus, Sutter, Tulare, Tuolum ne, Yolo, and Yuba
counties. Border communities (Nevada cities) are Carson City, Incline Village, Minden, Reno,
Sparks, and Zephyr Cove.
3. Bay Area - Alameda, Contra Costa, Marin, Monterey, Napa, San Benito, San Francisco, San
Mateo, Santa Clara, Santa Cruz, Solano, and Sonoma counties.
4. Southern - Imperial, Kern, Orange, Riverside, San Bernardino, San Diego, San Luis Obispo,
Santa Barbara, and Ventura counties. Border communities (Nevada cities) are Las Vegas and
Henderson. Border communities (Arizona cities) are Bullhead City, Kingman, Lake Havasu City,
Parker, and Yuma.
5. Los Angeles County.
1 Regional average rates are calculated using FY 2015 -16 paid claims.
2 The Rate Regions, including specified border communities, are listed in the California Code of Regulations, Title 9, Section 1820.115
(i) and reprinted below.
Exhibit G
Page 1 of 3
Documentation Standards For Client Records
The documentation standards are described below under key topics related to client care. All
standards must be addressed in the client record; however, there is no requirement that the
record have a specific document or section addressing these topics. All medical records shall be
maintained for a minimum of ten (10) years from the date of the end of the Agreement.
A. Assessments
1. The following areas will be included as appropriate as a part of a comprehensive client
record.
Relevant physical health conditions reported by the client will be prominently
identified and updated as appropriate.
Presenting problems and relevant conditions affecting the client’s physical health and
mental health status will be documented, for example: living situation, daily activities,
and social support.
Documentation will describe client’s strengths in achieving client plan goals.
Special status situations that present a risk to clients or others will be prominently
documented and updated as appropriate.
Documentations will include medications that have been described by mental health
plan physicians, dosage of each medication, dates of initial prescriptions and refills,
and documentations of informed consent for medications.
Client self report of allergies and adverse reactions to medications, or lack of known
allergies/sensitivities will be clearly documented.
A mental health history will be documented, including: previous treatment dates,
providers, therapeutic interventions and responses, sources of clinical data, relevant
family information and relevant results of relevant lab tests and consultations reports.
For children and adolescents, pre-natal and perinatal events and complete
developmental history will be documented.
Documentations will include past and present use of tobacco, alcohol, and caffeine,
as well as illicit, prescribed and over-the-counter drugs.
A relevant mental status examination will be documented.
A DSM-5 diagnosis, or a diagnosis from the most current ICD, will be documented,
consistent with the presenting problems, history mental status evaluation and/or
other assessment data.
2. Timeliness/Frequency Standard for Assessment
An assessment will be completed at intake and updated as needed to document
changes in the client’s condition.
Client conditions will be assessed at least annually and, in most cases, at more
frequent intervals.
B. Client Plans
1. Client plans will:
have specific observable and/or specific quantifiable goals
Exhibit G
Page 2 of 3
identify the proposed type(s) of intervention
have a proposed duration of intervention(s)
be signed (or electronic equivalent) by:
the person providing the service(s), or
a person representing a team or program providing services, or
a person representing the MHP providing services
when the client plan is used to establish that the services are provided under
the direction of an approved category of staff, and if the below staff are not
the approved category,
a physician
a licensed/ “waivered” psychologist
a licensed/ “associate” social worker
a licensed/ registered/marriage and family therapist or
a registered nurse
In addition,
client plans will be consistent with the diagnosis, and the focus of intervention
will be consistent with the client plan goals, and there will be documentation
of the client’s participation in and agreement with the plan. Examples of the
documentation include, but are not limited to, reference to the client’s
participation and agreement in the body of the plan, client signature on the
plan, or a description of the client’s participation and agreement in progress
notes.
client signature on the plan will be used as the means by which the
CONTRACTOR(S) documents the participation of the client
when the client’s signature is required on the client plan and the client refuses
or is unavailable for signature, the client plan will include a written explanation
of the refusal or unavailability.
The CONTRACTOR(S) will give a copy of the client plan to the client on request.
2. Timeliness/Frequency of Client Plan:
Will be updated at least annually
The CONTRACTOR(S) will establish standards for timeliness and frequency for the
individual elements of the client plan described in Item 1.
C. Progress Notes
1. Items that must be contained in the client record related to the client’s progress in
treatment include:
The client record will provide timely documentation of relevant aspects of client care
Mental health staff/practitioners will use client records to document client encounters,
including relevant clinical decisions and interventions
All entries in the client record will include the signature of the person providing the
service (or electronic equivalent); the person’s professional degree, licensure or job
title; and the relevant identification number, if applicable
All entries will include the date services were provided
The record will be legible
The client record will document follow-up care, or as appropriate, a discharge
summary
Exhibit G
Page 3 of 3
2. Timeliness/Frequency of Progress Notes:
Progress notes shall be documented at the frequency by type of service indicated below:
A. Every Service Contact
Mental Health Services
Medication Support Services
Crisis Intervention
Exhibit H
Page 1 of 6
STATE MENTAL HEALTH REQUIREMENTS
1. CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2. PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business
and Professions and Welfare and Institutions Codes.
3. CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with all
State of California and Federal statutes and regulations regarding confidentiality,
including but not limited to confidentiality of information requirements at 42, Code
of Federal Regulations sections 2.1 et seq; California Welfare and Institutions
Code, sections 14100.2, 11977, 11812, 5328; Division 10.5 and 10.6 of the
California Health and Safety Code; Title 22, California Code of Regulations,
section 51009; and Division 1, Part 2.6, Chapters 1-7 of the California Civil Code.
4. NON-DISCRIMINATION
A. Eligibility for Services
CONTRACTOR shall prepare and make available to COUNTY and to the
public all eligibility requirements to participate in the program plan set
forth in the Agreement. No person shall, because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance.
B. Employment Opportunity
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer, rates
of pay or other forms of compensation, use of facilities, and other terms
and conditions of employment.
Exhibit H
Page 2 of 6
C. Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all further
funds, until CONTRACTOR can show clear and convincing evidence to
the satisfaction of COUNTY that funds provided under this Agreement
were not used in connection with the alleged discrimination.
D. Nepotism
Except by consent of COUNTY’s Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR.
5. PATIENTS' RIGHTS
CONTRACTOR shall comply with applicable laws and regulations, including but
not limited to, laws, regulations, and State policies relating to patients' rights.
STATE CONTRACTOR CERTIFICATION CLAUSES
1. STATEMENT OF COMPLIANCE: CONTRACTOR has, unless exempted,
complied with the non-discrimination program requirements. (Gov. Code§ 12990 (a-f)
and CCR, Title 2, Section 111 02) (Not applicable to public entities.)
2. DRUG-FREE WORKPLACE REQUIREMENTS: CONTRACTOR will comply
with the requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-
free workplace by taking the following actions:
a. Publish a statement notifying employees that unlawful manufacture,
distribution, dispensation, possession or use of a controlled substance is prohibited and
specifying actions to be taken against employees for violations.
b. Establish a Drug-Free Awareness Program to inform employees about:
1) the dangers of drug abuse in the workplace;
2) the person's or organization's policy of maintaining a drug-free
workplace;
3) any available counseling, rehabilitation and employee assistance
programs; and,
4) penalties that may be imposed upon employees for drug abuse
violations.
c. Every employee who works on this Agreement will:
1) receive a copy of the company's drug-free workplace policy
statement; and,
2) agree to abide by the terms of the company's statement as a
condition of employment on this Agreement.
Exhibit H
Page 3 of 6
Failure to comply with these requirements may result in suspension of payments under
this Agreement or termination of this Agreement or both and CONTRACTOR may be
ineligible for award of any future State agreements if the department determines that any
of the following has occurred: the CONTRACTOR has made false certification, or
violated the certification by failing to carry out the requirements as noted above. (Gov.
Code §8350 et seq.)
3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION: CONTRACTOR
certifies that no more than one (1) final unappealable finding of contempt of court by a
Federal court has been issued against CONTRACTOR within the immediately preceding
two (2) year period because of CONTRACTOR’s failure to comply with an order of a
Federal court, which orders CONTRACTOR to comply with an order of the National
Labor Relations Board. (Pub. Contract Code §10296) (Not applicable to public entities.)
4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO
REQUIREMENT: CONTRACTOR hereby certifies that CONTRACTOR will comply with
the requirements of Section 6072 of the Business and Professions Code, effective
January 1, 2003.
CONTRACTOR agrees to make a good faith effort to provide a minimum number of
hours of pro bono legal services during each year of the contract equal to the lessor of
30 multiplied by the number of full time attorneys in the firm’s offices in the State, with
the number of hours prorated on an actual day basis for any contract period of less than
a full year or 10% of its contract with the State.
Failure to make a good faith effort may be cause for non-renewal of a state contract for
legal services, and may be taken into account when determining the award of future
contracts with the State for legal services.
5. EXPATRIATE CORPORATIONS: CONTRACTOR hereby declares that it is not
an expatriate corporation or subsidiary of an expatriate corporation within the meaning of
Public Contract Code Section 10286 and 10286.1, and is eligible to contract with the
State of California.
6. SWEATFREE CODE OF CONDUCT:
a. All CONTRACTORS contracting for the procurement or laundering of
apparel, garments or corresponding accessories, or the procurement of equipment,
materials, or supplies, other than procurement related to a public works contract, declare
under penalty of perjury that no apparel, garments or corresponding accessories,
equipment, materials, or supplies furnished to the state pursuant to the contract have
been laundered or produced in whole or in part by sweatshop labor, forced labor, convict
labor, indentured labor under penal sanction, abusive forms of child labor or exploitation
of children in sweatshop labor, or with the benefit of sweatshop labor, forced labor,
convict labor, indentured labor under penal sanction, abusive forms of child labor or
exploitation of children in sweatshop labor. CONTRACTOR further declares under
penalty of perjury that they adhere to the Sweatfree Code of Conduct as set forth on the
California Department of Industrial Relations website located at www.dir.ca.gov, and
Public Contract Code Section 6108.
Exhibit H
Page 4 of 6
b. CONTRACTOR agrees to cooperate fully in providing reasonable access
to the CONTRACTOR’s records, documents, agents or employees, or premises if
reasonably required by authorized officials of the contracting agency, the Department of
Industrial Relations, or the Department of Justice to determine the contractor’s
compliance with the requirements under paragraph (a).
7. DOMESTIC PARTNERS: For contracts of $100,000 or more, CONTRACTOR
certifies that CONTRACTOR is in compliance with Public Contract Code Section
10295.3.
8. GENDER IDENTITY: For contracts of $100,000 or more, CONTRACTOR
certifies that CONTRACTOR is in compliance with Public Contract Code Section
10295.35.
DOING BUSINESS WITH THE STATE OF CALIFORNIA
The following laws apply to persons or entities doing business with the State of
California.
1. CONFLICT OF INTEREST: CONTRACTOR needs to be aware of the following
provisions regarding current or former state employees. If CONTRACTOR has any
questions on the status of any person rendering services or involved with this
Agreement, the awarding agency must be contacted immediately for clarification.
Current State Employees (Pub. Contract Code §10410):
a). No officer or employee shall engage in any employment, activity or
enterprise from which the officer or employee receives compensation or has a financial
interest and which is sponsored or funded by any state agency, unless the employment,
activity or enterprise is required as a condition of regular state employment.
b). No officer or employee shall contract on his or her own behalf as an
independent contractor with any state agency to provide goods or services.
Former State Employees (Pub. Contract Code §10411):
a). For the two (2) year period from the date he or she left state employment,
no former state officer or employee may enter into a contract in which he or she
engaged in any of the negotiations, transactions, planning, arrangements or any part of
the decision-making process relevant to the contract while employed in any capacity by
any state agency.
b). For the twelve (12) month period from the date he or she left state
employment, no former state officer or employee may enter into a contract with any state
agency if he or she was employed by that state agency in a policy-making position in the
same general subject area as the proposed contract within the twelve (12) month period
prior to his or her leaving state service.
If CONTRACTOR violates any provisions of above paragraphs, such action by
CONTRACTOR shall render this Agreement void. (Pub. Contract Code §10420)
Exhibit H
Page 5 of 6
Members of boards and commissions are exempt from this section if they do not receive
payment other than payment of each meeting of the board or commission, payment for
preparatory time and payment for per diem. (Pub. Contract Code §10430 (e))
2. LABOR CODE/WORKERS' COMPENSATION: CONTRACTOR needs to be
aware of the provisions which require every employer to be insured against liability for
Worker's Compensation or to undertake self-insurance in accordance with the
provisions, and CONTRACTOR affirms to comply with such provisions before
commencing the performance of the work of this Agreement. (Labor Code Section 3700)
3. AMERICANS WITH DISABILITIES ACT: CONTRACTOR assures the State that
it complies with the Americans with Disabilities Act (ADA) of 1990, which prohibits
discrimination on the basis of disability, as well as all applicable regulations and
guidelines issued pursuant to the ADA. (42 U.S.C. 12101 et seq.)
4. CONTRACTOR NAME CHANGE: An amendment is required to change the
CONTRACTOR’s name as listed on this Agreement. Upon receipt of legal
documentation of the name change the State will process the amendment. Payment of
invoices presented with a new name cannot be paid prior to approval of said
amendment.
5. CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:
a. When agreements are to be performed in the state by corporations, the
contracting agencies will be verifying that the CONTRACTOR is currently qualified to do
business in California in order to ensure that all obligations due to the state are fulfilled.
b. "Doing business" is defined in R&TC Section 23101 as actively engaging
in any transaction for the purpose of financial or pecuniary gain or profit. Although there
are some statutory exceptions to taxation, rarely will a corporate contractor performing
within the state not be subject to the franchise tax.
c. Both domestic and foreign corporations (those incorporated outside of
California) must be in good standing in order to be qualified to do business in California.
Agencies will determine whether a corporation is in good standing by calling the Office of
the Secretary of State.
6. RESOLUTION: A county, city, district, or other local public body must provide
the State with a copy of a resolution, order, motion, or ordinance of the local governing
body, which by law has authority to enter into an agreement, authorizing execution of the
agreement.
7. AIR OR WATER POLLUTION VIOLATION: Under the State laws, the
CONTRACTOR shall not be: (1) in violation of any order or resolution not subject to
review promulgated by the State Air Resources Board or an air pollution control district;
(2) subject to cease and desist order not subject to review issued pursuant to Section
13301 of the Water Code for violation of waste discharge requirements or discharge
prohibitions; or (3) finally determined to be in violation of provisions of federal law
relating to air or water pollution.
Exhibit H
Page 6 of 6
8. PAYEE DATA RECORD FORM STD. 204: This form must be completed by all
contractors that are not another state agency or other governmental entity.
9. INSPECTION and Audit of Records and access to Facilities.
The State, CMS, the Office of the Inspector General, the Comptroller General, and their
designees may, at any time, inspect and audit any records or documents of
CONTRACTOR or its subcontractors, and may, at any time, inspect the premises,
physical facilities, and equipment where Medicaid-related activities or work is conducted.
The right to audit under this section exists for ten (10) years from the final date of the
contract period or from the date of completion of any audit, whichever is later.
Federal database checks.
Consistent with the requirements at § 455.436 of this chapter, the State must confirm the
identity and determine the exclusion status of CONTRACTOR, any subcontractor, as
well as any person with an ownership or control interest, or who is an agent or managing
employee of CONTRACTOR through routine checks of Federal databases. This
includes the Social Security Administration's Death Master File, the National Plan and
Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE),
the System for Award Management (SAM), and any other databases as the State or
Secretary may prescribe. These databases must be consulted upon contracting and no
less frequently than monthly thereafter. If the State finds a party that is excluded, it must
promptly notify the CONTRACTOR and take action consistent with § 438.610(c).
The State must ensure that CONTRACTOR with which the State contracts under this
part is not located outside of the United States and that no claims paid by a
CONTRACTOR to a network provider, out-of-network provider, subcontractor or financial
institution located outside of the U.S. are considered in the development of actuarially
sound capitation rates.
Exhibit H-1
Page 1 of 3
CERTIFICATION
I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly
authorized to legally bind the prospective Contractor to the clause(s) listed below. This
certification is made under the laws of the State of California.
Contractor/Bidder Firm Name (Printed):
Federal ID Number County of Fresno 94-6000512
_______________________________________________
By (Signature)
_ _____________________________________________
Printed Name and Title of Person Signing
______________________________________________
Date Executed
Executed in the County of Fresno
CONTRACTOR CERTIFICATION CLAUSES
1. STATEMENT OF COMPLIANCE
Contractor has, unless exempted, complied with the nondiscrimination program
requirements. (Gov. Code§ 12990 (a-f) and CCR, Title 2, Section 111 02) (Not
applicable to public entities.)
2. DRUG-FREE WORKPLACE REQUIREMENTS
Contractor will comply with the requirements of the Drug-Free Workplace Act of
1990 and will provide a drug-free workplace by taking the following actions:
a. Publish a statement notifying employees that unlawful manufacture,
distribution, dispensation, possession or use of a controlled substance is
prohibited and specifying actions to be taken against employees for
violations.
b. Establish a Drug-Free Awareness Program to inform employees about:
1) the dangers of drug abuse in the workplace;
Exhibit H-1
Page 2 of 3
CONTRACTOR CERTIFICATION CLAUSES (Continued)
2) the person's or organization's policy of maintaining a drug-free
workplace;
3) any available counseling, rehabilitation and employee assistance
programs; and
4) penalties that may be imposed upon employees for drug abuse
violations.
c. Every employee who works on the proposed Agreement will:
1) receive a copy of the company's drug-free workplace policy statement;
and,
2) agree to abide by the terms of the company's statement as a condition
of employment on the Agreement.
Failure to comply with these requirements may result in suspension of payments
under the Agreement or termination of the Agreement or both and Contractor
may be ineligible for award of any future State agreements if the department
determines that any of the following has occurred: the Contractor has made false
certification, or violated the certification by failing to carry out the requirements as
noted above. (Gov. Code §8350 et seq.)
3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION
Contractor certifies that no more than one (1) final unappealable finding of
contempt of court by a Federal court has been issued against Contractor within
the immediately preceding two-year period because of Contractor's failure to
comply with an order of a Federal court, which orders Contractor to comply with
an order of the National Labor Relations Board. (Pub. Contract Code §10296)
(Not applicable to public entities.)
4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO
REQUIREMENT
Contractor hereby certifies that Contractor will comply with the requirements of
Section 6072 of the Business and Professions Code, effective January 1,
2003. Contractor agrees to make a good faith effort to provide a minimum
number of hours of pro bono legal services during each year of the contract
equal to the lessor of 30 multiplied by the number of full time attorneys in the
firm’s offices in the State, with the number of hours prorated on an actual day
basis for any contract period of less than a full year or 10% of its contract with the
State. Failure to make a good faith effort may be cause for non-renewal of a state
contract for legal services, and may be taken into account when determining the
award of future contracts with the State for legal services.
Exhibit H-1
Page 3 of 3
CONTRACTOR CERTIFICATION CLAUSES (Continued)
5. EXPATRIATE CORPORATIONS
Contractor hereby declares that it is not an expatriate corporation or subsidiary of
an expatriate corporation within the meaning of Public Contract Code Section
10286 and 10286.1, and is eligible to contract with the State of California.
6. SWEATFREE CODE OF CONDUCT:
a. All Contractors contracting for the procurement or laundering of apparel,
garments or corresponding accessories, or the procurement of equipment,
materials, or supplies, other than procurement related to a public works
contract, declare under penalty of perjury that no apparel, garments or
corresponding accessories, equipment, materials, or supplies furnished to
the state pursuant to the contract have been laundered or produced in
whole or in part by sweatshop labor, forced labor, convict labor,
indentured labor under penal sanction, abusive forms of child labor or
exploitation of children in sweatshop labor, or with the benefit of
sweatshop labor, forced labor, convict labor, indentured labor under penal
sanction, abusive forms of child labor or exploitation of children in
sweatshop labor.
The contractor further declares under penalty of perjury that they adhere
to the Sweatfree Code of Conduct as set forth on the California
Department of Industrial Relations website located at www.dir.ca.gov, and
Public Contract Code Section 6108.
b. The contractor agrees to cooperate fully in providing reasonable access to
the contractor’s records, documents, agents or employees, or premises if
reasonably required by authorized officials of the contracting agency, the
Department of Industrial Relations, or the Department of Justice to
determine the contractor’s compliance with the requirements under
paragraph (a).
6. DOMESTIC PARTNERS
For contracts of $100,000 or more, Contractor certifies that Contractor is in
compliance with Public Contract Code section 10295.3.
7. GENDER IDENTITY
For contracts of $100,000 or more, Contractor certifies that Contractor is in
compliance with Public Contract Code section 10295.35.
Exhibit H-1
CERTIFICATION
I, the official named below, CERTIFY UNDER PENAL TY OF PERJURY that I am duly
authorized to legally bind the prospective Contractor to the clause(s) listed below. This
certification is made under the laws of the State of California.
Contractor/Bidder Firm Name (Printed): Behavioral Health Care Fremont Hospital
Federal ID Number County of Fresno 94-6000512
By (Signature) �
Printed Name and Title of Person Signing
Date Executed
Executed in the County of Fresno
CONTRACTOR CERTIFICATION CLAUSES
1.STATEMENT OF COMPLIANCE
Contractor has, unless exempted, complied with the nondiscrimination program
requirements. (Gov. Code§ 12990 (a-f) and.CCR, Title 2, Section 111 02) (Not
applicable to public entities.)
2.DRUG-FREE WORKPLACE REQUIREMENTS
Contractor will comply with the requirements of the Drug-Free Workplace Act of
1990 and will provide a drug-free workplace by taking the following actions:
a.Publish a statement notifying employees that unlawful manufacture,
distribution, dispensation, possession or use of a controlled substance is
prohibited and specifying actions to be taken against employees for
violations.
b.Establish a Drug-Free Awareness Program to inform employees about:
1)the dangers of drug abuse in the workplace;
Page 1 of 3
Exhibit H-1
CERTIFICATION
I, the official named below, CERTIFY UNDER PENAL TY OF PERJURY that I am duly
authorized to legally bind the prospective Contractor to the clause(s) listed below. This
certification is made under the laws of the State of California.
Contractor/Bidder Firm Name (Printed): Bakersfield Behavioral Health Hospital
Federal ID Number County of Fresno 94-6000512
�J By (Sig�
BECKIE SHAUINGER, CHIEF EXECUTIVE OFFICER
Printed Name and Title of Person Signing
Date Executed
Executed in the County of Fresno
CONTRACTOR CERTIF ICATION CLAUSES
1.STATEMENT OF COMPLIANCE
Contractor has, unless exempted, complied with the nondiscrimination program
requirements. (Gov. Code§ 12990 (a-f) and CCR, Title 2, Section 111 02) (Not
applicable to public entities.)
2.DRUG-FREE WORKPLACE REQUIREMENTS
Contractor will comply with the requirements of the Drug-Free Workplace Act of
1990 and will provide a drug-free workplace by taking the following actions:
a.Publish a statement notifying employees that unlawful manufacture,
distribution, dispensation, possession or use of a controlled substance is
prohibited and specifying actions to be taken against employees for
violations.
b.Establish a Drug-Free Awareness Program to inform employees about:
1)the dangers of drug abuse in the workplace;
Page 1 of3
STATE OF CALIFORNIA-DEPARTMENT OF FINANCE
PAYEE DATA RECORD
(Required when receiving payment from the State of California in lieu of IRS W-9)
STD. 204 (Rev. 6-2003)
INSTRUCTIONS: Complete all information on this form. Sign, date, and return to the State agency (department/office) address shown at
the bottom of this page. Prompt return of this fully completed form will prevent delays when processing payments. Information provided in
this form will be used by State agencies to prepare Information Returns (1099). See reverse side for more information and Privacy
Statement.
NOTE: Governmental entities, federal, State, and local (including school districts), are not required to submit this form.
PAYEE’S LEGAL BUSINESS NAME (Type or Print)
SOLE PROPRIETOR – ENTER NAME AS SHOWN ON SSN (Last, First, M.I.)
E-MAIL ADDRESS
MAILING ADDRESS
BUSINESS ADDRESS
CITY, STATE, ZIP CODE
CITY, STATE, ZIP CODE
ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): –
PARTNERSHIP
ESTATE OR TRUST
CORPORATION:
MEDICAL (e.g., dentistry, psychotherapy, chiropractic, etc.)
LEGAL (e.g., attorney services)
EXEMPT (nonprofit)
ALL OTHERS
PAYEE
ENTITY
TYPE
CHECK
ONE BOX
ONLY
INDIVIDUAL OR SOLE PROPRIETOR
ENTER SOCIAL SECURITY NUMBER:
(SSN required by authority of California Revenue and Tax Code Section 18646)
– –
NOTE:
Payment will not
be processed
without an
accompanying
taxpayer I.D.
number.
PAYEE
RESIDENCY
STATUS
California resident - Qualified to do business in California or maintains a permanent place of business in California.
California nonresident (see reverse side) - Payments to nonresidents for services may be subject to State income tax
withholding.
No services performed in California.
Copy of Franchise Tax Board waiver of State withholding attached.
I hereby certify under penalty of perjury that the information provided on this document is true and correct.
Should my residency status change, I will promptly notify the State agency below.
AUTHORIZED PAYEE REPRESENTATIVE’S NAME (Type or Print)
TITLE
SIGNATURE
DATE
TELEPHONE
( )
Please return completed form to:
Department/Office:
Unit/Section:
Mailing Address:
City/State/Zip:
Telephone: ( ) Fax: ( )
E-mail Address:
1
2
3
4
5
6
STATE OF CALIFORNIA-DEPARTMENT OF FINANCE
PAYEE DATA RECORD
STD. 204 (Rev. 6-2003) (REVERSE)
1
Requirement to Complete Payee Data Record, STD. 204
A completed Payee Data Record, STD. 204, is required for payments to all non-governmental entities and will be kept on file at each
State agency. Since each State agency with which you do business must have a separate STD. 204 on file, it is possible for a payee
to receive this form from various State agencies.
Payees who do not wish to complete the STD. 204 may elect to not do business with the State. If the payee does not complete the
STD. 204 and the required payee data is not otherwise provided, payment may be reduced for federal backup withholding and
nonresident State income tax withholding. Amounts reported on Information Returns (1099) are in accordance with the Internal
Revenue Code and the California Revenue and Taxation Code.
2
Enter the payee’s legal business name. Sole proprietorships must also include the owner’s full name. An individual must list his/her
full name. The mailing address should be the address at which the payee chooses to receive correspondence. Do not enter
payment address or lock box information here.
3
Check the box that corresponds to the payee business type. Check only one box. Corporations must check the box that identifies
the type of corporation. The State of California requires that all parties entering into business transactions that may lead to
payment(s) from the State provide their Taxpayer Identification Number (TIN). The TIN is required by the California Revenue and
Taxation Code Section 18646 to facilitate tax compliance enforcement activities and the preparation of Form 1099 and other
information returns as required by the Internal Revenue Code Section 6109(a).
The TIN for individuals and sole proprietorships is the Social Security Number (SSN). Only partnerships, estates, trusts, and
corporations will enter their Federal Employer Identification Number (FEIN).
4
Are you a California resident or nonresident?
A corporation will be defined as a "resident" if it has a permanent place of business in California or is qualified through the Secretary
of State to do business in California.
A partnership is considered a resident partnership if it has a permanent place of business in California. An estate is a resident if the
decedent was a California resident at time of death. A trust is a resident if at least one trustee is a California resident.
For individuals and sole proprietors, the term "resident" includes every individual who is in California for other than a temporary or
transitory purpose and any individual domiciled in California who is absent for a temporary or transitory purpose. Generally, an
individual who comes to California for a purpose that will extend over a long or indefinite period will be considered a resident.
However, an individual who comes to perform a particular contract of short duration will be considered a nonresident.
Payments to all nonresidents may be subject to withholding. Nonresident payees performing services in California or receiving rent,
lease, or royalty payments from property (real or personal) located in California will have 7% of their total payments withheld for State
income taxes. However, no withholding is required if total payments to the payee are $1,500 or less for the calendar year.
For information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below:
Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: wscs.gen@ftb.ca.gov
For hearing impaired with TDD, call: 1-800-822-6268 Website: www.ftb.ca.gov
5
Provide the name, title, signature, and telephone number of the individual completing this form. Provide the date the form was
completed.
6
This section must be completed by the State agency requesting the STD. 204.
Privacy Statement
Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, State, or local governmental agency, which
requests an individual to disclose their social security account number, shall inform that individual whether that disclosure is
mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it.
It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not
provided is subject to federal backup withholding and State law imposes noncompliance penalties of up to $20,000.
You have the right to access records containing your personal information, such as your SSN. To exercise that right, please contact
the business services unit or the accounts payable unit of the State agency(ies) with which you transact that business.
All questions should be referred to the requesting State agency listed on the bottom front of this form.
Exhibit I
Page 1 of 2
Medi-Cal Organizational Provider Standards
1. The organizational provider possesses the necessary license to operate, if applicable, and any
required certification.
2. The space owned, leased or operated by the provider and used for services or staff meets
local fire codes.
3. The physical plant of any site owned, leased, or operated by the provider and used for
services or staff is clean, sanitary and in good repair.
4. The organizational provider establishes and implements maintenance policies for any site
owned, leased, or operated by the provider and used for services or staff to ensure the safety
and well being of beneficiaries and staff.
5. The organizational provider has a current administrative manual which includes: personnel
policies and procedures, general operating procedures, service delivery policies, and
procedures for reporting unusual occurrences relating to health and safety issues.
6. The organizational provider maintains client records in a manner that meets applicable state
and federal standards.
7. The organization provider has staffing adequate to allow the County to claim federal
financial participation for the services the Provider delivers to beneficiaries, as described in
Division 1, Chapter 11, Subchapter 4 of Title 9, CCR, when applicable.
8. The organizational provider has written procedures for referring individuals to a psychiatrist
when necessary, or to a physician, if a psychiatrist is not available.
9. The organizational provider has as head of service a licensed mental health professional of
other appropriate individual as described in Title 9, CCR, Sections 622 through 630.
10. For organizational providers that provide or store medications, the provider stores and
dispenses medications in compliance with all pertinent state and federal standards. In
particular:
A. All drugs obtained by prescription are labeled in compliance with federal and state laws.
Prescription labels are altered only by persons legally authorized to do so.
B. Drugs intended for external use only or food stuffs are stored separately from drugs for
internal use.
C. All drugs are stored at proper temperatures, room temperature drugs at 59-86 degrees F
and refrigerated drugs at 36-46 degrees F.
Exhibit I
Page 2 of 2
D. Drugs are stored in a locked area with access limited to those medical personnel
authorized to prescribe, dispense or administer medication.
E. Drugs are not retained after the expiration date. IM multi-dose vials are dated and
initialed when opened.
F. A drug log is maintained to ensure the provider disposes of expired, contaminated,
deteriorated and abandoned drugs in a manner consistent with state and federal laws.
G. Policies and procedures are in place for dispensing, administering and storing
medications.
11. For organizational providers that provide day treatment intensive or day rehabilitation, the
provider must have a written description of the day treatment intensive and/or day treatment
rehabilitation program that complies with State Department of Health Care Service’s day
treatment requirements. The COUNTY shall review the provider’s written program
description for compliance with the State Department of Health Care Service’s day
treatment requirements.
12. The COUNTY may accept the host county’s site certification and reserves the right to
conduct an on-site certification review at least every three (3) years. The COUNTY may
also conduct additional certification reviews when:
The provider makes major staffing changes.
The provider makes organizational and/or corporate structure changes (example:
conversion from a non-profit status).
The provider adds day treatment or medication support services when medications shall
be administered or dispensed from the provider site.
There are significant changes in the physical plant of the provider site (some physical
plant changes could require a new fire clearance).
There is change of ownership or location.
There are complaints against the provider.
There are unusual events, accidents, or injuries requiring medical treatment for clients,
staff or members of the community.
Exhibit J
Page 1 of 2
Fresno County Mental Health Plan Grievances and Appeals Process
The Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance
and appeal process and an expedited appeal process to resolve grievances and
disputes at the earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee -for-
service providers to give verbal and written information to Medi-Cal beneficiaries
regarding the following:
How to access specialty mental health services
How to file a grievance about services
How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a grievance
form, an appeal form, and Request for Change of Provider Form. All of these
beneficiary materials must be posted in prominent locations where Medi-Cal
beneficiaries receive outpatient specialty mental health services, including the waiting
rooms of providers’ offices of service.
Please note that all fee-for-service providers and contract agencies are required to give
their clients copies of all current beneficiary information annually at the time their
treatment plans are updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without any
penalty, change in mental health services, or any form of retaliation. All Medi -Cal
beneficiaries can file an appeal or state hearing.
Grievances and appeals forms and self-addressed envelopes must be available for
beneficiaries to pick up at all provider sites without having to make a verbal or written
request. Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
(800) 654-3937 (for more information)
(559) 488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple, informal procedure in identifying and resolving provider
concerns and problems regarding payment authorization issues, other complaints and
concerns.
Exhibit J
Page 2 of 2
Informal provider problem resolution process – the provider may first speak to a
Provider Relations Specialist (PRS) regarding his or her complaint or concern.
The PRS will attempt to settle the complaint or concern with the provider. If the attempt
is unsuccessful and the provider chooses to forego the informal grievance process, the
provider will be advised to file a written complaint to the MHP address (listed above).
Formal provider appeal process – the provider has the right to access the provider
appeal process at any time before, during, or after the provider problem resolution
process has begun, when the complaint concerns a denied or modified request for MHP
payment authorization, or the process or payment of a provider’s claim to the MHP.
Payment authorization issues – the provider may appeal a denied or modified request
for payment authorization or a dispute with the MHP regarding the processing or
payment of a provider’s claim to the MHP. The written appeal must be submitted to the
MHP within ninety (90) calendar days of the date of the receipt of the non-approval of
payment.
The MHP shall have sixty (60) calendar days from its receipt of the appeal to inform the
provider in writing of the decision, including a statement of the reasons for the decision
that addresses each issue raised by the provider, and any action required by the
provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request, the
MHP utilizes Managed Care staff who were not involved in the initial denial or
modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be asked to
submit a revised request for payment within thirty (30) calendar days of receipt of the
decision
Other complaints – if there are other issues or complaints, which are not related to
payment authorization issues, providers are encouraged to send a letter of complaint to
the MHP. The provider will receive a written response from the MHP within sixty (60)
calendar days of receipt of the complaint. The decision rendered buy the MHP is final.
Exhibit K
Page 1 of 2
FFRREESSNNOO CCOOUUNNTTYY MMEENNTTAALL HHEEAALLTTHH PPLLAANN
IINNCCIIDDEENNTT RREEPPOORRTTIINNGG
PPRROOTTOOCCOOLL FFOORR CCOOMMPPLLEETTIIOONN OOFF IINNCCIIDDEENNTT RREEPPOORRTT
The Incident Report must be completed for all incidents involving clients. The staff person
who becomes aware of the incident completes this form, and the sup ervisor co-signs it.
When more than one client is involved in an incident, a separate form must be completed
for each client.
Where the forms should be sent - within 24 hours from the time of the incident
Incident Report should be sent to:
DBH Program Supervisor
Exhibit K
Page 2 of 2
INCIDENT REPORT WORKSHEET
When did this happen? (date/time) Where did this happen?
Name/DMH #
1. Background information of the incident:
2. Method of investigation: (chart review, face-to-face interview, etc.)
Who was affected? (If other than consumer)
List key people involved. (witnesses, visitors, physicians, employees)
3. Preliminary findings: How did it happen? Sequence of events. Be specific. If attachments are needed write
comments on an 8 1/2 sheet of paper and attach to worksheet.
Outcome severity: Nonexistent inconsequential consequential death not applicable unknown
4. Response: a) corrective action, b) Plan of Action, c) other
Completed by (print name)
Completed by (signature) Date completed
Reviewed by Supervisor (print name)
Supervisor Signature Date
Exhibit L
Page 1 of 3
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of entity D/B/A
Address (number, street) City State ZIP code
CLIA number Taxpayer ID number (EIN) Telephone number
( )
II. Answer the following questions by checking “Yes” or “No.” If any of the questions are answered “Yes,” list names and
addresses of individuals or corporations under “Remarks” on page 2. Identify each item number to be continued.
A. Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percent or more in the institution, organizations, or agency that have been convicted of a criminal
offense related to the involvement of such persons or organizations in any of the programs established
YES NO
by Titles XVIII, XIX, or XX? ......................................................................................................................... ❒ ❒
B. Are there any directors, officers, agents, or managing employees of the institution, agency, or
organization who have ever been convicted of a criminal offense related to their involvement in such
programs established by Titles XVIII, XIX, or XX? ...................................................................................... ❒ ❒
C. Are there any individuals currently employed by the institution, agency, or organization in a managerial,
accounting, auditing, or similar capacity who were employed by the institution’s, organization’s, or
agency’s fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) ........... ❒ ❒
III. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling
interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names
and addresses under “Remarks” on page 2. If more than one individual is reported and any of these persons are
related to each other, this must be reported under “Remarks.”
NAME ADDRESS EIN
B. Type of entity: ❒ Sole proprietorship ❒ Partnership ❒ Corporation
❒ Unincorporated Associations ❒ Other (specify)
C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations
under “Remarks.”
D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses
of individuals, and provider numbers. ..........................................................................................................
❒ ❒
NAME ADDRESS PROVIDER NUMBER
Exhibit L
Page 2 of 3
Exhibit L
Page 3 of 3
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... ❒ ❒
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... ❒ ❒
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ ❒ ❒
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... ❒ ❒
If yes, give date of change in operations.
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... ❒ ❒
VII. A. Is this facility chain affiliated? ...................................................................................................................... ❒ ❒
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
B. If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed) Title
Signature Date
Remarks
Exhibit M
1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHE R
RESPONSIBILITY MATTERS --PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is
providing the certification set ou t 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 certific ation 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 th e 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 M
2 of 2
CERTIFICATION
(1) The prospective primary participant certifies to the best of its knowledge and belief,
that it, its owners, officers, corporate managers and partners:
(a) Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of
or had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c) (d) Have not within a three-year period preceding this application/proposal
had one or more public transactions (Federal, State or local) terminated for cause or
default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanati on
to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or
Company)
Exhibit N
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “County”),
members of a contractor’s board of directors (hereinafter referred to as “County Contractor”), must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self-dealing transaction is defined below:
“A self-dealing transaction means a transaction to which the corporat ion 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 a pplicable
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 N
Page 2 of 2
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to)
(4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a)
(5) Authorized Signature
Signature: Date: