HomeMy WebLinkAboutAgreement A-18-418 with Exhibit A "List of Contractors'.pdfAgreement No. 18-418
1 MASTER AGREEMENT
2 This Agreement is made and entered into this 7th day of August , 2018, by and
3 between the COUNTY OF f:=RESNO, a Political Subdivision of the State of California, hereinafter
4 referred to as "COUNTY", and each CONTRACTOR listed in Exhibit A "List of Contractors", attached
5 hereto and by this reference incorporated herein, and collectively hereinafter referred to as
6 "CONTRACTORS", and such additional CONTRACTOR($) as may, from time to time during the term
7 · of this Agreement, be added by COUNTY. Reference in this Agreement to "parties" shall be
8 understood to refer to COUNTY and each individual CONTRACTOR, unless otherwise specified.
9 WI T N E S S E T H:
10 WHEREAS, Assembly Bill 403 provides for the discontinuation of the Rate Classification Level
11 (RCL) system for group homes, the creation of the Short-Term Residential Treatment Program
12 (STRTP) licensing category, and requires existing group homes to become licensed as an STRTP by
13 December 31, 2018; and
14 WHEREAS; Assembly Bill 1997 provides that a licensed STRTP shall provide or ensure access
15 to specialty mental health services to youth and non-minor dependents placed in their care and has
16 twelve (12) months from the date of licensure to obtain local mental health program approval, including
17 Medi-Cal site certification by said local Mental Health Plan, in order to provide said specialty mental
18 health services; and
19 WHEREAS, COUNTY through its Department of Behavioral Health (DBH) is a Mental Health
20 Plan (MHP) as defined in Title 9 of the California Code of Regulations (C.C.R.), Section 1810.226; and
21 WHEREAS, Fresno County youth and non-minor dependents placed in an STRTP within
22 Fresno County, an STRTP outside Fresno County, or a group home located outside the State of
23 California, are in need of specialty mental health services; and
24 WHEREAS, Assembly Bill 403 requires that the certification standards applicable to out-of-state
25 group homes be those required of an STRTP; and
26 WHEREAS, CONTRACTOR(S) are qualified and willing to provide said services pursuant to the
27 terms and conditions of this Agreement; and
28 WHEREAS, this Agreement shall supersede the Agreement between the COUNTY and RCL
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12, 13, and 14 group homes identified as COUNTY Agreement No. 14-313-1 as of December 31,
2018; and
WHEREAS, RCL 12, 13, and 14 group homes currently parties to Agreement 14-313-1 may
continue to provide services under said Agreement until STRTP licensure is achieved and mental
health program approval is obtained, or until December 31, 2018, whichever applies sooner.
NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties
hereto agree as follows:
1. SERVICES
A. CONTRACTOR(S) shall perform all services and fulfill all responsibilities
identified in Exhibit B, “Program Overview”, attached hereto and by this reference incorporated herein
and made part of this Agreement. CONTRACTOR’s shall also perform all services and fulfill all
responsibilities as set forth in their individual “Summary of Services,” as approved by the COUNTY
Mental Health Plan (MHP), attached hereto as Exhibits B-1, et seq. and incorporated herein by
reference.
B. CONTRACTOR(S) operating within Fresno County 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.
C. CONTRACTOR(S) operating outside of Fresno County shall obtain and maintain
mental health program approval by their local MHP or the State Department of Health Care Services
(DHCS).
D. CONTRACTOR(S) operating outside the State of California shall meet STRTP
licensure standards.
E. CONTRACTOR(S) 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.
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F. It is the expectation of the COUNTY that CONTRACTOR(S) provide timely
access to services that meet the State of California standards for care. CONTRACTOR(S) shall
provide non-urgent care services within ten (10) business days from request/referral to first
appointment. CONTRACTOR(S) shall provide psychiatry services within fifteen (15) business days
from request/referral to first appointment. CONTRACTOR(S) shall provide urgent services as soon as
needed based on each client’s needs. CONTRACTOR(S) shall track timeliness of services to clients
and provide a monthly report showing the monitoring or tracking tool that captures this data. COUNTY
and CONTRACTOR(S) shall meet to go over this monitoring or tracking tool that captures this data.
COUNTY and CONTRACTOR(S) shall meet to go over this monitoring tool on a monthly basis as
needed. COUNTY shall take corrective action if there is a failure to comply by CONTRACTOR(S) with
the above timely access standards. CONTRACTOR(S) shall also provide tracking tools and
measurements for effectiveness, efficiency, access, and client satisfaction indicators as required by
the Commission on Accreditation of Rehabilitation Facilities (CARF) standards and as further detailed
in Exhibits B-1, et seq. Documentation for these four (4) indicators shall include the following data: to
whom the indicator applied, who is responsible for collecting the data, time of measure, data source,
and target goal expectancy.
G. CONTRACTOR(S) located within the State of California shall utilize the
California Child and Adolescents Needs and Strengths (CANS-50) and Pediatric Symptom Checklist –
parent/caregiver version (PSC-35) tools to measure child and youth functioning, as intended by W &IC
Section 14707.5. CONTRACTOR(S) shall complete the CANS-50 and parents/caregivers will
complete the PSC-35 for children and youth, up to age eighteen (18). These tools shall be completed
at the beginning of treatment, every six (6) months following the first administration, and at the end of
treatment. Facilitators of these tools shall be trained by a CANS-certified trainer approved by the
State. Training for the PSC-35 is not required by the State of California.
H. It is acknowledged by all parties hereto that COUNTY’s DBH Administrative units
shall monitor the services provided by CONTRACTOR(S), as specified herein.
I. CONTRACTOR(S) shall participate in periodic workgroup meetings including
staff from COUNTY’s DBH as well as staff from COUNTY’s Departments of Social Services and/or
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Probation. The meetings shall be held at a frequency agreed upon between COUNTY and
CONTRACTOR(S), to discuss program requirements, data reporting, outcomes measurement,
training, policies and procedures, and overall program operations.
J. It is acknowledged by all parties hereto that upon execution of this Agreement,
CONTRACTOR(S)’ service site shall be identified in Exhibits B-1, et seq. Any change to
CONTRACTOR(S) location of the service site may be made only upon thirty (30) days advance written
notification to COUNTY’s DBH Director and upon written approval from COUNTY’s DBH Director, or
his or her designee. It is understood that any new service site for CONTRACTOR(S) who are already
part of this Agreement must receive Medi-Cal site certification before CONTRACTOR(S) provide
services under this Agreement at the new service site.
K. CONTRACTOR(S) shall maintain requirements as Organizational Providers
throughout the term of this Agreement, as described in Section Eighteen (18) of this Agreement. If for
any reason, this status is not maintained, the COUNTY may terminate this Agreement pursuant to
Section Three (3) of this Agreement.
L. CONTRACTOR(S) agree that prior to providing services under the terms and
conditions of this Agreement, CONTRACTOR(S) shall have appropriate staff hired and in place for
program services and operation or COUNTY may, in addition to other remedies it may have, suspend
referrals or terminate this Agreement in accordance with Section Three (3) of this Agreement.
M. COUNTY does not guarantee a minimum amount of services to
CONTRACTOR(S). COUNTY will refer/place clients at CONTRACTOR(S)’ facilities based upon
COUNTY’s needs and appropriateness of placement.
2. TERM
The term of this Agreement shall be for a period of three (3) years commencing upon
execution through and including June 30, 2021. This Agreement may be extended for two (2)
additional consecutive twelve (12) month periods upon written approval of both parties no later than
thirty (30) days prior to the first day of the next twelve (12) month extension period. The DBH Director,
or his or her designee, is authorized to execute such written approval on behalf of COUNTY based on
CONTRACTOR’s satisfactory performance.
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CONTRACTOR(S) added to this Agreement after the execution date shall become part
of the Agreement effective upon the date the executed signature page is received and approved by
the COUNTY’s DBH Director, or his or her designee, as set forth in Section Eleven (11) of this
Agreement.
The June 30 termination date specified herein shall be the termination date for all
CONTRACTOR(S), regardless of when CONTRACTOR is added to this Agreement. Any twelve (12)
month renewal period of this Agreement for any CONTRACTOR already providing services under this
Agreement shall commence on July 1st of the then current fiscal year.
3. TERMINATION
A. Non-Allocation of Funds - The terms of this Agreement, and the services to be
provided thereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated at any time by giving the CONTRACTOR(S) thirty (30) days advance written notice.
B. Breach of Contract - The COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of the COUNTY there is:
1) An illegal or improper use of funds;
2) A failure to comply with any term of this Agreement;
3) A substantially incorrect or incomplete report submitted to the COUNTY;
4) Improperly performed service.
In no event shall any payment by 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 each
CONTRACTOR the repayment to the COUNTY of any funds disbursed to that CONTRACTOR under
this Agreement, which in the judgment of the COUNTY were not expended in accordance with the
terms of this Agreement. Each CONTRACTOR shall promptly refund any such funds upon demand or
at COUNTY’s option; such repayment shall be deducted from future payments owing to that
CONTRACTOR under this Agreement.
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C. Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by COUNTY or COUNTY’s DBH Director, or his or her designee, or
one (1) or more CONTRACTOR(S) upon the giving of sixty (60) days advance written notice of an
intention to terminate.
4. COMPENSATION
COUNTY agrees to pay CONTRACTOR(S) and CONTRACTOR(S) agrees to receive
compensation based on rates per service modality. Said specialty mental health services and their
corresponding rates shall be referenced within each CONTRACTOR(S)’ respective Rate Sheets, as
represented in Exhibit D-1, et seq.
Compensation by COUNTY to CONTRACTOR(S) for placement is not provided for
under this Agreement.
A. Annual Contract Amounts
For fiscal year (FY) July 1, 2018 through June 30, 2019, in no event shall the
maximum compensation amount under this Agreement exceed Nine Hundred Thousand and No/100
Dollars ($900,000.00) for all CONTRACTOR(S) combined.
For FY July 1, 2019 through June 30, 2020, in no event shall the maximum
compensation amount under this Agreement exceed Nine Hundred Thousand and No/100 Dollars
($900,000.00) for all CONTRACTOR(S) combined.
For FY July 1, 2020 through June 30, 2021, in no event shall the maximum
compensation amount under this Agreement exceed Nine Hundred Thousand and No/100 Dollars
($900,000.00) for all CONTRACTOR(S) combined.
If this Agreement is extended for an additional twelve (12) month renewal period
for FY July 1, 2021 through June 30, 2022, in no event shall the maximum compensation amount
under this Agreement exceed Nine Hundred Thousand and No/100 Dollars ($900,000.00) for all
CONTRACTOR(S) combined.
If this Agreement is extended for an additional twelve (12) month renewal period
for FY July 1, 2022 through June 30, 2023, in no event shall the maximum compensation amount
under this Agreement exceed Nine Hundred Thousand and No/100 Dollars ($900,000.00) for all
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CONTRACTOR(S) combined.
The maximum amounts paid to each CONTRACTOR(S) identified in this
Agreement shall be as stated in the individual CONTRACTOR(S)’s “Summary of Services” documents
approved by the COUNTY’s DBH Director, or his or her designee, as attached in Exhibits B-1 et seq.
B. Maximum Compensation Amounts
In no event shall the total maximum compensation amount under this Agreement
for FY 2018-19, FY 2019-20, and FY 2020-21 combined exceed Two Million, Seven Hundred
Thousand and No/100 Dollars ($2,700,000.00) for all CONTRACTOR(S) combined.
If performance standards are met and this Agreement is extended for an
additional twelve (12) month term pursuant to Section 3, TERM, herein, then in no event shall the total
maximum compensation amount under this Agreement for FY 2018-19, FY 2019-20, FY 2020-21, and
FY 2021-22 exceed Three Million, Six Hundred Thousand and No/100 Dollars ($3,600,000.00) for all
CONTRACTOR(S) combined.
If performance standards are met and this Agreement is extended for an
additional twelve (12) month term pursuant to Section 3, TERM, herein, then in no event shall the total
maximum compensation amount under this Agreement for FY 2018-19, FY 2019-20, FY 2020-21, FY
2021-22, and FY 2022-23 exceed Four Million, Five Hundred Thousand and No/100 Dollars
($4,500,000.00) for all CONTRACTOR(S) combined.
C. It is understood that all expenses incidental to CONTRACTOR(S) performance
of services under this Agreement shall be borne by CONTRACTOR(S). If CONTRACTOR(S) fails to
comply with any provision of this Agreement, COUNTY shall be relieved of its obligation for further
compensation.
D. Payments shall be made by COUNTY to CONTRACTOR(S) in arrears, for
specialty mental health services provided during the preceding month, within forty-five (45) days after
the date of receipt and approval by COUNTY of the monthly invoicing as described in Section Five (5)
herein. Payments shall be made after receipt and verification of specialty mental health services
provided in the performance of this Agreement, in accordance with the individual “Summary of
Services” as provided for in Exhibits B-1 et seq., and shall be documented to COUNTY on a monthly
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basis by the tenth (10th) of the month following the month of said service provision.
E. COUNTY shall not be obligated to make any payments under this Agreement if
the request for payment is received by COUNTY more than sixty (60) days after this Agreement has
terminated or expired.
F. COUNTY shall be make payments under this Agreement for out-of-county youth
placed in a facility located within Fresno County, when Presumptive Transfer, defined by Assembly Bill
1299 (AB 1299), is granted. Presumptive Transfer is the process by which the responsibility for the
provision of, or arrangement and payment for, specialty mental health services from the county of
original jurisdiction to the county in which the foster child resides. In the event that a Waiver to
Presumptive Transfer is approved, then COUNTY shall not be responsible for compensating the
CONTRACTOR(S) for the specialty mental health services provided to out-of -county foster care clients
placed in their facility. Presumptive Transfer only applies to children and youth who reside within the
State of California and does not apply to children and youth placed out-of-state.
G. All final invoices and/or any final budget modification requests shall be submitted
by CONTRACTOR(S) within sixty (60) days following the final month of service for which payment is
claimed. No action shall be taken by COUNTY on invoices submitted beyond the sixty (60) day
closeout period. Any compensation which is not expended by CONTRACTOR(S) pursuant to the
terms and conditions of this Agreement shall automatically revert to COUNTY.
H. The services provided by CONTRACTOR(S) under this Agreement are funded in
whole or in part by the State of California. In the event that funding for these services is delayed by
the State Controller, COUNTY may defer payments to CONTRACTOR(S). The amount of the
deferred payment shall not exceed the amount of funding delayed by the State Controller to the
COUNTY. The period of time of the deferral by COUNTY shall not exceed the period of time of the
State Controller’s delay of payment to COUNTY plus forty-five (45) days.
I. CONTRACTOR(S) shall be held financially liable for any and all future
disallowances/audit exceptions due to CONTRACTOR(S) deficiency discovered through the
applicable State’s audit process and MHP’s utilization review process during the course of the
Agreement. At COUNTY’s election, the disallowed amount will be remitted within forty-five (45) days
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to COUNTY upon notification or shall be withheld from subsequent payments to CONTRACTOR(S).
CONTRACTOR(S) shall not receive reimbursement for any units of services rendered that are
disallowed or denied by the applicable MHP utilization review process or through the State
Department of Health Care Services (DHCS) cost report audit settlement process for Medi-Cal eligible
clients.
5. INVOICING
A. CONTRACTOR(S) shall invoice COUNTY in arrears by the tenth (10th) of each
month for specialty mental health services provided during the prior month to
DBHInvoices@co.fresno.ca.us and a carbon copy to the assigned DBH Mental Health Contracts Staff
Analyst. After CONTRACTOR(S) renders service to referred clients, CONTRACTOR(S) shall invoice
COUNTY for payment, certify the expenditure, and submit electronic claiming into COUNTY’s
electronic information system for all clients, including those eligible for Medi-Cal as well as those that
are not eligible for Medi-Cal, including contracted cost per unit and actual cost per unit. Invoices and
reports shall be in such detail as acceptable to COUNTY’s DBH, as described in this section. Reports
shall be in such detail as acceptable to COUNTY’s DBH, as described herein and in Section Fourteen
(14) of this Agreement. Additionally, invoices and supporting documentation may be mailed to: County
of Fresno, Department of Behavioral Health, Contracted Services Division, 3133 N. Millbrook, Fresno,
CA 93703, Attention: STRTP Contract Analyst. No reimbursement for services shall be made until the
invoice and report is received, verified, and approved by COUNTY’s DBH.
B. CONTRACTOR(S) shall submit to COUNTY by the tenth (10th) of each month, an
itemized invoice detailing all services and work performed herein at the rates identified in their
respective Exhibit D-1, et seq. Billing information must include the client’s name, patient ID number,
date of service, type of mental health service provided, duration of service, client’s International
Classification of Diseases (ICD) diagnosis, service provider name, units of service provided, rate of
service provided, and actual amount of service. No reimbursement for services shall be made until the
invoice, claims certification, and back-up documentation is received, verified and approved by
COUNTY’s DBH. COUNTY’s DBH must pay CONTRACTOR before submitting claims to DHCS for
Federal and State reimbursement for Medi-Cal eligible clients.
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C. At the discretion of COUNTY’s DBH Director, or his or her designee, if an invoice
is incorrect or is otherwise not in proper form or substance, COUNTY’s DBH Director, or his or her
designee, shall have the right to withhold payment as to only that portion of the invoice that is incorrect
or improper after five (5) days prior notice to CONTRACTOR(S). CONTRACTOR(S) agrees to
continue to provide services for a period of ninety (90) days after notification of an incorrect or
improper invoice. If after the ninety (90) day period, the invoice(s) is still not corrected to COUNTY
DBH’s satisfaction, COUNTY’s DBH Director, or his or her designee, may elect to terminate this
Agreement, pursuant to the termination provisions stated in Section Three (3) of this Agreement. In
addition, for invoices received ninety (90) days after the expiration of each term of this Agreement or
termination of this Agreement, at the discretion of COUNTY’s DBH Director, or his or her designee,
COUNTY’s DBH shall have the right to deny payment of any additional invoices received.
D. CONTRACTOR(S) must report all third party collections from other funding
sources such as private insurance, client private pay or any other third party. COUNTY expects the
invoice for reimbursement to equal the amount due CONTRACTOR less any funding sources not
eligible for Federal reimbursement and any other revenues generated by CONTRACTOR (i.e.,
private insurance, etc).
E. CONTRACTOR(S) shall submit monthly staffing reports that identify all direct
service and support staff, applicable licensure/certifications, and full time hours worked to be used as
a tracking tool to determine if CONTRACTOR(S)’s program is staffed according to the services
provided under this Agreement.
F. CONTRACTOR(S) must maintain such financial records for a period of seven (7)
years, or if there a dispute, audit or inspection, until it is resolved, whichever is later.
CONTRACTOR(S) will be responsible for any disallowances related to inadequate documentation.
G. CONTRACTOR(S) is responsible for collection and managing data in a manner
to be determined by DHCS and the DBH MHP in accordance with applicable rules and regulations.
COUNTY’s electronic information system is a critical source of information for purposes of monitoring
and obtaining reimbursement. CONTRACTOR(S) must attend the COUNTY DBH’s Business Office
training on documentation and billing and related cost reporting.
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H. CONTRACTOR(S) shall submit service data into COUNTY’s electronic
information system within thirty (30) calendar days from the date services were rendered. Federal and
State reimbursement for Medi-Cal specialty mental health services is based on public expenditures
certified by the CONTRACTOR(S). CONTRACTOR(S) must submit a signed certified public
expenditure report in the monthly invoice. DHCS expects the claim for Federal and State
reimbursement to equal the amount the COUNTY paid the CONTRACTOR(S) for the services
rendered less any funding sources not eligible for Federal reimbursement.
I. CONTRACTOR(S) must provide all necessary data to allow the COUNTY to bill
Medi-Cal, and any other third-party source, for services and meet State and Federal reporting
requirements. The necessary data can be provided by a variety of means, including but not limited to:
1) direct data entry into COUNTY’s electronic information system; 2) providing an electronic file
compatible with COUNTY’s electronic information system; or 3) integration between COUNTY’s
electronic information system and CONTRACTOR(S)’ information system(s).
J. If a Medi-Cal client has dual coverage, such as other health coverage (OHC), the
CONTRACTOR(S) will be responsible for billing the carrier and obtaining a payment/denial or have
validation of claiming with no response ninety (90) days after the claim was mailed.
CONTRACTOR(S) must report all revenue collected from OHC, third-party, or private-pay in each
monthly invoice and in the cost report that is required to be submitted. A copy of explanation of
benefits or CWM 1500 is required as documentation. CONTRACTOR(S) must comply with all laws
and regulations governing MediCare program, including, but not limited to: 1) the requirement of the
Medicare Act, 42 U.S.C. Section 1395 et seq.; and 2) the regulation and rules promulgated by the
Centers for Medicare and Medicaid Services as they relate to participation, coverage and claiming
reimbursement. CONTRACTOR(S) will be responsible for compliance as of the effective date of each
federal, state or local law or regulation specified.
K. Data entry into COUNTY’s electronic information system shall be the
responsibility of the CONTRACTOR(S). The direct specialty mental health services data must be
reconciled by the CONTRACTOR(S) to the monthly invoices submitted for payment. COUNTY shall
monitor the volume of services and cost of services entered into the COUNTY’s electronic information
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system. Any and all audit exceptions resulting from the provision and reporting of Medi-Cal services
by CONTRACTOR(S) shall be the sole responsibility of the CONTRACTOR(S). CONTRACTOR(S)
will comply with all applicable policies, procedures, directives and guidelines regarding the use of
COUNTY’s electronic information system.
L. Medi-Cal Certification and Mental Health Plan Compliance
CONTRACTOR(S) located within California shall establish and maintain Medi-
Cal certification or become certified within ninety (90) days of the start of each CONTRACTOR’s term
within this Agreement, through COUNTY prior to provide reimbursable services to Medi-Cal eligible
clients. Initial Medi-Cal certification for STRTP Facilities that have just obtained licensure shall be
established during the subsequent STRTP’s mental health program approval. In addition,
CONTRACTOR(S) located within the County of Fresno shall work with the COUNTY’s DBH to execute
the process if not currently certified by COUNTY for credentialing of staff.
If a Waiver of Presumptive Transfer applies, then staff of CONTRACTOR(S)
located outside of Fresno County shall work with the COUNTY’s DBH to execute the process for
credentialing of staff.
For CONTRACTOR(S) located within the State of California, service location
must be approved by the COUNTY’s DBH during the Medi-Cal certification process. During this
process, the CONTRACTOR(S) will obtain a legal entity number established by the DHCS, a
requirement for maintaining COUNTY’s MHP organizational provider status throughout the term of this
Agreement. CONTRACTOR(S) will be required to receive MHP approval and become Medi-Cal
certified prior to providing services to Medi-Cal eligible clients and seeking reimbursement from the
COUNTY. CONTRACTOR(S) will not be reimbursed by COUNTY for any services rendered prior to
certification. If CONTRACTOR(S) have received Medi-Cal certification/MHP approval from their host
county, then a copy of the approval must be provided to COUNTY.
CONTRACTOR(S) located out-of-state must submit documentation equivalent to
the above that is required by the State in which the CONTRACTOR(S) provide services.
CONTRACTOR(S)’ shall provide specialty mental health services in accordance
with the COUNTY’s MHP. CONTRACTOR(S) must comply with the “Fresno County Mental Health
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Plan Compliance Program and Code of Conduct” set forth in Exhibit E, attached hereto and
incorporated herein by reference.
CONTRACTOR(S) may provide direct specialty mental health services using
unlicensed staff as long as the individual is approved as an Organizational Provider by the COUNTY’s
MHP, is supervised by licensed staff who met the Board of Behavioral Sciences requirements for
supervision, works within his/her scope, and only delivers allowable direct specialty mental health
services. Unlicensed staff must also be credentialed by COUNTY’s DBH Managed Care.
It is understood that each service is subject to audit for compliance with Federal
and State regulations and that COUNTY may be making payments in advance of said review. In the
event that a service is disapproved, COUNTY may, at its sole discretion, withhold compensation or
offset from other payments due, the amount of said disapproved services. CONTRACTOR(S) shall be
responsible for audit exceptions to ineligible dates of services or incorrect application of utilization
review requirements.
6. INDEPENDENT CONTRACTOR
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 CONTRACTOR(S)’ officers, agents, and employees will at all times be acting and performing as
independent contractors, and shall act in an independent capacity and not as an officer, agent,
servant, employee, joint venture, partner, or associate of 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 each CONTRACTOR is performing their 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
which are directly or indirectly the subject of this Agreement.
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
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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’)
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 COUNTY or to this Agreement.
7. MODIFICATION
Any matters of this Agreement may be modified from time to time by the written consent
of all the parties without, in any way, affecting the remainder.
Notwithstanding the above, changes to services and responsibilities of the
CONTRACTOR(S) and changes to staffing, as set forth in Exhibits B-1 et seq., as needed, to
accommodate changes in the law relating to STRTPs and/or specialty mental health treatment, may
be made with the signed written approval of COUNTY’s DBH Director, or his or her designee, and
CONTRACTOR(S) through an amendment approved by County Counsel and the COUNTY’s Auditor-
Controller/Treasurer-Tax Collector’s Office.
In addition, changes to the volume of units of services/types of service units, and
changes to the service rate to be provided, as set forth in Exhibits D-1 et seq., may be made with the
written approval of COUNTY’s DBH Director, or his or her designee, and the individual
CONTRACTOR. Maximum compensation amounts payable to each CONTRACTOR may be modified
with the written approval of COUNTY’s DBH Director, or his or her designee.
Said modifications to service volume/types of service units, summary of services, and
maximum compensation amounts payable per CONTRACTOR shall not result in any change to the
total combined maximum compensation amount payable to all CONTRACTORS under this Master
Agreement, as stated herein.
8. NON-ASSIGNMENT
COUNTY and CONTRACTOR(S) shall not assign, transfer or subcontract this
Agreement nor their rights or duties under this Agreement without the prior written consent of
COUNTY and the individual CONTRACTOR seeking to make such assignment.
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9. HOLD-HARMLESS
CONTRACTOR(S) agrees to indemnify, save, hold harmless, and at COUNTY's request,
defend the COUNTY, its officers, agents and employees from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
COUNTY in connection with the performance, or failure to perform, by CONTRACTOR(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.
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).
10. INSURANCE
Without limiting COUNTY's right to obtain indemnification from CONTRACTOR(S) or any
third parties, each CONTRACTOR, at its sole expense, shall maintain in full force and effect the
following insurance policies throughout the term of this Agreement:
A. Commercial General Liability
Commercial General Liability Insurance with limits of not less than Two Million
Dollars ($2,000,000) per occurrence and an annual aggregate of Four Million
Dollars ($4,000,000). This policy shall be issued on a per occurrence basis.
COUNTY may require specific coverages including completed operations,
product liability, contractual liability, Explosion-Collapse-Underground, fire legal
liability or any other liability insurance deemed necessary because of the nature
of the Agreement.
B. Automobile Liability
ISO Form Number CA 00 01 covering any auto (Code 1), or if CONTRACTOR
has no owned autos, covering hired, (Code 8) and non-owned autos (Code 9),
with limits no less than $1,000,000 per accident for bodily injury and property
damage. If CONTRACTOR’(S) employees are not covered by
CONTRACTOR’(S) automobile liability insurance policy, CONTRACTOR shall
ensure that each employee as part of this Agreement procures and maintains
their own private vehicle coverage in force during the term of this Agreement, at
the employee’s sole cost and expense.
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C. Professional Liability
If CONTRACTOR(S) employs licensed professional staff (e.g. Ph.D., R.N.,
L.C.S.W., L.M.F.T.) in providing services, Professional Liability Insurance with
limits of not less than One Million Dollars ($1,000,000) per occurrence, Three
Million Dollars ($3,000,000) annual aggregate. CONTRACTOR agrees that it
shall maintain, at its sole expense, in full force and effect for a period of five (5)
years following the termination of this Agreement, one or more policies of
professional liability insurance with limits of coverage as specified herein.
D. Real and Property Insurance
CONTRACTOR(S) shall maintain a policy of insurance for all risk personal
property coverage which shall be endorsed naming the County of Fresno as an
additional loss payee. The personal property coverage shall be in an amount that
will cover the total of the COUNTY purchase and owned property, at a minimum,
as discussed in Section Twenty (20) of this Agreement.
All Risk Property Insurance
As applicable, CONTRACTOR(S) will provide property coverage for the full
replacement value of the COUNTY’S personal property in possession of
CONTRACTOR(S) and/or used in the execution of this Agreement. COUNTY will
be identified on an appropriate certificate of insurance as the certificate holder
and will be named as an Additional Loss Payee on the Property Insurance Policy.
E. Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
F. Child Abuse/Molestation and Social Services Coverage
Each CONTRACTOR shall have either separate policies or an umbrella policy
with endorsements covering Child Abuse/Molestation and Social Services
Liability coverage or have a specific endorsement on their General Commercial
liability policy covering Child Abuse/Molestation and Social Services Liability.
The policy limits for these policies shall be One Million Dollars ($1,000,000) per
occurrence with a Two Million Dollars ($2,000,000) annual aggregate. The
policies are to be on a per occurrence basis.
G. Waiver of Subrogation
CONTRACTOR hereby grants to COUNTY a waiver of any right to subrogation
which any insurer of said CONTRACTOR may acquire against the COUNTY by
virtue of the payment of any loss under such insurance. CONTRACTOR agrees
to obtain any endorsement that may be necessary to affect this waiver of
subrogation, but this provision applies regardless of whether or not the COUNTY
has received a waiver of subrogation endorsement from the insurer.
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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’) 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 each CONTRACTOR signs this Agreement,
CONTRACTOR(S) shall provide certificates of insurance and endorsements as stated above for all of
the foregoing policies, as required herein, to the County of Fresno, Department of Behavioral Health,
Contracted Services Division, 3133 N. Millbrook Ave, Fresno, California, 93703, Attention: STRTP
Contract Staff Analyst, stating that such insurance coverages have been obtained and are in full force;
that the County of Fresno, its officers, agents and employees will not be responsible for any premiums
on the policies; that such Commercial General Liability insurance names the County of Fresno, its
officers, agents and employees, individually and collectively, as additional insured, but only insofar as
the operations under this Agreement are concerned; that such coverage for additional insured shall
apply as primary insurance and any other insurance, or self-insurance, maintained by COUNTY, its
officers, agents and employees, shall be excess only and not contributing with insurance provided
under CONTRACTOR(S)’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, COUNTY may, in addition to other remedies it may have, suspend or terminate this
Agreement upon the occurrence of such event.
All policies shall be with admitted insurers licensed to do business in the State of
California. Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating
of A FSC VII or better.
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11. ADDITIONS/DELETIONS OF CONTRACTORS
COUNTY’s DBH Director, or his or her designee, reserves the right at any time during
the term of this Agreement to add new CONTRACTOR(S) to those listed in Exhibit A. It is understood
any such additions will not affect compensation paid to any other CONTRACTOR, and therefore such
additions may be made by COUNTY without notice to or approval of the other CONTRACTOR(S)
under this Agreement. These same provisions shall apply to the deletion of any CONTRACTOR(S)
contained in Exhibit A, except that deletions shall be by written mutual agreement between the
COUNTY and the particular CONTRACTOR to be deleted, or shall be in accordance with the
provisions of Section Three (3) of this Agreement.
12. LICENSES/CERTIFICATES
Throughout the term of this Agreement, CONTRACTOR(S) and CONTRACTOR(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.
13. RECORDS
CONTRACTOR(S) shall maintain records in accordance with COUNTY’s
“Documentation Standards for Client Records,” attached hereto as Exhibit F 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 ten (10) years from the
date of the end of the Agreement.
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14. REPORTS
A. Cost Report
CONTRACTOR(S) agrees to submit a complete and 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. The 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. 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. The CONTRACTOR(S) shall also submit with the cost report a copy of the
CONTRACTOR(S)’ general ledger that supports revenues and expenditures and reconciled detailed
report of reported total units of services rendered under this Agreement to the units of services
reported by CONTRACTOR(S) to 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 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 State annually. CONTRACTOR(S) shall remit a hard copy of cost report to County of Fresno,
Attention: Cost Report Team, PO BOX 45003, Fresno CA 93718. CONTRACTOR(S) shall remit the
electronic copy or any inquiries to DBHcostreportteam@co.fresno.ca.us
All Cost Reports must be prepared in accordance with General Accepted
Accounting Principles (GAAP) and Welfare and Institutions Code §§ 5651(a)(4), 5664(a), 5705(b)(3)
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and 5718(c). Unallowable costs such as lobby or political donations must be deducted on the cost
report and invoice reimbursement
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 on this Agreement and thereafter, COUNTY and
CONTRACTOR(S) agree to settle dollar amounts disallowed or settled in accordance with DHCS audit
settlement findings related to the Medi-Cal and EPSDT reimbursements. CONTRACTOR(S) will
participate in the several phases of settlements between COUNTY/CONTRACTOR and DHCS. The
phases are initial cost reporting for settlement, settlement according to State reconciliation of records
for paid Medi-Cal services and audit settlement-State DHCS audit: 1) initial cost reporting - after an
internal review by COUNTY, the COUNTY files cost report with State 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; 3) Audit Settlement-State DHCS audit. After final reconciliation and settlement DHCS may
conduct a review of medical records, cost reports 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.
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 funds have been recouped
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by means of an offset against any payments then or thereafter owing to CONTRACTOR(S) under
this or any other Agreement.
C. Outcome Reports
CONTRACTOR(S) shall submit to COUNTY outcome reports, as requested.
D. Additional Reports
In addition, CONTRACTOR(S) shall also furnish to COUNTY such statements,
records, reports, data, and other information as COUNTY may request pertaining to matters covered
by this Agreement. In the event that CONTRACTOR(S) fails to provide such reports or other
information required hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly
payments until there is compliance. In addition, CONTRACTOR(S) shall provide written notification
and explanation to COUNTY within five (5) days of any funds received from another source to conduct
the same services covered by this Agreement.
15. MONITORING
CONTRACTOR(S) agrees to extend to COUNTY’s staff, COUNTY’s DBH Director and
DHCS, or their designees, the right to review and monitor records, program or procedures, at any
time, in regard to clients, as well as the overall operation of CONTRACTOR(S)’ program, in order to
ensure compliance with the terms and conditions of this Agreement.
16. REFERENCES TO LAWS AND RULES
In the event any law, regulation, or policy referred to in this Master 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.
17. 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 requirements on
COUNTY and its subcontractors. CONTRACTOR(S) shall adhere to all State Requirements, including
those identified in Exhibit G “State Mental Health Requirements,” attached hereto and by this
reference incorporated herein.
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18. 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 H, “Medi-Cal Organizational Provider Standards,” attached hereto and by this reference
incorporated herein and made part of this Agreement. It is acknowledged that all references to
Organizational Provider and/or Provider in Exhibit H shall refer to CONTRACTOR(S). In addition,
CONTRACTOR(S) shall inform every client of their rights under the COUNTY’s Mental Health Plan as
described in Exhibit I, “Fresno County Mental Health Plan Grievances and Appeals Process,” attached
hereto and by this reference incorporated herein and made part of this Agreement. CONTRACTOR
shall also file an incident report for all incidents involving clients, following the DBH’s “Incident
Reporting and Intensive Analysis” policy and procedure guide and using the “Incident Report”
Worksheet identified in Exhibit J, attached hereto and by this reference incorporated herein and made
part of this Agreement, or a protocol and worksheet presented by CONTRACTOR(S) that is accepted
by COUNTY’s DBH Director, or his or her designee.
19. CONFIDENTIALITY
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.
20. 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 as required by law.
COUNTY and CONTRACTOR(S) acknowledge that the exchange of protected health
information (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)
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and other applicable laws. As part of the HIPAA Regulations, the Privacy Rule and the Security Rule
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).
21. 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 his or her designee(s), including but not limited to mobile storage devices.
If data is approved to be transferred, data must be stored on a secure server approved by the
COUNTY and transferred by means of a Virtual Private Network (VPN) connection, or another type of
secure connection. Said data must be encrypted.
C. COUNTY-Owned Computer Equipment
CONTRACTOR(S) may not use COUNTY computers or computer peripherals on
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non-COUNTY premises without prior authorization from the COUNTY’s Chief Information Officer,
and/or his or her 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)’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.
22. 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
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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 or veteran status.
CONTRACTOR(S) shall insure that the evaluation and treatment of employees and
applicants for employment are free of such discrimination. CONTRACTOR(S) and subcontractors
shall comply with the provisions of the Fair Employment and Housing Act (Gov. Code §12800 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-
11139.5), and the regulations or standards adopted by the awarding state agency to implement such
article. CONTRACTOR(S) 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 twenty-four (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(S) 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(S)
shall include the Non-Discrimination and compliance provisions of this clause in all subcontracts to
perform work under this Agreement.
23. 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 consumers, including, but not limited to,
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assessing the cultural and linguistic needs of its consumers, training of staff on the policies and
procedures, and monitoring its language assistance program. The CONTRACTOR(S)’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)’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)’s “vital documents” (those documents that contain information that is critical for
accessing CONTRACTOR(S)’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)’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)’s
plan to address all fifteen national cultural competency standards as set forth in Exhibit K, “National
Standards on Culturally and Linguistically Appropriate Services (CLAS)”
(http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport/pdf), attached hereto and by this
reference incorporated herein. 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(S)’s 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(S) on a monthly basis shall provide COUNTY DBH a monthly monitoring tool/report
that shows all CONTRACTOR(S) staff cultural competency trainings completed.
24. AMERICANS WITH DISABILITIES ACT
CONTRACTOR(S) agrees to ensure that deliverables developed and produced,
pursuant to this Agreement shall comply with the accessibility requirements of Section 508 of the
Rehabilitation Act and the Americans with Disabilities Act of 1973 as amended (29 U.S.C. §794 (d)),
and regulations implementing that Act as set forth in Part 1194 of Title 36 of the Code of Federal
Regulations. In 1998, Congress amended the Rehabilitation Act of 1973 to require Federal agencies
to make their electronic and information technology (EIT) accessible to people with disabilities.
California Government Code Section 11135 codifies section 508 of the Act requiring accessibility of
electronic and information technology.
25. CONFLICT OF INTEREST
No officer, agent, or employee of COUNTY who exercises any function or responsibility
for planning and carrying out the services provided under this Agreement shall have any direct or
indirect personal financial interest in this Agreement. In addition, no employee of COUNTY shall be
employed by CONTRACTOR(S) to fulfill any contractual obligations with COUNTY.
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 COUNTY.
26. CHARITABLE CHOICE
CONTRACTOR(S) may not discriminate in its program delivery against a client or
potential client on the basis of religion or religious belief, a refusal to hold a religious belief, or a refusal
to actively participate in a religious practice. Any specifically religious activity or service made
available to individuals by CONTRACTOR(S) must be voluntary as well as separate in time and
location from COUNTY-funded activities and services. CONTRACTOR(S) shall inform COUNTY as to
whether it is faith-based. If CONTRACTOR(S) identifies as faith-based, it must submit to COUNTY’s
DBH a copy of its policy on referring individuals to an alternate treatment provider, and include a copy
of this policy in its client admission forms. The policy must inform individuals that they may be referred
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to an alternative provider if they object to the religious nature of the program, and include a notice to
COUNTY’s DBH. Adherence to this policy will be monitored during annual site reviews and reviews of
client files. If CONTRACTOR(S) identifies as faith-based, by July 1 of each year CONTRACTOR will
be required to report to COUNTY’s DBH the number of individuals who requested referrals to alternate
providers based on religious objection.
27. 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(S) 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(S) under this Agreement. CONTRACTOR(S) further agrees that in the event
CONTRACTOR(S) 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.
28. SINGLE AUDIT CLAUSE
A. If CONTRACTOR(S) expends Seven Hundred Fifty Thousand Dollars 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
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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 to correct any material non-compliance or weakness found as a result of such audit. Such audit
shall be delivered to COUNTY’s DBH Business Office for review within nine (9) months of the end of
any fiscal year in which funds were expended and/or received for the program. Failure to 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 CONTRACTOR(S)’s Federal contracts do
not exceed the Seven Hundred Fifty Thousand and No/100 Dollars ($750,000.00) requirement or
CONTRACTOR(S)’ only funding is through Drug related Medi-Cal. If a single audit is not applicable, a
program audit must be performed and a program audit report with management letter shall be
submitted by CONTRACTOR(S) to COUNTY as a minimum requirement to attest to CONTRACTOR’s
solvency. Said audit report shall be delivered to COUNTY’s DBH 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’s cost, as determined by COUNTY’s Auditor-Controller/Treasurer-Tax Collector.
C. CONTRACTOR(S) shall make available all records and accounts for inspection
by COUNTY, the State of California, if applicable, the Comptroller General of the United States, the
Federal Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a
period of at least three (3) years following final payment under this Agreement or the closure of all
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other pending matters, whichever is later.
29. COMPLIANCE
CONTRACTOR(S) agrees to comply with the COUNTY’s “Contractor Code of Conduct
and Ethics” and the COUNTY’s Compliance Program in accordance with Exhibit E, as described
herein and in Sections Five (5), above. Within thirty (30) days of entering into this Agreement with the
COUNTY, CONTRACTOR(S) shall have all of CONTRACTOR(S)’ employees, agents and
subcontractors providing services under this Agreement certify in writing, that he or she has received,
read, understood, and shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR(S)
shall ensure that within thirty (30) days of hire, all new employees, agents and subcontractors
providing services under this Agreement shall certify in writing that he or she has received, read,
understood, and shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR(S)
understands that the promotion of and adherence to the Code of Conduct is an element in evaluating
the performance of CONTRACTOR(S) and its employees, agents and subcontractors.
Within thirty (30) days of entering into this Agreement, and annually thereafter, all
employees, agents and subcontractors providing services under this Agreement shall complete
general compliance training and appropriate employees, agents and subcontractors shall complete
documentation and billing or billing/reimbursement training. All new employees, agents and
subcontractors shall attend the appropriate training within thirty (30) days of hire. Each individual who
is required to attend training shall certify in writing that he or she has received the required training.
The certification shall specify the type of training received and the date received. The certification
shall be provided to the COUNTY’s Compliance Officer at 3133 N. Millbrook Ave, Fresno, California
93703. CONTRACTOR(S) agrees to reimburse COUNTY for the entire cost of any penalty imposed
upon COUNTY by the Federal Government as a result of CONTRACTOR(S)’ violation of the terms of
this Agreement.
30. ASSURANCES
In entering into this Agreement, CONTRACTOR(S) certifies that it is not currently
excluded, suspended, debarred, or otherwise ineligible to participate in the Federal Health Care
Programs: that it has not been convicted of a criminal offense related to the provision of health care
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items or services; nor has it been reinstated to participation in the Federal Health Care Programs after
a period of exclusion, suspension, debarment, or ineligibility. If COUNTY learns, subsequent to
entering into a contract, that CONTRACTOR(S) is ineligible on these grounds, COUNTY will remove
CONTRACTOR(S) from responsibility for, or involvement with, COUNTY’s business operations related
to the Federal Health Care Programs and shall remove such CONTRACTOR(S) from any position in
which CONTRACTOR(S)’ compensation, or the items or services rendered, ordered or prescribed by
CONTRACTOR(S) 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(S)
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 or (3) they have been reinstated to participation in the Federal
Health Care Programs after a period of exclusion, suspension, debarment, or ineligibility.
1) In the event the potential employee or subcontractor informs
CONTRACTOR(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, CONTRACTOR(S) will
ensure that said employee or subcontractor does no work, either directly or indirectly relating to
services provided to COUNTY.
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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 timeframe to
be determined by COUNTY to protect the interests of COUNTY consumers.
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 health care items or services;
and (3) have not been reinstated to participation in the Federal Health Care Program after a period of
exclusion, suspension, debarment, or ineligibility. In the event any existing employee or subcontractor
informs CONTRACTOR(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 health 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 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 timeframe 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 Federal Government as a result of CONTRACTOR(S)’
violation of CONTRACTOR(S)’ obligations as described in this Section.
31. PUBLICITY PROHIBITION
None of the funds, materials, property or services provided directly or indirectly under
this Agreement shall be used for CONTRACTOR(S)’ advertising, fundraising, or publicity (i.e.,
purchasing of tickets/tables, silent auction donations, etc.) for the purpose of self-promotion.
Notwithstanding the above, publicity of the services described in Section One (1) of this Agreement
shall be allowed as necessary to raise public awareness about the availability of such specific services
when approved in advance by COUNTY’s DBH Director, or his or her designee, and at a cost to be
provided in Exhibits D-1 et seq. for such items as written/printed materials, the use of media (i.e.,
radio, television, newspapers) and any other related expense(s).
32. COMPLAINTS
CONTRACTOR(S) shall log complaints and the disposition of all complaints from a client
or a client’s family. CONTRACTOR(S) shall provide a copy of the detailed complaint log entries
concerning COUNTY-sponsored clients to COUNTY at monthly intervals by the tenth (l0th) day of the
following month, in a format that is mutually agreed upon. In addition, CONTRACTOR(S) shall provide
details and attach documentation of each complaint with the log. CONTRACTOR(S) shall post signs
informing clients 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 clients within twenty-four (24)
hours of receipt of a complaint.
Within ten (10) days after each incident or complaint affecting COUNTY-sponsored
clients, CONTRACTOR(S) shall provide COUNTY with information relevant to the complaint,
investigative details of the complaint, the complaint and CONTRACTOR(S)’ disposition of, or
corrective action taken to resolve the complaint. In addition, CONTRACTOR(S) shall inform every
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client of their rights as set forth in Exhibit I and Exhibit J regarding grievances and incident reporting.
33. 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 by this reference incorporated
herein and made part of this Agreement. 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. CONTRACTOR(S) is required to submit a set of fingerprints for any person with a five (5) percent
or greater direct or indirect ownership interest in CONTRACTOR(S). COUNTY may terminate this
Agreement where any person with a five (5) percent or greater direct or indirect ownership interest in
the CONTRACTOR(S) 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@co.fresno.ca.us, Attention: Contracts
Administration. COUNTY may deny enrollment or terminate this Agreement where any person with a
five (5) percent or greater direct or indirect ownership interest in CONTRACTOR(S) has been
convicted of a criminal offense related to that person’s involvement with the Medicare, Medicaid, or
Title XXI program in the last ten (10) years.
34. DISCLOSURE – CRIMINAL HISTORY AND CIVIL ACTIONS
CONTRACTOR(S) is required to disclose if any of the following conditions apply to
them, their owners, officers, corporate managers and partners (hereinafter collectively referred to as
“CONTRACTOR(S)”):
A. Within the three (3) year period preceding the Agreement award, they have been
convicted of, or had a civil judgment rendered against them for:
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1) Fraud or a criminal offense in connection with obtaining, attempting to
obtain, or performing a public (federal, state, or local) transaction or
contract under a public transaction;
2) Violation of a federal or state antitrust statute;
3) Embezzlement, theft, forgery, bribery, falsification, or destruction of
records; or
4) False statements or receipt of stolen property.
B. Within a three (3) year period preceding their Agreement award, they
have had a public transaction (federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate CONTRACTOR(S)
from further business consideration. The information will be considered as part of the determination
of whether to continue and/or renew the Agreement 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 Responsibility Matters- Primary Covered Transactions” in the form set forth in Exhibit M,
attached hereto and by this reference incorporated herein and made part of this Agreement.
Additionally, CONTRACTOR(S) must immediately advise the COUNTY in writing if, during the term of
this Agreement: (1) CONTRACTOR(S) becomes suspended, debarred, excluded or ineligible for
participation in federal or state funded programs or from receiving Federal funds as listed in the
excluded parties’ list system (http://www.epls.gov); or (2) any of the above listed conditions become
applicable to 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 Responsibility
Matters.
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35. 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 this Agreement, the CONTRACTOR(S)
changes its status to operate as a corporation.
Members of the CONTRACTOR(S)’ Board of Directors shall disclose any self-dealing
transactions that they are a party to while CONTRACTOR(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 a “Self-Dealing Transaction Disclosure Form”, attached hereto as Exhibit N
and incorporated herein by reference and made part of this Agreement, and submitting it to the
COUNTY prior to commencing with the self-dealing transaction or immediately thereafter.
36. AUDITS AND INSPECTIONS
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. CONTRACTOR(S) shall, upon request
by the COUNTY, permit the COUNTY to audit and inspect all such records and data necessary to
ensure CONTRACTOR(S)’ compliance with the terms of this Agreement.
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
CONTRACTOR(S) shall be subject to the examination and audit of the State Auditor General for a
period of three (3) years after final payment under contract (California Government Code section
8546.7).
37. NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR(S)
Director, Fresno County SEE EXHIBIT A
Department of Behavioral Health
3133 N. Millbrook Ave.
Fresno, CA 93703
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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 (3) 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 (1) 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).
38. SEVERABILITY
If any non-material term, provision, covenant, or condition of this Agreement is held by
a court of competent jurisdiction to be invalid, void or unenforceable, the remainder of the provisions
shall remain in full force and effect, and shall in no way be affected, impaired or invalidated.
39. SEPARATE AGREEMENT
It is mutually understood by the parties that this Agreement does not, in any way, create
a joint venture among the individual CONTRACTORS. By execution of this Agreement,
CONTRACTOR(S) understand that a separate Agreement is formed between each individual
CONTRACTOR and COUNTY.
40. GOVERNING LAW
The parties agree that for the purpose of venue, performance under this Agreement is in
Fresno County, California.
The rights and obligations of the parties and all interpretation and performance of this
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Agreement shall be governed in all respects by the laws of the State of California.
41. SUPERSEDE
This Agreement shall supersede in its entirety and render null and void the Agreement
between parties identified in COUNTY Agreement No. 14-313-1, effective January 1, 2019.
42. ENTIRE AGREEMENT
This Agreement, including all Exhibits (listed below), constitutes the entire agreement
between CONTRACTOR(S) and COUNTY with respect to the subject matter hereof and supersedes
all previous agreement negotiations, proposals, commitments, writings, advertisements, publications,
and understandings of any nature whatsoever unless expressly included in this Agreement.
Exhibit A – List of Contractors
Exhibit B -- Program Overview
Exhibit B-1, et seq. Summary of Services
Exhibit C – Guiding Principles of Care Delivery
Exhibit D-1, et seq. – Budgets
Exhibit E – Fresno County Mental Health Compliance Plan and Code of
Conduct
Exhibit F – Documentation Standards for Client Records
Exhibit G – State Mental Health Requirements
Exhibit H – Medi-Cal Organizational Provider Standards
Exhibit I – Fresno County Mental Health Plan Grievances and Appeals
Process
Exhibit J – Protocol for Completion of Incident of Report
Exhibit K – CLAS EXHIBIT
Exhibit L – Disclosure of Ownership and Control Interest Statement
Exhibit M – Certification Regarding Debarment, Suspension, and Other
Responsibility Matters – Primary Covered Transactions
Exhibit N – Self-Dealing Transaction Disclosure Form
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1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and
2 year first hereinabove written .
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Fund/S ubclass:
Organization :
AccounUProgram :
0001 /10000
5630
7295/0
COUNTY OF FRESNO
ers the Board of Supervisors
of the County of Fresno
Date: x'· , -\ <?
BERNICE E. SEIDEL, Deputy
Clerk of the Board of Supervisors
County of Fresno , State of California
Date : _ _.;;.~-------''r'----\ ~~--
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PLEASE SEE ADDITIONAL
SIGNATURE PAGES ATTACHED
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CONTRACTOR:
PROMESA BEHAVIORAL HEALTH
Print Name:!1tclll!il.. UR /Yh11JOet6't.1 Stt!
Title: ----L-/3--'· Jee_' _;)._L_JJ._'e_J.I_I ___ _
Chairman of the Board, or President or any Vice President
By
�
Print Name: £'l,.L;v) Z. u,J i �A
Title: 'f, .,J N\J Ck. j)i Rcc.:r-DK
Secre tary of Corporation, or
Any Assistant Secretary, or
Chief Financial Officer, or
Any Assistant Treasurer
Mailing Address:
7120 N. Marks Avenue, Suite 100
Fresno, Ca. 93711
Phone No.: (559) 439-5437
Contact: Lisa Weigant, Chief Executive Officer
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PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
Exhibit A
Page 1 of 1
SHORT-TERM RESIDENTIAL TREATMENT PROGRAMS
MASTER AGREEMENT
VENDOR LIST
1. PROMESA BEHAVIORAL HEALTH (Exhibits B-1; C-1)
7120 N. Marks Avenue, Suite 110
Fresno, CA 93711
Phone#: (559) 439-5437
Contact for Notices: Chief Executive Officer
Exhibit B-1
Page 1 of 7
SHORT-TERM RESIDENTIAL TREATMENT PROGRAM
SUMMARY OF SERVICES
ORGANIZATION: Promesa Behavioral Health
ADDRESS: 7120 N. Marks Avenue, Suite 110
Fresno, CA 93711
TELEPHONE: (559) 439-5437
CONTACT PERSON: Lisa Weigant, Chief Executive Officer
CONTRACT PERIOD: July 10, 2018 – June 30, 2021
with two (2) optional twelve (12) month renewals
SUMMARY OF SERVICES
CONTRACTOR, Promesa Behavioral Health (Promesa), is a CARF accredited agency licensed
by the State of California to operate eight (8) separate short-term residential therapeutic
programs (STRTPs) which will provide short-term, specialized, and intensive treatment to youth
placed in their care, 24-hours a day, 7 days a week. Promesa is committed to providing high
quality, individualized, coordinated services which are aimed at successful short-term placement
and stabilization for the youth in their care. While stability is being achieved, staff concurrently
seeks permanency in a nurturing family (whether the family of origin, a loving foster home,
adoption, lower level of care, or transitional setting).
Promesa has fully incorporated a trauma-informed approach in their STRTP model, which
includes dedicated teams of licensed and/or registered clinicians, case managers, and
committed professionals to deliver specialty mental health services. Services are culturally
relevant, trauma-informed, age/developmentally appropriate, and adhere to CLAS guidelines.
Additionally, Promesa’s staff provides advocacy efforts on behalf of the youth as well as work
with additional available supports such as family members, CASA workers, mentors, public
defenders etc. Promesa is also a community provider of substance use disorder treatment
services as they understand that mental health and treatment of substance use disorders are
most effectively addressed concurrently.
TARGET POPULATION
Promesa shall provide specialty mental health services to male and female youth, aged twelve
(12) to eighteen (18) and non-minor dependents enrolled in the Extended Foster Care program.
Exhibit B-1
Page 2 of 7
SERVICE LOCATIONS
BARSTOW
1415 W. Barstow
Fresno, CA 93711
(559) 438-9344
VAN NESS
1027 N. Van Ness
Fresno, CA 93728
(559) 268-7613
MINARETS
718 E. Minarets
Fresno, CA 93720
(559) 447-1114
MILLBROOK
4291 N. Millbrook
Fresno, CA 93726
(559) 224-7967
SPRUCE
775 E. Spruce
Fresno, CA 93720
NILES 4
1942 E. Niles
Fresno, CA 93720
(559) 323-4957
NILES 5
1853 E. Niles
Fresno, CA 93720
(559) 325-3892
MADERA
10120 Lanesbridge Rd.
Madera, CA 93636
(559) 431-5532
CONTRACTOR SHALL BE RESPONSIBLE FOR THE FOLLOWING SERVICES:
Promesa incorporates the skills of culturally competent and multi-lingual professionals when
serving the needs of a culturally diverse population. Services shall be delivered timely and
collaboratively, with an emphasis of removing barriers to service and treatment. Training,
marketing, literature and educational tools are sensitive to the unique cultural needs of our
beneficiaries. Specifically, Promesa follows the Trauma Resiliency Model (TRM) which helps
the client understand the concept of resiliency and how to restore balance to the body and the
mind after traumatic experiences. This approach helps youth and their families manage trauma
stress events and restore balance in their lives
Promesa focuses on stabilization, mental health, and substance use disorder (SUD) services.
Stabilization aims to intervene with youth who exhibit escalated or assaultive behavior from
injuring or endangering themselves or others. All youth who enter Promesa will have an
individualized treatment plan completed with goals and objectives specific to the youth’s mental
health needs, as determined by previous assessments and the behavioral health assessment
completed by Promesa’s clinicians. SUD services are designed for clients who have a history of
alcohol and drug use that qualify by the criteria stated in the DSM-V and ASAM.
To meet these needs, Promesa will provide the following services to the STRTP clients:
A. All youth who enter Promesa will receive a mental health assessment and will have an
individualized Treatment Plan completed with goals and objectives specific to the youth’s
mental health needs as determined by the assessment. This plan is completed within 30
days of placement and is incorporated into the Needs and Services Plan. Each youth’s
Treatment Plan is individualized to meet her/his mental health needs and is developed in
accordance with the diagnosis provided. The Treatment Plan aims to address a number
Exhibit B-1
Page 3 of 7
of issues (i.e., multiple diagnosis using a reliable assessment (for example, Beck
Depression Index, Trauma Resilience). The Treatment Plan shall factor in
developmental as well as diagnostic issues.
B. A licensed mental health professional (LMHP) shall perform a clinical review every
ninety (90) days of the youth’s status and progress in treatment. This review determines
whether the youth should continue in an STRTP-level placement or be transitioned to a
lower level of care. The LMPH makes this determination in consultation with the
COUNTY placing agency. A report documenting this clinical assessment is maintained
in the youth’s record.
C. The LMHP shall provide all specialty mental health services to the youth’s needs, as
identified in the assessment and included in the client’s Treatment Plan.
D. Development of a Needs and Services Plan (NSP), with the cooperation/input of
beneficiary and authorized representative. The initial NSP is completed and signed
within ten (10) calendar days of admission and includes mental health needs identified in
the case plan, treatment plan, and any available mental health assessment. The NSP is
reviewed by a member of the direct service program staff at least every thirty (30)
calendar days.
E. Promesa shall ensure continuity of care, services, and treatment as the youth moves
from STRTP placement to home-based family care or other permanent living situation
through reunification, adoption or guardianship, in accordance with the case plan, NSP,
and/or Treatment Plan, as ensured by continuous review and transition planning.
F. The youth’s necessary specialty mental health services shall be identified and
documented in the youth’s NSP and Treatment Plan, and maintained in the youth’s
health record. The youth’s utilization of existing grievance processes for accessing
services shall also be documented and recorded in the youth’s health record.
G. Progress notes shall document the youth’s participation and responses to specialty
mental health treatment services. Progress notes shall meet all Medi-Cal documentation
requirements and shall be maintained in the youth’s health record.
H. Progress notes shall be entered into the youth’s health record, signed, and dated by the
LMHP who provided the service.
I. Promesa’s Head of Service shall review the progress notes completed by licensed staff
and registered interns on a weekly basis. Each note reviewed is signed and notated
with the date and time of review.
J. Promesa shall ensure that American Indian youth receive specialty mental health
services in accordance with the Federal Indian Child Welfare Act (25 U.S.C. Sec 1901 et
seq.).
Exhibit B-1
Page 4 of 7
K. All specialty mental health services shall be client-based, meet medical necessity, and
meet all Medi-Cal standards
L. Specialty Mental Health Services
a) Mental Health Assessment – clinical analysis of the history and current status of
a youth’s mental, emotional, or behavioral disorder to include relevant cultural
and social issues, history, diagnosis, and any recorded testing results. All youth
arriving into placement shall receive a Mental Health Assessment. .
b) Plan Development – the development of client plans to include the NSP,
approval of client plans, and monitoring of a beneficiaries progress. Minor clients
participate in the development of both the NSP and the Treatment Plan. The
NSP is a comprehensive detail of their personal goals and objectives for
improvement and exiting from Promesa’s program, while the Treatment Plan is
specific to mental health and behavioral improvements the youth would like to
work towards.
c) Therapy – therapeutic intervention that focuses on symptom reduction in order to
improve identified functional impairments. This service may be delivered to an
individual or group and may also include family therapy. Youth shall receive both
individual and group therapy at least once per week. The therapeutic modalities
are Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT),
and the Trauma Resiliency Model (TRM). CBT is effective in treating children
and adolescents who have persistent behavioral reactions, DBT focuses on
problem solving and acceptance-based strategies within a framework of
dialectical methods, and TRM focuses on the concept the biological basis of
trauma.
d) Collateral – any service activity to a significant support person in a client’s life
with the intent of improving or maintaining the mental health status of the
beneficiary. Collateral services include, but are not limited to, helping significant
support persons to understand and accept the client’s condition and involving
them in service planning and implementation of the Treatment Plan. Family
counseling or therapy, which is provided on behalf of the client, may be
considered collateral.
e) Case Management – any service that assists the youth to access the needed
social, vocational, medical, educational, rehabilitative or other community
services. Services may include, but are not limited to, communication,
coordination and referral to available resources.
f) Crisis Intervention – any emergency response that enables a client to cope with a
crisis. Activities are intended to support, improve or maintain the client’s mental
health status.
Exhibit B-1
Page 5 of 7
g) Rehabilitation – any activity that seeks to improve, maintain, or restore a youth’s
functional daily living, social, grooming, leisure, personal hygiene, while also
providing access to support resources and medication education.
h) Intensive Care Coordination (ICC) – participation in Child Family Team (CFT)
meetings to ensure care coordination of specialty mental health treatment
services for the youth. This includes comprehensive assessment and periodic
reassessment, development and revision of the plan, referral, monitoring and
follow up activities and transition. While the CFT process is an essential piece of
ICC, this element of a case plan is targeted case management that facilitates,
coordinates, and monitors for the full scope of Medi-Cal services, which meet
medical necessity criteria. Promesa’s ICC process organizes and matches care
across providers and child service systems, which allows the youth to be served
in the community, especially upon transition from STRTP.
i) Medication Support Services – any service that includes prescribing,
administering, dispensing and monitoring psychiatric medications or biologicals
which are necessary to alleviate the symptoms of mental health conditions.
Services may also include evaluation for the need of medication, evaluation of
clinical effectiveness and side effects, obtaining informed consent, medication
education and plan development related to the delivery of the service and or
assessment of the youth. Promesa’s contracts for psychiatry services with a
Board-Certified Psychiatrist and has the ability to schedule convenient
appointments for the youth. If a youth enters the program with a current
prescription for medication – including psychotropic medication – the prescription
shall be confirmed upon admittance. Youth with a current prescription for
psychotropic medication or assessed as potentially benefitting from psychotropic
medication, shall meet with the psychiatrist shortly after admittance. The
psychiatrist shall be able to meet with the youth monthly for monitoring if the
youth is on medication or more often as necessary if the youth reports concerns.
j) Intensive Day Treatment – Promesa does not provide intensive day treatment.
When referral calls are received requesting this service, Promesa will determine
if the youth’s needs can be met in its program and if services can be accessed in
Fresno County. If the youth is placed, Promesa would access the intensive day
treatment program through Fresno County Department of Behavioral Health. If
the youth cannot be served by Promesa, the placement worker would be directed
to those who are programmatically set-up to provide these services. When a
youth is admitted for residential treatment, and progresses sufficiently within their
Needs and Services Plan, with a clinical determination that the youth would
benefit from an Intensive Day Treatment program, the staff undertakes to secure
a placement for our youth in such a service.
k) Day Rehabilitation Services - Promesa does not provide day rehabilitation
services. When referral calls are received requesting this service, Promesa will
Exhibit B-1
Page 6 of 7
determine if the youth’s needs can be met in our program and if services can be
accessed in Fresno County. If the youth is placed, Promesa would access day
rehabilitation services through Fresno County Department of Behavioral Health.
If the youth cannot be served by Promesa, the placement worker would be
directed to those who are programmatically set-up to provide these services.
When youth who are in care are determined to need day rehabilitation services,
they are referred to and/or re-directed to those community agencies through
Fresno County.
STAFFING
A. All licensed, waivered, and registered mental health professional providing services in an
STRTP shall meet all legal requirements for professional licensing, waiver, or
registration, as applicable.
B. Adequate numbers and qualifications of direct service program staff shall be employed,
present, awake, and on duty seven (7) days per week.
C. A STRTP shall have at least one (1) full-time equivalent direct service program staff from
the following list employed for each six (6) children admitted to the program:
a) Physicians
b) Psychologists or psychologists who have received a waiver pursuant to WIC
Code 5751.2
c) Licensed Clinical Social Workers or registered professionals pursuant to WIC
Code 5751.2
d) Licensed Marriage, Family, and Child Therapists or registered professionals
pursuant to WIC Code 5751.2
e) Registered Nurses
f) Licensed Professional Clinical Counselors or registered professionals pursuant to
WIC Code 5751.2
g) Licensed Vocational Nurses
h) Psychiatric Technicians
i) Occupational Therapists
j) Mental Health Rehabilitation Specialists as defined in Section 630 of Title 9 CCR
D. Of the direct service program staff required above, a STRTP shall have one (1) half-time
equivalent LMHP employed for each six (6) children admitted to the program. A LMHP
who is employed to meet this requirement may also be the head of service, if employed
at least forty (40) hours per week.
E. The STRTP shall have access to a psychiatrist twenty-four (24) hours per day. When
needed, Promesa shall offer services via Telecare delivery. These services are
delivered in a technology transparent manner utilizing real-time high definition video
conferencing technology that is both HIPAA compliant and secure.
Exhibit B-1
Page 7 of 7
PERFORMANCE MEASURES/PROGRAM OUTCOMES
Promesa shall provide all project monitoring and compliance protocols, procedures, data
collection methods, and reporting requirements requested by the COUNTY. Promesa utilizes
performance and outcome measures for evaluating program and system effectiveness to
ensure services and service delivery strategies are positively impacting the youth in their care.
Performance outcome measures shall be reported to the COUNTY annually in accumulative
reports for overall program and contract evaluation.
Promesa will address each of the categories referenced below and may additionally propose
other performance and outcome measures that are deemed best to evaluate the services
provided and/or to evaluate overall program performance.
A. Access to care: The ability of clients to receive the right service at the right time.
a) Timeliness between referral to assessment and completion of assessment;
assessment to first treatment service; and first treatment service to subsequent
follow-up visit
B. Effectiveness: Objective results achieved through services.
a) Effectiveness of treatment interventions
b) Effectiveness of discharge planning (e.g., percentage of clients successfully
linked to lower levels of care)
C. Efficiency: Demonstration of the relationship between results and the resources used to
achieve them.
a) Length of client stay in program
b) Number of units of service per client
c) Cost per client
D. Satisfaction and Compliance: The degree to which clients, COUNTY, and other
stakeholders are satisfied with the services.
a) Audits and other performance and utilization reviews of health care services and
compliance with agreement terms and conditions
b) Surveys of persons serviced, family members, other health care providers, and
other stakeholders
Promesa understands that the COUNTY may adjust the performance and outcome measures
periodically throughout the duration of this Agreement, as needed, to best measure the
program. Promesa will utilize a computerized tracking system with which performance and
outcome measures and other relevant data, such as demographics, will be maintained.
Exhibit C
1
rev 01-02-2018
Fresno County Department of Behavioral Health Guiding
Principles of Care Delivery
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
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
6. Principle Six - Culturally Responsive
Exhibit C
3
rev 01-02-2018
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
10. Principle Ten - Continuous Quality Improvement and Outcomes-Driven
o Individual and program outcomes are collected and evaluated for quality and efficacy
Exhibit C
4
rev 01-02-2018
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 D-1
Promesa Behavioral Health
SERVICE
TIME BASE RATE PER
MINUTE
Mental Health Services
(Individual/Family/Group Therapy)
Staff Minute $2.30
Case Management Staff Minute $1.78
Crisis Services Staff Minute $3.42
Medication Support Staff Minute $4.25
Collateral Staff Minute $2.30
Plan Development Staff Minute $2.30
Assessment Staff Minute $2.30
Rehabilitation Staff Minute $2.30
ICC Staff Minute $1.78
Agency’s Comment:
Exhibit E
Page 1 of 3
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws,
regulations, rules and guidelines that apply to the provision and payment of mental health services.
Mental health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this “Contractor Code of Conduct and Ethics” with which
CONTRACTOR and its employees and subcontractor(s) shall comply. CONTRACTOR shall require
its employees and subcontractor(s) to attend a compliance training that will be provided by Fresno
County. After completion of this training, CONTRACTOR, its employee and subcontractor(s), must
sign the Contractor Acknowledgment and Agreement form and return this form to the Compliance
officer or designee.
CONTRACTOR and its employees and subcontractor shall:
1.Comply with all applicable laws, regulations, rules or guidelines when providing and billing for
mental health services.
2.Conduct themselves honestly, fairly, courteously and with a high degree of integrity in their
professional dealing related to their contract with the COUNTY and avoid any conduct that
could reasonably be expected to reflect adversely upon the integrity of the COUNTY.
3. Treat COUNTY employees, clients, and other mental health contractors fairly and with
respect.
4.NOT engage in any activity in violation of the COUNTY’s Compliance Program, nor engage in
any other conduct which violates any applicable law, regulation, rule or guideline
5.Take precautions to ensure that claims are prepared and submitted accurately, timely and are
consistent with all applicable laws, regulations, rules or guidelines.
6.Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement
of any kind are submitted.
7.Bill only for eligible services actually rendered and fully documented. Use billing codes that
accurately describe the services provided.
Exhibit E
Page 2 of 3
8. Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9. Promptly report to the Compliance Officer any suspected violation(s) of this “Code of Conduct
and Ethics” by COUNTY employees or other mental health contractors, or report any activity
that they believe may violate the standards of the Compliance Program, or any other
applicable law, regulation, rule or guideline. Fresno County prohibits retaliation against any
person making a report. Any person engaging in any form of retaliation will be subject to
disciplinary or other appropriate action by the COUNTY. CONTRACTOR may report
anonymously.
10. Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
11. Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
Exhibit E
Page 3 of 3
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and
Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof. I further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement. I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County. I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print): _____________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Signature :________________________________ Date : ___/____/___
For Group or Organizational Providers
Group/Org. Name (print): _______________________________________
Employee Name (print): ________________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Other:___________________________________________
Job Title (if different from Discipline): ___________________________
Signature: _________________________________ Date: ____/___/____
• • • •
• • • •
•
Exhibit F
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 F
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 F
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 G
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 G
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 G
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 G
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 G
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 G
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
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.
D. Drugs are stored in a locked area with access limited to those medical personnel
authorized to prescribe, dispense or administer medication.
EXHIBIT H
Page 2 of 2
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 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 I
Page 1 of 2
Fresno County Mental Health Plan
Grievances and Appeals Process
Grievances
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 I
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.
Section: Administration
Effective Date: 11/01/2010 Revised Date: 03/07/2018
Policy Title: Incident Reporting and Intensive Analysis
Approved by: Dawan Utecht (Director of Behavioral Health), Elizabeth Vasquez (Compliance Officer), Kannika
Toonnachat (Division Manager - Technology and Quality Management)
Department of Behavioral Health
Policy and Procedure Guide
PPG 1.2.4
MISSION STATEMENT
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.
Template Review Date 3/28/16
POLICY: The Fresno County Department of Behavioral Health (DBH) requires all of
its county-operated and contracted providers (through the Mental Health
Plan (MHP) and Substance Use Disorder (SUD) services) to complete a
written report of any incidents compromising the health and safety of
clients, employees, or community members. The incident report must
include a thorough description of: the incident itself, client information,
type of event, location, people directly involved, action taken, and outcome
(if known). The written report must be signed and submitted to the
Department of Behavioral Health Incident Reporting email address
DBHIncidentReporting@co.fresno.ca.us within 24 hours of the incident or
knowledge of the incident. An amendment to the original incident report
may be submitted if all the required information is not readily available
within the 24 hour reporting requirement. The Intensive Analysis
Committee (IAC) will review selected incidents. Incidents that occur within
the six months following discharge must also be reported.
PURPOSE:To ensure employees identify, document and report incidents consistently
and promptly. To review incidents and recommend system, policy, and
protocol changes. To increase best practice and safety in the provision of
behavioral health care and substance use disorder services.
REFERENCE: California Evidence Code 1157, 1157.5, 1157.6 and 1157.7., Welfare and
Institutions Code on Privileged Information**, DMH Letter 1995-04, page
7-12. Fresno County Management Directive, Chapter 1700, Subject 1750,
Mental Health Plan, Policy No. RSK 100.0. MHP Contract boilerplate,
Exhibit H. Fresno County DBH Incident Report, MHRC 24-Hour Unusual
Occurrence Report-DHCS form, PSD-RM 301 Report, PHF 24-Hour
Unusual Occurrence Report-DHCS form, Unusual Occurrence Report.
**Note: California Evidence Code 1157 does not guarantee that all committee
discussions, reports and records are protected from discovery and disclosure in all
cases.
Exhibit J
Page 1 of 6
Department of Behavioral Health
Policy and Procedure Guide
PPG 1.2.4
Policy Title: Reporting Incidents and Unusual Occurrences
Section: Administration Effective Date: 11/01/2010
DEFINITIONS:
24 Hours – 24 clock hours
Department of Behavioral Health Incident Reporting email address (DBH Incident Reporting)-
DBHIncidentReporting@co.fresno.ca.us
Department of Health Care Services- DHCS
Fresno County Department of Behavioral Health- DBH
Intensive Analysis Committee – IAC
Mental Health Plan- MHP
Mental Health Rehabilitation Center- MHRC
Psychiatric Health Facility- PHF
Quality Improvement Committee- QIC
Substance Use Disorder - SUD
Unusual Occurrence Report- UOR
An Incident is any event which jeopardizes the health and/or safety of clients, employees, or
members of the community.
Incidents include, but are not limited to:
•All client deaths
•Attempted suicide (resulting in serious injury)
•Homicide or attempts at homicide
•Injury connected to services or at a service site (self-inflicted or by accident)
•Medical Emergency connected to services or at a service site
•Other (i.e. Clients escaping from a locked facility, medication errors)
•Violence, Abuse or Assault connected to services or at a service site (toward
client, others or property; resulting in serious injury)
The Fresno County DBH Incident Report, MHRC/PHF 24-hour Unusual Occurrence Report,
PSD-RM 301 and/or Unusual Occurrence Report are all confidential reports and are not to be
part of the client’s medical record.
•DO NOT file a copy of or transcribe the Fresno County DBH Incident Report,
MHRC/PHF 24-hour Unusual Occurrence Report, PSD-RM 301 and/or Unusual
Occurrence Report in to the client’s medical record.
•DO NOT document in the medical record that a Fresno County DBH Incident
Report, MHRC/PHF 24-hour Unusual Occurrence Report, PSD-RM 301 and/or
Unusual Occurrence Report was filed.
•Details of the incident that are relevant to clinical treatment may be documented
in the client’s medical record by the appropriate practitioner.
Exhibit J
Page 2 of 6
Department of Behavioral Health
Policy and Procedure Guide
PPG 1.2.4
Policy Title: Reporting Incidents and Unusual Occurrences
Section: Administration Effective Date: 11/01/2010
PROCEDURE:
I. Employees having knowledge of an incident will follow the appropriate process listed in
sections II or III below:
II. DBH County Operated Programs
A. Employees involved in or first aware of an incident shall complete and submit
encrypted Form PSD-RM 301-Incident Report: Non-Employee to a supervisor
and/or Division Manager.
1. Supervisor and/or Division Manager shall review the report for
completeness and gather any further information needed. Supervisor,
Division Manager, or designee sends the encrypted report to the DBH
Incident Reporting email address, Division Manager and DBH Human
Resources email address within 24 hours of an incident or knowledge
of an incident.
2.Intensive Analysis Chair or designated committee member will review
the PSD-RM 301-Incident Report and request further information if
needed.
III. Contracted Providers
A. All contracted providers shall complete the Fresno County DBH Incident Report.
1. The report shall be completed and signed by the employee involved in or
first aware of an incident, reviewed and signed by a supervisor and/or
Program Director and the encrypted Incident Report will be sent to the
DBH Incident Reporting email address and designated Contract Staff
Analyst within 24 hours of an incident or knowledge of an incident.
2. Intensive Analysis Chair or designated committee member will review the
DBH Incident Report. If further information is needed, designated
Contract Staff Analyst shall assist in gathering requested information and
provide the information to Intensive Analysis Chair or designated
committee member.
B. In addition to completing the Fresno County DBH Incident Report under item III-
A, Mental Health Rehabilitation Centers (MHRC) and Psychiatric Health Facilities
(PHF) must also complete the respective below report.
1. MHRC shall complete the DHCS MHRC 24-Hour Unusual Occurrence
Report.
a. Report shall be completed and signed by staff involved in or first
aware of an incident, reviewed and signed by a supervisor and/or
Exhibit J
Page 3 of 6
Department of Behavioral Health
Policy and Procedure Guide
PPG 1.2.4
Policy Title: Reporting Incidents and Unusual Occurrences
Section: Administration Effective Date: 11/01/2010
Program Director and submitted to DHCS via fax: (916) 440-5600
or encrypted email to the DHCS designated reporting contact (per
form instructions), Contract Staff Analyst and the DBH Incident
Reporting email address within 24 hours of an incident or
knowledge of an incident.
2. PHF shall complete the DHCS PHF 24-Hour Unusual Occurrence Report.
a. Report shall be completed and signed by staff involved in or first
aware of an incident, reviewed and signed by a supervisor and/or
Program Director and submitted to DHCS via fax: (916) 440-5600
or encrypted email to the DHCS designated reporting contact (per
form instructions), Contract Staff Analyst and the DBH Incident
Reporting email address within 24 hours of an incident or
knowledge of an incident.
IV. Unusual Occurrence Reporting to DHCS
A. Unusual Occurrences may include but are not limited to physical injury and
death. The MHP will report Unusual Occurrences to DHCS as determined
necessary. The Unusual Occurrence Report (UOR) shall include:
1. A written description of the incident and outcome of the incident
2. List of persons directly involved/having direct knowledge of the incident
3. Report of providers investigation and conclusion.
B. If a reported incident is determined to be an Unusual Occurrence, the UOR shall
be completed and signed by a Division Manager or a designated IAC member.
Contracted Providers (not licensed directly by the state) who have determined an
incident to be an Unusual Occurrence may elect to submit their own UORs in lieu
of a DBH Division Manager or IAC member. The UOR shall be emailed
encrypted to the DHCS designated reporting contact (per DHCS instructions),
Contract Staff Analyst (if applicable) and the DBH Incident Reporting email
address within five (5) calendar days of an incident or knowledge of an incident.
MHRC’s and PHF’s will continue to follow reporting guidelines detailed above in
Section III, B1 and B2.
C. UORs sent to DHCS may be subject to further investigation and/or information
requested by DHCS, such as: Site Reviews and Plan(s) of Correction. All
correspondence between contracted provider and DHCS regarding UORs shall
also be sent to the Contract Staff Analyst and the DBH Incident Reporting email
address for informational purposes.
D. Site visits by DBH may be conducted as needed.
Exhibit J
Page 4 of 6
Department of Behavioral Health
Policy and Procedure Guide
PPG 1.2.4
Policy Title: Reporting Incidents and Unusual Occurrences
Section: Administration Effective Date: 11/01/2010
E. DBH may request contracted providers attest that an Intensive Analysis or similar
(i.e. incident review, possible cause) has occurred. DBH may request additional
analysis or information when necessary.
V. The IAC will review incidents and recommend system, policy, and protocol changes, as
needed, based on its findings. The IAC can conduct a case review with the employees
involved to determine possible cause. The IAC shall track and trend incidents and report
to the Quality Improvement Committee (QIC). The DBH Incident Reporting email
address shall be monitored by the Intensive Analysis Chair, with supportive monitoring
by the Quality Improvement Coordinator, Division Managers and Compliance Officer.
A. The IAC will be comprised of the following:
1. Intensive Analysis Chair – Chair shall be a Licensed Marriage and Family
Therapist, Licensed Clinical Social Worker, Psychologist, or Psychiatrist
2. Deputy Director
3. Quality Improvement Coordinator
4. Division Manager from Clinical Operations
5. Compliance Officer
6. Quality Improvement Licensed Mental Health Clinician(s)
7. Medical Director
8. Other subject matter experts as deemed necessary
9. +Case specific staff
B. The IAC shall review incidents and identify those that require further review to
determine possible cause.
C. The IAC shall meet at least quarterly unless there are no incidents during the
quarter. The IAC may meet more frequently as needed.
D. The IAC shall make recommendations for changes in policy, procedure and
practice.
E. When necessary, the IAC may report personnel concerns to the appropriate HR
department; the IAC does not make or take disciplinary actions but may be
obligated to share employee concerns.
F. Copies of Incident Reporting forms received and committee notes related to
action items will be maintained by the IAC for 10 years.
G. The IAC will report aggregate data and system recommendations at QIC.
Exhibit J
Page 5 of 6
Fresno County Department of Behavioral Health-Incident Report
Send completed forms to dbhincidentreporting@co.fresno.ca.us and designated contract analyst within 24 hours of an
incident or knowledge of an incident. DO NOT COPY OR REPRODUCE/NOT part of the medical record.
Client Information
Last Name: Click or tap here to enter text. First Name: Click or tap here to enter text. Middle Initial: Click or tap here to enter text.
Date of Birth:Click or tap here to enter text. Client ID#:Click or tap here to enter text. Gender: ☐ Male ☐ Female
County of Origin: Click or tap here to enter text.
Name of Reporting Party:Click or tap here to enter text. Name of Facility:Click or tap here to enter text.
Facility Address:Click or tap here to enter text. Facility Phone Number:Click or tap here to enter text.
Incident (check all that apply)
☐Homicide/Homicide Attempt ☐ Attempted Suicide (resulting in serious injury) ☐ Death of Client ☐ Medical Emergency
☐Injury (self-inflicted or by accident)☐Violence/Abuse/Attempts to Assault (toward others, client and/or property)
☐Other- Specify (i.e. medication errors, client escaping from locked facility, fire, poisoning, epidemic outbreaks, other
catastrophes/events that jeopardize the welfare and safety of clients, staff and /or members of the community): Click or tap here to
enter text.
Date of Incident: Click or tap here to enter text. Time of Incident: Click or tap here to enter text.☐am ☐pm
Location of Incident: Click or tap here to enter text.
Description of the Incident (Attach additional sheet if needed): Click or tap here to enter text.
Key People Directly Involved in Incident (witnesses, staff): Click or tap here to enter text.
Action Taken (check all that apply) ☐Consulted with Physician ☐ Called 911/EMS ☐ First Aid/CPR Administered ☐Law Enforcement Contacted☐Client removed from building ☐ Parent/Legal Guardian Contacted ☐Other (Specify): Click or tap here to enter text.
Description of Action Taken: Click or tap here to enter text.
Outcome of Incident (If Known): Click or tap here to enter text.
Form Completed by: __________________________________ _______________________________ _____________
Printed Name Signature Date
Reviewed by Supervisor/Program Manager: _____________________________ ___________________________ ________
Printed Name Signature Date
For Internal Use only:
☐Report to Administration ☐ Report to Intensive Analysis Committee for additional review ☐Request Additional Information
☐No Action ☐ Unusual Occurrence ☐ Other: Click or tap here to enter text.
Revised 12 /2017
Exhibit J
Page 6 of 6
National Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health and Health Care
The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care
disparities by establishing a blueprint for health and health care organizations to:
Principal Standard:
1.Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse
cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.
Governance, Leadership, and Workforce:
2.Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy,
practices, and allocated resources.
3.Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are
responsive to the population in the service area.
4.Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and
practices on an ongoing basis.
Communication and Language Assistance:
5.Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at
no cost to them, to facilitate timely access to all health care and services.
6.Inform all individuals of the availability of language assistance services clearly and in their preferred language,
verbally and in writing.
7.Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals
and/or minors as interpreters should be avoided.
8.Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the
populations in the service area.
Engagement, Continuous Improvement, and Accountability:
9.Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them
throughout the organization’s planning and operations.
10.Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into
measurement and continuous quality improvement activities.
11.Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health
equity and outcomes and to inform service delivery.
12.Conduct regular assessments of community health assets and needs and use the results to plan and implement
services that respond to the cultural and linguistic diversity of populations in the service area.
13.Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural
and linguistic appropriateness.
14.Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent,
and resolve conflicts or complaints.
15.Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and
the general public.
www.ThinkCulturalHealth.hhs.gov THINK 11
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The Case for the Enhanced National CLAS Standards
Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
— Dr. Martin Luther King, Jr.
Health equity is the attainment of the highest level of health for all people (U.S. Department of Health and Human
Services [HHS] Office of Minority Health, 2011). Currently, individuals across the United States from various cultural
backgrounds are unable to attain their highest level of health for several reasons, including the social determinants of
health, or those conditions in which individuals are born, grow, live, work, and age (World Health Organization, 2012),
such as socioeconomic status, education level, and the availability of health services (HHS Office of Disease Prevention
and Health Promotion, 2010). Though health inequities are directly related to the existence of historical and current
discrimination and social injustice, one of the most modifiable factors is the lack of culturally and linguistically appropriate
services, broadly defined as care and services that are respectful of and responsive to the cultural and linguistic needs of
all individuals.
Health inequities result in disparities that directly affect the quality of life for all individuals. Health disparities adversely
affect neighborhoods, communities, and the broader society, thus making the issue not only an individual concern but
also a public health concern. In the United States, it has been estimated that the combined cost of health disparities and
subsequent deaths due to inadequate and/or inequitable care is $1.24 trillion (LaVeist, Gaskin, & Richard, 2009).
Culturally and linguistically appropriate services are increasingly recognized as effective in improving the quality of care
and services (Beach et al., 2004; Goode, Dunne, & Bronheim, 2006). By providing a structure to implement culturally and
linguistically appropriate services, the enhanced National CLAS Standards will improve an organization’s ability to address
health care disparities.
The enhanced National CLAS Standards align with the HHS Action Plan to Reduce Racial and Ethnic Health Disparities
(HHS, 2011) and the National Stakeholder Strategy for Achieving Health Equity (HHS National Partnership for Action to
End Health Disparities, 2011), which aim to promote health equity through providing clear plans and strategies to guide
collaborative efforts that address racial and ethnic health disparities across the country. Similar to these initiatives, the
enhanced National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care
disparities by providing a blueprint for individuals and health and health care organizations to implement culturally and
linguistically appropriate services. Adoption of these Standards will help advance better health and health care in the
United States.
Bibliography:
Beach, M. C., Cooper, L. A., Robinson, K. A., Price, E. G., Gary, T. L., Jenckes, M. W., Powe, N.R. (2004). Strategies for improving minority healthcare quality. (AHRQ
Publication No. 04-E008-02). Retrieved from the Agency of Healthcare Research and Quality website:
http://www.ahrq.gov/downloads/pub/evidence/pdf/minqual/minqual.pdf
Goode, T. D., Dunne, M. C., & Bronheim, S. M. (2006). The evidence base for cultural and linguistic competency in health care. (Commonwealth Fund Publication No. 962).
Retrieved from The Commonwealth Fund website: http://www.commonwealthfund.org/usr_doc/Goode_evidencebasecultlinguisticcomp_962.pdf
LaVeist, T. A., Gaskin, D. J., & Richard, P. (2009). The economic burden of health inequalities in the United States. Retrieved from the Joint Center for Political and Economic
Studies website: http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic%2
0Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf
National Partnership for Action to End Health Disparities. (2011). National stakeholder strategy for achieving health equity. Retrieved from U.S. Department of Health and
Human Services, Office of Minority Health website: http://www.minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286
U.S. Department of Health and Human Services. (2011). HHS action plan to reduce racial and ethnic health disparities: A nation free of disparities in health and health care.
Retrieved from http://minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). Healthy people 2020: Social determinants of health. Retrieved
from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=39
U.S. Department of Health and Human Services, Office of Minority Health (2011). National Partnership for Action to End Health Disparities. Retrieved from
http://minorityhealth.hhs.gov/npa
World Health Organization. (2012). Social determinants of health. Retrieved from http://www.who.int/social_determinants/en/
www.ThinkCulturalHealth.hhs.gov THINK 11
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I
Exhibit L
Page 1 of 2
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of entity D/B/A
Address (number, street) City State ZIP code
CLIA number Taxpayer ID number (EIN) Telephone number
( )
II. Answer the following questions by checking “Yes” or “No.” If any of the questions are answered “Yes,” list names and
addresses of individuals or corporations under “Remarks” on page 2. Identify each item number to be continued.
A. Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percent or more in the institution, organizations, or agency that have been convicted of a criminal
offense related to the involvement of such persons or organizations in any of the programs established
YES NO
by Titles XVIII, XIX, or XX? ......................................................................................................................... ❒ ❒
B. Are there any directors, officers, agents, or managing employees of the institution, agency, or
organization who have ever been convicted of a criminal offense related to their involvement in such
programs established by Titles XVIII, XIX, or XX? ...................................................................................... ❒ ❒
C. Are there any individuals currently employed by the institution, agency, or organization in a managerial,
accounting, auditing, or similar capacity who were employed by the institution’s, organization’s, or
agency’s fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) ........... ❒ ❒
III. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling
interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names
and addresses under “Remarks” on page 2. If more than one individual is reported and any of these persons are
related to each other, this must be reported under “Remarks.”
NAME ADDRESS EIN
B. Type of entity: ❒ Sole proprietorship ❒ Partnership ❒ Corporation
❒ Unincorporated Associations ❒ Other (specify)
C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations
under “Remarks.”
D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses
of individuals, and provider numbers. ..........................................................................................................
❒ ❒
NAME ADDRESS PROVIDER NUMBER
Exhibit L
Page 2 of 2
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... ❒ ❒
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... ❒ ❒
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ ❒ ❒
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... ❒ ❒
If yes, give date of change in operations.
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... ❒ ❒
VII. A. Is this facility chain affiliated? ...................................................................................................................... ❒ ❒
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
B. If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed) Title
Signature Date Remarks
Exhibit M
Page 1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2. The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The prospective
participant shall submit an explanation of why it cannot provide the certification set out
below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation
shall disqualify such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which
reliance was placed when the department or agency determined to enter into this
transaction. If it is later determined that the prospective primary participant knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause or default.
4. The prospective primary participant shall provide immediate written notice to
the department or agency to which this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as
used in this clause, have the meanings set out in the Definitions and Coverage
sections of the rules implementing Executive Order 12549. You may contact the
department or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
Exhibit M
Page 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) Have not within a three-year period preceding this application/proposal had one
or more public transactions (Federal, State or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or
Company)
Exhibit N
Page 1 of 2
SELF-DEALING TRANSAC TION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “County”),
members of a contractor’s board of directors (hereinafter referred to as “County Contractor”),
must disclose any self-dealing transactions that they are a party to while providing goods,
performing services, or both for the County. A self-dealing transaction is defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in
which one or more of its directors has a material financial interest”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1)Enter board member’s name, job title (if applicable), and date this disclosure is being
made.
(2)Enter the board member’s company/agency name and address.
(3)Describe in detail the nature of the self-dealing transaction that is being disclosed to
the County. At a minimum, include a description of the following:
a.The name of the agency/company with which the corporation has the
transaction; and
b.The nature of the material financial interest in the Corporation’s transaction that
the board member has.
(4)Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5)Form must be signed by the board member that is involved in the self-dealing
transaction described in Sections (3) and (4).
Exhibit 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:
I I